cms_GA
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10,655 rows sorted by facility_name descending
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 649 | 649 | ZEBULON PARK HEALTH AND REHABILITATION | 115295 | 343 PLANTATION WAY | MACON | GA | 31210 | 2018-07-19 | 582 | B | 0 | 1 | 855W11 | Based on record review and staff interview, the facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) to the resident or responsible party upon discharge from Medicare Part A services to indicate that they understood the contents of the form for two of three residents (R) reviewed (#9 and #45). Findings include: Review of a Beneficiary Notice-Residents discharged Within the Last Six Months form, provided by the facility, revealed that R #9 was discharged off Medicare Part A skilled services on 5/25/18 and remained in the facility afterwards with benefit days remaining. Further review of this form revealed that R #45 was discharged off skilled services on 6/25/18, and remained in the facility with benefit days remaining. There was no evidence provided that the SNFABN was provided to either R#9 or R#45. During interview on 7/18/18 at 3:01 p.m. with Case Manager it was reported that if she notifies the family member via telephone she does not typically send a letter. Case Manager further reported that the SNFABN is typically provided to residents who discharge to home in the event they decide to stay an extra day in the facility. However, the SNFABN has not been provided to residents remaining in the facility that were going to be long term. Case Manager confirmed that she did not provide SNFABN forms for R#9 and R#45. | 2020-09-01 |
| 650 | 650 | ZEBULON PARK HEALTH AND REHABILITATION | 115295 | 343 PLANTATION WAY | MACON | GA | 31210 | 2019-11-15 | 656 | D | 0 | 1 | GS7J11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews the facility failed to follow the care plan for two of 32 sampled residents (R) (#154 and R#28). Findings include: 1. Review of the electronic medical record (EMR) for R#154 revealed a [DIAGNOSES REDACTED]. Further review of the EMR revealed a care plan for altered nutritional status related to no free-standing water with an onset date of 11/7/19. Interview with Resident Care Coordinator (RCC) CC on 11/15/19 at 11:15 a.m. who confirmed that there were two cups of water in resident's room. RCC CC reported that there should be no cups or water in resident's room due to fluid restriction and this information is listed on resident's care plan. Observation on 11/13/19 at 8:14 a.m. revealed R#154 in bed in room with a cup of water on nightstand dated 11/12/19, 11-7. Observation on 11/14/19 at 8:20 a.m. revealed R#154 in bed in room with a cup of water noted on her over bed table. Observation on 11/15/19 at 9:25 a.m. revealed a cup of coffee 1/4 full and a full cup of water in R#154's room. Interview on 11/15/19 at 11:23 a.m. with Licensed Practical Nurse (LPN) DD who reported that she was aware that the water cup and coffee was in resident's room. LPN DD was not aware that the care plan indicated no water at the bedside. Cross Refer to F684. 2. A review of the medical record for R#28 revealed resident was admitted to the facility with [DIAGNOSES REDACTED]. Review of the care plan, revised on 9/26/19, revealed that R#28 is at fall risk related to history of falls, with a fall risk score of 12. Continued review revealed that the resident has a scoot chair, and balance concerns, along with impaired memory. Review of the Interventions include, but not limited to the following: non-skid socks/non-skid shoes; place resident in an open area for maximum observation opportunities; anticipate resident's needs; check on resident frequently; and have a fall mat on both sides of bed. Observation on 11/1… | 2020-09-01 |
| 651 | 651 | ZEBULON PARK HEALTH AND REHABILITATION | 115295 | 343 PLANTATION WAY | MACON | GA | 31210 | 2019-11-15 | 684 | D | 0 | 1 | GS7J11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews, the facility failed to follow Physician's Orders for one of five [MEDICAL TREATMENT] residents (R) (#154) with fluid restrictions. Findings include: Observation on 11/13/19 at 8:14 a.m. revealed R#154 in bed in room with a cup of water on nightstand dated 11/12/19, 11-7. Observation on 11/14/19 at 8:20 a.m. revealed R#154 in bed in room with a cup of water noted on her over bed table. Observation on 11/15/19 at 9:25 a.m. revealed a cup of coffee 1/4 full and a full cup of water in room. Review of the electronic medical record (EMR) for R#154 revealed a [DIAGNOSES REDACTED]. Further review of the EMR revealed a Precautions Order for no free water or water at bedside beginning on 11/7/19. Interview with Resident Care Coordinator (RCC) CC on 11/15/19 at 11:15 a.m. who confirmed that there were two cups of water in resident's room. RCC CC reported that there should be no cups or water in resident's room due to fluid restriction. Interview on 11/15/19 at 11:23 a.m. with Licensed Practical Nurse (LPN) DD who reported that she was aware that the water cup and coffee were in resident's room. R#154 had both a cup of coffee and a cup of water in the room. However, she instructed the CNA to move the water cup from the over bed table but not out of the room. LPN DD confirmed the order for no water at the bedside and acknowledged that she was not aware of the order for no water at bedside. | 2020-09-01 |
| 652 | 652 | ZEBULON PARK HEALTH AND REHABILITATION | 115295 | 343 PLANTATION WAY | MACON | GA | 31210 | 2019-11-15 | 880 | D | 0 | 1 | GS7J11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and review of the policy titled Routes of Drug Administration, and staff interviews, the facility failed to administer eye drops in a sanitary manner for one resident (R) (#6); failed to ensure that the urinary catheter bag and tubing were kept off the floor for one resident (#21); and failed to keep personal items off clean linen in the laundry room. Findings include: 1. A review of the policy titled Routes of Drug Administration revealed that when eye drops were administered the first step was to wash hands, the cap to the bottle was to be sat on a clean dry surface, and after eye drops were administered, the hands were to be washed again. An observation on 11/14/19 at 8:43 a.m. of Licensed Practical Nurse (LPN) AA administering eye drops to R#6 revealed that she donned gloves and didn't sanitize her hands or wash with soap/water prior to donning her gloves. She touched multiple objects with her gloves on. She sat the eye drops on a napkin that was already on the table. She took a cup that the resident handed her with her gloved hand and did not remove the gloves, sanitize, and don a clean pair of gloves. She then touched the bedside table with her gloved hands and then administered eye drops without washing her hands, sanitizing or changing gloves. The LPN confirmed that she donned gloves on entering the resident's room, touched multiple surfaces without washing her hands, sanitizing or donning clean gloves. She stated that the purpose of wearing gloves when administering eye drops was to keep the rate of infection down. An interview on 11/14/19 at 9:54 a.m. with the Director of Nursing (DON) revealed that she expected the nurses to verify and follow the physician order [REDACTED]. During a follow-up interview on 11/14/19 at 10:33 a.m. the DON confirmed that not sanitizing hands and touching other surfaces was an infection control issue. She stated that she did not know why the nurse did not sanitize or … | 2020-09-01 |
| 4309 | 4309 | ZEBULON PARK HEALTH AND REHABILITATION | 115295 | 343 PLANTATION WAY | MACON | GA | 31210 | 2016-06-17 | 156 | D | 0 | 1 | XJQ911 | Based on record review and staff interview, the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN), to allow the beneficiary to make an informed decision related to continuance of Medicare skilled services and the financial responsibility for those services if Medicare does not reimburse. This notice was not provided for three (3) of three (3) residents (#97, #110, and #224). From a sample size of thirty-three (33). The reviewed were the resident's discharged from skilled Medicare services and remained in the facility. Findings include: A review of the Liability Notices for residents #97, #110, and #224 was conducted and revealed that they were discharged from skilled Medicare services and remained in the facility. Further review revealed the only notice provided to the residents was the Notice of Medicare Non-Coverage. There was no evidence that the facility had issued an SNFABN (Centers of Medicare/Medicaid Services - CMS form ) notice to the residents, providing the opportunity to continue with skilled services, at their cost, if Medicare did not reimburse. Interview on 06/17/16 at 9:20 a. m. with the Case Manager (CM)/Discharge Planner revealed that he/she was not familiar with the CMS form . Continued interview revealed that he/she provided residents with a verbal notice of their right to appeal. The CM confirmed that no training on providing CMS form had been provided by previous CM. The CM confirmed that the three (3) residents reviewed were only provided the non-coverage form and were not provided the SNFABN form. The CM confirmed that there is no facility policy on providing the CMS form . | 2019-11-01 |
| 4310 | 4310 | ZEBULON PARK HEALTH AND REHABILITATION | 115295 | 343 PLANTATION WAY | MACON | GA | 31210 | 2016-06-17 | 157 | D | 0 | 1 | XJQ911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to notify the physician according to facility policy, Medication Administration General Guidelines for a resident who refused sliding scale insulin administration for one (1) resident (#234) of twelve (12) residents receiving sliding scale insulin. The census sample was thirty-three (33). Findings include: Review of the facility's policy and procedure for Medication Administration General Guidelines revealed the following: If a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time, the space provided on the front of the Medication Administration Record [REDACTED]. If two consecutive doses of a medication are withheld or refused, the physician should be notified. Review of the 5/28/16 admission Minimum Data Set (MDS) assessment for R#73, noted in section I the following [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Fingerstick Blood Sugar (FSBS) before meals (AC) and hour sleep (HS). Sliding Scale Humalog 100 u/milliliter (ml) Notify Medical Doctor (MD) / Nurse Practitioner (NP) if blood sugar less than 60 or greater than 400. 200-250=4 units, 251-300= 6 units, 301-350=8 units, 351-400=10 units, 401-450=12 units. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Review of the back of the (MONTH) (YEAR) MAR indicated [REDACTED].m Further review of the MAR indicated [REDACTED]. During an interview on 6/15/16 at 7:45 p.m. with (LPN), LL she stated that the resident refuses the Sliding Scale Insulin at 9:00 p.m. and stated that she usually documents the refusal on the back of the MAR. Further interview revealed that the resident refused the ordered sliding scale insulin when she attempted to administer the insulin for FSBS's 200 or greater on 6/2, 6/7, 6/10, 6/11, 6/12 and 6/14 . Continued interview with LPN LL revealed she did not notify the Medical Doctor (M.D.), or Nurse Practitioner (NP) of the resident refu… | 2019-11-01 |
| 4311 | 4311 | ZEBULON PARK HEALTH AND REHABILITATION | 115295 | 343 PLANTATION WAY | MACON | GA | 31210 | 2016-06-17 | 280 | D | 0 | 1 | XJQ911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and record review the facility failed to revise the Fall Intervention Plan (FIP) to reflect fall interventions for two (2) residents #224 and #233 from a total sample of thirty three (33) residents. Findings include: 1. Resident #224 was a ninety six (96) year old long term care resident that was admitted to the facility on [DATE] after a hospitalization for general weakness. Her [DIAGNOSES REDACTED]. Review of the Admission Minimum Date Set ((MDS) dated [DATE] revealed that the resident had a Brief Interview for Mental Status (BIMS) Score of 6 which indicates serve cognitive impairment. Continued review of the MDS revealed that the resident required extensive assistance with transfers, Activities or Daily Living (ADL) and Walking. The resident was assessed as total dependent for locomotion on and off of the unit. Review of the Fall Intervention Plan (FIP) revealed that the following interventions were initiated on 06/06/16: Low bed, call light in reach, educate how to use call light, encourage to call for assistance to toilet at first urge to void, encourage use of non-skid shoes/socks, foot wear, provide non-skid socks, hydration - fluids of choice within reach, medications - consider medication side effects, medications - review regimen and times given, and vision - keep glasses available. The following interventions were initiated on 06/07/16: Alarm, pressure sensitive on bed and fall mat at one side of bed. Review of the Comprehensive Falls Assessment revealed that nursing staff signed the form on 06/06/16 and only indicated that the resident was a new admit. Further review of the assessment form revealed the boxes that were to be checked regarding the resident risk for falls were blank. Review of the medical record revealed that an SBAR was completed on 06/13/16 due to a fall, Vital signs were obtained. The nurse ' s notes revealed that resident was heard calling for help and upon staff entering the… | 2019-11-01 |
| 4312 | 4312 | ZEBULON PARK HEALTH AND REHABILITATION | 115295 | 343 PLANTATION WAY | MACON | GA | 31210 | 2016-06-17 | 282 | D | 0 | 1 | XJQ911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow the careplan for one (1) resident (#73) recieving anticoagulant medication and one (1) resident (resident #43) receiving treatment for [REDACTED]. Findings include: 1. Review of R#73's Plan of Care dated 6/2/16 revealed a Problem Resident at risk for abnormal bleeding and may bruise easily related to anticoagulant therapy. The interventions included to give anticoagulant medications as ordered. However, review of the resident's 6/3 Physician orders [REDACTED]. Further review of the MAR indicated [REDACTED]. During an interview with the Director of Nurses (DON) on 6/17/16 at 9:30 a.m. the DON confirmed the nurses failed to follow the Plan of Care for the Problem identified to administer medication as ordered. 2. Review of resident #43 Treatment Record dated 6/3/16 revealed a pressure ulcer to the Sacrum that measured 1x0.5x0.1 centimeter . Observation on 06/15/2016 at 12:44 p.m. of dressing change of resident #43 with Registered Nurse (RN), AA revealed that she cleaned the wound with Normal Saline, placed calcium alginate over the wound bed and covered with Allevyn Foam Dressing. RN, AA verified during the observation that she cleaned the wound with Normal Saline, placed calcium alginate on the wound bed and covered Allevyn Foam Dressing. Interview also revealed that there was approximately 40 % slough covering the wound and it measured 1.0 x0.5 x 0.1 cm. RN, AA was uncertain about staging the wound. Interview on 06/15/2016 at 1:02 p.m. with Wound Care Nurse, RN, AA revealed that she thought that Calcium Alginate and collagen dressing were the same product. Interview on 06/15/2016 at 2:00 p.m. with Wound Care Nurse, RN, AA revealed that she spoke with the Wound Care Nurse who held the full-time position and after speaking with this nurse, she was able to locate the collagen dressing. She stated that she had removed the dressing that she initially applied during th… | 2019-11-01 |
| 4313 | 4313 | ZEBULON PARK HEALTH AND REHABILITATION | 115295 | 343 PLANTATION WAY | MACON | GA | 31210 | 2016-06-17 | 309 | D | 0 | 1 | XJQ911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and review of the Facilities Medication Administration Policy, the facility failed to follow the Physician order's for administration of an Anticoagulant medication for one (1) resident (#73), administration of Sliding Scale Insulin and one (1) resident (#234) a pressure wound dressing for one (1) resident (#43) from a total sample of thirty-three (33) residents. Findings include: Review of the facilities Medication Administration General Guidelines revealed the following: Medications are administered in accordance with written orders of the attending physician. 1. Review of resident #73's 5/21/16 Physician order's revealed [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. [MEDICATION NAME] 3.5 mg by mouth (po) every day. Recheck International Normalized Ratio (INR) 6/6/16. Review of the INR control sheet dated 6/3/16 revealed INR 1.2, [MEDICATION NAME] dose at time of test 3.0 mg po every day. Increase 3.5 mg. Review of the (MONTH) Medication Administration Record [REDACTED]. However review of the physician's orders [REDACTED]. During an interview with the Director of Nurses (DON) on 6/15/16 at 6:28 p.m. she confirmed the nurses failed to follow the 6/3/16 physician's orders [REDACTED].The DON revealed that the [MEDICATION NAME] 3.5 mg po should have been started on 6/3. The DON further revealed it is her expectation the nurses follow the Physician orders. 2. Review of resident #234's History and Physical dated 6/6/16 revealed [DIAGNOSES REDACTED]. Review of the (MONTH) Admission Physician orders [REDACTED].=4 units, ,251-300=6 units,301-350=8 units, 351-400 =10 units, 401- 450 =12 units. Review of the physician's orders [REDACTED].=4 units, 251-300=6 units ,301-350=8 units, 351-400 =10 units, 401- 450 =12 units. Less than 60 or greater than 400 call Medical Doctor(MD) . Humalog 100 units/milliliter (ml) Give 16 units sq three times a day before meals at 0730 a.m., 11:30 a.m., 4:30 p.m.… | 2019-11-01 |
| 4314 | 4314 | ZEBULON PARK HEALTH AND REHABILITATION | 115295 | 343 PLANTATION WAY | MACON | GA | 31210 | 2016-06-17 | 314 | D | 0 | 1 | XJQ911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview the facility failed to apply the correct treatment dressing during observation of wound care treatment for one (1) resident (#43) from a total sample of thirty-three (33) residents. Findings include: Review of Quarterly Minimum Data Sets (MDS) revealed that resident #43 had an unhealed pressure ulcer that was unstageable and one pressure area that was a stage three (3). [DIAGNOSES REDACTED]. Review of the Medical record for resident #43 revealed that the Braden Scale was done quarterly and was last done on 3/11/16 with the resident being assessed to have a Braden Score of 12, indicating that the resident was at high risk for developing a pressure ulcer. Review of the Treatment Record for resident #43 dated May, (YEAR) revealed that the sacral pressure ulcer was being staged as a stage three (3) and the wound base tissue type was granulation tissue. The treatment record documented that the sacral pressure ulcer was responding to treatment. The treatment record revealed treatment was started on 3/2/16. Review of measurements for the month of (MONTH) documented no change in size of wound. On 5/4/16 wound measured 0.5 x 0.2 x 0.1 centimeters. On 5/25/16 the wound measured 0.5 x 0.2 x 0.1 centimeters. Review of the (MONTH) 2106 physician order [REDACTED].#43 revealed a physician's orders [REDACTED]. Review of the Careplan for resident #43 revealed that the resident had a stage three (3) pressure ulcer to the sacrum. Review also revealed that the physician's wound orders were to be followed. Review of resident #43s Treatment Record dated 6/3/16 revealed a pressure ulcer to the Sacrum that measured 1 x 0.5 x 0.1 centimeter. An observation on 06/15/2016 at 7:45 a.m. revealed resident #43 was asleep in bed, lying on her back in a low bed with an air mattress and a fall mat beside the bed. Observation and interview on 06/15/2016 at 12:44 p.m. of dressing change for resident #43 with Registered Nu… | 2019-11-01 |
| 4315 | 4315 | ZEBULON PARK HEALTH AND REHABILITATION | 115295 | 343 PLANTATION WAY | MACON | GA | 31210 | 2016-06-17 | 323 | D | 0 | 1 | XJQ911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review of the facities Policy, Fall Management at a Glance the facility failed to ensure interventions were in place to prevent falls for one (1) resident (#233) from a total sample of thirty- three (33) residents. Findings include: Review of the facility Policy Fall Guidelines provided by the facility revealed: 1. Intent: The Falls program is an interdisciplinary approach to the management of patients at high risk for falls. 2. Goal: Our goal is to be proactive in our efforts to identify risk factors that reduce the frequency of falls and serious injuries. 3 .Program Process : a. Comprehensive Falls Assessment to be completed on Admission, Readmission, Quarterly, Annually and as clinically indicated. b. Falls Intervention Plan (FIP)- Based on the findings from the Comprehensive Falls Assessment , implement appropriate interventions on the FIP. c. Should a Fall occur: Event management form will be completed. Investigation and assessment of fall circumstances needs to be captured on the Event Management form. Nursing documentation will reflect the following, complete Situation, Background , Assessment, Recommendation(SBAR) if applicable: i. Circumstances of the fall to paint an accurate picture(who,what,when,where and why) will be described in the Interdisciplinary Team (IDT) note, along with head to toe nursing assessment, immediate intervention(s) initiated and documentation of the effectiveness of that intervention for seventy- two (72) hours to ensure effectiveness. ii. The nurse responsible for the patient's care at time of a fall needs to implement an immediate intervention on the FIP targeted to protect patient safety and /or serious injury. iii. Subsequent documentation for the next seventy - two (72) hours, or longer if indicated, should address: complete head to toe nursing assessment , site of injury if applicable, interventions initiated related to current fall event, effectiveness … | 2019-11-01 |
| 4316 | 4316 | ZEBULON PARK HEALTH AND REHABILITATION | 115295 | 343 PLANTATION WAY | MACON | GA | 31210 | 2016-06-17 | 371 | F | 0 | 1 | XJQ911 | Based on observation, staff interview, and record review the facility failed to ensure the meat slicer was cleaned and sanitized after usage to prevent cross contamination. This deficient practice had the potential to effect all fifty four (54) residents receiving an oral diet. Findings include: Observation on 06/16/16 at 10:30 a. m. in the kitchen, the meat slicer revealed that it was covered with a white frosted plastic bag. The plastic bag was removed from the slicer which revealed food particles, tan and brown in color on the underside of the blade. The Dietary Manager (DM) removed the top blade guard which revealed more food substance that covered the inside top of blade which was tan and brown in color. Interview on 06/16/16 at 10:30 a. m. with Dietary Manager revealed she confirmed that the meat slicer had a plastic bag covering the machine. She confirmed that when a plastic bag is placed over a piece of equipment it indicates that the equipment is clean and ready for use. The DM confirmed that there was tan and brown food particles on the top and bottom of the slicer blade. She expects staff to properly clean and wash the slicer and inspect the slicer before placing the plastic bag over the top. The DM revealed that turkey was sliced last evening and expected the cook to clean the slicer better. She revealed that she does not have a policy for kitchen cleaning and that the cleaning schedule was the policy. Further interview with the DM revealed that she confirmed that evening dietary staff have not initialed on the daily cleaning schedule when tasks have been completed for the past three (3) days. She expects staff to complete cleaning tasks and initial the form when they are completed. Review of the Daily Cleaning Schedule for the week of (MONTH) 13-19th revealed that the evening dietary sheet was blank, staff had not initialed any kitchen equipment had been cleaned for the week. Review documentation revealed that the dietary staff had an in-service conducted on 03/31/16 and staff were educated on the sl… | 2019-11-01 |
| 4317 | 4317 | ZEBULON PARK HEALTH AND REHABILITATION | 115295 | 343 PLANTATION WAY | MACON | GA | 31210 | 2016-06-17 | 514 | E | 0 | 1 | XJQ911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to accurately document medication administration leaving blanks/holes on the Medications Administration Records (MARs) for seven (7) residents (#236, #71, #234, #1, #80, #73, and #135) out of 12 residents receiving sliding scale insulin. The census sample size was thirty-three (33). 1. Resident #135 admitted to the facility on [DATE]. [DIAGNOSES REDACTED]., Vitamin B12 deficiency, [MEDICAL CONDITION]/[MEDICAL CONDITIONS] Disease, [MEDICAL CONDITION], and [MEDICAL CONDITION], Review of the medical record revealed that the physician had ordered for the resident to have Finger Stick Blood Sugar (FSBS) completed at 6:30 a. m. and 4:30 p. m. The physician ordered [MEDICATION NAME], ten (10) units subcutaneously at bedtime daily as well as [MEDICATION NAME] Sliding Scale Insulin: 201-250 four (4) units, 251-300 six (6) units, 301-350 eight (8) units, and 351-450 10 units. Review of the (MONTH) (YEAR) Medical Administration Record (MAR) revealed on 06/13/16 at 4:30 p. m. the Finger Stick Blood Sugar (FSBS) check the resident had a blood sugar reading of two hundred forty four (244). Continued review of the MAR revealed the units of sliding scale insulin for that blood sugar reading was blank. Review of the (MONTH) (YEAR) MAR revealed that the resident Fasting Blood Sugar (FSBS) on 05/07/16 at 4:30 p. m. was blank. Continued review of the (MONTH) MAR revealed on 05/08/16 at 4:30 p. m. the resident had a FSBS of two hundred seventy (270), the MAR was blank for the amount of sliding scale insulin the resident was to receive. Further review of the (MONTH) MAR revealed on 05/22/16 the FSBS for 6:30 a. m. was blank. Review of the (MONTH) (YEAR) MAR revealed on 04/17/16, 04/25/16, and 04/30/16 the MAR was blank. Review of the laboratory results in the medical record revealed the resident had a Hemoglobin A1C (HbA1C) lab completed on 04/26/16. The results of (9.3) which indicated high (r… | 2019-11-01 |
| 5510 | 5510 | ZEBULON PARK HEALTH AND REHABILITATION | 115295 | 343 PLANTATION WAY | MACON | GA | 31210 | 2015-03-26 | 282 | D | 0 | 1 | Q5YD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to ensure that care and services were provided according to the care plan for one (1) resident (#152) related to inappropriate behaviors, and one (1) resident (#65) related to sliding scale Insulin coverage from a sample of twenty (20) residents. Findings include: 1. Review of the Quarterly Minimum Data Set assessment dated [DATE] indicated that resident #152 exhibited physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually for one to three (1 to 3) days during the seven (7) day look back period. Review of the Comprehensive Care Plan dated 1/9/15 revealed that the resident exhibits inappropriate behaviors such as; screams out loudly, sobs at random when around others and physically aggressive behavior. The goal was that the resident would not injure self or others as a result of her behavior during the review period. The interventions included to assure safety of resident and others, to notify/consult physician of any new behaviors or exacerbation of behaviors, pharmacy consult, and administer medication as ordered. Review of the clinical record for resident #152 revealed a Note to the attending Physician from the Consultant Pharmacist dated 2/11/15 that the resident had been acting strangely since starting her [MEDICATION NAME] per nurse and to please consider trying a different Antipsychotic medication that she would possibly adjust to better. The Physician replied on 2/12/15 that an evaluation was underway. Review of the physician's orders [REDACTED]. This order was noted on 2/6/15 by Registered Nurse (RN) AA. Interview conducted with RN AA on 3/25/15 at 2:35 p.m. revealed that she attempted to have resident #152 placed in a psychiatric facility for behaviors or, to see if a Psychiatrist would visit. RN AA further revealed that she could not get an available Psychiatrist to see the resident or, an ava… | 2018-08-01 |
| 5511 | 5511 | ZEBULON PARK HEALTH AND REHABILITATION | 115295 | 343 PLANTATION WAY | MACON | GA | 31210 | 2015-03-26 | 309 | D | 0 | 1 | Q5YD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to follow Physician's orders for two (2) residents (#152, #65) related to inappropriate behaviors and sliding scale Insulin coverage. The sample size was twenty (20) residents. Finding include: 1. Review of the Quarterly Minimum Data Set assessment dated [DATE] indicated that resident #152 exhibited physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually for one to three (1 to 3) days during the seven (7) day look back period. Review of the Comprehensive Care Plan dated 1/9/15 revealed that the resident exhibits inappropriate behaviors such as; screams out loudly, sobs at random when around others and physically aggressive behavior. The goal was that the resident would not injure self or others as a result of her behavior during the review period. The interventions included to assure safety of resident and others, to notify/consult physician of any new behaviors or exacerbation of behaviors, pharmacy consult, and administer medication as ordered. Review of the clinical record for resident #152 revealed a Note to the attending Physician from the Consultant Pharmacist dated 2/11/15 that the resident had been acting strangely since starting her [MEDICATION NAME] per nurse and to please consider trying a different Antipsychotic medication that she would possibly adjust to better. The Physician replied on 2/12/15 that an evaluation was underway. Review of the Physician's Order dated 2/6/15 revealed to get a Psychiatric Consult for behaviors. This order was noted on 2/6/15 by Registered Nurse (RN) AA. Interview conducted with RN AA on 3/25/15 at 2:35 p.m. revealed that she attempted to have resident #152 placed in a psychiatric facility for behaviors or, to see if a Psychiatrist would visit. RN AA further revealed that she could not get an available Psychiatrist to see the resident or, an available bed at the … | 2018-08-01 |
| 6704 | 6704 | ZEBULON PARK HEALTH AND REHABILITATION | 115295 | 343 PLANTATION WAY | MACON | GA | 31210 | 2014-05-01 | 309 | D | 0 | 1 | 4EEG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to follow the physician's order related to medication administration for one (1) resident (#76) from a sample of twenty (20) residents. Findings include: Observation on [DATE] at 4:02 p.m. of the first floor East Hall medication cart revealed one (1) vial of Humulog Insulin 100 Unit for use as sliding scale coverage for resident #76. Continued observation revealed that the Insulin had expired [DATE]. Review of the Medication Administration Record [REDACTED]. Interview on [DATE] at 4:02 p.m. with the first floor east medication cart LPN EE revealed that opened vials of Insulin are discarded in twenty eight (28) days and that the facility's procedure was to remove expired medication and discharged residents medication from the medication cart and put it the medication destruction box located in the medication storage room. | 2017-10-01 |
| 6705 | 6705 | ZEBULON PARK HEALTH AND REHABILITATION | 115295 | 343 PLANTATION WAY | MACON | GA | 31210 | 2014-05-01 | 371 | D | 0 | 1 | 4EEG11 | Based on observations and staff interviews the facility failed to label and /or date food stored in the resident 's freezer and refrigerator in two (2) of two (2) nourishment rooms. Findings include: Observation on 04/29/14 at 3:45 p.m. and 4/30/14 at 4:10 p.m. of the first floor resident nourishment room revealed that the freezer unit contained an open box of Outshine Orange Fruit Bars with no label or date opened. Observation on 04/29/14 at 3:50 p.m. of the second floor resident nourishment room revealed that the freezer unit contained a one (1) quart clear container with a red and green substance with no label or date. Continued observation revealed that the refrigerator also contained one (1), two point six (2.6) ounce Starkist Tuna package with no resident label, one (1) opened bottle of Great Value Ranch Dressing with no label or date and a small two (2) ounce ceramic dish that contained a bright yellow jelly like food item that was wrapped in plastic wrap with no label or date. Observation on 04/30/14 at 4:15pm of the second floor resident's nourishment room revealed that the freezer unit contained a twelve (12) ounce Styrofoam cup with an unidentifiable brown substance with no label or date. Continued observation revealed that the refrigerator contained one (1), two point six (2.6) ounce package of Starkist tuna with no resident information and a one (1) ounce disposable paper cup that contained a white substance that was covered with plastic wrap and had no label or date. Observation on 05/01/14 at 8:40am of the second floor resident's nourishment room revealed that the freezer unit still contained the twelve (12) ounce Styrofoam cup with an unidentifiable brown substance with no label or date. Continued observation revealed that the refrigerator contained one (1), two point six (2.6) ounce package of Starkist tuna with no resident information, one (1) ounce disposable paper cup that contained a white substance that was covered with plastic wrap and had no label or date and an eight (8) ounce Styrofoam c… | 2017-10-01 |
| 6706 | 6706 | ZEBULON PARK HEALTH AND REHABILITATION | 115295 | 343 PLANTATION WAY | MACON | GA | 31210 | 2014-05-01 | 431 | E | 0 | 1 | 4EEG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations of the facility medication storage rooms and medication administration carts, staff interviews and record review, the facility failed to discard medications for discharged residents and failed to ensure that medication carts were free of expired medications for two (2) of two (2) medication rooms and one (1) of four (4) medication carts. Findings Include: Observation of the first floor medication storage room on 4/30/14 starting at 2:19 p.m. revealed the following: -There were two (2) unopened Humalog 100u/milliter medication vials in the refrigerator filled 12/24/13 and 12/10/13 for resident A who was discharged home on[DATE]. -There was (1) an unopened Levemir 100u/milliter (ml) medication vial in the refrigerator filled 2/20/14 for resident B who was discharged home on[DATE] -There was one (1) opened Tuberculin 1ml vial in a drawer with no date opened. Observation of the medication storage room cabinet at this time, revealed discharged residents medications stored in a plastic white container with the current residents floor stock medications as follows: - There was one(1) used blister pack with two (2) of (4) four Coumadin five (5) milligrams (mg) tablets filled 4/4/14 for resident C who was discharged home on[DATE]. - There was one(1) used blister pack with five (5) of (7) seven Coumadin five (5) mg tablets filled 4/5/14 for resident D who was discharged home on[DATE]. Continued observation revealed the following unused medications for resident #1 who was admitted on [DATE]: -Three (3) unused blister packs with seven (7) of seven (7) Coumadin two (2) mg tablets filled 4/5/14. -One (1) unused blister pack with seven (7) of seven (7) Coumadin 2.5 mg tablets filled 3/5/14 -One (1) unused blister pack with four (4) of four (4) Coumadin 2.5 mg tablets filled 3/10/14 -One (1) used blister pack with six (6) of seven (7) Coumadin two (2) mg tablets filled 4/10/14 -One (1) used blister pack with four (4) of seven (7) Coumadi… | 2017-10-01 |
| 3065 | 3065 | WYNFIELD PARK HEALTH AND REHABILITATION | 115625 | 223 W.THIRD AVENUE | ALBANY | GA | 31701 | 2019-03-28 | 641 | D | 1 | 0 | FU3211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, and staff interviews the facility failed to accurately assess one resident of four sampled residents. Findings include: Review of the Face Sheet revealed R#1 was admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. Review of the Admission Minimum (MDS) data set [DATE] revealed that R#1 was assessed on admission as not having any venous, or arterial ulcers, she did not have any pressure ulcers, open [MEDICAL CONDITION], did not have any wounds, and did not have any skin problems. Review of a History and Physical note dated 2/22/19 documented that the Nurse Practitioner (NP) examined R#1 on 2/22/19 and documented a discoloration to the residents 2nd digit on her left foot. Review of a History and Physical dated 2/25/19 documented that the Physician examined R#1 and the physical exam revealed that R#1 had a small discoloration to the 2nd digit of the left foot. Review of the Podiatry Consultation dated 2/27/19 revealed that R#1 had a lesion on the her 2nd digit on her left foot that measured 0.4 centimeters (cm) x 0.4 cm. with [DIAGNOSES REDACTED] (redness) and that the toe was painful to touch. During an interview on 3/28/19 at 4:15 p.m. with Registered Nurse (RN) EE revealed that on her Skilled Service Nursing Assessments that she completed, that she never took R#1's sock off to examine her feet and that she was unaware that there was an issue with the resident's foot and that she only learned that there was a problem during the discharge care plan meeting. Cross Reference F686 | 2020-09-01 |
| 3066 | 3066 | WYNFIELD PARK HEALTH AND REHABILITATION | 115625 | 223 W.THIRD AVENUE | ALBANY | GA | 31701 | 2019-03-28 | 686 | D | 1 | 0 | FU3211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, and staff interviews the facility failed to monitor, and provide wound care for one Resident (R#1) of four residents reviewed. Findings include: Review of the Face Sheet revealed R#1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) for R#1 dated 2/28/19 documented that the resident's Brief Interview for Mental Status (BIIMs) score was eight indicating that the resident was moderately cognitively impaired and that her functional status required two plus person assist for dressing. R#1 was assessed on admission as not having any venous, or arterial ulcers, she did not have any pressure ulcers, open [MEDICAL CONDITION], did not have any wounds, and did not have any skin problems. Review of a History and Physical note dated 2/22/19 documented that the Nurse Practitioner (NP) examined R#1 on 2/22/19 and documented the residents' history of present illness to be R#1 complained of bilateral foot pain and shoulder pain. Physical Exam revealed a discoloration to the residents 2nd digit on her left foot. Further review revealed that there were not any Physician orders [REDACTED]. Review of a History and Physical dated 2/25/19 documented that the Physician examined R#1 and the physical exam revealed that R#1 had a small discoloration to the 2nd digit of the left foot. Further review revealed that there was not any evidence to indicate that the discoloration was addressed. Review of the Podiatry Consultation dated 2/27/19 revealed that R#1 was being seen because the resident's toes hurt when she wore shoes. Further review of the Podiatry Consultation note revealed that the patient's [DIAGNOSES REDACTED]. Review of the additional notes section on this same Podiatry Consultation revealed that the lesion on the residents 2nd digit on her left foot measured 0.4 centimeters (cm) x 0.4 cm. with [DIAGNOSES REDACTED] (redness) and that the toe was painful to to… | 2020-09-01 |
| 3067 | 3067 | WYNFIELD PARK HEALTH AND REHABILITATION | 115625 | 223 W.THIRD AVENUE | ALBANY | GA | 31701 | 2016-04-15 | 159 | D | 0 | 1 | P0W211 | Based on interview, record review, and review of policies and procedures, the facility failed to ensure that each resident or their financial representative had received a quarterly accounting of their personal funds. This deficient practice had the potential to affect 1 Resident (R) 84 of 3 residents who were reviewed for personal funds. Findings include: During an interview via telephone with R84's financial representative on 4/12/16 at 9:00 a.m. she confirmed that she was the person who had a Power of Attorney (POA) for R84 and she was responsible for her financial affairs. R84's POA added that she had not received an accounting or a statement relative to the balance that remained in R84's personal fund. Review of the medical record for R84 indicated that she was admitted to this facility on 11/5/14 and she was unable to communicate orally and she required total assistance for all of her activities of daily living. Review of the financial statement for R84 dated 4/13/16 indicated that she had a balance in her personal funds. Review of the facility's policies and procedures indicated a document titled, Patient Trust Fund Procedures revised on 10/29/12 which provided the following information: .Quarterly Statements Trust fund activity statements should be printed out and distributed to the resident or responsible party each calendar quarter. These statements must be signed by the resident or responsible party, returned to the facility, and filed in a quarterly statement binder . An interview with the Financial Controller on 4/13/16 at 8:33 a.m. revealed that she was unaware of the facility's policy relative to sending and receiving quarterly statements. The Controller stated that she was unaware that each statement had to be filed in a separate binder once it was signed and returned back to the facility; consequently she had not completed that task for each resident. The Financial Controller could not provide any documentation that reflected that R84's POA had received any quarterly statements. | 2020-09-01 |
| 3068 | 3068 | WYNFIELD PARK HEALTH AND REHABILITATION | 115625 | 223 W.THIRD AVENUE | ALBANY | GA | 31701 | 2016-04-15 | 241 | D | 0 | 1 | P0W211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to promote a dignified dining experience for 2 residents (Resident (R) R2 and R5) out of 31 sampled residents when the staff isolated R2 and R5 from their peers in the dining room and served the residents' food on Styrofoam plates and their fluids in disposable plastic cups. The facility failed to promote resident dignity in dining when the staff served the residents that took their meals in the 4th floor dining room on plastic plates and used plastic disposable cups for fluids during meals. Findings include: 1. Record review of R2's clinical record indicated the facility admitted the resident on 4/23/98 with [DIAGNOSES REDACTED]. Review of R2's quarterly Minimum Data Assessment (MDS), a comprehensive assessment tool completed by the facility staff, with an Assessment Reference Date (ARD- the end date of the look-back period) of 1/13/16, indicated the staff documented under sections C1000, C1300, and E0100 the resident had severely impaired cognitive skills for daily decision making, but no signs or symptoms of [MEDICAL CONDITION] or [MEDICAL CONDITION]. Under section E0200, the staff documented the resident exhibited physical behaviors toward others, and other behaviors not directed toward others 1 to 3 days per week but did not reject care. Review of R2's care plan, dated 8/27/14 with a staff review date of 1/31/16, indicated the staff did not include any problem statements, goals, or staff interventions related to inappropriate behaviors in the dining room, seating the resident away from other residents while in the dining room, or to use disposable Styrofoam take-out containers and plastic cups for food and fluids. Review of R2's Medication Administration Records (MARs) dated 11/1/15 through 4/13/16, revealed the MARs included an area titled, Behavior Pattern Monitoring for the staff to document R2's behaviors. Further review of the documentation indicated the staff d… | 2020-09-01 |
| 3069 | 3069 | WYNFIELD PARK HEALTH AND REHABILITATION | 115625 | 223 W.THIRD AVENUE | ALBANY | GA | 31701 | 2016-04-15 | 253 | E | 0 | 1 | P0W211 | Based on observation, interview and review of the facility's Weekly Water Temps Log, the facility failed to ensure that hot water temperatures were maintained at a comfortable level in resident rooms (hot water was too cool) in 8 rooms on three (3) of three (3) resident floors. Findings include: Observations of resident rooms and interviews with residents on 4/11/16 at approximately 11:46 a.m. and 4/12/16 at 3:15 p.m. revealed the hot water in the bathroom sinks was cool to touch after running the hot water for approximately 10-15 minutes. During interviews with Resident (R)90-room 212B, R112-room 227A, R228-room 203, R28-room 207B, the residents all stated that the hot water was too cool for use when receiving and/or during bed baths. Observations of the hot water in the following rooms on 4/11/16 at approximately 3:43 p.m. and on 4/12/16 at approximately 9:43 a.m. revealed the hot water was cool for R229-room 312, R225-room 310A, R118- room 406B, and R88-room 433[NAME] R28 stated when Certified Nursing Assistants (CNAs) assisted her with her bed baths they would get hot water in a basin from the shower room. During an interview with the Maintenance Director (MD) on 4/13/16 at approximately 10:45 a.m., the MD stated he likes to maintain the water temperatures in the resident rooms at an average of 105 degrees Fahrenheit (F) and not above 110 F. On 4/13/16 at 11:00 a.m. during a tour of the resident rooms accompanied by the MD, the MD calibrated his thermometer and took the water temperatures in the following rooms: Room 212-102.8 degrees Fahrenheit (F) Room 227-105.5 F Room 203-101.1 F Room 207- 100.9 F Room 312-105.3 F Room 310- 100.2 F Room 406- 98 F Room 433- 100.9 F. Review of the facility's Weekly Water Temps Log for the months of (MONTH) and (MONTH) (YEAR) revealed that 10 of 12 rooms monitored for (MONTH) had water temperatures below 105 degrees F. The log for (MONTH) (YEAR) revealed 10 of 12 rooms with water temperatures below 105 F. On 4/13/16 at 12:35 p.m. the MD and the Regional Environmental Service … | 2020-09-01 |
| 3070 | 3070 | WYNFIELD PARK HEALTH AND REHABILITATION | 115625 | 223 W.THIRD AVENUE | ALBANY | GA | 31701 | 2016-04-15 | 278 | D | 0 | 1 | P0W211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to code the Quarterly Minimum Data Set (MDS) for a limb prosthesis for 1 of 31 sampled residents, Resident (R) 131. Findings include: Observation on 4/11/16 at 3:25 p.m. revealed R131 in his room in bed with a left hand splint in place. On the far end of his room were an elevated adaptive walker and a prosthetic leg in a black shoe. Earlier that day at approximately 10:00 a.m. observation revealed the resident sat in his wheel chair. The left leg of his pants hung down empty. A left AKA (above the knee amputation) was noted. During an interview on 4/12/16 at approximately 8:45 a.m., R131 stated the prosthetic leg and walker in his room belonged to him. Review of the medical record indicated the facility readmitted the resident on 12/22/15 with multiple [DIAGNOSES REDACTED]. Review of R131's 30-day Minimum Data Set (MDS), dated [DATE], documented R131's limb prosthesis under mobility devices. Review of R131's Quarterly MDS, dated [DATE], did not document R131's limb prosthesis under mobility devices. During an interview on 4/15/16 at 12:10 p.m., Resident Assessment Instrument Coordinator (RAI) 6 stated, It was an oversight for not coding. | 2020-09-01 |
| 3071 | 3071 | WYNFIELD PARK HEALTH AND REHABILITATION | 115625 | 223 W.THIRD AVENUE | ALBANY | GA | 31701 | 2016-04-15 | 279 | D | 0 | 1 | P0W211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility filed to ensure that 2 of 31 sampled residents (Resident (R) 33 and R131) were care planned for [MEDICAL TREATMENT] and a prosthetic leg. This deficient practice had the potential to allow residents to not receive the appropriate care to meet their needs. Findings include: 1. On 04/13/16 at 9:20 a.m., R33 was observed on a roll away bed to get into the elevator to go to the [MEDICAL TREATMENT] clinic. During record review of R33's medical record there was an admission date of [DATE] with [DIAGNOSES REDACTED]. During review of R33's annual Minimum Data Set assessment ((MDS) dated [DATE] and a quarterly MDS assessment dated [DATE] revealed that the resident received [MEDICAL TREATMENT]. Review of R33's care plan dated 5/12/15 with an update completed in (MONTH) (YEAR) revealed there was no care plan for the resident's [MEDICAL TREATMENT]. On 04/14/16 at 2:30 p.m., during an interview, the Quality Assurance Nurse (QA1) was asked if she could find the resident's care plan for [MEDICAL TREATMENT]. She stated that she could not locate it and there should be one. On 04/14/16 at 3:00 p.m., during an interview, the Resident Care Coordinator Registered Nurse (RN4) stated that there should be a care plan that would address the resident's [MEDICAL TREATMENT]. She said that she would expect to see a care plan that addressed how often the resident goes and where the access site was located and that blood pressure cannot be taken on whatever arm the access site was located. Review of the facility policy and procedure entitled, Developing an Interdisciplinary Care Plan- At a Glance indicated the following information: Components- 1. Each care plan must demonstrate interdisciplinary team involvement .and must contain a. Problem statement- Problems, limitations, needs, behaviors, possibilities for improvement, and risks should be identified b. Goal- should lead to an outcome c. Interventions- sho… | 2020-09-01 |
| 3072 | 3072 | WYNFIELD PARK HEALTH AND REHABILITATION | 115625 | 223 W.THIRD AVENUE | ALBANY | GA | 31701 | 2016-04-15 | 281 | D | 0 | 1 | P0W211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow physician's orders for weighing 1 resident (Resident (R) 221) out 31 residents in the Stage 2 sample. This deficient practice had the potential to delay physician notification of any changes in the resident's weight and lead to a potential delay in treatment measures. Findings include: Review of the clinical record for R221 indicated the facility admitted the resident from the hospital on [DATE] with [DIAGNOSES REDACTED]. Review of R221's weights documented in the Weights 4th Floor binder indicated a 2/1/16 hospital weight of 211 lbs. and a facility admission weight of 211 lbs. obtained on 2/4/16. The staff documented additional dates and weights as follows: 2/5/16: 204 lbs. 2/10/16: 204 lbs. 2/15/16: 209 lbs. 2/16/16: 209 lbs. Additional review of the form in the binder indicated the staff did not document any subsequent weights for R221 after 2/16/16. Review of Nutrition Note: Admission, dated 2/4/16, indicated the staff documented the resident's Usual Body Weight (UBW) as 230 lbs., her hospital weight as 224 lbs., and her current weight as 211 lbs. The staff documented a Nutrition [DIAGNOSES REDACTED]. The staff recommended an intervention for the staff to monitor the resident's weights. Review of the resident's clinical record revealed a Physician's Order, dated 2/19/16, that directed the staff HMP (House Med Pass) 90 milliliters (ml) twice a day for meal supplementation and to monitor routine weights due to poor appetite. Review of a Nutrition Note: Significant Change form, dated 2/29/16, indicated R221 received hospice comfort measures. The staff documented the resident's UBW as 230 lbs. with a current weight of 211 lbs. The resident's oral intake was documented as low. The staff documented the resident's Nutrition [DIAGNOSES REDACTED]. Review of R221's care plan indicated the staff updated the care plan in collaboration with hospice. The care plan included a problem st… | 2020-09-01 |
| 3073 | 3073 | WYNFIELD PARK HEALTH AND REHABILITATION | 115625 | 223 W.THIRD AVENUE | ALBANY | GA | 31701 | 2016-04-15 | 282 | D | 0 | 1 | P0W211 | Based on observation, record review, interview, and review of policies and procedures, the facility failed to implement the pressure ulcer care plan for 1 of 31 residents (Resident (R) 229) in the Stage 2 sample. This deficient practice had the potential to allow the development of pressure ulcers in this resident with an increased risk for skin breakdown. Findings include: Observation of R229 on 4/13/16 from 10:05 a.m. until 11:25 a.m. revealed that she was seated in a Broda chair (a chair that lifts and tilts in order to provide repositioning for long term care residents) and she continued to cry out for the entire hour and 20 minutes. R229 repeated over and over again, This hurts, and I can't get up. Could someone help me? Observation of the Broda chair at that time revealed that it had plastic pads on the sides and back, but it did not have a separate pressure reducing cushion on the seat. R229 continued to pull at the thigh pads and scoot down in the chair. Review of the medical record revealed the facility admitted R229 on 3/28/16 with depressive episodes and anxiety, and that she had an increased risk for skin breakdown. Review of the pressure ulcer care plan dated 4/6/16 revealed that R229 was at high risk for pressure ulcers related to overall aging and disease process. The Interventions the facility developed included the use of a pressure reduction cushion when she was out of bed. An interview with the wound care nurse, Licensed Practical Nurse (LPN) 3 and the Occupational Therapy Director on 4/13/16 at 11:45 a.m. revealed the Broda chair was intended to reposition residents but it did not include a pressure reducing cushion on the seat. The Occupational Director added that there are special cushions that inflate which are pressure reducing devices, but R229 did not have that type of cushion on the seat of her Broda chair. Review of the facility's policies and procedures revealed an undated document entitled, Developing an Interdisciplinary Care Plan - At a Glance that provided the following informatio… | 2020-09-01 |
| 3074 | 3074 | WYNFIELD PARK HEALTH AND REHABILITATION | 115625 | 223 W.THIRD AVENUE | ALBANY | GA | 31701 | 2016-04-15 | 323 | D | 0 | 1 | P0W211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assure the staff clarified a physician's order for thickened fluids, failed to update the resident's care plan with information related to swallowing difficulty and need for thickened fluids, and failed to provide the clinically-appropriate thickness of fluid for 1 resident (Resident (R) 221) out of 31 sampled residents. This deficient practice had the potential to cause injury to the resident from aspiration of fluid into the lungs and possibly leading to the development of aspiration pneumonia. Findings include: Review of the clinical record for R221 indicated the facility admitted the resident on 2/3/16 from the hospital with a history of dehydration. The resident's [DIAGNOSES REDACTED]. Review of R221's admission Minimum Data Set (MDS), a comprehensive assessment tool complet4ed by the facility staff), dated 2/10/16 indicated the resident had a Brief Interview for Mental Status score of 8 out of 15, which indicated she had moderately impaired cognitive skills for daily decision-making. Under section K0100, Swallowing Disorders, the staff failed to code the assessment to reflect the resident's swallowing difficulty. Review of a Physician's Order, dated 4/6/16, indicated the physician ordered R221's fluid consistency changed to thickened liquids; however, the order failed to provide the consistency of thickened fluids (nectar, honey or pudding thick) the resident was to receive. Further review of the Physician's Orders indicated no subsequent clarification order had been obtained or provided. Review of the resident's care plan indicated the staff developed a problem statement with an onset date of 3/6/16 that read, in part, .Alteration in nutrition due to prolonged illness with multiple health complications at risk for nutritional compromise, dehydration, wt (weight) loss .Resident on hospice- decline/wt loss expected. The problem statement included the following goa… | 2020-09-01 |
| 3075 | 3075 | WYNFIELD PARK HEALTH AND REHABILITATION | 115625 | 223 W.THIRD AVENUE | ALBANY | GA | 31701 | 2016-04-15 | 329 | D | 0 | 1 | P0W211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure the resident's drug regimen remained free from unnecessary drugs, including duplicate therapy and excessive duration, for 1 resident (Resident (R) 51) of 31 sampled residents when the facility failed to ensure the physician provided a clinical rationale for the continued use of [MEDICAL CONDITION] medications without the implementation of a gradual dose reduction. Findings include: Review of R51's clinical record indicated the facility admitted the resident on 11/27/14 with [DIAGNOSES REDACTED]. Review of the resident's quarterly Minimum Data Set (MDS) a comprehensive assessment tool completed by the facility staff, dated 2/3/16, indicated under sections C0500 and C1300, the staff documented the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated the resident had moderate cognitive impairment, but signs or symptoms of [MEDICAL CONDITION]. Under sections E0100, and E0200 through E0800, the staff documented the resident exhibited no signs or symptoms of [MEDICAL CONDITION], no physical or verbal behaviors directed toward others, no behaviors not directed at others, and no rejection of care. Under section N0410, the staff documented the resident received an antipsychotic medication on 7 of 7 days of the look-back period, and antidepressant medication on 7 of the 7 days of the look-back period, and a hypnotic (sleep) medication on 2 of the 7 days of the look-back period. Review of R51's physician's orders [REDACTED]. a. [MEDICATION NAME] (an antidepressant medication), 150 milligrams (mg) every morning for depression. (Order date: 12/21/15); b. [MEDICATION NAME] (an [MEDICATION NAME] medication used to help prevent or minimize the side effects of antipsychotic medications), 2 mg daily for EPS (Extrapyramidal symptoms- involuntary movement disorders that can result from antipsychotic medication use). (Order date: 7/23/15); c. [MEDICATIO… | 2020-09-01 |
| 3076 | 3076 | WYNFIELD PARK HEALTH AND REHABILITATION | 115625 | 223 W.THIRD AVENUE | ALBANY | GA | 31701 | 2016-04-15 | 371 | E | 0 | 1 | P0W211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure food safety when they did not prepare or serve pureed cold food at or below 41 degrees Fahrenheit (F). This deficient practice had the potential to affect 28 of 28 residents who had a physician's orders [REDACTED]. Failure to maintain cold food at a safe temperature created an environment in which bacteria could proliferate and spread food borne illness. Findings include: Observation of the lunch meal on 4/13/16 at 12:30 p.m. revealed that the pureed dessert, angel food cake with mandarin oranges and whipped topping, was holding at 46 degrees F. The pureed dessert was prepared in the facility's kitchen and transported to the 2nd, 3rd, and 4th floors where the residents' lived and dined. The temperature of the pureed dessert was taken on the 2nd and 3rd floor dining rooms and the individual servings from both floors recorded at 46 degrees F. An interview with the Food Service Manager on 4/13/16 at 12:40 p.m. confirmed that the pureed dessert was holding at 46 degrees F which was not a safe temperature per the 2013 Food Code. Per the Food Code, cold food must be maintained at or below 41 degrees F to ensure food safety. The Food Service Manager added that the kitchen staff had prepared the pureed dessert the previous day on 4/12/16. Review of the Prepared Food Temperature Record dated (MONTH) (YEAR) revealed that the kitchen staff had failed to take or record the temperature of the pureed dessert before it was removed from the refrigerated unit. The temperature of the pureed dessert was not taken before it left the kitchen and was transported for service on the 2nd, 3rd, and 4th dining rooms on 4/13/16. Review of the facility's undated policy regarding food temperatures titled, TIME AS A PUBLIC HEALTH CONTROL, which was posted in the kitchen revealed the following information: Time as a public health control will be used for the potentially hazardous foods listed … | 2020-09-01 |
| 3077 | 3077 | WYNFIELD PARK HEALTH AND REHABILITATION | 115625 | 223 W.THIRD AVENUE | ALBANY | GA | 31701 | 2016-04-15 | 520 | D | 0 | 1 | P0W212 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interview, the facility failed to have an effective Quality Assessment and Assurance (QAA) Committee to ensure compliance with the facilities written Plan of Correction (PoC) to ensure that deficient practices were corrected with an alleged compliance date of 5/27/16, for one (1) resident (R#281) of seventeen (17) sampled residents. Cross reference F279 and F329 Findings include: 1. Review of the facility PoC for F279 included: The Quality Assurance (QA) Registered Nurse (RN) will complete a Performance Improvement (PI) Audit Tool weekly times four weeks (x4) or until substantial compliance is achieved with an indicator to check the services and special needs provided for the residents are care planned, however there was no evidence of a care plan related to [MEDICAL CONDITION] medications being administered to the R#281. 2. Review of the facility PoC for F329 included: Each resident ' s drug regimen will be free from unnecessary drugs. The Administrator will in-service physician for documenting a rationale for continuing use of prescribed Antipsychotic medications. The Resident Care RN Coordinators and QA RN will complete PI Audits weekly x4 weeks or until substantial compliance is achieved. Indicators will include the pharmacy recommendations for Antipsychotic medication reductions and rationale from the physician if s/he doesn ' t agree with the recommendation. This will be monitored by the QaPI Committee monthly and corrective measures will be implemented, however there was no evidence of an accurate [DIAGNOSES REDACTED].#281. During an interview on 6/17/16 at 12:26 p.m., the physician stated that he did not add those [DIAGNOSES REDACTED]. | 2020-09-01 |
| 3078 | 3078 | WYNFIELD PARK HEALTH AND REHABILITATION | 115625 | 223 W.THIRD AVENUE | ALBANY | GA | 31701 | 2019-07-23 | 583 | E | 1 | 0 | 4XFF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, review of the facility Statement Of Residents' Rights, family interview and staff interview, the facility failed to secure the confidentiality of therapy records for 23 of 30 residents (R) (#8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29 and 30) reviewed for records. Findings include: Review of the facility Statement Of Residents' Rights revealed that the nursing facility shall protect and promote (the resident's) rights to confidentiality of personal and clinical records. On 7/21/19, the family member for R#1 provided copies of the medical record for R#1 that she had requested and obtained from the facility Admission's Director (Admission's Coordinator) on 7/11/19. Included in the copies were 12 pages of Integra Rehabilitation Associate Reconciliation Report dated 7/11/19 that documented the names of 23 other residents who resided in the facility and the specific therapy treatments that were provided to each resident. Telephone interview with the family member on 7/23/19 at 10:50 a.m. confirmed that the Associate Reconciliation Report was included in the packet she had received on 7/11/19. Review of the Integra Rehabilitation Associate Reconciliation Report dated 7/11/19 revealed the following 23 residents with their specific therapy treatments: 1. R#8 was provided wheelchair training for a total of 30 minutes. 2. R#9 was provided 10 minutes of neuromuscular re-education and 7 minutes of orthotics/prosthetics management/training 3. R#10 was provided 20 minutes of therapeutic exercise and 20 minutes of orthotics/prosthetics management/training 4. R#11 was provided 15 minutes of therapeutic activities, 14 minutes of therapeutic exercise and 31 minutes of neuromuscular re-education. 5. R#12 was provided 45 minutes of evaluation of swallowing function and 35 minutes treatment of [REDACTED]. 6. R#13 was provided 35 minutes of Speech/Language/Pathology (SLP) treatment, 15 minutes of t… | 2020-09-01 |
| 3079 | 3079 | WYNFIELD PARK HEALTH AND REHABILITATION | 115625 | 223 W.THIRD AVENUE | ALBANY | GA | 31701 | 2019-07-23 | 600 | D | 1 | 0 | 4XFF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record reviews, staff interviews and review of the facility policy titled, Grievances Abuse Prohibition, the facility failed to ensure the safety of one of four residents (R#1) reviewed for abuse. Findings include: Review of the policy Grievances Abuse Prohibition C. Identification of coverage and responsibility. 1. Patients in our center will not be subjected to abuse by anyone (including but not limited to: center staff, other patients, consultants or volunteers, staff of other agencies serving the individual, family members or legal guardians, friends, or other individuals). Review of the Face Sheet revealed reviewed face sheet revealed Resident #1 (R#1) has the following [DIAGNOSES REDACTED]. Review of the Nurses Note dated 6/20/19 through 7/6/19 revealed an entry dated 6/29/19 that Housekeeper Aide AA observed R#1 being hit by another resident (Resident #2) with his fist. It is noted that the housekeeper reported the attack on R#1 to a Certified Nurse Aide, (CNA), whereas the CNA reported to the nurse about R#2 was hitting R#1 with his fist. R#1 skin was assessed and noted to have some redness to top of her right hand; noted with redness to her left thigh areas with some swelling; noted some redness to upper left arm and some swelling. R#1 was observed by the nurse displaying facial grimace when the nurse touched R#1 forehead. The physician ordered x-rays for each reddened area. And that the physician wanted to include the right hand in the x-ray order. (sic). Review of the Nurse Practitioner (NP) Progress Notes dated 5/30/19 revealed R#1 was in a Geri chair and was nonverbal. R#1 has had a mild decline and a poor appetite. The Progress Notes dated 7/1/19 revealed R#1 was noted with heavy bruising to her left thigh; bruising with [MEDICAL CONDITION] to her left arm. And that she has recently had an overall decline and does continue under hospice services. Review of the physician progress notes [REDACTED].#2) who apparently, wi… | 2020-09-01 |
| 3080 | 3080 | WYNFIELD PARK HEALTH AND REHABILITATION | 115625 | 223 W.THIRD AVENUE | ALBANY | GA | 31701 | 2019-07-23 | 684 | D | 1 | 0 | 4XFF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and staff interview, the facility failed to provide treatments as ordered by the vascular wound clinic physician for one of six residents (R#7) reviewed for wounds from a total sample of 30 residents. Findings include: R#7 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that the resident had a brief Interview for Mental Status (BIMS) score of 12, indicating she had some confusion; required extensive assistance of staff for bed mobility, ambulation in room and toileting; and had one (1) Stage III pressure sore. Review of the resident's care plan revealed that she was at risk for or had actual skin breakdown with appropriate interventions. Observation of R#7 on 7/22/19 at 12:41 p.m. revealed her in her wheelchair in her room. She was clean, neat and without odors. She appeared well hydrated and well nourished. She was wearing thick socks and sandals. On 7/23/19 at 9:15 a.m., an assessment of the resident's feet with the third floor Registered Nurse (RN)/Assistant Director of Nursing (ADON) BB revealed that the resident's right foot was wrapped in a gauze roll that was dry and intact. Observation of the resident's left foot revealed no breakdown. review of the resident's medical record revealed [REDACTED]. The physician was notified and the abrasion treated. Weekly wound assessments were performed. Review of the Weekly Wound Report dated 3/18/19 revealed that the area was now an unstageable pressure sore that measured 1.5 x 1.6 x 0 centimeters (cms.) with slough, moderate exudate and no odor. The physician was notified and treatment obtained to cleanse the wound with normal saline (NS), pat dry, apply silver alginate (an antimicrobial for use in treatment of [REDACTED]. Review of the electronic Treatment Administration Records (eTARS) for 3/2019 and 4/2019 revealed that treatment was provided as ordered. Review of the Weekly Wound Report… | 2020-09-01 |
| 3081 | 3081 | WYNFIELD PARK HEALTH AND REHABILITATION | 115625 | 223 W.THIRD AVENUE | ALBANY | GA | 31701 | 2019-07-23 | 686 | D | 1 | 0 | 4XFF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, review of the facility Skilled Inpatient Services: treatment of [REDACTED].#4) reviewed for pressure ulcers. Findings include: Review of the facility Skilled Inpatient Services: treatment of [REDACTED]. condition. The management of tissue loads includes the repositioning of the patient every 2 hours and the utilization of positioning devices as appropriate to promote proper alignment. The goal is to reduce the effects of pressure, shear and friction that affects healing. R#4 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that R#4 had a Brief Interview for Mental Status (BIMS) score of 9, indicating that he had cognitive impairment; had no behaviors; required extensive assistance of two staff for bed mobility and toilet use; was non-ambulatory; was always incontinent of bladder and bowel; received feedings via a gastrostomy tube and pureed diet; had no significant weight loss in the last 6 months; had no pressure ulcers, but had MSAD (Moisture Associated Skin Damage). Review of the resident's current care plan revealed that the resident was at risk for skin breakdown or had actual skin breakdown related to his decreased movement, bowel and bladder incontinence, and decreased bed mobility with interventions for nursing staff to assist the resident to turn and reposition frequently and to inspect skin during care and bathing and report any changes to the charge nurse. Review of the electronic Nurses' Note dated 6/30/19 at 9:50 a.m. revealed that R#4 had a skin problem on his buttocks that was newly identified on night shift 6/29/19. However, continued review of the Nurses' Notes, Physician orders, Weekly Wound Reports, and electronic Treatment Administration Records (eTAR) revealed that there was no indication that the Treatment Nurse was notified so that treatment could be obtained and initiated timely. There was no indication that th… | 2020-09-01 |
| 3082 | 3082 | WYNFIELD PARK HEALTH AND REHABILITATION | 115625 | 223 W.THIRD AVENUE | ALBANY | GA | 31701 | 2018-09-05 | 585 | D | 1 | 0 | G30Y11 | > Based on observation, interview, and record review, the facility failed to ensure that an intervention to address a documented grievance was consistently implemented for one resident (A), from a total sample of five residents. Findings include: A review of the Report of Resident Grievance/Compliments forms revealed that a family member of Resident (R) A complained on 8/7/18 that a female resident had wandered into RA's room one day during the previous week. The form documented that the resident, who wandered into the room, had to be assisted out of RA's room by staff. The facility identified the resident who wandered into R A's room and monitored her for two days for any further wandering behavior. In addition, facility staff also implemented the use of a velcro stop sign stretched across the entrance door to R A's room, to deter any further wandering into her room. However, the facility failed to ensure that the intervention of the velcro stop sign was being implemented consistently, to keep the issue from reoccuring. During observations on 9/5/18 at 11:05 a.m., 11:45 a.m., 1:11 p.m., and 2:35 p.m. the velcro stop sign was observed to be hanging down at the entrance door to R A's room, not secured across it. During an interview on 9/5/18 at 3:06 p.m., R A's family member stated that she had to redirect a resident out of R A's room the day prior, on 9/4/18. She stated that the velcro stop sign was not in use during her visit, and it was not across the door when she arrived. | 2020-09-01 |
| 3083 | 3083 | WYNFIELD PARK HEALTH AND REHABILITATION | 115625 | 223 W.THIRD AVENUE | ALBANY | GA | 31701 | 2017-10-05 | 332 | D | 0 | 1 | KU9S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the medication error rate was less than 5%. A total of 31 medication opportunities were observed with three errors, for two of six residents, for a total error rate of 9.6%. Findings include: 1. During an observation on 10/4/17 at 8:50 a.m., Licensed Practical Nurse (LPN) AA administered an 81 milligram (mg) [MEDICATION NAME] coated aspirin to Resident (R) #140. However, a review of the clinical record revealed a physician's order since 4/23/13 for an 81 mg chewable aspirin tablet to be administered. Also during the observation on 10/4/17 at 8:50 a.m., LPN AA administered two drops of Refresh eye drops to R#140's left eye and three drops in the right eye. However, a review of the clinical record revealed a physician's order, since 9/13/17, for one drop of Refresh eye drops to be administered to each eye. 2. During an observation on 10/4/17 at 11:46 a.m., LPN BB administered 10 units of [MEDICATION NAME] R insulin to R #169 for a blood sugar level of 332. A review of the physician's orders revealed an order, since 8/28/17, for [MEDICATION NAME] R insulin to be administered on sliding scale basis. However, the sliding scale stopped at a blood sugar level reading of 300. There was no physician's order for the amount of insulin to administer for a blood sugar level of 332. After surveyor inquiry, a physician's order was obtained for licensed nursing staff to administer 12 units of [MEDICATION NAME] R insulin for blood sugar levels greater than 300. During an interview on 10/5/17 at 12:12 p.m., the Director of Nursing (DON) stated that LPN BB should have notified the resident's physician or nurse practitioner to obtain an order of how much insulin to administer. | 2020-09-01 |
| 3084 | 3084 | WYNFIELD PARK HEALTH AND REHABILITATION | 115625 | 223 W.THIRD AVENUE | ALBANY | GA | 31701 | 2017-10-05 | 406 | D | 0 | 1 | KU9S11 | Based on staff interview and record review, the facility failed to provide skilled Occupational Therapy services, as recommended, for one resident (#72) from a total sample of 25 residents. Findings include: Resident (R) #72 received restorative nursing services, since 2/26/16, of passive range of motion and splinting to bilateral hands and wrists to reduce the risk of contractures. A review of the Restorative Intervention Plan revealed a 1/27/17 entry that the resident was discharged from restorative services and referred to therapy. A Comprehensive Rehabilitation Screen form documented that the resident was referred due to the splints no longer fitting. The form, signed by a Certified Occupational Therapy Assistant (COTA) on 1/31/17, documented that an Occupational Therapy (OT) evaluation was recommended. However, there was no evidence in the clinical record that the OT evaluation was completed. During an interview on 10/5/17 at 11:35 a.m. the OT confirmed that the COTA completed the therapy screen and recommended an OT evaluation due to the resident removing her splints. However, the recommendation was never communicated to her (the OT), therefore it was not completed. After surveyor inquiry, the resident's physician was notified of the recommendation and an order was obtained to complete the evaluation. On 10/5/17 an evaluation was completed and skilled OT services were initiated. A review of the Occupational Therapy Certification and Daily Note forms revealed that the resident had not experienced a decline in range of motion since restorative nursing services had been discontinued on 1/27/17. | 2020-09-01 |
| 3085 | 3085 | WYNFIELD PARK HEALTH AND REHABILITATION | 115625 | 223 W.THIRD AVENUE | ALBANY | GA | 31701 | 2018-11-02 | 550 | D | 0 | 1 | BP8G11 | Based on resident interview staff interview and record review, the facility failed to ensure that there was a process in place to identify people who were not registered to vote and wished to vote (R#137, R#136, R#118, R#104, and R#90), within the time frame to register. The census size was 53 residents. Findings include: During an interview on 10/30/18 at 2:20 p.m. with residents (R#137, R#136, R#118, R#104, R#90, and R#140) in attendance for resident council it was revealed that there had been no arrangements made for voting. During an interview on 10/30/18 at 3:46 p.m. with the Admissions Coordinator/ Social Director revealed that the social service department was responsible for arranging for assisting residents in voting. She stated that the family normally brings the absentee ballot for the resident. She stated for residents that don't have involved family that Social Services was responsible for assisting the residents who wished to vote. Review of the Resident Council Minutes from 10/20/17 to the present time revealed no mention of reviewing the residents' right to vote. During an interview on 10/31/18 at 8:26 a.m. with the Admissions Coordinator/ Social Director it was revealed that the social worker on each floor compiled a list last week of all residents who were interested in voting. The Admissions Coordinator/ Social Director stated that she was certain that no one voted in the primary election, but she was unsure of why. She was also notified that several residents had indicated interest in voting and that the names of some of them were not on the lists that had been received. During an interview on 10/31/18 at 9:10 a.m. with the Social Assistant BB it was revealed that some residents were not registered to vote. She stated that on admission the residents were asked if they were registered voters. She also stated that she was unaware of a process to assist a resident in registering to vote if they were interested in voting. During an interview on 10/31/18 at 9:19 a.m. with the Social Assistant CC re… | 2020-09-01 |
| 3086 | 3086 | WYNFIELD PARK HEALTH AND REHABILITATION | 115625 | 223 W.THIRD AVENUE | ALBANY | GA | 31701 | 2018-11-02 | 584 | D | 0 | 1 | BP8G11 | Based on observation and interviews the facility failed to ensure the upkeep of resident wheelchairs related to dirt and build up and exposed backing on a wheelchair. This affected three residents (R#65, R#69, R#121, R#139, and R#132). The facility census was 173 residents. Findings include: Observation on 10/30/18 at 9:25 a.m. revealed dirt build up on spokes of wheelchair for R#139. Observation on 10/30/18 at 9:41 a.m. revealed dirt and build up on spokes of wheelchair for R#65. Observation on 10/30/18 at 4:52 p.m. revealed wheelchair for R#69 to have batting exposed on the upper back of the wheelchair. Observation on 10/30/18 at 4:59 p.m. revealed dirt and build up on wheelchair for R#132. Observation on 10/31/18 at 11:43 a.m. revealed dirt and debris noted on undercarriage of the wheelchair for R#121. Interview on 10/31/18 at 1:41 p.m. with the Administrator revealed that she has seen the floor techs washing wheelchairs but there is no schedule or any documentation for this. She further reported that she is not aware of the last time wheelchairs were washed but going forward housekeeping will create a schedule for wheelchair cleaning. Interview on 10/31/18 at 1:45 p.m. with the Assistant Administrator who reported that the floor techs clean wheelchairs in the early mornings or in the afternoons but there was not a specific date identified. The assistant administrator then provided a copy of wheelchair schedule for (MONTH) (YEAR). Per the list all wheelchairs on 400 hall had been cleaned for the month of October. Assistant Administrator further reported that the check mark by the room number indicated both wheelchairs cleaned in the room. However, the form did not have a date as to when the wheelchairs were done. The Assistant Administrator also confirmed dust and dirt build up on resident wheelchairs and also the exposed backing to one wheelchair. | 2020-09-01 |
| 3087 | 3087 | WYNFIELD PARK HEALTH AND REHABILITATION | 115625 | 223 W.THIRD AVENUE | ALBANY | GA | 31701 | 2018-11-02 | 677 | D | 0 | 1 | BP8G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interviews, the facility failed to ensure that activities of daily living (ADL) was provided for one dependent resident (R) R#155, in relation to shower, oral care and nail care. The sample size was 53. Findings include: A review of the clinical record for R #155 revealed resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 99, which indicated severe cognitive impairment. Section G revealed resident requires total assistance with bathing, shower, oral care, nail care, dressing, toileting and personal hygiene. Observation on 10/29/18 at 10:00 a.m., 12:00 p.m., 2:00 p.m., 4:00 p.m. 10/30/18 at 11:00 a.m., 10/31/18 at 10:40 a.m., revealed the resident (R) R#155 was scheduled for shower on every Tuesdays, Thursdays and Saturdays, but shower was not done, oral care was not done, mouth odor noted, nails long, and dirty underneath on both hands. Interview on 10/31/18 at 1:50 p.m., with Certified Nursing Assistant (CNA) JJ stated that she asked charge nurse about resident because that was the first time she worked on fourth floor; she was from Agency, the nurse told (CNA) JJ to give R#155 bed bath and don't get her up. Interview on 10/31/18 at 2:29 p.m. with Licensed Practical Nurse (LPN) EE denies what CNA JJ said; (LPN) EE revealed that activities of daily living (ADL) care consists of bathing, shower, oral care, turn and reposition every two hours, out of bed to Geri-chair, dressing, brushing teeth and nail care. She stated CNAS' can cut resident's fingernails if they are not diabetic. She further stated that she did not notice that R#155 shower was not done on Tuesday, or that the fingernails were long and dirty. Interview on 10/31/18 at 2:40 p.m. with the Director of Nursing (DON) stated CNA's are to do nail care every day when providing ADL care. Sh… | 2020-09-01 |
| 3088 | 3088 | WYNFIELD PARK HEALTH AND REHABILITATION | 115625 | 223 W.THIRD AVENUE | ALBANY | GA | 31701 | 2018-11-02 | 679 | D | 0 | 1 | BP8G11 | Based on observations, record review and staff interviews, facility failed to provide an ongoing one on one activities for eighteen days for one resident (R) R #155, who needed extensive to total assistance by staff for provision of all care. The sample size was 53. Findings include: During observations on 10/29/18 at 12:30 p.m.; 1:30 p.m., 2:30 p.m., 3:30 p.m.; 10/30/18 at 8:00 a.m., 9:00 a.m., 10:00 a.m., 11:00 a.m., 12:00 p.m., 1:00 p.m., 2:00 p.m., 3:00 p.m., and 4:00 p.m.; 10/31/18 at 9:00 a.m., 11:00 a.m.; 1:00 p.m.; 3:00 p.m.; and 5:00 p.m.; R#155 was observed laying at back on bed, head of bed elevated approximately 40 degrees with continuous feeding tube, without any activity nor nursing staff to turn or reposition her. Further observations revealed that there was no television in R#155 room, and there were no interactions by staff with the resident. 10/31/18 at 4:00 p.m., reviewed facility Policies and Procedures dated (MONTH) (YEAR), and R#155, care plan revealed that It is the policy of Wynfield Park Health and Rehabilitation to provide one on one daily activity program for R#155. 10/31/18 at 2:10 p.m., in an interview with Activity Coordinator (AC), she said she was sorry she did not provide one on one activity for R#155, due to staffing issues; the activity staff assigned for the fourth floor went on vacation since 10/12/18, came back on 10/29/18, but was busy and unable to get to resident (R) R#155. During the interview, Activity Coordinator (AC) said the last one on one activity with R#155 was 10/12/18; and said she would make adjustment immediately. 10/3/18 at 2:40 p.m., an interview with Administrator and Director of Nursing (DON) revealed they were not aware that the Activity Coordinator (AC) was not providing one on one activity for R#155. | 2020-09-01 |
| 3089 | 3089 | WYNFIELD PARK HEALTH AND REHABILITATION | 115625 | 223 W.THIRD AVENUE | ALBANY | GA | 31701 | 2018-11-02 | 684 | D | 0 | 1 | BP8G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interviews, the facility failed to follow the Physician order [REDACTED].#431, with respect to performing 6:00 a.m., 11:00 a.m., finger stick and administration of Sliding Scale (SS) [MEDICATION NAME] Insulin. The sample size was 53 residents. Findings include: A review of the clinical record for R#431 revealed that resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 99, which indicated cognitive impairment. Section N revealed that the resident received insulin for high blood sugar. Review of the Physician order [REDACTED]. Review of Medication Administration Record (MAR) for (MONTH) (YEAR) revealed that finger stick was not completed on 10/30/18 at 6:00 a.m., and 11:00 a.m., and [MEDICATION NAME]sliding scale was not administered until 1:40 p.m. The Licensed Practical Nurse (LPN) EE entered in the computer that the blood sugar was 362, and administered 16 units of [MEDICATION NAME]at 11:00 a.m., however the insulin was not administeted until 1.40 p.m. 10/30/18 at 1:24 p.m., an interview with resident (R) R#431, daughter stated she was afraid of the care provided by facility. (LPN) EE entered and stated she did finger stick, blood sugar was 362. Surveyor asked to see doctor's order which revealed that finger stick should be done at 6:00 a.m., and 11:00 a.m., but this was not done. 10/30/18 at 1:26 p.m., in an interview with (LPN) EE as to why she waited until 1:24 p.m. to do finger stick and if she notified doctor to obtain one time order to do finger stick and administer sliding scale Insulin, (LPN) EE replied, I was very busy to get to the resident and I did not call the doctor. Interview on 10/30/18 at 1:28 p.m., with the Director of Nursing (DON), she stated that it was her expectation for all staff to follow physician orders. 1:30 p.m., DON … | 2020-09-01 |
| 3090 | 3090 | WYNFIELD PARK HEALTH AND REHABILITATION | 115625 | 223 W.THIRD AVENUE | ALBANY | GA | 31701 | 2018-11-02 | 689 | D | 0 | 1 | BP8G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and policy titled Maintenance Inspection Instructions, the facility failed to ensure that handrails were securely fixed to the wall in one resident bathroom for a Resident (R)# 52) that was able to independtly use the bathroom. The facility census was 173 residents. Findings include: Review of Minimum Data Set (MDS) annual assessment dated [DATE] revealed that R#52 was unsteady but able to stabilize without human assistance when moving on and off the toilet. During tour on 10/30/18 at 9:55 a.m., with Maintenance Assistant OO, in room [ROOM NUMBER] it was discovered that the handrail by the toilet was loose in the bathroom for room [ROOM NUMBER]. Maintenance Assistant reported that hand rails are not typically checked in the bathroom routinely but on an as needed basis. He then reported that he would take care of the loose rail. Interview on 10/30/18 at 3:47 p.m. with the Maintenance Supervisor who reported that the checking of the security of hand rails in residents' bathrooms are done on an as needed basis. He further reported that he relies on staff to inform him if a handrail needs to be replaced. He denied that checking for handrails is a part of his monthly preventative maintenance tasks. Observation on 10/30/18 at 4:54 p.m. R#52 was observed ambulating in the room coming out of the bathroom. Upon entering the bathroom, the handrail by the toilet remained loose. Interview with the Assistant Administrator on 10/30/18 at 5:15 p.m. who reported that the Maintenance Director is working on repairing the handrail in room [ROOM NUMBER]. However, when touring room [ROOM NUMBER] the handrail in the bathroom was found to be off the wall and laying on the floor and the Maintenance Director was not in the bathroom. The Assistant Administrator reported that he would stay in the room with resident until the rail was secured to assure resident's safety. He also reported if resident needed assistant to the bathroom… | 2020-09-01 |
| 3091 | 3091 | WYNFIELD PARK HEALTH AND REHABILITATION | 115625 | 223 W.THIRD AVENUE | ALBANY | GA | 31701 | 2018-11-02 | 755 | D | 0 | 1 | BP8G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to follow the policy titled Storage of Medications and Biologicals. They failed to ensure disposal of expired medications in one of six medication carts. The sample size was 53. Findings Include: Review of the facility's Storage of Medications and Biologicals/Medication Administration policy with an issue dated (MONTH) (YEAR) revealed Latanoprost ([MEDICATION NAME]) eye drop was to be used for 42 days and discarded; also facility was to ensure that medications and biologicals are stored, labeled, and disposed of properly by expiration date. On 10/30/18 at 10:13 a.m., one out of six medication carts were observed, one expired medication was found in one of six carts. On 10/30/18 at 10:13 a.m., during an observation with Licensed Practical Nurse (LPN) HH, expired medication was found in cart number one of the second floor east cart used for one resident, 15 various times in (MONTH) (YEAR). One bottle of Latanoprost Ophthalmic Solution 0.005% (percentage) eye drop for resident (R) R#3 opened 7/3/18, expired on 9/1/18. Lot number 5f. An interview on 10/30/18 at 10:15 a.m. with the Licensed Practical Nurse (LPN) HH, revealed staff are expected to date and label all medications when opened, and check for expired medications in the medication carts daily prior to administering medication to all residents. Record review revealed an order to administer Latanoprost Ophthalmic Solution 0.005% (percentage) one drop instill in both eyes at bedtime, and (typed in capital letters), DISCARD 6 WEEKS AFTER OPENING BOTTLE. The Latanoprost ([MEDICATION NAME]) eye drop expired 9/1/18. LPN LL administered expired eye drops to resident (R) R#3 for eight days (10/16,10/20, 10/21, 10/24, 10/25, 10/26, 10/29, and 10/30/18); LPN MM administered expired eye drops for seven days (10/17, 10/18, 10/19, 10/22, 10/23, 10/28 and 10/31/18); and LPN NN administered expired eye drops one day (10/27/18). The… | 2020-09-01 |
| 3092 | 3092 | WYNFIELD PARK HEALTH AND REHABILITATION | 115625 | 223 W.THIRD AVENUE | ALBANY | GA | 31701 | 2018-11-02 | 761 | D | 0 | 1 | BP8G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and policy review, facility failed to discard expired [MEDICATION NAME] prior to expiration date in the medication storeroom refrigerator. The sample size was 53 residents. Findings include: Review of the facility policy titled Medication Storage dated [DATE], revealed that medications and biologicals be stored properly, following manufacturer's or provider pharmacy recommendations, to maintain their integrity and support safe and effective drug administration. Procedure number two revealed that outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure closures should be immediately removed from stock and disposed of according to procedures for medication disposal. Observation on [DATE] at 9:28 a.m. of the medication storage room on 4th floor, with Registered Nurse (RN) GG revealed that a refrigerator, used for medications, contain of one vial of expired [MEDICATION NAME] two (2) milligram (mg) per milliliter (ml) with an expiration date of ,[DATE]. Observation on [DATE] at 3:00 p.m. of the medication storage room on 4th floor with Director of Nursing (DON) revealed the same refrigerator, used for medications, with one two (2) milligram (mg) per milliliter (ml) [MEDICATION NAME] vials with an expiration date of [DATE]. [DATE] at 9:30 a.m. an interview with RN GG stated she just started working with facility three weeks ago. She also stated that night nurses were supposed to do medication check in the medication storage room. Interview on [DATE] at 9:40 a.m., and [DATE] at 3:24 p.m., with Director of Nursing (DON), stated she could not understand why the expired resident's medication was still in the refrigerator. She stated that the nurses as well as the pharmacist should be looking at all the medications checking for expiration dates. She also stated that the pharmacist was in the facility last week in doing Regimen Reviews. She further… | 2020-09-01 |
| 3093 | 3093 | WYNFIELD PARK HEALTH AND REHABILITATION | 115625 | 223 W.THIRD AVENUE | ALBANY | GA | 31701 | 2018-11-02 | 842 | D | 0 | 1 | BP8G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to ensure the Medication Administration Record documentation (MAR) was completed for residents (R) R#431. The sample was 53 residents. Findings include: A review of the clinical record for R#431 revealed resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 99, which indicated cognitive impairment. Section N revealed that the resident received insulin for high blood sugar. Review of the Physician order [REDACTED]. Review of the (MONTH) (YEAR) Medication Administration Record (MAR) revealed there were two opportunities for medications with two missed episodes of documentation; there were two opportunities for Blood Sugar monitoring's with two missed episodes of documentation. Continued review of clinical record revealed no evidence of the Physician being notified of missed opportunities. 10/30/18 at 1:26 p.m., in an interview with the Licensed Practical Nurse (LPN) EE, she was asked why she waited until 1:24 p.m. to do finger stick and if she notified the doctor to obtain one-time order to do finger stick and administer sliding scale Insulin. (LPN) EE replied, I was very busy to get to the resident and I did not call the doctor. Interview on 10/30/18 at 1:28 p.m., with the Director of Nursing (DON) stated that it is her expectation for all staff to follow physician orders. 1:30 p.m., DON called Nurse Practitioner and obtained order for one-time finger stick and to give sliding scale insulin. 1:30 p.m. 16 units of [MEDICATION NAME] sliding scale was administered. 10/30/18 at 4:06 p.m., DON called Licensed Practical Nurse (LPN) FF, who stated she did finger stick at 6:00 a.m., blood sugar was 182, and she entered it in the computer. DON asked (LPN) FF, but the computer was red, which means you did not enter the blood sugar nor sign t… | 2020-09-01 |
| 3094 | 3094 | WYNFIELD PARK HEALTH AND REHABILITATION | 115625 | 223 W.THIRD AVENUE | ALBANY | GA | 31701 | 2018-11-02 | 883 | D | 0 | 1 | BP8G11 | Based on record reviews, interviews and review of the facility policy Immunization of Residents the facility failed to screen and educate two out of five residents for the pneumococcal vaccine. Findings include: A review of the facility policy Immunization of Residents dated (YEAR), reveals residents will be screened and offered the pneumococcal vaccine, as appropriate. During the random review of the immunization records reveal: R#50 Had flu vaccine 10/17/18. No record of pneumonia vaccine found in electronic chart. R#179 Had flu vaccine 10/13/17. No record of pneumonia vaccine found in electronic chart. R#136 Had flu vaccine 10/13/18. No record of the pneumonia vaccine found in electronic chart. R#103 Had flu vaccine 10/18/18. No record of the pneumonia vaccine found in electronic chart. R#20 Had flu vaccine 10/31/17. Pneumonia vaccine given 5/5/15. During the random review for vaccine screening for infection prevention, it was discovered that two (R#136 and R#179) of five residents reviewed did not receive screening and education for the pneumococcal vaccine. Both residents were eligible for the vaccine. On 11/1/18, 1:00 p.m., the Administrator agrees the two residents should have been screened and educated regarding the pneumococcal vaccine. She provided copies of the Georgia Registry of Immunization Transactions and Services (GRITS) report for the two residents. The information in the reports support the findings that the two residents should have been screened and offered education regarding the pneumococcal vaccine. | 2020-09-01 |
| 3095 | 3095 | WYNFIELD PARK HEALTH AND REHABILITATION | 115625 | 223 W.THIRD AVENUE | ALBANY | GA | 31701 | 2019-12-11 | 656 | D | 1 | 0 | KU6O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff interview and the facility policy titled, Patient's Plan of Care the facility failed to followed interventions for the use of a mechanical lift for one of six residents reviewed for care plans for mechanical lifts. Findings include: Review of the facility policy titled, Patient's Plan of Care Intent: Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental and psychosocial needs. Review of the Face Sheet revealed R#4 was admitted to the facility with the following [DIAGNOSES REDACTED]. Review of the care plan for R#4 dated 11/21/19 revealed that R#4 is a mechanical lift transfer. The Hoyer lift transfer will be two people at all times, and the Hoyer straps will be secured. During an interview on 12/11/19 at 11:07 a.m. with Certified Nurse Aide (CNA) FF revealed that the resident was lying in bed with a Hoyer lift pad under him. There was no other CNA in the room to help spot the transfer. CNA FF stated that she was familiar with the facility policy requiring two people for transfer with a Hoyer lift. During an interview on 12/11/19 at 3:38 p.m. the Director of Nursing (DON) revealed that resident who has been care planned for a Hoyer lift transfer must have two people at all times for the transfer During an interview on 12/11/19 at 3:49 p.m. with the Administrator revealed that the staff had a good understanding of the Hoyer policy but that the CNA FF did not wait for the spotter. | 2020-09-01 |
| 3096 | 3096 | WYNFIELD PARK HEALTH AND REHABILITATION | 115625 | 223 W.THIRD AVENUE | ALBANY | GA | 31701 | 2019-12-11 | 689 | D | 1 | 0 | KU6O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff interview and facility policy titled, Lift Free Policy for Patients Residents the facility failed to use two people when transferring one of six residents (R#4) while using a mechanical lift. Findings include: Review of the facility policy titled, Lift Free Policy for Patients Residents All non-weight bearing patients/residents will be transferred from bed to chair and vice versa with the use of a Hoyer lift. This procedure will be accomplished by two (2) employees at all times. Review of the Face Sheet revealed R#4 has the following [DIAGNOSES REDACTED]. During an interview on 12/11/19 at 10:22 a.m. with Licensed Practical (LPN) EE revealed LPN EE was in the hallway, and she overheard Certified Nurse Aide (CNA) FF asking CNA AA to come and spot her. She saw a visitor talking to CNA FF. CNA AA was on her way when LPN EE heard a loud boom and ran into the room and saw the resident lying on the floor. The resident was positioned on the floor with his right side of his neck on the left Hoyer lift leg. CNA AA was not in the room to spot the transfer. During an interview on 12/11/19 at 11:07 a.m. with CNA FF revealed that the resident was lying in bed with a Hoyer lift pad under him and she had got him dressed for church. CNA FF continued to state that a visitor was in the room waiting for the resident to be transferred to a Geri-chair. CNA FF stated that there was no one in the room to help spot the resident during the transfer. CNA FF left the room to get the Hoyer lift, leaving the resident in the bed. When CNA FF returned to the room, she hooked the straps to the Hoyer hooks. CNA FF had already asked CNA AA to come to the room to be her spotter and CNA FF stated that she was coming. She begins lifting the resident from the bed and started moving the Hoyer from over the bed and the strap on the left shoulder came loose. The resident, which is a double [MEDICAL CONDITION], tumbled out of the pad. CNA FF fell on to… | 2020-09-01 |
| 5202 | 5202 | WYNFIELD PARK HEALTH AND REHABILITATION | 115625 | 223 W.THIRD AVENUE | ALBANY | GA | 31701 | 2015-03-05 | 431 | D | 0 | 1 | YVHG11 | Based on observation and staff interviews, the facility failed to ensure expired medications were properly disposed of timely on two (2) of six (6) medication carts on one (1) of three (3) floors. Findings Include: Observation on Second floor East medication cart on 3/5/2015 at 12:20 p.m. revealed the following expired medications: [REDACTED] 1. One (1) opened vial of Lantus Insulin with a first use date of 1/31/15 and an expiration date of 2/27/15 written on the vial. 2. One (1) opened vial of Levemir Insulin with a open date of 1/10/15 and an expiration date of 2/28/15 written on the vial. An interview with Licensed Practical Nurse (LPN) BB on 3/5/2015 at 12:20 p.m. he/she revealed the above medications were expired. He/she revealed the Lantus Insulin expired twenty eight (28) days after opening and the Levemir Insulin expired forty two (42) days after opening. Observation on Second floor West medication cart on 3/5/2015 at 12:35 p.m. revealed the following expired medication: 1. One (1) opened vial of Humalog insulin U 100 with a first used date of 1/9/15 and an expiration date of 2/8/2015 written on the label. An interview with Licensed Practical Nurse (LPN) AA on 3/5/2015 at 12:35 p.m. revealed the Humalog insulin was expired . An interview with the Director of Nursing (DON) on 3/5/2015 at 2:55 p.m. revealed that the nurse is to date the Insulin when it is opened, count the number of days it is good for and put that date on the sticker. The DON further stated that it was his /her expectation that the nurse check the expiration date on the Insulin before giving it . | 2018-12-01 |
| 6633 | 6633 | WYNFIELD PARK HEALTH AND REHABILITATION | 115625 | 223 W.THIRD AVENUE | ALBANY | GA | 31701 | 2013-10-25 | 241 | D | 0 | 1 | X8BC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview and record review the facility failed to assist one (1) resident (A) of twenty eight (28) sampled residents with toileting in a timely manner. Findings include: Review of the clinical record for resident A revealed multiple [DIAGNOSES REDACTED]. The resident is assessed as always continent of both bowel and bladder. The resident was assessed as being cognitively intact with a BIMS score of 15. Review of the resident's Care Plan dated 4/7/12 revealed the resident requires assistance with activities of daily living with an intervention to assist with activities of daily living as needed. There was no specific intervention to address the resident's toileting needs. Observation and interview on 10/22/13 at 12:05 p.m., the resident stated that he/she had been waiting for the bedpan since 11:29 am and that he/she needed to have a bowel movement. Observation and interview on 10/24/13 at 8:15 a.m., the resident stated that on 10/23/13 on the 3-11 shift he/she had to wait from 5:00 p.m. to 8:15 p.m. for a bedpan. The resident stated that he/she ended up soiling herself/himself because he/she could not hold it any longer. The resident stated he/she does not like to do that and that it made him/her feel bad. The resident stated that he/she does not have incontinent episodes often but he/she did have to wait for the bedpan for a long time Too often. | 2017-11-01 |
| 6634 | 6634 | WYNFIELD PARK HEALTH AND REHABILITATION | 115625 | 223 W.THIRD AVENUE | ALBANY | GA | 31701 | 2013-10-25 | 309 | D | 0 | 1 | X8BC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to obtain a Hemacult as ordered by the physician for one (1) (#103) and failed to administer a medication as ordered for one (1) resident (#41) of twenty eight (28) sampled residents. Findings include: 1. Review of the nurses notes for resident #103 documented that the resident was having blood tinge sheets after a bowel movement. The physician was in the building and ordered a Hemacult with the next bowel movement. The 10/9/13 SBAR Communication Form and progress note documented that the resident had a loose stool that got on the sheets. Upon observing the sheets, there was possible blood in the bowel movement. There was a notation on the physician's orders [REDACTED]. During an interview and review of the clinical record with the Resident Care Coordinator on 10/24/13 at 5:15 p.m. she confirmed that the staff wrote stool culture instead of a Hemacult. 2. Resident #41 had an abnormally high potassium level of 6.0 on 5/24/13 . On 6/3/13 the Nurse Practitioner ordered for nursing staff to hold the resident's potassium chloride medication for two days, administer one 15 gram (gm) dose of [MEDICATION NAME], and obtain a follow up potassium level on 6/7/13. A review of the June 2013 Medication Administration Record [REDACTED]. | 2017-11-01 |
| 6635 | 6635 | WYNFIELD PARK HEALTH AND REHABILITATION | 115625 | 223 W.THIRD AVENUE | ALBANY | GA | 31701 | 2013-10-25 | 312 | D | 0 | 1 | X8BC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to trim and clean fingernails for one (1) resident (#76), failed to shave one (1) male resident (A) and failed to provide timely assistance two (2) residents (A and #103) after a bowel movement of twenty eight (28) sampled residents. Findings include: 1. Observation on 10/23/13 from 9:45 a.m. to 11:40 a.m., there was a very strong bowel movement odor in resident #103's room. Nearly two (2) hours later at 11:40 a.m., staff had cleaned the resident after he/she had the bowel movement. The resident's bed linens were soiled with a large amount of feces. The resident was assessed and coded by the facility on the 7/10/13 Quarterly Minimum Data Set (MDS) as requiring extensive assistance with toilet use and total dependence on staff for personal hygiene. Review of the resident's clinical record revealed a care plan dated 2/11/13 for incontinence of bladder and bowel habits with the intervention to provide perineal care after incontinent episodes. 2. Resident #76 was observed with long, dirty and jagged fingernails on 10/22/13 at 2:00 p.m., 4:30 p.m., 10/23/13 at 10:15 a.m., 2:30 p.m., 4:45 p.m., 10/24/13 at 8:00 a.m., 9:10 a.m. (CNA providing am care), 11:45 a.m., 6:00 p.m., and on 10/25/13 at 8:30 a.m. Review of the resident clinical record revealed a care plan dated 6/21/12 which requires extensive/total assistance with activities of daily living. Review of the Quarterly MDS dated [DATE] revealed the resident requires extensive assistance with personal hygiene. An interview with certified nursing assistant (CNA) T on 10/25/13 at 11:15 a.m. revealed that they follow the CNA Care Plan for the care that has to be done for the resident. She revealed that they were able to trim and clean the residents fingernails whenever needed. An interview with the Director of Nursing on 10/25/13 at 11:30 a.m., revealed that residents fingernails should be trimmed and cleaned when needed. 3.… | 2017-11-01 |
| 6636 | 6636 | WYNFIELD PARK HEALTH AND REHABILITATION | 115625 | 223 W.THIRD AVENUE | ALBANY | GA | 31701 | 2013-10-25 | 367 | D | 0 | 1 | X8BC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to serve the correct diet as ordered by the physician for one (1) resident (#76) of twenty eight (28) sampled residents. Findings include: Review of resident #76 clinical record revealed that the resident had a physician's orders [REDACTED]. However, on 10/24/13 at 1:50 p.m. the resident was served a regular diet of fried chicken, cabbage, peas, cornbread, cake with icing. The diet card read Regular diet. The resident only ate bites of food. The resident stated that she was having a hard time lately chewing and swallowing. On 10/25/13 at 8:35 a.m., the resident was served a regular diet of sausage patty, grits, eggs, and a biscuit. The only ate bites of food. During an interview with the Director of Nursing on 10/25/13 at 2:15 p.m., she confirmed that the resident should have been served pureed diet. | 2017-11-01 |
| 6637 | 6637 | WYNFIELD PARK HEALTH AND REHABILITATION | 115625 | 223 W.THIRD AVENUE | ALBANY | GA | 31701 | 2013-10-25 | 502 | D | 0 | 1 | X8BC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and record reviews the facility failed to obtain a laboratory test to check the [MEDICATION NAME]/[MEDICATION NAME] level for one (1) resident (#68) as ordered by the physician of twenty (28) sampled residents. Findings include: Record review for resident #68 revealed the resident had a [DIAGNOSES REDACTED]. The 9/25/13 laboratory test results revealed that the resident's [MEDICATION NAME] level was low at 7.4, with an acceptable range of 10-20. On 10/1/13 the physician wrote an order to increase the resident's [MEDICATION NAME] to 400 mg for two days and then to recheck the [MEDICATION NAME] level in two weeks. Review of the October Medication Administration Record [REDACTED]. An interview on 10/25/13 at 4:30 p.m. with the Registered Nurse AA . she/he confirmed that the laboratory test had not been obtained. | 2017-11-01 |
| 6638 | 6638 | WYNFIELD PARK HEALTH AND REHABILITATION | 115625 | 223 W.THIRD AVENUE | ALBANY | GA | 31701 | 2013-10-25 | 504 | D | 0 | 1 | X8BC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined the facility failed to assure laboratory testing be done only when ordered by the primary physician for one resident (#31) of the twenty eight (28) sampled residents. Findings include: Review of the clinical record for resident #31 revealed a physician's orders [REDACTED]. Record review revealed the resident had TSH level done on 2/2/13 and 9/18/13. An interview with the Director of Nursing on 10/25/13 at 11:45 a.m. revealed that an extra TSH test had been done due to human error in the scheduling of laboratory tests and should have only been done once. | 2017-11-01 |
| 6639 | 6639 | WYNFIELD PARK HEALTH AND REHABILITATION | 115625 | 223 W.THIRD AVENUE | ALBANY | GA | 31701 | 2013-10-25 | 505 | D | 0 | 1 | X8BC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews and record reviews, the facility failed to notify the physician timely of low [MEDICATION NAME] levels for one (1) resident (#68) and an elevated potassium level for one (1) resident (#41) of twenty-eight (28) sampled residents. Findings include: 1. The medical record for resident #68 revealed a [DIAGNOSES REDACTED]. The resident had a physician's orders [REDACTED]. The resident's 9/5/13 laboratory test revealed that the resident's [MEDICATION NAME] level was low at 2.9, with the acceptable range of 10-20. The results were faxed to the resident's physician on 9/6/13. However, there was no evidence that the nursing staff verified that the physician had received the test results until 9/11/13 when the physician ordered to increase the resident's [MEDICATION NAME] to 400 mg every day for four (4) days and then to redraw the [MEDICATION NAME] level. The resident's 9 /25/13 laboratory test revealed the resident's [MEDICATION NAME] was low at 7.4 . The laboratory results were faxed to the physician on 9/26/13. However, there was no evidence that the nursing staff verified that the physician was aware of the low [MEDICATION NAME] level until 10/1/13 when a new order was written to increase the [MEDICATION NAME] to 400 mg for two (2) days and to draw a [MEDICATION NAME] level in two (2) weeks. 2. Record review for resident #41 had multiple [DIAGNOSES REDACTED]. The resident received forty (40) miliequivalents (meq) of potassium chloride daily. The resident had an abnormally high potassium level of 6.0 on 5/24/13. A review of the clinical record revealed no evidence that nursing staff attempted to initially notify the physician of the abnormal results until 5/28/13. A copy of the laboratory results documented they were faxed on 5/28/13. After not receiving any response from the physician, there was no evidence of follow up by nursing staff to ensure the results were received by the physician until 5/31/13. A cop… | 2017-11-01 |
| 6640 | 6640 | WYNFIELD PARK HEALTH AND REHABILITATION | 115625 | 223 W.THIRD AVENUE | ALBANY | GA | 31701 | 2014-11-18 | 225 | D | 1 | 0 | IO1F11 | Based on review of the facility's Grievances Abuse Prohibition Policy and Procedures, resident and staff interviews, the facility failed to immediately investigate an allegation of rough treatment from staff by one (1) resident (A) of eight (8) sampled residents. Findings include: Interview with resident A on 11/17/14 at 2:50 p.m. revealed that a staff member came into his room on 10/30/14, pulled the privacy curtain closed and told him that he needed to be changed or needed a bath. He said that he told her no, not to bother him. Resident A said that the staff member grabbed him and tried to make him get up. He then tried to get her to stop but she wouldn't. Resident A said that he started pulling and hitting her back and at that time she hit and scratched his arm by grabbing and pulling him. He added that when it was over other staff members came into his room and helped him. Resident A stated that he told the staff member to go away but she wouldn't. Review of the Minimum Data Set (MDS) for resident A indicated that on 9/17/14 his Brief Interview for Mental Status (BIMS) score was thirteen (13). Resident A was cognitively intact. Review of the Grievance Abuse Prohibition Policy and Procedures indicated in Section 1. Reporting, A.) Once a complaint or situation is identified involving alleged mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of patient property the incident will be immediately reported. 1.) The Administrator or designee will immediately notify the Complaint Investigation Intake and Referral Unit and the legal representative and/or interested family member of the incident and the pending investigation. The Ombudsman will also be notified as appropriate. The Administrator or designee will direct the investigation. Interview with the Social Worker on 11/18/14 at 9:50 a.m. revealed that resident A's family member questioned her by phone about what was going on and what had happened to the resident. The Social Worker stated that the family member reported that… | 2017-11-01 |
| 8068 | 8068 | WYNFIELD PARK HEALTH AND REHABILITATION | 115625 | 223 W.THIRD AVENUE | ALBANY | GA | 31701 | 2012-03-29 | 241 | D | 0 | 1 | LF6S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and record review, it was determined that the facility failed to promote care that enhanced one resident's (#45) dignity in a total sample of 36 residents. Findings include: Resident #45 had [DIAGNOSES REDACTED]. He/She was coded on the 1/17/12 quarterly Minimum Data Set (MDS) assessment as cognitively impaired and as needing total assistance with dressing. There was not a plan of care developed to address the resident's personal care needs, including dressing. There was a 1/17/12 social service note that the resident was not able to make his/her wants and needs known or to communicate with others. Resident #45 was observed on 3/27/12 at 8:35 a.m. sitting in a geri-chair. His/Her shirt had not been pulled down so, his/her abdomen and right breast were exposed. The resident was sitting in a geri-chair in the 4th floor activity room at 9:30 a.m. and 9:50 a.m., his/her shirt had not been pulled down so, his/her left breast and nipple were exposed. The resident was reclined in a geri-chair in the day area on the 3rd floor at 2:35 p.m. He/She had constant involuntary movements of his/her head and extremities. His/Her right side of his/her shirt was not pulled down so that the lower part of his/her right breast was exposed. | 2016-07-01 |
| 8069 | 8069 | WYNFIELD PARK HEALTH AND REHABILITATION | 115625 | 223 W.THIRD AVENUE | ALBANY | GA | 31701 | 2012-03-29 | 246 | D | 0 | 1 | LF6S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, it was determined that the facility failed to continue to provide adaptations for one resident's (#113) wheelchair to maintain proper body symmetry and to accommodate the wheelchair positioning needs for two residents (#19 and #45) in a total sample of 36 residents. Findings include: 1. Skilled therapy staff noted on the 10/10/11 physical therapy discharge report at that time, the resident #113 was using a wheelchair with bilateral lateral supports and a pommel cushion to encourage pelvic alignment. However, on 3/28/12 at 8:15 a.m., 10:00 a.m. and at 11:10 a.m., the resident was observed sitting in the wheelchair without bilateral lateral supports. The resident's body was observed to be twisted to the right side of his/her wheelchair. During those observations, the resident's wheelchair did not have footrests and his/her feet were dangling approximately two inches above the floor. In an interview on 3/29/12 at 12:15 p.m., the physical therapist stated that the use of bilateral lateral supports had not been discontinued from therapy. She stated that, from a therapy standpoint, the resident needed the lateral supports for positioning in the wheelchair. 2. Resident #19 had [DIAGNOSES REDACTED]. Licensed nursing staff completed a quarterly MDS assessment on 2/22/12. They coded the resident as needing total assistance with transfer, locomotion on/off unit, dressing, eating, toileting, bathing and hygiene. Resident #19 was observed sitting in a wheelchair without any foot rest supports on 3/26/12 during initial tour between 11:50 a.m. and 12:13 p.m. and at 2:30 p.m., on 3/27/12 at 7:30 a.m., 10:00 a.m., 11:30 a.m., 2:00 p.m., 3:35 p.m., on 3/28/12 at 7:30 a.m., 10:45 a.m., and 1:25 p.m. and on 3/29/12 at 7:50 a.m., 9:34 a.m., 10:45 a.m. and 12:20 p.m. During all of the observations, both of the resident's feet were dangling and not touching the floor. The resident did not make any attempt to … | 2016-07-01 |
| 8070 | 8070 | WYNFIELD PARK HEALTH AND REHABILITATION | 115625 | 223 W.THIRD AVENUE | ALBANY | GA | 31701 | 2012-03-29 | 253 | E | 0 | 1 | LF6S11 | Based on observations, it was determined that the facility failed to maintain an environment that was free from one ill-fitting air conditioning unit, a broken call light cover plate, one chipped wallboard, a torn curtain lining, and an ill-fitting door on a bedside table in four rooms on two (300 and 400) of four halls. Findings include: Observations were made on 3/26/12 between 11:50 a.m. and 12:13 p.m., 2:20 p.m., 2:47 p.m., 3:10 p.m. and 3:25 p.m., on 3/27/12 at 7:35 a.m. and 4:58 p.m., on 3/28/12 at 7:05 a.m. and 2:00 p.m., and/or on 3/29/12 at 9:15 a.m 300 Hall 1. The room air conditioning unit in room 306 had partially pulled out of the wall which left an opening. Sunlight outside of the building could be seen through the opening. There was dust on the wall and the air conditioner. 2. There was a brown build-up on the floor around the base of the toilet in the bathroom for room 302. A soiled urinal was stored on the back of the toilet. A soiled urinal was hanging on the grab bar in bath tub. There were four wash basins and a bedside commode stored in the bath tub. The bathroom had a urine odor. 400 hall 1. The hinge side of the door on the bedside table in room 407A was sagging. 2. There was a hole in the wall behind the B bed in room 407. 3. There were pieces missing from the call light plate in room 412. The wall around that plate was chipped. 4. The curtain lining on the window in room 417 was torn. | 2016-07-01 |
| 8071 | 8071 | WYNFIELD PARK HEALTH AND REHABILITATION | 115625 | 223 W.THIRD AVENUE | ALBANY | GA | 31701 | 2012-03-29 | 276 | D | 0 | 1 | LF6S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to complete a quarterly Minimum Data Set (MDS) assessment at least every 92 days for four residents from a sample of 49 residents. Findings include: A list of 49 residents with late or missing MDS 3.0 Federal OBRA assessments was obtained by the State Survey Agency prior to the survey. On 3/28/12 the facility provided documentation that they had identified a problem with late or missing MDS's in December 2011 and had implemented a plan of correction with a target date of completion for the end of March 2012. However, after a review of the State Survey Agency list with MDS coordinator QQ on 3/29/12 at 10 a.m., and a review of facility audits of lists of residents identified with late or missing MDS's, four residents were identified as not having a quarterly MDS assessment completed. These assessments had not been identified by the facility. 1. One resident had a quarterly MDS completed on 7/1/11. A quarterly assessment should have been completed in October 2011 prior to the resident being discharged from the facility on 11/7/11. However, the facility failed to complete the quarterly MDS. 2. One resident had an admission MDS completed on 8/16/11. A quarterly assessment should have been completed in November 2011 prior to the resident being discharged [DATE]. However, the facility failed to complete the quarterly MDS. 3. One resident had an annual MDS completed on 6/15/11. Quarterly assessments should have been completed in September and December 2011. However, the facility failed to complete the quarterly MDS's. 4. One resident had a quarterly MDS completed on 8/17/11. The facility identified on 3/27/12 that a quarterly MDS was due by 3/7/12. However, the facility failed to complete the quarterly MDS. | 2016-07-01 |
| 8072 | 8072 | WYNFIELD PARK HEALTH AND REHABILITATION | 115625 | 223 W.THIRD AVENUE | ALBANY | GA | 31701 | 2012-03-29 | 278 | D | 0 | 1 | LF6S11 | Based on observation, interviews with staff and resident, and record review, it was determined that the facility had failed to accurately code one resident's (H) dental status from a sample of 36 residents. Findings include: During the initial interview on 03/26/12 at 2:39 p.m., resident H stated that some of his/her teeth were missing and his/her dental bridge had been broken over a year ago and prior to admission to the facility. The resident did not remember if anyone had assessed his/her teeth since he/she had been in the facility. He/She said that no one had asked him/her if he/she would like to see a dentist. The resident stated chewing was difficult because of his/her missing teeth. However, a review of the 12/27/11 Minimum Data Set (MDS) assessment revealed that licensed nursing staff had inaccurately coded the resident's oral/dental status as having no concerns. See F412 for additional information regarding resident H. | 2016-07-01 |
| 8073 | 8073 | WYNFIELD PARK HEALTH AND REHABILITATION | 115625 | 223 W.THIRD AVENUE | ALBANY | GA | 31701 | 2012-03-29 | 279 | D | 0 | 1 | LF6S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility had failed to ensure that a comprehensive care plan was developed for three residents (#2, H and #45) from a total sample of 36 residents. Findings include: 1. Resident #2 was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident was coded by staff on his/her 1/10/2012 Minimum Data Set (MDS) for his/her significant change assessment as being cognitively impaired, having highly impaired vision and unclear speech, rarely/never understanding staff, totally dependent on staff for bed mobility, transfer, dressing, hygiene, bathing, eating and toileting, incontinent of bowel and bladder, receiving a tube feeding, having limitations in range of motion to bilateral upper and lower extremities, having had a urinary tract infection within the last 30 days, having had a weight loss of 5% in the last month or 10% in the last 6 months, having facial expressions of pain daily and, having received an antipsychotic, antidepressant and antibiotic medication. The resident's current care plan dated 12/2011 addressed the triggered areas for cognitive loss, activities, pressure ulcer, urinary incontinence and pain. According to the 1/23/2012 Care Area Assessment (CAA) Summary, nursing staff had documented that a care plan would be initiated for the resident to also include the triggered areas of visual function, communication, psychological well-being, activities, falls, nutritional status, feeding tubes, dehydration/fluid maintenance, and [MEDICAL CONDITION] drug use. However, staff did not develop a comprehensive care plan after the resident's 1/10/2012 significant change comprehensive assessment which addressed the triggered areas of visual function, communication, psychological well-being, falls, nutritional status, feeding tubes, dehydration/fluid maintenance and [MEDICAL CONDITION] drug use. On 3/28/2012 at 8:10 a.m., MDS coordinator SS stated that nursing staff had failed … | 2016-07-01 |
| 8074 | 8074 | WYNFIELD PARK HEALTH AND REHABILITATION | 115625 | 223 W.THIRD AVENUE | ALBANY | GA | 31701 | 2012-03-29 | 282 | E | 0 | 1 | LF6S11 | Based on observation, record review and staff interview, it was determined that the facility had failed to ensure that care plan interventions were implemented to address the personal care needs of three (#11, W and #113) residents' with dirty fingernails and one resident (W) with a heavy beard, the provision of range of motion exercises, splints, foot positioning devices and/or braces as planned for five residents ( R, W, #19, #128, and #45), and to prevent falls for one resident (#188) from a total sample of 36 residents. Findings include: 1. Resident #11 had a care plan intervention since 3/22/10 for total care including nail care by nursing staff. However, the resident was observed the have had a thick black substance underneath his/her fingernails on 3/27/12 at 8:15 a.m. and 5:00 p.m., 3/28/12 at 7:55 a.m. and 11:20 a.m. See F312 for additional information regarding resident #11. 2. Resident #113 had a 5/21/11 care plan intervention for staff to provide assistance with activities of daily living. However, the resident had a thick black substance underneath his/her fingernails on 3/28/12 at 8:15 a.m. and 2:00 p.m. and on 3/29/12 at 8:15 a.m. See F312 for additional information regarding resident #113. 3. Resident #128 had a care plan since 10/29/11 to address his/her frequent pain at multiple sites due to arthralgia. There was an intervention for active range of motion exercises to be provided by the restorative nursing staff six (6) days per week to prevent joint contracture. However, the staff had not provided active range of motion exercises to the resident. See F318 for additional information regarding resident #128. 4. Resident R had a care plan since 5/25/11 to address his/her Impaired mobility related to cognitive impairment and dementia. There was an intervention for nursing staff to perform passive range of motion exercises to affected joints as indicated and document, and to assist with positioning and transfers as necessary. There were current restorative orders for the resident to be out of bed in… | 2016-07-01 |
| 8075 | 8075 | WYNFIELD PARK HEALTH AND REHABILITATION | 115625 | 223 W.THIRD AVENUE | ALBANY | GA | 31701 | 2012-03-29 | 287 | D | 0 | 1 | LF6S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to complete and transmit two residents' discharge assessments in a total sample of 49 residents with late or missing Minimum Data Set (MDS) assessments as of 2/13/12 and one resident's (#132) entry assessment from a total sample of 36 residents. Findings include: A list of 49 residents with late or missing MDS 3.0 Federal OBRA assessments was obtained by the State Survey Agency prior to the survey. On 3/28/12 the facility provided documentation that they had identified a problem with late or missing MDS's in December 2011 and had implemented a plan of correction with a target date of completion of the end of March 2012. However, after a review of the State Survey Agency list with MDS coordinator QQ, and a review of facility audits of lists of residents identified with late or missing MDS's, three residents were identified as not having a discharge or entry MDS assessments completed by the facility. Those assessments had not been identified by the facility as having been late or missing. 1. One resident was discharged from the facility on 9/21/11. However, a discharge assessment was not completed. 2. One resident was admitted to the facility on [DATE]. The resident was no longer at the facility. However, a discharge assessment was not completed. 3. Resident #132 was hospitalized from [DATE] through 1/25/12. However, the facility did not complete an entry MDS assessment when the resident returned to the facility on [DATE]. | 2016-07-01 |
| 8076 | 8076 | WYNFIELD PARK HEALTH AND REHABILITATION | 115625 | 223 W.THIRD AVENUE | ALBANY | GA | 31701 | 2012-03-29 | 312 | E | 0 | 1 | LF6S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, it was determined that the facility failed to ensure that four residents' (#11, #45, W and #113) fingernails were clean and trimmed, that two residents' (#45 and W) were shaved and that one resident (A) was provided oral care from a total sample of 36 residents. Findings include: 1. Resident #11 was coded by the facility on the 2/10/12 quarterly Minimum Data Set (MDS) assessment as needing total assistance from staff for personal hygiene. The resident had a care plan intervention since 3/22/10 for total care by nursing staff including nail care. However, the resident was observed with a thick black substance underneath his/her fingernails on 3/27/12 at 8:15 a.m. and 5:00 p.m., and on 3/28/12 at 7:55 a.m. and 11:20 a.m. 2. Resident #113 was coded by the facility on the 1/6/12 quarterly MDS assessment as needing total assistance from staff for hygiene. The resident had a 5/21/11 care plan intervention for staff to provide assistance with activities of daily living (ADL). However, the resident was observed with a thick black substance underneath his/her fingernails on 3/28/12 at 8:15 a.m. and 2:00 p.m. and on 3/29/12 at 8:15 a.m. 3. Resident W was coded by the facility on the 2/02/12 MDS for annual comprehensive assessment as needing total assistance from staff for personal hygiene, toilet use, dressing, transfer and bathing. The resident had a care plan intervention since 2/16/12 for direct care staff to provide assistance with all ADLs. However, the resident was observed with long and dirty nails on 3/26/12 at 3:30 p.m., on 3/27/12 at 4:00 p.m., 3/28/12 at 8:50 a.m., 1:00 p.m. and 4:00 p.m. and on 3/29/12 at 8:55 a.m. and 10:30 p.m. In addition, during the observations on 3/27/12 and 3/28/12, the resident had a heavy growth of facial hair. 4. Resident A was admitted on [DATE] with [DIAGNOSES REDACTED]. Licensed staff coded him/her on the 1/10/12 significant change MDS assessment as cogni… | 2016-07-01 |
| 8077 | 8077 | WYNFIELD PARK HEALTH AND REHABILITATION | 115625 | 223 W.THIRD AVENUE | ALBANY | GA | 31701 | 2012-03-29 | 313 | D | 0 | 1 | LF6S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews with resident and staff, and record review, it was determined that the facility failed to provide services to assist one resident (W) to improve his/her vision status from a total sample of 36 residents. Findings include: Resident W had [DIAGNOSES REDACTED]. He/she was coded by staff on the 2/02/12 annual Minimum Data Set (MDS) assessment as having impaired vision without corrective lens. A consult was located in the resident's medical record from Dixon Eye Care dated 11/2/11. The resident's vision was documented as 20/80 in his/her right eye and 20/400 in his/her left eye which required eye glasses. During an interview on 3/28/12 at 2:03 p.m., resident W stated he/she did not have any glasses. He/she stated that he/she thought that the eye care vision place was waiting for the money. During an interview on 3/28/12 at 4:00 p.m., the social service staff stated that they were not aware that the resident required glasses and was also unaware of the consult from Dixon eye care that had been done on 11/02/11. Therefore, the facility had not addressed the resident's need for eye glasses to improve his/her vision. | 2016-07-01 |
| 8078 | 8078 | WYNFIELD PARK HEALTH AND REHABILITATION | 115625 | 223 W.THIRD AVENUE | ALBANY | GA | 31701 | 2012-03-29 | 318 | E | 0 | 1 | LF6S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews with residents and staff, and record review, it was determined that the facility failed to provide range of motion exercises, adaptive devices and/or ambulation assistance to maintain function, range of motion abilities and prevent contractures for five residents (W, #19, R, H and S) in a total sample of 36 residents. Findings include: 1. Resident W had [DIAGNOSES REDACTED]. He/She was coded on the 2/02/12 Minimum Data Set (MDS) assessment as needing total assistance for all activities of daily living (ADLs). There was a care plan since 2/16/12 to address his/her need for extensive assistance with activities of daily living (ADLs). There was an intervention for restorative nursing services as indicated. On the 3/10/12 Functional Program form, the occupational therapist documented that nursing staff was to properly place a left shoulder brace on the resident daily and a left resting hand splint daily to prevent further contractures. However, it was observed on 3/27/12 at 4:00 p.m., on 3/28/12 at 8:50 a.m., 1:00 p.m., 2:15 p.m. and 4:50 p.m. and on 3/29/12 on 8:55 a.m., 10:30 a.m. and 11:30 a.m., that staff had failed to apply the left resting hand splint. During the observations on 3/28/12 and 3/29/12, the staff also had failed to apply the left shoulder brace on the resident. During an interview on 3/28/12 at 2:15 p.m., resident W stated that he/she had not worn the hand splint for about two weeks. He/She stated that the shoulder brace had not been put on that morning because the girl said that she did not know how to do it. In an interview on 3/29/12 at 12 p.m., the occupational therapy aide confirmed that the staff should have applied a splint to the resident's left hand and a brace to his/her left shoulder every day. She/He said that this (the application of the splint and brace) had been a concern since the CNAs caring for the resident were made responsible for applying those splints and braces. During an … | 2016-07-01 |
| 8079 | 8079 | WYNFIELD PARK HEALTH AND REHABILITATION | 115625 | 223 W.THIRD AVENUE | ALBANY | GA | 31701 | 2012-03-29 | 323 | E | 0 | 1 | LF6S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interview, it was determined that the facility failed to maintain safe hot water temperatures in 10 rooms and one common shower on one (2nd floor) of three resident inhabited floors in the facility, and to apply a chair alarm for one resident (#188) with a history of falls from a sample of 36 residents. Findings include: During the initial tour of the facility on 03/26/12 at 12:20 p.m., the hot water temperatures on the second floor were checked by the Maintenance Director with a facility calibrated thermometer on . 1. The hot water temperature in one of two common shower rooms was 125.3 degrees Fahrenheit (F.) 2. The hot water temperature in room 205 was 124.6 degrees F.; in room 206 was 122.4 degrees F.; in room 207 was 124.5 degrees F.; in room 208 was 123.1 degrees F. and; in room 239 was 120.8 degrees F. During an interview on 03/26/12 at 1:00 p.m., the Maintenance Director stated that he had recently been hired by the facility and was unable to find previous hot water temperature log records. He later located water temperature logs which documented water temperature monitoring through 02/06/12 was done once a month in only one room on each floor. There was not any documentation that water temperatures had been monitored by staff after 02/06/12. Subsequent investigation by the facility, following the observation of elevated hot water temperatures on the 2nd floor, revealed that the hot water pump and and mixing valve were defective and required replacing. The facility consistently monitored the water temperatures until the pump and mixing valve were replaced on 3/29/12. 2. Resident #188 had [DIAGNOSES REDACTED]. He/She was coded on the 2/26/12 Minimum Data Set (MDS) assessment as having cognitive impairments and as needing total assistance for care. There were handwritten interventions on the resident's initial care plan to address his/her risk for falls. Those interventions were dated 3/22… | 2016-07-01 |
| 8080 | 8080 | WYNFIELD PARK HEALTH AND REHABILITATION | 115625 | 223 W.THIRD AVENUE | ALBANY | GA | 31701 | 2012-03-29 | 334 | D | 0 | 1 | LF6S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, it was determined the facility failed to ensure that two residents (#110 and #112) were offered the influenza and pneumococcal vaccines from a total sample of thirty-six residents. Findings include: The facility's Influenza and Pneumoccocal vaccination standing orders policy, dated 1/3/12, documented the facility would administer the influenza vaccination to residents who were [AGE] years or older, or who had a need or want to reduce the likelihood of becoming ill with the flu or transmitting it to others, or who had certain medical conditions. according to the policy, the pneumococcal vaccination would be administered to residents who were [AGE] years old or older, or who were younger than 65 but with underlying conditions. The policy was that a record of the immunizations would be maintained yearly to include the residents who received the vaccines, those who did not receive the vaccines, and those who refused the vaccines. Administrative nursing staff provided Infection Control Surveillance documentation dated 2/3/12 that stated the facility had identified it was not in compliance with immunization administration guidelines. However, as of 3/29/12, there was no evidence residents #110 and #112 had been offered the influenza and pneumococcal vaccines. 1. Resident #110 was admitted to the facility on [DATE]. An Admission Minimum Data Set (MDS) assessment was completed on 1/16/12. The assessment documented the influenza vaccine had not been offered and the pneumococcal vaccine had been offered but declined. However, there was no evidence in the clinical record the resident had been offered but declined the pneumococcal vaccine. There was no evidence the resident had been offered the influenza vaccine. 2. Resident #112 was admitted to the facility on [DATE]. An Admission MDS assessment was completed on 11/3/11. On the assessment, staff coded the resident as having had the influenza vaccine outside the facility. The asse… | 2016-07-01 |
| 8081 | 8081 | WYNFIELD PARK HEALTH AND REHABILITATION | 115625 | 223 W.THIRD AVENUE | ALBANY | GA | 31701 | 2012-03-29 | 412 | D | 0 | 1 | LF6S11 | Based on observation, record review, and resident and staff interview, it was determined that the facility failed to provide or to arrange for dental services for the one resident (H). who had dental problems from a total sample of 36 residents. Findings include: During an interview on 03/26/12 at 2:39 p.m., resident H stated that he/she was missing some teeth and that his/her dental bridge had broken prior to admission to the facility much more than a year ago. The resident did not remember anyone assessing his/her teeth since being in the facility or asking him/her if he/she wanted to see a dentist. The resident stated that chewing was difficult because of the missing teeth. There was a handwritten note dated 10/8/10 on the resident's care plan that he/she had missing teeth and poor dental hygiene. The documented goal was that he/she would be free of any oral/dental problems. However. licensed staff coded the resident on the 12/27/11 Minimum Data Set (MDS) assessment as having had no concerns with oral/dental status. There was a 3/22/12 registered dietician's nutritional assessment of the resident that he/she had problems of chewing. During an interview on 03/28/12 at 3:39 p.m., the social worker VV stated that the nurse was supposed to obtain the information about dental needs and then give it to the designated person in the financial department. On 3/28/12 at 3:50 p.m., the employee from the financial department stated that, upon admission, residents were informed about a plan for dental coverage that allowed the residents to decrease their liability owed to the facility when paying for the plan. She stated that, after admission, residents could be referred to the program for further information by notification to her by the nursing staff. She stated that, after admission, when dental concerns were discovered, she thought the nurse or social worker would communicate the (dental) concerns and follow up on them During interviews with three random LPNs on the second floor on 03/28/12 at 3:50 p.m. and again on 03… | 2016-07-01 |
| 8082 | 8082 | WYNFIELD PARK HEALTH AND REHABILITATION | 115625 | 223 W.THIRD AVENUE | ALBANY | GA | 31701 | 2012-03-29 | 428 | D | 0 | 1 | LF6S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to ensure that the consultant pharmacist identified and reported the administration of the incorrect dosage of a medication for one resident (#132) and failed to ensure that a consultant pharmacist's recommendation was reported to the physician and Director of Nursing in a timely manner for one resident (#128) in a total sample of 36 residents. Findings include: 1. According to the 2007 Drug Information Handbook for Nursing, Geriatric Considerations with the use of Levothyroxine included that TSH must be monitored since insufficient thyroid replacement (elevated TSH) is a risk for coronary artery disease. Resident #132 was hospitalized from 2/7 to 2/9/12. During that hospital stay, his/her TSH level was reported to have been elevated to 43.2 on 2/8/2012 so, his/her dosage of Synthroid was adjusted. According to the February physician's orders [REDACTED]. The 2/9/12 readmission orders [REDACTED]. They incorrectly transcribed it as 75mcg on the nursing home's physician order [REDACTED]. Review of the resident's February Medication Administration Record [REDACTED]. There was not evidence that the facility identified the transcription error from 2/9/12 until after the follow up TSH was obtained on 3/16/12. There was a follow-up TSH level done on 3/16/12. The results of that laboratory test were reported as 51.84 which was higher than when he/she was in the hospital. However, nursing staff did not notify the physician about that elevated TSH level until 3/19/12. At that time, the physician ordered a dosage change to 100mcg of Synthroid. There was no evidence that the consultant pharmacist identified and reported the transcription error and the administration of the wrong dosage of Synthroid during his/her drug regimen reviews done on 2/16/12 and 3/19/12. 2. According to the 2007 Drug Information Handbook for Nursing, the risk of bleeding with the use of Lovenox … | 2016-07-01 |
| 8083 | 8083 | WYNFIELD PARK HEALTH AND REHABILITATION | 115625 | 223 W.THIRD AVENUE | ALBANY | GA | 31701 | 2012-03-29 | 441 | E | 0 | 1 | LF6S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, it was determined that the facility failed to maintain a complete record of incidents and corrective actions related to infections. Findings include: The Director of Nursing stated on 3/29/12 at 2:40 p.m. that as of January 2012, the Resident Care Coordinators on each resident floor were responsible for maintaining the infection control logs for the residents on that floor. However, a review of the infections control logs for resident floors 2, 3, and 4, revealed the logs were incomplete for residents identified as having infections, the start and end date of antibiotics if ordered, the type of infection, any symptoms present, laboratory tests obtained, and organisms cultured. In addtion, a review of the infection control log for the facility prior to January 2012 revealed incomplete logs of infections for December 2011. During a random observation of the second floor on 3/29/12 at 2:50 p.m. one resident was noted to have isolation precautions posted outside his/her door. A review of the clinical record revealed the resident had been admitted to the facility on [DATE] with MRSA of the right hip wound. However, this resident was not included in the infection control log for the second floor. | 2016-07-01 |
| 8084 | 8084 | WYNFIELD PARK HEALTH AND REHABILITATION | 115625 | 223 W.THIRD AVENUE | ALBANY | GA | 31701 | 2012-03-29 | 505 | D | 0 | 1 | LF6S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, it was determined the facility failed to ensure the physician was notified timely of an abnormal laboratory test for one resident (#132) from a total sample of 36 residents. Findings include: Resident #132 had a [MEDICAL CONDITION] Stimulating Hormone (TSH) level obtained on 3/16/12. The results were available to the facility on [DATE]. The laboratory reported that the TSH test results were abnormally high at 51.84 from a normal range of 0.27 to 4.2. However, there was no evidence the facility notified the attending physician until 3/19/12 when, the physician ordered an increase in the dose of the medication. The resident's daily dose of [MEDICATION NAME] was increased from 75 mcg to 100 mcg. The physician also ordered that the facility obtain another TSH level for the resident in six weeks. | 2016-07-01 |
| 8990 | 8990 | WYNFIELD PARK HEALTH AND REHABILITATION | 115625 | 223 W.THIRD AVENUE | ALBANY | GA | 31701 | 2012-09-19 | 282 | D | 1 | 0 | Y8EN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, and staff interview, the facility failed to maintain head-of-bed elevation in accordance with the Plan of Care for one (1) resident (#1) who received gastrostomy tube feeding, of seven (7) residents having gastrostomy tubes, on the survey sample of eight (8) residents. Findings include: Please refer to F322 for additional information regarding Resident #1. Record review for Resident #1 revealed an order on the resident's September 2012 physician's orders [REDACTED]. The Plan of Care for Resident #1 identified the resident's use of a feeding tube, and specified as an Intervention to elevate the head of the bed at least 30 degrees. However, during an observation of Resident #1 conducted on 09/19/2012 at 12:40 p.m., the resident was observed in a flattened bed with the tube feeding on the continuous tube feeding formula running as ordered. During an interview with Certified Nursing Assistant (CNA) EE and CNA FF conducted at 12:50 p.m. on 09/19/2012, CNA FF acknowledged that the resident had been in a flat position in bed with the tube feeding running. | 2015-09-01 |
| 8991 | 8991 | WYNFIELD PARK HEALTH AND REHABILITATION | 115625 | 223 W.THIRD AVENUE | ALBANY | GA | 31701 | 2012-09-19 | 322 | E | 1 | 0 | Y8EN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, facility policy review, product manufacture instruction review, facility staff training document review, and staff interview, the facility failed to maintain head-of-bed elevation, in accordance with facility policy and the Plan of Care, for one (1) resident (#1) who received gastrostomy tube feeding, and failed to utilize a tube feeding DeClogger device as indicated by the manufacturer's instructions for one (1) resident (#5), who also had a gastrostomy tube, of seven (7) residents having gastrostomy tubes, on the survey sample of eight (8) residents. The facility also failed to train staff on the proper use of the tube feeding DeClogger device. Findings include: 1. Record review for Resident #1 revealed an order on the resident's September 2012 physician's orders [REDACTED]. The facility's policy on Feeding Systems, in the Continuous Feeding section, specified that for feedings administered via tube, if not contraindicated, to elevate the head of the resident's bed for the duration of the feeding, and to allow the resident to remain with the head elevated. Further record review revealed that the Plan of Care for Resident #1 identified the resident's use of a feeding tube, and specified as an Intervention to elevate the head of the bed at least 30 degrees. However, during an observation of Resident #1 conducted on 09/19/2012 at 12:40 p.m., the resident was observed in a flattened bed with the tube feeding on the continuous feeding mode running at 70 cubic centimeters per hour. During an interview conducted with Certified Nursing Assistant (CNA) EE and CNA FF at the time of this observation, CNA FF stated they had just transferred the resident to the bed with a mechanical lift and changed the resident's brief. During additional interview with both CNAs at 12:50 p.m. on 09/19/2012, CNA FF acknowledged that the resident had been in a flat position in bed with the tube feeding running. 2. Review of t… | 2015-09-01 |
| 9257 | 9257 | WYNFIELD PARK HEALTH AND REHABILITATION | 115625 | 223 W.THIRD AVENUE | ALBANY | GA | 31701 | 2012-08-31 | 314 | D | 1 | 0 | UTLJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and hospital document review, the facility failed to ensure that the appropriate care was provided to promote healing of existing pressure sores for two (2) residents (# 2 and #3) from a survey sample of six (6) residents. Findings include: 1. Record review for Resident #2 revealed that the June 2012 Treatment Record-Wound Assessment form documented a Stage II sacral ulcer measuring 6 centimeters (cm.) by 3.3 cms. by 0.5 cms. A 06/26/2012 order on the June 2012 physician's orders [REDACTED]. The resident's June and July 2012 Treatment Records revealed that the treatment was done as ordered on [DATE] and 06/28/2012, but was not done again until seven days later, on 07/05/2012. A 07/02/2012 notation on the resident's July 2012 Treatment Record-Wound Assessment form documented a closed fluid blister on the left foot, and that staff would skin prep the area. However, there was no evidence that the physician was notified of this area on that date, and not evidence that a treatment order was obtained. There was, however, documentation on the July 2012 Treatment Record for a (non-physician ordered) treatment of [REDACTED]. A 07/05/2012, 3:30 a.m. Interdisciplinary Progress Notes entry documented that Resident #2 had experienced a change in status, and a Notes entry of 9:15 a.m. documented that the resident had been transferred to the hospital. A 07/05/2012, 5:45 p.m. hospital Nursing Notes entry documented an assessment which described the area on the left foot as an unstageable blister. 2. Record review for Resident #3 revealed that prior to 08/06/2012, the resident had a physician's orders [REDACTED]. The resident's August 2012 physician's orders [REDACTED]. On 08/20/2012, the physician's orders [REDACTED]. However, the resident's August 2012 Treatment Record documented an entry for a (non-physician-ordered) treatment of [REDACTED]. Entries on this Treatment Record documented that this treatment was done on 08/20/2012 and on… | 2015-08-01 |
| 9919 | 9919 | WYNFIELD PARK HEALTH AND REHABILITATION | 115625 | 223 W.THIRD AVENUE | ALBANY | GA | 31701 | 2010-08-05 | 225 | D | 0 | 1 | 1EZP11 | Based on review of personnel records and staff interview, it was determined that the facility failed to thoroughly investigate the past histories of one of 18 employees hired since the last survey (6/11/09). Findings include: A review of the personnel files for 18 employees hired since 6/11/09 revealed that one employee had a hire date of 8/3/09. However, review of that employee's personnel record revealed that the results of the employee's criminal background check were not obtained until 8/20/09 (17 days later). On 8/5/10 at 11:00 a.m., the Human Resources Director confirmed that the employee had worked with the residents beginning 8/3/09 but, the results of the employee's criminal background check had not been obtained until 8/20/09. | 2015-04-01 |
| 9920 | 9920 | WYNFIELD PARK HEALTH AND REHABILITATION | 115625 | 223 W.THIRD AVENUE | ALBANY | GA | 31701 | 2010-08-05 | 253 | E | 0 | 1 | 1EZP11 | Based on observations, it was determined that the facility failed to ensure that air conditioning units were in good repair and free of dust; failed to maintain clean linen cart and splint cart covers; failed to maintain a clean water fountain; failed to maintain clean shower curtains and towel carts in the shower rooms; failed to maintain one tub in good repair in a shower room; and failed to maintain an unstained ceiling tile in one resident's bathroom on three of four (second, third and fourth) floors in the facility. Findings include: Observations were made during the initial Tour on 8/3/10 between 7:50 a.m. and 10:00 a.m. and between 3:05 p.m. and 4:15 p.m., on 8/4/10 between 11:52 a.m. and 12:30 p.m., and on 8/5/10 at 10:05 a.m. Second Floor 1. Large sections of the porcelain was chipped off of the inside of the bathtub in one of the two shower rooms. 2. There was one stained ceiling tile in the bathroom of room 205. 3. The grout around the toilet base was stained and crumbling in the bathroom of room 339. Third Floor 1. There were dried, white liquid spills on the cover of the linen cart on the central hall. 2. There were tan stains on the cover of the linen cart on the west hall. 3. There was a build-up of dust and dried brown stains on the cover of the storage cart used for residents' splints on the west hall. 4. There were dried, tan and white splatters on two linen carts on the east hall. 5. There was dust on the shelves of the towel cart in the east hall shower room. 6. There was a thick black substance at the base of the drinking spout on the water fountain in the dining room/activity room. 7. The air conditioner temperature control knob was missing in room 309. 8. The privacy curtain in room 314 had large stained areas. 9. The air conditioner vent cover was broken and had pieces missing in room 321. 10. The air conditioner vent cover had a heavy build-up of dust and debris in room 326. The window track had a build up of a black substance. Fourth Floor 1. There were dried, white liquid spills on the … | 2015-04-01 |
| 9921 | 9921 | WYNFIELD PARK HEALTH AND REHABILITATION | 115625 | 223 W.THIRD AVENUE | ALBANY | GA | 31701 | 2010-08-05 | 309 | E | 0 | 1 | 1EZP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to ensure that medications were administered as ordered by the physician for nine residents (#5, #8, #9, #12, #14, #18, #19, #22 and #24) from a total sample of 24 residents. Findings include: According to the facility's policy and procedures for 'Diabetes Monitoring', diabetic medications were supposed to be administered according to the physicians' orders. However, licensed nurses failed to administer insulin as ordered by the physician for residents #8, #24, and #22. 1. Resident #12 had a physician's orders [REDACTED]. However, review of the Medication Administration Records (MARS) revealed that licensed nursing staff had failed to administer the [MEDICATION NAME] for three of five days in August 2010, for 23 of 31 days in July 2010, for 22 of 30 days in June 2010 and for 21 of 31 days in May 2010. Although licensed nursing staff had written on those MARS to hold the [MEDICATION NAME] if the resident's blood pressure was less than 100/60, there was not a physician's orders [REDACTED]. There was no evidence that licensed nursing staff had notified the physician about the resident's blood pressure or that they had not administered the [MEDICATION NAME] as ordered. Resident #12 had a physician's orders [REDACTED]. However, review of the MARS revealed that licensed nursing staff had incorrectly administered [MEDICATION NAME] to the resident when his/her SBP was less than 120. They held it for one of four days in August 2010 (SBP was 118), for nine of 31 days in July 2010 (SBP was between 109 and 118), for 17 of 30 days in June 2010, (SBP was between 107 and 118) and for 22 of 31 days in May 2010 (SBP was between 90 and 117). Resident #12 had a physician's orders [REDACTED]. However, review of the June 2010 MAR revealed that licensed nursing staff had not applied the patch to the resident as scheduled on 6/12/10, 6/18/10, 6/21/10, 6/24/10, 6/27/10 and 6/30/10… | 2015-04-01 |
| 9922 | 9922 | WYNFIELD PARK HEALTH AND REHABILITATION | 115625 | 223 W.THIRD AVENUE | ALBANY | GA | 31701 | 2010-08-05 | 428 | E | 0 | 1 | 1EZP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the consultant pharmacist had failed to identify and report to the attending physician and director of nursing that the blood pressure was not monitored as ordered for one resident (#5); that medications were not administered as ordered for four residents (#12, #18, #14 and #19); and that medications were unavailable for two residents (#12 and #18) from a total sample of 24 residents. Findings include: 1. Resident #12 had a physician's orders [REDACTED]. The resident also had a physician's orders [REDACTED]. Although the consultant pharmacist had reviewed the medical record for resident #12 on 6/7/10 and 7/9/10, he/she had failed to identify and report to the resident's attending physician and the director of nursing that licensed nursing staff had not administered the Zestril to the resident for six of nine days in July 2010, for 22 of 30 days in June 2010, for 21 of 31 days in May 2010. The consultant pharmacist had failed to identify and report that licensed nursing staff had administered the Cardura to the resident although the resident's systolic blood pressure was less than 120 for 17 of 30 days in June 2010 and for 22 of 31 days in May 2010. The consultant pharmacist had failed to identify and report that the Transderm patch was unavailable for six of ten days in June 2010. 2. Resident #5 had [DIAGNOSES REDACTED]. The resident had a 2/8/10 physician's orders [REDACTED]. Review of the resident's MARs revealed that nursing staff failed to obtain the resident's blood pressure for seven times in April, 15 times in May, 23 times in June, and three times in July 2010. Although, the consultant pharmacist reviewed the resident's drug regimen on 6/4/10 and on 7/8/10, he/she failed to identify and report those irregularities. 3. Resident #19 had a 6/21/10 physician's orders [REDACTED]. However, review of the July 2010 MAR indicated [REDACTED]. During an interview on 8/5/10 at 12:… | 2015-04-01 |
| 9923 | 9923 | WYNFIELD PARK HEALTH AND REHABILITATION | 115625 | 223 W.THIRD AVENUE | ALBANY | GA | 31701 | 2010-08-05 | 441 | D | 0 | 1 | 1EZP11 | Based on observations and review of the Centers for Disease Control recommendations and the facility's Policy on Glucose Fingersticks, it was determined that the facility failed to ensure that licensed nursing staff wore gloves during the acquisition of fingerstick blood sugar levels for one (#11) of 24 sampled residents and three randomly observed residents. Findings include: According to the Centers for Disease Control (CDC), the recommended infection control and safe injection practices to prevent patient-to-patient transmission of bloodborne pathogens included hand hygiene (hand washing with soap and water or use of an alcohol-based hand rub) and gloves. Medical staff were supposed to wear gloves during fingerstick glucose monitoring and during other procedures that involved potential exposure to blood or body fluids. Gloves were to be changed between patient contacts. After touching potentially blood-contaminated objects, gloves were supposed to be changed before touching clean surfaces. (CDC. Transmission of Hepatitis B Virus Among Persons Undergoing Blood Glucose Monitoring in Long Term Care Facilities. MMWR 2005; 54 (09): 220-223). According to the facility's policy on obtaining glucose fingersticks, nursing staff were supposed to wash their hands and put on gloves prior to obtaining a resident's glucose fingerstick. However, a licensed nurse failed to wear gloves during the acquisition of fingerstick blood sugar levels for resident #11 and three other randomly observed residents. During observations of a licensed nurse obtaining fingerstick blood sugar levels for resident #11 and three other residents on 8/3/10 between 4:12 p.m. and 4:46 p.m., she failed to wear gloves. | 2015-04-01 |
| 9924 | 9924 | WYNFIELD PARK HEALTH AND REHABILITATION | 115625 | 223 W.THIRD AVENUE | ALBANY | GA | 31701 | 2010-08-05 | 318 | D | 0 | 1 | 1EZP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interview, it was determined that the facility had failed to provide restorative nursing services as ordered by the physician for one resident (#11) of nine residents who received restorative nursing services from a total sample of 24 residents. Findings include: Resident #11 was observed lying in the bed on 8/3/10 at 8:00 a.m.. He/She had bilateral upper and lower extremity contractures. There was a physician's orders [REDACTED]. The resident was observed wearing the bilateral hand splints and bilateral knee splints on 8/3/10 at 10:55 am., on 8/4/10 at 9:50 a.m. and on 8/5/10 at 10:00 a.m. However, review of the 8/10 Restorative Nursing Record revealed that the passive range of motion exercises and the bilateral hand and lower extremity splints were not provided for the resident for two of four days in August 2010. Restorative nursing staff had documented on the record that the services were withheld on 8/1/10 and 8/2/10. Review of the 7/10 Restorative Nursing Record revealed that the passive range of motion exercises and the bilateral hand and lower extremity splints were not provided for the resident for four of 31 days in July 2010. Restorative nursing staff had documented on the record that services were withheld on 7/2/10, 7/13/10, 7/15/10, and 7/29/10. Review of the 6/10 Restorative Nursing Record revealed that passive range of motion exercises and the bilateral hand and lower extremity splints were not provided for the resident for eight of 30 days in June 2010. Restorative nursing staff had documented on the record that services were withheld on 6/1/10 and 6/4/10 because of "lack of time". Review of the 5/10 Restorative Nursing Record revealed that passive range of motion exercises and the bilateral hand and lower extremity splints were not provided for the resident for five of 31 days in May 2010. Restorative nursing staff had documented on the record that the services had been withheld… | 2015-04-01 |
| 9925 | 9925 | WYNFIELD PARK HEALTH AND REHABILITATION | 115625 | 223 W.THIRD AVENUE | ALBANY | GA | 31701 | 2010-08-05 | 315 | D | 0 | 1 | 1EZP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to remove an indwelling catheter as ordered for one resident (#4) from a sample of three residents with indwelling catheters from a total sample of 24 residents. Findings include: Resident #4 had an indwelling catheter since at least March 2010. On 4/30/10 and 5/13/10, licensed nursing staff documented that the resident's catheter had to be changed because urine was leaking around the catheter into the resident's brief and there was no urine in his/her bedside drainage bag. On 5/18/10, the licensed nursing staff documented that the resident did not have any urine draining into his/her bedside drainage bag and urine was leaking into his/her brief. On 5/22/10, licensed nursing staff documented that the resident's catheter was not draining and urine was leaking around it into his/her brief. On 5/25/10, a physician's orders [REDACTED]. However, review of the nurses' documentation revealed that the resident's catheter was not removed until 5/28/10. During an interview on 8/5/10 at 10:30 a.m., unit supervisor "CC" confirmed that nursing staff had not removed the catheter on 5/25/10 as ordered and did not know why it was not removed until until three days later. | 2015-04-01 |
| 9926 | 9926 | WYNFIELD PARK HEALTH AND REHABILITATION | 115625 | 223 W.THIRD AVENUE | ALBANY | GA | 31701 | 2010-08-05 | 469 | F | 0 | 1 | 1EZP11 | Based on resident and staff interview, and observations, it was determined that the facility failed to maintain an effective pest control program so that the facility was free of mice and roaches on all three floors (second, third and fourth) and failed to maintain a system to evaluate the effectiveness of the program. Findings include: Fourth Floor 1. During the group interview of 8/5/10 at 10:00 a.m., one of the five residents in attendance stated that there were "rats in the hall at night" and staff put sticky trays out and caught them. That resident resided on the fourth floor. The resident stated that this was an every-night occurrence. In an interview on 8/4/10 at approximately 9:30 a.m., the maintenance supervisor said that the exterminator came out to the facility every month and as needed. He said that since poison could no longer be used in the facility, they relied on the sticky traps. He stated that, on occasion, if a hole was noted in the wall and the cobase was pulled away from the wall, the wall was sprayed with a deterrent and any holes were plugged. He said that whenever a resident reported sighting a mouse, a sticky trap was placed in that area. He said that the traps were not given to the resident to place but, staff put it under the bed and under the bedside table in addition to wherever the mouse was sighted. However, there was no evidence of any ongoing monitoring of where and when mice were sighted so that the effectiveness of the pest control system could be evaluated. Third Floor 1. During an interview with residents "R" and "Y" on 8/5/10 at 8:10 a.m., they stated that a mouse had been caught in a sticky trap in their room approximately three weeks ago. There was an empty sticky trap observed on the floor next to the resident's closet. Both residents also stated that large, three inch long roaches had been seen in their room approximately every other day for the past three months. During the interview, the residents were eating breakfast in their room and a three inch long roach crawled a… | 2015-04-01 |
| 9927 | 9927 | WYNFIELD PARK HEALTH AND REHABILITATION | 115625 | 223 W.THIRD AVENUE | ALBANY | GA | 31701 | 2010-08-05 | 282 | D | 0 | 1 | 1EZP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to implement the care plan interventions for administering medications and obtaining laboratory tests as ordered for one resident (#18) from a total sample of 24 residents. Findings include: Resident #18 had a care plan since 10/14/09 with an intervention for the licensed nurses to administer the resident's anticoagulant ([MEDICATION NAME]) medication as ordered. The resident had a 9/15/09 physician's orders [REDACTED]. However, review of the resident's May 2010 and June 2010 Medication Administration Records (MARs) revealed that the licensed nurses failed to administer the resident's [MEDICATION NAME] on 5/17/10, 5/24/10, 5/25/10, 6/12/10 and 6/16/10. The 9/15/09 order was changed on 7/8/10 to 10 milligrams (mg) of [MEDICATION NAME] on Mondays, Wednesdays, Fridays, Saturdays and Sundays and 7.5 milligrams (mg) on Tuesdays and Thursdays. However, review of the resident's July 2010 MAR indicated [REDACTED]. See F309 for additional information regarding resident #18. Resident #18 had a care plan since 10/14/09 with an intervention for the licensed nurses to administer the resident's pain medication as ordered by the physician. The resident had a 4/7/10 physician's orders [REDACTED]. However, review of the May 2010 MAR indicated [REDACTED]. The licensed nurses documented on the back of the MAR indicated [REDACTED]. During an interview on 8/5/10 at 10:05 a.m., licensed nurse "CC" stated that the medication was not administered because it was not in the facility. He/she stated that the licensed nurses had not obtained a hand written copy of the resident's prescription from the physician in order to have the medication refilled timely. See F309 for additional information regarding resident #18. Resident #18 had a care plan since 10/14/09 with an intervention for the licensed nurses to monitor his/her International Ratio (INR) blood level as ordered. The resident … | 2015-04-01 |
| 9928 | 9928 | WYNFIELD PARK HEALTH AND REHABILITATION | 115625 | 223 W.THIRD AVENUE | ALBANY | GA | 31701 | 2010-08-05 | 502 | D | 0 | 1 | 1EZP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to obtain laboratory tests as ordered for three residents (#9, #14 and #18) from a total sample of 14 residents. Findings include: 1. Resident #18 had a 7/13/10 physician's orders [REDACTED]. However, those laboratory tests were not done. During an interview on 8/5/10 at 10:05 a.m., licensed nurse "CC" stated that the order was not ever placed in the laboratory book to be obtained. 2. Resident #14 had a 7/1/10 physician's orders [REDACTED]. However, the laboratory testing was not done. During an interview with licensed nurse "CC" on 8/3/10 at 3:20 p.m., licensed nurse "CC" stated that the licensed nurses had not yet attempted to obtain the resident's stools for hemoccult testing. 3 Resident #9 was admitted with [DIAGNOSES REDACTED]. On 5/29/10, there was a hospital performed [MEDICATION NAME] laboratory test to determine the resident's blood clotting time. The initial value was 76.2 seconds and increased the next day to 86.3 (normal range between 9.5 to 11.8 seconds). According to the hospital's record, the blood thinning medication, [MEDICATION NAME], was placed on hold and a vitamin K injection was given to restore the resident's clotting capability. By 6/2/10, the hospital's laboratory test results noted that the resident's [MEDICATION NAME] level was 15.5 seconds. At that time, the [MEDICATION NAME] was restarted at "a low dose". On 6/9/10, a physician's orders [REDACTED]. level the next morning and every month thereafter. However, the July [MEDICATION NAME] laboratory test was not done. In an interview on 8/4/10 at 11:30 a.m., the licensed nurse unit manager said that the [MEDICATION NAME] laboratory test had not been entered in the facility's laboratory book for tests scheduled to be done. | 2015-04-01 |
| 9929 | 9929 | WYNFIELD PARK HEALTH AND REHABILITATION | 115625 | 223 W.THIRD AVENUE | ALBANY | GA | 31701 | 2010-08-05 | 411 | D | 0 | 1 | 1EZP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, and record review, it was determined that the facility failed to obtain dental services for one resident ("K") with complaints of jaw pain from a total sample of 24 residents. Findings include: Resident "K" had a [DIAGNOSES REDACTED]. The CNAs stated that they had seen the resident complain of jaw pain by pointing to his/her jaw. CNA "ZZ" stated during an interview on 8/5/10 at 9:45 a.m. that the resident could express pain by grunting or crying out and then pointing to where he/she hurt. During an interview on 8/3/10 at 2:45 p.m., resident "K" indicated his/her jaw hurt by nodding and cupping his/her right jaw with his/her hand when asked if he/she was having pain anywhere. A review of the resident's clinical record revealed that on 7/22/10, the physician visited the resident and documented in his progress note that the resident had possible jaw pain related to ill-fitting dentures. The physician also documented that it would be difficult to have the resident assessed in a dental office because he/she could not sit up in a chair but, would see if there was an office where he/she could be seen. The physician noted that the resident might need refitting of his/her dentures. However, there was no evidence in the clinical record that a dental follow-up had been obtained for the resident. Licensed nurse "AA" stated on 8/4/10 at 11:25 a.m. that she knew a few months ago that there was an issue with the resident's dentures not fitting correctly and staff had tried leaving them out. However, the resident liked to wear them. Licensed nurse "CC" stated on 8/4/10 at 11:25 a.m. that there had been no attempts made to obtain a dental consult for the resident. | 2015-04-01 |
| 9930 | 9930 | WYNFIELD PARK HEALTH AND REHABILITATION | 115625 | 223 W.THIRD AVENUE | ALBANY | GA | 31701 | 2010-08-05 | 328 | D | 0 | 1 | 1EZP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, it was determined that the facility failed to ensure that oxygen supplies were maintained in a sanitary manner for one resident ("S"), that oxygen supples were dated properly for three residents (#6, "V" and "S") and that [MEDICAL CONDITION] supplies were maintained in a sanitary manner for one resident (#6) from a sample of 11 residents receiving oxygen therapy and two residents with tracheostomies from a total sample of 24 residents. Findings include: According to the facility's policy and procedure for oxygen administration , the exterior of the oxygen concentrators were supposed to be cleaned weekly. 1. During observations on 8/3/10 at 8:40 a.m., 8/4/10 at 9:40 a.m. and 8/5/10 at 10:20 a.m., resident "S" was receiving oxygen at 2 liters a minute via nasal cannula. The oxygen concentrator's filter on the back of the machine had a heavy build-up of white dust. There were no dates on the resident's oxygen tubing and humidifier bottle. During an interview on 8/5/10 at 10:25 a.m., licensed nurse "DD" stated that all oxygen equipment and supplies were supposed to be cleaned and replaced every Wednesday night by the night nurse and that the nurse was supposed to date the humidifier bottle with a black marker when it was changed. 2. During the initial tour on 8/3/10 between 8:10 a.m. and 8:50 a.m., resident "V" was receiving oxygen through a nasal canula. The oxygen concentrator humidifier bottle was dated 7/5/10. However, in an interview on 8/4/10 at 12:30 p.m., the registered nurse (RN) charge nurse stated that all oxygen tubing, humidifier bottles and nebulizer tubing were supposed to be changed every Thursday and as needed. On 8/5/10 at 8:00 a.m., resident "V" was observed sitting up in a wheelchair in his/her room. The resident was not receiving oxygen at the time but, stated that he/she needed it. He/she stated that there had been water dripping in his/her nose whenever he/she used th… | 2015-04-01 |
| 9931 | 9931 | WYNFIELD PARK HEALTH AND REHABILITATION | 115625 | 223 W.THIRD AVENUE | ALBANY | GA | 31701 | 2010-08-05 | 322 | D | 0 | 1 | 1EZP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and record review, it was determined that the facility failed to ensure the head of the bed was elevated while nutritional formula was infusing for one resident (#4) and to administer flushes and medications by gravity flow for one resident (#1) and to administer water flushes at the appropriate temperature and by gravity flow for one resident (#14) for a total of three residents in a sample of ten residents with gastrostomy tubes from a total sample of 24 residents. Findings include: According to the facility's policy and procedure for tube feedings, all residents receiving continuous feedings were to have the head of the bed raised to 30 to 45 degrees for at least half an hour after flushes and medication administration. Nursing staff were not supposed to force solution into the tube but, allow it to flow by gravity. 1. Resident #4 had a gastrostomy tube for feedings since at least June 2009. He/She had a physician's orders [REDACTED]. Upon entering the resident's room on 8/4/10 at 10:30 a.m. to observe urinary incontinence care being provided by certified nursing assistant "EE", the head of the resident's bed was flat while the feeding was infusing at 55 ml per hour. CNA "EE" was obtaining supplies for the procedure when the resident began coughing. The resident coughed approximately five more times before CNA " EE" elevated the head of the resident's bed and paused the feeding. After elevating the head of the resident's bed, he/she stopped coughing. 2. Resident #1 had a gastrostomy tube in place with an order to administer 50 ml of water flush before and after medications. During observation of medication pass on 8/4/10 at 8:15 a.m., licensed nurse "FF" used a syringe to push the water flush through the resident's gastrostomy tube before and after giving the medications. She did not allow it to flow by gravity. Licensed nurse "FF" also pushed 30 ml of liquid Prostat through the tube with a syringe and failed to allow… | 2015-04-01 |
| 9932 | 9932 | WYNFIELD PARK HEALTH AND REHABILITATION | 115625 | 223 W.THIRD AVENUE | ALBANY | GA | 31701 | 2010-08-05 | 371 | F | 0 | 1 | 1EZP11 | Based on observation and staff interviews, it was determined that the facility failed to ensure that the correct water temperatures were being obtained during the wash and rinse cycle of the dishwasher. Findings include: During observation of the use of the dishwasher on 8/4/10 at 12:50 p.m. with the assistant dietary manager, she stated that the acceptable water temperatures for the wash and rinse cycles were between 110 and 120 degrees Fahrenheit (F.). However, the manufacturer's recommendations posted on the dishwasher listed the accepted temperatures for the wash and rinse cycles as 120 degrees F.. Observations of the dishwasher thermometer while dietary staff ran the machine for three complete (wash and rinse) cycles on 8/4/10 at 12:50 p.m. revealed that the wash water temperature was only 110 degrees F. and the highest rinse water temperature was 118 degrees F.. During observations on 8/5/10 at 8:45 a.m. with the Dietary Manager and Maintenance Manager, the dishwasher water temperatures were 100 degrees F. for the wash cycle and 110 degrees F. for the rinse cycle. On the third wash and rinse cycles, the water temperatures were 120 degrees F.. The Maintenance Director stated, at that time, that the machine should be run for at least 4 cycles before washing and rinsing the dishes to ensure the correct water temperatures. | 2015-04-01 |
| 10262 | 10262 | WYNFIELD PARK HEALTH AND REHABILITATION | 115625 | 223 W.THIRD AVENUE | ALBANY | GA | 31701 | 2011-06-07 | 469 | E | 1 | 0 | 5JU611 | Based on resident interview, staff interview, and review of the Resident Council minutes, the facility failed to ensure that an effective pest control system was in place on two (2) floors (third and forth floors) of three (3) resident floors. Findings include: 1. The following resident interviews were conducted on the fourth floor on the facility: - Resident "A" stated, during interview on 06/07/11 at 4:00 p.m., that large cockroaches with wings come out on the floor from around the built-in closet area at night, and not during the day. He stated that this occurs nightly, as recently as the previous night, and that he would get up and try to "stomp" them. He stated this has happened since the previous month. The resident stated that he had reported this problem about the cockroaches to the Maintenance Director, who had had put out sticky traps. Prior interview with the Administrator on 06/07/2011 at 2:30 p.m. revealed that a new Maintenance Director had started on 05/31/2011. - Resident "B" stated, during interview on 06/07/2011 at 4:05 p.m., that she had been in the facility in her current room for approximately two months. The resident stated that she had seen large roaches under the other resident's bed in her room, the week before last. She stated that she did not like roaches. - Resident "C' stated, during interview on 06/07/2011 at 4:10 p.m., that she had seen large roaches at night. She stated that she had reported these roaches to a nursing staff member. - Resident "D" stated, during interview on 06/07/2011 at 4:15 p.m., that she had reported large roaches in her room about 2 to 3 days prior. 2. The following resident interviews were conducted on the third floor of the facility: - Resident "E" stated, during interview on 06/07/2011 at 4:45 p.m., that he had seen a large roach in his room a couple of nights prior. He stated that this problem with roaches had been reported in the Resident Council meetings. - Resident "F" stated, during interview on 06/07/2011 at 5:10 p.m., that he had observed large roache… | 2014-10-01 |
| 6069 | 6069 | WRIGHTSVILLE NURSING HOME | 115406 | 608 WEST COURT STREET | WRIGHTSVILLE | GA | 31096 | 2014-10-02 | 431 | D | 0 | 1 | 0FZL11 | Based on observation, Expired Drug Policy, Controlled Drug Reconciliation Policy, review of the Controlled Drug Record and staff interviews, the facility failed to ensure expired medications were disposed of in a timely manner and failed to ensure that Controlled Medication were reconciled accurately for one (1) resident (#10) on one (1) of four (4) medication cart . Finding includes: Observation of the medication cart (hall one) on 9-30-14 at 12:30 p.m. revealed the following medication was found to be expired: One (1) opened bottle (with an open date of 9-29-14) of ALL DAY ALLERGY Tablets with an expiration date of 02/2014. An interview with Licensed Practical Nurse (LPN) AA on 9-30-14 at 2:20 p.m. revealed that she confirmed this medication was expired. Review of the Facility policy titled Wrightsville Nursing Home Expired Drug Policy revealed the charge nurse should check the expiration dates of the medications on the medication cart at the beginning of their shift to prevent an expired drug being administered to a resident. Review of the Controlled Drug Record Form (Hall 2) for one (1) resident (#10) who had an physician's order for Lyrica capsule 50 milligram (mg), had fifteen (15) tablets available. Observation of the Lyrica 50 mg package for resident #10 revealed sixteen (16) tablets remained in the medication package. An interview with Licensed Practical Nurse (LPN) BB on 9-30-14 at 1:30 p.m. revealed the Controlled Drug Record (CDR) and the medication packet did not match but they should. Continued interview with LPN BB revealed that this was missed during the morning count with the off-going nurse. Review of the Facility policy titled Wrightsville Nursing Home Controlled Drug Reconciliation Policy revealed the controlled drugs must be reconciled every shift by the oncoming and off-going charge nurses. | 2018-04-01 |
| 6070 | 6070 | WRIGHTSVILLE NURSING HOME | 115406 | 608 WEST COURT STREET | WRIGHTSVILLE | GA | 31096 | 2014-10-02 | 465 | E | 0 | 1 | 0FZL11 | Based on observations, and staff interview, the facility failed to ensure that one (1) of two (2) ice machines, located in the main dining room, were maintained in a sanitary manner. Findings include: Observation of the ice machines on 9/29/14 at 10.45 a.m. revealed the facility had two (2) ice machines located in the main dining area. The smaller ( Manitowoc, S model ) ice machine had a copious amount of a dark brown substance on the plastic shield inside the ice compartment. Observation of the smaller ( Manitowoc, S model ) ice machine on 9/29/14 at 10.50 a.m. with the Maintenance Director revealed a copious amount of a dark brown substance on the plastic shield inside the ice compartment. The Maintenance Director verified, at this time, the presence of the dark brown substance and revealed he is responsible for cleaning the ice machines monthly. The Maintenance Director revealed that he was not aware of a specific policy relating to cleaning the ice machines although he does keep a Preventive Maintenance Program (monthly) log for cleaning the ice machines. Review of the cleaning schedule for the ice machines revealed the Preventive Maintenance Program log does not specify which ice machine is cleaned monthly although there is a date of September 5th, 2014 with a note of OK. | 2018-04-01 |
| 7052 | 7052 | WRIGHTSVILLE NURSING HOME | 115406 | 608 WEST COURT STREET | WRIGHTSVILLE | GA | 31096 | 2012-11-29 | 160 | D | 0 | 1 | NWYL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to convey resident's funds within thirty (30) days of death for two (2) residents (AA and BB) of five (5) residents records reviewed. Findings include: 1. Review of the resident trust fund account for resident AA revealed that the resident expired on [DATE]. The remaining balance in the resident's trust fund account was one hundred and eight dollars and fifty five ($108.55) which was no dispersed until [DATE]. 2. Review of the resident trust fund account for resident BB revealed that the resident expired on [DATE]. The remaining balance in the resident's trust fund account was six hundred and forty two dollars and twelve cents ($642.12) which was not dispersed until [DATE]. Interview with the facility bookkeeper on [DATE] at 10:15 a.m. revealed that the bookkeeper was aware that funds for deceased residents must be dispersed to the responsible party within thirty (30) of the death of a resident. Continued interview revealed that the bookkeeper verified that funds for these residents were not dispersed within the thirty (30) day time frame. | 2017-08-01 |
| 7053 | 7053 | WRIGHTSVILLE NURSING HOME | 115406 | 608 WEST COURT STREET | WRIGHTSVILLE | GA | 31096 | 2012-11-29 | 279 | D | 0 | 1 | NWYL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop a care plan related to urinary incontinence for one (1) resident (#102) from a sample of twenty four (24) residents. Findings include: Resident #102 was admitted to the facility in 8/2012 with a [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed that resident was assessed as occasionally incontinent and the care area assessment (CAA) summary revealed that urinary incontinence had triggered and would be addressed in the care plan. There was no evidence that a care plan was developed for urinary incontinence. Continued review revealed that the resident had a fall on 10/22/12 resulting in a fracture of his right hip and hospitalization . After readmission to the facility on [DATE], a Significant Change MDS assessment was completed, dated 11/1/12, revealing that the resident was assessed as always incontinent of bladder. A second review of the resident care plan revealed no evidence that a care plan had been developed for urinary incontinence. Interview with the MDS Coordinator, on 11/27/12 at 3:53 p.m., revealed that she acknowledged that there was not a care plan for urinary incontinence. | 2017-08-01 |
| 9151 | 9151 | WRIGHTSVILLE NURSING HOME | 115406 | 608 WEST COURT STREET | WRIGHTSVILLE | GA | 31096 | 2011-04-29 | 241 | E | 0 | 1 | D4MS11 | Based on observation and staff interviews the facility failed to promote/maintain resident dignity during the dining experience for fifteen (15) of seventeen (17) in the secure unit dining area. Findings include: Observation on 4/26/11 at 12:30 p.m. revealed twelve (12) residents eating in the secured unit dining area. Continued observation revealed that the only utensils available to the residents was a plastic spoon. Three (3) residents had whole pork chops on their plate, one (1) resident picked up the pork chop and bit it and two (2) residents used their spoons to cut their meat without much success. Continued observation revealed that three (3) residents were served from Styrofoam plates, one (1) because staff was afraid the resident would hurt him/herself with any other type of dishes and two (2) because they cough and spit in their plates. Interview 4/28/2011 at 12:30 p.m. with resident "A" revealed that the kitchen always sends plastic spoons but never knives and forks. Continued interview revealed that she can usually eat all the food with the spoon but sometime he/she needs a fork. Interview 4/28/2011 at 12:50 p.m. with Certified Nursing Assistant (CNA) "DD" revealed that the residents get plastic spoons because they might harm themselves or staff with metal silverware. However, the CNA was unable to verbalize any time when someone was attacked with silverware. Continued interview revealed that none of the residents eating in the secure unit dining area exhibited violent behaviors. Interview 4/28/11 at 1:17 p.m. with the Dietary Manager revealed that she was instructed by the nurses to send the plastic spoons for resident safety and that plastic spoons have been used for about six (6) month. Interview 4/28/2011 at 2:23 p.m. with the Director of Nursing (DON) revealed that plastic spoons were being used for resident safety. Continued interview revealed that the DON was not aware of any violent behavior from any of the residents on the secure unit and that she was not aware of any residents eating on Styr… | 2015-08-01 |
| 9152 | 9152 | WRIGHTSVILLE NURSING HOME | 115406 | 608 WEST COURT STREET | WRIGHTSVILLE | GA | 31096 | 2011-04-29 | 280 | D | 0 | 1 | D4MS11 | Based on observations, record review, staff interviews and review of the facility documents, the facility failed to revise the care plan to reflect new approaches after a fall on 4/16/11 for one (1) resident (#77) from a sample of thirty-three (33) residents. Findings include: Review of the medial record for resident #77 revealed that the resident had a fall on 4/6/11 and again on 4/16/11. Review of the resident's care plan dated 1/19/11 revealed a care plan for at risk for falls related to daily antipsychotic medications, with the following approaches: Observe for increased Lethargy and malaise, awareness of environmental hazards, report any unsteady gait and notify physician if any falls occur. Interview with the Restorative Nurse on 4/28/11 at 1:14 p.m. revealed that after a resident falls, the intervention is put on the Care Tracker and then added to the resident's care plan. Continued interview revealed that the care plan was not revised to reflect any new approaches after resident #77 experienced a second fall on 4/16/11. | 2015-08-01 |
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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 );