cms_GA
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| Link | rowid | facility_name | facility_id | address | city | state | zip ▼ | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 528 | 528 | PRUITTHEALTH - MARIETTA | 115276 | 70 SAINE DRIVE SW | MARIETTA | GA | 30008 | 2020-02-26 | 609 | D | 1 | 0 | CR9111 | > Based on staff interview, record review and review of the facility's policy titled Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, the facility failed to report an allegation of abuse to the State Survey Agency (SSA) within the required time frame for one resident (R#1) of 4 sampled residents. Findings include: During an interview on 2/25/2020 at 10:10 a.m., R#1 stated to this surveyor that he refused to allow Certified Nursing Assistant (CNA) AA in his room or allow her to touch him. He reported that he is legally blind and CNA AA was mean and rude to him. The resident angrily states that he is blind but CNA AA treated him like he was stupid. The resident further stated that he informed the Social Worker (SW) regarding how he was being treated and did not want CNA AA back in his room. An interview with the SW on 2/25/2020 at 11:30 a.m. revealed that she spoke with the R#1 on 2/24/2020 in which he reported to her that CNA AA was mean to him and did not want her to come back into his room or provide him any care. SW further stated that she completed a grievance report at that time and reported the incident to the Administrator. An interview on 2/25/2020 at 11:40 a.m. with the Administrator revealed that according to the report the facility became aware of the allegation on 2/24/2020. He further stated that he did not consider the incident as an allegation of abuse and therefore did not report the incident to the State agency. Review of the facility policy titled Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property revised on 4/26/2017, stated that mental abuse: includes but is not limited to humiliation, harassment, threats of punishment or deprivation. The suspected abuse will be reported within two hours to the State Survey Agency. | 2020-09-01 |
| 529 | 529 | PRUITTHEALTH - MARIETTA | 115276 | 70 SAINE DRIVE SW | MARIETTA | GA | 30008 | 2020-02-26 | 690 | D | 1 | 0 | CR9111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, record review, and facility policy review Lippincott indwelling urinary catheter care and management, the facility failed to provide appropriate indwelling urinary catheter care for one resident (R) #3, of three sampled residents. Findings include: Review of the facility policy for Indwelling urinary catheter (Foley) care and management revised 3/24/2017 indicated in the Implementation section to Provide routine hygiene for meatal care; note that cleaning the meatal area with antiseptic solutions isn't necessary. To avoid contaminating the urinary tract, always clean by wiping away from-never toward- the urinary meatus. Use soap and water or a perineal cleaner to clean the [MEDICAL CONDITION] area after each bowel movement. Avoid frequent and vigorous cleaning of the area. Review of the Quarterly Minimum Data Set (MDS) for R#3 dated 2/02/2020 revealed that his [DIAGNOSES REDACTED]. Review of the Brief Interview for Mental Status (BIMS) indicated a score of 15 indicating the resident was cognitively intact. R#3 had an indwelling foley catheter on admission to the facility. Review of the Care Plan for R #3 dated 10/15/2019 revealed a care plan for an Indwelling Foley Catheter. Approaches included: Provide perineal care every day and PRN Report redness, swelling, discharge or urinary related odor to supervisor Follow aseptic technique with Cath insertion and irrigation Observe and report the change in color, odor, presence of cloudiness or sediment in urine to charge nurse Report complaints of pain/discomfort from cath to charge nurse Record intake and output as ordered Check Cath q (every) shift for patency, proper position of tubing and bag. Report Cath leakage to charge nurse. Review of the Medication Administration Record [REDACTED]. A review of the Quarterly MDS dated [DATE] revealed a BIMS score of 15 indicating that he was cognitively intact. The resident required total care for all activities of daily l… | 2020-09-01 |
| 530 | 530 | PRUITTHEALTH - MARIETTA | 115276 | 70 SAINE DRIVE SW | MARIETTA | GA | 30008 | 2018-04-19 | 585 | D | 0 | 1 | 2G1211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record, and facility policy review, the facility staff failed to ensure personal clothing were returned when sent to the laundry and when items were reported missing there was an effective and timely process in place to replace items that were not found for one sampled resident (Resident {R}#71) out of 21 residents reviewed for missing personal items. Findings include: On 4/16/18 at 2:57 p.m., in the facility's conference room` an interview was conducted with the Administrator concerning laundry and missing items. The Administrator stated Anyone can write up the grievance form for the missing items. We look in the resident's room and if it's a laundry issue, we look in laundry and take the resident down to the laundry to look. If we don't find it, we reimburse them. Review of the facility's Concerns/Grievances policy, revised 6/2/2017 revealed the following: . A concern/grievance may be filed verbally or in writing. Grievance forms will be kept at the Administrator's office and./or in other area designated by Administrator in the center. If the resident files a grievance to any person, the staff person should immediately inform the Administrator or his/her designee. Procedure: 1. The staff member taking the grievance: The staff person will provide assistance in completing the Concern/Grievance Form should the person making the filing need assistance. Grievances should be resolved within three business days with the Administrator's signature and reported back to the person filing the grievance. The grievance form should be given back to the Administrator or his/her designee to be logged and placed in the grievance book. 2. The Administrator or his/her designee will be responsible for tracking all grievances. The Administrator or his/her designee will enter the grievance form information into the Grievance Log Form and place the original form in the log book. This will provide a central place for all grievances.… | 2020-09-01 |
| 531 | 531 | PRUITTHEALTH - MARIETTA | 115276 | 70 SAINE DRIVE SW | MARIETTA | GA | 30008 | 2019-07-24 | 568 | D | 1 | 1 | I5PG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, resident and staff interviews and review of the policy titled Resident Trust Policy, the facility failed to provide quarterly financial statements for two of two cognitively intact residents (R) reviewed that had a trust fund account managed by the facility (R#14, R#61). The facility managed 93 resident trust fund accounts. Findings include: Review of the facility policy titled Resident Trust Policy dated (MONTH) 2009, revealed number 6. Quarterly statements will be provided in writing to the resident or the resident's responsible representative within 30 days after the end of the quarter. 1. Record review for R#14 revealed a Quarterly Minimum Data Set (MDS) assessment dated [DATE] which documented a Brief Interview for Mental Status (BIMS) summary score of 14, which indicates the resident is cognitively intact. Interview on 7/21/19 at 12:53 p.m., R#14 revealed she does not receive a quarterly statement for her trust fund account that the facility manages. Review of printed Resident Fund Management Service dated 7/24/19 at 10:21 a.m., revealed on page three (3), R#14 has an active trust fund account that is managed by facility. 2. Record review for R#61 revealed a Quarterly Minimum Data Set (MDS) assessment dated [DATE] which documented a Brief Interview for Mental Status (BIMS) summary score of 15, which indicates the resident is cognitively intact. Interview on 7/22/19 at 11:13 a.m., R#61 revealed she does not receive a quarterly statement for her trust fund account that the facility manages. Review of printed Resident Fund Management Service dated 7/24/19 at 10:21 a.m., revealed on page two (2), R#61 has an active trust fund account that is managed by facility. Interview on 7/23/19 at 4:55 p.m. with Accounts payable/Financial Counselor, responsible for the resident trust fund accounts, stated during the admission process, the residents are given the choice to have the facility manage a trust fund for their money. … | 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 |
| 533 | 533 | PRUITTHEALTH - MARIETTA | 115276 | 70 SAINE DRIVE SW | MARIETTA | GA | 30008 | 2019-07-24 | 689 | D | 1 | 1 | I5PG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, policy review and interviews, the facility failed to provide supervised smoking for one resident (R#7) reviewed for smoking. The sample size was 55. Findings include: Review of the facility policy titled Smoke Free Policy with a revised date of 11/5/18, revealed the policy statement to be as of (MONTH) 1, (YEAR), smoking is not allowed on the healthcare center premises by visitors, partners or patients/residents. Smoking will only be allowed in outdoor designated areas for those residents grandfathered in prior to (MONTH) 1, (YEAR). Procedure bullet 10: when the patient/resident is identified as needing supervision, the supervision shall be provided by a partner who is physically present in the designated smoking area for all residents who need supervision based on their Smoking Observation Form or electronic documentation. Review of the clinical record for R #7 revealed resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 15, which indicated no cognitive impairment. Section J revealed resident was a current smoker. Review of facilities Smoker Worksheet, revealed R#7 name was on the list of identified smokers in the facility. Review of Smoking Observation Form documented that residents were to be assessed on admission, re-admission, or with a significant change. Review of Quarterly Smoking Observation Form for R#7, dated 3/12/19 and 7/22/19, revealed question one: Does the resident smoke? Yes column is checked. Question two: Does the resident have a past history of smoking? Yes column is checked. Supervision will be required at all designated smoking times when the patient/resident observation identifies any potential hazard risk, as evidenced by any boxes checked Yes. Patient/resident smoking status upon observation: Supervised Smoker. Review o… | 2020-09-01 |
| 534 | 534 | PRUITTHEALTH - MARIETTA | 115276 | 70 SAINE DRIVE SW | MARIETTA | GA | 30008 | 2019-07-24 | 692 | D | 1 | 1 | I5PG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interviews, record review and review of the facility policy Hydration: Dietary Service. The facility failed to provide hydration (ice/water) at the bedside for two of fifty-five sampled residents, (R) (R#61 and R#304). Findings include: 1. Review of the clinical record for R#61 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 15, which indicated no cognitive impairment. Interview on 7/22/19 at 11:20 a.m. in R#61 room, she stated she rarely gets fresh ice water. No visible water pitcher in R#61 room. Observation on 7/23/19 at 8:05 a.m., there is no visible water pitcher or drinking cup on residents side of the room. Observation on 7/23/19 at 3:06 p.m., resident sitting at her beside. She stated that no-one brought her any ice water today. There is no visible water pitcher or water cup on her over bed table. Interview on 7/24/19 at 8:26 a.m. with R#61, stated she was given a pitcher of ice water today, when she hasn't had a pitcher for ice water in a long time. She could not remember exactly how long it has been since she had ice water. Interview on 7/24/19 at 9:34 a.m. with Certified Nursing Assistant EE stated that she passes ice twice daily on her shift. She further stated that she offers R#61 ice water everyday, but resident refuses and throws her water pitcher in the trash. 2. Medical record review for resident R#304 revealed she was admitted to the facility on [DATE]. She readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review for R#304 admission Minimum Data Set (MDS) assessment dated [DATE] which documented a BIMS summary score of 15, indicating cognitively intact. An interview and observation on 7/22/19 at 9:53 a.m. R#304 did not have a water pitcher in the room. The resident revealed that they she has liquids on the meal t… | 2020-09-01 |
| 535 | 535 | PRUITTHEALTH - MARIETTA | 115276 | 70 SAINE DRIVE SW | MARIETTA | GA | 30008 | 2019-07-24 | 725 | F | 1 | 1 | I5PG11 | > Based on observation, review of facility records, and resident and staff interview, it was determined that the facility failed to provide staff in sufficient numbers to care for the needs of seven Residents (R) #13 , R A, R B, R C, R#23, R#24, R D on two of two units as identified in resident and facility assessments. Findings include: A review of the Facility assessment dated (MONTH) 2019 revealed that the facility cared for a very high percentage of residents that required the assistance of two-plus persons with daily care such as bed mobility, transfers, toilet use, and dressing. The assessment also documented that the facility had high percentages of residents with cognitive impairments and behavioral health needs that impacted resident care. A review of the facility's Alphabetical census of residents dated 7/21/19 revealed that there were 106 residents onsite - 55 on the 200 Hall and 51 on the 100 Hall. A review of the Daily Staffing Schedule for 7/21/19 revealed two nurses and two certified nursing assistants (CNAs) were scheduled to care for residents on the 200 Hall, and an equivalent number on the 100 Hall. Observation on 7/21/19 at 11:30 AM of the staff on the 200 Hall confirmed that two CNAs were available to provide care to the 55 residents on that hall. During an observation on 7/22/19 at 11:15 a.m., the family of Resident #13 was seen to arrive at the facility for a visit. A few minutes into the visit, one of the family members was observed to remove a manicure set from her bag and proceed to trim the nails of the resident. The resident's nails were observed to be about a centimeter long. During an interview with the family member, at the time of this observation it was revealed that she trims his nails during her weekly visits because the staff are busy and not able to get to it. During a group interview on 7/23/19 at 11:10 a.m. with members of the resident council it was revealed that residents were dissatisfied with the number of staff available on the various shifts to care for their needs. Re… | 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 |
| 537 | 537 | PRUITTHEALTH - MARIETTA | 115276 | 70 SAINE DRIVE SW | MARIETTA | GA | 30008 | 2019-07-24 | 812 | E | 1 | 1 | I5PG11 | > Based on observation, staff interview, and review of facility provided data, the facility failed to ensure kitchen staff were wearing hair protectors in the food preparation area. In addition, the facility failed to ensure the dish machine room was safe and sanitary; specifically, free from broken floor tiles and free from dirty water containing food debris accumulating on the floor. This practice had the potential to affect 103 residents receiving an oral diet. The census was 108 residents. The findings include: An initial tour of the kitchen was conducted on 7/21/19 at 11:20 a.m. with Cook CC, Kitchen Aide BB, and Kitchen Aide AA, the Food Service Manager (FSM) was unavailable. The kitchen staff was observed in the process of cooking and preparing for the lunch meal. A small amount of food debris was observed on kitchen floor tiles, walls were clean. The dish machine wash and rinse cycle was tested twice by a Kitchen Aide with two (2) small batches of dirty dishes. The wash and rinse cycle were within required range for a low temperature machine. The floor drain in the dish machine room was not draining water. Floor tiles around the drain area in the middle of the floor, appeared loose, and broken. A large amount of cloudy pooled water containing food debris was noted in the middle of the room, approximately five (5) inches deep at the drain site. Water was also observed pooled over two black rubber safety mats. A brief interview was conducted with Kitchen Aide AA on 7/21/19 at 11:50 a.m. during the tour in the dish machine room, where she confirmed the floor drain has not been draining right for some time that maintenance was aware of it. A second tour of the kitchen was conducted on 7/22/19 at 4:00 p.m. with the FSM, where she confirmed there were broken tiles and water pooling around the drain area in the dish machine room, she confirmed maintenance was aware of the drainage problem. During the continued tour, Cook MM was observed working in the kitchen, on the dinner meal preparation, without a beard net.… | 2020-09-01 |
| 538 | 538 | PRUITTHEALTH - MARIETTA | 115276 | 70 SAINE DRIVE SW | MARIETTA | GA | 30008 | 2019-07-24 | 814 | E | 1 | 1 | I5PG11 | > Based on observation and staff interviews, the facility failed to ensure the sanitary handling of used cooking oil/refuse, and failed to ensure that kitchen staff had adequate accessibility to the grease trap grounds area for disposal. The census was 108 residents. Findings include: An initial tour of the kitchen was conducted on 7/21/19 at 11:20 a.m. with Cook CC, Kitchen Aide BB, and Kitchen Aide AA, the Food Service Manager (FSM) was unavailable. The kitchen staff was observed in the process of cooking and preparing for the lunch meal. The latest health inspection dated 7/12/19, was posted, documenting a score of 98%. Food prep areas, kitchen equipment and food storage areas were observed to be clean and in order. The initial tour continued to the loading dock area, dumpster area, and the grease trap area with Kitchen Aide BB. The back door was closed to the kitchen. During the observation of the walk-through area to the outside, used as a pass through to the kitchen back door, revealed seven (7) dead insects and a box-like mouse trap. At 12:00 p.m. while the tour continued outside, near the dumpster area, Kitchen Aide BB explained they dump the grease and oil in the grass behind the dumpster. The grease trap container was observed located behind a six (6) foot fence. The fence door was unlatched; however, the Kitchen Aide was unable to open the gate fully, less than 1.5 feet. A large number of weeds and Kudzu vines were surrounding the grease trap container and the surrounding area. The grease trap container was observed to be the size of a tall, large barrel-type trash receptacle with a lid. Several broken wheelchairs were noted under the Kudzu vine, along with other old equipment not fully visible under the vines. The weeds and vines prevented access to the grease trap container to observe it more closely. A second tour of the kitchen was conducted on 7/22/19 at 4:00 p.m. with the FSM, where she confirmed that the fryer oil is changed on Saturday. The cooking oil in the fryer appeared clean upon observati… | 2020-09-01 |
| 539 | 539 | PRUITTHEALTH - MARIETTA | 115276 | 70 SAINE DRIVE SW | MARIETTA | GA | 30008 | 2019-07-24 | 914 | D | 1 | 1 | I5PG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and staff interview the facility failed to ensure that privacy curtains were clean and provided full visual privacy, which included a total of six of 119 beds on one of two units. The facility census was 108 residents. Findings include: Observation on 7/21/19 at 2:16 p.m., revealed in room [ROOM NUMBER], center privacy curtain approximately two feet too short. Observation on 7/21/19 at 3:33 p.m., revealed in room [ROOM NUMBER], center privacy curtain approximately two feet too short. Observation on 7/22/19 at 10:53 a.m., revealed in room [ROOM NUMBER], bed A and bed B had no privacy curtain at all. Observation on 7/22/19 at 11:04 a.m., revealed in room [ROOM NUMBER], privacy curtain on bed B dirty with dried food particles. Observation on 7/22/19 at 12:11 p.m., revealed in room [ROOM NUMBER], center privacy curtain approximately two feet too short. Observation on 7/23/19 at 11:55 a.m., revealed in room [ROOM NUMBER], center privacy curtain approximately two feet too short. Interview on 7/24/19 at 10:05 a.m. with Housekeeping Aide DD, stated she inspects the privacy curtains daily to make sure they are clean. She stated if the privacy curtains need to be changed, she notifies the floor tech, to take down to be laundered. She stated she was not sure if there was a routine schedule for laundering the privacy curtains. She stated that she has not noticed any privacy curtains that were too short or missing in any of the rooms on A-Hall. Interview on 7/24/19 at 6:05 p.m. with Housekeeping Supervisor, stated her expectation is that the housekeeping aides look at the privacy curtains every day. If a curtain is identified as being dirty, they are to notify the floor tech to remove the curtain and replace it with a clean one. She stated there is not a routine schedule of laundering the privacy curtains. She further stated that if the housekeeping staff are checking the privacy curtains daily, she is not sure how there could be a … | 2020-09-01 |
| 540 | 540 | PRUITTHEALTH - MARIETTA | 115276 | 70 SAINE DRIVE SW | MARIETTA | GA | 30008 | 2017-07-27 | 242 | D | 0 | 1 | 4OJ711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff and resident interviews, the facility failed to allow the choice of bathing frequency for one of three sampled residents (Resident (R)#70) reviewed for choices. The sample size was 26 residents. Findings include: Review of R#70's clinical record revealed the [DIAGNOSES REDACTED]. The MDS revealed the resident did not display behaviors and required total assistance of one person for bathing . Review of the updated care plan dated 5/25/17 revealed the intervention for one Certified Nurse Aide (CNA) to assist the resident with showers on scheduled shower days and as needed. Review of the Shower Schedule revealed R#70 should receive a shower two times a week on the evening shift. Interview with R#70, in his room, on 7/25/17 at 10:03 a.m. revealed the resident did not get to choose how often he received a bath. The resident stated he received a shower one to two times a month. He further stated he would like one at least two times a week . Interview with CNA CC on 7/26/17 at 12:16 p.m. revealed each resident received a shower two times a week and staff completed a skin sheet when they complete the shower . Interview with Unit Manager AA on 7/26/17 at 12:38 p.m. revealed each resident received a shower two times a week. The CNA should document on the skin sheets and on the Kiosk (CNA computer charting) after each shower. Interview with the Director of Health Services (DHS) on 7/26/17 at 4:40 p.m. revealed the CNA should complete a skin sheet with each shower and document the shower on the Kiosk. Interview with Corporate Nurse BB on 7/27/17 at 8:40 a.m. revealed the residents should receive showers based on their choice. Corporate Nurse BB also stated the facility did not have a policy regarding bathing choices but would refer to Resident's Rights. Review of the Bath Report from the Kiosk and the Skin Monitoring sheets from 5/1/17 to 7/26/17 at 4:30 a.m. (a period of 13 weeks and two days) revealed the resident only … | 2020-09-01 |
| 2616 | 2616 | AUTUMN BREEZE HEALTH AND REHAB | 115580 | 1480 SANDTOWN ROAD SW | MARIETTA | GA | 30008 | 2020-01-15 | 584 | E | 1 | 0 | S0LW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, complainant and staff interviews, the facility failed to ensure that the facility was free of odors, on two (2) Halls (B and C), of five (5) Halls. Findings include: Observation on 1/14/19 at 9:00 a.m. revealed a strong urine odor upon entrance into the facility. A strong urine odor was throughout the facility on the B Hall, and near the conference room. Observation on 1/14/19 at 10:38 a.m. of a random check of resident's rooms for odor revealed the following: room [ROOM NUMBER] -strong urine odor B Hall rooms at 10:40 a.m. revealed: room [ROOM NUMBER]- strong odor Observation on 1/14/2020 at 10:50 a.m. on the B Hall of a random walk through of resident rooms revealed following; a strong odor at the end of the Hall B. Observation on 1/14/2020 at 11:00 a.m. of random check of resident lounge revealed strong pungent odor, five residents in room. Observation on 1/14/2020 at 2:25 p.m. of a random walk through on the C Hall revealed a strong urine odor, residents doors open, no ADL care being provided at this time. Observation on 1/15/2020 at 9:00 a.m. of a random walk through of the facility revealed a strong pungent, musty, smell in the hallway (C) around the Employee Lounge, the Business Office, the Conference Room, Rooms-134, 135, 136, and 137. A strong old urine odor in room [ROOM NUMBER]. Residents were not being changed at that time, residents doors open. Observation on 1/15/2020 at 10:09 a.m. revealed a strong (pungent) odor at end of hall (C) near conference room, business office and employee lounge. No incontinent care being provided at this time. Observation on 1/15/2020 at 10:11 a.m. of a random walkthrough of hall way (C) revealed a strong old urine smell around rooms # 131, and 132. No ADL care being provided at this time. Observation on 1/15/2020 at 3:30 p.m. of a walk through in the hall way (C) near room [ROOM NUMBER], the conference room, and the employee lounge, revealed a strong pungent odor. No ADL car… | 2020-09-01 |
| 2617 | 2617 | AUTUMN BREEZE HEALTH AND REHAB | 115580 | 1480 SANDTOWN ROAD SW | MARIETTA | GA | 30008 | 2018-03-09 | 584 | D | 0 | 1 | UXT911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and resident and staff interview, the facility failed to have hot water readily available for resident use in two of five halls. The facility census was 84 Findings include: Observation on 3/6/18 at 9:47 a.m. revealed the hot water tap in the bathroom between rooms [ROOM NUMBERS] on the B hall produced only a trickle of cold water when turned on. Interview with Resident (R)#72 at the time of this observation revealed the facility had been unable to regulate the hot water in the bathroom and had decided to turn it off a few months before. Interview on 3/6/18 at 11:43 a.m. with family member A revealed the water in the bathrooms on B hallway usually takes too long to heat up to a temperature appropriate for washing up. Observation on 3/6/18 of the hot water temperature in the bathroom between rooms [ROOM NUMBERS] on the B hallway revealed the water remained cold after five minutes of continuous running. Interview on 3/8/18 at 1:55 p.m. with Certified Nursing Assistant (CNA) MM revealed she regularly works with residents on the B hall. It takes several minutes for the hot water in some of the rooms on that hallway to come to a temperature that is appropriate for giving the residents a bed bath or taking care of other personal care needs. To mitigate this lack, the CNAs bring hot water from other rooms on the hallway if hot water is needed immediately and the CNA cannot wait for the water in the resident's bathroom to heat up to a comfortable temperature. Observation on 3/9/17 at 7:34 a.m. revealed that the hot water (which was turned off the previous day) had been turned on in the bathroom shared by residents in rooms [ROOM NUMBERS] on the B hall. The hot water tap now had good pressure, but the water temperature had not changed upwards after five minutes. Interview on 3/9/18 at 7:53 a.m. with the maintenance director revealed he was aware that some of the rooms in the building had inadequate hot water. He sa… | 2020-09-01 |
| 2618 | 2618 | AUTUMN BREEZE HEALTH AND REHAB | 115580 | 1480 SANDTOWN ROAD SW | MARIETTA | GA | 30008 | 2018-03-09 | 656 | D | 0 | 1 | UXT911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review. observation, and Interview the facility failed to implement a Comprehensive Care Plan for three (3) residents (R) #16 related to smoking, R#72 related to helping the resident with daily oral care, and R#82 related to ensuring the resident's medication goals and interventions to meet resident needs. This deficient practice had the potential to effect residents who smoke, residents that require assistance with Activities of Daily Living (ADL) care, and residents that have a daily drug regimen. The facility census was 84, and the sample size was 21. Findings Include: Record Review revealed the resident (R) #16 was admitted the facility on 6/7/17 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] section C-cognitive patterns; the resident has a Brief Interview for Mental Status (BIMS) score of 9 indicating the resident has moderate cognitive impairment. Further review of the quarterly MDS of section J- health conditions sub-section J1300 tobacco use; indicates the resident uses tobacco. Review of the comprehensive care plan initiated 6/8/17 for R#16 does not indicate the resident is care planned for tobacco use or smoking. Observation of R#16 smoking on 3/6/18 at 11:00 a.m. while in the designated smoking area revealed the resident smoking with a smoke apron that was torn and not fitting properly, and a large white plastic industrial size bucket half filled with water is noted for disposal of the resident's ashes and cigarettes after smoking. Observation of R#16 smoking on 3/8/18 at 2:00 p.m. while in the designated smoking area revealed the resident wearing a torn smoking apron not fitting properly, a large white plastic industrial sized bucket is used for the disposal of the resident's ashes and cigarette's after smoking. Interview on 3/8/18 at 1:09 p.m. with the MDS Coordinator revealed when a resident is admitted to the facility a smoking assessment is completed on admission and the… | 2020-09-01 |
| 2619 | 2619 | AUTUMN BREEZE HEALTH AND REHAB | 115580 | 1480 SANDTOWN ROAD SW | MARIETTA | GA | 30008 | 2018-03-09 | 677 | D | 0 | 1 | UXT911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, and record review, the facility failed to provide daily oral care for one dependent resident (#72) for 3 of 5 survey days. The sample size was 84. Findings include: Review of the clinical records for Resident (R)#72 revealed [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment of 2/12/18 revealed R#72 had a Brief Interview for Mental Status BIMS score of 11, indicating moderate cognitive impairment and had an active [DIAGNOSES REDACTED]. The annual MDS also documented that the resident needed extensive assistance with personal hygiene and was totally dependent on staff for assistance with other activities of daily living (ADLs) such as eating, dressing, toilet use, and bathing. No behavioral symptoms such as rejection of care was documented. During an interview on 3/6/18 at 9:17 a.m., R#72 said she was unable to brush her own teeth, but staff did not always assist in brushing her teeth. In fact, staff had failed to brush her teeth, daily, for several weeks, even months. Observation of the resident's oral cavity at the time of the above interview revealed teeth that were stained a dark yellow and was covered with an extensive amount of plaque and food. Review of a progress note from a mobile dentistry firm which visits the facility and provides dental service to the residents revealed the resident was seen for a recall exam on 3/17/17. The dental note on that day documented under oral hygiene that the resident had heavy calculus, plaque, and food present. Review of the dental progress notes from recall exams on 9/28/17 and 12/11/17 again described the resident's oral hygiene as heavy calculus, plaque, and food. Observation on 3/7/18 at 12:30 p.m. revealed the resident sitting outside the dining room waiting to go in for lunch. The resident's teeth were observed to be still stained yellow with an extensive amount of plaque and food. Interview on 3/8/18 at 1:52 p.m. with… | 2020-09-01 |
| 2620 | 2620 | AUTUMN BREEZE HEALTH AND REHAB | 115580 | 1480 SANDTOWN ROAD SW | MARIETTA | GA | 30008 | 2018-03-09 | 684 | D | 0 | 1 | UXT911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure physician's orders were followed for one resident (#48) to repeat laboratory tests and arrange for an outside consult with the nephrologist. The sample size was 84 residents Findings include: Review of the clinical records for Resident (R)#48 revealed she was admitted on [DATE] after a stay at an acute care facility where she was treated for [REDACTED]. Review of the admission Minimum Data Set (MDS) assessment of 1/19/18 for R#48 revealed active [DIAGNOSES REDACTED]. The assessment also documented that the resident had received insulin injections 3/7 days and a diuretic for 7/7 days during the assessment period. Review of the laboratory (labs) results of a Basic Metabolic Panel (BMP) completed for the resident on 1/8/18 revealed a creatinine level of 1.4 and a protein level of 5.2. These were noted to be outside of the acceptable ranges. Further review of these laboratory results revealed the nurse practitioner (NP) documented on 1/11/18 that the resident had acute kidney injury and had a baseline [MEDICATION NAME] of 1.2 per hospital notes and noted that the resident should follow up with nephrology, Pro-Stat 30cc twice a day for 30 days should be added to her diet, and the BMP should be repeated in two weeks. Review of the physician order sheet for 1/11/18 revealed orders were written for staff to repeat the labs in 2 weeks, add Pro-Stat, 30 cc for 30 days to the resident's diet, and make a follow-up appointment with the nephrologist for the resident. Review of the clinical records for the resident revealed documentation on the Medication Administration Records for (MONTH) (YEAR) and (MONTH) (YEAR) that the resident received Pro-Stat 30 cc twice a day. However, there was no evidence that the resident was sent for a follow-up appointment with nephrology nor that the BMP lab were repeated as ordered. Interview on 3/8/18 at 1:20 p.m. with Licensed Practical Nurse (LPN) N… | 2020-09-01 |
| 2621 | 2621 | AUTUMN BREEZE HEALTH AND REHAB | 115580 | 1480 SANDTOWN ROAD SW | MARIETTA | GA | 30008 | 2018-03-09 | 693 | D | 0 | 1 | UXT911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, facility failed to follow physician's orders as written for one of three residents (R) #79 who receive nutrition via a [DEVICE] (GT). On 3/5/18 at 7:00 p.m. R#79s tube feeding of [MEDICATION NAME] 1.5 noted to be running at 90cc per hour (hr) On 3/6/18 at 8:33a.m. [MEDICATION NAME] 1.5 hanging at 90cc per hr. At 12:15 p.m. noted [MEDICATION NAME] 1.5 continues to flow at 90cc per hr. At 2:30 p.m. [MEDICATION NAME] 1.5 continues at 90cc per hr. On 3/6/18 at 2:42 p.m. review of R#79s record revealed a physician order dated 2/22/18 for [MEDICATION NAME] 1.5 to run at 75cc per hr. A nutrition note dated 3/5/18 read, monthly wound assessment. Tube feeding decreased per last recommendation to 75cc per hr. for 19 hrs. and Zinc supplements started. On 3/6/18 at 3:33 p.m. an interview with the Registered Dietician (RD) revealed that she does not always physically visualize the tube feeding flow rates. She looks at the physician orders to determine what the resident should be receiving. When asked if she noted that R#79s tube feeding was flowing at a rate of 90 cc per hr. rather than the 75cc per hr. she documented on, she stated she did not note the discrepancy. On 3/6/18 at 3:35 p.m. a conversation with Unit Manager, BB, indicated that her duties are to review charge nurse activities daily. This includes review of physician orders and following through to make sure they are properly carried out. This included visualizing order changes. When asked if she physically looks at the Medication Administration Records (MARS) and reconciles them with the physical order, she stated yes. In this case she would have reviewed the physician's order, reviewed the MAR indicated [REDACTED]. When the Unit Manger BB was asked to escort surveyor to room where she confirmed that the tube feeding was flowing at the rate of 90 cc per hr. Employee GG, who has not been observed for his skills competency since 6/18/16,… | 2020-09-01 |
| 2622 | 2622 | AUTUMN BREEZE HEALTH AND REHAB | 115580 | 1480 SANDTOWN ROAD SW | MARIETTA | GA | 30008 | 2018-03-09 | 849 | D | 0 | 1 | UXT911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review facility failed to obtain a physician's order for one resident (R) #78 for hospice services. Sample size was 22. Resident #78 was admitted [DATE] with [DIAGNOSES REDACTED]. His medications include but not limited to [MEDICATION NAME] 1 milligram (mg) by mouth (PO) every (q) 4hours (hr). [MEDICATION NAME] 5-325 mg po twice daily (BID), [MEDICATION NAME] 20 mg po q 2 hr as needed (PRN), [MEDICATION NAME] 2.5 mg via nebulizer q 6 hr prn, [MEDICATION NAME] 2 mg po q 6 prn. Review of R #78 medical record revealed he was placed on hospice effective 1/27/18 per hospice benefit election form. When R# 78 was admitted to the facility, another hospice began providing services. Further review of resident's record did not evidence an order for [REDACTED]. On 3/8/18 at 2:04 p.m. an interview with Charge Nurse GG, revealed R #78 was transferred from a facility providing hospice services. Nurse GG stated R # 78 was receiving service through the current company providing services at the facility; therefore R #78 came to the facility and hospice care continued. Further conversation revealed the charge nurse was unable to locate the order and that the hospice nurse would be notified. On 3/9/18 at 11:08 a.m. a telephone interview with Hospice Nurse NN revealed that she had no knowledge of the resident receiving hospice care through her company while R# 78 was at the previous facility. She stated she first met resident three days after his return to facility. When asked if she recalled seeing or if she had a copy of the physician's order for the resident to receive hospice she stated she would have that information faxed to surveyor. As of 3/9/18 2:11 p.m. no was information received from Hospice Nurse NN. On 3/9/18 at 2:15 p.m. an interview with Assistant Director of Nursing (ADON) revealed that during R # 78's stay at the previous facility he was receiving hospice through that facility but care was not through the curr… | 2020-09-01 |
| 2623 | 2623 | AUTUMN BREEZE HEALTH AND REHAB | 115580 | 1480 SANDTOWN ROAD SW | MARIETTA | GA | 30008 | 2019-03-14 | 577 | C | 0 | 1 | TB9111 | Based on observation, resident and staff interview, the facility failed to post the state survey results or notification of the availability and location of said results for residents and visitors/family during four of four days of the survey. The facility census was 90. Findings include: During an interview with members of the resident council on 3/13/19 beginning at 11:34 p.m., 7 of 7 members of the council who were present agreed that they were not aware the results of the most recent state surveys were available for their viewing, nor did they know where these results were located. Review of the Brief Interview for Mental Status (BIMS) scores on the most recent Minimum Data Set (MDS) assessments completed for the members of the council attending the interview revealed that 6 of 7 had scores ranging between 13 and 15 indicating that they were considered to be cognitively intact. Observation of the lobby area and resident accessible areas in the facility on 3/13/19 beginning at 12:20 p.m. revealed no signs of the recent state survey results or signage announcing the location or availability of those results. During an observation in the company of the administrator on 3/14/19 at 12:53 p.m. revealed she could not locate the state survey results in the lobby/reception area nor on the wall near the nurses' station at the intersection of the A and B halls. There was also no indication that the results were usually located in these areas except for an empty metal receptacle on the wall near the nurses' station on the A/B halls. After a brief search of her office and other areas, the administrator was observed to locate a binder with the survey results in her office and these she placed in the receptacle near the nurses' station on the A/B halls. During this observation, the administrator indicated that the state survey results were usually available at the nurses' stations to be accessed by residents and in the lobby area to be available for visitors. During an interview with the social worker on 3/14/19 at 1:00 p.m… | 2020-09-01 |
| 2624 | 2624 | AUTUMN BREEZE HEALTH AND REHAB | 115580 | 1480 SANDTOWN ROAD SW | MARIETTA | GA | 30008 | 2019-03-14 | 640 | D | 0 | 1 | TB9111 | **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) assessment were transmitted within 14 days of completion to Centers for Medicare and Medicaid Services (CMS) Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) System for five resident (R) 6, R#4, R#5, R#1, R#7. The facility also, failed to complete a discharge MDS assessment for four residents R#2, R#9, R#3, R#8. Total of nine records reviewed. The sample size was 32. Finding Included: An interview was conducted on 03/5/19 at 4:30 p.m. - 5:20 p.m. with the MDS Coordinator and the Assistant Director of Nursing (ADON) regarding MDS record over 120 days' old. The following was revealed. 1. R#6 was admitted on [DATE] and remains in the facility. Review of a listing of R#6's completed and transmitted MDS revealed quarterly assessment dated [DATE] was the last assessment transmitted for R#6. The MDS coordinator revealed that R#6 quarterly assessment dated [DATE] was completed, closed, transmitted to the QIES ASAP System on 12/31/18. 2. R#4 was admitted on [DATE] discharged from the facility 10/1/18. Review of a listing of R#4's completed and transmitted MDS revealed admission assessment dated [DATE] was the last assessment transmitted for R#4. The MDS coordinator revealed that R#4 discharge assessment 10/2/18 was completed, closed and transmitted. MDS coordinator could not locate facility's MDS 3.0 NH Final Validation Report for the month of (MONTH) (YEAR). 3. R#5 admitted [DATE] remains in the facility. Review of a listing of R#5's completed and transmitted MDS revealed quarterly assessment dated [DATE] was the last assessment transmitted for R#5. The MDS Coordinator revealed that R#5 quarterly assessment was on 12/30/18 was completed, closed, transmitted to the QIES ASAP System on 12/31/18. 4. R#1 admitted on [DATE] remains in the facility. Review of a listing of R#1's completed and transmitted MDS revealed … | 2020-09-01 |
| 2625 | 2625 | AUTUMN BREEZE HEALTH AND REHAB | 115580 | 1480 SANDTOWN ROAD SW | MARIETTA | GA | 30008 | 2019-03-14 | 801 | F | 0 | 1 | TB9111 | Based on staff interview and record review, the facility failed to ensure that the staff designated as Dietary Manager was a certified dietary or food service manager, or had a similar food service management certification or degree. There were 89 out of 90 residents that received an oral diet. Findings include: A review of the personnel file for the Dietary Manager revealed a change of status from dietary cook to dietary manager effect date of 12/28/16. A further review of the file revealed an active ServSafe Certification since 10/23/18. However, there was no evidence that the Dietary Services Supervisor had any additional dietary or food service certification or degree. An interview was conducted on 3/4/19 at 11:00 a.m. with the Dietary Manager (DM) regarding a food service management certification or degree. The DM revealed that he did not have a food service management certification or degree. An interview was conducted on 3/5/19 at 10:10 a.m. with the Administrator. The Administrator revealed that she reviewed the regulations and the DM should have food service management certification or degree. | 2020-09-01 |
| 2626 | 2626 | AUTUMN BREEZE HEALTH AND REHAB | 115580 | 1480 SANDTOWN ROAD SW | MARIETTA | GA | 30008 | 2019-03-14 | 812 | F | 0 | 1 | TB9111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and review of policy Georgia Nutrition Consulting, Inc. Expiration, Use By and Best if Used By Dates, the facility failed to discard expired food items. These deficient practices had the potential to affect 89 of 90 residents receiving an oral diet, of whom seven received thickened liquids. Findings included: Review of the policy of the policy Georgia Nutrition Consulting, Inc. Expiration, Use By and Best if Used By Dates revealed: Expiration This date determines when the food is no longer safe to eat. An observation of the dry storage area while accompanied by the dietary manager during the initial kitchen tour on [DATE] at 10:20 a.m. revealed two 8 ounce Thicken Nectar use by date [DATE]. One 46- ounce Honey like Consistency Thickened Sweetened Tea used by date [DATE]. Twenty-seven 4-ounce Honey like thickened lemon flavored water used by date [DATE]. Three 4-ounce Honey like thickened lemon flavored water used by date [DATE]. One gallon jar of Maraschino Cherries expired date [DATE]. An interview was conducted on [DATE] at 11:00 a.m. with the Dietary Manager (DM) regarding the expired items in the dry storage area. The DM confirmed that the items were expired. He also revealed that he is solely responsible for checking the dates for expired food items. He revealed he checks the dates on all food items when the delivery comes in twice a week. The DM revealed that he does educate the staff on checking for expired food items. An interview was conducted on [DATE] at 3:50 p.m. with the Administrator and the DM regarding the expired food items found during the initial kitchen tour. The Administrator revealed that she was not aware of the expired items in the kitchen and she was sorry the surveyor had to find the expired items. An interview was conducted on [DATE] at 4:30 p.m. with the administrator regarding the expired items in the dry storage area. Administrator revealed her expectations that the food ite… | 2020-09-01 |
| 2627 | 2627 | AUTUMN BREEZE HEALTH AND REHAB | 115580 | 1480 SANDTOWN ROAD SW | MARIETTA | GA | 30008 | 2018-10-11 | 684 | E | 1 | 0 | VTF411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff and Physician interview, review of facility policy for insulin administration and education records for carrying out Physician orders, the facility failed to administer medications in accordance with Physician orders for four (4) residents (R), (R#1, R#2, R#3, and R#5) from a sample of six (6) residents reviewed for medications. The facility census was ninety (90) residents. Findings include: Review of the facility policy titled Insulin Administration revised (MONTH) 2014, revealed Step 8 is to check the order for the amount of insulin. Step 12 is to double check the order for the amount of insulin. Review of facility education summary dated 3/13/18 for Physician Orders- How to Carry Out revealed the Licensed Nursing Staff are to make sure to clarify order with Physician/Nurse Practitioner (NP) if the order is not clear. The 11-7 Charge Nurses must conclude the daily activity by checking charts for new orders and ensure they are already entered into the system . The Education Attendance Record indicated fifteen (15) Licensed Nurses signed the roster. Review of the clinical record for R#1 revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R#1 was transferred from the facility to a hospital on [DATE]. Review of the Physician orders for R#1 revealed an order dated 6/5/18 to discontinue all current orders for [MEDICATION NAME] (Quetiapine [MEDICATION NAME]) and decrease (indicated by downward arrow) [MEDICATION NAME] 25 milligrams (mg) by mouth (PO) twice a day (BID) and 50 mg PO every bedtime (Q HS) for a diagnosis (dx) of [MEDICAL CONDITION]. Review of the (MONTH) (YEAR) Medication Administration Record (MAR) for R#1 revealed on 6/5/18 the previous orders for [MEDICATION NAME] had been discontinued and a new order for [MEDICATION NAME] dated 6/5/18 had been added as follows: Quetiapine [MEDICATION NAME] 25 mg tab take [MEDICATION NAME] 25 mg by mouth two times a day for [MEDICAL CONDITI… | 2020-09-01 |
| 2628 | 2628 | AUTUMN BREEZE HEALTH AND REHAB | 115580 | 1480 SANDTOWN ROAD SW | MARIETTA | GA | 30008 | 2018-10-11 | 756 | D | 1 | 0 | VTF411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, review of the Consultant Pharmacist Agreement, and Consultant Pharmacist interview, the Consultant Pharmacist failed to address an error in transcription of an order for [REDACTED]. Findings include: Review of facility Consultant Pharmacist Agreement, Required Consultant Services, signed by the facility on 11/30/16, revealed the Consultant Pharmacist is required to strive to assure that medications and/or biologicals are requested, received and administered in a timely manner as ordered by the authorized prescriber ( in accordance with Applicable Law) Review of the clinical record for R#1 revealed a physician's orders [REDACTED].#1 was transferred from the facility to a hospital on [DATE]. There were no additional orders for Quetiapine [MEDICATION NAME] for R#1 after 6/5/18. Review of the (MONTH) (YEAR) and (MONTH) (YEAR) Medication Administration Record [REDACTED].m from 6/6/18 through 7/25/18. There were no documented administrations of Quetiapine [MEDICATION NAME] 50 mg PO at HS from 6/6/18 through 7/25/18. R#1 missed fifty (50) administrations of Quetiapine [MEDICATION NAME] 50 mg PO at HS. Review of the Pharmacy Progress Notes for R#1 revealed the Consultant Pharmacist had reviewed his medication regimen on 6/20/18 and 7/20/18. There were no references to Quetiapine [MEDICATION NAME] on those dates on the Pharmacy Progress Notes. Review of the clinical record for R#2 revealed a Physician order [REDACTED]. 201 - 251 = 4 units (U) 251 - 300 = 6 U 301 - 350 = 8 U 351 - 400 = 10 U 401 - 500 = 12 U Review of the (MONTH) (YEAR) MAR for R#2 revealed on 3/22/18 at 11:00 a.m. documentation indicated R#2's fingerstick blood sugar (FSBS) result was one hundred sixty-six (166) and she was documented to have been administered 4 U Humalog Insulin in the right upper quadrant (RUQ). Review of the (MONTH) (YEAR) MAR for R#2 revealed on 5/3/18 at 4:00 p.m. the FSBS reading was one hundred eighty- nine (189) and was documented to … | 2020-09-01 |
| 4308 | 4308 | PRUITTHEALTH - MARIETTA | 115276 | 70 SAINE DRIVE SW | MARIETTA | GA | 30008 | 2019-07-24 | 584 | E | 1 | 1 | I5PG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and interviews, the facility failed to ensure that it was maintained in a safe, clean and comfortable home-like environment in seven resident rooms (rooms 200, 201, 203, 206, 209, 210, 227), common shower room and supply storage room, on one of two units. The census was 108. Findings include: Observation on 7/21/19 at 11:20 a.m., revealed on second floor, A Hall supply/storage fluorescent room light out, making room dark during retrieval of supplies. Observation on 7/21/19 at 11:30 a.m., revealed in room [ROOM NUMBER] light bowl sitting on sink counter; ripped wallpaper strip above bed A; peeling particle board on sink counter; hole in ceiling, between two beds, with electrical face plate partially covering opening; hole in ceiling tile in bathroom, approximately two inches in diameter; light in bathroom missing globe fixture; hole in ceiling tile in bathroom, approximately one inch circular around sprinkler head. Observation on 7/21/19 at 12:51 p.m., revealed in room [ROOM NUMBER], electrical outlet in wall with broken face plate. Observation on 7/21/19 at 12:55 p.m., revealed in room [ROOM NUMBER], a hole in ceiling tile in bathroom, approximately two inches in diameter; call light reset button missing on wall unit; chair rail missing around room on bed B side of the room. Observation on 7/21/19 at 2:16 p.m., revealed in room [ROOM NUMBER], hole in ceiling, between two beds, with electrical face plate partially covering opening. Observation on 7/21/19 at 2:18 p.m., revealed common shower room on second floor, with strong, unidentifiable and gagging odor. Observation on 7/22/19 at 11:04 a.m., revealed in room [ROOM NUMBER], bathroom had very strong urine odor; male urinal in clear plastic bag hanging on grab bar, with dark discolored ring around urinal opening. Observation on 7/22/19 at 12:11 p.m., revealed in room [ROOM NUMBER], hole in ceiling, between two beds, with electrical face plate partially covering opening. … | 2019-11-01 |
| 4500 | 4500 | PRUITTHEALTH - MARIETTA | 115276 | 70 SAINE DRIVE SW | MARIETTA | GA | 30008 | 2015-09-30 | 248 | D | 0 | 1 | IBUU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff and resident interviews the facility failed to ensure individualized activities were provided to meet the needs of one(1)resident B from a sample of fifty-four(54)residents. Findings include: During an initial observation and interview with resident B on 09/28/2015 at 11:00 a.m. she/he revealed they did not like to leave their room. She/He stays in bed most of the day because of weakness and prefers to read or watch television. She/He is not able to read anymore because of [MEDICAL CONDITION]. She/He indicated that her/his television/cable had not been working for a little over a week. She/He was told that none of the cable on the second floor hallway was working. Resident B reported the outage on the day the cable went out. On 09/28/2015 at 2:15 p.m. an interview with GG from maintenance revealed the cable on the second floor has been out for about a week. A further interview with HH maintenance supervisor revealed after a power outage last week several channels of cable have not been working. He has been unable to get anyone from the cable company to provide a service call. A tour of the second floor with GG and HH, HH revealed no cable channels are available to the residents on second floor. A follow up interview and observation of B on 9/29/2015 at 11:40 a.m. Resident B was sitting up in her/his bed, television not on. She/He revealed the cable has not been fixed yet. Resident indicated she/he is to tried to get out of bed and hopes the cable will be back on soon. Resident Broommate ' s television is not working. On 9/29/2015 at 11:45 am an interview was conducted with II Activities director regarding activities and a review of the activities calendar. II revealed that residents that do not come out of their rooms are assigned to a one on one visit at least two (2)times a week. The visits should be according to resident's interests as much as possible. Resident B is scheduled to have visits on M… | 2019-09-01 |
| 4501 | 4501 | PRUITTHEALTH - MARIETTA | 115276 | 70 SAINE DRIVE SW | MARIETTA | GA | 30008 | 2015-09-30 | 279 | D | 0 | 1 | IBUU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop a Vision Care Plan for one(1)resident #68 with impaired vision and no corrective lenses from a sample of twenty-eight(28)residents. Findings include: A record review for resident #68 revealed an Admission Minimum Data Set(MDS) assessment dated [DATE] which documented in Section B- Hearing, Speech, and Vision that the resident's vision was impaired, able to see large print but not regular print in newspapers/books and had no corrective lenses. Section V-Care Area Assessment (CAA) triggered Vision with the decision to be care planned. A record view of resident #68 care plans revealed no evidence a care plan for vision had been developed. An interview conducted on 9/30/15 at 10:46 a.m. with the Care Plan Coordinator CC confirmed the Annual MDS assessment dated [DATE] triggered Vision with the decision to be care planned. Further, she confirmed a Vision Care Plan was never developed and that a care plan for Vision should have been developed. | 2019-09-01 |
| 4502 | 4502 | PRUITTHEALTH - MARIETTA | 115276 | 70 SAINE DRIVE SW | MARIETTA | GA | 30008 | 2015-09-30 | 309 | D | 0 | 1 | IBUU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interviews the facility failed to follow a physician order [REDACTED]. Findings Include: An observation of resident #8 was made on 9/30/2015 at 8:05 a.m. on the second floor at the far exit door next to room [ROOM NUMBER]. The resident was trying to get the door open, screaming, someone get her back. A Certified Nurse Assistant(CNA)responded to the residents call and requested assistance from Licensed Practical Nurse (LPN)JJ . A record review of resident #8 on 9/30/2015 at 8:10 a.m. revealed a Brief Interview of Mental Status score (BIMS) of three (3) and [DIAGNOSES REDACTED]. A Physician' s order dated 9/1/2015 through 9/30/2015 was signed and dated on 9/2/2015 for a Wander guard and to check function and placement every shift was noted. A further observation was made of resident #8 in her/his room on 9/30/2015 at 8:10 a.m. No WanderGaurd was observed to be on resident #8. An interview during this observation of resident #8 with JJ revealed resident #8 does not have a wander guard on and (LPN)JJ believed that the wander guard was discontinued in the past. Review of the physician' s order for a WanderGuard was signed on 9/2/2015 and verified with (LPN)JJ. 9/30/2015 an interview with the Director of Nurses (DON) at 11:35 a.m. revealed there was a physician's orders [REDACTED]. There is no WanderGuard on resident #8. It is her expectation that physician's order [REDACTED]. Review of physician orders [REDACTED]. discontinue [MEDICATION NAME] twenty five (25) milligrams (mg) and give [MEDICATION NAME] thirty seven point five (37.5) milligrams (mg) by mouth daily for depression. Review of the Medication Administration Record [REDACTED]. Interview on 9/30/2015 at 11:20 a.m. with BB Licensed Practical Nurse (LPN) Unit Manager revealed that the nurse giving the medication 12/10/2014 through 12/12/2014 should have notified someone that the ordered dose was not available on the cart. She stated that the nu… | 2019-09-01 |
| 4503 | 4503 | PRUITTHEALTH - MARIETTA | 115276 | 70 SAINE DRIVE SW | MARIETTA | GA | 30008 | 2015-09-30 | 313 | D | 0 | 1 | IBUU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interviews, the facility failed to ensure needed ophthalmology services for one (1) resident ('A') from a sample of twenty-eight (28) residents. Findings include: Resident was assessed on his most recent Quarterly assessment dated [DATE] to have moderate vision impairment, with no corrective lenses. The Care plan indicated impaired vision, but did not utilize glasses or corrective lenses. The resident was admitted to facility on 9/19/14. Resident was observed attempting to read on 9/29/15 at 11:28 am. Resident revealed he used to wear glasses, but just quit wearing them, had no idea where they might be .Resident was requested to read a sentence from his book, but was unable to, just mumbled various words. Residents Bim score was 5. Interview with residents Certified Nursing Assistant (CNA) AA on 9/29/15 at 11:28 am revealed resident was always reading his books, told CNA he loved to read. She was not aware if he could actually read or not. Interview with the Unit Manager BB on 9/29/15 at 11:51 am revealed that if a resident was assessed for poor vision, and no corrective lenses, that resident should be placed on the list for the next ophthalmology visit. He visits approximately every three (3) months, last visit was (MONTH) (YEAR). Did not know how resident 'A' was missed for an eye exam. He arrived to the unit with out glasses. Interview with the Minimal Data Set (MDS) coordinator CC on 9/29/15 at 11:59 am revealed that the assessment and care plan are completed for impaired vision, but MDS does not make recommendations for eye evaluations. A complete assessment was done by nursing, who would then notify Social Services, who was responsible for keeping the list of residents needing an eye appointment. Interview with Social Services DD on 9/29/15 at 1:50pm revealed that she would receive a Communication Form from nursing requesting an Ophthalmology consult. Then that resident would be pl… | 2019-09-01 |
| 4504 | 4504 | PRUITTHEALTH - MARIETTA | 115276 | 70 SAINE DRIVE SW | MARIETTA | GA | 30008 | 2015-09-30 | 323 | D | 0 | 1 | IBUU11 | Based on observations, staff interviews and review of the Safety Data sheet the facility failed to ensure a hazardous chemical was stored securely in one (1) shower out of four (4) showers in the facility. Findings include: During the initial tour of the facility on 9/28/2015 at 10:30 am the shower room (#1) was propped open with a linen cart. An open cabinet inside the shower contained a spray bottle, unlabeled, half full of a blue substance. A second observation at 12:15pm that day revealed the shower door shut, unlocked and the same spray bottle of blue substance unlocked in the cabinet in the shower. The same day at 3:20 p.m. a tour was conducted while interviewing JJ unit manager. Shower (#1) was found propped open with a trash can and the shower cabinet open. An unlabeled spray bottle half full of a blue substance was in the unlocked cabinet. JJ indicated that the substance is a disinfectant that should be locked up in the cabinet and the shower room should be locked when not in use. JJ further revealed the staff memo posted on the shower cabinet door indicates before staff leave the shower the disinfectant bottle should be placed back into the locked cabinet. During an interview with the Administrator and the Director of nurses on 9/29/2015 at 330 Pm revealed the blue substance in the spray bottle was Clorox Commercial Solutions Green Works Concentrated glass cleaner. The Materials Safety Data Sheet provided indicated this hazardous chemical may cause skin irritation, serious eye irritation and is flammable. It was the expectation of the Administrator that this chemical be stored in a locked cabinet when not in use and safely out of residents harm. 9/29/2015 at 4:15pm a follow up interview was conducted with the Administrator and HH. They were unable to identify if staff had been directed to keep chemicals locked in the past. An in-service was provided to housekeeping staff on that day to educate on the proper storage of hazardous chemicals. | 2019-09-01 |
| 4505 | 4505 | PRUITTHEALTH - MARIETTA | 115276 | 70 SAINE DRIVE SW | MARIETTA | GA | 30008 | 2015-09-30 | 332 | D | 0 | 1 | IBUU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations record review and staff interview observed during medication administration on one (1)of six (6) halls the facility failed to ensure that one(1)of four(4)medication nurses administered medications without a medication error rate of five percent or greater. Findings include: An observation conducted during medication pass on 9/29/15 beginning at 4:38 p.m. revealed one 1)of four (4)nurses administering medications on one (1) of six (6) halls with three (3) errors observed from twenty-seven (27)opportunities. This resulted in a medication error rate of six point eighty-nine percent (6.89%). An observation on 9/29/15 at 5:46 p.m. with Licensed Practical Nurse(LPN)MM administered sennosides-[MEDICATION NAME] eight point six, and fifty(8.6-50)milligrams (mg)by mouth (PO) twice a day (BID) as needed to resident #93. Review of the physician's orders [REDACTED]. An observation on 9/29/15 at 5:47 p.m. revealed MM administered [MEDICATION NAME] 0.5 mg one(1) tablet PO to resident #93. Review of the physician's orders [REDACTED]. A interview with the Licensed Practical Medication Nurse MM on 9/29/15 at 6:00 p.m. MM revealed the correct dosage for Sennosides-[MEDICATION NAME], and the correct dosage and time for [MEDICATION NAME] were not followed as physician ordered and should have been followed. In an Interview with the Director of Nursing (DON) on 9/30/15 at 12:40 p.m., revealed her expectation for nurses is that they follow standards and the facilities protocols and guidelines during medication pass and storage. The DON further revealed that during medication pass, the nurses are expected to follow the physician orders [REDACTED]. | 2019-09-01 |
| 4506 | 4506 | PRUITTHEALTH - MARIETTA | 115276 | 70 SAINE DRIVE SW | MARIETTA | GA | 30008 | 2015-09-30 | 441 | D | 0 | 1 | IBUU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interviews the facility failed to follow infection control practices during medication pass for one(1)of three(3)medication carts out of six(6)units. Finding includes: During medication pass observation on 9/29/15 at 5:40 p.m. The Licensed Practical Nurse NN was observed during medication pass to drop one(1) pill inside the medication cart draw([MEDICATION NAME] 100 milligrams(mg)one (1) tablet)and noted three(3)pills on top of the medication cart( [MEDICATION NAME] 0.6 mg one(1)tablet, [MEDICATION NAME] 50 mg one(1)tablet, and half(1/2)tablet 1.25 mg [MEDICATION NAME] 1 tablet). The nurse picked up all four (4) pills with a spoon and placed in a medication cup and administered them to the resident. Interview with the Licensed Practical Nurse NN on 9/29/2015 at 6:06 p.m., revealed she should have wasted the medications that was dropped on cart. In an interview conducted on 09/30/2015 at 11:18 a.m., with the Director of Nursing(DON)revealed her expectation for nurses is that they follow standards and the facilities protocols and guidelines during medication pass and storage. Review of the Facility Infection Prevention and Control Program Overview dated 2/05/15 documented Implementation of Control Measures: Prevention of spread of infections is accomplished by use of Standard Precautions and other barriers . | 2019-09-01 |
| 4507 | 4507 | PRUITTHEALTH - MARIETTA | 115276 | 70 SAINE DRIVE SW | MARIETTA | GA | 30008 | 2015-09-30 | 466 | E | 0 | 1 | IBUU11 | Based on observation and staff interview the facility failed to maintain the required amount of emergency water on site. The current facility census was one hundred seventeen(117)residents. Findings include: An observation and interview on 09/29/2015 at 8:18 a.m. with EE the Dietary manager and FF Corporate dietary consultant, revealed there were sixty(60)gallons of water available for emergency use. A review of(NAME)emergency water requirements chart indicated that Georgia three(3)day emergency stock requires ninety-six(96)gallons of water for one hundred twenty(120)bed facility or three(3) liters per resident per day for three(3)days. | 2019-09-01 |
| 4907 | 4907 | AUTUMN BREEZE HEALTH AND REHAB | 115580 | 1480 SANDTOWN ROAD SW | MARIETTA | GA | 30008 | 2015-09-24 | 279 | D | 0 | 1 | YH7R11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review,and staff interviews the facility failed to develop a care plan for one (1) resident #12 with a foley catheter from a sample size of five (5)census residents with foley catheters in the facility. Finding includes: Resident #12 is a seventy-eight (78) year old female admitted to Autumn Breeze Healthcare Center on 07/28/2015 under Hospice Care. She has a right above the knee amputation, a gastric tube with continuous feeds, and a Foley catheter due to a stage IV sacral ulcer located on her right Ischium. Further review of Resident #12 medical record revealed the Minimum Data Set (MDS) admission assessment dated [DATE] Section H assessed as having the use of indwelling Foley catheter. Review of the same assessment in Section V.Care Area Assessments (CAA) indicated that a care plan would be developed to address the use of the Foley catheter with goals and interventions. Resident #12 medical record also revealed a comprehensive care plan dated 8/14/2015 was developed with no evidence of a care plan to address resident's Foley catheter. Interview conducted on 09/23/15 at 2:25 p. m. with Licensed Practical Nurse (LPN) FF who acknowledged that the care plan for urinary incontinence with indwelling catheter was not present on the comprehensive care plan. Interview conducted with the Director of Nursing (DON) on 09/23/15 at 2:35 p. m. also acknowledged that a care plan for urinary incontinence with indwelling catheter was not found in resident medical record. She further revealed that a care plan should have been completed as indicated in the CAA. Interview conducted with the MDS Coordinator on 09/23/15 at 2:50 p. m. who acknowledged that a care plan for urinary incontinence with indwelling catheter was not completed on the comprehensive assessment as indicated on the CAA. She also revealed that this was an oversight and would make the corrections immediately. | 2019-04-01 |
| 4908 | 4908 | AUTUMN BREEZE HEALTH AND REHAB | 115580 | 1480 SANDTOWN ROAD SW | MARIETTA | GA | 30008 | 2015-09-24 | 282 | D | 0 | 1 | YH7R11 | Based on observations, staff interviews and record reviews it was determined that the facility failed to ensure resident ' s written plan of care was followed. This was evident for one (1) resident #17 of thirty three (33) sampled resident's. Findings Include: Record review of resident #17 revealed a care plan dated 7/17/2014 indicating the resident is at risk for decline in nutrition/hydration status with appropriate goals and interventions including offer resident diet and supplements per orders. Cross reference F309 | 2019-04-01 |
| 4909 | 4909 | AUTUMN BREEZE HEALTH AND REHAB | 115580 | 1480 SANDTOWN ROAD SW | MARIETTA | GA | 30008 | 2015-09-24 | 309 | D | 0 | 1 | YH7R11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident observations, record review, and staff interviews it was determined that the facility failed to follow a physician order [REDACTED]. Findings Include: Observation on 9/22/2015 at 1pm with resident #17 during lunch in the dining room revealed no ice cream, yogurt or health shake on the resident ' s tray and observation on 9/23/2015 at 1pm with resident #17 during lunch in the dining room revealed no ice cream, yogurt or health shake on the resident ' s tray. Record review revealed a physician order [REDACTED]. Review of facility policy dated (MONTH) 2000 revealed that diet orders will be conveyed in writing via a diet change form to the dietary department. Review of dietary cards for resident #17 revealed that no supplements were indicated for the lunch tray for 9/23/2015. Review of dietary progress notes dated 7/15/2014 indicate adding another health shake on dinner tray, dated 10/7/2014 indicates supplemented with health shake, dated 12/30/2014 indicates health shake twice daily, dated 4/7/2015 indicates reducing health shake to daily, dated 7/7/2015 indicates no nutritional concerns, and dated 7/15/2015 indicates add another health shake on dinner tray. The Registered Dietitian Nutritional recommendations dated 7/15/2014 indicate weight decreased - health shake on lunch and dinner tray, and dated 4/21/2015 indicate weight gain - discontinue health shake twice daily and start health shake daily on lunch tray. Staff interview on 9/23/2015 at 1:15pm with Dietary Manager revealed that resident #17 did not receive a health shake, yogurt or ice cream on her tray for lunch on 9/23/2015. When further questioned about the order for a health shake, yogurt and ice cream on the resident ' s tray at lunch she indicated that the order had been changed to a health shake on the lunch tray, however when further questioned she could not produce an order indicating that change. Interview on 9/23/2015 at 2pm with the Registered Dietitian reve… | 2019-04-01 |
| 4910 | 4910 | AUTUMN BREEZE HEALTH AND REHAB | 115580 | 1480 SANDTOWN ROAD SW | MARIETTA | GA | 30008 | 2015-09-24 | 371 | F | 0 | 1 | YH7R11 | Based on observations and a staff interview, the facility failed to properly store food under sanitary conditions in the walk in freezer. Findings include: Tour of the facility kitchen conducted on 9/21/2015 at 9:30 am revealed icicles hanging from the ceiling of the walk in freezer with water dripping on to several boxes of magic cups supplement. The next observation later this same day at 1pm revealed icicles continues hanging from the ceiling in the walk in freezer and continue to drip on several boxes of frozen supplements. Final observation conducted on 9/23/2015 at 9 am revealed icicles still remain in the freezer and continue to drip on several boxes of frozen supplements. Interview on 9/23/2015 at 9:05 am with the Director of Food Service revealed that she would have the maintenance look at the freezer and get it repaired. She also indicated that the magic cups were disposed of that were dripped on the last two (2) days. | 2019-04-01 |
| 4911 | 4911 | AUTUMN BREEZE HEALTH AND REHAB | 115580 | 1480 SANDTOWN ROAD SW | MARIETTA | GA | 30008 | 2015-09-24 | 431 | D | 0 | 1 | YH7R11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the Facility policy Medication Storage in the Healthcare Centers, and staff interview, the facility failed to ensure proper medication storage were maintained for one (1) of four (4) medication carts on one (1) of five (5) wings. Findings include: During observations of medication pass on [DATE] at 5:10 p.m. the B hall Licensed Practical Medication Nurse (LPN) AA was observed to leave a cup of medications which includes, vitamin C 500 mg 1 tab, Gabapentin three (3) 100 mg caps PO (By Mouth), Hydralazine 50 mg 1 tab PO, Tramadol Hydrochloride 50 mg 1 tab PO unattended on top of the medication cart. Further observations revealed two (2) residents sitting in their wheel chairs adjacent to the medication cart. Interview conducted with LPN AA on [DATE] at 5:40 p.m., revealed she should not have left the cup of medications unattended on top of her medication cart. During observations of medication storage on [DATE] at 9:25 a.m., revealed one (1) bottle of Humalog one hundred (100) units was dated opened on [DATE] and dated expired on [DATE]. Further review of the medication label revealed the medication should discard twenty-eight days from open date. Interview conducted with LPN Medication Nurse BB on [DATE] at 9:25 a.m., revealed that the Humalog insulin medication is expired and should have been discarded. Interview conducted on [DATE] at 11:18 a.m., with the Director of Nursing (DON) revealed her expectation for nurses is that they follow standards and the facilities protocols and guidelines during medication pass and storage. The DON further revealed that there should be no expired medication stored in the medication cart, and medications should not be left unattended on the medication cart. Medication administration a protocols were followed secured was that the nurse will lock the cart when it is not in view. Further narcotics are kept double locked. Review of facility policy Medication Storage and Medication … | 2019-04-01 |
| 4912 | 4912 | AUTUMN BREEZE HEALTH AND REHAB | 115580 | 1480 SANDTOWN ROAD SW | MARIETTA | GA | 30008 | 2015-09-24 | 514 | D | 0 | 1 | YH7R11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record reviews, staff/resident interviews the facility failed to transcribe the written physician orders [REDACTED].#121) out of a random sample of thirty-three (33) residents. Findings include: Per medical record review resident #121 is a sixty-two (62) year old female admitted to Autumn Breeze Healthcare Center on 09/15/2015 with status [REDACTED]. Physician orders [REDACTED]. foley catheter care every shift, and anchor catheter at all times. Per review of the medical record, the physician orders, Medication Administration Record (MAR) and Treatment Administration Record (TAR), the TAR did not reflect the physician orders [REDACTED]. The admission checklist was completed however not signed. The twenty-four( 24) hour chart checks were documented as completed, however staff failed to note that the foley treatment orders were not present on the TAR. Review of the nurses notes since admission did not reflect foley catheter care performed from 09/15/15 - 09/21/15. Review of the Certified Nurse Assistant (CNA) activities of daily living (ADL) documentation in Point Click Care (PCC) does not specify foley care has been performed. Interview conducted with resident #121 who stated she has a permanent foley due to a urinary blockage diagnosed in (MONTH) (YEAR). She stated she has had a foley continuously since (MONTH) (YEAR). She stated her foley and bag are changed monthly and as needed. Resident further stated her foley was last changed on 09/06/15 prior to admission to Autumn Breeze and on 08/06/15 prior to her surgery for [REDACTED]. She acknowledged that the staff were performing foley care at least twice day and sometimes more. She stated just can ' t say yes they are providing foley every shift meaning at minimum three times a day. She stated they keep the foley anchored properly and are very attentive to my needs. Interview was conducted on 09/23/15 at 2:07pm with Licensed Practical Nurse (LPN) FF who upon revie… | 2019-04-01 |
| 4913 | 4913 | AUTUMN BREEZE HEALTH AND REHAB | 115580 | 1480 SANDTOWN ROAD SW | MARIETTA | GA | 30008 | 2015-09-24 | 520 | F | 0 | 1 | YH7R12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of policy and procedure, facility Plan of correction review and staff interviews, the facility failed to have an effective Quality Assessment and Assurance (QAA) committee that developed and implemented a process to ensure all opened medications were properly dated and discarded timely by the plan of correction date of 11/06/2015. Cross refer F431 Review of the policy titled(NAME)Health System Quality Improvement Principles documented: We as a company will ensure that our processes or systems identify areas to improve the outcomes that will benefit all our staff and residents. Process improvement is a systematic or scientific approach to studying work and making improvements to how work gets done. It involves fact finding, not fault finding, through data collection and root cause analysis to identify and measure the problem and its source. Once the source of the problem is identified, improvement comes through generating salutations that address the root cause of the problem. Review of the Plan of Correction documented: The Director of Nursing (DON), Assistant Director of Nursing (ADON) and Nursing Consultant will monitor staff for compliance with respect to medication administration and storage. The DON, ADON and RN Supervisors will audit medication dates to ensure outdated medications will be disposed of properly. Review of the facility's in-service records revealed education was provided to staff members on 10/19/15 through 10/23/15 related to checking of the medication cart for out of date medications and unattended medication cart every shift. During a health revisit conducted on 03/14/16 an observation of the medication cart C/D at 10:30 a.m. revealed one (1) open vial of [MEDICATION NAME] that was not dated. Observation of medication cart E at 10:52 a.m. revealed two (2) multi-dose opened vials of normal saline that were not dated. Observation of the medication refrigerator for the A,B,C, and D halls on 03/… | 2019-04-01 |
| 5721 | 5721 | PRUITTHEALTH - MARIETTA | 115276 | 50 SAINE DRIVE SW | MARIETTA | GA | 30008 | 2014-10-30 | 282 | D | 0 | 1 | RG0T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews, the facility failed to ensure that the plan of care for one (1) resident (4) for dental services was followed from a sample of thirty-three (33) residents. Findings Include: Observation conducted on 10/28/2014 at 11:36am of resident 4 revealed that his front teeth were broken, and very discolored. Review of resident's care plan dated 6/4/2014 indicated that one of his problems was that he has his natural teeth with obvious caries and does have complaints of pain on his bottom front teeth. Goals include adequate oral care/hygiene daily thru next review and he will have carious teeth causing pain to be extracted/treated to resolve pain by next review. Interventions include refer to dentist/dental hygienist for evaluation and recommendations, assist with oral hygiene daily, observe oral cavity when assisting with oral care for bleeding, increased pain, swelling, coating, sores and any other abnormalities and report to nurse if present, observe for loose, missing or carious teeth and notify nurse, and medicate for pain per physicians' orders. Another problem identified in the care plan was alteration in comfort related to complaints of pain to head, neck and bottom front teeth. Goal listed was to be kept comfortable as much as possible thru next review. Interventions include administer pain medication per physician's orders [REDACTED]. This care plan was reviewed on 8/28/2014 with no changes in problems or interventions. Interview conducted 10/29/2014 at 12:00pm with Registered Nurse GG revealed that she could not find a dental consult in the chart. Interview conducted on 10/29/2014 at 12:45pm with Register Nurse, Minimum Data Set (MDS) Coordinator CC revealed that when she generates the care plan she notifies social services. CC acknowledged that on 8/28/2014 when she reviewed the care plan she did not follow up on the dental consult but should have. Interview conducted on 10/29/14 at 1:… | 2018-05-01 |
| 5722 | 5722 | PRUITTHEALTH - MARIETTA | 115276 | 50 SAINE DRIVE SW | MARIETTA | GA | 30008 | 2014-10-30 | 312 | D | 0 | 1 | RG0T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of the medical record, family and staff Interviews, the facility failed to provide personal hygiene care for one (1) resident (T) requiring extensive assistance, from a sample of thirty-three (33) residents. Findings include: Observation conducted on 10/27/14 at 12:51 P.M. revealed the resident in bed unshaven, with a rash and scabs noted on bilateral legs and arms. His fingernails were long and dirty with a brown substance under three nails of the left hand. Interview conducted on 10/28/14 at 10:33 A.M. with the brother of resident T revealed the resident's toenails are never trimmed and his fingernails are always dirty. Observation conducted on 10/28/14 at 2:31 P.M. revealed the resident has long, dirty (3) fingernails. Three fingers on the left hand continue to have a brown, dried substance on the nail beds and under the nails. There is also a brown substance under two (2) fingernails of the right hand. He is unshaven. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated the resident requires limited assistance with most Activity of Daily Living (ADLS) but extensive assistance with toileting, personal hygiene which includes combing hair, shaving, washing/drying face and hands and total dependence for bathing. This MDS did not assess the resident for any behaviors or as being resistive to care. Observation conducted on 10/29/14 at 9:38 A.M. revealed the resident was in his wheel chair propelling through the hallway. He was dressed with a t-shirt and sweat pants. The sweat pants were heavily soiled and stained. His hair was not combed and he continued to be unshaven. The fingernails were untrimmed and three fingers on the left hand continued to have a dried brown substance on the nail beds and under the nails. There was a brown substance under the nails of two fingers on the right hand. Review of the Grievance Log from January 2014 through October 2014 revealed seven (7) complaints ma… | 2018-05-01 |
| 5723 | 5723 | PRUITTHEALTH - MARIETTA | 115276 | 50 SAINE DRIVE SW | MARIETTA | GA | 30008 | 2014-10-30 | 328 | D | 0 | 1 | RG0T11 | Based on observations, review of the facility's policy and manufacturer guidelines, and staff interviews, the facility failed to maintain the cleanliness of oxygen (O2) equipment for two (2) residents (#101 and #51), of six (6) residents receiving continuous oxygen therapy on two (2) of two (2) nursing units. Findings include: 1. Observations conducted on 10/27/14 at 2:47 PM, 10/28/14 at 7:29 AM, and 10/29/14 at 10:15 AM revealed the Invacare Platinum Series 5 oxygen concentrator for resident #101 had filters on each side that were coated with a thick layer of white dust. On 10/30/14 at 7:55 AM the concentrator had one side caked with white dust and the filter on the other side was rolled up and dusty, and appeared to have been rinsed. Interview conducted 10/30/2014 at 8:45 AM with the Director of Nursing (DON) in the room of resident #101, revealed filters on the O2 concentrator should have been washed or changed Sunday by the nursing supervisor and this one must have been missed. 2. Observation on 10/30/2014 at 1:51 PM revealed an Invacare platinum 5 oxygen concentrator providing continuous oxygen via Nasal Cannula to resident #51 had both filters coated with dust. Interview conducted on 10/30/2014 at 2:31 PM with Registered Nurse GG in the room of resident #51 revealed oxygen filters are supposed to be cleaned or changed on Sundays. GG acknowledged these filters were not changed or cleaned Sunday. Review of the facility policy entitled Oxygen Administration Safety and Storage revealed the large external black filter should be washed with soap and water once each week and as needed (PRN). Review of the manufacturer's guidelines for the Invacare Platinum Series 5 oxygen concentrator revealed both filters should be removed and cleaned at least once a week or more frequently depending on environmental conditions. | 2018-05-01 |
| 5724 | 5724 | PRUITTHEALTH - MARIETTA | 115276 | 50 SAINE DRIVE SW | MARIETTA | GA | 30008 | 2014-10-30 | 364 | E | 0 | 1 | RG0T11 | Based on observation, resident and staff Interviews, the facility failed to ensure the food served was palatable and warm for seven (7) residents (A,B, C, D, E, F G,) from a sample of thirty-three (33) residents. 1. Interview conducted on 10/28/14 at 1:55 P.M. with resident F revealed he received the breakfast he ordered however, it was served cold. Interview conducted on 10/29/14 at 9:25 A.M. with resident F revealed his breakfast was served cold again this morning. Review of the Resident Council minutes for 1/23/14 and 4/29/14 revealed complaints had been made related to poor tasting food and/or the food being served cold. Observation conducted on 10/30/14 at 7:30 A.M. in the kitchen revealed the kitchen staff preparing breakfast trays and stacking them on a open cart. The trays for this cart were completed at 7:41 A.M. and a test tray was requested to be placed on the bottom of the cart rack at this time. At 7:45 A.M. the cart was delivered to the Cambridge Wing and announced to the staff that breakfast trays were on the floor. At 7:46 A.M. the Certified Nursing Aide's (CNA's) began passing the trays to the residents. The cart was followed until the last tray for residents's that feed themselves was delivered at 7:59 A.M. There were four trays remaining for residents that required assistance with eating. At 8:01 A.M. the test tray consisting of scrambled eggs, bacon and grits was first sampled by CNA AA and then the Surveyor. Both agreed the eggs were cold and the grits were slightly warm. 2. Interview conducted 0/27/14 at 1:00PM with resident A revealed the food is usually cold whether served in the dining room or resident room. A further revealed the the food carts are rolled to the hallways but trays are cold by the time the food is served in the rooms. Observation conducted on 10/19/2014 from 8:10AM until 8:35AM of the Cambridge Hallway revealed the food cart full of trays was left unattended and un-served during this time. Certified Nursing Assistants (CNAs) began removing trays from the cart and serving … | 2018-05-01 |
| 5725 | 5725 | PRUITTHEALTH - MARIETTA | 115276 | 50 SAINE DRIVE SW | MARIETTA | GA | 30008 | 2014-10-30 | 441 | D | 0 | 1 | RG0T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of the facility policy and staff interview, the facility failed to ensure proper procedures were followed in maintaining and storing personal care equipment in three (3) resident bathrooms on one (1) of six (6) halls (A Hall). Findings include: Observation conducted 10/27/2014 at 1:58 PM in the bathroom of room [ROOM NUMBER] on the A Hall of the Bristol Floor, revealed two (2) bedpans unlabeled and un-bagged on the floor beside the toilet. The bathroom is shared by two (2) residents and one (1) resident is capable of using the bathroom with assistance. Observation conducted 10/27/14 at 2:07 PM in the bathroom of room [ROOM NUMBER] on the A Hall of the Bristol Floor, revealed a used bedside drainage bag from a Foley catheter set, hanging on a hook on the wall behind the toilet. The connection that would fit into the catheter was uncovered and the bag and tubing were not in a protective plastic bag. The bag contained small amounts of brown liquid. The bathroom is used by two (2) male residents. Observation conducted 10/27/14 at 2:31 PM in room [ROOM NUMBER] of the A Hall of the Bristol Floor, revealed a gray plastic washbasin on the floor under the sink, there was no label to identified who the wash basin belonged to and it was not in a bag. The room is occupied by two (2) female residents. Interview conducted 10/30/2014 at 10:30:01 AM with the Director of Nursing (DON) revealed the policy of the facility is for all bedpans, basins, urinals to be labeled and stored in plastic bags and hanging on wall hooks in the resident bathrooms. The DON indicated rounds should be made daily to ensure compliance with the policy. Review of the facility policy for Bedpans and Urinals indicated that bedpans and urinals will be issued to an individual patient/resident, will be labeled and stored in a plastic bag in the patient/resident's closet, bedside stand, on a shelf in the patient/resident's bathroom or hanging on handrail in t… | 2018-05-01 |
| 6090 | 6090 | AUTUMN BREEZE HEALTH AND REHAB | 115580 | 1480 SANDTOWN ROAD SW | MARIETTA | GA | 30008 | 2014-10-16 | 167 | C | 0 | 1 | SM1J11 | Based on observation, interview with one (1) resident (S) and facility staff, the facility failed to make survey results readily accessible to the residents. The census was ninety (90) residents. Findings include: Interview with resident S conducted on 10/15/14 at 1:21 P.M. revealed he was not aware he had access to the state survey results and has never seen them anywhere. Observation conducted on 10/15/14 at 2:08 P.M. revealed the State Survey results was in a binder, located in a bin on the wall of the front lobby. The lobby and the residents' halls have a locked door between them preventing residents access to the survey results, Interview conducted with the Administrator on 10/15/14 at 2:12 P.M. confirmed the survey results are in a binder on the wall of the front lobby and the results are not posted anywhere else in the facility. The administrator further confirmed the residents do not have access to the survey results kept in the lobby. She said she will make a second copy and place them on the wall in the hallway by the nurse's station. | 2018-04-01 |
| 6091 | 6091 | AUTUMN BREEZE HEALTH AND REHAB | 115580 | 1480 SANDTOWN ROAD SW | MARIETTA | GA | 30008 | 2014-10-16 | 272 | D | 0 | 1 | SM1J11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interview, the facility failed to provide a comprehensive assessment related to dental care for one (1) resident (R), from a sample of twenty-eight (28) residents. Findings include: Observation conducted 10/14/2014 at 3:04 PM revealed resident R had easily visible, broken, jagged and discolored front upper and lower teeth. Record review for resident R revealed an Admission Minimum Data Set ((MDS) dated [DATE] which assessed the resident as having no broken, missing or damaged teeth. Interview with resident R conducted on 10/14/14 at 3:05 PM revealed she had broken her front teeth prior to admission to the facility and that she is very concerned about her broken teeth. She does not have discomfort from them and is able to eat but she knows dental problems can make her very ill. She further revealed that no one has spoken with her about this problem. Interview with the MDS nurse AA conducted on 10/16/14 at 8:56 AM revealed she completed the assessment for resident R and did not record the residents' dental problems. She further revealed that she should have done so to ensure the Social Service Director would address the problems. Interview with the Social Services Director conducted on 10/16/14 at 10:15 AM revealed dental services are offered in house, however, she was unaware of the dental issues of resident R. | 2018-04-01 |
| 6092 | 6092 | AUTUMN BREEZE HEALTH AND REHAB | 115580 | 1480 SANDTOWN ROAD SW | MARIETTA | GA | 30008 | 2014-10-16 | 280 | D | 0 | 1 | SM1J11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interviews, the facility failed to update and revise the care plan for one (1) resident (#130) from a sample of twenty-eight (28) residents. Findings include: Record review for resident #130 revealed a Minimum Data Set (MDS) Admission assessment dated [DATE] which assessed the resident as requiring supervision/oversight with Activities of Daily Living (ADLS) including toileting. The resident was assessed as always continent of bowel and bladder. Further review of the MDS Quarterly assessment dated [DATE] assessed the resident as having occasional urinary incontinence during the seven day look back period. Review of the care plan revealed it was not revised to identify occasional urinary incontinence with goals and interventions. Interview with a direct care Certified Nursing Assistant (CNA) conducted on 10/16/14 at 8:05 AM revealed the resident is continent most all of the time. He is ambulatory and takes himself to the bathroom. Only on occasion has the resident had an accident and wet himself. The resident does not call to tell the staff he is wet, it is found during every two (2) hour rounding checks. Interview conducted on 10/16/14 at 9:31 AM with the MDS Registered Nurse (RN)AA revealed she does not do the care plans for the Dementia Unit but did confirm if is a change in continence, the care plan should be updated for urinary incontinent. Interview MDS RN for the Dementia Unit CC conducted on 10/16/14 at 9:47 AM revealed the information obtained for the seven day look back period for incontinence is found in the CNA's ADL flowsheet. If the resident is having occasional incontinence it would be care planned. She further confirmed there is no revised care plan related to urinary incontinence for resident #130. | 2018-04-01 |
| 6093 | 6093 | AUTUMN BREEZE HEALTH AND REHAB | 115580 | 1480 SANDTOWN ROAD SW | MARIETTA | GA | 30008 | 2014-10-16 | 312 | D | 0 | 1 | SM1J11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and family and staff interview, the facility failed to provide nail care for two (2) residents (# 24 and X), requiring extensive assistance with all areas of personal cleanliness, from a sample of twenty-eight (28) residents. Findings include: 1. Observation of resident #24 conducted on 10/14/2014 at 2:21 PM revealed brown debris under untrimmed fingernails. Review of the Minimum Data Set (MDS) Quarterly assessment for resident #24 dated 09/03/2014 assessed the resident as needing extensive assistance in all areas of personal hygiene. The care plan for resident #24 indicated her fingernails are to be kept clean and trimmed. Observation and interview with the Director of Nursing (DON) conducted on 10/15/14 at 3:30 PM revealed resident #24 had an accumulation of brown debris under untrimmed nails. The DON indicated the Certified Nursing Assistants (CNAs) are all aware that every residents nails are to be checked with each bedbath or shower every day, cleaned and trimmed as needed. She acknowledged resident # 24 needed nail care. 2. Observation of resident X conducted on 10/14/14 at 3:30 PM revealed brown debris under untrimmed finger nails. Review of the MDS Quarterly assessment dated [DATE] assessed resident X as requiring extensive assistance in all areas of personal hygiene. Review of the care plan included interventions listed under Activity of Daily Living indicating her nails are to be kept clean and trimmed. Interview with a family member of resident X conducted on 10/14/2014 at 3:30 PM revealed her finger nails are not cleaned or trimmed with bathing. The family member further indicated the resident sometimes attempts to feed herself with her hands. | 2018-04-01 |
| 6094 | 6094 | AUTUMN BREEZE HEALTH AND REHAB | 115580 | 1480 SANDTOWN ROAD SW | MARIETTA | GA | 30008 | 2014-10-16 | 441 | E | 0 | 1 | SM1J11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of facility inservice attendance sheets and staff interviews, the facility failed to store personal care equipment in a sanitary manner in resident bathrooms on three (3) of five (5) halls. Findings include: C Hall Observation conducted on 10/15/14 at 1:08 P.M. in the bathroom shared by five (5) residents in rooms C-133 and C-135 revealed a two (2) wash basins stacked one inside of the other inside a clear plastic bag. One (1) basin was labeled and the other one was not. Observation conducted on 10/15/14 at 1:27 P.M. of the bathroom shared by four (4) residents in rooms C-132 and C-134 revealed two (2) wash basins, one stacked inside of the other in a clear plastic bag. One basin was labeled and the other was not. D Hall Observation conducted on 10/15/14 at 1:34 P.M. of the bathroom shared by four (4) residents in rooms D-149 and D-147 revealed three (3) wash basins, two (20 were labeled with different names stacked on inside the other, one (10 was unlabeled. There were also two (2) unlabeled urinals in one clear plastic bag. A second clear plastic bag contained a toilet commode bucket with no label. B Hall Observation conducted on 10/15/14 at 1:41 P.M. of the bathroom shared by four (4) residents on rooms B-128 and B-130 revealed four (4) wash basins all stacked inside each other in one (1) clear plastic bag. One basin had a resident label on it, the other three (3) were unlabeled. Observation conducted at 10/15/14 at 1:58 P.M. with the Assistant Director of Nursing (ADON)/Infection Control RN acknowledged the above findings. Interview conducted on 10/15/14 at 2:05 P.M. with the ADON/Infection Control RN revealed that staff know better than to bag personal equipment in one bag and they know personal equipment is to be labeled. Interview conducted on 10/15/14 at 4:31 P.M. with the ADON/Infection Control Nurse revealed there is no policy for proper storage and labeling of personal care equipment. There have been a… | 2018-04-01 |
| 6779 | 6779 | AUTUMN BREEZE HEALTH AND REHAB | 115580 | 1480 SANDTOWN ROAD SW | MARIETTA | GA | 30008 | 2014-10-03 | 309 | D | 1 | 0 | 78SO11 | Based on observation, record review, resident, family and staff interviews the facility failed to follow physician's order and ensure timely transportation for one (1) resident ('X) from seven (7) sampled residents. Findings include: Review of a facility Concern Form dated 8/18/14 revealed that resident X family member reported to the Social Worker that resident X was complaining about her itchy, scratchy scalp. According to the documentation on the Concern Form the Nursing Supervisor was notified and follow up actions were initiated. Review of the Physician Telephone Orders revealed a dermatology consult due to scratchy dry itchy scalp was written on 08/21/2014. On 8-25-2014 the Administrator signed the Concern Form acknowledging that Resident X concerns were resolved and indicated that a dermatology consult was scheduled. Review of the facilities Transportation Request Form revealed the resident was scheduled on 9-10-2014 at 11:00 a.m. and 9-16-2014 at 10:00 a.m. for a dermatology appointment. On 9-10-2014 there was a notation on the form that transportation was late and the doctor office refused to see the resident and she was rescheduled for 9-16-2014. On 9-16-2014 there was documentation that transportation arrived late for her appointment and resident was rescheduled for 10-10-2014. On 10/03/14 at 1:10 p.m. an interview with the Social Worker confirmed that resident X was scheduled for dermatology appointments but was unable to participate due to transportation problems. On 10/03/14 at 2:53 p.m. observation revealed resident X was sitting in her room visiting with a family member. An interview , at this time, revealed the resident continues to complain about her itchy scalp. Her family member confirmed that the resident continues to complain of having an itchy scalp. Continued interview revealed that resident X was aware of her dermatology appointments but missed them because staff had not gotten her up and ready in time. When transportation arrived at the facility, she was not ready and they left without t… | 2017-10-01 |
| 6867 | 6867 | PRUITTHEALTH - MARIETTA | 115276 | 50 SAINE DRIVE SW | MARIETTA | GA | 30008 | 2013-02-07 | 314 | D | 0 | 1 | NGK511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview the facility failed to administer a wound treatment according to wound clinic orders for one (1) resident (#36) from a sample of thirty four (34) residents. Findings include: Observation of a pressure sore treatment conducted 2/6/13 at 10:30am revealed that Treatment nurse AA cleaned the wound with Normal Saline, patted the wound dry, applied [MEDICATION NAME], and then covered the wound with a composite dressing. Review of the most recent wound clinic orders dated 1/15/13 at 2:00pm indicated the wound was to be cleaned with mild soap and water, rinsed then dried, paint heel ulcer with [MEDICATION NAME], two (2) times per day, cover with four by fours and secure with Kerlix and tape. Off load pressure on heels at all times. Follow up in one (1) month on 2/12/13. Further record reviewed revealed no other wound treatment orders since the 1/15/13 orders. Interview with the treatment nurse AA on 2/6/13 at 10:40am revealed she had missed the most recent wound clinic orders dated 1/15/13. She further indicated that she had been informed by the(NAME)wound consultant that soap and water would dry out the wound and she needed to use normal saline or sterile water. AA revealed that the treatment had only been done one (1) time per day from 1/15/13 through 2/6/13, and Normal Saline was used to clean the wound rather than mild soap and water. After the treatment observation by the surveyor on 2/6/13 at 10:30am, the treatment nurse contacted the attending physician to clarify the treatment orders. | 2017-09-01 |
| 7092 | 7092 | AUTUMN BREEZE HEALTH AND REHAB | 115580 | 1480 SANDTOWN ROAD SW | MARIETTA | GA | 30008 | 2013-01-24 | 274 | D | 0 | 1 | TD5P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interview the facility failed to ensure that a Significant Change assessment was completed for one (1) resident (# 21) from a sample of thirty-nine (39) residents. Findings include: Record review revealed a physician's orders [REDACTED].# 21 to have a Hospice evaluation. The evaluation was completed that afternoon and the resident was admitted to Avista Care Hospice. There was no significant change assessment done reflecting this change for the resident. Interview with the Minimum Data Set (MDS) nurse CC on 1/ 24/13 at 10:45am revealed that a significant change assessment was not done as required. | 2017-08-01 |
| 7093 | 7093 | AUTUMN BREEZE HEALTH AND REHAB | 115580 | 1480 SANDTOWN ROAD SW | MARIETTA | GA | 30008 | 2013-01-24 | 315 | D | 0 | 1 | TD5P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview the facility failed to ensure a urinary catheter was secured to prevent excessive tension on the catheter for one (1) resident (#21) from a sample of thirty-nine (39) residents. Findings include: Observation of resident # 21 on 1/24/13 at 10:30am with Certified Nursing Assistant (CNA) GG revealed the resident did not have the urinary catheter secured. The penis had a small ulcerated area on the head and a reddened area at the meatus. GG found several catheter securing devices in the resident's room that had not been used. Review of the resident's care plan dated 11/29/12 indicated the resident had a Foley catheter related to [MEDICAL CONDITION], and a pressure ulcer. An intervention was in place to anchor the catheter to prevent excessive tension. Further record review revealed the resident had a healing stage 2 pressure ulcer to the sacral area, and had a [DIAGNOSES REDACTED]. Further interview with the CNA GG on 1/24/13 at 10:40 am revealed that all catheters should be secured. | 2017-08-01 |
| 7703 | 7703 | AUTUMN BREEZE HEALTH AND REHAB | 115580 | 1480 SANDTOWN ROAD SW | MARIETTA | GA | 30008 | 2014-01-08 | 157 | D | 1 | 0 | TEVL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to notify the physician of changes in the health condition of two (2) residents (#1, #2) of five (5) sampled residents. Findings include: 1. Resident #1, the nurse failed to notify the physician of a discrepancy between his response to an abnormal urinanalysis laboratory value report and the actual laboratory tests that were ordered. Review of the Urinanalysis Lab Report for Resident #1 dated 12/12/13 indicated abnormalities that included moderate blood in the urine, moderate leukocytes or white blood cells and cloudy color. There were hand written notes on the Lab Report that documented the physician was notified, wait for culture and no culture ordered. The lab report was initialled by the nurse. Review of the Nurse's Notes for Resident #1 dated 12/12/13 indicated that the urinanalysis results were reported to the physician but the physician stated to wait for the culture results.The nurse failed to notify the physician that there was no urine culture ordered. This failure resulted in a no treatment for [REDACTED].#1. Interview with the assistant director of nursing (ADON) on 12/31/13 at 1:50 PM revealed that the nurse failed to notify the primary physician that a urine culture and sensitivity was not ordered or in progress for Resident #1. When the physician replied to the abnormal report of the urinanalysis that he would wait for the culture and sensitivity results the nurse should have told him that only a urinanalysis was ordered not a culture and sensitivity. On 12/31/2013 at 2:10 PM a telephone interview was made with the assistant director of nursing (ADON) via speaker phone to Resident #1 ' s primary physician regarding the physician's order [REDACTED]. The primary physician said that he was not notified that a culture and sensitivity was not in progress for Resident #1 when the nurse gave him the abnormal urinanalysis results on 12/12/13. He stated that if he had… | 2017-01-01 |
| 7704 | 7704 | AUTUMN BREEZE HEALTH AND REHAB | 115580 | 1480 SANDTOWN ROAD SW | MARIETTA | GA | 30008 | 2014-01-08 | 281 | D | 1 | 0 | TEVL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, state board of nursing nurse practice act review and laboratory report review the facility failed to ensure that the nursing services provided met professional nursing standards of quality for two (2) residents (#1, #2) that were at risk for the development of pressure ulcers and one resident (#1) with abnormal laboratory results of five (5) sampled residents. The nursing staff failed to fully inform the physician of the status of laboratory results for Resident #1 which delayed the treatment for [REDACTED].#1 and failed to inform the physician of the development of a pressure ulcer for Resident #2. Findings include: The Georgia Registered Nurse Practice Act, Article 43-26-3(6) indicates that the Practice of Nursing includes the provision of nursing care: administration, supervision, evaluation, or any combination thereof, of nursing practice. 1. Review of the Urinanalysis Lab Report for Resident #1 dated 12/12/13 indicated abnormalities that included moderate blood in the urine, moderate leukocytes or white blood cells and cloudy color. There were hand written notes on the Lab Report that documented the physician was notified, and said to wait for culture. The nurse documented on the Lab Report that there was no culture ordered. The Lab Report was initialled by the nurse. Review of the Nurse's Notes for Resident #1 dated 12/12/13 indicated that the urinanalysis results were reported to the physician but the physician stated to wait for the culture results. The nurse failed to notify the physician that there was no urine culture ordered. This failure resulted in a no treatment for [REDACTED].#1. Interview with the assistant director of nursing (ADON) on 12/31/13 at 1:50 PM revealed that the nurse failed to notify the primary physician that a urine culture and sensitivity was not ordered or in progress for Resident #1. When the physician replied to the abnormal report of the urinanalysis that he would w… | 2017-01-01 |
| 7705 | 7705 | AUTUMN BREEZE HEALTH AND REHAB | 115580 | 1480 SANDTOWN ROAD SW | MARIETTA | GA | 30008 | 2014-01-08 | 314 | D | 1 | 0 | TEVL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and facility pressure ulcer protocol review the facility failed to ensure that two residents (#1, #2) of five (5) sampled residents received the necessary treatment and services to promote healing and prevent infection of pressure ulcers. Findings include: 1. Review of the Admission Record for Resident #1 indicated the resident was admitted into the facility on [DATE]. Review of the Physician order [REDACTED].#1 indicated that the primary physician ordered treatment to the coccyx wound and right gluteal deep tissue injury on 11/27/2013. Review of the admission Non-Decubitus Skin Condition Record dated 11/27/13 indicated that Resident #1 ' s coccyx pressure ulcer measured 7.0 x 9.5 with no depth. The color of the wound bed was pink/yellow. Review of the Wound Care note dated 12/6/13 (9 days after admission) indicated that Resident #1 ' s pressure ulcer to the coccyx measured 7.0 x 9.5 x 0.2 cm and was un-stageable. The wound had deteriorated and had 100 % necrotic tissue. The primary physician and wound specialist were not notified of the deterioration of the pressure ulcer on Resident #1's coccyx. Interview with the wound care nurse on 01/02/13 at 9:30 AM revealed that the nurse recalled Resident #1. The wound nurse said that the initial wound assessment was done on 11/27/13 for Resident #1. According to the wound nurse there was no depth to the coccyx wound and there was 50% pink healthy tissue, 10% granulation tissue and the wound had scattered with yellow slough. The wound nurse added that there was no visible muscle, cartilage or bone and there was no black tissue and no odor when Resident #1 ' s wound was initially assessed. Resident #1 was first seen by the wound specialist on 12/10/13, thirteen (13) days after being admitted into the facility and after the wound had deteriorated. The wound nurse stated that the facility does not contact the wound care specialist to notify them of newly adm… | 2017-01-01 |
| 7706 | 7706 | AUTUMN BREEZE HEALTH AND REHAB | 115580 | 1480 SANDTOWN ROAD SW | MARIETTA | GA | 30008 | 2014-01-08 | 502 | D | 1 | 0 | TEVL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to fully inform the physician of the status of a laboratory report for one (1) resident (#1) of five (5) residents sampled. Finding include: Review of the Urinanalysis Lab Report for Resident #1 dated 12/12/13 indicated abnormalities that included moderate blood in the urine, moderate leukocytes or white blood cells and cloudy color. There were hand written notes on the Lab Report that documented the physician was notified, and to wait for culture. The nurse documented on the Lab Report that there was no culture ordered. The Lab Report was initialled by the nurse. Review of the Nurse's Notes for Resident #1 dated 12/12/13 indicated that the urinanalysis results were reported to the physician but the physician stated to wait for the culture results. The nurse failed to notify the physician that there was no urine culture ordered. This failure resulted in a no treatment for [REDACTED].#1. Interview with the assistant director of nursing (ADON) on 12/31/13 at 1:50 PM revealed that the nurse failed to notify the primary physician that a urine culture and sensitivity was not ordered or in progress for Resident #1. When the physician replied to the abnormal report of the urinanalysis that he would wait for the culture and sensitivity results the nurse should have told him that only a urinanalysis was ordered not a culture and sensitivity. On 12/31/2013 at 2:10 PM a telephone interview was made with the assistant director of nursing (ADON) via speaker phone to Resident #1 ' s primary physician regarding the physician's order [REDACTED]. The primary physician said that he was not notified that a culture and sensitivity was not in progress for Resident #1 when the nurse gave him the abnormal urinanalysis results on 12/12/13. He stated that if he had known that there was no culture and sensitivity of the urine in progress he would have treated Resident #1 with antibiotics for the abnormalit… | 2017-01-01 |
| 7975 | 7975 | PRUITTHEALTH - MARIETTA | 115276 | 50 SAINE DRIVE SW | MARIETTA | GA | 30008 | 2013-07-08 | 315 | D | 1 | 0 | 42RK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide the necessary care to one (1) resident (#1), regarding an indwelling urinary drainage catheter, of five (5) sampled residents, by failing to change the catheter according to physician's orders [REDACTED]. Findings include: Record review for Resident #1 revealed Physician's Interim Orders sheets, dated 05/17/2013 and timed at 7:00 p.m., which referenced an order for [REDACTED]. However, further record review, to include review of the June 2013 Treatment Record and Skilled Daily Nurses Notes, revealed no evidence to indicate that Resident #1's catheter had been changed in June, as ordered. During interview with the DON and Administrator on 7/8/2013 at 2:00 p.m. it was acknowledged that the Nurse's Notes and Treatment Record indicated that Resident #1's indwelling urinary drainage catheter had not been changed as the physician ordered. | 2016-07-01 |
| 8189 | 8189 | AUTUMN BREEZE HEALTH AND REHAB | 115580 | 1480 SANDTOWN ROAD SW | MARIETTA | GA | 30008 | 2013-06-06 | 309 | D | 1 | 0 | A7MV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide medications as ordered by the physician to one (1) resident (#1) of four (4) sampled residents. Findings include: The admission orders [REDACTED]. On 4/25/2013 there was an order to discontinue the [MEDICATION NAME] 1 mg at bedtime and start [MEDICATION NAME] 25 mg orally at bedtime for hallucinations. An additional order dated 5/17/2013 documented to discontinue the [MEDICATION NAME] 1 mg orally at bedtime when the supply was depleted and start [MEDICATION NAME] 0.5 mg orally at bedtime for dementia. Review of the Medication Administration Record [REDACTED]. However, review of the May Medication Administration Record [REDACTED]. The [MEDICATION NAME] 1 mg was changed to 0.5 mg as directed by the 5/17/2013 order. Interview with the administrative nursing staff on 6/6/2013 at 3:00 pm revealed that the 5/17/2013 order was the result of a pharmacy recommendation. The pharmacist was not aware of the 4/25/2013 order to discontinue the [MEDICATION NAME] and administer [MEDICATION NAME] because the resident was still receiving the [MEDICATION NAME] 1 mg. The nurse also stated at 4:00 pm that the order written on 4/25/2013 to discontinue [MEDICATION NAME] and administer [MEDICATION NAME] was the order that should have been followed from 4/25/2013 to the present. A new physician's orders [REDACTED]. | 2016-06-01 |
| 8430 | 8430 | PRUITTHEALTH - MARIETTA | 115276 | 50 SAINE DRIVE SW | MARIETTA | GA | 30008 | 2011-08-25 | 225 | E | 0 | 1 | QBY711 | Based on record review, review of the facility Abuse prohibition policy and staff interviews the facility failed to report an allegation of abuse to the State Survey and Certification Agency for one resident (A) from a sample of twenty-nine (29) residents and failed to check past histories of individuals from previous employers for five (5) of five (5) employee files reviewed. Findings include: 1. Review of the facility complaint log revealed a complaint dated 5-1-11 for resident A who reported that on 4-30-11 she was being cleaned and felt that the Certified Nursing Assistant(CNA) touched her inappropriately in the vaginal area. Continued review revealed that the resident stated that she began to scream and yell, and said that she did not want him to clean her like that. Review of the followup investigation, by the facility on 5-3-11, revealed that the resident stated that the male CNA was rubbing inside her private area, it made her feel violated and she did not like it. Interview on 8/25/11 at 10:00 a.m. with the Director of Nursing (DON) and the facility Administrator revealed that the facility policy is to investigate all allegations of abuse. Continued interview revealed that the DON acknowledged that she did not report the complaint because she felt it was not substantiated. Interview with the Licensed Practical Nurse (LPN) unit manager on 8/25/11 at 1:39 p.m. revealed that the resident did not complain to her but she had received the complaint from the social services director. Continued interview revealed that when she interviewed the resident the day after the alleged incident, the resident stated that she didn't like the way the CNA touched her. Review of the facility Abuse Prohibition Policy revealed that once a complaint or situation is identified involving alleged mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property the incident will be immediately reported to the Complaint Investigation Intake and Referral Unit at the State Agency. 2. Revie… | 2016-01-01 |
| 8431 | 8431 | PRUITTHEALTH - MARIETTA | 115276 | 50 SAINE DRIVE SW | MARIETTA | GA | 30008 | 2011-08-25 | 371 | D | 0 | 1 | QBY711 | Based on observation, and staff interviews, the facility failed to store foods properly. Findings include: Kitchen tour with dietary aide AA on 8/22/2011 at 8:10a.m. revealed that that the walk-in freezer contained hash browns and bread sticks that were not properly sealed and had not been labeled with date opened. Staff member removed these items and acknowledged that the items should have been labeled with date opened. During an interview with the Dietary Manager on 08/23/2011 at 12:50p.m., the manager revealed the facility has no written policy regarding labeling opened foods with date, however the staff have been trained that they are suppose to date opened items. Interview with dietary aide BB on 08/24/2011 at 12:15pm, revealed that opened foods are to be stored with a label containing contents and the date opened. | 2016-01-01 |
| 8527 | 8527 | AUTUMN BREEZE HEALTH AND REHAB | 115580 | 1480 SANDTOWN ROAD SW | MARIETTA | GA | 30008 | 2011-07-28 | 502 | D | 0 | 1 | ENIG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of physician's orders, Medication Administration Record (MAR), and staff interview, the facility failed to timely obtained a [MEDICATION NAME] level according to physician's order for one (1) resident (#7) from a sample of thirty one (31) residents. Findings include: Record review for resident #7 revealed a physician's order dated 7/14/11 for [MEDICATION NAME] 300mg by mouth (po) should be changed from every morning (AM) to every evening (PM) at bedtime, then repeat the [MEDICATION NAME] level in one (1) week. There was no evidence in the medical record that the repeated [MEDICATION NAME] level had been done. Review of the July 2011 MAR indicated the repeat [MEDICATION NAME] level order had been transcribed to the MAR and should have been done one (1) week for 7/14/11. There was no evidence on the MAR that the repeat [MEDICATION NAME] level had been done. Further record review revealed a [MEDICATION NAME] level done 7/26/11. Interview with the Licensed Practical Nurse (LPN) AA on 7/26/11 at 2:30pm revealed the repeat [MEDICATION NAME] level ordered 7/14 was not completed by 7/21/11, one week, as ordered. | 2016-01-01 |
| 8750 | 8750 | AUTUMN BREEZE HEALTH AND REHAB | 115580 | 1480 SANDTOWN ROAD SW | MARIETTA | GA | 30008 | 2012-11-13 | 279 | D | 1 | 0 | 2T8B11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, Transfer and Bed Mobility Status Tool review, and staff interview, the facility failed to ensure the development of a Care Plan which described the services, related to the assessed need of a lift for transfer, to be provided to one (1) resident (#1) from the survey sample of five (5) residents. Findings include: Please cross refer to F323 for more information regarding Resident #1. Review of the medical record for Resident #1 revealed that the resident's Care Plan documented an admission date of [DATE]. A Transfer and Bed Mobility Status Tool, also dated 11/07/2011, indicated the resident required extensive assistance and was unable to bear weight on the lower extremities, and referenced an Intervention specifying the use a total lift with a full body sling. Further review of the resident's Care Plan referenced above revealed an entry of 11/14/2011 which identified that Resident #1 required assistance with activities of daily living related to decreased mobility/[MEDICAL CONDITION]. An Intervention was to provide adaptive/safety equipment as needed. An additional 11/14/2011 Care Plan entry identified the resident to be at risk for falls/injuries related to needed assistance with mobility, and Interventions included to provide the assistance needed with mobility. However, further review revealed no reference on the resident's Care Plan of the resident requiring the use of a total lift with full body sling, even though the resident's need for a total lift with sling had been identified on the Transfer and Bed Mobility Status Tool on 11/07/2011, one week prior to the development of this Care Plan. During an interview conducted on 11/06/2012 at 3:45 pm., the Director of Nursing acknowledged Resident #1's use of a lift during transfer. | 2015-11-01 |
| 8751 | 8751 | AUTUMN BREEZE HEALTH AND REHAB | 115580 | 1480 SANDTOWN ROAD SW | MARIETTA | GA | 30008 | 2012-11-13 | 323 | D | 1 | 0 | 2T8B11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, Bruise Investigation and Supervisor Report review, Bed Safety Device Risk Review Tool review, Transfer and Bed Mobility Status Tool review, and staff interview, the facility failed to ensure adequate supervision during the transfer by lift for one (1) resident (#1), who had been identified as having difficulty with balance/trunk control, from the survey sample of five (5) residents. Findings include: Review of the medical record for Resident #1 revealed a Care Plan entry of 11/14/2011 which identified that Resident #1 required assistance with activities of daily living related to decreased mobility/[DIAGNOSES REDACTED]. One of the Interventions to was to provide adaptive/safety equipment as needed. A Bed Safety Device Risk Review Tool completed on 11/07/2011 identified Resident #1 as having difficulty with balance or trunk control. A Transfer and Bed Mobility Status Tool dated 11/07/2011 indicated the resident required extensive assistance, being unable to bear weight on the lower extremities. One of the Interventions referenced on this Transfer and Bed Mobility Status Tool was to use a total lift with a full body sling. A Nurse's Notes entry dated 10/25/2012 at 2:30 p.m. documented that Resident #1 had been injured by the lift while being transferred. The same Notes entry also documented that the doctor was notified and an order was received to apply ice to the left eye every two (2) hours for six (6) hours to decrease swelling. A subsequent Nurse's Notes entry of 10/25/2012 at 10:00 p.m. documented that the resident was noted with bruising to the left side of the eye. A Bruise Investigation report form dated 10/26/2012 documented Resident #1's left eye injury, and documented that the bruise had occurred upon transfer with the mechanical lift. A Supervisor Report dated 10/27/2012 documented that the incident occurred when the employee removed the strap from the mechanical lift, the resident moved, and the lift… | 2015-11-01 |
| 8809 | 8809 | AUTUMN BREEZE HEALTH CARE CTR | 115580 | 1480 SANDTOWN ROAD | MARIETTA | GA | 30008 | 2012-10-24 | 157 | D | 1 | 0 | 3XTZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to notify the family of one (1) resident, (A) in a survey sample of four (4) residents regarding changes in treatment orders and change in condition of a wound. Findings include: Review of the physician's telephone orders for resident A dated 9/7/2012, revealed an order for [REDACTED]. Review of the 9/12/2012 physician orders [REDACTED]. An additional physician's orders [REDACTED]. An interview with family member of resident A was conducted on 10/24/2012 at 2:45 p.m. and revealed the family member was not aware the resident had a Stage IV pressure area until 9/28/2012 when observed at the wound clinic and the condition of the wound. Further, said was never aware of the area on the sacrum until appointment. An interview with Nurse AA on 10/24/2012 at 12:40 p.m., revealed that the responsible party had not been notified of the physician's orders [REDACTED]. In addition, it was stated that on 9/24/2012 the wound consult was ordered because the sacral wound was unstageable, had purulent drainage with slough and necrotic tissue and the responsible party had not been notified of the condition of the wound. | 2015-10-01 |
| 8810 | 8810 | AUTUMN BREEZE HEALTH CARE CTR | 115580 | 1480 SANDTOWN ROAD | MARIETTA | GA | 30008 | 2012-10-24 | 314 | D | 1 | 0 | 3XTZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to provide the necessary treatment and services in wound care to promote healing to one (1) resident, (A), in survey sample of four (4) residents as ordered by the physician. Findings include: Review of the physician's orders [REDACTED]. There was also a sacral wound treatment order to tuck ? strength Dakins moistened gauze into wound and necrotic tissue, apply Zinc barrier cream around the good tissue, cover with an abdominal pad and secure with tape. However, there was no evidence found in the medical record that these new treatment orders were done as ordered on [DATE] or 9/30/12. During an interview with Nurse AA on 10/24/2012 at 4:50 p.m., who confirmed that the orders were not followed. It was stated by the Director of Nursing that [MEDICATION NAME] was not use for treatments at the facility. There was no evidence in the medical record that the nurse receiving the order on 9/28/2012 called and notified the ordering physician of the facility policy regarding [MEDICATION NAME] and obtaining a clarification of the treatment order. | 2015-10-01 |
| 9246 | 9246 | AUTUMN BREEZE HEALTH CARE CTR | 115580 | 1480 SANDTOWN ROAD | MARIETTA | GA | 30008 | 2012-04-24 | 315 | D | 1 | 0 | XS6611 | Based on record review and staff interview, the facility failed to change an indwelling urinary catheter in conformance with a physician's order for one (1) resident (#1) from a survey sample of four (4) residents. Findings include: Record review for Resident #1 revealed a 02/07/2012 Physician's Telephone Orders Form which ordered that a Foley catheter be inserted in relation to the resident's Stage III sacral wound, and ordered that the Foley catheter be changed every month and as needed. Further record review revealed a 03/17/2012 Nurse's Note which documented that Resident #1 had been transferred to the hospital. However, further record review revealed no evidence to indicate that the resident's indwelling urinary catheter had been changed, per the physician's order, between the 02/07/2012 order date and the 03/17/2012 hospital transfer, representing a period of approximately five-and-one-half (5 1/2) weeks, even though the physician's order specified for the catheter to be changed monthly. During an interview with the Director of Nursing (DON) conducted on 04/24/2012 at approximately 4:00 p.m., the DON acknowledged the physician's order specifying that the urinary catheter be changed monthly. | 2015-08-01 |
| 10171 | 10171 | PRUITTHEALTH - MARIETTA | 115276 | 50 SAINE DRIVE SW | MARIETTA | GA | 30008 | 2011-08-25 | 428 | D | 1 | 1 | QBY711 | Based on record review, review pf Medication Administration Record [REDACTED]. Findings include: Review of the record for resident #32 revealed that from the past twelve (12) months of monthly medication reviews, six (6) months were missing, 5/2011, 2/2011, 12/2010, 11/2010, 10/2010, and 8/2010. Interview with the Director of Nursing (DON) on 8/25/11 at 11:45am revealed that there was no more documentation available related to Pharmacy Drug Regimen Reviews for this resident. Interview with Social Services "DD" on 8/25/11 at 12:15pm revealed the resident had not been out to the hospital in the past eighteen (18) months. | 2014-12-01 |
| 10602 | 10602 | AUTUMN BREEZE HEALTH CARE CTR | 115580 | 1480 SANDTOWN ROAD | MARIETTA | GA | 30008 | 2010-11-17 | 224 | D | C9BJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and hospital document review, the facility failed to provide the services necessary to assess and obtain timely treatment for one (1) resident ("C") from a survey sample of three (3) residents. Findings include: Record review for Resident "C" revealed a 04/20/2010 Physician's Admission History and Physical which documented that the resident's breast exam had been deferred. A physician's Progress Note dated 10/25/2010 documented that during the April 2010 History and Physical, the palpation portion of the breast exam had been deferred, but that visualization for asymmetry and assessment for nipple drainage had been unremarkable. Further review of the resident's record revealed documentation indicating that weekly assessments had been done, with no notations indicating that staff had either identified or documented any changes or dimpling of the right breast. However, a Nurse's Note of 10/24/2010 at 6:00 p.m. documented that the resident's family member had reported a lump in the resident's right breast. This Note documented that upon assessment, a lump approximately the size of a golf ball was palpated on the inner portion, and extending toward the middle, of the resident's right breast, with indentation observed. This Note further documented that the physician was notified, and an order was received to send the resident to the hospital emergency room . A hospital ED Record of 10/24/2010 documented that Resident "C" was diagnosed with [REDACTED]. A Physician's Progress Note of 10/27/2010 documented that a breast exam had revealed considerable induration with skin retraction. During an interview with the Assistant Director of Nursing (ADON) conducted on 11/17/2010 at 1:20 p.m., she stated that she expected staff to do a head-to-toe assessment and to report any changes or abnormal findings. The ADON stated that she had examined Resident "C"'s breasts and noted that the right breast looked dif… | 2014-03-01 | ||
| 1683 | 1683 | WESTBURY CONYERS, LLC | 115469 | 1420 MILSTEAD ROAD | CONYERS | GA | 30012 | 2017-07-27 | 241 | D | 0 | 1 | DRP811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, clinical record reviews, and review of facility policy titled Quality of Life-Dignity, the facility failed to ensure resident dignity was maintained, and failed to safeguard clinical information for two of 29 residents (Resident (R) #187, and Resident (R) #201). R#187 & R#201 had Swallow Precautions and diet instructions posted on the wall behind their beds. The findings included: Review of the facility's Quality of Life - Dignity policy revised (MONTH) 09 noted Residents shall be treated with dignity and respect at all times. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth .Staff shall maintain an environment in which confidential clinical information is protected. 1. Review of R#187's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed R#187 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Brief Interview for Mental Status (BIMS) score, R#187 was severely cognitively impaired, scoring 5 out of 15 on the assessment. There were no signs of depression, and no maladaptive behaviors noted on the assessment. R#187 required extensive assistance of two staff for bed mobility and transfers; extensive assistance of one staff for dressing and eating; and total assistance of one staff for toileting and bathing. According to Section K of the MDS, R#187 was 62 inches tall and weighed 150 pounds. She received some nutrition via a feeding tube, and had a mechanically altered and therapeutic diet. R#187 had No loss of liquids/solids from mouth when eating or drinking; no holding food in mouth/cheeks or residual food in mouth after meals; no coughing or choking during meals or when swallowing medications; and no complaints of difficulty or pain when swallowing. During the assessment period, R#187 had Speech Therapy, Respiratory Therapy, and passive Range of Motion (ROM) Restorative Therapy. Review o… | 2020-09-01 |
| 1684 | 1684 | WESTBURY CONYERS, LLC | 115469 | 1420 MILSTEAD ROAD | CONYERS | GA | 30012 | 2017-07-27 | 279 | D | 0 | 1 | DRP811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, clinical record review and review of facility policy titled Care Plans - Comprehensive , the facility failed to ensure a nutrition care plan was developed for one of 29 residents (Resident (R)#201). Upon admission, R#201 was assessed as requiring a nutrition care plan, and facility staff failed to develop the plan of care. The findings included: Review of the facility's Care Plans - Comprehensive policy revised (MONTH) 2010 noted The comprehensive care plan is based on a thorough assessment that includes, but is not limited to the MDS (Minimum Data Set). Each resident's comprehensive care plan is designed to: a. Incorporate identified problem areas; b. Incorporate risk factors associated with identified problems; c. Build on the resident's strengths; Reflect the resident's expressed wishes regarding care and treatment goals; e. Reflect treatment goals, timetables and objectives in measurable outcomes; f. Identify the professional services that are responsible for each element of care; g. Aid in preventing or reducing declines in the resident's functional status and/or functional levels; h. Enhance the optimal functioning of the resident by focusing on a rehabilitative program; and i. Reflect currently recognized standards of practice for problem areas and conditions. Areas of concern that are triggered during the resident assessment are evaluated using specific assessment tools (including Care Area Assessments) before interventions are added to the care plan. Review of R#201's clinical record revealed R#201 was admitted into the facility on [DATE] and re-admitted on [DATE]. R#201's admission Mininum Data Set ((MDS) dated [DATE] listed [DIAGNOSES REDACTED]. R#201's BIMS score was 9 out of 15, which indicated moderate cognitive impairment. R#201 required the total assistance of two staff for bed mobility, and transfers; and total assistance of one staff for dressing, eating, toileting, hygiene and bathing. Sec… | 2020-09-01 |
| 1685 | 1685 | WESTBURY CONYERS, LLC | 115469 | 1420 MILSTEAD ROAD | CONYERS | GA | 30012 | 2017-07-27 | 319 | D | 0 | 1 | DRP811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and clinical record review, the facility failed to provide psychological services to one resident (Resident (R) #118) of 29 sampled residents. R#118 had a [DIAGNOSES REDACTED]. The findings included: Review of the clinical record for R#118 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed R#118 had a Brief Interview for Mental Status (BIMS) score of 13, which indicted intact cognition. The MDS recorded that R#118 had no mood or behavior symptoms, and received an anti-depressant for the seven days prior to the assessment. Review of the Care Area Assessment (CAA) for the admission MDS dated [DATE] revealed psychosocial well-being, mood state, and behavioral symptoms did not trigger for care plan development. Review of the care plan dated [DATE] revealed a problem identified with the use of anti-anxiety and anti-depressant medication. Interventions included monitoring for signs and symptoms of mood changes and depression, and symptoms of adverse side effects of the medication. Additional interventions included administering the medication as ordered and educating R#118 and family of the risk and benefits of the medication. Physician orders [REDACTED]. There were no medicines ordered for [MEDICAL CONDITION] or [MEDICAL CONDITION] disorder. The clinical record included a physician order [REDACTED]. There was no evidence in the clinical record of a psychological (psych) evaluation having been completed as ordered. Observation of R#118 on [DATE] at 3:52 p.m. in her room revealed her sitting on the side of the bed and she stated she did not want to talk because she was watching a movie. Observation of R#118 on [DATE] at 8:55 a.m. in her room revealed her to be lying in bed and she stated she did not want to talk because she was not feeling well and just wanted to see the nurse. Interview with Social Services (SS) DD on [DATE] at … | 2020-09-01 |
| 1686 | 1686 | WESTBURY CONYERS, LLC | 115469 | 1420 MILSTEAD ROAD | CONYERS | GA | 30012 | 2017-07-27 | 441 | E | 0 | 1 | DRP811 | Based on observations, interviews, clinical record review, and review of facility policy, the facility failed to prevent potential cross contamination for 30 residents in the main dining room during meal time; and for three of 29 sampled residents (Residents (R)#93, R#137, R#17). The findings included: Review of the facility's policy Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices dated (MONTH) 2008 noted the following: Employees must wash their hands: a. After personal body functions (i.e., toileting, blowing/wiping nose, coughing, sneezing, etc.); .h. After engaging in other activities that contaminate the hands. Review of the facility's policy Handwashing/Hand Hygiene revised (MONTH) 2012 noted: Employees must wash hands for at least fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: .c. Before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice); .g. Before and after assisting a resident with meals; .s. After handling soiled equipment or utensils. 1. Observation on 7/24/17 at 12:09 p.m. in the facility's main dining room revealed two Dietary Aides (DA) served beverages of water and tea to 30 residents. Observation on 7/24/17 at 12:17 p.m. in the facility's main dining room revealed the system the DAs used for serving the residents was as follows: DAs picked up resident diet cards which were lying on the dining table in front of the residents. The DAs then took the cards to the serving line and retrieved resident plates as indicated on their diet cards. While serving the plates, and providing meal set-up, the DAs touched eating surfaces of the plates, and moved/touched resident cups from which the residents had already drank. After serving a resident, the DAs went to the next resident to retrieve their diet card, and performed the same tasks. The DAs used no hand hygiene in between serving the 30 residents, picking up diet cards, touching eating surfaces, and moving resident b… | 2020-09-01 |
| 3459 | 3459 | ROCKDALE HEALTHCARE CENTER | 115670 | 1510 RENIASSANCE DRIVE | CONYERS | GA | 30012 | 2016-10-13 | 282 | G | 0 | 1 | PYE811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, it was determined the facility failed to follow pain management in accordance with the care plan interventions for 1 of 28 sampled residents (R) (R#38). Specifically, the pain medication [MEDICATION NAME] was ordered on [DATE] to be administered twice daily for [MEDICAL CONDITION] pain and was not made available to R#38 until 10/5/16, 14 days after the medication was prescribed. This failure caused the resident to experience pain and actual harm when R#38 revealed in an interview on 10/10/16 at 11:58 a.m. that there was nothing that eased her [MEDICAL CONDITION] pain in her left leg while she waited 2 weeks before receiving [MEDICATION NAME]. Refer F309). Findings include: An interview with R#38 on 10/10/16 at 11:58 a.m. revealed the resident was admitted to the facility with orders for [MEDICATION NAME] and it was two weeks before she got the [MEDICATION NAME] because the medication never came in. R#38 said that she was in pain (while waiting for the [MEDICATION NAME]) and there was nothing that eased the pain of [MEDICAL CONDITION] in her left leg. Additionally, R#38 stated that the facility has been out of [MEDICATION NAME] this week. R#38 said that her pain level has been between 6 and 8 (on a scale of 0-10, with 10 being most severe) for 4 days without [MEDICATION NAME]. R#38 said that she told the medication nurse and the charge nurse but no [MEDICATION NAME] was administered to her. Health record review for R#38 revealed the resident was admitted to the facility on [DATE] for rehabilitation therapy following hip joint replacement surgery. Review of the care plan for R#38 dated 9/30/16 revealed a plan with the focus of: Resident is on pain medication therapy related to status [REDACTED]. Interventions to address R#38's pain included to: administer medication as ordered. Review of the physician's orders [REDACTED]. [MEDICATION NAME] Tablet 7.5/325 mg ([MEDICATION NAME]/[MEDICATION NAME]) 2 tablets e… | 2020-09-01 |
| 3460 | 3460 | ROCKDALE HEALTHCARE CENTER | 115670 | 1510 RENIASSANCE DRIVE | CONYERS | GA | 30012 | 2016-10-13 | 309 | G | 0 | 1 | PYE811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews, it was determined the facility failed to provide prescribed medications to ensure adequate pain management for 1 of 28 sampled residents (R) (R#38), that experienced mild to severe pain after hip replacement surgery. The inadequate management of R#38's pain medication regime that included [MEDICATION NAME], Tylenol and [MEDICATION NAME] caused the resident to experience pain, causing actual harm identified to have existed beginning on 9/22/2016. Findings include: Health record review for R#38 revealed the resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] for R#38 indicated her Brief Interview for Mental Status (BIMS) summary score was 8, indicating moderate cognitive impairment. According to the MDS, R#38 was assessed to have pain frequently during the last five days. R#38's reported her pain level was 5 on a scale of 0-10, with 10 being most severe. Review of the physician's orders [REDACTED]. [MEDICATION NAME] Tablet ([MEDICATION NAME]/[MEDICATION NAME]) 7.5/325 milligrams (mg) take two tablets by mouth (PO) every four hours as needed (PRN) for pain (left hip replacement). Tylenol tablet 325 mg give one PO every six hours PRN for pain. [MEDICATION NAME] Capsule 100 mg PO two times a day for [MEDICAL CONDITION] (nerve damage that may cause numbness or pain and weakness). [MEDICATION NAME] Capsule 25 mg ([MEDICATION NAME] Potassium- anti-[MEDICAL CONDITION]) give one capsule PO four times a day related to presence of unspecified artificial hip joint. Review of the E-MAR (Electronic Medication Administration Record) documentation of [MEDICATION NAME] administration for 9/21/16 through 9/30/16 and 10/1/16 through 10/5/16 revealed the [MEDICATION NAME] was signed off by nurses as administered on six (6) occasions: 9/21/16 at 9:00 a.m. 9/25/16 at 9:00 a.m. 9/26/16 at 9:00 a.m. 9/27/16 at 5:00 p.m. … | 2020-09-01 |
| 3461 | 3461 | ROCKDALE HEALTHCARE CENTER | 115670 | 1510 RENIASSANCE DRIVE | CONYERS | GA | 30012 | 2016-10-13 | 514 | G | 0 | 1 | PYE811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview it was determined the facility failed to accurately document the administration of pain medication for one resident (R) (R#38) that experienced mild to severe pain after hip replacement surgery. The sample was 28 residents. (This standard is cited at harm level. Refer F309). The findings include: Record review revealed R#38 was admitted into the facility for rehabilitation therapy on 9/21/16. A review of the physician's orders [REDACTED]. A review of R#38's (MONTH) (YEAR) Electronic Medication Administration Record [REDACTED]. The facility was unable to provide documentation that R#38 resident received pain medication following the reports of pain. A review of the resident's E-MARs and pain assessment for the month of (MONTH) (YEAR) revealed R#38 complained of mild to moderate pain on the following dates 10/1/16 and 10/2/16. The facility was unable to provide documentation that R#38 received pain medication at the time resident complained of pain. Further review of the (MONTH) (YEAR) E-MAR also revealed the facility staff documented R#38 received [MEDICATION NAME] capsules on the following dates: 9/21/16, 9/25/16, 9/26/16, 9/27/16, 9/29/16, and 9/30/16 at 9:00 a.m. Review of the Medication Error Report dated 10/5/16 revealed the facility did not receive the [MEDICATION NAME] capsules for R#38 until 10/5/16. The [MEDICATION NAME] medication was not administered to R#38 despite the signatures of nurses on six occasions because the medication was not available in the facility. The facility conducted in-services and disciplinary action was taken to address this deficient practice. Interview with the Unit Manager (UM) on 10/13/16 at 10:55 a.m. revealed at the time of the R #38's discharge from the hospital on [DATE] the staff failed to obtain a written order from the facility physician for the resident's [MEDICATION NAME] and notify the pharmacy of the order until 10/5/16. The facility failed to maintain accura… | 2020-09-01 |
| 3462 | 3462 | ROCKDALE HEALTHCARE CENTER | 115670 | 1510 RENIASSANCE DRIVE | CONYERS | GA | 30012 | 2018-10-18 | 656 | D | 1 | 1 | WJ7611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of records and staff interview, it was determined that the facility failed to follow the plan of care related to activities of daily living (ADL) for two residents R#6 related to assistance with bed mobility and R#20 due to unkept nails, of 25 sampled residents. Findings include: Review of the clinical records for Resident (R) #20 revealed she was admitted on [DATE] and has current [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS) assessment records for the resident revealed the most recent assessment to be an Annual MDS assessment dated [DATE] revealed that R#20 was assessed as needing extensive assistance with bed mobility, dressing, toilet use, and personal hygiene and total assistance with transfers. The resident was also assessed as needing the assistance of two plus people with bed mobility, transfers, and toilet use. Under the Care Area Assessment Summary of this assessment and the previous comprehensive MDS assessment of 8/14/17, ADLs triggered and the decision was made to complete a plan of care for that area. A review of the plan of care for R#20 revealed a plan of care in place since 8/28/17 for ADL/Self-care deficit revealed the resident needs two staff participation in toilet use, transfer, and bed mobility. A review of the facility incident report dated 5/11/18 and last revised 5/22/18 revealed that on 5/11/18 at 10:00 p.m., the charge nurse observed R#20 on the floor in her room with a Certified Nursing Assistant (CNA) at her side. The resident was assessed and assisted back to bed by two members of staff using the Hoyer lift. A review of the 200-hall assignment sheet of 5/11/18 revealed that CNA EE was assigned responsibility for caring for the residents in a block of rooms which included the room belonging to R#20. The assignment sheet also documented that a fall had occurred on CNA EE's shift. A review of an undated written statement by CNA EE revealed that she was in the room belonging to R#20 b… | 2020-09-01 |
| 3463 | 3463 | ROCKDALE HEALTHCARE CENTER | 115670 | 1510 RENIASSANCE DRIVE | CONYERS | GA | 30012 | 2018-10-18 | 677 | D | 1 | 1 | WJ7611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and staff interviews, the facility failed to ensure that activities of daily living (ADL) was provided for one dependent residents (R) R#6 related to nail care. The sample size was 25. Findings include: A review of the clinical record for R #6 revealed resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 00, which indicated severe cognitive impairment. Section G revealed resident requires extensive assistance with dressing, toileting and personal hygiene. Observation on 10/16/18 at 11:07 a.m., 10/17/18 at 9:26 a.m. and 10/18/18 at 10:48 a.m. revealed resident with long nails with brown substance underneath them on both hands. Interview on 10/17/18 at 9:37 a.m., with Certified Nursing Assistant (CNA) GG stated she gets her assignment from the charge nurse as to which residents need a bath. She stated that for ADL care, she bathes residents on their bath days, she gets them up, dresses them, brushes their teeth, brushes hair, shaves residents if they need it and also stated that she does nail care on bath days, unless they need it more often. She stated that she did not notice resident with dirty fingernails today. Interview on 10/18/18 at 10:10 a.m. Licensed Practical Nurse (LPN) Unit Manager HH, stated her expectation is staff should be attempting daily to provide care as per orders and/or care plan. ADL care consists nail care and should be done on bath days, but can be and should be done more often, if needed. She further stated she encourages charge nurses to assist CNA's with persuading residents to accept care. Verified R#6 nails were long and dirty with brown material underneath. An interview on 10/18/18 at 3:05 p.m. with Director of Nursing (DON), stated it is her expectation that staff follow the care plan as written pertaining to all aspects of ca… | 2020-09-01 |
| 3464 | 3464 | ROCKDALE HEALTHCARE CENTER | 115670 | 1510 RENIASSANCE DRIVE | CONYERS | GA | 30012 | 2018-10-18 | 689 | D | 1 | 1 | WJ7611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility records, policies, and staff interviews, it was determined that the facility failed to provide the level of assistance required during Activities of Daily Living (ADL) care resulting in a fall for one resident (R#20) of 25 sampled residents. Findings include: Review of the clinical records for Resident (R)#20 revealed she was admitted on [DATE] and has current [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS) assessment records for the resident revealed the most recent assessment to be an annual MDS assessment of 8/9/18 in which she was assessed as needing extensive assistance with bed mobility, dressing, toilet use, and personal hygiene and total assistance with transfers. The resident was also assessed as needing the assistance of two plus people with bed mobility, transfers, and toilet use. The resident's need for the assistance of two plus persons for bed mobility, transfers, and toilet use on the most recent assessment did not represent a change from quarterly MDS assessments completed on 2/12/18 and 5/13/18 and the last comprehensive assessment of 8/14/17. A review of the electronic medical record (EMR) of the Resident Detail or Kardex report for 5/11/18 revealed R#20 was totally dependent on staff for turning and repositioning in bed and required the assistance of two members of staff to reposition and turn in bed. A review of the facility incident report dated 5/11/18 and last revised 5/22/18 revealed that on 5/11/18 at 10:00 p.m., the charge nurse observed R#20 on the floor in her room with a Certified Nursing Assistant (CNA) at her side. The resident was assessed and assisted back to bed by two members of staff using the Hoyer lift. A review of the 200-hall assignment sheet of 5/11/18 revealed that CNA EE was assigned responsibility for caring for the residents in a block of rooms which included the room belonging to R#20 at the time of the resident's fall. The assignment sheet also documente… | 2020-09-01 |
| 4745 | 4745 | WESTBURY CONYERS, LLC | 115469 | 1420 MILSTEAD ROAD | CONYERS | GA | 30012 | 2015-12-03 | 282 | D | 0 | 1 | N6HI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interview, the facility failed to follow the care plan related to providing Range of Motion (ROM) for one (1) resident (Q), and failed to follow the care plan related to provision of mouth care as needed for one (1) resident (J). The sample size was thirty-six (36) residents. Findings include: During observation on 11/30/2015 at 3:02 p.m., resident Q was observed to have contractures to the fingers of their right hand, and bilateral knees. Review of resident Q's Quarterly Minimum Data Set ((MDS) dated [DATE] noted that they had no cognitive deficits, and were receiving restorative nursing services for active range of motion (AROM) six days a week. Review of the resident's Restorative Care Plan for Active Assisted Range of Motion (AAROM) noted that the resident had impaired functional joint mobility, and interventions included to provide AAROM on the right upper extremity six times weekly. During interview with resident Q on 12/02/2015 at 10:30 a.m., they stated that ROM had not been done for over three weeks. During interview on 12/03/2015 at 4:18 p.m., resident Q stated that staff still had not done ROM for him/her that day. During observation on 12/04/2015 at 1:09 p.m., Restorative Certified Nursing Assistant (RCNA) AA was asked to perform the restorative services that she normally provided for resident Q. During observation at this time, the RCNA had resident Q do AROM with a weight to their left arm, and AROM without a weight to the right arm. During further observation, the RCNA then applied a splint to the resident's right hand, without doing ROM to the contracted fingers. During an observation on 12/02/2015 at 11:15 a.m. resident J was in a hospital bed with the head of the bed (HOB) elevated 45 degrees. The gastrostomy tube ([DEVICE]) feeding via pump, continuous feedings with no sign or symptoms of distress or discomfort. The resident responds with yes / no and thumbs up to simp… | 2019-07-01 |
| 4746 | 4746 | WESTBURY CONYERS, LLC | 115469 | 1420 MILSTEAD ROAD | CONYERS | GA | 30012 | 2015-12-03 | 312 | D | 0 | 1 | N6HI11 | Based on observations and resident interview the facility failed to consistently provide Activities of Daily Living (ADL) for one (1) resident (J) who was totally dependent on staff for oral hygiene from a sample of thirty six (36) residents. Findings include: Review of the Quarterly Minimum Data Set (MDS) assessment for resident J dated 9/25/2015 on 12/03/2015 9:00 a.m. revealed that the resident was assessed as being totally dependent with Personal Hygiene. Review of record for resident J revealed a careplan for oral/dental health problems indicating resident needs assistance with oral care with intervention to provide mouth care as needed. During an observations on 12/02/2015 11:15 a.m.,12/02/2015 4:34 p.m., 12/03/2015 8:41 a.m., 12/03/2015 3:15 p.m., 12/04/2015 9:57 a.m. revealed visible build up on teeth and tongue. During an interview on 12/02/2015 11:15 a.m. resident J indicated No when ask if the staff brushed his teeth. During an interview with the Director of Nursing (DON) on 12/4/2015 at 2:30 p.m. the DON provided surveyor a copy of the facilities mouth care policy, and resident (J's) care plan. The DON was informed the resident stated mouth care was not being provided. Reviewed the Dental Mobile Dentistry report dated 11-6-2015 that states soft tissure red and inflamed with heavy build up. The DON confirmed understanding of the complaint, surveyors observations, and the report from the dentist. | 2019-07-01 |
| 4747 | 4747 | WESTBURY CONYERS, LLC | 115469 | 1420 MILSTEAD ROAD | CONYERS | GA | 30012 | 2015-12-03 | 318 | D | 0 | 1 | N6HI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interview, the facility failed to consistently provide range of motion (ROM) and splinting as ordered for one (1) resident (Q). The sample size was thirty-six (36) residents. Findings include: During observation on 11/30/2015 at 3:02 p.m., resident Q was observed to have contractures to the fingers of their right hand, and bilateral knees. During further observation, a splint device was noted on the resident's nightstand, but none seen on his/her right hand. During interview with resident Q at this time, they stated that they could apply the splint to their hand, but that it was easier if staff did it, and that the splint had not been on at all that day. Review of resident Q's Quarterly Minimum Data Set ((MDS) dated [DATE] noted that they had no cognitive deficits, and were receiving restorative nursing services for active range of motion (AROM) six days a week, and splint application seven days a week. Review of the resident's Restorative Care Plan for Active Assisted Range of Motion (AAROM) noted that the resident had impaired functional joint mobility, and interventions included to provide AAROM on the right upper extremity six times weekly. Further review of the care plans revealed a care plan for use of a right hand C-bar splint to minimize the risk for further contracture. Review of physician's orders [REDACTED]. Review of a Restorative Progress Note dated 11/27/2015 at 9:15 a.m. revealed that the resident was able to participate in AROM exercises to upper extremities in all planes with assistance from RNA (Restorative Nursing Aide) 6 times weekly. Following exercises RNA assists resident with applying right hand C-bar splint, splint is applied prior to lunch and removed at dinner each day. During observation on 12/02/2015 at 10:30 a.m., a splint was noted on resident Q's nightstand. During interview with the resident at this time, they stated that ROM had not been done for over th… | 2019-07-01 |
| 4748 | 4748 | WESTBURY CONYERS, LLC | 115469 | 1420 MILSTEAD ROAD | CONYERS | GA | 30012 | 2015-12-03 | 323 | D | 0 | 1 | N6HI11 | Based on observation and staff interview, it was determined that the facility failed to ensure that two (2) toilet extenders and five (5) ceiling lights were maintained in a safe manner on three (3) of eight (8) halls. Findings include: On 11/30/2015 at 3:20 p.m., the toilet extender in the adjoining bathroom for rooms 49 and 51 was observed to be wobbly. Three of the four legs did not have rubber end covers which made the legs shorter and prevented contact with the floor. During an interview with the Administrator on 11/30/2015 at 4:20 p.m., he confirmed the toilet extender was wobbly. Interview with Certified Nursing Assistant (CNA) HH on 12/4/2015 at 10:00 a.m., revealed that one of the four residents (#108) in the two rooms toileted himself/herself. During observation in resident #134's room on 12/01/2015 at 8:28 a.m., the plastic commode seat of the toilet extender was noted to be split from the back of the seat all the way to the front, except for an approximate one-inch section at the front holding the two sections together. During further observation, the commode seat was beginning to spread apart, with almost no separation near the piece holding the sections together at the front of the seat, to an approximate 0.25-inch gap at the back of the commode seat. This was verified during interview with Licensed Practical Nurse (LPN) BB at this time, who had Maintenance remove the toilet extender right away. During further interview with LPN BB at this time, she stated that resident #134 was able to independently ambulate and use the bathroom. During observation of the facility on 12/4/2015 at 1:00 p.m. it was revealed in the room of resident #80 on the secure unit ceiling light had a broken cover. Further observations revealed that three (3) lights in the activity room on the C unit also had broken light covers and the group area on A hall had one (1) ceiling light that was broken. An interview on 12/4/2015 at 3:00 pm with the Maintenance Director regarding the ceiling lights with broken and or missing covers a… | 2019-07-01 |
| 5826 | 5826 | WESTBURY CONYERS, LLC | 115469 | 1420 MILSTEAD ROAD | CONYERS | GA | 30012 | 2015-01-15 | 247 | D | 0 | 1 | 2C2411 | **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 one (1) resident (Q) was notified prior to getting a new roommate on three (3) different occasions. The sample size was twenty-nine (29) residents. Findings include: Interview with resident Q on 01/12/15 at 3:17 p.m., he/she revealed that since they had been admitted to the facility, they have had several different roommates, and was not told beforehand that he/she was getting one. Upon further interview, resident Q revealed that one day he/she was out of their room visiting with a family member, and when they came back to their room, a new roommate had been admitted to their room. Review of resident Q's clinical record revealed that he/she was admitted to the facility on [DATE]. Review of the most recent Quarterly Minimum (MDS) data set [DATE] revealed that he/she had no cognitive deficits. Interview with the Social Services Director (SSD) on 01/15/15 at 8:48 a.m., revealed that either herself or the nurse would tell a resident when they were getting a new roommate. Upon further interview, she stated that they did this as soon as they knew, but sometimes in an emergency it may be at the time of the move. Continued interview revealed that she documented resident notification of new roommates in the Interdisciplinary Progress Notes (IPN) in the resident's clinical record. Review of a list provided by the Admissions Director revealed that three residents had been admitted to resident Q's room on 10/23/14, 11/11/14, and 01/03/15. Review of the IPN for those dates revealed no mention that resident Q had been notified that they would be receiving a new roommate. Interview with the SSD on 01/15/15 at 11:42 a.m., revealed that she would not have made an entry in the IPN in resident Q's clinical record about the three new roommates, as she only notified residents of room to room transfers, and these three residents were new admissions. During inter… | 2018-05-01 |
| 5827 | 5827 | WESTBURY CONYERS, LLC | 115469 | 1420 MILSTEAD ROAD | CONYERS | GA | 30012 | 2015-01-15 | 279 | D | 0 | 1 | 2C2411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop a comprehensive care plan for anticoagulant use for one (1) resident (#103), who had been on [MEDICATION NAME] therapy since September of 2014. The sample size was twenty-nine (29) residents. Findings include: Review of the clinical record for resident #103 revealed that they had a [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] and the most recent Quarterly MDS assessment dated [DATE] revealed that resident #103 received an anticoagulant all seven days of the assessment period. Review of the active clinical record revealed that no care plan was developed for the anticoagulant use. Interview with the Case Mix Director HH on 01/14/15 at 1:49 p.m., she stated that they usually develop an anticoagulant care plan for residents on [MEDICATION NAME] therapy, and verified that resident #103 did not have one in their active clinical record. Interview with the Director of Nursing on 01/14/15 at 1:57 p.m. revealed that an Acute Care Plan dated 09/02/14 for Anticoagulant Therapy was located in the resident's overflow clinical record in the Medical Records department, but she would have to ask the MDS staff if a comprehensive care plan for anticoagulant use should be developed. | 2018-05-01 |
| 5828 | 5828 | WESTBURY CONYERS, LLC | 115469 | 1420 MILSTEAD ROAD | CONYERS | GA | 30012 | 2015-01-15 | 280 | D | 0 | 1 | 2C2411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to integrate the hospice care plan with the facility care plan to show coordination of care for one (1) resident (#36) receiving hospice services. The sample size was twenty-nine (29) residents. Findings include: Review of the Physician order [REDACTED]. Review of a Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed that she was under Hospice care. Review of the comprehensive care plan revealed that a care plan for admission to hospice services had been developed on 11/07/14. However, review of the remainder of the resident's twenty comprehensive care plans revealed that there was no integration or mention of hospice into any of the interventions to reflect the care and services which the facility and hospice would provide in order to be responsive to the needs of this hospice resident. Interview with Case Mix Director HH on 01/14/15 at 1:35 p.m., she stated that a copy of the care plan calendar was given to the hospice providers, so they could attend the care plan meeting if they were able to. During interview with the MDS staff at this time II stated that they generally integrated hospice services into the facility care plan, and JJ revealed that she had developed a separate hospice care plan for resident #36, but she did not integrate the hospice and facility care plans to reflect coordination of care. Interview with Unit Manager GG on 01/15/15 at 12:15 p.m., she stated that the only people signed in on the Care Plan Conference Sheet for resident #36 dated 10/24/14 were facility staff, with no hospice staff in attendance. Review of the Brightmoor Hospice Nursing Facility Hospice Services Agreement, Plan of Care section, noted that the Hospice and Nursing Facility will jointly develop and agree upon a coordinated Plan of Care which is consistent with the hospice philosophy and is responsive to the unique needs of the Residential Hospice Patient and his o… | 2018-05-01 |
| 5829 | 5829 | WESTBURY CONYERS, LLC | 115469 | 1420 MILSTEAD ROAD | CONYERS | GA | 30012 | 2015-01-15 | 332 | D | 0 | 1 | 2C2411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff and Pharmacist interview, the facility failed to ensure the medication error rate was less than five per cent (5%). There were three (3) errors observed with twenty-seven (27) opportunities by one (1) of four (4) nurses on one (1) of eight (8) halls, for a med error rate of eleven and eleven one-hundreds per cent (11.11%). Findings include: On 01/14/15 at 8:57 a.m., Registered Nurse (RN) AA was observed preparing resident #6's morning medications on the Terrace Unit, and the following concerns were noted: 1. After giving resident #6 the oral inhalation medication, [MEDICATION NAME], RN AA was observed to wait only eight seconds before giving a different oral inhalation medication, [MEDICATION NAME]. After exiting the resident's room at 9:26 a.m., RN AA was asked how long she waited between giving puffs of the [MEDICATION NAME] and [MEDICATION NAME], and she responded a few seconds. 2. RN AA was observed to give resident #6 one tab of Oyster Shell Calcium with Vitamin D. Later review of the physician's orders [REDACTED]. 3. RN AA was observed to give resident #6 one drop to each eye of [MEDICATION NAME] Lubricant eye drops. Later review of the physician's orders [REDACTED]. Interview with RN AA on 01/14/15 at 1:30 p.m., she verified that the eye drops order for resident #6 was for [MEDICATION NAME] Balance solution, and that she gave [MEDICATION NAME] Lubricant eye drops. Upon further interview, she stated the [MEDICATION NAME] must have come from the facility's stock supply, as it did not have a Pharmacy label on it. RN AA verified that the calcium she gave to resident #6 contained Vitamin D, and was unable to locate any Calcium without Vitamin D in her medication cart. Observation of the facility's central medication room on 01/14/15 at 1:47 p.m., revealed the only [MEDICATION NAME] eye drops they stocked was the [MEDICATION NAME] Lubricant; this was verified during interview with Central Supply emp… | 2018-05-01 |
| 5830 | 5830 | WESTBURY CONYERS, LLC | 115469 | 1420 MILSTEAD ROAD | CONYERS | GA | 30012 | 2015-01-15 | 441 | D | 0 | 1 | 2C2411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, Infection Control Policy review and staff interviews the facility failed to use proper hand hygiene and gloving for one (1) resident (#80) on contact isolation with Methicillin Resistant Staphylococcus Aureus (MRSA). The sample size was twenty-nine (29) residents. Findings include: Observation on 01/12/15 12:47 p.m. revealed that Certified Nursing Assistant (CNA) BB distributed a meal tray to resident #80 who was on contact isolation without using gloves or washing her hands. Observation of another CNA on 01/13/15 at 12:30 p.m. revealed that she entered the room of resident #80 who was still on contact isolation without using gloves or washing her hands. The CNA was observed to move items from the resident's bedside table, leave the room, retrieve the meal tray from the cart and assist with set up of the tray. Continued observation revealed that the CNA then left the room, retrieved another tray from the cart and distributed the tray to another resident without washing her hands or using hand sanitizer. Observation on 01/14/15 12:32 p.m. revealed CNA BB distributed a meal tray to resident #80 on contact isolation without putting on gloves or washing her hands. CNA BB was observed leaning on the bed, touching the bed rail, and assisting the resident with tray set up and condiments. CNA BB did wash her hands at the resident's sink before leaving the room. Review of the Physician order [REDACTED].# 80 revealed an order for [REDACTED]. Interview with the Infection Control (IC) Nurse on 01/15/15 at 9:45 a.m. revealed that staff should follow the proper guidelines for a resident on isolation precautions by sanitizing and/or washing hands before and after passing a tray as well as should sanitize before and after leaving the room of a resident on contact isolation. Continued interview revealed that it would depend on what staff are doing for the resident. A gown may be the appropriate personal protective equipment (PPE), espec… | 2018-05-01 |
| 7066 | 7066 | WESTBURY CONYERS, LLC | 115469 | 1420 MILSTEAD ROAD | CONYERS | GA | 30012 | 2013-04-18 | 279 | D | 0 | 1 | PSHL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interviews, the facility failed to develop a plan of care with interventions and goals related to an unstageable pressure ulcer identified on admission for one (1) resident (#155) from a sample of thirty-six (36) residents. Findings: Observation on 4/18/13 at 10:56 a.m. of the dressing change for resident #155 performed by the Licensed Practical Nurse (LPN), Treatment Supervisor and treatment nurse LPN FF revealed an unstageable wound to the left heel. The dressing was removed from the resident's left heel, cleaned with normal saline and a new dressing applied. Review of the medical record revealed Resident #155 was admitted on [DATE] with the Diagnoses: [REDACTED]. Review of the Minimum Data Set (MDS) admission assessment dated [DATE] revealed the resident was assessed with [REDACTED]. Review of the Care Area Assessment Summary (CAAS) revealed that the resident would be care planned for pressure ulcer. Review of the initial nursing skin assessment dated [DATE] revealed a femoral bypass on the left inner foot, a dark area on the ankle, and an ulcer on the left heel. Review of the skin assessment dated [DATE] revealed old surgical scars noted to abdomen, and the left lower leg. The bilateral heels were dry and flaky. The left heel was observed with an open deep tissue injury. Review of Braden Scale for predicting pressure sore risk revealed 3/25/13 = 17 and 4/02/13 = 15. Review of the medical record revealed a care plan initiated and revised on 4/12/13 for the potential for pressure ulcer development related to impaired mobility and [MEDICAL CONDITION]. The goal was for the resident not to develop any pressure ulcer unless clinically unavoidable through next review period with a target date of 7/31/13. There was no evidence that a care plan had been developed to address the unstageable pressure ulcer to the left heel with interventions and goals. Interview on 4/18/13 at 9:49 am with Regist… | 2017-08-01 |
| 7067 | 7067 | WESTBURY CONYERS, LLC | 115469 | 1420 MILSTEAD ROAD | CONYERS | GA | 30012 | 2013-04-18 | 386 | B | 0 | 1 | PSHL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and record review, the facility failed to ensure that admission orders [REDACTED]#110, #196, # 115, #155, #210) from a sample of thirty-six (36) residents. Findings include: 1. Review of the medical record for resident #210, admitted on [DATE], revealed the physician's admission orders [REDACTED]. Additional physician orders dated from 3/12/13 to 3/28/13 were also not signed by the physician. 2. Review of the medical record for resident #115, admitted on [DATE], revealed the physician's admission orders [REDACTED]. Additional physician's orders dated from 3/21/13 to 3/31/13 for Resident #115 also were not signed. 3. Review of the medical record for resident #155, admitted on [DATE], revealed the physician's admission orders [REDACTED]. Interview on 4/16/13 at 2:17 p.m. with the Director of Nursing, (DON) revealed the expectation was for a physician to sign the orders for a newly admitted or readmitted resident within forty-eight (48) hours to seventy-two (72) hours. 4. Review of admission orders [REDACTED] 5. Review of readmission orders [REDACTED]. 6. Review of admission orders [REDACTED] 7. Review of Physician's order for resident #91 dated 2/1/13 revealed no physician's signature 8. Review of the February, 2013 POF for resident #47 revealed the physician's orders were not signed. Review of the facility Policy and Procedure for Physician Services revealed physician orders and progress notes shall be maintained in accordance with current OBRA regulations and facility policy. Interview with the Director of Nursing on 4/16/13 at 2:17 p.m. revealed the Physician's Order Forms (POFs) should be signed the next time the physician visits. Her expectation is that when the physician comes to see his patient, he should sign that resident's POF at that time. Her expectation also is that when a resident is readmitted , the physician has 48 to 72 hours to see the resident and sign the orders. Her expectation is that the physicia… | 2017-08-01 |
| 7068 | 7068 | WESTBURY CONYERS, LLC | 115469 | 1420 MILSTEAD ROAD | CONYERS | GA | 30012 | 2013-04-18 | 514 | D | 0 | 1 | PSHL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interviews, the facility failed to accurately document the treatment for one resident (#126) with a splint device out of a sample of thirty-six (36) residents. Findings: Observation on 4/16/13 at 2:47 p.m., 4/17/13 at 10:13 a.m. and 4/18/13 at 11:53 a.m. revealed Resident #126 lying in her bed with a splint on her right wrist and hand. Review of medical record revealed a physician's orders [REDACTED]. Review of the medical record revealed a physician's ancillary order dated 3/31/13 for nursing restorative as needed per plan of care. The nursing orders were to apply a splint to the hand as ordered. Review of the medical record revealed Resident #126 had a care plan for a splint to the left hand to prevent further contracture. Interview on 4/17/13 at 5:19 p.m. with the Director of Nursing (DON) and Registered Nurse (RN) EE confirmed Resident #126 had a care plan for a hand splint to the left hand Review of the Restorative Nursing Flow Record for March, 2013 and April, 2013 revealed application of a splint to the left (Lt) hand six (6) hours per day. | 2017-08-01 |
| 8358 | 8358 | WESTBURY HEALTH & REHABILITATION CENTER - CONYERS | 115469 | 1420 MILSTEAD ROAD | CONYERS | GA | 30012 | 2011-11-17 | 166 | D | 0 | 1 | O70T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and resident and staff interviews, the facility failed to ensure that one (1) resident (Z) was made aware of the the progress toward resolution of a grievance from a sample of thirty-five (35) residents. Findings include: Review of the resident care plan dated 8/26/11 and updated 11/15/11 for resident Z revealed the resident was at risk for falls related to impaired mobility and at risk for fractures related to [DIAGNOSES REDACTED]. Goal: resident will not have any falls requiring hospitalization through next review date. Intervention: Take extra caution when transferring resident or assisting with activities of daily living (ADLs). Interview on 11/15/11 at 2:08 p.m. with resident Z revealed that there was an incident with a Certified Nursing Assistant (CNA), when the CNA was rude, a few weeks ago that occurred in the early morning. The CNA was helping the resident to get up out of bed and the resident was holding on to the siderail. The CNA told the resident to stop holding onto the siderail and not to hold onto the CNA either. Resident revealed he/she told the CNA he/she was afraid of falling on the floor without holding onto something because he/she had fallen before at another facility. Continued interview revealed that the resident does not want this CNA around him/her anymore because she would let him/her hit the floor The resident did not know the name of the CNA but would recognize her if she saw her. The resident further revealed that he/she had reported the incident but was not sure who he/she reported to. Interview on 11/15/11 at 2:20 p.m. with Registered Nurse (RN) AA revealed she was aware of the resident's complaint about a CNA and Social Services had met with the resident to discuss it. Review of the Grievance Log dated 10/17/11 completed by Social Services revealed a report was made by Social Services after talking with the resident and the grievance was referred to Nursing and Administration. Review of … | 2016-02-01 |
| 8359 | 8359 | WESTBURY HEALTH & REHABILITATION CENTER - CONYERS | 115469 | 1420 MILSTEAD ROAD | CONYERS | GA | 30012 | 2011-11-17 | 241 | D | 0 | 1 | O70T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and resident and staff interviews, the facility failed to provide care and services in a manner to promote dignity for one (1) resident (Z) from a sample of thirty-five (35) residents. Findings include: Review of medical record revealed resident Z with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed that the resident requires two (2) person assist for transfer to and from bed. Review of care plan dated [DATE] and updated [DATE] revealed resident Z at risk for falls related to impaired mobility and at risk for fractures related to [DIAGNOSES REDACTED]. Goal: resident will not have any falls requiring hospitalization through next review date. Take extra caution when transferring resident or assisting with activities of daily living (ADLs). Interview on [DATE] at 8:45 a.m. with resident Z revealed that not all the facility staff are always helpful and nice. Continued interview revealed that there was an incident when transferring from bed to wheelchair when the staff member spoke rudely to her/him. The resident further acknowledged that he/she is afraid of falling out of bed and likes to hold on when being transferred. The resident further indicated that sometimes he/she feels the staff would not care if he/she died . Interview on [DATE] at 2:08 p.m. with resident Z revealed that the resident did not know the name of the Certified Nursing Assistant (CNA) that was rude, but would recognize the CNA if he/she saw her. Continued interview revealed the incident with the CNA occurred a few weeks ago, in the early morning, as the CNA was helping the resident to get up out of bed. The resident was holding on to the siderail, the CNA told the resident to stop holding onto the siderail and not to hold onto the CNA either. The resident indicated that he/she told the CNA he/she was afraid of falling on the floor without holding onto something because he/she had fallen at another facility. Th… | 2016-02-01 |
| 1112 | 1112 | RIVERSIDE HEALTH CARE CENTER | 115375 | 5100 WEST ST NW | COVINGTON | GA | 30014 | 2020-02-13 | 584 | D | 1 | 1 | W93S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and interviews the facility failed to ensure that it was maintained in a safe clean and comfortable homelike environment in seven resident rooms with dirty air filters and dirty vents on the heating and air wall units. Findings include: 1. An observation on 2/10/20 at 11:30 a.m. of the air conditioner/heat pump (ac/hp) wall unit in room [ROOM NUMBER] revealed that the ac/hp system had two air filters located in the front that are clogged with thick amount of dust and debris. The outside of the unit revealed the vents were covered with black dirty with debris. 2. An observation on 2/11/20 at 11:20 a.m. observation of the ac/hp wall unit in room [ROOM NUMBER] revealed that unit had two air filters located in the front clogged up with thick amount of grey dust and debris. The outside of the unit revealed the vents were covered with black dirty with debris. An interview on 2/11/20 at 11: 21 a.m. with R#82 revealed that he has never seen anyone from the housekeeping or maintenance department wipe the outside of the ac/hp unit or clean/replace the air filters. 3. An observation on 2/11/20 at 11:22 a.m. of the ac/hp wall unit in room [ROOM NUMBER] revealed that the two air filters located in the front clogged with thick amount of grey dust and debris. The outside of the ac/hp unit revealed the vents were covered with black dirty with debris. Interview on 2/11/2020 at 11:23 p.m. with R#116 revealed that the resident has never seen anyone from housekeeping wipe the outside of the ac/hp unit or clean/replace the air filters. 4. An observation on 2/11/2020 at 11:26 a.m. of the ac/hp wall unit in room [ROOM NUMBER] revealed that the two air filters located in the front clogged with thick amount of dust and debris. The outside of the ac/hp unit was dirty with debris. 5. An observation on 2/11/2020 at 12:00 p.m. of the ac/hp wall unit in room [ROOM NUMBER] revealed thick with dust on the two air filters. 6. An observation on 2/11/202… | 2020-09-01 |
| 1113 | 1113 | RIVERSIDE HEALTH CARE CENTER | 115375 | 5100 WEST ST NW | COVINGTON | GA | 30014 | 2020-02-13 | 657 | D | 0 | 1 | W93S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of policy titled Care Plan Policy, the facility failed to invite one resident, Resident (R) #140, of 43 sampled residents, to participate in the development of her plan of care. Findings include: A review of policy titled Care Plan Policy dated 12/12/2017 revealed Policy Statement: Each resident will have a plan of care to identify problems, needs, and strengths that will identify how the facility staff will provide services to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. Standard of Practice: 3. A baseline plan of care will be developed by the interdisciplinary team (with resident input) for each resident within forty-eight (48) hours of the resident's admission to the facility. The baseline plan of care will consist of information that will provide effective and person-centered care that meets professional standards of quality care. 4. The facility must provide the resident and the representative, if applicable, with a written summary of the baseline care plan by the completion of the comprehensive care plan. The summary must be in a language and conveyed in a manner the resident and/or representative can understand. This summary must include but is not limited to a. The initial goals of the resident, b. A summary of the resident's medications and dietary instructions, c. Any services and treatments to be administered by the facility and personnel acting on behalf of the facility, d. Any updated information based on the details of the comprehensive care plan, as necessary. 11. The resident has the right to participate in the care planning process, including the right to identify individuals or roles to be included in the planning process, the right to request meetings and the right to request revisions to the person-centered plan of care. An interview and observation on 2/11/2020 at 8:39 a.m. with R#140 revealed that no one has … | 2020-09-01 |
| 1114 | 1114 | RIVERSIDE HEALTH CARE CENTER | 115375 | 5100 WEST ST NW | COVINGTON | GA | 30014 | 2020-02-13 | 688 | D | 0 | 1 | W93S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to provide rehabilitation equipment in a timely manner to one resident, Resident (R) #96 of 43 sampled residents. Findings include: An interview and observation on 2/10/2020 at 11:19 a.m. with R#96 revealed that she has received therapy quite a few times during her time there. She further indicated her neck has started drawing to her right shoulder and has informed her Physician and therapy is aware. The resident was observed with her head drawing to the right shoulder. Additionally, she reported a neck pillow had been ordered twice, but she has not yet received it. A review of R#96's [DIAGNOSES REDACTED]. Additionally, R#96 underwent neck surgery in (MONTH) 2019. A review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed the following triggered care areas: Activities of Daily Living (ADL) functional/rehab potential, and pain. It further revealed R#96 scored 15 on the Brief Interview for Mental Status (BIMS). A review of the Quarterly MDS assessment dated [DATE] revealed resident requires extensive assistance with transfers, dressing, and toileting, with set up with bathing, and has functional limitation in range of motion (ROM) on one side of her upper extremity. A review of R#96's care plan revealed the following problem areas: 1. Right shoulder contracture and has a problem with her left shoulder rotator cuff. Goal is for the resident to minimize further contraction through next review date. Interventions include; support affected area, keep affected area clean, monitor skin breakdown, assist with ROM as needed, reinforce activities recommended, encourage participation in selfcare as allowed, perform actions to maintain an adequate nutritional status. 2. limited physical mobility related to (r/t) Weakness. Goal is that the resident will demonstrate the appropriate use of adaptive device(s) to increase mobility through the review date. Device: Right … | 2020-09-01 |
| 1115 | 1115 | RIVERSIDE HEALTH CARE CENTER | 115375 | 5100 WEST ST NW | COVINGTON | GA | 30014 | 2020-02-13 | 761 | D | 0 | 1 | W93S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews and facility policy titled, Name of Pharmacy Insulin Drug Chart dated (YEAR) and Medication Storage: Storage Medications, the facility failed to ensure that insulin medications are labeled with open and/or expiration dates on two of seven medication carts. Findings include: A review of the Medication Storage: Storage of Medications, number 12 page 2, indicated that Insulin products should be stored in the refrigerator until opened. Note the date for insulin vials and pens when first used. A review of the Pharmacy Name Insulin Drug Chart dated (YEAR), provided by Licensed Practical Nurse (LPN) HH, indicated that the [MEDICATION NAME] R has a shelf-life of 31 days and the [MEDICATION NAME] has a shelf-life of 28 days when outside of refrigerator. Observation and interview on [DATE] at 11:30 a.m. of the Unit one medication cart (A ) revealed the following concern: one opened insulin [MEDICATION NAME] vial, for R#111, with no open nor expired date present. An interview, at this time, with the Licensed Practical Nurse (LPN) HH revealed that this vial should be discarded. An observation and interview of Unit one medication cart (B) on [DATE] at 11:45 a.m. revealed the following: two open insulin vials: (one [MEDICATION NAME] R vial dated as opened on [DATE] and one [MEDICATION NAME] vial dated as opened on [DATE]), both without an expiration dates documented for R#71. An interview, at this time, with LPN HH was conducted that there was no expiration dates listed on these vials and there should have been. A review of the January/February 2020 electronic Medication Administration Record [REDACTED]. An interview on [DATE] at 12:00 p.m. with the Director of Nursing (DON) revealed that all insulins should be dated with an open and an expiration date. She stated that the expiration date should be 28 days after opening for all insulins. A review of the Pharmacy Consultant report, Med Station Review dated [DATE] cond… | 2020-09-01 |
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CREATE TABLE [cms_GA] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );