cms_GA
Data source: Big Local News · About: big-local-datasette
10,655 rows sorted by inspection_text
This data as json, copyable, CSV (advanced)
| Link | rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text ▼ | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 382 | 382 | APPLING NURSING AND REHABILITATION PAVILION | 115262 | 163 EAST TOLLISON STREET | BAXLEY | GA | 31513 | 2018-07-12 | 761 | D | 0 | 1 | 802511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. 07/11/18 an observation on C Hall Licensed Practical Nurse (LPN) GG at 7:56 a.m. LPN GG was observed to walk down the C hall towards the rotunda and administer medications to a resident in the hall way leaving stock medications on top of the medication cart and his back was to the cart. At 7:58 a.m. LPN GG was observed to go into room [ROOM NUMBER] and left the same medication on top of the medication cart, unsupervised with stock medications in closed bottles, on top of the medication cart (no observed residents on hall). Further observation revealed that LPN GG was in room [ROOM NUMBER] approximately 3 minutes before returning to the unsupervised cart, the cart was parked outside of the room and to the right on the wall, not in view of LPN G[NAME] On 07/11/18 at 8:13 a.m. Interview with LPN GG reported that medications should not be left on top of the medication unsupervised. 07/12/18 10:10 AM Interview with LPN Nurse Manager AA on A hall reported that it is not acceptable to leave medications on the top of the med cart out of view. Also stated that she educates nurses on policies and procedures. In continued interview with nurse manager AA revealed that nurses receive orientation on hire and also the Director of Nurses (DON) does in-service education on needed areas of concern or skills that need addressed. 7/12/18 10:37 a.m. Interview with the DON revealed that she expects the nurses to lock all medications in the medication cart when they are not by their cart and follow the medication administration policy. 7/12/18 11:19 a.m. Interview with the Assistant Director of Nursing (ADON) reported that licensed practical nurse GG received education related not leaving medication on the cart unsupervised. The ADON provided education material signed and dated on 4/27/17 and 5/15/18; Medication Pass Guidelines. Review of the A monthly pharmacy Medication Pass Guidelines, dated 6/18/18; 1. Medication Cart and Drug Security; c. Appropriate drug s… | 2020-09-01 |
| 6412 | 6412 | ALTAMAHA HEALTHCARE CENTER | 115577 | 1311 WEST CHERRY STREET | JESUP | GA | 31545 | 2014-06-25 | 441 | E | 0 | 1 | OWMB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Observation on 6/23/14 at 7:44 a.m. and 1:00 p.m., on 6/24/14 at 10:35 a.m. and on 6/25/14 at 7:45 a.m., there were two (2) bedpans and two (2) bath basins on the shelf above the toilet in the adjoining bathroom for rooms [ROOM NUMBERS] on the B Hall. Staff had failed to label the bedpans and basins with the residents' names and failed to appropriately store the bedpans and basins in bags to prevent cross contamination. One (1) of the bedpans had dried fecal material inside the bowl. Observation on 6/23/14 at 7:51 a.m., on 6/25/14 at 12:32 p.m. and on 6/25/14 at 7:50 a.m., there was one (1) bedpan and three (3) bath basins on the shelf above the toilet in the adjoining bathroom for rooms [ROOM NUMBERS] on the B Hall. Staff had failed to appropriately store the bedpan and bath basins in bags to prevent cross contamination. An interview with the Licensed Practical Nurse (LPN) AA, the infection control nurse on 6/25/14 at 8:05 a.m. revealed that the residents' bath basins and bedpans were suppose to be washed completely after use, labeled with the resident's name, stored in a plastic bag and placed in the resident's bathroom on the shelf above the toilet. Observation and interview on 6/25/14 at 8:10 a.m. with LPN AA confirmed that staff failed to appropriately clean and store the residents' bedpans and bath basins in the adjoining bathrooms for rooms 203, 204, 205 and 206. Based on observations, staff interviews and handwashing policy review, facility failed to ensure that staff maintained proper handwashing between resident contact during dining observation to prevent possible cross contamination on two (2) of three (3) halls. Also, facility failed to ensure that personal care items were labeled and stored to prevent possible cross contamination on one (1) of three (3) halls. Findings include: 1.) During the dinner dining observation on the C-hall between 5:35 p.m.-6:00 p.m. on 6/22/14, revealed a Certified Nursing Assistant (CNA) took a tra… | 2018-01-01 |
| 6534 | 6534 | WARNER ROBINS REHABILITATION CENTER | 115612 | 1601 ELBERTA ROAD | WARNER ROBINS | GA | 31088 | 2014-02-27 | 333 | D | 0 | 1 | 23LW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #59 had [DIAGNOSES REDACTED]. There was a care plan in place since 11/4/13 for the use of [MEDICAL CONDITION] medications related to [MEDICAL CONDITION]. The care plan included an intervention for nurses to administer medications as ordered. There was a physician's orders [REDACTED]. However, a review of the January 2014 and February 2014 Medication Administration Record [REDACTED]. The dispensing pharmacy confirmed the medication error during an interview on 2/27/14 at 2:22 p.m. Based on observation, record review and staff interviews the facility failed to ensure that a medications, with potential serious side effects, is given as order by the physician for two (2) residents (#59 and 149) by two (2) nurses of five (5). Findings include: 1. Record review of the physician orders [REDACTED].m During observation of medication administration on 2/27/14 at 9:14 a.m. with Licensed Practical Nurse (LPN) AA revealed that the resident was given [MEDICATION NAME] 1 mg at this time. Review of the MAR indicated [REDACTED]. An interview with LPN AA at 9:33 a.m. revealed that she thought the medication administration time had been changed but she was confused. She did not realize she had given the [MEDICATION NAME] 1 mg although confirmed that the night nurse had signed off as giving the medication at 6:00 a.m. and the resident had received another dose. She revealed that the physician should be contacted and it should be determined if the resident can go on the scheduled trip out of the facility this morning. An interview with the Administrator on the same day at 10:01 a.m. revealed she had called the resident's physician who ordered to monitor the resident's blood pressure before and during the field trip. | 2017-12-01 |
| 8824 | 8824 | MEMORIAL MANOR NURSING HOME | 115711 | 1500 EAST SHOTWELL STREET | BAINBRIDGE | GA | 39819 | 2015-08-12 | 278 | D | 1 | 0 | I93Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) Resident #04 was admitted to the facility in January 2014 was a [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed no antipsychotic medications in Section N. Review of the August 2015 Physician order [REDACTED]. Review of the October 2014 and November 2014 Medication Administration Record [REDACTED]. Interview with the MDS Coordinator AA on 8/11/15 at 12:48 p.m., revealed that the coding on this particular MDS was incorrect and stated that she gets her information from the diagnosis, and medication in Point Click Care (PCC). Based on record review and staff interviews, the facility failed to ensure that the Minimum Data Set (MDS) accurately reflected the assessment of two (2) residents (#01 and #04) regarding pressure sores, and anti-psychotic medication from a total sample of ten (10). Findings include: 1). Resident #01 was admitted to the facility in January 2014 with a [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment dated [DATE] revealed that Section M: Skin Conditions had no evidence of any unhealed pressure ulcers at Stage one (1) or higher. Review of the Wound Care: Weekly Wound Assessment/Condition Report (Pressure and Non-Pressure) dated 7/03/2015 revealed a Suspected Deep Tissue Injury (SDTI) to the right heel, which was first observed on 6/30/15. Review of the Wound Care: Weekly Wound Assessment/Condition Report (Pressure and Non-Pressure) dated 7/30/15 revealed a Stage two (2) to the left heel, which was first observed on 6/30/15. Interview with the Treatment Nurse GG and the MDS Coordinator AA on 8/11/2015 at 1:00 p.m., revealed that the MDS was miscoded regarding the pressure sores. Continued interview revealed that the right heel was a reddened area and the left heel had an unstageable deep tissue injury due to slough in the wound bed at the time of assessment. | 2015-10-01 |
| 2814 | 2814 | WESTWOOD HEALTHCARE AND REHABILITATION | 115601 | 101 STOCKYARD ROAD | STATESBORO | GA | 30458 | 2017-12-21 | 657 | D | 1 | 1 | 9VJ211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > 2. R#183 (a closed record) was admitted in 10/2016 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status Score (BIMS) of 15 indicating she was alert and oriented; had trouble falling/staying asleep; rejected care daily; required limited assistance from one staff person for most activities of daily living (adls); was non-ambulatory; was on a scheduled pain medication regimen; and received antianxiety, antidepressant, and opioid medications daily. Review of the care plan dated 2/4/17 revealed that the resident was very independent with decision making and that the only behavior the resident exhibited was resistance to care at times including ADL care, wound treatments and medications. Review of the Admissions Packet revealed that the facility was a smoke free facility at the time of R#183's admission. Continued review revealed that items not allowed in a resident's room included cigarette lighters due to fire safety regulations. R#183 signed the Admissions Packet on 10/31/16 indicating that she would comply with all facility policies, procedures and regulations relating to the health, safety and welfare of all residents, staff and visitors including the smoking policy. Review of the Interdisciplinary Progress Note (IDPN) dated 12/22/16 revealed that R#183 was noted smoking on the activity patio. Staff re-educated the resident at that time that the facility had a smoke free policy and the resident voiced her understanding. Review of the Investigation Summary dated 12/30/16 sent to the State Agency (SA) revealed that on 12/28/16, the previous Treatment Nurse and Unit Manager (UM) were preparing R#183 for a shower and wound care. R#183 requested the UM to place her cell phone in her purse at that time. When the UM placed the cell phone in the resident's purse, she noted a pack of cigarettes and a lighter inside the purse. The previous Director of Nurs… | 2020-09-01 |
| 999 | 999 | LAGRANGE HEALTH AND REHAB | 115354 | 2111 WEST POINT ROAD | LAGRANGE | GA | 30240 | 2018-12-18 | 609 | D | 1 | 0 | TXXR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on Complainant and staff interviews, and review of the Grievance Log, the facility failed to initiate an investigation of an allegation of missing narcotics for one (1) resident (R#2) from a sample of eight (8) residents. Findings include: Interview on 12/18/18 at 10:50 a.m. with the East Unit Manager EE revealed that a family thought that they had brought medication but home to the facility; but, they had not brought any medication. She revealed that the resident was a Hospice resident from the Hospital and no medications were brought with the resident from the hospital. She revealed that she did not report the allegation because she never received any medication. She revealed that she should have filed this information on a complaint allegation form. Interview on 12/18/18 at 11:55 a.m. with the Complainant revealed that a family member of the resident was concerned about the resident's [MEDICATION NAME]. He revealed that a family member stated that a blister pack of [MEDICATION NAME] was stuck in a Bible although when she checked the Bible the pills were missing. He revealed that the family member had reported the missing narcotic to the staff and that the staff did not do anything about it. Interview on 12/18/18 at 12:55 p.m. with LPN FF revealed that the resident's family member had call her into the room and revealed that the family member had placed a card of medication in a book and it is now missing. She revealed that she referred the family member to the Director of Nursing (DON). She revealed that this was reported to her supervisor immediately. She revealed that she did not fill out a complaint investigation form for the missing medication. Interview on 12/18/18 at 1:10 p.m. with the DON revealed that she talked to the family member, who had a several complaints, although she was never informed of any missing narcotics. She revealed that an investigation was never completed on allegation of missing medication. She revealed … | 2020-09-01 |
| 4140 | 4140 | CRESTVIEW HEALTH & REHAB CTR | 115525 | 2800 SPRINGDALE ROAD | ATLANTA | GA | 30315 | 2017-03-24 | 166 | D | 1 | 0 | BIP011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on Complainant and staff interviews, and the Grievance Log the facility failed to ensure follow-up of a grievance of one (1) resident (R#4) of a feeling of neglect from a sample of twelve residents. Findings include: Interview on 3/20/17 at 12:30 pm with the Complainant revealed that (R#4) no longer wants to be in the facility. She revealed that the staff would not always answer the call light. She revealed that on the day that she was sent out to the Emergency Rood (ER), (January 2, (YEAR)), the Certified Nurse Assistant (CNA) did not provide care for her. She revealed that the staff did not change (R#4) when she was first admitted . She revealed that the (R#4) was wet with brown rings in her bed, (R#4) was wet from shoulder to toes on the next day. This was shown to the Nurse and Certified Nursing Assistant (CNA). The resident was discharged to an acute care hospital on [DATE] and was admitted to another facility when discharged from the hospital. Interview on 3/21/17 at 7:00 pm with the Administrator revealed that she had no conversations with the Complainant about any allegations. Interview on 3/22/17 at 1:08 pm with Licensed Practical Nurse (LPN) DD revealed that (R#4) talked about she was worried that there was not enough staff to to assist with her care. She revealed that (R#4) also stated that she felt like the Certified Nurse Assistants (CNA's) were not paying her any attention because of her size. She revealed that the (R#4) reported that she felt uncomfortable with the staff. Interview on 3/26/17 at 1:00 pm with the Complainant revealed that she had made several phone calls to the Administrator with no response to her concerns. She revealed that there was an on going problem at the facility that was never resolved. Review of the Grievance Log dated 8/31/16 indicated a grievance filed concerning (R#4) was wet from urine from shoulders to feet. Further review of Grievance log dated on 12/13/16 indicted (R#4) left wet from 060… | 2020-03-01 |
| 2799 | 2799 | PRUITTHEALTH - LANIER | 115600 | 2451 PEACHTREE INDUSTRIAL BLVD | BUFORD | GA | 30518 | 2017-05-11 | 281 | G | 1 | 0 | LD2311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, family and staff interviews and review of the State of Georgia Rule 410-10.02 Standard of Practice for Licensed Practical Nurses (LPN) the facility failed to maintain professional nursing standards of quality as evidenced by not ensuring that enteral feeding and water flushes where documented or given to one resident (R A) who was hospitalized with urinary tract infection, severe dehydration, electrolyte imbalance, acute [MEDICAL CONDITION] and pneumonia. The sample size was three and the census was 92. Findings include: Review of the State of Georgia Rule 410-10-02 Standards of Practice for Licensed Practical Nurses (LPN) 1. The practice of licensed practical nursing means the provision of care for compensation, under the supervision of a physician [MEDICATION NAME] medicine, a dentist [MEDICATION NAME] dentistry, a podiatrist [MEDICATION NAME] podiatry, or a registered nurse [MEDICATION NAME] nursing in accordance with applicable provisions of law. Such care shall relate to the promotion of health, the prevention of illness and injury, and the restoration and maintenance of physical and mental health through acts authorized by the board, which shall include, but not be limited to the following: d) Administering treatments and medications by various routes 3. Documentation a) Failing to maintain a patient record that accurately reflects the nursing assessment, care, treatment, and other nursing services provided to a patient. Review of R A clinical record, revealed the resident was admitted to the facility on [DATE] after a hospital stay for a stroke with left side [MEDICAL CONDITION] and dysphagia. The resident has a history of [MEDICAL CONDITION] Fibrillation (AFib), [MEDICAL CONDITIONS], Type 2 diabetes, [MEDICAL CONDITIONS], Hypertension, [MEDICAL CONDITION] and obesity. The resident was admitted to the facility with a Gastric Feeding tube (GT). Review of resident's Physician orders [REDACTED]. Flush tu… | 2020-09-01 |
| 4760 | 4760 | COUNTRYSIDE HEALTH CENTER | 115592 | 233 CARROLLTON STREET | BUCHANAN | GA | 30113 | 2016-07-13 | 425 | D | 1 | 0 | JZ1V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, faxed record review, review of Nursing 2014 Drug Handbook, review of Omnicare Longterm Care (LTC) Facility Pharmacy Services and Procedures manual, staff interview, pharmacist interview and physician interview the facility failed to provide Pharmaceutical Services to request clarification of an order for [REDACTED]. Findings include: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the front of the chart binder, the face sheet, the (MONTH) Medication Administration Record [REDACTED]. Continued Review of the POS [REDACTED]. Review of the MAR for Resident #2 revealed she had received Ceftin 500 mg bid from 6/16/16 through 6/23/16 for fourteen (14) doses. Review of the Nurses 2014 Drug Handbook revealed on page 298 that Ceftin (Cefuroxime Axetil) is a second generation Cephalosporin. Review of page 300 revealed Ceftin is contraindicated for patients who are Hypersensitive to other Cephalosporin antibiotics. Review of Omnicare Longterm Care (LTC) Facility Pharmacy Services and Procedures Manual page 77, revealed the facility should ensure all resident information is complete and accurate, has been reconciled and is verified with the Physician/ Prescriber before faxing or transmitting orders to pharmacy. Additional review revealed the pharmacy may contact the facility by fax or phone before dispensing a medication when the pharmacist believes there is a need to clarify the medication order because the order is contraindicated. Review of facility faxed records file for 6/16/16 revealed no requests for clarification were received by the facility regarding the order for Ceftin for Resident #2. Review of facility copy of Omnicare shipment invoice dated 6/16/16 indicated Ceftin for Resident #2 was delivered to the facility at 10:30 p.m. Interview 7/13/16 at 9:45 a.m. with the Director of Nurses (DON) revealed the pharmacy is not supposed to send any medication that is contraindic… | 2019-07-01 |
| 4690 | 4690 | SADIE G. MAYS HEALTH & REHABILITATION CENTER | 115542 | 1821 ANDERSON AVENUE NW | ATLANTA | GA | 30314 | 2016-08-19 | 280 | D | 1 | 0 | 0RHV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, observations and staff interviews, the facility failed to revise the care plan for one resident (R5) out of 9 sampled residents. Findings include: R5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. During all days of the complaint investigation, the resident was observed in her wheelchair and moved throughout the facility. The resident was not observed with a cup of water in her hand. Review of R5's care plan dated 4/29/16 revealed that the resident was identified to be at risk for falls. A review of the Nurse's Notes dated 7/14/16, documented that the resident was observed out of bed ambulating and drinking 2 to 3 liters of water per hour. Per Nurse's Notes the physician was aware. On 7/21/16, the resident sustained [REDACTED]. An interview was conducted with the Director of Health Services (DHS) and the Corporate Nurse on 8/19/16 at 9:20 a.m. Per the DHS, the resident had a history of [REDACTED]. A review of R5's care plan revealed that the facility did update the care plan on 7/21/16, which stated that the resident had sustained a fall and that the new intervention was to encourage the resident to spend time in the common areas. There was no mention in the care plan that the resident would compulsively drink fluids, that the resident had a history of [REDACTED]. Cross refer to F323 The facility failed to implement the policies and procedures for fall prevention for R5. | 2019-08-01 |
| 4172 | 4172 | ANDERSON MILL HEALTH AND REHABILITATION CENTER | 115145 | 2130 ANDERSON MILL RD | AUSTELL | GA | 30106 | 2017-02-03 | 225 | D | 1 | 0 | KWE811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, review of the facility's Abuse and Neglect Prohibition Policy and resident and staff interview, the facility failed to report to the State Survey Agency (SSA) an allegation of abuse for one resident (R#8) from a sample of (3) residents reviewed. The Census was 135 residents. Findings include: Review of the facility's Abuse and Neglect Prohibition Guidelines noted: Facility supervisors will immediately correct and intervene in reported or identified situations in which abuse, neglect, injuries of unknown origin, or misappropriation or resident property are at risk of occurring. The facility will conduct an investigation of any alleged abuse/neglect, exploitation, mistreatment, injuries of unknown origin or misappropriation of resident property in accordance with state law. The facility will report such allegations to the state within 24 hours Review of the facility's Reporting and Response section of their Abuse and Neglect Prohibition Guidelines noted. The facility will report all investigation findings to the state within five (5) calendar days. The facility will report all allegations and substantiated occurrences of abuse, neglect, injuries of unknown origin, and misappropriation of property to the state agency and law enforcement officials within twenty-four (24) hours of identification. The facility will complete an incident/accident report in accordance with OP2 0401.02 incident/accident reporting for residents Review of the clinical record for R#8 revealed that she had [DIAGNOSES REDACTED]. Review of her Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that she had a Brief Interview for Mental Status (BIMS) score of 13 indicating she is cognitively intact. During interview with R#8 on 2/1/17 at 2:30 p.m., she was noted to speak slowly but clearly. R#8 indicated during interview that about a week prior to the interview, a nurse came into her room to give her medication about 9:30 p.m. or 10:00 p… | 2020-02-01 |
| 3696 | 3696 | SMITH MEDICAL NURSING CARE CTR | 115691 | 501 EAST MCCARTY ST | SANDERSVILLE | GA | 31082 | 2019-11-01 | 657 | G | 1 | 0 | T47P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, review of the facility's Falls Management policy, and staff interview, it was determined that the facility failed to evaluate the effectiveness of current interventions to prevent falls and failed to revise the FIP (Fall Intervention Plan) to include new interventions to prevent falls for one resident (R) (#1) of three residents reviewed for falls. This failure resulted in actual harm when R#1 sustained facial fractures after a fall on [DATE]. Findings include: Review of the undated facility policy titled Falls Management revealed that the goal of an intervention may not always be to prevent falls (but), to prevent injury .(Staff) should determine the cause of the fall and decide how a similar fall could be prevented for the resident (Staff) should update the FIP (Falls Intervention Plan) immediately and the date the intervention was put into place .At a minimum, the FIP will be reviewed with the MDS schedule and subsequent care plan review .A change in FIP should also trigger a note to explain reason for change (i.e , intervention no longer needed, intervention not working and why, etc.) .All falls should be reviewed daily by reviewing the medical chart to ensure that a new intervention was added to the FIP, evidence that an appropriate intervention was put into place to prevent further falls and the FIP updated. R#1 (a closed record) was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident had a medical decline and was admitted to Hospice Services on [DATE] for severe dementia. R#1 expired on [DATE]. Review of the Quarterly Minimum Data Set (MDS) for R#1 dated [DATE] revealed that he had a Brief Interview for Mental Status (BIMS) score of 3 indicating that he had severe cognitive impairment. R#1 had a care plan dated [DATE] for falls related to the use of [MEDICAL CONDITION] medication with the following interventions for nursing staff: Provide safe, clutter free environment; call light within reach … | 2020-09-01 |
| 4952 | 4952 | PRUITTHEALTH - SHEPHERD HILLS | 115452 | 800 PATTERSON RD | LA FAYETTE | GA | 30728 | 2016-03-21 | 514 | J | 1 | 0 | Z2SU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff interview, Controlled Drug Record review, and Medication Administration Record (MAR) review, the facility failed to accurately document medications administered for two (2) residents (R#1 and R#3), from a sample of twenty-four (24) residents. 1. Specifically for Resident #1, who had [DIAGNOSES REDACTED]. to failure to document the 7:00 a.m. dose on the resident's MAR or Controlled Drug Record after administration. R#1 had been admitted with an order for [REDACTED]. The Physician was contacted two (2) times with the residents' complaints of ongoing pain and the facility received 2 additional physician orders [REDACTED]. The facility failed to record the subsequent physician orders [REDACTED]. 2. Additionally, Resident #3 received [MEDICATION NAME] Insulin seventy (70) units subcutaneously (sq) four (4) times, administration of [MEDICATION NAME] Diskus one (1) inhalation 1 time and Fluvall 0.5 ml intramuscular (IM) 1 time, during the month of October, without the accompanying documentation on the MAR. This resulted in a situation in which the facility' s non-compliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment or death to residents. The facility' s Administrator, Director of Health Services (DHS), Corporate Clinical Consultant, and Nursing Supervisor EE Registered Nurse (RN) were informed of the Immediate Jeopardy on (MONTH) 25, (YEAR) at 5:00 p.m. The non-compliance related to the Immediate Jeopardy was identified to have existed on (MONTH) 14, (YEAR), the date another resident (#2) received two (2) antihypertensive medications with no order for these medications and was transferred emergently to the hospital, according to Nurses notes, fading in and out of consciousness with a blood pressure of 64/38. He was subsequently admitted to the ICU with a [DIAGNOSES REDACTED]. The Immediate Jeopardy continued through (MONTH) 20, (YEAR), the … | 2019-03-01 |
| 4951 | 4951 | PRUITTHEALTH - SHEPHERD HILLS | 115452 | 800 PATTERSON RD | LA FAYETTE | GA | 30728 | 2016-03-21 | 490 | J | 1 | 0 | Z2SU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff interview, and review of established corporate policy and procedures, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently, to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The facility failed to ensure resident drug therapy was administered safely, accurately, and in accordance with physician's orders [REDACTED].#1 and #2) from a total survey sample of twenty-four (24) residents. Resident #1, with a physician order [REDACTED].(MONTH) 4, (YEAR), when he was transferred to an acute longterm care facility. Resident #2, who did not have an order for [REDACTED]. On (MONTH) 25, (YEAR), a determination was made that a situation in which the facility's non-compliance with one or more of the requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Administrator, Corporate Clinical Consultant, Director of Health Services (DHS) and Nursing Supervisor EE Registered Nurse (RN) were informed of the Immediate Jeopardy on (MONTH) 25, (YEAR) at 5:00 p.m. The Immediate Jeopardy was identified to have existed on (MONTH) 14, (YEAR), when the facility failed to ensure the accurate administration of medication to Resident #2. An allegation of jeopardy removal was received on (MONTH) 26, (YEAR). Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on (MONTH) 1, (YEAR), and the facility remained out of compliance at the lower scope and severity of D while the process of evaluation of the nursing staffs' compliance with physicians orders, education, and facility policies and procedures, continued. In-service materials and records were reviewed, all medication administration records were reviewed for resident pic… | 2019-03-01 |
| 4693 | 4693 | SADIE G. MAYS HEALTH & REHABILITATION CENTER | 115542 | 1821 ANDERSON AVENUE NW | ATLANTA | GA | 30314 | 2016-08-19 | 323 | D | 1 | 0 | 0RHV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff interviews, and facility policy and procedure review, the facility failed to implement the policies and procedures for fall prevention for 1 resident (R5) out of 9 residents. Further, the facility failed to maintain a safe environment for the residents in one of four hallways ( D hallway cart) the medication cart drawer was broken and would not lock. Findings include: 1. R5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The initial Minimum Data Set (MDS) assessment, Section J, dated 4/28/16 identified that the resident was at high risk for falls. R5's care plan dated 4/29/16, identified the resident to be at risk for falls due to the use of cardiovascular and psychotropic medication use. One of the approaches identified was to .maintain a safe environment: clutter free, free of spills . The Nurse's Notes dated 7/21/16 documented that R5 sustained a fall, .Heard resident screaming in hallway. Observed resident sitting on the floor in a puddle of water in front of air conditioning unit outside of room . The resident did not sustain an injury per review of the Nurse's Notes. R5's care plan was updated on 7/21/16 and stated that the resident sustained [REDACTED].enfluence (sic) spending time in common area . A review was conducted of the facility's incident report and it documented that the resident was .ambulating in hallway, observed resident sitting on the floor in a puddle of water in front of air conditioner unit . There was no further investigation identified on this document that showed that the facility evaluated the fall or evaluated the potential for future falls by the resident. An interview was conducted with the Director of Health Services (DHS) on 8/19/16 at 11:40 a.m. along with the Corporate Nurse. When asked if there were any supportive investigative documents on the fall that R5 sustained on 7/21/16, the DHS stated that the resident was incontinent of bowel and bladder… | 2019-08-01 |
| 4066 | 4066 | SEARS MANOR NURSING HOME | 115520 | 3311 LEE STREET | BRUNSWICK | GA | 31521 | 2017-04-25 | 329 | D | 1 | 0 | PUN411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff interviews, and review of the facility's policy titled [MEDICAL CONDITION] Medication Monitoring, the facility failed to ensure behavioral monitoring was being completed for one resident (R), #1, who was receiving antipsychotic and antianxiety medications, [MEDICATION NAME] and [MEDICATION NAME] from a sample of three residents. Findings Include: The facility's policy [MEDICAL CONDITION] Medication Monitoring most recently dated (MONTH) (YEAR), revealed, 'Nurses will monitor behaviors and side effects and report to Medical Doctor (MD) as needed', and 'The facility supports the goal of determining the underlying cause of behavioral symptoms so the appropriate treatment of [REDACTED]. Review of the medical record revealed that R#1 was admitted to the facility with diagnoses, per the Face Sheet including: [MEDICAL CONDITION] without behavioral disturbance, repeated falls, vitamin D deficiency, [MEDICAL CONDITIONS], essential hypertension, gastro-[MEDICAL CONDITION] reflux without esophagitis, [MEDICAL CONDITION] Stage 3 (moderate), and dysphagia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] and the annual MDS assessment dated [DATE] indicated that R#1 had a Brief Interview for Mental Status (BIMS) score of 2 out of 15 indicating the resident had severely impaired cognition. The resident was assessed as exhibiting no behaviors during the look back period. The physician's orders [REDACTED]. The Medication Administration Record [REDACTED]. There was no record in the MAR indicated [REDACTED]. Review of the Progress Notes for R#1 dated 12/2/16 through 4/23/17 revealed no evidence of any documentation of behaviors. Review of the Patient at Risk (PAR) notes revealed no behaviors had been documented. During an interview with the Director of Nursing (DON) on 4/25/17 at 11:00 a.m., she acknowledged that she was unable to find any documentation in the resident's clinical record to indicate … | 2020-08-01 |
| 4906 | 4906 | MEADOWBROOK HEALTH AND REHAB | 115561 | 4608 LAWRENCEVILLE HIGHWAY | TUCKER | GA | 30084 | 2016-04-01 | 514 | D | 1 | 0 | 5HQU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, staff interviews, and the facility records, the facility failed to ensure documentation of blood sugar results for one (1) resident ( L ) and failed to document why a medication was not administered for one (1) resident (#12). The sample was nineteen (19) residents. Findings included: 1. Interview on 04/01/16 at 12:35 pm with the Director of Nursing (DON) revealed that the nurse did not document the residents blood sugar on the 19th. She revealed that the nurse should have written the results of the 6:40 am blood sugar; but, she did not. Interview on 4/1/16 at 12:00 pm with the Staff Development Nurse GG revealed that the nurses are trained in orientation on documentation. She revealed that there are also computer classes that the staff are required to take on documentation. She revealed that the nurse should have documented the blood sugar results for the resident. She revealed that all staff has had inservices on documentation. Review of the policy titled Insulin Administration documented: Documentation includes: 1. The resident's blood glucose result, as ordered; 2. The dose and concentration of the insulin's injection; 3. Size and gauge of the needle used for injection; 4. Injection site (presence or absence of any bruising, pain, redness, swelling or unusual marks on or near the injection site); 5. How well the resident tolerated the procedure. Reporting : 1. Notify your supervisor if the resident refuses the insulin injection 2. Notify the physician if the resident has signs and symptoms of [DIAGNOSES REDACTED] that are not resolved by following the facility protocol for [DIAGNOSES REDACTED] management. 3. Report excessive bruising, swelling, pain, redness, or unusual marks on or around the injection site. Review of the Medication Administration Record (MAR) for Resident L indicated on 12/19/15 no data entry for 6:30 a.m. blood sugar report. Review of the Acknowledgement of Receipt Form dated 12/19/12 … | 2019-04-01 |
| 5076 | 5076 | ORCHARD VIEW REHABILITATION & SKILLED NURSING CTR | 115146 | 8414 WHITESVILLE ROAD | COLUMBUS | GA | 31907 | 2016-01-08 | 282 | E | 1 | 0 | UCIF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, staff interviews, review of the Facility's Investigation Report and Facility staff Inservice Training Record review, the facility failed to ensure, for resident #30 was transferred with assistance of three staff assisting using the Mechanical Lift transfer as specified by the plan of care; for resident A, failed to obtain the Behavioral Health consult, failed to assess [MEDICAL TREATMENT] shunt site as specified by the plan of care, and: failed to notify the Physician of a cognitive change for one resident (#237), of the thirty-seven (37) sampled residents. Findings include: 1. For resident #30, the facility had identified a need for the resident to be transferred with the assistance of three (3) staff persons with a Mechanical Lift on the Transfer Assessment form which had initially been completed on 2/16/15. The assessment was based on the resident's physical condition, cognitive status and weight. The facility failed, however, to follow their plan of care, indicating the resident to be transferred with the assistance of three staff persons, to ensure the resident's safety during mechanical lift transfers. This failure resulted in a continued risk for subsequent falls during staff assisted transfers. Resident #30 had [DIAGNOSES REDACTED]. The resident had a plan of care of 1/29/15 for risk for falls/injury related to weakness, impaired mobility, cognitive loss, bilateral [MEDICAL CONDITION] since 2003, [MEDICAL CONDITION], balance deficit, incontinence, impaired vision and hearing, medication, and a history of falls. An intervention with the plan of care for this problem included to transfer the resident with appropriate devices, the use of the mechanical lift, and with three person assistance and to handle gently. An interview with certified nursing assistant (CNA) FF conducted on 1/7/16 at 4:30 p.m. revealed that she usually worked with this resident. CNA FF stated she worked with the resident on 12/22/… | 2019-01-01 |
| 3991 | 3991 | ADVANCED HEALTH AND REHAB OF TWIGGS COUNTY | 115727 | 113 SPRING VALLEY ROAD | JEFFERSONVILLE | GA | 31044 | 2017-08-10 | 309 | D | 1 | 0 | 5YLC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on closed medical record review and staff interviews the facility failed to provide care and services in accordance with the admission assessment for 1 of 3 Residents (R#1) reviewed for care and services . The facilty failed to follow the physican's admission orders [REDACTED]. Finding include; Record review revealed R#1 was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. Upon admission to the facility his [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] Section I2900 revealed that R#1 was coded for diabetes mellitus. The facility failed to develop a care plan relative to managing diabeties. Review of the hospitial records prior to admission to the facility revealed orders dated 5/27/17 indicating that the resident was receiving insulin per sliding scale before meals and at bed time, in addition to insulin 10 units at bedtime. Upon admission to the facility a form titled, Physician's Interim/Telephone Orders dated 6/1/17 at 2:00 p.m., reflected an order to discontinue Basagllar Kwik Pen Insulin Glargihe Injections. During interview with R#1's physician on 8/10/17 at approximately 2:30 p.m., regarding the discontinued insulin order he stated, I do not remember all the details, but I believe there was no dosage for it, if I remember correctly. I held off on the insulin and did not start a sliding scale, because I was more concerned with the his behaviour since he was on multiple medications for his behavior. When asked about the blood glucose of 516 on 6/13/17, the physician said he would be more concerned with [DIAGNOSES REDACTED]. Review of the Medication Administration Record (MAR) for (MONTH) (YEAR), revealed orders to receive [MEDICATION NAME] 500 mg (milligrams) twice daily. It is documented on the MAR that R#1 refused [MEDICATION NAME] at least six times. The MAR reflects refusals of the [MEDICATION NAME] 500mg's at 9:00 a.m., on 6/3/17,6/14/17 and 6/15/17 and at 9:00… | 2020-09-01 |
| 1954 | 1954 | PRUITTHEALTH - ATHENS HERITAGE | 115509 | 960 HAWTHORNE AVENUE | ATHENS | GA | 30606 | 2018-07-26 | 842 | D | 1 | 1 | GMU011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on closed record review and interview, the facility failed to provide a complete and accurate clinical record documenting the assessments, interventions and ongoing monitoring for one of 45 residents in the survey sample, Resident (R)#254 when her clinical condition rapidly declined on 4/10/18 requiring a transfer to the hospital. The findings include: Closed record review revealed R#254 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R#254 was in the facility for less than 14 days and did not have a completed Minimum Data Set (MDS). The facility document Admission/Nursing Observation Form documented R#254 as being oriented times three (person, time and location), and requiring supervision with assistance with Activities of Daily Living (ADLs). A review of R#254's nursing notes revealed the following documentation for 4/10/18: 4/10/18 VS (vital signs) Temp (temperature) 37.6; P (pulse) 68; R (respirations) 40; B/P (blood pressure) 120/88. Skilled nursing provided. For nausea and vomiting receive [MEDICATION NAME] 4 mg (milligrams) at 1 p.m. PRN(as needed). Pt's L[NAME] (level of consciousness) decreased. MD (medical doctor) notified. Send to the (name of hospital) for further evaluation and treatments. See nurse's notes. No time stamp for this note. 4/10/18 2:30 p.m. Resident V/S's 129/6; 72 (pulse);18 (respirations) 98 (temp); 85% (O2 saturation) noted exhibiting episode of n/v (nausea/vomiting), attending nurse administered [MEDICATION NAME] x (times) 1 dose with effectiveness noted. Res (resident) position (sic) in bed. Skin color rosy and warm to touch, breathing pattern unlabored, HOB (head of bed) up for comfort. Attending nurse and staff monitoring. Signed by (name of former Unit Manager) 4/10/18 3:00 p.m. Resident continues worsening. Pt (patient) become clamy (sic). Slightly unresponsive. Pinpoint pupils observed. Vital signs taken: BP 84/60; P 63, O2 4/10/18 3:30 p.m. Condition worsen (sic). MD notified. Re… | 2020-09-01 |
| 2934 | 2934 | WARNER ROBINS REHABILITATION CENTER | 115612 | 1601 ELBERTA ROAD | WARNER ROBINS | GA | 31088 | 2017-10-26 | 315 | D | 1 | 1 | 9WJL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on closed record review, interview, and review of facility policy, it was determined the facility failed to ensure two Residents (R)#26 and (R)#129 from a sampled 34 residents with a catheter received the appropriate care and services to prevent infection and trauma. The findings include: 1. Review of a facility document titled Suprapubic Catheter revised 5/23/17 documents the purpose is to provide proper care of the catheter site to reduce skin irritation and and/or infection. The document indicates the care procedure and documentation of care in the treatment record. Closed record review revealed R#26 was admitted to the facility 4/10/17 with [DIAGNOSES REDACTED]. A review of the resident's quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident was assessed with [REDACTED]. The resident was coded as requiring total assistance with bed mobility, transfer, and activities of daily living; continent of bowel and using a suprapubic catheter; and fall history. Review of the resident's catheter care plan with a revision date of 6/4/17 indicates the resident was at risk for UTIs related to the suprapubic catheter. Interventions include observe for pain/discomfort due to catheter; encourage fluids by mouth; change suprapubic catheter monthly; position catheter drainage bag and tubing below the level of the bladder; check tubing for kinks during rounds and as necessary; suprapubic catheter care as ordered; treatment to catheter are ordered; and leg strap on catheter tubing to promote proper drainage. Review of physician orders dated 4/23/17 revealed the following; - monitor suprapubic catheter site every shift for signs of infection - position drainage bag and tubing below the level of the resident's bladder - catheter care every shift with warm water and soap - encourage extra fluids every shift to prevent risk of infection - leg strap on always to promote drainage - change suprapubic catheter monthly and as needed. Review of p… | 2020-09-01 |
| 1951 | 1951 | PRUITTHEALTH - ATHENS HERITAGE | 115509 | 960 HAWTHORNE AVENUE | ATHENS | GA | 30606 | 2018-07-26 | 692 | D | 1 | 1 | GMU011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on closed record review, interview, and review of facility policy, the facility failed to ensure one of four residents (R) (R#152) reviewed for nutrition was screened and assessed by the Dietary Manager and Dietitian in accordance with facility policy and served the correct diet. These failures placed the resident at risk for choking, aspiration (inhalation of food, stomach acid, or saliva into the lungs), weight loss and exacerbation of other nutritional problems. Findings include: Closed record review revealed R#152 was admitted to the facility on [DATE] following hospitalization ; the resident was discharged home on[DATE]. R#152 was not in the facility during the survey. Review of a document titled Notification of Admission Form dated 7/3/18 revealed the resident had been living with her son prior to admission with plans to return home after rehabilitation. [DIAGNOSES REDACTED]. The reason for the resident's hospitalization was abdominal pain for one to two weeks with nausea and vomiting. The resident was also newly diagnosed with [REDACTED]. The resident was documented as being on a mechanical soft diet. Review of the resident's Baseline Care Plan dated 7/3/18 indicated the resident's goal was to increase strength so she could go home. The resident was documented as having experienced an activity of daily living (ADL) decline related to a stroke. The goal was for the resident to improve ADL function to maintain independence through the next 30 days. The care plan identified a problem of diabetes and risk for hyper or [DIAGNOSES REDACTED]. The goal was for the resident's blood sugar to be maintained to the next 30 days. The nutrition section of the care plan was blank, it had not been filled out. The Admission/Nursing Observation Form dated 7/3/18, under the section titled Eating revealed the resident was on a mechanical soft diet and she had a poor appetite. Review of a document titled Hospital Patient Visit Report dated 7/3/18, u… | 2020-09-01 |
| 4141 | 4141 | CRESTVIEW HEALTH & REHAB CTR | 115525 | 2800 SPRINGDALE ROAD | ATLANTA | GA | 30315 | 2017-03-24 | 241 | D | 1 | 0 | BIP011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on complainant and staff interviews, and the Grievance Log, the facility failed to ensure the promoting of self esteem and self-worth of one (1) resident (R#4) from a sample of twelve (12) residents. Findings include: Interview on 3/20/17 at 12:30 p.m. with the Complainant revealed that the (R#4) no longer wants to be in the facility. She revealed that the staff would not always answer the call light. She revealed that on the day that R#4 was sent out to the emergency room (ER), (MONTH) 2, (YEAR), the Certified Nurse Assistant (CNA) did not provide care for her. She revealed that R#4 was wet from head to toe on the day after admission and that the staff did not change the resident when she first came in and that she had brown rings in the bed. The complainant revealed that she had shown this to the nurse and the certified nursing assistant. Record review reveals the resident was discharged on [DATE], to the hospital, and was admitted to another facility upon discharge from the hospital. Interview on 3/21/17 at 7:00 p.m. with the Administrator revealed that she had no conversations with the Complainant concerning any allegations. Interview on 3/22/17 at 11:50 a.m. with Certified Nurse Assistant (CNA) BB revealed that the pads under the resident was brown because the resident did not have on a brief. She revealed that the R#4 was wet. Interview on 3/22/17 at 1:08 p.m. with Licensed Practical Nurse (LPN) DD revealed that R#4 talked about she was worried that there was not enough staff to to assist with her care. She revealed that R#4 also revealed that she felt like the Certified Nurse Assistants (CNA's) were not paying her any attention because of her size. She revealed that the R#4 reported that she felt uncomfortable. LPN DD revealed that she went to the the room of R#4 when the family member came and got her. She revealed that the resident was wet and that the sheets had small brown rings. Interview on 3/26/17 at 1:00 p.m. with the C… | 2020-03-01 |
| 4790 | 4790 | PRUITTHEALTH - FAIRBURN | 115506 | 7560 BUTNER ROAD | FAIRBURN | GA | 30213 | 2016-06-09 | 333 | D | 1 | 0 | WGW111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on complainant interview, staff interviews and the Medication Administration Record [REDACTED]. Findings include: Resident E was admitted to the facility on [DATE] with multiple diagnosis, including: Weakness, [MEDICAL CONDITIONS] ([MEDICAL CONDITION]), high Cholesterol, [MEDICAL CONDITIONS], Dementia, Hypertension, Decreased appetite, [MEDICAL CONDITION] Ulcer, Chronic [MEDICAL CONDITION], Depression, Vascular Neurocognitive Disorder with Behavioral problems. The resident had a physician's orders [REDACTED]. Apply patch to skin every day. Remove old patch. Rotate site and do not repeat the site for fourteen (14) days. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Interview on 5/18/16 at 10:30 a.m. with the Complaint D revealed that he had concerns about all of the patches being left on resident E and not being changed. He revealed that the staff could not have been assessing the resident and leaving all the medicine patches on her. Interview on 5/18/16 at 2:32 p.m. with Licensed Practical Nurse (LPN) AA revealed that there were inservices every so often on patches. She revealed that on the 3-11 shift, the nurse is to check and make sure that the medication patch is on and in place. She revealed that the resident is physically checked. She revealed that if the patches are not in place, she would notify the supervisor and called the resident's physician. Interview on 5/18/16 at 2:35 p.m. with LPN BB of the 300 Hall revealed that she worked with resident E on (MONTH) 3rd, (YEAR). She revealed that she took off the old patch and put on a new one. She revealed that the old medication patch would have had a date of 4/2/16 written on it. She revealed that she had inservices on how to administer medication patches. Interview on 5/18/16 at 3:00 p.m. with LPN HH on the 200 Hall revealed that she has had inservices on how to administer medication patches. Interview on 5/19/16 at 9:15 a.m. with the Interim Administrator ZZ revealed that… | 2019-06-01 |
| 4789 | 4789 | PRUITTHEALTH - FAIRBURN | 115506 | 7560 BUTNER ROAD | FAIRBURN | GA | 30213 | 2016-06-09 | 281 | D | 1 | 0 | WGW111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on complainant interview, staff interviews, and the facility Medication Administration Record [REDACTED]. Findings include: Resident E was admitted to the facility on [DATE] with multiple diagnosis, including: Weakness, [MEDICAL CONDITIONS] ([MEDICAL CONDITION]), high Cholesterol, [MEDICAL CONDITIONS], Dementia, Hypertension, Decreased appetite, [MEDICAL CONDITION] Ulcer, Chronic [MEDICAL CONDITION], Depression, Vascular Neurocognitive Disorder with Behavioral problems. The resident had a physician's orders [REDACTED]. Apply patch to skin every day. Remove old patch. Rotate site and do not repeat the site for fourteen (14) days. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Review of the Five day, Minimum Data Set ((MDS) dated [DATE], revealed in Section C: Cognitive Pattern as unable to complete due to impaired cognitive status. Section G: Functional Status, A-J the resident was assessed for extensive assist. Interview on 5/18/16 at 10:30 a.m. with the Complaint D revealed that he had no further complaints other than the ones already voiced. He revealed that he had concerns about all of the patches being left on resident E and not being changed. He revealed that the staff could not have been assessing the resident and leaving all the medicine patches on her. Interview on 5/18/16 at 2:35 p.m. with Licensed Practical Nurse (LPN) BB of the 300 Hall revealed that she worked with resident E on (MONTH) 3rd, (YEAR). She revealed that she took off the old patch and put on a new one. She revealed that the old medication patch would have had a date of 4/2/16 written on it. She revealed that she had inservices on how to administer medication patches on (MONTH) 12, (YEAR). Interview on 5/18/16 at 3:15 p.m. with CNA EE of the 200 Hall revealed that she would report to the nurse if a resident have a lot of patches on. Interview on 5/19/16 at 9:15 a.m. with the Interim Administrator ZZ revealed that an investigation was completed on why th… | 2019-06-01 |
| 4060 | 4060 | JOE-ANNE BURGIN NURSING HOME | 115272 | 321 RANDOLPH STREET | CUTHBERT | GA | 39840 | 2017-04-17 | 323 | G | 1 | 0 | 74SZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on electronic clinical record review, staff interviews, review of the facility policy titled, Fall Management, review of the facility forms titled, Incident Details reports, and review of the facility's Root Cause Analysis forms it was determined that the facility failed to re-evaluate the effectiveness of current fall protective measures and failed to implement Fall Prevention Protocol II, per facility policy, and put new measures in place to prevent additional falls for one Resident (R) (#1) who experienced seven falls in three months. This resulted in actual harm for R#1, who fell on [DATE], while ambulating and sustained a laceration to the back of the head which required transfer to the emergency room for treatment. The sample size was 3 residents with a history of falls. Findings include: Review of the facility's policy titled, Fall Management in pertinent part as specified in the Procedure section, that the resident will be considered high risk for falls if their total score on the fall risk assessment is 10 or above. If the score is 10-14, implement Protocol I which includes the following: Frequently orient and repetitively reinforce use of call bell and ensure it is within reach. Reassess for safe footwear, institute bowel and bladder routine as appropriate, conduct a medication review, evaluate the need for an adjustment in resident's daily activity schedule, educate resident's family regarding those interventions and encourage family assistance and support. If the score is 14-18, implement Protocol II, in addition to all interventions noted in Protocol 1. Fall Prevention Protocol II interventions to be intiated, in pertinent part: implement chair or bed alarm as appropriate, initiate half-hour hourly checks and/or placement of resident at nursing station, as needed. Implement use of protective equipment (helmets, hip pads), as indicated. Record review for R#1 revealed the resident had the following [DIAGNOSES REDACTED]. The… | 2020-08-01 |
| 4059 | 4059 | JOE-ANNE BURGIN NURSING HOME | 115272 | 321 RANDOLPH STREET | CUTHBERT | GA | 39840 | 2017-04-17 | 280 | G | 1 | 0 | 74SZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on electronic clinical record review, staff interviews, review of the facility's policy titled, Fall Management and review of the facility forms titled, Incident Details report the facility failed to evaluate and revise the care plan interventions and/or determine the need to identify additional approaches for fall prevention for one (1) resident (R) (#1) who had been assessed to be at risk for falls and who sustained additional falls. This resulted in actual harm for R #1 when the resident experienced a subsequent fall and sustained a laceration to the head. The sample size was 3 residents with history of falls. Findings include: Review of the facility's Policy titled, Fall Management revealed, in pertinent part, the policy was to establish criteria for the identification of residents who are at a higher risks for falls/injury, to be utilized by Nursing Staff to help prevent falls and subsequent injury related to falls. Further review revealed that, all potential safety problems should be identified and included in the resident's plan of care. If resident has other falls, has repeated falls or falls with injury, Fall Prevention protocol will be implemented. Record review for R#1 revealed that the [DIAGNOSES REDACTED]. The facility had completed a Quarterly Minimum Data Set (MDS) assessment on 12/15/16. Section C- Cognitive Patterns documented the resident as having severe cognitive impairment. Section G- Functional Status of this MDS documented that the resident was independent with walking/locomotion in the room and required supervision while walking in the corridor. The resident had a care plan start date of 2/2/17 for being at risk for falls related to impaired cognition and short/long term memory problems. It noted that the resident was found on floor on 2/2/17. The care plan approaches included: be sure call light is within reach and encourage to use for assistance as needed, respond promptly to all requests for assistance, bed … | 2020-08-01 |
| 2516 | 2516 | FULTON CENTER FOR REHABILITATION LLC | 115569 | 2850 SPRINGDALE ROAD SW | ATLANTA | GA | 30315 | 2018-09-27 | 684 | E | 1 | 1 | KB6111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, clinical record review, observations, and staff interviews, the facility failed to ensure three (R#14, R#74, and R#197) received appropriate services to ensure their highest practicable physical well-being. Specifically, R#14 was not treated in a timely manner for a broken leg, R#74 did not receive timely treatment for [REDACTED].#197 was not assessed prior to being moved after a fall. The findings include: 1. The facility's policies related to a resident change of condition were requested from the Director of Nursing (DON) on 9/27/18 at approximately 2:30 p.m. The DON stated that she was not able to locate any such policies. R#14 was admitted to the facility on [DATE] with diagnoses, according to the Admission Record dated 9/26/18, including heart failure and hypertension. A Risk Management System Report, dated 8/29/18 noted, Resident stated that another resident accidentally hit her left foot with a power chair at 200-hall nurses' station. Resident verbalized pain to left extremity. Warm to touch. Color consistent to ethnicity. Resident assisted to bed. Minimal movement to left leg. The report indicated the resident's physician was notified of the incident. The Minimum Data Set (MDS), a quarterly assessment of overall health status, dated 6/23/18, indicated R#14 was cognitively intact (the Brief Interview for Mental Status (BIMS) test score was 15/15), and the resident was totally dependent upon one to two staff members to complete most of her Activities of Daily Living (ADLs), including transfers. The assessment indicated the resident was independent with ambulation after being transferred to her power wheelchair. In addition, the assessment indicated the resident had limited range of motion to her upper and lower extremities on one side of her body. The ADL (Activates of Daily Living) Care Plan, dated 9/14/18, read: Focus: Resident requires assistance for ADLs; and Goal: Resident's ADL care needs will be… | 2020-09-01 |
| 1024 | 1024 | CONDOR HEALTH LAFAYETTE | 115360 | 110 BRANDYWINE BOULEVARD | FAYETTEVILLE | GA | 30214 | 2019-08-23 | 580 | D | 1 | 1 | KYLB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on family (Responsible Party) and staff interview, record review, and facility policy titled Condition Change of a Resident, the facility failed to notify the family/representative (RP) of new medication orders and medication change orders of one resident (R)#102. The sample size was 62 Findings include: Review of the Admission record for R#102 revealed she was admitted with diagnoses, that include but not limited to; other [MEDICAL CONDITION], generalized anxiety disorder, hostility, [MEDICAL CONDITION] with behavioral disturbance, hypertension. Review of the Adminission Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 5, indicating severe cognitive impairment. Mood none. Behavior: verbal behavioral symptoms directed toward others. (threatening others, screaming at others, cursing at others). Functional status: needs extensive assistance in all areas. Bowel and Bladder: always incontinent of bowel and bladder. Record review of the Quarterly MDS dated [DATE] revealed a BIMS of 5, indicated severe cognitive impairment. Mood none. Behavior: none. Functional status: needs extensive assistance in all areas. An was assessed as receving an antidepressant on three out of seven days in this assessment period. Review of a Physician order [REDACTED]. No documentation located that family/RP was notified of medication change. Review of a Physician order [REDACTED]. No documentation located that family/RP was notified of medication change. Review of a Physician order [REDACTED]. No documentation located that family/RP was notified of medication change. Review of a Physician order [REDACTED]. No documentation located that family/RP was notified of medication change. Review of a Physician order [REDACTED]. No documentation located that family/RP was notified of medication change. Review of a Physician order [REDACTED]. No documentation located that family/RP was notified of medication change. An interview o… | 2020-09-01 |
| 1572 | 1572 | SUMMERHILL ELDERLIVING HOME & CARE | 115430 | 500 STANLEY STREET | PERRY | GA | 31069 | 2019-05-31 | 677 | D | 1 | 1 | U20X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on family and staff interviews, and record review the facility failed to provide scheduled bath for one of 48 Resident (R#498) dependent on staff for activities of daily living (ADLs). Findings include: Review of the clinical record revealed R#498 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 5/13/19 Admissions Minimum Data Set (MDS) revealed the resident was assessed as needing extensive assistance with dressing, personal hygiene, and toilet use. Review of the care plan revealed R#498 has an Activities of Daily Living (ADL) self-care performance deficit related to fatigue, recent rectal surgery, decreased mobility, and pain. Bathing/showering requires assistance by staff. R#498 should be provided a sponge bath when a full bath or shower cannot be tolerated. R#498 requires assistance by staff with personal hygiene and oral care. An interview with a family member of R#498 on 5/28/19 at 1:01 p.m., revealed that her father was in the facility for one week before receiving a bath. She stated he has not received any ADL care including, but not limited to, a haircut, cleaning of nails, and grooming of facial hair. During an interview on 5/30/19 at 12:05 p.m. with AA (RN Unit Manager). RN AA stated that R#498 is supposed to receive a bath on Tuesdays, Thursdays, and Saturdays. During baths he is supposed to be groomed. Review of an ADL task on Kardex revealed that the resident is to receive baths on Tuesdays, Thursdays, and Saturdays between the times of 11 p.m. to 7 a.m. R#498 received a bath on 5/19/19, 5/23/19, 5/24/19, 5/25/19, 5/26/19, 5/27/19, 5/30/19, and 5/31/19; however, the resident did not receive a bath until six days after being admitted to the facility. During an interview on 5/31/19 at 11:04 a.m. with the Assistant Director of Nursing (ADON) revealed that when a new admission comes into the facility the care information gathered during the initial assessment is entered into the Kardex and elec… | 2020-09-01 |
| 4136 | 4136 | ANDERSON MILL HEALTH AND REHABILITATION CENTER | 115145 | 2130 ANDERSON MILL RD | AUSTELL | GA | 30106 | 2017-03-08 | 490 | J | 1 | 0 | 03RZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on family and staff interviews, record review and review of the facility's Policy and Procedure for Elopement, it was determined the facility failed to be administered in a manner to investigate an Elopement of one resident (R#1) as to the cause and to prevent the likelyhood of elopement for the additional ten (10) at risk residents (R#2, R#3, R#4, R#5, R#6, R#7, R#8, R#9, R#10, and R#11) of a total of eleven residents with wandering behaviors and wearing a Wanderguard bracelet. The facility's Interim Administrator, Director of Regulatory Compliance, and the Interim Director of Nursing (DON) were notified of the Immediate Jeopardy on 3/6/2017 at 2:00 p.m. The non-compliance related to the Immediate Jeopardy was identified to have existed on 9/28/2016, the date a resident (R#1) wearing a Wanderguard, was found in the parking lot by staff on the 3:00 p.m. to 11:00 p.m. shift followed on 10/1/2017 when the resident eloped through the front door of the facility and fell on the main road (Anderson Mill Road) sustaining a hematoma to the back of her head. The noncompliance related to the Immediate Jeopardy continued through 3/7/2017 and was removed on 3/8/2017. The Immediate Jeopardy is outlined as follows: The Immediate Jeopardy was related to the facility's non-compliance with the program requirements at 42 C.F.R.: 483.25(h), Accidents/Hazards (F323 S/S: J) 483.75, Administration (F490 S/S: J) 483.75(o)(1), Quality Assessment and Assurance Committee Members/Meet Quarterly/Plans (F520 S/S: (J) Additionally, Substandard Quality of Care was identified with the requirements at 42 C.F.R. 483.25(h), Accidents/Hazards (F323 S/S: J). On 3/8/2017, the facility provided a Credible Allegation Compliance (A[NAME]) of Jeopardy Removal alleging that interventions had been put into place to remove the immediate jeopardy on 3/8/2017. Based on observations, record reviews and review of the facility's policies as outlined in the Credible Allegation of Comp… | 2020-03-01 |
| 4632 | 4632 | PRUITTHEALTH - MACON | 115288 | 2255 ANTHONY ROAD | MACON | GA | 31204 | 2016-08-08 | 314 | D | 1 | 0 | S83P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on family interview, observation, record review and staff interview the facility failed to ensure that a pressure ulcer dressing for one (1) resident A was changed per physician orders [REDACTED]. The sample size was thirteen (13) residents. Findings include: Record review of the medical record for resident A revealed that the resident was admitted to the facility on [DATE], and was presently receiving [DEVICE] feedings, on a Ventilator, had a indwelling urinary catheter, assessed with [REDACTED]. During an interview with resident A's daughter on 8/07/2016, at 2:40 PM, the daughter informed this Surveyor that approximately 2:30 PM 8/07/2016, two (2) Certified Nursing Assistants (CNAs) came into the room to clean up the resident before the shift change was over. When the resident was turn to the side, the daughter asked that she wanted to see the wound and take a cell phone picture of the wound and dressing. The cell phone picture was taken by the family member. The daughter then proceeded to show the cell phone picture to the Surveyor and it showed a soiled dressing with stool on it. The daughter then informed the Surveyor that the CNAs never informed the nurses that the dressing was soiled and needed to be changed as no one ever came in the room to changed the soiled dressing on the sacral wound. An interview with the staff nurse CC on 8/07/2016 at 3:30 PM, revealed that no CNAs informed the staff nurses or treatment nurse that the sacral wound dressing for resident A was soiled and needed be changed. Record review of the pressure ulcer treatment orders for resident A revealed that the sacral pressure ulcer was to be cleaned with normal saline, then skin prep to be applied to the periwound, pack the wound with Mesalt, cover with a dry dressing and secure with tape. The dressing was to be changed daily and as needed (PRN). An interview with the CNA assigned to the resident on 8/8/2016 at 10:10 AM, revealed that she never informed the … | 2019-08-01 |
| 925 | 925 | LIFE CARE CENTER OF GWINNETT | 115347 | 3850 SAFEHAVEN DRIVE | LAWRENCEVILLE | GA | 30044 | 2017-10-12 | 425 | D | 1 | 0 | GRKE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on family interview, staff interviews, record review, review of the facility Physician order [REDACTED].#1) of three (3) sampled residents. Findings include: An interview with the Complainant and the Resident's (R1's) Responsible party on 10/12/17 at 12:05 p.m. revealed R1's family believes the facility abruptly stopped administering Zoloft to R1 as prescribed, causing her mental health to decline and her dementia worsen and caused her recent fall and subsequent injury because it made her dizzy. Review of the clinical record for Resident (R#1) revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Record Review revealed the resident had experienced a fall on 9/9/17 attempting to go to the toilet without assistance. The resident had sustained a laceration to her head requiring four staples to close to the wound. Review of the Physician order [REDACTED]. clarify and include in new order discontinuation of the existing order. Review of Physician orders [REDACTED]. Review of the Hospital discharge medicine list also revealed two orders for Sertraline 25mg 1 tablet by mouth daily. Further review of the physician's orders [REDACTED]. The order did not indicate that the order to discontinue was only for the duplicate order. An additional order dated 9/16/17 for Sertraline 25 mg tablet daily indicating the medication was resumed on 9/17/17. Review of the Medication Administration Record [REDACTED]. The order for Sertraline 25 mg one daily was not transcribed to the (MONTH) (YEAR) MAR until (MONTH) 17, (YEAR) indicating (R#1) did not receive medication as ordered by the Physician from (MONTH) 1, (YEAR)-September 16, (YEAR). Interview on 10/12/17 with Registered Nurse (RN)/Unit Manager HH revealed that R#1 was admitted to the facility with a prescription for Zoloft/Sertraline and another antidepressant medication. However, the hospital orders were duplicated in transcription, for Sertraline 25 mg one daily. The facility nurse reviewed … | 2020-09-01 |
| 4680 | 4680 | PRUITTHEALTH - VIRGINIA PARK | 115531 | 1000 BRIARCLIFF ROAD NE | ATLANTA | GA | 30306 | 2016-08-24 | 514 | D | 1 | 0 | 3CUI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review the facility failed to maintain accurate and complete clinical records for 2 of 9 sampled residents (R108, R57). Findings include: 1. Review of the closed clinical record revealed Resident (R) 108 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R108 had 13 falls within one year. Review of the Care Plan dated 4/19/16 indicated R108 had interventions put in place after each of the falls. Review of 9 incident reports dated 2/02/16 through 4/19/16 revealed the staff did not document which interventions, if any, were in place at the time of R108's falls. During an interview on 8/23/16 at 8:08 a.m. the Treatment Nurse said she administered the first aid after R108's last fall. She said the nurses did not normally document which interventions were in place at the time of a resident's fall. During an interview on 8/23/16 at 8:45 a.m. the Director of Nursing (DON) said the nurses referred to the resident's care plan and the nurse aides referred to an activities of daily living (ADL) guide in order to know which interventions should be in place for that resident. The DON said the staff did not document in the incident report or in nurse's notes what interventions were in place at the time of a resident's fall. The DON said she could see how it would be beneficial to document the interventions in order to know if they were utilized and if they were effective or not. She said that was not the current procedure for the facility. 2. R57's record was reviewed on 8/22/16 at 11:05 a.m. R57's [DIAGNOSES REDACTED]. Review of the resident's physician order [REDACTED]. Foley catheter care was to be completed every shift. Review of an Admission/Nursing Observation Form, dated 5/17/16, completed upon readmission to the facility, indicated Bladder Resident/Family reports: Brief (marked with an X) and Hx (History) of UTI (Urinary tract infection) Indwelling Catheter DX (diagnosis) HX UTI Size 16. R57 was observ… | 2019-08-01 |
| 5078 | 5078 | ORCHARD VIEW REHABILITATION & SKILLED NURSING CTR | 115146 | 8414 WHITESVILLE ROAD | COLUMBUS | GA | 31907 | 2016-01-08 | 315 | D | 1 | 0 | UCIF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, it was determined the facility failed to address a decline in urinary incontinence for one (1) resident (#237) from a total sample of thirty-seven (37) residents. Findings include: Resident #237 was admitted to the facility, on the Rehabilitation Unit, on 9/15/15 with [DIAGNOSES REDACTED]. Licensed nursing staff documented that the resident had frequent urinary incontinence on the Admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 9/22/15. The resident's urinary continence improved to only occasional urinary incontinence as documented on the 14 day MDS assessment (ARD of 9/27/15). On 10/12/15, the resident was transferred to a different unit in the facility. The resident's urinary continence declined to always incontinent as documented on the quarterly MDS assessment (ARD of 12/21/15). Licensed nursing staff developed a plan of care dated 9/30/15 that documented the resident had frequent episodes of bladder incontinence, occasional bowel incontinence and was at risk for altered skin integrity. On 12/23/15 update to the plan of care documented that the resident continued to be at risk for infection and altered skin integrity. However, the decline in urinary continence was not addressed. A review of the clinical record revealed no evidence that licensed nursing staff had developed and implemented interventions to address the resident's decline in urinary continence. During an interview on 1/7/16 at 9:47 a.m., Certified Nursing Assistant (CNA) OO stated that that resident #237 was incontinent and had been so since being transferred to the current unit of the facility. During an interview on 1/8/16 at 12:25 p.m., the Assistance Director of Nursing (ADON) confirmed that licensed nursing staff had not addressed the decline in urinary continence for resident #237. | 2019-01-01 |
| 5082 | 5082 | ORCHARD VIEW REHABILITATION & SKILLED NURSING CTR | 115146 | 8414 WHITESVILLE ROAD | COLUMBUS | GA | 31907 | 2016-01-08 | 406 | D | 1 | 0 | UCIF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, it was determined the facility failed to maintain a Level II Preadmission Screening and Resident Review (PASRR) assessment for one (1) resident (#97) from a total sample of thirty-seven (37) residents. Findings include: Resident #97 had [DIAGNOSES REDACTED]. During an interview on 1/7/16 at 12:41 p.m. Social Service staff JJ confirmed and provided documentation that a Level II PASRR assessment had been completed for the resident on 4/1/2012 by Adult Protective Services (APS) Healthcare. However, she was unable to locate a copy of the assessment. There was no evidence the facility maintained a copy of the resident's Level II PASRR assessment. | 2019-01-01 |
| 5079 | 5079 | ORCHARD VIEW REHABILITATION & SKILLED NURSING CTR | 115146 | 8414 WHITESVILLE ROAD | COLUMBUS | GA | 31907 | 2016-01-08 | 319 | D | 1 | 0 | UCIF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, it was determined the facility failed to obtain a Physician ordered consultation to address one (1) resident's (A) complaints of Hallucinations from a total sample of thirty-seven (37) residents. Findings include: Resident A was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Licensed nursing staff developed a plan of care on 9/16/15 that documented the resident was a new admission to the facility, had multiple medical problems, was alert and oriented and communicated without difficulty. The plan of care was updated on 11/3/15 with a new intervention for a Care Now consultation due to Audio-Visual Hallucinations. A review of the clinical record revealed an 11/2/15 nurse's note entry that documented the resident complained of hearing and seeing things and of waking him/herself up at night by talking in his/her sleep. A subsequent nurse's note on 11/3/15 documented that the Nurse Practitioner addressed the resident's concern of hearing and seeing things by ordering a Care Now consultation. The 11/3/15 order was for licensed nursing staff to obtain a Care Now consultation due to Audio-Visual Hallucinations. After 11/3/15, although there was no evidence the resident continued to experience Hallucinations, there was also no indication that licensed nursing staff had obtained the consultation as ordered. During an interview on 1/8/16 at 12:25 p.m. the Assistant Director of Nursing (ADON) confirmed that the resident had not received the 11/3/15 consultation to address Hallucinations as ordered. | 2019-01-01 |
| 1606 | 1606 | PINE KNOLL NURSING & REHAB CTR | 115443 | 156 PINE KNOLL DRIVE | CARROLLTON | GA | 30117 | 2019-08-30 | 609 | D | 1 | 0 | QEF711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, review of a policy titled Abuse, Neglect and Exploitation the facility failed to notify the State Survey Agency (SSA) within the required two-hour time period after Resident (R) #1 sustained an injury of unknown source, a hematoma (bruise) on his forehead. This failure affected one resident (R#1) of three sampled residents. Findings include: Review of the undated face sheet in the Electronic Health Record (EHR) revealed R#1 was admitted to the facility in the spring of 2019 and his [DIAGNOSES REDACTED]. Review of the 7/29/19 Quarterly Minimum Data Set, section C, revealed R#1's Brief Interview for Mental Status (BIMS) score to be three out of 15, signifying severe cognitive impairment. Review of section G revealed R#1 required extensive assistance for nearly all Activities of Daily Living (ADLs). Review of a 7/21/19 at 7:35 p.m. progress note revealed a large hematoma was noted on R#1's forehead, the previous shift denied knowledge of the injury, R#1 could not provide history of the hematoma, and the injury was unwitnessed. Review of the policy titled Abuse, Neglect and Exploitation, updated on 12/2017, revealed revealed Injuries of Unknown Source to be defined as the source of the injury was not observed by any person or the source of the injury could not be explained by the resident. Further review revealed the definition to also include the injury was suspicious because of the extent of the injury or the location of the injury. Further review revealed an immediate investigation should take place when abuse is suspected, such as an injury of unknown origin. An interview with the Administrator on 8/29/19 at 2:40 p.m. revealed that she first became aware of R#1's injury of unknown origin to his forehead on 7/22/19, the day after it was first documented by the duty nurse. The Administrator stated all injuries of unknown origin must be reported to the SSA within two hours of discovery, with no exceptions.… | 2020-09-01 |
| 3019 | 3019 | EASTMAN HEALTHCARE & REHAB | 115622 | 556 CHESTER HIGHWAY | EASTMAN | GA | 31023 | 2018-03-12 | 550 | D | 1 | 0 | W7TD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, review of the facility policy titled, Smoking, Residents and Employees the facility failed to ensure that smoking privledges were not restricted for one resident (#2) from a total sample of 11 residents. Findings include: The had a policy regarding smoking. The Smoking, Residents and Employees policy documented that all smoking equipment for residents would be left with the charge nurse and stored in a secured area. Smoking restrictions will not be placed on any resident for the convenience of the staff, but for the safety and well being of the resident. Based upon assessment a resident may be deemed at risk to self or others when smoking and therefore assessed to be unsafe to smoke. The nurse will make the appropriate documentation in the resident's clinical record and notify the responsible party and physician as necessary. The policy further documented that information regarding smoking priviledges, including restrictions, would be documented in the resident's care plan. Resident (R)#2 was admitted to the facility on [DATE]. The resident was evaluated and intially careplanned as being a smoker. There was no evidence on the smoking assessment or initial careplan of any smoking privileges restrictions. However, a review of the clinical record revealed nurses notes entries by Licensed Practical Nurse (LPN) AA on 2/11/18 and 2/23/18 that documented the resident was being restricted from smoking for being found with cigarettes. The 2/11/18 19:20 Behavior Note documented that the resident had been observed with two extra cigarettes he had on himself at the 7:00 p.m. smoke break and was informed that he would not be allowed to attend the next smoke break at 10:00 p.m. or the smoke break the next day on 2/12/18 at 6:00 a.m. The 2/23/18 22:05 Behavior note documented that the resident did not have any cigarettes in the basket (maintained by staff) but then pulled out two cigarettes he had on himself at the 10… | 2020-09-01 |
| 811 | 811 | PRUITTHEALTH - AUGUSTA | 115334 | 2541 MILLEDGEVILLE ROAD | AUGUSTA | GA | 30904 | 2017-06-16 | 309 | D | 1 | 0 | TF3T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to assure that one resident, Resident #1 (R#1) of the three sampled residents recieved physican ordered pain medications until five days after admission to the facility. Facility census was 83. Findings include: Resident #1 (R#1) admitted [DATE] with a primary [DIAGNOSES REDACTED]. Additional [DIAGNOSES REDACTED]. A Pain Observation Form was completed on 6/12/2017 listing arthritis, [MEDICAL CONDITION], perineal and scrotal [MEDICAL CONDITION], shooting pain in legs, especially at night, discomfort to lower extremities, knees, and discomfort to buttocks. [MEDICATION NAME] 10/325 miligrams (mg) 1 by mouth every six hours as needed for pain. Review of the 'Admission Interim Care Plans Form' dated 6/12/2017 for R#1 revealed to 'administer pain medications per physician's orders [REDACTED]. Review of the out-patient medication orders, dated 6/9/2017 listed 23 active medications, including [MEDICATION NAME]-[MEDICATION NAME] 10 mg/[MEDICATION NAME] 325 mg to be taken one tablet by mouth every six hours as needed for pain. Review of the 'physician's orders [REDACTED]. Review of the 'Medication Record' dated 6/9/2017 reveals that resident did not receive any [MEDICATION NAME]-[MEDICATION NAME] 10mg/325mg [MEDICATION NAME] until 6/14/2017. Review of the 'Skilled Daily Nurses Note' dated 6/11/2017 at 5:00 a.m. reveals R#1 complained of lower limb pain and was given 650 mgs of Tylenol. Review of the 'Skilled Daily Nurses Note' dated 6/9/2017 reveals that [MEDICATION NAME]-[MEDICATION NAME] 10mg/325mg [MEDICATION NAME] had not been brought by the pharmacy yet. R#1 had some relief. Intensity of the pain was rated a '10' on a scale of 0-10, with 0 being no pain and ten being the highest pain. R#1 was complaining of shooting pain at night in both legs. Review of the 'Skilled Daily Nurses Note' dated 6/14/2017 at 5:30 p.m. reveal complaint of right lower extremity pain, no intensity documented. [ME… | 2020-09-01 |
| 2995 | 2995 | EAGLE HEALTH & REHABILITATION | 115618 | 405 S COLLEGE ST | STATESBORO | GA | 30458 | 2017-12-18 | 655 | D | 1 | 0 | OZA311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to develop a baseline care plan for one resident, Resident (R)#1, of five sampled residents. The baseline care plan did not include the minimum healthcare information necessary to properly care for the resident including services for transmission based precautions, Foley catheter care, gastrostomy tube ([DEVICE]) care and peripherally inserted central catheter (PICC) care. Findings include: Record review revealed that the resident was admitted to the facility on (MONTH) 16, (YEAR) then transferred on (MONTH) 27, (YEAR) to an acute care hospital at the request of the family. Review of the immediate (base) care plan, not dated, revealed there was no care planning to address the resident's ongoing infection with [MEDICAL CONDITION] (c. diff), Foley catheter, PICC line or gastrostomy tube as noted on R#1's discharge instructions dated (MONTH) 16, (YEAR) from her prior facility. Review of the R#1's 'Admission Assessment, dated (MONTH) 16, (YEAR), listed that resident was admitted with [DIAGNOSES REDACTED], a Foley catheter and a PICC line. Interview with the Wound Care Nurse, Licensed Practical Nurse (LPN) GG on 12/18/2017 at 12:30 p.m. who confirmed that resident's infection with [DIAGNOSES REDACTED] was on-going at the time off admission and that transmission based precautions were implemented on admission. LPN GG also confirmed that resident had a PICC line present in her right arm, a Foley catheter, and a [DEVICE], all present on admission. Interview with the of Director Nursing (DON) on 12/18/2017 at 4:35 p.m. who confirmed that resident was admitted with [DIAGNOSES REDACTED], a PICC line, a Foley catheter and a [DEVICE]. Review of the resident's base line care plan with the DON who agreed that R#1's care plan did not provide adequate information for addressing the resident's immediate needs and that Acute Care Plans should have been added for PICC line care, Foley catheter care, [DE… | 2020-09-01 |
| 4495 | 4495 | SIGNATURE HEALTHCARE OF BUCKHEAD | 115110 | 54 PEACHTREE PARK DRIVE N.E. | ATLANTA | GA | 30309 | 2016-09-02 | 205 | D | 1 | 0 | NU4N11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure a bed hold notice was provided to 1 of 12 sampled residents (R12) and/or her responsible party upon transfer to a local hospital. Findings include: Closed record review for Resident (R)12 revealed the resident had a [DIAGNOSES REDACTED]. Review of the resident's computerized financial record revealed the resident failed to pay her patient liability owed to the facility for 3 consecutive months. On 8/29/16 at 2:25 p.m. during an interview with the Business Office Assistant (BOA), she reported she visited the resident in her room on 4/11/16 to issue the resident a 30 day discharge notice. The BOA said the resident refused to accept the paper notice, therefore, she left the notice on the resident's bed side table. Additionally, the BOA reported the contact number the facility had on record for the resident's responsible party, was no longer working. On 4/11/16 at 5:30 p.m. the closed record indicated the resident began yelling and was uncontrollable, therefore, she was sent out to the local hospital for treatment and medication management. The following day the local hospital notified the facility of the resident's status and anticipated transport back to the nursing center. At this time the facility denied R12's readmission for failure to pay. A current policy entitled Bed Hold Policy Requirement and Notification indicated if a resident is transferred out of the facility, the facility will provide written information about the facility's bed hold policy. The Social Service Director (SSD) was interviewed on 8/29/16 at 12:00 p.m. The SSD said no bed hold notice was given to, or sent out with, the transfer paperwork informing the resident of her rights. On 4/11/16 the resident was discharged from the facility according to the Business Office Assistant without any information regarding the facility's Bed Hold Policy. During an interview with the Administrator on 8/29/16 at 2:40 p… | 2019-09-01 |
| 4375 | 4375 | NORTHEAST ATLANTA HEALTH AND REHABILITATION CENTER | 115504 | 1500 S JOHNSON FERRY ROAD | ATLANTA | GA | 30319 | 2016-11-09 | 323 | G | 1 | 0 | 3P2Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure a safe environment for three (3) residents (R15, R28 and R29). Specifically, the facility: a). failed to provide adequate supervision and assistive devices to prevent accidents for R15 who had a history of [REDACTED]. R15 sufferred actual harm when she fell again contributing to an additional hip fracture which led to her ultimate demise, and; b). failed to ensure the environment remained as free from accident hazards as possible for R28 and R29 who required multiple electrical devices when their medical equipment was plugged in to a power strip, this resulted in actual harm when the facility unplugged the pressure prevention mattress used for R28 who had severe pressure sores. (cross refer to F314) The facility census was one-hundred-nine (109) and the sample was seventy-seven (77) residents. Review of the CMS Form 672, signed and dated on [DATE] by the Director of Nursing revealed a total of 10 residents ambulated, 3 ambulated with assistance, 2 are bedfast, and therefore at least a total of 97 residents are at fall risk. Findings include: 1. Review of the Transfer/ Discharge Report revealed R15 was re-admitted to the facility on [DATE] from the hospital after having Open Reduction and Internal Fixation (ORIF) surgery to repair a fractured hip. R15 had [DIAGNOSES REDACTED]. The resident expired on [DATE]. Review of the hospital records [DATE] History and Physical revealed This patient is a very pleasant, [AGE] year-old with a known history of heart failure, chronic pain, neuropathy, spinal stenosis, and generalized debility, who apparently has been having pain in her right lower extremity for the past several days. According to her son, the R15 has not incurred any falls; however, he was informed last Thursday that the R15 had gently slumped to the ground. He states that ever since that time, she has been having severe right lower extremity pain. She has been working with… | 2019-11-01 |
| 4497 | 4497 | SIGNATURE HEALTHCARE OF BUCKHEAD | 115110 | 54 PEACHTREE PARK DRIVE N.E. | ATLANTA | GA | 30309 | 2016-09-02 | 323 | G | 1 | 0 | NU4N11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure residents were provided with interventions and supervision to prevent repeat falls for 1 of 12 sampled residents (R4). Resident (R4) sustained injuries during 2 falls at the Nursing facility. One fall resulted in hospitalization . Findings include: Record review for R4 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the 3/7/16 admission Minimum Data Set (MDS) assessment revealed the resident had no falls in the 6 months prior to admission, required extensive assistance of two for transfers, and scored 12 out of 15 on the Brief Interview for Mental Status (BIMS) - meaning moderate cognitive impairment. Closed record review for (R4) on 8/31/16 at 9:40 a.m. revealed upon admission the resident was assessed for falls and a care plan was generated on 3/9/16. Review of the care plan indicated the resident was at risk for falls related to impaired balance, amputations and vision loss. Interventions included to provide call light within reach, keep area free of clutter, staff to assist with transfers, side rails use as an enabler, provide adequate lighting and report falls to physician and responsible party. Review of the electronic skilled nurses' notes with the Staff Development Coordinator (SDC) revealed a nurse's note dated 3/23/16 timed at 4:15 p.m. indicating R4 who is a bilateral above the knee amputee was heard in her room screaming for help. A Certified Nurse Aide (CNA) went to R4's room and alerted the nurse to come and assist because the resident had fallen and help was needed to get the resident off the floor. Review of a form in the closed record labeled Nursing assessment dated [DATE] revealed the resident sustained [REDACTED]. The resident was seen by the facility's physician and an X-ray was obtained with negative finding. An updated plan of care dated 3/23/16 revealed the resident fall was related to her leaning over in her wheelchair to p… | 2019-09-01 |
| 4496 | 4496 | SIGNATURE HEALTHCARE OF BUCKHEAD | 115110 | 54 PEACHTREE PARK DRIVE N.E. | ATLANTA | GA | 30309 | 2016-09-02 | 282 | G | 1 | 0 | NU4N11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure residents were provided with interventions as outlined on the care plan for 1 of 12 sampled residents (R4). Resident (R) 4 sustained injuries during 2 falls at the Nursing facility. One fall resulted in hospitalization (Cross Reference F323). Findings include: Record review for R4 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. The 3/7/16 admission Minimum Data Set (MDS) assessment indicated the resident had no falls in the 6 months prior to admission, required extensive assistance of two for transfers, and scored 12 out of 15 on the Brief Interview for Mental Status (BIMS) - meaning moderate cognitive impairment. Review of the 3/9/16 care plan indicated the resident was at risk for falls related to impaired balance, amputations and vision loss. Interventions included to provide call light within reach, keep area free of clutter, staff to assist with transfers, side rails use as an enabler, provide adequate lighting and report falls to physician and responsible party. Review of the electronic skilled nurses' notes with the Staff Development Coordinator (SDC) revealed a nurse's note dated 3/23/16 timed at 4:15 p.m. indicating R4 was found on the floor. The care plan was updated on 3/23/16, indicating that the resident's fall was related to her leaning over in her wheelchair to pick up her remote control and an intervention was added instructing maintenance to assess the resident's wheelchair for proper functionality and to keep items within reach. Interview with the Maintenance Director on 9/1/16 at 12:30 p.m. regarding his assessment of the resident's wheelchair revealed he had a Maintenance Log Book kept at each nurses' station. He said the Maintenance Book was checked frequently. The Maintenance Director said staff were instructed to document any maintenance request in the book, but staff were inconsistent with documenting their requests. He further report… | 2019-09-01 |
| 2996 | 2996 | EAGLE HEALTH & REHABILITATION | 115618 | 405 S COLLEGE ST | STATESBORO | GA | 30458 | 2017-12-18 | 842 | D | 1 | 0 | OZA311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure that care which followed the physician's orders for one resident, Resident (R)#1, of five sampled residents related to care and maintenance of a peripherally inserted central catheter (PICC) and maintenance of a gastrostomy tube ([DEVICE]) insertion site was documented in the resident's record, as preformed. Findings include: Record review revealed that the resident was admitted to the facility on (MONTH) 16, (YEAR) then transferred on (MONTH) 27, (YEAR) to an acute care hospital at the request of the family. Record review of R#1's admitting Physician's Orders dated (MONTH) 16, (YEAR), revealed orders to change the PICC line dressing every seven days and as necessary (PRN) when soiled, and orders to change the PICC line catheter cap every seven days, with blood draws, and PRN. Review of additional Telephone Orders, from the physician, were received and documented that same day in the Physician's Orders, without a time documented, to require observation of resident's sutures to the [DEVICE] site daily for signs and symptoms of infections, and to remove sutures from [DEVICE] site on 11/24/2017. Review of the R#1's Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed no documentation confirming that the PICC line dressing was checked or changed on 11/24/2017 or that the PICC line cap was changed on 11/24/2017, as indicated in the MAR. Continuing review of the MAR revealed that the [DEVICE] site was not recorded as checked on 11/23/2017 through 11/27/2017 and the sutures for R#1's [DEVICE] site were not recorded as having been removed on 11/24/2017. Review of R#1's Interdisciplinary Progress Notes revealed there was no documentation to confirm that the PICC line dressing was checked or changed on 11/24/2017, the PICC line cap was changed on 11/24/2017, nor the [DEVICE] site was checked for five days and there was not evidence that the [DEVIC… | 2020-09-01 |
| 15 | 15 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2019-06-07 | 656 | D | 1 | 0 | 2RIR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure that medication for pain was administered for one of 12 residents(A) and failed to provide wound care for one of 12 residents (B) as care planned. Findings include: 1. During interviews on 6/3/19 at 12:00 p.m. and 6/4/19 at 1:50 p.m. Resident (R) A stated that nursing staff waits until her pain medication runs out to order more. Record review revealed that RA had a care plan since 2/819 for being at risk for alteration in comfort related to [MEDICAL CONDITION] reflux disease, generalized pain and skin alteration. The care plan included an intervention for licensed nursing staff to administer medication as ordered. Further record review revealed that there was a physician's orders [REDACTED]. There was also a physician's orders [REDACTED]. However, a review of the clinical record revealed that the resident did not receive the scheduled [MEDICATION NAME] pain medication as ordered and as care planned on 4/23/19 at 12:00 p.m. and 6:00 p.m. Record revealed that on 5/24/19 a physician's orders [REDACTED]. The resident received [MEDICATION NAME] as scheduled through the 5/24/19 6:00 p.m. dose. The [MEDICATION NAME] 10-325mg was then administered routinely afterward until the supply on hand was exhausted on 5/29/19 at 6:00 p.m. Therefore, the resident did not receive the scheduled [MEDICATION NAME] pain medication as ordered and as care planned on 5/30/19 at 12:00 a.m., 6:00 a.m., 12:00 p.m. and 6:00 p.m. Cross refer to F697 2. Record review revealed that RB had a care plan problem, dated 4/2/19, for receiving treatment with an antibiotic for bilateral [MEDICAL CONDITION]. The care plan problem was updated on 4/29/19 to include the use of an intravenous antibiotic and an intervention for nursing staff to provide wound care as ordered. A review of the clinical record revealed a physician's orders [REDACTED]. This treatment was ordered to treat venous wounds to the right and left la… | 2020-09-01 |
| 1160 | 1160 | SOUTHLAND HEALTHCARE AND REHAB CENTER | 115376 | 606 SIMMONS ST | DUBLIN | GA | 31040 | 2019-12-10 | 569 | D | 1 | 0 | TW0H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure that the resident trust account balance remained under the $2000 limit to maintain eligibility for Medicaid services for one resident (#8), from a total sample of 12 residents. Findings include: The facility had a Resident Trust Fund policy. The policy documented that fund balances for Medicaid recipients should be monitored monthly by the Resident Trust Custodian to ensure that state maximum balances are not exceeded. Resident (R) #8 was admitted to the facility on [DATE]. A resident trust account was opened on 6/18/19. A review of the Authorization and Agreement to Handle Resident Funds form revealed that the resident had enrolled in a non-transferring resident fund account and opted for direct deposit of social security and supplemental security income. A review of the account activity for R#8 revealed that the account balance exceeded the $2000 limit from 10/1/19 through 12/9/19. However, there was no evidence that the facility addressed the balance of excess funds, that began in October, until 12/9/19. During interviews on 12/9/19 at 3:40 p.m. and 4:20 p.m., the Business Office Manager stated that she had been in contact with the social security office because R#8 continued to receive her full benefits check, and she did not know if the social security office was aware the resident was in a nursing home. A review of a facsimile cover sheet revealed that contact with the social security office did not occur until 12/9/19. | 2020-09-01 |
| 16 | 16 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2019-06-07 | 684 | D | 1 | 0 | 2RIR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure that wound treatments were provided as ordered by the physician for one of 12 residents (R B). Findings include: Record review revealed that Resident (R) B had [DIAGNOSES REDACTED]. During an interview on 6/5/19 at 3:45 p.m. R B stated that Treatment Nurse DD had applied a silver alginate dressing to her legs and she was not supposed to. A review of the clinical record revealed a physician's orders [REDACTED]. This treatment was ordered to treat venous wounds to the right and left lateral calves. During an interviews on 6/6/19 at 4:00 p.m. and 6/7/19 at 10:45 a.m., with Treatment Nurse DD confirmed that she had applied [MEDICATION NAME] Ag, which contains silver, to the open areas on the resident's lower extremities, one day prior to a visit to the wound clinic in (MONTH) 2019, to try something different to help the resident because she was upset about her legs. Treatment nurse DD confirmed that she did not obtain a physician's orders [REDACTED]. A review of wound clinic notes dared 5/10/19 confirmed that RB reported the use of silver dressings to her lower extremity wounds. During an interview on 6/7/19 at 12:55 a.m., with the Director of Nursing (DON) revealed that she expected licensed nursing staff to obtain a physician's orders [REDACTED]. | 2020-09-01 |
| 4691 | 4691 | SADIE G. MAYS HEALTH & REHABILITATION CENTER | 115542 | 1821 ANDERSON AVENUE NW | ATLANTA | GA | 30314 | 2016-08-19 | 282 | G | 1 | 0 | 0RHV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to follow the care plan for 1 of 9 sampled residents (R4) related to bowel management, which resulted in R4 having a stool impaction. After R4's hospitalization , the facility failed to monitor R4's bowel movements (BMs) and initiate bowel medications timely per the care plan, which increased the likelihood for further impaction, and causing actual harm. Findings include: The Admission Record indicated R4's [DIAGNOSES REDACTED]. The 2/4/16 plan of care related to bowel incontinence with a risk of constipation, included: Document episodes of incontinence each shift; observe for bowel movement (BM) each shift; report if no BM for 2-3 days, and administer medications as ordered. The Quarterly Change in Status Minimum Data Set (MDS), with an assessment reference date of 4/14/16, indicated R4 had severely impaired cognition, was dependent on staff for toilet use, and was always incontinent of bowel function. The 4/8/16 BM Report indicated R4 had a small, soft BM. The BM Report dated 4/9/16 to 4/21/16 (13 days) indicated R4 did not have any BMs. The 4/22/16 BM Report indicated R4 had a small BM. During an interview with Licensed Practical Nurse (LPN) 3 on 8/18/16 at 10:45 a.m., she said the Nurse Aides (NAs) were to report to the nurses when a resident did not have a BM for 2 to 3 days. LPN3 said between 4/8/16 and 4/22/16, the NAs did not report that R4 had any bowel issues. The 4/22/16 Situation, Background, Assessment, Recommendation (SBAR) Communication Form indicated R4 had an elevated heart rate of 102, and elevated temperature of 102 degrees Fahrenheit, an elevated blood sugar of 170, and a decreased oxygen saturation level of 89 %. The SBAR Communication Form indicated R4 was not responding as usual and refused to eat, drink, or take his medications. During an interview with Registered Nurse (RN) 14 on 8/19/16 at 11:10 a.m., RN14 said on 4/22/16, R4 had a decline in his medical sta… | 2019-08-01 |
| 3231 | 3231 | FOUNTAIN BLUE REHAB AND NURSING | 115636 | 3051 WHITESIDE ROAD | MACON | GA | 31216 | 2018-11-27 | 580 | D | 1 | 0 | SH9Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to notify the responsible party, in a timely manner, of the development of a pressure ulcer for one resident (A) from a total sample of six residents. Findings include: Resident (R) A had a new physician's orders [REDACTED]. During an interview on 11/27/18 at 2:08 p.m. Licensed Practical Nurse (LPN) AA stated that on 10/5/18 the order was written for a pressure ulcer. The pressure ulcer was a closed, dark, Deep Tissue Injury (DTI). However, there was no evidence in the clinical record that the resident's responsible party was notified of the pressure ulcer or treatment ordered on [DATE]. On 10/18/18 the consultant wound care physician evaluated R [NAME] A nurse note entry documented an unsuccessful attempt to notify the resident's responsible party and second contact person of the wound care physician's visit and wound debridement that occurred on 10/18/18. However, after the initial documented attempt on 10/18/18, there was no further evidence in the clinical record that further attempts were made to notify R A responsible party of the pressure ulcer to the sacrum until 11/1/18. During an interview on 11/27/18 at 2:43 p.m., R A's responsible party confirmed that she was not notified of when the pressure ulcer was first identified. | 2020-09-01 |
| 2980 | 2980 | PRUITTHEALTH - FITZGERALD | 115617 | 185 BOWEN'S MILL HIGHWAY | FITZGERALD | GA | 31750 | 2019-07-03 | 808 | D | 1 | 0 | KWBX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to obtain a therapeutic diet consultation, as ordered by the physician, for one of three residents (R#5) reviewed for diets. Findings include: Resident (R) #5 had [DIAGNOSES REDACTED]. There were care plans in place for the potential for alteration in nutrition and a desire to lose weight with an intervention for a Registered Dietician (RD) consultation and/or evaluation as needed. A review of the Yearly Weight Record Form for 2019 revealed that R#5 had lost 11 pounds, as care planned, since 2/15/19. A review of the clinical record revealed R#5 had been receiving a no added salt (NAS), liberalized diabetic (LDD), regular consistency diet since 2/18/19. On 5/2/19 R#5 received a cortisone injection to the left knee. A review of the physician's note from 5/2/19 revealed a [DIAGNOSES REDACTED]. Following the cortisone injection, an order was written on 5/2/19 to obtain a dietician consultation with the resident to discuss a low carbohydrate, weight reduction diet for DJD of the left knee and [MEDICAL CONDITION]. However, there was not any evidence in the clinical record that the dietician consultation was obtained as ordered until after surveyor inquiry on 6/25/19. During an interview on 6/25/19 at 2:00 p.m., the Assistant Director of Health Services (ADHS) confirmed that the physician's orders [REDACTED]. On 6/25/19 the RD was notified of the order via the Registered Dietician E-Fax Recommendation Form. The RD responded on 6/25/19 with a recommendation to discontinue the NAS, LDD, regular consistency diet and start a NAS, no concentrated sweets (NCS), regular consistency diet, adding fruit only for desserts. During an interview on 7/3/19 at 10:30 a.m. the Director of Health Services (DHS) stated that she would have expected nursing staff to have acted on the 5/2/19 order for the dietician consultation prior to surveyor inquiry on 6/25/19. | 2020-09-01 |
| 3232 | 3232 | FOUNTAIN BLUE REHAB AND NURSING | 115636 | 3051 WHITESIDE ROAD | MACON | GA | 31216 | 2018-11-27 | 625 | E | 1 | 0 | SH9Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to provide bed hold information at the time of transfer to the hospital or within 24 hours for three residents (#2, #5, and #6) from a total sample of six residents. Findings include: The facility's Bed Hold policy documented that the resident and a family member or legal representative shall be given notice of the bed hold options at the time of hospitalization or therapeutic leave. However, there was no evidence that the facility provided bed hold information at the time of hospitalization or within 24 hours for residents #2, #5 and #6. 1. Resident (R) #2 was hosptalized on [DATE]. Although the facility provided written information of the bed hold policy on admission on 3/3/17, a review of the clinical record revealed no evidence that the resident and responsible party were provided with information on bed hold also at the time of transfer or within 24 hours for the 10/18/18 hospitalization . 2. R#5 was hosptalized on [DATE]. Although the facility provided written information of the bed hold policy on admission on 10/5/17, a review of the clinical record revealed no evidence that the resident and responsible party were provided with information on bed hold also at the time of transfer or within 24 hours for the 10/30/18 hospitalization . 3. R#6 was hosptalized on [DATE]. Although the facility provided written information of the bed hold policy on admission on 10/12/18, a review of the clinical record revealed no evidence that the resident and responsible party were provided with information on bed hold also at the time of transfer or within 24 hours for the 11/2/18 hospitalization . During an interview on 11/27/18 at 10:00 a.m., the Social Service Director stated that bed hold information had not been provided at the time of hospitalization for R#2, R#5 and R#6. | 2020-09-01 |
| 1028 | 1028 | CONDOR HEALTH LAFAYETTE | 115360 | 110 BRANDYWINE BOULEVARD | FAYETTEVILLE | GA | 30214 | 2018-12-17 | 580 | D | 1 | 0 | S35E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record reviews the facility failed to notify the Physician/Nurse Practitioner (NP) of a transfer to the hospital for one resident (C) of three sampled residents. Findigs include: Review of the undated face sheet in the Electronic Medical Record (EMR) for R C revealed the resident was admitted to the facility on [DATE] and was discharged to a local hospital on [DATE]. Contnued review of the undated [DIAGNOSES REDACTED]. Review of Quarterly Minimum Data Set (MDS), dated [DATE], section C, revealed R C to have a Brief Interview for Mental Status (BIMS) score of three out of 15, signifying severely impaired cognition. Review of section G of the MDS revealed the resident required either extensive assistance or was totally dependent on caregivers for all of her Activities of Daily Living (ADLs). Review of a progress note, dated 11/3/18 at 7:10 p.m. revealed the resident's family came in to visit and noted the resident was sleeping. Further review revealed that the family member asked the staff nurse if the resident had been sedated and the nurse stated the resident had not been sedated. Further review revealed that the resident's family member then called the 911 without discussing the call with the nurse and that the resident was transferred to a nearby Emergency Department (ED). Review of a progress note, dated 11/3/18 at 7:58 p.m. revealed a late entry describing an earlier, but unstated time, revealed the staff Licensed Practicial Nurse (LPN) BB wrote that R C was sleeping during rounds but easily aroused. Further review revealed that the resident opened her eyes when her name was called when the paramedics arrived. A telephone interview on 11/29/18 at 2:15 p.m. with (LPN) BB revealed that she was the resident's nurse the evening that the family member called 911 and took the resident to the hospital. LPN BB stated after she came on duty she visited and assessed R C. LPN BB further revealed that she had no concerns abou… | 2020-09-01 |
| 4436 | 4436 | DOUGLASVILLE NURSING AND REHABILITATION CENTER | 115273 | 4028 HWY 5 | DOUGLASVILLE | GA | 30135 | 2016-10-05 | 281 | J | 1 | 0 | ELW111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and review of resident records, the Georgia Practical Nurses Practice Act professional standards published in the Lippincott Procedures for Safe Medication Administration Practice, General, and the facility policy titled, Medication Administration General Guidelines, the facility failed to ensure that the services provided to 4 of 52 sampled residents (R7, R5, R25, and R34) met professional standards for medication administration. Specifically: Resident (R) 7 was given [MEDICATION NAME] (laxative medication) without a physician order and the [MEDICATION NAME] was mixed with Pine-Sol cleaning solution, without checking the label of the product. The hazardous solution was administered to R7. After staff administered the Pine-Sol to the resident and the resident took a sip of the solution, she complained of burning in her throat and required transportation to the hospital emergency room for evaluation. The facility failed to administer medication to R5 prior to a surgical procedure, as ordered by the physician. The facility failed to administer an antibiotic medication, to R25, until 3 days after it was ordered for an infection. The facility administered three doses of [MEDICATION NAME] (opioid pain medication) to R34 after the medication was discontinued by the physician. The census was 229. The facility's failure to ensure that medications were administered based on physician order caused, or was likely to cause serious injury, harm, impairment, or death to a resident. On 9/27/16 at 5:55 p.m. the Administrator and Director of Nursing (DON) were notified that the failure to protect residents from neglect (F224 at scope and severity of J), the failure to ensure professional standards of nursing care were followed (F281 at scope and severity of J), the failure to provide specialized respiratory services (F328 scope and severity of J), and the failure to assure the facility was administered in a manner to assure that each resi… | 2019-10-01 |
| 401 | 401 | HARBORVIEW SATILLA | 115265 | 1600 RIVERSIDE AVE | WAYCROSS | GA | 31501 | 2018-02-15 | 812 | F | 1 | 1 | LMHT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, observation, and review of policy titled Food Receiving and Storage Facility A failed to assure that food prep equipment was clean and properly stored, maintain the cleanliness of the icemaker and fans, discard expired items, and label and date items in two reach in refrigerators. Facility B failed to assure that items in the dry storage area and in resident pantries were labeled and dated and discarded by the use by date. This included three of three food pantries at facility B and kitchens at Facility A and Facility B. The census for Facility A and Facility B was 161 residents. Findings include: Facility B [DATE] at 11:11 a.m. Brief kitchen tour of Facility B conducted with Dietary Manager revealed the following: 1. There was a box of shredded cheese with an in date of [DATE] but there was not way to determine the expiration date of the cheese. 2. There were eggs in the refrigerator but there was no way to determine the expiration date of the eggs. 3. Two 46 fluid ounce (oz) thickened water containers with an open date of [DATE] and (1) one thickened juice container that was open but did not have an open date on it. The directions for the items stated once opened store at ambient temperatures for up to 8 hours or refrigerate for up to 7 days. 4. The storage containers for rice, flour, and meal did not have an open or use by date. 5. In the reach in freezer there were (5) five 32 ounce (oz.) packages of frozen baby carrots with no expiration date. 6. Three bags of diced carrots with an in date of ,[DATE] and (MONTH) 26, (YEAR) listed on the package. 7. Six packages of 12 count hamburger buns with an expiration date of [DATE]. Interview on [DATE] at 11:35 a.m. with the Dietary Manager revealed that there should be a label on each container containing the flour, sugar, and corn meal. She further explained that when the items are placed in the plastic storage container a label should be added to the container identifying t… | 2020-09-01 |
| 5088 | 5088 | NORTHEAST ATLANTA HEALTH AND REHABILITATION CENTER | 115504 | 1500 S JOHNSON FERRY ROAD | ATLANTA | GA | 30319 | 2016-01-21 | 226 | J | 1 | 0 | KRH911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review and review of policy and procedure, it was determined the facility failed to have an effective system to ensure the implementation of the facility's Abuse and Neglect Prohibition policy for one (1) of twenty-five (25) sampled residents (Resident #1). Licensed Practical Nurses (LPN) MM and LL and Certified Nursing Assistant (CNA) 11 were alleged to have verbally abused and neglected Resident (#1). The alleged abusers worked on the third shift (11 p.m. until 7 a.m.) The facility's corporate office and Administrator had been aware of the alleged abuse since [DATE] but failed to follow the facility's policy and protect the residents from the alleged perpetrators, when they allowed LPN MM, LPN LL and CNA 11 to continue to work and provide direct care to residents. (Refer F155,F281 F223, F225) The facility's failure to implement the facility's Abuse and Neglect Prohibition policy to protect residents from abuse has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy on [DATE] at 8:45 a.m. An acceptable Allegation of Compliance (AoC) was received on [DATE] and the State Survey Agency validated the Immediate Jeopardy was removed on [DATE] as alleged. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: A review of the facility's Abuse and Neglect Prohibition policy defined Abuse as: the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm, pain, or mental anguish. The facility will conduct an investigation of any alleged abuse/neglect, injuries of unknown origin, or misappropriati… | 2019-01-01 |
| 1843 | 1843 | PREMIER ESTATES OF DUBLIN, LLC | 115495 | 1634 TELFAIR STREET | DUBLIN | GA | 31021 | 2018-01-05 | 625 | E | 1 | 0 | JYBR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review and review of the Resident Information and Reference Guide, the facility failed to provide bed hold information, in writing, at the time of transfer to the hospital, or within 24 hours, for three residents (A, #2, and #3) of three sampled residents. Findings include: The Resident Information and Reference Guide booklet, provided to residents and/or family on admission to the facility, documented that the facility would provide written information that described the bed hold policy when a resident was transferred to the hospital. The booklet also documented that the facility was required to provide written information to the resident, family or legal representative that specifies duration of bed hold during which the resident would be able to return and resume residence in the facility. Provide written information that specifies bed availability and re-admission practice if the hospitalization or therapeutic leave exceeds the bed hold period under the state plan. Provide notice within 24 hours. The booklet further documented the following procedure in the Bed Hold Requirement and Notification section: [NAME] Complete the Bed Hold Form prior to transferring a resident to the hospital. In cases of emergency transfer, written notification must be provided within 24 hours of transfer. B. Complete the Bed Hold Form prior to the resident leaving the facility for a therapeutic leave C. Provide a copy of the Bed Hold Form to the resident and place a copy in the medical record. However, there was no evidence that the facility consistently provided bed hold information, in writing, at the time of hospitalization or within 24 hours for residents A, #2, and #3. 1. Resident (R) A was hosptalized on [DATE], 10/11/17, 11/3/17 and 11/28/17. Although the facility provided written information of the bed hold policy on admission, a review of the clinical and financial records revealed no evidence that the resident and responsi… | 2020-09-01 |
| 1030 | 1030 | CONDOR HEALTH LAFAYETTE | 115360 | 110 BRANDYWINE BOULEVARD | FAYETTEVILLE | GA | 30214 | 2018-12-17 | 770 | D | 1 | 0 | S35E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review the facility laboratory failed to deliver a report of an anti-[MEDICAL CONDITION] drug level, ordered stat (immediately), for one resident (R) C of three sampled residents. Findings include: Review of the undated face sheet in the Electronic Medical Record (EMR) R C was admitted to the facility on [DATE] and was discharged on [DATE]. Review of the undated [DIAGNOSES REDACTED]. Review of R C's quarterly Minimum Data Set (MDS), dated [DATE], section C, revealed R#1 to have a Brief Interview for Mental Status (BIMS) score of three out of 15, signifying severely impaired cognition. Review of section G of the MDS revealed R C required either extensive assistance or was totally dependent on caregivers for all of her Activities of Daily Living (ADLs). Review of a physician's orders [REDACTED]. Review of R C's Medication Administration Record [REDACTED]. Review of a Physical Assessment document, dated 10/31/18 at 11:15 a.m. revealed that Nurse Practitioner (NP) EE examined the resident at that time. Further review revealed NP EE assessed R C as being in a post-ictal (after [MEDICAL CONDITION]) state after sustaining an acute [MEDICAL CONDITION] and that the resident was dazed and mumbling words. Further review revealed NP EE ordered a stat [MEDICATION NAME] level and other lab work and consulted with the resident's physician, who was also the facility Medical Director. Review of the Lab Results Report, dated 12/6/18 at 11:52 a.m., for R C revealed a [MEDICATION NAME] level blood test, among other tests, was drawn on 10/31/18 at 2:38 p.m. and was received by the laboratory on 10/31/18 at 4:47 p.m. Further review of the results revealed the [MEDICATION NAME] level was not available. Review of a Nurse's Note, dated 10/31/18 at 12:40 p.m., revealed a provider was making rounds and noted that the resident was twitching and foaming at the mouth, and was mumbling and staring into space. Further review revealed the provide… | 2020-09-01 |
| 1257 | 1257 | PRUITTHEALTH - EASTSIDE | 115391 | 2795 FINNEY CIRCLE | MACON | GA | 31217 | 2018-08-17 | 868 | J | 1 | 0 | RM0M11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review, and review of the Quality Assurance and Performance Improvement policy, the facility failed to utilize the Quality Assurance and Performance Improvement (QAPI) system to oversee the Advance Directive system and ensure staff were trained to respond appropriately during an emergency situation in an effort to prevent errors or delays in emergency resuscitative efforts. The facility had a census of 64 residents. An Abbreviated/Partial Extended Survey to investigating complaint GA# 560 was initiated on [DATE] and concluded on [DATE]. The complaint was substantiated with deficiencies. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator and Director of Health Services (DHS) were informed of the Immediate Jeopardy on [DATE] at 3:30 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on [DATE]. The Immediate Jeopardy continued through [DATE] and was removed on [DATE]. The immediate jeopardy is outline as follows: Resident (R) A had not executed an Advance Directive. R A experienced a change in condition on [DATE], becoming unresponsive while staff attempted to assist the resident out of the bathroom, after he had sustained an unwitnessed fall. Cardiopulmonary resuscitation (CPR) was initiated by certified nursing staff, and Emergency Medical Services (EMS) were notified. However, the resident's Advance Directive status was inaccurately assessed by licensed nursing staff as Do Not Resuscitate (DNR) and CPR was stopped prior to the arrival of EMS services and in absence of physician's orders [REDACTED]. The inaccurate Advance Directive status of DNR was obtained by licensed nursing staff from an incorrectly labeled form included in the Medication Administration Record (MA… | 2020-09-01 |
| 4585 | 4585 | MOLENA HEALTH & REHAB | 115693 | 185 HILL STREET | MOLENA | GA | 30258 | 2018-09-20 | 656 | D | 1 | 1 | IJ4211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review, and review of the facility policy titled Care Plans, Comprehensive Person-Centered, the facility failed to follow the Care Plan related to providing showers for two residents (R) (A and B) out of 37 sampled residents. Findings include: 1. R A was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) Annual assessment dated [DATE] documented R A with a Brief Interview of Mental Status (BIMS) score of 11 indicating cognition moderately impaired. R A required two-person physical help limited to transfer only with bathing. Review of the Care Plan for R A reviewed on 6/29/18 documented resident requires supervision and some limited to extensive staff assistance with her Activities of Daily Living (ADL's). Interventions included: Baths Tuesday, Thursday, and Saturday from 3-11 p.m. During an interview on 9/17/18 at 10:02 a.m., R A revealed that the North hall shower room does not work. Resident stated that all residents must use the South hall shower room. Resident stated that she does not always get a shower and she has waited for so long that she washed herself in her bathroom. Interview with Licensed Practical Nurse (LPN) BB on 9/19/18 at 3:30 p.m. revealed that the showers sheets for R A for (MONTH) and (MONTH) (YEAR) could not be located. 2. R B was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment dated [DATE] documented R B with a BIMS score of 08 indicating cognition moderately impaired. R B required set-up help only with physical part of bathing activity. Review of the Care Plan revised on 8/1/18 documented R B requires supervision with most ADL's. Resident may require extensive assistance with bath/showers at times. Interventions included bath/ shower as scheduled and as needed, assist as needed. Review of the Certified Nursing Assistant (CNA) Skin Assessment Checklist provided by the facility as the shower … | 2019-09-01 |
| 17 | 17 | MAGNOLIA MANOR METHODIST NSG C | 115004 | 2001 SOUTH LEE STREET | AMERICUS | GA | 31709 | 2019-06-07 | 697 | D | 1 | 0 | 2RIR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review, and review of the facility policy titled, Obtaining and Receiving Medications from Pharmacy the facility failed to ensure the medication for pain was obtained timely for one of 12 residents (R A). Findings include: The facility had an Obtaining and Receiving Medications from Pharmacy policy. The policy documented that medications that must be reordered by the nurse included controlled substance medications. The policy further documented that Schedule II medications such as [MEDICATION NAME] and [MEDICATION NAME] products required a signed prescription by the physician and should be reordered at least seven days in advance. During interviews on 6/3/19 at 12:00 p.m. and 6/4/19 at 1:50 p.m. Resident (R) A stated that nursing staff waited until her pain medication ran out to order more. Record review revealed that RA had a care plan since 2/8/19 for being at risk for alteration in comfort related to [MEDICAL CONDITION] reflux disease, generalized pain and skin alteration with an intervention for licensed nursing staff to administer medication as ordered. Further record review revealed a Physician's order since 2/15/19 for [MEDICATION NAME] 10-325 milligrams (mg) to be administered every six hours for pain. There was also a physician's order since 2/13/19 for [MEDICATION NAME] 10-325 mg to be administered every six hours as needed for pain. However, a review of the clinical record revealed that the resident did not receive the scheduled [MEDICATION NAME] pain medication as ordered and as care planned on 4/23/19 at 12:00 p.m. and 6:00 p.m. On 4/23/19 a Physician's order was obtained to 1) Hold [MEDICATION NAME] 10-325 mg every six hours and resume when it was available. 2) Administer [MEDICATION NAME] 10-325 mg every six hours, scheduled and discontinue when the [MEDICATION NAME] became available. 3) Keep the order for [MEDICATION NAME] 10-325 mg every six hours as needed for pain. A review of the (MONTH) 2019 M… | 2020-09-01 |
| 4445 | 4445 | DOUGLASVILLE NURSING AND REHABILITATION CENTER | 115273 | 4028 HWY 5 | DOUGLASVILLE | GA | 30135 | 2016-10-05 | 520 | K | 1 | 0 | ELW111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review, and review of the facility's policy titled, Quality Improvement Committee, the facility failed to maintain a Quality Assurance (QA) program which reviewed, developed, and implemented plans to correct quality deficiencies for all 229 residents living in the facility as of 9/26/16. The facility's QA program failed to: identify and respond to a pattern of failures regarding the identification, protection, and timely reporting of allegations of neglect, abuse, and misappropriation of property. Failed to identify and respond to a failure to have emergency equipment, proper sized cannulas, at the bedside for residents in the ventilator (vent) unit and address staff competencies. Failed to conduct root cause analysis of known problems and implement solutions. The facility was aware of multiple and repeated individual grievances from residents, families, and the resident council regarding staffing, pest control, and dietary services. The census was 229 and the sample size was 52. An abbreviated and partial extended survey was conducted from 9/26/16 through 10/5/16 to investigate complaints, GA 372, GA 244, GA 972, GA 111, GA 424, GA 053, the survey was conducted by Healthcare Management Solutions (HCMS), LLC on behalf of the Georgia State Survey Agency (SSA). The facility was found to not be in substantial compliance with the Medicare/Medicaid regulations at 42 CFR 483 Subpart B requirements for Long Term Care Facilities. The following deficiencies resulted from the facility's non-compliance related to GA 244, GA 972, GA 11, GA 424, and GA 053. The census was 229 residents and the sample size was 52 residents. On 9/27/16 a determination was made that a situation in which the non-compliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. On 9/27/16 at 5:55 p.m. the Administrator and Director of Nursing (DON) were noti… | 2019-10-01 |
| 5089 | 5089 | NORTHEAST ATLANTA HEALTH AND REHABILITATION CENTER | 115504 | 1500 S JOHNSON FERRY ROAD | ATLANTA | GA | 30319 | 2016-01-21 | 281 | J | 1 | 0 | KRH911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review, review of policy and procedure and review of the National Council of State Boards of Nursing [DATE] Georgia Practical Nurses Practice Act, it was determined the facility failed to ensure services provided met professional standards for one(1) of twenty-five (25) sampled residents (Resident #1). Observation of video surveillance of Resident #1's care on [DATE] revealed the resident pushing his call button and calling out Help Me multiple times for symptoms of shortness of breath and chest discomfort. Licensed Practical Nurse (LPN) MM told resident #1 to Stop pushing call light, what is wrong now? Resident #1 replied My heart at 4:46 a.m. LPN MM checked Resident #1's blood pressure at 4:54 a.m. and told Resident #1 that there was nothing wrong with him, he was having anxiety and that he just needed to calm down. Resident #1 continued to summon for help and call out Help Me. Certified Nursing Assistant (CNA) 11 entered Resident #1's room, asked him what he wanted, changed the resident's brief and removed his oxygen nasal cannula. Resident #1 was unresponsive when CNA 11 completed the brief change. CNA 11 called for the nurse and when LPN MM responded CNA 11 said, I came in, he died !. LPN MM appeared to check Resident #1's chest for respirations by placing her ear over his chest. LPN MM and CNA 11 left Resident #1's room, leaving him unattended. They did not perform CPR. CNA 11 returned to Resident #1's room and put the resident's pillow under his head, put his oxygen nasal cannula on his face, covered the resident with a sheet and raised the head of his bed. LPN LL entered Resident #1's room at 6:15 a.m. She placed a back board behind Resident #1 in bed. LPN LL manipulated an oxygen tank but was unable get it operational. The first chest compressions for CPR were performed by LPN LL at 6:34 a.m. The paramedics arrived at 6:38 a.m. Resident #1 was pronounced dead at 7:00 a.m. on [DATE]. (Refer F155, F157, F22… | 2019-01-01 |
| 5084 | 5084 | NORTHEAST ATLANTA HEALTH AND REHABILITATION CENTER | 115504 | 1500 S JOHNSON FERRY ROAD | ATLANTA | GA | 30319 | 2016-01-21 | 155 | J | 1 | 0 | KRH911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review, review of policy and procedure, review of Emergency Medical System (EMS) records and video surveillance review, it was determined the facility failed to honor the explicit Advance Directive wishes of one (1) of twenty-five (25) sampled residents (Resident #1). Resident #1 had an Advanced Directive which specified he desired to be provided Cardio [MEDICAL CONDITION] Resuscitation (CPR) if cardiac or respiratory arrest occurred. However, on [DATE], LPN MM and LPN LL failed to initiate CPR for Resident #1 when he was found unresponsive at 5:28 a.m. 911 Emergency was not called until 6:25 a.m. LPN LL began chest compressions at 6:34 a.m. EMS arrived at 6:38 a.m. and determined Resident #1 had no pulse and was not breathing. Resident #1 did not respond to the resuscitation efforts of the paramedics and was pronounced dead at 7:00 a.m. (Refer F223, F281, F282) The facility's failure to ensure residents' Advance Directives were honored has caused, or had the likelihood to cause, serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy on [DATE] at 8:45 a.m. An acceptable Allegation of Compliance (AoC) was received on [DATE] and the State Survey Agency validated the Immediate Jeopardy was removed on [DATE] as alleged, The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. Findings include: Review of the facility policy for Advance Directives (OP2 0303.00 Release Date: (MONTH) 2005 Chapter: Resident Rights) documented: The resident has a right to accept or refuse medical or surgical treatment and to formulate an advance directive in accordance with state and federal law. The facility uses… | 2019-01-01 |
| 1029 | 1029 | CONDOR HEALTH LAFAYETTE | 115360 | 110 BRANDYWINE BOULEVARD | FAYETTEVILLE | GA | 30214 | 2018-12-17 | 658 | D | 1 | 0 | S35E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review, review of the Emergency Medical Services (EMS) report, and review of the Georgia Standards of Practice for Licensed Practical Nurses (LPN) 410.10-.02, the facility failed to provide services that met professional standards of quality as evidenced by the duty Licensed Practical Nurse (LPN) failing to provide an accurate, meaningful report to Emergency Medical Services (EMS) personnel during an emergent transfer of Resident (R) C to the hospital and by not reporting this transfer to the resident's physician or Nurse Practitioner (NP) for one resident of three sampled residents Findings include: Review of Georgia Rules of the Board of Nursing 410.10.02 Standards of Practice for Licensed Practical Nurses 1. (a) Participating in patient assessment activities and the planning, implementation, and evaluation of the delivery of health care services and other specialized tasks when appropriately educated and consistent with board rules and regulations; (b) Providing direct personal patient observation, care, and assistance in hospitals, clinics, nursing homes, or emergency treatment facilities, or other health care facilities in areas of practice including, but not limited to: coronary care, intensive care, emergency treatment, surgical care and recovery, obstetrics, pediatrics, outpaitent services, [MEDICAL TREATMENT], speciality labs, home health care, or other such areas of practice. Review of the undated face sheet in the Electronic Medical Record (EMR) for R C revealed the resident was admitted to the facility on [DATE] and was discharged to a local hospital on [DATE]. Contnued review of the undated [DIAGNOSES REDACTED]. Review of Quarterly Minimum Data Set (MDS), dated [DATE], section C, revealed R C to have a Brief Interview for Mental Status (BIMS) score of three out of 15, signifying severely impaired cognition. Review of section G of the MDS revealed the resident required either extensive assistance or wa… | 2020-09-01 |
| 317 | 317 | ORCHARD VIEW REHABILITATION & SKILLED NURSING CTR | 115146 | 8414 WHITESVILLE ROAD | COLUMBUS | GA | 31907 | 2019-06-28 | 580 | D | 1 | 0 | EDYH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review the facility failed to notify the physician and/or the Responsible Party (RP) for two residents out of five, Resident (R)#5 and R#16, after significant change in medical conditions occurred with each resident. Progress note review revealed R#5 presented concerning vital signs on [DATE] at 10:33 a.m. and was discharged to the hospital on [DATE] at 8:37 p.m. Further review of the Progress notes and multiple interviews with facility personnel, including R#5's physician, revealed the physician was not notified of the change in R#5's condition, even after she was discharged to the hospital. Progress note review also revealed R#16 had bloody stool on [DATE] and [DATE]. Further review of the progress notes and staff interviews revealed no evidence the physician or RP were notified. Director of Nursing (DON) interview revealed that the only place a significant change of condition was documented would be in the progress notes. Findings include: 1. Review of the undated face sheet in the Electronic Health Record (EHR) revealed R#5 was admitted to the facility on [DATE] and discharged on [DATE]. Further review revealed her [DIAGNOSES REDACTED]. Review of an admission progress note dated [DATE] at 4:12 p.m. revealed her [DIAGNOSES REDACTED]. Review of R#5's [DATE] at 10:33 a.m. progress note revealed Respiratory Therapist (RT) HH wrote that R#5 had a low oxygen saturation (the amount of oxygen dissolved in the blood) of 84 - 88% and the resident was lethargic. Further review revealed the residents pulse rate was 140 - 155 beats per minute. Further review revealed RT HH notified the nurse. Review of the Mayo Clinic website found at: www.mayoclinic.org/symptoms/hypoxemia/basics/definition/sym- 930 revealed oxygen saturation (pulse ox) Values under 90 percent are considered low. Interview on [DATE] at 3:45 p.m. with Respiratory Therapist (RT) HH in the surveyor's workroom revealed that RT HH said that he had been an R… | 2020-09-01 |
| 2279 | 2279 | SYL-VIEW HEALTH CARE CENTER | 115544 | 411 PINE STREET | SYLVANIA | GA | 30467 | 2017-11-02 | 157 | D | 1 | 1 | LIXQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review the facility failed to notify the responsible party of a significant change in medication for one resident (R#70). Sample size was 29 residents. Findings include: Resident #70 was admitted to the facility with [DIAGNOSES REDACTED]. R#70 was started on [MEDICATION NAME] 0.5 mg every morning and 0.5 mg every night for a total of one mg daily on 4/11/2017. [MEDICATION NAME] is an antipsychotic medication used to treat [MEDICAL CONDITION]. The dose of [MEDICATION NAME] was increased on 5/10/2017 to 0.5 mg every morning and one mg every night. The dose was increased again on 6/14/17 to one mg every morning and two mg every night. The total dose was increased from 1.5 mg daily to 3.0 mg daily, thereby doubling the dose of a high risk medication. While the change in dosage does not constitute a life-threatening condition and is not a new treatment or response to a new condition, it is a signifcant increase (doubling) in total dosage of a high risk medication and exponentially increased the resident's risk of adverse reactions. The facility's practice is to notify the responsible party anytime a medication is changed, started or discontinued and to document that notification in the nurse's progress notes of their computerized records. There is no evidence in the computerized records in Point, Click Care that the daughter was notified. There is no evidence in the hard copy/paper chart of the family being notified as well. In an interview with R#70's responsible party, conducted on 10/31/2017 at 12:35 p.m., revealed that after noting an increase in sedation and discussing it with facility staff, she was informed of the increase in the dosage amounts of [MEDICATION NAME] that R#70 was taking. She stated she had never been informed by the facility staff of the changes in the medication dosage. Furthermore, when she asked the staff to contact the physician regarding the increased sedation she had observed, the staff… | 2020-09-01 |
| 1253 | 1253 | PRUITTHEALTH - EASTSIDE | 115391 | 2795 FINNEY CIRCLE | MACON | GA | 31217 | 2018-08-17 | 658 | J | 1 | 0 | RM0M11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review, review of the Georgia Board of Nursing Rule ,[DATE]-.02 Standards of Practice for Licensed Practical Nurses, review of the Standards of Practice for Registered Professional Nurses: ,[DATE]-.01, the facility failed to provide adequate supervision of certified nursing staff regarding the initiation and cessation of cardiopulmonary resuscitation (CPR) during an emergency situation for one resident (A), from a total sample of 19 residents. An Abbreviated/Partial Extended Survey investigating complaint GA# 560 was initiated on [DATE] and concluded on [DATE]. The complaint was substantiated with deficiencies. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator and Director of Health Services (DHS) were informed of the Immediate Jeopardy on [DATE] at 3:30 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on [DATE]. The Immediate Jeopardy continued through [DATE] and was removed on [DATE]. The facility implemented a Credible Allegation of Compliance related to the Immediate Jeopardy on [DATE]. The immediate jeopardy is outline as follows: Resident (R) A had not executed an Advance Directive. R A experienced a change in condition on [DATE], becoming unresponsive while staff attempted to assist the resident out of the bathroom, after he had sustained an unwitnessed fall. Cardiopulmonary resuscitation (CPR) was initiated by certified nursing staff, and Emergency Medical Services (EMS) were notified. However, the resident's Advance Directive status was inaccurately assessed by licensed nursing staff as Do Not Resuscitate (DNR) and CPR was stopped, prior to the arrival of EMS services and in absence of physician's orders [REDACTED]. The inaccurate Advance Directive st… | 2020-09-01 |
| 604 | 604 | PRUITTHEALTH - MACON | 115288 | 2255 ANTHONY ROAD | MACON | GA | 31204 | 2019-05-28 | 658 | D | 1 | 0 | F4GX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review, review of the Georgia Nurse Practice Act, licensed nursing staff failed exercise competent independent judgement by not verifying the location of one resident (A) to ensure their safety, from a total sample of 19 residents. Findings include: Review of the Rules and Regulations of the State of Georgia, Rule 410-10-.02 Standards of Practice for Licensed Practical Nurse addressed Rule 410-10-.02 (a) Participating in patient assessment activities and the planning, implementation, and evaluation of the delivery of health care services and other specialized tasks when appropriately educated and consistent with board rules and regulations; (b) Providing direct personal patient observation, care, and assistance in hospitals, clinics, nursing homes, or emergency treatment facilities, or health care facilities in area of practice including, but not limited to: coronary care, intensive care, emergency treatment, surgical care and recovery, obstetrics, pediatrics, outpatient services, [MEDICAL TREATMENT], specialty labs, home health care, or other such areas of practice. (f) Performing other specialized tasks as appropriately educated. 2. Responsibility: Each individual is responsible for personal acts of negligence under the law. Licensed practical nurses are liable if the perform functions for which they are not prepared by education and experience and for which supervision is not provided. The facility had a job description for Licensed Practical Nurses (LPN). The job description included an essential supervisory function of exercising independent judgement. The job description acknowledgement was signed by LPN AA on 10/19/15. However, LPN AA failed to exercise competent independent judgement on 5/12/19 by not verifying the location of Resident (R) A, when the resident was not in her room. A 5/13/19 9:09 a.m. Nurse's Note documented that LPN AA was summoned by nursing staff on D hall that RA was lying on the gr… | 2020-09-01 |
| 4404 | 4404 | PIONEER HEALTH OF CENTRAL GEORGIA | 115564 | 712 PATTERSON STREET | BYROMVILLE | GA | 31007 | 2016-12-10 | 501 | J | 1 | 0 | QBL111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review, the Medical Director failed to assure care was provided that met current standards of practice in areas including resident-to-resident abuse and use of [MEDICAL CONDITION] medications. The facility's failure to ensure residents were protected from further physical abuse by R#39 was determined to be likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 12/8/16 and determined to first exist on 10/23/16, when R#39 first threatened R#56 with harm using a wire clothes hanger. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy on 12/8/16 at 2:55 p.m. An acceptable AoC was received on 12/10/16 and the surveyors validated the Immediate Jeopardy was removed on 12/10/16 as alleged. The deficient practice remained at a D (isolated potential for more than minimal harm) scope and severity while the facility developed and implemented the Plan of Correction and the facility's Quality Assurance Committee monitored the effectiveness of the systemic changes. Findings include: During the annual recertification survey and complaints investigation from 12/5/16 to 12/10/16, the facility was found out of compliance with regulatory requirements regarding prevention of resident-to-resident abuse and use of [MEDICAL CONDITION] medications. Cross-reference F222: Chemical Restraints - the facility failed to ensure resident (R) #56 and R#83 were not chemically restrained. The facility administered an array of [MEDICAL CONDITION] medications, including PRN (as needed) injections of medications and multiple medications from the same drug class, to manage residents' behaviors for staff convenience. [DIAGNOSES REDACTED]. The rationale and effectiveness of the medications was not consistently documented. Cross-reference F223: Physical Abuse - the facility failed to ensure that R#39's physically abusive behaviors were addressed and i… | 2019-11-01 |
| 1255 | 1255 | PRUITTHEALTH - EASTSIDE | 115391 | 2795 FINNEY CIRCLE | MACON | GA | 31217 | 2018-08-17 | 835 | J | 1 | 0 | RM0M11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review, the facility administration failed to ensure effective monitoring of the Advance Directive system and failed to ensure staff were trained to respond appropriately during an emergency situation in an effort to prevent errors or delays in emergency resuscitative efforts. The facility had a census of 64 residents. An Abbreviated/Partial Extended Survey investigating complaint GA# 560 was initiated on [DATE] and concluded on [DATE]. The complaint was substantiated with deficiencies. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator and Director of Health Services (DHS) were informed of the Immediate Jeopardy on [DATE] at 3:30 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on [DATE]. The Immediate Jeopardy continued through [DATE] and was removed on [DATE]. The facility implemented a Credible Allegation of Compliance related to the Immediate Jeopardy on [DATE]. The immediate jeopardy is outline as follows: Resident (R) A had not executed an Advance Directive. R A experienced a change in condition on [DATE], becoming unresponsive while staff attempted to assist the resident out of the bathroom, after he had sustained an unwitnessed fall. Cardiopulmonary resuscitation (CPR) was initiated by certified nursing staff, and Emergency Medical Services (EMS) were notified. However, the resident's Advance Directive status was inaccurately assessed by licensed nursing staff as Do Not Resuscitate (DNR) and CPR was stopped, prior to the arrival of EMS services and in absence of Physician's Order to stop resuscitative efforts. The inaccurate Advance Directive status of DNR was obtained by licensed nursing staff from an incorrectly labeled form included in the Medicatio… | 2020-09-01 |
| 2023 | 2023 | ORCHARD HEALTH AND REHABILITATION | 115522 | 1321 PULASKI SCHOOL ROAD | PULASKI | GA | 30451 | 2017-10-08 | 278 | J | 1 | 0 | UU0Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review, the facility failed to accurately assess one resident (R) #1, as high-risk for elopement on admission (resident had a known history of elopement and attempted elopement) resulting in the resident successfully eloping on [DATE]. The facility failed to re-assess the resident and his elopement risk after his return. He eloped again on [DATE] with his remains found on [DATE]. The Sample size was six residents. On [DATE] a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator, Director of Nursing (DON), and the Regional Vice President (RVP) were informed of the immediate jeopardy on [DATE] at 6:45 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on [DATE]. The immediate jeopardy continued through [DATE], and was removed on [DATE]. The facility implemented a Credible Allegation of Compliance related to the immediate jeopardy on [DATE]. The immediate jeopardy is outlined as follows: Resident #1 (R#1) was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident had a Brief Interview for Mental Status (BIMs) score of 6 indicating that the resident was severely cognitively impaired. The resident's functional status was documented that the resident's locomotion (walking) on the unit required supervision meaning oversight encouragement or cueing. Record review revealed that on [DATE], R#1 eloped from this facility and walked about one mile down the highway. The resident was found by staff and returned to the facility. Further record review revealed that after the resident eloped on [DATE], that the facility failed to update the resident's care plan and failed to put new care plan interventi… | 2020-09-01 |
| 1254 | 1254 | PRUITTHEALTH - EASTSIDE | 115391 | 2795 FINNEY CIRCLE | MACON | GA | 31217 | 2018-08-17 | 678 | J | 1 | 0 | RM0M11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review, the facility failed to accurately assess the Advance Directive status and provide continued Cardiopulmonary Resuscitation (CPR) for one resident (A) and failed to ensure the Advance Directive status was accurately reflected on the physician's orders for two residents (#2 and #3), from a total sample of 19 residents. An Abbreviated/Partial Extended Survey investigating complaint GA# 560 was initiated on [DATE] and concluded on [DATE]. The complaint was substantiated with deficiencies. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator and Director of Health Services (DHS) were informed of the Immediate Jeopardy on [DATE] at 3:30 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on [DATE]. The Immediate Jeopardy continued through [DATE] and was removed on [DATE]. The facility implemented a Credible Allegation of Compliance related to the Immediate Jeopardy on [DATE]. The immediate jeopardy is outline as follows: Resident (R) A had not executed an Advance Directive. RA experienced a change in condition on [DATE], becoming unresponsive while staff attempted to assist the resident out of the bathroom, after he had sustained an unwitnessed fall. Cardiopulmonary resuscitation (CPR) was initiated by certified nursing staff, and Emergency Medical Services (EMS) were notified. However, the resident's Advance Directive status was inaccurately assessed by licensed nursing staff as Do Not Resuscitate (DNR) and CPR was stopped, prior to the arrival of EMS services and in absence of Physician's Order to stop resuscitative efforts. The inaccurate Advance Directive status of DNR was obtained by licensed nursing staff from an incorrectly labeled form included in the Medic… | 2020-09-01 |
| 3478 | 3478 | LAUREL PARK AT HENRY MED CTR | 115673 | 1050 HOSPITAL DRIVE | STOCKBRIDGE | GA | 30281 | 2019-02-04 | 678 | J | 1 | 0 | HHND11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review, the facility failed to accurately assess the Advance Directive status for one resident (#4) and failed to accurately document the Advance Directive status for one resident (#12) from a total sample of 30 residents. An Abbreviated/Partial Extended Survey investigating complaints GA 836, GA 960, GA 577, GA 661 and GA 672 was initiated on (MONTH) 2, 2019 and concluded on (MONTH) 3, 2019. Complaints GA 836, GA 960, GA 577, and GA 661 were unsubstantiated. After review by the State Survey Agency, further investigation was needed for complaint GA 672, and a re-entry was initiated on (MONTH) 28, 2019 and concluded on (MONTH) 4, 2019. An additional complaint, GA 099 was also investigated. Complaint GA 672 was substantiated with deficiencies. Complaint GA 099 was partially substantiated with deficiencies. As indicated on the facility's Form CMS-672, Resident Census and Conditions of Resident Form, the facility's census on (MONTH) 3, 2019 was 83. On (MONTH) 29, 2019, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Administrator, Nurse Consultant UUU, and Area Vice President were informed of the Immediate Jeopardy on (MONTH) 29, 2019 at 4:15 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on (MONTH) 19, (YEAR). The Immediate Jeopardy continued through (MONTH) 29, 2019 and was removed on (MONTH) 30, 2019. The Immediate Jeopardy is outlined as follows: 1. Resident (R) #4 had not executed an Advance Directive. On (MONTH) 19, (YEAR), R#4 was found in bed, unresponsive, with no vital signs. The resident's Advance Directive status was initially inaccurately assessed by licensed nursing staff as Do Not Resuscitate (DNR) in the electronic record, therefore, no emergency basic life support was … | 2020-09-01 |
| 3476 | 3476 | LAUREL PARK AT HENRY MED CTR | 115673 | 1050 HOSPITAL DRIVE | STOCKBRIDGE | GA | 30281 | 2019-02-04 | 655 | J | 1 | 0 | HHND11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review, the facility failed to develop a baseline care plan for the advance directive status for one resident (#4) from a total sample of 30 residents. An Abbreviated/Partial Extended Survey investigating complaints GA 836, GA 960, GA 577, GA 661 and GA 672 was initiated on (MONTH) 2, 2019 and concluded on (MONTH) 3, 2019. Complaints GA 836, GA 960, GA 577, and GA 661 were unsubstantiated. After review by the State Survey Agency, further investigation was needed for complaint GA 672, and a re-entry was initiated on (MONTH) 28, 2019 and concluded on (MONTH) 4, 2019. An additional complaint, GA 099 was also investigated. Complaint GA 672 was substantiated with deficiencies. Complaint GA 099 was partially substantiated with deficiencies. As indicated on the facility's Form CMS-672, Resident Census and Conditions of Resident Form, the facility's census on (MONTH) 3, 2019 was 83. On (MONTH) 29, 2019, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Administrator, Nurse Consultant UUU, and Area Vice President were informed of the Immediate Jeopardy on (MONTH) 29, 2019 at 4:15 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on (MONTH) 19, (YEAR). The Immediate Jeopardy continued through (MONTH) 29, 2019 and was removed on (MONTH) 30, 2019. The Immediate Jeopardy is outlined as follows: 1. Resident (R) #4 had not executed an Advance Directive. On (MONTH) 19, (YEAR), R#4 was found in bed, unresponsive, with no vital signs. The resident's Advance Directive status was initially inaccurately assessed by licensed nursing staff as Do Not Resuscitate (DNR) in the electronic record, therefore, no emergency basic life support was immediately provided. The Physician and the Director of Health Services… | 2020-09-01 |
| 1252 | 1252 | PRUITTHEALTH - EASTSIDE | 115391 | 2795 FINNEY CIRCLE | MACON | GA | 31217 | 2018-08-17 | 656 | J | 1 | 0 | RM0M11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review, the facility failed to develop a care plan for the advance directive status for four residents (A, #2, #3, and #15) from a total sample of 19 residents. An Abbreviated/Partial Extended Survey investigating complaint GA# 560 was initiated on [DATE] and concluded on [DATE]. The complaint was substantiated with deficiencies. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator and Director of Health Services (DHS) were informed of the Immediate Jeopardy on [DATE] at 3:30 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on [DATE]. The Immediate Jeopardy continued through [DATE] and was removed on [DATE]. The facility implemented a Credible Allegation of Compliance related to the Immediate Jeopardy on [DATE]. The immediate jeopardy is outline as follows: Resident (R) A had not executed an Advance Directive. R A experienced a change in condition on [DATE], becoming unresponsive while staff attempted to assist the resident out of the bathroom, after he had sustained an unwitnessed fall. Cardiopulmonary resuscitation (CPR) was initiated by certified nursing staff, and Emergency Medical Services (EMS) were notified. However, the resident's Advance Directive status was inaccurately assessed by licensed nursing staff as Do Not Resuscitate (DNR) and CPR was stopped, prior to the arrival of EMS services and in absence of physician's orders [REDACTED]. The inaccurate Advance Directive status of DNR was obtained by licensed nursing staff from an incorrectly labeled form included in the Medication Administration Record (MAR) book. The DHS pronounced the resident's death at the facility on [DATE] at 7:09 a.m. at which time she notified the physician and family. The DHS wa… | 2020-09-01 |
| 2872 | 2872 | PINEWOOD NURSING CENTER | 115607 | 433 NORTH MCGRIFF STREET | WHIGHAM | GA | 39897 | 2018-07-13 | 600 | D | 1 | 0 | O6WT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review, the facility failed to ensure one resident (R) (#2) was protected from sexual abuse of 3 sampled residents. The facility census was 68 residents. Findings include: Review of R#1's Annual Minimum Data Set ((MDS) dated [DATE] revealed his Brief Interview for Mental Status (BIMS) of 05 indicating that he was cognitively impaired. A quarterly MDS assessment dated [DATE] revealed R#1's BIMS 04. Review of the current diagnosis's listing for R#1 reveals he has unspecified [MEDICAL CONDITION] and cognitive communication deficit. Review of R#2's quarterly MDS dated [DATE] revealed a BIMS score providing cognitive status was not able to be performed. An annual MDS dated [DATE] revealed the BIMS score was again unable to be assessed. Review of the current diagnosis's listing for R#2 reveals he has an unspecified lack of expected normal physiological development in childhood and a cognitive communication deficit. Review of a nursing note dated 4/3/2018 at 1:30 p.m. by a Licensed Practical Nurse (LPN) revealed it was brought to her attention that R#1 was making sexual advances to workers in the facility. She explained to R#1 that is was inappropriate to talk and approach workers that way. Review of the Social Service Director (SSD) notes dated 4/11/2018 at 10:10 a.m. revealed the SSD and administrator asked R#1 if he made any inappropriate, sexual comments to anyone, and he said no. Administrator informed resident that it has been reported that he has made inappropriate, sexual comments to others and that behavior was not acceptable and would not be tolerated in this facility. R#1 again, denied behaviors. Administrator asked R#1 did he understand what she said regarding behaviors. R#1 stated yes mam, said bye, and walked away. Review of a nursing note dated 6/30/2018 at 4:00 a.m. revealed a Certified Nursing Assistant (C.N.A) informed an LPN that she walked in on R#1 in the room with R#2, and that she observed R#1 … | 2020-09-01 |
| 2688 | 2688 | PINEWOOD MANOR NURSING HOME & REHABILITATION CNTR | 115586 | 277 COMMERCE STREET | HAWKINSVILLE | GA | 31036 | 2019-11-07 | 689 | D | 1 | 0 | 1NRG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review, the facility failed to ensure that an accident, that occurred during a transfer and resulted in injury, was reported timely to prevent a delay in care for one of three residents (R#1) reviewed for accidents. Findings include: Resident (R) #1 had [DIAGNOSES REDACTED]. A care plan, dated 5/5/19, documented that R#1 was bed and chair bound and required physical assistance with bed mobility, transfers and locomotion. The care plan also included that a Geri-chair was utilized for comfort and positioning. A review of the clinical record revealed that a change in condition was identified on 7/29/19. An untimed 7/29/19 nurse's note documented that R#1's family thought the resident had a sprained left lower extremity. The Physician was notified, and orders were received to obtain x-rays of the bilateral lower extremities due to swelling, to rule out fracture. A review of the x-ray results revealed fractures to the left lateral cortex of the fibula and anterior cortex of the distal tibia. A walker boot was ordered applied to the left lower extremity. The resident's transfer status was also changed to be completed via a mechanical lift. Record review revealed a Physician order [REDACTED]. Review of a Radiology report dated 7/29/19 documented: a subtle medial malleolus fracture is suspected. Review of a Radiology report dated 7/30/19 documented: Non displaced [MEDICAL CONDITION] cortex of the fibula, questionable [MEDICAL CONDITION] cortex of the distal tibia. The facility initiated an investigation into the cause of the left lower extremity fractures. A subsequent 7/29/19 7:45 a.m. nurses note, completed by the Director of Nursing (DON), documented: she was made aware of the origin of the injury by a staff member on 7/29/19. On the Thursday prior to 7/29/19 (which would have been 7/25/19), when the resident was being transferred from the bed to the Geri-chair, her foot had become lodged between the bottom of the … | 2020-09-01 |
| 3480 | 3480 | LAUREL PARK AT HENRY MED CTR | 115673 | 1050 HOSPITAL DRIVE | STOCKBRIDGE | GA | 30281 | 2019-02-04 | 760 | D | 1 | 0 | HHND11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review, the facility failed to ensure that one resident (#11) from free from medication errors from a total sample of 30 residents. Findings include: Resident #11 was admitted to the facility on [DATE]. A review of the admission orders [REDACTED]. One drop of [MEDICATION NAME] 0.25% opthalmic solution was ordered to be administered twice daily to both eyes. One drop of [MEDICATION NAME] 0.01% opthalmic solution was ordered to be administered daily, at bedtime. A review of the clinical record, including the Medication Administration Record [REDACTED]. In addition, the 9:00 p.m. doses of [MEDICATION NAME] were not administered as ordered on [DATE] and 11/25/18, with documentation that the medication was unavailable. During an interview on 1/31/19 at 12:05 p.m. Licensed Practical Nurse (LPN) FF stated that when medications arrive from the pharmacy, they come to the nursing station and the nurses sign for them and add them to the medication carts. She also stated that if she documented the medications were not available, then that meant she did not have the medications to give. If she had them, she would have administered the medications as ordered. However, during an interview on 1/31/19 at 11:23 a.m., Pharmacist EE stated that the eye medications were filled on 11/24/18 and delivered to the facility that same day, around 5:00 p.m. | 2020-09-01 |
| 3323 | 3323 | FORT VALLEY HEALTH AND REHAB | 115651 | 604 BLUEBIRD BOULEVARD | FORT VALLEY | GA | 31030 | 2018-07-25 | 656 | D | 1 | 0 | 75FB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review, the facility failed to ensure that pressure ulcer treatment was provided as care planned for one resident (A) from a total sample of eight residents. Findings include: Resident (R) A was admitted to the facility on [DATE] with a stage IV pressure ulcer to the sacrum. There was a care plan problem in place, since 1/8/18, to address the pressure ulcer. The care plan included an intervention for licensed nursing staff to administer treatments as ordered. There was a physician's orders [REDACTED]. However, a review of the clinical record, including the Treatment Administration Record, revealed no evidence that the pressure ulcer treatment had been provided, as care planned, for three days in (MONTH) (5/5, 5/6 and 5/20/18), six days in (MONTH) (6/2, 6/3, 610, 6/16, 6/17 and 6/23/18), and one day in (MONTH) (7/15/18). During an interview on 7/24/18 at 12:10 p.m. Resident (R) A stated that his pressure ulcer treatment does not always get changed on the weekends. He stated that the facility did not have a wound treatment nurse on the weekends so the nurses had to decide on who was going to do treatments, and then it still did not get done. Interviews on 7/24/18 at 10:45 a.m. and 2:40 p.m. with the wound treatment Licensed Practical Nurse (LPN) stated that she provided wound treatments during the week (Monday through Friday) and the Registered Nurse (RN) supervisor provided wound treatments on the weekends. She also stated that she had noticed at times that treatments were not completed as ordered over the weekends. An interview on 7/24/18 at 3:38 p.m., with the Registered Nurse (RN) weekend supervisor AA stated that she was supposed to provide wound treatments, as ordered, and did so, if she was only supervising. However, she stated that she was unable to if she was also pulled to administer medications. She stated that if she was pulled to administer medications, she would also try and provide treatments to t… | 2020-09-01 |
| 3324 | 3324 | FORT VALLEY HEALTH AND REHAB | 115651 | 604 BLUEBIRD BOULEVARD | FORT VALLEY | GA | 31030 | 2018-07-25 | 686 | E | 1 | 0 | 75FB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review, the facility failed to ensure that pressure ulcer treatment was provided as ordered for three residents (A, #2 and #3) from a total sample of eight residents. Findings include: During interviews on 7/24/18 at 10:45 a.m. and 2:40 p.m. the wound treatment Licensed Practical Nurse (LPN) stated that she provided wound treatments during the week (Monday through Friday) and the Registered Nurse (RN) supervisor provided wound treatments on the weekends. She also stated that she had noticed at times that treatments were not completed as ordered over the weekends. During an interview on 7/24/18 at 3:38 p.m., RN weekend supervisor AA stated that she was supposed to provide wound treatments, as ordered, and did so, if she was only supervising. However, she stated that she was unable to if she was also pulled to administer medications. She stated that if she was pulled to administer medications, she would also try and provide treatments to those residents assigned to her, but always had one or two that did not get completed. 1. Record review revealed that resident (R) A was admitted to the facility on [DATE] with a stage IV pressure ulcer to the sacrum. There was a care plan problem in place, since 1/8/18, to address the pressure ulcer that included an intervention for licensed nursing staff to administer treatments as ordered. The current physician ordered pressure ulcer treatment, since 5/11/18, was for licensed nursing staff to cleanse the pressure ulcer to the sacrum with normal saline or wound cleanser, apply Hydrogel, cover with an Alginate wound dressing and cover with a dry dressing daily and as needed. However, a review of the clinical record revealed no evidence that the pressure ulcer treatment had been provided, as ordered, for one weekend day in (MONTH) (5/20/18), six days in (MONTH) (6/2, 6/3, 610, 6/16, 6/17 and 6/23/18), and one day in (MONTH) (7/15/18). During an interview on 7/24/18 at 12:10 p.m.… | 2020-09-01 |
| 2974 | 2974 | PRUITTHEALTH - FITZGERALD | 115617 | 185 BOWEN'S MILL HIGHWAY | FITZGERALD | GA | 31750 | 2019-07-03 | 688 | D | 1 | 0 | KWBX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review, the facility failed to ensure that restorative nursing services were consistently provided for one of four residents (B) reviewed for restorative nursing. Findings include: The facility had a Lippincott Procedure for a Restorative Nursing Program. The procedure noted that it was the policy of the facility to provide restorative nursing which focuses on achieving and maintaining optimal physical, mental and psychosocial functioning of the resident. The restorative nursing program is under the supervision of a licensed nurse and provided by restorative nursing assistants or certified nursing assistants or any other qualified staff. The procedure also documented if it is determined that the resident would benefit from a Restorative Nursing Program, the nurse should arrange for such a minimum of six days a week, unless otherwise noted. During an interview on 6/24/19 at 12:35 p.m., the Assistant Director of Health Services (ADHS) stated that she oversaw the restorative program and restorative certified nursing assistant (CNA) BBB provided the restorative nursing services. The ADHS also stated that restorative services are usually set up to be provided three to five times per week or as tolerated. She added that currently restorative CNA BBB had been out of the facility, since last week, on leave, and that a list of all residents who received restorative nursing services would be given to the CNA's assigned to the residents that day (6/24/19). Resident (R) B had [DIAGNOSES REDACTED]. She received skilled physical therapy services from 2/19/19 through 4/30/19 and was discharged to a Restorative Nursing Program on 5/1/19. Care plan problems were developed on 4/30/19 for requiring restorative assistance to maintain goals and for being at an increased risk for falls with interventions to complete passive range of motion (PROM) exercises and ambulate as able with a bariatric walker for 15 to 80 feet, with staff t… | 2020-09-01 |
| 4405 | 4405 | PIONEER HEALTH OF CENTRAL GEORGIA | 115564 | 712 PATTERSON STREET | BYROMVILLE | GA | 31007 | 2016-12-10 | 520 | J | 1 | 0 | QBL111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review, the facility failed to maintain an effective Quality Assurance (QA) program that systematically reviewed quality of care related to resident-to-resident abuse and use of [MEDICAL CONDITION] medications. The facility's failure to maintain an effective QA program that implemented a plan to safeguard residents from further physical abuse by R#39 was determined to be likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 12/8/16 and determined to first exist on 10/23/16, when R#39 first threatened R#56 with harm using a wire clothes hanger. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy on 12/8/16 at 2:55 p.m. An acceptable Allegation of Compliance (AoC) was received on 12/10/16 and the surveyors validated the Immediate Jeopardy was removed on 12/10/16 as alleged. The deficient practice remained at an F (widespread potential for more than minimal harm) scope and severity related to additional findings of non-compliance and Substandard Quality of Care. Findings include: During the annual recertification survey and complaints investigation from 12/5/16 to 12/10/16, the facility was found out of compliance with regulatory requirements regarding prevention of resident-to-resident abuse and use of [MEDICAL CONDITION] medications. Cross-reference F223: Physical Abuse. The facility failed to ensure that R#39's physically abusive behaviors were addressed and interventions were implemented to keep residents safe from further potential harm. R#39 threatened R#56 with harm from a wire clothes hanger on 10/23/16. On 12/5/16, R#39 was observed hitting R#56 with a wire clothes hanger. The facility responded with an intervention to remove all wire clothes hangers from R#39's possession. On 12/8/16, a wire clothes hanger was observed in R#39's room. The nursing staff assigned to work with R#39 were unaware of the in… | 2019-11-01 |
| 2026 | 2026 | ORCHARD HEALTH AND REHABILITATION | 115522 | 1321 PULASKI SCHOOL ROAD | PULASKI | GA | 30451 | 2017-10-08 | 490 | J | 1 | 0 | UU0Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review, the facility failed to maintain an effective Quality Assurance (QA) program that systematically reviewed the residents and the physical environment for elopement risks. The sample size was 6 residents. On [DATE] a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator, Director of Nursing (DON), and the Regional Vice President (RVP) were informed of the immediate jeopardy on [DATE] at 6:45 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on [DATE]. The immediate jeopardy continued through [DATE], and was removed on [DATE]. The facility implemented a Credible Allegation of Compliance related to the immediate jeopardy on [DATE]. The immediate jeopardy is outlined as follows: Resident #1 (R#1) was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident had a Brief Interview for Mental Status (BIMs) score of 6 indicating that the resident was severely cognitively impaired. The resident's functional status was documented that the resident's locomotion (walking) on the unit required supervision meaning oversight encouragement or cueing. Record review revealed that on [DATE], R#1 eloped from this facility and walked about one mile down the highway. The resident was found by staff and returned to the facility. Further record review revealed that after the resident eloped on [DATE], that the facility failed to update the resident's care plan and failed to put new care plan interventions in place to prevent the resident from eloping from the facility again. On [DATE], R#1 eloped from the facility between the hours of 10:30 a.m. and 1:30 p.m. The resident was last seen in the morning exerc… | 2020-09-01 |
| 1251 | 1251 | PRUITTHEALTH - EASTSIDE | 115391 | 2795 FINNEY CIRCLE | MACON | GA | 31217 | 2018-08-17 | 580 | J | 1 | 0 | RM0M11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review, the facility failed to notify the physician and responsible party in a timely manner, of a change in condition for one resident (A) from a total sample of 19 residents. An Abbreviated/Partial Extended Survey investigating complaint GA# 560 was initiated on [DATE] and concluded on [DATE]. The complaint was substantiated with deficiencies. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator and Director of Health Services (DHS) were informed of the Immediate Jeopardy on [DATE] at 3:30 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on [DATE]. The Immediate Jeopardy continued through [DATE] and was removed on [DATE]. The facility implemented a Credible Allegation of Compliance related to the Immediate Jeopardy on [DATE]. The immediate jeopardy is outline as follows: Resident (R) A had not executed an Advance Directive. R A experienced a change in condition on [DATE], becoming unresponsive while staff attempted to assist the resident out of the bathroom, after he had sustained an unwitnessed fall. Cardiopulmonary resuscitation (CPR) was initiated by certified nursing staff, and Emergency Medical Services (EMS) were notified. However, the resident's advance directive status was inaccurately assessed by licensed nursing staff as Do Not Resuscitate (DNR) and CPR was stopped, prior to the arrival of EMS services and in absence of physician's orders [REDACTED]. The inaccurate Advance Directive status of DNR was obtained by licensed nursing staff from an incorrectly labeled form included in the Medication Administration Record (MAR) book. The DHS pronounced the resident's death at the facility on [DATE] at 7:09 a.m. at which time she notified the physician and fa… | 2020-09-01 |
| 2025 | 2025 | ORCHARD HEALTH AND REHABILITATION | 115522 | 1321 PULASKI SCHOOL ROAD | PULASKI | GA | 30451 | 2017-10-08 | 323 | J | 1 | 0 | UU0Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review, the facility failed to provide a secure environment for one resident (R) #1 of six residents sampled with a known history of elopement and elopement attempts. After a successful elopement from the facility on [DATE], the facility failed to address the resident's risks after the elopement, failed to assess for and evaluate those risks, and failed to implement interventions to reduce those risks. R#1 was able to successfully elope a second time and was found, deceased , four days after the elopement. The sample size was 6 residents. On [DATE] a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator, Director of Nursing (DON), and the Regional Vice President (RVP) were informed of the immediate jeopardy on [DATE] at 6:45 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on [DATE]. The immediate jeopardy continued through [DATE], and was removed on [DATE]. The facility implemented a Credible Allegation of Compliance related to the immediate jeopardy on [DATE]. The immediate jeopardy is outlined as follows: Resident #1 (R#1) was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident had a Brief Interview for Mental Status (BIMs) score of 6 indicating that the resident was severely cognitively impaired. The resident's functional status was documented that the resident's locomotion (walking) on the unit required supervision meaning oversight encouragement or cueing. Record review revealed that on [DATE], R#1 eloped from this facility and walked about one mile down the highway. The resident was found by staff and returned to the facility. Further record review revealed that after the re… | 2020-09-01 |
| 3483 | 3483 | LAUREL PARK AT HENRY MED CTR | 115673 | 1050 HOSPITAL DRIVE | STOCKBRIDGE | GA | 30281 | 2019-02-04 | 867 | J | 1 | 0 | HHND11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record reviews and policy review, the facility failed to utilize the Quality Assurance and Performance Improvement (QAPI) system to oversee the Advance Directive system, to ensure advance directive documentation was maintained and accurate in the clinical record, in an effort to prevent errors or delays in emergency basic life support measures. The facility had a census of 86 residents. An Abbreviated/Partial Extended Survey investigating complaints GA 836, GA 960, GA 577, GA 661 and GA 672 was initiated on (MONTH) 2, 2019 and concluded on (MONTH) 3, 2019. Complaints GA 836, GA 960, GA 577, and GA 661 were unsubstantiated. After review by the State Survey Agency, further investigation was needed for complaint GA 672, and a re-entry was initiated on (MONTH) 28, 2019 and concluded on (MONTH) 4, 2019. An additional complaint, GA 099 was also investigated. Complaint GA 672 was substantiated with deficiencies. Complaint GA 099 was partially substantiated with deficiencies. As indicated on the facility's Form CMS-672, Resident Census and Conditions of Resident Form, the facility's census on (MONTH) 3, 2019 was 83. On (MONTH) 29, 2019, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Administrator, Nurse Consultant UUU, and Area Vice President were informed of the Immediate Jeopardy on (MONTH) 29, 2019 at 4:15 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on (MONTH) 19, (YEAR). The Immediate Jeopardy continued through (MONTH) 29, 2019 and was removed on (MONTH) 30, 2019. The Immediate Jeopardy is outlined as follows: 1. Resident (R) #4 had not executed an Advance Directive. On (MONTH) 19, (YEAR), R#4 was found in bed, unresponsive, with no vital signs. The resident's Advance Directive status was… | 2020-09-01 |
| 1203 | 1203 | PRUITTHEALTH - MONROE | 115379 | 4796 HIGHWAY 42 NORTH | FORSYTH | GA | 31029 | 2019-09-16 | 684 | D | 1 | 0 | DP3B11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record reviews the facility failed to obtain medications in a timely manner for one resident (#2), and to administer medications as ordered for one resident (A) from a total sample of 12 residents. Findings include: 1. Resident (R) #2 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A review of Physicians Orders revealed the resident had medications that included [MEDICATION NAME] 5 milligrams (mg) once daily, [MEDICATION NAME] Extended two 100 mg capsules at bedtime, levetiracetam 1,000 mg twice daily, [MEDICATION NAME] 17 grams daily, and multivitamin with minerals once daily A review of the clinical record revealed that R#2 did not receive the [MEDICATION NAME] Extended on 1/27/19 at 9:00 p.m. as scheduled. A review of the (MONTH) 2019 Medication Administration History revealed that the medication was documented as not administered and drug/item unavailable. A nurse's note dated 1/28/19 at 1:51 a.m. documented that medications were not received from the pharmacy and that communication was sent to the pharmacy. The nurse note did not specify the type of communication sent to the pharmacy. A further review of the clinical record revealed that R#2 also did not receive the scheduled doses of [MEDICATION NAME], levetiracetam, [MEDICATION NAME], and multivitamin on 1/28/19 at 9:00 a.m., as ordered. A review of the (MONTH) 2019 Medication Administration History revealed that the medications were also charted as not administered and drug/item unavailable. During an interview on 9/16/19 at 2:10 p.m., the Administrator stated that the pharmacy sent out seven days worth of medications on 1/19/19, therefore the medications would have been out on 1/27/19 or 1/28/19. The pharmacy sent out an additional five days worth of medications on the night of 1/28/19. The facility maintained an Emergency Medication Kit. A review of the list of medications contained within the kit revealed that it included five doses of… | 2020-09-01 |
| 2471 | 2471 | RIVER TOWNE CENTER | 115566 | 5131 WARM SPRINGS RD | COLUMBUS | GA | 31909 | 2019-10-10 | 677 | D | 1 | 0 | PV5P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record reviews, the facility failed to ensure Activities of Daily Living (ADL) assistance was provided in a thorough manner for one of 15 residents (R#11) reviewed for ADL assistance. Findings include: R#11 had [DIAGNOSES REDACTED]. The resident was assessed on the 7/8/19 Quarterly Minimum Data Set (MDS) assessment has having communication and cognitive deficits and being dependent on nursing staff for ADL's including personal hygiene and bathing. A care plan, was in place, since at least 10/18/18, that included the resident had a self-care performance deficit in ADL's with an intervention for nursing staff to provide ADL assistance as needed and to anticipate and meet the resident's needs. However, the facility failed to ensure that the ADL's of personal hygiene and/or bathing were provided in a thorough manner. A review of nurses notes and respiratory notes revealed that on 7/6/19 R#11 was observed to have a fly flying around her face and additional insects on her neck, near her stoma and [MEDICAL CONDITION] site. The insects were removed and the physician was notified. The resident was removed from the room, showered, and reassessed to ensure no other insects were observed, then transferred to a different room. During an interview on 10/7/19 at 10:35 a.m. the Respiratory Therapy Director (RT) stated she was making her first rounds that morning on 7/6/19 and noted the gauze around R#11's [MEDICAL CONDITION] and stoma site was soiled, and as she was changing the gauze she noticed what looked like a maggot when she removed the gauze. RT stated that the resident had a large neck and extra tissue growth/flap near her stoma site, above it. LPN DD came into the room and assisted her to tilt the resident's head back, so she could then pulled up the skin and saw a few more of the insects. The RT Director stated that they had to hyper-extend the neck and separate the skin fold to see the additional insects. The RT director … | 2020-09-01 |
| 2472 | 2472 | RIVER TOWNE CENTER | 115566 | 5131 WARM SPRINGS RD | COLUMBUS | GA | 31909 | 2019-10-10 | 686 | E | 1 | 0 | PV5P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record reviews, the facility failed to ensure pressure ulcer treatments and/or assessments were provided and documented consistently for five of seven residents (R#10, R#9, R#2, R#13, and R#12) reviewed for pressure ulcers. Findings include: During an interview on 9/24/19 at 3:20 p.m., Treatment Nurse, Licensed Practical Nurse (LPN) FF stated the she started doing wound treatments at the facility at the end of (MONTH) and had provided treatments as ordered. She further stated that she had problems with documentation in the computer at times. When she provided a treatement, then would click off on it in the computer as being completed, the computer would spin and spin like it was taking a long time to accept/save, and that it happened often. LPN FF also stated that she had problems trying to input orders into the computer on her laptop and would usually have to use the computers at the nursing stations. LPN Treatment Nurse FF was not employed at the facility after 10/2/19. 1. Resident (R) #10 had [DIAGNOSES REDACTED]. In addition, an arterial doppler report, dated 7/6/19 documented moderate stenosis in the arterial system of the left lower extremity. The resident was assessed on the 7/22/19 Quarterly Minimum Data Set (MDS) assessment as having cognitive impairment, being nonambulatory, and ranging from needing extensive assistance to being dependent on nursing staff for Activities of Daily Living (ADL's). A care plan was in place, dated 8/20/19, that included that R#10 had the potential for skin impairment related to weakness and bowel and bladder incontinence with an intervention for nursing staff to monitor and document location, size, and treatment of [REDACTED]. However, nursing staff failed to monitor and document the location, size and treatment of [REDACTED]. R #10 had a pressure ulcer to the left hip that was initially assessed by the wound physician on 9/11/19. The initial assessment documented that the press… | 2020-09-01 |
| 2470 | 2470 | RIVER TOWNE CENTER | 115566 | 5131 WARM SPRINGS RD | COLUMBUS | GA | 31909 | 2019-10-10 | 656 | E | 1 | 0 | PV5P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record reviews, the facility failed to ensure pressure ulcer treatments and/or assessments were provided and documented consistently for four of seven residents (R#10, R#9, R#2 and R#14) and failed to ensure that Activities of Daily Living (ADL) assistance was provided in a thorough manner for one of 7 residents(R#11) reviewed for pressure ulcers. Findings include: During an interview on 9/24/19 at 3:20 p.m., Treatment Nurse, Licensed Practical Nurse (LPN) FF stated the she started doing wound treatments at the facility at the end of (MONTH) and had provided treatments as ordered. She further stated that she had problems with documentation in the computer at times. When she provided a treatement, then would click off on it in the computer as being completed, the computer would spin and spin like it was taking a long time to accept/save, and that it happened often. LPN FF also stated that she had problems trying to input orders into the computer on her laptop and would usually have to use the computers at the nursing stations. 1. Resident (R) #10 had [DIAGNOSES REDACTED]. In addition, an arterial doppler report, dated 7/6/19 documented moderate stenosis in the arterial system of the left lower extremity. A care plan was in place, dated 8/20/19, that included that R#10 had the potential for skin impairment related to weakness and bowel and bladder incontinence. The care plan included an intervention, also dated 8/20/19, for nursing staff to monitor and document location, size, and treatment of [REDACTED]. However, nursing staff failed to monitor and document the location, size and treatment of [REDACTED]. R #10 had a pressure ulcer to the left hip that was initially assessed by the wound Physician on 9/11/19. The initial assessment documented that the pressure ulcer was a stage 4 and measured 13.8 cm x 8cm x 0.1 centimeters (cm), with 100% thick adherent devitalized necrotic tissue. A review of the clinical record reve… | 2020-09-01 |
| 1432 | 1432 | PRUITTHEALTH - FORSYTH | 115418 | 521 CABINESS ROAD | FORSYTH | GA | 31029 | 2019-11-04 | 880 | E | 1 | 0 | C2JS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record reviews, the facility failed to maintain an infection control program that included thorough and complete surveillance for four residents (#12, #7, #11 and #8) of six residents treated with an antiparasitic medication between (MONTH) and (MONTH) 2019. Finding include: During an interview on 10/29/19 at 10:00 a.m. the Administrator confirmed that the facility had some residents who had experienced rashes and that the facility was thinking the cause was environmental. A review of the timeline of interventions implemented by the facility revealed that the following interventions had been implemented: 1)The concentration of detergent used in washing machine for laundry was decreased on 5/31/19 2) The washing machine was serviced to ensure proper chemical flushing on 5/31/19 3) Dermatologist consultations were obtained as ordered 4) Steroid medications were implemented as ordered 5) Body audits were completed on all residents on 9/15/19 6) Topical medication treatments were obtained as ordered 7) Ivermectin (antiparasitic) medication use was implemented as ordered 8) Deep cleaning of rooms as scheduled 9) Mattresses were inspected 10) Medications were reviewed verbally with the pharmacist the week of 10/14/19 11) [MEDICATION NAME] baby products including soap and lotion were added to the affected residents 12) Hospice Certified Nursing Assistants (CNA's) were asked not to bring in products 13) Ecolab was consulted for the use of any other available detergents A review of the pharmacy list of residents who were dispensed Ivermectin, an antiparasitic medication, for use, revealed five Residents (R) (#3, #10, #11, #12, and #7). A sixth resident, R#8, was also identified as receiving Ivermectin between (MONTH) 2019 and (MONTH) 2019. A review of the Line Listing for Infections, a part of the facility's Infection Control Program, revealed that R#3 and R#10 were included in the (MONTH) and (MONTH) line listings respective… | 2020-09-01 |
| 340 | 340 | SIGNATURE HEALTHCARE OF MARIETTA | 115206 | 811 KENNESAW AVENUE | MARIETTA | GA | 30060 | 2019-02-03 | 835 | J | 1 | 0 | JJVJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and review of clinical records it was determined that the Administration failed to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently to ensure each resident attained or maintained the highest possible level of physical, mental and psychological well-being. Resident #1 injured his finger on 12/27/18. The Administrator was unaware of the extent of the injury until 1/4/19. The facility census was 123. An abbreviated survey was initiated on 1/10/19 and concluded on 2/3/19 to investigate complaint number GA 960 to determine compliance with Federal and State Long Term Care Requirements, 42 CFR, Part 483, Subpart B, Requirements for Long Term Care Facility. The allegation of deficient practice related to resident neglect was substantiated. The following deficiencies were cited. The census on 2/3/19 was 126. A determination was made that a situation in which the facility's non-compliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. On 1/30/19 at 5:05 p.m. the facility's Administrator and the Director of Health Service (DHS), were informed of an Immediate Jeopardy (IJ). The non-compliance related to the Immediate Jeopardy was identified to have existed on 12/27/18. At the time of the exit on 2/3/19, the State Survey Agency had not received an acceptable Creditable Allegation of Compliance, therefore, the IJ was ongoing. The immediate jeopardy is outlined as follows: The IJ was determined to exist as of 12/27/18, when R#1 cut the tip of the left pinky finger with a fingernail clipper. Clinical staff treated and applied a self-adhering bandage/wrap to the finger. The resident was transferred to the hospital on [DATE] and diagnosed with [REDACTED].#1 being hospitalized , subsequently the affected area was surgically removed. Immediate Jeopardy was related to the facilit… | 2020-09-01 |
| 4998 | 4998 | UNIVERSITY NURSING & REHAB CTR | 115467 | 180 EPPS BRIDGE RD | ATHENS | GA | 30606 | 2016-02-03 | 309 | D | 1 | 0 | 1G5Q11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and the facility records, the facility failed to ensure that one (1) Licensed Practical Nurse (LL) dispense the correct medication to one (1) resident (K) of the sampled nineteen (19) residents. Findings include: Interview on 2/1/16 at 1:40 pm with Licensed Practical Nurse (LPN) LL revealed that she had gotten pain medication for another resident. She revealed that the resident's medication was 400 mg of [MEDICATION NAME]. She revealed that she put the resident's medication on resident K bedside table. She revealed that resident K was doing something in her room and then she came around her and picked up the other resident medication ( [MEDICATION NAME] 400 mg) . She revealed that she do not leave medication at the resident's bedside table. The nurse revealed that she was in a hurry and it was her fault, she checked the vital signs,and monitored the resident the rest of the shift. She revealed that resident K takes a lot of pain medication; but, she did not have any pain medication the rest of the shift. She revealed that she notified the resident's daughter, notified Medical Doctor. The nurse revealed that she has had in-services on medication dispensing. She revealed that she had medication in-services during orientation. Interview on 2/1/16 at 1:50 pm of resident K revealed the medication was sitting on the table. She revealed that the nurse left the soon because she had something to do. She revealed that she thought that the medication was hers, so she took it. She revealed that she did not get sick from the medication. She revealed that the staff took good care of her and continues to take good care of her. She revealed that the staff is good at the facility. She revealed that it was her fault that she took the wrong medication. Resident ambulating in room. Review of the In-service Summary and Attendance Record dated 11/26/15 indicated an in-service on the topic: Medication Administration & documentation of Med erro… | 2019-02-01 |
| 5153 | 5153 | DUNWOODY HEALTH AND REHABILITATION CENTER | 115270 | 5470 MERIDIAN MARK ROAD, BLDG E | ATLANTA | GA | 30342 | 2015-12-10 | 309 | D | 1 | 0 | SFD011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews, and record reviews the facility failed to administer five (5) doses of IV [MEDICATION NAME] as ordered by physician for one (1) resident BB out of a random sample of three (3) residents Findings include: Record review of record for resident BB is a [AGE] year old male admitted to Golden Living Center (GLC) on 09/18/15. Resident has a history of ,[MEDICAL CONDITION].-difficile ([MEDICAL CONDITION]) and acute osteo[DIAGNOSES REDACTED]. Resident BB has a double lumen PICC line in right upper extremity. He was admitted on intravenous (IV) [MEDICATION NAME] every day (QD). Record review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. 9/19/15. 9/20/15, 9/21/15, and 9/22/15. Record review of nurse's notes dated 09/19/15 at 12:30 p.m. revealed that the nurse spoke at length with resident's spouse concerning medication concerns as doses missed from hospital to here. Doctor notified of missed doses. Interview conducted with Licensed Practical Nurse CC on 12/10/15 at 1:00 p.m. who stated she recalled the wife of resident BB informing the staff of the five (5) missed doses of IV [MEDICATION NAME]. CC further stated upon reviewing the physician's orders [REDACTED]. Interview conducted on 12/10/15 at 1:20 p.m. with the Director of Nursing (DON) revealed she investigated the event and discovered the omissions were due a medication transcription error resulting in five (5) missed doses of IV [MEDICATION NAME]. The nursing staff were educated on the facility policy regarding proper medication administration and transcription procedures and a copy of this training has been placed in their individual Human Resources (HR) file. She further stated it is her expectation that each nursing staff member be aware of the policies as written and adhere to the policies in their daily practice. | 2018-12-01 |
| 2513 | 2513 | FULTON CENTER FOR REHABILITATION LLC | 115569 | 2850 SPRINGDALE ROAD SW | ATLANTA | GA | 30315 | 2018-09-27 | 580 | D | 1 | 0 | KB6111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews, clinical record review and review of facility policy, the facility failed to notify the required entities for one (1) of 21 sampled residents (R) (R#197). R#197's hospice provider was not notified after the resident had a change in condition. The findings included: Review of R#197's clinical record revealed an admission date of [DATE] with admitting [DIAGNOSES REDACTED]. Review of R#197's Admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 0 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the resident was severely cognitively impaired. According to the assessment, R#197's life expectancy was less than six months and she received hospice services. Review of R#197's Hospice care plan dated 6/9/18 revealed the following: Focus: admitted on hospice care due to [DIAGNOSES REDACTED]. Intervention: Assess for pain, restlessness, agitation, constipation and other symptoms of discomfort; medicate as ordered and evaluate effectiveness; bereavement service provided by hospice as needed to help with grief and loss; support to resident and family including caregivers and other residents; center staff will notify hospice of significant changes, clinical complications needing P[NAME] (plan of care) change; code status DNR (do not resuscitate); provide ADL (activities of daily living) support, companionship and other interventions as desired by resident; and provide resident with food and fluids as desired for physical and emotional support. Review of R#197's Risk Management System report dated 7/3/18 revealed the resident had a fall on this date; however, the time of the fall was not documented. Licensed Practical Nurse (LPN) JJ obtained the resident's vital signs post fall at 3:15 p.m. (Temperature - 98.6 degrees, Pulse - 91, Respirations - 20 and Blood pressure 151/74). The report noted the resident was transported to the hospital via ambulance at 10:30 p.m. The circumstances of… | 2020-09-01 |
| 2968 | 2968 | PRUITTHEALTH - FITZGERALD | 115617 | 185 BOWEN'S MILL HIGHWAY | FITZGERALD | GA | 31750 | 2019-07-03 | 600 | J | 1 | 0 | KWBX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews, medical record review, review of written statements, review of the facility policy titled, Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property review of the facility policy titled, Reporting Patient Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Property and review of the police report, it was determined that the facility failed to ensure that one of 14 residents (R#7) was free from sexual abuse, and the facility failed to provide protection for one of 14 residents (R#7) causing continued fear after an allegation of sexual abuse was made on 6/8/19. The facility census was 69 residents. On (MONTH) 25, 2019, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Administrator, Director of Health Services (DHS), Acting Assistant Director of Health Services (AADHS), the newly hired Assistant Director of Health Services (ADHS), and the Regional Vice President (VP) were informed of the Immediate Jeopardy on (MONTH) 25, 2019 at 5:25 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on (MONTH) 8, 2019. The Immediate Jeopardy continued through (MONTH) 27, 2019 and was removed on (MONTH) 28, 2019. The facility implemented a Removal Plan related to the Immediate Jeopardy on 6/27/19. The Immediate Jeopardy is outlined as follows: On (MONTH) 8, 2019 Resident (R) #6, a cognitively intact male, was observed by two Certified Nursing Assistants (CNA) in R#7's (a cognitively impaired female) room with his hand under R#7's covers, and was kissing the resident on her face. Per staff interviews, review of written statements and review of the police report, R#7 was fearful, crying and complained of pain to her perineal area. The two CNA's immediately report… | 2020-09-01 |
| 2969 | 2969 | PRUITTHEALTH - FITZGERALD | 115617 | 185 BOWEN'S MILL HIGHWAY | FITZGERALD | GA | 31750 | 2019-07-03 | 607 | J | 1 | 0 | KWBX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews, medical record review, review of written statements, review of the facility policy titled, Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation and review of the facility policy titled Abuse Prevention and Reporting and review of the facility policy titled, No Retaliation for Good Faith Reporting of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property it was determined that the facility failed to implement the protection and reporting component of their abuse policy when two LPN's failed to report an incident of sexual abuse for one of 14 residents (R#7) reviewed for abuse and the facility failed to provide protection for one of one residents ( R#7) after an allegation of sexual abuse was made on (MONTH) 8, 2019. The facility census was 69 residents. On (MONTH) 25, 2019, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Administrator, Director of Health Services (DHS), Acting Assistant Director of Health Services (AADHS), the newly hired Assistant Director of Health Services (ADHS), and the Regional Vice President (VP) were informed of the Immediate Jeopardy on (MONTH) 25, 2019 at 5:25 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on (MONTH) 8, 2019. The Immediate Jeopardy continued through (MONTH) 27, 2019 and was removed on (MONTH) 28, 2019. The facility implemented a Removal Plan related to the Immediate Jeopardy on 6/27/19. The Immediate Jeopardy is outlined as follows: On (MONTH) 8, 2019 Resident (R) #6, a cognitively intact male, was observed by two Certified Nursing Assistants (CNA) in R#7's (a cognitively impaired female) room with his hand under R#7's covers, and was kissing the resident on her face. Per staff interviews, … | 2020-09-01 |
| 344 | 344 | SIGNATURE HEALTHCARE OF MARIETTA | 115206 | 811 KENNESAW AVENUE | MARIETTA | GA | 30060 | 2019-11-14 | 658 | D | 1 | 0 | VEPN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews, observations, record review, review of facility policy titled Medication Administration and review of the Georgia Nurse Practice Act (chapter 410-10), the facility failed to provide supervision with the administration of medications for one of five sampled residents (R) (#10). Findings include: The Practice of Nursing includes, but is not limited to, provision of nursing care; administration, supervision, evaluation, or any combination thereof, of nursing practice; teaching; counseling; the administration of medications and treatments as prescribed by a physician [MEDICATION NAME] medicine in accordance with Article 2 of Chapter 34 of this title. Guideline #20 of the facility's Administering Medications General Guidelines policy documented the resident is always observed after administration to ensure that the dose was completely ingested. Review of the clinical record revealed R#10 has [DIAGNOSES REDACTED]. R#10 is his own responsible party. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed R#10 with a Brief Interview for Mental Status (BIMS) score of 15, indicating cognition intact. A Physician's Note dated 10/15/19 revealed R#10 with intermittent confusion, staff documented that he gets belligerent and aggressive at times. He is a bit demanding about his medications. During an interview on 10/29/19 at 7:30 a.m., R#10 revealed Licensed Practical Nurse (LPN) QQ gave him all his morning medication at 6:00 a.m. He then opened the drawer to his bedside table and produced a clear dosage cup, containing 10 pills. R#10 stated LPN QQ left the pills for him to take later. During an interview on 10/29/19 at 7:42 a.m., LPN QQ stated R#10 is medication seeking and she did not leave any pills with him. LPN QQ went to R#10's room and R#10 stated he had taken the pills because he didn't want anyone to take them from him. He then reached underneath his bed covers and produced the cup of medication. He also reached… | 2020-09-01 |
Advanced export
JSON shape: default, array, newline-delimited
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 );