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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2943 | 2943 | LEE COUNTY HEALTH AND REHABILITATION | 115614 | 214 MAIN STREET | LEESBURG | GA | 31763 | 2018-11-16 | 948 | D | 0 | 1 | JOF211 | Based on observations and staff interviews, it was determined that the facility failed to ensure that the facility had provided at least a sixteen-hour dining assistant training program to the activity director who was being allowed to feed a resident. The census size was 57 residents. Findings include: During an observation on 11/13/18 at 12:44 p.m. in the[NAME]Flint Dining Room, R#210 was physically assisted to eat by the activity director during the meal. During an interview on 11/15/18 at 9:40 a.m. with the activity director, she revealed her training was with the Director of Nursing (DON). She further stated the DON goes through a check off list, I've been checked off 2 1/2 years, this coming (MONTH) will be 3 years. She concluded by saying she was not a certified nursing assistant, she was a certifed activity director. During an interview on 11/15/18 at 10:25 a.m. with the DON she revealed the facility does not use paid feeding assistants. She further revealed when the activity director is feeding a resident that there is always a nurse around. She further stated that the activity director does not fit the definition of the paid feeding assistant. During an observation on 11/15/18 at 12:21 p.m. R# 210 was being fed by her daughter. A restorative aide and the speech therapist were present in the dining room. During an interview on 11/15/18 at 12:32 p.m. with the speech therapist she revealed for R#210, that in-attention was the main reason why she was screened, and that is the reason she is on the pureed diet. She further revealed she has never worked with the activity director concerning feeding R#210 or any other resident (s). During an interview on 11/15/18 at 1:46 p.m. with the Administrator she revealed that after reviewing the education by the DON that it does not meet the requirements for the activity director to feed residents. The Administrator further stated the activity director will no longer assist R#201 or any residents with eating. | 2020-09-01 |
| 2455 | 2455 | PIONEER HEALTH OF CENTRAL GEORGIA | 115564 | 712 PATTERSON STREET | BYROMVILLE | GA | 31007 | 2018-12-19 | 947 | L | 0 | 1 | J8WU11 | Based on review of personnel records, review of training records, interview, and review of the facility assessment, it was determined the facility failed to develop, implement, and maintain an in-service training program to ensure the continuing competency of Certified Nurse Aides for the required 12 hours of Annual in-service training was provided to include, at a minimum, dementia management training and resident abuse prevention. The failure to implement a training program that included current professional standards and guidelines for nurse aides to ensure continuing competency, constituted Immediate Jeopardy for three Resident's (R#16, R#64 and R#71). The facility census was 80 residents. A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. On 12/7/18 at 2:00 p.m., the Administrator, Social Worker and Regional Nurse Consultant were informed of the first identified immediate jeopardy. The noncompliance related to the first Immediate Jeopardy was identified to have existed on 9/5/18. The Immediate Jeopardy continued through 12/11/18 and was removed on 12/12/18. On 12/17/18 at 8:19 a.m. the Administrator and Regional Nurse Consultant were notified of a second identified immediate jeopardy. The noncompliance related to the second Immediate Jeopardy was identified to have existed on 6/29/18. The Immediate Jeopardy continued through 12/17/18 and was removed on 12/18/18. 1) The first Immediate Jeopardy is outlined as follows: On 9/5/18, R#64, a severely cognitively impaired male resident, was found in the bed with R#16, a severely cognitively impaired female resident, and were engaged in sexual intercourse. R#16 was sent to a women's clinic for evaluation and treatment. R#64 was transferred to a psychiatric facility and returned to the facility sixteen days later with instructions for behavior management program and medications. However, the facility failed to deve… | 2020-09-01 |
| 2454 | 2454 | PIONEER HEALTH OF CENTRAL GEORGIA | 115564 | 712 PATTERSON STREET | BYROMVILLE | GA | 31007 | 2018-12-19 | 943 | L | 0 | 1 | J8WU11 | Based on review of personnel files, employee training documentation, and staff interviews, review of the facility policy titled, Freedom of Abuse, Neglect, and Exploitation; Abuse Prevention Standard it was determined that the facility failed to ensure training was provided to educate staff on activities that constitute abuse, neglect, and/or exploitation. Additionally, the facility failed to ensure staff were educated on dementia management and resident abuse prevention. The facility's failure to ensure all staff were trained, per facility policy, on factors related to abuse, neglect, and exploitation placed residents in the facility at risk that imminent serious harm or death could occur. The facility census was 80 residents. A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. On 12/7/18 at 2:00 p.m., the Administrator, Social Worker and Regional Nurse Consultant were informed of the first identified immediate jeopardy. The noncompliance related to the first Immediate Jeopardy was identified to have existed on 9/5/18. The Immediate Jeopardy continued through 12/11/18 and was removed on 12/12/18. On 12/17/18 at 8:19 a.m. the Administrator and Regional Nurse Consultant were notified of a second identified immediate jeopardy. The noncompliance related to the second Immediate Jeopardy was identified to have existed on 6/29/18. The Immediate Jeopardy continued through 12/17/18 and was removed on 12/18/18. 1) The first Immediate Jeopardy is outlined as follows: On 9/5/18, R#64, a severely cognitively impaired male resident, was found in the bed with R#16, a severely cognitively impaired female resident, and were engaged in sexual intercourse. R#16 was sent to a women's clinic for evaluation and treatment. R#64 was transferred to a psychiatric facility and returned to the facility sixteen days later with instructions for behavior management program and medications. H… | 2020-09-01 |
| 567 | 567 | CHATSWORTH HEALTH CARE CENTER | 115280 | 102 HOSPITAL DRIVE | CHATSWORTH | GA | 30705 | 2018-06-07 | 925 | E | 1 | 1 | MLO511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, review of the facility policy titled Pest Control, review of the pest control service records, resident and staff interviews, the facility failed to follow the pest control recommendations to help reduce flies and the potential for other pest in the facility. The facility census was 108 residents. Findings include: Review of the facility policy titled Pest Control dated May, 2008 documented: Our facility shall maintain an effective pest control program. Policy Interpretation and Implementation documented: This facility maintains an ongoing pest control program to ensure that the building is kept free of insects and rodents. Observation on 6/4/18 12:15 p.m. revealed a fly on R #91 while she was sleeping in her bed. Record review for R#91 revealed a Quarterly Minimum Data Set (MDS) assessment dated [DATE] which indicated a Brief Interview for Mental Status (BIMS) was not conducted due to severe cognitive impairment. R#91 was not a candidate for interview. Observation on 6/4/18 at 12:59 p.m. revealed six flies on R#19 while the resident was in bed. An interview on 6/5/18 at 11:55 a.m. with the Family of R#19 revealed the resident's room gets quite dirty and there are flies in the resident's room at times. The Family stated she visits R#19 once a week and cleans up when she visits. Observation at the time of the interview revealed one fly on the resident's bed and one fly on the residents' bedside table. During an interview on 6/4/18 at 12:57 p.m. with R#4, he complained about flies in his room. Observation at the time of the interview revealed four to five flies on the resident's bed and landing on his face. There was a sticky fly strip noted above the resident's bed with six dead flies on it. During the interview with R#4, Housekeeper OO entered the room and stated there were a lot of flies because of the side door people use to come in and out of the facility. Record review for R#4 revealed a Quarterly MD… | 2020-09-01 |
| 817 | 817 | UNIVERSITY EXTENDED CARE/WESTW | 115336 | 561 UNIVERSITY DRIVE | EVANS | GA | 30809 | 2018-03-23 | 925 | E | 0 | 1 | YGXR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interviews, the facility failed to follow pest control company recommendations to help reduce the potential for rodents and other pests. The facility census was 141 residents (R), and the sample size was 39. Findings include: During interview with R#129 on 3/19/18 at 7:17 p.m., he stated that in the past month they had caught two mice in his room. Observation at this time revealed sticky traps positioned under his air conditioner unit, and behind his nightstand. Review of R#129's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that he had a Brief Interview for Mental Status (BIMS) score of 15 (a BIMS score of 13 to 15 indicates no cognitive impairment). Review of his clinical record revealed that he was admitted to the facility on [DATE]. During interview with R#40 on 3/20/18 at 12:00 p.m., she stated that there had been a problem with rodents and bugs about six months ago, but that she had not seen any recently. Review of R#40's Annual MDS dated [DATE] revealed that she had a BIMS score of 15. During interview with R#129 on 3/20/18 at 2:59 p.m., he stated that the last time he had seen a mouse in a trap was about ten days ago. He further stated that his roommate (R#31) had a package of sugar in her nightstand, and a visitor noted that there were rat pellets in the nightstand drawer, and the sugar packages had been torn into and eaten. R#129 further stated that he had seen a total of four mice in his room since admission, each about four inches long. During interview with R #31 on 3/20/18 at 3:05 p.m., she stated that she had seen three mice since she was admitted to the facility. Review of R#31's clinical record revealed that she was admitted on [DATE], and the BIMS score on her Admission MDS dated [DATE] was 15. Review of Pest Prevention Service Reports from the facility's contracted pest control company revealed that the last visit was on 3/14/18, and included a critical recom… | 2020-09-01 |
| 1427 | 1427 | TIFTON HEALTH AND REHABILITATION CENTER | 115412 | 1451 NEWTON DRIVE | TIFTON | GA | 31794 | 2019-08-22 | 925 | F | 0 | 1 | NZN211 | Based on observation, review of the facility policy titled Pest Control, and staff interviews, the facility failed to maintain an effective pest control program to control flies in the kitchen. The deficient practice had the potential to affect 80 of 85 residents receiving an oral diet. Findings include: During an observation on 8/22/19 at 12:25 p.m. it was observed that five flies were in the food serving area. Two flies were observed landing on the metal shelf above the steam table that was holding food being served for lunch. One fly was landing on a cart used to serve resident meals to the hallways. Two kitchen staff were observed waving the flies away from the food serving area and plates of prepared foods. During an interview on 8/22/19 at 12:29 p.m., the Certified Dietary Manager (CDM) revealed her food delivery truck was here today and left the back door open. She confirmed there is no fly killer located near the back door only the door fan blower to keep flies from entering the kitchen during a food delivery. During an interview on 8/22/19 at 1:20 p.m., the Administrator stated there should not be any flies in the kitchen area. Review of the facility policy titled Pest Control dated 9/2017 revealed: A program will be established for the control of insects and rodents for the Dining Services department. 1. The Dining Services Director coordinates with the Director of Maintenance to arrange pest control services on monthly basis, or as needed. | 2020-09-01 |
| 1931 | 1931 | TAYLOR COUNTY HEALTH AND REHABILITATION | 115507 | 165 SOUTH BROAD STREET | BUTLER | GA | 31006 | 2018-08-16 | 925 | D | 0 | 1 | UE1311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of the facility policy titled Pest Control, review of the pest control service records, resident and staff interviews, the facility failed to help reduce flies and the potential for other pests in the facility. The facility census was 35 residents. Findings include; Review of the facility policy titled Pest Control dated (MONTH) 2013 documented, Procedural Guidelines state; This center maintains an on-going pest control program to promote that our building is kept free of insects and rodents. Observation on 8/14/18 at 11:44 a.m. noted a fly on resident (R)# 47. R#47 had a [MEDICAL CONDITION] (trach) open to air (not covered). The fly was noted approximately five inches from [MEDICAL CONDITION]. Resident unable to communicate effectively. When asked if there are flies in her room often, resident nodded her head. Resident had not brief interview for mental status score (BIMS). The BIMS is a test given by medical professionals that helps determine a patient's cognitive understanding Observation on 8/14/18 at 1:53 p.m. during a medication administration of his roommate, noted R #11 with two flies on his person. R #11 was sleeping during the observation. Observation on 8/15/18 at 9:05 a.m. during a wound treatment observation for her roommate, noted fly landing on and off R#50. Per most recent annual Minimum Data Set ((MDS) dated [DATE], R#50 receives tube feedings and requires extensive assistance with all areas of activities of daily living. When asked if she often experiences flies in her room, resident stated yes. R#50 has a BIMS of 15. A BIMS score of 13-15 indicates resident is cognitively intact. On 8/15/18 at 11:00 a.m. during tour of the facility's perimeter noted the back of the air condition in room [ROOM NUMBER] was off and laying on the ground. An interview and observation on the same day at 11:30 a.m. with the Maintenance Director, he was asked how often does he make rounds around the outsi… | 2020-09-01 |
| 2047 | 2047 | ROBERTA HEALTH AND REHAB | 115523 | 420 MYTLE DRIVE | ROBERTA | GA | 31078 | 2019-07-18 | 925 | F | 1 | 1 | P6KR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, facility reports and staff interviews, the facility failed to provide an effective pest control program for multiple areas within the facility including the kitchen and residents areas. This failure affected all residents who reside in the facilty. The current census was 87. Findings include: 1. Initial Observations on 7/15/19 at 11:20 a.m. with the Dietary Manager (DM) and Registered Dietician (RD) present - and verifying observations in the dry storage area of one live roach on floor, two live roaches on the wall and one unidentifiable bug crawling into the ceiling. One roach was observed up on the ceiling area in the DM office. The back-door area was observed with webs up in the corner. The DM stated that she would notify the Pest Control company who would come out and treat. Last treatment was noted on 6/17/19 and monthly prior. On 7/16/19 at 3:10 p.m. One live roach was observed on the wall in the dry storage room. On 7/17/19 at 11:15 a.m. one live roach was observed in the dry storage top doorway area and at 12:40 p.m. additional observations was seen: of a live roach crawling on the wall in the dishwasher area, on the floor at the stove/oven area and one dead roach back under the kitchen prep table. On 7/18/19 at 2:30 p.m. an observation was made of one live roach on the wall behind the dry storage door. An interview with dietary staff 'AA' and 'BB' who both stated every morning that roaches are 'dropping all over.' 2. An observation tour was conducted on 7/15/19 from 11:15 a.m. to 12:00 p.m. in the rooms and the hallway on Hall-2 as follows: room [ROOM NUMBER] two live roaches were noted on the hall floor outside the room; many dead insects were observed along the length of the floor baseboards on both sides of the hall; room [ROOM NUMBER]A multiple live ants were observed crawling on the wall located just inside the door-jam; room [ROOM NUMBER]A a live spider was observed crawling across the drywall above the… | 2020-09-01 |
| 2390 | 2390 | MEADOWBROOK HEALTH AND REHAB | 115561 | 4608 LAWRENCEVILLE HIGHWAY | TUCKER | GA | 30084 | 2018-06-26 | 925 | D | 1 | 0 | UDIU11 | > Based on observation, interview, and record review, the facility failed to maintain an effective pest control program, as evidenced by cockroach and flying insect infestation in two halls out of five. The facility census was 122. Findings include: On 6/25/18 at 11:30 a.m. a small cockroach was observed on the surveyor's desk in the unit manager's office on the first floor. A small flying insect was noted flying around the surveyor's head also. Review of the pest prevention service agreement, dated 8/11/2017, revealed a service agreement for twice a month on-site pest prevention and control services. Review of pest prevention service reports dated 6/15/2018, 6/1/2018, 5/12/2018, 5/14/2018, 5/1/2018, 4/13/2018, 4/2/2018, 3/15/2018, 3/1/2018, 2/15/2018, 1/15/2018 and 1/3/2018 revealed facility visits on those dates. Review of complaint/grievance report, dated 3/1/2018 revealed a complaint of gnats in resident's room. Review of the resident council minutes, dated 4/11/2018, revealed a complaint of bugs in rooms B-37, A-4 bathroom, A-hall shower room, and E-50. On 6/26/2018 at 1:40 p.m. LPN BB was interviewed. She stated she saw bugs in the facility at least twice a week and, often, every day. On 6/26/2018 at 1:45 p.m. CNA MM was interviewed on the first floor. She stated she had worked at the facility for two years. She also stated she saw bugs in the facility every day. On 6/26/2018 at 1:50 p.m. LPN NN was interviewed at the second-floor nurse's station. She stated she had worked at the facility for three months. She also stated she saw bugs in the facility every day, usually roaches. On 6/26/2018 at 1:55 p.m. CNA OO was interviewed on the second-floor. She stated she had worked at the facility since 2011. She also stated she saw bugs in the facility about two times a month. She stated she saw fruit flies fairly often. On 6/26/2018 at 2:00 p.m. housekeeping director PP was interviewed near the main lobby. He stated the housekeepers were part of a separate company, working under contract for the entity. He stated h… | 2020-09-01 |
| 2430 | 2430 | PIONEER HEALTH OF CENTRAL GEORGIA | 115564 | 712 PATTERSON STREET | BYROMVILLE | GA | 31007 | 2020-01-15 | 925 | F | 0 | 1 | N7S811 | Based on observation, interview, and review of the facilities pest control contract and service records, the facility failed to maintain an effective pest control in the kitchen with the potential to affect all 76 out of 81 residents receiving oral feedings. Findings include: An observation and interview on 1/14/20 at 11:30 a.m. of small ants located near the dishwashing sink and the three compartment sink. Dietary aide BB observed and verified the small ants crawling on the wall, she and the Dietary manager stated that pest control comes by monthly, but the kitchen staff still has issues with small ants. Interview on 1/14/20 at 2:12 p.m. the Maintenance Director revealed he was unaware of the kitchen having issues with small ants he stated that pest control does come to the facility monthly. Interview on 1/15/20 at 11:55 a.m. with pest control staff member stated that he would have to use a sugar bait for the small ants in the kitchen. He stated the chemical used for other ants and insects doesn't work on the small ants. Review of the CPS management form dated (MONTH) 2019 - (MONTH) 2020 revealed pest control comes out monthly to treat the kitchen for German roaches and flies but not for ants. | 2020-09-01 |
| 2474 | 2474 | RIVER TOWNE CENTER | 115566 | 5131 WARM SPRINGS RD | COLUMBUS | GA | 31909 | 2019-10-10 | 925 | D | 1 | 0 | PV5P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews, record reviews and review of pest control company service reports, the facility failed to maintain effective pest control for one resident hall (300) of eight resident halls in the facility. Findings include: The facility had a contract in place with a pest control company, since 1/5/18. The contract included interior insect inspection and control for pests to be provided twice monthly. The contract also specified that the facility had six existing and three new insect light traps at that time. A review of the pest control company Service Inspection Report forms from (MONTH) 2019 through (MONTH) 2019 revealed that twice monthly pest control services had been provided on 6/4/19, 6/14/19, 7/1/19, 7/18/19, 8/15/19, 8/22/19, 9/17/19 and 9/26/19. A review of nurses notes and respiratory notes revealed that on 7/6/19 R#11 was observed to have a fly flying around her face and additional insects on her neck, near her stoma and [MEDICAL CONDITION] site. The insects were removed and the physician was notified. The resident was removed from the room, showered, and reassessed to ensure no other insects were observed, then transferred to a different room. The 7/6/19 12:26 p.m. nurse progress note documented that the resident's family member was notified that the resident was moved to the 200 hall due to flies being in her room. The nurse note also documents that the family member was satisfied with the move and stated the residents' room always had flies in it. During an interview on 10/7/19 at 10:35 a.m. the Respiratory Therapy (RT) Director stated she was making her first rounds that morning on 7/6/19 and noted the gauze around R#11's [MEDICAL CONDITION] and stoma site was soiled, and as she was changing the gauze she noticed what looked like a maggot when she removed the gauze. RT stated that the resident had a large neck and extra tissue growth/flap near her stoma site, above it. Licensed Practical Nurse (LPN) DD came into the r… | 2020-09-01 |
| 2511 | 2511 | FULTON CENTER FOR REHABILITATION LLC | 115569 | 2850 SPRINGDALE ROAD SW | ATLANTA | GA | 30315 | 2019-09-19 | 925 | D | 1 | 0 | 6Q4W11 | > Based on observation, record review, review of facility pest control service records, resident, family and staff interviews the facility failed to follow the pest control recommendations to reduce the number of roaches and another potential pest in the facility. This deficient practice effected 4 residents (R#6, R#4, R#5, and RD) from a census of 102. Findings include: Interview with R#6 conducted on 9/18/19 at 9:15 a.m. revealed that she found roaches in her bed, her room, hallway and on the ceiling. They are mostly seen at night and even when they spray the building they come back. R#6 most recent Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) summary score 12 which indicates moderate cognitive impairment. Interview with R#4 conducted on 9/18/2019 at 9:30 a.m. revealed that she saw roaches in her room and hallway day and night and once she tried to kill them but was told by staff not to do so. Resident #4 most recent MDS assessment documented a BIMS summary of 11 which indicates moderate cognitive impairment. Interview with the Dietary Manager on 9/18/2019 at 9:35 a.m. revealed that the pest control technician came out the previous week and fogged the kitchen with noted improvement with the roaches. Interview with the Administrator conducted on 9/18/2019 at 10:30 a.m. revealed that he is aware of the roaches in the facility and have an ongoing contract with a pest control company who treats the facility monthly and more often if necessary. He further claimed that the roach problems are due to residents hoarding in rooms and the inability to treat with a stronger chemical. Interview with the Resident Council President conducted on 9/18/2019 at 11:00 a.m. revealed that she noticed roaches in the shower room and the residents that attend the resident council meeting complain often of the bugs in the facility. Interview and observation conducted on 9/18/2019 at 1:10 p.m. with R#5) revealed during the interview, a roach crawled out of resident's bedside table drawer and later… | 2020-09-01 |
| 2655 | 2655 | LEGACY TRANSITIONAL CARE & REHABILITATION | 115585 | 460 AUBURN AVENUE N.E. | ATLANTA | GA | 30312 | 2018-01-12 | 925 | E | 0 | 1 | OCIP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an effective pest control program on two out of three halls. Findings include: On 1/9/18 at 12:35 p.m. a cockroach is observed crawling across bathroom floor in room [ROOM NUMBER]. Resident (R) #97 says there are bugs in there (the bathroom) and he sees them every day. There is a gap in wall between baseboard and commode in bathroom. On 1/9/18 at 1:00 p.m. a cockroach was observed crawling in front of 4th floor nurses station. On 1/10/17 at 12:00 p.m. during an interview with daughter of Resident (R) #157 she stated that she observed a dead insect on the floor of R#157's room, and that she has seen bugs every time she visits her mother several times a week. There is a gap in the wall between commode and baseboard in the bathroom. On 1/12/18 at 12:30 p.m. during tour of second floor with the Director of Maintenance, KK affirms observation of cockroaches on the bathroom floor of room [ROOM NUMBER], and in room [ROOM NUMBER]. There are gaps between the baseboards and commodes in the bathrooms of these rooms. Review of a Pest Control company invoices revealed the following recommendations: On 4/19/17, revealed a recommendation to seal holes in walls behind commodes. On 5/24/17, revealed recommendations to repair holes in the walls in guest rooms, to repair cracks and crevices, and to seal or replace loose or broken tiles. On 6/28/17, revealed recommendations to repair holes in walls on second floor, repair loose or broken tiles, and an observation of live activity at fourth floor nurses station. On 7/20/17, reveals recommendation for sealing holes in the walls, seal or replace loose or broken tiles, and observations of live activity on fourth floor nurses station and shower room on fourth floor. On 8/10/17, revealed recommendations to repair the hole in the wall on second floor, seal or replace loose or broken tiles, and live activity in fourth floor guest rooms a… | 2020-09-01 |
| 2880 | 2880 | PINEWOOD NURSING CENTER | 115607 | 433 NORTH MCGRIFF STREET | WHIGHAM | GA | 39897 | 2018-07-13 | 925 | D | 0 | 1 | KW3I11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to maintain an effective pest control program. The sample size was 37 residents. The facility census was 69 residents. Findings include: During the initial tour of the kitchen conducted on 07/09/18, at 11:58 a.m. there were two dead insects noted around the milk cooler. One was lying in front of the milk cooler; it was brown in color and approximately one and one-quarter inch in length. The second insect was lying to the left of the milk cooler and was similar in coloring and size. The Dietary Manager (DM) confirmed that the pest control company comes out to the facility twice monthly. She could not recall the date of the most recent visit. During the initial tour of the facility conducted on 7/9/18 from 12:45 p.m. to 2:00 p.m. room [ROOM NUMBER] was noted with numerous (more than six) dead winged insects smaller than a dime on top of air conditioning unit. During an interview conducted on 7/11/18 at 5:49 p.m., employee GG revealed she sees bugs in the facility daily and that the pest control company comes monthly. Interview on 7/12/18 at 12:25 p.m. the DM confirmed the presence of at least one fly in the kitchen food prep and serving line area. Interview on 7/12/18 at 2:49 p.m., with the Maintenance Director (MD) revealed that the MD provided a copy of the Pest Control company most recent bill for a visit dated 6/19/18. The MD confirmed tha he visits twice monthly and that 6/19/18 was the most recent visit. He confirmed the facilty's pest problem. Observation on 7/12/18 at 2:52 p.m. a dead small brown insect, smaller than a dime, was noted in front of the toilet in the public restroom. During an interview with staff member DD conducted on 7/13/18 at 11:15 a.m., she confirmed the facility has a problem with insects including water bugs. She stated the facility policy is: if you see it, kill it, put it in a bag and dispose of it in the dumpster. She also stated that if st… | 2020-09-01 |
| 3035 | 3035 | EASTMAN HEALTHCARE & REHAB | 115622 | 556 CHESTER HIGHWAY | EASTMAN | GA | 31023 | 2018-06-21 | 925 | F | 1 | 1 | F93Q11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interviews and record review the facility failed to provide adequate pest control for the facility related to flies and roaches. The census was eighty-four (84). Findings include: Observation on 6/18/18 at 11:27 a.m. during the initial tour revealed that in the dry storage area on the shelving and boxes, one box with white powder substance on it and one with a hole in the bottom corner of it, there were several small bugs crawling in and around the boxes and on the shelving. Observation on 6/18/18 at 11:27 a.m with the Dietary Manager (DM) verified that there were bugs on the shelving and said she would report it to the Administrator. Also on 6/19/18 at 12:00 p.m. an observation was made of pests still crawling on the shelves where dry goods are stored. The DM verified the pest crawling on the shelves on 6/19/18 at 4:24 p.m. by saying I see them. Continued by saying that the treatment that was done earlier was obviously not working. Observation on 6/20/18 at 9:40 a.m. in an observation with the DM of the kitchen pantry shelves, she confirmed that the pest were still crawling around on the shelves in the pantry. Interview on 6/20/18 at 9:40 a.m. the DM confirmed pest in the pantry by saying, yes I still see them also, I'll go call the pest control company and have him come back out and treat the issue again. Observation on 06/18/18 at 12:00 p.m. flies were observed to be flying around dining room. counted 3, landing on residents plates, R37, R67and R29. R37 is paralyzed from the neck down and unable to shoo flies away, his plate was sat on the table at 12:58 and he did not eat until 1:17, flies were landing on him and his food during his wait, he receives a thick puree diet. During a second dining on 6/18/18 at 12:35 p.m. a CNA was observed feeding R#2 and was observed swatting a fly off of his food and the was observed to continue to feed R#2. Observation on 6/19/18 at 12:15 p.m. revealed that flies were observed to be… | 2020-09-01 |
| 3038 | 3038 | EASTMAN HEALTHCARE & REHAB | 115622 | 556 CHESTER HIGHWAY | EASTMAN | GA | 31023 | 2019-07-24 | 925 | F | 1 | 0 | EMU611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review the facility failed to maintain an effective pest control program causing a flying insect infestation observed throughout the facility, on multiple occasions for five of five survey days. A series of observations further revealed at least one dumpster behind the facility kitchen was uncovered during the five-day survey, providing harborage for multiple flying insects the entire time. Observation also revealed the screen door to the facility kitchen was left open during a four-day period. Multiple observations further revealed flying insects to land on residents and to crawl on them. Several flying insect observations were confirmed by the Medical Director (MD) and the Administrator. Interview with the facility Pest Control Consultant (PCC) revealed the facility was not implementing his recommendations beyond spraying of insecticides, rendering the facility pest control program only partly effective. Findings include: Interview with R#3 on 7/17/19 at 2:47 p.m. revealed her to by lying in bed covered with a white sheet. A common housefly was observed on her sheet. Interview with the Administrator on the 100-hall on 7/17/19 at 3:15 p.m. revealed he was measuring temperatures with an infrared thermometer. He stated he agreed there was a flying insect flying around his head. On 7/17/19 at 11:00 p.m. R#8 was interviewed in the hall outside room [ROOM NUMBER]. He was seated in a wheelchair. There was a flying insect flying around his head. On 7/17/19 at 11:15 p.m. a through-and-through gouge about the size of a pack of cigarettes was noted in the drywall near the floor to the left of the door to room [ROOM NUMBER]. On 7/17/19 at 11:17 p.m. the Administrator and the surveyor directly observed resident room [ROOM NUMBER]. The Administrator stated he agreed there was a flying insect in the room. Interview with the Director of Nursing (DON) on 7/19/19 at 12:30 p.m. revealed she stated she did not beli… | 2020-09-01 |
| 3211 | 3211 | FOUNTAIN BLUE REHAB AND NURSING | 115636 | 3051 WHITESIDE ROAD | MACON | GA | 31216 | 2018-03-01 | 925 | D | 0 | 1 | MRLK11 | Based on observation, interview, and review of the facilities pest control contract and service records, the facility failed to maintain an effective pest control in the kitchen and in one of two food pantries with the potential to affect all 74 residents receiving oral feedings. Findings include: Interview with Dietary Manager on 2/28/18 at 12:39 p.m. who identified on the wall near the prep sink two live roaches on the wall. There was also a glue trap on the floor that was full of dead roaches. Dietary Manager reported that pest control is present at the facility every two weeks. It was further reported that the kitchen is deep cleaned once a month. 200 hall pantry tour on 3/1/18 at 3:12 p.m. with Licensed Practical Nurse (LPN) KK revealed: 1. There was a roach crawling on the counter in the pantry. 2. There were 3 dead roaches in the refrigerator. At this time, LPN KK verified roach on counter and reported the facility is supposed to have pest control out to take care of this. However, LPN KK was not aware of when pest control was present. Observation on 3/1/18 at 3:30 p.m. with the Administrator present in the food pantry on 200 hall and confirmed that there were dead roaches in the refrigerator. Interview with Maintenance Supervisor on 3/1/18 at 6:11 p.m. who reported that if he is aware of roaches in the facility he will notify the Administrator so that the pest control provider can be contacted. Maintenance Director reported that he does not have a pest control book for reporting when roaches are seen. It is reported that staff typically verbalizes any sightings to him. However, he denies that he has been informed of roaches in the kitchen or in the food pantry. Review of Pest Control contract which revealed that services began with facility on 8/17/17 with one service per month. | 2020-09-01 |
| 3354 | 3354 | LIFE CARE CENTER | 115654 | 176 LINCOLN AVE | FITZGERALD | GA | 31750 | 2018-05-31 | 925 | E | 1 | 0 | 4MP511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and staff and resident interviews, it was determined that the facility failed to maintain an effective pest control program to control flies on three of four halls. Findings include: 1. During an observation and an interview with Resident (R) A on 5/31/18 at 9:39 a.m., multiple flies were observed crawling on the resident's bed, coffee cup, on top of his refrigerator and on the resident. The resident was attempting to swat the flies away but was observed to have limited use of his upper extremities. The resident stated These flies are aggravating as hell. During the interview, the flies were also flying around and landing on the surveyor. The resident stated that the flies had been an ongoing problem and he had complained to the nurses and to the Director of Nursing (DON). Review of the Nurses Notes dated 5/23/18 revealed documentation that the resident had voiced complaints of the flies. 2. During an observation and interview with R B on 5/31/18 at 10:15 a.m., he stated that there were flies all over the place. During the interview with the resident, a fly was observed crawling on his leg and the resident stated See there! The resident also stated that everybody complains about the flies. 3. During an observation on 5/31/18 at 10:22 a.m. and at 12:23 p.m., three flies were observed crawling on the resident and an overbed table in room South 3 bed [NAME] 4. On 5/31/18 at 12:07 p.m., three flies were observed crawling on a resident's neck and back who was sitting at a table in television lounge area on the West Hall. The DON attempted to swat the flies off of the resident without success. 5. On 5/31/18 at 12:09 p.m., a fly was observed resting on the bed that a resident lying on in room W 4 bed B. 6. On 5/31/18 at 12:13 p.m., flies were observed in rooms W 6 and W 23. 7. During an observation of the West Hall on 5/31/18 from 12:07 p.m. to 12:20 p.m., two Certified Nursing Assistants (CNA), AA and BB, were … | 2020-09-01 |
| 148 | 148 | BROWN HEALTH AND REHABILITATION | 115090 | 545 COOK STREET | ROYSTON | GA | 30662 | 2018-08-09 | 924 | D | 1 | 1 | ST5L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and staff interview, the facility failed to ensure that two handrails were firmly and securely attached to the wall on 100 hall and in room [ROOM NUMBER] bathroom. The facility census was 95 and the sample size was 34. Findings include: Observation on 8/6/18 at 10:50 a.m., revealed a loose full length handrail in the bathroom. Observation on 8/6/18 at 2:41 p.m., revealed a loose handrail, on the left side of the hallway, at the beginning of 100 hall, between room [ROOM NUMBER] and 150. Walking tour on 8/9/18 at 10:10 a.m. with Maintenance Supervisor, confirmed the loose handrails on the 100 Hall and in room [ROOM NUMBER]. Interview on 8/9/18 at 10:10 a.m. with Maintenance Supervisor, stated staff put work orders into computer system, and he sorts them according to priority and distributes assignments to the staff. The staff work on work orders, plus perform general maintenance for facility, such a checking emergency exits, checking call lights and water temperatures, side rails, hand rails, cleaning Air Conditioner coils, changing AC filters, checking emergency doors. He further stated there is no formal checklist for routine maintenance items, but that the work orders are kept in the computer software system. He stated he was not aware of any loose handrails in the facility. | 2020-09-01 |
| 1426 | 1426 | TIFTON HEALTH AND REHABILITATION CENTER | 115412 | 1451 NEWTON DRIVE | TIFTON | GA | 31794 | 2019-08-22 | 924 | D | 0 | 1 | NZN211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure that three handrails were firmly and securely attached to the wall on one of four halls. Findings include: An observation on 8/22/19 at 12:20 p.m. revealed a loose handrail and gap between the rail and end cap across from room [ROOM NUMBER], the handrail between room [ROOM NUMBER] and 140 was coming loose from the wall and the handrail between room [ROOM NUMBER] and the shower room was coming loose from the wall. An interview held on 8/22/19 at 1:03 p.m. with the Maintenance Director, verified the three loose handrails. He indicated he was not aware of the loose handrails in the facility until environmental rounds. An interview held on 8/22/19 at 2:25 p.m. with the Administrator revealed she has had the handrails in a Quality Assurance and Performance Improvement (QAPI) program and have been fixing the handrails a little at a time. She stated it started a few months ago and is ongoing but does not have a completion date. Review of the facility policy titled Safety Management Plan revised 2/17 revealed: 3. The facility maintains and supervises grounds, equipment, and systems through a preventative maintenance program that accomplishes routine inspection, maintenance and testing. | 2020-09-01 |
| 1500 | 1500 | ROSWELL NURSING & REHAB CENTER | 115422 | 1109 GREEN STREET | ROSWELL | GA | 30075 | 2018-09-28 | 924 | D | 1 | 1 | T04T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and staff interview, the facility failed to ensure that two handrails were firmly and securely attached to the wall on two of 4 halls. The facility census was 213 and the sample size was 60. Findings include: Observation on 9/24/18 at 11:52 a.m. revealed a loose handrail, on the right side of the hallway, on Magnolia Way, outside of room [ROOM NUMBER] [NAME] Observation on 9/26/18 at 10:36 a.m. revealed a loose handrail, on the right right of the hallway, on Branches Unit, outside resident pantry kitchen. Interview on 9/28/18 at 3:02 p.m. with Maintenance Supervisor, verified the two loose handrails. He stated there was no specific time or schedule that hand rails are checked for stability. He stated that he was not aware of the loose handrails in the facility until walking rounds. | 2020-09-01 |
| 1827 | 1827 | NHC HEALTHCARE FT OGLETHORPE | 115492 | 2403 BATTLEFIELD PKWY | FORT OGLETHORPE | GA | 30742 | 2018-04-19 | 924 | D | 0 | 1 | XDDO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure that five handrails were firmly and securely attached to the wall on two of 7 halls. Findings include: Observation on 4/16/18 at 12:28 p.m. revealed a loose handrail, on the left side of hallway, at the beginning of 300 Hall at the entrance to the assisted dining room. Observation on 4/16/18 at 1:07 p.m. revealed a loose handrail, on the left side of the hallway, between rooms [ROOM NUMBERS]. Observation on 4/16/18 at 3:21 p.m. revealed a loose handrail on the right side entrance to 300 Hall, across from assisted dining room entrance. Observation on 4/17/18 at 10:35 a.m. revealed a loose handrail on the left side of the hallway, outside room [ROOM NUMBER]. Observation on 4/17/18 at 4:30 p.m. revealed a loose handrail on the right side of the hallway, between rooms [ROOM NUMBERS]. Walking tour on 4/17/18 at 10:30 a.m. with Maintenance Assistant, confirmed the loose handrails on the 200 Hall and 300 Hall. Interview on 4/18/18 at 10:00 a.m. with Maintenance Assistant, stated there was no specific time or schedule that hand rails are checked for stability. He stated that staff members either fill out a Maintenance requisition form or call on the phone or let him know in passing, if they notice anything needing repair, from resident equipment to facility machines and hand rails. He stated that he was not aware of the loose handrails in the facility. | 2020-09-01 |
| 2362 | 2362 | GRACEMORE NURSING AND REHAB | 115554 | 2708 LEE STREET | BRUNSWICK | GA | 31520 | 2019-11-14 | 924 | D | 0 | 1 | 6DLG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, and facility policy review titled, Maintenance Service the facility failed to ensure that one of eight handrails on the 100 long Hall were firmly and securely attached to the wall. Findings Include: Review of facility policy titled, Maintenance Service revealed the following; Policy Statement-Maintenance service shall be provided to all areas of the building, grounds, and equipment. Policy Interpretation and Implementation: 1. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 2. Maintenance tasks include, but are not limited to: a. Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines. b. Maintaining the building in good repair and free from hazards. Observation on 11/12/19 at 12:39 p.m. in room [ROOM NUMBER] revealed that the handrail was loose and not firmly attached to the wall. Record review of the Quarterly Minimum Data Set ((MDS) dated [DATE], for R#25, revealed that the resident had a Brief Interview Status (BIMS) score of 15 which indicated the resident was cognitively intact Interview on 11/12/19 at 12:45 p.m. with R#25 revealed the railing in the bathroom had been loose for about a week. Continued interview with R#25 revealed that this rail is used for balance when sitting and getting up from the toilet seat. Observation and interview on 11/12/19 at 4:46 p.m. with the Administrator and Maintenance Director confirmed the loose handrail. The Administrator revealed that there is no immediate plan to repair due to company is in progress of building a new facility. | 2020-09-01 |
| 4033 | 4033 | BOSTICK NURSING CENTER | 115732 | 1700 BOSTICK CIRCLE | MILLEDGEVILLE | GA | 31061 | 2019-11-19 | 923 | D | 1 | 0 | ETBZ11 | > Based on observation, interview and service record review, the facility failed to maintain adequate ventilation in the bathroom of one room on the 700 hall. Findings include: During an interview on 11/19/19 at 11:50 a.m., Resident A stated that the bathroom air vent in his room did not work and had not worked since he had been at the facility. RA stated that when he takes a shower in the bathroom with the door closed, the bathroom steams up so much that he can barely see. He stated he had filed a complaint with the ombudsman's office about it. During an interview on 11/19/19 at 12:20 p.m., the Administrator stated that the air system was serviced routinely by an air conditioning company, and he had not received any complaints regarding bathroom ventilation. During an interview and observation on 11/19/19 at 1:20 p.m., Air Conditioning Technician BB stated that a test and balance was performed when the building was first built, before it opened, and the bathroom exhaust vents were set to draw up 70 cubic feet of air per minute (cfu). During an observation of the ceiling air vent in the bathroom for RA, air conditioning technician BB stated that there was probably something wrong with the vent, but he would need to return with equipment to determine what the problem was. A subsequent visit to assess the bathroom ventilation was completed on 11/22/19. A review of the air conditioning company service record revealed that a problem was identified. The service record documented that one main exhaust fan motor starter had tripped for the odd halls. The starter was reset and checked and operation was normal. | 2020-09-01 |
| 731 | 731 | PRUITTHEALTH - WASHINGTON | 115325 | 112 HOSPITAL DRIVE | WASHINGTON | GA | 30673 | 2018-06-27 | 921 | D | 0 | 1 | 830B11 | Based on observation and staff interview, the facility failed to maintain two of two public water fountains in a clean and sanitary manner. The facility census was 39. Findings include: Observation on 6/24/18 at 3:22 p.m., 6/25/18 at 8:18 a.m., 6/25/18 at 4:01 p.m., 6/26/18 at 9:19 a.m., 6/26/28 at 4:33 p.m., 6/27/18 at 7:58 a.m., and 6/27/18 at 2:00 p.m., revealed that the public water fountain in the front lobby to have green slimy residue on the spigot and in the drain area. Observation on 6/24/18 at 4:18 p.m., 6/25/18 at 8:20 a.m., 6/25/18 at 4:04 p.m., 6/26/18 at 9:21 a.m., 6/26/18 at 4: 35 p.m., 6/27/18 at 8:01 a.m., and 6/27/18 at 2:03 p.m., revealed that the public water fountain on A Hall to have green slimy residue on the spigot and in the drain area; also pink material dried over the surface bowl of the fountain. An interview on 6/27/18 at 2:30 p.m. with the Maintenance Director revealed that the housekeeping staff are supposed to clean the public water fountains when they clean the public restrooms. He stated he has new housekeeping staff, but they have been oriented as to their job responsibilities. He stated there is not a formal checklist for compliance or understanding about what their specific job responsibilities are. He verified that the two public water fountains were dirty with green slimy residue on the spigot and in the drain area and the fountain on A Hall had dried pink material on the bowl of the fountain. An interview on 6/27/18 at 4:03 p.m. with Housekeeping tech DD revealed that she is new and is still getting a feel of what her responsibilities are. She stated she was not told that she was supposed to be cleaning the public water fountains every day. An interview on 6/27/18 at 7:08 p.m. with the Administrator revealed that she has not been informed of any concerns with the environment or dirty water fountains. She stated there was not any policies or procedures for cleaning the public water fountains. | 2020-09-01 |
| 1107 | 1107 | WOOD DALE HEALTH AND REHABILITATION | 115374 | 1102 BURLEYSON ROAD | DALTON | GA | 30720 | 2018-03-15 | 921 | D | 0 | 1 | BX1M11 | Based on direct observations and staff interviews, the facility failed to provide a receptacle to collect the waste water from an opening in the drain pipe when the kitchen area's emergency eye wash station is in use. This is one of four eye wash stations in the facility. Findings include: Observation of the kitchen area's exclusive bathroom on 3/12/18, 11:10 a.m. revealed a pipe-sized opening in the drain pipe extending from the basin of the eye wash station to the floor. When the Dietary Services Manager (DSM) turned on the eye wash faucets, the water ran into the basin and out onto the floor through the opening in the pipe. There was no bucket or other receptacle to collect the running water and no floor drain through which the water could run into. In an interview with the DSM on 3/12/18, 11:25 a.m., the DSM stated she complained to maintenance about the uncovered hole but received no verbal or written response to her concern or repair as yet. She stated her concerns about the amount of water that would cover the floor during a kitchen staff emergency that required flushing of the eyes. She further stated her concerns about the risk of a secondary accident such as a fall on the wet floor, loosening of the floor tiles, rusting of the metal lockers and mold growth. Observation of the kitchen area's bathroom on 3/15/18, 9:00 a.m. revealed the drainpipe of the eye wash basin still open with nothing available to catch the running water. In a staff interview with the Maintenance Supervisor (MS) on 03/15/18 10:30 a.m., he confirmed the pipe opening on the emergency eyewash/shower station. He stated his Regional Engineering and Safety Manager (ESM) told him this unit was only for emergencies and waste water would just get cleaned up. When asked if he thought water running onto the floor was a safety issue due to fall risk, chemical risk, or worse, he responded his instructions came from his boss, the ESM. He further stated there were no state or federal regulations that required him or the facility to install a floor… | 2020-09-01 |
| 3691 | 3691 | SMITH MEDICAL NURSING CARE CTR | 115691 | 501 EAST MCCARTY ST | SANDERSVILLE | GA | 31082 | 2018-10-04 | 921 | E | 1 | 1 | 1T3M11 | > Based on observation and staff interview, the facility failed to maintain one of one public water fountain in a clean and sanitary manner. The facility census was 50. Findings include: Observation on 10/1/18 at 11:32 a.m., 10/2/18 at 8:18 a.m., 10/3/18 at 12:01 p.m. and 10/4/18 at 8:09 a.m. revealed public water fountain to the left of the nurses station with brown water stains around the spigot and drain area. During observation on 10/1/18 at 1:12 p.m., noted resident to be drinking water from public water fountain to the left of the nurses station. An interview with the Administrator on 10/4/18 at 3:20 p.m.revealed that housekeeping is responsible for cleaning the water fountain daily. She verified the public water fountain was dirty with brown water stains at the spigot and at the drain area. She further stated there is no evaluation process where staff are evaluated on job performance. | 2020-09-01 |
| 4589 | 4589 | MOLENA HEALTH & REHAB | 115693 | 185 HILL STREET | MOLENA | GA | 30258 | 2018-09-20 | 921 | E | 1 | 1 | IJ4211 | > Based on observation and staff interview, the facility failed to repair one of one housekeeping station with a nondraining/nonfunctioning utility sink; and failed to ensure one of two shower rooms was operational. The census was 48 residents. Findings include: 1. On 9/18/18 at 11:30 a. m. during an observation of the housekeeping utility room/closet area, the utility sink was filled with dirty, tan colored water with a full five-gallon white bucket with dirty, tan colored liquid under the sink. The floor surrounding around the mounted chemical hoses and the utility sink was wet. An interview was conducted on 9/18/18 at 11:35 a.m. with housekeeping staff CC. When asked about the process for filling and emptying their mop buckets, she stated that they were having to mix the chemicals with water by hand in the mop buckets, not being able to mix them in the sink. She confirmed that the sink had been broken for over a month. An interview was conducted on 9/18/18 at 11:30 a. m. with the Maintenance Director in the housekeeping utility room. After observing under the sink, he stated that there was something wrong with the P-Trap and stated he would look into it. 2. During an interview on 9/17/18 at 10:02 a.m., Resident (R) A revealed that the North hall shower room does not work. R A stated that all residents must use the South hall shower room. Observation and interview on 9/17/18 at 11:10 a.m., Certified Nursing Assistant (CNA) AA confirmed that the North hall shower room was not functional and has been out of order for about a year due to flooring issues. During an interview on 9/20/18 at 1:30 p.m., Maintenance Director stated he has been out of work recently and that the facility had been attempting to hire maintenance help for four months. Further interview on 9/20/18 at 3:10 p.m. revealed that the North hall shower room has been closed off to residents since (MONTH) (YEAR). The Maintenance Director stated that the problem is related to an issue with the flooring joists and subfloor. The flooring under the tile w… | 2019-09-01 |
| 2181 | 2181 | RENAISSANCE CENTER FOR NURSING AND HEALING | 115537 | 415 AIRPORT ROAD | GRIFFIN | GA | 30223 | 2018-11-29 | 920 | E | 0 | 1 | QJ0I11 | Based on observations and staff interviews in the main dining for three days of the survey, the facility did not ensure residents could be moved from the dining room promptly in the event of an emergency. Findings include: 1. Observations on 11/5/18 during the noon meal in the main dining room revealed there were 10 tables in the main dining room. The tables were in rows of three except for one table closest to the dining room two entry door, at this table three residents were sitting. Further observations revealed at least 10 residents in an area that would require the staff to constantly move residents to make safe access for other residents. Interview with the Certified Dietary Manager during the initial tour of the kitchen on 11/5/18 at approximately 9:45 a.m. revealed she started one month prior and mostly restorative staff were in charge of arranging the residents in the dining room. 2. Observations in the main dining room on 11/6/18 at 12:19 p.m. revealed Certified Nursing Assistants (CNAs) WW and XX wheeled residents to a table at the back of the room. In the process the staff had to move another resident out of the way to get the resident to the back table. Then another resident wheeled themselves into the dining room and was not able to get around residents without staff having to move those residents. Interview at that time in the main dining room with CNAs WW and XX revealed that the back tables in the main dining room have several restorative residents who need assistance with eating and residents who ate independently also sat in that area. 3. Observations on 11/7/18 at 8:20 a.m. revealed as many as 29 residents in the main dining room eating breakfast. There were approximately 75% of residents in wheelchairs being assisted into the dining room by staff with the remaining 25% who were able to self-propel or ambulate independently into the dining room. Residents who could self-propel came into the dining room at various times. 4. Observation in the main dining room during the noon meal on 11/7/18 rev… | 2020-09-01 |
| 2879 | 2879 | PINEWOOD NURSING CENTER | 115607 | 433 NORTH MCGRIFF STREET | WHIGHAM | GA | 39897 | 2018-07-13 | 920 | D | 0 | 1 | KW3I11 | Based on observations and interviews the facility failed to ensure adequate lighting in one of three resident dining areas. The census was 69 and the sample size was 37. Findings include: Observation on 7/11/18 at 9:40 a.m. revealed that the 300 Hall dining room has two ceiling fans with light fixtures. Each light fixture has four individual bulbs. One of the two fixtures had three of the four lights not functioning and the second fixture had one of the four lights not working. There are also lighting fixtures along three of the four walls of the dining room. These fixtures appeared to have multiple lights inside the length of the fixture itself. One of the three fixtures was not lit even though the light switch was turned on. The fourth wall contained three double windows and an exit door. The window shades were pulled shut and the room was dark. There were three residents seated in the dining room with one of the three being non-ambulatory and seated in a reclining geri-chair. On 7/12/18 at 1:00 p.m. the 300 Hall dining room was checked and the lighting situation remained the same as the 7/11/18 observation. There were four residents seated in the dining room with one of the four being non-ambulatory and seated in a reclining geri-chair. The television was playing. The room appeared dark. During a facility tour conducted on 7/13/18 at 4:45 p.m. with the Maintenance Director (MD) and the Medical Records Coordinator (MR), the lighting observations from 7/11/18 and 7/12/18 were confirmed; the MD and the MR confirmed that the lighting fixtures remained in the same condition and that the room was dark. | 2020-09-01 |
| 476 | 476 | EARLY MEMORIAL NURSING FACILITY | 115271 | 11740 COLUMBIA STREET | BLAKELY | GA | 39823 | 2019-08-16 | 919 | D | 0 | 1 | RUW911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interviews the facility failed to ensure that all components of the nurse call system in four of 49 resident shared bathrooms (bathrooms for rooms: 213 and 215, 209 and 211, 205 and 207, 229 and 231) were fully functional and the facility failed to ensure that there was a monitoring system in place to identify call light issues in resident bathrooms. Findings include: Observation on 8/13/19 at 8:40 a.m. revealed the call light string did not work when pulled in the shared bathroom for room [ROOM NUMBER] and 215. Observation on 8/13/19 at 8:49 a.m. revealed the call light did not work when the string was pulled in the shared bathroom for room [ROOM NUMBER] and 211. Observation on 8/13/19 at 8:51 a.m. revealed the call light did not work when the string was pulled in the shared bathroom for room [ROOM NUMBER] and 207. Observation on 8/13/19 at 9:09 a.m. revealed the call light did not work when pulled for the shared bathroom for room [ROOM NUMBER] and 231. During a tour of 200 hall north with the Maintenance Director on 8/13/19 from 2:10 p.m. until 2:33 p.m. revealed the following: 1. In the shared bathroom for room [ROOM NUMBER] and 207 the call light came but only when force was used to pull the string. 2. In the shared bathroom for room [ROOM NUMBER] and 211 call light came on but only after force was used to pull the string. 3. In the shared bathroom for room [ROOM NUMBER] and 231 the call light came on but only after force was used to pull the string. Interview on 8/13/19 at 2:33 p.m. with the Maintenance Director revealed that the call lights at the bedside are checked monthly to assure functionality but he reported that the call lights in the bathrooms are not checked on a monthly basis. The Maintenance Director revealed that the call lights in the bathroom are only checked when he or his staff are notified that there is an issue. He further reported that the bathroom call lights are not used much and have … | 2020-09-01 |
| 809 | 809 | PRUITTHEALTH - AUGUSTA | 115334 | 2541 MILLEDGEVILLE ROAD | AUGUSTA | GA | 30904 | 2018-03-01 | 919 | D | 0 | 1 | 4EX411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, the facility failed to ensure that the call light communication system was functioning adequately to allow residents to call for staff assistance in five rooms (334A, 335A, 336A & 336B, 339A, and 117A) on two of three halls (100 hall and 300 hall). The facility census was 79 residents. Findings include: Observations on 2/26/18 at 10:15 a.m., during intial tour of resident rooms revealed the following: 1. On the 300 Hall, room [ROOM NUMBER] bed A, the call light was tested by pushing the red button. The light above the door did not light up and no sound was heard. 2. On the 300 Hall, room [ROOM NUMBER] bed A, the call light was tested by pushing the red button. The light above the door did not light up and no sound was heard. 3. On the 300 Hall, room [ROOM NUMBER] bed A, the call light was tested by pushing the red button. The light above the door did not light up and no sound was heard. 4. On the 300 Hall, room [ROOM NUMBER] bed B, the call light was tested by pushing the red button. The light above the door did not light up and no sound was heard. 5. On the 300 Hall, room [ROOM NUMBER] bed A, the call light was tested by pushing the red button. The light above the door did not light up and no sound was heard. 6. On the 100 Hall, room [ROOM NUMBER] bed A, the call light was tested by pushing the red button. The light above the door did not light up and no sound was heard. There was no resident currently residing in bed- A however, it was available for new admission. Review of the quarterly Preventative Maintenance provided by Corporate Environmental Services Director, revealed that the call light maintenance for the fourth quarter was completed on 11/3/2017, which would have cycled to be checked the next quarter on (MONTH) 3, (YEAR), according to the Coporate Environmental Services Director. The report showed that rooms 1-4 and 29-40, had not been checked during the month of Febuary, which… | 2020-09-01 |
| 1711 | 1711 | CHAPLINWOOD NURSING HOME | 115477 | 325 ALLEN MEMORIAL DRIVE SW | MILLEDGEVILLE | GA | 31061 | 2019-06-25 | 919 | D | 0 | 1 | G4S811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interviews, the facility failed to ensure that the call light communication system was functioning adequately to allow residents to call for staff assistance for five of 96 call lights. Findings include: Observations on 6/10/19 at 11:29 a.m., during initial tour of resident rooms revealed the following: 1. room [ROOM NUMBER] bed A, the call light was tested by pushing the red button. The light above the door did not light up and no sound was heard at nurse's station. 2. room [ROOM NUMBER] bed A, the call light was tested by pushing the red button. The light above the door did not light up and no sound was heard at the nurse's station. 3. room [ROOM NUMBER] bed B, the call light was tested by pushing the red button. The light above the door did not light up and no sound was heard at the nurse's station. 4. room [ROOM NUMBER] bed B, the call light was tested by pushing the red button. The light above the door did not light up and no sound was heard at the nurse's station. 5. room [ROOM NUMBER] bathroom emergency call light did not have a pull string to enable the resident to call for help, if needed. Walking rounds on 6/10/19 at 4:00 p.m. with Maintenance Supervisor he stated that his day to day routine includes checking hot water temperatures, emergency doors, call lights, repairs for wheelchairs and room repairs, if needed. He stated the facility uses the TELS system, but staff continue to stop him and verbally tell him things that require his attention. He stated that he checks the call lights once per month, not on any specific days. He verified the bedside call light in rooms 116 B, 131 A, 133 A, 302 B were not working. He also verified the missing pull cord for the emergency call light in the bathroom for room [ROOM NUMBER]. | 2020-09-01 |
| 3641 | 3641 | NANCY HART CENTER FOR NURSING AND HEALING LLC | 115686 | 2117 DOCTOR WARD ROAD | ELBERTON | GA | 30635 | 2020-01-16 | 919 | D | 0 | 1 | D2MI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interviews the facility failed to ensure that all components of the nurse call system in 3 of 50 resident shared room (for rooms: 200 and 202) were fully functional and the facility failed to ensure that there was a monitoring system in place to identify call light issues in resident rooms. Findings include: Record Review of Facility Policy Call Light Policy not dated revealed a Call light will be provided for each Resident in the facility. A standard call light is available at each bed. For Resident's that are handicapped and unable to use the standard call light, a handicapped style will be provided. Interview with Resident Council on 1/15/20 at 3:00 p.m. revealed that Resident Z reported to staff that her call light does not work. Resident Z stated the light outside her door will light up when the call button is pushed but, it does not light up and alert staff at the nurse's station. Resident Z stated she has reported this to staff on multiple occasions but that it has been an issue since she came to the facility about three (3) years ago. Observation of call light system on 1/15/20 at 4:00 p.m. revealed that room [ROOM NUMBER] and room [ROOM NUMBER] do not have properly functioning call lights. Surveyor verified that call light in both of those resident rooms signal the light at the resident door but they do not light up or indicate at the nurses station to alert staff. Interview with DON on 01/15/120 at 4:20 p.m. revealed that she was completely unaware there were any issues with any of the call light or the call light system. The DON stated they have not put in alternative means for residents to alert staff because DON was unaware there was a concern and a need for any alternate means for residents to alert staff. Interview with Maintenance Director on 01/15/20 at 4:45 p.m. revealed that he was aware that the call system was not functioning properly, and that room [ROOM NUMBER] & 202 are affected. Maintena… | 2020-09-01 |
| 3854 | 3854 | HILL HAVEN NURSING HOME | 115710 | 880 RIDGEWAY ROAD | COMMERCE | GA | 30529 | 2020-02-13 | 919 | E | 0 | 1 | MKUM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and resident and staff interviews the facility failed to ensure that all components of the nurse call system in eight of 63 resident shared rooms (for rooms: 8, 17, 18, 29, 30 and 32) were fully functional and the facility failed to ensure that there was an effective monitoring system in place to identify call light issues in resident rooms. Findings include: Record Review of Facility Policy Preventative Maintenance Service Policy revealed It shall be the policy of[NAME]Haven Nursing Home to conduct preventative and routine maintenance on areas and equipment as identified through completing preventative maintenance checklists. Maintenance Supervisor will be responsible for making necessary repairs, performing necessary routine maintenance or arranging for an alternate service provider to complete work as identified in a timely manner. An interview on 2/11/2020 at 09:30 a.m. with Resident (R) #20 revealed his call light did not work. Review of R#20's Annual Minimum Data Set (MDS) revealed a Brief Interview of Mental Status (BIMS) assessment of 14, indicating the resident was cognitively intact. Observation of all call lights in facility on 2/11/2020 at 9:40 a.m. revealed out of 35 rooms there were 8 rooms affected (room [ROOM NUMBER] B, #8 B, #18 A, #29 A & B, #30 A & B, and #32 A & B.) An interview with Maintenance Director on 2/11/2020 at 10:00 a.m. revealed he has previously contacted an electrician who came out a few weeks ago to look at the call light system but the Maintenance Director stated he has not received any follow-up information from the electrician. The Maintenance Director stated he does not have any record of the date the electrician came and he was unable to provide any documentation of the visit since the electrician did not bill the facility. Record review of last six months of call light logs revealed the facility was only able to provide call light logs for (MONTH) 2020 and that staff … | 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 |
| 808 | 808 | PRUITTHEALTH - AUGUSTA | 115334 | 2541 MILLEDGEVILLE ROAD | AUGUSTA | GA | 30904 | 2018-03-01 | 914 | D | 0 | 1 | 4EX411 | Based on observation and staff interview the facility failed to ensure that privacy curtains provided full visual privacy, which included a total of four of 100 beds on two of six halls. The facility census was 79 residents. Findings include: On 2/28/18 at 12:40 p.m., during walking tour with Housekeeping Supervisor, observation revealed privacy curtains in rooms 223C, 225A, 331B and 331D were short approximately four feet from end of the curtain to the wall, which did not ensure full visual privacy for the resident during patient care. Interview on 2/28/18 at 12:40 p.m., with Housekeeping Supervisor, stated that housekeeping staff are given assignments for which rooms which need privacy curtains need to be laundered. He stated that when the original curtain is taken down, the housekeeping staff put up a temporary curtain to provide privacy during care. He stated that he was not aware that the temporary curtains were not long enough to provide full privacy for the residents receiving care. Interview on 3/1/18 at 8:49 a.m., with Housekeeping Supervisor, stated he changed the privacy curtains out in rooms 223C, 225A, and 331B and 331D yesterday. Surveyor informed him that the curtains were checked early this morning at 7:45 am, and curtains did not provide full privacy for residents. He stated that he misunderstood the rooms that were shown to him the previous day. He stated curtains with 42 hooks are the longest that he could order, but he had some 18 hook curtains that he will hang along with the others to make sure residents are provided full privacy. | 2020-09-01 |
| 1081 | 1081 | THOMSON HEALTH AND REHABILITATION | 115365 | 511 MT. PLEASANT ROAD | THOMSON | GA | 30824 | 2017-12-15 | 914 | D | 0 | 1 | SBKV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to ensure that privacy curtains provided full visual privacy, which included a total of eight (8) of 150 rooms on four (4), 200, 400, 500 and 600, of six (6) halls. The facility census was 117 residents. Findings include: During the Environmental tour on 12/15/17 between 12:49 p.m. and 1:30 p.m. with the Environmental Assistant Manager, observation revealed resident privacy curtains with a width space/gap of 25 inches or less which did not ensure full visual privacy coverage during patient care, including rooms 206, 401, 403, 411, 417, 503, 507, and 603. In room [ROOM NUMBER] there was a 25 inch space/gap from end of privacy curtain for Bed B and the wall and there was no privacy curtain between bed A and bed B in room [ROOM NUMBER]. Interview on 12/15/17 at 1:09 p.m. with Licensed Practical Nurse (LPN) DD, who reported that the privacy curtain should be pulled prior to providing care. LPN DD confirmed that the privacy curtain was not up between Bed A and Bed B in room [ROOM NUMBER] and the expectation is that the door would be closed prior to providing care. Interview on 12/15/17 at 1:25 p.m. with the Environmental Assistant Manager who reported that it is his responsibility to assure that privacy curtains are the correct length. It was further reported that privacy curtains are checked whenever they need to be changed out due to stains but are not checked on a routine basis. | 2020-09-01 |
| 1215 | 1215 | CEDAR SPRINGS HEALTH AND REHAB | 115381 | 148 CASON ROAD | CEDARTOWN | GA | 30125 | 2018-05-10 | 914 | E | 0 | 1 | EUN811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide full privacy for residents in their rooms as evidenced by privacy curtains which were not wide enough to extend the length of the ceiling curtain tracks, missing curtain panels or missing the complete curtain in eight of 40 rooms sampled on two of three halls. Findings include: Observation during initial tour on 5/7/18 at 10:58 a.m., revealed that the privacy curtain in room [ROOM NUMBER] B was approximately four feet too short and did not providing full visual privacy for resident. Observation during initial tour on 5/7/18 at 11:10 a.m., revealed that the privacy curtain in room [ROOM NUMBER] B was approximately two feet too short and did not providing full visual privacy for resident. Tour and observation of Hall C on 5/9/18 from 4:00 p.m. to 6:00 p.m. revealed privacy curtains which were too short, missing curtain panels or missing in the following rooms: room [ROOM NUMBER]-A: missing complete curtain room [ROOM NUMBER]-B: missing the middle curtain panel room [ROOM NUMBER]-A: 12 inches short room [ROOM NUMBER]-B: 3 feet short room [ROOM NUMBER]-A: missing curtain panel room [ROOM NUMBER]-A: 2 feet short room [ROOM NUMBER]-B: missing curtain panel room [ROOM NUMBER]-B: 2 feet short room [ROOM NUMBER]-C: missing curtain panel room [ROOM NUMBER]-B: 3 feet short Observation during initial tour on 5/8/18 at 9:00 a.m. revealed that the privacy curtain in room [ROOM NUMBER] B had a large tanish-brown stain in center of curtain. Observation during initial tour on 5/8/18 at 9:27 a.m. revealed that the privacy curtain in room [ROOM NUMBER] A, had a sticky, gummy substance stuck to bottom of privacy curtain. Interview on 5/10/18 at 12:58 p.m., with the Housekeeping Assistant Supervisor, confirmed the identified concerns with privacy curtains. She stated that there is no specific policy on inspecting the privacy curtains, or how often to wash them. She further stated that she was not … | 2020-09-01 |
| 1237 | 1237 | PRUITTHEALTH - CRESTWOOD, LLC | 115385 | 415 PENDLETON PLACE | VALDOSTA | GA | 31602 | 2019-01-31 | 914 | D | 0 | 1 | Q4IB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to ensure that privacy curtains provided full visual privacy, for a total of three of fifteen rooms on the Memory Support Unit (MSU). The facility census was 74 residents. Findings include: The Environmental tour began on 1/31/19 at 10:16 a.m. with the Maintenance Director, Director of Health Services, Assistant Director of Health Services, Nurse Consultant, Housekeeping Supervisor, and Registered Nurse (RN) BB. Observation revealed resident privacy curtains with a width space/gap of approximately 56.5 inches which did not ensure full visual privacy during patient care for rooms 351, 355, 357. In room [ROOM NUMBER] there was no privacy curtain at the foot of the bed for the Bed B and there was a 56.5 inch space/gap from the wall for Bed A in room [ROOM NUMBER]. During an interview on 1/31/19 at 10:16 a.m. with the DHS revealed that her expectation is that staff will pull curtains up to assure privacy when providing care to residents and that going forward there will be an audit of all rooms to assure 100% privacy and if short curtains are identified they will be replaced. Interview on 1/31/19 at 10:21 a.m. with Housekeeping Supervisor revealed that privacy curtains are removed and rehung monthly. The Housekeeping Supervisor also revealed that if short curtains are identified by staff they are taken down and replaced. However, the Housekeeping Supervisor denied being aware of any short privacy curtains prior to today. | 2020-09-01 |
| 1616 | 1616 | PRUITTHEALTH - SHEPHERD HILLS | 115452 | 800 PATTERSON RD | LA FAYETTE | GA | 30728 | 2019-04-19 | 914 | D | 0 | 1 | 752G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to ensure that privacy curtains provided full visual privacy, which included a total of three beds (222A, 225A, 226A) of 106 beds on one of three halls. The facility census was 106 residents. Findings include: Observation on 4/15/19 at 3:11 p.m. revealed room [ROOM NUMBER] bed A did not have a privacy curtain, to provide full visual privacy during care. Observation on 4/15/19 at 4:06 p.m. revealed room [ROOM NUMBER] bed A did not have a privacy curtain, to provide full visual privacy during care. Observation on 4/15/19 at 4:20 p.m. revealed room [ROOM NUMBER] bed A did not have a privacy curtain, to provide full visual privacy during care. Interview on 4/19/19 at 11:43 a.m. with Housekeeping Supervisor, stated that privacy curtains are inspected daily by the housekeeping staff, and are laundered only when visibly soiled or dirty. The staff take down the soiled or dirty curtain, and replace with a temporary curtain, until the original curtain is washed and ready to be re-hung. He stated he is not sure why replacement curtains were not placed when they were taken down to be laundered. He verified during walking rounds the rooms identified during the survey that were missing privacy curtains. | 2020-09-01 |
| 1734 | 1734 | BRYANT HEALTH AND REHABILITATION CENTER | 115479 | 134 S 6TH STREET | COCHRAN | GA | 31014 | 2020-02-12 | 914 | D | 0 | 1 | KFZ411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interview, the facility failed to ensure rooms had privacy curtains that provided total visual privacy for three of 37 rooms in which three residents resided (Room #'s 201, 207, and 204). Findings include: 1. During an observation on 2/9/2020 at 12 p.m. in room [ROOM NUMBER] there was a short privacy curtain for Bed B. 2. During observation of room [ROOM NUMBER] on 2/9/2020 at 3:38 p.m. there was a short privacy curtain between Bed A and Bed B. 3. Observation on 2/9/2020 at 11:25 a.m., 2/10/2020 at 10:42 a.m. and 3:55 p.m. revealed the resident in room [ROOM NUMBER] had no privacy curtain. A tour was conducted on 2/12/2020 from 2:55 p.m. until 2:59 p.m. with the House Keeping Supervisor who confirmed that there was a short privacy curtain in room [ROOM NUMBER] due to the curtain track being short. It was reported that housekeeping staff should be pulling the privacy curtains daily when in the room to check for stains and to assure that the curtains are the appropriate length. The Housekeeping Director was unaware of the short curtain in rooms [ROOM NUMBERS]; and the missing curtain in room [ROOM NUMBER]. The Housekeeping Supervisor initially reported that the previous Maintenance Director had been notified of the short privacy curtains and was supposed to order curtains. However, there was no documentation provided to support the order for new privacy curtains. | 2020-09-01 |
| 1748 | 1748 | EAST LAKE ARBOR | 115482 | 304 FIFTH AVENUE | DECATUR | GA | 30030 | 2019-09-13 | 914 | E | 1 | 0 | MDGN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations and staff interviews, the facility failed to ensure rooms had privacy curtains that provided total visual privacy for fourteen (14) of forty-two (42) rooms in which three (3) residents resided in (Rooms #111A, #204A and #408B). Findings include: During wound care observations conducted on 9/11/2019, between the hours of 8:30 a.m. to 9:00 a.m. for residents #2 and #3 (rooms #111A and 408B) revealed privacy curtain surrounding resident's beds were too short to provide complete privacy during care. On 9/12/2019 at 9:15 a.m. observation of medication administration via pe[DEVICE] for resident #4, the resident's privacy curtain was too short to provide completed privacy during care. Random tour of the building revealed rooms # 102 (a/b), 105 (a/b) 108 (a/b), 109 (a/b), 301(a/b),302(a/b), 303 (a/b) 304 (a/b), 306 (a/b), 401 (a/b), 403 (a/b), 406 (a/b), 407 (a/b), 408 (a/b) and 409 (a/b) revealed privacy curtains were 4-6 inches short of complete surrounding of the bed to ensure complete privacy. Interview with Housekeeping Supervisor conducted on 9/11/2019 at 11:15 a.m. revealed that the short curtains were noted, and a quote was submitted to the Administrator on (MONTH) 5, (YEAR), and is currently waiting for the approval to replace the curtains. Interview with Maintenance Director on 9/11/2019 at 11:30 a.m. who revealed that all of the curtains in the facility are the same size except the rooms with the four (4) beds. Interview with the Corporate Administrator conducted on 9/11/2019 at 11:45 a.m. who stated that he was unaware that the privacy curtains were too short and will see to them being replaced as soon as possible. Interview with Administrator 9/11/2019 at 1:40 p.m. revealed that he submitted the quotes to have the privacy curtains replaced with the correct length (MONTH) 2019 and awaiting the approval from the corporate office to purchase the curtains with the correct length. | 2020-09-01 |
| 2134 | 2134 | AZALEALAND NURSING HOME | 115534 | 2040 COLONIAL DRIVE | SAVANNAH | GA | 31406 | 2018-08-09 | 914 | E | 0 | 1 | JD6Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff and resident interviews, the facility failed to ensure rooms had privacy curtains that provided full visual privacy for the residents in 22 rooms out of a total of 49 rooms on three (3) of three (3) halls. This deficiency affected 41 residents out of a facility census of 72. Findings include The environmental tour began on 8/7/18 at 9:32 a.m. with the Director of Nursing (DON), and at 11:39 a.m. with the Contract Maintenance Director. Observation revealed resident privacy curtains that had a space/gap of 54 inches or less that did not provide full visual privacy coverage during patient care in the following rooms: #1, #3, #4, #7, #8, #9, #10, #11, #16, #18, #24, #26, #27, #28, #29, #30, #31, #34, #36, #37, #39 and #44. During an interview with the Director of Nursing (DON) on 8/7/18 at 9:32 a.m. while on a walk through of random rooms (room [ROOM NUMBER]-#13) she agreed that the privacy curtains did not provide the full visual privacy for those residents required to meet Federal Regulations. During an interview on 8/7/18 at 11:39 a.m., with the Contract Maintenance Supervisor, AA, (housekeeping), revealed that no training had been provided to her regarding the privacy curtains. During an interview with BB at which time he revealed that facility maintenance is responsible for putting up and removing the privacy curtains. He stated that his expectations are that if the Account Manager, CC, has any problems with the curtains it should be reported at once to the facility. During an interview with CNA, DD, on 8/7/18 at 11:44 a.m. she stated that she was not aware that the curtains should provide privacy from one end of the rod to the other end. She felt that as long as the curtain hid the person from the opening of the door there wasn't a problem. She reported that she understood if another resident or staff member were to come into the room it would be a privacy issue for the resident. She also stated that she has rec… | 2020-09-01 |
| 2429 | 2429 | PIONEER HEALTH OF CENTRAL GEORGIA | 115564 | 712 PATTERSON STREET | BYROMVILLE | GA | 31007 | 2020-01-15 | 914 | D | 0 | 1 | N7S811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to ensure that privacy curtains provided full visual privacy, for four (4) of 33 resident rooms. (Room numbers 102-B, 110-A, 209-A, 216-B). Findings include: Observations in room [ROOM NUMBER]A on 1/14/20 at 2:39 p.m. revealed track for privacy curtain is broken and privacy curtain cannot be pulled to assure 100% privacy. Observations in room [ROOM NUMBER]-A at 3:00 p.m. on 1/14/20 short privacy curtains observed in room. During environmental tour with Maintenance Director and Housekeeping Supervisor (HSK) on 1/15/20 at 8:19 a.m. the following was revealed and confirmed: 1. At 8:23 a.m. in room [ROOM NUMBER]B HSK Supervisor confirmed short track. She reported that housekeeping has been doing an audit of privacy curtains related to hooks, making sure they have no holes in them, and making sure the track is not falling, However, they have been not auditing to assure that privacy curtains assure full privacy. 2. At 8:26 a.m. in room [ROOM NUMBER] privacy curtain for bed A is short due to curtain sticking on the track. The privacy curtain for Bed B is short due to a nail stopping the curtain from being pulled all the way around the bed. 3. At 8:50 a.m. in room [ROOM NUMBER]B the ceiling track is hanging and call privacy curtain is short. The privacy curtains for beds A, B, and C are short. 4. At 8:55 a.m. in room [ROOM NUMBER] the privacy track is broken and will not allow for the privacy curtain to be fully pulled for Bed [NAME] | 2020-09-01 |
| 2584 | 2584 | ALTAMAHA HEALTHCARE CENTER | 115577 | 1311 WEST CHERRY STREET | JESUP | GA | 31545 | 2018-09-03 | 914 | D | 0 | 1 | THIC11 | Based on observation and staff interview the facility failed to ensure that privacy curtains provided full visual privacy, which included a total of 4 of 8 rooms on 200 hall (B hall) affecting 1 of 3 halls. The facility census was 58 residents. Findings include: Observations: On 9/1/18 at 1:07 p.m. in room B-205 there short privacy curtains for Bed A and Bed B. On 9/1/18 at 1:21 p.m. in room B-208 there were short privacy curtains for Bed A and Bed B. On 9/1/18 at 2:59 p.m. in room B-204 there was a short privacy curtain for Bed B. On 9/1/18 at 3:13 p.m. in room B-207 there was a short privacy curtain for Bed [NAME] Environmental tour began on 9/3/18 at 10:50 a.m. with the Maintenance Director. Observation revealed resident privacy curtains with space/gap of 84 inches or less which did not ensure full visual privacy for residents including rooms B-204, B-205, B-207, and B-208. Interview on 9/3/18 at 11:29 a.m. with Maintenance who reported that he does not typically check privacy curtains and housekeeping is responsible for cleaning and hanging. Interview on 9/3/18 at 11:31 a.m. with Housekeeping Supervisor who revealed that she just assumed that all of the privacy curtains were the same size. She explained that privacy curtains are removed when laundered but her staff should pull privacy curtains to make sure they go all the way around when they are hung up. She further reported that the expectation is that a curtain will be replaced if it does not go all the way around. Housekeeping Supervisor denied having knowledge of short privacy curtains. Interview on 9/3/18 at 11:40 a.m. with Housekeeper (HSK) DD who revealed that privacy curtains are pulled and checked for staining but not necessarily to check for gaps. She further reported that if short privacy curtains are observed the supervisor will be notified. Interview on 9/3/18 at 2:20 p.m. with the Administrator who reported that the short privacy curtains that were up were temporary curtains and were only up while the others were being washed and the correct le… | 2020-09-01 |
| 2654 | 2654 | LEGACY TRANSITIONAL CARE & REHABILITATION | 115585 | 460 AUBURN AVENUE N.E. | ATLANTA | GA | 30312 | 2018-01-12 | 914 | D | 0 | 1 | OCIP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that bedrooms assure full visual privacy as evidenced by privacy curtains that were too short and did not provide full privacy for the residents. The sample size was 29 residents. Findings include: Interview with Maintenance Services (MM) on 1/10/17 at 9:52 a.m. in room [ROOM NUMBER], he stated that the curtain between 405-1 and 405-2 is too short and dirty. The curtain has multiple stains on it. He has a large bin full of clean curtains and is replacing curtains this morning. On 1/11/18 10:35 a.m. the door was open to the hall while Resident (R) #27 receiving care from a Certified Nursing Assistant (CNA) GG, and a Licensed Practical Nurse (LPN) FF. From the hall, the resident's adult brief, his bare legs with white socks, and white t-shirt was observed. There is a gap between the bottom of the privacy curtain and the resident's bed. On 1/11/18 at 10:40 a.m. during an interview with LPN FF outside of R#27's room he observed the curtain length on R#27's bed and living area and says it is too short to provide privacy. He agrees you can see uncovered resident from the hall. Many of the curtains on this hall are too short. Review of Resident Rights Policy, undated, reveals a policy that the resident has the right to personal privacy and confidentiality of his or her personal and clinical needs. During an interview and tour with Administrator on 1/12/18 at 11:00 a.m. all the privacy curtains in the facility were being assessed for providing privacy. The Administrator toured the following rooms with the surveyor and agreed that the privacy curtains that are not long enough to provide privacy: 405-1, 406-1, 407-2, 407-3, 409-2+3, 410-3, 411-1+2, 412-1, 413-2, 415-1+2, and 416-1+2. 1/12/18 12:30 p.m. In room [ROOM NUMBER] the Director of Maintenance was observed measuring the distance between the bottom of the privacy curtain and the floor. The gap is 24 inches. The pri… | 2020-09-01 |
| 2725 | 2725 | COUNTRYSIDE HEALTH CENTER | 115592 | 233 CARROLLTON STREET | BUCHANAN | GA | 30113 | 2019-01-10 | 914 | E | 0 | 1 | 3O5311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to provide privacy curtains of enough size to give full privacy for nine beds on two of two halls. The facility census was 57 residents. Findings include: Initial tour of the facility on 1/7/19 beginning at 11:26 a.m. revealed a privacy curtain in room [ROOM NUMBER]-A which was approximately 40 inches too short to provide full privacy for the resident in that bed space. Continued observation of room [ROOM NUMBER]-C revealed the privacy curtain was approximately 40 inches too short to provide full privacy for the resident. Further observation of the floor revealed the privacy curtain in 116-A was approximately 24 inches too short to provide full privacy for the resident. During initial tour on 1/7/19 at 2:59 p.m., revealed privacy curtain in room [ROOM NUMBER] B approximately three and half feet too short, not providing full visual privacy for resident; privacy curtain in 106 C approximately three and half feet too short, not providing full visual privacy for resident. During initial tour on 1/8/19 at 8:44 a.m., revealed privacy curtain in room [ROOM NUMBER] B approximately two and half feet too short, not providing full visual privacy for resident. During initial tour on 1/8/19 at 10:19 a.m., revealed privacy curtain in room [ROOM NUMBER] C approximately one and half feet too short, not providing full visual privacy for resident. During initial tour on 1/9/19 at 12:20 p.m., revealed privacy curtain in room [ROOM NUMBER] A approximately two feet too short, not providing full visual privacy for resident. During initial tour on 1/9/19 at 12:23 p.m., revealed in room [ROOM NUMBER] B, there was no privacy curtain suspended from ceiling, to provide full visual privacy for resident. Interview on 1/10/19 at 3:33 p.m., with Maintenance Supervisor, verified on walking rounds the concerns identified during the survey. He stated that staff will make hand written work orders for items and concerns … | 2020-09-01 |
| 2783 | 2783 | HERITAGE INN HEALTH AND REHABILITATION | 115597 | 307 JONES MILL ROAD | STATESBORO | GA | 30458 | 2019-02-14 | 914 | D | 0 | 1 | M1C011 | Based on observation and staff interview the facility failed to ensure that privacy curtains provided full visual privacy, which included a total of seven of 92 beds (T-1B, T-8 A and B, T-5 A, T-6 A and B, T-7 A), on one of three units. Findings include: During initial tour on 2/11/19 at 10:25 a.m., revealed privacy curtain in room T-1 B approximately two feet too short, not providing full visual privacy for resident. During initial tour on 2/11/19 at 10:29 a.m., revealed privacy curtain in room T-8 A approximately three feet too short, not providing full visual privacy for resident; a second curtain separating bed A and bed B was approximately six inches too short. During initial tour on 2/11/19 at 10:41 a.m., revealed privacy curtain in room T-8 B approximately three feet too short, not providing full visual privacy for resident. During initial tour on 2/11/19 at 10:47 a.m., revealed privacy curtain in room T-5 A approximately four feet too short, not providing full visual privacy for resident. During initial tour on 2/11/19 at 10:52 a.m., revealed privacy curtain in room T-6 A approximately six feet too short, not providing full visual privacy for resident; a second curtain separating bed A and bed B was approximately one foot too short. During initial tour on 2/11/19 at 10:54 a.m., revealed privacy curtain in room T-7 A approximately two and half feet too short, not providing full visual privacy for resident. During initial tour on 2/11/19 at 1:13 p.m., revealed privacy curtain in room T-7 B approximately two feet too short, not providing full visual privacy for resident. Interview on 2/14/19 at 12:02 p.m. with Maintenance Supervisor, verified on walking rounds the concerns identified during the survey. He stated that staff make work orders in the computer TELS system. He further stated that he was not aware of regulations about resident privacy curtains, as he is new working in long-term care. | 2020-09-01 |
| 2896 | 2896 | PINEWOOD NURSING CENTER | 115607 | 433 NORTH MCGRIFF STREET | WHIGHAM | GA | 39897 | 2019-11-22 | 914 | E | 0 | 1 | IUU711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, the facility failed to ensure that the resident 's room had privacy curtains that provided full visual privacy for eight of 39 rooms (Rooms: 206, 210, 211, 304, 308, 309, 316, and 317) reviewed for privacy curtains. Findings include: 1. An observation during the initial tour on 10/28/19 at 10:24 a.m. revealed either short privacy curtains or missing privacy curtains in the following rooms: Rooms (Rm) 206 had one missing privacy curtain for A bed and rooms 210, 211, 304, 308, 309, 316, and 317 (had gaps between from either A bed to the middle curtain or the wall and/either between the B bed to the window or the middle curtain to the B bed). Observation and interview on 10/28/19 at 12:00 p.m., revealed that R#469, in room [ROOM NUMBER], was observed sitting on the side of his bed (Bed A) facing the doorway. R#469 was observed to be without clothes from the waist down and was exposed to others from the hallway. Observation revealed that there was not a privacy curtain for Bed [NAME] Interview on 10/30/19 at 12:05 p.m. with R#469 in room [ROOM NUMBER] revealed that his privacy curtain fell due to him accidentally pulling it down about three days ago. R#469 stated he would prefer to have a privacy curtain. An observation of the resident 's privacy curtains on two of two halls (Hall 200 and Hall 300) was completed on 10/31/19 at 10:25 a.m. with the Administrator, Director of Nursing (DON), Housekeeping Supervisor (HK), and Maintenance Supervisor (MS). During the tour the MS completed measurements of the gaps that were identified above. The largest gap measured was 64 inches and the shortest gap measured was 30 inches. Post survey interview on 11/21/19 at 12:33 p.m. with the Administrator revealed that she was unaware the privacy curtains were too short. The Administrator stated that she depended on her Nursing Supervisors who make rounds every morning to let her know and that there had not been any mentio… | 2020-09-01 |
| 3050 | 3050 | EASTMAN HEALTHCARE & REHAB | 115622 | 556 CHESTER HIGHWAY | EASTMAN | GA | 31023 | 2019-10-23 | 914 | D | 0 | 1 | PMJ811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview and staff interview, the facility failed to provide privacy for residents in four out of 50 rooms and failed to ensure that the privacy curtain in one room out of 50 rooms was clean. Findings include: An observation on 10/20/19 at 2:13 p.m. revealed that the privacy curtain in Room (Rm) 101-B does not provide full visual privacy for resident (R)#13. During the interview with R#13, she stated that this bothers her and states that she had been told that the facility was supposed to be getting new privacy curtains. An observation on 10/21/19 at 5:38 p.m. revealed that the privacy curtain in [RM #] did not provide full visual privacy for R#13. A follow-up interview with R#13 revealed that the curtain remained short and facility staff had not hung any additional curtains. An observation on 10/22/19 at 8:38 a.m. revealed that the privacy curtain in [RM #] still did not provide full visual privacy for R#13. An observation on 10/22/19 at 8:58 a.m. of Rm 111-A, 111-B, 111-C revealed that the privacy curtains in that room did not provide full visual privacy for the residents. An observation on 10/22/19 at 9:03 a.m. revealed that the privacy curtain in Rm 114-A was too short to provide full visual privacy. The privacy curtain in Rm 114-B did not slide on the track consequently it did not provide full visual privacy for the resident. An observation and interview on 10/22/19 at 10:10 a.m. with the Head of Housekeeping of [RM #] privacy curtain confirmed that the privacy curtain was too short to provide full visual privacy. An observation of Rm 111-A with the Head of Housekeeping confirmed that the privacy curtain was too short to provide full visual privacy. An observation of Rm 111-B with the Head of Housekeeping confirmed that the privacy curtain was too short to provide full visual privacy. An observation of Rm 111-C with the Head of Housekeeping confirmed that the privacy curtain was too short to provide full v… | 2020-09-01 |
| 3191 | 3191 | RIVER BROOK HEALTHCARE CENTER | 115635 | 390 SWEAT STREET | HOMERVILLE | GA | 31634 | 2019-07-24 | 914 | D | 0 | 1 | FNFD11 | Based on observation, staff interview and facility policy titled, Resident Rights and Dignity Management the facility failed to ensure that privacy curtains provided full visual privacy, for five of 33 rooms (B3, A8, A10, A13, A15) for two of three halls, (A-hall and B-hall). Findings include: Review of the facility policy titled Resident Rights and Dignity Management, not dated, revealed #6 Resident's private space and property shall be respected at all times. During the Environmental tour on 7/24/19 starting at 8:45 a.m. with the Administrator and the Maintenance Director, observation revealed resident privacy curtain, affecting two residents, in room B3 between bed A and bed B had a gap of 10.5 inches from the wall to the edge of the curtain. Room A8, effecting one resident, did not have a privacy curtain at the end of the bed near the door to the hall way and had part of the privacy curtain track missing. Room A10 privacy curtain track was loose from the ceiling between bed A and bed B and the privacy curtain loose off the track and was not able to be closed completely. Room A13, affecting three residents, did not have a curtain at the foot of any of the beds and was missing a section of the track near the door to the hallway. Room A15, affecting two residents, did not have a privacy curtain track or a curtain between bed B and bed C. An interview held on 7/24/19 at 9:48 a.m. with the Administrator revealed the roof over the A-Hall had previously leak but has been fixed. (completed on 7/19/19). The Administrator indicated the maintenance director had been fixing the ceilings in the rooms and has had to remove some of the curtain tracks and curtains. They have moved some of the residents and closed off some of the rooms. The rooms that are closed off are in the process of being remodeled. Room A9 and A14 are closed for repair. A8 is empty. A1 is storage. A5 and A7 are offices. He indicated a new curtain track and curtains have been ordered and delivered. There are ten rooms currently available for resident use… | 2020-09-01 |
| 3807 | 3807 | GLENWOOD HEALTHCARE | 115703 | PO BOX 869 | GLENWOOD | GA | 30428 | 2017-12-21 | 914 | D | 0 | 1 | 30UZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to ensure that privacy curtains and blinds provided full visual privacy, which included a total of five (5) of 26 rooms on one (1) of two (2) halls. The facility census was 40 residents. Findings include: The Environmental tour began on 12/21/17 at 9:32 a.m. and at 9:56 a.m. with the Maintenance Director. Observation revealed resident privacy curtains with a width space/gap of 50 inches or less which did not ensure full visual privacy coverage during patient care including rooms 102, 106, 107, 108, and 109. In room [ROOM NUMBER] there was a 50 inch space/gap from the wall for Bed B. Interview on 12/21/17 at 9:56 a.m. with the Maintenance Director who reported that he housekeeping checks the curtains to assure that they are clean but he was unsure of who is supposed to be checking the length to assure privacy. Interview on 12/21/17 at 9:59 a.m. with the Director of Nursing (DON) revealed that guardian angel rounds are completed twice a shift and staff are supposed to pull curtains to assure privacy curtains are the proper lengths. However, guardian rounds have not been done since last week. Interview on 12/21/17 at 10:02 a.m. with the Administrator regarding guardian rounds. The Administrator explained that usually everybody just checks on everybody and if there is a problem the rounds sheet is completed. It was further expressed that short privacy curtains had not been identified. Administrator reported that she has not told staff to pull privacy curtains during the guardian angel rounds. She further reported that Certified Nurse Assistants (CNAs) know that if the privacy curtain does not pull to assure 100% privacy that an Licensed Practical Nurse (LPN) should be notified. Interview on 12/21/17 at 10:22 a.m. with the DON who revealed that her expectation is that staff would pull privacy curtains to make sure they are the correct length and not soiled. If it's pulled and there is co… | 2020-09-01 |
| 4018 | 4018 | OCEANSIDE HEALTH AND REHAB | 115730 | 7 ROSEWOOD AVENUE | TYBEE ISLAND | GA | 31328 | 2019-01-10 | 914 | E | 0 | 1 | SFEW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff and resident interviews, and the facility policy titled Privacy Curtains, the facility failed to ensure rooms had privacy curtains that provided full visual privacy for 22 rooms out of two (2) of two (2) halls. This deficiency affected 38 residents out of a facility census of 69. Findings include: During the initial tour conducted on 1/7/19 at 10:00 a.m., observations revealed privacy curtains on the West Hall and East Hall that was too short when pulled together and failed to provide full visual privacy for resident occupants in semi private rooms. The environmental tour began on 1/7/19 at 1:50 p.m. with the Administrator and Maintenance Supervisor (MS). Observations revealed resident privacy curtains that had a space/gap of anywhere from 6 (six) inches to 6 feet that did not provide full visual privacy coverage during patient care in the following rooms: #103, #107, #108, #110, #112, #114, #115, #117, #201, #203, #207, #208, #209, #210, #212, #215, #218, #220, #225, and #227. In addition, observation of room [ROOM NUMBER] a semi-private room revealed two resident occupancy but, bed A did not have a privacy curtain nor a bracket that enclosed the bed. During an interview with the Administrator on 1/7/19 at 1:50 p.m. (while on a walk through of random rooms room [ROOM NUMBER]-#227) he agreed that the privacy curtains did not provide the full visual privacy for those residents occupying semi private rooms based on the Federal Regulations. The Administrator stated that the problem lack of having sufficient privacy curtains was addressed in QAA (Quality Assurance) and an order has been placed for 108 curtains prior to the surveyors entrance to the facility today. The Administrator stated that the facility maintenance is responsible for putting up and removing the privacy curtains. He stated that his expectations are that rooms have privacy curtains that provide full privacy. During an interview on 1/7/19 at 2:10 p.m.… | 2020-09-01 |
| 425 | 425 | MITCHELL COUNTY NURSING HOMES | 115266 | 37 SOUTH ELLIS STREET | CAMILLA | GA | 31730 | 2019-09-20 | 912 | E | 1 | 0 | 5G2B11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and staff interviews Facility #2 failed to ensure that three of four residents (R) (R#7, R#8 and R#9) who resided in a four-bed ward had a minimum of 80 square feet of living space per resident in the room. Findings include: During an observation on 9/6/19 at 8:45 a.m., four residents in room [ROOM NUMBER] were observed sharing a room with the beds in close proximity to each other. On 9/6/19 at 11:02 a.m., the Maintenance Director measured the room with a tape measure. The distance between Bed A mattress and Bed B mattress was 38 inches. The distance between Bed B footboard and the head of Bed C was 31 inches. The distance between Bed C mattress and Bed D mattress is 54 inches. The total room measurement was 22 feet 10 inches by 17 feet 4 inches. The storage closet was included in the measurement and was not subtracted from the living space per resident. During an interview with the Maintenance Director on 9/6/19 at 1:44 p.m., he stated the residents in that room did not have 80 square feet of living area per resident. During an interview with Administrator DD, for Facility #2 on 9/6/19 at 1:49 p.m., he stated that there was not a waiver and that room and the room had been like that since 1961. During an observation with the Administrator on 9/11/19 at 11:29 a.m., the Maintenance Director re-measured the room and obtained 17 feet 6 inches by 21 feet as the total room size. The measured living space for Bed A, for R#7, was 9 feet by 5 feet for a total of 45 square feet. However, the wall closet occupied 4.7 feet leaving R#7 with 40.3 square feet of living area. The measured living space for Bed B, for R#8, was 9 feet by 8 feet for a total of 72 square footage living area. The measured living space for Bed C was 12 feet 1 inch by 8 feet for a total of 96.8 square footage of living area. The measured living space for Bed D, for R#9, was 9 feet by 3.5 feet for a total of 27 square feet. However, the wall closet occupied 4.7… | 2020-09-01 |
| 3605 | 3605 | PARKSIDE CENTER FOR NURSING AND REHAB AT ELLIJAY | 115683 | 1362 SOUTH MAIN STREET | ELLIJAY | GA | 30540 | 2018-11-29 | 912 | D | 0 | 1 | 7PQZ11 | Based on observation, resident and staff interview, the facility failed to accommodate one resident's (R) RA environment to ensure RA had 80 square feet of living space in a multiple resident bedroom. The sample size was 49 residents. Findings include: Observation on 11/26/18 at 11:22 a.m. resident sitting on her bed. There is a small armoire to the right of the bed against the wall at the head of the bed. Her television is mounted on the wall at the foot of the bed, shoulder height with screen pointed at angle toward floor. There are books and her daily use items stacked on her over bed table, pushed against the side of her bed. There were clothes folded on the foot of the bed and a loaf of bread tucked underneath her bedspread so that wandering residents don't bother her belonging. Interview with RA on 11/26/18 at 11:22 a.m., in her room, sitting on side of her bed, which is in the middle of a three resident room, she stated that her room is too small. She stated there is not enough of room for her to have a chair to sit in. She stated during further interview that she has to store things underneath her bed, because she does not have enough space to keep any of her personal belongings. She further stated that she had asked to be transferred to another room, but has not been moved, even when new people are admitted . She stated that she would like for me to inquire about this situation. Interview on 11/28/18 at 10:26 a.m. with Social Worker, stated that rooms are assigned based on resident physical needs. Social Worker stated there is no seniority for room changes over new admissions. She further stated that she keeps a notebook with a waiting list of residents requesting room changes or transfers. She stated during further interview that RA was placed on waiting list (MONTH) 13. She stated RA was moved into bed A in the same room on 8/20/18, and she stayed one week, but demanded to be moved back to her bed. During continued interview with Social Worker, she stated there is currently one additional resident ahea… | 2020-09-01 |
| 588 | 588 | CHULIO HILLS HEALTH AND REHAB | 115287 | 1170 CHULIO ROAD | ROME | GA | 30161 | 2018-08-02 | 909 | C | 0 | 1 | QK7911 | Based on observation, record review, and staff interview, the facility failed to provide evidence that they were conducting regular inspections of bed frames, mattresses, and bed rails, as part of a regular maintenance program, to identify areas of possible entrapment. 71 residents in the facility had either half bed rails or other attached bed accessory such as a bed cane (including residents (R) #21 and R#33), and the facility census was 89 residents. Findings include: Observation on 7/31/18 at 11:10 a.m. revealed that R#21 had an enabler-type rail at the top of the open side of her bed that had a large oval-shaped opening in the center of the rail. The length inside the bars as measured with the surveyor's tape measure was 12 inches, and the inside measurement from the top of the rail to the bottom of the rail was 6-1/2 inches. During interview with the Assistant Director of Nursing (ADON) on 7/31/18 at 2:02 p.m., she stated that the rail on R#21's bed was called a bed cane, and it was used to assist her in positioning. She verified during observation the large opening in the center of the rail, and stated that there must be some sort of padding that could be put in the middle of the opening. Observation of R#33's bed on 8/1/18 at 4:45 p.m. revealed that she had the same type of bed cane on one side of her bed with similar interior measurements as R#21's device. During interview with the Maintenance Supervisor on 8/2/18 at 9:51 a.m., he stated that he checked bed rails to ensure they were securely fastened to the bed as he walked around the facility checking other things like the hot water temperatures. He further stated that all the rails in the facility were checked at least once a month, but that he did not have documentation of this. Review of the facility's Policy and Procedure on Bed Safety revised on 10/1/10 revealed: The facility will strive to prevent/reduce hazards such a patient entrapment associated with hospital bed. In an effort to reduce/prevent death/injuries from entrapment associated with hos… | 2020-09-01 |
| 1371 | 1371 | LUMBER CITY NURSING & REHABILITATION CENTER | 115404 | 93 HIGHWAY 19 | LUMBER CITY | GA | 31549 | 2018-08-30 | 909 | D | 0 | 1 | MO5811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, clinical record review, observations, and staff interviews, the facility failed to ensure bed rails were safely installed and maintained for two residents ( R)#33 and R#60 of 30 total residents in the sample. Findings include: Review of a document titled the Bed Entrapment Grid, dated 3/3/16 provided to the facility by the Corporate Maintenance Manager on 8/28/18, was reviewed and indicted any gap within any bedrail (Zone 1) used by the facility was be no larger than 4 3/4 inches (length or width). 1. R#33 was admitted to the facility on [DATE] with diagnoses, according to the Face Sheet, dated 12/24/14 including severe dementia and type II diabetes. Review of the resident's quarterly MDS dated [DATE] documented the requires extensive assistance to complete all activities of daily living (ADLs) including bed mobility and had impairment of mobility on both sides of her lower body. The resident's ADL care plan, most recently revised on 6/18/18 was reviewed and indicated R#33 could use half side rails for positioning in bed as desired. Observations of R#33, laying in her bed, were made throughout the day on 8/27/18, 8/28/18, 8/29/18, and 8/30/18. The resident remained in bed much of the time on each of these days, only rising for meals, due to her personal preference. Half side rails on each side of the resident's bed were observed to be in the up position throughout this period of time. The rails fit snugly to the mattress on both sides of the bed. 2. R#60 was admitted to the facility on [DATE] with diagnoses, according to the Face Sheet, dated 12/24/14 including history of stroke, [MEDICAL CONDITION], and muscle weakness. Review of the resident's most recent Minimum Data Set (MDS), a quarterly assessment of overall health status dated 8/15/18, indicated required extensive assistance from staff to complete all of his activities of daily living (ADLs), including bed mobility, and had impairment of mobility on one… | 2020-09-01 |
| 3653 | 3653 | MOUNTAIN VIEW HEALTH CARE | 115688 | 547 WARWOMAN ROAD | CLAYTON | GA | 30525 | 2019-03-28 | 909 | D | 0 | 1 | UHZV11 | Based on observations, review of the facility policy titled Bed Safety, review of manufacturer's guidelines titled Bed Rail Entrapment Risk Notification Guide, and staff interviews, the facility failed to ensure that the side rails for eight resident's beds were installed per manufacturer's guidelines out of 100 residents. Findings include: Review of the facility's policy titled Bed Safety revised (MONTH) 2007 revealed the Policy Statement - our facility shall strive to provide a safe sleeping environment for the resident. Further review of the Policy Interpretation and Implementation under section 2 revealed to try to prevent deaths/injuries from the beds and related equipment (including the frame, mattress, side rails, headboard, footboard and bed accessories), the facility shall promote the following approaches: a. Inspection by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment risks; c. Ensure that when bed system components are worn and need to be replaced, components meet manufacturer specifications; d. Ensure that bed side rails are properly installed using the manufacturer's instructions and other pertinent safety guidance to ensure proper fit (e.g. avoid bowing, ensure proper distance from the headboard and footboard, etc.) Observation on 3/25/19 at 10:40 a.m. revealed a raised side rail on the right side of the bed in room A13 bed 2. The side rail was loose and able to be moved back and forth, side to side and lean inward when raised. Further observations starting on 3/25/19 at 11:30 a.m. of beds on the A hall revealed additional beds with side rails that were loose, could be moved back and forth or when raised leaned outward or inward over the bed: A1 bed 1, A5 bed 3, A7 bed 1 and 2, A9 bed 1, and A15 beds 2 and 3. The above beds were all beds that had manual cranks. During an interview on 3/26/19 at 4:50 p.m., the Maintenance Director stated that they do Plan of Correction (P[NAME]) rounds weekly.… | 2020-09-01 |
| 24 | 24 | PARK PLACE NURSING FACILITY | 115005 | 1865 BOLD SPRINGS ROAD | MONROE | GA | 30655 | 2019-11-15 | 908 | F | 0 | 1 | O88D11 | Based on observations and interview, the facility failed to ensure that essential equipment in the kitchen was in working order as evidenced by, ice build up inside and around the door frame of the walk-in freezer observed on four of four days during the survey. There are 161 residents that receive an oral diet. Findings include: During the initial tour on 11/12/19 at 10:05 a.m. with the Certified Food Service Manager (CFSM) the surveyor inspected the walk-in freezer. During the inspection, the inside door frame, ceiling and floor inside door opening, had visible ice formation. Additional observations during follow-up visits to the kitchen, revealed continued ice buildup on the walk-in freezer door frame, ceiling and floor during all four days of the survey. Interview on 11/15/19 at 4:00 p.m. with the CFSM, stated that staff scrape off the ice in the walk-in cooler everyday. She stated that she has not reported the issue to the maintenance department. She further stated there were no policies related to maintenance of the walk-in freezer. | 2020-09-01 |
| 433 | 433 | DUNWOODY HEALTH AND REHABILITATION CENTER | 115270 | 5470 MERIDIAN MARK ROAD, BLDG E | ATLANTA | GA | 30342 | 2019-04-04 | 908 | J | 1 | 0 | KBNL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the facility failed to ensure the first floor side exit door was working properly to alert staff when a resident was exiting the building unattended. This failure resulted in one Resident (R#8) out of six residents eloping from the facility undetected. On 4/2/19, a determination was made that a situation in which the facility's non-compliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator was informed of the Immediate Jeopardy on 4/2/19 at 4:30 p.m. The non-compliance related to the Immediate Jeopardy was identified to have existed as of 3/26/19. The Immediate Jeopardy continued through 4/3/19 and was removed on 4/4/19. The Immediate Jeopardy is outlined as follows: On 3/26/19 resident (R) #8 exited the facility undetected through an exit door on the first floor that was not functioning properly. The resident was found on the ground by a bystander near a busy road. The bystander called 911 and Emergency Medical System (EMS) arrived at the scene. The resident was taken to the local hospital and treated for [REDACTED]. The facility was unaware of the resident's elopement until they were notified by the emergency roiagnom on [DATE]. R#8 has a history of wandering and was wearing a Wander Guard bracelet on her ankle when she left the facility. It was determined that a handicap assessable door on the first floor which has an alarm system was not working properly and therefore, the resident was able to elope from the facility undetected. The Immediate Jeopardy was related to the facility's non-compliance with the program requirements as follows: CFR 483.21(b)(2) Comprehensive Person-Centered Care Plans (F657 Scope and Severity: J). CFR 483.25(d) (1)(2) Free of Accident, Hazards/Supervision/Devices (F689 Scope and Severity: J). CFR 483.90 (d)(2) Essential Equipment, Saf… | 2020-09-01 |
| 716 | 716 | BRIARWOOD HEALTH AND REHABILITATION CENTER | 115322 | 3888 LAVISTA ROAD | TUCKER | GA | 30084 | 2018-08-09 | 908 | D | 1 | 1 | V58711 | > Based on observation, interview, review of facility data and review of manufacture's manual, the facility failed to perform routine maintenance on air flow mattress pumps that contained an external filter. This failure had potential to negatively affect five (5) of eight (8) residents (R), R#25, R#34, R#46, R#48, and R#59 that were using this type of therapy mattress. The facility census was 89. The resident sample size was 25. Findings include: An observation was conducted on 8/7/18 at 3:15 p. m. of all resident's in the facility with air flow type mattresses after another surveyor noticed a dirty filter on the air mattress pump for R#25. This was observation was confirmed, and eight (8) beds were observed to have this type and/or brand of air mattress that had air flow pumps with external filters. Three (3) of the eight (8) mattress pumps had filters that were observed to be either clean or black in color; five (5) of the filters were light gray in color with a thick amount of gray appearing dust/dirt, with the potential to impede air flow. During an interview on 8/8/18 at 8:00 a. m. with Central Services Clerk HH in the Central Services (CS) office, she confirmed that resident air mattresses are ordered by her. She explained that she receives a call from the Supervisor to obtain an air mattress, then she contacts the bed mattress vendor, confirming that they have a contract with them for mattresses. She confirmed they set up the beds and do repairs on them. When asked, who is responsible for the filters on the air mattress pumps, she stated she would check into it, that her department doesn't do that. She stated that once the bed is set up, the nursing staff will report or call if any air flow problems come up. During an observational tour on 8/8/18 at 9:30 a. m. of resident rooms with the Maintenance Director, he confirmed that there are two types of air mattresses in use. He stated that their contract vendor provides the non-filter type of air flow mattress; but the filter type air flow mattress and pumps … | 2020-09-01 |
| 842 | 842 | PRUITTHEALTH - SAVANNAH | 115339 | 12825 WHITE BLUFF ROAD | SAVANNAH | GA | 31419 | 2019-05-24 | 908 | E | 1 | 0 | WK1Z11 | > Based on observation and staff interviews, the facility failed to maintain the handicapped access doors located at the facility's main entry which resulted in the failure of the automatic doors to open. This had the potential to affect all handicapped residents who were not physically able to open the doors manually to enter/re-enter the building. Findings include: On 5/21/19 at 10:30 a.m. three residents in wheelchairs were observed outside of the facility's main entrance way. Surveyor attempted to enter the facility using the handicapped entrance and depressed the access pad located on the right column of the main entry to the facility. The doors failed to open, and the access pad was depressed again. Resident (R) #4 advised the surveyor that the handicapped access pad was not working. Continued interview with R#4. at this time, revealed that the pad had not been working properly since the first time he came here about a year ago. Interview with an additional resident located outside the building, R#6, revealed that the doors had not been working properly for at least a year. They worked intermittently and were finally repaired about a month ago. That repair lasted a few days, then the doors went back to the way they worked before. If you pressed the pad a certain way, sometimes the doors would open. R#5 agreed that the doors had not been since he was admitted , and he had waited for staff to assistance to get back in. The residents stated that maintenance and other staff were already aware that there was a problem. Interview on 5/21/19 at 10:50 a.m. at the courtesy desk with Staff Member AA who revealed that he worked at the courtesy desk all day Monday through Friday and was aware that the pad used to open the double doors was not fully functional. Interview with Occupational Therapist (OT) HH on 5/22/19 at 10:40 a.m. in the therapy room who revealed that resident families had complained about the handicapped doors not working frequently but she had not reported the problem because everyone knew they weren'… | 2020-09-01 |
| 1785 | 1785 | PROVIDENCE HEALTHCARE | 115484 | 1011 SOUTH GREEN STREET | THOMASTON | GA | 30286 | 2018-04-27 | 908 | D | 0 | 1 | Z19411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff and resident interviews, the facility failed to maintain patient care equipment in safe operating condition for one bathroom affecting four of 32 residents. Findings include: During an observation on 4/24/18 at 3:38 p.m. of the bathroom between rooms [ROOM NUMBERS], revealed the toilet seat was not attached to the toilet base. Observation and interview with the Administrator on 4/24/18 at 3:45 p.m., the Administrator confirmed the toilet seat was broken. She stated she would have to take that bathroom out of service until the maintenance supervisor could repair it. During an interview with Resident (R) B on 4/24/18 at 3:55 p.m., the resident stated that he toilets himself and had told maintenance weeks ago that the seat was broken. He also revealed telling the housekeepers of the same issue. The resident does not recall their names. During an interview on 4/27/18 at 9:26 a.m. with Housekeeper AA revealed that when she found something broken she told the nurse. She revealed being unaware of a broken toilet seat between rooms [ROOM NUMBERS]. During an interview with Licensed Practical Nurse (LPN) BB on 4/24/18 at 4:00p.m. revealed that there was an application on their personal phones alerting the Maintenance Supervisor that something was broken. She further revealed not having the application on her phone, but could have told a co-worker who could have logged the complaint into the system. She revealed being unaware of a broken toilet seat and that the only resident that would have been able to tell anyone was R A of the four residents affected. During an interview on 4/27/18 9:50 a.m. with the Maintenance Supervisor revealed that staff were to use a program called TELS to alert him that a maintenance issue existed. The Maintenance Supervisor demonstrated using his phone the notification on 4/23/18 at 8:00 p.m. on the TELS program about the broken toilet seat between rooms 405-407. The person lodging the concern in… | 2020-09-01 |
| 1901 | 1901 | SANDY SPRINGS HEALTH AND REHABILITATION | 115504 | 1500 S JOHNSON FERRY ROAD | ATLANTA | GA | 30319 | 2018-10-25 | 908 | F | 0 | 1 | RVOF11 | Based on observations, interview, and record review, the facility failed to maintain essential equipment in the kitchen in a safe manner for residents and staff. Specifically, the dish machine, ice maker, and steamer were either not maintained or not operating properly creating safety hazards. Findings include: 1. (MONTH) 22, (YEAR) a. On 10/22/18 from 9:10 a.m. through 9:37 a.m. the initial kitchen inspection was conducted with the Food Service Supervisor (FSM). The ice machine had a plastic rectangular shield on the inside. The shield was positioned to hang from two screws, one on each top corner above the ice. One of the screws was missing and the corner of the shield on this side hung barely above the level of the ice. The FSM stated the plastic shield must have just come off over the weekend. The FSM stated he would notify maintenance of this and have it repaired. The FSM and surveyor inspected the dish machine area. There was a booster (type of water heater to heat rinse water to proper sanitizing temperatures for a high temperature dish machine) for the dish machine encased in a stainless-steel box with a lid. This was located below and adjacent to the dish machine. It was in an area that was wet from the water of the dish machine. The booster had a stainless-steel cover/lid to protect the contents of the box. The lid covering the box was rusted through; there was a rusted section of a couple inches on top of the cover to the box. In this rusted section, there was a hole in the top of the lid of approximately one-half inch in size in which water could enter the box where the heater and electrical components were located. In addition to the safety concern of water accessing the electrical components, potential issues were noted with the dishwasher temperatures as well as with the strength of the chemical sanitizer The FSM said he would follow up with the company who owned and serviced the dish machine, Ecolab, and would let the surveyor know what he found out. b. On 10/22/18 at approximately 3:30 p.m. the F… | 2020-09-01 |
| 2406 | 2406 | MEADOWBROOK HEALTH AND REHAB | 115561 | 4608 LAWRENCEVILLE HIGHWAY | TUCKER | GA | 30084 | 2018-12-14 | 908 | F | 0 | 1 | WTW011 | Based on observations, interview, and record review, the facility failed to maintain essential equipment in the kitchen in a safe manner for residents and staff. Specifically, the dish machine, and the three-compartment sink were either not maintained or not operating properly creating safety hazards. Findings include: During the initial tour on 12/11/18 at 9:20 a.m. with the Dietary Manager (DM) the surveyor inspected the dish machine area. The entire floor in the dish machine area was wet and some areas with puddles of water. As the dish rack went thru the wash cycle of the it was noted the machine had a surge of water coming from underneath the machine onto the floor. Also, during the initial tour, the entire floor area in front and surrounding the three-compartment sink was observed to have an accumulation of water. An additional observation on 12/14/18 at 9:08 a.m. revealed the Dietary Aide AA running dishes thru the dish machine. Underneath the dish machine is the temperature gauge that is housed in a steel box. Connected under that steel box are white pipes that are connected to two other steel boxes under the temperature gauge. These steel boxes lead to the floor drain. When the machine went thru the wash and rinse cycles instead of the water draining thru the steel boxes to the drain in the floor, the water over flowed onto the floor creating water puddles in dish machine room; the overflowed water spilled into the area where the clean dishes were stored, ice machine, reach in cooler for milk and supplements. Observation of the three-compartment sink on 12/14/18 at 9:20 a.m. revealed staff member had finished washing and rinsing pots and pans and was cleaning out the sink. The entire floor in front of the three -compartment sink was wet. Closer observation underneath sink revealed the piping connected to the sink was discolored with peeling paint. Water was dripping from the piping coming from the sink. An interview with Dietary Aide (DA) AA on 12/14/18 at 9:30 a.m. near the dish machine revealed there h… | 2020-09-01 |
| 2603 | 2603 | HEALTHCARE AT COLLEGE PARK, LLC | 115579 | 1765 TEMPLE AVENUE | COLLEGE PARK | GA | 30337 | 2018-03-23 | 908 | D | 0 | 1 | QDVD11 | Based on observation and staff interviews, the facility failed to perform routine maintenance per facility policy on oxygen (O2) concentrators for three residents, Resident #74 (R #74), Resident #77 (R #77) and Resident #85 (R #85). Findings include: 1. Observation of R #74 on 3/19/2018 at 9:53 a.m. noted the O2 concentrator without the air filter. Observation of R #74 on 3/20/2018 at 10:53 a.m. noted the O2 concentrator without the air filter. Observation of R #74 on 3/21/2018 at 10:20 a.m. noted the O2 concentrator without the air filter. Observation of R #74 on 3/22/2018 at 1:40 p.m. noted the O2 concentrator without the air filter. 2. Observation of R #77 on 3/19/2018 at 3:00 p.m. noted the water level in the disposable O2 humidifier bottle was below the refill line. The disposable O2 humidifier bottle, dated 3/15/18, showed the date it was replaced. R #77 was wearing O2 via nasal cannula (NC) at three liters per minute (3 LPM) in no apparent distress. Observation of R #77 on 3/21/2018 at 12:30 p.m. noted the disposable O2 humidifier bottle was empty. R #77 was wearing O2 via NC 3 LPM in no apparent distress. Observation of R #77 on 3/23/2018 at 8:28 a.m. noted the disposable O2 humidifier bottle was empty. R #77 was wearing O2 via NC 3 LPM in no apparent distress. 3. Observation of R #85 on 3/19/2018 at 1:30 p.m. noted the water level in the disposable O2 humidifier bottle was below the refill line. The disposable O2 humidifier bottle dated 3/15/18, showed the date it was replaced. R #85 was wearing O2 via NC 3 LPM. Observation of R #85 on 3/20/2018 at 11:00 a.m. noted the water level in the disposable O2 humidifier bottle was below refill line. R #85 was wearing O2 via NC 3 LPM in no apparent distress. Observation of R #85 on 3/22/2018 at 5:00 p.m. noted the disposable O2 humidifier bottle was empty. R #85 was wearing O2 via NC 3 LPM in no apparent distress. Observation of R #85 on 3/23/2018 at 8:43 a.m. noted the disposable O2 humidifier bottle was empty. R #85 was wearing O2 via NC 3 LPM in no apparent di… | 2020-09-01 |
| 3690 | 3690 | SMITH MEDICAL NURSING CARE CTR | 115691 | 501 EAST MCCARTY ST | SANDERSVILLE | GA | 31082 | 2018-10-04 | 908 | E | 1 | 1 | 1T3M11 | > Based on observation during laundry and an environmental tour with facility staff, the facility failed to maintain a clean dryer in the laundry room, resulting to accumulation of lint at the back of laundry dryer and the facility failed to ensure that essential equipment in the kitchen was in working order. The facility census was 50. The findings include: Observation of the laundry room, with staff, on 10/3/18 at 9:20 a.m. revealed facility has one large washing machine and one large dryer for all residents' laundry. Observation of the back of the dryer revealed an accumulation of lint, and the area was dirty. An interview with a laundry aide on 10/3/18 at 9:40 a.m. revealed that she cleans and empties the front of the dryer daily but does not clean the back of the dryer as she is unable to access this area. During a tour with the Maintenance Staff (MS), Fire Marshall (FM), Laundry Aide (LA), Director of Nursing (DON) and Administrator on 10/3/18 between 9:20 a.m.; all expressed concern that the laundry dryer was dirty with accumulation of lint, which they see as a fire hazard. Review of the Facility Policies and Procedures (undated but signed by the Administrator on 10/4/18) titled Policy On Washing Linen And Clothing revealed that Dryer lint filters should be cleaned at least once per day or as specified by the manufacturer. During an initial tour of the kitchen and an interview with the Dietary Manager (DM) on 10/1/18 at 10:22 a.m. observation of the stove revealed that one burner was not working and another burner was missing the knob. The DM stated she did not know how long it had been like that. Observation of the double oven revealed that one side not functioning. The door on the left of the oven had a pad lock on it to keep the door from falling off. When asked if the malfunctioning areas affects the staff's ability to prepare meals the DM stated no. The Maintenance Director was not available for interview. An interview on 10/2/18 at 1:50 p.m. with Registered Dietician (RD) revealed that she was not aw… | 2020-09-01 |
| 41 | 41 | NORTH DECATUR HEALTH AND REHABILITATION CENTER | 115012 | 2787 NORTH DECATUR ROAD | DECATUR | GA | 30033 | 2018-12-06 | 883 | D | 0 | 1 | 46UW11 | Based on resident interviews, staff interviews record review and policies titled Immunizations: Influenza (Flu) Vaccination of Residents and Staff and Standing Orders for Administering Pneumococcal Vaccines to Adults; the facility failed to document rationale of resident (R)#24 refusal of Flu and provide vaccine information statement (VIS) and offering of Pneumococcal vaccine and VIS to R# B. Sample was 2 of 5. Findings include; During review of facility's infection control processes on 12/6/18 at 11:41 a.m. unable to locate documentation for R#24 regarding refusal of flu vaccine. Also, unable to locate documentation that education via the VIS as recommended by the Center for Disease Control (CDC) was provided to resident and /or family member. Further review of R#24's minimum data set (MDS) which a is part of the United States federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes; assessed R#24 with a Brief Interview for Mental Status (BIMS) of two. BIMS is a test given by medical professionals that helps determine a patient's cognitive understanding. A score of 00-07 indicates severe cognitive impairment. R#24 has family member who is the responsible party (RP). An interview with Director of Nursing (DON), with Corporate representative present, Director of Clinical Services, on 12/6/18 at 12:00 p.m. revealed that the electronic medical record (EMR) should show that the resident and /or RP was provided the VIS education. DON attempted to evidence the education had been given. Upon continued review of the R#24's record DON was unable to confirm the VIS education was provided; Nor was there evidence of a nurse's note indicating VIS education had been provided or discussed. On 12/6/18 at 12:55 p.m. Corporate representative, Director of Clinical Services provided a document dated 12/6/18 indicating the resident's RP had been contacted to discuss administration of the flu vaccine. The RP refused however; the reason for refusal not documented nor was it cle… | 2020-09-01 |
| 147 | 147 | BROWN HEALTH AND REHABILITATION | 115090 | 545 COOK STREET | ROYSTON | GA | 30662 | 2018-08-09 | 883 | D | 0 | 1 | ST5L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interviews and review of the facility policy titled Immunizations: Pneumococcal Vaccination (PPV) of Residents, the facility failed to offer the pneumonia vaccine to two residents (R) R#15 and R#40 of five residents reviewed for the pneumonia vaccine. The sample size was 34 residents. Findings include: Review of the clinical record for R#15 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. There was no indication that the pneumonia vaccine was offered or administered to the resident. Review of the clinical record for R#40 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. There was no indication that the pneumonia vaccine was offered or administered to the resident. Review of the facility policy titled Immunizations: Pneumococcal Vaccination (PPV) of Residents reviewed and updated (MONTH) (YEAR), procedural guidelines state that all residents of our facility should receive the Pneumococcal vaccine if they are [AGE] years of age or older or younger than [AGE] years with underlying conditions that are associated with increase susceptibility to infection or increase risk for serious disease and its complications. Each residents Pneumococcal immunization status will be determined upon admission or soon afterwards, and will be documented in the resident's medical record. All residents with undocumented or unknown Pneumococcal vaccination status will be offered the vaccine. Informed consent in the form of a discussion regarding risk and benefits of vaccination will occur prior to vaccination. Interview on 8/8/18 at 11:35 a.m. with Infection Control nurse, stated she only works 16 hours per week. She stated that for the influenza/Pneumonia vaccinations, she gets consents for each residents. She was sending letters to the family and the family was to contact the facility for refusal. She stated that she was unable to find any documentation… | 2020-09-01 |
| 404 | 404 | HARBORVIEW SATILLA | 115265 | 1600 RIVERSIDE AVE | WAYCROSS | GA | 31501 | 2019-02-21 | 883 | E | 0 | 1 | L5UF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and staff interviews, the facility failed to provide annual education for immunizations for four of five residents in Building [NAME] The census was 88 residents. Findings include: A review of the Influenza Prevention policy (undated), revealed; It is the policy of Long-Term Care to reduce the risk of influenza infection and transmission within the facilities. Page 1, item #2 indicates Education pertaining to the epidemiology, transmission and [DIAGNOSES REDACTED]. Page 2, item#1 indicates on admission, the resident/responsible party will be made aware of the availability of the influenza vaccination. Page 2, item#3 indicates Residents will be vaccinated annually for influenza, unless contraindicated. Interview on 2/19/19 at 1:25p.m. an interview with Infection Preventionist (IP), revealed the undated policy is the most current version, she dated and signed the current version. A review of Influenza vaccine policy with a revised date of 2012 from 2001 MED-Pass revealed; All residents will be offered the influenza vaccine annually and the facility shall provide pertinent information. Item #4 revealed prior to the vaccination, the resident will be provided information and education, and provision of such education shall be documented in the medical record. A review of the admission packet revealed a document labeled Harborview Health Systems labeled as item#1, revealed residents receive a written notice upon admission from Centers for Disease Control Vaccine Information. The admission packet contains Resident Immunization Consent or Refusal Form indicating the facility provides information regarding the risks and benefits of the influenza and pneumococcal immunization vaccines. Vaccine information statement, a 4-page document from CDC is included in the admission packet. 1. A review of the medical record for resident (R)#46 revealed an Informed Consent to Receive Vaccines signed and dated 8/1/14. An interview on 2/21/19 … | 2020-09-01 |
| 1655 | 1655 | WESTBURY MCDONOUGH, LLC | 115463 | 198 HAMPTON STREET | MCDONOUGH | GA | 30253 | 2019-01-31 | 883 | D | 0 | 1 | 4NRX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide evidence that education for the benefits and potential side effects was provided for four residents (R) (R#100, R#93, R#105, and R#117), of five resident's reviewed, prior to the residents consenting to or refusing both the influenza and pneumococcal vaccinations. The sample size was 55 residents. Findings include: 1. Review of R#100's Pneumococcal and Influenza Vaccination Consent Form dated 10/9/18 revealed that the responsible party (RP) indicated for R#100: YES, I would like to receive the Influenza Vaccination. I DO NOT wish to receive the Pneumococcal Vaccination. There was no indication on this consent form that education for the risks and benefits of the vaccines was provided. Review of an electronic Update Immunization record for the influenza immunization revealed that R#100 consented to and received the vaccine on 10/11/18. The section on this record that education was provided to the resident/family was left blank. Review of an electronic Update Immunization record dated 3/26/16 for the [MEDICATION NAME] vaccine revealed that R#100 was not eligible for the vaccine because he had it previously on 8/1/15. 2. Review of R#93's Pneumococcal and Influenza Vaccination Consent Form dated 10/9/18 revealed that the responsible party (RP) indicated for R#93: YES, I would like to receive the Influenza Vaccination. YES, I would like to receive the Pneumococcal Vaccination. There was no indication on this consent form that education for the risks and benefits of the vaccines was provided. Review of an electronic Update Immunization record for the influenza immunization revealed that R#93 consented to and received the vaccine on 10/11/18. The section on this record that education was provided to the resident/family was left blank. Review of an electronic Update Immunization record for the [MEDICATION NAME] vaccine revealed that R#93 consented and received the vaccine on 1… | 2020-09-01 |
| 2116 | 2116 | SOCIAL CIRCLE NSG & REHAB CTR | 115532 | 671 NORTH CHEROKEE ROAD | SOCIAL CIRCLE | GA | 30025 | 2019-01-26 | 883 | D | 0 | 1 | SDK511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide evidence that education was provided for one resident (R) (R#52) prior to the resident refusing both the influenza and pneumococcal vaccines. Five residents were reviewed for the provision of immunizations, and the sample size was 60 residents. Findings include: Review of R#52's Quarterly Minimum (MDS) data set [DATE] revealed that she had a Brief Interview for Mental Status (BIMS) score of 10 (a BIMS score of 8 to 12 indicates moderate cognitive impairment). Review of an Update Immunization report dated 7/10/18 revealed that the family refused the [MEDICATION NAME] vaccine for R#52. Review of the Update Immunization report dated 10/10/18 revealed that R#52 refused the Influenza vaccine. The section Education Provided To Resident/Family was left blank on both of the immunization reports. During interview with the Licensed Practical Nurse Infection Control Nurse on 1/26/19 at 2:51 p.m., she verified that there was no documentation that education was provided to either the responsible party or resident to ensure they were aware of the risks and benefits of the vaccines so that an informed decision could be made. Review of the facility's Vaccination of Residents policy revised (MONTH) (YEAR) revealed: Prior to receiving vaccinations, the resident or legal representative will be provided information and education regarding the benefits and potential side effects of the vaccination. Provision of such education shall be documented in the resident's medical record. | 2020-09-01 |
| 2486 | 2486 | RIVER TOWNE CENTER | 115566 | 5131 WARM SPRINGS RD | COLUMBUS | GA | 31909 | 2017-12-22 | 883 | D | 0 | 1 | ZNPV11 | Based on medical record review, staff interviews, review of the facility policy titled, Pneumococcal Vaccine the facility failed to offer the pneumonia vaccine to five of five residents (R) #4, R #86, R #92, R #115, R #235, that were reviewed for the pneumonia vaccine. The sample size was 39 residents Findings include: Medical record revealed that residents (R) #4, R #86, R #92, R #115, R #235) did not have a screening, education form or consent forms for the pneumonia vaccine. Interview on 12/21/17 at 3:30 p.m. in the office of the Infection Control Practitioner (ICP) RN revealed that there was not any evidence of any documentation available for the pneumococcal vaccine tracking and monitoring, and that the facility does not offer the pneumonia vaccination on admission or give education on the vaccination to the residents or resident's representatives. Further interview with ICP RN revealed that it (the pneumonia vaccine) has not been offered in the 1 1/2 years that she has been in this position. ICP RN revealed that this has been discussed with the Medical Director previously and determined that this needs to be put in place. ICP RN further revealed that she thinks it has not been done due to payment issues. Further interview with ICP RN revealed that the vaccines are discussed at the 72-hour meeting, but nothing is documented in the charts and that education or consent forms are not completed. Interview on 12/22/17 at 9:55 a.m. in the Administrator's office with the Administrator revealed that she has been in the interim position since (MONTH) (YEAR) and became full-time on 10/23/17. The Administrator stated she does not know anything about the pneumonia vaccine process in this facility. Review of the facility's policy titled Pneumococcal Vaccine version 2.0 requires that all residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Requirements under subparts include: 1. Prior to or upon admission, residents will be assessed for eligibility to receive the pneumoco… | 2020-09-01 |
| 2895 | 2895 | PINEWOOD NURSING CENTER | 115607 | 433 NORTH MCGRIFF STREET | WHIGHAM | GA | 39897 | 2019-11-22 | 883 | D | 0 | 1 | IUU711 | Based on record review, staff interviews and review of the facility policy titled, Pneumococcal Vaccine the facility failed to offer and/or document administration of the pneumonia vaccine for two of five residents (R) (R#26, R#320) reviewed for Pneumococcal immunizations. Findings include: Review of the facility policy titled, Pneumococcal Vaccine dated revised (MONTH) (YEAR), revealed: All residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. 2. Assessments of pneumococcal vaccination status will be conducted within five (5) working days of the resident's admission if not conducted prior to admission. 4. Pneumococcal vaccines will be administered to residents (unless medically contraindicated, already given, or refused) per the facility physicians-approved pneumococcal vaccination protocol. 1. Review of the Consent for Flu and Pneumococcal Vaccines: for R#26 revealed the resident signed the consent form on 10/8/19 indicating permission to receive the flu and pneumonia vaccine. The form indicated he received the flu vaccine on 10/8/19. A record review indicated he did not receive a pneumococcal vaccine. Review of R#26 Declination of Influenza or Pneumococcal Vaccination form revealed it was not completed. Review of R#26 electronic record, Medication Administration Record (MAR) and paper record did not indicate a pneumococcal vaccine was given. 2. Review of the Consent for Flu and Pneumococcal Vaccines for R#320 revealed the resident signed the consent form on 10/9/19 indicating permission to receive the flu and pneumonia vaccine. The form indicated she received the flu vaccine on 10/9/19. A record review indicated he did not receive a pneumococcal vaccine. Review of R#320 Declination of Influenza or Pneumococcal Vaccination form revealed it was not completed. Review of R#320 electronic record, MAR and paper record did not indicate a pneumococcal vaccine was given. An interview on 10/30/19 at 3:18 p.m. with the Director of Nursing (DON) revealed she would expect t… | 2020-09-01 |
| 2916 | 2916 | CANDLER SKILLED NURSING UNIT | 115610 | 5353 REYNOLDS STREET | SAVANNAH | GA | 31405 | 2019-06-06 | 883 | B | 0 | 1 | BC0E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the facility policy titled Standing Orders for Influenza Vaccine Protocol, and staff interview, the facility failed to provide documented evidence that education/information was provided to residents prior to being offered the flu or pneumonia vaccine for five residents (R) (#800, #801, #112, #113, and #114) of 13 sampled residents. Findings include: Review of the clinical record revealed R#800 was admitted to the facility on [DATE]. It was documented in the clinical record that the patient/caregiver refused the flu vaccine. Further review of the clinical record revealed no documented evidence that the resident received education/information prior to being offered the flu vaccine. Review of the clinical record revealed R#801 was admitted to the facility on [DATE]. It was documented in the clinical record that the patient/caregiver refused the flu vaccine. Further review of the clinical record revealed no documented evidence that the resident received education/information prior to being offered the flu vaccine. Review of the clinical record revealed R#112 was admitted to the facility on [DATE]. It was documented in the clinical record that the patient/caregiver refused the pneumonia vaccine. Further review of the clinical record revealed no documented evidence that the resident received education/information prior to being offered the pneumonia vaccine. Review of the clinical record revealed R#113 was admitted to the facility on [DATE]. It was documented in the clinical record that the patient/caregiver refused the pneumonia vaccine. Further review of the clinical record revealed no documented evidence that the resident received education/information prior to being offered the pneumonia vaccine. Review of the clinical record revealed R#114 was admitted to the facility on [DATE]. It was documented in the clinical record that the patient/caregiver refused the pneumonia vaccine. Further review of the clinical re… | 2020-09-01 |
| 3094 | 3094 | WYNFIELD PARK HEALTH AND REHABILITATION | 115625 | 223 W.THIRD AVENUE | ALBANY | GA | 31701 | 2018-11-02 | 883 | D | 0 | 1 | BP8G11 | Based on record reviews, interviews and review of the facility policy Immunization of Residents the facility failed to screen and educate two out of five residents for the pneumococcal vaccine. Findings include: A review of the facility policy Immunization of Residents dated (YEAR), reveals residents will be screened and offered the pneumococcal vaccine, as appropriate. During the random review of the immunization records reveal: R#50 Had flu vaccine 10/17/18. No record of pneumonia vaccine found in electronic chart. R#179 Had flu vaccine 10/13/17. No record of pneumonia vaccine found in electronic chart. R#136 Had flu vaccine 10/13/18. No record of the pneumonia vaccine found in electronic chart. R#103 Had flu vaccine 10/18/18. No record of the pneumonia vaccine found in electronic chart. R#20 Had flu vaccine 10/31/17. Pneumonia vaccine given 5/5/15. During the random review for vaccine screening for infection prevention, it was discovered that two (R#136 and R#179) of five residents reviewed did not receive screening and education for the pneumococcal vaccine. Both residents were eligible for the vaccine. On 11/1/18, 1:00 p.m., the Administrator agrees the two residents should have been screened and educated regarding the pneumococcal vaccine. She provided copies of the Georgia Registry of Immunization Transactions and Services (GRITS) report for the two residents. The information in the reports support the findings that the two residents should have been screened and offered education regarding the pneumococcal vaccine. | 2020-09-01 |
| 3184 | 3184 | RIVER BROOK HEALTHCARE CENTER | 115635 | 390 SWEAT STREET | HOMERVILLE | GA | 31634 | 2018-07-19 | 883 | D | 0 | 1 | MS7111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interviews and review of the facility policy titled Infection Prevention, the facility failed to offer the pneumonia vaccine to one resident (R#60) of five residents reviewed for the pneumonia vaccine. The sample size was 30 residents. Findings include: Review of the medical record revealed that resident (R)#60's family member was educated about vaccination and signed the consent for the resident to receive the pneumonia vaccine on admission date of [DATE]. Review of Immunization Record revealed that the pneumonia vaccine was not given. Review of immunization tab in the electronic medical records documented that no immunizations were administered. Review of the 60-day Minimum Data Sets ((MDS) dated [DATE] revealed that R#60 had a Brief Interview for Mental Status (BIMS) score of 99 indicating that the resident was not able to complete the assessment. The MDS documented that the resident had both short-term and long-term memory problems. Review of Medication Administration Records back to (MONTH) (YEAR) revealed no documentation that R#60 received the pneumonia vaccine. Interview on 7/19/18 at 10:33 a.m. with the Licensed Practical Nurse (LPN) and Infection Control Nurse DD revealed that she was trying to locate proof of pneumonia vaccination. Interview on 7/19/18 at 11:55 a.m. with LPN Infection Control DD revealed that she had reviewed the resident's Medication Administration Record [REDACTED]. Interview on 7/19/18 at 12:59 p.m. with the Administrator revealed that her expectation was that on admission the resident's wishes regarding immunization were clarified. If they wish to receive the vaccines the physician was to be contacted and an order obtained and the vaccine administered. She also stated that the infection control nurse called the hospital and hospital staff stated that R#60 received the vaccine but they were having difficulty showing proof of immunization. Review of the facility policy reveal… | 2020-09-01 |
| 3210 | 3210 | FOUNTAIN BLUE REHAB AND NURSING | 115636 | 3051 WHITESIDE ROAD | MACON | GA | 31216 | 2018-03-01 | 883 | E | 0 | 1 | MRLK11 | Based on record review and staff interview, the facility failed to provide documentation of the administration of the (YEAR)-2018 influenza vaccine for three of five residents (R) reviewed (R #4, R #46, and R #64), who had consented to receive it. The sample size was 29 residents. Findings include: Review of Influenza Immunization Informed Consents for R #4 dated 9/21/16; for R #64 dated 10/18/17; and for R #46 dated 10/28/17 revealed that either the resident or responsible party acknowledged that they had received education on the risks and benefits associated with the influenza vaccine, and consented to receive it. Review of these residents' clinical records revealed that there was no evidence that they received the influenza vaccine as requested in the (YEAR)-2018 influenza season. During interview with interim Director of Nursing (DON) CC and the Administrator on 3/1/18 at 2:37 p.m., they verified that there was no documentation that residents #4, #64, and #46 received the influenza vaccine in (YEAR) or (YEAR). The Administrator stated during further interview that the facility had a change in their documentation system the previous year, and the nurses did not always document correctly. The Administrator further stated that the facility had ordered enough of the influenza vaccine for all of the residents, and that the vaccine was gone so she thought everybody had received it. Review of the facility's undated Immunization Policy & Procedure revealed: Upon admission, the immunization record will be completed and filed in the resident's chart. Immunizations will be administered as requested. MAR (Medication Administration Record) documentation follow-up will ensure adequate monitoring and documentation of this procedure. Review of the facility policy Immunizations: Influenza (Flu) Vaccination of Residents, Staff and Volunteers (revised 2009) revealed the following: Current and newly admitted residents, all staff, and volunteers will be offered the influenza vaccine from (MONTH) of each year through the end of (… | 2020-09-01 |
| 3363 | 3363 | LIFE CARE CENTER | 115654 | 176 LINCOLN AVE | FITZGERALD | GA | 31750 | 2018-09-13 | 883 | E | 0 | 1 | H1YP11 | Based on observation, interview and record review, the facility failed to offer and/or document administration of the pneumonia vaccine on four out of six residents (R#26, R#59, R#91 and R#88) and the flu vaccine for one resident (R#91) out of six residents. The census sample size was 51. Findings include: 1. Review of medical record for R# 26 revealed that consents for both flu and pneumonia vaccine were signed. Review also revealed that there was no documentation to show that the pneumonia vaccine was offered or given to the resident. Interview on 09/12/18 at 10:30 a.m. with RN Supervisor/Infection Control Nurse GG revealed that the resident refused the pneumonia vaccine by history at the hospital prior to admission to the facility. During interview the surveyor pointed out that the consent was signed at the facility after refusing the vaccine at the hospital. Interview with RN Supervisor/Infection Control Nurse GG confirmed that there was no documentation that the vaccine was offered at the facility. She stated that the nurses working the medication cart for that hall were responsible for offering and documenting vaccines on admission. 2. Review of the medical record for R# 59 revealed that there was a consent signed for the pneumonia vaccine on 10/26/17 but there was no documentation in the medical record of the pneumonia vaccine being offered or given to the resident. Interview on 9/12/18 at 10:31 a.m. with[NAME]Greene, RN Supervisor/Infection Control Nurse confirmed that there was no documentation to show that the resident was offered or given a pneumonia vaccine. 3. Review of medical record for R# 91 revealed that there was a signed consent for both the flu and pneumonia vaccine dated 11/7/16. Review revealed no documentation of the resident being offered or given to the resident. Interview on 9/12/18 at 12:50 p.m. with RN Supervisor/Infection Control Nurse GG confirmed that there was no documentation to show that the resident was offered a pneumonia or influenza vaccine. 4. Review of the medical record fo… | 2020-09-01 |
| 3622 | 3622 | HEARDMONT HEALTH AND REHABILITATION | 115685 | 1043 LONGSTREET ROAD | ELBERTON | GA | 30635 | 2020-01-09 | 883 | E | 0 | 1 | RJJ511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, and review of facility policy titled Vaccination of Residents, the facility failed to vaccinate an eligible resident with the influenza vaccine (Resident (R) #252) and failed to have facility personnel administer and document that the residents received the influenza vaccine in their medical records. This affected five of seven residents reviewed for immunizations (R#22, R#23, R#33 and R#46). Findings include: 1. A review of the facility Roster/Sample Matrix dated/printed 12/15/19, revealed that R#252, was admitted after influenza vaccines were administered at the facility, and requested to receive the influenza vaccine on admission. A review of R#252's medical record revealed a document titled Precautionary Injections Consent under which the family has indicated they 'voluntarily give consent for the influenza vaccine to be given.' This document is signed by the responsible party and dated 11/21/19. An post survey telephone interview with the Administrator and the Director of Nursing (DON) on 1/9/2020 at 2:31 p.m. revealed that R#252 did not receive the flu vaccine as requested. The DON revealed that after the contract pharmacy came into the facility to administer the flu vaccine that any new admissions, who requested the flu vaccine, would prompt nursing to notify the contract pharmacy of the request. The DON revealed that they had so many new admissions during late (MONTH) that the request just fell through the cracks. She confirmed that R#252 did not receive the flu vaccine as requested. A review of the medical records on R #22, R #23, R #33 and R #46 revealed no evidence of documentation related to the influenza vaccine being administered. Review of the Resident Flu Vaccine Roster for 2019 revealed that 17 of 36 residents that requested the flu vaccine only had a temperature recorded on the Flu Vaccine Roster and that 19 of 36 resident had a temperature and a site (marked left or right) but witho… | 2020-09-01 |
| 4000 | 4000 | ADVANCED HEALTH AND REHAB OF TWIGGS COUNTY | 115727 | 113 SPRING VALLEY ROAD | JEFFERSONVILLE | GA | 31044 | 2018-12-06 | 883 | D | 0 | 1 | ODI611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on residents' medical record review and facility staff interviews the facility failed to document influenza and pneumococcal immunizations were received by two (Resident (R)#20 and R#298) of six residents whose records were reviewed for administration of influenza and pneumococcal immunizations during the (YEAR)/2019 flu season. R#20 and R#298 consented to receive the influenza and pneumococcal immunizations during this flu season. Findings include: 1. Review of the face sheet in the medical record for R#20 revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #20 is his own responsible party and makes his own medical decisions. He has not been deemed incompetent. Review of the resident's Significant Change Minimum Data Set ((MDS) dated [DATE] revealed that R#20 has a BIMS (brief interview for mental status) score of 12/15. Review of the medical record for R#20 revealed a signed consent, dated 9/12/18, to receive the influenza and pneumococcal immunizations. Review of the medication administration record (MAR) and immunization record for R#20 revealed he had not received the influenza and pneumococcal immunizations as of 12/4/18. Review of the monthly Physician's Order for R#20 for the months of (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR) revealed a Physician's Order that the resident may have influenza immunization and an additional order that resident may have the pneumococcal immunization An interview on 12/4/18 at 10:30 a.m., with the Assistant Director of Nursing (ADON), at the back nurses' station, she stated R#20 had not received the immunizations he consented to because the Hospice nurse instructed her not to. There was no documentation from the ADON or the Hospice nurse stating not to administer the immunizations. A phone call to the Hospice nurse on 12/4/18 at 10:40 p.m. at the back nurses' station from the ADON confirmed the Hospice nurse did not document R#20 should not … | 2020-09-01 |
| 896 | 896 | PRUITTHEALTH - TOCCOA | 115345 | 633 FALLS ROAD | TOCCOA | GA | 30577 | 2018-07-24 | 881 | F | 1 | 0 | H8KB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, review of the policy titled Antibiotic Stewardship Program and staff interviews, the facility failed to perform analysis of antibiotic surveillance data and document follow-up measures in response to the data for six of six months of (YEAR) infection control data reviewed (January (YEAR) through (MONTH) (YEAR)). (Refer F880) Findings include: Review of the facility policy titled Antibiotic Stewardship Program dated 11/28/17, revised 6/13/18 documented As part of the Infection Prevention and Control Program,[NAME]Health will implement and maintain and Antibiotic Stewardship Program (ASP). The goal of ASP is to promote appropriate use of antibiotics to treat infections and reduce possible adverse events associated with antibiotic use. Antibiotic Time Out- Reassessment of the continuing need and choice of antibiotics when the clinical picture is clearer and more diagnostic information is available. The antibiotic time out should be performed within 2-3 days after antibiotics are initiated. Indication- a valid sign, symptom, or [DIAGNOSES REDACTED]. The ASP Team will be established to be accountable for promoting and overseeing antibiotic stewardship activities. The ASP Team will monitor and review the following data: Infections and antibiotic usage patterns on a regular basis, Antibiogram reports for trends of antibiotic resistance, Antibiotic resistance patterns for multidrug resistant organisms (e.g.[MEDICAL CONDITION], VRE, ESBL, CRE, etc.), Number of antibiotics prescribed (e.g. days of therapy) and the number of residents treated each month, include a separate report for the number of residents on antibiotics that did not meet criteria for active infection. ACTION: a) All[NAME]Health facilities will implement evidence-based ASP protocols to help guide optimal decisions for therapy and to ensure appropriate antibiotic selection. b) An antibiotic time-out (ATO) will be performed after the initiation of all antibiotic… | 2020-09-01 |
| 1046 | 1046 | MACON REHABILITATION AND HEALTHCARE | 115362 | 505 COLISEUM DRIVE | MACON | GA | 31217 | 2019-07-03 | 881 | E | 0 | 1 | EU2V11 | Based on review of the facility policy titled Antibiotic Stewardship and staff interviews, the facility failed to establish an Antibiotic Stewardship Program that included antibiotic use protocols and a monitoring system to track and trend antibiotic use. The facility census was 82 residents. Findings include: During a review of the facility policy titled Antibiotic Stewardship revised 2/2/18 revealed a policy statement: antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program. Standards of Practice: 1. The purpose of our Antibiotic Stewardship Program is to monitor the use of antibiotics in our residents. The policy explains the orientation, training and education, prescriber information to be provided, and other pertinent information related to monitoring antibiotics. During an interview on 7/02/19 at 10:20 a.m., the Administrator revealed there has been no Antibiotic Stewardship Program functioning since (MONTH) (YEAR). The Administrator stated she was notified by RN AA upon hire on 5/31/19 that no Antibiotic Stewardship Program was in place for the facility. The Administrator stated she does not know why there was no program in place from (MONTH) (YEAR) through (MONTH) 2019 so that tracking and trending of antibiotic use could be monitored. She confirmed that from 3/1/19 (her hire date) to 5/31/19, she was unaware that there was not a functioning Antibiotic Stewardship Program in the facility. She confirmed but could not say why no actual collection of data or trending was done from 5/31/19 through 7/2/19 by the nursing staff. During an interview on 7/2/19 at 10:30 a.m., RN AA stated she alerted the Administrator when she first started that there was no information on an Antibiotic Stewardship Program in the facility. She stated that since the beginning of (MONTH) 2019 they have just been getting things together and no action has been taken thus far related to collection of data or the trending of antibiotic use in the facility. | 2020-09-01 |
| 1207 | 1207 | PRUITTHEALTH - MONROE | 115379 | 4796 HIGHWAY 42 NORTH | FORSYTH | GA | 31029 | 2019-10-10 | 881 | E | 0 | 1 | W78L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide evidence of a process for periodic review of antibiotic prescribing practices, and to document follow-up measures in response to the data for nine of nine months of 2019 infection control data reviewed (January 2019 through (MONTH) 2019). This had the potential to affect any resident who was prescribed an antibiotic. The facility census was 70 residents. Findings include: Review of the facility's 2019 Infection Monitoring Logs revealed that they captured information monthly that included the resident's name; room number; date of S/S (signs and symptoms); I/C (infection control) Cat. (category); and ABT Tx (antibiotic treatment). Further review of these monthly line listings revealed that they did not contain information such as the resident's signs and symptoms; if a culture or x-ray was done; and if the organism was sensitive to the ordered antibiotic. During interview with the Registered Nurse (RN) Infection Control Nurse on 10/10/19 at 11:43 a.m., she stated that she did not use any infection assessment tools to assess the minimum criteria for initiation of antibiotics. She further stated that she had been told about the McGeer criteria and it was available in the computer, but that she had never used it before. She further stated that the Physician and nurses would look at the resident's signs and symptoms, vital signs, lab reports, etc. before ordering an antibiotic, and that she ensured this was done but had no documentation of this. She stated that she would call the Physician if she had a concern about the appropriateness of an ordered antibiotic, and that he would sometimes change it. The Infection Control Nurse stated during continued interview that the pharmacist did a monthly report that included antibiotic usage which was giving to the DHS (Director of Health Services), but that the pharmacist did not come to QAPI meetings. During interview with the Admini… | 2020-09-01 |
| 1476 | 1476 | ROSWELL NURSING & REHAB CENTER | 115422 | 1109 GREEN STREET | ROSWELL | GA | 30075 | 2020-02-27 | 881 | D | 0 | 1 | HR4Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, document review and staff interview, the facility failed to develop and implement a comprehensive plan to monitor the use of antibiotics for one (Resident (R)84) of six residents reviewed for unnecessary medications. Findings include: Review of R84's face sheet revealed R84 was readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the hospital's Discharge Document indicated that Rifaximin (an antibiotic used to decrease the [MEDICAL CONDITION] load in certain illnesses/diseases) 550 mg (milligrams) through a gastrostomy tube (a tube placed to administer medications and nutrition directly into the stomach) twice a day. The hospital discharge document lacked documentation of an indication for the use of the medication Rifaximin. Upon re-admission to the facility, review of the monthly physician orders [REDACTED]. Interviewed on 2/27/20 at 2:15 PM, the Director of Nursing (DON) stated the medication Rifaximin is given to treat R84's liver disease and is not for the treatment of [REDACTED]. The DON stated that staff selected the wrong [DIAGNOSES REDACTED]. Review of the facility's infection logs dated (MONTH) 2019 and (MONTH) 2020 revealed R84 was reviewed by Infection Preventionist/LPN. The [DIAGNOSES REDACTED]. Interview with the Infection Preventionist/LPN on 2/27/20 at 12:46 PM confirmed R84 was given Rifaximin prior to hospital admission and since the resident returned for the hospital. The Infection Preventionist/LPN stated R84 was receiving the Rifaximin for the treatment of [REDACTED]. | 2020-09-01 |
| 2353 | 2353 | MAGNOLIA MANOR OF MIDWAY | 115553 | 652 NORTH COASTAL HIGHWAY 17 | MIDWAY | GA | 31320 | 2019-03-15 | 881 | F | 0 | 1 | QVLL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, review of the facility policy titled, Antibiotic Stewardship and review of the facility policy titled, Antibiotic Stewardship- Staff and Clinician Training and Roles the facility failed to establish an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use. The facility failed to follow and implement its own policy requirements to ensure that oversight of antibiotic use and staff education. This had the potential to affect all residents in the facility. Findings include: Review of the policy titled, Antibiotic Stewardship (revised (MONTH) (YEAR)) documented the following requirements: Policy Interpretation and Implementation: 1.The purpose of our Antibiotic Stewardship Program is to monitor the use of antibiotics in our residents. 2. Orientation, training and education of staff will emphasize the importance of antibiotic stewardship and will include how inappropriate use of antibiotics affects the individual residents and overall community Review of the policy titled, Antibiotic Stewardship- Staff and Clinician Training and Roles (revised (MONTH) (YEAR)) revealed the following requirements: Policy Interpretation and Implementation: Director of Nursing (DON and Infection Preventionist (IP) 2. The DON will monitor individual resident antibiotic regimens including: a) Reviewing clinical documentation supporting antibiotic orders; and b) Compliance with start/stop dates and/or days or therapy 3. The IP will monitor over time and report: a) Measures of antibiotic use (new antibiotic starts/1000 resident days AND days of therapy /1000 resident days.) b) Antibiotic susceptibility patterns (antibiogram data for specific timeframe) and: c) Negative outcomes of events related to antibiotic use, for example 1. [DIAGNOSES REDACTED]icile infections, 2. Adverse drug events; and 3. Antibiotic resistance rates. During an interview with the Director of Nursing (DON) on 2/22/19 at… | 2020-09-01 |
| 2775 | 2775 | GRACE HEALTHCARE OF TUCKER | 115596 | 2165 IDLEWOOD ROAD | TUCKER | GA | 30084 | 2019-09-12 | 881 | F | 0 | 1 | ZHIC11 | Based on record review, interviews and review of policies titled, Infection Prevention and Control Program dated 2001, revised (MONTH) (YEAR); and Antibiotic Stewardship dated 2001 revised (MONTH) (YEAR), revealed that the facility was not following these policies for an effective Antibiotic Stewardship program. All facility residents receiving antibiotics had the potential to be affected. Findings include: A Review of the Infection Control book from (MONTH) (YEAR) to (MONTH) 2019 revealed that no antibiotic stewardship usage investigation was present. An interview on 09/12/19 at 2:05 p.m. with the Director of Nursing (DON) who stated that a meeting with the Medical Director was done regarding the Antibiotic Stewardship program and that he agreed with the program. However, no documentation was done to validate this meeting nor of the other Medical Doctors being notified. The Staff Development Coordinator (SDC) Registered Nurse stated that she started working at this facility about two weeks ago and upon review of previous months related to IC, she determined the program was not effective and developed a Performance Improvement Plan (PIP) on 8/28/19 that had not been presented to Quality Assurance Performance Improvement (QAPI) committee. A review of the PIP did not reveal a plan related implementation of the Antibiotic Stewardship program. A review of the policy titled, Infection Prevention and Control dated 2001, revised (MONTH) (YEAR), indicated the following: -Policy Interpretation and Implementation 4. The elements of the infection prevention and control program consist of coordination/oversight, policies/procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection and employee health and safety. 8. Antibiotic Stewardship a. Culture reports, sensitivity data, and antibiotic usage reviews are included in surveillance activities. b. Medical criteria and standardized definitions of infections are used to help recognize and manage infections. c. Antibiotic usage is… | 2020-09-01 |
| 3318 | 3318 | FORT VALLEY HEALTH AND REHAB | 115651 | 604 BLUEBIRD BOULEVARD | FORT VALLEY | GA | 31030 | 2018-05-18 | 881 | E | 0 | 1 | NJ3X11 | Based on observation, record review and staff interview, the facility failed to establish an Antibiotic Stewardship program. Findings include: During an interview with the Director of Nursing (DON) on 5/18/18 at 3:35 p.m., she stated that an antibiotic stewardship had not been started at the facility. The facility's infection control binder had a printout from the CDC (Center of Disease Control) titled The Core Elements of Antibiotic Stewardship for Nursing Homes. No other information was in the binder. Review of the facility's Infection Control Program-Antibiotic Stewardship policy revealed that the facility would establish a system for the use and monitoring of adverse effects of antibiotics. | 2020-09-01 |
| 4 | 4 | A.G. RHODES HOME WESLEY WOODS | 115002 | 1819 CLIFTON ROAD, N.E. | ATLANTA | GA | 30329 | 2019-02-14 | 880 | D | 0 | 1 | PXEL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and review of facility policy titled, Handwashing/Hand Hygiene the facility failed to ensure food was served in a sanitary manner for six of 41 residents (R), R#63 and five unsampled resident) residing on the secured unit. Findings include: Review of the facility's document entitled Handwashing/Hand Hygiene policy (undated) noted the following: 6. Wash hands with soap and water for the following situations: a. When hands are visibly soiled; b. After contact with a resident with infectious diarrhea .7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: a. Before and after coming on duty; b. Before and after direct contact with residents; .i. After contact with a resident's intact skin; .l. After contact with objects in the immediate vicinity of the resident; .o. Before and after eating or handling food; p. Before and after assisting a resident with meals. Review of the clinical record for R#63 revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's Quarterly MDS dated [DATE] revealed the resident required the limited assistance of one staff person for eating and required the extensive assistance of one staff person for personal hygiene. During the lunch meal observation in the north dining room of the facility's secured unit on 1/28/19 at 1:07 p.m. an unsampled resident was seated at a dining table waiting to be served her lunch meal. The resident's left shoe was off of her foot and the resident was having difficulty putting her shoe back on. At this time, the Activity Director (AD) was passing out utensils wrapped in cloth napkins to all of the resident in the dining room and when the AD approached this unsampled resident, the AD set the tray of utensils down on the table and then assisted the resident by putting her shoe on for her. After the resident's shoe was on, the AD picked up the tray an… | 2020-09-01 |
| 40 | 40 | NORTH DECATUR HEALTH AND REHABILITATION CENTER | 115012 | 2787 NORTH DECATUR ROAD | DECATUR | GA | 30033 | 2018-12-06 | 880 | D | 0 | 1 | 46UW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interviews, the facility failed to maintain an effective infection control program related to labeling and storage of personal care equipment; also failed to utilize proper technique while providing [MEDICAL CONDITION] care for one resident (R) R#38. The facility census was 61 residents. Findings include: Observation on 12/3/18 at 11:16 a.m. revealed in room [ROOM NUMBER] B, un-bagged and unlabeled urinal on the floor behind the toilet and an unlabeled bar of soap on the sink ledge, in a bathroom shared by two male residents. Observation on 12/3/18 at 11:20 a.m. revealed in room [ROOM NUMBER] B, four unlabeled and unbagged bath basins, in a bathroom shared by two female residents. Observation on 12/3/18 at 11:27 a.m. revealed in room [ROOM NUMBER] A, un-bagged and unlabeled nebulizer mask sitting on bedside nightstand. Observation on 12/3/18 at 11:34 a.m. revealed in room [ROOM NUMBER] B, bar of hand soap sitting on sink ledge in bathroom shared by two male residents. Also, un-bagged nebulizer mask sitting on bedside nightstand. Observation on 12/3/18 at 11:46 a.m. revealed in room [ROOM NUMBER] B, labeled but un-bagged urinal in bathroom. Enteral feeding bottle hanging from pole at bedside to bed B, dated 12/1/18. No resident currently residing in bed B. Observation on 12/6/18 at 9:01 a.m. [MEDICAL CONDITION] care performed by Licensed Practical Nurse (LPN) EE for Resident (R) #38. Nurse EE gathered supplies and entered R #38 room. She washed her hands and donned clean gloves. Nurse EE removed soiled [MEDICAL CONDITION] dressing from stoma site. Moderate amount of brown drainage noted on dressing. No odor detected. Nurse removed gloves and applied clean gloves. She did not wash her hands or use hand sanitizer. She [MEDICAL CONDITION] kit and cleanse around [MEDICAL CONDITION] with normal saline. She placed drain sponge on residents chest and resident had a coughing spell and drain sponge was propelled off chest… | 2020-09-01 |
| 83 | 83 | GLENWOOD HEALTH AND REHABILITATION CENTER | 115025 | 4115 GLENWOOD RD | DECATUR | GA | 30032 | 2018-11-01 | 880 | D | 0 | 1 | GW4111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and facility policy review, the facility failed to utilize proper hand hygiene prior to performing wound care for one of two residents, Resident (R) #15. Improper hand hygiene can promote the spread of infection in a facility. Findings include: R#15 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Wound Evaluation and Management Summary note dated 10/30/18 revealed the resident was admitted to the facility with the following wounds: Stage 4 pressure wound to the sacrum measuring 5.5 x 7.5 x 0.5 centimeters (cm). Stage 4 pressure wound of the right ischium measuring 1.8 x 3.5 x 1cm. Stage 4 pressure wound of the left ischium measuring 3 x 4.5 x 2.5 cm. The Wound Evaluation and Management Summary stated that the dressings were to be changed daily. Review of the facility policy titled Hand Hygiene dated 2012 stated Using an alcohol-based hand rub is appropriate after contact with inanimate objects in the patient's environment. Review of the facility policy titled Artificial Finger Nails stated the following: I. Length of nails: Fingernails should be kept clean, healthy, and short (1.4 inch or less beyond the tip of the finger.) II: Artificial nails: Artificial nails or nails enhancements should not be worn by any person whose responsibilities include handling of sterile supplies and/or direct hands-on resident contact. III. Nail polish: If used, nail polish should not be chipped. Studies have demonstrated that chipped nail polish may support the growth of organisms on the fingernails. If nail polish is worn, it should not be worn for more than 4 days. At the end of 4 days, nail polish should be removed and freshly reapplied. During an observation of wound care on 10/31/18 at 11:00 a.m. Licensed Practical Nurse (LPN) AA set up supplies to change R#15's dressing on the left ischium. She was observed to have long nails with chipped and worn polish and confirmed that they were artificial.… | 2020-09-01 |
| 101 | 101 | CENTER FOR ADVANCED REHAB AT PARKSIDE, THE | 115040 | 110 PARK CITY ROAD | ROSSVILLE | GA | 30741 | 2018-08-23 | 880 | D | 0 | 1 | 07R411 | Based on observation, record review and staff interview, the facility failed to perform hand hygiene after performing incontinence care for one resident (R) (R#25). The sample size was 34 residents. Findings include: On 8/20/18 at 4:13 p.m., Certified Nursing Assistant (CNA) BB was observed performing perineal care, including the rectal area and buttocks, for R#25 after she had been incontinent of a moderate amount of urine. After the perineal care was completed, the CNA did not remove their gloves, and placed the resident's pants back on, and pulled the bed sheet and quilts back over her. CNA BB was then observed to place the call pad over the resident's abdomen, and used the motorized controls to lower the bed height, then repositioned the pillow under R#25's head before removing their gloves. During interview with the Licensed Practical Nurse (LPN) Infection Control Nurse on 8/22/18 at 10:34 a.m., she stated that staff should remove their gloves and wash their hands immediately after the soiled linen is placed in a bag following perineal care, before they touched the resident or did any other care. Review of the facility's Perineal Care policy revised (MONTH) (YEAR) revealed: 8b. Wash perineal area, wiping from front to back. 9. Discard disposable items into designated containers. 10. Remove gloves and discard into designated container. 11. Wash and dry your hands thoroughly. Review of the facility's Handwashing/Hand Hygiene policy revised (MONTH) (YEAR) revealed: 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: b. Before and after direct contact with residents. j. After contact with blood or bodily fluids. | 2020-09-01 |
| 146 | 146 | BROWN HEALTH AND REHABILITATION | 115090 | 545 COOK STREET | ROYSTON | GA | 30662 | 2018-08-09 | 880 | E | 1 | 1 | ST5L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and staff interviews, the facility failed to maintain an effective infection control program related to labeling and storage of personal care equipment; also failed to maintain cross contamination of clean linen during the folding process; and failed to maintain sanitary dining supplies. The facility census was 73 residents. Findings include: 1. Observation on 8/6/18 at 10:00 a.m., revealed in room [ROOM NUMBER], an unlabeled and unbagged urinal hanging on the grab bar in the bathroom that was shared by by two female residents. 2. Observation on 8/6/18 at 10:08 a.m., revealed in room [ROOM NUMBER], an unlabeled and unbagged urinal in the bathroom that was shared by two male residents. 3. Observation on 8/6/18 at 10:48 a.m., revealed in room [ROOM NUMBER], an unlabeled bedpan in a plastic bag, in the bathroom that is shared by four male residents. 4. Observation on 8/7/18 at 2:44 p.m., with Laundry Aide II, folding clean linen using a Helping Hand securing device to hold the end of a blanket. The blanket was touching the floor during the folding process. After the blanket was folded, she then proceeded to fan/slap the blanket against her legs, as if to remove wrinkles from blanket. Afterwards, she placed the blanket on top of already folded blankets stacked on the folding table. 5. Observation on 8/7/18 at 2:56 p.m., with Laundry Aide JJ, folding clean linen at the folding table, allowing the clean bed linen (sheet) to rest upon her abdomen while folding. Afterwards, she placed the sheet on top of a stack of already folded sheets stacked on the table. 6. Observation on 8/8/18 at 2:18 p.m., revealed that dining room three, had black metal condiment baskets that held clear plastic containers with sugar, salt and pepper packets for resident use. Six of the six baskets had yellow, black, crusted mold substance inside the basket bottom. Interview on 8/7/18 at 3:19 p.m., with Laundry Aide II, stated that she did not notice the… | 2020-09-01 |
| 169 | 169 | HABERSHAM HOME | 115099 | HIGHWAY 441 NORTH, BOX 37 | DEMOREST | GA | 30535 | 2019-06-27 | 880 | D | 1 | 1 | 3SRU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and staff interviews, the facility failed to maintain an effective infection control program related to labeling and storage of personal care equipment; also failed to practice infection control policy for washing and/or sanitizing hands during wound care procedure. The facility census was 76 residents. Findings include: 1. Observation on 6/24/19 at 12:24 p.m. revealed in room [ROOM NUMBER] B, an un-bagged and unlabeled toothbrush sitting on sink counter and un-bagged and unlabeled urinal sitting on the floor beside the toilet. Observation on 6/21/19 at 1:28 p.m. revealed in room [ROOM NUMBER] A, two (2) un-bagged and unlabeled toothbrushes sitting on sink counter. Bathroom is shared by two (2) female residents. Observation on 6/24/19 at 1:50 p.m. revealed in room [ROOM NUMBER] B, one (1) un-bagged and unlabeled toothbrush sitting on sink counter and one un-bagged and unlabeled bath basin on floor under the sink. Bathroom is shared by two (2) female residents. Observation on 6/24/19 at 1:58 p.m. revealed in room [ROOM NUMBER] A, one (1) un-bagged and unlabeled toothbrush sitting on sink counter. Bathroom is shared by two (2) female residents. Observation on 6/24/19 at 2:07 p.m. revealed in room [ROOM NUMBER] B two (2) un-bagged and unlabeled toothbrushes sitting on sink counter. Bathroom is shared by two (2) female residents. Observation on 6/25/19 at 10:14 a.m. revealed in room [ROOM NUMBER], one (1) unbagged and unlabeled toothbrush sitting on sink counter. Bathroom is shared by two (2) female residents. Observation on 6/25/19 at 10:47 a.m. revealed an un-bagged and unlabeled urinal sitting on grab bar in bathroom. 2. Observation on 6/26/19 at 2:03 p.m., with Licensed Practical Nurse (LPN) wound care nurse JJ performed wound care for R#13. She gathered all materials needed for the procedure and placed them in plastic cups. She sanitized the residents over bed table and placed a barrier on the table and placed the plas… | 2020-09-01 |
| 198 | 198 | SIGNATURE HEALTHCARE AT TOWER ROAD | 115115 | 26 TOWER RD | MARIETTA | GA | 30060 | 2019-01-31 | 880 | D | 0 | 1 | TKWX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, review of Infection Control Reports and the policy titled [MEDICAL CONDITION] it was determined that the facility failed to ensure infection control procedures were followed to prevent the spread of infection for one Resident (R#106) with a [DIAGNOSES REDACTED]. Findings include: Review of the facility policy titled [MEDICAL CONDITION] revised in 2014 indicated preventive measures would be taken to prevent the occurrence of [MEDICAL CONDITION] infections among residents and precautions would be taken while caring for residents with [MEDICAL CONDITION] to prevent transmission. The policy documented in pertinent part, reservoirs for [MEDICAL CONDITION] included infected people and surfaces. The policy indicated spores could persist on resident care items and surfaces for several months and were resistant to common cleaning and disinfection methods. Steps towards prevention and early intervention included increasing awareness of risk factors, frequent hand washing with soap and water, wearing gloves, disinfectant of items with a disinfecting agent recommended for [MEDICAL CONDITIONS], household bleach or an EPA (Environmental Protection Agency) registered germicidal agent effective against [MEDICAL CONDITION]. The policy directed staff to wear gloves when caring for residents, washing hands with soap and water upon exiting the room of a resident and strict adherence to hand hygiene. The policy indicated contact isolation gloves and a gown must be worn by staff. Personal protective equipment (PPE) was to be utilized by all staff and visitors. The policy indicated for disposing of used PPE, staff where to place the dirty PPE in the red biohazard bags in the resident's room. PPE should be removed right away if it got soaked with blood or other body fluids and staff were to make sure the bags were not overfilled. The monthly Quality Assurance Performance Improvement (QAPI) infection Control Reports were reviewed for… | 2020-09-01 |
| 217 | 217 | SIGNATURE HEALTHCARE OF SAVANNAH | 115120 | 815 EAST 63 STREET | SAVANNAH | GA | 31405 | 2018-06-07 | 880 | E | 0 | 1 | 3B0P11 | Based on observations and staff interviews the facility failed to follow infection control procedures by staff failing to sanitize hands during the passing of meal trays on one of four (1/4) halls and touching the rims of 24 glasses on a tray while filling each glass with ice and beverages during dining for approximately 50 residents. This had the potential to effect 111 residents. Findings include: Observation on 6/4/18 at 12:15 p.m. revealed that the Chaplain was touching the rim of the glasses with his fingers while filling the glasses with ice and beverages. This observation revealed 24 glasses on the tray (tray one (1) positioned on a small rolling cart. Interview with the Chaplain on 6/7/18 at 5:10 p.m. revealed that he really didn't have any training on how to pour ice and beverages in a glass, that he had observed other staff members . He revealed that he assisted with dinner meals on Mondays and Thursdays. Interview on 6/7/18 at 5:20 p.m., with RNP FF, reported that that the proper technique of filling the glasses with beverages is to avoid touching the rims of each glass. She verified that there are usually 24 glasses per a tray. She verified receiving training and that some of the staff who were assisting in the dining room on 6/4/18 was only assisting for that day because the state was in the building. She further stated that she was the staff who assisted with the second set of glasses to ensure the process was done correctly. 2. During observation of lunch service on Unit 2 on 6/4/18 at 1:23 p.m., Certified Nursing Assistant (CNA) LL was observed to serve resident (R) (R #34) lunch in her room. After putting the lunch tray on the resident's overbed table, CNA LL was observed to position R #34's overbed table in front of her, move the wheelchair and swing back the footrests of the wheelchair, and remove the trash can liner out of the trash can in the room. CNA LL was then observed to leave the room, obtain another lunch tray out of the food delivery cart, and took the tray in R #52's room. Continued … | 2020-09-01 |
| 226 | 226 | SIGNATURE HEALTHCARE OF SAVANNAH | 115120 | 815 EAST 63 STREET | SAVANNAH | GA | 31405 | 2019-08-08 | 880 | D | 0 | 1 | FZQ711 | Based on record review, observations, and staff interviews the facility failed to ensure infection control preventive measures were being maintain for one of 20 residents (R#22) who were assessed to require assistance for feeding. Findings include: An observation on 8/6/19 at 12:42 p.m. revealed Certified Nursing Assistant (CNA) FF sitting on R#22's bed scrolling through her cell phone, and eating her lunch, which was porkchops, with her hands. In addition, CNA FF was observed feeding R#22 her lunch (which was a pureed meal). A later observation was made with Licensed Practical Nurse (LPN) HH to identify and confirm the observation on 8/6/19 at 12:42 p.m. During this observation, CNA FF was observed sitting in the same position, sideways on the bed eating her lunch, which was pork chops, using her hands. After being observed doing this CNA FF picked up the spoon and started to feed R#22. LPN HH informed the CNA that she could not eat while feeding the residents nor use her phone. Interview with the CNA FF on 8/6/19 at 12:43 p.m. revealed that she received in-service training on infection control about not eating while feeding residents and not using her phone. Interview on 8/7/19 at 11: 52 a.m., with the Administrator and the DON revealed that the Administrator stated that his expectations are that CNAs should never have personal food in the resident's rooms. The Administrator stated that nursing staff are to monitor for cross contamination and for infection control concerns. Further interview with the Director of Nursing (DON) revealed that his expectations are that the CNAs and nursing staff should not eat while feeding their residents, per the facility policy. The DON stated that he wanted the CNAs to focus on feeding the residents. Further interview with the DON revealed that he considers staff sitting on the bed, while he or she is eating, an infection control issue. During a later interview on 8/8/19 at 11:10 a.m., the DON revealed that staff are in-serviced on infection control including using their teleph… | 2020-09-01 |
| 237 | 237 | MAGNOLIA MANOR OF COLUMBUS NURSING CENTER - EAST | 115124 | 2010 WARM SPRINGS RD | COLUMBUS | GA | 31904 | 2018-08-16 | 880 | D | 0 | 1 | YI7C11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, clinical record review, observations, and staff and resident interviews, the facility failed to ensure proper infection control measures were followed for two residents (R) R#20 and R#59 of 56 total sampled residents. Specifically, R#20 received antibiotic treatment for [REDACTED]. And a blood glucose monitor was not properly sanitized prior to use for R#59. Findings include: Review of the facility's Antibiotic Mission Statement, dated 10/17 read, in pertinent part, Our center embraces the importance of an infection prevention and control program that includes an antimicrobial stewardship program, providing antibiotic use protocols and monitoring to prevent antibiotic resistance. We are committed to the prudent use of antibiotics on behalf of all patients we serve through a sustainable antimicrobial stewardship program. The McGee's Criteria dated 10/12 and utilized by the facility as the guide for antibiotic use for UTIs read, in pertinent part, For urinary tract infections without a catheter the new definitions differ substantially from the original guidelines. The definitions take into account the low probability of UTI in residents without catheters if symptoms are not present as well as they now take into account the need for a urine culture for microbiologic confirmation; and Criteria 1: At least one of the following signs or symptoms: Acute costovertebral angle pain or tenderness, suprapubic pain, gross hematuria, new or marked increase in incontinence, new or marked increase in urgency, new or marked increase in frequency. In the absence of fever or leukocytosis, then two or more of the following sub-criteria: suprapubic pain, gross hematuria, new or marked increase in incontinence, new or marked increase in urgency, new or marked increase in frequency; and Criteria 2: At least 105 cfu(colony forming unit)/ml (milliliter) of no more than two species of microorganisms in a voided urine sample, or at leas… | 2020-09-01 |
| 257 | 257 | NURSE CARE OF BUCKHEAD | 115129 | 2920 PHARR COURT SOUTH NW | ATLANTA | GA | 30305 | 2017-12-21 | 880 | F | 0 | 1 | 2MCC11 | Based on observation, interviews and record review, the facility failed to maintain an effective infection prevention and control program that demonstrated ongoing surveillance, recognition, investigation and control of infection to prevent the onset and spread of infection. The sample size was 42. Findings include: Review of the Infection Control Monthly/Yearly Report from 1/17 to 11/17 revealed the facility did not have collected surveillance data for five out of 10 months (June through October). During interview with Director of Nursing (DON), the Infection Control Preventionist (ICP) on 12/21/2017 at 7:41 a.m., reported the facility's Infection Control Nurse had taken another position in the facility and the facility had been without a nurse in that position for several months. The DON stated I just started the infection control duties in September. Further interview with the DON stated, she did not know where the infection control tracking data for the five missing months (June through October) was. She stated she checked with the previous employee, and she doesn't have any data for those months. Review of facility's undated policy titled Infection Prevention and Control Program Overview indicated the major activity of the program is surveillance of infections with implementation of control measures and prevention of infections. The policy further explained that the Infection Preventionist (IP) monitored the resident infection cases and completed the line listing of infections and monthly report forms. The IP would then report to the Infection Prevention Committee, reports to the DON, and provided feedback to staff as needed. Compliance with the infection prevention practice is monitored and documented by staff evaluation and observation of practices. The DON was interviewed on 12/21/17 at 7:41 a.m., about the infection rates being between 2.33% and 7.6%, and she stated she does not know why, and re-stated that she assumed the responsibility of Infection Control in (MONTH) (YEAR). | 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 );