cms_GA: 4913

In collaboration with The Seattle Times, Big Local News is providing full-text nursing home deficiencies from Centers for Medicare & Medicaid Services (CMS). These files contain the full narrative details of each nursing home deficiency cited regulators. The files include deficiencies from Standard Surveys (routine inspections) and from Complaint Surveys. Complete data begins January 2011 (although some earlier inspections do show up). Individual states are provides as CSV files. A very large (4.5GB) national file is also provided as a zipped archive. New data will be updated on a monthly basis. For additional documentation, please see the README.

This data as json, copyable

rowid facility_name facility_id address city state zip inspection_date deficiency_tag scope_severity complaint standard eventid inspection_text filedate
4913 AUTUMN BREEZE HEALTH AND REHAB 115580 1480 SANDTOWN ROAD SW MARIETTA GA 30008 2015-09-24 520 F 0 1 YH7R12 **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 The DON, ADON and RN Supervisors will audit medication dates to ensure outdated medications will be disposed of properly.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. 2019-04-01