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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 4034 | 4034 | GLEN EAGLE HEALTHCARE AND REHAB | 115733 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2018-09-27 | 661 | D | 0 | 1 | PH4V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and review of facility policy titled Transfer or Discharge, Preparing a Resident for, the facility failed to develop a discharge summary and a recapitulation of the residents stay for one resident (R) (R#155) who was discharged to the community. The sample size was five residents. Finding include: Review of the clinical records for resident (R) #155 revealed she was admitted with a [DIAGNOSES REDACTED]. Review of the Discharge Planning for Actual Discharge assessment dated [DATE] under section Reason for discharge #3. Recap of the resident's stay revealed that the only information documented was Resident was admitted to the facility on . During an interview on 9/27/18 at 9:50 a.m. with the Social Services Director revealed that she is responsible for initiating the Discharge Planning for Actual Discharge form in the computer. Continued interview revealed that she did not know that a discharge summary or recapitulation of stay had to completed for a resident when they discharge from the facility. During an interview on 9/27/18 at 9:54 a.m. with LPN AA revealed that nursing enters some of the information on the Discharge Planning for Actual Discharge form. Continued interview revealed that LPN AA acknowledged that there was not a recapitulation of the resident's stay or discharge summary completed for R#155. Further interview revealed that LPN AA stated that she was not aware that a recapitulation or discharge summary had to be completed when a resident discharges from the facility. | 2020-09-01 |
| 5952 | 5952 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2012-12-06 | 241 | D | 0 | 1 | I2VT11 | Based on observations and staff interviews, it was determined that the facility failed to promote the dignity of one resident (#35) from a total sample of 34 residents. Findings include: Licensed nursing staff coded resident #35 as totally dependent for dressing on the 9/12/12 quarterly Minimum Data Set (MDS) assessment. The resident was observed to have been dressed in a hospital gown and sweat pants while out of bed in a geri chair on 12/4/12 at 8:32 a.m., 3:10 p.m. and 5:00 p.m., on 12/5/12 at 8:10 a.m., 9:15 a.m., 10:00 a.m., 1:10 p.m., 2:25 p.m., 3:45 p.m. and 4:44 p.m., and on 12/6/12 at 7:50 a.m., 9:02 a.m., 9:45 a.m. and 11:10 a.m. During an interview on 12/6/12 at 9:50 a.m., certified nursing assistant CC stated that the reason the resident had been dressed in a hospital gown was because, it was easier. On 12/6/12 at 12:15 p.m., the Director of Nursing (DON) stated that she was not aware that resident #35 was being dressed in a hospital gown daily. The DON said that, if she would have known, the staff would have gotten the resident a different type of shirt to wear when he was out of bed. | 2018-05-01 |
| 5953 | 5953 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2012-12-06 | 282 | D | 0 | 1 | I2VT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and record reviews, it was determined that the facility failed to ensure that care plan interventions were implemented for one resident (#26) from a sample of two residents with gastrostomy feeding tubes and for two residents(#35 and #70) from a sample of four residents with limitations in range of motion in a total sample of 34 residents. Findings include: 1. Resident #26 had a care plan interventions since at least 1/20/09 for nursing staff to keep the head of the resident's bed elevated 30 degrees and for licensed nursing staff to continuously infuse [MEDICATION NAME] AC formula at 50 milliliters (ml) per hour through a gastrostomy tube. However, it was observed on 12/3/12 at 11:45 a.m., 1:05 p.m., 3:40 p.m. and 4:10 p.m., and on 12/4/12 at 3:30 p.m. and 4:40 p.m., that the head of the resident's bed was not elevated 30 degrees while formula was infusing at 50 milliliters per hour. It was also observed that on 12/5/12 from 8:05 a.m. until 11:10 a.m. that licensed nursing staff had failed to administer [MEDICATION NAME] AC formula to the resident as ordered. See F322 for additional information regarding resident #26. 2. Resident #35 had a care plan intervention since at least 1/4/12 for nursing staff to apply a left hand grip splint and a right hand theraplus in the morning and remove them in the afternoon. However, it was observed that nursing staff had not applied those devices to the resident's hands on 12/4/12 at 3:10 p.m. and 5:00 p.m., on 12/5/12 at 8:10 a.m., 9:15 a.m., 10:00 a.m., 1:10 p.m., 2:25 p.m., 3:45 p.m. and 4:55 p.m., and on 12/6/12 at 7:50 a.m., 9:02 a.m. and 9:45 a.m. See F318 for additional information regarding resident #35. 3. Resident #70 had a care plan since 3/25/10 to address his/her dependence in activities of daily living (ADLs) related to his/her mobility and due to severe contractures. There was a handwritten intervention on that plan for the provision of a range of motion program by resto… | 2018-05-01 |
| 5954 | 5954 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2012-12-06 | 312 | D | 0 | 1 | I2VT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview with a resident and staff, it was determined that the facility failed to provide assistance with nail and/or skin care for two (A and #70) of the 34 sampled residents. Findings include: 1. According to the Western Schools Nursing Care of the Older Adult, second edition, good skin care for older adults included the use of skin moisturizers daily. However, nursing staff failed to address the identified problem of dry and scaly skin for resident A. Resident A was admitted to the facility in August, 2012. Licensed nursing staff documented on the 8/24/12 Admission Nursing Assessment that resident A had dry skin on both of his/her the lower extremities. A body diagram was circled on the resident's feet and shins to designate the areas of dry skin. The nurse noted in the special treatments and procedures section the word moisturizer. On the 8/31/12 admission Minimum Data Set (MDS) assessment, licensed staff had documented that the resident needed extensive assistance with ADLs, and received hospice services. The resident had a care plan since 9/19/12 to address his/her risk for impaired skin integrity related to his/her level of mobility (bedbound) and thin, fragile skin. There was an intervention for nursing staff to observe the resident's skin daily during routine care. However, there was not an intervention to describe the treatment and services to be that provided to address the resident's dry skin. However according to the December, 2012 ADL flow sheet, Resident A was supposed to have been assisted or supervised by facility staff with bed mobility, transfers, dressing, grooming, bathing and mouth care each day on each shift It was observed on 12/05/12 at 8:30 a.m. that resident A had dry and scaly skin on the front of both of his/her legs. Resident A said that he/she only received baths and skin care (lotion) from the hospice aide on Tuesdays and Thursdays but, the facility staff did not bathe h… | 2018-05-01 |
| 5955 | 5955 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2012-12-06 | 318 | D | 0 | 1 | I2VT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interview, it was determined that the facility failed to ensure hand splints were used to prevent further decline in range of motion for two residents (#35 and #70) in a sample of four residents with range of motion limitations from a total sample of 34 residents. Findings include: 1. During an interview on 12/04/12 at 8:29 a.m., licensed nursing staff reported that resident #35 had contractures and that his/her arms were drawn up against his/her chest. Licensed nursing staff completed a quarterly Minimum Data Set (MDS) assessment on 9/12/12 and coded resident #35 with functional limitations in his/her upper extremities on both sides. There was a care plan intervention since at least 1/04/12 for nursing staff to apply a left hand grip splint and a theraplus in his/her right hand in the morning and remove them in the afternoon. However, it was observed that nursing staff had not applied any device to the resident's hands on 12/4/12 at 3:10 p.m. , on 12/5/12 at 8:10 a.m., 9:15 a.m., 10:00 a.m., 1:10 p.m., 2:25 p.m., 3:45 p.m. and 4:55 p.m., and on 12/6/12 at 7:50 a.m., 9:02 a.m. and 9:45 a.m. On 12/6/12 at 9:45 a.m., restorative certified nursing assistant DD confirmed that the resident did not have the splints in place but, she did not know why. During an interview on 12/06/12 at 12:20 p.m., the Director of Nursing (DON) did not know why staff had not applied the resident's splints/hand rolls as needed. 2. Resident #70 had a [DIAGNOSES REDACTED]. The staff coded the resident on his/her 8/30/12 quarterly MDS assessment as having impaired range of motion on both sides of his/her upper and lower extremities. The resident's care plan since 3/25/10 noted that she/he was dependent on staff to meet all of his/her activities of daily living (ADL) needs related severe contractures. Staff documented on the care plan that the restorative nursing staff would provide range of motion exercises for the resident … | 2018-05-01 |
| 5956 | 5956 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2012-12-06 | 322 | D | 0 | 1 | I2VT11 | **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 provide appropriate services to prevent complications and to provide formula via tube feedings as ordered for one resident (#26) from a sample of two residents with gastrostomy tubes from a total sample of 34 residents. Findings include: According to the American Society of Consultant Pharmacists Medication Guide for the Long Term Care Nurse, licensed nursing staff was to ensure that the resident's head of the bed was elevated 30 - 45 degrees, and to check for stomach residual prior to administering medications. However, nursing staff failed to maintain the head of the bed elevated at 30 degrees for resident #26 and failed to check for stomach residual prior to administering medications. Resident #26 had [DIAGNOSES REDACTED]. The resident had a gastrostomy tube in place and a physician's orders [REDACTED]. There were care plan interventions since at least 1/20/09 for the following: nursing staff to keep the resident's head of the bed elevated 30 degrees; for licensed nursing staff to infuse [MEDICATION NAME] AC formula continuously at a rate of 50 ml per hour via the gastrostomy tube and; to check for residual feeding every shift and if it was greater than 100 ml to hold administration of the formula for one hour then resume it but if remained greater than 100 ml then notify the doctor. However, it was observed that staff had only elevated the head of the resident's bed 10 degrees while the tube feeding was infusing on 12/03/12 at 11:45 a.m., 1:05 p.m., 3:40 p.m. and 4:10 p.m. It was observed that the tube feeding was infusing on 12/04/12 at 3:30 p.m. and 4:40 p.m. but, the head of the resident's bed was elevated only approximately five (5) degrees. It was observed on 12/05/12 at 8:05 a.m., 8:32 a.m., 9:30 a.m., 10:30 a.m., and 10:50 a.m. that the head of the resident's bed had not been elevated so, he/she was laying flat. Although, the tube… | 2018-05-01 |
| 5957 | 5957 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2014-10-23 | 174 | E | 0 | 1 | N8EW11 | Based on observation, staff interviews, and resident interviews the facility failed to provide reasonable access to the private use of a telephone without being overheard by staff or other residents for four (4) residents (#13, 86, #91 and A) of a forty (40) sampled residents. Findings include: 1. Observation on 10/21/14 at 2:27 p.m. of resident # 91 standing at the nurse's station using the phone. The resident stated after getting off the phone that that she is aware that the residents are suppose to have privacy while on the phone, but doesn't know how much privacy is possible with everyone standing around during her call and she doesn't even have a chair to sit down in. An interview with the family of resident A on 10/22/14 at 10:00 a.m. revealed that when she calls and talks to her brother, she feels that he can not carry on a conversation because she can hear the conversations of people standing next to him better than she can hear him talking. She stated that his speech is not clear and he is easily distracted by the others around him. An interview on 10/22/14 at 11:15 a.m. with Licensed Practical Nurse (LPN) KK revealed that residents can come to the nurse's station whenever they want to use the phone. The residents are not allowed in the office but the staff will dial the number and pass the phone through the window. Continued interview with LPN KK revealed that they can either go to the Director of Nursing (DON)'s office or the Social Worker's office. An interview with the DON) on 10/23/14 at 3:15 p.m. revealed that residents can use any of the nursing station phones at any time and if they want to talk privately they can either use her office or the social worker's office. She stated that at one time they had a cordless phone but a resident threw the phone and broke it and it hasn't been replaced. 2. During an interview on 10/20/14 at 3:29 p.m. with resident #13 revealed that there was no privacy when using the telephone at the nursing station and that their conversation could be overheard by others. Du… | 2018-05-01 |
| 5958 | 5958 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2014-10-23 | 279 | D | 0 | 1 | N8EW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observation, record review and staff interviews the facility failed to develop a care plan for refusal of care for one (1) resident (#99) who refused bathing of forty (40) sampled residents. Findings include: Record review of the Point Click Care, electronic record, for Resident #99 revealed the following Diagnoses: [REDACTED]. Observation on 10/21/14 at 9:50 a.m. and 4:30 p.m. revealed the resident had moderate facial hair, matted and unkept hair and had a body odor of old urine while wearing tan pants, which were dry. An observation on 10/22/14 7:30 a.m. of the resident in bed, wearing pajamas with a continued smell of old urine. Observation on 10/22/14 at 12:50 p.m. revealed the resident ambulating in the hallway, wearing four (4) shirts, was not shaved and continued to have a strong urine odor. An observation on 10/23/14 at 8:40 a.m. of the resident sitting in the smoking area revealed the resident was clean shaven, hair neatly combed and not matted and did not smell of urine. An interview with Certified Nursing Assistance (CNA) BB on 10/23/14 at 9:00 a.m. revealed that she had bathed the resident yesterday which was the first time in one week she had been assigned to this resident. Review of the facility bathing schedule reveals the resident is to be bathed/assisted on Monday, Wednesday and Friday's. Review of the electronic CNA charting Documentation Survey Report confirmed that on 10/22/14 the resident received a bath. Further review revealed that on 10/6, 8, 10, 17 and 20/2014 the resident was coded with 8/8 which per the Code Assessment for Point Click Care reveals the care was not given. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] and 5/24/14 revealed the resident had no behaviors of refusing care during the look back period. The resident was assessed on the Quarterly MDS dated [DATE] on the Brief Mental Interview of 4 indicating the resident has severe cognitive impairment. A telephone interview with the… | 2018-05-01 |
| 5959 | 5959 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2014-10-23 | 441 | F | 0 | 1 | N8EW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interview the facility failed in hand hygiene (hand washing) practices consistent with accepted standards of practice, to reduce the spread of infections and prevent cross-contamination during meal service and while filling cups with ice and water, in the facility's main dining room and on three (3) of three (halls). Findings include; 1. Observation on 10/20/14 at 5:06 p.m., on the 300 hall, a random Certified Nursing Assistant (CNA) was observed delivering trays to multiple rooms, knocking on doors and going in and out of rooms setting trays up, and not washing or hand sanitizing between residents. Observation on 10/20/14 5:10 p.m. of the food cart sitting on 200 hall outside of room [ROOM NUMBER]. A random CNA was observed in room [ROOM NUMBER] assisting the resident in the B bed, after finishing assisting resident with eating, the CNA brought the used food tray out and set it next to a undelivered unopened food tray on the open food cart. The CNA then pushed the food cart down the hall to room [ROOM NUMBER] and took the uneaten food tray into the room and did not wash/santitize her hands before or after delivering this new tray. An interview on 10/23/14 at 10:37 a.m. with the Director of Nursing (DON) she verified that staff should santitize their hands when they leave the resident's room. She confirms that hand santitizer is available in every room as you enter the room. The DON reveals that the facility has done many infection control education inservices for all staff. 2. Observation on 10/20/14 at 12:45 p.m. of a random Certified Nursing Assistant (CNA) passing out trays to residents in the Main Dining Room, without sanitizing or washing her hands between trays/residents. Observation of the CNA opening food containers, uncovering food and touching residents and tables without washing/santitizing her hands. Observation on 10/20/14 at 12:47 p.m. of CNA AA pushing a resident into dining room, in a wheelchai… | 2018-05-01 |
| 5960 | 5960 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2015-08-13 | 157 | D | 0 | 1 | BPJ811 | Based on record review and interviews, the facility failed to notify the resident's responsible party for changes in the resident's condition for one (1) resident (F) on a sample of twenty-six (26) residents. Findings include: Interview with the family of resident F on 08/10/15 at 4:40 p.m. revealed that if he falls I get a call but other than that they don't call me. Per the resident's clinical profile, this family member is the resident's responsible party. Interview on 08/14/15 at 1:30 p.m. with the resident revealed that if there are any changes in treatment or medication I want them to contact my brother. Medical record review revealed Nurse's Notes and Progress notes indicating laboratory tests with abnormal results, notes regarding treatments and medication changes. No reference was found indicating that the family of the resident was notified. Interview on 08/14/15 at 1:45 p.m. with the Social Services Director revealed that letters are not mailed to family inviting them to Care Plan Meetings. She further stated that some families were called, but no families have been called in a long time. She further stated that the last time this resident's family was called about a Care Plan Meeting was 10/13/14 | 2018-05-01 |
| 5961 | 5961 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2015-08-13 | 161 | B | 0 | 1 | BPJ811 | Based on record review and staff interview the facility failed to maintain a surety bond of appropriate value to secure residents funds. The resident census eighty-eight. Findings include A review of the Resident Trust Fund Statements revealed that the fund balances for April, May, June and July 2015 all exceeded the $75,000 value of the surety bond. Balances ranged from 63,094.22 to 98,567.95. During an interview on 08/14/15 at 3:51 p.m. with the Business Office Manager, it was confirmed that the bank statements balances for April, May, June and July 2015 exceeded the amount of the current surety bond and did not adequately secure the resident's personal funds. | 2018-05-01 |
| 5962 | 5962 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2015-08-13 | 223 | D | 0 | 1 | BPJ813 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility self-reported incidents, interview and policy review, the facility failed to protect residents from abuse. This deficient practice affected one (R74) of two residents sampled as evidenced by the review of two incident reports for abuse. Findings included: Review of the facility self-reported incident completed on 1/25/16 revealed a staff member was observed pushing a resident (R74) down the hallway with excessive force on 1/22/16. Further review of the report revealed the time of the incident had not been documented. The allegation also identified a Licensed Practical Nurse (LPN)2, who had pushed R74 with excessive force. Review of the facility investigation revealed the process initiated to prevent further incidents was Social Service Designee (SSD) 1 had spoken to LPN 2 about the harsh treatment per documentation on the incident investigation report completed on 1/25/16. There was no documented evidence of an attempt to interview R74 or other residents on the 100 Hall. LPN2 continued to work in the facility on 1/22/16 to the end of the shift. Review of the record for R74 revealed [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Assessment ((MDS) dated [DATE] revealed the resident had documented behaviors of wandering. Review of the care plan dated 7/31/15, revealed staff was to redirect the resident away from the area to his room and provide medications as ordered. Interview on 2/6/16 at 10:45 a.m., the Director of Nursing (DON) acknowledged she was not aware of the incident until 1/25/16 when it was reported by Social Service. The DON stated that LPN2 had quit on 1/25/16 related to her pay check bounced. The DON verified LPN2 continued to work after the incident through the end of the shift on 1/22/16 and for an additional two days. Interview with SSD1 on 2/6/16 at 11:00 a.m. identified LPN2 as the staff person she witnessed using excessive force to push R74 on 1/22/16 about 5:30 p.m. SSD1 stated R74 w… | 2018-05-01 |
| 5963 | 5963 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2015-08-13 | 225 | D | 0 | 1 | BPJ813 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of a facility self-reported incident, interview and review of facility policy, the facility failed to report the abuse immediately (within 24 hours) of a resident (R74) for one of two residents reviewed. Findings included: Review of the facility self-reported incident dated 1/25/16 identified a staff member was observed pushing a resident down the hallway with excessive force on 1/22/16. Further review of the report revealed the time of the incident had not been documented. The allegation also identified a Licensed Practical Nurse (LPN) 2, who had pushed R74 with excessive force. Review of the facility investigation revealed the report was dated 1/25/16, three days after the incident occurred on 1/22/16. The report indicated the steps taken to prevent further incidents included the Social Service Designee (SSD)1 had spoken to LPN2 about the harsh treatment of [REDACTED]. LPN2 continued to work to the end of the shift and 12 hour shifts on the next two days, Saturday and Sunday, before resigning on Monday 1/25/16. In addition, the initial report of an abuse investigation to the state agency was not completed until 1/25/16. Interview on 2/6/16 at 10:45 a.m., the Director of Nursing (DON) acknowledged she was not aware of the incident until 1/25/16 when it was reported by Social Service. The DON stated that LPN 2 had quit on 1/25/16 related to her pay check bounced. The DON verified LPN 2 continued to work after the incident through the end of the shift on 1/22/16 and for an additional two days. Review of the investigation continued with the DON and with the conclusion the incident did not confirm the allegation of abuse. The DON concluded, based on the statement by LPN2, that it may have looked like she (LPN2) pushed R74 but stated she didn't. The DON was questioned regarding the two witnesses who confirmed LPN2 had used excessive force and shoved R74 down the hall; however, the DON just shrugged her shoulders and stated She alr… | 2018-05-01 |
| 5964 | 5964 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2015-08-13 | 226 | E | 0 | 1 | BPJ811 | Based on record review, observations, and interviews, the facility failed to report to the State Agency eight (8) of eight (8) substantial incidents of potential abuse per policy and procedure for census sample of twenty-six and total number of residents being eighty-eight (88). Findings include: A review of medical records revealed an incident of resident to resident altercation occurring on 05/23/15. Although the family and Medical Doctor were notified of the incident, the facility did not report the potentially abusive occurrence to the State Agency as required by the facility policy for abuse prevention. Interview on 08/12/15 at 4:00 p.m. with the Administrator revealed that there were no investigations for this resident. Interview on 08/13/15 at 08:30 a.m. with the Administrator confirmed that the incident was not reported to the State Agency. Further record review revealed incidents dated 12/11/14, 03/11/15, another on 05/23/15, 06/28/15, 06/30/15, 07/12/15 and 07/29/15 that were not reported to the State Agency. Interview on 08/14/15 at 2:05 p.m. with the Administrator revealed that physical altercations between residents resulting in injuries should be reported to the State Agency and had not been. The Administrator stated that she expected all incidents with injuries to be reported as required. | 2018-05-01 |
| 5965 | 5965 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2015-08-13 | 253 | E | 0 | 1 | BPJ811 | Based on observation and interview the facility failed to provide a sanitary environment for residents on three (3) of three (3) halls. Findings include: Observation of Room 100 on 08/11/15 at 8:10 a.m. showed a heavy build up of dirt on the edges of the floor and a strong urine odor was noted in the resident bathroom. Observation in Room 112 on 08/10/15 at 4:01 p.m. showed a strong urine odor in the resident bathroom and the grout of the floor tile in the bathroom had a black discoloration. A heavy build-up of dirt along edges of the floor in the resident room was also observed. Observation in Room 104 on 08/11/15 at 8:16 a.m. showed a heavy build up of dirt along the edges of the room. Observation of Room 110 on 08/11/15 at 8:35 a.m. showed a heavy build up of dirt on the floor in the resident room and bathroom. The grout was noted to be black between tiles on the bathroom floor and there was a very strong urine odor in the bathroom. Observation of Room 112 on 08/11/15 at 08:56 a.m. showed a heavy build up of dirt along the perimeter of the room. Observation of Room 116 on 08/11/15 at 9:30 a.m. showed a build up of dirt around the edges of the floor of the room. A strong urine odor was noted in the bathroom and there was a black discoloration in the grout between the bathroom floor tiles. Observation of Room 106 on 08/11/15 at 10:02 a.m. showed a build up of dirt on the edges of room. The bathroom toilet had a leak with a puddle in the corner of the bathroom which was also reported to Licensed Practical Nurse BB at this time, and she reported the leak to maintenance. Grout in floor tile of the bathroom had a black discoloration and a strong odor of urine. Observation of Room 120 on 08/11/15 at 8:14 a.m. showed that the bathroom had a heavy build up of black substance around toilet bowl. Observation of Room 102 on 08/11/15 at 10:25 a.m. showed a heavy build up of dirt around the edges of the room on floor. Black discoloration was observed in the grout on the tile floor of the bathroom and there was a strong urin… | 2018-05-01 |
| 5966 | 5966 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2015-08-13 | 279 | D | 0 | 1 | BPJ811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews the facility failed to develop and revise a care plan for two (2) resident's # (17 and 44) from a total of twenty-six (26) sampled residents. Review of resident #17's Comprehensive Minimum Data System (MDS) revealed the resident was admitted to the facility on [DATE]. Active [DIAGNOSES REDACTED]. A review of the Electronic Medical Record (EMR) revealed that the resident had falls documented by nursing staff on 02/01/15, 02/23/15 and 07/27/15. During an interview with the Director of Nurses (DON) on 08/13/15 at 4:15 p.m. it was revealed that the nurse's on the floor do the updates to the care plan. The DON confirmed that the care plan for resident #17 was not updated or revised for falls that occurred on 02/01, 02/23, and 7/27/15. Record review for resident #44 revealed a fall from a chair on 08/09/15, resulting in an injury. Further review revealed that on 08/03/15, the resident was found sitting on the floor between the wheelchair and the bed. On 07/26/15 the resident was found lying on the floor with resulting injury. Additional falls were noted on 05/16/15 and 12/07/14. A review of the resident's plan of care indicated that the resident was at high risk for falls, with communication/comprehension difficulty, gait/balance problems, and incontinence. The Care Plan was initiated 08/22/14. All interventions were dated 08/22/14. No new interventions had been added. Interview on 08/13/15 at 2:18 p.m. with the Director of Nurses revealed that nursing and other staff are expected to update care plans as soon as possible after every fall. she also stated that new interventions should be put in place with each fall. Interview with the Administrator on 08/14/15 at 4:25 p.m. revealed that care plans should be updated with each fall and new interventions should be implemented with each fall. | 2018-05-01 |
| 5967 | 5967 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2015-08-13 | 323 | D | 0 | 1 | BPJ811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide a positioning device for a wheelchair bound resident to prevent accident and/ or injury for one (1) resident (#55) from a census sample of twenty-six (26). Findings include: Review of Lists of [DIAGNOSES REDACTED].#55 had [DIAGNOSES REDACTED]. Review of the Minimum (MDS) data set [DATE] showed the resident to have both short and long term memory problems, and that he/she required limited assistance with locomotion. Observation on 08/10/15 at 4:17 p.m. showed resident #55 to be barefoot and dragging their right foot under the wheelchair with no foot pedal on wheelchair. Interview on 08/10/15 at 4:17 p.m. with Licensed Practical Nurse (LPN) BB revealed that she had been made aware that resident was dragging their foot under wheelchair and that the resident was to have a foot pedal on their wheelchair on affected right (R) side due to (R) sided weakness. Observation on 08/12/15 at 8:10 a.m. showed that resident #55 was up in a wheelchair with slipper socks on. The resident did not have foot pedal on their wheelchair. Observation on 08/13/15 at 1:18 PM of resident #55 showed that resident was up in wheelchair with no foot pedal on the right side and resident was propelling the wheelchair independently and was dragging their right foot under the wheelchair. Observation on 08/13/15 at 1:22 p.m. revealed a missing piece of linoleum in front of the door to the resident's room that was approximately 8 x 6 inches in size and that the resident rolled directly over this area with his foot dragging under the wheelchair. Review of the resident's Care plan showed a care plan for Peripheral Vascular Disease. He also had care plans for being bed and chair bound with interventions to provide appropriate physical support during mobility, transfers and locomotion enforcing comfort and safety. Interview on 08/13/15 at 2:15 p.m. with Certified Nursing Assistant (CNA) CC, revealed that… | 2018-05-01 |
| 5968 | 5968 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2015-08-13 | 328 | D | 0 | 1 | BPJ812 | Deficiency Text Not Available | 2018-05-01 |
| 5969 | 5969 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2015-08-13 | 356 | B | 0 | 1 | BPJ812 | Deficiency Text Not Available | 2018-05-01 |
| 5970 | 5970 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2015-08-13 | 363 | F | 0 | 1 | BPJ813 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to follow the pre-planned written menus. This deficient practice had the potential to affect all of the residents who dined in this facility. Findings included: Observation of the kitchen during a complaint investigation on 2/6/16 at 11:45 a.m. revealed that the facility had two notebooks that contained written menus with serving sizes. Review of the menus revealed that the facility prepared and served a variety of therapeutic diets which included: carbohydrate controlled renal pureed mechanical soft low sodium Observation of the food that was prepared for the residents ' lunch meal on 2/6/16 at 12:00 p.m. revealed that the food that was prepared was not the food that was written on the pre-planned menu. An interview with the Dietary Manager (DM) on 2/6/16 at 12:00 p.m. confirmed that the facility did not prepare the foods that were listed on the preplanned menu. When interviewed about why the facility failed to prepare the food that was written on the menu, the DM stated that he just liked to mix things up. Per the DM the food that should have been prepared included: roast turkey gravy cornbread stuffing green bean casserole dinner roll margarine mandarin oranges Observation of the prepared food, revealed that the facility prepared the following foods: oven roasted turkey steamed cabbage sweet potatoes cornbread chocolate cake/icing baked lasagna salad/garlic bread An interview with the Registered Dietitian (RD) on 2/6/16 at 12:00 p.m. revealed that she completed the nutritional assessments for each resident who resided in this facility. The RD added that there were residents in the facility who required physician ordered therapeutic diets such as those residents with diabetes or [MEDICAL CONDITION]. When interviewed, about how she could complete a nutritional assessment or ensure that each resident had received the appropriate foods per their physician ordered diet if th… | 2018-05-01 |
| 5971 | 5971 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2015-08-13 | 371 | E | 0 | 1 | BPJ811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews the facility failed to store food under sanitary conditions for the resident census sample of twenty-six (26) and the total number of residents being eighty-eight (88). During tour on 08/13/15 at 12:30 p.m. with the Dietary Manager the following were observed in the kitchen: [MEDICATION NAME] Chloride (PVC) pipe under the dish rinse sink had an area approximately six inches long with heavy build up of corrosion on the drain line. Two galvanized metal fire extinguisher pipes hanging over the range were noted to be rusty. The bottom shelf, legs, and poles of the clean dish table were noted to have large area of chipped paint and rust. The lower shelf and legs of the microwave table had large areas of chipped paint and rust. The window sash around the dirty dish receiving area was noted to have a heavy build up of rust and large flakes of rust chipping and flaking off. The conditions listed above were confirmed at the time by the Dietary Manager. Tour with the Administrator on 08/13/15 at 1:30 p.m. confirmed the conditions. During this same tour with the Administrator, two boxed of raw potatoes were on the small porch outside the kitchen. The top of the box was partially open and flies were noted in and around the boxes. Interview on 08/13/15 at 1:30 p.m. with the Administrator revealed that her expectations were that the kitchen would be clean and free from rust and chipping paint and that there would not be food items on the back porch. | 2018-05-01 |
| 5972 | 5972 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2015-08-13 | 372 | D | 0 | 1 | BPJ811 | Based on observation and interview the facility failed to dispose of garbage and refuse properly for the census of eighty-eight (88) residents. Findings Include: 08/13/15 at 12:30 p.m. kitchen tour with the Dietary Manager revealed the following: On exiting the back kitchen door, onto the small external porch area: Clutter of multiple empty boxes, Two old unused air conditioner units, One rolling mop bucket, Two air conditioner vent covers Two boxes of raw potatoes. The top box of potatoes was noted to be partially opened and flies noted to be flying around the boxes. One fly observed on top of the potatoes box During this same tour with the Dietary Manager, the lid on the trash dumpster was noted to be raised with trash in the dumpster exposed with multiple flying insects around the inside of the dumpster. 08/13/15 at 1:30 p.m. interview with the Administrator revealed that everyone in the community uses this dumpster, especially the people in the apartments across the street. She also stated that she expected the porch area to be clean, without debris and refuse. | 2018-05-01 |
| 5973 | 5973 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2015-08-13 | 441 | E | 0 | 1 | BPJ812 | Deficiency Text Not Available | 2018-05-01 |
| 5974 | 5974 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2015-08-13 | 456 | E | 0 | 1 | BPJ811 | Based on observations and interviews the facility failed to ensure essential equipment is maintained in safe operating condition for the resident's microwave and refrigerator in the resident snack area at nurses station one for the resident census size of twenty -six and total number of residents being eighty-eight (88). 08/13/15 at 12:30 p.m. Kitchen tour with Dietary Manager revealed the following: The right side of the resident refrigerator, in pantry room at the nurses station was noted to have long area of peeling bubbled paint with a large area of chipped and peeling rust. The resident microwave, in pantry room at nurses station one, was observed to have a large area of rust along the bottom edge of internal microwave housing. An area of rust was noted to run approximately 75% along the entire width of the bottom of the internal microwave housing. Interview and tour on 08/13/15 at 1:30 p.m. with the Administrator confirmed the above conditions and rust. | 2018-05-01 |
| 5975 | 5975 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2015-08-13 | 463 | D | 0 | 1 | BPJ813 | Based on observation and interview, the facility failed to ensure two bathroom call systems on the 200 Hall had pull strings long enough to be reached by residents. This practice affected one of three hallways. Findings include: Observation of the 200 Hall shower room on 2/6/16 at 1:00 p.m. revealed the call light beside the toilet had a pull string approximately 4 inches in length. Observation of room 219 on 2/6/16 at 1:20 p.m. revealed the call light beside the toilet had a pull string approximately 4 inches in length. Interview with the Director of Nursing (DON) on 2/6/16 at 1:40 p.m. acknowledged the call light pull strings in the 200 Hall shower room and room 219 were too short. The DON stated if a resident were to be on the floor in either location they would not be able to reach the pull cord for the call system. An interview was conducted with the Administrator on 2/6/16 at 2:00 p.m. The Administrator stated she was not aware of the call light pull cords being so short. | 2018-05-01 |
| 5976 | 5976 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2015-08-13 | 465 | E | 0 | 1 | BPJ812 | Deficiency Text Not Available | 2018-05-01 |
| 5977 | 5977 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2015-08-13 | 469 | E | 0 | 1 | BPJ811 | Based on observation, interview and review of pest control contract the facility failed to provide effective pest control placing the residents at risk for insect borne illness on three (3) of three (3) halls with a census sample size of twenty-six (26) and total number of residents in facility being eighty-eight. Findings include: Observation of Room 110 on 08/11/15 at 8:35 a.m. showed an insect ran across the floor in the residents' room. Observation of Room 116 on 08/11/15 at 9:30 a.m. showed a fly in the residents' room. Observation of Room 108 on 08/11/15 at 10:44 a.m. showed a fly in the resident's room. Observation in the Sitting Room on 300 hall on 08/12/15 at 8:45 a.m. showed 7 flies. Observation in Administrative Building on 08/12/15 at 12:45 p.m. showed a large reddish-brown roach crawled across the floor. Observation of Room 108 on 08/13/15 at 9:00 a.m. showed that there was a fly in the bathroom. Observation of the hallway connecting 300 and 200 hall on 08/13/15 at 12:15 p.m. showed a resident sitting in the hallway killing flies with a fly swatter. Observation of the back hallway that led into the Dining Room on 08/13/15 at 1:17 p.m. showed a fly. Observation of the 100 hall nurses station desk on 8/13/15 showed a fly crawling on the desk. Observation of the connecting hall between 200 and 300 hall on 08/13/15 at 2:00 p.m. showed a second resident sitting in the hallway killing flies with fly swatter. Observation of the sitting room on 300 hall on 08/14/15 at 10:15 a.m. showed a resident seated on a bench with two (2) flies crawling on resident's left leg and one (1) fly crawling on her right arm. Observation of connecting hallway between 200 and 300 hall showed a resident carrying a fly swatter in wheelchair with him. Interview and tour with Head of Housekeeping on 08/13/15 at 09:10 a.m. confirmed that there were flies in resident rooms, bathrooms and hallways. Interview with Administrator on 08/13/2015 at 9:15 a.m. confirmed that there were flies in the building. | 2018-05-01 |
| 5978 | 5978 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2015-08-13 | 493 | F | 0 | 1 | BPJ812 | Based on observation and staff interview the facility failed to ensure there was an Administrator in place for the management of the facility. Findings include: During an observation and interview on 1/20/16 at 9:15 a.m. with the Director of Nursing (DON) she stated that the Administrator was not at the facility and that his last day was the previous Friday (1/15/16). Further interview revealed that an Administrator from a sister facility was on her way and that a new Administrator would be starting on Monday 1/25/16. During an interview with the Visiting Administrator on 1/20/16 at 4:00 p.m. she revealed that she was the Administrator at the Eastman Facility. She stated this was her first time at this facility and she was here because surveyors were in the building. | 2018-05-01 |
| 5979 | 5979 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2015-08-13 | 520 | F | 0 | 1 | BPJ812 | Based on record review and staff interview the facility failed to have a Quality Assessment and Assurance (QAA) process that developed and implemented an effective plan to ensure that compliance with the Plan of Correction (P(NAME)) was achieved for five (5) of ten (10) deficiencies written during the August 2015 Standard Survey (F253, F371, F372, F 456, F469). Findings include: During an interview with the Director of Nursing and Licensed Practical Nurse Unit Manager on 1/21/16 at 6:50 p.m. to 7:25 p.m. revealed that Quality Assessment and Assurance meetings are done monthly with the Administrator, Medical Director, DON, and LPN Unit Manager along with other disciplines. And, based on the data that is collected the committee decides what issues need to be addressed. The DON stated that she makes daily rounds and if issues come up she will bring it to the Quality Assurance Assessment (QAA) meeting. The DON further stated that she takes the concerns to the Administrator to address the issues and that she herself is not able to contact the Cooperate Office. She further stated that the previous Administrator informed her that he had notified the Cooperate office about the issues but had not received a response. During an interview on 1/20/16 at 4:45 p.m. with the Housekeeping Supervisor, Director of Nurses (DON) and the Visiting Administrator, Review of the the Quality Assessment Performance Improvement action plan provided by the facility, revealed the plan listed problems but did not list dates when the problems were identified. The Visiting Administrator, stated there was no way to tell when the problems were identified because it did not include dates of identification and did not address the system to identify other areas that may be affected. The surveyor questioned why the facility was in the condition it was in currently (in regards to environmental concerns) and the DON and the Housekeeping Supervisor stated that they thought it had gotten better. During an interview on 1/21/16 at 4:00 p.m. with the Visitin… | 2018-05-01 |
| 5980 | 5980 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2016-02-06 | 223 | D | 1 | 0 | R5VO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility self-reported incidents, interview and policy review, the facility failed to protect residents from abuse. This deficient practice affected one (R74) of two residents sampled as evidenced by the review of two incident reports for abuse. Findings included: Review of the facility self-reported incident completed on 1/25/16 revealed a staff member was observed pushing a resident (R74) down the hallway with excessive force on 1/22/16. Further review of the report revealed the time of the incident had not been documented. The allegation also identified a Licensed Practical Nurse (LPN)2, who had pushed R74 with excessive force. Review of the facility investigation revealed the process initiated to prevent further incidents was Social Service Designee (SSD) 1 had spoken to LPN 2 about the harsh treatment per documentation on the incident investigation report completed on 1/25/16. There was no documented evidence of an attempt to interview R74 or other residents on the 100 Hall. LPN2 continued to work in the facility on 1/22/16 to the end of the shift. Review of the record for R74 revealed [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Assessment ((MDS) dated [DATE] revealed the resident had documented behaviors of wandering. Review of the care plan dated 7/31/15, revealed staff was to redirect the resident away from the area to his room and provide medications as ordered. Interview on 2/6/16 at 10:45 a.m., the Director of Nursing (DON) acknowledged she was not aware of the incident until 1/25/16 when it was reported by Social Service. The DON stated that LPN2 had quit on 1/25/16 related to her pay check bounced. The DON verified LPN2 continued to work after the incident through the end of the shift on 1/22/16 and for an additional two days. Interview with SSD1 on 2/6/16 at 11:00 a.m. identified LPN2 as the staff person she witnessed using excessive force to push R74 on 1/22/16 about 5:30 p.m. SSD1 stated R74 w… | 2018-05-01 |
| 5981 | 5981 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2016-02-06 | 225 | D | 1 | 0 | R5VO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of a facility self-reported incident, interview and review of facility policy, the facility failed to report the abuse immediately (within 24 hours) of a resident (R74) for one of two residents reviewed. Findings included: Review of the facility self-reported incident dated 1/25/16 identified a staff member was observed pushing a resident down the hallway with excessive force on 1/22/16. Further review of the report revealed the time of the incident had not been documented. The allegation also identified a Licensed Practical Nurse (LPN) 2, who had pushed R74 with excessive force. Review of the facility investigation revealed the report was dated 1/25/16, three days after the incident occurred on 1/22/16. The report indicated the steps taken to prevent further incidents included the Social Service Designee (SSD)1 had spoken to LPN2 about the harsh treatment of [REDACTED]. LPN2 continued to work to the end of the shift and 12 hour shifts on the next two days, Saturday and Sunday, before resigning on Monday 1/25/16. In addition, the initial report of an abuse investigation to the state agency was not completed until 1/25/16. Interview on 2/6/16 at 10:45 a.m., the Director of Nursing (DON) acknowledged she was not aware of the incident until 1/25/16 when it was reported by Social Service. The DON stated that LPN 2 had quit on 1/25/16 related to her pay check bounced. The DON verified LPN 2 continued to work after the incident through the end of the shift on 1/22/16 and for an additional two days. Review of the investigation continued with the DON and with the conclusion the incident did not confirm the allegation of abuse. The DON concluded, based on the statement by LPN2, that it may have looked like she (LPN2) pushed R74 but stated she didn't. The DON was questioned regarding the two witnesses who confirmed LPN2 had used excessive force and shoved R74 down the hall; however, the DON just shrugged her shoulders and stated She alr… | 2018-05-01 |
| 5982 | 5982 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2016-02-06 | 226 | D | 1 | 0 | R5VO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of a facility self-reported incident, interview and review of the policy, the facility failed to implement the abuse policy, report the abuse immediately and failed to develop a policy with direction to protect a resident from further abuse during the investigation. This occurred for one (R74) of two investigations reviewed for abuse. Findings included: Review of the facility self-reported incident completed on 1/25/16 revealed a staff member was observed pushing a resident (R74) down the hallway with excessive force on 1/22/16. Further review of the report revealed the time of the incident had not been documented. The allegation also identified a Licensed Practical Nurse (LPN) 2, who had pushed R74 with excessive force. Review of the facility investigation revealed the process initiated to prevent further incidents was that the Social Service Designee (SSD)1 had spoken to LPN 2 about the harsh treatment. There was no documented evidence of an attempt to interview R74 or other residents on the 100 Hall. LPN2 continued to work in the facility on 1/22/16 to the end of the shift. Interview on 2/6/16 at 10:45 a.m., the Director of Nursing (DON) acknowledged she was not aware of the incident until 1/25/16 when it was reported by Social Service. The DON stated that LPN 2 had quit on 1/25/16 related to her pay check bounced. The DON verified LPN 2 continued to work after the incident through the end of the shift on 1/22/16 and for an additional two days. Interview with SSD1 on 2/6/16 at 11:00 a.m. identified LPN2 as the staff person she witnessed using excessive force to push R74 on 1/22/16 at about 5:30 p.m. SSD1 stated R74 was threatening to hit another resident and she called for help because she couldn't redirect him. SSD1 stated LPN2 responded and stepped in between the residents to protect the resident who was threatened by R74. LPN2 pushed R74 in the back twice through the door way using excessive force. SSD1felt this met the … | 2018-05-01 |
| 5983 | 5983 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2016-02-06 | 363 | F | 1 | 0 | R5VO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to follow the pre-planned written menus. This deficient practice had the potential to affect all of the residents who dined in this facility. Findings included: Observation of the kitchen during a complaint investigation on 2/6/16 at 11:45 a.m. revealed that the facility had two notebooks that contained written menus with serving sizes. Review of the menus revealed that the facility prepared and served a variety of therapeutic diets which included: carbohydrate controlled renal pureed mechanical soft low sodium Observation of the food that was prepared for the residents ' lunch meal on 2/6/16 at 12:00 p.m. revealed that the food that was prepared was not the food that was written on the pre-planned menu. An interview with the Dietary Manager (DM) on 2/6/16 at 12:00 p.m. confirmed that the facility did not prepare the foods that were listed on the preplanned menu. When interviewed about why the facility failed to prepare the food that was written on the menu, the DM stated that he just liked to mix things up. Per the DM the food that should have been prepared included: roast turkey gravy cornbread stuffing green bean casserole dinner roll margarine mandarin oranges Observation of the prepared food, revealed that the facility prepared the following foods: oven roasted turkey steamed cabbage sweet potatoes cornbread chocolate cake/icing baked lasagna salad/garlic bread An interview with the Registered Dietitian (RD) on 2/6/16 at 12:00 p.m. revealed that she completed the nutritional assessments for each resident who resided in this facility. The RD added that there were residents in the facility who required physician ordered therapeutic diets such as those residents with diabetes or [MEDICAL CONDITION]. When interviewed, about how she could complete a nutritional assessment or ensure that each resident had received the appropriate foods per their physician ordered diet if th… | 2018-05-01 |
| 5984 | 5984 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2016-02-06 | 371 | D | 1 | 0 | R5VO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure food safety when they did not: 1) follow the manufacturer's recommendations when operating the dish machine, 2) date and label potentially hazardous foods to prevent serving expired items, 3) defrost meat appropriately, 4) cover ready to eat food while stored to prevent cross contamination, and 5) sanitize their dishware in clean water. This deficient practice had the potential to affect all 87 residents who resided in this facility. Findings included: 1. Observation of the kitchen on 2/4/16 at 4:00 p.m. during a complaint investigation revealed a Dietary Aide (DA 1) had been operating the dish machine. DA 1 was observed placing four racks of dishes in the dish machine and removing the dishes from the rack after they air dried. Review of the manufacturer ' s label that was affixed to the front of the dish machine revealed the minimum water temperature for both the wash and rinse cycles were 120 degrees Fahrenheit (F). Observation of the dish machine during operation for six separate trials revealed that the water temperature did not reach 120 degrees F during all six trials. The temperature ranged from 93-98 degrees F. Review of the Dishwasher Temperature/Chemical Record dated February 2016, on 2/4/16 at 4:30 p.m., revealed the water temperature and the chemical sanitizer needed to be monitored and recorded three times each day; at breakfast, lunch and dinner. Further review of the temperature log revealed the water temperature and the parts per million (PPM- chemical sanitizer) was not recorded for lunch or dinner on 2/2/16, not recorded for any of the meals on 2/3/16, and it was not recorded for any of the meals on 2/4/15. An interview with the Dietary Manager (DM) on 2/4/16 at 4:45 p.m. revealed the facility water system was not functioning properly; consequently the water in the dish machine could not reach the minimum temperature of 120 degrees F for either … | 2018-05-01 |
| 5985 | 5985 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2016-02-06 | 456 | F | 1 | 0 | R5VO11 | Based on observation, record review and interview, the facility failed to maintain their essential equipment in safe operating condition. The facility failed to ensure that their kitchen equipment was maintained and functioning properly and failed to ensure water temperatures the hand sinks, shower rooms and laundry area contained warm water for bathing, hand washing and laundering of resident clothing. This deficient practice had the potential to affect all of the residents who resided in this facility. Findings included: 1.The following observations were made in the facility kitchen on 2/4/16 from 4:00- 5:30 p.m.: a. The convection oven that was located next to the tilt skillet had black electrical tape holding the metal piping in place on the side of the oven. In addition, the face plate that covered the electrical components was missing which exposed the components. An interview with the Dietary Cook at that time, revealed that the convection oven had been broken for approximately one month. b. Observation of the tilt skillet revealed that the electrical cord had a plastic covering that was cracked and chipped which exposed the underlying components and the on/off temperature dial on the front of the skillet was missing. Staff had to put their hands inside the metal housing to operate the skillet. Additional observation underneath the skillet revealed a large metal drain that was not functioning properly. There was approximately two inches of discolored liquid surrounding the drain which allowed the discolored liquid to leak out into the kitchen. c. Observation of the two stove/ovens behind the tilt skillet were missing the bottom face plates which exposed the electrical elements and allowed the pilot lights to remain uncovered. The fire from the pilot lights were in full view. d. Observation of the milk and beverage cooler revealed the front rubber seal was broken and not held tightly in place and there was condensation around the cooler. Inside the cooler was a thermometer that did not have a face plate cov… | 2018-05-01 |
| 5986 | 5986 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2016-02-06 | 493 | D | 1 | 0 | R5VO11 | Based on record review, interview and review of policies and procedures, the facility governing body failed to ensure: 1) each facility employee was paid timely, 2) the Quality Assurance Performance Improvement (QA/PI) committee met quarterly and had the appropriate members present, and 3) develop effective policies and procedures. This deficient practice had the potential to affect all of the residents who resided in this facility. Findings included: 1. Review of two Complaint Intake IDs; GA 800 and GA 970 received on 12/16/15 and 1/27/16 respectively, revealed that the facility might have some difficulties meeting their payroll obligations. Per the complainants, who requested to remain anonymous, the facility was in a financial bind , they were concerned that some of the employees might walk out and their payroll checks were being held. An interview with a Licensed Practical Nurse (LPN1) on 2/4/16 at 4:30 p.m. revealed that some of the nurses at this facility had not been paid per the facility policy and one LPN2 quit a few days previously due to non-payment. LPN1 added that many of the facility employees received their payroll checks late and soon after they deposited the checks, they were returned for insufficient funds. Review of the personnel file revealed LPN2 had written a note that stated, I (name of the employee) resign on 1/25/16. The note did not state why LPN2 resigned. During an interview on 2/5/16 at 2:30 p.m., Employee10 (E10) (an anonymous source) stated that she was aware of the hand written note in LPN2' s personnel file. E10 added that before LPN2 left the facility, she told E10 that she was resigning due to not receiving paychecks timely. An interview with a Nurse Aide (NA1) on 2/5/15 at 11:30 a.m. revealed the facility would hold the employee paychecks until after the bank closed for the day. NA1 added that their checks were supposed to be ready at 2:00 p.m. on paydays but the facility held their checks, until 4:00 p. m. When interviewed about why the checks were held until 4:00 p.m. on payd… | 2018-05-01 |
| 5987 | 5987 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2016-02-06 | 520 | F | 1 | 0 | R5VO11 | Based on interview and record review, the facility failed to ensure that each member of the Quality Assessment and Performance Improvement (QA/PI)) committee attended the meetings and met on a quarterly basis to address concerns that had been identified throughout the facility. The facility failed to develop plans of action with measurable goals and interventions to ensure that the identified concerns would not be repeated in the future. They failed to identify and correct concerns with, 1) the environment and housekeeping, 2) maintenance of essential equipment, 3) a properly functioning water system and 4) the lack of funds to pay their employees. This deficient practice had the potential to affect all 87 residents who resided in this facility. Findings include: 1. Review of the Statement of Deficiencies, the federal 2567 report dated 1/20/16 and the Plan of Correction (P(NAME)) for the revisit with a date certain of 2/4/16, revealed that the facility had failed to maintain the environment in a safe and sanitary fashion. 2. Observation of the kitchen on 2/4/16 from 4:00pm through 5:30pm revealed that the facility failed to maintain their essential equipment in safe operating condition. The facility ' s tilt skillet, stove/ovens, water faucets, walk-in freezer, dish machine, and convection oven were either missing parts, held together with electrical tape, or and not functioning properly. For additional information refer to F456. An interview with the Dietary Manager (DM) on 2/6/16 at 12:00pm revealed that he did not have a policy and procedure relative to how to maintain the kitchen equipment effectively. The DM stated that he did attend the QA/PI meetings but the concerns about the kitchen equipment was not discussed. When interviewed about how he could ensure that these concerns would not continue in the future if they were not addressed in the QA/PI meetings, the DM stated he was unsure. Review of the 1st Quarter Monthly QA/PI Meeting Agenda revealed that the facility was to discuss the deficient practices th… | 2018-05-01 |
| 6270 | 6270 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2015-02-20 | 257 | E | 1 | 0 | JG8W11 | Based on observation and staff interviews the facility failed to maintain a safe and comfortable temperature on one (1) (100 Hall) of three (3) halls. Findings include: During the initial tour of the facility on 2/20/15 at 10:50 a.m., the air temperature in the Men's Shower room was noted to be very cold and uncomfortable. The air temperature at that time was 65.4 degrees Fahrenheit (F). The air temperature in the Women's Shower room was 73 degrees F. During an interview with staff AA and BB on 2/20/15 at 12:15 p.m., they stated that there had not been any central heat and air for about a year. During an interview with the maintenance supervisor on 2/20/15 at 11:15 a.m., the maintenance supervisor stated that the central heating and cooling unit had been burned out since at least 3/2014. He/She further stated that he/she had submitted a bid to replace the central heating and air unit on 1/8/15 and had not yet had a response from corporate. He/She stated that it was inexcusable. | 2018-02-01 |
| 6271 | 6271 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2015-02-20 | 456 | F | 1 | 0 | JG8W11 | Based on observation and staff interviews, it was determined that the facility failed maintain one of two water heaters to ensure there was hot water on three of three halls. Findings include: During the initial tour of the facility on 2/20/15 at 10:50 a.m. with the maintenance supervisor, Director of Nursing and the housekeeping supervisor, the following rooms were checked and were found to not to have adequate hot water: Women's Shower room- 86.5 degrees Fahrenheit (F.), Men's Shower Room- 83 F., room 118- 93.2 F., room 108- 91.6 F., room 102- 91.8 F., room 101- 91.4 F., room 100- 86.9 F., room 220- 91 F., room 216- 97 F., room 214- 94 F., room 204- 94.6 F., room 201- 94 F., room 304- 88 F., room 310- 88 F., room 312- 82.6 F. and room 316- 82 F. During an interview with staff AA and BB on 2/20/15 at 12:15 p.m., they stated that there had not been adequate hot water in the resident rooms or shower for about three weeks and no heat for about a year. During a random observation on 2/20/15 at 12:30 p.m., a resident told the Director of Nursing (DON) that the shower was cold this morning. During a group interview held with four (4) residents on 2/20/15 at 1:25 p.m. it was revealed that all four (4) residents concurred that there had been no hot water for a couple of months and that it was too cold in the shower. One (1) resident stated that he/she would take a sponge bath from now on. During an interview with the maintenance supervisor on 2/20/15 at 11:15 a.m., revealed that for the last six (6) to seven (7) days there had been very little hot water in the building. He/She stated that one (1) of the two (2) hot water heaters stopped functioning a couple weeks ago which left the one (1) water heater serving the entire building, except for the laundry. He/she stated that he/she had obtained two (2) bids to replace the water heater on January 8, 2015 and January 31, 2015. He/She further stated that he/she had not received approval from corporate to replace the unit. He/She stated that the delay was inexcusable. | 2018-02-01 |
| 8545 | 8545 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2011-11-10 | 280 | D | 0 | 1 | 1JXD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and record review, it was determined that the facility failed to continue to implement planned interventions to address the positioning needs of one resident (#63) and failed to revise interventions to address continued falls for one resident (#38) in a total sample of 28 residents. Findings include: 1. On the 5/27/11 Minimum Data Set (MDS) assessment, licensed staff coded resident # 63 as having limitaton with range of motion to one side of his/her upper extremity. On the 9/1/11 MDS assessment, the resident was coded with a decline in the limited range of motion to include both of his/her upper extremities. There was a care plan since 8/28/10 to address his/her risk for injury from falls due to limited mobility, havig been bed to gerichair bound and having [MEDICAL CONDITION] and a [MEDICAL CONDITION] disorder. The interventions included having the call light close (to the resident) and for staff to promptly answer it, staff providing all activities of daily living, for staff to transfer the resident with the hoya lift, and staff to monitor the resident for positioning for possible injury. A new intervention was added on 8/22/11 for the resident to be screened by occupational therapy services for an evaluation if indicated. However, although the resident was observed to lean to the left in his/her geri-chair, there was no evidence that the resident was provided any restorative therapy services after his/her hospital return in July 2011 or was evaluated by the occupational therapist for further skilled therapy. See F 311 for additional information regarding resident # 63. 2. Resident #38 had a care plan and physician's orders [REDACTED]. There was an intervention for physical therapy skilled services to be provided for the resident three times a week for two weeks for therapeutic exercises therapeutic activities, gait-training, and neuromuscular re-education. However, there was no evidence that the physic… | 2016-01-01 |
| 8546 | 8546 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2011-11-10 | 282 | D | 0 | 1 | 1JXD11 | Based on observations, record review and staff interview, it was determined that the facility failed to implement care plan interventions to provide oral care for one resident A and to provide assistance with shaving for one resident (#74) in a total sample of 28 residents. Findings include: 1. On the 9/01/11 and 5/27/11 Minimum Data Sets (MDS) assessments, licensed staff coded resident A as needing total assistance for hygiene. There was a care plan since 8/28/11 to address his/her dependence on staff to meet his/her activities of daily living (ADL) needs because of his/her limited mobility. There was an intervention for staff to explain procedures prior to performing his/her daily oral care. However, the resident was observed on 11/7/11 at 3:20 p.m., 11/9/11 at 8:30 a.m. and 11:30 a.m., and on 11/10/11 at 9:50 a.m. to have teeth that were caked with debris. See F312 for additional information regarding resident A. 2. Resident #74 had a care plan since 11/8/11 to address his/her self care deficit with an intervention for nursing staff to assist him with shaving on bath days and as needed. According to staff documentation on the the resident's ADL Flow sheet that was reviewed on 11/10/11 9:10 am, the resident had been given a shower every day from 11/1 thru 11/9/11. However, resident #74 was observed to have had several days growth of facial hair on 11/8/11 at 8:17 a.m. and 4:32 p.m., on 11/9/11 at 8:50 a.m., 11:05 a.m., 3:00 p.m. and 4:05 p.m. and, on 11/10/11 at 8:00 a.m. and 10:10 a.m. See F312 for additional information regarding resident #74. | 2016-01-01 |
| 8547 | 8547 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2011-11-10 | 311 | D | 0 | 1 | 1JXD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview and record review, it was determined that the facility failed to continue to provide services to address the maintenance or improvement of positioning for one resident (#63) in a total sample of 28 residents. Findings include: Resident # 63 had [DIAGNOSES REDACTED]. The resident had been coded on the 5/27/11 Minimum Data Set ( MDS) assessment as having limitation with range of motion on one side of his/her upper extremity. On the 9/01/11 MDS, the resident was coded to have had a decline of limited range of motion in both of his/her upper extremities. staff developed a care plan to address the resident's risk for injury due to limited mobility, being bed to chair bound and having [MEDICAL CONDITION] and a [MEDICAL CONDITION] disorder. There was an intervention for staff to monitor his/her positioning for possible injury. Staff added an intervention on 8/22/11 for the resident to be screened by occupational therapy services and evaluated as indicated. The resident was observed attending a church service on 11/9/11 at 10:30 a.m. He/she was seated in a geri-chair in the reclining position. Although staff had provided a back support and bolster for the left arm of the resident's geri-chair, his/her upper torso was leaning toward the left side. The resident was observed to still be in the activity room at 11:30 a.m. Despite the resident continuing to lean to the left side of the geri-chair, the staff, who was present in the room, failed to attempt to reposition the resident into the correct position. The resident continued to be leaning to the left side while seated in geri-chair in the day room at 3 p.m. Although there were positioning devices to the back and left arm of the geri-chair, the resident continued to inappropriately lean to the left so that there was not any support for his/her head or neck. On 11/10/11 at 8:30 a.m., the resident was observed seated in geri-chair. He/She was leaning to the left si… | 2016-01-01 |
| 8548 | 8548 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2011-11-10 | 312 | D | 0 | 1 | 1JXD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interview, it was determined that the facility failed to provide oral care for one resident (A) and to assist with shaving for one resident (#74) in a total sample of 28 residents. Findings include: 1. Resident Ahad [DIAGNOSES REDACTED]. On the 9/01/11 Minimum Data Set (MDS) assessment, licensed staff had coded him/her as needing total assistance for hygiene. The resident's care plan since 8/28/11 noted that the resident depended on staff to meet his/her activities of daily living (ADL) needs because of his/her limited mobility. There was an intervention for (nursing) staff to explain procedures prior to performing the resident's daily oral care. However, it was observed that daily oral care was not provided for resident A. The 9/20/11 nurse's note at 12:30 p.m. described the resident having had a tooth come out while he/she was eating. The tooth was described as having been black in color and, chipped and broken in places. Nursing staff wrote that the other teeth surrounding the open area were dark in color. However, there was no evidence that the resident's attending physician or a dentist had been contacted about those problems with the resident's teeth. During an interview on 11/7/11 at 3:10 p.m., resident A stated that staff helped him/her to brush his/her teeth less than once a month. The resident's teeth were observed on 11/7/11 at 3:20 p.m., on 11/9/11 at 8:30 a.m. and 11:30 a.m., and on 11/10/11 at 9:50 a.m. to have been caked with debris. 2. On the 10/27/11 MDS assessment, licensed nursing staff coded resident #74 as needing total assistance with personal hygiene and grooming. Nursing staff developed a care plan dated 11/8/11 to address the resident's self care deficit with an intervention for nursing staff to assist with shaving on his/her bath day and as needed. Review of the resident's ADL flow sheet revealed nursing staff's documentation that the resident had been given a shower on … | 2016-01-01 |
| 8549 | 8549 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2011-11-10 | 323 | D | 0 | 1 | 1JXD11 | **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 provide interventions to prevent falls for one resident (# 38) from a sample of 28 residents and to secure razors in one common shower room (100 hall) of three common shower rooms in the facility. Findings include: 1. Review of the medical record for resident #38 revealed staff documentation about the resident having fallen but not been injured on 08/12/11, 08/29/11, 09/11/11, 09/12/11, 09/12/11, 10/04/11, 10/19/11 10/23/11, and 11/09/11. The facility developed and implemented interventions to prevent falls. Record review revealed that the resident had been provided skilled physical therapy services from 9/01/11 to 9/09/11 to reduce the likelihood of falls then, a referral had been made for restorative nursing services for maintaining skill in ambulation and strength in both legs. Staff's documentation revealed that the resident was provided range of motion exercises as ordered from 09/10/11 through 11/10/11. However, the resident continued to fall with the last fall documented as happening on 11/09/11. The physician wrote an order on 10/24/11 for physical therapy staff to evaluate and treat the resident as indicated. The order was for the resident to be seen by a skilled physical therapist three times a week for two weeks for skilled physical therapy services. However, there was no evidence that those services had been provided. During an interview on 11/10/11 at 10:45 a.m., occupational therapist CC could not locate evidence that a physical therapy evaluation had been done despite the order for it or that those skilled services had been provided. During an interview on 11/10/11 at 11:00 a.m., the Restorative Nursing Services registered nurse (RN) AA and certified nursing assistant, (CNA) BB said that nursing staff was not aware of any physical therapy services but, were providing restorative nursing services. During an interview on 11/10/… | 2016-01-01 |
| 8550 | 8550 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2011-11-10 | 371 | F | 0 | 1 | 1JXD11 | Based on observation, staff interview, and record review, it was determined that the facility failed to hold and serve potentially hazardous food at safe temperatures to prevent potential food borne illnesses for seven of eight residents on pureed diets and 28 of 76 residents who were served mechanical soft or regular diets. Findings include: During an observation on 11/7/11 at 12:35 p.m., foods were observed being held and served in the danger zone (above 41 degrees Fahrenheit (F.) and below 135 degrees F.) which allowed for the growth of organisms which could cause food borne illness. Pureed chicken was being held and served at 120 degrees F. The potato salad was being held and served at 54 degrees F The foods were checked with a facility calibrated thermometer. Seven residents had been served the pureed chicken. There were 28 residents who had been served the potato salad. In an interview on 11/08/11 on 12:37 p.m., the Dietary Manager said that the potatoes were warm when the salad was mixed. However, the temperature log documentation indicated that the potatoes had been at 40 degrees F at 11:55 a.m On 11/08/11 at 1:20 p.m., the Dietary Manager stated that residents on a mechanical soft diet and those eating at the first seating in the dining room had been served potato salad. | 2016-01-01 |
| 10215 | 10215 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2010-04-08 | 253 | B | 0 | 1 | OHLM11 | Based on observation, it was determined that the facility failed to maintain an environment that was free from stained and dirty clean linen carts, dried food splatters, dried spills, dirt , dust, non-fitting commode tank covers, gaps in floor tiles, and rust in room 216 and on all three Halls (100 Hall, 200 Hall, 300 Hall). Findings include: Observations were made during the Initial Tour on 4/6/10 at 9:45 a.m. and the General Observations Tour on 4/8/10 between 8:30 a.m. and 10:30 a.m. 100 Hall 1. There were dust and dried liquid spills on the shelves of the clean linen cart in the hall. 200 Hall 1. There was a buildup of dirt in the corners of the bottom shelf of the clean linen cart in the hall. There were dust and dried liquid spills on the other shelves of the cart. 2. There was a loose door handle to the bathroom of room 216. There was a gap in the corner where the floor tiles met the wall. There was a rusty leg on the raised toilet seat. The commode tank cover did not fit the tank. 300 Hall 1. There were dried brown liquid spills on the shelves of the clean linen cart in the hall. There were dried liquid spills on the cart cover. Pantry 1. There were dried food splatters inside of the microwave. There were dried pink liquid spills inside the refrigerator's crisper drawers. | 2014-12-01 |
| 10216 | 10216 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2010-04-08 | 203 | D | 1 | 1 | OHLM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, it was determined that the facility failed to provide written notice of the discharge and of the required information for one resident (#1) of three residents discharged from the facility in a total sample of 18 residents. Findings include: According to the 2/19/10 at 9:30 a.m. nurse's notes, resident #1 had and altercation with a licensed nurse and the resident was picked up by the county sheriff's department. The licensed nurse documented on 2/19/10 at 1:45 p.m. that the psychiatric hospital was consulted about the resident's admission. There was a 2/19/2010 physician's orders [REDACTED]. On 2/26/10 (seven days later) there was a physician's orders [REDACTED]. However, there was no evidence that the facility had notified the resident and a family member or legal representative in writing of the discharge the reason for the discharge, the effective date of the discharge, the location to which the resident was being discharged , notice that the resident had the right to appeal the action to the State, and the name, address, and telephone number of the State Long Term Care Ombudsman. During an interview on 04/07/10 at 2:00 p.m., the Administrator confirmed that the facility had not provided the required written notification of the discharge and information to the resident and family member or legal representative. | 2014-12-01 |
| 10217 | 10217 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2010-04-08 | 441 | D | 0 | 1 | OHLM11 | **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 assure that one of four newly hired employees were free of communicable disease before allowing direct contact with residents or that one of two CNAs observed practiced proper hand hygiene after bowel incontinence care. Findings include: The facility's policy to "New Employee Screening" documented that the employee health coordinator (or designee) would accept documented verification of two-step TST ([MEDICATION NAME] skin test)or BAMT (blood assay for [DIAGNOSES REDACTED] [DIAGNOSES REDACTED]) results within the preceding 12 months. 1. A review of 14 employees' personnel records revealed that one certified nursing assistant was hired by the facility on 1/13/10. However, there was no evidence that the facility had performed a [MEDICATION NAME] screening test (PPD) and received the results prior to her having had direct contact with residents. The most recent PPD result documented for the resident was dated 7/1/09. However, there was no evidence that the facility had verified that it had been a two-step TST within those preceding 12 months. 2. After completion of bowel incontinence care for resident #6 on 4/6/10 at 4 p.m., it was observed that CNA "AA" failed to remove her soiled gloves. The CNA did not remove or change his/her gloves or wash his/her hands prior to redressing the resident and positioning him/her in a geri-chair. | 2014-12-01 |
| 10218 | 10218 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2010-04-08 | 241 | E | 0 | 1 | OHLM11 | Based on observations, it was determined that the facility failed to promote a dignified dining experience for thirteen residents (#4, #13, #14, #11 and nine residents randomly observed) in the small dining room from a total sample of 18 residents. Findings include: 1. Resident #4 drank four ounces of water at lunch prior to receiving staff assistance. Resident #4 was observed on 4/6/10 at 12:35 p.m. in the small dining room being assisted to eat by a Certified Nursing Assistant (CNA). The CNA was inappropriately feeding the resident at a fast pace. The CNA did not allow the resident to swallow each bite before giving him/her more to eat. The CNA did not offer the resident any of the iced tea until after he/she had eaten all of the food on the plate. Resident #4 was observed on 4/7/10 at 12:25 p.m. in the small dining room slowly feeding himself/herself. A CNA was inappropriately giving the resident a few bites of food then walking over to another table and standing over another resident to feed him/her a few bites to eat. Resident #4 continued to slowly feed himself. At that time, another CNA was observed to be seated between two residents while assisting them to eat. However, that CNA inappropriately turned her back completely towards one resident while assisting the other resident to eat. 2. Resident #13 was observed on 4/8/10 from 12:05 p.m. to 12:31 p.m. eating lunch in the small dining room. The resident was seated at a table with resident #14 and another resident. A CNA was seated between resident #14 and the other resident. The CNA stopped assisting those two residents to eat when, she repeatedly got up and walked around the table to prompt resident #13 to continue to eat and drink fluids. At that time, it was observed that four other nursing staff members were supervising or assisting ten residents to eat. Two of the four nursing staff members were standing over the residents while assisting them to eat. 3. Resident #11 was observed on 4/8/10 from 8:10 a.m. to 8:30 a.m. in the small dining room being fed… | 2014-12-01 |
| 10219 | 10219 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2010-04-08 | 315 | D | 0 | 1 | OHLM11 | Based on observations, it was determined that the facility failed to provide proper incontinence care for one (#6) of the seven incontinent residents from the total sample of 18 residents. Findings include: During an observation of bowel incontinence care being provided for resident #6 on 4/6/10 at 4:00 p.m., CNA (Certified Nursing Assistant ) "AA" cleaned the resident's rectal area. The CNA then inappropriately wiped up into the resident's perineal area several times using the same disposable wipe that was soiled with feces. | 2014-12-01 |
| 10220 | 10220 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2010-04-08 | 160 | D | 0 | 1 | OHLM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and record reviews, it was determined that the facility failed to convey the personal funds of one resident (#15) to the probate jurisdiction administering the resident's estate within 30 days of the resident's death. Findings include: Resident #15 expired on [DATE]. A review of the resident's "Resident Trust Fund Statement" for [DATE] revealed that a balance of $50.45 remained in the resident's trust fund account. During an interview on [DATE] at 1:00 p.m., the facility's bookkeeper stated that the resident had been his/her own responsible party and that no family member had come forward to receive the resident's monies. The facility's policy on residents' funds documented that, if a balance remained in the account that was due the patient/responsible party within 30 days of discharge, a check would be issued to the patient/responsible party. If a balance remained in the account that was due to the facility, once the exact amount due was determined, the facility would issue a check to the facility's General account. During a telephone interview with the facility's CFO (Chief Financial Officer) on [DATE] at 1:30 p.m., he stated that the $50.45 remained in the resident's trust account because it had not been determined if the resident owed any money to the facility since the Explanation of Benefits for Medicare and Medicaid services had not been received by the facility. | 2014-12-01 |
| 10221 | 10221 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2010-04-08 | 205 | D | 1 | 1 | OHLM11 | **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 one resident (#1), who required an emergency transfer from the facility, with written notice within 24 hours that specified the duration of the facility's bed-hold policy from a total sample of 18 residents. Findings include: According to the 2/19/10 at 9:30 a.m. nurse's notes, resident #1 had an altercation with staff which resulted in injuries to the staff. The license nurse documented on 2/19/2010 at 1:45 p.m. that the behavorial (psychiatric) hospital was consulted for admission of the resident. There was a 2/19/10 physician's orders [REDACTED]. On 2/26/10 (seven days later), there was a physician's orders [REDACTED]. However, although the resident had required an emergency transfer from the facility to the behavioral (psychiatric) hospital on [DATE], there was no evidence that a written notice that specified the duration of the bed-hold policy had been given to the resident and a family member or legal representative within 24 hours of the transfer. On 4/07/10 at 2:00 p.m., the Administrator confirmed that the facility had not provided written notice to the resident and family member of the facility's bed-hold policy. | 2014-12-01 |
| 3366 | 3366 | SOUTHWELL HEALTH AND REHABILITATION | 115655 | 260 MJ TAYLOR ROAD | ADEL | GA | 31620 | 2018-08-02 | 761 | D | 0 | 1 | NKDP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review and staff interviews, the facility failed to remove expired medications by the expiration date in one out of two medication (med) storage rooms. The facility census was 81 residents. Findings included: During an observation on 7/31/18 at 2:55 p.m. of the North Wing Medication (med) storage room, with LPN BB, revealed ten (10) expired medications. Inside a refrigerator in the med storage room, a small plastic bag contained medication that needed to be refrigerated. The medication was 10 bottles of liquid [MEDICATION NAME] with the expiration date of 12/2017. Interview with LPN BB confirmed that the medication was expired. Further interview revealed that she didn't know who was responsible for removing the expired medication from the refrigerator in the med room. On 8/2/18 review of the Storage of Medications policy dated (MONTH) 3, 2013, revealed that all expired, damaged, mislabeled, and/or contaminated medications should be removed from the storage area for medications available for administration and stored separately. During an interview on 8/2/18 at 10:00 a.m. with the Director of Nursing (DON), revealed that it is her expectation that nursing staff remove expired medication from the medication storage room and be given to her or the Assistant Director of Nursing (ADON) for them to prepare the medication for destruction by the pharmacy. During an interview on 8/2/18 at 12:45 p.m. with the Consulting Pharmacist revealed that she visits the facility every month. She stated that she checks the refrigerators in the med storage room for expired medication during her monthly visit. Further interview revealed that she checks [MEDICATION NAME] Purified Protein Derivative (PPD), Influenza vaccines, and narcotics. Continued interview revealed that she did not know how the expired [MEDICATION NAME] had been missed during her monthly visits. She stated that her expectation is that narcotics be counted every shift a… | 2020-09-01 |
| 3367 | 3367 | SOUTHWELL HEALTH AND REHABILITATION | 115655 | 260 MJ TAYLOR ROAD | ADEL | GA | 31620 | 2019-08-19 | 623 | D | 1 | 0 | QWU811 | > Based on record review, staff interviews, and review of the facility policy titled, Transfers and Discharges the facility failed to notify the resident and the resident's representative in writing of the reason for transfer/discharge to a geriatric psychiatric facility for one of three residents (R) (R#1) reviewed for transfers and discharges. Findings include: Review of the policy titled, Transfers and Discharges dated (MONTH) 2013 documented the following: Except in emergencies, facility must notify the resident, the resident's physician, and, if known, the resident's guardian, family member(s), surrogate or representative prior to Discharge or Transfer. The notice in section (D) must be provided thirty (30) days prior to Discharge or Transfer unless one of the following circumstances exist, in such case the notice in section (d) should be provided as soon as practical before the Transfer or Discharge: 1. The health and safety of the resident or other individuals would be endangered. 2. The resident's health has improved to allow a more immediate Transfer or Discharge. 3. An immediate Transfer or Discharge is required by the resident's urgent medical needs; or 4. The resident has not resided at CSLC for thirty (30) days. Review of the Minimum Data Set (MDS) for R#1 list revealed the resident was discharged from the facility on 6/7/19 with return anticipated. Review of the 6/7/19 Progress Notes revealed the resident was noted with excessive wandering. The physician was notified and gave orders to send the resident to a geriatric psychiatric facility for admission. The resident's wife was called and informed of the new order to send the resident to the geriatric psychiatric facility. However, further review of the record revealed that there was not any documentation that the resident or the resident's representative were given a written notice for the reason for the transfer/discharge. During an interview with the Director of Nursing on 8/19/19 at 4:00 p.m., she stated the staff were supposed to complete the tr… | 2020-09-01 |
| 3368 | 3368 | SOUTHWELL HEALTH AND REHABILITATION | 115655 | 260 MJ TAYLOR ROAD | ADEL | GA | 31620 | 2019-08-19 | 625 | D | 1 | 0 | QWU811 | > Based on record review, staff interview, and review of the facility policy titled, Bed Hold Policy the facility failed to provide bed hold information at the time of transfer or within 24 hours of a transfer for one of three residents (R) (R#1) reviewed for transfers and discharges. Findings include: Review of the policy and procedure titled, Bed Hold Policy dated (MONTH) (YEAR) documented the facility shall provide written notice of its bed hold policy to each resident and a family member or other representative of the resident: i: At the time of admission; and ii. At the time the resident is transferred to another care environment. In the event a resident is transferred due to an emergency, then such resident's family, guardian, or other representative shall be provided with a copy of CSLC's bed hold policy within twenty-four (24) hours of such transfer. Record review revealed R#1 was admitted to a geriatric psychiatric facility on 6/7/19. Although the facility provided written information on the bed hold policy on admission on 2/22/19, a review of the clinical record revealed the resident's responsible party was not provided information on the bed hold policy at the time of transfer and was not provided the bed hold information until 6/11/19. During an interview with the Director of Nursing on 8/19/19 at 4:00 p.m., she confirmed that the bed hold information had not been provided at the time of transfer. | 2020-09-01 |
| 3369 | 3369 | SOUTHWELL HEALTH AND REHABILITATION | 115655 | 260 MJ TAYLOR ROAD | ADEL | GA | 31620 | 2018-08-28 | 656 | D | 1 | 0 | CVRQ11 | > Based on staff interviews and record review, the facility failed to ensure that the appropriate method of transfer was utilized, as care planned for one resident (#1) from a total sample of six residents. Findings include: Resident (R) #1 had a care plan since 3/8/17 for being weak most days and needing help and reminders not to fall. The care plan included an intervention for Certified Nursing Assistants (CNA's) to use a Hoyer lift and at least two people to assist with all transfers. There was an additional care plan for falls, included in the electronic portion of the clinical record, dated 7/17/18, that also included an intervention for staff to use a Hoyer lift with the assistance of two staff members for all transfers. However, on 8/11/18, R#1 was transferred from the bed to a geri-chair and from the geri-chair to the bed without the use of a Hoyer lift as care planned. During an interview on 8/27/18 at 2:50 p.m. CNA AA stated that she transferred the resident out of bed to the geri-chair and later transferred her back to bed on 8/11/18. She confirmed that a Hoyer lift was not used to assist with the transfers. During an interview on 8/28/18 at 12:15 p.m., CNA BB, who was also present when R#1 was assisted back to bed on 8/11/18, confirmed that a Hoyer lift was not used to assist with the transfer. Cross reference to F689 | 2020-09-01 |
| 3370 | 3370 | SOUTHWELL HEALTH AND REHABILITATION | 115655 | 260 MJ TAYLOR ROAD | ADEL | GA | 31620 | 2018-08-28 | 689 | D | 1 | 0 | CVRQ11 | > Based on staff interviews and record review, the facility failed to ensure that the appropriate method of transfer was utilized for one resident (#1) from a total sample of six residents. Findings include: Resident (R) #1 had a care plan since 3/8/17 for being weak most days and needing help and reminders not to fall. The care plan included an intervention for Certified Nursing Assistants (CNA's) to use a Hoyer lift and at least two people to assist with all transfers. There was an additional care plan for falls, included in the electronic portion of the clinical record, dated 7/17/18, that also included an intervention for staff to use a Hoyer lift with the assistance of two nursing staff for all transfers. In addition to the care plan, a Lift/Transfer Assessment form, dated 4/25/18, documented that for transfers to and from bed to chair, chair to toilet, and chair to chair, a Hoyer lift and two persons was required. The Resident Profile, maintained in the electronic portion of the clinical record and accessible via the computerized kiosks, for CNA's to access, also included that the resident was to be transferred from bed to chair and chair to chair with a Hoyer lift and the assistance of two nursing staff. However, on 8/11/18, R#1 was transferred from the bed to a geri-chair and from the geri-chair to the bed without the use of a Hoyer lift as care planned and assessed. During an interview on 8/27/18 at 2:50 p.m. CNA AA stated that she transferred the resident out of bed to the geri-chair and later transferred her back to bed on 8/11/18. She confirmed that a Hoyer lift was not used to assist with the transfers. During an interview on 8/28/18 at 12:15 p.m., CNA BB, who was also present when R#1 was assisted back to bed on 8/11/18, confirmed that a Hoyer lift was not used to assist with the transfer. | 2020-09-01 |
| 3371 | 3371 | SOUTHWELL HEALTH AND REHABILITATION | 115655 | 260 MJ TAYLOR ROAD | ADEL | GA | 31620 | 2017-09-28 | 279 | E | 0 | 1 | YELK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility failed to develop a care plan to address [MEDICATION NAME] use and antipsychotic medication use for one resident (#61), dental status for one resident (#110) from a total sample of 24 residents. Findings include: 1. Resident #61 had a physician's orders [REDACTED]. There was also a physician's orders [REDACTED]. However, a review of the clinical record revealed that facility nursing staff failed to develop a care plan for the use of the medications. During an interview on 9/28/17 at 9:28 a.m., the Director of Nursing (DON) stated that [MEDICATION NAME] and antipsychotic medications are medications that are usually included in the care plan. 2. Resident #110 was admitted with [DIAGNOSES REDACTED]. pylori infection and Stage II and Stage III sacral pressure ulcers (buttocks). The comprehensive MDS assessment dated [DATE] notes obvious or likely cavity or broken teeth and the 7/1/17 Dental Care Area Assessment worksheet states a care plan will be developed to adress the identified needs in this area. Review of the care plan dated 7/7/17 reveals a problem area for trouble swallowing but nothing for dental issues. During an interview on 9/27/17 at 10:30 a.m., the DON confirmed there was no care plan developed for the dental issues identifed on the assessment. | 2020-09-01 |
| 3372 | 3372 | SOUTHWELL HEALTH AND REHABILITATION | 115655 | 260 MJ TAYLOR ROAD | ADEL | GA | 31620 | 2019-12-18 | 640 | F | 0 | 1 | 0K8D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, and review of the facility policy titled, Comprehensive Assessment, Minimum Data Set (MDS) the facility failed to ensure that Minimum Data Set (MDS) assessments were transmitted timely within 14 days of completion to the Centers for Medicare and Medicaid Services (CMS) Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) System for 15 of 15 residents reviewed (R#5, R#13, R#15, R#16, R#12, R#14, R#17, R#8, R#3, R#11, R#7, R#9, R#4, R#2, R#10). The facility census was 93. Findings include: Review of the facility policy titled, Comprehensive Assessment, Minimum Data Set (MDS) dated effective (MONTH) (YEAR), revealed; B. 1. The facility will use the Resident Assessment Instrument (RAI) specified by the state of Georgia. 1. A record review revealed R#5 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. R#5 had a comprehensive MDS completed on 10/30/19, 8/8/19, 5/16/19, and 2/22/19. R#5's care plans were reviewed and updated on 10/31/19. R#5 Comprehensive Assessment was completed on 10/30/19 but review of MDS Transmission Results indicated the assessment was not transmitted to CMS within 14 days of completion. A record review revealed R#13 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. R#13 had a comprehensive MDS completed on 11/7/19, 8/16/19, 5/22/19, 2/28/19, and 11/28/18. R#13's care plans were reviewed and updated on 11/17/19. R#13's Comprehensive Assessment was completed on 11/7/19 but review of MDS Transmission Results indicated the assessment was not transmitted to CMS within 14 days of completion. A record review revealed R#15 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The last care plan review was completed on 11/7/19. R#15's Comprehensive Assessment was completed on 11/5/19 but review of MDS Transmission Results indicated the assessment was not transmitted to CMS within 14 days of completion… | 2020-09-01 |
| 4276 | 4276 | SOUTHWELL HEALTH AND REHABILITATION | 115655 | 260 MJ TAYLOR ROAD | ADEL | GA | 31620 | 2016-07-01 | 247 | D | 0 | 1 | 0GTS11 | Based on record review, resident and staff interview, the facility failed to provide information that one (1) resident (#99) was notified of a change in roommate. The sample size was forty-two (42) residents. Findings include: An interview on 06/28/2016 at 09:08 a.m. with resident #99, revealed that the facility staff do not provide any notice when a new roommate is admitted to his/her room. He/she stated that roommates just show up. An additional interview with the resident on 06/29/2016 at 10:52 a.m. revealed that the resident's current roommate had been in the room for about three (3) months and prior to the current roommate there had been two (2) other residents admitted to the resident's room within a two (2) week time frame and that staff did not provide any notification the resident was getting a new roommate prior to the roommates moving into the room. An interview with the Admission Coordinator on 06/29/2016 at 10:38 a.m., revealed that when there is an admission, the resident residing in the room is notified, although the notification may not be documented in the resident's record. The Admission Coordinator revealed that the notification may be only verbal and the facility has no specific policy related to room changes. | 2020-01-01 |
| 4277 | 4277 | SOUTHWELL HEALTH AND REHABILITATION | 115655 | 260 MJ TAYLOR ROAD | ADEL | GA | 31620 | 2016-07-01 | 279 | D | 0 | 1 | 0GTS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to develop comprehensive care plan for two (2) residents (#70 and #24) for diabetes management from a sample of 42 residents. Findings include: 1. Resident #70 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Review of the medical record revealed a physician order [REDACTED]. FSBS results 61-140 give 0 units, FSBS results 141-180 give 2 units, FSBS results 181-240 give 4 units, FSBS results 241-300 give 6 units, FSBS results 301-400 give 8 units, FSBS greater than 400 give 12 units and call the physician. The resident was also ordered [MEDICATION NAME] Insulin 30 units subcutaneously in the evening. Review of the comprehensive care plan revealed no plan to address the resident's sliding scale insulin coverage, hypo/[MEDICAL CONDITION] or the FSBS as ordered by the physician. Interview on 06/30/16 at 5:40 p.m. with Licensed Practical Nurse(LPN) CC revealed that he/she is responsible for coding the Minimum Data Set (MDS) assessments and that it was an oversight and therefore a care plan to address the resident's Diabetes Mellitus with insulin coverage was not developed and not addressed. 2. Resident #24 was admitted to the facility on [DATE]. On 6/20/16 the resident was newly diagnosed with [REDACTED]. In addition to the new [DIAGNOSES REDACTED]. The physician also ordered a routine dose of [MEDICATION NAME] to be administered at bedtime and 500 milligrams (mg) of [MEDICATION NAME] be administered twice daily with meals. However, a review of the clinical record revealed that a plan of care had not been developed to address the resident's new diagnosis. Cross reference to F309. | 2020-01-01 |
| 4278 | 4278 | SOUTHWELL HEALTH AND REHABILITATION | 115655 | 260 MJ TAYLOR ROAD | ADEL | GA | 31620 | 2016-07-01 | 282 | E | 0 | 1 | 0GTS11 | **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 ensure that blood sugar levels were obtained and/or insulin administered as care planned for five residents (#99, #84, #23, #104 and #38), failed to provide wound treatment as care planned for one (1) resident (#64) from a total sample of forty-two (42) residents. Findings include: 1. Resident #99 had a care plan problem in place since 12/22/15 for having a potential for altered nutrition with an intervention for licensed nursing staff to obtain blood sugar levels (Accucheck/Finger Stick Blood Sugar-FSBS) as ordered and administered insulin based on a sliding scale as indicated. However, a review of the clinical record revealed that licensed staff did not administer the correct amount of insulin on 4/10/16 at the scheduled time of 4 p.m Cross reference to F309. 2. Resident #84 had a care plan intervention since 8/24/15 for nursing staff to obtain blood sugar levels as ordered. There was a physician's orders [REDACTED]. However, a review of the clinical record revealed that licensed nursing staff did not document the blood sugar level results twice in (MONTH) (YEAR) (4/15/16 and 4/23/16) and once in (MONTH) (YEAR) (5/13/16). Cross reference to F514 3. Resident #104 was originally admitted to the facility on [DATE], discharged for one day 05/20/16 and re-admitted on [DATE]. The resident had a [DIAGNOSES REDACTED]. Review of the comprehensive care plan problem to address the resident's Diabetes Mellitus included and intervention for Accucheck/Finger Stick Blood Sugar (FSBS) before meals and at bedtime with sliding scale insulin coverage as indicated. Review of the medical record for this resident revealed a physician's orders [REDACTED]. If less than 60 follow hypoglycemic protocol, FSBS results 61-140 give 0 units, FSBS results 141-180 give 1 units, FSBS results 181-240 give 2 units, FSBS results 241-300 give 4 units, FSBS results 301-400 give 6 units and … | 2020-01-01 |
| 4279 | 4279 | SOUTHWELL HEALTH AND REHABILITATION | 115655 | 260 MJ TAYLOR ROAD | ADEL | GA | 31620 | 2016-07-01 | 309 | E | 0 | 1 | 0GTS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, it was determined the facility failed to administer insulin as ordered and/or failed to follow facility protocol and notify the physician of blood sugar levels less than sixty (60) or greater than 400 for eleven (11) residents (#109, #75, #99, #84, #24, #23, #38, #87, #70, #83, and #104 ) of twenty-two (22) residents reviewed with ordered blood sugar levels from a total sample of forty-two (42) residents. Findings include: Review of the facility's [DIAGNOSES REDACTED] Protocol documented for nursing staff to do the following: If a blood glucose level is less than 60 and the resident is asymptomatic, give orange juice. If a blood glucose level is less than 60 and the resident is symptomatic, give one [MEDICATION NAME] of [MEDICATION NAME] 50% in Water (D50W) intravenously. If the blood sugar is not corrected, notify the physician. On 6/30/16 at 9:50 a.m., the Assistant Director of Nursing (ADON) reviewed the protocol and confirmed that for a blood sugar level result of less than 60, after the intervention was implemented, the blood sugar would need to be rechecked in thirty (30) minutes, and if it was still less than 60, the physician should be notified. The ADON stated that nurses would document the initial low blood sugar level and the rechecked level on the Insulin Flow Sheet and would also follow- up with a nursing note about what was done. 1. Resident #109 had a [DIAGNOSES REDACTED]. There was a physician's order, since 2/16/16, for licensed nursing staff to obtain a finger stick blood sugar (FSBS) level daily in the morning. A review of the (MONTH) (YEAR) Medication Administration Record (MAR), which included the Insulin Flow Sheet, revealed that the resident had a blood sugar level result of less than sixty on the following dates: 3/22/16 at 6 a.m., the blood sugar level was 58 3/23/16 at 6 a.m., the blood sugar level was 57 3/26/16 at 6 a.m., the blood sugar level was 59 3/30/16 at 6 a.m., th… | 2020-01-01 |
| 4280 | 4280 | SOUTHWELL HEALTH AND REHABILITATION | 115655 | 260 MJ TAYLOR ROAD | ADEL | GA | 31620 | 2016-07-01 | 314 | D | 0 | 1 | 0GTS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview ,the facility failed to follow physician's wound care orders and failed to notify the resident's physician in a timely manner of wound care recommendations which included treatment with an antibiotic and laboratory test recommendations for one (1) resident (#64) with a stage four pressure ulcer to the sacrum from a total sample of forty two (42) residents. Findings include: Review of resident #64's Quarterly 5/18/16 Minimum Data Set (MDS) assessment revealed in section I the [DIAGNOSES REDACTED]. In addition, in section M, he/she was coded with a ) stage four (4) pressure ulcer. Review of the 3/23/16 Wound Care physician's recommendations revealed the following: stage four (4) pressure ulcer cleanse daily with saline, pack with one half inch plain gauze soaked in [MEDICATION NAME], then cover with [MEDICATION NAME], place a [MEDICATION NAME] border gauze do this twice daily. On 3/24/16 a physician's orders [REDACTED]. ( Clean wound to sacrum with normal saline , pack with [MEDICATION NAME] soaked gauze, cover with [MEDICATION NAME] and [MEDICATION NAME] twice daily (bid) until next visit in one week 4/1/16.) Record review of the (MONTH) Treatment Record Review revealed the 3/24/16 physician's orders [REDACTED]. However, during further review of the Treatment Record it was noted that the wound care was documented as done only once a day on 3/24,3/25, 3/28, 3/29, 3/30 and 3/31/16, instead of twice a day as ordered per physician. During an interview on 6/29/16 at 7:50 a.m. the Wound Care nurse confirmed the documentation on the Treatment Record noted that the dressing change was only done once a day on 3/24/16, 3/25/16,3/28/16,3/29/16,3/30/16 and 3/31/16. The Wound Care nurse further stated that this came to his/her attention on 3/26/16 and 3/27/16. He/she stated that he/she spoke to the Director of Nursing (DON) about the treatment had only been done once a day instead of twice a day as ordered. During… | 2020-01-01 |
| 4281 | 4281 | SOUTHWELL HEALTH AND REHABILITATION | 115655 | 260 MJ TAYLOR ROAD | ADEL | GA | 31620 | 2016-07-01 | 329 | D | 0 | 1 | 0GTS11 | **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 monitor for targeted behaviors for two (2) residents (#43 and #115) who were receiving antipsychotic medications from a total sample of forty two (42) residents. Findings include: 1. Resident #43 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the medical record revealed the physician ordered for the resident to receive [MEDICATION NAME] 2.5 mg by mouth two (2) times every day. Review of the Medication Administration Record [REDACTED]. However, there was not any documentation that the licensed nursing staff were monitoring the resident for any targeted behaviors. 2. Resident #115 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the medical record revealed the physician had ordered [MEDICATION NAME] 0.25 mg by mouth two (2) times every day. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. However, there was not any documentation that the licensed nursing staff was monitoring the resident for any targeted behaviors. Interview on 06/30/16 at 2:10 p.m. with the Director of Nursing (DON) revealed there should have been a Behavioral Monitoring Form in the MAR for the Licensed Nursing staff to document behaviors of residents receiving an antipsychotic medication. The DON stated that the Behavioral Monitoring form was a hand written form and the Licensed Practical Nurse (LPN) caring for the resident was responsible for placement of the behavioral monitoring form in the MAR book. The DON revealed that the licensed nursing staff were to document every shift any behaviors for residents that receive an antipsychotic medication. He/she confirmed that the nursing staff had not been documenting the resident's behaviors for both resident #43 and #115. Interview on 06/30/16 at 2:25 p.m. with LPN LL , he/she stated that the Behavioral Monitoring form was typically placed in the MAR book by the Registered Nurse (R… | 2020-01-01 |
| 4282 | 4282 | SOUTHWELL HEALTH AND REHABILITATION | 115655 | 260 MJ TAYLOR ROAD | ADEL | GA | 31620 | 2016-07-01 | 332 | D | 0 | 1 | 0GTS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility failed to ensure that the correct form of aspirin was administered for two (2) residents (#70 and #37) by 2 of three (3) nurses for a medication error rate of 8%. Findings include: During an observation on 6/29/16 at 9:18 a.m., Licensed Practical Nurse (LPN) LL administered one (1) eighty-one (81) milligram (mg) [MEDICATION NAME] coated aspirin tablet to resident #70. A review of the clinical record revealed an order since 10/28/15 for the resident to receive 81 mg of aspirin daily. However, the order did not specify [MEDICATION NAME] coated aspirin. During an observation on 6/30/16 at 8:55 a.m., LPN AA administered one 81 mg [MEDICATION NAME] coated aspirin tablet to resident #37. A review of the clinical record revealed an order since 10/24/13 for the resident to receive 81 mg of aspirin daily. However, the order did not specify [MEDICATION NAME] coated aspirin. On 6/30/16 at 9:50 a.m., the Assistant Director of Nursing (ADON) stated that the nurses were not suppose to administer an [MEDICATION NAME] coated aspirin unless the order specified it. | 2020-01-01 |
| 4283 | 4283 | SOUTHWELL HEALTH AND REHABILITATION | 115655 | 260 MJ TAYLOR ROAD | ADEL | GA | 31620 | 2016-07-01 | 356 | C | 0 | 1 | 0GTS11 | Based on record review and staff interview, the facility failed to include the total number of hours worked by direct care staff on the nurse staffing posting for five (5) days of the survey. The facility census was 91 residents. Findings include: Review of the nurse staffing sheet posted near the centrally located nurses station on 06/27/16 at 7:15 p.m., 06/28/16 at 2:35 p.m., 06/29/16 at, 8:15 a.m., 06/30/16 at 4:45 p.m., and 07/01/16 at 9:40 a.m., the actual hours worked by licensed nurses was not documented. Interview on 07/01/16 at 11:00 a.m. with Certified Nurse Assistant (CNA) OO he/she stated that he/she was responsible for completing the nurse staffing sheet in the mornings when he/she was working. The CNA stated that his/her process for completing the form was to review the nursing schedule for that day which is completed by the Director of Nursing (DON). CNA OO further stated that he/she only documents the number of each staff on the staffing form and had not been told that the total number of hours needed to be placed on the staffing sheet along with the number of staff. Interview on 07/01/16 at 3:50 p.m. with the DON, he/she stated that he/she was not aware that the actual hours were required to be listed on the nurse staff sheet. | 2020-01-01 |
| 4284 | 4284 | SOUTHWELL HEALTH AND REHABILITATION | 115655 | 260 MJ TAYLOR ROAD | ADEL | GA | 31620 | 2016-07-01 | 371 | E | 0 | 1 | 0GTS11 | Based on observation, staff interview, and documentation review the facility failed to label and date opened food items before storage in the walk-in freezer and the walk-in refrigerator; failed to discard prepared food items by the use by date; failed to clean the stand-up mixer after use to prevent cross contamination; and failed to follow manufactures recommendations for the use of the EcoLab Quaternary sanitizing solution in the three compartment sink to prevent food borne illness. This deficient practice had the potential to effect eight three (83) residents receiving an oral diet. Findings include: Observation on 06/28/16 on 8:20 a.m. of the walk-in freezer revealed a plastic wrapped light brown bag that was twelve (12) inches in length and six (6) inches in width, a light brown bag that was opened and partially used, this bag was not wrapped and a clear plastic resealable bag that contained a pink food item that was eight (8) inches in length and four (4) inches in width with no label or date. Observation on 06/28/16 at 8:30 a.m. of the walk-in refrigerator revealed an opened one (1) gallon container of pickle relish, an opened a one gallon container of Teriyaki Sauce and Worcestershire Sauce and an opened 8 pound container of cantaloupe chunks with no date. In addition, there was an aluminum pan that was 12 inches in length, 10 inches in width, and 4 inches in depth that was wrapped with plastic wrap and the label stated the food item was vegetable soup, preparation date 06/23/16 and a use by date of 06/26/16. Observation on 06/28/16 at 8:40 a.m., the stand-up mixer revealed it was sitting on top of a stainless steel table with the top of the mixing bowl wrapped in plastic wrap and the whip and beater was stored inside the bowl. Further observation revealed a brown/orange sticky to touch food substance under the mixing arm were the whip or beater would attach. Interview on 06/28/16 at 8:45 a.m. with the Director of Food Service he/she stated acknowledgement that the wrapped light brown bag did not have a … | 2020-01-01 |
| 4285 | 4285 | SOUTHWELL HEALTH AND REHABILITATION | 115655 | 260 MJ TAYLOR ROAD | ADEL | GA | 31620 | 2016-07-01 | 441 | D | 0 | 1 | 0GTS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interview, the facility failed to ensure that injectable medications were administered in a manner to prevent contamination and exposure to possible bodily fluids for two residents (#104 and #77) of four residents observed for Medication Administration, from a total sample of forty-two (42) residents. Findings include: During an observation on 6/29/16 at 10:50 a.m., Licensed Practical Nurse (LPN) BB administered one (1) unit of [MEDICATION NAME] R insulin subcutaneously in the right arm of resident #104. However, during the insulin administration, the LPN did not wear gloves. During an observation on 6/29/16 at 11: 00 a.m., LPN BB administered eight (8) units of [MEDICATION NAME]subcutaneously in the right arm of resident #77. However, during the insulin administration, the LPN did not wear gloves. On 6/30/16 at 9:50 a.m., the Assistant Director of Nursing (ADON) confirmed that the nurse should have worn gloves when administering insulin injections. | 2020-01-01 |
| 4286 | 4286 | SOUTHWELL HEALTH AND REHABILITATION | 115655 | 260 MJ TAYLOR ROAD | ADEL | GA | 31620 | 2016-07-01 | 469 | D | 0 | 1 | 0GTS11 | Based on observation and resident and staff interview the facility failed to properly maintain an effective pest control program in one resident room. The census was ninety one (91) residents. Findings include: Observations on 06/28/2016 at 8:36 a.m. and on 6/29/16 at 3:26 p.m., ants were observed crawling along the wall in room 349. Interview on 6/30/2016 at 8:41 a.m., with resident M, he/she stated that there were roaches in his/her room at times. During this interview a roach was killed by the resident as it crawled along the wall. Resident M denied seeing any other bugs or rodents in his/her room or at the facility. On 6/30/2016 at 9:42 a.m., ants were confirmed crawling on resident M's wall in room 349. The Chief Engineer of Operations (CEO) stated that staff should look in rooms and report any issues identified related to the ants. Environmental Services Supervisor (ESS) stated that he/she was not aware that there were ants in this room. Review of the Pest Control Service agreement with Astro Exterminating Services, Inc. noted documented monthly pest sprays with the last service date on 6/13/16. Review with the ESS, of the pest site log, noted documentation that room 349 had sugar ants on 5/25/16 which was treated on 5/31/16. | 2020-01-01 |
| 4287 | 4287 | SOUTHWELL HEALTH AND REHABILITATION | 115655 | 260 MJ TAYLOR ROAD | ADEL | GA | 31620 | 2016-07-01 | 514 | E | 0 | 1 | 0GTS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to maintain accurate clinical records regarding the administration of scheduled Insulin, Sliding Scale Insulin and Fingerstick Blood Sugars for five (5) residents(#38 ,#87,#70, #8 and #104) from a total sample of forty- two (42) residents. Findings include: 1. Review of the (MONTH) (YEAR) physician's orders [REDACTED]. Review of the (MONTH) Medication Administration Record [REDACTED]. The space for licensed nursing staff to document was blank. Further review of the (MONTH) (YEAR) physician's orders [REDACTED]. Review of the (MONTH) MAR indicated [REDACTED]. The space for licensed nursing staff to document was blank. Review of the (MONTH) (YEAR) physician's orders [REDACTED]. Review of the (MONTH) MAR indicated [REDACTED]. The space for licensed nursing staff to document was blank. Further review of the (MONTH) (YEAR) physician's orders [REDACTED]. Review of the (MONTH) MAR indicated [REDACTED]. The space for licensed nursing staff to document was blank. During an interview on 7/1/16 at 12:30 p.m., with the Director of Nursing (DON), he/she stated that on the above dates the [MEDICATION NAME] for resident #87 was not documented as administered by the licensed nursing staff. The DON, further stated that he/she expected the nurses to document their initials on the MARs when medications were administered. 2. Resident #8 had a physician's orders [REDACTED]. obtain fasting blood sugar levels in the morning, three times weekly, on Monday, Wednesday, and Friday. However, a review of the clinical record, including the (MONTH) (YEAR) Medication Administration Records (MAR's) and nurses' notes, revealed that licensed nursing staff did not document the fasting blood sugar level results, that were scheduled to be obtained, on 6/15/16, 6/22/16 and 6/29/16. 3. Resident #84 had a physician's orders [REDACTED]. However, a review of the clinical record, including the MAR's and nurses' notes, revea… | 2020-01-01 |
| 5485 | 5485 | COOK SENIOR LIVING CENTER | 115655 | 706 NORTH PARRISH AVE . | ADEL | GA | 31620 | 2016-01-14 | 161 | E | 0 | 1 | DE3911 | Based on record review and staff interview, the facility failed to ensure that the Surety Bond covered the balance in the Resident Trust account for five (5) of six (6) months reviewed. The facility had sixty five (65) resident accounts. Findings include: The facility had a Surety Bond in the amount of $40,000.00 effective since 10/8/2012. A review of the Resident Trust Fund bank statements from (MONTH) (YEAR) through (MONTH) (YEAR) revealed the following ending balances that exceeded the $40,000.00 surety bond limit: July (YEAR): $46,592.28 August (YEAR): $44,279.23 September (YEAR): $44,454.53 November (YEAR): $40,553.32 December (YEAR): $65,901.14 During interviews on 1/12/16 at 3:30 p.m. and 1/14/16 at 7:54 a.m., the Administrator confirmed the ending balances for July, August, September, (MONTH) and (MONTH) (YEAR) exceeded the Surety Bond limit of $40,000.00. After surveyor inquiry, the amount of the Surety Bond limit was increased on 1/13/16 to $70,000.00. | 2018-09-01 |
| 5486 | 5486 | COOK SENIOR LIVING CENTER | 115655 | 706 NORTH PARRISH AVE . | ADEL | GA | 31620 | 2016-01-14 | 323 | D | 0 | 1 | DE3911 | Based on observation and interview, it was determined the facility failed to install grab bars in three (3) resident bathrooms and failed to tightly secure grab bars in four (4) resident bathrooms from a total of twenty (20) bathrooms on two (2) of four (4) resident halls. Findings include: On 1/11/16 at 3:03 p.m. there was a loose grab bar next to the toilet in the bathroom of room 361. On 1/12/16 at 8:51 a.m. there were three loose grab bars inside the shower in the bathroom of room 360. Certified Nursing Assistant (CNA) II stated at the time of this observation that the residents did use the shower but with assistance from staff. The administrator was notified of the loose grab bars in the bathrooms of room 360 and room 361 on 1/12/16 at 4:10 p.m. During a subsequent observation on 1/13/16 at 2:20 p.m., the grab bars that had previously been observed to be loose in rooms 360 and 361 were no longer loose. However the following were observed: 1. In the bathroom of room 322 there was no grab bar outside the shower. 2. In the bathroom of room 332 there was no grab bar outside the shower. 3. In the bathroom of room 311 there was no grab bar outside the shower. 4. In the bathroom of room 353 there was a loose grab bar outside the shower. 5. In the bathroom of room 360 there was a loose grab bar outside the shower. 6. In the bathroom of room 361 there was a loose grab bar inside the shower. 7. In the bathroom of room 347 there was a grab bar attached to a door frame but the door frame was split. On 1/12/16 at 11:10 a.m. resident A stated that he/she used the tub (in his/her bathroom) and had asked for grab bars but they had not been installed. During an interview with the Administrator and Maintenance Director on 1/14/16 at 2:33 p.m., the Maintenance Director stated that residents' rooms are checked monthly for needed repairs. He also stated that work orders, submitted by facility staff, are also completed. The administrator confirmed that after surveyor inquiry, grab bars had been installed in the bathrooms and the … | 2018-09-01 |
| 5487 | 5487 | COOK SENIOR LIVING CENTER | 115655 | 706 NORTH PARRISH AVE . | ADEL | GA | 31620 | 2016-01-14 | 328 | D | 0 | 1 | DE3911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that oxygen was administered at the correct rate for two residents (#2 and #72)and failed to properly store oxygen equipment for one resident (#2) from a total sample of thirty (30) residents. Findings include: The facility had a Respiratory Therapy policy and procedure. The policy documented that respiratory equipment was to be stored in a plastic bag and labeled with the resident's name and date of when the equipment would need to be changed. 1. Resident #2 had a [DIAGNOSES REDACTED]. There was a physician's orders [REDACTED]. During an observation on 1/13/16 at 8:21 a.m. with licensed nursing staff HH, the resident was observed in his/her room without oxygen being administered. There was nasal cannula tubing attached to the wall connected oxygen flowmeter. The nasal cannula end was laying on the floor. The oxygen flowmeter was on and set to deliver oxygen at a rate of eight (8) liters per minute. There was also an oxygen mask and tubing attached to an oxygen concentrator. The oxygen mask was hanging on a dresser. The oxygen concentrator was off. Licensed nursing staff HH replaced the nasal cannula (that had been laying on the floor) and the oxygen mask (that was hanging on the dresser), applied the new nasal cannula to the resident and adjusted the rate to two (2) liters per minute. After five minutes, licensed nursing staff HH returned and adjusted the oxygen rate to three (3) liters per minute. During an observation on 1/14/16 at 8:40 a.m. resident #2 was observed receiving oxygen via a nasal cannula and tubing attached to the wall connection flowmeter at a rate of one (1) liter per minute. On 1/14/16 at 8:41 a.m. licensed nursing staff FF confirmed the rate of one (1) liter per minute was incorrect and adjusted the flowmeter to deliver oxygen at three (3) liters per minute as ordered. 2. Resident #72 had a physician's orders [REDACTED]. During an observatio… | 2018-09-01 |
| 6280 | 6280 | COOK SENIOR LIVING CENTER | 115655 | 706 NORTH PARRISH AVE . | ADEL | GA | 31620 | 2015-02-05 | 280 | K | 1 | 0 | XT5M11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, Entity Reported Incident Intake review, facility investigative report review, resident Smoking Assessment Questionaire review, facility Smoking Policy and Procedure review, resident interview, facility staff written statement review, and staff interview, the facility failed to review and revise the Plan of Care for one (1) resident (B) who smoked cigarettes, regarding a facility-imposed restriction on the resident maintaining smoking materials and regarding staff monitoring to ensure the resident's safety; failed to review and revise the Plan of Care to reflect cigarette smoking for one (1) resident (E), who did not smoke cigarettes upon admission but later initiated smoking after admission, but for whom the facility failed to implement monitoring to ensure safety while smoking; and failed to review and revise the Plan of Care to reflect routine monitoring related to the unsafe behavior of one (1) resident (A), regarding Resident A's behavior of providing cigarettes and a lighter to another resident (Resident #1) who was assessed to require supervision while smoking. The total survey sample was nine (9) residents, all of whom smoked cigarettes. A Smoker's List provided by the facility documented a total of fifteen (15) residents who were identified by the facility to smoke cigarettes. The facility's failure to ensure adequate monitoring and supervision to residents who smoked 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 immediate jeopardy is outlined as follows: - Resident B was assessed as safe to smoke unsupervised and to posses smoking materials upon facility admission. As a result of a 2011 incident involving Resident B using a cigarette lighter unsafely, the facility restricted her possession of cigarettes and a lighter. Instea… | 2018-02-01 |
| 6281 | 6281 | COOK SENIOR LIVING CENTER | 115655 | 706 NORTH PARRISH AVE . | ADEL | GA | 31620 | 2015-02-05 | 281 | K | 1 | 0 | XT5M11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, facility investigative report review, resident Smoking Assessment Questionaire review, resident interview, facility staff written statement review, National Council of State Boards of Nursing Model Nursing Practice Act and Model Nursing Administrative Rules review, and staff interview, the facility failed to ensure routine surveillance and monitoring regarding cigarette smoking, in accordance with professional standards of practice, for one (1) resident (#1) who was assessed by the facility to require supervision while smoking, but for whom the facility failed to ensure routine monitoring regarding the resident's unsafe behavior of obtaining smoking materials without staffs' knowledge; for one (1) resident (B) who smoked without supervision but who had a restriction on her access to a cigarette lighter; and for one (1) resident (E), who did not smoke at the time of facility admission but began smoking cigarettes after admission, but for whom the facility failed to provide routine monitoring to ensure the resident's safety during smoking. The total survey sample was nine (9) residents, all of whom smoked cigarettes. A Smoker's List provided by the facility documented a total of fifteen (15) residents who were identified by the facility to smoke cigarettes. The facility's failure to ensure adequate monitoring to residents who smoked 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 immediate jeopardy is outlined as follows: - Resident #1 required staff supervision while smoking, and nursing staff kept her smoking materials locked, but Resident #1 had a history of [REDACTED]. However, despite the Model Nursing Administrative Rules, Chapter 2 - Standards of Nursing Practice specifying that the nurse provide monitoring, facility nursing staff… | 2018-02-01 |
| 6282 | 6282 | COOK SENIOR LIVING CENTER | 115655 | 706 NORTH PARRISH AVE . | ADEL | GA | 31620 | 2015-02-05 | 282 | J | 1 | 0 | XT5M11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, Entity Reported Incident Intake review, facility investigative report review, resident interview, and staff interview, the facility failed to ensure monitoring, in accordance with the Plan of Care, one (1) resident (#1) who smoked cigarettes and whose Plan of Care specified monitoring for the behavior of obtaining cigarettes from other residents, from the total survey sample of nine (9) residents, all of whom smoked cigarettes. A Smoker's List provided by the facility documented a total of fifteen (15) residents who were identified to smoke cigarettes. The facility's failure to ensure adequate monitoring of Resident #1 related to cigarette smoking resulted in 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 immediate jeopardy is outlined as follows: - Resident #1 required supervision while smoking, and staff were to keep smoking her materials in the medication cart. Resident #1 had a history of [REDACTED]. Resident #1's Plan of Care specified that staff monitor her related to her behavior of obtaining cigarettes from other residents. However, the facility failed to ensure monitoring, as specified by the Plan of Care, to address Resident #1's attempts to obtain smoking materials. On 01/19/2015, Resident #1 obtained 2 cigarettes from Resident A and gained access to Resident A's lighter, attempted to light a cigarette and ignited her hair. Resident #1 was transferred to the Burn Center with second and/or third [MEDICAL CONDITION] the left side of the face, forehead, temple, cheek and external ear, requiring skin grafts. Resident #1 returned to the facility on [DATE], but on 01/24/15, was again found with a cigarette provided by Resident A without staff knowledge. The facility's Administrator and Director of Nursing (DON) were informed of the immediate jeopardy on J… | 2018-02-01 |
| 6283 | 6283 | COOK SENIOR LIVING CENTER | 115655 | 706 NORTH PARRISH AVE . | ADEL | GA | 31620 | 2015-02-05 | 323 | K | 1 | 0 | XT5M11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, Entity Reported Incident Intake review, facility investigative report review, resident Smoking Assessment Questionaire review, facility Smoking Policy and Procedure review, resident interview, facility staff written statement review, and staff interview, the facility failed to ensure routine supervision and monitoring related to cigarette smoking for one (1) resident (#1) who smoked cigarettes and had been assessed by the facility to require staff supervision while smoking; failed to provide supervision and monitoring for one (1) resident (B) who smoked cigarettes without supervision but for whom the facility restricted access to smoking materials; and failed to ensure routine supervision for one (1) resident (E), who began smoking cigarettes after facility admission and was assessed by the facility to require staff supervision while smoking. The total survey sample was nine (9) residents, all of whom smoked cigarettes. A Smoker's List provided by the facility documented a total of fifteen (15) residents who were identified by the facility to smoke cigarettes. The facility's failure to ensure adequate monitoring and supervision to residents who smoked 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 immediate jeopardy is outlined as follows: - Resident #1 was assessed upon admission to require supervision while smoking for reasons including, but not limited to, an inability to safeguard smoking materials without endangering other residents, and the absence of, or inability to exhibit, cognitive skills for safe smoking. Staff were to maintain Resident #1's smoking materials locked in the medication cart and provide them to the resident during supervised smoking. Resident #1 had a known history of asking other residents for cigarettes, ob… | 2018-02-01 |
| 6284 | 6284 | COOK SENIOR LIVING CENTER | 115655 | 706 NORTH PARRISH AVE . | ADEL | GA | 31620 | 2015-02-05 | 490 | K | 1 | 0 | XT5M11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility document review, facility policy review, resident interview, and staff interview, facility administration failed to ensure supervision/monitoring regarding the smoking behaviors of four (4) residents (#1, A, B, and E) who were assessed as unsafe to smoke without staff supervision and/or who exhibited unsafe behaviors of either obtaining smoking paraphernalia from, or providing smoking paraphernalia to, other residents without the knowledge of facility staff. The total survey sample was nine (9) residents, all of whom smoked cigarettes, with a Smoker's List provided by the facility documenting a total of fifteen (15) residents who smoked. For Resident #1, who was assessed to require supervision while smoking, the facility failed to provide routine monitoring to address the resident's unsafe behavior of obtaining smoking paraphernalia from other residents (including Resident A) and either smoking, or attempting to smoke, unsupervised. For Resident B, who was restricted from maintaining smoking materials in her possession related to a history of unsafe lighter use, the facility failed to routinely monitor to prevent the resident from unsafely accessing smoking paraphernalia. For Resident E, who did not smoke upon facility admission, but then began to smoke cigarettes after admission and was assessed to require staff supervision while smoking, the facility failed to provide monitoring to ensure the resident's safety while smoking. The facility's Administrator and Director of Nursing (DON) were informed of the immediate jeopardy on January 30, 2015 at 12:00 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on January 19, 2015, the date Resident #1, who was assessed by the facility to require staff supervision while smoking cigarettes, obtained two (2) cigarettes and gained access to a cigarette lighter without the knowledge of staff, attempted to light the cigarett… | 2018-02-01 |
| 6544 | 6544 | COOK SENIOR LIVING CENTER | 115655 | 706 NORTH PARRISH AVE . | ADEL | GA | 31620 | 2015-02-05 | 166 | D | 0 | 1 | 9KKL11 | The standard survey conducted February 2, 2015 through February 5, 2015 revealed noncompliance at F166 at the Scope/Severity of D. Additional noncompliance at F166 was not identified as a result of the abbreviated survey of January 23, 2015 through February 5, 2015. Therefore, the noncompliance at F166 identified during the standard survey is cited on this standard survey Form CMS-2567, as referenced below: Based on record review and staff interview, the facility failed to make prompt efforts to resolve a grievance pertaining to Activities of Daily Living care related to one (1) resident (F) from the standard survey sample of twenty-four (24) residents. Findings include: Resident F's Quarterly Minimum Data Set assessment of December 2014 documented, in Section C - Cognitive Patterns, a Brief Interview for Mental Status Score of 15, indicating the resident was cognitively intact. Section G - Functional Status documented that Resident F required extensive assistance with personal hygiene, including shaving. Further record review for Resident F revealed a consultant physician's Report of Consultation form dated 01/07/2015 reporting that Resident F had complained of not receiving shaves on a regular basis. The physician requested in this Report of Consultation to have the Director of Nursing (DON) contact the physician's office. However, review of Resident F's record revealed no evidence of follow-up action by the DON or other staff related to this grievance of 01/07/2015 involving Resident F's complaint of not being shaven. There was neither evidence of an attempt to resolve this grievance for Resident F, nor evidence of physician contacted by the DON. Additionally, review of the facility's Grievance Log, with the DON in attendance, on 02/05/2015 at 9:28 a.m. revealed no documented evidence of this grievance related to shaving for Resident F, nor of any efforts to resolve the grievance. During an interview with the DON conducted at the time of this Grievance Log review (02/05/2015 at 9:28 a.m.), the DON acknowledged… | 2017-12-01 |
| 6545 | 6545 | COOK SENIOR LIVING CENTER | 115655 | 706 NORTH PARRISH AVE . | ADEL | GA | 31620 | 2015-02-05 | 312 | D | 0 | 1 | 9KKL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A standard survey conducted February 2, 2015 through February 5, 2015 revealed noncompliance at F312 at the Scope/Severity of D. Additional noncompliance at F312 was not identified as a result of the abbreviated survey of January 23, 2015 through February 5, 2015. Therefore, the noncompliance at F312 identified during the February 2, 2015 through February 5, 2015 standard survey is cited on this standard survey Form CMS-2567, as referenced below: Based on observation, record review, resident interview, and staff interview, the facility failed to ensure that two (2) residents (F and #82) assessed as requiring staff assistance to carry out Activities of Daily Living care received the necessary care and services to maintain good grooming, of a total of twenty-four (24) residents on the standard survey sample. Findings include: 1. Record review for Resident F revealed a Quarterly Minimum Data Set (MDS) assessment having an Assessment Reference Date in December of 2014 in which Section C - Cognitive Patterns documented a Brief Interview of Mental Status Summary Score of 15, indicating the resident was cognitively intact. Section I - Active [DIAGNOSES REDACTED]. Section G - Functional Status documented that Resident F had impairment in the Functional Limitation in Range of Motion in the upper extremity on one side, and that the resident required the extensive assistance of staff with personal hygiene, including shaving. During an observation of Resident F conducted on 02/03/2015 at 9:30 a.m., Resident F was observed to have several days growth of facial hair. During an interview with Resident F conducted at the time of this 02/03/2015, 9:30 a.m. observation, Resident F stated he had not received a shave since the previous week. Observations of Resident F conducted later in the day of 02/03/2015 at 5:05 p.m., and then on 02/04/2015 at 7:53 a.m., revealed Resident F still had facial hair and had not been shaved. During an observation of Resident F co… | 2017-12-01 |
| 6546 | 6546 | COOK SENIOR LIVING CENTER | 115655 | 706 NORTH PARRISH AVE . | ADEL | GA | 31620 | 2015-02-05 | 313 | D | 0 | 1 | 9KKL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A standard survey conducted February 2, 2015 through February 5, 2015 revealed noncompliance at F313 at the Scope/Severity of D. Additional noncompliance at F313 was not identified as a result of the abbreviated survey of January 23, 2015 through February 5, 2015. Therefore, the noncompliance at F313 identified during the February 2, 2015 through February 5, 2015 standard survey is cited on this standard survey Form CMS-2567, as referenced below: Based on medical record review, staff interview, and resident interview, the facility failed to arrange vision services, related to an eye examination for eye glasses, after the request of one (1) resident (Q) from a standard survey sample of twenty-four (24) residents. Findings Include: Record review for Resident Q revealed an Annual Minimum Data Set assessment having an Assessment Reference Date in November of 2014 which documented in Section C - Cognitive Patterns a Brief Interview for Mental Status Summary Score of 13, indicating the resident was cognitively intact. Section I - Active [DIAGNOSES REDACTED]. During an interview with Resident Q conducted on 02/04/2015 at 10:00 a.m., Resident Q referenced having a vision deficit. Resident Q stated that in the past, he had informed staff that he would like to obtain eye glasses. Observation of Resident Q conducted at the time of this interview revealed the resident was not wearing eye glasses. During a later interview with Resident Q conducted on 02/04/2015 at 2:33 p.m., the resident stated he could not specifically remember which staff member he had spoken to when making the request to obtain eye glasses, but stated that the staff member had told him that an appointment would be made. During an interview with Social Worker (SW) AA conducted on 02/04/2015 at 2:04 p.m., SW AA stated she was not aware that Resident Q wanted glasses. When questioned about the provision of vision services to facility residents, SW AA stated that a local optometrist would … | 2017-12-01 |
| 8092 | 8092 | COOK SENIOR LIVING CENTER | 115655 | 706 NORTH PARRISH AVE . | ADEL | GA | 31620 | 2013-08-15 | 280 | D | 0 | 1 | FB2I11 | Based on record review and staff interview the facility failed to update and/or revise the care plan for the occurrence of a fall and a fracture obtained as a result of the fall for one (1) resident (A) of a sample of thirty three (33) residents. Findings include: An interview with resident A on 08/13/2013 03:18 p.m. revealed that she had a fall in the bathroom. The resident maintained that the floor was wet and her foot slipped and their left arm bent up behind her and she hit her head on the commode. The resident reports that she had her slippers on and was using a walking stick at the time of the fall A review of the Tracking Record to Improve Patient Safety (TRIPS) report dated 07/31/2013 revealed that at 18:45 the resident had an unwitnessed fall while ambulating in their bathroom resulting in a fracture to their left wrist and hand. A review of the plan of care revealed the resident had a fall prevention care plan but was not updated to reflect the most recent fall and to addressed the left hand and wrist fracture. An interview on 08/15/2013 with the Director of Nursing (DON) revealed that the care plan should have been update by the nursing staff immediately after the fall to reflect the resident's fall and fracture and was not done. | 2016-07-01 |
| 8093 | 8093 | COOK SENIOR LIVING CENTER | 115655 | 706 NORTH PARRISH AVE . | ADEL | GA | 31620 | 2013-08-15 | 282 | D | 0 | 1 | FB2I11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, it was the facility failed to follow the care plan to provide passive range of motion and splint application for one (1) resident (#40) and to implement the care plan intervention to report to the physician and obtain timely treatment of [REDACTED].#47) of three (33) sampled residents. Findings include: Review of the clinical record for Resident #40 revealed that the resident had a current physician's orders [REDACTED]. Record review of the resident's Quarterly Minimum Data Set (MDS) of 7/12/13 revealed impaired function of range in motion of both upper and lower extremities on one side. The resident is assessed as receiving restorative nursing care for both passive and active range of motion seven (7) days per week with no splint assistance. Review of the resident's care plan dated 2/22/13 for impaired mobility and right sided weakness with the following interventions: active assist range of motion left upper and left lower extremities daily as tolerated, passive range of motion right upper and lower extremities daily as tolerated, knee splint to be worn three hours on the right knee and then three hours on the left knee daily as tolerated. Place pillow between legs if wearing splint in bed, perform range of motion prior to applying knee splint. The resident was observed in the bed on 8/13/13 at 2:30 p.m. and 4:00 p.m., on 8/14/13 at 8:30 a.m., 12:00 p.m. and 5:15 p.m. and on 8/15/13 at 8:35 am, and 11:00 a.m. with no splints on the resident's knees or right hand. During an observation of the restorative nursing care on 8/15/13 at 12:40 p.m., the restorative aide failed to provide range of motion to the right knee before applying the knee splint. The aide also failed to provide range of motion to the right hand and arm prior to applying the hand splint and there was no range of motion done to the left upper and lower extremities as outlined in the plan of care. During an interview with Certified Nu… | 2016-07-01 |
| 8094 | 8094 | COOK SENIOR LIVING CENTER | 115655 | 706 NORTH PARRISH AVE . | ADEL | GA | 31620 | 2013-08-15 | 314 | D | 0 | 1 | FB2I11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review the facility failed to report to the physician and obtain timely treatment of [REDACTED].#47) of thirty three (33) sampled residents. Findings include: Record review revealed that resident #47 had multiple [DIAGNOSES REDACTED]. Review of record revealed that the resident was identified as being at risk for the development of pressures ulcers on admission assessment of 3/18/13. Review of the resident's care plan revealed a care plan for impaired skin integrity with an intervention to monitor skin for redness, irritation, open areas and to document, report and take action as indicated. Review of the Weekly Skin Assessment form, completed by licensed nursing staff, dated 4/3/13, revealed documentation of a four (4) inch long by two (2) inch wide red and broken area to the resident's right buttock. Review of the clinical record revealed there was no evidence that the open area to the right buttock was reported to the physician and there was no physician's order for treatment until 4/10/13. Review of the treatment notes on 4/10/13, revealed the open area on the right buttock was assessed by licensed nursing staff as a stage 2 pressure ulcer measuring 5.7 x 3.5 x An interview with the Director of Nursing (DON) on 8/15/13 at 10:43 a.m. revealed that the physician should have been notified and a new treatment order obtained on 4/3/13 when the pressure ulcer was first identified by the licensed nursing staff completing the skin assessment. | 2016-07-01 |
| 8095 | 8095 | COOK SENIOR LIVING CENTER | 115655 | 706 NORTH PARRISH AVE . | ADEL | GA | 31620 | 2013-08-15 | 318 | D | 0 | 1 | FB2I11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to provide passive range of motion and failed to apply knee and hand splints as ordered by the physician and as outlined in the plan of care for one (1) resident (#40) of 33 residents. Findings include: Review of the clinical record for Resident #40 revealed that he had a current physician's orders [REDACTED]. Record review of the resident's Quarterly Minimum Data Set (MDS) of 7/12/13 revealed impaired function of range in motion of both upper and lower extremities on one side. The resident is assessed as receiving restorative nursing care for both passive and active range of motion seven (7) days per week with no splint assistance. Review of the resident's care plan dated 2/22/13 for impaired mobility and right sided weakness with the following interventions: active assist range of motion (ROM) left upper and left lower extremities daily as tolerated, passive range of motion right upper and lower extremities daily as tolerated, knee splint to be worn three hours on the right knee and then three hours on the left knee daily as tolerated. Place pillow between legs if wearing splint in bed, perform range of motion prior to applying knee splint. Review of the splint instructions dated 1/21/12, signed by the Physical Therapist, for the knee splint revealed the resident to wear the knee splint on the right knee for three (3) hours then on the left knee for three (3) hours. The instructions include special instructions to place a pillow between the resident's legs if wearing the knee splint while in bed and that the resident should receive range of motion prior to splinting. Instructions for use of the hand splint were not available. Review of the restorative nursing care documentation record revealed the resident was to receive active ROM to the upper and lower left and right extremities daily as tolerated and was signed as done daily. The document revealed the resident is… | 2016-07-01 |
| 8096 | 8096 | COOK SENIOR LIVING CENTER | 115655 | 706 NORTH PARRISH AVE . | ADEL | GA | 31620 | 2013-08-15 | 333 | D | 0 | 1 | FB2I11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure that one (1) resident (#72) received a prescribed medication of a sample of thirty three (33) residents. Findings include: Review of the record for resident #72 reveals multiple [DIAGNOSES REDACTED]. Review of the record for resident #72 revealed, a report of consultation, that the resident was seen by the Ophthalmologist on 6/24/13 and returned to the facility for an order for [REDACTED]. [REDACTED]. Review of the resident's Medication Administration Record [REDACTED]. An interview with staff BB on 8/15/13 at 10:00 a.m., revealed that the reason for this oversight was unknown. An interview with the Director of Nursing on 8/16/13 at 2:00 p.m. revealed that the [MEDICATION NAME] 1% eye drops were not carried over on the August MAR but should have been discovered on the month's end reconciliation of physician's orders [REDACTED]. | 2016-07-01 |
| 8097 | 8097 | COOK SENIOR LIVING CENTER | 115655 | 706 NORTH PARRISH AVE . | ADEL | GA | 31620 | 2013-08-15 | 371 | F | 0 | 1 | FB2I11 | Based on staff interview and observation, it was determined the facility failed to have the necessary supplies to maintain a protocol by which the sanitizing chemical levels were tested . The census was eighty four (84) with two (2) residents receiving tube feeding. Findings include: Observation and interview on 8/13/13 at 11:45 a.m. with the dietary staff revealed they were unable to test the sanitizer sink for proper sanitizer concentration. An interview with the dietary staff supervisor on 8/13/13 at 11:50 a.m. revealed there were no supplies available to test the chemical level. An interview 8/14/13 at 10:00 a.m. with the kitchen operations manager revealed that he could not test the chemical strength of the sanitizer sink because they did not have strips to do so and further stated he did not know when the strips would be available. Record review of the Sanitizer Solution log revealed that sanitization levels were not checked between 8/9-8/13/2013. | 2016-07-01 |
| 8335 | 8335 | COOK SENIOR LIVING CENTER | 115655 | 706 NORTH PARRISH AVE . | ADEL | GA | 31620 | 2012-02-23 | 156 | B | 0 | 1 | 028H11 | Based on record review and staff interview, it was determined that the facility had failed to provide three (#33, #100, and #51) of three sampled residents, who were discharged from Medicare Part A services, with the CMS- form and the Skilled Nursing Advanced Beneficiary Notice (SNFABN) form (CMS - ) or a mandatory uniform Denial Letter to inform the resident of his/her right to an appeal and potential liability for the non-covered services and the estimated cost of those non-covered services. Findings include: On 2/23/12 at 1:12 p.m., the Minimum Data Set (MDS) coordinator stated that she had not provided the CMS- form and the SNFABN form or a mandatory uniform Denial Letter to residents who had been discontinued from Medicare Part A services for coverage reasons. She had incorrectly provided the CMS-R-131, a Medicare Part B form. Twenty-three residents had been discharged from Medicare Part A services for coverage reasons since 9/27/11. 1. Resident #33 was notified by the facility on 1/26/12 that Medicare Part A coverage for skilled services would end on 1/30/12. However, the facility failed to provide the resident with the required CMS form and the CMS- form or a uniform Denial Letter to inform the resident of his/her right to an appeal and potential liability for the non-covered services and the estimated cost of those non-covered services if the resident chose to continue to receive them. 2. Resident #100 was notified by the facility on 10/7/11 that Medicare Part A coverage for skilled services would end on 10/10/11. However, the facility failed to provide the resident with the required CMS form and the SNFABN form or uniform Denial Letter to inform the resident of his/her right to an appeal and potential liability for the non-covered services and the estimated cost of those non-covered services if the resident chose to continue to receive them. 3. Resident #51 was notified by the facility on 11/28/11 that Medicare Part A coverage for skilled services would end on 12/1/11. However, the facility failed to pro… | 2016-03-01 |
| 8336 | 8336 | COOK SENIOR LIVING CENTER | 115655 | 706 NORTH PARRISH AVE . | ADEL | GA | 31620 | 2012-02-23 | 241 | E | 0 | 1 | 028H11 | Based on observations, it was determined that the facility failed to provide a dignified dining experience during two of two meals observed in the South hall dining room. Findings include: Observations during the lunch meals on 2/20/12 and 2/22/12 in the South hall dining room revealed that residents sat and watched other residents eat before being served and/or assisted to eat their meals. 1. On 2/20/12, nursing staff were observed serving residents' lunch trays in the South Hall dining room from 11:30 a.m. to 11:50 a.m. At 11:50 a.m., there were 31 residents and 5 nursing staff members in the dining room. All five staff members were seated and assisting residents to eat but, not all of the residents had been served their meal. Seven residents had not been served. Those seven residents were not served and assisted to eat until 12:15 p.m. 2. One resident was observed with his/her lunch plate set up in front of him/her but, his/her silverware was not wrapped from 11:30 a.m. to 12:05 p.m. The resident began eating at 12:05 p.m after staff unwrapped the silverware. 3. One resident was observed playing with his/her food and untensils from 11:30 a.m. to 12:05 p.m. A staff member finished assisting another resident at 12:05 p.m. and then sat down to assist the resident. 4. On 2/22/12 at 11:20 p.m., staff failed to serve lunch at the same time to a table of five residents. During the observation, the first resident was served at 11:25 a.m. and the last resident at the table was not served until 12:02 p.m. 5. On 2/22/12 between 11:20 a.m. and 12:05 p.m., there were seven residents sitting at one table. The first resident at that table was served at 11:25 a.m. but, the last resident was not served his/her meal tray until 30 minutes later at 11:55 a.m Another table had five residents seated at it. The first resident was served at 11:30 a.m. but, the last resident was not served until 30 minutes later at 12:00 noon. Across the back of the dining room were five residents seated in a line. Staff served the first resident at 1… | 2016-03-01 |
| 8337 | 8337 | COOK SENIOR LIVING CENTER | 115655 | 706 NORTH PARRISH AVE . | ADEL | GA | 31620 | 2012-02-23 | 253 | E | 0 | 1 | 028H11 | Based on observations, it was determined that the facility failed to maintain an environment that was free from dirty floors, rusty metal frames on raised toilet seats, a broken toilet paper holder, a rusty free standing toilet paper holder, a soiled commode chair seat, worn finishes on nightstands, a broken nightstand door, cracked and bubbled wallpaper, stored unused equipment in a common shower room, peeling trim on overbed tables, peeling wood and, soiled urinals on one (North hall) of four halls. Findings include: Observations were made during the initial tour on 2/20/12 between 11:10 a.m. and 11:40 a.m. and, during the environmental tour on 2/23/12 between 1:15 p.m. and 2:00 p.m 1. The bathroom floor around the door frame had a heavy build up of a black substance in room 344. The nightstand door was broken at the A bed location. 2. There was a rusty metal frame on the raised toilet seat in the bathroom of room 346. The toilet paper holder was broken. The seat of the commode chair was soiled. The floor had a heavy build up of dust and debris. 3. There was a rusty metal frame on the raised toilet seat in the bathroom of room 350. The wood was peeling off of the bathroom door. 4. The finish was worn off of the nightstands for A and B beds in room 354. There was a rusty free standing toilet paper holder in the bathroom. 5. The wallpaper was cracked and bubbled on the wall next to the window in room 341. 6. The edging was peeling off of the overbed table in room 345A. 7. There was a urinal on the siderail that had a dried white substance along the inside of it in room 352C. 8. There was a urinal on the overbed table that had a black substance along the lid in room 356C. 9. There were three mechanical lifts, two reclining chairs, two overbed tables, two geri chair table tops, a tube feeding pole, a tube feeding pump, two vital sign machines, a mattress overlay, a blood pressure machine, five straight chairs and one wheelchair stored in the common shower room. | 2016-03-01 |
| 8338 | 8338 | COOK SENIOR LIVING CENTER | 115655 | 706 NORTH PARRISH AVE . | ADEL | GA | 31620 | 2012-02-23 | 282 | D | 0 | 1 | 028H11 | Based on observation, record review and staff interview, it was determined that the facility failed to provide nail care for one (#106) of 32 sampled residents. Findings include: Resident #106 was coded by licensed staff on the 1/14/12 quarterly Minimum Data Set (MDS) assessment as requiring limited assistance with personal hygiene. The resident had a plan of care since 10/12/11 to address his/her self care deficit. There was an intervention for staff to provide nail care weekly and as needed. However, the resident was observed to have brown matter underneath his/her fingernails on both hands on 2/21/12 at 10:15 a.m., on 2/22/12 at 11:00 a.m. after receiving a shower, and on 2/23/12 at 10:15 a.m See F312 for additional information regarding resident #106. | 2016-03-01 |
| 8339 | 8339 | COOK SENIOR LIVING CENTER | 115655 | 706 NORTH PARRISH AVE . | ADEL | GA | 31620 | 2012-02-23 | 309 | D | 0 | 1 | 028H11 | **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 administer medications as ordered for two residents (#86 and #104) from a total sample of 32 residents. Findings include: 1. Resident #86 had a physician's orders [REDACTED]. However, a review of the October 2011 Medication Administration Record [REDACTED]. A review of the December 2011 MAR indicated [REDACTED]. Licensed nursing staff documented on that MAR indicated [REDACTED]. However, there was no evidence of when the medication was obtained or that the dose was administered. 2. Resident #104 had a physician's orders [REDACTED]. However, a review of nursing staff's documentation on the resident's MAR indicated [REDACTED]. During an interview on 2/22/12 at 4:30 p.m., the Director of Nursing (DON) stated that the restart and administration of the medication on 2/10/12 was an error on the nurses part. On 2/23/12 at 11:30 a.m., the resident's physician stated that the facility had called him after surveyor inquiry. He stated that he had written an order for [REDACTED].> | 2016-03-01 |
| 8340 | 8340 | COOK SENIOR LIVING CENTER | 115655 | 706 NORTH PARRISH AVE . | ADEL | GA | 31620 | 2012-02-23 | 312 | D | 0 | 1 | 028H11 | Based on observation, record review and staff interview, it was determined that the facility failed to provide nail care for one (#106) of 32 sampled residents. Findings include: Resident #106 was coded by licensed staff on the 1/14/12 quarterly Minimum Data Set (MDS) assessment as requiring limited assistance with personal hygiene. The resident had a plan of care since 10/12/.11 to address his/her self care deficit related to his/her generalized weakness. There was an intervention for staff to provide nail care weekly and as needed. However, the resident was observed to have brown matter underneath his/her fingernails on both hands on 2/21/12 at 10:15 a.m., on 2/22/12 at 11:00 a.m. after being given a shower by nursing staff and, on 2/23/12 at 10:15 a.m During an interview on 2/23/12 at 10:50 a.m., certified nursing assistant (CNA) BB stated that staff would clean under a resident's fingernails if they noticed they were dirty. | 2016-03-01 |
| 8341 | 8341 | COOK SENIOR LIVING CENTER | 115655 | 706 NORTH PARRISH AVE . | ADEL | GA | 31620 | 2012-02-23 | 314 | D | 0 | 1 | 028H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and record review, it was determined that the facility failed to ensure interventions were in place to prevent pressure ulcer development for one resident (#72 ) who had a history of [REDACTED]. Findings include: Resident #72 had an annual Minimum Data Set (MDS) assessment completed on 12/2/11. Licensed staff coded him/her as requiring extensive assistance with bed mobility, personal hygiene, bathing, and dressing and total assistance with transfers and toilet use. The resident was coded as being at risk for pressure ulcer development. In section M1200 of the MDS assessment, licensed staff had checked that a pressure reducing device for the bed was in use. Nursing staff developed a care plan dated 2/25/11 to address the resident's risk for skin integrity impaired because of having had a pressure ulcer on admission, impaired mobility, bowel and bladder incontinence and decreased nutritional status. During observation on 2/20/12 at 3:15 p.m., the resident was in bed sleeping. The alternating pressure pump attached to the foot board of the bed was in the 'off' position so that the overlay pressure pad was not inflated. It was observed on 2/21/12 at 8:10 a.m., 9:00 a.m., 1:30 p.m., 3:00 p.m., 4:10 p.m. and 5:10 p.m. and on 2/22/12 at 7:05 a.m., 8:20 a.m. and 8:55 a.m., that the resident was in the bed with the alternating pressure pump in the 'off' position and the overlay pressure pad not inflated. | 2016-03-01 |
| 8342 | 8342 | COOK SENIOR LIVING CENTER | 115655 | 706 NORTH PARRISH AVE . | ADEL | GA | 31620 | 2012-02-23 | 328 | E | 0 | 1 | 028H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews with a resident and staff, it was determined that the facility failed to properly store respiratory therapy equipment for four sampled residents (#32, #73, #90 and A) and for two unsampled residents from a total sample of 32 residents. Findings include: Review of the facility's Policy and Procedure for Respiratory Therapy Equipment revealed that oxygen cannulas and tubing were to be stored in a plastic bag when not in use. Nebulizers were to be stored in a plastic bag. Staff were to change the prefilled humidifier bottles when the water level was low. However, staff failed to implement those procedures for residents #32, #73, #90, A and two unsampled residents. 1. Resident #32's nebulizer mouthpiece and tubing were uncovered and laying on the floor on 2/20/12 at 3:05 p.m. and on 2/21/12 at 8:30 a.m. 2. The oxygen mask and tubing for resident #73 was uncovered and draped over the oxygen meter on the wall on 2/20/12 at 3:00 p.m. On 2/21/12 at 8:35 a.m., the mask and tubing was in a plastic bag dated 6/12/11. 3. The nebulizer mouthpiece and tubing for resident #90 was uncovered, draped over the oxygen meter and was not dated on 2/20/12 at 2:30 p.m. and on 2/21/12 at 8:35 a.m. 4. Resident A had a 9/29/11 physician's orders [REDACTED]. However, the resident's oxygen was set at 3Liters/minute and the humidifier bottle was empty on 2/20/12 at 2:30 p.m., 2/21/12 at 9:00 a.m., and 4:00 p.m., 2/22/12 at 8:35 a.m. and 4:45 p.m. and on 2/23/12 at 10:00 a.m. There was also an uncovered oxygen mask draped over the oxygen meter on those dates and times. During an interview on 2/23/12 at 10:00 a.m., resident A stated that the inside of his/her nose would get dry, sore and would bleed at times. The following observations were made during the initial tour on 2/20/12 between 11:10 a.m. and 11:40 a.m 5. The oxygen tubing was draped over the oxygen meter and was not dated in room [ROOM NUMBER]A. 6. The oxygen mas… | 2016-03-01 |
| 8343 | 8343 | COOK SENIOR LIVING CENTER | 115655 | 706 NORTH PARRISH AVE . | ADEL | GA | 31620 | 2012-02-23 | 371 | F | 0 | 1 | 028H11 | Based on observations and staff interview, it was determined that the facility failed to maintain the floor pantry ice machine on the North Hall in a clean and sanitary condition. Findings include: During the environmental tour on 2/23/12 at 1:13 p.m., the ice machine in the floor pantry on the North hall had a heavy build up of a brown substance in the back of the machine where the ice was made. During an interview on 2/23/12 at 3:05 p.m., the administrator stated that the floor tech was supposed to be cleaning the machine. After surveyor inquiry, he/she provided a cleaning schedule to be instituted 2/24/12. | 2016-03-01 |
| 8344 | 8344 | COOK SENIOR LIVING CENTER | 115655 | 706 NORTH PARRISH AVE . | ADEL | GA | 31620 | 2012-02-23 | 428 | D | 0 | 1 | 028H11 | Based on record review and staff interview, it was determined that the facility failed to act upon a pharmacy recommendation for one resident (#86) from a total sample of 32 residents. Findings include: Resident #86 had a recommendation from the pharmacist on 9/30/11 for the physician to review the continued need for the medication Procrit due to the medication being held several times for hemaglobin levels greater than 12. The resident's attending physician's documented response on the recommendation form was that another physician had ordered the medication. There was no further evidence in the clinical record that the pharmacist's recommedation was addressed. The Director of Nursing confirmed on 2/23/12 at 4:40 p.m. that the recommendation was not addressed. | 2016-03-01 |
| 8345 | 8345 | COOK SENIOR LIVING CENTER | 115655 | 706 NORTH PARRISH AVE . | ADEL | GA | 31620 | 2012-02-23 | 431 | D | 0 | 1 | 028H11 | Based on observation, record review and staff interview, it was determined that the facility failed to properly store controlled medications in a separately locked compartment on one (North) of two halls. Findings include: Review of the facility's Policy and Procedure for Controlled Medications revealed that controlled drugs were to be placed in the locked controlled drug cabinet in the medication rooms. However, nursing staff failed to secure a controlled drug in the North Hall medication room. During an observation of the North Hall medication storage room on 2/23/12 at 12:00 p.m., there was a bubble pack of 30 tablets of Vicodin 5/500 milligrams in an unlocked cabinet. There was a sheet of paper wrapped around the pack with the resident's name, a date of 2/22/12 and a note on it that 30 tablets remained. Licensed nurse AA stated at that time that the medication should not have been stored in an unlocked cabinet. The nurse immediately placed the medication in a separate locked box that was affixed to the wall. AA stated that when a controlled substance had been discontinued, the medication and the count sheet was supposed to be taken to the nursing supervisor. | 2016-03-01 |
| 10068 | 10068 | COOK SENIOR LIVING CENTER | 115655 | 706 NORTH PARRISH AVE . | ADEL | GA | 31620 | 2010-06-04 | 279 | D | 0 | 1 | M4C211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews and record reviews, it was determined that the facility failed to develop a care plan for one resident (#1) to address his/her history of fecal impactions from a total sample of 17 residents. Findings include: Resident #1 had been receiving 100 milligrams (mg) of [MEDICATION NAME] every day since 7/23/09. There was a 7/28/09 order for 30 cubic centimeters (cc) of Milk of Magnesia every day "as needed" (prn) constipation. However, a review of the resident's care plan since 8/26/09 did not include the resident's problem of constipation and potential for fecal impaction. On 11/15/09, the nurse's notes documented that the resident complained of lower abdominal pain. The licensed nurse noted that she checked the resident for a fecal impaction and felt large, very hard stool. The resident's doctor was notified. The resident was given a Fleets enema and had good results. On 11/16/09, the physician ordered 30 cubic centimeters (cc) of [MEDICATION NAME] twice a day. The 4/10/10 nurse's notes described the resident as restless and crying from pain. The licensed nurse documented that she assessed the resident and found that he/she was impacted with large hard stool in his/her rectum. The nurse noted that she removed the impaction and gave the resident a Fleets enema and an "as needed" laxative. During an interview with the Registered Nurse (RN) Supervisor and Nurse "JJ" on 6/4/10 at 11:15 a.m., they stated that they were not aware that the resident had constipation or history of a second fecal impaction on 4/10/10. The RN supervisor stated that interventions to address the resident's potential for having a fecal impaction should have been on the care plan. After reviewing the resident's medical record with the nurse, the Registered Nurse supervisor confirmed that the resident did not have a care plan to address his/her risk for constipation and fecal impactions. See F309 for additional information regarding reside… | 2015-03-01 |
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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 );