cms_GA
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| Link | rowid | facility_name | facility_id | address ▼ | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2294 | 2294 | SAVANNAH SQUARE HEALTH CENTER | 115546 | 1 SAVANNAH SQUARE DRIVE | SAVANNAH | GA | 31406 | 2016-08-11 | 371 | E | 0 | 1 | X51711 | Based on observation, staff interview, and documentation review the facility failed to ensure opened food items in the walk-in refrigerator were labeled and dated; failed to ensure serving pans were stored dry not wet nested to prevent bacterial growth for two of four days of the survey; failed to ensure mixer was cleaned properly after usage; failed to have male staff working in the kitchen wear hair restraint over facial hair; and failed to ensure fans used in the food preparation area were clean and free from dust/lent. This deficient practice had the potential to effect thirty three (33) residents receiving an oral diet. Findings include: Review of the policy for Food Safety in Receiving and Storage revealed food that is repacked will be placed in a leak-proof, pest proof, non-absorbent, sanitary container with a tight fitting lid. The container will be labeled with name of the contents and dated with the date it was transferred to the new container. Opened packages will be resealed tightly and dated with date open to prevent contamination. Review of the policy for Manual Cleaning and Sanitizing with Three (3) Compartment Sink revealed to allow all equipment, utensils, etc. to drain and air-dry. Review of the Equipment Cleaning Procedures revealed after each use wipe machine with warm water-detergent solution including legs and underside of shaft. Continued review of the Equipment Cleaning Procedures revealed no procedure for cleaning portable fans. Review of the policy for Uniforms for Food and Dining Service Employees revealed hair must be restrained and off shoulder. The facility also had a policy titled Security and Traffic in the Kitchen which revealed all individuals entering the department are required to wear hair restraints. Observation on 08/08/16 at 11:45 a.m. of the walk-in refrigerator revealed an opened three (3) pound bag of cheddar cheese cubes that had no label or date Observation on 08/08/16 at 11:50 a.m. revealed two (2) male dietary staff working in the kitchen with facial hair that was no… | 2020-09-01 |
| 2295 | 2295 | SAVANNAH SQUARE HEALTH CENTER | 115546 | 1 SAVANNAH SQUARE DRIVE | SAVANNAH | GA | 31406 | 2016-08-11 | 520 | C | 0 | 1 | X51711 | Based on record review and staff interview, the facility failed to maintain a Quality Assessment and Assurance (QAA) Committee meeting quarterly for the first and second quarters of (YEAR), to identify, develop and implement corrective action plans ensuring deficient practices were corrected. The Census was thirty five (35). Findings include: During an interview with 5-Star Corporate Nurse, EE Registered Nurse (RN) on 8/11/16 at 2:25 p.m., she stated the facility was unable to provide documentation of the Quality Assessment and Assurance (QAA) Committee meetings during the first and second quarter of the year (YEAR). She stated that multiple staff turn-over caused missing documentation of these Quality Assessment and Assurance (QAA) Committee meetings being held. | 2020-09-01 |
| 2296 | 2296 | SAVANNAH SQUARE HEALTH CENTER | 115546 | 1 SAVANNAH SQUARE DRIVE | SAVANNAH | GA | 31406 | 2018-10-03 | 695 | D | 0 | 1 | API511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain a clean air filter for an oxygen concentrator for one of one residents (R#6) reviewed. With a census sample of 16 residents. Findings include: Review of [DIAGNOSES REDACTED]. Review of the Physician order [REDACTED]. Observation on 9/30/18 at 12:36 p.m., 10/2/18 at 2:13 p.m. and 10/3/18 at 8:50 a.m. revealed that the oxygen concentrator filter for R#6 was very dirty with a heavy build-up of dust in the filter. Observation also revealed the tubing from the concentrator was connected to the resident's continuous positive airway pressure (C-PAP) machine. Review of the care plan revealed that the resident had recurring episodes of shortness of breath (SOB) due to musculoskeletal impairment with a goal to maintain normal breathing pattern as evidenced by eupnea, normal skin color, and regular respiratory rate/pattern through the review date. The resident was to use the [MEDICAL CONDITION] machine at night. The resident had the potential and/or an actual altered respiratory pattern due to inability to maintain an effective airway clearance with interventions to provide treatments as ordered, if ineffective notify his Healthcare Practitioner, and he was to use his [MEDICAL CONDITION] at night and would need assistance with placement and cleaning of his [MEDICAL CONDITION] device, which helped him have restful sleep and maintain his oxygenation. Observation and interview on 10/3/18 at 9:08 AM of R#6 with the Assistant Director Of Nursing/ Interim Director Of Nursing (DON) confirmed that the air filter to the oxygen concentrator was very dusty and that the oxygen concentrator was connnected to the resident's [MEDICAL CONDITION] machine at night. She stated that she did not know how many residents use oxygen and that they had no system in place to keep the air filters clean. The Interim DON also revealed that she was not sure when the last time was that the filter was cl… | 2020-09-01 |
| 2297 | 2297 | SAVANNAH SQUARE HEALTH CENTER | 115546 | 1 SAVANNAH SQUARE DRIVE | SAVANNAH | GA | 31406 | 2017-10-12 | 282 | D | 0 | 1 | IGQY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to follow the plan of care for staff to provide water flushes per (physician) order for one resident (R) (R#39) who received enteral feedings through a [MEDEQUIP] tube ([DEVICE]) from a sample of twenty-two (22) residents. The census was twenty-eight (28) residents. Findings include: Review of the electronic record (e-record) for R#39 revealed that he had a [DIAGNOSES REDACTED]. Review of his care plan dated 9/26/17 revealed that he was at risk for an inability to maintain his nutrition/hydration related to his NPO (nothing by mouth) status with an intervention for licensed nursing staff to provide water flushes per (physician) order. Review of the Order Summary Report revealed a physician's orders [REDACTED].(ccs) of water before and after (enteral) feeding three times a day for hydration. During observation of medication and enteral feeding administration for R#39 on 10/11/17 at 11:19 a.m., Licensed Practical Nurse (LPN) AA drew up 30 ccs of water in a container and pushed the water with the syringe through the resident's [DEVICE]. LPN AA then administered 4[AGE] ccs of [MEDICATION NAME] 1.2 enteral feeding to R#39. LPN AA drew up another 30 ccs of water and pushed the water through the [DEVICE]. LPN AA then administered the crushed medication (Xenazyne, a medication that treats involuntary movement disorders) through the resident's [DEVICE] followed by another 30 ccs of water. LPN AA failed to flush the resident's [DEVICE] with 100 ccs water before and after the administration of the resident's feeding ([MEDICATION NAME] 1.2 cal) as ordered and as care planned. On 10/12/17 at 11:25 a.m., the Director of Nursing (DON) stated that he expected licensed nursing staff to administer water flushes as ordered by the physician and as care planned. Cross refer to F322. | 2020-09-01 |
| 2298 | 2298 | SAVANNAH SQUARE HEALTH CENTER | 115546 | 1 SAVANNAH SQUARE DRIVE | SAVANNAH | GA | 31406 | 2017-10-12 | 322 | D | 0 | 1 | IGQY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of the facility Enteral Nutrition Guidelines Policy and Medication Pass Observation Policy and staff interview, the facility failed to use correct technique when checking the placement of the [MEDEQUIP] tube ([DEVICE])( a tube inserted through the abdomen that delivers nutrition/hydration directly into the stomach); failed to check the residual before a bolus enteral feeding was administered as ordered by the physician; failed to allow water flushes to flow by gravity through the [DEVICE] as recommended by professional standards of practice; and failed to administer the correct amount of water flush before and after administration of the enteral feeding as ordered by the physician and as care planed for one (1) resident (R#39) with a [MEDEQUIP] tube from a sample of twenty-two (22) residents. The census was twenty-eight (28) residents. Findings include: Review of the facility Enteral Nutrition Guidelines dated 3/15/12 revealed that the nurse checks placement of all feeding tubes prior to intermittent feedings .and the nurse irrigates the feeding tube with the prescribed amount of water every 4-8 hours to maintain or restore patency of the feeding tube and to provide free water to maintain adequate hydration for the resident. Review of the facility Medication Pass Observation Policy revealed that when medications were administered with enteral nutritional feedings, staff should check the placement of the [MEDEQUIP] tube and flush the tube with at least 30cc of warm water before and after medications are administered. However, review of the policies revealed that there were no specific procedural guidelines for how staff were supposed to check the tube for placement and administer a water flush. Review of the electronic record (e-record) for R#39 revealed that he had a [DIAGNOSES REDACTED]. Review of his care plan dated 9/26/17 revealed that he was at risk for an inability to maintain his nutrition/hy… | 2020-09-01 |
| 2299 | 2299 | SAVANNAH SQUARE HEALTH CENTER | 115546 | 1 SAVANNAH SQUARE DRIVE | SAVANNAH | GA | 31406 | 2017-10-12 | 323 | D | 0 | 1 | IGQY11 | Based on observation, record review, review of facility policy and staff interview, the facility failed to have an effective monitoring system to ensure that safe hot water temperatures were maintained in three (3) resident rooms (rooms 326, 334 and 335) on one (1) of three (3) halls. The census was twenty-eight (28) residents. Findings include: During the Initial Tour of the facility on 10/10/17, the following unsafe hot water temperatures were obtained using the surveyor's digital thermometer: At 8:04 a.m., the hot water temperature in room 335 was 124.9 degrees Farenheit (F). One resident resided in the room. At 8:05 a.m., the hot water temperature in room 334 was 125.1 degrees (F). One resident resided in the room. At 8:08 a.m., the hot water temperature in room 326 was 125.1 degrees (F). One resident resided in the room. Interview with LPN AA on 10/10/17 at 8:15 a.m. revealed that the residents in rooms 326, 335 and 334 were cognitively impaired and did not use the sinks in their rooms unassisted by staff. On 10/10/17 at 8:26 a.m. the following unsafe hot water temperatures were confirmed with the Maintenance Supervisor using the facility digital thermometer: At 8:26 a.m., the hot water temperature in room 327 was 125.4 degrees (F). There were no residents occupying this room. At 8:29 a.m., the hot water temperature in room 335 was 123.1 degrees (F) At 8:31 a.m., the hot water temperature in room 334 was 122.3 degrees (F) At 8:34 a.m., the hot water temperature in room 326 was 120.5 degrees (F) Interview with the Maintenance Supervisor on 10/10/17 at 8:36 a.m. revealed that he had checked the hot water temperatures last week and that the highest temperature was 117 degrees (F). Continued interview revealed that he checked the hot water temperatures at least monthly in five (5) rooms. On 10/10/17 at 8:40 a.m., the temperature gauge for the boiler was 110 degrees (F). The Maintenance Supervisor adjusted the temperature down to 105 degrees (F) at that time. On 10/10/17 at 8: 45 a.m., the Director of Nursing (DO… | 2020-09-01 |
| 2300 | 2300 | SAVANNAH SQUARE HEALTH CENTER | 115546 | 1 SAVANNAH SQUARE DRIVE | SAVANNAH | GA | 31406 | 2017-10-12 | 441 | D | 0 | 1 | IGQY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of facility policy and staff interview, the facility failed to ensure that licensed nursing staff washed her hands prior to donning clean gloves during wound care for one resident (R) (R#6) of three (3) residents observed for wound care from a sample of twenty-two (22) residents. Findings include: Review of the Five [ENTITY] Senior Living: Clean Dressing Change Technique dated 3/10/15 revealed that clean technique should be used to promote wound healing and prevent cross-contamination among and between residents and caregivers. A clean covering should be used for a work surface on which to place assembled supplies. Once a clean field was established, contamination should be prevented by only reaching into the clean field with clean hands and never after gloves have touched anything off the field. After the soiled dressing was removed, staff should remove the soiled gloves, dispose of them properly and wash her hands. Staff should don clean gloves and cleanse the wound. After cleansing the wound, staff should remove her soiled gloves, dispose of them properly and wash her hands. Staff should don clean gloves and apply treatment. After the wound was treated, staff should remove her gloves, dispose of them and wash her hands. Review of the medical record for R#6 revealed that he had [DIAGNOSES REDACTED]. Continued review revealed that he was admitted with shearing on the left dorsal second toe and had a current physician's orders [REDACTED]. During observation of wound treatment on 10/12/17 at 9:15 a.m., Licensed Practical Nurse (LPN) AA sanitized her hands and obtained supplies from the treatment cart that included Secora Protective ointment in a small medicine cup, a bottle of Saf Clens wound cleanser, one pad of skin prep and a packet of non-woven gauze sponges. However, instead of placing a clean cover on a work surface on which to place the supplies, LPN AA placed the supplies directly on top of t… | 2020-09-01 |
| 3878 | 3878 | SEMINOLE MANOR NURSING HOME | 115712 | 100 FLORENCE STREET | DONALSONVILLE | GA | 39845 | 2016-06-09 | 161 | E | 0 | 1 | CYJG11 | Based on interview and record review, the facility failed to ensure that the surety bond covered the daily balances for the Resident Trust Account for five (5) of six (6) months reviewed. Findings include: The facility had a surety bond in the amount of $25,000 effective from 6/15/15 to 6/15/16 and managed forty-eight (48) resident accounts. A review of the Resident Trust Account bank statements revealed that from (MONTH) (YEAR) to (MONTH) (YEAR), the daily balances exceeded the Bond amount every month, for the following number of days each month: January (YEAR): 12 of 31 days February (YEAR): 6 of 29 days March (YEAR): 6 of 31 days April (YEAR): 12 of 30 days May (YEAR): 15 of 31 days During an interview on 6/9/16 at 12:40 p.m., the Business Office Manager stated that the balances exceeded the surety bond limit due to dates social security deposits were received and vision and dental insurance money that had not been paid out yet, pending the vision and dental companies completing a credentialing process. | 2020-09-01 |
| 3879 | 3879 | SEMINOLE MANOR NURSING HOME | 115712 | 100 FLORENCE STREET | DONALSONVILLE | GA | 39845 | 2016-06-09 | 282 | D | 0 | 1 | CYJG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility failed to follow the plan of care to thoroughly and routinely complete assessments of pressure ulcers for two (2) residents #41 and #70 from a total sample of twenty-three (23) residents. Findings include: 1. Resident #41 had a plan of care in place since 3/23/16 for having an unstageable pressure ulcer to the coccyx due to poor nutrition, cognitive status and immobility. The plan of care was updated on 4/14/16 to include an intervention for nursing staff to assess the pressure ulcer weekly for location, stage, size (length, width and depth) presence or absence of granulation tissue and epithelization. However, there was no documented weekly assessment of the pressure ulcer after 4/12/16 until 4/25/16, when it was documented as closed. The resident was hospitalized from [DATE] through 4/28/16 and returned to the facility with a stage two pressure ulcer to the coccyx. After being thoroughly assessed on 4/28/16, there was no documented weekly assessment of the pressure ulcer again until 5/13/16, when it was documented as healed. A new stage two pressure ulcer was identified to the coccyx on 5/26/16. However, there was no documented weekly assessment of the pressure ulcer again until 6/8/16, when it was documented as healed. 2. Resident #70 was readmitted to the facility on [DATE] with a stage two pressure ulcer to the coccyx. There was a plan of care since 5/18/16 for being readmitted with a pressure ulcer to the coccyx. The plan of care included an intervention for nursing staff to assess the pressure ulcer weekly for location, stage, size (length, width and depth) presence or absence of granulation tissue and epithelization. However, after being thoroughly assessed on 5/5/16, there was no documented weekly assessment of the pressure ulcer again until 5/25/16, when it was documented as healed. During an interview on 6/9/16 at 12:20 p.m., the Assistant Director of Nursing (ADON) stated th… | 2020-09-01 |
| 3880 | 3880 | SEMINOLE MANOR NURSING HOME | 115712 | 100 FLORENCE STREET | DONALSONVILLE | GA | 39845 | 2016-06-09 | 314 | D | 0 | 1 | CYJG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility failed to complete thorough, weekly documented assessments of pressure ulcers for two (2) residents (#41) and (#70) from a total sample of twenty-three (23) residents. Findings include: The facility's Wound Protocol policy and procedure documented to assess pressure ulcers weekly, including measurement. 1. Resident #41 had [DIAGNOSES REDACTED]. There a plan of care in place since 3/23/16 for having an unstageable pressure ulcer to the coccyx due to poor nutrition, cognitive status and immobility. The plan of care was updated on 4/14/16 to include an intervention for nursing staff to assess the pressure ulcer weekly for location, stage, size (length, width and depth) presence or absence of granulation tissue and epithelization. A review of the clinical record revealed that nursing staff documented assessments of the pressure ulcer on 3/23/16, 3/24/16, 3/29/16, 4/6/16 and 4/12/16. However, the assessments on 3/29/16, 4/6/16 and 4/12/16 were not thorough to include staging and measurements. In addition, there was no documented weekly assessment of the pressure ulcer after 4/12/16 until 4/25/16, when it was documented as closed. The resident was hospitalized from [DATE] through 4/28/16 and returned to the facility with a stage two pressure ulcer to the coccyx. After being thoroughly assessed on 4/28/16, there was no documented weekly assessment of the pressure ulcer again until 5/13/16, when it was documented as healed. A new stage two pressure ulcer was identified to the coccyx on 5/26/16. However, there was no documented weekly assessment of the pressure ulcer again until 6/8/16, when it was documented as healed. During an observation on 6/8/16 at 11:04 a.m., with the ADON, the pressure ulcer to the coccyx was observed to be healed. 2. Resident #70 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged to the hospital on [DATE] and returned on 5/5/16… | 2020-09-01 |
| 3881 | 3881 | SEMINOLE MANOR NURSING HOME | 115712 | 100 FLORENCE STREET | DONALSONVILLE | GA | 39845 | 2016-06-09 | 325 | D | 0 | 1 | CYJG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility failed to accurately assess the nutritional needs for one resident (#70), upon readmission from a hospital stay, from a total sample of twenty-three (23) residents. Findings include: Resident #70 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged from the facility on 4/22/16, to receive aggressive therapy services, and returned on 5/5/16. The resident's weight on return from the hospital, on 5/5/16, was documented as 132.2 pounds. His/her previous weight on 4/18/16 (before going to the hospital on [DATE]) was 157 pounds. This was a loss of 24.8 pounds. Facility nursing staff identified the weight loss and implemented interventions. However, a readmission/hospital return nutritional assessment completed by the dietician on 5/12/16, failed to identify and address the resident's significant weight loss. The dietician documented on the 5/12/16 Medical Nutritional Therapy Assessment form that the resident weighed 157 pounds. The resident's BMI was calculated at 27.8 and classified as overweight. In addition, a dietary note completed by the dietary manager on 5/16/16 only documented the resident's weight of 157 pounds prior to the hospitalization , instead of the most recent weights available of 132.2 pounds on 5/5/16 and 136.3 pounds on 5/13/16. During an interview on 6/9/16 12:20 p.m. the Assistant Director of Nursing (ADON) stated she had not put in the hospital return weight in the computer when the dietary notes and assessment were completed. However, they did have a verbal meeting on the resident and dietary staff was aware the resident had a weight loss and that nursing staff was monitoring to make sure the hospital return weight was an accurate weight (since it was a big drop in weight from before the hospital admission) and interventions were in place. | 2020-09-01 |
| 3882 | 3882 | SEMINOLE MANOR NURSING HOME | 115712 | 100 FLORENCE STREET | DONALSONVILLE | GA | 39845 | 2016-06-09 | 431 | D | 0 | 1 | CYJG11 | Based on observation and staff interview, the facility failed to ensure expired medications were properly disposed of in a timely manner in one (1) of one (1) medication room refrigerator. Findings Include: Observation on 6/9/16 at 8:15 a.m. in the medication room refrigerator revealed one (1) bag of nine (9) unopened vials and one (1) opened vial of Ativan 2 milligram (mg) per milliliter (ml) one (1) ml vials for R #24 with an expiration date of 5/2016 on all ten (10) vials. Observation further revealed a (MONTH) Daily Refrigerator Check Off Sheet secured to the refrigerator door with a signature present for 6/4 only. Instructions on the check off sheet stated refrigerator in medication room will be checked daily by an Licensed Practical Nurse(LPN) to make sure all medications are properly labeled with date opened written on bottle and not box and that all expired medications are pulled from the refrigerator as needed. After procedure is done LPN will initial in proper area that this has been done and that everything is correct in the refrigerator. During an interview on 6/9/16 at 8:15 a.m. with the Patient Care Coordinator, she revealed the ten (10) vials of Ativan 2 mg/ml one (1) ml vials expired on 5/31/16 and should have been removed from the refrigerator. The Patient Care Coordinator confirmed the (MONTH) Daily Refrigerator Check Off sheet was signed off in (MONTH) only on 6/4/16. The Patient Care Coordinator revealed that the LPN assigned to check the medication refrigerator according to the check off sheet should check for expired medications and initial that it has been checked according to the instructions on the sheet. She further revealed the medication refrigerator should be checked daily for expired medications according to the instructions. During an interview on 6/9/16 at 9:15 a.m. the Director of Nurses (DON) revealed the Daily Refrigerator Check Off sheet was an old internal form the Patient Care Coordinator developed and the new nurses would not know to use the check sheet. Futher interview on … | 2020-09-01 |
| 3883 | 3883 | SEMINOLE MANOR NURSING HOME | 115712 | 100 FLORENCE STREET | DONALSONVILLE | GA | 39845 | 2018-08-26 | 644 | D | 0 | 1 | LV3R11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the facility policy Admission Criteria, and staff interview, the facility failed to refer two residents (R) (#21 and #36) for a pre-admission screening and resident review (PASRR) Level II when the residents experienced a change in behavioral status. The sample size was 29. Findings include: Review of the facility policy titled Admission Criteria revised (YEAR) revealed: 8. Nursing and medical needs of individuals with mental disorders or intellectual disabilities will be determined by coordination with the Medicaid Pre-Admission Screening and Resident Review (PASRR) program to the extent practicable. 1. Record review for R#21 revealed a Pre-Admission Screening/Resident Review (PASRR) Level I assessment dated [DATE] that did not indicate that the resident had a serious mental illness, developmental disability or related condition. Review of the Nurse's Notes for R#21 dated 8/31/17 revealed the physician requested a psychiatric evaluation due to resident's recent behaviors. Further review of the Nurse's Notes dated 9/1/17 documented R#21 was sent to the behavior unit at the hospital. On 9/14/17 resident returned to the facility following a lengthy stay at the inpatient behavioral health unit. No behaviors noted at this time. Review of the clinical record for R#21 revealed [DIAGNOSES REDACTED]. The resident had admission [DIAGNOSES REDACTED]. Further review of the clinical record for R#21 revealed a physician order dated 1/15/18 for [MEDICATION NAME] 300 milligrams (mg) by mouth three times per day for manic episode, a physician's order dated 9/14/17 for [MEDICATION NAME] 1 mg at bedtime for delusional disorder and Trazadone 100 mg at bedtime for [MEDICAL CONDITION]. Review of the Care Plan last revised 5/4/18 revealed R#21 has socially inappropriate/disruptive behavioral symptoms as evidenced by hollering out and cussing. Further review revealed the resident requires [MEDICAL CONDITION] medication for depressi… | 2020-09-01 |
| 3884 | 3884 | SEMINOLE MANOR NURSING HOME | 115712 | 100 FLORENCE STREET | DONALSONVILLE | GA | 39845 | 2018-08-26 | 656 | D | 0 | 1 | LV3R11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Record review and staff interviews the facility failed to develop a comprehensive care plan for a [MEDICAL CONDITIONS] and for the use of a blood thinner (Eloquis) for one Resident (R) (R#31) and failed to develop a comprehensive care plan related to the use of an antianxiety medication for one residents (R) (R#19) for a total of two residents from a sample of 29 residents. Findings include: Record review revealed that R# 31 was admitted to the facility with [DIAGNOSES REDACTED]. Review of Nurses Notes dated 7/16/2018 03:05 revealed the following documentation: Called and spoke with the resident's Physician's office and reported that pulse was faint and the leg was warm to touch from knee down to foot and resident has 3+ [MEDICAL CONDITION] noted in foot as reported this AM. New orders to send to the ER for eval and treat. Notified responsible party of new orders to send resident to ER (emergency room ) via telephone. Report given to the ER. Resident in route to ER via gerichair accompanied by SMNH staff via facility ambulance. Record review revealed that R# 31 was transferred to the emergency roiagnom on [DATE], for [MEDICAL CONDITION] and pain to the right foot and leg. Radiology report dated 7/16/18, documented [MEDICAL CONDITION] of the SFV to peroneal artery. Physician admission orders [REDACTED].H. (Nursing Home) Dx (diagnosis) [MEDICAL CONDITION] to RLE (to right lower extremity). Physician order [REDACTED]. Review of the Medication Administration Record [REDACTED]. Review of the care plans for R# 31 revealed that there was no evidence that a care plan was developed to address the resident's [MEDICAL CONDITION] and there was no evidence of a care plan to address the Eloquis (blood thinner). Interview and review of medications for R# 31 on 8/26/18 at 8:57 a.m. with the RN Weekend Supervisor revealed that the resident is currently taking Eloquis but that she was not sure what this medication was for. The RN Weekend Supervisor lo… | 2020-09-01 |
| 3885 | 3885 | SEMINOLE MANOR NURSING HOME | 115712 | 100 FLORENCE STREET | DONALSONVILLE | GA | 39845 | 2018-08-26 | 690 | D | 0 | 1 | LV3R11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, and facility policy review Perineal Care and Catheter Care, the facility failed to ensure that incontinent care and/or Foley catheter care were performed in a timely manner to prevent a potential Urinary Tract Infection [MEDICAL CONDITION] due to fecal contamination for one resident (R) R#20 from a total sample of 29. Findings include: During observation of incontinent/Foley catheter care, on 8/24/18 at 11:28 a.m., revealed that the Certified Nursing Assistant (CNA) AA, put her gloves on her hands, then put six white wash clothes in the sink without a basin, and removed the soiled brief from the resident, which was soaked all the way down to the pink drawl sheet with brown liquid. Continued observation revealed that the CNA did not remove the pink drawl sheet at this time; however, she had the resident lay back on the drawl sheet. With the same gloves that were used to remove the soiled brief, she retrieved one of the wash clothes from the sink, and wiped front to back on the left side of the perineal area, then with another wash cloth she washed the labia using downward [MEDICAL CONDITION], changing the direction of her wash cloth. However, at no time did the CNA clean the right side of the perineal area. At this point, the CNA changed her gloves, and had the resident roll over to her left side, rolled the drawl sheet under the resident's bottom. The CNA changed her gloves, obtained another wash cloth from the sink, and began to wipe the Catheter tube while holding near the meatus, moving in a downwards direction. There was no Catheter strap observed at this time. The CNA again changed her gloves, and grabbed two wash cloths out of the sink, then she began cleaning the resident's bottom, wiping from bottom to top, removing all the brown liquid fecal matter from her bottom. After changing her gloves, she put two paper drawl sheets under the resident, rolled the resident onto her back, and … | 2020-09-01 |
| 3886 | 3886 | SEMINOLE MANOR NURSING HOME | 115712 | 100 FLORENCE STREET | DONALSONVILLE | GA | 39845 | 2018-08-26 | 726 | D | 0 | 1 | LV3R11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, and review of the facility policy of Catheter Care and Perineal Care, it was determined that the facility failed to ensure that one Certified Nursing Assistant (CNA) demonstrated competency in providing adequate incontinent care and/or catheter care for one resident (R) (R#20) from a total sample of 29. Findings include: During observation of incontinent/Foley catheter care, on 8/24/18 at 11:28 a.m., revealed that the CNA, AA, put her gloves on her hands, then put six white wash clothes in the sink without a basin, and removed the resident's soiled brief, but did not remove the soiled drawl sheet. Continued observation revealed that the CNA had the resident lay back on the soiled drawl sheet. With the same gloves that were used to remove the soiled brief, she retrieved one of the wash clothes from the sink, and wiped front to back on the left side of the perineal area, then with another wash cloth she washed the labia using downward [MEDICAL CONDITION], changing the direction of her wash cloth. However, at no time did the CNA clean the right side of the perineal area. At this point, the CNA changed her gloves, and had the resident roll over to her left side, rolled the drawl sheet under the resident's bottom. The CNA changed her gloves, obtained another wash cloth from the sink, and began to wipe the Catheter tubing while holding near the meatus, in a downwards direction. The CNA again changed her gloves, and grabbed two wash cloths out of the sink, then she began cleaning the resident's bottom, wiping from bottom to top, removing all the brown liquid fecal matter from her bottom. After changing her gloves, she put two paper drawl sheets under the resident, rolled the resident onto her back, and obtained a hand towel, which she begins to clean her labia area again. During further observation, the CNA changed her gloves, had the resident roll to her right side, while the CNA pulled the soil… | 2020-09-01 |
| 3887 | 3887 | SEMINOLE MANOR NURSING HOME | 115712 | 100 FLORENCE STREET | DONALSONVILLE | GA | 39845 | 2018-08-26 | 756 | E | 0 | 1 | LV3R11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and staff interviews, the facility's consultant pharmacist failed to identify and report irregularities related to the continued use after 14 days of as needed (prn) [MEDICAL CONDITION] medications for two Ridents(R) (R# 19, R#11) of five residents reviewed. The sample size was 29 residents. Findings include: Review of the clinical record for R#19 revealed [DIAGNOSES REDACTED]. Review of the Phsysician orders for R#19's revealed an order since 8/17/17 for .5 milligrams(mg) of [MEDICATION NAME] every 12 hours prn. Review of R#19's monthly Medication Administration Records from (MONTH) (YEAR) through (MONTH) (YEAR) revealed the prn [MEDICATION NAME] was administered to the resident one time in (MONTH) (YEAR), four times in (MONTH) (YEAR), seven times in (MONTH) (YEAR), seven times in (MONTH) (YEAR), five times in (MONTH) (YEAR), three times in (MONTH) (YEAR), one time in (MONTH) (YEAR), eight times in (MONTH) (YEAR) and two times in (MONTH) (YEAR). Review of the consultant pharmacist Monthly Drug Regimen Reviews dated 11/30/17, 12/29/18, 1/31/18, 2/27/18, 3/20/18, 4/30/18, 5/31/18, 6/29/18 and 7/31/18 revealed no recommendations to address the continued use of the prn [MEDICATION NAME]. Interview on 08/26/18 at 10:53 a.m. with Register Nurse(RN) BB revealed she was not aware of the regulation for a stop order date after 14 days of a [MEDICAL CONDITION] medication. 2. Review of the clinical recordfor R#11 revealed [DIAGNOSES REDACTED]. Review of the monthly Mediation Administration Records for R#11 for (MONTH) (YEAR) through (MONTH) (YEAR) revealed [MEDICATION NAME] 0.25 mg as needed was administered to the resident two time's in (MONTH) (YEAR) and (MONTH) (YEAR) three times, and (MONTH) (YEAR). Review of the consultant Pharmacist Monthly Drug Regimen Reviews dated 11/30/17, 12/29/18, 1/31/18, 2/27/18, 3/20/18, 4/30/18, 5/31/18, 6/29/18 and 7/31/18 revealed no recommendations to address the continued use of the prn [MEDIC… | 2020-09-01 |
| 3888 | 3888 | SEMINOLE MANOR NURSING HOME | 115712 | 100 FLORENCE STREET | DONALSONVILLE | GA | 39845 | 2018-08-26 | 758 | E | 0 | 1 | LV3R11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to document the clinical indication for continued use and intended duration of therapy for four residents(R) #19, R#31, R#11, R#13) and that had orders for as needed (prn) [MEDICAL CONDITION] medications beyond the 14 days. The sample size was 29 residents. Findings include: 1. Review of R#19's clinical record revealed [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of R#19's monthly Medication Administration Records from (MONTH) (YEAR) through (MONTH) (YEAR) revealed the prn [MEDICATION NAME] was administered to the resident one time in December, four times in January, seven times in February, seven times in March, five times in April, three times in May, one time in June, eight times in (MONTH) and two times in August. Interview on 8/26/18 at 10:53 a.m. with Registered Nurse (RN) BB, revealed she was not aware of the 14 day stop order date required for prn [MEDICAL CONDITION] medications. 2. Record review revealed that R# 31 was admitted to the facility with [DIAGNOSES REDACTED]. Record Review of the Electronic Medication Administration Record [REDACTED]. Further review revealed that the resident is currently receiving [MEDICATION NAME] 0.5 mg two times daily without a stop order date. Record Review of the Medication Administration Records (MAR) from (MONTH) (YEAR) through (MONTH) (YEAR) for R#36 revealed that the resident has an order for [REDACTED]. Interview on 8/26/18 at 9: 50 a.m. with the Consultant Pharmacist revealed that he comes to the facility on e time a month to review medications. Further interview with the Consultant Pharmacist revealed that he stated that he was not familiar with the new Federal Regulation and that he was not aware that PRN (as needed) medications could not be ordered for more than 14 days without a stop date. 3. Review of R# 11's clinical record revealed [DIAGNOSES REDACTED]. Review of R# 11's monthly Mediation Adminis… | 2020-09-01 |
| 3889 | 3889 | SEMINOLE MANOR NURSING HOME | 115712 | 100 FLORENCE STREET | DONALSONVILLE | GA | 39845 | 2018-08-26 | 759 | E | 0 | 1 | LV3R11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interviews, and facility policy review Administering Medications, the facility failed to ensure that the medication error rate was less than 5%. There were two errors with 32 opportunities for two of four residents (R) (R#38 and R#55) by one of two nurses observed, for a medication error rate of 6.25%. Findings include: 1.) On 8/25/18 at 8:21 a.m., Licensed Practical Nurse (LPN) CC was observed preparing R#38's medications, including one capsule of [MEDICATION NAME] (nerve pain medication and anticonvulsant) 100 milligram (mg). However, during further observation, the medication bag revealed to give 200 mg. At the end of preparing all 10 medications, the LPN agreed that was all that she was giving the resident at this time, and only one [MEDICATION NAME] capsule was prepared. Review of the Physician Order Report dated 7/25/18-8/25/18 revealed to give [MEDICATION NAME] 100 mg capsule, totaling 200 mg, twice a day (BID). Review of the Order Administration revealed that the last date the medication was administered was on 8/25/18 at 8:33 a.m. Interview with LPN, CC on 8/25/18 at 11:45 a.m., she confirmed that the resident takes 200 mg of [MEDICATION NAME]. Continued interview revealed that she was sure that she gave the resident 200 mg this morning and said that if there was an even number in his [MEDICATION NAME] bag then she did not give, but one. During interview, the LPN counted the medication with the surveyor and there was 18 pills in the [MEDICATION NAME] bag; however, unsure of the number in the bag at the start of the shift. After counting, the nurse said that if the package had an odd number in there then she only gave one and since there was an even number, she gave two capsules this morning. 2.) On 8/25/18 at 8:39 a.m., LPN CC, was observed preparing R#55's four medications, including Aspirin, Singular, [MEDICATION NAME], and [MEDICATION NAME]. At the end of preparing all four medications, t… | 2020-09-01 |
| 3890 | 3890 | SEMINOLE MANOR NURSING HOME | 115712 | 100 FLORENCE STREET | DONALSONVILLE | GA | 39845 | 2018-08-26 | 812 | E | 0 | 1 | LV3R11 | Based on observation, record review, interviews, and review of the facility's policy titled, Monitoring Food Temperatures for Meal Service, the facility failed to ensure that two food items (chicken patties and pureed bread) were maintained on the steam table at a temperature of 135 degrees Fahreheit (F) or greater for two consecutive days. This affected 3 of 5 residents that received a pureed diet. Findings include: Interview on 8/24/18 at 12:34 p.m. with the Dietary Assistant revealed that the food comes from the hospital and that when the food is received then they take beginning temperatures and document those temperatures in the book. The Dietary Assistant revealed that after they have been serving food about 30 - 35 minutes then they retake the food temperatures to ensure that they are maintaining the food at the correct temperature. Further interview revealed that the temperature was not as hot as it should have been for the pureed bread and for the chicken patties. The Dietary Assistant revealed that the temperature for the chicken patties was 130.9 degrees and the temperature for the pureed bread was 112.9 degrees. Review of the steam table temperature log book revealed that temperatures for food served had been recorded prior to the food being served except for the chicken patties. Further review revealed that there was not a recorded temperature for the chicken patties. The Dietary Assistant said that the temperature of the chicken patties should have been taken and should have recorded in the book but that they were not. Interview on 8/25/18 at 11:00 a.m. with the Dietary Manager revealed that when the food is taken from the Hospital Kitchen to the Nursing Home that the temperature is to be taken on all food items and all temperatures are documented in the log book prior to the food being served. Further interview revealed that temperatures are taken before the food is served and again midway through or toward the end of serving and that these temperatures should be documented in the log book as well.… | 2020-09-01 |
| 3891 | 3891 | SEMINOLE MANOR NURSING HOME | 115712 | 100 FLORENCE STREET | DONALSONVILLE | GA | 39845 | 2017-09-09 | 241 | D | 0 | 1 | IEJF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and facility policy titile Quality of Life-Dignity, the facility failed to maintain dignity for one resident, R56 of a sample of 25 twenty-five .The facility census was 55 fifty-five residents. Finding include: Review of clincial record revealed R56 was admitted to the facility on [DATE]. The following [DIAGNOSES REDACTED]. R56 had a urinary tract infection UTI on 7//17 and recieved treatment. Review of R56's care plan dated 1/31/17 i for occassional bladder incontinence and peri care with interventions. Review of facility policy title Quality of Life-Dignity revealed that staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal cae and during treatment procedure. Observation on 9/8/17 at 2;15 p.m. revealed R56 was exposed wearing a brief when Certified Nursing Assistant, CNA FF pulled down her pants in the front lobby to check for peri care R56 was sitting in a recliner in the front lobby with other residents. CNA FF approached resident pulled down her pants from waist to upper thigh and proceeded to pat R56's brief in different area without wearing gloves and washing her hands. When she patted R56 brief in between her legs, R56 holler out. This was done in the presence of another CNA, CNA HH and the surveyor who was standing next to R56 during the observation. Interview with CNA FF at the time of the observation revealed that R56 is unable to communicate her toilet needs. She further stated she was checking R56 to see if she need changing. During an attempt to interview R56 and review of a Basic Mental Status BIMS it was revealed that R56 was not cognitive and not able to be interviewed. Interview on 9/8/17 at 2:42 p.m. with CNAFF revealed she was assigned to monitor R56 and other residents in the front lobby. She stated residents in the front lobby are taken to hall bathroom in front of the nurses station to check for peri care… | 2020-09-01 |
| 3892 | 3892 | SEMINOLE MANOR NURSING HOME | 115712 | 100 FLORENCE STREET | DONALSONVILLE | GA | 39845 | 2017-09-09 | 279 | D | 0 | 1 | IEJF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop individualized care plan related to multiple urinary tract infections and [MEDICATION NAME] antibiotics for one (1) resident #37 (R#37) from a census sample of twenty-five (25) residents. Findings include: Resident #37 was admitted with the diagnoses, that included but not limited to, hypertension, anxiety disorder, gastro-[MEDICAL CONDITION] reflux disease, diabetes mellitus type 2, [MEDICAL CONDITION], candidiasis, [DIAGNOSES REDACTED], vitamin B12 deficiency, anxiety disorder, [MEDICAL CONDITION], dementia. The Minimum Data Set (MDS) Section I - Active Diagnoses: [REDACTED].#37 had an urinary infection within the last thirty (30) days for a quarterly assessment dated [DATE]; PPS (Prospective Payment System) 5 day assessment dated [DATE]; PPS 14 day assessment dated [DATE]; PPS 30 day assessment dated [DATE]; and PPS 5 day assessment dated [DATE]. Review of resident #37 care plan dated 4/28/15 on 9/8/17 at 5:55 p.m. revealed that there was no individualized care for urinary tract infections or the [MEDICATION NAME] antibiotic which resident #37 was receiving on this care plan. During an interview with the MDS Coordinator on 9/9/17 at 12:05 p.m. revealed that R#37 did not have a care plan for the multiple urinary tract infection or the [MEDICATION NAME] antibiotics. She revealed that this should have been care planned, and that this was an oversight. Cross reference to F 315 | 2020-09-01 |
| 3893 | 3893 | SEMINOLE MANOR NURSING HOME | 115712 | 100 FLORENCE STREET | DONALSONVILLE | GA | 39845 | 2017-09-09 | 315 | D | 0 | 1 | IEJF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews and facility perineal care policy, the facility failed to provide proper technique and effective perineal care to prevent infection for one (1) resident #37 (R#37) from a sample of twenty-five (25) residents. Findings include: Review of Perineal Care policy dated 11/1/16 reads all staff members involved in performing perineal care to residents will promote cleanliness, prevent infections to the extent possible, prevent and assess for skin breakdown and promote comfort. 13. Females a. Cleanse perineum from front to back. b. Cleanse the labia folds, urethral meatus and vaginal orifice using clean portion of cloth or new cloth with each stroke. An observation on 9/8/17 at 3:11 p.m. of Certified Nurse Aide (CNA) CC performing perineal care on R#37 revealed that R#37 was assisted to a standing position and CNA CC begin washing her in a back and forth motion. Upon cleaning the rectum area of resident, brown fecal material was observed. During this observation, CNA CC stated that R#37 had not had a recent bowel that the feces from a prior perineal care. An observation on 9/9/17 at 10:12 a.m. with CNA AA and with the assistance of CNA BB who transfer R#37 from the wheelchair to the bed using a gait belt. Upon positioning the resident in the bed, the resident stated she needed to pee, and the two CNA's transfered the resident back to the wheel chair and took her to the bathroom. Resident was observed wearing a brief that was mildly wet. R#37 urinated in the toilet. During this observation, CNA AA stated that she would provide perineal care to R#37 who was sitting on the toilet. CNA AA assist R#37 to a standing position, and R#37 used the grab bar next to the commode for support. CNA BB got the wash cloth from the sink and towels located in R#37 room. CNA AA begin performing perineal care to R#37 who was standing. Resident thighs were observed to be tightly closed and CNA AA was using the wash cloth and was not ab… | 2020-09-01 |
| 3894 | 3894 | SEMINOLE MANOR NURSING HOME | 115712 | 100 FLORENCE STREET | DONALSONVILLE | GA | 39845 | 2017-09-09 | 441 | E | 0 | 1 | IEJF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review,and staff interviews, the facility failed to ensure the infection control program contained effective surveillance and tracking of nosocomial infections for the faciity, and the facility failed to use proper handwashing techniques and or don gloves while providing care for one resident (R#56) in a sample of 25 residents. The facility census was 55. Findings: 1. Review of facility infection control logs dated (MONTH) (YEAR) through (MONTH) (YEAR) revealed the facility did track some infections; however, the infection control log did not contain all of the nosocomial infections that occured in the facility, nor did it track the rate of infection. Additionally, there was no documented evidence of mapping, quality improvement activities, review of infection control policies and procedures or reccomended actions and follow-up related to nosocomial infections that occured in the facility. Review of the facility Policies and Procedures: Infection Control revealed the system shall monitor and evaluate all infections and communicable diseases of residents. Further review of the policy revealed the Infection Control Committee (ICC) is responsible for the investigation, control and prevention of infections associated with care provided by the facility. The functions of the ICC include; establishing surveillance and reporting programs, establishing policies and procedures, implementing outbreak investigation and control, reviewing policies and procedures for infection control and recommending actions and follow-up relating to nosocomial infections. Review of the facility Infection Control Surveillance Policy revealed the Infection Control Nurse (ICN) is responsible for surveillance of infections among residents. Further review of the policy revealed nosocomial rates will be calculated and when a resident is identified as having developed an infection an abstract of pertinent data including the identification and locat… | 2020-09-01 |
| 3895 | 3895 | SEMINOLE MANOR NURSING HOME | 115712 | 100 FLORENCE STREET | DONALSONVILLE | GA | 39845 | 2017-09-09 | 520 | D | 0 | 1 | IEJF12 | Based on record review, review of the facility's Plan of Correction, and interview, the facility failed to develop and implement corrective action plans to resolve an identified concern placed in Quality Assurance (QA) related to perineal/catheter care for one resident (R#16) from a sample of two residents. R#16 did not receive perineal/catheter care to prevent possible infection. Findings include: Interview on 11/3/17 at 2:45 p.m. with the Registered Nurse Infection Control and Quality Assurance office, (RN, IC, QA) revealed the facility had two urinary tract infections for the month of October, and no urinary tract infections for any of the resident's with catheters. She stated that perineal care and Foley catheter care was still in QA and that all citations from the standard survey were in Q[NAME] Review of the facility Plan of Correction revealed a Mandatory in-service was conducted on 11/2/17 on Superbugs an Infection Control, Perineal Care Validation Check-Offs/Surveillance was conducted monthly. | 2020-09-01 |
| 5268 | 5268 | SEMINOLE MANOR NURSING HOME | 115712 | 100 FLORENCE STREET | DONALSONVILLE | GA | 39845 | 2015-04-23 | 315 | D | 0 | 1 | 20S111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, the facility failed to ensure that three (3) of three (3) residents with indwelling catheters ( #5, #21 ,#63) received the appropriate care and treatment for [REDACTED]. Findings include: Observations of resident #5 on 04/20/15 at 3:32 p.m., 4/21/15 at 8:49 a.m. and 3:11 p.m. and on 04/22/15 at 8:45 a.m. and 3:27 p.m. revealed that the resident did not have a dignity bag covering the catheter drainage bag. Observations of resident #21 on 04/20/15 at 1:41 p.m. and at 3:20 p.m. revealed that the resident did not have a dignity bag covering the catheter drainage bag. Observation of resident #63 on 4/21/15 at 3:05 p.m. and on 4/22/15 at 4:04 p.m. revealed that the resident was in the bed, with the Foley catheter hanging on the bedside with no dignity bad covering it. An interview conducted on 04/23/15 at 12.15 p.m. with Certified Nursing Assistant (CNA) BB revealed that all residents with indwelling catheters should have dignity bags covering the catheter drainage bag. An interview conducted on 04/22/15 at 4:00 p.m. with the Director of Nursing (DON) revealed the staff are to use dignity bags for all residents with indwelling catheters. Observation of resident #5 and #63 with the DON confirmed there was no dignity bags covering the catheter drainage bags. | 2018-11-01 |
| 5269 | 5269 | SEMINOLE MANOR NURSING HOME | 115712 | 100 FLORENCE STREET | DONALSONVILLE | GA | 39845 | 2015-04-23 | 441 | D | 0 | 1 | 20S111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy, observations and staff interviews, the facility failed to ensure that certified nursing staff washed or sanitized hands after direct resident contact during meal service on one (1) of three (3) halls (North Hall). The census was fifty nine (59) with three (3) residents receiving tube feedings. Findings include: Observation of North Hall noon meal service on 04/20/15 at 12:15 p.m. revealed Certified Nursing Assistant (CNA) AA removed a meal tray from the food cart and entered room [ROOM NUMBER]. He/she moved the bedside table next to the bed and assisted the resident to a sitting position by placing his/her hands on each shoulder of the resident. He/she moved the bedside table over the resident and set up the meal tray touching the drinking portion of the residents straw with his/her hand. Further observation revealed CNA AA entered room [ROOM NUMBER] with a meal tray and adjusted the bed by touching the remote control. He/she adjusted the residents' pillow and proceeded to set up the meal tray touching the residents bread and drinking portion of the straw with his/her hands. CNA AA returned to the food cart, retrieved another tray and entered room [ROOM NUMBER]. He/she adjusted the bed, touching the remote control and proceeded to set up the meal tray touching the drinking portion of the straw with her hand. CNA AA returned to the food cart, retrieved another tray and entered room [ROOM NUMBER]. He/she adjusted the bedside table and proceeded to set up the residents' meal tray touching the drinking portion of the straw with her hand. CNA AA failed to wash or sanitize his/her hands throughout the entire procedure. An interview conducted on 04/20/15 at 1:30 p.m. with CNA AA revealed he/she should wash/sanitize hands between residents when passing out trays. The CNA confirmed he/she did not sanitize/wash his/her hands. Review of the facility policy entitled Handwashing - Infection Control - #2 reads: Wash your hands bef… | 2018-11-01 |
| 6840 | 6840 | SEMINOLE MANOR NURSING HOME | 115712 | 100 FLORENCE STREET | DONALSONVILLE | GA | 39845 | 2014-07-24 | 280 | D | 0 | 1 | P7B611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, the facility failed to revise the Care Plan of one (1) resident (#67) to reflect the resident's significant weight loss and interventions to address the resident's assessed nutritional needs, from a survey sample of twenty-seven (27) residents. Findings include: Resident #67's 06/18/2014 Quarterly Minimum Data (MDS) assessment documented diagnoses, in Section I-Active Diagnoses, including but not limited to [MEDICAL CONDITION] and Hypertension. Resident #67's July 2014 Physician order [REDACTED]. Resident #67's Vitals Report documented the 06/11/14 facility readmission weight to be 162.2 pounds, but also documented the resident's 06/02/2014 (pre-hospitalization ) weight had been 174.4 pounds, thus indicating that Resident #67 lost from 174.4 to 162.2 pounds, or seven (7) percent, while hospitalized . Further review of Resident #67's 06/18/2014 Quarterly MDS referenced above revealed that Section K - Swallowing/Nutritional Status identified the resident's weight loss of 5 percent or more in the previous month (as referenced in the June 2014 Vitals Report above). In addition, the Registered Dietician (RD) identified Resident #67's weight loss in a 06/18/2014 Nutritional Re-Evaluation form, and also recommended dietary supplementation with Ensure. However, review of the Comprehensive Care Plan for Resident #67 revealed that, despite the resident's recent colon resection surgery, despite the 06/18/2014 MDS identifying a significant weight loss in the previous month (during hospitalization ), and despite the RD identifying on 06/18/2014 that the resident needed nutritional supplementation with Ensure dietary supplement, the facility failed to revise the resident's Care Plan to identify the significant weight loss or interventions to address the assessed nutritional needs after the resident's facility readmission following colon surgery. During an interview conducted on 07/23/2014 at 2:00 p.m. wi… | 2017-10-01 |
| 6841 | 6841 | SEMINOLE MANOR NURSING HOME | 115712 | 100 FLORENCE STREET | DONALSONVILLE | GA | 39845 | 2014-07-24 | 282 | D | 0 | 1 | P7B611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to ensure the provision of care in accordance with the Care Plan of one (1) resident (#68), regarding indwelling urinary catheter care, of six (6) sampled residents having indwelling urinary catheters, on the total survey sample of twenty-seven (27) residents. Findings Included: Resident #68's 04/30/2014 Quarterly Minimum Data Set assessment documented [DIAGNOSES REDACTED]. Resident #68's monthly July 2014 Physician order [REDACTED]. Review of Resident #68's current Care Plan dated 05/06/2014 revealed an entry originally dating from 11/12/0213 which identified the resident's use of an indwelling urinary catheter. This Care Plan listed Approaches, related to Resident #68's indwelling urinary catheter use, which included for staff to maintain the resident's urinary catheter system as a closed system as much as possible. However, during observations of Resident #68 on 07/21/14 at 11:31 a.m., and on 07/22/14 at 8:52 a.m., 10:20 a.m., and 5:00 p.m., the indwelling urinary catheter drainage bag was observed to leak urine onto the floor. An observation of Resident #68 on 07/23/14 at 8:42 a.m. then revealed the catheter drainage bag had been replaced and was no longer leaking. During an interview with the Treatment Nurse conducted on 07/23/2014 at 9:50 a.m., the Treatment Nurse acknowledged that prior to this standard survey, the most recent change of Resident #68's indwelling urinary catheter and catheter bag had occurred on 06/02/2014. Cross refer to F315 for more information regarding Resident #68. | 2017-10-01 |
| 6842 | 6842 | SEMINOLE MANOR NURSING HOME | 115712 | 100 FLORENCE STREET | DONALSONVILLE | GA | 39845 | 2014-07-24 | 315 | D | 0 | 1 | P7B611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to maintain the indwelling urinary catheter system in a manner to prevent leakage and the potential for urinary tract infections for one (1) resident (#68), whose indwelling urinary catheter drainage bag was observed to leak, of six (6) sampled residents having indwelling urinary catheters, on the total survey sample of twenty-seven (27) residents. Findings Included: Record review for Resident #68 revealed a Quarterly Minimum Data Set (MDS) assessment having an Assessment Reference Date of 04/30/2014 which documented a facility Entry Date of 12/06/2013, and documented in Section I - Active [DIAGNOSES REDACTED]. Section G - Functional Status of this MDS documented that Resident #68 was totally dependent on staff for toilet use. Section H - Bladder and Bowel of this MDS documented that Resident #68 utilized an indwelling urinary catheter, and Section M - Skin Conditions documented that Resident #68 had a Stage 3 pressure ulcer which had been present upon facility admission. Review of Resident #68's monthly July 2014 Physician order [REDACTED]. Observation of Resident #68 conducted on 07/21/2014 at 11:31 a.m., during the initial survey entry tour, revealed the resident's indwelling urinary catheter was intact; however, this observation also revealed that the indwelling urinary catheter drainage bag was leaking urine onto the floor. Observation of Resident #68 conducted on 07/22/2014 at 8:52 a.m. revealed the resident's indwelling urinary catheter drainage bag was again observed leaking urine onto the floor. Additional observations of Resident #68 conducted on 07/22/2014 at 10:20 a.m. and at 5:00 p.m. revealed the resident's indwelling urinary catheter drainage bag to continue to leak urine onto the floor. A subsequent observation of Resident #68 conducted on 07/23/2014 at 8:42 a.m. revealed the resident's indwelling urinary catheter drainage bag to have been re… | 2017-10-01 |
| 6843 | 6843 | SEMINOLE MANOR NURSING HOME | 115712 | 100 FLORENCE STREET | DONALSONVILLE | GA | 39845 | 2014-07-24 | 325 | D | 0 | 1 | P7B611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide follow-up related to a dietary supplement recommended by the Registered Dietician for one (1) resident (#67) upon the resident's facility readmission from the hospital after colon surgery, from a survey sample of twenty-seven (27) residents. Findings include: Record review for Resident #67 revealed a Quarterly Minimum Data assessment with an Assessment Reference Date of 06/18/2014 which documented in Section I - Active [DIAGNOSES REDACTED]. Review of Resident #67's Physician order [REDACTED]. A Vitals Report for Resident #67 documented that on 06/02/2014, prior to the resident's hospital admission for colon resection surgery, the resident's weight was 174.4 pounds. This Vitals Report then documented that upon Resident #67's readmission from the hospital to the nursing facility on 06/11/2014, his weight had declined to 162.2 pounds, thus representing a 12.2 pound, or 7 percent, weight loss while in the hospital. A Nutritional Re-Evaluation form for Resident #67, which was signed by the Registered Dietician (RD) and dated 06/18/2014, documented the resident's recent weight loss, and the RD recommended that the resident receive the dietary supplement Ensure twice a day between meals. However, further review of Resident #67's clinical record, to include review of the June 2014 and July 2014 Physician order [REDACTED].#67 receive Ensure as a dietary supplement. During an interview with the Director of Nurses (DON) conducted on 07/23/2014 at 11:45 a.m., the DON acknowledged that Resident #67 did not have a current physician's orders [REDACTED]. The DON also stated that the 06/18/2014 RD recommendation for Resident #67 should have been forwarded to the facility's Patient Care Coordinator for notification of the physician, but further acknowledged that this RD recommendation had not been forwarded. Further review of Resident #67's physician's orders [REDACTED].#67 receive one … | 2017-10-01 |
| 7392 | 7392 | SEMINOLE MANOR NURSING HOME | 115712 | 100 FLORENCE STREET | DONALSONVILLE | GA | 39845 | 2014-05-28 | 225 | D | 1 | 0 | JP8L11 | Based on staff interviews, resident interviews, and review of the facility's abuse policy,the facility failed to report an allegation of abuse and failed to follow their policy during investigations of alleged abuse, for one resident (A) from a sample of four (4) residents. Findings include: During an interview with the Director of Nursing (DON) on 5-28-14 at 2:30 pm, she stated that on 5-12-14, it was reported to her, that on the previous night on the 3 to 11 shift a certified nursing assistant(CNA) BB had an altercation with resident A. Per the DON, resident A asked the 3 to 11 shift charge nurse (CC) around 8:00 PM for someone to come in and to change her. Nobody had checked on her or changed her since the day shift CNA about 1:30 PM. The charge nurse CC asked CNA BB who was assigned to resident A to go and change her. CNA BB and a second CNA went into resident A's room to change her. As the CNA, BB went into the room, resident A started yelling at the CNA BB, why hadn't she checked and/or changed her since she came on duty at 3:00 pm. CNA BB began to argue with resident A. During the resident's interview on 5-28-14 at 4:30 PM resident A stated, the CNA came in my room mad. Per the resident the CNA BB slammed down both side-rails hard and 'snatched my brief off''. She said, she didn't want to work with me. Record review of a Resident-Family Complaint form dated 5/11/14 revealed that the 3 to 11 charge nurse CC was in the hallway outside of the room and heard the commotion and went into the room and asked, CNA BB to step out of the room. As CNA BB was leaving the room, resident A' called CNA BB a whore. CNA BB turned back into the room, and pointed her finger in resident A's face and told her to go look into a mirror and she would see a whore. Resident A was interviewed on 5-28-14, at 4:30 pm, she said, CNA BB and I really do not like each other. However per the resident, CNA BB had never gotten rough with her before. Resident A stated that if she had moved her head while the CNA BB pointed that finger in her f… | 2017-05-01 |
| 8117 | 8117 | SEMINOLE MANOR NURSING HOME | 115712 | 100 FLORENCE STREET | DONALSONVILLE | GA | 39845 | 2012-10-04 | 159 | E | 0 | 1 | JB8C11 | Based on record review and staff interview, it was determined that the facility had failed to ensure that residents' personal funds in excess of $50.00 was deposited in an interest bearing account for 35 residents who had authorized the facility to manage their personal funds. Findings include: A review of the resident trust fund accounts revealed that the facility had a fiduciary responsibility for 35 residents' personal funds. A review of residents' trust fund accounts ledger sheets for the period from March 2012 to August 2012 revealed that no interest had been credited to any of those accounts for the 35 residents. In an interview on 10/02/12 at 2:30 p.m., a facility business office representative AA said that the facility had stopped crediting the earned interest to the residents' trust fund accounts about a year ago when the bank, in which the facility had deposited the residents' money, had stopped paying interest on that account. The facility had failed to system to effectively manage the personal funds of Medicaid residents with more than $50 and that of Medicare residents with more than $100 for which it had a fiduciary responsibility by not ensuring that it was deposited in an interest bearing account. | 2016-07-01 |
| 8118 | 8118 | SEMINOLE MANOR NURSING HOME | 115712 | 100 FLORENCE STREET | DONALSONVILLE | GA | 39845 | 2012-10-04 | 282 | D | 0 | 1 | JB8C11 | Based on record review, observations and staff interviews, it was determined that the facility failed to implement care plan interventions for fall prevention for one resident (#61) in a sample of 34 residents. Findings include: Licensed nursing staff documented in the 9/11/12 nursing notes that resident #61 was in his/her room yelling. The resident was discovered on the floor at his/her bedside. Nursing staff documented that there were no visible injuries to the resident and he/she denied having any injuries. A review of the resident's care plan revealed that he/she was identified as being at risk for falls. There was an care plan intervention to prevent falls for nursing staff to apply a bed and chair alarm at all times. However, observations at 8 a.m. on 10/3/12 and 10/4/12 revealed that nursing staff had not effectively implement that intervention for the use of an alarm on 10/3/12 or applied it on 10/4/12 at 8 a.m. See F323 for additional information regarding resident #61. | 2016-07-01 |
| 8119 | 8119 | SEMINOLE MANOR NURSING HOME | 115712 | 100 FLORENCE STREET | DONALSONVILLE | GA | 39845 | 2012-10-04 | 323 | D | 0 | 1 | JB8C11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, it was determined that the facility failed to implement a planned intervention to promote the safety of one resident (#61) in a total sample of 34 residents. Findings include: 1. Resident #61 had [DIAGNOSES REDACTED]. On 10/01/12 at 4:12 p.m., licensed nursing staff stated that on 9/11/12, resident #61 was in his/her room and yelling. The resident was discovered on the floor at his/her bedside. Nursing staff noted that there were not any visible injuries to the resident and he/she denied having any injuries. A review of the resident's care plan revealed that he/she was identified as being at risk for falls. There was an care plan intervention to prevent falls for nursing staff to apply a bed and chair alarm at all times but, it was not done. During an observation with registered nurse BB on 10/03/12 at 8:00 a.m., the resident was in bed. Although, there was a tab alarm and a pressure-sensor alarm present, nursing staff had not turned them on so, they were not functioning. Following that observation, nurse BB activated the alarms and confirmed that both of them should have been on while the resident was in bed. During an observation on 10/04/12 at 8:00 a.m., the resident was in his/her room sitting in a wheelchair. However, staff had not applied a chair alarm to the wheelchair. This observation was confirmed by the facility's social worker at that time. | 2016-07-01 |
| 8120 | 8120 | SEMINOLE MANOR NURSING HOME | 115712 | 100 FLORENCE STREET | DONALSONVILLE | GA | 39845 | 2012-10-04 | 328 | E | 0 | 1 | JB8C11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interview, it was determined that the facility failed to ensure that respiratory care equipment and suction catheters were stored in a sanitary manner for seven (#61, #32, #6, #49, #54, #12, and #30) of 23 residents receiving oxygen therapy or suctioning. Findings include: According to The Johns Hopkins Hospital Clinical Practice Manual for Respiratory Equipment, respiratory equipment has a role as an important source of transmitting microorganisms causing respiratory diseases. All equipment should be covered when not in use. However, nursing staff had failed to cover respiratory equipment being used by residents #61, #32, #6, #49, #54, #12 and #30 to reduce the risk for contamination. 1. During observations in resident #61's room (104B) on 10/01/12 at 3:25 p.m., 10/02/12 at 9:29 a.m., and 10/03/12 at 8:05 a.m., there was an uncovered nasal cannula and nebulizer mask. The nasal cannula was attached to an oxygen cylinder on the back of a wheelchair. It was dangling approximately eight (8) inches above the floor between the back and seat of the wheelchair. 2. Resident #32 was observed in his/her room (102B) on 10/01/12 at 12:50 p.m., His/Her portable suction machine was on his/her overbed table. There was approximately 100 milliliters (ml.) of cloudy liquid in the suction cannister and an uncovered [MEDICATION NAME] suction tip on the overbed table. On 10/02/12 at 10:15 a.m., there was approximately 200 ml of cloudy liquid in the suction cannister and the uncovered suction tip was on the resident's overbed table. On 10/03/12 at 8:05 a.m., the suction cannister had been emptied but, the suction tip remained uncovered on the resident's overbed table. 3. Resident #6's was observed in his/her room (98B) on 10/01/12 at 3:00 p.m., 10/02/12 at 9:12 a.m., and 10/03/12 at 8:05 a.m. His/her uncovered nasal cannula was attached to a portable oxygen tank on the left side of his/her bed. 5. During an observation in resident #… | 2016-07-01 |
| 8121 | 8121 | SEMINOLE MANOR NURSING HOME | 115712 | 100 FLORENCE STREET | DONALSONVILLE | GA | 39845 | 2012-10-04 | 441 | F | 0 | 1 | JB8C11 | Based on record review and staff interview, it was determined that the facility failed to ensure that the infection control program contained effective surveillance. Findings include: Review of the facility's infection control log from June 2012 to August 2012 revealed that there was not any evidence that the facility had identified the causative organism and implemented strategies to prevent the spread of infection. The facility documented that eight residents had urinary tract infections in 6/12 and four residents had urinary tract infections in 7/12. There was not any evidence that staff did an infection summary for 8/12. Although the facility documented if cultures had been done, there was no documentation if the culture was positive for organisms. There was no documentation to indicate if the infections were nosocomial or community acquired. During an interview on 10/3/12 at 3:00 p.m., the infection control nurse confirmed that the facility's infection control surveillance documentation was incomplete. | 2016-07-01 |
| 9667 | 9667 | SEMINOLE MANOR NURSING HOME | 115712 | 100 FLORENCE STREET | DONALSONVILLE | GA | 39845 | 2011-03-03 | 281 | E | 0 | 1 | YS9Q11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the facility's policy and procedure on insulin administration and staff interview, it was determined that licensed nursing staff failed to consistently rotate the injection sites for insulin administration for five residents (#11, #4, #5, #12 and #2) who received subcutaneous insulin from a total sample of 15 residents. Findings include: The "Rules and Regulations for Nursing Homes, Chapter 290-5-8-.10 notes that all medications must be administered by medical or nursing personnel in accordance with the Medical and Nurse Practice Acts of the State of Georgia. According to the University of Wisconsin Hospitals and Clinics Authority, "Insulin Injection Sites" Health Information ( April 4, 2004), insulin could be irritating to the skin and underlying fatty tissue. Damaged tissue did not absorb insulin easily or at the correct rate. Therefore, rotating the injection sites for insulin administration helped prevent damage to the skin and tissue and, allowed for the correct absorption of insulin. The "Patient information: Diabetes mellitus type 2: insulin treatment" information, authored by David K. McCullough MD, noted that the site of injection could affect how injected insulin worked. He wrote: clinicians usually recommended rotating injection sites to minimize tissue irritation. According to the facility's Policy and Procedure for subcutaneous injections, licensed nursing staff were supposed to rotate the sites of injections to prevent unnecessary trauma and to aid in the absorption of the medication. Licensed nursing staff were supposed to document the date, time, type and site of the injection. However, licensed nursing staff failed to rotate insulin injection sites for residents #2, #4, #5, #11 and #12. 1. Resident #11 had a [DIAGNOSES REDACTED]. He/She had a physician's orders [REDACTED]. However, review of the Medication Administration Records (MARs) and Diabetic Flow Sheets revealed no evidence that licens… | 2015-06-01 |
| 9668 | 9668 | SEMINOLE MANOR NURSING HOME | 115712 | 100 FLORENCE STREET | DONALSONVILLE | GA | 39845 | 2011-03-03 | 282 | E | 0 | 1 | YS9Q11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and record review, it was determined that the facility failed to ensure that the plans of care were followed to provide supplements as ordered for one resident (#6), to rotate the insulin injection sites for one resident (#4), to provide appropriate incontinence care for three residents (#4, #5 and #13) and to ensure that the oxygen humidifier bottles were filled with water for two residents (#3 and #2) from a total sample of 15 residents. Findings include: 1. Resident #6 had [DIAGNOSES REDACTED]. He/she had unavoidable significant weight loss because of his/her [DIAGNOSES REDACTED]. The resident had a physician's orders [REDACTED]. The resident had a care plan intervention since 7/20/10 for staff to provide supplements as ordered. However, during observations of meals on 3/1/2011 at 12:25 p.m., on 3/2/2011 at 8:25 a.m., and on 3/3/2011 at 8:20 a.m., staff failed to serve the fortified milkshakes to the resident. See F325 for additional information regarding resident #6. 2. Resident #4 had [DIAGNOSES REDACTED]. The resident had a care plan since 12/14/10 with interventions that included licensed nursing staff to rotate injection sites for insulin doses. However, review of the resident's Medication Administration Records (MARs) and the Diabetic Flow Sheets revealed that there was no evidence that licensed nursing staff rotated the resident's insulin injection sites for 29 of 31 times in December 2010, for 31 of 31 times in January 2011, for 28 of 28 times in February 2011 and for 3 of 3 times in March 2011. See F281 for additional information regarding resident #4. Also, resident #4 had a care plan since 12/14/10 with interventions for nursing staff to provide incontinence care after each incontinent episode and to apply moisture barrier. However, during observation of urinary incontinence care provided on 3/2/11 at 11:05 a.m., nursing staff inappropriately wiped from the back to the front and failed to apply moisture barr… | 2015-06-01 |
| 9669 | 9669 | SEMINOLE MANOR NURSING HOME | 115712 | 100 FLORENCE STREET | DONALSONVILLE | GA | 39845 | 2011-03-03 | 328 | E | 0 | 1 | YS9Q11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, it was determined that the facility failed to properly store nebulizer equipment for two unsampled residents, failed to ensure that the humidifier bottles were adequately filled with water for two sampled residents (#2 and #3) and failed to date the oxygen tubing and humidifiers for 11 unsampled residents and for five (#1, #2, #3, #4 and #13) sampled residents, who utilized oxygen in a census of 19 residents in the facility with respiratory therapy orders. Findings include: According to the Johns Hopkins Hospital's Clinical Practice Manual for Respiratory Equipment, respiratory equipment was an important source of transmitting microorganisms causing respiratory diseases. The guideline for heated and cold nebulizers was for the entire set-up to be changed every 48 hours. The guideline for cleaning nebulizer equipment documented that the mouthpiece/mask should be rinsed with warm water and dried after each use and that all equipment should be covered when not in use. The guideline related to the use of oxygen noted that replacing the delivery system was to be done every 7 days. However, staff failed to change respiratory equipment for residents #2, #3, #4 and #13 and 11 unsampled residents, and failed to cover respiratory equipment when not in use for two unsampled residents. In an interview on 3/1/11 at approximately 9:00 a.m., licensed nurse stated that the facility did not have a system to monitor the care of respiratory equipment and that changes in the equipment were usually done on an 'as needed' basis. 1. During the Initial Tour on 3/1/2011 at 9:30 a.m. and on 3/3/2011 at 10:40 a.m., the tubing on the oxygen concentrator for the resident in room [ROOM NUMBER]A was not dated. 2. During the Initial Tour on 3/1/2011 at 9:30 a.m. and on 3/3/2011 at 10:41 a.m., the tubing on the oxygen concentrator for the resident in room [ROOM NUMBER]B was not dated. 3. During the Initial Tour on 3/1/… | 2015-06-01 |
| 9670 | 9670 | SEMINOLE MANOR NURSING HOME | 115712 | 100 FLORENCE STREET | DONALSONVILLE | GA | 39845 | 2011-03-03 | 325 | D | 0 | 1 | YS9Q11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, it was determined that the facility failed to ensure that nutritional supplements were provided as ordered by the physician for one resident (#6) in a sample of seven residents with weight loss from a total sample of 15 residents. Findings include: Resident #6 had [DIAGNOSES REDACTED]. He/She received Hospice services and had an unavoidable significant weight loss of 10 percent in six months from 130 pounds (9/2010) to 117 pounds (2/14/2010) due to his/her [DIAGNOSES REDACTED]. The resident had a physician's orders [REDACTED]. There was a care plan intervention since 7/2010 for staff to provide supplements as ordered. However, during observations of lunch on 3/1/2011 at 12:25 p.m., and breakfast on 3/2/2011 at 8:25 a.m. and on 3/3/2011 at 8:20 a.m., staff failed to serve the fortified milkshake to the resident. The resident's diet card documented that he/she was to be served milkshakes at each meal. Although staff had failed to serve the resident the fortified milkshake at those times, staff had inaccurately documented on the Percentage Sheets that the resident had consumed 60 percent of his/her supplement at lunch on 3/1/2011 and 100 percent of his/her supplement at breakfast on 3/2/2011. On 3/2/2011 at 1:05 p.m., the dietary manager stated that dietary staff were responsible for placing the resident's milkshake on his/her meal tray prior to the tray leaving the kitchen. On 3/3/2011 at 11:45 a.m., the Assistant Director of Nursing (ADON) stated that certified nursing assistants were responsible for checking the resident's diet card and ensuring that all the supplements were on the resident's tray prior to serving the resident. Although staff had failed to serve the resident the fortified milkshakes, staff were observed to implement other care plan interventions to prevent further weight loss for the resident such as serving Ensure pudding to him/her at each meal. | 2015-06-01 |
| 9671 | 9671 | SEMINOLE MANOR NURSING HOME | 115712 | 100 FLORENCE STREET | DONALSONVILLE | GA | 39845 | 2011-03-03 | 309 | D | 0 | 1 | YS9Q11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, it was determined that the facility failed to administer medication as ordered for one resident (#12) from a total sample of 15 residents. Findings include: Resident #12 had [DIAGNOSES REDACTED]. He/She had a physician's orders [REDACTED]. However, review of the resident's Medication Administration Records (MARs) and Diabetic Flow Sheets revealed that licensed nursing staff failed to administer the insulin as ordered on the 1/14 and 1/17/11 at 5:00 p.m. and on 2/9, 2/11, 2/21, and 2/25/11 at 5:00 p.m.. Licensed nursing staff documented that the insulin was held because the resident's fingerstick blood sugar (FSBS) levels were 118 on 1/14/11, 112 on 1/17/11, 113 on 2/9/11, 123 on 2/11/11, 72 on 2/21/11 and 153 on 2/25/11. There was not a physician's orders [REDACTED]. | 2015-06-01 |
| 9672 | 9672 | SEMINOLE MANOR NURSING HOME | 115712 | 100 FLORENCE STREET | DONALSONVILLE | GA | 39845 | 2011-03-03 | 315 | D | 0 | 1 | YS9Q11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations it was determined that the facility failed to provide effective incontinence care for three residents (#4, #5 and #13) from a sample of five incontinent residents from a total sample of 15 residents. Findings include: 1. Resident #4 had [DIAGNOSES REDACTED]. Licensed nursing staff coded the resident as requiring extensive assistance with personal hygiene and bathing on the 12/10/10 initial Minimum Data Set (MDS) assessment. He/She had a care plan since 12/14/10 with interventions that included nursing staff to provide incontinence care after each incontinent episode and to apply a moisture barrier. However, during an observation of urinary incontinence care being provided on 3/2/11 at 11:05 a.m., certified nursing assistant (CNA) "GG" inappropriately cleansed, rinsed and dried the resident's buttocks and rectal area from the back to the front. In addition, nursing staff "GG" failed to apply moisture barrier. 2. Resident #5 had [DIAGNOSES REDACTED]. Licensed nursing staff coded the resident as requiring total assistance with all activities of daily living on the 12/16/10 quarterly MDS assessment. He/She had a care plan since 5/1/08 with interventions for nursing staff to provide incontinence care and apply moisture barrier. However, during an observation of bowel and urinary incontinence care being provided on 3/2/11 at 10:45 a.m., CNA "HH" inappropriately wiped the resident from the rectal area to the vaginal area with a soiled washcloth. There was a small amount of bowel movement observed on the washcloth. In addition, nursing staff failed to apply moisture barrier. 3. Resident #13 had [DIAGNOSES REDACTED]. Licensed nursing staff coded the resident as requiring total assistance with all activity of daily living on the 1/27/11 quarterly MDS assessment. He/She had a care plan since 10/24/06 with interventions for nursing staff to provide incontinence care after each incontinent episode and to apply moisture barrier. Howev… | 2015-06-01 |
| 9673 | 9673 | SEMINOLE MANOR NURSING HOME | 115712 | 100 FLORENCE STREET | DONALSONVILLE | GA | 39845 | 2011-03-03 | 322 | D | 0 | 1 | YS9Q11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and record review, it was determined that the facility failed to ensure that one resident (#5) with a gastrostomy tube received the appropriate treatment to prevent complications from a sample of three residents with gastrostomy tubes from a total sample of 15 residents. Findings include: According to the "Best Practice Guidelines for Tube Feedings" by Ross Products Division/Abbott Laboratories, to minimize the risk of aspiration, the head of the bed should be between 30 - 45 degrees during and for 30 to 60 minutes after tube feeding. However, staff failed to maintain the head of the bed elevated for an appropriate time period following a bolus feeding for resident #5. Resident #5 had [DIAGNOSES REDACTED]. cal. Glucerna five times daily. During observation of incontinence care being provided on 3/2/11 at 10:45 a.m., which immediately followed an observation of a bolus feeding at 10:35 a.m., the certified nursing assistant lowered the resident's head of the bed to flat position (10 minutes after the feeding). | 2015-06-01 |
| 9674 | 9674 | SEMINOLE MANOR NURSING HOME | 115712 | 100 FLORENCE STREET | DONALSONVILLE | GA | 39845 | 2011-03-03 | 505 | D | 0 | 1 | YS9Q11 | **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 promptly notify the resident's attending physician about a high critical BUN and Creatinine and a low potassium level for one resident (#3) from a total sample of 15 residents. Findings include: Resident #3 had [DIAGNOSES REDACTED]. The resident had a history of [REDACTED]. On 12/2/10, the attending physician ordered one dose of 40 milliequivalents (meq.) of Potassium and repeat the potassium level in one week. On 12/9/10, a potassium level of 3.2 (low) was reported to the physician and he/she ordered potassium 20 meq. twice daily for two days and repeat a metabolic panel on 12/16/10. The laboratory staff contacted the facility on 12/16/10 at 6:38 a.m. with the laboratory test results of a low potassium level of 3.0, a high critical BUN level of 62 and a high critical creatinine level of 3.1. Review of the nurses notes and the laboratory's test results form revealed that nursing staff failed to notify the physician about those abnormal test results until 12/17/10 at 8:30 a.m. (more than 24 hours later). At that time, the physician ordered 20 meq. of potassium twice daily for three days and repeat a potassium blood level on 12/21/10. During an interview on 3/3/11 at 1:25 p.m., the Director of Nursing was unable to provide any reason for the delay in notification of the physician. | 2015-06-01 |
| 8401 | 8401 | HUTCHESON MED CTR SUBACUTE UNI | 115040 | 100 GROSS CRESCENT CIRCLE | FORT OGLETHORPE | GA | 30742 | 2011-09-22 | 170 | B | 0 | 1 | VTI211 | Based on staff interviews and facility policy the facility failed to ensure that mail is delivered promptly following delivery to the facility for one (1) resident (P) from a sample of twenty-one (21) residents. Interview with resident P conducted on 9/22/2011 at 9:30 a.m. revealed that Saturday mail is delivered on occasions when activities staff is in the building otherwise they get their mail on Monday. Interview with Administrator conducted on 9/22/2011 at 10:00 a.m. revealed that postal service delivers mail on Saturdays to the facility and restorative staff is responsible for delivering it to the residents. Occasionally, when activity staff work on Saturday, they sometime deliver the mail. The Administrator further indicated that she cannot swear that the mail is delivered to residents on every Saturday. Interview conducted with Activity Director on 9/22/2011 at 10:36 a.m. revealed that Activity staff delivers mail to residents on Saturdays, when they are scheduled to work, and other staff member should be delivering the mail when Activity staff are not at work. During the week days all mail is delivered by Activities Staff. There has been several occurrences in which mail that was delivered on Saturday from postal services was still in the facility's mail box on Monday morning. Review of facility policy revealed that mail is to be delivered to the residents, sealed and unopened, through the facility's normal mail delivery system. The Administrator indicated normal mail delivery is Monday thru Saturday. | 2016-01-01 |
| 8402 | 8402 | HUTCHESON MED CTR SUBACUTE UNI | 115040 | 100 GROSS CRESCENT CIRCLE | FORT OGLETHORPE | GA | 30742 | 2011-09-22 | 371 | D | 0 | 1 | VTI211 | Based on observation, and staff interviews, the facility failed to date and label open food items in the freezer in the building A kitchen. Findings include: On initial tour of the building A kitchen on 09/19/2011 at 1:35 p.m. with the Director of Dietary, the freezer contained french toast sticks, french fries, mandarin blend vegetables, and corn that had been opened and were labeled and dated. The Dietary Director acknowledged that the open containers should have been labeled and dated. Interview with BB on 09/21/2011 at 1:30 p.m., revealed that staff has been trained to store opened food in a labeled container with contents and date opened. Interview on 09/21/2011 at 1:40 p.m. with AA, revealed that any food being stored should be labeled with contents and the date opened. | 2016-01-01 |
| 8771 | 8771 | HUTCHESON MED CTR SUBACUTE UNI | 115040 | 100 GROSS CRESCENT CIRCLE | FORT OGLETHORPE | GA | 30742 | 2012-10-25 | 241 | D | 1 | 0 | HIQS11 | Based on resident interview and family interview, the facility failed to provide assistance with toileting as requested to maintain the dignity of three (3) residents (A, B, and C) from a survey sample of nine (9) residents. Findings include: During an interview with Resident A conducted on 10/12/2012 at 12:00 p.m., the resident stated that he/she had needed to have a bowel movement and when he/she had requested to be toileted by staff, he/she was told by the certified nursing assistant to go in the brief. The resident stated that this made him/her feel bad. The resident's spouse, who was in attendance at the time of this interview, stated that the resident was told to go in the brief routinely. During an interview with Resident B conducted on 10/12/2012 at 11:30 a.m., the resident stated that she had been eating dinner in her room when her roommate, Resident C, requested to be taken to the bathroom. Resident B stated that the certified nursing assistant told Resident C to go in the brief because staff could not take the resident to the bathroom during meals. Resident B stated that Resident C then had a bowel movement in her brief, further stating that she had a hard time eating her dinner because the smell was unpleasant. | 2015-10-01 |
| 9697 | 9697 | HUTCHESON MED CTR SUBACUTE UNI | 115040 | 100 GROSS CRESCENT CIRCLE | FORT OGLETHORPE | GA | 30742 | 2012-01-23 | 441 | D | 1 | 0 | 4O0411 | Based on observation, staff interview, and facility policy review, the facility failed to follow the infection control policy and ensure a sanitary environment related to the use of glucometers for four (4) residents (#7, #8, #9, and #10) in a survey sample of ten (10) residents. Findings include: Review of the operators manual for the glucometer used by the facility revealed that the machine was to be cleaned with a 10% bleach solution and that alcohol was not to be used. However, observation on 01/23/2012 of Nurse "AA" using the glucometer on Residents #7 and #8 at 11:34 a.m. and 11:38 a.m., respectively, revealed that the machine was not cleaned prior to the test on Resident #7, and was cleaned with alcohol after the blood was obtained and the tests were done on Residents #7 and #8. Observation of Patient Care Tech "BB" conducted on 01/23/2012 at 11:45 a.m. revealed that the glucometer was not cleaned prior to taking it into the room of Resident #9. Stains were observed on the over-bed table upon which the box containing the glucometer was placed. The Patient Care Tech was wearing gloves and placed the glucose strip on the over-bed prior to obtaining the blood sample. The glucose strip was then picked up and the resident's blood was placed on the strip. The hands were washed after the procedure, however, the glucometer was not cleaned after the test. Observation of Patient Care Tech "BB" conducted on 01/23/2012 at 11:50 a.m. revealed that the box with the glucometer was taken into the room of Resident #10 without being cleaned. The box with the glucometer was placed on the resident's over-bed table next to personal toiletry items. Wearing gloves, the Patient Care Tech placed the blood on the glucose strip and the test was completed. The hands were washed after the test, however, the glucometer was not cleaned. During an interview with the Infection Control Nurse conducted on 01/23/2012 at 3:00 p.m., this Nurse stated that the infection control policy was that reusable equipment was not used for the care of ano… | 2015-05-01 |
| 10528 | 10528 | HUTCHESON MED CTR SUBACUTE UNI | 115040 | 100 GROSS CRESCENT CIRCLE | FORT OGLETHORPE | GA | 30742 | 2010-12-14 | 309 | D | 7FWP11 | **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 treatments as ordered by the physician for two (2) residents (#s 1 and 2) in a survey sample of six (6) residents. Findings include: 1. Record review for Resident #1 revealed a 10/20/2010 physician's orders [REDACTED]. However, further record review, to include review of the November 2010 Treatment record, revealed no evidence to indicate that this treatment was done on 11/18/2010 at 9:00 a.m., and on 11/01/2010, 11/02/2010, 11/03/2010, 11/23/2010 and 11/27/2010 at 9:00 p.m., as ordered and scheduled. 2. Record review for Resident #2 revealed an 11/04/2010 physician's orders [REDACTED]. However, further record review, to include review of the November 2010 Treatment record, revealed no evidence to indicate that this treatment was done on the 7:00 a.m.-7:00 p.m. shift on 11/07/2010, 11/08/2010, 11/09/2010, 11/12/2010, 11/14/2010, 11/23/2010, 11/26/2010, 11/27/2010, and 11/28/2010, as ordered and scheduled. During an interview with Nurse "AA" conducted on 12/14/2010 at 1:45 p.m., this nurse acknowledged that the treatments referenced above were not done as ordered for Resident #1 and Resident #2. | 2014-04-01 | ||
| 3904 | 3904 | NORTHRIDGE HEALTH AND REHABILITATION | 115714 | 100 MEDICAL CENTER DRIVE | COMMERCE | GA | 30529 | 2019-01-10 | 600 | J | 0 | 1 | XS0411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility record review, staff and resident interviews, it was determined the facility failed to ensure two residents (R) (R#121 and R#55) from a sampled 57 residents were free from physical and psychological abuse. R#121 was subjected to a painful failed urinary catheter insertion along with verbal threats from a staff member. Five days later on 12/23/18, R#55 was subjected to painful dis-impaction removal of stool by the same employee. On 1/8/19, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator, Director of Nursing, and the Regional Nurse Consultant and Regional Nurse Consultant were informed of the immediate jeopardy on 1/8/19 at 5:14 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on 12/18/18. The immediate jeopardy continued through 1/9/19 and was removed on 1/10/19. The immediate jeopardy was related to the facility's noncompliance with the program requirements at 42 C.F.R. 483.12 (a)(a)(1), Freedom from Abuse, Neglect, and Exploitation (F600, Scope/Severity: J); 42 CFR 483.12(b)(1)?(4), Develop/Implement Abuse/Neglect, etc. Policies (F607, Scope/Severity: J); 42 CFR 483.12(c)(2)?(4) Alleged Violations-Investigate/Prevent/Correct (F610, Scope/Severity: J); 42 C.F.R. 483.21(b)(3)(i), Professional Standards (F658, Scope/Severity: J); 42 C.F.R. 483.70, Administration (F835, Scope/Severity: J). Additionally, Substandard Quality of Care was identified at: F600, Freedom from Abuse, Neglect and Exploitation F607, Develop/Implement Abuse/Neglect, etc. Policies F610, Alleged Violations-Investigate/Prevent/Correct A Credible Allegation of Compliance was received on 1/10/19. Based on observations, record reviews, interviews and review of the facility's policies and staff training as outlined in th… | 2020-09-01 |
| 3905 | 3905 | NORTHRIDGE HEALTH AND REHABILITATION | 115714 | 100 MEDICAL CENTER DRIVE | COMMERCE | GA | 30529 | 2019-01-10 | 607 | J | 0 | 1 | XS0411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, review of the facility's abuse investigation, and review of facility policy titled Abuse Prohibition, it was determined the facility failed to implement abuse interventions for two alleged abuse incidents involving residents (R) R#121 and R#55 by the same employee. The facility failed to implement a thorough investigative process for R#121. The facility failed to implement a monitoring system of the alleged perpetrator thereby leading a second abuse incident involving R#55. The survey sample was 57 residents. On 1/8/19, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator, Director of Nursing, and the Regional Nurse Consultant and Regional Nurse Consultant were informed of the immediate jeopardy on 1/8/19 at 5:14 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on 12/18/18. The immediate jeopardy continued through 1/9/19 and was removed on 1/10/19. The immediate jeopardy was related to the facility's noncompliance with the program requirements at 42 C.F.R. 483.12 (a)(a)(1), Freedom from Abuse, Neglect, and Exploitation (F600, Scope/Severity: J); 42 CFR 483.12(b)(1)?(4), Develop/Implement Abuse/Neglect, etc. Policies (F607, Scope/Severity: J); 42 CFR 483.12(c)(2)?(4) Alleged Violations-Investigate/Prevent/Correct (F610, Scope/Severity: J); 42 C.F.R. 483.21(b)(3)(i), Professional Standards (F658, Scope/Severity: J); 42 C.F.R. 483.70, Administration (F835, Scope/Severity: J). Additionally, Substandard Quality of Care was identified at: F600, Freedom from Abuse, Neglect and Exploitation F607, Develop/Implement Abuse/Neglect, etc. Policies F610, Alleged Violations-Investigate/Prevent/Correct A Credible Allegation of Compliance was received on 1/10/19. Based on observations, record reviews,… | 2020-09-01 |
| 3906 | 3906 | NORTHRIDGE HEALTH AND REHABILITATION | 115714 | 100 MEDICAL CENTER DRIVE | COMMERCE | GA | 30529 | 2019-01-10 | 610 | J | 0 | 1 | XS0411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and review of facility investigations, it was determined the facility failed to thoroughly investigate the 12/18/18 incident where R#121 was subjected to a painful urinary catheter insertion and verbal threats. The facility failed to develop preventive measures in place to ensure no other vulnerable residents experience abuse from the same nurse. This failure resulted in the 12/23/18 incident in which R#55 was subject painful removal of stool by the same nurse. The sample size was 57. This deficient practice created the potential that abuse would go unrecognized, not addressed, and perpetuate a culture in which abuse could occur. On 1/8/19, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator, Director of Nursing, and the Regional Nurse Consultant and Regional Nurse Consultant were informed of the immediate jeopardy on 1/8/19 at 5:14 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on 12/18/18. The immediate jeopardy continued through 1/9/19 and was removed on 1/10/19. The immediate jeopardy was related to the facility's noncompliance with the program requirements at 42 C.F.R. 483.12 (a)(a)(1), Freedom from Abuse, Neglect, and Exploitation (F600, Scope/Severity: J); 42 CFR 483.12(b)(1)?(4), Develop/Implement Abuse/Neglect, etc. Policies (F607, Scope/Severity: J); 42 CFR 483.12(c)(2)?(4) Alleged Violations-Investigate/Prevent/Correct (F610, Scope/Severity: J); 42 C.F.R. 483.21(b)(3)(i), Professional Standards (F658, Scope/Severity: J); 42 C.F.R. 483.70, Administration (F835, Scope/Severity: J). Additionally, Substandard Quality of Care was identified at: F600, Freedom from Abuse, Neglect and Exploitation F607, Develop/Implement Abuse/Neglect, etc. Policies F610, Alleged Violations-Invest… | 2020-09-01 |
| 3907 | 3907 | NORTHRIDGE HEALTH AND REHABILITATION | 115714 | 100 MEDICAL CENTER DRIVE | COMMERCE | GA | 30529 | 2019-01-10 | 658 | J | 0 | 1 | XS0411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the Georgia Practical Nurses Practice Act, it was determined the facility failed to ensure professional standards of care were maintained for two residents (R) (R#121 and R#55) from a sampled 57 residents. Specifically, nursing staff were not following the standard of care related to urinary catheter insertion for R#121 and the treatment for [REDACTED]. On 1/8/19, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator, Director of Nursing, and the Regional Nurse Consultant and Regional Nurse Consultant were informed of the immediate jeopardy on 1/8/19 at 5:14 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on 12/18/18. The immediate jeopardy continued through 1/9/19 and was removed on 1/10/19. The immediate jeopardy was related to the facility's noncompliance with the program requirements at 42 C.F.R. 483.12 (a)(a)(1), Freedom from Abuse, Neglect, and Exploitation (F600, Scope/Severity: J); 42 CFR 483.12(b)(1)?(4), Develop/Implement Abuse/Neglect, etc. Policies (F607, Scope/Severity: J); 42 CFR 483.12(c)(2)?(4) Alleged Violations-Investigate/Prevent/Correct (F610, Scope/Severity: J); 42 C.F.R. 483.21(b)(3)(i), Professional Standards (F658, Scope/Severity: J); 42 C.F.R. 483.70, Administration (F835, Scope/Severity: J). Additionally, Substandard Quality of Care was identified at: F600, Freedom from Abuse, Neglect and Exploitation F607, Develop/Implement Abuse/Neglect, etc. Policies F610, Alleged Violations-Investigate/Prevent/Correct A Credible Allegation of Compliance was received on 1/10/19. Based on observations, record reviews, interviews and review of the facility's policies and staff training as outlined in the Credible Allegation of Compliance, it was v… | 2020-09-01 |
| 3908 | 3908 | NORTHRIDGE HEALTH AND REHABILITATION | 115714 | 100 MEDICAL CENTER DRIVE | COMMERCE | GA | 30529 | 2019-01-10 | 835 | J | 0 | 1 | XS0411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews it was determined that Administration failed to ensure that the facility was administered in a manner that enabled it to use its resources effectively and efficiently to ensure each resident attained or maintained the highest possible level of physical, mental and psychological well-being. The Administration failed to conduct a thorough investigation of an employee's verbal threats and physical abusive actions for Resident (R) #121 on 12/12/18 while attempting to insert an indwelling urinary catheter and for disregarding R #55's complaints of pain during a rectal dis-impaction to remove stool on 12/23/18. The facility census was 151 residents. On 1/8/19, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator, Director of Nursing, and the Regional Nurse Consultant and Regional Nurse Consultant were informed of the immediate jeopardy on 1/8/19 at 5:14 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on 12/18/18. The immediate jeopardy continued through 1/9/19 and was removed on 1/10/19. The immediate jeopardy was related to the facility's noncompliance with the program requirements at 42 C.F.R. 483.12 (a)(a)(1), Freedom from Abuse, Neglect, and Exploitation (F600, Scope/Severity: J); 42 CFR 483.12(b)(1)?(4), Develop/Implement Abuse/Neglect, etc. Policies (F607, Scope/Severity: J); 42 CFR 483.12(c)(2)?(4) Alleged Violations-Investigate/Prevent/Correct (F610, Scope/Severity: J); 42 C.F.R. 483.21(b)(3)(i), Professional Standards (F658, Scope/Severity: J); 42 C.F.R. 483.70, Administration (F835, Scope/Severity: J). Additionally, Substandard Quality of Care was identified at: F600, Freedom from Abuse, Neglect and Exploitation F607, Develop/Implement Abuse/Neglect, etc. Policie… | 2020-09-01 |
| 3909 | 3909 | NORTHRIDGE HEALTH AND REHABILITATION | 115714 | 100 MEDICAL CENTER DRIVE | COMMERCE | GA | 30529 | 2016-11-03 | 157 | D | 0 | 1 | BL1O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to notify the responsible party (RP) of a change in treatment for 1 resident (R) (R#188) with severe cognitive impairment. The sample was twenty five (25) resiednts. Findings include: Record review for R#188 revealed the resident had a [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment for R#188 dated 7/7/16 revealed a Brief Interview for Mental Status (BIMS) summary score of 6 indicating severe cognitive impairment. A telephone interview conducted on 10/31/2016 at 11:45 a.m. with the complainant/RP for R#188 revealed he had concerns with the facility withdrawing money from R#188's personal funds account to purchase a sexual device without notifying him first. The complainant/RP stated the Social Worker and the Unit Nurse called him after the device had already been purchased and attempted to let R#188 to try it. He further stated they asked him to pick up this sexual device because R#188 was not able to use it. The complainant said R#188 has Alzheimer ' s and does not remember anything. He is the representative of R#188's funds and the facility should have contacted him before they purchased this item. The complainant stated that he facility should have informed him and of their decision to purchase and try a sexual device because he would have told them no and does not agree with it. Review of the care plan for R #188 identified the resident had inappropriate behaviors with an intervention to purchase of a personal item for possible relief of sexual desires at the resident's request. The care plan revealed that the family discontinued the intervention. The note did not provide a date for the discontinuation of the intervention. Review of a Social Service note dated 10/3/16 documented the faimily/RP of R#188 was notified of the purchase of a personal item to assist in possible relief of sexual desires on 9/30/16 and the family expressed an understanding. Review… | 2020-09-01 |
| 3910 | 3910 | NORTHRIDGE HEALTH AND REHABILITATION | 115714 | 100 MEDICAL CENTER DRIVE | COMMERCE | GA | 30529 | 2016-11-03 | 159 | D | 0 | 1 | BL1O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to notify the responsible party (RP) for 1 resident (R) (R#188) with severe cognitive impairment, prior to withdrawing personal funds for the purchase of a personal sexual device. The sample was twenty five (25) residents. Refer F157 Findings include: A telephone interview conducted on 10/31/2016 at 11:45 a.m. with the complainant/RP for R#188 revealed he had concerns with the facility withdrawing money from R#188's personal funds account to purchase a sexual device without notifying him first. The complainant/RP stated the Social Worker and the Unit Nurse called him after the device had already been purchased and attempted to let R#188 to try it. He further stated they asked him to pick up this sexual device because R#188 was not able to use it. The complainant said R#188 has Alzheimer ' s and does not remember anything. He is the representative of R#188's funds and the facility should have contacted him before they purchased this item. The complainant stated that he facility should have informed him and of their decision to purchase and try a sexual device because he would have told them no and does not agree with it. Record review for R#188 revealed the resident had a [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment for R#188 dated 7/7/16 revealed a Brief Interview for Mental Status (BIMS) summary score of 6 indicating severe cognitive impairment. Review of the Patient Trust Fund Authorization Agreement dated 1/13/16 for R#188 revealed the RP signed the agreement authorizing the facility to make personal petty cash withdrawals and pay for barber/beauty charges from the resident's personal trust fund account. Review of R#188's personal trust fund account summary revealed a withdrawal in the amount of forty-three dollars and eighty-five cents ($43.85). The withdrawal posted to the account on 10/3/16. Record review for R#188 revealed a receipt dated 9/30/16 i… | 2020-09-01 |
| 3911 | 3911 | NORTHRIDGE HEALTH AND REHABILITATION | 115714 | 100 MEDICAL CENTER DRIVE | COMMERCE | GA | 30529 | 2016-11-03 | 253 | D | 0 | 1 | BL1O11 | Based on observation, interview, and record review, the facility failed to maintain a clean, comfortable and sanitary environment on two (2) of five (5) halls. Findings include: Observation on 11/01/2016 at 10:49 a.m. and 11/03/2016 at 08:17 a.m. of Room 264 revealed a strong urine odor in the resident bathroom, which was a shared bathroom. Observation on 10/31/2016 at 12:00 p.m. and 11/03/2016 at 08:10 a.m. of Room 283 revealed a strong urine odor in the resident bathroom, which was a shared bathroom. Observation on 10/31/2016 at 12:10 p.m. and 11/03/2016 at 08:14 a.m. of Room 275 revealed a strong urine odor in the resident bathroom, which was a shared bathroom. Observation of dried brown material on the arm of the raised toilet seat and a brown build-up around the base of the toilet. Debris was also observed in the heating and air conditioning unit. Observation on 11/01/2016 at 09:04 a.m. and 11/03/2016 at 08:15 a.m. of Room 271 revealed that the privacy curtain between the A and B bed had black circular stains towards the bottom of the curtain. Observation on 10/31/2016 at 12:05 p.m. and 11/03/2016 at 11:50 a.m., in the hallway on C-Unit revealed that the handrail near the dining area had a corner bumper with an area that was uncovered and a gap in the handrail of approximately 1 inch. The handrail near the dinning room on C Unit, was also observed to have one of the supporting brackets that had broken through the sheetrock. The handrail had multiple supporting brackets and so was secure on the wall at this time. Interview and observation on 11/03/2016 at 12:08 p.m. with Head of Housekeeping revealed that environmental services was responsible for preventing chronic odors in the bathrooms. During the interview, he stated that they had a chemical that would break down the build up in the bathrooms that created the odor. He confirmed that there was a strong urine odor in the above listed bathrooms, dried brown material on the arm of the raised potty seat in Room 275 which was a shared bathroom and that there wa… | 2020-09-01 |
| 3912 | 3912 | NORTHRIDGE HEALTH AND REHABILITATION | 115714 | 100 MEDICAL CENTER DRIVE | COMMERCE | GA | 30529 | 2016-11-03 | 371 | E | 0 | 1 | BL1O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, and document review the facility failed to ensure opened and bulk food items were covered, labeled and dated in one (1) of two (2) walk in refrigerators, baking dry storage area and shelving unit under stainless steel food preparation table. The facility failed to discard food by the use by date and failed to ensure the stand-up mixer was clean and sanitary. This deficient practice had the potential to effect one hundred fifty two (152) residents receiving an oral diet. Findings include: Observation on 10/31/16 at 2:10 p.m. of walk-in refrigerator #1 revealed an opened 1 gallon container of Fat Free Raspberry Vinaigrette and 1 gallon container of French Dressing with no date. Observation on 10/31/16 at 2:35 p.m. of 2 white storage bins with wheels containing sugar and flour revealed the clear plastic lid to the sugar bin was left opened. Observation on 10/31/16 at 2:40 p.m. of the wire storage rack towards the back of the kitchen containing baking supplies revealed three (3), fourteen (14) ounce cans of Nestle La Lechera sweetened condensed milk with a use by date of [DATE]. Observation on 10/31/16 at 3:00 p.m. of the stand-up mixer revealed it was covered with a frosted white plastic bag which had black marking stating cleaned and sanitized on 10/23. The plastic bag was removed from the mixer which revealed inside the mixing bowl was a dark brown substance on the bottom that was 2 inches in length and one eighth (1/8) inch in width. Continued observation revealed the dark brown substance was on the mixing beater in 2 spots the size of a pencil eraser. Further observation revealed the Food Service Director touching the underside of the mixing arm and their hand was covered with the dark brown substance, surveyor touched the area under the mixing arm and the brown substance was sticky to touch and had the smell of grease. Observation on 10/31/16 at 3:10 p.m. of a large white rectangle storage bin under a… | 2020-09-01 |
| 3913 | 3913 | NORTHRIDGE HEALTH AND REHABILITATION | 115714 | 100 MEDICAL CENTER DRIVE | COMMERCE | GA | 30529 | 2016-11-03 | 514 | D | 0 | 1 | BL1O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and record review, the facility failed to consistently document wound assessments to reflect measurements and staging of a pressure ulcer for one (1) of three (3) sampled residents (R) (R#187) with pressure ulcers. The sample size was twenty-five (25). Findings include: Staff interview on 11/01/2016 at 08:00 a.m. with Registered Nurse (RN)/Treatment Nurse AA revealed that R#187 had a terminal ulcer on right heel that was covered with eschar. The resident was receiving hospice services and was care planned for decline. The interview also revealed that the resident had an unstageable ulcer to the right lateral calf also along with multiple [MEDICAL CONDITION]. Review of the Treatment Administration Record (TAR) for R#187 revealed a wound to the right calf and right lateral foot. Neither wound was staged or identified as to type of wound. Review of Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed that R#187 was receiving Hospice Services, had a Brief Interview of Mental Status (BIMS) summary score of 10, indicating moderate cognitive impairment, was always incontinent of bladder and bowel and had active [DIAGNOSES REDACTED]. Observation and interview on 11/02/2016 at 10:10 a.m. of wound care for R#187 with RN AA revealed no concerns. The wound on the right heel was covered with eschar, it measured 2.5 x 2.5 centimeter. Wound on right MTPJ was covered with eschar, it measured 2.5 x 2 centimeters. The wound on the right lateral foot was covered with eschar, it measured 2 x 1.7 centimeters, the wound on the right ankle had been covered by an eschar cap but it has sloughed off according to the wound care nurse, the total area for this wound measures1 x 1 centimeters and the open area measures 0.5 x 0.5 centimeters. This area had a small to moderate amount of bright red bleeding, indicating that there was some blood flow. The wound to the right lateral calf was treated every other day an… | 2020-09-01 |
| 5064 | 5064 | NORTHRIDGE HEALTH AND REHABILITATION | 115714 | 100 MEDICAL CENTER DRIVE | COMMERCE | GA | 30529 | 2015-04-09 | 309 | D | 0 | 1 | 79CJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews, the facility failed to document the Arteriovenous Fistula (AV) site for bruit and thrill in the Medication Administration Record [REDACTED]. The resident sample size was thirty-four (34). Findings include: Resident #117 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Review of the clinical records for resident #117 revealed that the physician's orders [REDACTED]. Further review of the resident's MAR from 03/01/15 through 04/08/15 revealed that there was no evidence of documentation showing that licensed staff had checked the resident's AV fistula for bruit and thrill as ordered. Interview on 04/09/15 at 9:25 a.m. with Licensed Practical Nurse (LPN) GG revealed that she checks resident #117's AV fistula every shift for bruit and thrill, but does not record it on the MAR indicated [REDACTED]. Continued interview revealed that she could not explain why licensed staff did not document checking the AV Fistula for bruitt and thrill for over one month, despite the resident receiving [MEDICAL TREATMENT] since admission on 08/03/11. LPN GG confirmed that the MAR indicated [REDACTED]. Interview on 04/09/15 at 10:15 a.m. with Registered Nurse (RN) FF consultant for Ethica and the Director of Nursing (DON) revealed that they expect licensed staff to document when the bruit and thrill are checked on the resident's MAR. They both confirmed that the MAR for checking AV fistula to left upper arm bruit and thrill had not been documented from 03/01/15 through 04/09/15. The DON acknowledged that it was basic nursing practice to document that the bruit and thrill were completed as ordered by the physician. Continued interview with the DON revealed that she expected licensed staff to document that the fistula site had been checked as soon as it was completed. Observation on 04/09/15 at 9:30 a.m. revealed LPN GG adding in the times for nursing staff to complete checking the AV f… | 2019-02-01 |
| 5065 | 5065 | NORTHRIDGE HEALTH AND REHABILITATION | 115714 | 100 MEDICAL CENTER DRIVE | COMMERCE | GA | 30529 | 2015-04-09 | 328 | D | 0 | 1 | 79CJ11 | Based on observations, staff interview and review of facility records/policies, the facility failed to ensure that oxygen concentrator filters were clean for two (2) of thirty-one (31) residents (#192,#156) that received continuous oxygen therapy. Findings include: Observation of resident #192 on 04/06/15 at 9:20 a.m. during intial tour of the facility revealed the resident resting in bed receiving oxygen therapy via nasal cannula at two liters per min (2L/Min). The oxygen concentrator located at the residents bedside had one filter which was heavily covered in white lint. Observation of resident #192 on 04/06/15 at 2:35 p.m. revealed the resident sitting up in bed watching television with continuous oxygen therapy via nasal cannula at 2L/min in progress. The oxygen concentrator was still heavily covered in white lint. Observations of resident #192 on 4/07/15 at 9:25 a.m. and again on 04/08/15 at 8:00 a.m. revealed the resident in her room with continuous oxygen via nasal cannula at 2L/min in progress. The residents oxygen filter continued to be heavily covered in white lint and the sterile water bottle was not labeled or dated. Observations of Unit D on 4/06/15 at 9:25 a.m., 04/07/15 at 2:23 p.m. and again on 04/08/15 at 9:27 a.m. revealed that resident #156 was receiving oxygen therapy via nasal cannula at 2L/min. The oxygen concentrator had a filter which was heavily covered with white lint. Random observations on Units A, B, C and E conducted on 04/08/15 at 10:30 a.m. revealed that there were a total of (31) thirty-one residents in the facility receiving oxygen therapy. Twenty-nine (29) of those residents had clean oxygen concentrators filters. During observation rounds of resident #192 and resident #156 with the Director of Nursing (DON) on 4/08/15 at 10:49 a.m. she confirmed that the oxygen concentrator filters for both residents were heavily covered in lint. The DON further revealed that the filters had not been changed per facility policy. Continued interview revealed that maintenance was responsible for … | 2019-02-01 |
| 5066 | 5066 | NORTHRIDGE HEALTH AND REHABILITATION | 115714 | 100 MEDICAL CENTER DRIVE | COMMERCE | GA | 30529 | 2015-04-09 | 371 | E | 0 | 1 | 79CJ11 | Based on observations and staff interview the facility failed to ensure food items in one (1) of two (2) walk-in refrigerators had valid expiration dates; failed to properly clean stand-up mixer and meat slicer after usage; failed to properly maintain the cleanliness of 1 of five (5) resident nourishment freezers. The census during the survey was one hundred forty (140). Findings include: 1. Observation on 04/06/15 at 9:30 a.m. revealed the kitchen had two (2) walk-in refrigerators and the first walk-in refrigerator contained dairy products. Continued observation of the dairy walk-in refrigerator revealed there were 5, thirty two (32) ounce containers of vanilla flavored Dannon yogurt and 1, (32) ounce container of strawberry flavored Dannon yogurt with an expiration date of (MONTH) 03, (YEAR). Interview on 04/06/15 at 9:30 a.m. with the Dietary Manager (DM) revealed that he expects staff to review the expiration dates on food products when being stored in the walk-in refrigerator. He confirmed that the six (6) containers of Dannon flavored yogurts were expired. The DM acknowledged that the expired yogurt was in the walk-in refrigerator and that food items should have a current/valid expirations date. He further revealed that he expects staff to throw way expired food items. Observation on 04/06/15 at 9:45 a.m. of the stand-up mixer revealed that it was covered with a clear plastic bag. When the clear plastic bag was removed there was a powdery white substance covering the area under the mixing arm where the beater would be attached. Continued observation of the stand-up mixer revealed that there was also an orange food substance under the mixing arm. The orange food substance was two (2) inches in length and one half (1/2) inch in width near where that beater would be attached. Interview on 04/06/15 at 9:45 a.m. with the DM revealed that when the clear plastic bag is covering any kitchen equipment it is expected that the equipment is clean and ready for use. He confirmed that the stand-up mixer had the powdery w… | 2019-02-01 |
| 5067 | 5067 | NORTHRIDGE HEALTH AND REHABILITATION | 115714 | 100 MEDICAL CENTER DRIVE | COMMERCE | GA | 30529 | 2015-04-09 | 441 | D | 0 | 1 | 79CJ11 | Based on observations and staff interviews the facility failed to ensure appropriate infection control measures were followed during the provision of direct care for one (1) resident (#129) who had a positive urine culture for Extended Spectrum Beta Lactamase (ESBL). The facility also failed to wash or sanitize hands during the delivery, set-up, and assistance between residents during one (1) of two (2) dining observations. The census was one hundred and forty (140) residents, with one hundred and thirty-four (134) of whom received oral alimentation. Findings include: 1. Observation of resident #129 on 04/06/15 at 4:00 p.m. revealed that the resident was on isolation precautions. Further observation revealed a sign on the resident's door indicating the need to see the nurse before entering the resident's room. An Isolation cart with Personal Protective Equipment (PPE) was noted outside of the resident's door. Interview with Registered Nurse (RN) BB on 04/07/2015 at 9:00 a.m., BB confirmed that resident #129 was on contact isolation for ESBL in her urine and indicated the ESBL was detected in the resident's labs on 04/02/15. RN BB revealed that staff was to don PPE before entering the room and to remove the PPE before exiting the room. BB added that the staff had also been instructed to wash their hands or to use the hand sanitizer before leaving the room. Continued interview revealed that there was a sign outside the resident's door requesting that all visitors see the nurse before entering the resident's room for instructions on how and why to wear the PPE. Observation of Certified Nursing Assistant (CNA) DD on 04/08/15 at 8:40 a.m. revealed DD entering the room of resident #129 after donning gloves only before entering the room. DD was observed in resident #129's room readjusting the resident's linens and reaching over and leaning against the resident's bed while assisting the resident. DD was observed leaving the room without washing her hands after removing her gloves. Interview with the Director of Nursing (… | 2019-02-01 |
| 6300 | 6300 | NORTHRIDGE HEALTH AND REHABILITATION | 115714 | 100 MEDICAL CENTER DRIVE | COMMERCE | GA | 30529 | 2013-11-14 | 371 | F | 0 | 1 | 3YTE11 | Based on observation, and staff interviews the facility failed to properly sanitize pots and pans in the three (3) compartment sink. This failure effected all residents receiving oral alimentation or one hundred and thirty five (135) residents. Findings include the following : 1. Observation on 11/11/2013 at 11:45 a.m., of the three (3) compartment sink located in the dish washing area revealed that there were pots soaking in the wash compartment of the sink. The Quaternary sanitizing sink was full with no pots or pans in it. The Sanitizer solution was tested with the solution registering 0 ppm. Normal range per manufacturer recommendation was 150 parts per million (ppm)-200 ppm. Review of the daily Sanitizer Reporting Log for 11/11/13 read 200 ppm. Interview with the Food Service Director on 11/13/13 at 12:19 p.m., revealed that the EcoLab representative needed to come in to re-educate the employees on the use of the Sanitizer solution, and how to read the strips. | 2018-02-01 |
| 7657 | 7657 | NORTHRIDGE HEALTH AND REHABILITATION | 115714 | 100 MEDICAL CENTER DRIVE | COMMERCE | GA | 30529 | 2014-02-20 | 224 | J | 1 | 0 | LWSQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, staff interview, hospital ER Triage Record review, and facility Follow-Up Report review, the facility failed to prevent neglect by failing to ensure that the WanderGuard system, utilized by facility staff for the supervision of residents at risk for elopement/wandering behavior on the first floor Units B and C, provided alarm coverage which included a set of unlocked doors located in a first floor corridor which was accessible to Unit B and Unit C residents, and which exited the nursing facility into the adjoining hospital. This failure resulted in neglect by allowing the elopement of one (1) Unit B resident (#1), who was at risk for wandering/elopement and who utilized a WanderGuard bracelet, on the total survey sample of fourteen (14) residents. Resident #1, while wearing a WanderGuard bracelet, was able to access this unsecured first-floor corridor on 02/09/2014, pass through the unalarmed corridor doors, exit the nursing facility through this corridor, enter the adjoining hospital and elope. Resident #1 then fell and hit his/her head on pavement, was taken to the hospital emergency room and found to have facial abrasions, a nasal laceration requiring sutures, a nasal fracture, and a fractured right knee cap. This resulted in a situation in which the facility's non-compliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator and Director of Nursing were informed of the immediate jeopardy on February 18, 2014 at 9:30 a.m. The non-compliance related to the immediate jeopardy was identified to have existed on February 9, 2014 (the date Resident #1 eloped from the facility via a set of unlocked, unalarmed, and unsecured doors located within a corridor which lead from the nursing facility to the adjoining hospital), continued through February 18, 2014, and was removed on Febr… | 2017-02-01 |
| 7658 | 7658 | NORTHRIDGE HEALTH AND REHABILITATION | 115714 | 100 MEDICAL CENTER DRIVE | COMMERCE | GA | 30529 | 2014-02-20 | 282 | K | 1 | 0 | LWSQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, facility staff interview, hospital ED Nursing Record review, hospital ED Discharge Instructions review, and facility Follow-Up Report review, the facility failed to ensure resident supervision for elopement/wandering behavior, in accordance with the Care Plan which specified WanderGuard bracelet use to address elopement/wandering behavior, by failing to ensure that the WanderGuard system provided protection which included a set of double doors located in one (1) first floor corridor which was accessible to Unit B and Unit C residents, and which exited the nursing facility into an adjoining hospital facility. The failure of the facility to ensure WanderGuard alarm protection on the double doors contained within this unsecured corridor allowed this corridor to serve as an unsecured route of exit for one (1) resident (#1) who eloped through this corridor, and as a potential unsecured route of exit for four (4) additional residents (#5, #11, #12, and #14), whose Care Plans specified the use of WanderGuard bracelets to address known elopement/wandering behavior, on the total survey sample of fourteen (14) residents. Resident #1 subsequently accessed this unsecured corridor on 02/09/2014 without the knowledge of facility staff, exited the facility through the corridor, and eloped through the adjoining hospital. Resident #1 traveled along a street for approximately one-half mile, fell on to the pavement, was taken to the hospital Emergency Department (ED), and was found to have facial abrasions, a nasal laceration requiring sutures, a nasal fracture, and a fractured right knee cap. This resulted in a situation in which the facility's non-compliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator and Director of Nursing were informed of the immediate jeopardy on February 18, 2014… | 2017-02-01 |
| 7659 | 7659 | NORTHRIDGE HEALTH AND REHABILITATION | 115714 | 100 MEDICAL CENTER DRIVE | COMMERCE | GA | 30529 | 2014-02-20 | 323 | K | 1 | 0 | LWSQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, EMS Prehospital Care Report Summary review, hospital Record of Admission report review, hospital ER Triage Record review, hospital ED Nursing Record review, nursing facility Follow-Up Report review, Weather.com report review, MapQuest.com report review, hospital staff interview, and nursing facility staff interview, the facility failed to ensure that the WanderGuard alarm system, utilized by the facility to alert staff of attempts by residents having wandering/elopement behavior to exit the facility, included alarm coverage for a set of unlocked double doors contained in one (1) first floor corridor which was accessible to Unit B and Unit C residents, and which exited the nursing facility into the adjoining hospital facility. The facility's failure to ensure WanderGuard alarm protection on these unlocked doors located in this corridor leading from the nursing facility into the hospital thus allowed this corridor to serve as a route of elopement for one (1) resident (#1) who utilized a WanderGuard bracelet for wandering/exit-seeking behavior and eloped through these unlocked/unalarmed doors, and as a potential route of elopement for four (4) additional residents (#5, #11, #12, and #14) on the survey sample with known elopement/wandering behavior, all of whom utilized WanderGuard bracelets and had access to this unsecured nursing home/hospital corridor, on the total survey sample of fourteen (14) residents. Resident #1 accessed this unsecured corridor on 02/09/2014, exited the nursing facility through this corridor via these unalarmed and unlocked doors, and eloped through the adjoining hospital. Resident #1 then traveled along a street for a distance of approximately one-half mile, fell hitting his/her head on the pavement, was taken to the hospital Emergency Department (ED), and was found to have sustained facial abrasions, a nasal laceration requiring sutures, a nasal fracture, and a fractured ri… | 2017-02-01 |
| 7660 | 7660 | NORTHRIDGE HEALTH AND REHABILITATION | 115714 | 100 MEDICAL CENTER DRIVE | COMMERCE | GA | 30529 | 2014-02-20 | 520 | K | 1 | 0 | LWSQ11 | Based on observation, record review, and staff interview, the facility failed to ensure oversight by, and the involvement of, the Quality Assessment/Performance Improvement (QA/PI) Committee in the formulation and implementation of a corrective action plan developed in response to resident elopement. This corrective action plan was developed regarding the elopement of one (1) resident (#1) who resided on Unit B, had wandering/elopement behavior, and utilized a WanderGuard bracelet, of five (5) sampled Unit B and Unit C residents (#1, #5, #11, #12, and #14) with known elopement/wandering behavior who utilized WanderGuard bracelets, on the total survey sample of fourteen (14) residents. Resident #1, who utilized a WanderGuard bracelet to address wandering behavior and resided on Unit B, eloped through unlocked double doors which had no WanderGuard alarm and which were located in a corridor leading from facility Unit B into the adjoining hospital. Facility administrative staff developed a corrective action plan in response to Resident #1's elopement to address this failure of the WanderGuard alert system to protect Resident #1, and the additional residents of Units B and C who were at risk for elopement/wandering, from eloping through these unlocked and unalarmed corridor doors. However, this corrective action plan was developed and implemented prior to QA/PI Committee review, analysis and evaluation. This resulted in a situation in which the facility's non-compliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the immediate jeopardy on February 18, 2014 at 9:30 a.m. The non-compliance related to the immediate jeopardy was identified to have existed on February 9, 2014 (the date Resident #1 eloped from the facility via the set of unlocked, unalarmed, and unsecured doors located within the corridor which lead from the nursing facility to the… | 2017-02-01 |
| 7781 | 7781 | NORTHRIDGE HEALTH AND REHABILITATION | 115714 | 100 MEDICAL CENTER DRIVE | COMMERCE | GA | 30529 | 2012-03-22 | 166 | E | 0 | 1 | 7S9T11 | Based on record review, family, resident and staff interviews, the facility failed to make a prompt effort to address grievances related to missing personal property for three (3) residents (D, Q and R). The sample size was forty-three (43) residents. Findings include: On 3/19/12 at 12:20 p.m., a family member of resident Q stated that missing personal property was an ongoing problem at the facility. They stated that the resident was currently missing pants and jackets. They added that they see resident's clothing on the wrong resident. On 3/20/12 at 2:20 p.m., resident R stated there had been an ongoing problem with missing clothing or that it took a long time to get clothing back, and that they were currently missing pants. They added that they knew that some of their labeled clothes had been found in other resident's closets. Review of the Resident Council minutes revealed the following: October 2011: Two (2) residents reported missing clothing, and one (1) resident reported missing eyeglasses. November 2011: Four (4) residents reporting missing clothing December 2011: Noted the facility was addressing issues with clothes being mixed in with the linen. January 2012: Three (3) residents reported having socks that weren't theirs, and one (1) resident reported missing socks. February 2012: One (1) resident expressed there was a delay in getting clothing returned once it goes to the laundry. Two (2) residents reported missing clothing items. An internal e-mail dated 02/20/12 to the Social Services Director noted the facility had 81 pieces of resident clothing that was returned from the laundry service (outside the facility) due to resident's clothing being mixed into the linens. March 2012: Notation that the social worker would be available on 3/11/12, as she had acquired many lost items such as glasses and dentures. Two (2) residents reported missing clothing at this meeting. On 3/22/12 at 8:52 a.m., Social Services employee MM stated there had been an ongoing problem with missing laundry for some time. She said … | 2016-12-01 |
| 7782 | 7782 | NORTHRIDGE HEALTH AND REHABILITATION | 115714 | 100 MEDICAL CENTER DRIVE | COMMERCE | GA | 30529 | 2012-03-22 | 167 | C | 0 | 1 | 7S9T11 | Based on observation, resident and staff interviews, the facility failed to post the availability of the State survey results. The facility census was 147, and the sample size was forty-three (43) residents. Findings include: On 3/20/12 at 2:20 p.m., resident R, who resided on Unit C, stated that they knew they had the option to review the State survey results, but did not know where they were located. At 2:50 p.m., a notebook containing the State inspection results were found on a table on a short hallway near an elevator on the main level (Units B and C) of the facility. No posting of the availability of these survey results were found on any of the five (5) nursing units on the three (3) floors of the facility. On 3/22/12 at 9:45 a.m., Social Services employee MM verified that there was no posting of availability of the State survey results anywhere in the facility. | 2016-12-01 |
| 7783 | 7783 | NORTHRIDGE HEALTH AND REHABILITATION | 115714 | 100 MEDICAL CENTER DRIVE | COMMERCE | GA | 30529 | 2012-03-22 | 246 | E | 0 | 1 | 7S9T11 | Based on observation and staff interview the facility failed to provide seating with appropriate seat height related to dining surfaces that encourages independence and comfort during meals for three (3) residents (#164, #12 and #31) from a sample of forty-three (43) residents. Findings include: Observation of the E Unit dining area on 3/19/12 at 1:15 p.m. revealed resident #164 was sitting in a low dining room chair at lunch; the resident had to lift their arms up and over the table to reach their food. On 3/21/12 at 1:20 p.m., residents #12 and # 31 were observed sitting in low dining room chairs at lunch; their chins were at the level of the top of the table. Resident #31 was having to raise her arm up and over the table to reach the items on the lunch tray. At 1:40 p.m., Licensed Practical Nurse E-Unit Manager verified this observation, and stated the table was too high and the chair was too low. | 2016-12-01 |
| 7784 | 7784 | NORTHRIDGE HEALTH AND REHABILITATION | 115714 | 100 MEDICAL CENTER DRIVE | COMMERCE | GA | 30529 | 2012-03-22 | 252 | E | 0 | 1 | 7S9T11 | Based on observation, family and staff interviews, the facility failed to provide a homelike dining environment on two (2) of five (5) nursing units (B and E). Findings include: On 3/19/12 at 12:24 p.m., a family member of resident Q stated that the E-Unit needed a day room that was more elder-friendly, such as one that contained rockers and sofas. The family member added that the facility used the dining room for activities, and it was the only place the residents could socialize. During observations in the E-Unit dining and activity room on 3/19/12 at 1:15 p.m. and 3/21/12 at 3:28 p.m., the following was noted: There was a large screen TV on the wall and a radio/CD player machine on a window ledge, but both were off. The blinds were lowered so that there was very little natural light coming in, and there were no curtains on the windows. The only furnishings in the room were six square institutional-appearing tables, and two large plastic semi-circular tables. Eight of eight wood-framed chairs were badly marred on the armrests and legs. On top of a soft drink vending machine was a suction machine, clearly visible inside a clear plastic bag. There were a few arts and crafts-type decorations on the wall, and two pieces of framed artwork near the corner of one wall. There was a brown-stained ceiling tile just inside the entrance to the room. On one wall there was a fixture covered with a metal shield that contained a soft blue light; a resident was noted to sit directly under this light during lunch observations on 3/19/12 and 3/21/12. The paint around the pipe encasing the electric cord for this light was peeling. There were multiple scuff marks on all four walls. On 3/22/12 at 9:57 a.m., Maintenance Director CC stated that the blue bulb light fixture in the dining room was a fly trap. He added that dining room chairs were not replaced unless they were broken. On 3/22/12 at 11:00 a.m., the Director of Nurses (DON) verified that the dining room on the E-Unit was institutional-like. She added that the chairs were mi… | 2016-12-01 |
| 7785 | 7785 | NORTHRIDGE HEALTH AND REHABILITATION | 115714 | 100 MEDICAL CENTER DRIVE | COMMERCE | GA | 30529 | 2012-03-22 | 253 | E | 0 | 1 | 7S9T11 | Based on observation and staff interview the facility failed to provide a clean and well maintained environment on four (4) of five (5) Units, A,B,E, and D; in three (3) of four (4) dining rooms, A, B and E; two (2) of four (4) pantries, A and B Units; four (4) resident rooms, 303, 306, 311, and 314 on A-Unit and 259 and 261 on D-Unit. This involved sticky floors, broken and marred furniture, dirty windows, and stained and scuffed walls. Findings include: B-Unit dining room observations on 3/19/12 at 12:20 p.m. just prior to the lunch service and again on 3/20/12 at 12:30 p.m. revealed: 1. The floor was sticky and had visible dirt and grime. A large window on the right side of the room had a heavy build-up of cobwebs, debris, dirt and dried brown leaves all around the outside of the window. Fifteen (15) residents were in the dining room waiting to be served lunch. 2. Observations on 3/21/12 at 8:30 a.m. the floor remained sticky and dirty. The lower walls, painted blue under a chair rail of molding, had numerous white streaks going down the walls. These streaks were present around the parameter of the room. A tall gray trash can cover had dried red stains. Three (3) serving carts were observed along the left wall and the bottom shelf of two (2) had large dried coffee colored stains and a build-up of dirt and grime in the corners. The water fountain in the immediate left corner nearest the entrance had a heavy build-up of dust on the side vent. The dining room was observed again at 12:30 p.m. and the same concerns remained. 3. The Pantry adjacent to the B-Unit dining room was observed on 3/21/12 at 8:30 a.m. and 12:30 p.m. Floor tiles were missing in front of the refrigerator and there was a heavy build up of dirt in the corner of the floor by the refrigerator and also along the bottom grill of the refrigerator. On 3/22/12 at 11:45 a.m. a tour was conducted with Environmental Services Staff, CC, DD, and EE . Concerns were reviewed with them for the B-Unit dining room and the snack kitchen next to it. They agreed t… | 2016-12-01 |
| 7786 | 7786 | NORTHRIDGE HEALTH AND REHABILITATION | 115714 | 100 MEDICAL CENTER DRIVE | COMMERCE | GA | 30529 | 2012-03-22 | 280 | D | 0 | 1 | 7S9T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and observation it was determined that the facility failed to update and/ or revise the care plan for two (2) residents (# 156 and #167)) following each assessment from a sample of forty-three (43) residents. The facility failed to update a care plan regarding actual/ current needs for assistance with dinning for #156 and to address behaviors for another resident, #167. Findings included: 1. The care plan for resident # 156 indicated that she was unable to eat independently and needed assistance with nutritional intake. The care plan directed staff to cut her food into bite-sized pieces, provide verbal cues to encourage intake and maintain a low noise level in the dining room. The resident was observed at lunch on 3/21/12 between 12:45 a.m. and 1:15 p.m. The staff served her a sloppy joe sandwich on a bun, baked beans, salad and grapes. The sandwich was left whole, no verbal cueing from staff was observed, and a radio placed behind the resident was playing loud music. The music was audible from 35 feet away and the resident was seated 7 feet from the radio. The resident was observed to eat more than half of her food without the need for assistance and/or cueing. 2. Interview with Licensed Practical Nurse (LPN) GG on 3/20/12 at 2:15 p.m. revealed resident # 167 had behaviors of hitting out at staff and refusing care, particularlly in the early morning. LPN GG described this not a big problem because Certified Nursing Aides (CNA) have been told to leave the resident and return at a later time or have a different staff person provide care. Resident #167 was assessed on the quarterly Minimum Data Set ((MDS) dated [DATE] as having physical and verbal behaviors one (1) to three (3) times during the assessment process. Review of the Social Service, dated 3/05/12 revealed that the resident tried to hit another resident that had wandering behaviors. Review of the care plan dated 01/12/12 revealed that the resident was not care p… | 2016-12-01 |
| 7787 | 7787 | NORTHRIDGE HEALTH AND REHABILITATION | 115714 | 100 MEDICAL CENTER DRIVE | COMMERCE | GA | 30529 | 2012-03-22 | 323 | D | 0 | 1 | 7S9T11 | Based on observation, record review and staff interview, the facility failed to secure a chemical so that it was inaccessible to cognitively-impaired residents on one (1) of five (5) units (E-Unit). Findings include: On 03/22/12 at 11:08 a.m., the Patient (common) Bath on E-Unit was noted to be unlocked. Just inside the door on the sink at wheelchair-height was a half-full spray bottle of Virex 256, One-Step Disinfectant and Deodorant. In the hallway close to this common bath were two (2) residents who were able to walk without assistance; three (3) residents that could maneuver their merrywalkers without assistance; and one (1) resident who could self-propel their wheelchair. This was verified by Licensed Practical Nurse Unit Manager LL, who stated all of these residents had cognitive impairment. She added that the staff did not keep this door locked all the time, but that the Certified Nursing Assistants were supposed to lock up the chemicals when they were done using them. The Material Safety Data Sheet (MSDS) on Virex noted that it may be mildly irritating to eyes and skin, and may cause irritation and corrosive effects to nose, throat and respiratory tract if inhaled. | 2016-12-01 |
| 7788 | 7788 | NORTHRIDGE HEALTH AND REHABILITATION | 115714 | 100 MEDICAL CENTER DRIVE | COMMERCE | GA | 30529 | 2012-03-22 | 332 | E | 0 | 1 | 7S9T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to ensure a medication error rate of 5% or less for four (4) residents, residents #80, #92, #159 and # 147. Fifty-six (56)opportunities were observed with four (4) medication errors for three (3) of six (6) nurses on four (4) of five (5) halls resulting in a medication error rate of 7.14%. Findings include: Observation of Licensed Practical Nurse (LPN) II on 3/21/12 at 8:25 a.m. on the C-Unit revealed: 1. Resident # 92 received one 81 milligram [MEDICATION NAME] coated extended release Aspirin. Review of the physician orders [REDACTED]. Interview with the nurse on 3/21/12 at 9:43 a.m. confirmed that she gave the [MEDICATION NAME] coated extended release Aspirin instead of the chewable. Interview with LPN KK, the C-Unit Manager on 3/21/2012 at 9:45 a.m. revealed that resident # 92 should have received the 81 milligram chewable aspirin as ordered. Observation of LPN JJ on 3/21/12 at 8:58 a.m. on the D-Unit revealed: 2. Resident # 159 was administered one (1) drop of Liquitears in each eye. Review of the physician orders [REDACTED]. Interview with LPN JJ on 3/21/12 at 9:25 a.m. revealed that she had given the Liquitears instead of the ordered [MEDICATION NAME]. Observation of LPN JJ on 3/21/12 at 9:20 a.m. on the B-Unit revealed: 3. Resident # 80 was handed [MEDICATION NAME] nasal spray to self administer. The resident did not blow their nose before using the nasal inhalation spray and gave herself the two inhalations in each nostril about 5 seconds apart. The only directions on the medication label was for 2 sprays each nostril every day for 4 weeks, with a prescribed date of 3/14/12. Review of the policy for nasal inhalations revealed that the resident was supposed to blow their nose gently before the nasal inhalation spray was administered and if the resident required more than one inhalation spray, the nurse should wait one minute between the nasal inhalations. Inter… | 2016-12-01 |
| 9828 | 9828 | NORTHRIDGE HEALTH AND REHABILITATION | 115714 | 100 MEDICAL CENTER DRIVE | COMMERCE | GA | 30529 | 2010-11-04 | 156 | B | 0 | 1 | IGRP11 | Based on record review and staff interview the facility failed to provide appropriate notification of Medicare non-coverage for three (3) residents (#21, #43 and #51) on a sample of thirty-one (31) residents. Findings include During an interview on 11/04/10 at 2:15 p.m. the Business Office Manager stated she called the responsible parties of residents #43, #51 and #21 and notified them of the resident's date to be discharged from skilled Medicare services and informed them of their right to have a demand bill submitted. She stated she then mailed the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) (CMS form- ) to the responsible party. Review of the SNFABN for the resident's revealed there was no signature and no indication on the form as to the decision to submit a demand bill. Further review revealed these residents remained in the facility after they were discharged from skilled Medicare services. She stated she usually received the forms returned to the facility with a signature. She further stated she does not have documentation of the decision as to whether a demand bill was to be submitted. She does not provide the resident or the responsible party with the Notice of Medicare Provider Non-coverage (CMS form ). She stated she was not aware she had to issue the notice. | 2015-05-01 |
| 9829 | 9829 | NORTHRIDGE HEALTH AND REHABILITATION | 115714 | 100 MEDICAL CENTER DRIVE | COMMERCE | GA | 30529 | 2010-11-04 | 279 | D | 0 | 1 | IGRP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to develop a care plan that reflected the resident's individual needs and plan of care for one (1) resident, #106, from a sample of thirty-one (31). Findings include. Record review revealed resident #106 has [DIAGNOSES REDACTED]. Further review of the medical record also indicated that the resident received [MEDICAL TREATMENT] three times per week at a center outside the facility. The care plan dated 4/18/10 identified the resident as receiving [MEDICAL TREATMENT], however, there was no specific intervention that included care of the access site, potential infection control concerns or monitoring measures. Interview on 11/04/10 at 10:15 am with Licensed Practical Nurse "AA" revealed that the [MEDICAL TREATMENT] should have been monitored and should have been included in the care plan. She stated that when a resident returns from [MEDICAL TREATMENT], they were to have a [MEDICAL TREATMENT] communication checklist. This list included pre and post [MEDICAL TREATMENT] weight, any complication related to [MEDICAL TREATMENT] or the access site, insulin sliding scale before and after [MEDICAL TREATMENT], weights and blood sugar results, if done in the [MEDICAL TREATMENT] center. She stated that this communication form was not consistently used and a staff member calls once a week to get the pre and post [MEDICAL TREATMENT] weights. | 2015-05-01 |
| 9830 | 9830 | NORTHRIDGE HEALTH AND REHABILITATION | 115714 | 100 MEDICAL CENTER DRIVE | COMMERCE | GA | 30529 | 2010-11-04 | 456 | E | 0 | 1 | IGRP11 | Based on observation and staff interview the facility failed to ensure that two (2) of two (2) walk-in freezers in the dietary department had door seals that were secure and prevented the build-up of frost and ice on the thresholds and floors of the freezers. Findings include: During the initial tour of the kitchen on 11/02/10 at 10:00 a.m. a build-up of frost was observed around the right side of the large walk-in freezer that held meats. On 11/04/10 at 10:10 am the same large walk-in freezer was observed to have a broken gasket/seal around the right door frame with a build up of frost and ice in that area. Interview at that time with the Dietary Manager revealed the gasket had a heat source in it that prevented the frost build-up but it is not functioning properly at the present time. The freezer that held the frozen vegetables and bread had a metal strip around the door area that had fallen off when the Dietary Manager opened the door on 11/04/10 at 10:15 a.m. There was frost build-up on the right side of the door and on the inside of the freezer door and handle. She stated that they had tried to repair the meat freezer but it continues to pull away from the door edge and you can see where foam filler has been sprayed into the area. The temperature of the meat freezer was observed to be 2 degrees Farenheit and the temperature in the vegetable and bread freezer was 9 degrees Farenheit. The facility had just received a food delivery by their purveyor. The Administrator was notified of the problem with the walk-in freezers on 11/04/10 at 11:00 a.m. On 11/05/10 at 8:45 a.m. observation of the meat freezer and the vegetable freezer revealed that there was no frost around the door but both thresholds had ice on them and the floor of both freezers had a thin coating of ice on them. This was confirmed with a dietary line supervisor. | 2015-05-01 |
| 4053 | 4053 | GRACEWOOD NSG FACILITY(UNIT 9) | 11A200 | 100 MYRTLE BLVD., EAST CENTRAL REG HOSP | GRACEWOOD | GA | 30812 | 2018-08-19 | 584 | E | 0 | 1 | EQDC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of the policy titled Enteral Nutrition Pump- Cleaning and Disinfection and staff interviews, the facility failed to maintain tube feeding poles in a clean and sanitary condition for nine of 17 resident (R) (#25, #3, #7, #76, #10, #9, #14, #15, and #178) that received enteral tube feeding, and failed to maintain clean and dust free hallway walls in one of two units (Unit 1). Findings include: 1. Observations of the tube feeding pole for R#25 on 8/17/18 at 12:00 p.m., on 8/18/18 at 8:40 a.m. and 11:30 a.m., and on 8/19/18 at 8:50 a.m. revealed dried, heavily splattered tube feeding on the base and wheels of the pole. 2. Observations of the tube feeding pole for R#3 on 8/17/18 at 12:45 p.m., on 8/18/18 at 8:30 a.m., 11:35 a.m. and 2:40 p.m., and on 8/19/18 at 8:40 a.m. revealed dried, heavily splattered tube feeding on the base and wheels of the pole. 3. Observations of the tube feeding pole for R#7 on 8/17/18 at 1:00 p.m., on 8/18/18 at 8:25 a.m., 11:40 a.m. and 2:36 p.m., and on 8/19/18 at 8:45 a.m. revealed dried, heavily splattered tube feeding on the base and wheels of the pole. 4. Observation of the tube feeding pole for R#76 on 8/17/18 at 1:15 p.m., on 8/18/18 at 9:05 a.m., 11:45 a.m. and 2:43 p.m., and on 8/19/18 at 8:30 a.m. revealed dried, heavily splattered tube feeding on the base and wheels of the pole. 5. Observations of the tube feeding pole for R#10 on 8/17/18 at 1:10 p.m., on 8/18/18 at 9:10 a.m., 11:50 a.m. and 2:40 a.m., and on 8/19/18 at 8:35 a.m. revealed dried, heavily splattered tube feeding on the base and wheels of the pole. 6. Observation of room [ROOM NUMBER] on 8/17/18 beginning at 2:58 p.m. revealed the tube feeding pole for Resident (R)#9 in bed A had a large amount of dried, beige-colored substance on the base of the pole. Observation of room [ROOM NUMBER] on 8/18/18 beginning at 10:50 a.m. revealed the tube feeding pole for R#9 in bed A had a large amount of dried, beige-colored subst… | 2020-09-01 |
| 4054 | 4054 | GRACEWOOD NSG FACILITY(UNIT 9) | 11A200 | 100 MYRTLE BLVD., EAST CENTRAL REG HOSP | GRACEWOOD | GA | 30812 | 2018-08-19 | 730 | F | 0 | 1 | EQDC11 | Based on record review and staff interview, the facility failed to ensure that the annual 12-hour minimum education for Certified Nursing Assistants (CNA) included Dementia Care training for three of three CNA education transcripts reviewed. Findings include: Review of the employee files for CNA AA, CNA BB and CNA CC revealed all three CNAs had completed an annual minimum education/training of 12 hours, however, the training did not include the required annual Dementia Care training. Interview on 8/18/18 at 9:00 a.m. with the Training Program Administrator (TPA) and the Registered Nurse Educator (RNE) revealed that Dementia Care training is typically conducted in (MONTH) of each year. The TPA and the RNE stated they did not have record of the rosters for Dementia Care training in (MONTH) (YEAR). They stated another person was in the position. They stated that they looked but could not find the roster sign-in sheets. The RNE stated the facility did not have a policy related to required education for CNAs. | 2020-09-01 |
| 4055 | 4055 | GRACEWOOD NSG FACILITY(UNIT 9) | 11A200 | 100 MYRTLE BLVD., EAST CENTRAL REG HOSP | GRACEWOOD | GA | 30812 | 2018-08-19 | 812 | E | 0 | 1 | EQDC11 | Based on observation and staff interviews, the facility failed to maintain a clean floor in the satellite kitchen in Building 15 of the hospital complex and to clear state who is responsible for cleaning the ktichen floor. The facility census was 29. Findings include: Observation of the satellite kitchen in Building 15 on 8/18/18 at 11:30 a.m. revealed three dead cockroaches in the corner of the room next to a broken dishwasher and two dead cockroaches underneath the dishwashing sink next to the broken dishwasher. During an observation of the satellite kitchen in Building 15 with the Assistant Food Service Manager (FSM) on 8/18/18 at 12:19 p.m., he confirmed the presence of the dead cockroaches. He stated the facility received routine visits from a local pest control service to address problems with bugs throughout the facility complex as evidenced by the cockroaches being dead. He stated the satellite kitchen was used to receive bulk cooked food from the main kitchen. The food is placed on the steam table, checked for appropriate serving temperatures, plated and transported to the skilled nursing facility (SNF) for the residents. He further stated the kitchen staff was responsible for cleaning the areas of the satellite kitchen where food is handled but the housekeeping staff was responsibility for cleaning the satellite kitchen floor when the kitchen staff was done for the day. On 08/18/18 at 2:28 p.m., the Assistant FSM supplied the pest control service records dating back one year from (MONTH) (YEAR) to date which detailed monthly service calls, services provided and areas of concentration including the satellite kitchen. The satellite kitchen received monthly treatments for roaches. The last pest control service visit was 8/14/18. During an observation of the satellite kitchen in Building 15 with the Housekeeping Team Leader on 8/19/18 at 1:21 p.m. she confirmed the presence of the dead bugs still in the same places for the second day of observation. She stated, to her knowledge, the housekeeping staff was n… | 2020-09-01 |
| 4056 | 4056 | GRACEWOOD NSG FACILITY(UNIT 9) | 11A200 | 100 MYRTLE BLVD., EAST CENTRAL REG HOSP | GRACEWOOD | GA | 30812 | 2019-09-26 | 759 | E | 0 | 1 | 2COK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview and a review of the facility policy and procedure Medication Administration in DBHDD Hospitals, the facility failed to ensure the medication error rate was less than five percent (5%). There were two errors with 26 opportunities by two of three nurses observed which resulted in a medication error rate of 7.14%. Findings include: 1. On 9/25/19 at 7:45 a.m., Registered Nurse (RN) AA was observed giving R#16 his morning medications. The medications included Levetiracetam 100 milligrams (mg) / 2.5 milliliters (ml). After preparing all of the medications for R#16, RN AA verified she poured 2.5 ml in a liquid medication cup. A review of the Physician's Orders dated 9/12/19 revealed to administer Levetiracetam 100 mg/ml solution, 500 mg twice daily starting on 9/23/19. During an interview on 9/25/19 at 9:15 a.m., RN AA verified that she did not check the Medication Administration Record (MAR) and only went by the label instructions on the medication bottle which was for 2.5 ml twice daily. She confirmed that the label on the medication bottle did not match the current Physician Order An interview with the Nurse Manager on 9/25/19 at 9:56 p.m. revealed the medication nurses are responsible for checking the MAR prior to administering any prepared medications. 2. Observation on 9/25/19 at 11;58 a.m. of Licensed Practical Nurse (LPN) BB giving R#6 his medications. The medications included a multivitamin liquid suspension. After giving R#6 all of the medications via a [DEVICE], she confirmed she did not shake well the liquid multivitamin as per the manufacturer's instructions. An interview with the Nurse Manager on 9/25/19 at 12:45 p.m. confirmed that LPN BB did not follow the manufacturer's instructions or the facility's policy for the liquid multivitamin by not shaking it well prior to administration. A record review of the Medication Administration in DBHDD Hospitals reviewed and revised on 3/4/2019… | 2020-09-01 |
| 4057 | 4057 | GRACEWOOD NSG FACILITY(UNIT 9) | 11A200 | 100 MYRTLE BLVD., EAST CENTRAL REG HOSP | GRACEWOOD | GA | 30812 | 2019-09-26 | 812 | E | 0 | 1 | 2COK11 | Based on observations, staff interview, and the facility policy titled Policy -Food Purchasing, Receiving, Production, and Preparation 03-6647 Storage, the facility failed to ensure one of one walk in freezer was maintained in a clean sanitize condition and that food items were properly labeled and stored in a sanitary manner in one of two walk in coolers , one of one walk in freezer, and one of three food storage floor bins . This had the potential to effect 10 residents receiving oral fed diets. Findings include: Record review of the facility policy titled Policy-Food Purchasing, Receiving, Production and Preparation, 03-6647 Storage revealed the following: (1). protect food from contamination and spoiling during storage and preparation. Discard food in open containers within three (3) days of opening. (4). b. store all food in original containers or in NSF internationl approved containers. and once removed from the original containers store unused portion of opened food in tightly closed approval food grade bulk containers. (b). as appropriate cover with cool wrap or aluminum foil and label with the contents and dated (c). label all perishable food with the date it was put in the container and a use-by date determined according to Georgia DPH (Department of Public Health) Food Service Rules and Regulation Observation of one walk in freezer 's floor on 9/23/19 at 11:53 a.m. revealed the following concerns: 1. small bits of food particles and one unwrapped chicken breast patty on the freezer floor 2. dark brown substances, and pieces of white and brown cardboard scattered on the freezer floor 3. unlabeled opened sausage links wrapped in Saran wrap with no open date and expiration date 4. unlabeled open hash brown in a plastic bag with no open date with no open date and expiration date 5. open bag of carrots (unlabeled) stored in a plastic bag not properly sealed and stored in a large cardboard box with flaps not properly sealed Observation of one walk in cooler on 9/23/19 at 11:56 a.m. revealed the following con… | 2020-09-01 |
| 4491 | 4491 | GRACEWOOD NSG FACILITY(UNIT 9) | 11A200 | 100 MYRTLE BLVD., EAST CENTRAL REG HOSP | GRACEWOOD | GA | 30812 | 2016-03-24 | 282 | D | 0 | 1 | TMDQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility staff and Nurse Practitioner interviews, the facility failed to follow the Care Plan/Client Profile for turning and re-positioning for (1) resident (#1) with existing pressure sores from a sample size of twenty-two (22) residents. Findings include: Record review revealed that resident #1 was admitted [DATE] with the following Diagnosis: [REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that the resident was totally dependent on two staff persons for bed mobility and had one (1) existing Stage I pressure sore, one (1) Stage II pressure sore and one (1) Stage III pressure sore with slough. review of the resident's medical record revealed [REDACTED]. review of the resident's medical record revealed [REDACTED]. Review of the facility's Policy titled Care of the Individual with a Decubitus Ulcer documented that all pressure should be relieved from the ulcer. The individual must not sit or lie on the decubitus ulcer (pressure sore) even for a few minutes. Review of Care plan/Client Profile for resident #1 documents turn and reposition turn every two (2) hours. Interview on 3/24/2016 at 2:45 p.m. with the Nurse Practitioner (NP) revealed that the resident had current Physician orders [REDACTED]. On 3/24/16 at 3:00 p.m. the NP confirmed that the resident was not fully turned and repositioned as per the Physician/NP orders. Interview with the Director of Therapy on 3/24/16 at 1:46 p.m. revealed that the resident was supposed to be fully turned on his/her left side or right side and those positions were maintained with the use of supportive devices. Continued interview revealed that multiple wedges and positioning devices were available and that the certified nursing staff had been trained how to use the wedges and the positioning devices. Interview with the Director of Nursing on 3/24/16 at 1:48 p.m. revealed that she expected the staff to turn and reposition residents as they were train… | 2019-10-01 |
| 4492 | 4492 | GRACEWOOD NSG FACILITY(UNIT 9) | 11A200 | 100 MYRTLE BLVD., EAST CENTRAL REG HOSP | GRACEWOOD | GA | 30812 | 2016-03-24 | 314 | D | 0 | 1 | TMDQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility staff and Nurse Practitioner interview, the facility failed to properly turn and re-position one (1) resident (#1) with existing pressure sores from a sample size of twenty-two (22) residents. Findings include: Record review revealed that resident #1 was admitted [DATE] with the following Diagnosis: [REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that the resident was totally dependent on two staff persons for bed mobility and had one (1) existing Stage I pressure sore, one (1) Stage II pressure sore and one (1) Stage III pressure sore with slough. review of the resident's medical record revealed [REDACTED]. review of the resident's medical record revealed [REDACTED]. Review of the facility's Policy titled Care of the Individual with a Decubitus Ulcer documented that all pressure should be relieved from the ulcer. The individual must not sit or lie on the decubitus ulcer (pressure sore) even for a few minutes. Observation on 3/22/2016 at 6:50 a.m. and at 8:10 a.m., revealed the resident was lying on his/her back in the bed placing pressure on the pressure sores on the resident' s right hip and the right ischium. Observation on 3/22/16 at 10:20 a.m., revealed the resident was lying on his/her back in the bed. Staff had placed a wedge under the resident's left middle back and the resident was observed lying on his/her right side with direct pressure being placed on the resident' s pressure sores on the resident's right hip and right ischium. Observation on 3/22/2016 at 11:55 a.m., revealed the resident was lying on his/her back in the bed. Although the staff had placed a wedge under his/her right hip, the resident's pressure sore on his/her right ischium was observed to remain in contact with the mattress. Observation on 3/22/2016 at 1:32 p.m., revealed the resident was lying on his/her back in the bed with unrelieved pressure on the pressure sore on the right ischi… | 2019-10-01 |
| 4493 | 4493 | GRACEWOOD NSG FACILITY(UNIT 9) | 11A200 | 100 MYRTLE BLVD., EAST CENTRAL REG HOSP | GRACEWOOD | GA | 30812 | 2016-03-24 | 371 | E | 0 | 1 | TMDQ11 | Based on observation and staff interview, the facility failed to date opened food items prior to storage in one (1) of two (2) dry storage rooms, in three (3) of four (4) walk- in refrigerators, and in one (1) of two (2) walk- in freezers; failed to appropriately store scoops in the containers of sugar, rice and flour in one (1) of two (2) dry storage rooms; failed to ensure that the fan was free of dust in one (1) of four (4) walk-in refrigerators. The census was forty-two (42) residents. Finding include: Observations on 3/21/16 at 10:45 a.m. revealed the following: Observation of one (1) of the two (2) dry storage rooms revealed one (1) open five (5) pound bag of Quick Grits, one (1) open two (2) pound bag of Bran Flakes cereal and one (1) open two (2) pound bag of oatmeal. These items were noted to be opened but were not labeled with the date the items were opened. Further observation revealed a scoop, with the handle touching the food items, in each of the following containers: sugar, rice and the flour container. Observation in the walk-in refrigerator #1 revealed one (1) opened plastic bag of hamburger patties that was not labeled with the open date. Observation also revealed a build-up of dust on the fan in the walk-in refrigerator #1. Observations of the walk-in refrigerator #2 revealed one (1) opened bag of French fries and one (1) opened bag of flour that were observed to be open but did not have the dates of when they were opened. Observation also revealed one (1) plastic bag of an unidentified substance on the floor under the food that was not dated or labeled. Observation of the walk-in refrigerator #3 revealed one (1) opened package of sliced cheese that was opened but did not have the date when it was opened. Observation of the walk-in freezer #4 revealed one (1) opened package of chocolate chip cookie dough that did not have the date when it was opened. Interview on 3/21/16 at 2:00 p.m. with the Registered Dietician /Dietary Manager, revealed that all the food items in the dry storage area, in the… | 2019-10-01 |
| 4494 | 4494 | GRACEWOOD NSG FACILITY(UNIT 9) | 11A200 | 100 MYRTLE BLVD., EAST CENTRAL REG HOSP | GRACEWOOD | GA | 30812 | 2016-03-24 | 514 | D | 0 | 1 | TMDQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility staff and physician interview, the facility failed to accurately and completely document the appearance of non-pressure wounds for one (1) resident (#5). The sample size was twenty-two (22) residents. Findings include: Review of resident #5's Admission Minimum Data Set ((MDS) dated [DATE] revealed that the resident was at risk of pressure ulcer development and had a Stage 2 pressure ulcer. Review of the care plan dated 06/11/15 revealed that the resident was at risk for impaired skin integrity as related to history of decubitus and high risk assessment score for decubitus. Further review of this care plan revealed that it was updated on 01/26/16 to note that the resident's buttocks had some small red areas, and to continue with current treatment and monitor. Review of a hospital wound care assessment dated [DATE] revealed that resident #5's buttocks had several unmeasurable areas of maceration and redness; evidence of peeling and open skin to some areas; bloody and dark brown drainage; and full thickness ulceration to the sacrum and bilateral buttocks extending to the posterior thighs. Review of resident #5's Nurse's Notes on re-admission to the facility dated 01/29/16 noted the resident's sacrum had full-thickness ulceration, but there was no measurements or other description of the appearance of the wound. Review of a Hospital Return Nursing assessment dated [DATE] noted that the section labeled Body Chart was left blank with no abnormalities listed. Review of a Health Note dated 01/29/16 noted that resident #5 had returned from the hospital, a body inspection was completed with an RN and the attending physician DD, and multiple open areas were noted to the buttocks, crease as well as an open area to the groin. Further review of this form revealed that the wounds were not classified as to the type of wound, measured, nor any documentation of the appearance of the wounds. Review of Registered Nur… | 2019-10-01 |
| 6844 | 6844 | GRACEWOOD NSG FACILITY(UNIT 9) | 11A200 | 100 MYRTLE BLVD., EAST CENTRAL REG HOSP | GRACEWOOD | GA | 30812 | 2013-07-17 | 371 | E | 0 | 1 | UVWN11 | Based on observations and staff interview, it was determined that the facility failed to ensure that two (2) portable fans with dust/debris did not blow over uncovered food. Census= two (22) residents. Finding include: 1. Observation on 7/15/13 at 12:30 p.m. revealed a large portable fan, with an accumulation dust/debris sitting on the floor behind the steam table. This fan was blowing directly towards the steam table where meal trays were being prepared. 2. Observation on 7/16/13 at 1:35 p.m. revealed one (1) of the two (2) portable fans with an accumulation of dust/debris blowing towards the food prep area where food items were being prepared. Observation on 7/16/13 at 1:40 p.m. revealed , the second fan, with an accumulation of dust and debris, on top of a rolling cart, next to the conveyor belt, where clean dishes were coming out of the dishwasher. This fan was blowing directly on three (3) large metal pans. 2. Observation on 7/17/13 at 9:00 a.m. revealed a fan with an accumulation of dust/debris clinging to it, in the steam table area. This fan was blowing across a multiple level cart of food, some uncovered. Interview with the Dietary Supervisor on 7/17/13 at 9:00 a.m., revealed that the fan should not be blowing across the steam table. | 2017-10-01 |
| 6845 | 6845 | GRACEWOOD NSG FACILITY(UNIT 9) | 11A200 | 100 MYRTLE BLVD., EAST CENTRAL REG HOSP | GRACEWOOD | GA | 30812 | 2013-07-17 | 469 | F | 0 | 1 | UVWN11 | Based on observations, and staff interviews, the facility failed to maintain an effective pest control program in the kitchen. The facility census was twenty-two (22). Findings include: Observation in the kitchen on 7/16/13 between 1:45 p.m. and 2:00 p.m., revealed the following concerns: a red roach crawling on top of the table next to the steamer machine, a small black bug crawling on the wall next to the pantry door, a red roach crawling on the floor behind the steam table and a red roach crawling on a stack of Styrofoam plates on top of the steam table. Observation of the kitchen on 07/17/2013 at 9:00 a.m., revealed two (2) brown roaches crawling on the post near the steam stable and one (1) dead roach on the bottom of the post. Continued observation revealed four (4) small black bugs crawling on the post, a brown roach and a small black bug crawling on the lower shelf on the middle of the steam table. Interview with the Dietary Supervisor on 7/16/13 at 2:05 p.m. revealed that from time to time there are issues with roaches in the kitchen . Continued interview revealed that there are four (4) wooden pallets in the kitchen, and had seen roaches crawling on these pallets. She indicated that she has been trying to replace these pallets. Interview on 7/17/13 at 9:00 a.m. with the Dietary Supervisor revealed that approximately two (2) weeks ago she had noticed a worsening problem with the bugs and had notified the pest control provider, Orkin, who came the evening of 7/1/13, providing treatment. Interview with the Administrator on 7/17/2013 at 2:35 p.m., revealed that she was not aware of any current problems with pest in the kitchen; however, the facility has had problems in the past and contracted with Orkin, who would come quarterly and as needed. | 2017-10-01 |
| 6846 | 6846 | GRACEWOOD NSG FACILITY(UNIT 9) | 11A200 | 100 MYRTLE BLVD., EAST CENTRAL REG HOSP | GRACEWOOD | GA | 30812 | 2013-07-17 | 520 | D | 0 | 1 | UVWN11 | Based on record review and staff interview, the facility failed to hold Quality Assessment and Assurance (QAA) meetings at least quarterly and failed to ensure that a physician attended those meetings. The facility census was twenty-two (22). Findings include: Review of the QAA minutes, provided by the facility during the standard survey, revealed that the meetings were held on 3/29/12, 7/30/12, 11/30/12, 4/10/13 and 6/28/13. Continued review revealed that the physician was present for two (2) of the five (5) meetings, on 4/10/13 and 6/28/13; however, there was no evidence there was any quarterly QAA meeting held between November 2012 and April 2013. Interview with the Unit Manager on 7/17/13 at 1:00 p.m., revealed that the physician was not present at every meeting and confirmed there was no evidence of a meeting being held between November 2012 and April 2013. Telephone interview with the Administrator on 7/24/13 at 2:30 p.m. during the QA process revealed that there was no evidence of any QAA meeting sign in sheets for the physician. | 2017-10-01 |
| 8122 | 8122 | GRACEWOOD NSG FACILITY(UNIT 9) | 11A200 | 100 MYRTLE BLVD., EAST CENTRAL REG HOSP | GRACEWOOD | GA | 30812 | 2012-01-12 | 253 | B | 0 | 1 | IUIJ11 | Based on observations, staff interviews and review of the facility policy, the facility failed to ensure that six (6) wheelchairs on two (2) of two (2) halls and one (1) IV pole were free of an soiled matter. Findings include: Random observations of wheelchairs during the environmental rounds on 1/10/11 at 2:00 p.m. revealed that there was a build up an ivory colored, dried substance on sides and under the bottoms of the crossbars on six (6) different wheelchairs. Living Area 1 1. The purple wheelchair in room 116 had an dried, ivory substance on the left side and under its cross bars. 2. The blue wheelchairs in room 109 had an dried, ivory colored substance on the left side and under its crossbars. Living Area 2- The blue wheelchairs in rooms 267, 266, 259 and 256 had an ivory, colored substance on both sides and under their crossbars. During an interview on 1/10/12 at 2:50 p.m., Certified Nursing Assistant (CNA) FF said Occupational Therapy department (OT) had a staff member who was responsible for pressure washing all of the wheelchairs. FF said that the dried, Ivory colored substance on the wheelchairs was formula. In an interview on 1/11/12 at 10:49 am, the OT/Physical Therapy Tech EE said that all of the wheelchairs were scheduled to be cleaned every six weeks. EE said the wheelchairs had last been cleaned on 11/16/11. EE explained that he/she was behind on the cleaning schedule because of the holidays. EE said that there was not a facility policy for cleaning. She/He said that he/she was responsible for pressure washing all of the wheelchairs for the whole campus. EE added that the CNAs on each unit were responsible for cleaning the wheelchairs, if it was needed before the scheduled time for pressure cleaning. Review of the Pressure Washing schedule indicated that the last steam cleaning for the wheelchairs were done between 11/15/11-11/21/11. Living Area 2 The bottom bottom of the IV/ tube feeding pole In room 258 was soiled with a dried, ivory substance. | 2016-07-01 |
| 8123 | 8123 | GRACEWOOD NSG FACILITY(UNIT 9) | 11A200 | 100 MYRTLE BLVD., EAST CENTRAL REG HOSP | GRACEWOOD | GA | 30812 | 2012-01-12 | 332 | E | 0 | 1 | IUIJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to ensure that their medication error rate was less than 5%. Five (5) errors out of fifty (50) opportunities for four (4) of ten (10) residents were noted by two (2) of five (5) nurses on two (2) of two (2) units. The facility's medication error rate was 10%. Findings include: 1. During an observation on 01/10/12 at 8:15 a.m., Licensed Practical Nurse (LPN) HH crushed all of resident #7's pills, including a [MEDICATION NAME] Delayed Release Orally Disintegrating Tablet, then mixed them with applesauce and gave them to the resident by mouth. However, according to the physician's orders [REDACTED]. A review of the Geriatric Dosage Handbook, 12th Edition, revealed that orally-disintegrating [MEDICATION NAME] ([MEDICATION NAME]) tablets should not be swallowed whole or chewed, but could either be placed on the tongue and allowed to dissolve, or dispersed in 10 milliliters (mL) of water in an oral syringe and administered. 2. On 01/10/12 at 11:42 a.m., LPN HH was observed giving medications to resident #25. HH gave the resident two puffs from an Atrovent inhaler in quick succession and then immediately gave the resident Iwo quick puffs of an [MEDICATION NAME] inhaler. However, review of the manufacturers' package inserts for the inhalers revealed that they had not been administered correctly. The nurse was supposed to firmly press the Atrovent canister against the mouthpiece one (1) time and then wait at least 15 seconds before repeating. If a resident's doctor prescribed more than one spray of [MEDICATION NAME] ([MEDICATION NAME]) then, the facility should have waited one (1) minute and shaken the inhaler again (before administering another spray). On 01/10/12 at 2:35 p.m., LPN HH confirmed that he/she had crushed the [MEDICATION NAME] tablet for resident #7. She provided the pharmacy packaging for the [MEDICATION NAME], which was labeled to include instructions to disso… | 2016-07-01 |
| 8124 | 8124 | GRACEWOOD NSG FACILITY(UNIT 9) | 11A200 | 100 MYRTLE BLVD., EAST CENTRAL REG HOSP | GRACEWOOD | GA | 30812 | 2012-01-12 | 356 | C | 0 | 1 | IUIJ11 | Based on observations and interviews with staff, the facility failed to post the nurse staffing data on all three days of the survey. Findings include: During observations in Liviing Areas 1 and 2 on 1/9/12, 1/10/12, and 1/11/12, it was noted that the facility had failed to post the required notice about nurs staffing data. The facilty had not posted a notice whcih included the following information: the facility name; the day's date; the total number and actual number of hours worked by licensed and unlucensed nursing staff providieng direct resident care on each shift and; resicent census. During an interview on 1/11/11 at 11:05 am, the Director of Nursing said that the facility had not posted the (nurse) staffing data the survey. The Director of Nursing said that she had not been poating the required informaton but only the nurses'schedule. In an interview on 1/11/12 at 11:10 a.m., the Infection Control Nurse said that she was unaware of the regulation for posted staffing. | 2016-07-01 |
| 8125 | 8125 | GRACEWOOD NSG FACILITY(UNIT 9) | 11A200 | 100 MYRTLE BLVD., EAST CENTRAL REG HOSP | GRACEWOOD | GA | 30812 | 2012-01-12 | 441 | D | 0 | 1 | IUIJ11 | Based on observation, record review, and staff interview, the facility failed to ensure that facility staff washed their hands and/or changed their gloves after handling a contaminated object for one resident (#30). The sample size was twelve (12) residents. Findings include: On 01/11/12 at 7:45 a.m., an observation of resident #30's skin was done with Registered Nurse (RN) CC. When the incontinent brief was pulled back, the resident had a small amount of non-formed stool in the brief, as well as a plastic thermometer probe cover. The nurse removed the probe cover from the brief with his/her gloved fingers and threw it in the trash. Without changing his/her gloves or washing his/her hands, he/she then removed and replaced the resident's heel protectors, pulled down the resident's shirt, pulled up the bed covers and patted the resident on the back before removing her gloves and washing her hands. On 01/11/12 at 8:55 a.m., the Unit Manager stated that if the gloves were contaminated then she expected the staff to change gloves and/or wash their hands before they provided any other care. Review of the facility's Infection Control Policy on Standard and Transmission Based Precautions outlined that hand hygiene was the single most effective method to prevent the spread of disease. Employees and clients should wash their hands frequently and thoroughly and use good hand washing technique after removal of gloves and anytime there was exposure to blood or body fluids. Clean, non-sterile gloves should be worn when touching or at risk of touching excretions, and changed between procedures on the same client. However, during an interview on 01/11/12 at 11:00 a.m., RN CC confirmed that he/she did not immediately change gloves after handling the thermometer probe cover that had been in resident #30's incontinent brief. | 2016-07-01 |
| 9966 | 9966 | GRACEWOOD NSG FACILITY(UNIT 9) | 11A200 | 100 MYRTLE BLVD., EAST CENTRAL REG HOSP | GRACEWOOD | GA | 30812 | 2010-09-23 | 371 | F | 0 | 1 | C3EB11 | Based on observation, record review, review of facility policy, and staff interview the facility failed to store, prepare and serve food under sanitary conditions. This was evidenced by: storing pots and utensils that were dirty and wet; improper storage of food scoops; not ensuring that walk-in refrigerators were clean; not repairing water leaks; maintaining potentially hazardous hot food food on the steam table below 135 degrees Fahrenheit; improper storage of baking pans; improper functioning of the dishwashing machine; and lack of sanitizer in the manual 3 compartment sink. This failure affected all residents who were fed orally. Findings include: Observation on 9/21/10 between 10:00 a.m.-11:30 a.m. with the Dietary Manager revealed the following concerns: 1. Three of six serving ladles were stored wet; 1 of 2 scoops was stored dirty and wet; 6 large baking pans were stored wet. 2. A large storage unit of sugar contained a scoop with the handle touching the product. 3. The walk-in meat refrigerator had a very strong foul odor. Interview at that time with the dietary staff who maintained this area revealed that the area is cleaned daily. However, review of the facility's Central Kitchen Cleaning Checklist for the Meat Room revealed that the last cleaning verification was signed on 7/26/10. 4. Observation of the tray line at the beginning of the lunch meal on 9/21/10 revealed that the Dietary Manager calibrated her thermometer and obtained the following temperatures from food being held on the steam table: Pureed beets 100 degrees Fahrenheit (F) Pureed green beans 100 degrees F Pureed carrots 100 degrees F Ground carrots 98 degrees F Ground noodles 118 degrees F Pureed noodles 112 degrees F Pureed beef 130 degrees F Review of the food temperature log for 9/21/10 for the lunch meal revealed that dietary staff had only checked the temperature of three (3) food items on the steam table. 5. Observation of the dishwashing machine with the Food Service Supervisor on 9/22/10 at 8:00 a.m. revealed the following: The ma… | 2015-04-01 |
| 9967 | 9967 | GRACEWOOD NSG FACILITY(UNIT 9) | 11A200 | 100 MYRTLE BLVD., EAST CENTRAL REG HOSP | GRACEWOOD | GA | 30812 | 2010-09-23 | 372 | F | 0 | 1 | C3EB11 | Based on observation, review of facility policy and staff interview the facility failed to ensure that areas around refuse containers were clean and free of foul odors to prevent harborage of pests. Findings include: Observation on 9/21/10 between 10:00 a.m.-11:30 a.m. with the Dietary Manager revealed the following concerns: One (1) of two (2) trash compactors located in a parking area behind the loading dock had a stream (about 9 feet long) of a dark foul smelling liquid that also contained some unknown debris. The Dietary Manager indicated that the bottom of one of the trash compactors had been leaking and needed to be replaced. This replacement occurred several days ago, but the area around the compactor had not been cleaned. The top of the waste oil container (located in the same parking area) had a pool of oil that contained food debris. Review of the facility's Clean Parking Area policy revealed that it would be hosed down daily. This was not done. | 2015-04-01 |
| 9968 | 9968 | GRACEWOOD NSG FACILITY(UNIT 9) | 11A200 | 100 MYRTLE BLVD., EAST CENTRAL REG HOSP | GRACEWOOD | GA | 30812 | 2010-09-23 | 469 | F | 0 | 1 | C3EB11 | Based on observation, record review and staff interview the facility failed to maintain an environment that is free from pests. This failure affected all residents who were served food prepared in the kitchen and who were fed in the dining area on Unit 1. Findings include: Observation with the Dietary Manager and Food Service Supervisor in the kitchen on 9/20/10, between 11:15 a.m.- 11:40 a.m., 9/21/10, between 10:00 a.m.-11:30 a.m. and 9/22/10 between 8:00 a.m.- 9:00 a.m. revealed live roaches on the steam table, other food preparation surfaces, walls and floor. Review of the facility's pest extermination contract revealed the contract was valid until until 6/30/13. According to this contract, the kitchen was scheduled for two (2) service treatments per month to address an infestation of German Roaches. Interview with the Dietary Manager (DM) on 9/21/10 at 10:00 a.m. revealed roaches in the kitchen area had been an on-going problem. She added that the most recent extermination service for the kitchen was provided on 9/08/10. However, the tray line area continues to be heavily populated with roaches. During dining observation on 9/20/10 at 12:45 p.m. in Unit 1 dinning area, three (3) large roaches were observed on the floor of the dinning area while four (4) resident's were being fed lunch by staff. An interview with Registered Nurse "RR" at this time revealed that the exterminator had sprayed about three (3) days ago. The meal trays were delivered on a rolling cart from the main kitchen. A large gap was noted at the bottom and top of the outside door located in the dinning room. Observation on 9/22/10 at 4:45 p.m. of the Unit 1 shower room revealed several small bugs crawling on the shower table. Observation on 9/22/10 at 4:15 p.m. of resident room 267 revealed a small bug crawling on the hand washing sink. | 2015-04-01 |
| 9969 | 9969 | GRACEWOOD NSG FACILITY(UNIT 9) | 11A200 | 100 MYRTLE BLVD., EAST CENTRAL REG HOSP | GRACEWOOD | GA | 30812 | 2010-09-23 | 281 | G | 0 | 1 | C3EB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to provide services that met professional standards of quality. This was evidenced by the failure to clarify with the physician the urgency of providing x-ray services to rule out a possible fractured extremity resulting in harm for one (1) resident #23 of twenty one (21) sampled residents. Findings include: Record review revealed that resident #23 had a Health Note dated 3/02/10 at 7:00 a.m., indicating that nursing staff noted swelling of the right upper thigh and knee, with a light brown discoloration below the knee. It also indicated that the right lower extremity was warm to touch. Based on facility assessments (MDS, dated [DATE]) the resident was unable to communicate or make her needs known and was totally dependent on staff for all activities of daily living. Review of a physician's orders [REDACTED]. Review of a Health Note dated 3/02/10 at 10:00 a.m. revealed the nurse indicated that the x-ray would be done on 3/03/10, 24 hours after the injury was identified. In an interview on 9/22/10 at 11:00 a.m. with Licensed Practical Nurse (LPN) "AA" she acknowledged the physician's orders [REDACTED]. She added that since the physician did not request "stat" (immediate) x-rays she accepted that date without question. The nurse did not clarify with the physician the urgency of obtaining the x-rays sooner than 3/03/10. The Registered Nurse (RN) Manager was also present at the time of the interview with this LPN and later indicated that because of the resident's condition she would have expected the LPN to report the 24 hour delay of x-ray services to the RN Manager for further guidance. This was not done. The RN Manager acknowledged that other arrangements could have been made to have the x-ray services provided in a timelier manner. Standards of Practice for Licensed Practical Nurses-- In accordance with 2.3.2 Standards Related to Licensed Practical Nurses: The licensed practical n… | 2015-04-01 |
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CREATE TABLE [cms_GA] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );