cms_GA
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| Link | rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate ▼ |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 10626 | 10626 | MUSCOGEE MANOR & REHAB CENTER | 115146 | 7150 MANOR RD | COLUMBUS | GA | 31907 | 2010-09-01 | 157 | D | 4BQ511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to ensure that the physician was consulted in a timely manner for two (2) residents (#s 1 and 2 ), who had experienced significant changes in condition related to urinary tract symptoms, from a survey sample of eight (8) residents. Findings include: 1. Record review for Resident #1 revealed a Nurses Progress Note of 07/30/2010 at 9:45 p.m. which documented that the resident was noted to have cloudy and foul smelling urine. However, further record review revealed no evidence to indicate that the physician was consulted regarding this resident's significant change in physical condition until a Nurse's Progress Note of 08/03/2010 at 1:30 p.m. documented that a new order had been received. An order signed by the nurse practitioner, and dated 08/03/2010 at 8:50 a.m., specified that urine be collected for a urinalysis with culture and sensitivity. This represented an approximate three (3) day delay in physician consultation. A urinalysis laboratory report for Resident #1 dated as collected on 08/04/2010 documented urine with a positive [MEDICATION NAME], three (3) plus abnormal white blood cells, and one (1) plus abnormal protein. A physician's telephone order of 08/06/2010 specified that the resident receive the [MEDICATION NAME] milligrams twice daily for three weeks for a urinary tract infection. 2. Record review for Resident #2 revealed a Nurse's Progress Note of 08/16/2010 at 6:30 a.m. which documented that during a urinary catheter change, thick and milky white secretions were noted in the resident's peri-area. A foul odor was also noted. This Note did not document physician consultation regarding the resident's significant change in status at that time, but rather documented that the resident had been added to physician rounds for evaluation and treatment. A Nurse's Progress Note of 08/24/2010 at 7:30 p.m. documented that upon assessment of the resident's … | 2014-01-01 | ||
| 10627 | 10627 | MUSCOGEE MANOR & REHAB CENTER | 115146 | 7150 MANOR RD | COLUMBUS | GA | 31907 | 2010-09-01 | 514 | D | 4BQ511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to ensure that the clinical record was complete for one (1) resident (#2) from a survey sample of eight (8) residents. Findings include: Record review revealed that Resident #2 had a 07/13/2010 physician's orders [REDACTED]. However, there was no documentation of any signs or symptoms of [MEDICAL CONDITION] in the Nurses Progress Notes, or elsewhere in the clinical record. Resident #2 also had a 07/27/2010 physician's orders [REDACTED]. However, there was no documentation of any signs or symptoms or the reason for this new treatment regimen in the Nurses Progress Notes or anywhere else in the clinical record. This was acknowledged by licensed staff member "AA" on 08/25/2010 at 4:30 p.m. | 2014-01-01 | ||
| 10628 | 10628 | GOLDEN LIVINGCENTER - DUNWOODY | 115270 | 5470 MERIDIAN MARK ROAD, BLDG E | ATLANTA | GA | 30342 | 2010-09-01 | 225 | D | 7R0511 | Based on record review and staff interview, it was determined that the facility failed to immediately report an injury of unknown origin to the state regulatory agency for one (1) resident #1 in a survey sample of four (4) residents. Finding include: The Interdisciplinary Progress Note dated 8/8/2010 documentation revealed that at 7:40 a.m. resident #1 was noted by the oncoming nurse to have a swollen right eye and the physician was notified. The Physician's Progress Note dated 8/8/2010 revealed that the resident had a bruise to the right eye that was identified as an ocular contusion. Review of the letter sent to the state regulatory agency dated 8/17/2010, revealed that the bruise of unknown origin to the eye of the resident was reported on 8/10/2010, two days after the bruise was noted by the physician on 8/8/2010 rather than immediately as required During an interview with the Director of Nursing on 9/1/2010 at 10:45 a.m., it was confirmed that the injury of unknown origin was not reported to the state until 8/10/2010. A phone interview with the Director of Nursing on 9/9/2010 at 2:20 p.m. revealed that the Physician's Progress note identified the bruise to the right eye as an ocular contusion that indicated an injury of unknown origin. It was further confirmed that the injury should have been reported that day to the state regulatory agency and an investigation immediately started. | 2014-01-01 | ||
| 10629 | 10629 | HERITAGE HEALTHCARE OF LAFAYETTE | 115304 | 205 ROADRUNNER BOULEVARD | LAFAYETTE | GA | 30728 | 2009-05-13 | 203 | D | L1C411 | Based on record review and staff interview, the facility failed to issue a written notice of discharge/transfer at least 30 days before the discharge or transfer for one (1) resident from seventeen (17) sampled residents. Findings includes: Record review for resident #16 revealed a nurse's note dated 4/30/09 that indicated the resident was discharge to another nursing home. Further review revealed a social service note dated 4/20/09 that the social service staff spoke with the resident's son regarding that the resident had been observed smoking in the room and that cigarettes were found in the room. No other written notification related to the resident's discharge was found in the resident's medical record. Interview with Social Worker "AA" on 5/13/09 at 10:10 am revealed that she did not issue a written notice related to discharge of this resident to another nursing home. | 2014-01-01 | ||
| 10630 | 10630 | HERITAGE HEALTHCARE OF LAFAYETTE | 115304 | 205 ROADRUNNER BOULEVARD | LAFAYETTE | GA | 30728 | 2009-05-13 | 322 | D | L1C411 | Based on observations, staff interviews, and review of facility policy, the facility failed to provide appropriate positioning, during incontinence care, for two residents (2) residents (#4, #9) receiving gastrostomy tube feeding from a sample of seventeen (17) residents. Findings include: 1. Observation on 5/13/09 at 8:15 am of CNA "BB" providing incontinence care to resident # 9 revealed that tube feeding was being administered via a pump at 55 cc per hour. During the care the head of the resident's bed was flat and the tube feeding continued to infuse. Interview on 5/13/09 at 8:35 am with CNA "BB" revealed that the she was suppose to keep the head of the bed up during incontinent care or get the nurse to turn the tube feeding off. "BB" acknowledge that the feeding continued to infuse while the resident was flat in bed. 2. Observation on 5/11/09 at 1:30pm. of CNA "BB" providing incontinence care to resident #4, revealed that tube feeding was infusing via pump and she lowered the head of the bed to lower tha thirty (30) degrees. The CNA did not pause or stop the feeding while providing care. Interview on 5/11/09 at 1:35pm with CNA "BB" revealed that she was never instructed to stop or pause the feeding pump when providing care. She further revealed that she never notified the nurse prior to care or lowering the head of the bed. Interview with Director of Nursing (DON) "CC" on 5/11/09 at 3:10pm revealed that she was not aware of a policy to stop or pause the feeding pump when head of the bed is lowered. Review of the facility policy for Tube Feeding indicated that a resident's head will be elevated at least 30-45 degrees at all times with continuous feedings unless temporarily stopped when the head is lowered to render care. | 2014-01-01 | ||
| 10631 | 10631 | HERITAGE HEALTHCARE OF LAFAYETTE | 115304 | 205 ROADRUNNER BOULEVARD | LAFAYETTE | GA | 30728 | 2009-05-13 | 502 | D | L1C411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the February 2009 Pharmacist consultant report and staff interview the facility failed to ensure that a Comprehensive Metabolic Panel was obtained in a timely manner for one (1) resident (#1) from a sample of seventeen (17) residents. Findings include: Review of the medical record for resident #1 revealed a physician's orders [REDACTED]. Further review revealed no laboratory results in the record. Review of the Monthly Pharmacist Reviews dated February 2009 indicated a CMP was due in February and then every 6 months. Interview with Unit Manager "EE" on 5/12/09 at 1:00pm revealed that when laboratory test are ordered there is one drawn at the time of order as a baseline and then as frequent as ordered by the physician. "EE" further revealed the first/base line or any CMP had not been done after the 2/23/09 physician's orders [REDACTED]. | 2014-01-01 | ||
| 10632 | 10632 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2010-09-02 | 157 | D | 42L211 | **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 immediately inform the family member of one (1) resident (#1), in a survey sample of twenty four (24) residents, of the development of a pressure sore. Findings include: A review of Resident #1's Nurse's Notes dated 4/26/2010 revealed documentation that the family member was notified of the resident's excoriated gluteal cleft and buttocks and of a treatment order for [MEDICATION NAME] cream. On 6/20/2010, documentation in the Treatment Record revealed that the left upper buttock had developed a sheet sheared area that was turning necrotic with eschar and slough measuring 4.0 by 1.0 centimeters. It was also documented that the area was treated with Santyl. However, there was no documentation to indicate that the responsible party of the resident was notified of the wound and treatment. During interview with Nurse "AA" conducted on 08/24/2010 at 2:45 p.m., this nurse acknowledged that there was no documentation to indicate that the responsible party was notified of the progression of the wound. | 2014-01-01 | ||
| 10633 | 10633 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2010-09-02 | 162 | E | 42L211 | Based on record review and staff interview, the facility failed to appropriately manage resident accounts for fifteen (15) residents (#s 5, 6, 7, 9, 11, 12, 14, 15, 16, 17, 19, 20, 22, 23 and 24) in a survey sample of twenty-four (24) residents, related to charging and deducting a fee for laundry service from the resident trust fund account, but for which payment had already been made under Medicaid. Finding include: Review of the facility's resident trust fund Patient Activity Report revealed the following: 1. For Resident #5, the facility deducted a charge of $31 from the resident trust fund on 05/31/2010 for laundry service. 2. For Residents #9, #17, and #19, the facility deducted a charge of $31 from the resident trust fund on 03/31/2010 and 07/31/2010 for laundry service. Review of the August 2010 Account Statements for these residents revealed that the facility did credit $31 for that month to these residents' accounts on 08/26/2010, after the initiation of this complaint survey during which the issue was identified. 3. For Residents #6, #7, #11, #12, #22, and #23, the facility deducted a charge of $31 from the resident trust fund on 03/31/2010 for laundry service. 4. For Residents #14, #15, #16, #20, and #24, the facility deducted a charge of $31 from the resident trust fund on 03/31/2010 and 07/31/2010 for laundry service. During an interview with Staff Member "BB" conducted on 08/24/2010 at 3:30 p.m., this staff member stated that she/he was aware that some residents had been charged the laundry fee incorrectly. Staff Member "BB" also acknowledged that there was no system in place to ensure that residents who were charged the laundry fee were identified and that the money was reimbursed back into the account. | 2014-01-01 | ||
| 10634 | 10634 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2011-03-10 | 160 | E | 82I011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to convey within thirty (30) days the balance of resident trust funds, and a final accounting of those funds, to the individual administering the resident's estate. This affected four (4) randomly reviewed trust fund accounts belonging to deceased residents. Findings include: A review of resident trust fund accounts managed by the facility revealed that the following trust fund account disbursements made to the estates of deceased residents exceeded 30 days: ? Resident expired on [DATE], disbursement made on [DATE] ? Resident expired on [DATE], disbursement made on [DATE] ? Resident expired on [DATE], disbursement made on [DATE] ? Resident expired on [DATE], disbursement made on [DATE] This information was confirmed by Office Manager "DD" in an interview on [DATE] at 10:15 a.m. | 2014-01-01 | ||
| 10635 | 10635 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2011-03-10 | 164 | E | 82I011 | Based on observation and staff interview, the facility failed to provide privacy during medication pass for three (3) observed residents on two (2) of three (3) halls with three (3) of three (3) nurses. Findings include: During medication pass with LPN "BB" from 12:44 p.m.- 12:55 p.m., she was observed to close the mini blinds in a resident's room but left the door open to the hallway. While administering an insulin injection into the resident's abdominal area, one (1) person was observed walking by the open door. Also, the privacy curtain between the beds was not pulled and the resident's roommate was in their bed. During observation of med pass with LPN "AA" at 11:35 a.m. on 3/09/11, she did not close the resident's door, pull the privacy curtain or close the mini blinds during a blood sugar (BS) check and the administration of an injection in the resident's abdomen area. The resident's roommate was in the room. On 3/09/11 at 11:55 a.m., LPN "CC" was observed obtain a blood sample to monitoring a resident's blood sugar. LPN "CC did not close the resident's door during the blood glucose check. Three persons were observed to walk by the resident's door. Interview with the Director of Nursing (DON) on 3/08/11 at 1:30 p.m. confirmed that privacy should include closing the resident's bedroom door, window blinds, and privacy curtains. When giving an injection a resident should be provided privacy. | 2014-01-01 | ||
| 10636 | 10636 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2011-03-10 | 279 | D | 82I011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to develop a comprehensive plan of care that included measurable objectives and timetables to meet a resident's medical needs related to weight loss and antianxiety medications for one (1) resident, (#24) on a sample of nineteen (19) residents. Findings include: 1. Review of the physician orders [REDACTED]. She was ordered Carnation Instant Breakfast 120 milliliters three (3) times a day on 2/22/11. Observation of the lunch meal on 3/08/11 at 12:20 p.m. revealed that resident #24 was served chopped meat, white rice, sweet potatoes, brussel sprouts, a roll, fruit, tea, water and coffee. Interview with Licensed Practical Nurse (LPN) Clinical Manager at that time revealed that the rice was considered to be a fortified food item. Record review revealed an admission weight, dated 9/22/10, of 178.8 pounds and a height of 61 inches. Following monthly weights were: 10/2010=177 pounds; 12/2010=165 pounds; 1/08/11=155 pounds. Review of the medical record for resident #24 revealed that no care plan had been developed for this resident. The Minimum Data Set (MDS) assessment from her admission on 9/22/10 were on the medical record and the RAP summaries. However, there was no individualized plan of care related to nutrition or weight loss for the resident. On 3/08/11 at 4:00 p.m., interview with the MDS Coordinator revealed that resident #24 did not have a care plan that addressed her nutritional status. 2. Review of the Physician order [REDACTED]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The most recent quarterly MDS 3.0 assessment documented that the resident was receiving an antianxiety medication daily. On 3/8/2011 at 4:15 p.m. review of resident #24's medical record revealed that there was no developed plan of care related to antianxiety medications. Interview with the MDS Coordinator on 3/08/2011 at 4:00 p.m. revealed… | 2014-01-01 | ||
| 10637 | 10637 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2011-03-10 | 280 | D | 82I011 | Based on record review and staff interview the facility failed to revise a Plan of Care to reflect the change in condition of one (1) resident (#11) and the dental needs for one (1) resident ("A") from a sample of nineteen (19) residents. Findings include: 1. A review of the clinical record of resident #11 revealed that she had experienced significant weight loss as follows: 03/01/2011; Weight: 117 (12.7% loss in 3 months) 01/13/2011; Weight: 127 (5.2% loss in 1 month) 12/20/2010; Weight: 134 (baseline weight) Further record review revealed the resident's care plan regarding the potential alteration in nutrition status had not been reviewed or revised since 12/24/10. An interview with the facility's Care Plan Coordinator on 3/08/11 at 3:00 p.m. revealed the care plan had not been revised to reflect this weight loss. Although the care plan did not reflect the resident's weight loss, review of Dietary Notes revealed the weight loss was identified and interventions in place to address the weight loss. 2. A family interview for resident "A" on 3/07/11 at 7:30 p.m., revealed the resident had lost weight since admission and the resident's dentures no longer fit properly. Review of the resident's care plan revealed a care plan that addressed nutrition but that had not been updated to reflect the ill fitting dentures. Interview with the Minimum Data Set (MDS) Coordinator on 3/08/11 revealed she had not been made aware of a denture problem for resident "A", therefore, the care plan had not been revised. Interview with the Social Worker on 3/08/11 at 10:13 a.m. revealed she was aware of the resident's ill fitting dentures but had not been able to arrange for a dental visit. She agreed the care plan has not been updated to reflect the ill fitting dentures. | 2014-01-01 | ||
| 10638 | 10638 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2011-03-10 | 281 | D | 82I011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to meet professional standards of quality of care related to obtaining a blood sugar and administering insulin before meals for one (1) resident (#36) from a sample of nineteen (19) residents. Findings include: During the medication pass observation on 3/07/11 at 12:44 p.m. and 12:55 p.m. Licensed Practical Nurse (LPN), "BB" was observed to check the resident's blood glucose (BG) level and then to administer a routine dose of insulin ([MEDICATION NAME] 10 units). Interview with the Licensed Practical Nurse (LPN),"BB", at 12:55 p.m. on 3/07/11 revealed she was aware that the resident had already eaten lunch prior to the BG being checked and the insulin being administered. Review of the March 2011 Physician order [REDACTED]. A later review of the March 2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]" had signed that the blood glucose check was completed at 11:30 a.m. and that that insulin was administered at this time (11:30 a.m). Reference: The Georgia Nurse Practice Act 943-26-1;Article 2; subsection 2.3.2- Standards Related to Licensed Practical Nurse Professional Accountability revealed that the practice practical nursing as a Licensed Practical Nurse (LPN) by performing for compensation acts authorized by the board related to the maintenance of health and prevention of illness through acts, which shall include: administering treatments and medication as ordered by a physician. 2.3.1 B. Demonstrates honesty and integrity in nursing practice. Cross Refer to F-309 | 2014-01-01 | ||
| 10639 | 10639 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2011-03-10 | 287 | F | 82I011 | Based upon observation, record review and staff interviews the facility failed to ensure that Minimum Data Set (MDS) 3.0 transmitted and accepted since 10/01/11. Findings include: Upon entrance to facility it was determined the facility had a census of ninety two (92) but after reconciliation it was discovered that the resident census pool contained twenty three (23) residents. A telephone interview with the Georgia State MDS Coordinator on 3/08/11 at 9:34 a.m. revealed that since 10/01/10, only eleven (11) MDS 3.0 had been submitted and accepted from the facility. An interview with the Administrator on 3/07/11 at 12:00 p.m. revealed she was aware there had been issues with rejection of 3.0 MDS at submission. Interview on 3/08/11 at 8:45 a.m. with the Administrator and MDS coordinator revealed they were unaware that only eleven (11) MDS 3.0 had been accurately transmitted and accepted since 10/01/11. | 2014-01-01 | ||
| 10640 | 10640 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2011-03-10 | 309 | D | 82I011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and staff interview, the facility failed to ensure that physician orders [REDACTED]. Findings include: Record review for resident #36 revealed that she was admitted with a [DIAGNOSES REDACTED]. Review of the March Physician order [REDACTED]. The resident was to receive [MEDICATION NAME] (type of insulin) ten (10) units before meals. During the medication pass observation on the C-hall with Licensed Practical Nurse (LPN), "BB", on 3/07/11 from 12:44 a.m.-12:55 p.m., LPN "BB" was observed to complete a blood glucose (BG) level then to administer [MEDICATION NAME] (insulin) ten (10) units. Interview with the LPN "BB" on 3/07/11 at 12:55 p.m. revealed that the resident had eaten lunch prior to resident's BG being checked and/or insulin being administered. Interview with the Director of Nursing (DON) on 3/09/11 at 2:45 p.m. revealed expectations were that the physicians order would be followed. Review of the March 2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]" signed that the accucheck was completed at 11:30 a.m. and also, that insulin was administered at the same time, documenting the insulin was administered prior to the lunch meal and not after the meal. | 2014-01-01 | ||
| 10641 | 10641 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2011-03-10 | 441 | K | 82I011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of manufacturer's recommendations and staff interview, the facility failed to ensure an Infection Control Program designed to ensure a safe environment to prevent the development and transmission of disease and infection by failing to ensure the cleaning and sanitizing of glucometers between each resident use. This affected two (2) sampled residents, (#17 and #36) and nineteen (19) residents who received blood glucose monitoring on a daily basis via a multiple resident use glucometers. This failure resulted in the likelihood of an immediate and serious threat to resident health and safety for these twenty-one (21) residents. Therefore, it was determined that the likelihood of an immediate and serious threat to the resident health and safety existed from March 8, 2011 related to glucometers not being cleaned and disinfected when used for multiple residents until March 10, 2010, when a plan of correction was implemented by the facility to remove the jeopardy situation. Additional concerns, not related to jeopardy, were identified regarding hand washing during the medication pass observation. Findings include: 1. During medication pass on the A-Hall with LPN, "CC", on 3/08/11 from 11:51 a.m. she donned her gloves, took the glucometer out of the medication cart drawer, used the meter to check resident #17's blood glucose level. The nurse returned the glucometer to the medication cart drawer, but did not clean or disinfect the meter after use. In addition, LPN continue to draw up insulin and administer the injection without changing the gloves or washing her hands. Interview with LPN, "CC", on 3/08/11 at 12:08 p.m. revealed she did not clean the glucometer before she went into the resident #17 room, stating that she thinks she might have cleaned it after the last resident, but was unsure. 2. During medication pass task on the B-Hall on 3/08/11 at 12:40 a.m. with LPN "AA" revealed prior to checking a rand… | 2014-01-01 | ||
| 10642 | 10642 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2011-03-10 | 463 | E | 82I011 | Based on record review, observation and staff interview, the facility failed to ensure that two (2) call lights in resident's bathrooms (#24 and a randomly observed resident) on the C-hall was maintained in functioning order. Findings include: During facility environmental rounds on 3/08/11 at 11:08 a.m., in bathroom C-14, there was no pullcord and/or toggle on the call light system. However, there was a 4 inch x 4 inch orange sign that reminded the resident to call for assistance, "we don't want you to fall". Staff interview with the Maintenance Supervisor on 3/09/11 at 9:10 a.m., revealed the toggle for the bathroom call system had been fixed the day before. He indicated that if a resident was using that particular restroom and needed help, than the resident would have to verbally call for help. A log was kept at the nursing station for staff to enter maintenance requests which he checks at the beginning of the shift and throughout the day. In addition, he does room rounds daily and facility wide rounds monthly. Review of the nursing station repair request log for February and March 2011 revealed no reference of call light problem in bathroom C-14. During the initial observation of resident #24's room on 3/07/2011 at 12:14 p.m. there was no toggle or call light cord in the resident's bathroom. There were signs posted in the bathroom that stated please call for assistance, "we don't want you to fall". On 3/08/2011 at 11:15 a.m. Licensed Practical Nurse (LPN"BB") was observed to wash her hands in this bathroom. When questioned by the surveyor the nurse stated that there was no way to use the call light in this bathroom. | 2014-01-01 | ||
| 10643 | 10643 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2011-03-10 | 490 | K | 82I011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observation, record review and staff interviews, the facility failed to be administered in a manner that ensured staff members were trained appropriately regarding the need to clean and disinfect glucometers between each resident. This affected 21 residents currently in the facility who received daily monitoring of blood glucose levels where mult-use glucometers are used. This failure resulted in the likelihood of an immediate and serious threat to resident health and safety for those 21 residents. Therefore, it was determined that the likelihood of an immediate and serious threat to resident health and safety existed from March 8, 2011 until March 10, 2011 when a plan of correction was implemented by the facility to remove the jeopardy situation. Findings include: Interview on 3/8/11 at 1:00 p.m. with the Administrator, Director of Nursing (DON) and the Clinical Education Director revealed that the DON was unaware of the revision to F441 dated July 17, 2009 and was that the DON and the Clinical Education Director were not familiar with the facility Policy for cleaning and disinfecting of the blood glucose monitors. Review of the facility policy Cleaning/Disinfecting Glucometers with creation date of 4/30/10 and fax date of 3/08/11, from the corporate office, revealed that alcohol should never be used, as it can damage the LED (light emitting diode) readout and the machine, if no visible soil is present, should be disinfected after each use following the manufacture direction or wipe with a cloth damped with EPA (environmental protection agency) registered detergent/germicide that has a TB ([MEDICAL CONDITION]), HBV ([MEDICAL CONDITION]),[MEDICAL CONDITION](human immunodeficiency virus) label or dilute beach solution of 1:10 concentration, and allow to self dry. At this time the DON revealed that he had an in-serviced and instructed all professional staff to clean the blood glucose monitors with an alcohol wipe before and after use… | 2014-01-01 | ||
| 10644 | 10644 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2011-03-10 | 325 | D | 82I011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to ensure nutritional parameters were maintained for two (2) residents ("B" and #11) from a sample of nineteen (19) residents. Findings include: 1. Review of the physician orders [REDACTED]. She was ordered Carnation Instant Breakfast 120 milliliters three (3) times a day on 2/22/11. Observation of the lunch meal on 3/08/11 at 12:20 p.m. revealed that resident #24 was served chopped meat, white rice, sweet potatoes, brussel sprouts, a roll, fruit, tea, water and coffee. Interview with Licensed Practical Nurse (LPN) Clinical Manager at that time revealed that the rice was considered to be a fortified food item. The resident was observed to quickly eat the meat, rice and tea but no other food items. No substitutes or second servings were offered. Interview with the resident at that time revealed she did not have much of an appetite and had lost weight since admission to the facility. She decribed herself as a picky eater at times but does like the vanilla drink she receives with her medications. Record review revealed an admission weight, dated 9/22/10, of 178.8 pounds and a height of 61 inches. Following monthly weights were: 10/2010=177 pounds; 12/2010=165 pounds; 1/08/11=155 pounds. Review of the medical record for resident #24 revealed that no care plan had been developed for this resident. There was no individualized plan of care related to nutrition or weight loss for the resident. Interview with the LPN Manager revealed she considered the weight loss for this resident as beneficial. 2. A review of the clinical record of resident #11 revealed that she had experienced significant weight loss as follows: 03/01/2011; Weight: 117 (12.7% loss in 3 months) 01/13/2011; Weight: 127 (5.2% loss in 1 month) 12/20/2010; Weight: 134 (baseline weight) Further record review revealed the resident's care plan regarding the potential alteration in nutrition status had not been revi… | 2014-01-01 | ||
| 10645 | 10645 | POWDER SPRINGS NURSING & REHAB CENTER | 115538 | 3460 POWDER SPRINGS ROAD | POWDER SPRINGS | GA | 30127 | 2009-06-17 | 225 | D | 5ICH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and resident interview the facility failed to ensure that an injury of unknown origin was investigated and immediately reported to the State Survey and Certification Agency for one (1) resident ("A") on a sample of thirty (30) residents. The findings include: Review of a Nurse's Note dated 5/22/0 at 5:30 p.m. revealed that resident "A" complained of chest pain since 5/21/09 and had received an antacid and pain medication without relief. The physician was notified and orders were obtained to send the resident to the hospital emergency room for evaluation. Review of a Nurse's Note dated 5/23/09 at 2:15 a.m. revealed the resident returned from the hospital with a [DIAGNOSES REDACTED]. The 24 Hour Report/Change of Condition Report dated 5/22/09 included a notation that the resident had returned to the facility at 2:00 a.m. with a fractured right rib. Interview with the Licensed Practical Nurse Unit Manager (LPN) "EE" on 6/15/09 at 2:05 p.m. revealed she was unaware that the resident had a fractured rib and would obtain the report from the hospital. Review of the Radiologist Report with an order date of 5/22/09 documented there was a subacute [MEDICAL CONDITION] posterior 12th rib. Review of the Minimal Data Set assessment revealed resident "A" had short term memory loss, however interview with the resident on 6/15/09 at 11:30 a.m. revealed the resident was able to state place of residence, day of the week, month and year of admission, and family information. During interview with the resident on 6/15/09 at 3:10 p.m. he/she remember having severe pain in the chest area and he/she was told of the rib fracture a few days ago but could not remember which day. Interview with the Director of Nurses (DON) on 6/16/09 at 7:22 a.m. revealed she was unaware that the resident had a fractured rib and therefore it had not been been investigated or reported to the State Agency. Further interview with the DON on 6/16/09 at 9:30 a.m.… | 2014-01-01 | ||
| 10646 | 10646 | POWDER SPRINGS NURSING & REHAB CENTER | 115538 | 3460 POWDER SPRINGS ROAD | POWDER SPRINGS | GA | 30127 | 2009-06-17 | 431 | B | 5ICH11 | Based on staff interview, it was determined that the facility failed to establish a system of records of receipt and disposition of all controlled drugs. The findings include: During an interview with the Director of Nurses, on 6/17/09 at 7:45 a.m., she stated that the facility did not have any system of reconciliation of controlled drugs and the facility relied on proof of use sheets utilized during shift to shift controlled drug counts done by staff nurses. | 2014-01-01 | ||
| 10647 | 10647 | POWDER SPRINGS NURSING & REHAB CENTER | 115538 | 3460 POWDER SPRINGS ROAD | POWDER SPRINGS | GA | 30127 | 2009-06-17 | 309 | D | 5ICH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to follow physician's orders for blood glucose monitoring for one (1) resident (#7) and follow up appointments after an injury for one (1) resident (#13) and on a sample of thirty (30) residents. The findings include: 1. Record review revealed resident #7 to have a [DIAGNOSES REDACTED]. In addition to the routine insulin, the resident was to receive additional insulin as needed based on blood glucose monitoring at 6:30 a.m. and 4:30 p.m. Physician orders included to notify the physician for blood glucose values greater than 400. Review of the facility policy [MEDICAL CONDITION] (elevated blood glucose), the clinical record should have included the resident's symptoms, blood sugar results, the resident's oral intake, notification of the physician and family, and the resident's response to treatment. A review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Interview with Licensed Practical Nurse "EE" on 6/16/09 at 12:30 p.m. confirmed that the physician was not made aware of this elevated blood sugar. Interview on 6/16/09 at 4:00 p.m. with the Director of Nursing revealed the nurse should have documented the blood sugar, the resident's symptoms and that the physician was notified. 2. Review of a Nurse's Note dated 5/22/0 at 5:30 p.m. revealed resident #13 returned to the facility from the emergency room with a [DIAGNOSES REDACTED]. There was no documentation that the resident had a follow up physician visit after this injury. Interview with the Assistant Director of Nurses on 6/17/09 at 8:20 a.m. confirmed that a follow up physician visit had not been conducted. | 2014-01-01 | ||
| 10648 | 10648 | POWDER SPRINGS NURSING & REHAB CENTER | 115538 | 3460 POWDER SPRINGS ROAD | POWDER SPRINGS | GA | 30127 | 2009-06-17 | 371 | F | 5ICH11 | Based on observation, record review and staff interview the facility failed to store and prepare food under sanitary conditions for all residents consuming food (total = 187). The findings include: Observation of the kitchen on 6/15/09 at 10:00 a.m. revealed: The microwave was soiled inside with food particles on all sides, particularly the top and bottom. A pan of pureed bread was sitting on top of the stove ledge. The Food Service Director (FSD) confirmed it was for the lunch meal and should be refrigerated or held at 135 degrees Fahrenheit (F). In the dishmachine area the tile floor was wet and soapy. The FSD stated staff washed the floor a few times each day and used a hose with a sprayer attachment. Observation revealed the water from the floor was being sprayed onto clean dished that were stacked on carts. The can opener in the food preparation area had a thick, dark gummy substance built up on the blade. The microwave in the dining room was dirty on all six (6) sides. Observation on 6/16/09 at 7:05 a.m. revealed: Three (3) items in the cooler did not register a temperature of 41 degrees F or less. The facility thermometer was calibrated twice to ensure accuracy. Pork chops were 47 degrees, black eyed peas were 49 and buttermilk was 48 degrees F. These items were in the cooler over eighteen (18) hours. The tile floor throughout the kitchen needed repair including grout cleaning and replacement. Interview with the Administrator and Maintenance Director on 6/17/09 at 9:00 a.m. revealed they were aware of the tile problems but did not have a specific plan for repairs at this time. Review of the Daily Cleaning Assignments for kitchen staff provided by the facility and signed by staff for 5/11/09 to 6/07/09 revealed cleaning the microwave was not listed under any assignments. | 2014-01-01 | ||
| 10649 | 10649 | POWDER SPRINGS NURSING & REHAB CENTER | 115538 | 3460 POWDER SPRINGS ROAD | POWDER SPRINGS | GA | 30127 | 2009-06-17 | 364 | E | 5ICH11 | Based on observation, resident and staff interview the facility failed to serve food using methods that conserve the nutritional value for all residents consuming food (total = 187). The findings include: Observation of the kitchen on 6/15/09 at 10:00 a.m. revealed ground pork chops, gravy, potatoes and rutabagas were being held hot on trayline. Interview with the Food Service Director (FSD) at that time revealed staff were served at 11:00 a.m. and residents were served at noon. Observation on 6/16/09 at 7:30 a.m. revealed a large pan of green beans boiling on the stove. The FSD stated the beans were for lunch at noon. At 9:55 a.m. the trayline held chicken stew, mashed potatoes, gravy and beef steak also for lunch. Interview with resident "H" on 6/16/09 at 3:00 p.m. revealed the green beans were always over cooked. | 2014-01-01 | ||
| 10650 | 10650 | POWDER SPRINGS NURSING & REHAB CENTER | 115538 | 3460 POWDER SPRINGS ROAD | POWDER SPRINGS | GA | 30127 | 2009-06-17 | 253 | B | 5ICH11 | Based on observation and staff interview the facility failed to provide housekeeping services to maintain a sanitary and comfortable interior related to dirty floors and furniture in need of repair on two (2) of three (3) Wings (East and West) and one (1) of two (2) solariums. The findings include: During intial tour of the East Wing on 6/15/09 at 11:30 a.m. the floors of the hallways were observed to be dirty with a black substance waxed into the tile floor. General observation tour on 6/16/2009 at 9:30 a.m. revealed that the three (3) hallways that make-up the East Wing of the building were in need of stripping and rewaxing. Additional observations at that time: Room 204- The door frame to the bathroom was scuffed and missing paint. The inside of the bathroom door was scuffed and the paint was peeling in a one (1) foot by eight (8) inch section. Room 236- The bedside table for the resident in the second bed was marred and scraped and had missing veneer across the entire front and at the bottom corners. Room 247- The floor was marred with the wax scraped as if someone had pulled something heavy across the floor. Interview with the Administrator on 6/16/2009 at 3:15 p.m. revealed that she was aware the hallways were in need of stripping and waxing. Observation on the West wing on 6/16/09 at 7:25 a.m. revealed the following: Room 302 - Bed A nightstand was missing the trim strip around the top of the stand. Room 326 - The foot board was missing the side strips, exposing bare wood or fiber board. Room 335 - Bed A footboard was scuffed on the edges and was missing the finish. Room 337 - A water stain was on the wall to the right of the air conditioner and was visible from the hallway. One of two (1 of 2) solariums had peeling wallpaper at the air conditioner and window sill. The pink sofa's vinyl was darkened in spots making the sofa appear dirty. One of two (1 of 2) green benches in the hallway had vinyl that had was discolored. Interview on 6/16/09 at 2:00 p.m. with the Maintenance and Housekeeping Supervisors con… | 2014-01-01 | ||
| 10651 | 10651 | POWDER SPRINGS NURSING & REHAB CENTER | 115538 | 3460 POWDER SPRINGS ROAD | POWDER SPRINGS | GA | 30127 | 2009-06-17 | 363 | D | 5ICH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to provide fruit juice as planned on the menu for breakfast for one (1) resident, resident "D" on a sample of thirty (30) residents. The findings include: Review of the physician orders [REDACTED]. Review of the prepared and planned menu for 6/16/2009 revealed that the resident should have received four (4) ounces of a juice with breakfast. Observation of the resident on 6/16/2009 at 7:50 a.m. revealed that the resident received the pureed food as ordered but not the juice as indicated on the meal plan. The resident told the surveyor that they liked juice. Observation of the resident on 6/17/2009 at 7:40 a.m. revealed that the resident did not receive any juice for breakfast. Interview with Certified Nursing Assistant (CNA) "BB" at that time revealed she did not know why the resident had not received juice. It was observed that other residents in the dining room did receive juice with their breakfast. Review of the resident's diet card did not list juice as a dislike. | 2014-01-01 | ||
| 10652 | 10652 | POWDER SPRINGS NURSING & REHAB CENTER | 115538 | 3460 POWDER SPRINGS ROAD | POWDER SPRINGS | GA | 30127 | 2009-06-17 | 372 | C | 5ICH11 | Based on observation and staff interview, the facility failed to ensure refuse containers were in good condition for the garbage compactor. The findings include: Observation on 6/15/09 at 11:45 a.m. revealed the garbage compactor to be dripping a dark liquid from the roller end. The liquid was sufficient in quantity to cause a oily, milky runoff three (3) feet wide by sixteen (16) feet long. Interview on 6/15/09 at 3:35 p.m. with the Maintenance Director confirmed that the compactor was leaking and needed repair. | 2014-01-01 | ||
| 10653 | 10653 | CARTERSVILLE HEIGHTS | 115571 | 78 OPAL STREET | CARTERSVILLE | GA | 30120 | 2010-09-27 | 314 | D | DI8T11 | **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 pressure sore treatments as ordered by the physician for two (2) residents (#2 and #6) in a survey sample of eight (8) residents. Findings include: 1. Record review for Resident #2 revealed an 08/13/2010 Minimum Data Set assessment which indicated that the resident had one Stage IV pressure sore, with an open lesion on the foot. The resident's Pressure Ulcer Documentation Form indicated that the resident had a left heel pressure sore. Additionally, the resident's September 2010 treatment record documented that the resident had [DIAGNOSES REDACTED]. A current physician's orders [REDACTED]. with Kling every day. However, review of the September 2010 treatment record referenced above revealed no documented evidence to indicate that the dressing change was done on Sunday, 09/26/2010, as ordered. During a treatment observation for Resident #2 conducted on 09/27/2010 at 11:45 a.m., when Treatment Nurse "BB" began the treatment procedure and removed the existing dressing on the resident's left heel pressure sore, this nurse stated that the dressing removed from the left heel wound was dated 9/25/2010, and that the dressing had not been done on 09/26/2010, as ordered. 2. Record review for Resident #6 revealed a 09/02/2010 Minimum Data Set assessment which indicated that the resident had [DIAGNOSES REDACTED]. A current physician's orders [REDACTED]. However, review of the September 2010 treatment record revealed no documented evidence to indicate that the dressing was changed on 09/26/2010, as ordered. Additionally, during a treatment observation for Resident #6 conducted on 09/27/2010 at 3:15 p.m., the existing dressing on the upper back of Resident #6 was dated 09/25/2010. During an interview with Treatment Nurse "BB" conducted on 09/27/2010 at 3:15 p.m., this nurse acknowledged that the dressing was not changed on 09/26/2010 as ordered. | 2014-01-01 | ||
| 10654 | 10654 | CARTERSVILLE HEIGHTS | 115571 | 78 OPAL STREET | CARTERSVILLE | GA | 30120 | 2010-09-27 | 309 | D | DI8T11 | **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 wound care as ordered by the physician for two (2) residents (#5 and #7) in a survey sample of eight (8) residents. Findings include: 1. Record review for Resident #5 revealed a 07/15/2010 Minimum Data Set assessment which indicated that the resident had no pressure ulcers or stasis ulcers at that time, but did have a [DIAGNOSES REDACTED]. Further record review for Resident #5 revealed a current physician's orders [REDACTED]. However, review of the September 2010 treatment record referenced above revealed no documented evidence to indicate that the treatment was done on Sunday, 09/26/2010. During an interview with Treatment Nurse "BB" conducted on 09/27/2010 at 2:00 p.m., this nurse acknowledged that the treatment was not done on 09/26/2010 as ordered. 2. Record review for Resident #7 revealed a 09/23/2010 Minimum Data Set assessment which indicated that the resident had [DIAGNOSES REDACTED]. A current physician's orders [REDACTED]. However, review of the September 2010 treatment record revealed no documented evidence to indicate that the treatment was done on Sunday, 09/26/2010. During an interview with Treatment Nurse "BB" conducted on 09/27/2010 at 2:15 p.m., this nurse acknowledged that the treatment was not done as ordered on [DATE]. | 2014-01-01 | ||
| 10655 | 10655 | FOUNTAINVIEW CTR FOR ALZHEIMER | 115697 | 2631 NORTH DRUID HILLS ROAD N E | ATLANTA | GA | 30329 | 2010-09-21 | 323 | G | GYV611 | Based on resident medical record review, staff interview, facility Investigative Report review, and hospital Discharge Summary review, the facility failed to ensure a safe transfer, per facility policy and the plan of care, for one (1) resident (#1) from five (5) sampled residents. This resulted in actual harm to the resident, with the resident sustaining bleeding lacerations to the left eyebrow area and left side of the forehead, a hematoma on top of the head, and a skin tear on the right hand, with bruising. Findings include: Medical record review for Resident "A" revealed a Care Plan entry dated 05/28/2010 which indicated that resident required the assistance of two (2) persons with total lift transfers. A Nurse's Note of 09/01/2010 timed at 4:00 p.m. documented the nurse had been called to the room of Resident "A" at around 2:35 p.m. by Certified Nursing Assistant (CNA) "CC" and observed the resident with bleeding lacerations to the left eyebrow area and left side of the forehead, a hematoma on top of the head, and an approximate 2 centimeter (cm.) by 2 cm. skin tear on the right hand, with bruising. This Note documented that the physician was notified, Emergency Medical Services was called, and the resident was transported the to the hospital around 3:00 p.m. A review of hospital Discharge Summary record dated 09/13/2010 for Resident "A" revealed documentation that the resident did not receive fractures and had no orbital damage, but had received sutures to the left forehead. The facility conducted an investigation into this resident's injury and obtained a statement from CNA "CC", who was the CNA who had been caring for the resident during the shift at the time of the discovery of the resident's injury on 09/01/2010. CNA "CC" gave a written statement in which she documented that she and another staff member had put Resident "A" in the bed, changed the resident's diaper, then left the room to assist another resident. The CNA documented that the family of Resident "B", the roommate of Resident "A", then came … | 2014-01-01 | ||
| 10610 | 10610 | MILLER NURSING HOME | 115039 | 206 GRACE ST | COLQUITT | GA | 39837 | 2010-10-19 | 157 | D | NOYT11 | **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 immediately consult with the physician and notify the family when there was a significant change in the physical status of one (1) resident (#1) from a survey sample of four (4) residents. Findings include: Record review for Resident #1 revealed the resident's September 2010 Physician order [REDACTED]. An original Admissions Nursing Assessment documented that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An Alteration In Skin Integrity Report of 08/28/2010 specifically documented that the resident had a right above-the-knee amputation and a left below-the-knee amputation, but documented no problem related to the left knee. A later Alteration In Skin Integrity Report of 09/04/2010 documented that by that time, bruising and [MEDICAL CONDITION], with discoloration, were noted to the left knee. Additionally, documentation on the September 2010 General Notes indicated that the resident was medicated with [MEDICATION NAME] 5-500 milligrams for specific complaints of pain in the left leg on 09/04/2010 at 3:00 a.m., 09/07/2010 at 4:00 a.m., and 09/08/2010 at 5:30 a.m.. However, further record review revealed no evidence to indicate that the physician and the family were notified about this significant change status of the resident's left knee, as indicated by bruising, discoloration, [MEDICAL CONDITION], and continued complaints of pain, until a Nurse's Note of 09/10/2010 at 2:40 p.m. documented that the nurse was called to the room of the resident by a certified nursing assistant. This Note documented that the nurse noted ischemic skin breakdown to the resident's left knee, and documented that the physician was notified of the observed breakdown at that time. A Nurse's Note of 09/10/2010 at 2:50 p.m. documented that the family was notified. The above was acknowledged by licensed staff member "AA" during an interview conducted on… | 2014-02-01 | ||
| 10611 | 10611 | TOWER ROAD HEALTHCARE AND REHABILITATION CENTER | 115115 | 26 TOWER RD | MARIETTA | GA | 30060 | 2010-10-18 | 225 | D | DMLD11 | Based on family interview and staff interview, it was determined that the facility failed to investigate allegations of misappropriation of resident property reported to facility staff by the family of one (1) resident ("A") in a survey sample of five (5) residents. Findings include: During an interview with a family member of Resident "A" conducted on 10/12/2010 at 3:45 p.m., the family member stated that it had been reported to the Administrator that someone in a white uniform had been observed by the resident standing in front of an opened drawer and had started to pull things out, at which time the resident screamed and the person left the room. The family member stated that another allegation had been reported to the Administrator in which perfume was allegedly stolen from the resident's room. During an additional interview with the family of Resident "A" conducted by telephone on 10/14/2010 at 6:15 p.m., the family member alleged that the stolen perfume referenced above was valued at $110.00. The family member also alleged that a pair of earrings had been stolen from the resident's jewelry box, and that this allegation was also reported to the Administrator. During an interview with the Administrator conducted on 10/12/2010 at 4:10 p.m., the Administrator acknowledged that there was an allegation reported by the resident's family of an intruder in the resident's room attempting to steal something, but further acknowledged that neither this allegation, nor the allegation regarding the stolen perfumed, were investigated or reported to the State regulatory agency by the facility. During an additional interview with the Administrator conducted on 10/18/2010 at 11:55 a.m., the Administrator stated that the allegation regarding missing earrings was not investigated or reported to the State survey agency. | 2014-02-01 | ||
| 10612 | 10612 | ANDERSON MILL HEALTH AND REHABILITATION CENTER | 115145 | 2130 ANDERSON MILL RD | AUSTELL | GA | 30106 | 2010-10-13 | 157 | D | Y3K611 | **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 immediately notify the family of a dislocated right hip arthroplasty for one (1) resident (#1) in a survey sample of four (4) residents. Findings include: Record review for Resident #1 revealed an Accumulative [DIAGNOSES REDACTED]. A physician's note referencing a physician's visit of 08/21/2010 documented that Resident #1 had experienced a dislocation of the right hip and had undergone a closed reduction in the hospital on [DATE], and was then admitted to the nursing facility on 08/20/2010. A Physician's Telephone Order of 08/20/2010 specified that the resident was to have an x-ray of the right hip prior to the a physician's appointment scheduled on 09/17/2010. A Radiology Report dated 09/02/2010 documented that the impression was a dislocation of the right arthroplasty. A Nursing Daily Skilled Summary dated 09/02/2010 at 10:30 p.m. documented that the x-ray result had been received and was positive for a dislocation of the right hip arthroplasty, and that the resident's physician was notified of the results. However, further record review, to include review of the Nursing Daily Skilled Summary, revealed no evidence to indicate that the resident's family had been notified of this resident's significant change in physical status. During an interview with the Director of Nursing (DON) conducted on 10/13/2010 at 11:10 a.m., the DON acknowledged that the resident's family was not notified of the results of the x-ray done on 09/02/2010 that indicated a dislocation of the resident's right hip arthroplasty. | 2014-02-01 | ||
| 10613 | 10613 | ANDERSON MILL HEALTH AND REHABILITATION CENTER | 115145 | 2130 ANDERSON MILL RD | AUSTELL | GA | 30106 | 2010-10-13 | 309 | D | Y3K611 | Based on record review and staff interview, it was determined that the facility failed to provide care, in accordance with a physician's order for a surgical consultation, for one (1) resident (#1) in a survey sample of four (4) residents. Findings include: Record review for Resident #1 revealed a Physician's Telephone Order of 08/20/2010 which specified that the resident was to have an x-ray of the right hip prior to the a physician's appointment scheduled on 09/17/2010. A Radiology Report dated 09/02/2010 documented that the impression was a dislocation of the resident's right arthroplasty. A Nursing Daily Skilled Summary dated 09/02/2010 at 10:30 p.m. documented that the resident's attending physician had been made aware of the x-ray result which was positive for a dislocation of the right hip arthroplasty, and documented that the attending physician ordered for staff on the 7:00 a.m.-3:00 p.m. shift to follow-up with the surgeon the next morning. However, further record review, to include review of the Nursing Daily Skilled Summary, revealed no evidence to indicate that the surgeon was notified of the x-ray results, as specified by the resident's attending physician's order. During an interview with the Director of Nursing (DON) conducted on 10/13/2010 at 11:10 a.m., the DON acknowledged that the surgeon was not notified of the results of the x-ray, as specified by the attending physician's order. | 2014-02-01 | ||
| 10614 | 10614 | GLENN-MOR NURSING HOME | 115480 | 10629 U.S. HIGHWAY 19 SOUTH | THOMASVILLE | GA | 31792 | 2010-08-26 | 502 | D | S0VI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to obtain laboratory tests as ordered for two residents ( #6 and #10) from a total sample of 15 residents. Findings include: 1. Resident #6 had a 4/6/10 pharmacy recommendation for a lipid panel and a HgbA1c now and every 12 months to monitor his/her use of [MEDICATION NAME]. The resident's attending physician approved that recommendation on 5/3/10 and ordered that those laboratory tests be obtained on 5/5/10 and then annually. However, the laboratory tests were not obtained as ordered until 8/25/10, after surveyor inquiry. During an interview on 8/25/10 at 10:50 a.m., licensed nurse "AA" confirmed that nursing staff had failed to obtain the laboratory tests as ordered. 2. Resident #10 was admitted on [DATE]. There was an 8/9/10 physician's orders [REDACTED].) and a Liver Function Test (LFT) to be obtained the week of admission and then every 6 months thereafter with a start date of 8/11/10. The order included that a Potassium level was to be obtained the week of admission and then once a month thereafter with a start date of 8/11/10. However, those laboratory tests were not obtained until 8/26/10, after surveyor inquiry. On 8/26/10 at 11:20 a.m., the Director of Nurses provided a copy of the laboratory results and confirmed that those laboratory tests had not been obtained until that day (8/26/10). Resident #10 had a critical high [MEDICATION NAME] time (PT) level of 44 seconds (normal range of 9.5 - 11.8 seconds) and a critical high International Normalized Ratio (INR) of 4.5 ( normal range 2 - 3) on 8/11/10. The physician ordered that nursing staff hold the resident's [MEDICATION NAME] for two days and then recheck the resident's PT and INR levels again on 8/13/10. However, nursing staff failed to obtain the PT and INR levels until 8/16/10. On 8/16/10, the laboratory results form noted that the resident's PT was high at 17 seconds and the physician was n… | 2014-02-01 | ||
| 10615 | 10615 | GLENN-MOR NURSING HOME | 115480 | 10629 U.S. HIGHWAY 19 SOUTH | THOMASVILLE | GA | 31792 | 2010-08-26 | 253 | D | S0VI11 | Based on observations, it was determined that the facility failed to maintain an environment that was free from dust, dirt, improperly fitting vents, stained ceiling tiles, missing light bulbs and light covers and broken air conditioner vent covers in nine of 31 residents' rooms on both halls (100 and 200) of the facility. Findings include: Observations were made on 8/24/10 between 9:30 a.m. and 10:35 a.m. 100 Hall 1. The bathroom's ceiling tiles did not fit so, there were gaps in the ceiling in room 108. 2. There were two dried brown stained ceiling tiles in room 103. 200 Hall 1. There was a dried brown stained ceiling tile in the bathrooms in rooms 201 and 212. 2. The bathroom ceiling light fixture was missing a bulb and light cover in room 205. 3. The air conditioner vent covers had a build up of dust in rooms 207, 209, 211 and 214. 4. The bathroom's ceiling vent was loose in room 209. 5. A part of the air conditioner's plastic vent cover was broken off in room 207. | 2014-02-01 | ||
| 10616 | 10616 | GLENN-MOR NURSING HOME | 115480 | 10629 U.S. HIGHWAY 19 SOUTH | THOMASVILLE | GA | 31792 | 2010-08-26 | 315 | D | S0VI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to ensure that one resident (#1) had a medical [DIAGNOSES REDACTED]. Findings include: Resident #1 had an indwelling urinary catheter since at least 12/14/09. However, review of the resident's medical record revealed [REDACTED]. During an interview on 8/25/10 at 2:00 p.m., the Director of Nursing (DON) stated that the resident had the catheter because the resident's family had requested it. | 2014-02-01 | ||
| 10617 | 10617 | GLENN-MOR NURSING HOME | 115480 | 10629 U.S. HIGHWAY 19 SOUTH | THOMASVILLE | GA | 31792 | 2010-08-26 | 387 | D | S0VI11 | Based on record review, staff interview, and review of the facility's Quality Assurance committee meeting minutes, it was determined that one resident (#1) was not seen by a physician at least once every 60 days in a sample of 15 residents. Findings include: Resident #1 had a 1/14/10 physician's progress note signed by his/her attending physician. However, there was not another physicians's progress note or evidence of a physician's visit to the resident until a 7/19/10 progress note signed by the Medical Director. During an interview on 8/25/10 at 11 a.m., the Director of Nursing (DON) stated that the facility had identified that the resident's attending physician had not visited him/her since January, 2010. She said that the problem had been discussed in the April Quality Assurance meeting and a corrective action plan was developed. She said that as of July, the attending physician had still not visited the resident so, the Medical Director visited him/her. However, despite the facility having identified the lack of physician's visits to resident #1 in April, a physician did not visit the resident until 7/19/10. | 2014-02-01 | ||
| 10618 | 10618 | GLENN-MOR NURSING HOME | 115480 | 10629 U.S. HIGHWAY 19 SOUTH | THOMASVILLE | GA | 31792 | 2010-08-26 | 164 | D | S0VI11 | Based on observation, it was determined that the facility failed to provide personal privacy during incontinence care for one resident (#3) from a total sample of 15 residents. Findings include: During an observation of incontinence care being provided on 8/25/10 at 4:20 p.m., certified nursing assistant (CNA) "BB" failed to close the privacy curtain between the A and B beds in the room. Resident #3 was exposed from the waist down and his/her roommate was present in the room. | 2014-02-01 | ||
| 10619 | 10619 | GLENN-MOR NURSING HOME | 115480 | 10629 U.S. HIGHWAY 19 SOUTH | THOMASVILLE | GA | 31792 | 2010-08-26 | 225 | D | S0VI11 | **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 investigate the cause of a fracture for one resident (#3) from a total sample of 15 residents. Findings include: Resident #3 sustained a moderately displaced and mildly angulated spiral fracture to his/her left distal tibia and fibula that was identified by an x-ray report on 2/8/10. Licensed nursing staff documented in the 2/5/10 at 4:17 a.m. nursing notes that a certified nursing assistant (CNA) had observed that the resident's left ankle had [MEDICAL CONDITION] (swelling) and was painful with movement. However, review of the resident's record revealed no known etiology (cause) for the fracture. The licensed nurse coded the resident as requiring extensive assistance of one staff member (3/2) for bed mobility and dressing on the 12/8/09 quarterly Minimum Data Set (MDS) assessment. During an interview on 8/25/10 at 9:50 a.m., the Director of Nursing confirmed that the facility did not conduct a thorough investigation to determine the cause of the resident's fracture. | 2014-02-01 | ||
| 10620 | 10620 | GLENN-MOR NURSING HOME | 115480 | 10629 U.S. HIGHWAY 19 SOUTH | THOMASVILLE | GA | 31792 | 2010-08-26 | 323 | D | S0VI11 | **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 evaluate the effectiveness of or develop new interventions to prevent injury from the bed siderails for one resident (#3) from a total sample of 15 residents. Findings include: Resident #3 had [DIAGNOSES REDACTED]. He/She sustained a moderately displaced and mildly angulated spiral fracture to his/her left distal tibia and fibula that was identified by an x-ray report on 2/8/10. Licensed nursing staff documented in the 2/5/10 at 4:17 a.m. nursing notes that a certified nursing assistant (CNA) observed that the resident's left ankle had edema (swelling) and was painful with movement. However, review of the resident's record revealed no known etiology (cause) for the fracture. During an interview on 8/25/10 at 9:50 a.m., the Director of Nursing (DON) stated that the facility did not complete an investigation into the cause of the resident's fracture. He/she stated that the resident had probably hit his/her leg on the side rail of the bed and it had fractured because of having osteopenia. However, the 2/8/10 x-ray report noted "diffuse osteopenia" only in the resident's left ankle. The resident was observed in bed on 8/24/10 at 11:50 a.m., 12:40 p.m., 2:40 p.m., on 8/25/10 at 11:00 a.m., 12:00 p.m. and on 8/26/10 at 7:55 a.m. with 3/4 siderails up. There was not any padding on them. During an interview on 8/26/10 at 11:30 a.m., the DON stated that padded siderails had been tried after the resident's fracture but, the resident had removed them. He/she stated that there was no documentation related to the resident having had padding on his/her siderails or about the resident's behavior of removing them. She said that there were not any other interventions that had been put in place. During an interview on 8/26/10 at 9:45 a.m., CNA "CC" stated that he/she had not seen padding on the resident's siderails after the resident's 2/2010 fracture. There … | 2014-02-01 | ||
| 10621 | 10621 | CRESTVIEW HEALTH & REHAB CTR | 115525 | 2800 SPRINGDALE ROAD | ATLANTA | GA | 30315 | 2010-10-27 | 157 | D | CU8M11 | Based on record review and staff interview, the facility failed to promptly consult with the physician, and immediately notify the family, regarding a significant change in the physical status of one (1) resident (#1) of thirteen (13) sampled residents Findings include: Record review for Resident #1 revealed Nurse's Note of 09/17/2010 at 11:22 a.m. which documented that the resident was alert and responsive, with no distress observed. Then, a Nurse's Note of 09/17/2010 at 5:30 p.m. documented that staff had noted softness and puffiness of the resident's left hand. There was no evidence to indicate that the physician was consulted or that the family of the resident was notified of this change in status at that time. A Nurse's Note of 09/25/2010 at 9:30 a.m. documented that the resident left arm had been elevated with a pillow roll and the left leg was elevated due to swelling. There was no evidence to indicate that the physician was consulted or that the family of the resident was notified of this change in status at that time. A Nurse's note of 10/19/2010 at 6:30 p.m. documented that the resident's family was concerned about the resident having left arm swelling. This Note documented that the physician was notified at that time, and that orders were received for a chest x-ray and Doppler studies of the left arm. During an interview conducted on 10/26/2010 at 2:15 p.m., the Director of Nursing stated that she called the doctor as soon as the family told her the resident's arm was swollen. | 2014-02-01 | ||
| 10622 | 10622 | PALMYRA NURSING HOME | 115628 | 1904 PALMYRA ROAD | ALBANY | GA | 31702 | 2010-10-15 | 314 | D | E1CR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations and staff interview, it was determined that the facility failed to provide the treatment as ordered for healing for one resident, Resident #2, out of a sample of four residents with pressure sores, from a total sample of five residents. Findings include: Based on review of the documentation on the facility's Wound Record for Resident #2, revealed an unknown stage pressure sore to the right heel, which was facility acquired and first identified on 7/16/10. A review documentation on the Treatment Record revealed there was a treatment order, to cleanse the right heel with normal saline, apply [MEDICATION NAME] and dry dressing, and to change every three days. This order was discontinued on 10/11/10 when a new physician's orders [REDACTED]. However, during an observation of the resident's right heel and dressing on 10/15/10 at 3:10 p.m. with licensed staff member "AA" revealed that the dressing over the right heel pressure sore was the [MEDICATION NAME] dressing. The [MEDICATION NAME] was then reapplied at that time. Another observation of the resident's right heel with licensed staff member "AA" at 4:40 p.m. on 10/15/10 revealed that the [MEDICATION NAME] dressing was in place over the pressure sore on the right heel. This was confirmed by licensed staff "AA" at 3:10 p.m. and 4:40 p.m. during interview. A review of the documentation on the October 2010 treatment record on 10/15/10 at 3:45 p.m. revealed that the old treatment order to cleanse the right heel with normal saline, apply [MEDICATION NAME] and dry dressings, and to change every three days, was still being documented as done from 10/11/10 through 10/15/10. There no documentation that the new treatment order of 10/11/10 had been transcribed nor implemented by staff to cleanse the right heel with normal saline, apply Santyl and dry dressings, and to change every other day. This was acknowledged by licensed staff "AA" at 5:20 p.m. during an interview. | 2014-02-01 | ||
| 10623 | 10623 | PALMYRA NURSING HOME | 115628 | 1904 PALMYRA ROAD | ALBANY | GA | 31702 | 2010-10-15 | 315 | D | E1CR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and staff interviews, it was determined that the facility had failed to ensure the appropriate care to prevent urinary tract infections for one resident, Resident #2, from a sample of five residents. Findings include: Resident #2 was observed on 10/15/10 at 3:10 p.m. in bed with smeared, dried bowel movement (BM) on the right buttock and in the perineal area. At that time, the resident was not having a bowel movement. Both licensed staff member "AA" and certified nursing assistant "'BB", who were in the room during the observation, acknowledged that this was old bowel movement and that the resident had not been cleaned thoroughly after her last bowel movement. A review of a culture and sensitivity reports from Doctors Laboratory, Inc. revealed documentation showing that the resident had a urinary tract infection on 4/23/10 with a positive [MEDICATION NAME] and over 100,000 colonies/milliliter of Eschericia Coli (E. Coli) and another urinary tract infection with a positive [MEDICATION NAME] and over 100,000 colonies/milliliter of E. Coli on 8/10/10. | 2014-02-01 | ||
| 10624 | 10624 | GOLD CITY CONVALESCENT CENTER | 115689 | 222 MOORE DRIVE | DAHLONEGA | GA | 30533 | 2010-10-27 | 203 | D | 0EJX11 | Based on record review and staff interview, it was determined that the facility failed to notify three (3) of four (4) sampled residents (#2, #3, and #4), and family members of these residents, in writing of the residents' transfer to the hospital and of additional information as required. Findings include: Record review revealed Nurse's Notes dated 10/17/2010 at 7:00 pm. for Resident #2, 10/21/2010 at 5:30 p.m. for Resident #3, and 10/11/2010 at 10:50 a.m. for Resident #4 which documented that each resident had been transferred to the hospital. However, for each of these residents, there was no evidence to indicate that either before hospital transfer, at the time of hospital transfer, or since hospital transfer, each resident and the resident's family had received a written notice of the transfer indicating the reason for the transfer, the date of the transfer, the location to which the resident was being transferred, a statement that the resident had the right to appeal the action to the State, and the State Ombudsman's name, address and telephone number. During an interview conducted on 10/27/2010 at 12:46 p.m., the facility's Director of Nursing acknowledged that there was no evidence of a written notice of transfer containing the required information specified above having been issued/provided to Resident #2, #3, and #4, and to resident family members, regarding the residents' hospital transfers. | 2014-02-01 | ||
| 10625 | 10625 | D SCOTT HUDGENS CENTER FOR SKILLED NURSING, THE | 115690 | 3500 ANNANDALE LANE | SUWANEE | GA | 30024 | 2010-07-15 | 371 | F | DUNS11 | Based on observation and staff interview the facility failed to ensure that foods being served to residents in the facility's main dining room were held at a temperature necessary to prevent the likelihood of foodborne illnesses. This affected all residents in the facility (census = 15). Findings include: Observation on 7/13/10 at 12:15 p.m., with dietary employee "EE", in the serving kitchen of the dining room revealed a stainless steel pan full of tossed green salad was sitting unrefrigerated on a cart in the serving area. Continued observation revealed that the pan of salad was sitting in another pan containing ice. A temperature check of the tossed salad, using a digital thermometer, revealed that the temperature was 62 degrees Fahrenheit, well above the safe holding temperature of 41 degrees Fahrenheit. Further observation revealed a small stainless steel pan of chopped ham, being used to make chef salads, sitting on the cart. The pan of chopped ham was being held at room temperature without any means of keeping the ham cold. The temperature of the chopped ham was measured with a digital thermometer at 61 degrees Fahrenheit. | 2014-02-01 | ||
| 10584 | 10584 | TOWER ROAD HEALTHCARE AND REHABILITATION CENTER | 115115 | 26 TOWER RD | MARIETTA | GA | 30060 | 2010-11-14 | 309 | D | K6XU11 | **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 administer a medication, [MEDICATION NAME] (blood thinner) as ordered for one (1) resident #1 in a survey sample of six (6) residents. Findings include: A review of the 10/27/2010 physician's orders [REDACTED]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. During an interview with the Director of Nursing on 11/14/2010 at 1:00 p.m., it was confirmed that the medication was not administered on 10/27/2010. In addition, an interview and observation with the Director of Nursing at 2:00 p.m. revealed that the [MEDICATION NAME] was at the facility on 10/27/2010 and available to be administered. | 2014-03-01 | ||
| 10585 | 10585 | MAGNOLIA MANOR OF COLUMBUS NURSING CENTER - EAST | 115124 | 2010 WARM SPRINGS RD | COLUMBUS | GA | 31904 | 2010-11-10 | 281 | D | Inf | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, staff interview, review of a facility nurse's written statement, and review of the Model Nurse Practice Act/Model Nursing Administrative Rules, the facility failed to ensure that services, regarding medication administration, were provided in accordance with professional standards of quality and a physician's orders [REDACTED]. Findings include: As specified in the Model Nurse Practice Act/Model Nursing Administrative Rules, Chapter Two - Standards of Nursing Practice, Part 2.3.2 (J), Standards Related to Licensed Practical/Vocational Nurse, the nurse will administer medications accurately. Record review for Resident #1 revealed a current November 2010 physician's orders [REDACTED]. However, observation of Resident #1 conducted on 11/09/2010 at 4:30 p.m. revealed two [MEDICATION NAME]es applied to the resident's back. One [MEDICATION NAME] was dated as having been applied on 11/08/2010 and was on the resident's right back shoulder area. The second patch had an illegible date of application and was on the resident's right mid-back. This was acknowledged by Nurse "AA" and the Director of Nursing (DON), both of whom were in attendance at the time of this observation. During an interview with the DON conducted on 11/09/2010 at 4:40 p.m., the DON acknowledged that only one [MEDICATION NAME] should have been applied to Resident #1. In a written statement dated 11/11/2010 provided by Nurse "BB", Nurse "BB" documented that on 11/08/2010, she had removed a [MEDICATION NAME] dated 11/05/2010 from the left chest of Resident #1, and had then applied a new [MEDICATION NAME]. The nurse further documented that during the application of the [MEDICATION NAME] on 11/08/2010, the resident had exhibited some agitation, and that during the process of providing the resident comfort, she did not recall taking the removed [MEDICATION NAME] off the bed and discarding it. The nurse then indicated in her statement that this… | 2014-03-01 | ||
| 10586 | 10586 | OXLEY PARK HEALTH AND REHABILITATION | 115387 | 181 OXLEY DRIVE | LYONS | GA | 30436 | 2009-10-22 | 323 | D | B8MH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and record review, it was determined that the facility failed to ensure that one resident (#11) of 13 residents dependent on staff for transfers was appropriately transferred from the wheelchair to the bed from a total sample of 18 residents. Findings include: Resident #11 had a [DIAGNOSES REDACTED]. His/her care plan did not include any interventions to address his/her need for staff assistance to transfer. On 10/20/09 at 1:25 p.m., during an observation of the resident being transferred from his/her wheelchair to the bed, two certified nursing assistants (CNAs) inappropriately lifted the resident under his/her arms and by the waistband of the resident's pants. | 2014-03-01 | ||
| 10587 | 10587 | CORDELE HEALTH AND REHABILITATION | 115429 | 1106 NORTH 4TH STREET | CORDELE | GA | 31015 | 2010-09-01 | 241 | D | W2R511 | Based on observation, it was determined that the facility failed to provide care in a dignified manner for one resident (#9) from a total sample of 16 residents. Findings include: On the 6/9/10 significant change of status Minimum Data Set (MDS) assessment, licensed nursing staff coded resident #9 as being dependent on staff for bed mobility, dressing, personal hygiene and toileting. During the provision of incontinence care by CNA "MM" on 8/30/10 at 2:40 p.m., the resident's draw sheet and fitted sheet were observed to be wet with urine. After applying a clean brief, certified nursing assistant (CNA) "MM" did not remove or change those wet sheets. At that time, CNA "MM" stated that the hospice CNA was in the building and would be returning to give the resident a bed bath. However, it was observed that the resident laid on the wet sheets until at least one hour later, at 3:40 p.m., when the hospice CNA was bathing the resident and then changed the wet sheets. | 2014-03-01 | ||
| 10588 | 10588 | CORDELE HEALTH AND REHABILITATION | 115429 | 1106 NORTH 4TH STREET | CORDELE | GA | 31015 | 2010-09-01 | 309 | D | W2R511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to administer medication as ordered for one resident (#6) and failed to obtain a physician's orders [REDACTED].#8), from a total sample of 16 residents. Findings include: 1. Resident #8 had a physician's orders [REDACTED]. A review of the resident's June 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. However, review of the clinical record revealed that there was no evidence of a physician's orders [REDACTED]. During an interview on 8/31/10 at 3:30 p.m., licensed nurse "AA" confirmed that there was not a physician's orders [REDACTED]. Licensed nurse "AA" stated on 8/31/10, after surveyor inquiry, that she had clarified the order with the physician, who wanted it to be administered routinely. 2. Resident #6 had been receiving 3.5 milligrams (mg) of [MEDICATION NAME] daily since 7/23/10. On 7/29/10, the physician ordered 100 milligrams (mg) of [MEDICATION NAME] (an antibiotic) twice daily for ten days to treat a urinary tract infection. There was an 8/2/10 physician's orders [REDACTED]. PT and INR levels were obtained on 8/5/10. The results were available on 8/6/10. The resident's PT and INR levels were reported as having been abnormally high at 25.1 ( normal range 9.5 to 11.8 seconds) and 4.29 respectively. There was a handwritten physician's orders [REDACTED]. However, a review of the August 2010 MAR indicated [REDACTED]. Another PT and INR level was obtained on 8/8/10 with the results available on 8/8/10. The PT and INR levels had increased and were reported as having been critically high at 31.4 and 5.42 respectively. At that time, [MEDICATION NAME] was ordered to be held and then the other orders for reducing the dosage of [MEDICATION NAME] and obtaining PT/INR levels were followed. | 2014-03-01 | ||
| 10589 | 10589 | CORDELE HEALTH AND REHABILITATION | 115429 | 1106 NORTH 4TH STREET | CORDELE | GA | 31015 | 2010-09-01 | 312 | D | W2R511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, it was determined that the facility failed to ensure that oral hygiene was performed as needed for one resident (#9), from a total sample of 16 residents. Findings include: Resident #9 had medical [DIAGNOSES REDACTED]. On the 6/9/10 significant change of status Minimum Data Set (MDS) assessment, licensed nursing staff coded resident #9 as having been dependent on staff for hygiene and bathing. Resident #9 only received nutrition (enteral formula) through a gastrostomy tube. It was observed on 8/30/10 at 11:15 a.m., 1:15 p.m., and 2:15 p.m. that nursing staff had not provided oral care and the resident had a heavy build-up of a thick, white substance on his/her lips. | 2014-03-01 | ||
| 10590 | 10590 | CORDELE HEALTH AND REHABILITATION | 115429 | 1106 NORTH 4TH STREET | CORDELE | GA | 31015 | 2010-09-01 | 164 | D | W2R511 | Based on observations and resident interviews, it was determined that the facility failed to provide privacy while bathing and assistance with dressing for two residents ("A" and "B") of five residents interviewed. Findings include: During the group interview on 8/30/10 at 1:50 p.m., two of the four residents in attendance complained that they did not like the nursing staff allowing other residents to be in the shower room while they were receiving care. On 8/31/10 at 10:20 a.m. and at 3:40 p.m., it was observed that the common shower room had a key pad lock on the outside of the door but, the door was not completely closed. Upon entering the shower room, there was a central area with a commode and sink, which was surrounded by three (3) shower stalls and one tub stall. Each of those stalls had privacy curtains to provide personal privacy for a resident while being bathed. During an interview on 8/31/10 at 10:20 a.m., Certified Nursing Assistant (CNA) " RR" stated each CNA baths assigned residents. "RR" said that the shower room door should be locked so, other residents could not come. He/she stated that residents were dressed in the central area of the shower room after they received a shower. It was observed at that time that there was not a means to ensure personal privacy in the central area where residents were dressed. During an interview on 9/1/10 at 11:00 a.m., the Administrator stated that the shower room door did not automatically lock when closed. She said that there was a "lock" button on the outside that had to be pushed before the door was locked. She said that several residents preferred to use the commodes in the common shower room rather than the bathrooms in their own rooms. Resident "A" stated on 8/30/10 at 1:50 p.m. that during his/her shower in the common shower room, the privacy curtain was pulled around the shower stall but the shower room door was not locked and several residents came into the room to use the toilet. The resident said that he/she felt uncomfortable with other residents com… | 2014-03-01 | ||
| 10591 | 10591 | CORDELE HEALTH AND REHABILITATION | 115429 | 1106 NORTH 4TH STREET | CORDELE | GA | 31015 | 2010-09-01 | 328 | E | W2R511 | **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 ensure that oxygen tubing and nasal cannulas were appropriately stored when not in use for three residents (#12 and two randomly observed residents), that nebulizer masks and tubing were appropriately stored when not in use for four residents (#9 and three randomly observed residents), that the humidifier bottle was filled with water for one resident (#9), and that an oxygen cannister was appropriately secured for one randomly observed resident from four sampled residents and 13 total resident receiving respiratory treatment. Findings include: According to the facility's Resident Census and Conditions of Resident from (dated 8/30/10), 13 residents were receiving respiratory treatment. 1. During an observation of resident #9 on 8/30/10 at 11:15 a.m., his/her nebulizer mask and tubing had been inappropriately stored uncovered on top of the nebulizer compressor. Resident #9 received oxygen continuously at 2 liters per minute through a nasal cannula. It was observed on 8/30/10 at 11:15 a.m., 1:15 p.m. and 2:40 p.m., and on 8/31/10 at 9:00 a.m., 12:35 p.m., 1:30 p.m., and 3:15 p.m. that the humidifier bottle on the oxygen concentrator was empty. During an interview on 9/1/10 at 11:20 a.m., the Director of Nursing (DON) stated that the nurses were responsible for ensuring that there was water in the humidifier bottles on the oxygen concentrators. On 9/1/10 at 11:40 a.m., licensed nurse "BB" stated that water was not added to the humidifier bottles but, the bottles were changed out weekly. However, the facility's policy on Use of Oxygen instructed nursing staff that if a reusable humidifier was used, it should be emptied, rinsed, dried and refilled with sterile water daily. 2. The front panel of resident #12's oxygen concentrator was dusty . The oxygen tubing and nasal cannula were uncovered and draped over the night stand on 8/31/10 at 3:40 p.m. a… | 2014-03-01 | ||
| 10592 | 10592 | CORDELE HEALTH AND REHABILITATION | 115429 | 1106 NORTH 4TH STREET | CORDELE | GA | 31015 | 2010-09-01 | 323 | E | W2R511 | Based on observation and record review, it was determined that the facility failed to safely store hazardous chemicals to prevent residents' access in two of two common shower rooms(women's and men's). Findings include: During the General Observations Tour of the facility on 9/1/10 from 10:45 a.m. to 11:25 a.m., the following observations were made: 1. The Women's Shower was unlocked and unsupervised. Staff had not locked a cabinet in that shower which contained a spray bottle of Germicidal Cleaner. The bottle had the printed manufacturer's recommendation "to keep out of reach of children, may cause eye or skin irritation." There was also a container of Cavi Wipes with a cautionary label that it was harmful if absorbed through the skin and caused moderate eye irritation. 2. The Men's Shower room was unlocked and unsupervised. Staff had left a spray bottle of Germicidal Cleaner hanging on the handrail in one of the shower stalls with a manufacturer's recommendation to keep out of reach of children and may cause eye or skin irritation. | 2014-03-01 | ||
| 10593 | 10593 | CORDELE HEALTH AND REHABILITATION | 115429 | 1106 NORTH 4TH STREET | CORDELE | GA | 31015 | 2010-09-01 | 225 | D | W2R511 | Based on record review, it was determined that the facility failed to thoroughly investigate the past histories of two of ten newly hired employees. Findings include: A review of ten (10) newly hired employees' files revealed that two did not contain evidence of the results of a criminal background check. 1. A certified nursing assistant began working at the nursing facility on 8/16/10 after transferring from another one. However, the facility failed to obtain a new criminal background check. The previous criminal background check results had been obtained on 10/4/05. 2. A certified nursing assistant was hired on 6/10/10. The facility originally requested a background check on 6/2/10. However, there was no evidence that the results were obtained until another request was made on 8/31/10. | 2014-03-01 | ||
| 10594 | 10594 | CORDELE HEALTH AND REHABILITATION | 115429 | 1106 NORTH 4TH STREET | CORDELE | GA | 31015 | 2010-09-01 | 371 | D | W2R511 | **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 dispose of 11 bottles of expired [MEDICATION NAME] enteral nutrition. Findings include: On 9/1/10 at 11:15 a.m., 11 bottles of [MEDICATION NAME] enteral nutrition were observed being stored in a cabinet in the floor pantry. They had an expiration date of 7/1/2010. During an interview on 9/1/10 at 11:45 a.m., the Director of Nursing stated that were not any residents receiving [MEDICATION NAME] at that time. She stated that she was not sure who was responsible for checking the expiration dates on supplements and enteral feedings. | 2014-03-01 | ||
| 10595 | 10595 | CORDELE HEALTH AND REHABILITATION | 115429 | 1106 NORTH 4TH STREET | CORDELE | GA | 31015 | 2010-09-01 | 469 | F | W2R511 | Based on observations and interviews with residents and staff, it was determined that the facility failed to maintain an effective pest control program so that the facility was free of flies in the dining rooms, and the 200 hallway. Findings include: 1. During the group interview held after lunch on 8/30/10 at 1:50 p.m., all four residents in attendance complained about flies in the dining room, residents' rooms and hallways of the facility. Resident "A" had a fly swatter with him/her at the meeting and several flies landed on his/her shirt during the meeting. Resident "U" stated that the flies were awful this year and pointed out two lights in the dining room that he/she stated were purchased by the facility to help get rid of the flies. One of those lights was turned on at that time but, the other one was unplugged. Several flies were seen in the room during the meeting. 2. On 8/30/10 at 12:50 p.m., several flies were observed in the large dining room while the residents were being served lunch. One fly was on a resident's head. One was crawling on the floor. Staff members, who were assisting residents with their meals, were swatting the flies away with their hands. 3. During an interview on 8/31/10 at 5:30 p.m., the Administrator stated that the bug lights were purchased to help get rid of flies. She said that she had been advised by the Pest control company that the lights were supposed to stay off until meal time so they would attract the flies during the meal times. However, it had been observed on 8/30/10 at 1:50 p.m. that one of the bug lights was on after the mid-day meal in the large dining room. However, on 8/31/10 at 8:25 a.m. and 12:20 p.m. during the meals, the bug light in the small dining room on the 200 hall had not been turned on by staff but, the two in the main dining room had been. At 12:40 p.m., two flies were observed in the large dining room. There were flies in the 200 hallway and outside of room 214. 5. During an interview on 9/1/10 at 10:45 a.m. resident "F" stated that he/she ate all m… | 2014-03-01 | ||
| 10596 | 10596 | CORDELE HEALTH AND REHABILITATION | 115429 | 1106 NORTH 4TH STREET | CORDELE | GA | 31015 | 2010-09-01 | 253 | E | W2R511 | Based on observations, it was determined that the facility failed to repair chipped and/or broken shower tiles in two of two shower rooms, failed to repair a leaking sink in the floor pantry, failed to clean dust from an oscillating fan in one room, failed to maintain a clean microwave on station II, and failed to replace a light switch cover in one room, failed to maintain intact double doors on one hall from a review of both wings. Findings include: The following observations were made during the Initial Tour of the facility on 8/30/10 from 8:45 a.m. to 10:30 a.m. and during the General Observations Tour on 9/1/10 from 10:45 a.m. to 11:25 a.m.: 1. There was a dusty oscillating fan in room 105. 2. The light switch cover was missing in the bathroom of room 106. 3. Tere was a small trash can containing dirty gloves outside of the doors at the end of 200 hall. There was mold growing inside it. 4. There was dried food debris on the inside of a microwave on Station II. 5. Three shower stalls in the women's bath had chipped and/or broken tiles with dull edges. 6. One shower stall in the men's bath had chipped and/or broken tile. 7. The floor was stained around the base of the commode in the men's common bath. 8. The plumbing under the sink in the floor pantry was leaking. 9. It was observed on 8/31/10 at 12:40 p.m. that double doors at the end of North Hall had not been maintained. The bottom of of the North Hall egress double door was not flush with the floor which left an opening to the exterior of the building. Although the double doors met in the center of the door frame, a section at the center of each door had been gouged which resulted in a hole when the doors were closed. The hole provided an opening to the exterior of the building. See F469 example #8 for additional information about the doors at the end of North Hall. | 2014-03-01 | ||
| 10597 | 10597 | CORDELE HEALTH AND REHABILITATION | 115429 | 1106 NORTH 4TH STREET | CORDELE | GA | 31015 | 2010-09-01 | 514 | D | W2R511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, it was determined that the facility failed to ensure that licensed nurses documented administration of two medications on the August Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Findings include: Resident #9's physician had ordered 400 milligrams (mg) of [MEDICATION NAME] be administered twice daily through the gastrostomy tube. [MEDICATION NAME] was scheduled to be administered at 5:00 a.m. and 5:00 p.m. However, licensed nursing staff failed to document that the 5:00 p.m. dose of [MEDICATION NAME] had been administered on 8/27/10, 8/28/10, 8/29/10, 8/30/10 and 8/31/10. There was a 8/25/10 physician's orders [REDACTED]. However, licensed nursing staff failed to document that [MEDICATION NAME] had been administered on 8/27/10, 8/29/10 and 8/30/10. | 2014-03-01 | ||
| 10598 | 10598 | CORDELE HEALTH AND REHABILITATION | 115429 | 1106 NORTH 4TH STREET | CORDELE | GA | 31015 | 2010-09-01 | 463 | E | W2R511 | Based on observations, and resident and staff interviews, it was determined that the facility failed to properly maintain the call light system for seven beds on one of two halls (200). Findings include: 1. During the group interview on 8/30/10 at 1:50 p.m., one resident ("B") of the four residents in attendance complained that the call light in his/her room did not always work. During an observation on 9/1/10 at 8:30 a.m., seven of the call lights(rooms 204 bed 3, 203 bed 3, 201 beds 1 and 2 , 219 bed 2, 200 bed 3, 205 bed 3) in residents' rooms on the 200 hall were not working. Residents "E" and "D" stated that the call lights had not worked correctly for about the last one to two weeks. They stated that sometimes the light would turn on (light up) without either of them pushing the button. They stated that the staff had told them they did not know what was wrong with the call light system. During an interview on 9/1/10 at 9:30 a.m., the Administrator stated that the facility had recently had a problem with a call light on the 100 hall but, she was not aware of any problems with call lights on the 200 hall. She provided documentation on 8/19/10 that the facility had requested another service visit from their contractor for problems with the system in one room on 100 hall and a lot (of rooms) on the North side. According to that request, there had been a service visit on Monday (August16, 2010). Although the facility was aware of problems with the call light system, there was no evidence of continued monitoring of the call light system to determine its operational status. When the administrator contacted the Maintenance Director on 9/11/10 at 9:39 a.m., he confirmed that he had not performed any random checks of the call light system. At 10:20 a.m., the Administrator provided a list of the call lights on the 200 hall that had been checked by the Maintenance Supervisor. He identified two call lights that were not functioning properly. The Administrator reported that the Maintenance Director said that he had found… | 2014-03-01 | ||
| 10599 | 10599 | CORDELE HEALTH AND REHABILITATION | 115429 | 1106 NORTH 4TH STREET | CORDELE | GA | 31015 | 2010-09-01 | 428 | D | W2R511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the consultant pharmacist failed to identify that the frequency of administering a hypnotic had been changed without a physician's orders [REDACTED]. Findings include Resident #8 had a physician's orders [REDACTED]. However, a review of the resident's June 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. However, review of the clinical record revealed that there was no evidence of a physician's orders [REDACTED]. During an interview on 8/31/10 at 3:30 p.m., licensed nurse "AA" confirmed that there was not a physician's orders [REDACTED]. However, nursing staff administered Ambien to the resident every night in June and July and 30 of 31 nights in August, 2010. Although the consultant pharmacist reviewed the resident's drug regimen in July and August 2010, she failed to identify the change in the the frequency of administration of Ambien without a physician's orders [REDACTED]. See F309 for additional information regarding resident #8. | 2014-03-01 | ||
| 10600 | 10600 | MEADOWBROOK HEALTH AND REHAB | 115561 | 4608 LAWRENCEVILLE HIGHWAY | TUCKER | GA | 30084 | 2010-11-17 | 202 | D | IU2W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to document the reason for one (1) resident's discharge, Resident #1, from a survey sample of eight (8) residents. Findings include: A review of the medical record for resident #1 revealed the resident was discharged to the hospital on [DATE] due to dangerous aggressive behaviors to others. There was no documentation noted in the medical record by the attending physician or extender as to an inability to meet the resident's needs in the facility or of plans for discharge. A telephone interview conducted on 11/17/10 at 12:26 p.m. with the physician, revealed he had told the discharge planner at the hospital that the resident could not return to the facility because she was dangerous to self and others. The physician further confirmed that he had not documented in the resident's medical record nor had he informed the family that the resident could not return to the facility. | 2014-03-01 | ||
| 10601 | 10601 | MEADOWBROOK HEALTH AND REHAB | 115561 | 4608 LAWRENCEVILLE HIGHWAY | TUCKER | GA | 30084 | 2010-11-17 | 203 | D | IU2W11 | Based on record review and staff interview the facility failed to issue a discharge notice to the resident and family member of the resdient of the discharge and the reasons for the move in writing for one (1) resident, Resident #1, in a survey sample of eight (8) resdients. Findings include: Based on review of the medical record of resident #1, there was no documentation in the resident's medical record that showed the facility provided a discharge notice as soon as practical to the resident and/or family member as required. This notice should include the reason for the transfer/discharge; the effective date of the transfer or discharge; the location to which the resident was transferred or discharged ; the right of appeal, and how to notify the ombudsman (name, address, and telephone number). During an interview with the administrator on 11/17/2010 at 12:45 p.m., the administrator said he had told the complainant about the injured staff member and said that the resident could not return to the facility. However, the administrator said that this conversation with the family member had not been documented. | 2014-03-01 | ||
| 10602 | 10602 | AUTUMN BREEZE HEALTH CARE CTR | 115580 | 1480 SANDTOWN ROAD | MARIETTA | GA | 30008 | 2010-11-17 | 224 | D | C9BJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and hospital document review, the facility failed to provide the services necessary to assess and obtain timely treatment for one (1) resident ("C") from a survey sample of three (3) residents. Findings include: Record review for Resident "C" revealed a 04/20/2010 Physician's Admission History and Physical which documented that the resident's breast exam had been deferred. A physician's Progress Note dated 10/25/2010 documented that during the April 2010 History and Physical, the palpation portion of the breast exam had been deferred, but that visualization for asymmetry and assessment for nipple drainage had been unremarkable. Further review of the resident's record revealed documentation indicating that weekly assessments had been done, with no notations indicating that staff had either identified or documented any changes or dimpling of the right breast. However, a Nurse's Note of 10/24/2010 at 6:00 p.m. documented that the resident's family member had reported a lump in the resident's right breast. This Note documented that upon assessment, a lump approximately the size of a golf ball was palpated on the inner portion, and extending toward the middle, of the resident's right breast, with indentation observed. This Note further documented that the physician was notified, and an order was received to send the resident to the hospital emergency room . A hospital ED Record of 10/24/2010 documented that Resident "C" was diagnosed with [REDACTED]. A Physician's Progress Note of 10/27/2010 documented that a breast exam had revealed considerable induration with skin retraction. During an interview with the Assistant Director of Nursing (ADON) conducted on 11/17/2010 at 1:20 p.m., she stated that she expected staff to do a head-to-toe assessment and to report any changes or abnormal findings. The ADON stated that she had examined Resident "C"'s breasts and noted that the right breast looked dif… | 2014-03-01 | ||
| 10603 | 10603 | CANTON NURSING CENTER | 115606 | 321 HOSPITAL ROAD | CANTON | GA | 30114 | 2010-11-30 | 309 | D | LIVR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to administer medications as ordered by the physician for one (1) resident (#1) in a survey sample of six (6) residents. Findings include: Record review for Resident #1 revealed a Social Progress Notes entry of 10/11/2010 which documented that the resident had been admitted to the facility on that date. The resident's admission physician's orders [REDACTED]. However, further record review, to include review of the October 2010 Medication Record, revealed no evidence to indicate that the medication was administered, as ordered and scheduled, on 10/16/2010 at 8:00 a.m., 10/17/2010 at 8:00 p.m., and 10/24/2010 at 8:00 a.m. During an interview with the Director of Nursing (DON) conducted on 11/18/2010 at 1:20 p.m., the DON acknowledged there was no evidence to indicate that the medication doses were administered as ordered. Additional review of the 10/11/2010 physician's orders [REDACTED]. During an interview with the DON at 1:15 p.m. on 11/18/2010, the DON acknowledged there was no evidence to indicate that the medication was administered as ordered. | 2014-03-01 | ||
| 10604 | 10604 | GOLD CITY CONVALESCENT CENTER | 115689 | 222 MOORE DRIVE | DAHLONEGA | GA | 30533 | 2009-09-24 | 323 | D | MGH611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to ensure that three (3) residents (#6, #9, and #12) of nineteen (19) sampled residents at risk for falls had appropriate safety devices in use. Findings include: Review of the quarterly Minimum Data Set (MDS) for resident #12 dated 7/29/09 revealed the resident had fallen in the past thirty (30) days as well as in the past thirty-one (31) to sixty (60) days. Review of the care plan developed to address the risk for falls revealed the resident had an intervention to have an alarm on her wheelchair. During an observation on 9/23/09 at 2:20 p.m. the resident was observed up in the wheelchair, however, there was no alarm in place. During an interview on 9/24/09 at 9:00 a.m. the Director of Nursing (DON) confirmed that the resident should have an alarm when the resident is in her wheel chair. She further stated that the Certified Nursing Assistant (CNA) responsible for restorative nursing had a book with a list of residents who required alarms and safety devices, and she checks these devices daily for their appropriate use. She added, that the use of an alarm on this resident's wheelchair was not listed in the book and must have been left off. Record review for resident #9 revealed that the resident had a history of [REDACTED]. During an observation on 9/24/09 at 12:58 p.m. and on 9/25/09 at 8:15 a.m. the resident was observed in a high back wheelchair and a self release belt was not in place. An interview on 9/25/09 at 8:15 a.m. with Certified Nursing Assistant (CNA) "AA" confirmed that a self release belt was not in place. During an observation on 9/26/09 at 8:50 a.m. the resident was observed in bed and a safety pad was not placed beside the bed. During an interview with Licensed Practical Nurse "BB" on 9/26/09 at 9:10 a.m. she confirmed that the safety pad was not beside the bed. During an interview on 9/26/09 at 10:45 a.m. Restorative LPN "EE" stated the restorative … | 2014-03-01 | ||
| 10605 | 10605 | GOLD CITY CONVALESCENT CENTER | 115689 | 222 MOORE DRIVE | DAHLONEGA | GA | 30533 | 2009-09-24 | 282 | D | MGH611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to ensure for two(2) residents (#9 & 12) on a sample of nineteen (19) residents, that care plans were followed related to the use of chair alarms, safety floor pad and self release seat belts. Findings include: Record review for resident #9 revealed that the resident fell on [DATE], 5/12/09, 5/16/09, 5/31/09, 6/8/09, 6/12/09, 6/15/09, 7/15/09, 7/20/09, and 8/22/09. The care plan dated 9/3/09 indicated that the resident was at risk for falls and was care planned to have a low bed with a safety pad and a self release belt when the resident is in the wheelchair. During an observation on 9/24/09 at 12:58 p.m. and on 9/25/09 at 8:15 a.m. the resident was observed in a high back wheelchair and a self release belt was not in place. An interview on 9/25/09 at 8:15 a.m. with Certified Nursing Assistant "AA" confirmed that a self release belt was not in place. During an observation on 9/26/09 at 8:50 a.m. the resident was observed in bed and a safety pad was not placed beside the bed. During an interview with Licensed Practical Nurse "BB" on 9/26/09 at 9:10 a.m. she confirmed that the safety pad was not beside the bed. Review of the comprehensive care plan for resident #12 revealed a care plan was developed to address the risk for falls. The care plan was reviewed in the care plan meeting on 7/27/09. An intervention added on 5/12/09 indicated the resident should have a tab alarm applied to her wheelchair. During an observation on 9/23/09 at 2:30 p.m., the resident was observed up in the wheelchair with no tab alarm in place. During an interview on 9/23/09 at 3:10 p.m. the Minimum Data Set (MDS) Coordinator "AA" stated the resident was supposed to have the tab alarm, however, she had no explanation as to why it had not been applied. | 2014-03-01 | ||
| 10606 | 10606 | FORT GAINES HEALTH AND REHAB | 115696 | 101 HARTFORD ROAD, WEST | FORT GAINES | GA | 39851 | 2010-11-17 | 202 | D | 9ZTI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to ensure that a physician documented the necessity of a transfer and discharge from the facility for one resident (#1) of three residents reviewed for transfers/discharges from a total sample of five residents. Findings include: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. There was a physician's orders [REDACTED]. A nurse's note entry on 9/10/10 at 2 p.m. documented the resident as stable upon being transferred by car to Medical Center Barbour psychiatric ward for behavior problems. The nurse wrote that the family was aware and the physician was notified. A social service note dated 9/10/10 described the resident's behavior as having become combative and very agitated. The social service staff noted that the resident was being transferred to the Geripsych unit at Barbour Medical Center and that the family and physician were notified. The resident was discharged from the facility on 9/10/10. The Director of Nursing (DON) stated on 11/17/10 at 1:55 p.m., that the resident's physician and medical director had been contacted by the Assistant Director of Nursing (ADON) about transferring the resident on 9/10/10. The physician stated, on 11/17/10 at 3:05 p.m., that the facility had legitimate concerns about the resident's attempting to leave the facility. However, there was not any documentation by the resident's attending physician or another physician about the specific reason for the resident's immediate transfer and discharge to the Medical Center. | 2014-03-01 | ||
| 10607 | 10607 | FORT GAINES HEALTH AND REHAB | 115696 | 101 HARTFORD ROAD, WEST | FORT GAINES | GA | 39851 | 2010-11-17 | 203 | D | 9ZTI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility discharged on e(#1) of three residents without notifying the resident and the resident's family in writing about the specific reason for the discharge and any of the other required information in a total sample of five residents. Findings include: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. There was a physician's orders [REDACTED]. A nurse's note entry on 9/10/10 at 2 p.m. documented the resident as being transferred to Medical Center Barbour psychiatric ward for behavior problems, the family was aware of it and that the physician had been notified. A social service note dated 9/10/10 described the resident as having become combative and very agitated so, he/she was being transferred to the Geripsych unit at Barbour Medical Center. The note indicated that the resident's family and physician were notified. The resident was discharged from the facility on 9/10/10. The administrator stated on 11/17/10 at 10:10 a.m. that the resident was discharged from the facility for safety concerns. The Director of Nursing stated on 11/17/10 at 1:55 p.m., that the resident was transferred and discharged from the facility because of his/her wandering behaviors. However, there was no documentation in the clinical record that the facility had provided written notice to the resident and his family about the discharge, the reason for the discharge, the effective date of the discharge, the location to which the resident was being discharged , or the resident's right to appeal the action to the State, and provide the State long term care ombudsman's name, phone number or address. | 2014-03-01 | ||
| 10608 | 10608 | FORT GAINES HEALTH AND REHAB | 115696 | 101 HARTFORD ROAD, WEST | FORT GAINES | GA | 39851 | 2010-11-17 | 205 | D | 9ZTI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to ensure that, two residents (#1 and #2) of three residents who were transferred out of the facility, their family members were provided written information which specified the duration of the facility's bed hold policy from a total sample of five residents. Findings include: The facility's Admission Agreement included a policy on bed holds. The agreement documented the resident and a family member or legal representative would be given notice of the bed hold option at the time of hospitalization or therapeutic leave. The Social Service Director stated during an interview on 11/17/10 at 2:05 p.m., that the bed hold policy was supposed to be sent with residents during transfers out of the facility. However, she said that she did not know if it was being done. She was not sure who was assigned responsibility for sending out the notices. She stated that if the facility was sending it, should have been documented "somewhere." 1. There was a 9/10/10 physician's orders [REDACTED]. However, there was no evidence to indicate that the resident and family had been given written notice which specified the duration of the facility's bed hold policy at the time he/she left the facility. 2. Resident #2 was hosptalized on [DATE] and again on 10/12/10 due to an acute change in condition. However, there was no evidence that the resident and family were given written notice which specified the duration of the facility's bed hold policy at the time the resident left the facility. | 2014-03-01 | ||
| 10609 | 10609 | FORT GAINES HEALTH AND REHAB | 115696 | 101 HARTFORD ROAD, WEST | FORT GAINES | GA | 39851 | 2010-11-17 | 407 | D | 9ZTI11 | Based on record review and staff interview, it was determined that the facility failed to obtain a physician's order prior to a psychiatric evaluation to determine the appropriateness of inpatient psychiatric care for one resident (#1) from at total sample of five residents. Findings include: A social service note entry dated 9/9/10 documented that a staff person from the geri-psychiatric unit at Barbour Medical Center was at the facility to evaluate resident #1's behavioral problems in order to determine if he/she met the criteria for placement at the geripsychiatric unit.. However, a review of the clinical record revealed that there was not a physician's order for that psychiatric evaluation. The Social Service Director stated on 11/17/10 at 2:05 p.m., that the Director of Nursing told her to contact Barbour Medical Center geri-psychiatric services to evaluate the resident. The resident's physician stated on 11/17/10 at 3:05 p.m. that she was not aware that an (psychiatric) evaluation and had not ordered one to be done. | 2014-03-01 | ||
| 10516 | 10516 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2009-08-20 | 504 | D | 3EK711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to ensure that laboratory tests were obtained as ordered for five residents (#5, #7, #18, #19 and #30) from a total sample of 30 residents. Findings include: 1. Resident #18 had a 1/16/09 physician's orders [REDACTED]. A review of the resident's medical record revealed [REDACTED]. However, there was not a physician's orders [REDACTED]. 2. Resident #19 had a 1/21/09 physician's orders [REDACTED]. A review of the resident's medical record revealed [REDACTED]. However, there was not a physician's orders [REDACTED]. During an interview on 8/20/09 at 11:45 a.m., licensed nurse "DD" stated that the additional laboratory tests performed for residents #18 and #19 were obtained in error and did not have a physician's orders [REDACTED]. 3. Resident #5 had a physician's orders [REDACTED]. A review of the resident's medical record revealed [REDACTED]. However, there was not a physician's orders [REDACTED]. 4. Resident #7 had a Complete Metabolic Panel (CMP) obtained on 5/13/09 and 5/14/09. However, review of the resident's medical record revealed [REDACTED]. 5. Review of resident #20's closed record revealed a 3/30/09 physician's orders [REDACTED]. A review of the resident's medical record revealed [REDACTED]. However, nursing staff did not have a physician's orders [REDACTED]. During an interview on 8/20/09 at 11:15 a.m., licensed nurse "CC" stated that the additional laboratory tests performed on residents #5 and #7 were obtained in error. Nursing staff did not have a physician's orders [REDACTED]. | 2014-04-01 | ||
| 10517 | 10517 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2009-08-20 | 325 | E | 3EK711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to ensure that the resident's attending physician reviewed and addressed the registered dietician's recommendations timely for five residents (#6, #18, #19, #26 and #30), and failed to follow a physician's orders [REDACTED].#2) of 15 residents with weight loss from a total sample of 30 residents. Findings include: 1. Resident #18 had [DIAGNOSES REDACTED]. Licensed staff coded the resident as independent in eating on the 4/1/09 Significant Change of Condition comprehensive assessment. He/She was on a Regular diet. Resident #18 had a 5/20/09 and 6/17/09 registered dietician's recommendation for 30 milliliters (ml) of protein supplement twice a day because of his/her significant weight loss of 10% in six months, a low [MEDICATION NAME] level and meal intake of less than 75%. Staff recorded the resident's weight as 188.8 pounds in May, 186.2 in June and 181.8 in July, 2009. The resident's [MEDICATION NAME] level on 6/1/09 was below normal at 18 (normal range, 20-40). However, despite the continued gradual weight loss and low [MEDICATION NAME] level, the resident's attending physician did not act on those recommendations until 7/21/09 (34 days later) at which time the physician ordered the protein supplement. 2. Resident #6 had [DIAGNOSES REDACTED]. Licensed staff coded the resident as independent with eating on the 4/11/09 MDS assessment. Resident #6 had a 4/22/09 registered dietician's recommendation for fortified meals because of meal intake of less than 75%, a body mass index (BMI) of less than 19, having wounds, a low [MEDICATION NAME] and a low [MEDICATION NAME] level. The resident's 4/9/09 [MEDICATION NAME] level was 10.7 (normal range 20-40) and his/her [MEDICATION NAME] level was 3.0 (normal range 3.4-4.8). However, despite the decreased intake, the recorded BMI of less than 19, and the low [MEDICATION NAME] and [MEDICATION NAME] levels, the resident's … | 2014-04-01 | ||
| 10518 | 10518 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2009-08-20 | 282 | D | 3EK711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and record review, it was determined that the facility failed to implement the plan of care to prevent falls for one resident (#27) of six residents with a history of falls from a total sample of 30 residents. Findings include: Resident #27 had a history of [REDACTED]. However, on 8/20/09 at 9:15 a.m., 10:15 a.m., 11:50 a.m. and 12:50 p.m., the resident was sitting in his/her wheelchair, but staff had failed to apply the chair alarm. See F323 for additional information regarding resident #27. | 2014-04-01 | ||
| 10519 | 10519 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2009-08-20 | 428 | E | 3EK711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to ensure that the resident's attending physician acted on the consultant pharmacist's recommendations in a timely manner for nine residents (#2, #3, #9, #18, #19, #20, #24, #27 and #30) from a total sample of 30 residents. Findings include: 1. Resident #18 had a 7/30/09 consultant pharmacist recommendation to increase the dose of Stalevo to aid in reducing the potential of falls and to change the time of the resident's Flomax from morning to hour of sleep to reduce any orthostatic hypotension to aid in reducing falls. However, the physician did not act on those recommendations until 8/19/09, at which time he/she increased the dose of Stalevo and changed the time of administering of Flomax to bedtime. 2. Resident #19 had a 3/26/09 consultant pharmacist recommendation for a [DIAGNOSES REDACTED]. However, the physician did not act on that recommendation until 5/27/09, at which time he/she gave a [DIAGNOSES REDACTED]. 3. Resident #20 had a 7/30/09 consultant pharmacist recommendation for the resident's Miralax be mixed with 8 ounces of water or juice according to the manufacturer's recommendations instead of the 4 ounces of liquid that the nursing staff had been administering. However, the physician did not act on that recommendation until 8/18/09, at which time he/she ordered nursing staff to give the Miralax with 8 ounces of water or juice. The resident also had a 6/30/09 consultant pharmacist recommendation for a potassium replacement due to the resident receiving HCTZ daily without a potassium supplement. The resident's 6/30/09 potassium level was low at 3.1 (normal range 3.5-5.3). However, the physician did not act on that recommendation until 7/15/09, at which time, he/she ordered 20 miliequivalents (meq) of KDur daily. During an interview on 8/20/09 at 8:30 a.m., licensed nurse "DD" stated that the consultant pharmacist gave the recommendations to the D… | 2014-04-01 | ||
| 10520 | 10520 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2009-08-20 | 225 | D | 3EK711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to thoroughly investigate the past history of one of sixteen employees, and failed to report one injury of unknown origin to the State survey and certification agency. Findings include: 1. According to the 4/30/09 nurse's notes at 1:40 p.m., resident #12 had [MEDICAL CONDITION] and discoloration on his/her right hand, wrist and lower forearm, and complained of pain. The resident was sent to the emergency room (ER) for evaluation. It was determined that he/she did not have a fracture but had a contusion of the right wrist. Although the facility had investigated that injury and determined it had been of unknown origin, it was not reported to the State survey and certification agency. 2. Review of the personnel records for sixteen employees revealed that the facility hired an employee on 9/22/08. However, the facility failed to thoroughly investigate his/her history including having obtained a current criminal background check prior him/her working at the facility. On 8/20/09 at 1:00 p.m., the administrator stated that the facility staff were unable to locate the background check. | 2014-04-01 | ||
| 10521 | 10521 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2009-08-20 | 323 | D | 3EK711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, it was determined that the facility failed to provide a chair alarm as planned to prevent falls for one resident (#27) of six residents with a history of falls from a total sample of 30 residents and failed to ensure that two handrails were secured to the wall on one unit (Unit IV) of five units in the facility. Findings include: 1. Resident #27 had a history of [REDACTED]. However, on 8/20/09 at 9:15 a.m., 10:15 a.m., 11:50 a.m. and 12:50 p.m., the resident was sitting in his/her wheelchair, but staff had failed to apply the chair alarm. On 8/20/09 at 12:50 p.m., certified nursing assistant "AA" confirmed that the resident did not have a chair alarm on his/her wheelchair. "AA" stated at that time that staff did not apply an alarm on the resident's wheelchair. On 8/20/09 at 12:55 p.m., licensed nursing staff "BB" stated that staff did not apply an alarm on the resident's wheelchair because, the resident did not attempt to get out of his/her wheelchair unassisted. However, according to the 7/15/09 at 9:10 p.m. nurses' notes, nursing staff had found the resident on the floor in his/her room next to his/her wheelchair. 2. During the General Observation Tour of the Facility on 8/20/09 at 11 a.m., two sections of handrails were loose in the Unit IV hall between the common bath and the residents' telephone room, and between rooms 442 and 440. | 2014-04-01 | ||
| 10522 | 10522 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2009-08-20 | 505 | D | 3EK711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, it was determined that the facility failed to promptly notify the physician about an abnormally high [MEDICATION NAME]/INR level and an abnormally high BUN level for one resident (#3) from a sample of 30 residents. Findings include: Nursing staff had given 5 milligrams (mgs) of [MEDICATION NAME] daily to resident #3 since his/her admission on 6/9/09. Licensed nursing staff had obtained a [MEDICATION NAME]/INR blood level on the resident on 6/15/09. Although, the INR was abnormally high at 3.69 (therapeutic range was between 2.0 and 3.0), licensed nursing staff had failed to notify the physician about that result until 7/7/09 (22 days later). At that time, the physician ordered nursing staff to hold the [MEDICATION NAME] that day and then decrease the dose to 2.5 mgs and alternating that with 5 mgs every other day. On 8/19/09 at 11:00 a.m., the consultant pharmacist stated that licensed nursing staff should have notified the resident's physician about the abnormally high INR result prior to 7/7/09. Resident #3 had an abnormally high BUN level of 52 reported on 8/4/09. The normal range for a BUN level was between 7 and 18. Although the resident had an abnormally high BUN level of 31 on 6/6/09 prior to his/her admission to the facility on [DATE], there was no evidence that licensed nursing staff had notified the resident's physician about the even higher BUN result on 8/4/09. | 2014-04-01 | ||
| 10523 | 10523 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2009-08-20 | 253 | C | 3EK711 | Based on observations, it was determined that the facility failed to maintain an environment that was free from dust, rust, stains, missing baseboards, dirt, cobwebs and/or debris on all five hallways in the facility. Findings include: The following were observed on 8/18/09 between 8:55 a.m. and 11:00 a.m. and on 8/20/09 at 10:00 a.m. and 11:00 a.m. 500 Hall 1. There were rusty metal bedpan holders mounted on the bathroom walls in rooms 522 and 523. 2. There was a heavy build up of dust on the bathroom ceiling vents in rooms 523, 540, 541, 542, 543, 545 and 547. 3. There were rusty metal bases on the suction machines in rooms 512 and 541. 4. The laminate finish was peeling off of the side of the nightstand in room 544. 5. There were cobwebs on the furniture in room 531. 6. There was a dried brown liquid substance on the bathroom ceiling light fixtures in rooms 526 and 528. 7. The bathroom light fixture in room 526 was separated from the ceiling on two sides. 8. There was a Exelon medication patch dated 7/5/09 attached to the shower wall in room 521. 9. There were scuffs and gouges on the door of the common bath. 10. There was approximately a five foot section of baseboard missing in the dining area. 11. There was a section of baseboard missing in the hall next to the supply closet. 400 Hall 1. There were scuffs and paint peeling off of the wall next to the linen storage room. 2. There were scuffs and gouges on the door of the common bath. 3. The baseboards were scuffed and stained in the television area. 4. There were stains and paint peeling off of the bottom cabinets in the clean utility room. 300 Hall 1. There was a heavy build up of dust on the ceiling vents in rooms 310 and 331. 2. There were rusted out areas at the bottom of the bathroom door frames in rooms 313 and 331. 3. There were rusty grab bars in the bathrooms in rooms 315, 320 and 342. 4. There were dried brown stains on the bathroom ceiling in room 344. 5. There were dried brown splatter stains on the walls and ceiling of the soiled linen room. 6. … | 2014-04-01 | ||
| 10524 | 10524 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2009-08-20 | 368 | E | 3EK711 | Based on group interview and staff interview, it was determined that the facility failed to offer bedtime snacks to six of fourteen residents who attended the group interview. Findings include: During the group interview on 8/19/09 at 3:00 p.m., six of the fourteen residents said that they were not offered bedtime snacks. During interviews conducted on 8/20/09 between 8:20 a.m. and 9:00 a.m. with the six residents in the group interview who had reported not being offered bedtime snacks, they said that nursing staff did not offer them a bedtime snack on the previous evening (8/19/09). During an interview on 8/20/09 at 9:30 a.m., the Director of Nursing stated that bedtime snacks were kept stocked on the units and nursing staff was responsible for offering them to the residents. | 2014-04-01 | ||
| 10525 | 10525 | BELL MINOR HOME, THE | 115020 | 2200 OLD HAMILTON PLACE NE | GAINESVILLE | GA | 30507 | 2009-11-11 | 332 | E | TBSG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and record reviews, it was determined that for two (2) of the eight (8) residents observed the facility failed to ensure a medication error rate that was less than 5%. Two (2) of four (4) nurses observed during forty-six (46) opportunities made three (3) errors resulting in a medication error rate of 6.25%. Findings include: During the morning medication pass on 11/10/09 the following errors were observed: 1. A resident on the B 1 Hall was given his medications at 8:45 a.m. Record review for this resident revealed current physician orders [REDACTED]. 2. A resident on the B 2 Hall was given his medications at 8:55 a.m. and an antihypertensive medication, [MEDICATION NAME] was included. The medications were given with water. Review of the current physician's orders [REDACTED]. 3. The same resident on the B 2 Hall was given an anticonvulsant medication, [MEDICATION NAME], 200 milligrams at 8:55 a.m. Review of the current physician's orders [REDACTED]. | 2014-04-01 | ||
| 10526 | 10526 | BELL MINOR HOME, THE | 115020 | 2200 OLD HAMILTON PLACE NE | GAINESVILLE | GA | 30507 | 2009-11-11 | 441 | F | TBSG11 | Based on observation and staff interview the facility failed to ensure for a resident census of one hundred and one (101) that linen was handled in a manner to prevent development or transmission of infection. On 11//10/09 at 10:20 a.m. observations of the laundry room revealed the following: The Housekeeping Supervisor (HS) and the Floor Technician (FT) were observed folding clean linen. The clean sheets were observed to touch the floor, the employees clothing and the employee chin, face, nose and body. Employees HS and FT were observed to handle soiled linen wearing no clothing protectors and only disposable gloves. Personal drink containers were observed on the folding table. Interview at that time with HS revealed they have to work in the laundry a couple of times a week. During a second observation on 11/11/09 at 8:50 a.m. the Housekeeping Supervisor, Floor Technician and a Housekeeper were observed in the laundry folding linen and the linen was again observed to touch the floor. Review of the facility protocol The Laundry Process , 6-15 1/1/2000, section: Transferring Soiled Linen, third paragraph instructs that personal protective equipment is to be used when handling laundry. | 2014-04-01 | ||
| 10527 | 10527 | BELL MINOR HOME, THE | 115020 | 2200 OLD HAMILTON PLACE NE | GAINESVILLE | GA | 30507 | 2009-11-11 | 253 | B | TBSG11 | Based on observation and staff interview the facility failed to ensure for one (1) of two (2) common bathing areas (B Hall), and for two (2) of twelve (12) rooms observed that the environment was clean and not in need of repairs. Findings include: During environment observations on 11/10/09 at 11:25 a.m. the following was observed: 1. A build up of black mold was observed around the edges of the showers and wall in the common bathing areas on B Hall. Two (2) broken tiles were observed in the shower area. 2. Two (2) air conditioner/heater units in rooms B-23 and B-24 had broken control panel covers. On 11/11/09, accompanied by the Maintenance Director and Housekeeping Director, the common bathing area on B Hall was observed. The black mold in the first shower had been partially removed but the other shower, tub and sink area continued to have black mold and only one (1) of two (2) broken tiles had been repaired. | 2014-04-01 | ||
| 10528 | 10528 | HUTCHESON MED CTR SUBACUTE UNI | 115040 | 100 GROSS CRESCENT CIRCLE | FORT OGLETHORPE | GA | 30742 | 2010-12-14 | 309 | D | 7FWP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to provide treatments as ordered by the physician for two (2) residents (#s 1 and 2) in a survey sample of six (6) residents. Findings include: 1. Record review for Resident #1 revealed a 10/20/2010 physician's orders [REDACTED]. However, further record review, to include review of the November 2010 Treatment record, revealed no evidence to indicate that this treatment was done on 11/18/2010 at 9:00 a.m., and on 11/01/2010, 11/02/2010, 11/03/2010, 11/23/2010 and 11/27/2010 at 9:00 p.m., as ordered and scheduled. 2. Record review for Resident #2 revealed an 11/04/2010 physician's orders [REDACTED]. However, further record review, to include review of the November 2010 Treatment record, revealed no evidence to indicate that this treatment was done on the 7:00 a.m.-7:00 p.m. shift on 11/07/2010, 11/08/2010, 11/09/2010, 11/12/2010, 11/14/2010, 11/23/2010, 11/26/2010, 11/27/2010, and 11/28/2010, as ordered and scheduled. During an interview with Nurse "AA" conducted on 12/14/2010 at 1:45 p.m., this nurse acknowledged that the treatments referenced above were not done as ordered for Resident #1 and Resident #2. | 2014-04-01 | ||
| 10529 | 10529 | PRUITTHEALTH - MACON | 115288 | 2255 ANTHONY ROAD | MACON | GA | 31204 | 2011-01-18 | 314 | G | PDM311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and resident and staff interview, the facility failed to implement recommended interventions in a timely maner for one (1) resident with a high risk for pressure ulcers. from a sample of six (6) resident. This resulted in actual harm for one (1) resident (#1) that was not immediate jeopardy. Findings include: Review of the medical record for this resident revealed that he was admitted on [DATE] with multiple [DIAGNOSES REDACTED]. The resident had a gastrostomy tube in place for tube feeding. Review of the admission body audit form dated 12/24/10 revealed no open areas on the sacrum, hips, buttocks, ankles, feet and heels. There was a reddened area on the buttocks but was documented as blanchable. Review of the weekly skin assessment performed on 01/03/1, ten days after admission to the facility, revealed the following: right plantar foot #2 stage II 1.8 centimeter (cm) x 1.1 cm with blister right plantar foot #1 stage ll 3.1 cm x 3.2 cm with blister right heel stage I 6 cm x 6 cm with no drainage left plantar foot stage II 3 cm x 4.5 cm with blister left heel unstageable 4 cm x 4 cm suspected deep tissue injury left heel unstageable 3.5 cm x 3.5 cm suspected deep tissue injury left ankle#1 0.5 cm x 0.5 cm x < 0.1 cm with granulation tissue, light drainage let ankle #2 unstageable 1 cm x 1 cm suspected deep tissue injury left ankle #3 stage II 1.1 cm x 1 cm left third toe stage I 0 .5 cm x 0..5 cm left buttocks stage II 1 cm x 2 cm x less than 0.1 cm left buttocks stage III irregular shape with granulation tissue with slough no drainage right buttocks #1 stage I 3 cm x 1.5 cm x < 0.1 cm granulation tissue and slough right great toe stage I I cm x 1 cm no drainage left third toe stage I 0 .5 cm x 0.5 cm During an interview with the Licensed Practical Nurse (LPN) "AA" on 01/18/11 at 10:00 a.m. and again at 12:30 p.m. she revealed that she had first assessed the resident on 12/24/10 and on 12/29/10 realized th… | 2014-04-01 | ||
| 10530 | 10530 | PLACE AT MARTINEZ, THE | 115308 | 409 PLEASANT HOME ROAD | AUGUSTA | GA | 30907 | 2011-01-14 | 203 | D | OC1P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff and family interview, the facility failed to provide a written notice of discharge to one (1) resident (Resident "C"), and to the resident's family, on a survey sample of six (6) residents. Findings include: Review of the medical record for Resident "C" revealed a Nurse's Note of 12/27/2010 at 6:00 p.m. which documented that the resident had been evaluated for behavior. A telephone physician's orders [REDACTED]. Interview with the resident's family on 01/14/2011 at 9:45 a.m. revealed that they were told the resident could not return to the facility as the resident was being placed in the ambulance. Interview with the facility Social Worker on 01/14/2011 at 9:20 a.m. confirmed that she had called the hospital, talked to the social worker there and told the hospital staff member that it would not be safe for the resident to return to the nursing facility. However, during this interview, the facility Social Worker further stated that facility staff had not contacted the physician to place in writing why the resident could not return and did not issue the written notice of discharge to the family. Record review revealed no evidence to indicate that a written notice of discharge had been provided to the family, or to the resident, regarding the resident's 12/27/2010 discharge. Interview with the Administrator and the Director of Nurses on 01/14/2011 at 11:30 a.m. revealed that they were not aware they needed to put in writing the reasons for the resident's discharge and issue the written notice of discharge to the resident and to the family. | 2014-04-01 | ||
| 10531 | 10531 | WARRENTON HEALTH AND REHABILITATION | 115321 | 813 ATLANTA HIGHWAY | WARRENTON | GA | 30828 | 2013-10-02 | 309 | D | 383J11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to monitor for the effectiveness of Insulin administration for a high blood sugar level; failed to administer Insulin as ordered by the physician; failed to monitor for signs and symptoms of [MEDICAL CONDITION] ; and failed to document the resident's refusal of care and services for one resident (#1) of three (3) residents with diabetes from a total sample of ten (10) residents. Findings include: Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident had a 9/19/13 physician's orders [REDACTED]. every evening for dementia with behavioral disturbances, [MEDICATION NAME] 50 mg every bedtime for anxiety, [MEDICATION NAME] 5 mg every day for hypertension and [MEDICATION NAME] 5 mg. every bedtime for dementia. The physician also ordered staff to obtain laboratory tests including a comprehensive metabolic profile to be done the next day (9/20/13). The resident was admitted to the secured unit. The resident had an initial care plan dated 9/20/13 with appropriate interventions to address the resident ' s risk for falls; risk for pressure sores, skin tears or bruising; nutrition; potential for pain; potential for high blood pressure; and behaviors (depression, anxiety, aggression and combativeness). On 9/23/13, the results of the laboratory tests were obtained and revealed that the resident had a high glucose level of 455 (normal range was between 65 -100). The physician was notified and ordered staff to administer 15 units of [MEDICATION NAME] every day with supper (scheduled at 5:00 p.m.) and to obtain finger stick blood sugar levels every morning (scheduled for 6:00 a.m.). On 9/23/13, the resident ' s care plan was revised to address his/her new [DIAGNOSES REDACTED]. Licensed nursing staff documented in the 9/24/13 at 5:45 a.m. Interdisciplinary Progress Note (IDPN) that the resident's fingerstick blood sugar was 578 and that the resident was w… | 2014-04-01 | ||
| 10532 | 10532 | OAKS - ATHENS SKILLED NURSING, THE | 115419 | 139 ALPS ROAD | ATHENS | GA | 30606 | 2011-01-24 | 309 | D | ZGW511 | Based on record review and staff interview, the facility failed to provide care as specified by physician's orders for a hospital transfer for one (1) resident (#1) from a survey sample of five (5) residents. Findings include: Record review for Resident #1 revealed a Nurse's Note of 12/12/2010 at 4:00 p.m. which documented that at around 3:15 p.m., the resident pulled the fire alarm and in the process of trying to get away from the alarm, she hit her right forearm on the door frame. This Note documented that nurses noticed bruising and swelling to the right forearm, and that the resident complained of pain to the arm. This Note also documented that the physician was notified and gave an order to transfer the resident to the emergency room . However, a Nurse's Note of 12/12/2010 at 4:45 p.m. documented that the Director of Nursing (DON) stated not to send the resident to the emergency room , that the hospital could not do anything for a hematoma and that it would dissolve on its own. A Nurse's Note of 12/12/2010 at 7:08 p.m. documented that the physician was called to inform him that the resident was not being sent out as ordered, per the DON. This Note documented that the physician again ordered to send the resident out, but that the DON was calling a second doctor to discuss the resident's condition. This Note documented that the resident continued to complain of pain, and the swelling and bruising continued. A Nurse's Note of 12/12/2010 at 9:30 p.m. documented that the resident remained in the facility and that Tylenol had been administered for pain. A Nurse's Note of 12/13/2010 at 2:30 a.m. documented that no return call had been received from the second physician, and that the resident remained in the facility at that time, with the right arm continuing to be swollen and black. A Nurse's Note of 12/13/2010 at 7:30 a.m. documented the resident still remained in the facility at that time, that the wrist to elbow was dark purple, and that an X-ray was ordered. Further record review revealed that despite receivin… | 2014-04-01 | ||
| 10533 | 10533 | HARALSON NSG & REHAB CENTER | 115431 | 315 FIELD STREET | BREMEN | GA | 30110 | 2009-08-26 | 225 | D | FH9411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to ensure that injuries of unknown origin and allegations of abuse were immediately reported to the facility Administrator and to the State survey and certification agency, and that these allegations were thoroughly investigated for two residents (#1 and "A") of twenty four (24) sampled residents. Findings include: 1. Observation of resident #1 on 8/25/09 at 3:20 p.m. during a skin assessment revealed that Certified Nursing Assistants (CNA) "AA" and "BB" identified that the resident had an extensive, deep purple bruise between the fourth and fifth toe on the right foot. It extended behind the toes on the bottom of the foot and on the top of the foot. The CNA's indicated that they did not know how or when this injury occurred. They added that they discovered the bruise while getting the resident out of bed yesterday (8/24/09) and reported it to Licensed Practical Nurse (LPN) "DD" as soon as it was discovered. Record review revealed that there was no mention of the bruise in the nurses notes for 8/24/09. LPN "CC", the Unit Manager, located a Nurse/Physician Communication Record dated 8/24/09 included documentation of "Client has bruised area to right little toe area, ran over toe when rolling in wheel chair". This Communication Record was signed by LPN "DD". A telephone interview with LPN "DD"on 8/25/09 at 4:50 p.m. revealed that he had not witnessed the event but had been told by the Risk Manager that she had witnessed the event. An interview with the Risk Manager on 8/25/09 at 5:05 p.m. revealed that she had seen the resident with his foot behind the wheel of the wheelchair mid-morning on 8/24/09. She was aware that the CNA's had discovered the bruise before the resident got up for the morning on 8/24/09. She added, that she did not witness the resident's foot being run over with the wheel chair and acknowledged that this was an unwitnessed injury of unknown origin th… | 2014-04-01 | ||
| 10534 | 10534 | HARALSON NSG & REHAB CENTER | 115431 | 315 FIELD STREET | BREMEN | GA | 30110 | 2009-08-26 | 279 | D | FH9411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff and resident interview the facility failed to develop a comprehensive care plan related to long-term symptoms affecting daily care for two (2) residents, ("A" and "B") of a sample of twenty-four (24) residents. Findings include: 1. During the initial tour conducted on 8/24/09 beginning at 11:00 a.m. the Unit Manager stated Resident "A" had difficulty swallowing and was going to have a procedure performed to stretch her esophagus. The Unit Manager further stated this difficulty had been a long term problem for the resident, but she had declined the procedure in the past. The resident, who was assessed as cognitively intact on the Minimum Data Set ((MDS) dated [DATE], stated she had difficulty swallowing, could only take small bites of food at a time, needed to have her throat stretched, and could not eat some foods during interviews on 8/24/09 at 1:05 p.m., 8/25/09 at 8:05 a.m. and 12:50 p.m. and 5:50 p.m. and again on 8/26/09 at 7:50 a.m. These conversations took place during meals in the main dining room. Each time the resident explained her difficulty and either was eating very little or asking for alternates. The Dietary Manager was interviewed on 8/26/09 at 11:00 a.m. and stated she was aware of the resident's problem with swallowing. She further stated, the resident's weight had been stable over the past year and that the resident would ask for foods that she could comfortably eat and that she frequently asked for alternates. Review of the Comprehensive Care Plan for the resident did not reveal any problem related to eating patterns or difficulty swallowing. The Care Plan Coordinator was interviewed on 8/26/09 at 9:05 a.m. She acknowledged she had not included this problem. 2. Record review for resident "B" revealed a current physician's orders [REDACTED]. According to the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of resident's care plan did … | 2014-04-01 | ||
| 10535 | 10535 | HARALSON NSG & REHAB CENTER | 115431 | 315 FIELD STREET | BREMEN | GA | 30110 | 2009-08-26 | 280 | D | FH9411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to update the Comprehensive Care Plan for one (1) resident, #3 of twenty-four (24) sampled residents related to the resident's desire to lose weight. Findings include: Review of the Comprehensive Care Plan for resident #3 revealed an update added 5/23/09 to a problem concerning the resident's risk for weight loss. The update revealed the resident actually desired to lose weight and that any weight loss would be planned and desired. However, the goals were not updated to reflect this and a current goal continued until the next review was to avoid significant weight loss. Review of interventions revealed the resident was also to continue receiving fortified foods twice a day. Review of the Minimum (MDS) data set [DATE] revealed the resident was on a planned weight change program. The Care Plan Coordinator and the Unit Coordinator were interviewed on 8/26/09 at 9:00 a.m. and both stated they were aware of the resident's desire to lose weight and acknowledged that the care plan was not revised with interventions to achieve this goal. | 2014-04-01 | ||
| 10536 | 10536 | HARALSON NSG & REHAB CENTER | 115431 | 315 FIELD STREET | BREMEN | GA | 30110 | 2009-08-26 | 315 | D | FH9411 | Based on observation, record review and staff interview the facility failed to follow acceptable technique to prevent urinary tract infections during incontinent care for two (2) residents (#4 and #14) of twenty-four (24) sampled residents. Findings include: 1. On 8/25/09 at 9:30 a.m. Certified Nursing Assistant (CNA) "GG" was observed providing incontinence care to resident #4. The CNA used a perineal spray cleanser and washcloths. When the CNA cleaned the perineal area some of the perineal spray came in contact with the resident's skin. The resident protested . When the CNA turned the resident on her side to cleanse the anal area she wiped from the back to the front. Review of the facility's policy on Perineal Care revealed that washing should be performed from front to back. Review of the clinical record for this resident revealed laboratory reports dated 8/04/09 and 8/22/09 for urine cultures and sensitivities. Both revealed a urinary tract infection and the infecting organism was Escherichia coli. The resident was treated on both occasions with antibiotic therapy. 2. Record review for resident #14 revealed the resident was assessed on the 6/24/09 Minimum Data Set as being incontinent of bowel/bladder and as being dependent on staff for assistance of activities of daily living and as having a history of urinary tract infections. An observation on 8/24/09 at 4:00 p.m. revealed two Certified Nursing Assistants were leaving the resident's room. Certified Nursing Assistants (CNA) "HH" and "II" assisted the resident to the bathroom to provide incontinence care. A soiled brief was removed as the resident had been incontinent of bowel and bladder. Using a clean washcloth, the resident's perineal area was cleaned of feces by wiping one time with a back to front motion. A second clean washcloth was used to wipe the resident at mid perineum toward the back. The resident began urinating and was seated back on the toilet seat. Urine and a small amount of feces was noted on top of the toilet seat as the resident sat back … | 2014-04-01 | ||
| 10537 | 10537 | HARALSON NSG & REHAB CENTER | 115431 | 315 FIELD STREET | BREMEN | GA | 30110 | 2009-08-26 | 325 | D | FH9411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to put interventions in place to address the protein needs of one (1) resident (#5) of twenty-four (24) sampled residents. Findings include: Review of the clinical record for resident #5 revealed blood was drawn on 7/30/09 to determine the resident's protein levels. The results of the test indicated the resident's [MEDICATION NAME] and [MEDICATION NAME] levels were below the normal range. The physician ordered a repeat test in eight (8) weeks and a nutrition consult with the Registered Dietician (RD). Review of the Nutritional Progress Notes revealed the RD completed the consult on 7/31/09. No new interventions were recommended to address the low protein levels. The RD documented interventions were already in place. Review of the clinical record revealed the resident had been on fortified foods at all meals since 5/22/09. Review of the resident's current Comprehensive Care Plan revealed a new problem added 8/10/09 addressing the resident's recent six (6) month significant weight loss of ten point five percent (10.5%). Although the family states the weight loss was desirable and put the resident at her usual weight, low [MEDICATION NAME] levels put the resident at risk if further weight is lost. The Care Plan did not address interventions to specifically address the low protein. The Unit Manager was interviewed on 8/26/09 at 8:40 a.m. and stated residents with nutritional risk are discussed at weekly Standards of Care (SOC) meetings. Review of the Nurses' Notes revealed the resident was discussed at these meetings on 8/03/09, 8/13/09 and 8/20/09. There were no interventions discussed at these meetings to address the protein levels. The Unit Manager stated the RD does not attend these meetings. Nutritional concerns are referred verbally to the dietician as needed. The Dietary Manager was interviewed on 8/2/609 at 6:30 p.m. She stated fortified foods do not contain added protein. | 2014-04-01 | ||
| 10538 | 10538 | HARALSON NSG & REHAB CENTER | 115431 | 315 FIELD STREET | BREMEN | GA | 30110 | 2009-08-26 | 332 | E | FH9411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to maintain an error rate of less than five (5) percent. During observation of medication pass on 8/25/09 between 8:30 a.m. and 10:45 a.m. two (2) nurses were observed, during forty five (45) opportunities to pass medications. Four (4) errors were observed on one (1) of two (2) units resulting in a medication error rate of 8.88%. Findings include: 1. Licensed Practical Nurse (LPN) "JJ" administered two (2) puffs of [MEDICATION NAME] Multidose Inhaler to a resident. The second puff was administered ten (10) seconds after the first puff. In an interview with the LPN "JJ" at 8:40 a.m. she acknowledged that she should have waited two (2) minutes between puffs. A review of the facility's policy for administration of Oral Inhalations confirmed that two (2) minutes should elapse before administering the second puff. 2. LPN "KK" administered two (2) puffs of [MEDICATION NAME] Multidose Inhaler. The first and second puff was administered three (3) seconds apart. In an interview with this LPN she acknowledged that she should have waited at least one (1) minute between puffs. 3 & 4. Record review for the same resident revealed a physician's orders [REDACTED]. In an interview with LPN "KK" she confirmed that these two medications were omitted. | 2014-04-01 | ||
| 10539 | 10539 | HARALSON NSG & REHAB CENTER | 115431 | 315 FIELD STREET | BREMEN | GA | 30110 | 2009-08-26 | 161 | E | FH9411 | Based on record review and staff interview, the facility failed to purchase a surety bond of sufficient value to assure the security of all resident trust funds deposited with the facility for 87 of 87 managed accounts. Findings include: Record review revealed the current surety bond was in the amount of $35,000.00. A review of bank statements for the Resident Trust Account revealed balances that exceeded this amount for the following months: 1. February 2009: 4 days were over the bond amount, the highest was $37,098.40 2. March 2009: 9 days over, the highest balance was $39,791.69 3. April 2009: 6 days over, the highest balance was $37,698.48 4. May 2009: The average daily balance was over the bond amount. 5. June 2009: The average daily balance was over the bond amount. 6. July 2009: The average daily balance was over the bond amount. Interview on 8/25/09 at 3:00 p.m. with the Business Office Manager revealed that she did not know the amount of the surety bond or that the account balance exceeded the bond amount. | 2014-04-01 | ||
| 10540 | 10540 | HARALSON NSG & REHAB CENTER | 115431 | 315 FIELD STREET | BREMEN | GA | 30110 | 2009-08-26 | 365 | D | FH9411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to provide liquids and food prepared to the consistency ordered by the physician for one (1) resident (#17) of a sample of twenty-four (24) residents. Findings include: Observation of the lunch service on 8/26/09 at 12:55 p.m. revealed resident #17 was served two (2) bowls of chili for residents on a regular diet. Review of the resident's current Physician order [REDACTED]. The Dietary Manager was interviewed on 8/26/09 at 2:15 p.m. and confirmed that the resident should have been served the pureed chili. Observation on 8/25/09 at 9:15 a.m. during medication pass revealed that a medication nurse administered medications to resident #17 with liquids that were not thickened. Review of the August 2009 physician's orders [REDACTED]. Observation in the resident's room revealed an image of a bumble bee over the resident's bed. Interview with Licensed Practical Nurse (LPN) "LL" on 8/26/09 at 10:00 a.m. confirmed that the image of the bumble bee is a reminder to staff to provide thickened liquids to the resident. She added, that the medication nurse should have given the medications with thickened liquids. | 2014-04-01 | ||
| 10541 | 10541 | HARALSON NSG & REHAB CENTER | 115431 | 315 FIELD STREET | BREMEN | GA | 30110 | 2009-08-26 | 456 | E | FH9411 | Based on observation and staff interview, the facility failed to maintain two (2) of two (2) microwave ovens and one (1) of two (2) refrigerators on two (2) of two (2) units. Findings include: During the observational tour of the facility conducted on 8/25/09 at 11:00 a.m. the following areas of concern were noted in two (2) of two (2) pantries. 1. Unit I- the microwave contained a build up of a black/brown substance on the back wall, and a chipped burned area on the top inside door. 2. Unit II- the microwave contained an accumulation of dried food particles/stains on the inside, and the plastic on the inside of the door was melted in two (2) areas. The inside of the refrigerator contained a moderate amount of water on the bottom shelf, the rubber seal around the door was torn, detached and had a build up of mold/mildew. Resident and staff food was being stored inside the refrigerator. The Administrator was made aware of these concerns during an interview on 8/25/09 at 6:30 p.m. | 2014-04-01 | ||
| 10542 | 10542 | NEW HORIZONS LIMESTONE | 115487 | 2020 BEVERLY ROAD NE | GAINESVILLE | GA | 30501 | 2010-09-29 | 279 | D | OSSL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure that one (1) resident (#3) and One (1) resident (#121) both who resided in "B" Building had a care plan developed of the continuous use of a hypnotic medication (#3) and a care plan based on assessment of positioning needs (#121). Findings include: Review of the current quarterly Minimum Data Set assessment ((MDS) dated [DATE] as well as the annual MDS assessment dated [DATE] recorded resident #3 as receiving a hypnotic medication seven (7) times a week during these assessment periods . Review of the current Physician order [REDACTED]. Review of past four (4) months of Medication Administration Records (June 2010, July 2010, August 2010 and September 2010) documented the resident was administered the medication every night. No care plan had been developed for the hypnotic medication with interventions for possible side effects or for interventions to implement alternate sleep pattern techniques. Interview with the Care Plan/MDS Nurse (staff "BB") on 9/28/10 at 11:20 a.m. revealed she had not done a care plan for the routine use of this resident's hypnotic medication. She usually included hypnotic medication use as part of the psychoactive medication care plan but had failed to do so for resident #3. Resident #121 was observed on 9/27/2010 at 12:25 p.m. in the main dining room sitting in a Broda chair waiting for lunch to be served. The resident was leaning to the right. Multiple staff members were present in the dining room but did not attempt to reposition the resident. The resident's lunch tray was served at 1:00 p.m. Certified Nursing Assistant ( CNA) "ZZ" fed the resident. "Staff member "ZZ" made no attempt to reposition the resident to correct body alignment, but continued to feed the resident, whose head was resting on the staff member's shoulder. Review of the Comprehensive Care Plan did not identified any concerns with positioning. The Care Plan Coordinator was i… | 2014-04-01 | ||
| 10543 | 10543 | NEW HORIZONS LIMESTONE | 115487 | 2020 BEVERLY ROAD NE | GAINESVILLE | GA | 30501 | 2010-09-29 | 312 | D | OSSL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interview, the facility failed to consistently provide oral hygiene for one (1) totally dependent resident ('A') and one (1) resident ('B') who needed limited to extensive assistance with hygiene. Both residents resided in the "B" building. The total sample size was twenty-eight (28) residents. Findings include: 1. On 9/27/10 at 3:07 p.m., resident 'A' stated the staff didn't clean his/her teeth. The resident added that they would ask staff to help brush his/her teeth, but was usually told that they'd be back to do it, but they would never come back. He/she added that the last time they saw a dentist, the dentist said their teeth needed to be brushed every day. Review of the resident's Activities of Daily Living (ADL) care plan developed 7/25/10 noted the resident was dependent for all ADLs including bathing, grooming and hygiene due to [MEDICAL CONDITION] with multiple contractures, and interventions included to provide oral care every shift and as needed. A Dental Treatment/Exam document for resident 'A' dated 4/05/10 noted that the oral hygiene status included heavy plaque and heavy calculus and that oral hygiene needed improving, and recommended that the teeth must be brushed twice a day. The Certified Nursing Assistants' (CNA) ADL Notebook noted that the resident was dependent for teeth/mouth care. 2. On 9/28/10 at 10:45 a.m., resident 'B' stated that the staff only assisted him/her with oral hygiene weekly. They added that they usually had to ask the staff to assist them, because the staff didn't do it routinely. Review of the resident's ADL care plan developed 4/16/10 noted the resident needed limited to extensive assist with ADLs due to [MEDICAL CONDITION], and interventions included to assist with/provide mouth care every shift. On 9/29/10 at 9:00 a.m., the resident was noted to have paralysis of the left arm, and needed a wheelchair for mobility due to an amputation of the righ… | 2014-04-01 |
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CREATE TABLE [cms_GA] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );