{"rowid": 1, "facility_name": "A.G. RHODES HOME WESLEY WOODS", "facility_id": 115002, "address": "1819 CLIFTON ROAD, N.E.", "city": "ATLANTA", "state": "GA", "zip": 30329, "inspection_date": "2019-02-14", "deficiency_tag": 656, "scope_severity": "G", "complaint": 0, "standard": 1, "eventid": "PXEL11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews and review of the facility policy titled, Care Planning - Interdisciplinary Team the facility failed to follow the care plan for one resident (R), #49. Actual harm was identified when R#49 suffered a midline laceration to the forehead and a [MEDICAL CONDITION] (Cervical) vertebral body requiring the use of a C-spine collar when she fell from her bed after being left unattended during a bed bath on 12/15/18. Additionally, the facility failed to develop a care plan for one Resident (R#94) for the use of a travel pillow for neck positioning. The sample size was 26 residents. Findings include: Review of the facility's policy titled Care Planning - Interdisciplinary Team reviewed on 3/1/18 noted: 1. A comprehensive care plan for each resident is developed within seven (7) days of completion of the resident assessment (MDS (Minimum Date Set)); 2. The care plan is based on the resident's comprehensive assessment and is developed by a care planning/interdisciplinary team. The policy did not include additional information regarding the development and implementation of resident care plans. 1. Review of the clinical record for R#49 revealed that the resident had the following [DIAGNOSES REDACTED]., [MEDICAL CONDITION] (left eye) and depression. Review of the Annual MDS, for R#49, dated 9/5/18 and review of the Quarterly MDS dated [DATE] revealed that the resident was assessed to be severely cognitively impaired, had physical and verbal behaviors directed towards others for one to three days during the assessment period. Review of Section G of this MDS documented that during this assessment period the resident was assessed to be dependent on staff for bathing requiring two plus person assist for bathing. R#49 had no impairment of the upper or lower extremities. Continued review revealed during this assessment period the resident had no falls and did not utilize any restraints or alarms. Review of the Fall care plan for R#49 last reviewed on 1/24/19 revealed the resident was a fall risk and required extensive to total assistance for Activities of Daily Living (ADLs). Pertinent interventions in place at the time of the resident's fall on 12/15/18 included the following: to assist with all ADLs, total transfer assist with Hoyer lift, floor mat at bedside, assist rails x 2; Broda chair when out of bed for comfort and positioning; and to keep bed in low position. Review of the Behavior care plan for R#49 last reviewed on 1/24/19 revealed that R#49 had behaviors - at risk for complications/side effects r/t (related to) use of antipsychotic and other mood stabilizing medication use. The interventions documented that if resistive/combative behavior was noted, leave R#49 alone and return when safe to do so/provide additional assist as needed. Review of a handwritten statement dated 12/21/18 written by CNA FF documented the following: On 12/15/18 at 10:45 a.m., I (CNA FF) entered room [ROOM NUMBER]. I began washing R#49's upper body and during the process she was fighting. She was yanking on the face towel and shirt. She punch at me and hit the right bedrail. I let her head down and lifted the right bedrail up and begin peri care. I turned her (R#49) to her left side to clean her bottom. She continue swinging her right arm backward towards me and pushing back. I felt that I could not clean her well, so I place her on her back. I went to pull right bedrail back down (meaning put the siderail in place) and R#49 grabbed it and begin shaking and punching it. I left it up (meaning that the siderail was not in place) and walked to the doorway and called for help. While I was standing in the doorway I heard a bang and when I turned around R#49 was laying on her back on the floor. I went towards her and yelled for the nurse. Signed by CNA FF. (sic) During an interview at the nurses' station on 1/30/19 at 11:55 a.m. with Registered Nurse Charge Nurse AA on 12/15/18, revealed that CNA FF told Registered Nurse AA that R#49 was combative so she (CNA FF) went to the resident's door to ask for help and when she turned back around the resident was on the floor. CN AA said that even if CNA FF felt like she had to go get someone, she should have made sure the bed was lowered as indicated in R#49's plan of care. During an interview at the nurses' station on 1/30/19 at 3:20 p.m. with CNA EE, CNA EE revealed that it usually required two staff to care for R#49. When asked about steps to take when the resident became combative during care, CNA EE said staff were supposed to wait until she calms down and then try to give care later. Telephone interview on 1/30/19 at 4:43 p.m. with CNA FF revealed on 12/15/18 the CNA FF was providing care to R#49 when the resident became aggressive. CNA FF said the resident and she played tug of war with the face towel while CNA FF washed the resident's upper extremities. According CNA FF, R#49 was striking out at the CNA FF and also punched the side rail with her right fist. Continued interview with CNA FF revealed that she did not re-approach the resident as indicated in her care plan and did not use the call light to seek help from other staff. During a follow-up interview at the nurses' station on 1/31/19 at 9:58 a.m. with Registered Nurse Charge Nurse AA revealed that the she thinks the resident's care plan called for one person for receiving care in bed and two people if resident is combative. Cross Reference F689 2. Review of the clinical record for R#94 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment for R#94 dated 1/8/19 revealed R#94 was severely cognitively impaired and required extensive to total assistance of one to two staff persons for all activities of daily living (ADLs). During this assessment period, R#94 received occupational therapy (OT), passive range of motion (PROM), and splint/brace assistance. Review of the Task tab printed from the electronic record for R#94 on 1/31/19 revealed Restorative staff was to provide R#94 with Passive Range of Motion (PROM) to the left hand six times per week for 15 minutes for each treatment and was to apply a splint/brace to her left hand for up to six hours - six times per week. The Task tab did not list the use of a travel neck pillow to be used for proper head positioning. Review of the comprehensive care plans for R#94 last reviewed on 1/12/19 revealed that there was not a plan of care developed to address proper neck/head positioning. Review of the Occupational Therapy (OT) Discharge Summary for R#94 dated 1/11/19 revealed one of the discharge recommendations was to continue to use cervical travel pillow when in bed and in Broda chair. Review of an Interdisciplinary Communication Memo for R#94 dated 1/11/19 completed by OT BB documented the following: Continue to use cervical travel pillow when in bed and Broda chair to maintain appropriate head positioning. Observation of R#94 in her room on 1/28/19 at 10:55 a.m. revealed that R#94 was lying in her bed with the head of the bed (HOB) elevated approximately 30 degrees. R#94 had a travel neck pillow around the back of her neck and the resident's head was bent forward and to the right near her shoulder with the resident's chin touching her chest as she slept. Interview at the nurses' station on 1/30/19 at 12:06 p.m. with Registered Nurse Charge Nurse AA revealed that R#94 used the travel neck pillow for positioning and for comfort. Interview on 1/30/19 at 3:50 p.m. with the Director of Nursing (DON) and Minimum Data Set (MDS) Coordinator revealed that R#94 had used the travel neck pillow for quite some time (over a year) at the daughter's request because she felt her mother was comfortable with its use. The MDS Coordinator confirmed that a care plan should have been developed to address the use of the resident's travel neck pillow. Cross Reference F688", "filedate": "2020-09-01"}
{"rowid": 2, "facility_name": "A.G. RHODES HOME WESLEY WOODS", "facility_id": 115002, "address": "1819 CLIFTON ROAD, N.E.", "city": "ATLANTA", "state": "GA", "zip": 30329, "inspection_date": "2019-02-14", "deficiency_tag": 688, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "PXEL11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews and review of the facility policy titled, Resident Mobility and Range of Motion the facility failed to assess and provide treatment for one Resident (R), (R#94) for neck positioning. The sample size was 26 residents. Findings include: Review of the facility's policy titled Resident Mobility and Range of Motion reviewed on 2/1/18 revealed 3. Residents with limited range of motion will receive treatment and services to increase and/or prevent further decrease in range of motion; 4. Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable .5. Therapy will evaluate/reevaluate the resident's mobility on a routine basis to determine the need for range of motion exercises. Review of the clinical record for R#94 revealed an Annual Minimum Data Set (MDS) assessment dated [DATE] with documented [DIAGNOSES REDACTED]. Continued review of the MDS revealed R#94 was severely cognitively impaired and exhibited no behaviors during the assessment period. The resident required extensive to total assistance of one to two staff persons for all Activities of Daily Living (ADLs). During this assessment period, R#94 received Occupational Therapy (OT), passive range of motion (ROM), and splint/brace assistance. Review of the Task tab for R#94 printed from the electronic record on 1/31/19 revealed the resident required total assistance for eating; required two-person total dependence for bathing, bed mobility, and dressing. These tasks were to be completed by the Certified Nursing Assistants (CNAs). Further review revealed Restorative staff was to provide the resident with passive ROM to the left hand six times per week for 15 minutes for each treatment and was to apply a splint/brace to her left hand for up to six hours - six times per week. The Task tab did not list the use of a travel neck pillow to be used for proper head positioning. Review of the comprehensive care plans for R#94 last reviewed on 1/12/19 revealed the plan did not list appropriate head positioning as a focus area requiring interventions. Review of Therapy Screening Forms for R#94 dated 4/26/18, 7/31/18, 9/25/18 and 12/17/18 revealed a section with instructions to Indicate all areas reflecting a change in condition or an area with a deficit that may warrant therapy. For each screening form, the items in this section were left blank and unaddressed. Some of the items included in this section were: Poor positioning/body alignment, swallowing difficulties, choking/coughing with meals/meds. The 12/17/18 screening form recommended an OT evaluation. Review of the OT Discharge Summary for R#94 dated 1/11/19 revealed R#94 received OT services from 12/18/18 through 1/11/19. R#94 received OT services for the following reasons: 1) increase trunk strength; 2) increase sitting balance during ADLs; 3) to achieve normal anatomical alignment of the right hand for three hours using a hand roll; 4) to exhibit a decrease in pain at rest in the left hand to improve functional use of upper extremities during ADLs; and 5) to safely wear finger extension splint on left fingers for up to five hours. R#94 was discharged from OT services on 1/11/19 due to achieving the highest practical level of functioning. One of the discharge recommendations was to continue to use cervical travel pillow when in bed and in Broda chair. Review of an Interdisciplinary Communication Memo for R#94 dated 1/11/19 completed by OT BB documented the following: to Continue to use cervical travel pillow when in bed and Broda chair to maintain appropriate head positioning. Observation in the resident's room on 1/28/19 at 10:55 a.m. revealed R#94 was lying in her bed with the head of the bed (HOB) elevated approximately 30 degrees. R#94 had a travel neck pillow around the back of her neck and the resident's head was bent forward and to the right near her shoulder with the resident's chin touching her chest as she slept. Observation in the resident's room on 1/30/19 at 11:35 a.m. revealed R#94 was lying in her bed and positioned slightly on her right side. The resident had the travel neck pillow around her neck, and her chin rested on her chest near her right shoulder. Interview at the nurses' station on 1/30/19 at 12:06 p.m. with Registered Nurse Charge Nurse (CN) AA revealed that R#94 used the travel neck pillow for positioning and for comfort. Registered Nurse CN AA confirmed, at this time, that the resident's head alignment was chin-to-chest, and stated that it had been that way for at least several months. Observation in the day room of the secured unit on 1/30/19 at 2:35 p.m. with OT BB present revealed R#94 was sitting in a padded Broda chair with her travel neck pillow behind her neck. The resident's chin was resting on her chest and leaning towards her right shoulder. During an interview at this time with OT BB in the day room of the secured unit, the therapist confirmed R#94 did not have appropriate neck positioning. OT BB revealed the travel neck pillow was something the family wanted the resident to have to address the resident's right lateral lean of her head towards her right shoulder that began over a year ago. OT BB stated that it was possible the travel neck pillow was contributing to the resident's chin sitting on her chest and therefore, OT BB felt she needed to screen the resident regarding neck flexion and the possible use of a neck collar. Interview on 1/30/19 at 3:50 p.m. with the Director of Nursing (DON) and MDS Coordinator revealed R#94's daughter encouraged and provided the use of the travel neck pillow. The DON said the pillow was brought in by the daughter over a year ago because the daughter felt her mother was comfortable with its use. Observation of R#94 in the day room of the secured unit with the DON present on 1/30/19 at 4:10 p.m. revealed the resident had the travel neck pillow around her neck and the resident's chin was resting on her chest. During an interview at this time in the day room of the secured unit with the DON, the DON stated she had not seen the resident's head/neck in that position before and felt that it (chin-to-chest position) was something that had recently happened. Interview on 1/31/19 at 8:55 a.m. with the DON revealed the DON had spoken with OT BB and that the therapist informed her that the intended purpose was for the travel neck pillow to be used as a preventative intervention for hyper-extension of the resident's neck (going backwards) but after looking again, the OT BB felt the travel neck pillow may be causing flexion of the neck muscle (going forward). Interview on 1/31/19 at 10:38 a.m. with the DON revealed OT BB assessed R#94 (on the morning of 1/31/19), and OT BB was going to call the residents daughter to discuss discontinuing the use of the travel neck pillow. Follow-up interview with the DON on 1/31/19 at 11:46 a.m. revealed that the DON spoke with the resident's daughter and that the daughter explained that the initial reason for getting the travel neck pillow was to keep the resident's head from leaning to the right side. She said the daughter realized that the resident's head was now moving forward in the chin-to-chest position and the daughter agreed with discontinuing the use of the travel neck pillow. Interview on 1/31/19 at 12:46 p.m. with OT BB revealed the therapist completed the resident's screening and the resident was going to be picked up for therapy to do some neck exercises and stretching and to determine if a soft collar should be utilized. OT BB said the daughter was in agreement of discontinuing the use of the travel neck pillow. Follow-up interview on 1/31/19 at 2:05 p.m. with OT BB revealed when asked about the resident's quarterly therapy screens not addressing the resident's neck posture, OT BB said that when she evaluated the resident earlier in (MONTH) 2019, she looked at her mostly for her hand splint. OT BB said she didn't realize until today (1/31/19) how thick and heavy the travel neck pillow was and said, gravity and the pillow are causing it (the resident's neck) to move forward and thrust her chin against her chest. The therapist stated the travel neck pillow needs to be discontinued.", "filedate": "2020-09-01"}
{"rowid": 3, "facility_name": "A.G. RHODES HOME WESLEY WOODS", "facility_id": 115002, "address": "1819 CLIFTON ROAD, N.E.", "city": "ATLANTA", "state": "GA", "zip": 30329, "inspection_date": "2019-02-14", "deficiency_tag": 689, "scope_severity": "G", "complaint": 0, "standard": 1, "eventid": "PXEL11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews and review of the facility policy titled, Fall Policy the facility failed to provide supervision during a bed bath to prevent an avoidable fall for one Resident (R), #49. Actual harm was identified when R#49 suffered a midline laceration to the forehead and a [MEDICAL CONDITION] (Cervical) vertebral body requiring the use of a C-spine collar when she fell from her bed after being left unattended during a bed bath on 12/15/18. The sample size was 26 residents. Findings include: Review of the facility's policy titled, Fall Policy reviewed 3/1/18 revealed The facility will identify each resident who is at risk for falls and will plan appropriate care and implement interventions to assist in fall prevention. The facility will attempt to decrease falls with injury by providing an environment that is free from potential hazards. Review of the clinical record for R#49 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. and depression. Review of the Annual Minimum Data Set (MDS), for R#49, dated 9/5/18 and review of the Quarterly MDS dated [DATE] revealed that the resident was assessed to be severely cognitively impaired, had physical and verbal behaviors directed towards others for one to three days during the assessment period. Review of Section G of this MDS documented that during this assessment period the resident was assessed to be dependent on staff for bathing and required two plus person assist for bathing. R#49 had no impairment of the upper or lower extremities. Continued review revealed during this assessment period the resident had no falls and did not utilize any restraints or alarms. Review of a handwritten statement dated 12/21/18 written by Certified Nursing Assistant (CNA) FF documented the following: On 12/15/18 at 10:45 a.m., I (CNA FF) entered room [ROOM NUMBER]. I began washing R#49's upper body and during the process she was fighting. She was yanking on the face towel and shirt. She punch at me and hit the right bedrail. I let her head down and lifted the right bedrail up and begin peri care. I turned her (R#49) to her left side to clean her bottom. She continue swinging her right arm backward towards me and pushing back. I felt that I could not clean her well, so I place her on her back. I went to pull right bedrail back down (meaning put the siderail in place) and R#49 grabbed it and begin shaking and punching it. I left it up (meaning that the siderail was not in place) and walked to the doorway and called for help. While I was standing in the doorway I heard a bang and when I turned around R#49 was laying on her back on the floor. I went towards her and yelled for the nurse. Signed by CNA FF. (sic) Review of a Fall Report dated 12/15/18 completed by Registered Nurse Charge Nurse (CN) AA documented the following: CN AA (Registered Nurse Charge Nurse AA) was summoned to R#49's room and that the resident was noted lying on the floor on the right side of her bed .range of motion done, patient assessed and placed back on the bed. According to the report, the fall resulted in a laceration to the top of the resident's scalp. There were no other injuries noted. Predisposing Physiological Factors affecting the fall were noted as confused, drowsy, incontinent, recent change in condition, impaired memory and recent change in medications/New. Review of the section titled Witnesses revealed there were No Witnesses found. According to the report, the resident's Physician and family were notified of the fall. There was no other information included in the report. Record review of the Health Status Notes for R#49 dated 12/15/18 documented by Registered Nurse Charge Nurse AA revealed the following documentation in pertinent part: summoned to resident's room by caregiver, resident noted lying on the floor with a laceration to forehead extending to top of head with a small amount of bleeding. Patient assessed, and range of motion done and placed back to bed. Vital signs stable. Small amount of bleeding noted, able to control the bleeding. Neuro checks completed and intact .spoke to Nurse Practitioner who gave orders to send to ER (emergency room ). Spoke with patient's son and niece who agreed for her (R#49) to be sent out. Review of a History and Physical (H&P) Hospital Final Report from the acute care hospital dated 12/15/18 documented that R#49 was a [AGE] year old female with severe dementia, who presents from nursing home after ground level fall (do not know many details of how fall happened, attempting to contact nursing home and family) .Non-contrast head CT (computed tomography) scan revealed left parietal and occipital hemorrhage which appeared to be hemorrhagic conversion of ischemic stroke given fairly localized to PCA territory (neurosurgery in agreement). Patient also found to have a C1 fracture for which she was placed in a C-spine collar. Further review of this H&P revealed that the Assessment/Plan documents . found to have a left parietal and occipital ICH ([MEDICAL CONDITION]) which appears to stay fairly confined to the left PCA territory, suggesting hemorrhagic conversion of an ischemic stroke rather than traumatic ICH. She (R#49) was also found to have a C1 fracture which will require stabilization. On exam, she moves all extremities equally and spontaneously. Review of R#49's Task List Report (a list of tasks to be completed by the Certified Nursing Assistants (CNAs) printed on 1/31/19 revealed the tasks of completing personal hygiene, bathing, and bed mobility were initiated on 1/13/17 (the resident's date of admission). According to the report, R#49 required the total assistance of one-two persons for personal hygiene; she required the extensive assistance of one person for bathing; and she required the extensive assistance of one person for bed mobility. According to the Task Report, the resident's level of assistance during ADLs had not changed since the tasks were initiated on 1/13/17. Observation in the resident's room on 1/30/19 at 11:09 a.m. revealed the resident was in her bed sleeping and the head of bed (HOB) was elevated approximately 30-45 degrees. The bed was in a low position. R#49 wore a neck collar, and the floor mat was on the floor to the left side of the bed. Continued observations revealed a healed vertical scar down the middle of the resident's forehead spanning from the middle of her forehead and into her hairline. During an interview at the nurses' station on 1/30/19 at 11:55 a.m. with Registered Nurse CN AA revealed that on 12/15/18, when the nurse entered the resident's room after the fall, R#49 was on the floor and had a laceration to her forehead that was deep. R#49 was sent out to the emergency room for the laceration and once at the hospital, it was found that her injuries were more than that. Registered Nurse CN AA said she remembered CNA FF was in the resident's room providing care. CNA FF told Registered Nurse CN AA that R#49 was combative, so she came to the door to ask for help and when she turned back around the resident was on the floor. Registered Nurse CN AA said staff were trained to use the call light if a resident became combative. The nurse said staff should get help to come to the room because at that point they (residents) can't be left unsupervised. Registered Nurse CN AA continued that even if (CNA FF) felt like she had to go get someone, she should have made sure the bed was lowered. Interview at the nurses' station on 1/30/19 at 3:20 p.m. with CNA EE revealed that CNA EE did not usually work with R#49, but that she had assisted other CNA's who had were assigned to assist the resident. CNA EE said it usually required two staff to care for the resident because, she (R#49) fights. Continued interview with CNA EE revealed that when residents become combative staff were supposed to wait until she (the resident) calms down and then try to give care later. Go in with two people once she calms down. Telephone interview on 1/30/19 at 4:43 p.m. with CNA FF revealed on the day of the resident's fall, she entered the resident's room to provide care (bed bath). The resident was sitting in bed with the head of the bed (HOB) elevated approximately 60 degrees. CNA FF said she raised the bed in order to provide care and left the resident with the HOB elevated and in a sitting position in order to wash the resident's face and upper extremities. CNA FF said the bilateral side rails were lowered (meaning that they were in place). When CNA FF began to wash the resident's face, the resident became combative and was grabbing at the towel. CNA FF said they were playing tug of war with the towel. CNA FF said she was able to complete washing the resident's upper extremities and then began to put on the resident's shirt. At this point, CNA FF said the resident began to swing at her which prevented the CNA FF from being able to put the resident's arms in her shirt. CNA FF stated that at one point in an attempt to hit CNA FF, that R#49 punched the side rail. Once CNA FF completed the resident's upper body, she lowered the HOB and lifted the side rail towards the HOB (meaning that the side rails were not in place), so she could complete peri care for the resident. CNA FF stated she raised the side rail to complete peri care because it was easier to reach the resident with the side rail raised (meaning that the side rail was not in place). CNA FF turned the resident over on her left side while the resident was still being combative, and the resident was using her right hand to swing back at CNA FF and grabbing the towel. CNA FF said she continued to take the towel out of the resident's hand. Once on her left side, CNA FF realized that the resident had been incontinent of bowel. The resident continued to be combative and striking and CNA FF realized she needed help to complete the resident's care. At this point, CNA FF said she attempted to put the side rail back in place and attempted to lower the bed. Due to the resident's physical aggression, she was unable to do so, but CNA FF stated she believed the bed did lower some. CNA FF then went to the doorway of the resident's room to call for assistance from another staff member. CNA FF said she called for help three times and then heard a loud thump and turned around and saw the resident's feet on the floor. CNA FF went to the resident's side of the room and found the resident on the floor on her back with her head near the dividing wall between the resident's and her roommate's beds. R#49's legs were near the foot of her bed. CNA FF said she screamed out for help. Continued interview with CNA FF revealed that sometimes it required one and two staff members to provide care for R#49. When asked about methods of caring for residents who are exhibiting combative/resistive behaviors, CNA FF said options were: 1) re-approaching, 2) pushing call light, and 3) calling for help. CNA FF said she did not re-approach the resident and did not use the call light to seek help from other staff. CNA FF said the resident required a Hoyer lift for transfers and required staff assistance for bed mobility. According to CNA FF, R#49's level of assistance in bed mobility sometimes varied. Interview on 1/31/19 at 9:33 a.m. with CNA GG revealed R#49 usually required two person assist, but sometimes, it depends. CNA GG worked on 12/15/18, the day the resident fell from bed. CNA GG said she was on the other hall when the fall occurred but was told by CNA FF that the resident fell out of bed. CNA FF told CNA GG that she went to the resident's doorway to call her for assistance because the resident was being combative and fighting and while at the door CNA FF heard a thump and turned around and realized the resident fell out of bed. CNA GG said that when caring for combative residents, it was the staff's responsibility to make sure they (the residents) are safe before leaving their side to get help, or that staff should push call light to get assistance. During a follow-up interview on 1/31/19 at 9:58 a.m. with Registered Nurse CN AA, the nurse was asked what she saw when she walked into the resident's room. Registered Nurse CN AA said R#49 was face down on the floor and she could see a little blood on the floor. At that time, she turned the resident over and saw the laceration in the middle of her forehead. Registered Nurse CN AA said she thinks the bed was still in a high position and the side rail was up towards the HOB. Registered Nurse CN AA continued by stating she thinks that the resident's care plan called for one person for receiving care in bed and two people if resident is combative. Interview on 1/31/19 at 10:18 a.m. with Licensed Practical Nurse (LPN) HH revealed she was present along with Registered Nurse CN AA in R#49's room on 12/15/18, immediately after the fall. LPN HH said R#49's bed was in a high position and that the side rail was up towards the head of the bed (meaning the side rail was not in place). LPN HH revealed that she did not work on R#49's hall so she was not familiar with the kind of assistance the resident required; however, LPN HH said that when providing care for a combative resident that sometimes you need to get someone else or re-approach. Make sure the resident is safe and then ring call bell for assistance. An interview on 1/31/19 at 10:20 a.m. with the facility's Associate Medical Director (AMD) and the facility's Director of Nursing (DON) confirmed R#49's fall resulted in a C1 fracture. The AMD acknowledged that he was aware of the resident's combative behaviors and said the resident was very strong. During the interview, the DON said that when dealing with combative residents there should be two staff, and if a CNA realizes more assistance is needed, then they should get more help. The DON said it would have been a better choice for CNA FF to use the call light to ask for assistance, or to have lowered the bed and then seek help. She said that for R#49, one-two staff were required for care while in bed, it was at the CNA's discretion depending on the resident's behavior. Post survey telephone interview on 2/14/19 at 5:15 p.m., with the Administrator and Director of Nursing (DON) revealed that the Task List is a mini care plan that lists out Activities of Daily Living for CNA's for care planned individualized approaches. The DON revealed that if a resident has been assessed (such as for MDS) to require two plus person assist for baths then a two plus person assist bath should be provided. Further interview, at this same time, with the DON and Administrator revealed that during the facility's investigation of the fall they determined that CNA FF had left the bed in a high position and that the side rail was in the up position (meaning that the side rail was not in place at the time the resident fell out of bed). Continued interview with the DON revealed that what should have happened that did not happen was that CNA FF should have gotten additional assistance by using the call light or by yelling out, the CNA should have lowered the bed before leaving the resident, and that CNA FF should have ensured the safety of the resident. Post survey telephone interview on 2/14/19 at 6:25 p.m., with CNA FF clarified that that she was familiar with working with R#49, and that R#49 had exhibited behaviors like this before when she had provided care previously. CNA FF stated that previously she had been able to talk to the resident and redirect her but on 12/15/19 she was not able to re-direct the resident. CNA FF further revealed that she should have let the side rail down (put the side rail in place), and that she should have used the call button to call for help or even used her cell phone to call for help and that she should not have walked away from the resident.", "filedate": "2020-09-01"}
{"rowid": 4, "facility_name": "A.G. RHODES HOME WESLEY WOODS", "facility_id": 115002, "address": "1819 CLIFTON ROAD, N.E.", "city": "ATLANTA", "state": "GA", "zip": 30329, "inspection_date": "2019-02-14", "deficiency_tag": 880, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "PXEL11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and review of facility policy titled, Handwashing/Hand Hygiene the facility failed to ensure food was served in a sanitary manner for six of 41 residents (R), R#63 and five unsampled resident) residing on the secured unit. Findings include: Review of the facility's document entitled Handwashing/Hand Hygiene policy (undated) noted the following: 6. Wash hands with soap and water for the following situations: a. When hands are visibly soiled; b. After contact with a resident with infectious diarrhea .7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: a. Before and after coming on duty; b. Before and after direct contact with residents; .i. After contact with a resident's intact skin; .l. After contact with objects in the immediate vicinity of the resident; .o. Before and after eating or handling food; p. Before and after assisting a resident with meals. Review of the clinical record for R#63 revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's Quarterly MDS dated [DATE] revealed the resident required the limited assistance of one staff person for eating and required the extensive assistance of one staff person for personal hygiene. During the lunch meal observation in the north dining room of the facility's secured unit on 1/28/19 at 1:07 p.m. an unsampled resident was seated at a dining table waiting to be served her lunch meal. The resident's left shoe was off of her foot and the resident was having difficulty putting her shoe back on. At this time, the Activity Director (AD) was passing out utensils wrapped in cloth napkins to all of the resident in the dining room and when the AD approached this unsampled resident, the AD set the tray of utensils down on the table and then assisted the resident by putting her shoe on for her. After the resident's shoe was on, the AD picked up the tray and passed out the remaining two cloth wrapped utensils that were on the tray. The AD did not perform hand hygiene before passing the utensils to the two other unsampled residents. Upon completion of passing out the utensils, still having performed no hand hygiene, the AD then served and provided meal set-up for three other unsampled residents. Continued observation of this meal service at 1:15 p.m., revealed the AD left the dining room area and went to R#63's room to escort the resident to the dining room for lunch. The AD was observed to brush R#63's hair as the resident was sitting on her bed. After brushing the resident's hair, the AD prompted the resident to stand up and then escorted R#63 to the dining room by using side by side assistance while holding the resident's hand. Once in the dining room, the AD assisted the resident in sitting down at the table. Without performing any hand hygiene, the AD served the resident her meal tray and then provided meal set-up. Interview with the AD in the north hallway of the secured unit on 1/28/19 at 1:25 p.m. revealed when the AD was asked what she should have done after assisting the unsampled resident with her shoe, the AD paused and then said, My hands! The AD continued and said that because she was multi-tasking, she over-looked the step of washing her hands or using hand sanitizer after assisting the resident with her shoe and after brushing R#63's hair. The AD said she missed that step. Interview at 1:30 p.m. at the nurses' station with Registered Nurse Charge Nurse (CN) AA revealed that the AD was also a CNA (Certified Nursing Assistant) and that she assisted the other CNA's with meal service on the unit at least once or twice each week. Registered Nurse CN AA confirmed that the AD should have performed hand hygiene after assisting the residents with their dressing and hygiene tasks. In addition, Registered Nurse CN AA said hand hygiene should be conducted between each resident's meal set-up.", "filedate": "2020-09-01"}
{"rowid": 5, "facility_name": "A.G. RHODES HOME WESLEY WOODS", "facility_id": 115002, "address": "1819 CLIFTON ROAD, N.E.", "city": "ATLANTA", "state": "GA", "zip": 30329, "inspection_date": "2017-03-23", "deficiency_tag": 247, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "6QM511", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview with facility staff, review of the electronic records, and review of the policy titled Room Change/Roommate Assignment, revised (MONTH) 2006, the facility failed to ensure that written notification of room change was provided before moving a resident from the third floor to the fourth floor for one of 32 sampled residents (R) (R#194). Findings include: Review of a Social service assessment dated [DATE]; the resident is coded as independent for decision making skills and understanding the need for placement and participated in the placement decision. Review of the Room Change/Roommate assignment policy, revised in (MONTH) 2006 includes in part; Prior to changing a room or roommate assignment all parties involved in the change assignment (e.g.) Residents and their representatives (sponsors) will be given a 2-day advanced notice of such change. The notice of a change in room or roommate assignment may be oral or in writing, or both, and will include the reason(s) for such change. On 3/20/2017 at 1:00 p.m., R#194 was interviewed and he reported that he was very upset at the time that he was moved to this room from the third floor. He stated this happened about three months ago and no one prepared him for a room change. The resident said, they came to me after I finished my breakfast and moved me the same day. The resident stated, They told me I had to be moved because I no longer needed therapy and I became long term care. If they do it again I will speak up for myself because that really upset me. Review of the Shift Charting Notes dated 1/16/2017 at 9:49 a.m., the resident was transferred to (a room on the fourth floor) per staff. Medications and personally belongings transferred, report given as well. Review of a General Social Services Note dated 1/12/2017 at 3:18 p.m, documents the resident is to remain for long term care. MSW left a message on voice mail of his daughter to discuss room change to the 4th floor- traditional long term care unit. Advised bed is available a telephone service would need to be established if they desire a land line, needs a dresser and TV. Requested a return call to discuss this further. Planning for change to a fourth floor room, if agreeable. On 3/22/2017 at 11:03 a.m., during interview with the Social Service Associate he confirmed that he did not receive a return call from R#194's daughter and he did not call her back, nor did he document any conversation with the resident regarding any room changes. He stated that he was off for the weekend holiday and returned on 1/17/2017 and was then notified the resident had been moved from the fourth floor on 1/16/2016. He provided the surveyor with a room change notification form dated 1/17/2017 at 9:11 a.m., the form included new room number on the fourth floor and the residents' daughters' name as being notified a day after the move occurred.", "filedate": "2020-09-01"}
{"rowid": 6, "facility_name": "A.G. RHODES HOME WESLEY WOODS", "facility_id": 115002, "address": "1819 CLIFTON ROAD, N.E.", "city": "ATLANTA", "state": "GA", "zip": 30329, "inspection_date": "2017-03-23", "deficiency_tag": 328, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "6QM511", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, facility policy review and staff interviews, the facility failed to ensure residents received proper [MEDICATION NAME] treatment and care by not capping the sterile end of an intravenous (IV) tubing nor removing air from syringes and intravenous tubing. This had the potential to affect one of two residents (R) (R#37) currently receiving IV medications in a universe of 32 sampled stage 2 residents. Failure to cap the sterile end on an IV could result in a resident infection and failing to remove air from syringes or intravenous lines could result in an air [MEDICAL CONDITION] (a blood vessel blockage caused by air bubbles in the circulatory system). Findings include: Observation in R#37's room on 3/23/17 from 9:30 a.m. - 10:00 a.m. revealed Licensed Practical Nurse (LPN) (LPN KK) verbalized intention to flush R#37's right hand intravenous (IV) catheter using a 10 cc syringe of sterile normal saline (NS), However, as she moved toward the IV with the syringe, she had not expelled the visualized air from the syringe. Surveyor stopped the procedure requesting she expel the air. She held the syringe horizontally expelling liquid while the air bubble remained. She turned to resume flushing and again was asked to remove the air from the syringe, requesting LPN KK hold it vertically, syringe tip up, to examine and expel the air bubble. LPN KK did remove the air, shaking her head, offering that she was nervous being watched but can do this as she flushed the IV extension tube with the NS. LPN KK then opened the sterile IV tubing package and connected a 100 cc bag NS with 1 gram of [MEDICATION NAME] (an Antibiotic) to the IV tubing. She ran the solution through the tubing without closing clamp or turning filter upside down. LPN KK then strung the tubing through the medication pump (used to regulate the time and amount of solution administered). The pump began beeping when it was turned on. It was noted there were multiple air bubbles still in the tubing. She had difficulty clearing them. She decided to switch tubing out to a dial flow rather than use a pump. She disconnected the medication bag from the pump tubing and ran the medication through the new dial a flow tubing then connected to the resident. The clamp to the R#37's extension tubing had not yet been opened. There was air still noted in the dial a flow tubing when surveyor asked to see it before proceeding. LPN KK then disconnected from R#37's and cleared the tubing of air and reconnected but the solution would not drip after she unclamped. She unhooked the IV tubing and draped it over the IV pole without capping the exposed connection tip. The tubing was noted to swing back and forth a few times when draped over pole. LPN KK cleaned tip with alcohol and covered with the cap after surveyor pointed her over sight out to her as she went to leave R#37's room. Examination of Facility Policy Administration of Infusion Therapy, Procedure for Continuous or Intermittent Infusion last reviewed 9/27/16 specified in step 7: Remove the tubing from the package and close the roller clamp. Step 10: Hang the bag (with the previously inserted tubing) on the pole, squeeze the drip chamber to establish the proper fluid level (1/2 - 2/3 full). Turn the filter upside down, open the roller clamp, and prime system of air. Step 12: Remove air from normal saline flush syringe (to flush the infusion access device.) Step 16: Disconnect administration set from injection valve and place sterile cap over leur-lock end of IV tubing. Interview of LPN KK at 10:00 a.m. revealed she was upset with myself and should have assured air was removed from syringe and tubing before proceeding. She acknowledged that capping the connection tip would protect from contamination. She further revealed she has had training in IV care but does so infrequently. During the 11:00 a.m. Interview on 3/23/17 of the Director of Nursing (DON), revealed LPN KK should have followed the IV procedures and My biggest concern is in regard to (LPN KK's) lack of air removal from the syringe and IV tubing. The DON revealed the facility does not perform competencies on nurses regarding IV medication administration but would see LPN KK is re-educated. However, at 12:30 p.m.,, the DON provided a copy of a 3/1/2016 Medication pass observation report performed by an RN Pharmacy Consultant of LPN KK performing a Normal Saline IV flush. The document did not include a check off of the expected steps of the observed IV push procedures nor was the use of intermittent IV med bag infusion or tubing care documented as part of the observations performed on 3/1/16.", "filedate": "2020-09-01"}
{"rowid": 7, "facility_name": "A.G. RHODES HOME WESLEY WOODS", "facility_id": 115002, "address": "1819 CLIFTON ROAD, N.E.", "city": "ATLANTA", "state": "GA", "zip": 30329, "inspection_date": "2017-03-23", "deficiency_tag": 371, "scope_severity": "F", "complaint": 0, "standard": 1, "eventid": "6QM511", "inspection_text": "Based on observation, staff interview, anonymous interviews, review of dish washer temperature log, and review of the Dish Machine Temperatures policy, revised 1/2016, and the Uniform Dress Code policy dated 1/2016, the facility failed to ensure the high temperature dishwasher wash temperature was maintained at 160 degrees Fahrenheit (F) and final rinse temperature was maintained at 180 degrees (F), or higher, The facility failed to have test strips for the dishwasher and attach the test strips to the dishwasher log as required by facility policy, and failed to ensure that staff wore hair and beard restraints while in the kitchen. This failure had the potential to effect 128 residents that received food from the kitchen. Findings include: Observation on 3/21/17 at 10:37 a.m. of the electronic dishwasher monitor screen revealed that it was red and had a tringle with an exclamation point (!) in it. In an interview at this time Dietary Aide DD stated that the dishwasher monitor screen was red and had an exclamation point in the triangle, because the water temperature in the dishwasher was too low. Dietary Aide DD stated that the dishwasher was a hot water dishwasher, the wash water temperature is supposed to be 160 degrees F and the rinse is supposed to be 180 F, but the water temperature has been fluctuating. Continued observation on 3/21/17 from 10:37a.m. to 10:45 a.m. revealed that the Dietary Aide DD continued to wash the dishes and the monitor continued to be red with an exclamation point inside a triangle. The wash water temperatures on the electronic monitor fluctuated from 132 to 157 degrees F and the rinse temperature fluctuated from 177 degrees F to 192 degrees F. Further observation revealed Dietary Aide DD never verified the water temperature fluctuation with a test strip attached to a dish. In an interview at this time the Dietary Aide stated that he had washed about 10 racks of dishes and the other staff member put them on the storage rack. In further interview, Dietary Aide DD stated that his supervisor instructed him to continue to wash dishes, the repair person had been called and was on his way. In an interview on 3/21/17 at 11:05 AM the Dietary Manager CC stated that she had the staff re- wash all the dishes that were ran through the dishwasher using the three compartment sink and she in-serviced the staff on not using the dishwasher when the water temperatures were not correct. Duringan interview on 3/21/17 at 3:09 PM the Dishwasher repair person stated that the wash water temperature in the dishwasher was only getting up to 140 F degrees for wash temperature and the rinse water temperature was at 160 degrees F, but the wash should be at 160 degrees F, the rinse should be at 180 degree F, he would run his test strips through the dishwasher once he gets the water temperature corrected. In continued interview the Dishwasher repairman stated that the dishwasher booster heater was tripped by the cold water that had been sitting in the pipes and he would email this surveyor the invoice once the work was completed. Surveyor received an email from the dishwasher repair person on 3/21/17 at 4:07 p.m., requesting a call back. When called the repair person stated ESR booster heater not working, Temp was low on rinse and wash tank, reset booster heater, now reading 195 on the rinse, 160 on the wash. During an interview on 3/22/17 at 10:48 AM the Dietary Manager stated that the dishwasher's electric monitor was not working, she called the repair person to replace it and she did not have test strips to check the water temperature of the dishwasher. Review of the facility's Dish Machine Temperatures policy dated revised 1/16 revealed: Single-tank, conveyor, dual temperature machine: Wash temperature 160 degrees F, Final rinse temperature 180 F -194 F. High Temperature Dish machine- Record on Dish machine record form wash and final rinse temperatures during each period of use. Once a day, run a test strip through the dish machine to verify the surface temperature of a dish. Attach the used test strip to the temperature log. The test strip must verify that the surface temperature of the plate reached 160 degrees F. If documentation of the temperatures and test strips has been assigned to a Food and Nutrition Associate confirms that it is completed at each meal period. Director determines if reading is due to malfunctioning gauge or inappropriate temperature .If due to inappropriate water temperature (high temperature machine) or inappropriate concentration of sanitizer solution (low temperature), implements disposable service ware, contacts sources of repairs, documents action taken on back of form. Review of the facility's dishwasher log for the month of (MONTH) (YEAR) revealed that there were no test strips attached to the dishwasher log verify the surface temperature of a dish. In a confidential interview on 3/20/17 at 1:33 p.m. an employee stated that the staff are only wearing hair nets because surveyors were in the building. Observation on 3/21/17 at 12:05 p.m. revealed that Dietary Aide EE had facial hair and was in the kitchen without a beard restraint. In an interview at this time Dietary Aide EE stated that he is supposed to have on a beard restraint when he is in the kitchen. Observation 3/21/17 at 12:05 p.m. revealed that Licensed Practical Nurse (LPN) FF was in the main kitchen in the food prep area without a hair net. In an interview on 3/21/17 at 12:01 p.m. the Dietary Manager stated that staff are not supposed to be in the kitchen without hair nets or beard restraints. Review of the facility's Uniform Dress Code policy dated 1/16 revealed . Wear the approved hair restraint when on duty. The only exception is to remove hair restraints when delivering trays to patients/residents . Facial hair must be effectively restrained as per local and state regulations .", "filedate": "2020-09-01"}
{"rowid": 8, "facility_name": "MAGNOLIA MANOR METHODIST NSG C", "facility_id": 115004, "address": "2001 SOUTH LEE STREET", "city": "AMERICUS", "state": "GA", "zip": 31709, "inspection_date": "2019-01-25", "deficiency_tag": 584, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "4HRK11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and review of facility documents the facility failed to maintain a safe/clean/comfortable homelike environment for the residents in six rooms (out of 24 rooms) on one unit (out of five). Specifically, six rooms on Unit 300 had significant areas of bare walls where the paint had been scratched, scuffed or peeled off. The documents reviewed included the Daily Housekeeping Room Checklist, Housekeeping Review, Work Order Logs and the Call In Work Orders listing. Findings include: A tour of Unit 300 was conducted with the Maintenance Director (MD) beginning on 1/25/19 at 10:35 a.m. The following areas were confirmed with the MD including: room [ROOM NUMBER]: Multiple areas on one of four walls where paint is scuffed, scratched and peeling, missing; room [ROOM NUMBER]-A: Multiple areas on the wall behind the head of the bed where paint is missing; room [ROOM NUMBER]-A: Multiple areas on the wall behind the head of the bed where paint is missing; room [ROOM NUMBER]: A line of multiple scratched, scuffed areas where paint is missing approximately four feet from floor (waist high) on two of four walls; room [ROOM NUMBER]: Multiple areas on one of four walls where paint is scuffed, scratched and peeling, missing above the cove base; room [ROOM NUMBER]: An area on the entry wall five feet in length approximately three feet from floor (waist high) where paint is missing, scratched, scuffed. During an interview conducted on 1/25/19 at 9:57 a.m. with Maintenance Tech CC revealed that he receives work orders from the maintenance office to complete specific painting tasks. He could not confirm if there was any type of regular scheduled inspection of the rooms for routine maintenance. An interview with the Administrator was conducted on 1/25/19 at 10:15 a.m. revealed that the facility is currently undergoing a renovation by unit. She could not confirm when Unit 300 was scheduled for renovation but stated that even though they are under renovation in other areas, they are still addressing day to day maintenance issues including painting on Unit 300. An interview was conducted with the MD on 1/25/19 at 10:25 a.m. confirmed that staff call the Maintenance Department for any issues such as lights that need replacing and other repairs that may be needed. The maintenance staff create a work order, prioritize and then assign the task. He also confirmed there is no process for routinely auditing resident room conditions. He stated that the housekeeping department manager contacts the maintenance department for any repairs or issues noted during their daily cleaning of resident rooms and common areas. He was unsure if the housekeeping department utilized any type of checklists. He confirmed that there isn't any type of written communication process between housekeeping and maintenance. An interview was conducted on 1/25/19 at 10:30 a.m. with the Housekeeping Director (HD). She confirmed that the communication her department has with maintenance is mostly verbal. She provided a copy of a two page form entitled Housekeeping Review that addresses the cleanliness of the resident rooms and/or common areas but does not specifically reflect any required observations for maintenance issues or concerns. She stated that she uses the form several times a month basis but confirmed it is not completed on every resident room or on a routine scheduled basis. The form states: Directions: Members of the quality action team will review specific areas of the facility. A mark in the 'no' column may indicate a problem. The form contains a list of 17 areas to observe and check yes or no with a space for comments. The end of the form includes a place to document Problems identified; Probably reasons for problems; Goals; Action plan; Responsible staff. The HD also provided a copy of a Daily Housekeeping Room Checklist that includes space for daily checks of three rooms for the following areas: Bathroom; Resident's Room; Curtains; Bedside Table; Window Sill; Furniture; Floors; Pantry. It also has space to note what housekeeper is assigned to the room and any comments/date. Observed and reviewed a clipboard located on the wall of the nursing station for 300 Hall/Unit with forms entitled Work Order Log on 1/25/19 at 12:50 p.m. The form has a place for the month and year to be written in. One sheet was labeled Sept. (YEAR) and contained entries dated from 9/13/18 through 12/10/18. A second sheet was labeled Dec. (YEAR) and contained entries dated from 12/11/18 through 1/25/19. There are no entries on either sheet concerning paint issues in resident rooms. During an interview conducted on 1/25/19 at 1:13 p.m. with the Administrator, she confirmed that she does not have a policy on conducting any type of environmental rounds or the routine monitoring of the condition of resident rooms. She stated the MD performs preventative maintenance in the building.", "filedate": "2020-09-01"}
{"rowid": 9, "facility_name": "MAGNOLIA MANOR METHODIST NSG C", "facility_id": 115004, "address": "2001 SOUTH LEE STREET", "city": "AMERICUS", "state": "GA", "zip": 31709, "inspection_date": "2019-01-25", "deficiency_tag": 656, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "4HRK11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to follow the care plan related to administering medications as ordered for one Resident (R) (R#114). The sample size was 49 residents. Findings include: Review of the medical record revealed that R# 114 had the [DIAGNOSES REDACTED]. Record review revealed a care plan for the potential for medication side effects related to [MEDICAL CONDITION] medication. This care plan documented an intervention to administer medications as ordered. Further record review revealed a Physician order, with a start date of (MONTH) 1, (YEAR), for [MEDICATION NAME] 0.25 milligrams (mg) to take one tablet twice daily as needed (prn) for 60 days for agitation. Review of the Medication Administration Record [REDACTED]. Interview on 1/24/19 at 9:40 a.m. with Licensed Practical Nurse (LPN) II confirmed that the PRN [MEDICATION NAME] 0.25 mg order was started in (MONTH) (YEAR) and should have ended (MONTH) 1, 2019. Interview with the Registered Nurse (RN) Unit Manager on 1/24/19 at 9:45 a.m. revealed that they typically get a report from the pharmacy when a medication needs to be stopped and the pharmacy consultant sends a monthly report. The Unit Manager revealed that a report had been received from the pharmacy consultant on 1/22/19, but she had not reviewed or followed up on the recommendations yet.", "filedate": "2020-09-01"}
{"rowid": 10, "facility_name": "MAGNOLIA MANOR METHODIST NSG C", "facility_id": 115004, "address": "2001 SOUTH LEE STREET", "city": "AMERICUS", "state": "GA", "zip": 31709, "inspection_date": "2019-01-25", "deficiency_tag": 657, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "4HRK11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of the facility policy titled Comprehensive Person -Centered, the facility failed to update and revise a comprehensive care plan to reflect the vascular site and monitoring of the site for one resident out of five sampled residents (R#133) receiving [MEDICAL TREATMENT] services. Findings include: Record review of policy titled Care Plans Comprehensive Person-Centered stated It is the intent of Magnolia Manor facilities to develop and implement a person-centered plan of care for each resident that include goals for admission, discharge and desired outcomes. 3. (B) Incorporate risk factors (s) associated with the identified problems(s). (D) reflect treatment goals and objectives in measurable goals. B. Reflect the resident's specified goals for admission and desired outcomes. B. Reflect the resident's specified goals for admission and desired outcomes. F. Enhance the optimal functioning of the resident utilizing rehabilitative program as indicated. (5). Care plan are revised as changes in the resident's condition dictates. Reviews are made at least quarterly. The resident has the right to participate in the process and to approve any changes to the plan of care. Record review revealed that R#133 had a Physician order dated 8/20/18 for an AV Fistula (ateriovenous fistula) shunt and attended [MEDICAL TREATMENT] two days a week on Monday and Friday. The Minimum Data Set ((MDS) dated [DATE] section C revealed a Brief Interview Mental Status (BIMS) score of 15 (a score of 15 out of 15 indicates cognitive intact) and a section O revealed a coding for [MEDICAL TREATMENT]. Review of [MEDICAL TREATMENT] care plan dated 10/16/18 (last reviewed on 1/2/19) revealed that there was not any interventions in place to monitor the vascular site or checking the site for bruit and thrill. Interview on 1/24/19 at 3:24 a.m., with the Director of Nursing (DON) revealed that staff should check every shift for bruit and thrill and observe for any infections at the site. She further stated the [MEDICAL TREATMENT] care plan should reflect how often to check and monitor the site. Interview on 1/25/19 at 1:09 p.m., Register Nurse (RN) DD revealed that she was not aware that the [MEDICAL TREATMENT] care plan did not provide interventions about monitoring of the AV shunt site. She further stated that the [MEDICAL TREATMENT] care plan was updated on today 1/25/19 (after the concern was identified during the survey). Interview on 1/25/19 at 1:15 p.m., with the Minimum Data Set (MDS) Coordinator revealed that the [MEDICAL TREATMENT] care plan should be specific to resident care needs. She confirmed that the [MEDICAL TREATMENT] care plan was not revised until 1/25/19 to address monitoring of the AV site.", "filedate": "2020-09-01"}
{"rowid": 11, "facility_name": "MAGNOLIA MANOR METHODIST NSG C", "facility_id": 115004, "address": "2001 SOUTH LEE STREET", "city": "AMERICUS", "state": "GA", "zip": 31709, "inspection_date": "2019-01-25", "deficiency_tag": 758, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "4HRK11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to assure that PRN (as needed) medications were taken as ordered for one Resident (R) #114. The sample size was 49 residents. Findings include: Review of the medical record revealed that R#114 had the following [DIAGNOSES REDACTED]. Record review of the chart revealed an order, with a start date of (MONTH) 1, (YEAR), for [MEDICATION NAME] 0.25 milligrams (mg) with one tablet taken by mouth twice daily as needed for 60 days for agitation. Review of the Medication Administration Record [REDACTED]. Interview on 1/24/19 at 9:40 a.m. with Licensed Practical Nurse (LPN) II confirmed that the [MEDICATION NAME] PRN order started in (MONTH) and should have ended (MONTH) 1, 2019. It was reported that typically orders on the rehab unit are not written this way and that the pharmacy notifies when there is a hard stop on an order. Interview with the Registered Nurse (RN) Unit Manager JJ on 1/24/19 at 9:45 a.m. revealed that she had received a report from the pharmacy consultant on Tuesday but she had not reviewed or followed up on the recommendations yet.", "filedate": "2020-09-01"}
{"rowid": 12, "facility_name": "MAGNOLIA MANOR METHODIST NSG C", "facility_id": 115004, "address": "2001 SOUTH LEE STREET", "city": "AMERICUS", "state": "GA", "zip": 31709, "inspection_date": "2017-01-26", "deficiency_tag": 280, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "DVCB11", "inspection_text": "Based on staff interview and record review, it was determined that the facility failed to revise a plan of care to include a pressure ulcer for one resident (#194) from a total sample of 22 residents. Findings include: A review of Resident (R) #194's clinical record revealed the resident had a stage two pressure ulcer to the left elbow since 10/31/16. During an interview on 1/24/17 at 10:12 a.m., Licensed Practical Nurse (LPN) AA confirmed the resident had a stage two pressure ulcer to the left elbow, identified on 10/31/16. There was a plan of care in place, dated 10/26/16, that R#194 was at risk for pressure areas related to incontinence and decreased mobility. Although interventions were implemented to address the pressure ulcer, the plan of care was not revised to include the presence of the pressure ulcer to the left elbow, until 1/25/17, after surveyor inquiry. During an interview on 1/26/17 at 1:49 p.m., Registered Nurse (RN) BB confirmed that the plan of care had not been revised and stated it was an oversight.", "filedate": "2020-09-01"}
{"rowid": 13, "facility_name": "MAGNOLIA MANOR METHODIST NSG C", "facility_id": 115004, "address": "2001 SOUTH LEE STREET", "city": "AMERICUS", "state": "GA", "zip": 31709, "inspection_date": "2018-02-01", "deficiency_tag": 761, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "0R9911", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the Medication Administration Procedural Guidelines and interviews the facility failed to ensure that the medication cart was locked during medication administration on one of four medication carts observed during medication administration. Findings include: Observation on 01/31/18 at 4:42 p.m. during Medication Administration with Licensed Practical Nurse (LPN) LPN AA on Unit 1 medication cart. revealed that LPN AA parked the medication cart outside along the opposite wall from room [ROOM NUMBER] on Unit 1 and at 4:21 p.m. and returned to the medication cart to remove medications to administer to the other resident in room, 125 A bed. At 4:24 p.m. LPN AA was observed to remov medications from the cart that was against the wall on the other side of the hall on Unit 1 that was not in direct view of the nurse in the residents room [ROOM NUMBER] [NAME] LPN AA then left the medication cart unlocked going into room [ROOM NUMBER] A leaving the door open however, the LPN's back was to the medication cart the entire time she was in the room. LPN AA then came out of the room and called for assistance to help reposition the resident in the bed, not realizing that the medication cart remained unlocked. LPN AA then went back into room [ROOM NUMBER] A continuing to leave the medication cart unlocked. After repositioning the resident with assistance and administering the residents medication the surveyor observed by standing right out side of residents door. LPN AA came out of the room at 4:35 p.m. Interview with the LPN AA, at this time revealed that she had not received any training here at the facility and did not have a preceptor here before starting on the floor, LPN AA also reported she was an agency nurse and started on the medication cart two months ago and comes two times a week. Interview on 2/1/18 at 11:00 a.m. with the Director of nursing reported that the licensed nursing staff do a skills check off list and Life safety packet annually and that on hire agency nurses only do the life safety packet but do not do a skills check off. The DON also reported that the facility receives a packet of the training and skills for agency nurse and what skills they have completed. The DON reported that the expectation is a safety expectation that the medication cart remains locked at all times. Interview on 2/1/18 2:00 at p.m. with RN Unit Manager on 200 Hall reported that all nurses and agency included know that the medication cart is to be locked when they are not in it or by it. Interview on 2/1/18 at 2:45 p.m. with the Administrator who reported that agency nurses receive training from the company they work with and that is noted in our contracts and that when they come to work in this facility the agency nurses receive the facility Life Safety Orientation packet on hire and in the packet they are to review it and it includes the facility Policies and Procedures and where they are located on each unit and in every department. The Administrator reported that any nurse would know that they are to lock their medication cart when not in it. Stated she is aware of the agency nurse that was observed during medication administration yesterday and stated of course her expectations would be that the LPN should have locked the medication cart. Review of the facility Medication Administration Procedural Guidelines dated (MONTH) (YEAR)- #18. During routine administration of medications, the medication cart is kept in the doorway of the patient's room, with open drawers facing inward and all other sides closed. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to patients or others passing by.", "filedate": "2020-09-01"}
{"rowid": 14, "facility_name": "MAGNOLIA MANOR METHODIST NSG C", "facility_id": 115004, "address": "2001 SOUTH LEE STREET", "city": "AMERICUS", "state": "GA", "zip": 31709, "inspection_date": "2018-02-01", "deficiency_tag": 812, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "0R9911", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and review of the facility's policy for food and nutrition the facility failed to maintain sanitary resident nourishment refrigerators in unit pantries, failed to store food items properly in resident nourishment refrigerator and failed to dispose of expired food items in a timely manner in resident nourishment pantry on three of five units. Findings include: Observation on [DATE] at 8:14 a.m. of resident nourishment pantry on Unit 3 revealed thickened sweet tea dated as expired on [DATE]. Confirmed as expired by Licensed Practical Nurse (LPN) A[NAME] Observation on [DATE] at 9:39 a.m. of resident nourishment pantry on Unit 1 revealed five cartons of Impact Advanced Reconstituted Nutritional Drink dated expired [DATE]. Confirmed by Registered Nurse (RN) BB as expired. Observation on [DATE] at 9:44 a.m. of resident nourishment refrigerator in the pantry on Unit 5 revealed two unlabeled/undated frozen food items in a take-out container in the freezer. Confirmed by LPN CC. LPN CC stated that the food items that were in the freezer had been brought in for a resident but she was unsure for which resident or when they were brought in. Observation on [DATE] at 9:55 a.m. of resident nourishment refrigerator in the pantry on Unit 4 revealed a large spill of brown liquid in the bottom of the refrigerator. Observation also revealed that the refrigerator contained the following an unlabeled/ undated open coke can, covered loosely by a paper towel, an open unlabeled/undated two- liter grape [MEDICATION NAME] beverage, an unlabeled/undated personal cup, a plate of food with staff signature of SH, LPN and dated [DATE]. The previously listed food items were intermingled with resident nourishment items. A separate employee refrigerator was provided for employee food and was labeled employee. LPN DD confirmed the previous findings. Interview with LPN DD revealed that all staff were responsible for upkeep of the resident nourishment pantries and refrigerators. Interview on [DATE] at 10:10 a.m. with the Administrator and RN, Infection Control Nurse EE revealed that they expect the Unit Manager to make sure that food items are not expired, dated and labeled. If the Unit Manager found that the pantry or refrigerator needed attention, then the expectation was that the Unit Manager would assign personnel to clean it or check food items as needed. They stated that their expectations regarding storage of food items was that staff food items would be stored separately from resident food items which was why staff refrigerators were provided. They stated that if staff and resident food items were stored in the same refrigerator that they would expect them to be stored on separate shelves as well as being dated and labeled. Review of policy for food and nutrition revealed that foods were to be stored, prepared, distributed and served under sanitary conditions. The policy also stated that perishable food items provided for residents must be in air tight containers and stored in the refrigerator in the pantry on the nursing unit and must have the date and the resident's name on it. The policy stated that perishable items left in the refrigerator for more than 48 forty-eight hours would be discarded.", "filedate": "2020-09-01"}
{"rowid": 15, "facility_name": "MAGNOLIA MANOR METHODIST NSG C", "facility_id": 115004, "address": "2001 SOUTH LEE STREET", "city": "AMERICUS", "state": "GA", "zip": 31709, "inspection_date": "2019-06-07", "deficiency_tag": 656, "scope_severity": "D", "complaint": 1, "standard": 0, "eventid": "2RIR11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure that medication for pain was administered for one of 12 residents(A) and failed to provide wound care for one of 12 residents (B) as care planned. Findings include: 1. During interviews on 6/3/19 at 12:00 p.m. and 6/4/19 at 1:50 p.m. Resident (R) A stated that nursing staff waits until her pain medication runs out to order more. Record review revealed that RA had a care plan since 2/819 for being at risk for alteration in comfort related to [MEDICAL CONDITION] reflux disease, generalized pain and skin alteration. The care plan included an intervention for licensed nursing staff to administer medication as ordered. Further record review revealed that there was a physician's orders [REDACTED]. There was also a physician's orders [REDACTED]. However, a review of the clinical record revealed that the resident did not receive the scheduled [MEDICATION NAME] pain medication as ordered and as care planned on 4/23/19 at 12:00 p.m. and 6:00 p.m. Record revealed that on 5/24/19 a physician's orders [REDACTED]. The resident received [MEDICATION NAME] as scheduled through the 5/24/19 6:00 p.m. dose. The [MEDICATION NAME] 10-325mg was then administered routinely afterward until the supply on hand was exhausted on 5/29/19 at 6:00 p.m. Therefore, the resident did not receive the scheduled [MEDICATION NAME] pain medication as ordered and as care planned on 5/30/19 at 12:00 a.m., 6:00 a.m., 12:00 p.m. and 6:00 p.m. Cross refer to F697 2. Record review revealed that RB had a care plan problem, dated 4/2/19, for receiving treatment with an antibiotic for bilateral [MEDICAL CONDITION]. The care plan problem was updated on 4/29/19 to include the use of an intravenous antibiotic and an intervention for nursing staff to provide wound care as ordered. A review of the clinical record revealed a physician's orders [REDACTED]. This treatment was ordered to treat venous wounds to the right and left lateral calves. During an interview on 6/5/19 at 3:45 p.m. R B stated that Treatment Nurse DD had applied a silver alginate dressing to her legs and she was not supposed to. During interviews on 6/6/19 at 4:00 p.m. and 6/7/19 at 10:45 a.m., Treatment Nurse DD confirmed that she had applied [MEDICATION NAME] Ag, which contains silver, to the open areas on the resident's lower extremities, one day prior to a visit to the wound clinic in (MONTH) 2019, to try something different to help the resident because she was upset about her legs. Treatment nurse DD confirmed that she did not obtain a physician's orders [REDACTED]. A review of wound clinic notes from 5/10/19 confirmed RB reporting the use of silver dressings to her lower extremity wounds. Cross refer to F684", "filedate": "2020-09-01"}
{"rowid": 16, "facility_name": "MAGNOLIA MANOR METHODIST NSG C", "facility_id": 115004, "address": "2001 SOUTH LEE STREET", "city": "AMERICUS", "state": "GA", "zip": 31709, "inspection_date": "2019-06-07", "deficiency_tag": 684, "scope_severity": "D", "complaint": 1, "standard": 0, "eventid": "2RIR11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure that wound treatments were provided as ordered by the physician for one of 12 residents (R B). Findings include: Record review revealed that Resident (R) B had [DIAGNOSES REDACTED]. During an interview on 6/5/19 at 3:45 p.m. R B stated that Treatment Nurse DD had applied a silver alginate dressing to her legs and she was not supposed to. A review of the clinical record revealed a physician's orders [REDACTED]. This treatment was ordered to treat venous wounds to the right and left lateral calves. During an interviews on 6/6/19 at 4:00 p.m. and 6/7/19 at 10:45 a.m., with Treatment Nurse DD confirmed that she had applied [MEDICATION NAME] Ag, which contains silver, to the open areas on the resident's lower extremities, one day prior to a visit to the wound clinic in (MONTH) 2019, to try something different to help the resident because she was upset about her legs. Treatment nurse DD confirmed that she did not obtain a physician's orders [REDACTED]. A review of wound clinic notes dared 5/10/19 confirmed that RB reported the use of silver dressings to her lower extremity wounds. During an interview on 6/7/19 at 12:55 a.m., with the Director of Nursing (DON) revealed that she expected licensed nursing staff to obtain a physician's orders [REDACTED].", "filedate": "2020-09-01"}
{"rowid": 17, "facility_name": "MAGNOLIA MANOR METHODIST NSG C", "facility_id": 115004, "address": "2001 SOUTH LEE STREET", "city": "AMERICUS", "state": "GA", "zip": 31709, "inspection_date": "2019-06-07", "deficiency_tag": 697, "scope_severity": "D", "complaint": 1, "standard": 0, "eventid": "2RIR11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review, and review of the facility policy titled, Obtaining and Receiving Medications from Pharmacy the facility failed to ensure the medication for pain was obtained timely for one of 12 residents (R A). Findings include: The facility had an Obtaining and Receiving Medications from Pharmacy policy. The policy documented that medications that must be reordered by the nurse included controlled substance medications. The policy further documented that Schedule II medications such as [MEDICATION NAME] and [MEDICATION NAME] products required a signed prescription by the physician and should be reordered at least seven days in advance. During interviews on 6/3/19 at 12:00 p.m. and 6/4/19 at 1:50 p.m. Resident (R) A stated that nursing staff waited until her pain medication ran out to order more. Record review revealed that RA had a care plan since 2/8/19 for being at risk for alteration in comfort related to [MEDICAL CONDITION] reflux disease, generalized pain and skin alteration with an intervention for licensed nursing staff to administer medication as ordered. Further record review revealed a Physician's order since 2/15/19 for [MEDICATION NAME] 10-325 milligrams (mg) to be administered every six hours for pain. There was also a physician's order since 2/13/19 for [MEDICATION NAME] 10-325 mg to be administered every six hours as needed for pain. However, a review of the clinical record revealed that the resident did not receive the scheduled [MEDICATION NAME] pain medication as ordered and as care planned on 4/23/19 at 12:00 p.m. and 6:00 p.m. On 4/23/19 a Physician's order was obtained to 1) Hold [MEDICATION NAME] 10-325 mg every six hours and resume when it was available. 2) Administer [MEDICATION NAME] 10-325 mg every six hours, scheduled and discontinue when the [MEDICATION NAME] became available. 3) Keep the order for [MEDICATION NAME] 10-325 mg every six hours as needed for pain. A review of the (MONTH) 2019 Medication Administration Record [REDACTED]. On 5/24/19 a Physician's order was again written to 1) Hold [MEDICATION NAME] 10-325 mg every six hours and resume when available 2) Administer [MEDICATION NAME] 10-325mg every six hours, scheduled, for pain and discontinue when [MEDICATION NAME] is available. The resident received [MEDICATION NAME] as scheduled through the 5/24/19 6:00 p.m. dose. The [MEDICATION NAME] 10-325mg was then administered routinely afterward until the supply on hand was exhausted on 5/29/19 at 6:00 p.m. When the on-hand supply of [MEDICATION NAME] 10-325 mg was exhausted, the [MEDICATION NAME] still had not been obtained from the pharmacy. During an interview on 6/3/19 at 12:40 p.m., Licensed Practical Nurse (LPN) AA stated that she phoned the pharmacy on the morning of 5/29/19 (a Wednesday) to check on the status of the [MEDICATION NAME] because she only had two doses of the [MEDICATION NAME] (for 12:00 p.m. and 6:00 p.m.) remaining. LPN AA stated that the pharmacy said they were waiting on a physician signature to fill the prescription. A new Physician's order was obtained on 5/30/19 to administer one Tylenol #4 every six hours as needed until the [MEDICATION NAME] arrived from the pharmacy. A review of the (MONTH) 2019 MAR's and narcotic logs revealed that the resident did not receive the Tylenol #4 until 12:30 a.m. on 5/31/19. Therefore, after the on-hand supply of [MEDICATION NAME] was exhausted and prior to obtaining and receiving the Tylenol #4 medication, the resident missed four scheduled [MEDICATION NAME] pain medication doses on 5/30/19 at 12:00 a.m., 6:00 a.m., 12:00 p.m. and 6:00 p.m. During an interview on 6/3/19 at 1:40 p.m. the Director of Nursing (DON) stated that the nurses should be checking and following up on medications that are low at the beginning of the week.", "filedate": "2020-09-01"}
{"rowid": 18, "facility_name": "PARK PLACE NURSING FACILITY", "facility_id": 115005, "address": "1865 BOLD SPRINGS ROAD", "city": "MONROE", "state": "GA", "zip": 30655, "inspection_date": "2018-07-19", "deficiency_tag": 656, "scope_severity": "G", "complaint": 0, "standard": 1, "eventid": "9U3P11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, family and staff interviews, the facility staff failed to follow the comprehensive care plan for Resident (R #40) on how to safely transfer the resident from one surface to another. On 7/5/18, R#40 was transferred improperly, without the use of a Hoyer lift, resulting in R#40 sustaining two fractured ribs on the left side. The sample size was 46 residents. Findings include: Record review revealed that R #40 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of R#40's most recent comprehensive Minimum Data Set (MDS), a five-day scheduled assessment with an Assessment Reference Date (ARD) of 4/25/18 coded R#40 as cognitively moderately impaired, requiring cues/supervision with decision making and requiring extensive assistance of two people for bed mobility and totally dependent of two people for transfers. Review of the Comprehensive care plan dated 12/13/17 with an Approach: Transfer with the help of one person and updated on 4/15/18 to 4/18/18 to reflect dependent Extensive, related to weakness, need total assist with Activities of Daily Living (ADL) and Hoyer lift by two persons under the Goal section. A hand written note at the bottom of the care plan dated 4/18/18: (MONTH) use Hoyer lift prn (as needed) during transfers related to weakness. The care plan was updated on 7/10/18 under Approach: Transfer-two person Hoyer lift. A review of the facility document Nurse Aide's Information Sheet also referred to by the facility staff as the ADL sheet (a communication tool used by the Certified Nursing Assistants (CNA) to determine a resident's ADL needs, including transfers) documented that R#40 needed assistance of one staff member to place from bed into the wheelchair. An update was made on 7/9/18 for use of Hoyer lift by two persons for transfers. Review of the facility investigation statement, written by CNA BB, revealed that the CNA had never worked with R#40 prior to this incident and had transferred R#40 from her bed to her recliner, at the request of the resident, and failed to obtain assistance from another staff member and did not use the Hoyer lift. CNA BB was on medical leave during the survey process and not available for interview. On 7/18/18 at 12:55 p.m. an interview was conducted with Licensed Practical Nurse (LPN) FF (who was assigned to the resident on 7/5/18) at the D hall nurse's station. LPN FF was asked how does staff know how to care for the residents they are assigned. LPN FF replied, The CNAs should look in the ADL book to determine the resident's transfer status. We also have meetings in the morning at the start of the shift. If they don't know they should ask. When the CNAs come in they should get their assignment and check the ADL book then meet with the nurse. There is no reason for them not to know how to transfer a resident. Further interview with LPN FF was asked to review the ADL sheet and acknowledged that it documented R#40 as an assist of one to transfer to the wheelchair. When asked who completed the ADL sheet, LPN FF stated that nursing was responsible for completing at the time of admission, We write it up in pencil, so it can be updated (with information from the care plan). On 7/18/18 at 2:45 p.m. an interview was conducted with the Director of Nursing (DON) in her office. The DON was asked to explain the incident and investigation when R#40 was transferred on 7/5/18 resulting in rib fractures. The DON stated, We had never seen the resident get out of the bed, we want her to get up, but she refuses, and her family does not want her to get up. The DON stated that the aide had got R#40 out of bed on the morning of 7/5/18 using improper transfer techniques. The DON further stated that R#40 was normally bed bound and the aide should not have attempted to transfer the resident without assistance and should have used a Hoyer lift. The DON confirmed that CNA BB had worked at the facility for about a month and she had never worked with R#40 prior to the date of the incident. When asked how CNA BB would know what R#40's transfer status was the DON stated that it was on the ADL sheet (information from the resident's care plan). The DON was asked to review the information on the ADL sheet at the time of transfer. The DON verified that at the time of the transfer the ADL sheet documented R#40 as a one person assist for transfers to the chair and that this information was incorrect. When asked what the ADL sheet should have documented, the DON stated that it should have been updated to reflect the resident's actual transfer status at that time. The DON further stated that R#40 did not get out of bed and she was totally dependent, and the ADL sheet should have reflected that she needed, at minimum, a two person assist and / or a Hoyer lift for safe transfers. No further information was provided prior to the end of the survey process. Cross reference to F689", "filedate": "2020-09-01"}
{"rowid": 19, "facility_name": "PARK PLACE NURSING FACILITY", "facility_id": 115005, "address": "1865 BOLD SPRINGS ROAD", "city": "MONROE", "state": "GA", "zip": 30655, "inspection_date": "2018-07-19", "deficiency_tag": 689, "scope_severity": "G", "complaint": 0, "standard": 1, "eventid": "9U3P11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, family and staff interviews and records review, the facility staff failed to ensure that the correct information regarding safe transfer techniques for Resident (R#40) was accurate on the Certified Nursing Assistants (CNAs) care communication tool, the Activities of Daily Living (ADL) sheet. Between 4/18/18 and 7/5/18 R#40 was documented throughout the clinical record as being totally dependent for transfers and requiring a Hoyer lift for safe transfers. On 7/5/18 Certified Nursing Assistant (CNA) BB transferred R#40 without assistance of another staff member and without using a Hoyer lift. Following the transfer R#40 was documented as having increased pain on the left side and an X-Ray completed later that day documented that R#40 had acute fractures of two ribs on the left side resultling in the resident being transferred to the hospital for evaluation. The sample size was 46 residents. Findings include: Observation of R#40 on 7/16/18 at 9:30 a.m. revealed the resident was lying in her bed with her family at the bedside. An interview in R#40's room was conducted with a family member who stated that their mother was doing okay but that a couple of weeks ago she had been transferred from her bed to her recliner by an aide (CNA BB) and was found to have two fractured ribs following the transfer. When asked how the fractured ribs occurred the family of R#40 stated that the aide (CNA BB) had transferred the resident without assistance and did not use a Hoyer lift, which was how she was normally transferred. The family member further stated that the facility had reported the incident to the State and it was their understanding that the facility had investigated the incident. Review of R#40's clinical record revealed the resident's [DIAGNOSES REDACTED]. A review of R#40's most recent Comprehensive Minimum Data Set (MDS), a five-day assessment with an Assessment Reference Date (ARD) of 4/25/18, coded R#40 as being cognitively moderately impaired with poor decision making requiring cues/supervision. R#40's functional status was coded as requiring extensive assistance of two people for bed mobility and totally dependent of two people for transfers. Review of the Comprehensive care plan dated 12/13/17 with an Approach: Transfer with the help of one person and updated on 4/15/18 to 4/18/18 to reflect dependent Extensive, related to weakness, need total assist with Activities of Daily Living (ADL) and Hoyer lift by two persons under the Goal section. A hand written note at the bottom of the care plan dated 4/18/18: (MONTH) use Hoyer lift prn (as needed) during transfers related to weakness. The care plan was updated on 7/10/18 under Approach: Transfer-two person Hoyer lift. Located in a book at the nurse's station on the unit where R#40 resided there was an undated document titled Nurse Aide's Information Sheet (also referred to by the facility staff as the ADL sheet (a communication tool used by the CNAs to determine a resident's ADL needs, including transfers). Review of the sheet revealed R#40 was documented as requiring assistance of one staff member to place in wheelchair. An update was made on 7/9/18 for use of Hoyer lift by two persons for transfers. Further review of R#40's clinical record revealed that the resident was discharged from physical therapy on 4/18/18. The discharge summary documented the following; Patient progress and response to treatment: Per Medical Doctor, patient (pt.) is to discharge (D/C) from skilled physical therapy (PT) services. Transfers: Dependent. Review of the Nurse's Monthly Progress Note revealed the following: Dated: 4/24/18, Licensed Practical Nurse (LPN) AA documented R#40 as being totally dependent for bed mobility and transfers requiring a Hoyer lift. R#40's Activities of Daily Living are documented as deteriorated. Assistive Devices, Hoyer. Dated: 6/27/18, LPN AA documented R#40 as being totally dependent for bed mobility and transfers requiring a Hoyer lift. Assistive Devices, Hoyer. Review of R#40's Nursing notes revealed the following documentation: Dated: 7/5/18 at 3:12 p.m. notified by CNA that resident was complaint of (c/o) severe pain to left side, assessment done, noted resident c/o pain to left rib cage, [MEDICATION NAME] (a pain medication) 5/325 milligrams (mg) tablet (tab), 1 (one) given and Medical Director notified, X-ray of left rib cage and abdominal (ABD) area ordered, son notified. A review of R#40's Patient Report from the mobile imaging company revealed the following documentation: Dated: 7/5/18. Reason: Pain. In: 4:30 p.m. Examination: Left rib series. Findings: The visualized ribs demonstrate fractures of the left lateral 10th and 11th ribs. No underlying pneumothorax demonstrated. No overlying subcutaneous [MEDICAL CONDITION] noted. Patchy infiltrate in the left lung base. Impression: 1. Acute left lateral 10th and 11th rib fractures. 2. Left lower lobe pneumonia. Dated: 7/5/18 at 6:51 p.m. received x-ray report results of abdomen and left rib cage, revealed abdomen with nonobstructive bowel gas pattern and left lateral 10 and 11th rib fractures. Resident denies falling or bumping self into anything, c/o left rib pain [MEDICATION NAME] 5/325 mg by mouth (po) given for pain, spoke with son regarding resident c/o pain to left rib and abdomen area and of x-ray results. Will continue to monitor. Dated: 7/5/18 at 6:55 p.m. X- ray results for abdomen and chest showing fractured left 10th and 11th ribs and left lower lobe pneumonia. Called Medical Director and left message and also faxed results. Awaiting return call at this time. Dated: 7/5/18 at 8:56 p.m. No response from Medical Doctor. 911 called and hospital called and given report to nurse. Son notified that resident was going to be sent to emergency room (ER) for further evaluation. Awaiting transport at this time. A review of R#40's hospital admission record dated 7/5/18, revealed the following documentation: Disposition Summary: Preliminary [DIAGNOSES REDACTED]. Review of the facility investigative report conducted by the Director of Nursing (DON) regarding the incident with R#40 on 7/5/18, revealed the following written statements: Review of the written statement by CNA BB had never worked with R#40 prior to this incident and had transferred R#40 from her bed to her recliner, at the request of the resident, and failed to obtain assistance from another staff member and did not use the Hoyer lift. CNA BB was on medical leave during the survey process and not available for interview. Review of the written statement of dated 7/9/18 revealed a statement from an Occupational Therapist (OT) II who was in the room working with R#40's roommate at the time of R#40's transfer by CNA BB. The OT documented, in part, the following: I observed the CNA complete the transfer without a gait belt as she instructed R#40 to hold her neck as she proceeded to transfer her to the recliner as she held her by the side of her elastic waist pants. At the completion of the transfer I heard R#40 say, I don't want to do that again. The OT was not available for interview during the survey process. On 7/17/18 at 3:30 p.m., an interview was conducted with CNA CC at the D Hall nurse's station. CNA CC was asked what information she was provided regarding each resident's transfer status. CNA CC stated, I am familiar with the residents and know what they need. If I don't know then I will ask the nurse, or I can ask another aide. When asked if there was any type of communication tool, a care card or cheat sheet that directed the aides to the ADL needs of each resident, CNA CC stated I do not know of any. An interview on 7/17/18 at 4:00 p.m., with the Physical Therapy (PT) Supervisor in the therapy office. The PT Supervisor was asked if he was familiar with R#40 and he stated that he had worked with her in (MONTH) and (MONTH) of (YEAR) to get her back to her prior level of function. The PT Supervisor stated that at the request of her family and her physician her therapy was discontinued on 4/18/18. The PT Supervisor also stated at the time of discharge the resident was totally dependent, could not stand, walk or assist with her transfers. She needed a Hoyer lift for transfers. When asked how that information was communicated to nursing staff, the PT Supervisor stated that when therapy documented that someone was dependent nursing knew to initiate a Hoyer lift. An interveiw on 7/18/18 at 9:40 a.m., with CNA DD on the [NAME] hallway. CNA DD was asked how she knew the transfer status of each resident she worked with, especially if they were new to her. CNA DD stated, We have an ADL book that tells us what the resident care needs are. We can go to that book and see what to do. We also meet every day at three o'clock as a team to discuss the residents. On 7/18/18 at 12:55 p.m., an interview was conducted with LPN FF (who was assigned to the resident on 7/5/18 the day of the fall) at the D hall nurse's station. LPN FF was asked, how does staff know how to transfer a resident? LPN FF stated, The CNAs should look in the ADL book to determine the resident's transfer status. We also have meetings in the morning at the start of the shift. If they don't know they should ask. When the CNAs come in they should get their assignment and check the ADL book then meet with the nurse. There is no reason for them not to know how to transfer a resident. Further interview with LPN FF when asked what she could remember about R#40's functional ability leading up to the 7/5/18 incident, LPN FF stated R#40 could not walk and generally stayed in the bed. She had a recliner and from time to time I would see her in it. When asked how she was normally transferred into the recliner from the bed. LPN FF stated, I would say by a Hoyer lift. The resident had a lot of [MEDICAL CONDITION] and skin issues. I would question her being a one-person transfer, I wouldn't move her by myself and would call for help. LPN FF was asked to review the ADL sheet and the LPN acknowledged that it documented R#40 as an assist of one to transfer to the wheelchair. LPN FF commented the sheet was not correct at the time R#40 fell . We write it up in pencil so it can be updated. When asked what should have happened when R#40 was identified as being totally dependent by PT, LPN FF stated that the ADL sheet should have been updated. When asked how an update would be communicated to the aides working with the residents, LPN FF stated, They have to read the ADL book. Further interview with LPN FF revealed that on 7/5/18 the day of the fall, she had administered medications to R#40 at about 9:30 a.m.she was not sure of the time but the aide went in the resident's room to provide ADL care. LPN FF further stated that R #40 was put back into her bed by lunchtime and that she was unaware that R#40 was in pain until she went in to check on her at about 2:30 p.m. at which time she assessed the resident, provided pain medication and contacted the physician. The aide should never have transferred the resident without assistance. LPN FF stated that R#40 was very alert that day, unusually so, and asked to be put in the recliner. She revealed the aide should have asked for help. Before this incident the aides who worked with R#40 had been using the Hoyer lift. On 7/18/18 at 2:30 p.m. an interview was conducted with LPN AA, the Unit Supervisor, at the D Hall nurse's station. When asked about R#40, LPN AA stated that she was very familiar with the resident and that she hadn't been transferred in about two months leading up to the incident as she did not get out of the bed. If she was to be transferred then she was assessed for use of a Hoyer lift as she was not able to turn herself. When asked what it meant when therapy stated someone was total dependent, LPN AA stated that if the therapy department stated someone was total dependent that meant they could not bear weight and would need a Hoyer lift for transfers. When asked about the incident on 7/5/18 when R#40 was transferred, LPN AA stated She wasn't getting out of bed. I don't know what happened, the aide should have used the Hoyer lift. The ADL sheet was reviewed with LPN AA at this time. LPN AA was asked if the information regarding R#40's transfer ability was correct. LPN AA stated the ADL sheet used by the CNAs was incorrect, it documented that R#40 was a one person assist. When asked if this was the document used by the aides to determine a resident's transfer status LPN AA stated that it was. On 7/18/18 at 2:45 p.m. an interview was conducted with the Director of Nursing (DON) in her office. The DON was asked about the incident that occurred on 7/5/18, when an improper transfer occurred with R#40 that resulted in the residents rib fractures. The DON stated, We had never seen the resident get out of the bed. We wanted her to get up but she refuses and her family does not want her to get up. The DON stated that the aide had got R#40 out of bed on the morning of 7/5/18, using improper transfer techniques. The DON further stated that R#40 was normally bed bound and the aide should not have attempted to transfer the resident without assistance and should have used a Hoyer lift. The DON confirmed that CNA BB had worked at the facility for about a month and she had never worked with R#40 prior to the date of the incident. When asked how CNA BB would know how to transfer a resident that was new to her. DON stated that it was on the ADL sheet. The DON was asked to review the information on the ADL sheet at the time of transfer. The DON verified that at the time of the transfer the ADL sheet documented R#40 as a one person assist for transfers to the chair and that this information was incorrect. The DON further stated that R#40 did not get out of bed and she was totally dependent and the ADL sheet should have reflected that she needed, at minimum, a two person assist and/or a Hoyer lift for safe transfers. . On 7/18/18 at 4:30 p.m. an interview with the Administrator and Clinical Services Administrator was conducted in the Clinical Service Administrator's office regarding improper transfer of R#40 on 7/5/18. The Clinical Services Administrator stated that R#40 was transferred improperly and that the ADL sheet should have correctly reflected the resident's transfer status as that was the communication tool used by the CNAs. Observation and interview on 7/19/18 at 12:10 p.m. with CNA GG revealed that R#40 in her bed. During the repositioning observation by CNA GG revealed that she had worked with R#40 for a long time. When asked what R#40 transfer status was between the end of her therapy on 4/18/18 and the date of the incident on 7/5/18, CNA GG stated, When she came out of therapy in (MONTH) she did pretty well, she would stand and pivot but then in (MONTH) she stopped being able to assist with transfers and started requiring a Hoyer lift. CNA GG further stated, Starting then I always used a Hoyer lift on her, she cannot stand. When asked about the ADL book CNA GG stated that she did not realize that the ADL sheet was incorrect and further stated that R#40 had never really been a one person assist, she required extensive assistance regardless of what it says in the ADL sheet. An interview on 7/19/18 at 12:10 p.m., outside of R#40's room , with LPN HH, a nurse who has worked with R#40 consistently since was admitted . When asked about R#40's transfer status and what happened on 7/5/18, the day R#40 fell . LPN HH replied, She has required a Hoyer lift since May. She cannot stand and she cannot walk. Everyone was aware, but the aide was new and had never worked with this resident prior to the date of the incident. The aide should have asked for help or instructions, regardless of what it said on the ADL sheet. CNA BB did not know her. On 7/19/18 at 3:15 p.m. a telephone interview was conducted with R#40's Medical Doctor (MD). The MD was asked to describe R#40's functional status between 4/18/18 and 7/5/18. The MD stated, Zero, she cannot do anything independently, she has to be moved, she cannot do anything. When asked if one person would be able to safely transfer the resident, the MD stated, Absolutely not. That would be unsafe and the resident could not be safely transferred in that manner. She cannot do anything, she has been totally dependent for a long time. A review of the facility undated policy titled Facility Assessment documents, in part, the following: Staff Training Topics: Address areas of weakness as determined in nurse aides' performance reviews and facility assessment and may address the special needs of residents as determined by the facility staff. Staff Competencies: Activities of daily living - transfers, using gait belt, using mechanic (sic) lifts. On 7/10/18 the facility submitted a follow up report to the incident that occurred on 7/5/18 with R#40 that documented, Based on written statements and verbal reports, we believe that the left rib fracture happened during resident transfer. No further information was provided prior to the end of the survey process. A post survey telephone interview on 8/1/18 at 1:53 p.m., during Quality Assurance review, with the DON revealed the facility does have a process for what to do if the resident's physician does not return their phone calls. She revealed that the nurse would contact the Medical Director for direction but that the resident was also complaining of shortness of breath and the nurses felt the resident needed to be transferred to the emergency room (ER) for further evaluation. A post survey QA telephone call on 8/2/18 at 10:47 a.m. with the Clinical Services Administrator revealed that the resident had been a resident at the facility off and on for many years and the staff were familiar with her. She stated that the resident had experienced many fractures over the years due to osteopenia. She further revealed that this resident had been refusing to get out of bed for the last two months but that on 7/5/18 had asked to get up. The CNA was a new PRN (as needed) who did not know the resident. She confirmed that the resident was transferred improperly to get out of bed and that the CNA had also transferred her back to bed around lunchtime. It was at this time that the resident began complaining of pain in the rib area which progressed to also having shortness of breath. The Clinical Services Administrator revealed that the nurse did not document the resident's shortness of breath in the nurses notes, although it is documented in the five day report submitted to the state agency. After receiving the x-ray results, the nurse contacted the resident's physician and was awaiting a return call but due to the resident's shortness of breath, the nurse felt the resident should be transferred to the ER for immediate evaluation. The Clinical Services Administrator revealed that neither CNA BB or OT II had reported to nursing the improper transfer on 7/5/18. Review of the, undated, policy titled Physician Notification 5. The license nurse to notified Medical Director if no response from the attending Physician within 4 hours for any medical emergency. Review of an undated policy titled Hoyer Lift Policy: This is the policy to (name of) Facility to use a Hoyer lift as needed to assure a resident is moved safely and as comfortably as possible. Procedure: The procedure for using Hoyer lift includes, but is not limited to the following: There must be at least 2 people to assist with transfer. Review of policy titled Gait Belt Policy and acceptance form revealed that every CNA that works here wears a gait belt. It is your responsibility to wear your Gait Belt daily. The facility provided signed documentation the CNA BB had signed as agreed on 5/8/18, to wear a gait belt.", "filedate": "2020-09-01"}
{"rowid": 20, "facility_name": "PARK PLACE NURSING FACILITY", "facility_id": 115005, "address": "1865 BOLD SPRINGS ROAD", "city": "MONROE", "state": "GA", "zip": 30655, "inspection_date": "2019-11-15", "deficiency_tag": 585, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "O88D11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interviews, record review and review of facility policies, the facility failed to make prompt effort to file a grievance for one resident (R) #25 who verbally reported to staff she was missing her lower denture. The sample size was fifty-seven residents. Findings include: Review of an undated policy titled Dental Policy revealed 3. Nursing staff to report missing dentures, notify social service, and fill out concern forms. Review of the policy titled Complaint (Grievance) Policy revised date of (MONTH) (YEAR) revealed Such complaints may include those related to his or her treatment, medical care, missing clothing or other complaints regarding their stay. Record review of the Minimum Data Set (MDS) significant change assessment dated [DATE] revealed R#25 had a Brief Interview for Mental Status of nine indicating moderate cognitive impairment. An interview and observation was conducted on 11/12/19 at 11:50 a.m. with R#25 who responded to interview questions appropriately. The resident was asked about dentures. The resident revealed she is missing her bottom denture. Observation of only top dentures in the resident's mouth. The resident also revealed she reported to the staff and the dentist that she was missing her lower denture. The resident revealed the lower denture has been missing for a couple of months. An interview was conducted on 11/15/19 at 3:25 p.m. with the Certified Nursing Assistant (CNA) CC. The CNA revealed R#25 had reported to the staff during mealtime in the dining room a month ago that she was missing her bottom denture. Record review of R#25's dental notes dated 9/10/19 revealed Patient states her lower denture has been lost. An interview was conducted on 11/15/19 at 9:44 a.m. with the Social Service Director (SSD). The SSD was asked how the facility handles residents missing items. The SSD revealed when a person reports (verbally or in writing) a missing item a grievance form is completed by the staff and the completed form is turned in to the social service department. The social service department will start the investigation to locate/replace the missing item. The SSD revealed there was no grievance filed for R#25's missing lower denture.", "filedate": "2020-09-01"}
{"rowid": 21, "facility_name": "PARK PLACE NURSING FACILITY", "facility_id": 115005, "address": "1865 BOLD SPRINGS ROAD", "city": "MONROE", "state": "GA", "zip": 30655, "inspection_date": "2019-11-15", "deficiency_tag": 732, "scope_severity": "C", "complaint": 0, "standard": 1, "eventid": "O88D11", "inspection_text": "Based on observation and staff interview the facility failed to categorize licensed and unlicensed nursing staff directly responsible for resident care per shift and failed to make certain staffing information was accurate and current. The facility census was 163. Findings include: An observation on 11/12/19 at 10:15 a.m., of the nurse staff information posted on the A/B hall near the treatment nurses office revealed a census of 161. The staffing posting consisted of 4 pages of staff names, staff assigned rooms, staff assigned breaks, staff assigned task, and total employee hours. The staff posting did not include the facility name or the number of licensed and unlicensed staff per unit. The posting appeared to be a facility schedule that listed all staff assigned to work for that day. The information included all licensed and unlicensed staff, as well as staff that do not provide direct care. Further review revealed that the nightshift CNA's assignment did not list the rooms assigned, but instead listed see book. It was difficult for a visitor or resident to know which staff (licensed or unlicensed) was assigned to provide care. An interview on 11/12/19 at 10:46 a.m., with the staffing coordinator, she revealed the A/B hall nursing station was the only place in the facility where the daily staffing is posted. An observation on 11/13/19 at 9:15 a.m,. of the nurse staff information posted on the A/B hall revealed a census of 161 which was not correct due to the actual census being 163.", "filedate": "2020-09-01"}
{"rowid": 22, "facility_name": "PARK PLACE NURSING FACILITY", "facility_id": 115005, "address": "1865 BOLD SPRINGS ROAD", "city": "MONROE", "state": "GA", "zip": 30655, "inspection_date": "2019-11-15", "deficiency_tag": 812, "scope_severity": "F", "complaint": 0, "standard": 1, "eventid": "O88D11", "inspection_text": "Based on observation, policy review and staff interviews, the facility failed to ensure opened food items in the dry storage area were securely covered, labeled and dated; failed to discard food items by expiration date; failed to maintain sanitary conditions in the kitchen by not stacking wet cookware and ensuring the cleanliness of kitchen equipment and not changing gloves during puree process. The facility also failed to maintain proper holding temperatures for cold food items at 41 degrees Fahrenheit (F) or below during meal service. There are 161 residents that receive an oral diet. Findings include: 1. Observation during initial tour on 11/12/19 from 10:05 a.m. to 10:31 a.m. with Certified Food Service Manager (CFSM), revealed in the dry storage area one opened/unsealed 12 ounce box of raisins with no open date; one 16 ounce opened/unsealed box of dry rice with no open date. In the walk in cooler, a large clear storage container with cooked chili with use by date of 11/3/19; one clear container with gravy with use by date of 11/5/19; one clear container of macaroni and cheese with use by date of 11/3/19; one clear storage container with red food substance, unlabeled with no use by date (identified by staff as stewed tomatoes); a large clear storage container of food substance, unlabeled with no use by date (identified by staff as green beans) and one stainless steel container of dinner rolls with use by date of 11/5/19. Interview on 11/12/19 at 11:15 a.m. with Certified Food Service Manager (CFSM) stated that the kitchen staff know that foods are to be dated and discarded after three days. She further stated that she has had many discussion with the dietary staff about not saving the leftover food, because they rarely use it. She verified the concerns identified during the initial tour. 2. Observation during initial tour on 11/12/19 from 10:05 a.m. to 10:31 a.m. with Certified Food Service Manager (CFSM), revealed food slicer on the back table with dried food debris on the blade and the slide tray; wet nesting of three stainless steel cake pans and two stainless steel medium sized holding pans, which were stacked with wet condensation between them; dust and crumbs/food particles on bottom shelving of stainless steel table with pots/pans and serving utensils stored on the shelf. Review of untitled and undated documentation provided by CFSM regarding cleaning and sanitizing stationary equipment, revealed to scrape or remove food from the equipment surfaces and to wash the equipment surfaces. Interview on 11/12/19 at 11:15 a.m. with Certified Food Service Manager (CFSM) stated staff have a cleaning list they are to do before leaving, and the shift supervisor checks the duties off before the staff leave for the day. During further interview, she stated there is not a scheduled list of cleaning tasks to be done. She stated she would talk with the supervisors about the dirtiness of the kitchen shelving and equipment and the wet nesting of the dishes. She verified the concerns identified during the initial tour. 3. During observation of steam table temperatures on 11/14/19 at 11:45 a.m., obtained by Dietary Cook DD with the facility's calibrated digital thermometer, observation of cold food item of jello, temperature was 47.9 degrees Farenheit (F) and milk temperature was 67 degrees F. Bowls of jello noted to be sitting on tray rack, with no ice bath. Milk cartons sitting in a shallow dish on the counter, with no ice bath. Review of untitled and undated documentation provided by CFSM regarding food temperatures, revealed cold foods should be held at 41 degrees or lower. Interview on 11/14/19 at 12:16 a.m. with Certified Food Service Manager (CFSM) stated that they check the temperature of the foods when they remove them from the oven, during mid service and post service. She stated that they don't obtain temperatures for the cold items, they just take them from the cooler when its time to serve. She verified the concerns identified during the initial tour. 4. During observation of puree food process on 11/15/19 at 10:29 a.m. with Dietary Cook DD, she measured out desired portion of fish filets and placed into food processor, along with bread slices and melted butter. During the blending process, she stopped the blender and placed her dirty gloved hand into the blender bowl to mix the partially blended food. Without changing her gloves, she continued the blending process, until food was blended smooth. She washed the blender bowl and lid in the three compartment sink, but did not allow the items to air dry before continuing the pureeing of squash. Interview on 11/15/19 at 10:55 a.m. with Dietary Cook DD, stated that she didn't think about changing her gloves before putting her hand into the food to mix the items in the blender to make it easier to puree. She further stated that she didn't know that she had to wait for the blender bowl and lid to air dry, before proceeding with the puree process. She stated she has always just rinsed them off and continued to puree until all items were pureed. Interview on 11/15/19 at 4:00 p.m. with CFSM, stated that they do not have policy and procedures for the kitchen, that she uses the servesafe manual for best practices. She stated that she did not have anything in reference to food storage and labeling/dating of opened food items or the process of pureeing foods.", "filedate": "2020-09-01"}
{"rowid": 23, "facility_name": "PARK PLACE NURSING FACILITY", "facility_id": 115005, "address": "1865 BOLD SPRINGS ROAD", "city": "MONROE", "state": "GA", "zip": 30655, "inspection_date": "2019-11-15", "deficiency_tag": 840, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "O88D11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to provide documentation of a written agreement or contract with the company providing out patient [MEDICAL TREATMENT] services for one resident (R) (#44) of 3 residents receiving [MEDICAL TREATMENT] services. Findings include: A review of the clinical record revealed R#44 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The resident's most recent Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) of three, indicating severe cognitive impairment. Section: O revealed the resident was receiving [MEDICAL TREATMENT] while a resident in the facility. Review of the physician's orders [REDACTED]. Review of the Facility Resident Census and Conditions of Residents Form dated 11/12/19 revealed the facility had three residents receiving [MEDICAL TREATMENT] at an outside certified end-stage [MEDICAL TREATMENT] facility. Interview on 11/13/19 at 4:56 p.m., with the Assistant Administrator revealed the facility had been trying for months to obtain a [MEDICAL TREATMENT] agreement from the [MEDICAL TREATMENT] center but has not had any luck. She stated she would call again to speak with someone who understood the importance of having this information on file. During an interview on 11/14/19 at 12:05 p.m., the Administrator stated the facility had made several attempts to get a contract from the [MEDICAL TREATMENT] center. He reported and confirmed that when R# 44 was admitted , he was not made aware that there was not a [MEDICAL TREATMENT] contract. He further stated that he had made several attempts to get an agreement with the [MEDICAL TREATMENT] provider but had not been successful until today.", "filedate": "2020-09-01"}
{"rowid": 24, "facility_name": "PARK PLACE NURSING FACILITY", "facility_id": 115005, "address": "1865 BOLD SPRINGS ROAD", "city": "MONROE", "state": "GA", "zip": 30655, "inspection_date": "2019-11-15", "deficiency_tag": 908, "scope_severity": "F", "complaint": 0, "standard": 1, "eventid": "O88D11", "inspection_text": "Based on observations and interview, the facility failed to ensure that essential equipment in the kitchen was in working order as evidenced by, ice build up inside and around the door frame of the walk-in freezer observed on four of four days during the survey. There are 161 residents that receive an oral diet. Findings include: During the initial tour on 11/12/19 at 10:05 a.m. with the Certified Food Service Manager (CFSM) the surveyor inspected the walk-in freezer. During the inspection, the inside door frame, ceiling and floor inside door opening, had visible ice formation. Additional observations during follow-up visits to the kitchen, revealed continued ice buildup on the walk-in freezer door frame, ceiling and floor during all four days of the survey. Interview on 11/15/19 at 4:00 p.m. with the CFSM, stated that staff scrape off the ice in the walk-in cooler everyday. She stated that she has not reported the issue to the maintenance department. She further stated there were no policies related to maintenance of the walk-in freezer.", "filedate": "2020-09-01"}
{"rowid": 25, "facility_name": "NORTH DECATUR HEALTH AND REHABILITATION CENTER", "facility_id": 115012, "address": "2787 NORTH DECATUR ROAD", "city": "DECATUR", "state": "GA", "zip": 30033, "inspection_date": "2017-02-09", "deficiency_tag": 278, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "OC5011", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews, the facility failed to accurately assess pressure ulcers for one resident (R) (R#5) and failed to accurately asssess the oral/dental status for one resident (R#90) who had missing and broken teeth. The sample was 27 residents. Findings include: 1. R#5 was admitted to the facility on [DATE]. Further review of the record revealed the resident did not have pressure ulcers present on admission to the facility. A significant change MDS assessment was conducted on 3/23/16 and the resident was coded as having no pressure sores. On a quarterly MDS dated [DATE], the resident was coded as having an unstageable pressure sore to both heels which were present upon admission and present on the prior assessment. Review of the clinical record revealed the resident had unstageable pressure sores on her bilateral heels which developed in the facility. In addition, a quarterly MDS assessment was conducted on 9/9/16 and again the resident was coded as having the pressure sores present on admission. Review of a quarterly MDS dated [DATE] indicated the resident had a Stage 3 pressure sore upon admission and present on prior assessment. During an interview on 2/9/17 at 6:40 p.m., the MDS Coordinator confirmed she completed the assessments and further stated the resident's pressure sores her on bilateral heals were acquired in-house and both MDS assessments dated 6/23/16 and 12/2/16 were not coded correctly. 2. Review of records revealed R#90 was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. Physician orders [REDACTED]. Observation of R#90 on 2/07/17 at 10:43 a.m. revealed the resident had several teeth missing in the upper and lower gums and several teeth, broken with caries. Review of a Clinical Health Status assessment completed for R#90 on 4/26/16 revealed under the section, Oral/Respiratory, that the resident had broken, loose, or carious teeth. Review of the latest Clinical Health Status assessment last completed for the resident on 10/24/16 also revealed the resident was documented as having broken, loose, or carious teeth. Review of the most recent Quarterly Minimum Data Set (MDS) assessment completed for R#90 on 12/9/16 revealed in Section C - Cognitive Patterns - a Brief Interview for Mental Status (BIMS) score of 10 which indicates a moderate cognitive impairment. Further review of the last comprehensive assessment completed for R#90, the Annual MDS assessment with reference date of 5/3/16, revealed in Section L - Oral/Dental Status - the resident was documented as having no dental issues such as caries or broken teeth. Interview on 2/9/17 at 1:55 p.m. with the current MDS Coordinator revealed she was not employed at the facility when the last comprehensive MDS assessment was completed for R#90 and, therefore, could not explain why that assessment, completed by the previous MDS coordinator, documented that the resident had no dental issues while current observations indicate, and the comprehensive Clinical Health Status assessments documents the resident has broken and carious teeth.", "filedate": "2020-09-01"}
{"rowid": 26, "facility_name": "NORTH DECATUR HEALTH AND REHABILITATION CENTER", "facility_id": 115012, "address": "2787 NORTH DECATUR ROAD", "city": "DECATUR", "state": "GA", "zip": 30033, "inspection_date": "2017-02-09", "deficiency_tag": 280, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "OC5011", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to revise the comprehensive care plan to reflect the addition of [MEDICATION NAME] (an antipsychotic) to the medication regimen for one resident (R) (R#59) from a sample of 27 residents. Refer F329 Finding include: Review of the physician orders [REDACTED]. Review of section N of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed antipsychotic medications were documented as administered each day of the seven day look back period. Further review revealed the comprehensive care plan dated revised 12/1/16 indicated there was not a care plan developed to address the use of the antipsychotic medication. During an interview on 2/9/17 at 6:40 p.m., the MDS Coordinator confirmed the care plan was not revised to include [MEDICATION NAME] after the quarterly MDS was conducted in (MONTH) (YEAR).", "filedate": "2020-09-01"}
{"rowid": 27, "facility_name": "NORTH DECATUR HEALTH AND REHABILITATION CENTER", "facility_id": 115012, "address": "2787 NORTH DECATUR ROAD", "city": "DECATUR", "state": "GA", "zip": 30033, "inspection_date": "2017-02-09", "deficiency_tag": 282, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "OC5011", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of policy and procedures, the facility failed to routinely implement care plan interventions related to behavior monitoring for one resident (R) (R#90) being treated with an antipsychotic medication from a sample of 27 residents. Refer F329 Findings include: Review of records revealed R#90 was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. Physician orders [REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment for R#90 with reference date of 12/19/16 revealed in Section C - Cognitive Patterns - a Brief Interview for Mental Status (BIMS) score of 10 which indicates the resident has a moderate cognitive impairment. Section I - Active [DIAGNOSES REDACTED]. Review of the resident's Annual MDS assessment with a reference date of 5/3/16 revealed that [MEDICAL CONDITION] drug use and behavioral symptoms triggered on Section V - Care Area Assessment (CAA) Summary - and the decision was made to complete a plan of care for these areas. Review of the policy titled Behavior Management Guideline dated 11/1/16 revealed that each resident's drug regiment will be free from unnecessary drugs, defined as a drug when used without adequate monitoring. A care plan is developed for residents exhibiting negative behaviors or those on an antipsychotic medication, and a monitoring system is established for targeted behaviors and medication side effects and effectiveness. Review of the Plan of Care for R#90, last revised 10/28/16 revealed a focus area related to the potential for drug-related complications associated with the use of antianxiety and antipsychotic medications, physical and verbal altercations with roommates and staff, and refusal of medications. The goal was for staff to monitor for psychiatric drug complications through the next review date. Interventions included: monitoring and reporting side effects to the attending physician; monitoring and documenting target behaviors such as symptoms of agitation, cursing, hitting at staff; and reporting behavioral changes to the physician. Review of the Medication Administration Records (MARs) for (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR) revealed [MEDICATION NAME] 0.5 mg, [MEDICATION NAME] HCL 50 mg, [MEDICATION NAME] 20 mg, and [MEDICATION NAME] 0.5 mg were administered as ordered. Review of the records for R#90 revealed Behavior Monthly Flow Sheets on which staff were instructed to monitor and document the presence of behaviors such as agitation, [MEDICAL CONDITION], and uncooperativeness for the resident related to her use of anti-psychotic, antidepressant, and antianxiety medications. These monthly monitoring sheets were included in the resident's records for (MONTH) through November, (YEAR), and February, (YEAR). However, no behavior monitoring sheets were found for the months of December, (YEAR) and January, (YEAR). Interview conducted on 2/9/17 at 4:50 p.m. with Medical Records Staff AA revealed that the administrative staff pulls behavior monitoring sheets each month from the monitoring book kept on the medicine carts and delivers these to the medical records department for filing in residents' records. However, he was never given a sheet for R#90 for (MONTH) (YEAR) or (MONTH) (YEAR). To his knowledge, behavior monitoring flow sheets were not completed for R#90 for these two months. Interview on 2/9/17 at 5:00 p.m. with Licensed Practical Nurse (LPN) BB revealed that the nurses are not required to routinely chart side effects unless side effects are noted. However, they are required to complete the behavior monitoring sheets for all residents receiving antipsychotic medications on every shift. Observation done at the time of the interview revealed Behavior Log on the medicine cart which contained Behavior Monthly Flow Sheets for R#90 and other residents being monitored for behaviors for the month of February, (YEAR). Behavior monitoring sheets for no other months were available in this log.", "filedate": "2020-09-01"}
{"rowid": 28, "facility_name": "NORTH DECATUR HEALTH AND REHABILITATION CENTER", "facility_id": 115012, "address": "2787 NORTH DECATUR ROAD", "city": "DECATUR", "state": "GA", "zip": 30033, "inspection_date": "2017-02-09", "deficiency_tag": 329, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "OC5011", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to monitor two residents (R) for behaviors, that received antipsychotic medication (R#59 and R#90). The sample was 27 residents. Findings include: 1. Review of the physician orders [REDACTED]. Review of the Behavior Flow Sheet for (MONTH) (YEAR) revealed no evidence of behavior monitoring for hallucinations and wandering on the following dates and times: 2/3/17 on night shift 2/4/17 on night shift 2/5/17 on night shift 2/7/17 on night shift 2/8/17 on day, evening and night shift Further review of the medical record revealed no evidence of behavior monitoring for the months of October, November, and (MONTH) (YEAR) and (MONTH) (YEAR). An Interview on 2/9/17 at 7:55 p.m. with the Unit Coordinator DD confirmed there was no evidence of behavior monitoring for the dates noted in (MONTH) (YEAR). She further stated, in the past, the documentation of behaviors had been stored in a notebook, however, the notebook could not be located. 2. Review of the policy titled Behavior Management Guideline dated 11/1/16 revealed that each resident's drug regiment will be free from unnecessary drugs, defined as a drug when used without adequate monitoring. A care plan is developed for residents exhibiting negative behaviors or those on an antipsychotic medication, and a monitoring system is established for targeted behaviors and medication side effects and effectiveness. Review of records revealed Resident (R) #90 was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. Physician orders [REDACTED].; and an Abnormal Involuntary Movement Scale (AIMS) to be completed quarterly. Review of the most recent quarterly Minimum Data Set (MDS) assessment for R#90 with a reference date of 12/19/16 revealed in Section C - Cognitive Patterns - a Brief Interview for Mental Status (BIMS) score of 10 which indicates the resident has a moderate cognitive impairment. Section [NAME] - Behavior - of the same assessment documented the resident exhibited no evidence of [MEDICAL CONDITION], and no behaviors such as verbal/physical aggression nor rejection of care during the previous seven days. Section I - Active [DIAGNOSES REDACTED]. Review of the resident's Annual MDS assessment with a reference date of 5/3/16 revealed that [MEDICAL CONDITION] drug use and behavioral symptoms triggered on Section V - Care Area Assessment (CAA) Summary - and the decision was made to complete a plan of care for these areas. Review of the Plan-of-Care for R#90, last revised 10/28/16 revealed a focus area related to the potential for drug-related complications associated with the use of antianxiety and antipsychotic medications, physical and verbal altercations with roommates and staff, and refusal of medications. The goal was for staff to monitor for psychiatric drug complications through the next review date. Interventions included: monitoring and reporting side effects to the attending physician; monitoring and documenting target behaviors such as symptoms of agitation, cursing, hitting at staff; and reporting behavioral changes to the physician. Review of the Plan-of-Care for R#90, last revised 10/28/16 revealed a focus area related to behaviors such as yelling during care, shouting, and cursing. The accompanying goal was for the resident to calm down with staff interventions. Those interventions included: staff to attempt interventions before behaviors begin; give meds as ordered; and let attending physician know if behaviors interfere with daily life. Review of the Medication Administration Records (MARs) for (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR) revealed [MEDICATION NAME] 0.5 mg, [MEDICATION NAME] HCL 50 mg, [MEDICATION NAME] 20 mg, and [MEDICATION NAME] 0.5 mg were administered as ordered. Review of nurses' progress notes and medication administration notes completed for R#90 from 2/1/16 through 2/7/17 revealed no documentation of adverse effects related to anti-psychotic use. Review of the records for R#90 revealed a quarterly Abnormal Involuntary Movement Scale (AIMS) was last completed on 1/12/17 with no symptoms of Tardive Dyskinesia related to the use of an anti-psychotic medication noted. Review of the records for R#90 revealed Behavior Monthly Flow Sheets on which staff were instructed to monitor and document the presence of behaviors such as agitation, [MEDICAL CONDITION], and uncooperativeness for the resident related to her use of anti-psychotic, antidepressant, and antianxiety medications. These monthly monitoring sheets were included in the resident's records for (MONTH) through November, (YEAR), and February, (YEAR). However, no behavior monitoring sheets were found for the months of December, (YEAR) and January, (YEAR). Interview conducted on 2/9/17 at 4:50 p.m. with AA, the staff member responsible for medical records, revealed that the administrative staff pulls behavior monitoring sheets each month from the monitoring book kept on the medicine carts and delivers these to the medical records department for filing in residents' records. However, he was never given a sheet for R#90 for (MONTH) (YEAR) or (MONTH) (YEAR). To his knowledge, behavior monitoring flow sheets were not completed for R#90 for these two months. Interview on 2/9/17 at 5:00 p.m. with Licensed Practical Nurse (LPN) BB revealed that the nurses are not required to routinely chart side effects unless side effects are noted. However, they are required to complete the behavior monitoring sheets for all residents receiving antipsychotic medications on every shift. Observation done at the time of the interview revealed Behavior Log on the medicine cart which contained Behavior Monthly Flow Sheets for R#90 and other residents being monitored for behaviors for the month of February, (YEAR). Behavior monitoring sheets for no other months were available in this log.", "filedate": "2020-09-01"}
{"rowid": 29, "facility_name": "NORTH DECATUR HEALTH AND REHABILITATION CENTER", "facility_id": 115012, "address": "2787 NORTH DECATUR ROAD", "city": "DECATUR", "state": "GA", "zip": 30033, "inspection_date": "2017-02-09", "deficiency_tag": 514, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "OC5011", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and review of policy and procedure, the facility failed to maintain accurate clinical records for two residents (R), (R#77) related to [DIAGNOSES REDACTED].#59) related to inaccurate documentation of gastric tube feedings from a sample of 27 residents. Findings include: Review of facility policy titled Medication Review - Admission/ReAdmission revealed Medication review is intended to eliminate prescribing medication errors at care transitions by generating a complete and accurate list of resident medications. The second medication review will include review of admission orders [REDACTED]. 1. Review of the clinical record for R#77 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Continued review revealed R#77 was a male. Review of the hospital clinical record for R#77 revealed he had been admitted on [DATE] and discharged to the facility on [DATE] and had not had surgery during his hospital admission. Transfer orders from the hospital for R#77, dated 12/27/16, included an order for [REDACTED]. Facility admission orders [REDACTED]. Review of the December, (YEAR) and January, (YEAR) MAR for R#77 revealed [MEDICATION NAME] 250 mg had been initialed as administered at 9:00 a.m. on 12/28/16, 1/2/17, 1/3/17 and 1/4/17. Interview 2/9/17 at 11:45 a.m. with the Director of Nurses (DON) revealed the [DIAGNOSES REDACTED]. The DON acknowledged the order for [MEDICATION NAME] had been transcribed incorrectly and recorded as administered incorrectly. The DON revealed the process for avoiding transcription errors for newly admitted residents is to review the MAR/TAR and compare with the admission orders [REDACTED]. The DON revealed she had compared the admission and transfer orders with the MAR for R#77 but had not noticed there was only one space to sign out [MEDICATION NAME] 250 mg on the MAR and that the spaces for 12/29/16, 12/30/16, and 12/31/16 had been crossed out. The DON revealed she also had not noted the error in the [DIAGNOSES REDACTED]. Interview 2/9/17 at 3:30 p.m. with the Administrator revealed she had checked pharmacy records and [MEDICATION NAME] 250 mg had been delivered for R#77. She indicated after checking medication disposition records for the [MEDICATION NAME] for R#77 had not been destroyed or returned to the pharmacy. The Administrator revealed the nurse who transcribed the admission orders [REDACTED]. Review of pharmacy disposition records for the month of (MONTH) indicated there had been no [MEDICATION NAME] destroyed or returned to the pharmacy. Review of Pharmacy dispensing records indicated six [MEDICATION NAME] 250 mg tablets were delivered to the facility on [DATE] for R#77. 2. Review of the Physician orders [REDACTED]. every shift and to administer [MEDICATION NAME] per the [DEVICE] as ordered Review of the MAR revealed the following missing documentation for the administration of the water flushes: 10/16/16 at 6:00 a.m. 10/28 at 6:00 a.m. 11/11/16 at 12:00 a.m. and 6:00 p.m. 11/12/16 at 6:00 a.m. 11/15/16 at 12:00 p.m. and 6:00 p.m. 11/16/16 at 12:00 p.m. and 6:00p.m. 12/17/16 at 7:00 a.m. Review of the MAR revealed the following missing documentation for the checking GT placement: 10/16/16 10/31/16 11/16/16 11/25/16 1/17/17 2/5/17 at 7:00 a.m. Review of the MAR revealed the following missing documentation for [DEVICE] feedings: 11/2/16 at 1:00 a.m. and 5:00a.m. 11/3/16 at 9:00a.m. 11/11/16 at 5:00 p.m. and 9:00 p.m. 11/15/16 at 5:00 p.m. 11/16/16 at 1:00 a.m. 12/14/16 at 1:00 p.m. 12/16/16 at 1:00 p.m. 12/20/16 at 1:00 p.m. 12/24/16 at 5:00 p.m. 1/17/17 at 1:00 p.m. 2/2/17 at 1:00 p.m. During an interview on 2/9/17 at 6:15 p.m., the Director of Nursing (DON), confirmed there were holes and missing documentation on the MARs and she further stated her expectation is for the nurses to document when they give the medication and/or treatments.", "filedate": "2020-09-01"}
{"rowid": 30, "facility_name": "NORTH DECATUR HEALTH AND REHABILITATION CENTER", "facility_id": 115012, "address": "2787 NORTH DECATUR ROAD", "city": "DECATUR", "state": "GA", "zip": 30033, "inspection_date": "2018-12-06", "deficiency_tag": 584, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "46UW11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews, the facility failed to ensure that it was maintained in a safe, clean and comfortable home-like environment in nine resident rooms (rooms 3 B, 5 B, 11 B, 14 B, rooms 12, 20, 23, 30 and room [ROOM NUMBER]) on two of two halls. The facility census was 61. Findings include: Observation on 12/3/18 at 11:19 a.m., revealed in room [ROOM NUMBER] B, residents bedside tabletop fan, with dust build-up on the fan grill and blades. Observation on 12/3/18 at 11:48 a.m., revealed in room [ROOM NUMBER] B, scratched and peeling paint along the wall close to bathroom doorway. Observation on 12/3/18 at 2:47 p.m., revealed in room [ROOM NUMBER], electrical phone plate loosely hanging on wall, at the head of bed between bed A and bed B. Observation on 12/4/18 at 8:58 a.m., revealed in room [ROOM NUMBER], window curtain has circular stains in three different spots, approximately three by three inches. Window sill has dust build up with cob webs in low corner. Observation on 12/4/18 at 9:37 a.m., revealed in room [ROOM NUMBER] B, wall to the right of bed B, scuffed paint approximately four feet in length. Observation on 12/6/18 at 11:15 a.m., revealed in room [ROOM NUMBER] B, a large hole in the wall on the window side of the room, near the floor baseboard, window curtain noted with multiple brown stains, resembling liquid spill on curtain. Also, patch of peeling paint at head of bed B. Observation on 12/6/18 at 12:00 p.m., revealed in room [ROOM NUMBER], window curtain noted with multiple brown stains, resembling liquid spill on curtain. Observation on 12/6/18 at 2:31 p.m., revealed in room [ROOM NUMBER], window curtains with multiple red colored stains, appearing to be blood stains. Also, cob webs noted in left lower corner of window. Observation on 12/6/18 at 2:31 p.m., revealed in room [ROOM NUMBER], floor length window curtains stained with red and blue substance splattered on bottom of floor length curtains. Interview on 12/6/18 at 3:35 p.m., with Maintenance Supervisor, stated that he does routine room checks, checking side-rails, call lights, hot water temps and any other work orders that are submitted from the staff. He stated that he prioritizes the work orders based on need. He verified during walking rounds the concerns identified during the survey. He stated that he has a plan of painting the resident rooms when rooms become vacant, but will do before then, if the need is urgent. Interview on 12/6/18 at 3:44 p.m., with housekeeping aide, II, she stated that she works housekeeping on the weekends and her daily duties include sweeping, mopping, cleaning resident restroom, emptying trash, cleaning toilet and sink, restocking supplies in restroom, she dusts the rooms. She further stated that she dusts the residents personal belongings if they give her permission to dust. Interview on 12/6/18 at 3:52 p.m., with Housekeeping Supervisor, stated that the housekeeping staff go through a week of training with an experienced housekeeping staff on the floor. He further stated that they use the five & seven step cleaning process for training purposes. He stated that he does a Quality Control Inspection (QCI) of each deep clean room, which is done when the resident room becomes vacant. He verified during walking rounds the concerns identified during the survey. He further stated that he has tried washing the window curtains, but they get damaged during the wash cycle, so he will need to figure out how to clean the window curtains.", "filedate": "2020-09-01"}
{"rowid": 31, "facility_name": "NORTH DECATUR HEALTH AND REHABILITATION CENTER", "facility_id": 115012, "address": "2787 NORTH DECATUR ROAD", "city": "DECATUR", "state": "GA", "zip": 30033, "inspection_date": "2018-12-06", "deficiency_tag": 636, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "46UW11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review and policy titled Resident Assessment Instrument process, the facility failed to assess the resident (R) #24 on the Minimum Data Set (MDS) assessment for depression. Sample size was 37. Findings include; R#24 was admitted on [DATE]. [DIAGNOSES REDACTED]. During an unnecessary medication record review on 12/4/18 at 1:46 p.m. a review of R#24 medications include but not limited to [MEDICATION NAME] 10 mg 1 tab daily by mouth (po) for depression, [MEDICATION NAME] .5mg po for agitation at hour of sleep, (hs) and [MEDICATION NAME] 5mg daily for dementia. Further record review revealed Pharmacy Consultant reviewed R#24 record on 10/17/18 and made a recommendation to attempt a gradual dose reduction (GDR) for [MEDICATION NAME]. On 10/29/18 the Physician documented a GDR was contraindicated for this resident and declined the pharmaceutical recommendation. Continued review of R#24 record offers evidence resident was receiving psychiatric services and was last seen on 11/26/18. The review of records revealed a Nurse Practioner assessed resident on 11/12/18. The active problem list included a [DIAGNOSES REDACTED]. Review of several of R#24's most recent MDS did not assess the resident as having depression. MDS reviews included an annual dated 12/2/17 and quarterly's dated 2/7/18, 4/24/18, 7/10/18, and 9/19/18. Review of care plan revealed the resident is care planned for review of [MEDICAL CONDITION] medications. An interview with the Director of Nursing (DON) on 12/6/18 at 10:00 a.m. revealed the facility has been without a fulltime MDS Coordinator for more than 30 days. DON continued to state that corporate personnel and staff members from other facilities have been filling the positions. A telephone interview on 12/6/18 at 11:23 a.m. with, Regional Nurse Resident Assessment Consultant (RAC) revealed the MDS Coordinator is responsible for reviewing all MDS's in the facility. In clinical morning meetings what should take place is a review of orders to ensure there are corresponding [DIAGNOSES REDACTED]. There has been a lot of turnover. An interview with Corporate Area Resident Care Management Director (RCMD) on 12/6/18 at 12:00 p.m. stated she has been with the company since (MONTH) (YEAR). Stated she has identified care plan update issues. Her position is to come into the facility on and off to train the MDS Coordinator. The RCMDF Continued to state that now she comes to facility on a regular basis, especially since both staff members in MDS department resigned in (MONTH) and (MONTH) (YEAR). Continued interview indicated the process to ensuring the MDSs are accurate is to review the resident record, speak to staff and conduct resident interviews. Currently a new MDSs coordinator had been hired and is in orientation. An interview on 12/06/18 at 2:01 p.m. with Area RCMD confirmed R#24 had not been assessed for depression on the MDSs. Continued to state they just in put the [DIAGNOSES REDACTED]. Review of facility policy dated (MONTH) (YEAR) titled Resident Assessment Instrument (RAI) process states, on page 2 of 6, under procedure; the facility conducts a comprehensive assessment (MDS) to identify the resident's needs, strengths, goals, life history, and preferences within 14 days after admission (Initial admission assessment). This excludes readmissions where there is no significant change in the resident's physical or mental condition. The assessment must include at the following: j. Disease [DIAGNOSES REDACTED].", "filedate": "2020-09-01"}
{"rowid": 32, "facility_name": "NORTH DECATUR HEALTH AND REHABILITATION CENTER", "facility_id": 115012, "address": "2787 NORTH DECATUR ROAD", "city": "DECATUR", "state": "GA", "zip": 30033, "inspection_date": "2018-12-06", "deficiency_tag": 655, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "46UW11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review and policy title Baseline Care Plan, the facility failed to develop a baseline care plan for one resident (R) [NAME] Sample size was 37. Findings include; Resident A was admitted on [DATE]. [DIAGNOSES REDACTED]. Medications ordered included but not limited to; fleet oil enema (mineral oil),insert 133 milliliters (ml) rectally every 24 hours(hrs.) as needed(prn) for constipation may self-administer, senna tablet 8.6 milligrams (mg) (sennosides) give two tablets by mouth (po) at bedtime (hs) for laxatives, [MEDICATION NAME] powder (polyethylene [MEDICATION NAME] 3350) give 17 grams (gms) po at hs for constipation, [MEDICATION NAME] capsule 100 mg ([MEDICATION NAME] sodium) give one capsule po prn for constipation. An interview on 12/3/18 at 1:51 p.m. with R A stated hasn't had a BM in nine days. Continued to state has told the Certified Nursing Assistant (CNA) and the charge nurse. An interview with R A on 12/4/18 at 5:08 p.m. stated had bowel movement (BM) and is feeling much better. Stated they administered an enema and now is ready to go home. Record review on 12/5/18 on 8:19 a.m. evidenced a nurse's note dated 12/4/18 at 2:10 p.m. Medical Doctor (MD) at bedside this shift to assess and review medications; new orders to discontinue (d/c) [MEDICATION NAME], start [MEDICATION NAME] 50mg prn; Fleets Enema prn, and give senna and [MEDICATION NAME] every (q) hs; orders noted; Enema administered this shift with results; large loose stools noted. Resident states to writer, It's just what the doctor ordered. States, I feel much better. Further review of medical record on 12/5/18 at 9:32 a.m. revealed that two nursing skilled documentations dated 12/2/18 and 12/3/18 revealed the resident was assessed for being constipated. Review of resident record revealed there was no baseline care plan in place to address the resident's issue with constipation. An interview on 12/5/18 at 10:13 a.m. with Director of Nursing (DON) indicated the initial care plans should be under the tab in the electronic medical record (EMR), record which states baseline care plan. When DON attempted to retrieve R A's care plan, DON stated there was no care plan that had been initiated for this resident. The DON further stated that the person who regularly addresses and completes the MDS and care plans, is no longer with the facility. There have been staff members from other facilities coming in to assist with the MDS process, along with corporate personnel. A new person has filled the position on Monday 12/3/18 (day of survey entrance) and is being oriented to the facility and residents. An interview on 12/6/18 at 1:11 p.m. with Corporate Area Resident Care Management Director(RCMD) indicated the R A now had a baseline care plan which was developed 12/5/18, five days after admission. Per policy titled Baseline Care Plan dated (MONTH) (YEAR), on page two of four, states within 48 hours of admission to facility, the initial assessment information gathered will be used to initiate the baseline care plan (Electronic Health Record).", "filedate": "2020-09-01"}
{"rowid": 33, "facility_name": "NORTH DECATUR HEALTH AND REHABILITATION CENTER", "facility_id": 115012, "address": "2787 NORTH DECATUR ROAD", "city": "DECATUR", "state": "GA", "zip": 30033, "inspection_date": "2018-12-06", "deficiency_tag": 656, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "46UW11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews the facility failed to develop a plan of care to address activities of daily living (ADL's) for one resident (R#38), Oxygen usage for two resident (R#3, R#29) and failure to implement care plan intervention for one resident (R #55) related to Restorative Nursing for Range of Motion (ROM) and one resident (R #214) for ADL care. The sample size was forty residents. Findings include : Review of the clinical record for R#3 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She had no known drug allergies and elected full code status. Review of the physician's orders [REDACTED]. Review of the most recent Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 13, indicating she was cognitively intact; a Mood Total Severity Score of 0, indicating she was not depressed; and displayed no behaviors. Continued review of the same assessment documented R#3 as using oxygen while a resident. Review of the care plan, updated 11/28/18, did not include a care plan for oxygen to include goals and interventions. Observation and interview with R#3 on 12/03/18 at 12:25 p.m. revealed R#3 was wearing O2 via NC at 4.5 LPM. When asked if she knew what her O2 liter flow was supposed to be, she stated she believed her physician order [REDACTED]. She stated she was in no respiratory distress. Observation and interview with R#3 on 12/04/18 at 1:14 p.m., she was alert, oriented and pleasant sitting up in her wheelchair in her room. She was wearing O2 at 3 LPM via NC using a portable E-cylinder. She stated she was in no respiratory distress. Observation of R#3 on 12/04/18 at 4:49 p.m., noted she was asleep wearing O2 via NC at 3 LPM. She was in no apparent respiratory distress. Observation and interview of R#3 on 12/05/18 at 8:40 a.m., R#3 was seated upright in her bed wearing O2 via NC at 3 LPM. She stated she had just finished breakfast and was in no respiratory distress. Observation and interview with R#3 on 12/06/18 at 9:40 a.m., revealed she was wearing O2 via NC at 3 LPM. She stated she was in no apparent distress. Review of the vital signs for R#3 revealed an admission, 7/24/18 at 19:24 (7:24 p.m.), blood O2 saturation 99% on room air, which indicated her hemoglobin was adequately saturated with O2. Further review of O2 saturations for R#3 revealed an O2 saturation of 96% on 7/26/18 at 6:57 a.m. on O2 via NC. No O2 liter flow was documented. Continued review of O2 saturations for R#3 revealed an O2 saturation of 96% on O2 on 12/3/18 at 6:29 a.m.; 96% on O2 on 12/3/18 at 16:04 (4:04 p.m.); and 98% on O2 on 12/4/18 at 00:29 (12:29 a.m.). None of the O2 saturation readings reviewed indicated an O2 liter flow. In an interview with the Area Resident Care Manager (RCM) Director 12/6/18 at 11:34 a.m. regarding the contents of the care plan, she confirmed O2 was not included in the initial care plan or subsequent care plan updates. She identified facility issues such as the resignations of the MDS Director in (MONTH) (YEAR) and the MDS Coordinator in (MONTH) (YEAR) which delayed care plan and MDS updates and assessments. The Area RCM Director further explained the Sava (corporate) process for completion of the MDS assessment included reviewing the clinical record, speaking to the staff directly involved in resident care and resident interviews. 2. A review of the clinical record for R #38 revealed resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 10, which indicated mild cognitive impairment. Section G revealed that the resident was assessed for total dependence for dressing, toilet use and personal hygiene. Review of updated care plan for R#38, dated 8/1/18, did not have evidence that R#38 had a care plan problem to include assistance needed with Activities of Daily Living (ADL) care. Observation on 12/3/18 at 1:49 p.m., 12/4/18 at 3:05 p.m., and 12/5/18 at 9:06 a.m., revealed that fingernails on both hands have dark brown material underneath and are untrimmed. 3. A review of the clinical record for R #214 revealed resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #214 is a new admission and entry tracking Minimum Data Set ((MDS) dated [DATE] is only MDS available, therefore, no data available at this time. Review of care plan initiated 11/28/18 resident has activity of daily living self-care deficit related to left hip pain, difficulty walking and malaise. Interventions to care include encourage active participation in tasks, receives extensive to total care for baths, staff to do nail care, allow sufficient time to perform tasks and praise resident for all efforts at self-care. Observation on 12/3/18 at 12:48 p.m., 12/4/18 at 11:02 a.m., and 12/5/18 at 10:09 a.m., and 12/6/18 at 8:30 a.m. revealed that nails are untrimmed and dirty underneath on both hands. Resident stated he would like for them to be trimmed. 4. A review of the clinical record for R #29 revealed resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 13, which indicated no cognitive impairment. Section O revealed that the resident was assessed for Oxygen use while a resident. Interview on 12/6/18 at 1:11 p.m., with Registered Nurse (RN) CC stated that the Minimum Data Set (MDS) nurses do the initial care plan after the Admission Assessment is completed. She further stated that the interdisciplinary team (IDT) team can add to the care plan at any time and after the quarterly assessments are completed. During further interview, she verified that the facility has been without an MDS nurse for three weeks. She stated that she visits the facility daily and does MDS assessments when she visits. She further stated that other MDS nurses employed by corporate help out as well. Interview on 12/6/18 at 4:17 p.m., with RN BB stated that it is her expectation that the MDS nurses generate care plan for each area of concern that the resident will need to be addressed while a resident in the facility. Interview on 12/6/18 at 4:32 p.m., with RN BB verified that R#29 did not have a care plan to address his daily use of Oxygen therapy. 5. Review of resident (R#55's) medical record revealed the resident was admitted to the facility on (MONTH) 13, (YEAR) with [DIAGNOSES REDACTED]. Further review of R#55 medical record revealed his Minimum Data Set (MDS) quarterly assessment dated (MONTH) 3, (YEAR) indicated that R #55 has impairments to one side on the upper extremities and has impairments of both legs on the lower extremities. Additionally, according to resident Minimal Data Set he is receiving Restorative Services for 6 weeks with splinting devices. Review of R#55 care plans indicated that he was care plan for receiving Restorative Care for splint/brace assistance. The goal for R#55 was for him to achieve the highest level of optimal functioning with splinting over the next six weeks, the interventions included splinting to left elbow extremity with splint for first eight hours. Review of resident physician orders [REDACTED].#55 to have splinting brace on left elbow extremity and left resting hand splint with digit separator for first eight hours with skin checks. Program scheduled for six days a week for six weeks. Observation made on 12/04/18 at approximately 10:38 a.m revealed resident R#55 left hand contracted while in bed asleep without splinting device in place. At the time of the observation the splint was observed lying on his dresser beside him. Observation made on 12/05/18 at 1:34 p.m revealed resident R#55 in his bed asleep with the splinting device lying on top of the dresser beside him. Observation made on 12/05/18 at 2:44 p.m revealed resident R#55 in his bed awake with splinting device on his dresser. Review of resident restorative log for the month of (MONTH) (YEAR) through (MONTH) (YEAR) indicated there were no documented refusals of R#55 refusing to wear splinting devices. Additionally, there were no documented times to show when restorative aids place splinting devices on and off the R#55. On (MONTH) 5, (YEAR) at 02:15 p.m an interview was conducted with Certified Nursing Assistant (CNA) GG she stated that R#55 was supposed to have his splint brace on for eight hours a day and that she put his splint on earlier doing the shift but remove it after 2:30 p.m. She also stated that he cannot make his needs known and he rarely refuses care. On (MONTH) 5, (YEAR) at 3:30 p.m an interview was conducted with the Director of Clinical Services. She stated that R#55 should've had his splint on for the shift unless he refused care. She also stated that the Minimal Data Set Coordinator is responsible for making sure restorative is caring out their duties but at this time they currently do not have a MDS coordinator that oversees restorative nursing duties. Additionally, She did state that they are in the process of training an individual to take over for MDS at this time.", "filedate": "2020-09-01"}
{"rowid": 34, "facility_name": "NORTH DECATUR HEALTH AND REHABILITATION CENTER", "facility_id": 115012, "address": "2787 NORTH DECATUR ROAD", "city": "DECATUR", "state": "GA", "zip": 30033, "inspection_date": "2018-12-06", "deficiency_tag": 677, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "46UW11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews, the facility failed to ensure that activities of daily living (ADL) was provided for two dependent residents (R) R#38 and R#214 related to nail care. The sample size was 40. Findings include: 1. A review of the clinical record for R #38 revealed resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 10, which indicated mild cognitive impairment. Section G revealed that the resident was assessed for total dependence for dressing, toilet use and personal hygiene. Review of updated care plan for R #38, dated 8/1/18, did not have evidence that R #38 had a care plan problem to include assistance needed with Activities of Daily Living (ADL) care. Observation on 12/3/18 at 1:49 p.m., 12/4/18 at 3:05 p.m., and 12/5/18 at 9:06 a.m., revealed that fingernails on both hands have dark brown material underneath and are untrimmed. 2. A review of the clinical record for R #214 revealed resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #214 is a new admission and entry tracking Minimum Data Set ((MDS) dated [DATE] is only MDS available, therefore, no data available at this time. Observation on 12/3/18 at 12:48 p.m., 12/4/18 at 11:02 a.m., and 12/5/18 at 10:09 a.m., and 12/6/18 at 8:30 a.m. revealed that nails are untrimmed and dirty underneath on both hands. Resident stated he would like for them to be trimmed. Interview on 12/6/18 at 8:34 a.m. with Certified Nursing Assistant (CNA) AA stated she is assigned 1-12 residents each day. She provides daily care consisting of bathing, shaving, brushing teeth, assisting with eating (meal set-up) and dressing, and feeding if they need help. If the residents are bed bound, she stated that she turns them every two hours. When asked about providing nail care, she stated that she checks nails about every two weeks, and cleans them if they are dirty. She further stated that she trims nails once per month. During further interview, she stated that she had not noticed that R#38 or R#214 needed their nails cleaned or trimmed. Interview on 12/6/18 at 8:55 a.m., with Registered Nurse (RN) BB, stated that when she has extra CNA staff, she will assign the extra person to do nail care and shaving residents. She stated if there are no extra staff members available assigned to nail care, it is her expectation that the CNA assigned to the resident check their nails daily and clean and trim them if needed. During further interview, she stated that she has a extra CNA assigned to take care of nails today. Interview on 12/6/18 at 5:22 p.m., with RN BB, verified that R#38 and R#214 had dirty and untrimmed fingernails.", "filedate": "2020-09-01"}
{"rowid": 35, "facility_name": "NORTH DECATUR HEALTH AND REHABILITATION CENTER", "facility_id": 115012, "address": "2787 NORTH DECATUR ROAD", "city": "DECATUR", "state": "GA", "zip": 30033, "inspection_date": "2018-12-06", "deficiency_tag": 684, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "46UW11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, Interviews and record reviews, the facility failed to ensure quality care and services in accordance with professional standards for one resident (R#55) for the provision of Restorative Nursing for Range of Motion (ROM). The sample size was 40. The Findings: Review of resident (#55) medical record revealed the resident was admitted to the facility on (MONTH) 13, (YEAR) with [DIAGNOSES REDACTED]. Further review of resident (#55) medical record revealed his Minimum Data Set (MDS) quarterly assessment dated (MONTH) 3, (YEAR) indicated that resident (#55) has impairments to one side on the upper extremities and has impairments of both legs on the lower extremities. Additionally, according to resident MDS he is receiving Restorative Services for 6 weeks with splinting devices. Review of resident physician orders [REDACTED].#55) to have splinting brace on left elbow extremity and left resting hand splint with digit separator for first eight hours with skin checks. The program was scheduled for six days a week for six weeks. Observation made on 12/04/18 at approximately 10:38 a.m revealed resident R#55 left hand contracted while in bed asleep without splinting device in place. At the time of the observation the splint was observed lying on his dresser beside him. Observation made on 12/05/18 at approximately 01:34 p.m revealed resident R#55 in his bed asleep with the splinting device lying on top of the dresser beside him. Observation made on 12/05/18 at approximately 02:44 p.m revealed resident R#55) in his bed awake with splinting device on his dresser. Review of resident restorative log for the month of (MONTH) (YEAR) through (MONTH) (YEAR) indicated there were no documented refusals of resident (#55) refusing to wear splinting devices. Additionally, there were no documented times to show when restorative aids applied splinting devices on and off R(#55). On (MONTH) 5, (YEAR) at 02:15 PM an interview was conducted with Certified Nursing Assistant (CNA) GG she stated that R#55 was supposed to have his splint brace on for eight hours a day and that she put his splint on earlier doing the shift but remove it after 2:30 p.m. She also stated that he cannot make his needs known and he rarely refuses care. On (MONTH) 5, (YEAR) at 3:30 PM an interview was conducted with the Director of Clinical Services. She stated that R#55 should've had his splint on for the shift unless he refused care. She also stated that the Minimal Data Set Coordinator is responsible for making sure restorative is caring out their duties but at this time they currently do not have a MDS coordinator that", "filedate": "2020-09-01"}
{"rowid": 36, "facility_name": "NORTH DECATUR HEALTH AND REHABILITATION CENTER", "facility_id": 115012, "address": "2787 NORTH DECATUR ROAD", "city": "DECATUR", "state": "GA", "zip": 30033, "inspection_date": "2018-12-06", "deficiency_tag": 695, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "46UW11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to maintain resident [MEDICAL CONDITION], medication nebulizer and oxygen equipment in a sanitary manner for three of seven sampled residents, Resident (R)#29, R# 38 and R#3. Findings include: 3. The facility failed to maintain resident [MEDICAL CONDITION], medication nebulizer and oxygen equipment in a sanitary manner for three of seven sampled residents, Resident (R)#29, R# 38 and R#3. Findings include: 3. Review of the clinical record for R#3 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She had no known drug allergies and elected full code status. Review of the physician's orders [REDACTED]. 1. Oxygen (O2) at two liters per minute (LPM) via nasal cannula (NC). 2. Change O2 tubing every Tuesday and when visibly soiled. 3. Pulse oximetry every shift 4. Check and clean (O2) concentrator filter every month and as needed. Observation of the O2 concentrator for R#3 on 12/03/18 at 12:25 p.m. revealed the equipment in good working order but the washable dust filter was covered with a thick, pale gray layer of dust. Observation of the O2 concentrator for R#3 on 12/04/18 at 1:14 p.m., revealed the washable filter was covered with a thick, pale gray layer of dust. Observation of the O2 concentrator for R#3 on 12/04/18 at 4:49 p.m., revealed the washable filter was covered with a thick, pale gray layer of dust. Observation of the O2 concentrator for R#3 on 12/05/18 at 8:40 a.m., revealed the washable filter was clean. Review of the most recent Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 13, indicating she was cognitively intact; a Mood Total Severity Score of 0, indicating she was not depressed; and displayed no behaviors. Continued review of the same assessment documented R#3 as using oxygen while a resident. In an interview with R#3 on 12/5/18 at 8:40 a.m. regarding maintenance of the O2 concentrator, she stated she did not recall who or when the washable filter was cleaned. She was wearing O2 via NC at 3 LPM and neither displayed or expressed any signs/symptoms of respiratory distress. Review of facility policies related to O2 administration did not reveal any policy or procedure for cleaning O2 concentrator filters. DONE. 2. A review of the clinical record for R #38 revealed resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 10, which indicated mild cognitive impairment. Section G revealed that the resident was assessed for total dependence for dressing, toilet use and personal hygiene. Observation on 12/3/18 at 1:53 p.m. resident sitting in wheelchair in hallway outside his room. [MEDICAL CONDITION] speaking valve is dirty with brown debris on cap. There is not [MEDICAL CONDITION] around the tube and [MEDICAL CONDITION] are dirty with brown stained color. Observation on 12/4/18 at 7:54 a.m. resident in bed.[MEDICAL CONDITION] intact, but without a dressing [MEDICAL CONDITION] valve remains dirty. A review of the clinical record for R #29 revealed resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 13, which indicated no cognitive impairment. Section O revealed that the resident was assessed for Oxygen use while a resident. Observation on 12/3/18 at 10:14 a.m. Oxygen concentrator filter noted with thick layer of gray colored debris. Nebulizer mask un-bagged and undated, sitting on bedside nightstand. Observation on 12/4/18 at 8:25 a.m. Oxygen concentrator filter remains with thick layer of gray debris. Observation on 12/4/18 at 3:14 p.m. Oxygen concentrator filter remains dirty with thick layer of gray debris. Interview on 12/6/18 at 4:32 p.m. with Registered Nurse (RN) BB stated that the facility has an outside contract with Specialized Medical Services (SMS) that comes weekly to care for the residents [MEDICAL CONDITION]. She stated the nursing staff change the Oxygen tubing and nebulizer masks weekly. She further stated it is her expectation that the nurses change tubing weekly and clean the Oxygen filters weekly or as needed.", "filedate": "2020-09-01"}
{"rowid": 37, "facility_name": "NORTH DECATUR HEALTH AND REHABILITATION CENTER", "facility_id": 115012, "address": "2787 NORTH DECATUR ROAD", "city": "DECATUR", "state": "GA", "zip": 30033, "inspection_date": "2018-12-06", "deficiency_tag": 757, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "46UW11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review and staff interview, the facility failed to ensure that one residents drug regimen was free from unnecessary medication with duplicated drug therapy for one resident (R) #17. The sample size was 40. Findings include: Review of facility policy titled Physician order [REDACTED]. Procedure receiving a written or faxed order number two: The licensed nurse receiving the order verifies the order to ensure it is complete and that it includes resident name, room/bed, date of order, time of order, Physician signature and date, Physician name, Medication name, accurate dosage, accurate frequency, duration of order, if applicable, accurate route if applicable and medical indication for medication or reason for use. Observation of medication administration on 12/4/18 at 8:25 a.m. with Licensed Practical Nurse (LPN) EE revealed she administered multiple medications to R#17. The following observations were made: Calcium + vitamin D3 (a medication given as a supplement) 600/400 milligram (mg) tablet one time a day, Duloxetine (a medication used to treat depression) 60 mg capsule one time a day, [MEDICATION NAME] (a medication used to treat [MEDICAL CONDITION]) 300 mg capsule one time a day, [MEDICATION NAME] (a medication used to treat hypertension) 25 mg two times a day (bid), [MEDICATION NAME] (a medication used to treat fluid retention) 20 mg two times a day (bid), [MEDICATION NAME] (a medication used to treat acid reflux) 20 mg two times a day (bid) and [MEDICATION NAME] (a medication used to treat pain) 10 mg three times a day (TID), Aspirin (a medication used as a blood thinner) 81 mg one time a day, Senna (a medication used as stool softener) 8.6 mg two tablets one time a day, Isorbide (a medication used to treat hypertension) 30 mg one time a day and Polyethylene [MEDICATION NAME] (a medication used to treat constipation) 17 grams (gm) one time a day. During reconciliation with review of R#17 printed physician orders [REDACTED]. medication order was for [MEDICATION NAME] 20 mg two times a day (bid), administration times at 6:00 a.m. and 4:00 p.m. and [MEDICATION NAME] 20 mg three times a day (TID), with administration times at 9:00 a.m., 1:00 p.m. and 9:00 p.m. Interview on 12/4/18 at 10:36 a.m. with Registered Nurse (RN) BB stated the night shift nurses are responsible for verifying Physician order [REDACTED]. During further interview, she stated that she checks every MAR indicated [REDACTED]. Interview on 12/4/18 at 12:10 p.m. with RN BB stated she contacted R#17 Physician regarding clarification of the two duplicate medications and clarification orders were obtained from physician to discontinue one each of the duplicated orders.", "filedate": "2020-09-01"}
{"rowid": 38, "facility_name": "NORTH DECATUR HEALTH AND REHABILITATION CENTER", "facility_id": 115012, "address": "2787 NORTH DECATUR ROAD", "city": "DECATUR", "state": "GA", "zip": 30033, "inspection_date": "2018-12-06", "deficiency_tag": 759, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "46UW11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview and policy review, the facility failed to ensure it was free of a medication error rate greater than five percent by not ensuring medications were given as ordered by physician for two residents (R) R#17 and R#54. A total of 29 medication opportunities were observed, and there were four errors for two of three residents (R) R#17 and R#54, by one of two nurses observed during medication pass, for a medication error rate of 13.79%. The census was 61 and the sample size was 40. Findings include: Review of the facility policy titled Medication Administration revised (MONTH) 2008 revealed under procedure number: 2: Verify the medication label against the medication sheet for accuracy of drug frequency, duration, strength and route. Section C: Report any discrepancies to the pharmacy. Do not administer the mediation until the discrepancy is resolved. Observation of medication administration on 12/4/18 at 8:04 a.m. on side one, cart one, with Licensed Practical Nurse (LPN) EE revealed she administered multiple medications to R#54. The following observations were made: [MEDICATION NAME] (a medication used to hypertension) 25 milligram (mg) tablet, [MEDICATION NAME] (a medication used to treat acid reflux) 150 mg tablet, [MEDICATION NAME] (a medication used to treat depression) 10 mg tablet, [MEDICATION NAME] (a medication used to treat hypertension) 5 mg tablet, Calcium + vitamin D3 (a medication given as a supplement) 600/400 mg tablet and vitamin D3 (a medication given as a supplement) 1000 units, two tablets. After all of the R #54's 9:00 a.m. medications had been prepared, LPN EE counted the number of medications to be given, and verified during interview that what she prepared was all of the medications R#54 received for that time of day. During reconciliation with review of R#54 printed physician orders for the month of (MONTH) (YEAR) revealed the following orders: [MEDICATION NAME] 25 mg two times a day; vitamin D tablet 2000 unit, give two tablets one time a day; [MEDICATION NAME] 150 mg two times a day; [MEDICATION NAME] 5 mg two times a day; [MEDICATION NAME] 10 mg one time a day; Calcium-D 600/400 mg-unit one time a day. Licensed Practical Nurse (LPN) EE failed to administer R#54 the correct dosage of vitamin D3 per physician orders of 2,000 units, two tablets a day. Observation of medication administration on 12/4/18 at 8:25 a.m. on side one, cart one, with Licensed Practical Nurse (LPN) EE revealed she administered multiple medications to R#17. The following observations were made: Calcium + vitamin D3 (a medication given as a supplement) 600/400 milligram (mg) tablet one time a day, Duloxetine (a medication used to treat depression) 60 mg capsule one time a day, [MEDICATION NAME] (a medication used to treat [MEDICAL CONDITION]) 300 mg capsule one time a day, [MEDICATION NAME] (a medication used to treat hypertension) 25 mg two times a day, [MEDICATION NAME] (a medication used to treat fluid retention) 20 mg two times a day, [MEDICATION NAME] (a medication used to treat acid reflux) 20 mg two times a day and [MEDICATION NAME] (a medication used to treat pain) 10 mg three times a day, Aspirin (a medication used as a blood thinner) 81 mg one time a day, Senna (a medication used as stool softener) 8.6 mg two tablets one time a day, Isorbide (a medication used to treat hypertension) 30 mg one time a day and Polyethylene [MEDICATION NAME] (a medication used to treat constipation) 17 grams (gm) one time a day. During reconciliation with review of R#17 printed physician orders for the month of (MONTH) (YEAR) revealed the following orders: Duplicated orders for [MEDICATION NAME] 10 mg three times a day, with scheduled administration times at 6:00 a.m, 2:00 p.m. and 10:00 p.m. and the duplicated order of [MEDICATION NAME] 10 mg three times a day, with administration times at 9:00 a.m., 1:00 p.m. and 9:00 p.m. The second duplicated medication order for [MEDICATION NAME] 20 mg two times a day, administration times at 6:00 a.m. and 4:00 p.m. and [MEDICATION NAME] 20 mg three times a day, with administration times at 9:00 a.m, 1:00 p.m. and 9:00 p.m. Interview on 12/4/18 at 10:36 a.m. with Registered Nurse (RN) BB, stated that night shift staff are responsible for verifying physician orders against Medication Administration Records (MAR). She stated that she checks every one of the MAR's herself for accuracy. She verified the orders fort R#17 for [MEDICATION NAME] 10 milligrams (mg) three times a day (TID) and [MEDICATION NAME] 10 mg TID and [MEDICATION NAME] 20 mg TID and [MEDICATION NAME] 20 mg two times a day (bid), to be duplicated orders. Interview on 12/4/18 at 10:50 a.m. with Licensed Practical Nurse (LPN) EE, who read the physician orders for R#54 Vitamin D3 to read 2000 units, give two tabs every morning. She immediately stated to the surveyor I only gave two tablets this morning. She asked surveyor if she could go give the additional two tablets? Interview on 12/4/18 at 12:10 p.m. with RN BB, stated that she had contacted R#17 Physician regarding clarification of two duplicated medications and clarification orders were obtained from physician to discontinue one of each of the duplicated orders.", "filedate": "2020-09-01"}
{"rowid": 39, "facility_name": "NORTH DECATUR HEALTH AND REHABILITATION CENTER", "facility_id": 115012, "address": "2787 NORTH DECATUR ROAD", "city": "DECATUR", "state": "GA", "zip": 30033, "inspection_date": "2018-12-06", "deficiency_tag": 761, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "46UW11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and policy review, the facility failed to ensure that all drugs and biological's were discarded prior to expiration date. The facility census was 61. Findings include: Review of the facility policy titled Medication Storage in the facility dated ,[DATE], revealed the policy as medications and biological's are stored safely, securely and properly, following manufacturer's recommendations or those of the supplier. Procedure letter H revealed outdated, contaminated or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal. Observation on [DATE] at 2:53 p.m. of medication storage room/Central Supply room, with Administrator and Clinical Director of Health Services, revealed medications neatly arranged on multiple shelves. Observation of random bottles of medication revealed a 16 ounce bottle of Mineral Oil with expiration date of ,[DATE] and a 16 ounce bottle of [MEDICATION NAME] Cough syrup with expiration date of ,[DATE]. Interview on [DATE] at 2:53 p.m. with Administrator, stated that Central Supply Clerk is responsible for keeping the medications stocked and checked for expiration dates. She was not sure of how often she checks the medications/supplies. Interview on [DATE] at 9:10 a.m. with Central Supply Clerk, stated that she checks the medications in the supply room for expiration dates once per month. She stated that when she finds medications that are expired, she gives them to the Director of Nursing (DON). She stated she was not aware of the two bottles of expired liquids in the supply room.", "filedate": "2020-09-01"}
{"rowid": 40, "facility_name": "NORTH DECATUR HEALTH AND REHABILITATION CENTER", "facility_id": 115012, "address": "2787 NORTH DECATUR ROAD", "city": "DECATUR", "state": "GA", "zip": 30033, "inspection_date": "2018-12-06", "deficiency_tag": 880, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "46UW11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interviews, the facility failed to maintain an effective infection control program related to labeling and storage of personal care equipment; also failed to utilize proper technique while providing [MEDICAL CONDITION] care for one resident (R) R#38. The facility census was 61 residents. Findings include: Observation on 12/3/18 at 11:16 a.m. revealed in room [ROOM NUMBER] B, un-bagged and unlabeled urinal on the floor behind the toilet and an unlabeled bar of soap on the sink ledge, in a bathroom shared by two male residents. Observation on 12/3/18 at 11:20 a.m. revealed in room [ROOM NUMBER] B, four unlabeled and unbagged bath basins, in a bathroom shared by two female residents. Observation on 12/3/18 at 11:27 a.m. revealed in room [ROOM NUMBER] A, un-bagged and unlabeled nebulizer mask sitting on bedside nightstand. Observation on 12/3/18 at 11:34 a.m. revealed in room [ROOM NUMBER] B, bar of hand soap sitting on sink ledge in bathroom shared by two male residents. Also, un-bagged nebulizer mask sitting on bedside nightstand. Observation on 12/3/18 at 11:46 a.m. revealed in room [ROOM NUMBER] B, labeled but un-bagged urinal in bathroom. Enteral feeding bottle hanging from pole at bedside to bed B, dated 12/1/18. No resident currently residing in bed B. Observation on 12/6/18 at 9:01 a.m. [MEDICAL CONDITION] care performed by Licensed Practical Nurse (LPN) EE for Resident (R) #38. Nurse EE gathered supplies and entered R #38 room. She washed her hands and donned clean gloves. Nurse EE removed soiled [MEDICAL CONDITION] dressing from stoma site. Moderate amount of brown drainage noted on dressing. No odor detected. Nurse removed gloves and applied clean gloves. She did not wash her hands or use hand sanitizer. She [MEDICAL CONDITION] kit and cleanse around [MEDICAL CONDITION] with normal saline. She placed drain sponge on residents chest and resident had a coughing spell and drain sponge was propelled off chest onto pillow on bed. Nurse picked the drain sponge from the pillow and placed it around [MEDICAL CONDITION]. She removed her gloves and put on clean gloves to [MEDICAL CONDITION]. She did not wash her hands or use any hand sanitizer. She removed gloves and applied clean gloves and then applied the [MEDICAL CONDITION]. Nurse cleaned up after procedure and discarded trash in soiled utility room. Nurse did not wash her hand or use hand sanitizer at any point during the procedure, or after it was completed. Interview on 12/6/18 at 9:30 a.m. with LPN EE, stated that she was nervous during the procedure and she forgot to wash her hands after changing gloves. She further stated that she normally washes her hands during the [MEDICAL CONDITION] care. Interview on 12/6/18 at 4:17 p.m. with Registered Nurse BB, verified on walking rounds the infection control concerns identified during the survey. She stated that it is her expectation that residents personal care equipment be labeled with their name and be stored in a clear bag. She further stated that there was not a policy on labeling and storing of resident personal care equipment.", "filedate": "2020-09-01"}
{"rowid": 41, "facility_name": "NORTH DECATUR HEALTH AND REHABILITATION CENTER", "facility_id": 115012, "address": "2787 NORTH DECATUR ROAD", "city": "DECATUR", "state": "GA", "zip": 30033, "inspection_date": "2018-12-06", "deficiency_tag": 883, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "46UW11", "inspection_text": "Based on resident interviews, staff interviews record review and policies titled Immunizations: Influenza (Flu) Vaccination of Residents and Staff and Standing Orders for Administering Pneumococcal Vaccines to Adults; the facility failed to document rationale of resident (R)#24 refusal of Flu and provide vaccine information statement (VIS) and offering of Pneumococcal vaccine and VIS to R# B. Sample was 2 of 5. Findings include; During review of facility's infection control processes on 12/6/18 at 11:41 a.m. unable to locate documentation for R#24 regarding refusal of flu vaccine. Also, unable to locate documentation that education via the VIS as recommended by the Center for Disease Control (CDC) was provided to resident and /or family member. Further review of R#24's minimum data set (MDS) which a is part of the United States federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes; assessed R#24 with a Brief Interview for Mental Status (BIMS) of two. BIMS is a test given by medical professionals that helps determine a patient's cognitive understanding. A score of 00-07 indicates severe cognitive impairment. R#24 has family member who is the responsible party (RP). An interview with Director of Nursing (DON), with Corporate representative present, Director of Clinical Services, on 12/6/18 at 12:00 p.m. revealed that the electronic medical record (EMR) should show that the resident and /or RP was provided the VIS education. DON attempted to evidence the education had been given. Upon continued review of the R#24's record DON was unable to confirm the VIS education was provided; Nor was there evidence of a nurse's note indicating VIS education had been provided or discussed. On 12/6/18 at 12:55 p.m. Corporate representative, Director of Clinical Services provided a document dated 12/6/18 indicating the resident's RP had been contacted to discuss administration of the flu vaccine. The RP refused however; the reason for refusal not documented nor was it clear that the VIS was used to discuss the risks and benefits of the vaccine. An interview on 12/6/18 at 1:20 p.m. with DON and Director of Clinical Services present, revealed resident was offered the Pneumonia vaccine upon his admission in on 6/4/18. Four days after his admission. DON further stated no conversation about pneumonia took place this current flu season. An interview on 12/6/18 at 1:30 p.m. RB revealed does not remember when last received the pneumonia vaccine. Further stated that no one discussed administration on the pneumonia vaccine either upon his admission in (MONTH) (YEAR) or during this current flu season. R B has a BIMS of 10. A score of 08-12 indicates moderate cognitive impairment. RA was able to answer screening questions without difficulty; cohesively and coherently. Review of facility's policy titled Immunizations: Influenza Vaccination of Residents and Staff revised 2/2018 states on page 29 under Administration procedure bullet point B states; the VIS will be used to discuss the risks and benefits of the vaccine. In the case of residents this may be with their authorized representative when appropriate. Bullet point C states; Resident may refuse vaccination. Vaccination refusal and reason why should be documented. Review of facility's policy titled Standing Orders for Administering Pneumococcal Vaccines to Adults, no date, states on page two of four, bullet #3; provide all patients with a copy of the most current federal VIS.", "filedate": "2020-09-01"}
{"rowid": 42, "facility_name": "BELL MINOR HOME, THE", "facility_id": 115020, "address": "2200 OLD HAMILTON PLACE NE", "city": "GAINESVILLE", "state": "GA", "zip": 30507, "inspection_date": "2016-11-10", "deficiency_tag": 278, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "M6O611", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews, the facility failed to accurately assess the dental status for one (1) resident (R #30) who had missing and broken teeth and failed to accurately assess the swallowing/nutritional status for one (1) resident (R) (R #72) that exhibited signs and symptoms of possible swallowing disorder by coughing during meals. The sample was thirty six (36) residents. Findings include: 1. Record review for R#30 revealed a Nursing Admission Evaluation and Initial Plan of Care dated 9-8-14 and 10/03/2016, in the oral status section questions #79 and #81 was not checked to indicate the resident had missing and broken teeth. Review of the Minimum Data Set (MDS) assessment for R#30 dated 10/10/2016 did not indicate in Section L- Dental Status that the resident had missing and broken natural teeth. Observation conducted on 11/9/2016 at 12:23 p.m., revealed the R#30 sitting in the dining hall waiting for lunch. Missing and broken broken teeth noted during this observation. During an interview with the R#30 on 11/10/2016 at 9:29 a.m., it was observed that he was missing several teeth on the top and bottom of his gums. There were a few teeth on the left bottom gum that was visible when the resident opened his mouth. R#30 revealed he does not have any trouble eating and that he had not talked with anyone about receiving dental services. R#30 further stated that he had gingivitis in the past that resulted in some of his teeth coming out. Interview on 1/10/2016 at 11:54 a.m. with the MDS Coordinator DD confirmed that the MDS assessment for R#30 dated 10/10/2016 did not indicate the resident had broken or missing natural teeth. DD said R#30 would be re-assessed to verify if there are any missing or broken teeth. Subsequent interview with the MDS Coordinator DD conducted on 11/10/16 at 12:15 p.m. confirmed that after re-assessment, R#30 did have missing and broken teeth. DD further confirmed the dental status for R#30 was not properly coded in the MDS assessment. 2. R#72 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment for R#72 dated 8/8/16 documented in Section K- Swallowing/Nutritional Status that the resident did not exhibit any signs and symptoms of possible swallowing disorder. Record review for R#72 revealed a Diet of NCS/NAS (No Concentrated Sweets/No Added Salt), regular texture, nectar thick liquids consistency. Dietary Supplement: Magic cup two times a day with lunch and supper. Review of admission orders [REDACTED]. Review of speech therapy notes dated 8/3/16, 8/4/16, 8/5/16 and 8/8/16 revealed R#72 had swallowing difficulties and was unable to tolerate regular foods well and exhibited coughing while drinking liquids. Interview on 11/10/2016 at 12:56 p.m. with the Dietary Supervisor (DS) revealed that she is responsible for the nutritional status of the MDS assessments. The DS stated she usually gets her information from the nursing assessment, nutritional assessments, [DIAGNOSES REDACTED]. The DS confirmed that she inaccurately assesses R#72's swallowing status as having no concerns and that she must have missed it.", "filedate": "2020-09-01"}
{"rowid": 43, "facility_name": "BELL MINOR HOME, THE", "facility_id": 115020, "address": "2200 OLD HAMILTON PLACE NE", "city": "GAINESVILLE", "state": "GA", "zip": 30507, "inspection_date": "2016-11-10", "deficiency_tag": 279, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "M6O611", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to develop a care plan for one (1) resident (R) (#86) related to missing/broken teeth. The sample was thirty-six (36) residents. Findings included: On 11/07/2016 at 2:32 p.m., R#86 was observed to have missing, broken, and discolored teeth. A review of the Admission Minimum Data Set (MDS) assessment dated [DATE] documented in Section L- Dental Status that the resident had obvious or likely cavity or broken natural teeth. Section V- Care Area Assessment (CAA) triggered Dental Status with the decision to be care planned. A review of the medical record for R#86 revealed no evidence of a care plan related to the resident's dental status. During an interview with MDS Coordinator DD on 11/9/2016 at 3:53 p.m. she stated that she has been working at the facility since (MONTH) 2013. She confirmed that when a resident is assessed to have likely cavity or broken natural teeth, the MDS staff will create a care plan related to dental. She confirmed that there was no dental plan of care in place for R#86. DD stated that the reason the care plan was not created was pure human error'. She had addressed the impairments in the CAA and stated, At this point, it is just human error.", "filedate": "2020-09-01"}
{"rowid": 44, "facility_name": "BELL MINOR HOME, THE", "facility_id": 115020, "address": "2200 OLD HAMILTON PLACE NE", "city": "GAINESVILLE", "state": "GA", "zip": 30507, "inspection_date": "2016-11-10", "deficiency_tag": 323, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "M6O611", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of policy and procedure, the facility failed to conduct neurological assessments (Neuro Checks) for one (1) resident (R) (R#134) after an unwitnessed fall. The sample was thirty six (36) residents. Findings Include: Review of the facility's Fall Prevention Protocol documented: Action (Step 4) After an incident of a fall, complete the Post Fall Risk Assessment, notify MD and Responsible Party, start Neuro check if there is a suspected head injury or for an unwitnessed fall as per facility Protocol: Record review for R#134 revealed admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) summary score of 6, indicating severe cognitive impairment. R#134 was assessed for wandering 1 out of 3 days to a potentially dangerous place. Section G: Functional Status: Activities of Daily Living (ADL) resident requires supervised oversight encouragement or cueing with one person physical assist with bed mobility and transfer. Resident requires limited assistance with one person assist with walk-in room, walk-in corridor, locomotion on unit and locomotion off unit. A Nurse's progress note of 6/24/16 at 11:18 p.m., documented that the resident had a fall in her room resulting with injuries to include a skin tear to her right elbow, and a laceration to her right cheek,secondary to the resident attempting to turn off her light in her bedroom. R#134 confirmed to the staff she fell beside her bed while trying to turn off a light. Staff encouraged the resident to use her call light button when she needed something, staff placed non-skid socks on resident for added safety. Review of the Fall Assessment Note dated 6/25/16 at 02:55 revealed (unwitnessed fall) R#134 had intermittent confusion 1-2 falls in the last 3 months Ambulatory/Continent Adequate (with or without glasses). No noted drop between lying and standing. The care plan has been reviewed and updated per completion of this assessment, family, resident, and MD aware. IDT team to continue review for effectiveness of plan. Reassess per policy. Further record review for R#134 revealed no evidence or documentation of neurological assessments (Neuro checks). During interview with the Director of Nursing (DON) and the Nursing home Administrator on 11/10/16 at 1:45 p.m., both acknowledged there was no documentation of a Neuro checks for R#134 after her fall on 6/24/16. The facility failed to follow it's own Fall Prevention Protocol regarding Neuro checks for R#134 after an unwitnessed fall.", "filedate": "2020-09-01"}
{"rowid": 45, "facility_name": "BELL MINOR HOME, THE", "facility_id": 115020, "address": "2200 OLD HAMILTON PLACE NE", "city": "GAINESVILLE", "state": "GA", "zip": 30507, "inspection_date": "2016-11-10", "deficiency_tag": 363, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "M6O611", "inspection_text": "Based on observation and staff interview the facility failed to follow recipes for the preparation of pureed stewed tomatoes and puree navy bean soup. This deficient practice had the potential to effect eleven (11) residents receiving pureed consistency from a total of ninety three (93) residents receiving an oral diet. Findings include: Review of the General Food Preparation and Handling policy revealed food items will be prepared to conserve maximum nutritive value, develop and enhance flavor and keep free of injurious organisms and substances. Review of the facilities menu for Wednesday, week five supper meal revealed puree diet was to receive pureed navy bean soup, stewed tomatoes with okra, cornbread, margarine, citrus gelatin, and milk. Observation on 11/09/16 at 1:40 p.m. of BB dietary aide preparing the food items for the puree supper meal. BB opened a one hundred two (102) ounce can of stewed tomatoes, placed contents inside a large blender bowl, added twelve (12) slices of white bread and turned blender machine on to pureed. Once the stewed tomatoes were pureed BB placed the contents in a stainless steel pan that was five (5) inches in length, 12 inches in width and six (6) inches in depth, covered with a lid then placed in refrigerator. Further observation revealed BB puree the navy bean soup for the supper meal. BB opened a 6 pound 6 ounce can of navy beans, placed the contents in the large blender bowl, turned blender machine on, stirred, and added water. Once the beans were pureed BB placed the contents in a stainless steel pan that was 5 inches in length, 12 inches in width, and 6 inches in depth. The dietary aid placed a lid on the top of the pan then placed in the refrigerator. Review of the recipe for Stewed [NAME]toes revealed the ingredients were to consist of chopped onions, melted margarine, crushed canned tomatoes, granulated sugar, and celery powder. The method for preparation 1) Saute onions in the margarine until golden brown. 2) Add remaining ingredients to onions. Mix well, bring to boil, simmer, covered ten (10) to twenty (20) minutes. 3) Portion with a four (4) ounce ladle. Continued review of the Stewed [NAME]to recipe revealed directions for diet preparations Puree: prepare as directed, Blenderize and strain. Review of the Bean Soup recipe revealed the ingredients included: dry beans, navy or northern, Boiling water, ham bones, chopped onions, diced carrots, and diced celery. The method of preparation 1) Wash beans thoroughly in cold water. 2) Cover beans with boiling water, cook two (2) minutes, turn off heat, let stand one hour or longer. 3) Simmer beans for one hour. 4) Add ham bones, onions, carrots, and celery to the water and beans. 5) Cook covered for one and one half hours or until beans are tender, mash beans. 6) Add water. 7) Remove ham bones. 8) Serve. Continued review of the Bean Soup recipe revealed directions for diet preparation: Puree, prepare as directed, Blenderize and strain. Interview on 11/09/16 at 1:40 p.m. with BB, dietary aide revealed she confirmed she did not follow the recipe for Stewed [NAME]toes. BB revealed there was no documentation indicating to add bread or how much bread to add when pureeing the Stewed [NAME]toes. BB revealed she had been told by the dietary Manager (DM) to add one slice of bread per serving for stewed tomatoes. Continued interview with BB revealed she did know there was a recipe for Bean soup. BB revealed the method she prepared the pureed navy bean soup is how she had been performing the task. BB revealed sometimes she would add pureed onion to the pureed beans. When asked if she tastes the pureed food items, B revealed no she does not taste. Interview on 11/09/16 at 1:42 p.m. with the DM revealed she confirmed BB, dietary aide, did not follow the recipes as printed in the recipe book for Stewed [NAME]toes or for Navy Bean soup. The DM revealed there is no documentation indicating how much bread for staff to add to some of the recipes. The DM revealed she did not realize there was even a recipe for the bean soup. The DM confirmed BB pureed navy bean straight from the can for the supper meal and did not add any of other ingredients listed on the recipe. When asked why the puree consistency diet was not prepared navy bean soup as the menu indicated, the DM could not explain. Continued interview with the DM revealed she sometimes will taste the pureed food items but not all the time. Interview on 11/09/16 at 1:44 p.m. with the Registered Dietitian (RD) revealed she expects the facility to follow the recipes as printed. Continued interview with the dietitian revealed she was not aware the facility was not following recipes.", "filedate": "2020-09-01"}
{"rowid": 46, "facility_name": "BELL MINOR HOME, THE", "facility_id": 115020, "address": "2200 OLD HAMILTON PLACE NE", "city": "GAINESVILLE", "state": "GA", "zip": 30507, "inspection_date": "2016-11-10", "deficiency_tag": 364, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "M6O611", "inspection_text": "Based on observation and staff interview the facility failed to prepare puree food in a manner to conserve nutrient value by prolonged re-heating. This deficient practice had the potential to effect eleven (11) residents receiving pureed consistency from a total of ninety three (93) residents receiving an oral diet. Findings include: Review of the General Food Preparation and Handling policy revealed food items will be prepared to conserve maximum nutritive value, develop and enhance flavor and keep free of injurious organisms and substances. Review of the Meat and Vegetable Preparation policy revealed vegetables: Avoid overcooking and long holding times. Observation on 11/09/16 at 12:30 p.m. of the steam table revealed the pureed mixed vegetable had a dark orange brown color and the puree scalloped potatoes and puree chicken were light brown in color. Interview on 11/09/16 at 12:30 p.m. with the Dietary Manager (DM) revealed she knew the pureed food items were being held for a long period of time. When asked why the pureed foods were being held for a long period time the DM revealed that the ovens under the stove top are not working properly and if was difficult to get food items re-heated at the proper temperature in a timely manner. The DM revealed she had dietary staff puree food items early and put in oven in order to get up to the proper temperatures. Interview on 11/09/16 at 1:30 p.m. with BB, dietary aide revealed they wanted to clarify the process of the pureed food items prepared for the lunch meal today. BB revealed she began re-heating the pureed food items in the oven at 9:30 a. m. The dietary aide revealed the oven had not been working properly for the past two (2) weeks and in order to get the puree food items re-heated to the proper temperature she had start the process early. Interview on 11/09/16 at 1:35 p. m. with the registered dietitian (RD) revealed she expects the facility to re-heat the pureed food items no earlier than 1 hour before the meal is to be served. The dietitian was not aware that BB, dietary aide, was re-heating the puree food items as early as 9:30 a.m. .", "filedate": "2020-09-01"}
{"rowid": 47, "facility_name": "BELL MINOR HOME, THE", "facility_id": 115020, "address": "2200 OLD HAMILTON PLACE NE", "city": "GAINESVILLE", "state": "GA", "zip": 30507, "inspection_date": "2016-11-10", "deficiency_tag": 371, "scope_severity": "F", "complaint": 0, "standard": 1, "eventid": "M6O611", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and documentation review the facility failed to follow manufactures recommendations for sanitizing dishware in the three (3) compartment sink to prevent foodborne illness; failed securely wrap opened food items in the dry storage area as well in one (1) of 3 refrigerators for two (2) of four (4) days of the survey; failed to prevent wet nesting of stainless steel food pans to prevent bacterial growth; failed to ensure the stand-up mixer was cleaned after usage to prevent contamination; failed to ensure the inside ice slide to the ice machine was clean and free from debris. This deficient practice had the potential to effect all ninety three (93) residents receiving an oral diet. Findings include: Observation on 11/07/16 at 11:30 a.m. of AA, dietary aide, wash several cooking utensils in the 3 compartment sink revealed AA took the cooking utensils from the rinse sink compartment, then swished them all in the sanitizing solution compartment for a couple of seconds then placed on a shelf area to dry. Further observation revealed a poster was hung on the wall above the 3 compartment sink which indicated to submerge items for one to two (1-2) minutes. Observation on 11/07/16 at 11:35 a.m. of the first reach-in refrigerator revealed a stainless steel pan, five (5) inches in length, twelve (12) inches in width, and six (6) inches in depth containing a block of sliced American cheese that was eight (8) inches in length and four (4) inches in width and depth opened and not securely wrapped, the top of the cheese was exposed to the air. Observation on 11/07/16 at 11:40 a.m. of the stand-up mixer revealed under the mixing arm was an off white substance that was splattered around in several different areas. Observation on 11/07/16 at 11:45 a.m. of an inverted stack of three stainless steel pans ten (10) inches in length, 12 inches in width and 6 inches in depth, located under the food preparation table near the oven revealed when the top 2 pans were lifted and removed water was found underneath. Observation on 11/07/16 at 11:50 a.m. of the dry storage area revealed a clear re-sealable plastic bag containing shredded coconut. Continued observation revealed the clear plastic bag was not sealed and the shredded coconut did not have a date opened. Observation on 11/07/16 at 12:05 p.m. of the ice machine revealed eight (8) brown spots in center of the stainless steel ice slide located inside the machine the size of a pencil eraser. Interview on 11/07/16 at 11:30 a. m. with AA, Dietary Aide revealed she confirmed she did not submerge the utensils for 1 minute in the sanitizing solution of the 3 compartment sink and confirmed she swished the items in the sanitizing solution for only a few seconds. AA revealed there was a dietary in-service completed recently on using the 3 compartment sink and she did attend. When asked if she recalled how long to submerge dishware in the sanitizing solution AA revealed ten (10) seconds. Interview on 11/07/16 at 12:10 p.m. with the Dietary Manager (DM) revealed she confirmed the facility uses EcoLab Quaternary sanitizing solution for the 3 compartment sink. The DM confirmed dietary staff were in-serviced recently regarding the 3 compartment and were education that items need to be submerged for 1 minute and expects dietary staff to follow the in-service education. Continued interview with the DM revealed they confirmed the opened block of sliced American cheese was not wrapped before placing in the stainless steel pan in the reach-in refrigerator. The DM expects staff to wrap food items before storing in the refrigerator. The DM confirmed the stainless steel pans stacked under the food preparation table were stored wet. The Dietary Manager revealed she expects dietary staff to stack pans after they are dry. The DM confirmed the shredded coconut in the dry storage area was in a re-sealable plastic bag that was not sealed and did not have a date. She expects staff to close the re-sealable plastic bags and place date on opened food items before storing in dry storage. Observation on 11/09/16 at 2:25 p.m. of the stand-up mixer revealed the off white substance remained under the mixing arm. Continued observation revealed when the off white substance was touched it flaked off with finger. Observation on 11/09/16 at 2:30 p.m. of the first reach-in refrigerator revealed the same stainless steel pan containing the block of sliced American cheese. The American cheese was in a re-sealable clear plastic bag however the plastic was not sealed and the cheese was exposed to the air. Observation on 11/09/16 at 2:35 p.m. of the ice machine in the kitchen revealed the 8 brown spots the size of a pencil eraser on the stainless steel ice slide located inside the ice machine. Continued observation revealed when the spots were touched with a paper towel they were removable. Interview on 11/09/16 at 2:35 p.m. with the Dietitian revealed she confirmed there was an off white substance under the mixing arm. Interview on 11/09/16 at 2:35 p.m. with the DM revealed she confirmed the off white substance under the mixing arm. The DM revealed dietary staff uses the stand-up mixer about once a week and staff has not used the mixer this week. The DM expects dietary staff to clean the stand-up mixer after usage. Continued interview with the DM revealed she confirmed the clear re-sealable plastic bag containing sliced American cheese was not closed. The DM revealed she spoke with dietary staff on Monday regarding sealing food items while be stored in the refrigerator. The DM expects dietary staff to securely wrap or seal opened food items in plastic bags while being stored in the refrigerator. Further interview with the DM revealed she confirmed the brown spots on the ice slide inside the ice machine and confirmed when the surveyor touched them with a paper towel the spots were removable. The DM revealed dietary staff are expected to wipe the ice slide inside the ice machine daily as part of regular routine cleaning. Review of the Cleaning Dishes - Manual Dishwashing policy revealed to place the dishes in the sanitizing sink. Allow to stand according to the manufacturer's guidelines for sanitizer. Review of the EcoLab Product Specification Document for Multi-Quat Sanitizer revealed immerse all utensils for at least 1 minute. Review of the Food Storage policy revealed plastic containers with tight fitting covers must be used for storing cereal, cereal products, flour, sugar, dried vegetable, and broken lots of bulk foods. All containers must be legible and accurately labeled and dated. Continued review of the policy revealed leftover food is stored in covered containers or wrapped carefully and securely, each items is clearly labeled and dated before being refrigerated. Further review of the policy revealed all foods should be covered, labeled and dated. Review of the cleaning sheet revealed mixers are to be cleaned after each use. The DM revealed despite the title of the cleaning sheet stating Sample, the dietary staff are to use and follow. Review of the Food Preparation and Handling policy revealed Equipment: all food service equipment should be cleaned, sanitized, dried, and reassembled after each use. Review of the in-services completed in the dietary department for the past 12 months revealed dietary staff were educated on 03/29/16 regarding Food Safety, people who are elderly are receiving [MEDICAL CONDITION], or have chronic illnesses are more susceptible to foodborne illness than health people. Dietary staff also completed an in-service on 10/25/16 regarding Sanitizing Dishware, 3 compartment sink. Sanitizer in 3 compartment sink be aware of procedures, submerge at least 1 minute.", "filedate": "2020-09-01"}
{"rowid": 48, "facility_name": "BELL MINOR HOME, THE", "facility_id": 115020, "address": "2200 OLD HAMILTON PLACE NE", "city": "GAINESVILLE", "state": "GA", "zip": 30507, "inspection_date": "2016-11-10", "deficiency_tag": 431, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "M6O611", "inspection_text": "Based on observation, record review and staff interviews, the facility failed to ensure that expired medications were disposed of properly in one (1) of two (2) medication storage rooms. (Unit A). Findings include: Review of the facility's policy titled Storage of Medications and Biologicals with revision date 10/20/2016 revealed on number five (5): The facility should ensure the Medications, Biologicals, Syringes and Needles are monitored for expiration dates, secured and stored appropriately. Observation on 11/09/2016 at 11:45 a.m. of the medication room on A hallway revealed one (1) bottle of ASA 325mg with expiration date 10/2016, one (1) bottle of Fiber Laxative with expiration date of 09/2016 and one (1) bottle of Zinc Sulfate with expiration date 09/2016. Interview on 11/09/2016 at 11:50 a.m. with the Licensed Practical Nurse (LPN)/Charge Nurse HH revealed the nurses check their medication carts daily and check the medications in the storage room especially when they have to get a medication from the storage room for the medication cart. LPN HH confirmed that the medications were expired. Interview on 11/09/2016 at 12:00 p.m. with the Director of Nursing (DON) confirmed that the medications: [REDACTED]. Stated the the medication rooms are checked every Sunday and the nurses check all of the medications daily and as needed. Stated her expectations are for there to be no expired medications on the medication carts or in the medication storage rooms.", "filedate": "2020-09-01"}
{"rowid": 49, "facility_name": "BELL MINOR HOME, THE", "facility_id": 115020, "address": "2200 OLD HAMILTON PLACE NE", "city": "GAINESVILLE", "state": "GA", "zip": 30507, "inspection_date": "2016-11-10", "deficiency_tag": 456, "scope_severity": "F", "complaint": 0, "standard": 1, "eventid": "M6O611", "inspection_text": "Based on observation and staff interviews, the facility failed to maintain two (2) of three (3) ovens in the kitchen in optimal working condition in order to prepare resident meals. This deficient practice had the potential to effect all ninety three (93) residents receiving an oral diet. Findings include: Observation and interview on 11/09/16 at 12:30 p.m. with the Dietary Manager (DM) revealed the 2 ovens under the stove top were not functional and had not be working correctly for the past four (4) months. The DM revealed that sometimes the oven works and sometimes it does not. When asked what it meant, work, the DM revealed sometimes the oven gets hot and sometimes it does not. Continued interview with the DM regarding the interview conducted on 11/07/16 at 12:15 p. m. when she told surveyor there was no kitchen equipment under repair or out of service, the DM revealed the convention was working probably but failed to report the 2 standard ovens did not work at times. Further interview with the DM revealed the free standing convention oven is working properly however there is not enough room to cook food items and re-heat the pureed foods. Interview on 11/09/16 at 1:30 p.m. with the facilities registered dietitian (RD) revealed she was not aware the standard ovens had not been functioning properly for the past 4 months. The RD revealed she visits the facility at least once a month and goes into the kitchen but was not aware of the malfunctioning ovens until today. Interview on 11/09/16 at 2:15 p.m. with CC, Maintenance Assistant revealed he was not aware the dietary department had problems with the ovens. He revealed 2 weeks ago the natural gas to the entire building was shut off to run a new gas line to the back-up generator and all kitchen equipment was turned off. CC revealed he was in the kitchen 2 weeks ago to re-light the pilot on the stove and ovens and the DM did not revealed any concerns with any kitchen equipment. Interview on 11/10/16 at 9:55 a.m. with CC, Maintenance Assistant revealed he expects the DM to submit a work order through the facilities computer system for any kitchen equipment issues. CC confirmed there was no work order submitted for the malfunctioning standard ovens and was only verbally told of the issue yesterday. Continued interview with CC revealed the DM was able to notify him verbally of kitchen equipment issues but expects the DM to follow up by submitting a work order. Interview on 11/10/16 at 10:15 a.m. with the DM revealed she verbally notified a maintenance worker 4 months ago that the ovens were not functioning properly. When which maintenance worker she spoke with the DM asked revealed they no longer are employed with the facility. The DM revealed she had never placed a work order in the computer to notify maintenance the issues with the oven. Interview on 11/10/16 at 11:00 a. m. with the Administrator revealed she was not aware of any issues with the ovens until it was brought to her attention yesterday. When asked if the DM revealed to her that the ovens had not been functioning correctly for the past 4 months, the Administrator was not aware. The Administrator revealed the DM can verbally notify maintenance of a kitchen issue but expects a work order to be completed as follow-up. Continued interview with the Administrator revealed the facility does not have a policy regarding completing work orders for equipment issues.", "filedate": "2020-09-01"}
{"rowid": 50, "facility_name": "BELL MINOR HOME, THE", "facility_id": 115020, "address": "2200 OLD HAMILTON PLACE NE", "city": "GAINESVILLE", "state": "GA", "zip": 30507, "inspection_date": "2016-11-10", "deficiency_tag": 514, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "M6O611", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to ensure documentation for the use of a splint or refusal to use a splint for one (1) resident (R) (R#65) with a left hand contracture and failed to consistently document the urinary output for one (1) resident (R#93) with a urinary catheter. The sample was thirty six (36) residents. Findings include: 1. Record review for resident #65 revealed an Annual Minimum Data Set (MDS) assessment dated [DATE] revealed the [DIAGNOSES REDACTED]. Review of the care plan for R#65 dated 8/8/2016 indicated a left hand contracture [MEDICAL CONDITION] secondary to history of [MEDICAL CONDITION]. The goal of the facility is to minimize decline in left hand contracture. An intervention included to place splint as tolerated and maintain contracture and treatment prn as ordered. Review of restorative nursing care weekly notes dated 8/25/16 documented: range of motion active, transfer, dressing or grooming fair. The resident making fair progress towards goals. Continue with restorative nursing program. Observations of R#65 revealed a left hand contracture with no splint device in place on 11/09/2016 at 9:56 a.m. and 11/9/2016 at 12:00 p.m. An interview with R#65 on 11/9/2016 at 9:56 a.m. revealed the left hand contracture was the result of a past stroke. R#65 further stated she is unable to use her left hand to assist with any daily activity. Review of restorative CNA progress notes section dated 8/25/16 documented: range of motion active, training skill/practice: transfer/dressing or grooming progress is fair towards goals. Further review of the clinical record for R#65 revealed no evidence of documentation when the splint was placed or if the splint was tolerated by the resident. Further Record Review revealed no evidence of documentation related to (r/t) splint and/or refusal of splint wearing. Review of care plan revealed left hand contracture with intervention to splint as tolerated-no issues Interview with Charge Nurse OO on 11/10/2016 at 11:33 a.m. revealed the R#65 is not on restorative care services at this time and is able to eat without assistance, R#65 does not need restorative care services. This is documented in the Electronic Medical Record (EMR) and there are not any recommendations for restorative care for the resident. Interview with Certified Nursing Assistants (CNAs) MM and NN on 11/10/2016 at 1:55 p.m., revealed R#65 was on restorative care services previously for splint use as tolerated. CNA MM stated that R#65 refused to wear the hand splint. When asked if this information was documented, CNA's MM and NN were unaware if refusal of splint treatment was documented in the EMR. Interview with the Administrator on 11/10/2016 at 3:21 p.m., that the hand splint treatments, and restorative care services for R#65 was not documented for either the use of or refusal of wearing the hand splint as tolerated per the care plan. 2. Review of the policy for recording input and outputs documented that the facility will ensure that fluid intakes and outputs are calculated and recorded every twenty four (24) hours. R#93 was admitted to the facility on [DATE] with a urinary catheter for [MEDICAL CONDITION] and acute kidney injury. R#93 was discharged on [DATE] and re-admitted on [DATE] with continued urinary catheter. Review of the Physician orders [REDACTED]. Review of Medication Administration Record [REDACTED]. Interview on 11/10/2016 at 9:10 a.m. with the Certified Nursing Assistant (CNA) GG revealed that urinary outputs are recorded on the vital signs sheet which is provided by the nurse at the start of the shift. Outputs are recorded twice per shift (at the beginning and at end of the shift) and the vital signs sheet is handed back to the nurse for input into the computer. Interview on 11/10/2016 at 9:23 a.m. with the Licensed Practical Nurse (LPN) FF revealed that urinary output is recorded by the CNA on the vital signs sheet which she gives the CNA at the start of the shift. The CNA returns the form to the nurse at the end of the shift and at that time the nurse records the total output on the computer system. Interview on 11/10/2016 at 10:35 a.m. with the Director of Nursing (DON) revealed that the CNAs are expected to record urinary output on vital signs sheet and then hand the sheet over to the nurse at some point in their shift to enter it on the computer. The DON stated she expects the urinary output to be entered in the computer on each shift.", "filedate": "2020-09-01"}
{"rowid": 51, "facility_name": "BELL MINOR HOME, THE", "facility_id": 115020, "address": "2200 OLD HAMILTON PLACE NE", "city": "GAINESVILLE", "state": "GA", "zip": 30507, "inspection_date": "2018-12-06", "deficiency_tag": 580, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "Q9R911", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to notify the physician of a change in condition for one sampled Resident (R) #72 out of a total of 34 residents. Findings include: Resident #72 was admitted to the facility on [DATE] and re-admitted on [DATE] with current [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] for R#72 revealed the resident's cognition was intact, with the Brief Interview for Mental Status (BIMS) score of 15/15. The care plan dated 10/22/18 revealed the problem statement, I have an actual impairment to skin integrity r/t (related to) fistula which created an abdominal abscess to my LLQ (left lower quadrant). I have an ostomy bag in place for drainage. Interventions included: Staff will follow facility protocols for treatment of [REDACTED]. Treatment nurse and WC (wound care) will observe on rounds/document location, size and treatment of [REDACTED]. to MD. During resident observation and interview on 12/3/18 at 2:38 p.m., R#72 stated that a few weeks ago, she had a [MEDICAL CONDITION] done. I had a bump on my belly (pointed to her lower left abdomen), and had nurses look at it, but they never did anything about it until it turned into a bump, and I complained of that knot there, and they looked at it, but just said it will go away, or that I need to get 'cleaned out' (have a bowel movement). Then it formed a head, and then they had the doctor look at it, and he said it was a cyst, and opened it. It went down about 1-1/2 inches into my colon. So, they did this [MEDICAL CONDITION] . Review of the Nurses' Notes revealed: 8/21/2018 18:58 Nurses Note: C/O (complained of) stomach hurting all day. Said it hurt more than usual. Will continue to monitor. (No follow up documentation was noted by nursing for this change of condition until 8/25/18) 8/25/2018 16:55 Nurses Note: C/O stomach hurting. Resident stated she felt something on her left side of her abdomen. I felt her stomach and noted slight swelling on the left side of her abdomen. Resident stated it was tender to the touch. Will continue to monitor. 8/31/2018 13:50 Nurses Note: C/o stomach pain more than usual. Resident says the severity of the pain has increased. Says pain medication only helps a little. Will continue to monitor. Seven attempts were made to contact the nurse who wrote the above notes, but she was unavailable for interview. 10/13/2018 11:54 Nurses Note: Resident has a large abscess to L (left) hip. Area is red and inflamed. Resident states that area was tender yesterday, but (sic) did not notice the nodule until today. Tx (treatment) nurse aware. Warm compresses applied to area. 10/13/2018 14:15 Nurses Note. BP (blood pressure) 10/65 (sic) Temp (temperature) 98.1 axillary, Pulse 66, RR (respiratory rate) 17. Resident c/o of tenderness on L hip abscess. 10/14/2018 10:46 Nurses Note: Stool and pus drainage from abscess on L hip. 2 Tylenol 500mg given with minimal relief. ABD (abdominal) pad applied. 10/16/2018 20:35 Skin/Wound Note Text: Resident seen by NP (Nurse Practitioner) for abscess to left hip. Resident had very dark brown and white puss with very foul smell noted draining out of abscess opening. Resident abscess was sharp debrided and flushes with NSS (normal saline solution). resident had dankins (sic) (Dakin's solution) soaked gauze packing applied to wound and covered with ABD pad. 10/17/2018 13:27 Nurses Note: Transport picked resident up @ 1325. Resident left facility via stretcher on route to ER (emergency room ) for CT (computed tomography) scan of abscess in left quadrant. On 12/05/18 at 3:39 p.m., in the 100 hall during an interview with Registered Nurse (RN) DD, nursing notes for R #72 were reviewed and RN DD was queried as to what does Will continue to monitor mean as it relates to the residents' complaints. RN DD stated if she saw the note, Will continue to monitor, she would follow up with it, whatever the problem was. RN DD stated, I don't use that wording, because it doesn't specify the nurse's action. It's vague. On 12/5/18 at 3:43 p.m., in the 200 hall, Licensed Practical Nurse (LPN) CC was queried as to what does Will continue to monitor mean as it relates to the residents' complaints. Licensed Practical Nurse (LPN) CC stated if she saw the note Will continue to monitor, she would wonder how often it should be monitored, hourly, weekly? LPN CC stated, It's very vague, probably I would call the doctor, or go to my charge nurse for clarity. On 12/6/18 at 10:28 a.m., in the 100 hall, RN BB was queried as to what does Will continue to monitor mean as it relates to the residents' complaints. RN BB stated, Will continue to monitor? If I saw that note, I would expect another entry and the follow up where the nurse reassessed and documented the follow up that the nurse did with a reassessment. Interview on 12/6/18 at 10:21 a.m., in the Interim Director of Nurse's (DON) office, the DON agreed the note written by the nurse dated 8/25/18 indicated a change of condition for R#72. Maybe a hernia, doctor certainly needs to be aware of it. LLQ pain I would be thinking bowel impaction, diverticulitis, [MEDICAL CONDITION]. 'Will continue to monitor' to me would mean going back to the resident every 15-30 minutes to reassess. It's very vague to document 'continue to monitor.' I would prefer she said to return in 15-30 minutes to reassess, especially with complaints of pain, some tenderness upon palpation. (She should have) call(ed) the doctor with the change of condition, because it is pain related. R#72 is a very articulate lady, communicates well. She has frequently complained, not necessarily physical. In reference to the 8/31/18 note, the DON stated, But even with a history (of complaints), the nurse should have assessed and monitored, six days later, concerned about this because it has increased, pain should have been assessed more specifically for location, intensity, frequency, (and the nurse) should have notified the doctor. If she had called the doctor right away, maybe he would have ordered an abdominal xray then to see what was going on. Better to call the doctor and be told it's not a problem, then to not call and have something like this happen. Interview on 12/6/18 at 11:42 a.m., in her office, the RN Administrator stated regarding the 8/25/18 Nurse's Note she would expect some kind of follow up to resolve it or give a reason why it stopped being monitored. I would have expected her to notify the physician, and it was a change of condition. Interview on 12/6/18 at 11:53 a.m. with the Medical Director (MD) who stated R#72's condition was, One of those things that you could be brewing, and you don't know about it until you get imaging studies. The MD further stated he was made aware of the resident's tender abdomen and complaints on 9/19/18, and, If it came to my attention earlier, I would have come in to see her (R#72). I assume I would have examined her and asked her if she had any signs and symptoms .if I had been called sooner, I would have addressed her problems. The facility provided the policy titled, Notification of resident's change in condition dated (MONTH) 2014, and updated (MONTH) (YEAR). The policy directed, 2.3. except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status.", "filedate": "2020-09-01"}
{"rowid": 52, "facility_name": "BELL MINOR HOME, THE", "facility_id": 115020, "address": "2200 OLD HAMILTON PLACE NE", "city": "GAINESVILLE", "state": "GA", "zip": 30507, "inspection_date": "2018-12-06", "deficiency_tag": 641, "scope_severity": "B", "complaint": 0, "standard": 1, "eventid": "Q9R911", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately reflect the number of falls since admission/entry or prior assessment on the Minimum Data Set (MDS) at the time of the assessment of one Resident (R) (#35) out of thirty-four (34) sampled residents. Findings include: Interview with R #35 on 12/03/18 3:44 p.m. in his room revealed that he fell about three months ago and cracked a bone. Review of the Progress Notes dated 6/24/18 revealed that R #35 was heard yelling out I need help at 2:00 a.m. The aide arrived first in the room and alerted nurse that he was sitting on the floor. Nurse noted resident to be sitting on bottom with legs stretched out apart from each other. Resident stated that he rolled out of bed. Wheelchair noted to be rolled away from resident with brakes unlocked. Medical Doctor (MD) notified and family notified. Review of the Quarterly Minimum Data Set (MDS) for R #35 dated 7/10/18 revealed in Section: A- Re-entry from acute hospital on [DATE] C- Brief Interview Mental Status (BIMS)-14 cognitively intact J- No falls Review of the Quarterly MDS Assessment for R #35 dated 10/5/18 revealed in Section: A- Reentry 7/3/18 from an acute hospital. C-BIMS- 15 cognitively intact J- No falls Interview with the current MDS Coordinators (II and JJ) in the conference room on 12/06/18 at 4:00 p.m. revealed there was no reference to R #35's falls on the (MONTH) 10, (YEAR) or (MONTH) 5, (YEAR) MDS assessments. They stated that they were aware that R #35 had fallen as a Care Plan for his falls was written. They stated that a correction would be made to the MDS.", "filedate": "2020-09-01"}
{"rowid": 53, "facility_name": "BELL MINOR HOME, THE", "facility_id": 115020, "address": "2200 OLD HAMILTON PLACE NE", "city": "GAINESVILLE", "state": "GA", "zip": 30507, "inspection_date": "2018-12-06", "deficiency_tag": 657, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "Q9R911", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to revise care plans to address the current care needs of two sampled Residents (R#'s 72 and 55) out of 34 residents. Findings included: The facility provided the policy titled, Resident Assessments, dated 11/28/17 which directed, Resident assessments will be completed upon admission, quarterly, annually, and with a significant change in status. The resident's comprehensive assessment is not only for the purpose of understanding a resident's needs, but to understand their strengths, goals, like history and preferences . 1. R#72 was admitted to the facility on [DATE] and re-admitted on [DATE] with current [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] R#72 revealed the resident's cognition was intact, with the Brief Interview for Mental Status (BIMS) score of 15/15. The care plan dated 10/22/18 revealed the problem statement, I have an actual impairment to skin integrity r/t (related to) fistula which created an abdominal abscess to my LLQ (left lower quadrant). I have an ostomy bag in place for drainage. Interventions included: Staff will follow facility protocols for treatment of [REDACTED]. Treatment nurse and WC (wound care) will observe on rounds/document location, size and treatment of [REDACTED]. to MD. During resident interview on 12/3/18 at 2:38 p.m., in the resident's room R#72 stated that a few weeks ago, she had a [MEDICAL CONDITION] done. R#72 further stated, Staff never comes in to check my [MEDICAL CONDITION] bag, I have not told them not to check it, they just don't. When I think it's full, I call them, and they empty it. Last Saturday, I misjudged, and the bag broke; it was such a mess. During an interview with R#72 on 12/4/18 at 9:35 a.m., in the resident's room, the resident stated, Nobody on last evening or night shifts checked my [MEDICAL CONDITION] bag. On 12/4/18 at 4:18 p.m. in the 100 hall nurse's station, the Certified Nursing Assistant (CNA) Kardex for R #72 was reviewed with Registered Nurse (RN) DD. RN DD, who stated there were no directions for the CNAs to check or care for the resident's [MEDICAL CONDITION] listed on the CNA care plan. On 12/5/18 at 2:09 p.m., in the resident's room, R #72 was asked how staff cares for her [MEDICAL CONDITION]. R #72 responded, Nobody had checked her bag the last day, and nobody checks it ever, unless I ask. On 12/6/18 at 4:44 p.m, the care plan for R #72 was reviewed with the Interim Director of Nursing (DON). The DON agreed there were no specific interventions in the care plan or the CNA Kardex care plan to direct the nursing staff to care for R#72's fistula/ostomy bag. The Interim DON acknowledged that nursing staff did not check the resident's ostomy bag. An interview on 12/6/18 at 3:28 p.m. concerning who is responsible for updating care plans was conducted with Minimum Data Set (MDS) Nurse JJ in her office. MDS Nurse JJ stated that floor nurses do not add to the care plan. Weekend and night shift nurses communicate with the MDS nurses via email with updates, information is also obtained from the communication board or morning report to update care plans. MDS Nurse JJ further stated we update the Kardex for the CNAs also. When asked if she knew why R#72's care plan was not updated to include ostomy care, MDS Nurse JJ responded R#72's care plan should include interventions like checking the amount and consistency of stool, monitoring of skin integrity. MDS Nurse JJ agreed specific interventions were not in place for R#72, because the Kardex, pulls the information from the care plan, and it wasn't there. 2. R#55 was admitted to the facility on [DATE] with current [DIAGNOSES REDACTED]. R#55's Quarterly Minimum Data Set ((MDS) dated [DATE] recorded the resident was severely cognitively impaired. The MDS noted R#55 required extensive assistance of staff for bed mobility, transfers, dressing, eating and toilet use, and was totally dependent on staff for personal hygiene, locomotion and bathing. Review of the Activities of Daily Living (ADLs) care plan dated 11/6/18 directed staff: Anticipate my needs. BATHING: I require total staff participation with bathing. BED MOBILITY: I require total x2 staff participation to reposition and turn in bed. CODE STATUS: DNR (do not resuscitate). DRESSING: I require total x1 staff participation to dress. EATING: I require total assist x1 staff participation to eat. Heel boots as tolerated. PERSONAL HYGIENE/ORAL CARE: I require total staff participation with personal hygiene and oral care. Promote dignity by ensuring my privacy. SIDE RAILS: 3/4 Side rails up for safety during care provision, to assist with bed mobility. Observe for injury or entrapment related to side rail use. Reposition PRN (as needed) to avoid injury. Staff to keep in mind that my level of assistance may fluctuate r/t (related to) my significant impairments in cognition and mobility. Document amount of assistance required. TOILET USE: I require total assist x2 staff participation to use toilet. TRANSFER: I require total assist x2 staff participation with transfers. SKIN INSPECTION: I require for staff to observe my skin for changes/alterations during ADL (Activities of Daily Living) care. Observe for redness, open areas, scratches, cuts, bruises and report changes to the Nurse. Review of the total care plan directed the intervention repositioning the resident, but R#55's care plan did not contain any information directing staff to position the resident during meals. Observation of R#55 on 12/3/18 at 1:18 p.m. in the dining room revealed the resident finished her lunch meal with one episode of coughing and was fed her meal by staff. The resident's broda chair was not reclined at 90 degrees and her head and neck were not supported during the meal. Observation further revealed the resident sat forward to take a bite from the offered spoon or straw, and periodically relaxed her head against the chair back. R#55's neck was mildly hyperextended. R#55's broda chair had a blue 3-sided strapped-on foam support behind the resident with wings laterally, which was placed behind her shoulder blades. This support acted as another layer of width behind her back, and with the chair back not upright, the resident rested the top of her head against the chair with more hyperextension of the neck than before, when she rested. On 12/4/18 at 4:18 p.m. R#55's Kardex was reviewed at the 100 nurse's station, with Registered Nurse (RN) DD, there were no positioning devices or instructions on positioning during meals listed on the CNA care plan (listed on Kardex). An interview on 12/6/18 at 3:28 p.m. in the Minimum Data Set (MDS) office concerning who is responsible for updating care plans was conducted with Minimum Data Set (MDS) Nurse J[NAME] MDS Nurse JJ stated that floor nurses do not add to the care plan. Weekend and night shift nurses communicate with the MDS nurses via email with updates, information is also obtained from the communication board or morning report to update care plans. MDS Nurse JJ further stated we update the Kardex for the CNAs also. MDS Nurse JJ further stated R#55's care plan should include the devices used for positioning and positioning during meals. MDS Nurse JJ agreed specific interventions were not in place for R#55, because the Kardex, pulls the information from the care plan, and no device interventions are listed. Interview on 12/6/18 at 4:44 p.m. with the Interim Director of Nurses (DON) in the Conference Room. The DON reviewed the resident's care plan and Kardex and agreed there were no specific interventions in the care plan or the CNA Kardex care plan to direct the nursing staff to place devices for R#55's positioning during meals. Cross reference F684 for R#55", "filedate": "2020-09-01"}
{"rowid": 54, "facility_name": "BELL MINOR HOME, THE", "facility_id": 115020, "address": "2200 OLD HAMILTON PLACE NE", "city": "GAINESVILLE", "state": "GA", "zip": 30507, "inspection_date": "2018-12-06", "deficiency_tag": 658, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "Q9R911", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews, and review of facility policy it was determined the facility failed to the ensure resident's electronic Medication Administration Record [REDACTED]. Findings include: Review of facility policy and procedures titled Medication Administration General Guidelines Section 7.1, Nursing Care Center Pharmacy Policy & Procedure Manual -dated 2007 indicated the following: - The person who prepares the dose for administration is the person who administers the dose - The individual who administers the medication dose, records the administration on the resident's MAR (medication administration record) immediately following the medication being given. - The resident's MAR/TAR is initialed by the person administering the medication, in the space provided under the date, and on the line for that for that specific medication dose administration and time. Initials on each MAR/TAR are verified with a full signature in the space provided or on the nursing care center's master employee signature log. Medication pass observation revealed on 12/3/18 at 10:27 a.m., Licensed Practical Nurse (LPN) KK administer the following medications to R#83: [MEDICATION NAME] 0.5 (anti-anxiety) milligrams (mg) one tablet PO (by mouth); Aspirin 81mg (blood thinner use to prevent [MEDICAL CONDITION] or stroke) one tablet PO; [MEDICATION NAME] 6.25 mg (medication for blood pressure and heart failure) one tablet PO; [MEDICATION NAME] 75mg (anti platelet) one tablet PO; [MEDICATION NAME] 40 mg (blood pressure) one tablet PO; [MEDICATION NAME] 150 mg (antidepressant) tablet PO [MEDICATION NAME] 5 mg (bladder spasms) one tablet PO; Duo Neb ([MEDICATION NAME]-[MEDICATION NAME]) 0.5 mg-3 mg(2.5 mg base)/3 mL nebulization solution used for nebulizer treatment ( a combination of [MEDICATION NAME][MEDICATION NAME] used to treat and prevent symptoms (wheezing and shortness of breath). A review of the eMAR during the medication reconciliation for R#83 revealed the medications that were administered by LPN KK were signed off (initialed) on the by Registered Nurse (RN) BB prior to the preparation and administration of medications by LPN KK. Initials were verified to identify nurse by reviewing the facility nurse Signature List. An interview conducted in the hallway on B Unit on 12/3/18 at 10:45 a.m. with LPN KK confirmed that medication administration for R#83 were initialed as prepared and administered by another nurse. When questioned why the medications were initialed as administered by another nurse, she stated she was training a new nurse. An interview with RN BB on 12/3/18 at 10:55 a.m. on B Unit revealed the RN was newly employed was being trained on medication administration by LPN KK and was directed by LPN to initial that the medication was given to reflect that it was given in a timely manner. Interview was conducted on 12/5/18 at 1:40 p.m. with LPN LL, unit nurse on B Hall. She stated that the time window for administering medications was one hours before and one hour after the prescribed time. She stated that she initialed a resident's medication after administering theprescribed medications Interview was conducted on 12/5/18 at 1:48 p.m. with LPN MM, Charge Nurse on B Hall. LPN MM stated that she initialed a resident's medication after administering the prescribed medications. She would never initial medications that she did not prepare and give to a resident herself. Interview was conducted on 12/6/18 at 4:15 p.m. with the Interim Director of Nursing (DON) in the DON's office. The DON stated the nurse who prepares and administers the medication to a resident is to initial the resident's medication administration record. A Nurse would never sign for another nurse, if prepared and given then sign after administered.", "filedate": "2020-09-01"}
{"rowid": 55, "facility_name": "BELL MINOR HOME, THE", "facility_id": 115020, "address": "2200 OLD HAMILTON PLACE NE", "city": "GAINESVILLE", "state": "GA", "zip": 30507, "inspection_date": "2018-12-06", "deficiency_tag": 684, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "Q9R911", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to assess for positioning for Resident (R) #55 during meals. The sample included 34 residents. Findings included: R#55 admitted to the facility on [DATE] with current [DIAGNOSES REDACTED]. R#55's Quarterly Minimum Data Set ((MDS) dated [DATE] recorded staff evaluated R#55 as severely cognitively impaired. The MDS noted R#55 required extensive assistance of staff for bed mobility, transfers, dressing, eating and toilet use, and was totally dependent on staff for personal hygiene, locomotion and bathing. Review of the Activities of Daily Living (ADLs) care plan dated 11/6/18 directed staff: Anticipate my needs. BATHING: I require total staff participation with bathing. BED MOBILITY: I require total x (times) 2 staff participation to reposition and turn in bed. CODE STATUS: DNR (do not resuscitate). DRESSING: I require total x1 staff participation to dress. EATING: I require total assist x1 staff participation to eat. Heel boots as tolerated. PERSONAL HYGIENE/ORAL CARE: I require total staff participation with personal hygiene and oral care. Promote dignity by ensuring my privacy. SIDE RAILS: 3/4 Side rails up for safety during care provision, to assist with bed mobility. Observe for injury or entrapment related to side rail use. Reposition PRN (as needed) to avoid injury. Staff to keep in mind that my level of assistance may fluctuate r/t (related to) my significant impairments in cognition and mobility. Document amount of assistance required. TOILET USE: I require total assist x2 staff participation to use toilet. TRANSFER: I require total assist x2 staff participation with transfers. SKIN INSPECTION: I require for staff to observe my skin for changes/alterations during ADL (Activities of Daily Living) care. Observe for redness, open areas, scratches, cuts, bruises and report changes to the Nurse. Observations of R#55 on 12/3/18 at 1:18 p.m., revealed the resident's Broda chair back was not at 90 degrees and her head and neck were not supported during the meal. Observation further revealed the resident sat forward to take a bite from the offered spoon or straw, and periodically relaxed her head against the chair back. R#55's neck was mildly hyperextended. R#55's Broda chair had a blue three-sided strapped-on foam support behind the resident with wings laterally, which was placed under her shoulder blades. This support acted as another layer of width behind the resident's back, and with the chair back not upright, the resident rested the top of her head against the chair with more hyperextension of the neck than before, when she rested. Interview on 12/4/18 at 4:16 p.m. with Certified Nursing Assistant (CNA) FF in the resident's room, who stated R#55 travels in a Broda chair or is in bed, and staff used a positioning support for her in the Broda chair. CNA FF stated, I never noticed her having position problems when she eats, and never reported it to the charge nurse. CNA FF further stated the CNAs use the Kardex as the CNA care plan. Interview 12/4/18 at 4:18 p.m. with Registered Nurse (RN) DD, who printed off R#55's Kardex and stated there were no positioning devices or instructions on positioning the resident during meals listed on the CNA care plan. Observation on 12/5/18 at 8:58 a.m. in the dining room revealed R#55 was fed breakfast by staff. R#55 was positioned in the same way as observed on 12/3/18, with no head and neck support to sit upright with her neck slightly hyperextended. At 9:23 a.m. the resident had a short episode of coughing. Staff did not reposition the resident during or after her coughing episode. Interview on 12/5/18 at 9:30 a.m. with the CNA in the dining room, who fed the resident breakfast, CNA NN stated she never noticed the resident sitting upright with no support and did not notice the resident sitting back in the chair periodically. CNA NN further stated she did not report positioning concerns to the nurse. Observation on 12/5/18 at 1:00 p.m. in the dining room revealed R#55 fed the lunch meal by staff. R#55 had the same positioning as previous observations, and ate lunch utilizing the same process of sitting forward to eat and drink and periodically resting the top of her head against the chair back causing her neck to be slightly hyperextended. Interview on 12/5/18 at 1:19 p.m. in the dining room with CNA EE who stated the blue lateral support was used to help keep the resident straight in the chair because the resident likes to lean left. CNA EE further stated that she has never seen anyone put a pillow behind the resident when she eats, but, I think a pillow would help her during eating her meals. I never reported the resident's positioning problems to the nurse. Interview on 12/5/18 at 1:40 p.m. at the nurse's station with RN AA who stated she has worked here six months, and That's the way she's always been, referring to the resident's positioning during meals and support devices. RN AA stated she never noticed any positioning problems but frequently monitors R#55's dining room during meals. Interview on 12/5/18 at 1:42 p.m. at the nurse's station with RN DD who stated therapy was working with the resident's positioning, and she has never made a referral to therapy for the resident's positioning. Interview on 12/5/18 at 1:53 p.m.in the Therapy Room with the Physical Therapy Assistant (PTA) and served as the department manager, who stated R#55 ended on Physical Therapy caseload on 12/29/16, almost two years ago. The PTA stated she placed the light blue covering on the resident's chair, a Cozy to offer support at that time, and later nursing added the blue support with lateral side stays for the trunk. The PTA stated, Nobody has made me aware of any concerns for positioning during meals. No referrals have come through nursing for her (R#72's) positioning. Interview on 12/5/18 at 2:01 p.m. with CNA GG who fed the resident lunch, stated she did not notice the resided having trouble with positioning during her meal. CNA GG further stated she never reported any positioning concerns to the nurse. During a follow up interview on 12/5/18 at 2:23 p.m. outside R#55's door, the PTA stated she just finished assessing the resident's chair and placed a pillow under the Cozy because the Broda chair would not come up to 90 degrees. The PTA stated she instructed the CNAs to add one more pillow if it appears the resident needed it during meals. The PTA then spoke to RN DD about this change, to which RN DD answered, OK, but as of 12/6/18 at 2:19 p.m., no Nurse's Note was documented, and no changes to the care plan or Kardex were made. Interview on 12/6/18 at 9:56 a.m., the PTA stated she planned to watch the resident at the lunch meal with the pillow placed. When asked if she would have expected nursing staff to refer the resident to therapy since 12/2016 for positioning during meals, the PTA expressed agreement by saying, I see what you mean. Interview on 12/6/18 at 11:20 with the Interim Director of Nursing (DON) who stated from a dietary standpoint it was certainly a concern for R#55's head to go back and rest on the chair, with the hyperextended neck, especially during eating to prevent choking. The DON stated, I would expect the staff to notice this, CNAs to report to the nurse and the nurses should have noticed over time and referred (her) to therapy for positioning evaluation. Interview on 12/6/18 at 2:44 p.m. with the Speech Language Pathologist (SLP) who stated she did not know R#55, however, generally the proper position for eating would be as upright as possible. The SLP further stated, A resident with dementia and some hyperextension would depend on staff to position her as upright as possible for eating. The facility provided the policy titled, Assistance with meals policy, dated 11/28/17 and updated 8/7/18, which directed staff, 1.c. Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity . An additional policy was provided by the facility titled, Rehabilitative nursing care, dated 11/2016 which directed, 2. Nursing personnel are trained in rehabilitative nursing care. Our facility has an active program of rehabilitative nursing which is developed and coordinated through the resident's care plan .4. Rehabilitative nursing care is performed daily for those residents who require such service. Such program includes, but is not limited to: a. Maintaining good body alignment and proper positioning . The facility failed to observe, assess and refer the resident for proper positioning during meals.", "filedate": "2020-09-01"}
{"rowid": 56, "facility_name": "BELL MINOR HOME, THE", "facility_id": 115020, "address": "2200 OLD HAMILTON PLACE NE", "city": "GAINESVILLE", "state": "GA", "zip": 30507, "inspection_date": "2017-12-14", "deficiency_tag": 550, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "4OSS11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations record review, review of the facility policy titled Social Service- Dignity Policy, resident and staff interviews, the facility failed to promote care in a manner that maintained or enhanced each resident's dignity and respect. Specifically, three of 29 sampled residents (R B, R A and R C) stated that they are undressed and naked in the shower room while other residents are present. (Refer F583) Findings include: Review of the facility policy titled Social Service- Dignity Policy revised (MONTH) (YEAR) documented: According to federal regulations, the facility must promote care for residents in a manner, and in an environment, that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. Dignity means that their interactions with the resident, staff carries out activities which assist the resident to maintain or enhance his/her self-esteem and self-worth. 1. Record review for R B revealed an Annual Minimum Data Set (MDS) assessment dated [DATE] which documented a Brief Interview for Mental Status (BIMS) summary score of 14, indicating no cognitive impairment. The resident required extensive assistance with bathing and personal hygiene. Interview on 12/11/17 at 2:39 p.m. with R B revealed that staff undress and re-dress her in front of other resident's in the shower room. Resident B further stated that when she is finished with her shower, the staff transport her from the shower stall to the area where they dress everyone with only a small towel covering her. Resident B stated that this has been going on for so long that she has had to just turn it into a funny thing so that it's not an embarrassing thing and will tell herself Well, here comes (name!). R B further stated That's just the way it is! Interview on 12/14/17 at 10:29 a.m. with Certified Nursing Assistant (CNA A) who was actively providing care in the shower room revealed that they always have two residents in the shower room but not more than that unless one is leaving out and one is coming in. CNA A stated that the residents are in the tub area together being undressed and stated we try to have them back to back. CNA A further stated that once undressed, the resident is taken into the shower stall uncovered and naked. CNA A stated when they are finished with the resident's shower they put a towel over them and they are taken back to the tub area to be dried off and re-dressed. When CNA A was asked why the residents are not undressed and re-dressed separately or privately, she stated because they do two at a time with two CNAs and they usually finish their showers at the same time so they are dressed in the dressing area at the same time. She further stated there is only one curtain for that area CNA A stated that no residents have ever told her that they are embarrassed or humiliated. Interview on 12/14/17 at 11:19 a.m. with the Administrator revealed she was not aware that the staff were undressing and re-dressing residents in front of each other in the shower rooms. The Administrator stated she expects staff to maintain a resident's privacy and dignity at all times. The Administrator stated that the staff should not be dressing and undressing resident's in the open area where the bathtub is located. She stated that the two shower stalls in each shower room (Unit A and Unit B) are very large with privacy curtains. The staff should undress, shower and re-dress the residents in the shower stalls. 2. Review of the policy titled Resident Rights Policy, last revised 8/22/17, the resident has a right to a dignified existence and the right to personal privacy. Review of the Annual Minimum Data Set (MDS) Assessment for Resident (R) A dated 10/13/17 revealed the resident has a Brief Interview for Mental Status (BIMS) score of 13 indicating the resident is cognitively intact. The resident was also assessed on the annual assessment as needing the support of one person with bathing and dressing. During interviews conducted on 12/11/17 at 3:26 p.m. and on 12/14/17 at 1:50 p.m., Resident A said she received showers on Mondays and Thursdays, and the staff takes as many as five or six residents in at a time into the shower area. Only two residents at a time can be showered in the two curtained shower stalls. However, the other residents wait right outside the curtained areas, sometimes wearing simply a towel. Afterwards, the two residents receiving a shower at any one time are taken into another curtained drying area to be toweled off and dressed in clean garments. She feels embarrassed at such times - while waiting outside the shower stall and while being dressed. She complained to the facility, at least once before, about having to sit undressed among several other residents. The facility addressed her concern, and the situation got better for a while, but it has deteriorated again to where staff are taking five or more residents in to the shower room at the same time. Observation of the vacant shower room on the resident's hall on 12/12/17 at 8:15 a.m. revealed the shower room consisted of two curtained shower stalls and an open area just in front of these stalls. To the right, when facing the shower stall, was a large area, also curtained with an old spa tub containing several discarded items. One wall of this tub area also had a curtain, and behind it was a toilet and sink. Review of facility care records revealed RA and several other residents are scheduled for showers on Mondays and Thursdays; other residents in the facility are scheduled for showers on Tuesdays and Fridays. Interview on 12/14/17 at 12:34 p.m. with Certified Nursing Assistant (CNA) AA revealed she sometimes provides showers for the residents if the shower team is not available. CNA AA said when she provides showers to residents, she usually does so on an individual basis. However, if another CNA is using the shower room at the same time to bathe another resident, they may take the two residents into the drying area at the same time. She takes care to protect the privacy of the residents and there are never more than two residents in for a shower when she assists residents with taking a shower. However, she has seen the shower teams take several residents into the shower area at the same time because of the volume of showers the team is required to complete on shower days. Interview on 12/14/17 at 2:00 p.m. with D, a family member of the roommate for Resident A revealed she has received complaints from Resident A and the roommate that several residents are taken into the shower area at the same time and must wait along with several other residents for their showers while sometimes dressed in only a towel. Family member D also said she reported to the state ombudsman, her concerns that several residents were being left in the hallway while awaiting their showers. This practice (residents waiting in the hallway outside the shower room prior to receiving a shower) occurred on a regular basis, but improved after it was addressed by the ombudsman earlier this year. 3. On 12/13/17 at 10:30 a.m. interview with Resident C revealed that, while crying, she states that she does not feel like she is treated with respect and dignity when she is taken to the shower and has to take her clothes off in front of other people who are also in the shower room waiting to take a shower. Review of R C Care Plan, dated 11/30/17, reveals planning for: a behavior problem related to (r/t) dietary preferences and inability to be satisfied with meals served even if an alternative meal choice is requested. Resident may manipulate family and staff at times. Resident C has negative feelings regarding staff and facility characterized by; anxiety, mistrust, conflict/anger, ineffective coping related to: unrealistic expectations regarding meals, ADL's, and activities after discharging from Hospice care. Family is aware of resident's inability to cope and persistent complaints. Interventions for the above behaviors include: Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. Other interventions include: Discuss feelings about placement with resident, offer activities of which resident has shown interest, talk with resident about setting realistic self-expectations and goals.", "filedate": "2020-09-01"}
{"rowid": 57, "facility_name": "BELL MINOR HOME, THE", "facility_id": 115020, "address": "2200 OLD HAMILTON PLACE NE", "city": "GAINESVILLE", "state": "GA", "zip": 30507, "inspection_date": "2017-12-14", "deficiency_tag": 561, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "4OSS11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the policy titled Resident Rights Policy, resident and staff interviews, the facility failed to ensure one of 29 sampled residents (R B) right to self-determination. Specifically, R B was told by staff that she was not allowed to have a peanut butter sandwich for a snack unless there was jelly on it. R B stated she told the staff she does not like jelly and she should be allowed to eat what she wants. Findings include: Review of the policy titled Resident Rights Policy revised 8/22/17 documented that the resident has the right to self-determination. The resident has the right to exercise his or her rights as a resident of the facility. Record review for R B revealed an Annual Minimum Data Set (MDS) assessment dated [DATE] which documented a Brief Interview for Mental Status (BIMS) summary score of 14, indicating no cognitive impairment. Resident B was assessed as not having a swallowing disorder or dental conditions. Section F- Preferences for Customary Routine and Activity assessed that it is very important to R B to have snacks between meals. During an interview with R B on 12/11/17 at 3:10 p.m. she stated that she loves peanut butter sandwiches but the staff always put jelly on it. Resident B stated that when she asks the Certified Nursing Assistants (CNA), they tell her they cannot just make a peanut butter sandwich. Resident B stated they tell her they have to put jelly on it. Resident B stated she has told the staff she does not like jelly and they put way too much on it! Resident B stated that she should get to eat what she wants and what she likes. Interview on 12/13/17 at 1:50 p.m. with the Dietary Supervisor (DS) revealed the dietary staff deliver pre-made sandwiches to the resident pantry three times a day for snacks. She stated typically they always have peanut butter and jelly, pimento cheese, bologna, ham, and turkey sandwiches for snacks. The DS stated that if a resident asks for just a peanut butter sandwich they are not allowed to serve that. She stated the peanut butter sandwich has to have jelly on it. The DS stated this is not a written policy but it has been ordered by the Administrator because of choking hazard. The DS stated that they are supposed to honor the resident's preferences and choices. She stated this rule comes directly from the Administrator and was not a recommendation by the Registered Dietician. The DS stated this has been the rule for year and years. Interview on 12/13/17 at 2:18 p.m. with the Administrator revealed the Medical Director nor the Registered Dietician ever recommended to her that they should not be allowed to serve the residents a peanut butter sandwich without jelly on it, nor have they told her it was a choking hazard. The Administrator stated that [AGE] years ago, she had a personal experience in which a resident choked on a peanut butter sandwich and it just has scared her really bad. She stated it's just something she ordered for resident safety, not to restrict anyone from having what they want.", "filedate": "2020-09-01"}
{"rowid": 58, "facility_name": "BELL MINOR HOME, THE", "facility_id": 115020, "address": "2200 OLD HAMILTON PLACE NE", "city": "GAINESVILLE", "state": "GA", "zip": 30507, "inspection_date": "2017-12-14", "deficiency_tag": 583, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "4OSS11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of policy titled Resident Rights Policy, and resident, family, and staff interview, the facility failed to provide privacy of their persons during showers to three residents (A, B, and C) from a sample of 29 residents. Findings include: 1. Review of the policy titled Resident Rights Policy, last revised 8/22/17, the resident has a right to a dignified existence and the right to personal privacy. Review of the Annual Minimum Data Set (MDS) Assessment for Resident (R) A dated 10/13/17 revealed the resident has a Brief Interview for Mental Status (BIMS) score of 13 indicating the resident is cognitively intact. The resident was also assessed on the annual assessment as needing the support of one person with bathing and dressing. During interviews conducted on 12/11/17 3:26 p.m. and on 12/14/17 at 1:50 p.m., Resident A said she received showers on Mondays and Thursdays, and the staff takes as many as five or six residents in at a time into the shower area. Only two residents at a time can be showered in the two curtained shower stalls. However, the other residents wait right outside the curtained areas, sometimes wearing simply a towel. Afterwards, the two residents receiving a shower at any one time are taken into another curtained drying area to be toweled off and dressed in clean garments. She feels embarrassed at such times - while waiting outside the shower stall and while being dressed. She complained to the facility, at least once before, about having to sit undressed among several other residents. The facility addressed her concern, and the situation got better for a while, but it has deteriorated again to where staff are taking five or more residents in to the shower room at the same time. Observation of the vacant shower room on the resident's hall on 12/12/17 at 8:15 a.m. revealed the shower room consisted of two curtained shower stalls and an open area just in front of these stalls. To the right, when facing the shower stall, was a large area, also curtained with an old spa tub containing several discarded items. One wall of this tub area also had a curtain, behind which was a toilet and sink. Review of facility care records revealed RA and several other residents are scheduled for showers on Mondays and Thursdays; other residents in the facility are scheduled for showers on Tuesdays and Fridays. Interview on 12/14/17 at 12:34 p.m. with Certified Nursing Assistant (CNA) AA revealed she sometimes provides showers for the residents if the shower team is not available. CNA AA said when she provides showers to residents, she usually does so on an individual basis. However, if another CNA is using the shower room at the same time to bathe another resident, they may take the two residents into the drying area at the same time. She takes care to protect the privacy of the residents and there are never more than two residents in for a shower when she assists residents with taking a shower. However, she has seen the shower teams take several residents into the shower area at the same time because of the volume of showers the team is required to complete on shower days. Interview on 12/14/17 at 2:00 p.m. with D, a family member of the roommate for Resident A revealed she has received complaints from Resident A and the roommate that several residents are taken into the shower area at the same time and must wait along with several other residents for their showers while sometimes dressed in only a towel. Family member D also said she reported to the state ombudsman, her concerns that several residents were being left in the hallway while awaiting their showers. This practice (residents waiting in the hallway outside the shower room prior to receiving a shower) occurred on a regular basis, but improved after it was addressed by the ombudsman earlier this year. 2. Record review for R B revealed an Annual Minimum Data Set (MDS) assessment dated [DATE] which documented a Brief Interview for Mental Status (BIMS) summary score of 14, indicating no cognitive impairment. R#62 resident required extensive assistance with bathing and personal hygiene. Interview on 12/11/17 at 2:39 p.m. with R Brevealed that staff pull curtains for privacy when they are in the shower stall but when she is finished with her shower, the staff transport her from the shower stall to the area where they dress everyone with only a small towel covering her. Resident B stated there are two or three residents in an open area where they are undressed and re-dressed. Resident B further stated that this has been going on for a long time. Observation on 12/13/17 at 9:12 a.m. of Unit A shower room revealed two shower stalls, both with privacy curtains. There was a large open room/common area with a bathtub in the corner. There was one large privacy curtain that could be pulled to close off this entire area. Observation on 12/13/17 at 9:14 a.m. of Unit B shower room revealed two shower stalls, both with privacy curtains. There was a large open room/common area with a bathtub in the corner. There was one large privacy curtain that could be pulled to close off this entire area. Interview on 12/14/17 at 10:29 a.m. with Certified Nursing Assistant A (CNA A) who was actively providing care in the shower room revealed that they (staff) always have two residents in the shower room but not more than that unless one is leaving out and one is coming in. CNA A stated that the residents are in the tub area together being undressed and stated we try to have them back to back. CNA A further stated that once undressed, the resident is taken into the shower stall uncovered and naked. CNA A stated when they are finished with the resident's shower they put a towel over them and they are taken back tub area to be dried off and re-dressed. CNA A confirmed that residents are typically in this area together at the same time and there is no privacy between them. When CNA A was asked why the residents are not undressed and dressed separately or privately, she stated because they do two at a time with two CNAs and they usually finish their showers at the same time so they are dressed in the dressing area at the same time. She further stated that if they did one resident at a time, they would never get all their showers completed because there is a lot of residents in this facility. CNA A stated that no residents have ever told her that they are embarrassed or humiliated. CNA A stated that she has worked here since (MONTH) (YEAR) and this has been the process for showers since she has been here. CNA A confirmed she received education related to privacy and dignity and was able to verbalize that curtains should always be pulled, doors should always remain closed and privacy for the residents should be maintained and stated but there is only one curtain in the dressing area of the shower room. Interview on 12/14/17 at 11:19 a.m. with the Administrator revealed she was not aware that the staff were undressing and re-dressing residents in front of each other in the shower rooms. The Administrator stated she expects staff to maintain a resident's privacy and dignity at all times. The Administrator stated that the staff should not be dressing and undressing resident's in the open area where the bathtub is located. She stated that the two shower stalls in each shower room (Unit A and Unit B) are very large with privacy curtains. The staff should undress, shower and re-dress the residents in the shower stalls. Review of the Relias Transcript for CNA A revealed she completed and Met requirements for the course titled Assist patient in and out of shower on 11/10/17. The course Description documented: Ensure privacy by closing the door and curtains, if available and the course Rationale documented: This maintains the individual's dignity and right to privacy. 3. On 12/13/17 at 10:30 a.m. interview with Resident C revealed that, while crying, she states that she does not feel like she is treated with respect and dignity when she is taken to the shower and has to take her clothes off in front of other people who are also in the shower room waiting to take a shower. Review of R C Care Plan, dated 11/30/17, reveals planning for: a behavior problem related to (r/t) dietary preferences and inability to be satisfied with meals served even if an alternative meal choice is requested. Resident may manipulate family and staff at times. Resident C has negative feelings regarding staff and facility characterized by; anxiety, mistrust, conflict/anger, ineffective coping related to: unrealistic expectations regarding meals, ADL's, and activities after discharging from Hospice care. Family is aware of resident's inability to cope and persistent complaints. Interventions for the above behaviors include: Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. Other interventions include: Discuss feelings about placement with resident, offer activities of which resident has shown interest, talk with resident about setting realistic self-expectations and goals.", "filedate": "2020-09-01"}
{"rowid": 59, "facility_name": "WILLIAM BREMAN JEWISH HOME, THE", "facility_id": 115022, "address": "3150 HOWELL MILL ROAD N.W.", "city": "ATLANTA", "state": "GA", "zip": 30327, "inspection_date": "2018-02-08", "deficiency_tag": 578, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "G4GK11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and policy review, the facility failed to determine whether or not the resident wanted to formulate an Advanced Directive, for five residents (R) observed. R# 11, R# 72, R#255, R# 84 and R#254. The sample size was 22 residents. Findings include: 1. Medical Record review revealed that Resident (R) #72 review of the medical record for R#72 revealed that there was not any evidence that an Advance Directive was completed. Further review of the admission file for R#72 revealed that the form, Responsible/Legal Guardian & Advanced Directive Checklist (no date) was incomplete. No response were checked for choice and there was not any evidence that an Advance Directive checklist was documented. 2. Medical Record review for R #255 reveals that there was not any evidence that the resident had an Advance Directive. Further review of the Acknowledgement of Receipt of Admission for Rehabilitation form reveals that there is not a check mark next to the Georgia Advance Directive for Healthcare. 3. Medical Record review for R #84 reveals that there was not any evidence that the resident had an Advance Directive. Further review revealed that R #84 does have a completed Acknowledgement of Receipt of Admission for Rehabilitation Information form in the resident's Admission Folder. 4. Medical Record review for R # 254 revealed that there was not any evidence that the resident had an Advance Directive on their medical record or in their admission folder. Further review of theAcknowledgement of Receipt of Admission for Rehabilitation information form revealed that R#254 does not have a check mark next to Georgia Advance Directive for Healthcare. 5. Medical record review for resident R#11 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 10, which indicated no cognitive impairment. Further review on clinical record on 2/6/18 lacked evidence that the resident had been offered options to formulate an advance Directive. Document titled Responsibility/Legal Guardian & Advanced Directive Information was provided by Social Services Director on 2/6/18. The form revealed that resident was responsible for self, but no other information was documented on the form as to her choice to formulate or not formulate Advanced Directives. Based on interview, record review and policy review, the facility failed to determine whether or not the resident wanted to formulate an advanced directive, for seven residents (R) observed. R# 11, R#76, R# 38, , R# 72, R#255, R# 84 and R#254; out of a sample of 22 Findings include: For all resident's in the sample, a form titled Responsibility/Legal Guardian and Advanced Directive Checklist were missing information regarding resident's response to an offer of formulating an advanced directive. On 2/6/18 11:31 a.m. an interview with Social Services Director (SSD) was able to provide a folder evidencing a form titled Responsibility/Legal Guardian and Advanced Directive Checklist. This document shows where the facility provided information to the resident and/or family member on legal guardianship, and Power of Attorney (POA) along with an advanced directives checklist. The checklist included a decision made by the resident to formulate an advance directive or not. This document did offer a decision. No decision was noted. Further interview by the SSD indicated the facility no longer uses the form as it was becoming confusing for the staff. When asked how does the facility know what the resident's decision was in the event of an emergency, SSD stated they use a form titled Acknowledgement of Receipt of Admission for Rehabilitation information. This document lists the Georgia Advanced Directive for Healthcare. A check by the document name indicates the resident and /or family member received the document. When asked what the time frame is for return of the document SSD stated we asked they return it within 24 hours. When the time frame runs out there is no follow up done. SSD was once again asked what is done if there is no documentation of resident's preference regarding advanced directives. SSD stated if there is no information on the record the resident the resident is considered to be a full code. On 2/7/18 11:23 a.m. an interview with Director of Health Services (DHS) and Administrator revealed that the form titled Responsibility/Legal Guardian & Advanced Directive Checklist is no longer used because their attorney stated it was not a legal document. When asked where is the resident's response to advance directives education documented, DHS stated that it should be in the admission noted or on the dashboard of the Electronic Medical Record (EMR). On 2/7/18 01:06 p.m. further interview with the DHS revealed the facility does not have any documentation as to resident's preference to execute an advance directive. A review of facility policy titled Advance Directives, no date, states information about whether or not the resident has executed an advanced directive, shall be displayed prominently in the medical record. Also, if the resident indicates that he or she has not established advance directive, the facility staff will offer assistance in establishing advance directives. The resident will be given the option to accept or decline the assistance, and care will not be contingent on either decision. Nursing staff will document in the medical record the offer to assist and the resident's decision to accept or decline.", "filedate": "2020-09-01"}
{"rowid": 60, "facility_name": "WILLIAM BREMAN JEWISH HOME, THE", "facility_id": 115022, "address": "3150 HOWELL MILL ROAD N.W.", "city": "ATLANTA", "state": "GA", "zip": 30327, "inspection_date": "2018-02-08", "deficiency_tag": 641, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "G4GK11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure that Minimum Data Set (MDS) assessments were accurate for one resident (R) #9 for the use of injectable's and insulin. The sample size was 22 residents. Findings Include: Record review revealed R#9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as three, which indicates cognitive impairment. Section I-Active [DIAGNOSES REDACTED]. Review of MDS dated [DATE], section N-Medications, N0300 Injections: indicated that resident received 0 injections in last 7 days; NO350 Insulin was left blank. Review of a care plan initiated on 2/8/18, revealed that resident has potential for hyperglycemic or hypoglycemic episodes secondary to diabetes: resident uses insulin. Interview on 2/8/18 at 3:11 p.m., with MDS Coordinator, stated she gets information for the MDS assessments by having a face to face interview with the residents and information is obtained from the direct care staff caring for the residents. She stated information about medications is obtained from the electronic Medication Administration Record [REDACTED]. She verified that the 8/1/17 MDS did not reflect that the resident has received insulin injections 7 out of 7 days. She further stated that she would go ahead and modify the MDS assessment to indicate resident received insulin injections 7 out of 7 days.", "filedate": "2020-09-01"}
{"rowid": 61, "facility_name": "WILLIAM BREMAN JEWISH HOME, THE", "facility_id": 115022, "address": "3150 HOWELL MILL ROAD N.W.", "city": "ATLANTA", "state": "GA", "zip": 30327, "inspection_date": "2018-02-08", "deficiency_tag": 656, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "G4GK11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to follow the care plan for one resident (R) #47 related to not placing a fall mat at the bedside post fall on 1/9/18. The sample size was 22 residents. Findings include: A review of the clinical record for R#47 revealed resident was admitted to the facility with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as two, which indicated cognitive impairment. Review of the care plan dated 1/9/18, revealed that R#47 had impaired physical mobility related to a fall from the bed. Interventions to be implemented included bed in low position and fall mat at bedside. Observation on 2/7/18 at 12:05 p.m., 2/8/18 at 9:19 a.m. and 2/8/18 at 4:11 p.m. revealed no fall mat at bedside, nor stored in the closet or under the bed. A review of facility policy titled Fall Management Program with effective date (MONTH) 25, 2010, revealed that the date and time of each fall and new intervention will be added to the care plan. Interview on 2/8/18 at 2:51 p.m., with Licensed Practical Nurse (LPN) AA, revealed that the procedure for when residents have a fall is to do a complete head to toe assessment, assessing for any injuries. She then notifies the Shift Supervisor, the residents Physician and family member. The residents nurse and the Supervisor discuss possible interventions and collaborate together what intervention is best suited for the situation. Supervisor inputs the intervention into electronic medical record (EMR) and the floor nurse is responsible for follow-up on implementation. She further stated the residents are observed for 72 hours post fall. She stated she did not know why R#47 didn't have a fall mat at the bedside. Interview on 2/8/18 at 4:06 p.m., with Assistant Director of Nursing, revealed that she and the floor Charge Nurse confer together discussing possible interventions to put in place after residents experience a fall. She further revealed that it is the facility's policy to implement interventions after each fall. She stated that when fall mats are ordered, the Certified Nursing Assistant (CNA) or the Charge Nurse are responsible for getting floor mats and placing them at bedside.", "filedate": "2020-09-01"}
{"rowid": 62, "facility_name": "WILLIAM BREMAN JEWISH HOME, THE", "facility_id": 115022, "address": "3150 HOWELL MILL ROAD N.W.", "city": "ATLANTA", "state": "GA", "zip": 30327, "inspection_date": "2018-02-08", "deficiency_tag": 758, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "G4GK11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to indicate the need to extend orders for as needed (PRN) antianxiety medications for two residents (R#31 and R#25) beyond 14 days, and failed to document the reason for the extension or the period during which the extended order should be in effect. The sample size was 22 residents. Findings include: Review of the clinical records for Resident (R) #31 revealed she was admitted to the facility with [DIAGNOSES REDACTED]. Review of a Significant Change Minimum Data Set (MDS) assessment of 11/21/17 revealed the resident had evidence of mood symptoms, behaviors directed at others occurred 1-3 days during the assessment period, had active [DIAGNOSES REDACTED]. Review of the most recent physician order [REDACTED]. Further review of the clinical records for R#31 revealed no documentation that the PRN anxiolytic should continue beyond 14 days, the period during which it should be continued, or a rationale for its continued use. Interview with the Medical Director on 2/08/18 at 2:37 p.m. revealed the resident has had significant trauma in recent months and was placed on hospice soon after admission due to declining health. The resident has since been discharged from hospice, but continues to experience anxiety and needs the antianxiety medication on an as needed basis. He was not aware that he should have documented the ongoing need for this medication, but will do so going forward. 2. Review of clinical record for Resident (R) #25 revealed he was admitted to the facility with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 15, which indicates no cognitive impairment. Review of (MONTH) (YEAR) Physician order [REDACTED].#25 was prescribed Klonopin 0.5 milligrams (mg) at bedtime as needed (PRN) for anxiety, with original order date of 8/8/17. Further review of the PO did not indicate that the use of the PRN medication had been re-evaluated by the physician, for continued use. Interview on 2/8/18 at 1:58 p.m., with Medical Director, stated that he has not been evaluating the continued need for PRN antipsychotic medications. He stated that if he wrote an order for [REDACTED]. He stated he has not been addressing orders for PRN antipsychotic's, but will start, because the government regulations have changed.", "filedate": "2020-09-01"}
{"rowid": 63, "facility_name": "WILLIAM BREMAN JEWISH HOME, THE", "facility_id": 115022, "address": "3150 HOWELL MILL ROAD N.W.", "city": "ATLANTA", "state": "GA", "zip": 30327, "inspection_date": "2018-02-08", "deficiency_tag": 761, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "G4GK11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and policy review, the facility failed to ensure medications were dated appropriately when opened to determine the discard date, in one of two medication carts; and failed to discard expired biological's and medical supplies prior to expiration date in one of two medication storage rooms. The sample size was 22 residents. Findings include: 1. Observation on 2/6/18 at 4:25 p.m., third floor medication cart revealed one opened and used [MEDICATION NAME] respiratory inhaler. The inhaler had a sticker from the pharmacy that indicated the medication should be discarded 90 days after opening. The inhaler did not have a date when opened. Further observation, on the same medication cart, was [MEDICATION NAME] Propionate liquid, approximtely 1/2 of 16 ounce bottle, with expiration date of 12/17. 2. Observation on 2/6/18 at 4:25 p.m., in the third floor medication storage room revealed two catheter irrigation trays with expiration date of 1/18. 3. During medication pass on 2/7/18 at 12:28 p.m., with Licensed Practical Nurse (LPN) AA, revealed an opened multiple-dose vial of [MEDICATION NAME] Insulin with opened date of 1/2/18. A label on the vial read discard after 28 days. Review of the facility policy titled, Pharmacy Services and Procedures policy, revised (MONTH) 2013, indicated that the facility should ensure that medications and biological's have an expiration date on the label and have not been retained longer than recommended by the manufacturer or supplier. The policy further indicated the facility should record the date opened on the medication container when the medication has a shortened expiration date once opened. Review of the policy titled, Recommended Minimum Medication Storage Parameters, revised (MONTH) 29, (YEAR), indicated that multiple-dose vials for injection, are to be dated when opened and discard unused portion after 28 days or in accordance with manufacturer's recommendations. The parameters for [MEDICATION NAME] Inhalation Spray, indicated after initial priming, discard after 120 sprays or three months after first use. Interview on 2/6/18 at 4:25 p.m., Licensed Practical Nurse (LPN) AA stated that she doesn't know when the inhaler was opened. She stated that she puts open dates on all the medications that she opens. She stated that each of the med nurses are supposed to check the medication carts and storage rooms daily for expired medications and supplies. Interview on 2/7/18 at 12:40 p.m., LPN AA stated the policy for opened injectable medications is 30 days. She verified the opened bottle of [MEDICATION NAME]had 1/2/18 open date and the pharmacy sticker indicated to discard 28 days after opening.", "filedate": "2020-09-01"}
{"rowid": 64, "facility_name": "WILLIAM BREMAN JEWISH HOME, THE", "facility_id": 115022, "address": "3150 HOWELL MILL ROAD N.W.", "city": "ATLANTA", "state": "GA", "zip": 30327, "inspection_date": "2019-02-28", "deficiency_tag": 578, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "952S11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to accurately document the Advance Directive status for one Resident (R) R#18 from a sample of 17 residents reviewed for Advance Directives. Findings include: Review of the record for R#18 revealed the resident was admitted on [DATE] with the [DIAGNOSES REDACTED]. Review of the resident's most recent Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was coded as 15, which indicated no cognitive impairment. A review was conducted of the physician orders [REDACTED]. Review of the facility form titled, Order Summary Report for R#18 documented Advanced Directive: CPR, order date [DATE]; order status active and documented active orders as of [DATE]. Review of the resident's care plan, provided by MDS Coordinator A for R#18, documented two Advance Directive (AD) code status determinations. The care plan focus area reflects a code status as Full Code with a date initiated of [DATE], revision on [DATE]. Another care plan focus area reflects a code status as Do not Resuscitate (DNR) with a date initiated of [DATE], revision on [DATE]. Further record review for R#18 revealed a form titled, Physician order [REDACTED]. The POLST was signed by the resident and dated [DATE]. The section for discussion and signatures was blank for the physician's name and signature. The POLST was found at the front of the record in a clear document sleeve with a bright orange DNR sticker positioned at the top of the clear plastic document sleeve. On [DATE] at 10:38 a.m. an interview was conducted with the Social Worker (SW), she explained that the process to obtain Advance Directive information for a resident begins in admission; they work with the long-term care and rehab residents. Those residents receive an admission packet that starts with an Advance Directive checklist where residents can choose options. If they can sign for themselves, they must have a good BIMS score, meaning no impairment cognitively. If they have a Power of Attorney or a Living Will, that will be requested. The SW stated that it is the Social Worker's responsibility to discuss those options on the form with the resident and family. The SW further stated that the Unit Secretary will scan and upload the forms into the electronic record and place a copy of the original in the hard copy medical record. On [DATE] at 9:30 a.m. an interview was conducted with MDS Coordinator A in the MDS office with MDS Coordinator B and the Director of Nursing (DON) present. A review and confirmation of the quarterly and annual MDS was conducted. A printed copy of the resident's quarterly care plan was provided, dated [DATE]. When MDS Coordinator A was asked where the nursing staff would look for the Advance Directive information and preference, she stated that in an emergency they run to the hard copy chart to find the code status located at the front of the chart. After review of the provided documents with the MDS Coordinators with the DON present, the MDS Coordinators stated that the POLST form signed by the resident on [DATE] is an error. They revealed that the POLST forms have not been officially initiated in the facility yet; they confirmed the POLST form located in the front of the resident's record that is signed by the resident, is not signed by the Physician, and should not have been in the record. They confirmed the care plan indicating a DNR code status is in error. The DON explained that the POLST has not been initiated yet, because another Social Worker that is planning to initiate the POLST form for all residents that choose a DNR determination has been on maternity leave. No documentation was found in the record from the Social Worker regarding a change in the resident's Advance Directive status. In addition, the MDS Coordinator A and the DON explained that once an order is received by the Physician, the nursing staff will have the Unit Secretary scan in the AD into the electronic system and the original copy is placed in the hard copy record. The DON stated the plan now was to get a hold of the Physician's Nurse Practitioner, the resident and family to sort out the wishes of the resident, then get an order if there is a change. On [DATE] at 4:00 p.m. the DON provided a copy of a monthly follow-up visit conducted by the Nurse Practitioner for R#18, dated [DATE]. The note documents: POLST is reviewed with resident on day of exam. No acute changes or concerns per staff. On the bottom of page 5 of the follow-up exam, there is a hand-written note dated [DATE] and signed by the Nurse Practitioner that documents: reviewed POLST election and resident continues to desire elections charted on POLST form ,[DATE]. The DON also provided a printed copy of the original POLST form with the Physician's signature added and dated [DATE]. The DON confirmed that the POLST form is the form the facility has decided to use but confirmed that it has not been initiated yet.", "filedate": "2020-09-01"}
{"rowid": 65, "facility_name": "WILLIAM BREMAN JEWISH HOME, THE", "facility_id": 115022, "address": "3150 HOWELL MILL ROAD N.W.", "city": "ATLANTA", "state": "GA", "zip": 30327, "inspection_date": "2019-02-28", "deficiency_tag": 604, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "952S11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, and record review the facility failed to ensure that one resident (R), # 296 out of 2 residents reviewed was free from restraints from a sample of 39 residents. Findings include: Review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE] documented R#296 with a Brief Interview for Mental Status (BIMS) score of 99, indicating that the resident was cognitively impaired. Further review of R#296 MDS provided evidence that R#296 required two-person extensive assistance with transfers and no documented evidence for use of restraint. Further review of resident R#296 clinical records shows that resident (R#296) was not assessed for the use of restraints. Additionally, there were no Physician order, plan of care or progress notes to show the needed use of restraints. Multiple observations were made of resident R#296 with a seatbelt around his torso area while sitting in his wheelchair. On 2/26/19 at 1:00 p.m., observed resident in the garden room involved in activities. Resident in wheelchair while seatbelt around his torso area. On 2/27/19 at 12:45 p.m., observed resident in dining room area eating his lunch, resident in a wheelchair with a seatbelt fasten around his torso currently. On 2/27/19 at 2:02 p.m. an interview was conducted with Registered Nurse FF, she stated that R#296 has a seat around him while he is in the wheelchair because he has problems with [MEDICAL CONDITION] activity and the seatbelt is being used to keep him for falling out wheelchair. On 2/28/19 at 3:05 p.m. an interview was conducted with the Director of Nursing (DON), she stated that R#296 should not have a seatbelt around his torso. The DON stated she believes that the daughter brought the wheelchair for R#296 to have but at this time the resident does not have a Physician order for [REDACTED].", "filedate": "2020-09-01"}
{"rowid": 66, "facility_name": "WILLIAM BREMAN JEWISH HOME, THE", "facility_id": 115022, "address": "3150 HOWELL MILL ROAD N.W.", "city": "ATLANTA", "state": "GA", "zip": 30327, "inspection_date": "2019-02-28", "deficiency_tag": 656, "scope_severity": "G", "complaint": 0, "standard": 1, "eventid": "952S11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and review of the facility documents the facility failed to follow the care plan/ Nursing Kardex related to two staff assistance for transfers for one resident (R) #67 of two residents reviewed. Actual harm was identified when R#67 sustained a left arm fracture from an improper transfer. Findings include: Record review revealed that R#67 was admitted to the facility on [DATE], current [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 4 indicating severe impaired cognition. Continued review of the MDS revealed the resident required extensive assistance with bed mobility and extensive assistance with transfers requiring two plus person physical assist. Review of the significant change MDS dated [DATE] revealed R#67 had a BIMS score of 10 which indicates the resident's cognition was moderately impaired. Section G revealed that the resident was assessed for total dependence assist by two plus persons for transfer. Review of the care plan, revision on, 2/6/19 with a problem onset dated 9/24/18 impaired physical mobility related to fall. Interventions for R#67 requires two persons with all transfers and mechanical lift transfer as needed. Review of the MDS 3.0 Nursing Kardex dated 10/8/18 revealed under transfer that R#67 requires the assist of two plus person. A phone interview was conducted on 2/27/19 at 12:45 p.m. with Certified Nursing Assistant (CNA) EE, regarding the incident with R#67. The CNA revealed the resident refused to use the lift to get up. She asked the resident if she could she stand and pivot to the wheel chair and the resident said yes. The CNA revealed the resident was sitting on the side of the bed and had both her feet on the floor. The resident was assisted to a standing position and pivot to the wheel chair and the resident's left arm went up. The CNA revealed she felt pressure from the resident and eased her in the wheel chair. The CNA revealed she notified her charge nurse and called the supervisor. The CNA revealed she did not ask for assistance from another staff person. CNA revealed she is aware of the residents Kardex (guide on how to take care of the residents) and did not look at the resident's Kardex prior to the transfer. The CNA revealed she does not have a reason of why she did not look at the Kardex. An Interview was conducted on 02/27/19 at 11:46 a.m. the Assistant Director of Nursing (ADON) regarding R#67 transfers. The ADON revealed that R#67 is care plan transfer with two people or two people and a lifting device. The ADON revealed that each resident has a Kardex hanging at the end of the resident bed on a clip board that gives the CNA guidance on how to care for the residents. Refer to F689", "filedate": "2020-09-01"}
{"rowid": 67, "facility_name": "WILLIAM BREMAN JEWISH HOME, THE", "facility_id": 115022, "address": "3150 HOWELL MILL ROAD N.W.", "city": "ATLANTA", "state": "GA", "zip": 30327, "inspection_date": "2019-02-28", "deficiency_tag": 689, "scope_severity": "G", "complaint": 0, "standard": 1, "eventid": "952S11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff and family interviews, and review of the facility documents the facility failed to ensure a safe and secure environment related to accidents, for one of two residents (R) reviewed for falls. Actual harm was identified on 1/11/19 when R#67 was transferred improperly by one Certified Nursing Assistants (CNA) when the resident required assistance of two staff resulting in a fracture to the left arm. Findings included: Record review revealed that R#67 was admitted to the facility on [DATE], current [DIAGNOSES REDACTED]. On 1/16/19 [DIAGNOSES REDACTED].#67 [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 4 indicating severe impaired cognition. Continued review of the MDS revealed the resident required extensive assistance with bed mobility and extensive assistance with transfers requiring two plus person physical assist. Review of the significant change MDS dated [DATE] revealed R#67 had a BIMS score of 10 which indicates the resident's cognition was moderately impaired. Section G revealed that the resident was assessed for total dependence assist by two plus persons for transfer and toilet use. The resident was assessed as total dependence for care. Review of the care plan, revision on, 2/6/19 with a problem onset dated 9/24/18 revealed impaired physical mobility related to fall. Interventions for R#67 requires two persons with all transfers and mechanical lift transfer as needed. Review of the MDS 3.0 Nursing Kardex dated 10/8/18 revealed under transfer that R#67 requires the assist of two plus person. Review of the progress note dated 1/11/19 at 10:40 a.m. revealed: Writer was notified by Certified Nursing Assistant (CNA) during transferring of resident from bed to wheel chair, resident knees gave out and was going down. CNA broke fall by supporting her arm under resident left armpit and ease her into wheel chair. ROM (range of motion) performed. Able to move RT (right) arm. HEX (history) old FX (fracture) to LT (left) shoulder and muscle weakness. C/O (complained of) discomfort to LT shoulder. NP (Nurse Practitioner) notified and ordered X - Ray LT shoulder. Review of the Physician orders [REDACTED]. Review of the x-ray of the left shoulder dated 1/11/19 revealed: no acute fracture or other acute abnormality Review of the progress note dated 1/13/19 at 05:08 it is documented in part c/o (complain of) pain in the left shoulder, medicated for pain x 1. There is no evidence that the nurse assessed the resident's left shoulder. Review of an Progress Note dated 1/15/19 at 02:24 it was documented in part by an Licensed Practical Nurse; Resident was assessed, to observe left upper arm and shoulder swollen and purple color discoloration. .An interview was conducted on 2/27/19 at 11:46 a.m. with the Assistant Director of Nursing (ADON) revealed the sister of R#67 called the ADON from the resident's eye appointment on 1/15/19 and requested that the ADON look at Resident # 67 arm because the resident was still complaining of pain and the resident had swelling and bruising. The ADON revealed on 1/16/19 she assessed R#67 and the left arm was swollen and bruising and called the Physician. The Physician gave an order to x-ray the left clavicle, left shoulder and left humerus. The x-ray was completed on 1/16/19 and the results of the x-ray revealed a [MEDICAL CONDITION] humerus. An Encounter note written by a Physician dated 1/22/19 documented R#67 was seen for a proximal humerus fracture that occurred while she was in care at the (Name) home. She was not using the lift but was being lowered to the floor and a pop was felt. She was initially told that her arm was not broken, but subsequently a fracture was determined to be present. The onset date of 1/11/19, lowered to the floor, CNA said she heard a snap. She is right-hand dominant. She also has limited hand functions and a moderate amount of pain. An interview was conducted on 2/27/19 12:01 p.m. with Registered Nurse Supervisor DD regarding the incident with R#67. Supervisor DD stated when she arrived at the floor, she assessed the resident. The resident verbalized pain and there was no swelling at the time of her assessment. The Supervisor asked the CNA why she was transferring the resident alone and the CNA responded she was helping another CNA, and this was not her assigned resident. Supervisor DD revealed the CNA should have had another staff person to assist her with the transfer. Supervisor DD revealed the CNA should have checked the resident's Kardex (guide on how to take care of the residents) prior to the transfer. Supervisor BB revealed that the Kardex was located at the end of each residents' bed on a clip board. The CNA's are in-serviced on using the Kardex as a resource. An interview was conducted on 2/27/19 at 12:30 p.m. with R#67 and her sister/Responsible Party (RP). Resident #67 family revealed on 1/16/19 she met R#67 at the eye doctor and when R#67 arrived she was crying. The resident expressed that she was in pain and her left arm hurt. The family member looked under R#67 clothes and seen that the arm was swollen and black and blue. The RP called the facility and spoke with the Assistant Director of Nursing (ADON) and asked her to assess the resident's arm. The next day when she arrived at the facility, she was informed by the ADON that R#67 had a [MEDICAL CONDITION]. The RP made an appointment for the resident to be seen by and orthopedic physician on 1/17/19. A phone interview was conducted on 2/27/19 at 12:45 p.m. with Certified Nursing Assistant (CNA) EE, regarding the incident with R#67. The CNA revealed the resident refused to use the lift to get up. She asked the resident if she could stand and pivot to the wheel chair and the resident said yes. The CNA revealed the resident was sitting on the side of the bed and had both her feet on the floor the CNA stood in front of the resident. The CNA revealed she placed her left arm under the resident's right armpit and her right arm went under the residents left arm pit. The resident was assisted to a standing position and pivot to the wheel chair and the resident's left arm went up the CNA revealed she felt pressure from the resident and eased her in the wheel chair. The CNA revealed she notified her charge nurse and called the supervisor. The CNA revealed she did not ask for assistant from another staff person. CNA revealed she is aware of the residents Kardex (guide on how to take care of the residents) and did not look at the resident's Kardex prior to the transfer. The CNA revealed she does not have a reason of why she did not look at the Kardex. Review of the Radiology report dated 1/16/19 revealed Impression: Acute displaced proximal humeral fracture. Review of the orthopedics History and Physical report dated 1/17/19 revealed the following, R#67 seen today for a left proximal humerus fracture. She has moderate amount of pain. An interview was conducted on 2/28/19 at 11:40 a.m. with the Director of Staff Development regarding if CNA EE received any in-service training for using the Kardex. The Staff Development Director revealed in-services are done but she has no documentation to support that CNA EE was in-service on using the Kardex.", "filedate": "2020-09-01"}
{"rowid": 68, "facility_name": "WILLIAM BREMAN JEWISH HOME, THE", "facility_id": 115022, "address": "3150 HOWELL MILL ROAD N.W.", "city": "ATLANTA", "state": "GA", "zip": 30327, "inspection_date": "2017-03-30", "deficiency_tag": 278, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "U5BR11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to accurately code the Minimum Data Set (MDS) for one resident (R#109) taking a diuretic out of a total sample of 35 residents. Findings include: Resident #109 was admitted [DATE] with a [DIAGNOSES REDACTED]. Record review of the Admission MDS assessment dated [DATE] revealed in section N: medications that resident received two of the seven days of a diuretic in the last seven days. Review of the (MONTH) (YEAR) Physician order [REDACTED]. Interview with the MDS Coordinator on 3/30/17 at 12:30 p.m. confirmed that the MDS was miscoded during that time", "filedate": "2020-09-01"}
{"rowid": 69, "facility_name": "WILLIAM BREMAN JEWISH HOME, THE", "facility_id": 115022, "address": "3150 HOWELL MILL ROAD N.W.", "city": "ATLANTA", "state": "GA", "zip": 30327, "inspection_date": "2017-03-30", "deficiency_tag": 282, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "U5BR11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews, the facility failed to follow the care plans related to the monitoring of blood glucose levels and the treatment of [REDACTED].#17) from a total sample of 35 residents. Findings include: Record review for resident (R) #17 revealed the resident was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of the care plan dated 1/9/17 stated R#17 has the potential for hypoglycemic and hyperglycemic episodes secondary to DM with the goal to provide relief of hypo/hyperglycemic episodes within 30 minutes of interventions. Continued review revealed to monitor blood sugar (glucose) levels per physician's orders [REDACTED]. Review of the Physician order [REDACTED].-300, give five (5) u, 301-350, give seven (7) u; greater than 351, give 10 u. Review of the Medication Record for (MONTH) (YEAR) revealed no evidence of blood glucose (bg) level documentation at bedtime for 1/6/17, 1/7/17, 1/8/17, and/or 1/24/17. Review of the The Medication Record for (MONTH) (YEAR) revealed no evidence of BG level documentation for 3/18/17. During interview with the Director of Nursing (DON) on 3/30/17 3:20 p.m., she confirmed that the care plan was not followed regarding blood sugars. 2.) During observation on 3/30/17 at 7:00 a.m. with Registered Nurse (RN) EE, she cleaned the pressure ulcer to the sacral wound with Dakins solution, then applied an oil [MEDICATION NAME] dressing to the wound bed and applied the calcium alginate to the tunneling area. Continued observation revealed that a sponge was applied to the site and a new canister applied to the wound. Review of the care plan for R#17 dated 1/9/17 revealed that resident has a pressure ulcer and the intervention included to treatment per current physician orders. Review of the (MONTH) (YEAR) Physician order [REDACTED]. Interview with the Assistant Director of Nursing (ADON) on 3/30/17 at 10:30 a.m., revealed that wound care for the resident's treatment is to apply the black sponge, which is the deriding agent and the application of the suction to the wound vac.", "filedate": "2020-09-01"}
{"rowid": 70, "facility_name": "WILLIAM BREMAN JEWISH HOME, THE", "facility_id": 115022, "address": "3150 HOWELL MILL ROAD N.W.", "city": "ATLANTA", "state": "GA", "zip": 30327, "inspection_date": "2017-03-30", "deficiency_tag": 309, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "U5BR11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy review, and staff interviews, the facility failed to follow physician's orders for the administration of insulin per sliding scale. Findings include: Record review for R#17 revealed that the resident was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of the Physician Orders dated 1/20/17 revealed an order for [REDACTED]. Review of the Medication Record (MR) for (MONTH) (YEAR) revealed one incorrect dose of insulin administered at bedtime (HS) on 1/21/17, which was documented at 212. During further review, the MR revealed that four u of insulin were given; however, two u ordered. Review of the Physician Orders for (MONTH) (YEAR) revealed order for [MEDICATION NAME] 100 u/ml per sliding scale for BG greater than 160 mg/dl; give via subcutaneous injection before meals and at bedtime at 7:00 a.m., 12:00 p.m., 5:00 p.m. and 9:00 p.m. Continued review revealed that the sliding scale is as follows: 161-200, give one u, 201-250, give three u, 251-300, give five u, 301-350, give seven u; greater than 351, give 10 u. Review of the MR for (MONTH) (YEAR) revealed a total of seven (7) occasions when insulin coverage had no evidence of documentation for the following dates: 7:00 a.m. administration: 2/6/17 BG=174, 2/12/17 BG=162; bedtime administration: 2/4/17 BG=198, 2/5/17 BG=176, 2/11/17 BG=213, 2/12/17 BG=189, and 2/18/17 BG=187. Review of the (MONTH) (YEAR) MR revealed four (4) incorrect doses given, which includes the following: on 3/2/17 at 5:00 p.m. the BG was 232, and the resident was given two u instead of five units. Then on 3/8/17 BG=380, five u given, not 10 u as ordered; and on 3/13/17 BG=262-three (3) u given, instead of five (5) units. Review of the (MONTH) (YEAR) Physician Orders continued the same sliding scale insulin orders as (MONTH) (YEAR). Interview with Licensed Practical Nurse (LPN) DD on 3/29/17 at 11:15 a.m., she stated that inservices are held for all new medications, including how to draw up, if applicable, and administer. Continued interview revealed that annual inservices are held related to general medication administration. The procedure for self-reported medication errors is to contact the nursing supervisor, monitor the resident for any adverse reactions, complete the appropriate medication error paperwork and contact the physician and/or family. During an interview with the Director of Nursing (DON) on 3/30/17 3:20 p.m., she confirmed the discrepanceies on the Medication Records from (MONTH) (YEAR) through (MONTH) (YEAR). Continued interview revealed that she was unable to give an explanation for the medication discrepancies. Review of the Facility Policy and procedures titled, Administering Medications Version 2.0, Accucheck Blood Sugar Testing and Insulin Administration revealed that all detail the steps for correct documentation of the testing and administration processes: 1.) Date, time, blood glucose level. 2.) Type and amount of insulin administered and the injection site. 3.) If blood glucose level is above or below normal range, document the time the physician was notified. 4.) Any results achieved and when those results were observed. 5.) Signature and file.", "filedate": "2020-09-01"}
{"rowid": 71, "facility_name": "WILLIAM BREMAN JEWISH HOME, THE", "facility_id": 115022, "address": "3150 HOWELL MILL ROAD N.W.", "city": "ATLANTA", "state": "GA", "zip": 30327, "inspection_date": "2017-03-30", "deficiency_tag": 314, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "U5BR11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy review, and staff interviews, the facility failed to ensure that one resident (R#64) pressure ulcer measurements were completed weekly from a total sample of 35 residents. Findings include: Review of the Documentation section of the facility's Pressure Ulcer Treatment policy and procedure revealed that following wound care, the wound appearance, including wound bed, edges, and presence of drainage should be documented. All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound should be documented. Review of R #64's clinical record revealed that he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of his Admission Minimum Data Set ((MDS) dated [DATE] noted that he had one Stage 2 pressure ulcer which was present on admission. Review of an impaired skin integrity care plan developed on 2/24/17 revealed that R #64 had a Stage 2 abrasion to his left buttock. Review of his Braden Scale (a tool used to predict pressure ulcer development) dated 3/10/17 revealed a score of 14 (moderate risk for development of a pressure ulcer). Review of an [MEDICATION NAME] lab test dated 3/13/17 revealed a result of 1.5 (normal 3.5-5.0). Review of R #64's Wound Evaluation Form revealed that he had a Stage II pressure wound to the left buttock. On 2/24/17, the wound was measured as 1.5 cm (centimeters) long by 0.1 cm wide. On 3/3/17, the wound measurements were recorded as 1.0 cm long by 0.5 cm wide. On 3/10/17, the wound was measured as 0.5 cm long by 0 cm wide. Further review of all three of these wound assessments revealed that the depth was left blank in the Size sections of the form. During interview with the Assistant Director of Nursing (ADON) on 3/30/17 at 1:19 p.m., she stated that the nurse that measured and described the wound should have recorded the depth on the Wound Evaluation Form. During further interview, the ADON verified that this had not been done for R #64's left buttock pressure ulcer, and that the nurse should have recorded a 0 (zero) if the wound had no depth. Review of R #64's impaired skin integrity care plan dated 3/16/17 revealed that he had developed a Stage 2 darkish hue boggy blister to the left heel measuring 2.0 cm by 1.0 cm. Review of a Wound Evaluation Form for this left heel pressure ulcer revealed that the only assessment documented was on 3/16/17. Further review of this form revealed that the left heel had eschar in the wound bed. Review of computerized nurse's notes revealed no documentation of the left heel wound measurements and appearance. Review of physician's orders [REDACTED]. On 3/29/17 at 6:43 a.m., Licensed Practical Nurse (LPN) CC was observed performing R #64's left heel wound care. During this observation, no blister was seen, and the left heel appeared to have eschar in the wound bed surrounded by pink tissue. During interview with LPN DD on 3/30/17 at 10:18 a.m., she stated that the 11:00 p.m. to 7:00 a.m. shift nurse did the dressing changes, wound measurements and staging. During interview with the ADON on 3/30/17 at 1:19 p.m., she stated that there was an RN (Registered Nurse) on the night shift that measured and described wounds weekly. The ADON verified that there was no documentation on the Wound Evaluation Form after 3/16/17 for the left heel wound, and the only measurements she could find in the nurse's notes was on 3/18/17. Review of this note revealed the measurement was for the left buttock wound, not for the heel wound. The ADON further stated that if the heel wound contained eschar, that it would be unstageable, but the treatment would remain the same. During interview with the ADON on 3/30/17 at 3:27 p.m., she stated that she was not able to find a facility policy that specified how often wound assessments and measurements should be done. Review of the facility's Wound Evaluation Form revealed to COMPLETE SECTION BELOW (with date, size, stage, drainage, wound bed, undermining/tunneling, and periwound) WHEN AN ULCER IS FIRST DISCOVERED AND ON A WEEKLY BASIS THEREAFTER.", "filedate": "2020-09-01"}
{"rowid": 72, "facility_name": "WILLIAM BREMAN JEWISH HOME, THE", "facility_id": 115022, "address": "3150 HOWELL MILL ROAD N.W.", "city": "ATLANTA", "state": "GA", "zip": 30327, "inspection_date": "2017-03-30", "deficiency_tag": 328, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "U5BR11", "inspection_text": "Based on observations, record review, policy and procedure review, and staff interviews the facility failed to maintain clean inlet filters on oxygen concentrators for five residents (R) receiving oxygen therapy ( R#80, R#182, R#181, R#111, R#96). The sample size was 7 residents receiving oxygen therapy via oxygen concentrators. Findings include: 1. Observation on 3/28/17 at 2:47 p.m. revealed R # 182 lying in bed awake receiving oxygen by nasal cannula at 3 liters per minute (LPM). The concentrator had one filter on the right side of the machine, coated in a thick layer of dust. Physician order: oxygen at 3 liters by nasal cannula every shift. Observation on 3/29/17 at 9:47 a.m. revealed R # 182 lying in bed awake receiving oxygen by nasal cannula at 3 liters per minute (LPM). The concentrator had one filter on the right side of the machine, coated in a thick layer of dust. 2. Observation on 3/28/17 at 3:22 p.m. revealed R # 181 lying in bed with eyes closed receiving oxygen by nasal cannula at 2 liters per minute (LPM). The concentrator had one filter on the right side of the machine, coated in a thick layer of dust. Physician order: oxygen 2 - 5 liters as needed by nasal cannula to keep oxygen level above ninety (90) percent. Observation on 3/29/17 at 9:48 a.m. revealed R # 181 lying in bed with eyes closed receiving oxygen by nasal cannula at 2 liters per minute (LPM). The concentrator had one filter on the right side of the machine, coated in a thick layer of dust. 3. Observation on 3/28/17 at 3:35 p.m. revealed R # 111 seated in recliner chair at bedside receiving oxygen by nasal cannula at 3 liters per minute (LPM). The concentrator had one filter on the right side of the machine, coated in a thick layer of dust. Physician order: oxygen continuously at 3 liters by by nasal cannula at night and 3 liters as needed during the day. Observation on 3/29/17 at 10:26 a.m. revealed R # 111 asleep in bed, private sitter at bedside. R # 111 is receiving oxygen by nasal cannula at 3 liters per minute (LPM). The concentrator had one filter on the right side of the machine, coated in a thick layer of dust. 4. Observation on 3/28/17 at 3:38 p.m. revealed R # 96 lying in recliner chair at bedside receiving oxygen by nasal cannula at 2 liters per minute (LPM). The concentrator had one filter on the right side of the machine, coated in a thick layer of dust. Physician order: oxygen continuously at 2 liters by nasal cannula or face mask to keep saturation above ninety (90) percent. Observation on 3/29/17 at 10:06 a.m. revealed R # 96 in bed, CNA at bedside providing morning care. R # 96 is receiving oxygen by nasal cannula at 2 liters per minute(LPM). The concentrator had one filter on the right side of the machine, coated in a thick layer of dust. Observation with the Director of Nursing (DON) on 3/29/17 from 4:35 p.m. to 4:58 p.m. confirmed the oxygen concentrators for R # 181, R # 182, R # 111, R # 207 had one filter on the right side of the machine coated with dust. Facility Policy on Departmental (Respiratory Therapy) - Prevention of Infection stated that filters from oxygen concentrators should be washed every 7 days with soap and water, rinse and squeeze dry, allow filter to dry prior to replacing back into machine. Telephone interview with LPN AA on 3/30/17 at 10:45 a.m. Stated that she works 3rd shift on the 3rd floor, and part of her duties include cleaning the oxygen concentrator filters on that floor weekly every Thursday, but she was off last week Thursday and Friday. Stated also that she did not follow up on 3/27/17 to ensure the oxygen concentrator filters were cleaned after resuming her normal work schedule. Telephone interview with LPN BB on 3/30/17 at 11:19 a.m. stated that she works 3rd shift on the 2nd floor and part of her duties include cleaning the oxygen concentrator filters on that floor with soap and water, air dry, and replace them every Thursday of every week, but forgot to clean them last week. Telephone interview with LPN CC on 3/30/17 at 3:00 p.m. stated that she started working on the 5th floor 3rd shift Wednesday last week, but did not clean the oxygen concentrator filters on that floor because she was not told during orientation that it was part of her duties to get the filters cleaned every week. Stated that she was only given that information yesterday by her supervisor. Interview with DON on 3/30/17 at 11:05 a.m. stated that there was no flow sheet or documentation to show when the oxygen concentrator filters were cleaned. However, she stated that as of yesterday she added a flow sheet to the Treatment Administration Record for all residents receiving oxygen. 5. On 3/27/17 at 12:53 p.m., the filter on the back of R #80's oxygen concentrator was observed to be covered with a thick coating of a white, dust-like material. Further observation at this time revealed that the tubing for the nasal cannula that delivered the oxygen to the resident was dated 3/21. During observation on 3/27/17 at 4:15 p.m. and 3/28/17 at 9:10 a.m., the nasal cannula tubing was dated 3/27/17, 7-3 (7:00 a.m. to 3:00 p.m. shift). Further observation revealed that there was still a thick coating of a white dust-like material on the oxygen concentrator filter.", "filedate": "2020-09-01"}
{"rowid": 73, "facility_name": "GLENWOOD HEALTH AND REHABILITATION CENTER", "facility_id": 115025, "address": "4115 GLENWOOD RD", "city": "DECATUR", "state": "GA", "zip": 30032, "inspection_date": "2016-07-28", "deficiency_tag": 226, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "44GN11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of facility policy, the facility failed to ensure the abuse policy and procedure was followed to ensure 1 of 1 allegations of abuse was thoroughly investigated for 1 of 1 residents reviewed for abuse. (Resident #45) Findings include: On 7/25/16 at 3:30 PM, the Executive Director provided a policy titled Verification of Investigation of Alleged Mistreatment, Abuse, Neglect, Injuries of Unknown Source and Misappropriation of Resident Property Guideline, dated 3/2002 and revised 2013, and indicated the policy was the one currently used by the facility. The policy indicated .In the event of an alleged violation .involving mistreatment, neglect, abuse, injuries of unknown source or misappropriation of property, the center investigates the alleged violation thoroughly and reports the results of all investigation to the Executive Director as well as to state agencies as required by state and federal law. Investigation is conducted per the nursing policy Reporting Alleged Violations and documented on the Verification of Investigation form. Documentation reflects resident assessment; record reviews and sufficient employees/individuals were interviewed to derive at conclusion findings .Event Investigation: .The Executive Director, Director of Nursing or designee will initiate an event investigation immediately after the occurrence .2. Interview all people involved in the event. Discuss the event with associates involved, but DO NOT take written statements .8. Determine what recommendation or interventions have been or will be taken to prevent recurrence On 7/27/16 at 8:58 [NAME]M., record review indicated Resident # 45 was originally admitted to the facility on [DATE] with the most recent readmission on 7/15/16 with [DIAGNOSES REDACTED].diabetes mellitus type II, obesity, [MEDICAL CONDITION] and [MEDICAL CONDITION] A quarterly MDS (Minimum Data Set) assessment, completed on 5/11/16, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident had normal cognition, the resident had no hallucinations or delusions, required extensive 2 person transfer assist and was independent for locomotion off of the unit. A sign out/in log for all appointment and leave of absence (LOA) form for Resident #45 indicated I, the responsible person named below, hereby accept complete responsibility for the above named resident, while away from (facility name). I will complete this form on departure from (facility name) and return to (facility name) . The sign in/out log indicated the resident signed himself out LOA on 7/7/16 at 11:51 [NAME]M. and returned to the facility on [DATE] at 2:30 P.M. A nurse note, dated 7/8/16 at 10:31 P.M., indicated received resident in bed sleeping, which was not the normal behavior. Writer could not wake the resident to take evening medications, vs (vital signs) blood pressure: 102/65, spo2 (oxygen saturation) 93%, blood sugar 165. Family members (mother and sister) visited because he did not answer their calls. Writer notified his NP (nurse practitioner), advised to hold BP (blood pressure) medications only for this evening. Will continue to monitor. A nurse note, dated 7/9/16 at 11:23 [NAME]M., indicated change of condition altered mental status. Resident received this morning in his bed, very difficult to wake up. Resident was unable to say any word but 'yes Mam', very slow to arouse, unable to swallow, very poor left hand grip tongue protruding from mouth which is not normal. Resident is on ABT (antibiotic)[MEDICATION NAME] mg (milligrams) for urinary tract infection [MEDICAL CONDITION] but was not given this morning because resident was unable to swallow, VS (vital signs) 97.6, 74, 18, 135/64, O2 (oxygen) saturation (sat) 93 at room air, O2 applied at 3 l (liters)/m (minute) and O2 sat went up to 97%. NP notified and she came and assessed resident, order received to send resident to emergency room (ER) on a 911. Resident sent to ER. Residents mother called and notified, resident left facility at 10:30 [NAME]M. A laboratory report, dated 7/9/16, indicated Resident #45 had a urine drug screen completed the test indicated the resident tested positive for cocaine and opiates. A consultation from the hospital dated 7/10/16, indicated history of present illness: a [AGE] year old male with a history of [MEDICAL CONDITION] secondary to a fall, hypertension, diabetes, recurrent UTI (urinary tract infection) and [MEDICAL CONDITION]. He presented to the emergency room via EMS due to altered mental status. It was reported that normally he is able to carry on conversation and feed himself and yesterday he was found to be very confused and unable to do any of the activities of daily living that he normally does. (Resident ' s name) was actually recently admitted to (hospital name) from (MONTH) 30th to (MONTH) 2nd due to a UTI. At that time, he also presented with altered mental status and [MEDICAL CONDITION]. Urine drug screen was done, interestingly was positive for cocaine and opiates. An Incident report, dated 7/11/16, was faxed to the Department of Health Regulation Division. The report indicated date and time of incident: 7/10/16. Details of incident: Resident was sent to (hospital name) due to altered mental status. Hospital called facility and stated that it was abuse on our part because (resident name) tested positive for cocaine. Physician notified: YES. Steps taken by facility to prevent further incidents: blank A 5 day follow up investigation, dated 7/15/16, was faxed to the Department of Health Regulation Division. The report indicated the resident was sent to (hospital name) due to altered mental status. Hospital called facility and stated that it was abuse on the facility's part because (resident name) tested positive for cocaine. Case Manager from the hospital contacted the facility and informed the facility that the hospital doctor believed this was abuse because the resident tested positive for cocaine. Because the potential allegation of abuse was present, the facility self-reported this incident. Details of the investigation: Executive Director, Admissions Director and hospital liaison met with the specific doctor that made the statement (allegation) at (hospital name). After speaking directly to the specific doctor making the statement, the doctor informed the Executive Director and all parties at the meeting that she was not aware that the resident in question was able to get around and/or sign themselves out to go into the community. The doctor initially believed that since the resident was paraplegic, that the resident was bed ridden. She also stated that she never suggested or agreed that the hospital case manager should document or contact the facility with an allegation of abuse as to it was merely her opinion. She was speaking from her opinion without fully understanding the resident's ability to leave the facility. It was explained to the doctor that this resident signs himself out, and leaves the facility for hours. The resident also catches transportation to move throughout the city and the resident is self-responsible. After receiving more information in regards to the resident's ability and resident rights, the doctor apologized for the allegation and stated that maybe I should ask questions first before using words like abuse or neglect. Conclusion: Facility concluded that this was a non-substantiated allegation. Facility will continue to monitor and respond to all allegations from residents, family members and all interested parties. Plan: Facility will continue to monitor for any allegations of abuse, neglect or any other incident involving its resident and staff. During an interview, on 7/27/16 at 2:30 P.M., Employee DD indicated she was the charge nurse on duty the morning of 7/9/16. She indicated she could not figure out what was causing the residents change in his mental status other than he was having increased pain from leg spasms and was on pain medication for this. She indicated the resident does not have many visitors other than his mother but she had a recent accident and has not been able to come to the facility. She indicated the resident is his own legal representative, he is alert and oriented and signs himself out for LOA's. She indicated she has never seen the resident come back from a leave of absence impaired. During an interview, on 7/27/16 at 2:50 P.M., Employee JJ indicated she was on duty the day of 7/9/16 and observed the change in mental status for the resident and reported it to the charge nurse and the charge nurse assessed the resident and sent him to the emergency room for an evaluation. She indicated the resident goes LOA and takes the Transport bus by himself and is not accompanied by anyone. She indicated he is usually gone just a couple of hours and has never seen him return from a LOA impaired. During an interview, on 7/27/16 at 3:30 P.M., the DON (Director of Nursing) indicated on the evening of 7/10/16 the evening supervisor contacted her and indicated a case worker from the hospital called the nursing facility and indicated the resident had a drug screen completed and tested positive for cocaine, and the doctor at the hospital feels the facility was negligent and it was abuse on the facilities part because the resident tested positive for cocaine. The DON indicated she did not interview any residents or staff as part of the investigation because of confidentiality, she indicated she notified the Executive Director and turned the investigation over to him. During an interview, on 7/27/16 at 3:35 PM, the Executive Director indicated the facility was made aware of the situation on 7/10/16 an incident report was completed and faxed to the state and an investigation was started. The ED (Executive Director) indicated the 5 day follow up investigation was completed and faxed to the state on 7/15/16. The ED indicated the investigation consisted of obtaining an appointment with the physician at the hospital where the resident was transferred to and discussed the allegation of abuse/neglect and that the resident was his own legal representative and did leave the facility on LOA's. The ED indicated he did interview staff verbally but there was no written documentation of this. On 7/27/16 at 5:15 P.M., the Executive Director presented 2 written statements from employees and indicated these were the 2 employees that were verbally interviewed regarding the situation but was never documented on paper until 7/27/16. Letter #1, dated 7/27/16, (resident name) was readmitted to the unit on 7/15/16. Prior to his arrival, a verbal report was called to the receiving nurse. This report stated that the resident was positive for cocaine abuse. I asked (resident name) if he was aware of the above and he stated emphatically that the hospital made a mistake and that if needed he was willing to have a repeat blood test. He stated that has never been my lifestyle. I informed (resident name) that I did not have an order to do a blood test but that it was ill advised for him to continue taking illegal drugs. Letter #2, dated 7/27/16, upon residents return from the hospital on [DATE] writer interviewed resident about dx (diagnosis) cocaine abuse per hospital report. Writer explained and educated the resident regarding cocaine especially since he's already on multiple pain medications. Resident denied any cocaine use and stated that I got wrong information. He stated that his mom already spoke to the hospital because they have misidentified somebody's blood as his. An Admission Agreement, undated, was received from the Director of Nursing on 7/28/16. The Admission Agreement indicated: .Drug and Medication: No medications (including non- prescription items such as aspirin or vitamins) are to be brought in for residents in this facility .Personal Choice: Entering and Leaving the Nursing Home: You have the right to enter and leave the nursing home as you choose, unless medically contraindicated as determined by your physician in accordance with state law. The facility may require you to inform it at the time you are leaving and re-entering the nursing home's grounds .", "filedate": "2020-09-01"}
{"rowid": 74, "facility_name": "GLENWOOD HEALTH AND REHABILITATION CENTER", "facility_id": 115025, "address": "4115 GLENWOOD RD", "city": "DECATUR", "state": "GA", "zip": 30032, "inspection_date": "2016-07-28", "deficiency_tag": 253, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "44GN11", "inspection_text": "Based on observation, interview, record, and facility vendor service agreement review, the facility failed to maintain dining areas and two (2) resident rooms on the Magnolia Wing in clean and sanitary condition. Findings include: Review of the current Vendor's Master Service Agreement revealed the following: -Services hereunder shall consist of housekeeping and laundry services provided on a scheduled and on call basis. - Areas to be serviced: Cafeteria and dining areas. Clean baseboards. Clean and sanitize lavatory and toilet bowls . - All laundry equipment is the property of GGNSC (Golden Living Center) Party, and all repairs and maintenance of such equipment are the GGNSC Party sole responsibility. - - Each GGNSC Party shall at all times keep and maintain all laundry equipment in good operating condition and repair in accordance with manufacturer's recommendations and applicable law and such equipment shall have sufficient capacity to permit laundry and linen items to be processed by Vendor in a timely and efficient manner. 1. On 7/26/16 at 9:19 AM, Resident #117 room was observed standing near her bed. Residents ' bed control was lying on the bed spread. The bed control had exposed wires and there was some type of black sticky substance all over the back of it. 2. On 7/25/16 at 10:12 AM, Resident #143's bathroom was observed to have several dried splattered brown stains on the wall and on the outside of the toilet. Resident #143 stated We share with people in the other room also. 3. At 11:00 am during observation of the Magnolia Wing dining areas, there was a buildup of dirt in the corners and along the base boards of both dining areas. Residents were sitting in the dining area after participating in an activity. At 11:10 AM the Environmental Manager (EM) was queried about cleaning of the dining areas, particularly the floors. EM stated We have two people here on the 3 to 11 PM shift. One person is in laundry and the other person is doing the floors. On 7/27/16 at 9:25 AM, an interview was conducted with the Regional Environmental Manager (REM). REM was taken to the dining areas on the Magnolia Wing and shown the black dirty substance in the corners and along the base boards. REM stated Yes we need to do better with these areas. REM agreed the dirt on the floor, in the corners and along the base boards in the dining area should have been addressed by the housekeeping staff. On 7/27/16 at 9:40 AM an environmental tour was conducted with the Director of Nursing (DON) and Executive Director. Observed Resident #117 ' s bed control with wires exposed and sticky black substance. Dining area in which housekeeping staff had begun to clean and strip the floor. Resident #143 ' s bathroom wall and toilet with splattered brown stains were brought to their attention. They both agreed that these things needed to be addressed immediately. The facility failed to provide a clean and sanitary environment for the residents on the Magnolia wing.", "filedate": "2020-09-01"}
{"rowid": 75, "facility_name": "GLENWOOD HEALTH AND REHABILITATION CENTER", "facility_id": 115025, "address": "4115 GLENWOOD RD", "city": "DECATUR", "state": "GA", "zip": 30032, "inspection_date": "2016-07-28", "deficiency_tag": 254, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "44GN11", "inspection_text": "Based on observation, interview, and review of the Vendor's Master Service Agreement the facility failed to provide four (4) sampled residents (Residents #3, #117, #143 and #213) out of 31 residents sampled with clean bed linen, mattresses and pillows in good condition. Findings include: Review of the current Vendor's Master Service Agreement revealed the following: -Services hereunder shall consist of housekeeping and laundry services provided on a scheduled and on call basis. - Areas to be serviced: Cafeteria and dining areas. Clean baseboards. Clean and sanitize lavatory and toilet bowls . - All laundry equipment is the property of GGNSC (Golden Living Center) Party, and all repairs and maintenance of such equipment are the GGNSC Party sole responsibility. -- - Each GGNSC Party shall at all times keep and maintain all laundry equipment in good operating condition and repair in accordance with manufacturer's recommendations and applicable law and such equipment shall have sufficient capacity to permit laundry and linen items to be processed by Vendor in a timely and efficient manner. 1. Observation and interview on 7/25/16 at 5:19 PM revealed Resident #3's pillow cover cracked and in disrepair. Resident #3 stated I don't like it. 2. During observation and interview with Resident #213 on 7/25/16 at 5:57 PM the resident stated that his bed pillow and mattress were filthy. Observed the resident's stained malodorous pillow and soiled malodorous mattress. Resident #213 stated the mattress was uncomfortable to him. 3. On 7/26/16 at 9:19 AM, entered Resident # 117's room. Resident #117 ' s bed was observed to be made up with a blanket that had a large tear in it. When asked to see the linen on the bed, the resident pulled back the blanket and there were multiple brown, yellow and green stains on the sheet. Resident removed the pillow case and the pillow had multiple brown stains all over it. CNA MM entered the resident ' s room and when asked how often the linen was changed. CNA MM replied CNA on night shift gets some of the people up. Linen should be changed every other day. The person that gets her up should change it because they see it. Needs to be changed. 4. On 7/26/16 at 10:12 AM, Resident # 143 ' s room was observed, resident had a dull, dingy colored pillow on the bed. When the resident pulled back the bed linen and exposed a flattened mattress with a faded blue cover on it. Resident #143 stated I have to fold it (pillow) in half to put my head on it and the mattress is not very comfortable but I guess that's all they have . On 7/27/16 at 9:40 AM, environmental tour was conducted with the Director of Nursing (DON) and Executive Director. Resident #117 who had brown stained pillow, torn bedspread. Resident #143 rooms who had flattened dingy colored pillow and mattress, bathroom wall and toilet with splattered brown stains were brought to management staff attention. They both agreed that these things needed to be addressed immediately and began to have staff remove the torn bedspread and bring new pillows to the resident ' s rooms. Interview and observation on 7/27/16 at 10:06 AM with the Director of Nursing Services (DNS) revealed Resident #3's pillow cover was cracked and flaking. Additionally, resident #213's pillow and mattress were observed heavily soiled. The DNS stated that she would replace both pillows and Resident #213's mattress. DNS stated will have the staff to audit all resident mattresses and pillows today", "filedate": "2020-09-01"}
{"rowid": 76, "facility_name": "GLENWOOD HEALTH AND REHABILITATION CENTER", "facility_id": 115025, "address": "4115 GLENWOOD RD", "city": "DECATUR", "state": "GA", "zip": 30032, "inspection_date": "2016-07-28", "deficiency_tag": 279, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "44GN11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to develop a written comprehensive care plan for 1 of 5 residents reviewed for unnecessary medications. (Resident #12) Findings include: On 7/28/16 at 9:40 [NAME]M., record review indicated Resident #12's [DIAGNOSES REDACTED].diabetes type II, major [MEDICAL CONDITIONS], [MEDICAL CONDITIONS] and anxiety A significant change MDS (Minimum Data Set) assessment, completed on 6/20/16, documented Resident #12 had an active [DIAGNOSES REDACTED]. The current physician's orders [REDACTED]. The sliding scale orders were: 0-59 give 0 units, notify physician if blood sugar below 60 60-199 give 0 units 200-249 give 4 units 250-300 give 6 units, 301-349 give 8 units, 350-400 give 10 units, if blood sugar above 401 notify the physician. The [MEDICATION NAME]was originally ordered on [DATE] and the Humalog sliding scale insulin was ordered on [DATE]. On 7/28/16 at 11:00 [NAME]M., the care plans for Resident #12 was reviewed there was no care plan for the resident ' s [DIAGNOSES REDACTED]. During an interview, on 7/28/16 at 11:15 [NAME]M., Employee EE stated Resident #12 did not have a care plan in place for her [DIAGNOSES REDACTED]. During an interview, on 7/28/16 at 11:30 [NAME]M., the Director of Nursing stated the facility does not have a policy regarding the development of a care plan they go by the RAI (Resident Assessment Instrument) standards. During an interview, on 7/28/16 at 12:04 P.M., Employee FF stated Resident #12 was diagnosed with [REDACTED]. Employee FF indicated when the resident has a new [DIAGNOSES REDACTED]. The facility failed to develop comprehensive care plans for resident receiving insulin.", "filedate": "2020-09-01"}
{"rowid": 77, "facility_name": "GLENWOOD HEALTH AND REHABILITATION CENTER", "facility_id": 115025, "address": "4115 GLENWOOD RD", "city": "DECATUR", "state": "GA", "zip": 30032, "inspection_date": "2016-07-28", "deficiency_tag": 323, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "44GN11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record, and facility policy review, the facility failed to provide adequate supervision for 1 sampled resident (Resident #61) from a sampled 31 residents. On 4/26/16 Resident #61 had expressed a desire to leave the facility, however the resident could not leave the facility unless accompanied by a family member. The facility was not aware the resident had left the facility unsupervised until 10 pm on 4/26/16. Findings include: Review of the facility's policy titled Elopement revised 2013 revealed the following information elopement is defined as that situation where a resident with impaired decision making ability , who is oblivious to his/her own safety, needs and therefore at risk for injury outside the confines of the living center, has left the living center without knowledge of staff. Review of Resident #61's active clinical record revealed the resident was readmitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Minimum Data Set (MDS), Medicare 30 day, indicated the resident was cognitively intact with a score of 13. -Quarterly MDS, dated [DATE] indicated the resident displayed no wandering behavior not exhibited and required supervision with all activities of daily living. Review of Care plans initiated on 3/11/16 revealed the following: Focus: - Resident #61 has impaired neurological status related to: Parkinson's disease, Dementia Focus: I forget things and can become anxious and it can create possible safety risks for me related to [DIAGNOSES REDACTED]. Review of the resident ' s progress notes revealed a late entry note dated 4/26/16 11:02Note Text: Resident noted to have left the faciity on this date without signing out. Resident's emergency contact person was called to determine if resident was picked up early for pending discharge. Family denies discharging resident early and stated that they were unaware of where resident may have gone. Resident was scheduled to be discharged to a PCH on 4-27-16 and was aware of this plan. Resident was present during discharge care plan meeting and was in agreement with discharge. Facility notified appropriate authorities and followed facility protocol for procedural variance. Resident is discharged from facility. The facility ' s investigation concerning this incident contained staff interviews and review of the facility monitoring tape. The investigation documents staff first identified the resident as missing around 10:45 PM, when it was noticed by the 3- 11 shift Charge Nurse who did not give the resident his medication because he was not in his room. Evening shift nurse stated medications were not administered to the resident during the shift since he was not present. CNA also reported to the charge nurse that she did not see the resident early in the shift. Documentation indicated on 4/26/16, before noon the resident was at the Dogwood unit and approached the nurse ' s station requesting to be signed out. Resident was told at that time that sister or niece needs to be with resident in order for him to sign out. Staff was aware that the resident wanted to leave the facility and the front desk was notified to keep an eye out for the resident. Review of facility ' s staff statements indicated housekeeping staff saw Resident #61 on the[NAME]bus at 3:30 pm and then the resident transferred to the[NAME]train between 4:00 - 4:15 pm. Afternoon Nurse PP stated I was assigned to Resident #61 around 5:00 pm when I was informed that the nurse who was supposed to come in for the GA/Dogwood cart (unit where resident ' s room was located) had not shown up . Between 7:30 - 8:00 pm I was asked by the CNA where Resident #61 was. I told her I wasn ' t ' sure and to ask the nurse assigned to him to see if she had seen him. Shortly thereafter when the primary nurse assigned to Resident #61 asked me had I seen him I stated that I had not seen him since around 2:30 pm in the front lobby looking out of the window On 7/25/16 at 4:39 PM. interview with Social Worker CC was conducted concerning residents who are assessed for elopement risk. SW CC stated the facility has a safety committee that meets concerning all residents who are risk for elopement. An assessment is completed and those who are risk for elopement have wander-guard bracelets placed on them. Social worker completes an elopement care plan for those residents at risk and the 3-11 PM nurses check all wander guards, to make sure the residents have them on. On 7/28/16 at 2:40 PM, the Director of Nursing (DON) and the Executive Director were interviewed concerning Resident # 61 who went missing from the facility on 4/26/16. The Executive Director stated the resident was not considered an elopement risk because he had never left the grounds before that day without anyone with him. Also, the resident was aware that he was being discharged to a personal care home the next day. When asked about the resident's [DIAGNOSES REDACTED]. We watched the tape and he planned to leave, He timed when the bus was coming and walked right out there and got on the bus. When asked why staff did not know the resident had left until 10:45 PM. the Executive Director and the DON both stated he was a very social guy and was rarely in his room. Executive Director and DON were asked why Resident #61 was being discharged to a personal care home, for what reason. Executive Director replied he was being discharged to a personal care home because that is where his family wanted him to go . When asked about the care plan that indicated the resident forgot things, became anxious and this was noted to create safety risks for the resident. DON stated he could make his needs known The facility was aware the resident wanted to leave but failed to provide closer monitoring of the resident ' s whereabouts. Several hours went by before the facility realized the resident was missing.", "filedate": "2020-09-01"}
{"rowid": 78, "facility_name": "GLENWOOD HEALTH AND REHABILITATION CENTER", "facility_id": 115025, "address": "4115 GLENWOOD RD", "city": "DECATUR", "state": "GA", "zip": 30032, "inspection_date": "2016-07-28", "deficiency_tag": 328, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "44GN11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and facility policy review the facility failed to ensure 1 resident (Resident #128) of 31 residents sampled, received the prescribed amount of enteral nutrition within a 24 hour timeframe. Findings include: Review of the facility's policy titled Administration of Enteral Feeding last reviewed 11/02/15 indicated Procedure: to ensure all residents who receive enteral feeding receive the appropriate care and services. - check physician orders-formula, amount, rate, flushes, and residual parameters. -document the amount of formula administered, the amount of free water administered and any exceptions noted with the administration of enteral feeding to the resident. On 7/26/16 at 9:17 a.m., Resident # 128 was observed in bed asleep with the head of the bed (HOB) at 45 degrees. A full bottle (1500 milliliters) of Osmolyte 1.0 (liquid nutrition) dated 7/26/16 at 4:30 AM was hanging on a pole connected to an infusion pump. The pump was turned off and the tubing was capped and draped over the pole. At 12:00 PM CNA JJ was observed with Resident #128 lying flat in the bed, providing incontinence care. The pump remained turned off On 7/26/16 at 2:20 PM, Resident #128 was observed in bed, HOB at 45 degrees, tube feeding (TF) was infusing at 75 ml/hr., no flush bag hanging. On 7/27/2016 9:15 AM , Resident #128 was observed in hospital gown in bed with 1500 ml (full bottle) of Osmolyte 1.0, dated 7/27 at 5:15 AM hanging on infusion pump pole capped and not connected to resident, not infusing. At 10:23 AM Resident #128 remained in bed and TF, remained off. Review of the Physician order [REDACTED].) for 22 hours to provide 1650 kilocalorie's in 1650 ml of volume. Every 2 hours flush peg tube with 200 ml of water. On 7/27/16 at 11:14 AM LPN KK was queried about the infusion times for Resident #128 ' s tube feeding and how often did the resident receives a flush. LPN KK responded it should be up for 12 hours and off for 8 hours. It was infusing when I came in but I turned it off to give medication. When asked why is the bottle still full. LPN KK offered no response. When asked how often he gives the resident flushes, LPN KK responded 200 ml every 4 hours. ON 7/27/16 at 11:20 AM, DON, & Executive Director were present on the unit and were asked if staff document daily how much TF was infused on Resident #128. DON responded staff does not document the amount of TF that is infused. DON was asked to check the pump in order to see the amount infused on the TF pump. Pump indicated 254 ml had been infused but a full bottle of TF was hanging. DON reviewed the physician order [REDACTED]. x 22 hours. When asked how the facility ensures the ordered amount is being infused daily when there is no documentation to indicate amount infused. DON and Executive Director stated We will began having staff document the amount of TF infused on each shift. The facility failed to ensure that Resident #128 received the prescribed enteral nutrition.", "filedate": "2020-09-01"}
{"rowid": 79, "facility_name": "GLENWOOD HEALTH AND REHABILITATION CENTER", "facility_id": 115025, "address": "4115 GLENWOOD RD", "city": "DECATUR", "state": "GA", "zip": 30032, "inspection_date": "2016-07-28", "deficiency_tag": 431, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "44GN11", "inspection_text": "Based on observation and interview, the facility failed to ensure expired medications were removed from 2 of 5 medication storage rooms, reviewed for medication storage. (Georgia and Dogwood) Findings include: On 7-27-2016 at 3:46 P.M., the policy entitled, Medication Storage in the Facility, Storage of Medications, was provided by the Assistant Administrative Director, and reviewed. The policy indicated, Procedures .H. Outdated, contaminated, or deteriorated medications .are immediately removed from inventory, disposed of according to procedures for medication disposal On 7-27-2016 at 10:02 [NAME]M., an observation of the medication storage room on Georgia Unit, was conducted with Employee G[NAME] A box labeled Heparin Lock Flush Solution, USP 10USP Heparin units/mL, was observed in the upper cabinet to the left of the locked medication storage refrigerator, and had an expiration date of (MONTH) 29, 2014. The box contained 13 preloaded and individually packaged Posi Flush Heparin Lock Flush Syringes. Each of the 13 individually packaged Heparin Flush syringes were labeled with the expiration date of (MONTH) 29, 2014. An interview at the time of the observation with Employee GG, indicated the out dated Heparin Lock Flush Solution, should have been removed from the medication storage room and discarded upon expiration. The employee indicated it was the responsibility of the nursing staff to look for and remove expired medications from the medication storage rooms. On 7-27-2016 at 10:28 [NAME]M., an observation of the medication storage room on Dogwood Unit, was conducted with Employee HH. 3 individual IV (intravenous) medications were observed in the locked medication storage refrigerator. Each of the 3 medications were labeled, Meropenem one gram (Merrem 1 GM) 100 ML IV infusion, and each had it's own stamped expiration date. The expiration dates were 6/08/2016, 6/13/2016, and 6/10/2016. An interview at the time of the observation with Employee HH, indicated the out dated Meropenem IV medication should have been removed from the medication storage refrigerator and discarded upon expiration. Employee HH indicated it was the responsibility of all nursing staff to check for expired medications and discard them per facility protocol.", "filedate": "2020-09-01"}
{"rowid": 80, "facility_name": "GLENWOOD HEALTH AND REHABILITATION CENTER", "facility_id": 115025, "address": "4115 GLENWOOD RD", "city": "DECATUR", "state": "GA", "zip": 30032, "inspection_date": "2016-07-28", "deficiency_tag": 441, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "44GN11", "inspection_text": "Based on observation, interview, and review of the facility vendor service agreement, it was determined the facility failed to handle and transport linens to prevent cross-contamination between dirty and clean linen in the laundry room. Findings include: Review of the current Vendor's Master Service Agreement revealed the following: -Services hereunder shall consist of housekeeping and laundry services provided on a scheduled and on call basis. - Areas to be serviced: Cafeteria and dining areas. Clean baseboards. Clean and sanitize lavatory and toilet bowls . - All laundry equipment is the property of GGNSC (Golden Living Center) Party, and all repairs and maintenance of such equipment are the GGNSC Party sole responsibility. Each GGNSC Party shall at all times keep and maintain all laundry equipment in good operating condition and repair in accordance with manufacturer's recommendations and applicable law and such equipment shall have sufficient capacity to permit laundry and linen items to be processed by Vendor in a timely and efficient manner. During a tour of the laundry on 7/27/16 at 9:19 AM interview with the housekeeping and laundry director (AA) and observation of the physical layout of the laundry's clean and dirty areas revealed the laundry from the Magnolia wing that is adjacent to the laundry in delivered into a corridor outside the laundry. There is no direct access into the dirty laundry room. The laundry must be transported through the clean laundry room in close proximity to the front door of the dryers. Interview with AA (the Environmental Services Director) during the observation of the laundry revealed a door was needed between the hallway and the dirty laundry room to prevent cross contamination of clean clothing from the dirty laundry transported through the clean room. Additionally, a barrel containing mop heads and towels was observed at the junction between the clean and dirty rooms. AA stated the items in the barrel were clean but then instructed the staff to re-wash the mop heads and towels that were in the barrel because they were contaminated and dirty. There were open bags of dirty laundry piled in large bins in the dirty laundry that had spilled out of the bins onto the floor of the laundry room. Observation of the clean laundry folding area during the same observation on 7/27/16 at 9:19 AM revealed towels, linen, and resident laundry draped on a desk and spilling out of barrels onto the floor. AA explained that the linen that was observed dragging on the floor was going to be discarded because it was stained and tattered. Interview with the Director of Nursing Service (DNS) 07/27/2016 10:37 AM regarding the laundry revealed that she would notify the Executive Director of the cross-contamination potential between the dirty and clean clothing as soon as possible. 07/27/2016 12:03:40 PM interview with the Regional Director for Environmental Services in the conference room revealed the concern of cross-contamination of dirty laundry going into the clean room before going into the washing area had been discussed in past years. The facility considered the cost of an additional door into the laundry through a support wall prohibitive and the discussion ceased because of the age of the building.", "filedate": "2020-09-01"}
{"rowid": 81, "facility_name": "GLENWOOD HEALTH AND REHABILITATION CENTER", "facility_id": 115025, "address": "4115 GLENWOOD RD", "city": "DECATUR", "state": "GA", "zip": 30032, "inspection_date": "2016-07-28", "deficiency_tag": 456, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "44GN11", "inspection_text": "Based on observation, interview and review of the vendor service agreement , the facility failed to keep the 3 (#1, #2, #3) of 4 laundry's washing machines in good working order. Findings include: Review of the current Vendor's Master Service Agreement revealed the following: -Services hereunder shall consist of housekeeping and laundry services provided on a scheduled and on call basis. - Areas to be serviced: Cafeteria and dining areas. Clean baseboards. Clean and sanitize lavatory and toilet bowls . - All laundry equipment is the property of GGNSC (Golden Living Center) Party, and all repairs and maintenance of such equipment are the GGNSC Party sole responsibility. Each GGNSC Party shall at all times keep and maintain all laundry equipment in good operating condition and repair in accordance with manufacturer's recommendations and applicable law and such equipment shall have sufficient capacity to permit laundry and linen items to be processed by Vendor in a timely and efficient manner. During tour of the laundry with AA (the Environmental Services Director) on 7/27/16 at 9:19 AM 2 (#1, #3) of 4 washing machines were observed leaking large pools of water onto the laundry room floor. The facility staff stemmed the flow of water with bedspreads. 07/27/2016 12:03 PM interview with the Regional Director for Environmental Services in the conference room revealed that AA had contacted the laundry washer manufacturer regarding the leaking washers and was waiting for documentation/call logs from the company. Follow-up interview with AA on 07/27/2016 4:25 PM in the day room revealed the technician from Laundry Equipment Sales responded to his call today and repaired the washers (#1 and #3). On 07/28/2016 at 12:52 PM observation and interview with AA revealed that the washing machines #1 was not leaking. However, new leaks were observed from washer #2 and washer #3.", "filedate": "2020-09-01"}
{"rowid": 82, "facility_name": "GLENWOOD HEALTH AND REHABILITATION CENTER", "facility_id": 115025, "address": "4115 GLENWOOD RD", "city": "DECATUR", "state": "GA", "zip": 30032, "inspection_date": "2018-11-01", "deficiency_tag": 604, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "GW4111", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews, and review of facility policy, the facility failed to ensure that one (1) of 35 sampled residents (R) (R#44) was free from a physical restraint. While R#44 was seated in a high-back wheelchair, the resident's legs were strapped together for approximately three (3) hours, and the resident was unable to move her legs. The findings included: Review of R#44's clinical record revealed the resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of R#44's Significant Change Minimum Data Set (MDS) assessment dated [DATE] and her Quarterly MDS dated [DATE] revealed the resident was severely cognitively impaired and had no physical behaviors. R#44 required extensive to total assistance for all activities of daily living (ADLs) and utilized a wheelchair for mobility. The resident had no falls during either assessment period. R#44 received no therapy services and no restraints or alarms were used during either assessment period. Review of R#44's ADL care plan dated 11/4/17 noted R#44 had an ADL self-care performance deficit related to (r/t) Alzheimer's and weakness. Goal for R#44 was to maintain current level of function in ADLs thru the review date. Interventions included: Dressing: receives total to extensive assist with one staff support; Bathing/hygiene - she receives shower 3 times per week with total assist from staff. Staff will trim her nails as needed (prn); encourage active participation in tasks; Bed mobility: requires total to extensive assistance by 1- to 2 (1-2) staff to reposition in bed and as necessary; Eating: requires extensive assistance with eating; Transfer: requires total assist by 1-2 staff to move between surfaces; Observe/document/report prn any changes any potential for improvement, reasons for self-care deficit, expected course, declines in function; Praise all efforts at self-care; physical therapy/occupational therapy (PT/OT) evaluation and treatment as per MD (doctors) orders. The care plan did not reference the use of a restraint. Review of R#44's fall care plan dated 11/4/17 revealed the resident was a moderate risk for falls r/t confusion and being unaware of safety needs. Interventions included: Anticipate and meet the resident's needs; Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed; Ensure that the resident is wearing appropriate footwear rubber sole bottoms and describe correct client footwear; Review information on past falls and attempt to determine cause of falls. Record possible root causes. After remove any potential causes if possible. Educate resident/family/caregiver/IDT (Interdisciplinary Team) as to causes; and transfer with mechanical lift with the assistance of two staff. The care plan did not reference the use of a restraint. Review of R#44's OT Discharge Summary dated 6/21/18 noted Patient will demonstrate increase in upright sitting posture for 30 minutes in order to participate in social activities within the unit and for environmental orientation with use of appropriate seating device .wheelchair modification and adaptation including providing a high back recline chair, a saddle wedge cushion to improve posture for social interaction and comfort during meals. Staff education on positioning technique and application and care . Review of R#44's physician's orders [REDACTED].>Review of the Magnolia Assignment Sheet dated 10/31/18 revealed a Certified Nursing Assistant (CNA) was assigned to R#44. Review of the Magnolia Assignment Sheet dated 10/31/18 noted CNA FF was assigned to the resident for the 7:00 a.m. - 3:00 p.m. shift. Observations in R#44's room on 10/29/18 at 12:40 p.m. revealed the resident was in bed and appeared to be sleeping. A high-back wheelchair was sitting next to the resident's bed and a cushion had been placed in the seat of the wheelchair. Observations in the common area day room of Magnolia Hall on 10/31/18 at 10:00 a.m. revealed R#44 was sitting in a high-back wheelchair. R#44 was not seated correctly in the wheelchair and the resident's bottom was sliding forward in the seat of the chair. R#44's feet were positioned on the wheelchair's padded footrests, and the resident's legs were held together directly below the knees with a black strap that buckled in the front of the resident's legs. Interview at this time with R#44's Unit Manager (UM) CC confirmed the strap around the resident's legs was restricting the resident's movement, and R#44 was not able to unbuckle the strap without assistance. UM CC said the strap should not be in place and stated she would get with therapy to find out about the positioning/placement of the strap. When asked about the staff responsible for getting the resident up this morning, UM CC said she'd have to check with the 11 p.m. -7:00 a.m. shift staff because that's who got her up this morning. When asked if the resident had been checked and changed since that time, UM CC said the resident had been and she would determine who was responsible for taking care of the resident during the day shift (today). Observation on 10/31/18 at 10:10 a.m. in the therapy department revealed four (4) therapy staff re-positioned the resident in the wheelchair and discovered that the cushion in the seat of the wheelchair had been placed backwards in the seat. During this observation an interview with Certified Occupational Therapist Assistant (COTA) DD confirmed the strap should not have been buckled around the resident's knees/legs. COTA DD said the cushion in the wheelchair was an anti-thrust cushion used to prevent R#44 from sliding forward in the chair. COTA DD said, when the cushion is placed in the seat of the wheelchair correctly, the strap of the cushion should be buckled underneath the set of the wheelchair. During a follow-up interview at the nurses' station with UM CC on 10/31/18 at 11:35 a.m. UM CC again stated that the 11:00 p.m. - 7:00 a.m. staff assisted the resident in getting up this morning. UM CC stated the 7:00 a.m. - 3:00 p.m. staff who was assigned to R#44 this morning became ill and had to go home early from her shift. UM CC said the 7:00 a.m. - 3:00 p.m. staff did toilet the resident before she went home early due to illness. UM CC said there were no other staff working with the resident on the morning of 10/31/18. Interview on 10/31/18 at 12:45 p.m. in the hallway of Magnolia unit with Licensed Practical Nurse (LPN) EE revealed the nurse was not aware of the staff who was responsible for getting the resident up that morning. Interview on 11/1/18 at 12:00 p.m. with the facility's Director of Nursing (DON) revealed UM CC informed her on 10/31/18 that R#44's legs had been inappropriately and improperly restrained with the seat cushion's straps and buckle. Interview on 11/1/18 at 12:39 p.m. at the nurses' station with Certified Nursing Assistant (CNA) FF revealed she was assigned to R#44 on the morning of 10/31/18; however, the overnight staff had already dressed and gotten R#44 up that morning. CNA FF said she did see the overnight CNA wheel R#44 out to the common area around 7:10 a.m. on the morning of 10/31/18, but CNA FF did not notice that the resident's legs were restrained. CNA FF said she got sick about an hour into her shift and then left for home around 8:00 a.m. The aide said she did not toilet R#44 before leaving the facility on the morning of 10/31/18. CNA FF said she was aware that the strap to the cushion was to be buckled underneath the seat of the wheelchair. Review of the facility's Restraint Management policy revised (MONTH) (YEAR) noted: Restraints are implemented in accordance with State and Federal regulations. If indicated, the least restrictive restraint is used for the least amount of time. Restraints are not used as a disciplinary action or for the convenience of the facility to control behavior .Definitions - Physical Restraint is any manual method, physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body .Examples of Physical Restraints - Physical restraints include, but are not limited to, leg restraints, hand mitts, soft ties, lap cushions, and lap trays the resident cannot remove easily. The reason for the restraint must be documented in the resident's plan of care.", "filedate": "2020-09-01"}
{"rowid": 83, "facility_name": "GLENWOOD HEALTH AND REHABILITATION CENTER", "facility_id": 115025, "address": "4115 GLENWOOD RD", "city": "DECATUR", "state": "GA", "zip": 30032, "inspection_date": "2018-11-01", "deficiency_tag": 880, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "GW4111", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and facility policy review, the facility failed to utilize proper hand hygiene prior to performing wound care for one of two residents, Resident (R) #15. Improper hand hygiene can promote the spread of infection in a facility. Findings include: R#15 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Wound Evaluation and Management Summary note dated 10/30/18 revealed the resident was admitted to the facility with the following wounds: Stage 4 pressure wound to the sacrum measuring 5.5 x 7.5 x 0.5 centimeters (cm). Stage 4 pressure wound of the right ischium measuring 1.8 x 3.5 x 1cm. Stage 4 pressure wound of the left ischium measuring 3 x 4.5 x 2.5 cm. The Wound Evaluation and Management Summary stated that the dressings were to be changed daily. Review of the facility policy titled Hand Hygiene dated 2012 stated Using an alcohol-based hand rub is appropriate after contact with inanimate objects in the patient's environment. Review of the facility policy titled Artificial Finger Nails stated the following: I. Length of nails: Fingernails should be kept clean, healthy, and short (1.4 inch or less beyond the tip of the finger.) II: Artificial nails: Artificial nails or nails enhancements should not be worn by any person whose responsibilities include handling of sterile supplies and/or direct hands-on resident contact. III. Nail polish: If used, nail polish should not be chipped. Studies have demonstrated that chipped nail polish may support the growth of organisms on the fingernails. If nail polish is worn, it should not be worn for more than 4 days. At the end of 4 days, nail polish should be removed and freshly reapplied. During an observation of wound care on 10/31/18 at 11:00 a.m. Licensed Practical Nurse (LPN) AA set up supplies to change R#15's dressing on the left ischium. She was observed to have long nails with chipped and worn polish and confirmed that they were artificial. LPN AA sanitized her hands with alcohol rub, then reached into her pocket, retrieved the keys to the treatment cart and opened it. She then opened several drawers on the cart and began to open dressings and dropped them onto a clean field. After touching the treatment cart and opening several drawers, she removed unsterile gauze from a packet without sanitizing her hands, put them into a cup, applied wound cleanser and then used them to clean R#15's wound. During an interview with LPN AA on 11/1/18 at 12:07 p.m., she revealed that she thought she could have artificial nails if she kept them short. An interview with Registered Nurse (RN) BB, Wound Care Coordinator revealed that she was unaware of a facility policy advising staff providing direct patient care should not wear artificial nails. During an interview with the Assistant Director of Nursing (ADON) Infection Control Nurse, on 11/1/18 at 12:24 p.m., she confirmed that the facility policy prohibited direct care staff from wearing artificial nails. She also confirmed that LPN AA should have sanitized her hands prior to removing the unsterile gauze for wound care, and that by not doing so she had contaminated her hands.", "filedate": "2020-09-01"}
{"rowid": 84, "facility_name": "GLENWOOD HEALTH AND REHABILITATION CENTER", "facility_id": 115025, "address": "4115 GLENWOOD RD", "city": "DECATUR", "state": "GA", "zip": 30032, "inspection_date": "2017-11-08", "deficiency_tag": 272, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "FY6A11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to accurately assess dental status for one resident (#46). Sample size was 35 residents. Findings include: Resident #46 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) annual reassessment dated [DATE] was completed by staff. Review of this MDS assessment, including the accompanying Care Area Assessments (CAA's), revealed the facility staff failed to accurately assess this residents dental status. During interview on 11/3/2017 at 4:47 p.m., MDS nurse AA confirmed that R #46 was not accurately coded on the Annual Reassessment MDS or included in the CA[NAME] She stated that reassessments are done by face to face visits. She further stated that she may be confusing this resident with another. If she is made aware of a miscoding by staff or herself, then she will make a modification. She could not find a dental assessment on his record.", "filedate": "2020-09-01"}
{"rowid": 85, "facility_name": "GLENWOOD HEALTH AND REHABILITATION CENTER", "facility_id": 115025, "address": "4115 GLENWOOD RD", "city": "DECATUR", "state": "GA", "zip": 30032, "inspection_date": "2017-11-08", "deficiency_tag": 281, "scope_severity": "D", "complaint": 1, "standard": 1, "eventid": "FY6A11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, review of the Georgia Practice Act for Registered Nurses (RN) and Licensed Practical Nurses (LPN), staff and family interviews the facility failed to ensure that resident vital signs were monitored per the Physician orders [REDACTED].#_), that Physician orders [REDACTED].#6) that received [MEDICATION NAME] injection, that nurses were conducting narcotic reconciliation per the facility's policy for one resident (R#201) reviewed for use of injectable [MEDICATION NAME] and that nurses were confirming that the pharmacy label for medications corresponded with the physician's orders [REDACTED].#201 and R#137). The resident sample was 35. Findings include: Review of the Georgia Practice Act for Registered Nurses 2.2.2: Standards Related to Registered Nurse Responsibility for Nursing Practice Implementation. [NAME] Implements treatments and therapy, including medication administration, delegated medicals and independent nursing functions. Review of the Georgia Practice Act for Licensed Practical Nurses 2.3.2: Responsibilities for Nursing Practice Implementation. [NAME] Implements appropriate aspects of client care in a timely manner. 1. Provides assigned and delegated aspects of client's health care plan. 2. Implements treatments and procedures. 2. Administers medications accurately. K. Documents care provided. 1. Review of the Controlled Substance Accountability Sheet for R#6 revealed a pharmacy medication label with an original date of 5/23/17 for [MEDICATION NAME] INJ 2MG/ML (2 milligrams per milliliter) [MEDICATION NAME]- Inject 0.5ML (0.25ML). Review of the Physician order [REDACTED]. Review of the MAR indicated [REDACTED]. Interview on 11/3/17 at 1:50 p.m. with the DON and the Consulting Pharmacist (CP) confirmed that R#6 does not have an order for [REDACTED].#6, they should have notified the nursing supervisor and an order for [REDACTED]. 2. Review of the policy titled Controlled Drugs dated (MONTH) 2005 and revised (MONTH) 2011 documented: To ensure that controlled drugs are inventoried and administered as required by State and Federal agencies: 1. Maintain a declining inventory record by resident by drug on all controlled drugs. Records must be accurate and include: *Name of resident *Prescription number and name of issuing pharmacy *Drug name and strength *Medication form *Route of administration *Strength and dose administered *Date and time of administration *Signature of the person administering the drug 2. Reconcile the declining inventory record at the beginning and the end of each shift. Reconciliation is performed by a physical count of the remaining medication by two persons who are legally authorized to administer medications. Observation on 11/2/17 at 1:50 p.m. with LPN CC and Unit Manager LPN DD of the West Wing storage medication refrigerator on 11/2/17 at 1:50 p.m. revealed a plastic package with four vials of [MEDICATION NAME]. The label read; 2MG/ML, Inject 1MG (0.25ML) intramuscularly every four hours as needed, prescribed to R#201. Review of the Controlled Substance Accountability Sheet with LPN CC revealed the last dated entry of dispense was 10/31/17 with a remaining quantity of five vials. LPN CC and the Unit Manager, LPN DD looked in the refrigerator and were unable to locate the fifth vial of [MEDICATION NAME]. Interview on 11/2/17 at 1:58 p.m. with LPN CC revealed she had not conducted a count of the [MEDICATION NAME] in the West Wing medication storage refrigerator because the night shift nurse had to leave early due to an emergency. LPN CC confirmed that she signed the Change of Shift Controlled Substances Count Sheet but that she had only counted the narcotics in her assigned medication cart, but not the narcotics in the medication storage refrigerator. Interview with the Director of Nursing (DON) on 11/2/17 at 3:55 p.m. revealed that after an investigation it was discovered that on 10/28/17, R#201 was having [MEDICAL CONDITION] and LPN CC administered [MEDICATION NAME] on the dayshift. The DON stated that the LPN CC never signed out the [MEDICATION NAME] on the Controlled Substance Accountability Sheet on 10/28/17. The DON stated that if the nurses had been properly conducting narcotic counts as they are supposed to each shift, the discrepancy would have been discovered on 10/28/17 during the 3:00 p.m. count. The DON confirmed that the nursing staff had been signing off with their signatures on the Change of Shift Controlled Substances Count Sheet, that narcotic counts had been conducted. Review of the Change of Shift Controlled Substances Count Sheet revealed signed signatures from the Nurse Departing from Duty and the Nurse Arriving on Duty indicating that all narcotics had been accounted for on the following dates and time: 10/28/17 at 3:00 p.m., 11:00 p.m., 10/29/17 at 7:00 a.m., 3:00 p.m., 11:00 p.m., 10/30/17 at 7:00 a.m., 3:00 p.m., 11:00 p.m., 10/31/17 at 7:00 a.m., 3:00 p.m., 11:00 p.m., 11/1/17 at 7:00 a.m., 3:00 p.m., 11:00 p.m. and 11/2/17 at 7:00 a.m. A total of 15 shift narcotic counts were documented by nurses indicating that five vials of [MEDICATION NAME] prescribed to R#201 was remaining. Cross refer to F431 3. Record Review for R#201 revealed a Physician order [REDACTED]. Review of the pharmacy label for [MEDICATION NAME] indicated Inject 1 MG (.25ml) every four hours as needed for [MEDICAL CONDITION]. Review of the Medication Administration Record [REDACTED]. Review of the Controlled Substance Accountability Sheet indicated the amount administered 1 on 9/3/17 and 9/9/17. Record review for R#137 revealed a Physician order [REDACTED]. Review of the pharmacy label for [MEDICATION NAME] with original date of 10/27/17 indicated Inject Intramuscularly 1 vial every eight hours. [MEDICATION NAME] INJ 2MG/ML. Review of the Controlled Substance Accountability Sheet indicated [MEDICATION NAME] was dispensed on 10/28/17 at 3:00 a.m., 11:00 a.m. and 1:00 p.m. with amount administered 1. Interview on 11/3/17 at 12:30 p.m. with the DON and the Consulting Pharmacist (CP) confirmed that the pharmacy label for [MEDICATION NAME] and the order for [MEDICATION NAME] on the facility's Physician order [REDACTED].", "filedate": "2020-09-01"}
{"rowid": 86, "facility_name": "GLENWOOD HEALTH AND REHABILITATION CENTER", "facility_id": 115025, "address": "4115 GLENWOOD RD", "city": "DECATUR", "state": "GA", "zip": 30032, "inspection_date": "2017-11-08", "deficiency_tag": 323, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "FY6A11", "inspection_text": "Based on observation and interview, the facility failed to assure electrical safety in five rooms on two of five units where an electrical power strip was used to provide electricity to multiple medical devices. The sample size was 35 residents. Findings include: 1. Observation on 11/1/2017 at 11:04 a.m., on the Magnolia Unit, revealed room 117 a with a power strip sitting on the floor at the head of the bed. The power strip was not affixed to the wall but plugged into an electrical outlet to the right of the hospital bed. Connected to the power strip and supplying electrical current was a hospital bed. 2. Observation on 11/1/2017 at 11:14 a.m., on the East Unit, revealed three resident rooms (103 b, 106, and 121 c) with power strips affixed to the wall and plugged into an electrical outlet. Connected to the power strips and supplying electrical current were hospital beds, feeding pump and oxygen concentrators. 3. Observation on 11/1/2017 at 11:14 a.m., on the East Unit, revealed room 120 d with two power strips connected to each other and affixed to the wall. Connected to the power strips and supplying electrical current was a hospital bed and oxygen machine. 4. Observation on 11/1/2017 at 11:32 a.m., on the Georgia Unit, revealed a power strip in use in the dining room. The power strip was supplying electricity to the communal television and was noted to be hanging from the television and plugged into outlet in the wall. Interview on 11/3/2017 at 10:35 a.m., with Environmental Supervisor, stated he knows that powers trips can be used for residents personal equipment such as personal fans, phone chargers, radios, and televisions. He further stated he was not aware that power strips could not be used with Medical equipment.", "filedate": "2020-09-01"}
{"rowid": 87, "facility_name": "GLENWOOD HEALTH AND REHABILITATION CENTER", "facility_id": 115025, "address": "4115 GLENWOOD RD", "city": "DECATUR", "state": "GA", "zip": 30032, "inspection_date": "2017-11-08", "deficiency_tag": 372, "scope_severity": "F", "complaint": 0, "standard": 1, "eventid": "FY6A11", "inspection_text": "Based on observation and interviews, the facility failed to ensure that the surrounding area of one of one dumpster was maintained free of garbage and debris; and failed to secure two of three grease barrel lids to prevent insect and rodent infestation. Findings include: A tour of the dumpster area was conducted on 11/01/2017 at 11:08 a.m. revealed the following concerns: there was a pile of weathered garbage, containing paper trash and vinyl gloves, approximately three feet behind dumpster in a grass area; there was broken and damaged chairs stored behind the dumpster. Furthermore, three grease barrels are located beside the dumpster, and two of the three barrels had lids that were unsealed and ajar. On 11/2/2017 at 12:25 p.m. during an interview with the Corporate Dietary Manager, he stated that he was not aware the grease barrels were not able to be sealed. He stated that he would contact the company,[NAME]Industries, to order the locking rings that seal the barrels and lids. He also stated that the trash and debris around the dumpster was not the responsibility of the kitchen staff. On 11/3/2017 at 10:35 a.m., with Environmental Supervisor, stated that he orders a roll-off dumpster monthly to haul off the damaged furniture and equipment stored outside the dietary department. On 11/3/2017 at 11:04 a.m. during an interview with the Assistant Administration, he stated that there was no written policy or process related to the maintenance of the dumpster area. He stated that the Maintenance Department is responsible for the upkeep of the exterior grounds, including trash and debris around the dumpster.", "filedate": "2020-09-01"}
{"rowid": 88, "facility_name": "GLENWOOD HEALTH AND REHABILITATION CENTER", "facility_id": 115025, "address": "4115 GLENWOOD RD", "city": "DECATUR", "state": "GA", "zip": 30032, "inspection_date": "2017-11-08", "deficiency_tag": 425, "scope_severity": "D", "complaint": 1, "standard": 1, "eventid": "FY6A11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interviews, the facility's Dispensing Pharmacy failed to ensure an accurate dosage on the pharmacy medication label for one resident (R#201) that received Ativan liquid injection and failed to ensure that Physician orders [REDACTED]. orders [REDACTED].#137 and R#201). The resident sample was 35. Findings include: 1. Record review for R#137 revealed a physician's orders [REDACTED]. Review of the medication pharmacy label on the plastic bag containing vials of Ativan 2MG/ML, prescribed to R#137 indicated Inject Intramuscularly 1 vial every eight hours. Interview with the Consulting Pharmacist (CP) on 11/3/17 at 1:55 p.m. revealed she does conduct random audits and selects random medication carts. She stated she checks the control sheet for narcotics and ensures that the medication count matches what is on the control sheet. The CP further stated she does check the narcotics in the medication storage refrigerators but only to check for expiration dates and the correct amount of medication. She stated she does not check for the accuracy of the pharmacy label to ensure that it matches the facility's Physician order. Interview on 11/3/17 at 5:00 p.m. with the Dispensing Pharmacist (DP) revealed that narcotic medications orders have to be reordered after six months. He stated the order for Ativan 1 MG injection previously prescribed for R#137 on 3/28/17 could no longer be filled. He stated the pharmacy received an order directly from the physician's office on 10/27/17 for Inject Intramuscularly 1 Vial every 8 hours quantity five and five remaining. The DP stated the facility would have to call for the remaining five vials. The DP stated the prescription does not read PRN (as needed). The DP stated there are several dispensing pharmacist and per the system notes, the pharmacist called the facility and documented that the prescription was reported to LPN KK and two other staff names. The DP stated that no last names were documented in the notes and he is unable to confirm if the actual prescription was faxed to the facility. Interview on 11/3/17 at 6:42 p.m. with Unit Manager LPN KK revealed that the prescription for IM Ativan for R#137 had expired so she called the Physician's office and asked them to send a new prescription. The Nurse at the Physician's office stated that she sent a prescription for IM Ativan directly to the pharmacy. LPN KK stated that the Pharmacy then called to clarify the order and she was telling them not to send multi dose vials and to send the 1ML vials. The Pharmacy asked her to call the physician's office back for a new prescription for a single dose vial. LPN KK called the Physician's office back and they stated that were faxing it to the pharmacy right then. LPN KK stated that she expected the order to be the same exact order for Ativan as he had been on for months and the only thing she wanted to make sure is that they send a single dose 1ML vials. LPN KK stated she did not request the new prescription from the pharmacy because it was a renewal. LPN KK stated they did not tell her that the prescription was a change from the previous prescription and they never faxed her the new prescription. LPN KK stated that the nurse should have compared the pharmacy label to the Medication Administration Record [REDACTED]. 2. Record review for R#201 revealed a physician's orders [REDACTED]. Review of the medication pharmacy label on the plastic bag containing vials of Ativan 2MG/ML, prescribed to R#201 indicated Inject 1 MG (0.25ML) IM every four hours as needed with original date of 8/29/17. Interview on 11/3/17 at 5:30 p.m. with the Dispensing Pharmacist (DP) revealed that the prescription order with an original date o 8/29/17 with the medication label that indicates Lorazepam INJ 2MG/ML, Inject 1MG (0.25ml) is a pharmacy error. The DP stated that the correct dosage for 1MG would be 0.5ML, not 0.25ML. The DP stated that the pharmacy technician receives an order and enters the order into the system. The Pharmacist is responsible for checking all orders for accuracy of dates, names, dosages etc. then the pharmacist checks a box indicating that he reviewed the medication. An electronic signature is captured when this box is checked. The DP stated that this check system is only conducted when an order first comes in, not with each refill. The DP further stated that the receiving Pharmacist called the physician's office and clarified that the order should be for 1MG (0.5ml). The DP stated that he could not find documentation in the system notes or fax documentation that the facility was notified when the prescription was changed from the original order. The Pharmacist stated when the currier delivers medications, the facility nurse will reconcile the medication from the manifest sheet to the medications actually in the tote.", "filedate": "2020-09-01"}
{"rowid": 89, "facility_name": "GLENWOOD HEALTH AND REHABILITATION CENTER", "facility_id": 115025, "address": "4115 GLENWOOD RD", "city": "DECATUR", "state": "GA", "zip": 30032, "inspection_date": "2017-11-08", "deficiency_tag": 431, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "FY6A11", "inspection_text": "Based on observation, record review, review of the policy titled Controlled Substance and staff interviews, the facility failed to ensure that a controlled substance, Lorazepam (Ativan) liquid injection, was accounted for in two of four medication storage refrigerators (West Wing Medication Storage Room and Dogwood/Georgia Medication Storage Room). The resident census was 35. Findings include: Review of the policy titled Controlled Drugs dated (MONTH) 2005 and revised (MONTH) 2011 documented: To ensure that controlled drugs are inventoried and administered as required by State and Federal agencies: Maintain a declining inventory record by resident by drug on all controlled drugs. Reconcile the declining inventory record at the beginning and the end of each shift. Reconciliation is performed by a physical count of the remaining medication by two persons who are legally authorized to administer medications. 1. Observation of the West Wing medication storage room on 11/2/17 at 1:50 p.m. revealed a locked refrigerator that when opened by staff contained commonly used medications and a controlled substance, Lorazepam (Ativan) liquid injectable. Observation with Licensed Practical Nurse (LPN) CC revealed a plastic package with four vials of Ativan. The label read; two milligrams per milliliter (2 MG/ML), Inject 1 MG (0.25 ML) intramuscularly every four hours as needed, prescribed to R#201. Review of the Controlled Substance Accountability Sheet with LPN CC revealed the last dated entry of dispense was 10/31/17 with a remaining quantity of five vials. LPN CC and the Unit Manager, LPN DD looked in the refrigerator and were unable to locate the fifth vial of Ativan. Interview on 11/2/17 at 1:58 p.m. with LPN CC revealed she had not conducted a count of the Ativan in the West Wing medication storage refrigerator because the night shift nurse had to leave early due to an emergency. LPN CC stated that the second night shift nurse, LPN EE told her that they had counted narcotics prior to the nurse leaving early. LPN CC confirmed that she signed the Change of Shift Controlled Substances Count Sheet but that she had only counted the narcotics in her assigned medication cart, but not the narcotics in the medication storage refrigerator. Interview on 11/2/17 at 2:24 p.m. with the Unit Manager, LPN DD revealed that if the night shift nurse left early, it would not negate a narcotic count and that LPN CC should have counted the Ativan in the refrigerator with another nurse at the beginning of her shift. Interview with the Director of Nursing (DON) on 11/2/17 at 3:55 p.m. revealed that after an investigation, it was discovered that on 10/28/17 R#201 was having seizures and LPN CC administered Ativan. The DON stated that LPN CC never signed out the Ativan on the Controlled Substance Accountability Sheet on 10/28/17 and did not record the administration of the Ativan on the Medication Administration Record [REDACTED]. The DON stated that if the nurses had been conducting narcotic counts as they are supposed to each shift, the discrepancy would have been discovered on 10/28/17 during the 3:00 p.m. count. The DON confirmed that the nursing staff had been signing off with their signatures on the Change of Shift Controlled Substances Count Sheet, that narcotic counts had been conducted. Review of the Progress Note dated 10/28/17 created by LPN CC at 2:50 p.m. documented: Writer called to resident bedroom at 1:17 p.m. and observe him having a seizure. Timed activity for a full minute. Ativan adm IM. Resident made comfortable. He seemed to quiet down but started seizing again. Shift Supervisor called to room to observe behavior. (Name) hospice nurse called, order to provide comfort measures or send him to their house facility. Resident finally calmed down after several episodes of seizures. VS 112/64, 66, 18, 97.5 (sic) Further review of the Change of Shift Controlled Substances Count Sheet revealed numerous signed signatures from the Nurse Departing from Duty and the Nurse Arriving on Duty indicating that all narcotics had been accounted for on the following dates and times: 10/28/17 at 3:00 p.m., 11:00 p.m., 10/29/17 at 7:00 a.m., 3:00 p.m., 11:00 p.m., 10/30/17 at 7:00 a.m., 3:00 p.m., 11:00 p.m., 10/31/17 at 7:00 a.m., 3:00 p.m., 11:00 p.m., 11/1/17 at 7:00 a.m., 3:00 p.m., 11:00 p.m. and 11/2/17 at 7:00 a.m. A total of 15 shift narcotic counts were documented by nurses indicating that five vials of Ativan prescribed to R#201 was remaining, after a vial was dispensed without record on 10/28/17, leaving only four vials of Ativan. Interview with the Consulting Pharmacist (CP) on 11/3/17 at 1:55 p.m. revealed she does conduct random audits and selects random medication carts. She stated she checks the control sheet for narcotics and ensures that the medication count matches what is on the control sheet. The CP further stated she does check the narcotics in the medication storage refrigerators but only to check for expiration dates and the correct amount of medication. She stated she does not check for the accuracy of the pharmacy label to ensure that it matches the facility's Physician order. Interview on 11/3/17 at 3:45 p.m. with LPN GG confirmed that her signature was on the Change of Shift Controlled Substances Count Sheet between 10/28/17 and 11/2/17. LPN GG stated she counts the narcotics on the medication cart first, then counts the narcotics in the medication storage refrigerator. LPN GG stated that she cannot recall how many vials of Ativan was in the labeled bag prescribed for R#201. Interview on 11/3/17 at 3:55 p.m. with Registered Nurse (RN) HH revealed her signature is on the Change of Shift Controlled Substances Sheet between 10/28/17 and 11/2/17. RN HH revealed that on 10/28/17 (3:00 p.m. - 11:00 p.m.), she started narcotic count on the medication cart but then she received a new admission, then a call from hospice that needed information on a resident and she just got distracted and never made it to the refrigerator to count the Ativan. RN HH stated she should have conducted a narcotic count in the West Wing medication storage refrigerator and that is the protocol but she was just really busy that day at that particular time. Interview on 11/3/17 at 6:07 p.m. with LPN EE revealed she was working on the nightshift (11:00 p.m. - 7:00 a.m.) on 11/1/17 through 11/2/17. She stated that LPN FF was working that evening with her and had to leave early at 6:30 a.m. She stated that she and LPN FF conducted a count of the med cart narcotics, but they had not counted the narcotics in the West Wing medication storage refrigerator. LPN DD stated that the protocol does include counting the narcotics in the refrigerator and it was just overlooked. 2. Observation of the medication storage refrigerator on 11/2/17 at 3:20 p.m. in the Dogwood/Georgia medication storage room revealed a 20MG/10 ML (20 milligrams per 10 milliliters) vial of Ativan prescribed to R#138. The vial did not have graduation marks but appeared to have a 1/4 of liquid Ativan remaining. Review of the Controlled Substance Accountability Sheet indicated that 0.5 ML had been dispensed 10 times on 8/11/17 at 10:00 a.m. and 6:00 p.m., 9/19/17, 9/20/17, 9/21/17, 10/15/17, 10/16/17, 10/21/17, and 10/22/17 at 10:00 a.m. and 5:00 p.m., with 5 ML quantity remaining. Interview on 11/2/17 at 3:25 p.m. with the Unit Manager, LPN JJ revealed that there is no way to measure how much Ativan liquid remains in the 10 ML vial and stated It looks like 5 ML to me. LPN JJ further stated he's never had any problems in the past with the vials coming up short once all doses had been administered. He stated that he called pharmacy and told them that there was no way they could keep track of the Ativan amounts from the 10 ML multi use vial and they were supposed to fix it. Observation with LPN JJ of an unopened 20MG/10 ML Ativan vial was held next to the opened vial. The unopened vial liquid reached the top of the wrap around label and the opened bottle was clearly less than half of the vial. LPN JJ confirmed that if the resident received ten 0.5 ML doses of the Ativan, there should have been 1/2 the liquid left (5 ML) and that the amount of liquid left was only about 1/4 full. Interview with the DON on 11/2/17 at 3:55 p.m. confirmed that with 20MG/10 ML vials of Ativan, there is no way to accurately measure how much Ativan is in the bottle once opened. She confirmed that according to the Controlled Substance Accountability Sheet, R#138 was administered 0.5 ML of Ativan injection 10 times and that there should be 5 ML remaining in the vial. The DON observed an unopened vial of Ativan liquid injection compared to the opened 10 ML vial prescribed to R#138 and confirmed it did not look like it was 1/2 full. The DON immediately removed the 20MG/10 ML vial of Ativan and instructed the Unit Manager, LPN JJ to write up a report, discard the medication and call pharmacy to have it replaced with 1 ML bottles. Interview on 11/3/17 at 12:40 p.m. with the DON revealed she has no way of knowing how much Ativan was in the 20MG/10 ML prescribed to R#138 so she wanted to have the remaining contents drawn up so she could be sure there was 5 ML of liquid remaining. The DON had a nurse come into the room and draw up the remaining Ativan in the 20MG/10 ml vial. The nurse announced once extracted by syringe that there was only 3 ML of Ativan left in the vial. The DON again confirmed that there should have been 5 ML remaining in the vial and there was no way to account for the missing 2 ML of liquid Ativan.", "filedate": "2020-09-01"}
{"rowid": 90, "facility_name": "GLENWOOD HEALTH AND REHABILITATION CENTER", "facility_id": 115025, "address": "4115 GLENWOOD RD", "city": "DECATUR", "state": "GA", "zip": 30032, "inspection_date": "2017-11-08", "deficiency_tag": 441, "scope_severity": "C", "complaint": 0, "standard": 1, "eventid": "FY6A11", "inspection_text": "Based on a review of facility records, policy review, and staff interview, the facility failed to maintain an infection control program designed to provide a sanitary environment for its residents for the period beginning (MONTH) (YEAR) to (MONTH) (YEAR). The facility census was 205. Finding include: Review of the undated Infection Prevention Manual revealed the facility's infection prevention program should include: surveillance of infections; investigation of outbreaks; regular review of the policies and procedures of the program with updates in response to changes; staff education related to infection prevention; incorporation of infection prevention into the quality assurance process; and the utilization of an Infection Preventionist to carry out the daily functions of the infection prevention program. Further review of the Infection Prevention Manual revealed the infection prevention program should also include reporting and documentation mechanisms. The Infection Preventionist is expected to monitor line listings of infections and complete monthly report forms which are reported to the Quality Assurance (QA) Committee and other staff for feedback. The infection preventionist is also expected to monitor and document compliance with infection prevention practices. Review of the facility's infection control program documents revealed documentation that the infection control program was maintained, accordingly, for the periods prior to (MONTH) (YEAR) and after (MONTH) (YEAR). However, the infection control program documents for the period (MONTH) (YEAR) through (MONTH) (YEAR) consisted only of line listings of infections maintained on the individual units of the facility, and facility wide CAI/HAI sheets for the months of (MONTH) (YEAR) and (MONTH) (YEAR) with calculated percentages of infections identified in the facility during those months. Interview on 11/2/17 at 2:15 p.m. with Registered Nurse (RN), BB revealed, she assumed the role of infection preventionist for the facility in (MONTH) (YEAR). Any previous records of the program would need to be obtained from the Director of Nursing (DON). 11/02/2017 2:41:41 PM - Interview with the DON revealed she functioned as the person in charge of the infection control program for the facility from (MONTH) through (MONTH) after the previous infection preventionist left. The DON further revealed that the facility's infection control program was not centralized; each of the five wings/units in the facility kept a line listing of infections on that unit for each month; the DON reviewed these listings at the end of the month, calculated the infection percentages, and took the findings to the QA Committee for month in question; she did not, during that time, maintain a centralized infection control program records nor did maintain copies after the findings after they were taken to the QA Committee.", "filedate": "2020-09-01"}
{"rowid": 91, "facility_name": "GLENWOOD HEALTH AND REHABILITATION CENTER", "facility_id": 115025, "address": "4115 GLENWOOD RD", "city": "DECATUR", "state": "GA", "zip": 30032, "inspection_date": "2017-11-08", "deficiency_tag": 463, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "FY6A11", "inspection_text": "Based on observations, resident and staff interviews, the facility failed to ensure that the call light communication system was functioning adequately to allow residents to call for staff assistance in five rooms (M123, W127, W130, W142, and D214) on three of five units. The facility census was 205 residents. Findings include: Observations on 10/30/17 at 11:27 a.m., during initial tour of resident rooms revealed the following: 1. On the Magnolia Unit, Room 123 bed A, did not have a call light for resident use and the call light casing in the bathroom was loose and partially hanging on wall. 2. On West Unit, Room 127 bed B, Room 130 bed A and Room 142 bed C, the call light was not functioning on initial tour. 3. On Dogwood Unit, Room 214, the call light casing in the bathroom was loose and partially hanging on wall. Interview on 10/30/17 at 12:36 p.m., with the Maintenance Supervisor revealed he had repaired the call lights in rooms M123 bed A bathroom and obtained a functioning call light for 123 bed A; repaired the call lights in W127 bed B, W130 bed A, and W142 bed C; repaired the bathroom call light in D214. He reported that they were now functioning properly.", "filedate": "2020-09-01"}
{"rowid": 92, "facility_name": "GLENWOOD HEALTH AND REHABILITATION CENTER", "facility_id": 115025, "address": "4115 GLENWOOD RD", "city": "DECATUR", "state": "GA", "zip": 30032, "inspection_date": "2017-11-08", "deficiency_tag": 514, "scope_severity": "E", "complaint": 1, "standard": 1, "eventid": "FY6A11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interviews, the facility failed to ensure that the administration, justification, and effectiveness of PRN (as needed) antianxiety medication ([MEDICATION NAME] injection) was consistently documented on the Medication Administration Record (MAR) for five residents (R#6, R#137, R#138, R#201 and R#228) and vital signs were not recorded weekly, for one resident (#11), from (MONTH) (YEAR) until (MONTH) (YEAR). The resident sample was 35. Findings include: 1. Review of the Controlled Substance Accountability Sheet for R#6 revealed a pharmacy medication label with an original date of 5/23/17 for [MEDICATION NAME] INJ 2MG/ML (2 milligrams per milliliter) [MEDICATION NAME]- Inject 0.5 ML (0.25 ML). Review of the Physician order revealed no orders for [MEDICATION NAME] matching the pharmacy medication label. Review of the MAR revealed no order for [MEDICATION NAME] matching the pharmacy medication label, therefor, there was no documentation or evidence that [MEDICATION NAME] 0.25 ML injection had been administered to R#6. Interview on 11/3/17 at 1:50 p.m. with the DON and the Consulting Pharmacist confirmed that R#6 does not have an order for [REDACTED]. The DON stated that the nurses should have noticed that there was no order for [MEDICATION NAME] and no order for [MEDICATION NAME] on the MAR. The DON further stated that the nurses should not have administered [MEDICATION NAME] to R#6, they should have notified the nursing supervisor and an order for [REDACTED]. The DON stated that the nurse receiving the telephone order is responsible for faxing the order to the pharmacy and entering the order into the electronic charting system, which in turn generates the order on the MAR. The DON stated she would have to find out who the nurse was that received the order. 2. Record review for R#137 revealed a Physician order for [REDACTED]. Review of the Controlled Substance Accountability Sheet for R#137 revealed that [MEDICATION NAME] liquid injection was dispensed on 8/1/17 at 8:00 a.m. and 8:00 p.m., 8/2/17 at 4:00 a.m. and 7:35 p.m., 8/3/17 at 6:00 a.m., 9/23/17 at 5:00 a.m., 9/30/17 at 8:00 p.m., 10/1/17 at 4:30 p.m., 10/2/17 at 2:00 p.m., 10/4/17 at 6:00 a.m. and 7:35 p.m., 10/9/17 at 7:454 p.m., 10/11/17 at 6:00 a.m., 10/13/17 at 1:00 a.m., 10/19/17 at (no time), 10/22/17 at 6:00 p.m., and 10/28/17 at 3:00 a.m., 11:00 a.m., and 1:00 p.m. Review of the MAR revealed no documentation or evidence that [MEDICATION NAME] was administered on these dates. 3. Record review for R#138 revealed a Physician's order start date 11/30/16 for [MEDICATION NAME] Solution 2 MG/ML (two milligram per milliliter), Inject 1 MG subcutaneously as needed for unspecified [MEDICAL CONDITION] anxiety, give every six hours PRN (as needed) agitation. Review of the Controlled Substance Accountability Sheet for R#138 revealed 0.5 ML of [MEDICATION NAME] was dispensed on 8/11/17 at 10:00 a.m. and 6:00 p.m., 10/15/17 at 10:00 a.m., 10/16/17 at 2:00 a.m., 10/22/17 at 10:00 a.m. Review of the MAR revealed no documentation or evidence that [MEDICATION NAME] injection was administered on these dates. Interview on 11/3/17 at 1:50 p.m. with the DON and the Consulting Pharmacist confirmed that documentation on the MAR for R#138 was not consistently conducted by the nurses in correlation to the [MEDICATION NAME] dispensed on the Controlled Substance Accountability Sheet. The DON stated that all medications are to be documented on the MAR. 4. Record review for R#201 revealed a Physician order for [REDACTED]. Review of the Controlled Substance Accountability Sheet for R#201 indicated that [MEDICATION NAME] liquid injection was dispensed on 9/10/17 at 6:00 p.m., 9/13/17 at 11:00 a.m., 9/14/17 at 2:00 p.m., 9/22/17 at 9:00 a.m. and 2:00 p.m., 9/29/17 at 11:00 p.m., 10/2/17 at 2:00 a.m. and 10/31/17 at 10:00 p.m. Review of the MAR revealed no documentation or evidence that [MEDICATION NAME] was administered on these dates. Interview on 11/3/17 at 3:45 p.m. with LPN GG revealed that she personally has never administered [MEDICATION NAME] injection for R#201 but it is expected to not only document on the substance control sheet but to execute it on the MAR at the time given, to select the code for justification and also document in the nurse's notes. 5. Record review for R#228 revealed a Physician order for [REDACTED]. Review of the Controlled Substance Accountability Sheet for R#228 revealed [MEDICATION NAME] liquid injection was dispensed on 8/17/17 at 4:00 a.m. Review of the MAR revealed no documentation or evidence that [MEDICATION NAME] was administered on this date. Interview on 11/3/17 at 6:07 p.m. with LPN EE revealed when she administers a narcotic medication, she is expected fill the out the substance control sheet with the date and time, dosage, number of single vials, wasted mount with another nurse/witness. LPN EE further stated she would document in the nurse progress notes and the MAR. On the MAR she must pick the justifying code for administration and it is supposed to be done right then when the narcotic was given not later. LPN EE stated the computer captures the time of entry and alerts the nurse to document the effectiveness. 6. Review of the facility Policy titled Physician Orders policy, dated (MONTH) 2011, indicated the licensed nurse receiving the order verifies the order to ensure it is complete and that it includes: accurate dosage, accurate frequency and duration as applicable. Further review of the Physician Orders policy indicated a physician's order is required prior to the discontinuation of any current order. R#11 was re-admitted to the facility on [DATE], after a hospitalization for an acute [MEDICAL CONDITION]. The resident had the following [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 0, which indicated severe cognitive impairment. Record review of the hospital discharge Physician orders, dated 5/4/17, and handwritten orders with the same date signed by Registered Nurse (RN) KK and signed by the Nurse Practitioner (NP), revealed the resident had the following orders for treatment of [REDACTED]. Review of the electronic Physician Orders dated 5/4/17, signed by RN KK, revealed an order for [REDACTED].>[MEDICATION NAME] 0.1 milligrams (mg)-two tablets-three times per day-for three days only although the orders were signed by the NP. Review of the electronic Medication Administration Record (MAR) for May, June, (MONTH) and (MONTH) (YEAR) the resident's vital signs should be taken and recorded weekly. Further review revealed the resident's vital signs were taken although were not recorded in the record. An interview with RN KK and the Director of Nursing on 11/3/17 at 4:42 p.m. revealed that two nurses review the admission orders [REDACTED]. Review of the computer generated Physician's orders dated 5/4/17 are signed only by RN KK. The DON further revealed that this process, of having two nurses confirm the Physician orders, was not in place until after this error was identified by the surveyor. RN KK revealed that she made an entry error for the [MEDICATION NAME] which was not identified until the survey began on 10/18/17. Interview and review of the electronic Medication Administration Record (MAR), supplied by the DON on 11/8/17 at 6:00 p.m., for June, (MONTH) and (MONTH) (YEAR) revealed that the resident's blood pressure should be taken and recorded weekly since 5/4/17. Review of the MAR revealed a check that the blood pressure was taken although there is no evidence of the results for June, (MONTH) and (MONTH) (YEAR). The DON confirmed that staff did not document the resident blood pressure from (MONTH) 8, (YEAR) until the resident became symptomatic in (MONTH) (YEAR).", "filedate": "2020-09-01"}
{"rowid": 93, "facility_name": "MILLER NURSING HOME", "facility_id": 115039, "address": "206 GRACE ST", "city": "COLQUITT", "state": "GA", "zip": 39837, "inspection_date": "2018-06-28", "deficiency_tag": 640, "scope_severity": "E", "complaint": 1, "standard": 1, "eventid": "KTS211", "inspection_text": "> Based on record review and interview the facility failed to transmit resident Minimum Data Assessment (MDS) assessments timely for eight residents (R4, R2, R17, R20, R14, R7, R26 and R10). The facility census was 98. Findings include: Interview on 06/28/18 at 3:29 p.m. with Registered Nurse (RN) AA regarding the Minimum Data Assessments (MDS) revealed that a (MONTH) 10, (YEAR) batch of resident assessments were downloaded but was not uploaded and that it was that the facility's mistake. RN AA revealed that it is the responsibly of the facility to check to make sure that the assessments are uploaded and confirm that the assessments have been received. RN AA revealed that the 5/10/18 file was saved to Downloads, but was never exported, so there was not a receipt alerting her of the batch. Interview on 6/28/18 at 3:30 p.m. with the Director of Nursing (DON) and RN CC revealed that the MDS nurse in the facility is responsible for making sure the download of assessments is complete. The DON inquired with the MDS assessment nurses as to why the assessments were late. At this time, RN CC revealed that the QI data that is reported monthly is generated by reviewing the Resident Assessment Instrument (RAI) MDS schedule and reporting any assessments that haven't been completed by the RAI assessment due date. RN CC revealed that the 5/10/18 batch had been completed and sent to a zip file to be submitted to CMS, which caused the report to drop off the assessment due report however, it was never taken from the zip file and submitted and this caused the assessments to be sent in late. Interview on 6/28/18 at 3:32 p.m. with CC RN MDS revealed she made a file and uploaded the batch to the file and downloaded it to the site but apparently it did not go through. RN MDS CC revealed that when processing MDS assessments we save a zip file in the charting system and from there we must sign into the Quality Improvement and Evaluation System (QIES) submission website and attach the zip file to the state website; however, on 5/10/18, I failed to complete the second step of the process.", "filedate": "2020-09-01"}
{"rowid": 94, "facility_name": "MILLER NURSING HOME", "facility_id": 115039, "address": "206 GRACE ST", "city": "COLQUITT", "state": "GA", "zip": 39837, "inspection_date": "2017-07-13", "deficiency_tag": 167, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "TBPW11", "inspection_text": "Based on observation and interview, it was determined that the facility failed to make the most recent survey results readily available to residents. Findings include: During an interview on 7/13/17 at 2 p.m., Resident (R) A stated she was unaware of the survey report. During an interview on 7/13/17 at 2:20 p.m., RB stated the he did not know where the survey results were kept. An observation on 7/13/17 at 2:40 p.m. revealed a sign posted on the large bulletin board, located across from the Unit 1 nurses station. The sign documented that the survey results were posted at the Nurses Station to be viewed at anytime. However, an observation of the nurses station revealed no visible survey results posted at that time. Registered Nurse (RN) AA was unable to locate the survey results. The Director of Nursing (DON) was able to locate the survey results in a folder in the drawer, behind the nurses station. She confirmed that the results were kept behind the nurses station.", "filedate": "2020-09-01"}
{"rowid": 95, "facility_name": "MILLER NURSING HOME", "facility_id": 115039, "address": "206 GRACE ST", "city": "COLQUITT", "state": "GA", "zip": 39837, "inspection_date": "2019-11-07", "deficiency_tag": 578, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "C7SX11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, and review of the facility's policy titled, Advance Directives the facility failed to obtain a Physician's signature and a concurring Physician's signature for a Physician order [REDACTED].#55, R#42 and R#117). This deficient practice affected 3 of 7 residents reviewed for Do Not Resuscitate. Findings include: Review of Advance Directives Policy revealed: 2. Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, and/or his/her family members, about the existence of any written advance directives. POLST Additional Guidance for Health Care Professionals III. When a POLST form is signed by an Authorized Person (other than the patient's Health Care Agent) and Attending Physician: I. If Section A indicates Allow Natural Death - Do Not Attempt Resuscitation, this order may be implemented when the patient is a candidate for non-resuscitation as defined in Georgia Code Section 31-39-2(4). A concurring physician signature is Required per Georgia Code Section 31-39-4(c). 1. Review of the medical record for R#55 revealed a POLST with a verbal signature noted for Allow Natural Death with one Physician signature on 9/13/17. There was not any evidence of any documentation that R#55 had a power of attorney for healthcare nor was there a healthcare agent identified. During an interview on 11/5/19 at 4:00 p.m. with the facility's Long-Term Care (LTC) Director revealed that if a resident has a legal next of kin to sign the POLST only one Physician's signature has been gotten and was signed by an authorized person who is not the health care agent. The LTC Director further reported that if there was no legal next of kin two Physician signatures would be needed. The LTC Director reviewed the POLST for R#55 and she confirmed that there was only one Physician signature for R#55. Upon reading the POLST LTC Director acknowledged that a concurring physician's signature was needed when residents do not sign the form and there is not a health care agent. 2. A review of the Quarterly Minimum Data Sets dated 8/20/19 for R#42 revealed that the resident had both long-term and short-term memory problems and was unable to answer the assessment questions. A review of the medical record for R#42 revealed a Physician order [REDACTED]. An interview on 11/6/19 at 10:35 a.m. with the Assistant Director of Nursing confirmed that the resident did not have a healthcare agent and that only one Physician had signed his POLST form. An interview on 11/6/19 at 10:54 a.m. with Social Service CC confirmed that R#42 did not have a healthcare agent on file. Social Service CC brought a POLST in that was signed on 11/6/19 after surveyor inquiry by a second physician. She confirmed that prior to surveyor inquiry that the lack of appropriate signatures for the POLST to be legal had not been identified. 3. A review of the Admission MDS assessment dated [DATE] for R#117 documented both long-term and short-term memory problems with the resident being unable to answer assessment questions. A review of the POLST form dated 4/18/19 for R#117 revealed it was signed by only one Physician, and the responsible party. The resident had no Power of Attorney (POA) or healthcare agent. A review of the Face Sheet identified that R#117 had an Advanced Directive of DNR. An interview on 11/5/19 at 4:06 p.m. with the facility's Long-Term Care (LTC) Director revealed if there was no responsible party or next of kin, we obtain two physician signatures, but if there was a responsible party or a next of kin that they had only been getting one physician signature and the signature of the responsible party. The LTC Director confirmed that based on what was written on the POLST form that there needed to be two concurring Physician signatures if there was no Power of Attorney with a legal healthcare agent. A review of the POLST with the LTC Director for R#117 confirmed that there was the signature of the next of kin and one physician signature and there was no legal healthcare agent for R#117. An interview on 11/6/19 at 11:29 a.m. with the LTC Director again confirmed that R#117 did not have a healthcare agent.", "filedate": "2020-09-01"}
{"rowid": 96, "facility_name": "MILLER NURSING HOME", "facility_id": 115039, "address": "206 GRACE ST", "city": "COLQUITT", "state": "GA", "zip": 39837, "inspection_date": "2019-11-07", "deficiency_tag": 584, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "C7SX11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews the facility failed to ensure the resident fans on the vent unit were clean and free from dust build up for four of 15 rooms on Unit Two (Rooms: 20, 19, 22, 14). Findings include: The following observations were made: On 11/4/19 at 12:21 p.m. in room [ROOM NUMBER] there was a fan sitting on the table at the foot of Bed B that had a buildup of dust. On 11/4/19 at 1:13 p.m. in room [ROOM NUMBER] there was a fan at the end of Bed A with dust buildup. On 11/4/19 at 1:16 p.m. in room [ROOM NUMBER] at the end of bed A there was a fan with dust buildup On 11/5/19 at 8:09 a.m. in room [ROOM NUMBER] there was a fan with black dust buildup on the blades. On 11/5/19 at 3:10 p.m. in room [ROOM NUMBER] there was a fan with thick dust buildup. On 11/5/19 at 3:18 p.m. in room [ROOM NUMBER] there was dust noted on the fan. On 11/5/19 at 3:20 p.m. in room [ROOM NUMBER] there was dust noted on the fan. On 11/6/19 at 9:21 a.m. in room [ROOM NUMBER] there was dust noted on the fan by the sink. On 11/6/19 at 9:22 a.m. in room [ROOM NUMBER] there was dust noted on the fan. On 11/6/19 at 9:23 a.m. in room [ROOM NUMBER] there was dust build up on the fan. On 11/6/19 at 9:24 a.m. in room [ROOM NUMBER] there was dust noted on the fan. During a tour of Unit Two on 11/7/19 at 9:50 a.m. the Director of Nursing (DON) confirmed that in room [ROOM NUMBER] there was dust and buildup on the fan, in room [ROOM NUMBER] there was dust build up on the fan blade and the fan grille, in room [ROOM NUMBER] there was dust build up on the fan grille and, in room [ROOM NUMBER] there was dust build up on the fan and fan grille. During an interview with the DON on 11/7/19 at 9:58 a.m. revealed the Certified Nursing Assistants (CNAs) should clean fans when they are identified as having dust buildup. The DON further revealed that Maintenance should be notified when there is dust on the fan blades. The DON stated that CNAs should be wiping down the fans daily. There is no policy on personal fans and how often they should be cleaned.", "filedate": "2020-09-01"}
{"rowid": 97, "facility_name": "CENTER FOR ADVANCED REHAB AT PARKSIDE, THE", "facility_id": 115040, "address": "110 PARK CITY ROAD", "city": "ROSSVILLE", "state": "GA", "zip": 30741, "inspection_date": "2018-08-23", "deficiency_tag": 583, "scope_severity": "D", "complaint": 1, "standard": 1, "eventid": "07R411", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and staff interview, the facility failed to provide privacy of one resident's (R) body (R#25) during incontinence care and a shower. The sample size was 34 residents. Findings include: Review of R#25's clinical record revealed that she had [DIAGNOSES REDACTED]. Review of R#25's Modification of Annual Minimum Data Set ((MDS) dated [DATE] revealed that she had a Brief Interview for Mental Status (BIMS) score of 9 (a BIMS score of 8 to 12 indicates moderate cognitive impairment); was extensive assistance for personal hygiene and toilet use; and needed physical help in part of bathing activity. On 8/20/18 at 4:13 p.m., Certified Nursing Assistant (CNA) BB was observed performing incontinence care for R#25 with her permission. CNA BB was observed to remove the resident's pants and incontinent brief, had the resident wipe herself with a washcloth, and then the CNA further cleaned the resident's perineal area and buttocks, before placing a clean brief back on her. Further observation revealed that R#25 was in a semi-private room in a bed closest to the window, and the bottom of the window blinds were raised approximately eight inches. Continued observation revealed that her room looked out to the front of the facility, and there was a car parked parallel to the building outside of her window. Further observation revealed that the door to the hallway had never been closed, and the privacy curtain between the two beds in the room had been not been pulled the entire length from wall to wall, leaving an opening of approximately 24 inches. On 8/22/18 at 7:25 a.m., R#25 was observed receiving a shower with her permission in the common shower room on the Mauve Hall by CNAs CC and DD. Continued observation revealed that R#25 pulled up on the grab bar just inside the shower room door, so that the CNA could remove her incontinent brief and pants, and then she sat back down on the shower chair (her shirt was still on). During further observation, another CNA was heard to knock on the shower room door, and CNAs CC and DD responded patient care. Continued observation revealed that this third CNA opened the hallway door into the shower room, and left it open with her head and upper body leaning inside the shower room with R#25 directly ahead, for approximately 15 seconds while she talked to CNAs CC and DD. Continued observation revealed that there was a privacy curtain available between the hallway door and the grab bar where R#25 was seated, but it had not been pulled. During interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) on 8/23/18 at 10:34 a.m., they stated that the blinds to a room should be completely lowered when incontinence care was being provided. The ADON stated during further interview that as long as the resident was covered enough from being seen that the privacy curtain did not necessarily have to be pulled the entire way, but that the hallway door should be closed during perineal care. Review of the facility's Perineal Care policy revised (MONTH) (YEAR) revealed to avoid unnecessary exposure of the resident's body.", "filedate": "2020-09-01"}
{"rowid": 98, "facility_name": "CENTER FOR ADVANCED REHAB AT PARKSIDE, THE", "facility_id": 115040, "address": "110 PARK CITY ROAD", "city": "ROSSVILLE", "state": "GA", "zip": 30741, "inspection_date": "2018-08-23", "deficiency_tag": 689, "scope_severity": "D", "complaint": 1, "standard": 1, "eventid": "07R411", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, resident and staff interview, the facility failed to evaluate the risk of leaving one resident (R) (R#25) unattended while sitting on the side of the bed, resulting in a fall from the bed. The sample size was 34 residents. Findings include: Review of R#25's clinical record revealed that she had [DIAGNOSES REDACTED]. Review of R#25's Modification of Annual Minimum Data Set ((MDS) dated [DATE] revealed that she had a Brief Interview for Mental Status (BIMS) score of 9 (a BIMS score of 8 to 12 indicates moderate cognitive impairment); she needed extensive assistance of two or more persons for transfers; was not steady, only able to stabilize with staff assistance for surface to surface transfer; had functional limitation in range of motion on one side of upper and lower extremities; and had one fall with no injury since prior MDS assessment. During interview with R#25 on 8/20/18 at 4:24 p.m., she stated that she had a fall today when staff was in the room with her. She further stated that she fell off the side of the bed onto the fall mat, and that the staff tried but were unable to catch her from falling. Observation at this time revealed that R#25 was in a bed lowered to the floor with an alarm, a bed rail up on both sides of the mattress, and she had a brace on her left leg. During interview with R#25 on 8/21/18 at 8:38 a.m., she stated that when she was receiving therapy in her room yesterday, the therapist sat her up on the side of the bed and then turned around, and she fell off the bed. During further interview, R#25 stated that she had left arm, back and right-sided facial pain after this fall. Review of incident reports revealed that R#25 had a fall from the wheelchair during a staff transfer on 11/25/17; unwitnessed falls from bed on 2/1/18, 3/30/18, and 6/26/18; and a fall from the bed during therapy on 8/20/18. During an observation of a transfer by Certified Nursing Assistants (CNA) CC and DD on 8/22/18 at 7:25 a.m., the tops of R#25's knees were both noted to be reddened and have skin tears. During interview with CNA CC at this time, she stated that R#25 had a fall on Monday (8/20/18), and she thought it was from that. R#25's left arm and leg were observed to be paralyzed, and she was not able to use them to assist with the transfer. Continued observation revealed that the CNAs placed a gait belt around R#25's waist after sitting her up on the side of the bed, and when CNA CC turned around to prepare the wheelchair and CNA DD did not have a firm grasp on the gait belt, the resident started to drift backwards on the bed before being caught supported by CNA DD. During interview with Physical Therapist Assistant (PT-A) EE on 8/22/18 at 12:43 p.m., she stated that she had heard that R#25 had a fall recently when a therapist was working with her, and that she was sitting on the side of the bed and was left unattended. During interview with Occupational Therapist-Registered (OT-R) FF on 8/22/18 at 1:03 p.m., she stated that on 8/20/18 she was working with R#25 on transfers, range of motion to her left arm and neck, and postural control. She further stated that she sat the resident up on the side of the bed, and that the resident's sitting balance on the side of the bed was fair. She stated during continued interview that she got up to move R#25's wheelchair closer to her, which was about two feet away, and had to go around the back of the wheelchair to unlock it. She further stated that she saw from her peripheral vision that the resident was falling, but was not able to get around the wheelchair and back to her before she fell . She stated during continued interview that the resident's whole body fell on to the fall mat at one time, as she had no protective reflexes from the stroke, and the only thing she complained of was that her head hurt just a little bit. During interview with the Physical Therapy (PT) Rehab Director on 8/22/18 at 1:16 p.m., he stated that R#25 had been assessed by PT and OT as Mod/3 for bed mobility supine to sitting, which meant one-person assist. He stated during further interview that one-person transfer assist would have been sufficient, but that he would have had the wheelchair positioned closer to R#25 and would have let go of the resident when she was sitting up. Review of an Occupational Therapy Treatment Encounter Note(s) for R#25 dated 8/20/18 revealed: This OT positioned this pt (patient) EOB (edge of bed) with pt demonstrating F- (fair minus) balance utilizing RUE (right upper extremity) to maintain balance, OT went to position w/c (wheelchair) to bed in preparation for t/f (transfer). Pt lost balance to left and fell from bed onto floor mat on floor beside bed.", "filedate": "2020-09-01"}
{"rowid": 99, "facility_name": "CENTER FOR ADVANCED REHAB AT PARKSIDE, THE", "facility_id": 115040, "address": "110 PARK CITY ROAD", "city": "ROSSVILLE", "state": "GA", "zip": 30741, "inspection_date": "2018-08-23", "deficiency_tag": 690, "scope_severity": "D", "complaint": 1, "standard": 1, "eventid": "07R411", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, and staff interview, the facility failed to perform perineal care in a manner to prevent potential urinary tract infections [MEDICAL CONDITION] to the extent possible for one resident (R) (R#25). The sample size was 34 residents. Findings include: Review of R#25's clinical record revealed that she had [MEDICAL CONDITION] (paralysis on one side of the body) following a stroke, urine retention, and a history of UTIs. Review of R#25's Modification of Annual Minimum Data Set ((MDS) dated [DATE] revealed that she was always incontinent of urine, and needed extensive assistance for toilet use. Review of R#25's urine cultures revealed infections with the following organisms: 11/14/17: Proteus mirabilis 3/20/18: Proteus mirabilis 5/10/18: [MEDICATION NAME] raffinosus During an observation of incontinence care with R#25's permission by Certified Nursing Assistant (CNA) BB on 8/20/18 at 4:13 p.m., the CNA was observed to obtain and place several wet washcloths on top of the resident's bed rail before removing her incontinent brief, which had a moderate amount of urine in it. Further observation revealed that the CNA asked R#25 if she wanted to wipe herself and she responded yes, and was given one of the wet washcloths. The resident was observed to wipe her right eye with the washcloth, and the CNA instructed her to wipe between her legs at which time she reached between her legs and wiped herself several times from the rectal area towards the urethra (back to front). Continued observation revealed that the CNA did not stop and instruct her the proper way to wipe. CNA BB was then observed to get another one of the wet washcloths on the bed rail, and cleaned the resident's perineal area properly from the front towards the back, and then turned her to her side and washed her buttocks with another wet washcloth from the bed rail. Further observation revealed that CNA BB did not dry the resident's skin before putting a clean incontinent brief on her. During interview with CNA BB on 8/20/18 at 4:35 p.m., he stated that he usually got a bath basin with water and peri-wash to perform incontinence care, but that R#25 liked to wipe herself, so he just used the wet washcloths. During an observation of a shower with R#25's permission on 8/22/18 at 7:25 a.m., she was observed in the common shower room in a shower chair with a large circular opening in the seat of the chair, and was placed in the shower stall by CNA CC. After washing the rest of her body, CNA CC obtained a clean soapy washcloth and first wiped R#25's inguinal areas, and then used the same washcloth to wipe the perineal and rectal area from underneath the opening in the chair in a circular and back and forth motion, and then rinsed her off. During interview with the Licensed Practical Nurse (LPN) Infection Control Nurse on 8/22/18 at 10:34 a.m., she stated that her expectations were that the staff wipe from the front to the back when doing perineal care, and that a separate section of the washcloth be used for each stroke. She stated during further interview that if a resident was allowed to wipe themselves and was doing it incorrectly, that the staff should educate them on why it was important to go from the front to the back due to the possible increase in urinary tract infection, and if they needed assistance to do so. The LPN Infection Control nurse further stated that a bath basin should be used for perineal care with warm water and soap and plenty of washcloths, and that it was not acceptable to place the washcloths on the bed rail, as there may be microbes on the rail. She further stated that the resident should be dried before a clean brief was applied. During continued interview, she stated that perineal care should be done in the same manner when a resident was in a shower chair and the staff reaching up from the opening in the chair, with a clean washcloth used and the resident cleaned from the front to the back with a different area of the washcloth for each stroke. Review of the facility's Perineal Care policy revised (MONTH) (YEAR) revealed: The following equipment and supplies will be necessary when performing this procedure: 1. Wash basin . Steps in the Procedure: 1. Place the equipment on the bedside stand . 3. Fill the wash basin one-half full of warm water. Place the wash basin on the bedside stand within easy reach. 8. For a female resident: a. Wet washcloth and apply soap or skin cleansing agent. b. Wash perineal area, wiping from front to back. (4) Gently dry perineum.", "filedate": "2020-09-01"}
{"rowid": 100, "facility_name": "CENTER FOR ADVANCED REHAB AT PARKSIDE, THE", "facility_id": 115040, "address": "110 PARK CITY ROAD", "city": "ROSSVILLE", "state": "GA", "zip": 30741, "inspection_date": "2018-08-23", "deficiency_tag": 812, "scope_severity": "F", "complaint": 0, "standard": 1, "eventid": "07R411", "inspection_text": "Based on observation, record review and staff interview, the facility failed to ensure that two foods served from the steam table were held at 135 degrees or higher; that a fan mounted over a drink preparation area was free of dust; and that the amount of sanitizer used in the low temperature dish machine was 50 parts per million (PPM) to prevent potential chemical contamination of food on two of two observations. There were 123 residents that consumed an oral diet. Findings include: 1. During the initial tour of the kitchen on 8/20/18 beginning at 12:00 p.m., a light to moderate build-up of dust was observed on the wall-mounted fan over the drink preparation area. This same observation was made on 8/21/18 at 3:50 p.m. During interview with the Dietary Manager on 8/23/18 at 9:03 a.m., she stated that Maintenance was responsible for cleaning the fans in the kitchen, and that they did so weekly or every other week. She verified during further interview that the wall-mounted fan over the drink preparation area had a light to moderate dust build-up, would contact Maintenance to clean it, and thought they last cleaned it on Friday (six days ago). During interview with Maintenance Technician II on 8/23/18 at 12:36 p.m., he stated that he cleaned the fan over the drink machine today per the Dietary Manager's request, and that he had no documentation of the last time the fan had been cleaned. 2. During observation of the preparation of pureed foods on 8/21/18 at 3:33 p.m., the food processor parts were observed to be washed in the low-temperature dish machine between and after foods prepared, which was connected to a container of sodium hypochlorite sanitizer. Dietary Aide GG was observed to check the chemical concentration of the final rinse water after running the food processor equipment through using a chlorine test strip, and she stated she would interpret the result as 75 (PPM). She stated during further interview that she was trained that the result should not be less than 50 (PPM). On 8/23/18 at 8:56 a.m., the Dietary Manager was observed checking the sanitizer level in the low-temperature dish machine that was currently in use washing resident breakfast dishes. She stated during interview that she would record the chlorine level as 100 (PPM), and stated she thought the level should be 100. She verified during further interview that the Dish Machine Warewashing log specified a concentration of 50 PPM of the chlorine sanitizer, and stated that a level over 50 was OK as it just meant that more sanitizer was coming out. Review of a Dish Machine Warewashing log for (MONTH) (YEAR) revealed that the Chlorine Sanitizer PPM range was listed as 50 PPM, and the results obtained from 8/1/18 through 8/23/18 at noon revealed concentrations between 75 and 100 PPM recorded 65 of 68 times. Review of the facility policy Sanitization revised (MONTH) 2008 revealed: Low-Temperature Dishwasher (Chemical Sanitization): Final rinse with 50 parts per million hypochlorite (chlorine) for at least 10 seconds. Review of the facility policy Dishwashing Machine Use revised (MONTH) 2010 revealed: Dishwashing machine chemical sanitizer concentrations and contact times will be as follows: Chlorine: Minimum Concentration 50-100 ppm. 3. During observation of steam table temperatures taken at supper by Cook HH on 8/21/18 at 5:25 p.m. using the facility's calibrated thermometer, all of the foods were observed to be greater than 135 degrees Fahrenheit (F), except for the meatballs which did not register above 120 degrees F after several checks, and the Prince Edward blend vegetables temperature was 110 degrees F. This was verified during interview with the Dietary Manager at this time, who instructed staff to remove the two foods and place them back in the steamer to reheat. The Dietary Manager further stated that two residents had already received the meatballs. During interview with the Dietary Manager on 8/23/18 at 9:03 a.m., she verified that both the meatballs and the mixed vegetables were below the required holding temperature of 135 degrees at supper on 8/21/18. She further stated that about six residents had already been served the mixed vegetable. She stated during continued interview that food for supper was usually placed on the steam table around 5:00 p.m., and that most of the juices had gone out of the pan by the time the temperatures were checked on 8/21/18. The Dietary Manager further stated that the meatballs were usually held in a smaller pan than they were on 8/21/18. Review of the facility's Food Preparation and Service policy with a revised date of (MONTH) 2014 revealed: Food Preparation, Cooking and Holding Temperatures and Times: 1. The danger zone for food temperatures is between 41 degrees F and 135 degrees F. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness. 2. Potentially hazardous foods include meats, poultry, seafood, cut melon, eggs, milk, yogurt and cottage cheese. 3. The longer foods remain in the danger zone the greater the risk for growth of harmful pathogens. Therefore, PHF (potentially hazardous foods) must be maintained below 41 degrees F or above 135 degrees F.", "filedate": "2020-09-01"}