cms_GA
Data source: Big Local News · About: big-local-datasette
10,655 rows sorted by scope_severity
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 52 | 52 | BELL MINOR HOME, THE | 115020 | 2200 OLD HAMILTON PLACE NE | GAINESVILLE | GA | 30507 | 2018-12-06 | 641 | B | 0 | 1 | Q9R911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately reflect the number of falls since admission/entry or prior assessment on the Minimum Data Set (MDS) at the time of the assessment of one Resident (R) (#35) out of thirty-four (34) sampled residents. Findings include: Interview with R #35 on 12/03/18 3:44 p.m. in his room revealed that he fell about three months ago and cracked a bone. Review of the Progress Notes dated 6/24/18 revealed that R #35 was heard yelling out I need help at 2:00 a.m. The aide arrived first in the room and alerted nurse that he was sitting on the floor. Nurse noted resident to be sitting on bottom with legs stretched out apart from each other. Resident stated that he rolled out of bed. Wheelchair noted to be rolled away from resident with brakes unlocked. Medical Doctor (MD) notified and family notified. Review of the Quarterly Minimum Data Set (MDS) for R #35 dated 7/10/18 revealed in Section: A- Re-entry from acute hospital on [DATE] C- Brief Interview Mental Status (BIMS)-14 cognitively intact J- No falls Review of the Quarterly MDS Assessment for R #35 dated 10/5/18 revealed in Section: A- Reentry 7/3/18 from an acute hospital. C-BIMS- 15 cognitively intact J- No falls Interview with the current MDS Coordinators (II and JJ) in the conference room on 12/06/18 at 4:00 p.m. revealed there was no reference to R #35's falls on the (MONTH) 10, (YEAR) or (MONTH) 5, (YEAR) MDS assessments. They stated that they were aware that R #35 had fallen as a Care Plan for his falls was written. They stated that a correction would be made to the MDS. | 2020-09-01 |
| 136 | 136 | MAGNOLIA MANOR OF COLUMBUS NURSING CENTER - WEST | 115045 | 2000 WARM SPRINGS RD | COLUMBUS | GA | 31904 | 2019-10-31 | 641 | B | 0 | 1 | OMYR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment for hospice for three resident's (R) R#75, R#43, and R#114 of 16 hospice residents. Findings include: 1. Record review revealed that R#75 was admitted to the facility on [DATE] on Hospice. Review of the Quarterly MDS assessment dated [DATE] for Section O: Special treatments and Programs revealed that Hospice was not triggered for R#75. Record review of the facility care plan for R#75 with an onset date of 3/29/19 with a problem area of hospice due to [MEDICAL CONDITIONS] and nutritional marasmus. Approaches: Coordinate care with hospice team, coordinate care with hospice to assure the resident has little pain as possible, provide resident and family with grief and spiritual counseling if desired, hospice to visit as ordered/indicated. Review of the hospice care plan from the hospice company dated 9/19/19 revealed R#75 had a current care plan with hospice. 2. Review of the medical record revealed that R#43 was admitted to the facility on [DATE] and was a hospice resident. Review of the Annual MDS dated [DATE] and the Quarterly MDS assessment dated [DATE] revealed that on Section O, the resident was not triggered for receiving hospice. Review of the facility care plan dated with a problem onset of 6/22/19 revealed R#43 was on hospice due to a terminal [DIAGNOSES REDACTED]. 3. Record review revealed that R#114 resident is a hospice resident. Review of the Re-Admission MDS assessment dated [DATE] revealed R#114 was readmitted to the facility and continued on hospice although hospice did not trigger on the re-admission MDS assessment. Review of the facility care plan with a problem onset of 10/18/19 revealed the resident was admitted to the facility on hospice. Coordination of care for the facility and hospice were in place on the care plan. An interview on 10/31/19 at 5:23 p.m. with Registered Nurse (RN/MDS) DD stated there is… | 2020-09-01 |
| 191 | 191 | SIGNATURE HEALTHCARE OF BUCKHEAD | 115110 | 54 PEACHTREE PARK DRIVE N.E. | ATLANTA | GA | 30309 | 2019-08-01 | 640 | B | 0 | 1 | FRPF11 | Based on record review and staff interview, the facility failed to ensure that a discharge Minimum Data Set (MDS) assessment was transmitted within 14 days of discharge to the Centers for Medicare and Medicaid Services (CMS) Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) System for four of seven discharged residents (R) reviewed (#1, #3, #4, and #6). Findings include: 1. Review of the discharge record revealed R#1 was discharged from the facility on 3/22/19. Review of R#1's MDS list revealed there was an Admission assessment completed on 2/15/19, and the MDS discharge assessment was not completed until 6/12/19. 2. Review of the discharge record revealed R#3 was discharged from the facility on 2/20/19. Review of R#3's MDS list revealed there was an Admission assessment completed on 2/13/19, but there was no MDS discharge assessment listed. 3. Review of the discharge record revealed R#4 was discharged from the facility on 4/15/19. Review of R#4's MDS list revealed there was an Admission assessment completed on 2/7/19, but there was no MDS discharge assessment listed. 4. Review of the discharge record revealed R#6 was discharged from the facility on 4/26/19. Review of R#6's MDS list revealed there was an Admission assessment completed on 3/23/19, but there was no MDS discharge assessment listed. During an interview on 8/1/19 at 1:45 p.m. MDS Coordinator Licensed Practical Nurse JJ revealed that she left in (MONTH) of (YEAR) and assessments were current. She stated when she returned in (MONTH) of 2019, the assessments were behind. The four late discharge assessments were completed on 8/1/19. | 2020-09-01 |
| 205 | 205 | SIGNATURE HEALTHCARE AT TOWER ROAD | 115115 | 26 TOWER RD | MARIETTA | GA | 30060 | 2018-02-22 | 582 | B | 0 | 1 | HW6Q11 | [NAME] Tracy Based on record review and staff interview the facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) to two (2) residents (R) #20 and (R) [NAME] of three (3) residents or their responsible party's for two of three residents (R) reviewed (#34 and #46), who were discharged off Medicare Part A services and remained in the facility. Findings include: Review of a Beneficiary Notice-Residents discharged Within the Last Six Months form provided by the facility revealed in the clinical record for R#20 the resident started to receive physical therapy and occupational therapy services on 12/6/17 and these services ended on 12/26/17 with benefit days remaining. Review of the clinical records for (R) [NAME] revealed the resident started to receive physical therapy and occupational therapy services on 12/15/17 and these services ended on 1/8/18 with benefit days remaining. During an interview with Social Worker, AA on 2/21/18 at 2:56 p.m she stated she did not issue a SNFABN to (R)E or R#20. She also stated she did not know that a SNFABN had to be issued to residents who did not exhaust their coverage days of skilled services and who remained in the facility. | 2020-09-01 |
| 208 | 208 | SIGNATURE HEALTHCARE OF SAVANNAH | 115120 | 815 EAST 63 STREET | SAVANNAH | GA | 31405 | 2018-06-07 | 567 | B | 0 | 1 | 3B0P11 | Based on observation, record review, resident (R) and staff interviews, the facility failed to have petty cash available for resident withdrawal after posted banking hours from 9:00 a.m. to 8:00 p.m. on weekdays, and 9:00 a.m. to 7:00 p.m. on weekends. The facility handled a total of 73 resident trust fund accounts. Findings include: 1. During interview with the Business Office Manager (BOM) on 6/7/18 at 8:31 a.m., she stated that if a resident wanted to withdraw $50.00 or less from their trust fund account, they obtained this from the receptionist. She further stated that the receptionist was there from 8:00 a.m. to 8:00 p.m. seven days a week. The BOM stated during further interview that if a resident let her know in advance that they wanted to withdraw money outside of these times that she would arrange to leave it with the nurse, but that the facility did not routinely keep petty cash with the nurses at night. During interview with receptionist KK on 6/7/18 at 8:36 a.m., she stated that she worked 8:00 a.m. to 4:00 p.m., and another receptionist came in to work from 4:00 p.m. until 8:00 p.m. She further stated that there was a receptionist during these times seven days a week. Receptionist KK stated during continued interview that if a resident wanted their money after 8:00 p.m., that the receptionist was gone for the day, and the resident would not have access to their money. Observation at this time revealed a laminated sign taped to the ledge of the receptionist window that noted: BANKING HOURS MONDAY-FRIDAY 9AM-8PM SATURDAY-SUNDAY 9AM-7PM During interview with R P on 6/7/18 at 8:52 a.m., he stated that he had not tried, but was told in the Resident Council meeting that it was impossible to get money out of his account after the receptionist left at night. During interview with R R on 6/7/18, she stated that she had not needed to, but knew that she could not get money out of her account at night. During interview with R Q on 6/7/18 at 9:04 a.m., he stated that he attempted once on a weekend after the recep… | 2020-09-01 |
| 209 | 209 | SIGNATURE HEALTHCARE OF SAVANNAH | 115120 | 815 EAST 63 STREET | SAVANNAH | GA | 31405 | 2018-06-07 | 582 | B | 0 | 1 | 3B0P11 | Based on record review and staff interview, the facility failed to issue the Notice of Medicare Non-Coverage (NOMNC) to two residents (R) discharged off Medicare Part A services (R #35 and R #101), and failed to mail a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) to the responsible party for completion for one resident (R #35). Three residents were reviewed for provision of the proper notices. Findings include: Review of the Beneficiary Notice-Residents discharged Within the Last Six Months form completed by the facility revealed that R #101's last covered day of Part A Services was 5/21/18, she remained in the facility, and did not use all of her benefit days. Review of the beneficiary notices revealed the only notice completed was the SNFABN. Review of the Beneficiary Notice-Residents discharged Within the Last Six Months form revealed that R #35's last covered day was 4/7/18, she did not exhaust all of her benefit days, and she remained in the facility. Review of the beneficiary notices revealed that the only notice provided was the SNFABN, and the section on the form to indicate whether or not the resident or responsible party wanted to continue skilled services was blank. During interview with the Social Services Director (SSD) on 6/6/18 at 3:09 p.m., she stated that when she took over issuing the beneficiary notices a few months ago, that she was told to discard all notice forms except the SNFABN, and the CMS (Centers for Medicare and Medicaid Services)-R-131 form for residents on Part B services. She stated during further interview that one of the forms she was told not to use anymore was the NOMNC, so she had not been issuing one for any resident coming off skilled services. She further stated that when she was not able to contact a responsible party in person or by phone to explain the resident's right to appeal and continue skilled services, that she did not mail the form to them, nor request the form be completed and returned to her. | 2020-09-01 |
| 280 | 280 | NEWNAN HEALTH AND REHABILITATION | 115138 | 244 EAST BROAD STREET | NEWNAN | GA | 30263 | 2019-07-11 | 732 | B | 0 | 1 | 8NL611 | Based on observation and staff interviews, the facility failed to assure the nurse staffing information form was fully completed for four of four days during the survey. Findings include: During observation on 7/9/19 at 8:13 a.m. the daily staffing was posted but missing the facility name. During an interview with the Director of Nursing (DON) on 7/11/19 at 8:49 a.m. it was reported that night supervisor is responsible for completing daily staffing form and a copy is left for her to post each day. During an interview with the Administrator on 7/11/19 at 10:26 a.m. who confirmed that the posted staffing information did not have the facility name on it. The Administrator reported that it had not been noticed that the facility name was not on the form. | 2020-09-01 |
| 309 | 309 | ORCHARD VIEW REHABILITATION & SKILLED NURSING CTR | 115146 | 8414 WHITESVILLE ROAD | COLUMBUS | GA | 31907 | 2018-02-08 | 582 | B | 0 | 1 | I6B011 | Based on record review and staff interview, the facility failed to provide evidence that the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) was issued for two of three residents (R) reviewed (R #73 and #166), who were discharged off Medicare Part A services and remained in the facility. The sample size was 38 residents. Findings include: Review of a SNF (Skilled Nursing Facility) Beneficiary Protection Notification Review (Form CMS- ) revealed that R #73 was discharged off Part A services on 12/7/17, with 69 benefit days remaining. Review of a Beneficiary Notice-Residents discharged Within the Last Six Months form revealed that she remained in the facility after skilled services ended. Review of her Beneficiary Notices revealed that only the Notice of Medicare Non-Coverage form (NOMNC)(Form CMS- ) was provided, which was signed by the responsible party (RP) on 12/4/17. Review of the Form CMS- revealed that R #166 was discharged off Part A services on 1/12/18, with 55 benefit days remaining. Review of a Beneficiary Notice-Residents discharged Within the Last Six Months form revealed that he remained in the facility after skilled services ended. Review of his Beneficiary Notices revealed that only the NOMNC was provided, which was signed by the resident on 1/8/18. During interview with Bookkeeper KK on 2/7/18 at 2:31 p.m., she stated that none of the residents that remained in the facility after Part A services ended were issued a SNFABN. During interview with Social Worker (SW) JJ on 2/8/18 at 9:07 a.m., she stated that she did not see a SNFABN in R #73's file since (YEAR). She stated during further interview that she was sure she issued it, but could not find documentation that a SNFABN was provided for R #166 for his services ending on 1/12/18. SW JJ further stated that all residents coming off Part A were issued a NOMNC two days prior to termination of services, and that the case worker assigned to a particular unit also issued the SNFABN if the resident remained in the building. She further state… | 2020-09-01 |
| 393 | 393 | CALHOUN NURSING HOME | 115264 | 265 TURNER STREET | EDISON | GA | 39846 | 2016-08-11 | 356 | B | 0 | 1 | 7CY211 | Based on observation and interview the facility failed to display the actual hours worked by the nursing staff. The facility census was fifty-seven (57) residents. Findings Include: During an observation on 8/11/15 at 4:00 p.m. the staffing form was posted. However, it did not document actual hours worked for nursing staff. An interview with the Director of Nursing on 8/11/16 at 4:08 p.m. confirmed the actual hours worked by the nursing staff was not posted correctly. | 2020-09-01 |
| 452 | 452 | DUNWOODY HEALTH AND REHABILITATION CENTER | 115270 | 5470 MERIDIAN MARK ROAD, BLDG E | ATLANTA | GA | 30342 | 2017-10-05 | 278 | B | 0 | 1 | 957M11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, hospice and facility staff interview, the facility failed to accurately code the Minimum Data Set (MDS) assessment for hospice services for one resident (R) #197, and for Level II PASRR (Preadmission Screening and Resident Review) for one resident #182. The sample size was 33 residents. Findings include: 1. Review of R #197's insurance information revealed that her primary payer source was hospice since 1/28/17. Review of the physician's orders [REDACTED]. Review of her significant change MDS dated [DATE], and the quarterly MDS dated [DATE] was not coded as receiving hospice services. During interview with Licensed Practical Nurse (LPN) Unit Manager PP on 10/3/17 at 4:37 p.m. she stated that R #197 was receiving hospice services. During interview 10/5/17 at 10:23 a.m.with Registered Nurse (RN) RR the Hospice Case Manager stated, R #197 was on hospice services for [MEDICAL CONDITION]. During interview with the MDS Director on 10/5/17 at 6:06 p.m. she verified that R #197 was not coded as receiving hospice services on the significant change assessment dated [DATE] or the quarterly MDS dated [DATE] and that it was an error. Review of R#181's clinical records noted upon admission to the facility on [DATE] the residents [DIAGNOSES REDACTED]. Review of the Level II PASRR Outcome Notification dated 11/19/15 revealed a PASRR level II review was completed for R#181 to determine whether nursing facility placement was appropriate and to determine what mental illness/intellectual disability services the resident would need, including what services could be provide by the facility, and what specialized services should be arranged for through another entity. Review of the significant change (MDS) completed with a reference date of 5/7/17 documented in Section A1500 - Preadmission Screening and Resident Review (PASRR) noted R#118 had not been evaluated by Level II PASRR and found to have a serious mental illness. | 2020-09-01 |
| 532 | 532 | PRUITTHEALTH - MARIETTA | 115276 | 70 SAINE DRIVE SW | MARIETTA | GA | 30008 | 2019-07-24 | 577 | B | 1 | 1 | I5PG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and staff interview, it was revealed that the facility failed to post notice of the availability of state survey results in prominent places in the facility. Findings include: During a group interview with members of the resident council on 7/23/19 at 10:10 a.m., it was revealed that few members of the resident council knew of the whereabouts of the state survey results and how they could access them. One resident said he believed they were to be found in the lobby area, but could not be sure of the exact location. An observation on 7/23/19 at 12:30 p.m. of the lobby area of the facility accompanied by the Regional Nurse Consultant, revealed a cherry wood cabinet attached to the wall at the left of the main entrance. A green sign attached to the closed door of the cabinet read: Please drop kudo cards here; please deposit payments here; please place [MEDICATION NAME] contact cards here. Inside the cabinet, once the doors were opened, was a binder labeled: Results of Past 3 Surveys; (MONTH) 27, (YEAR), (MONTH) 30, (YEAR), (MONTH) 12, (YEAR). During an interview with the Regional Nurse Consultant at the time of this observation, she revealed that the residents are supposed to be educated on the availability of the survey results and where to find them. She agreed that there was no indication in the area as to where the survey results were kept and that visitors/families/residents would not necessarily know the results were available in the cabinet when the door was closed. An observation of the lobby area on 7/23/19 at 4:29 p.m. revealed a new sign had been placed on the closed door of the cabinet containing the survey results. The new sign stated: Survey Results. During an interview on 7/24/19 at 2:57 p.m. with the Activity Director (AD) it was revealed that she usually educates the residents and family members after surveys that state survey results are available, and that they are entitled to see new results after they … | 2020-09-01 |
| 536 | 536 | PRUITTHEALTH - MARIETTA | 115276 | 70 SAINE DRIVE SW | MARIETTA | GA | 30008 | 2019-07-24 | 732 | B | 1 | 1 | I5PG11 | > Based on observation and staff interview, the facility failed to post the nurse staffing information on one of four days of the survey. The facility census was 106. Findings include: During an observation on 7/21/19 at 11:06 a.m. it was revealed that the posted nurse staffing information displayed in a glass at the front of the first floor of the facility carried the date of 7/20/19. During random observations of the posted nurse staffing information on 7/21/19 between 11:06 a.m. and 5:30 p.m., it was revealed that the information displayed was from 7/20/19 - the previous day's numbers. During an interview with the administrator on 7/22/19 at 9:48 a.m., it was revealed that the posting of the daily staffing is the responsibility of the weekend nursing supervisor. The administrator said that the weekend nursing supervisor did not come in to work on 7/21/19. Thus, the staffing for 7/21/19 was completed but not posted, and senior staff were distracted with the survey and overlooked posting the information later in the day. | 2020-09-01 |
| 584 | 584 | CHULIO HILLS HEALTH AND REHAB | 115287 | 1170 CHULIO ROAD | ROME | GA | 30161 | 2018-08-02 | 640 | B | 0 | 1 | QK7911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to transmit Minimum Data Set (MDS) assessments within 14 days after completion for 3 discharged residents (R) (R#1, R#2, and R#3). The sample size was 43 residents. During an interview on [DATE] at 4:45 p.m. with the MDS Coordinator, she stated she did not transmit the discharges on [DATE] for R#1 who died in the facility, [DATE] for R#2 who was discharged to the community, and on [DATE] for R#3 who was discharged to another facility. Review of the MDS, on the computer during the time of the interview, for each resident with the MDS Coordinator revealed that all three assessments stated they had been completed. When asked why other assessments stated received, the MDS Coordinator stated that once the assessment has been transmitted and is received by the State then it will change from completed to received, and she did not transmit these three discharges and stated, Just to be honest, I don't know why.) | 2020-09-01 |
| 585 | 585 | CHULIO HILLS HEALTH AND REHAB | 115287 | 1170 CHULIO ROAD | ROME | GA | 30161 | 2018-08-02 | 641 | B | 0 | 1 | QK7911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews and facility data, the facility failed to ensure that Minimum Data Set (MDS) assessments for four (4) residents were accurate, for the following: a facility acquired pressure ulcer status for two (2) residents, Resident (R) R#21 and R#60, the Hospice care status for two (2) residents, R#53 and R#87, and the hydration status for one (1) resident, R#87. The resident sample size was 43. The facility census was 89. 1. Review of R #87's Quarterly Minimum Data Set ((MDS) dated [DATE], and his Annual MDS dated [DATE], revealed that he had a [DIAGNOSES REDACTED].#87 was checked as having the condition of dehydration. During interview with the MDS Coordinator on 7/30/18 at 2:45 p.m., she stated that R#87 was in the hospital in January, and had a [DIAGNOSES REDACTED]. She stated during further interview that the dehydration was not a problem when his (MONTH) and (MONTH) MDSs were done, and that she should have removed that [DIAGNOSES REDACTED]. 2. Review of R#21's Significant Change MDS dated [DATE], and her Quarterly MDS dated [DATE], revealed that she had a Stage 2 pressure ulcer. Review of the CMS-802 dated 7/30/18 revealed that R#21 currently had a facility-acquired pressure ulcer. Review of a Pressure Wounds report dated 7/30/18 revealed that R#21 was not on this list as currently having a pressure ulcer. During interview with the the MDS Coordinator on 7/30/18 at 2:45 p.m., she verified that she had coded R#21 as having a Stage 2 pressure ulcer on the (MONTH) and (MONTH) MDSs. Review of a Daily/Weekly Ulcer Note dated 11/25/17 revealed that treatment was initiated to a Stage 2 pressure ulcer to R#21's right heel. Review of a Daily/Weekly Ulcer Note dated 12/15/17 revealed that this wound had resolved. This was verified during interview with Registered Nurse (RN) AA on 7/30/18 at 4:15 p.m., who stated that R#21 did not currently have a wound. 3. Review of R#21's Quarterly MDS dated [DATE], and the CMS-802 dated 7… | 2020-09-01 |
| 649 | 649 | ZEBULON PARK HEALTH AND REHABILITATION | 115295 | 343 PLANTATION WAY | MACON | GA | 31210 | 2018-07-19 | 582 | B | 0 | 1 | 855W11 | Based on record review and staff interview, the facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) to the resident or responsible party upon discharge from Medicare Part A services to indicate that they understood the contents of the form for two of three residents (R) reviewed (#9 and #45). Findings include: Review of a Beneficiary Notice-Residents discharged Within the Last Six Months form, provided by the facility, revealed that R #9 was discharged off Medicare Part A skilled services on 5/25/18 and remained in the facility afterwards with benefit days remaining. Further review of this form revealed that R #45 was discharged off skilled services on 6/25/18, and remained in the facility with benefit days remaining. There was no evidence provided that the SNFABN was provided to either R#9 or R#45. During interview on 7/18/18 at 3:01 p.m. with Case Manager it was reported that if she notifies the family member via telephone she does not typically send a letter. Case Manager further reported that the SNFABN is typically provided to residents who discharge to home in the event they decide to stay an extra day in the facility. However, the SNFABN has not been provided to residents remaining in the facility that were going to be long term. Case Manager confirmed that she did not provide SNFABN forms for R#9 and R#45. | 2020-09-01 |
| 678 | 678 | PRUITTHEALTH - BROOKHAVEN | 115313 | 3535 ASHTON WOODS DRIVE NE | ATLANTA | GA | 30319 | 2018-02-08 | 582 | B | 0 | 1 | 7TEM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to provide the Advanced Beneficiary Notice (ABN) to one, Resident (R)#253, of three records reviewed for those residents who were discharged from Medicare services with Medicare days remaining. Findings include: Review of the admission Minimum Data Set (MDS), section A1600, dated 8/16/17, for R#253 revealed he was admitted to the facility on [DATE]. Review of facility records reveal R#253 was provided with a Notice of Medicare Non- Coverage (NOMNC) on 8/28/17. This allowed him to an expedited review of a service termination if chose to appeal the termination. This does not fulfill the facility's obligation to advise the resident of potential liability for payment. He remained in the facility for long term care services. He was not provided with the ABN to inform him of the ending of skilled services that may not be paid for by Medicare so that he could assume financial responsibility if he wanted to continue those services. On 2/6/18 at 1:30 p.m. during an interview with R#253, he stated his family member told him his therapy ended because Medicare would no longer pay for it. He reported he was not given the option to continue his therapy and pay for it himself and had not been told how much it would cost if he chose to continue therapy. On 2/6/18 at 2:15 p.m., interview with the Administrator and the Business Office Manager (BOM) in the Administrator's office, they both confirmed R#253 was not provided with the ABN. The BOM stated she was not aware she was required to issue both the NOMNC and the ABN when a resident remained in the facility. On 2/7/18 review of facility policy Advance Beneficiary Notices (ABNs), effective (MONTH) 2009 and most recently revised 7/19/16, in section titled Procedure Number 3 states, A copy of the Advance Beneficiary Notice will be provided to the patient/resident for his/her records and a copy will be maintained in the patient/resident's record. The facil… | 2020-09-01 |
| 690 | 690 | PRUITTHEALTH - AUSTELL | 115314 | 1700 MULKEY RD | AUSTELL | GA | 30106 | 2018-03-22 | 655 | B | 0 | 1 | 7J3111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide the resident and their representative with a summary of the baseline care plan, which would include goals of the resident, medications, and dietary instructions, services and treatments administered by the facility. In addition, the baseline care plan would include the facility's personnel and updated information based on the details of the comprehensive care plan as necessary for two (Residents (R) #50 and R#175) of six residents who were new admissions and reviewed for compliance with baseline care plan requirements. The total sample was 23 residents. Findings include: 1. Review of the face sheet in the medical record for R#50 revealed the resident was admitted to the facility on [DATE]. A review of the Baseline Care Plan revealed it was not dated when it was initiated. The last page of the baseline care plan contains a section that stated, Post Admission Care Conference/Initial Care Plan Meeting Date: ______________, was blank and contained no date to verify that the post-admission care conference had been completed with the resident and his responsible party. The next area on the Baseline Care Plan had spaces to check what had been completed: Baseline Care Plan and Admission Physician order [REDACTED]. The last area had a section titled Attendees: _____ This area contained the signature of one staff member. R#50 nor his responsible party signed as attended. The Registered Nurse signature at the bottom of the page was dated 2/27/18. During an interview with the Administrator on 3/22/18 at 11:45 a.m. in the conference room, he stated the Nurse Navigator who is responsible for scheduling the post admission care conferences left the facility in January. He stated a new person assumed the position (MONTH) 15, (YEAR). He also stated the Director of Health Services (DHS) was responsible for completing those duties in the time that no one filled the position of Nurse Navigator. … | 2020-09-01 |
| 812 | 812 | UNIVERSITY EXTENDED CARE/WESTW | 115336 | 561 UNIVERSITY DRIVE | EVANS | GA | 30809 | 2018-03-23 | 640 | B | 0 | 1 | YGXR11 | Based on record review and staff interview, the facility failed to ensure that Minimum Data Set (MDS) assessments were transmitted within 14 days of completion to CMS's (Centers for Medicare and Medicaid Services) Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) system for two residents (R) (R#2 and R#3). The sample size was 39 residents. Findings include: 1. Review of a listing of R#2's completed and transmitted MDS revealed that a Quarterly MDS with an Assessment Reference Date (ARD) of 10/8/17 was the last MDS transmitted for her. Review of the MDS Transmission Results Summary provided by the Regional MDS Coordinator revealed Target Date 1/7/18 and the assessment was rejected. 2. Review of a listing of R#3's completed and transmitted MDS revealed that a Quarterly MDS with an Assessment Reference Date (ARD) of 10/16/17 was the last MDS transmitted for her. Review of the MDS Transmission Results Summary revealed Target Date 1/15/18 and the assessment was rejected. Interview on 3/21/18 at 3:15 p.m. with the Regional MDS Coordinator revealed the Quarterly Assessments for R#2 and R#3 were completed and submitted timely, however, they were rejected and required correction. She stated that they were never re-submitted and she does not know why. The Regional MDS Coordinator stated that the person that submitted the assessments no longer works in the facility and she is not aware of any reports or programs in the facility to monitor missing or late assessments. She stated when they receive notice that an assessment was rejected they typically make the correction right then and re-submit the assessment. | 2020-09-01 |
| 881 | 881 | PRUITTHEALTH - TOCCOA | 115345 | 633 FALLS ROAD | TOCCOA | GA | 30577 | 2017-03-30 | 465 | B | 0 | 1 | K22H11 | Based on observation, interview, and review of facility policy, it was determined the facility failed to develop a system to ensure the smoking aprons for eight smokers were properly sanitized. The facility stored the residents' smoking aprons in the soiled utility room, and was unable to identify a system to ensure the common use smoking aprons were thoroughly cleaned after daily use. Findings include: Observation on 3/29/17 at 9:03 a.m. revealed six residents in the outside smoking area supervised by an activities staff member. Four of the six residents were wearing a smoking apron. Further observation revealed 12 smoking aprons stored in the facility soiled utility room next to the nursing station between the Blue and Magnolia Units. The smoking aprons were gray in color with stains and the neck and waist straps were white in color but dirty. One smoking apron was missing the neck straps; another smoking apron was missing the waist straps; and another smoking apron was completely frayed around the edges of the neck collar. Two smoking aprons were on the floor by the mop bucket. Interview with the Licensed Practical Nurse (LPN) Supervisor AA on Magnolia Unit at 3/29/17 at 11:30 a.m. revealed the smoking aprons were stored at one time in the medication and room folded up. It was decided this was not good since the folding would cause the aprons to crease and crack. Storage was then switched to the dirty utility room so the aprons could be hung up. Aprons are not assigned to the smoking residents. She had no idea why it was decided to store the apron in the soiled utility room. Supervisor AA further stated she did not know how often or when the smoking aprons were cleaned. On 3/29/17 at 11:50 a.m. interview with the Assistant Director of Health Services (ADHS) at the nurses' station between the Blue Unit and Magnolia Unit revealed she has worked at the facility for seven months and did not know anything about cleaning the aprons or why they are stored in the soiled utility room. The ADHS stated she would find out… | 2020-09-01 |
| 904 | 904 | BOLINGREEN HEALTH AND REHABILITATION | 115346 | 529 BOLINGREEN DRIVE | MACON | GA | 31210 | 2020-01-09 | 732 | B | 0 | 1 | TXH811 | Based on observation and staff interview, the facility failed to post the nurse staffing information daily for two of four days. The facility census was 107. Findings include: During an observation on 1/6/2020 at 10:16 a.m., the posted nurse staffing information displayed in a glass at the front of the first floor of the facility carried the date of 1/2/2020. During random observations of the posted nurse staffing information on 1/6/2020 between 11:26 a.m. and 3:30 p.m., the information displayed was from 1/2/2020, which was the past weekend numbers. During an observation on 1/7/2020 at 11:11 a.m., the posted nurse staffing information displayed in a glass at the front of the first floor of the facility carried the date of 1/6/2020. During an interview on 1/7/2020 at 11:48 a.m., the administrator in training revealed that the posting of the daily staffing is the responsibility of the staffing coordinator. She stated she's aware the information posted is reflective of the previous day. The administrator said that the staffing coordinator did not come into work on 1/6/2020. Thus, the staffing for 1/6/2020 was completed but not posted. He reported the facility does not have a policy to support the expectations related to daily staffing post. During an interview on 1/9/2020 at 9:10 a.m. the Staffing Coordinator revealed he's responsible for posting the nurse staffing on a daily basis. He confirmed that the information displayed on 1/6/2020 reflected staffing for 1/2/2020 because he was out of the office on vacation. | 2020-09-01 |
| 920 | 920 | LIFE CARE CENTER OF GWINNETT | 115347 | 3850 SAFEHAVEN DRIVE | LAWRENCEVILLE | GA | 30044 | 2019-04-26 | 640 | B | 1 | 1 | YLUP11 | > Based on record review and staff interview, the facility failed to ensure that discharge Minimum Data Set (MDS) assessments were transmitted within 14 days of discharge to the Centers for Medicare and Medicaid Services (CMS) Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) System for three of six discharged residents (R) (#1, #100, #101) reviewed. Findings include: Review of a CASPER (Certification and Survey Provider Enhanced Reports) Report (GA) MDS 3.0 Missing OBRA (Omnibus Budget Reconciliation Act) Assessment report with a run date of 4/26/19 revealed that R#1, R#100, and R#101 had missing MDS assessments. Review of R#1 MDS listing in the facility's computerized MDS system revealed that she had an Entry Tracking Record dated 11/16/18, an OBRA Admission/5-day assessment on 11/23/18, a 14-day assessment on 11/29/18, a 30-day assessment on 12/17/18, and a Discharge/Return Anticipated MDS on 12/19/18. Review of R#1's computerized Nurse's Notes dated 12/19/18 at 1:36 p.m. revealed that she was discharged to the hospital. During interview with Licensed Practical Nurse (LPN) MDS Coordinator KK on 4/25/19 at 2:35 p.m., she stated that all of R#1's MDS in their computerized system had a Status of Completed, except for the Entry and Admission MDS, which had a Status of Accepted. MDS LPN KK stated during continued interview that R#1's Discharge MDS was completed on 12/27/18, and verified that her Discharge MDS did not have a Status of Accepted. During interview with LPN MDS Coordinator NN at this time, she stated the facility transitioned from one computerized software system to another one in (MONTH) of (YEAR), and during this time they had to manually select which MDS to transmit to CMS. LPN MDS NN stated during continued interview that they chose not to submit R#1's Discharge MDS in error, and would do so that day. During interview with LPN MDS Coordinator NN on 4/26/19 at 10:04 a.m., she stated that R#101 was discharged from the facility on 1/24/19, and that they had comple… | 2020-09-01 |
| 944 | 944 | DELMAR GARDENS OF GWINNETT | 115350 | 3100 CLUB DRIVE | LAWRENCEVILLE | GA | 30044 | 2018-07-26 | 582 | B | 0 | 1 | OG2711 | Based on record review and staff interview, the facility failed to ensure that two of three residents (R) (#4 and #37) received the CMS- Form: Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN). The total census was 59. Findings include: 1.) Review of R4's Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review revealed that Medicare Part A Skilled Services Episode Start Date was 12/26/17 and Last covered day of Part A Service was 1/26/18. The facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted. Continued review revealed that the resident remained in the facility and a CMS- Form: Notice of Medicare Provider Non-Coverage (NOMNC) was given on 1/23/18; however, no evidence that the CMS- was provided to the resident and/or the resident's representative. The explanation was that it was not effective until 4/30/18. 2.) Review of R37's Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review revealed that Medicare Part A Skilled Services Episode Start Date was 1/5/18 and Last covered day of Part A Service was 2/1/18. The facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted. Continued review revealed that the resident remained in the facility and a CMS- Form: Notice of Medicare Provider Non-Coverage (NOMNC) was given on 1/30/17; however, no evidence that the CMS- was provided to the resident and/or the resident's representative. The explanation was that it was not effective until 4/30/18. Interview with the Administrator Assistant AA, on 7/24/18 at 11:45 a.m., she stated that Corporate stated that the SNF ABN did not need to be given out and said that they were not effective until (MONTH) 30, (YEAR). However, she confirmed that the SNF ABN were not given for these two residents. Review of the email dated 4/27/18 from the Regional Nurse Specialist revealed that effective 4/30/18, there is a new requirement to use a revised SNF ABN form that will replace the SNF Den… | 2020-09-01 |
| 992 | 992 | LAGRANGE HEALTH AND REHAB | 115354 | 2111 WEST POINT ROAD | LAGRANGE | GA | 30240 | 2019-08-08 | 640 | B | 0 | 1 | CDOM11 | Based on record review and staff interview, the facility failed to ensure that a discharge Minimum Data Set (MDS) assessment was transmitted within 14 days of discharge to the Centers for Medicare and Medicaid Services (CMS) Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) System for three of six residents (R) reviewed for discharge (#1, #2, and #3). Findings include: 1. Review of the discharge record revealed R#1 was discharged from the facility on 3/14/19. Review of R#1's MDS list revealed there was an Admission assessment completed on 3/7/19, and the MDS discharge assessment was not completed. 2. Review of the alphabetical census of the current residents dated 8/5/19 revealed R#2 no longer resides in the facility. Review of R#2's MDS list revealed there was an Admission assessment completed on 3/8/19, but there was no MDS discharge assessment listed. 3. Review of the alphabetical census of the current residents dated 8/5/19 revealed R#3 no longer resides in the facility. Review of R#3's MDS list revealed there was an Admission assessment completed on 3/8/19, but there was no MDS discharge assessment listed. During an interview on 8/8/19 at 1:48 p.m., MDS Coordinator AA revealed the facility did not have an MDS Coordinator for four months. She has been employed for two weeks and confirmed the above discharge assessments had not been completed. She stated they pulled the schedule from (MONTH) 1 until now and have been trying to catch up. MDS Coordinator AA stated that she is unable to transmit assessment because she does not yet have her password. Interview with the Director of Nursing on 8/8/19 at 5:04 p.m. revealed she expects staff to conduct and transmit assessments timely. She stated that the corporate nurse could have been transmitting the assessment in the meantime while the new MDS staff are waiting on passwords. Review of the document titled Chapter 5: Submission and Correction of the MDS assessment dated (MONTH) 2019 revealed for all non-Admission OBRA and PPS as… | 2020-09-01 |
| 1267 | 1267 | PRUITTHEALTH - EASTSIDE | 115391 | 2795 FINNEY CIRCLE | MACON | GA | 31217 | 2018-11-16 | 640 | B | 0 | 1 | 6XMT11 | Based on policy review and interview the facility failed to transmit three (R#1, R#2, and R#3) of the three Minimum Data Sets (MDS) in a timely manner. The census was sixty-six (66). Findings include: In an interview with the MDS coordinator on 11/15/18 at 10:52 a.m. she said that the Significant Change MDS for R#2 was completed on 9/11/18 but she overlooked transmitting it. Also stated that R#1 has a discharge MDS that is not complete. Continued interview revealed that an Annual MDS on R#3 was completed on 9/13/18 and transmitted on 9/26/18 but was rejected and sent back on 10/5/18 and that she has not reviewed and re-transmitted it. The MDS Coordinator confirmed that she is responsible for ensuring that the MDS's are transmitted in a timely manner. She also revealed that a consultant is supposed to pull the MDS report to ensure that the MDS's are transmitted timely. Policy from RAI manual titled Transmitting MDS Data dated 10/17 revealed that Transmitting Data: Assessment Transmission: Comprehensive Assessments must be transmitted electronically within 14 days of the care plan completion date. All other MDS assessments must be submitted within 14 days of the MDS completion date. | 2020-09-01 |
| 1310 | 1310 | QUIET OAKS HEALTH CARE CENTER | 115396 | 125 QUIET OAKS DRIVE | CRAWFORD | GA | 30630 | 2019-09-12 | 568 | B | 0 | 1 | MO6711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interview, the facility failed to provide a quarterly statement to the resident and/or responsible party (RP) for one resident (R)(#11) since her account was opened on 3/8/19. In addition, the facility failed to provide quarterly statements for any resident or RP since (MONTH) of 2019. The facility handled a total of 20 resident trust fund accounts. Findings include: During interview with R#11 on 9/9/19 at 11:57 a.m., she stated that she had never received a statement of how much money she had in her trust fund account. Review of R#11's Admission Minimum Data Set ((MDS) dated [DATE], and her Quarterly MDS dated [DATE], revealed that she had a Brief Interview for Mental Status (BIMS) score of 13 (a BIMS score of 13 to 15 indicates no cognitive impairment). Review of a Trust Fund Account Balances report as of 8/30/19 revealed that R#11 currently had a trust fund account, with a positive balance. Review of R#11's two most recent quarterly statements revealed that her account was opened on 3/8/19. Review of the resident signature line on both of the statements had typed in unable to sign, and that the statements were mailed to the RP. The facility representative and witness lines were blank. On 9/11/19 at 10:50 a.m., the Administrative Assistant stated that she was responsible for handling the resident trust fund accounts. She stated during further interview that if a resident could take care of their own affairs, she would give them the quarterly statement, and if not, she mailed the statement to the RP listed on the Face Sheet on the chart. The Administrative Assistant further stated that she felt R#11 was not able to manage her own affairs, and so would have mailed her quarterly statement to her RP. She stated during continued interview that before mailing a quarterly statement, she signed it and had another staff person witness it, and she kept a copy. She stated that she was behind in mailing out qu… | 2020-09-01 |
| 1353 | 1353 | PRUITTHEALTH - SPRING VALLEY | 115401 | 651 RHODES DRIVE | ELBERTON | GA | 30635 | 2019-06-20 | 582 | B | 0 | 1 | 2PJB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review and interviews, the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) to two (2) residents (R) #16 and #24 out of three (3) residents who were reviewed after being discharged from Medicare Part A Services and remained in the facility. The sample size was 25. Findings include: Review of the facility policy titled Advance Beneficiary Notices (ABNs) revised 7/19/2016 revealed the purpose of an Advanced Beneficiary Notice (ABN) is to inform the patient/resident that Medicare will probably not pay for a certain item or service in a specific situation, even if Medicare might pay for the item or service under different circumstances. This allows the patient/resident to make an informed decision about whether or not to receive the item or service for which he/she may have to pay out of pocket or through other insurance. Procedure 1. If physician orders services for treatment of [REDACTED]. The facility will discuss the options related to non-covered services with the patient/resident and will answer any inquiries from the patient/resident. The patient/resident will receive instruction and guidance of options with each Advance Beneficiary Notice issued. Review of a Beneficiary Notice-Residents discharged Within the Last Six Months form revealed that R#16 and R#24 remained in the facility after skilled services ended. 1. Review of records for R#16 indicated that services were initiated on 3/11/19 and discharged from Medicare Part A services on 5/3/19 and remained in the facility. Review of her Beneficiary Notices revealed that only the Notice of Medicare Non-Coverage form (NOMNC)(Form CMS- ) was provided, which was signed by the resident on 5/3/19. There was no evidence that the facility had issued an SNFABN (Form CMS- ) to R#16 providing the opportunity to continue with skilled services, at her cost, if Medicare did not reimburse. 2. Review of records for R#2… | 2020-09-01 |
| 1428 | 1428 | HARBORVIEW HEALTH SYSTEMS JESUP | 115414 | 1090 W ORANGE ST | JESUP | GA | 31545 | 2017-08-17 | 161 | B | 0 | 1 | 73MR11 | Based on staff interview, review of the resident trust account bank statements, and the Long Term Care Facility Resident's Fund Bond, the facility failed to have a surety bond to cover the amount of funds in the resident trust account. There were 61 residents in the facilty with personal funds accounts. Findings include: The facility had a Long Term Care Facility Resident's Fund Bond in the amount of $25,347.02. However, a review of the bank statements for the resident trust account from (MONTH) through (MONTH) (YEAR) revealed that the balance in the resident trust account exceeded the amount of the surety bond on the following dates: February (YEAR): 2/3/17 through 2/17/17 (15 days) March (YEAR): 3/3/17 through 3/22/17 (20 days) April (YEAR): 4/3/17-4/7/17 and on 4/19/17 (six days) May (YEAR): 5/3/17 through 5/9/17, 5/10/17, and 5/16/17 through 5/22/17 (15 days) June (YEAR): 6/2/17 through 6/5/17 (four days) July (YEAR): 7/3/17 through 7/10/17 and on 7/20/17 (nine days) During an interview on 8/16/17 at 2:40 p.m., the Administrator stated that the surety bond is overseen by the corporate office and she would contact them. | 2020-09-01 |
| 1442 | 1442 | OAKS - ATHENS SKILLED NURSING, THE | 115419 | 490 KATHWOOD DR | ATHENS | GA | 30607 | 2018-03-15 | 640 | B | 0 | 1 | OUTZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure that Minimum Data Set (MDS) assessments were transmitted within 14 days of completion to CMS's (Centers for Medicare and Medicaid Services) Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) system for three residents (R) (R #5, R #4, R #6). In addition, the facility failed to complete a Discharge MDS for one resident (R #3). The sample size was 42 residents. Findings include: 1. Review of a listing of R # 5's completed and transmitted MDS revealed that an Annual MDS with an Assessment Reference Date (ARD) of 10/27/17 was the last MDS transmitted for her. Review of R #4's MDS listings revealed that an Annual MDS with an ARD date of 10/13/17 was the last MDS transmitted for her. Review of R #6's MDS listings revealed that a Quarterly MDS with an ARD date of 10/27/17 was the last MDS transmitted for him. Review of an alphabetical resident census revealed that R #4, R #5, and R #6 were currently residents in the facility. During interview with Case Mix Coordinator (CMC) EE on 3/15/18 at 8:19 a.m., she stated that every week or two they received a report (CMS Submission Report) that would alert them if there was a transmission error when an MDS was sent. She further stated that all of the CMCs were responsible for looking at this report, to see why an MDS may have been rejected, fix the data that caused the rejection, and then re-submit it. Review of MDS Transmission Results with CMC EE on her computer at this time revealed that R #5 had a Quarterly MDS with an ARD date of 1/15/18 that had a Status Date of 1/29/18 (this is when the MDS was attempted to be transmitted), that had a Status of Rejected. Review of MDS Transmission Results for R #4 revealed her Quarterly MDS with an ARD date of 1/3/18 had a Status Date of 1/12/18, and a Status of Rejected. Review of the MDS Transmission Results for R #6 revealed that he had a Quarterly MDS wi… | 2020-09-01 |
| 1450 | 1450 | OAKS - ATHENS SKILLED NURSING, THE | 115419 | 490 KATHWOOD DR | ATHENS | GA | 30607 | 2019-03-21 | 640 | B | 0 | 1 | JLDH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure that Minimum Data Set (MDS) assessments were transmitted within 14 days of completion to CMS's (Centers for Medicare and Medicaid Services) Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) system for two residents (R) (R#2 and R#6) of 39 sampled residents. Findings include: 1. Review of R#2's completed and transmitted MDS records revealed that an Entry Tracking Record dated 9/18/18 and an Admission assessment dated [DATE]. Review of the alphabetic resident census revealed that R#2 was not currently a resident in the facility. There is no evidence that a Discharge Assessment was completed. Review of an unlabeled report provided by MDS Case Mix Director, dated 3/19/19 at 6:27 p.m., revealed that a discharge assessment was transmitted 10/16/18 with an accepted status dated 10/19/18 at 2:41 p.m. Interview on 3/19/18 at 4:40 p.m., with MDS Coordinator GG, stated that there was a discharge assessment in the facility computer system; however, she was unable to provide a submission identification number. Interview on 3/20/19 at 10:31 a.m., interview with Case Mix Director, revealed that resident's discharge assessment was batched in a zip file to corporate on 10/16/18. She further stated that corporate sends the assessments into the national QIES system. She stated that the transmit by date is the end date for the facility to submit the MDS and the status date is the date the corporate marks the assessment as accepted or rejected and posts the reports in the national QIES system. She confirmed that the discharge assessment for R#2 was not submitted by corporate into the national QIES system. 2. Review of R#6's completed and transmitted MDS records revealed that an Entry Tracking Record dated 10/2/18, an Admission assessment dated [DATE] and a 14 day Prospective Payment System (PPS) dated 10/16/18. Review of the alphabetic resident census … | 2020-09-01 |
| 1537 | 1537 | THOMASVILLE HEALTH & REHAB, LLC | 115427 | 120 SKYLINE DRIVE | THOMASVILLE | GA | 31757 | 2019-08-01 | 577 | B | 0 | 1 | B2DQ11 | Based on observation, resident and staff interviews and review of the facility policy titled Residents Rights, the facility failed to ensure survey results are accessible to all residents and/or visitors, and for one resident (R) #27 who used a wheelchair for mobility for three of four days of the survey. Findings include: During an observation on 7/31/19 at 12:30 p.m., a copy of the survey results were noted to be in the front lobby behind an arm chair in a corner. During an observation and interview on 7 31/19 at 12:32 p.m. with the Maintenance Director, it was revealed that the survey results are were posted 5 feet 8 inches from the floor. He also stated at that time, the arm chair in front of the survey results is extended from the wall 34 1/2 inches. When the surveyor requested to view the survey results, the Maintenance Director had to move the arm chair to allow access. During an interview on 7/31/19 at 12:45 p.m. Resident (R) #27, who used a wheelchair for mobility, stated she could not reach the survey result book. Review of the most recent Minimum Data Set (MDS) assessment for R#27 dated 5/31/19 indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. A review of the facility's policy,Residents Rights revised (MONTH) (YEAR), revealed the following: federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to examine survey results. During an interview on 7/31/19 at 12:36 p.m., the Administrator confirmed residents in a wheelchairs would not be able to view the survey results. | 2020-09-01 |
| 1570 | 1570 | SUMMERHILL ELDERLIVING HOME & CARE | 115430 | 500 STANLEY STREET | PERRY | GA | 31069 | 2019-05-31 | 577 | B | 1 | 1 | U20X11 | > Based on observation, resident, and staff interviews, and review of the facility policy titled, Examination of Survey Results the facility failed to post notice of the availability of the State survey results so that residents (R) and/or visitors were aware of its location and had access to the book for two of four days of the survey in the [NAME]nda Building. Findings include: Examination of Survey Results Survey reports and plans of correction are readily accessible to the resident and to the public. Policy Interpretation and Implementation 1. A copy of the most recent survey report as well as our plan for correcting identified problems will be kept in this facility's front sitting room. During a tour of the Memory Care Unit in the [NAME]nda building 5/28/19 at 12:30 p.m. observation revealed that there was a sign posted to go to nurse to get results of the last survey. Further tour of the Memory Care unit revealed that the survey book was located on a shelf behind the nurse's station and was not readily accessible to residents or family members without requiring nursing assistance. During a tour of the [NAME]nda Building on 5/31/19 at 8:52 a.m. with the Assistant Director of Nursing (ADON) it was confirmed that there were not any notices of where to find the survey results in the [NAME]nda Building. A sign was later found, on the Memory Care unit, that documented, Ask nurse for survey results. The survey results were found on a shelf behind the nurse's station on the memory care unit and was not readily accessible to residents or family members without requiring nursing assistance. During an interview on 5/31/19 at 9:45 a.m. with Administrative Assistant FF, revealed that in the past the survey book was kept at the nurse's station and should always be in a location easily accessible and that there should be a sign stating where the book is located. Administrative Assistant FF revealed that she is responsible for the survey book in the main building and that this information may not have been relayed to the n… | 2020-09-01 |
| 1573 | 1573 | SUMMERHILL ELDERLIVING HOME & CARE | 115430 | 500 STANLEY STREET | PERRY | GA | 31069 | 2019-05-31 | 732 | B | 1 | 1 | U20X11 | > Based on observation and staff interviews, the facility failed to post nurse staffing information in a prominent place readily accessible to residents and visitors for twp of four days of the survey in the [NAME]nda building and the facility failed to ensure the form was complete for two of four days in the main building. The facility census was 152 residents. Findings include: During a tour of [NAME]nda Building on 5/29/19 at 12:50 p.m. the required nurse staffing information was not able to be located. On 5/29/19 at 2:15 p.m. the required nurse staffing was observed posted at entrance by 300 hall of the main building but the facility name was not on the form. Interview with the Assistant Director of Nursing on 5/31/19 at 8:36 a.m. revealed that the nurse staffing hours are posted at the front entrance of the main building. She further revealed that hours are not posted in the [NAME]nda building. During an interview on 5/31/19 at 8:45 a.m. with the Administrator, it was confirmed that nurse staffing hours are only posted in the main building. During an interview with the Scheduler on 5/31/19 at 9:52 a.m. it was reported that the same form has been used since taking the scheduling position as this is what was provided to her. The Scheduler revealed that she was never told to post in the [NAME]nda building. | 2020-09-01 |
| 1638 | 1638 | SOUTHLAND HEALTH AND REHABILITATION | 115460 | 151 WISDOM ROAD | PEACHTREE CITY | GA | 30269 | 2018-01-11 | 655 | B | 0 | 1 | U71N11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident, family, and staff interview, medical record review, and review of facility policy, the facility failed to complete the baseline care plan summary and provide a copy to the resident and resident representative for five of five sampled residents (Residents (R)#187, R#237, R#238, R#239, R#364) who were new admissions to the facility. The findings include: 1. R #187 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the medical record revealed a baseline care plan, dated 12/30/17. Further review of the baseline care plan revealed the section, written summary of the baseline care plan, was left blank. The section marked Representative signature was also blank. In an interview with the Director of Nursing on 1/11/18, at 10:00 a.m., she acknowledged the baseline care plan was not complete. 2. Review of the medical record for R #237 revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The medical record revealed a Baseline Care Plan form dated 12/21/17 that was partially completed. The section titled Written Summary of Baseline Care Plan was blank. The section titled Completion Signatures was blank for the resident and resident representative. There was no evidence in the medical record that a summary of the care plan was provided to the resident or resident's representative. Interview with R #237, in his room, on 1/9/18 at 9:00 a.m. revealed he did not know anything about care planning and he was not given a copy of the care plan when admitted to the facility. R#237 stated I just go to therapy when they tell me, but it isn't helping. 3. Review of the medical record for R #238 revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The medical record revealed a Baseline Care Plan form dated 1/3/18 that was partially completed. The section titled Written Summary of Baseline Care Plan was blank. The section titled Completion Signatures was blank for n… | 2020-09-01 |
| 1651 | 1651 | WESTBURY MCDONOUGH, LLC | 115463 | 198 HAMPTON STREET | MCDONOUGH | GA | 30253 | 2019-01-31 | 582 | B | 0 | 1 | 4NRX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure that Skilled Nursing Facility Advance Beneficiary Notices (SNFABN) were completed with the resident's (R) or responsible party's (RP) signature, designation of their choice of whether or not to continue to receive skilled services after discharge off Medicare Part A, documentation of attempts to get the form completed, and/or why the form was not completed for two of three residents reviewed (R#87 and R#92). In addition, the facility failed to obtain or document the attempts to obtain the resident or RP signature on the Notice of Medicare Non-Coverage (NOMNC) for one resident (R#92). The sample size was 55 residents. Findings include: 1. Review of a Beneficiary Notice-Residents discharged Within the Last Six Months form revealed that R#87's discharge date of f Medicare Part A services was 1/15/19, and he remained in the facility with Part A benefit days remaining. Review of R#87's NOMNC revealed that the effective date coverage of his current PT (Physical Therapy) and OT (Occupational Therapy) services would end as of 1/15/19, and he signed the form to acknowledge his right to appeal this decision. Review of R#87's SNFABN revealed that beginning on 1/16/19, he may have to pay out of his pocket for PT and OT if he did not have other insurance that may cover the costs. Review of the What To Do Now section of this notice revealed for him to choose an option about whether to get the care listed above (PT and OT). Further review of the notice revealed that none of the three options were chosen (the options were to continue the care and bill Medicare; or continue the care but don't bill Medicare; or don't want the care listed), and the form was not signed by the resident or RP. Review of the signature line revealed that by signing, it meant you've received and understood the notice. Review of R#87's Admission Minimum Data Set ((MDS) dated [DATE] revealed that he had a Brief I… | 2020-09-01 |
| 1723 | 1723 | AZALEA TRACE NURSING CENTER | 115478 | 910 TALBOTTON RD | COLUMBUS | GA | 31904 | 2016-10-14 | 356 | B | 0 | 1 | 5ZK111 | Based on observation and staff interview, the facility failed to ensure required nurse staffing information, was updated daily for 4 of 7 days and posted at the beginning of each shift in a location that was easily accessible to residents and visitors. Findings include: During the initial tour on 10/10/16 at 9:20 a.m., the nursing staff information was observed posted in the first floor hallway leading to the 100 even number rooms across from the nursing station. There was a nurse staffing form which had the staffing completed for 10/5/16 and 10/6/16. The form was not completed daily. The following dates were left blank 10/7/16, 10/8/16, 10/9/16, and 10/10/16. During an interview on 10/10/16 at 12:45 p.m. with the Director of Nursing (DON) she stated the nurse staffing totals would always be a day behind due to having call offs and to ensure the daily nurse staffing sheet was accurate she completed them the next day not the same day. The DON stated she used the staffing book located on the front desk to complete the nurse staffing information for the days when she was not present at the facility. According to the DON, she not familiar with the regulation regarding nurse staffing posting daily. | 2020-09-01 |
| 1726 | 1726 | AZALEA TRACE NURSING CENTER | 115478 | 910 TALBOTTON RD | COLUMBUS | GA | 31904 | 2017-11-16 | 156 | B | 0 | 1 | NUQ511 | Based on record review, resident interview, and staff interview the facility failed to ensure that resident's rights were reviewed with residents throughout the duration of their stay at the facility. The facility census was 100 with a sample size of 32. Findings include: Review of resident council minutes for (YEAR) revealed that there was no indication that resident rights were being discussed with residents during council meetings. Interview on 11/16/17 at 9:27 a.m. with the Resident council president who reported that resident rights are not discussed and she is not aware of where the rights are posted. Interview on 11/16/17 at 9:40 a.m. with Resident (R) #2 who reported that staff do not talk about resident's rights on a regular basis. R#2 reported that no one has asked her if she wants to attend a resident council meeting. R#2 further stated that she is aware a little of her rights but it has been a while since they were discussed. R#2 reported being a resident at this facility for more than two (2) years. Interview on 11/16/17 at 9:44 a.m. with R#34 who reported that resident rights were discussed at admission but has not been discussed since. R#34 reported being a resident in the facility for about a year. Interview on 11/16/17 at 9:50 a.m. with the Admissions Director who confirmed that resident's rights are not discussed during resident council meetings but going forward she would discuss resident rights with residents. Admissions Director reported that she basically followed the template of the previous Admission Director regarding resident council meetings and notes. Admissions Director reported that now that she is aware that resident rights need to be discussed she will do so. Interview on 11/16/17 at 1:43 p.m. with R#89 who was unable to identify a time in which resident rights are discussed other than at admission. Interview on 11/16/17 at 5 p.m. with the Administrator who reported that he does not think it is correct that resident rights are not discussed. It was reported that previous Activity d… | 2020-09-01 |
| 1787 | 1787 | PROVIDENCE HEALTHCARE | 115484 | 1011 SOUTH GREEN STREET | THOMASTON | GA | 30286 | 2019-05-16 | 582 | B | 0 | 1 | 55TI11 | Based on record review and staff interview, the facility failed to provide evidence that the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) and the Notice of Medicaid Non-Coverage (NOMNC) was issued for one of two residents (R) reviewed (R#25), who was discharged off Medicare Part A services and remained in the facility. Findings include: R#25's Medicare Part A Skilled Services began on 10/15/18 and last covered day was on 11/25/18. The resident remained in the facility. Review of SNFABN revealed the form was not signed. However, there was a handwritten note dated 11/21/18 indicating that a family representative had been contacted. Review of the NOMNC revealed that the document had not been signed and there was no evidence of either document being provided to R#25 or the family representative. Interview on 5/15/19 at 12:59 p.m. with Social Services Director (SSD) who reported that R#25's family was notified via telephone of services ending but a copy of the form was not mailed to the family. SSD further reported that if telephone contact is made notices are not mailed to the family. SSD confirmed that R#25 remained in the facility. | 2020-09-01 |
| 1793 | 1793 | NEW HORIZONS LIMESTONE | 115487 | 2020 BEVERLY ROAD NE | GAINESVILLE | GA | 30501 | 2017-03-09 | 167 | B | 0 | 1 | SNS711 | Based on observation, record review, resident and staff interview, the facility failed to post Notice of the availability and location of the State Survey results in building [NAME] The census for Building A was 113 residents. Findings include: During initial tour of the facility on 3/6/17 from 10:15 a.m. to 11:00 a.m., throughout the facility, specifically the front lobby, activity board and nurses ' station (Units 1, 2 and 3) revealed no evidence of the State Survey results and no evidence of a notice for the availability or location of the State Survey results. Interview with the Resident Council President (RCP) on 3/7/17 at 8:48 a.m., revealed that she did not know where the survey results are located in the facility. RCP stated that she has never seen the survey results and that she doubts the other residents know where to find the survey results. Review of RCP's most recent Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) summary score of 15, indicating no cognitive impairment. Further observation on 3/7/17 between 12:30 p.m. to 12:36 p.m., revealed the survey results posted on an activity board, near the nursing station on Units 1, 2, and 3 that had not been previously observed. A plastic sheet with the words written - P[NAME] (Plan of Correction) for survey of 6/18/15 - do not remove. Review of Resident Council Minutes from (MONTH) (YEAR) to (MONTH) (YEAR), revealed no discussions related to the residents' rights to review State Survey results or where the State Survey results are posted. Interview with resident (R) X on 3/7/17 at 4:10 p.m. revealed that he would be interested in reviewing the survey results if he knew where it was posted. Record review for R X documented the most recent BIMS score of 11, indicating moderate impairment. Interview with R Y on 3/7/17 at 4:16 p.m. revealed that she is interested in reviewing the survey results, but do not know where to find them. Record review for R Y documented the most recent BIMS score of 15, indicating no cognitive im… | 2020-09-01 |
| 1978 | 1978 | ROSS MEMORIAL HEALTH CARE CTR | 115515 | 1780 OLD HIGHWAY 41 | KENNESAW | GA | 30152 | 2018-04-12 | 582 | B | 0 | 1 | L5SJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to provide the Advanced Beneficiary Notice (ABN) to five, Resident (R)#13, R#46, R#61, R#71 and R#175, of five records reviewed for those residents who were discharged from Medicare services with Medicare days remaining and remained in the facility. Findings include: 1. Review of the face sheet in the medical record for R#13 reveals the resident was admitted to the facility on [DATE] and currently resides in the facility. Review of facility records reveal R#13 was provided with a Notice of Medicare Non- Coverage (NOMNC) on [DATE] for services ending [DATE] with Medicare days remaining. This allowed her to an expedited review of a service termination if she chose to appeal the termination. This does not fulfill the facility's obligation to advise the resident of potential liability for payment. She remained in the facility for long term care services. R #13 was not provided with the ABN to inform her of the ending of skilled services that may not be paid for by Medicare so that she could assume financial responsibility if she wanted to continue those services. 2. Review of the face sheet in the medical record for R#46 reveals he was admitted to the facility on [DATE]. Review of facility records reveal R#46 was provided with a NOMNC on [DATE] for services ending on [DATE] with Medicare days remaining. This allowed him to an expedited review of a service termination if he chose to appeal the termination. This does not fulfill the facility's obligation to advise the resident of potential liability for payment. He remained in the facility for long term care services. R#46 was admitted to Hospice services on [DATE] and expired in the facility on [DATE]. R #46 was not provided with the ABN to inform him of the ending of skilled services that may not be paid for by Medicare so that he could assume financial responsibility if he wanted to continue those services. 3. Review of the face sheet in t… | 2020-09-01 |
| 2051 | 2051 | THE PAVILION AT BRANDON WILDE | 115524 | 4275 OWENS ROAD | EVANS | GA | 30809 | 2020-01-30 | 638 | B | 1 | 1 | RFJ511 | > Based on record review and staff interview, the facility failed to complete a Quarterly Minimum Data Set (MDS) Assessment not less than every three (3) months for five (5) out of seven (7) residents reviewed (R#3, R#4, R#5, R#6 and R#7). Findings include: Review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.16, dated October 2018 revealed: The Quarterly assessment is an OBRA (Omnibus Budget Reconciliation Act) non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type. It is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored. 1. Review of the R#3's MDS Assessment revealed that an Annual MDS Assessment was completed on 9/9/19. Further review revealed there was no evidence that a Quarterly MDS Assessment was completed in December 2019. Review of the MDS Calendar for December 2019 revealed the resident was scheduled for a Quarterly Assessment on 12/8/19. 2. Review of the R#4's MDS Assessment revealed that an Annual MDS Assessment was completed on 6/26/19 and a Quarterly Assessment was completed on 9/18/19. Further review revealed there was no evidence that a Quarterly Assessment was completed in December 2019. Review of the MDS Calendar for December 2019 revealed the resident was scheduled for a Quarterly Assessment on 12/11/19. 3. Review of the R#5's MDS Assessment revealed that an Annual MDS Assessment was completed on 6/24/19 and a Quarterly Assessment was completed on 9/18/19. Further review revealed there was no evidence that a Quarterly Assessment was completed in December 2019. Review of the MDS Calendar for December 2019 revealed the resident was schduled for a Quarterly Assessment on 12/11/19. 4. Review of the R#6's MDS Assessment revealed that an Annual MDS Assessment was completed on 6/24/19 and a Quarterly Assessment was completed on 9/1… | 2020-09-01 |
| 2052 | 2052 | THE PAVILION AT BRANDON WILDE | 115524 | 4275 OWENS ROAD | EVANS | GA | 30809 | 2020-01-30 | 640 | B | 1 | 1 | RFJ511 | > Based on record reviews and staff interviews the facility failed to ensure that Minimum Data Sets (MDS) assessments were transmitted within 14 days of completion to CMS's (Centers for Medicare and Medicaid Services) Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) system for six (6) rsidents (R#1, R#2, R#3, R#4, R#5 and R#7). The sample size was 32. Findings include: 1. Review of R#1's completed and transmitted MDS records revealed that a Discharge Part A was due on 8/31/19. Further review revealed there was no evidence that a Discharge Tracking Assessment was completed. 2. Review of R#2's completed and transmitted MDS records revealed a Discharge Part A dated 9/13/19 with submission date of 9/19/19. Further review revealed there was no evidence that a Discharge Tracking Assessment was completed. 3. Review of R#3's completed and transmitted MDS records revealed a MDS Quarterly Assessment was completed 12/21/18 and submitted on 2/21/19 which should have been submitted by 2/1/19. 4. Review of R#4's completed and transmitted MDS records revealed a MDS Quarterly Assessment was completed on 1/7/19 and submitted on 4/18/19 which should have been submitted by 3/21/19. 5. Review of R#5's completed and transmitted MDS records revealed a MDS Quarterly Assessment was completed on 1/2/19 and submitted on 4/1/19 which should have been submitted by 3/21/19. 6. Review of R#7's completed and transmitted MDS records revealed a MDS Quarterly Assessment was completed on 1/7/19 and submitted on 4/18/19 which should have been submitted by 4/17/19. Interview with the MDS Coordinator on 1/29/2020 at 2:45 p.m. revealed that she has been employed at the facility since May 2019 as the MDS Coordinator. She further stated that when she first came to the facility the Interim MDS Coordinator, who had been at the facility since January 2019, explained to her that OBRA assessments from February 2019 had not been completed but that all Medicare Part A assessments were complete. She further stated that sh… | 2020-09-01 |
| 2109 | 2109 | SOCIAL CIRCLE NSG & REHAB CTR | 115532 | 671 NORTH CHEROKEE ROAD | SOCIAL CIRCLE | GA | 30025 | 2019-01-26 | 641 | B | 0 | 1 | SDK511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interviews, the facility failed to document the [DIAGNOSES REDACTED].#15 in the 11/14/18 Annual and the previous four Quarterly Minimum Data Set (MDS) assessments dated 10/11/18, 7/17/18, 6/23/18, and 4/28/18. In addition, the facility failed to accurately document the discharge status as 01 for R#60 for Community (private home/apt, board/care, assisted living, group home in the 1/2/19, MDS Discharge Assessment-Section A2100. The discharge status was documented as acute hospital. The sample size was 34 residents. Findings include: 1. Record review for R#15 revealed was admitted to the facility on [DATE] and re-admitted on [DATE] with the following [DIAGNOSES REDACTED]. Review of the thinned clinical record revealed the additional [DIAGNOSES REDACTED]. Review of the most recent MDS Annual assessment, dated 11/14/18, did not include the dementia diagnosis. Further review of the previous Quarterly MDS assessments, dated 10/11/18, 7/17/18, and 6/23/18 also omitted the dementia diagnosis. 2. Review of the closed clinical record for R#60 revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged , from the facility, on 1/2/19. Review of the most recent MDS Discharge Assessment, dated 1/2/19, documented the discharge status in Section A Identification Information, A2100 as 03. Acute Hospital. Review of the Physician order [REDACTED]. In an interview with the MDS Director on 01/26/19 at 7:24 p.m. regarding the MDS discrepancies, she confirmed the omission of the dementia [DIAGNOSES REDACTED].#60. She accepted responsibility for these inaccuracies. In an interview with the Director of Nursing (DON) on 1/26/19 at 8:00 p.m. revealed that her expectation was that the MDS Director and other MDS contributors would make every effort to be accurate and thorough in their assessments. | 2020-09-01 |
| 2126 | 2126 | SOCIAL CIRCLE NSG & REHAB CTR | 115532 | 671 NORTH CHEROKEE ROAD | SOCIAL CIRCLE | GA | 30025 | 2017-03-02 | 167 | B | 0 | 1 | 13ES11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interview, the facility failed to post the availability and location of the State survey results in areas of the facility that were prominent and accessible to the public. The facility census was 59 residents. Findings include: During interview with resident (R) R on 3/1/17 at 10:16 a.m., she stated that she was not sure where the State inspection results were kept, and that she would be interested in reviewing them. Review of the resident's most recent Minimum Data Set (MDS) assessment dated [DATE] revealed that she had a Brief Interview for Mental Status (BIMS) score of 15 (a score of 13 to 15 indicates no cognitive impairment). Review of Resident Council minutes from (MONTH) (YEAR) through (MONTH) (YEAR) revealed that there was no evidence that the availability of the State survey results were discussed with the residents, nor the location of the survey results. On 3/1/17 at 10:30 a.m., a notebook containing the State inspection results was observed located in a translucent gray plastic bin on a wall between the nurse's station and the dining room. During further observation, the only wording that was clearly visible on the notebook was above the top of this gray bin, and it read Most Recent. Further observation revealed that the wording on the notebook below the top of the gray bin, that was visible but more difficult to see, were the words Standard Licensure Survey. During observation of common areas at the entrance of the facility, lobby area, and around the nurse's station and dining room on 3/2/17 at 10:15 a.m. revealed that there were no signs that posted the availability and location of the survey results. During interview with the Administrator at this time, she stated the location of the State survey results was explained to the resident or family on admission, but she was unsure whether or not residents were reminded during Resident Council meetings that this was available t… | 2020-09-01 |
| 2130 | 2130 | PRUITTHEALTH - SWAINSBORO | 115533 | 856 HIGHWAY 1 SOUTH | SWAINSBORO | GA | 30401 | 2018-08-30 | 568 | B | 0 | 1 | BCFK11 | Based on record review, family and staff interview, the facility failed to provide evidence that quarterly statements from two of two resident (R) (R#11 and R#43) trust fund accounts reviewed were being sent to the responsible parties (RP). The facility handled a total of 56 resident accounts. Findings include: 1. During interview with R#11's RP on 8/28/18 at 9:01 a.m., revealed that the RP did not receive quarterly statements from the resident's trust fund account. He added during continued interview that he got these statements in the past, but did not get them now. Review of the facility's Trial Balance report dated 8/28/18, revealed that R#11 currently had a trust fund account being managed by the facility. During interview with the Financial Manager on 8/29/18 at 8:50 a.m., she stated that she sent out quarterly statements for the residents and RPs that wanted them, and that she pretty much just knew who these people were. She stated during further interview that she did mail quarterly statements to R#11's RP. Review of R#11's Resident Fund Management Service Statement for the Period 12/30/17 through 3/30/18 revealed that the resident's name and the address of the facility were on the statement, and it did not contain the RP's name and/or mailing address. During interview with the Financial Manager at this time, she stated that she had to look up RPs' addresses in the computer, and then handwrite the name and address on the outside of the envelope for all of the quarterly statements mailed to RPs. She stated during continued interview that she had no proof that the quarterly statements were being mailed to R#11's RP. During continued interview, the Financial Manager stated that she had never received any quarterly statements for the period of 4/1/18 through 6/30/18 from corporate, who managed the accounts, and stated that she mailed a Resident Statement Landscape report to the RPs, but could not provide evidence that this was done. 2. Review of the Trial Balance report revealed that the facility managed R#43… | 2020-09-01 |
| 2205 | 2205 | ARROWHEAD HEALTH AND REHAB | 115539 | 239 ARROWHEAD BOULEVARD | JONESBORO | GA | 30236 | 2017-06-15 | 160 | B | 0 | 1 | 4B7G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of facility policy for Conveyance of Funds upon a Resident's Discharge, Eviction or Death, the facility failed to ensure resident funds were conveyed timely for three out of five resident accounts reviewed (Resident (R)#16, R#9 and R#110). Specifically, resident funds were not conveyed within 30 days of discharge in accordance to the facility's established policy. Findings include: Per the facility policy, titled Conveyance of Funds upon a Resident's Discharge, Eviction or Death. Item #3 states, within 30 days of discharge eviction or death of a resident the facility will convey the resident's personal funds and a final accounting of those funds to the individual or probate judication administering the resident's estate, in accordance with State law. During an interview with the Business Office Manager (BOM) on [DATE] at 1:29 p.m., she discussed the circumstances below with R#16, R#9 and R#110. Regarding R#16's funds, the BOM stated she was notified of his death approximately one week after R#16 expired in the hospital. She stated R#16's Social Security check for (MONTH) (YEAR) was deposited into the facility's Auto Care Cost Account (corporate accounts). Review of the Trial Balance Form, during the interview, indicated R#16 had a negative balance of 1,012.93 - expired on [DATE]. Upon further review, the facility received a Social Security Administration letter dated [DATE]; the letter informed the facility they were paid $1,170.00 too much in benefits. The BOM stated, Corporate is working on returning the money to Social Security; it has not come back to me yet. When asked if she could contact corporate for an interview to determine what date the funds will or whether the funds had been returned to Social Security, she replied, the corporate person that is working on this account is out of the office today, but I will call her tomorrow to get an update. Review of the Closed Account Summary Report… | 2020-09-01 |
| 2245 | 2245 | SADIE G. MAYS HEALTH & REHABILITATION CENTER | 115542 | 1821 ANDERSON AVENUE NW | ATLANTA | GA | 30314 | 2018-03-01 | 641 | B | 0 | 1 | SKTN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure each resident received an assessment which accurately reflected the resident's status at the time of the assessment for one Resident (R) #145 reviewed for accuracy of assessments related to Pre-Admission Screening and Resident Review (PASARR). The Minimum Data Set (MDS) assessment identified a [DIAGNOSES REDACTED].#145 did not have this resulted in six inaccurate MDSs completed for the past 11 months.The total sample size was 34. Findings include: On 2/27/18 review of the medical record for R#145 revealed the most recent MDS dated [DATE] contained a [DIAGNOSES REDACTED]. There was no Level II PASARR in the medical record for R#145. During the medical record review, the [DIAGNOSES REDACTED]. Interview with the Director of Social Services (DSS) in her office, on 2/28/18 at 9:10 a.m. confirmed a Level II PASARR had not been completed for R#145. On 2/29/18 at 9:35 a.m. during an interview with the MDS coordinator in her office, she stated she obtained [DIAGNOSES REDACTED]. When asked, where the [DIAGNOSES REDACTED].#145 was found in the medical record, the MDS coordinator was not able to locate the [DIAGNOSES REDACTED]. The MDS coordinator stated if R#145 does not have a [DIAGNOSES REDACTED]. Review of the medical record for R#145 reveals MDS assessment completed as follows: Quarterly assessment dated [DATE], Section I6000 has a [DIAGNOSES REDACTED].>Quarterly assessment dated [DATE], Section I6000 has a [DIAGNOSES REDACTED].>Quarterly assessment dated [DATE], Section I6000 has a [DIAGNOSES REDACTED].>Quarterly assessment dated [DATE], Section I6000 has a [DIAGNOSES REDACTED].>Discharge assessment dated [DATE], Section I6000 has a [DIAGNOSES REDACTED].>Significant change assessment dated [DATE] Section I6000 has a [DIAGNOSES REDACTED].>During a second interview with the MDS coordinator in her office, on 3/1/18 at 10:00 a.m. she stated she reviewed the entire medical record for R#1… | 2020-09-01 |
| 2421 | 2421 | WESTBURY MEDICAL CARE AND REHAB | 115563 | 922 MCDONOUGH ROAD | JACKSON | GA | 30233 | 2019-11-07 | 582 | B | 0 | 1 | PH4511 | Based on record review, review of the facility policy titled Advance Beneficiary Notices and staff interviews, the facility failed to provide the Notice of Medicare Non-coverage (NOMNC), Medicare Form , to two residents (R) (#63 and #133) of three residents who were reviewed after being discharged from Medicare Part A Services and remained in the facility. Findings include: Review of the undated facility policy titled Advance Beneficiary Notices revealed: 4 b. For Part A items and services, the facility shall use the Skilled Nursing Facility Advance Beneficiary Notices (SNFABN) Form CMS- . 5. A Notice of Medicare Non-Coverage (NOMNC) Form CMS- , shall be issued to the resident/representative when Medicare covered services are ending, no matter if resident is leaving the facility or remaining in the facility. This informs the resident on how to request an appeal or expedited determination from their Quality Improvement Organization (QIO). Review of a Beneficiary Notice-Residents discharged Within the Last Six Months form revealed that both R#63 and R#133 remained in the facility after skilled services ended. 1. Review of records for R#63 indicated that services were initiated on 8/16/19 and discharged from Medicare Part A services on 9/13/19 and remained in the facility. Review of her Beneficiary Notices revealed that only the Skilled Nursing Facility Advance Beneficiary Notices (SNFABN)(Form CMS- ) was provided, which was signed by the resident responsible party on 8/29/19. There was no evidence that the facility had issued an Notice of Medicare Non-Coverage (NOMNC)(Form CMS- ) to R#63 providing the opportunity to request an appeal or expedited determination from their QIO. 2. Review of records for R#133 indicated that services were initiated on 3/29/19 and discharged from Medicare Part A services on 5/22/19 and remained in the facility. Review of her Beneficiary Notices revealed that only the Skilled Nursing Facility Advance Beneficiary Notices (SNFABN)(Form CMS- ) was provided, which was signed by the resident … | 2020-09-01 |
| 2498 | 2498 | CRISP REGIONAL NSG & REHAB CTR | 115568 | 902 BLACKSHEAR ROAD | CORDELE | GA | 31015 | 2018-11-01 | 568 | B | 0 | 1 | 8QD811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, family and staff interviews, the facility failed to provide evidence that a quarterly financial statement for one resident (R) R #41 trust fund account was being sent to the responsible party (RP). The deficient practice had the potential to affect 56 residents with trust fund accounts managed by the facility. The sample size was 37 residents. Findings include: Record review for R #41 revealed a Quarterly Minimum Data Set (MDS) assessment dated [DATE] which documented a Brief Interview for Mental Status (BIMS) Summary score not rated indicating severe cognitive impairment. Review of the Facility's Trial Balance Report dated (MONTH) (YEAR) revealed that R #41 currently had a trust fund account being managed by the facility. During an interview with R #41's Responsible Party (RP) on 10/29/18 at 1:00 p.m. she stated the facility manages R#41's funds but she did not receive a financial quarterly statement from the resident trust fund account. During an Interview conducted on 11/01/18 at 1:30 p.m. with the Facility's Book Keeper; She verified R#41 had a trust fund account and that R#41's and that the residents RP is her granddaughter. The Book Keeper continued to inform residents quarterly financial bank statements are mailed quarterly either to resident's Responsible person (RP) or given to residents at the facility who are able to sign for their statement. The Book keeper continued to reveal the financial statements are mailed out with a return stamped envelope that should be returned to the facility with the RP's signature indicating the quarterly statement was received. She stated R #41's statement was mailed to the RP but was not able to provide evidence that this was done. | 2020-09-01 |
| 2709 | 2709 | COUNTRYSIDE HEALTH CENTER | 115592 | 233 CARROLLTON STREET | BUCHANAN | GA | 30113 | 2018-01-05 | 582 | B | 0 | 1 | RXF711 | Based on record review and staff interview it was determined that the facility failed to provide Notice of Medicare Non-Coverage (NOMNC) to three (3) of three (3) selected residents; one resident (R#150) with a planned discharge and two residents (R#41) and (R#11) discharged from Medicare Part A Services, that chose to remain in the facility. Sample size was 30 residents. Facility census was 51 residents. Findings include: On 1/03/18 at 11:35 a.m. A review was conducted on three selected residents that received beneficiary protection notification from the facility. One resident (R#150) voluntarily discharged and two remained in the facility with services discontinued; residents (R#41) and (R#11). Review of records for R#41 indicates that services for physical therapy, occupational therapy and speech were initiated on 12/6/17 with services ending 12/31/17, date of Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) was 12/27/17. No evidence was found that the Notice of Medicare Non-Coverage (NOMNC) (CMS ) form was provided to the resident by the facility. Review of records for R#11 indicates that services for physical therapy, occupational therapy and speech were initiated on 9/26/17 with services ending 11/24/17, date of Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) was 11/21/17. No evidence was found that the Notice of Medicare Non-Coverage (NOMNC) (CMS ) form was provided to the resident by the facility. Review of records for R#150 indicates that services were initiated on 11/17/17 with services ending 11/30/17, date of Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) was not found. No evidence was found that the Notice of Medicare Non-Coverage (NOMNC) (CMS ) form was provided to the resident by the facility. During an interview on 1/03/18 at 11:35 a.m. with the Social Services Director, she confirmed that she handles all the beneficiary notifications. She further stated the facility uses the SNFABN (CMS ) form only and that she has never given the NOMNC (CMS ) form to the re… | 2020-09-01 |
| 2846 | 2846 | WAYCROSS HEALTH AND REHABILITATION | 115605 | 1910 DOROTHY STREET | WAYCROSS | GA | 31501 | 2017-10-19 | 253 | B | 0 | 1 | J09I11 | Based on observation and staff interviews, the facility failed to provide a sanitary environment free from urine odor for two shared bathrooms on Hall A (Room A-1 and Room A-10). This had the potential to effect four residents. The sample size was 33 residents. Findings include: Several observations were made on 10/16/17 at 11:21 a.m, 1:38 p.m, 10/17/17 at 9:27 a.m, 10:35 a.m , 10/18/17 at 11:00 a.m, 2:35 p.m, 5:15 p.m, 10/19/17 at 10:00 a.m, 11:20 a.m, and 2:00 p.m revealed strong urine odor in resident's bathrooms for Room A-1 and Room A-10. Interview and observation of Rooms A-1 and A-10 with Administrator on 10/19/17 at 2:09 p.m revealed that she was unaware of an urine odor in the bathrooms. She verified the strong odor in both bathrooms. She further stated that she can have the problem addressed within 20 minutes and have staff use vinegar to eliminate the odors. She stated that her expectations are that all facility staff address any urine odor and refer to housekeeping staff. Interview and observation of Room A-1 and A-10 with Director of Nursing on 10/19/17 at 2:11 p.m revealed that she identified the urine odor in Room A-1 earlier on 10/16/17 and had addressed the issue with the Housekeeping Supervisor. She was unaware that an urine odor was present on today in bathroom A-1. She felt that at least one of the residents per each room who shared the bathroom was having urine spills. She reported that her expectations are that the facility is free of urine odors caused by urine spills. She also stated that she felt the urine odors are embedded in the bathroom tiles. She stated the facility protocol is for staff to log all work orders in the Housekeeping/Maintenance Log. The log is kept at the nursing stations. Late interview with the Administrator on 10/19/17 at 2:31 p.m revealed that her investigations of the situation revealed that one of the residents is care plan for urinating on the bathroom floor. She stated that her expectations are that staff follow the facility policy and procedure with monitoring,… | 2020-09-01 |
| 2847 | 2847 | WAYCROSS HEALTH AND REHABILITATION | 115605 | 1910 DOROTHY STREET | WAYCROSS | GA | 31501 | 2017-10-19 | 278 | B | 0 | 1 | J09I11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interview, the facility failed to ensure that the Minimum Data Set (MDS) assessment was accurate related to dental status for one resident (R) (#31), and for Level II PASRR (Preadmission Screening and Resident Review) status for one resident (#56). The sample size was 33 residents. Findings include: 1. Review of R #31's Annual MDS dated [DATE] revealed that she was coded as having no oral or dental issues, and review of the Care Area Assessment Summary (CAAS) for this MDS revealed that Dental Care did not trigger as an area of concern. Review of a risk for mouth pain due to teeth in poor condition care plan revealed an effective date of 7/2/12. Review of an Admission assessment dated [DATE] noted that R #31 had missing natural teeth and decayed areas. Observation of R #31's teeth on 10/17/17 at 1:53 p.m. revealed that there were several missing teeth on the top, and there one was broken tooth near the front and the remaining teeth were discolored and appeared to be in poor condition. Interview with R #31 at this time revealed that she denied tooth pain or difficulty chewing her food. Interview with the Social Services Director on 10/18/17 at 5:11 p.m. revealed that R #31 had not elected to sign up for the facility's contracted dentistry service. Interview with the Resident Assessment Instrument (RAI) Director on 10/19/17 at 8:40 a.m. revealed that she was the one that coded the dental section of the MDS, and that when she had done R #31's assessment the previous week she did not see any missing or broken teeth. She further stated that since the resident denied mouth pain, she didn't go any further to assess when the resident said she was having no oral problems. During interview with the RAI Director on 10/19/17 at 9:31 a.m., she stated that she had just made another observation of R #31's teeth, and saw a black area on a tooth on the top right side toward the back, and a broken tooth on… | 2020-09-01 |
| 2882 | 2882 | PINEWOOD NURSING CENTER | 115607 | 433 NORTH MCGRIFF STREET | WHIGHAM | GA | 39897 | 2019-11-22 | 582 | B | 0 | 1 | IUU711 | Based on record review and staff interview the facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN- ) for two of three residents (R) (R#27 and R#221) reviewed for ABN Notices that had been discharged from Medicare Part A coverage. Findings include: 1. Record review for R#27 revealed that skilled services were initiated on 7/26/19 and services ended on 8/9/19. Review of the documentation that was provided by the Business Office Manager (BOM) revealed that there was not any evidence that the SNF ABN CMS- form was provided to R#27 or to R#27's Responsible Party. 2. Record review for R#221 revealed skilled services were initiated on 9/19/19 and services ended on 10/22/19. Review of documentation that was provided by the BOM revealed that there was not any evidence that the SNF ABN CMS- form was provided to R#221 or R#221's Responsible Party. Interview on 10/31/19 at 11:13 a.m. with the BOM revealed that she confirmed that R#27 and R#221 remained in the facility after skilled services were discontinued and the SNF ABN- was not given to the residents. The BOM revealed that she was unaware that residents should receive SNF ABN - and she did not have a copy of a SNF ABN- in her possession and she was not aware of this regulation. | 2020-09-01 |
| 2916 | 2916 | CANDLER SKILLED NURSING UNIT | 115610 | 5353 REYNOLDS STREET | SAVANNAH | GA | 31405 | 2019-06-06 | 883 | B | 0 | 1 | BC0E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the facility policy titled Standing Orders for Influenza Vaccine Protocol, and staff interview, the facility failed to provide documented evidence that education/information was provided to residents prior to being offered the flu or pneumonia vaccine for five residents (R) (#800, #801, #112, #113, and #114) of 13 sampled residents. Findings include: Review of the clinical record revealed R#800 was admitted to the facility on [DATE]. It was documented in the clinical record that the patient/caregiver refused the flu vaccine. Further review of the clinical record revealed no documented evidence that the resident received education/information prior to being offered the flu vaccine. Review of the clinical record revealed R#801 was admitted to the facility on [DATE]. It was documented in the clinical record that the patient/caregiver refused the flu vaccine. Further review of the clinical record revealed no documented evidence that the resident received education/information prior to being offered the flu vaccine. Review of the clinical record revealed R#112 was admitted to the facility on [DATE]. It was documented in the clinical record that the patient/caregiver refused the pneumonia vaccine. Further review of the clinical record revealed no documented evidence that the resident received education/information prior to being offered the pneumonia vaccine. Review of the clinical record revealed R#113 was admitted to the facility on [DATE]. It was documented in the clinical record that the patient/caregiver refused the pneumonia vaccine. Further review of the clinical record revealed no documented evidence that the resident received education/information prior to being offered the pneumonia vaccine. Review of the clinical record revealed R#114 was admitted to the facility on [DATE]. It was documented in the clinical record that the patient/caregiver refused the pneumonia vaccine. Further review of the clinical re… | 2020-09-01 |
| 2947 | 2947 | BAPTIST VILLAGE, INC. | 115615 | 2650 CARSWELL AVE | WAYCROSS | GA | 31502 | 2019-06-06 | 732 | B | 0 | 1 | 1X3T11 | Based on observation and staff interviews, the facility failed to assure the nurse staffing information form was complete for one of four days in the main building. Findings include: During a tour of the facility on 6/5/19 at 4:30 p.m. the nurse staff posting was observed near the receptionist desk at the entrance of the facility. Interview with Receptionist PP on 6/06/19 at 4:13 p.m. who reported that staffing information is posted daily by the receptionist. Upon review of the nurse staff postings for the week it was confirmed that total hours were not documented on the form or on the board that displayed the information. Receptionist PP revealed that she did not know the hours and that someone in corporate may be responsible for them. During an interview with the Administrator on 6/6/19 at 4:23 p.m., it was confirmed that the nurse staffing form did not have total hours. The Administrator reviewed the posted staffing template that was in the nurse staffing book and confirmed that the total hours were not being posted this week. The Administrator further reported that she was not sure why the total hours were not being posted. | 2020-09-01 |
| 3047 | 3047 | EASTMAN HEALTHCARE & REHAB | 115622 | 556 CHESTER HIGHWAY | EASTMAN | GA | 31023 | 2019-10-23 | 645 | B | 0 | 1 | PMJ811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical records and staff and resident interviews, the facility failed to ensure the need of a PreAdmission Screening/Resident Review (PASARR) to ensure that individualized care and services were offered to meet residents' needs for three of 10 sampled residents (R) (R#62, R#51, R#53,) that were reviewed for PASARR. Findings include: 1.Review of medical record for R# 62 revealed [DIAGNOSES REDACTED]. Further review of the medical record indicated the following behaviors: On 7/16/19 at 5:13 p.m. R#62 was documented as initiating a physical altercation with another resident in which the other resident was hit in the mouth causing a tooth to dislodge. This ultimately resulted in a behavioral hospital stay. 1. On 1/13/19 at 12:25 a.m. R#62 was documented as initiating a physical altercation with another resident. 2. On 2/8/19 at 10:33 a.m. R#62 was documented as sitting in the hallway yelling and cursing, that he is going burn that [***] to the ground. 3. On 2/13/19 at 5:35 p.m. R#62 became physically aggressive with another resident who bumped into him in the hallway. As a result of this R#62 kicked the other resident in the leg. The other resident then threw water on R#62 and he responded by kicking the resident in the face while he was bending down to rub leg. 4. On 5/30/19 at 9:19 p.m. R#62 was documented as making negative comments towards self. Just let me die. I thought you would just let me die by now. Resident asked did he want to die or harm himself resident stated, No. 5. On 6/4/19 at 2:27 p.m. R#62 was documented as making negative comments towards self. Just let me die. Just get a gun and kill me already. Resident asked did he want to die or harm himself resident stated, No. 6. On 6/5/19 at 8:36 a.m. R#62 was documented as making negative comments towards self and verbal aggression towards staff. Just like that stupid Nazi [***] wants me to hurt. Just let me die. Just get a gun and kill me already. 7. On 6/5/19… | 2020-09-01 |
| 3120 | 3120 | PRUITTHEALTH - SYLVESTER | 115629 | 104 MONK STREET | SYLVESTER | GA | 31791 | 2017-09-28 | 278 | B | 0 | 1 | EO6S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to code the Dental section of the Minimum Data Set (MDS) accurately for two residents (R) (#15 and #72) who were edentulous (without teeth) with no dentures. The sample size was 35 residents. Findings include: 1. Review of R #15's Significant Change MDS dated [DATE] revealed that he had no dental issues, and Dental Care did not trigger as an area of concern on the Care Area Assessment Summary (CAAS). Review of his potential for weight loss care plan revealed that the weight loss potential was related to a therapeutic diet, disease process, and use of dentures. Review of Nursing Monthly Assessment Forms dated 12/5/16, 1/5/17, 7/5/17, and 8/24/17 revealed that he was assessed as having no natural teeth or tooth fragments. During observations on 9/25/17 at 4:59 p.m., 9/27/17 at 1:05 p.m., and 9/28/17 at 8:32 a.m., R #15 was observed to be edentulous, with no dentures in his mouth. During interview with Registered Nurse (RN) MDS Coordinator AA on 9/28/17 at 8:41 a.m., she stated that she usually looked at the dental section of the nursing assessment to code the dental section of the MDS. She further stated that as long as a resident had dentures and they fit well, that she would not code the resident as edentulous. During interview with Certified Nursing Assistant (CNA) BB on 9/28/17 at 8:32 a.m., she stated that R #15 used to have dentures, but that she had not seen them for a while. During observation at this time, she was not able to find any dentures for R #15 in his room. During interview with Licensed Practical Nurse (LPN) CC on 9/28/17 at 8:36 p.m., she stated that R #15's dentures were lost over a year ago, and he has had none since then. During interview with RN MDS Coordinator AA on 9/28/17 at 8:41 a.m., she stated that the look-back period for coding the Dental section of the MDS was seven days from the Assessment Reference Date (ARD). 2. Review of R #72's Si… | 2020-09-01 |
| 3152 | 3152 | PRUITTHEALTH - GRANDVIEW | 115631 | 165 WINSTON DRIVE | ATHENS | GA | 30607 | 2018-04-05 | 732 | B | 0 | 1 | 4XQB11 | Based on observation and staff interviews, the facility failed to post the daily nurse staffing information on two of four days (4/3/18 and 4/4/18) of the survey. The facility census was 68 residents. Findings include: During initial tour on 4/2/18 at 11:06 a.m., the daily nurse staff posted on the wall across from the nurses station revealed it was dated 3/30/18, indicating that staffing information had not been posted for the weekend days of 3/31/18 and 4/1/18. During observation on 4/3/18 at 8:30 a.m., 11:19 a.m., 3:00 p.m. and 4:30 p.m., the daily nurse staffing posted on the wall across from the nurses station revealed it was dated 4/2/18. During observation on 4/4/18 at 8:23 a.m., 12:03 p.m., 4:00 p.m., the daily nurse staffing posted on the wall across from the nurses station revealed it was dated 4/2/18, indicating that staffing information had not been posted for 4/3/18. An interview on 4/5/18 at 7:58 a.m., with Assistant Director of Health Services (ADHS) revealed that she assumed responsibility of posting the daily nurse staffing in the absence of the Director of Health Services (DHS). She further revealed that because its not something she routinely does, that she forgets to post it sometimes. An interview on 4/5/18 at 1:06 p.m., with Administrator, revealed that the DHS responsibilities had been split between the Interim DHS and the ADHS. She stated her expectation are for the daily nurse staffing to be posted by the early morning. She further stated the ADHS has been the person posting the daily nurse staffing, but she probably forgot to do it. | 2020-09-01 |
| 3168 | 3168 | SAVANNAH BEACH HEALTH AND REHAB | 115633 | 26 VAN HORNE STREET | TYBEE ISLAND | GA | 31328 | 2017-07-23 | 247 | B | 1 | 1 | NETP11 | > Based on record review, staff and resident interviews and review of the Admission policy related to room change, the facility failed to have a system in place to ensure that one resident (R#18) of 16 sampled residents were notified prior to a roommate change. Findings include: Review of the facility policy for Admission Agreement, B: Notice of Rights and Services, 11. Notifications of Changes, II. The Facility must also promptly notify the Resident and, if known, the Resident's legal representative or interested family member when there is: [NAME] a change in room or roommate assignment as specified in 483.15 (E)(2):or B. A change in resident rights under Federal or State Law or regulation as specified in paragraph (B)(1) of this section. During a resident interview on 7/21/17 at 3:40 p.m. the resident stated he had several new roommates but that he was not told that he would be getting a new roommate. An interview with the Social Worker (SW) on 7/22/17 at 11:15 p.m. revealed that he though it was the Admission Coordinator who was to notify the residents of room changes or getting a new roommate. The Admission Coordinator, who is also a nurse, was working on the medication cart on 7/22/17 and was interviewed, with the SW, on the same day at 11:18 p.m. and revealed that he only handles the new admissions and that the SW is responsible for notification of room changes. Further interview with the SW at this revealed that he did not know who was responsible for notification of a new roommate and agrees that the residents are not being notified of room changes. An interview with the Administrator on 7/23/17 at 12:37 p.m. revealed that it is the responsibility of the SW to notify resident's of room changes or if they are getting a new roommate. She was not aware that the residents were not being notified prior to getting a new roommate. | 2020-09-01 |
| 3199 | 3199 | FOUNTAIN BLUE REHAB AND NURSING | 115636 | 3051 WHITESIDE ROAD | MACON | GA | 31216 | 2018-03-01 | 582 | B | 0 | 1 | MRLK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to completely fill out the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) with the resident or responsible party's signature to indicate that they understood the contents of the form for two of three residents (R) reviewed (#34 and #46), who were discharged off Medicare Part A services. The sample size was 29 residents. Findings include: Review of a Beneficiary Notice-Residents discharged Within the Last Six Months form provided by the facility revealed that R #46 was discharged off Medicare Part A skilled services on 11/24/17 and remained in the facility afterwards with benefit days remaining. Further review of this form revealed that R #34 was discharged off skilled services on 12/26/17, and remained in the facility with benefit days remaining. Review of R #46's Annual Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status score of 5 (a BIMS score of 0 to 7 indicates severe cognitive impairment). Review of a Notice of Medicare Non-Coverage (NOMNC) form revealed his skilled services would end on 11/24/17, and the resident signed the form on that date which indicated he understood that he could appeal the decision to discharge him off skilled services. Review of his SNFABN form dated 11/20/17 revealed that Option 2 was checked, which indicated that the resident did not want to continue to receive skilled nursing services, Physical Therapy (PT), or Occupational Therapy (OT). Further review of this form revealed that there was no signature on the form of the patient or authorized representative. Review of R #34's Annual MDS dated [DATE] revealed that he had a BIMS score of 5. Review of a NOMNC revealed that his skilled services would end on 12/26/17, which he signed on the same day. Review of his SNFABN form dated 12/22/17 revealed that Option 2 was checked, but there was no signature on the form of the patient or authorized representative. … | 2020-09-01 |
| 3212 | 3212 | FOUNTAIN BLUE REHAB AND NURSING | 115636 | 3051 WHITESIDE ROAD | MACON | GA | 31216 | 2019-03-07 | 582 | B | 0 | 1 | PBN411 | Based on record review and staff interview the facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) to two of three sampled residents (R#74 and R#63) who were reviewed after being discharged from Medicare Part A Services and remained in the facility. Findings include: Review of the record for R# 74 revealed the resident started occupational therapy services on 02/01/2019 and services ended on 02/15/2019. Review of the record for R# 63 revealed the resident started occupational therapy services on 11/01/2018 and services ended on 02/15/2019. An interview on 3/07/2019 at 1:46 PM with the Business Office Manager revealed that she was new to the position and was not aware that the resident R#73 and R#63 needed to receive a Beneficiary Protection Notification Review upon discharge from Medicaid Part A services. A post survey interview with the Business Office Manager (BOM) on 3/21/19 at 2:41 p.m. revealed that she had been in her position for several months and was trained by the previous BOM. She revealed that the previous BOM had instructed her to use another Center for Medicare Services (CMS) form (for part B) and was giving those to the residents. She has gotten the correct forms from the CMS website but is still unsure of all the information that is needed to complete the forms. | 2020-09-01 |
| 3275 | 3275 | KEYSVILLE NURSING HOME & REHAB | 115644 | 1005 GA HIGHWAY 88 | BLYTHE | GA | 30805 | 2019-08-22 | 582 | B | 0 | 1 | 0ZDB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the Skilled Nursing Facility Advance Beneficiary Notices (SNFABN) were completed with the designation of their choice of whether or not to continue to receive skilled services after discharge off Medicare Part A, their right to appeal the decision for the termination of Medicare Part A services, and the potential liability for continued services should their appeal be denied, for two of three residents (R) reviewed (#35 and #43), who remained in the facility. Findings include: Review of a facility-completed worksheet Beneficiary Notice-Residents discharged Within the Last Six Months, revealed that R#35 and R#43 were discharged from a Medicare-covered Part A stay, still had benefit days remaining, and remained in the facility after their last covered day. 1. Review of the Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review form for R#35 indicated that services were initiated on 1/29/19 and discharged from Medicare Part A services on 2/17/19, and he remained in the facility with Part A benefit days remaining. Review of R#35's Advance Beneficiary Notice of Noncoverage revealed that the effective date coverage of his Skilled Part A Nursing services would end as of 2/17/19, and his responsible party signed the form, on 2/7/19. Review of the What to Do Now section of this notice revealed for him to choose an option about whether to get the care listed above Skilled Part A Nursing. Further review of the notice revealed that none of the three options were chosen (the options were to continue the care and bill Medicare; or continue the care but don't bill Medicare; or don't want the care listed). 2. Review of the SNF Beneficiary Protection Notification Review form for R#43 indicated that services were initiated on 4/11/19 and discharged from Medicare Part A services on 5/3/19, and she remained in the facility with Part A benefit days remaining. Review of R#… | 2020-09-01 |
| 3325 | 3325 | FORT VALLEY HEALTH AND REHAB | 115651 | 604 BLUEBIRD BOULEVARD | FORT VALLEY | GA | 31030 | 2019-08-08 | 582 | B | 0 | 1 | ZDTW11 | Based on record review and staff interview it was determined the facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN- ) to two of three residents (R) (R#30 and R#41) reviewed that were discharged from Medicare Part A coverage. Findings included: A review of Form CMS- SNF Beneficiary Protection Notification Review was conducted on R#30 and R#41 that remained in the facility with skilled services discontinued. Review of records for R#30 revealed that skilled services were initiated on 4/25/19 with services ending 5/17/19. Review of documentation that was provided by the Business Office Manager (BOM) revealed no evidence that the SNF ABN CMS- form was provided to the resident by the facility. Review of records for R#41 revealed that skilled services were initiated on 1/24/19 with services ending 2/21/19. Review of documentation that was provided by the BOM revealed no evidence that the SNF ABN CMS- form was provided to the resident by the facility. An interview on 8/8/19 at 9:00 a.m. with the BOM. She confirmed that R#30 remains in the facility and was discharged from Physical Therapy, Occupational Therapy, Speech Therapy, and Skilled Nursing service on 5/17/19 and was not provided SNF ABN- . The BOM confirmed R#41 remains in the facility and was discharged from Physical Therapy, Occupational Therapy, and Skilled Nursing service on 6/13/19 and was not provided SNF ABN- . | 2020-09-01 |
| 3376 | 3376 | EASTVIEW NURSING CENTER | 115656 | 3020 JEFFERSONVILLE ROAD | MACON | GA | 31217 | 2019-04-11 | 582 | B | 0 | 1 | 5T1O11 | Based on record review and staff interview it was determined that the facility failed to provide Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN), Form CMS- to three (3) of three (3) selected residents discharged from Medicare Part A Services. One resident (R) R#268 was discharged to the community, two residents, R#41 and R#48 were discharged from Medicare Part A Services, but chose to remain in the facility. The sample size was 31 residents. Findings include: A review of the clinical record for R#41 indicated the resident started skilled services 2/12/19, last covered day of SNF Medicare Part A services documented as 3/6/19, for skilled speech therapy services. The resident chose to remain in facility. There was no evidence that the facility had issued an SNFABN (Form CMS- ) to R#41 or the beneficiary's representative, providing the opportunity to continue with skilled services, at his cost, if Medicare did not reimburse. A review of the clinical record for R#48 indicated that the resident started skilled services 3/6/19, with the last covered day of SNF Medicare Part A services documented as 3/10/19, for skilled nursing services. The resident chose to remain in the facility. There was no evidence that the facility had issued an SNFABN (Form CMS- ) to R#48 or the beneficiary's representative, providing the opportunity to continue with skilled services, at her cost, if Medicare did not reimburse. A review of the clinical record for R#268 indicated that the resident started skilled services 12/13/18, with the last covered day of SNF Medicare Part A services on 3/6/19, for skilled physical therapy services and occupational therapy services. The last therapy service date is documented as 3/5/19. The resident was discharged to the community 3/7/19. No evidenced was found that the NOMNC (Form CMS- ) was provided to the resident/or beneficiary representative acknowledging the resident/or beneficiary's representative had been provided a copy of the form or an explanation of why the form was not provided. A… | 2020-09-01 |
| 3494 | 3494 | LAUREL PARK AT HENRY MED CTR | 115673 | 1050 HOSPITAL DRIVE | STOCKBRIDGE | GA | 30281 | 2019-07-25 | 640 | B | 1 | 1 | QV4S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interview and review of RAI manual Submission and correction of the MDS Assessments, the facility failed to ensure that Minimum Data Set (MDS) discharge assessments were transmitted within 14 days of discharge to CMS's (Centers for Medicare and Medicaid Services) for two residents (R) (R #3 and R #4). Findings include: A review of Submission and Correction of the MDS Assessments from the RAI manual revealed, the MDS Completion Date (Z0500B) must be no later than 14 days after the Assessment Reference Date (ARD) (A2300). 1.Review of the electronic medical record of list of completed and transmitted MDS revealed that a discharge assessment had not been completed for R#3. Review of the census confirmed that R#3 was not currently a resident in the facility. R# 3 admitted to the facility on [DATE] and discharged from the facility on 2/13/19. 2.Review of the electronic medical record list of completed and transmitted MDS revealed that a discharge assessment had not been completed for R#4. Review of the census confirmed that R#4 was not currently a resident in the facility. R# 4 admitted to the facility on [DATE] and discharged from the facility on 2/25/19. During an interview with MDS Registered Nurse (RN) HH and MDS RN II on 7/25/19 at 9:22 a.m. it was reported that MDS assessments are done on admission, quarterly, annually, and at discharge. MDS RN II reported that R#3 discharged from the facility on 2/13/19 and confirmed that there was no discharge assessment completed for this resident. MDS RN HH reported that MDS is responsible for completing the discharge assessment and typically the assessment should be opened the same day of the discharge. It was further reported that discharge assessments are typically completed within a few days of discharge. MDS RN II reported that meetings are held at least weekly and residents who will be discharging are discussed. When questioned how the assessments for R#3 and R#4 were missed it was … | 2020-09-01 |
| 3519 | 3519 | RETREAT, THE | 115675 | 898 COLLEGE ST | MONTICELLO | GA | 31064 | 2018-07-26 | 641 | B | 0 | 1 | NKPU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interview, the facility failed to ensure the Minimum Data Set (MDS) assessments related to bed rails used as restraints were accurate for 39 residents, including ten sampled residents (R) (R#25, R#29, R#21, R#43, R#35, R#32, R#40, R#16, R#3, and R#12). The facility census was 51 residents. Findings include: During interview with the MDS Coordinator on 7/23/18 at 1:50 p.m., she stated that according to the RAI (Resident Assessment Instrument) manual, if a resident could rise independently, any bed rail including small transfer bars were considered a restraint. Review of CMS's (Centers for Medicare and Medicaid Services) RAI MDS 3.0 Manual, Section P: Restraints, revealed that the intent of this section was to record the frequency over the 7-day look-back period that the resident was restrained. Review of the Steps for Assessment section noted that the device should be classified as a restraint only when it meets the criteria of the restraint definition. During interview with the MDS Coordinator on 7/23/18 at 2:19 p.m., she stated that none of the bed rails or transfer bars used in the facility met the criteria of a restraint. Review of the MDS Section P, Restraints and Alarms, provided by the MDS Coordinator at this time revealed: Physical restraints are any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. During further interview, the MDS Coordinator stated that this did not apply to any of the residents who had bed rails, and that she was coding them as having a bed rail in Section P even though they did not meet the definition of a physical restraint for that resident. During interview with the MDS Coordinator on 7/23/18 at 4:28 p.m., she stated that the CMS Form-672 (Resident Census and Conditions of Residents) in… | 2020-09-01 |
| 3646 | 3646 | WILLOWBROOKE COURT AT LANIER VILLAGE ESTATES | 115687 | 4145 MISTY MORNING WAY | GAINESVILLE | GA | 30506 | 2018-09-16 | 582 | B | 0 | 1 | 94FP11 | Based on record review and interviews, the facility failed to file a claim when requested by the beneficiary for three residents (R) #59; #41; #263 of five residents during the Beneficiary Protection Notification review. Findings include: During record review for R #59 that was conducted on 9/15/18, the facility provided a copy of the resident's Centers for Medicaid and Medicare (CMS) form and the CMS NOMNC (Notice of Medicare Non-Coverage) which indicated that the effective date coverage for current skilled services will end on 3/26/18. The notice was signed as being received by the resident representative on 3/22/18. The resident representative marked YES opting for the resident to continue to receive the services; requesting an appeal. During record review for R #41 that was conducted on 9/15/18, the facility provided a copy of the resident's CMS form and the CMS NOMNC which indicated that the effective date coverage for current skilled services will end on 5/30/18. The notice was signed as being received by the resident on 5/27/18. The resident marked YES opting to continue to receive the services; requesting an appeal. During record review for R#263 that was conducted on 9/15/18, the facility provided a copy of the resident's CMS form and the CMS NOMNC which indicated that the effective date coverage for current skilled services will end on 5/11/18. The notice was signed as being received by the resident on 9/5/18. The resident marked YES opting to continue to receive the services; requesting an appeal. Interview with the Social Services Director (SSD) on 9/15/18 at 9:17 am she stated that she is responsible for providing the NONMNC notices to the residents. She was asked to provide the appeal information for R #59, #41, and #263 seeing as they had opted to continue to receive the services. She stated that the residents had never requested an appeal and that they were not provided the services beyond the end of services date. Interview with the Nursing Home Administrator (NHA) on 9/15/18 at 11:05 a.m. she st… | 2020-09-01 |
| 3784 | 3784 | WASHINGTON CO EXTENDED CARE FACILITY | 115702 | 610 SPARTA ROAD | SANDERSVILLE | GA | 31082 | 2018-01-19 | 582 | B | 0 | 1 | YZ8111 | Based on record review and staff interview, the facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) (Form CMS- ) to two (2) residents (R) (R#33 and #12) of two (2) residents who remained in the facility from a sample of three (3) residents who were discharged from Medicare Part A services in the last six (6) months. Findings include: 1. R#33 was discharged from Medicare Part A services on 7/3/17 and remained in the facility. However, the only notice that was provided to the resident was the Notice of Medicare Non-Coverage (NOMNC) (Form CMS- ). There was no evidence that the facility had issued an SNFABN (Form CMS- ) to R#33 or her responsible party, providing the opportunity to continue with skilled services, at her cost, if Medicare did not reimburse. 2. R#12 was discharged for m Medicare Part A services on 8/24/17 and remained in the facility. However, the only notice provided to the resident was the Notice of Medicare Non-Coverage (NOMNC) (Form CMS- ). There was no evidence that the facility had issued the SNFABN (Form CMS- ) to R#12 or his responsible party, providing the opportunity to continue with skilled services, at his cost, if Medicare did not reimburse. On 1/19/18 at 8:45 a.m., the Administrator confirmed that R#33 and R#12 had not been issued the SNFABN (Form CMS- ) although both had remained in the facility. Further interview revealed that the facility had revised their policy in (YEAR) that either form (NOMNC or SNFABN) could be issued to residents who remained in the facility. | 2020-09-01 |
| 3789 | 3789 | WASHINGTON CO EXTENDED CARE FACILITY | 115702 | 610 SPARTA ROAD | SANDERSVILLE | GA | 31082 | 2018-12-06 | 732 | B | 0 | 1 | TFW611 | Based on observation and staff interviews the facility failed to have an up to date staffing posting on 12/3/18 and to maintain the posted daily nurse staffing data for a minimum of 18 months. The facility census 58. Findings include: Observation on 12/3/18 at 10:30 a.m. upon entering the facility the staffing posting revealed date 12/1/18. The information posted included the census; shift, category of staffing, Registered Nurse (RN), Licensed Practical Nurse (LPN) and Certified Nurse Assistant (CNA); the number of staff, planned hours, and the actual hours. An interview was conducted on 12/4/18 at 8:45 a.m. with the Administrator regarding the staffing posting revealed that staff posting should be completed the first thing in the morning by 8:30 a.m. - 8:45 a.m. The Administrator revealed that the Director of Nursing (DON) is responsible for training, overseeing the staffing posting, and keeping 18 months of staffing posting. An interview was conducted on 12/4/18 at 9:00 a.m. with the DON regarding the staffing posting revealed that the staff posting should be posted as early as possible and should be up by 8:30 a.m. Any correction on the posting is completed by the ward clerk and keep for 18 months. A policy and review of the 18 months was requested. An interview was conducted on 12/4/18 at 12:30 p.m. with the DON revealed that the facility did not have a policy on staffing posting. An interview was conducted on 12/5/18 at 12:55 p.m. with[NAME] Clerk AA who is responsible for the daily schedule (assignment) and posting the daily nursing staffing.[NAME] Clerk AA confirmed that the staff posting for 12/3/18 and was not posted when survey team entered the building. She revealed that she was not aware the staffing posting had to be up at a certain time. The surveyor requested the daily posted staffing sheets that the facility currently has kept however[NAME] Clerk AA revealed she does not have 18 months of the staffing sheets.[NAME] Clerk AA revealed she was not aware that she was required to keep 18 months of the … | 2020-09-01 |
| 3971 | 3971 | SENIOR CARE CENTER - BRUNSWICK | 115721 | 2611 WILDWOOD DRIVE | BRUNSWICK | GA | 31520 | 2019-05-23 | 582 | B | 0 | 1 | 80SI11 | Based on record review and staff interview, the facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) to the resident or responsible party upon discharge from Medicare Part A services to for two of three residents (R) reviewed (R#166 and R#187). Findings include: Review of a Beneficiary Notice-Residents discharged Within the Last Six Months form, provided by the facility, revealed that R #166 was discharged off Medicare Part A skilled services on 5/6/19 and R #187 discharged off Part A services on 1/18/19 with both residents remaining in the facility afterwards with benefit days remaining. Record review revealed that there was no evidence that the SNFABN was provided to either R#166 or R#187. Interview on 5/22/19 at 8:43 a.m. with Social Services II revealed that that SNF ABN was not provided to R#187. Interview on 5/22/19 at 8:46 a.m. with Social Services JJ revealed that SNF ABN was not provided to R#166. | 2020-09-01 |
| 4203 | 4203 | MAPLE RIDGE HEALTH CARE CENTER | 115543 | 22 MAPLE RIDGE DRIVE S.E. | CARTERSVILLE | GA | 30120 | 2016-04-07 | 356 | B | 0 | 1 | CD9711 | Based on observation and interview the facility failed to display the actual hours worked by the nursing staff. With a facility census of sixty-nine (69) residents. Findings Include: During an observation on 4/04/16 at 12:15 p.m.,4/05/16 at 2:00 p.m. and 4/06/16 at 3:10 p.m the staffing form was posted. However, the staffing did not document actual hours worked for nursing staff. Interview with the Administrator on 04/08/2016 at 5:28 p.m. confirmed that the actual hours worked by the nursing staff were not posted correctly for the dates of 4/4,4/5, and 4/6/16. | 2020-02-01 |
| 4219 | 4219 | NORTHSIDE GWINNETT EXTENDED CARE CENTER | 115645 | 650 PROFESSIONAL DRIVE | LAWRENCEVILLE | GA | 30046 | 2015-10-08 | 278 | B | 0 | 1 | WUC411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to accurately code on the Minimum Data Set (MDS) for hospice services for one (1) resident (#8), and for dental status for one (1) resident (#278). The sample size was twenty-four (24) residents. Findings include: 1. Review of resident #8's Significant Change MDS dated [DATE] and Quarterly MDS dated [DATE] revealed that she was not receiving hospice services. Review of the resident's care plans revealed that she had a care plan developed for hospice care due to the terminal condition of heart failure. Review of the hospice agreement for resident #8 noted she was started on hospice services on 03/26/15. During interview with Registered Nurse (RN) MDS staff EE on 10/08/15 at 9:05 a.m., she stated that she knew when a resident was placed on hospice services because she was given the physician's orders [REDACTED]. Upon further interview, she verified that she did not code the resident as receiving hospice services on the last two MDS assessments. 2. Review of resident #278's Annual MDS dated [DATE] revealed that she had no Oral/Dental issues. Review of the care plans revealed that no plan had been developed for dental. During observation of resident #278 on 10/05/15 at 2:41 p.m., she was observed to have her own natural teeth on the bottom, but no teeth on the top. During further observation at this time, the resident's top dentures were observed in a denture cup in the bathroom. During observation at lunch on 10/07/15 at 1:50 p.m., Nurse Tech GG was seen feeding resident #278, and the resident did not have her top dentures in. During interview with Nurse Tech GG at this time, she stated that the resident did not like to wear her dentures. During further observation at this time, the Tech was noted to offer and then put the resident's top plate in, and the resident immediately removed the dentures from her mouth. During interview with RN MDS staff EE on 10/08/15 at 9:05 … | 2020-02-01 |
| 4251 | 4251 | BONTERRA TRANSITIONAL CARE & REHABILITATION | 115555 | 2801 FELTON DRIVE | EAST POINT | GA | 30344 | 2016-04-14 | 247 | B | 0 | 1 | BE2O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interview, the facility failed to provide documentation that two (2) residents (Q and R) were notified of a change in roommate. The sample size was forty (40) residents. Findings include: During interview with resident Q on 04/11/16 at 2:38 p.m., he stated that they got a new roommate about a week after they were admitted to the facility, but was not notified of this. Review of resident Q's clinical record revealed that they were admitted on [DATE]. Review of the new roommate's clinical record revealed that he was admitted to resident Q's room on 02/04/16. Review of the computerized interdisciplinary progress notes revealed there was no documentation that resident Q had been notified that he was going to get a new roommate in February. Review of resident Q's Admission Minimum Data Set ((MDS) dated [DATE] revealed that they were assessed as being cognitively intact. During interview with resident R on 04/12/16 at 9:59 a.m., he stated that they had recently gotten a new roommate, but they could not remember the date. Upon further interview, resident R stated that the staff just brought the new roommate in the room, and that he (resident R) didn't know anything about it. Review of resident R's computerized interdisciplinary progress notes since (MONTH) of (YEAR) revealed that there was no documentation of the resident being notified that they were getting a new roommate. Review of resident R's MDS dated [DATE] revealed that they were assessed as having moderately-impaired cognition. During interview with the Social Services Director (SSD) on 04/14/16 at 8:25 a.m., she stated that whenever there was a new admission to the facility, either herself, the nurse, or someone in the Admissions department would tell the resident(s) already in the room that they were going to get a new roommate. Upon further interview, she stated that this notification was always done verbally, and not documented anywhere. During… | 2020-01-01 |
| 4252 | 4252 | BONTERRA TRANSITIONAL CARE & REHABILITATION | 115555 | 2801 FELTON DRIVE | EAST POINT | GA | 30344 | 2016-04-14 | 278 | B | 0 | 1 | BE2O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, hospice and facility staff interview, the facility failed to ensure that the Minimum Data Set (MDS) was accurate related to receiving hospice services for one (1) resident #22. In addition, the facility failed to ensure that the MDS was accurate related to receiving [MEDICAL TREATMENT] services and being edentulous (no teeth) for one (1) resident (#11). The sample size was forty (40) residents. Findings include: 1. Review of resident #22's Annual MDS dated [DATE] noted that they were receiving hospice care. Review of the Quarterly MDS dated [DATE] noted that they were coded as not receiving hospice care. Review of resident #22's clinical record revealed a care plan for admission to hospice services for end-stage Alzheimer's. Interview with the hospice Director of Nursing on 04/14/16 at 11:20 a.m. revealed that resident #22 had been on hospice services since 10/31/14. During interview with the Registered Nurse (RN) MDS Coordinator BB on 04/13/16 at 2:14 p.m., she stated that resident #22 should have been coded as being on hospice on the Quarterly MDS on 02/10/16. 2. During observation on 04/12/16 at 1:12 p.m. and 4:12 p.m., resident #11 was noted to be edentulous. Review of an Oral/Dental assessment dated [DATE] noted that the resident was edentulous, and had no dentures. Review of resident #11's Annual MDS dated [DATE] noted that the item of no natural teeth or tooth fragment(s) (edentulous) in the Dental section of the MDS was not selected. In addition, the Special Treatments and Programs section of this MDS revealed that the resident was coded as receiving [MEDICAL TREATMENT] services. Review of the care plans revealed that a Dental care plan had not been developed for resident #11, nor were any interventions found in any of the care plans to address the missing teeth. Further review of the care plans revealed that resident #11 received [MEDICAL TREATMENT] three times a week for a [DIAGNOSES REDACTED]. R… | 2020-01-01 |
| 4377 | 4377 | NORTHEAST ATLANTA HEALTH AND REHABILITATION CENTER | 115504 | 1500 S JOHNSON FERRY ROAD | ATLANTA | GA | 30319 | 2016-11-09 | 356 | B | 1 | 0 | 3P2Y11 | > Based on observation and staff interview, the facility failed to ensure required nurse staffing information, was updated daily and posted at the beginning of each shift for residents and visitors in the facility. This had the potential to affect residents who were capable of reading the information as well as visitors to the facility. The facility census was one-hundred-nine (109) and the sample was seventy-seven (77) residents. Findings include: Observtion on 8/8/16 at 8:55 a.m., the nursing staff information was posted in the hallway leading to the East unit by the admission office. There were three nursing staff forms posted with the top form showing a date of 7/30/16, the second form was dated 7/31/16 and the third form was dated 8/1/16. On 8/12/16 at 9:35 a.m., during a group conversation with the Administrator, receptionist and unit manager (UM)162, the receptionist stated that the nurse staffing should be posted daily. She discussed that the scheduler left about a month ago and the managers were all in charge of ensuring it got updated. The Administrator stated, his admission manger had noticed it right away and changed it immediately. The Administrator was informed the postings were from (MONTH) and were over a week old upon entering. The receptionist confirmed this for the Aministrator and he stated, That was my fault, I will own that. | 2019-11-01 |
| 4387 | 4387 | WESTBURY MEDICAL CARE AND REHAB | 115563 | 922 MCDONOUGH ROAD | JACKSON | GA | 30233 | 2015-09-17 | 161 | B | 0 | 1 | M5A011 | Based on record review and staff interview, the facility failed to ensure that the surety bond covered the ending balances in the resident trust account for four (4) of twelve (12) months reviewed. The facility handled a total of one-hundred and thirty-three (133) resident accounts. Findings include: Review of the surety bond revealed that it was in the amount of $100,000.00, and the effective date of the bond was 01/01/15 through 01/01/16. Review of resident trust account bank statements revealed that two accounts were used; one account received deposits and the other was used to write checks for liability and other expenses. The ending balances in both accounts were added together each month from (MONTH) of 2014 to (MONTH) of (YEAR), and in the following months the ending balance exceeded the surety bond limit: October 2014: $108, 922.04 December 2014: $113, 253.06 April (YEAR): $106,493.41 July (YEAR): $105,990.97 During interview with administrative employee MM, who handled the resident trust account, on 09/16/15 at 4:40 p.m., she stated that Social Security occasionally direct-deposited checks into the resident trust account twice in one month, and the facility only wrote resident liability checks once a month, and in those instances the ending balances in the trust account would exceed the surety bond limit. Upon further interview on 09/17/15 at 12:05 p.m., employee MM stated that because the trust fund balances exceeded the surety bond limit only a few times a year and for only a few days before liability checks were written and cleared, she did not feel that they needed to increase the bond limit. Review of trust account check images revealed checks did not clear to drop the balances below the surety bond limit until 01/15/15 for the excessive (MONTH) ending balance, and on 11/06/15 for the excessive (MONTH) ending balance. | 2019-11-01 |
| 4409 | 4409 | GOLD CITY HEALTH AND REHAB | 115689 | 222 MOORE DRIVE | DAHLONEGA | GA | 30533 | 2015-06-04 | 252 | B | 0 | 1 | PHUS11 | Based on observations, and staff interview the facility failed to maintain odor free environment for two (2) of two (2) common shower rooms, and two (2) resident bathrooms from two (2) of four (4) halls, (A 9 and D 3). Findings included: During an environmental tour of the facility on 6/4/15 at 1:45pm with the maintenance Director the following was observed: 1. The D Hall common shower had a pervasive musty odor. 2. The A Hall common shower had pervasive odor of urine. 3. Resident room A9 bathroom had a strong urine odor. 4. Resident room D3 had a strong urine odor. Interview with the Maintenance Director on 6/4/2015 at 2:15pm revealed the D Hall common shower room was only used for hospice residents, of which there are only two (2). He acknowledged that odors were present in these areas. | 2019-11-01 |
| 4422 | 4422 | TWIN FOUNTAINS HOME | 115709 | 1400 HOGANSVILLE ROAD | LAGRANGE | GA | 30240 | 2016-02-18 | 161 | B | 0 | 1 | UDN011 | Based on interview and record review it was determined that the facility failed to ensure that the surety bond covered the ending bank balances for the resident trust account for four (4) out of six (6) months reviewed. This deficient practice had the potential to effect seventy four (74) with resident trust fund accounts. Findings include: Review of the surety bond revealed that it was in the amount of $75,000.00 with effective date of (MONTH) 01, (YEAR) through (MONTH) 01, (YEAR). Continue review of the surety bond documents revealed that on (MONTH) 7, (YEAR) the bond was increased to $76,000.00. A review of the Resident Trust Account bank statements revealed the ending balances exceeded the Bond amount for the following months: September (YEAR) ending balance $80,796.52 November (YEAR) ending balance $81,410.67 December (YEAR) ending balance $122,283.62 January (YEAR) ending balance $79,558.12 Interview on 02/18/16 at 9:20 a. m. with the Administrator revealed the facility has an off-site Finance Department that handles the resident trust fund and banking statements. She confirmed that the banking statements provided for review were for the resident trust account funds. She revealed that she reviews the beginning and ending banking statements monthly. Continued interview with the Administrator revealed that she noticed during a monthly review of the banking statement that the ending balance was over the surety bond by $50 therefore she had the surety bond increased from $75,000 to $76,000. The administrator revealed that she confirmed that the ending balances for (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR) resident trust fund banking statements were over the surety bond amount. Telephone interview on 02/18/16 at 9:30 a. m. with AA in accounting revealed that the reason that several of the months ending balances were over the surety bond amount was due to checks not clearing. | 2019-11-01 |
| 4449 | 4449 | STEVENS PARK HEALTH AND REHABILITATION | 115294 | 820 STEVENS CREEK ROAD | AUGUSTA | GA | 30907 | 2015-10-29 | 167 | B | 0 | 1 | 6J0E11 | Based on observation, record review, resident and staff interview, the facility failed to post a notice of the availability of the State survey results for two (2) of four (4) days of the survey. The facility census was forty-eight (48) residents. Findings include: Review of the (YEAR) monthly Resident Council Minutes from (MONTH) to (MONTH) revealed that there was no documentation that the residents in the meeting were informed that they had the ability to review the State survey results, nor where the results were located. During multiple observations in the facility on 10/26/15 and10/27/15, revealed that the survey results were not found, nor was a sign found posted to indicate the availability and location of the results. During interview with the Administrator on 10/28/15 at 1:28 p.m., he verified that there was no sign posted announcing the location of the survey results anywhere in the building. During observation at this time, he obtained a brownish-tan colored notebook labeled on the spine with a white sticker with half-inch tall print labeled Licensure Results, that was inside a horizontal file holder on a desk in the hallway near the main entrance. Interviews were done with three residents who were active in the Resident Council, all of whom were coded as being cognitively intact on their most recent Minimum Data Set (MDS). During interview with resident R on 10/28/15 at 1:28 p.m., she stated that she did not know that she had the ability to review the survey results, and did not know where they were located. During interview with resident S on 10/29/15 at 9:01 a.m., she stated that she did not ever recall staff discussing the availability of the survey results in the Resident Council meetings, and she did not know she had the ability to review them. During interview with resident T on 10/29/15 at 10:32 a.m., she did not recall anyone ever mentioning that she had the ability to review the results of the State survey inspections, did not know where the results were located, and that she would be interes… | 2019-10-01 |
| 4489 | 4489 | OAKS HEALTH CTR AT THE MARSHES OF SKIDAWAY ISLAND | 115715 | 95 SKIDAWAY ISLAND PARK ROAD | SAVANNAH | GA | 31411 | 2016-01-14 | 356 | B | 0 | 1 | JF7O11 | Based on record review and staff interview, the facility failed to include the total number of hours worked by direct care staff on the nurse staffing posting for four (4) of five (5) days of the survey. The facility census was nineteen (19) residents. Findings include: During initial tour of the facility on 01/10/16 beginning at 4:30 p.m., the posting of the nurse staffing information was seen by the Peachtree nurse's station. During further observations on each day of the survey on 01/11/16 at 11:45 a.m.; 01/12/16 at 12:20 p.m.; 01/13/16 at 12:34 p.m.; and 01/14/16 at 8:38 a.m. revealed that the nurse staffing information lacked the total number of hours worked. During interview with the Director of Nursing (DON) on 01/14/16 at 8:38 a.m., they stated that a staff nurse completed this form, and that they (the DON) went back later to fill in the total number of hours worked by the staff. Review of the nurse staffing information forms from 09/01/15 to 01/14/16 revealed that none of the forms included the total number of hours worked by the nursing staff, except for on 01/10/16. | 2019-10-01 |
| 4526 | 4526 | ROBERTA HEALTH AND REHAB | 115523 | 420 MYTLE DRIVE | ROBERTA | GA | 31078 | 2015-06-04 | 160 | B | 0 | 1 | P54911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure that resident trust funds were disbursed within thirty (30) days of expiration for five (5) of seven (7) accounts reviewed. Findings include: 1. Resident #59 expired on [DATE] and monies were not disbursed until [DATE] in the amount of $844.02, seventy seven (77) days after death. 2. Resident #73 expired on [DATE] and monies were not disbursed until [DATE] in the amount of $30.74, eight six (86) days after death. 3. Resident #45 expired on [DATE] had a total amount of $3837.49 in trust account, only $1114.00 was disbursed on [DATE], the remaining $2723.49 is in the bank, resident had been deceased for over sixty (60) days 4. Resident Q expired on [DATE] and monies were not disbursed until [DATE] in the amount of $969.87, seventy seven (77) days after death. 5. Resident #33 expired on [DATE] and monies have not been disbursed for the amount of $831.31 and $532.40, over one hundred (100) days after death. Interview on [DATE] at 5:10 p.m. with the Office Manager revealed that she is new to learning the rules and guidelines, she was hired on [DATE]. She confirmed that the resident trust accounts were to be closed and monies disbursed within 30 days. The Office Manager acknowledged that the checks to the appropriate responsible parties were not disbursed within the 30 days after death for the five residents. The Office Manager revealed that she had closed the accounts and entered the information into the computer system and did not realize that some of the checks were not disbursed to the resident's families. | 2019-09-01 |
| 4531 | 4531 | AVALON HEALTH AND REHABILITATION | 115528 | 120 SPRING STREET | NEWNAN | GA | 30263 | 2015-06-11 | 372 | B | 0 | 1 | STSR11 | Based on observations and staff interviews, the facility failed to properly dispose of garbage and refuge for one (1) of four (4) dumpsters. Findings include: Observations conducted on 6/9/15 at 4:20 PM and 6/10/15 at 8:00 AM, from the window of the conference room, revealed a very large open dumpster with card board boxes and trash in it. Interview conducted 6/10/15 at 2:35 PM with the Maintenance Director revealed the large twenty (20) yard open dumpster behind the building is intended for card board and boxes only. Observation conducted 6/10/15 at 2:40 PM of the large open dumpster, with the Maintenance Director, revealed mainly card board boxes on the right end but the left end was completely full of trash bags containing food, cups and other trash Items. Chicken bones were noted in the dumpster with flies flying around. Further interview conducted 6/10/15 at 2:42 PM with the Maintenance Director revealed there is not supposed to be trash or food items thrown in the dumpster at any time and staff have been informed of this. He revealed there are two (2) covered dumpsters around the corner that are specifically for trash and food items. | 2019-09-01 |
| 4662 | 4662 | MACON REHABILITATION AND HEALTHCARE | 115362 | 505 COLISEUM DRIVE | MACON | GA | 31217 | 2016-04-08 | 278 | B | 0 | 1 | J22Q11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and resident and staff interview, the facility failed to ensure that the Minimum Data Set (MDS) assessment was accurate for functional range of motion (ROM) for one (1) resident (C), and antipsychotic medication use for one (1) resident (#61) from a total sample of thirty (30) residents. Findings include: 1. During an interview on 4/5/16 at 8:17 a.m., resident C stated that he had a contracture of his left hand. During an observation on 4/5/16 at 2:31 p.m., the fingers of resident C's left hand were noted to be closed in a fist, with the thumb between the third and fourth fingers. A review of the clinical record revealed the Activity of Daily Living (ADL) care plan documented that the resident had contractures of the left hand. A physician's progress note, dated 12/3/15, documented resident C had contractures. A 4/3/16 Occupational Therapist Progress Note documented that the resident had contractures with limited ROM of the upper and lower extremities, with impaired functional activity tolerance. However, a review of the Quarterly MDS assessment, dated 1/2/16, documented the resident as having no functional limitations to ROM. During interview on 4/6/16 at 1:38 p.m., MDS staff BB stated that she should have coded resident C as having functional limitation in ROM of his upper extremities on the Quarterly MDS assessment due to the hand contractures. 2. Resident #61 had [DIAGNOSES REDACTED]. A review of physician's orders [REDACTED]. However, the Quarterly MDS assessment, with an Assessment Reference Date (ARD) of 2/22/16, documented that the resident had not received an antipsychotic medication. During interview on 4/6/16 at 1:38 p.m., MDS staff BB verified that resident #61 had received an antipsychotic medication for all seven days of the MDS assessment period in February, but she did not code the antipsychotic medication use on the 2/22/16 MDS assessment. | 2019-08-01 |
| 4799 | 4799 | HEALTHCARE AT COLLEGE PARK, LLC | 115579 | 1765 TEMPLE AVENUE | COLLEGE PARK | GA | 30337 | 2015-08-20 | 156 | B | 0 | 1 | R61O11 | Based on Record Reviews, and Staff Interviews, the facility failed to ensure three (3) residents (#41, #89, and #91) received and signed Advance Beneficiary Notice out of twenty-one (21) sampled residents. Findings Include: During review of the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN), revealed resident #41, with date of notice 3/19/15, resident #89, with date of notice 4/13/15, and Resident #91, with date of notice 5/28/15, were not signed and dated by the resident and/or the authorized representative. Further review of the (SNFABN) revealed no documented evidence that the resident and/or representative received and/or was notified of any end of service/options notices. During an interview with the Business Office Manager BB on 8/19/15 at 4:00 p.m., revealed that the (SNFABN) were mailed out, but she did not obtain any signatures from the residents/authorized representatives, or ensured the notices were received, or returned back to her from the Resident/Authorized Representative. | 2019-06-01 |
| 4919 | 4919 | MOUNTAIN VIEW HEALTH CARE | 115688 | 547 WARWOMAN ROAD | CLAYTON | GA | 30525 | 2015-04-30 | 159 | B | 0 | 1 | DJ4U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of resident trust fund accounts and staff interview, the facility failed to follow acceptable accounting principles were maintained as related to withdrawals of resident monies for six (6) Medicaid residents (#20, #40, #60, #77, #83 and #106) from ten (10) Medicaid accounts reviewed. Facility manages seventy-two (72) resident accounts. Sixty- eight (68) of these accounts are Medicaid. Findings include: Review of resident fund accounts conducted 4/30/15 at 9:44am with Business Office Manager AA revealed that the facility failed to ensure that monies withdrawn from personal fund accounts for Medicaid residents were used for the resident. Resident trust accounts with accounting concerns were as followed: Review of resident #20 trust account revealed that on (MONTH) 14, (YEAR) $1499.00 was withdrawn for the resident's account. The check indicated this was for mobility chair but the facility had no receipt for this withdrawal. Review of resident #40 trust account revealed that on (MONTH) 9, (YEAR) $500.00 was withdrawn from the resident's account by a family member. There was no evidence that this money was used for the resident. Review of resident #60 trust account revealed that on (MONTH) 6, 2014 $40.00 was withdrawn for the resident's account by a family member. There was no evidence that this money was used for the resident. Review of resident #77 trust account revealed that on (MONTH) 12, (YEAR) $600.00 was withdrawn for the resident's account by a family member. There was no evidence that this money was used for the resident. Review of resident #83 trust account revealed that on (MONTH) 31, (YEAR) the family withdrew the $50.00 dollars that was in the resident's account. This Medicaid resident was admitted on [DATE]. There was no evidence that this money was used for the resident. Review of resident #106 trust account revealed that on (MONTH) 27, (YEAR) $75.00 was withdrawn for the resident's account by a family member. There… | 2019-04-01 |
| 4929 | 4929 | PLACE AT POOLER, THE | 115293 | 508 SOUTH ROGERS STREET | POOLER | GA | 31322 | 2015-07-23 | 278 | B | 0 | 1 | HGHZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, it was determined that the facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the resident's status for four residents (#22, #59, #2 and #5) from a sample of twenty-one (21) residents. Findings include: 1. Resident #22 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident required supervision only with ambulation and had no falls since the last MDS assessment dated [DATE]. However, review of the Nurses' Note dated 4/19/15 at 5:30 a.m., revealed that the resident got up to go to the bathroom, began to urinate, slipped in the urine and fell on the floor. The resident sustained [REDACTED]. Staff addressed the fall, updated the resident's care plan and provided therapy for gait training, balance, strength, activities of daily living and transfer. The resident was discharged to the Restorative Nursing Program for ambulation with a rolling walker and active range of motion exercises. During an interview with MDS Coordinator ZZ on 7/23/15 at 11:00 a.m., she/he confirmed that the 4/19/15 fall should have been captured on the Significant Change MDS assessment dated [DATE]. Further interview with ZZ at that time revealed that she/he obtained the MDS assessment data from the Nurses' Notes and from morning meetings. Continued interview with ZZ revealed that although the fall had been addressed by staff, she/he had missed capturing the fall on the 6/7/15 MDS assessment. 1. Record review of an Annual Minimum Data Set (MDS) assessment completed in (MONTH) (YEAR) revealed that resident #59 had no dental problems in response to Question L0200. Review of the Annual Dietary Assessment completed on 2/3/15 indicated that the resident was edentulous. Observations of the resident on 7/22/15 at 8:46 a.m. and 12:31 p.m. revealed that the resident was edentulous but was a… | 2019-03-01 |
| 4940 | 4940 | PRUITTHEALTH - CRESTWOOD | 115385 | 415 PENDLETON PLACE | VALDOSTA | GA | 31602 | 2015-05-21 | 253 | B | 0 | 1 | IG2V11 | Based on observations and staff interviews, the facility failed to maintain a clean and comfortable environment in six (6) rooms ( #100,102,103,104,105, and 316) of thirty-eight (38) rooms. Findings include: Observations on 5/18/15 at 10.52 a.m., 5/19/15 at 12.15 p.m., 5/20/15 at 7.30 a.m., and 5/21/15 at 8.55 a.m. revealed the hot water faucet in the bathroom sink of room 316 to be inoperable. The room was occupied by two (2) residents. Tour of room 316 with the Maintenance Director on 5/21/15 at 9.05 a.m. confirmed the faucet was inoperable. The Maintenance Director further revealed he had no knowledge of the faucet needing repair. Observations on 05/18/15 at 10:50 a.m. revealed that the toilet in the bathroom in room 100 had a black buildup around the inside of the toilet bowl. Observation of room 102 revealed a heavy build up of dust and debris on the air vent in the bathroom ceiling. It was also observed that the shower wall and floor was noted to have a large area of soap scum type buildup around the shower wall approximately two (2) foot up from the floor. The grab bar, made of galvanized steel, in the shower was noted to have a large build up of soap scum with a small area of rust noted at the end of the grab bar closest to the wall. The shower in room 103 was noted to have black buildup around the bottom wall of the shower approximately two (2) foot up from the floor around the shower wall. The shower grab bar was observed to have a build up of soap scum and the grab bar had a small area of rust on the bar closest to the wall. Further observation revealed that the wooden entrance door, going into the shower, would not close. In room 104, the shower was noted to have large area of debris and black buildup around the perimeter of the floor and around the perimeter of the shower wall approximately two (2) foot high from the floor. The toilet was noted to have a black buildup around the inside of the toilet bowl. The shower had a heavy buildup of scum on the floor and a small area of rust was noted on the sh… | 2019-03-01 |
| 4964 | 4964 | PRESBYTERIAN VILLAGE | 115490 | 2000 EAST-WEST CONNECTOR | AUSTELL | GA | 30106 | 2015-05-07 | 372 | B | 0 | 1 | 7X7L11 | Based on observation and staff interviews, the facility failed to ensure that garbage and refuse was properly disposed and contained to prevent leaks for one (1) of two (2) dumpsters. Findings include: An observation conducted on 5/4/15 at 10:05 AM with the Director of Dining Services revealed two (2) garbage dumpsters located alongside the loading dock. One (1) containing garbage and one (1) containing card board. There was approximately a two foot gap between the dumpsters and the concrete wall in which the ground was heavily covered with trash, rotting food, plastic bags, paper products and a black thick sludge type substance lining the entire length of the two dumpsters. Further observation revealed the dumpster containing garbage did not have a plug on the drain. An interview conducted on 5/4/15 at 10:08 AM with the Director of Dining Services revealed the engineering department is responsible for cleaning the dumpster area. She acknowledged the area is very dirty and that there is no plug on the dumpster containing garbage. Interview conducted on 5/4/15 at 10:19 AM with the Director of Property Management revealed the Property Management Department is responsible for keeping the dumpster area clean and acknowledged the area is very dirty and that there is no plug on the dumpster containing garbage. | 2019-03-01 |
| 4982 | 4982 | CHURCH HOME REHABILITATION AND HEALTHCARE | 115708 | 2470 HWY 41 N | FORT VALLEY | GA | 31030 | 2015-04-30 | 161 | B | 0 | 1 | 12G211 | Based on record review and staff interview the facility failed to maintain a surety bond of appropriate value to secure resident funds. The resident census was fifty-nine (59.) Findings include: A review of the Resident Trust Fund statements revealed that the the fund balances for (MONTH) 2014, (MONTH) 2014, (MONTH) 2014,January (YEAR),February (YEAR), and (MONTH) (YEAR) all exceeded the $5,000 surety bond. Balances ranged from $5, 891 to $8.343. An interview with the Financial Manager on 4/29/15 at 3:10 p.m. confirmed that the bank statements every month had exceeded the amount of the current surety bond and did not adequately secure the resident's personal funds. | 2019-03-01 |
| 4992 | 4992 | PRUITTHEALTH - LAFAYETTE | 115304 | 205 ROADRUNNER BOULEVARD | LAFAYETTE | GA | 30728 | 2015-04-16 | 503 | B | 0 | 1 | 2GWE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure that their Clinical Laboratory Improvement Amendments (CLIA) waiver was in good standing for laboratory services offered by the facility. Twenty-six (26) residents received accuchecks, from a census of ninety-nine (99) residents residing in the facility since the waiver expired on [DATE]. Findings include: Review of the CLIA Certificate of Waiver revealed the Expiration date was listed as [DATE]. Interview conducted on [DATE] at 1:47 PM with the Administrator revealed this was an oversight that was discovered on [DATE], and reinstatement was in progress. | 2019-02-01 |
| 5081 | 5081 | ORCHARD VIEW REHABILITATION & SKILLED NURSING CTR | 115146 | 8414 WHITESVILLE ROAD | COLUMBUS | GA | 31907 | 2016-01-08 | 356 | B | 1 | 0 | UCIF11 | > Based on observation and interview the facility failed to display the actual hours worked by the nursing staff. The facility census was one hundred and sixty-six (166) residents. Findings Include: During an observation on 1/08/2015 at 02:00 p.m. the staffing form was posted. However, it did not document actual hours worked for nursing staff. Interview with the Administrator on 01/08/2016 at 6:08 p.m. confirmed the actual hours worked by the nursing staff was not posted correctly. | 2019-01-01 |
| 5132 | 5132 | MEDICAL MANAGEMENT HEALTH AND REHAB CENTER | 115692 | 1509 CEDAR AVE | MACON | GA | 31204 | 2016-01-29 | 356 | B | 1 | 0 | 8Z9H11 | > Based on record review and staff interview, the facility failed to maintain eighteen (18) months of nurse staffing information. The current facility census was eighty-seven (87) residents, and the sample size was thirty (30) residents. Findings include: During interview with the Assistant Director of Nurses (ADON) on 01/29/16 at 1:26 p.m., she was asked to provide the archived copies of the facility's Nursing Daily Staffing records. Review of these records revealed that two months were provided. During interview with the ADON on 01/29/16 at 2:20 p.m., she stated that she was unaware that the Daily Staffing Information must be maintained for eighteen months. | 2019-01-01 |
| 5167 | 5167 | PRUITTHEALTH - EASTSIDE | 115391 | 2795 FINNEY CIRCLE | MACON | GA | 31217 | 2015-04-10 | 156 | B | 0 | 1 | 1NOO11 | Based on observation, record review, and staff interview, the facility failed to post the information on how to contact the State survey and certification agency for three (3) of five (5) days of the survey. The facility census was seventy-six (76) residents. Findings include: During an interview with Licensed Practical Nurse BB on 04/08/15 at 7:20 a.m. related to her awareness of who to contact for any abuse concerns, she stated that she was not aware of where the phone number was to contact the Stage agency. During a walk-through of the hallways and common areas of the facility at this time revealed that no printed information on how to contact the State was located. During interview with the Minimum Data Set Coordinator on 04/08/15 at 10:45 a.m., she stated that the number to contact the State was on a bulletin board in the hallway off the main entrance, but verified that the poster was no longer there. During interview with the Director of Nurses (DON) on 04/08/15 at 11:15 a.m., she verified that the State information was not posted, and stated that it must have been taken down to paint the walls about three weeks earlier. During further interview and observation at 11:19 a.m., the DON stated that she found a bulletin board with the State and Ombudsman information inside a closet, and that she would have someone hang it back up. Review of the facility's Abuse Prevention policy revealed that all required posters and materials will be appropriately displayed. | 2018-12-01 |
| 5169 | 5169 | PRUITTHEALTH - EASTSIDE | 115391 | 2795 FINNEY CIRCLE | MACON | GA | 31217 | 2015-04-10 | 278 | B | 0 | 1 | 1NOO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interviews, the facility failed to ensure that the Minimum Data Set (MDS) assessment was accurate related to incontinence for one (1) resident (B); for Preadmission Screening and Resident Review (PASRR) Level II (2) for one (1) resident (#69); and for Pressure ulcers for one (1) resident (#36) from a sample of twenty-seven (27) residents. Findings include Review of the clinical record revealed that resident B a [AGE] year old male was admitted to the facility on [DATE]. Review of the Admission MDS assessment dated [DATE] revealed that the resident was coded as being continent of bowel and bladder, which triggered the Care Area Assessment Summary (CAAS) to address it in the care plan. Review of the Quarterly MDS assessment dated [DATE] which coded the resident as always continent of bowel and bladder, Review of the Care Plan dated 12/23/14 revealed that resident B was Incontinent of Bowel and bladder with interventions to provide incontinent care after each incontinent episode and change soiled or wet clothing as needed. Interview on 04/09/15 at 8:15 a.m. with resident B revealed that he was able to let staff know when he has to have a bowel movement. He further revealed that he uses his urinal and he keeps his urinal on so he won't wet himself. Continued interview revealed that he does wet himself when he has a spasm which is frequently and this is the way he has always been. Interview on 04/09/15 at 8:30 a.m. with Certified Nursing Assistant (CNA) EE revealed that resident B does let staff know when he needs to have a bowel movement and he can use his urinal but he wets himself frequently. CNA EE further revealed that resident B does not like to get up or leave his room and he is able to voice his needs and wants. Interview on 04/09/15 at 8:45 a.m. with Registered Nurse DD revealed that resident B can let staff know when he needs to have a bowel movement, but he is incontinent. RN DD further rev… | 2018-12-01 |
| 5172 | 5172 | PRUITTHEALTH - EASTSIDE | 115391 | 2795 FINNEY CIRCLE | MACON | GA | 31217 | 2015-04-10 | 372 | B | 0 | 1 | 1NOO11 | Based on observation and staff interview the facility failed to ensure that garbage and refuse was properly contained to prevent leaks for one (1) of three (3) dumpsters on two (2) of four (4) days of the survey. Findings include: Observation on 4/6/15 at 10:35 a.m. revealed three large dumpsters the dumpster in the middle had a foul odor. There was no plug observed for the middle dumpster and at the left bottom of the dumpster was a four (4) inch hole with a rust colored substance surrounding it. Continued observation revealed a milky white substance leaking from the hole and pooling to a 4x6 inch area of drainage on the ground. Observation on 4/7/15 at 3:15 p.m. revealed the middle dumpster still with the milky white substance leaking from the hole and settling on the ground. Continued observation revealed there were also numerous amount of flies and brown colored insects crawling into the opened hole. Interview on 4/9/15 at 4:45 p.m. with the dietary manager revealed that the dietary department was responsible for maintaining the dumpsters, but they were assisted by the other department when it comes to keeping it clean on a daily basis. Observation with the dietary manager at that time revealed that a brand new dumpster was sitting on the same site as the original dumpster, however the 4x6 inch area of the milky white substance was still on the ground. The dietary manager confirmed that the milky white substance came from the original dumpster that was leaking. | 2018-12-01 |
| 5242 | 5242 | EAST LAKE ARBOR | 115482 | 304 FIFTH AVENUE | DECATUR | GA | 30030 | 2015-05-21 | 156 | B | 0 | 1 | 466Q11 | Based on record review and staff interview, the facility failed to provide the required Liability and Appeal notices for one (1) of three (3) residents who were discharged from Medicare Part A Services. Findings include: During an interview with the Social Services Director (SSD), on 05/21/15 at 11:35 a.m. the SSD revealed that resident #50 was discharged from skilled services on 05/19/15 and that he remained in the facility afterwards. Review of Notice of Medicare Non-Coverage notice dated 05/13/15 revealed that resident #50 signed the CMS Form but was not provided the CMS Form providing the resident with an informed choice regarding whether or not to continue with services and the potential costs. The SSD acknowledged that she did not have resident #50 sign the Advanced Beneficiary Notice (ABN) because she had never seen the notice before and was unaware that she was required to provide the notice to residents being discharged from Medicare Part A who were to remain in the facility. | 2018-11-01 |
| 5260 | 5260 | FOX GLOVE CENTER | 115569 | 2850 SPRINGDALE ROAD SW | ATLANTA | GA | 30315 | 2015-05-14 | 247 | B | 0 | 1 | 0HLO11 | Based on review of facility policy, resident and staff interviews, the facility failed to follow the policy for notifying current residents of a new roommate for four (4) residents (A, B, C and D) from a sample size was thirty- three (33) residents. Findings include: 1. Interview on 05/14/2015 at 10:30 p.m. with resident A revealed he received a new roommate approximately one (1) month ago and did not receive any prior notification of the new resident being placed in the room with him. 2. Interview on 05/12/15 at 09:04 a.m. with resident B revealed he received a new roommate approximately one (1) week ago and did not receive any prior notification. 3. Interview on 05/11/15 at 02:31 p.m. with resident D revealed she received a new roommate approximately six (6) weeks ago and did not receive any prior notification. 4. Interview on 05/11/15 at 02:04 p.m. with resident C revealed she received a new roommate approximately two (2) months ago and did not receive any prior notification. Interview on 05/14/2015 at 11:50 a.m. with the Admissions Coordinator revealed once she assigns a new resident to a room, she copies all of the clinical information, the room assignment and distributes the information to the various disciplines. She does not notify the residents currently in the room, she assumed nursing notifies the current resident. Interview on 05/14/2015 at 12:01 p.m. with 200 Hall Unit Manager HH revealed nursing staff does not notify residents related to roommate changes. She further indicated that in the past Admissions staff notified current residents of new admissions to the room. Review of the facility policy for room transfers revealed that notification of room change or new roommate will be provided in writing within required time frames when necessary to meet state regulation. A resident who is receiving a new roommate will be given as much notice as possible and provide information about the new roommate while maintaining confidentiality regarding medical information. | 2018-11-01 |
| 5286 | 5286 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2015-07-31 | 159 | B | 0 | 1 | OBW211 | Based on review of resident fund accounts, review of the Resident Trust Fund Account Agreement and resident, family and staff interviews, the facility failed to ensure quarterly statement for three (3) cognitive residents ( C, D and E ) and the responsible parties for two (2) cognitively impaired residents (F and G) of five (5) residents reviewed from thirty four (34) personal funds accounts managed by the facility. Findings include: A review of the Resident Trust Fund Account Agreement form documents: It is understood that the personal funds to be placed in an interest bearing Resident Trust Fund Account (Handled as a petty cash and/or checking account), and that a quarterly accounting of such funds will be given to the resident and/or responsible party/legal representative. An interview conducted on 07/27/15 at 1:31 p.m. with resident C revealed she does not receive a quarterly statement of her personal funds account. An interview conducted on 07/28/15 at 9:30 a.m. with resident E revealed she does not receive a quarterly statement of her personal funds account. An interview conducted on 07/28/15 at 10:16 a.m. with the responsible party of resident F revealed she does not receive a quarterly statement of her personal funds account. An interview conducted on 07/28/15 at 10:19 a.m. with resident D revealed she does not receive a quarterly statement of her personal funds account. An interview conducted on 07/28/15 at 11:01 a.m. with the responsible party of resident G revealed she does not receive a quarterly statement of her personal funds account. An interview conducted on 07/29/15 at 3:20 p.m. with the Business Office Manager revealed she does not provide quarterly statements for residents with a personal funds account, regardless of cognition, unless they request one. She does send a statement to the responsible parties. She has never provided a quarterly statement to either the residents C and G or their responsible party because the facility is not the representative payee for these accounts. She was not awa… | 2018-10-01 |
| 5300 | 5300 | LUMBER CITY NURSING & REHABILITATION CENTER | 115404 | 93 HIGHWAY 19 | LUMBER CITY | GA | 31549 | 2015-01-22 | 372 | B | 0 | 1 | QM5O11 | Based on observation and staff interview the facility failed to properly maintain the area surrounding two (2) of two (2) dumpsters to prevent pests. Findings include: Observation on 01/20/15 at 11:30 a.m. revealed that there were two (2) dumpsters located on bare ground behind the facility. Continued observation revealed that the dumpster on the right hand side had two (2) crinkle cut French fries located on the ground four (4) inches from the dumpster and a piece of bread like item that was five (5) inches in length and one (1) inch in width and light brown in color. Interview on 01/20/15 at 11:30 a.m. with the Dietary Manager (DM) that he/she is responsible for the maintenance and condition of the dumpsters and the dumpster area. The DM revealed that he/she inspects that area surrounding the dumpster's one to two (1-2) times a day. The DM revealed that he/she had inspected that dumpster area earlier and did not notice any food debris. The DM revealed that it is important to keep the area surrounding the dumpsters clean and verified that there was food debris on the ground next to the dumpsters. | 2018-10-01 |
| 5318 | 5318 | CUMMING NURSING CENTER | 115551 | 2775 CASTLEBERRY ROAD | CUMMING | GA | 30041 | 2015-03-05 | 159 | B | 0 | 1 | 5C6611 | Based on review of funds, and staff interviews, the facility failed to ensure that resident funds were available on the weekends for sixty-three (63) resident with fund accounts. Finding include: Review of resident funds revealed that the facility manages sixty-three (63) resident accounts. Interview with the Business Office Manager (BOM) on 3/4/15 at 10:45 a.m., revealed that residents has access to their account Monday through Friday from 9:00 a.m. to 5:00 p.m., but not on the weekends. She revealed that until two (2) years ago, the money was available on the weekends with the supervisor; however, no resident ever requested any money, so the Administrator decided to just make the money available Monday through Friday. Interview with the Administrator on 3/4/15 at 12:30 p.m., revealed that after the facility was cited seven to eight (7-8) years ago for not having funds available for the residents on the weekends, the facility left $50.00 with the weekend nursing supervisor. He further indicated that about three to four (3-4) years ago, this procedure was stopped because the residents were not using the money over the weekends. He indicated that no resident had complained of monies not being available on the weekends. | 2018-10-01 |
| 5327 | 5327 | MAGNOLIA MANOR OF ST SIMONS REHAB & NURSING CENTER | 115582 | 2255 FREDERICA ROAD | SAINT SIMONS ISLAND | GA | 31522 | 2014-11-20 | 253 | B | 0 | 1 | NWCY11 | Based on observation, it was determined that the facility failed to maintain a clean and comfortable environment in four (4) of thirty seven (37) bathrooms on three (3) of four (4)halls. Findings include: 1. Observation on 11/18/14 at 10:31 a.m. revealed the bathroom floor had a heavy build up of dust and debris especially along the edges behind the toilet in resident room 304. 2. Observation on 11/18/14 at 9:59 a.m. revealed a heavy build up of dust on the ceiling vent and the floor under the sink had a heavy build up dust and debris in the bathroom in resident room 312. 3. Observation on 11/18/14 at 8:42 a.m. revealed the metal frame on the raised toilet seat and several rusted areas in the bathroom in resident room 403. | 2018-10-01 |
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 );