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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 9675 | 9675 | JAMES B CRAIG CENTER | 11A556 | CENTRAL STATE HOSPITAL | MILLEDGEVILLE | GA | 31062 | 2012-01-06 | 160 | E | 0 | 1 | 5SOM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to convey residents' funds within thirty (30) days of the death of the residents for five (5) of six (6) resident records reviewed ("A", "B", "C", "D", "E"). Findings include: 1. Review of the Resident Trust Fund Account Records revealed resident "A" expired [DATE]. Continued review revealed that as of [DATE], the remaining funds in the amount of $150.35 had not been disbursed. Telephone interview on [DATE] at 2:30 p.m. with staff member "A6" in the Central State Hospital Cashier's Office revealed the facility had tried to contact the resident's sister and was waiting for the sister's response to disburse the funds. Review of records provided by the Central State Cashier's Office revealed a letter was mailed to the deceased resident's sister on [DATE], one-hundred-six (106) days after the resident expired. 2. Review of the Resident Trust Account Records revealed that resident "B" expired [DATE]. Continued review revealed that funds in the amount of $158.22 were disbursed on [DATE] to the Business Administration Fund for the contract burial of the resident. The disbursement was forty (40) days after the resident expired. 3. Review of the Resident Trust Account Records revealed that resident "C" had expired [DATE]. Continued review revealed that funds in the amount of $35.00 were disbursed on [DATE] to the Business Administration Fund for the contract burial of the resident. The disbursement was thirty-seven (37) days after the resident expired. 4. Review of the Resident Trust Account Records for revealed that resident "D" had expired [DATE]. Continued review revealed that funds in the amount of $1848.00 were disbursed on [DATE] to a relative of the resident. The disbursement was seventy-five (75) days after the resident expired. 5. Review of the Resident Trust Account Records revealed that resident "E" expired [DATE]. Continued review revealed that as of [DATE], the remaining fund… | 2015-06-01 |
| 9676 | 9676 | JAMES B CRAIG CENTER | 11A556 | CENTRAL STATE HOSPITAL | MILLEDGEVILLE | GA | 31062 | 2012-01-06 | 241 | D | 0 | 1 | 5SOM11 | Based on observation, staff interview, and record review, the facility failed to provide care in a manner to promote dignity during dining for one resident (#21) from a sample of thirty-six (36) residents and three (3) random residents. Findings include: 1. Observation in the dining area on Unit Craig 6 on 1/3/12 at 1:15 p.m. revealed Certified Nursing Assistant (CNA) "HH" feeding resident #21. The CNA was standing on the resident's right side to feed her, although there were chairs available for use. Observation in the dining area of Unit Craig 6 on 1/4/12 at 12:40 p.m. revealed CNA "HH" standing to the left of the resident's wheelchair to feed her. Continued observation revealed that Registered Nurse (RN) "FF", who relieved CNA "HH" to finish feeding resident #21 also stood on the resident's left side to feed her. There was a chair available at the table where the resident's wheelchair was parked. 2. Observation of lunch in the dining area of Unit Craig 6 on 1/4/12 at 12:30 p.m. revealed CNA "II" standing on the left side of a resident to feed him. Interview with the Director of Nursing (DON) on 1/4/12 at 1:20 p.m. revealed that staff members feeding residents should be interacting with the residents, making mealtime a pleasurable experience for the residents. Continued interview revealed that the staff member should be in a seated position when feeding the residents.. 3. Observation on 01/04/12 at 12:24 p.m. during lunch in the main dining room revealed two (2) residents being fed by CNA staff. The CNAs, who were feeding these residents, were conversing between themselves, more than with the residents they were feeding. Both of the residents were seated at the same table and the two (2) CNAs had a constant conversation between themselves, rarely, if ever conversing with the residents at the table. Continued observation revealed that a female CNA entered the dining room, one (1) the CNAs feeding a resident turned began to converse with the CNA, turning his back to the resident. Interview with Certified Nursing … | 2015-06-01 |
| 9677 | 9677 | JAMES B CRAIG CENTER | 11A556 | CENTRAL STATE HOSPITAL | MILLEDGEVILLE | GA | 31062 | 2012-01-06 | 279 | D | 0 | 1 | 5SOM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to establish a comprehensive care plan regarding adaptive devices and weight loss for two(2) residents (#75 and #108) from a sample of thirty-six (36) residents. Findings include: 1. Review of the clinical record for resident #75 revealed that the resident had a 10% weight loss in six (6) months, weighing 115 pounds in April, 2011 and 96 pounds in October, 2011. Review of the annual Minimum Data Set Assessment (MDS) completed October, 2011 revealed that the resident had been assessed with [REDACTED]. Review of the Care Area Assessment (CAA) indicated that the resident would be care planned for the weight loss. The facility had implemented interventions to address the weight loss but there was no evidence that a care plan had been initiated for weight loss. Interview with Registered Nurse, (RN)/Charge Nurse "AA" on 01/05/12 at 3:00 p.m. revealed that there was no care plan for the resident related to weight loss. Interview with the RN/Team Leader "CC" at 3:15 p.m. revealed that they had discussed the resident's weight loss in team meeting and it should have been care planned. Observation of resident #75 on 01/05/12 at 1:52 p.m.revealed that the resident had an overlap tray/lap buddy attached to her wheelchair. Review of the clinical record for this resident revealed that the Occupational Therapist (OT) had assessed the resident for this as well as a seatbelt to provide optimal upright positioning in the wheelchair when out of bed. The OT determined that these measures were the least restrictive and appropriate measures for positioning and safety as well as mobility purposes. Review of the care plan for resident #75 revealed no evidence that a care plan had been initiated for the overlap table /lap buddy or the padded siderails. Interview with Registered Nurse, (RN)/Charge Nurse "AA" on 01/05/12 at 3:00 p.m. revealed that, after reviewing the resident's medical record, … | 2015-06-01 |
| 9678 | 9678 | JAMES B CRAIG CENTER | 11A556 | CENTRAL STATE HOSPITAL | MILLEDGEVILLE | GA | 31062 | 2012-01-06 | 281 | D | 0 | 1 | 5SOM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to follow their policy for obtaining informed consent for adaptive devices for three (3) residents (# 75,#108, #86) and a physician's order for side rails for one (1) resident (#86) from a sample of thirty six (36) residents. Findings include: 1. Observation of resident #75 on 01/05/12 at 1:52 p.m. revealed that the resident had an overlap tray/lap buddy attached to her wheelchair. Review of the clinical record for this resident revealed that the Occupational Therapist (OT) had assessed the resident for this as well as a seatbelt to provide optimal upright positioning in the wheelchair when out of bed. The OT determined that these measures were the least restrictive and appropriate measures for positioning and safety as well as mobility purposes. Further review of the medical record revealed that the consent for the adaptive devices had been signed by Registered Nurse, (RN)/Charge Nurse "AA" for Craig 5 and the Physician. Review of the facility policy revealed that the consent for utilization of the devices is required from the client and/or family in all nursing facilities. The resident has a son who is listed as her next of kin and responsible party. It is noted in the social worker notes that it is difficult to contact him at time, however there is no evidence in the record to indicate that any attempt was made to inform him that the resident would be needing the devices and that his consent would be required. Interview with RN "AA" on 01/05/12 at 3:00 p.m. revealed that she it is the facility policy that a signed consent for utilization of the device is required from the client and/or family in all facilities. Continued interview revealed that this had not been done when she and a physician signed for the resident to have an overlap table/lap buddy and seatbelt without consent of the resident's son who is listed as her responsible party. 2. Observation of resident… | 2015-06-01 |
| 9679 | 9679 | JAMES B CRAIG CENTER | 11A556 | CENTRAL STATE HOSPITAL | MILLEDGEVILLE | GA | 31062 | 2012-01-06 | 313 | D | 0 | 1 | 5SOM11 | **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 (#108) from a sample of thirty-six (36) residents received proper treatment to maintain vision Findings include: Review of the clinical record for resident #108 revealed that the resident had a [DIAGNOSES REDACTED]. Continued review revealed a Central State Consultation sheet dated 6/9/10 for an annual eye exam. The eye exam was done on 12/13/10 with an order for [REDACTED]. Interview with the agency nurse, working on the Craig 4 unit, on 01/06/12 at 4:45 p.m. revealed that she did not know where to find the record of any eye exams done on the resident but would ask other staff members. After looking for another eye exam report, there was no evidence that the resident had had an annual exam since 12/13/10.. | 2015-06-01 |
| 9680 | 9680 | JAMES B CRAIG CENTER | 11A556 | CENTRAL STATE HOSPITAL | MILLEDGEVILLE | GA | 31062 | 2012-01-06 | 322 | D | 0 | 1 | 5SOM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to follow a physician's order to increase the infusion rate for an enteral feeding and failed to label the infusion with the hang time for one (1) resident (#82) from a sample of thirty-six (36) residents. Findings include: Observation of resident #82 on 01/03/12 at 12:51 p.m. revealed a bottle of 1.2 calorie [MEDICATION NAME] Enteral Tube Feeding infusing at 60 cubic centimeters (cc) per hour. Continued observation revealed no label on the bottle to indicate the time the infusion was hung. Review of medical record revealed a physician's order dated 01/03/12 at 10:50 a.m. to stop the current [MEDICATION NAME] feeding and increase the infusion rate to 65cc per hour continuously for 180 days. Continued review revealed that the order was signed off by the nurse at 1:00 p.m. Observation of resident #82 on 01/03/12 at 2:06 p.m. and 4:27 p.m. revealed a bottle of 1.2 calorie [MEDICATION NAME] Enteral Tube Feeding continuing to infuse at 60 cubic centimeters (cc) per hour. Continued observation revealed no label on the bottle to indicate the time the infusion was hung. Interview on 01/03/12 at 4:33 p.m. with Registered Nurse (RN) Charge Nurse "AA" revealed that there was no time on the bottle of tube feeding to indicate when it was hung and that the feeding had not been increased per the physician's order, although it had been updated on the Medication Administration Record [REDACTED] Review of facility policy for Enteral Feeding revealed that the container should include type of formula, amount of formula, infusion rate and the time formula hung with the nurse initials and/or signature. | 2015-06-01 |
| 9681 | 9681 | JAMES B CRAIG CENTER | 11A556 | CENTRAL STATE HOSPITAL | MILLEDGEVILLE | GA | 31062 | 2012-01-06 | 323 | D | 0 | 1 | 5SOM11 | Based on observation and staff interview, the facility failed to provide supervision for three (3) residents (#122, #153 and "E") of nine (9) smokers from a sample of thirty six (36) residents. Findings include: 1. Observation on 01-04-12 at 1:10 p.m. revealed residents #122 and resident # 153 were smoking outside the exit door, in the courtyard, off of Unit Craig four (4) and were unattended by a staff member. Interview with the Director of Nursing on 01-04-12 at 1:30 p.m. revealed that staff should be present when a resident is smoking. Continued interview revealed that the facility set up smoking times for the residents so a staff member could be present with the resident. Interview on 01-05-12 at 2:00 p.m. with Registered Nurse (RN) "RR" revealed that that a staff member should have been with the residents when they were outside smoking. Continued interview revealed that smoking supplies are kept at the nursing station. 2. Observation on 1/6/12 at 11:22 a.m. revealed resident "E" sitting by himself in a plastic chair outside the door from Unit Craig 5 to the courtyard. He was smoking one cigarette and had another unlit cigarette in the chair beside him. Interview on 1/6/12 at 11:22 a.m. with resident "E" revealed that he received the cigarettes from the box behind the nurse's station on Unit Craig 6 and that he got a light from a staff member on Unit Craig 5. Interview with RN "FF" on 1/6/12 at 11:25 a.m. confirmed that the resident was smoking unaccompanied by a staff member. Interview with the DON on 01/05/12 at 5:15 p.m. revealed that the facility felt that having staff supervise all residents while smoking provided for their safety. Review of the facility smoking policy revealed that the residents who have the opportunity for personal use of tobacco products will be afforded the opportunity to use such products at specified times in designated outside areas. Staff supervision will be maintained during those times. | 2015-06-01 |
| 9682 | 9682 | JAMES B CRAIG CENTER | 11A556 | CENTRAL STATE HOSPITAL | MILLEDGEVILLE | GA | 31062 | 2012-01-06 | 431 | D | 0 | 1 | 5SOM11 | Based on observation and review of the facility policy for medication Room Standards the facility failed to label medications with the expiration date on six (6) bottles of nasal spray on four (4) medication carts on two (2) of six (6) units. Findings include: 1. Observation on 1/4/12 at 12:05 p.m. of the two (2) medication carts on Craig 5 revealed that cart #2 had two (2) bottles of Calcitonin-Salmon nasal spray and one (1) bottle of Fosamax nasal spray that were not labeled with the expiration date. 2. Observation on 1/4/12 at 12:15 p.m. of the (2) medication carts on Craig 6 revealed that the Green cart had three (3) bottles of Calcitonin-Salmon nasal spray that were not labeled with the expiration date. Review of the facility policy for medication room standards revealed that medications must have a securely attached label that clearly indicated expiration date of all time-dated medications. | 2015-06-01 |
| 9683 | 9683 | JAMES B CRAIG CENTER | 11A556 | CENTRAL STATE HOSPITAL | MILLEDGEVILLE | GA | 31062 | 2012-01-06 | 425 | D | 0 | 1 | 5SOM11 | Based on observations, record review and staff interviews, the facility failed to discard expired medication timely on one (1) of six (6) units. Findings include: Observation on 1/4/12 at 11:00 a.m. of two (2) medication carts on Craig 1 with Licensed Practical Nurse (LPN) "VV" revealed thirteen (13) bottles of Calcitonin-Salmon Nasal Spray with blue expiration labels dated 12/27/11. Interview with LPN "VV" on 1/04/12 at 11:05 a.m. revealed that all medications, including nose drops , are returned to the pharmacy every thirty (30) days to be replaced or refilled. Interview with the Pharmacist for Craig 1 on 1/04/12 at 11:20 a.m. revealed that a blue expiration label on the medication bottles dated 12/27/11 is expired and should have been returned to the pharmacy. | 2015-06-01 |
| 9684 | 9684 | JAMES B CRAIG CENTER | 11A556 | CENTRAL STATE HOSPITAL | MILLEDGEVILLE | GA | 31062 | 2012-01-06 | 164 | D | 0 | 1 | 5SOM11 | Based on observation and staff interview, the facility failed to ensure that privacy was provided and maintained during the provision of care for one (1) resident (#69) from a sample of thirty six (36) residents. Findings include: Observation on 01-03-12 at 1:55 p.m. with Licensed Practical Nurse (LPN) "PP" revealed Certified Nursing Assistant (CNA) "OO" changing the adult brief for resident #69. The resident was standing at the end of the bed with his pants off, while the CNA provided care. Continued observation revealed that the door was open to the room and the privacy curtains were not pulled closed. Interview with LPN "PP" on 01/03/12 at 1:55 p.m. confirmed that the resident was exposed, that the door was open and that the privacy curtains were not pulled. Interview on 01-05-12 on 2:00 p.m. with Registered Nurse (RN) Team leader for Craig 4 "QQ" and RN Unit Manager for Craig 4 "RR" revealed that the staff should respect the privacy of the residents and that the door should have been closed and the privacy curtains pulled when care was being provided. | 2015-06-01 |
| 9685 | 9685 | JAMES B CRAIG CENTER | 11A556 | CENTRAL STATE HOSPITAL | MILLEDGEVILLE | GA | 31062 | 2012-01-06 | 441 | F | 0 | 1 | 5SOM11 | Based on observation and staff interview the facility failed to maintain appropriate infection control measures to prevent the likelihood of the spread of infection for two (2) ice scoops in the kitchen, one (1) ice scoop on one (1) of six (6) Units (Craig 6), and the cleaning and disinfecting of one (1) glucometer on one (1) of six (6) Units (Craig 7). Findings include: 1. Observation on 01-04-12 at 11:50 a.m. revealed that two (2) ice scoops for the two (2) ice machines, providing ice for all residents in the facility, located in the kitchen area, behind the serving line, were uncovered and lying on top of the ice maker. The two scoops were uncovered and were not in any type of container. Further observation revealed that the staff used the ice scoops to get ice for the resident's drinks and than replaced the scoop back on top of the ice maker. Interview on 01-04-12 at 1:20 p.m. with the Food Service Manager confirmed that the scoops for the ice in the kitchen were uncovered and should be covered or placed in some type of container. 2. Observation on 1/03/12 at 10:30 a.m. and on 1/06/12 at 4:15 p.m. revealed an uncovered metal ice scoop lying on a tray beside a portable ice chest on the counter in the six (6) Craig Nurses' station. Interview on 1/06/12 at 4:15 p.m. with Registered Nurse (RN) "FF" Unit Manager of the six (6) Craig unit revealed the ice scoop and ice in the portable ice chest is used to serve residents, staff, or anyone who would like a glass of water or need ice for a drink. Continued review revealed that the RN revealed was not aware the ice scoop needed to be covered. 3. During a random observation of a blood glucose check on the Unit Craig seven (7) on 01/04/12 at 3:40 p.m. revealed that Licensed Practical Nurse (LPN) "TT" failed to clean or disinfect the glucometer machine according to facility policy after use. After completing the blood glucose testing, the LPN placed the glucometer on the medication cart, discarded the sharps into the sharps container, cleaned the glucometer with an alcoh… | 2015-06-01 |
| 9686 | 9686 | JAMES B CRAIG CENTER | 11A556 | CENTRAL STATE HOSPITAL | MILLEDGEVILLE | GA | 31062 | 2012-01-06 | 463 | E | 0 | 1 | 5SOM11 | Based on observations and staff interviews the facility failed to maintain a functioning call light system for twenty one (21) of one hundred forty five (145) call lights checked on six (6) of six (6) units. Findings include: Observations on 01-03-11 starting at 1:30 p.m. revealed that twenty one (21) call lights were not working in the following rooms: The call lights for beds 101 B and 118 B on Unit/Craig 1 would not light up or sound at the nursing station. Call lights for beds 154 on Unit/Craig 2 would not light up or sound at the nursing station. Call lights for beds 110 C, 117C, 124 A and B, 128, and 132 A,B,and C on Unit/Craig 4 would not light up or sound at the nursing station. Call lights for beds 111 A, 113 A and B, 116 A, 117, 118 B, 125C, and 133 B on Unit/Craig 5 would not light up or sound at the nursing station. Call light for bed 167 C on Unit/Craig 6 would not light up or sound at the nursing station. Call light cord for 133 B on Unit/ Craig 7 did not have a push button at the end of the cord. Interview with Registered Nurse (RN) Craig 4 Unit Manager "RR" on 01-03-12 at 3:10 p.m. confirmed that the call lights were not working. Continued interview revealed that if a call light is found not working, then it is replaced by the maintenance department. The nurse acknowledged that there is not a check list for the call light and that it should be added to the check list of the room. Interview and observation on 01-03-12 starting at 3:30 p.m. with the Maintenance Director confirmed that the call lights were not working. Further observation and interview revealed that cords needed to be replaced. Continued interview revealed that the staff are to keep extra light cords on the units so they can be replaced when one is not working, however, if the call lights need worked, the staff is to send a work order to the maintenance department. | 2015-06-01 |
| 9687 | 9687 | JAMES B CRAIG CENTER | 11A556 | CENTRAL STATE HOSPITAL | MILLEDGEVILLE | GA | 31062 | 2013-07-11 | 371 | E | 0 | 1 | QTLZ11 | Based on observation and staff interview it was determined that the facility failed to properly store and label refrigerated inventory in a safe and sanitary manner in one (1) walk in cooler and one (1) refrigerator in the kitchen. This effected all residents receiving oral alimentation (59) Findings include: Observation of the kitchen on 7/8/13 at 11:45 a.m. revealed four (4) plastic bags of unknown yellow/orange food substance inside the walk in cooler. The four bags (4) bags had no label to identify the contents, date received and/or use by date. One bag in the refrigerator was opened and was not labeled identifying the date opened. Interview with the dietary supervisor on 7/8/13 at 11:55 a.m. revealed that the bag did not have an open date and/or the date the bag was received. Continued interview revealed that all food products should contain date received and/or open and use by date. | 2015-06-01 |
| 9688 | 9688 | JAMES B CRAIG CENTER | 11A556 | CENTRAL STATE HOSPITAL | MILLEDGEVILLE | GA | 31062 | 2013-07-11 | 441 | E | 0 | 1 | QTLZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, facility policy review and staff interview, the facility failed to ensure that staff washed their hands between resident contact and after handling linen, to prevent the spread of possible cross contamination on three (3) of the five (5) halls (Craig 6, Craig 5 and Craig 1) and the main dining room. Findings include: 1. Observation on 7/6/13 at 12:00 p.m. in the Craig 6 dining room revealed that there were a total of five (5) residents, four (4) needing total assistance and one (1) requiring set up only and a total of four (4) staff. Continued observation revealed that Certified Nursing Assistant (CNA) "BB" did not wash/sanitize her hands after entering the dining room prior to feeding one (1) dependent resident After assisting residents to the dining room, CNA "CC" began passing out the lunch trays from the locked cart, without washing/sanitizing her hands. Further observation revealed that Licensed Practical Nurse (LPN) "EE" assisted residents in the dining room, touching their wheelchairs, clothing and their dietary cards, without washing her hands, prior to feeding a dependent resident. CNA "DD" did not wash her hands prior to assisting a dependant resident to eat her lunch, after the CNA touched the resident's wheelchair, clothing and another resident's lunch tray. 2. Observation on 7/6/13 at 12:15 p.m. in the Craig 5 dining room revealed that there were a total of four (4) residents, two (2) needing total assistance and two (2) needing set up and encouragement from staff with a total of five (5) staff. Continued observation revealed that CNA "AA" assisted one (1) resident with setting up the tray without washing/sanitizing his hands. While putting two (2) patties of butter on the residents mashed potatoes, the CNA touched the butter patties with bare hands, wiped his hands on a napkin, and took the plastic tops off three (3) drinks on the lunch tray, touching the rim of each glass. Continued observation revealed t… | 2015-06-01 |
| 9974 | 9974 | JAMES B CRAIG CENTER | 11A556 | CENTRAL STATE HOSPITAL | MILLEDGEVILLE | GA | 31062 | 2010-05-19 | 241 | D | 0 | 1 | 9MHY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure that care was provided in a manner to promote dignity for one (1) resident (#4) of the sampled twenty-five (25) residents. Findings include: Observation on 5/18/10 at 8:05 a.m. revealed resident #4 sitting in a geri-chair in the day room with both feet uncovered exposing multiple pressure sores. Continued observation revealed the following pressure sores: eschar covered inner heels bilaterally, with edges of peeling skin; left foot inner plantar area with a one-by-one centimeter (1x1 cm) dried scab; right great toe, right second and fourth toe with a black scabbed area. There was a foul odor present. The dayroom was filled with residents and staff that were finishing up breakfast. Review of the clinical record for resident #4, revealed [DIAGNOSES REDACTED]. During interview on 5/18/10 at 8:15 a.m., Licensed Practical Nurse (LPN) "HH", indicated that there was nothing wrong with exposing this resident's feet. Continued interview revealed that after the Certified Nursing Assistants (CNA) showered the resident, on the night (11-7) shift, they placed the resident in the day room. LPN "HH" acknowledged that there was a foul odor and then requested the staff to remove the resident from the day room. Interview on 5/19/10 at 9:35 a.m. with Registered Nurse (RN) "GG", revealed that after resident #4 had a shower the staff placed the resident in the day room until the treatment nurse was ready to complete the wound care. Interview on 5/19/10 at 12:00 p.m. with the Director of Nursing, revealed that the expectation would be that the resident had something covering the feet. | 2015-04-01 |
| 9975 | 9975 | JAMES B CRAIG CENTER | 11A556 | CENTRAL STATE HOSPITAL | MILLEDGEVILLE | GA | 31062 | 2010-05-19 | 315 | D | 0 | 1 | 9MHY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to provide incontinence care in a manner to decrease the likelihood of a Urinary Tract Infection for three (3) residents (#4, #16 and #20) of the sampled twenty-five (25) residents. Findings include: 1. Observation on 5/19/10 at 9:25 a.m. of incontinent care for resident #16, performed by Certified Nursing Assistant (CNA) "FF" revealed that the CNA washed the perineal area from front to back in an up and down motion with the same area of the wash cloth. Review of the clinical record for resident #16, revealed a history of Urinary Tract Infections. Review of the Minimum Data Set ((MDS) dated [DATE] revealed the resident was totally dependent on staff for Activities of Daily Living and was incontinent. Interview on 5/19/10 at 11:50 am with the Director of Nursing (DON) revealed that the CNA's are trained by the staff development department. Continued interview revealed that the CNA's get their training before becoming certified and that is a one time thing. There are inservices throughout the year to ensure that they are providing appropriate care. 2. Observation on 5/18/10 at 9:20 a.m. of incontinence care for resident #4, performed by CNA "JJ", revealed that the CNA cleaned the sacral area from top to bottom, using three (3) cleansing [MEDICAL CONDITION], using the same disposable wipe. Continued observation revealed that the CNA did not clean the buttocks. The resident was repositioned and the CNA used one (1) disposable wipe to clean across the perineum using a side to side and up and down motion. CNA "JJ" failed to clean the vaginal area and did not obtain clean wipes. Review of the MDS dated [DATE], revealed the resident was totally dependent on staff for ADLs and was incontinent. Interview on 5/18/10 at 9:40 a.m. with CNA "JJ" revealed that clean wipes should have been used. 3. Observation on 5/19/10 at 8:45 a.m. of incontinent care for resident #20, performed by CNA "EE", rev… | 2015-04-01 |
| 9976 | 9976 | JAMES B CRAIG CENTER | 11A556 | CENTRAL STATE HOSPITAL | MILLEDGEVILLE | GA | 31062 | 2010-05-19 | 371 | F | 0 | 1 | 9MHY11 | Based on observation, and staff interview the facility failed to maintain the temperatures held on the steam table to decrease the likelihood of a food borne illness, and failed to ensure that the dish machine was operating at the appropriate temperatures to clean the eating utensils affecting one-hundred (100) oral alimentation residents. Findings include: 1. Observation on 5/18/10 at 7:05 a.m. of the food line revealed breakfast being served on trays with water in them. Continued observation revealed that the Dietary staff placed plates with eggs, ham, and bread on the wet parts of tray. Sixteen (16) wet trays were served to residents. Interview on 5/18/10 at 8:05 a.m. with the Dietary Staff "BB", acknowledged that the trays were wet and should not have been used. 2. Observation on 5/18/10 at 11:18 a.m. of the lunch meal revealed that the sloppy joe meat registered at one hundred and thirty degrees (130) Fahrenheit (F). The food safety standard for items on the steam table is for a minimum of one-hundred and thirty-five (135) degrees F. The temperature was checked with the facility's calibrated thermometer. Interview on 5/18/10 at 11:30 a.m. with Dietary Staff "CC", revealed that the food needed to be reheated. Interview on 5/19/10 at 12:25 p.m. with the Dietary Manager (DM), revealed that the Dietary Staff knew that the food temperatures were wrong and that the food should be re-heated prior to serving to the residents. 3. Observation on 5/18/10 at 12:00 p.m. of the Dish Machine revealed that the machine was a high temperature machine. The wash cycle temperature assessment revealed a temperature of 130 degrees and the rinse cycle revealed a temperature of 160 degrees. Review of the manufacturer recommendations revealed that the minimal wash cycle temperature should be 160 degrees F and that the rinse cycle temperature should be a minimum of 180 degree F. | 2015-04-01 |
| 9977 | 9977 | JAMES B CRAIG CENTER | 11A556 | CENTRAL STATE HOSPITAL | MILLEDGEVILLE | GA | 31062 | 2010-05-19 | 278 | D | 0 | 1 | 9MHY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the status of one (1) resident (#4) of the sampled twenty-five (25) residents. Findings include: Observation on 5/18/10 at 8:05 a.m., revealed that resident #4 was in the day room sitting in the geri-chair with both feet uncovered. There were multiple pressure sores on the feet. Continued observation revealed the following pressure sores: five centimeters (5cm) black eschar on the inner side of both heels; a one-by-one centimeter (1x1 cm) dried scab area on the plantar side of the left foot; great toe on the right foot with a two (2 cm) dried scab; and the second and fourth toe on the right foot with a 0.1 cm scabbed area. Review of the clinical record revealed that the resident returned from the hospital on [DATE] with the pressure sores and attends a wound care clinic every other week. Review of the Minimum Data Set (MDS) completed on 5/4/10 revealed no evidence that the pressures sores had been assessed and/or coded in Section "M", questions #1, #2, #3 and #5, even though the resident had pressure sores during the assessment period. During interview on 5/18/10 at 8:15 a.m. Licensed Practical Nurse (LPN) "HH" acknowledged that the pressure sores were present on re-admission to the facility. During interview on 5/18/10 at 8:25 a.m., the physician, while observing the pressure sores, acknowledged the pressure sores were present on re-admission to the facility from the hospital. | 2015-04-01 |
| 10500 | 10500 | JAMES B CRAIG CENTER | 11A556 | CENTRAL STATE HOSPITAL | MILLEDGEVILLE | GA | 31062 | 2009-04-16 | 514 | E | 1 | 0 | RX6X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to maintain clinical records on each resident in accordance with accepted professional standards and practices that are complete, accurately documented, readily accessible and systematically organized for one (1) resident (#1) from a sample of four (4) residents and other resident's documents ranging from 2008 to 3/25/09, at which time the situation was corrected. Findings include: In the facility's Mortality Review Summary dated 3/25/09 for Resident #1, one of the issues that was documented as a problem during the review, was loose documents found in a drawer in the Nurse's Station (i.e. these items were not filed in the record for review). These items consisted of Medication Administration Records for February 2009 and March 2009, Client Flow Sheets for January 2009 and March 2009, Food and Fluid sheets for February 2009 and March 2009, Vital Sign records for 6/15/08 through 3/01/09, 2008 [MEDICAL CONDITION] Records, some Laboratory Reports that had been seen by the physician, but not filed in the record, Pharmacy/Consultant Notes of 10/29/08 and 9/25/08, Pain Assessments with various dates, Monthly Nursing Review note dated 10/08, One integrated progress note sheet dated 9/25/08 through 10/07/08, Physician's Progress note dated 11/10/08, and Renewal Orders dated 11/10/08. During interview with Administrative Nurse "AA" on 4/16/09 at 3:30 p.m., she stated that during this period of time, there was not a full-time clerk assigned to this unit and thus the filing had not been kept up to standards. At the time of this survey, the above deficiency had been corrected, as the facility had implemented the following: 1. Assigned a clerk to cover this unit to ensure that all filing is kept up to date and in accordance with standards. 2. Administrative Nursing Staff had developed a policy that addressed the practice of recording vital signs in multiple places, as the above method made tre… | 2014-07-01 |
| 4053 | 4053 | GRACEWOOD NSG FACILITY(UNIT 9) | 11A200 | 100 MYRTLE BLVD., EAST CENTRAL REG HOSP | GRACEWOOD | GA | 30812 | 2018-08-19 | 584 | E | 0 | 1 | EQDC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of the policy titled Enteral Nutrition Pump- Cleaning and Disinfection and staff interviews, the facility failed to maintain tube feeding poles in a clean and sanitary condition for nine of 17 resident (R) (#25, #3, #7, #76, #10, #9, #14, #15, and #178) that received enteral tube feeding, and failed to maintain clean and dust free hallway walls in one of two units (Unit 1). Findings include: 1. Observations of the tube feeding pole for R#25 on 8/17/18 at 12:00 p.m., on 8/18/18 at 8:40 a.m. and 11:30 a.m., and on 8/19/18 at 8:50 a.m. revealed dried, heavily splattered tube feeding on the base and wheels of the pole. 2. Observations of the tube feeding pole for R#3 on 8/17/18 at 12:45 p.m., on 8/18/18 at 8:30 a.m., 11:35 a.m. and 2:40 p.m., and on 8/19/18 at 8:40 a.m. revealed dried, heavily splattered tube feeding on the base and wheels of the pole. 3. Observations of the tube feeding pole for R#7 on 8/17/18 at 1:00 p.m., on 8/18/18 at 8:25 a.m., 11:40 a.m. and 2:36 p.m., and on 8/19/18 at 8:45 a.m. revealed dried, heavily splattered tube feeding on the base and wheels of the pole. 4. Observation of the tube feeding pole for R#76 on 8/17/18 at 1:15 p.m., on 8/18/18 at 9:05 a.m., 11:45 a.m. and 2:43 p.m., and on 8/19/18 at 8:30 a.m. revealed dried, heavily splattered tube feeding on the base and wheels of the pole. 5. Observations of the tube feeding pole for R#10 on 8/17/18 at 1:10 p.m., on 8/18/18 at 9:10 a.m., 11:50 a.m. and 2:40 a.m., and on 8/19/18 at 8:35 a.m. revealed dried, heavily splattered tube feeding on the base and wheels of the pole. 6. Observation of room [ROOM NUMBER] on 8/17/18 beginning at 2:58 p.m. revealed the tube feeding pole for Resident (R)#9 in bed A had a large amount of dried, beige-colored substance on the base of the pole. Observation of room [ROOM NUMBER] on 8/18/18 beginning at 10:50 a.m. revealed the tube feeding pole for R#9 in bed A had a large amount of dried, beige-colored subst… | 2020-09-01 |
| 4054 | 4054 | GRACEWOOD NSG FACILITY(UNIT 9) | 11A200 | 100 MYRTLE BLVD., EAST CENTRAL REG HOSP | GRACEWOOD | GA | 30812 | 2018-08-19 | 730 | F | 0 | 1 | EQDC11 | Based on record review and staff interview, the facility failed to ensure that the annual 12-hour minimum education for Certified Nursing Assistants (CNA) included Dementia Care training for three of three CNA education transcripts reviewed. Findings include: Review of the employee files for CNA AA, CNA BB and CNA CC revealed all three CNAs had completed an annual minimum education/training of 12 hours, however, the training did not include the required annual Dementia Care training. Interview on 8/18/18 at 9:00 a.m. with the Training Program Administrator (TPA) and the Registered Nurse Educator (RNE) revealed that Dementia Care training is typically conducted in (MONTH) of each year. The TPA and the RNE stated they did not have record of the rosters for Dementia Care training in (MONTH) (YEAR). They stated another person was in the position. They stated that they looked but could not find the roster sign-in sheets. The RNE stated the facility did not have a policy related to required education for CNAs. | 2020-09-01 |
| 4055 | 4055 | GRACEWOOD NSG FACILITY(UNIT 9) | 11A200 | 100 MYRTLE BLVD., EAST CENTRAL REG HOSP | GRACEWOOD | GA | 30812 | 2018-08-19 | 812 | E | 0 | 1 | EQDC11 | Based on observation and staff interviews, the facility failed to maintain a clean floor in the satellite kitchen in Building 15 of the hospital complex and to clear state who is responsible for cleaning the ktichen floor. The facility census was 29. Findings include: Observation of the satellite kitchen in Building 15 on 8/18/18 at 11:30 a.m. revealed three dead cockroaches in the corner of the room next to a broken dishwasher and two dead cockroaches underneath the dishwashing sink next to the broken dishwasher. During an observation of the satellite kitchen in Building 15 with the Assistant Food Service Manager (FSM) on 8/18/18 at 12:19 p.m., he confirmed the presence of the dead cockroaches. He stated the facility received routine visits from a local pest control service to address problems with bugs throughout the facility complex as evidenced by the cockroaches being dead. He stated the satellite kitchen was used to receive bulk cooked food from the main kitchen. The food is placed on the steam table, checked for appropriate serving temperatures, plated and transported to the skilled nursing facility (SNF) for the residents. He further stated the kitchen staff was responsible for cleaning the areas of the satellite kitchen where food is handled but the housekeeping staff was responsibility for cleaning the satellite kitchen floor when the kitchen staff was done for the day. On 08/18/18 at 2:28 p.m., the Assistant FSM supplied the pest control service records dating back one year from (MONTH) (YEAR) to date which detailed monthly service calls, services provided and areas of concentration including the satellite kitchen. The satellite kitchen received monthly treatments for roaches. The last pest control service visit was 8/14/18. During an observation of the satellite kitchen in Building 15 with the Housekeeping Team Leader on 8/19/18 at 1:21 p.m. she confirmed the presence of the dead bugs still in the same places for the second day of observation. She stated, to her knowledge, the housekeeping staff was n… | 2020-09-01 |
| 4056 | 4056 | GRACEWOOD NSG FACILITY(UNIT 9) | 11A200 | 100 MYRTLE BLVD., EAST CENTRAL REG HOSP | GRACEWOOD | GA | 30812 | 2019-09-26 | 759 | E | 0 | 1 | 2COK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview and a review of the facility policy and procedure Medication Administration in DBHDD Hospitals, the facility failed to ensure the medication error rate was less than five percent (5%). There were two errors with 26 opportunities by two of three nurses observed which resulted in a medication error rate of 7.14%. Findings include: 1. On 9/25/19 at 7:45 a.m., Registered Nurse (RN) AA was observed giving R#16 his morning medications. The medications included Levetiracetam 100 milligrams (mg) / 2.5 milliliters (ml). After preparing all of the medications for R#16, RN AA verified she poured 2.5 ml in a liquid medication cup. A review of the Physician's Orders dated 9/12/19 revealed to administer Levetiracetam 100 mg/ml solution, 500 mg twice daily starting on 9/23/19. During an interview on 9/25/19 at 9:15 a.m., RN AA verified that she did not check the Medication Administration Record (MAR) and only went by the label instructions on the medication bottle which was for 2.5 ml twice daily. She confirmed that the label on the medication bottle did not match the current Physician Order An interview with the Nurse Manager on 9/25/19 at 9:56 p.m. revealed the medication nurses are responsible for checking the MAR prior to administering any prepared medications. 2. Observation on 9/25/19 at 11;58 a.m. of Licensed Practical Nurse (LPN) BB giving R#6 his medications. The medications included a multivitamin liquid suspension. After giving R#6 all of the medications via a [DEVICE], she confirmed she did not shake well the liquid multivitamin as per the manufacturer's instructions. An interview with the Nurse Manager on 9/25/19 at 12:45 p.m. confirmed that LPN BB did not follow the manufacturer's instructions or the facility's policy for the liquid multivitamin by not shaking it well prior to administration. A record review of the Medication Administration in DBHDD Hospitals reviewed and revised on 3/4/2019… | 2020-09-01 |
| 4057 | 4057 | GRACEWOOD NSG FACILITY(UNIT 9) | 11A200 | 100 MYRTLE BLVD., EAST CENTRAL REG HOSP | GRACEWOOD | GA | 30812 | 2019-09-26 | 812 | E | 0 | 1 | 2COK11 | Based on observations, staff interview, and the facility policy titled Policy -Food Purchasing, Receiving, Production, and Preparation 03-6647 Storage, the facility failed to ensure one of one walk in freezer was maintained in a clean sanitize condition and that food items were properly labeled and stored in a sanitary manner in one of two walk in coolers , one of one walk in freezer, and one of three food storage floor bins . This had the potential to effect 10 residents receiving oral fed diets. Findings include: Record review of the facility policy titled Policy-Food Purchasing, Receiving, Production and Preparation, 03-6647 Storage revealed the following: (1). protect food from contamination and spoiling during storage and preparation. Discard food in open containers within three (3) days of opening. (4). b. store all food in original containers or in NSF internationl approved containers. and once removed from the original containers store unused portion of opened food in tightly closed approval food grade bulk containers. (b). as appropriate cover with cool wrap or aluminum foil and label with the contents and dated (c). label all perishable food with the date it was put in the container and a use-by date determined according to Georgia DPH (Department of Public Health) Food Service Rules and Regulation Observation of one walk in freezer 's floor on 9/23/19 at 11:53 a.m. revealed the following concerns: 1. small bits of food particles and one unwrapped chicken breast patty on the freezer floor 2. dark brown substances, and pieces of white and brown cardboard scattered on the freezer floor 3. unlabeled opened sausage links wrapped in Saran wrap with no open date and expiration date 4. unlabeled open hash brown in a plastic bag with no open date with no open date and expiration date 5. open bag of carrots (unlabeled) stored in a plastic bag not properly sealed and stored in a large cardboard box with flaps not properly sealed Observation of one walk in cooler on 9/23/19 at 11:56 a.m. revealed the following con… | 2020-09-01 |
| 4491 | 4491 | GRACEWOOD NSG FACILITY(UNIT 9) | 11A200 | 100 MYRTLE BLVD., EAST CENTRAL REG HOSP | GRACEWOOD | GA | 30812 | 2016-03-24 | 282 | D | 0 | 1 | TMDQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility staff and Nurse Practitioner interviews, the facility failed to follow the Care Plan/Client Profile for turning and re-positioning for (1) resident (#1) with existing pressure sores from a sample size of twenty-two (22) residents. Findings include: Record review revealed that resident #1 was admitted [DATE] with the following Diagnosis: [REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that the resident was totally dependent on two staff persons for bed mobility and had one (1) existing Stage I pressure sore, one (1) Stage II pressure sore and one (1) Stage III pressure sore with slough. review of the resident's medical record revealed [REDACTED]. review of the resident's medical record revealed [REDACTED]. Review of the facility's Policy titled Care of the Individual with a Decubitus Ulcer documented that all pressure should be relieved from the ulcer. The individual must not sit or lie on the decubitus ulcer (pressure sore) even for a few minutes. Review of Care plan/Client Profile for resident #1 documents turn and reposition turn every two (2) hours. Interview on 3/24/2016 at 2:45 p.m. with the Nurse Practitioner (NP) revealed that the resident had current Physician orders [REDACTED]. On 3/24/16 at 3:00 p.m. the NP confirmed that the resident was not fully turned and repositioned as per the Physician/NP orders. Interview with the Director of Therapy on 3/24/16 at 1:46 p.m. revealed that the resident was supposed to be fully turned on his/her left side or right side and those positions were maintained with the use of supportive devices. Continued interview revealed that multiple wedges and positioning devices were available and that the certified nursing staff had been trained how to use the wedges and the positioning devices. Interview with the Director of Nursing on 3/24/16 at 1:48 p.m. revealed that she expected the staff to turn and reposition residents as they were train… | 2019-10-01 |
| 4492 | 4492 | GRACEWOOD NSG FACILITY(UNIT 9) | 11A200 | 100 MYRTLE BLVD., EAST CENTRAL REG HOSP | GRACEWOOD | GA | 30812 | 2016-03-24 | 314 | D | 0 | 1 | TMDQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility staff and Nurse Practitioner interview, the facility failed to properly turn and re-position one (1) resident (#1) with existing pressure sores from a sample size of twenty-two (22) residents. Findings include: Record review revealed that resident #1 was admitted [DATE] with the following Diagnosis: [REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that the resident was totally dependent on two staff persons for bed mobility and had one (1) existing Stage I pressure sore, one (1) Stage II pressure sore and one (1) Stage III pressure sore with slough. review of the resident's medical record revealed [REDACTED]. review of the resident's medical record revealed [REDACTED]. Review of the facility's Policy titled Care of the Individual with a Decubitus Ulcer documented that all pressure should be relieved from the ulcer. The individual must not sit or lie on the decubitus ulcer (pressure sore) even for a few minutes. Observation on 3/22/2016 at 6:50 a.m. and at 8:10 a.m., revealed the resident was lying on his/her back in the bed placing pressure on the pressure sores on the resident' s right hip and the right ischium. Observation on 3/22/16 at 10:20 a.m., revealed the resident was lying on his/her back in the bed. Staff had placed a wedge under the resident's left middle back and the resident was observed lying on his/her right side with direct pressure being placed on the resident' s pressure sores on the resident's right hip and right ischium. Observation on 3/22/2016 at 11:55 a.m., revealed the resident was lying on his/her back in the bed. Although the staff had placed a wedge under his/her right hip, the resident's pressure sore on his/her right ischium was observed to remain in contact with the mattress. Observation on 3/22/2016 at 1:32 p.m., revealed the resident was lying on his/her back in the bed with unrelieved pressure on the pressure sore on the right ischi… | 2019-10-01 |
| 4493 | 4493 | GRACEWOOD NSG FACILITY(UNIT 9) | 11A200 | 100 MYRTLE BLVD., EAST CENTRAL REG HOSP | GRACEWOOD | GA | 30812 | 2016-03-24 | 371 | E | 0 | 1 | TMDQ11 | Based on observation and staff interview, the facility failed to date opened food items prior to storage in one (1) of two (2) dry storage rooms, in three (3) of four (4) walk- in refrigerators, and in one (1) of two (2) walk- in freezers; failed to appropriately store scoops in the containers of sugar, rice and flour in one (1) of two (2) dry storage rooms; failed to ensure that the fan was free of dust in one (1) of four (4) walk-in refrigerators. The census was forty-two (42) residents. Finding include: Observations on 3/21/16 at 10:45 a.m. revealed the following: Observation of one (1) of the two (2) dry storage rooms revealed one (1) open five (5) pound bag of Quick Grits, one (1) open two (2) pound bag of Bran Flakes cereal and one (1) open two (2) pound bag of oatmeal. These items were noted to be opened but were not labeled with the date the items were opened. Further observation revealed a scoop, with the handle touching the food items, in each of the following containers: sugar, rice and the flour container. Observation in the walk-in refrigerator #1 revealed one (1) opened plastic bag of hamburger patties that was not labeled with the open date. Observation also revealed a build-up of dust on the fan in the walk-in refrigerator #1. Observations of the walk-in refrigerator #2 revealed one (1) opened bag of French fries and one (1) opened bag of flour that were observed to be open but did not have the dates of when they were opened. Observation also revealed one (1) plastic bag of an unidentified substance on the floor under the food that was not dated or labeled. Observation of the walk-in refrigerator #3 revealed one (1) opened package of sliced cheese that was opened but did not have the date when it was opened. Observation of the walk-in freezer #4 revealed one (1) opened package of chocolate chip cookie dough that did not have the date when it was opened. Interview on 3/21/16 at 2:00 p.m. with the Registered Dietician /Dietary Manager, revealed that all the food items in the dry storage area, in the… | 2019-10-01 |
| 4494 | 4494 | GRACEWOOD NSG FACILITY(UNIT 9) | 11A200 | 100 MYRTLE BLVD., EAST CENTRAL REG HOSP | GRACEWOOD | GA | 30812 | 2016-03-24 | 514 | D | 0 | 1 | TMDQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility staff and physician interview, the facility failed to accurately and completely document the appearance of non-pressure wounds for one (1) resident (#5). The sample size was twenty-two (22) residents. Findings include: Review of resident #5's Admission Minimum Data Set ((MDS) dated [DATE] revealed that the resident was at risk of pressure ulcer development and had a Stage 2 pressure ulcer. Review of the care plan dated 06/11/15 revealed that the resident was at risk for impaired skin integrity as related to history of decubitus and high risk assessment score for decubitus. Further review of this care plan revealed that it was updated on 01/26/16 to note that the resident's buttocks had some small red areas, and to continue with current treatment and monitor. Review of a hospital wound care assessment dated [DATE] revealed that resident #5's buttocks had several unmeasurable areas of maceration and redness; evidence of peeling and open skin to some areas; bloody and dark brown drainage; and full thickness ulceration to the sacrum and bilateral buttocks extending to the posterior thighs. Review of resident #5's Nurse's Notes on re-admission to the facility dated 01/29/16 noted the resident's sacrum had full-thickness ulceration, but there was no measurements or other description of the appearance of the wound. Review of a Hospital Return Nursing assessment dated [DATE] noted that the section labeled Body Chart was left blank with no abnormalities listed. Review of a Health Note dated 01/29/16 noted that resident #5 had returned from the hospital, a body inspection was completed with an RN and the attending physician DD, and multiple open areas were noted to the buttocks, crease as well as an open area to the groin. Further review of this form revealed that the wounds were not classified as to the type of wound, measured, nor any documentation of the appearance of the wounds. Review of Registered Nur… | 2019-10-01 |
| 6844 | 6844 | GRACEWOOD NSG FACILITY(UNIT 9) | 11A200 | 100 MYRTLE BLVD., EAST CENTRAL REG HOSP | GRACEWOOD | GA | 30812 | 2013-07-17 | 371 | E | 0 | 1 | UVWN11 | Based on observations and staff interview, it was determined that the facility failed to ensure that two (2) portable fans with dust/debris did not blow over uncovered food. Census= two (22) residents. Finding include: 1. Observation on 7/15/13 at 12:30 p.m. revealed a large portable fan, with an accumulation dust/debris sitting on the floor behind the steam table. This fan was blowing directly towards the steam table where meal trays were being prepared. 2. Observation on 7/16/13 at 1:35 p.m. revealed one (1) of the two (2) portable fans with an accumulation of dust/debris blowing towards the food prep area where food items were being prepared. Observation on 7/16/13 at 1:40 p.m. revealed , the second fan, with an accumulation of dust and debris, on top of a rolling cart, next to the conveyor belt, where clean dishes were coming out of the dishwasher. This fan was blowing directly on three (3) large metal pans. 2. Observation on 7/17/13 at 9:00 a.m. revealed a fan with an accumulation of dust/debris clinging to it, in the steam table area. This fan was blowing across a multiple level cart of food, some uncovered. Interview with the Dietary Supervisor on 7/17/13 at 9:00 a.m., revealed that the fan should not be blowing across the steam table. | 2017-10-01 |
| 6845 | 6845 | GRACEWOOD NSG FACILITY(UNIT 9) | 11A200 | 100 MYRTLE BLVD., EAST CENTRAL REG HOSP | GRACEWOOD | GA | 30812 | 2013-07-17 | 469 | F | 0 | 1 | UVWN11 | Based on observations, and staff interviews, the facility failed to maintain an effective pest control program in the kitchen. The facility census was twenty-two (22). Findings include: Observation in the kitchen on 7/16/13 between 1:45 p.m. and 2:00 p.m., revealed the following concerns: a red roach crawling on top of the table next to the steamer machine, a small black bug crawling on the wall next to the pantry door, a red roach crawling on the floor behind the steam table and a red roach crawling on a stack of Styrofoam plates on top of the steam table. Observation of the kitchen on 07/17/2013 at 9:00 a.m., revealed two (2) brown roaches crawling on the post near the steam stable and one (1) dead roach on the bottom of the post. Continued observation revealed four (4) small black bugs crawling on the post, a brown roach and a small black bug crawling on the lower shelf on the middle of the steam table. Interview with the Dietary Supervisor on 7/16/13 at 2:05 p.m. revealed that from time to time there are issues with roaches in the kitchen . Continued interview revealed that there are four (4) wooden pallets in the kitchen, and had seen roaches crawling on these pallets. She indicated that she has been trying to replace these pallets. Interview on 7/17/13 at 9:00 a.m. with the Dietary Supervisor revealed that approximately two (2) weeks ago she had noticed a worsening problem with the bugs and had notified the pest control provider, Orkin, who came the evening of 7/1/13, providing treatment. Interview with the Administrator on 7/17/2013 at 2:35 p.m., revealed that she was not aware of any current problems with pest in the kitchen; however, the facility has had problems in the past and contracted with Orkin, who would come quarterly and as needed. | 2017-10-01 |
| 6846 | 6846 | GRACEWOOD NSG FACILITY(UNIT 9) | 11A200 | 100 MYRTLE BLVD., EAST CENTRAL REG HOSP | GRACEWOOD | GA | 30812 | 2013-07-17 | 520 | D | 0 | 1 | UVWN11 | Based on record review and staff interview, the facility failed to hold Quality Assessment and Assurance (QAA) meetings at least quarterly and failed to ensure that a physician attended those meetings. The facility census was twenty-two (22). Findings include: Review of the QAA minutes, provided by the facility during the standard survey, revealed that the meetings were held on 3/29/12, 7/30/12, 11/30/12, 4/10/13 and 6/28/13. Continued review revealed that the physician was present for two (2) of the five (5) meetings, on 4/10/13 and 6/28/13; however, there was no evidence there was any quarterly QAA meeting held between November 2012 and April 2013. Interview with the Unit Manager on 7/17/13 at 1:00 p.m., revealed that the physician was not present at every meeting and confirmed there was no evidence of a meeting being held between November 2012 and April 2013. Telephone interview with the Administrator on 7/24/13 at 2:30 p.m. during the QA process revealed that there was no evidence of any QAA meeting sign in sheets for the physician. | 2017-10-01 |
| 8122 | 8122 | GRACEWOOD NSG FACILITY(UNIT 9) | 11A200 | 100 MYRTLE BLVD., EAST CENTRAL REG HOSP | GRACEWOOD | GA | 30812 | 2012-01-12 | 253 | B | 0 | 1 | IUIJ11 | Based on observations, staff interviews and review of the facility policy, the facility failed to ensure that six (6) wheelchairs on two (2) of two (2) halls and one (1) IV pole were free of an soiled matter. Findings include: Random observations of wheelchairs during the environmental rounds on 1/10/11 at 2:00 p.m. revealed that there was a build up an ivory colored, dried substance on sides and under the bottoms of the crossbars on six (6) different wheelchairs. Living Area 1 1. The purple wheelchair in room 116 had an dried, ivory substance on the left side and under its cross bars. 2. The blue wheelchairs in room 109 had an dried, ivory colored substance on the left side and under its crossbars. Living Area 2- The blue wheelchairs in rooms 267, 266, 259 and 256 had an ivory, colored substance on both sides and under their crossbars. During an interview on 1/10/12 at 2:50 p.m., Certified Nursing Assistant (CNA) FF said Occupational Therapy department (OT) had a staff member who was responsible for pressure washing all of the wheelchairs. FF said that the dried, Ivory colored substance on the wheelchairs was formula. In an interview on 1/11/12 at 10:49 am, the OT/Physical Therapy Tech EE said that all of the wheelchairs were scheduled to be cleaned every six weeks. EE said the wheelchairs had last been cleaned on 11/16/11. EE explained that he/she was behind on the cleaning schedule because of the holidays. EE said that there was not a facility policy for cleaning. She/He said that he/she was responsible for pressure washing all of the wheelchairs for the whole campus. EE added that the CNAs on each unit were responsible for cleaning the wheelchairs, if it was needed before the scheduled time for pressure cleaning. Review of the Pressure Washing schedule indicated that the last steam cleaning for the wheelchairs were done between 11/15/11-11/21/11. Living Area 2 The bottom bottom of the IV/ tube feeding pole In room 258 was soiled with a dried, ivory substance. | 2016-07-01 |
| 8123 | 8123 | GRACEWOOD NSG FACILITY(UNIT 9) | 11A200 | 100 MYRTLE BLVD., EAST CENTRAL REG HOSP | GRACEWOOD | GA | 30812 | 2012-01-12 | 332 | E | 0 | 1 | IUIJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to ensure that their medication error rate was less than 5%. Five (5) errors out of fifty (50) opportunities for four (4) of ten (10) residents were noted by two (2) of five (5) nurses on two (2) of two (2) units. The facility's medication error rate was 10%. Findings include: 1. During an observation on 01/10/12 at 8:15 a.m., Licensed Practical Nurse (LPN) HH crushed all of resident #7's pills, including a [MEDICATION NAME] Delayed Release Orally Disintegrating Tablet, then mixed them with applesauce and gave them to the resident by mouth. However, according to the physician's orders [REDACTED]. A review of the Geriatric Dosage Handbook, 12th Edition, revealed that orally-disintegrating [MEDICATION NAME] ([MEDICATION NAME]) tablets should not be swallowed whole or chewed, but could either be placed on the tongue and allowed to dissolve, or dispersed in 10 milliliters (mL) of water in an oral syringe and administered. 2. On 01/10/12 at 11:42 a.m., LPN HH was observed giving medications to resident #25. HH gave the resident two puffs from an Atrovent inhaler in quick succession and then immediately gave the resident Iwo quick puffs of an [MEDICATION NAME] inhaler. However, review of the manufacturers' package inserts for the inhalers revealed that they had not been administered correctly. The nurse was supposed to firmly press the Atrovent canister against the mouthpiece one (1) time and then wait at least 15 seconds before repeating. If a resident's doctor prescribed more than one spray of [MEDICATION NAME] ([MEDICATION NAME]) then, the facility should have waited one (1) minute and shaken the inhaler again (before administering another spray). On 01/10/12 at 2:35 p.m., LPN HH confirmed that he/she had crushed the [MEDICATION NAME] tablet for resident #7. She provided the pharmacy packaging for the [MEDICATION NAME], which was labeled to include instructions to disso… | 2016-07-01 |
| 8124 | 8124 | GRACEWOOD NSG FACILITY(UNIT 9) | 11A200 | 100 MYRTLE BLVD., EAST CENTRAL REG HOSP | GRACEWOOD | GA | 30812 | 2012-01-12 | 356 | C | 0 | 1 | IUIJ11 | Based on observations and interviews with staff, the facility failed to post the nurse staffing data on all three days of the survey. Findings include: During observations in Liviing Areas 1 and 2 on 1/9/12, 1/10/12, and 1/11/12, it was noted that the facility had failed to post the required notice about nurs staffing data. The facilty had not posted a notice whcih included the following information: the facility name; the day's date; the total number and actual number of hours worked by licensed and unlucensed nursing staff providieng direct resident care on each shift and; resicent census. During an interview on 1/11/11 at 11:05 am, the Director of Nursing said that the facility had not posted the (nurse) staffing data the survey. The Director of Nursing said that she had not been poating the required informaton but only the nurses'schedule. In an interview on 1/11/12 at 11:10 a.m., the Infection Control Nurse said that she was unaware of the regulation for posted staffing. | 2016-07-01 |
| 8125 | 8125 | GRACEWOOD NSG FACILITY(UNIT 9) | 11A200 | 100 MYRTLE BLVD., EAST CENTRAL REG HOSP | GRACEWOOD | GA | 30812 | 2012-01-12 | 441 | D | 0 | 1 | IUIJ11 | Based on observation, record review, and staff interview, the facility failed to ensure that facility staff washed their hands and/or changed their gloves after handling a contaminated object for one resident (#30). The sample size was twelve (12) residents. Findings include: On 01/11/12 at 7:45 a.m., an observation of resident #30's skin was done with Registered Nurse (RN) CC. When the incontinent brief was pulled back, the resident had a small amount of non-formed stool in the brief, as well as a plastic thermometer probe cover. The nurse removed the probe cover from the brief with his/her gloved fingers and threw it in the trash. Without changing his/her gloves or washing his/her hands, he/she then removed and replaced the resident's heel protectors, pulled down the resident's shirt, pulled up the bed covers and patted the resident on the back before removing her gloves and washing her hands. On 01/11/12 at 8:55 a.m., the Unit Manager stated that if the gloves were contaminated then she expected the staff to change gloves and/or wash their hands before they provided any other care. Review of the facility's Infection Control Policy on Standard and Transmission Based Precautions outlined that hand hygiene was the single most effective method to prevent the spread of disease. Employees and clients should wash their hands frequently and thoroughly and use good hand washing technique after removal of gloves and anytime there was exposure to blood or body fluids. Clean, non-sterile gloves should be worn when touching or at risk of touching excretions, and changed between procedures on the same client. However, during an interview on 01/11/12 at 11:00 a.m., RN CC confirmed that he/she did not immediately change gloves after handling the thermometer probe cover that had been in resident #30's incontinent brief. | 2016-07-01 |
| 9966 | 9966 | GRACEWOOD NSG FACILITY(UNIT 9) | 11A200 | 100 MYRTLE BLVD., EAST CENTRAL REG HOSP | GRACEWOOD | GA | 30812 | 2010-09-23 | 371 | F | 0 | 1 | C3EB11 | Based on observation, record review, review of facility policy, and staff interview the facility failed to store, prepare and serve food under sanitary conditions. This was evidenced by: storing pots and utensils that were dirty and wet; improper storage of food scoops; not ensuring that walk-in refrigerators were clean; not repairing water leaks; maintaining potentially hazardous hot food food on the steam table below 135 degrees Fahrenheit; improper storage of baking pans; improper functioning of the dishwashing machine; and lack of sanitizer in the manual 3 compartment sink. This failure affected all residents who were fed orally. Findings include: Observation on 9/21/10 between 10:00 a.m.-11:30 a.m. with the Dietary Manager revealed the following concerns: 1. Three of six serving ladles were stored wet; 1 of 2 scoops was stored dirty and wet; 6 large baking pans were stored wet. 2. A large storage unit of sugar contained a scoop with the handle touching the product. 3. The walk-in meat refrigerator had a very strong foul odor. Interview at that time with the dietary staff who maintained this area revealed that the area is cleaned daily. However, review of the facility's Central Kitchen Cleaning Checklist for the Meat Room revealed that the last cleaning verification was signed on 7/26/10. 4. Observation of the tray line at the beginning of the lunch meal on 9/21/10 revealed that the Dietary Manager calibrated her thermometer and obtained the following temperatures from food being held on the steam table: Pureed beets 100 degrees Fahrenheit (F) Pureed green beans 100 degrees F Pureed carrots 100 degrees F Ground carrots 98 degrees F Ground noodles 118 degrees F Pureed noodles 112 degrees F Pureed beef 130 degrees F Review of the food temperature log for 9/21/10 for the lunch meal revealed that dietary staff had only checked the temperature of three (3) food items on the steam table. 5. Observation of the dishwashing machine with the Food Service Supervisor on 9/22/10 at 8:00 a.m. revealed the following: The ma… | 2015-04-01 |
| 9967 | 9967 | GRACEWOOD NSG FACILITY(UNIT 9) | 11A200 | 100 MYRTLE BLVD., EAST CENTRAL REG HOSP | GRACEWOOD | GA | 30812 | 2010-09-23 | 372 | F | 0 | 1 | C3EB11 | Based on observation, review of facility policy and staff interview the facility failed to ensure that areas around refuse containers were clean and free of foul odors to prevent harborage of pests. Findings include: Observation on 9/21/10 between 10:00 a.m.-11:30 a.m. with the Dietary Manager revealed the following concerns: One (1) of two (2) trash compactors located in a parking area behind the loading dock had a stream (about 9 feet long) of a dark foul smelling liquid that also contained some unknown debris. The Dietary Manager indicated that the bottom of one of the trash compactors had been leaking and needed to be replaced. This replacement occurred several days ago, but the area around the compactor had not been cleaned. The top of the waste oil container (located in the same parking area) had a pool of oil that contained food debris. Review of the facility's Clean Parking Area policy revealed that it would be hosed down daily. This was not done. | 2015-04-01 |
| 9968 | 9968 | GRACEWOOD NSG FACILITY(UNIT 9) | 11A200 | 100 MYRTLE BLVD., EAST CENTRAL REG HOSP | GRACEWOOD | GA | 30812 | 2010-09-23 | 469 | F | 0 | 1 | C3EB11 | Based on observation, record review and staff interview the facility failed to maintain an environment that is free from pests. This failure affected all residents who were served food prepared in the kitchen and who were fed in the dining area on Unit 1. Findings include: Observation with the Dietary Manager and Food Service Supervisor in the kitchen on 9/20/10, between 11:15 a.m.- 11:40 a.m., 9/21/10, between 10:00 a.m.-11:30 a.m. and 9/22/10 between 8:00 a.m.- 9:00 a.m. revealed live roaches on the steam table, other food preparation surfaces, walls and floor. Review of the facility's pest extermination contract revealed the contract was valid until until 6/30/13. According to this contract, the kitchen was scheduled for two (2) service treatments per month to address an infestation of German Roaches. Interview with the Dietary Manager (DM) on 9/21/10 at 10:00 a.m. revealed roaches in the kitchen area had been an on-going problem. She added that the most recent extermination service for the kitchen was provided on 9/08/10. However, the tray line area continues to be heavily populated with roaches. During dining observation on 9/20/10 at 12:45 p.m. in Unit 1 dinning area, three (3) large roaches were observed on the floor of the dinning area while four (4) resident's were being fed lunch by staff. An interview with Registered Nurse "RR" at this time revealed that the exterminator had sprayed about three (3) days ago. The meal trays were delivered on a rolling cart from the main kitchen. A large gap was noted at the bottom and top of the outside door located in the dinning room. Observation on 9/22/10 at 4:45 p.m. of the Unit 1 shower room revealed several small bugs crawling on the shower table. Observation on 9/22/10 at 4:15 p.m. of resident room 267 revealed a small bug crawling on the hand washing sink. | 2015-04-01 |
| 9969 | 9969 | GRACEWOOD NSG FACILITY(UNIT 9) | 11A200 | 100 MYRTLE BLVD., EAST CENTRAL REG HOSP | GRACEWOOD | GA | 30812 | 2010-09-23 | 281 | G | 0 | 1 | C3EB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to provide services that met professional standards of quality. This was evidenced by the failure to clarify with the physician the urgency of providing x-ray services to rule out a possible fractured extremity resulting in harm for one (1) resident #23 of twenty one (21) sampled residents. Findings include: Record review revealed that resident #23 had a Health Note dated 3/02/10 at 7:00 a.m., indicating that nursing staff noted swelling of the right upper thigh and knee, with a light brown discoloration below the knee. It also indicated that the right lower extremity was warm to touch. Based on facility assessments (MDS, dated [DATE]) the resident was unable to communicate or make her needs known and was totally dependent on staff for all activities of daily living. Review of a physician's orders [REDACTED]. Review of a Health Note dated 3/02/10 at 10:00 a.m. revealed the nurse indicated that the x-ray would be done on 3/03/10, 24 hours after the injury was identified. In an interview on 9/22/10 at 11:00 a.m. with Licensed Practical Nurse (LPN) "AA" she acknowledged the physician's orders [REDACTED]. She added that since the physician did not request "stat" (immediate) x-rays she accepted that date without question. The nurse did not clarify with the physician the urgency of obtaining the x-rays sooner than 3/03/10. The Registered Nurse (RN) Manager was also present at the time of the interview with this LPN and later indicated that because of the resident's condition she would have expected the LPN to report the 24 hour delay of x-ray services to the RN Manager for further guidance. This was not done. The RN Manager acknowledged that other arrangements could have been made to have the x-ray services provided in a timelier manner. Standards of Practice for Licensed Practical Nurses-- In accordance with 2.3.2 Standards Related to Licensed Practical Nurses: The licensed practical n… | 2015-04-01 |
| 9970 | 9970 | GRACEWOOD NSG FACILITY(UNIT 9) | 11A200 | 100 MYRTLE BLVD., EAST CENTRAL REG HOSP | GRACEWOOD | GA | 30812 | 2010-09-23 | 309 | G | 0 | 1 | C3EB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure that, residents were closely monitored for acute pain, following a new injury. This was evidenced by the failure to assess for potential pain for one (1) resident #23 following a leg injury and resulted in harm to the resident. The sample size was twenty one (21) residents. Findings include: Record review revealed that resident #23 was [AGE] years old, non-verbal and has [DIAGNOSES REDACTED]. Further record review revealed a Health Note dated 3/02/10 at 7:00 a.m., indicating that nursing staff noted swelling of the right upper thigh and knee and lower leg area, with a light brown discoloration below the knee. It also indicated that the right lower extremity was warm to touch. Review of a Health Note dated 3/03/10 at 2:00 a.m. indicated the resident's right lower extremity was painful to touch when assessed. In another note dated 3/03/10 at 3:00 a.m. nursing staff indicate the resident's right leg is tender to touch. In the Health Note dated 3/03/10 at 5:30 a.m. nursing staff indicate the resident was transported to the hospital emergency room via ambulance and determined to have sustained a fractured tibia and fibula. Record review revealed the resident had a physician orders [REDACTED]. Review of the resident's March 2010 Medication Administration Record [REDACTED]. The first dose of [MEDICATION NAME] was administered nine (9) hours after the injury was identified. There was no documentation that the resident was being monitored and assessed more closely for potential pain during that nine (9) hour period. This was confirmed in an interview with the Registered Nurse Manager on 9/22/10 at 3:30 p.m. | 2015-04-01 |
| 9971 | 9971 | GRACEWOOD NSG FACILITY(UNIT 9) | 11A200 | 100 MYRTLE BLVD., EAST CENTRAL REG HOSP | GRACEWOOD | GA | 30812 | 2010-09-23 | 225 | G | 0 | 1 | C3EB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to have evidence that injuries of unknown source were thoroughly investigated. This was supported by the failure to interview all staff who may have been in contact with/or witnessed an incident related to the fractured tibia and fibula of one (1) resident #23 of twenty one (21) sampled residents. The failure to conduct a thorough and complete investigation of an injury of unknown origin resulted in harm to resident #23. Findings include: Record review revealed that resident #23 was [AGE] years old, non-verbal and has [DIAGNOSES REDACTED]. The annual MDS, conducted 11/10/09, assessed the resident as having severely impaired cognitive skills, unable to make needs known and totally dependent on staff for all care and activities of daily living. The resident was also assessed as requiring 2 persons or more for positioning, transfers and lifting. Further record review revealed a Health Note dated 3/02/10 at 7:00 a.m., indicating that nursing staff noted swelling of the right upper thigh and knee and lower leg area, with a light brown discoloration below the knee. It also indicated that the right lower extremity was warm to touch. Review of the facility's Investigative Report dated 3/05/10 revealed that on 3/03/10 the resident was sent to the emergency room (ER) for evaluation of the swelling and discoloration of the right lower extremity. The ER confirmed that the resident sustained [REDACTED]. This Investigative Report also had a Summary of Interviews. In addition, the Registered Nurse Manager provided an attachment of five (5) statements from Certified Nursing Assistants and one (1) from an Occupational Therapy Technician who worked either first or second shift. However, there was no evidence of interviews or inquiries from staff who worked third shift (11:00 p.m.-7:00 a.m.) the morning the injury was discovered. An interview on 9/22/10 at 3:15 p.m. with the Registered Nurse Manager… | 2015-04-01 |
| 9972 | 9972 | GRACEWOOD NSG FACILITY(UNIT 9) | 11A200 | 100 MYRTLE BLVD., EAST CENTRAL REG HOSP | GRACEWOOD | GA | 30812 | 2010-09-23 | 441 | D | 0 | 1 | C3EB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the nurse failed to clean the stethoscope after direct contact on resident #14 abdomen and proceeded to use the same stethoscope making direct contact with resident #23. The sample included twenty-one (21) residents. The findings included: During observation of medication pass on 9/22/10 at 8:21 a.m. LPN "GG" used the diaphragm of the stethoscope placing it on the abdomen of resident #14 when checking for placement of the gastrostomy tube ([DEVICE]). LPN "GG" took the stethoscope and hung it on the side of the medication cart. At 8:50 a.m. LPN "GG" removed the same stethoscope from the medication cart. The nurse did not clean the diaphragm of the stethoscope and proceeded to place it on the abdomen of resident #23 to check the placement of the [DEVICE]. Interview with LPN "GG" on 09/22/10 9:57 a.m. revealed the nurse confirmed she did not clean the stethoscope and used it for both residents. | 2015-04-01 |
| 9973 | 9973 | GRACEWOOD NSG FACILITY(UNIT 9) | 11A200 | 100 MYRTLE BLVD., EAST CENTRAL REG HOSP | GRACEWOOD | GA | 30812 | 2010-09-23 | 322 | E | 0 | 1 | C3EB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observation, record review and staff interview that facility failed to ensure that nursing staff checked gastric ([DEVICE]) tube placement before administering medications for six (6) residents (#12, 14, 17, 21, 22, and 28) and failure to administered medication through the NG tube by gravity flow for two (2) residents (#4 and 37). There were twenty four (24) of thirty two (32) residents on nasogastric feedings. Findings include: During observation of medication administration on 9/22/10 at 7:58 a.m. with Licensed Practical Nurse (LPN) "QQ" for resident #22, and at 8:25 a.m. for resident #28, who receive feeding and medication through a gastric tube, revealed that LPN "QQ" did not check placement of the [DEVICE] prior to administration of medications. Review of the facility policy and procedure for giving medications through a feeding tube revealed that the LPN should check placement before giving medications and that medications giving via a [DEVICE] should be allowed to flow by gravity. An interview with the Nurse Manager and the Assistant Director of Nursing on 9/22/10 at 12:05 p.m. revealed that placement should be checked by injecting a small amount of air into the tube then checking for bowel sounds with a stereoscope. She does not know why this was not done. During observation of medication pass on 9/21/10 at 3:40 pm for resident #37, LPN "HH"did not use a gravity method to administer the medications. The nurse injected all medications with a syringe. Observation on 9/21/10 at 3:52 pm revealed LPN "HH" did not use a gravity method to administer medications via the [DEVICE] to resident #4. Observation during medication pass on 9/21/10 at 4:05 pm revealed RN "II" did not ascultate to check placement of the [DEVICE] (resident #17) according to the facility's policy. At 4:25 pm LPN "II" did not ascultate to check placement of the [DEVICE] for resident #21. During medication pass on 9/22/10 at 8:07 am LPN "JJ" did not check place… | 2015-04-01 |
| 6205 | 6205 | GEORGIA REGIONAL ATLANTA LTC | 11A186 | 3073 PANTHERSVILLE RD, SNF BLDG. #17 | DECATUR | GA | 30034 | 2014-09-11 | 160 | B | 0 | 1 | BOSE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews the facility failed to ensure that resident trust funds were disbursed within thirty (30) days of death for one of three (1 of 3) accounts reviewed. Findings include: Review of three (3) expired residents with trust fund accounts for the last six (6) months revealed that resident #3 expired on [DATE]. A payment of $4923.72 was paid to the Funeral Home on [DATE] leaving a balance of $1332.00 which was not disbursed to the responsible party until [DATE]. Interview with the Financial Operation Generalist on [DATE] at 11:00 a.m., revealed that she has held the position since July, 2014, and when reviewing the records realized that the outstanding balance was not paid, and sent the payment to the family. Continued interview revealed that she was aware that funds should be disbursed within 30 days. | 2018-03-01 |
| 6206 | 6206 | GEORGIA REGIONAL ATLANTA LTC | 11A186 | 3073 PANTHERSVILLE RD, SNF BLDG. #17 | DECATUR | GA | 30034 | 2014-09-11 | 278 | D | 0 | 1 | BOSE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews the facility failed to accurately assess one(1) resident ( #1), for [MEDICAL CONDITION] medication use on the Admission Minimum Data Set (MDS) assessment from a sample of seventeen (17) residents. Findings Include: Review of the clinical record revealed that resident # 1 was admitted to the facility on [DATE] from Central State Hospital with [DIAGNOSES REDACTED]. Review of the Admission MDS assessment dated ,[DATE] revealed that the resident was assessed as severely cognitively impaired, totally dependent on staff for all care and receiving Insulin injections daily during the seven (7) day look back period. Further review revealed that he exhibited verbal behaviors one to three (1-3) days during the seven (7) day look back period but there was no evidence of the resident receiving an antipsychotic and/or antidepressant medications. Review of the electronic Physicians Orders dated 07/01/14 revealed that the resident was prescribed [MEDICATION NAME] ([MEDICATION NAME]) 3 milligrams (mgs) every evening by Gastrostomy tube (G tube) for Depression/Mood, and [MEDICATION NAME] ([MEDICATION NAME]) 50 mgs every morning by G tube for Depression. Review of the July, August, and September 2014 Medication Administration Records (MAR) revealed that the resident continued to receive these medications daily as ordered. Review of a Psychiatric Review, completed on 08/15/14, revealed that the resident had an Axis I [DIAGNOSES REDACTED]. His medications include the [MEDICAL CONDITION] medications of [MEDICATION NAME] ([MEDICATION NAME]) 3 milligrams daily and [MEDICATION NAME] ([MEDICATION NAME]) 50 milligrams daily. The recommendation of the Interdisciplinary Team ( IDT) was to keep him on his [MEDICAL CONDITION] medications at this time and to continue to monitor the effectiveness of these medications. Interview with Registered Nurse BB Minimum Data Set (MDS) Coordinator on 09/11/14 at 12:00 p.m., rev… | 2018-03-01 |
| 6207 | 6207 | GEORGIA REGIONAL ATLANTA LTC | 11A186 | 3073 PANTHERSVILLE RD, SNF BLDG. #17 | DECATUR | GA | 30034 | 2014-09-11 | 431 | D | 0 | 1 | BOSE11 | Based on observations and staff interview the facility failed to monitor the temperature of the medication storage refrigerator on one (1) of three (3) units (unit 4). Findings include: Observations on 9/10/14 at 10:33 a.m. and 11:32 a.m. of the medication storage refrigerator on unit four (4) revealed there was no thermometer in the refrigerator to record the temperature. Continued observation revealed that the stored medications were sitting on a small plate in a pool of water. There was a wet towel in the refrigerator also. The stored medications included: two (2) vials of Humulin Insulin 70/30, one (1) vial of Humulin R Insulin, one (1) vial of Levemir Insulin 100 units/milliliter (u/ml), and Novolog Insulin 100u/ml. Staff Interview on 9/10/14 at 10:35 a.m. with Registered Nurse (RN) AA revealed that since the unit opened around a month ago there has been no thermometer in the refrigerator and this has been reported to her supervisors Continued interview revealed that the refrigerator had a wet towel in it because staff defrosted the freezer. Staff Interview on 9/10/14 at 10:45 a.m. with the Director of Nursing ( DON )revealed that she was unaware that there was no thermometer in the refrigerator until yesterday. Continued interview revealed that without a thermometer, there was no way for the refrigerator temperature to be monitored to ensure that the medications were stored within a safe temperature range. | 2018-03-01 |
| 7140 | 7140 | GEORGIA REGIONAL ATLANTA LTC | 11A186 | 3073 PANTHERSVILLE RD, SNF BLDG. #17 | DECATUR | GA | 30034 | 2014-08-07 | 224 | J | 1 | 0 | 080W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility Investigative Report review, and facility staff interview, the facility failed to prevent neglect during the provision of Activities of Daily Living (ADL) Care for one (1) resident (#1), who was totally dependent on staff for ADL care and who received a second degree burn from staff's unsafe use of a hair dryer, on the total survey sample of seven (7) residents. After Resident #1 received a shower and as direct-care staff dried her hair utilizing an electric hair dryer, the resident sustained [REDACTED]. Resident #1's second degree burn wound later developed slough, the resident was transferred to the Burn Center for treatment, and she received antibiotic drug therapy for the treatment of [REDACTED]. The facility's Service Director was informed of the immediate jeopardy on August 5, 2014 at 3:00 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on July 9, 2014 (the date Resident #1 sustained a second degree burn from a hair dryer requiring hospital transfer, treatment at the Burn Center, and the subsequent administration of antibiotic drug therapy for infection), continued through August 06, 2014, and was removed on August 07, 2014. The facility implemented a credible allegation of jeopardy removal related to the immediate jeopardy on August 06, 2014. The facility's failure to ensure the safe use of a hair dryer during the provision of ADL care to Resident #1 resulted in neglect, as the resident received a second degree burn to the left flank measuring twelve (12) inches by six (6) inches with peeling skin and bullous blistering which caused the resident to groan in pain and exhibit facial grimacing, and resulted in referral to the Burn Center and receipt of antibiotic drug therapy for the treatment of [REDACTED].#1 had sustained the second degree burn while receiving care on July 09, 2014, the direct-care staff member, who was drying the resident's hair with a ha… | 2017-08-01 |
| 7141 | 7141 | GEORGIA REGIONAL ATLANTA LTC | 11A186 | 3073 PANTHERSVILLE RD, SNF BLDG. #17 | DECATUR | GA | 30034 | 2014-08-07 | 282 | J | 1 | 0 | 080W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility Investigative Report review, and facility staff interview, the facility failed to ensure the provision of care in accordance with the Plan of Care to meet the Activities of Daily Living (ADL) needs of one (1) resident (#1), whose Plan of Care identified to be totally dependent for ADL care due to decreased mobility and deficits in cognition and communication, and whose Plan of Care further specified the provision of personal care to meet the resident's needs, on the total survey sample of seven (7) residents. As Resident #1's hair was dried with an electric hair dryer after a shower, the resident sustained [REDACTED]. Resident #1's second degree burn wound later developed slough, and the resident was treated at the Burn Center and received antibiotic drug therapy for the treatment of [REDACTED]. The facility's Service Director was informed of the immediate jeopardy on August 5, 2014 at 3:00 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on July 9, 2014 (the date Resident #1 sustained a second degree burn from a hair dryer requiring hospital transfer, treatment at the Burn Center, and the subsequent administration of antibiotic drug therapy for infection), continued through August 06, 2014, and was removed on August 07, 2014. The facility implemented a credible allegation of jeopardy removal related to the immediate jeopardy on August 06, 2014. The facility's failure to ensure the safe use of a hair dryer during Activities of Daily Living care resulted in Resident #1 sustaining a second degree burn to the left flank measuring twelve (12) inches by six (6) inches with peeling skin and bullous blistering, causing the resident to groan in pain and exhibit facial grimacing, to later develop slough, require transfer to the Burn Center, and require treatment with antibiotic drug therapy for infection of the wound. During the August 5, 2014, 3:00 p.m. interview referen… | 2017-08-01 |
| 7142 | 7142 | GEORGIA REGIONAL ATLANTA LTC | 11A186 | 3073 PANTHERSVILLE RD, SNF BLDG. #17 | DECATUR | GA | 30034 | 2014-08-07 | 323 | J | 1 | 0 | 080W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, facility Investigative Report review, Occupational Therapy Evaluation review, physician interview, and facility staff interview, the facility failed to ensure the supervision necessary to prevent an accident resulting in a second degree burn during Activities of Daily Living (ADL) Care for one (1) resident (#1), who was totally dependent on staff for ADL care, on the total survey sample of seven (7) residents. As direct-care staff dried Resident #1's hair using an electric hair dryer after the resident had received a shower, Resident #1 sustained a second degree burn to the left flank measuring twelve (12) inches by six (6) inches with peeling skin and bullous blistering at the edges, causing the resident to groan in pain and exhibit facial grimacing. Resident #1's second degree burn wound later developed slough, and the resident was transferred to the Burn Center for evaluation and treatment and was treated with antibiotic drug therapy for infection. This resulted in a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Service Director was informed of the immediate jeopardy on August 5, 2014 at 3:00 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on July 9, 2014 (the date Resident #1 sustained a second degree burn from a hair dryer requiring hospital transfer, treatment at the Burn Center, and the subsequent administration of antibiotic drug therapy for infection), continued through August 06, 2014, and was removed on August 07, 2014. The facility implemented a credible allegation of jeopardy removal related to the immediate jeopardy on August 06, 2014. The facility's failure to ensure the safe use of a hair dryer during the provision of Activities of Daily Living care to Resident #1 resulted in the r… | 2017-08-01 |
| 7143 | 7143 | GEORGIA REGIONAL ATLANTA LTC | 11A186 | 3073 PANTHERSVILLE RD, SNF BLDG. #17 | DECATUR | GA | 30034 | 2014-08-07 | 490 | J | 1 | 0 | 080W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, facility administration failed to ensure a system by which to assess and monitor direct-care staffs' provision of Activities of Daily Living (ADL) Care, to thereby ensure resident safety during the use of electric hair dryers, after one (1) resident (#1) who was totally dependent for ADL care sustained a second degree burn to the left flank as direct-care staff used an electric hair dryer in an unsafe manner. The survey sample was seven (7) residents. For Resident #1, direct-care staff failed to utilize a hair dryer in a safe manner while drying Resident #1's hair after the resident received a bath. Resident #1 sustained a second degree burn to the left flank twelve (12) by six (6) inches in size, with peeling skin and bullous blistering, causing the resident to groan in pain and exhibit facial grimacing. Resident #1's second degree burn developed slough, the resident was transferred to the Burn Center and treated with antibiotic drug therapy for wound infection. In response to this incident involving Resident #1 receiving a second degree burn due to staff's unsafe use of a hair dryer, the facility implemented a corrective plan involving Policy revision and staff in-service training; however, the facility failed to develop and implement a protocol to allow for the ongoing monitoring of staffs' use of hair dryers when providing resident care, to ensure ongoing resident safety. This resulted in a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Service Director was informed of the immediate jeopardy on August 5, 2014 at 3:00 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on July 9, 2014 (the date Resident #1 sustained a second degree burn from a hair dryer requiring hospital transfer, trea… | 2017-08-01 |
| 7144 | 7144 | GEORGIA REGIONAL ATLANTA LTC | 11A186 | 3073 PANTHERSVILLE RD, SNF BLDG. #17 | DECATUR | GA | 30034 | 2014-08-07 | 520 | J | 1 | 0 | 080W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to ensure Quality Assurance (QA) Committee's participation in, and oversight of, the development of a corrective action plan developed by the facility in response to a incident involving one (1) resident (#1), related to a second degree burn sustained during Activities of Daily Living (ADL) Care. The total survey sample was seven (7) residents. Resident #1 sustained a left flank second degree burn resulting from direct-care staff's unsafe use of a hair dryer after the resident received a bath. Resident #1 sustained a second degree burn to the left flank measuring twelve (12) inches by six (6) inches, which had peeling skin and bullous blistering, and caused the resident to groan in pain and exhibit facial grimacing. Resident #1's left flank second degree burn wound later developed slough, the resident was transferred to the Burn Center for treatment, and received antibiotic drug therapy for infection of the wound. This resulted in a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Service Director was informed of the immediate jeopardy on August 5, 2014 at 3:00 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on July 9, 2014 (the date Resident #1 sustained a second degree burn from a hair dryer requiring hospital transfer, treatment at the Burn Center, and the subsequent administration of antibiotic drug therapy for infection), continued through August 06, 2014, and was removed on August 07, 2014. The facility implemented a credible allegation of jeopardy removal related to the immediate jeopardy on August 06, 2014. The facility's failure to ensure the safe use of a hair dryer during the provision of Activities of Daily Living care to Resident #1 resulted in the residen… | 2017-08-01 |
| 7394 | 7394 | GEORGIA REGIONAL ATLANTA LTC | 11A186 | 3073 PANTHERSVILLE RD, SNF BLDG. #17 | DECATUR | GA | 30034 | 2012-12-13 | 322 | D | 0 | 1 | KHMD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and facility policy review, the facility failed to properly flush gastrostomy and jejunostomy tubes during medication administration for three (3) residents (#18, #8, #11) from a sample of seventeen (17) residents. Findings include: 1. Observation on 12/12/12 from 8:02 a.m. until 8:27 a.m. of medication administration to Resident #18 revealed Licensed Practical Nurse (LPN) BB administering six (6) medications via the resident's gastrostomy-tube ([DEVICE]). The LPN did not flush the [DEVICE] after the final medication was given. Observation on 12/12/12 at 12:18 p.m. revealed that the LPN administered a medication via the [DEVICE] without flushing the [DEVICE] before or after the medication was administered. 2. Observation on 12/12/12 from 8:30 a.m. until 8:50 a.m of medication administration for Resident #8 revealed LPN BB administer nine (9) medications via the resident's jejunostomy tube. The LPN did not flush the jejunostomy tube (j-tube) prior to administering the medications and did not flush the j-tube after the final medication was given. Continued observation revealed that the LPN checked the j-tube for residual prior to medication administration 3. Observation on 12/12/12 from 9:05 a.m. until 9:55 a.m. of medication administration for Resident #11 revealed LPN administer eleven (11) medications via the resident's [DEVICE]. The LPN did not flush the [DEVICE] after the final medication was given. Review of the facility protocol for Medical Administration via Enteral Tube Feeding revealed instructions to flush the feeding tube with thirty (30) cubic centimeters (cc) of water prior to administering medication and flush the tube with thirty (30) cc of water after administering medication. Review of the policy revealed jejunostomy tubes are checked for patency only (DO NOT check residual in Jejunostomy tube) and flushed with five (5) to thirty (30) cc of water prior to administering medication, unless … | 2017-05-01 |
| 7395 | 7395 | GEORGIA REGIONAL ATLANTA LTC | 11A186 | 3073 PANTHERSVILLE RD, SNF BLDG. #17 | DECATUR | GA | 30034 | 2012-12-13 | 431 | E | 0 | 1 | KHMD11 | Based on observation, staff interviews, and policy review, the facility failed to ensure that expired medications were discarded appropriately after twenty-eight (28) days on two (2) of two (2) facility medication carts. Findings Include: 1. Observation on 12/12/12 at 2:10 p.m. of the Suite Three (3) Medication Cart revealed six (6) eye drop medications on the medication cart that had not been appropriately discarded after being opened for more than 28 (twenty-eight) days. The medication included the following: - Artificial Tears one-half (1/2) fluid ounce bottle was opened and dated 4/06/12. - Erythromycin Ophthalmic ointment 0.5% one-eighth (1/8) ounce tube was opened and dated 10/09/12. - Dexamethasone/Tobramycin 0.05% - 0.3% sterile five (5) milliliter (ml) bottle was opened and dated 11/05/12. - Gentamicin Sulfate 0.3% three (3) milligrams (mg) per milliliter (ml) eye drops in The stop date was 10/22/12. There was no opening date written on the outside label or on the bottle of eye drops. - Erythromycin ophthalmic ointment 0.5% (one-eighth)1/8 ounce tube was opened 9/19/12 with a stop date of 9/26/12. - Neomycin and Polymyxin B Sulfates, Bacitracin Zinc, and Hydrocortisone ophthalmic ointment one-eighth (1/8) per ounce tube was opened 11/07/12.daily. Interview on 12/12/12 at 2:15 p.m. with Licensed Practical Nurse (LPN) BB confirmed the opening dates of the six (6) medications and verified the medications should have been discarded after twenty-eight (28) days. Interview on 12/12/12 at 2:22 p.m. with Registered Nurse (RN) AA revealed the medications open beyond twenty-eight (days) should have been discarded. Review of the facility's medication storage policy dated June, 2012 revealed all multi-dose vials will expire (twenty-eight) days once the vial is opened. All eye drops expire twenty-eight (28) days once it is opened. 2. Observation on 12/12/12 at 1:30 p.m. of the medication cart for Suite 2 revealed two (2) eye drop medications on the medication cart that had not been appropriately discarded after being… | 2017-05-01 |
| 9475 | 9475 | GEORGIA REGIONAL ATLANTA LTC | 11A186 | 3073 PANTHERSVILLE RD, SNF BLDG. #17 | DECATUR | GA | 30034 | 2011-07-20 | 241 | D | 0 | 1 | 6F1J11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interview, the facility failed to ensure that staff knocked on the door before entering for five (5) of twenty four (24) resident rooms (1724, 1745, 1748, 1750 and 1752). Findings include: 1. Observation on 7/19/11 at 8:30 am revealed that a housekeeper entered room [ROOM NUMBER] without knocking. There were four (4) residents in the room. 2. Observation on 7/19/11 at 8:34 a.m. revealed that the same house keeper entered room [ROOM NUMBER] without knocking there was one (1) resident in the room. 3. Observation on 7/19/11 at 8:55 am revealed that a Health Service Technician (HST) entered room [ROOM NUMBER] without knocking. Observation on 7/19/11 at 8:59 am revealed that a Respiratory Staff member entered room [ROOM NUMBER] without knocking. Continued observation revealed that the Respiratory Staff member left the room and reentered at 9:03 am, again without knocking. Observation on 7/19/11 at 10:09 am revealed the Director of Nursing entered room [ROOM NUMBER] without knocking. There were two (2) residents in the room. 4. Observation on 7/20/11 8:42 am revealed three (3) housekeepers entered room [ROOM NUMBER] without knocking on the door. There were three (3) residents in the room. Continued observations at 8:50 am revealed that a housekeeping staff entered room [ROOM NUMBER] without knocking. Observation on 7/20/11 at 9:42 am revealed that a Certified Nursing Assistant (CNA) "GG" entered room [ROOM NUMBER] without knocking. 5. Observation on 7/20/11 at 9:16 am revealed a CNA entered room [ROOM NUMBER] without knocking. Interview on 7/20/11 at 10:42 am with Licensed Practical Nurse (LPN) "DD" revealed that the staff is supposed to knock on the door before entering the room. Interview on 7/20/11 at 10:53 am Registered Nurse (RN) "FF" revealed that she did not knock on the door, but that the policy is to knock before entering a room at all times and that staff is trained to knock on the door before entering. Int… | 2015-07-01 |
| 9476 | 9476 | GEORGIA REGIONAL ATLANTA LTC | 11A186 | 3073 PANTHERSVILLE RD, SNF BLDG. #17 | DECATUR | GA | 30034 | 2011-07-20 | 280 | D | 0 | 1 | 6F1J11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure that the care plan was updated/revised for one (1) resident (#26) from a sample of fifteen (15) residents. Findings include: Review of the quarterly Minimum Data Set (MDS) assessment for resident #26 revealed that a quarterly assessment was done 5/23/11. Review of the resident care plans revealed that there was no evidence that the careplan had been updated/revised since the annual MDS assessment dated [DATE]. Interview with Service Director on 7/19/11 at 3:05 p.m., revealed that the care plan is to be updated quarterly and that the care plan had not been revised since 11/23/10. | 2015-07-01 |
| 9477 | 9477 | GEORGIA REGIONAL ATLANTA LTC | 11A186 | 3073 PANTHERSVILLE RD, SNF BLDG. #17 | DECATUR | GA | 30034 | 2011-07-20 | 287 | C | 0 | 1 | 6F1J11 | Based on staff interview, the facility failed to ensure that the Minimum Data Set (MDS) assessments were transmitted to the State Office in a timely manner. Findings include: Review of the State Data Base in June, 2011 revealed no MDS assessment information had been transmitted to the state. Review of voice mail messages left with and e-mail messages received by the State Agency MDS coordinator and State MDS Automation Coordinator revealed no evidence that any communication had been received from the facility since January 31, 2011 related to transmission problems until May, 2011 when it was discovered that there was no MDS information in the State data base. Interview with Service Coordinator, on 7/18/11 at 10:05 a.m.,revealed that she began having problems with the MDS 3.0 program the first part of November 2010 and called the state MDS office to report the problem. Continued interview revealed that she contacted J-Raven (the software company) who uninstalled and reinstalled the program and a security patch but she continued to have problems with transmission. Further interview revealed that even though there were computers problems, they were still meeting and CP were are being completed. | 2015-07-01 |
| 9478 | 9478 | GEORGIA REGIONAL ATLANTA LTC | 11A186 | 3073 PANTHERSVILLE RD, SNF BLDG. #17 | DECATUR | GA | 30034 | 2011-07-20 | 281 | D | 0 | 1 | 6F1J11 | Based on observations, record review and staff interviews, the facility failed to meet professional standards of practice related to checking feeding tube placement prior to administering medication for three (3) residents (#5,# 15, and #21) from a sample of fifteen (15) residents. Findings include: 1. Observation on 7/19/11 at 8:30 am during medication pass for resident # 5 with Licensed Practical Nurse (LPN) "CC" revealed that the nurse did not check the feeding tube for placement before giving medication to the resident. 2. Observation on 7/19/11 at 8:55 am during medication pass for resident #15 with LPN "CC" revealed that the feeding tube was not checked for placement prior to administration of medication. 3. Observation on 7/19/11 at 9:36 am during medication pass for resident #21 with LPN "CC" revealed that the nurse did not check the feeding tube for placement tube prior to administration of medication. Interview on 7/20/11 at 10:00 am with LPN "EE" Suite 3 revealed that the staff is suppose to check for placement prior to administering medication through a feeding tube. Interview on 7/20/11 at 10:08 am with a Registered Nurse (Charge Nurse) "FF" revealed that the staff should make sure that the resident is position properly, then check for placement. Continued interview revealed Review of the Medication Administration Via Enteral Tube Feeding policy revealed that the feeding tube should be checked for patency and placement. Review of the Medication Administration Observation GRH/A Skilled Nursing form dated 10/11/11 indicated that LPN "CC" was checked off. Review of the Georgia Practical Nurses Practice Act revealed that the practice of licensed practical nursing means the provision of care for compensation. Section 2.3.2 Standards Related to Practical Nurse-Subsection J-Administers medication accurately | 2015-07-01 |
| 9479 | 9479 | GEORGIA REGIONAL ATLANTA LTC | 11A186 | 3073 PANTHERSVILLE RD, SNF BLDG. #17 | DECATUR | GA | 30034 | 2011-07-20 | 332 | E | 0 | 1 | 6F1J11 | Based on observations conducted during the medication pass, it was determined that the facility failed to ensure that it was free of a medication error rate of five (5) percent or greater. Findings include: Observations conducted on 7/19/11 beginning 8:30 a.m. revealed two (2) of two (2) nurses on two (2) of two (2) halls administering medications. Three (3) medication errors were observed out of fifty-one (51) opportunities. This resulted in a medication error rate of 5.8 percent. 1. Resident # 5 had a feeding tube that was to be flushed with 30 cubic centimeters (cc) of water before and after medication administration. The nurse did not flush the tube. 2. Resident #21 had a feeding tube that was to be flushed with 30cc of water before and after medication administration. The nurse did not flush the tube. 3. Resident #11 had a feeding tube that was to be flushed with 30 cubic centimeters (cc) of water before and after medication administration. The nurse flushed the tube with 60cc's of water before giving the medication but did not flush the tube after the medication was given.. Review of the Medication Administration Via Enteral Tube Feeding policy revealed that the feeding tube should be flushed with 30cc of water prior to and after administration of medications. | 2015-07-01 |
| 10331 | 10331 | ROSE HAVEN NURSING FACILITY | 11A115 | 400 SOUTH PINETREE BLVD. | THOMASVILLE | GA | 31792 | 2011-02-16 | 280 | D | 0 | 1 | C5SB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, it was determined that the facility failed to revise a care plan intervention for the correct amount of a gastrostomy tube water flush for one resident (#9) in a sample of eight residents with gastrostomy tubes from a total sample of ten residents. Findings include: Resident #9 had a physician's orders [REDACTED]. The order included to increase the water flush administered after the gastrostomy tube pump was turned off and before turning it on, from 90 cc to 120 cc. However, the gastrostomy tube care plan, most recently revised on 2/2011, incorrectly documented an intervention for nursing staff to give 150 cc of water to the resident before and after each gastrostomy tube feeding. See F327 for additional information regarding resident #9. | 2014-08-01 |
| 10332 | 10332 | ROSE HAVEN NURSING FACILITY | 11A115 | 400 SOUTH PINETREE BLVD. | THOMASVILLE | GA | 31792 | 2011-02-16 | 327 | D | 0 | 1 | C5SB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, it was determined that the facility failed to administer the correct amount of water flush for one resident (#9) with a gastrostomy tube in a sample of eight residents with gastrostomy tubes from a total sample of ten residents. Findings include: Resident #9 had [DIAGNOSES REDACTED]. There was a physician's orders [REDACTED]. The order included to increase the water flush administered after the gastrostomy tube pump was turned off and before turning it on, from 90 cc to 120 cc. However, a review of the January and February 2011 Enteral Feeding Records documentation revealed that nursing staff continued to administer 100 cc of water every four hours from 1/26/11 to 2/15/11 and, 90 cc of water after the pump was turned off and before turning it back on from 1/26/11 to 1/31/11. | 2014-08-01 |
| 10333 | 10333 | ROSE HAVEN NURSING FACILITY | 11A115 | 400 SOUTH PINETREE BLVD. | THOMASVILLE | GA | 31792 | 2011-02-16 | 314 | D | 0 | 1 | C5SB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, it was determined that the facility failed to ensure that one resident (#1) received pressure sore treatment timely in a sample of two residents with pressure sores from a total sample of ten residents. Findings include: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He/she had an unavoidable pressure sore on his/her coccyx since March 2010. There was a physician's orders [REDACTED]. During an observation of incontinence care provided by Certified Nursing Assistants (CNAs) "CC" and "BB" on 2/14/11 at 1:17 p.m., a stage III pressure sore was observed on the resident's coccyx. There was not a dressing on it. The resident was again observed on 2/15/11 at 9:15 a.m. and there was not a dressing on the pressure sore. A review of the resident's clinical record documentation revealed that a dressing had last been placed on the pressure sore on 2/13/11. There was no evidence that treatment had been provided to the pressure sore on 2/14/11. CNA "CC" stated on 2/15/11 at 11:21 a.m. that she had noticed that the resident did not have a dressing on his/her pressure sore during the provision of incontinence care on 2/14/11 at 1:17 p.m.. However, she did not inform the resident's nurse about it. | 2014-08-01 |
| 10334 | 10334 | ROSE HAVEN NURSING FACILITY | 11A115 | 400 SOUTH PINETREE BLVD. | THOMASVILLE | GA | 31792 | 2013-09-05 | 279 | D | 0 | 1 | VG6Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to update the plan of care to to include a problem statement, goals and measurable interventions for a new feeding tube placement for one (1) resident (#9) of a sample of seventeen (17) residents. Findings include: Resident #9 had multiple [DIAGNOSES REDACTED]. Review of the resident's clinical record revealed the resident had been in the hospital 06/01/13 - 06/19/13 for fever and dehydration due to severe acute gastroenteritis and had a feeding tube placed during this hospital stay. Review of the Minimum Data Set (MDS) revealed that a quarterly assessment had been done 06/27/2013 and the resident was assessed with [REDACTED]. Review of the resident's care plan revealed there was no care plan for the feeding tube although the resident was care planned for aspiration precautions. An interview on 09/05/13 at 11:07 a.m. with the facility physician revealed that prior to the residents hospital return on 06/19/2013, the resident had never had a feeding tube. A telephone interview on 09/05/13 at 10:15 a.m. with the MDS coordinator revealed that the care plan had not been updated after the quarterly assessment on 06/27/2013. She further revealed that she only works on the weekends so the charge nurse also helps with updating the care plans. An interview on 09/05/2013 at 10:48 a.m. with the Charge Nurse confirmed there had been an updated entry to the aspiration care plan on 06/13/18, noting the feeding tube placement, but did not include new interventions. Continued interview revealed there should have been interventions related to the feeding tube. | 2014-08-01 |
| 4035 | 4035 | CAMBRIDGE POST ACUTE CARE CENTER | 115771 | 2020 MCGEE ROAD | SNELLVILLE | GA | 30078 | 2019-01-25 | 609 | D | 1 | 0 | 01SH11 | > Based on record review and staff interviews, review of the facility's Abuse Prevention Policy', revised 3/1/18, review of the 'Grievance/Complaint ' form revised 1/18/10 and review of the 'Grievance Log' entries beginning (MONTH) (YEAR) through (MONTH) 2019 revealed the facility failed to ensure that an allegation of physical abuse was reported to the State Agency (SA) for one Resident (R) (R#1). The sample size was ten residents. Findings include: Record Review revealed a 'Grievance/Complaint Form' was completed on 11/11/18 by the Director of Nursing in response to a complaint sent by R#1's family via e-mail to the Administrator on 11/11/18 at 2:23 p.m. alleging possible physical abuse of R#1. The completed 'Grievance/Complaint Form' documented the investigation of the allegation including resident and staff interviews and written statements obtained from staff. The allegation was not substantiated. Interview and review of the 'Grievance/Complaint Form' for R#1 on 1/8/19 at 2:38 p.m. with the Director of Nursing (DON) who confirmed that she was aware of the incident, had conducted the investigation, and was confident that no abuse had occurred. Review of the 'Facility Incident Report Form's revised 2/17/17 revealed no record that a report had been filed with the SA related to the allegation of abuse for R#1 dated 11/11/18. Interview and document review on 1/10/19 at 6:45 p.m. with the DON and the Administrator who confirmed that the incident had not been reported to the SA in accordance with federal regulations. The administrator confirmed he is the abuse coordinator for the facility and that he forwarded the allegation of abuse to the DON upon receipt of the allegation and it was investigated. The incident was not reported to the SA because abuse was not found and the police were not notified. | 2020-09-01 |
| 4036 | 4036 | CAMBRIDGE POST ACUTE CARE CENTER | 115771 | 2020 MCGEE ROAD | SNELLVILLE | GA | 30078 | 2019-01-25 | 677 | D | 1 | 0 | 01SH11 | > Based on record review, resident and family interview and staff interview, the facility failed to provide timely adl care to ensure that the needs of five of 98 residents (R), (R#2, R#3, R#4, R#5 and R#6) were met for the residents to achieve the highest practicable level of well-being. This includes residents who are continent or mostly continent of bowel and bladder not receiving assistance to and from toileting facilities in a timely manner, not receiving fresh ice and water routinely across shifts. Facility census was 130. Findings include: `. Interview 1/8/19 at 8:30 a.m. outside of the facility with the son of R#5 who revealed that his mother voiced complaints to him frequently about having to wait for staff to help her to the bathroom. He also stated that when he has been visiting it has taken staff longer than 40 minutes to answer call lights and that weekends and evenings seem to be the worst. He confirms that his mother is 'mostly continent' and has not observed staff asking her if she needs assistance. She is able to voice her needs and doesn't ask for much assistance. Her water is frequently warm and almost empty. He has stated his concerns to the nurses and other staff but has never filed a formal complaint. He sees a lot of staff work double shifts and believes that may affect their ability to care for the residents. R#5's most recent Minimum Data Set (MDS) Quarterly Assessment, dated 10/30/18, Section C: Cognitive Status, revealed a Brief Interview of Mental Status (BIMS) score of nine, indicating mild cognitive impairment. Review of Section G: Functional Status revealed that R#5 requires extensive one-person assistance for toileting and Section H: Bowel and Bladder, subsections H0300 and H0400 reveal that she is occasionally incontinent of bowel and bladder. Section H Bowel and Bladder, subsection H0200, Urinary Toileting Program reveals that resident was on a toileting program beginning 3/14/18. This was discontinued on or about 8/17/18 and restarted 1/7/19. Review of resident assessments revea… | 2020-09-01 |
| 4037 | 4037 | CAMBRIDGE POST ACUTE CARE CENTER | 115771 | 2020 MCGEE ROAD | SNELLVILLE | GA | 30078 | 2016-08-18 | 170 | E | 0 | 1 | 0P7K11 | Based on review of policy and procedure, resident and staff interviews, the facility failed to ensure prompt delivery of resident mail that arrived to the facility on weekends. The facility census was one hundred thirty two (132) residents. Findings include: Review of the policy titled Resident Rights documented: The resident has the right to privacy in written communications, including the right to send and receive mail promptly that is unopened. Interview on 08/17/2016 at 4:54 p.m. with Resident #71 revealed that they did not receive their mail on the weekends. Interview on 08/18/2016 8:19 a.m. with the Social Services Assistant (SSA) revealed that the activity staff are not present on Saturdays. The SSA is not sure if the mail is delivered to residents on weekends. The SSA further stated that at one time, there were problems with the mail delivery on weekends and suggested that surveyor follow up with Activities director. Interview on 08/18/2016 at 8:34 a.m. with the Activities Director (AD) revealed that there is no designated person available to check the mail on Saturdays. The AD said if they are aware that a resident is expecting an item, they will call the facility to request that the mailbox is checked. The AD further stated that residents have not complained at the resident council meetings about not getting mail on the weekends. Interview on 8/18/16 at 12:30 p.m. with the Administrator revealed that the facility does receive mail on Saturdays, however, if a resident receives mail it is not distributed until Monday because the mail has to be sorted by someone in the business office. The Administrator further stated that the weekend receptionist is responsible for getting the mail on the weekends but is not required to distribute the mail to residents. | 2020-09-01 |
| 4038 | 4038 | CAMBRIDGE POST ACUTE CARE CENTER | 115771 | 2020 MCGEE ROAD | SNELLVILLE | GA | 30078 | 2016-08-18 | 252 | E | 0 | 1 | 0P7K11 | Based on observations and interviews, the facility failed to ensure a homelike environment in two dining rooms (main and dependent) during meal service. The facility census was one hundred thirty six (136) Findings include: An observation on 08/16/2016 at 5:39 p.m. in the main (independent) dining room revealed sixteen (16) out of eighteen (18) residents were served their meals on food trays. The trays were not removed from the tables for the duration of the meal. An observation on 08/17/2016 at 12:20 p.m. in the dependent dining room revealed twenty one (21) of twenty three (23) residents were served their meals on food trays, The trays were not removed from the tables for the duration of the meal. Interview on 08/18/2016 at 7:52 a.m. with administrative staff CC that assisted with dining revealed that the facility's standard of practice is to remove the meal plate and food items from the serving tray unless requested otherwise by resident. Interview on 08/18/2016 at 7:57 a.m. with the DON revealed it is the facility's goal to make sure that residents feel at home and receive a friendly experience overall. The DON stated that for residents in the main dining room, it is expected that the meal trays be removed from the table so that dining does not appear like an institutional setting. The DON further stated that in the assistive (dependent) dining room, the trays are not removed because in the event the resident has to be moved it is easier to contain the food and that some residents did not want the trays removed. The DON stated the facility does not have a policy related to dining or homelike environment in the dining room. | 2020-09-01 |
| 4039 | 4039 | CAMBRIDGE POST ACUTE CARE CENTER | 115771 | 2020 MCGEE ROAD | SNELLVILLE | GA | 30078 | 2016-08-18 | 253 | E | 0 | 1 | 0P7K11 | Based on observation, review of policy and procedure and staff interview, the facility failed to maintain effective housekeeping and maintenance services to ensure that the interior environment was clean, orderly, and in good repair on two (2) of four (4) halls (A and D). Findings include: Review of the policy titled Housekeeping documented: several purpose which include, but not limited to; The Complete Room Schedule ensures that each resident room is discharged -clean on a monthly basis. To show Housekeeping employees the proper method to sanitize a washroom or bathroom in a long term care facility. 7 Steps Daily Washroom Cleaning: 1. Check Supplies 2. Empty Trash 3. Dust Mop Floor 4. Clean and Sanitize Sink and Tub (Steps 5-6 is missing). To show Housekeeping employees the proper method to sanitize a patient's room or any area in a healthcare facility. 5 Step Patient Room Cleaning Procedure: 1. Empty Trash 2. Horizontal Surfaces 3. Spot Clean Walls 4. Dust Mop (Step 5 is missing). Review of the policy titled Preventative Maintenance documented: In order to provide a safe environment for residents, employees and visitors, a preventative maintenance program has been implemented to promote the maintenance of the equipment in a state of good repair. Routine inspections promote safety throughout the facility and aid in keeping equipment in good working order and operating in accordance to manufacturer guidelines. Regular inspection, testing, and replacement or repair of equipment and operational systems contribute to preservation of the facility's assets. During observations on 08/15/2016 beginning at 9:08 a.m. and on 08/18/2016 beginning at 11:11 a.m. of the A Hall, the following concerns were identified: In room 1 there was a buildup on front of the air conditioning (A/C) unit, a hole in wall over the A/C unit, furniture in the room that had missing varnish, rusty legs on the over toilet seat and a scuffed bathroom door with missing wood pieces. In room 3 there were loose baseboards by bed b, a scuffed bathroom d… | 2020-09-01 |
| 4040 | 4040 | CAMBRIDGE POST ACUTE CARE CENTER | 115771 | 2020 MCGEE ROAD | SNELLVILLE | GA | 30078 | 2016-08-18 | 282 | E | 0 | 1 | 0P7K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interviews, the facility failed to ensure the bed alarm and chair alarm was in place according to the care plan interventions for one (1) of thirty six (36) sampled residents (#31). (Refer F323) Findings include: Review of the policy titled Care Plans documented: Each resident will have a plan of care to identify problems, needs and strengths that will identify how the interdisciplinary team will provide care. The care plan contains resident problems/needs/strengths, resident goals and interdisciplinary approaches. Record review for Resident #31 revealed a Quarterly Minimum Data Set (MDS) assessment dated [DATE] which documented in Section J- Health Conditions that the resident had two (2) falls without injury since admission and prior to the assessment. Review of the Annual MDS, Section V- Care Area Assessment (CAA) triggered Falls with the decision to be care planned. Review of the care plan for Resident #31 initiated 4/7/16 identified the resident is at risk for falls related to being unaware of safety needs. An intervention in place, but not limited to, documented: The resident uses an alarm on wheel chair and in bed. Ensure the device is in place as needed. The care plan initiated on 06/14/2016 indicated that the resident uses [MEDICAL CONDITION] medications related to Behavioral Management for [MEDICAL CONDITION] with history of Hallucinations. The interventions included, but no limited to, monitor/record/report to physician the occurrence of target behavior symptoms of pacing, wandering, disrobing, inappropriate violence/aggression towards staff/others and document per facility protocol and bed alarm for bed and chair alarm when out of bed. Observation on 08/16/2016 at 3:20 p.m. reveled Resident #31 her room in bed. There was no evidence of a bed alarm in place. Observation on 08/17/2016 at 11:45 a.m. in the activity area revealed Resident #31 in a wheelchair. There was no evidence of a ch… | 2020-09-01 |
| 4041 | 4041 | CAMBRIDGE POST ACUTE CARE CENTER | 115771 | 2020 MCGEE ROAD | SNELLVILLE | GA | 30078 | 2016-08-18 | 323 | E | 0 | 1 | 0P7K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation record review, policy and procedure review and staff interviews, the facility failed to ensure that assistive devices (bed and chair alarms) were in use as prescribed by the physician for one (1) resident (#31) that had a history of [REDACTED]. Additionally, the facility failed to ensure the bedrails were correctly installed and properly fitted on two (2) of four (4) halls. Three (3) beds (2b, 9b, 13a) on Hall A and three (3) beds (9b, 10a, 12b) on C Hall. The sample was thirty six (36) residents. Findings include: 1. Record review for Resident #31 revealed a Quarterly Minimum Data Set (MDS) assessment dated [DATE] which documented a Brief Interview for Mental Status (BIMS) summary score of 4, indicating severe cognitive impairment. Section G- Functional status documented the resident required extensive assistance with one person physical assist for toilet use, personal hygiene, bathing, bed mobility, dressing and eating and two person assist for transfer. Section J- Health Conditions documented that the resident had two (2) falls without injury since admission and prior to the assessment. Review of the Annual MDS, Section V- Care Area Assessment (CAA) triggered Falls with the decision to be care planned. Review of the care plan for Resident #31 initiated 4/7/16 identified the resident is at risk for falls related to being unaware of safety needs. An intervention in place, but not limited to, documented: The resident uses an alarm on wheel chair and in bed. Ensure the device is in place as needed. The care plan initiated on 06/14/2016 indicated that the resident uses psychotropic medications related to Behavioral Management for psychosis with history of Hallucinations. The interventions included, but no limited to, monitor/record/report to physician the occurrence of target behavior symptoms of pacing, wandering, disrobing, inappropriate violence/aggression towards staff/others and document per facility protocol and bed a… | 2020-09-01 |
| 4042 | 4042 | CAMBRIDGE POST ACUTE CARE CENTER | 115771 | 2020 MCGEE ROAD | SNELLVILLE | GA | 30078 | 2016-08-18 | 431 | E | 0 | 1 | 0P7K11 | Based on observation, interviews and record review, the facility failed to ensure that (2) two of six (6) medication carts and one (1) of three (3) treatment carts on two (2) of four (4) halls (D and C Halls) were secure when left unattended. Findings included: On 8/15/2016 at 11:20 a.m. during a tour of the D Hall, one medication cart was observed on the hall in front of Room D2. The cart was observed unlocked and unsecured. A box of eye drops labeled with a residents name was observed on top of the medication cart. Observation of this cart at 11:23 a.m. with the Director of Nursing (DON) confirmed that the medication cart was unlocked and the eye drops were on top of the medication cart. Interview with the DON at the time of the observation revealed it was the expectation that the medication and treatment carts are locked when not in use. Interview at 11:25 a. m. with the Licensed Practical Nurse (LPN) FF revealed that she had been asked to do something and thought she had put the eye drops back into the cart and had locked it. On 8/15/2016 at 11:42 a.m. during a tour of the D Hall, one treatment cart was observed on the hall in front of Room D4. The treatment cart was observed unlocked and unsecured. Interview at 11:43 a.m. with the LPN Treatment Nurse GG confirmed that she had left the treatment cart unlocked. She stated that she thought she had locked it. On 8/15/2016 at 2:56 p.m. a medication cart on D Hall was observed on the outside of the nursing station facing out as residents and visitors passed. The cart was observed unlocked and unsecured. LPN FF came out from behind the nursing station and confirmed that it was her cart. LPN FF then proceeded to lock the medication cart. On 8/17/2016 at 5:44 p.m. a medication cart on C Hall was observed on the hall near Room C8 unattended. The cart was unlocked and unsecured. At 5:47 p.m. LPN HH came down the hall and confirmed that it was her cart. She locked the cart at that time. A review of the policy provided by the DON on 8/18/2016 titled Deliver, Receipt, Sto… | 2020-09-01 |
| 4043 | 4043 | CAMBRIDGE POST ACUTE CARE CENTER | 115771 | 2020 MCGEE ROAD | SNELLVILLE | GA | 30078 | 2016-08-18 | 441 | E | 0 | 1 | 0P7K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, policy and procedure review and staff interviews, the facility failed to ensure proper hand hygiene was maintained by the staff in an effort to prevent the potential spread of infection and disease, while serving meals to residents in one (1) of three (3) dining rooms (D Hall Dining). This failure had the potential to affect all residents eating in the dining room. Additionally, the facility failed to properly label and store personal care equipment on two (2) of four (4) halls (A and C Halls). The facility census was one hundred thirty six (136) residents. Findings include: 1. Review of the policy titled Storage of items in Resident Rooms documented: Resident ' s personal items will be orderly and properly stored. Policy regarding storage of items in resident rooms state that bedpans should be clean and stored on bottom shelf of bedside stands. Wash Basins to be stored in the upper shelf of the bedside stand. Cosmetic items and personal items should be stored in the top drawer. Resident cosmetic items can be stored in the bathroom only if labeled. No items will be stored on floors of resident rooms. Review of the policy titled Hand Hygiene dated 8/18/2016 documented: All staff will use proper hand washing techniques to prevent the spread of infection. Dining observation on 08/15/2016 at 12:11 p.m. in main dining room during lunch administrative staff CC was passing sweet tea to residents when she touched a resident on the shoulder. CC continued passing tea to other residents and did not sanitize or wash hands after touching a resident. CC then picked up keys that had fallen to floor and did not sanitize or wash hands before putting ice in a cup. Observation on 8/15/2016 at 8:44 a.m. and 8/18/2016 at 10:59 a.m. on D Hall in room [ROOM NUMBER] there was one (1) wash basin in bathroom not bagged or labeled. Observation on 8/15/2016 at 1:35 p.m. and 8/18/2016 at 11:20 a.m. on A Hall in room [ROOM NUMBER] there was one (1) … | 2020-09-01 |
| 4044 | 4044 | CAMBRIDGE POST ACUTE CARE CENTER | 115771 | 2020 MCGEE ROAD | SNELLVILLE | GA | 30078 | 2016-08-18 | 469 | E | 0 | 1 | 0P7K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and review of the facility's pest control contract and service records, the facility failed to maintain an effective pest control program in a manner to ensure the kitchen and dining room was free of pest. Findings included: A tour of the kitchen conducted on 8/15/2016 at 9:00 a.m. revealed multiple flies flying around the food preparation area. Observation on 8/17/2016 at 4:21 p.m. revealed the kitchen staff setting up the tray line with the lunch meal food items. A large black fly landed and crawled on the tray line steam table. There were multiple flies flying around the food and throughout the kitchen. During an interview with the Dietary Manager on 8/17/2016 at 4:30 p.m. she stated that they were working on getting the flies under control. She stated that they had fly lights but they were told that they had to remove them. She stated that the flies were coming from the outside when they open the door. Observation of the outside door at the time of the interview revealed multiple flies flying near the door area and multiple flies landed on the ground and wall. There were a few empty garbage cans outside in this area. The Dietary Manager stated that these were cleaned with multipurpose spray. The dumpster area was observed at this time. There was an infestation of flies observed near and around the garbage disposal area. There was a malodorous smell near the garbage area. During an interview with the Nursing Home Administrator (NHA) on 8/17/2016 at 5:24 p.m. he stated that they placed fly traps outside. He stated that the pest control company does monthly service inside and outside of the facility and that they will come to the facility on demand and will re-spray and retreat as needed. . Interview on 8/18/2016 at 11:15 a.m. with the NHA revealed the facility does not have a policy related to pest control, however, provided the pest control contract and service records at this time. A review of the pest con… | 2020-09-01 |
| 4045 | 4045 | CAMBRIDGE POST ACUTE CARE CENTER | 115771 | 2020 MCGEE ROAD | SNELLVILLE | GA | 30078 | 2018-09-27 | 625 | E | 0 | 1 | 0V3G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and review of the facility policy, the facility failed to provide the Bed Hold Policy to six residents (R) (R#25, R#36, R#86, R#98, R#111, R#123) who were transferred to the hospital. The sample size was 31 residents. Findings include: 1. Review of R#25's clinical record revealed an admission date of [DATE] and the [DIAGNOSES REDACTED]. Review of R#25's annual Minimum Data Set ((MDS) dated [DATE] revealed the Brief Interview for Mental Status (BIMS) score of 10, indicating the resident had moderately impaired cognition. Review of the Nurse's Note dated 8/28/18 and timed 11:28 p.m. revealed the Nurse Practitioner gave an order to send R#25 to the emergency room for altered mental status. Review of the Nurse's Note dated 9/5/18 and timed 8:20 p.m. revealed R#25 returned from the hospital at 2:30 p.m. Review of the Hospital Discharge Form dated 9/5/18 revealed R#25's discharge [DIAGNOSES REDACTED]. Further review of the resident's clinical record lacked evidence the facility provided the resident with the bed hold policy on transfer. Interview with the Administrator on 9/26/18 at 12:50 p.m. on the C hall, revealed the facility did not send a copy of the Bed Hold Policy with any of the residents when they are transferred to the hospital. Interview with the Assistant Director of Nursing (ADON) BB on 9/27/18 at 10:05 a.m. at the nurses' station revealed the facility did not send a copy of the Bed Hold Policy with the residents when the residents went to the hospital. ADON BB further stated it was not on the computer, so she did not know how they would get it. The Administrator, upon asking for the Bed Hold Policy provided a document titled Bed Hold Agreement to Pay Private Rate with no date. The document indicated, Due to the high demand for Skilled Nursing Facility placements, it is necessary for this facility to explain the policies concerning reserving beds for residents that must be in the hospital for … | 2020-09-01 |
| 4046 | 4046 | CAMBRIDGE POST ACUTE CARE CENTER | 115771 | 2020 MCGEE ROAD | SNELLVILLE | GA | 30078 | 2018-09-27 | 656 | D | 0 | 1 | 0V3G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and facility policy review, the facility failed to implement the comprehensive care plans for three residents. (R) (R#10, R#58, and R#98) of three residents of 31 sampled residents. R#10 was identified as requiring assistance with personal hygiene (baths/showers) The resident reported that she not received assistance with bath/showers. R#58 was assessed with [REDACTED]. R#98 was assessed to have experienced weight loss in the past five months. The facility failed to develop and implement care plan interventions to address this resident's weight loss. Findings include: 1. Review of R#10's admission Minimum Data Set ((MDS) dated [DATE] indicated the resident was admitted into the facility on [DATE]. Her [DIAGNOSES REDACTED]. The resident was assessed with [REDACTED]. The resident was assessed as requiring extensive assistance for bed mobility and dressing, toilet use and personal hygiene; requiring two-person physical assistance for transfers. And the resident was assessed as being totally dependent on one-person assistance for bathing. Review of the resident's Care Plan dated 9/14/18 indicated on the ADL Self-Care Deficit Care Plan that R#10 required assistance with bathing/showering three times a week. Staff to provide a shower as scheduled and as necessary. Resident requires staff participation with bathing. Interview with R#10 in her room on 9/25/18 at 11:00 a.m. revealed the resident gets up when she likes, does her own grooming but wishes they (the Certified Nursing Assistants (CNA's) would help her get a shower. R#10 explained that she uses a transfer board to get into her wheelchair but can't use it to get into the shower chair. R#10 also stated that she can't stand up to take a shower. R#10 said that occasionally she gets a sponge bath in her room. R#10 further stated that she washes herself in her bathroom sink. She cannot wash her hair in the sink, so she just wets her hair and combs it … | 2020-09-01 |
| 4047 | 4047 | CAMBRIDGE POST ACUTE CARE CENTER | 115771 | 2020 MCGEE ROAD | SNELLVILLE | GA | 30078 | 2018-09-27 | 658 | D | 1 | 0 | 0V3G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, and interview the facility failed to ensure professional standards were followed in that the physician's orders to prepare Resident (R#119) for surgery were not followed. The sample size was 31 residents. Georgia Nurse Practice Act (8) Practice nursing as a registered professional nurse means to practice nursing by performing for compensation any of the following: (J) Administering medications and treatments as prescribed by a physician [MEDICATION NAME] medicine in accordance with Article 2 of Chapter 34 of this title, a dentist [MEDICATION NAME] dentistry in accordance with Chapter 11 of this title, or a podiatrist [MEDICATION NAME] podiatry in accordance with Chapter 35 of this title Findings include: Review of R#119's record included the following Diagnosis: [REDACTED]. Review of R#119's Minimum Data Set (MDS) with an Assessment Review date of 9/5/18 indicated in Section B for the Brief Interview for Mental Status (BIMS) showed a summary score of four which indicated cognitive impairment. Section G showed R#119 was not steady in balance during transitions and was only able to stabilize with staff assistance. Reviewing Section G also showed R#119 was in need of extensive assist of one person physical assist for bed mobility, dressing and personal hygiene. R#119 was in need of extensive assist with two person physical assist for transfers and toilet use. Review of R#119's care plan with a last reviewed date of 8/4/18 indicated The resident has an alteration in neurological status r/t (related to) shunt in head, history of going to the hospital for draining of the shunt, at risk for [MEDICAL CONDITION]. The care plan indicated The resident has impaired cognitive function/dementia or impaired thought processes r/t dementia. Review of the Nurses Note dated 8/1/18 at (6:25 p.m.) indicated per the Assistant Director of Nursing (ADON) Resident (R#119) went to Neuro appt. Returned with new orders which daughter, conveyed … | 2020-09-01 |
| 4048 | 4048 | CAMBRIDGE POST ACUTE CARE CENTER | 115771 | 2020 MCGEE ROAD | SNELLVILLE | GA | 30078 | 2018-09-27 | 677 | D | 0 | 1 | 0V3G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to provide assistance with activities of daily living (ADL's) to one resident (R #10) who required staff assistance out of three residents reviewed for ADL's. R #10 was not provided with showers. This created the potential for uncleanliness, skin breakdown and discomfort for the resident. Findings include: Interview with the Director of Nursing (DON) in the conference room on 9/27/18 at 12:23 p.m. revealed that the facility has no policy regarding activities of daily living (ADL). R #10 was admitted into the facility on [DATE]. Current [DIAGNOSES REDACTED]. Review of the 6/12/18 Admission Minimal Data Set (MDS) Section C-Cognitive Status, the resident was coded with a Brief Interview for Mental Status Score (BIMS) of 15, cognitively intact. Under Section D- the resident was coded 00, no mood issues identified. Under Section E- Behavior, the resident was coded no behaviors. The resident was not coded with rejection of care. Under Section G-Functional Status, R #10 was coded as requiring extensive assistance with bed mobility, dressing, personal hygiene, toilet use and transfers; eating required supervision and set up only; totally dependent for bathing. Under Section V- Care Area Assessment Summary-Care Planning Decisions were determined for: ADL's, urinary incontinence, activities, falls, nutritional status, fluid maintenance, pressure ulcers and [MEDICAL CONDITION] drug use. Review of the 9/10/18 Quarterly MDS Section C-Cognitive Status, R #10 was coded with a BIMS score of 11 which indicated moderately impaired cognition. Under Section E-Behavior the resident was coded with, no refusal of care. Under Section G- Functional Status- The resident was coded for extensive assistance for bed mobility, transfers, toileting. The resident coded for limited assistance for personal hygiene. The resident coded for total dependence for bathing. Review of the Care plan revised on… | 2020-09-01 |
| 4049 | 4049 | CAMBRIDGE POST ACUTE CARE CENTER | 115771 | 2020 MCGEE ROAD | SNELLVILLE | GA | 30078 | 2018-09-27 | 686 | D | 0 | 1 | 0V3G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interviews, medical record review, and facility policy review, the facility failed to provide physician ordered care and services to two residents with pressure ulcers, Residents (R) #58 and R#330. The sample size was 31. The findings include: 1.Review of R#58's record indicated the resident's [DIAGNOSES REDACTED]. Review of R#58's Minimum Data Set (MDS) with an assessment review date (ARD) of 7/27/18 indicated under Section G Activities of Daily Living (ADL) that self performance for bed mobility was total dependence two person physical assist. Transfer self performance was total dependence with two persons physical assist. Self performance for dressing was total dependence with one person physical assist. Self performance for eating was total dependence with one person assist. Review of the Brief Interview for Mental Status (BIMS) indicated the resident had long and short term memory issues. Review of R#58's Medication Review Report signed by the doctor on 9/12/18 indicated the resident had an order started 3/16/18 for applying heel protectors to both heels when resident is in bed, every shift. Review of the 9/1/18 to 9/30/18 Medication Administration Record (MAR) showed Apply heel protectors to both heels when resident is in bed, every shift. Review of the MARs for the months of 4/2018 to 8/2018 showed that the use of the heel protector was each MAR and documented for three times a day. Review of the 4/16/2018 5:47 p.m. Skin/Wound Note showed Note Text: Stage 1 to left heel: resolved. Wound base 100% intact skin, no redness. Treatment was D/C. Continue to apply heel protectors to both heel for prevention. Review of a progress note dated 8/8/18 progress note unstageable wound reopened to right heel. Review of the Skin and Wound - Wound Assessment document dated 9/16/18 indicated pressure type of wound deep tissue injury to the right heel acquired in house. This document indicated the wound was new. T… | 2020-09-01 |
| 4050 | 4050 | CAMBRIDGE POST ACUTE CARE CENTER | 115771 | 2020 MCGEE ROAD | SNELLVILLE | GA | 30078 | 2018-09-27 | 689 | D | 0 | 1 | 0V3G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interviews, and review of the facility policy, the facility failed to provide interventions for the prevention of falls for one of one residents (R) #20 reviewed for falls. Sample size was 31 residents. Findings included: Review of Resident (R) #20's clinical record revealed an admission date of [DATE] and the [DIAGNOSES REDACTED]. Review of R#20's quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of eight, indicating moderately impaired cognition. The resident required supervision with bed mobility, transfers, locomotion and eating. The MDS indicated the resident required limited assistance with walking and personal hygiene and required extensive assistance with dressing and toilet use. The resident was not steady and only able to stabilize with staff assistance when moving from a seated to standing position, walking, and turning around. The resident was not steady but able to stabilize without staff assistance with moving on and off the toilet and surface to surface transfers. The MDS indicated the resident utilized a walker and wheelchair, had one non-injury fall since the previous assessment, and utilized a chair alarm daily. Review of R#20's care plan for falls and activities of daily living, dated 7/10/18 listed the interventions: requires limited assistance of one staff for transfers and turning and repositioning in bed; educate the resident to call for assistance prior to transferring; determine and address causative factors of the fall; pharmacy consult to evaluate medications; provide activities that promote exercise and strength building where possible; physical therapy consult for strength and mobility; wheel chair alarm for safety and check the alarm for placement and position every shift. Review of R#20's Nurses' Notes and care plan revealed the following four falls: 3/14/18 timed 11:11 a.m. - the resident's roommate came and report… | 2020-09-01 |
| 4051 | 4051 | CAMBRIDGE POST ACUTE CARE CENTER | 115771 | 2020 MCGEE ROAD | SNELLVILLE | GA | 30078 | 2018-09-27 | 692 | D | 0 | 1 | 0V3G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interviews, and review of policy, the facility failed to provide interventions as planned for one of eight residents (R#98) reviewed for nutrition. The sample size was 31 residents. Findings include: Review of Resident (R) #98's clinical record revealed the admission date of [DATE] and the [DIAGNOSES REDACTED]. The Care Area Assessment (CAA) for nutrition dated 4/9/18 revealed the resident had shown actual weight gain with the potential for altered nutrition related to therapeutic diet due to [DIAGNOSES REDACTED]. Review of R#98's quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had short and long term memory problems and displayed verbal behaviors one to three days of the last seven days. The MDS revealed the resident required extensive assistance of one person for bed mobility, dressing, toilet use and personal hygiene. The resident required extensive assistance of two people for transfers and required limited assistance with eating. The MDS revealed R#98 had weight loss and was not on a physician prescribed weight loss regimen. The resident received a mechanically altered diet and did not receive diuretics. Review of the clinical record revealed R#98 was in the hospital for mood and behaviors from 5/16/18 to 5/31/18. Review of the facility document titled Weight List revealed the following weights: 4/2/18 - 156.6 pounds (#) 4/16/18 - 154.2 # 5/1/18 - 151.4 # 5/9/18 - 149.2 # 6/1/18 - 139.8 # 6/2/18 - 139 # 7/1/18 - 127.2 # 7/3/18 - 129.1 # 7/9/18 - 123.4 # 7/16/18 - 123.6 # 7/24/18 - 121.3 # 8/1/18 - 120 # 9/3/18 - 123.6 # Consisting of a 33 pound or 21 percent weight loss five months. Review of the Physicians Orders listed the orders: 2/18/17 to 5/31/18 - magic cup one time a day 5/31/18 - regular mechanical soft diet 6/6/18 - fortified foods and weekly weights times four 6/6/18 to 7/25/18 - sugar free Health shake two times a day 7/11/18 - red napkin program and restart weekl… | 2020-09-01 |
| 4052 | 4052 | CAMBRIDGE POST ACUTE CARE CENTER | 115771 | 2020 MCGEE ROAD | SNELLVILLE | GA | 30078 | 2018-09-27 | 698 | D | 0 | 1 | 0V3G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain communication with a [MEDICAL TREATMENT] center to coordinate care for one Resident (R) #328 of two residents reviewed for [MEDICAL TREATMENT]. The sample size was 31. The findings include: Review of the medical record for R#328 revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. No mood or behaviors were noted. R #328 was assessed to requires limited assistance of two people for bed mobility, transfers, and toileting. The resident was assessed for having occasional mild pain and receiving scheduled and as needed pain medication. Resident was documented no for receiving [MEDICAL TREATMENT] while a resident and not a resident. Review of the physician orders [REDACTED]. - [MEDICAL TREATMENT] on Tuesday, Thursday, and Saturday, with a chair time of 9:15 a.m. - Renal, carbohydrate-controlled diet, regular texture, thin liquids consistency. - Remove pressure dressing from site four hours after returning from [MEDICAL TREATMENT]. - Check graft for positive bruit and thrill every shift. - No blood pressure (B/P) or blood sticks to left arm (graft site). Review of the admission care plan revealed a problem identified with the need for [MEDICAL TREATMENT]. Interventions included: - Check and change dressing daily at access site and document. - Check for bruit and thrill as ordered and per facility protocol. - Do not draw blood or take B/P in left arm with graft. - Monitor for dry skin and apply lotion as needed. - Monitor /document/report to doctor (MD) as needed any signs/symptoms of infection to access site, redness, swelling, warmth or drainage. - Obtain vital signs and weight per protocol. Report significant changes in pulse, respiration and B/P immediatel… | 2020-09-01 |
| 5270 | 5270 | CAMBRIDGE POST ACUTE CARE CENTER | 115771 | 2020 MCGEE ROAD | SNELLVILLE | GA | 30078 | 2015-05-15 | 242 | D | 0 | 1 | PB4N11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, family interview, resident interview, and staff interview, the facility failed to ensure that food dislikes were observed for one (1) resident (R) from the survey sample of thirty-two (32) residents. Findings include: Record review for Resident R revealed a Quarterly Minimum Data Set (MDS) assessment having an Assessment Reference Date of 02/15/2015 which documented diagnoses, in Section I - Active Diagnoses, including, but not limited to, [MEDICAL CONDITION], Heart Failure, Hypertension, and Diabetes Mellitus. Section C - Cognitive Patterns of this MDS documented Resident R to have a Brief Interview for Mental Status Summary Score of 13, thus indicating the resident was cognitively intact. Review of Resident R's current physician's orders [REDACTED]. During interview with Resident R conducted on 05/12/2015 at 9:27 a.m., the resident stated that there were quite a few foods he/she could not eat either because the stomach just won't accept them, or because of allergy. Resident R stated that despite giving a list of these foods to the kitchen staff, he/she continued to receive foods that were on this food list. The resident added that he/she usually ate a protein bar provided by the family at lunch, and a peanut butter and jelly sandwich at supper, as he/she could not eat heavy foods at night. During an interview with a family member of Resident R conducted on 05/12/2015 at 9:46 a.m., the family member stated that the only persistent concern the family had about the resident's care was related to the food. Upon further interview, the family member stated that more than once, he/she had provided a list to the facility of foods Resident R could not eat, but the resident continued to receive some of these foods. The family member further stated that at least two meal trays a day were sent back to the kitchen uneaten, and that Resident R subsisted on breakfast, a protein bar at lunch, and a peanut butter and jel… | 2018-11-01 |
| 5271 | 5271 | CAMBRIDGE POST ACUTE CARE CENTER | 115771 | 2020 MCGEE ROAD | SNELLVILLE | GA | 30078 | 2015-05-15 | 272 | D | 0 | 1 | PB4N11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility Resident Incident Log review, and staff interview, the facility failed to ensure the completion of Fall Assessments quarterly and/or after falls, per facility protocol, for two (2) residents (#43 and #134) from a survey sample of thirty-two (32) residents. Findings include: 1. Record review for Resident #43 revealed a Quarterly Minimum Data Set (MDS) assessment having an Assessment Reference Date of 04/06/2015 which documented an original facility admission date of [DATE]. Section I - Active [DIAGNOSES REDACTED].#43 had [DIAGNOSES REDACTED]. Section J - Health Conditions documented that Resident #43 had experienced two or more falls since admission. Additional review of the medical record of Resident #43 revealed a previous Quarterly MDS assessment and preceding Annual MDS assessment having Assessment Reference Dates of 11/23/2014 and 08/25/2014, respectively, which also documented the resident to have experienced two or more falls since admission. Additionally, a Significant Change MDS assessment was completed for Resident #43 on 01/10/2015. Review of the Fall Risk Assessments for Resident #43 revealed that Fall Risk Assessments had been completed on 02/26/2014, 05/21/2014, and 08/2014; however, there was no evidence of any Fall Risk Assessment having been completed for Resident #43 since the (MONTH) 2014 Fall Assessment referenced above. During an interview conducted on 05/15/2015 at 11:00 a.m. with the Assistant Director of Nursing (ADON), the ADON stated that resident Fall Risk Assessments were to be completed upon facility admission, quarterly, and after a fall. As indicated above, MDS assessments had been completed for Resident #43 on 11/23/2014, 01/10/2015, and 04/06/2014. In addition, the Care Plan of Resident #43 documented an actual fall from the bed on 04/12/2015 (with an updated Intervention indicating the addition of a floor mat). However, even though MDS assessments had been completed fo… | 2018-11-01 |
| 5272 | 5272 | CAMBRIDGE POST ACUTE CARE CENTER | 115771 | 2020 MCGEE ROAD | SNELLVILLE | GA | 30078 | 2015-05-15 | 329 | D | 0 | 1 | PB4N11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, consultant pharmacist's Consultation Report review, and staff interview, the facility failed to ensure that the drug regimen was free from an unnecessary drug, related to excessive dose, for one (1) resident (#96), for whom the facility failed to decrease the nightly Trazadone dose as indicated by the physician via a Consultant Pharmacist report, from a survey sample of thirty-two (32) residents. Findings include: Record review for Resident #96 revealed a Quarterly Minimum Data Set (MDS) assessment having an Assessment Reference Date of 04/27/2015 which documented in Section I - Active [DIAGNOSES REDACTED]. Review of the current (MONTH) (YEAR) physician's orders [REDACTED]. Review of the consultant pharmacist's Consultation Report having a Recommendation Date of 03/31/2015 for Resident #96 documenting the resident's order for Trazadone 50 mg at bedtime since (MONTH) of 2014 (referenced above), and requesting that the physician consider decreasing the resident's Trazadone dose to 25 mgs at bedtime. A notation on this Consultation Report form, signed by the physician and dated 04/12/2015, indicated the physician accepted this recommendation and instructed the facility to implement the pharmacy recommendation as written. However, further review of the clinical record of Resident #96 revealed no evidence of a subsequent physician's orders [REDACTED]. Report referenced above, specifying to decrease the Trazadone dose from 50 mgs to 25 mgs at bedtime. Additionally, review of the (MONTH) and (MONTH) (YEAR) Medication Administration Records for Resident #96 revealed documentation indicating that the resident continued to received a dose of Trazadone 50 mgs every evening from 04/12/2014 (the date of the physician's notation on the Consultation Report referenced above instructing the Trazadone dose be decreased to 25 mgs every evening) through 05/12/2015 (a total of 31 days). During an interview with the Assistant Director of Nu… | 2018-11-01 |
| 5273 | 5273 | CAMBRIDGE POST ACUTE CARE CENTER | 115771 | 2020 MCGEE ROAD | SNELLVILLE | GA | 30078 | 2015-05-15 | 353 | E | 0 | 1 | PB4N11 | Based on observation, record review, and staff interview, the facility failed to ensure a sufficient number of staff to assist dependent residents with eating during two (2) of two (2) dining observations done on three (3) of four (4) halls and in the dining room. Forty-five (45) residents were dependent on staff for eating on the A, B, and C halls. Findings include: During dining observations conducted on 05/11/2015 beginning at 12:30 p.m., it was noted that there was one Certified Nursing Assistant (CNA) to distribute all lunch trays and feed the three (3) dependent residents eating on the C-hall. Continued observation revealed that two (2) carts with meal trays were delivered from the kitchen and the last tray was distributed at 12:55 p.m. CNA MM was observed to feed the first resident in Room C-12 beginning at 1:16 p.m., then left to feed another resident in Room C-18 when the first resident was refusing to eat. Continued observation revealed the CNA then went back to attempt to feed the resident in Room C-12, once he/she was finished in Room C-18. Further observations revealed that the last resident to be fed was in Room C-9, and he/she was not fed until 1:29 p.m., when a second CNA NN came to assist CNA MM. During a second dining observation done on 05/12/15 during supper on the A-hall beginning at 5:30 p.m., thirteen (13) residents were observed to eat in their rooms. Further observation revealed there was only one (1) staff member to distribute the trays, and there were five (5) dependent residents that needed to be fed. A second staff member was available to feed residents after the trays had been delivered, and the dependent residents were fed at the following times: - A resident in Room A-8 was fed at 5:37 p.m., and her roommate, who was observed to be alert, was not fed until 5:50 p.m. - A resident in Room A-11 was fed at 5:40 p.m. - A resident in Room A-7 was fed at 5:53 p.m. A third staff member was then observed to assist, and fed a resident in Room A-13 at 5:59 p.m. Review of a Complaint/Grievance… | 2018-11-01 |
| 5274 | 5274 | CAMBRIDGE POST ACUTE CARE CENTER | 115771 | 2020 MCGEE ROAD | SNELLVILLE | GA | 30078 | 2015-05-15 | 428 | D | 0 | 1 | PB4N11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, consultant pharmacist's Consultation Report review, consultant pharmacist interview, and facility staff interview, the facility failed to ensure that a Gradual Dose Reduction recommendation by the consultant pharmacist regarding the drug Trazadone was acted upon for one (1) resident (#96) from a survey sample of thirty-two (32) residents. Findings include: Record review for Resident #96 revealed a Quarterly Minimum Data Set assessment of 04/27/2015 which documented diagnoses, in Section I - Active Diagnoses, that included, but were not limited to, Hypertension, Diabetes Mellitus, History of Cerebrovascular Accident, and [DIAGNOSES REDACTED]/Hemiparesis. Resident #96's (MONTH) (YEAR) physician's orders [REDACTED]. A consultant pharmacist's Consultation Report for Resident #96 dated 03/31/2015 requested that the physician consider a Gradual Dose Reduction for Trazadone and decrease the Trazadone dose to 25 mgs at bedtime. The physician then signed this Consultation Report form on 04/12/2015, noting acceptance and instructing implementation of this recommendation. However, further review of Resident #96's record revealed no evidence of any action taken by the facility related to the physician's 04/12/2015 instructions, via the Consultation Report referenced above, to decrease the Trazadone dose to 25 mgs, and the resident's (MONTH) and (MONTH) (YEAR) Medication Administration Records documented the resident continued to received Trazadone 50 mgs every evening from 04/12/2014 through 05/12/2015 (31 days). During an interview with the Consultant Pharmacist conducted on 05/13/2015 at 2:15 p.m., the consultant pharmacist acknowledged that he/she had recommended a dose reduction of Resident #96's evening Trazadone dose from 50 mgs to 25 mgs on 03/31/2015. The Consultant Pharmacist stated that as he/she was recently looking through the resident's orders, he/she notice that the dose reduction was signed by the attending physicia… | 2018-11-01 |
| 6034 | 6034 | CAMBRIDGE POST ACUTE CARE CENTER | 115771 | 2020 MCGEE ROAD | SNELLVILLE | GA | 30078 | 2015-05-07 | 282 | G | 1 | 0 | DR3Q11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, EMS Call Sheet Detail Form review, hospital history and physical examination [REDACTED]#8), and failed to administer pressure sore treatment as ordered by the physician as specified by the Care Plan of one (1) resident (#3). The abbreviated survey sample was nine (9) residents. Resident #8 sustained harm, as the resident was found with a laceration around the left temple area requiring hospital transfer and stapling, and was diagnosed with [REDACTED]. Findings include: 1. Resident #8's Annual Minimum Data Set (MDS) assessment of 03/24/2015 documented diagnoses, in Section I - Active Diagnoses, including, but not limited to, Arthritis and [MEDICAL CONDITION]. Section G - Functional Status documented Functional Limitation in Range of Motion (ROM) and that the resident required two (2)-plus persons for transfer. The Care Plan of Resident #8 identified as a Focus area that the resident had an Activities of Daily Living self-care performance deficit related to reasons which included, but were not limited to, limited ROM and limited mobility. This Care Plan identified as an Intervention to address Resident #8's self-care performance deficit that the resident required mechanical lift transfers with the assistance of two (2)-plus staff. A 04/13/2015, 3:34 p.m. Progress Notes entry documented that at 9:45 a.m., Certified Nursing Assistant (CNA) CC and Licensed Practical Nurse (LPN) AA transferred the resident to bed by Hoyer lift and observed blood in the resident's hair and an approximate 3 centimeter (cm) laceration to the left side of the head. Emergency Medical Services (EMS) was called, per physician's orders [REDACTED]. During a 04/22/2015, 1:25 p.m. interview, LPN AA stated that Resident #8 had been in the dining room on 04/13/2015 at 6:30 a.m., and that after breakfast, LPN AA and CNA CC transferred the resident via Hoyer Lift to bed, at which time the CNA notified him/her of blood on the back of R… | 2018-05-01 |
| 6035 | 6035 | CAMBRIDGE POST ACUTE CARE CENTER | 115771 | 2020 MCGEE ROAD | SNELLVILLE | GA | 30078 | 2015-05-07 | 314 | D | 1 | 0 | DR3Q11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, and staff interview, the facility failed to ensure pressure sore treatment in conformance with a physician's orders [REDACTED].#3). The abbreviated survey sample was nine (9) residents. Findings include: Record review for Resident #3 revealed an Annual MDS assessment having an Assessment Reference Date of 04/21/2015 which documented an original admission date of [DATE]. Section I - Active [DIAGNOSES REDACTED].#3 had [DIAGNOSES REDACTED]. Section G - Functional Status of this MDS documented that Resident #3 either required the extensive assistance of staff, or was totally dependent on staff, for all Activities of Daily Living, and Section M - Skin Conditions documented the resident had existing pressure sores at the time of assessment. In addition to the [DIAGNOSES REDACTED]. Record form documented [DIAGNOSES REDACTED]. Review of the Clinical Care Plan Detail form for Resident #3 revealed the form to document pressure sore development on the resident's right great toe (Stage I); left outer ankle (Suspected Deep Tissue Injury, or SDTI); right inner ankle (SDTI); and right outer ankle (SDTI), with each having an onset date of 04/19/2015. The current physician's orders [REDACTED]. as needed. However, even though the physician's orders [REDACTED].#3 specified a pressure sore dressing which included the application of a foam dressing to the resident's left medial ankle, Resident #3 was observed on 04/22/2015 at 11:40 a.m. with no dressing on the left ankle pressure sore. During an interview with Licensed Practical Nurse (LPN) ZZ conducted on 04/22/2015 at 11:40 a.m., at the time of the observation referenced above, LPN ZZ acknowledged the absence of a dressing on the left ankle pressure sore of Resident #3. During a subsequent interview with Certified Nursing Assistant (CNA) UU conducted on 04/22/2015 at 11:50 a.m., CNA UU also acknowledged the absence of a dressing on the resident's left ankle when the… | 2018-05-01 |
| 6036 | 6036 | CAMBRIDGE POST ACUTE CARE CENTER | 115771 | 2020 MCGEE ROAD | SNELLVILLE | GA | 30078 | 2015-05-07 | 323 | G | 1 | 0 | DR3Q11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, facility Mechanical Lift Policy review, EMS Call Sheet Detail Form review, hospital Patient Information Form review, hospital history and physical examination [REDACTED]#8). The total abbreviated survey sample was nine (9) residents. Resident #8 sustained harm, as the resident was found to have a laceration around the left temple area requiring hospital transfer and stapling, and was diagnosed with [REDACTED]. Findings include: Review of the facility's Mechanical Lift Policy revealed the Policy to specify that for resident safety, two (2) or more personnel must be in attendance when a mechanical lift was used. Record review for Resident #8 revealed an Annual Minimum Data Set (MDS) assessment having an Assessment Reference Date of 03/24/2015 which documented diagnoses, in Section I - Active Diagnoses, which included, but were not limited to, Arthritis and Alzheimer's disease. Section C - Cognitive Patterns of this MDS documented that Resident #8 had a Brief Interview for Mental Status (BIMS) Summary Score of 99, thus indicating the resident to be unable to complete the BIMS interview. Section G - Functional Status documented that Resident #8 had a Functional Limitation in Range of Motion, with impairment on both sides in the upper and lower extremities, and that the resident required the extensive assistance of two (2)-plus persons for transfer. A Progress Notes entry of 04/13/2015, timed at 3:34 p.m. and titled as a Nurse's Note, for Resident #8 documented the following: At 9:45 a.m., Certified Nursing Assistant (CNA) CC was preparing to use a Hoyer lift to place Resident #8 back to bed after breakfast and asked Licensed Practical Nurse (LPN) AA to assist with the transfer. Resident #8 was already in the dining room when LPN AA and CNA CC arrived earlier that morning. Resident #8 was guided into the proper position after the Hoyer lift was in the proper place over the bed, the resident was lowered… | 2018-05-01 |
| 6037 | 6037 | CAMBRIDGE POST ACUTE CARE CENTER | 115771 | 2020 MCGEE ROAD | SNELLVILLE | GA | 30078 | 2015-05-07 | 498 | G | 1 | 0 | DR3Q11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility Mechanical Lift Policy review, EMS Call Sheet Detail Form review, hospital history and physical examination [REDACTED]#8), who required mechanical lift transfer. The abbreviated survey sample was nine (9) residents. Resident #8 sustained harm, as the resident was found to have a laceration around the left temple area requiring hospital transfer and stapling, and was diagnosed with [REDACTED]. Findings include: Record review for Resident #8 revealed the Annual Minimum Data Set (MDS) assessment of 03/24/2015 documented, in Section I - Active Diagnoses, the resident to have [DIAGNOSES REDACTED]. Section G - Functional Status documented that Resident #8 had Functional Limitation in Range of Motion and impairment on both sides in the upper/lower extremities required extensive assistance of two (2) - plus persons for transfer. A Progress Notes entry of 04/13/2015 at 3:34 p.m. for Resident #8 documented that at 9:45 a.m., Certified Nursing Assistant (CNA) CC requested that Licensed Practical Nurse (LPN) AA assist in a Hoyer lift transfer of Resident #8 to bed. Resident #8 was lifted to the bed via Hoyer lift and lowered to bed. LPN AA and CNA CC then observed Resident #8 to have blood in the hair, and to have an approximate three (3) centimeter (cm) laceration to the left side of the back of the head. The Assistant Director of Nursing (ADON) was notified, the physician was contacted and ordered Resident #8's hospital transfer, and Emergency Medical Services (EMS) was called. The EMS Call Sheet Detail form of 4/13/2015 documented that EMS staff responded to the facility to transport Resident #8 who had a laceration to the left side of the head. EMS staff were informed by facility staff that they observed blood on Resident #8 around breakfast, and that the resident might have been mistakenly hit in the head the previous shift. The Special Comments section of this EMS Call Sheet Detail form included that Reside… | 2018-05-01 |
| 6674 | 6674 | CAMBRIDGE POST ACUTE CARE CENTER | 115771 | 2020 MCGEE ROAD | SNELLVILLE | GA | 30078 | 2014-03-20 | 309 | D | 0 | 1 | V2L711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, hospital Physician's Orders document review, hospital Transfer Report To Post Acute Care form review, and staff interview, the facility failed to ensure that care was provided to one (1) resident (#108), in accordance with a physician's order specifying bruit monitoring related to [MEDICAL TREATMENT], on the total survey sample of thirty-four (34) residents. Findings include: Record review for Resident #108 revealed the Annual Minimum Data Set (MDS) assessment, with an Assessment Reference Date of 10/21/2013, documented in Section I - Active [DIAGNOSES REDACTED]. Section O - Special Treatments and Programs of this MDS documented that Resident #108 received [MEDICAL TREATMENT]. Observation of Resident #108 conducted on 03/19/2014 at 8:00 a.m. revealed the resident to be seated in a wheelchair, and a [MEDICAL TREATMENT] venous fistula was observed in the resident's left arm. Further record review for Resident #108 revealed a physician's order, originally dating from 03/20/2012, which specified that nursing staff check the bruit on the resident's left arm every shift. Review of Resident #108's August 2013 Medication Administration Record [REDACTED]. However, further review of this August 2013 MAR indicated [REDACTED]. Additionally, review of Resident #108's September 2013 MAR indicated [REDACTED]. Review of a hospital Physician's Orders form for Resident #108 revealed that the resident was transferred and admitted to the hospital on [DATE], and a hospital physician's order dated 01/21/2014 specified to discharge the resident back to the nursing facility on that date. Review of the hospital transfer documents revealed a Transfer Report To Post Acute Care form dated 01/21/2014 for Resident #108 which documented that the resident had End Stage [MEDICAL CONDITION], however, further review of the 01/21/2014 hospital transfer documents for Resident #108 revealed no evidence of a physician's order to monito… | 2017-11-01 |
| 6675 | 6675 | CAMBRIDGE POST ACUTE CARE CENTER | 115771 | 2020 MCGEE ROAD | SNELLVILLE | GA | 30078 | 2014-03-20 | 441 | D | 0 | 1 | V2L711 | Based on observation and staff interview, the facility failed to ensure that staff changed gloves between resident contact to prevent possible cross contamination during meal service on one (1) hall (Hall B) of four (4) facility halls. Findings include: Observation on 03/19/2014 at 7:35 a.m. revealed one (1) certified nursing assistant (CNA) to enter room B-16 with a breakfast tray for the resident in bed B. With gloved hands, the CNA cleared off the overbed table and set up the breakfast tray for the resident. The CNA left the room and without changing gloves, picked up another meal tray from the covered tray cart and again returned to room B-16, to bed A. The CNA then exited the room with two (2) empty coffee mugs in her left hand, and while still wearing the same soiled gloves, went down the hall and into a room, came out wearing a glove on only the left hand but with both coffee mugs filled, and returned to room B-16. The CNA was observed to give each resident in Room B-16 a coffee cup, and at that time, she removed the glove on her left hand and washed her hands. During an interview with the Director of Nursing (DON) conducted on 03/20/2014 at 10:55 a.m., the DON stated that she expected staff to apply gloves to take a tray to a resident, but then to remove the gloves before leaving the room, and to put on new gloves to bring another resident's tray. | 2017-11-01 |
| 7959 | 7959 | NEW LONDON HEALTH CENTER | 115771 | 2020 MCGEE ROAD | SNELLVILLE | GA | 30078 | 2012-06-21 | 278 | D | 0 | 1 | 866711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to conduct assessments which accurately reflected the condition of the resident for (1) resident (# 147) from a sample of forty-three (43). Findings include: Resident #147 was admitted to the facility in December 2010 with multiple diagnosis' including but not all inclusive, of [MEDICAL CONDITION], dysphasia, [MEDICAL CONDITION], Alzheimer's, Gastro-esphogeal reflux disease, abnormal blood sugar and obesity. The resident had a physician's orders [REDACTED]. A speech therapy assessment, at the time of admission, identified the need for aspiration precautions secondary to food pocketing and swallowing issues. Record review of the Nutritional assessment dated [DATE] revealed the need for an altered mechanically diet, small portions to encourage weight reduction and to be fed by staff. Record review of Nurses Notes dated 12/28/11 contained documentation that the resident was totally dependent for all care and pockets food at intervals. A note dated 01/16/12 at 4:30 p.m. noted the resident required suctioned for holding fluids in the mouth. Review of the Minimum Data Set (MDS) annual assessment, dated 11/14/11 and the Quarterly MDS Assessments, dated 02/13/12 and 5/26/12 documented incorrectly that the resident had no swallowing disorders. | 2016-09-01 |
| 7960 | 7960 | NEW LONDON HEALTH CENTER | 115771 | 2020 MCGEE ROAD | SNELLVILLE | GA | 30078 | 2012-06-21 | 279 | D | 0 | 1 | 866711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to develop a comprehensive care plan for a resident who had a history of [REDACTED].#3, from a sample of forty-three (43) residents. Findings include: Review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed resident #3 was assessed at risk for falls related to a history of falls and a fracture prior to admission. Review of the Comprehensive Care Plan based on the initial assessment revealed the Care Plan did not address the fall risk, or any interventions to prevent further falls. The Care Plan Coordinator was interviewed on 6/20/12 at 10:30 a.m. and stated the Care Plan did not address the resident's fall risk. | 2016-09-01 |
| 7961 | 7961 | NEW LONDON HEALTH CENTER | 115771 | 2020 MCGEE ROAD | SNELLVILLE | GA | 30078 | 2012-06-21 | 282 | D | 0 | 1 | 866711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon staff interview and record review the facility failed to follow the care plan to notify the physician of significant weight loss for one (1) resident (#147) of forty-three (43) sampled residents. Findings include: Resident #147 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Record review of the resident's weight for 12/2011 was 208 pounds (lbs), 1/2012 was 205 lbs, 2/12 was 189 lbs. Review of Dietary Progress Note dated 2/20/12 revealed the February weight was obtained 2/04/12. The resident had lost 16 pounds between January and February, which was equal to a 7.8 percent (%) weight loss in one month. Record review of the resident's care plan revealed the resident's nutritional status was assessed at risk. An intervention dated 01/04/12 revealed the physician was to be notified of any significant weight loss. Record review of the twenty four (24) hour report for 2/19/12 revealed the resident was placed on the doctor's list to be seen for loss of appetite. A Physician's Progress Note revealed the resident was seen on 02/20/12. Cross to F325 | 2016-09-01 |
| 7962 | 7962 | NEW LONDON HEALTH CENTER | 115771 | 2020 MCGEE ROAD | SNELLVILLE | GA | 30078 | 2012-06-21 | 312 | D | 0 | 1 | 866711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview and staff interview the facility failed to provide routine cleaning of dentures for one (1) resident, A, from a sample of forty-three (43) residents. Findings include: Record review for resident A revealed that he/she had an activities of daily living (ADL) Self Care Performance Deficit related to [MEDICAL CONDITION], paralysis agitans, muscle weakness, difficulty in walking, and left wrist drop(radial nerve palsy). During an interview with resident A on 6/19/12 at 10:15 a.m. the resident stated that his/her dentures were seldom cleaned by staff members. The resident stated that he/she was not able to clean the dentures independently because of his/her health condition. On 6/19/12 at 3:00 p.m. interviews with Certified Nursing Assistants (CNAs) HH and II revealed that residents' dentures are cleaned after every meal. However, an interview with the facility's Director of Nursing (DON) at that time revealed that there was no evidence of documentation confirming that the residents' dentures were cleaned. | 2016-09-01 |
| 7963 | 7963 | NEW LONDON HEALTH CENTER | 115771 | 2020 MCGEE ROAD | SNELLVILLE | GA | 30078 | 2012-06-21 | 323 | D | 0 | 1 | 866711 | Based on record review and staff interview the facility failed to ensure a resident with a history of falls did not sustain additional falls. This affected one (1) resident, #3, from a sample of forty-three (43) residents. Findings include: Record review for resident #3 revealed that she had been admitted to the facility after experiencing a fall at home which resulted in a fractured hip. Further record review revealed the resident's care plan did not address interventions related to her fall risk. Further record review revealed the resident fell out of her wheelchair in the lobby of the facility on 6/19/12 with no injuries resulting. This information was confirmed in an interview with the facility's Care Plan Coordinator in an interview on 6/20/12 at 10:30 a.m. | 2016-09-01 |
| 7964 | 7964 | NEW LONDON HEALTH CENTER | 115771 | 2020 MCGEE ROAD | SNELLVILLE | GA | 30078 | 2012-06-21 | 441 | E | 0 | 1 | 866711 | Based on observation and staff interview the facility failed to ensure that proper infection control practices were in place to prevent cross contamination for residents receiving nebulizer treatments. This affected one (1) resident, #15, from a sample of forty-three (43) residents. The facility also failed to ensure hygienic practices were in place during residents' dining programs. Findings include: Observation on 6/19/12 at 4:29 p.m. revealed resident #15 had a nebulizer with attached face mask sitting on top of the bed side cabinet. The nebulizer and mask were not being stored in a plastic bag. There was no protective barrier between the cabinet and the nebulizer and mask. At 4:30 p.m. the resident received a respiratory treatment using the nebulizer and mask. Following the treatment at 4:40 p.m. the nebulizer and mask were observed once again sitting uncovered on top of the bed side cabinet. Observation on 6/20/12 at 9:54 a.m. revealed a nebulizer and mask sitting uncovered on the bed side cabinet for resident #15. A respiratory treatment was given at 10:00 am using the nebulizer and mask. At 10:10 a.m. the nebulizer and mask were again observed sitting on top of bed side cabinet uncovered and with no barrier between the cabinet and the mask and nebulizer. The Director of Nursing (DON) was interviewed on 6/21/12 at 11:16 a.m. and stated nebulizers and other respiratory equipment should be covered when not in use. She further stated that after each use respiratory equipment should be cleaned and placed back into a protective bag. During dining observations on 6/18/12 at 12:10 p.m. on Hall D staff members assisting residents with dining were observed picking up beverage glasses by the rims and having their fingers touching the inside of glassware. Staff members were also observed touching residents, readjusting residents' clothes, cutting up residents' food, and leaving the dining room area to carry trays to another residents on the D hall. The staff members were not wearing gloves and had not been observed wa… | 2016-09-01 |
| 8828 | 8828 | NEW LONDON HEALTH CENTER | 115771 | 2020 MCGEE ROAD | SNELLVILLE | GA | 30078 | 2015-07-21 | 225 | D | 1 | 0 | N1NR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, family interview and staff interview, the facility failed to investigate an allegation of neglect of a medication overdose for one (1) resident (C) from a total sample of seven (7) residents. Findings include: Record review revealed that resident (C) was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The [AGE] year old resident was sent to the emergency roiagnom on [DATE], with difficulty breathing and [MEDICAL CONDITION]. The resident was admitted to the hospital, had a chest x-ray and was diagnosed with [REDACTED]. Review of the resident's nursing home medications did not reveal any orders for [MEDICATION NAME], opiates, or narcotics and this information was given to the emergency roiagnom on [DATE], by the nursing home nursing staff. An interview with the complainant/family member on 7/21/15, at 9:30 AM states that she/he went to the nursing home on 6/08/2015, and told the Administrator that she was informed by the physician in the emergency room that the resident was found to have an overdose of [MEDICATION NAME] and opiates in an urinalysis on 6/08/2015 in the emergency room and she/he wanted to know how this could happen. The complainant/family member informed this Surveyor during the interview of 7/21/15, that the administrator said that he would investigate this allegation and would get back with her/him. The complainant/family member stated that as of 7/21/15, they had never received any information regarding the allegation of overdose of narcotics from the Administrator. During the investigation of 7/21/15, the Administrator stated during an interview at 2:10 PM, with this Surveyor that the Administrator and Director of Nursing during that time on 6/08/2015, were no long employed at the facility and he was now the new Administrator. The Administrator informed this Surveyor during the interview on 7/21/15, that he was aware of the allegation of the narcotic overdose in the emergency room but di… | 2015-10-01 |
| 9338 | 9338 | NEW LONDON HEALTH CENTER | 115771 | 2020 MCGEE ROAD | SNELLVILLE | GA | 30078 | 2012-07-16 | 314 | D | 1 | 0 | MD2J11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure timely assessment and identification of pressure ulcers for one (1) resident (#2) from a survey sample of four (4) residents. Findings include: Review of the medical record for Resident #2 revealed an Initial and Weekly Pressure Ulcer Health Record, with an Effective Date of 02/07/2012, which documented that the resident had [DIAGNOSES REDACTED]. This Ulcer Health Record documented that the resident had a Stage III upper scrotal pressure ulcer measuring 2.0 centimeters (cms.) by 0.6. cm. with an actual Date of Onset of 02/06/2012. An Initial and Weekly Pressure Ulcer Health Record with an Effective Date of 03/11/2012, timed at 12:35, documented a Stage III scrotal pressure ulcer measuring 2.0 cms. by 3.8 cms. by 0.3 cm. An Initial and Weekly Pressure Ulcer Healing Record of 03/11/2012, timed at 14:13, documented a Stage III upper scrotal pressure ulcer measuring 0.7 cm. by 1.5 cms. by 0.3 cm., and an Initial and Weekly Pressure Ulcer Health Record of 03/11/2012, timed at 14:14, documented a lower scrotal Stage III pressure ulcer measuring 0.7 cm. by 3.5 cms. by 0.3 cm. These Ulcer Health Records all documented the Date of Onset of these pressure ulcers as being 02/06/2012, and that the wounds were to be cleaned with Santyl as ordered. However, further record review revealed no evidence to indicate that these pressure sores had been identified, to ensure timely treatment, prior to being identified as Stage III wounds on 02/06/2012. During an interview with the Director of Nursing conducted on 05/16/2012 at 4:45 p.m., the Director of Nursing acknowledged that Resident #2 should have been assessed and that the pressure sores referenced above should have been identified prior to their becoming Stage III wounds. | 2015-08-01 |
| 9464 | 9464 | NEW LONDON HEALTH CENTER | 115771 | 2020 MCGEE ROAD | SNELLVILLE | GA | 30078 | 2011-01-07 | 166 | D | 0 | 1 | K5SV11 | Based on record review and resident, family and staff interview the facility failed to provide two (2) residents, "A" and "C" of twenty-seven (27) sampled residents with prompt resolution to grievances reported. These concerns were related to the excessive use of disposable briefs for resident "A" and the manner in which personal belongings were searched for resident "C". Findings include: Resident "C" was interviewed on 1/05/2010 at 11:00 a.m. and stated he was upset with the way Social Worker "GG" had handled a situation that resulted in his personal belongings being searched without his permission, and in the presence of his roommate. This incident occurred on 12/09/2010 in the resident's room. He further stated he spoke with Social Worker "GG" several days later about his dissatisfaction and asked that she report the incident to the Administrator. Stated so far he has not received any feedback from Administration so he considers this an unresolved issue. Review of the grievance file revealed there were no grievances recorded for 2010. Social Worker "GG" was interviewed on 1/06/2010 at 2:50 p.m. and stated she does not always document resident concerns as grievances, and she further stated she did not inform the Administrator of resident "C"s complaint. Review of the facility's policy on grievances revealed a formal procedure that included written documentation and prompt resolution within three (3) business days. During a family interview on 1/04/11 at 5:39 p.m. revealed a grievance was voiced to administrative staff regarding a concern that facility staff were using the incontinence briefs, purchased for resident "A", for other residents. The family member had spoken to the Administrator, Licensed Practical Nurse (LPN) "AA" and the Director of Nursing (DON). An interview on 1/07/11 at 8:40 a.m. with LPN "AA" revealed the resident's family member had spoken to her and she was aware of their concern. . Review of the grievance log for 2010 revealed no grievances were noted throughout the year. | 2015-07-01 |
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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 );