cms_GA
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10,655 rows sorted by facility_id
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 1 | A.G. RHODES HOME WESLEY WOODS | 115002 | 1819 CLIFTON ROAD, N.E. | ATLANTA | GA | 30329 | 2019-02-14 | 656 | G | 0 | 1 | PXEL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews and review of the facility policy titled, Care Planning - Interdisciplinary Team the facility failed to follow the care plan for one resident (R), #49. Actual harm was identified when R#49 suffered a midline laceration to the forehead and a [MEDICAL CONDITION] (Cervical) vertebral body requiring the use of a C-spine collar when she fell from her bed after being left unattended during a bed bath on 12/15/18. Additionally, the facility failed to develop a care plan for one Resident (R#94) for the use of a travel pillow for neck positioning. The sample size was 26 residents. Findings include: Review of the facility's policy titled Care Planning - Interdisciplinary Team reviewed on 3/1/18 noted: 1. A comprehensive care plan for each resident is developed within seven (7) days of completion of the resident assessment (MDS (Minimum Date Set)); 2. The care plan is based on the resident's comprehensive assessment and is developed by a care planning/interdisciplinary team. The policy did not include additional information regarding the development and implementation of resident care plans. 1. Review of the clinical record for R#49 revealed that the resident had the following [DIAGNOSES REDACTED]., [MEDICAL CONDITION] (left eye) and depression. Review of the Annual MDS, for R#49, dated 9/5/18 and review of the Quarterly MDS dated [DATE] revealed that the resident was assessed to be severely cognitively impaired, had physical and verbal behaviors directed towards others for one to three days during the assessment period. Review of Section G of this MDS documented that during this assessment period the resident was assessed to be dependent on staff for bathing requiring two plus person assist for bathing. R#49 had no impairment of the upper or lower extremities. Continued review revealed during this assessment period the resident had no falls and did not utilize any restraints or alarms. Review of the Fal… | 2020-09-01 |
| 2 | 2 | A.G. RHODES HOME WESLEY WOODS | 115002 | 1819 CLIFTON ROAD, N.E. | ATLANTA | GA | 30329 | 2019-02-14 | 688 | D | 0 | 1 | PXEL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews and review of the facility policy titled, Resident Mobility and Range of Motion the facility failed to assess and provide treatment for one Resident (R), (R#94) for neck positioning. The sample size was 26 residents. Findings include: Review of the facility's policy titled Resident Mobility and Range of Motion reviewed on 2/1/18 revealed 3. Residents with limited range of motion will receive treatment and services to increase and/or prevent further decrease in range of motion; 4. Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable .5. Therapy will evaluate/reevaluate the resident's mobility on a routine basis to determine the need for range of motion exercises. Review of the clinical record for R#94 revealed an Annual Minimum Data Set (MDS) assessment dated [DATE] with documented [DIAGNOSES REDACTED]. Continued review of the MDS revealed R#94 was severely cognitively impaired and exhibited no behaviors during the assessment period. The resident required extensive to total assistance of one to two staff persons for all Activities of Daily Living (ADLs). During this assessment period, R#94 received Occupational Therapy (OT), passive range of motion (ROM), and splint/brace assistance. Review of the Task tab for R#94 printed from the electronic record on 1/31/19 revealed the resident required total assistance for eating; required two-person total dependence for bathing, bed mobility, and dressing. These tasks were to be completed by the Certified Nursing Assistants (CNAs). Further review revealed Restorative staff was to provide the resident with passive ROM to the left hand six times per week for 15 minutes for each treatment and was to apply a splint/brace to her left hand for up to six hours - six times per week. The Task tab did not list the use of a travel neck pillow to be used… | 2020-09-01 |
| 3 | 3 | A.G. RHODES HOME WESLEY WOODS | 115002 | 1819 CLIFTON ROAD, N.E. | ATLANTA | GA | 30329 | 2019-02-14 | 689 | G | 0 | 1 | PXEL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews and review of the facility policy titled, Fall Policy the facility failed to provide supervision during a bed bath to prevent an avoidable fall for one Resident (R), #49. Actual harm was identified when R#49 suffered a midline laceration to the forehead and a [MEDICAL CONDITION] (Cervical) vertebral body requiring the use of a C-spine collar when she fell from her bed after being left unattended during a bed bath on 12/15/18. The sample size was 26 residents. Findings include: Review of the facility's policy titled, Fall Policy reviewed 3/1/18 revealed The facility will identify each resident who is at risk for falls and will plan appropriate care and implement interventions to assist in fall prevention. The facility will attempt to decrease falls with injury by providing an environment that is free from potential hazards. Review of the clinical record for R#49 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. and depression. Review of the Annual Minimum Data Set (MDS), for R#49, dated 9/5/18 and review of the Quarterly MDS dated [DATE] revealed that the resident was assessed to be severely cognitively impaired, had physical and verbal behaviors directed towards others for one to three days during the assessment period. Review of Section G of this MDS documented that during this assessment period the resident was assessed to be dependent on staff for bathing and required two plus person assist for bathing. R#49 had no impairment of the upper or lower extremities. Continued review revealed during this assessment period the resident had no falls and did not utilize any restraints or alarms. Review of a handwritten statement dated 12/21/18 written by Certified Nursing Assistant (CNA) FF documented the following: On 12/15/18 at 10:45 a.m., I (CNA FF) entered room [ROOM NUMBER]. I began washing R#49's upper body and during the process she was fighting. She was yanking on the face towe… | 2020-09-01 |
| 4 | 4 | A.G. RHODES HOME WESLEY WOODS | 115002 | 1819 CLIFTON ROAD, N.E. | ATLANTA | GA | 30329 | 2019-02-14 | 880 | D | 0 | 1 | PXEL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and review of facility policy titled, Handwashing/Hand Hygiene the facility failed to ensure food was served in a sanitary manner for six of 41 residents (R), R#63 and five unsampled resident) residing on the secured unit. Findings include: Review of the facility's document entitled Handwashing/Hand Hygiene policy (undated) noted the following: 6. Wash hands with soap and water for the following situations: a. When hands are visibly soiled; b. After contact with a resident with infectious diarrhea .7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: a. Before and after coming on duty; b. Before and after direct contact with residents; .i. After contact with a resident's intact skin; .l. After contact with objects in the immediate vicinity of the resident; .o. Before and after eating or handling food; p. Before and after assisting a resident with meals. Review of the clinical record for R#63 revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's Quarterly MDS dated [DATE] revealed the resident required the limited assistance of one staff person for eating and required the extensive assistance of one staff person for personal hygiene. During the lunch meal observation in the north dining room of the facility's secured unit on 1/28/19 at 1:07 p.m. an unsampled resident was seated at a dining table waiting to be served her lunch meal. The resident's left shoe was off of her foot and the resident was having difficulty putting her shoe back on. At this time, the Activity Director (AD) was passing out utensils wrapped in cloth napkins to all of the resident in the dining room and when the AD approached this unsampled resident, the AD set the tray of utensils down on the table and then assisted the resident by putting her shoe on for her. After the resident's shoe was on, the AD picked up the tray an… | 2020-09-01 |
| 5 | 5 | A.G. RHODES HOME WESLEY WOODS | 115002 | 1819 CLIFTON ROAD, N.E. | ATLANTA | GA | 30329 | 2017-03-23 | 247 | D | 0 | 1 | 6QM511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview with facility staff, review of the electronic records, and review of the policy titled Room Change/Roommate Assignment, revised (MONTH) 2006, the facility failed to ensure that written notification of room change was provided before moving a resident from the third floor to the fourth floor for one of 32 sampled residents (R) (R#194). Findings include: Review of a Social service assessment dated [DATE]; the resident is coded as independent for decision making skills and understanding the need for placement and participated in the placement decision. Review of the Room Change/Roommate assignment policy, revised in (MONTH) 2006 includes in part; Prior to changing a room or roommate assignment all parties involved in the change assignment (e.g.) Residents and their representatives (sponsors) will be given a 2-day advanced notice of such change. The notice of a change in room or roommate assignment may be oral or in writing, or both, and will include the reason(s) for such change. On 3/20/2017 at 1:00 p.m., R#194 was interviewed and he reported that he was very upset at the time that he was moved to this room from the third floor. He stated this happened about three months ago and no one prepared him for a room change. The resident said, they came to me after I finished my breakfast and moved me the same day. The resident stated, They told me I had to be moved because I no longer needed therapy and I became long term care. If they do it again I will speak up for myself because that really upset me. Review of the Shift Charting Notes dated 1/16/2017 at 9:49 a.m., the resident was transferred to (a room on the fourth floor) per staff. Medications and personally belongings transferred, report given as well. Review of a General Social Services Note dated 1/12/2017 at 3:18 p.m, documents the resident is to remain for long term care. MSW left a message on voice mail of his daughter to discuss room change to the 4th floor- traditional… | 2020-09-01 |
| 6 | 6 | A.G. RHODES HOME WESLEY WOODS | 115002 | 1819 CLIFTON ROAD, N.E. | ATLANTA | GA | 30329 | 2017-03-23 | 328 | D | 0 | 1 | 6QM511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, facility policy review and staff interviews, the facility failed to ensure residents received proper [MEDICATION NAME] treatment and care by not capping the sterile end of an intravenous (IV) tubing nor removing air from syringes and intravenous tubing. This had the potential to affect one of two residents (R) (R#37) currently receiving IV medications in a universe of 32 sampled stage 2 residents. Failure to cap the sterile end on an IV could result in a resident infection and failing to remove air from syringes or intravenous lines could result in an air [MEDICAL CONDITION] (a blood vessel blockage caused by air bubbles in the circulatory system). Findings include: Observation in R#37's room on 3/23/17 from 9:30 a.m. - 10:00 a.m. revealed Licensed Practical Nurse (LPN) (LPN KK) verbalized intention to flush R#37's right hand intravenous (IV) catheter using a 10 cc syringe of sterile normal saline (NS), However, as she moved toward the IV with the syringe, she had not expelled the visualized air from the syringe. Surveyor stopped the procedure requesting she expel the air. She held the syringe horizontally expelling liquid while the air bubble remained. She turned to resume flushing and again was asked to remove the air from the syringe, requesting LPN KK hold it vertically, syringe tip up, to examine and expel the air bubble. LPN KK did remove the air, shaking her head, offering that she was nervous being watched but can do this as she flushed the IV extension tube with the NS. LPN KK then opened the sterile IV tubing package and connected a 100 cc bag NS with 1 gram of [MEDICATION NAME] (an Antibiotic) to the IV tubing. She ran the solution through the tubing without closing clamp or turning filter upside down. LPN KK then strung the tubing through the medication pump (used to regulate the time and amount of solution administered). The pump began beeping when it was turned on. It was noted there were multiple air bubb… | 2020-09-01 |
| 7 | 7 | A.G. RHODES HOME WESLEY WOODS | 115002 | 1819 CLIFTON ROAD, N.E. | ATLANTA | GA | 30329 | 2017-03-23 | 371 | F | 0 | 1 | 6QM511 | Based on observation, staff interview, anonymous interviews, review of dish washer temperature log, and review of the Dish Machine Temperatures policy, revised 1/2016, and the Uniform Dress Code policy dated 1/2016, the facility failed to ensure the high temperature dishwasher wash temperature was maintained at 160 degrees Fahrenheit (F) and final rinse temperature was maintained at 180 degrees (F), or higher, The facility failed to have test strips for the dishwasher and attach the test strips to the dishwasher log as required by facility policy, and failed to ensure that staff wore hair and beard restraints while in the kitchen. This failure had the potential to effect 128 residents that received food from the kitchen. Findings include: Observation on 3/21/17 at 10:37 a.m. of the electronic dishwasher monitor screen revealed that it was red and had a tringle with an exclamation point (!) in it. In an interview at this time Dietary Aide DD stated that the dishwasher monitor screen was red and had an exclamation point in the triangle, because the water temperature in the dishwasher was too low. Dietary Aide DD stated that the dishwasher was a hot water dishwasher, the wash water temperature is supposed to be 160 degrees F and the rinse is supposed to be 180 F, but the water temperature has been fluctuating. Continued observation on 3/21/17 from 10:37a.m. to 10:45 a.m. revealed that the Dietary Aide DD continued to wash the dishes and the monitor continued to be red with an exclamation point inside a triangle. The wash water temperatures on the electronic monitor fluctuated from 132 to 157 degrees F and the rinse temperature fluctuated from 177 degrees F to 192 degrees F. Further observation revealed Dietary Aide DD never verified the water temperature fluctuation with a test strip attached to a dish. In an interview at this time the Dietary Aide stated that he had washed about 10 racks of dishes and the other staff member put them on the storage rack. In further interview, Dietary Aide DD stated that his supervis… | 2020-09-01 |
| 4235 | 4235 | A.G. RHODES HOME WESLEY WOODS | 115002 | 1819 CLIFTON ROAD, N.E. | ATLANTA | GA | 30329 | 2017-01-25 | 225 | D | 1 | 0 | HX8G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, review of policy and procedures, and staff interviews, the facility failed to ensure that a staff member immediately reported a witnessed incident of staff to resident abuse for one of three sampled residents (R) (R#1) to the any department heads until 17 days after the incident. Specifically, on 12/26/16 in the dining room at the end of dinner, Certified Nursing Assistant (CNA) AA witnessed another CNA (CNA FF) grab R#1 by the back of his shirt pulling him down into his wheelchair and pull the resident backward in his wheelchair by his shirt. CNA AA did not report the incident to any department heads until 1/12/17. The Director of Nursing (DON) was able to view the facility surveillance camera and confirmed that CNA FF pulled the resident backward in his wheelchair by first grabbing the back of his shirt collar and then by the middle back of the shirt. CNA FF worked a total of 10 shifts (12/28/16, 12/29/16, 12/30/16, 1/2/17, 1/3/17, 1/4/17, 1/6/17, 1/7/17, 1/8/17 and 1/9/17) after the incident on 12/26/17 but was not assigned to R#1 during these shifts. CNA FF was terminated on 1/13/17. This failure to immediately report staff to resident abuse caused by CNA FF increased the potential of mistreatment to other residents residing in the facility. Findings include: Review of the undated policy titled Abuse Prevention Policy and Procedures documents: Training-During orientation, all new staff and volunteers will be oriented to the facility policy related to Abuse Prevention including what constitutes abuse, mistreatment, exploitation, neglect and misappropriation of resident property; what to do if they hear or see abuse, neglect, mistreatment, exploitation or misappropriation of resident property. Prevention- The facility will provide residents, families and staff information at how and whom they may report concerns, incidents and grievance without fear of retribution. Identification- Identification of injuries or even… | 2020-01-01 |
| 4864 | 4864 | A.G. RHODES HOME WESLEY WOODS | 115002 | 1819 CLIFTON ROAD, N.E. | ATLANTA | GA | 30329 | 2016-05-13 | 278 | E | 0 | 1 | L11S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facilty failed to ensure that the Minimum Data Set (MDS) accurately reflected the dental status for one (1) resident (#158) and failed to accurately assess for the use of a diuretic for six (6) residents (#45, # 59, #78, #109, #121, #156, and #209). The sample size was forty-two (42) residents. Findings include: 1. During observations on 05/10/16 at 12:43 p.m. and 05/11/16 at 8:11 a.m., of resident #158, the resident was noted to be edentulous and have no dentures in place. Review of an Oral assessment dated [DATE] noted that the resident had no natural teeth or tooth fragments (edentulous). Review of a Dentist's Progress Notes dated 06/15/15 noted the resident was edentulous. Review of a Significant Change MDS dated [DATE] noted that the resident was assessed as having no dental issues. An interview with MDS Coordinator AA on 05/12/16 at 3:12 p.m., she verified that the Dental section of the MDS, dated [DATE], was not accurately assessed, as the resident was edentulous. 2. Record Review of the Order Summary for resident #209 dated 4/1/2016 revealed the resident had a physician's orders [REDACTED]. [MEDICATION NAME] HCL is a [MEDICATION NAME]. Review of the Admission MDS assessment dated [DATE], Section N, revealed the resident was assessed for diuretic use for seven (7) days, although there was no evidence the resident was on a diuretic. 3. Record Review of the Order Summary for resident #121 dated 2/26/2016 revealed the resident had a physician's orders [REDACTED]. [MEDICATION NAME] HCL is a [MEDICATION NAME]. Review of the Quarterly MDS assessment dated [DATE], Section N, revealed the resident was assessed for diuretic use for seven (7) days, although there was no evidence the resident was on a diuretic. 4. Record Review of the Order Summary for resident #59 dated 3/1/2016, 12/1/2015 and 9/1/15 revealed the resident had a physician's orders [REDACTED]. [MEDICATION NAME] HCL is a … | 2019-04-01 |
| 6100 | 6100 | A.G. RHODES HOME WESLEY WOODS | 115002 | 1819 CLIFTON ROAD, N.E. | ATLANTA | GA | 30329 | 2015-03-20 | 241 | D | 0 | 1 | T23O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to provide care and services in a manner that promoted dignity during dining for two of two dining observations in the secure unit on the 2nd floor. This deficient practice had the potential to affect all 22 residents who dined in the secured unit. Findings include: On 3/16/15 at 12:35 p.m. two Certified Nursing Assistants (CNA-Employee#92 and CNA#212) placed white paper placemats on four white plastic rectangular tables. With the exception of window valances, the room was bare of homelike decorations. The only background sound was the loud noise from the call light at the Nurse's Station. Facility staff assisted 22 residents on the locked unit to the dining room between 12:38 p.m. - 12:50 p.m. Meal service did not begin until 12:54 p.m. Staff failed to offer beverages to the residents as the residents waited for lunch. Staff failed to offer residents in wheel chairs an opportunity to move from wheel chair to dining chair. As staff assisted each resident to a table, CNA#212 inquired as to their preference for a clothing protector. Two of the residents stated emphatically they chose not to wear a clothing protector. CNA#212 placed clothing protectors on both residents despite their protestations. At 1:19 p.m. the Occupational Therapist (OT-Employee#278) sat at the far end of the smallest table, between two residents. A volunteer stood to the left of OT#278 and slightly behind one of the residents. As OT#278 encouraged that resident to use a weighted spoon, OT#278 spoke to the volunteer about the resident's [DIAGNOSES REDACTED]. The table included five of the resident's peers and CNA #212 at the opposite end. After several minutes of conversation, OT#278 asked CNA#212 a question about the resident, and CNA#212 joined the conversation. Both staff and volunteer failed to engage any of the residents in social dining conversations, but spoke at length to one another about one of the resi… | 2018-03-01 |
| 6101 | 6101 | A.G. RHODES HOME WESLEY WOODS | 115002 | 1819 CLIFTON ROAD, N.E. | ATLANTA | GA | 30329 | 2015-03-20 | 242 | D | 0 | 1 | T23O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to allow a resident to make daily choices about his healthcare to ensure that he could experience the best possible quality of life. This deficient practice had the potential to affect one (R153) resident out of a Stage 2 sample of 36. Findings include: An observation of R153's room on 3/16/15 at 2:10 p.m. revealed that there was a bed in his room but he did not have an electric sleeper reclining chair. An interview conducted on 3/16/15 at 4:10 p.m. with R153 revealed that he was not allowed to bring his electric recliner into the facility. Per the resident, he preferred to sleep in his recliner rather than the facility bed. He slept in his recliner when he lived at home. R153 added that he filed a grievance some time ago with the Social Worker (SW). R153 stated that the SW told him that he would need a bigger room if he wanted to bring his reclining chair into the facility. The SW added R153's name to the waiting list for a bigger room that would house both his bed and his reclining chair. R153 stated that he did not remember when he filed the complaint with the SW but he had waited a long time. A confidential interview was conducted on 3/17/15 at 3:20 p.m. with a staff member that revealed that R153 would frequently not comply with sleeping in his bed. The staff member stated the resident complained that his bed was uncomfortable and he could not sleep lying down. The staff member stated that R153 told her that when he slept in the facility bed, he woke up frequently. The staff member added that she was not aware of any reason why R153 could not have his recliner in his room. An interview conducted on 3/18/15 at 2:00 p.m. with the Director of Nursing (DON) revealed that R153 did request a recliner in his room so he could sleep better. According to the DON, there was not enough room for both his bed and a recliner, and the bed would have to be removed, however the DON sta… | 2018-03-01 |
| 6102 | 6102 | A.G. RHODES HOME WESLEY WOODS | 115002 | 1819 CLIFTON ROAD, N.E. | ATLANTA | GA | 30329 | 2015-03-20 | 278 | D | 0 | 1 | T23O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop an accurate comprehensive assessment relative to dental needs for one (R69) of two residents who were evaluated for oral and dental needs out of a Stage 2 sample of 36. Findings include: Observation of R69 on 3/17/15 at 10:30 a.m. revealed that she had many missing teeth and the three teeth that she had remaining were discolored, broken and had sharp edges. Review of the medical record revealed that R69 was admitted on [DATE]. Review of the Minimum Data Set (MDS) quarterly comprehensive assessments dated, 6/25/14, 9/24/14, 12/22/14, and the annual MDS assessment dated [DATE] revealed that staff coded the resident as having no dental or oral concerns. Review of the MDS assessments in Section L- Oral/Dental Status revealed the following questions: A. Broken or loosely fitting full or partial denture (chipped, cracked, uncleanable, or loose) B. No natural teeth or tooth fragment(s) (edentulous) C. Abnormal mouth tissue (ulcer, masses, oral [MEDICAL CONDITION], including under denture or partial if one is worn) D. Obvious or likely cavity or broken natural teeth E. Inflamed or bleeding gums or loose natural teeth F. Mouth or facial pain, discomfort or difficulty with chewing G. Unable to examine H. None of the above I. WAS THE RESIDENT REFERRED TO S(NAME)IAL SERVICES TO ARRANGE FOR DENTAL EXAM? 1. Yes 2. No Review of each of the three MDS quarterly assessments and the annual MDS assessment revealed that staff had coded R69 as H, none of the above and 2 the resident was not referred to Social Services to arrange for a dental exam. Observation and interview with R69 and the Director of Nursing (DON) on 3/19/15 at 3:29 p.m. confirmed that R69's teeth were in very poor condition. The resident stated that her teeth can be painful and she would like to be referred to a dentist. The DON confirmed that R69's oral condition was poor and since her admission to this facility s… | 2018-03-01 |
| 6103 | 6103 | A.G. RHODES HOME WESLEY WOODS | 115002 | 1819 CLIFTON ROAD, N.E. | ATLANTA | GA | 30329 | 2015-03-20 | 371 | F | 0 | 1 | T23O11 | Based on observation, interview and record review, the facility failed to ensure food safety when they did not maintain cold holding food temperatures at 41 degrees Fahrenheit (F) or below at point of service. This deficient practice had the potential to affect all of the residents who ate their meals at this facility. Findings include: Observation of the kitchen on 3/18/15 at 11:45 a.m. revealed the staff had prepared a cold apple dessert for all of the residents including those who had a physician ordered pureed diet. Observation of the upright metal serving cart that housed the cold food revealed that there were approximately 70-100 individual servings of the apple dessert. An interview with the Director of Dining Services (DDS) on 3/18/15 at 12:30 p.m. confirmed that the staff had prepared the apple dessert earlier in the morning and had placed them in the refrigerated unit to ensure food safety. The DDS stated that the meal was ready for service. Observation of the DDS taking the temperature of the apple desserts with a calibrated thermometer revealed that they were holding in the danger zone (41-135 degrees F). The DDS took the temperature of five individual servings of the dessert while still on the metal serving cart at 12:30 p.m. (at point of service) and each of the servings were holding between 72-76 degrees F. Observation of the dining room on 3/18/15 at 12:45 p.m. revealed that staff had served several residents the apple dessert before ensuring the food was holding at the appropriate temperature and safe for consumption. After removing the apple desserts from the resident trays, the DDS proceeded to take the temperature of the apple desserts that remained in the dining room, and they were also holding between 72-76 degrees F. An interview with the DDS on 3/18/15 at 12:45 p.m. confirmed that the apple desserts were holding in the danger zone and that staff should not have served them to the residents until the proper holding temperature had been realized. Review of the facility's Food Safety Audit da… | 2018-03-01 |
| 6104 | 6104 | A.G. RHODES HOME WESLEY WOODS | 115002 | 1819 CLIFTON ROAD, N.E. | ATLANTA | GA | 30329 | 2015-03-20 | 441 | D | 0 | 1 | T23O11 | Based on observation, interview and review of the Employee Handbook, the facility failed to ensure that the direct care staff utilized standard infection control practices during meal service on the secured unit (second floor). This deficient practice had the potential to affect all 22 residents who received their meals in the secured unit's north dining room. Findings include: Observation on 3/16/15 at 12:35 p.m. in the secured unit dining room revealed two Certified Nursing Assistants (CNA-Employee#92 and CNA#212) who began their shift at 7:00 a.m. wearing the same uniforms they wore during the meal service. The CNAs were observed holding the resident's clean paper placemats against their potentially contaminated uniforms while dispensing the placemats. Dining observation on 3/16/15 at 12:38 p.m. revealed staff assisted the residents to the dining area as needed and the residents who were able to ambulate independently did so. Several residents touched the handrails outside the dining room, and those who wheeled in touched the unclean wheels of their chairs prior to the meal. Meal service began at 12:54 p.m. Staff failed to provide residents any type of hand sanitation prior to the meal service. At 1:10 p.m, CNA#212 sat on a rolling stool at the end of the first table to the left from the entrance and moved freely between two residents. As she assisted each resident with various utensils, she touched the resident's hands, arms, glassware by the lip of the glasses, opened straws, readjusted wheelchairs and did not sanitize her hands after touching potentially contaminated objects or between the two residents. During meal observations on 3/16/15 and 3/17/15, CNA#212 was noted to have long acrylic fingernails that extended approximately 1/2 inch past her fingertips. During the first dining observation, (1:03pm-2:00pm) CNA#92 was at the second table to the right of the dining room entrance. CNA#92 had a haircut that was short in the back, but long on both sides of her face. Each time she leaned to assist the reside… | 2018-03-01 |
| 6105 | 6105 | A.G. RHODES HOME WESLEY WOODS | 115002 | 1819 CLIFTON ROAD, N.E. | ATLANTA | GA | 30329 | 2015-03-20 | 466 | F | 0 | 1 | T23O11 | Based on interview and record review, the facility failed to establish procedures to ensure that they could distribute potable and non-potable water to all three resident floors in the event of an emergency. This had the potential to affect all of the 131 residents who resided in this facility. Findings include: During the entrance conference on 3/16/15 at 8:00 a.m. the Administrator was asked to provide the survey team with the facility's procedure to ensure water availability in the case of an emergency. Review of the, Emergency Operation Policy and Procedure Manual, revealed a document titled, Emergency Operation Procedures Utility Failure that provided the following in the Maintenance: Non-Potable Water and Dietary Department sections of the policy: In the event of a water outage the facility will provide non-potable water for basic operations. The facility has a 200 gallon container for disbursement of water to Environmental Services and for nursing bathing functions. All non-potable water will be distributed through the Maintenance department. Water will be provided by (food service company) in the event the emergency lasts longer than 3 days. Review of this policy revealed that the document did not include a protocol for distributing water to the residents in the case of an emergency that may continue for any length of time. When interviewed on 3/19/2015 at 8:15 a.m. about how the facility would remove the outside water and how they would distribute the water in the case of an emergency, the Administrator stated that the facility would need to utilize buckets to remove the water from the outside 200 gallon tank. However, he added that they would have to purchase more buckets to provide water to each floor in the case of an emergency because they did not have enough buckets on hand. The Administrator confirmed that the facility did not have any written documentation relative to how they would distribute potable and non-potable water in the case of an emergency. | 2018-03-01 |
| 7396 | 7396 | A.G. RHODES HOME WESLEY WOODS | 115002 | 1819 CLIFTON ROAD, N.E. | ATLANTA | GA | 30329 | 2017-01-25 | 223 | G | 1 | 0 | HX8G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of policy and procedure and interview, the facility failed to ensure that one of three sampled residents (R) (R#1) was free from abuse. Specifically, actual harm was identified on 12/26/16 when R#1, a resident with advanced dementia and [MEDICAL CONDITION], was mistreated in the form of physical abuse, mental abuse, intimidation and corporal punishment when a Certified Nursing Assistant (CNA) FF pulled the resident backward in his wheelchair from the back of his collar and back of his shirt. R#1 would not respond to interview questions however, a telephone interview with the Family on 1/25/17 at 3:55 p.m. revealed she recalled one evening that a nurse called to report she was having problems giving R#1 his medication and reported he seemed more agitated than usual. The Family stated she talked to R#1 on this occasion on the telephone and he told her someone is pushing me around and being mean to me. A post survey interview during the Quality Assurance (QA) process, with the DON on 1/30/17 at 2:15 p.m. revealed a review of the facility video surveillance confirmed the abuse and she could actually see the shirt pressing against the resident's neck as he was being pulled backward in his wheelchair. This incident was entity reported to the State Agency on 1/12/17 (GA 510). Findings include: Review of the facility's undated policy titled Abuse Prevention Policy and Procedures documented: It is the intent of this facility to actively preserve each resident's right to be free from mistreatment, neglect, abuse, exploitation or misappropriation of resident property. We believe each resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion. This policy applies to anyone subjecting a resident to abuse including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the individual, family members o… | 2017-04-01 |
| 8126 | 8126 | A.G. RHODES HOME WESLEY WOODS | 115002 | 1819 CLIFTON ROAD, N.E. | ATLANTA | GA | 30329 | 2012-01-11 | 281 | D | 0 | 1 | Z8U311 | Based on observation, review of the facility policy for filing grievances and resident and staff interviews the facility failed to follow their policy of reporting grievances for one resident (1) (A) from a sample of thirty-two (32) residents. Findings include: Interview with resident A on 01/09/12 at 1:07 p.m. revealed that a staff member had been rude to her about two (2) weeks ago. The staff member had stood over the resident, spoken to her rudely, with her hands on her hips and pointed her finger in the resident's face. The resident reported the incident to the evening/night supervisor who had come to her room and taken her statement. Review of the facility policy for filing grievances revealed that to initiate a grievance and/or complaint the resident, guardian, or representative must submit an oral or written complaint to the Administrator or Director of Social Services. In the event of an oral complaint, the substance of the issue will be promptly reduced in written form for a prompt investigation. The administrator delegated the responsibility of grievance and/or complaint investigation to the social services department. Interview with the Social Worker AA on 01/11/12 at 11:59 a.m. revealed that she did not have any complaint/grievance report regarding any staff member being rude but that the unit manager might have it. Interview with the Licensed Practical Nurse (LPN) Unit Manager 3 BB on 01/11/12 at 1:43 p.m. revealed that she was not aware of this situation and had no documentation regarding this situation. Continued interview revealed that the resident could have reported this to any one (1) of three (3) people but that all reports are not necessarily written down if they can be handled and taken care of immediately, however, this one should have been documented. Interview with the Director of Nurses (DON) on 01/11/12 at 2:12 p.m. revealed that the evening/night supervisor is very good at documenting incidences that occur but sometimes the matters are taken care of rather quickly and are not placed on… | 2016-06-01 |
| 8127 | 8127 | A.G. RHODES HOME WESLEY WOODS | 115002 | 1819 CLIFTON ROAD, N.E. | ATLANTA | GA | 30329 | 2012-01-11 | 431 | D | 0 | 1 | Z8U311 | Based on observation, review of the facility policy for medication storage and staff interview the facility failed to secure medications in a locked area for one (1) of six (6) medication rooms. Findings include: Observation on 01/09/12 at 8:34 a.m., during initial tour, revealed that the medication storage room door was opened and unlocked on the third (3rd) Floor. There were no licensed personnel in the nurses station but there were residents and unlicensed personnel in the hallway. Interview on 1/09/12 at 8:40 a.m. with Licensed Practical Nurse (LPN) BB revealed that the door to the medication room should be locked at all times. A second interview with LPN BB at 1:04 p.m. revealed that there was a problem with the medication room door and that it had to be slammed in to order to be secured. Review of the facility Policy revealed that medications and biologicals are stored safely, securely and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel and pharmacy personnel. | 2016-06-01 |
| 9689 | 9689 | A.G. RHODES HOME WESLEY WOODS | 115002 | 1819 CLIFTON ROAD, N.E. | ATLANTA | GA | 30329 | 2010-04-21 | 441 | D | 0 | 1 | 9TT311 | Based on observation and staff interview, the facility failed to ensure that staff washed hands appropriately for one (1) resident (#2), of a sample of twenty-four (24) residents. Findings include: Observation on 04/20/10 at 12:20 p.m. revealed two (2) Certified Nursing Assistants (CNAs) providing incontinence care for resident #2 who had been incontinent of urine and stool. After incontinence care was completed CNA "CC" removed her soiled gloves, gathered a bag of soiled linens including towels and wash cloths, gathered a bag of contaminated gloves and took both bags outside to the soiled linen and trash hampers (both attached to one cart). Continued observation revealed that the CNA returned to the resident's room, arranged the resident's top covers on the bed and placed the call button in reach without washing her hands. CNA "EE" assisted CNA "CC" with care and after care had been completed, removed her gloves, assisted in positioning the resident in bed, pulled up the bed covers without washing her hands. Interviews with CNAs "CC" and "EE" on 04/20/10 at 12:45 p.m. revealed that they should have washed their hands. Interview on 4/21/10 at 2:30 p.m. with the Director of Nurses revealed that whenever you touch dirty, the hands need to be washed before touching the resident again. | 2015-05-01 |
| 9690 | 9690 | A.G. RHODES HOME WESLEY WOODS | 115002 | 1819 CLIFTON ROAD, N.E. | ATLANTA | GA | 30329 | 2010-04-21 | 253 | C | 0 | 1 | 9TT311 | Based on observation and staff interview, the facility failed to provide housekeeping services necessary to maintain a clean and sanitary environment for six (6) of six (6) halls. Findings include: Observation during intial tour on 04/19/10 and during environmental tour on 04/20/10 at 1:00 P.M. with the Plant Manager and the Housekeeping Supervisor revealed that there were dusty ceiling vents in the Interview on 4/20/10 at 1:00 p.m. with the Plant Manager and Housekeeping Supervisor revealed that the vents were dusty. | 2015-05-01 |
| 9691 | 9691 | A.G. RHODES HOME WESLEY WOODS | 115002 | 1819 CLIFTON ROAD, N.E. | ATLANTA | GA | 30329 | 2010-04-21 | 241 | D | 0 | 1 | 9TT311 | Based on observations and staff interview, the facility failed to provide a dignified dining experience and failed to promote an environment that enhanced the dignity of two (2) residents (#14 and #17) from a sample of twenty four (24) residents and two (2) randomly observed residents. Findings include: 1. Observation on 4/20/10 at 8:33 a.m. revealed resident #14 seated in the 200 South Hall dining room for breakfast being fed by staff. Continued observation revealed that the staff member, feeding resident #14, was having a conversation with another staff member across the room, who was feeding two (2) residents, instead of interacting with the residents they were feeding. 2. Observation at 1:10 pm on 4/20/2010 of the 200 South hallway revealed a staff member yelling out two (2) resident names to a staff member down the corridor. Anyone in the area could hear the resident's names. Interview on 4/21/2010 at 2:00 pm with Licensed Practical Nurse (LPN) "AA" Unit Manager for the 200 Floor revealed that the staff are expected to give full attention to each resident while feeding or care is being provided. Continued interview revealed that the staff had been inserviced on interaction with the resident. 3. Observation on 04/21/10 beginning at 8:15 a.m. revealed resident #17 being fed by LPN "FF" in the 200 South Hall dining room. The resident exhibited behaviors including being verbally and physically abusive to the staff, refusing to eat her breakfast, and pouring liquids onto the floor. Two staff persons feeding residents and the nurse all laughed at the resident's behavior. Interview with LPN "AA" on 04/21/10 at 8:55 a.m. revealed that these behaviors are frequent for this resident and that staff laughing at the resident could be considered a dignity concern. | 2015-05-01 |
| 8 | 8 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2019-01-25 | 584 | D | 0 | 1 | 4HRK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and review of facility documents the facility failed to maintain a safe/clean/comfortable homelike environment for the residents in six rooms (out of 24 rooms) on one unit (out of five). Specifically, six rooms on Unit 300 had significant areas of bare walls where the paint had been scratched, scuffed or peeled off. The documents reviewed included the Daily Housekeeping Room Checklist, Housekeeping Review, Work Order Logs and the Call In Work Orders listing. Findings include: A tour of Unit 300 was conducted with the Maintenance Director (MD) beginning on 1/25/19 at 10:35 a.m. The following areas were confirmed with the MD including: room [ROOM NUMBER]: Multiple areas on one of four walls where paint is scuffed, scratched and peeling, missing; room [ROOM NUMBER]-A: Multiple areas on the wall behind the head of the bed where paint is missing; room [ROOM NUMBER]-A: Multiple areas on the wall behind the head of the bed where paint is missing; room [ROOM NUMBER]: A line of multiple scratched, scuffed areas where paint is missing approximately four feet from floor (waist high) on two of four walls; room [ROOM NUMBER]: Multiple areas on one of four walls where paint is scuffed, scratched and peeling, missing above the cove base; room [ROOM NUMBER]: An area on the entry wall five feet in length approximately three feet from floor (waist high) where paint is missing, scratched, scuffed. During an interview conducted on 1/25/19 at 9:57 a.m. with Maintenance Tech CC revealed that he receives work orders from the maintenance office to complete specific painting tasks. He could not confirm if there was any type of regular scheduled inspection of the rooms for routine maintenance. An interview with the Administrator was conducted on 1/25/19 at 10:15 a.m. revealed that the facility is currently undergoing a renovation by unit. She could not confirm when Unit 300 was scheduled for renovation but stated that even though they… | 2020-09-01 |
| 9 | 9 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2019-01-25 | 656 | D | 0 | 1 | 4HRK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to follow the care plan related to administering medications as ordered for one Resident (R) (R#114). The sample size was 49 residents. Findings include: Review of the medical record revealed that R# 114 had the [DIAGNOSES REDACTED]. Record review revealed a care plan for the potential for medication side effects related to [MEDICAL CONDITION] medication. This care plan documented an intervention to administer medications as ordered. Further record review revealed a Physician order, with a start date of (MONTH) 1, (YEAR), for [MEDICATION NAME] 0.25 milligrams (mg) to take one tablet twice daily as needed (prn) for 60 days for agitation. Review of the Medication Administration Record [REDACTED]. Interview on 1/24/19 at 9:40 a.m. with Licensed Practical Nurse (LPN) II confirmed that the PRN [MEDICATION NAME] 0.25 mg order was started in (MONTH) (YEAR) and should have ended (MONTH) 1, 2019. Interview with the Registered Nurse (RN) Unit Manager on 1/24/19 at 9:45 a.m. revealed that they typically get a report from the pharmacy when a medication needs to be stopped and the pharmacy consultant sends a monthly report. The Unit Manager revealed that a report had been received from the pharmacy consultant on 1/22/19, but she had not reviewed or followed up on the recommendations yet. | 2020-09-01 |
| 10 | 10 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2019-01-25 | 657 | D | 0 | 1 | 4HRK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of the facility policy titled Comprehensive Person -Centered, the facility failed to update and revise a comprehensive care plan to reflect the vascular site and monitoring of the site for one resident out of five sampled residents (R#133) receiving [MEDICAL TREATMENT] services. Findings include: Record review of policy titled Care Plans Comprehensive Person-Centered stated It is the intent of Magnolia Manor facilities to develop and implement a person-centered plan of care for each resident that include goals for admission, discharge and desired outcomes. 3. (B) Incorporate risk factors (s) associated with the identified problems(s). (D) reflect treatment goals and objectives in measurable goals. B. Reflect the resident's specified goals for admission and desired outcomes. B. Reflect the resident's specified goals for admission and desired outcomes. F. Enhance the optimal functioning of the resident utilizing rehabilitative program as indicated. (5). Care plan are revised as changes in the resident's condition dictates. Reviews are made at least quarterly. The resident has the right to participate in the process and to approve any changes to the plan of care. Record review revealed that R#133 had a Physician order dated 8/20/18 for an AV Fistula (ateriovenous fistula) shunt and attended [MEDICAL TREATMENT] two days a week on Monday and Friday. The Minimum Data Set ((MDS) dated [DATE] section C revealed a Brief Interview Mental Status (BIMS) score of 15 (a score of 15 out of 15 indicates cognitive intact) and a section O revealed a coding for [MEDICAL TREATMENT]. Review of [MEDICAL TREATMENT] care plan dated 10/16/18 (last reviewed on 1/2/19) revealed that there was not any interventions in place to monitor the vascular site or checking the site for bruit and thrill. Interview on 1/24/19 at 3:24 a.m., with the Director of Nursing (DON) revealed that staff should check every shift for bruit a… | 2020-09-01 |
| 11 | 11 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2019-01-25 | 758 | D | 0 | 1 | 4HRK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to assure that PRN (as needed) medications were taken as ordered for one Resident (R) #114. The sample size was 49 residents. Findings include: Review of the medical record revealed that R#114 had the following [DIAGNOSES REDACTED]. Record review of the chart revealed an order, with a start date of (MONTH) 1, (YEAR), for [MEDICATION NAME] 0.25 milligrams (mg) with one tablet taken by mouth twice daily as needed for 60 days for agitation. Review of the Medication Administration Record [REDACTED]. Interview on 1/24/19 at 9:40 a.m. with Licensed Practical Nurse (LPN) II confirmed that the [MEDICATION NAME] PRN order started in (MONTH) and should have ended (MONTH) 1, 2019. It was reported that typically orders on the rehab unit are not written this way and that the pharmacy notifies when there is a hard stop on an order. Interview with the Registered Nurse (RN) Unit Manager JJ on 1/24/19 at 9:45 a.m. revealed that she had received a report from the pharmacy consultant on Tuesday but she had not reviewed or followed up on the recommendations yet. | 2020-09-01 |
| 12 | 12 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2017-01-26 | 280 | D | 0 | 1 | DVCB11 | Based on staff interview and record review, it was determined that the facility failed to revise a plan of care to include a pressure ulcer for one resident (#194) from a total sample of 22 residents. Findings include: A review of Resident (R) #194's clinical record revealed the resident had a stage two pressure ulcer to the left elbow since 10/31/16. During an interview on 1/24/17 at 10:12 a.m., Licensed Practical Nurse (LPN) AA confirmed the resident had a stage two pressure ulcer to the left elbow, identified on 10/31/16. There was a plan of care in place, dated 10/26/16, that R#194 was at risk for pressure areas related to incontinence and decreased mobility. Although interventions were implemented to address the pressure ulcer, the plan of care was not revised to include the presence of the pressure ulcer to the left elbow, until 1/25/17, after surveyor inquiry. During an interview on 1/26/17 at 1:49 p.m., Registered Nurse (RN) BB confirmed that the plan of care had not been revised and stated it was an oversight. | 2020-09-01 |
| 13 | 13 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2018-02-01 | 761 | D | 0 | 1 | 0R9911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the Medication Administration Procedural Guidelines and interviews the facility failed to ensure that the medication cart was locked during medication administration on one of four medication carts observed during medication administration. Findings include: Observation on 01/31/18 at 4:42 p.m. during Medication Administration with Licensed Practical Nurse (LPN) LPN AA on Unit 1 medication cart. revealed that LPN AA parked the medication cart outside along the opposite wall from room [ROOM NUMBER] on Unit 1 and at 4:21 p.m. and returned to the medication cart to remove medications to administer to the other resident in room, 125 A bed. At 4:24 p.m. LPN AA was observed to remov medications from the cart that was against the wall on the other side of the hall on Unit 1 that was not in direct view of the nurse in the residents room [ROOM NUMBER] [NAME] LPN AA then left the medication cart unlocked going into room [ROOM NUMBER] A leaving the door open however, the LPN's back was to the medication cart the entire time she was in the room. LPN AA then came out of the room and called for assistance to help reposition the resident in the bed, not realizing that the medication cart remained unlocked. LPN AA then went back into room [ROOM NUMBER] A continuing to leave the medication cart unlocked. After repositioning the resident with assistance and administering the residents medication the surveyor observed by standing right out side of residents door. LPN AA came out of the room at 4:35 p.m. Interview with the LPN AA, at this time revealed that she had not received any training here at the facility and did not have a preceptor here before starting on the floor, LPN AA also reported she was an agency nurse and started on the medication cart two months ago and comes two times a week. Interview on 2/1/18 at 11:00 a.m. with the Director of nursing reported that the licensed nursing staff do a skills check off list and Lif… | 2020-09-01 |
| 14 | 14 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2018-02-01 | 812 | E | 0 | 1 | 0R9911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and review of the facility's policy for food and nutrition the facility failed to maintain sanitary resident nourishment refrigerators in unit pantries, failed to store food items properly in resident nourishment refrigerator and failed to dispose of expired food items in a timely manner in resident nourishment pantry on three of five units. Findings include: Observation on [DATE] at 8:14 a.m. of resident nourishment pantry on Unit 3 revealed thickened sweet tea dated as expired on [DATE]. Confirmed as expired by Licensed Practical Nurse (LPN) A[NAME] Observation on [DATE] at 9:39 a.m. of resident nourishment pantry on Unit 1 revealed five cartons of Impact Advanced Reconstituted Nutritional Drink dated expired [DATE]. Confirmed by Registered Nurse (RN) BB as expired. Observation on [DATE] at 9:44 a.m. of resident nourishment refrigerator in the pantry on Unit 5 revealed two unlabeled/undated frozen food items in a take-out container in the freezer. Confirmed by LPN CC. LPN CC stated that the food items that were in the freezer had been brought in for a resident but she was unsure for which resident or when they were brought in. Observation on [DATE] at 9:55 a.m. of resident nourishment refrigerator in the pantry on Unit 4 revealed a large spill of brown liquid in the bottom of the refrigerator. Observation also revealed that the refrigerator contained the following an unlabeled/ undated open coke can, covered loosely by a paper towel, an open unlabeled/undated two- liter grape [MEDICATION NAME] beverage, an unlabeled/undated personal cup, a plate of food with staff signature of SH, LPN and dated [DATE]. The previously listed food items were intermingled with resident nourishment items. A separate employee refrigerator was provided for employee food and was labeled employee. LPN DD confirmed the previous findings. Interview with LPN DD revealed that all staff were responsible for upkeep of the resident nourishm… | 2020-09-01 |
| 15 | 15 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2019-06-07 | 656 | D | 1 | 0 | 2RIR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure that medication for pain was administered for one of 12 residents(A) and failed to provide wound care for one of 12 residents (B) as care planned. Findings include: 1. During interviews on 6/3/19 at 12:00 p.m. and 6/4/19 at 1:50 p.m. Resident (R) A stated that nursing staff waits until her pain medication runs out to order more. Record review revealed that RA had a care plan since 2/819 for being at risk for alteration in comfort related to [MEDICAL CONDITION] reflux disease, generalized pain and skin alteration. The care plan included an intervention for licensed nursing staff to administer medication as ordered. Further record review revealed that there was a physician's orders [REDACTED]. There was also a physician's orders [REDACTED]. However, a review of the clinical record revealed that the resident did not receive the scheduled [MEDICATION NAME] pain medication as ordered and as care planned on 4/23/19 at 12:00 p.m. and 6:00 p.m. Record revealed that on 5/24/19 a physician's orders [REDACTED]. The resident received [MEDICATION NAME] as scheduled through the 5/24/19 6:00 p.m. dose. The [MEDICATION NAME] 10-325mg was then administered routinely afterward until the supply on hand was exhausted on 5/29/19 at 6:00 p.m. Therefore, the resident did not receive the scheduled [MEDICATION NAME] pain medication as ordered and as care planned on 5/30/19 at 12:00 a.m., 6:00 a.m., 12:00 p.m. and 6:00 p.m. Cross refer to F697 2. Record review revealed that RB had a care plan problem, dated 4/2/19, for receiving treatment with an antibiotic for bilateral [MEDICAL CONDITION]. The care plan problem was updated on 4/29/19 to include the use of an intravenous antibiotic and an intervention for nursing staff to provide wound care as ordered. A review of the clinical record revealed a physician's orders [REDACTED]. This treatment was ordered to treat venous wounds to the right and left la… | 2020-09-01 |
| 16 | 16 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2019-06-07 | 684 | D | 1 | 0 | 2RIR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure that wound treatments were provided as ordered by the physician for one of 12 residents (R B). Findings include: Record review revealed that Resident (R) B had [DIAGNOSES REDACTED]. During an interview on 6/5/19 at 3:45 p.m. R B stated that Treatment Nurse DD had applied a silver alginate dressing to her legs and she was not supposed to. A review of the clinical record revealed a physician's orders [REDACTED]. This treatment was ordered to treat venous wounds to the right and left lateral calves. During an interviews on 6/6/19 at 4:00 p.m. and 6/7/19 at 10:45 a.m., with Treatment Nurse DD confirmed that she had applied [MEDICATION NAME] Ag, which contains silver, to the open areas on the resident's lower extremities, one day prior to a visit to the wound clinic in (MONTH) 2019, to try something different to help the resident because she was upset about her legs. Treatment nurse DD confirmed that she did not obtain a physician's orders [REDACTED]. A review of wound clinic notes dared 5/10/19 confirmed that RB reported the use of silver dressings to her lower extremity wounds. During an interview on 6/7/19 at 12:55 a.m., with the Director of Nursing (DON) revealed that she expected licensed nursing staff to obtain a physician's orders [REDACTED]. | 2020-09-01 |
| 17 | 17 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2019-06-07 | 697 | D | 1 | 0 | 2RIR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review, and review of the facility policy titled, Obtaining and Receiving Medications from Pharmacy the facility failed to ensure the medication for pain was obtained timely for one of 12 residents (R A). Findings include: The facility had an Obtaining and Receiving Medications from Pharmacy policy. The policy documented that medications that must be reordered by the nurse included controlled substance medications. The policy further documented that Schedule II medications such as [MEDICATION NAME] and [MEDICATION NAME] products required a signed prescription by the physician and should be reordered at least seven days in advance. During interviews on 6/3/19 at 12:00 p.m. and 6/4/19 at 1:50 p.m. Resident (R) A stated that nursing staff waited until her pain medication ran out to order more. Record review revealed that RA had a care plan since 2/8/19 for being at risk for alteration in comfort related to [MEDICAL CONDITION] reflux disease, generalized pain and skin alteration with an intervention for licensed nursing staff to administer medication as ordered. Further record review revealed a Physician's order since 2/15/19 for [MEDICATION NAME] 10-325 milligrams (mg) to be administered every six hours for pain. There was also a physician's order since 2/13/19 for [MEDICATION NAME] 10-325 mg to be administered every six hours as needed for pain. However, a review of the clinical record revealed that the resident did not receive the scheduled [MEDICATION NAME] pain medication as ordered and as care planned on 4/23/19 at 12:00 p.m. and 6:00 p.m. On 4/23/19 a Physician's order was obtained to 1) Hold [MEDICATION NAME] 10-325 mg every six hours and resume when it was available. 2) Administer [MEDICATION NAME] 10-325 mg every six hours, scheduled and discontinue when the [MEDICATION NAME] became available. 3) Keep the order for [MEDICATION NAME] 10-325 mg every six hours as needed for pain. A review of the (MONTH) 2019 M… | 2020-09-01 |
| 4602 | 4602 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2016-08-16 | 282 | D | 1 | 0 | 60V711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record reviews, it was determined that the facility failed to ensure that plans of care for the administration of medications for blood pressure (BP) were followed for two (2) residents (#4 and #5) from a total sample of eight (8) residents. Findings include: 1. Resident #4 had a 9-30-15 plan of care for increased risk for fluctuation in blood pressure (BP) due to Hypertension with an approach of medication as ordered. The facility failed to administer an as needed BP medication ([MEDICATION NAME]) for this resident in the month of (MONTH) (YEAR). See additional information for resident #4 at F309. 2. Resident #5 had a 12-16-15 plan of care for resident has [DIAGNOSES REDACTED]. The facility failed to administer an as needed BP medication ([MEDICATION NAME]) for this resident in the months of (MONTH) (YEAR) and (MONTH) (YEAR). See additional information for resident #5 at F309. | 2019-08-01 |
| 4603 | 4603 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2016-08-16 | 309 | D | 1 | 0 | 60V711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record reviews, review of the facility's Pharmacy Procedural Guidelines number 26 and staff interviews, it was determined that the facility had failed to ensure that physicians' orders were followed for administration of an as needed (prn) blood pressure (BP) medication ([MEDICATION NAME]) for three (3) residents (#1, #4 and #5) from four (4) residents reviewed with orders for a prn BP medication, from a total sample of eight (8) residents. Findings include: Review of the facility's Pharmacy Procedural Guidelines number 26, revealed the following: In addition to documenting administration of the drug on the front of the patient's Medication Administration Record (MAR), whenever medications are given on a prn basis, the nurse administering the dose is responsible for entering all of the following information on the reverse side of the patient's MAR. A. The date, time, medication, dose, route of administration, and if appropriate, the injection site; B. The patient's complaint or the symptoms for which the drug was given; C. The observed results achieved from giving the dose; D. The date, nurse's signature and title. 1. Resident #1 wad admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She had physician's orders [REDACTED].) daily, [MEDICATION NAME] 80 mg. daily, [MEDICATION NAME] 10 mg. daily and [MEDICATION NAME] 100 mg. every (q) eight (8) hours. Review of the MAR for (MONTH) (YEAR) revealed all of these routine medications given as ordered. She was discharged (death) from the facility on 7-23-16. According to the Nurses Notes (NN) of 7-11-16 at 5:30 p.m., it was documented that the physician called about resident's BP elevated 207/89. New orders received and resident informed of new orders. These new orders were: BP systolic greater than (>) 180 to give 0.2 [MEDICATION NAME] prn and BP diastolic >100 to give 0.2 mg. [MEDICATION NAME] prn. There was a clarification order for the prn [MEDICATION NAME] 0.2 mg. on 7-13-16 … | 2019-08-01 |
| 4920 | 4920 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2015-05-21 | 157 | D | 0 | 1 | 334911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review the facility failed to timely notify one (1) resident's (#183) responsible party, of a change in condition, from a total sample of thirty five (35) residents. Findings include: Resident #183 had [DIAGNOSES REDACTED]. A review of the resident's clinical record revealed the resident had a chronic problem of poor appetite. On 3/6/15, a nurse's note entry documented the resident was pocketing food and would not swallow. The resident's primary physician was notified on 3/6/15 and new orders were obtained for a urinalysis and culture and sensitivity to be obtained and a speech therapy screen was requested on 3/6/15. The facility did identified the resident's change in condition and notified the physician promptly, there was no evidence the resident's responsible party was notified of the change in condition that started on 3/6/15 until two (2) days later, on 3/8/15. On 3/8/15 a nurse's note entry documented the resident's responsible party visited the resident, noticed a change in the resident, and was then notified of the new occurrence of pocketing of food. The Director of Nursing confirmed during an interview on 5/21/15 at 3:45 p.m., there was no evidence in the clinical record that the resident's responsible party was notified the resident's change in condition that started on 3/6/15, until 3/8/15. | 2019-03-01 |
| 4921 | 4921 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2015-05-21 | 323 | E | 0 | 1 | 334911 | Surveyor: S. Renee Allan Based upon observation and staff interviews the facility failed to ensure that toilet seats were secure in eleven (11) resident rooms on three (3) of five (5) halls. Census was forty (40). Findings include: Observation during facility tour, being on 5/20/15 at 8:40 a.m. revealed that residents bathrooms in room 131 and 144, on Hall A, and residents bathrooms in rooms 315, 321/323 (shared), 340, and 342 on Hall C and residents bathroom 411, 420, 434, and 441 on Hall D were noted to have raised toilet seats with attached plastic handles that were not securely affixed to the toilet bowl and could be manually moved 3-5 inches off either side of the toilet bowl resulting in unsafe resident seating. Resident bathrooms 415 and 420 on Hall D were noted to have regular toilet seats that were not securely affixed to the toilet bowl and could be manually moved 2-3 inches off either side of the toilet bowl resulting in unsafe resident seating. Additional observations during facility tour on 5/20/2015 at 8:40 a.m. The grab bar in room #345 was located to the right side of the toilet and the mounting screws holding the bar to the ceramic service were observed protruding from the bracket by approximately 1/3 inch. The grab bar was unstable and moveable. The grab bar in room 440 was in front of the toilet and could be shifted up or down on the mounting brackets by approximately one inch. Areas of concern were observed during an interview on 5/20/2015 at 2:40 p.m. with the Maintenance Director and the Assistant Director of Administration who agree that the areas needed to be repaired or replaced. | 2019-03-01 |
| 4922 | 4922 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2015-05-21 | 431 | D | 0 | 1 | 334911 | Based on observation and interviews, it was determined the facility failed to ensure that medications were labeled correctly and expired medications were disposed of timely on one (1) of five (5) units. Findings include: During an observation on 5/21/15 at 1:25 p.m. with Registered Nurse LL, an unopened two pack box of EpiPens was observed in one (1) of the three (3)medications carts on Unit 5. The box of EpiPens had an expiration date of Jan (YEAR). Registered Nurse LL confirmed during the observation, the medication had expired and removed it from the medication cart. | 2019-03-01 |
| 5702 | 5702 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2015-06-09 | 253 | E | 1 | 0 | SYB211 | Based on staff interviews, observations, family interview, information provided by the family member and review of the facility's admission packet to residents or their families, it was determined that the facility had failed to ensure that for one (1) resident (#A ), his/her nightstand was free from food debris/spills and clutter and and failed to ensure for three (3) residents (#A, #B and #3), that food items were stored properly, from a sample of six (6) residents. Findings include: Staff interview with the housekeeping supervisor on 6-9-15 at 2:45 p.m. revealed that one of the housekeepers' weekly duties was to, with a certified nursing assistant (CNA) present, to check each residents' dresser drawers and nightstands for spills and clutter and to clean them. Also, a review of a portion of the facility's admission information to each resident or their responsible parties revealed that food items were to be stored in a container with a lid The facility failed to do both for this resident as evidenced by the following. A telephone interview with the family member on 6-9-15 at 2:18 p.m. revealed that he/she had gone to the facility around 4:30 p.m. on 5-31-15, to get resident A's belongings out of his/her room. The family member stated that when he/she opened the nightstand drawers he/she had observed the following. There were suckers with a hole on the outside of the wrapper, loose pieces of Gold Fish crackers, loose chocolate chip cookies and loose pieces of potato chips, and also large amounts of mice droppings in all three drawers of the nightstand. He/she also noted a tissue box, with a hole underneath it, where the mice had chewed through it. Review of evidence (pictures) of 5-31-15 of the inside of the three drawers of this resident's nightstand revealed that there were loose food items, such as loose Goldfish crackers, uneaten cookies, suckers and strings of beads. There were also evidence of mice droppings in all three of these nightstand drawers. Also, an interview with the alert roommate (B) of residen… | 2018-05-01 |
| 5703 | 5703 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2015-06-09 | 280 | D | 1 | 0 | SYB211 | Based on staff interviews and record reviews, it was determined that the facility had failed to ensure that a plan of care was written with interventions to address one (1) resident's (A) history of taking uneaten food into his/her room, from a sample of six (6) residents. Findings include: On 6-9-15, at 5:57 p.m., and interview with Certified Nursing Assistant (CNA) CC, who routinely had worked with resident A, revealed that he/she would take uneaten food into the room. CNA CC stated that if, he/she found uneaten food in this resident's room, he/she would throw it away. Review of the resident's plan of care revealed that problem onset dates were 12/10/14, with a most recent review of 3/4/15 by the interdisciplinary team. There was no problem written with a goal or interventions to address the resident's history of taking uneaten food into the room. | 2018-05-01 |
| 5704 | 5704 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2015-06-09 | 441 | E | 1 | 0 | SYB211 | Based on observations, staff interviews and review of the facility's admission packet, it was determined that the facility had failed to properly clean/sanitize one resident's (A) environment to prevent spread of infection and had failed to store food items in a way to prevent contamination of these food items for three residents (A, B and 3) from a sample of six (6) residents. Findings include: Staff interview with the housekeeping supervisor on 6-9-15 at 2:45 p.m. revealed that one of the housekeepers' weekly duties was to, with a certified nursing assistant (CNA) present to check each residents' dresser drawers and nightstands for spills and clutter and to clean them. Also, a review of a portion of the facility's admission information to each resident or their responsible parties revealed that food items were to be stored in a container with a lid The facility failed to do both for this resident as evidenced by the following. Phone interview with the family member on 6-9-15 at 2:18 p.m. revealed that he/she had gone to the facility around 4:30 p.m. on 5-31-15, to get resident A's belongings out of his/her room. The family member stated that when he/she opened the nightstand drawers he/she had observed the following. There were suckers with a hole on the outside of the wrapper, loose pieces of Gold Fish crackers, loose chocolate chip cookies and loose pieces of potato chips, and also large amounts of mice droppings in all three drawers of the nightstand. He/she also noted a tissue box, with a hole underneath it, where the mice had chewed through it. Review of evidence (pictures) of 5-31-15 of the inside of the three (3) drawers of this resident's nightstand revealed that there were loose food items, such as loose Goldfish crackers, uneaten cookies, suckers and strings of beads. There were also evidence of mice droppings in all three of these nightstand drawers. Also, the alert roommate (B) of resident A, stated that he/she had observed mice on the other side of the room. On 6-9-15, at 5:57 p.m., CNA CC, who rou… | 2018-05-01 |
| 6106 | 6106 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2014-04-03 | 246 | D | 0 | 1 | JF3211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to have the easy call light with in reach for one (1) resident (# 54) from a sample of thirty-four (34) residents. Findings include: Record review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE] revealed multiple [DIAGNOSES REDACTED]. Section G-Functional Status revealed the resident is totally dependent on staff for all Activities of Daily Living (ADL) and a Brief Interview for Mental Status (BIMS) score of 14 which indicates Cognitively Intact. An observation on 04/1/2014 at 10:15 a.m. of the resident laying on his back in bed, on a air mattress, while the call light was attached to the privacy curtain which was about four (4) feet away from residents head. An interview with resident, at this time, revealed the resident could not reach the call light. Observations on 4/1/14 at 12:12 p.m., 4/1/14 at 3:30 p.m. and on 4/2/14 at 9:43 a.m. revealed the call light to be attached to the privacy curtain and out of reach of the resident. An interview on 4/2/14 at 12:45 p.m. with Certified Nursing Assistant (CNA) DD confirmed that resident #54 was assessed as total assist with all ADL and dependent upon staff for all aspects of care and confirmed that the resident's call light was attached to the privacy curtain and the resident was unable to utilize the call light in this position. Review of the resident Care Plan dated revised on 1/29/14, revealed the resident as dependent for activities of daily living (ADL's) task performance related to [MEDICAL CONDITION], contractures upper and lower extremities and [MEDICAL CONDITION] and included an intervention for Easy touch call light in bed. | 2018-03-01 |
| 6107 | 6107 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2014-04-03 | 282 | D | 0 | 1 | JF3211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to follow the intervention for resident #54 care plan to ensure an easy call light was available to the resident and located on his on bed for one (1) resident (# 54)of thirty four (34) sampled residents. Findings include; Record review of resident # 54 revealed the Minimum Data Set (MDS)assessment dated [DATE] revealed the resident to have a Brief Interview for Mental Status (BIMS) score of 14 which indicates the resident is Cognitively Intact. An included a [DIAGNOSES REDACTED]. Review of the care plan, updated on 1/29/14, revealed an intervention for an Easy Touch call light in bed and the need for total care to be provided by staff for activities of daily living. An observation on 04/1/2014 at 10:15 a.m. of the resident in his room in bed, revealed the resident was observed laying on his back on a air mattress and the call light is attached to the privacy curtain which is about four (4) feet away from resident's head. Further interview revealed that he knew where the call light was which was clipped on the curtain but that the he could not reach the call light because it was not by his head. The resident revealed that he would holler out to staff when he needed assistance. Observations on 4/1/14 at 12:12 p.m., 4/1/14 at 3:30 p.m. and 4/2/14 at 9:43 a.m. that the call light was attached to the privacy curtain. An interview on 4/2/14 at 12:45 p.m. with Certified Nursing Assistant (CNA) DD revealed that the resident requires total care and can not do anything for himself and confirmed that the call light was attached to the privacy curtain. She has no explanation as to why the call is not on the residents head. cross to 246 | 2018-03-01 |
| 6108 | 6108 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2014-04-03 | 329 | D | 0 | 1 | JF3211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and record review the facility failed to monitor one (1) resident (#57) for the use and potential adverse side effects of a [MEDICAL CONDITION] medication of thirty four (34) sampled residents. Findings include: Review of the resident's Medication Administration Record [REDACTED]. Record review of the resident's physician orders, dated 3/13/14, reveal a new order for Risperdone 0.25 milligram (mg) one (1) daily. Record review of resident #57 physician orders [REDACTED]. A review of the resident's medical record revealed [REDACTED]. During an interview on 4/2/14 at 3:00 p.m. with the 100 hall Registered nurse (RN) manager, revealed that she did not know why the resident had been placed on the medication, she felt that while the resident had been very demented she (RN) did not believe that the resident had any increased hallucinations. During a review of the resident's medical record, including the March 2014 Medication Administration Record [REDACTED]. | 2018-03-01 |
| 6847 | 6847 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2014-09-24 | 323 | D | 1 | 0 | 2O8U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review and review of the facility ' s fall management program the facility failed to provide care to prevent falls for two (2) residents (#3 and #4) from a sample of six (6) residents. Findings include: 1. Record review indicated that Resident #3 was admitted into the facility in January of 2014 and was identified as at risk for falls at that time. Her [DIAGNOSES REDACTED]. Further record review for Resident #3 indicated that she sustained several falls without injury on 4-14, 4-26, 4-30, 5-17, 6-16, 6-25, 6-26, 7-20, 7-26, 8-1, 8-11, 8-13 and 9-20-14. Resident #3 sustained falls with minor injury on four (4) occasions: 4-13-14 at 9:50 p.m. small cut to left side of her head. 6-1-14 at 7:45 a.m. hematoma to the back of her head. 6-16-14 at 3:20 p.m. pink area to forehead. 7-23-14 at 7:45 p.m. laceration to the left outer eye brow. Record review with the unit manager for unit 1 on 9-24-14 at 2:10 pm revealed that the 4-30-14 intervention for physical therapy referral had not been done until 5-14-14. Also, the recommendation of 5-14-14 by skilled therapy for a one-half lap tray to wheelchair had not been added as an intervention to the resident ' s plan of care for at risk for falls, until 8-13-14. She could not provide evidence/documentation that the one-half lap tray had ever been used for the resident from 5-14-14 until 8-13-14. The unit manager stated she did not know why this physical therapy evaluation had been delayed and recommendation had not been followed up on in a timely manner. On 9-22-14 a recommendation was made for physical therapy to evaluate resident #3 for continuous sliding out of wheelchair. 9-24-14 the therapist recommended a pommel cushion in the wheelchair. However, it was not until after surveyor inquiry at 4:20 pm on 9-24-14, that facility staff located a pommel cushion to place under the resident while in the wheelchair. Resident #3 observed on 9-23-14 at 3:10 pm and 4:15 … | 2017-09-01 |
| 7446 | 7446 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2012-07-19 | 328 | D | 0 | 1 | MVG911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of facility policy, and staff interview, it was determined that the facility had failed to properly store three residents' (#30, #89 and room [ROOM NUMBER] A) nebulizer masks from a total of 34 sampled residents and a random observation. Findings include: Review of the facility's policy on Nebulizer Treatment revealed that the nebulizer mask sets were to be stored in a plastic bag. However, it was observed that facility staff were not storing three residents' nebulizer masks in that manner. 1. Resident #30's nebulizer machine was observed on the floor with the uncovered mask being stored in the nebulizer on 7/16/12 at 3:30 p.m., 7/17/12 at 8:35 a.m., and 11:00 a.m. and on 7/18/12 at 9:50 a.m. and 2:00 p.m. 2. Resident #89's nebulizer mask was observed being stored in the nebulizer uncovered next to a urinal on 7/16/12 at 2:00 p.m. and 4:00 p.m., 7/17/12 at 8:55 a.m. and 11:15 a.m. and 7/18/12 at 9:45 a.m. 3. During a random observation of room [ROOM NUMBER] A on 7/16/12 at 3:15 p.m., and on 7/18/12 at 10:00 a.m., the resident's nebulizer mask was uncovered and stored in the dresser drawer. During an interview on 7/19/12 at 10:45 a.m., the Director of Nursing confirmed that those nebulizer masks were improperly stored. | 2017-03-01 |
| 7447 | 7447 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2012-07-19 | 463 | D | 0 | 1 | MVG911 | Based on observation, it was determined that the facility failed to ensure that three rooms had call light buttons for A beds and failed to ensure that three call lights were functioning on one (secured unit-400 Hall) of five halls. Findings include: On 7/17/12 at 10:15 a.m., there were not any buttons on the call light devices in rooms 431A, 441A, and 443A to activate the call light. The call light in room 420 A did not work. Although during an interview at that time, licensed nurse AA stated that the residents in those rooms would not have been able to use the call lights, the call lights would not function at those locations. After surveyor inquiry at that time, facility staff placed call light buttons in rooms 431A, 441A and room 443A and the call light was repaired in room 420A. On 7/18/12 at 9:15 a.m., the call lights in room 443 (A and B) did not work. When it was reported to the Administrator at that time, she had the two residents in that room relocated to another room on the unit. The Administrator stated, at that time, that the company that inspected the facility's call system would be there on 7/19/12 to service the call system. | 2017-03-01 |
| 8598 | 8598 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2012-12-27 | 309 | D | 1 | 0 | UDR711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and observation, the facility failed to ensure that an order was obtained for the treatment of [REDACTED].#3) from a survey sample of eight (8) residents. Findings include: Record review for Resident #3 revealed the December 2012 physician's orders [REDACTED]. A Wound Evaluation Request sheet of 12/10/2012 documented a large, open area on the resident's right lower leg, above the ankle. A notation on this sheet indicated that the treatment nurse (Nurse AA) was notified of this open area on the right lower leg, and that this nurse stated to cover the area with a dry dressing until she could see it. This sheet documented that the physician was notified. A Nurse's Notes entry of 12/10/2012 at 9:00 a.m. documented the discovery of this open area to Resident #3's right lower leg, and noted that a telephone call had been made to the nurse practitioner, with a message left. However, further record review revealed no evidence to indicate that the nurse practitioner/physician returned the telephone call or that a physician's orders [REDACTED]. A Nurse's Notes entry of 12/17/2012 documented that the nurse practitioner had visited, but specifically documented that no new orders were obtained. During an observation of Resident #3 conducted on 12/27/2012 at 4:10 p.m., the resident was noted to have lymph [MEDICAL CONDITION] of both legs, and to have a dressing dated 12/27/2012 on the right lower leg, even though there was no evidence of a physician's orders [REDACTED]. During an interview with Nurse AA conducted on 12/27/2012 at 4:00 p.m., she acknowledged the above. During an interview with the Assistant Director of Nursing conducted on 12/27/2012 at 4:20 p.m., this nurse stated that an order should have been obtained and written for the dressing on the open area on Resident #3's right lower leg. She acknowledged that for any dressing to any open area for any resident, an order should be obtained. | 2015-12-01 |
| 8599 | 8599 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2012-12-27 | 314 | D | 1 | 0 | UDR711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure that the appropriate care was provided to promote healing of existing pressure sores, related to the assessment and monitoring for one (1) resident (#4) with pressure sores, of five (5) sampled residents with pressure sores, and from total survey sample of eight (8) residents. Findings include: Record review for Resident #4 revealed a December 2012 Treatment Record - Wound Assessment sheet which documented that on 12/05/2012, the resident had a Stage IV pressure sore to the sacrum and a Stage III pressure sore to the right heel. This Treatment Record entry documented that the sacral pressure sore measured 10 centimeters (cms.) by 9 cms. by 2.5 cms., with the wound having granulation and slough, moderate serosanguinous drainage, tunneling, and an unattached wound margin with the surrounding skin intact. The right heel pressure sore was documented as measuring 0.8 cm. by 1.2 cm. by 0.1 cm., with the wound having an [MEDICATION NAME] wound base and granulation, light serosanguinous drainage, no tunneling, and an attached wound margin with the surrounding skin intact. A Care Plan entry of 12/05/2012 noted the Stage IV area to the coccyx and the Stage III area to the right heel, with one of the Approaches being to monitor the progress of the wounds and document the progress weekly. A notation adjacent to this Approach indicated to see treatment record. A 12/08/2012 entry on the Treatment Record - Wound Assessment sheet documented that the sacral wound had red/yellow tissue to the base, with the edges of the wound unattached, with tunneling and a moderate amount of serosanguinous drainage noted. This Assessment also documented that the wound to the right heel had reddish/pink tissue to the base and a light amount of serosanguinous drainage, and was soft to touch. A 12/10/2012 entry on the Treatment Record - Wound Assessment documented that a light amount of serosanguinous dra… | 2015-12-01 |
| 9339 | 9339 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2010-09-16 | 508 | D | 0 | 1 | DMXF11 | **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 obtain annual mammograms as ordered for one resident (#4) from a total sample of thirty residents. Findings included: Resident #4 had a physician's orders [REDACTED]. However, review of the resident's medical record revealed [REDACTED]. During an interview on 9/15/10 at 1:45 p.m., the unit supervisor confirmed that the staff had not obtained the mammogram annually since 2007. | 2015-07-01 |
| 9340 | 9340 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2010-09-16 | 504 | D | 0 | 1 | DMXF11 | **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 only obtain laboratory tests that were ordered by the physician for one resident (#2) from a total sample of thirty residents. Findings include: A review of resident #2's medical record revealed nursing staff had obtained a complete metabolic panel (CMP) on 7/30/10 and a basic metabolic panel (BMP) on 8/18/10 for him/her. However, there was not any evidence in the medical record that those laboratory tests were ordered by a physician. During an interview on 9/15/10 at 10:35 a.m., the unit supervisor confirmed that both of those laboratory tests had been erroneously obtained without a physician's orders [REDACTED]. | 2015-07-01 |
| 9341 | 9341 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2010-09-16 | 502 | D | 0 | 1 | DMXF11 | **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 obtain a laboratory test on the date ordered by the attending physician for one resident (#2) from a total sample of thirty residents. Findings include: Resident #2 had a 7/29/10 physician's orders [REDACTED]. However, that laboratory test was not obtained until 9/2/10. During an interview on 9/15/10 at 10:35 a.m., the unit supervisor confirmed that the nursing staff had failed to obtain the laboratory test on 7/30/2010 as ordered by the physician. | 2015-07-01 |
| 9342 | 9342 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2010-09-16 | 315 | D | 0 | 1 | DMXF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, it was determined that the facility failed to provide proper incontinence care for two (#2 and #3) of seven sampled incontinent residents from a total sample of thirty residents. Findings include: 1. During an observation of urinary and bowel incontinence care being provided for resident #2 on 9/15/10 at 10:00 a.m., certified nursing assistant (CNA) "BB" improperly wiped five (5) times from the resident's rectal area (back) to the perineal area(front) with fecal matter on the wash cloth. review of the resident's medical record revealed [REDACTED]. 2. During an observation of urinary incontinence care being provided for resident #3 on 9/15/10 at 2:15 p.m., CNA "CC' squirted liquid Tena body wash into the basin of water. After cleansing the resident, the CNA used the same sudsy water to rinse the resident's skin. The manufacturer's directions on the bottle of Tena were to rinse (the skin) with water after cleansing. | 2015-07-01 |
| 9343 | 9343 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2010-09-16 | 505 | D | 0 | 1 | DMXF11 | **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 promptly notify physician about the critically high laboratory test results for one resident (#5) in a total sample of 30 residents. Findings include: The facility received laboratory test results for resident #5 on 8/27/10 which reported that the resident had a critical high potassium level of 6.7, with 3.5 - 5.3 being the normal range. The report was stamped as having been received by the facility on 8/27/10 (Friday). However, there was no evidence that the physician was notified about the critical high potassium level until 8/31/10 (Tuesday), when, he ordered that another potassium level to be drawn immediately. The potassium level was reported as having been 6.6 at that time. The physician ordered that the resident be given six doses of 30 grams of [MEDICATION NAME] every six hours. During a phone interview on 9/15/10 at 2:30 p.m., the attending physician stated that he would have expected to be called by the facility about critical high laboratory test results even if it was after normal office hours or on the weekend. He said that he would have ordered another potassium level to be drawn to confirm the previous results. He stated that he usually re-orders laboratory tests if elevated potassium levels are reported to verify that it was actually an elevated level. He did not feel that the resident was in serious harm due to the delay in not notifying him until Tuesday. During an interview on 9/16/10 at 11:30 a.m., the Director of Nurses stated that the facility received laboratory test results on the computer in her office. She said that the results were printed each day and then the original was kept for the physician to sign. A copy was taken to unit where the resident was located and placed on his/her chart. The physician was immediately notified about any critical laboratory test results. She stated that the physician came to the facility every… | 2015-07-01 |
| 9344 | 9344 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2010-09-16 | 282 | D | 0 | 1 | DMXF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews with resident and staff and record reviews, it was determined that the facility failed to implement the care plan interventions for one resident with a history of abdominal pain and constipation from a total sample of 30 residents. Findings include: Resident " M" had a care plan since 2/10/10 which identified him/her as being at risk for constipation. The interventions included that the resident should be given 30 cc (cubic centimeters) of Milk of Magnesia ( MOM ) if he/she did not have a bowel movement in three days and then a [MEDICATION NAME] suppository if there were not any results from the MOM after eight hours. Nursing staff documentation on the August Medication Administration Record [REDACTED]. Nursing staff wrote on the back of the MAR indicated [REDACTED]. Nursing staff wrote that the results of the resident having been given MOM were pending. Nursing staff gave the resident another 30 cc of MOM on 8/30/10 at 5:00 p.m. because of not having had a bowel movement for three (3) days. However, according to his/her care plan, nursing staff should have given a [MEDICATION NAME] suppository to the resident. Resident "M " had a care plan dated 8/5/10 that described the resident of having complained about having abdominal pain due to a hernia. There was a intervention that the resident would be given an abdominal belt when one was available. Although there was a 9/11/2010 nurses note that she/he was going to check on the abdominal belt, there was no evidence as of 9/15/2010 that resident had been given one. The facility did not give an abdominal belt to the resident until 9/16/210 after the surveyor's inquiry. See F309 for more information for resident " M". | 2015-07-01 |
| 9345 | 9345 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2010-09-16 | 309 | D | 0 | 1 | DMXF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and staff interviews, it was determined that the facility failed to ensure that TED hose were applied as ordered by the physician for one resident (#2), failed to administer medication as ordered for one resident (#29), failed to provide an abdominal belt as ordered for one resident (#29), and failed to thoroughly assess an open wound for one resident (#17) from a total sample of 30 residents. Findings include: 1. During an interview on 9/16/10 at 10:40 a.m., treatment nurse "GG" said that measurements of non-pressure wounds were done at least weekly. The treatment nurse documented on 6/2/10 that resident #17 had a wound on the bottom of his/her right foot with a red wound base with dry yellow skin surrounding the wound, and a small amount of bloody drainage. Although the staff provided treatment to the wound as ordered by the physician and did weekly assessments of the wound, those assessments did not include any measurements of it. It was observed during wound treatment on 9/16/10 at 9:30 a.m., that the wound on the plantar surface of the resident's right foot at the fifth metatarsal head was approximately 1 inch by 1/4 inch. It had a pink wound bed with minimal serous drainage and a noticeable foul odor. On 9/16/2010 at 10:40 a.m., treatment nurse "GG" explained that measurements had not been taken of resident #17's wound because initially it had been a callous. On 9/16/10 at 10:50 a.m., treatment nurse "LL" said that the wound on the resident's right foot had not been measured because it had been a callous and had been trimmed by the podiatrist. On 9/16/10 at 12:45 p.m., the Director of Nursing (DON) stated that the wound on the resident's right foot had not been measured since originally it had been a callous, but it should have been measured. 2. Resident " M" had a physician's orders [REDACTED]. Nursing staff documented on the August MAR indicated [REDACTED]. The nurse wrote on the back of the MAR i… | 2015-07-01 |
| 9346 | 9346 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2010-09-16 | 328 | E | 0 | 1 | DMXF11 | **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 the humidifier water bottles and/or oxygen tubing were dated for six (6) residents (#1, #6, #17, #29 and 2 random observations of residents) and failed to ensure that oxygen was set at the correct rate for one resident (#17), who received oxygen therapy, from a total sample of 30 residents. Findings include: 1. A review of the medical record revealed that resident #17 had a physician's orders [REDACTED]. However, it was observed on 9/14/10 at 1:00 p.m., 9/15/10 at 1:15 p.m. and on 9/16/10 at 9:30 a.m., that the resident oxygen concentrator had been incorrectly set to a rate of 3 1/2 liters per minute instead of 2 liters a minute. It was observed on 9/14/10 at 1:00 p.m., 9/15/10 at 1:15 p.m. and 9/16/10 at 9:30 a.m., that nursing staff had not dated the humidifier water bottle on the oxygen concentrator for resident #17. 2.. During random observations in room [ROOM NUMBER] on the Initial Tour on 9/14/10 at 10:15 a.m. and on 9/16/10 at 12:55 p.m., it was noted that licensed nursing staff had failed to ensure that the humidifier water bottle and the oxygen tubing on the oxygen concentrator were dated. 3. During a random observation in room [ROOM NUMBER]B on the Initial Tour on 9/14/10 at 10:20 a.m., it was noted that nursing staff had not dated a humidifier water bottle and the oxygen tubing on the oxygen concentrator used for a resident. 4. It was observed on 9/14/10 at 10:20 a.m., 9/15/10 at 4:00 p.m. and 9/16/10 at 8:10 a.m., that nursing staff had not dated the humidifier water bottle on the oxygen concentrator used for resident #29. 5. Observations during the initial tour on 9/14/10 between 10:20 a.m. to 11:50 a.m. and at 1:15 p.m. and 3:20 p.m. revealed that the humidifier water bottle on the oxygen concentrator used for resident #6 had not been dated by nursing staff. 6. It was observed on 9/14/10 at 2:05 p.m., 9/15/10 at 7:47 a.m., 10:55 a… | 2015-07-01 |
| 9692 | 9692 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2012-01-04 | 157 | D | 1 | 0 | F5T911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure that the physician was notified in a timely manner of the need to alter treatment significantly for one (1) resident (#1) from a survey sample of ten (1) residents. Findings include: Closed record review for Resident #1 revealed a Nurse's Notes entry of 07/13/2011 at 1:00 p.m. which documented that the resident had been admitted to the facility with [DIAGNOSES REDACTED]. Record review revealed a 07/13/2011 physician's admission order which specified for Resident #1 to receive [MEDICATION NAME] 5 milligrams (mgs.) daily, and the resident's July 2011 Medication Administration Record [REDACTED]. daily, and the resident's July 2011 MAR indicated [REDACTED] A Nurse's Notes entry of 07/23/2011 at 9:42 p.m. documented that the family member (who was named as the resident's designated legal decision maker per the Durable General Power of Attorney referenced above) had requested that Resident #1 not receive any [MEDICATION NAME] or any [MEDICATION NAME] due to previous adverse reactions the resident had experienced. Further record review revealed no evidence to indicate that facility staff notified the physician at that time of the family member's instruction to not administer [MEDICATION NAME] and [MEDICATION NAME], as ordered. However, the resident's July 2011 MAR indicated [REDACTED]. dose was refused on 07/26/2011, and documented that the [MEDICATION NAME] 5 mg. dose was held on 07/27/2011 at the family member's request. This July 2011 MAR indicated [REDACTED]. The resident's July 2011 MAR indicated [REDACTED]. dose was held on 07/24/2011, and specifically documented that the [MEDICATION NAME] 25 mg. dose was not given on 07/27/2011 per the family member's request. This MAR indicated [REDACTED]. A 07/27/2011, 10:35 p.m. Nurse's Note documented that the family member had again requested that the resident not receive [MEDICATION NAME] or [MEDICATION NAME] due to the resident's… | 2015-05-01 |
| 9693 | 9693 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2012-01-04 | 309 | D | 1 | 0 | F5T911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to administer the medications [MEDICATION NAME] and [MEDICATION NAME] per physician's orders to ensure the continuity of care for one (1) resident (#2) from a survey sample of ten (10) residents. Findings include: Record review for Resident #2 revealed a 12/16/2011 verbal physician's order specifying for the resident to receive [MEDICATION NAME] 10 milligrams (mgs.) at bedtime when available. However, although the resident's December 2011 Medication Administration Record [REDACTED]. at bedtime at 9:00 p.m., further review this MAR indicated [REDACTED]. Additionally, a 01/02/2012 verbal physician's order specified to hold [MEDICATION NAME] 10 milligrams at bedtime until available. Record review for Resident #2 also revealed the resident had been receiving [MEDICATION NAME] 10 mgs. daily. A verbal physician's order of 12/16/2011 specified to discontinue the daily order, and to give [MEDICATION NAME] 10 mgs. by mouth twice a day. However, the resident's December 2011 MAR indicated [REDACTED]. The resident's January 2012 MAR indicated [REDACTED]. Documentation on the reverse sides of these MARs specifically indicated that, for December 2011, twenty (20) doses of the [MEDICATION NAME] had not been administered between 12/17/2011 and 12/31/2011, and for January 2012, three (3) doses of [MEDICATION NAME] had not been administered as ordered, due to the medication needing authorization/prior approval from the physician. A verbal physician's order of 01/02/2012 specified to hold [MEDICATION NAME] 10 mg. twice daily therapy until available. A Nurse's Note of 12/16/2011 at 11:45 a.m. documented that when called, the pharmacist informed nursing staff that both the [MEDICATION NAME] and [MEDICATION NAME] drug therapies referenced above would require prior approval and that the pharmacy would facsimile to the physician's office a prior approval form. Nurse's Notes entries of 12/22/2011 and 12/… | 2015-05-01 |
| 9694 | 9694 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2012-01-04 | 385 | D | 1 | 0 | F5T911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure prompt physician response and follow-up to inquiries regarding the medication drug therapy and medication availability for one (1) resident (#2) on the survey sample of ten (10) residents. Findings include: Please cross refer to F309 for more information regarding Resident #2. Record review for Resident #2 revealed a verbal physician's orders [REDACTED].) patch daily. However, the resident's November 2011 Medication Administration Record [REDACTED]. A Nurse's Notes entry of 11/29/2011 documented that the [MEDICATION NAME] had not been available due to needing prior approval from the physician, and that a nurse at the physician's office had been contacted by the facility's Director of Nursing for clarification. A verbal physician's orders [REDACTED]. Further record review revealed no evidence to indicate that the physician had been contacted by facility staff to obtain additional care instruction prior to 11/29/2011 regarding the resident not receiving the [MEDICATION NAME] as ordered, since the original order date of 11/11/2011.. A Nurse's Notes entry of 11/29/2011 documented that the [MEDICATION NAME] was still not available due to it needing prior approval, per the pharmacist. This Note documented that the necessary forms had been provided by facsimile to the physician's office per the pharmacy, further stating they would facsimile the forms again, which would be the third time. A Nurse's Notes entry of 12/16/2011 at 11:10 a.m. documented when facility staff again placed a telephone call to the pharmacist to inquire about the [MEDICATION NAME]es, the pharmacist stated that the pharmacy was still awaiting prior approval from the physician for this medication. A Nurse's Note of 12/16/2011 at 11:35 a.m. documented that facility staff had received a telephone call from staff at the physician's office stating that prior approval for this medication had been denied to the r… | 2015-05-01 |
| 9695 | 9695 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2012-01-04 | 514 | D | 1 | 0 | F5T911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure that the medical record for one (1) resident (#1) was accurate and complete from a survey sample of ten (10) residents. Findings include: Closed record review for Resident #1 revealed 07/13/2011 discharge orders from the hospital referencing an order for [REDACTED]., but did not include the frequency of administration for this medication. Review of the Medication Administration Record [REDACTED]. Resident #1 had a 07/20/2011 physician's orders [REDACTED]. daily. However, there was no order on the resident's written admission orders [REDACTED]. daily. Record review also revealed that Resident #1 had an order for [REDACTED]. Interview with the Director of Nursing on 12/14/2011 at 5:00 p.m. revealed that the physician had been notified of the resident's low blood pressure on 7/29/2011 at 6:00 p.m., while she was on her way home from work. She stated that she had called the unit charge nurse on Unit Four to write the physician's orders [REDACTED]. twice a day and HCTZ 25 mg. daily) on 07/29/2011, a little after 6:00 p.m. However, there was no documentation in the record that an order had been written to hold the afore mentioned blood pressure medications. Further review of the closed record revealed that the [MEDICATION NAME] 20 had been held for the evening dose on 07/28/2011 and for both morning and evening doses on 07/29/2011, 07/30/2011 and 07/31/2011. The HCTZ 25 mg. had been held on 07/29/2011, 07/30/11 and 07/31/2011. | 2015-05-01 |
| 10335 | 10335 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2011-03-21 | 323 | G | 1 | 0 | S4HQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, Incident/Accident Report review, and staff interview, it was determined that the facility failed to ensure that one (1) resident (#1) received the necessary supervision, and Hoyer lift transfer, as specified by the Care Plan to minimize the risk of a fall for one (1) resident (#1), and failed to use floor mats as specified by the Care Plan to serve as a fall precaution for one (1) resident (#4), from a survey sample of six (6) residents who had been assessed as being at risk for falls. Resident #1 subsequently fell and sustained a fracture of the right leg. Findings include: 1. Clinical record review for Resident #1 revealed a record Face Sheet which documented that the resident had [DIAGNOSES REDACTED]. A Care Plan entry of 02/24/2010 identified the resident to be at risk for falls, with Approaches to address this risk which included to monitor/anticipate/intervene for factors causing falls. A Nurse's Notes entry of 02/01/2011 at 2:50 p.m. documented that the licensed nurse had been called to the resident's room by a nursing assistant and observed the resident to be sitting on the floor in the room. This Note documented that the resident had fallen while being changed, and that the resident complained of right knee pain, with swelling noted to the right knee and thigh. A Nurse's Notes entry of 02/01/2011 at 3:00 p.m. documented that the physician was notified of the resident's condition, and that an order was received to send the resident to the hospital for evaluation. A Nurse's Notes entry of 02/01/2011 at 3:40 p.m. documented that Emergency Medical Services had arrived to transport the resident to the hospital, and a Nurse's Notes entry of 02/01/2011 at 7:00 p.m. documented that the resident had been admitted to the hospital with [REDACTED]. A 02/01/2011 facility Incident/Accident Report which referenced Resident #1's fall documented that Nursing Assistant In Training "AA" had been providing incontinen… | 2014-07-01 |
| 10336 | 10336 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2011-03-21 | 495 | G | 1 | 0 | S4HQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, Incident/Accident Report review, and staff interview, the facility failed to ensure that a nursing assistant had demonstrated competency and had been determined competent in the provision of care before allowing the nursing assistant in training to transfer and provide incontinence care for one (1) resident (#1) from a survey sample of six (6) residents. This failure resulted in actual harm ([MEDICAL CONDITION] leg) for Resident #1. Findings include: Cross refer to F323 for more information regarding Resident #1. Clinical record review for Resident #1 revealed a Care Plan entry of 02/24/2010 which identified the resident to be at risk for falls and included the use of a Hoyer lift for all transfers, as well as to monitor/anticipate/intervene for factors causing falls. A Nurse's Notes entry of 02/01/2011 at 2:50 p.m. documented that the licensed nurse had been called to the resident's room and observed the resident sitting on the floor in the room, after having fallen while being changed. This Note documented that the resident complained of right knee pain, with swelling noted to the right knee and thigh, and that an order was received to send the resident to the hospital for evaluation. A Nurse's Notes entry of 02/01/2011 at 3:40 p.m. documented that the resident was transported to the hospital, and a Nurse's Notes entry of 02/01/2011 at 7:00 p.m. documented that the resident had a [DIAGNOSES REDACTED]. A 02/01/2011 facility Incident/Accident Report which referenced Resident #1's fall documented that Nursing Assistant In Training "AA" had been providing incontinence care to Resident #1 at the sink, but the resident was unable to hold on and Nursing Assistant "AA" thus slid the resident to the floor. This resulted in the resident sustaining a [MEDICAL CONDITION] distal femur. In a written statement dated 02/01/2011, Nursing Assistant In Training "AA" documented that when Resident #1 needed a changed brief, she assisted … | 2014-07-01 |
| 10337 | 10337 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2011-03-21 | 282 | G | 1 | 0 | S4HQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, Incident/Accident Report review, and staff interview, it was determined that the facility failed to ensure that one (1) resident (#1) received supervision and Hoyer lift transfer, as specified by the Care Plan, and failed to use floor mats as specified by the Care Plan for one (1) resident (#4), from a survey sample of six (6) residents. Resident #1 fell and sustained a [MEDICAL CONDITION] leg. Findings include: 1. Cross refer to F323, Example 1, for more information regarding Resident #1. Clinical record review for Resident #1 revealed a Care Plan entry of 02/24/2010 which identified the resident to be at risk for falls, with Approaches which included the use of a Hoyer lift for all transfers and to monitor/anticipate/intervene for factors causing falls. A Nurse's Notes entry of 02/01/2011 at 2:50 p.m. documented that the nurse observed the resident on the floor in the room after having fallen while being changed. The resident complained of right knee pain, and swelling was noted to the right knee and thigh. A Nurse's Notes entry of 02/01/2011 at 3:00 p.m. documented that the physician was notified and ordered a hospital transfer, and a Nurse's Notes entry of 02/01/2011 at 7:00 p.m. documented that the resident had been admitted to the hospital with [REDACTED]. A 02/01/2011 facility Incident/Accident Report documented that Nursing Assistant In Training "AA" had been providing incontinence care to Resident #1 at the sink and then slid the resident to the floor. The resident sustained [REDACTED]. During an interview with Nursing Assistant In Training "AA" conducted on 03/02/2011 at 4:10 p.m., the nursing assistant stated she had been working by herself when providing care to Resident #1. In a written statement provided by the Director of Nursing (DON), the DON documented that Resident #1 had been transferred by Nursing Assistant "AA" without the use of a mechanical lift (as specified in the Care Plan), and … | 2014-07-01 |
| 10516 | 10516 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2009-08-20 | 504 | D | 3EK711 | **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 laboratory tests were obtained as ordered for five residents (#5, #7, #18, #19 and #30) from a total sample of 30 residents. Findings include: 1. Resident #18 had a 1/16/09 physician's orders [REDACTED]. A review of the resident's medical record revealed [REDACTED]. However, there was not a physician's orders [REDACTED]. 2. Resident #19 had a 1/21/09 physician's orders [REDACTED]. A review of the resident's medical record revealed [REDACTED]. However, there was not a physician's orders [REDACTED]. During an interview on 8/20/09 at 11:45 a.m., licensed nurse "DD" stated that the additional laboratory tests performed for residents #18 and #19 were obtained in error and did not have a physician's orders [REDACTED]. 3. Resident #5 had a physician's orders [REDACTED]. A review of the resident's medical record revealed [REDACTED]. However, there was not a physician's orders [REDACTED]. 4. Resident #7 had a Complete Metabolic Panel (CMP) obtained on 5/13/09 and 5/14/09. However, review of the resident's medical record revealed [REDACTED]. 5. Review of resident #20's closed record revealed a 3/30/09 physician's orders [REDACTED]. A review of the resident's medical record revealed [REDACTED]. However, nursing staff did not have a physician's orders [REDACTED]. During an interview on 8/20/09 at 11:15 a.m., licensed nurse "CC" stated that the additional laboratory tests performed on residents #5 and #7 were obtained in error. Nursing staff did not have a physician's orders [REDACTED]. | 2014-04-01 | ||
| 10517 | 10517 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2009-08-20 | 325 | E | 3EK711 | **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 the resident's attending physician reviewed and addressed the registered dietician's recommendations timely for five residents (#6, #18, #19, #26 and #30), and failed to follow a physician's orders [REDACTED].#2) of 15 residents with weight loss from a total sample of 30 residents. Findings include: 1. Resident #18 had [DIAGNOSES REDACTED]. Licensed staff coded the resident as independent in eating on the 4/1/09 Significant Change of Condition comprehensive assessment. He/She was on a Regular diet. Resident #18 had a 5/20/09 and 6/17/09 registered dietician's recommendation for 30 milliliters (ml) of protein supplement twice a day because of his/her significant weight loss of 10% in six months, a low [MEDICATION NAME] level and meal intake of less than 75%. Staff recorded the resident's weight as 188.8 pounds in May, 186.2 in June and 181.8 in July, 2009. The resident's [MEDICATION NAME] level on 6/1/09 was below normal at 18 (normal range, 20-40). However, despite the continued gradual weight loss and low [MEDICATION NAME] level, the resident's attending physician did not act on those recommendations until 7/21/09 (34 days later) at which time the physician ordered the protein supplement. 2. Resident #6 had [DIAGNOSES REDACTED]. Licensed staff coded the resident as independent with eating on the 4/11/09 MDS assessment. Resident #6 had a 4/22/09 registered dietician's recommendation for fortified meals because of meal intake of less than 75%, a body mass index (BMI) of less than 19, having wounds, a low [MEDICATION NAME] and a low [MEDICATION NAME] level. The resident's 4/9/09 [MEDICATION NAME] level was 10.7 (normal range 20-40) and his/her [MEDICATION NAME] level was 3.0 (normal range 3.4-4.8). However, despite the decreased intake, the recorded BMI of less than 19, and the low [MEDICATION NAME] and [MEDICATION NAME] levels, the resident's … | 2014-04-01 | ||
| 10518 | 10518 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2009-08-20 | 282 | D | 3EK711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and record review, it was determined that the facility failed to implement the plan of care to prevent falls for one resident (#27) of six residents with a history of falls from a total sample of 30 residents. Findings include: Resident #27 had a history of [REDACTED]. However, on 8/20/09 at 9:15 a.m., 10:15 a.m., 11:50 a.m. and 12:50 p.m., the resident was sitting in his/her wheelchair, but staff had failed to apply the chair alarm. See F323 for additional information regarding resident #27. | 2014-04-01 | ||
| 10519 | 10519 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2009-08-20 | 428 | E | 3EK711 | **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 the resident's attending physician acted on the consultant pharmacist's recommendations in a timely manner for nine residents (#2, #3, #9, #18, #19, #20, #24, #27 and #30) from a total sample of 30 residents. Findings include: 1. Resident #18 had a 7/30/09 consultant pharmacist recommendation to increase the dose of Stalevo to aid in reducing the potential of falls and to change the time of the resident's Flomax from morning to hour of sleep to reduce any orthostatic hypotension to aid in reducing falls. However, the physician did not act on those recommendations until 8/19/09, at which time he/she increased the dose of Stalevo and changed the time of administering of Flomax to bedtime. 2. Resident #19 had a 3/26/09 consultant pharmacist recommendation for a [DIAGNOSES REDACTED]. However, the physician did not act on that recommendation until 5/27/09, at which time he/she gave a [DIAGNOSES REDACTED]. 3. Resident #20 had a 7/30/09 consultant pharmacist recommendation for the resident's Miralax be mixed with 8 ounces of water or juice according to the manufacturer's recommendations instead of the 4 ounces of liquid that the nursing staff had been administering. However, the physician did not act on that recommendation until 8/18/09, at which time he/she ordered nursing staff to give the Miralax with 8 ounces of water or juice. The resident also had a 6/30/09 consultant pharmacist recommendation for a potassium replacement due to the resident receiving HCTZ daily without a potassium supplement. The resident's 6/30/09 potassium level was low at 3.1 (normal range 3.5-5.3). However, the physician did not act on that recommendation until 7/15/09, at which time, he/she ordered 20 miliequivalents (meq) of KDur daily. During an interview on 8/20/09 at 8:30 a.m., licensed nurse "DD" stated that the consultant pharmacist gave the recommendations to the D… | 2014-04-01 | ||
| 10520 | 10520 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2009-08-20 | 225 | D | 3EK711 | **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 thoroughly investigate the past history of one of sixteen employees, and failed to report one injury of unknown origin to the State survey and certification agency. Findings include: 1. According to the 4/30/09 nurse's notes at 1:40 p.m., resident #12 had [MEDICAL CONDITION] and discoloration on his/her right hand, wrist and lower forearm, and complained of pain. The resident was sent to the emergency room (ER) for evaluation. It was determined that he/she did not have a fracture but had a contusion of the right wrist. Although the facility had investigated that injury and determined it had been of unknown origin, it was not reported to the State survey and certification agency. 2. Review of the personnel records for sixteen employees revealed that the facility hired an employee on 9/22/08. However, the facility failed to thoroughly investigate his/her history including having obtained a current criminal background check prior him/her working at the facility. On 8/20/09 at 1:00 p.m., the administrator stated that the facility staff were unable to locate the background check. | 2014-04-01 | ||
| 10521 | 10521 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2009-08-20 | 323 | D | 3EK711 | **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 a chair alarm as planned to prevent falls for one resident (#27) of six residents with a history of falls from a total sample of 30 residents and failed to ensure that two handrails were secured to the wall on one unit (Unit IV) of five units in the facility. Findings include: 1. Resident #27 had a history of [REDACTED]. However, on 8/20/09 at 9:15 a.m., 10:15 a.m., 11:50 a.m. and 12:50 p.m., the resident was sitting in his/her wheelchair, but staff had failed to apply the chair alarm. On 8/20/09 at 12:50 p.m., certified nursing assistant "AA" confirmed that the resident did not have a chair alarm on his/her wheelchair. "AA" stated at that time that staff did not apply an alarm on the resident's wheelchair. On 8/20/09 at 12:55 p.m., licensed nursing staff "BB" stated that staff did not apply an alarm on the resident's wheelchair because, the resident did not attempt to get out of his/her wheelchair unassisted. However, according to the 7/15/09 at 9:10 p.m. nurses' notes, nursing staff had found the resident on the floor in his/her room next to his/her wheelchair. 2. During the General Observation Tour of the Facility on 8/20/09 at 11 a.m., two sections of handrails were loose in the Unit IV hall between the common bath and the residents' telephone room, and between rooms 442 and 440. | 2014-04-01 | ||
| 10522 | 10522 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2009-08-20 | 505 | D | 3EK711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, it was determined that the facility failed to promptly notify the physician about an abnormally high [MEDICATION NAME]/INR level and an abnormally high BUN level for one resident (#3) from a sample of 30 residents. Findings include: Nursing staff had given 5 milligrams (mgs) of [MEDICATION NAME] daily to resident #3 since his/her admission on 6/9/09. Licensed nursing staff had obtained a [MEDICATION NAME]/INR blood level on the resident on 6/15/09. Although, the INR was abnormally high at 3.69 (therapeutic range was between 2.0 and 3.0), licensed nursing staff had failed to notify the physician about that result until 7/7/09 (22 days later). At that time, the physician ordered nursing staff to hold the [MEDICATION NAME] that day and then decrease the dose to 2.5 mgs and alternating that with 5 mgs every other day. On 8/19/09 at 11:00 a.m., the consultant pharmacist stated that licensed nursing staff should have notified the resident's physician about the abnormally high INR result prior to 7/7/09. Resident #3 had an abnormally high BUN level of 52 reported on 8/4/09. The normal range for a BUN level was between 7 and 18. Although the resident had an abnormally high BUN level of 31 on 6/6/09 prior to his/her admission to the facility on [DATE], there was no evidence that licensed nursing staff had notified the resident's physician about the even higher BUN result on 8/4/09. | 2014-04-01 | ||
| 10523 | 10523 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2009-08-20 | 253 | C | 3EK711 | Based on observations, it was determined that the facility failed to maintain an environment that was free from dust, rust, stains, missing baseboards, dirt, cobwebs and/or debris on all five hallways in the facility. Findings include: The following were observed on 8/18/09 between 8:55 a.m. and 11:00 a.m. and on 8/20/09 at 10:00 a.m. and 11:00 a.m. 500 Hall 1. There were rusty metal bedpan holders mounted on the bathroom walls in rooms 522 and 523. 2. There was a heavy build up of dust on the bathroom ceiling vents in rooms 523, 540, 541, 542, 543, 545 and 547. 3. There were rusty metal bases on the suction machines in rooms 512 and 541. 4. The laminate finish was peeling off of the side of the nightstand in room 544. 5. There were cobwebs on the furniture in room 531. 6. There was a dried brown liquid substance on the bathroom ceiling light fixtures in rooms 526 and 528. 7. The bathroom light fixture in room 526 was separated from the ceiling on two sides. 8. There was a Exelon medication patch dated 7/5/09 attached to the shower wall in room 521. 9. There were scuffs and gouges on the door of the common bath. 10. There was approximately a five foot section of baseboard missing in the dining area. 11. There was a section of baseboard missing in the hall next to the supply closet. 400 Hall 1. There were scuffs and paint peeling off of the wall next to the linen storage room. 2. There were scuffs and gouges on the door of the common bath. 3. The baseboards were scuffed and stained in the television area. 4. There were stains and paint peeling off of the bottom cabinets in the clean utility room. 300 Hall 1. There was a heavy build up of dust on the ceiling vents in rooms 310 and 331. 2. There were rusted out areas at the bottom of the bathroom door frames in rooms 313 and 331. 3. There were rusty grab bars in the bathrooms in rooms 315, 320 and 342. 4. There were dried brown stains on the bathroom ceiling in room 344. 5. There were dried brown splatter stains on the walls and ceiling of the soiled linen room. 6. … | 2014-04-01 | ||
| 10524 | 10524 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2009-08-20 | 368 | E | 3EK711 | Based on group interview and staff interview, it was determined that the facility failed to offer bedtime snacks to six of fourteen residents who attended the group interview. Findings include: During the group interview on 8/19/09 at 3:00 p.m., six of the fourteen residents said that they were not offered bedtime snacks. During interviews conducted on 8/20/09 between 8:20 a.m. and 9:00 a.m. with the six residents in the group interview who had reported not being offered bedtime snacks, they said that nursing staff did not offer them a bedtime snack on the previous evening (8/19/09). During an interview on 8/20/09 at 9:30 a.m., the Director of Nursing stated that bedtime snacks were kept stocked on the units and nursing staff was responsible for offering them to the residents. | 2014-04-01 | ||
| 18 | 18 | PARK PLACE NURSING FACILITY | 115005 | 1865 BOLD SPRINGS ROAD | MONROE | GA | 30655 | 2018-07-19 | 656 | G | 0 | 1 | 9U3P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, family and staff interviews, the facility staff failed to follow the comprehensive care plan for Resident (R #40) on how to safely transfer the resident from one surface to another. On 7/5/18, R#40 was transferred improperly, without the use of a Hoyer lift, resulting in R#40 sustaining two fractured ribs on the left side. The sample size was 46 residents. Findings include: Record review revealed that R #40 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of R#40's most recent comprehensive Minimum Data Set (MDS), a five-day scheduled assessment with an Assessment Reference Date (ARD) of 4/25/18 coded R#40 as cognitively moderately impaired, requiring cues/supervision with decision making and requiring extensive assistance of two people for bed mobility and totally dependent of two people for transfers. Review of the Comprehensive care plan dated 12/13/17 with an Approach: Transfer with the help of one person and updated on 4/15/18 to 4/18/18 to reflect dependent Extensive, related to weakness, need total assist with Activities of Daily Living (ADL) and Hoyer lift by two persons under the Goal section. A hand written note at the bottom of the care plan dated 4/18/18: (MONTH) use Hoyer lift prn (as needed) during transfers related to weakness. The care plan was updated on 7/10/18 under Approach: Transfer-two person Hoyer lift. A review of the facility document Nurse Aide's Information Sheet also referred to by the facility staff as the ADL sheet (a communication tool used by the Certified Nursing Assistants (CNA) to determine a resident's ADL needs, including transfers) documented that R#40 needed assistance of one staff member to place from bed into the wheelchair. An update was made on 7/9/18 for use of Hoyer lift by two persons for transfers. Review of the facility investigation statement, written by CNA BB, revealed that the CNA had never worked with R#40 prior to this incident and had tran… | 2020-09-01 |
| 19 | 19 | PARK PLACE NURSING FACILITY | 115005 | 1865 BOLD SPRINGS ROAD | MONROE | GA | 30655 | 2018-07-19 | 689 | G | 0 | 1 | 9U3P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, family and staff interviews and records review, the facility staff failed to ensure that the correct information regarding safe transfer techniques for Resident (R#40) was accurate on the Certified Nursing Assistants (CNAs) care communication tool, the Activities of Daily Living (ADL) sheet. Between 4/18/18 and 7/5/18 R#40 was documented throughout the clinical record as being totally dependent for transfers and requiring a Hoyer lift for safe transfers. On 7/5/18 Certified Nursing Assistant (CNA) BB transferred R#40 without assistance of another staff member and without using a Hoyer lift. Following the transfer R#40 was documented as having increased pain on the left side and an X-Ray completed later that day documented that R#40 had acute fractures of two ribs on the left side resultling in the resident being transferred to the hospital for evaluation. The sample size was 46 residents. Findings include: Observation of R#40 on 7/16/18 at 9:30 a.m. revealed the resident was lying in her bed with her family at the bedside. An interview in R#40's room was conducted with a family member who stated that their mother was doing okay but that a couple of weeks ago she had been transferred from her bed to her recliner by an aide (CNA BB) and was found to have two fractured ribs following the transfer. When asked how the fractured ribs occurred the family of R#40 stated that the aide (CNA BB) had transferred the resident without assistance and did not use a Hoyer lift, which was how she was normally transferred. The family member further stated that the facility had reported the incident to the State and it was their understanding that the facility had investigated the incident. Review of R#40's clinical record revealed the resident's [DIAGNOSES REDACTED]. A review of R#40's most recent Comprehensive Minimum Data Set (MDS), a five-day assessment with an Assessment Reference Date (ARD) of 4/25/18, coded R#40 as being cognitively … | 2020-09-01 |
| 20 | 20 | PARK PLACE NURSING FACILITY | 115005 | 1865 BOLD SPRINGS ROAD | MONROE | GA | 30655 | 2019-11-15 | 585 | D | 0 | 1 | O88D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interviews, record review and review of facility policies, the facility failed to make prompt effort to file a grievance for one resident (R) #25 who verbally reported to staff she was missing her lower denture. The sample size was fifty-seven residents. Findings include: Review of an undated policy titled Dental Policy revealed 3. Nursing staff to report missing dentures, notify social service, and fill out concern forms. Review of the policy titled Complaint (Grievance) Policy revised date of (MONTH) (YEAR) revealed Such complaints may include those related to his or her treatment, medical care, missing clothing or other complaints regarding their stay. Record review of the Minimum Data Set (MDS) significant change assessment dated [DATE] revealed R#25 had a Brief Interview for Mental Status of nine indicating moderate cognitive impairment. An interview and observation was conducted on 11/12/19 at 11:50 a.m. with R#25 who responded to interview questions appropriately. The resident was asked about dentures. The resident revealed she is missing her bottom denture. Observation of only top dentures in the resident's mouth. The resident also revealed she reported to the staff and the dentist that she was missing her lower denture. The resident revealed the lower denture has been missing for a couple of months. An interview was conducted on 11/15/19 at 3:25 p.m. with the Certified Nursing Assistant (CNA) CC. The CNA revealed R#25 had reported to the staff during mealtime in the dining room a month ago that she was missing her bottom denture. Record review of R#25's dental notes dated 9/10/19 revealed Patient states her lower denture has been lost. An interview was conducted on 11/15/19 at 9:44 a.m. with the Social Service Director (SSD). The SSD was asked how the facility handles residents missing items. The SSD revealed when a person reports (verbally or in writing) a missing item a grievance form is com… | 2020-09-01 |
| 21 | 21 | PARK PLACE NURSING FACILITY | 115005 | 1865 BOLD SPRINGS ROAD | MONROE | GA | 30655 | 2019-11-15 | 732 | C | 0 | 1 | O88D11 | Based on observation and staff interview the facility failed to categorize licensed and unlicensed nursing staff directly responsible for resident care per shift and failed to make certain staffing information was accurate and current. The facility census was 163. Findings include: An observation on 11/12/19 at 10:15 a.m., of the nurse staff information posted on the A/B hall near the treatment nurses office revealed a census of 161. The staffing posting consisted of 4 pages of staff names, staff assigned rooms, staff assigned breaks, staff assigned task, and total employee hours. The staff posting did not include the facility name or the number of licensed and unlicensed staff per unit. The posting appeared to be a facility schedule that listed all staff assigned to work for that day. The information included all licensed and unlicensed staff, as well as staff that do not provide direct care. Further review revealed that the nightshift CNA's assignment did not list the rooms assigned, but instead listed see book. It was difficult for a visitor or resident to know which staff (licensed or unlicensed) was assigned to provide care. An interview on 11/12/19 at 10:46 a.m., with the staffing coordinator, she revealed the A/B hall nursing station was the only place in the facility where the daily staffing is posted. An observation on 11/13/19 at 9:15 a.m,. of the nurse staff information posted on the A/B hall revealed a census of 161 which was not correct due to the actual census being 163. | 2020-09-01 |
| 22 | 22 | PARK PLACE NURSING FACILITY | 115005 | 1865 BOLD SPRINGS ROAD | MONROE | GA | 30655 | 2019-11-15 | 812 | F | 0 | 1 | O88D11 | Based on observation, policy review and staff interviews, the facility failed to ensure opened food items in the dry storage area were securely covered, labeled and dated; failed to discard food items by expiration date; failed to maintain sanitary conditions in the kitchen by not stacking wet cookware and ensuring the cleanliness of kitchen equipment and not changing gloves during puree process. The facility also failed to maintain proper holding temperatures for cold food items at 41 degrees Fahrenheit (F) or below during meal service. There are 161 residents that receive an oral diet. Findings include: 1. Observation during initial tour on 11/12/19 from 10:05 a.m. to 10:31 a.m. with Certified Food Service Manager (CFSM), revealed in the dry storage area one opened/unsealed 12 ounce box of raisins with no open date; one 16 ounce opened/unsealed box of dry rice with no open date. In the walk in cooler, a large clear storage container with cooked chili with use by date of 11/3/19; one clear container with gravy with use by date of 11/5/19; one clear container of macaroni and cheese with use by date of 11/3/19; one clear storage container with red food substance, unlabeled with no use by date (identified by staff as stewed tomatoes); a large clear storage container of food substance, unlabeled with no use by date (identified by staff as green beans) and one stainless steel container of dinner rolls with use by date of 11/5/19. Interview on 11/12/19 at 11:15 a.m. with Certified Food Service Manager (CFSM) stated that the kitchen staff know that foods are to be dated and discarded after three days. She further stated that she has had many discussion with the dietary staff about not saving the leftover food, because they rarely use it. She verified the concerns identified during the initial tour. 2. Observation during initial tour on 11/12/19 from 10:05 a.m. to 10:31 a.m. with Certified Food Service Manager (CFSM), revealed food slicer on the back table with dried food debris on the blade and the slide tray; wet nest… | 2020-09-01 |
| 23 | 23 | PARK PLACE NURSING FACILITY | 115005 | 1865 BOLD SPRINGS ROAD | MONROE | GA | 30655 | 2019-11-15 | 840 | D | 0 | 1 | O88D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to provide documentation of a written agreement or contract with the company providing out patient [MEDICAL TREATMENT] services for one resident (R) (#44) of 3 residents receiving [MEDICAL TREATMENT] services. Findings include: A review of the clinical record revealed R#44 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The resident's most recent Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) of three, indicating severe cognitive impairment. Section: O revealed the resident was receiving [MEDICAL TREATMENT] while a resident in the facility. Review of the physician's orders [REDACTED]. Review of the Facility Resident Census and Conditions of Residents Form dated 11/12/19 revealed the facility had three residents receiving [MEDICAL TREATMENT] at an outside certified end-stage [MEDICAL TREATMENT] facility. Interview on 11/13/19 at 4:56 p.m., with the Assistant Administrator revealed the facility had been trying for months to obtain a [MEDICAL TREATMENT] agreement from the [MEDICAL TREATMENT] center but has not had any luck. She stated she would call again to speak with someone who understood the importance of having this information on file. During an interview on 11/14/19 at 12:05 p.m., the Administrator stated the facility had made several attempts to get a contract from the [MEDICAL TREATMENT] center. He reported and confirmed that when R# 44 was admitted , he was not made aware that there was not a [MEDICAL TREATMENT] contract. He further stated that he had made several attempts to get an agreement with the [MEDICAL TREATMENT] provider but had not been successful until today. | 2020-09-01 |
| 24 | 24 | PARK PLACE NURSING FACILITY | 115005 | 1865 BOLD SPRINGS ROAD | MONROE | GA | 30655 | 2019-11-15 | 908 | F | 0 | 1 | O88D11 | Based on observations and interview, the facility failed to ensure that essential equipment in the kitchen was in working order as evidenced by, ice build up inside and around the door frame of the walk-in freezer observed on four of four days during the survey. There are 161 residents that receive an oral diet. Findings include: During the initial tour on 11/12/19 at 10:05 a.m. with the Certified Food Service Manager (CFSM) the surveyor inspected the walk-in freezer. During the inspection, the inside door frame, ceiling and floor inside door opening, had visible ice formation. Additional observations during follow-up visits to the kitchen, revealed continued ice buildup on the walk-in freezer door frame, ceiling and floor during all four days of the survey. Interview on 11/15/19 at 4:00 p.m. with the CFSM, stated that staff scrape off the ice in the walk-in cooler everyday. She stated that she has not reported the issue to the maintenance department. She further stated there were no policies related to maintenance of the walk-in freezer. | 2020-09-01 |
| 4289 | 4289 | PARK PLACE NURSING FACILITY | 115005 | 1865 BOLD SPRINGS ROAD | MONROE | GA | 30655 | 2016-03-10 | 371 | F | 0 | 1 | JQUV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, it was determined that the facility staff failed to ensure opened food items were securely wrapped, labeled, and dated in the dry storage area and walk-in freezer. This deficient practice had the potential to effect one hundred and fifty seven (157) residents receiving an oral diet. Findings include: Observation on 03/7/16 at 12:16 p.m. of the dry storage area revealed 3-2Lbs 3ounce bags of frosted flakes cereal out of shipping box on four tier dry storage food shelve with no expiration date visible on food product. Observation on 3/7/16 at 12:18 p.m. observed 1-25 pound bag of Sweet Onion Hush Puppy mix by House-Autry opened on dry storage food shelve without visible date of opening on this dry food product. Observation on 3/7/16 at 12:20 p.m. observed opened 1-10 pound bag of Barilla [MEDICATION NAME] Macaroni wrapped in plastic with no opening date visible on this food product. Observation on 3/7/16 at 12:30 p.m. observed on FIFO (first in first out) can rack 1-8 pound dented can of Grape Jelly by West Creek placed on FIFO can rack for facility use. On same FIFO storage rack observed 1-6 pound 12 ounce dented can of Rice Pudding by GFS. Observation on 3/7/16 at 12:35 p.m. observe 1-20 pound opened box of Green Split Peas with all of food product exposed to open room air with no open date or no visible plastic covering of food product. Observation on 03/7/16 at 12:45 p.m. in walk-in freezer revealed 1-2 pound 8ounce bag of opened Fry and Serve Hash Puppies on top freeze shelves with no visible opening date. Observation on 3/7/16 at 1:35 a.m. during interview with kitchen manager on food storage policies stated all employees must date any and all opened food products before storing on food shelves. On 3/7/16 at 12:05 p.m. during kitchen tour which kitchen manager accompanied surveyor during inspection and verified all food storage finding and concerns. Facility staff must ensure that all food products… | 2019-11-01 |
| 4290 | 4290 | PARK PLACE NURSING FACILITY | 115005 | 1865 BOLD SPRINGS ROAD | MONROE | GA | 30655 | 2016-03-10 | 431 | E | 0 | 1 | JQUV11 | Based on observations and staff interview the facility failed to provide expired floor stock medication was removed from the medication storage room from one (1) out of two (2) storage rooms and one out of four (4) medication cart. Findings include: Review of the facility policy and procedure for expired medications revealed the unit secretary will check medication rooms monthly for expired floor stock or any other expired items within the medication room. Medications are then removed from the facility. Observation on 3/9/16 at 12:11 p.m. of the A hall cart floor stock storage draw revealed an opened bottle of ferrosol liquid with an expiration date of 10/15 confirmation of expired date by the A hall nursing supervisor. Observation on 3/10/16 at 2:20 p.m. of one of the medication storage rooms that cover the A, B, C, and D hall revealed two (2) bottles of magnesium expired on 4/15, lactaid lactase enzyme tablets expired on 8/14 and one expired on 10/15, four (4) bottles of pro-stat liquid supplement bottles expired on 12/16/15. Staff interview on 3/10/16 with BB revealed that the bottled medications were expired and should be checked monthly and removed by the service coordinator assigned. Staff interview on 3/10/16 with CC service coordinator revealed that she and another coordinator checks the medication storage rooms and removes all expired floor stock medications by placing them in the bin for expired medications. Review of the pro-stat medications revealed that she was not sure if they were expired accounting to the way they were dated. | 2019-11-01 |
| 4291 | 4291 | PARK PLACE NURSING FACILITY | 115005 | 1865 BOLD SPRINGS ROAD | MONROE | GA | 30655 | 2016-03-10 | 441 | D | 0 | 1 | JQUV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and resident observation during lunch dining service. It was determined that staff failed to follow infection control practices effecting for resident (#111) and resident (#120). This was evident for 2 out of 72 residents during stage 1 of survey process. Findings include: 03/08/2016 1:12:51 PM -Surveyor observed staff member #AA Certified Nursing Assistant during lunch service in dining room [ROOM NUMBER] bare hand touching resident #120 chopped meat sandwich. After surveyor intervention observed staff member #DD discarded the contaminated sandwich and replace it with a new one. This was verified with another surveyor and facility staff. 03/08/2016 1:13 PM-Interview with staff member #AA reveals staff member #AA discarded the sandwich and replaced it with a new sandwich from the kitchen. On 3/8/16 at 1:00 p.m. observed in dining room [ROOM NUMBER] observed staff member #DD touching resident (#111) ham sandwich with their bare hands. After surveyor intervention observed staff member #DD discarded the contaminated sandwich and replace it with a new one. On 3/10/16 at 10:36 a.m. during interview with infection control nurse and review of infection control handwashing policy verified that all staff members are in-service on handwashing when assisting residents during meal services. Facility must ensure all staff member continue to practice infection control standard during residents meal service. | 2019-11-01 |
| 5208 | 5208 | PARK PLACE NURSING FACILITY | 115005 | 1865 BOLD SPRINGS ROAD | MONROE | GA | 30655 | 2015-11-03 | 153 | C | 1 | 0 | SXJL11 | > Based on review of the Policy for Release of Medical Information and staff interviews, the facility failed to allow the Legal Representative access to the medical record for one (1) resident (A). This failure had the potential to affect all residents in the facility. The census was one hundred sixty four (164) residents. Findings include: Intake Details dated 10/5/15 revealed the sister of Resident A requested a copy of the medical records for her brother. The Administrator charged a fee for making the copies. The sister was denied access when she ask is she could come to the facility and view the records. Review of the Park Place Nursing Facility Policy for Release of Medical Information provided on (MONTH) 2, (YEAR), documented: 4) The Administrator will contact and give the patient or family responsible party the count of pages and cost to produce requested medical information. 5) If patient or family responsible party agrees to cost, then the records will be produced within 10 days. 6) If patient or family responsible party agrees to cost, then records will be produced within ten (10) days. An interview with the Administrator on (MONTH) 2, (YEAR) at 3:20 p.m. revealed that the facility releases medical records to the resident or responsible party upon agreement to the cost of the copies. The Administrator confirmed that the resident ' s daughter requested to view the medical records and he denied access due to inability to monitor use of the records, such as taking pictures of part of the records. An interview with medical records staff member on (MONTH) 2, (YEAR) at 4:04 p.m. revealed that the process for obtaining medical records is to direct the resident, if no longer residing in the facility, to the Administrator. MR staff member informed that the medical record is not copied until the resident or responsible party agrees to the cost of the copies. She stated that the medical record is not provided for resident/ responsible party for view. Review of the Grievance Log, dated (MONTH) 20, (YEAR) revealed o… | 2018-11-01 |
| 5503 | 5503 | PARK PLACE NURSING FACILITY | 115005 | 1865 BOLD SPRINGS ROAD | MONROE | GA | 30655 | 2015-02-05 | 323 | D | 0 | 1 | ZUHN11 | Based on observations, record review, facility policy and staff interview it was determined that the facility failed to ensure that the resident's environment was free of accident hazards for one (1) resident (#57) from a sample of forty-eight (48) residents. Findings include: Observation during intial tour of the facility on 02/02/15 at 11:00 a.m. room E-69, revealed a private bathroom for resident #57 with a soft raised toilet seat that was torn on both sides and the back with jagged edges exposing the foam. Continued observation on 2/03/15, at 3:00 p.m., 02/04/15 at 7:45 a.m. and 2:30 p.m., and again on 02/05/15 at 7:30 a.m. and 8:10 a.m., revealed that the raised soft toilet seat was still torn with jagged edges exposing the foam remained in the resident's private bathroom. Interview with CC the Private Sitter on 02/04/2015 at 9:24 a.m., revealed that resident #57 uses the raised soft toilet seat several times daily with assistance from staff. CC further revealed that the resident was not able to ambulate to the bathroom unassisted and required help from staff. Interview with the Infection Control (IC) Nurse on 02/04/15 at 10:45 am revealed that resident #57 uses the private bathroom with the soft raised toilet seat daily, and required assistance from the staff but continued to wear adult diapers. Observation on 02/05/15 at 9:15 a.m. of the private bathroom for resident #57 with the IC Nurse she confirmed that the soft toilet seat was torn on both sides and in the back with jagged edges exposing the foam. She further revealed that the toilet seat would be replaced. Interview with Certified Nursing Assistant (CNA) BB on 02/05/15 at 8:15 a.m. revealed that resident #57 was on a toileting program with staff toileting the resident every two (2)hours especially after meals and as needed. CNA BB further revealed that the resident continues to use the private bathroom with the torn toilet seat several times daily and at times asks to remove the torn seat to allow the resident to sit on the regular seat. Interview on… | 2018-08-01 |
| 5504 | 5504 | PARK PLACE NURSING FACILITY | 115005 | 1865 BOLD SPRINGS ROAD | MONROE | GA | 30655 | 2015-02-05 | 371 | E | 0 | 1 | ZUHN11 | Based on observation and staff interviews the facility failed to properly demonstrate the usage of the three (3) compartment sink to prevent the potential for food borne illness. This had the potential to effect one hundred and fifty-two (152) residents who received oral alimentation. Findings include: Observation on 02/04/15 at 3:40 p.m. revealed that AA , the cook did not properly sanitize the blender bowl and lid after usage in the three (3) compartment sink. Continued observation revealed that the cook washed the blender bowl and lid in soapy water; next she rinsed the items in the rinse compartment. The cook then placed the blender bowl and lid in the sanitizing solution and then removed both items after being immersed for only (fifteen) seconds. Further observation of the three (3) compartment sink revealed that a poster was hanging above the sink from Patco, the company that provides the facility with chemicals, which indicated the appropriate steps and technique for usage of the three (3) compartment sink including how long to submerge items in the sanitizing solution which stated one (1) minute or longer. Interview with AA the cook on 02/04/15 at 3:40 p.m. revealed that the way she demonstrated to the surveyor how to clean and sanitize the blender bowl and lid was how she was told to clean items in the three (3) compartment sink. Continued interview revealed that she does not recall the last time there was an in-service regarding the proper usage of the three (3) compartment sink. Interview with the Dietary Manager (DM) on 02/04/15 at 3:42 p.m. revealed that she was not able to verbalize to the surveyor how to properly use the 3 compartment sink. Continued interview with the DM revealed that she had been educating her staff that they just need to swish items in the sanitizing solution and then place them on the rack to dry. The DM revealed that she was not aware that items needed to be immersed in the sanitizing solution for at least one minute per recommendations of the manufacturer as indicated on the … | 2018-08-01 |
| 5505 | 5505 | PARK PLACE NURSING FACILITY | 115005 | 1865 BOLD SPRINGS ROAD | MONROE | GA | 30655 | 2015-02-05 | 372 | C | 0 | 1 | ZUHN11 | Based on observations and staff interviews the facility failed to maintain the condition of one (1) large compacting dumpster to ensure it was free from leakage and failed to properly cover the garbage in the dumpster to prevent the harborage of pests. Findings include: Observation on 02/02/15 at 11:00 a.m. of the dumpster area revealed that the facility had one (1) compacting dumpster sitting on a concrete pad. Continued observation of the dumpster revealed that the area to deposit garbage was open and ten (10) garbage bags were visible. Further observation revealed a large leak coming from under the front of the dumpster. A stream of pale white fluid ran forward to the front of the concrete pad and formed a pool. The pool of white fluid was eight (8) feet in length, 1 foot in width, and two (2) inches deep. Interview with the Dietary Manager (DM) on 02/02/15 at 11:00 a.m. revealed that she had never seen the area to deposit garbage closed and that garbage was constantly exposed. Continued interview revealed that she knew about the leak in the dumpster for two (2) weeks and admitted that the white fluid coming from the dumpster was milk and juices from the dietary department. The DM further revealed that dietary and housekeeping share responsibility for keeping the dumpster area clean. Interview with the Director of Maintenance on 02/02/15 at 11:05 a.m. revealed that the only time the area to deposit garbage in the dumpster is closed is when garbage is being compacted or at the end of the day. He revealed that at the end of the day the last individual discarding garbage compacts the garbage and leaves the compacting ram inside the main garbage storage area. Once the plunger is pushed in it covers the area that garbage is deposited. The Director of Maintenance confirmed that they have known about the leak coming from the dumpster for the past few weeks. He confirmed that the white liquid coming from the dumpster was milk and juices from the kitchen garbage. Observation on 02/03/15 at 3:45 p.m. of the compacting d… | 2018-08-01 |
| 6557 | 6557 | PARK PLACE NURSING FACILITY | 115005 | 1865 BOLD SPRINGS ROAD | MONROE | GA | 30655 | 2013-06-27 | 156 | B | 0 | 1 | DT4T11 | Based on record review and staff interview, the facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN), and failed to document that the resident was being discharged from skilled therapy on the Notice of Medicare Non-Coverage form (Generic Notice) for one (1) resident (#86) from a total of four (4) residents that were reviewed. Findings include: Review of the Generic Notice for resident #86 revealed that the resident would no longer be covered for skilled nursing services effective 5/30/13; however, no evidence that the SNFABN was provided to the resident and/or legal representative. Interview with the Admissions Director on 6/26/13 at 8:30 a.m., revealed that resident #86 remained in the facility after being discharged from skilled nursing services on 5/30/13; even though, she had had not used up hundred (100) days of Medicare of eligibility. Continued interview revealed that she issues the SNFABN for all residents coming off Medicare services, but this particular case got overlooked. | 2017-11-01 |
| 6558 | 6558 | PARK PLACE NURSING FACILITY | 115005 | 1865 BOLD SPRINGS ROAD | MONROE | GA | 30655 | 2013-06-27 | 281 | D | 0 | 1 | DT4T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the Georgia Practical Nurse Practice Act and staff interviews, the facility failed to ensure that services provided met professional standards of quality for one (1) resident (#219) from a sample of forty-two (42) residents. Findings include: Review of the clinical record for resident #219 revealed that the resident was admitted to the facility in January 2013 with the following Diagnosis: [REDACTED]. Review of the Gwinnett Hospital System Progress Notes dated 1/20/13 revealed that the resident would be discharged to a nursing home with hospice care. Continued review revealed that the resident's family was in agreement for hospice care at the nursing home. Review of the Gwinnett Hospital System Nursing Home Transfer Orders dated 1/21/13 revealed for the resident to follow up with hospice. These transfer orders were noted 1/22/13 by Licensed Practical Nurse WW Review of the facility admitting orders revealed no evidence of an order for [REDACTED]. Interview on 6/27/13 at 9:48 a.m. with the Social Worker (SW) HH and the Admission Clerk II, who assists the SW revealed that the resident's family changed their mind on admission related to hospice; however, there is no evidence of documentation of this discussion with the family. Further interview with the SW at 12:21 p.m., revealed that she goes by what the Admission Clerk tells her, but that she personally did not discuss Hospice with the family. Interview with the DON on 6/27/13 at 11:35 a.m., acknowledged that the hospital nursing home transfer orders did specify to follow up with hospice and this was not done. Review of the Georgia Practical Nurses Practice Act revealed that the practice of licensed practical nursing for compensation includes, but shall not be limited to: -Section 2.3.2-Subsection E-seeks clarification of orders when needed | 2017-11-01 |
| 6559 | 6559 | PARK PLACE NURSING FACILITY | 115005 | 1865 BOLD SPRINGS ROAD | MONROE | GA | 30655 | 2013-06-27 | 356 | B | 0 | 1 | DT4T11 | Based on record review and staff interview, the facility failed to include three (3) of the five (5) required areas of information on the daily posted staffing sheets for three (3) of the four (4) days of survey. The census was one hundred and fifty-eight (158). Findings include: Observations on 6/24/13 at 12:05 p.m. and 6/25/13 at 7:15 a.m. revealed that the daily staffing sheet was posted but did not contain the name of the facility, the census nor the total number and/or actual number of hours worked per discipline. Observation on 6/26/13 at 7:15 a.m. revealed that the daily staffing sheet did not contain the name of the facility or the total hours worked. Interview with the Clinical Administrator on 6/26/13 at 10:15 a.m., revealed that the daily staffing sheet did not contain the required name of the facility and/or the total hours worked by staff. | 2017-11-01 |
| 6560 | 6560 | PARK PLACE NURSING FACILITY | 115005 | 1865 BOLD SPRINGS ROAD | MONROE | GA | 30655 | 2013-06-27 | 431 | E | 0 | 1 | DT4T11 | Based on observations, staff interviews and review of facility policy, the facility failed to ensure that expired medications and/or medications not labeled when opened were removed from three (3) of six (6) medication carts on three (3) of six (6) units (B, D and E) and two (2) of two (2) medication rooms. Also, the facility failed to ensure that one (1) of the six (6) medication carts was locked when unattended during medication pass. Findings include: 1. Observations of the medication carts on 6/26/13 beginning at 7:02 a.m. revealed the following concerns: -D-hall medication cart- there were three (3) out of six (6) bottles of Insulin, including Humalog and Levemir, that had no date when opened on either the box nor the bottle. Interview on 6/26/13 at 7:02 a.m., Licensed Practical Nurse (LPN) BB acknowledged that the Insulin should have been dated when opened and written on the label on the box. -B-hall medication cart-there was an eight (8) ounce bottle of CertaVite liquid that was labeled as opened 6/21/13 but the bottle had an expiration date of 4/13. -E-hall medication cart-there was one (1) bottle of Vitamin D 400 International Unit (IU) one hundred (100) tablets, labeled opened 9/30/12 and with an expiration date of 4/13; one (1) sixteen (16) ounce bottle of Cherry flavored Acetaminophen liquid, 160 milligrams per 5 milliliters, with an expiration date of 10/12 and floor stock of Novolin R, labeled with an opened date of 5/10/13. Interview with LPN DD, during observation on medication cart on the E-hall, on 6/26/13 at 8:47 a.m., revealed that Insulin is good for twenty-eight (28) days after opened, and concurred that the expired medications should not have been on the medication cart. Interview with Unit Manager FF on the E-hall on 6/26/13 at 9:05 a.m.,revealed that none of the expired medications should have been on the medication carts. 2. Observation of the medication room on the E-F hall on 6/26/13 at 9:05 a.m. with the Unit Manager FF revealed the following: one (1) unopened bottle of one hundred (1… | 2017-11-01 |
| 6561 | 6561 | PARK PLACE NURSING FACILITY | 115005 | 1865 BOLD SPRINGS ROAD | MONROE | GA | 30655 | 2013-06-27 | 441 | F | 0 | 1 | DT4T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observation, review of facility policy and staff interviews, the facility failed to ensure that staff washed and/or sanitized their hands prior to serving meal trays in two (2) of two (2) dining rooms, on three (3) of six (6) halls (halls D, E and F) and to ensure that resident's personal hygiene items were properly labeled and stored in two (2) rooms on one (1) hall (B) of six (6) halls, and that six (6) of ten (10) new employees had a [MEDICATION NAME] skin test (PPD) prior to contact with residents and that one (1) of six (6) current contract employees had their annual PPD skin test done timely (SS, TT, UU, V V, XX, YY, LL. The census was one hundred and fifty eight (158). Findings include: 1. Observation of the dining service on the D-hall on 6/24/13 at 12:40 p.m., revealed that Certified Nursing Assistant (CNA) JJ took a tray into a room and placed the tray on a resident's overbed table, then pulled the resident up in the bed, and proceeded to set up the resident's tray, touching a straw. Continued observation revealed the CNA returned to the cart and obtained another tray for another resident without washing and/or sanitizing her hands. During this observation on the D-hall dining service, there was no evidence of hand sanitizer available either in the hallway and/or resident's rooms. Observation of a second meal service on 6/26/13 at 7:45 a.m. in the dependent dining room (Dining room [ROOM NUMBER]) revealed two (2) hand sanitizers available at each end of the dining room. At 7:55 a.m. the Clinical Administrator, who was helping with meal service, took a bowl with a banana peel from a resident's tray to the trash can but did not wash nor sanitize her hands before moving to help the next resident. Continued observation in dining room [ROOM NUMBER] on 6/26/13 at 8:01 a.m. revealed that when one (1) of the two (2) hand sanitizers, the one (1) closest to the outside door was empty. Continued observation on 6/26/13 at at 8:03 a.m… | 2017-11-01 |
| 8218 | 8218 | PARK PLACE NURSING FACILITY | 115005 | 1865 BOLD SPRINGS ROAD | MONROE | GA | 30655 | 2011-12-15 | 244 | E | 0 | 1 | 9FEJ11 | Based on record review, resident and staff interview the facility failed to act upon a grievance from the Resident Group Council concerning a lack of privacy when staff discussed resident's personal information. Findings include: Review of the resident council minutes dated 7/11/2011 documented a resident voiced a concern that nursing staff talked too loud to each other when discussing another resident's care. Further review of the October 2011 Resident Council Minutes documented that the nursing staff were yelling resident information down the hallway to each other during both day and night shifts. There was no documentation in either of these records that this concern was addressed or acted upon. Interview on 12/14/11 at 11:20 a.m. with resident D revealed that the resident council does not resolve all the issues discussed in the meetings. This resident revealed that both nurses and the Certified Nursing Assistants (CNA) talk loudly in the hallways and shower rooms about residents, such as calling out a resident's name and asking another staff member if that particular resident has had a bowel movement during the shift. Resident D further revealed that when they are in the shower room, CNAs talk in loud voices about resident's bowel habits. The resident revealed that a nurse recently told a resident in the hallway that they needed a bath because the resident smelled bad. The resident further revealed this type of talk happens on a regular basis and the issue had been discussed in resident council several times but has not changed. Interview with Social Workers (E) on 12/14/11 at 2:16 p.m. revealed when this concerned was voiced in resident council and reported to the Director of Nursing. An inservice was conducted with staff related to this matter. However, review of the inservice content revealed subject matter was related to noise only, and did not address staff discussing resident information in the hallways. Interview with the Director of Nurses on 12/15/11 at 9:04 a.m. revealed she had held an inserviced w… | 2016-05-01 |
| 8219 | 8219 | PARK PLACE NURSING FACILITY | 115005 | 1865 BOLD SPRINGS ROAD | MONROE | GA | 30655 | 2011-12-15 | 280 | D | 0 | 1 | 9FEJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to follow the plan of care related to oral care for one (1) resident, resident G on a sample of thirty-two (32) residents. Findings include: During the resident interview on 12/12/11 at 12:35 p.m. resident G was observed to have a dirty mouth. His teeth were broken and yellow. During the interview the resident stated he never brushed his teeth and staff did not assist him with brushing his teeth. Review of the Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed that resident G was assessed as having obvious or likely cavity or broken natural teeth. He was also assessed as needing limited assistance for hygiene which includes brushing his teeth. Review of the Care Area Assessment (CAA) notes for this same time revealed that the resident did trigger for dental and the need to care plan. Review of the care plan for ADLs dated 10/20/11 revealed that the Certified Nursing Assistants (CNAs) are supposed to assist with oral care after each meal. The care plan did not address if the resident refused dental care by the dentist or oral care provided by the staff. There was no documentation on the ADL Sheets for resident G that noted he had received oral care for that day. Further interview with resident G on 12/13/11 at 2:40 p.m. revealed that to the best of his knowledge staff had not offered to clean his teeth. Interview with the Unit Manager on F Hall and the Nursing Supervisor on 12/13/11 at 2:45 p.m. revealed that they do not have any documentation that the resident refuses oral care and/or that oral care had been provided. | 2016-05-01 |
| 8220 | 8220 | PARK PLACE NURSING FACILITY | 115005 | 1865 BOLD SPRINGS ROAD | MONROE | GA | 30655 | 2011-12-15 | 441 | D | 0 | 1 | 9FEJ11 | Based on observation and interview the facility failed to ensure that reusable multi patient equipment was cleaned appropriately between residents during the medication pass for one (1) Licensed Practical Nurse (LPN) out of three nurses (3) observed. Findings include: During observation of fingerstick blood glucose monitoring on 12/14/11 at 11:40 a.m. Licensed Practical Nurse (LPN) CC was observed to take a small basket into a resident's room and place it directly onto the resident's overbed table. This basket contained the glucometer and lancets. The nurse was observed to clean the opening for the test strip with a PDI bleach wipe for 5 seconds and then did the testing for glucose levels. When she finished checking the glucose level she put the glucometer back into the basket with the clean lancets and carried it back to the cart. Interview with LPN CC at this time revealed that she had only been working in this facility a few weeks and had not been told how long to clean the glucometer and where to place it after cleaning. She also acknowledged that she should have placed a barrier before setting the glucometer basket on the overbed table. Interview with the Nursing Supervisor, Registered Nurse (RN) DD on 12/14/11 at 2:15 p.m. revealed that the representative from the glucometer company told them to wet the surface and allow 2 minutes to dry. Instructions on the box of PDI sanitizing wipes with 1:10 bleach in it states to wet surface and allow to dry. When asked about a clean field for the glucometer at this same time the Nursing Supervisor stated that the nurse should have put down a barrier before placing the glucometer on the overbed table. She also stated she should have cleaned the glucometer before putting it back in the basket with the clean lancets. | 2016-05-01 |
| 8221 | 8221 | PARK PLACE NURSING FACILITY | 115005 | 1865 BOLD SPRINGS ROAD | MONROE | GA | 30655 | 2011-12-15 | 493 | C | 0 | 1 | 9FEJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to employ an person who was licensed by the State office to serve as Administrator of the facility. Findings include: Review of the Disclosure of Ownership and Control form dated [DATE] documented the name and signature of the current administrator of the facility. Review of the Georgia State Board of Nursing Home Administrators license documented that this Administrator's license had expired on [DATE]. Interview with the Administrator on [DATE] at 2:40 p.m. confirmed that his administrators license had expired [DATE]. He further revealed he did not become aware that his nursing administrators license had expired until around [DATE] at which time he reapplied for a new licensed. | 2016-05-01 |
| 9978 | 9978 | PARK PLACE NURSING FACILITY | 115005 | 1865 BOLD SPRINGS ROAD | MONROE | GA | 30655 | 2010-08-12 | 279 | D | 0 | 1 | 55J411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to develop a care plan to address the use of psychoactive medications related to monitoring of potential adverse side effects and/or if the medications are providing the intended affects for 2 residents, resident #59 and #21 and for resident "C" related to dental care on a sample of twenty-one (21) residents. The findings include: 1. Review of the Physician order [REDACTED].#59 revealed that she was on Klonopin 0.5 milligrams each day, [MEDICATION NAME] 25 milligrams at night, [MEDICATION NAME] 15 milligrams three times a day, [MEDICATION NAME] 100 milligrams in the morning and 50 milligrams at night for anxiety, depression and behaviors. Review of the care plan dated 7/2010 revealed that the facility had not addressed the use of these medications related to negative side effects or to determine if they were working as the physician intended. Interview with the MDS Coordinator on 8/12/2010 at 2:00 p.m. revealed that she had always included the use of the psychoactive medications to a falls or nutrition care plan. Review of the falls care plan revealed mention that the resident received [MEDICAL CONDITION] meds but did not address specifics to monitoring for behaviors or side effects monitoring. 2. During a family interview for resident "C" on 8/10/2010 at 9:30 a.m. they stated that the resident had recently had a tooth extraction. The resident had the extraction on 8/7/2010 with the family taking her to the dentist office for the service. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident did not have any problem with chewing and needed limited assistance with activities of daily living. Review of the plan of care for resident "C" on 8/11/2010 at 1:00 p.m. revealed that the facility had not developed a care plan related to dental or mouth care needs for this resident. Interview with the MDS Coordinator on 9/11/2010 at 1:30 p.m. confir… | 2015-03-01 |
| 9979 | 9979 | PARK PLACE NURSING FACILITY | 115005 | 1865 BOLD SPRINGS ROAD | MONROE | GA | 30655 | 2010-08-12 | 281 | D | 0 | 1 | 55J411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to clarify a medication order for the exact dosage the physician wanted for one (1) resident, resident #47 on a sample of twenty-one (21) residents. Findings include: During the medication pass observed on 9/11/2010 at 8:00 a.m. the nurse, Licensed Practical Nurse (LPN) "MM" was observed to give resident # 47 liquid [MEDICATION NAME] 5 cc's which equaled 50 milligrams. Review of the Physician order [REDACTED].=100 mg) by mouth each day at 8:30 a.m. Interview with LPN "LL" revealed that she would give 10 cc/ 100 milligrams of the [MEDICATION NAME]. Interview with Registered Nurse "KK" revealed that she would give the 10 cc of [MEDICATION NAME] but stated that the order was not clear. None of the three nurses interviewed stated that they would call the physician for clarification of the order. The physician was notified and the order clarified to read give liquid [MEDICATION NAME] 10 cc's to equal 100 milligrams. Review of the Nursing Practice and Regulation Acts of Georgia for Registered Nurses and Licensed Practical Nurses revealed that their responsibility was to seek clarification of physician orders [REDACTED]. | 2015-03-01 |
| 9980 | 9980 | PARK PLACE NURSING FACILITY | 115005 | 1865 BOLD SPRINGS ROAD | MONROE | GA | 30655 | 2010-08-12 | 156 | B | 0 | 1 | 55J411 | Based on record review and staff interview, the facility failed to provide three (3) residents (#3,107 and 123), with Medicare availability remaining, of the twenty-one (21) sample residents with the Notice of Provider Noncoverage (form CMS- ), notifying the resident of his/her right to an expedited review. The Findings include: Review the records for residents #3, #107 and #123 who had been discharge from Medicare services as no longer meeting the criteria for service revealed the form (CMS- ) which explained the resident's right for an expedited review and reconsideration of discharge. Review of the form CMS- for resident #123 with date of notice 5/18/10 revealed that he/she was no longer eligible for skilled therapy services on 5/19/10 and had an estimated cost of $190.00 per day, which was signed by authorized representative; however, the option to pay for the services themselves, was left blank. Review of the form CMS- for resident #107 with date of notice 4/20/10 revealed that he/she was no longer eligible for skilled therapy services as of 4/23/10 with an estimated cost of $119.03 per day, signed by authorized representative; however, the option box, was left blank. No evidence of form CMS- for all three (3) residents reviewed according to Liability Notices and Beneficiary Appeal Rights Review "S&C0920." Interview with the Social Service Director on 8/11/10 at 3:00 p.m., she indicated that she was unaware of the form CMS- . Reported that when these services are going to be discontinued, then staff gave her three (3) days notice and she gets information and fills out form CMS- . Also, she then calls the family and notifies the family of the residents discharge from service, which would be the date of notification and then the family would have seventy-two (72) hours from that date when services are discharged . | 2015-03-01 |
| 9981 | 9981 | PARK PLACE NURSING FACILITY | 115005 | 1865 BOLD SPRINGS ROAD | MONROE | GA | 30655 | 2010-08-12 | 314 | G | 0 | 1 | 55J411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview it was determined that the facility failed to ensure that residents who entered the facility without pressure sores did not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable. This failure to monitor resident's at risk for skin breakdown affected one (1) resident (#21) on a sample of twenty-one (21) residents and resulted in actual harm. Findings include: Record review for resident #21 revealed all MDS assessments since her admitted on 2/05/09 revealed the resident had never been assessed as having had a pressure sore before. Review of the record revealed the resident had a [DIAGNOSES REDACTED]. Review of the MDS dated 7/18/10 assessed this resident as having one (1) Stage I and three (3) Stage IV pressure sores. Review of the Weekly [MEDICAL CONDITION] assessment dated [DATE] documented resident #21 had two (2) new Stage IV pressure sores on the right outer foot. One pressure sore was measured as being 1.0 by 1.0 centimeters, black in color and necrotic. The other pressure sore to the right foot was measured as being 1.2 by 1.2 cm, brown in color and necrotic. Review of a Nurses Note dated 7/13/10 documented the resident had a new skin problem with a three (3) cm pressure sore to the left lower buttock. Further review of the Weekly Skin Lesion assessment dated [DATE] documented the new Stage IV pressure sore that was found to the resident's left buttock measured as 2.0 by 3.0 cm, grey in color and necrotic. After the pressure sores were identified (7/13/10) a [MEDICATION NAME] level was done with a low result of 16.1 (normal range of 20-40). A [DIAGNOSES REDACTED]. Observation on 8/11/10 at 9:15 a.m. of the wound treatment to the resident's right foot revealed there were two (2) Stage IV pressure sores to the right foot one near the 5th digit and the other of the mid area of the outer foot. There was also a Stage IV pressure sore to… | 2015-03-01 |
| 9982 | 9982 | PARK PLACE NURSING FACILITY | 115005 | 1865 BOLD SPRINGS ROAD | MONROE | GA | 30655 | 2010-08-12 | 282 | G | 0 | 1 | 55J411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to follow the care plan for one (1) resident (# 21) on a sample of twenty one (21) residents related to skin assessments and reporting of skin conditions that contributed to an identified pressure sores that resulted in actual harm to the resident. Findings include: Review of the Resident Assessment Protocol dated 1/25/10 for resident #21 documented the resident was at risk for skin breakdown related to impaired bed mobility and incontinence of bowel and bladder and to proceed to the care plan. Review of the care plan dated 1/24/10 documented that visual skin assessments were to be done with the resident's bath and activities of daily living and to report any red or open areas. Review of the Weekly [MEDICAL CONDITION] Assessment sheets dated 7/12/10 documented the resident was found with two (2) stage IV pressure sores to her right foot and on 7/14/10 was found with one (1) stage IV pressure sore to her left buttock. During interview with the Director of Nurses (DON) on 8/11/10 at 9:35 am she revealed that the Certified Nursing Assistants (CNA) gave a shower to this resident twice weekly and they are responsible for documenting and reporting any skin problems/observations. She could not provide evidence that they were reporting or documenting any of these areas on resident #21. There were no routine skin assessments being conducted on any of the residents in the facility by licensed (LPN or RN) nurses. Weekly assessments are conducted for resident with identified pressure ulcers. Interview with one CNA "BB" on 8/12/10 at 9:45 am revealed she had provided care for this resident during the month of July 2010 and she had noticed a blood red area on the resident's "bottom". She was applied a "cream" to the area. She stated she had reported the area to a nurse but could not recall which nurse. Interview with CNA "CC" on 8/12/10 at 9:55 am who also cared for the resident during the time… | 2015-03-01 |
| 10338 | 10338 | PARK PLACE NURSING FACILITY | 115005 | 1865 BOLD SPRINGS ROAD | MONROE | GA | 30655 | 2011-02-01 | 328 | D | 1 | 0 | 4N3N11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to monitor the oxygen saturation level, in accordance with the physician's order, for one (1) resident (#1) of five (5) sampled residents. Findings include: Record review for Resident #1 revealed that the January 2011 Physician's Orders sheet, dated as having been reviewed on 12/27/2010, referenced physician's orders to administer oxygen 2.0 liters per minute per nasal cannula as needed for [MEDICAL CONDITION], and to monitor the resident's oxygen saturation to keep the oxygen saturation at 90 percent. The resident's January 2011 PRN Medication Administration Record [REDACTED]. However, further record review, to include review of the line on this PRN Medication Administration Record [REDACTED]. During an interview conducted on 02/01/2011 at 2:50 p.m., the Assistant Administrator acknowledged that the resident's oxygen saturation levels had not been recorded and there was no way to determine the resident's oxygen levels. | 2014-07-01 |
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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 );