{"rowid": 528, "facility_name": "PRUITTHEALTH - MARIETTA", "facility_id": 115276, "address": "70 SAINE DRIVE SW", "city": "MARIETTA", "state": "GA", "zip": 30008, "inspection_date": "2020-02-26", "deficiency_tag": 609, "scope_severity": "D", "complaint": 1, "standard": 0, "eventid": "CR9111", "inspection_text": "> Based on staff interview, record review and review of the facility's policy titled Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, the facility failed to report an allegation of abuse to the State Survey Agency (SSA) within the required time frame for one resident (R#1) of 4 sampled residents. Findings include: During an interview on 2/25/2020 at 10:10 a.m., R#1 stated to this surveyor that he refused to allow Certified Nursing Assistant (CNA) AA in his room or allow her to touch him. He reported that he is legally blind and CNA AA was mean and rude to him. The resident angrily states that he is blind but CNA AA treated him like he was stupid. The resident further stated that he informed the Social Worker (SW) regarding how he was being treated and did not want CNA AA back in his room. An interview with the SW on 2/25/2020 at 11:30 a.m. revealed that she spoke with the R#1 on 2/24/2020 in which he reported to her that CNA AA was mean to him and did not want her to come back into his room or provide him any care. SW further stated that she completed a grievance report at that time and reported the incident to the Administrator. An interview on 2/25/2020 at 11:40 a.m. with the Administrator revealed that according to the report the facility became aware of the allegation on 2/24/2020. He further stated that he did not consider the incident as an allegation of abuse and therefore did not report the incident to the State agency. Review of the facility policy titled Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property revised on 4/26/2017, stated that mental abuse: includes but is not limited to humiliation, harassment, threats of punishment or deprivation. The suspected abuse will be reported within two hours to the State Survey Agency.", "filedate": "2020-09-01"}
{"rowid": 529, "facility_name": "PRUITTHEALTH - MARIETTA", "facility_id": 115276, "address": "70 SAINE DRIVE SW", "city": "MARIETTA", "state": "GA", "zip": 30008, "inspection_date": "2020-02-26", "deficiency_tag": 690, "scope_severity": "D", "complaint": 1, "standard": 0, "eventid": "CR9111", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, record review, and facility policy review Lippincott indwelling urinary catheter care and management, the facility failed to provide appropriate indwelling urinary catheter care for one resident (R) #3, of three sampled residents. Findings include: Review of the facility policy for Indwelling urinary catheter (Foley) care and management revised 3/24/2017 indicated in the Implementation section to Provide routine hygiene for meatal care; note that cleaning the meatal area with antiseptic solutions isn't necessary. To avoid contaminating the urinary tract, always clean by wiping away from-never toward- the urinary meatus. Use soap and water or a perineal cleaner to clean the [MEDICAL CONDITION] area after each bowel movement. Avoid frequent and vigorous cleaning of the area. Review of the Quarterly Minimum Data Set (MDS) for R#3 dated 2/02/2020 revealed that his [DIAGNOSES REDACTED]. Review of the Brief Interview for Mental Status (BIMS) indicated a score of 15 indicating the resident was cognitively intact. R#3 had an indwelling foley catheter on admission to the facility. Review of the Care Plan for R #3 dated 10/15/2019 revealed a care plan for an Indwelling Foley Catheter. Approaches included: Provide perineal care every day and PRN Report redness, swelling, discharge or urinary related odor to supervisor Follow aseptic technique with Cath insertion and irrigation Observe and report the change in color, odor, presence of cloudiness or sediment in urine to charge nurse Report complaints of pain/discomfort from cath to charge nurse Record intake and output as ordered Check Cath q (every) shift for patency, proper position of tubing and bag. Report Cath leakage to charge nurse. Review of the Medication Administration Record [REDACTED]. A review of the Quarterly MDS dated [DATE] revealed a BIMS score of 15 indicating that he was cognitively intact. The resident required total care for all activities of daily living and had an indwelling urinary catheter upon admission. Review of the Physician's Orders for R #3 dated 12/5/2019 revealed orders for: May change indwelling foley cath monthly as needed for blockage, clogging, dislodgement, sedimentation, s/s (signs and symptoms) of bleeding, or infection. Catheter: Diagnosis, [MEDICAL CONDITION] bladder and pressure injury to the sacrum. Observation of Certified Nursing Assistant (CNA) BB a indwelling foley catheter care was provided to R #3 on 2/25/2020 at 10:40 a.m. revealed: 1. Failed to use warm water or a basin to provide catheter care 2. Using wet wipes he washed the base of the penis and top of the scrotum. 3. He failed to wash the meatus of the penis. 4. Failed to wipe down the catheter tubing. Interview with CNA BB conducted on 2/25/2020 at 10:45 a.m. revealed that he was last trained on catheter care was December 2019. He also revealed that it was ok to wet wipes while providing catheter care but did not have any explanation regarding washing the meatus or the catheter tubing. Interview with the Nurse Consultant on 2/26/2020 at 1:49 p.m. revealed that the Clinical Competent Coordinator (CCC), provides a skill check-off annually which includes catheter care. Review of a Skills Competency Checklist Form: CNA Annual for CNA BB dated 12/9/19 included catheter care. The skill checks off include Lippincott Procedure dated 3/24/2017 and included washing the meatus/catheter insertion site.", "filedate": "2020-09-01"}
{"rowid": 530, "facility_name": "PRUITTHEALTH - MARIETTA", "facility_id": 115276, "address": "70 SAINE DRIVE SW", "city": "MARIETTA", "state": "GA", "zip": 30008, "inspection_date": "2018-04-19", "deficiency_tag": 585, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "2G1211", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record, and facility policy review, the facility staff failed to ensure personal clothing were returned when sent to the laundry and when items were reported missing there was an effective and timely process in place to replace items that were not found for one sampled resident (Resident {R}#71) out of 21 residents reviewed for missing personal items. Findings include: On 4/16/18 at 2:57 p.m., in the facility's conference room` an interview was conducted with the Administrator concerning laundry and missing items. The Administrator stated Anyone can write up the grievance form for the missing items. We look in the resident's room and if it's a laundry issue, we look in laundry and take the resident down to the laundry to look. If we don't find it, we reimburse them. Review of the facility's Concerns/Grievances policy, revised 6/2/2017 revealed the following: . A concern/grievance may be filed verbally or in writing. Grievance forms will be kept at the Administrator's office and./or in other area designated by Administrator in the center. If the resident files a grievance to any person, the staff person should immediately inform the Administrator or his/her designee. Procedure: 1. The staff member taking the grievance: The staff person will provide assistance in completing the Concern/Grievance Form should the person making the filing need assistance. Grievances should be resolved within three business days with the Administrator's signature and reported back to the person filing the grievance. The grievance form should be given back to the Administrator or his/her designee to be logged and placed in the grievance book. 2. The Administrator or his/her designee will be responsible for tracking all grievances. The Administrator or his/her designee will enter the grievance form information into the Grievance Log Form and place the original form in the log book. This will provide a central place for all grievances. 3. The Administrator or his/her designee is responsible for following up with the complainant to make sure that the grievance has been resolved or that they understand what actions have been taken. The Administrator or on-site manager will complete the log and form accordingly. On 04/17/18 at 2:58 p.m., R#71, who was admitted into the facility on [DATE] and responded to interview questions appropriately was asked about personal property and if any of his belongings ever been missing. R#71 responded Since I have been here I have had five pairs of my shorts missing, from the laundry. I told the Charge Nurse, and nothing was done, that was in (MONTH) of this year. On 4/18/18 at 9:30 a.m. in the facility's laundry area, the Laundry Manager was asked how he found about resident's missing items and what is done to locate those items. The Laundry Manager replied Morning stand-up meeting is when I find out about missing items. I come back and let my staff know. I also post it on the board back there. Observation of a bulletin board in the laundry area, there were two hand written notes on lined paper with no date that read: (resident name and room number, not R #71): missing shorts, (resident name): missing clothes;(resident name): black blouse, white shirt, two gray pants, white tennis shoes. Also, a large gray bin on wheels, full of clothing was pointed out by the Laundry Manager who stated Those are unlabeled clothing. At the end of the week, we take those up to the units, walk around to see if anyone can identify these things. On 4/18/18 at 10:15 a.m., at the nurse's station of the Cambridge Unit the Unit Nurse Manager QQ (Nurse Manager QQ) was queried concerning R#71's five pairs of missing shorts from the laundry. Nurse Manager QQ stated I spoke with him this morning and he told me he thinks he had five pairs of shorts missing. When asked if she knew about the missing shorts from laundry in January, Nurse Manager QQ replied He wasn't on this floor in January, he used to be downstairs. We should have filled out a form, but to be honest we don't have those forms up here. There were a lot of things that weren't here on the unit when I first got up here as the manager and slowly I have been getting them. When something is missing I usually go to the laundry to look for it At 11:10 a.m., Nurse Manager QQ left the unit and returned with a Missing Items-Laundry Services Form and stated, This is the form that should be filled out for missing laundry When asked where the form would be kept, Unit Manager QQ replied in the med room. When asked how would staff other than nurses have access to the forms since the medication room was locked. Nurse Manager QQ replied they would have to ask the nurses for the form. On 4/19/18 at 8:20 a.m., the facility's Grievance/Complaint log book was reviewed. The logs contained multiple residents and families' grievances from (MONTH) (YEAR) to (MONTH) (YEAR). The log indicated the staff member taking the grievance, an explanation of what the grievances was as well as the facility's resolution. There was no grievance log for R #71's missing shorts. The Administrator stated that these were all the grievances that she was aware of. On 4/19/18 at 8:45 a.m., in the facility's conference room during an interview with the Administrator concerning the facility's laundry process and handling of reported missing personal items, the Administrator who had come to the facility in (MONTH) of (YEAR) stated when I came the laundry person was only here for 4.5 hours a day on day and afternoon, that is s what we were budgeted for. I increased it to 7.5 hours. When someone is admitted we are supposed to complete a clothing inventory and make sure all their items are labeled. When family brings in new items or the resident goes out to shop and get new items they are supposed to make sure staff labels the item and that could be anyone (nurse, CNA). That doesn't always happen, and we end up with clothing in the laundry that we don't know who it belongs to. In the past we were reimbursing or purchasing the item from our petty cash card here at the facility. But corporate changed that policy and we now submit to them (corporate office) and they reimburse and that it could be a family member because they are the Power of Attorney. I am in the process of purchasing a good clothing labeler.", "filedate": "2020-09-01"}
{"rowid": 531, "facility_name": "PRUITTHEALTH - MARIETTA", "facility_id": 115276, "address": "70 SAINE DRIVE SW", "city": "MARIETTA", "state": "GA", "zip": 30008, "inspection_date": "2019-07-24", "deficiency_tag": 568, "scope_severity": "D", "complaint": 1, "standard": 1, "eventid": "I5PG11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, resident and staff interviews and review of the policy titled Resident Trust Policy, the facility failed to provide quarterly financial statements for two of two cognitively intact residents (R) reviewed that had a trust fund account managed by the facility (R#14, R#61). The facility managed 93 resident trust fund accounts. Findings include: Review of the facility policy titled Resident Trust Policy dated (MONTH) 2009, revealed number 6. Quarterly statements will be provided in writing to the resident or the resident's responsible representative within 30 days after the end of the quarter. 1. Record review for R#14 revealed a Quarterly Minimum Data Set (MDS) assessment dated [DATE] which documented a Brief Interview for Mental Status (BIMS) summary score of 14, which indicates the resident is cognitively intact. Interview on 7/21/19 at 12:53 p.m., R#14 revealed she does not receive a quarterly statement for her trust fund account that the facility manages. Review of printed Resident Fund Management Service dated 7/24/19 at 10:21 a.m., revealed on page three (3), R#14 has an active trust fund account that is managed by facility. 2. Record review for R#61 revealed a Quarterly Minimum Data Set (MDS) assessment dated [DATE] which documented a Brief Interview for Mental Status (BIMS) summary score of 15, which indicates the resident is cognitively intact. Interview on 7/22/19 at 11:13 a.m., R#61 revealed she does not receive a quarterly statement for her trust fund account that the facility manages. Review of printed Resident Fund Management Service dated 7/24/19 at 10:21 a.m., revealed on page two (2), R#61 has an active trust fund account that is managed by facility. Interview on 7/23/19 at 4:55 p.m. with Accounts payable/Financial Counselor, responsible for the resident trust fund accounts, stated during the admission process, the residents are given the choice to have the facility manage a trust fund for their money. If the resident elects the facility to manage their trust fund, an agreement is signed and she sets up the account. She stated that residents are informed they have access to their money 24 hours per day. She further stated that she gives the residents quarterly statements in person within the month after the quarter ends, if the resident is their own responsible party. She stated the residents sign a ledger to acknowledge receipt of their quarterly statement. She confirmed the facility was managing resident trust for both R#14 and R#61. She further stated she was unable to find any documentation that R#14 or R#61 had acknowledged receiving their quarterly statement for the past four quarters.", "filedate": "2020-09-01"}
{"rowid": 532, "facility_name": "PRUITTHEALTH - MARIETTA", "facility_id": 115276, "address": "70 SAINE DRIVE SW", "city": "MARIETTA", "state": "GA", "zip": 30008, "inspection_date": "2019-07-24", "deficiency_tag": 577, "scope_severity": "B", "complaint": 1, "standard": 1, "eventid": "I5PG11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and staff interview, it was revealed that the facility failed to post notice of the availability of state survey results in prominent places in the facility. Findings include: During a group interview with members of the resident council on 7/23/19 at 10:10 a.m., it was revealed that few members of the resident council knew of the whereabouts of the state survey results and how they could access them. One resident said he believed they were to be found in the lobby area, but could not be sure of the exact location. An observation on 7/23/19 at 12:30 p.m. of the lobby area of the facility accompanied by the Regional Nurse Consultant, revealed a cherry wood cabinet attached to the wall at the left of the main entrance. A green sign attached to the closed door of the cabinet read: Please drop kudo cards here; please deposit payments here; please place [MEDICATION NAME] contact cards here. Inside the cabinet, once the doors were opened, was a binder labeled: Results of Past 3 Surveys; (MONTH) 27, (YEAR), (MONTH) 30, (YEAR), (MONTH) 12, (YEAR). During an interview with the Regional Nurse Consultant at the time of this observation, she revealed that the residents are supposed to be educated on the availability of the survey results and where to find them. She agreed that there was no indication in the area as to where the survey results were kept and that visitors/families/residents would not necessarily know the results were available in the cabinet when the door was closed. An observation of the lobby area on 7/23/19 at 4:29 p.m. revealed a new sign had been placed on the closed door of the cabinet containing the survey results. The new sign stated: Survey Results. During an interview on 7/24/19 at 2:57 p.m. with the Activity Director (AD) it was revealed that she usually educates the residents and family members after surveys that state survey results are available, and that they are entitled to see new results after they are received. The AD said the survey results were also once available in a book in the sitting area on the second floor and she often directed families and visitors to those results. However, she was not sure if the results were still displayed in that area. Observation on 7/24/19 at 3:12 p.m. of the sitting area accompanied by the AD revealed that the survey results were not displayed anywhere in that area.", "filedate": "2020-09-01"}
{"rowid": 533, "facility_name": "PRUITTHEALTH - MARIETTA", "facility_id": 115276, "address": "70 SAINE DRIVE SW", "city": "MARIETTA", "state": "GA", "zip": 30008, "inspection_date": "2019-07-24", "deficiency_tag": 689, "scope_severity": "D", "complaint": 1, "standard": 1, "eventid": "I5PG11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, policy review and interviews, the facility failed to provide supervised smoking for one resident (R#7) reviewed for smoking. The sample size was 55. Findings include: Review of the facility policy titled Smoke Free Policy with a revised date of 11/5/18, revealed the policy statement to be as of (MONTH) 1, (YEAR), smoking is not allowed on the healthcare center premises by visitors, partners or patients/residents. Smoking will only be allowed in outdoor designated areas for those residents grandfathered in prior to (MONTH) 1, (YEAR). Procedure bullet 10: when the patient/resident is identified as needing supervision, the supervision shall be provided by a partner who is physically present in the designated smoking area for all residents who need supervision based on their Smoking Observation Form or electronic documentation. Review of the clinical record for R #7 revealed resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 15, which indicated no cognitive impairment. Section J revealed resident was a current smoker. Review of facilities Smoker Worksheet, revealed R#7 name was on the list of identified smokers in the facility. Review of Smoking Observation Form documented that residents were to be assessed on admission, re-admission, or with a significant change. Review of Quarterly Smoking Observation Form for R#7, dated 3/12/19 and 7/22/19, revealed question one: Does the resident smoke? Yes column is checked. Question two: Does the resident have a past history of smoking? Yes column is checked. Supervision will be required at all designated smoking times when the patient/resident observation identifies any potential hazard risk, as evidenced by any boxes checked Yes. Patient/resident smoking status upon observation: Supervised Smoker. Review of document titled Smokers in the Facility undated, provided by facility, revealed that R#7 name was on the document. Review of document titled Smoking Location of the Facility undated, provided by the facility, revealed the court yard on the first floor as the designated smoking area. Based on review of R#7's comprehensive care plan a provided, resident is a current smoker and wished to continue to enjoy smoking with supervision, initiated on 3/12/19 and revised on 7/22/19. Observation on 7/21/19 at 2:00 p.m., resident was observed smoking in the designated smoking area (court yard on first floor). He was smoking one cigarette and holding a second cigarette in his hand. He was wearing a smoking apron. There was no evidence of any staff members present during the smoking period. Surveyor remained with resident until he was finished smoking. Interview on 7/21/19 at 2:00 p.m. with R#7, stated he smokes by himself most of the time, but staff give him cigarettes and light them for him, and then they leave. Observation on 7/21/19 at 2:10 p.m., staff member GG removed resident smoking apron, upon re-entry into facility. Staff member stated that he just gets the cigarettes from the nurses station and lights them for resident and puts the apron on and takes it off. He asked surveyor Is someone supposed to be outside with him when smoking? Interview on 7/23/19 at 8:45 a.m. with housekeeping aide HH, stated she was asked to start sitting with resident today, during the 8:30 smoking break. Interview on 7/23/19 at 1:21 p.m with Admininistrator, stated the facility is a non-smoking facility, but there is one resident who was grandfather in. He stated that there is not a formal schedule as to who is supposed to attend smoke breaks with the resident. He further stated that staff from housekeeping, dietary, activities and nursing are supposed to supervise the resident during smoke breaks. He further stated that he makes sure someone is with resident while smoking. On the weekends and when he is not in facility, he stated it is the responsibility of the Nursing Supervisor to ensure a staff member is with resident during smoke breaks. When questioned about Sunday episode when resident was observed in courtyard smoking unsupervised, he responded that the weekend Supervisor called out on Sunday, and he does not know who would or should have made sure the resident had supervision for smoking.", "filedate": "2020-09-01"}
{"rowid": 534, "facility_name": "PRUITTHEALTH - MARIETTA", "facility_id": 115276, "address": "70 SAINE DRIVE SW", "city": "MARIETTA", "state": "GA", "zip": 30008, "inspection_date": "2019-07-24", "deficiency_tag": 692, "scope_severity": "D", "complaint": 1, "standard": 1, "eventid": "I5PG11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interviews, record review and review of the facility policy Hydration: Dietary Service. The facility failed to provide hydration (ice/water) at the bedside for two of fifty-five sampled residents, (R) (R#61 and R#304). Findings include: 1. Review of the clinical record for R#61 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 15, which indicated no cognitive impairment. Interview on 7/22/19 at 11:20 a.m. in R#61 room, she stated she rarely gets fresh ice water. No visible water pitcher in R#61 room. Observation on 7/23/19 at 8:05 a.m., there is no visible water pitcher or drinking cup on residents side of the room. Observation on 7/23/19 at 3:06 p.m., resident sitting at her beside. She stated that no-one brought her any ice water today. There is no visible water pitcher or water cup on her over bed table. Interview on 7/24/19 at 8:26 a.m. with R#61, stated she was given a pitcher of ice water today, when she hasn't had a pitcher for ice water in a long time. She could not remember exactly how long it has been since she had ice water. Interview on 7/24/19 at 9:34 a.m. with Certified Nursing Assistant EE stated that she passes ice twice daily on her shift. She further stated that she offers R#61 ice water everyday, but resident refuses and throws her water pitcher in the trash. 2. Medical record review for resident R#304 revealed she was admitted to the facility on [DATE]. She readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review for R#304 admission Minimum Data Set (MDS) assessment dated [DATE] which documented a BIMS summary score of 15, indicating cognitively intact. An interview and observation on 7/22/19 at 9:53 a.m. R#304 did not have a water pitcher in the room. The resident revealed that they she has liquids on the meal tray and she saves the liquids to have to drink throughout the day. An observation on 7/22/19 at 3:42 p.m. R#304 had no water pitcher visible. An observation on 7/23/19 8:42 a.m. R#304 had no water pitcher visible. An observation on 7/23/19 at 9:07 a.m. R#304 sitting up in bed eating breakfast noted one glass of water on tray. no water picture visible. An observation on 7/23/19 at 10:54 a.m. of two certified nursing assistant (CNA) KK and PP passing ice, water, and juice on first floor hall [NAME] The CNA KK entered R#304 room and came out no ice, water, or juice was provided to R#304. An interview was conducted on 7/23/19 at 11:03 a.m. with R#304. The resident revealed the staff came in and ask her did she have a pitcher for ice water and she informed them she did not have one. Resident revealed the staff told her they would get a water pitcher for her. An interview was conducted on 7/23/19 at 11:48 a.m. with CNA KK regarding provided hydration to the residents in the facility. The CNA revealed when passing hydration to the residents the residents are asked if they would prefer Ice, water, and/or juice. The CNA also revealed Ice, water, juice is passed/offered to the residents each shift and at the resident request. The CNA revealed If the resident does not have a pitcher one will be provided. An interview was conducted on 7/23/19 at 12:15 p.m. with PP CN[NAME] The CNA revealed she assisted with passing ice water on C hall and was aware that R#304 did not have a pitcher. The CNA revealed she did not provide a pitcher to R#304 and was not sure if the CNA KK provided the residents with a pitcher. An observation on 7/23/19 4:42 p.m. R#304 had no water pitcher visible. An interview was conducted 7/23/19 at 4:55 p.m. with the Administrator and the Senior Nurse Consultant LL. The Senior Nurse Consultant confirmed that R#304 did not have a pitcher at her bedside. Both the Administrator and Senior Nurse Consultant revealed that their expectations are that the ice water is passed to all residents to ensure that they stay hydrated. Review of the facility policy titled Hydration: Dietary Service. with a revised date of 10/18/17 revealed: Each resident/patient will be provided a drinking glass and water pitcher in their room unless they are on fluid restriction. Water pitchers are filled with ice/water at least but limited to twice per day.", "filedate": "2020-09-01"}
{"rowid": 535, "facility_name": "PRUITTHEALTH - MARIETTA", "facility_id": 115276, "address": "70 SAINE DRIVE SW", "city": "MARIETTA", "state": "GA", "zip": 30008, "inspection_date": "2019-07-24", "deficiency_tag": 725, "scope_severity": "F", "complaint": 1, "standard": 1, "eventid": "I5PG11", "inspection_text": "> Based on observation, review of facility records, and resident and staff interview, it was determined that the facility failed to provide staff in sufficient numbers to care for the needs of seven Residents (R) #13 , R A, R B, R C, R#23, R#24, R D on two of two units as identified in resident and facility assessments. Findings include: A review of the Facility assessment dated (MONTH) 2019 revealed that the facility cared for a very high percentage of residents that required the assistance of two-plus persons with daily care such as bed mobility, transfers, toilet use, and dressing. The assessment also documented that the facility had high percentages of residents with cognitive impairments and behavioral health needs that impacted resident care. A review of the facility's Alphabetical census of residents dated 7/21/19 revealed that there were 106 residents onsite - 55 on the 200 Hall and 51 on the 100 Hall. A review of the Daily Staffing Schedule for 7/21/19 revealed two nurses and two certified nursing assistants (CNAs) were scheduled to care for residents on the 200 Hall, and an equivalent number on the 100 Hall. Observation on 7/21/19 at 11:30 AM of the staff on the 200 Hall confirmed that two CNAs were available to provide care to the 55 residents on that hall. During an observation on 7/22/19 at 11:15 a.m., the family of Resident #13 was seen to arrive at the facility for a visit. A few minutes into the visit, one of the family members was observed to remove a manicure set from her bag and proceed to trim the nails of the resident. The resident's nails were observed to be about a centimeter long. During an interview with the family member, at the time of this observation it was revealed that she trims his nails during her weekly visits because the staff are busy and not able to get to it. During a group interview on 7/23/19 at 11:10 a.m. with members of the resident council it was revealed that residents were dissatisfied with the number of staff available on the various shifts to care for their needs. Resident (R) A said sometimes staff say there are not enough of them available to get her roommate up. When this happens, her roommate remains in bed. Resident A also said that, during meal services, the CNAs come to the residents' rooms and turns off their call lights, telling them that staff will return to assist them when they are done with serving the meal. When this happens, she must wait a long time for assistance if she needs to go to the bathroom. During such waits, she sometimes wets herself. Other times, she is left in the bathroom and it is the nurse who comes after a considerable amount of time to get her off the potty. A review of the most recent minimum data set (MDS) assessment for Resident A revealed a Brief Interview for Mental Status (BIMS) score of 15. A score of 13-15 indicates a resident is cognitively intact. The assessment also documented that this resident needed extensive assistance of two-plus persons for activities of daily living (ADLs) such as transfers, bed mobility, toilet use, and personal hygiene. A review of the most recent minimum data set (MDS) assessment for the roommate of Resident A revealed the roommate was assessed as having a severe cognitive deficit and needed extensive to total assistance with ADLs such as transfers, dressing, and toilet use. Resident B said, during the same interview, that it sometimes take more than an hour for staff to respond to her call for assistance to be taken to the bathroom. The resident said she takes a water pill, so when she (I) need(s) to go, she (I) need(s) to go, and she has accidents when she must wait an hour or more for staff to respond to her call. A review of the most recent MDS assessment for Resident B revealed a BIMS score of 15 revealing the resident to be cognitively intact. The resident was assessed as needing extensive assistance with transfers, dressing, toilet-use, and personal hygiene. During the same group interview, Resident C said that he did not believe that staff was simply reluctant to come when the residents called. Instead, he believed that they are short-staffed. Thus, when the staff took a long time to respond to the residents' call lights, it meant they were with another resident. Resident C said there was usually only one CNA on each hallway. Sometimes, the nurse would come in, turn his call light off, and say she is working with another resident and would be back when she could. He said he receives the care he needs, it just takes much longer than is warranted. Resident A said this state of affairs has existed for several months. A review of the most recent MDS assessment completed for Resident C revealed a BIMS of 15, indicating that he was cognitively intact. Resident C was assessed as needing extensive assistance with bed mobility, transfer, eating, and toilet use. During an interview on 7/24/19 at 3:36 p.m. with CNA MM, it was revealed that she normally works the 3:00 p.m. to 11:00 p.m. (evening) shift, and was one of four CNAs scheduled and available to work on the 200 Hall that evening. The CNA said three of those four CNAs had also worked during the previous shift and was held over to work on the evening shift. CNA MM said the evening shift usually had four CNAs, but occasionally five were scheduled. However, though rare, sometimes there were only two. If only two CNAs are scheduled to provide care on that hall, then the nurses are expected to help with providing showers etc. On the weekends, staff are expected to pick up extra shifts so that there is not less than four CNAs on the evening shift. During an interview on 7/24/19 at 5:11 p.m., CNA NN revealed she has been responsible for the daily scheduling of nurses and CNAs for the facility since (MONTH) 2019. CNA NN said she schedules staff for each day/each shift based on the daily census. Depending on that census, the minimum number of CNAs she will schedule on the day and evening shifts are four on each hall; the minimum amount for the night shift are three on each floor/hall. However, 4-5 CNAs are usually scheduled on each floor/hall on the day shift and 3-4 on the evening shift. On the night shift, she usually schedules 2-3 CNAs on each floor/hall. The numbers are the same 7 days a week. When there are call-outs for the CNAs, she tries to replace them with part-time staff. If she is not able to replace them with part-time staff, then the nurses are expected to help. Sometimes she will fill in on the shift for a CNA who cannot come in. For example, she was scheduled as one of the five CNAs, scheduled to work the 100 hall/first floor on that shift. CNA NN admitted that, of the five CNAs scheduled for the upstairs (200) hall, three were CNAs from the previous shift who had agreed to work an extra shift that day. During an interview on 7/24/19 at 5:34 p.m. with CNA OO, it was revealed that five CNAs had indeed been scheduled for the 200 hall on the 3-11 shift that day. However, one of those scheduled CNAs was the activity director who was not, at the time, working on the floor. Another of the scheduled CNA was the medical records clerk who was also not working on the floor. CNA OO said the only CNAs working on the hall during the shift were three CNAs who were not listed on the original schedule provided by the facility, but who had worked during the previous shift and was then working extra hours. This CNA said many of the CNAs had worked extra shifts for several months During initial screening on 7/22/19 at 11:54 a.m., with resident #23, stated that there is not enough staff to put him to bed when he wants to go to bed. He has to sit for hours in wheelchair, waiting for someone to put him back to bed. During initial screening on 7/22/19 at 1:45 p.m. with resident #24, stated that there is not enough staff to change his diaper but once per shift. He further stated staff come in and turn off his call light, without asking him what he needs. He stated that he does not get up out of bed, because there is not enough staff to put him back to bed, causing him to sit up longer than he desires. Interview on 7/21/19 at 1:45 p.m., with Certified Nursing Assistant (CNA) FF, stated that she was called in today to help work on the floor. She stated that she does get pulled to work on the floor at times, when they are short staffed. She stated that she will work some extra hours when they ask her too. Interview on 7/21/19 at 2:48 p.m. with CNA II, stated she has 28 residents to care for today, because they are short staffed. She stated she normally would have help on the A Hall and she would have about 15 residents. She stated that today, she is on the floor by herself. Interview on 7/24/19 at 9:34 a.m. with CNA EE, stated that she has on average of 10-12 residents per shift. She stated that when staff call in (a lot on weekends), then she will have about 18 residents by herself. She stated that she does work extra shifts, when she is able, working about six extra shifts per month, sometimes they are double shifts. Interview on 7/24/19 at 10:05 a.m. with Housekeeping Aide DD, stated that she has helped the residents with requests, when she sees that the staff are busy helping others. She stated she answers call lights and will get residents drinks and snacks when they ask. An interview was conducted on 7/22/19 9:29 a.m. with D regarding sufficient staffing. She revealed the facility does not have enough staff. D revealed she was incontinent of both bowel and bladder and had to wait over an hour for staff to come and provide incontinence care. D revealed she will place her light on and it may take up to an hour. D revealed on 11p.m.-7a.m. there is one CNA for the entire hall.", "filedate": "2020-09-01"}
{"rowid": 536, "facility_name": "PRUITTHEALTH - MARIETTA", "facility_id": 115276, "address": "70 SAINE DRIVE SW", "city": "MARIETTA", "state": "GA", "zip": 30008, "inspection_date": "2019-07-24", "deficiency_tag": 732, "scope_severity": "B", "complaint": 1, "standard": 1, "eventid": "I5PG11", "inspection_text": "> Based on observation and staff interview, the facility failed to post the nurse staffing information on one of four days of the survey. The facility census was 106. Findings include: During an observation on 7/21/19 at 11:06 a.m. it was revealed that the posted nurse staffing information displayed in a glass at the front of the first floor of the facility carried the date of 7/20/19. During random observations of the posted nurse staffing information on 7/21/19 between 11:06 a.m. and 5:30 p.m., it was revealed that the information displayed was from 7/20/19 - the previous day's numbers. During an interview with the administrator on 7/22/19 at 9:48 a.m., it was revealed that the posting of the daily staffing is the responsibility of the weekend nursing supervisor. The administrator said that the weekend nursing supervisor did not come in to work on 7/21/19. Thus, the staffing for 7/21/19 was completed but not posted, and senior staff were distracted with the survey and overlooked posting the information later in the day.", "filedate": "2020-09-01"}
{"rowid": 537, "facility_name": "PRUITTHEALTH - MARIETTA", "facility_id": 115276, "address": "70 SAINE DRIVE SW", "city": "MARIETTA", "state": "GA", "zip": 30008, "inspection_date": "2019-07-24", "deficiency_tag": 812, "scope_severity": "E", "complaint": 1, "standard": 1, "eventid": "I5PG11", "inspection_text": "> Based on observation, staff interview, and review of facility provided data, the facility failed to ensure kitchen staff were wearing hair protectors in the food preparation area. In addition, the facility failed to ensure the dish machine room was safe and sanitary; specifically, free from broken floor tiles and free from dirty water containing food debris accumulating on the floor. This practice had the potential to affect 103 residents receiving an oral diet. The census was 108 residents. The findings include: An initial tour of the kitchen was conducted on 7/21/19 at 11:20 a.m. with Cook CC, Kitchen Aide BB, and Kitchen Aide AA, the Food Service Manager (FSM) was unavailable. The kitchen staff was observed in the process of cooking and preparing for the lunch meal. A small amount of food debris was observed on kitchen floor tiles, walls were clean. The dish machine wash and rinse cycle was tested twice by a Kitchen Aide with two (2) small batches of dirty dishes. The wash and rinse cycle were within required range for a low temperature machine. The floor drain in the dish machine room was not draining water. Floor tiles around the drain area in the middle of the floor, appeared loose, and broken. A large amount of cloudy pooled water containing food debris was noted in the middle of the room, approximately five (5) inches deep at the drain site. Water was also observed pooled over two black rubber safety mats. A brief interview was conducted with Kitchen Aide AA on 7/21/19 at 11:50 a.m. during the tour in the dish machine room, where she confirmed the floor drain has not been draining right for some time that maintenance was aware of it. A second tour of the kitchen was conducted on 7/22/19 at 4:00 p.m. with the FSM, where she confirmed there were broken tiles and water pooling around the drain area in the dish machine room, she confirmed maintenance was aware of the drainage problem. During the continued tour, Cook MM was observed working in the kitchen, on the dinner meal preparation, without a beard net. The staff's beard, mustache and goatee facial hair were uncovered. An interview was conducted with the Maintenance Director (MD) on 7/23/19 at 16:40 p.m. where he stated that a local plumbing company came out on Thursday. He explained the first he knew about the drain problem was on Wednesday. The plumber snaked the drain on Thursday, but it didn't work. He confirmed loose and broken tiles but did not know how long the problem was there. He stated that on Friday they were supposed to have the jetting of the drain conducted by the plumbing company, but he could not come, he called to say he was sending a subcontractor, but confirmed it wasn't done. The MD confirmed they would wet vac the area. Observation of the drain area with the MD reveals a larger pooled area from what was observed on 7/21/19, the water appearing cloudy, with food debris. Two safety mats located along the side of the dish machine were covered with water. A request was made from the MD for a copy of the work orders and/or invoices for plumbing repairs. During a brief observation in the kitchen on 7/23/19 at 12:48 p.m. Cook MM was observed in the lunch meal tray line dishing up food items with a hair protector/net on, a beard guard on that covered his lower beard, however, facial hair in the goatee and mustache areas were not covered. A brief interview was conducted on 7/23/19 at 4:00 p.m. with Nurse Consultant LL during the request for the facility policy regarding kitchen staff attire, to include hair requirements. The Nurse Consultant confirmed the kitchen staff know that hair and beard nets are an expectation, that all hair needs to be covered. A review was conducted of the provided facility policy titled, Dietary Partner Hygiene and Dress Code, revised date, 6/2016. Policy Statement: it is the policy for partners working in the Dietary Department to dress in a manner appropriate for preparing, handling and serving food that prevents contamination and spread of bacteria. Scope: This applies to all dietary partners, and any person(s) who handles and serves food employed by the facility. Hygiene: No. 2 documented- hair is covered with hair net and/or cap. Facial hair is completely covered with a hair net or beard guard. A review was conducted of two (2) facility provided plumbing invoices. The invoice date of 4/2/19, note documentation reflects- jet service related to the kitchen sink floor was backing up. The line was jetted and it was discovered to have a separation down the line. The line needs to be dug up and repaired. The invoice date of 7/18/19, documentation note reflects- jet service for the kitchen line floor drain by the dishwasher was snaked first and cleared up of a cup and knife. It was still backing up when it had to be jetted and cleared, 30-day warranty.", "filedate": "2020-09-01"}
{"rowid": 538, "facility_name": "PRUITTHEALTH - MARIETTA", "facility_id": 115276, "address": "70 SAINE DRIVE SW", "city": "MARIETTA", "state": "GA", "zip": 30008, "inspection_date": "2019-07-24", "deficiency_tag": 814, "scope_severity": "E", "complaint": 1, "standard": 1, "eventid": "I5PG11", "inspection_text": "> Based on observation and staff interviews, the facility failed to ensure the sanitary handling of used cooking oil/refuse, and failed to ensure that kitchen staff had adequate accessibility to the grease trap grounds area for disposal. The census was 108 residents. Findings include: An initial tour of the kitchen was conducted on 7/21/19 at 11:20 a.m. with Cook CC, Kitchen Aide BB, and Kitchen Aide AA, the Food Service Manager (FSM) was unavailable. The kitchen staff was observed in the process of cooking and preparing for the lunch meal. The latest health inspection dated 7/12/19, was posted, documenting a score of 98%. Food prep areas, kitchen equipment and food storage areas were observed to be clean and in order. The initial tour continued to the loading dock area, dumpster area, and the grease trap area with Kitchen Aide BB. The back door was closed to the kitchen. During the observation of the walk-through area to the outside, used as a pass through to the kitchen back door, revealed seven (7) dead insects and a box-like mouse trap. At 12:00 p.m. while the tour continued outside, near the dumpster area, Kitchen Aide BB explained they dump the grease and oil in the grass behind the dumpster. The grease trap container was observed located behind a six (6) foot fence. The fence door was unlatched; however, the Kitchen Aide was unable to open the gate fully, less than 1.5 feet. A large number of weeds and Kudzu vines were surrounding the grease trap container and the surrounding area. The grease trap container was observed to be the size of a tall, large barrel-type trash receptacle with a lid. Several broken wheelchairs were noted under the Kudzu vine, along with other old equipment not fully visible under the vines. The weeds and vines prevented access to the grease trap container to observe it more closely. A second tour of the kitchen was conducted on 7/22/19 at 4:00 p.m. with the FSM, where she confirmed that the fryer oil is changed on Saturday. The cooking oil in the fryer appeared clean upon observation. Tour of the back door walk through area was observed to be free of dead insects. Tour of the outside grease trap area, revealed the fence gate to the grease trap area could be opened half-way, some of the weeds near the gate were observed to be stomped down. The FSM explained they are not using the grease trap, that the weeds are too high, they have saved the oil. Observation revealed two large uncovered metal pots containing dark colored cooking oil, was stored under the warming oven on the floor tile, located next to the gas stove. The FSM stated another place like on the back covered porch area, or in the walk thru area would be better place to store it. The back-porch area is open on one side, and is an area where the oxygen tanks are stored. A brief interview was conducted with the Administrator on 7/23/19 at 8:45 a.m. in his office, where he explained that the facility utilizes two community organizations that they donate equipment to. The organization will pick up discarded equipment quarterly that might be used for parts; that items that need to be fixed are kept in the maintenance shed. During an interview on 7/23/19 at 4:30 p.m. the Maintenance Director (MD) was asked who was responsible for the area around the grease trap. The MD explained that he was just told about it yesterday afternoon, that the facility's landscaping contractor will be called, they will have them cut them (the weeds) back. He stated the landscaping crew was due out this week. He confirmed he did not know how long the grease trap area has looked that way. He confirmed old wheelchairs were put out there by therapy for repurposing, an outside company was to pick up them for repurposing, stating that the equipment out there, are not fixable items. The MD also confirmed the weeds and Kudzu are thick, as tall as four (4) feet high in places, and confirmed that he had looked yesterday. He also confirmed they have a pest control contractor that comes out frequently, the last time was on 7/17/19, that they have a running contract with them. He again confirmed the responsibility for the weeds is the landscaping company. A request was made from the MD for a copy of the pest control policy and a policy for grease trap maintenance. The MD stated he did not have a policy to ask the FSM, that she may have one. An observation was conducted on 7/23/19 at 11:30 a.m. with the FSM present, for the lunch meal pureed food process, with Cook CC. During this time, the two metal pots of old cooking oil were no longer observed under the warming oven. The FSM confirmed the oil was put in the trap, with help last night. On 7/23/19 at 12:30 p.m. during observation of food temperature testing with the FSM, she confirmed there is no facility policy for the dumpsters and grease trap, or cooking oil disposal. An interview and tour of the grease trap area was conducted on 7/24/19 at 9:10 a.m. with the Rehab Director (RD). During the tour of the grease trap area behind the gate, she explained that the old rehab equipment is given to maintenance to take to the shed. She confirmed that no one in her department placed the broken wheelchairs and other items out there. She explained what the process for old and broken equipment to be removed is; that they fill out a maintenance request, in the shared maintenance log book located on each nursing unit. Then maintenance picks up the equipment, then fixes the equipment, if possible. The RD confirmed the staff in her department do not take away equipment, that she doesn't know what happens to unusable equipment, their department only gets back usable, fixed equipment. The RD then walked to the nurse's station to the maintenance book and pointed to a recent request dated 7/16/19 for a resident wheelchair that was broken and needed replaced. The Maintenance Request form had a date of 7/16/19 and a note documenting replaced brakes.", "filedate": "2020-09-01"}
{"rowid": 539, "facility_name": "PRUITTHEALTH - MARIETTA", "facility_id": 115276, "address": "70 SAINE DRIVE SW", "city": "MARIETTA", "state": "GA", "zip": 30008, "inspection_date": "2019-07-24", "deficiency_tag": 914, "scope_severity": "D", "complaint": 1, "standard": 1, "eventid": "I5PG11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and staff interview the facility failed to ensure that privacy curtains were clean and provided full visual privacy, which included a total of six of 119 beds on one of two units. The facility census was 108 residents. Findings include: Observation on 7/21/19 at 2:16 p.m., revealed in room [ROOM NUMBER], center privacy curtain approximately two feet too short. Observation on 7/21/19 at 3:33 p.m., revealed in room [ROOM NUMBER], center privacy curtain approximately two feet too short. Observation on 7/22/19 at 10:53 a.m., revealed in room [ROOM NUMBER], bed A and bed B had no privacy curtain at all. Observation on 7/22/19 at 11:04 a.m., revealed in room [ROOM NUMBER], privacy curtain on bed B dirty with dried food particles. Observation on 7/22/19 at 12:11 p.m., revealed in room [ROOM NUMBER], center privacy curtain approximately two feet too short. Observation on 7/23/19 at 11:55 a.m., revealed in room [ROOM NUMBER], center privacy curtain approximately two feet too short. Interview on 7/24/19 at 10:05 a.m. with Housekeeping Aide DD, stated she inspects the privacy curtains daily to make sure they are clean. She stated if the privacy curtains need to be changed, she notifies the floor tech, to take down to be laundered. She stated she was not sure if there was a routine schedule for laundering the privacy curtains. She stated that she has not noticed any privacy curtains that were too short or missing in any of the rooms on A-Hall. Interview on 7/24/19 at 6:05 p.m. with Housekeeping Supervisor, stated her expectation is that the housekeeping aides look at the privacy curtains every day. If a curtain is identified as being dirty, they are to notify the floor tech to remove the curtain and replace it with a clean one. She stated there is not a routine schedule of laundering the privacy curtains. She further stated that if the housekeeping staff are checking the privacy curtains daily, she is not sure how there could be a room that didn't have a curtain at all, or some rooms with short curtains in the middle.", "filedate": "2020-09-01"}
{"rowid": 540, "facility_name": "PRUITTHEALTH - MARIETTA", "facility_id": 115276, "address": "70 SAINE DRIVE SW", "city": "MARIETTA", "state": "GA", "zip": 30008, "inspection_date": "2017-07-27", "deficiency_tag": 242, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "4OJ711", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff and resident interviews, the facility failed to allow the choice of bathing frequency for one of three sampled residents (Resident (R)#70) reviewed for choices. The sample size was 26 residents. Findings include: Review of R#70's clinical record revealed the [DIAGNOSES REDACTED]. The MDS revealed the resident did not display behaviors and required total assistance of one person for bathing . Review of the updated care plan dated 5/25/17 revealed the intervention for one Certified Nurse Aide (CNA) to assist the resident with showers on scheduled shower days and as needed. Review of the Shower Schedule revealed R#70 should receive a shower two times a week on the evening shift. Interview with R#70, in his room, on 7/25/17 at 10:03 a.m. revealed the resident did not get to choose how often he received a bath. The resident stated he received a shower one to two times a month. He further stated he would like one at least two times a week . Interview with CNA CC on 7/26/17 at 12:16 p.m. revealed each resident received a shower two times a week and staff completed a skin sheet when they complete the shower . Interview with Unit Manager AA on 7/26/17 at 12:38 p.m. revealed each resident received a shower two times a week. The CNA should document on the skin sheets and on the Kiosk (CNA computer charting) after each shower. Interview with the Director of Health Services (DHS) on 7/26/17 at 4:40 p.m. revealed the CNA should complete a skin sheet with each shower and document the shower on the Kiosk. Interview with Corporate Nurse BB on 7/27/17 at 8:40 a.m. revealed the residents should receive showers based on their choice. Corporate Nurse BB also stated the facility did not have a policy regarding bathing choices but would refer to Resident's Rights. Review of the Bath Report from the Kiosk and the Skin Monitoring sheets from 5/1/17 to 7/26/17 at 4:30 a.m. (a period of 13 weeks and two days) revealed the resident only received 12 showers, instead of 26 based on two showers a week. Interview with the resident, in his room, on 7/27/17 at 9:03 a.m. revealed the resident stated he was happy because he received a shower the day before. The facility failed to provide showers per the resident's choice.", "filedate": "2020-09-01"}
{"rowid": 2616, "facility_name": "AUTUMN BREEZE HEALTH AND REHAB", "facility_id": 115580, "address": "1480 SANDTOWN ROAD SW", "city": "MARIETTA", "state": "GA", "zip": 30008, "inspection_date": "2020-01-15", "deficiency_tag": 584, "scope_severity": "E", "complaint": 1, "standard": 0, "eventid": "S0LW11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, complainant and staff interviews, the facility failed to ensure that the facility was free of odors, on two (2) Halls (B and C), of five (5) Halls. Findings include: Observation on 1/14/19 at 9:00 a.m. revealed a strong urine odor upon entrance into the facility. A strong urine odor was throughout the facility on the B Hall, and near the conference room. Observation on 1/14/19 at 10:38 a.m. of a random check of resident's rooms for odor revealed the following: room [ROOM NUMBER] -strong urine odor B Hall rooms at 10:40 a.m. revealed: room [ROOM NUMBER]- strong odor Observation on 1/14/2020 at 10:50 a.m. on the B Hall of a random walk through of resident rooms revealed following; a strong odor at the end of the Hall B. Observation on 1/14/2020 at 11:00 a.m. of random check of resident lounge revealed strong pungent odor, five residents in room. Observation on 1/14/2020 at 2:25 p.m. of a random walk through on the C Hall revealed a strong urine odor, residents doors open, no ADL care being provided at this time. Observation on 1/15/2020 at 9:00 a.m. of a random walk through of the facility revealed a strong pungent, musty, smell in the hallway (C) around the Employee Lounge, the Business Office, the Conference Room, Rooms-134, 135, 136, and 137. A strong old urine odor in room [ROOM NUMBER]. Residents were not being changed at that time, residents doors open. Observation on 1/15/2020 at 10:09 a.m. revealed a strong (pungent) odor at end of hall (C) near conference room, business office and employee lounge. No incontinent care being provided at this time. Observation on 1/15/2020 at 10:11 a.m. of a random walkthrough of hall way (C) revealed a strong old urine smell around rooms # 131, and 132. No ADL care being provided at this time. Observation on 1/15/2020 at 3:30 p.m. of a walk through in the hall way (C) near room [ROOM NUMBER], the conference room, and the employee lounge, revealed a strong pungent odor. No ADL care being provided at that time. Interview on 1/15/2020 at 9:15 a.m. with Licensed Practical Nurse (LPN) AA, (B Hall), revealed that there was a resident #5 (R#5) that would pee on the floor and her bed. She revealed that housekeeping clean, spray, and mop resident's room. She revealed that it helps with odors sometimes. 2. Observation conducted on 1/14/2020 at 9:00 a.m. revealed a strong urine odor in the facility front lobby area, as well as the B and C Halls. Continuous observations of the odor on the C-hall at 10:00a.m., 11:20 a.m.,12:30 p.m. 2:00p.m. and 3p.m. During these observations, the resident's room doors were open and it did not appear that the resident's care was being provided. Observation on 1/15/2020 at 8:50 a.m., accompanied by the facility's Administrator, revealed an extremely strong odor throughout the C-hall and continued to linger consistently throughout the day. Random observations conducted at 9:30a.m, 10:50a.m. 11:30 a.m. 1:00 p.m. 2:30 p.m., 3:00 p.m. and 4:00 p.m. The conference room was located at the end of C-hall and the door was unable to remain open due to the odor in the hallway. Interview with Unit Manager (UM) BB conducted on 1/15/2020 at 11:24 a.m. revealed that the odor on C-hall may be coming from a resident in room for R#4. He stated that one of the residents that reside in that room family does her laundry and haven't done them lately and maybe the source of the odor. UM BB also stated that this same resident urinates on the floor and in her bed and will not allow staff to provide care for her until she gives permission and therefore may also be another source of the odor. During a random observation on B-hall conducted on 1/15/2020 at 11:20 a.m. revealed a strong pungent odor at the end of B- hall. The odor continued to be observed at 1:00 p.m and 2:15 p.m. Observations throughout the investigation conducted on 1/14/2020 and 1/15/2020 revealed housekeeping staff continuously spraying a deodorizer throughout the building to mask the odor. Interview with the housekeeping director conducted on 1/15/2020 at 4:38 p.m. revealed that his staff clean resident's rooms daily, which includes mopping the floors and emptying the trash. He also stated that a lemon blast spray is used throughout the facility to help with the odors.", "filedate": "2020-09-01"}
{"rowid": 2617, "facility_name": "AUTUMN BREEZE HEALTH AND REHAB", "facility_id": 115580, "address": "1480 SANDTOWN ROAD SW", "city": "MARIETTA", "state": "GA", "zip": 30008, "inspection_date": "2018-03-09", "deficiency_tag": 584, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "UXT911", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and resident and staff interview, the facility failed to have hot water readily available for resident use in two of five halls. The facility census was 84 Findings include: Observation on 3/6/18 at 9:47 a.m. revealed the hot water tap in the bathroom between rooms [ROOM NUMBERS] on the B hall produced only a trickle of cold water when turned on. Interview with Resident (R)#72 at the time of this observation revealed the facility had been unable to regulate the hot water in the bathroom and had decided to turn it off a few months before. Interview on 3/6/18 at 11:43 a.m. with family member A revealed the water in the bathrooms on B hallway usually takes too long to heat up to a temperature appropriate for washing up. Observation on 3/6/18 of the hot water temperature in the bathroom between rooms [ROOM NUMBERS] on the B hallway revealed the water remained cold after five minutes of continuous running. Interview on 3/8/18 at 1:55 p.m. with Certified Nursing Assistant (CNA) MM revealed she regularly works with residents on the B hall. It takes several minutes for the hot water in some of the rooms on that hallway to come to a temperature that is appropriate for giving the residents a bed bath or taking care of other personal care needs. To mitigate this lack, the CNAs bring hot water from other rooms on the hallway if hot water is needed immediately and the CNA cannot wait for the water in the resident's bathroom to heat up to a comfortable temperature. Observation on 3/9/17 at 7:34 a.m. revealed that the hot water (which was turned off the previous day) had been turned on in the bathroom shared by residents in rooms [ROOM NUMBERS] on the B hall. The hot water tap now had good pressure, but the water temperature had not changed upwards after five minutes. Interview on 3/9/18 at 7:53 a.m. with the maintenance director revealed he was aware that some of the rooms in the building had inadequate hot water. He said he attributed this to a malfunctioning circulating pump and planned to replace it. Observation on 3/9/18 at 3:00 p.m. with the maintenance director water from the hot water taps in the following bathrooms only reached the following temperatures after five or more minutes of having the taps turned on: 1. Hallway B, bathroom shared by rooms [ROOM NUMBERS] = 98 degrees Fahrenheit (F). 2. Hallway B, bathroom shared by rooms [ROOM NUMBERS] = 91 degrees F. 3. Hallway A, bathroom in room [ROOM NUMBER] = 100 degrees F. 4. Hallway A, bathroom in room [ROOM NUMBER] = 99 degrees F. 5. Hallway A, bathroom shared by rooms [ROOM NUMBERS] = 101 degrees F. Interview on 3/9/18 at 3:15 p.m. with the maintenance director revealed he checks water temperatures, weekly, and tries to have the water temperatures between 100 degrees F and 110 degrees F. He does not perform preventative maintenance, but fixes problems as they are reported to him; He has been having some issues with the circulation pump and this contributes to the hot water taking a long time to rise to acceptable levels in some of the rooms. When the pump goes out, he fixes it, but it has been going in and out recently and he plans to go to the local hardware store to purchase a replacement pump he can have one ordered and available to him within 24 hours.", "filedate": "2020-09-01"}
{"rowid": 2618, "facility_name": "AUTUMN BREEZE HEALTH AND REHAB", "facility_id": 115580, "address": "1480 SANDTOWN ROAD SW", "city": "MARIETTA", "state": "GA", "zip": 30008, "inspection_date": "2018-03-09", "deficiency_tag": 656, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "UXT911", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review. observation, and Interview the facility failed to implement a Comprehensive Care Plan for three (3) residents (R) #16 related to smoking, R#72 related to helping the resident with daily oral care, and R#82 related to ensuring the resident's medication goals and interventions to meet resident needs. This deficient practice had the potential to effect residents who smoke, residents that require assistance with Activities of Daily Living (ADL) care, and residents that have a daily drug regimen. The facility census was 84, and the sample size was 21. Findings Include: Record Review revealed the resident (R) #16 was admitted the facility on 6/7/17 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] section C-cognitive patterns; the resident has a Brief Interview for Mental Status (BIMS) score of 9 indicating the resident has moderate cognitive impairment. Further review of the quarterly MDS of section J- health conditions sub-section J1300 tobacco use; indicates the resident uses tobacco. Review of the comprehensive care plan initiated 6/8/17 for R#16 does not indicate the resident is care planned for tobacco use or smoking. Observation of R#16 smoking on 3/6/18 at 11:00 a.m. while in the designated smoking area revealed the resident smoking with a smoke apron that was torn and not fitting properly, and a large white plastic industrial size bucket half filled with water is noted for disposal of the resident's ashes and cigarettes after smoking. Observation of R#16 smoking on 3/8/18 at 2:00 p.m. while in the designated smoking area revealed the resident wearing a torn smoking apron not fitting properly, a large white plastic industrial sized bucket is used for the disposal of the resident's ashes and cigarette's after smoking. Interview on 3/8/18 at 1:09 p.m. with the MDS Coordinator revealed when a resident is admitted to the facility a smoking assessment is completed on admission and then annually. Interview revealed if the resident is assessed to be a smoker; a care plan is completed to note the residents is a smoker with goals and interventions in place. Interview on 3/9/18 at 2:53 p.m. with the Director of Nursing (DON) revealed when a resident is assessed on admission to be a smoker; staff are expected to develop and implement a comprehensive care plan for the resident to meet the goals and interventions to ensure the resident is smoking safely. During the interview the DON revealed his expectation is for staff to follow the facility's smoking policy and procedures, and ensure the smoking residents have the proper materials such as smoke aprons and ashtrays for safe smoking. Review of the facility's policy and procedure titled Smoking revealed; metal containers with self-closing cover devices into which ashtray can be provided in all areas where smoking is permitted. Review of the facility's policy titled Care Plans, Comprehensive Person-Centered revealed: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. Resident #82 Record Review revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Current medications listed: [MEDICATION NAME] 100 units/ml vial sliding scale per accu check before meals. [MEDICATION NAME] 100 units/ml give 35 units at night and 15 units in the morning. [MEDICATION NAME] 0.25 mg TID as needed for anxiety; Discontinued 2/14/18, donepezil 10 mg at bedtime, [MEDICATION NAME] 10 mg daily, Eliquis 5 mg twice daily, [MEDICATION NAME] powder 17 gm in 8 ounces (oz.) of liquid, [MEDICATION NAME] 20 mg daily, and potassium 10 MEQ daily. Review of annual Minimum Data Set ((MDS) dated [DATE] section C- cognitive patterns; revealed the resident has a Brief Interview for Mental Status score (BIMS) of 15, indicating the resident is cognitively intact. Review of section N- medications indicates the resident receives injections for insulin, insulin solution, opioids, and antipsychotic medications. Further review of the annual MDS section V- Care Area Assessment (CAA) revealed the R#82 triggered for [MEDICAL CONDITION] drug use, falls, pressure ulcer, and nutritional status, with the issues to be addressed in the resident's care plan. Review of the Care Plan initiated 11/17/17 revealed there is no care plan related to the residents' antidepressant or antipsychotic drug use to reflect person centered goals and interventions. Interview with the Director of Nursing (DON) on 3/9/18 at 2:47 p.m. revealed if a care area for the resident triggers to be addressed on the person-centered care plan; the responsible staff is expected to place the area of concern on the residents' person-centered care plan with goals and interventions to be implemented daily. Review of the facility's policy titled Care Plans, Comprehensive Person-Centered revealed: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs was developed. Review of the annual Minimum Data Set (MDS) assessment of 2/12/18 revealed R#72 had [DIAGNOSES REDACTED]. No behavioral symptoms such as rejection of care was documented. Under the Care Area Assessment Summary (CAAS) of the assessment, ADL/Functional rehab triggered and the decision was made to complete a plan of care for that area. Review of the plan of care initiated 2/26/17 for assistance with all ADLs secondary to weakness, intellectual disability, and [MEDICAL CONDITION] revealed interventions which included mouth care daily and as needed. During an interview on 3/6/18 at 9:17 a.m., R#72 said she was unable to brush her own teeth, but staff did not always assist in brushing her teeth. In fact, staff had failed to, regularly, brush her teeth for several weeks, even months. Observation of the resident's oral cavity at the time of the above interview revealed teeth that were stained a dark yellow and had an extensive amount of plaque and food. Review of dental progress notes for the resident from 3/17/17, 9/28/17 and 12/11/17 revealed the resident's oral hygiene was described as having heavy calculus, plaque, and food. Observation of the resident's mouth on 3/7/18 at 12:30 p.m. and again on 3/8/18 4:35 p.m. revealed her teeth to have the same appearance - dark yellow with extensive plaque and food build-up. Interview on 3/9/18 at 7:16 a.m. with Licensed Practial Nurse (LPN) DD revealed he works the 7:00 p.m. to 7:00 a.m. shift on the resident's hall. The Certified Nursing Assistants (CNAs) that work the 11:00 p.m. to 7:00 a.m. shift are responsible for completing ADL tasks for each resident as needed. The nurse on the unit is responsible for overseeing the CNAs' work and ensuring that the ADLs are completed. R#72 is totally dependent on staff for ADL care such as oral hygiene. The nurses rely on the CNAs to accurately report that ADLs are completed for the resident, but the nurse is also responsible for checking the resident's oral status during the administration of medications or during other interactions with the resident; Observation of the resident's oral area on 3/9/18 at 7:29 a.m. with LPN DD in attendance revealed the resident's teeth had been recently brushed. The teeth were still discolored, but appeared to have no build-up of food or other materials. Interview again with LPN DD at the time of this observation revealed that the resident's oral care/condition is affected by the CNA assigned to the resident on any given day. Some CNAs are meticulous with the resident's oral hygiene; for others (from another hall for example), oral care may be done in a careless manner or not at all. CROSS-REFERENCE TO F677", "filedate": "2020-09-01"}
{"rowid": 2619, "facility_name": "AUTUMN BREEZE HEALTH AND REHAB", "facility_id": 115580, "address": "1480 SANDTOWN ROAD SW", "city": "MARIETTA", "state": "GA", "zip": 30008, "inspection_date": "2018-03-09", "deficiency_tag": 677, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "UXT911", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, and record review, the facility failed to provide daily oral care for one dependent resident (#72) for 3 of 5 survey days. The sample size was 84. Findings include: Review of the clinical records for Resident (R)#72 revealed [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment of 2/12/18 revealed R#72 had a Brief Interview for Mental Status BIMS score of 11, indicating moderate cognitive impairment and had an active [DIAGNOSES REDACTED]. The annual MDS also documented that the resident needed extensive assistance with personal hygiene and was totally dependent on staff for assistance with other activities of daily living (ADLs) such as eating, dressing, toilet use, and bathing. No behavioral symptoms such as rejection of care was documented. During an interview on 3/6/18 at 9:17 a.m., R#72 said she was unable to brush her own teeth, but staff did not always assist in brushing her teeth. In fact, staff had failed to brush her teeth, daily, for several weeks, even months. Observation of the resident's oral cavity at the time of the above interview revealed teeth that were stained a dark yellow and was covered with an extensive amount of plaque and food. Review of a progress note from a mobile dentistry firm which visits the facility and provides dental service to the residents revealed the resident was seen for a recall exam on 3/17/17. The dental note on that day documented under oral hygiene that the resident had heavy calculus, plaque, and food present. Review of the dental progress notes from recall exams on 9/28/17 and 12/11/17 again described the resident's oral hygiene as heavy calculus, plaque, and food. Observation on 3/7/18 at 12:30 p.m. revealed the resident sitting outside the dining room waiting to go in for lunch. The resident's teeth were observed to be still stained yellow with an extensive amount of plaque and food. Interview on 3/8/18 at 1:52 p.m. with Certified Nursing Assistant (CNA) MM revealed she assists the resident with ADLs such as changing and eating during the 7:00 a.m. to 3:00 p.m. shift. However, the resident receives a shower and oral care from the CNAs on the 11:00 p.m. to 7:00 a.m. shift. Interview on 3/8/18 at 3:06 p.m. with Licensed Practical Nurse (LPN) CC revealed that the unit nurse is responsible for ensuring that the CNAs perform daily oral hygiene for the residents. She ensures that this is done by observing residents' oral area during medication administration and other services. Observation on 3/8/18 4:35 p.m. of R#72 revealed her teeth were in the same condition as the previous two days - dark yellow with extensive plaque and food build-up. Interview on 3/9/18 at 7:16 a.m. with LPN DD revealed he works the 7:00 p.m. to 7:00 a.m. shift on the resident's hall. The CNAs that work the 11:00 p.m. to 7:00 a.m. shift are responsible for completing ADL tasks for each resident as needed. The nurse on the unit is responsible for overseeing the CNAs' work and ensuring that the ADLs are completed. R#72 is totally dependent on staff for ADL care such as oral hygiene. The nurses rely on the CNAs to accurately report that ADLs are completed for the resident, but the nurse is also responsible for checking the resident's oral status during the administration of medications or other interactions with the resident; Observation of the resident's oral area on 3/9/18 at 7:29 a.m. with LPN DD in attendance revealed the resident's teeth had been recently brushed; the teeth were still discolored, but there appeared no build-up of food or other materials. Interview again with LPN DD at the time of this observation revealed that the resident's oral care/condition is affected by the CNA assigned to the resident on any given day. Some CNAs are meticulous with the resident's oral hygiene; for others (from another hall for example), oral care may be done in a careless manner or not at all.", "filedate": "2020-09-01"}
{"rowid": 2620, "facility_name": "AUTUMN BREEZE HEALTH AND REHAB", "facility_id": 115580, "address": "1480 SANDTOWN ROAD SW", "city": "MARIETTA", "state": "GA", "zip": 30008, "inspection_date": "2018-03-09", "deficiency_tag": 684, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "UXT911", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure physician's orders were followed for one resident (#48) to repeat laboratory tests and arrange for an outside consult with the nephrologist. The sample size was 84 residents Findings include: Review of the clinical records for Resident (R)#48 revealed she was admitted on [DATE] after a stay at an acute care facility where she was treated for [REDACTED]. Review of the admission Minimum Data Set (MDS) assessment of 1/19/18 for R#48 revealed active [DIAGNOSES REDACTED]. The assessment also documented that the resident had received insulin injections 3/7 days and a diuretic for 7/7 days during the assessment period. Review of the laboratory (labs) results of a Basic Metabolic Panel (BMP) completed for the resident on 1/8/18 revealed a creatinine level of 1.4 and a protein level of 5.2. These were noted to be outside of the acceptable ranges. Further review of these laboratory results revealed the nurse practitioner (NP) documented on 1/11/18 that the resident had acute kidney injury and had a baseline [MEDICATION NAME] of 1.2 per hospital notes and noted that the resident should follow up with nephrology, Pro-Stat 30cc twice a day for 30 days should be added to her diet, and the BMP should be repeated in two weeks. Review of the physician order sheet for 1/11/18 revealed orders were written for staff to repeat the labs in 2 weeks, add Pro-Stat, 30 cc for 30 days to the resident's diet, and make a follow-up appointment with the nephrologist for the resident. Review of the clinical records for the resident revealed documentation on the Medication Administration Records for (MONTH) (YEAR) and (MONTH) (YEAR) that the resident received Pro-Stat 30 cc twice a day. However, there was no evidence that the resident was sent for a follow-up appointment with nephrology nor that the BMP lab were repeated as ordered. Interview on 3/8/18 at 1:20 p.m. with Licensed Practical Nurse (LPN) NN revealed that neither follow-up labs nor a nephrology appointment had been completed for R#48 per the physician's orders of 1/11/18. He was not sure why these had been overlooked. The process when new orders are written for residents are for the doctor/NP to flag the charts to indicate when new orders have been written. The unit nurse is then responsible for adding the orders in the computer system. For orders for appointments such as to the nephrologist, the nurse fills out a form requesting that the appropriate appointment be made and this is given to the scheduler to make the appointment. To ensure that orders are not overlooked, the evening nurses also complete and sign a 24-hour chart check. Further interview on 3/8/18 at 2:26 p.m. with LPN NN revealed he had spoken with the NP who gave new orders for the resident to have labs drawn on 3/9/18 and for an appointment to be made with the nephrologist. The nephrology appointment was scheduled for 3/20/18. Interview on 3/8/18 at 3:26 p.m. with the Director of Nursing (DON) revealed the facility has a straightforward process in place to ensure that doctor's orders are followed. The doctor/NP writes the orders, and flags the chart, thus notifying the unit nurse that new orders are being requested for that resident. The nurse puts the orders for medication, etc. into the computer system, and completes requisitions, if needed, for labs. The night nurses are also to perform a 24-hour chart check to ensure orders are not missed. The DON had no explanation, under the circumstances, why this process was not followed and how two orders from 1/11/18 for this resident were overlooked. Interview on 3/9/18 at 2:25 p.m. with the NP, OO revealed she had requested the repeat labs for R#48 because the resident's albumen was low and since she had ordered a protein supplement, she wanted to follow up to see if it had any effect. She did not expect any negative effects from the oversight and would check the new labs that were done that morning. She had ordered the follow up for the nephrologist because of the resident's history of renal function, but had not given a time frame on the order sheet as to when the follow-up should be made.", "filedate": "2020-09-01"}
{"rowid": 2621, "facility_name": "AUTUMN BREEZE HEALTH AND REHAB", "facility_id": 115580, "address": "1480 SANDTOWN ROAD SW", "city": "MARIETTA", "state": "GA", "zip": 30008, "inspection_date": "2018-03-09", "deficiency_tag": 693, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "UXT911", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, facility failed to follow physician's orders as written for one of three residents (R) #79 who receive nutrition via a [DEVICE] (GT). On 3/5/18 at 7:00 p.m. R#79s tube feeding of [MEDICATION NAME] 1.5 noted to be running at 90cc per hour (hr) On 3/6/18 at 8:33a.m. [MEDICATION NAME] 1.5 hanging at 90cc per hr. At 12:15 p.m. noted [MEDICATION NAME] 1.5 continues to flow at 90cc per hr. At 2:30 p.m. [MEDICATION NAME] 1.5 continues at 90cc per hr. On 3/6/18 at 2:42 p.m. review of R#79s record revealed a physician order dated 2/22/18 for [MEDICATION NAME] 1.5 to run at 75cc per hr. A nutrition note dated 3/5/18 read, monthly wound assessment. Tube feeding decreased per last recommendation to 75cc per hr. for 19 hrs. and Zinc supplements started. On 3/6/18 at 3:33 p.m. an interview with the Registered Dietician (RD) revealed that she does not always physically visualize the tube feeding flow rates. She looks at the physician orders to determine what the resident should be receiving. When asked if she noted that R#79s tube feeding was flowing at a rate of 90 cc per hr. rather than the 75cc per hr. she documented on, she stated she did not note the discrepancy. On 3/6/18 at 3:35 p.m. a conversation with Unit Manager, BB, indicated that her duties are to review charge nurse activities daily. This includes review of physician orders and following through to make sure they are properly carried out. This included visualizing order changes. When asked if she physically looks at the Medication Administration Records (MARS) and reconciles them with the physical order, she stated yes. In this case she would have reviewed the physician's order, reviewed the MAR indicated [REDACTED]. When the Unit Manger BB was asked to escort surveyor to room where she confirmed that the tube feeding was flowing at the rate of 90 cc per hr. Employee GG, who has not been observed for his skills competency since 6/18/16, was providing care for R#79 when the concerns were identified. On 3/6/18 at 3:41 p.m. requested the Unit Manger BB to show surveyor the 24 hour MARS in the Electronic Medical Record (EMR) system. Review of the MAR indicated [REDACTED]. Employee BB was unable to state how long the rate had been wrong. On 3/7/18 at 2:37 p.m. review of R#79s MARs dated 2/22/18 through 3/6/18 revealed staff documented tube feeding rate was flowing at 75cc per hr.", "filedate": "2020-09-01"}
{"rowid": 2622, "facility_name": "AUTUMN BREEZE HEALTH AND REHAB", "facility_id": 115580, "address": "1480 SANDTOWN ROAD SW", "city": "MARIETTA", "state": "GA", "zip": 30008, "inspection_date": "2018-03-09", "deficiency_tag": 849, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "UXT911", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review facility failed to obtain a physician's order for one resident (R) #78 for hospice services. Sample size was 22. Resident #78 was admitted [DATE] with [DIAGNOSES REDACTED]. His medications include but not limited to [MEDICATION NAME] 1 milligram (mg) by mouth (PO) every (q) 4hours (hr). [MEDICATION NAME] 5-325 mg po twice daily (BID), [MEDICATION NAME] 20 mg po q 2 hr as needed (PRN), [MEDICATION NAME] 2.5 mg via nebulizer q 6 hr prn, [MEDICATION NAME] 2 mg po q 6 prn. Review of R #78 medical record revealed he was placed on hospice effective 1/27/18 per hospice benefit election form. When R# 78 was admitted to the facility, another hospice began providing services. Further review of resident's record did not evidence an order for [REDACTED]. On 3/8/18 at 2:04 p.m. an interview with Charge Nurse GG, revealed R #78 was transferred from a facility providing hospice services. Nurse GG stated R # 78 was receiving service through the current company providing services at the facility; therefore R #78 came to the facility and hospice care continued. Further conversation revealed the charge nurse was unable to locate the order and that the hospice nurse would be notified. On 3/9/18 at 11:08 a.m. a telephone interview with Hospice Nurse NN revealed that she had no knowledge of the resident receiving hospice care through her company while R# 78 was at the previous facility. She stated she first met resident three days after his return to facility. When asked if she recalled seeing or if she had a copy of the physician's order for the resident to receive hospice she stated she would have that information faxed to surveyor. As of 3/9/18 2:11 p.m. no was information received from Hospice Nurse NN. On 3/9/18 at 2:15 p.m. an interview with Assistant Director of Nursing (ADON) revealed that during R # 78's stay at the previous facility he was receiving hospice through that facility but care was not through the current company. When asked where the order for hospice services would be located for services provided in this facility she stated she would locate them. On 3/9/18 at 2:40 p.m. ADON return indicating there was no physician's order for hospice care to be administered at this facility.", "filedate": "2020-09-01"}
{"rowid": 2623, "facility_name": "AUTUMN BREEZE HEALTH AND REHAB", "facility_id": 115580, "address": "1480 SANDTOWN ROAD SW", "city": "MARIETTA", "state": "GA", "zip": 30008, "inspection_date": "2019-03-14", "deficiency_tag": 577, "scope_severity": "C", "complaint": 0, "standard": 1, "eventid": "TB9111", "inspection_text": "Based on observation, resident and staff interview, the facility failed to post the state survey results or notification of the availability and location of said results for residents and visitors/family during four of four days of the survey. The facility census was 90. Findings include: During an interview with members of the resident council on 3/13/19 beginning at 11:34 p.m., 7 of 7 members of the council who were present agreed that they were not aware the results of the most recent state surveys were available for their viewing, nor did they know where these results were located. Review of the Brief Interview for Mental Status (BIMS) scores on the most recent Minimum Data Set (MDS) assessments completed for the members of the council attending the interview revealed that 6 of 7 had scores ranging between 13 and 15 indicating that they were considered to be cognitively intact. Observation of the lobby area and resident accessible areas in the facility on 3/13/19 beginning at 12:20 p.m. revealed no signs of the recent state survey results or signage announcing the location or availability of those results. During an observation in the company of the administrator on 3/14/19 at 12:53 p.m. revealed she could not locate the state survey results in the lobby/reception area nor on the wall near the nurses' station at the intersection of the A and B halls. There was also no indication that the results were usually located in these areas except for an empty metal receptacle on the wall near the nurses' station on the A/B halls. After a brief search of her office and other areas, the administrator was observed to locate a binder with the survey results in her office and these she placed in the receptacle near the nurses' station on the A/B halls. During this observation, the administrator indicated that the state survey results were usually available at the nurses' stations to be accessed by residents and in the lobby area to be available for visitors. During an interview with the social worker on 3/14/19 at 1:00 p.m. it was revealed that she usually reviewed the results of the annual and complaint state surveys with the residents in resident council, especially after the completion of said surveys, and that she often informed them at such times where the results could be located. The social worker also said that residents and their families and visitors have access to at least three copies of the state survey results. The first of these copies is usually kept in the reception area where families and visitors can have access to it. The two other copies are kept at the nurses' stations on the A/B halls and on the memory care unit/E hall. The residents have access to the copies that are located on the halls. During an observation of the nurses' station on the memory care unit/E hall accompanied by the MDS coordinator on 3/14/19 at 1:08 p.m., it was revealed that there was no available copy of the state survey results and the MDS coordinator said she would need to ask the administrator where the results might be located. During an interview with the administrator on 3/14/19 at 2:31 p.m. it was revealed that copies of the survey results are usually kept in the reception area and at the nurses' stations to be available to residents/families/visitors. The results were usually kept at a level convenient for the residents to reach. The administrator said that she did not know who had removed all copies of the results from their usual locations nor why these and the signs pointing to their locations had been removed, but she had located the folder with the missing results from the A/B hall nurses' station area and had replaced it along with the sign documenting that these were the state survey results. During an observation on 3/14/19 at 2:41 p.m. of the wall next to the A/B hall nurses' station it was revealed a metal wall receptacle with the survey results in a black binder and a new label on the wall indicating these were the Survey Results.", "filedate": "2020-09-01"}
{"rowid": 2624, "facility_name": "AUTUMN BREEZE HEALTH AND REHAB", "facility_id": 115580, "address": "1480 SANDTOWN ROAD SW", "city": "MARIETTA", "state": "GA", "zip": 30008, "inspection_date": "2019-03-14", "deficiency_tag": 640, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "TB9111", "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) assessment were transmitted within 14 days of completion to Centers for Medicare and Medicaid Services (CMS) Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) System for five resident (R) 6, R#4, R#5, R#1, R#7. The facility also, failed to complete a discharge MDS assessment for four residents R#2, R#9, R#3, R#8. Total of nine records reviewed. The sample size was 32. Finding Included: An interview was conducted on 03/5/19 at 4:30 p.m. - 5:20 p.m. with the MDS Coordinator and the Assistant Director of Nursing (ADON) regarding MDS record over 120 days' old. The following was revealed. 1. R#6 was admitted on [DATE] and remains in the facility. Review of a listing of R#6's completed and transmitted MDS revealed quarterly assessment dated [DATE] was the last assessment transmitted for R#6. The MDS coordinator revealed that R#6 quarterly assessment dated [DATE] was completed, closed, transmitted to the QIES ASAP System on 12/31/18. 2. R#4 was admitted on [DATE] discharged from the facility 10/1/18. Review of a listing of R#4's completed and transmitted MDS revealed admission assessment dated [DATE] was the last assessment transmitted for R#4. The MDS coordinator revealed that R#4 discharge assessment 10/2/18 was completed, closed and transmitted. MDS coordinator could not locate facility's MDS 3.0 NH Final Validation Report for the month of (MONTH) (YEAR). 3. R#5 admitted [DATE] remains in the facility. Review of a listing of R#5's completed and transmitted MDS revealed quarterly assessment dated [DATE] was the last assessment transmitted for R#5. The MDS Coordinator revealed that R#5 quarterly assessment was on 12/30/18 was completed, closed, transmitted to the QIES ASAP System on 12/31/18. 4. R#1 admitted on [DATE] remains in the facility. Review of a listing of R#1's completed and transmitted MDS revealed quarterly assessment dated [DATE] was the last assessment transmitted for R#1. The MDS Coordinator revealed that R#1 quarterly assessment dated [DATE] was completed, closed transmitted to the QIES ASAP System on 12/31/18. 5. R#7 admitted [DATE] remains in the facility. Review of a listing of R#7's completed and transmitted MDS revealed quarterly assessment dated [DATE] was the last assessment transmitted for R#7. The MDS Coordinator revealed that R#7 annual assessment dated [DATE] was completed, closed and transmitted to the QIES ASAP System on 12/31/18. 6. R#2 admitted [DATE] discharged from the facility on 10/28/18. The MDS coordinator revealed R#2 discharge assessment was not completed. 7. R#9 admitted [DATE] discharged from the facility on 1/24/19. The MDS coordinator revealed R#9 discharge assessment was not completed. 8. R#3 admitted on [DATE] discharged from the facility on 12/15/18. The MDS coordinator revealed R#3 discharge assessment was not completed. 9. R#8 admitted on [DATE] discharged from the facility on 1/15/19. The MDS coordinator revealed R#8 discharge assessment was not completed. An interview was conducted on 03/5/19 at 5:25 p.m. with the MDS Coordinator revealed she did not complete the discharge assessment on R#2, R#9, R#3, and R#8. The MDS Coordinator and ADON revealed R#6, R#4, R#5, R#1, R#7 MDS assessments were completed and transmitted on 12/31/18. The MDS Coordinator revealed she would review the MDS 3.0 NH Final Validation Report for that time frame of the MDS assessment that were transmitted. The following information was requested from the MDS Coordinator and ADON a copy of the facility's MDS 3.0 NH Final Validation Report for that time frame of the MDS record 120 day's old. Copy of the facility policy on regarding completing MDS and transmitting assessments. The requested items were not provided to the surveyor. Interview on 3/5/19 at 5:30 p.m. with the Administrator and Regional Vice President regarding expectations of the MDS/Care Plan department. Both revealed assessment should be completed/transmitted timely. The Administrator revealed that she does not have an audit in place to check for completion/transmission of assessments. The Surveyor requested copy of the facility policy on regarding completing MDS and transmitting assessments. This information was not provided to the surveyor. Review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.14, page 2-36 dated (MONTH) (YEAR) revealed: Discharge Assessment Return Not Anticipated. Must be completed when the resident is discharge from the facility and the resident is not excepted to return to the facility within 30 days. Must be completed within 14 days after the discharge date . Must be submitted within 14 days after the MDS completion date.", "filedate": "2020-09-01"}
{"rowid": 2625, "facility_name": "AUTUMN BREEZE HEALTH AND REHAB", "facility_id": 115580, "address": "1480 SANDTOWN ROAD SW", "city": "MARIETTA", "state": "GA", "zip": 30008, "inspection_date": "2019-03-14", "deficiency_tag": 801, "scope_severity": "F", "complaint": 0, "standard": 1, "eventid": "TB9111", "inspection_text": "Based on staff interview and record review, the facility failed to ensure that the staff designated as Dietary Manager was a certified dietary or food service manager, or had a similar food service management certification or degree. There were 89 out of 90 residents that received an oral diet. Findings include: A review of the personnel file for the Dietary Manager revealed a change of status from dietary cook to dietary manager effect date of 12/28/16. A further review of the file revealed an active ServSafe Certification since 10/23/18. However, there was no evidence that the Dietary Services Supervisor had any additional dietary or food service certification or degree. An interview was conducted on 3/4/19 at 11:00 a.m. with the Dietary Manager (DM) regarding a food service management certification or degree. The DM revealed that he did not have a food service management certification or degree. An interview was conducted on 3/5/19 at 10:10 a.m. with the Administrator. The Administrator revealed that she reviewed the regulations and the DM should have food service management certification or degree.", "filedate": "2020-09-01"}
{"rowid": 2626, "facility_name": "AUTUMN BREEZE HEALTH AND REHAB", "facility_id": 115580, "address": "1480 SANDTOWN ROAD SW", "city": "MARIETTA", "state": "GA", "zip": 30008, "inspection_date": "2019-03-14", "deficiency_tag": 812, "scope_severity": "F", "complaint": 0, "standard": 1, "eventid": "TB9111", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and review of policy Georgia Nutrition Consulting, Inc. Expiration, Use By and Best if Used By Dates, the facility failed to discard expired food items. These deficient practices had the potential to affect 89 of 90 residents receiving an oral diet, of whom seven received thickened liquids. Findings included: Review of the policy of the policy Georgia Nutrition Consulting, Inc. Expiration, Use By and Best if Used By Dates revealed: Expiration This date determines when the food is no longer safe to eat. An observation of the dry storage area while accompanied by the dietary manager during the initial kitchen tour on [DATE] at 10:20 a.m. revealed two 8 ounce Thicken Nectar use by date [DATE]. One 46- ounce Honey like Consistency Thickened Sweetened Tea used by date [DATE]. Twenty-seven 4-ounce Honey like thickened lemon flavored water used by date [DATE]. Three 4-ounce Honey like thickened lemon flavored water used by date [DATE]. One gallon jar of Maraschino Cherries expired date [DATE]. An interview was conducted on [DATE] at 11:00 a.m. with the Dietary Manager (DM) regarding the expired items in the dry storage area. The DM confirmed that the items were expired. He also revealed that he is solely responsible for checking the dates for expired food items. He revealed he checks the dates on all food items when the delivery comes in twice a week. The DM revealed that he does educate the staff on checking for expired food items. An interview was conducted on [DATE] at 3:50 p.m. with the Administrator and the DM regarding the expired food items found during the initial kitchen tour. The Administrator revealed that she was not aware of the expired items in the kitchen and she was sorry the surveyor had to find the expired items. An interview was conducted on [DATE] at 4:30 p.m. with the administrator regarding the expired items in the dry storage area. Administrator revealed her expectations that the food items in the kitchen are checked daily for expiration dates. An interview was conducted on [DATE] at 4:45 p.m. with Administrator and DM regarding how the facility discard expired food items. The DM revealed that all food items are marked with a date that is delivered. The food items are discarded thirty days after opening or the expiration date if it comes first. Review of the list provided by the Administrator revealed six residents with a physician order [REDACTED].>", "filedate": "2020-09-01"}
{"rowid": 2627, "facility_name": "AUTUMN BREEZE HEALTH AND REHAB", "facility_id": 115580, "address": "1480 SANDTOWN ROAD SW", "city": "MARIETTA", "state": "GA", "zip": 30008, "inspection_date": "2018-10-11", "deficiency_tag": 684, "scope_severity": "E", "complaint": 1, "standard": 0, "eventid": "VTF411", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff and Physician interview, review of facility policy for insulin administration and education records for carrying out Physician orders, the facility failed to administer medications in accordance with Physician orders for four (4) residents (R), (R#1, R#2, R#3, and R#5) from a sample of six (6) residents reviewed for medications. The facility census was ninety (90) residents. Findings include: Review of the facility policy titled Insulin Administration revised (MONTH) 2014, revealed Step 8 is to check the order for the amount of insulin. Step 12 is to double check the order for the amount of insulin. Review of facility education summary dated 3/13/18 for Physician Orders- How to Carry Out revealed the Licensed Nursing Staff are to make sure to clarify order with Physician/Nurse Practitioner (NP) if the order is not clear. The 11-7 Charge Nurses must conclude the daily activity by checking charts for new orders and ensure they are already entered into the system . The Education Attendance Record indicated fifteen (15) Licensed Nurses signed the roster. Review of the clinical record for R#1 revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R#1 was transferred from the facility to a hospital on [DATE]. Review of the Physician orders for R#1 revealed an order dated 6/5/18 to discontinue all current orders for [MEDICATION NAME] (Quetiapine [MEDICATION NAME]) and decrease (indicated by downward arrow) [MEDICATION NAME] 25 milligrams (mg) by mouth (PO) twice a day (BID) and 50 mg PO every bedtime (Q HS) for a diagnosis (dx) of [MEDICAL CONDITION]. Review of the (MONTH) (YEAR) Medication Administration Record (MAR) for R#1 revealed on 6/5/18 the previous orders for [MEDICATION NAME] had been discontinued and a new order for [MEDICATION NAME] dated 6/5/18 had been added as follows: Quetiapine [MEDICATION NAME] 25 mg tab take [MEDICATION NAME] 25 mg by mouth two times a day for [MEDICAL CONDITION]. The administrations were scheduled for 9:00 a.m. and 5:00 p.m. Continued review of the (MONTH) (YEAR) and (MONTH) (YEAR) MAR's revealed the order to administer [MEDICATION NAME] 25 mg PO BID had been documented as administered from 6/6/18 at 5:00 p.m. through 7/25/18 at 5:00 p.m. There were no documented administrations of [MEDICATION NAME] 50 mg PO at HS. There was no order transcribed to the (MONTH) (YEAR) and (MONTH) (YEAR) MAR's for [MEDICATION NAME] 50 mg PO at HS and there was no corresponding order transcribed to the monthly electronic Physician order for [REDACTED]. An interview regarding Physician orders not transcribed correctly was conducted with the Director of Nurses (DON) on 10/11/18 at 8:40 p.m. The DON revealed he had been unaware the [MEDICATION NAME] order for R#1 on 6/5/18 had not been transcribed correctly. The DON confirmed the process of twenty-four (24) hours chart checks for all new orders should capture any orders not completely or correctly transcribed. Review of the clinical record for R#2 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. R#2 was transferred from the facility to a hospital on [DATE]. Review of Physician orders for R#2 revealed an order dated 3/21/18 as follows: Humalog 100 units/ml cartridge accu-check with Humalog 100 units/ml vial sliding scale 201-251=4 units (U) 251-300=6U 301-350=8U 351-400=10U 401-500=12U Call MD for blood sugar less than ( ) 500 Review of the (MONTH) (YEAR) MAR for R#2 revealed on 3/22/18 at 11:00 a.m. the finger stick blood sugar (FSBS) result was documented to be 166 and R#2 was documented to have had 4 units of Humalog Insulin administered in the right upper quadrant (RUQ). There was no FSBS result recorded on 3/22/18 at 4:00 p.m. and the 9:00 p.m. FSBS result was documented on the MAR as low. The Nurse's progress notes were reviewed for symptoms and treatment of [REDACTED]. Review of the (MONTH) (YEAR) MAR for R#2 revealed on 5/3/18 at 4:00 p.m. a FSBS result was documented to be 189 and 4U Humalog Insulin was documented to have been administered in the left lower quadrant (LLQ). A review of the Nurse's Notes for R#2 for 5/3/18 did not reveal any signs, symptoms or treatment of [REDACTED]. Continued review of the (MONTH) (YEAR) MAR revealed on 5/18/18 at 11:00 a.m. R#2 had a documented FSBS result of 127. R#2 was documented to have been administered 4U of Humalog Insulin in the RLQ. On 5/23/18 at 11:00 a.m. R#2 was documented to have had a FSBS result of 143 and was documented to have been administered 4U Humalog in the LLQ. The Nurses Notes were reviewed for R#2 on 5/18/18 and 5/23/18 and there were no documented concerns or treatment for [REDACTED]. An interview regarding insulin coverage administration was conducted with Licensed Practical Nurse (LPN) CC on 10/11/18 at 3:12 p.m. LPN CC confirmed documenting administration of Humalog Insulin coverage for R#2, for FSBS results less than 201 on 3/22/18 at 11:00 a.m., 5/18/18 at 11:00 a.m., 5/23/18 at 11:00 a.m. and on 5/3/18 at 4:00 p.m. LPN CC indicated he knows the sliding scale coverage order does not include FSBS results less than 201 and did not have any idea why he documented these administrations. LPN CC was sure he had not administered Humalog Insulin for coverage of FSBS less than 201. An interview with the DON regarding documentation of insulin coverage administration was conducted on 10/11/18 at 8:40 p.m. The DON revealed the documentation of insulin coverage administration for FSBS less than 201 had not been noticed when all the resident's MAR's were reviewed at the end of (MONTH) (YEAR) and at the end of (MONTH) (YEAR). All the MAR's are reviewed to check for errors, omissions and correct transcription of orders. The DON revealed the current electronic MAR program asks the nurse when documenting the FSBS result if the result is high or low, and if the nurse answers the question it will record high or low instead of the numerical FSBS result. The DON revealed the nurses have been educated not to answer if the FSBS is high or low. Review of the clinical record for R#3 revealed admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Physician orders for R#3 revealed an order dated 10/2/18 to decrease Trazadone 25 mg po q 2:00 p.m. A previous order for R#3 dated 9/20/18 was also on the MAR for Trazadone 150 mg, give half tab by mouth at noon every day. There were no clarification orders for Trazadone on the (MONTH) (YEAR) Physician orders until the surveyor made an inquiry on 10/11/18. Review of the (MONTH) (YEAR) MAR for R#3 revealed R#3 had been documented as being administered Trazadone 50 mg , take half tablet = 25 mg by mouth every evening. This was scheduled for 5:00 p.m. and initialed from 10/3/18 through 10/10/18. An additional order on the MAR for the former order for Trazadone 150 mg tablet, give one half tablet by mouth at noon every day was also documented as continuing to be administered at 12:00 p.m. daily from 10/1/18 through 10/11/18. Review of the Psychiatric Consult physician progress notes [REDACTED]. R#3 had documented administrations of 100 mg Trazadone daily for nine (9) days, with an order to administer Trazadone 25 mg daily. Review of the Nurse's Notes and incident log for R#3 revealed there had been no falls during the 9 days. An interview on 10/10/18 at 1:20 p.m. was conducted with the DON regarding the order to decrease Trazadone to 25 mg po daily at 2:00 p.m. for R#3. The DON revealed the order, written by the Psychiatric Consult Physician, was not clear and should have been clarified. An interview regarding the order to decrease Trazadone for R#5 was conducted on 10/10/18 at 2:00 p.m. with the Physician who wrote the order. The Physician revealed she had thought the order was clear. The Physician did not remember anyone calling her to clarify the order. The Physician confirmed she had meant to decrease the dosage of Trazadone for R#5 to a total of 25 mg to be administered once a day to try to prevent falls. Review of the clinical record for R#5 revealed admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Physician orders for R#5 revealed an order dated 10/2/18 to discontinue all [MEDICATION NAME] orders at family's request. Additionally, the Physician ordered [MEDICATION NAME] 250 mg po BID and q HS. Review of the (MONTH) (YEAR) MAR for R#5 revealed documented administration of [MEDICATION NAME] 250 mg po BID at 9:00 a.m. and 5:00 p.m. and HS on 10/3/18, 10/4/18, 10/5/18, 10/6/18, 10/7/18, 10/9/18, and 10/10/18. Continued review of the (MONTH) (YEAR) MAR for R#5 revealed the prior order, dated 6/26/18 for [MEDICATION NAME] 375 mg po BID had not been discontinued and R#5 had documentation of continued administrations of [MEDICATION NAME] 375 mg po BID at 9:00 a.m. and 5:00 p.m. until 10/8/18. Review of the Psychiatric Consult physician progress notes [REDACTED]. R#5 received an increase in the [MEDICATION NAME] dose for six (6) days. An interview regarding the administration of two different doses of [MEDICATION NAME] for R#5 was conducted on 10/11/18 at 6:55 p.m. with LPN BB. LPN BB revealed she could not remember administering two different doses of [MEDICATION NAME] to R#5 at the same time. LPN BB confirmed her initials on the (MONTH) (YEAR) MAR documenting she had administered [MEDICATION NAME] 250 mg PO at 5:00 p.m. on 10/4/18 and 10/5/18, and [MEDICATION NAME] 375 mg PO at 5:00 p.m. on 10/4/18 and 10/5/18. LPN BB revealed she does not think she would have given both doses at [MEDICATION NAME] but should have checked the order. An interview was conducted with LPN CC regarding the administration of two different doses of [MEDICATION NAME] was conducted on 10/11/18 at 7:05 p.m. LPN CC revealed he could not be sure he had administered two different doses of [MEDICATION NAME] to R#5 at the same time. LPN CC confirmed he had documented administering [MEDICATION NAME] 375 mg PO and [MEDICATION NAME] 250 mg PO concurrently at 9:00 a.m. on 10/3/18, 10/4/18, 10/5/18, and 10/9/18. LPN CC revealed he did not think he had administered both doses of [MEDICATION NAME] but could not be sure because he does not document administering medications unless he has administered the medications. During an interview regarding administering medications according to Physicians orders conducted with the DON on 10/11/18 at 8:41 p.m. the DON revealed he was concerned regarding Physician orders not being completely transcribed and R#2 having documented administrations of insulin coverage with blood sugars not sufficient to require coverage. The DON revealed the 24 hour chart check should be finding these incomplete transcription errors. The continuing process of checking the prior months orders and comparing them with the MAR's and checking the next months MAR's and comparing them with the latest Physician orders should be discovering the errors at the end of the month. This process also checks for errors in administration such as documenting insulin coverage errors. The DON acknowledged the processes did not capture the errors for R#1, R#2, R#3, and R#5. Cross refer to F756", "filedate": "2020-09-01"}
{"rowid": 2628, "facility_name": "AUTUMN BREEZE HEALTH AND REHAB", "facility_id": 115580, "address": "1480 SANDTOWN ROAD SW", "city": "MARIETTA", "state": "GA", "zip": 30008, "inspection_date": "2018-10-11", "deficiency_tag": 756, "scope_severity": "D", "complaint": 1, "standard": 0, "eventid": "VTF411", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, review of the Consultant Pharmacist Agreement, and Consultant Pharmacist interview, the Consultant Pharmacist failed to address an error in transcription of an order for [REDACTED]. Findings include: Review of facility Consultant Pharmacist Agreement, Required Consultant Services, signed by the facility on 11/30/16, revealed the Consultant Pharmacist is required to strive to assure that medications and/or biologicals are requested, received and administered in a timely manner as ordered by the authorized prescriber ( in accordance with Applicable Law) Review of the clinical record for R#1 revealed a physician's orders [REDACTED].#1 was transferred from the facility to a hospital on [DATE]. There were no additional orders for Quetiapine [MEDICATION NAME] for R#1 after 6/5/18. Review of the (MONTH) (YEAR) and (MONTH) (YEAR) Medication Administration Record [REDACTED].m from 6/6/18 through 7/25/18. There were no documented administrations of Quetiapine [MEDICATION NAME] 50 mg PO at HS from 6/6/18 through 7/25/18. R#1 missed fifty (50) administrations of Quetiapine [MEDICATION NAME] 50 mg PO at HS. Review of the Pharmacy Progress Notes for R#1 revealed the Consultant Pharmacist had reviewed his medication regimen on 6/20/18 and 7/20/18. There were no references to Quetiapine [MEDICATION NAME] on those dates on the Pharmacy Progress Notes. Review of the clinical record for R#2 revealed a Physician order [REDACTED]. 201 - 251 = 4 units (U) 251 - 300 = 6 U 301 - 350 = 8 U 351 - 400 = 10 U 401 - 500 = 12 U Review of the (MONTH) (YEAR) MAR for R#2 revealed on 3/22/18 at 11:00 a.m. documentation indicated R#2's fingerstick blood sugar (FSBS) result was one hundred sixty-six (166) and she was documented to have been administered 4 U Humalog Insulin in the right upper quadrant (RUQ). Review of the (MONTH) (YEAR) MAR for R#2 revealed on 5/3/18 at 4:00 p.m. the FSBS reading was one hundred eighty- nine (189) and was documented to have been administered 4 U Humalog Insulin in the left lower quadrant (LLQ). On 5/18/18 at 11:00 a.m. R#2 had a documented FSBS result of one hundred twenty-seven (127) and was documented to have been administered 4 U Humalog Insulin in the right lower quadrant (RLQ). On 5/23/18 at 11:00 a.m. R#2 was documented to have had a FSBS result of one hundred forty-three (143) and was documented to have been administered 4 U Humalog Insulin in the left upper quadrant (LUQ). A review of Consultation Reports for R#2 indicated the Consultant Pharmacist reviewed the medication regimen on 4/19/18 through 4/20/18 and 6/20/18 through 6/22/18. There was no recommendation regarding sliding scale insulin coverage. An interview was conducted regarding review of resident's medication regimens with the Consultant Pharmacist on 10/15/18 at 1:00 p.m. The Consultant Pharmacist revealed she reviews each resident's medication regimen every month by checking orders on the hard copy of the clinical records and then checking the electronic MAR's. The Consultant Pharmacist revealed she checks for errors in transcribing orders as well as any irregularities in the documentation of medication regimen. The Consultant Pharmacist revealed she has to share a computer with the nursing staff who are documenting in the electronic clinical records. The Consultant Pharmacist confirmed she may have missed the incomplete transcription of the Quetiapine [MEDICATION NAME] on 6/5/18 for R#1 and the errors in documentation of sliding scale insulin coverage for R#2 in (MONTH) (YEAR) and (MONTH) (YEAR), because she may not have had full access to the Medication Administration Records. Cross refer to F684", "filedate": "2020-09-01"}
{"rowid": 4308, "facility_name": "PRUITTHEALTH - MARIETTA", "facility_id": 115276, "address": "70 SAINE DRIVE SW", "city": "MARIETTA", "state": "GA", "zip": 30008, "inspection_date": "2019-07-24", "deficiency_tag": 584, "scope_severity": "E", "complaint": 1, "standard": 1, "eventid": "I5PG11", "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 seven resident rooms (rooms 200, 201, 203, 206, 209, 210, 227), common shower room and supply storage room, on one of two units. The census was 108. Findings include: Observation on 7/21/19 at 11:20 a.m., revealed on second floor, A Hall supply/storage fluorescent room light out, making room dark during retrieval of supplies. Observation on 7/21/19 at 11:30 a.m., revealed in room [ROOM NUMBER] light bowl sitting on sink counter; ripped wallpaper strip above bed A; peeling particle board on sink counter; hole in ceiling, between two beds, with electrical face plate partially covering opening; hole in ceiling tile in bathroom, approximately two inches in diameter; light in bathroom missing globe fixture; hole in ceiling tile in bathroom, approximately one inch circular around sprinkler head. Observation on 7/21/19 at 12:51 p.m., revealed in room [ROOM NUMBER], electrical outlet in wall with broken face plate. Observation on 7/21/19 at 12:55 p.m., revealed in room [ROOM NUMBER], a hole in ceiling tile in bathroom, approximately two inches in diameter; call light reset button missing on wall unit; chair rail missing around room on bed B side of the room. Observation on 7/21/19 at 2:16 p.m., revealed in room [ROOM NUMBER], hole in ceiling, between two beds, with electrical face plate partially covering opening. Observation on 7/21/19 at 2:18 p.m., revealed common shower room on second floor, with strong, unidentifiable and gagging odor. Observation on 7/22/19 at 11:04 a.m., revealed in room [ROOM NUMBER], bathroom had very strong urine odor; male urinal in clear plastic bag hanging on grab bar, with dark discolored ring around urinal opening. Observation on 7/22/19 at 12:11 p.m., revealed in room [ROOM NUMBER], hole in ceiling, between two beds, with electrical face plate partially covering opening. Observation on 7/23/19 at 11:55 a.m., revealed in room [ROOM NUMBER], chair rail around the beds, missing chunks of wood, exposing splintered wood rail. Interview on 7/24/19 at 5:26 p.m., with Maintenance Director, stated that each nurses station has a notebook that staff members fill out a hand written work order for items or concerns needing maintenance repair. He stated that he checks the notebooks 3-4 times per day. He further stated he prioritizes items/concerns that relate to resident care. During walking rounds, he verified concerns identified during survey.", "filedate": "2019-11-01"}
{"rowid": 4500, "facility_name": "PRUITTHEALTH - MARIETTA", "facility_id": 115276, "address": "70 SAINE DRIVE SW", "city": "MARIETTA", "state": "GA", "zip": 30008, "inspection_date": "2015-09-30", "deficiency_tag": 248, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "IBUU11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff and resident interviews the facility failed to ensure individualized activities were provided to meet the needs of one(1)resident B from a sample of fifty-four(54)residents. Findings include: During an initial observation and interview with resident B on 09/28/2015 at 11:00 a.m. she/he revealed they did not like to leave their room. She/He stays in bed most of the day because of weakness and prefers to read or watch television. She/He is not able to read anymore because of [MEDICAL CONDITION]. She/He indicated that her/his television/cable had not been working for a little over a week. She/He was told that none of the cable on the second floor hallway was working. Resident B reported the outage on the day the cable went out. On 09/28/2015 at 2:15 p.m. an interview with GG from maintenance revealed the cable on the second floor has been out for about a week. A further interview with HH maintenance supervisor revealed after a power outage last week several channels of cable have not been working. He has been unable to get anyone from the cable company to provide a service call. A tour of the second floor with GG and HH, HH revealed no cable channels are available to the residents on second floor. A follow up interview and observation of B on 9/29/2015 at 11:40 a.m. Resident B was sitting up in her/his bed, television not on. She/He revealed the cable has not been fixed yet. Resident indicated she/he is to tried to get out of bed and hopes the cable will be back on soon. Resident Broommate ' s television is not working. On 9/29/2015 at 11:45 am an interview was conducted with II Activities director regarding activities and a review of the activities calendar. II revealed that residents that do not come out of their rooms are assigned to a one on one visit at least two (2)times a week. The visits should be according to resident's interests as much as possible. Resident B is scheduled to have visits on Monday, Wednesday, and Friday of each week. A record review of Resident B s Activity progress notes indicated a visit on 7/13/2015 and resident enjoys watching TV in her/his room. The visit on 4/23/2015 revealed the resident likes to watch TV in her/his room. II knew that resident Bs television was not working but did not know for how long. Further record review revealed the Care Plan meeting dated 5/22/2015 in which resident B was self-directed with her/his activities, enjoyed watching television in her/his room and the goal was for the resident to not experience isolation thru the next review.", "filedate": "2019-09-01"}
{"rowid": 4501, "facility_name": "PRUITTHEALTH - MARIETTA", "facility_id": 115276, "address": "70 SAINE DRIVE SW", "city": "MARIETTA", "state": "GA", "zip": 30008, "inspection_date": "2015-09-30", "deficiency_tag": 279, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "IBUU11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop a Vision Care Plan for one(1)resident #68 with impaired vision and no corrective lenses from a sample of twenty-eight(28)residents. Findings include: A record review for resident #68 revealed an Admission Minimum Data Set(MDS) assessment dated [DATE] which documented in Section B- Hearing, Speech, and Vision that the resident's vision was impaired, able to see large print but not regular print in newspapers/books and had no corrective lenses. Section V-Care Area Assessment (CAA) triggered Vision with the decision to be care planned. A record view of resident #68 care plans revealed no evidence a care plan for vision had been developed. An interview conducted on 9/30/15 at 10:46 a.m. with the Care Plan Coordinator CC confirmed the Annual MDS assessment dated [DATE] triggered Vision with the decision to be care planned. Further, she confirmed a Vision Care Plan was never developed and that a care plan for Vision should have been developed.", "filedate": "2019-09-01"}
{"rowid": 4502, "facility_name": "PRUITTHEALTH - MARIETTA", "facility_id": 115276, "address": "70 SAINE DRIVE SW", "city": "MARIETTA", "state": "GA", "zip": 30008, "inspection_date": "2015-09-30", "deficiency_tag": 309, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "IBUU11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interviews the facility failed to follow a physician order [REDACTED]. Findings Include: An observation of resident #8 was made on 9/30/2015 at 8:05 a.m. on the second floor at the far exit door next to room [ROOM NUMBER]. The resident was trying to get the door open, screaming, someone get her back. A Certified Nurse Assistant(CNA)responded to the residents call and requested assistance from Licensed Practical Nurse (LPN)JJ . A record review of resident #8 on 9/30/2015 at 8:10 a.m. revealed a Brief Interview of Mental Status score (BIMS) of three (3) and [DIAGNOSES REDACTED]. A Physician' s order dated 9/1/2015 through 9/30/2015 was signed and dated on 9/2/2015 for a Wander guard and to check function and placement every shift was noted. A further observation was made of resident #8 in her/his room on 9/30/2015 at 8:10 a.m. No WanderGaurd was observed to be on resident #8. An interview during this observation of resident #8 with JJ revealed resident #8 does not have a wander guard on and (LPN)JJ believed that the wander guard was discontinued in the past. Review of the physician' s order for a WanderGuard was signed on 9/2/2015 and verified with (LPN)JJ. 9/30/2015 an interview with the Director of Nurses (DON) at 11:35 a.m. revealed there was a physician's orders [REDACTED]. There is no WanderGuard on resident #8. It is her expectation that physician's order [REDACTED]. Review of physician orders [REDACTED]. discontinue [MEDICATION NAME] twenty five (25) milligrams (mg) and give [MEDICATION NAME] thirty seven point five (37.5) milligrams (mg) by mouth daily for depression. Review of the Medication Administration Record [REDACTED]. Interview on 9/30/2015 at 11:20 a.m. with BB Licensed Practical Nurse (LPN) Unit Manager revealed that the nurse giving the medication 12/10/2014 through 12/12/2014 should have notified someone that the ordered dose was not available on the cart. She stated that the nurse circles the date to indicate that the dose was not given. In an interview on 9/30/2015 at 11:40 a.m. with the Director of Nursing (DON) revealed that it is her expectation that the nurse should have called the pharmacy about the medication not being available on 12/10/2014 and then notify the physician for direction about the medication for that day.", "filedate": "2019-09-01"}
{"rowid": 4503, "facility_name": "PRUITTHEALTH - MARIETTA", "facility_id": 115276, "address": "70 SAINE DRIVE SW", "city": "MARIETTA", "state": "GA", "zip": 30008, "inspection_date": "2015-09-30", "deficiency_tag": 313, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "IBUU11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interviews, the facility failed to ensure needed ophthalmology services for one (1) resident ('A') from a sample of twenty-eight (28) residents. Findings include: Resident was assessed on his most recent Quarterly assessment dated [DATE] to have moderate vision impairment, with no corrective lenses. The Care plan indicated impaired vision, but did not utilize glasses or corrective lenses. The resident was admitted to facility on 9/19/14. Resident was observed attempting to read on 9/29/15 at 11:28 am. Resident revealed he used to wear glasses, but just quit wearing them, had no idea where they might be .Resident was requested to read a sentence from his book, but was unable to, just mumbled various words. Residents Bim score was 5. Interview with residents Certified Nursing Assistant (CNA) AA on 9/29/15 at 11:28 am revealed resident was always reading his books, told CNA he loved to read. She was not aware if he could actually read or not. Interview with the Unit Manager BB on 9/29/15 at 11:51 am revealed that if a resident was assessed for poor vision, and no corrective lenses, that resident should be placed on the list for the next ophthalmology visit. He visits approximately every three (3) months, last visit was (MONTH) (YEAR). Did not know how resident 'A' was missed for an eye exam. He arrived to the unit with out glasses. Interview with the Minimal Data Set (MDS) coordinator CC on 9/29/15 at 11:59 am revealed that the assessment and care plan are completed for impaired vision, but MDS does not make recommendations for eye evaluations. A complete assessment was done by nursing, who would then notify Social Services, who was responsible for keeping the list of residents needing an eye appointment. Interview with Social Services DD on 9/29/15 at 1:50pm revealed that she would receive a Communication Form from nursing requesting an Ophthalmology consult. Then that resident would be placed on list to be seen at next visit. Unit Managers usually ensured those needs were met. DD had never received a communication from nursing until today concerning this resident, he will be seen 10/5/15. Resident # 123 admitted [DATE], Bims = 5, [AGE] year Quarterly assessment dated [DATE] indicated Dx of HTN, DM, [MEDICAL CONDITIONS], [MEDICAL CONDITIONS]/[MEDICAL CONDITION], and depression. Resident had moderate impairment with vision, no corrective lenses Care plan indicated goals /interventions for impaired vision, unable to see large or regular print, but can identify objects and headline print. Does not utilize glasses or corrective lenses. 09/29/2015 11:28:57 AM attempted to interview res, speech very stilted, but he did say he used to wear glasses, but just quit, did not know where they were. He had books on bedside table and stated he could read them, but when asked to read, just mumbled various words, unable to read. Review of RP for resident revealed he is in Adult Protective Services. 09/29/2015 11:46:16 AM Res has been reading his books, and told CNA he loves to read. She was not aware if he could actually read or not. 09/29/2015 11:51:42 AM Interview w/Barbara Brown LPN Unit Manager revealed that if resident was assessed for poor vision, w/no corrective lenses present, should be placed on the list for the next visit by the eye doctor. MD visits unit approximately every three months. Last visit was (MONTH) (YEAR). Does not know how resident was missed for an eye exam. Resident did not arrive to facility w/eye glass. 09/29/2015 11:59:20 AM Interview w/(NAME)Sonora LPN MDS Coordinator revealed that a care plan is completed for impaired vision, but MDS does not recommend vision app' t for evaluation. A complete assessment is done by nursing by nursing who would then notify Social Services, who was responsible for keeping the list of residents needing to be seen. 09/29/2015 1:43:38 PM Interview w/Barbara Brown LPN revealed Social Services is ultimately responsible for assuring eye exams are completed as needed. Basically res had not complained and was overlooked. However, he will be seen [DATE]. 09/29/2015 1:50:38 PM Interview w/ Social Services Lynne(NAME)revealed that she would receive a Communication Form from nursing requesting an Ophthalmology consult. Then that resident would be placed on list to be seen at next visit. Unit managers usually stay on top of needs. Had never received communication from nursing concerning this resident.", "filedate": "2019-09-01"}
{"rowid": 4504, "facility_name": "PRUITTHEALTH - MARIETTA", "facility_id": 115276, "address": "70 SAINE DRIVE SW", "city": "MARIETTA", "state": "GA", "zip": 30008, "inspection_date": "2015-09-30", "deficiency_tag": 323, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "IBUU11", "inspection_text": "Based on observations, staff interviews and review of the Safety Data sheet the facility failed to ensure a hazardous chemical was stored securely in one (1) shower out of four (4) showers in the facility. Findings include: During the initial tour of the facility on 9/28/2015 at 10:30 am the shower room (#1) was propped open with a linen cart. An open cabinet inside the shower contained a spray bottle, unlabeled, half full of a blue substance. A second observation at 12:15pm that day revealed the shower door shut, unlocked and the same spray bottle of blue substance unlocked in the cabinet in the shower. The same day at 3:20 p.m. a tour was conducted while interviewing JJ unit manager. Shower (#1) was found propped open with a trash can and the shower cabinet open. An unlabeled spray bottle half full of a blue substance was in the unlocked cabinet. JJ indicated that the substance is a disinfectant that should be locked up in the cabinet and the shower room should be locked when not in use. JJ further revealed the staff memo posted on the shower cabinet door indicates before staff leave the shower the disinfectant bottle should be placed back into the locked cabinet. During an interview with the Administrator and the Director of nurses on 9/29/2015 at 330 Pm revealed the blue substance in the spray bottle was Clorox Commercial Solutions Green Works Concentrated glass cleaner. The Materials Safety Data Sheet provided indicated this hazardous chemical may cause skin irritation, serious eye irritation and is flammable. It was the expectation of the Administrator that this chemical be stored in a locked cabinet when not in use and safely out of residents harm. 9/29/2015 at 4:15pm a follow up interview was conducted with the Administrator and HH. They were unable to identify if staff had been directed to keep chemicals locked in the past. An in-service was provided to housekeeping staff on that day to educate on the proper storage of hazardous chemicals.", "filedate": "2019-09-01"}
{"rowid": 4505, "facility_name": "PRUITTHEALTH - MARIETTA", "facility_id": 115276, "address": "70 SAINE DRIVE SW", "city": "MARIETTA", "state": "GA", "zip": 30008, "inspection_date": "2015-09-30", "deficiency_tag": 332, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "IBUU11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations record review and staff interview observed during medication administration on one (1)of six (6) halls the facility failed to ensure that one(1)of four(4)medication nurses administered medications without a medication error rate of five percent or greater. Findings include: An observation conducted during medication pass on 9/29/15 beginning at 4:38 p.m. revealed one 1)of four (4)nurses administering medications on one (1) of six (6) halls with three (3) errors observed from twenty-seven (27)opportunities. This resulted in a medication error rate of six point eighty-nine percent (6.89%). An observation on 9/29/15 at 5:46 p.m. with Licensed Practical Nurse(LPN)MM administered sennosides-[MEDICATION NAME] eight point six, and fifty(8.6-50)milligrams (mg)by mouth (PO) twice a day (BID) as needed to resident #93. Review of the physician's orders [REDACTED]. An observation on 9/29/15 at 5:47 p.m. revealed MM administered [MEDICATION NAME] 0.5 mg one(1) tablet PO to resident #93. Review of the physician's orders [REDACTED]. A interview with the Licensed Practical Medication Nurse MM on 9/29/15 at 6:00 p.m. MM revealed the correct dosage for Sennosides-[MEDICATION NAME], and the correct dosage and time for [MEDICATION NAME] were not followed as physician ordered and should have been followed. In an Interview with the Director of Nursing (DON) on 9/30/15 at 12:40 p.m., revealed her expectation for nurses is that they follow standards and the facilities protocols and guidelines during medication pass and storage. The DON further revealed that during medication pass, the nurses are expected to follow the physician orders [REDACTED].", "filedate": "2019-09-01"}
{"rowid": 4506, "facility_name": "PRUITTHEALTH - MARIETTA", "facility_id": 115276, "address": "70 SAINE DRIVE SW", "city": "MARIETTA", "state": "GA", "zip": 30008, "inspection_date": "2015-09-30", "deficiency_tag": 441, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "IBUU11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interviews the facility failed to follow infection control practices during medication pass for one(1)of three(3)medication carts out of six(6)units. Finding includes: During medication pass observation on 9/29/15 at 5:40 p.m. The Licensed Practical Nurse NN was observed during medication pass to drop one(1) pill inside the medication cart draw([MEDICATION NAME] 100 milligrams(mg)one (1) tablet)and noted three(3)pills on top of the medication cart( [MEDICATION NAME] 0.6 mg one(1)tablet, [MEDICATION NAME] 50 mg one(1)tablet, and half(1/2)tablet 1.25 mg [MEDICATION NAME] 1 tablet). The nurse picked up all four (4) pills with a spoon and placed in a medication cup and administered them to the resident. Interview with the Licensed Practical Nurse NN on 9/29/2015 at 6:06 p.m., revealed she should have wasted the medications that was dropped on cart. In an interview conducted on 09/30/2015 at 11:18 a.m., with the Director of Nursing(DON)revealed her expectation for nurses is that they follow standards and the facilities protocols and guidelines during medication pass and storage. Review of the Facility Infection Prevention and Control Program Overview dated 2/05/15 documented Implementation of Control Measures: Prevention of spread of infections is accomplished by use of Standard Precautions and other barriers .", "filedate": "2019-09-01"}
{"rowid": 4507, "facility_name": "PRUITTHEALTH - MARIETTA", "facility_id": 115276, "address": "70 SAINE DRIVE SW", "city": "MARIETTA", "state": "GA", "zip": 30008, "inspection_date": "2015-09-30", "deficiency_tag": 466, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "IBUU11", "inspection_text": "Based on observation and staff interview the facility failed to maintain the required amount of emergency water on site. The current facility census was one hundred seventeen(117)residents. Findings include: An observation and interview on 09/29/2015 at 8:18 a.m. with EE the Dietary manager and FF Corporate dietary consultant, revealed there were sixty(60)gallons of water available for emergency use. A review of(NAME)emergency water requirements chart indicated that Georgia three(3)day emergency stock requires ninety-six(96)gallons of water for one hundred twenty(120)bed facility or three(3) liters per resident per day for three(3)days.", "filedate": "2019-09-01"}
{"rowid": 4907, "facility_name": "AUTUMN BREEZE HEALTH AND REHAB", "facility_id": 115580, "address": "1480 SANDTOWN ROAD SW", "city": "MARIETTA", "state": "GA", "zip": 30008, "inspection_date": "2015-09-24", "deficiency_tag": 279, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "YH7R11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review,and staff interviews the facility failed to develop a care plan for one (1) resident #12 with a foley catheter from a sample size of five (5)census residents with foley catheters in the facility. Finding includes: Resident #12 is a seventy-eight (78) year old female admitted to Autumn Breeze Healthcare Center on 07/28/2015 under Hospice Care. She has a right above the knee amputation, a gastric tube with continuous feeds, and a Foley catheter due to a stage IV sacral ulcer located on her right Ischium. Further review of Resident #12 medical record revealed the Minimum Data Set (MDS) admission assessment dated [DATE] Section H assessed as having the use of indwelling Foley catheter. Review of the same assessment in Section V.Care Area Assessments (CAA) indicated that a care plan would be developed to address the use of the Foley catheter with goals and interventions. Resident #12 medical record also revealed a comprehensive care plan dated 8/14/2015 was developed with no evidence of a care plan to address resident's Foley catheter. Interview conducted on 09/23/15 at 2:25 p. m. with Licensed Practical Nurse (LPN) FF who acknowledged that the care plan for urinary incontinence with indwelling catheter was not present on the comprehensive care plan. Interview conducted with the Director of Nursing (DON) on 09/23/15 at 2:35 p. m. also acknowledged that a care plan for urinary incontinence with indwelling catheter was not found in resident medical record. She further revealed that a care plan should have been completed as indicated in the CAA. Interview conducted with the MDS Coordinator on 09/23/15 at 2:50 p. m. who acknowledged that a care plan for urinary incontinence with indwelling catheter was not completed on the comprehensive assessment as indicated on the CAA. She also revealed that this was an oversight and would make the corrections immediately.", "filedate": "2019-04-01"}
{"rowid": 4908, "facility_name": "AUTUMN BREEZE HEALTH AND REHAB", "facility_id": 115580, "address": "1480 SANDTOWN ROAD SW", "city": "MARIETTA", "state": "GA", "zip": 30008, "inspection_date": "2015-09-24", "deficiency_tag": 282, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "YH7R11", "inspection_text": "Based on observations, staff interviews and record reviews it was determined that the facility failed to ensure resident ' s written plan of care was followed. This was evident for one (1) resident #17 of thirty three (33) sampled resident's. Findings Include: Record review of resident #17 revealed a care plan dated 7/17/2014 indicating the resident is at risk for decline in nutrition/hydration status with appropriate goals and interventions including offer resident diet and supplements per orders. Cross reference F309", "filedate": "2019-04-01"}
{"rowid": 4909, "facility_name": "AUTUMN BREEZE HEALTH AND REHAB", "facility_id": 115580, "address": "1480 SANDTOWN ROAD SW", "city": "MARIETTA", "state": "GA", "zip": 30008, "inspection_date": "2015-09-24", "deficiency_tag": 309, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "YH7R11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident observations, record review, and staff interviews it was determined that the facility failed to follow a physician order [REDACTED]. Findings Include: Observation on 9/22/2015 at 1pm with resident #17 during lunch in the dining room revealed no ice cream, yogurt or health shake on the resident ' s tray and observation on 9/23/2015 at 1pm with resident #17 during lunch in the dining room revealed no ice cream, yogurt or health shake on the resident ' s tray. Record review revealed a physician order [REDACTED]. Review of facility policy dated (MONTH) 2000 revealed that diet orders will be conveyed in writing via a diet change form to the dietary department. Review of dietary cards for resident #17 revealed that no supplements were indicated for the lunch tray for 9/23/2015. Review of dietary progress notes dated 7/15/2014 indicate adding another health shake on dinner tray, dated 10/7/2014 indicates supplemented with health shake, dated 12/30/2014 indicates health shake twice daily, dated 4/7/2015 indicates reducing health shake to daily, dated 7/7/2015 indicates no nutritional concerns, and dated 7/15/2015 indicates add another health shake on dinner tray. The Registered Dietitian Nutritional recommendations dated 7/15/2014 indicate weight decreased - health shake on lunch and dinner tray, and dated 4/21/2015 indicate weight gain - discontinue health shake twice daily and start health shake daily on lunch tray. Staff interview on 9/23/2015 at 1:15pm with Dietary Manager revealed that resident #17 did not receive a health shake, yogurt or ice cream on her tray for lunch on 9/23/2015. When further questioned about the order for a health shake, yogurt and ice cream on the resident ' s tray at lunch she indicated that the order had been changed to a health shake on the lunch tray, however when further questioned she could not produce an order indicating that change. Interview on 9/23/2015 at 2pm with the Registered Dietitian revealed that the resident should have been getting the health shake, yogurt and ice cream on her lunch tray. #2 Per medical record review a physician order [REDACTED]. Physician order [REDACTED]. Observation conducted on 09/23/15 at 2:25 p. m., by surveyor accompanied by Licensed Practical Nurse (LPN) FF revealed, foley bag covered, and draining clear yellow urine. Foley bag was labeled with a dark orange sticker reflecting the date the foley bag and catheter was placed which was 07/20/15 at 10:30 a. m., prior to resident #12's admission. As of 09/23/15 resident #12 had been in the facility for fifty-eight (58) days and the foley catheter has not been changed as ordered. Interview was conducted on 09/23/15 at 2:25 p. m., with LPN FF who acknowledged that the TAR did not reflect documentation of the resident ' s foley being changed since admission. Interview conducted with the Director of Nursing (DON) on 09/23/15 at 2:35 p. m. DON acknowledged that the TAR did not reflect that the foley had been changed. She stated her expectation is that the staff follow the physician orders [REDACTED].", "filedate": "2019-04-01"}
{"rowid": 4910, "facility_name": "AUTUMN BREEZE HEALTH AND REHAB", "facility_id": 115580, "address": "1480 SANDTOWN ROAD SW", "city": "MARIETTA", "state": "GA", "zip": 30008, "inspection_date": "2015-09-24", "deficiency_tag": 371, "scope_severity": "F", "complaint": 0, "standard": 1, "eventid": "YH7R11", "inspection_text": "Based on observations and a staff interview, the facility failed to properly store food under sanitary conditions in the walk in freezer. Findings include: Tour of the facility kitchen conducted on 9/21/2015 at 9:30 am revealed icicles hanging from the ceiling of the walk in freezer with water dripping on to several boxes of magic cups supplement. The next observation later this same day at 1pm revealed icicles continues hanging from the ceiling in the walk in freezer and continue to drip on several boxes of frozen supplements. Final observation conducted on 9/23/2015 at 9 am revealed icicles still remain in the freezer and continue to drip on several boxes of frozen supplements. Interview on 9/23/2015 at 9:05 am with the Director of Food Service revealed that she would have the maintenance look at the freezer and get it repaired. She also indicated that the magic cups were disposed of that were dripped on the last two (2) days.", "filedate": "2019-04-01"}
{"rowid": 4911, "facility_name": "AUTUMN BREEZE HEALTH AND REHAB", "facility_id": 115580, "address": "1480 SANDTOWN ROAD SW", "city": "MARIETTA", "state": "GA", "zip": 30008, "inspection_date": "2015-09-24", "deficiency_tag": 431, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "YH7R11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the Facility policy Medication Storage in the Healthcare Centers, and staff interview, the facility failed to ensure proper medication storage were maintained for one (1) of four (4) medication carts on one (1) of five (5) wings. Findings include: During observations of medication pass on [DATE] at 5:10 p.m. the B hall Licensed Practical Medication Nurse (LPN) AA was observed to leave a cup of medications which includes, vitamin C 500 mg 1 tab, Gabapentin three (3) 100 mg caps PO (By Mouth), Hydralazine 50 mg 1 tab PO, Tramadol Hydrochloride 50 mg 1 tab PO unattended on top of the medication cart. Further observations revealed two (2) residents sitting in their wheel chairs adjacent to the medication cart. Interview conducted with LPN AA on [DATE] at 5:40 p.m., revealed she should not have left the cup of medications unattended on top of her medication cart. During observations of medication storage on [DATE] at 9:25 a.m., revealed one (1) bottle of Humalog one hundred (100) units was dated opened on [DATE] and dated expired on [DATE]. Further review of the medication label revealed the medication should discard twenty-eight days from open date. Interview conducted with LPN Medication Nurse BB on [DATE] at 9:25 a.m., revealed that the Humalog insulin medication is expired and should have been discarded. Interview conducted on [DATE] at 11:18 a.m., with the Director of Nursing (DON) revealed her expectation for nurses is that they follow standards and the facilities protocols and guidelines during medication pass and storage. The DON further revealed that there should be no expired medication stored in the medication cart, and medications should not be left unattended on the medication cart. Medication administration a protocols were followed secured was that the nurse will lock the cart when it is not in view. Further narcotics are kept double locked. Review of facility policy Medication Storage and Medication Administration in the Healthcare Centers, revealed note the date on the label for insulin when first used .Outdated medications are immediately removed .disposed of according to procedures for medication. Further review of the facility policy on medication administration revealed No medications are kept on top of the cart, the cart must be clearly visible to the personnel administering medications.", "filedate": "2019-04-01"}
{"rowid": 4912, "facility_name": "AUTUMN BREEZE HEALTH AND REHAB", "facility_id": 115580, "address": "1480 SANDTOWN ROAD SW", "city": "MARIETTA", "state": "GA", "zip": 30008, "inspection_date": "2015-09-24", "deficiency_tag": 514, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "YH7R11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record reviews, staff/resident interviews the facility failed to transcribe the written physician orders [REDACTED].#121) out of a random sample of thirty-three (33) residents. Findings include: Per medical record review resident #121 is a sixty-two (62) year old female admitted to Autumn Breeze Healthcare Center on 09/15/2015 with status [REDACTED]. Physician orders [REDACTED]. foley catheter care every shift, and anchor catheter at all times. Per review of the medical record, the physician orders, Medication Administration Record (MAR) and Treatment Administration Record (TAR), the TAR did not reflect the physician orders [REDACTED]. The admission checklist was completed however not signed. The twenty-four( 24) hour chart checks were documented as completed, however staff failed to note that the foley treatment orders were not present on the TAR. Review of the nurses notes since admission did not reflect foley catheter care performed from 09/15/15 - 09/21/15. Review of the Certified Nurse Assistant (CNA) activities of daily living (ADL) documentation in Point Click Care (PCC) does not specify foley care has been performed. Interview conducted with resident #121 who stated she has a permanent foley due to a urinary blockage diagnosed in (MONTH) (YEAR). She stated she has had a foley continuously since (MONTH) (YEAR). She stated her foley and bag are changed monthly and as needed. Resident further stated her foley was last changed on 09/06/15 prior to admission to Autumn Breeze and on 08/06/15 prior to her surgery for [REDACTED]. She acknowledged that the staff were performing foley care at least twice day and sometimes more. She stated just can ' t say yes they are providing foley every shift meaning at minimum three times a day. She stated they keep the foley anchored properly and are very attentive to my needs. Interview was conducted on 09/23/15 at 2:07pm with Licensed Practical Nurse (LPN) FF who upon review of the MAR and TAR, acknowledged the written MD orders for foley catheter care were not transcribed and or placed in the treatment book. LPN GG further acknowledged she has taken care of the resident several times since admission and foley catheter care has been performed by herself and her assigned CNAs when pericare or bathing is performed. Interview conducted with the Director of Nursing (DON) at 2:25 p. m. who acknowledged the nurse who transcribed the admission orders [REDACTED]. She further stated this was a new nurse who she assigned another nurse to supervise her through this task. The DON further stated it is her expectation that physician orders [REDACTED]. The DON later stated she found the transcribed treatment orders which were left on a shelf at the nurses station. No documentation of foley care was noted on the treatment sheet and the monthly foley changes were not transcribed. The DON stated she added the monthly foley changes and placed the corrected treatment order sheet in the TAR.", "filedate": "2019-04-01"}
{"rowid": 4913, "facility_name": "AUTUMN BREEZE HEALTH AND REHAB", "facility_id": 115580, "address": "1480 SANDTOWN ROAD SW", "city": "MARIETTA", "state": "GA", "zip": 30008, "inspection_date": "2015-09-24", "deficiency_tag": 520, "scope_severity": "F", "complaint": 0, "standard": 1, "eventid": "YH7R12", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of policy and procedure, facility Plan of correction review and staff interviews, the facility failed to have an effective Quality Assessment and Assurance (QAA) committee that developed and implemented a process to ensure all opened medications were properly dated and discarded timely by the plan of correction date of 11/06/2015. Cross refer F431 Review of the policy titled(NAME)Health System Quality Improvement Principles documented: We as a company will ensure that our processes or systems identify areas to improve the outcomes that will benefit all our staff and residents. Process improvement is a systematic or scientific approach to studying work and making improvements to how work gets done. It involves fact finding, not fault finding, through data collection and root cause analysis to identify and measure the problem and its source. Once the source of the problem is identified, improvement comes through generating salutations that address the root cause of the problem. Review of the Plan of Correction documented: The Director of Nursing (DON), Assistant Director of Nursing (ADON) and Nursing Consultant will monitor staff for compliance with respect to medication administration and storage. The DON, ADON and RN Supervisors will audit medication dates to ensure outdated medications will be disposed of properly. Review of the facility's in-service records revealed education was provided to staff members on 10/19/15 through 10/23/15 related to checking of the medication cart for out of date medications and unattended medication cart every shift. During a health revisit conducted on 03/14/16 an observation of the medication cart C/D at 10:30 a.m. revealed one (1) open vial of [MEDICATION NAME] that was not dated. Observation of medication cart E at 10:52 a.m. revealed two (2) multi-dose opened vials of normal saline that were not dated. Observation of the medication refrigerator for the A,B,C, and D halls on 03/14/2016 at 10:54 a.m. revealed two (2) opened vials of [MEDICATION NAME] purified protein. One vial was dated 1/15/16. The second vial was not dated. Interview on 03/14/2016 3:45:43 PM with the Corporate Nurse revealed that medication carts were checked daily on the night shift (11:00 p.m. -7:00 p.m.) twice a week by management staff. Telephone interview with the Corporate Nurse on 03 /17/16 at 9:28 a.m. revealed that the previous ADON had done morning rounds and checked the medication carts. The Corporate Nurse further stated the previous ADON is no longer employed with the facility and she could not provide documentation of monitoring, audits or collected data. The current auditing tool in use did not begin until (MONTH) 9, (YEAR), when the facility was notified that they were not in compliance. Telephone interview with the Administrator on 03/17/16 at 10:50 a.m. revealed she had located the ADON's notebook which documented that the medication carts had been checked on 2/5/16, 2/22/16, and 3/9/16. The Administrator was unable to provide further evidence of monitoring and/or auditing. The Administrator further confirmed the current medication monitoring tool had begun on (MONTH) 9, (YEAR), when the facility was notified that they were not in compliance.", "filedate": "2019-04-01"}
{"rowid": 5721, "facility_name": "PRUITTHEALTH - MARIETTA", "facility_id": 115276, "address": "50 SAINE DRIVE SW", "city": "MARIETTA", "state": "GA", "zip": 30008, "inspection_date": "2014-10-30", "deficiency_tag": 282, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "RG0T11", "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 the plan of care for one (1) resident (4) for dental services was followed from a sample of thirty-three (33) residents. Findings Include: Observation conducted on 10/28/2014 at 11:36am of resident 4 revealed that his front teeth were broken, and very discolored. Review of resident's care plan dated 6/4/2014 indicated that one of his problems was that he has his natural teeth with obvious caries and does have complaints of pain on his bottom front teeth. Goals include adequate oral care/hygiene daily thru next review and he will have carious teeth causing pain to be extracted/treated to resolve pain by next review. Interventions include refer to dentist/dental hygienist for evaluation and recommendations, assist with oral hygiene daily, observe oral cavity when assisting with oral care for bleeding, increased pain, swelling, coating, sores and any other abnormalities and report to nurse if present, observe for loose, missing or carious teeth and notify nurse, and medicate for pain per physicians' orders. Another problem identified in the care plan was alteration in comfort related to complaints of pain to head, neck and bottom front teeth. Goal listed was to be kept comfortable as much as possible thru next review. Interventions include administer pain medication per physician's orders [REDACTED]. This care plan was reviewed on 8/28/2014 with no changes in problems or interventions. Interview conducted 10/29/2014 at 12:00pm with Registered Nurse GG revealed that she could not find a dental consult in the chart. Interview conducted on 10/29/2014 at 12:45pm with Register Nurse, Minimum Data Set (MDS) Coordinator CC revealed that when she generates the care plan she notifies social services. CC acknowledged that on 8/28/2014 when she reviewed the care plan she did not follow up on the dental consult but should have. Interview conducted on 10/29/14 at 1:41pm with the Transportation Coordinator, EE revealed she had been notified on 6/11/14 about the resident needing a dental appointment and had contact the resident's responsible party. The resident's responsible party indicated that she would make the appointment and transportation according to her schedule. EE was unaware that the dental issue was not resolved.", "filedate": "2018-05-01"}
{"rowid": 5722, "facility_name": "PRUITTHEALTH - MARIETTA", "facility_id": 115276, "address": "50 SAINE DRIVE SW", "city": "MARIETTA", "state": "GA", "zip": 30008, "inspection_date": "2014-10-30", "deficiency_tag": 312, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "RG0T11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of the medical record, family and staff Interviews, the facility failed to provide personal hygiene care for one (1) resident (T) requiring extensive assistance, from a sample of thirty-three (33) residents. Findings include: Observation conducted on 10/27/14 at 12:51 P.M. revealed the resident in bed unshaven, with a rash and scabs noted on bilateral legs and arms. His fingernails were long and dirty with a brown substance under three nails of the left hand. Interview conducted on 10/28/14 at 10:33 A.M. with the brother of resident T revealed the resident's toenails are never trimmed and his fingernails are always dirty. Observation conducted on 10/28/14 at 2:31 P.M. revealed the resident has long, dirty (3) fingernails. Three fingers on the left hand continue to have a brown, dried substance on the nail beds and under the nails. There is also a brown substance under two (2) fingernails of the right hand. He is unshaven. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated the resident requires limited assistance with most Activity of Daily Living (ADLS) but extensive assistance with toileting, personal hygiene which includes combing hair, shaving, washing/drying face and hands and total dependence for bathing. This MDS did not assess the resident for any behaviors or as being resistive to care. Observation conducted on 10/29/14 at 9:38 A.M. revealed the resident was in his wheel chair propelling through the hallway. He was dressed with a t-shirt and sweat pants. The sweat pants were heavily soiled and stained. His hair was not combed and he continued to be unshaven. The fingernails were untrimmed and three fingers on the left hand continued to have a dried brown substance on the nail beds and under the nails. There was a brown substance under the nails of two fingers on the right hand. Review of the Grievance Log from January 2014 through October 2014 revealed seven (7) complaints made related to the lack of bathing and personal hygiene. Interview with the Unit Manager on 10/29/14 at 3:31 P.M. revealed the shower schedule for this resident is Wednesday and Saturdays. Nails and shaving is considered part of personal hygiene. She indicated that she had noticed the brown substance on his nail beds today. Review of the Bath Report from 9/29/14 until 10/29/14 revealed the only showers received were on 10/01/14, 10/15/14, 10/20/14, 10/22/14 and 10/29/14.", "filedate": "2018-05-01"}
{"rowid": 5723, "facility_name": "PRUITTHEALTH - MARIETTA", "facility_id": 115276, "address": "50 SAINE DRIVE SW", "city": "MARIETTA", "state": "GA", "zip": 30008, "inspection_date": "2014-10-30", "deficiency_tag": 328, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "RG0T11", "inspection_text": "Based on observations, review of the facility's policy and manufacturer guidelines, and staff interviews, the facility failed to maintain the cleanliness of oxygen (O2) equipment for two (2) residents (#101 and #51), of six (6) residents receiving continuous oxygen therapy on two (2) of two (2) nursing units. Findings include: 1. Observations conducted on 10/27/14 at 2:47 PM, 10/28/14 at 7:29 AM, and 10/29/14 at 10:15 AM revealed the Invacare Platinum Series 5 oxygen concentrator for resident #101 had filters on each side that were coated with a thick layer of white dust. On 10/30/14 at 7:55 AM the concentrator had one side caked with white dust and the filter on the other side was rolled up and dusty, and appeared to have been rinsed. Interview conducted 10/30/2014 at 8:45 AM with the Director of Nursing (DON) in the room of resident #101, revealed filters on the O2 concentrator should have been washed or changed Sunday by the nursing supervisor and this one must have been missed. 2. Observation on 10/30/2014 at 1:51 PM revealed an Invacare platinum 5 oxygen concentrator providing continuous oxygen via Nasal Cannula to resident #51 had both filters coated with dust. Interview conducted on 10/30/2014 at 2:31 PM with Registered Nurse GG in the room of resident #51 revealed oxygen filters are supposed to be cleaned or changed on Sundays. GG acknowledged these filters were not changed or cleaned Sunday. Review of the facility policy entitled Oxygen Administration Safety and Storage revealed the large external black filter should be washed with soap and water once each week and as needed (PRN). Review of the manufacturer's guidelines for the Invacare Platinum Series 5 oxygen concentrator revealed both filters should be removed and cleaned at least once a week or more frequently depending on environmental conditions.", "filedate": "2018-05-01"}
{"rowid": 5724, "facility_name": "PRUITTHEALTH - MARIETTA", "facility_id": 115276, "address": "50 SAINE DRIVE SW", "city": "MARIETTA", "state": "GA", "zip": 30008, "inspection_date": "2014-10-30", "deficiency_tag": 364, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "RG0T11", "inspection_text": "Based on observation, resident and staff Interviews, the facility failed to ensure the food served was palatable and warm for seven (7) residents (A,B, C, D, E, F G,) from a sample of thirty-three (33) residents. 1. Interview conducted on 10/28/14 at 1:55 P.M. with resident F revealed he received the breakfast he ordered however, it was served cold. Interview conducted on 10/29/14 at 9:25 A.M. with resident F revealed his breakfast was served cold again this morning. Review of the Resident Council minutes for 1/23/14 and 4/29/14 revealed complaints had been made related to poor tasting food and/or the food being served cold. Observation conducted on 10/30/14 at 7:30 A.M. in the kitchen revealed the kitchen staff preparing breakfast trays and stacking them on a open cart. The trays for this cart were completed at 7:41 A.M. and a test tray was requested to be placed on the bottom of the cart rack at this time. At 7:45 A.M. the cart was delivered to the Cambridge Wing and announced to the staff that breakfast trays were on the floor. At 7:46 A.M. the Certified Nursing Aide's (CNA's) began passing the trays to the residents. The cart was followed until the last tray for residents's that feed themselves was delivered at 7:59 A.M. There were four trays remaining for residents that required assistance with eating. At 8:01 A.M. the test tray consisting of scrambled eggs, bacon and grits was first sampled by CNA AA and then the Surveyor. Both agreed the eggs were cold and the grits were slightly warm. 2. Interview conducted 0/27/14 at 1:00PM with resident A revealed the food is usually cold whether served in the dining room or resident room. A further revealed the the food carts are rolled to the hallways but trays are cold by the time the food is served in the rooms. Observation conducted on 10/19/2014 from 8:10AM until 8:35AM of the Cambridge Hallway revealed the food cart full of trays was left unattended and un-served during this time. Certified Nursing Assistants (CNAs) began removing trays from the cart and serving the breakfast trays to the residents in the rooms at 08:35 AM. 3. During an interview with resident C on 10/27/14 at 2:30pm the resident revealed that the food was always cold from sitting in the hallways before being served. Second interview with resident C on 10/30/14 at 9:30am revealed that she only ate eggs, toast, and cold cereal for breakfast, and that the eggs were always cold. 4. During interview conducted 10/28/14 at 9:10am with resident B, he revealed that the food was just horrible. There was no taste, and not a good selection. He ate in his room, and the food was always cold. On 10/30/14 at 8:30am Resident B was observed eating breakfast with Speech Therapy (ST) in attendance. Resident B revealed his food was cold. 5. Interview with resident G on 10/30/14 at 9:10am revealed she did not eat breakfast, but did go to the dining room for lunch and dinner, and that the food was often cold because it sat on the food carts too long. 6. Interview conducted 10/28/2014 at 9:35am with Resident D in his room revealed that he stated the food is tough and difficult to eat and the food brought to the rooms is cold. 7. Interview conducted 10/28/2014 at 9:20am with Resident (E) in her room revealed that the food is cold when they bring it to the room.", "filedate": "2018-05-01"}
{"rowid": 5725, "facility_name": "PRUITTHEALTH - MARIETTA", "facility_id": 115276, "address": "50 SAINE DRIVE SW", "city": "MARIETTA", "state": "GA", "zip": 30008, "inspection_date": "2014-10-30", "deficiency_tag": 441, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "RG0T11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of the facility policy and staff interview, the facility failed to ensure proper procedures were followed in maintaining and storing personal care equipment in three (3) resident bathrooms on one (1) of six (6) halls (A Hall). Findings include: Observation conducted 10/27/2014 at 1:58 PM in the bathroom of room [ROOM NUMBER] on the A Hall of the Bristol Floor, revealed two (2) bedpans unlabeled and un-bagged on the floor beside the toilet. The bathroom is shared by two (2) residents and one (1) resident is capable of using the bathroom with assistance. Observation conducted 10/27/14 at 2:07 PM in the bathroom of room [ROOM NUMBER] on the A Hall of the Bristol Floor, revealed a used bedside drainage bag from a Foley catheter set, hanging on a hook on the wall behind the toilet. The connection that would fit into the catheter was uncovered and the bag and tubing were not in a protective plastic bag. The bag contained small amounts of brown liquid. The bathroom is used by two (2) male residents. Observation conducted 10/27/14 at 2:31 PM in room [ROOM NUMBER] of the A Hall of the Bristol Floor, revealed a gray plastic washbasin on the floor under the sink, there was no label to identified who the wash basin belonged to and it was not in a bag. The room is occupied by two (2) female residents. Interview conducted 10/30/2014 at 10:30:01 AM with the Director of Nursing (DON) revealed the policy of the facility is for all bedpans, basins, urinals to be labeled and stored in plastic bags and hanging on wall hooks in the resident bathrooms. The DON indicated rounds should be made daily to ensure compliance with the policy. Review of the facility policy for Bedpans and Urinals indicated that bedpans and urinals will be issued to an individual patient/resident, will be labeled and stored in a plastic bag in the patient/resident's closet, bedside stand, on a shelf in the patient/resident's bathroom or hanging on handrail in the bedroom. The policy indicated that bedpans and urinals will not be stored on the floor or near clean patient/resident care items.", "filedate": "2018-05-01"}
{"rowid": 6090, "facility_name": "AUTUMN BREEZE HEALTH AND REHAB", "facility_id": 115580, "address": "1480 SANDTOWN ROAD SW", "city": "MARIETTA", "state": "GA", "zip": 30008, "inspection_date": "2014-10-16", "deficiency_tag": 167, "scope_severity": "C", "complaint": 0, "standard": 1, "eventid": "SM1J11", "inspection_text": "Based on observation, interview with one (1) resident (S) and facility staff, the facility failed to make survey results readily accessible to the residents. The census was ninety (90) residents. Findings include: Interview with resident S conducted on 10/15/14 at 1:21 P.M. revealed he was not aware he had access to the state survey results and has never seen them anywhere. Observation conducted on 10/15/14 at 2:08 P.M. revealed the State Survey results was in a binder, located in a bin on the wall of the front lobby. The lobby and the residents' halls have a locked door between them preventing residents access to the survey results, Interview conducted with the Administrator on 10/15/14 at 2:12 P.M. confirmed the survey results are in a binder on the wall of the front lobby and the results are not posted anywhere else in the facility. The administrator further confirmed the residents do not have access to the survey results kept in the lobby. She said she will make a second copy and place them on the wall in the hallway by the nurse's station.", "filedate": "2018-04-01"}
{"rowid": 6091, "facility_name": "AUTUMN BREEZE HEALTH AND REHAB", "facility_id": 115580, "address": "1480 SANDTOWN ROAD SW", "city": "MARIETTA", "state": "GA", "zip": 30008, "inspection_date": "2014-10-16", "deficiency_tag": 272, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "SM1J11", "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 provide a comprehensive assessment related to dental care for one (1) resident (R), from a sample of twenty-eight (28) residents. Findings include: Observation conducted 10/14/2014 at 3:04 PM revealed resident R had easily visible, broken, jagged and discolored front upper and lower teeth. Record review for resident R revealed an Admission Minimum Data Set ((MDS) dated [DATE] which assessed the resident as having no broken, missing or damaged teeth. Interview with resident R conducted on 10/14/14 at 3:05 PM revealed she had broken her front teeth prior to admission to the facility and that she is very concerned about her broken teeth. She does not have discomfort from them and is able to eat but she knows dental problems can make her very ill. She further revealed that no one has spoken with her about this problem. Interview with the MDS nurse AA conducted on 10/16/14 at 8:56 AM revealed she completed the assessment for resident R and did not record the residents' dental problems. She further revealed that she should have done so to ensure the Social Service Director would address the problems. Interview with the Social Services Director conducted on 10/16/14 at 10:15 AM revealed dental services are offered in house, however, she was unaware of the dental issues of resident R.", "filedate": "2018-04-01"}
{"rowid": 6092, "facility_name": "AUTUMN BREEZE HEALTH AND REHAB", "facility_id": 115580, "address": "1480 SANDTOWN ROAD SW", "city": "MARIETTA", "state": "GA", "zip": 30008, "inspection_date": "2014-10-16", "deficiency_tag": 280, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "SM1J11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interviews, the facility failed to update and revise the care plan for one (1) resident (#130) from a sample of twenty-eight (28) residents. Findings include: Record review for resident #130 revealed a Minimum Data Set (MDS) Admission assessment dated [DATE] which assessed the resident as requiring supervision/oversight with Activities of Daily Living (ADLS) including toileting. The resident was assessed as always continent of bowel and bladder. Further review of the MDS Quarterly assessment dated [DATE] assessed the resident as having occasional urinary incontinence during the seven day look back period. Review of the care plan revealed it was not revised to identify occasional urinary incontinence with goals and interventions. Interview with a direct care Certified Nursing Assistant (CNA) conducted on 10/16/14 at 8:05 AM revealed the resident is continent most all of the time. He is ambulatory and takes himself to the bathroom. Only on occasion has the resident had an accident and wet himself. The resident does not call to tell the staff he is wet, it is found during every two (2) hour rounding checks. Interview conducted on 10/16/14 at 9:31 AM with the MDS Registered Nurse (RN)AA revealed she does not do the care plans for the Dementia Unit but did confirm if is a change in continence, the care plan should be updated for urinary incontinent. Interview MDS RN for the Dementia Unit CC conducted on 10/16/14 at 9:47 AM revealed the information obtained for the seven day look back period for incontinence is found in the CNA's ADL flowsheet. If the resident is having occasional incontinence it would be care planned. She further confirmed there is no revised care plan related to urinary incontinence for resident #130.", "filedate": "2018-04-01"}
{"rowid": 6093, "facility_name": "AUTUMN BREEZE HEALTH AND REHAB", "facility_id": 115580, "address": "1480 SANDTOWN ROAD SW", "city": "MARIETTA", "state": "GA", "zip": 30008, "inspection_date": "2014-10-16", "deficiency_tag": 312, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "SM1J11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and family and staff interview, the facility failed to provide nail care for two (2) residents (# 24 and X), requiring extensive assistance with all areas of personal cleanliness, from a sample of twenty-eight (28) residents. Findings include: 1. Observation of resident #24 conducted on 10/14/2014 at 2:21 PM revealed brown debris under untrimmed fingernails. Review of the Minimum Data Set (MDS) Quarterly assessment for resident #24 dated 09/03/2014 assessed the resident as needing extensive assistance in all areas of personal hygiene. The care plan for resident #24 indicated her fingernails are to be kept clean and trimmed. Observation and interview with the Director of Nursing (DON) conducted on 10/15/14 at 3:30 PM revealed resident #24 had an accumulation of brown debris under untrimmed nails. The DON indicated the Certified Nursing Assistants (CNAs) are all aware that every residents nails are to be checked with each bedbath or shower every day, cleaned and trimmed as needed. She acknowledged resident # 24 needed nail care. 2. Observation of resident X conducted on 10/14/14 at 3:30 PM revealed brown debris under untrimmed finger nails. Review of the MDS Quarterly assessment dated [DATE] assessed resident X as requiring extensive assistance in all areas of personal hygiene. Review of the care plan included interventions listed under Activity of Daily Living indicating her nails are to be kept clean and trimmed. Interview with a family member of resident X conducted on 10/14/2014 at 3:30 PM revealed her finger nails are not cleaned or trimmed with bathing. The family member further indicated the resident sometimes attempts to feed herself with her hands.", "filedate": "2018-04-01"}
{"rowid": 6094, "facility_name": "AUTUMN BREEZE HEALTH AND REHAB", "facility_id": 115580, "address": "1480 SANDTOWN ROAD SW", "city": "MARIETTA", "state": "GA", "zip": 30008, "inspection_date": "2014-10-16", "deficiency_tag": 441, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "SM1J11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of facility inservice attendance sheets and staff interviews, the facility failed to store personal care equipment in a sanitary manner in resident bathrooms on three (3) of five (5) halls. Findings include: C Hall Observation conducted on 10/15/14 at 1:08 P.M. in the bathroom shared by five (5) residents in rooms C-133 and C-135 revealed a two (2) wash basins stacked one inside of the other inside a clear plastic bag. One (1) basin was labeled and the other one was not. Observation conducted on 10/15/14 at 1:27 P.M. of the bathroom shared by four (4) residents in rooms C-132 and C-134 revealed two (2) wash basins, one stacked inside of the other in a clear plastic bag. One basin was labeled and the other was not. D Hall Observation conducted on 10/15/14 at 1:34 P.M. of the bathroom shared by four (4) residents in rooms D-149 and D-147 revealed three (3) wash basins, two (20 were labeled with different names stacked on inside the other, one (10 was unlabeled. There were also two (2) unlabeled urinals in one clear plastic bag. A second clear plastic bag contained a toilet commode bucket with no label. B Hall Observation conducted on 10/15/14 at 1:41 P.M. of the bathroom shared by four (4) residents on rooms B-128 and B-130 revealed four (4) wash basins all stacked inside each other in one (1) clear plastic bag. One basin had a resident label on it, the other three (3) were unlabeled. Observation conducted at 10/15/14 at 1:58 P.M. with the Assistant Director of Nursing (ADON)/Infection Control RN acknowledged the above findings. Interview conducted on 10/15/14 at 2:05 P.M. with the ADON/Infection Control RN revealed that staff know better than to bag personal equipment in one bag and they know personal equipment is to be labeled. Interview conducted on 10/15/14 at 4:31 P.M. with the ADON/Infection Control Nurse revealed there is no policy for proper storage and labeling of personal care equipment. There have been a couple of in-services given related to personal care items. Further, she was extremely disappointed to see the personal care items unlabeled and in shared bags. when she rounded with me. Review of facility's In-Service attendance sheets dated 5/14/14 and 9/17/14 revealed that Certified Nursing Assistants (CNA) need to bag all toiletries, bed pans, urinals and label them and bagged individually. 2. Observations of resident bathrooms on B Hall revealed the following: On 10/14/2014 at 2:19:50 PM the bathroom shared by three (3) residents between rooms [ROOM NUMBERS] had an unlabelled wash basin on the floor, not in a plastic bag and two (2) unlabeled tooth brushes, not in containers, on the sink. On 10/14/2014 at 2:36:11 PM the bathroom shared by four (4) residents between rooms [ROOM NUMBERS] revealed one (1) pink bedpan in plastic bag- unlabeled hanging tied on the towel bar. On 10/14/2014 at 3:18:29 PM the bathroom between rooms [ROOM NUMBERS] had three (3) unlabeled bedpans and one (1) unlabeled emesis basin. Interview conducted 10/16/2014 at 10:37:25 AM with the Director of Nursing (DON) revealed that personal care equipment should be labeled, stored in plastic bags and toothbrushes kept at the bedside. Interview conducted 10/16/2014 at 10:56:17 AM with BB revealed bedpans , washbasins and toothbrushes should be labeled, stored in plastic bags and toothbrushes kept at the bedside.", "filedate": "2018-04-01"}
{"rowid": 6779, "facility_name": "AUTUMN BREEZE HEALTH AND REHAB", "facility_id": 115580, "address": "1480 SANDTOWN ROAD SW", "city": "MARIETTA", "state": "GA", "zip": 30008, "inspection_date": "2014-10-03", "deficiency_tag": 309, "scope_severity": "D", "complaint": 1, "standard": 0, "eventid": "78SO11", "inspection_text": "Based on observation, record review, resident, family and staff interviews the facility failed to follow physician's order and ensure timely transportation for one (1) resident ('X) from seven (7) sampled residents. Findings include: Review of a facility Concern Form dated 8/18/14 revealed that resident X family member reported to the Social Worker that resident X was complaining about her itchy, scratchy scalp. According to the documentation on the Concern Form the Nursing Supervisor was notified and follow up actions were initiated. Review of the Physician Telephone Orders revealed a dermatology consult due to scratchy dry itchy scalp was written on 08/21/2014. On 8-25-2014 the Administrator signed the Concern Form acknowledging that Resident X concerns were resolved and indicated that a dermatology consult was scheduled. Review of the facilities Transportation Request Form revealed the resident was scheduled on 9-10-2014 at 11:00 a.m. and 9-16-2014 at 10:00 a.m. for a dermatology appointment. On 9-10-2014 there was a notation on the form that transportation was late and the doctor office refused to see the resident and she was rescheduled for 9-16-2014. On 9-16-2014 there was documentation that transportation arrived late for her appointment and resident was rescheduled for 10-10-2014. On 10/03/14 at 1:10 p.m. an interview with the Social Worker confirmed that resident X was scheduled for dermatology appointments but was unable to participate due to transportation problems. On 10/03/14 at 2:53 p.m. observation revealed resident X was sitting in her room visiting with a family member. An interview , at this time, revealed the resident continues to complain about her itchy scalp. Her family member confirmed that the resident continues to complain of having an itchy scalp. Continued interview revealed that resident X was aware of her dermatology appointments but missed them because staff had not gotten her up and ready in time. When transportation arrived at the facility, she was not ready and they left without taking her. She further revealed she had not received any medication to relieve the itching and scabs had occurred on her scalp from excessive scratching. On 10/3/14 at 3:00 p.m. an interview with the facility's scheduler revealed resident X was scheduled to be transported on the 9-10-14 and 9-16-14 for dermatology appointments but the transport service arrived late to the facility. On the 10th the resident was transported to the dermatologist office but they refused to see her and she was brought back to the facility. Continued interview revealed that on the 16th transportation services arrived late again and she called the dermatology office to report the late arrival and requested that she be seen but they refused and she remained at the facility. On 10/03/14 at 3:10 p.m. an interview with the Certified Nursing Assistant (CNA) A revealed she was assigned to accompany resident X to her dermatology appointment on 9-16-14, however the transport service arrived late to pick them up and was told by the scheduler they would not be going because the dermatology office refused to see her. On 10/03/14 at 3:31 p.m., an interview and observation with Licensed Practical Nurse (LPN) BB confirmed the resident was not seen for her dermatology appointments citing transportation as the cause. Continued interview and observation revealed when the LPN BB examined Resident X scalp she revealed a moderate amount of dry skin flakes throughout the top section of head and three (3) scabs ranging from 2-3 cm. The LPN further revealed that the physician had not been notified of the missed appointments and there was no treatment ordered to relieve the resident's itchy scalp. Interview with the unit manager AA on 10/3/14 at 4:01 p.m. revealed the transportation service arrived late to the facility and resident X did not make it to her dermatology appointments. Interview on 10/03/14 at 4:10 p.m. with the Director of Nursing (DON) revealed that the the physician and family had not been notified of the missed appointments. Continued interview revealed there was no attempt to resolve the late transportation arrivals to the facility with the transportation company that prevented resident X from gaining access to medical treatment. An interview with the administrator on 10/03/14 at 4:41 p.m. revealed that the resident experienced a delay in two (2) dermatology appointments due to transportation issues. The administrator further indicated that no interventions had been developed to resolve transportation services arriving late and causing the resident to miss her appointments.", "filedate": "2017-10-01"}
{"rowid": 6867, "facility_name": "PRUITTHEALTH - MARIETTA", "facility_id": 115276, "address": "50 SAINE DRIVE SW", "city": "MARIETTA", "state": "GA", "zip": 30008, "inspection_date": "2013-02-07", "deficiency_tag": 314, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "NGK511", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview the facility failed to administer a wound treatment according to wound clinic orders for one (1) resident (#36) from a sample of thirty four (34) residents. Findings include: Observation of a pressure sore treatment conducted 2/6/13 at 10:30am revealed that Treatment nurse AA cleaned the wound with Normal Saline, patted the wound dry, applied [MEDICATION NAME], and then covered the wound with a composite dressing. Review of the most recent wound clinic orders dated 1/15/13 at 2:00pm indicated the wound was to be cleaned with mild soap and water, rinsed then dried, paint heel ulcer with [MEDICATION NAME], two (2) times per day, cover with four by fours and secure with Kerlix and tape. Off load pressure on heels at all times. Follow up in one (1) month on 2/12/13. Further record reviewed revealed no other wound treatment orders since the 1/15/13 orders. Interview with the treatment nurse AA on 2/6/13 at 10:40am revealed she had missed the most recent wound clinic orders dated 1/15/13. She further indicated that she had been informed by the(NAME)wound consultant that soap and water would dry out the wound and she needed to use normal saline or sterile water. AA revealed that the treatment had only been done one (1) time per day from 1/15/13 through 2/6/13, and Normal Saline was used to clean the wound rather than mild soap and water. After the treatment observation by the surveyor on 2/6/13 at 10:30am, the treatment nurse contacted the attending physician to clarify the treatment orders.", "filedate": "2017-09-01"}
{"rowid": 7092, "facility_name": "AUTUMN BREEZE HEALTH AND REHAB", "facility_id": 115580, "address": "1480 SANDTOWN ROAD SW", "city": "MARIETTA", "state": "GA", "zip": 30008, "inspection_date": "2013-01-24", "deficiency_tag": 274, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "TD5P11", "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 a Significant Change assessment was completed for one (1) resident (# 21) from a sample of thirty-nine (39) residents. Findings include: Record review revealed a physician's orders [REDACTED].# 21 to have a Hospice evaluation. The evaluation was completed that afternoon and the resident was admitted to Avista Care Hospice. There was no significant change assessment done reflecting this change for the resident. Interview with the Minimum Data Set (MDS) nurse CC on 1/ 24/13 at 10:45am revealed that a significant change assessment was not done as required.", "filedate": "2017-08-01"}
{"rowid": 7093, "facility_name": "AUTUMN BREEZE HEALTH AND REHAB", "facility_id": 115580, "address": "1480 SANDTOWN ROAD SW", "city": "MARIETTA", "state": "GA", "zip": 30008, "inspection_date": "2013-01-24", "deficiency_tag": 315, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "TD5P11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview the facility failed to ensure a urinary catheter was secured to prevent excessive tension on the catheter for one (1) resident (#21) from a sample of thirty-nine (39) residents. Findings include: Observation of resident # 21 on 1/24/13 at 10:30am with Certified Nursing Assistant (CNA) GG revealed the resident did not have the urinary catheter secured. The penis had a small ulcerated area on the head and a reddened area at the meatus. GG found several catheter securing devices in the resident's room that had not been used. Review of the resident's care plan dated 11/29/12 indicated the resident had a Foley catheter related to [MEDICAL CONDITION], and a pressure ulcer. An intervention was in place to anchor the catheter to prevent excessive tension. Further record review revealed the resident had a healing stage 2 pressure ulcer to the sacral area, and had a [DIAGNOSES REDACTED]. Further interview with the CNA GG on 1/24/13 at 10:40 am revealed that all catheters should be secured.", "filedate": "2017-08-01"}
{"rowid": 7703, "facility_name": "AUTUMN BREEZE HEALTH AND REHAB", "facility_id": 115580, "address": "1480 SANDTOWN ROAD SW", "city": "MARIETTA", "state": "GA", "zip": 30008, "inspection_date": "2014-01-08", "deficiency_tag": 157, "scope_severity": "D", "complaint": 1, "standard": 0, "eventid": "TEVL11", "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 changes in the health condition of two (2) residents (#1, #2) of five (5) sampled residents. Findings include: 1. Resident #1, the nurse failed to notify the physician of a discrepancy between his response to an abnormal urinanalysis laboratory value report and the actual laboratory tests that were ordered. Review of the Urinanalysis Lab Report for Resident #1 dated 12/12/13 indicated abnormalities that included moderate blood in the urine, moderate leukocytes or white blood cells and cloudy color. There were hand written notes on the Lab Report that documented the physician was notified, wait for culture and no culture ordered. The lab report was initialled by the nurse. Review of the Nurse's Notes for Resident #1 dated 12/12/13 indicated that the urinanalysis results were reported to the physician but the physician stated to wait for the culture results.The nurse failed to notify the physician that there was no urine culture ordered. This failure resulted in a no treatment for [REDACTED].#1. Interview with the assistant director of nursing (ADON) on 12/31/13 at 1:50 PM revealed that the nurse failed to notify the primary physician that a urine culture and sensitivity was not ordered or in progress for Resident #1. When the physician replied to the abnormal report of the urinanalysis that he would wait for the culture and sensitivity results the nurse should have told him that only a urinanalysis was ordered not a culture and sensitivity. On 12/31/2013 at 2:10 PM a telephone interview was made with the assistant director of nursing (ADON) via speaker phone to Resident #1 ' s primary physician regarding the physician's order [REDACTED]. The primary physician said that he was not notified that a culture and sensitivity was not in progress for Resident #1 when the nurse gave him the abnormal urinanalysis results on 12/12/13. He stated that if he had known that there was no culture and sensitivity of the urine in progress he would have treated Resident #1 with antibiotics for the abnormalities identified in the urinanalysis. The primary physician said that the nurse should have informed him that there was no urine culture and sensitivity ordered for Resident #1. Additionally for Resident #1, review of the Admission Record indicated the resident was admitted into the facility on [DATE]. Review of the Cumulative [DIAGNOSES REDACTED].#1 dated 11/27/13 indicated [DIAGNOSES REDACTED]. Review of the Physician order [REDACTED].#1 indicated that the primary physician ordered treatment to the coccyx wound and right gluteal deep tissue injury on 11/27/2013. Review of the admission Non-Decubitus Skin Condition Record dated 11/27/13 indicated that Resident #1 ' s coccyx pressure ulcer measured 7.0 x 9.5 with no depth. The color of the wound bed was pink/yellow. Review of the Wound Care note dated 12/6/13 indicated that Resident #1 ' s pressure ulcer to the coccyx measured 7.0 x 9.5 x 0.2 cm and was un-stageable. According to the treatment nurse's documentation t pressure ulcer on the coccyx had deteriorated and had 100 percent (%) necrotic tissue. Interview with the wound care nurse on 01/02/13 at 9:30 AM revealed that the nurse recalled Resident #1. The wound nurse said that the initial wound assessment was done on 11/27/13 for Resident #1. According to the wound nurse, there was no depth to the coccyx wound and there was 50% pink health tissue, 10% granulation tissue and the wound bed was scattered with yellow slough on 11/27/13. The wound nurse added that there was no visible muscle, cartilage or bone and there was no black tissue and no odor when Resident #1 ' s wound was initially assessed. The wound care nurse said that the wound specialist visited weekly on Tuesday. Resident #1 was admitted on a Wednesday. The next scheduled visit for the wound specialist was on 12/03/13 but that visit was not made. Resident #1 was first seen by the wound specialist on 12/10/13, thirteen (13) days after being admitted into the facility and after the wound had deteriorated. The wound nurse stated that the facility does not contact the wound care specialist to notify them of newly admitted residents. The facility notified the wound care specialist of new residents with wounds only when they were in the facility for weekly rounds. Interview with the assistant director of nursing (ADON) and the wound nurse on 1/2/14 at 10:40 AM revealed that the wound specialist was not notified of new residents with wounds until rounds were made on Tuesdays. No phone notification or written notification was made. The wound care specialist was not notified of the presence of Resident #1 or the deterioration of the pressure ulcers and deep tissue injuries until 12/10/13. Telephone interview with the primary physician on 01/2/14 at 12:00 PM revealed that the primary physician deferred to the wound care specialist for wound care. The primary physician stated that he was unsure whether he was notified of the deterioration of Resident #1 ' s wound but that he left the management of wounds to the wound care team. On 12/10/13 the wound care physician ordered [MEDICATION NAME] Ointment to the coccyx wound bed daily for seven (7) days. According to reference material in Web MD, [MEDICATION NAME] ointment was indicated for treatment of [REDACTED]. The physician continued the daily wound dressings. Review of the facility Skin Program protocol indicated in Step 6 that residents with wounds would have appropriate treatment. If there was deterioration or no change in a wound within two (2) weeks the treatment would be changed. Review of the Care Plan for Pressure Ulcers dated 12/06/13 for Resident #1 indicated that there was a Stage III pressure ulcer on the coccyx and the presence of a deep tissue injury on the right gluteal fold on admission. One of the interventions for the pressure ulcers was to notify the MD as needed (prn) with any changes in skin integrity. 2. Clinical record review of the Admission Record for Resident #2 revealed that the resident was admitted into the facility in October of 2013. Further review of the Admission Record for Resident #2 indicated [DIAGNOSES REDACTED]. There was no reference to a pressure ulcer on the Admission Record. Review of the Treatment Record for Resident #2 indicated that the resident was given pressure ulcer care to a new sacral wound on 10/21/2013. Interview with the wound care nurse on 1/2/14 at 12:56 PM revealed that Resident #2 was admitted into the hospital on [DATE] and readmitted into the facility on [DATE]. The wound nurse said that she was off from work on the weekend of 10/19/13 and 10/20/13 and did not perform the skin check on Resident #2 until Monday 10/21/13. At that time the wound nurse noted the Stage III pressure ulcer to Resident #2 ' s sacrum. The wound nurse said that she thought the wound was hospital acquired because she did not know whether Resident #2 was turned while at the hospital. Further interview with the wound nurse on 1/2/14at 2:00 PM revealed that there was another wound nurse that did a skin assessment on Resident #2 on the weekend of 10/19/13 and 10/20/13, but there was no documentation of the assessment. The wound nurse said that though she documented that she observed Resident #2 ' s pressure ulcer on 10/18/13 she did not actually see and assess the wound until 10/21/13. Further interview with the wound nurse on 1/2/14 at 2:15 PM revealed that she did not actually see the wound on Resident #2 on 10/18/13 but heard by word of mouth of the ulcer. The certified nursing assistant ( AA ) reported the wound to the other wound nurse. Interview with the CNA ( AA ) on 1/2/14 at 2:30 PM revealed that AA worked on 10/19/13. AA said that Resident #2 had a tear/open area on her backside that was red and close to the crack. AA said that when she reported the wound to the other wound nurse on that Saturday the 19 of October the nurse remarked that Resident #2 needed treatment. Interview with the ADON on 1/2/14 at 2:30 PM revealed that she agreed that the wound seemed worst by Monday 10/21/13. The wound should have been treated over the weekend. During the interview with the wound care nurse on 1/2/14 at 2:30 PM the nurse stated that the Stage III ulcer to Resident #2 ' s coccyx measured 3.2 x 2.0 x 0.2 cm on Monday 10/21/13. The wound was reported to the physician on that Monday. Review of the Focused Wound Exam by wound care specialist on 10/22/13 indicated that the Pressure Ulcer on Resident #2 ' s sacrum measured 3.5 cm x 4.5 cm x 0.1 cm depth with necrotic tissue. The physician performed a surgical excisional debridement of the wound. Review of the facility Skin Program protocol indicated in the fourth step that a certified nursing assistant (CNA) will observe resident skin condition daily during care and report skin conditions to the Licensed Nurse. Step 5 indicated that all open areas would be identified and documented on the appropriate forms. Step 6 indicated that residents with wounds would have appropriate treatment. If there was deterioration or no change in a wound within two (2) weeks the treatment would be changed. Review of the Care Plan for Risk for Skin Breakdown dated 10/09/13 for Resident #2 included interventions to report any signs of skin breakdown to the treatment nurse, responsible party and physician (MD).", "filedate": "2017-01-01"}
{"rowid": 7704, "facility_name": "AUTUMN BREEZE HEALTH AND REHAB", "facility_id": 115580, "address": "1480 SANDTOWN ROAD SW", "city": "MARIETTA", "state": "GA", "zip": 30008, "inspection_date": "2014-01-08", "deficiency_tag": 281, "scope_severity": "D", "complaint": 1, "standard": 0, "eventid": "TEVL11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, state board of nursing nurse practice act review and laboratory report review the facility failed to ensure that the nursing services provided met professional nursing standards of quality for two (2) residents (#1, #2) that were at risk for the development of pressure ulcers and one resident (#1) with abnormal laboratory results of five (5) sampled residents. The nursing staff failed to fully inform the physician of the status of laboratory results for Resident #1 which delayed the treatment for [REDACTED].#1 and failed to inform the physician of the development of a pressure ulcer for Resident #2. Findings include: The Georgia Registered Nurse Practice Act, Article 43-26-3(6) indicates that the Practice of Nursing includes the provision of nursing care: administration, supervision, evaluation, or any combination thereof, of nursing practice. 1. Review of the Urinanalysis Lab Report for Resident #1 dated 12/12/13 indicated abnormalities that included moderate blood in the urine, moderate leukocytes or white blood cells and cloudy color. There were hand written notes on the Lab Report that documented the physician was notified, and said to wait for culture. The nurse documented on the Lab Report that there was no culture ordered. The Lab Report was initialled by the nurse. Review of the Nurse's Notes for Resident #1 dated 12/12/13 indicated that the urinanalysis results were reported to the physician but the physician stated to wait for the culture results. The nurse failed to notify the physician that there was no urine culture ordered. This failure resulted in a no treatment for [REDACTED].#1. Interview with the assistant director of nursing (ADON) on 12/31/13 at 1:50 PM revealed that the nurse failed to notify the primary physician that a urine culture and sensitivity was not ordered or in progress for Resident #1. When the physician replied to the abnormal report of the urinanalysis that he would wait for the culture and sensitivity results the nurse should have told him that only a urinanalysis was ordered not a culture and sensitivity. On 12/31/2013 at 2:10 PM a telephone interview was made with the assistant director of nursing (ADON) via speaker phone to Resident #1 ' s primary physician regarding the physician's order [REDACTED]. The primary physician said that he was not notified that a culture and sensitivity was not in progress for Resident #1 when the nurse gave him the abnormal urinanalysis results on 12/12/13. He stated that if he had known that there was no culture and sensitivity of the urine in progress he would have treated Resident #1 with antibiotics for the abnormalities identified in the urinanalysis. The primary physician said that the nurse should have informed him that there was no urine culture and sensitivity ordered for Resident #1. 2. Review of the Admission Record for Resident #1 indicated the resident was admitted into the facility on [DATE]. Review of the Physician order [REDACTED].#1 indicated that the primary physician ordered treatment to the coccyx wound and right gluteal deep tissue injury on 11/27/2013. Review of the admission Non-Decubitus Skin Condition Record dated 11/27/13 indicated that Resident #1 ' s coccyx pressure ulcer measured 7.0 x 9.5 with no depth. The color of the wound bed was pink/yellow. Review of the Wound Care note dated 12/6/13 (9 days after admission) indicated that Resident #1 ' s pressure ulcer to the coccyx measured 7.0 x 9.5 x 0.2 cm and was un-stageable. The wound had deteriorated and had 100 % necrotic tissue. There was no documentation on the health record that the primary physician and wound specialist were notified of the deterioration of the pressure ulcer on Resident #1's coccyx. Interview with the wound care nurse on 01/02/13 at 9:30 AM revealed that the nurse recalled Resident #1. According to the wound nurse there was no depth to the coccyx wound and there was 50% pink healthy tissue, 10% granulation tissue and the wound had scattered with yellow slough on admission. Resident #1 was first seen by the wound specialist on 12/10/13, thirteen (13) days after being admitted into the facility and after the wound had deteriorated. On 12/10/13 the wound care physician ordered [MEDICATION NAME] Ointment to the coccyx wound bed daily for seven (7) days. According to reference material in Web MD, [MEDICATION NAME] ointment was indicated for treatment of [REDACTED]. Interview with the assistant director of nursing (ADON) and the wound nurse on 1/2/14 at 10:40 AM revealed that the facility was that the wound specialist was not notified of new residents with wounds until rounds were made on Tuesdays. No phone notification or written notification was made. The wound care specialist was not notified of the presence of Resident #1 or the pressure ulcers and deep tissue injuries until 12/10/13. Telephone interview with the primary physician on 01/2/14 at 12:00 PM revealed that the primary physician deferred to the wound care specialist for wound care. Review of the Care Plan for Pressure Ulcers dated 12/06/13 for Resident #1 indicated that one of the interventions for the pressure ulcers was to notify the MD as needed (prn) with any changes in skin integrity. 3. Clinical record review of the Admission Record for Resident #2 revealed that the resident was admitted into the facility in October of 2013. There was no reference to a pressure ulcer on the Admission Record. Review of the facility Skin Program protocol indicated in the fourth step that a certified nursing assistant (CNA) will observe resident skin condition daily during care and report skin conditions to the Licensed Nurse. Step 5 indicated that all open areas would be identified and documented on the appropriate forms. Step 6 indicated that residents with wounds would have appropriate treatment. Review of the Care Plan for Risk for Skin Breakdown dated 10/09/13 for Resident #2 included interventions to report any signs of skin breakdown to the treatment nurse, responsible party and physician (MD). Review of the Treatment Record for Resident #2 indicated that the resident was given pressure ulcer care to a new sacral wound on 10/21/2013. Interview with the wound care nurse on 1/2/14 at 12:56 PM revealed that Resident #2 was admitted into the hospital on [DATE] and readmitted into the facility on [DATE]. The wound nurse said that she was off from work on the weekend of 10/19/13 and 10/20/13 and did not perform the skin check on Resident #2 until Monday 10/21/13. At that time the wound nurse noted the Stage III pressure ulcer to Resident #2 ' s sacrum. Further interview with the wound nurse on 1/2/14 at 2:15 PM revealed that she did not actually see the wound on Resident #2 on 10/18/13 but heard by word of mouth of the ulcer. The certified nursing assistant ( AA ) reported the wound to the other wound nurse. Interview with the CNA ( AA ) on 1/2/14 at 2:30 PM revealed that AA worked on 10/19/13. AA said that Resident #2 had a tear/ open area on her backside that was red and close to the crack . AA said that when she reported the wound to the other wound nurse on that Saturday the 19 of October the nurse remarked that Resident #2 needed treatment. Interview with the ADON on 1/2/14 at 2:30 PM revealed that she agreed that the wound seemed worst by Monday 10/21/13. The wound should have been treated over the weekend. During the interview with the wound care nurse on 1/2/14 at 2:30 PM the nurse stated that the Stage III ulcer to Resident #2 ' s coccyx measured 3.2 x 2.0 x 0.2 cm on Monday 10/21/13. The wound was reported to the physician on that Monday. Review of the Focused Wound Exam by wound care specialist on 10/22/13 indicated that the Pressure Ulcer on Resident #2 ' s sacrum measured 3.5 cm x 4.5 cm x 0.1 cm depth with necrotic tissue. The physician performed a surgical excisional debridement of the wound.", "filedate": "2017-01-01"}
{"rowid": 7705, "facility_name": "AUTUMN BREEZE HEALTH AND REHAB", "facility_id": 115580, "address": "1480 SANDTOWN ROAD SW", "city": "MARIETTA", "state": "GA", "zip": 30008, "inspection_date": "2014-01-08", "deficiency_tag": 314, "scope_severity": "D", "complaint": 1, "standard": 0, "eventid": "TEVL11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and facility pressure ulcer protocol review the facility failed to ensure that two residents (#1, #2) of five (5) sampled residents received the necessary treatment and services to promote healing and prevent infection of pressure ulcers. Findings include: 1. Review of the Admission Record for Resident #1 indicated the resident was admitted into the facility on [DATE]. Review of the Physician order [REDACTED].#1 indicated that the primary physician ordered treatment to the coccyx wound and right gluteal deep tissue injury on 11/27/2013. Review of the admission Non-Decubitus Skin Condition Record dated 11/27/13 indicated that Resident #1 ' s coccyx pressure ulcer measured 7.0 x 9.5 with no depth. The color of the wound bed was pink/yellow. Review of the Wound Care note dated 12/6/13 (9 days after admission) indicated that Resident #1 ' s pressure ulcer to the coccyx measured 7.0 x 9.5 x 0.2 cm and was un-stageable. The wound had deteriorated and had 100 % necrotic tissue. The primary physician and wound specialist were not notified of the deterioration of the pressure ulcer on Resident #1's coccyx. Interview with the wound care nurse on 01/02/13 at 9:30 AM revealed that the nurse recalled Resident #1. The wound nurse said that the initial wound assessment was done on 11/27/13 for Resident #1. According to the wound nurse there was no depth to the coccyx wound and there was 50% pink healthy tissue, 10% granulation tissue and the wound had scattered with yellow slough. The wound nurse added that there was no visible muscle, cartilage or bone and there was no black tissue and no odor when Resident #1 ' s wound was initially assessed. Resident #1 was first seen by the wound specialist on 12/10/13, thirteen (13) days after being admitted into the facility and after the wound had deteriorated. The wound nurse stated that the facility does not contact the wound care specialist to notify them of newly admitted residents. The facility notified the wound care specialist of new residents with wounds when they were in the facility for weekly rounds. Interview with the assistant director of nursing (ADON) and the wound nurse on 1/2/14 at 10:40 AM revealed that the wound specialist was not notified of new residents with wounds until rounds were made on Tuesdays. No phone notification or written notification was made. The wound care specialist was not notified of the presence of Resident #1 or the pressure ulcers and deep tissue injuries until 12/10/13. Telephone interview with the primary physician on 01/2/14 at 12:00 PM revealed that the primary physician deferred to the wound care specialist for wound care. On 12/10/13 the wound care physician ordered [MEDICATION NAME] Ointment to the coccyx wound bed daily for seven (7) days. According to reference material in Web MD, [MEDICATION NAME] ointment was indicated for treatment of [REDACTED]. Review of the Care Plan for Pressure Ulcers dated 12/06/13 for Resident #1 indicated that there was a Stage III pressure ulcer on the coccyx and the presence of a deep tissue injury on the right gluteal fold on admission. One of the interventions for the pressure ulcers was to notify the MD as needed (prn) with any changes in skin integrity. 2. Clinical record review of the Admission Record for Resident #2 revealed that the resident was admitted into the facility in October of 2013. Further review of the Admission Record for Resident #2 indicated [DIAGNOSES REDACTED]. There was no reference to a pressure ulcer on the Admission Record. Review of the Treatment Record for Resident #2 indicated that the resident was given pressure ulcer care to a new sacral wound on 10/21/2013. Interview with the wound care nurse on 1/2/14 at 12:56 PM revealed that Resident #2 was admitted into the hospital on [DATE] and readmitted into the facility on [DATE]. The wound nurse said that she was off from work on the weekend of 10/19/13 and 10/20/13 and did not perform the skin check on Resident #2 until Monday 10/21/13. At that time the wound nurse noted the Stage III pressure ulcer to Resident #2 ' s sacrum. Further interview with the wound nurse on 1/2/14 at 2:15 PM revealed that she did not actually see the wound on Resident #2 on 10/18/13 but heard by word of mouth of the ulcer. The certified nursing assistant ( AA ) reported the wound to the other wound nurse. Interview with the CNA ( AA ) on 1/2/14 at 2:30 PM revealed that AA worked on 10/19/13. AA said that Resident #2 had a tear/ open area on her backside that was red and close to the crack . AA said that when she reported the wound to the other wound nurse on that Saturday the 19 of October the nurse remarked that Resident #2 needed treatment. Interview with the ADON on 1/2/14 at 2:30 PM revealed that she agreed that the wound seemed worst by Monday 10/21/13. The wound should have been treated over the weekend. During the interview with the wound care nurse on 1/2/14 at 2:30 PM the nurse stated that the Stage III ulcer to Resident #2 ' s coccyx measured 3.2 x 2.0 x 0.2 cm on Monday 10/21/13. The wound was reported to the physician on that Monday. Review of the Focused Wound Exam by wound care specialist on 10/22/13 indicated that the Pressure Ulcer on Resident #2 ' s sacrum measured 3.5 cm x 4.5 cm x 0.1 cm depth with necrotic tissue. The physician performed a surgical excisional debridement of the wound. Review of the facility Skin Program protocol indicated in the fourth step that a certified nursing assistant (CNA) will observe resident skin condition daily during care and report skin conditions to the Licensed Nurse. Step 5 indicated that all open areas would be identified and documented on the appropriate forms. Step 6 indicated that residents with wounds would have appropriate treatment. Review of the Care Plan for Risk for Skin Breakdown dated 10/09/13 for Resident #2 included interventions to report any signs of skin breakdown to the treatment nurse, responsible party and physician (MD).", "filedate": "2017-01-01"}
{"rowid": 7706, "facility_name": "AUTUMN BREEZE HEALTH AND REHAB", "facility_id": 115580, "address": "1480 SANDTOWN ROAD SW", "city": "MARIETTA", "state": "GA", "zip": 30008, "inspection_date": "2014-01-08", "deficiency_tag": 502, "scope_severity": "D", "complaint": 1, "standard": 0, "eventid": "TEVL11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to fully inform the physician of the status of a laboratory report for one (1) resident (#1) of five (5) residents sampled. Finding include: Review of the Urinanalysis Lab Report for Resident #1 dated 12/12/13 indicated abnormalities that included moderate blood in the urine, moderate leukocytes or white blood cells and cloudy color. There were hand written notes on the Lab Report that documented the physician was notified, and to wait for culture. The nurse documented on the Lab Report that there was no culture ordered. The Lab Report was initialled by the nurse. Review of the Nurse's Notes for Resident #1 dated 12/12/13 indicated that the urinanalysis results were reported to the physician but the physician stated to wait for the culture results. The nurse failed to notify the physician that there was no urine culture ordered. This failure resulted in a no treatment for [REDACTED].#1. Interview with the assistant director of nursing (ADON) on 12/31/13 at 1:50 PM revealed that the nurse failed to notify the primary physician that a urine culture and sensitivity was not ordered or in progress for Resident #1. When the physician replied to the abnormal report of the urinanalysis that he would wait for the culture and sensitivity results the nurse should have told him that only a urinanalysis was ordered not a culture and sensitivity. On 12/31/2013 at 2:10 PM a telephone interview was made with the assistant director of nursing (ADON) via speaker phone to Resident #1 ' s primary physician regarding the physician's order [REDACTED]. The primary physician said that he was not notified that a culture and sensitivity was not in progress for Resident #1 when the nurse gave him the abnormal urinanalysis results on 12/12/13. He stated that if he had known that there was no culture and sensitivity of the urine in progress he would have treated Resident #1 with antibiotics for the abnormalities identified in the urinanalysis. The primary physician said that the nurse should have informed him that there was no urine culture and sensitivity ordered for Resident #1.", "filedate": "2017-01-01"}
{"rowid": 7975, "facility_name": "PRUITTHEALTH - MARIETTA", "facility_id": 115276, "address": "50 SAINE DRIVE SW", "city": "MARIETTA", "state": "GA", "zip": 30008, "inspection_date": "2013-07-08", "deficiency_tag": 315, "scope_severity": "D", "complaint": 1, "standard": 0, "eventid": "42RK11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide the necessary care to one (1) resident (#1), regarding an indwelling urinary drainage catheter, of five (5) sampled residents, by failing to change the catheter according to physician's orders [REDACTED]. Findings include: Record review for Resident #1 revealed Physician's Interim Orders sheets, dated 05/17/2013 and timed at 7:00 p.m., which referenced an order for [REDACTED]. However, further record review, to include review of the June 2013 Treatment Record and Skilled Daily Nurses Notes, revealed no evidence to indicate that Resident #1's catheter had been changed in June, as ordered. During interview with the DON and Administrator on 7/8/2013 at 2:00 p.m. it was acknowledged that the Nurse's Notes and Treatment Record indicated that Resident #1's indwelling urinary drainage catheter had not been changed as the physician ordered.", "filedate": "2016-07-01"}
{"rowid": 8189, "facility_name": "AUTUMN BREEZE HEALTH AND REHAB", "facility_id": 115580, "address": "1480 SANDTOWN ROAD SW", "city": "MARIETTA", "state": "GA", "zip": 30008, "inspection_date": "2013-06-06", "deficiency_tag": 309, "scope_severity": "D", "complaint": 1, "standard": 0, "eventid": "A7MV11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide medications as ordered by the physician to one (1) resident (#1) of four (4) sampled residents. Findings include: The admission orders [REDACTED]. On 4/25/2013 there was an order to discontinue the [MEDICATION NAME] 1 mg at bedtime and start [MEDICATION NAME] 25 mg orally at bedtime for hallucinations. An additional order dated 5/17/2013 documented to discontinue the [MEDICATION NAME] 1 mg orally at bedtime when the supply was depleted and start [MEDICATION NAME] 0.5 mg orally at bedtime for dementia. Review of the Medication Administration Record [REDACTED]. However, review of the May Medication Administration Record [REDACTED]. The [MEDICATION NAME] 1 mg was changed to 0.5 mg as directed by the 5/17/2013 order. Interview with the administrative nursing staff on 6/6/2013 at 3:00 pm revealed that the 5/17/2013 order was the result of a pharmacy recommendation. The pharmacist was not aware of the 4/25/2013 order to discontinue the [MEDICATION NAME] and administer [MEDICATION NAME] because the resident was still receiving the [MEDICATION NAME] 1 mg. The nurse also stated at 4:00 pm that the order written on 4/25/2013 to discontinue [MEDICATION NAME] and administer [MEDICATION NAME] was the order that should have been followed from 4/25/2013 to the present. A new physician's orders [REDACTED].", "filedate": "2016-06-01"}
{"rowid": 8430, "facility_name": "PRUITTHEALTH - MARIETTA", "facility_id": 115276, "address": "50 SAINE DRIVE SW", "city": "MARIETTA", "state": "GA", "zip": 30008, "inspection_date": "2011-08-25", "deficiency_tag": 225, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "QBY711", "inspection_text": "Based on record review, review of the facility Abuse prohibition policy and staff interviews the facility failed to report an allegation of abuse to the State Survey and Certification Agency for one resident (A) from a sample of twenty-nine (29) residents and failed to check past histories of individuals from previous employers for five (5) of five (5) employee files reviewed. Findings include: 1. Review of the facility complaint log revealed a complaint dated 5-1-11 for resident A who reported that on 4-30-11 she was being cleaned and felt that the Certified Nursing Assistant(CNA) touched her inappropriately in the vaginal area. Continued review revealed that the resident stated that she began to scream and yell, and said that she did not want him to clean her like that. Review of the followup investigation, by the facility on 5-3-11, revealed that the resident stated that the male CNA was rubbing inside her private area, it made her feel violated and she did not like it. Interview on 8/25/11 at 10:00 a.m. with the Director of Nursing (DON) and the facility Administrator revealed that the facility policy is to investigate all allegations of abuse. Continued interview revealed that the DON acknowledged that she did not report the complaint because she felt it was not substantiated. Interview with the Licensed Practical Nurse (LPN) unit manager on 8/25/11 at 1:39 p.m. revealed that the resident did not complain to her but she had received the complaint from the social services director. Continued interview revealed that when she interviewed the resident the day after the alleged incident, the resident stated that she didn't like the way the CNA touched her. Review of the facility Abuse Prohibition Policy revealed that once a complaint or situation is identified involving alleged mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property the incident will be immediately reported to the Complaint Investigation Intake and Referral Unit at the State Agency. 2. Review of five (5) employee files revealed no evidence that reference checks had been done prior to hire. Interview with the Staffing Coordinator JJ on 8/25/11 at 9:00 a.m. revealed that there is no evidence of reference checks prior to hire in the employee file. Continued interview revealed that the staffing coordinator acknowledged that he had not contacted previous employers for four (4) of the five (5) files reviewed. He further indicated he called the previous employer for one (1) file reviewed but there was no evidence on file of this being done. Review of the facility's Abuse Prohibition policy revealed that the facility will conduct a thorough investigation of the histories of individuals being considered for hire and all reasonable efforts will be made to check references and information from previous and/or current employers.", "filedate": "2016-01-01"}
{"rowid": 8431, "facility_name": "PRUITTHEALTH - MARIETTA", "facility_id": 115276, "address": "50 SAINE DRIVE SW", "city": "MARIETTA", "state": "GA", "zip": 30008, "inspection_date": "2011-08-25", "deficiency_tag": 371, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "QBY711", "inspection_text": "Based on observation, and staff interviews, the facility failed to store foods properly. Findings include: Kitchen tour with dietary aide AA on 8/22/2011 at 8:10a.m. revealed that that the walk-in freezer contained hash browns and bread sticks that were not properly sealed and had not been labeled with date opened. Staff member removed these items and acknowledged that the items should have been labeled with date opened. During an interview with the Dietary Manager on 08/23/2011 at 12:50p.m., the manager revealed the facility has no written policy regarding labeling opened foods with date, however the staff have been trained that they are suppose to date opened items. Interview with dietary aide BB on 08/24/2011 at 12:15pm, revealed that opened foods are to be stored with a label containing contents and the date opened.", "filedate": "2016-01-01"}
{"rowid": 8527, "facility_name": "AUTUMN BREEZE HEALTH AND REHAB", "facility_id": 115580, "address": "1480 SANDTOWN ROAD SW", "city": "MARIETTA", "state": "GA", "zip": 30008, "inspection_date": "2011-07-28", "deficiency_tag": 502, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "ENIG11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of physician's orders, Medication Administration Record (MAR), and staff interview, the facility failed to timely obtained a [MEDICATION NAME] level according to physician's order for one (1) resident (#7) from a sample of thirty one (31) residents. Findings include: Record review for resident #7 revealed a physician's order dated 7/14/11 for [MEDICATION NAME] 300mg by mouth (po) should be changed from every morning (AM) to every evening (PM) at bedtime, then repeat the [MEDICATION NAME] level in one (1) week. There was no evidence in the medical record that the repeated [MEDICATION NAME] level had been done. Review of the July 2011 MAR indicated the repeat [MEDICATION NAME] level order had been transcribed to the MAR and should have been done one (1) week for 7/14/11. There was no evidence on the MAR that the repeat [MEDICATION NAME] level had been done. Further record review revealed a [MEDICATION NAME] level done 7/26/11. Interview with the Licensed Practical Nurse (LPN) AA on 7/26/11 at 2:30pm revealed the repeat [MEDICATION NAME] level ordered 7/14 was not completed by 7/21/11, one week, as ordered.", "filedate": "2016-01-01"}
{"rowid": 8750, "facility_name": "AUTUMN BREEZE HEALTH AND REHAB", "facility_id": 115580, "address": "1480 SANDTOWN ROAD SW", "city": "MARIETTA", "state": "GA", "zip": 30008, "inspection_date": "2012-11-13", "deficiency_tag": 279, "scope_severity": "D", "complaint": 1, "standard": 0, "eventid": "2T8B11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, Transfer and Bed Mobility Status Tool review, and staff interview, the facility failed to ensure the development of a Care Plan which described the services, related to the assessed need of a lift for transfer, to be provided to one (1) resident (#1) from the survey sample of five (5) residents. Findings include: Please cross refer to F323 for more information regarding Resident #1. Review of the medical record for Resident #1 revealed that the resident's Care Plan documented an admission date of [DATE]. A Transfer and Bed Mobility Status Tool, also dated 11/07/2011, indicated the resident required extensive assistance and was unable to bear weight on the lower extremities, and referenced an Intervention specifying the use a total lift with a full body sling. Further review of the resident's Care Plan referenced above revealed an entry of 11/14/2011 which identified that Resident #1 required assistance with activities of daily living related to decreased mobility/[MEDICAL CONDITION]. An Intervention was to provide adaptive/safety equipment as needed. An additional 11/14/2011 Care Plan entry identified the resident to be at risk for falls/injuries related to needed assistance with mobility, and Interventions included to provide the assistance needed with mobility. However, further review revealed no reference on the resident's Care Plan of the resident requiring the use of a total lift with full body sling, even though the resident's need for a total lift with sling had been identified on the Transfer and Bed Mobility Status Tool on 11/07/2011, one week prior to the development of this Care Plan. During an interview conducted on 11/06/2012 at 3:45 pm., the Director of Nursing acknowledged Resident #1's use of a lift during transfer.", "filedate": "2015-11-01"}
{"rowid": 8751, "facility_name": "AUTUMN BREEZE HEALTH AND REHAB", "facility_id": 115580, "address": "1480 SANDTOWN ROAD SW", "city": "MARIETTA", "state": "GA", "zip": 30008, "inspection_date": "2012-11-13", "deficiency_tag": 323, "scope_severity": "D", "complaint": 1, "standard": 0, "eventid": "2T8B11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, Bruise Investigation and Supervisor Report review, Bed Safety Device Risk Review Tool review, Transfer and Bed Mobility Status Tool review, and staff interview, the facility failed to ensure adequate supervision during the transfer by lift for one (1) resident (#1), who had been identified as having difficulty with balance/trunk control, from the survey sample of five (5) residents. Findings include: Review of the medical record for Resident #1 revealed a Care Plan entry of 11/14/2011 which identified that Resident #1 required assistance with activities of daily living related to decreased mobility/[DIAGNOSES REDACTED]. One of the Interventions to was to provide adaptive/safety equipment as needed. A Bed Safety Device Risk Review Tool completed on 11/07/2011 identified Resident #1 as having difficulty with balance or trunk control. A Transfer and Bed Mobility Status Tool dated 11/07/2011 indicated the resident required extensive assistance, being unable to bear weight on the lower extremities. One of the Interventions referenced on this Transfer and Bed Mobility Status Tool was to use a total lift with a full body sling. A Nurse's Notes entry dated 10/25/2012 at 2:30 p.m. documented that Resident #1 had been injured by the lift while being transferred. The same Notes entry also documented that the doctor was notified and an order was received to apply ice to the left eye every two (2) hours for six (6) hours to decrease swelling. A subsequent Nurse's Notes entry of 10/25/2012 at 10:00 p.m. documented that the resident was noted with bruising to the left side of the eye. A Bruise Investigation report form dated 10/26/2012 documented Resident #1's left eye injury, and documented that the bruise had occurred upon transfer with the mechanical lift. A Supervisor Report dated 10/27/2012 documented that the incident occurred when the employee removed the strap from the mechanical lift, the resident moved, and the lift hit the resident's eye. In a written statement by Certified Nursing Assistant (CNA) AA dated 10/25/2012, CNA AA indicated that while transferring Resident #1 from the bed to the wheelchair, as she was removing the straps from the lift, the bar swung to the left side of the resident's cheek. During an interview conducted on 11/06/2012 at 3:45 pm., the Director of Nursing acknowledged that Resident #1 was hit by the lift bar while CNA AA was transferring her via total lift. During a telephone interview conducted on 11/13/2012 at 4:45 p.m. with CNA BB, CNA BB stated that she had assisted CNA AA during the transfer of Resident #1 on 10/25/2012. CNA BB stated that while transferring the resident from the bed to the wheelchair, CNA AA removed the straps from the lift by accident, and the bar swung to the resident and hit her upper left cheek. During interview on 11/13/2012 at 5:00 p.m., the Staff Development Coordinator stated that CNA AA should have followed the facility's protocol to remove one lift strap at a time slowly so the bar would remain stable during the transfer process.", "filedate": "2015-11-01"}
{"rowid": 8809, "facility_name": "AUTUMN BREEZE HEALTH CARE CTR", "facility_id": 115580, "address": "1480 SANDTOWN ROAD", "city": "MARIETTA", "state": "GA", "zip": 30008, "inspection_date": "2012-10-24", "deficiency_tag": 157, "scope_severity": "D", "complaint": 1, "standard": 0, "eventid": "3XTZ11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to notify the family of one (1) resident, (A) in a survey sample of four (4) residents regarding changes in treatment orders and change in condition of a wound. Findings include: Review of the physician's telephone orders for resident A dated 9/7/2012, revealed an order for [REDACTED]. Review of the 9/12/2012 physician orders [REDACTED]. An additional physician's orders [REDACTED]. An interview with family member of resident A was conducted on 10/24/2012 at 2:45 p.m. and revealed the family member was not aware the resident had a Stage IV pressure area until 9/28/2012 when observed at the wound clinic and the condition of the wound. Further, said was never aware of the area on the sacrum until appointment. An interview with Nurse AA on 10/24/2012 at 12:40 p.m., revealed that the responsible party had not been notified of the physician's orders [REDACTED]. In addition, it was stated that on 9/24/2012 the wound consult was ordered because the sacral wound was unstageable, had purulent drainage with slough and necrotic tissue and the responsible party had not been notified of the condition of the wound.", "filedate": "2015-10-01"}
{"rowid": 8810, "facility_name": "AUTUMN BREEZE HEALTH CARE CTR", "facility_id": 115580, "address": "1480 SANDTOWN ROAD", "city": "MARIETTA", "state": "GA", "zip": 30008, "inspection_date": "2012-10-24", "deficiency_tag": 314, "scope_severity": "D", "complaint": 1, "standard": 0, "eventid": "3XTZ11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to provide the necessary treatment and services in wound care to promote healing to one (1) resident, (A), in survey sample of four (4) residents as ordered by the physician. Findings include: Review of the physician's orders [REDACTED]. There was also a sacral wound treatment order to tuck ? strength Dakins moistened gauze into wound and necrotic tissue, apply Zinc barrier cream around the good tissue, cover with an abdominal pad and secure with tape. However, there was no evidence found in the medical record that these new treatment orders were done as ordered on [DATE] or 9/30/12. During an interview with Nurse AA on 10/24/2012 at 4:50 p.m., who confirmed that the orders were not followed. It was stated by the Director of Nursing that [MEDICATION NAME] was not use for treatments at the facility. There was no evidence in the medical record that the nurse receiving the order on 9/28/2012 called and notified the ordering physician of the facility policy regarding [MEDICATION NAME] and obtaining a clarification of the treatment order.", "filedate": "2015-10-01"}
{"rowid": 9246, "facility_name": "AUTUMN BREEZE HEALTH CARE CTR", "facility_id": 115580, "address": "1480 SANDTOWN ROAD", "city": "MARIETTA", "state": "GA", "zip": 30008, "inspection_date": "2012-04-24", "deficiency_tag": 315, "scope_severity": "D", "complaint": 1, "standard": 0, "eventid": "XS6611", "inspection_text": "Based on record review and staff interview, the facility failed to change an indwelling urinary catheter in conformance with a physician's order for one (1) resident (#1) from a survey sample of four (4) residents. Findings include: Record review for Resident #1 revealed a 02/07/2012 Physician's Telephone Orders Form which ordered that a Foley catheter be inserted in relation to the resident's Stage III sacral wound, and ordered that the Foley catheter be changed every month and as needed. Further record review revealed a 03/17/2012 Nurse's Note which documented that Resident #1 had been transferred to the hospital. However, further record review revealed no evidence to indicate that the resident's indwelling urinary catheter had been changed, per the physician's order, between the 02/07/2012 order date and the 03/17/2012 hospital transfer, representing a period of approximately five-and-one-half (5 1/2) weeks, even though the physician's order specified for the catheter to be changed monthly. During an interview with the Director of Nursing (DON) conducted on 04/24/2012 at approximately 4:00 p.m., the DON acknowledged the physician's order specifying that the urinary catheter be changed monthly.", "filedate": "2015-08-01"}
{"rowid": 10171, "facility_name": "PRUITTHEALTH - MARIETTA", "facility_id": 115276, "address": "50 SAINE DRIVE SW", "city": "MARIETTA", "state": "GA", "zip": 30008, "inspection_date": "2011-08-25", "deficiency_tag": 428, "scope_severity": "D", "complaint": 1, "standard": 1, "eventid": "QBY711", "inspection_text": "Based on record review, review pf Medication Administration Record [REDACTED]. Findings include: Review of the record for resident #32 revealed that from the past twelve (12) months of monthly medication reviews, six (6) months were missing, 5/2011, 2/2011, 12/2010, 11/2010, 10/2010, and 8/2010. Interview with the Director of Nursing (DON) on 8/25/11 at 11:45am revealed that there was no more documentation available related to Pharmacy Drug Regimen Reviews for this resident. Interview with Social Services \"DD\" on 8/25/11 at 12:15pm revealed the resident had not been out to the hospital in the past eighteen (18) months.", "filedate": "2014-12-01"}
{"rowid": 10602, "facility_name": "AUTUMN BREEZE HEALTH CARE CTR", "facility_id": 115580, "address": "1480 SANDTOWN ROAD", "city": "MARIETTA", "state": "GA", "zip": 30008, "inspection_date": "2010-11-17", "deficiency_tag": 224, "scope_severity": "D", "complaint": null, "standard": null, "eventid": "C9BJ11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and hospital document review, the facility failed to provide the services necessary to assess and obtain timely treatment for one (1) resident (\"C\") from a survey sample of three (3) residents. Findings include: Record review for Resident \"C\" revealed a 04/20/2010 Physician's Admission History and Physical which documented that the resident's breast exam had been deferred. A physician's Progress Note dated 10/25/2010 documented that during the April 2010 History and Physical, the palpation portion of the breast exam had been deferred, but that visualization for asymmetry and assessment for nipple drainage had been unremarkable. Further review of the resident's record revealed documentation indicating that weekly assessments had been done, with no notations indicating that staff had either identified or documented any changes or dimpling of the right breast. However, a Nurse's Note of 10/24/2010 at 6:00 p.m. documented that the resident's family member had reported a lump in the resident's right breast. This Note documented that upon assessment, a lump approximately the size of a golf ball was palpated on the inner portion, and extending toward the middle, of the resident's right breast, with indentation observed. This Note further documented that the physician was notified, and an order was received to send the resident to the hospital emergency room . A hospital ED Record of 10/24/2010 documented that Resident \"C\" was diagnosed with [REDACTED]. A Physician's Progress Note of 10/27/2010 documented that a breast exam had revealed considerable induration with skin retraction. During an interview with the Assistant Director of Nursing (ADON) conducted on 11/17/2010 at 1:20 p.m., she stated that she expected staff to do a head-to-toe assessment and to report any changes or abnormal findings. The ADON stated that she had examined Resident \"C\"'s breasts and noted that the right breast looked different. The ADON further stated that she would have expected staff to have made the appropriate notification regarding this change. However, during an interview with the Regional Clinical Director conducted on 11/17/2010 at 1:50 p.m., she stated that the nurse who had performed the weekly skin assessments had stated that she had not noted any changes. An observation of the resident on 11/17/2010 at 12:05 p.m. revealed that the resident had dimpling of the right breast.", "filedate": "2014-03-01"}
{"rowid": 1683, "facility_name": "WESTBURY CONYERS, LLC", "facility_id": 115469, "address": "1420 MILSTEAD ROAD", "city": "CONYERS", "state": "GA", "zip": 30012, "inspection_date": "2017-07-27", "deficiency_tag": 241, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "DRP811", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, clinical record reviews, and review of facility policy titled Quality of Life-Dignity, the facility failed to ensure resident dignity was maintained, and failed to safeguard clinical information for two of 29 residents (Resident (R) #187, and Resident (R) #201). R#187 & R#201 had Swallow Precautions and diet instructions posted on the wall behind their beds. The findings included: Review of the facility's Quality of Life - Dignity policy revised (MONTH) 09 noted Residents shall be treated with dignity and respect at all times. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth .Staff shall maintain an environment in which confidential clinical information is protected. 1. Review of R#187's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed R#187 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Brief Interview for Mental Status (BIMS) score, R#187 was severely cognitively impaired, scoring 5 out of 15 on the assessment. There were no signs of depression, and no maladaptive behaviors noted on the assessment. R#187 required extensive assistance of two staff for bed mobility and transfers; extensive assistance of one staff for dressing and eating; and total assistance of one staff for toileting and bathing. According to Section K of the MDS, R#187 was 62 inches tall and weighed 150 pounds. She received some nutrition via a feeding tube, and had a mechanically altered and therapeutic diet. R#187 had No loss of liquids/solids from mouth when eating or drinking; no holding food in mouth/cheeks or residual food in mouth after meals; no coughing or choking during meals or when swallowing medications; and no complaints of difficulty or pain when swallowing. During the assessment period, R#187 had Speech Therapy, Respiratory Therapy, and passive Range of Motion (ROM) Restorative Therapy. Review of R#187's care plan dated 3/10/17 addressed R#187's self-care deficits. Interventions included: 1) assisting/cueing/reinforcing R#187 to perform bed mobility skills using side rails to roll from side to side in bed with assistance; 2) motivate and encourage by praising effort, not just success; 3) position and reposition R#187 in bed for comfort, joint support and skin integrity/pressure relief. Continued review of the care plan revealed the potential for Activities of Daily Living (ADL) self-care performance deficits. Interventions included: 1) R#187 is totally dependent on staff for repositioning and turning in bed; 2) dress daily in appropriate clothing daily (sic); 3) R#187 requires staff participation to dress-resident totally dependent on staff with dressing. The care plan did not address eating or swallowing precautions. Review of the R#187's clinical record revealed a physician's orders [REDACTED]. Observations on 7/25/17 at 9:30 a.m., inside R#187's bedroom revealed a sign titled Swallow Precautions was posted on the wall above R#187's head of bed. Observations on 7/26/17 at 9:21 a.m. inside R#187's room revealed the posting remained on the wall above R#187's headboard, and noted the following: Swallowing precautions - 5/23/17 - Recommendation - pureed diet and thin liquids - supervision during all oral intake/sit up with hips flexed at 90 degrees for all oral intake/take small bites and sips/ at least 2 swallows per bite of food and sip of liquid/alternate bites of solid with sips of liquid - resident may have pureed texture and thin liquids with CNA (certified nursing assistant) staff or family. 2. Review of R#201's clinical record revealed R#201 was admitted into the facility on [DATE] and re-admitted on [DATE]. R#201's Admission MDS dated [DATE] listed [DIAGNOSES REDACTED]. R#201's BIMS score was 9 out of 15, which indicated moderate cognitive impairment. R#201 required the total assistance of two staff for bed mobility, and transfers; and total assistance of one staff for dressing, eating, toileting, hygiene and bathing. Section K of the assessment noted R#201 had complaints of difficulty or pain when swallowing. R#201 measured 64 inches tall, weighed 122 pounds during the assessment period, and received a mechanically altered diet. Section V (Care Area Assessment Summary) of the MDS noted that Nutritional Status triggered as a care area for care planning. The triggering conditions were as follows: [MEDICATION NAME]/IV feeding while not a resident & mechanically altered diet while a resident. The analysis of R#201's nutritional status noted this care area as an Actual need/problem. Review of R#201's care plan dated 7/1/17 revealed the resident did not have a plan of care to address his nutritional status. Observations on 7/26/17 at 2:20 p.m. in R#201's room revealed R#201 was in bed lying on his right side. On the wall above his headboard was a sign posted which read: Swallow precautions - dated 7/6/17 - pureed diet, honey consistency/sit up with hips flexed at 90 degrees for all oral intake/ take small bites and sips/ no straws/no thin liquid/no ice chips/crush medication/alternate bites of solid with sips of liquid/check for pocketing. Interview on 7/26/17 at 3:36 p.m. with Certified Nursing Aide (CNA) JJ in the hallway of R#201's room revealed R#201 required total assistance from staff for feeding. CNA JJ stated R#201 did pretty well with eating in the evening time. CNA JJ said the swallow precautions posting above R#201's bed was there to provide staff with information regarding feeding R#201. CNA JJ stated R#201's roommate sometimes had visitors in their room, and the sign was visible to anyone who entered the room. During an interview on 7/27/17 at 9:17 a.m. with the facility's Director of Nursing (DON) in the common sitting area of R #187's hallway, the DON confirmed the swallow precaution posting above R#201's beds should not be there as it was a dignity and privacy issue. The DON stated that information should be listed in the CNA care tracking kiosks, and also in the resident's nursing care plan; however, the residents' personal clinical care information should not be posted in the residents' rooms. Interview on 7/27/17 at 11:07 a.m. with CNA KK in the hallway of R#201's room revealed the aide worked with both R#187 and R#201. CNA KK stated she referred to the swallow precautions posting above the residents' beds for guidance in feeding the residents. CNA KK did not recall any swallowing precaution information being listed in the CNA care tracking kiosks; only above the residents' beds.", "filedate": "2020-09-01"}
{"rowid": 1684, "facility_name": "WESTBURY CONYERS, LLC", "facility_id": 115469, "address": "1420 MILSTEAD ROAD", "city": "CONYERS", "state": "GA", "zip": 30012, "inspection_date": "2017-07-27", "deficiency_tag": 279, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "DRP811", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, clinical record review and review of facility policy titled Care Plans - Comprehensive , the facility failed to ensure a nutrition care plan was developed for one of 29 residents (Resident (R)#201). Upon admission, R#201 was assessed as requiring a nutrition care plan, and facility staff failed to develop the plan of care. The findings included: Review of the facility's Care Plans - Comprehensive policy revised (MONTH) 2010 noted The comprehensive care plan is based on a thorough assessment that includes, but is not limited to the MDS (Minimum Data Set). Each resident's comprehensive care plan is designed to: a. Incorporate identified problem areas; b. Incorporate risk factors associated with identified problems; c. Build on the resident's strengths; Reflect the resident's expressed wishes regarding care and treatment goals; e. Reflect treatment goals, timetables and objectives in measurable outcomes; f. Identify the professional services that are responsible for each element of care; g. Aid in preventing or reducing declines in the resident's functional status and/or functional levels; h. Enhance the optimal functioning of the resident by focusing on a rehabilitative program; and i. Reflect currently recognized standards of practice for problem areas and conditions. Areas of concern that are triggered during the resident assessment are evaluated using specific assessment tools (including Care Area Assessments) before interventions are added to the care plan. Review of R#201's clinical record revealed R#201 was admitted into the facility on [DATE] and re-admitted on [DATE]. R#201's admission Mininum Data Set ((MDS) dated [DATE] listed [DIAGNOSES REDACTED]. R#201's BIMS score was 9 out of 15, which indicated moderate cognitive impairment. R#201 required the total assistance of two staff for bed mobility, and transfers; and total assistance of one staff for dressing, eating, toileting, hygiene and bathing. Section K of the assessment noted R#201 had complaints of difficulty or pain when swallowing. R#201 measured 64 inches tall, weighed 122 pounds during the assessment period, and received a mechanically altered diet. R#201 received [MEDICAL TREATMENT] services while a resident. Section V (Care Area Assessment Summary) of the MDS noted that Nutritional Status triggered as a care area for care planning. The triggering conditions were as follows: [MEDICATION NAME]/IV feeding while not a resident & mechanically altered diet while a resident. The analysis of R#201's of the nutritional status noted this care area as an Actual need/problem. Review of R#201's Registered Dietician (RD) Admission Nutritional assessment dated [DATE] revealed the resident weighed 124 pounds (#) at a height of 64 inches, and received a pureed diet with honey thick liquids. R#201 had his own teeth, and was totally dependent on staff for meals. R#201 noted with a 15-20# weight loss in the last month. Hospital weight noted at 154 #. Current weight is 30# less than hospital weight. Review of R#201's weight records revealed the following: 7/6/17 - 124# 7/10/17 - 122# 7/18/17 - 108# 7/25/17 - 98.5# Review of R#201's Dietary Manager Nutrition Summary dated 7/19/17, revealed R#201 was at risk for weight loss due to fluctuating intake. Review of R#201's meal intake record from 7/13/17 through 7/25/17 revealed R#201 ate between zero- 25 percent (%) for 20 meals; ate between 26%-50% for seven meals; ate between 51% - 75% for four meals; and refused to eat for one meal. Review of R#201's care plan dated 7/1/17 revealed the resident had pressure ulcers, and one of the interventions to address the pressure ulcers was the use of dietary supplements. Further review of the care plan revealed R#201 did not have a care plan to address the potential for and recent weight loss, swallowing precautions, fluctuating meal intake, and alteration in nutritional status. Observations on 7/26/17 at 2:20 p.m. in R#201's room revealed R#201 was in bed lying on his right side. On the wall above his headboard was a sign posted which read: Swallow precautions - dated 7/6/17 - pureed diet, honey consistency/sit up with hips flexed at 90 degrees for all oral intake/ take small bites and sips/ no straws/no thin liquid/no ice chips/crush medication/alternate bites of solid with sips of liquid/check for pocketing. Interview on 7/26/17 at 3:19 p.m. with the facility's Assistant Director of Nursing (ADON) revealed the MDS nurse or Dietary Manager (DM) were responsible for developing residents' nutrition care plans. The ADON confirmed R#201 received [MEDICAL TREATMENT] services, and had the potential for weight loss. The ADON stated nutrition should be a part of the residents' plan of care. Interview on 7/26/17 at 3:36 p.m. with Certified Nursing Assistant (CNA) JJ revealed R#201 required total assistance from staff for feeding. CNA JJ stated R#201 ate pretty well in the evening time. During an interview on 7/26/17 at 4:03 p.m. with the MDS Coordinator, the nurse said R#201 did not trigger for a nutrition care plan upon admission and that was the reason one was not developed. Any nutrition/weight issues, the MDS Coordinator incorporated into the [MEDICAL TREATMENT] care plan. The MDS Coordinator stated she was not aware of R#201's weight loss and not aware of the implemented swallowing precautions. She said she usually receives a copy of recommendations regarding swallowing precautions from Speech Therapy, and from the recommendations develops a plan of care. The MDS Coordinator confirmed the nutrition care plan was not developed and should have been. Interview on 7/27/17 at 9:17 a.m. with the facility's Director of Nursing (DON) revealed interventions to address R#201's nutritional status had been implemented; however, a care plan detailing the care R#201 received was not in place. The DON confirmed R#201 should have a nutrition care plan in place.", "filedate": "2020-09-01"}
{"rowid": 1685, "facility_name": "WESTBURY CONYERS, LLC", "facility_id": 115469, "address": "1420 MILSTEAD ROAD", "city": "CONYERS", "state": "GA", "zip": 30012, "inspection_date": "2017-07-27", "deficiency_tag": 319, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "DRP811", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and clinical record review, the facility failed to provide psychological services to one resident (Resident (R) #118) of 29 sampled residents. R#118 had a [DIAGNOSES REDACTED]. The findings included: Review of the clinical record for R#118 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed R#118 had a Brief Interview for Mental Status (BIMS) score of 13, which indicted intact cognition. The MDS recorded that R#118 had no mood or behavior symptoms, and received an anti-depressant for the seven days prior to the assessment. Review of the Care Area Assessment (CAA) for the admission MDS dated [DATE] revealed psychosocial well-being, mood state, and behavioral symptoms did not trigger for care plan development. Review of the care plan dated [DATE] revealed a problem identified with the use of anti-anxiety and anti-depressant medication. Interventions included monitoring for signs and symptoms of mood changes and depression, and symptoms of adverse side effects of the medication. Additional interventions included administering the medication as ordered and educating R#118 and family of the risk and benefits of the medication. Physician orders [REDACTED]. There were no medicines ordered for [MEDICAL CONDITION] or [MEDICAL CONDITION] disorder. The clinical record included a physician order [REDACTED]. There was no evidence in the clinical record of a psychological (psych) evaluation having been completed as ordered. Observation of R#118 on [DATE] at 3:52 p.m. in her room revealed her sitting on the side of the bed and she stated she did not want to talk because she was watching a movie. Observation of R#118 on [DATE] at 8:55 a.m. in her room revealed her to be lying in bed and she stated she did not want to talk because she was not feeling well and just wanted to see the nurse. Interview with Social Services (SS) DD on [DATE] at 3:15 p.m. at the nurse station revealed she could not find any documentation in R#118 clinical record that a psych evaluation had been completed. She also revealed the resident was not receiving any psych services. Observation of R#118 on [DATE] at 4:08 p.m. in the hall revealed her to be self-propelling a wheelchair towards her room. She stated she was getting supplies for her roommate but when she got back to her room it would be a good time to talk. Interview with R#118 in her room on [DATE] at 4:15 p.m. revealed she has lived in the facility for three months. She stated she was previously living in a homeless shelter after her fiance died . She further revealed that she was [MEDICAL CONDITION] and had not been able to afford her medications so she had gone without them for several weeks. As a result, she had a [MEDICAL CONDITION] and fell which is why she ended up in the facility. She stated her mood is going up and down and she really needs to be back on her medicine. R#118 stated, The doctor ordered a psych evaluation for me before giving me the medication but I haven't seen anyone yet. Interview with Licensed Practical Nurse (LPN) GG on [DATE] at 4:24 p.m. at the medication cart revealed R#118 is usually easy to get along with unless she wants medication. If she gets anxiety medication and pain medication at the same time, then she just sleeps. LPN GG stated she thought the doctor wanted to have a psych evaluation done but she was not aware if it had been completed. Interview with the Director of Nursing (DON) on [DATE] at 4:30 p.m. at the nurse station revealed R#118 does have a [DIAGNOSES REDACTED]. She stated that the facility would not necessarily have to get a psych evaluation and if she had been in the facility on [DATE], she would have left a note in the clinical record for the doctor to tell him she did not need a psych evaluation. Interview with Physician FF on [DATE] at 5:12 p.m. in the dietary office revealed he ordered a psych evaluation on R#118 because she was a new resident for him. He stated the history is sometimes difficult to obtain from residents but she had a [DIAGNOSES REDACTED]. He further stated he was not aware that the evaluation was not completed because he never received any recommendations. Interview with Registered Nurse (RN) EE Unit Manager on [DATE] at 10:08 a.m. at the nurse station revealed an order for [REDACTED]. RN EE stated, the order for the psych evaluation for R#118 dated [DATE] should have been called to the psych service utilized by the facility but, I don't know what happened. RN EE stated they usually work in conjunction with Social Services because they schedule the appointments. Interview with SS CC and SS DD on [DATE] at 10:47 a.m. in their office revealed the nursing staff will contact them when a consult is ordered and they make the referral. They both stated they were not made aware of the order in (MONTH) (YEAR) for a psych evaluation for R#118. Interview with Certified Nursing Assistant (CNA) BB on [DATE] at 10:59 a.m. in the hall revealed she has a good relationship with R#118. R#118 is usually happy and likes to help the other residents. Sometimes she stays in bed all day, which is rare for her, but she has pain and swelling in her legs. CNA BB stated, I usually tell the nurse when she does not want to get up. CNA BB revealed R#118 does not have any aggressive behaviors and she thinks R#118 likes living in the facility. Interview with the DON on [DATE] at 11:30 a.m. in her office revealed she does not have a written policy or procedure to verify that physician orders [REDACTED]. She further revealed that she was on vacation during the time in (MONTH) (YEAR) when the order for a psych evaluation for R#118 was missed.", "filedate": "2020-09-01"}
{"rowid": 1686, "facility_name": "WESTBURY CONYERS, LLC", "facility_id": 115469, "address": "1420 MILSTEAD ROAD", "city": "CONYERS", "state": "GA", "zip": 30012, "inspection_date": "2017-07-27", "deficiency_tag": 441, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "DRP811", "inspection_text": "Based on observations, interviews, clinical record review, and review of facility policy, the facility failed to prevent potential cross contamination for 30 residents in the main dining room during meal time; and for three of 29 sampled residents (Residents (R)#93, R#137, R#17). The findings included: Review of the facility's policy Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices dated (MONTH) 2008 noted the following: Employees must wash their hands: a. After personal body functions (i.e., toileting, blowing/wiping nose, coughing, sneezing, etc.); .h. After engaging in other activities that contaminate the hands. Review of the facility's policy Handwashing/Hand Hygiene revised (MONTH) 2012 noted: Employees must wash hands for at least fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: .c. Before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice); .g. Before and after assisting a resident with meals; .s. After handling soiled equipment or utensils. 1. Observation on 7/24/17 at 12:09 p.m. in the facility's main dining room revealed two Dietary Aides (DA) served beverages of water and tea to 30 residents. Observation on 7/24/17 at 12:17 p.m. in the facility's main dining room revealed the system the DAs used for serving the residents was as follows: DAs picked up resident diet cards which were lying on the dining table in front of the residents. The DAs then took the cards to the serving line and retrieved resident plates as indicated on their diet cards. While serving the plates, and providing meal set-up, the DAs touched eating surfaces of the plates, and moved/touched resident cups from which the residents had already drank. After serving a resident, the DAs went to the next resident to retrieve their diet card, and performed the same tasks. The DAs used no hand hygiene in between serving the 30 residents, picking up diet cards, touching eating surfaces, and moving resident beverages. Observation on 7/24/17 at 12:21 p.m. in the facility's main dining room revealed DA LL washed her hands, retrieved a paper towel and began to dry her hands. DA LL then used the paper towel to wipe her face, and then continued to dry her hands with the same paper towel. At 7/24/17 at 12:26 p.m., DA LL held a cup of coffee in her hand to serve to a resident. With the cup of coffee in one hand, DA LL used the other hand to move a yellow caution sign out of her walking path. The DA served the resident the coffee, and then went back to the serving line to continue serving the residents their meals. DA LL performed no hand hygiene before going back to the serving line. Interview on 7/24/17 at 12:35 p.m. with DA LL confirmed the system used on this date to serve the residents was the system the facility used every day. DA LL said the DAs did not perform hand hygiene in between picking up diet cards, serving residents, and touching cups. DA LL said that residents have often touched their diet cards and drinking cups before they are served their meals, and said there was a possibility for cross contamination. When asked about hand hygiene after drying her hands with the paper towel used to wipe her face, and after moving the yellow caution sign, DA LL stated she did not realize she did not clean her hands after those acts, and said she should have. During an interview on 7/24/17 at 12:45 p.m. with the facility's Dietary Manager (DM), the DM confirmed the system to serve residents in main dining room. The DM said staff were to hold plates underneath the plate, and hold cups at the bottom away from the eating and drinking surfaces. The DM said she had not realized before today the possibility for cross contamination, but confirmed there should be hand hygiene in between serving. The DM stated hand washing should have occurred after moving the yellow caution sign and after the DA wiped her face with the paper towel. 2. Observation on 7/24/17 at 1:05 p.m. in the dining room of the Secure Unit revealed Licensed Practical Nurse (LPN) NN fed Resident (R) #93. When R#93 spit food out LPN NN placed her hands over her nose and mouth, turned her head then turned back to face the resident with her hands covering her face. LPN NN then picked up the eating utensil and began feeding R#93 again without sanitizing her hands. Further observation in the same dining room revealed LPN NN stopped feeding R#93 and without sanitizing her hands began assisting R#137 who was coughing. LPN NN rubbed R#137 on the back then returned to feeding R#93 without sanitizing her hands between resident contacts. During interview on 7/25/17 at 8:57 a.m. on the Terrace Unit, LPN NN reported she forgot to use the sanitizer between resident contacts because she was trying to help R#137. LPN NN acknowledged she assisted several residents to eat yesterday, touched her face and resident's bodies and did not use sanitizer or wash her hands between residents. During interview on 7/27/17 at 11:05 a.m. in the conference room, the Director of Nursing (DON) reported she did not expect staff to use sanitizer after touching their face or their person while feeding a resident unless staff had some sort of bodily fluid discharge. She did acknowledge staff should have sanitized their hands between resident to resident contact and prior to feeding a resident. 3. During an interview with R#17 in her room on 7/25/17 at 8:15 a.m., an observation was made of Certified Nursing Assistant (CNA) AA delivering a breakfast tray and setting it on the bedside table. CNA AA proceeded to pick up a portion of biscuit with her bare hands and spread jelly on the surface. After picking up the remaining portion of biscuit with her bare hands and placing jelly on the surface, the CNA left the room. Interview with CNA AA on 7/25/17 at 8:30 a.m. in the hall confirmed she was touching resident food with her bare hands and stated she knew that gloves should have been worn. CNA AA stated, I have gloves in my pocket but didn't use them. Interview with the DON in the conference room on 7/27/17 at 11:00 a.m. confirmed staff are to use utensils to handle resident food and not their bare hands.", "filedate": "2020-09-01"}
{"rowid": 3459, "facility_name": "ROCKDALE HEALTHCARE CENTER", "facility_id": 115670, "address": "1510 RENIASSANCE DRIVE", "city": "CONYERS", "state": "GA", "zip": 30012, "inspection_date": "2016-10-13", "deficiency_tag": 282, "scope_severity": "G", "complaint": 0, "standard": 1, "eventid": "PYE811", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, it was determined the facility failed to follow pain management in accordance with the care plan interventions for 1 of 28 sampled residents (R) (R#38). Specifically, the pain medication [MEDICATION NAME] was ordered on [DATE] to be administered twice daily for [MEDICAL CONDITION] pain and was not made available to R#38 until 10/5/16, 14 days after the medication was prescribed. This failure caused the resident to experience pain and actual harm when R#38 revealed in an interview on 10/10/16 at 11:58 a.m. that there was nothing that eased her [MEDICAL CONDITION] pain in her left leg while she waited 2 weeks before receiving [MEDICATION NAME]. Refer F309). Findings include: An interview with R#38 on 10/10/16 at 11:58 a.m. revealed the resident was admitted to the facility with orders for [MEDICATION NAME] and it was two weeks before she got the [MEDICATION NAME] because the medication never came in. R#38 said that she was in pain (while waiting for the [MEDICATION NAME]) and there was nothing that eased the pain of [MEDICAL CONDITION] in her left leg. Additionally, R#38 stated that the facility has been out of [MEDICATION NAME] this week. R#38 said that her pain level has been between 6 and 8 (on a scale of 0-10, with 10 being most severe) for 4 days without [MEDICATION NAME]. R#38 said that she told the medication nurse and the charge nurse but no [MEDICATION NAME] was administered to her. Health record review for R#38 revealed the resident was admitted to the facility on [DATE] for rehabilitation therapy following hip joint replacement surgery. Review of the care plan for R#38 dated 9/30/16 revealed a plan with the focus of: Resident is on pain medication therapy related to status [REDACTED]. Interventions to address R#38's pain included to: administer medication as ordered. Review of the physician's orders [REDACTED]. [MEDICATION NAME] Tablet 7.5/325 mg ([MEDICATION NAME]/[MEDICATION NAME]) 2 tablets every 4 hours as needed for pain (left hip replacement) [MEDICATION NAME] Capsule 100 milligrams (mg) by two times a day for [MEDICAL CONDITION] pain Tylenol tablet 325 mg 1 tablet every 6 hours as needed for pain. The facility was unable to provide documentation that R #38 received pain medication for complaints of mild to moderate pain on the following dates: 9/22/16, 9/28/16, 9/30/16, 10/1/16, 10/1/16 and 10/2/16. A review of the (MONTH) Electronic Medication Administration Record [REDACTED] Review of the Medication Error Report dated 10/5/16 revealed the facility failed to obtain a written prescription for [MEDICATION NAME] Capsules until 10/5/16. [MEDICATION NAME] was not administered to R#38 despite the signatures of nurses on 6 occasions because the medication was not available in the facility. Interview with the Unit Manager (UM) 10/13/2016 at 10:39 a.m. revealed when the nurses asked R#38 if there was pain during the medication passes, R#38 said no. R#38's score was 0 when asked each shift after 10/8/16. That is what the nurses documented. R#38 never requested anything for pain to the UM's knowledge. If the resident did not report to the nurse of having pain, the resident would not receive any pain medication. The UM was unable to explain the lack of documentation of administration of pain medication on the dates the resident complained of mild to moderate pain. The facility failed to follow R#38 care plan interventions to address her post-surgical hip pain and [MEDICAL CONDITION] pain.", "filedate": "2020-09-01"}
{"rowid": 3460, "facility_name": "ROCKDALE HEALTHCARE CENTER", "facility_id": 115670, "address": "1510 RENIASSANCE DRIVE", "city": "CONYERS", "state": "GA", "zip": 30012, "inspection_date": "2016-10-13", "deficiency_tag": 309, "scope_severity": "G", "complaint": 0, "standard": 1, "eventid": "PYE811", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews, it was determined the facility failed to provide prescribed medications to ensure adequate pain management for 1 of 28 sampled residents (R) (R#38), that experienced mild to severe pain after hip replacement surgery. The inadequate management of R#38's pain medication regime that included [MEDICATION NAME], Tylenol and [MEDICATION NAME] caused the resident to experience pain, causing actual harm identified to have existed beginning on 9/22/2016. Findings include: Health record review for R#38 revealed the resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] for R#38 indicated her Brief Interview for Mental Status (BIMS) summary score was 8, indicating moderate cognitive impairment. According to the MDS, R#38 was assessed to have pain frequently during the last five days. R#38's reported her pain level was 5 on a scale of 0-10, with 10 being most severe. Review of the physician's orders [REDACTED]. [MEDICATION NAME] Tablet ([MEDICATION NAME]/[MEDICATION NAME]) 7.5/325 milligrams (mg) take two tablets by mouth (PO) every four hours as needed (PRN) for pain (left hip replacement). Tylenol tablet 325 mg give one PO every six hours PRN for pain. [MEDICATION NAME] Capsule 100 mg PO two times a day for [MEDICAL CONDITION] (nerve damage that may cause numbness or pain and weakness). [MEDICATION NAME] Capsule 25 mg ([MEDICATION NAME] Potassium- anti-[MEDICAL CONDITION]) give one capsule PO four times a day related to presence of unspecified artificial hip joint. Review of the E-MAR (Electronic Medication Administration Record) documentation of [MEDICATION NAME] administration for 9/21/16 through 9/30/16 and 10/1/16 through 10/5/16 revealed the [MEDICATION NAME] was signed off by nurses as administered on six (6) occasions: 9/21/16 at 9:00 a.m. 9/25/16 at 9:00 a.m. 9/26/16 at 9:00 a.m. 9/27/16 at 5:00 p.m. 9/29/16 at 9:00 a.m. 9/30/16 at 9:00 a.m. The [MEDICATION NAME] was not signed off as given for the remaining 22 dosing opportunities from 9/21/16 through 10/5/16. Review of the Medication Error Report dated 10/5/16 revealed the facility failed to obtain a written prescription for [MEDICATION NAME] capsules until 10/5/16. [MEDICATION NAME] was not administered to R#38 despite the signatures of nurses on six occasions because the medication was not available in the facility. Review of the E-MAR documentation for [MEDICATION NAME] from 9/21/16 thru 9/30/16 and 10/1/16 thru 10/8/16 revealed the [MEDICATION NAME] was administered as needed (prn) on the following dates/times: 9/23/16 at 7:47 p.m. for pain level of 5 (moderate), 9/24/16 at 4 p.m. for a pain level of 10 (excruciating), 9/25/16 at 3:32 a.m. for a pain level of 7 (moderate) 9/26/16 at 12:48 p.m. for a pain level of 10 (excruciating). 10/5/16 at 4:16 p.m. for a pain level of 6 (moderate). Review of the Controlled Substances Proof of Use forms dated 9/28/16 documents that 18 tablets of [MEDICATION NAME] 7.5/325 were dispensed on 9/28/16. R#38 received the medication on the following dates/times: 10/3/16 at 10:00 a.m., 10/3/16 at 7:00 a.m. 10/4/16 at 1:00 p.m., 10/4/16 at 7:00 p.m. 10/5/16 at 5:00 p.m., 10/5/16 at 11:00 p.m. 10/7/16 at 3:00 a.m. 10/7/16 at 7:00 a.m. 10/8/16 at 3 a.m. The last dose was given on 10/8/16 for a total of 18 tablets given to R#38. There was no record of the [MEDICATION NAME] doses recorded on the Controlled Substances Proof of Use form on the MAR indicated [REDACTED]. Review of the E-MAR for 9/21/16 thru 9/30/16 revealed the Tylenol was administered on the following dates: 9/21/16 for mild pain and 9/27/16 for unspecified pain level. There is no documentation on the MAR indicated [REDACTED]. Review of the E-MAR for 9/21/16 through 9/26/16 revealed that [MEDICATION NAME] ([MEDICATION NAME]) was administered to R#38 on two occasions (9/22/16 at 5:00 p.m. and 9/22/16 at 9:00 p.m.). Review of the pain assessments for R#38 on the E-MAR revealed the following: 9/22/16 at 7 a.m. - reports mild pain - (no documented pain medication) 9/23/16 at 7a.m. - reports mild pain - (no documented pain medication) 9/24/16 at 7 a.m. - reports mild pain - (no documented pain medication) 9/25/16 at 3 p.m. - reports mild pain - (no documented pain medication) 9/28/16 at 7 a.m. - reports moderate pain. - (no documented pain medication) 9/28/16 at 3 p.m. - reports moderate pain- (no documented pain medication) 9/30/16 at 7 a.m. - reports mild pain - (no documented pain medication) 10/1/16 at 7 a.m. - reports moderate pain - (no documented pain medication) 10/1/16 at 3 p.m. and 11 p.m. - reports mild pain - (no documented pain medication) 10/2/16 at 7 a.m. - reports moderate pain- (no documented pain medication) 10/5/16 at 7 a.m. - reports moderate pain - (no documented pain medication) 10/8/16 at 3 p.m. - reports mild pain- (no documented pain medication). On 9/28/16, 10/1/16, 10/2/16 and 10/5/16, R#38 complained of moderate pain and the facility failed to provide the prescribed pain medication to alleviate the resident's complaints of pain. Interview with R#38 on 10/10/16 at 11:58 a.m. revealed that when she was admitted into the facility there were orders for [MEDICATION NAME]. R#38 said that it was two weeks before she got the [MEDICATION NAME] because the medication never came in. R#38 said that she was in pain while waiting for the [MEDICATION NAME] and there was nothing that eased the pain of [MEDICAL CONDITION] in her left leg. Additionally, R#38 stated the facility has been out of [MEDICATION NAME] this week. R#38 said that her pain level has been between six and eight for four days without [MEDICATION NAME]. R#38 said that she told the medication nurse and the charge nurse that she had pain but no [MEDICATION NAME] was administered to her. R#38 stated that she is being discharged to home today with only Tylenol, no [MEDICATION NAME]. During the interview with R#38 on 10/10/16 at 12:07 p.m. the Rehabilitation Director entered the room to say goodbye to R#38. The resident informed the Rehabilitation Director that her pain level was a six. The Rehabilitation Director stated that she would check with the nurse to determine whether the resident could get medication for pain before leaving today. Continued interview with R#38 on 10/10/16 at 12:08 p.m. revealed that there was a delay in receipt of some of her other medications at the facility at the beginning of her stay on 9/21/16. The resident stated she is having pain now in left hip surgical area. Observation and interview with Unit Manager (UM) and R#38 on 10/10/2016 at 12:14 p.m. revealed The UM stated R#38's pain medication ([MEDICATION NAME]) is available today in the Pyxis Medication System. The UM said that R#38 was given [MEDICATION NAME] and a muscle relaxer this morning. R#38 replied to the UM that she was in pain today and the [MEDICATION NAME] was not made available to her. The UM stated if R#38 did not ask for the [MEDICATION NAME] it would not be given to her. The [MEDICATION NAME] is in the Pyxis. R#38 replied that she had asked for [MEDICATION NAME] for the past four days and was told it was not available. R#38 requested a [MEDICATION NAME], now. The resident stated that she is in pain now and would like a [MEDICATION NAME]. UM stated that she would get the resident something for pain, now. During an interview on 10/10/2016 12:40 p.m. the Administrator stated that R#38 would be given medication for pain right away. Observed on 10/10/16 at 12:43 p.m , revealed R#38 receive two [MEDICATION NAME] for pain from the medication nurse prior to exiting the facility. On 10/13/2016 at 10:39 a.m. an interview with the UM revealed the [MEDICATION NAME] was en route from the pharmacy and not available on 10/10/16. The UM explained that when the nurses asked R#38 if she had pain during the medication passes the resident said, no. The resident's pain score was 0 when she was asked each shift after 10/8/16. That is what the nurses documented in the E-MAR. R#38 never requested anything for pain to the UM's knowledge. If the resident did not report to the nurse that she was having pain she would not receive any pain medication. The facility did not provide documentation of the Pyxis dose of [MEDICATION NAME] given to the resident on 10/10/16 prior to discharge. An additional interview with the UM on 10/13/16 at 10:55 a.m. revealed the hospital did not send a paper prescription for the [MEDICATION NAME] when R#38 was discharged from the hospital to the facility. The hospital discharge orders came with the resident but not the paper prescription on 10/5/15 when the omission was identified. The facility staff called the pharmacy and the physician to get the prescription. The UM further stated the nurses may not have realized that the [MEDICATION NAME] was the same as the [MEDICATION NAME] and did not give the [MEDICATION NAME] until they realized it was the correct medication. Interview with the Administrator on 10/13/2016 at 2:16 p.m. revealed that the facility does not have a Medication Administration Policy. The staff follow medication administration protocols but there is no policy. The medication administration protocols were not provided during the survey. The facility failed to provide the prescribed scheduled and PRN pain medications to effectively manage R#38 ' s pain during her rehabilitation stay at the facility.", "filedate": "2020-09-01"}
{"rowid": 3461, "facility_name": "ROCKDALE HEALTHCARE CENTER", "facility_id": 115670, "address": "1510 RENIASSANCE DRIVE", "city": "CONYERS", "state": "GA", "zip": 30012, "inspection_date": "2016-10-13", "deficiency_tag": 514, "scope_severity": "G", "complaint": 0, "standard": 1, "eventid": "PYE811", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview it was determined the facility failed to accurately document the administration of pain medication for one resident (R) (R#38) that experienced mild to severe pain after hip replacement surgery. The sample was 28 residents. (This standard is cited at harm level. Refer F309). The findings include: Record review revealed R#38 was admitted into the facility for rehabilitation therapy on 9/21/16. A review of the physician's orders [REDACTED]. A review of R#38's (MONTH) (YEAR) Electronic Medication Administration Record [REDACTED]. The facility was unable to provide documentation that R#38 resident received pain medication following the reports of pain. A review of the resident's E-MARs and pain assessment for the month of (MONTH) (YEAR) revealed R#38 complained of mild to moderate pain on the following dates 10/1/16 and 10/2/16. The facility was unable to provide documentation that R#38 received pain medication at the time resident complained of pain. Further review of the (MONTH) (YEAR) E-MAR also revealed the facility staff documented R#38 received [MEDICATION NAME] capsules on the following dates: 9/21/16, 9/25/16, 9/26/16, 9/27/16, 9/29/16, and 9/30/16 at 9:00 a.m. Review of the Medication Error Report dated 10/5/16 revealed the facility did not receive the [MEDICATION NAME] capsules for R#38 until 10/5/16. The [MEDICATION NAME] medication was not administered to R#38 despite the signatures of nurses on six occasions because the medication was not available in the facility. The facility conducted in-services and disciplinary action was taken to address this deficient practice. Interview with the Unit Manager (UM) on 10/13/16 at 10:55 a.m. revealed at the time of the R #38's discharge from the hospital on [DATE] the staff failed to obtain a written order from the facility physician for the resident's [MEDICATION NAME] and notify the pharmacy of the order until 10/5/16. The facility failed to maintain accurate documentation of the administration of the [MEDICATION NAME] and [MEDICATION NAME] medications for R#38.", "filedate": "2020-09-01"}
{"rowid": 3462, "facility_name": "ROCKDALE HEALTHCARE CENTER", "facility_id": 115670, "address": "1510 RENIASSANCE DRIVE", "city": "CONYERS", "state": "GA", "zip": 30012, "inspection_date": "2018-10-18", "deficiency_tag": 656, "scope_severity": "D", "complaint": 1, "standard": 1, "eventid": "WJ7611", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of records and staff interview, it was determined that the facility failed to follow the plan of care related to activities of daily living (ADL) for two residents R#6 related to assistance with bed mobility and R#20 due to unkept nails, of 25 sampled residents. Findings include: Review of the clinical records for Resident (R) #20 revealed she was admitted on [DATE] and has current [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS) assessment records for the resident revealed the most recent assessment to be an Annual MDS assessment dated [DATE] revealed that R#20 was assessed as needing extensive assistance with bed mobility, dressing, toilet use, and personal hygiene and total assistance with transfers. The resident was also assessed as needing the assistance of two plus people with bed mobility, transfers, and toilet use. Under the Care Area Assessment Summary of this assessment and the previous comprehensive MDS assessment of 8/14/17, ADLs triggered and the decision was made to complete a plan of care for that area. A review of the plan of care for R#20 revealed a plan of care in place since 8/28/17 for ADL/Self-care deficit revealed the resident needs two staff participation in toilet use, transfer, and bed mobility. A review of the facility incident report dated 5/11/18 and last revised 5/22/18 revealed that on 5/11/18 at 10:00 p.m., the charge nurse observed R#20 on the floor in her room with a Certified Nursing Assistant (CNA) at her side. The resident was assessed and assisted back to bed by two members of staff using the Hoyer lift. A review of the 200-hall assignment sheet of 5/11/18 revealed that CNA EE was assigned responsibility for caring for the residents in a block of rooms which included the room belonging to R#20. The assignment sheet also documented that a fall had occurred on CNA EE's shift. A review of an undated written statement by CNA EE revealed that she was in the room belonging to R#20 between 9:30 p.m. and 10:00 p.m. on the night of the incident, and was getting ready to change her. The CNA further reported that she went to the closet to get a brief, and while at the closet, she observed the resident's left leg sliding over the other. The CNA hurriedly went to the resident's assistance, but by the time she arrived at the bedside, the resident's legs were both over the side of the bed, the resident was holding on to the side rail which made it difficult for the CNA to return her legs to the bed. The CNA said she felt that the best thing to do at that point was to brace her fall because she was too heavy for me to help back on the bed. She used the bed sheet to help lower the resident to the floor before calling the nurse. Review of the facility's documented investigation of the incident, including a completed Continuous Quality Improvement form dated 5/14/18 revealed the facility determined that the CNA was providing care to the resident in the absence of other staff and the resident fell when the CNA left the resident unattended in bed while she went to the closet to retrieve a brief. The final determination was that the fall was a result of staff not following P[NAME] with bed mobility. The facility's proposed solution was ongoing education to staff including care plan training and Kardex system training beginning in orientation. An interview on 10/17/18 at 3:50 p.m. the with the Director of Nursing (DON) and the Assistant DON revealed the Continuous Quality Improvement (CQI) form is used after an incident to determine what were the contributing factors and what are the corrective actions to be taken. The CQI completed ,after this incident, documented what the facility felt contributed to the incident where R#20 sustained a fall and the actions they needed to take to avoid a repeat of the incident. In this case, it was determined that the CNA should not have been providing care to R#20 on her own and should have had at least two staff assisting the resident. It was also determined that the CNA needed to be educated related to how to determine the care needs of the residents. CNA EE was new at the time of the incident and it was determined that the first step in education should be limited to her. However, it was also determined that other staff would later receive reeducation on accessing information related to the needs of residents in their care. The CNA was no longer employed at the facility. A review of the facility records revealed documentation that CNA EE received education from the ADON on 5/14/18 related to: the importance of checking to see what level of assistance (1 or 2 staff) each resident required; the importance of following the plan of care to ensure safety during resident care; and the importance of not positioning a resident and leaving that resident to gather more supplies. 2. Review of clinical record for R#6 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 00, which indicated severe cognitive impairment. Section G revealed resident requires extensive assistance with dressing, toileting and personal hygiene. Review of the care plan initiated on 4/10/18 and revised on 10/12/18, revealed resident has Activities of Daily Living (ADL) self care performance deficit related to [MEDICAL CONDITIONS] with right arm weakness, right elbow contracture and left leg weakness. Interventions to care include resident requires total dependence for personal care hygiene. Observation on 10/16/18 at 11:07 a.m., 10/17/18 at 9:26 a.m. and 10/18/18 at 10:48 a.m. revealed resident with long nails with brown substance underneath them on both hands. Interview on 10/17/18 at 9:37 a.m., with Certified Nursing Assistant (CNA) GG stated that for ADL care, she bathes residents on their bath days, she gets them up, dresses them, brushes their teeth, brushes hair, shaves residents if they need it and also stated that she does nail care on bath days, unless they need it more often. She stated that she did not notice R#6 with dirty fingernails today. Interview on 10/18/18 at 10:10 a.m. Licensed Practical Nurse (LPN) Unit Manager HH, stated her expectation is staff provide care as per orders and/or care plan. ADL care consists of nail care and should be done on bath days, but can be and should be done more often, if needed. She further stated she encourages charge nurses to assist CNA's with persuading residents to accept care. Verified R#6 nails were long and dirty with brown material underneath. Interview on 10/18/18 at 3:05 p.m., with Director of Nursing (DON), stated it is her expectation that staff follow the care plan as written pertaining to all aspects of care, including nail care. She further stated that if the CNA's need help with ADL care, they should be getting help from their Charge Nurse and their Unit Manager. DON stated the facility did not have a policy for nail care. Cross refer F677", "filedate": "2020-09-01"}
{"rowid": 3463, "facility_name": "ROCKDALE HEALTHCARE CENTER", "facility_id": 115670, "address": "1510 RENIASSANCE DRIVE", "city": "CONYERS", "state": "GA", "zip": 30012, "inspection_date": "2018-10-18", "deficiency_tag": 677, "scope_severity": "D", "complaint": 1, "standard": 1, "eventid": "WJ7611", "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 one dependent residents (R) R#6 related to nail care. The sample size was 25. Findings include: A review of the clinical record for R #6 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 00, which indicated severe cognitive impairment. Section G revealed resident requires extensive assistance with dressing, toileting and personal hygiene. Observation on 10/16/18 at 11:07 a.m., 10/17/18 at 9:26 a.m. and 10/18/18 at 10:48 a.m. revealed resident with long nails with brown substance underneath them on both hands. Interview on 10/17/18 at 9:37 a.m., with Certified Nursing Assistant (CNA) GG stated she gets her assignment from the charge nurse as to which residents need a bath. She stated that for ADL care, she bathes residents on their bath days, she gets them up, dresses them, brushes their teeth, brushes hair, shaves residents if they need it and also stated that she does nail care on bath days, unless they need it more often. She stated that she did not notice resident with dirty fingernails today. Interview on 10/18/18 at 10:10 a.m. Licensed Practical Nurse (LPN) Unit Manager HH, stated her expectation is staff should be attempting daily to provide care as per orders and/or care plan. ADL care consists nail care and should be done on bath days, but can be and should be done more often, if needed. She further stated she encourages charge nurses to assist CNA's with persuading residents to accept care. Verified R#6 nails were long and dirty with brown material underneath. An interview on 10/18/18 at 3:05 p.m. with Director of Nursing (DON), stated it is her expectation that staff follow the care plan as written pertaining to all aspects of care, including nail care. She further stated that if the CNA's need help with ADL care, they should be getting help from their Charge Nurse and their Unit Manager. The DON further revealed that the facility did not have a policy for nail care.", "filedate": "2020-09-01"}
{"rowid": 3464, "facility_name": "ROCKDALE HEALTHCARE CENTER", "facility_id": 115670, "address": "1510 RENIASSANCE DRIVE", "city": "CONYERS", "state": "GA", "zip": 30012, "inspection_date": "2018-10-18", "deficiency_tag": 689, "scope_severity": "D", "complaint": 1, "standard": 1, "eventid": "WJ7611", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility records, policies, and staff interviews, it was determined that the facility failed to provide the level of assistance required during Activities of Daily Living (ADL) care resulting in a fall for one resident (R#20) of 25 sampled residents. Findings include: Review of the clinical records for Resident (R)#20 revealed she was admitted on [DATE] and has current [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS) assessment records for the resident revealed the most recent assessment to be an annual MDS assessment of 8/9/18 in which she was assessed as needing extensive assistance with bed mobility, dressing, toilet use, and personal hygiene and total assistance with transfers. The resident was also assessed as needing the assistance of two plus people with bed mobility, transfers, and toilet use. The resident's need for the assistance of two plus persons for bed mobility, transfers, and toilet use on the most recent assessment did not represent a change from quarterly MDS assessments completed on 2/12/18 and 5/13/18 and the last comprehensive assessment of 8/14/17. A review of the electronic medical record (EMR) of the Resident Detail or Kardex report for 5/11/18 revealed R#20 was totally dependent on staff for turning and repositioning in bed and required the assistance of two members of staff to reposition and turn in bed. A review of the facility incident report dated 5/11/18 and last revised 5/22/18 revealed that on 5/11/18 at 10:00 p.m., the charge nurse observed R#20 on the floor in her room with a Certified Nursing Assistant (CNA) at her side. The resident was assessed and assisted back to bed by two members of staff using the Hoyer lift. A review of the 200-hall assignment sheet of 5/11/18 revealed that CNA EE was assigned responsibility for caring for the residents in a block of rooms which included the room belonging to R#20 at the time of the resident's fall. The assignment sheet also documented that a fall had occurred on the shift. A review of an undated written statement by CNA EE revealed that she was in the room of R#20 between 9:30 p.m. and 10:00 p.m., on the night of the incident, and was getting ready to change her. The CNA further reported that she went to the closet to get a brief, and while at the closet, she observed the resident's left leg sliding over the other. The CNA hurriedly went to the resident's assistance, but by the time she arrived at the bedside, the resident's legs were both over the side of the bed, the resident was holding on to the side rail which made it difficult for the CNA to return her legs to the bed. The CNA said she felt that the best thing to do at that point was to brace her fall because the resident was too heavy for me to help back on the bed. She used the bed sheet to help lower the resident to the floor before calling the nurse. Observation of the room of R#20 on 10/17/18 at 10:05 a.m. revealed the closet was located about three feet from the foot of the resident's bed. Review of a written statement by Licensed Practical Nurse (LPN) BB revealed that when she arrived for her shift on 5/12/18 she was notified that resident #20 had sustained a fall the night before. Review of the facility's documented investigation of the incident, including a completed Continuous Quality Improvement form dated 5/14/18 revealed the facility determined that the CNA was providing care to the resident in the absence of other staff and the resident fell when the CNA left the resident unattended in bed while she went to the closet to retrieve a brief. The final determination was that the fall was a result of staff not following care plan for bed mobility. The facility's proposed solution was ongoing education to staff including care plan training and Kardex system training beginning in orientation. An interview on 10/17/18 at 10:13 a.m. with CNA AA and LPN AA revealed that CNA AA has worked with the facility and has cared for R#20 for more than two years. LPN AA said the CNAs are made aware of the care needs of residents in staff meetings and via the electronic Kardex system. R#20 needs total assistance with bed mobility, transfers, and ADLs; the resident does not go to the bathroom. She is incontinent and wears briefs or uses a bed pan. At least two members of staff are required to assist her with bed mobility, transfers, and other ADLs such as changing. CNA AA further revealed that there has been no change in the level of care the resident needs, to her knowledge. The resident has always needed the assistance of at least two members of staff for these needs. An interview on 10/17/18 at 11:25 a.m. with LPN BB revealed she was the nurse on the 7:00 a.m. to 3:00 p.m. shift on 5/12/18. At the start of her shift, that day, she recalls receiving a report from the nurse on the previous shift that R#20 had fallen the night before. This nurse said she has worked with the resident off and on since the resident was admitted , but has been assigned to the resident's hall for about two years. The resident needs total assistance from at least two members of staff with ADLs, including bed mobility, changing and transferring. These needs have not changed since the resident was first admitted . During changing, the staff are to have both side rails up. At least two staff are to turn her on her side and cross her legs so that she does not roll back onto her back. LPN BB said the nurses learn about residents' care needs from the clinical records and pass this information on to the CNAs during briefings held at the start of each shift. An interview on 10/17/18 at 3:50 p.m. the with the Director of Nursing (DON) and Assistant DON (ADON) revealed the Continuous Quality Improvement (CQI) form is used after an incident to determine what were the contributing factors and what are the corrective actions that to be taken. The CQI completed after this incident documented what the facility felt contributed to the incident where R#20 sustained a fall and the actions they needed to take to avoid a repeat of the incident. In this case, it was determined that the CNA should not have been providing care to R#20 on her own. It was also determined that the CNA needed to be educated related to how to determine the care needs of the residents. CNA EE was new at the time of the incident and it was determined that the first step in education should be limited to her. However, it was also determined that other staff would later receive reeducation on accessing information related to the needs of residents in their care. The CNA was no longer employed at the facility. A review of the facility records revealed documentation that CNA EE received education by the ADON on 5/14/18 related to: the importance of checking to see what level of assistance (1 or 2 staff) each resident required; the importance of following the plan of care to ensure safety during resident care; and the importance of not positioning a resident and leaving that resident to gather more supplies. A review of the education records revealed a sign-in sheet dated 5/24/18 which documented that 12 members of the nursing staff received training on Location and utilization of Kardex, ADL's, and Lifting. This included the CNA EE. Interview on 10/18/18 at 11:36 a.m. with the staff educator revealed that the CNAs receive at least one day of classroom training and three days of hands-on training during orientation. During the classroom training, they are trained in policies/procedures and learn what education they are required to complete. Then, the new CNA is sent to the floor for three days to work with a more seasoned CN[NAME] The nurse educator checks in with the new CNA and her more seasoned CNA partner during those three days to ensure the CNA is receiving instruction in all needed areas. During that time, the nurse educator uses a checklist to ensure that the CNA has received instruction and can demonstrate skill in areas such as feeding a resident, taking vital signs, and emptying a catheter bag. During these four days of orientation, the CNA is taught how to access the electronic care plan system she/he will need to use to provide care for the resident. This electronic system contains the Kardex system which documents the level/type of care each resident needs, and the documentation system in which the CNAs document that the care has been done. Review of the training record for CNA EE revealed she completed the following training prior to the incident on 5/11/18: assisting patient in/out of bathroom; skin check; emptying urinary bag; feeding; hand washing; measuring blood pressure; measuring pulse and respiration; performing oral care; perineal care; protective devices; resident safe transfer and lifting; transfer patient to wheelchair and transport; and urinal care. There was no record of the CNA completing training on the Kardex system or how to use the system for determining the residents' care needs.", "filedate": "2020-09-01"}
{"rowid": 4745, "facility_name": "WESTBURY CONYERS, LLC", "facility_id": 115469, "address": "1420 MILSTEAD ROAD", "city": "CONYERS", "state": "GA", "zip": 30012, "inspection_date": "2015-12-03", "deficiency_tag": 282, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "N6HI11", "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 follow the care plan related to providing Range of Motion (ROM) for one (1) resident (Q), and failed to follow the care plan related to provision of mouth care as needed for one (1) resident (J). The sample size was thirty-six (36) residents. Findings include: During observation on 11/30/2015 at 3:02 p.m., resident Q was observed to have contractures to the fingers of their right hand, and bilateral knees. Review of resident Q's Quarterly Minimum Data Set ((MDS) dated [DATE] noted that they had no cognitive deficits, and were receiving restorative nursing services for active range of motion (AROM) six days a week. Review of the resident's Restorative Care Plan for Active Assisted Range of Motion (AAROM) noted that the resident had impaired functional joint mobility, and interventions included to provide AAROM on the right upper extremity six times weekly. During interview with resident Q on 12/02/2015 at 10:30 a.m., they stated that ROM had not been done for over three weeks. During interview on 12/03/2015 at 4:18 p.m., resident Q stated that staff still had not done ROM for him/her that day. During observation on 12/04/2015 at 1:09 p.m., Restorative Certified Nursing Assistant (RCNA) AA was asked to perform the restorative services that she normally provided for resident Q. During observation at this time, the RCNA had resident Q do AROM with a weight to their left arm, and AROM without a weight to the right arm. During further observation, the RCNA then applied a splint to the resident's right hand, without doing ROM to the contracted fingers. During an observation on 12/02/2015 at 11:15 a.m. resident J was in a hospital bed with the head of the bed (HOB) elevated 45 degrees. The gastrostomy tube ([DEVICE]) feeding via pump, continuous feedings with no sign or symptoms of distress or discomfort. The resident responds with yes / no and thumbs up to simple questions. The resident has a sour body odor,the neck area is visually moist, and his teeth are dry, and have a buildup of material between, front and back of his teeth. During an interview at this time resident J indicated no, when asked if the staff brushed his teeth. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] for resident J on 12/03/2015 9:00 a.m. revealed the MDS Personal Hygiene section indicated Total Dependence. Further review of the clinical record for resident J revealed a Careplan for Oral/Dental Health Problems indicating that the resident needs assistance with oral care with interventions that included to provide mouth care as needed. Review of the Dynamic Mobil Dentistry visit for resident J on 11/6/2015 revealed that the resident was assessed for red inflamed tissue, heavy calculus, plaque, and food debris in the teeth. During an observation on 12/02/2015 at 4:34 p.m. with CNA EE to provide oral care with swab, EE opened the swab, pushed the swab into a small bottle of mouth wash then proceeded with oral care. EE instructed the resident to open his mouth and explained he was going to clean his teeth. The resident followed commands as requested by employee. The resident kept his mouth open, but face grimaced during the oral care. Two (2) chunks of white material approximately half the size of a dime were removed with swab and placed on bath cloth that was placed on the residents chest during oral care. The tongue was cleaned during oral care on resident J, but white build up remained as well as white build up on both upper and lower teeth following oral care. During an interview on 12/03/2015 at 8:50 a.m. with CNA EE, he revealed that a damp swab with a mixture of tooth paste and mouth wash is used for oral care on resident J. CNA EE further revealed that the resident is Nothing by Mouth (NPO) and he does not want to gag the resident during mouth care. CNA EE also revealed that he is unable to visually see the resident's teeth at times because resident J does not open his mouth and will clamp his teeth together. During an observation on 12/03/2015 at 8:41 a.m. resident J noted lying with the HOB elevated 45 degrees, [DEVICE] feeding via pump running, eyes and mouth closed, face and neck were moist, and a sour body odor noted. The resident aroused with verbal stimuli, teeth exposed, and white build up noted on both upper and lower teeth. During an observation on 12/03/2015 at 3:15 p.m. resident J was observed in bed alert, continues to respond to simple questions with physical and verbal gestures. Teeth noted with buildup, and white secretions. During an observation on 12/04/2015 at 9:57 a.m. resident J observed up in wheel chair (w/c) in the day room attending activities while sitting at the end of the table. Yellow frothy foaming from the mouth was observed and the teeth were noted to be yellow with build up on and between the teeth. Cross-refer to F318 and F312.", "filedate": "2019-07-01"}
{"rowid": 4746, "facility_name": "WESTBURY CONYERS, LLC", "facility_id": 115469, "address": "1420 MILSTEAD ROAD", "city": "CONYERS", "state": "GA", "zip": 30012, "inspection_date": "2015-12-03", "deficiency_tag": 312, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "N6HI11", "inspection_text": "Based on observations and resident interview the facility failed to consistently provide Activities of Daily Living (ADL) for one (1) resident (J) who was totally dependent on staff for oral hygiene from a sample of thirty six (36) residents. Findings include: Review of the Quarterly Minimum Data Set (MDS) assessment for resident J dated 9/25/2015 on 12/03/2015 9:00 a.m. revealed that the resident was assessed as being totally dependent with Personal Hygiene. Review of record for resident J revealed a careplan for oral/dental health problems indicating resident needs assistance with oral care with intervention to provide mouth care as needed. During an observations on 12/02/2015 11:15 a.m.,12/02/2015 4:34 p.m., 12/03/2015 8:41 a.m., 12/03/2015 3:15 p.m., 12/04/2015 9:57 a.m. revealed visible build up on teeth and tongue. During an interview on 12/02/2015 11:15 a.m. resident J indicated No when ask if the staff brushed his teeth. During an interview with the Director of Nursing (DON) on 12/4/2015 at 2:30 p.m. the DON provided surveyor a copy of the facilities mouth care policy, and resident (J's) care plan. The DON was informed the resident stated mouth care was not being provided. Reviewed the Dental Mobile Dentistry report dated 11-6-2015 that states soft tissure red and inflamed with heavy build up. The DON confirmed understanding of the complaint, surveyors observations, and the report from the dentist.", "filedate": "2019-07-01"}
{"rowid": 4747, "facility_name": "WESTBURY CONYERS, LLC", "facility_id": 115469, "address": "1420 MILSTEAD ROAD", "city": "CONYERS", "state": "GA", "zip": 30012, "inspection_date": "2015-12-03", "deficiency_tag": 318, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "N6HI11", "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 consistently provide range of motion (ROM) and splinting as ordered for one (1) resident (Q). The sample size was thirty-six (36) residents. Findings include: During observation on 11/30/2015 at 3:02 p.m., resident Q was observed to have contractures to the fingers of their right hand, and bilateral knees. During further observation, a splint device was noted on the resident's nightstand, but none seen on his/her right hand. During interview with resident Q at this time, they stated that they could apply the splint to their hand, but that it was easier if staff did it, and that the splint had not been on at all that day. Review of resident Q's Quarterly Minimum Data Set ((MDS) dated [DATE] noted that they had no cognitive deficits, and were receiving restorative nursing services for active range of motion (AROM) six days a week, and splint application seven days a week. Review of the resident's Restorative Care Plan for Active Assisted Range of Motion (AAROM) noted that the resident had impaired functional joint mobility, and interventions included to provide AAROM on the right upper extremity six times weekly. Further review of the care plans revealed a care plan for use of a right hand C-bar splint to minimize the risk for further contracture. Review of physician's orders [REDACTED]. Review of a Restorative Progress Note dated 11/27/2015 at 9:15 a.m. revealed that the resident was able to participate in AROM exercises to upper extremities in all planes with assistance from RNA (Restorative Nursing Aide) 6 times weekly. Following exercises RNA assists resident with applying right hand C-bar splint, splint is applied prior to lunch and removed at dinner each day. During observation on 12/02/2015 at 10:30 a.m., a splint was noted on resident Q's nightstand. During interview with the resident at this time, they stated that ROM had not been done for over three weeks. During observation and interview on 12/02/2015 at 2:45 p.m., a splint was observed to the resident's right hand, and the resident stated that staff had exercised his/her arms and legs before applying it. During interview with resident Q on 12/03/2015 at 8:05 a.m., he/she stated that the splint was usually applied in the afternoon, and the splint was observed on the nightstand at this time. During observation on 12/03/2015 at 12:35 p.m., the resident was eating lunch, and there was no splint on the right hand. During observation on 12/03/2015 at 3:12 p.m., the resident was observed in bed with the splint on the nightstand. During interview at this time, resident Q stated the splint had not been applied yet that day and they had not received any ROM, and that he/she would apply the splint themself. During interview on 12/03/2015 at 4:18 p.m., resident Q stated that staff still had not done ROM for him/her. During interview with Restorative Certified Nursing Assistant (RCNA) AA on 12/04/2015 at 9:02 a.m., she stated that she could look in the computer to see which residents needed restorative services, and that she documented the treatments she did in the computer. During further interview, RCNA AA stated that resident Q was ordered to have AROM and splint to their right hand six times a week. During review of her computerized documentation at this time, RCNA AA showed documentation that on 12/03/15 at 12:02 p.m. and 12:11 p.m., 15 minutes of ROM was done and 460 minutes of splint assist done (note the observations and interview above on 12/03/2015 at 12:35 p.m., 3:12 p.m., and 4:18 p.m. that ROM and splint application had not been done by staff). Review of a Restorative report for the amount of minutes spent providing splint or brace assistance on 11/30/2015 at 2:17 p.m. noted 460. (note above that per observation and interview on 11/30/2015 at 3:02 p.m., the splint was not on). On 12/04/2015 at 1:09 p.m., RCNA AA was asked to perform the restorative services that she normally provided for resident Q. During observation at this time, the RCNA had resident Q do AROM with a weight to their left arm, and AROM without a weight to the right arm. During further observation, the RCNA then applied a splint to the resident's right hand, without doing ROM to the contracted fingers.", "filedate": "2019-07-01"}
{"rowid": 4748, "facility_name": "WESTBURY CONYERS, LLC", "facility_id": 115469, "address": "1420 MILSTEAD ROAD", "city": "CONYERS", "state": "GA", "zip": 30012, "inspection_date": "2015-12-03", "deficiency_tag": 323, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "N6HI11", "inspection_text": "Based on observation and staff interview, it was determined that the facility failed to ensure that two (2) toilet extenders and five (5) ceiling lights were maintained in a safe manner on three (3) of eight (8) halls. Findings include: On 11/30/2015 at 3:20 p.m., the toilet extender in the adjoining bathroom for rooms 49 and 51 was observed to be wobbly. Three of the four legs did not have rubber end covers which made the legs shorter and prevented contact with the floor. During an interview with the Administrator on 11/30/2015 at 4:20 p.m., he confirmed the toilet extender was wobbly. Interview with Certified Nursing Assistant (CNA) HH on 12/4/2015 at 10:00 a.m., revealed that one of the four residents (#108) in the two rooms toileted himself/herself. During observation in resident #134's room on 12/01/2015 at 8:28 a.m., the plastic commode seat of the toilet extender was noted to be split from the back of the seat all the way to the front, except for an approximate one-inch section at the front holding the two sections together. During further observation, the commode seat was beginning to spread apart, with almost no separation near the piece holding the sections together at the front of the seat, to an approximate 0.25-inch gap at the back of the commode seat. This was verified during interview with Licensed Practical Nurse (LPN) BB at this time, who had Maintenance remove the toilet extender right away. During further interview with LPN BB at this time, she stated that resident #134 was able to independently ambulate and use the bathroom. During observation of the facility on 12/4/2015 at 1:00 p.m. it was revealed in the room of resident #80 on the secure unit ceiling light had a broken cover. Further observations revealed that three (3) lights in the activity room on the C unit also had broken light covers and the group area on A hall had one (1) ceiling light that was broken. An interview on 12/4/2015 at 3:00 pm with the Maintenance Director regarding the ceiling lights with broken and or missing covers and the over toilet chair confirmed the above findings. The Maintenance Director replaced the over the toilet seat, and located light covers to complete the repairs to the observed lights.", "filedate": "2019-07-01"}
{"rowid": 5826, "facility_name": "WESTBURY CONYERS, LLC", "facility_id": 115469, "address": "1420 MILSTEAD ROAD", "city": "CONYERS", "state": "GA", "zip": 30012, "inspection_date": "2015-01-15", "deficiency_tag": 247, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "2C2411", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interview, the facility failed to provide documentation that one (1) resident (Q) was notified prior to getting a new roommate on three (3) different occasions. The sample size was twenty-nine (29) residents. Findings include: Interview with resident Q on 01/12/15 at 3:17 p.m., he/she revealed that since they had been admitted to the facility, they have had several different roommates, and was not told beforehand that he/she was getting one. Upon further interview, resident Q revealed that one day he/she was out of their room visiting with a family member, and when they came back to their room, a new roommate had been admitted to their room. Review of resident Q's clinical record revealed that he/she was admitted to the facility on [DATE]. Review of the most recent Quarterly Minimum (MDS) data set [DATE] revealed that he/she had no cognitive deficits. Interview with the Social Services Director (SSD) on 01/15/15 at 8:48 a.m., revealed that either herself or the nurse would tell a resident when they were getting a new roommate. Upon further interview, she stated that they did this as soon as they knew, but sometimes in an emergency it may be at the time of the move. Continued interview revealed that she documented resident notification of new roommates in the Interdisciplinary Progress Notes (IPN) in the resident's clinical record. Review of a list provided by the Admissions Director revealed that three residents had been admitted to resident Q's room on 10/23/14, 11/11/14, and 01/03/15. Review of the IPN for those dates revealed no mention that resident Q had been notified that they would be receiving a new roommate. Interview with the SSD on 01/15/15 at 11:42 a.m., revealed that she would not have made an entry in the IPN in resident Q's clinical record about the three new roommates, as she only notified residents of room to room transfers, and these three residents were new admissions. During interview with Admissions Director at this time, she stated that she verbally told a resident when they were getting a new roommate, but this was not documented anywhere. Interview with Unit Manager GG on 01/15/15 at 11:57 a.m., she stated that nursing may, but it was not their primary responsibility, to notify a resident when they were going to get a new roommate. Upon further interview, she verified that there was no documentation in the clinical record that resident Q was notified that he/she was getting a new roommate on 10/23/14, 11/11/14, or 01/03/15. Review of the facility's Room Change/Roommate Assignment policy and procedure revealed the following: Prior to changing a room or roommate assignment all parties involved in the change/assignment (e.g., residents or their representatives (sponsors)) will be given an advance notice of such change. The notice of a change in room or roommate assignment may be oral or in writing.", "filedate": "2018-05-01"}
{"rowid": 5827, "facility_name": "WESTBURY CONYERS, LLC", "facility_id": 115469, "address": "1420 MILSTEAD ROAD", "city": "CONYERS", "state": "GA", "zip": 30012, "inspection_date": "2015-01-15", "deficiency_tag": 279, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "2C2411", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop a comprehensive care plan for anticoagulant use for one (1) resident (#103), who had been on [MEDICATION NAME] therapy since September of 2014. The sample size was twenty-nine (29) residents. Findings include: Review of the clinical record for resident #103 revealed that they had a [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] and the most recent Quarterly MDS assessment dated [DATE] revealed that resident #103 received an anticoagulant all seven days of the assessment period. Review of the active clinical record revealed that no care plan was developed for the anticoagulant use. Interview with the Case Mix Director HH on 01/14/15 at 1:49 p.m., she stated that they usually develop an anticoagulant care plan for residents on [MEDICATION NAME] therapy, and verified that resident #103 did not have one in their active clinical record. Interview with the Director of Nursing on 01/14/15 at 1:57 p.m. revealed that an Acute Care Plan dated 09/02/14 for Anticoagulant Therapy was located in the resident's overflow clinical record in the Medical Records department, but she would have to ask the MDS staff if a comprehensive care plan for anticoagulant use should be developed.", "filedate": "2018-05-01"}
{"rowid": 5828, "facility_name": "WESTBURY CONYERS, LLC", "facility_id": 115469, "address": "1420 MILSTEAD ROAD", "city": "CONYERS", "state": "GA", "zip": 30012, "inspection_date": "2015-01-15", "deficiency_tag": 280, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "2C2411", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to integrate the hospice care plan with the facility care plan to show coordination of care for one (1) resident (#36) receiving hospice services. The sample size was twenty-nine (29) residents. Findings include: Review of the Physician order [REDACTED]. Review of a Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed that she was under Hospice care. Review of the comprehensive care plan revealed that a care plan for admission to hospice services had been developed on 11/07/14. However, review of the remainder of the resident's twenty comprehensive care plans revealed that there was no integration or mention of hospice into any of the interventions to reflect the care and services which the facility and hospice would provide in order to be responsive to the needs of this hospice resident. Interview with Case Mix Director HH on 01/14/15 at 1:35 p.m., she stated that a copy of the care plan calendar was given to the hospice providers, so they could attend the care plan meeting if they were able to. During interview with the MDS staff at this time II stated that they generally integrated hospice services into the facility care plan, and JJ revealed that she had developed a separate hospice care plan for resident #36, but she did not integrate the hospice and facility care plans to reflect coordination of care. Interview with Unit Manager GG on 01/15/15 at 12:15 p.m., she stated that the only people signed in on the Care Plan Conference Sheet for resident #36 dated 10/24/14 were facility staff, with no hospice staff in attendance. Review of the Brightmoor Hospice Nursing Facility Hospice Services Agreement, Plan of Care section, noted that the Hospice and Nursing Facility will jointly develop and agree upon a coordinated Plan of Care which is consistent with the hospice philosophy and is responsive to the unique needs of the Residential Hospice Patient and his or her expressed desire for hospice care.", "filedate": "2018-05-01"}
{"rowid": 5829, "facility_name": "WESTBURY CONYERS, LLC", "facility_id": 115469, "address": "1420 MILSTEAD ROAD", "city": "CONYERS", "state": "GA", "zip": 30012, "inspection_date": "2015-01-15", "deficiency_tag": 332, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "2C2411", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff and Pharmacist interview, the facility failed to ensure the medication error rate was less than five per cent (5%). There were three (3) errors observed with twenty-seven (27) opportunities by one (1) of four (4) nurses on one (1) of eight (8) halls, for a med error rate of eleven and eleven one-hundreds per cent (11.11%). Findings include: On 01/14/15 at 8:57 a.m., Registered Nurse (RN) AA was observed preparing resident #6's morning medications on the Terrace Unit, and the following concerns were noted: 1. After giving resident #6 the oral inhalation medication, [MEDICATION NAME], RN AA was observed to wait only eight seconds before giving a different oral inhalation medication, [MEDICATION NAME]. After exiting the resident's room at 9:26 a.m., RN AA was asked how long she waited between giving puffs of the [MEDICATION NAME] and [MEDICATION NAME], and she responded a few seconds. 2. RN AA was observed to give resident #6 one tab of Oyster Shell Calcium with Vitamin D. Later review of the physician's orders [REDACTED]. 3. RN AA was observed to give resident #6 one drop to each eye of [MEDICATION NAME] Lubricant eye drops. Later review of the physician's orders [REDACTED]. Interview with RN AA on 01/14/15 at 1:30 p.m., she verified that the eye drops order for resident #6 was for [MEDICATION NAME] Balance solution, and that she gave [MEDICATION NAME] Lubricant eye drops. Upon further interview, she stated the [MEDICATION NAME] must have come from the facility's stock supply, as it did not have a Pharmacy label on it. RN AA verified that the calcium she gave to resident #6 contained Vitamin D, and was unable to locate any Calcium without Vitamin D in her medication cart. Observation of the facility's central medication room on 01/14/15 at 1:47 p.m., revealed the only [MEDICATION NAME] eye drops they stocked was the [MEDICATION NAME] Lubricant; this was verified during interview with Central Supply employee CC. Observation of the Terrace Unit medication room with Central Supply employee CC on 01/14/15 at 2:14 p.m., she pointed out that a bottle of Oyster Shell Calcium without Vitamin D was available for staff to use. Interview with Pharmacist DD on 01/14/15 at 2:05 p.m. revealed that [MEDICATION NAME] Balance eye drops had a higher concentration of the active ingredient than [MEDICATION NAME] Lubricant eye drops, and therefore should not be used interchangeably. Review of the facility's Westbury Senior Care Pharmacy Policies and Procedures noted the following for Oral Inhalation Administration: Wait one (1) to two (2) minutes (after giving an inhaled medication) before administering the next inhaled medication. Interview with the Director of Nursing on 01/14/15 at 3:03 p.m., she stated that nurses should wait three to five minutes between inhaled medications.", "filedate": "2018-05-01"}
{"rowid": 5830, "facility_name": "WESTBURY CONYERS, LLC", "facility_id": 115469, "address": "1420 MILSTEAD ROAD", "city": "CONYERS", "state": "GA", "zip": 30012, "inspection_date": "2015-01-15", "deficiency_tag": 441, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "2C2411", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, Infection Control Policy review and staff interviews the facility failed to use proper hand hygiene and gloving for one (1) resident (#80) on contact isolation with Methicillin Resistant Staphylococcus Aureus (MRSA). The sample size was twenty-nine (29) residents. Findings include: Observation on 01/12/15 12:47 p.m. revealed that Certified Nursing Assistant (CNA) BB distributed a meal tray to resident #80 who was on contact isolation without using gloves or washing her hands. Observation of another CNA on 01/13/15 at 12:30 p.m. revealed that she entered the room of resident #80 who was still on contact isolation without using gloves or washing her hands. The CNA was observed to move items from the resident's bedside table, leave the room, retrieve the meal tray from the cart and assist with set up of the tray. Continued observation revealed that the CNA then left the room, retrieved another tray from the cart and distributed the tray to another resident without washing her hands or using hand sanitizer. Observation on 01/14/15 12:32 p.m. revealed CNA BB distributed a meal tray to resident #80 on contact isolation without putting on gloves or washing her hands. CNA BB was observed leaning on the bed, touching the bed rail, and assisting the resident with tray set up and condiments. CNA BB did wash her hands at the resident's sink before leaving the room. Review of the Physician order [REDACTED].# 80 revealed an order for [REDACTED]. Interview with the Infection Control (IC) Nurse on 01/15/15 at 9:45 a.m. revealed that staff should follow the proper guidelines for a resident on isolation precautions by sanitizing and/or washing hands before and after passing a tray as well as should sanitize before and after leaving the room of a resident on contact isolation. Continued interview revealed that it would depend on what staff are doing for the resident. A gown may be the appropriate personal protective equipment (PPE), especially if the resident is on contact isolation. Interview with CNA BB on 01/15/2015 1:18 p.m. revealed that she should knock before entering a resident's room. She further revealed that she does not have to necessarily gown and glove up when just serving a tray. CNA BB confirmed that she had received hand hygiene and isolation precaution inservices within the last few months. Review of the Hand Washing/ Hand Hygiene Policy revised August 2012 revealed that employees must wash their hands for at least fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: e. Before and after entering isolation precautions settings f. Before and after assisting a resident with meals Review of the Contact Precautions Policy revised August 2012 revealed: c. Gloves and Handwashing (1) In addition to wearing gloves as outlined under Standard Precautions, wear gloves (clean, non sterile) when entering the room. (3) Remove gloves before leaving the room and perform hand hygiene. Further review of the Procedure for Handwashing Policy revealed hands were to be washed (at a minimum): Before and after each resident contact After touching a resident or handling their his or her belongings", "filedate": "2018-05-01"}
{"rowid": 7066, "facility_name": "WESTBURY CONYERS, LLC", "facility_id": 115469, "address": "1420 MILSTEAD ROAD", "city": "CONYERS", "state": "GA", "zip": 30012, "inspection_date": "2013-04-18", "deficiency_tag": 279, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "PSHL11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interviews, the facility failed to develop a plan of care with interventions and goals related to an unstageable pressure ulcer identified on admission for one (1) resident (#155) from a sample of thirty-six (36) residents. Findings: Observation on 4/18/13 at 10:56 a.m. of the dressing change for resident #155 performed by the Licensed Practical Nurse (LPN), Treatment Supervisor and treatment nurse LPN FF revealed an unstageable wound to the left heel. The dressing was removed from the resident's left heel, cleaned with normal saline and a new dressing applied. Review of the medical record revealed Resident #155 was admitted on [DATE] with the Diagnoses: [REDACTED]. Review of the Minimum Data Set (MDS) admission assessment dated [DATE] revealed the resident was assessed with [REDACTED]. Review of the Care Area Assessment Summary (CAAS) revealed that the resident would be care planned for pressure ulcer. Review of the initial nursing skin assessment dated [DATE] revealed a femoral bypass on the left inner foot, a dark area on the ankle, and an ulcer on the left heel. Review of the skin assessment dated [DATE] revealed old surgical scars noted to abdomen, and the left lower leg. The bilateral heels were dry and flaky. The left heel was observed with an open deep tissue injury. Review of Braden Scale for predicting pressure sore risk revealed 3/25/13 = 17 and 4/02/13 = 15. Review of the medical record revealed a care plan initiated and revised on 4/12/13 for the potential for pressure ulcer development related to impaired mobility and [MEDICAL CONDITION]. The goal was for the resident not to develop any pressure ulcer unless clinically unavoidable through next review period with a target date of 7/31/13. There was no evidence that a care plan had been developed to address the unstageable pressure ulcer to the left heel with interventions and goals. Interview on 4/18/13 at 9:49 am with Registered Nurse (RN), Unit Manager EE confirmed the resident does not have a care plan addressing care of the unstageable pressure ulcer of the left heel.", "filedate": "2017-08-01"}
{"rowid": 7067, "facility_name": "WESTBURY CONYERS, LLC", "facility_id": 115469, "address": "1420 MILSTEAD ROAD", "city": "CONYERS", "state": "GA", "zip": 30012, "inspection_date": "2013-04-18", "deficiency_tag": 386, "scope_severity": "B", "complaint": 0, "standard": 1, "eventid": "PSHL11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and record review, the facility failed to ensure that admission orders [REDACTED]#110, #196, # 115, #155, #210) from a sample of thirty-six (36) residents. Findings include: 1. Review of the medical record for resident #210, admitted on [DATE], revealed the physician's admission orders [REDACTED]. Additional physician orders dated from 3/12/13 to 3/28/13 were also not signed by the physician. 2. Review of the medical record for resident #115, admitted on [DATE], revealed the physician's admission orders [REDACTED]. Additional physician's orders dated from 3/21/13 to 3/31/13 for Resident #115 also were not signed. 3. Review of the medical record for resident #155, admitted on [DATE], revealed the physician's admission orders [REDACTED]. Interview on 4/16/13 at 2:17 p.m. with the Director of Nursing, (DON) revealed the expectation was for a physician to sign the orders for a newly admitted or readmitted resident within forty-eight (48) hours to seventy-two (72) hours. 4. Review of admission orders [REDACTED] 5. Review of readmission orders [REDACTED]. 6. Review of admission orders [REDACTED] 7. Review of Physician's order for resident #91 dated 2/1/13 revealed no physician's signature 8. Review of the February, 2013 POF for resident #47 revealed the physician's orders were not signed. Review of the facility Policy and Procedure for Physician Services revealed physician orders and progress notes shall be maintained in accordance with current OBRA regulations and facility policy. Interview with the Director of Nursing on 4/16/13 at 2:17 p.m. revealed the Physician's Order Forms (POFs) should be signed the next time the physician visits. Her expectation is that when the physician comes to see his patient, he should sign that resident's POF at that time. Her expectation also is that when a resident is readmitted , the physician has 48 to 72 hours to see the resident and sign the orders. Her expectation is that the physician should sign all orders from the last POF to the current POF, including verbal/telephone orders. Continued interview revealed the facility has no system in place to ensure that the physicians' orders are signed.", "filedate": "2017-08-01"}
{"rowid": 7068, "facility_name": "WESTBURY CONYERS, LLC", "facility_id": 115469, "address": "1420 MILSTEAD ROAD", "city": "CONYERS", "state": "GA", "zip": 30012, "inspection_date": "2013-04-18", "deficiency_tag": 514, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "PSHL11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interviews, the facility failed to accurately document the treatment for one resident (#126) with a splint device out of a sample of thirty-six (36) residents. Findings: Observation on 4/16/13 at 2:47 p.m., 4/17/13 at 10:13 a.m. and 4/18/13 at 11:53 a.m. revealed Resident #126 lying in her bed with a splint on her right wrist and hand. Review of medical record revealed a physician's orders [REDACTED]. Review of the medical record revealed a physician's ancillary order dated 3/31/13 for nursing restorative as needed per plan of care. The nursing orders were to apply a splint to the hand as ordered. Review of the medical record revealed Resident #126 had a care plan for a splint to the left hand to prevent further contracture. Interview on 4/17/13 at 5:19 p.m. with the Director of Nursing (DON) and Registered Nurse (RN) EE confirmed Resident #126 had a care plan for a hand splint to the left hand Review of the Restorative Nursing Flow Record for March, 2013 and April, 2013 revealed application of a splint to the left (Lt) hand six (6) hours per day.", "filedate": "2017-08-01"}
{"rowid": 8358, "facility_name": "WESTBURY HEALTH & REHABILITATION CENTER - CONYERS", "facility_id": 115469, "address": "1420 MILSTEAD ROAD", "city": "CONYERS", "state": "GA", "zip": 30012, "inspection_date": "2011-11-17", "deficiency_tag": 166, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "O70T11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and resident and staff interviews, the facility failed to ensure that one (1) resident (Z) was made aware of the the progress toward resolution of a grievance from a sample of thirty-five (35) residents. Findings include: Review of the resident care plan dated 8/26/11 and updated 11/15/11 for resident Z revealed the resident was at risk for falls related to impaired mobility and at risk for fractures related to [DIAGNOSES REDACTED]. Goal: resident will not have any falls requiring hospitalization through next review date. Intervention: Take extra caution when transferring resident or assisting with activities of daily living (ADLs). Interview on 11/15/11 at 2:08 p.m. with resident Z revealed that there was an incident with a Certified Nursing Assistant (CNA), when the CNA was rude, a few weeks ago that occurred in the early morning. The CNA was helping the resident to get up out of bed and the resident was holding on to the siderail. The CNA told the resident to stop holding onto the siderail and not to hold onto the CNA either. Resident revealed he/she told the CNA he/she was afraid of falling on the floor without holding onto something because he/she had fallen before at another facility. Continued interview revealed that the resident does not want this CNA around him/her anymore because she would let him/her hit the floor The resident did not know the name of the CNA but would recognize her if she saw her. The resident further revealed that he/she had reported the incident but was not sure who he/she reported to. Interview on 11/15/11 at 2:20 p.m. with Registered Nurse (RN) AA revealed she was aware of the resident's complaint about a CNA and Social Services had met with the resident to discuss it. Review of the Grievance Log dated 10/17/11 completed by Social Services revealed a report was made by Social Services after talking with the resident and the grievance was referred to Nursing and Administration. Review of Grievance report dated 10/18/11 completed by the Director of Nursing (DON) revealed that the resident was on antibiotics for a urinary tract infection [MEDICAL CONDITION] at the time of the report and the resident could not remember the specific date and time of the incident. Report revealed will be alerted to report of incident after antibiotics are completed. If repeats this story, will reinitiate investigative process. Interview on 11/16/11 at 2:19 p.m. with the Director of Nursing (DON), revealed that she investigated the incident and wrote the report. The DON revealed that the resident had a raging UTI at the time of the incident and the DON thought there might be a clinical reason for the resident to be confused. Continued interview revealed that the DON confirmed she did not followup any more and did not write a follow up note because she did not hear any more about the incident. Review of the facility's Policy for Investigating Grievances and/or Complaints. The policy revealed the resident would be informed of the findings of the investigation, as well as any corrective actions recommended, within 5 working days of filing the grievance or complaint. Interview on 11/17/11 at 8:45 a.m. revealed that everything was explained last night regarding transfers from the bed. Resident revealed feeling safer with the lift or something to hold on to and this will be the new plan of care for transfers from bed to/from wheelchair.", "filedate": "2016-02-01"}
{"rowid": 8359, "facility_name": "WESTBURY HEALTH & REHABILITATION CENTER - CONYERS", "facility_id": 115469, "address": "1420 MILSTEAD ROAD", "city": "CONYERS", "state": "GA", "zip": 30012, "inspection_date": "2011-11-17", "deficiency_tag": 241, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "O70T11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and resident and staff interviews, the facility failed to provide care and services in a manner to promote dignity for one (1) resident (Z) from a sample of thirty-five (35) residents. Findings include: Review of medical record revealed resident Z with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed that the resident requires two (2) person assist for transfer to and from bed. Review of care plan dated [DATE] and updated [DATE] revealed resident Z at risk for falls related to impaired mobility and at risk for fractures related to [DIAGNOSES REDACTED]. Goal: resident will not have any falls requiring hospitalization through next review date. Take extra caution when transferring resident or assisting with activities of daily living (ADLs). Interview on [DATE] at 8:45 a.m. with resident Z revealed that not all the facility staff are always helpful and nice. Continued interview revealed that there was an incident when transferring from bed to wheelchair when the staff member spoke rudely to her/him. The resident further acknowledged that he/she is afraid of falling out of bed and likes to hold on when being transferred. The resident further indicated that sometimes he/she feels the staff would not care if he/she died . Interview on [DATE] at 2:08 p.m. with resident Z revealed that the resident did not know the name of the Certified Nursing Assistant (CNA) that was rude, but would recognize the CNA if he/she saw her. Continued interview revealed the incident with the CNA occurred a few weeks ago, in the early morning, as the CNA was helping the resident to get up out of bed. The resident was holding on to the siderail, the CNA told the resident to stop holding onto the siderail and not to hold onto the CNA either. The resident indicated that he/she told the CNA he/she was afraid of falling on the floor without holding onto something because he/she had fallen at another facility. The resident further indicated that he/she did not want this CNA around him/her anymore because he/she was afraid she would let him/her hit the floor. Interview on [DATE] at 2:20 p.m. with Registered Nurse (RN) AA revealed she was aware of resident's complaint about a CNA and Social Services met with the resident to discuss the incident. Interview on [DATE] at 2:19 p.m. with the Director of Nursing (DON) verified that it is a dignity issue when a resident does not feel safe in the facility or is spoken to rudely by any staff member.", "filedate": "2016-02-01"}
{"rowid": 1112, "facility_name": "RIVERSIDE HEALTH CARE CENTER", "facility_id": 115375, "address": "5100 WEST ST NW", "city": "COVINGTON", "state": "GA", "zip": 30014, "inspection_date": "2020-02-13", "deficiency_tag": 584, "scope_severity": "D", "complaint": 1, "standard": 1, "eventid": "W93S11", "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 homelike environment in seven resident rooms with dirty air filters and dirty vents on the heating and air wall units. Findings include: 1. An observation on 2/10/20 at 11:30 a.m. of the air conditioner/heat pump (ac/hp) wall unit in room [ROOM NUMBER] revealed that the ac/hp system had two air filters located in the front that are clogged with thick amount of dust and debris. The outside of the unit revealed the vents were covered with black dirty with debris. 2. An observation on 2/11/20 at 11:20 a.m. observation of the ac/hp wall unit in room [ROOM NUMBER] revealed that unit had two air filters located in the front clogged up with thick amount of grey dust and debris. The outside of the unit revealed the vents were covered with black dirty with debris. An interview on 2/11/20 at 11: 21 a.m. with R#82 revealed that he has never seen anyone from the housekeeping or maintenance department wipe the outside of the ac/hp unit or clean/replace the air filters. 3. An observation on 2/11/20 at 11:22 a.m. of the ac/hp wall unit in room [ROOM NUMBER] revealed that the two air filters located in the front clogged with thick amount of grey dust and debris. The outside of the ac/hp unit revealed the vents were covered with black dirty with debris. Interview on 2/11/2020 at 11:23 p.m. with R#116 revealed that the resident has never seen anyone from housekeeping wipe the outside of the ac/hp unit or clean/replace the air filters. 4. An observation on 2/11/2020 at 11:26 a.m. of the ac/hp wall unit in room [ROOM NUMBER] revealed that the two air filters located in the front clogged with thick amount of dust and debris. The outside of the ac/hp unit was dirty with debris. 5. An observation on 2/11/2020 at 12:00 p.m. of the ac/hp wall unit in room [ROOM NUMBER] revealed thick with dust on the two air filters. 6. An observation on 2/11/2020 at 12:25 p.m. of the ac/hp wall unit in room [ROOM NUMBER] revealed the two air filters are heavy with dust and debris, including black substance in some areas of the vent. 7. An observation on 2/11/2020 at 12:35 p.m. of the ac/hp wall unit in room [ROOM NUMBER] revealed thick dust on the two air filters. Observation and interview on 2/11/2020 at 3:40 p.m. through 4:00 p.m. with the Administrator, Maintenance Supervisor (MS), and Account Manager (AM). The MS revealed his department are responsible for removing all filters from the ac/hp then taking them outside and cleaning them. The MS revealed the air filters should be removed and cleaned at least monthly which is not currently doing. The AM revealed the housekeeping staff are responsible for wiping the outside of the ac/hp units daily. They confirm that the filters and vents are dirty and need to be cleaned and the filters replaced. An interview on 1/13/2020 at 4:01 p.m. with the Administrator revealed the facility does not have a policy on checking and cleaning the filters. Review of the manufacture owner's manual page 14: Care and Cleaning revealed: The most important thing you can do to maintain unit efficiency is to clean the filters once every two weeks as required. Clog filters reduce cooling, heating air flow. Page 15: Ice or frost forms on indoor coil if the filters are dirty.", "filedate": "2020-09-01"}
{"rowid": 1113, "facility_name": "RIVERSIDE HEALTH CARE CENTER", "facility_id": 115375, "address": "5100 WEST ST NW", "city": "COVINGTON", "state": "GA", "zip": 30014, "inspection_date": "2020-02-13", "deficiency_tag": 657, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "W93S11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of policy titled Care Plan Policy, the facility failed to invite one resident, Resident (R) #140, of 43 sampled residents, to participate in the development of her plan of care. Findings include: A review of policy titled Care Plan Policy dated 12/12/2017 revealed Policy Statement: Each resident will have a plan of care to identify problems, needs, and strengths that will identify how the facility staff will provide services to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. Standard of Practice: 3. A baseline plan of care will be developed by the interdisciplinary team (with resident input) for each resident within forty-eight (48) hours of the resident's admission to the facility. The baseline plan of care will consist of information that will provide effective and person-centered care that meets professional standards of quality care. 4. The facility must provide the resident and the representative, if applicable, with a written summary of the baseline care plan by the completion of the comprehensive care plan. The summary must be in a language and conveyed in a manner the resident and/or representative can understand. This summary must include but is not limited to a. The initial goals of the resident, b. A summary of the resident's medications and dietary instructions, c. Any services and treatments to be administered by the facility and personnel acting on behalf of the facility, d. Any updated information based on the details of the comprehensive care plan, as necessary. 11. The resident has the right to participate in the care planning process, including the right to identify individuals or roles to be included in the planning process, the right to request meetings and the right to request revisions to the person-centered plan of care. An interview and observation on 2/11/2020 at 8:39 a.m. with R#140 revealed that no one has approached her about a care plan meeting. The resident stated that she is in her right mind and wants to know about her care at the facility. A review Admission Minimum Data Set (MDS) assessment dated [DATE] for R#140 revealed a Brief Interview for Mental Status (BIMS) of 15 indicating the resident is cognitively intact. Record review revealed the resident was admitted to the facility on [DATE]. Record review revealed that a baseline care plan was completed on the day of admission and a comprehensive care plan was completed between 1/28/2020 and 1/31/2020. A review of the progress notes revealed that a care plan meeting was not held with the resident or that the resident was invited to participate in the development of her care plan. An interview on 2/13/20 at 11:33 a.m. with the Minimum Data Set (MDS) Coordinator CC, MDS Coordinator DD, and Clinical Case Manager (CCM) EE revealed that the Social Worker (SW) invites each resident to their care plan meeting, and communicates to the MDS department, which residents will be attending. They indicated after admission if the resident is receiving skilled care, the initial meeting is held within a few days of admission and they try to complete a progress note on the day of the meeting and include who attended. They further indicated a copy of the care plan is not provided to the resident or family member. Additionally, MDS Coordinator CC reported a care plan meeting had not been held with R#140 because she was not receiving skilled services, and further confirmed she had not met with the resident to review her plan of care. An interview on 2/13/2020 at 12:01 p.m. with the Social Services Director (SSD) revealed that if a resident is not admitted under skilled services, then a care plan meeting will not be scheduled for three months, when the Quarterly MDS assessment is due. An interview on 2/13/2020 at 2:30 p.m. with the Administrator revealed that on admission, they speak with the family and set a delivery of services meeting, the 48-hour care plan meeting. They let the resident know, and start discussing discharge plans and goals, then follow the routine cycle of care plan meetings. She indicated her expectation was to complete this same care planning process for all residents even if not under skilled services. She indicated she expects the MDS department to document these meetings in the progress notes.", "filedate": "2020-09-01"}
{"rowid": 1114, "facility_name": "RIVERSIDE HEALTH CARE CENTER", "facility_id": 115375, "address": "5100 WEST ST NW", "city": "COVINGTON", "state": "GA", "zip": 30014, "inspection_date": "2020-02-13", "deficiency_tag": 688, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "W93S11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to provide rehabilitation equipment in a timely manner to one resident, Resident (R) #96 of 43 sampled residents. Findings include: An interview and observation on 2/10/2020 at 11:19 a.m. with R#96 revealed that she has received therapy quite a few times during her time there. She further indicated her neck has started drawing to her right shoulder and has informed her Physician and therapy is aware. The resident was observed with her head drawing to the right shoulder. Additionally, she reported a neck pillow had been ordered twice, but she has not yet received it. A review of R#96's [DIAGNOSES REDACTED]. Additionally, R#96 underwent neck surgery in (MONTH) 2019. A review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed the following triggered care areas: Activities of Daily Living (ADL) functional/rehab potential, and pain. It further revealed R#96 scored 15 on the Brief Interview for Mental Status (BIMS). A review of the Quarterly MDS assessment dated [DATE] revealed resident requires extensive assistance with transfers, dressing, and toileting, with set up with bathing, and has functional limitation in range of motion (ROM) on one side of her upper extremity. A review of R#96's care plan revealed the following problem areas: 1. Right shoulder contracture and has a problem with her left shoulder rotator cuff. Goal is for the resident to minimize further contraction through next review date. Interventions include; support affected area, keep affected area clean, monitor skin breakdown, assist with ROM as needed, reinforce activities recommended, encourage participation in selfcare as allowed, perform actions to maintain an adequate nutritional status. 2. limited physical mobility related to (r/t) Weakness. Goal is that the resident will demonstrate the appropriate use of adaptive device(s) to increase mobility through the review date. Device: Right ASSIST BAR; Left: none. Intervention: MOBILITY: uses assistive device/enabler for bed mobility and transfers. A review of the Occupational Therapy (OT) Evaluation and Plan of Treatment note dated 8/31/19 revealed under Additional Abilities/Underlying Impairments: Tone and Posture; Posture = Head Forward. Evaluation Summary Components, Physical/Cognitive/Psychosocial Performance: impaired activity tolerance, functional strength, sitting tolerance and pain to surgical site and both shoulders. Self-care assessment score was 25 out of 48. There is no evidence in the evaluation of functional measurements for neck mobility of the resident post neck surgery. A review of OT Treatment Encounter Notes from 8/31/19 to 10/18/19 revealed instructions on cervical precautions for her neck was provided on 9/10/19 and 9/12/19; then on 9/27/19 Activities for midline neck alignment, patient demonstrates increased positioning and ROM; on 9/30/19 patient requires cues for neck positioning tends to position lateral to right, activities for midline; cervical precautions were then instructed on 10/1/19, 10/2/19, and 10/9/19. A review of the OT Discharge Summary dated 10/18/19 revealed her self-care assessment score to be 30 out of 48. There is no evidence of functional measurements for neck mobility for the resident post therapy. An interview on 2/13/2020 at 10:05 a.m. with Certified Occupational Therapy Assistant (COTA) FF, she reported they have seen R#96 multiple times, with the most recent treatment episode following her neck surgery in (MONTH) 2019. She reported the resident had sensory impairment related to the nerve damage in her neck and they worked on ROM for her neck. COTA FF reported after the resident's neck surgery, her neck began drawing to the right and requested an order for [REDACTED]. She indicated this item had not arrived for the resident to date. An interview on 2/13/2020 at 10:25 a.m. with the Director of Rehabilation (DOR) she indicated once she receives an Equipment Request, she sends it to Central Supply and they order the product. She indicated she sent this request to central supply on 10/15/19 and 11/4/19 to Certified Nursing Assistant (CNA) GG in central supply. The DOR indicated she follows up with central supply when ordered items are not received. DOR confirmed the resident had not received the foam cervical collar to date. An interview on 2/13/2020 at 10:49 a.m. with CNA GG revealed that she had placed orders for the sleep right neck pillow prior to 10/15/19. A review of the email string between CNA GG and the DOR, revealed a follow up was requested on 10/15/19. CNA GG replied she had ordered the item but would inquire about it. CNA GG revealed contacting the vendor representative on 10/22/19 who stated the collars were ordered on [DATE] and delivered on 9/9/19. CNA GG confirmed the foam cervical collars had not been received and inquired if the DOR wanted to re-order the items. There is no evidence of the DOR responding to this request in the medical record. A review of the email string revealed no response from the DOR. On 2/13/2020 at 11:06 a.m. CNA GG contacted their vendor representative who confirmed three foam cervical collars were ordered on [DATE] and shipped next day air and delivered on 9/9/19. At this time, CNA GG reordered the cervical collars via phone, and confirmed their method for following up on undelivered items includes a call to the company the item is ordered from. An interview on 2/13/2020 at 2:55 p.m. with the Administrator revealed that she was not aware of the missing collar. She indicated their process for ordering therapy items, is for therapy to notify central supply who places the order. Once the order is received, someone signs for delivery and the appropriate department is notified to pick it up. The Administrator agreed if it was delivered in September, they needed to track where it was. She further indicated the foam cervical collar is not an item that would require a physician's orders [REDACTED]. In an interview on 2/13/2020 at 7:28 p.m. with the DOR revealed that she is responsible for ensuring equipment arrives for a resident including following up on items ordered by the rehab department that have not been delivered. Additionally, the DOR screened the resident on 2/13/2020 at 7:45 p.m. for potential neck contracture and determined the following; Patient head noted in resting position in lateral flexion to right side. Patient able to correct self to mid line. No contracture noted.", "filedate": "2020-09-01"}
{"rowid": 1115, "facility_name": "RIVERSIDE HEALTH CARE CENTER", "facility_id": 115375, "address": "5100 WEST ST NW", "city": "COVINGTON", "state": "GA", "zip": 30014, "inspection_date": "2020-02-13", "deficiency_tag": 761, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "W93S11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews and facility policy titled, Name of Pharmacy Insulin Drug Chart dated (YEAR) and Medication Storage: Storage Medications, the facility failed to ensure that insulin medications are labeled with open and/or expiration dates on two of seven medication carts. Findings include: A review of the Medication Storage: Storage of Medications, number 12 page 2, indicated that Insulin products should be stored in the refrigerator until opened. Note the date for insulin vials and pens when first used. A review of the Pharmacy Name Insulin Drug Chart dated (YEAR), provided by Licensed Practical Nurse (LPN) HH, indicated that the [MEDICATION NAME] R has a shelf-life of 31 days and the [MEDICATION NAME] has a shelf-life of 28 days when outside of refrigerator. Observation and interview on [DATE] at 11:30 a.m. of the Unit one medication cart (A ) revealed the following concern: one opened insulin [MEDICATION NAME] vial, for R#111, with no open nor expired date present. An interview, at this time, with the Licensed Practical Nurse (LPN) HH revealed that this vial should be discarded. An observation and interview of Unit one medication cart (B) on [DATE] at 11:45 a.m. revealed the following: two open insulin vials: (one [MEDICATION NAME] R vial dated as opened on [DATE] and one [MEDICATION NAME] vial dated as opened on [DATE]), both without an expiration dates documented for R#71. An interview, at this time, with LPN HH was conducted that there was no expiration dates listed on these vials and there should have been. A review of the January/February 2020 electronic Medication Administration Record [REDACTED]. An interview on [DATE] at 12:00 p.m. with the Director of Nursing (DON) revealed that all insulins should be dated with an open and an expiration date. She stated that the expiration date should be 28 days after opening for all insulins. A review of the Pharmacy Consultant report, Med Station Review dated [DATE] conducted by the Consultant Pharmacist revealed that on this review docmented under Packaging and Labeling that the Date opened documented where required was assessed as not meet. An additional interview with the DON on [DATE] at 7:45 p.m. revealed that she had not been able to review the Pharmacy Consultant report dated [DATE] yet. She further revealed being behind on review the report.", "filedate": "2020-09-01"}