cms_GA
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| Link | rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid ▲ | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 3841 | 3841 | SGMC LAKELAND VILLA | 115707 | 138 WEST THIGPEN AVE | LAKELAND | GA | 31635 | 2018-09-09 | 578 | D | 0 | 1 | ZZXY11 | Based on record review and staff interview the facility failed to obtain a Physician's signature and a concurring Physician's signature for a Do Not Resuscitate Consent for one of three Residents (R) (R#29) without decision making capacity. The facility census was 62 residents. Findings include: Review of medical record for R#29 revealed a Do Not Resuscitate (DNR) Consent for an adult without decision making capacity that was signed by one Physician on 1/11/18 and the resident's son, who was not the resident's Health Care Agent, but there was no concurring Physician's signature. Further review of the Medical Record for R#29 revealed that there was a General Power of Attorney (POA) but not a Health Care Agent for R#29. On 9/7/18 at 4:45 p.m. DON provided copy of POA for R# 29 but the POA did not specify a health care agent. Admissions/Social Services reported that this is the only documentation that she has related to POA for R# 29. Interview on 9/8/18 at 11:05 a.m. with Admissions/Social Services who acknowledged that she educates residents and families related to choices related to formulating advance directives. She reported that residents without decision making capacity with no family available requires two physician signatures on DNR consent/order. If a resident has decision making capabilities and signs the consent/order only one physician's signature is needed. It was further reported that if a resident without decision making capacity has family the family member can sign, only one physician's signature would be needed. Lastly, it was reported that a resident without decision making capacity but with a health care agent only needs one physician's signature. Admissions/Social reported that she was not aware that a concurring physician's signature would be needed for a resident if the POA signed the consent/dnr form. | 2020-09-01 |
| 3842 | 3842 | SGMC LAKELAND VILLA | 115707 | 138 WEST THIGPEN AVE | LAKELAND | GA | 31635 | 2018-09-09 | 636 | D | 0 | 1 | ZZXY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, policy review and review of the Resident Assessment Instrument (RAI) Manual as well as staff interviews, the facility failed to correctly code one (1) Minimum Data Set Assessment (MDS) for one resident, Resident #37 (R#37). The facility census was 62 residents. Findings include: Record review revealed that R#37 has a [DIAGNOSES REDACTED]. Observations made on 9/7/2018 at 11:51 a.m., 9/8/2018 at 8:57, and 9/9/2018 at 9:13 am. revealed resident in bed with upper and lower bed rails elevated with padding on all rails and headboard. Review of the care plans for R#37 revealed side rails elevated times two for safety during care provisions, to assist with bed mobility, observe for injury, or entrapment related to side rail use. Interview on 9/7/2018 at 11:51 a.m. with Certified Nursing Assistant (CNA) AA revealed that the resident has a safety sitter with her at all times. She stated the padding on the side rails are used to keep her from hurting herself. The resident can get spastic at times. Continued interview on 9/8/2018 at 8:57 a.m. with CNA AA revealed R#37 will attempt to stand up in the bed and has no safety awareness. She is very unsteady on her feet. Interview with the Director of Nursing (DON) on 9/9/2018 at 9:30 a.m. revealed the facility uses the padded elevated side rails and padded head board for the resident's safety and protection from injury. The facility supplies a full-time safety sitter to be with the resident at all times. The DON stated he keeps a list at the nurse's desk of the residents who have side rails. Review of the list revealed R#37 required side rails but did not mention pads to side rails. His expectation is the MDS should reflect the use of side rails for R#37 Interview with the Minimum Data Set (MDS) Coordinator LPN CC on 9/09/2018 at 11:12 a.m. verified the most recent Quarterly MDS dated [DATE] did not indicate the use of side rails. Interview with the DON on 9/9/2018 at 12… | 2020-09-01 |
| 3843 | 3843 | SGMC LAKELAND VILLA | 115707 | 138 WEST THIGPEN AVE | LAKELAND | GA | 31635 | 2018-09-09 | 644 | D | 0 | 1 | ZZXY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to refer one resident (#33) for a pre-admission screening and resident review (PASARR) Level II assessment when the resident experienced a change in his emotional and behavioral status which impacted his day-to-day functioning. The sample size was 32 residents. Findings include: Review of the policy titled Preadmission Screening for Individuals with Mental Disorders or Intellectual Disability dated 3/10/17, the facility must notify the applicable state authority for resident review promptly after a significant change in the mental or physical condition of a resident. Review of the clinical records for Resident (R) #33 revealed the resident was admitted on [DATE] and readmitted on [DATE] with no psychiatric diagnoses. A Level I PASSARR authorization of 3/22/17 documented that the resident did not have a suspected mental illness or developmental disability. The admission Minimum Data Set (MDS) assessment of 7/24/16 also documented that the resident had no psychiatric diagnoses. A review of social work notes documented between 9/5/18 and 9/21/18 revealed the resident was counseled by the social worker for symptoms of depression. Review of a progress note from the consulting psychiatrist on 9/29/17 revealed the resident was seen for symptoms of depression and anxiety. The note further documented that the psychiatrist planned to add 7.5 mg of [MEDICATION NAME] to the resident's existing dose of [MEDICATION NAME] 20 mg daily and to also add [MEDICATION NAME] 5 mg three times a day for anxiety. A review of the current physician's orders [REDACTED]. A review of the most recent MDS assessment - the annual - of 7/26/18 revealed that the resident was not referred for a Level II PASRR evaluation but had active [DIAGNOSES REDACTED]. During an interview on 9/9/18 at 10:10 a.m. with Certified Nursing Assistant (CNA) CC, it was revealed that she has cared for R#33 for more than two years. At fir… | 2020-09-01 |
| 3844 | 3844 | SGMC LAKELAND VILLA | 115707 | 138 WEST THIGPEN AVE | LAKELAND | GA | 31635 | 2018-09-09 | 656 | D | 0 | 1 | ZZXY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews the facility failed to follow the care plan for four residents (R). R#37, R#45, R#54 and R#33. The facility census was 62 residents. Findings include: 1. R#37 has a [DIAGNOSES REDACTED]. Observations made on 9/7/2018 at 11:51 a.m., 9/8/2018 at 8:57, and 9/9/2018 at 9:13 am. revealed resident in bed with upper and lower bed rails elevated with padding on all rails and headboard. Review of R#37's care plan revealed side rails elevated times two for safety during care provisions, to assist with bed mobility, observe for injury, or entrapment related to side rail use. The care plan did not include the use of upper and lower rails and the use of padding to the rails and head board. Interview on 9/7/2018 at 11:51 a.m. with CNA AA revealed that the resident has a safety sitter with her at all times. She stated the padding on the side rails are used to keep her from hurting herself. The resident can get spastic at times. Continued interview on 9/8/2018 at 8:57 a.m. with CNA AA revealed R#37 will attempt to stand up in the bed and has no safety awareness. She is very unsteady on her feet. Interview with the DON on 9/9/2018 at 9:30 a.m. revealed the facility uses the padded elevated side rails and padded head board for the resident's safety and protection from injury. The DON stated he keeps a list at the nurse's desk of the residents who have side rails. Review of the list revealed R#37 required side rails, not the number of side rails, but did not mention pads to side rails. His expectation is the care plan should reflect the use of upper and lower side rails and the padding on the rails and head board for R#37. Interview with the MDS Coordinator LPN CC on 9/09/2018 at 11:12 a.m. verified the care plan only included side rails times two and did not include the padding to the rails or head board. Interview with the DON on 9/9/2018 at 12:11 p.m. revealed the facility does not complete side rail… | 2020-09-01 |
| 3845 | 3845 | SGMC LAKELAND VILLA | 115707 | 138 WEST THIGPEN AVE | LAKELAND | GA | 31635 | 2018-09-09 | 677 | D | 0 | 1 | ZZXY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to provide oral care for one resident (R) (#54) out of 32 sampled residents. Findings include: Observations on 9/7/18 at 11:00 a.m. and 9/08/18 at 10:48 a.m. and 3:02 p.m. revealed R#54 with thick tan build up on the top teeth. Review of the Minimum Data Set (MDS) Annual assessment dated [DATE] revealed R#54 was unable to complete the Brief Interview of Mental Status (BIMS). The resident has [DIAGNOSES REDACTED]. Observation on 9/09/18 at 08:30 a.m. revealed R#54 in bed with teeth noted to be clean. During an interview on 9/09/18 at 10:25 a.m., Certified Nursing Assistant (CNA) II revealed that she cleaned R#54's mouth at the beginning of her shift this morning. She stated that oral care is supposed to be done every day. Interview with the Director of Nursing (DON) on 9/09/18 at 12:42 p.m. revealed that he expects oral care to be provided every shift or more often. He stated that oral care should be part of R#53's comprehensive care plan. DON stated that in-services are provided to nursing staff regularly which covers oral care. The education record is done electronically and is not available for review on a Sunday. Review of the in-service education materials titled Oral Health in Nursing Homes dated 2/8/18 revealed that oral hygiene should be provided twice a day but at a minimum once daily. Review of the Job Aid titled Oral Care reviewed (MONTH) (YEAR) revealed no indication of frequency of oral care and only outlined procedure. | 2020-09-01 |
| 3846 | 3846 | SGMC LAKELAND VILLA | 115707 | 138 WEST THIGPEN AVE | LAKELAND | GA | 31635 | 2018-09-09 | 686 | D | 0 | 1 | ZZXY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of the facility policy titled Villa Wound Care, and staff interview, the facility failed to provide heel protectors as physician ordered for one resident (R) (#45) out of 32 sampled residents. Findings include: During wound care observation on 9/8/18 at 9:00 a.m., R#45 was in bed and no heel protectors were observed. Stage 2 pressure ulcer noted to left lateral foot. Treatment provided as ordered. Upon completion of the wound care treatment by Licensed Practical Nurse (LPN) HH, no heel protectors were placed on the resident. Minimum Data Set (MDS) Significant Change assessment dated [DATE] documented R#45 requires one person total dependence with bed mobility and dressing; and has one stage 2 pressure ulcer not present on admission. Review of the (MONTH) (YEAR) Physician Orders revealed an order dated 4/24/18 for Prevalon boots (soft boot designed to lift the heel off the mattress) on while in bed (please keep straight) and an order dated 1/30/18 for heel protectors to be worn at all times. Review of the Care Plan last reviewed on 8/16/18 revealed R#45 has potential/ actual impairment to skin integrity related to fragile skin and incontinence. Resident has stage 2 pressure ulcer to left lateral foot identified on 11/16/17. Interventions included: resident needs pressure relieving mattress, pillows, padding to protect skin while in bed. Observation on 9/08/18 at 10:45 a.m. and 3:13 p.m. revealed R#45 in bed sleeping. Resident was not wearing Prevalon boots or heel protectors of any kind. Observation on 9/09/18 at 8:38 a.m. revealed R#45 up in Geri chair in the day room. Resident was not wearing heel protectors. Interview with LPN HH on 9/09/18 at 8:59 a.m. revealed that R#45 is supposed to have on the big bulky boots while in bed. Interview with the Director of Nursing (DON) on 9/09/18 at 12:42 p.m. revealed that R#45 should have on heel protectors as ordered and that information should be communicat… | 2020-09-01 |
| 3847 | 3847 | SGMC LAKELAND VILLA | 115707 | 138 WEST THIGPEN AVE | LAKELAND | GA | 31635 | 2018-09-09 | 759 | E | 0 | 1 | ZZXY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to ensure the medication error rate was less than five per cent (5%). A total number of 27 medication opportunities were observed, and there were two errors for one of two residents (R) (R #14) by one of two nurses observed giving medications, for an error rate of 7.41%. The facility census was 62 residents, and the sample size was 32 residents. Findings include: On 9/8/18 at 11:30 a.m., Licensed Practical Nurse (LPN) KK was observed giving R#14 her noon medications which included [MEDICATION NAME] 20 grams (g or GM)/ 30 milliliters (ml's) and [MEDICATION NAME] Acid 750 mg/ 15 ml's given via gastrostomy tube ([DEVICE]). LPN KK combined both liquid medications together in a cup. Further observation revealed LPN KK poured 50 ml's of water through the tube, then the mixture of medications, and finally an additional 50 ml's of water. Review of R#14's (MONTH) (YEAR) Physician order [REDACTED]. [MEDICATION NAME] 10 GM/15 ml solution 20g - 20 g oral 3 times daily, first dose on Monday 7/16/18 at 8:00 p.m. oral or via peg; and valproate sodium 250 mg/5 ml syrup 750 mg - 750 mg oral three times daily, first does on Saturday 7/14/18 at 8:00 a.m. During an interview on 9/09/18 at 9:00 a.m., LPN KK revealed that her normal process is to mix all the medication together and give them together at one time for the [DEVICE]. Interview with the Director of Nursing (DON) on 9/09/18 at 12:42 p.m. revealed that it has always been the practice of the nurses at this facility to give medication all together and at one time through the g tube. Review of the document titled Patient Care Job Aide: Enteral Feedings - Instillation of Medications and PEG Care revised 2/12 revealed: 8. Pour liquid medication into measuring cup to obtain ordered amount. 10. Deliver the medication slowly and steadily. If the medication does not flow properly, do not force. If mixture too thick, dilute it. The facil… | 2020-09-01 |
| 9357 | 9357 | JOE-ANNE BURGIN NURSING HOME | 115272 | 321 RANDOLPH STREET | CUTHBERT | GA | 39840 | 2012-03-29 | 279 | D | 1 | 0 | ZZLX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, the facility failed to develop a comprehensive care plan which included indwelling Foley catheter use for one (1) resident (#2) from a survey sample of eight (8) residents. Findings include: Please cross refer to F315, example 1, for more information regarding Resident #2. Record review for Resident #2 revealed that the Resident Care Plan documented the resident's admitted as 05/02/2011. A May 2011 physician's orders [REDACTED].#2 to have an indwelling Foley catheter to bedside drainage, with catheter care to be provided twice daily. Observation of Resident #2 on March 28, 2012 at 3:15 p.m. revealed that the resident had an indwelling Foley catheter in place. However, further review of the Resident Care Plan for Resident #2 revealed that the facility had failed to develop a plan of care for the indwelling Foley catheter. | 2015-07-01 |
| 9358 | 9358 | JOE-ANNE BURGIN NURSING HOME | 115272 | 321 RANDOLPH STREET | CUTHBERT | GA | 39840 | 2012-03-29 | 282 | D | 1 | 0 | ZZLX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, the facility failed to follow the plan of care for one (1) resident (#2) regarding fluid restriction, and for one (1) resident (#3) regarding an enteral tube feeding, from a survey sample of eight (8) residents. Findings include: 1. Please refer to F309 for more information regarding Resident #2. Record review for Resident #2 revealed that the resident's March 2012 physician's orders [REDACTED]. A Resident Care Plan entry of 05/15/2011 identified a problem of the resident having the potential for alteration in cardiac output related to [DIAGNOSES REDACTED]. Interventions to address this noted problem included to encourage adequate fluid intake, while observing any ordered fluid restrictions. However, review of Resident #2's Intake and Output sheet revealed that during March 2012, the facility had given Resident #2 fluid in amounts which exceeded the physician's 1000 cc per 24 hour fluid restriction order on twelve (12) days in amounts ranging from 1277 ccs to 2134 ccs per 24 hours. 2. Please cross refer to F328 for more information regarding Resident #3. Record review for Resident #3 revealed a 03/02/2012 Care Plan entry identifying that the resident was dependent on tube feeding for nutrition, with an Approach to administer tube feedings as ordered. A physician's orders [REDACTED]. The resident's March 2012 medication record documented that on 03/02/2012, [MEDICATION NAME] was initiated at 30 mls per hour per gastrostomy tube, and on 03/03/2012, the resident received [MEDICATION NAME] at 35 mils per hour per gastrostomy. Then, on 03/04/2012, the resident began receiving [MEDICATION NAME] at 40 mls per hour. However, this medication record further documented that the formula continued at the rate of 40 mls per hour until 03/28/2012, with no documented additional attempts after 03/04/2012 to increase the resident's formula rate as ordered by the physician on 03/02/2012, even though there was no evidence to indicate that… | 2015-07-01 |
| 9359 | 9359 | JOE-ANNE BURGIN NURSING HOME | 115272 | 321 RANDOLPH STREET | CUTHBERT | GA | 39840 | 2012-03-29 | 309 | D | 1 | 0 | ZZLX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure that one (1) resident (#2), who was on fluid restriction, received the ordered amount of fluids, from a survey sample of eight (8) residents. Findings include: Record review for Resident #2 revealed an Admission/Readmission Care Plan sheet which documented an admission date of [DATE], and also documented that the resident had [DIAGNOSES REDACTED]. The resident's March 2012 physician's orders [REDACTED]. However, review of Resident #2's Intake and Output sheet revealed that the resident was given over the ordered 1000 ccs. of fluid per twenty-four (24) hour period on the following dates in the following amounts: on 03/01/2012, 2084 ccs; on 03/02/2012, 1912 ccs; on 03/04/2012, 1374 ccs; on 03/05/2012, 2091 ccs; on 03/06/2012, 1297 ccs; on 03/08/2012, 1277 ccs; on 03/09/2012, 1315 ccs; on 03/10/2012, 1677 ccs; on 03/21/2012, 1915 ccs; on 03/22/2012, 2134 ccs; on 03/24/2012, 1320 ccs; and on 03/25/2012, 1320 ccs. Based on the above, during March 2012, the facility had given Resident #2 fluid in amounts which exceeded the physician's 1000 cc per 24 hour fluid restriction order on twelve (12) days in amounts ranging from 1277 ccs to 2134 ccs per 24 hours. During an interview with Nurse "EE" conducted on 03/28/2012 at 2:15 p.m., this nurse stated that the certified nursing assistants were responsible for keeping up with resident fluid intake. | 2015-07-01 |
| 9360 | 9360 | JOE-ANNE BURGIN NURSING HOME | 115272 | 321 RANDOLPH STREET | CUTHBERT | GA | 39840 | 2012-03-29 | 315 | D | 1 | 0 | ZZLX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the facility's policy for indwelling urinary catheter care, and staff interview, the facility failed to provide the appropriate urinary catheter care for two (2) residents (#2 and #3), from four (4) residents with indwelling urinary catheters, on a total survey sample of eight (8) residents. Findings include: 1. During observation of Certified Nursing Assistants (CNAs) "AA" and "BB" performing Foley catheter care for Resident #2 on March 28, 2012 at 3:15 p.m., these CNAs utilized wipes to wipe downward on either side of the Foley catheter tubing during pericare, and used [MEDICATION NAME] swabs to wipe the peri area on either side of the catheter tubing as well. However, the CNAs failed to clean the Foley catheter tubing at the insertion site at all. 2. During observation of CNAs "CC" and "DD" performing Foley catheter care for Resident #3 on March 28, 2012 at 3:35 p.m., these CNAs used wipes to wipe downward on either side of the Foley catheter during peri care, and used [MEDICATION NAME] swabs to wipe downward on either side of the peri area, but they failed to clean the Foley catheter tubing from the proximal to the distal end. Rather, the CNAs used a [MEDICATION NAME] swab to wipe one time on the top of the catheter tubing. Also, during the observation referenced above, the resident's Foley catheter tubing was not secured to the leg either prior to or after the completion of catheter care. The facility's policy for the care of indwelling Foley catheters was reviewed, and it was determined that the policy did not include cleansing of the Foley catheter tubing. This was acknowledged by the Director of Nursing during interview on 03/29/2012 at 12:15 p.m.. | 2015-07-01 |
| 9361 | 9361 | JOE-ANNE BURGIN NURSING HOME | 115272 | 321 RANDOLPH STREET | CUTHBERT | GA | 39840 | 2012-03-29 | 328 | D | 1 | 0 | ZZLX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to follow the physicians' orders for a gastrostomy tube feeding, and failed to clarify the length of administration for an intravenous solution, for one (1) resident (#3) from a total survey sample of eight (8) residents. Findings include: Record review for Resident #3 revealed a Physician's Orders and Progress Notes sheet with a 03/01/2012 entry which documented that the resident had a gastrostomy tube. A 03/02/2012 physician's order on this Physician's Orders and Progress Notes sheet ordered [MEDICATION NAME] at 30 milliliters (mls) per hour per gastrostomy tube, and to advance by 5 ml increments every 24 hours as tolerated. Review of the resident's March 2012 medication record revealed a 03/02/2012 entry indicating that [MEDICATION NAME] was initiated at 30 mls per hour per gastrostomy tube on that date. A Progress Notes entry of 03/02/2012 at 10:24 p.m. which documented that [MEDICATION NAME] was infusing at 30 mls per hour, with no distress noted at that time. A 03/03/2012 notation on the medication record documented that the infusion rate had increased and that the resident received [MEDICATION NAME] at 35 mils per hour per gastrostomy tube on that date. A Progress Notes entry of 03/03/2012 at 10:08 a.m. documented that [MEDICATION NAME] was infusing at 35 mls per hour, and a Progress Notes entry of 03/03/2012 at 6:15 p.m. documented that the gastrostomy tube site was intact and patent, with no distress noted. A 03/04/2012 entry on the medication record documented that Resident #3 began receiving [MEDICATION NAME] at 40 mls per hour per gastrostomy tube, but also documented that the formula continued at that rate until 03/28/2012. Record review revealed no documented attempts after 03/04/2012 to increase the resident's formula rate by 5 mls per hour every 24 hours as tolerated, as originally ordered by the physician on 03/02/2012, even though further record re… | 2015-07-01 |
| 9362 | 9362 | JOE-ANNE BURGIN NURSING HOME | 115272 | 321 RANDOLPH STREET | CUTHBERT | GA | 39840 | 2012-03-29 | 502 | D | 1 | 0 | ZZLX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to obtain a urine culture and sensitivity laboratory test as ordered by the physician for one (1) resident (#2) from a survey sample of eight (8) residents. Findings include: Record review for Resident #2 revealed a 03/15/2012 physician's orders [REDACTED]. The Laboratory Report for this 03/15/2012 urinalysis revealed two-plus protein, one-plus occult blood, a three (3) to ten (10) white blood cell result, and "many bacteria". A 03/16/2012 physician's orders [REDACTED]. However, further record review revealed no evidence of a urine culture and sensitivity done as ordered on [DATE] or thereafter. During interview with the Director of Nursing on 03/28/2012 at 5:25 p.m., the DON acknowledged that the ordered 03/16/2012 urine culture and sensitivity had not been done. | 2015-07-01 |
| 3838 | 3838 | SGMC LAKELAND VILLA | 115707 | 138 WEST THIGPEN AVE | LAKELAND | GA | 31635 | 2015-08-27 | 161 | C | 0 | 1 | ZZKN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to purchase a surety bond to assure the security of the resident trust fund account. The facility managed forty-eight (48) resident's accounts. The census was fifty-five (55). Findings include: Review of the surety bond provided by the Administrator on [DATE] at 11:50 am, revealed the surety bond had expired on (MONTH) 1, (YEAR). During an interview with the Administrator at that time, he confirmed the surety bond had expired. Review of the [DATE] current account balance revealed the facility currently managed forty-eight (48) resident accounts with a current balance of $21,426.40. Six months of bank statements for the resident trust fund were reviewed and revealed the following balances: ,[DATE]- $45,341.06, ,[DATE]- $41,743.02, ,[DATE]-$50,328.91, ,[DATE]- $53,636.20, ,[DATE]- $45,824.47, ,[DATE]- $55,550.59. | 2020-09-01 |
| 3839 | 3839 | SGMC LAKELAND VILLA | 115707 | 138 WEST THIGPEN AVE | LAKELAND | GA | 31635 | 2015-08-27 | 371 | F | 0 | 1 | ZZKN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, it was determined that the facility had failed to ensure that the kitchen was clean, kitchen utensils cleaned appropriately and essential kitchen equipment was in good repair. Findings include: The following compliance issues were identified in the kitchen area on 8-25-15 at 3:10 pm: The rubber seal gasket on one door of the cooler had pulled away from the base of the door. Inside the cooler, there was a steam table pan underneath the condenser coil with dripping water into the pan. The Director of Food Service (DFS) stated that this was a [AGE] year old cooler. He had a requested of replacement about three weeks ago. Further interview revealed that the maintenance director had told him that this cooler could not be fixed anymore. Two large soup pots with soap and hot water, and one large roaster pan were on the floor, under the dish washing area. The head chef confirmed the above and stated that they were soaking or waiting to be cleaned. The following compliance issues were identified in the kitchen area on 8-25-15 at 4:10 pm: Observation revealed a fan with dust and dirt was on top of a food warmer and was blowing over the steam table area. A buildup up grease on the storage shelves behind the steam table. On top of these shelves, there were stored large pots and large serving spoons. This was confirmed by the head chef. He stated that these shelves had not been on a cleaning schedule. Two metal utility carts with rusted bases with a large baking pans on one and the tea and coffee dispensers on the other. A gouged area in the wall over the handwashing sink. There were chipped floor tiles in front of the convection oven. There was heavy grease and food debris build up on the inside of the blender base. There were three sheet pans and three large frying pans with heavy carbon build-up on the outside of them. This was confirmed by the DFS. | 2020-09-01 |
| 3840 | 3840 | SGMC LAKELAND VILLA | 115707 | 138 WEST THIGPEN AVE | LAKELAND | GA | 31635 | 2015-08-27 | 406 | D | 0 | 1 | ZZKN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and staff interview, the facility failed to provide the recommendation of Occupational and Physical rehabilitation services as outlined in the Preadmission Screening and Resident Review (PASRR) for one (1) resident #63. The sample census was eighteen (18). Findings Include: Review of the Admission Record on 8/26/15 at 2:40 p.m. revealed resident# 63 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) admitted d 6-17-15 Section was noted that resident #63 had active [DIAGNOSES REDACTED]. The MDS Section C note Brief Interview for Mental Status (BIMS) score 5, and Section G Functional Increase for Activities of Daily Living (ADL) was noted yes, Review of the APS Healthcare Level II dated 5-27-15 on 8/25/15 at 2:54 p.m. revealed treatment recommendation for Skilled Nursing Facility (SNF) placement with rehabilitation. And 24/7 nursing supervision needed at temporary SNF placement for OT/PT rehabilitation to promote healing for eventual return to group home. Review of the admission orders [REDACTED]. The SGMC Lanier Campus Discharge Summary dated 6/4/15 revealed resident #63 was to continue with touchdown weight bearing only with PT. However, the Consulting Orthopedic Doctor order written on 6/5/15 was noted to continue TDWB with Physical Therapy (PT). On 6/5/15 the PT did an evaluation only citing patient not allowed to ambulate at this time and referred resident #63 to restorative nursing. There was no Occupational Therapy (OT) evaluation conducted. A Rehab Communication Tool form dated 6/8/15 noted discontinue PT effective 6/9/15 secondary severity of mental [MEDICAL CONDITION] and status [REDACTED]. Further investigation revealed that resident #63 was seen by the Consulting Orthopedic Doctor on 6/19/15 and to return in four weeks with x-rays of right hip and right femur; on 7/17/15 to continue treatment, weight bearing as tolerated with instructions do not force him/her to weight bear, but allow what weigh… | 2020-09-01 |
| 5431 | 5431 | PRUITTHEALTH - FORT OGLETHORPE | 115409 | 1067 BATTLEFIELD PARKWAY | FORT OGLETHORPE | GA | 30742 | 2015-03-05 | 242 | D | 0 | 1 | ZZBE11 | Based on observations, resident and staff interviews, the facility failed to honor meal perference/choice for one () residents (K) from a sample of thirty-two (32) residents. Findings Include: 1. Interview conducted 3/3/15 at 9:20am with resident K revealed that he used to get vegetable soup and a grilled cheese for his alternate meal but now he only gets cereal. K further indicated that for the past month the kitchen has served him the main menu and do not honor his request for vegetable soup and grilled cheese sandwich. The resident revealed he was told by the dietary staff that it is too much of a hassle to make him a grilled cheese sandwich and that he may eat cereal and milk instead. Interview on 03/03/15 at 12:10pm with the Dietary Manager revealed the meal alternative is decided each morning and is her choice. She further revealed that the alternate is posted with the main menu in the hall near the dining room each morning When the Dietary Manager was asked about a policy regarding if a resident did not like the meal or the alternate, she responded with you are talking about the vegetable soup and grilled cheese sandwich. She indicated that the facility stopped providing any other alternatives for meal choice other than the daily chef choice for a meal alternative because it got out of control, it was like a domino effect, everyone was asking for a grilled cheese sandwich. Interview conducted 03/05/15 at 10:45am with the Director of Nursing (DON) revealed that residents have the right to choose their meal and an alternate is provided. DON further revealed the if residents do not like the meal or alternate, they may ask for something else, provided they ask in advance. Choices can be voiced at any time; however, residents cannot choose an alternative during meal time. They must wait until after the meal time is completed, then they may ask for a different meal. Observation conducted 03/02/15 at 1:00pm revealed the menu was posted in hallway to dining room but no alternate choice was posted. Observation cond… | 2018-09-01 |
| 5432 | 5432 | PRUITTHEALTH - FORT OGLETHORPE | 115409 | 1067 BATTLEFIELD PARKWAY | FORT OGLETHORPE | GA | 30742 | 2015-03-05 | 282 | D | 0 | 1 | ZZBE11 | Based record review, and staff interview, the facility failed to follow plan of care for one (1) resident (A) from thirty-two (32) sampled residents. Findings include: Review of the care plan for resident A revealed a care plan related to poor dentition for teeth described as broken and discolored. An intervention for this was to provide medications as ordered and that the resident was receiving Magic mouth wash. This plan of care was developed on 5/29/2014 and was reviewed on 8/25/2014, 10/16/2014, and 1/14/2015 which continue to include the Magic Mouthwash as an intervention. Interview with Case Mix Coordinator CC conducted on 3/3/2015 at 2:00 p.m. revealed that the Magic Wash was ordered upon admission and was placed as one of the intervention, however, the Magic Wash was never ordered from the pharmacy and resident had never received it. Refer to F412, Example #1. | 2018-09-01 |
| 5433 | 5433 | PRUITTHEALTH - FORT OGLETHORPE | 115409 | 1067 BATTLEFIELD PARKWAY | FORT OGLETHORPE | GA | 30742 | 2015-03-05 | 412 | D | 0 | 1 | ZZBE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, resident and staff interviews the facility failed to provide dental services for two (2) residents ( A and B) from thirty-two (32) sampled residents. Findings includes: 1. Observation conducted on 3/2/15 at 12:39 PM for resident A revealed multiple stain, missing, decayed /and or broken teeth. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] assessed the resident as having natural broken teeth. Review of the Care Area (CAA) Assessment Summary for this assessment revealed that dental care triggered and would be care planned. Review of an oral assessment conducted admission on 5/20/2014 revealed the resident had six (6) missing teeth and poor oral health. Review of admission physician's orders [REDACTED]. Interview with resident A conducted 3/3/2015 at 1:20 p.m. revealed she have never use any mouth wash since her admission nor seen a dentist. Interviews conducted 3/3/2015 at 1:30 p.m. with two (2) Certified Nursing Assistant (CNA) AA and BB, who cared for resident A revealed that they have never given the resident any mouth wash during oral care. Interview with Case Mix Coordinator CC conducted 3/3/2015 at 2:00 p.m. revealed that the Magic Wash was ordered upon admission, however, it was never ordered from the pharmacy and resident has never received it. 2. Observation conducted 3/2/2015 at 2:19 PM of resident B revealed missing lower teeth, with dark stain on her natural teeth. Interview with resident B on 3/3/2015 at 1:36 p.m. revealed when she was admitted to the facility she had a lower partial denture plate. Following her admission to the facility her dentures became missing and staff were unable to locate them. She revealed that she has asked on several occasions for facility staff to assist her in scheduling an appointment to have her partial replaced, without success. She further revealed that she has to eat soft food because her missing teeth make it hard for her to chew. She… | 2018-09-01 |
| 5434 | 5434 | PRUITTHEALTH - FORT OGLETHORPE | 115409 | 1067 BATTLEFIELD PARKWAY | FORT OGLETHORPE | GA | 30742 | 2015-03-05 | 465 | D | 0 | 1 | ZZBE11 | Based on observations, resident and staff interviews the facility failed to provide a comfortable water temperature for bathing for two (2) residents (C and D) from a sample of thirty-two (32) residents. Findings Include: Interview with resident C on 03/03/15 at 9:43am revealed that water temperature in shower room was too cold. He indicated he had reported this Certified Nursing Assistant (CNA) and the nursing staff. Interview conducted with resident D on 03/04/15 at 3:10pm revealed he felt the water temperature in the men's shower room was cold. He indicated that it had been this way for quite some time and is worse in the winter months. Staff are aware and no one seems to know how to fix it. Interview conducted on 03/05/15 at 9:05am with CNA GG revealed that female residents complain about once or twice a week about the water in the shower rooms being too cold. When this happens we shut the water off in both the men's and women's shower rooms temporarily to give the water time to heat up again. We usually wait fifteen (15) to thirty (30) minutes. If this does not work we call maintenance. GG indicated that maintenance is usually called once or twice each week about the water in the shower rooms being too cold. Interview conducted with Maintenance Director on 03/05/15 at 09:20am revealed. he receives calls or verbal requests about the water being too cold in the shower rooms about once a week. He will adjust water valve and recheck the water temperatures to make sure the water temperatures are maintain at the proper temperature level for residents comfort. Water temperature for the Men's and Women's showers taken on 3/5/15 at 1:42pm by the Maintenance Director revealed the following: Men's Shower 96 and 98 degrees Fahrenheit (F.) Women's Shower 96 degrees F. | 2018-09-01 |
| 5831 | 5831 | CHAPLINWOOD NURSING HOME | 115477 | 325 ALLEN MEMORIAL DRIVE SW | MILLEDGEVILLE | GA | 31061 | 2014-06-26 | 309 | D | 0 | 1 | ZYGZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews the facility failed to obtain a physician's order for [MEDICAL TREATMENT] treatments, and failed to monitor the [MEDICAL TREATMENT] for one (1) resident (# 68) receiving [MEDICAL TREATMENT] from a sample of twenty-seven (27) residents Findings include: Record review revealed that resident # 68 was admitted to the facility on [DATE] with the following diagnoses; Hypertension, End Stage [MEDICAL CONDITIONS], Chronic [MEDICAL CONDITION] Fibrillation, [MEDICATION NAME] Degeneration, and [MEDICAL CONDITION]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident required extensive assistance with activities of daily living and was assessed as receiving [MEDICAL TREATMENT] while a resident in the facility. Review of the resident was care plan, initiated on 03/20/14, for alteration in health maintenance related to [MEDICAL CONDITION], revealed that the resident was receiving [MEDICAL TREATMENT] treatments at a local [MEDICAL TREATMENT] center and had a permacath in the right [MEDICATION NAME] for [MEDICAL TREATMENT] treatments. The interventions included; the resident will continue [MEDICAL TREATMENT] treatments without complications; ensure the resident attends [MEDICAL TREATMENT] treatments as scheduled; and observe access site for complications. Review of the medical records revealed no evidence of a physician order for [REDACTED]. Interview with Licensed Practical Nurse (LPN) GG on 06/25/14 at 8:40 a.m. revealed that resident # 68 was a [MEDICAL TREATMENT] patient and had an access site on her right upper chest that was covered by a dressing. Continued interview revealed that the site is checked each shift for signs of infection or drainage and that it is intact, but could provide no evidence that this monitoring was being done. Interview with the Director Of Nursing (DON) on 06/25/14 at 2:50 p.m. revealed that resident # 68 had [MEDICAL TREATMEN… | 2018-05-01 |
| 5832 | 5832 | CHAPLINWOOD NURSING HOME | 115477 | 325 ALLEN MEMORIAL DRIVE SW | MILLEDGEVILLE | GA | 31061 | 2014-06-26 | 371 | F | 0 | 1 | ZYGZ11 | Based on observation and staff interview the facility failed to properly cover and label food items in the walk-in freezer, properly demonstrate the use of the three (3) compartment sink, and properly maintain temperature of puree food on the steam table to prevent the potential for foodborne illness. Thirteen (13) residents were receiving a puree diet. Findings include: Observation on 06/23/14 at 10:25 a.m. of the walk-in freezer revealed that there was a clear plastic bag that contained boneless rib patties that were not labeled or dated. Continued observation of the walk-in freezer revealed an open, unwrapped bag of French fries on the right side middle shelf. Observation on 06/25/14 at 12:45 p.m. of tray line temperatures taken by the Dietary Supervisor using the facilities calibrated thermometer revealed that the puree beef had a temperature of one hundred six degrees Fahrenheit (106F?). Observation on 06/25/14 at 2:25 p.m. revealed the evening cook AA pureed cooked carrots for the dinner meal. Continued observation revealed that AA washed the puree equipment in soapy water, rinsed, then dipped the items in the sanitizer solution and placed on drying rack. AA did not submerge the equipment for sixty (60) seconds as recommended for the chemical use of Quaternary Ammonium Compound (Quat) sanitizer. Interview on 06/23/14 at 10:40 a.m. with the Dietary Supervisor revealed that she confirmed that the boneless rib patties did not have a date and the French fries were not wrapped. Continued interview revealed that she expects staff to label and date all food items before placing them in the freezer or the refrigerator. She also expects staff to wrap items before placing them in the freezer or refrigerator. Interview on 06/25/14 at 12:55 p.m. with the Dietary Manager revealed that she confirmed that the puree beef was at one hundred six degrees Fahrenheit (106F?) and not at the proper holding temperature of one hundred thirty five degrees Fahrenheit (135F?). Interview on 06/25/14 at 2:30 p.m. with AA revealed that s… | 2018-05-01 |
| 5833 | 5833 | CHAPLINWOOD NURSING HOME | 115477 | 325 ALLEN MEMORIAL DRIVE SW | MILLEDGEVILLE | GA | 31061 | 2014-06-26 | 441 | F | 0 | 1 | ZYGZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, and staff interview the facility failed to store resident personal care equipment in a sanitary manner on three (3) of three(3) halls. Findings include: 1. Observations on 06/23/14 beginning at 12:20 p.m. of the 100 Hall revealed the following: -room [ROOM NUMBER]-The bathroom shared by two (2) residents had an uncovered toothbrush, and toothpaste lying on the small metal shelf located under the mirror. There were two (2) uncovered bath basins observed on the shelf underneath the sink. -room [ROOM NUMBER]-The bathroom in room [ROOM NUMBER], a private room, revealed a urinal sitting on top of the toilet tank uncovered. -room [ROOM NUMBER]-The bathroom, shared by two (2) residents, had two (2) bath basins sitting on the shelf under the sink uncovered and stacked together and one (1) bedpan that was uncovered. -room [ROOM NUMBER]-The bathroom, shared by two (2) residents, had one (1) uncovered bed pan and two (2) uncovered bath basins under the sink on the shelf and one uncovered bath basin on the floor under the sink. -room [ROOM NUMBER]-The bathroom in room [ROOM NUMBER], a private room, had an uncovered bath basin in the bathtub, and an uncovered urinal hanging on the grab bar beside the toilet. Beside the residents bed on the floor was another uncovered bath basin. Observations on 06/24/14 beginning at 9:35 a.m. of the same bathrooms on the 100 hall revealed that the personal care equipment in each of the bathrooms remained uncovered Interview with the Director of Nursing (DON) on 06/26/14 at 3:00 p.m. revealed that the facility did not have a specific policy for personal care equipment but, it was her expectation that staff place all bedpans, urinals, and bath basins in a plastic bag when not in use. She further revealed that resident's care equipment should never be left uncovered when not in use, or on the floor. 2. Observation on 06/23/14 at 2:10 p.m. of room [ROOM NUMBER] revealed that the bathroom had two (2) pink… | 2018-05-01 |
| 2376 | 2376 | FRIENDSHIP HEALTH AND REHAB | 115559 | 161 FRIENDSHIP ROAD | CLEVELAND | GA | 30528 | 2018-10-04 | 656 | D | 0 | 1 | ZYEV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interview, the facility failed to implement the care plan related to oral care every shift, showers per facility policy, and clean nails as necessary for one resident (R) (R#61). In addition, the facility failed to implement the care plan related to monitoring for behaviors and side effects for one resident (R#48), who was routinely receiving an antipsychotic medication. The sample size was 34 residents. Findings include: Review of R#61's Admission Minimum Data Set ((MDS) dated [DATE] revealed that he had a Brief Interview for Mental Status (BIMS) score of 11 (a BIMS score of 8 to 12 indicates that a resident has moderately impaired cognition). Review of R#61's care plan for oral/dental health problems including several carious teeth dated 9/11/18, revealed an intervention for dental/oral care every shift and PRN (as needed). Review of R#61's self-care deficit related to activities of daily living care plan revised on 9/17/18 revealed interventions for bath/shower per facility policy and PRN. Shampoo hair regularly. Check nail length and trim/file and clean on bath day and as necessary. Provide sponge bath as needed. Assist/provide oral care [NAME]M. and P.M., clean gums with toothette, rinse mouth with wash. Assist resident with personal hygiene as needed. Review of the facility's shower schedules revealed that R#61 was scheduled to receive a shower on Tuesdays and Thursdays. During interview with R#61 on 10/2/18 at 8:55 a.m., he stated that he had not had a shower or bed bath, nor had mouth care, since he was admitted to the facility (on 9/11/18). Observation at this time revealed that his fingernails appeared dirty with dark debris both over and under his fingernails. Observation on 10/2/18 at 1:26 p.m. revealed that R#61's fingers appeared dirty, and had dark debris underneath the fingernails. R#61 denied receiving a bath, shower, or mouth care during interview at this time. During i… | 2020-09-01 |
| 2377 | 2377 | FRIENDSHIP HEALTH AND REHAB | 115559 | 161 FRIENDSHIP ROAD | CLEVELAND | GA | 30528 | 2018-10-04 | 657 | D | 0 | 1 | ZYEV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interview, the facility failed to notify two residents (R) (R#69 and R#171) of the dates of their scheduled care planning conferences, to enable these residents to participate in the development and/or revision of their care plans and allow them to make decisions about their care and treatment options. The sample size was 34 residents. Findings include: Review of the facility policy Care Planning-Interdisciplinary Team revised (MONTH) 2013 revealed: Policy Statement: Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. 1. During interview with R#69 on 10/1/18 at 4:03 p.m., she stated that she had never been invited to a care plan meeting, and that this was something she would be interested in. Review of R#69's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that she had a Brief Interview for Mental Status (BIMS) score of 14 (a BIMS score of 13 to 15 indicates that a resident is cognitively intact). Further review of her MDS revealed that she had MDS assessments completed on 12/28/17, 3/29/18, 5/30/18, 6/25/18, and 9/24/18. Review of R#69's Invitation to attend Resident Care Plan Meeting forms revealed that on 12/27/18 (sic), 3/22/18, 5/9/18, and 8/14/18, the invitations with dates of the scheduled care plan meetings were sent to the resident's responsible party (RP) listed on her admissions packet face sheet, but no evidence that R#69 was notified or invited to her meetings. Review of Plan of Care/MDS Notes dated 1/9/18, 4/3/18, 6/26/18, and 9/25/18 revealed: Note Text: Care plan reviewed with IDT (interdisciplinary team). Family did not attend. Continue with plan of care. Review of Care Plan Session for… | 2020-09-01 |
| 2378 | 2378 | FRIENDSHIP HEALTH AND REHAB | 115559 | 161 FRIENDSHIP ROAD | CLEVELAND | GA | 30528 | 2018-10-04 | 677 | D | 0 | 1 | ZYEV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interview, the facility failed to consistently provide showers, nail, and mouth care for one resident (R) (R#61). The sample size was 34 residents. Findings include: Review of R#61's Admission Minimum Data Set ((MDS) dated [DATE] revealed that he had a Brief Interview for Mental Status (BIMS) score of 11 (a BIMS score of 8 to 12 indicates that a resident has moderately impaired cognition); had no behaviors including rejection of care; needed supervision for personal hygiene; and extensive assistance for bathing. Review of R#61's care plan for oral/dental health problems including several carious teeth, revealed an intervention for dental/oral care every shift and PRN (as needed). Review of R#61's self-care deficit related to activities of daily living care plan revealed an intervention for bath/shower per facility policy and PRN. Shampoo hair regularly. Check nail length and trim/file and clean on bath day and as necessary. Provide sponge bath as needed. Assist/provide oral care [NAME]M. and P.M., clean gums with toothette, rinse mouth with wash. Assist resident with personal hygiene as needed. Review of the facility's shower schedules revealed that R#61 was scheduled to receive a shower on Tuesdays and Thursdays. During interview with R#61 on 10/2/18 at 8:55 a.m., he stated that he had not had a shower or bed bath since he had been admitted to the facility (21 days ago on 9/11/18), and that staff will tell him that they were going to come and get him, but never do. He stated during further interview that he would like a shower every day, and had never refused one. Observation at this time revealed that his fingernails appeared dirty with dark debris both over and under his fingernails, and stated during interview that he did not remember the last time they were cleaned. R#61 stated during continued interview that he had not had his teeth brushed since he had been there, and would like t… | 2020-09-01 |
| 2379 | 2379 | FRIENDSHIP HEALTH AND REHAB | 115559 | 161 FRIENDSHIP ROAD | CLEVELAND | GA | 30528 | 2018-10-04 | 758 | D | 0 | 1 | ZYEV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, review of the policy titled Documentation- Behavior Monitoring and staff interviews, the facility failed to ensure that behavior and medication side effect monitoring was conducted for one resident (R) (#48) that exhibited behaviors of verbal outburst, pacing/wandering, exit seeking and obsessive drinking and received [MEDICATION NAME], an antipsychotic medication. The sample was 34 residents. Findings include: Review of the facility policy titled Documentation- Behavior Monitoring dated 3/10/16 documented When a resident receives and antipsychotic medication that is medically indicated and may help promote or maintain the resident's highest practicable mental, physical, and psychosocial wellbeing, the resident will be placed on behavior or monitoring. 1- All residents receiving antipsychotic medications will have Behavior Monitoring to include side effects monitoring in place. 2- Nursing Management will review all medication orders daily. 3- If there is a new order for antipsychotic medication, the nurse manager reviewing will verify that the resident has also been placed on Behavior Monitoring with side effects monitoring. 6- Behavior Monitoring will be initiated on all residents with Behavior incident, and the resident will remain on Behavior Monitoring until the Behavior has resolved or stabilized and Behavior Par is discontinued. 7- Behavior Monitoring will be documented each shift on the EMAR by the Charge Nurse. R#48 was admitted to the facility with [DIAGNOSES REDACTED]. Record review for R#48 revealed an Admission Minimum Data Set (MDS) assessment dated [DATE] which demented a Brief Interview for Mental Status summary score of 99 indicating the resident was unable to complete the interview. Staff assessed that the resident was fidgety or restless and moved around more than usual. R#48 exhibited behavioral symptoms not directed towards others and received antianxiety and antidepressant medications… | 2020-09-01 |
| 4670 | 4670 | HARTWELL HEALTH AND REHABILITATION | 115435 | 94 CADE STREET | HARTWELL | GA | 30643 | 2015-08-13 | 164 | E | 0 | 1 | ZXZ911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of clinical records, facility policy and Quality Assurance Event documentation, resident and staff interviews, the facility failed to provide visual privacy in the shower room for six (6) residents ( A, B, C, D, E, and F) from a sample of thirty-four (34) residents. Findings include: An interview conducted on 08/11/15 at 9:39 a.m. with resident E revealed there are three (3) to four (4) naked women in the shower room at one time. Continued interview revealed that the resident was very uncomfortable with being unclothed in the presence of other residents. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) Summary score of 11 and was able to make her needs known. During an interview conducted on 08/11/15 at 2:06 p.m. with resident B revealed there are three (3) to four (4) women in the shower room at one time and they can see each other naked. Resident B indicated this makes her feel embarrassed because she is very modest. Review of the MDS assessment dated [DATE] revealed the resident Bhad a BIMS summary score of 15 which indicated that the resident was cognitively intact. An interview conducted on 08/12/15 at 11:30 a.m. with resident C revealed there was often times when several men would be in the shower room at one time with no privacy and they could see each other naked. The resident revealed he had told the administrator he was never going to the shower room again because he felt embarrassed. Review of MDS assessment completed on 05/25/15 indicated a BIMS summary score of 12. An interview conducted on 08/13/15 at 8:23 a.m. with resident D revealed there were times when there were two (2) to 3 residents in the shower room at one time undressed, and not provided with privacy. The resident explained she is modest and embarrassed being showered with other residents. Review of the MDS assessment dated [DATE] that indicated a BIMS summary… | 2019-08-01 |
| 4671 | 4671 | HARTWELL HEALTH AND REHABILITATION | 115435 | 94 CADE STREET | HARTWELL | GA | 30643 | 2015-08-13 | 223 | D | 0 | 1 | ZXZ911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview and staff interviews and review of the Abuse Prohibition Policy and Procedures, the facility failed to implement measures to protect two (2) residents (A and B) from a sample thirty four (34) residents from sexual abuse by a resident with a history of sexual advances and inappropriate touching of females. Findings include: Record review for Resident A revealed a Quarterly Minimum Data Set (MDS) assessment dated [DATE], Section C - Cognitive Patterns that the resident had a Brief Interview for Mental Status (BIMS) Summary Score of 15, indicating that the resident was cognitively intact. An interview conducted on 08/11/15 at 8:43 a.m. with resident A revealed about two (2) weeks ago, a visually impaired resident in the facility put his hand on her shoulder while walking then he slid his hand down her side and pinched her butt. She said she mentioned it to her Certified Nurse Assistant (CNA) BB that day and BB indicated that something should be done about this resident, that he touches the staff also. Record review for Resident B revealed a Quarterly MDS assessment dated [DATE], Section C BIMS Summary Score 15, indicating that the resident was cognitively intact. Continued record review of the Situation Background Assessment Recommendation (SBAR) Form and Progress Note dated 06/27/15 documents that resident B stated a male patient came into her room the previous evening and rubbed her face and touched her breast. She was offered but did not want to move to a different room. The Director of Nurses (DON) confirmed she was aware of the incident but it was not reported to the state because the resident did not want it reported. An interview conducted on 08/13/15 at 12:15 p.m. with resident B confirmed the above incident. She said she told the resident that he was in the wrong room and he needed to go back to his room in which he did comply. She said she did not tell anyone that night. She said she did repor… | 2019-08-01 |
| 4672 | 4672 | HARTWELL HEALTH AND REHABILITATION | 115435 | 94 CADE STREET | HARTWELL | GA | 30643 | 2015-08-13 | 225 | D | 0 | 1 | ZXZ911 | Based on observation, resident interview, staff interviews, record review and review of the Abuse Prohibition Policy and Procedures, the facility failed to report and thoroughly investigate the alleged sexual abuse of one (1) resident (B) by another resident from a sample of thirty four (34) residents. Findings include: Record review of the Situation Background Assessment Recommendation (SBAR) Form and Progress Note dated 06/27/15 documented that resident B stated a male patient came into her room the previous evening and was rubbing her face and touched her breast. She did not want to move to a different room and she did not want a call to her husband because she did not want him to know. During a joint interview conducted on 08/13/15 at 1:26 p.m. with the Administrator and the Director of Nursing (DON) confirmed there was an incident on 06/26/15 that involved a male resident going into the room of female resident with inappropriate touching. The DON confirmed she was aware of the incident but it was not reported to the State as required by the facility Abuse Prevention Policy because the resident did not want it reported. | 2019-08-01 |
| 4673 | 4673 | HARTWELL HEALTH AND REHABILITATION | 115435 | 94 CADE STREET | HARTWELL | GA | 30643 | 2015-08-13 | 241 | E | 0 | 1 | ZXZ911 | Based on observation, review of Quality Assurance Event documentation, review of facility policy, and resident and staff interviews, the facility failed to promote care in the shower room in a manner that maintained the dignity of six (6) residents (A, B, C, D, E and F) from a sample of thirty-four (34) residents. Findings include: An interview conducted on 08/11/15 at 9:39 a.m. with resident E revealed there are three (3) to four (4) naked women in the shower room at one time and she does not like that. She is very uncomfortable with this and she feels fat. She feels uncomfortable around the skinny residents and does not understand why they cannot be covered with a towel until it is time for their turn in the shower stall. On 08/11/15 at 2:06 p.m. an interview with resident A revealed there are 3 to 4 women in the shower room at one time and they can see each other naked. She said she had to lose her modesty a long time ago. She said it does not personally bother her but she realizes it might bother others. During an interview conducted on 8/13/15 at 8:23 AM with resident D, she revealed there were times when there were two (2) to three (3) residents in the shower room at one time in which they were all naked and not provided with privacy. She said she is a modest person and she does not like it. She said it was so embarrassing. An interview conducted on 8/13/15 at 8:27 AM with resident Brevealed in the women's shower room there is typically two (2) to three (3) residents at one time. She said they are naked in front of each other. She said this really bothers her because she is a very modest woman. She said she has never been comfortable with being naked and she never even got naked in front of her husband. She said she never told anyone because she was afraid to make a fuss. An interview conducted on 08/12/15 at 11:30 a.m. with resident C revealed there were often times when several men would be in the shower room together with no privacy and they could see each other naked. He said he told the Administrator t… | 2019-08-01 |
| 4674 | 4674 | HARTWELL HEALTH AND REHABILITATION | 115435 | 94 CADE STREET | HARTWELL | GA | 30643 | 2015-08-13 | 272 | D | 0 | 1 | ZXZ911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to accurately assess one (1) resident (#97) for the [MEDICAL CONDITION] drug usage from a sample of thirty-four (34) residents. Findings include: Review of the Minimum Data Set (MDS) for Significant Change dated 05/18/15 revealed that the resident was assessed as not receiving antipsychotic medications during the 7 day look back period for that assessment. Review of the record revealed a physician order [REDACTED]. Review of the Medication Administration Record [REDACTED]. Interview on 08/15/15 at 11:30 a.m. with Licensed Practical Nurse CC revealed that upon reviewing the Medication Administration Record [REDACTED]. | 2019-08-01 |
| 2919 | 2919 | WARNER ROBINS REHABILITATION CENTER | 115612 | 1601 ELBERTA ROAD | WARNER ROBINS | GA | 31088 | 2016-08-26 | 251 | E | 0 | 1 | ZXOF11 | Based on record review and staff interview, the facility failed to ensure that the facility's Social Worker had the proper qualifications for a facility with over one hundred and twenty (120) beds. The facility census was one hundred and fifteen (115) residents. Findings include: Review of the facility's licensure revealed that the facility is licensed for one-hundred and twenty-six beds (126). Review of the facility's personnel files on 08/25/16 at 1:30 p.m. revealed that the education documented for the current Social Worker was an Associate's degree in Psychology. Interview on 08/25/16 at 2:30 p.m. with the Administrator revealed that the Social Worker has over one (1) year of experience working as a social worker at the facility. Post survey interview on 09/02/16 at 11:00 a.m. with the Director of Nursing (DON) revealed that the Social Services Director currently has an Associate's Degree in Psychology, thirty (30) hours Social Services Training course from Georgia Health Care Association (GHCA). Post survey interview on 09/06/16 at 10:03 a.m. with the Administrator revealed that the Social Services Director was hired prior to his coming to the facility and he was not aware that she does not have a Bachelor's degree. The Administrator further stated that his expectation of the Social Service Director would be to perform all job duties to meet all of the residents social service needs and he stated that the Social Services Director does that. The Administrator went on to say, she not only meets the needs but she exceeds expectations. Review of Section C of the Resident Census and Condition of Residents dated 08/23/16 documents that the facility has fifty-four (54) residents with documented signs and symptoms of depression, twenty-seven (27) residents with documented psychiatric diagnosis' (not including residents with dementia or residents with depression), ten residents with behavioral healthcare needs. Review of Section F of the Resident Census and Condition of Residents dated 08/23/16 documents that the fac… | 2020-09-01 |
| 2920 | 2920 | WARNER ROBINS REHABILITATION CENTER | 115612 | 1601 ELBERTA ROAD | WARNER ROBINS | GA | 31088 | 2016-08-26 | 279 | D | 0 | 1 | ZXOF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop a care plan for urinary incontinence for one (1) Resident (R)137) of thirty-five (35) sampled residents. Findings include: Review of the clinical record note dated 06/01/16 for R137 revealed the resident was assessed by a urologist for gross hematuria (blood in the urine) and possible bladder mass. Findings from this same note revealed resident reported nocturia (the need to urinate at night) and occasional urine urgency. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] Section H Bladder and Bowel revealed that R137 was assessed to be frequently incontinent (7 or more episodes of urinary incontinence, but at least one episode of continent voiding). No indwelling catheter. Continued review of the MDS Section V - Care Area Assessment (CAA) Summary revealed that Urinary Incontinence triggered as a concern, with the decision made to care plan. Review of the Southern Health Care Management (SHCM) Incontinence Evaluation Form dated 4/19/16 revealed that R137 had been incontinent for one week to one month, had a history of [REDACTED]. Review of the SHCM Incontinence Evaluation Form dated 5/17/16 revealed that R137 had been incontinent for one (1) week to one (1) month, required assistance of from one to two people to walk to the bathroom, to transfers to the toilet or bedside commode. Review of the care plans for R137 revealed no evidence that a care plan for urinary incontinence had been developed. Interview with the Registered Nurse (RN) Care Specialist Manager AA and LPN Care Specialist Manager BB, on 08/24/16 at 2:20 P.M., revealed the RN Care Specialist Manager AA is responsible for all MDS assessments and evaluations for the Care Area Assessment (CAA) and LPN Care Specialist Manager BB uses that data to complete individualized care plans and revisions. Continued interview revealed that R137 did not have a care plan addressing urinary incontinence a… | 2020-09-01 |
| 2921 | 2921 | WARNER ROBINS REHABILITATION CENTER | 115612 | 1601 ELBERTA ROAD | WARNER ROBINS | GA | 31088 | 2016-08-26 | 371 | E | 0 | 1 | ZXOF11 | Based on observations, staff interviews, and facility policy review the facility failed to assure that food was labeled, dated, and not expired in the kitchen in one (1) of one (1) walk in coolers. The facility failed to ensure food was labeled, dated, and not expired in two (2) of two (2) resident pantry refrigerators (East and West wing). The facility failed to monitor temperatures for the refrigerator and the freezer in one (1) of two (2) resident refrigerators; and the facility failed to ensure there was no buildup on the on dispensing lid of the ice machine in one (1) of two (2) ice machines in the resident food pantry's. The resident sample size was thirty-five (35) and the census was one hundred and fifteen (115). Findings include: Observation on 08/24/16 at 12:15 p.m. of the walk in cooler in the kitchen revealed a twelve (12) pound box of diced ham that did not have a used by date. Further observation revealed five packages of ranch dressing packages that were not in their original package that were not labeled with a use by or expiration date. Review of the facility's policy titled Food Storage Principles revealed the following: each package, box, can, etc. should be labeled with the expiration date, date of receipt, or when the item was stored after preparation. Observation on 08/25/16 at 11:30 a.m. of the East Wing Resident food pantry revealed six (6) 3.5 ounce Jello cups with an expiration date observed to be 7/21/16 (over one month expired). Observation on 08/25/16 at 11:40 a.m. of the West Wing resident food pantry refrigerator revealed that there was not a thermometer in the freezer, further observation revealed one styrofoam cup with no name or date in the freezer, one (1) 24 ounce Everfresh Watermelon juice bottle that was not labeled or dated, one (1) Captain D ' s cup that was not labeled or dated, one (1) gallon container of 1% milk with an expiration date of (MONTH) 15 (ten days past the expiration date), and two (2) one (1) quart containers 2% milk that were not labeled. A sticky build up … | 2020-09-01 |
| 2922 | 2922 | WARNER ROBINS REHABILITATION CENTER | 115612 | 1601 ELBERTA ROAD | WARNER ROBINS | GA | 31088 | 2016-08-26 | 441 | D | 0 | 1 | ZXOF11 | Based on observations and staff interviews, the facility failed to store wash basins, urinals, combs, and toothbrushes in a manner to prevent possible contamination in seven (7) of the thirty (30) shared bathrooms. The sample size was thirty-five (35) and the facility census was one hundred and fifteen (115). Findings include: 1. During an observation on 8/22/16 at 11:50 a.m. in the shared bathroom of room A-2 there were two (2) urinals sitting on the bathroom counter that were not labeled or in a plastic bag. This bathroom is noted to be shared by three residents. 2. During an observation on 8/22/16 at 11:54 a.m. in the shared bathroom of room A-11 there was one (1) urinal that was not labeled or in a plastic bag. This bathroom is noted to be shared by three residents. 3. During an observation on 8/22/16 at 11:56 a.m. in the shared bathroom of room C-1 there was one (1) urinal and one (1) wash basin observed on the shelf not bagged or labeled, one (1) wash basin on the floor, one (1) toothbrush and one (1) comb on bathroom counter not labeled or bagged. This bathroom is noted to be shared by three residents. 4. During an observation on 8/22/16 at 2:42 p.m. in the shared bathroom of room C-9 there was one (1) unlabeled wash basin that was not in a plastic bag. This bathroom is noted to be shared by three residents. 5. During an observation on 8/23/16 at 3:44 p.m. in the shared bathroom of room C-9 there was one (1) unlabeled wash basin that was not in a plastic bag. 6. During an observation on 8/23/16 at 1:12 p.m. in the shared bathroom for room D-1 there were two (2) toothbrushes that were not labeled or in a plastic bag, one (1) toothbrush bagged but not labeled, and two (2) yellow wash basins on the shelf in the bathroom that were not labeled or in a plastic bag. This bathroom is noted to be shared by two residents. 7. During an observation on 8/23/16 at 12:38 p.m. in the shared bathroom of room D8 there was one (1) wash basin on the shelf in the bathroom that was not labeled and was not in a plastic bag, and … | 2020-09-01 |
| 2202 | 2202 | ARROWHEAD HEALTH AND REHAB | 115539 | 239 ARROWHEAD BOULEVARD | JONESBORO | GA | 30236 | 2018-05-10 | 656 | D | 0 | 1 | ZXJG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, the facility failed to implement observations of target behaviors, side effects and adverse reactions of psychoactive medications according to the care plan interventions for one resident (R) #56, from a sample of 22 residents. Findings include: Record review revealed that R #56 was admitted to the facility on [DATE] with psychiatric [DIAGNOSES REDACTED]. The resident was prescribed [MEDICATION NAME] for dementia, [MEDICATION NAME] for [MEDICAL CONDITION] and [MEDICATION NAME] for anxiety on admission. Review of the resident care plan dated 2/20/18 revealed the resident was care planned for [DIAGNOSES REDACTED]. She takes psyche (sic) meds. Further review of the care plan revealed the following interventions were to be implemented: Administer medications as ordered. Observe/document for side effects and effectiveness. Observe/record occurrence for target behavior symptoms and document per facility protocol. Observe/record/report to MD as needed (prn) side effects and adverse reactions of psychoactive medications. Review of R #56's electronic medical record, Medication Administration Record [REDACTED]. An interview was conducted with Licensed Practical Nurse (LPN) BB on 5/9/18 at 8:45 a.m. at the medication cart. LPN BB was asked what type of behavioral monitoring was conducted for the medications given to R #56. She stated she would have to look it up in the Physician's Desk Reference (PDR). LPN BB was asked where this is documented, and she replied that it is documented in the nursing notes or on a behavior monitoring record in the electronic chart. An interview was conducted with the Director of Nursing(DON) on 5/9/18 at 10:59 a.m. in the DON's office. The DON was requested to locate any documentation related to behavioral monitoring and side effects/effectiveness of psychoactive medications for R #56. The DON was unable to produce the behavioral monitoring documentation for Feb… | 2020-09-01 |
| 2203 | 2203 | ARROWHEAD HEALTH AND REHAB | 115539 | 239 ARROWHEAD BOULEVARD | JONESBORO | GA | 30236 | 2018-05-10 | 842 | D | 0 | 1 | ZXJG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record and facility document review it was determined the facility failed to document accurately the administration of medications for one resident (R) (#56)from a census of 106 residents. Findings include: Record review revealed #56 was admitted to the facility on [DATE] with psychiatric [DIAGNOSES REDACTED]. The Admission Minimum Data Set ((MDS) dated [DATE], Section C Cognitive Patterns, C indicated the resident did not receive a Brief Interview for Mental Status (BIMS) due to resident is rarely/never understood. The staff assessment for mental status section C1000 indicated R #56 cognitive skills were severely impaired. Review of R #56's physician's orders [REDACTED]. Review of the resident's electronic Medication Administration Records (MAR) for February, March, (MONTH) and (MONTH) (YEAR) indicated that both the donepezil five mg twice daily and [MEDICATION NAME] 10 mg once daily was documented as given from 4/19/18 through 5/8/18 by nursing for a total dose of 20 mg daily for 20 days. An observation was conducted on 5/9/18 at 8:45 a.m. during the morning medication pass with Licensed Practical Nurse (LPN) BB. LPN BB pointed out the duplicate order on the electronic MAR and stated, This is wrong, I need to get it clarified by pharmacy and the physician, before I can give it. The nurse proceeded to call pharmacy and spoke to Pharmacist AA at 9:10 a.m., who verified that both orders were on the MAR. A review of the Pharmacy Consultation Report dated 4/30/18 revealed the Consultant Pharmacist' comment has order for donepezil 5mg twice daily. The recommendation was Please consider changing donepezil to 10 mg in the evening (d/c previous order). Physician's Response was marked as I decline the recommendation above and do not wish to implement any changes due to the reasons below: Resident currently on donepezil 10mg daily in am. (dated 5/3/18) Order was faxed to physician's office. Spoke with (Medical Doctor) … | 2020-09-01 |
| 7939 | 7939 | ROSEMONT AT STONE MOUNTAIN | 115565 | 5160 SPRING VIEW AVENUE | STONE MOUNTAIN | GA | 30083 | 2013-09-29 | 282 | G | 1 | 0 | ZXFN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility failed to provide services, related to incontinence care to address pressure sore prevention, as specified by the care plan for one (1) resident (#1), of three (3) residents having pressure sores, on the survey sample of eleven (11) sampled residents. Resident #1 subsequently developed two (2) dime-sized Stage 2 pressure sores. Findings include: Cross refer to F314 for more information regarding Resident #1. Record review for Resident #1 revealed an Annual Minimum Data Set assessment with an Assessment Reference Date of 09/03/2013 which documented, in Section I - Active Diagnoses, that the resident had [DIAGNOSES REDACTED]. The Care Plan for Resident #1 dated 9/11/2013 identified that the resident was at risk for pressure-sore development, and identified as Approaches to keep the resident as clean and dry as possible, to keep the linens clean and dry, and to provide incontinence care after each incontinent episode. During observation in the day room on 09/21/2013 at 12:00 noon, Resident #1 was noted to have a strong urine odor. A later interview, conducted on 09/21/2013 at 2:35 p.m., with Certified Nursing Assistant (CNA) EE revealed that this CNA had changed Resident #1's brief around 1:00 p.m., at the request of a nurse. Interview with Charge Nurse FF on 09/21/2013 at 2:40 p.m. revealed that Resident #1 been in the day room the entire morning, and that the nurse had to ask CNA EE to change Resident #1 at 1:00 p.m., when she smelled a urine odor. During a 09/21/13, 2:42 p.m. observation with Nurse FF and Nurse GG in attendance, even though Resident #1's diaper was dry after having been changed around 1:00 p.m., the draw sheets under the resident were still saturated with urine, and two Stage 2 pressure sores were observed on the resident's buttocks. During a 09/21/2013, 3:10 p.m. observation with the Wound Manager/Assistant Director of Nursing in attendance, this nurse ac… | 2016-09-01 |
| 7940 | 7940 | ROSEMONT AT STONE MOUNTAIN | 115565 | 5160 SPRING VIEW AVENUE | STONE MOUNTAIN | GA | 30083 | 2013-09-29 | 314 | G | 1 | 0 | ZXFN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility failed to ensure that one (1) resident (#1), of three (3) sampled residents having pressure sores, on the survey sample of eleven (11) residents, received the necessary care to prevent pressure sore reoccurrence. This failure resulted in harm for Resident #1, who developed two dime-sized Stage 2 pressure sores after the failure to provide timely incontinence care. The findings include: Record review for Resident #1 revealed an Annual Minimum Data Set (MDS) assessment with an Assessment Reference Date of 09/03/2013 which documented, in Section C - Cognitive Patterns, that the resident had a Brief Interview for Mental Status score of 4, indicating severe cognitive impairment. Section I - Active [DIAGNOSES REDACTED]. Section H - Bladder and Bowel documented that the resident was always incontinent of both bowel and bladder, and Section G - Functional Status documented that the resident was totally dependent on staff for toilet use. Section M - Skin Conditions of this MDS documented that at the time of the assessment, the resident had no unhealed pressure sores, but that the resident did have a history of Stage 2 pressure sores. Further record review for Resident #1 revealed no documented evidence of any current pressure sores. During an observation conducted in the day room on 09/21/2013 at 12:00 noon, Resident #1 was observed to be seated in a geri-chair, and a strong urine odor was noted at that time. During a later observation of Resident #1 conducted in the resident's room on 09/21/2013 at 2:24 p.m., the resident was observed in bed. A strong urine odor was noted upon entering the room, which was even stronger at the resident's bedside. During an interview with Certified Nursing Assistant (CNA) EE conducted on 09/21/2013 at 2:35 p.m., this CNA stated that he had changed Resident #1's brief just before the resident's lunch tray arrived around 1:00 p.m., at the request of a… | 2016-09-01 |
| 6080 | 6080 | PROVIDENCE HEALTHCARE | 115484 | 1011 SOUTH GREEN STREET | THOMASTON | GA | 30286 | 2015-04-02 | 282 | G | 1 | 0 | ZW7F11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, hospital history and physical examination [REDACTED]. The total survey sample consisted of seven (7) residents. The failure of the facility to ensure mechanical lift transfer for Resident X, as specified by the Care Plan, resulted in actual harm for Resident X, who was lowered to the floor during a chair-to-bed transfer and sustained a fractured arm and leg. Findings include: Record review revealed the Quarterly Minimum Data Set assessment of November 2014 to document, in Section I-Active Diagnoses, that Resident X had [DIAGNOSES REDACTED]. Section G - Functional Status documented Resident X's limitation/impairment in Range of Motion in the upper/lower extremities on both sides, and that he/she was totally dependent on staff for transfer. Review of the Care Plan for Resident X revealed a Problem/Need, originally dated October of 2014, which identified the resident to be at risk for falls related to reasons which included the [DIAGNOSES REDACTED]. An Approach included on the Care Plan to address the resident's risk for falls specified that the resident was to be transferred via total lift with the assistance of two (2) staff. However, despite the Care Plan of Resident X specifying the use of a lift during transfers as referenced above, a 01/02/2015, 5:25 p.m. Nurse's Notes entry for Resident X documented that certified nursing assistants (CNAs) transferred the resident from chair-to-bed by pivot transfer (instead of a lift, as required). This Nurse's Notes entry documented that Resident X could not bear weight and began going down, and due to the complaint of pain, an order for [REDACTED]. The 01/02/2015 Radiology Report for Resident X documented a moderately displaced fracture involving the proximal shaft of the right humerus, and a minimally displaced left femur fracture. A hospital History and Physical (H&P) Examination form for Resident X then documented hospital transfer and admission on 01/03/2015… | 2018-04-01 |
| 6081 | 6081 | PROVIDENCE HEALTHCARE | 115484 | 1011 SOUTH GREEN STREET | THOMASTON | GA | 30286 | 2015-04-02 | 323 | G | 1 | 0 | ZW7F11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, staff interview, hospital history and physical examination [REDACTED]. The total survey sample was seven (7) residents. This failure to transfer Resident X via mechanical lift as required resulted in actual harm for Resident X, who was lowered to the floor during transfer from the chair to the bed and sustained a fractured arm and leg. Findings include: Record review for Resident X revealed a Quarterly Minimum Data Set (MDS) assessment having an Assessment Reference Date of November 2014 which documented in Section I - Active [DIAGNOSES REDACTED]. Section C - Cognitive Patterns of this MDS documented Resident X to have a Brief Interview for Mental Status Summary Score of 13, indicating the resident was cognitively intact. Further review of the MDS assessment of Resident X referenced above revealed that Section G - Functional Status documented the resident had limitation in Range of Motion and impairment in both the upper and lower extremities on both sides, and that the resident was totally dependent on two-plus staff persons for transfer between surfaces. The Care Plan of October 2014 for Resident X identified that the resident was at risk for falls and specified that the resident was of a total-lift status. A Nurse's Notes entry of 01/02/2015, timed at 5:25 p.m., for Resident X documented that certified nursing assistants (CNAs) were transferring the resident from a Broda chair to the bed by way of a pivot transfer. This Nurse's Notes entry documented that Resident X could not stand or bear weight due to his/her [DIAGNOSES REDACTED]. The Nurse's Notes entry documented that Resident X was then placed in bed and began complaining of pain in the right upper arm and left thigh, and an order for [REDACTED]. A Physician's Telephone Orders form of 01/02/2015 for Resident X specified a STAT X-ray of the right arm humerus, elbow, and forearm related to pain, and a STAT X-ray of the left leg femur and tibul… | 2018-04-01 |
| 6082 | 6082 | PROVIDENCE HEALTHCARE | 115484 | 1011 SOUTH GREEN STREET | THOMASTON | GA | 30286 | 2015-04-02 | 498 | G | 1 | 0 | ZW7F11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, staff interview, hospital history and physical examination [REDACTED]. A total of seven (7) residents were sampled. The failure to ensure mechanical lift transfer for Resident X resulted in actual harm, when Resident X was lowered to the floor during transfer and sustained a fractured arm and leg. Findings include: Resident X's November 2014 Quarterly Minimum Data Set assessment documented diagnoses, in Section I-Active Diagnoses, including, but not limited to, Hypertension and [DIAGNOSES REDACTED], and Section C - Cognitive Patterns documented a Brief Interview for Mental Status Score of 13, indicating he/she was cognitively intact. Resident X's Care Plan identified a risk for falls and specified that he/she was total-lift status. However, a 01/02/2015, 5:25 p.m. Nurse's Notes entry documented that as certified nursing assistants (CNAs) were transferring Resident X from chair-to-bed by pivot transfer (rather than mechanical lift transfer as required), Resident X began going down. This Nurse's Notes entry documented that Resident X complained of right arm and left thigh pain, and a 01/02/2015 Radiology Report documented X-ray results revealing a moderately displaced [MEDICAL CONDITION] shaft of the right humerus and a minimally displaced left femur fracture. A 01/03/2015, 7:30 a.m. Nurse's Notes entry documented that Emergency Medical Services staff arrived to transport Resident X to the hospital, and the hospital history and physical examination [REDACTED]. The facility's investigation into the 01/02/2015 incident involving Resident X revealed facility Action Record forms for CNA SS and CNA ZZ documenting that, although Resident X required lift transfer, these CNAs used a stand-and-pivot transfer (rather mechanical lift transfer) to transfer Resident X, and he/she sustained right humerus and left femur fractures. During an interview with Resident X conducted on 01/28/2015 at 5:45 p.m., the resident… | 2018-04-01 |
| 10466 | 10466 | FOX GLOVE CENTER | 115569 | 2850 SPRINGDALE ROAD SW | ATLANTA | GA | 30315 | 2011-03-15 | 157 | D | 1 | 0 | ZVWY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility policy, and staff interview, the facility failed to notify the family in a timely manner of a change in condition for one (1) resident (#1) out of a sample of four (4) residents. Findings include: Review of the Interdisciplinary Progress Notes dated 1/2/11 revealed that resident #1 was observed during care to have a skin tear to the right buttock, the physician was contact and a [MEDICATION NAME] dressing was ordered. The responsible party was notified. On 1/10/11 the physician's order was changed to cleanse the right buttocks with wound cleanser and apply santyl ointment, and a wet to dry dry dressing with Dakin's solution daily. Continue review from 1/2/11 until resident went to the hospital on [DATE], revealed there was no evidence that the responsible party/family was notified that the skin tear progressed to a bed sore and/or that the treatment had changed. Review of the Pressure Ulcer Documentation Form for January 2011 for resident #1 revealed that there was a stage three (3) pressure sore on the sacrum, which progressed from 4x6 on 1/6/11 to 4x6.3 on 1/12/11 with no tunneling and/or undermining present. However, there was no evidence the family was notified of this change. Review of the facility policy, "Change in Condition of a Resident", effective date 1/2008, revealed the facility is to take appropriate action and provide timely communication to the resident's physician and responsible party relating to a change in condition of a resident. Interview with the Director of Nursing (DON) on 3/15/11 at 2:20 p.m., revealed that the family should have been notified and was unable to give a particular reason why they were not notified in change of condition. | 2014-07-01 |
| 10467 | 10467 | FOX GLOVE CENTER | 115569 | 2850 SPRINGDALE ROAD SW | ATLANTA | GA | 30315 | 2011-03-15 | 441 | D | 1 | 0 | ZVWY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure that staff maintained a clean field during dressing change of a pressure ulcer for one (1) resident (#2) from four (4) sampled residents. Findings include: Observation of a pressure ulcer treatment for [REDACTED]. all supplies and placed them on the built in dresser in the resident's room. The supplies were a box of gloves, a small pink tray with two (2) stacks of gauzes, a box of Santyl, a bottle of wound cleanser, tape and on top of one (1) stack of gauze was a non-stick dressing. Also, a clear plastic bag was placed on the bed. The nurse washed her hands and donned gloves prior to starting. The old dressing was already removed, so the nurse cleansed the wound, removed her gloves, and placed her balled up gloves to the left side of the pink tray with the gauzes and non-stick dressing. The nurse then washed her hands, gloved and cleaned the wound. After cleaning she removed her gloves and placed them in the bag on the bed, then washed hands and gloved again. At that time, she moved the non-stick dressing from the stack of gauze and placed it on the balled up soiled gloves and proceed to open the Santyl and place Santyl on the dressing. Then the nurse cleanse the wound again, removed gloves, and her washed hands. At this point, when the nurse went to get gloves out of the box, which was next to the dressing with the Saintly on it, the gloves were hard to come out and the nurse had to pull on the box which caused the bos to be lifted up and when lowered back down was lowered onto the Santyl dressing. She then applied the dressing to the resident's wound and secured the dressing with tape. Interview with the Director of Nursing (DON) on 3/15/11 at 3:15 p.m. revealed the soiled gloves should never have been placed next to the tray nor should have the Santyl dressing have been placed on the resident after contact with the glove box. Interview with the Staff Development Coordi… | 2014-07-01 |
| 10473 | 10473 | AZALEA HEALTH AND REHABILITATION | 115642 | 300 CEDAR ROAD | METTER | GA | 30439 | 2009-03-31 | 364 | E | 1 | 0 | ZVRN11 | Based on resident interview and a test tray, the facility failed to serve foods at the proper temperature for four (4) residents of ten (10) sampled residents. Findings include: During an interview conducted on 03/31/2009 at 10:30 a.m., Resident "D" stated that the food that was served was cold, and that staff did not ask to reheat the food. During an interview conducted on 03/31/2009 at 10:05 a.m., Resident "A"stated the food that was served earlier that morning was cold and that the three (3) meals served the previous day were all cold. Also, the resident stated that the food had always been cold since he/she had lived in the facility. Resident "B" stated during an interview conducted on 03/31/2009 at 10:20 a.m. that the food was sometimes cold and that staff never asked if they could reheat the food. Resident "C" stated during an interview conducted on 03/31/2009 at 10:55 a.m. that the food was always cold at breakfast. The surveyor was served a test tray at 12:15 p.m. on 03/31/2009, and the pork chop and gravy were only lukewarm. | 2014-07-01 |
| 5541 | 5541 | MEADOWBROOK HEALTH AND REHAB | 115561 | 4608 LAWRENCEVILLE HIGHWAY | TUCKER | GA | 30084 | 2015-08-11 | 314 | D | 1 | 0 | ZVO111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that an indwelling urinary drainage catheter did not cause a pressure ulcer on the meatus of one resident's penis (Z) in a sample of three residents with in-dwelling urinary catheters in a total sample of eight (8). Findings include: Health record review indicated that resident Z was admitted into the facility in (MONTH) of (YEAR). His [DIAGNOSES REDACTED]. Resident Z Brief Interview for Mental Status Score (BIMS) was nine (9) on the (MONTH) 9, (YEAR) quarterly assessment. Interview with the medication nurse CC on 08/12/15 at 1:15 p.m. revealed that resident Z returned from the hospital with a catheter in July. Interview with CNA II on 08/12/15 at 1:24 p.m. revealed that she did catheter care for resident Z on 08/4/15 and reported an open area on his penis to the nurse on that day. Observed the Skin Care Alert form dated 08/4/15 that the CNA provided to the nurse. Review of the Pointclickcare electronic nurses progress notes dated 08/04/15 at 7:35 p.m. for resident Z indicated that the resident was noted during activity of daily living (adl) care to have open areas around the tip of his penis with swelling and a foul odor. Resident Z was seen by the urologist on 08/04/15 and it was noted that he had raw non-infected skin on the meatus visible and nml. There were no physician's orders for care to resident Z's penile ulcer. Review of the facility policy for Urinary Catheter Care indicated in the Complication section D that the staff were to report any complaints the resident may have of burning, tenderness or pain in the urethral area. There was not further record in the nursing progress notes of the ulcer to resident Z's penis. On 08/10/15 at 12:46 p.m. the wound nurse documented on the Nursing: Weekly Skin condition Report (Pressure and Non Pressure Combined, Option 2) that resident Z had trauma via catheter on the meatus of his penis that measured 0.7 centimeter … | 2018-08-01 |
| 5542 | 5542 | MEADOWBROOK HEALTH AND REHAB | 115561 | 4608 LAWRENCEVILLE HIGHWAY | TUCKER | GA | 30084 | 2015-08-11 | 328 | D | 1 | 0 | ZVO111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that oxygen therapy was administered at the rate ordered by the Physician for one resident (X) of three residents with oxygen sampled in a total sample of eight (8) residents. Findings include: Health record review for resident X indicated a physician's orders [REDACTED]. Resident X was observed with Oxygen at 3.5 l/m on 08/11/15 at 4:00 p.m A second observation of resident X with Oxygen at 3.5 l/m on 08/12/15 at 7:45 a.m. The oxygen was observed on 8/12/15 on resident XX at 10:40 AM. Interview with the Director of Nursing (DON) on 08/12/15 at 10:45 a.m. revealed that resident X's oxygen order should have carried over onto the (MONTH) (YEAR) Physician order [REDACTED]. She added that the Oxygen orders were reviewed yesterday on 08/11/15. Resident X was observed with the DON on 08/12/15 at 10:45 a.m. with oxygen per nasal cannula at 3.5l/m. The oxygen rate of 3.5 l/m was confirmed with the DON. The DON immediately lowered the rate of the oxygen to 2 l/m and said that it was supposed to be on 2l/m not 3.5 l/m. | 2018-08-01 |
| 501 | 501 | DOUGLASVILLE NURSING AND REHABILITATION CENTER | 115273 | 4028 HWY 5 | DOUGLASVILLE | GA | 30135 | 2019-01-11 | 568 | D | 0 | 1 | ZVL511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interviews, staff interviews, and the review of the facility policy Resident Trust Fund the facility failed to provide resident trust fund account quarterly statements for three of three resident (R) A, R B, and R C reviewed. One hundred and eleven (111) resident trust fund accounts are managed by the facility. Findings included: Review of the policy updated 4/2014 titled, Resident Trust Fund revealed send statements to the resident or responsible parties, at a minimum on a quarterly basis. 1. Record review for R A was admitted to the facility on [DATE]. Review of a Minimum Data Set (MDS) annual assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) summary score of 7 out of 15 which indicates the resident is severe impairment. During an interview on 12/16/18 at 12:41 p.m. with R A regarding his trust fund account that the facility manages. Resident A revealed he has a trust fund account with the facility. Resident A revealed he does not receive a quarterly statement for his trust fund account that the facility manages. 2. Record review for R B was admitted to the facility on [DATE]. Review of an MDS quarterly assessment dated [DATE] revealed a BIMS of 13 out of 15 which indicates the resident is cognitively intact. During an interview on 12/16/18 at 1:01 p.m. with R B regarding his trust fund account that the facility manages. Resident B revealed he does not receive a quarterly statement for his trust fund account that the facility manages. Resident B revealed if he asks for his balance the staff will verbally tell him how much he has in his account. An Interview was conducted on 12/7/18 at 2:50 p.m. with QQ Business office Assistant regarding resident trust funds account. QQ Business office Assistant verified that R A and R B has a trust fund accounts that the facility manages. An Interview was conducted on 12/7/18 at 3:00 p.m. with RR the Business Office Manager (BOM) regarding resident's trust funds … | 2020-09-01 |
| 502 | 502 | DOUGLASVILLE NURSING AND REHABILITATION CENTER | 115273 | 4028 HWY 5 | DOUGLASVILLE | GA | 30135 | 2019-01-11 | 656 | D | 0 | 1 | ZVL511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff, resident, and family interview the facility failed to follow the care plan for one resident (R) (R#224) related to providing diabetic ulcer treatment as order. The sample size was 87 residents. Findings include: Review of the Minimum Data Set (MDS) Admission assessment dated [DATE] for R#224 revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating R#224 to be cognitively intact. Section G Functional Status revealed R#224 requires 2-person assistance for toileting. Section H Bowel and Bladder (B&B) revealed R#224 is always incontinent of bowel and bladder. Section I Active [DIAGNOSES REDACTED]. Review of the resident's care plan revealed a problem onset date of 11/21/18 related to pressure ulcer/potential for skin breakdown related to impaired mobility, incontinent of bowel and bladder, frequent diarrhea, multiple diabetic ulcers of the right foot and first and second fingers. Left below the knee [MEDICAL CONDITION]. Has abdominal abscess. History of reversal ostomy. Fragile skin. Resident noted to pick at skin; [DIAGNOSES REDACTED]. Approaches: Labs/Meds/Treatments as ordered. Notify the MD/NP of abnormal findings. An interview on 12/16/18 at 1:37 p.m. with the resident revealed that he has a wound on his right foot and it is supposed to be changed every other day but the last time it was changed was last week. Observation during this time of dressing on the right foot revealed a date of 12/12 (2018) written on tape attached to the dressing. A second interview on 12/17/18 at 1:15 p.m. with the resident revealed that the dressing to his right foot has not been changed. Observation of the dressing, at this time, revealed a date of 12/12 (2018) written on tape attached to the dressing. During an interview on 12/17/18 at 1:20 p.m. with Licensed Practical Nurse (LPN) KK in the resident's room, revealed that the dressing to the resident's right foot is dated 12/12 (2018). During an inter… | 2020-09-01 |
| 503 | 503 | DOUGLASVILLE NURSING AND REHABILITATION CENTER | 115273 | 4028 HWY 5 | DOUGLASVILLE | GA | 30135 | 2019-01-11 | 657 | D | 0 | 1 | ZVL511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to update the care plan to include a change from Foley catheter to Suprapubic catheter for one resident (R#137) of 87 sampled residents. Findings include: Review of the medical record for R#137 revealed the resident was admitted on [DATE]. Further review revealed the resident had a [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) of 99 indicating severe cognitive impairment. Review of the resident's care plan, updated on 10/30/18, revealed that the resident had an indwelling catheter with supporting diagnosis. Goals and approaches include but not limited to change Foley as directed in catheter policy and monitor for signs and symptoms of Urinary Tract Infection [MEDICAL CONDITION]. Review of the nephrology Consult dated 8/13/18 revealed recommendations for the resident to return for further tests. Review of the nephrology assessment and plan include but is not limited to; problem: [MEDICAL CONDITION] with chronic Foley; plan: Urology planning for Suprapubic catheter. In an interview on 12/19/18 at 10:45 a.m. with the dayshift unit manager of 300 hall, LPN AA, confirmed that the care plan has not been up-dated to show the suprapubic catheter that was inserted on 11/5/18 before this time. LPN AA further revealed that it is ultimately her responsibility to ensure that the care plan is updated with new and changing information and that the staff were made aware of the change in report that is held every shift. | 2020-09-01 |
| 504 | 504 | DOUGLASVILLE NURSING AND REHABILITATION CENTER | 115273 | 4028 HWY 5 | DOUGLASVILLE | GA | 30135 | 2019-01-11 | 684 | D | 1 | 1 | ZVL511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, staff, resident, and family interview the facility failed to follow the care plan for one resident (R) (R#224) related to providing diabetic ulcer treatment as order. The sample size was 87 residents. Findings include: Review of the Minimum Data Set (MDS) Admission assessment dated [DATE] for R#224 revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating R#224 to be cognitively intact. Section G Functional Status revealed R#224 requires 2-person assistance for toileting. Section H Bowel and Bladder (B&B) revealed R#224 is always incontinent of bowel and bladder. Section I Active [DIAGNOSES REDACTED]. Review of the resident's care plan revealed a problem onset date of 11/21/18 related to pressure ulcer/potential for skin breakdown related to impaired mobility, incontinent of bowel and bladder, frequent diarrhea, multiple diabetic ulcers of the right foot and first and second fingers. Left below the knee [MEDICAL CONDITION]. [DIAGNOSES REDACTED]. Approaches: Labs/Meds/Treatments as ordered. Notify the MD/NP of abnormal findings. An interview on 12/16/18 at 1:37 p.m. with the resident revealed that he has a wound on his right foot and it is supposed to be changed every other day but the last time it was changed was last week. Observation during this time of dressing on the right foot revealed a date of 12/12 (2018) written on tape attached to the dressing. A second interview on 12/17/18 at 1:15 p.m. with the resident revealed that the dressing to his right foot has not been changed. Observation of the dressing, at this time, revealed a date of 12/12 (2018) written on tape attached to the dressing. During an interview on 12/17/18 at 1:20 p.m. with Licensed Practical Nurse (LPN) KK in the resident's room, revealed that the dressing to the resident's right foot is dated 12/12 (2018). During an interview on 12/17/18 at 1:22 p.m. with Unit Manager FF revealed that the dressing to the resident's… | 2020-09-01 |
| 505 | 505 | DOUGLASVILLE NURSING AND REHABILITATION CENTER | 115273 | 4028 HWY 5 | DOUGLASVILLE | GA | 30135 | 2019-01-11 | 689 | E | 0 | 1 | ZVL511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility failed to maintain safe water temperatures in resident rooms (sinks) on three of five units. The census was 220. Findings include: Observation on 12/16/18 at 2:47 p.m. revealed the hot water at the sink of room [ROOM NUMBER] on the MT unit was uncomfortably hot to the hand and could not be run over the bare skin for even a few seconds. Observation on 12/16/18 between 3:15 p.m. and 3:51 p.m. of the water temperatures taken by the maintenance assistant XX at the sink in resident rooms on the MT unit revealed the following: 208=124.3 degrees Fahrenheit (F) 205= 121.8 degrees F 204= 136.5 degrees F 209= 121.9 degrees F 206= 131.5 degrees F 203= 132.4 degrees F 211= 121.2 degrees F 202=128.1 degrees F 210= 128.4 degrees F 224=122.1 degrees F 222= 122.3 degrees F 220=124.7 degrees F 218=123 degrees F 236=139.2 degrees F 234=146 degrees F 233=138.9 degrees F 232=142.1 degrees F 231=145 degrees F 239=138.5 degrees F 240=144.5 degrees F 241 Near shower) = 80.5 degrees F 242= (near shower) 81.5 degrees F 243= 83 degrees F (near shower) 244= 84.5 degrees F (near shower) Shower room = 81.1 degrees F During an interview on 12/16/18 at 4:29 p.m. with the Administrator, it was revealed that the maintenance department checks both showers and rooms but she was not sure how often these checks were one. Residents on the West unit had complained of the water on that unit being cold a few weeks before. As a result, the administrator had called the plumbers in and they had adjusted and/or replaced the existing hot water valves during their visit. She had not been made aware of any concerns with the water being too hot on any of the units. She planned immediately inform the staff to keep the residents from using the hot water on all the units until the water temperatures could be adjusted to comfortable and safe ranges. During a follow up interview on 12/16/18 at 4:42 p.m. with the Administrator… | 2020-09-01 |
| 506 | 506 | DOUGLASVILLE NURSING AND REHABILITATION CENTER | 115273 | 4028 HWY 5 | DOUGLASVILLE | GA | 30135 | 2019-01-11 | 690 | D | 0 | 1 | ZVL511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and family interview, and record review, the facility failed to remove a Foley catheter when clinically warranted for one resident (R) (R#205). The sample size was 87 residents. Findings Include: Review of the Minimum Data Set (MDS) Admission assessment dated [DATE] for R#205 revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating that R#205 was cognitively intact. Section G Functional Status revealed that R#205 required extensive one person assist with toilet use and managing catheter care. Section H Bowel and Bladder revealed R#205 has an indwelling Foley catheter, is always incontinent of bowel, and no toileting program has been used. Section I revealed Active [DIAGNOSES REDACTED]. An interview on 12/16/18 at 3:56 p.m. with a family member of R#205 revealed that she took the resident to the Urologist on Thursday, 12/6/18. She stated that the Urologist told her the catheter needed to come out and he would write the order for the nursing home to take it out on Monday. The family member asked that the date be changed to 12/11/18 due to other upcoming physician appointment, which the Urologist agreed. The Urologist office sent her a large envelope and a paper with the order to remove the catheter on Tuesday, 12/11/18, to give to the nursing home. The family member stated that the envelope was given to the nurse, at the medication cart, on return to the nursing home. The family member revealed that the catheter was still in and had not been removed yet. She stated that nurse FF told her that she had called the Urologist office but has not gotten a response back from them but stated that was several days ago. Observation on 12/17/18 at 6:00 p.m. and 12/18/18 at 12:00 p.m. revealed the resident in his bed with Foley Catheter in place. Review of the Urologist, History and Physical dated 12/6/18. Instructions: We will have his nursing home remove his urethral catheter on Tuesday (MONTH) 11, (YEAR) at s… | 2020-09-01 |
| 507 | 507 | DOUGLASVILLE NURSING AND REHABILITATION CENTER | 115273 | 4028 HWY 5 | DOUGLASVILLE | GA | 30135 | 2019-01-11 | 695 | D | 0 | 1 | ZVL511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and review of Physician's Orders and facility policies titled Oxygen Therapy and Guidelines for Frequency Changes of Respiratory Supplies, the facility failed to change disposable oxygen equipment in a timely manner for one resident (R), R#178. The sample size was 87. Findings include: Review of the clinical record revealed R#178 was [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed a comatose resident (Section B-Hearing, Speech and Vision) who required total/two-person assistance (Section G-Functional Status) for all activities of daily living (ADLs); and required oxygen (O2), suctioning, [MEDICAL CONDITION] (Section O-Special Treatments and Programs). Review of the care plan, reviewed 11/23/18, documented the problem/need related [MEDICAL CONDITION] was: risk for respiratory complications to include respiratory distress, infection, dehydration, and accidental decannulation. The goals included patent and adequate air exchange and freedom from recurrent infections, dehydration and decannulation. The interventions included: monitor for symptoms of respiratory infection-cough, increased secretions, change in color/odor, fever, abnormal laboratory values;[MEDICAL CONDITION] per Respiratory Therapy (RT). Review of the Physician's Orders, updated 7/31/18, revealed an order (originally dated 9/27/17) to [MEDICAL CONDITION] or t-piece every week. Review of the facility policy titled, Oxygen Therapy, revealed under Procedure, #8: change tubing weekly. Review of the policy titled, Guidelines for Frequency Changed of Respiratory Supplies, revealed [MEDICAL CONDITION]/collar, refillable humidifiers, aerosol corrugated tubing, and drainage bag should all be changed weekly. Observation of R#178 on 12/16/18 at 7:00 p.m. revealed a trach-dependent female, spontaneously breathing via a 35% (O2) aerosol t-piece (ATP), lyin… | 2020-09-01 |
| 508 | 508 | DOUGLASVILLE NURSING AND REHABILITATION CENTER | 115273 | 4028 HWY 5 | DOUGLASVILLE | GA | 30135 | 2019-01-11 | 758 | D | 0 | 1 | ZVL511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the behavior management policy, and staff interview, the facility failed to monitor behaviors for two residents (#169 and #16) receiving [MEDICAL CONDITION] medications. The sample size was 87 residents. Findings include: (1) Review of the policy Behavior Management and Psycho-pharmacological Medication Monitoring Protocol last updated 3/18 revealed that for each residents admitted on or receiving psycho-pharmacological medication, planned interventions for that resident's behaviors will be communicated to the appropriate staff members and those interventions and the responses to them are to be documented. The policy also revealed that those residents receiving psycho-pharmacological medications will be referred to the Behavior Management Committee. The committee will establish a behavior management program and review behavior monitoring documentation as part of that program as long as the resident continued to receive psycho-pharmacological medication. 1. A Review of the clinical records for Resident (R) #169 revealed he was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of the current physician's orders [REDACTED].#169 to receive: [MEDICATION NAME] (an antipsychotic) 50 mg twice a day (this was increased from 25 mg bid on 12/5/18); [MEDICATION NAME] (an anxiolytic) 1mg every six hours for agitation (this was increased from 0.5 mg on 11/14/18) ; [MEDICATION NAME] (an antidepressant) 40 mg daily; and [MEDICATION NAME] (an antidepressant) 75 mg daily (increased from 50 mg on 12/14/18). A review of the Minimum Data Set (MDS) assessment records for the resident revealed an Admission MDS assessment of 6/14/18 which revealed the resident had behavioral symptoms directed at himself which occurred daily. However, these behaviors were judged to not have a significant impact on the resident, his care, or his interaction with others. He was also assessed as exhibiting rejection of care behaviors 1-3 days during… | 2020-09-01 |
| 509 | 509 | DOUGLASVILLE NURSING AND REHABILITATION CENTER | 115273 | 4028 HWY 5 | DOUGLASVILLE | GA | 30135 | 2019-01-11 | 812 | E | 0 | 1 | ZVL511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and review of policy Food Storage (Dry, Refrigerated, and Frozen), the facility failed to discard expired food items, and failed to sanitize the thermometer probe between the taking of the temperatures of various food items on the steam table. These deficient practices had the potential to affect 210 residents receiving an oral diet, of whom six received thickened liquids. Findings include: Review of the policy titled Food Storage (Dry, Refrigerated, and Frozen) dated (YEAR), staff are to discard food that has passed the expiration date. Observation of the walk-in refrigerator while accompanied by the dietary manager during initial kitchen tour on [DATE] at 11:30 a.m. revealed three 46-ounce cartons of (brand) Nectar-like Thickened Orange juice with a use-by date of [DATE] and one 46-ounce (brand) Thickened Cranberry Cocktail with a use-by date of [DATE]. Interview on [DATE] at 11:40 a.m. with the dietary manager (DM) revealed that all food items in the kitchen have either a best by/use by manufacturer's date or a received on date added by staff when those foods are delivered. Most foods received in the kitchen are used or discarded within a year, or discarded by the manufacturer's expiration date. However, if opened at any time during that period, the staff add a discard by date and this is usually 3 or 7 days, depending on the food item. The thickened juices that were past the use-by date should have been used or discarded by the date indicated by the manufacturer. The employee responsible for stocking/restocking the shelves should have noticed the date and discarded these products. Observation on [DATE] at 11:49 a.m. of the DM taking the temperatures of various food items on the steam table revealed the DM sanitize the shaft of the thermometer using an alcohol wipe before wiping the shaft with a disposable napkin. Next, she proceeded to insert the shaft of the thermometer into a success… | 2020-09-01 |
| 510 | 510 | DOUGLASVILLE NURSING AND REHABILITATION CENTER | 115273 | 4028 HWY 5 | DOUGLASVILLE | GA | 30135 | 2019-01-11 | 842 | D | 0 | 1 | ZVL511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview the facility failed to ensure that medications were recorded in the electronic Medication Administration Record [REDACTED]. Findings include: Review of the Minimum Data Set (MDS) Admission assessment dated [DATE] for R#224 revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating the resident to be cognitively intact. Section G Functional Status revealed the resident requires 2-person assistance for toileting. Section H Bowel and Bladder (B&B) revealed the resident is always incontinent of bowel and bladder. Section I Active [DIAGNOSES REDACTED]. The resident had a history of [REDACTED]. Review of the Medication Administration Record [REDACTED]. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Review of the Departmental Notes for (MONTH) (YEAR) revealed that [MEDICATION NAME] 2.5 mg given on 11/26/18 at 7:59 a.m., 11/25/18 at 1:18 a.m., 11/28/18 at 2:30 p.m.,, 11/29/18 at 4:33 a m., 11:29 at 2:22 p.m., 11/29/18 at 7:08 p.m. and 11/30/18 at 4:46 a.m. Review of the (MONTH) (YEAR) Department Notes revealed that [MEDICATION NAME] 2.5 mg was given at 12/2/18 at 4:23 p.m., 12/3/18 at 6:46 a.m., 12/14/18 at 4:24 a.m., 12/15/18 at 7:35 a.m., 12/21/18 at 8:14 a.m. and 12/24/18 at 4:02 a.m. An interview with the Director of Nursing (DON) on 1/11/19 at 5:10 p.m. revealed that the facility has a new electronic record for medications and that they are aware of recording errors on the Electronic MAR. She did confirm that the nurses had made notes in their nursing notes (Departmental Notes) but not on the MAR indicated [REDACTED]. | 2020-09-01 |
| 511 | 511 | DOUGLASVILLE NURSING AND REHABILITATION CENTER | 115273 | 4028 HWY 5 | DOUGLASVILLE | GA | 30135 | 2019-01-11 | 880 | F | 0 | 1 | ZVL511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review, and policy reviews the facility failed to provide evidence that infection control surveillance data was collected in (MONTH) of (YEAR). Failed to provide documentation that infection control data collected in (MONTH) of (YEAR) was analyzed for trends and appropriate actions taken in response. In addition, the facility failed to do the following; conduct annual review and update their policies and infection prevention control program (IPCP); failed to don appropriate personal protective equipment (PPE) when entering a resident's room on transmission-based precautions; failed to use hand hygiene prior to donning PPE and during medication administration. The facility census was 220. Findings included: Review of an undated policy titled, Surveillance For Healthcare Associated Infections revealed; Policy Surveillance for Healthcare Associated Infections will be completed to calculate baseline rates, detect outbreaks, track progress, and to determine trends to help prevent the development or spread of infection (HAI). Procedure 3. Complete the Monthly Control Surveillance Log utilizing a new form each month. 1. Review of the Monthly Healthcare-Associated Infection (HAI) Report dated (MONTH) (YEAR)-November (YEAR) revealed facility did not have collected surveillance data for the month of (MONTH) (YEAR). Review of the Monthly Healthcare-Associated Infection (HAI) Report dated (MONTH) (YEAR) 18 revealed total infection cases; 1 UTI's with a Foley, 8 UTI's without a Foley, 3 URI, 2 LRI, 2 pressure ulcers, 2 skin, 1 [MEDICAL CONDITION], 1 other. Further review of the (MONTH) infection control data revealed that no infection control surveillance log was done nor summary of the infections. An interview was conducted on 12/19/18 at 11:45 a.m. with the Director of Nursing (DON) confirmed that the Monthly Infection Control Surveillance log should be used/completed per the policy. 2. Review of the IPCP no evid… | 2020-09-01 |
| 869 | 869 | RIDGEWOOD MANOR HEALTH AND REHABILITATION | 115341 | 1110 BURLEYSON DRIVE | DALTON | GA | 30720 | 2017-10-19 | 282 | D | 0 | 1 | ZVHZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to follow the care plan related to administration of insulin and Finger Stick Blood Sugar (FSBS) monitoring for one residents (#65) and failed to follow the plan of care related to behavior monitoring for one resident (#103) with behavioral symptoms that received an anti-psychotic medication. The sample size was 30 residents. Findings include: 1. Review of clinical record revealed R#65 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 14 out of 15. Review of the care plan last updated 8/24/17 revealed that R#65 has a [DIAGNOSES REDACTED]. Interventions include FSBS as ordered and medications as ordered. Review of the physician's orders [REDACTED].#65 revealed the following: FSBS three (3) times a day and Humalog Insulin 100 Units per milliliters (U/ML) 10 units (0.10 ML) subcutaneous (Sub-Q) AC with breakfast, lunch and supper. Review of the Medication Administration Record [REDACTED]. During an interview with the RN, FF on 10/19/17 at 12:10 a. m., she revealed that the nurse responsible for recording FSBS and Humalog administration no longer works at the facility. She also stated nurses are expected to document FSBS and administration of Humalog; however, she doesn't know what happened that caused the lack of documentation. 2. Review of the clinical record for Resident (R) #103 revealed [DIAGNOSES REDACTED]. Further review of the clinical record revealed a current physician's orders [REDACTED]. Review of the resident's records revealed a plan of care, last updated 9/6/17, for [MEDICAL CONDITION] medication use related to [DIAGNOSES REDACTED]. Review of the Medication Administration Record [REDACTED]. However, the behavior monitoring sheets revealed that the licensed nursing staff did not consistently monitor the resident for the targeted behaviors. … | 2020-09-01 |
| 870 | 870 | RIDGEWOOD MANOR HEALTH AND REHABILITATION | 115341 | 1110 BURLEYSON DRIVE | DALTON | GA | 30720 | 2017-10-19 | 309 | D | 0 | 1 | ZVHZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to follow the Physician's order to document observation of [MEDICAL TREATMENT] port every shift for one (1) resident (R#65) of one resident who receives [MEDICAL TREATMENT] treatment of [REDACTED]. Findings include: Review of clinical record revealed R#65 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 14 out of 15. Review of the Physician's orders dated (MONTH) (YEAR) and (MONTH) (YEAR) for R#65 revealed to observe [MEDICAL TREATMENT] port to right (rt) upper chest every shift for signs or symptoms (s/s) of bleeding. Review of the Medication Administration Record (MAR) dated (MONTH) (YEAR) and (MONTH) (YEAR) revealed no documentation of observation of [MEDICAL TREATMENT] port on 10/4/17 (11-7) shift, 9/16/17, 9/22/17, 9/26/17 (11-7) shift and 9/30/17 (7-3) shift. During an interview with Registered Nurse (RN) RCC, FF on 10/19/17 at 11:00 a.m., revealed the [MEDICAL TREATMENT] port should be checked every shift and documentation of the check should be recorded on the MAR and it was not. | 2020-09-01 |
| 871 | 871 | RIDGEWOOD MANOR HEALTH AND REHABILITATION | 115341 | 1110 BURLEYSON DRIVE | DALTON | GA | 30720 | 2017-10-19 | 329 | D | 0 | 1 | ZVHZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to monitor targeted behaviors for one residents (#103) with behavioral symptoms and failed to monitor for side effects for two residents (#103, and #30) that received anti-psychotic medications from a sample of thirty (30) residents. Findings include: 1. Review of the clinical record for Resident (R) #103 revealed [DIAGNOSES REDACTED]. Further review of the medical record revealed a current physician's orders [REDACTED]. Review of policy titled: Monitoring of Antipsychotics last updated (MONTH) (YEAR) documented: when antipsychotic therapy is initiated, the resident is to be monitored for behaviors on each shift every day. Side effects are also to be monitored on each shift, every day, and staff are to indicate whether side effects are noted or not noted. If side effects are observed and noted, then an explanation must be documented in the nurses' notes. Review of clinical records for R#103 revealed a Behavior Monitoring Record: [MEDICAL CONDITION] Medications sheet which indicated that the resident was to be monitored for two targeted behaviors: striking out at staff/other residents and crying. The sheet contained areas for the number of episodes per targeted area to be monitored each shift, the type of intervention to be initiated if the behaviors were observed, and the outcome of that intervention. The back of this sheet contained an area for side effects of the resident's [MEDICAL CONDITION] medications to be documented each shift; if no side effects were documented for the month, a box was available to check that no side effects noted this month. Review of the Medication Administration Record [REDACTED]. However, the behavior monitoring sheets revealed that the licensed nursing staff did not consistently monitor the resident for the targeted behaviors. There were at least 23 shifts in (MONTH) (YEAR) during which behaviors were not documented as being monitored and seven duri… | 2020-09-01 |
| 872 | 872 | RIDGEWOOD MANOR HEALTH AND REHABILITATION | 115341 | 1110 BURLEYSON DRIVE | DALTON | GA | 30720 | 2017-10-19 | 514 | D | 0 | 1 | ZVHZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to document administration of [MEDICATION NAME] and failed to document Physician notification of fingerstick blood sugars (FSBS) outside of parameters for one resident (R#83) from a sample of 30 residents. Findings include: 1. Review of the clinical record for R#77 revealed Physician orders [REDACTED]. The original order date was 3/10/17. Review of the Medication Administration Record (MAR) for R#77 for September, (YEAR) and October, (YEAR) revealed no documentation that nursing staff administered [MEDICATION NAME] as ordered at bedtime on 9/1/17, 9/2/17, 9/3/17 and 9/4/17. Continued review revealed no documentation for the administration of [MEDICATION NAME] Sprinkles from 9/8/17 through 9/13/17, 9/15/27 through 9/20/17, and 9/23/17 through 10/17/17. Continued review of the medical record revealed that the resident was in the facility on the dates that the above medications were to be administered. During an interview conducted on 10/17/17 at 4:40 p.m. the 100 hall Unit Manager revealed there was no regular evening charge nurse for the long hall for the first three weeks of September. Charge nurses from other areas and other shifts covered until the current full-time evening charge nurse was hired and trained. The Unit Manager confirmed the [MEDICATION NAME] ordered for R#77 to be administered at bedtime had only been documented as administered six times since 9/1/17. During and interview conducted on 10/17/17 at 4:50 p.m., Licensed Practical Nurse (LPN) AA revealed she had administered bedtime medications to R#77 since the last week of (MONTH) and remembers that she gave the [MEDICATION NAME] every evening but indicated she missed signing for administering the routine medication because it was listed with the as needed (PRN) medications. LPN AA confirmed she usually compares the medications listed on the packaging with the medications listed on the MAR but must have missed doin… | 2020-09-01 |
| 1636 | 1636 | MADISON HEALTH AND REHAB | 115457 | 2036 SOUTH MAIN STREET | MADISON | GA | 30650 | 2015-10-01 | 278 | F | 0 | 1 | ZV7N11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to accurately assess the Minimum Data Set (MDS) assessments for the use of corrective lenses for one (1) resident (#41), and dental status for one (1) resident (#31). The sample size was twenty-five (25) residents. Findings include: 1. Review of the Quarterly MDS assessment for resident #41 dated 07/09/15 noted that she had visual impairment, with no corrective lenses. Review of the Care Plan Notes dated 07/13/15 noted that she wore glasses for visual acuity with a history of retinal repair. Review of the comprehensive care plans revealed that a care plan had been developed for impaired visual function with the use of glasses for visual acuity. On 09/30/15 at 2:39 p.m., resident #41 was observed wearing eyeglasses while reading a magazine, and during interview stated that she wore glasses for reading only. During interview with Licensed Practical Nurse (LPN) MDS Coordinator on 10/01/15 at 10:02 a.m., she stated that she assumed that glasses had to be prescription glasses to be coded as having corrective lenses. Upon further interview, she stated that when she did the MDS vision assessment for resident #41, the resident had told her that she wore glasses for reading only, so she coded the resident as not having corrective lenses as she did not wear glasses at any other time. Upon further interview, she verified that resident #41 wore her glasses when the vision assessment was done. During further interview and record review with the MDS Coordinator at this same time, she verified that according to the MDS 3.0 section B1000 for Vision, the guidance was to code 'Yes' if corrective lenses or other visual aids were used when the visual ability was assessed. 2. During observation on 09/29/15 at 11:31 a.m., resident #31 was noted to be missing all of her upper teeth. During interview with the resident at this same time, she stated that she had no mouth or tooth pain, and could c… | 2020-09-01 |
| 1637 | 1637 | MADISON HEALTH AND REHAB | 115457 | 2036 SOUTH MAIN STREET | MADISON | GA | 30650 | 2015-10-01 | 371 | E | 0 | 1 | ZV7N11 | The facility failed to maintain one (1) item (chopped ham) on the steam table at 135 degrees (Fahrenheit) or above to prevent potential foodborne illness during observations at one (1) meal. There were sixty-eight (68) residents who consumed an oral diet, and two (2) residents on a diet with chopped meats. Findings include: Observed on 09/30/15 at 12:05 p.m., multiple food carts to have already been set up with trays for individual residents containing utensils, tea, water, and cartons of milk. Continued observations, revealed all foods on the steam table were at an acceptable temperature (above 135 degrees) to prevent foodborne illness, except for the chopped ham, which was 131.2 degrees using facility thermometer. This was verified during interview with the Dietary Supervisor, who stated that one tray with chopped ham had already been served to a resident. Interview with dietary aide AA on 9/30/15 at 12:05 p.m. she stated that she had taken the temperature of the chopped ham before serving and it was 160 degrees, but the reason the temp dropped so low was because she did not have a lid to cover the chopped ham once it was put on the steam table, and that she usually covered everything. Review of the facility's Dietary Services Policy and Procedure noted the following: -Steam Table: Must be able to maintain hot foods at temperatures of 135 degrees Fahrenheit or above. | 2020-09-01 |
| 9898 | 9898 | GRACEMORE NURSING AND REHAB | 115554 | 2708 LEE STREET | BRUNSWICK | GA | 31520 | 2010-09-23 | 322 | D | 0 | 1 | ZUT111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, it was determined that the facility failed to ensure that one (#6) of four sampled residents with feeding tubes received the correct amount of feeding as ordered by the physician from a total sample of 14 residents. Findings include: Resident #6 had a current physician's orders [REDACTED]. feeding was still infusing. During an interview on 9/22/10 at 8:30 a.m., licensed nurse "TT" stated that he/she did not know why the resident's tube feeding was still infusing. Review of the clinical record, Medication Administration Record [REDACTED] | 2015-04-01 |
| 9899 | 9899 | GRACEMORE NURSING AND REHAB | 115554 | 2708 LEE STREET | BRUNSWICK | GA | 31520 | 2010-09-23 | 371 | F | 0 | 1 | ZUT111 | Based on observation and staff interview, it was determined that the facility failed to ensure that the high temperature dishwasher was properly functioning to effectively destroy potential food borne illness. Findings include: During an observation of dietary staff washing dishes in the high temperature dishwasher on 9/23/10 at 8:20 a.m., the rinse cycle only reached 150 degrees Farenheit (F.). During an interview with the dietary manager at that time, she stated that the rinse cycle should reach 180 degrees F. (to effectively rinse dishware). | 2015-04-01 |
| 5503 | 5503 | PARK PLACE NURSING FACILITY | 115005 | 1865 BOLD SPRINGS ROAD | MONROE | GA | 30655 | 2015-02-05 | 323 | D | 0 | 1 | ZUHN11 | Based on observations, record review, facility policy and staff interview it was determined that the facility failed to ensure that the resident's environment was free of accident hazards for one (1) resident (#57) from a sample of forty-eight (48) residents. Findings include: Observation during intial tour of the facility on 02/02/15 at 11:00 a.m. room E-69, revealed a private bathroom for resident #57 with a soft raised toilet seat that was torn on both sides and the back with jagged edges exposing the foam. Continued observation on 2/03/15, at 3:00 p.m., 02/04/15 at 7:45 a.m. and 2:30 p.m., and again on 02/05/15 at 7:30 a.m. and 8:10 a.m., revealed that the raised soft toilet seat was still torn with jagged edges exposing the foam remained in the resident's private bathroom. Interview with CC the Private Sitter on 02/04/2015 at 9:24 a.m., revealed that resident #57 uses the raised soft toilet seat several times daily with assistance from staff. CC further revealed that the resident was not able to ambulate to the bathroom unassisted and required help from staff. Interview with the Infection Control (IC) Nurse on 02/04/15 at 10:45 am revealed that resident #57 uses the private bathroom with the soft raised toilet seat daily, and required assistance from the staff but continued to wear adult diapers. Observation on 02/05/15 at 9:15 a.m. of the private bathroom for resident #57 with the IC Nurse she confirmed that the soft toilet seat was torn on both sides and in the back with jagged edges exposing the foam. She further revealed that the toilet seat would be replaced. Interview with Certified Nursing Assistant (CNA) BB on 02/05/15 at 8:15 a.m. revealed that resident #57 was on a toileting program with staff toileting the resident every two (2)hours especially after meals and as needed. CNA BB further revealed that the resident continues to use the private bathroom with the torn toilet seat several times daily and at times asks to remove the torn seat to allow the resident to sit on the regular seat. Interview on… | 2018-08-01 |
| 5504 | 5504 | PARK PLACE NURSING FACILITY | 115005 | 1865 BOLD SPRINGS ROAD | MONROE | GA | 30655 | 2015-02-05 | 371 | E | 0 | 1 | ZUHN11 | Based on observation and staff interviews the facility failed to properly demonstrate the usage of the three (3) compartment sink to prevent the potential for food borne illness. This had the potential to effect one hundred and fifty-two (152) residents who received oral alimentation. Findings include: Observation on 02/04/15 at 3:40 p.m. revealed that AA , the cook did not properly sanitize the blender bowl and lid after usage in the three (3) compartment sink. Continued observation revealed that the cook washed the blender bowl and lid in soapy water; next she rinsed the items in the rinse compartment. The cook then placed the blender bowl and lid in the sanitizing solution and then removed both items after being immersed for only (fifteen) seconds. Further observation of the three (3) compartment sink revealed that a poster was hanging above the sink from Patco, the company that provides the facility with chemicals, which indicated the appropriate steps and technique for usage of the three (3) compartment sink including how long to submerge items in the sanitizing solution which stated one (1) minute or longer. Interview with AA the cook on 02/04/15 at 3:40 p.m. revealed that the way she demonstrated to the surveyor how to clean and sanitize the blender bowl and lid was how she was told to clean items in the three (3) compartment sink. Continued interview revealed that she does not recall the last time there was an in-service regarding the proper usage of the three (3) compartment sink. Interview with the Dietary Manager (DM) on 02/04/15 at 3:42 p.m. revealed that she was not able to verbalize to the surveyor how to properly use the 3 compartment sink. Continued interview with the DM revealed that she had been educating her staff that they just need to swish items in the sanitizing solution and then place them on the rack to dry. The DM revealed that she was not aware that items needed to be immersed in the sanitizing solution for at least one minute per recommendations of the manufacturer as indicated on the … | 2018-08-01 |
| 5505 | 5505 | PARK PLACE NURSING FACILITY | 115005 | 1865 BOLD SPRINGS ROAD | MONROE | GA | 30655 | 2015-02-05 | 372 | C | 0 | 1 | ZUHN11 | Based on observations and staff interviews the facility failed to maintain the condition of one (1) large compacting dumpster to ensure it was free from leakage and failed to properly cover the garbage in the dumpster to prevent the harborage of pests. Findings include: Observation on 02/02/15 at 11:00 a.m. of the dumpster area revealed that the facility had one (1) compacting dumpster sitting on a concrete pad. Continued observation of the dumpster revealed that the area to deposit garbage was open and ten (10) garbage bags were visible. Further observation revealed a large leak coming from under the front of the dumpster. A stream of pale white fluid ran forward to the front of the concrete pad and formed a pool. The pool of white fluid was eight (8) feet in length, 1 foot in width, and two (2) inches deep. Interview with the Dietary Manager (DM) on 02/02/15 at 11:00 a.m. revealed that she had never seen the area to deposit garbage closed and that garbage was constantly exposed. Continued interview revealed that she knew about the leak in the dumpster for two (2) weeks and admitted that the white fluid coming from the dumpster was milk and juices from the dietary department. The DM further revealed that dietary and housekeeping share responsibility for keeping the dumpster area clean. Interview with the Director of Maintenance on 02/02/15 at 11:05 a.m. revealed that the only time the area to deposit garbage in the dumpster is closed is when garbage is being compacted or at the end of the day. He revealed that at the end of the day the last individual discarding garbage compacts the garbage and leaves the compacting ram inside the main garbage storage area. Once the plunger is pushed in it covers the area that garbage is deposited. The Director of Maintenance confirmed that they have known about the leak coming from the dumpster for the past few weeks. He confirmed that the white liquid coming from the dumpster was milk and juices from the kitchen garbage. Observation on 02/03/15 at 3:45 p.m. of the compacting d… | 2018-08-01 |
| 3270 | 3270 | PARKSIDE POST ACUTE AND REHABILITATION | 115643 | 3000 LENORA CHURCH DRIVE | SNELLVILLE | GA | 30078 | 2018-12-13 | 804 | E | 0 | 1 | ZU6H11 | Based on observation, interview, record review and policy review, the facility failed to ensure six out of 37 sampled residents (R) (R#6, R#14, R#16, R#57, R#133, R#134), residents attending resident council meetings, and residents attending the group interview were served palatable food. Specifically, food was not satisfactory in taste or temperature and condiments were not consistently served creating the potential for dissatisfaction and weight loss. Findings include: 1.Background information Review of the Parkside Post-Acute & Rehabilitation Census dated 12/10/18 revealed there were 94 residents prescribed regular texture diets, 62 prescribed mechanical soft texture diets, and 23 prescribed pureed texture diets. Interview with the Dietary Manager on 12/10/18 at 9:30 a.m. was conducted in the kitchen during the initial kitchen inspection. The Dietary Manager indicated meal times were between 7:00 a.m. and 8:30 a.m. for breakfast, 12:00 p.m. and 1:20 p.m. for lunch, and 5:00 p.m. and 6:30 p.m. for dinner. The Dietary Manager stated meals were also served to residents residing in the personal care part of the building; they were served prior to the nursing home residents. The food was dished up in the kitchen from the steamtable and the individual meal trays were sent to residents eating off the hall carts and dining rooms on the units. Food was dished up from a steamtable in the main dining room for residents eating in the main dining room. The main dining room was served first for the nursing home residents. The Dietary Manager stated there was a main dining room and small dining rooms in the A and B units. The Dietary Manager stated residents could eat in their rooms if they wanted to or could eat in the dining rooms. The Dietary Manager stated there were six meal carts that were sent to A, B, C and [NAME] halls; A and B halls had two carts whereas C and [NAME] halls had one cart each. The facility Food Delivery Log undated, revealed for the lunch meal the main dining room meal service began at 12:00 noon, [N… | 2020-09-01 |
| 4791 | 4791 | WINDER HEALTH CARE & REHAB CTR | 115536 | 263 E MAY STREET | WINDER | GA | 30680 | 2015-06-18 | 309 | D | 0 | 1 | ZT7P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy, and staff interview, the facility failed to ensure that proper assessment and documentation was provided for the arteriovenous (AV) access site of one (1) resident (#147) that received [MEDICAL TREATMENT] treatment from a sample size of thirty-two (32) residents. Findings include: Review of the physician's orders [REDACTED]. Further review of the Physician's Progress Notes dated 05/19/15 revealed the resident had a left AV graft placement that was approved to use for [MEDICAL TREATMENT]. Observation of Licensed Practical Nurse (LPN) AA on 06/18/2015 at 10:35 a.m. revealed the nurse assessing resident #147's [MEDICAL TREATMENT] access for bruit and thrill. The dressing was noted to be clean and dry. Review of the Nurse's Notes and Medication Administration Record [REDACTED]. Review of the Nursing Department [MEDICAL TREATMENT] Facilitation Policy revealed that nursing staff are trained to check AV shunt daily for bruit and document the results of the assessment in the resident's clinical record. Interview with LPN AA on 06/18/2015 at 10:45 a.m. revealed that she checked for resident #147's bruit and thrill when he returned from [MEDICAL TREATMENT] but acknowledged that she forgets to document the assessment in the resident's clinical record. Interview with Unit Two Coordinator LPN BB on 06/18/2015 10:45 a.m., she confirmed that bruit and thrill had not been documented for resident #147 for the months of (MONTH) and (MONTH) (YEAR). Continued interview revealed that licensed staff should document the bruit and thrill in the nurse's notes section of the resident's clinical record after each assessment. LPN BB further revealed that she would be doing an inservice with the licensed staff about the importance of documentation for [MEDICAL TREATMENT] residents. Interview with the Director of Nursing (DON) on 06/18/2015 at 10:50 a.m. revealed that her expectation of the nursing staff was to documen… | 2019-06-01 |
| 4792 | 4792 | WINDER HEALTH CARE & REHAB CTR | 115536 | 263 E MAY STREET | WINDER | GA | 30680 | 2015-06-18 | 371 | E | 0 | 1 | ZT7P11 | Based on observation and staff interview the facility failed to label and date six (6) food items in the refrigerators and dry storage area for two (2) of four (4) days of the survey; and failed to properly clean the stand-up mixer after usage to prevent cross contamination. There were one hundred and thirty-seven (137) residents that received meals from the kitchen. Findings include: Observation on 06/15/15 at 10:35 a.m. of the stand-up mixer revealed that it was covered with a clear plastic bag. Continued observation revealed that after uncovering the stand-up mixer there was a powdery white food substance under the mixing arm and on the shaft to connect the beater. Interview on 06/15/15 at 10:35 a.m. with the Dietary Manager (DM), he confirmed that there was a white powdery food substance on the stand up mixer. The DM revealed that when the clear plastic bag is placed over the top of the stand-up mixer, this indicates that the equipment is clean and ready for use. The DM acknowledged that the plastic bag should not have been placed over the mixer since it was dirty. Continued interview revealed that he expected that all kitchen equipment should be cleaned after usage. Observation on 06/15/15 at 10:40 a.m. revealed that the single door stand up refrigerator had items on the top shelf that were opened and not labeled or dated. These items included a fifteen (15) ounce Starbucks ice coffee which was open with no label or date, 2 hardboiled eggs in a white eight (8) ounce Styrofoam cup covered with saran wrap with no label or date and a twenty four (24) ounce Heinz ketchup bottle was opened with no date. Interview on 06/15/15 at 10:40 a.m. with the DM revealed that he expects all food items stored in the kitchen should have a label and date. The DM confirmed that the Starbucks ice coffee, hard boiled eggs, and the ketchup all did not have a label or date and that they should. Observation on 06/15/15 at 10:45 a.m. of the metal preparation counter in the kitchen revealed a 4 gallon clear plastic container that conta… | 2019-06-01 |
| 4793 | 4793 | WINDER HEALTH CARE & REHAB CTR | 115536 | 263 E MAY STREET | WINDER | GA | 30680 | 2015-06-18 | 441 | E | 0 | 1 | ZT7P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, facility policy, and staff interview, the facility failed to ensure infection control procedures were followed for the care of linens of residents on isolation to prevent possible cross contamination. The resident census was one hundred thirty-nine (139). Findings include: Interview with Laundry Services (LS) CC, on 06/16/15 at 9:10 a.m. revealed that when they handle and sort the isolation linens, they wear a yellow, cloth, patient gown and disposable gloves. CC stated that when when she is done with the gown, she hangs the gown on the shelf where the regular dirty laundry is sorted. When asked what they wear to sort the regular dirty laundry, CC pointed to the same yellow, patient gown she wears to handle and sort the isolation linen. When asked how she prevents cross contamination by wearing the the same gown for the isolation linens and regular dirty linens, she shrugged her shoulder and stated I just wear that, pointing to the yellow gown. When asked if there was any disposable Personal Protective Equipment (PPE) provided for the laundry staff, CC acknowledged there was no disposable PPE in the laundry department. Interview with the Maintenance Supervisor (MS), on 06/18/15 at 10:55 a.m. revealed that he has not conducted any inservices with the laundry staff regarding infection control and the handling of isolation linens. The MS revealed that he thought there was currently disposable PPE in the laundry area and was surprised to find there was none. He confirmed that there should be a disposable PPE station in the laundry area for the handling of isolation linens and added that the laundry staff should not be wearing the same gown for the sorting of isolation linens and regular dirty linens. Continued interview revealed that the Housekeeping Supervisor (HS) normally handles the laundry inservices but stated that he knew that she hasn't done one related to infection control. Interview with the Infection Control Nurse… | 2019-06-01 |
| 9347 | 9347 | GOLDEN LIVINGCENTER - DECATUR | 115012 | 2787 NORTH DECATUR ROAD | DECATUR | GA | 30033 | 2011-06-03 | 279 | D | 0 | 1 | ZSUO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop a comprehensive care plan, after an annual assessment, related to pressure ulcer for one (1) resident (#20) from a sample of thirty-one (31) residents. Findings include: Review of the medical record for resident # 20 revealed that the resident was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE] revealed that the resident was assessed as being at high risk for pressure sores. The Care Area Assessment (CAA) triggered for pressure ulcer with a decision to care plan. The current Quarterly MDS 3.0 revealed resident #20 with a Stage ll (2) pressure ulcer to the sacrum. Review of the medical record revealed that the resident had a history of [REDACTED]. Review of the Wound Evaluation Flow Sheet dated 03/30/11 identified a Stage ll (2) pressure ulcer to the sacrum measuring 1.0 centimeter (cm) long by 0.5 cm wide with granulation tissue. The current treatment included cleaning the wound daily with wound cleanser and applying Santyl ointment (a debrider). Review of the resident care plan revealed no evidence that a care plan had been developed related to pressure ulcer. Interview on 06/02/11 1:20 p.m. the MDS coordinator revealed no evidence of a care plan in the electronic record or the chart for the pressure ulcer. | 2015-07-01 |
| 9348 | 9348 | GOLDEN LIVINGCENTER - DECATUR | 115012 | 2787 NORTH DECATUR ROAD | DECATUR | GA | 30033 | 2011-06-03 | 309 | D | 0 | 1 | ZSUO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to follow physician's orders for two residents (#6 and "A") from a sample of thirty-one (31) residents. Findings include: 1. Review of the medical record for resident #6 revealed that the resident had a discharge date of [DATE]. Review of the physician's order for discharge revealed the following: resident may discharge (d/c) home with home health services to include, nursing evaluation for medication and diabetic management, nursing assistant, medical social worker, physical therapy, occupational therapy, medications to include narcotics and durable medical equipment per therapy recommendation. The order was signed by the Physician on 3/31/11.. Review of the Physician Discharge Summary, written by the Social Worker, revealed that the resident received all medications but that no narcotics were given to the resident because none were ordered. The Interdisciplinary Discharge Summary dated 03/31/11 indicated the same. Review of the Physician Order sheet for March, 2011, which includes all active orders for March, 2011 revealed an order for [REDACTED]. Interview on 06/03/11 at 9:19 a.m. with the Assistant Director of Nursing revealed that after reviewing the medical record she was unable to find an order to discontinue the narcotic prior to discharge, therefore, the narcotic should have been given to the resident at discharge. Further interview revealed that the narcotics were not discharged with the resident as ordered by the physician. 2. Observation at 7:30 a.m.on 06/03/11 revealed a non-emergency transportation vehicle parked and waiting to transport a resident to an appointment. Interview at 8:50 a.m. on 06/03/11 the Social Worker revealed that resident "A" had an appointment outside the facility but that the appointment had to be rescheduled and that this was the second time for rescheduling. Continued interview revealed that the resident always had to have someone with her bec… | 2015-07-01 |
| 9349 | 9349 | GOLDEN LIVINGCENTER - DECATUR | 115012 | 2787 NORTH DECATUR ROAD | DECATUR | GA | 30033 | 2011-06-03 | 441 | D | 0 | 1 | ZSUO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure that appropriate infection control practices were followed related to handwashing after a dressing change for one (1) resident (#40) from a sample of thirty-one (31) residents. Findings include: Observation on 06/02/11 at 3:00 p.m.revealed Licensed Practical Nurse (LPN) "DD" perform a pressure ulcer treatment for [REDACTED]. After completing the treatment, the nurse gathered all soiled and unused [MEDICATION NAME] swabs, alcohol swabs and cotton applicators and put them into a red bio-hazard bag, along with her soiled gloves. While attempting to close the zip lock red bag, the nurse touched the inside and outside of the bag several times. The nurse put a glove onto her left hand, opened the door, went to the medication cart and discarded the red bag and her gloves into a large red bag on the side of the medication cart. Continued observation revealed that the nurse returned to the room, picked up two (2) packs of 4 by 4 gauze, took them to the medication cart, placed the packs on top of the cart and then placed inside the cart. The LPN did not wash her hands after removing her gloves, before picking up the packs of 4 x 4's or before entering the medication cart. Interview at 3:25 p.m. on 6/02/11 with LPN "DD" revealed that her hands were dirty when she picked up the 2 packs of gauze. Continued interview revealed that she should not have placed the packs of gauze into the medication cart but thrown them away. | 2015-07-01 |
| 9350 | 9350 | GOLDEN LIVINGCENTER - DECATUR | 115012 | 2787 NORTH DECATUR ROAD | DECATUR | GA | 30033 | 2011-06-03 | 280 | D | 0 | 1 | ZSUO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to develop a care plan related to pressure ulcer after a quartertly assessment for one (1) resident (#40) from a sample of thirty-one (31) residents. Findings include: Review of the quarterly Minimum Data Assessment (MDS) for resident #40 dated 4/15/11 revealed that the resident was assessed at high risk for pressure ulcer. Review of the medical record revealed that the facility had identified a Stage III (3) pressure ulcer on the right lateral ankle on 4/17/11. Review of the resident care plans revealed no evidence that a care plan was developed to address care and treatment of [REDACTED]. Interview with the Care Plan Coordinator on 6/1/11 at 2:45 p.m. confirmed that a care plan had not been developed related to pressure ulcer. | 2015-07-01 |
| 781 | 781 | HARBORVIEW HEALTH SYSTEMS THOMASTON | 115329 | 310 AVENUE F | THOMASTON | GA | 30286 | 2019-04-26 | 812 | F | 0 | 1 | ZS6U11 | Based on observation, interviews, and review of policies titled Thawing. Storing Prepared Foods, and Foods Brought by Family/Visitors the facility failed to assure that items were labeled and dated, used by expiration date, failed to use step to open trash can, failed to keep can opener free of buildup, failed to assure dishwasher was functioning at appropriate temperatures, failed to assure the cleanliness of the ice machine in the kitchen, and failed to follow the recipe when preparing puree meals. The facility also failed to assure the cleanliness of 1 of 2 resident food pantries and to assure that items in the resident refrigerator were stored appropriately. This practice affected 100 residents that received an oral diet. The facility census was 102. Findings include: During the initial kitchen tour with the Dietary Manager (DM) on 4/23/19 at 11:55 a.m. the following was observed: 1. In the reach in cooler there were five 32 fluid ounce (fl. oz.) containers of concentrated orange juices that were thawed and did not have an open date or expiration date. The package said to keep frozen. 2. In the dry storage area there was a bag of hamburger buns with a use by date of 2/12/19 and there was also a bag of hot dog buns that did not have an open date or an expiration date. 3. There was no step to open trashcan noted by either of the hand washing sinks. 4. The containers containing flour, sugar, rice, corn meal, and thickener were not labeled or dated. The thickener container noted to not have a tight-fitting lid and the thickener was in a white trash bag in the container. 5. The lip of ice machine had black buildup when the DM wiped it with a paper napkin. During interview with the DM on 4/23/19 at 12 p.m. she confirmed that she was not able to tell when the juice items in the refrigerator would expire due to not having a thaw date. DM reported that the bread was kept in the freezer and had been thawed for use although, the bread did not contain an open or use by date as a result of the freezing. DM further reporte… | 2020-09-01 |
| 9127 | 9127 | BRENTWOOD HEALTH AND REHABILITATION | 115361 | 115 BRENTWOOD DRIVE | WAYNESBORO | GA | 30830 | 2011-03-24 | 167 | B | 0 | 1 | ZS4T11 | Based on observation and staff interview, the facility failed to make the survey results readily accessible, and did not post a notice of their availability on four of four days of the survey. Findings include: During environmental observations, the previous survey results were found inside a glassed-in bulletin board just outside the dining room on a short corridor off the 'P' hall. The survey reports were pinned to the bulletin board along with multiple other postings, and not likely to be seen by residents or visitors unless they went to this dining room. No signs were seen anywhere in the facility that announced the availability and location of the survey results. On 3/23/11 at 5:00 p.m., the Administrator verified there was currently no sign posting availability of the survey results. | 2015-08-01 |
| 9128 | 9128 | BRENTWOOD HEALTH AND REHABILITATION | 115361 | 115 BRENTWOOD DRIVE | WAYNESBORO | GA | 30830 | 2011-03-24 | 282 | D | 0 | 1 | ZS4T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to follow the care plan related to the tube feeding administration rate for one (1) resident (#87). The sample size was thirty (30) residents. Findings include: Review of resident #87's clinical record revealed they were receiving all of their nutrition via a gastrostomy tube (GT). A physician's orders [REDACTED]. The feeding tube care plan dated 9/10/10 included an intervention to provide feeding per physician order. Six observations from 3/21/11 at 1:13 p.m. to 3/23/11 at 8:40 a.m., revealed that resident #87's feeding pump was programmed to deliver the enteral formula at a rate of 55 mL per hour. On 3/23/11 at 10:00 a.m., Licensed Practical Nurse (LPN) "BB" stated the enteral formula order on the Medication Administration Record [REDACTED]. Cross-refer to F322. | 2015-08-01 |
| 9129 | 9129 | BRENTWOOD HEALTH AND REHABILITATION | 115361 | 115 BRENTWOOD DRIVE | WAYNESBORO | GA | 30830 | 2011-03-24 | 312 | D | 0 | 1 | ZS4T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview the facility failed to ensure that one (1) resident ("A") on a sample of thirty (30) residents received the necessary services to maintain personal hygiene related to nail and oral care. Findings include: Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] documented that Resident "A" required extensive assistance for activities of daily living (ADLs) such as personal hygiene that included brushing their teeth. This MDS assessment also documented that this resident had limited range of motion (ROM) on one side of the body that included the upper and lower extremities. Interview with resident "A" on 3/21/11 at 1:53 p.m. revealed that the staff does not help the resident clean his/her teeth The resident revealed that he/she has never had his/her teeth cleaned since he/she had been at the facility. The resident also stated that he/she did not have a toothbrush or toothpaste. Observations of resident "A" on 3/21/11 at 1:56 p.m., on 3/22/11 at 9:20 a.m. and 4:05 p.m. revealed that the resident had long fingernails with a brown substance underneath the nails of both hands. Interview with a Licensed Practical Nurse (LPN) "AA" on 3/22/11 at 4:05 p.m. confirmed that the resident's nails were long and dirty and needed to be cleaned and trimmed. | 2015-08-01 |
| 9130 | 9130 | BRENTWOOD HEALTH AND REHABILITATION | 115361 | 115 BRENTWOOD DRIVE | WAYNESBORO | GA | 30830 | 2011-03-24 | 322 | D | 0 | 1 | ZS4T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to administer the ordered amount of enteral tube feeding for one (1) resident (#87). The sample size was thirty (30) residents. Findings include: Review of resident #87's clinical record noted they had [DIAGNOSES REDACTED]. A quarterly Minimum Data Set ((MDS) dated [DATE] noted the resident was totally dependent on staff for all activities of daily living. The feeding tube care plan developed 9/10/10 noted the resident received all nutrition, hydration and medications via a gastrostomy tube (GT). Observations of wound care on 3/23/11 at 9:06 a.m., and 3/24/11 at 8:50 a.m., noted that the resident had a Stage IV pressure ulcer to the left hip, and unstageable/deep tissue injury (DTI) to the tip of the right great toe, left lateral foot, and top of the left fifth toe. Review of the facility's Registered Dietician's (RD) note dated 2/18/11 revealed the resident's estimated protein needs were 87-99 grams, and that they were receiving 82.8 grams at the current enteral formula rate of 55 milliliters (mL) per hour. She recommended the enteral feeding be increased to 60 mL per hour to provide 90 grams of protein. On 2/24/11, a physician's orders [REDACTED]. On 3/21/11 at 1:13 p.m.; 3/22/11 at 2:25 p.m., 3:30 p.m., and 5:20 p.m.; and 3/23/11 at 7:15 a.m. and 8:40 a.m., resident #87's feeding pump was noted to be programmed to deliver 55 mL per hour of the enteral formula. On 3/23/11 at 10:00 a.m., Licensed Practical Nurse (LPN) 'BB' verified the pump was set to 55 mL per hour, and that the ordered rate was 60 mL per hour. She noted that on the label of the enteral formula bottle, a notation for a rate of 55 mL per hour had been handwritten. On 3/23/11 at 10:45 a.m., the RD stated that she made the recommendation to increase the tube feeding rate to 60 mL per hour because the previous rate of 55 mL per hour was not meeting the resident's protein needs. | 2015-08-01 |
| 9131 | 9131 | BRENTWOOD HEALTH AND REHABILITATION | 115361 | 115 BRENTWOOD DRIVE | WAYNESBORO | GA | 30830 | 2011-03-24 | 323 | E | 0 | 1 | ZS4T11 | Based on observation, record review and staff interview, the facility failed to ensure the environment remained as free of accident hazards as possible by not securing chemicals in one Soiled Linen room; not locking doors leading to rooms containing hot water heaters in two (2) Soiled Linen rooms on one hall; not ensuring that grab/assist bars or devices were securely attached in two resident rooms; not ensuring that an exit door locking mechanism was functional on one hall; and by not removing a damaged chair from the gazebo. Potential environmental hazards were noted on four (4) of five (5) halls and an outside common area. Findings include: 1. On 3/21/11 at 12:31 p.m., the grab bars on either side of the commode for rooms B-5/B-7 were not affixed securely and able to be pulled away from the wall approximately one inch. This was verified by the Maintenance Director at 1:00 p.m. On 3/23/11 at 2:40 p.m., Certified Nursing Assistant (CNA) "DD" stated that three of the four residents in these rooms were independently ambulatory. During a walk-through of the facility environment on 3/23/11 starting at 2:00 p.m., the following concerns were identified, and verified by the Maintenance Director: 2. The assist bars secured to bolts on the back of the commode seat in room D-14 had come loose on one side, and was freely movable approximately eight inches to the side, and the legs were wobbly. At 3:24 p.m., Licensed Practical Nurse (LPN) "EE" stated that one of the three residents in this room was able to toilet themselves without assistance. 3. In an outside courtyard area off Station II was a gazebo used by staff and residents. One of the wrought-iron chairs was totally missing the back of the chair, except for the arched support, leaving a large open back rest. 4. A full one-gallon plastic bottle with screw-on lid of Premium Plus Carpet and Upholstery Extraction Cleaner was found on the floor by the utility sink in the unlocked Soiled Linen room close to the Station I nurse's station. The Maintenance Director stated thi… | 2015-08-01 |
| 9132 | 9132 | BRENTWOOD HEALTH AND REHABILITATION | 115361 | 115 BRENTWOOD DRIVE | WAYNESBORO | GA | 30830 | 2011-03-24 | 468 | E | 0 | 1 | ZS4T11 | Based on observation and staff interview, the facility failed to ensure that there were handrails affixed to all sections of corridor walls on four of five halls. Findings include: During a walk-through of the facility environment with the Maintenance Director on 3/23/11 starting at 2:00 p.m., it was noted that there were no handrails affixed to the corridor walls in the following areas: (The approximate measurements included) STATION II: 1. Two 18-foot sections of wall on either side of the Activity Room doors across from the nurse's station; one 14-foot section outside the 'C' hall fire door; two 5-foot sections on the medication room side of the wall, and one 12-foot section on the opposite wall outside the fire doors on the 'P' hall. STATION I: 2. A 12-foot section of hallway on one side and 6-foot section on opposite wall near the small and large dining/activity rooms on the 'B' hall. The Maintenance Director stated these rails had been removed recently when renovation was done to the area. 3. A 6-foot section on one wall and 18-foot section on the opposite hallway wall between the main lobby and the nurse's station. | 2015-08-01 |
| 4962 | 4962 | EAST LAKE ARBOR | 115482 | 304 FIFTH AVENUE | DECATUR | GA | 30030 | 2016-03-29 | 280 | G | 1 | 0 | ZRKM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy and procedure review, record review and staff interviews, the facility failed to revise the Care Plan interventions in an effort to reduce the likelihood of subsequent falls and /or injuries related to falls for one (1) resident (D) with severe cognitive impairment, [MEDICAL CONDITION] disorder and physical behaviors. The sample was (6) residents. Resident D fell eleven (11) times from (MONTH) (YEAR) through (MONTH) (YEAR). Review of the Care Plan titled Falls dated 1/30/14 identified Resident D was at risk for falls. The Goal documented the resident will not suffer injury from a fall for the next three (3) months. The Long Term Target Date was 10/29/15, then updated through 1/21/16. Resident D had three (3) falls without injuries on 8/13/15, 9/8/15, 9/28/15 and one (1) fall with injury on 9/23/15 before a new intervention was added the Care Plan titled Falls. On 9/28/15 a new intervention was added to monitor the resident and re-direct as needed. After the new intervention had been implemented, Resident D had four (4) falls without injury on 10/2/15, 10/6/15, 10/7/15 and 10/8/15 and one (1) fall with an injury on 10/13/15. New interventions were not added until 10/13/15 and 10/22/15. A new intervention was added to the Care Plan titled Falls on 10/13/15 to start Occupational Therapy to assist with Activities of Daily Living (ADL) care, therapeutic exercises and neuromuscular re-education. On 10/22/15 a new intervention was added to the Care Plan titled Falls, to remind the resident to not transfer without assistant. However, review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] and the Annual MDS assessment dated [DATE] for Resident D both revealed a Brief Interview for Mental Status (BIMS) summary score of 01, indicating severe cognitive impairment. After the interventions were added on 10/13/15 and 10/22/15, Resident D had one (1) fall with injury on 11/9/15 and one (1) fall with no new injury, however, c… | 2019-03-01 |
| 4963 | 4963 | EAST LAKE ARBOR | 115482 | 304 FIFTH AVENUE | DECATUR | GA | 30030 | 2016-03-29 | 323 | G | 1 | 0 | ZRKM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of policy and procedure, record review and staff interviews, the facility failed to ensure adequate supervision for one (1) resident (D) with a history of multiple falls. The sample was six (6) residents. Resident D had a total of eleven (11) falls from (MONTH) (YEAR) through (MONTH) (YEAR). Ten (10) of the eleven (11) falls were unwitnessed (9/8/15, 9/23/15, 9/2815, 10/2/15, 10/6/15, 10/7/15, 10/8/15, 10/13/15, 11/9/15 and 11/12/15). Three (3) of the eleven (11) falls resulted in jury for Resident D (9/23/15, 10/13/15 and 11/9/15). Resident D had three (3) care plans that documented the resident's need for supervision. A Care Plan titled Visual Function documented in Approach with a start date of 1/30/14, that the resident needs supervision while ambulating in the hallway. A Care Plan titled Activities of Daily Living (ADL) Function/Rehabilitation Potential documented in Approach with a start date of 1/30/14 that the resident needs supervision and at times guided assistance while in hallway related to poor vision. A Care Plan titled Falls documented in Approach with a start date of 1/30/14 that the resident needs supervision by staff while ambulating in the hallway related to poor vision. Interview on 3/29/16 at 10:21 a.m. with the Registered Nurse (RN) Resident Care Coordinator (RCC) revealed the main intervention for this resident is supervision and that the staff is supposed to be supervising the resident. The facility's failure to ensure adequate supervision for a resident with a history of multiple falls caused actual harm for Resident D. On 9/23/15 the resident had an unwitnessed fall in the 200 Hall day room and sustained a head injury that required staples. On 10/13/15 the resident had an unwitnessed fall in her room and sustained an injury to the left eye with bruising and swelling. On 11/9/15 the resident had an unwitnessed fall in the 200 Hall day room and sustained a bleeding open wound to the left side of her h… | 2019-03-01 |
| 5595 | 5595 | SIGNATURE HEALTHCARE OF BUCKHEAD | 115110 | 54 PEACHTREE PARK DRIVE N.E. | ATLANTA | GA | 30309 | 2014-12-04 | 157 | D | 0 | 1 | ZQN211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, family and staff interviews, the facility failed to notify the family member/responsible party of a new diagnosis, isolation precautions and change in treatment for one (1) resident (X) from a sample of thirty-four (34) residents. Findings include: Interview with the family member of resident X conducted on 12/1/2014 at 2:41 p.m. revealed the resident was diagnosed with [REDACTED]. Record review for resident X revealed the family member was the responsible party and emergency contact for resident X. Review further revealed the resident tested positive for [MEDICAL CONDITION] on 11/22/2014. The Nurse Practitioner was notified and a new order was given to place X on isolation and to start two (2) antibiotics. There was no evidence in the clinical record that the responsible party/family member for resident X was notified of the new diagnosis, isolation or the new medication orders. Interview with License Practical Nurse AA conducted on 12/4/2014 at 8:15 a.m. revealed that laboratory test results were faxed to the facility on [DATE]. AA contacted the Nurse Practitioner who ordered contact precaution and isolation along with antibiotic therapy. AA acknowledged that the responsible party was not notified until 11/27/14 when she came to visit. Review of the facility Policy and Procedure: Change in Resident's Condition or Status revealed that except in medical emergencies, notifications will occur within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status. | 2018-07-01 |
| 5596 | 5596 | SIGNATURE HEALTHCARE OF BUCKHEAD | 115110 | 54 PEACHTREE PARK DRIVE N.E. | ATLANTA | GA | 30309 | 2014-12-04 | 309 | D | 0 | 1 | ZQN211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, the facility's policy for Controlled Medications, resident and staff interviews, the facility failed to ensure a physician's order for a pain medication was obtained and filled in a timely manner for one (1) resident (Z) from a sample of thirty-four (34) residents. Findings include: Review of the medical record for resident Z revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Further review revealed a physician's order dated 10/17/14 for [MEDICATION NAME] 5/325 milligrams (mg) give one (1) tablet for pain level one (1) thru five (5) and give two ( 2) tablets for pain level six (6) thru ten (10) by mouth (PO) every six (6) hours as needed (PRN) for [DIAGNOSES REDACTED]. Review of the Electronic Medication Administration Record [REDACTED]. Review of the EMAR for (MONTH) 2014 revealed no [MEDICATION NAME] was administered after 11/7/14 at 9:00 p.m. until 11/14/14 at 8:26 p.m. Interview conducted on 12/2/14 at 11:00 a.m. with resident Z revealed that during the month of (MONTH) for about a week, the facility did not have [MEDICATION NAME] available, that she had been taking for pain. Interview conducted 12/3/14 at 2:10 p.m. with resident Z revealed that during the time the [MEDICATION NAME] was unavailable she was unable to get a restful night's sleep. Review of the twenty-four (24) hour shift reports revealed that on 11/8/14 on the 11pm-7am shift and on 11/12/14 on the 10pm to 8am shift a hard script for [MEDICATION NAME] was needed for resident Z. Review of the medical record for resident Z revealed no evidence that the facility followed up with the physician to get a hard copy prescription for [MEDICATION NAME] for resident Z. Further review revealed no evidence that licensed staff attempted to contact the physician regarding the prescription until 11/11/14. Interview with the Director of Pharmacy on 12/4/14 at 11:45 a.m. revealed that the only [MEDICATION NAME] orders filled for the resident Z was on 10/17… | 2018-07-01 |
| 10159 | 10159 | TRANSITIONAL CARE CENTER | 115661 | 901 EAST 18TH ST | TIFTON | GA | 31793 | 2013-04-25 | 431 | D | 0 | 1 | ZQJG11 | Based on observation, staff interview and review of facility's policy, it was determined that the facility failed to discard seven vials of expired, unopened Pneumococcal Vaccine from the refrigerator in the medication room adjacent to the only nurses' station. Findings include: Review of the facility's policy for "Storage of Medications" dated 2010 revealed that the policy was for drugs and biologicals to be stored in a safe, secure and orderly manner and according to State and Federal Laws. the procedures included that no discontinued, outdated, or deteriorated drugs or biologicals were to be available for use in the facility. All such drugs were to be destroyed. Medications requiring refrigeration were to be stored in the refrigerator located in the drug room at the nurses' station. Medications would be stored separately from food and labeled. The refrigerator was supposed to be checked weekly, remain in clean condition and expired medications were to have been sent back to the pharmacy if unopened- if opened, they were to have been discarded per the designated disposal container. However, the facility failed to send seven unopened vials of expired Pneumococcal Vaccine back to the pharmacy. During the tour of the medication room on 4/24/13 at 11:17 a.m., there was a box containing seven unopened vials of Pneumococcal Vaccine Polyvalent (lot # 8) with expiration dates of 03/07/2013. During an interview on 4/24/13 at 11:20 a.m., nurse "AA" said that the in-house hospital pharmacy was responsible for checking dates and removing expired medications, other than insulin, from the facility's medication room refrigerator. After consulting with the Director of Nursing (DON), nurse "AA" said that the nurses on the unit were responsible for checking medications' expiration dates. Nurse "AA" removed the vials of expired medication and stated that he/she would return it to the in-house pharmacy for disposal. After surveyor inquiry, the facility changed their protocol for procurement of pneumovax to be prescribed as needed … | 2015-01-01 |
| 5525 | 5525 | PRUITTHEALTH - MONROE | 115379 | 4796 HIGHWAY 42 NORTH | FORSYTH | GA | 31029 | 2014-09-25 | 371 | D | 0 | 1 | ZOJ711 | Based on observation, and staff interview the facility failed to thaw frozen raw chicken in a sanitary manner to prevent the potential for food borne illness. Findings include: Observation on 09/24/14 at 11:50 a.m. revealed frozen raw chicken in a stainless steel colander under running water in a sink. The frozen raw chicken was not submerged in water. Interview with the Dietary Manager on 09/24/14 at 11:50 a.m. revealed that the frozen chicken should have been submerged in water with the water running. Interview with the Registered Dietitian on 09/24/14 at 12:30 p.m., she confirmed that the frozen chicken should have been submerged under running water for thawing. | 2018-08-01 |
| 8933 | 8933 | WOODLANDS HEALTH CARE | 115553 | 652 COASTAL HIGHWAY 17 NORTH | MIDWAY | GA | 31320 | 2011-09-29 | 156 | C | 0 | 1 | ZNQD11 | Based on record review and staff interview, it was determined the facility failed to issue the mandatory written Notice of Provider Noncoverage (form CMS- ) and a completed Skilled Nursing Facility Advance Beneficiary Notice (form CMS- ) to three of three residents (#107, #81, and #70) reviewed who had been discharged from Medicare Part A services. Findings include: The facility issued a Skilled Nursing Facility Advance Beneficiary Notice (form CMS- ) to resident #107 on 7/14/11, to resident #81 on 8/26/11, and to resident #70 on 6/6/11 notifying them of their discharge from Medicare Part A services on 7/17/11, 8/25/11, and 6/8/11 respectively. However, the facility failed to complete the estimated cost section of the form. Additionally, the facility had failed to issue the required Notice of Provider Noncoverage (CMS- ) to residents who had been discharged from Medicare Part A services. During an interview on 9/28/11 at 3:10 p.m., the business office manager, who was responsible for issuing the mandatory liability forms, said that she was not aware of the form CMS . She said that the facility had issued notices to the 12 residents who had been discharged from Medicare Part A services since June 2011. | 2015-09-01 |
| 8934 | 8934 | WOODLANDS HEALTH CARE | 115553 | 652 COASTAL HIGHWAY 17 NORTH | MIDWAY | GA | 31320 | 2011-09-29 | 166 | D | 0 | 1 | ZNQD11 | Based on review of the social service notes and interviews with residents and facility staff, it was determined that the facility failed to respond or attempt to resolve verbal complaints by two residents (A and B) about the rudeness of nursing staff from a total sample of 25 residents. 1. During interview on 09/26/11 at 10:45 a.m., resident A said that a certified nursing assistant had been rude to Resident C and he/she had reported it to the supervising nurse on the day it occurred. Resident A did not recall which supervisory nurse to whom he/she had reported the incident. In an interview 09/28/11 at 12:50 p.m., Resident C recalled the incident and said that the employee's (bad) attitude had been reported to a supervisor. In a subsequent interview on 09/28/11 at 1:00 p.m. about resident A's complaint involving rude behavior by an employee, Director of Nursing (DON) said that she did not remember it. Later that day at 2:48 p.m., the DON said that licensed practical nurse (LPN) AA had mentioned to her (DON) in passing that resident A had reported a certified nursing assistant (CNA) had been rude and had kicked the door. She said that the day of that report she had gone to Resident A's room with several other nurses to assist in the resident's care. The DON said at that time neither residents A or C , who had also been in the room, mentioned any concerns. The DON stated that there had not been a formal investigation of the incident and no other interview was conducted because, the resident did not indicate to her that there were any problems. In an interview on 09/29/11 at 8:00 a.m., the Administrator said that that the two nurses had been remiss in not investigating the resident's complaint but, it was now being addressed. She said that the employee named in the allegation had been suspended during the investigation. 2. During an interview on 9/27/11 at 11:35 a.m., resident B stated that staff had been rude to him/her. According to the 8/4/11 social service notes, resident B had complained during a care plan meet… | 2015-09-01 |
| 8935 | 8935 | WOODLANDS HEALTH CARE | 115553 | 652 COASTAL HIGHWAY 17 NORTH | MIDWAY | GA | 31320 | 2011-09-29 | 241 | D | 0 | 1 | ZNQD11 | Based on interviews with residents and staff, it was determined that the facility failed to ensure that nursing staff members were not rude in their interactions with three ( A B and C ) residents from a sample of twenty-five residents. Findings include: 1. During an interview on 09/26/11 at 10:45 a.m., resident A said that when an (nursing) employee had been rude to another resident, he/she had reported it to the supervising nurse on the day it happened. Resident A did not recall which supervisory nurse to whom he/she had reported the incident. The resident said that the nursing staff person was being rude to resident C (his/her roommate). Resident A said that he/she had intervened and told the nursing staff person not to speak to an elderly person that way. Resident A said the employee continued to have an attitude while assisting resident C to use a bedpan. In an interview 09/28/11 at 12:50 p.m., Resident C recalled the incident and the employee's (bad) attitude which had been reported to a supervisor. Resident A said that he/she told the nursing staff person that he/she also needed to use a bedpan but, the nursing staff person left the room without providing one. A said that after the nursing staff person was told to return to the resident's room, he/she had to ask the nursing staff person to clean the bedpan which still contained feces from earlier in the day. The resident added that the employee had cleaned it but with a very negative attitude. Resident A said the employee went into the bathroom, kicked something and later kicked the wall and and used profane language while in the bathroom. During the interview at 2:48 p.m. on 09/28/11 after interviewing resident A and some investigation, the DON and licensed practical nurse (LPN) AA, said AA had mentioned to her (DON) in passing that resident A had reported that a certified nursing assistant (CNA) had been rude and had kicked the door. The DON said that she did not recall AA's report but later that day she had gone into Resident A's room with several other… | 2015-09-01 |
| 8936 | 8936 | WOODLANDS HEALTH CARE | 115553 | 652 COASTAL HIGHWAY 17 NORTH | MIDWAY | GA | 31320 | 2011-09-29 | 279 | D | 0 | 1 | ZNQD11 | Based on review of the clinical record, care plans and interviews with facility staff, it was determined that the facility failed to develop a care plan for one of 25 residents (# 77) to ensure appropriate precautions in meeting the safety needs of other residents. During an interview on 9/28/11 at 8:15 a.m. the Social Service Director said that resident # 77 had not demonstrated any sexually inappropriate behavior since being admitted to the facility in July 2011. She said that he/she did not demonstrate that type of behavior in her/his previous communal living facility or the previous health care facility and had been assessed as safe by his/her caseworker. However, the resident had been included on the sex offender registry for an incident which in 9/28/11 at 9 a.m. interview, the Social Service Director described as a misdemeanor. Although the resident's history has the potential of putting her/him at risk for inappropriate behavior, the facility did not develop a care plan to address how to monitor the resident for the targeted behavior in order to decrease the potential risk to other residents. | 2015-09-01 |
| 8937 | 8937 | WOODLANDS HEALTH CARE | 115553 | 652 COASTAL HIGHWAY 17 NORTH | MIDWAY | GA | 31320 | 2011-09-29 | 309 | D | 0 | 1 | ZNQD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined the facility failed to administer a medication as ordered for one resident (# 110) from a sample of 25 residents. Findings include: Resident #110 had a physician's orders [REDACTED]. However, a review of the June 2011 Medication Administration Record [REDACTED]. The Director of Nursing stated on 9/29/11 at 10:49 a.m. that she could not confirm whether or not the medication was administered. | 2015-09-01 |
| 8938 | 8938 | WOODLANDS HEALTH CARE | 115553 | 652 COASTAL HIGHWAY 17 NORTH | MIDWAY | GA | 31320 | 2011-09-29 | 428 | D | 0 | 1 | ZNQD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined the pharmacist failed to identify a medication omission for one resident (# 110) from a sample of 25 residents. Findings include: Resident #110 had a physician's orders [REDACTED]. However, a review of the June and July 2011 Medication Administration Record [REDACTED]. It was observed that nursing staff initialed the MAR indicated [REDACTED]. However, nursing staff had not initialed the MAR indicated [REDACTED]. The Director of Nursing stated on 9/29/11 at 10:49 a.m. that she could not confirm whether or not the medication was administered. A review of the pharmacist signature sheet in the clinical record revealed that although the pharmacist had reviewed the resident's medication regime monthly on 6/24/11, 7/18/11, 8/15/11, and 9/14/11, he/she had not identified this irregularity. | 2015-09-01 |
| 2481 | 2481 | RIVER TOWNE CENTER | 115566 | 5131 WARM SPRINGS RD | COLUMBUS | GA | 31909 | 2017-12-22 | 568 | C | 0 | 1 | ZNPV11 | Based on record review and staff interview, the facility failed to provide a quarterly financial statement of a resident trust fund account for one resident (R) (#51). The deficient practice had the potential to affect 112 residents with trust fund accounts managed by the facility. Findings include: Review of a Resident Funds Accounts document with no revision date revealed that the Center shall furnish residents/patients with quarterly statements at the end of each calendar quarter. Record review for R#51 revealed a Quarterly Minimum Data Set (MDS) assessment which documented a Brief Interview for Mental Status (BIMS) summary score of 03, indicating severe cognitive impairment. During an interview on 12/18/17 at 2:32 p.m., with a Family member of R#51 revealed that she does not get quarterly statements and that her mother has been in the facility for 5 years. Family stated that they will tell her how much is in there if she asks. Review of the Resident Statement Landscape from 6/1/17 through 12/4/17 revealed R#51 to have an open Resident Trust Fund Account. No documentation was available to indicate that quarterly statements had been issued. Interview with Business Office Staff CC on 12/21/17 at 3:16 p.m. revealed that she has no idea how or when quarterly statements were sent out prior to the new company taking over on 10/1/17. She stated that the Business Office Manager recently quit and that she was responsible for the resident trust fund. Interview with the Administrator on 12/22/17 at 9:50 a.m. revealed that she was not aware of any issues with the resident trust fund until she reviewed the trial balance report requested by the surveyor. She stated that she expects a file to be maintained for each resident to include an appropriate authorization to handle the account and documentation of the method of sending the quarterly statement whether it was mailed or delivered in hand to the resident or family. | 2020-09-01 |
| 2482 | 2482 | RIVER TOWNE CENTER | 115566 | 5131 WARM SPRINGS RD | COLUMBUS | GA | 31909 | 2017-12-22 | 569 | C | 0 | 1 | ZNPV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure four of four sampled residents' (R) (#20, #9, #76, #15) trust fund accounts remained under the $2,000 limit to maintain eligibility for Medicaid services; and failed to convey resident funds and final accounting to the individual administering the resident's estate within 30 days upon the death of one residents (R) (#50). The facility managed 112 resident trust funds accounts. Findings include: Record review of a Resident Funds Accounts document with no revision date revealed that the facility will provide for the temporary safekeeping of personal funds only upon approval of the resident/patient or legal representative. Residents/Patients or estate representatives will receive a statement of account and refund, if applicable, within the time frame designated by the state after discharge or upon death of the resident. Review of the Trial Balance report as of [DATE] revealed the following current balances: R#20: The account balance was $3043.28. R#9: The account balance was $2245.52. R#76: The account balance was $2114.14. R#15: The account balance was $2324.93. R#50: The account balance was $832.15 and the status indicated that the resident expired on [DATE]. During an interview on [DATE] at 9:49 a.m., with Business Office Staff CC revealed that the Business Office Manager had recently quit on [DATE]. She stated that she would highlight the accounts that were over the Social Security Income (SSI) limit for the business office manager but was unsure why resident accounts were still over the limit. The Business Office Associate could not explain why funds were not disbursed after death for R#50. Interview with the Administrator on [DATE] at 9:34 a.m. revealed that she was not aware of the balances exceeding the SSI limit. She stated that the business office manager quit last week and was responsible for the resident trust fund. Administrator stated that she expects residen… | 2020-09-01 |
| 2483 | 2483 | RIVER TOWNE CENTER | 115566 | 5131 WARM SPRINGS RD | COLUMBUS | GA | 31909 | 2017-12-22 | 570 | C | 0 | 1 | ZNPV11 | Based on record review and staff interview, the facility failed to maintain a surety bond sufficient to cover the current total funds in the resident trust account. The deficient practice had the potential to affect 112 residents with trust fund accounts managed by the facility. Findings include: Resident Funds Accounts document with no revision date revealed that Centers will provide for the temporary safekeeping of personal funds only upon approval of the resident/patient or legal representative. The Center shall maintain a surety bond in accordance with CMS Regulations. Review of the Trial Balance Report as of 12/21/17 revealed the Resident Trust Fund Account totaling to $131, 855.81. Review of the State of Georgia, Department of Community Health, Long Term Care Facility Residents' Fund Bond dated 9/30/17 revealed a surety in the amount of $100,000. Interview with the Administrator on 12/22/17 at 09:50 a.m. revealed that she was not aware of the issues with the resident trust fund until she reviewed the trial balance report requested by the surveyor. She expects the trial balance report to be reviewed monthly to ensure that the resident liability care cost is swept and the surety bond to be adjusted as needed. | 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 );