cms_GA
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10,655 rows sorted by facility_name
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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 |
| 2019 | 2019 | A.G. RHODES HOME, INC - COBB | 115521 | 900 WYLIE ROAD | MARIETTA | GA | 30067 | 2019-10-03 | 584 | E | 1 | 1 | K1HZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, staff interviews, and review of the policy/procedure titled, Deep Clean, the facility failed to maintain a clean, sanitary environment in resident room (R) and bathroom (R221, R224, R225, R227, R230, R231, R233, and R235) on one of three halls. Findings include: Review of a document/policy titled, Deep Clean, provided by the Housekeeping Supervisor, revealed the following instructions for cleaning vents in bathrooms, and wall mounted fans in the resident's rooms. The policy stated, clean vents in bathroom, and clean all fans. Observations during environment rounds on 9/30/19, from 10:00 a.m. to 3:00 p.m., and on 10/1/19 from 8:30 a.m. to 12:50 p.m., of the 200/Pink Hall, revealed vents in resident bathrooms, and oscillating fans mounted on the wall in resident rooms, were found to be very heavily coated with dust as follows: Observation on 9/30/19 at 10:05 a.m., in resident room [ROOM NUMBER], revealed dust on the oscillating fan on bed A side of the room, dust observed on the vent in the bathroom, and a slow draining sink in the bathroom. Observation on 9/30/19 at 10:15 a.m., in resident room [ROOM NUMBER], revealed the vent in the bathroom, and the oscillating fan mounted on the wall on bed A side and bed B side of the room, was very dusty. Observation on 9/30/19 at 10:34 a.m., in resident room [ROOM NUMBER], revealed splatters of yellow/tan colored, unknown substance that appeared to be dried liquid nutrition, on the wall to the right of the B side headboard, and on the resident's nutrition pump. The resident received nutrition via a Percutaneous Endoscopy Gastrostomy (PEG) tube, and Covidien pump. Observation on 9/30/19 at 10:45 a.m., in resident room [ROOM NUMBER], revealed the vent in the bathroom, was very heavily coated in dust, and the oscillating fan mounted on the wall on bed A side, and bed B side, was very dusty. Observation on 9/30/19 at 11:30 a.m., in resident room [ROOM NUMBER], revealed the vent in th… | 2020-09-01 |
| 6755 | 6755 | A.G. RHODES HOME, INC - COBB | 115521 | 900 WYLIE ROAD | MARIETTA | GA | 30067 | 2013-10-24 | 323 | D | 0 | 1 | LPTM11 | Based on observation, review of facility's temperature logs, and staff interview, the facility failed to ensure that hot water for residents use was at a safe temperature in one (1) resident room of twelve (12) rooms on two (2) of six (6) halls on two (2) of two (2) resident floors. Findings include: Observations of water temperatures during the general environmental tour conducted with Facility Maintenance Director, using the facility thermometer, on 10/24/13 at 10:37 AM , revealed that the temperature of the hot water at the sink in room 234, on the green hall, was one hundred twenty one degrees (121) Fahrenheit (F). An interview conducted on 10/24/13 at 10:45 AM with the Maintenance Director revealed the water temperatures are always warmer on the green halls because this area is closest to the water heaters. He further indicated that water temperatures are checked weekly. Review of the facility's temperature logs from 8/5/13 through 10/21/13 revealed that eight (8) rooms per floor are checked weekly. The temperatures recorded on the logs revealed no temperatures above one hundred twenty degrees, (120) F in the residents' rooms checked. | 2017-10-01 |
| 521 | 521 | A.G. RHODES HOME, INC, THE | 115275 | 350 BOULVARD, S.E. | ATLANTA | GA | 30312 | 2020-01-16 | 554 | D | 0 | 1 | 3CHC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review the facility failed to ensure that one cognitively impaired resident (R) (#65) did not have access to and self-administer an over the counter medication of 48 sampled residents. Findings include: Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed in section (C) a Basic Interview for Mental Status score of 99 indicating severe cognitive impairment. Review of the care plan dated 8/22/19 for R#65 revealed she is at risk for impaired communication due to impaired cognition. R#65 was noted with meds, spices and other items in closet. Patient/family teaching done, items removed and given to family. During an observation on 1/13/2020 at 12:45 p.m. revealed R#65 sitting in a wheelchair in her room. She was noted to have a square shaped, opened packet in her hand and was coughing. An orange colored powder substance was observed on her lap. The packet was an Emergen-C Packet. During this time, a small three drawer plastic chest was observed next to R#65's bed. The drawers to the chest were clear allowing the ability to see inside without having to open the drawers. Inside the third drawer was a box of Emergen-C Packets that was not labeled with the resident's name or dated with an open date. The top of the box was observed to be open and there were unopened packets inside. During an observation on 1/14/2020 at 10:30 a.m., Emergen-C Packets box observed in the bottom drawer of the plastic chest sitting next to the bed of R#65. Review of the package insert information for Emergen-C Packet includes but is not limited to: Emergen-C is a nutritional supplement that contains vitamin C and other nutrients designed to boost your immune system and increase energy. It can be mixed with water to create a beverage and is a popular choice during cold and flu season for extra protection against infections. During an interview on 1/15/2020 at 10:00 a.m. with Licensed Practical Nurse (LPN) BB … | 2020-09-01 |
| 522 | 522 | A.G. RHODES HOME, INC, THE | 115275 | 350 BOULVARD, S.E. | ATLANTA | GA | 30312 | 2020-01-16 | 585 | D | 0 | 1 | 3CHC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident/staff interviews, and review of the facility policy titled, Grievances and Enforcement the facility failed to communicate and document grievance decisions to resident's family for two residents (R) (A and B) of 48 sampled residents. Findings Include: Review of the facility policy titled, Grievances and Enforcement dated (MONTH) 2014 revealed the Administrator or his/her designee shall act to resolve the complaint or shall respond to the complaint within three business days, including in the response a description of the review and appeal rights. 1. Review of the Grievance/ Concern Report dated 12/3/19 revealed family of R A filed a grievance with the facility. Corrective action included in-services for staff. The section of the grievance titled For Office Use Only was completely blank including notification of the date the facility responded to the person filing the grievance and if the complaint was resolved to the satisfaction of the resident/ resident's representative. Interview with the family of R A on 1/15/2020 at 12:20 p.m. revealed a grievance was filed. Family of R A denied receiving written or oral communication regarding the status or conclusion of the grievance. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed R A with a Brief Interview of Mental Status (BIMS) score of 7 indicating severely impaired cognition. 2. Interview with the family of R B on 1/15/2020 at 12:15 p.m. revealed a grievance was filed. Family of R B denied receiving written or oral communication regarding the status or conclusion of the grievance. Review of the MDS Significant Change assessment dated [DATE] revealed R B was unable to complete the BIMS assessment. Review of the Grievance Log from (MONTH) 2019 through (MONTH) 2020 revealed no documentation of associated grievances filed by the family of R B. All forms in the log did not address or specify what the status of grievances were, if the incidents had … | 2020-09-01 |
| 523 | 523 | A.G. RHODES HOME, INC, THE | 115275 | 350 BOULVARD, S.E. | ATLANTA | GA | 30312 | 2020-01-16 | 812 | F | 0 | 1 | 3CHC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and review of the facility policy titled, Food Storage and Handling, the facility failed to ensure opened frozen food items in the walk-in freezer and food items in the dry storage area were securely wrapped, labeled and dated; and failed to discard a food item by the use by date. In addition, the facility failed to maintain sanitary conditions of the two stand-alone ovens and the fryer. This practice had the potential to effect 127 of 131 residents receiving an oral diet. Findings Include: A review of the undated facility policy titled, Food Storage and Handling revealed that it is the policy of the Dining Services Department to cover, label, date, and store all foods in a safe, and appropriate manner to prevent food borne illness. Procedure: all cooked foods, pre-packaged open containers, protein-based salads, desserts and canned fruits are labeled, dated, and secure covered. Food Storage: unopened foods in refrigerator or dry storeroom, storage life is per manufacturer's guideline or supplier labeled guidelines (i.e. used by date). Procedure: Dating System for Open Foods, documented the facility will follow the U-Labeling P&P, to always securely cover food item. Using a label, complete the following: write the expiration date on the product using the guide, clearly write the products name, then return to designated storage (refrigeration, freezer or storeroom.) Check labels daily and discard outdated food. An initial observation and tour of the kitchen was conducted with the Food Service Director (FSD). The observational tour conducted on [DATE] from 9:50 a.m. to 10:20 a.m. of the kitchen and food storage areas revealed two ovens attached to the gas stove not in use. Two double stacked stand-alone ovens in use were dirty, containing old food debris and baked on grease on all shelves and the bottom of both ovens. The fryer oil appeared dirty with small particles of food debris floating in the oil. An o… | 2020-09-01 |
| 524 | 524 | A.G. RHODES HOME, INC, THE | 115275 | 350 BOULVARD, S.E. | ATLANTA | GA | 30312 | 2020-01-16 | 814 | F | 1 | 1 | 3CHC11 | > Based on observation, staff interview, and review of the facility policies titled, Grounds Cleanliness Policy and Disposal of Garbage and Refuse, the facility failed to ensure that trash was disposed of in a sanitary manner and failed to ensure that areas surrounding the compactor were free of trash debris. The facility census was 131. Findings include: A review conducted of the undated policies titled, Disposal of Garbage and Refuse revealed: Policy Explanation and Compliance Guidelines: 7. Refuse containers and dumpsters kept outside the facility shall be designed and constructed to have tightly fitting lids, doors, or covers. Surrounding areas shall be kept clean so that accumulation of debris and insect/rodent attractions are minimized. 8. Garbage should not accumulate or be left outside the dumpster. Review of the facility policy titled, Grounds Cleanliness Policy revealed: 5. The ground's crew clean the entire campus at least weekly. 6. Daily/weekly rounds are made by maintenance staff to make sure that grounds are clean and safe. An initial tour and observation was conducted on 1/13/2020 from 9:50 a.m. to 10:30 a.m. with the Food Service Director (FSD). The tour was of the kitchen, the kitchen back door area, the loading dock, the grease trap, and the garbage/refuse disposal area surrounding the compactor. The grease trap container located on the loading dock outside the back-kitchen door had a moderate amount of scrap wood and broken down/flat cardboard boxes lying on top of the trap. Access was blocked for any disposal of oil/or grease into the trap. Discarded plastic wrappings were observed on the floor behind the grease trap. The FSD explained that when the grease trap is full, she will call the vendor. She then confirmed the wood and cardboard should not be on the trap and she would have the Maintenance Director (MD) remove the items. Further observations of the kitchen loading dock revealed the trash compactor on the lower level. Observation of trash debris included but was not limited to the follo… | 2020-09-01 |
| 525 | 525 | A.G. RHODES HOME, INC, THE | 115275 | 350 BOULVARD, S.E. | ATLANTA | GA | 30312 | 2020-01-16 | 880 | D | 0 | 1 | 3CHC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interview, record review, and review of the Isolation - Notices of Transmission-Based Precautions, the facility failed to initiate contact precautions in a timely manner for one resident (R) (#86) on one of three floors. Findings include: During an interview on 1/15/2020 at 10:30 a.m. with R#86 she pulled her blouse away from her left shoulder to reveal blistering going down her shoulder. She stated she was diagnosed with [REDACTED]. During this time an observation was made of the resident's door, and outside the door, for a sign indicating to check with the nurse prior to entering, and there was no sign, and no Personal Protective Equipment (PPE) cart located outside of the room of R#86. During an interview on 1/15/2020 at 10:35 a.m. with Licensed Practical Nurse (LPN) DD she stated when someone is on transmission-based precautions there is a sign on the door stating, Check with nurse before entering room. She stated she was made aware that R#86 is on transmission-based precautions and confirmed there is no sign on the door and there is no PPE cart located outside the door. During an interview on 1/15/2020 at 10:40 a.m. with the DON he stated he was not made aware R#86 was diagnosed with [REDACTED]. During an interview on 1/15/2020 at 10:50 a.m. with the ADON and LPN CC, the ADON stated that he was made aware that R#86 was diagnosed with [REDACTED]. He stated putting a sign on the door would be a dignity issues so the staff advise visitors before they enter the room, they will need PPE. He stated that contact precautions should be considered and used on all residents and a PPE cart and sign was not needed. During an interview on 1/15/2020 at 11:10 a.m. with the DON he provided a copy of the facility isolation policy and stated that R#86 should have had a sign placed on the door and a PPE cart placed just outside the door when the [DIAGNOSES REDACTED]. During an interview on 1/16/2020 at 1:19 p.m. with… | 2020-09-01 |
| 526 | 526 | A.G. RHODES HOME, INC, THE | 115275 | 350 BOULVARD, S.E. | ATLANTA | GA | 30312 | 2018-08-30 | 656 | D | 0 | 1 | S7OL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to follow the plan of care related to [MEDICAL CONDITION] medications and behaviors for one resident (#68) from a sample of 44 residents. Findings include: A review of the clinical records revealed that Resident (R) #68 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the physician order [REDACTED]. A review of the Minimum Data Set (MDS) assessment records for Resident (R) #68 revealed a quarterly assessment dated [DATE] which revealed an active [DIAGNOSES REDACTED]. A further review of the MDS records for R#68 revealed an Admission assessment of 1/3/18 which also documented the resident had an active [DIAGNOSES REDACTED]. Under the Care Area Assessment Summary (CAAS) of that assessment, [MEDICAL CONDITION] drug and behavioral symptoms use triggered and the decision was made to complete a plan of care for those areas. Review of the Plan of Care records for R#68 revealed a plan of care, last updated on 6/15/18, for behaviors and a risk for complications/side effects related to the resident's use of [MEDICAL CONDITION] medications. Interventions included an attempt by the pharmacy consultant and physician of a gradual dose reduction unless the physician documented that a further reduction was contraindicated. A review of the pharmacy records revealed a recommendation on 7/11/18 for the resident's order for [MEDICATION NAME] 50 mg at bedtime to be reduced to 25 mg. A further review of the records revealed that the physician agreed with this recommendation on 7/17 18. A further review of the pharmacy records revealed that during the next medication review visit on 8/2/18, the consultant pharmacist documented that the physician agreed with the dose reduction for the [MEDICATION NAME] on 7/17/18, but that the dose reduction had not been carried out. Review of the Medication Administration Records (MARs) for (MONTH) and (MONTH) (YEAR) revealed the resident c… | 2020-09-01 |
| 527 | 527 | A.G. RHODES HOME, INC, THE | 115275 | 350 BOULVARD, S.E. | ATLANTA | GA | 30312 | 2018-08-30 | 758 | D | 0 | 1 | S7OL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of the pharmacy agreement, the facility failed to reduce the dose of an antidepressant medication for one resident (#68) from a sample of 44 residents after the pharmacist recommended and the physician agreed on a dose reduction. Findings include: A review of the Consultant Pharmacist Agreement dated 1/1/17 revealed that unnecessary drugs, including those given for excessive duration, will be identified by the pharmacist and reported to the attending physician, medical director, and director of nursing for action. A review of the clinical records revealed that Resident (R) #68 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the physician order [REDACTED]. A review of the pharmacy records revealed a recommendation by the consulting pharmacist on 7/11/18 for the resident's order for [MEDICATION NAME] 50 mg at bedtime to be reduced to 25 mg. A further review of the records revealed that the physician agreed with this on 7/17 18 and indicated that orders should be written to that effect. A further review of the pharmacy records revealed that during the next medication review visit on 8/2/18, the consultant pharmacist documented that the physician agreed with the dose reduction for the [MEDICATION NAME] on 7/17/18, but that the dose reduction had not been carried out. Review of the Medication Administration Records (MARs) for (MONTH) and (MONTH) (YEAR) revealed the resident continued to receive [MEDICATION NAME] 50 mg at bedtime as of August29, (YEAR). A review of the nurses' notes after (MONTH) 17, (YEAR) revealed no reference to the requested dose reduction, nor any explanation of why the dose reduction was not done. During an interview on 8/30/18 at 10:58 a.m. with Licensed Practical Nurse (LPN) AA it was revealed that the nurses ensure the physician/nurse practitioner sees all dose reduction recommendations as soon as possible after the pharmacist writes them. If… | 2020-09-01 |
| 4176 | 4176 | A.G. RHODES HOME, INC, THE | 115275 | 350 BOULVARD, S.E. | ATLANTA | GA | 30312 | 2016-02-11 | 252 | D | 0 | 1 | QEDL11 | Based on observation and staff interview, the facility failed to provide a homelike environment during meal service in one (1) of three (3) dining areas. The census of the facility was one hundred twenty-two (122), and one hundred twelve (112) residents received an oral diet. Findings include: During observations in the second floor resident dining area on 02/08/16 at 1:25 p.m. and on 02/11/16 at 9:00 a.m. revealed six (6) nursing staff distributing twenty (20) lunch meal trays and eighteen (18) breakfast meal trays to residents. Continued observation revealed that staff delivered and set up the residents' meals by placing the brown rectangular serving tray that contained the plated food items, beverages, condiments, and silverware in front of them. Further observation revealed that the staff did not remove the items from the meal trays. Observation on 02/11/16 at 9:15 a.m. in the first floor resident dining area revealed that four (4) nursing staff distributed fifteen (15) breakfast meals to the residents. Further observervation revealed that the staff removed the food items, beverages, condiments, and silverware from the tray before placing them in front of the residents. Interview on 02/11/16 at 9:05 a.m. with the wound treatment nurse revealed that she usually assisted with feeding residents on the second floor for breakfast and lunch. Continued interview revealed that she had only been told to uncover the food items for the residents, but had not been told to take items off of the tray when the items were served. During further interview, she stated that staff had not been inserviced on how to present resident meals. The treatment nurse further stated that the residents that ate in the second floor dining room needed feeding assistance, or had decreased cognition and needed to be supervised. During interview with the Director of Nurses (DON) on 02/11/16 at 9:25 a.m., he stated that he did not expect staff to remove plated food items from the meal trays, and that he did not have a policy regarding meal delive… | 2020-02-01 |
| 4177 | 4177 | A.G. RHODES HOME, INC, THE | 115275 | 350 BOULVARD, S.E. | ATLANTA | GA | 30312 | 2016-02-11 | 363 | D | 0 | 1 | QEDL11 | Based on observation, record review, and staff interview, the facility failed to follow the pre-planned menu at one (1) lunch meal for eighteen (18) residents receiving a pureed diet. One hundred and twelve (112) residents in the facility received an oral diet. Findings include: Review of the pre-planned dietary menu for lunch on Wednesday (02/10/16) revealed that the pureed consistency meal was listed as puree roast pork, mashed potatoes, puree squash casserole, puree bread, puree blueberry cobbler, margarine, unsweetened iced tea and whole milk. Observation of the posted menu located in the main dining room and all four (4) resident units revealed that the lunch meal was listed as country pork chops, white rice, squash casserole, dinner roll, blueberry cobbler, margarine, and unsweetened iced tea. On 02/10/16 at 12:20 a.m., dietary cook CC was observed plating a resident's pureed lunch meal, and it consisted of pureed pork, pureed rice, and pureed carrots. During interview with dietary cook BB on 02/10/16 at 12:25 p.m, she stated that the Dietary Manager told her to make pureed rice instead of pureed mashed potatoes, as well as to substitute pureed carrots for the squash casserole. During further interview, cook BB stated that they did not use production sheets that had the actual number of residents that received a regular, mechanical soft, renal, or pureed diet, but that the dietary staff just knew how much of each to prepare. During interview with the Dietary Manager on 02/10/16 at 12:50 p.m., she verified that the residents on a pureed diet received pureed white rice and pureed carrots for lunch instead of mashed potatoes and pureed squash casserole as specified by the pre-planned menu. The Dietary Manager further stated that the staff were supposed to notify the Registered Dietitian (RD) when a substitution was made to the menu, and that the dietitian was aware of the menu substitution but had not completed the form indicating which food items had been substituted. During interview with the RD on 02/10/16 … | 2020-02-01 |
| 4178 | 4178 | A.G. RHODES HOME, INC, THE | 115275 | 350 BOULVARD, S.E. | ATLANTA | GA | 30312 | 2016-02-11 | 371 | E | 0 | 1 | QEDL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility failed to label, date, and securely wrap opened food items in the walk-in freezer and in three (3) of four (4) resident/staff refrigerators; failed to have male staff wear a beard guard at all times while preparing food items; and failed to discard expired food items in one (1) of four (4) resident/staff refrigerators. There were one hundred and two (102) residents in the facility that received an oral diet. Findings include: 1. During observations in the walk-in freezer on 02/08/16 at 10:30 a.m., the following concerns were noted: There was an opened box of SaraLee frozen dinner roll dough in a blue bag, and the blue bag had a hole the size of a grapefruit, exposing the food product inside. There was an opened and wrapped package of whole wheat tortilla shells that was not labeled with an open date. There was a brown bag of french fries that was opened, tied off at the top, but not labeled with the open date. There was an unsealed Ziploc bag that contained a plastic-wrapped pink food item, which measured six (6) inches in length, four (4) inches in width, and two (2) inches thick. This pink food item was labeled with a date, but did not identify the food product inside the plastic bag. There was a clear plastic bag that contained an off-white frozen food product that was not labeled with a date. There were two (2) hot dog buns in a clear plastic bag stored behind a case of food, and the bag was not labeled with a date. During interview with the Dietary Manager (DM) on 02/08/16 at 10:45 a.m., she verified that there was a large hole in the blue SaraLee bag, that the frozen dough could be seen, and that the staff had made this hole. During further interview, she stated that she expected the staff to unwrap the food product, then re-wrap it. Upon further interview, the DM confirmed that there was no label or date on the opened package of whole wheat tortillas, no date on the… | 2020-02-01 |
| 6569 | 6569 | A.G. RHODES HOME, INC, THE | 115275 | 350 BOULVARD, S.E. | ATLANTA | GA | 30312 | 2013-05-16 | 323 | D | 0 | 1 | BVHM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interviews, the facility failed to ensure that mats were placed beside the bed for safety for one (1) resident (#17) from a sample of thirty one (31) residents: Findings include: Observations made on 5/15/13 at 2:19pm and 3:00pm revealed resident # 17 in a low bed with no mats placed beside the bed. Record review revealed a physician's orders [REDACTED].#17 to be in a Low bed with two (2) mats on the floor when in bed - Day, Evening and Night shift everyday. Interview with Licensed Practical Nurse (LPN) AA on 5/16/13 at 10:02 am revealed resident #17 should have mats on the floor beside the bed when the resident is in bed at all time for safety. AA further indicated that the resident often rolls out of the bed. Interview with Certified Nursing Assistant (CNA) BB on 5/16/13 at 10:30 am revealed that she did not put the mats on the floor when she put resident #17 in the bed. | 2017-11-01 |
| 8299 | 8299 | A.G. RHODES HOME, INC, THE | 115275 | 350 BOULVARD, S.E. | ATLANTA | GA | 30312 | 2011-11-10 | 309 | D | 0 | 1 | MNRU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of Physician's orders, the Medication Administration Records (MAR) and staff interviews, the facility failed to ensure that physician's orders were followed for one (1) resident (#154) from a sample of twenty seven (27) residents. Findings include: Review of a physician's order dated 6/16/11 for resident #154 indicated [MEDICATION NAME] HCL 25mg (3) every six (6) hours at 0500, 1100, 1700, and 2300. Hold medication for systolic blood pressure (SBP) less than 120 (SBP Review of the MARs for September, October, and November 2011 indicated that the [MEDICATION NAME] 75mg was administered fifteen (15) times when the SBP was below 120, and there were three (3) times when there was no evidence that blood pressure (B/P) or medication were done/given. September 2011 MAR: On 9/2/11 at 11:00am, B/P was 110/68 and [MEDICATION NAME] was given On 9/5/11 at 5:00am, B/P was 115/69, and medication was given On 9/5/11 at 5:00pm, B/P was 118/68, and medication was given On 9/6/11 at 11:00am, B/P was 110/60, and medication was given On 9/19/11 at 5:00pm, B/P was 102/62, and medication was given On 9/19/11 at 11:00pm, B/P was 102/62, and medication was given On 9/27/11 at 11:00am, there was no evidence on the MAR indicated [REDACTED]. October 2011 MAR: On 10/4/11 at 11:00am there was no evidence that the B/P was taken or that medication was administered. On 10/14/11 at 5:00am, B/P was 107/67, and medication was given On 10/22/11 at 5:00am, B/P was 112/67, and medication was given On 10/24/11 at 5:00am, B/P was 117/66, and medication was given On 10/24/11 at 5:00pm, B/P was 116/73, and medication was given On 10/27/11 at 5:00pm, B/P was 118/60, and medication was given On 10/28/11 at 11:00am B/P was 119/60, and medication was given November 2011 MAR: On 11/1/11 at 5:00am, B/P was 105/59, and medication was given On 11/3/11 at 11:00am there was no evidence that the B/P was taken or that medication was administered. On 11/4/11 at 11:00am, B/P was 10… | 2016-03-01 |
| 5952 | 5952 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2012-12-06 | 241 | D | 0 | 1 | I2VT11 | Based on observations and staff interviews, it was determined that the facility failed to promote the dignity of one resident (#35) from a total sample of 34 residents. Findings include: Licensed nursing staff coded resident #35 as totally dependent for dressing on the 9/12/12 quarterly Minimum Data Set (MDS) assessment. The resident was observed to have been dressed in a hospital gown and sweat pants while out of bed in a geri chair on 12/4/12 at 8:32 a.m., 3:10 p.m. and 5:00 p.m., on 12/5/12 at 8:10 a.m., 9:15 a.m., 10:00 a.m., 1:10 p.m., 2:25 p.m., 3:45 p.m. and 4:44 p.m., and on 12/6/12 at 7:50 a.m., 9:02 a.m., 9:45 a.m. and 11:10 a.m. During an interview on 12/6/12 at 9:50 a.m., certified nursing assistant CC stated that the reason the resident had been dressed in a hospital gown was because, it was easier. On 12/6/12 at 12:15 p.m., the Director of Nursing (DON) stated that she was not aware that resident #35 was being dressed in a hospital gown daily. The DON said that, if she would have known, the staff would have gotten the resident a different type of shirt to wear when he was out of bed. | 2018-05-01 |
| 5953 | 5953 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2012-12-06 | 282 | D | 0 | 1 | I2VT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and record reviews, it was determined that the facility failed to ensure that care plan interventions were implemented for one resident (#26) from a sample of two residents with gastrostomy feeding tubes and for two residents(#35 and #70) from a sample of four residents with limitations in range of motion in a total sample of 34 residents. Findings include: 1. Resident #26 had a care plan interventions since at least 1/20/09 for nursing staff to keep the head of the resident's bed elevated 30 degrees and for licensed nursing staff to continuously infuse [MEDICATION NAME] AC formula at 50 milliliters (ml) per hour through a gastrostomy tube. However, it was observed on 12/3/12 at 11:45 a.m., 1:05 p.m., 3:40 p.m. and 4:10 p.m., and on 12/4/12 at 3:30 p.m. and 4:40 p.m., that the head of the resident's bed was not elevated 30 degrees while formula was infusing at 50 milliliters per hour. It was also observed that on 12/5/12 from 8:05 a.m. until 11:10 a.m. that licensed nursing staff had failed to administer [MEDICATION NAME] AC formula to the resident as ordered. See F322 for additional information regarding resident #26. 2. Resident #35 had a care plan intervention since at least 1/4/12 for nursing staff to apply a left hand grip splint and a right hand theraplus in the morning and remove them in the afternoon. However, it was observed that nursing staff had not applied those devices to the resident's hands on 12/4/12 at 3:10 p.m. and 5:00 p.m., on 12/5/12 at 8:10 a.m., 9:15 a.m., 10:00 a.m., 1:10 p.m., 2:25 p.m., 3:45 p.m. and 4:55 p.m., and on 12/6/12 at 7:50 a.m., 9:02 a.m. and 9:45 a.m. See F318 for additional information regarding resident #35. 3. Resident #70 had a care plan since 3/25/10 to address his/her dependence in activities of daily living (ADLs) related to his/her mobility and due to severe contractures. There was a handwritten intervention on that plan for the provision of a range of motion program by resto… | 2018-05-01 |
| 5954 | 5954 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2012-12-06 | 312 | D | 0 | 1 | I2VT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview with a resident and staff, it was determined that the facility failed to provide assistance with nail and/or skin care for two (A and #70) of the 34 sampled residents. Findings include: 1. According to the Western Schools Nursing Care of the Older Adult, second edition, good skin care for older adults included the use of skin moisturizers daily. However, nursing staff failed to address the identified problem of dry and scaly skin for resident A. Resident A was admitted to the facility in August, 2012. Licensed nursing staff documented on the 8/24/12 Admission Nursing Assessment that resident A had dry skin on both of his/her the lower extremities. A body diagram was circled on the resident's feet and shins to designate the areas of dry skin. The nurse noted in the special treatments and procedures section the word moisturizer. On the 8/31/12 admission Minimum Data Set (MDS) assessment, licensed staff had documented that the resident needed extensive assistance with ADLs, and received hospice services. The resident had a care plan since 9/19/12 to address his/her risk for impaired skin integrity related to his/her level of mobility (bedbound) and thin, fragile skin. There was an intervention for nursing staff to observe the resident's skin daily during routine care. However, there was not an intervention to describe the treatment and services to be that provided to address the resident's dry skin. However according to the December, 2012 ADL flow sheet, Resident A was supposed to have been assisted or supervised by facility staff with bed mobility, transfers, dressing, grooming, bathing and mouth care each day on each shift It was observed on 12/05/12 at 8:30 a.m. that resident A had dry and scaly skin on the front of both of his/her legs. Resident A said that he/she only received baths and skin care (lotion) from the hospice aide on Tuesdays and Thursdays but, the facility staff did not bathe h… | 2018-05-01 |
| 5955 | 5955 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2012-12-06 | 318 | D | 0 | 1 | I2VT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interview, it was determined that the facility failed to ensure hand splints were used to prevent further decline in range of motion for two residents (#35 and #70) in a sample of four residents with range of motion limitations from a total sample of 34 residents. Findings include: 1. During an interview on 12/04/12 at 8:29 a.m., licensed nursing staff reported that resident #35 had contractures and that his/her arms were drawn up against his/her chest. Licensed nursing staff completed a quarterly Minimum Data Set (MDS) assessment on 9/12/12 and coded resident #35 with functional limitations in his/her upper extremities on both sides. There was a care plan intervention since at least 1/04/12 for nursing staff to apply a left hand grip splint and a theraplus in his/her right hand in the morning and remove them in the afternoon. However, it was observed that nursing staff had not applied any device to the resident's hands on 12/4/12 at 3:10 p.m. , on 12/5/12 at 8:10 a.m., 9:15 a.m., 10:00 a.m., 1:10 p.m., 2:25 p.m., 3:45 p.m. and 4:55 p.m., and on 12/6/12 at 7:50 a.m., 9:02 a.m. and 9:45 a.m. On 12/6/12 at 9:45 a.m., restorative certified nursing assistant DD confirmed that the resident did not have the splints in place but, she did not know why. During an interview on 12/06/12 at 12:20 p.m., the Director of Nursing (DON) did not know why staff had not applied the resident's splints/hand rolls as needed. 2. Resident #70 had a [DIAGNOSES REDACTED]. The staff coded the resident on his/her 8/30/12 quarterly MDS assessment as having impaired range of motion on both sides of his/her upper and lower extremities. The resident's care plan since 3/25/10 noted that she/he was dependent on staff to meet all of his/her activities of daily living (ADL) needs related severe contractures. Staff documented on the care plan that the restorative nursing staff would provide range of motion exercises for the resident … | 2018-05-01 |
| 5956 | 5956 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2012-12-06 | 322 | D | 0 | 1 | I2VT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, it was determined that the facility failed to provide appropriate services to prevent complications and to provide formula via tube feedings as ordered for one resident (#26) from a sample of two residents with gastrostomy tubes from a total sample of 34 residents. Findings include: According to the American Society of Consultant Pharmacists Medication Guide for the Long Term Care Nurse, licensed nursing staff was to ensure that the resident's head of the bed was elevated 30 - 45 degrees, and to check for stomach residual prior to administering medications. However, nursing staff failed to maintain the head of the bed elevated at 30 degrees for resident #26 and failed to check for stomach residual prior to administering medications. Resident #26 had [DIAGNOSES REDACTED]. The resident had a gastrostomy tube in place and a physician's orders [REDACTED]. There were care plan interventions since at least 1/20/09 for the following: nursing staff to keep the resident's head of the bed elevated 30 degrees; for licensed nursing staff to infuse [MEDICATION NAME] AC formula continuously at a rate of 50 ml per hour via the gastrostomy tube and; to check for residual feeding every shift and if it was greater than 100 ml to hold administration of the formula for one hour then resume it but if remained greater than 100 ml then notify the doctor. However, it was observed that staff had only elevated the head of the resident's bed 10 degrees while the tube feeding was infusing on 12/03/12 at 11:45 a.m., 1:05 p.m., 3:40 p.m. and 4:10 p.m. It was observed that the tube feeding was infusing on 12/04/12 at 3:30 p.m. and 4:40 p.m. but, the head of the resident's bed was elevated only approximately five (5) degrees. It was observed on 12/05/12 at 8:05 a.m., 8:32 a.m., 9:30 a.m., 10:30 a.m., and 10:50 a.m. that the head of the resident's bed had not been elevated so, he/she was laying flat. Although, the tube… | 2018-05-01 |
| 5957 | 5957 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2014-10-23 | 174 | E | 0 | 1 | N8EW11 | Based on observation, staff interviews, and resident interviews the facility failed to provide reasonable access to the private use of a telephone without being overheard by staff or other residents for four (4) residents (#13, 86, #91 and A) of a forty (40) sampled residents. Findings include: 1. Observation on 10/21/14 at 2:27 p.m. of resident # 91 standing at the nurse's station using the phone. The resident stated after getting off the phone that that she is aware that the residents are suppose to have privacy while on the phone, but doesn't know how much privacy is possible with everyone standing around during her call and she doesn't even have a chair to sit down in. An interview with the family of resident A on 10/22/14 at 10:00 a.m. revealed that when she calls and talks to her brother, she feels that he can not carry on a conversation because she can hear the conversations of people standing next to him better than she can hear him talking. She stated that his speech is not clear and he is easily distracted by the others around him. An interview on 10/22/14 at 11:15 a.m. with Licensed Practical Nurse (LPN) KK revealed that residents can come to the nurse's station whenever they want to use the phone. The residents are not allowed in the office but the staff will dial the number and pass the phone through the window. Continued interview with LPN KK revealed that they can either go to the Director of Nursing (DON)'s office or the Social Worker's office. An interview with the DON) on 10/23/14 at 3:15 p.m. revealed that residents can use any of the nursing station phones at any time and if they want to talk privately they can either use her office or the social worker's office. She stated that at one time they had a cordless phone but a resident threw the phone and broke it and it hasn't been replaced. 2. During an interview on 10/20/14 at 3:29 p.m. with resident #13 revealed that there was no privacy when using the telephone at the nursing station and that their conversation could be overheard by others. Du… | 2018-05-01 |
| 5958 | 5958 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2014-10-23 | 279 | D | 0 | 1 | N8EW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observation, record review and staff interviews the facility failed to develop a care plan for refusal of care for one (1) resident (#99) who refused bathing of forty (40) sampled residents. Findings include: Record review of the Point Click Care, electronic record, for Resident #99 revealed the following Diagnoses: [REDACTED]. Observation on 10/21/14 at 9:50 a.m. and 4:30 p.m. revealed the resident had moderate facial hair, matted and unkept hair and had a body odor of old urine while wearing tan pants, which were dry. An observation on 10/22/14 7:30 a.m. of the resident in bed, wearing pajamas with a continued smell of old urine. Observation on 10/22/14 at 12:50 p.m. revealed the resident ambulating in the hallway, wearing four (4) shirts, was not shaved and continued to have a strong urine odor. An observation on 10/23/14 at 8:40 a.m. of the resident sitting in the smoking area revealed the resident was clean shaven, hair neatly combed and not matted and did not smell of urine. An interview with Certified Nursing Assistance (CNA) BB on 10/23/14 at 9:00 a.m. revealed that she had bathed the resident yesterday which was the first time in one week she had been assigned to this resident. Review of the facility bathing schedule reveals the resident is to be bathed/assisted on Monday, Wednesday and Friday's. Review of the electronic CNA charting Documentation Survey Report confirmed that on 10/22/14 the resident received a bath. Further review revealed that on 10/6, 8, 10, 17 and 20/2014 the resident was coded with 8/8 which per the Code Assessment for Point Click Care reveals the care was not given. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] and 5/24/14 revealed the resident had no behaviors of refusing care during the look back period. The resident was assessed on the Quarterly MDS dated [DATE] on the Brief Mental Interview of 4 indicating the resident has severe cognitive impairment. A telephone interview with the… | 2018-05-01 |
| 5959 | 5959 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2014-10-23 | 441 | F | 0 | 1 | N8EW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interview the facility failed in hand hygiene (hand washing) practices consistent with accepted standards of practice, to reduce the spread of infections and prevent cross-contamination during meal service and while filling cups with ice and water, in the facility's main dining room and on three (3) of three (halls). Findings include; 1. Observation on 10/20/14 at 5:06 p.m., on the 300 hall, a random Certified Nursing Assistant (CNA) was observed delivering trays to multiple rooms, knocking on doors and going in and out of rooms setting trays up, and not washing or hand sanitizing between residents. Observation on 10/20/14 5:10 p.m. of the food cart sitting on 200 hall outside of room [ROOM NUMBER]. A random CNA was observed in room [ROOM NUMBER] assisting the resident in the B bed, after finishing assisting resident with eating, the CNA brought the used food tray out and set it next to a undelivered unopened food tray on the open food cart. The CNA then pushed the food cart down the hall to room [ROOM NUMBER] and took the uneaten food tray into the room and did not wash/santitize her hands before or after delivering this new tray. An interview on 10/23/14 at 10:37 a.m. with the Director of Nursing (DON) she verified that staff should santitize their hands when they leave the resident's room. She confirms that hand santitizer is available in every room as you enter the room. The DON reveals that the facility has done many infection control education inservices for all staff. 2. Observation on 10/20/14 at 12:45 p.m. of a random Certified Nursing Assistant (CNA) passing out trays to residents in the Main Dining Room, without sanitizing or washing her hands between trays/residents. Observation of the CNA opening food containers, uncovering food and touching residents and tables without washing/santitizing her hands. Observation on 10/20/14 at 12:47 p.m. of CNA AA pushing a resident into dining room, in a wheelchai… | 2018-05-01 |
| 5960 | 5960 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2015-08-13 | 157 | D | 0 | 1 | BPJ811 | Based on record review and interviews, the facility failed to notify the resident's responsible party for changes in the resident's condition for one (1) resident (F) on a sample of twenty-six (26) residents. Findings include: Interview with the family of resident F on 08/10/15 at 4:40 p.m. revealed that if he falls I get a call but other than that they don't call me. Per the resident's clinical profile, this family member is the resident's responsible party. Interview on 08/14/15 at 1:30 p.m. with the resident revealed that if there are any changes in treatment or medication I want them to contact my brother. Medical record review revealed Nurse's Notes and Progress notes indicating laboratory tests with abnormal results, notes regarding treatments and medication changes. No reference was found indicating that the family of the resident was notified. Interview on 08/14/15 at 1:45 p.m. with the Social Services Director revealed that letters are not mailed to family inviting them to Care Plan Meetings. She further stated that some families were called, but no families have been called in a long time. She further stated that the last time this resident's family was called about a Care Plan Meeting was 10/13/14 | 2018-05-01 |
| 5961 | 5961 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2015-08-13 | 161 | B | 0 | 1 | BPJ811 | Based on record review and staff interview the facility failed to maintain a surety bond of appropriate value to secure residents funds. The resident census eighty-eight. Findings include A review of the Resident Trust Fund Statements revealed that the fund balances for April, May, June and July 2015 all exceeded the $75,000 value of the surety bond. Balances ranged from 63,094.22 to 98,567.95. During an interview on 08/14/15 at 3:51 p.m. with the Business Office Manager, it was confirmed that the bank statements balances for April, May, June and July 2015 exceeded the amount of the current surety bond and did not adequately secure the resident's personal funds. | 2018-05-01 |
| 5962 | 5962 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2015-08-13 | 223 | D | 0 | 1 | BPJ813 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility self-reported incidents, interview and policy review, the facility failed to protect residents from abuse. This deficient practice affected one (R74) of two residents sampled as evidenced by the review of two incident reports for abuse. Findings included: Review of the facility self-reported incident completed on 1/25/16 revealed a staff member was observed pushing a resident (R74) down the hallway with excessive force on 1/22/16. Further review of the report revealed the time of the incident had not been documented. The allegation also identified a Licensed Practical Nurse (LPN)2, who had pushed R74 with excessive force. Review of the facility investigation revealed the process initiated to prevent further incidents was Social Service Designee (SSD) 1 had spoken to LPN 2 about the harsh treatment per documentation on the incident investigation report completed on 1/25/16. There was no documented evidence of an attempt to interview R74 or other residents on the 100 Hall. LPN2 continued to work in the facility on 1/22/16 to the end of the shift. Review of the record for R74 revealed [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Assessment ((MDS) dated [DATE] revealed the resident had documented behaviors of wandering. Review of the care plan dated 7/31/15, revealed staff was to redirect the resident away from the area to his room and provide medications as ordered. Interview on 2/6/16 at 10:45 a.m., the Director of Nursing (DON) acknowledged she was not aware of the incident until 1/25/16 when it was reported by Social Service. The DON stated that LPN2 had quit on 1/25/16 related to her pay check bounced. The DON verified LPN2 continued to work after the incident through the end of the shift on 1/22/16 and for an additional two days. Interview with SSD1 on 2/6/16 at 11:00 a.m. identified LPN2 as the staff person she witnessed using excessive force to push R74 on 1/22/16 about 5:30 p.m. SSD1 stated R74 w… | 2018-05-01 |
| 5963 | 5963 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2015-08-13 | 225 | D | 0 | 1 | BPJ813 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of a facility self-reported incident, interview and review of facility policy, the facility failed to report the abuse immediately (within 24 hours) of a resident (R74) for one of two residents reviewed. Findings included: Review of the facility self-reported incident dated 1/25/16 identified a staff member was observed pushing a resident down the hallway with excessive force on 1/22/16. Further review of the report revealed the time of the incident had not been documented. The allegation also identified a Licensed Practical Nurse (LPN) 2, who had pushed R74 with excessive force. Review of the facility investigation revealed the report was dated 1/25/16, three days after the incident occurred on 1/22/16. The report indicated the steps taken to prevent further incidents included the Social Service Designee (SSD)1 had spoken to LPN2 about the harsh treatment of [REDACTED]. LPN2 continued to work to the end of the shift and 12 hour shifts on the next two days, Saturday and Sunday, before resigning on Monday 1/25/16. In addition, the initial report of an abuse investigation to the state agency was not completed until 1/25/16. Interview on 2/6/16 at 10:45 a.m., the Director of Nursing (DON) acknowledged she was not aware of the incident until 1/25/16 when it was reported by Social Service. The DON stated that LPN 2 had quit on 1/25/16 related to her pay check bounced. The DON verified LPN 2 continued to work after the incident through the end of the shift on 1/22/16 and for an additional two days. Review of the investigation continued with the DON and with the conclusion the incident did not confirm the allegation of abuse. The DON concluded, based on the statement by LPN2, that it may have looked like she (LPN2) pushed R74 but stated she didn't. The DON was questioned regarding the two witnesses who confirmed LPN2 had used excessive force and shoved R74 down the hall; however, the DON just shrugged her shoulders and stated She alr… | 2018-05-01 |
| 5964 | 5964 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2015-08-13 | 226 | E | 0 | 1 | BPJ811 | Based on record review, observations, and interviews, the facility failed to report to the State Agency eight (8) of eight (8) substantial incidents of potential abuse per policy and procedure for census sample of twenty-six and total number of residents being eighty-eight (88). Findings include: A review of medical records revealed an incident of resident to resident altercation occurring on 05/23/15. Although the family and Medical Doctor were notified of the incident, the facility did not report the potentially abusive occurrence to the State Agency as required by the facility policy for abuse prevention. Interview on 08/12/15 at 4:00 p.m. with the Administrator revealed that there were no investigations for this resident. Interview on 08/13/15 at 08:30 a.m. with the Administrator confirmed that the incident was not reported to the State Agency. Further record review revealed incidents dated 12/11/14, 03/11/15, another on 05/23/15, 06/28/15, 06/30/15, 07/12/15 and 07/29/15 that were not reported to the State Agency. Interview on 08/14/15 at 2:05 p.m. with the Administrator revealed that physical altercations between residents resulting in injuries should be reported to the State Agency and had not been. The Administrator stated that she expected all incidents with injuries to be reported as required. | 2018-05-01 |
| 5965 | 5965 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2015-08-13 | 253 | E | 0 | 1 | BPJ811 | Based on observation and interview the facility failed to provide a sanitary environment for residents on three (3) of three (3) halls. Findings include: Observation of Room 100 on 08/11/15 at 8:10 a.m. showed a heavy build up of dirt on the edges of the floor and a strong urine odor was noted in the resident bathroom. Observation in Room 112 on 08/10/15 at 4:01 p.m. showed a strong urine odor in the resident bathroom and the grout of the floor tile in the bathroom had a black discoloration. A heavy build-up of dirt along edges of the floor in the resident room was also observed. Observation in Room 104 on 08/11/15 at 8:16 a.m. showed a heavy build up of dirt along the edges of the room. Observation of Room 110 on 08/11/15 at 8:35 a.m. showed a heavy build up of dirt on the floor in the resident room and bathroom. The grout was noted to be black between tiles on the bathroom floor and there was a very strong urine odor in the bathroom. Observation of Room 112 on 08/11/15 at 08:56 a.m. showed a heavy build up of dirt along the perimeter of the room. Observation of Room 116 on 08/11/15 at 9:30 a.m. showed a build up of dirt around the edges of the floor of the room. A strong urine odor was noted in the bathroom and there was a black discoloration in the grout between the bathroom floor tiles. Observation of Room 106 on 08/11/15 at 10:02 a.m. showed a build up of dirt on the edges of room. The bathroom toilet had a leak with a puddle in the corner of the bathroom which was also reported to Licensed Practical Nurse BB at this time, and she reported the leak to maintenance. Grout in floor tile of the bathroom had a black discoloration and a strong odor of urine. Observation of Room 120 on 08/11/15 at 8:14 a.m. showed that the bathroom had a heavy build up of black substance around toilet bowl. Observation of Room 102 on 08/11/15 at 10:25 a.m. showed a heavy build up of dirt around the edges of the room on floor. Black discoloration was observed in the grout on the tile floor of the bathroom and there was a strong urin… | 2018-05-01 |
| 5966 | 5966 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2015-08-13 | 279 | D | 0 | 1 | BPJ811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews the facility failed to develop and revise a care plan for two (2) resident's # (17 and 44) from a total of twenty-six (26) sampled residents. Review of resident #17's Comprehensive Minimum Data System (MDS) revealed the resident was admitted to the facility on [DATE]. Active [DIAGNOSES REDACTED]. A review of the Electronic Medical Record (EMR) revealed that the resident had falls documented by nursing staff on 02/01/15, 02/23/15 and 07/27/15. During an interview with the Director of Nurses (DON) on 08/13/15 at 4:15 p.m. it was revealed that the nurse's on the floor do the updates to the care plan. The DON confirmed that the care plan for resident #17 was not updated or revised for falls that occurred on 02/01, 02/23, and 7/27/15. Record review for resident #44 revealed a fall from a chair on 08/09/15, resulting in an injury. Further review revealed that on 08/03/15, the resident was found sitting on the floor between the wheelchair and the bed. On 07/26/15 the resident was found lying on the floor with resulting injury. Additional falls were noted on 05/16/15 and 12/07/14. A review of the resident's plan of care indicated that the resident was at high risk for falls, with communication/comprehension difficulty, gait/balance problems, and incontinence. The Care Plan was initiated 08/22/14. All interventions were dated 08/22/14. No new interventions had been added. Interview on 08/13/15 at 2:18 p.m. with the Director of Nurses revealed that nursing and other staff are expected to update care plans as soon as possible after every fall. she also stated that new interventions should be put in place with each fall. Interview with the Administrator on 08/14/15 at 4:25 p.m. revealed that care plans should be updated with each fall and new interventions should be implemented with each fall. | 2018-05-01 |
| 5967 | 5967 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2015-08-13 | 323 | D | 0 | 1 | BPJ811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide a positioning device for a wheelchair bound resident to prevent accident and/ or injury for one (1) resident (#55) from a census sample of twenty-six (26). Findings include: Review of Lists of [DIAGNOSES REDACTED].#55 had [DIAGNOSES REDACTED]. Review of the Minimum (MDS) data set [DATE] showed the resident to have both short and long term memory problems, and that he/she required limited assistance with locomotion. Observation on 08/10/15 at 4:17 p.m. showed resident #55 to be barefoot and dragging their right foot under the wheelchair with no foot pedal on wheelchair. Interview on 08/10/15 at 4:17 p.m. with Licensed Practical Nurse (LPN) BB revealed that she had been made aware that resident was dragging their foot under wheelchair and that the resident was to have a foot pedal on their wheelchair on affected right (R) side due to (R) sided weakness. Observation on 08/12/15 at 8:10 a.m. showed that resident #55 was up in a wheelchair with slipper socks on. The resident did not have foot pedal on their wheelchair. Observation on 08/13/15 at 1:18 PM of resident #55 showed that resident was up in wheelchair with no foot pedal on the right side and resident was propelling the wheelchair independently and was dragging their right foot under the wheelchair. Observation on 08/13/15 at 1:22 p.m. revealed a missing piece of linoleum in front of the door to the resident's room that was approximately 8 x 6 inches in size and that the resident rolled directly over this area with his foot dragging under the wheelchair. Review of the resident's Care plan showed a care plan for Peripheral Vascular Disease. He also had care plans for being bed and chair bound with interventions to provide appropriate physical support during mobility, transfers and locomotion enforcing comfort and safety. Interview on 08/13/15 at 2:15 p.m. with Certified Nursing Assistant (CNA) CC, revealed that… | 2018-05-01 |
| 5968 | 5968 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2015-08-13 | 328 | D | 0 | 1 | BPJ812 | Deficiency Text Not Available | 2018-05-01 |
| 5969 | 5969 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2015-08-13 | 356 | B | 0 | 1 | BPJ812 | Deficiency Text Not Available | 2018-05-01 |
| 5970 | 5970 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2015-08-13 | 363 | F | 0 | 1 | BPJ813 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to follow the pre-planned written menus. This deficient practice had the potential to affect all of the residents who dined in this facility. Findings included: Observation of the kitchen during a complaint investigation on 2/6/16 at 11:45 a.m. revealed that the facility had two notebooks that contained written menus with serving sizes. Review of the menus revealed that the facility prepared and served a variety of therapeutic diets which included: carbohydrate controlled renal pureed mechanical soft low sodium Observation of the food that was prepared for the residents ' lunch meal on 2/6/16 at 12:00 p.m. revealed that the food that was prepared was not the food that was written on the pre-planned menu. An interview with the Dietary Manager (DM) on 2/6/16 at 12:00 p.m. confirmed that the facility did not prepare the foods that were listed on the preplanned menu. When interviewed about why the facility failed to prepare the food that was written on the menu, the DM stated that he just liked to mix things up. Per the DM the food that should have been prepared included: roast turkey gravy cornbread stuffing green bean casserole dinner roll margarine mandarin oranges Observation of the prepared food, revealed that the facility prepared the following foods: oven roasted turkey steamed cabbage sweet potatoes cornbread chocolate cake/icing baked lasagna salad/garlic bread An interview with the Registered Dietitian (RD) on 2/6/16 at 12:00 p.m. revealed that she completed the nutritional assessments for each resident who resided in this facility. The RD added that there were residents in the facility who required physician ordered therapeutic diets such as those residents with diabetes or [MEDICAL CONDITION]. When interviewed, about how she could complete a nutritional assessment or ensure that each resident had received the appropriate foods per their physician ordered diet if th… | 2018-05-01 |
| 5971 | 5971 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2015-08-13 | 371 | E | 0 | 1 | BPJ811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews the facility failed to store food under sanitary conditions for the resident census sample of twenty-six (26) and the total number of residents being eighty-eight (88). During tour on 08/13/15 at 12:30 p.m. with the Dietary Manager the following were observed in the kitchen: [MEDICATION NAME] Chloride (PVC) pipe under the dish rinse sink had an area approximately six inches long with heavy build up of corrosion on the drain line. Two galvanized metal fire extinguisher pipes hanging over the range were noted to be rusty. The bottom shelf, legs, and poles of the clean dish table were noted to have large area of chipped paint and rust. The lower shelf and legs of the microwave table had large areas of chipped paint and rust. The window sash around the dirty dish receiving area was noted to have a heavy build up of rust and large flakes of rust chipping and flaking off. The conditions listed above were confirmed at the time by the Dietary Manager. Tour with the Administrator on 08/13/15 at 1:30 p.m. confirmed the conditions. During this same tour with the Administrator, two boxed of raw potatoes were on the small porch outside the kitchen. The top of the box was partially open and flies were noted in and around the boxes. Interview on 08/13/15 at 1:30 p.m. with the Administrator revealed that her expectations were that the kitchen would be clean and free from rust and chipping paint and that there would not be food items on the back porch. | 2018-05-01 |
| 5972 | 5972 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2015-08-13 | 372 | D | 0 | 1 | BPJ811 | Based on observation and interview the facility failed to dispose of garbage and refuse properly for the census of eighty-eight (88) residents. Findings Include: 08/13/15 at 12:30 p.m. kitchen tour with the Dietary Manager revealed the following: On exiting the back kitchen door, onto the small external porch area: Clutter of multiple empty boxes, Two old unused air conditioner units, One rolling mop bucket, Two air conditioner vent covers Two boxes of raw potatoes. The top box of potatoes was noted to be partially opened and flies noted to be flying around the boxes. One fly observed on top of the potatoes box During this same tour with the Dietary Manager, the lid on the trash dumpster was noted to be raised with trash in the dumpster exposed with multiple flying insects around the inside of the dumpster. 08/13/15 at 1:30 p.m. interview with the Administrator revealed that everyone in the community uses this dumpster, especially the people in the apartments across the street. She also stated that she expected the porch area to be clean, without debris and refuse. | 2018-05-01 |
| 5973 | 5973 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2015-08-13 | 441 | E | 0 | 1 | BPJ812 | Deficiency Text Not Available | 2018-05-01 |
| 5974 | 5974 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2015-08-13 | 456 | E | 0 | 1 | BPJ811 | Based on observations and interviews the facility failed to ensure essential equipment is maintained in safe operating condition for the resident's microwave and refrigerator in the resident snack area at nurses station one for the resident census size of twenty -six and total number of residents being eighty-eight (88). 08/13/15 at 12:30 p.m. Kitchen tour with Dietary Manager revealed the following: The right side of the resident refrigerator, in pantry room at the nurses station was noted to have long area of peeling bubbled paint with a large area of chipped and peeling rust. The resident microwave, in pantry room at nurses station one, was observed to have a large area of rust along the bottom edge of internal microwave housing. An area of rust was noted to run approximately 75% along the entire width of the bottom of the internal microwave housing. Interview and tour on 08/13/15 at 1:30 p.m. with the Administrator confirmed the above conditions and rust. | 2018-05-01 |
| 5975 | 5975 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2015-08-13 | 463 | D | 0 | 1 | BPJ813 | Based on observation and interview, the facility failed to ensure two bathroom call systems on the 200 Hall had pull strings long enough to be reached by residents. This practice affected one of three hallways. Findings include: Observation of the 200 Hall shower room on 2/6/16 at 1:00 p.m. revealed the call light beside the toilet had a pull string approximately 4 inches in length. Observation of room 219 on 2/6/16 at 1:20 p.m. revealed the call light beside the toilet had a pull string approximately 4 inches in length. Interview with the Director of Nursing (DON) on 2/6/16 at 1:40 p.m. acknowledged the call light pull strings in the 200 Hall shower room and room 219 were too short. The DON stated if a resident were to be on the floor in either location they would not be able to reach the pull cord for the call system. An interview was conducted with the Administrator on 2/6/16 at 2:00 p.m. The Administrator stated she was not aware of the call light pull cords being so short. | 2018-05-01 |
| 5976 | 5976 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2015-08-13 | 465 | E | 0 | 1 | BPJ812 | Deficiency Text Not Available | 2018-05-01 |
| 5977 | 5977 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2015-08-13 | 469 | E | 0 | 1 | BPJ811 | Based on observation, interview and review of pest control contract the facility failed to provide effective pest control placing the residents at risk for insect borne illness on three (3) of three (3) halls with a census sample size of twenty-six (26) and total number of residents in facility being eighty-eight. Findings include: Observation of Room 110 on 08/11/15 at 8:35 a.m. showed an insect ran across the floor in the residents' room. Observation of Room 116 on 08/11/15 at 9:30 a.m. showed a fly in the residents' room. Observation of Room 108 on 08/11/15 at 10:44 a.m. showed a fly in the resident's room. Observation in the Sitting Room on 300 hall on 08/12/15 at 8:45 a.m. showed 7 flies. Observation in Administrative Building on 08/12/15 at 12:45 p.m. showed a large reddish-brown roach crawled across the floor. Observation of Room 108 on 08/13/15 at 9:00 a.m. showed that there was a fly in the bathroom. Observation of the hallway connecting 300 and 200 hall on 08/13/15 at 12:15 p.m. showed a resident sitting in the hallway killing flies with a fly swatter. Observation of the back hallway that led into the Dining Room on 08/13/15 at 1:17 p.m. showed a fly. Observation of the 100 hall nurses station desk on 8/13/15 showed a fly crawling on the desk. Observation of the connecting hall between 200 and 300 hall on 08/13/15 at 2:00 p.m. showed a second resident sitting in the hallway killing flies with fly swatter. Observation of the sitting room on 300 hall on 08/14/15 at 10:15 a.m. showed a resident seated on a bench with two (2) flies crawling on resident's left leg and one (1) fly crawling on her right arm. Observation of connecting hallway between 200 and 300 hall showed a resident carrying a fly swatter in wheelchair with him. Interview and tour with Head of Housekeeping on 08/13/15 at 09:10 a.m. confirmed that there were flies in resident rooms, bathrooms and hallways. Interview with Administrator on 08/13/2015 at 9:15 a.m. confirmed that there were flies in the building. | 2018-05-01 |
| 5978 | 5978 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2015-08-13 | 493 | F | 0 | 1 | BPJ812 | Based on observation and staff interview the facility failed to ensure there was an Administrator in place for the management of the facility. Findings include: During an observation and interview on 1/20/16 at 9:15 a.m. with the Director of Nursing (DON) she stated that the Administrator was not at the facility and that his last day was the previous Friday (1/15/16). Further interview revealed that an Administrator from a sister facility was on her way and that a new Administrator would be starting on Monday 1/25/16. During an interview with the Visiting Administrator on 1/20/16 at 4:00 p.m. she revealed that she was the Administrator at the Eastman Facility. She stated this was her first time at this facility and she was here because surveyors were in the building. | 2018-05-01 |
| 5979 | 5979 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2015-08-13 | 520 | F | 0 | 1 | BPJ812 | Based on record review and staff interview the facility failed to have a Quality Assessment and Assurance (QAA) process that developed and implemented an effective plan to ensure that compliance with the Plan of Correction (P(NAME)) was achieved for five (5) of ten (10) deficiencies written during the August 2015 Standard Survey (F253, F371, F372, F 456, F469). Findings include: During an interview with the Director of Nursing and Licensed Practical Nurse Unit Manager on 1/21/16 at 6:50 p.m. to 7:25 p.m. revealed that Quality Assessment and Assurance meetings are done monthly with the Administrator, Medical Director, DON, and LPN Unit Manager along with other disciplines. And, based on the data that is collected the committee decides what issues need to be addressed. The DON stated that she makes daily rounds and if issues come up she will bring it to the Quality Assurance Assessment (QAA) meeting. The DON further stated that she takes the concerns to the Administrator to address the issues and that she herself is not able to contact the Cooperate Office. She further stated that the previous Administrator informed her that he had notified the Cooperate office about the issues but had not received a response. During an interview on 1/20/16 at 4:45 p.m. with the Housekeeping Supervisor, Director of Nurses (DON) and the Visiting Administrator, Review of the the Quality Assessment Performance Improvement action plan provided by the facility, revealed the plan listed problems but did not list dates when the problems were identified. The Visiting Administrator, stated there was no way to tell when the problems were identified because it did not include dates of identification and did not address the system to identify other areas that may be affected. The surveyor questioned why the facility was in the condition it was in currently (in regards to environmental concerns) and the DON and the Housekeeping Supervisor stated that they thought it had gotten better. During an interview on 1/21/16 at 4:00 p.m. with the Visitin… | 2018-05-01 |
| 5980 | 5980 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2016-02-06 | 223 | D | 1 | 0 | R5VO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility self-reported incidents, interview and policy review, the facility failed to protect residents from abuse. This deficient practice affected one (R74) of two residents sampled as evidenced by the review of two incident reports for abuse. Findings included: Review of the facility self-reported incident completed on 1/25/16 revealed a staff member was observed pushing a resident (R74) down the hallway with excessive force on 1/22/16. Further review of the report revealed the time of the incident had not been documented. The allegation also identified a Licensed Practical Nurse (LPN)2, who had pushed R74 with excessive force. Review of the facility investigation revealed the process initiated to prevent further incidents was Social Service Designee (SSD) 1 had spoken to LPN 2 about the harsh treatment per documentation on the incident investigation report completed on 1/25/16. There was no documented evidence of an attempt to interview R74 or other residents on the 100 Hall. LPN2 continued to work in the facility on 1/22/16 to the end of the shift. Review of the record for R74 revealed [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Assessment ((MDS) dated [DATE] revealed the resident had documented behaviors of wandering. Review of the care plan dated 7/31/15, revealed staff was to redirect the resident away from the area to his room and provide medications as ordered. Interview on 2/6/16 at 10:45 a.m., the Director of Nursing (DON) acknowledged she was not aware of the incident until 1/25/16 when it was reported by Social Service. The DON stated that LPN2 had quit on 1/25/16 related to her pay check bounced. The DON verified LPN2 continued to work after the incident through the end of the shift on 1/22/16 and for an additional two days. Interview with SSD1 on 2/6/16 at 11:00 a.m. identified LPN2 as the staff person she witnessed using excessive force to push R74 on 1/22/16 about 5:30 p.m. SSD1 stated R74 w… | 2018-05-01 |
| 5981 | 5981 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2016-02-06 | 225 | D | 1 | 0 | R5VO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of a facility self-reported incident, interview and review of facility policy, the facility failed to report the abuse immediately (within 24 hours) of a resident (R74) for one of two residents reviewed. Findings included: Review of the facility self-reported incident dated 1/25/16 identified a staff member was observed pushing a resident down the hallway with excessive force on 1/22/16. Further review of the report revealed the time of the incident had not been documented. The allegation also identified a Licensed Practical Nurse (LPN) 2, who had pushed R74 with excessive force. Review of the facility investigation revealed the report was dated 1/25/16, three days after the incident occurred on 1/22/16. The report indicated the steps taken to prevent further incidents included the Social Service Designee (SSD)1 had spoken to LPN2 about the harsh treatment of [REDACTED]. LPN2 continued to work to the end of the shift and 12 hour shifts on the next two days, Saturday and Sunday, before resigning on Monday 1/25/16. In addition, the initial report of an abuse investigation to the state agency was not completed until 1/25/16. Interview on 2/6/16 at 10:45 a.m., the Director of Nursing (DON) acknowledged she was not aware of the incident until 1/25/16 when it was reported by Social Service. The DON stated that LPN 2 had quit on 1/25/16 related to her pay check bounced. The DON verified LPN 2 continued to work after the incident through the end of the shift on 1/22/16 and for an additional two days. Review of the investigation continued with the DON and with the conclusion the incident did not confirm the allegation of abuse. The DON concluded, based on the statement by LPN2, that it may have looked like she (LPN2) pushed R74 but stated she didn't. The DON was questioned regarding the two witnesses who confirmed LPN2 had used excessive force and shoved R74 down the hall; however, the DON just shrugged her shoulders and stated She alr… | 2018-05-01 |
| 5982 | 5982 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2016-02-06 | 226 | D | 1 | 0 | R5VO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of a facility self-reported incident, interview and review of the policy, the facility failed to implement the abuse policy, report the abuse immediately and failed to develop a policy with direction to protect a resident from further abuse during the investigation. This occurred for one (R74) of two investigations reviewed for abuse. Findings included: Review of the facility self-reported incident completed on 1/25/16 revealed a staff member was observed pushing a resident (R74) down the hallway with excessive force on 1/22/16. Further review of the report revealed the time of the incident had not been documented. The allegation also identified a Licensed Practical Nurse (LPN) 2, who had pushed R74 with excessive force. Review of the facility investigation revealed the process initiated to prevent further incidents was that the Social Service Designee (SSD)1 had spoken to LPN 2 about the harsh treatment. There was no documented evidence of an attempt to interview R74 or other residents on the 100 Hall. LPN2 continued to work in the facility on 1/22/16 to the end of the shift. Interview on 2/6/16 at 10:45 a.m., the Director of Nursing (DON) acknowledged she was not aware of the incident until 1/25/16 when it was reported by Social Service. The DON stated that LPN 2 had quit on 1/25/16 related to her pay check bounced. The DON verified LPN 2 continued to work after the incident through the end of the shift on 1/22/16 and for an additional two days. Interview with SSD1 on 2/6/16 at 11:00 a.m. identified LPN2 as the staff person she witnessed using excessive force to push R74 on 1/22/16 at about 5:30 p.m. SSD1 stated R74 was threatening to hit another resident and she called for help because she couldn't redirect him. SSD1 stated LPN2 responded and stepped in between the residents to protect the resident who was threatened by R74. LPN2 pushed R74 in the back twice through the door way using excessive force. SSD1felt this met the … | 2018-05-01 |
| 5983 | 5983 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2016-02-06 | 363 | F | 1 | 0 | R5VO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to follow the pre-planned written menus. This deficient practice had the potential to affect all of the residents who dined in this facility. Findings included: Observation of the kitchen during a complaint investigation on 2/6/16 at 11:45 a.m. revealed that the facility had two notebooks that contained written menus with serving sizes. Review of the menus revealed that the facility prepared and served a variety of therapeutic diets which included: carbohydrate controlled renal pureed mechanical soft low sodium Observation of the food that was prepared for the residents ' lunch meal on 2/6/16 at 12:00 p.m. revealed that the food that was prepared was not the food that was written on the pre-planned menu. An interview with the Dietary Manager (DM) on 2/6/16 at 12:00 p.m. confirmed that the facility did not prepare the foods that were listed on the preplanned menu. When interviewed about why the facility failed to prepare the food that was written on the menu, the DM stated that he just liked to mix things up. Per the DM the food that should have been prepared included: roast turkey gravy cornbread stuffing green bean casserole dinner roll margarine mandarin oranges Observation of the prepared food, revealed that the facility prepared the following foods: oven roasted turkey steamed cabbage sweet potatoes cornbread chocolate cake/icing baked lasagna salad/garlic bread An interview with the Registered Dietitian (RD) on 2/6/16 at 12:00 p.m. revealed that she completed the nutritional assessments for each resident who resided in this facility. The RD added that there were residents in the facility who required physician ordered therapeutic diets such as those residents with diabetes or [MEDICAL CONDITION]. When interviewed, about how she could complete a nutritional assessment or ensure that each resident had received the appropriate foods per their physician ordered diet if th… | 2018-05-01 |
| 5984 | 5984 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2016-02-06 | 371 | D | 1 | 0 | R5VO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure food safety when they did not: 1) follow the manufacturer's recommendations when operating the dish machine, 2) date and label potentially hazardous foods to prevent serving expired items, 3) defrost meat appropriately, 4) cover ready to eat food while stored to prevent cross contamination, and 5) sanitize their dishware in clean water. This deficient practice had the potential to affect all 87 residents who resided in this facility. Findings included: 1. Observation of the kitchen on 2/4/16 at 4:00 p.m. during a complaint investigation revealed a Dietary Aide (DA 1) had been operating the dish machine. DA 1 was observed placing four racks of dishes in the dish machine and removing the dishes from the rack after they air dried. Review of the manufacturer ' s label that was affixed to the front of the dish machine revealed the minimum water temperature for both the wash and rinse cycles were 120 degrees Fahrenheit (F). Observation of the dish machine during operation for six separate trials revealed that the water temperature did not reach 120 degrees F during all six trials. The temperature ranged from 93-98 degrees F. Review of the Dishwasher Temperature/Chemical Record dated February 2016, on 2/4/16 at 4:30 p.m., revealed the water temperature and the chemical sanitizer needed to be monitored and recorded three times each day; at breakfast, lunch and dinner. Further review of the temperature log revealed the water temperature and the parts per million (PPM- chemical sanitizer) was not recorded for lunch or dinner on 2/2/16, not recorded for any of the meals on 2/3/16, and it was not recorded for any of the meals on 2/4/15. An interview with the Dietary Manager (DM) on 2/4/16 at 4:45 p.m. revealed the facility water system was not functioning properly; consequently the water in the dish machine could not reach the minimum temperature of 120 degrees F for either … | 2018-05-01 |
| 5985 | 5985 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2016-02-06 | 456 | F | 1 | 0 | R5VO11 | Based on observation, record review and interview, the facility failed to maintain their essential equipment in safe operating condition. The facility failed to ensure that their kitchen equipment was maintained and functioning properly and failed to ensure water temperatures the hand sinks, shower rooms and laundry area contained warm water for bathing, hand washing and laundering of resident clothing. This deficient practice had the potential to affect all of the residents who resided in this facility. Findings included: 1.The following observations were made in the facility kitchen on 2/4/16 from 4:00- 5:30 p.m.: a. The convection oven that was located next to the tilt skillet had black electrical tape holding the metal piping in place on the side of the oven. In addition, the face plate that covered the electrical components was missing which exposed the components. An interview with the Dietary Cook at that time, revealed that the convection oven had been broken for approximately one month. b. Observation of the tilt skillet revealed that the electrical cord had a plastic covering that was cracked and chipped which exposed the underlying components and the on/off temperature dial on the front of the skillet was missing. Staff had to put their hands inside the metal housing to operate the skillet. Additional observation underneath the skillet revealed a large metal drain that was not functioning properly. There was approximately two inches of discolored liquid surrounding the drain which allowed the discolored liquid to leak out into the kitchen. c. Observation of the two stove/ovens behind the tilt skillet were missing the bottom face plates which exposed the electrical elements and allowed the pilot lights to remain uncovered. The fire from the pilot lights were in full view. d. Observation of the milk and beverage cooler revealed the front rubber seal was broken and not held tightly in place and there was condensation around the cooler. Inside the cooler was a thermometer that did not have a face plate cov… | 2018-05-01 |
| 5986 | 5986 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2016-02-06 | 493 | D | 1 | 0 | R5VO11 | Based on record review, interview and review of policies and procedures, the facility governing body failed to ensure: 1) each facility employee was paid timely, 2) the Quality Assurance Performance Improvement (QA/PI) committee met quarterly and had the appropriate members present, and 3) develop effective policies and procedures. This deficient practice had the potential to affect all of the residents who resided in this facility. Findings included: 1. Review of two Complaint Intake IDs; GA 800 and GA 970 received on 12/16/15 and 1/27/16 respectively, revealed that the facility might have some difficulties meeting their payroll obligations. Per the complainants, who requested to remain anonymous, the facility was in a financial bind , they were concerned that some of the employees might walk out and their payroll checks were being held. An interview with a Licensed Practical Nurse (LPN1) on 2/4/16 at 4:30 p.m. revealed that some of the nurses at this facility had not been paid per the facility policy and one LPN2 quit a few days previously due to non-payment. LPN1 added that many of the facility employees received their payroll checks late and soon after they deposited the checks, they were returned for insufficient funds. Review of the personnel file revealed LPN2 had written a note that stated, I (name of the employee) resign on 1/25/16. The note did not state why LPN2 resigned. During an interview on 2/5/16 at 2:30 p.m., Employee10 (E10) (an anonymous source) stated that she was aware of the hand written note in LPN2' s personnel file. E10 added that before LPN2 left the facility, she told E10 that she was resigning due to not receiving paychecks timely. An interview with a Nurse Aide (NA1) on 2/5/15 at 11:30 a.m. revealed the facility would hold the employee paychecks until after the bank closed for the day. NA1 added that their checks were supposed to be ready at 2:00 p.m. on paydays but the facility held their checks, until 4:00 p. m. When interviewed about why the checks were held until 4:00 p.m. on payd… | 2018-05-01 |
| 5987 | 5987 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2016-02-06 | 520 | F | 1 | 0 | R5VO11 | Based on interview and record review, the facility failed to ensure that each member of the Quality Assessment and Performance Improvement (QA/PI)) committee attended the meetings and met on a quarterly basis to address concerns that had been identified throughout the facility. The facility failed to develop plans of action with measurable goals and interventions to ensure that the identified concerns would not be repeated in the future. They failed to identify and correct concerns with, 1) the environment and housekeeping, 2) maintenance of essential equipment, 3) a properly functioning water system and 4) the lack of funds to pay their employees. This deficient practice had the potential to affect all 87 residents who resided in this facility. Findings include: 1. Review of the Statement of Deficiencies, the federal 2567 report dated 1/20/16 and the Plan of Correction (P(NAME)) for the revisit with a date certain of 2/4/16, revealed that the facility had failed to maintain the environment in a safe and sanitary fashion. 2. Observation of the kitchen on 2/4/16 from 4:00pm through 5:30pm revealed that the facility failed to maintain their essential equipment in safe operating condition. The facility ' s tilt skillet, stove/ovens, water faucets, walk-in freezer, dish machine, and convection oven were either missing parts, held together with electrical tape, or and not functioning properly. For additional information refer to F456. An interview with the Dietary Manager (DM) on 2/6/16 at 12:00pm revealed that he did not have a policy and procedure relative to how to maintain the kitchen equipment effectively. The DM stated that he did attend the QA/PI meetings but the concerns about the kitchen equipment was not discussed. When interviewed about how he could ensure that these concerns would not continue in the future if they were not addressed in the QA/PI meetings, the DM stated he was unsure. Review of the 1st Quarter Monthly QA/PI Meeting Agenda revealed that the facility was to discuss the deficient practices th… | 2018-05-01 |
| 6270 | 6270 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2015-02-20 | 257 | E | 1 | 0 | JG8W11 | Based on observation and staff interviews the facility failed to maintain a safe and comfortable temperature on one (1) (100 Hall) of three (3) halls. Findings include: During the initial tour of the facility on 2/20/15 at 10:50 a.m., the air temperature in the Men's Shower room was noted to be very cold and uncomfortable. The air temperature at that time was 65.4 degrees Fahrenheit (F). The air temperature in the Women's Shower room was 73 degrees F. During an interview with staff AA and BB on 2/20/15 at 12:15 p.m., they stated that there had not been any central heat and air for about a year. During an interview with the maintenance supervisor on 2/20/15 at 11:15 a.m., the maintenance supervisor stated that the central heating and cooling unit had been burned out since at least 3/2014. He/She further stated that he/she had submitted a bid to replace the central heating and air unit on 1/8/15 and had not yet had a response from corporate. He/She stated that it was inexcusable. | 2018-02-01 |
| 6271 | 6271 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2015-02-20 | 456 | F | 1 | 0 | JG8W11 | Based on observation and staff interviews, it was determined that the facility failed maintain one of two water heaters to ensure there was hot water on three of three halls. Findings include: During the initial tour of the facility on 2/20/15 at 10:50 a.m. with the maintenance supervisor, Director of Nursing and the housekeeping supervisor, the following rooms were checked and were found to not to have adequate hot water: Women's Shower room- 86.5 degrees Fahrenheit (F.), Men's Shower Room- 83 F., room 118- 93.2 F., room 108- 91.6 F., room 102- 91.8 F., room 101- 91.4 F., room 100- 86.9 F., room 220- 91 F., room 216- 97 F., room 214- 94 F., room 204- 94.6 F., room 201- 94 F., room 304- 88 F., room 310- 88 F., room 312- 82.6 F. and room 316- 82 F. During an interview with staff AA and BB on 2/20/15 at 12:15 p.m., they stated that there had not been adequate hot water in the resident rooms or shower for about three weeks and no heat for about a year. During a random observation on 2/20/15 at 12:30 p.m., a resident told the Director of Nursing (DON) that the shower was cold this morning. During a group interview held with four (4) residents on 2/20/15 at 1:25 p.m. it was revealed that all four (4) residents concurred that there had been no hot water for a couple of months and that it was too cold in the shower. One (1) resident stated that he/she would take a sponge bath from now on. During an interview with the maintenance supervisor on 2/20/15 at 11:15 a.m., revealed that for the last six (6) to seven (7) days there had been very little hot water in the building. He/She stated that one (1) of the two (2) hot water heaters stopped functioning a couple weeks ago which left the one (1) water heater serving the entire building, except for the laundry. He/she stated that he/she had obtained two (2) bids to replace the water heater on January 8, 2015 and January 31, 2015. He/She further stated that he/she had not received approval from corporate to replace the unit. He/She stated that the delay was inexcusable. | 2018-02-01 |
| 8545 | 8545 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2011-11-10 | 280 | D | 0 | 1 | 1JXD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and record review, it was determined that the facility failed to continue to implement planned interventions to address the positioning needs of one resident (#63) and failed to revise interventions to address continued falls for one resident (#38) in a total sample of 28 residents. Findings include: 1. On the 5/27/11 Minimum Data Set (MDS) assessment, licensed staff coded resident # 63 as having limitaton with range of motion to one side of his/her upper extremity. On the 9/1/11 MDS assessment, the resident was coded with a decline in the limited range of motion to include both of his/her upper extremities. There was a care plan since 8/28/10 to address his/her risk for injury from falls due to limited mobility, havig been bed to gerichair bound and having [MEDICAL CONDITION] and a [MEDICAL CONDITION] disorder. The interventions included having the call light close (to the resident) and for staff to promptly answer it, staff providing all activities of daily living, for staff to transfer the resident with the hoya lift, and staff to monitor the resident for positioning for possible injury. A new intervention was added on 8/22/11 for the resident to be screened by occupational therapy services for an evaluation if indicated. However, although the resident was observed to lean to the left in his/her geri-chair, there was no evidence that the resident was provided any restorative therapy services after his/her hospital return in July 2011 or was evaluated by the occupational therapist for further skilled therapy. See F 311 for additional information regarding resident # 63. 2. Resident #38 had a care plan and physician's orders [REDACTED]. There was an intervention for physical therapy skilled services to be provided for the resident three times a week for two weeks for therapeutic exercises therapeutic activities, gait-training, and neuromuscular re-education. However, there was no evidence that the physic… | 2016-01-01 |
| 8546 | 8546 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2011-11-10 | 282 | D | 0 | 1 | 1JXD11 | Based on observations, record review and staff interview, it was determined that the facility failed to implement care plan interventions to provide oral care for one resident A and to provide assistance with shaving for one resident (#74) in a total sample of 28 residents. Findings include: 1. On the 9/01/11 and 5/27/11 Minimum Data Sets (MDS) assessments, licensed staff coded resident A as needing total assistance for hygiene. There was a care plan since 8/28/11 to address his/her dependence on staff to meet his/her activities of daily living (ADL) needs because of his/her limited mobility. There was an intervention for staff to explain procedures prior to performing his/her daily oral care. However, the resident was observed on 11/7/11 at 3:20 p.m., 11/9/11 at 8:30 a.m. and 11:30 a.m., and on 11/10/11 at 9:50 a.m. to have teeth that were caked with debris. See F312 for additional information regarding resident A. 2. Resident #74 had a care plan since 11/8/11 to address his/her self care deficit with an intervention for nursing staff to assist him with shaving on bath days and as needed. According to staff documentation on the the resident's ADL Flow sheet that was reviewed on 11/10/11 9:10 am, the resident had been given a shower every day from 11/1 thru 11/9/11. However, resident #74 was observed to have had several days growth of facial hair on 11/8/11 at 8:17 a.m. and 4:32 p.m., on 11/9/11 at 8:50 a.m., 11:05 a.m., 3:00 p.m. and 4:05 p.m. and, on 11/10/11 at 8:00 a.m. and 10:10 a.m. See F312 for additional information regarding resident #74. | 2016-01-01 |
| 8547 | 8547 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2011-11-10 | 311 | D | 0 | 1 | 1JXD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview and record review, it was determined that the facility failed to continue to provide services to address the maintenance or improvement of positioning for one resident (#63) in a total sample of 28 residents. Findings include: Resident # 63 had [DIAGNOSES REDACTED]. The resident had been coded on the 5/27/11 Minimum Data Set ( MDS) assessment as having limitation with range of motion on one side of his/her upper extremity. On the 9/01/11 MDS, the resident was coded to have had a decline of limited range of motion in both of his/her upper extremities. staff developed a care plan to address the resident's risk for injury due to limited mobility, being bed to chair bound and having [MEDICAL CONDITION] and a [MEDICAL CONDITION] disorder. There was an intervention for staff to monitor his/her positioning for possible injury. Staff added an intervention on 8/22/11 for the resident to be screened by occupational therapy services and evaluated as indicated. The resident was observed attending a church service on 11/9/11 at 10:30 a.m. He/she was seated in a geri-chair in the reclining position. Although staff had provided a back support and bolster for the left arm of the resident's geri-chair, his/her upper torso was leaning toward the left side. The resident was observed to still be in the activity room at 11:30 a.m. Despite the resident continuing to lean to the left side of the geri-chair, the staff, who was present in the room, failed to attempt to reposition the resident into the correct position. The resident continued to be leaning to the left side while seated in geri-chair in the day room at 3 p.m. Although there were positioning devices to the back and left arm of the geri-chair, the resident continued to inappropriately lean to the left so that there was not any support for his/her head or neck. On 11/10/11 at 8:30 a.m., the resident was observed seated in geri-chair. He/She was leaning to the left si… | 2016-01-01 |
| 8548 | 8548 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2011-11-10 | 312 | D | 0 | 1 | 1JXD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interview, it was determined that the facility failed to provide oral care for one resident (A) and to assist with shaving for one resident (#74) in a total sample of 28 residents. Findings include: 1. Resident Ahad [DIAGNOSES REDACTED]. On the 9/01/11 Minimum Data Set (MDS) assessment, licensed staff had coded him/her as needing total assistance for hygiene. The resident's care plan since 8/28/11 noted that the resident depended on staff to meet his/her activities of daily living (ADL) needs because of his/her limited mobility. There was an intervention for (nursing) staff to explain procedures prior to performing the resident's daily oral care. However, it was observed that daily oral care was not provided for resident A. The 9/20/11 nurse's note at 12:30 p.m. described the resident having had a tooth come out while he/she was eating. The tooth was described as having been black in color and, chipped and broken in places. Nursing staff wrote that the other teeth surrounding the open area were dark in color. However, there was no evidence that the resident's attending physician or a dentist had been contacted about those problems with the resident's teeth. During an interview on 11/7/11 at 3:10 p.m., resident A stated that staff helped him/her to brush his/her teeth less than once a month. The resident's teeth were observed on 11/7/11 at 3:20 p.m., on 11/9/11 at 8:30 a.m. and 11:30 a.m., and on 11/10/11 at 9:50 a.m. to have been caked with debris. 2. On the 10/27/11 MDS assessment, licensed nursing staff coded resident #74 as needing total assistance with personal hygiene and grooming. Nursing staff developed a care plan dated 11/8/11 to address the resident's self care deficit with an intervention for nursing staff to assist with shaving on his/her bath day and as needed. Review of the resident's ADL flow sheet revealed nursing staff's documentation that the resident had been given a shower on … | 2016-01-01 |
| 8549 | 8549 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2011-11-10 | 323 | D | 0 | 1 | 1JXD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, it was determined that the facility failed to provide interventions to prevent falls for one resident (# 38) from a sample of 28 residents and to secure razors in one common shower room (100 hall) of three common shower rooms in the facility. Findings include: 1. Review of the medical record for resident #38 revealed staff documentation about the resident having fallen but not been injured on 08/12/11, 08/29/11, 09/11/11, 09/12/11, 09/12/11, 10/04/11, 10/19/11 10/23/11, and 11/09/11. The facility developed and implemented interventions to prevent falls. Record review revealed that the resident had been provided skilled physical therapy services from 9/01/11 to 9/09/11 to reduce the likelihood of falls then, a referral had been made for restorative nursing services for maintaining skill in ambulation and strength in both legs. Staff's documentation revealed that the resident was provided range of motion exercises as ordered from 09/10/11 through 11/10/11. However, the resident continued to fall with the last fall documented as happening on 11/09/11. The physician wrote an order on 10/24/11 for physical therapy staff to evaluate and treat the resident as indicated. The order was for the resident to be seen by a skilled physical therapist three times a week for two weeks for skilled physical therapy services. However, there was no evidence that those services had been provided. During an interview on 11/10/11 at 10:45 a.m., occupational therapist CC could not locate evidence that a physical therapy evaluation had been done despite the order for it or that those skilled services had been provided. During an interview on 11/10/11 at 11:00 a.m., the Restorative Nursing Services registered nurse (RN) AA and certified nursing assistant, (CNA) BB said that nursing staff was not aware of any physical therapy services but, were providing restorative nursing services. During an interview on 11/10/… | 2016-01-01 |
| 8550 | 8550 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2011-11-10 | 371 | F | 0 | 1 | 1JXD11 | Based on observation, staff interview, and record review, it was determined that the facility failed to hold and serve potentially hazardous food at safe temperatures to prevent potential food borne illnesses for seven of eight residents on pureed diets and 28 of 76 residents who were served mechanical soft or regular diets. Findings include: During an observation on 11/7/11 at 12:35 p.m., foods were observed being held and served in the danger zone (above 41 degrees Fahrenheit (F.) and below 135 degrees F.) which allowed for the growth of organisms which could cause food borne illness. Pureed chicken was being held and served at 120 degrees F. The potato salad was being held and served at 54 degrees F The foods were checked with a facility calibrated thermometer. Seven residents had been served the pureed chicken. There were 28 residents who had been served the potato salad. In an interview on 11/08/11 on 12:37 p.m., the Dietary Manager said that the potatoes were warm when the salad was mixed. However, the temperature log documentation indicated that the potatoes had been at 40 degrees F at 11:55 a.m On 11/08/11 at 1:20 p.m., the Dietary Manager stated that residents on a mechanical soft diet and those eating at the first seating in the dining room had been served potato salad. | 2016-01-01 |
| 10215 | 10215 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2010-04-08 | 253 | B | 0 | 1 | OHLM11 | Based on observation, it was determined that the facility failed to maintain an environment that was free from stained and dirty clean linen carts, dried food splatters, dried spills, dirt , dust, non-fitting commode tank covers, gaps in floor tiles, and rust in room 216 and on all three Halls (100 Hall, 200 Hall, 300 Hall). Findings include: Observations were made during the Initial Tour on 4/6/10 at 9:45 a.m. and the General Observations Tour on 4/8/10 between 8:30 a.m. and 10:30 a.m. 100 Hall 1. There were dust and dried liquid spills on the shelves of the clean linen cart in the hall. 200 Hall 1. There was a buildup of dirt in the corners of the bottom shelf of the clean linen cart in the hall. There were dust and dried liquid spills on the other shelves of the cart. 2. There was a loose door handle to the bathroom of room 216. There was a gap in the corner where the floor tiles met the wall. There was a rusty leg on the raised toilet seat. The commode tank cover did not fit the tank. 300 Hall 1. There were dried brown liquid spills on the shelves of the clean linen cart in the hall. There were dried liquid spills on the cart cover. Pantry 1. There were dried food splatters inside of the microwave. There were dried pink liquid spills inside the refrigerator's crisper drawers. | 2014-12-01 |
| 10216 | 10216 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2010-04-08 | 203 | D | 1 | 1 | OHLM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, it was determined that the facility failed to provide written notice of the discharge and of the required information for one resident (#1) of three residents discharged from the facility in a total sample of 18 residents. Findings include: According to the 2/19/10 at 9:30 a.m. nurse's notes, resident #1 had and altercation with a licensed nurse and the resident was picked up by the county sheriff's department. The licensed nurse documented on 2/19/10 at 1:45 p.m. that the psychiatric hospital was consulted about the resident's admission. There was a 2/19/2010 physician's orders [REDACTED]. On 2/26/10 (seven days later) there was a physician's orders [REDACTED]. However, there was no evidence that the facility had notified the resident and a family member or legal representative in writing of the discharge the reason for the discharge, the effective date of the discharge, the location to which the resident was being discharged , notice that the resident had the right to appeal the action to the State, and the name, address, and telephone number of the State Long Term Care Ombudsman. During an interview on 04/07/10 at 2:00 p.m., the Administrator confirmed that the facility had not provided the required written notification of the discharge and information to the resident and family member or legal representative. | 2014-12-01 |
| 10217 | 10217 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2010-04-08 | 441 | D | 0 | 1 | OHLM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to assure that one of four newly hired employees were free of communicable disease before allowing direct contact with residents or that one of two CNAs observed practiced proper hand hygiene after bowel incontinence care. Findings include: The facility's policy to "New Employee Screening" documented that the employee health coordinator (or designee) would accept documented verification of two-step TST ([MEDICATION NAME] skin test)or BAMT (blood assay for [DIAGNOSES REDACTED] [DIAGNOSES REDACTED]) results within the preceding 12 months. 1. A review of 14 employees' personnel records revealed that one certified nursing assistant was hired by the facility on 1/13/10. However, there was no evidence that the facility had performed a [MEDICATION NAME] screening test (PPD) and received the results prior to her having had direct contact with residents. The most recent PPD result documented for the resident was dated 7/1/09. However, there was no evidence that the facility had verified that it had been a two-step TST within those preceding 12 months. 2. After completion of bowel incontinence care for resident #6 on 4/6/10 at 4 p.m., it was observed that CNA "AA" failed to remove her soiled gloves. The CNA did not remove or change his/her gloves or wash his/her hands prior to redressing the resident and positioning him/her in a geri-chair. | 2014-12-01 |
| 10218 | 10218 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2010-04-08 | 241 | E | 0 | 1 | OHLM11 | Based on observations, it was determined that the facility failed to promote a dignified dining experience for thirteen residents (#4, #13, #14, #11 and nine residents randomly observed) in the small dining room from a total sample of 18 residents. Findings include: 1. Resident #4 drank four ounces of water at lunch prior to receiving staff assistance. Resident #4 was observed on 4/6/10 at 12:35 p.m. in the small dining room being assisted to eat by a Certified Nursing Assistant (CNA). The CNA was inappropriately feeding the resident at a fast pace. The CNA did not allow the resident to swallow each bite before giving him/her more to eat. The CNA did not offer the resident any of the iced tea until after he/she had eaten all of the food on the plate. Resident #4 was observed on 4/7/10 at 12:25 p.m. in the small dining room slowly feeding himself/herself. A CNA was inappropriately giving the resident a few bites of food then walking over to another table and standing over another resident to feed him/her a few bites to eat. Resident #4 continued to slowly feed himself. At that time, another CNA was observed to be seated between two residents while assisting them to eat. However, that CNA inappropriately turned her back completely towards one resident while assisting the other resident to eat. 2. Resident #13 was observed on 4/8/10 from 12:05 p.m. to 12:31 p.m. eating lunch in the small dining room. The resident was seated at a table with resident #14 and another resident. A CNA was seated between resident #14 and the other resident. The CNA stopped assisting those two residents to eat when, she repeatedly got up and walked around the table to prompt resident #13 to continue to eat and drink fluids. At that time, it was observed that four other nursing staff members were supervising or assisting ten residents to eat. Two of the four nursing staff members were standing over the residents while assisting them to eat. 3. Resident #11 was observed on 4/8/10 from 8:10 a.m. to 8:30 a.m. in the small dining room being fed… | 2014-12-01 |
| 10219 | 10219 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2010-04-08 | 315 | D | 0 | 1 | OHLM11 | Based on observations, it was determined that the facility failed to provide proper incontinence care for one (#6) of the seven incontinent residents from the total sample of 18 residents. Findings include: During an observation of bowel incontinence care being provided for resident #6 on 4/6/10 at 4:00 p.m., CNA (Certified Nursing Assistant ) "AA" cleaned the resident's rectal area. The CNA then inappropriately wiped up into the resident's perineal area several times using the same disposable wipe that was soiled with feces. | 2014-12-01 |
| 10220 | 10220 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2010-04-08 | 160 | D | 0 | 1 | OHLM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and record reviews, it was determined that the facility failed to convey the personal funds of one resident (#15) to the probate jurisdiction administering the resident's estate within 30 days of the resident's death. Findings include: Resident #15 expired on [DATE]. A review of the resident's "Resident Trust Fund Statement" for [DATE] revealed that a balance of $50.45 remained in the resident's trust fund account. During an interview on [DATE] at 1:00 p.m., the facility's bookkeeper stated that the resident had been his/her own responsible party and that no family member had come forward to receive the resident's monies. The facility's policy on residents' funds documented that, if a balance remained in the account that was due the patient/responsible party within 30 days of discharge, a check would be issued to the patient/responsible party. If a balance remained in the account that was due to the facility, once the exact amount due was determined, the facility would issue a check to the facility's General account. During a telephone interview with the facility's CFO (Chief Financial Officer) on [DATE] at 1:30 p.m., he stated that the $50.45 remained in the resident's trust account because it had not been determined if the resident owed any money to the facility since the Explanation of Benefits for Medicare and Medicaid services had not been received by the facility. | 2014-12-01 |
| 10221 | 10221 | ABBEVILLE HEALTHCARE & REHAB | 115623 | 206 MAIN STREET EAST | ABBEVILLE | GA | 31001 | 2010-04-08 | 205 | D | 1 | 1 | OHLM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to provide one resident (#1), who required an emergency transfer from the facility, with written notice within 24 hours that specified the duration of the facility's bed-hold policy from a total sample of 18 residents. Findings include: According to the 2/19/10 at 9:30 a.m. nurse's notes, resident #1 had an altercation with staff which resulted in injuries to the staff. The license nurse documented on 2/19/2010 at 1:45 p.m. that the behavorial (psychiatric) hospital was consulted for admission of the resident. There was a 2/19/10 physician's orders [REDACTED]. On 2/26/10 (seven days later), there was a physician's orders [REDACTED]. However, although the resident had required an emergency transfer from the facility to the behavioral (psychiatric) hospital on [DATE], there was no evidence that a written notice that specified the duration of the bed-hold policy had been given to the resident and a family member or legal representative within 24 hours of the transfer. On 4/07/10 at 2:00 p.m., the Administrator confirmed that the facility had not provided written notice to the resident and family member of the facility's bed-hold policy. | 2014-12-01 |
| 258 | 258 | ABERCORN REHABILITATION CENTER | 115132 | 11800 ABERCORN STREET | SAVANNAH | GA | 31419 | 2017-01-19 | 371 | E | 0 | 1 | URZZ11 | Based on observation and staff interview and record review of the facility' policy, Food Storage Principles, the facility failed to properly label food in one walk in cooler and maintain two ceiling vents over a kitchen prep table to prevent contamination of foods. This deficient practice had the potential to affect 92 residents receiving an oral diet. The census size was 94 ninety-four. Observation on 1/17/2017 at 10:10 a.m., of the walk-in cooler revealed the following food items to have the following descriptive label and expiration dates: Blue berries date 12/16 Buttermilk dated 2/16 Interview with the Dietary Manager (DM), at this same time, verified the dates of both items. Interview on 1/19/17 at 3:10 p.m., with the DM revealed that dietary staff had mislabeled the food items. She revealed that dietary staff had omitted adding the year on the label of both items and stated that the year on the buttermilk should have been labeled as 2/16/2017 and the blue berries should have been labeled as 12/16/2017. The Dietary Manager revealed that both food items had Used by Dates that was prior to being opened and her dietary staff had forgotten to write the word Used by per her recommendation for labeling food items. The DM further revealed that her expectation is for all food items to be labeled correctly in the cooler after being opened and stored. Interview on 1/19/17 at 8:10 p.m. with the Administrator revealed that her expectations are that all food items are to have proper dates at all times. Review of the Facility Policy Food Storage Principles revealed a statement that documents: Label each package, box, can, etc. with the expiration date, date of receipt, or when the item was stored after preparation . Observation on 1/19/17 at 1:10 p.m., of the kitchen observed two (2) ceiling vents containing moss and leaves and under the vents was one prep table. Further observation of the vents revealed an absence of a screen between the metal openings that would had prevented the moss and leaves from escaping. Below the… | 2020-09-01 |
| 259 | 259 | ABERCORN REHABILITATION CENTER | 115132 | 11800 ABERCORN STREET | SAVANNAH | GA | 31419 | 2018-11-08 | 574 | D | 0 | 1 | LI3X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews, the facility failed to post, in a manner accessible to all residents, a list that included names, mailing address, and email address of all pertinent State agencies and advocacy groups. The facility census was 82 residents. Findings include: During the initial tour on 11/5/18 at 10:39 a.m. an interview was conducted with the Family Member of R#18. R#18 has a Brief Interview Mental Status Score (BIMS) of 3 (three), a score of 3 out of 15 indicates cognitive impaired. The interview revealed that the Family Member of R#18 has had a history of [REDACTED]. This family members verified being provided with the facility business card that listed a complaint call line at the time of R#18 's admission to the facility. The business card was later identified during the survey as a complaint line for the facility Corporate Hotline Number for complaints. When asked if he was familiar with the location of posting of the State Agency contact informaiton He answered No, and requested assistance. During a group interview 11/7/18 at 9:54 a.m., with the facility Resident Council Members five of the seven residents revealed they were unaware of the identifty of the Ombudsman and their right to contact the Ombudsman's Agency. All five (5) residents revealed they wanted to know about the Ombudsman's Role as an Advocacy for the Residents. Residents also verified being unaware of the location of the Ombudsman and State Agency contact information. Observation on three of four (3/4) days during the time frame of 11/5/18 at 11:00 am. 2:00 p.m., and 4:00 p.m., and 11/6/18 at 8:00 a.m., 2:00 p,m., and 4:00 p.m. and 11/7/18 at 8:00 a.m., 3:00 p.m. and 5:00 pm. revealed that there was no posting of the State Agency or the the Ombudsman contact information in a location that was visible to residents and families. On 11-7-18 at 11:05 a.m. during tour of facility (walk through of the halls and common area) with the Administrator (ADM) and t… | 2020-09-01 |
| 260 | 260 | ABERCORN REHABILITATION CENTER | 115132 | 11800 ABERCORN STREET | SAVANNAH | GA | 31419 | 2018-11-08 | 636 | D | 0 | 1 | LI3X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to complete a Minimum Data Set (MDS) Discharge Assessment for one resident (R#1) out of 30 sampled residents. Findings include: Resident admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Record review for R#1 revealed a completed MDS Admission assessment dated [DATE], MDS Discharge assessment dated [DATE] with return anticipated, and a MDS Admission assessment dated [DATE]. No other comprehensive assessments were documented for R#1. Resident was discharged home from the facility on 6/20/2018. An interview on 11/08/2018 at 8:14 a.m (AA) LPN MDS Case Manager revealed the resident was readmitted on [DATE] and was discharged home on[DATE]. She verified that a discharge MDS was not completed on the resident after he was discharged . She stated her process consists of pulling the MDS schedule off of the computer, prints it and puts the residents names and type of assessment due on a paper calendar. She does this monthly. She looks in the computer daily for new admissions, discharges or any change in payer types and opens up the assessments in the system. She adds or removes assessments on paper calendar as needed. She stated when a resident goes from a skilled type assessment to a non skilled assessment (ie: Medicaid) the dates change. She stated she did receive a call from the State informing her of the late/missing assessment. | 2020-09-01 |
| 261 | 261 | ABERCORN REHABILITATION CENTER | 115132 | 11800 ABERCORN STREET | SAVANNAH | GA | 31419 | 2018-11-08 | 656 | D | 0 | 1 | LI3X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, the facility failed to follow the care plan for one resident R#60 who received an intravenous (IV) medication. The sample size was 30 residents. Findings include: Record review revealed R#60 was an [AGE] year old female re-admitted to the facility on [DATE] with a diagnosis' that include [MEDICAL CONDITION], hypertension, pneumonia, and urinary tract infection. The Admission Minimum Data Set ((MDS) dated [DATE] revealed section C-Cognition with a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate impaired cognition. An observation of R#60 made on 11/05/2018 at 12:44 p.m. revealed a peripheral Intravenous (IV) catheter located in the residents left arm. The dressing covering the IV site was not dated and had blood in the catheter tubing. Review of R#60's care plan revealed resident receiving IV therapy for [MEDICAL CONDITION] to sacral region, with a goal indicating resident will remain free of complications of IV therapy throughout course of treatment. The Care Plan Interventions include dressing changes and IV site changes as ordered (per facility protocol), IV therapy per MD order, monitor IV site for potency, flush as ordered, and observe for signs and symptoms of infection/infiltration and notify MD if needed. Interview on 11/06/2018 at 7:50 a.m. with LPN MM who verified R#60 is no longer on IV medications. Interview on 11/07/2018 at 8:55 a.m. with LPN BB revealed R#60 was no longer on IV medications and was not aware resident has a IV in her arm. She verified according the the residents current orders that there are no orders to flush the IV, change the IV, or to change the IV dressing. She stated she has not had any inservices on medication administration and/or IV administration. She stated she is unsure of the policy and if the IV was a PICC line or a peripheral line. Interview on 11/07/2018 at 10:41 a.m. with R#60 revealed the nurse came in and removed the I… | 2020-09-01 |
| 262 | 262 | ABERCORN REHABILITATION CENTER | 115132 | 11800 ABERCORN STREET | SAVANNAH | GA | 31419 | 2018-11-08 | 694 | D | 0 | 1 | LI3X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation,staff and resident interview, record review, and review of policy titled Guidelines for preventing Intravenous Catheter-Related Infections the facility failed to get a physicians order for peripheral intravenous (IV) dressing changes, IV catheter flushes, IV site observation or IV catheter needle changes since re-admission to the facility on [DATE] with IV antibiotic orders for one resident (R) (R#60). The sample size was 30 residents. Findings include: Record review revealed R#60 was an [AGE] year old female re-admitted to the facility on [DATE] with a diagnosis' that include [MEDICAL CONDITION], hypertension, pneumonia, and urinary tract infection. The Admission Minimum Data Set ((MDS) dated [DATE] revealed section C-Cognition with a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate impaired cognition. An observation of R#60 made on 11/05/2018 at 12:44 p.m. revealed a peripheral IV located in residents left arm. The dressing covering the IV site was not dated and had blood in the catheter tubing. An observation of R#60 made on 11/06/2018 at 7:50 a.m. revealed resident sitting up in bed, noted the dressing for the peripheral IV in left arm was not dated. Blood was noted in the catheter tubing. An IV pole and pump was noted beside bed. An observation of R#60 made on 11/06/2018 at 4:12 p.m. revealed resident up in a wheelchair in her room, noted the dressing for the peripheral IV in left arm was not dated. Blood was noted in the catheter tubing. Review of R#60 Medication Administration Record [REDACTED]. No order for a peripheral IV flush, IV site monitoring for infection/infiltration/potency, or IV dressing changes noted on MAR for (MONTH) or November's MAR. MAR for (MONTH) (YEAR) indicated resident did not receive the IV antibiotic on 10/28/2018 and 10/29/2018 due to code 9 which indicates other: see nurses notes. The administration box for 10/27/2018 was blank. The MAR for (MONTH) (YEAR) indicate… | 2020-09-01 |
| 263 | 263 | ABERCORN REHABILITATION CENTER | 115132 | 11800 ABERCORN STREET | SAVANNAH | GA | 31419 | 2018-11-08 | 759 | D | 0 | 1 | LI3X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interviews, and review of the policy titled Medication Pass Guidelines the facility failed to ensure the medication error rate was less than five percent (5%). A total number of 31 medication opportunities were observed, and there were six errors for three of three residents (R) (R#71) and (R#76) and (R#60) by one nurse (LPN BB), that was observed administering medications. The error rate was 19.35%. The facility census was 82 residents, and the sample size was 30 residents. Findings include: Review of Policy titled Medication Pass Guidelines revised 4/25/17 reviewed Physicians Orders- Medications are administered in accordance with written orders of the attending physician. The Purpose of the policy is to ensure the most complete and accurate implementation of physicians medication orders and to optimize drug therapyfor each resident by providing for administration of drugs in an accurate, safe, timely, and sanitary manner. Administer medications within 60 minutes of the acheduled time. Observations made during medication pass to R#71 on 11/07/2018 at 8:13 a.m. with Licenced Practical Nurse (LPN) BB revealed an order for [REDACTED]. an order for [REDACTED]. an order for [REDACTED]. Observations made during medication pass to R#76 on 11/07/2018 at 8:30 a.m. with LPN BB revealed an order for [REDACTED]. The nurse varified she had a [MEDICATION NAME] 500mg tablet available but stated is was not scorable. Observations made during medication pass to R#60 on 11/07/2018 at 8:50 a.m. with LPN BB revealed an order for [REDACTED]. The medication was unavailable as a floor stock medication or on a medication punch cart for the resident and was not given to the resident. Review of the Physician order [REDACTED].>Review of the Physicians Orders for R#76 for (MONTH) (YEAR) revealed an order for [REDACTED].>Review of the Physician order [REDACTED]. Interview held on 11/07/2018 at 8:27 a.m. with LPN BB revealed she… | 2020-09-01 |
| 264 | 264 | ABERCORN REHABILITATION CENTER | 115132 | 11800 ABERCORN STREET | SAVANNAH | GA | 31419 | 2018-11-08 | 773 | D | 0 | 1 | LI3X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to ensure prompt notification to the physician of laboratory results that fall outside of the clinical reference range for two residents, Resident (R#25) and (R#80) out of a sample of 30 residents. Findings include: 1. Review of the laboratory results for R#25 revealed that a [MEDICAL CONDITION]-stimulating hormone (TSH) was drawn and results reported back to the facility on [DATE]. There was no documentation revealing that the attending Physician was notified of the results. There was no documentation in the clinical record to indicate that these labs were received on 9/26/18 or reviewed or that the attending Physician was aware of the results, thereby giving him the opportunity to evaluate and treat the resident. The following result were flagged by the laboratory as being out of the clinical reference range: TSH (a test done to find out if your [MEDICAL CONDITION] is working the way is should) Reference range: 0.35-5.50 ulU/mL test result: 0.02 (L) indicating that it was low. Review of the Progress Note section of the medical record did not contain any information about the above-mentioned lab results or notification to the attending physician. On 11/7/18 after identification of the lab concerns the facility notified the Physician and received an order to send the resident to the hospital. During an interview on 11/07/18 at 1:02 p.m. with the Director of Nursing (DON) revealed that when a lab is received, the nurse should document that the Physician had been notified of results. Continued interview revealed that facility Medical Director only wants to be notified of critical lab results. Further interview revealed that DON confirmed that there was no documentation supporting that the Physician had been notified of the abnormal lab results. During an interview on 11/08/18 at 10:30 a.m. with the DON revealed that the facility does not have a policy specific to reporting abnorma… | 2020-09-01 |
| 265 | 265 | ABERCORN REHABILITATION CENTER | 115132 | 11800 ABERCORN STREET | SAVANNAH | GA | 31419 | 2018-11-08 | 880 | E | 0 | 1 | LI3X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of facility policy Preventing Spread of Infection 2001 MED-PASS, Inc. (Revised (MONTH) 2012), and staff interview, the facility failed to ensure that a Certified Nursing Assistant (CNA) properly disposed of contaminated water and wash her hands with soap and water after providing care for one (1) resident (R) (R#70) of two (2) residents reviewed for transmission-based precautions (TBP) and the facility failed to serve food to the residents in a sanitary manner, for three meals observed over two days Findings include: 1. Review of policy provided by the facility revealed that In addition to Standard Precautions, implement Contact Precautions for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident care items in the resident's environment. Under section titled Gloves and Handwashing Sections B. While caring for a resident, change gloves after having contact with infection material (for example, fecal material and wound drainage. C. Remove gloves before leaving the room and perform hand hygiene. R#70 was admitted on [DATE] with a [DIAGNOSES REDACTED]. diff), a bacterium that can cause symptoms ranging from diarrhea to inflammation of the colon. Review of his medical record revealed that he was being treated with [MEDICATION NAME] (an antibiotic) for sixteen (16) days and had been placed on isolation/contact precautions. On 11/6/18 at 12:05 p.m., Certified Nursing Assistant (CNA) HH was observed providing incontinent care for a dependent resident. A kit with Personal Protection Equipment (PPE), i.e., gowns, gloves and masks, was observed hanging on the resident's room door. CNA HH donned a gown, and gloves before providing care. CNA HH performed care with three washcloths soaked in a basin of soap and water. CNA HH put all washcloths with fecal matter on them in the basin of… | 2020-09-01 |
| 266 | 266 | ABERCORN REHABILITATION CENTER | 115132 | 11800 ABERCORN STREET | SAVANNAH | GA | 31419 | 2017-11-16 | 225 | D | 0 | 1 | MGYB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, record review, and policy Abuse & Neglect Prohibition, the facility failed to thoroughly investigate bruise of known origin noted on arm for one Resident ( R) #102 out of a sample of 29 residents. Findings include: Review of admission Minimum Data Set (MDS) assessment dated [DATE] revealed R#102 was coded total care for bath and required extensive assistance with transfer two person. The Brief Interview for Mental Status (BIMS) revealed a score of 15 out of 15 which indicates the resident is cognitively intact. Review of Quarterly Review MDS dated [DATE] reveal the resident BIMS was coded -14. Interview on 11/14/17 12:30 p.m. and 2:30 p.m., R#102 stated that when Certified Nursing Assistant (CNA) DD and another CNA GG was assisting her to transfer to the shower chair on 8/14/17, she suffered a bruise to her upper right arm. and that her responsible party took a picture of the bruise and the incident was reported to facility staff, CNA BB, the Administrator and Licensed Practical Nurse (LPN) EE who assisted with taking a picture of the bruise. She continued to state that her responsible party reported the incident and showed the photo of the bruise to the Administrator. During several interviews with the Administrator on 11/14/17 at 2:49 p.m. 11/15/17 at 10:00 a.m. and 11/16/17 at 2:10 p.m. the Administration stated she was not aware of any allegations of abuse or incident of bruises involving R#102. She also said that she was not aware of any photos or speaking with R#102 or her responsible party about the incident, nor did any facility staff tell her of an incident resulting in R#102 sustaining any injury or bruises. The Administrator stated the facility policy is to start an investigation immediately when a complaint is made from a resident. On 11/14/17 12:30 p.m. an interview was done with R#102 in her room When the resident was asked about the incident that she reported, she stated that around… | 2020-09-01 |
| 267 | 267 | ABERCORN REHABILITATION CENTER | 115132 | 11800 ABERCORN STREET | SAVANNAH | GA | 31419 | 2017-11-16 | 282 | D | 0 | 1 | MGYB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and policy title Comprehensive Person-Centered Care Plans, the facility failed to follow the care plan to provide skin assessment and use of the Hoyer lift for transfers for one Resident R (#102). The sample size was 29 residents. Findings include: Refer to F 226 Review of clinical record revealed a Care Plan dated 7/6/17 coding for impaired skin integrity with the following interventions 1) observe skin during ADL (Activity of Daily Living) /incontinence care for any red or open areas and report to nurse 2) skin checks weekly by licensed nurse, report any skin problems to MD (Medical Doctor). Further review of Care Plan dated 7/6/17 revealed a coding for ADL Self Care performance deficit related to [MEDICAL CONDITION] immobility, debility with following interventions 1) observe for redness, open areas, scratches, cuts, bruises and report changes to the nurse 2) requires a Hoyer lift for transfers times (x 2) assist. Interview on 11/14/17 at 2:20 p.m. with R#102 revealed that Certified Nursing Assistant, CNA GG and CNA DD used a two-stand lift instead of the Hoyer lift when assisting with her transfer while in the shower room. She stated that she suffered a bruise to her upper right arm in (MONTH) (YEAR). She further stated that she has photo of the bruises which was shared with the Administrator by her Responsible party. She stated that Licensed Practical Nurse (LPN) EE was also made aware of the bruise and assisted her daughter with the photo. Interview on 11/15/17 at 12:53 p. m. with LPN DD verified being informed by CNADD that she no longer is assigned to R#102 because of injury caused resulting from using a two-stand lift instead of Hoyer lift. Reported that R#102 was assessed as total care during month of (MONTH) (YEAR) and required a Hoyer lift. Reported R#102 had a fear of falling. Interview on 11/15/17 at 1:23 p.m. with LPN EE verified observing the bruise on R#102 right upper arm and assisting… | 2020-09-01 |
| 268 | 268 | ABERCORN REHABILITATION CENTER | 115132 | 11800 ABERCORN STREET | SAVANNAH | GA | 31419 | 2017-11-16 | 460 | E | 0 | 1 | MGYB11 | Based on observations and staff interviews, the facility failed to ensure bedrooms were equipped to afford full visual privacy for each resident during personal care, treatment or as necessary for the residents. This deficient practice was noted for sample residents on Hall 1, Hall 2, and Hall 3. Individual ceiling track for privacy curtains and the actual curtains for semi private rooms were not in place during the initial tour. The sample size was 29 . The facility census was 84 . Findings include: 1. Observation on 11/13/17 at 10:30 a.m. , 2:00 p.m. and on 11/14/17 at 9:00 a.m., 11:00 a. m., 2:00 p.m., and on 11/15/17 at 1:00 p.m. 3:00 p.m. and 5:10 p.m. revealed the privacy curtains in the semi -private rooms on hall 1, hall 2, and hall 3 did not provide full privacy. An interview with a Certified Nursing Assistant (CNA) AA, on 11/16/17 at 9:30 a.m., revealed she was unaware that semi private rooms should be equipped with full privacy curtains for both residents. She stated that resident care is alternate at various times throughout the shift due to lack of privacy curtains. 2. On 11/16/17 at 9:55 a.m. the following observations were made; in room 32 A and B - there is one curtain between the beds which when pulled it's full length is approximately one foot too short to provide total privacy between the beds. There is also one curtain which is on a track that reaches from the wall by the door to the wall beside the window around the ends of both beds. However, the curtain, when pulled to it's full length is not long enough to provide privacy for both beds at the same time. When pulled out it's full length, and touching either of the walls with one end, there is an open area where the curtain ends which is about four feet in length, leaving the other resident without full privacy. The two residents in this room require assistance from staff with Activities of Daily Living ( ADL ) care. During an interview with the Administrator at time of observation on 11/16/17 at 5:20 p.m. the Administrator verified missing … | 2020-09-01 |
| 5143 | 5143 | ABERCORN REHABILITATION CENTER | 115132 | 11800 ABERCORN STREET | SAVANNAH | GA | 31419 | 2015-05-07 | 157 | D | 0 | 1 | CGV611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to notify the physician of abnormal blood pressure results for one (1) resident (#4), on a sample size of thirty-four (34) residents. Findings include: Review of the clinical record for resident #4 revealed that she was admitted to the facility on [DATE], and had [DIAGNOSES REDACTED]. Review of an Admission History and Physical dated 03/27/15 noted the resident had baseline [DIAGNOSES REDACTED] with [MEDICAL CONDITION] exacerbation and numerous medical co-morbidities. Review of the resident's Medication Administration Record [REDACTED]. Review of interdisciplinary Progress Notes noted that on 04/17/15, resident #4 refused to eat lunch or supper, and was noted to clear her throat prior to meds being given. Continued review of the Progress Notes noted that on 04/17/15 at 11:42 p.m., the resident was noted with a low oxygen saturation of 87 percent, the physician was contacted and an order for [REDACTED]. Review of Progress Notes dated 04/19/15 at 12:43 a.m. noted that the Emergency Department nurse was contacted and stated that resident #4 was admitted to the Intensive Care Unit for [MEDICAL CONDITION]. Review of resident #4's computerized vital signs records noted that on 04/16/15 at 11:11 p.m., the resident had a blood pressure (BP) of 70/35, and on 04/17/15 at 5:22 p.m. her BP was 113/44; there was no indication that the vital signs were retaken at any time those days. Review of the clinical record revealed that there was no indication that the physician was notified of these low BP's. Review of her MAR indicated [REDACTED]. During interview with Registered Nurse (RN) Unit Manager FF on 05/07/15 at 12:43 p.m., he verified that the BP was low on 04/16/15, and the diastolic BP was low on 04/17/15. Upon further interview, he verified that there was nothing documented that the physician was notified of these low BP's, and that he would have expected for the nurse to do so. Upon furt… | 2018-12-01 |
| 5144 | 5144 | ABERCORN REHABILITATION CENTER | 115132 | 11800 ABERCORN STREET | SAVANNAH | GA | 31419 | 2015-05-07 | 281 | D | 0 | 1 | CGV611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, and records review the facility failed to check for placement and residual for one (1) resident (#154) with a Gastrostomy Tube (GT). The Sample size was thirty-four (34) residents. Findings include: Resident (#154) admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Physician orders [REDACTED]. 1. [MEDICATION NAME] 1.2 at 50 milliliter (ml) per hour Continuous 2. Check for placement every shift before medications, before flushes, and after episodes of vomiting 3. Check tube for residual every shift, If >100 ml, re-check in 1 hour, if still >100 ml, hold and call physician 4. Change Enteral Bottle nightly at 12:00 a.m. and discard any unused solution Observation of the administration of [MEDICATION NAME] 75 milligram (mg) per GT on 5/6/15 at 5:00 p.m. revealed that staff did not check the gastrostomy tube for residual or check the gastrostomy tube for placement per the physician's orders [REDACTED]. Observation on 5/7/15 at 3:38 p.m. of the Kangaroo Pump Screw Water flush bag revealed that there was no hang date indicated on the bag. Interview on 5/6/15 at 5:36 p.m. with Registered Nurse (RN) AA revealed he/she should have checked for residual, and placement of the gastrostomy tube before administration of [MEDICATION NAME] 75 mg via gastrostomy tube. Interview on 5/6/15 at 5:45 p.m. with RN BB the Nurse Consultant revealed that staff are expected to follow the physician's orders [REDACTED]. | 2018-12-01 |
| 5145 | 5145 | ABERCORN REHABILITATION CENTER | 115132 | 11800 ABERCORN STREET | SAVANNAH | GA | 31419 | 2015-05-07 | 282 | E | 0 | 1 | CGV611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to follow the care plan for five (5) residents (#95, #74, #8, #16, Q) that required assistance with Activities of Daily Living (ADLs); and one (1) resident (#23) with pressure ulcers who required supplements to aid in wound healing. The sample size was thirty-four (34) residents. Findings include: Review of the Quarterly Minimum Data Set (MDS) assessment for resident #16 revealed that his functional status was extensive with one person physical assistance for dressing, bathing and personal hygiene. Further review revealed an ADL self care performance deficit care plan with an intervention to check nail length, trim and clean on bath day as necessary and report any changes to the nurse. Observation of resident #16 on 05/07/15 at 1:40 p.m. revealed him sitting up in bed eating lunch. His fingernails and toe nails were observed to be long on both hands and feet. He was unshaved with hair on his face. He revealed that someone does shave him, but he was not able to answer the last time he had been shaved by staff. Interview on 05/07/15 at 2:00 p.m. with Certified Nursing Assistant (CNA) DD revealed that resident #16 required total care for bathing and dressing. CNA DD further revealed that the resident does refuse care frequently and can be combative towards staff. DD revealed that the resident is blind and his moods are up and down. Continued interview revealed that he gets shaved frequently but most of the times he refuses to let staff cut his fingernails. Interview on 05/07/15 at 2:15 p.m. With the RN Unit Manager CC revealed that resident #16 is uncooperative with baths, cutting nails and shaving. Continued interview revealed that when his wife visits she can get him to cooperate with staff, but now his wife is not able to visit as often due to her poor health. Interview on 05/07/15 at 4:25 p.m. with the MDS Coordinator revealed that it was care planned for staff to … | 2018-12-01 |
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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 );