cms_GA
Data source: Big Local News · About: big-local-datasette
10,655 rows sorted by inspection_date descending
This data as json, copyable, CSV (advanced)
| Link | rowid | facility_name | facility_id | address | city | state | zip | inspection_date ▲ | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 227 | 227 | MAGNOLIA MANOR OF COLUMBUS NURSING CENTER - EAST | 115124 | 2010 WARM SPRINGS RD | COLUMBUS | GA | 31904 | 2020-02-27 | 578 | E | 0 | 1 | WB3D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and review of the policy titled, Advance Directives the facility failed to obtain a Physician's signature and a concurring Physician's signature for a Physician order [REDACTED]. (R) (R#67, R#120, R#118). Findings include: Review of the facility's policy titled, Advanced Directives documented the following: C. Procedures for periodically reviewing resident choices and preferences related to health care decisions after admission: 7. During Advanced Care Planning (ACP) conversations, education may be provided to residents on the Georgia Physician order [REDACTED]. The POLST is a physician's orders [REDACTED]. a. A POLST that has been appropriately completed will be accepted and followed by the facility. Review of the Advanced Directives policy related to residents without any advance directive revealed the following: B. The physician will have his/her medical decision concurred with by another physician when possible. 1. Review of medical record for R#67 revealed a POLST with a choice to allow natural death/DNR. The form was signed by one Physician and a family member that was not the residents Power of Attorney, but there was no concurring Physician's signature nor was the form dated. Further review of the Medical Record for R#67 revealed that there was not a Health Care Agent for R#67. 2. Review of medical record for R#120 revealed a POLST with a choice to allow natural death/DNR. The form was signed by a family member on 1/22/2020 but the form was not signed by a Physician. Further review of the medical record revealed that R#120 did not have a health care agent. During an interview with the Director of Nursing (DON) on 2/26/2020 at 2:18 p.m. revealed that on admission the nurse asks resident and family member regarding code status. It was further reported that Social Services was responsible for following up with the resident and family member regarding code status and Advanced directives. The DON a… | 2020-09-01 |
| 228 | 228 | MAGNOLIA MANOR OF COLUMBUS NURSING CENTER - EAST | 115124 | 2010 WARM SPRINGS RD | COLUMBUS | GA | 31904 | 2020-02-27 | 684 | D | 0 | 1 | WB3D11 | Based on observation, record review and staff interview, the facility failed to follow Physician's order for a splinting device and for a pureed renal diet for one resident (R) A) of 50 residents reviewed. Findings include: Review of R#A's medical record revealed a Physician's dietary order for a renal pureed diet. There was also a restorative order for splint to bilateral lower extremities for three hours a day as tolerated and splint to right knee for 6 to 8 hours daily. Restorative Supervisor provided a copy of daily restorative care for R# [NAME] Review of the restorative form revealed restorative services 21 days in (MONTH) and 15 days in (MONTH) 2020. Further review of the documentation did not reveal that splint devices were applied or refused for R# [NAME] During observations of R#A on 2/25/2020 at 8:53 a.m. and 2:40 p.m., 2/26/2020 at 8:42 a.m. and 1:05 p.m. there was no splinting device observed. During lunch observations on 2/24/2020 at 12:10 p.m. and 2/26/2020 at 12:13 p.m. there were no lunch trays delivered to room for R# [NAME] During an interview with R# A family member 2/26/2020 at 1:05 p.m. revealed that R# A had not received a meal tray since returning from the hospital in (MONTH) 2019. During an interview with Unit Manager MM on 2/26/2020 at 2:04 p.m. revealed that R# A had not received a pleasure tray since (MONTH) 2019 when he/she returned from the hospital. Unit Manager then confirmed current dietary order for pureed renal diet for R# [NAME] During an interview with the Director of Nursing on 2/26/2020 at 4:34 p.m. revealed that the nurse should have checked the orders. The DON also reported that the registered dietitian should have followed up on admission once it was determined that the order changed for dietary. The DON further revealed that there should have been clarification orders for the splints since the resident no longer was using those. During an interview with the DON on 2/26/202 at 5:18 p.m. revealed that when residents returned from hospital there was no order for the pureed … | 2020-09-01 |
| 229 | 229 | MAGNOLIA MANOR OF COLUMBUS NURSING CENTER - EAST | 115124 | 2010 WARM SPRINGS RD | COLUMBUS | GA | 31904 | 2020-02-27 | 695 | D | 0 | 1 | WB3D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff interviews, and review of the facility policy titled, Medication Administration the facility failed to obtain a Physician's Order for one of 26 Residents (R) (R#55) receiving oxygen. Findings include: Review of Medication Administration Policy updated on (MONTH) 2019 indicated, Medications are administered as prescribed, in accordance with good nursing principles. Guidelines are as follow but not limited to 1) Medications are administered in accordance with a valid prescriber order. 2) All current medications and dosage schedules, except topical medications used for treatments, are listed on the patient's Medication Administration Record [REDACTED] Review of Most current comprehensive Minimum Data Set (MDS) assessment dated [DATE] in Section O revealed R#55 received oxygen while a resident at the facility. Observations on 2/24/2020 at 11:34 a.m. revealed R#55 receiving oxygen therapy via nasal cannula at 2 LPM (liters per minute). Observations on 2/25/2020 at 9:21 a.m. and 2/25/2020 at 4:57 p.m. revealed R#55 receiving oxygen therapy via nasal cannula at 1.5 LPM. Review of the Medication Administration Record [REDACTED]. Review of Nursing notes during the time period of 12/24/19 through 2/25/2020 revealed R#55 received oxygen administration while at the facility. Review of care plan updated on 12/24/19 revealed R#55 was readmitted back to facility after a five-night hospital stay for [DIAGNOSES REDACTED]. Review of Medication Reconciliation form dated 12/24/19 upon return from hospital stay revealed no oxygen listed under active medication orders. Interview on 2/26/2020 at 3:20 p.m. with Registered Nurse (RN) KK revealed R#55 received oxygen at 2LPM continuously, but she has a history of taking it off on occasions. RN KK confirmed that oxygen should not have been given without an order and that it should have been documented on MAR for R#55. RN KK stated the admitting nurse should have clarified the… | 2020-09-01 |
| 230 | 230 | MAGNOLIA MANOR OF COLUMBUS NURSING CENTER - EAST | 115124 | 2010 WARM SPRINGS RD | COLUMBUS | GA | 31904 | 2020-02-27 | 760 | D | 0 | 1 | WB3D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and review of the facility's form titled, Control Drug Record, the facility failed to accurately reconcile a medication count with the off going shift for one of four medication carts that was reviewed for correct narcotic count/medication reconciliation. Findings include: On [DATE] at 10:04 a.m. observations were conducted for four of the eight medication carts to check for expired, unlabeled or undated medications. A narcotic count/dose check and review of the medication reconciliation form was also conducted on the four (4) medication carts: on Unit N1 (low side), Unit S2 (low side), Unit N2 (high side) and Unit S2 (high side). During the medication cart check on Unit S2 (low side) on [DATE] at 2:00 p.m. with LPN FF, a narcotic count/dose check was conducted. The narcotic medications were double locked. The medication cart was organized and clean. A review of the facility form titled, Controlled Drug Shift Audit Report revealed that the most recent narcotic reconciliation was documented as conducted on [DATE] from 6:45 a.m. to 7:15 a.m. with two nurse signatures documented; LPN OO, the off going shift nurse and LPN GG, the oncoming shift nurse. This form had documentation on the bottom that indicated that if any error cannot be reconciled, an incident report MUST be completed before reporting off shift and signed by both nurses. Review of the physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED] During the narcotic count and observation with LPN FF of the 15-medication dose packet ordered by the Physician on [DATE], this revealed two (2) [MEDICATION NAME] 150 mg capsules left in the bubble pack. The facility form titled, Control Drug Record for [MEDICATION NAME] 150 mg capsule documented on [DATE] at 7a.m. that one (1) capsule was left in the packet, signed by LPN OO, indicating a discrepancy. During the narcotic count and observation with LPN FF of a another 15-medica… | 2020-09-01 |
| 231 | 231 | MAGNOLIA MANOR OF COLUMBUS NURSING CENTER - EAST | 115124 | 2010 WARM SPRINGS RD | COLUMBUS | GA | 31904 | 2020-02-27 | 761 | E | 0 | 1 | WB3D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and review of the facility policy's titled, Pharmacy Services- Medication Storage in the Care Center and the facility policy titled, Pharmacy Services- Medication Administration-General, the facility failed to maintain temperature logs for 4 of 4 medication refrigerators, and failed to ensure food was not stored with medications in 2 of 4 medication refrigerators. In addition, the facility failed to ensure food was not stored in 1 of 8 medication carts and failed to ensure multi-dose medications were labeled with an open date to assist in determining a discard date in 4 of 8 medication carts. Findings include: A review of the facility policy titled, Pharmacy Services- Medication Storage in the Care Center, updated 10/2019, documented that medications and biologicals are stored safely, and properly following manufacturer's recommendation or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. At section No. 16, policy documented that refrigerated medications are kept in closed and labeled containers with internal and external medications separated and separate from fruit juices, applesauce, and other foods used in administering medications. Other foods are not stored in this refrigerator. A review of the facility policy titled, Pharmacy Services- Medication Administration-General, documented that the intent is that medications are administered as prescribed, in accordance with good nursing principles. At section No. 5, policy documented that medications dispensed for multi-use, e.g. blister/punch cards, large volume liquids, multidose vials, shall be labeled by the nurse as to the date of first use or first administration. Check expiration date of the medication. Under no circumstances should an expired medication be administered to a patient. Observations and medication storage checks we… | 2020-09-01 |
| 232 | 232 | MAGNOLIA MANOR OF COLUMBUS NURSING CENTER - EAST | 115124 | 2010 WARM SPRINGS RD | COLUMBUS | GA | 31904 | 2020-02-27 | 812 | E | 0 | 1 | WB3D11 | Based on observation, staff interview, and review of the facility policy titled, Ice Machines Policy & Procedure the facility failed to maintain the cleanliness and sanitation of the ice machine in the resident pantry. This had the potential to effect 123 residents receiving an oral diet. Findings include: Review of the facility policy titled Ice Machine Policy & Procedure revealed Policy: The following procedure will be followed check water filter, check air filter, clean coils, sanitize interior, and clean interior. Observation on 2/24/2020 at 11:20 a.m. of the ice machine of the south two pantry revealed yellow and brown stain on the outside door. Inside of the ice machine had a same yellow and brown debris. The metal joints (hinges that holds the door on) were brown in color. The side of the ice machine had grayish color debris going down the side. Inside the ice machine noted the metal joints brown in color was running into the ice. Inside the ice machine the upper inner splash panel has small specks of black debris Observation and interview on 2/26/2020 at 10:30 a.m. with the Maintenance Supervisor (MS) revealed a leaky brown rusty substance dripping into the ice machine. Interview at the time of the observation with the MS revealed that his expectations are for the ice machine to be cleaned thoroughly and free from grime and debris. He states it's his responsibility to check the ice machine on a monthly basis and that the ice filter is to be changed every ten years. He reported he didn't feel the residents could get sick from the leaky substance. Interview on 2/26/2020 at 1:44 p.m., the Maintenance Director (MD) revealed that it's his expectation is for the ice machine to be put on a preventative maintenance work log that is reviewed and checked off every six months. The MD described the filmy and flaky substances as a product of corrosion which resulted from water residue and calcium deposit built up, The MD further stated that he has since contacted the equipment service company to come out and clean/rep… | 2020-09-01 |
| 1470 | 1470 | ROSWELL NURSING & REHAB CENTER | 115422 | 1109 GREEN STREET | ROSWELL | GA | 30075 | 2020-02-27 | 554 | D | 0 | 1 | HR4Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the facility's interdisciplinary team failed to determine if the practice of self-administration of eye drops would be safe for the resident to perform for one of 39 sampled residents (Resident (R) 19). As a result of this deficient practice the R19 did not store the eye drops safely and securely. This deficient practice had the potential for the resident to not administer the eye drops as ordered by the physician, not follow infection control practices and safely or securely store the medications. Findings include: Review of R19's Face Sheet indicated was admitted to the facility on [DATE] and readmitted on [DATE], with a [DIAGNOSES REDACTED]. Review of R19's quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) date of 11/18/19 indicated that R19's Brief Interview for Mental Status (BIMS) score was 14 out of 15 which indicates the resident is cognitively intact. On 02/24/20 at 3:12 PM, four bottles of eye drops (one bottle of [MEDICATION NAME], one bottle of Dorzolamide, and two bottles of [MEDICATION NAME]) were on the edge of the over the bed table in R19's room. The resident explained they were the eye drops he used for his [MEDICAL CONDITION] and he had them in the room to administer the drops himself. R19 confirmed he had been self-administering the three eyedrops at the facility for a long time. Review of R19's Physician order [REDACTED]. Review of R19's Interdisciplinary Care Plan Conference Records dated 04/16/19, 07/23/19, 08/20/19, 10/01/19 and 12/31/19, lacked documented evidence the resident was evaluated for safe self-administration of eye drops. Review of R19's Care Plan lacked documented evidence of interventions for self-administration of eye drops. Review of R19's Medication Administration Record [REDACTED]. On 02/26/20 at 10:04 AM, the Registered Nurse (RN) confirmed eye drops were administered by the nursing staff and the residents do not s… | 2020-09-01 |
| 1471 | 1471 | ROSWELL NURSING & REHAB CENTER | 115422 | 1109 GREEN STREET | ROSWELL | GA | 30075 | 2020-02-27 | 656 | D | 0 | 1 | HR4Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and policy review the facility failed to develop a comprehensive care plan for self-administration of medications for one of 39 residents (Resident (R) 19), selected for review. This deficient practice had the potential to effect other residents in the facility who have specific needs not identified and documented in the care plan for care. Findings include: Review of R19's Face Sheet indicated was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. On 02/24/20 at 3:12 PM, four bottles of eye drops(one bottle of [MEDICATION NAME], one bottle of Dorzolamide and two bottles of [MEDICATION NAME]) were on the edge of the over the bed table in R19's room. The resident explained they were the eye drops for [MEDICAL CONDITION] and he had them in the room to administer himself. R19 confirmed he had been self-administering the three eyedrops at the facility for a long time. Review of R19's Interdisciplinary Care Plan Conference Records dated 04/16/19, 07/23/19, 08/20/19, 10/01/19 and 12/31/19, lacked documented evidence the resident was evaluated for safe self-administration of eye drops. Review of R19's Care Plan lacked documented evidence of interventions for self-administration of eye drops. On 02/26/20 at 1:08 PM, the Nurse Manager explained R19 wanted his eye drops by his bedside and had been administering them himself in the facility. On 02/27/20 at 11:37 AM, the Nurse Manager verified R19's care plan did not address self-administration of eye drop medications. and confirmed that the resident was self-administering the three eye drops. On 02/27/20 at 2:12 PM, the Director of Nursing (DON) confirmed R19 had been self-administering his eye drops without the creating a care plan for self-administration of medication. Review of the facility's policy titled, Care Planning-Resident Participation, dated 12/17, indicated the center will encourage and assist the r… | 2020-09-01 |
| 1472 | 1472 | ROSWELL NURSING & REHAB CENTER | 115422 | 1109 GREEN STREET | ROSWELL | GA | 30075 | 2020-02-27 | 657 | D | 0 | 1 | HR4Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and policy review the facility failed to update resident care plans for fall risk interventions for two of 39 residents (Resident (R) 134 and 151) reviewed for falls As a result of this deficient practice R134 had inappropriate interventions and R151 did not have new interventions after two falls in (MONTH) 2020. This deficient practice had the potential to effect other residents identified by the facility as being at risk for falls. Findings include: 1. Review of R134's Face Sheet indicted was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of R134's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ADR) of 01/21/20, documented the resident's functional status for bed mobility as totally dependent and required full staff performance every time in the seven day look back period. Review of R134's Fall Risk Evaluation, dated 12/10/19, identified a score of 19. If the total score is 10 or greater HIGH RISK for potential falls. The evaluation documented R134 was disoriented x (times) 3 at all times and unable to stand or walk. Review of R134's care plan titled, I am at risk for falls related to cognitive and physical impairment documented an intervention to be sure the call light is within reach and encourage use for assistance as needed. On 02/26/20 at 2:17 PM, the Registered Nurse (RN)1 confirmed R134 does not move in bed and does not use the call light to ask for help. On 02/26/20 at 2:21 PM, the Nurse Manager explained for a resident with a high risk for falls and totally dependent on nursing care there should be interventions in the care plan for rounds every two hours, place close to the nursing station and in bed A-close to the door in the resident room. After reviewing R134's care plan for fall risk, the Nurse Manager verified the intervention for placing the call light within reach was inappropriate and stated that the care plan should have been updated to … | 2020-09-01 |
| 1473 | 1473 | ROSWELL NURSING & REHAB CENTER | 115422 | 1109 GREEN STREET | ROSWELL | GA | 30075 | 2020-02-27 | 689 | D | 0 | 1 | HR4Z11 | Based on observation, resident interview, staff interview and review of facility's policy, the facility failed to secure using a rack/holder/stand for three of three portable oxygen tanks in Resident (R)100's room. The unsecured supplemental oxygen tanks could fall over with a risk of injury to R100. Findings include: Observation of R100's room on 02/27/20 at 8:15 AM revealed three green oxygen tanks standing without support. Interview on 02/27/20 at 8:15 AM, R100 stated he was told the tanks were empty and did not require to be secured. Interview with the Staff Development Coordinator/ RN on 02/27/20 at 2:30 PM confirmed the oxygen tanks are to be stored in a holder/rack/stand for safety and should not be left standing without support. Review of the facility's undated policy titled, Oxygen Administration revealed, Equipment and Supplies .#1. Portable oxygen cylinder (strapped to the stand). | 2020-09-01 |
| 1474 | 1474 | ROSWELL NURSING & REHAB CENTER | 115422 | 1109 GREEN STREET | ROSWELL | GA | 30075 | 2020-02-27 | 757 | D | 0 | 1 | HR4Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to ensure one (Resident (R) 129) of six residents reviewed for unnecessary medications, received duplicate medications. Findings include: Review of the face sheet for R129 revealed a re-admission date of [DATE] with [DIAGNOSES REDACTED]. Observation of medication pass for R129 on 2/25/20 at 9:00 AM revealed Registered Nurse (RN) 2 administered one table of a multivitamin with minerals (a dietary supplement) and one tablet of a multivitamin with iron (a dietary supplement). Review of R129's Medication Administration Record [REDACTED]. The multivitamin with iron one table daily was also ordered on [DATE]. The consulting Pharmacist, interviewed by telephone on 2/27/20 at 3:04 PM, acknowledged a multivitamin with iron and a multivitamin with minerals is duplicate therapy and could cause an overdose of some of the vitamins. The Pharmacist confirmed assessing residents for duplicate therapy is part of a medication regimen review. | 2020-09-01 |
| 1475 | 1475 | ROSWELL NURSING & REHAB CENTER | 115422 | 1109 GREEN STREET | ROSWELL | GA | 30075 | 2020-02-27 | 758 | D | 0 | 1 | HR4Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and policy review, the facility failed to ensure monitoring for behaviors and side effects for a resident on an anti-depressant medication for one of five residents (Resident (R) 167), selected for review. As a result of this deficient practice the resident was not monitored for behaviors or side effects of the administered anti-depressant medication. This deficient practice had the potential for overmedication due to not noticing the behaviors or side effects the resident was experiencing. Findings include: Review of R167's Face Sheet indicated was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. Review of R167's Physician order [REDACTED]. Review of R167's Medication Administration Record for (MONTH) 2020 documented daily dosing of [MEDICATION NAME] 20 mg and lacked documented evidence of monitoring of behaviors or side effects for administering an anti-depressant medication. Review of R167's care plan titled, I am on an antidepressant medication dated 11/19/19, indicated interventions to include, administer antidepressant medications as ordered by the physician and monitor/document side effects and effectiveness. Also, an intervention to observe and report adverse reactions to antidepressant therapy including change in behavior/mood/cognition. On 02/26/20 at 12:31 PM, the Nurse Manager confirmed the monitoring of behaviors and side effects of antidepressants were to be documented in the MAR and that R167's MAR lacked documented evidence of monitoring of behavior and side effects. Review of the facility's policy titled, Use of [MEDICAL CONDITION] Drugs, dated 10/17, lacked documented evidence of the need for monitoring of behaviors and side effects for [MEDICAL CONDITION] medications. On 02/27/20 at 12:13 PM the Risk Manager verified the facility's policy titled, Use of [MEDICAL CONDITION] Drugs, lacked documentation for monitoring of behaviors and side effects for [MEDICAL CONDITION] medica… | 2020-09-01 |
| 1476 | 1476 | ROSWELL NURSING & REHAB CENTER | 115422 | 1109 GREEN STREET | ROSWELL | GA | 30075 | 2020-02-27 | 881 | D | 0 | 1 | HR4Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, document review and staff interview, the facility failed to develop and implement a comprehensive plan to monitor the use of antibiotics for one (Resident (R)84) of six residents reviewed for unnecessary medications. Findings include: Review of R84's face sheet revealed R84 was readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the hospital's Discharge Document indicated that Rifaximin (an antibiotic used to decrease the [MEDICAL CONDITION] load in certain illnesses/diseases) 550 mg (milligrams) through a gastrostomy tube (a tube placed to administer medications and nutrition directly into the stomach) twice a day. The hospital discharge document lacked documentation of an indication for the use of the medication Rifaximin. Upon re-admission to the facility, review of the monthly physician orders [REDACTED]. Interviewed on 2/27/20 at 2:15 PM, the Director of Nursing (DON) stated the medication Rifaximin is given to treat R84's liver disease and is not for the treatment of [REDACTED]. The DON stated that staff selected the wrong [DIAGNOSES REDACTED]. Review of the facility's infection logs dated (MONTH) 2019 and (MONTH) 2020 revealed R84 was reviewed by Infection Preventionist/LPN. The [DIAGNOSES REDACTED]. Interview with the Infection Preventionist/LPN on 2/27/20 at 12:46 PM confirmed R84 was given Rifaximin prior to hospital admission and since the resident returned for the hospital. The Infection Preventionist/LPN stated R84 was receiving the Rifaximin for the treatment of [REDACTED]. | 2020-09-01 |
| 528 | 528 | PRUITTHEALTH - MARIETTA | 115276 | 70 SAINE DRIVE SW | MARIETTA | GA | 30008 | 2020-02-26 | 609 | D | 1 | 0 | CR9111 | > Based on staff interview, record review and review of the facility's policy titled Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, the facility failed to report an allegation of abuse to the State Survey Agency (SSA) within the required time frame for one resident (R#1) of 4 sampled residents. Findings include: During an interview on 2/25/2020 at 10:10 a.m., R#1 stated to this surveyor that he refused to allow Certified Nursing Assistant (CNA) AA in his room or allow her to touch him. He reported that he is legally blind and CNA AA was mean and rude to him. The resident angrily states that he is blind but CNA AA treated him like he was stupid. The resident further stated that he informed the Social Worker (SW) regarding how he was being treated and did not want CNA AA back in his room. An interview with the SW on 2/25/2020 at 11:30 a.m. revealed that she spoke with the R#1 on 2/24/2020 in which he reported to her that CNA AA was mean to him and did not want her to come back into his room or provide him any care. SW further stated that she completed a grievance report at that time and reported the incident to the Administrator. An interview on 2/25/2020 at 11:40 a.m. with the Administrator revealed that according to the report the facility became aware of the allegation on 2/24/2020. He further stated that he did not consider the incident as an allegation of abuse and therefore did not report the incident to the State agency. Review of the facility policy titled Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property revised on 4/26/2017, stated that mental abuse: includes but is not limited to humiliation, harassment, threats of punishment or deprivation. The suspected abuse will be reported within two hours to the State Survey Agency. | 2020-09-01 |
| 529 | 529 | PRUITTHEALTH - MARIETTA | 115276 | 70 SAINE DRIVE SW | MARIETTA | GA | 30008 | 2020-02-26 | 690 | D | 1 | 0 | CR9111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, record review, and facility policy review Lippincott indwelling urinary catheter care and management, the facility failed to provide appropriate indwelling urinary catheter care for one resident (R) #3, of three sampled residents. Findings include: Review of the facility policy for Indwelling urinary catheter (Foley) care and management revised 3/24/2017 indicated in the Implementation section to Provide routine hygiene for meatal care; note that cleaning the meatal area with antiseptic solutions isn't necessary. To avoid contaminating the urinary tract, always clean by wiping away from-never toward- the urinary meatus. Use soap and water or a perineal cleaner to clean the [MEDICAL CONDITION] area after each bowel movement. Avoid frequent and vigorous cleaning of the area. Review of the Quarterly Minimum Data Set (MDS) for R#3 dated 2/02/2020 revealed that his [DIAGNOSES REDACTED]. Review of the Brief Interview for Mental Status (BIMS) indicated a score of 15 indicating the resident was cognitively intact. R#3 had an indwelling foley catheter on admission to the facility. Review of the Care Plan for R #3 dated 10/15/2019 revealed a care plan for an Indwelling Foley Catheter. Approaches included: Provide perineal care every day and PRN Report redness, swelling, discharge or urinary related odor to supervisor Follow aseptic technique with Cath insertion and irrigation Observe and report the change in color, odor, presence of cloudiness or sediment in urine to charge nurse Report complaints of pain/discomfort from cath to charge nurse Record intake and output as ordered Check Cath q (every) shift for patency, proper position of tubing and bag. Report Cath leakage to charge nurse. Review of the Medication Administration Record [REDACTED]. A review of the Quarterly MDS dated [DATE] revealed a BIMS score of 15 indicating that he was cognitively intact. The resident required total care for all activities of daily l… | 2020-09-01 |
| 1902 | 1902 | PRUITTHEALTH - MOULTRIE | 115505 | 233 SUNSET CIRCLE | MOULTRIE | GA | 31768 | 2020-02-26 | 600 | D | 1 | 0 | HMTO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, review of the facility policy titled Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property and staff/resident interviews, the facility failed to ensure that one of five residents (R#1) reviewed were free from physical/verbal abuse. The Resident Census and Conditions of Residents Form CMS-672 dated 2/24/2020 revealed a census of 67 residents. Findings include: Review of the policy, Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Property revised 9/20/19 revealed Policy Statement It is the policy of (the facility) and its affiliated entities (collectively, the Organization) to actively preserve each patient's right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, exploitation, mistreatment, and misappropriation of patient property, (referred to collectively in this policy as abuse, neglect, mistreatment, and exploitation). The Organization and its partners should assure that best efforts are made to prevent any occurrences of any form of abuse, neglect and exploitation. Definitions: Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain, or mental anguish. Abuse includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Abuse also includes verbal abuse, sexual abuse, physical abuse, and mental abuse, including abuse facilitated or enabled through the use of technology. 1. Review of the Resident Face Sheet revealed Resident #1 (R#1) has the following [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 9 indicating moderate impaired cognition. Review of Facility Incident Report Form dated 2/1/2… | 2020-09-01 |
| 1903 | 1903 | PRUITTHEALTH - MOULTRIE | 115505 | 233 SUNSET CIRCLE | MOULTRIE | GA | 31768 | 2020-02-26 | 609 | D | 1 | 0 | HMTO11 | > Based on record review, staff interviews and review of the facility policy titled Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Property, the facility failed to notify the State Agency (SA) within the required two hours of an incident involving staff to resident physical/verbal abuse for one resident (R#1)) of five residents reviewed for abuse. Findings include: Review of the facility policy titled, Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Property revised on 7/29/19 Procedures: 1. Any allegation, suspicion, or identified occurrence is identified involving patient abuse, neglect, exploitation, mistreatment, and misappropriation of property, including injuries of an unknown source, should be immediately reported to the Administrator of the provider entity. 2. In accordance with applicable laws and regulations, the Administrator or his or her designee should notify the appropriate state agency (or agencies), the patient's attending physician, and the patients' designated representative of any allegation or incident described above and of the pending investigation The state survey agency and the state agency for adult protective services should be notified in accordance with state law through established procedures of any allegations of abuse, neglect exploitation or mistreatment, including injuries of an unknown source and misappropriation of patient property, within 2 hours after the allegation is made if the events upon which the allegation is based involved abuse or result in serious bodily injury, and not later than 24 hours if the events upon which the allegation is based do not involve abuse and do not result in serious bodily injury. The Ombudsman should also be notified as required by state law. The Administrator or designee should direct an investigation into the allegation or incident. Review of Facility Incident Report Form dated 2/1/2020 revealed an investigation for staff to resident abuse. It documented that o… | 2020-09-01 |
| 1613 | 1613 | PRUITTHEALTH - SHEPHERD HILLS | 115452 | 800 PATTERSON RD | LA FAYETTE | GA | 30728 | 2020-02-20 | 658 | D | 1 | 0 | QSIP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, review of facility policy titled Medication Administration: Oral Medication, and review of the Georgia Nurse Practice Act, the facility failed to provide supervision during the administration of medication for one of five sampled residents, (R) (R#13). Findings include: A review of the Georgia Nurse Practice Act, (chapter 410-10) revealed the following: The Practice of Nursing includes, but is not limited to, provision of nursing care; administration, supervision, evaluation, or any combination thereof, of nursing practice; teaching; counseling; the administration of medications and treatments as prescribed by a physician [MEDICATION NAME] medicine in accordance with Article 2 of Chapter 34 of this title. A review of the facility policy titled Medication Administration: Oral Medication reviewed and revised on 1/28/2020, Guideline #13, revealed the following: Administer medication and remain with the patient/resident while medication is swallowed. On 2/12/2020 at 9:59 a.m. Licensed Practical Nurse (LPN) AA was observed placing a medication cup containing eleven pills down on the over bed table with a cup of juice containing a powdered medication, and a cup of water, in front of R#13, then leaving the room and returning to hallway where R#13 was out of sight. Review of the clinical record for R#13 revealed on admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent Speech Therapy Evaluation dated 6/28/18 revealed R#13 had no signs of dysphagia, with no swallowing deficit and was recommended to continue with a regular texture diet and thin liquids, and no additional Speech Therapy required. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed R#13's Brief Interview for Mental Status (BIMS) score of 13, indicating his cognition was intact. Review of the February 2020 Medication Administration Record [REDACTED] [MEDICATION NAME] 100 milligram (mg) one po … | 2020-09-01 |
| 1112 | 1112 | RIVERSIDE HEALTH CARE CENTER | 115375 | 5100 WEST ST NW | COVINGTON | GA | 30014 | 2020-02-13 | 584 | D | 1 | 1 | W93S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and interviews the facility failed to ensure that it was maintained in a safe clean and comfortable homelike environment in seven resident rooms with dirty air filters and dirty vents on the heating and air wall units. Findings include: 1. An observation on 2/10/20 at 11:30 a.m. of the air conditioner/heat pump (ac/hp) wall unit in room [ROOM NUMBER] revealed that the ac/hp system had two air filters located in the front that are clogged with thick amount of dust and debris. The outside of the unit revealed the vents were covered with black dirty with debris. 2. An observation on 2/11/20 at 11:20 a.m. observation of the ac/hp wall unit in room [ROOM NUMBER] revealed that unit had two air filters located in the front clogged up with thick amount of grey dust and debris. The outside of the unit revealed the vents were covered with black dirty with debris. An interview on 2/11/20 at 11: 21 a.m. with R#82 revealed that he has never seen anyone from the housekeeping or maintenance department wipe the outside of the ac/hp unit or clean/replace the air filters. 3. An observation on 2/11/20 at 11:22 a.m. of the ac/hp wall unit in room [ROOM NUMBER] revealed that the two air filters located in the front clogged with thick amount of grey dust and debris. The outside of the ac/hp unit revealed the vents were covered with black dirty with debris. Interview on 2/11/2020 at 11:23 p.m. with R#116 revealed that the resident has never seen anyone from housekeeping wipe the outside of the ac/hp unit or clean/replace the air filters. 4. An observation on 2/11/2020 at 11:26 a.m. of the ac/hp wall unit in room [ROOM NUMBER] revealed that the two air filters located in the front clogged with thick amount of dust and debris. The outside of the ac/hp unit was dirty with debris. 5. An observation on 2/11/2020 at 12:00 p.m. of the ac/hp wall unit in room [ROOM NUMBER] revealed thick with dust on the two air filters. 6. An observation on 2/11/202… | 2020-09-01 |
| 1113 | 1113 | RIVERSIDE HEALTH CARE CENTER | 115375 | 5100 WEST ST NW | COVINGTON | GA | 30014 | 2020-02-13 | 657 | D | 0 | 1 | W93S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of policy titled Care Plan Policy, the facility failed to invite one resident, Resident (R) #140, of 43 sampled residents, to participate in the development of her plan of care. Findings include: A review of policy titled Care Plan Policy dated 12/12/2017 revealed Policy Statement: Each resident will have a plan of care to identify problems, needs, and strengths that will identify how the facility staff will provide services to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. Standard of Practice: 3. A baseline plan of care will be developed by the interdisciplinary team (with resident input) for each resident within forty-eight (48) hours of the resident's admission to the facility. The baseline plan of care will consist of information that will provide effective and person-centered care that meets professional standards of quality care. 4. The facility must provide the resident and the representative, if applicable, with a written summary of the baseline care plan by the completion of the comprehensive care plan. The summary must be in a language and conveyed in a manner the resident and/or representative can understand. This summary must include but is not limited to a. The initial goals of the resident, b. A summary of the resident's medications and dietary instructions, c. Any services and treatments to be administered by the facility and personnel acting on behalf of the facility, d. Any updated information based on the details of the comprehensive care plan, as necessary. 11. The resident has the right to participate in the care planning process, including the right to identify individuals or roles to be included in the planning process, the right to request meetings and the right to request revisions to the person-centered plan of care. An interview and observation on 2/11/2020 at 8:39 a.m. with R#140 revealed that no one has … | 2020-09-01 |
| 1114 | 1114 | RIVERSIDE HEALTH CARE CENTER | 115375 | 5100 WEST ST NW | COVINGTON | GA | 30014 | 2020-02-13 | 688 | D | 0 | 1 | W93S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to provide rehabilitation equipment in a timely manner to one resident, Resident (R) #96 of 43 sampled residents. Findings include: An interview and observation on 2/10/2020 at 11:19 a.m. with R#96 revealed that she has received therapy quite a few times during her time there. She further indicated her neck has started drawing to her right shoulder and has informed her Physician and therapy is aware. The resident was observed with her head drawing to the right shoulder. Additionally, she reported a neck pillow had been ordered twice, but she has not yet received it. A review of R#96's [DIAGNOSES REDACTED]. Additionally, R#96 underwent neck surgery in (MONTH) 2019. A review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed the following triggered care areas: Activities of Daily Living (ADL) functional/rehab potential, and pain. It further revealed R#96 scored 15 on the Brief Interview for Mental Status (BIMS). A review of the Quarterly MDS assessment dated [DATE] revealed resident requires extensive assistance with transfers, dressing, and toileting, with set up with bathing, and has functional limitation in range of motion (ROM) on one side of her upper extremity. A review of R#96's care plan revealed the following problem areas: 1. Right shoulder contracture and has a problem with her left shoulder rotator cuff. Goal is for the resident to minimize further contraction through next review date. Interventions include; support affected area, keep affected area clean, monitor skin breakdown, assist with ROM as needed, reinforce activities recommended, encourage participation in selfcare as allowed, perform actions to maintain an adequate nutritional status. 2. limited physical mobility related to (r/t) Weakness. Goal is that the resident will demonstrate the appropriate use of adaptive device(s) to increase mobility through the review date. Device: Right … | 2020-09-01 |
| 1115 | 1115 | RIVERSIDE HEALTH CARE CENTER | 115375 | 5100 WEST ST NW | COVINGTON | GA | 30014 | 2020-02-13 | 761 | D | 0 | 1 | W93S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews and facility policy titled, Name of Pharmacy Insulin Drug Chart dated (YEAR) and Medication Storage: Storage Medications, the facility failed to ensure that insulin medications are labeled with open and/or expiration dates on two of seven medication carts. Findings include: A review of the Medication Storage: Storage of Medications, number 12 page 2, indicated that Insulin products should be stored in the refrigerator until opened. Note the date for insulin vials and pens when first used. A review of the Pharmacy Name Insulin Drug Chart dated (YEAR), provided by Licensed Practical Nurse (LPN) HH, indicated that the [MEDICATION NAME] R has a shelf-life of 31 days and the [MEDICATION NAME] has a shelf-life of 28 days when outside of refrigerator. Observation and interview on [DATE] at 11:30 a.m. of the Unit one medication cart (A ) revealed the following concern: one opened insulin [MEDICATION NAME] vial, for R#111, with no open nor expired date present. An interview, at this time, with the Licensed Practical Nurse (LPN) HH revealed that this vial should be discarded. An observation and interview of Unit one medication cart (B) on [DATE] at 11:45 a.m. revealed the following: two open insulin vials: (one [MEDICATION NAME] R vial dated as opened on [DATE] and one [MEDICATION NAME] vial dated as opened on [DATE]), both without an expiration dates documented for R#71. An interview, at this time, with LPN HH was conducted that there was no expiration dates listed on these vials and there should have been. A review of the January/February 2020 electronic Medication Administration Record [REDACTED]. An interview on [DATE] at 12:00 p.m. with the Director of Nursing (DON) revealed that all insulins should be dated with an open and an expiration date. She stated that the expiration date should be 28 days after opening for all insulins. A review of the Pharmacy Consultant report, Med Station Review dated [DATE] cond… | 2020-09-01 |
| 1116 | 1116 | RIVERSIDE HEALTH CARE CENTER | 115375 | 5100 WEST ST NW | COVINGTON | GA | 30014 | 2020-02-13 | 812 | E | 0 | 1 | W93S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and review of policies titled Labeling and Dating Inservice, Labeling & Dating/Expired Foods/Covering Foods and Dating, Open Foods in Ziplock Bags, Environment, Manual Warewashing, and Warewashing, the facility failed to properly label food products; failed to maintain appropriate temperatures on the serving line for a cold food item; failed to properly air dry dome lids and maintain them in good condition; failed to maintain a clean food processor and microwave oven; failed to maintain an ice machine lid in good condition; and failed to ensure a waste receptacle next to the hand wash station had a lid. This had the potential to affect 138 residents receiving an oral diet. Findings include: During an interview and observation on [DATE] at 9:48 a.m. with the Dietary Manager (DM) he verified the following observations. Ice machine lid, upper right corner is broken exposing orange colored internal insulation. Dome lids were stacked one on top of another with visible moisture between the dome lids and in poor condition with a whitish discoloration on the underside of the lids. An observation of the inside of the microwave revealed dried reddish-brown food splattering on the ceiling and sides. During an interview and observation on [DATE] at 9:51 a.m. with the DM of the pantry, there was with an open package of spiral pasta and spaghetti, with unreadable open dates and no 'use by' dates. The DM reported the labels should include what the item is and have a 'use by' date on the label. During an interview and observation on [DATE] at 9:55 a.m. with the DM of the walk-in refrigerator there were three unlabeled open packages of cheese dated ,[DATE] with no 'use by' date. An unlabeled open package of shredded cabbage dated ,[DATE] with no 'use by' date. An open package of ham dated [DATE] with no 'use by' date. During an observation and interview on [DATE] at 11:51 a.m. with Cook AA she reported 23 resi… | 2020-09-01 |
| 3812 | 3812 | OAKS - BETHANY SKILLED NURSING, THE | 115705 | 1305 EAST NORTH STREET | VIDALIA | GA | 30475 | 2020-02-13 | 761 | D | 0 | 1 | GQDZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, and review of the facility policy titled, 'Medication Storage in the Healthcare Center the facility failed to ensure that all drugs and biologicals were secured and stored in a locked storage area that permitted only authorized personnel to have access for one of two medication storage areas. Findings include: Review of facility policy titled 'Medication Storage in the Healthcare Center' revised 09/15/17, states 'Only licensed nurses and the pharmacy personnel are allowed access to medications. Respiratory Therapists may access medications used in the provision of respiratory services. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access.' Observation on 2/12/2020 at 4:43 a.m. revealed unlocked medication cabinets in the East Wing nurse's station. The cabinets contained a supply of over the counter medications including, but not limited to, vitamin D3 supplement, multivitamin with minerals, aspirin, [MEDICATION NAME] D, [MEDICATION NAME] and TUMS. The nurse's station does not have doors that lock and neither nurse on duty was located in the nurse's station. During an interview with Unit Manager Registered Nurse (RN) BB on 2/12/2020 at 9:20 a.m. confirmed the medication cabinets at the East Wing nurse's station were not locked. RN BB stated the cabinets are to be locked at all times. During an interview with the Director of Nursing (DON) on 2/12/2020 at 10:02 a.m. revealed that she expects the medication cabinets to be locked at all times. | 2020-09-01 |
| 3813 | 3813 | OAKS - BETHANY SKILLED NURSING, THE | 115705 | 1305 EAST NORTH STREET | VIDALIA | GA | 30475 | 2020-02-13 | 812 | E | 0 | 1 | GQDZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and review of the facility's policy titled, Receipt and Storage of Food & Supplies and the facility policy titled, Leftovers. The facility failed to ensure that foods were properly labeled and dated in the dried foods pantry and to failed to discard expired foods in the walk-in cooler in the main kitchen. The deficient practice had the potential to affect 127 of 138 residents receiving an oral diet. Findings include: Review of the facility policy titled, Receipt and Storage of food and Supplies dated [DATE] revealed that in procedure section item number seven; The first in, first out (FIFO) method must be used to ensure proper rotation of all food items to prevent spoilage. Further facility policy review titled Leftovers dated [DATE] revealed under procedure section number five any food that is leftover may be used as follows: leftovers must be used within 72 hours (3 days). Kitchen Observation on [DATE] at 5:39 a.m. revealed during the tour of the dried food storage pantry all foods were labeled with a receive date and no expiration date. Interview with Dietary Manager (DM) at time of observation revealed that staff usually uses up the product that is opened within thirty days. Further interview revealed that food is discarded after the thirty days from the date that the food item is opened. Further observation of the pantry revealed a one-quart size zip lock bag of dried cereal was not labeled or dated which was confirmed by the DM. Observation of the walk-in cooler on [DATE] at 6:00 a.m. revealed a medium size tin pan of cut up fruit unlabeled with no open date observed, a small tin pan of gravy dated for [DATE] with no discard date. Further observation revealed a 180 oz container of Pace Enchilada Sauce with an expiration date of (MONTH) 20, 2019 which was confirmed by DM to be expired. Interview with DM on [DATE] at 6:15 a.m. in reference to when left over food items are to be discarded revealed t… | 2020-09-01 |
| 3814 | 3814 | OAKS - BETHANY SKILLED NURSING, THE | 115705 | 1305 EAST NORTH STREET | VIDALIA | GA | 30475 | 2020-02-13 | 880 | D | 0 | 1 | GQDZ11 | Based on observation, interviews, record review the facility failed to to ensure that glucometers that were cleaned, prior to use, remained clean when checking finger stick blood sugars for two of two residents observed. Findings include: During medication administration on 2/12/2020 at 5:59 a.m., Licensed Practical Nurse (LPN) 'AA' removed the glucometer (a device used to check blood sugar levels) out of the medication cart, sanitized his hands, donned gloves, laid the glucometer on the resident's bed without a barrier, wiped the right index finger of Resident #120 with alcohol and performed a blood glucose finger-stick. LPN AA then cleaned the glucometer with a germicidal bleach wipe and placed the wet glucometer directly on top of the medication cart to dry without a barrier. On 2/12/2020 at 7:08 a.m., LPN 'DD' removed a glucometer out of the medication cart for Resident #30, placed glucometer on the resident's bedside table without a barrier, sanitized her hands, donned gloves, wiped the resident's right index finger with an alcohol pad and performed a blood glucose finger-stick. LPN DD then cleaned the glucometer with a germicidal bleach wipe and placed it directly on top of the medication cart to dry without a barrier. During an interview on 2/12/2020 at 9:05 a.m., with the Unit Manager BB revealed the nurses were educated on the glucometers recently when the policy was revised within the last month. Unit Manager BB stated she would expect the nurses to provide a barrier on a clean surface while allow the glucometer to dry and prior to using it on the resident. | 2020-09-01 |
| 3854 | 3854 | HILL HAVEN NURSING HOME | 115710 | 880 RIDGEWAY ROAD | COMMERCE | GA | 30529 | 2020-02-13 | 919 | E | 0 | 1 | MKUM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and resident and staff interviews the facility failed to ensure that all components of the nurse call system in eight of 63 resident shared rooms (for rooms: 8, 17, 18, 29, 30 and 32) were fully functional and the facility failed to ensure that there was an effective monitoring system in place to identify call light issues in resident rooms. Findings include: Record Review of Facility Policy Preventative Maintenance Service Policy revealed It shall be the policy of[NAME]Haven Nursing Home to conduct preventative and routine maintenance on areas and equipment as identified through completing preventative maintenance checklists. Maintenance Supervisor will be responsible for making necessary repairs, performing necessary routine maintenance or arranging for an alternate service provider to complete work as identified in a timely manner. An interview on 2/11/2020 at 09:30 a.m. with Resident (R) #20 revealed his call light did not work. Review of R#20's Annual Minimum Data Set (MDS) revealed a Brief Interview of Mental Status (BIMS) assessment of 14, indicating the resident was cognitively intact. Observation of all call lights in facility on 2/11/2020 at 9:40 a.m. revealed out of 35 rooms there were 8 rooms affected (room [ROOM NUMBER] B, #8 B, #18 A, #29 A & B, #30 A & B, and #32 A & B.) An interview with Maintenance Director on 2/11/2020 at 10:00 a.m. revealed he has previously contacted an electrician who came out a few weeks ago to look at the call light system but the Maintenance Director stated he has not received any follow-up information from the electrician. The Maintenance Director stated he does not have any record of the date the electrician came and he was unable to provide any documentation of the visit since the electrician did not bill the facility. Record review of last six months of call light logs revealed the facility was only able to provide call light logs for (MONTH) 2020 and that staff … | 2020-09-01 |
| 1729 | 1729 | BRYANT HEALTH AND REHABILITATION CENTER | 115479 | 134 S 6TH STREET | COCHRAN | GA | 31014 | 2020-02-12 | 578 | D | 0 | 1 | KFZ411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure that two physicians signed a Physician order [REDACTED]. Findings include: A review of the Quarterly Minimum Data Sets dated [DATE] revealed a Brief Interview for Mental Status score of 99 indicating that the resident was unable to complete the interview with the staff assessment indicating that the resident had both short-term and long-term memory problems. A review of the Advanced Directives for R#39 revealed a POLST signed by only one physician and dated [DATE]. A review of the Physician order [REDACTED]. A review of the care plan revealed that R#39 had a care plan documenting request for a DNR, no Cardiopulmonary Resuscitation (CPR). An interview on [DATE] at 12:56 p.m. with the Social Service Director revealed that the resident was cognitively unable to make decisions. She confirmed that the POLST was signed on [DATE]. She also confirmed that there was only one physician signature and the resident does not have a Durable Power of Attorney for healthcare. She confirmed that there needed to be a concurring physician signature. An interview on [DATE] at 1:10 p.m. with the Director of Nursing revealed that she would expect for a resident who was not cognitively able to make decisions for themselves that the Advanced Directive would have a concurring physician signature. An interview on [DATE] at 2:52 p.m. with Licensed Practical Nurse/Unit Manager CC revealed that no residents have been resuscitated that had an Advanced Directive for DNR and no residents have not been resuscitated that had an Advanced Directive of Full Code. | 2020-09-01 |
| 1730 | 1730 | BRYANT HEALTH AND REHABILITATION CENTER | 115479 | 134 S 6TH STREET | COCHRAN | GA | 31014 | 2020-02-12 | 584 | D | 0 | 1 | KFZ411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a clean, comfortable and homelike environment in five of 37 resident rooms that had a build-up of dust, stained privacy curtains, rusty medical furniture and an uncomfortably cool room temperature. Findings include: During an observation on 2/9/2020 at 2:28 p.m. in room [ROOM NUMBER] there were stained privacy curtains, missing paint from around the window, and there was a stained ceiling tile over Bed [NAME] During an observation on 2/9/2020 at 3:30 p.m. in room [ROOM NUMBER] there was dust noted on top of the concentrator, stained privacy curtain near Bed B, and rust on the base of the over bed table. During an observation on 2/9/2020 at 3:38 p.m. in the shared bathroom for rooms [ROOM NUMBERS] there was dust buildup in the vents, buildup on the rail in the bathroom, and the middle privacy curtain in room [ROOM NUMBER] was stained. During an observation on 2/9/2020 at 3:51 p.m. in the bathroom for room [ROOM NUMBER] there was a strong odor, the call light string was brown, there was rust on the over the toilet seat, there was missing paint from the ceiling near the vent, there was dust buildup in the vent, there was missing paint from the wall, a hole in the wall near Bed B, and rust on the base of the overbed table by Bed [NAME] An interview with resident (R)#48 on 2/10/2020 at 9:45 a.m. revealed that her room was freezing. An observation of the resident revealed that the resident was covered with a blanket and the room was uncomfortably cool. The observation also revealed that the resident's room had an individual heating unit in it that was not turned on. The resident stated that she told Maintenance that the knob on the heater had come off and he said that the knob had been removed because the heater was a fire hazard. The resident stated that she had been able to use the heater until the last few days, but they had now told her not to use it because of it … | 2020-09-01 |
| 1731 | 1731 | BRYANT HEALTH AND REHABILITATION CENTER | 115479 | 134 S 6TH STREET | COCHRAN | GA | 31014 | 2020-02-12 | 677 | D | 0 | 1 | KFZ411 | Based on observation, staff interview and record review, the facility failed to ensure that the hair of two dependent residents (R) (#1 and #36) was kept clean of 33 sampled residents. Findings include: A review of the policy titled, Resident Hygiene: Bath and Shower Standard under subsection 9 stated that residents' hair was to be shampooed on each bath/shower day. 1. Observations on 2/9/2020 at 11:57 a.m., on 2/10/2020 at 9:37 a.m., and on 2/12/2020 at 11:05 a.m. revealed the hair of R#1 looked greasy. A review of the activity of daily living (ADL) sheets revealed that neither bathing nor the personal hygiene task specifically mentioned hair washing. A review of the care plan for the resident revealed that she required assistance with ADLs with documented interventions to anticipate and meet needs daily, total assistance of one person with bathing, dressing, personal hygiene, locomotion, toileting/incontinent care, eating and bed mobility. An interview on 2/12/2020 at 12:12 p.m. with the Certified Nursing Assistant (CNA) GG revealed that R#1 required total care. The CNA stated that the resident went to the shower one day a week and received bed baths the other days. She stated that shampooing of hair should be done when residents go to the shower. An observation and interview on 2/12/2020 at 12:22 p.m. with the Director of Nursing (DON) confirmed that the resident's hair was dirty and greasy looking. She stated that her expectation was that the resident's hair was to be washed when they go to the shower. 2. Observations of R#36 made on 2/9/2020 at 12:13 p.m., 2/10/2020 at 9:31 a.m., and 2/12/2020 at 11:26 a.m. revealed that the resident's hair looked greasy and dirty. A review of the ADL sheets for the resident revealed that neither bathing nor the personal hygiene task specifically mentioned hair washing. A review of the care plan revealed that the resident required assistance with ADLs with an intervention documented that she required total assistance by one person with bed mobility, eating, bathing, dressing… | 2020-09-01 |
| 1732 | 1732 | BRYANT HEALTH AND REHABILITATION CENTER | 115479 | 134 S 6TH STREET | COCHRAN | GA | 31014 | 2020-02-12 | 695 | D | 0 | 1 | KFZ411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of the facility policy titled Respiratory System Management - Oxygen, Administration - Nasal Cannula, and staff interviews, the facility failed to follow a Physician's Order for two residents (R) (#21 and #65) reviewed of 7 residents receiving oxygen. Findings include: 1. Review of the medical record for R#21 revealed a [DIAGNOSES REDACTED]. Further review of the medical record revealed a Physician's Order for oxygen at 3 LPM (liters per minute) with a start date of 11/21/17. During observations on 2/9/2020 at 3:30 p.m., 2/10/2020 at 10:57 a.m. and at 4:25 p.m., and 2/11/2020 at 9:03 a.m. and 1:38 p.m. R#21's oxygen was infusing between 2 LPM and 2.5 LPM. During an observation and interview with Licensed Practical Nurse (LPN) AA on 2/11/2020 at 1:38 p.m. she confirmed R#21's oxygen not being administered at 3 LPM per the Physician's Orders. During an interview with the Director of Nursing (DON) on 2/12/2020 at 11:59 a.m., DON confirmed that nurses should check oxygen each shift to assure that they are being administered correctly. 2. Review of the medical record revealed R#65 with [DIAGNOSES REDACTED]. Review of Physician Order dated 1/18/2020 revealed that the oxygen will be set for 3 LPM. Observations of R#65 on 2/9/2020 at 11:22 a.m. and 12:35 p.m., 2/10/2020 at 9:34 a.m. and 10:25 a.m., and 2/12/2020 at 11:45 a.m. revealed R#65 was receiving oxygen at 2 to 2.5 LPM. During an interview and observation on 2/12/2020 at 11:45 a.m., LPN AA confirmed that R#65's oxygen was at 2 LPM. LPN AA reported that the oxygen should be at 3 LPM. LPN AA reported that she was responsible for ensuring the residents oxygen was correct. Review of the undated facility policy titled Respiratory System Management; Oxygen, Administration- Nasal Canula revealed: 1. Check the residents clinical record for the physician's order. 5. Turn the flow meter to the ordered flow rate. | 2020-09-01 |
| 1733 | 1733 | BRYANT HEALTH AND REHABILITATION CENTER | 115479 | 134 S 6TH STREET | COCHRAN | GA | 31014 | 2020-02-12 | 880 | E | 0 | 1 | KFZ411 | Based on observations, staff interviews, and policy review titled Infection Prevention and Control Program, the facility failed to sanitize ice/water machine and failed to prevent possible cross contamination to clean laundry. This had the potential to effect 45 of 67 residents for the use of ice/water machine and 53 of 67 residents that the facility provided laundry services for personal clothing. Findings include: 1. An observation on 2/9/2020 at 12:50 p.m. revealed the ice/water machine dirty with brown substance at the bottom of tray. An observation on 2/10/2020 at 10:20 a.m. revealed the ice/water machine dirty with brown substance at the bottom of tray. Staff was observed getting ice from the ice/water machine at this time. On 2/10/2020 at 12:00 p.m. Resident (R) #42 was observed getting ice from the ice/water machine. A continued observation on 2/11/2020 at 9:27 a.m. revealed the ice/water machine remained dirty with brown substance at the bottom of tray. During an interview on 2/11/2020 at 4:33 p.m., Account Manager EE stated housekeeping staff are responsible for cleaning the ice/water machine daily with Virex (a one-step disinfectant cleaner and deodorant). She proceeded to clean the machine with the Virex and a white washcloth. A brown substance was noted on the washcloth after it was cleaned. During an interview on 2/11/2020 at 4:45 p.m., Licensed Practical Nurse (LPN) CC stated nurses do not get water or ice from the ice/water machine for residents but from the coolers. She stated that staff mainly uses it and it is occasionally used by residents who are able to operate the machine on their own. An interview on 2/12/2020 at 9:09 a.m. with Ice Machine Technician BB revealed the manufacturer recommends ice/water machine to be cleaned every six months. He stated he's not sure of how often it is to be cleaned in between service calls and they use a cleaning agent called Safe Clean Plus. He stated he was currently soaking the parts to the machine and that it had calcium build up on them. 2. During a tour … | 2020-09-01 |
| 1734 | 1734 | BRYANT HEALTH AND REHABILITATION CENTER | 115479 | 134 S 6TH STREET | COCHRAN | GA | 31014 | 2020-02-12 | 914 | D | 0 | 1 | KFZ411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interview, the facility failed to ensure rooms had privacy curtains that provided total visual privacy for three of 37 rooms in which three residents resided (Room #'s 201, 207, and 204). Findings include: 1. During an observation on 2/9/2020 at 12 p.m. in room [ROOM NUMBER] there was a short privacy curtain for Bed B. 2. During observation of room [ROOM NUMBER] on 2/9/2020 at 3:38 p.m. there was a short privacy curtain between Bed A and Bed B. 3. Observation on 2/9/2020 at 11:25 a.m., 2/10/2020 at 10:42 a.m. and 3:55 p.m. revealed the resident in room [ROOM NUMBER] had no privacy curtain. A tour was conducted on 2/12/2020 from 2:55 p.m. until 2:59 p.m. with the House Keeping Supervisor who confirmed that there was a short privacy curtain in room [ROOM NUMBER] due to the curtain track being short. It was reported that housekeeping staff should be pulling the privacy curtains daily when in the room to check for stains and to assure that the curtains are the appropriate length. The Housekeeping Director was unaware of the short curtain in rooms [ROOM NUMBERS]; and the missing curtain in room [ROOM NUMBER]. The Housekeeping Supervisor initially reported that the previous Maintenance Director had been notified of the short privacy curtains and was supposed to order curtains. However, there was no documentation provided to support the order for new privacy curtains. | 2020-09-01 |
| 713 | 713 | BRIARWOOD HEALTH AND REHABILITATION CENTER | 115322 | 3888 LAVISTA ROAD | TUCKER | GA | 30084 | 2020-02-06 | 583 | D | 1 | 1 | 8OIS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, staff interview, and review of the policy Resident Rights, dated February 2017, the facility failed to maintain privacy and confidentiality for four resident's (R) (R#71, R#91, R#47, and R#92), of 36 sampled residents, related to posting of signs regarding clinical and personal information in their rooms. Findings include: Review of the facility's policy entitled 'Resident Rights' with revision date: February 2017 revealed the following including but not limited to: The facility protects and promotes the rights of each resident. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. 1. Review of the Quarterly Minimum Data Set (MDS) for R#71 dated 1/1/20 revealed in section C a Basic Interview for Mental Status (BIMS) score of 00 indicating severely impaired cognition. Section D total severity mood score of 99 indicating R#71 was unable to communicate answers. Review of the care plan revised 1/10/2020 for R#71 revealed a focus for self care deficits related to Activities of Daily Living (ADL) for bathing, bed mobility, dressing, eating, and personal hygiene although there was no care plan in place related to maintaining privacy. During an observation on 2/03/2020 at 11:20 a.m. of R#71's room, a sign stating (in part), Reminders: Please & Thanks! Please keep tissues near the resident. Give water or juice, sipping cup or small cup. NO STRAWS. Offer it often. Prop with pillows on her right side, was observed sitting on the night stand next to her bed. During an observation on 2/04/2020 at 9:14 a.m. of R#71's room revealed the sign remains sitting on the night stand next to the bed of R#71. 2. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] for R#91 revealed in section C a Basic Interview for Mental Status (BIMS) score of 9 indicating moderate cognitive impairment. Section G Functional Statu… | 2020-09-01 |
| 2815 | 2815 | WARM SPRINGS MEDICAL CENTER NURSING HOME | 115603 | 5995 SPRING STREET | WARM SPRINGS | GA | 31830 | 2020-02-06 | 698 | D | 0 | 1 | EE2011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the facility policy titled [MEDICAL TREATMENT] Residents, and staff interviews, the facility failed to ensure that post-[MEDICAL TREATMENT] assessments were completed for one resident (R) (#28) reviewed of three residents receiving [MEDICAL TREATMENT]. Findings include: Record review revealed R#28 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the Admission Physician Orders dated 6/12/19 revealed an order for [REDACTED].>Review of the [MEDICAL TREATMENT] Communication Book revealed missing [MEDICAL TREATMENT] Communication Forms (DCF) for 15 scheduled [MEDICAL TREATMENT] days: 6/29/19, 7/23/19, 8/3/19, 8/8/19, 8/17/19, 8/22/19, 8/27/19, 8/31/19, 9/3/19, 9/5/19, 9/7/19, 9/10/19, 9/12/19, 9/14/19, and 9/21/19. Review of the DCF revealed the document to include pre-[MEDICAL TREATMENT] information such as date/time, name, date of birth (DOB), room number, medications given before [MEDICAL TREATMENT], meal/snack sent, shunt location/status, vital signs (VS), additional information, and the nurse's signature. The DCF further documents the [MEDICAL TREATMENT] Center Information including pre- and post-[MEDICAL TREATMENT] weights, start and end times of treatment, fluid removed, new physician orders, vital signs, and the nurse's signature. The DCF finally documents the Post-[MEDICAL TREATMENT] Information including date/time, shunt location/status, bruit/thrill present, bleeding present, general condition of the resident, vital signs, and the nurse's signature. Review of the Nurses Notes and Medication Administration Record [REDACTED]. During an interview with the Registered Nurse (RN) Supervisor on 2/06/2020 at 10:25 a.m., she stated she has been working at this facility less than two weeks and did not know what the post-[MEDICAL TREATMENT] nursing responsibilities were. During an interview with the interim Director of Nursing (DON) on 2/06/2020 at 10:30 a.m., she stated the post-[MEDI… | 2020-09-01 |
| 2816 | 2816 | WARM SPRINGS MEDICAL CENTER NURSING HOME | 115603 | 5995 SPRING STREET | WARM SPRINGS | GA | 31830 | 2020-02-06 | 812 | E | 0 | 1 | EE2011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and review of facility policy, the facility failed to ensure that open items in the dry storage and cooler were labeled and dated. The deficient practice had the potential to affect 68 of 72 residents receiving an oral diet. Findings include: Initial observation of the facility kitchen on 2/3/2020 at 11:00 a.m. with the Food Service Manager (FSM) revealed 30 containers of assorted spices in the dry storage area and two opened containers of milk in the cooler without labels to indicate the dates they were opened and when they should be discarded. During an interview with the FSM on 2/03/2020 at 11:21 a.m., she stated she has only been employed at this facility for two weeks and has not completed her assessment of the kitchen and processes. She discarded the undated items immediately. Review of the undated facility policy titled Food Storage revealed: 15. Leftover food is store is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Guidelines for Storage: Date your products with use by dates. The food category Spices, Herbs, Condiments, and [MEDICATION NAME] documented spices should be used from six months to two years. The food category Dairy Products documented milk should be used from 8 to 20 days. | 2020-09-01 |
| 3855 | 3855 | MEMORIAL MANOR NURSING HOME | 115711 | 1500 EAST SHOTWELL STREET | BAINBRIDGE | GA | 39819 | 2020-02-06 | 582 | E | 0 | 1 | TCIQ11 | Based on record review and staff interview the facility failed to provide a Notice of Medicare Non-coverage (NOMNC) to two of three residents (R) (#17 and #58) who were reviewed after being discharged from Medicare Part A Services and remained in the facility. Findings include: Review of records for R#17 indicated that services were initiated on 11/1/19 with services ending 11/27/19. The resident remained in the facility. The was no evidence that the Notice of Medicare Non-coverage (NOMNC) was provided to the resident. Review of records for R#58 indicated that services were initiated on 9/19/19 with services ending 10/23/19. The resident remained in the facility. The was no evidence that the Notice of Medicare Non-coverage (NOMNC) was provided to the resident. During an interview on 2/6/2020 at 10:25 a.m. with Registered Nurse (RN) Minimum Data Set (MDS) Coordinator FF it was reported that she has never given the NOMNC to residents remaining in the facility unless the insurance company provided it. RN MDS Coordinator FF reported that she was not aware that the NOMNC was required and denied that the facility had a policy about sending out notices when residents are discharged from Medicare Part A services. | 2020-09-01 |
| 3856 | 3856 | MEMORIAL MANOR NURSING HOME | 115711 | 1500 EAST SHOTWELL STREET | BAINBRIDGE | GA | 39819 | 2020-02-06 | 641 | D | 0 | 1 | TCIQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to ensure the Minimum Data Set (MDS) was coded correctly for one resident (R) (#51) related to the use of restraints and for one resident (R#27) related to receiving [MEDICAL TREATMENT] services of 44 sampled residents. Findings include: 1. A review of the MDS indicator for R#51 revealed the use of a restraint. An observation on 2/4/2020 at 8:11 a.m. revealed the resident was in bed unrestrained. A review of the Quarterly MDS dated [DATE] documented that the resident utilized a chair that prevented rising. An observation on 2/5/2020 at 8:58 a.m. revealed the resident was sitting up in a wheelchair in the activity area with no sign of a seat belt, lap buddy or cushion that would restrain the resident. An observation on 2/5/2020 at 4:49 p.m., and on 2/6/2020 at 8:44 a.m. revealed the resident was in bed unrestrained. An interview on 2/6/2020 at 9:55 a.m. with the Registered Nurse (RN)/MDS Coordinator FF revealed she thought that staff had used the Geri-chair with the resident at times because of increased weakness in her trunk. Further interview on 2/6/2020 at 11:09 a.m. with the RN/MDS Coordinator FF revealed that she was unable to locate documentation to show that the resident used a Geri-chair at times. During an interview with Licensed Practical Nurse (LPN)/MDS Nurse EE at this time revealed that the Quarterly MDS dated [DATE] was coded wrong related to the resident using a chair that prevents rising. She confirmed that the resident does not use a restraint and that she coded it wrong. 2. Review of the Admission Record revealed R#27 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Physician order [REDACTED].#27 is to have [MEDICAL TREATMENT] on Monday, Wednesday, and Friday. Review of MDS Quarterly assessment dated [DATE] indicated no [MEDICAL TREATMENT] while or while not a resident in the last 14 days. Review of Progress Note dated… | 2020-09-01 |
| 3857 | 3857 | MEMORIAL MANOR NURSING HOME | 115711 | 1500 EAST SHOTWELL STREET | BAINBRIDGE | GA | 39819 | 2020-02-06 | 655 | E | 0 | 1 | TCIQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility failed to develop a baseline care plan for three residents (R), (#53, #83, and #142) of 44 sampled residents. Findings include: 1. R#53 admitted to the facility with principal [DIAGNOSES REDACTED]. R#53 was initially admitted for short term rehabilitation for knee contracture. Review of the clinical electronic record, facility documentation, and Minimum Data Set (MDS) Assessment at entry, 5-day, 14-day, and 30-day, revealed R#54 was admitted to the facility on [DATE]. He had a Brief Interview for Mental Status (BIMS) score of 15, indicating cognition intact. Review of the Interim Care Plan (ICP) dated 12/5/18 revealed there was no interventions or instructional care specific for his [DIAGNOSES REDACTED]. Further review revealed there was no place to write a narrative, signature, or documentation that indicated the resident or representative was provided a summary of the baseline care plan that included the minimal information required. Interview on 2/06/2020 at 12:42 p.m., with the MDS Registered Nurse (RN) FF, and the MDS Licensed Practical Nurse (LPN) EE, confirmed the interim care plan was their baseline care plan, and it was completed by the nurse when the resident arrived. The nurse answered questions with information provided by resident, transfer papers, friends, and family, at admission or readmission and anything acute that came up afterwards. The information was entered by MDS staff. Interview further revealed they do not have a Baseline Care Plan policy and they take their direction from the Resident Assessment Instrument (RAI) manual. 2. R#83 had a BIMS score of 11, indicating moderate cognitive impairment. She was admitted to the facility with principal [DIAGNOSES REDACTED]. Review of the clinical record, facility documentation, and MDS Assessment at entry revealed R#83 was admitted to the facility on [DATE]. Review of the Interim Care Plan dated 1/13/2020 in the electronic… | 2020-09-01 |
| 3858 | 3858 | MEMORIAL MANOR NURSING HOME | 115711 | 1500 EAST SHOTWELL STREET | BAINBRIDGE | GA | 39819 | 2020-02-06 | 656 | D | 0 | 1 | TCIQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews the facility failed to follow the care plan related to oxygen therapy for one of 44 residents (R) (#75) reviewed for care plans. Findings include: Review of the medical record for R#75 revealed a [DIAGNOSES REDACTED]. Review of the Physician order [REDACTED]. Observations on 2/4/2020 at 1:23 p.m., 2/5/2020 at 7:56 a.m., and 2/6/2020 at 7:15 a.m. revealed R#75 receiving oxygen therapy via nasal cannula ranging from 3 and/or 3.5 LPM. During an interview and observation on 2/6/2020 at 9:32 a.m., the Director of Nursing (DON) confirmed that R#75 was receiving oxygen at 3 LPM. However, when the order was checked by Licensed Practical Nurse (LPN) II, it was revealed that R#75's oxygen should be at 2 LPM. The DON reported that it is the charge nurse's responsibility to assure that oxygen is given as ordered. Cross Refer F695. | 2020-09-01 |
| 3859 | 3859 | MEMORIAL MANOR NURSING HOME | 115711 | 1500 EAST SHOTWELL STREET | BAINBRIDGE | GA | 39819 | 2020-02-06 | 688 | D | 0 | 1 | TCIQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined that the facility failed to ensure appropriate services and assistance were provided to maintain or improve mobility when the residents demonstrated a limited mobility for one of 44 sampled residents (R) (#142). Findings include: Record review revealed that R#142 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During interview on 2/4/2020 at 1:20 p.m. R#142 was observed in bed leaning towards the left side. R#142 denied receiving any therapy services at this time. During an interview with the Physical Therapy (PT) Director on 2/5/2020 at 2:16 p.m. it was reported that a therapy referral is not automatic for new admissions. PT director went on to report that the therapy department does not screen everyone that is admitted into the facility. The PT Director reported that nursing has to refer residents to be seen by therapy. During an interview on 2/6/2020 at 10:33 a.m. Licensed Practical Nurse (LPN) II confirmed that R#142 has not received a therapy referral at this time. LPN II indicated that this had not been done due to R#142's payor source. LPN II reported that a referral for restorative services could be done but confirmed that a referral to restorative services has not been completed. During an interview on 2/6/2020 at 10:41 a.m., Registered Nurse (RN) Minimum Data Set (MDS) Coordinator FF revealed payment source is a factor related to R#142 being referred to therapy services but referrals are typically made within the first 21 days of a resident's admission into the facility. During an interview with the Director of Nursing (DON) on 2/6/2020 at 2:02 p.m. she confirmed that residents who are admitted with Range of Motion (ROM) limitations can be referred to therapy or to restorative services if therapy is not available. DON reviewed orders for R#142 and validated that there were no orders or referrals for restorative services. DON reported that R#142 should… | 2020-09-01 |
| 3860 | 3860 | MEMORIAL MANOR NURSING HOME | 115711 | 1500 EAST SHOTWELL STREET | BAINBRIDGE | GA | 39819 | 2020-02-06 | 695 | D | 0 | 1 | TCIQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interviews, and review of the facility policy titled Monitoring Oxygen Therapy the facility failed to follow the Physician's Order for one resident (R) (#75) of 20 residents receiving oxygen. Findings include: Review of the policy titled Monitoring Oxygen Therapy dated with a revision date of 1/31/2019 revealed to review the patient's chart for current oxygen therapy order and to check equipment for liter flow. Review of the medical record for R#75 revealed a [DIAGNOSES REDACTED]. Review of the Physician Orders revealed an order for [REDACTED]. Observations on 2/4/2020 at 1:23 p.m., 2/5/2020 at 7:56 a.m., and 2/6/2020 at 7:15 a.m. revealed R#75 receiving oxygen therapy via nasal cannula ranging from 3 and/or 3.5 LPM. During an interview and observation on 2/6/2020 at 9:32 a.m., the Director of Nursing (DON) confirmed that R#75 was receiving oxygen at 3 LPM. However, when the order was checked by Licensed Practical Nurse (LPN) II, it was revealed that R#75's oxygen should be at 2 LPM. The DON reported that it is the charge nurse's responsibility to assure that oxygen is given as ordered. | 2020-09-01 |
| 3861 | 3861 | MEMORIAL MANOR NURSING HOME | 115711 | 1500 EAST SHOTWELL STREET | BAINBRIDGE | GA | 39819 | 2020-02-06 | 812 | F | 0 | 1 | TCIQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, review of facility documentation, and review of the policies titled, Food Storage and Food Contamination, the facility failed to monitor dishwasher temperature (temp) daily to ensure proper wash and rinse temps were in a safe range; failed to discard expired foods in the dry storage area; failed to ensure opened food items in the walk-in cooler were properly labeled and dated; failed to ensure opened food in the walk-in freezer were securely wrapped, labeled and dated; and failed to maintain sanitary conditions of the two-compartment sink. This had the potential to affect 88 of 95 residents receiving an oral diet. Findings include: Review of the facility policies titled, Food Storage, and Food Contamination dated [DATE] revealed: 1.) Food items should be stored, thawed, and prepared in accordance with good sanitary practice. 2.) All products should be dated upon receipt and when they are prepared, use by dates are put on products, leftovers should be dated according to policy. 3.) Food to be frozen should be stored in airtight containers or wrapped in heavy-duty aluminum foil or special laminated papers. Label and date all food items. 4.) Raw fruits and vegetables will be washed before serving. 5.) All opened containers must be properly marked and covered, dated, and rotated. 6.) Water temperatures for washing dishes must be ,[DATE] degrees Fahrenheit, the rinse water must be ,[DATE] degrees Fahrenheit, if temperatures fall outside of acceptable range, maintenance department must be notified. Initial tour and observation of the kitchen on [DATE] between 11:35 a.m. and 12:20 p.m., with the Dietary Manager (DM), revealed the following concerns: 1. Observation at 11:40 a.m., during review of the dishwasher (temp) log, revealed there were no temp checks documented for (MONTH) 2020, additionally, there were 33 missed checks during (MONTH) 2020, and 32 missed checks during (MONTH) 2019. 2. Observation at 11:50… | 2020-09-01 |
| 3862 | 3862 | MEMORIAL MANOR NURSING HOME | 115711 | 1500 EAST SHOTWELL STREET | BAINBRIDGE | GA | 39819 | 2020-02-06 | 880 | D | 0 | 1 | TCIQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to administer eye drops in a sanitary manner for one resident (R) (#65) of two residents observed, failed to ensure that one resident room of 56 resident rooms had sanitizer available for staff usage, failed to ensure clean linen was not contaminated in the laundry area, and failed to ensure that one of three shower rooms was maintained in a sanitary manner to prevent the spread of disease. Findings include: 1. An observation on 2/5/2020 at 12:17 p.m. revealed that the sanitizer was out in room [ROOM NUMBER] and was verbally reported by Licensed Practical Nurse (LPN) GG to the housekeeping staff. An interview with the LPN revealed that she had verbally reported to housekeeping over several days that the sanitizer was empty. An observation on 2/5/2020 at 2:58 p.m. revealed that LPN GG administered eye drops to R#65 without putting a barrier down on the medication cart while preparing the resident's oral medication or in the resident's room on the bedside table that she sat the eye drops on while administering the resident's other medication. The observation revealed that she wore the same gloves to instill the eye drops that she wore when she handed the resident her cup of water and pill cup. The observation also revealed that there was no sanitizer in room [ROOM NUMBER] and the nurse did not wash her hands or use sanitizer prior to instilling the eye drops. An observation on 2/5/2020 at 3:00 p.m. revealed that there was still no sanitizer in room [ROOM NUMBER]. An interview on 2/5/2020 at 3:04 p.m. with LPN GG confirmed that she placed the eye drops on the resident's table without a barrier and handled the cup of water and pill cup with the same gloves on that she had on when she instilled the eye drops. An interview on 2/6/2020 at 1:16 p.m. with the Director of Nursing (DON) revealed that her expectation was for a barrier to be put down on the medicine cart and in t… | 2020-09-01 |
| 2214 | 2214 | TWIN VIEW HEALTH AND REHAB | 115540 | 211 MATHIS AVENUE | TWIN CITY | GA | 30471 | 2020-02-05 | 641 | D | 0 | 1 | 4LOJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and review of the facility policy titled Pre-Admission Screening and Resident Review (PASARR) the facility failed to ensure each resident received an assessment which accurately reflected the resident's status at the time of the assessment for five residents (R) (R#26, R#27, R#54, R#3, and R#9) of 41 residents reviewed for accuracy of assessments related to PASARR. Findings include: Review of the facility policy titled Pre-Admission Screening and Resident Review (PASARR), effective 1/2020, indicated: 8. The Interdisciplinary Assessment Team must use the MDS (Minimum Data Set) form currently mandated by Federal and State regulations to conduct the resident assessment. 9. The assessment process will include: a. Incorporating the recommendations from the PASARR level 2 determination and the PASARR evaluation report into the assessment, care planning and transition of care. 1. Review of the MDS Annual Assessment Section A1500 for R#26, dated 9/21/19, revealed it was not coded for PASARR level 2. R#26 had [DIAGNOSES REDACTED]. She had a PASARR level 2 dated 3/7/14 and received tele-psych services. She had a care plan for mood and behaviors and the use of antipsychotic medications. 2. Review of the MDS Annual Assessment Section A1500 for R#27, dated 3/21/19, revealed it was not coded for PASARR level 2. R#27 had [DIAGNOSES REDACTED]. He had a PASARR level 2 dated 4/3/15 and received tele-psych services. He had a care plan for medication complications and antidepressant use. 3. Review of the MDS Annual Assessment Section A1500 for R#54, dated 7/4/19, revealed it was not coded for PASARR level 2. R#54 had [DIAGNOSES REDACTED]. He had a PASARR level 2 dated 6/14/04 and received tele-psych services. He had a care plan for drug related complications. 4. Review of the MDS Annual Assessment Section A1500 for R#3 , dated 11/1/19, revealed it was not coded for PASARR level 2. R#3 had [DIAGNOSES REDACTED]. She had a PA… | 2020-09-01 |
| 2215 | 2215 | TWIN VIEW HEALTH AND REHAB | 115540 | 211 MATHIS AVENUE | TWIN CITY | GA | 30471 | 2020-02-05 | 761 | D | 0 | 1 | 4LOJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, policy review entitled Storage of Medications, and staff interview the facility failed to ensure proper storage of insulin for one of two medication carts. Findings include: Observation of medication cart on station three on 2/04/2020 at 10:00 a.m. revealed the following unopened [MEDICATION NAME] 100ml vial. The medication was verified as unopened and improperly stored by Unit Manager EE. Interview with the Unit Manager EE on 2/4/2020 at 11:34 a.m. in reference to expectations for storage of unopened insulin revealed that nurses are expected to store insulin in the refrigerator in the drug room until needed and not on the medication carts. Interview with Administrator on 2/05/2020 at 8:49 a.m. in reference to expectations for storage of insulins revealed that the insulins should be stored according to manufacturing directions if the package instructs to refrigerate, the expectation is for staff to follow those instructions and refrigerate the medication; not store them on the medication cart. Review of the facility policy titled Storage of Medication with an effective date of 1/2020 revealed under Policy Interpretation and Implementation: 9. Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station or other secured location. Medications must be stored separately from food and must be labeled accordingly. | 2020-09-01 |
| 2216 | 2216 | TWIN VIEW HEALTH AND REHAB | 115540 | 211 MATHIS AVENUE | TWIN CITY | GA | 30471 | 2020-02-05 | 812 | F | 0 | 1 | 4LOJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of the facility policy titled, Food Receiving and Storage, and staff interviews, the facility failed to discard expired items in the walk-in cooler; and failed to ensure that stored food items were secured with date and label in the reach-in freezer. The deficient practice had the potential to affect 88 of 89 residents receiving an oral diet. Findings include: On [DATE] at 11:21 a.m., during the initial tour of the reach-in freezer with the Cook CC, the following items were revealed: Five clear plastic bags and two blue plastic bags with unidentified, unlabeled food items. On [DATE] at 7:35 a.m., during a tour of the walk-in cooler with the Dietary Manager (DM), there was a carton of thicken water with an open date of [DATE] and a use by date of [DATE]. During an interview with the DM, she stated they usually keep it for seven days after it is opened and then throw it out. She confirmed that the used by date on the carton was [DATE] and it should have been thrown out. Follow up observation on [DATE] at 7:45 a.m., of the reach-in freezer with the DM revealed one clear plastic bag of waffles that had been opened and folded over, not secured. During an interview on [DATE] at 8:50 a.m., the DM and Cook DD stated the process for receiving and storing food in the freezer is the responsibility of the person that works 9 a.m. - 3:00 p.m. She also stated that person is to label and date the food when it is open and label what it is. During an interview with the Administrator on [DATE] at 7:50 a.m. she stated the procedure for receiving and storage of foods is to mark when it came in, mark when it is opened and date it. She stated she was unaware of food items in the reach in freezer not labeled or dated. She stated that she expected that the dietary staff would ensure there would be no expired or undated or unlabeled foods in the reach-in freezer. Review of the policy titled, Food Receiving and Storage, under Policy Inter… | 2020-09-01 |
| 324 | 324 | AMARA HEALTHCARE & REHAB | 115150 | 2021 SCOTT ROAD | AUGUSTA | GA | 30906 | 2020-01-30 | 657 | D | 0 | 1 | G24811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to update the comprehensive care plan to reflect interventions related to right [MEDICAL CONDITION] for one resident (R) (#89) of 40 sample residents. Findings include: Review of Significant Change Minimum Data Set ((MDS) dated [DATE] for R#89 revealed a Brief Interview for Mental Status (BIMS) Assessment score of nine out of 15 which indicates moderate cognitive impairment, and had [DIAGNOSES REDACTED]. Review of R#89 Physician order [REDACTED]. Review of the care plan for R#89 revised 12/30/19 revealed activities of daily living care plan included a [DIAGNOSES REDACTED]. Interventions do not address the precautions for the [MEDICAL CONDITION]. During an interview on 1/30/2020 at 10:05 a.m., the Care Plan Coordinator and Regional Care Plan Coordinator revealed care plans are updated as needed, on admission, with significant changes, and quarterly. During an interview on 1/30/2020 at 10:10 a.m., the Director of Nursing (DON) revealed she expects care plans to be updated as needed. She stated Certified Nursing Assistants (CNA) have a separate CNA care plan book located at the nurse's station for their review. DON confirmed the interventions concerning R#89's [MEDICAL CONDITION] are not addressed on any care plans. | 2020-09-01 |
| 325 | 325 | AMARA HEALTHCARE & REHAB | 115150 | 2021 SCOTT ROAD | AUGUSTA | GA | 30906 | 2020-01-30 | 761 | D | 0 | 1 | G24811 | Based on observations, policy review entitled Storage of Medication, and staff interview the facility failed to ensure disposal of expired medications by the appropriate expiration date on one of five medication carts. Findings Include: Observation for medication cart at station one A Hall on 1/29/2020 at 9:56 a.m. revealed one bottle of Vitamin D 3 50,000 I. U. with expiration date of (MONTH) 2019. All expired medications were confirmed to be out of date by nurse BB whom was present at time of observation. Interview with Director of Nursing (DON) on 1/30/2020 at 9:06 a.m. revealed that the expectation is for all expired drugs are to be removed from the medication cart and discarded when expiration date is reached. Facility policy review entitled Storage of Medication dated (MONTH) 2007 revealed under Policy Interpretation and Implementation: The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. | 2020-09-01 |
| 2048 | 2048 | THE PAVILION AT BRANDON WILDE | 115524 | 4275 OWENS ROAD | EVANS | GA | 30809 | 2020-01-30 | 554 | D | 1 | 1 | RFJ511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, record review and policy review, the facility failed to assess and determine if one resident, (R) R#55, of 55 sampled residents, for the ability to safely self-administer medications, prior to the resident exercising that right. Findings include: A review of the facility policy titled Self-Administration of Medications, revised December 2016, revealed the Policy Statement is that resident's have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. Policy Interpretation and Implementation 1. As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physial abilities to determine whether self-administering medications is clinically appropriate for the resident; 5. The staff and practitioner will document their findings and the choices of the residents who are able to self-administer mediations; 8. Self-administered medications must be stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible in the resident's room, the medications of residents permitted to self-administer will be stored on a central medication cart or in the medication room. Nursing will transfer the unopened medication to the resident when the resident requests them; 9. Staff shall identify and give to the Charge Nurse and medications found at the bedside that are not authorized for self-administration, for return to the family or responsible party. A review of the clinical record for R #55 revealed resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's Comprehensive Admission Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 13, which indicated no cognitive impairment. Observation on 1/27/2020 at 12:41 p.m., revealed on resident bedside night stand, three ov… | 2020-09-01 |
| 2049 | 2049 | THE PAVILION AT BRANDON WILDE | 115524 | 4275 OWENS ROAD | EVANS | GA | 30809 | 2020-01-30 | 582 | D | 1 | 1 | RFJ511 | > Based on Record review, staff interview and policy review, it was determined that the facility failed to completely fill out the Notice of Medicare Non-coverage (NOMNC), Medicare Form , and the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN), Medicare Form , with the resident or responsible party's signature to indicate that they understood the contents of the form for two of three selected residents (R) (R#26 and R#34), who were discharged off Medicare Part A services and who remained in the facility. Findings include: Review of the undated facility policy titled Procedures for issuing SNFABN's. Have beneficiary or authorized representative indicate option and sign and date. In the margins, note date of receipt indicating receipt of signed copy and make a copy, the original for the beneficiary or authorized representative and copy for the SNF. The SNF must obtain the signed SNFABN containing the signature of the resident or authorized representative. If the SNFABN is not returned in timely manner, document all contacts with authorized representative requesting return of signed copy. Review of a Beneficiary Notice-Residents discharged Within the Last Six Months form revealed that R#26 and R#34 both remained in the facility after skilled services ended. Review of records for R#26 indicated that services were initiated on 11/22/19 and discharged from Medicare Part A services on 12/30/19 and remained in the facility. Review of her Beneficiary Notices revealed that neither the Notice of Medicare Non-Coverage form (NOMNC)(Form CMS- ) or the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN), Medicare Form , were provided to the resident or the residents representative. The forms indicated that verbal notification was given to the resident representative on 12/27/19, but no evidence of signature acknowledging understanding of contents. Resident remained in the facility. Review of records for R#34 indicated that services were initiated on 12/10/19 and discharged f… | 2020-09-01 |
| 2050 | 2050 | THE PAVILION AT BRANDON WILDE | 115524 | 4275 OWENS ROAD | EVANS | GA | 30809 | 2020-01-30 | 585 | D | 1 | 1 | RFJ511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, staff and resident interviews, record review and review of facility policies, the facility failed to follow up on one grievances filed for one resident (R) #5 of 32 sampled residents. Findings include: Review of the facility's Grievance, Complaints and Missing property policy revealed the grievance coordinator would be responsible for informing the resident/resident's responsible party of the outcome and the right to receive the outcome/conclusion in writing. Review of the clinical record for R#5 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Grievance Form, dated 10/26/19, revealed there was a medication error on 10/26/19 when a [MEDICATION NAME] was applied to the resident's chest and remained on the resident until later in the evening. Review of the Grievance Form dated 10/26/19 revealed there was no evidence of the investigation being completed and no follow-up completed. An interview on 1/27/2020 at 11:25 a.m. with R #5 responsible party he stated he has filed grievances with the facility and there has been no follow up protocol. He said that he has had similar issues in the past of not having grievances followed up. He said the facility is under new management and there has been no acknowledgment of the grievances he has filled regarding regarding the family member. An interview on 1/28/2020 at 5:07 p.m. with the Director of Nursing (DON) revealed that she was not employed into the facility at the time the grievance was filed for R#5. She agrees that the grievance form was not completed although she is aware that the Physician was contacted, the resident was monitored to ensure there were no ill effects of the medication error. She stated that when she receives a grievance, she would complete the form including providing the form to the correct department, completing an investigation and completing a follow-up. An interview on 1/28/2020 at 1:15 p.m. with the … | 2020-09-01 |
| 2051 | 2051 | THE PAVILION AT BRANDON WILDE | 115524 | 4275 OWENS ROAD | EVANS | GA | 30809 | 2020-01-30 | 638 | B | 1 | 1 | RFJ511 | > Based on record review and staff interview, the facility failed to complete a Quarterly Minimum Data Set (MDS) Assessment not less than every three (3) months for five (5) out of seven (7) residents reviewed (R#3, R#4, R#5, R#6 and R#7). Findings include: Review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.16, dated October 2018 revealed: The Quarterly assessment is an OBRA (Omnibus Budget Reconciliation Act) non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type. It is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored. 1. Review of the R#3's MDS Assessment revealed that an Annual MDS Assessment was completed on 9/9/19. Further review revealed there was no evidence that a Quarterly MDS Assessment was completed in December 2019. Review of the MDS Calendar for December 2019 revealed the resident was scheduled for a Quarterly Assessment on 12/8/19. 2. Review of the R#4's MDS Assessment revealed that an Annual MDS Assessment was completed on 6/26/19 and a Quarterly Assessment was completed on 9/18/19. Further review revealed there was no evidence that a Quarterly Assessment was completed in December 2019. Review of the MDS Calendar for December 2019 revealed the resident was scheduled for a Quarterly Assessment on 12/11/19. 3. Review of the R#5's MDS Assessment revealed that an Annual MDS Assessment was completed on 6/24/19 and a Quarterly Assessment was completed on 9/18/19. Further review revealed there was no evidence that a Quarterly Assessment was completed in December 2019. Review of the MDS Calendar for December 2019 revealed the resident was schduled for a Quarterly Assessment on 12/11/19. 4. Review of the R#6's MDS Assessment revealed that an Annual MDS Assessment was completed on 6/24/19 and a Quarterly Assessment was completed on 9/1… | 2020-09-01 |
| 2052 | 2052 | THE PAVILION AT BRANDON WILDE | 115524 | 4275 OWENS ROAD | EVANS | GA | 30809 | 2020-01-30 | 640 | B | 1 | 1 | RFJ511 | > Based on record reviews and staff interviews the facility failed to ensure that Minimum Data Sets (MDS) assessments were transmitted within 14 days of completion to CMS's (Centers for Medicare and Medicaid Services) Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) system for six (6) rsidents (R#1, R#2, R#3, R#4, R#5 and R#7). The sample size was 32. Findings include: 1. Review of R#1's completed and transmitted MDS records revealed that a Discharge Part A was due on 8/31/19. Further review revealed there was no evidence that a Discharge Tracking Assessment was completed. 2. Review of R#2's completed and transmitted MDS records revealed a Discharge Part A dated 9/13/19 with submission date of 9/19/19. Further review revealed there was no evidence that a Discharge Tracking Assessment was completed. 3. Review of R#3's completed and transmitted MDS records revealed a MDS Quarterly Assessment was completed 12/21/18 and submitted on 2/21/19 which should have been submitted by 2/1/19. 4. Review of R#4's completed and transmitted MDS records revealed a MDS Quarterly Assessment was completed on 1/7/19 and submitted on 4/18/19 which should have been submitted by 3/21/19. 5. Review of R#5's completed and transmitted MDS records revealed a MDS Quarterly Assessment was completed on 1/2/19 and submitted on 4/1/19 which should have been submitted by 3/21/19. 6. Review of R#7's completed and transmitted MDS records revealed a MDS Quarterly Assessment was completed on 1/7/19 and submitted on 4/18/19 which should have been submitted by 4/17/19. Interview with the MDS Coordinator on 1/29/2020 at 2:45 p.m. revealed that she has been employed at the facility since May 2019 as the MDS Coordinator. She further stated that when she first came to the facility the Interim MDS Coordinator, who had been at the facility since January 2019, explained to her that OBRA assessments from February 2019 had not been completed but that all Medicare Part A assessments were complete. She further stated that sh… | 2020-09-01 |
| 2053 | 2053 | THE PAVILION AT BRANDON WILDE | 115524 | 4275 OWENS ROAD | EVANS | GA | 30809 | 2020-01-30 | 684 | D | 1 | 1 | RFJ511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview the facility staff failed to follow the Physician order [REDACTED].#5) related to the administration of a [MEDICATION NAME] that was not ordered for the resident of 32 sampled residents. Findings include: Review of the Administering Medications policy includes medications must be administered in accordance with the orders, the individual administering medication must identify the resident before administering medication, and medication is to be documented immediately after giving a resident the medication. Review of the clinical record for R#5 revealed admission to the facility on [DATE] with [DIAGNOSES REDACTED]. 1. Review of the Grievance Form dated 10/26/19 revealed there was a medication error on 10/26/19 with R#5 where a [MEDICATION NAME] was applied to the resident's chest and remained on R#5 until later in the evening. Review of the physician's orders [REDACTED].>Review of the Medication Administration Records (MAR's) for R#5 for August 2019 through December 2019 revealed there was no order for [MEDICATION NAME]. Review of the Nurse's Notes dated 10/27/19 at 8:00 p.m. revealed that the writer was called to R#5's room by a family member to ask what the patch on resident's chest. The writer looked at the resident orders to find no new orders had been received and no order for a [MEDICATION NAME]. This nurse removed patch from resident's chest, notified the Director of Nursing (DON) and Medical Director (MD). The MD gave instructions to take vital signs and recheck in 30 min (no issues with vitals noted). The MD was notified of the results and no further action was needed due to the patch is removed, will continue to observe for changes. R#5 did not have any negative effects related to the [MEDICATION NAME] being placed on her chest. An interview on 1/29/2020 at 12:25 p.m. with the MD for R# 5 revealed he received a phone call on evening of 10/26/19 around 8:15 p.m. regarding the resident having a [M… | 2020-09-01 |
| 2997 | 2997 | GLENVUE HEALTH AND REHAB | 115619 | 721 NORTH VETERANS BLVD | GLENNVILLE | GA | 30427 | 2020-01-30 | 656 | D | 0 | 1 | ZLXZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews the facility failed to follow the care plan for two of 24 residents (R#82, R#21) reviewed for care plans. Findings include: 1. Record review revealed that R#82 was admitted to the facility with [DIAGNOSES REDACTED]. A review of the Physician Orders for R#82 revealed an order for [REDACTED]. A review of the care plan revealed that R#82 was at risk for ineffective breathing pattern related to requiring oxygen with an intervention to follow the physician orders. An observation on 1/27/2020 at 11:51 a.m. revealed that portable oxygen for resident (R)#82 was set at 2 liters per minute (LPM) and the resident was up in a wheelchair. The observation revealed that the oxygen concentrator was also on and was set at 2.5 LPM. An observation on 1/28/2020 at 10:03 a.m. revealed that R#82 was in bed with oxygen on. The oxygen concentrator was set at 2.5 LPM. An observation on 1/29/2020 at 12:49 p.m. revealed that R#82 was in bed with oxygen on and the oxygen concentrator was set at 2.5 LPM. An interview and observation on 1/29/2020 at 2:16 p.m. with the Licensed Practical Nurse (LPN) AA of R#82 in Room B5-A confirmed the oxygen concentrator was set at 2.5 LPM. LPN AA also confirmed that the Physician Order documented the oxygen was to be set at 3 LPM. An interview on 1/29/2020 at 2:36 p.m. with the Director of Nursing (DON) revealed that her expectation was that oxygen was to be administered as ordered by the Physician. The DON confirmed that the oxygen for R#82 was ordered at 3 LPM. An interview on 1/30/2020 at 2:58 p.m. with the DON confirmed that R#82 and R#21 both have interventions on their care plan to administer oxygen as ordered and that her expectation was that the care plan was to be followed. An interview on 1/30/20 at 3:06 p.m. with the Nurse Consultant revealed that the facility used the RAI guidelines as their care plan policy. 2. Review of medical record for R#21 revealed [DIAGNOSES RE… | 2020-09-01 |
| 2998 | 2998 | GLENVUE HEALTH AND REHAB | 115619 | 721 NORTH VETERANS BLVD | GLENNVILLE | GA | 30427 | 2020-01-30 | 695 | D | 0 | 1 | ZLXZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, record review, and review of the facility policy titled, Oxygen Administration the facility failed to ensure that the Physician's order for oxygen administration was followed for one resident (R#82) and failed to obtain an order for [REDACTED]. Findings include: 1. A review of the policy titled, Oxygen Administration under subtitle 1. Preparation reveals that there was to be verification of the Physician's order. Record review revealed that R#82 was admitted to the facility with [DIAGNOSES REDACTED]. A review of the Physician Orders revealed an order for [REDACTED]. An observation on 1/27/2020 at 11:51 a.m. revealed that portable oxygen for resident (R)#82 was set at 2 liters per minute (LPM) and the resident was up in a wheelchair. The observation also revealed that oxygen concentrator was on and was set at 2.5 LPM. An observation on 1/28/2020 at 10:03 a.m. revealed that R#82 was in bed with oxygen on. The oxygen concentrator was set at 2.5 LPM. An observation on 1/29/2020 at 12:49 p.m. revealed that R#82 was in bed with oxygen on and the oxygen concentrator was set at 2.5 LPM. An interview and observation on 1/29/2020 at 2:16 p.m. with the Licensed Practical Nurse (LPN) AA of R#82 in Room B5-A confirmed the oxygen concentrator was set at 2.5 LPM. LPN AA also confirmed that the Physician Order documented the oxygen was to be set at 3 LPM. An interview on 1/29/2020 at 2:36 p.m. with the Director of Nursing (DON) revealed that her expectation was that oxygen was to be administered as ordered by the Physician. The DON confirmed that the oxygen for R#82 was ordered at 3 LPM. 2. Oxygen Administration - revised 2010 1. Verify that there is a Physician's order for this procedure. Review the Physician's orders or facility protocol for oxygen administration. Review of medical record for R#21 revealed [DIAGNOSES REDACTED]. During observations on 1/27/2020 at 3:17 p.m., 1/28/2020 at 4:28 p.m., and 1/29/2020 at 8:… | 2020-09-01 |
| 2999 | 2999 | GLENVUE HEALTH AND REHAB | 115619 | 721 NORTH VETERANS BLVD | GLENNVILLE | GA | 30427 | 2020-01-30 | 812 | F | 0 | 1 | ZLXZ11 | Based on observation, record review, staff interview, and review of the policy titled, Important Dietary Instruction Guide: Labeling and Dating, the facility failed to ensure opened and canned food items in the dry storage area were properly labeled and dated. This had the potential to affect 111 out of 120 residents receiving an oral diet. Findings include: 1. Review of the facility policy titled Important Dietary Instruction Guide: Labeling and Dating, revealed All Foods Must Have a Date Grocery truck opened times: Any items that have been opened but will be used again. During the initial tour on 01/27/2020 at 11:10 a.m. with the Dietary Manager revealed the following: (3) gallon-sized cans of ketchup not labeled for receiving date, (2) gallon-sized cans of whole kernel corn not labeled for receiving date, (7) gallon-sized cans of beets not labeled for receiving date, (1) gallon-sized can of apple sauce not labeled for receiving date, (1) 16 oz. bag of marshmallows opened with no opening date, (1) 16 oz. container of All Spice Seasoning opened with no opening date, and (1) 16 oz. container of Pumpkin Pie Spice opened with no opening date. An interview with the Dietary Manager on 12/17/19 at 8:15 a.m. revealed that that it is the expectations of everyone to label all food items with date item was received, opened, and expires. The DM explained that they receive supplies each week and supplies are to be labeled upon arrival. | 2020-09-01 |
| 3000 | 3000 | GLENVUE HEALTH AND REHAB | 115619 | 721 NORTH VETERANS BLVD | GLENNVILLE | GA | 30427 | 2020-01-30 | 880 | F | 0 | 1 | ZLXZ11 | Based on observation, staff interview, and review of the facility policy titled, Ice Machine and Ice Storage Chests the facility failed to provide a sanitary ice scoop for an ice machine serving five of five halls and failed to ensure a soap dispenser was working in one of three shower rooms. Findings include: Review of the Ice Machine and Ice Storage Chests policy dated (MONTH) 2012 revealed to keep ice scoop/bin in a covered container when not in use. During an interview on 1/30/2020 with the Maintenance Assistant he reported that the ice scoop should be kept on the outside of the ice machine. During an observation on 1/27/2020 at 11:20 a.m. of the ice machine on the F hall there was a blue scoop inside of the ice machine. During an observation on 1/27/2020 at 11:57 a.m. in the shower room on F hall the hand soap dispenser was not functioning. During an observation and interview on 1/30/202 at 11:45 a.m. Licensed Practical Nurse DD confirmed there was a scoop hanging in the ice machine. LPN DD also revealed that the ice scoop should be kept in the ice machine to keep residents from getting it. LPN DD reported that she is unsure of who is responsible for cleaning the ice machine or how frequently the ice machine is cleaned. During an observation and interview on 1/30/2020 at 12:04 p.m. Certified Nursing Assistant (CNA) FF was present at the ice machine on the F hall and was filling cooler with ice. CNA FF revealed that the ice scoop should be kept inside of the ice machine. During an interview and observation with the Maintenance Director on 1/30/2020 at 12:12 p.m. who confirmed that the scoop was in the ice machine. The Maintenance Director reported that the scoop should be stored on the outside of the ice machine. | 2020-09-01 |
| 2951 | 2951 | PRUITTHEALTH - FRANKLIN | 115616 | 360 SOUTH RIVER ROAD | FRANKLIN | GA | 30217 | 2020-01-29 | 812 | F | 0 | 1 | ES4X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and review of facility policies, the facility failed to dispose of expired food in the walk-in refrigerator and failed to maintain a clean and sanitary environment to prepare resident meals. This practice had the potential to affect 65 of 68 residents receiving an oral diet. Findings include: An initial tour of the kitchen was conducted on [DATE] at 11:10 a.m. The kitchen floor and mat sitting in front of the three-compartment sink had food debris on top of the mat and in the open holes of the floor mat. The shelf and floor next to the fryer was dirty with food debris. An observation of the walk-in refrigerator revealed a container of leftover cooked sweet potatoes with a label on it which read expires on [DATE]. On [DATE] at 8:05 a.m., a second observation of the kitchen was conducted along with the Dietary Manager (DM). The kitchen floor and mat sitting in front of the three-compartment sink was dirty with food debris on the mat and between the holes of the mat, the mat was sticky when walked on. The shelf and floor next to the fryer was dirty with food debris. The DM identified the mat and the floor under the mat was dirty, and the shelf and floor next to the fryer were dirty with debris. A review of the policy titled Cleaning Procedures: Kitchen Area revised [DATE] revealed the policy statement: It is the policy of the facility to maintain a clean and sanitary environment to prepare resident meals. Page two under Kitchen Floors Daily: Sweep and mop daily. Page three under Floor Mats Daily: remove floor mats to cart areas or outside wash area, scrub with hot, soapy solution and rinse by spraying with power hose or spray nozzle attachment on hose. An interview with DM on [DATE] at 8:30 a.m. was conducted. DM revealed kitchen staff who work second shift are to sweep, mop, wipe off shelves, and clean the equipment before leaving for the evening. DM stated he is the only one who removes the floor mats and powe… | 2020-09-01 |
| 137 | 137 | BROWN HEALTH AND REHABILITATION | 115090 | 545 COOK STREET | ROYSTON | GA | 30662 | 2020-01-24 | 812 | E | 1 | 1 | 1R0411 | > Based on observations, record review and staff interviews, the facility failed to ensure that all items on the kitchen tray line, specially ground pork, were held at the appropriate temperature to prevent food born illness which effected 20 residents who received ground meats. Findings include: Review of policies entitled, Food Preparation and Distribution, updated February 2019 revealed that a temperature monitoring log will be maintained throughout meal service hot foods will be held at greater or equal to 135 degrees Farenheit (F), cold foods will be held at less or equal to 41 degrees F, while frequently monitoring temperatures during meal service, if any temperature is determined to be out of ranger, corrective action will take place (hot items will be pulled from the tray line and re-heated until an internal temperature of 165 degree F for 15 seconds is reached; cold items will be pulled from the tray line and placed into an ice bath, cooler, freezer, or blast chiller until 41 degrees or lower is reached; and items will be re-checked and proper temperature verified before beginning to serve. Observation and interview of the main kitchen tray line temperature taken by Food Service Aide (FSA) AA with the facilities calibrated thermometer on 1/23/20 between 6:24 p.m. through 6:39 p.m., revealed that the ground pork had a temperature of 130 degrees F. Interview with FSA AA at this time revealed that he was unsure how many ground pork have been served so far. An interview with Dietary Manager on 1/24/20 at 12:51 p.m. revealed the facility has in-services monthly, and she expects that staff identify when temps are not correct and pull food and not serve any food at a temperature that is too low or too high. | 2020-09-01 |
| 3523 | 3523 | REHABILITATION CENTER OF SOUTH GEORGIA | 115676 | 2002 TIFT AVENUE NORTH | TIFTON | GA | 31794 | 2020-01-24 | 584 | D | 0 | 1 | N4IC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interviews the facility failed to ensure sanitary conditions related to cleanliness of hallways and resident rooms as related to buildup of dirt, debris, and spills on the floors, and stained walls, stained and bulging ceiling tile, dusty air vents. In addition, the facility faiiled to ensure one wheelchair was in good repair for one resident (R) #478). This practice effected two of five halls (400 & 500 Hall), three of 74 resident bathrooms (the bathrooms for rooms 501/502, 508/510, and 512/514), and one of 75 resident wheelchairs. Findings include: Review of the housekeeping to do list revealed that any wheelchairs that look frayed or are missing parts should be reported to the HSK Supervisor or to the Maintenance Director. Review of the Daily Cleaning Quality Inspection Form revealed that vents in bathroom should be free of dust and in resident rooms the walls, baseboards are clean and free of stains and/or visible damage. Review of the Cleaning Schedules revealed cleaning schedules shall be developed and implemented to ensure that our facility is maintained in a clean and comfortable manner. Review of the Maintenance Monthly Checks revealed ceiling tiles should be checked throughout the facility. 1. Observation on 1/22/20 at 10:10 a.m. in the shared bathroom for rooms 508/510 revealed there were bulging ceiling tiles. Observation on 1/22/20 9:57 a.m. in the shared bathroom for rooms 512/514 revealed there was dust in the vent and bulging ceiling tiles. Observation on 1/22/20 at 9:32 a.m. in the shared bathroom for rooms 501/502 revealed bulging ceiling tiles. Observation on 1/23/20 at 8:55 a.m. in room [ROOM NUMBER] the wheelchair for R#478 was observed to have a broken back and build up on spokes of the wheelchair. During an interview on 1/24/20 at 1:19 p.m. with the HSK Supervisor revlealed that housekeeping audit tools for cleaning are completed daily but they are discarded at the end of each week. The HS… | 2020-09-01 |
| 3524 | 3524 | REHABILITATION CENTER OF SOUTH GEORGIA | 115676 | 2002 TIFT AVENUE NORTH | TIFTON | GA | 31794 | 2020-01-24 | 684 | D | 1 | 1 | N4IC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff interviews, and review of the facility Policy and Procedure titled, Administering Medications the facility failed to follow physicians orders related to finger stick blood sugar (FSBS) checks for one resident (R) (R#277) of 49 residents. Findings include: Review of the admission record dated 6/26/19 and the discharge record dated 7/18/19 revealed the resident had the following [DIAGNOSES REDACTED]. Record review of the facilities Policy and Procedures titled, Administering Medications dated 3/22/17 revealed the following information: 3. Medications must be administered in accordance with orders, including any required time frame. 4. Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meals). Record review of the Medication Administration Record [REDACTED] Interview on 1/24/20 at 10:40 a.m. with the Assistant Director of Nursing (ADON) revealed she investigated a complaint from a family member of R#277 concerning his blood sugar being low. She further states that the FSBS results were 51mg/dl on 7/17/19 at 6:30 a.m. and 25mg/dl on 7/17/19 at 1:08 p.m. R#277 received 1 mg of [MEDICATION NAME] at 1:10 p.m. due to the low blood sugar. The ADON confirmed that the FSBS results at 1:08 p.m. were out of compliance according to the physician's orders, they were scheduled to be checked at 11:30 a.m. Interview on 1/24/20 at 11:03 a.m. and again at 12:21 p.m. the DON confirmed even with and hour before and an hour time frame for administering medications, the FSBS wasn't taken until 1:08 p.m. not at the ordered time of 11:30 a.m. She further stated the nurse was not within compliance of the physician's orders and confirmed the facility failed to check the FSBS at 11:30 a.m. per the physician's orders. Interview on 1/24/20 at 12:21 p.m. LPNAA revealed the FSBS should have been checked within an hour before and an hour after the scheduled ti… | 2020-09-01 |
| 3525 | 3525 | REHABILITATION CENTER OF SOUTH GEORGIA | 115676 | 2002 TIFT AVENUE NORTH | TIFTON | GA | 31794 | 2020-01-24 | 695 | D | 1 | 1 | N4IC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, staff interviews, and review of the facility policy titled, Oxygen Administration the facility failed to follow Physician's Order for one of 44 residents (R) (#74) reviewed for receiving oxygen. Findings include: Review of the policy titled Oxygen Administration dated 3/24/17 revealed the following procedure: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Review of the medical record for R#69 revealed [DIAGNOSES REDACTED]. Review of the Physician orders revealed an order for [REDACTED]. Observations on 1/22/20 at 10:08 a.m. and 2:28 p.m., on 1/23/2020 7:10 a.m., and on1/23/2020 at 7:37 a.m. revealed R#74 receiving oxygen therapy via nasal cannula ranging from 1.5 and/or 2/LPM. During an interview and observation on 1/24/19 at 8:31 a.m. Licensed Practical Nurse (LPN) FF confirmed that R#69 was currently receiving oxygen at 2 LPM. However, when the order was checked LPN revealed that the residents oxygen should be at 3 LPM. LPN FF revealed that nursing staff throughout the week should be looking to make sure oxygen is at the correct rate. During an interview with the Director of Nursing (DON) on 1/24/20 at 3:09 p.m. it was reported that the expectation is that staff will check to assure that oxygen at the right rate at beginning of the shift. | 2020-09-01 |
| 3526 | 3526 | REHABILITATION CENTER OF SOUTH GEORGIA | 115676 | 2002 TIFT AVENUE NORTH | TIFTON | GA | 31794 | 2020-01-24 | 842 | C | 1 | 1 | N4IC11 | > Based on observation, record review, staff interviews, and review of the facility policy titled, Release of Information and Resident Medical Record Information the facility failed to provide adequate protection of resident medical and financial information for all residents on all halls (200, 300, 400, 500, 600). The facility census was 133 residents. Findings include: Review of the Facility provided policy named, RELEASE OF INFORMATION and RESIDENT MEDICAL RECORD INFORMATION documents that the facility will, Maintain the confidentiality of the residents personal and clinical records. Observation on 01/23/20 at 12:28 p.m. of the back hall nurses station revealed at the nurse's station was a wall approximately 3 feet from the front of the station was a white board with the word REHAB 1 and 2 at the top three columns at the top marked: Medicare, Managed Care, and Falls. Under the Medicare column was written 502b, 503b, 504, 506, 509, 510, 511, 512, 514, 601, 603, 604, 605, 608, 610, and 611. Under Managed Care was 513b, 606 and 607. Under Falls was written 505. At the bottom of the board were three additional columns marked: ABT's, Functionals, and Hospital. Under ABT's was 509. Under Functionals was 509 admit, and 610 admit. Hospital had nothing. Mounted on the board were sheets of white paper along the right side. The heading on the top sheet was titled REHAB 500 & 600 HALL BATH SCHEDULE. It listed the days of the week and times for each rooms baths and or showers. The other white sheet was titled READ THE COMMUNICATION BOARD IN PCC EVERY SHIFT. It gives directions for staff functions. On the white board on wall to the right of the station had three columns at the top of the board marked: MDS, Medicare, and Functional. Under MDS was a white sheet of paper with a header These assessments MUST Be Completed On Time!!! Below that was Wing I and 300 Hall Front (MONTH) 2020 MDS. This listed resident's names for 7-day charting, type, responsible shift. The sheet taped next to it read 200/300 HALL NURSE (201-204,301-30… | 2020-09-01 |
| 3527 | 3527 | REHABILITATION CENTER OF SOUTH GEORGIA | 115676 | 2002 TIFT AVENUE NORTH | TIFTON | GA | 31794 | 2020-01-24 | 880 | F | 0 | 1 | N4IC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of policy, and staff interview, the facility failed to transport clothing from the laundry room in a sanitary manner with the potential to affect 99 of 133 residents whose laundry was cleaned by the facility and the failed to store personal items in a sanitary manner for three of 74 resident bathrooms in the facility. Findings include: 1. Review of the policy titled, Laundry and linen reveals that the purpose of this policy is to provide a process for the safe and aseptic handling, washing, and storage of linen. Under subsection, washing linen and other soiled items, item 7: Clean linen will remain hygienically clean (free of pathogens in sufficient numbers to cause human illness) through measures designed to protect it from environmental contamination, such as covering clean linen carts. An interview and tour of the laundry room on 1/24/20 at 11:04 p.m. with the Head of Housekeeping revealed that clean hanging clothes were covered while being transported down the hall. The observation revealed shelves with plastic containers that had resident names on them, and they were observed to contain small items such as socks, slippers and folded gowns. The observation also revealed that the plastic containers did not have lids. The interview with the Head of Housekeeping revealed that the purpose of covering clothing/laundry items was to prevent cross-contamination. During the interview the Head of Housekeeping revealed that these plastic containers were used to transport these small items down the halls to resident rooms. He confirmed that the plastic containers with clothing items in them were transported down the hall uncovered. He verified that the containers did not have lids and were not covered with a sheet or any other means of covering them. An interview on 1/24/20 at 2:55 p.m. with the Director of Nursing (DON) confirmed that all clean clothing items should be covered while being transported. 2. Observations on … | 2020-09-01 |
| 521 | 521 | A.G. RHODES HOME, INC, THE | 115275 | 350 BOULVARD, S.E. | ATLANTA | GA | 30312 | 2020-01-16 | 554 | D | 0 | 1 | 3CHC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review the facility failed to ensure that one cognitively impaired resident (R) (#65) did not have access to and self-administer an over the counter medication of 48 sampled residents. Findings include: Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed in section (C) a Basic Interview for Mental Status score of 99 indicating severe cognitive impairment. Review of the care plan dated 8/22/19 for R#65 revealed she is at risk for impaired communication due to impaired cognition. R#65 was noted with meds, spices and other items in closet. Patient/family teaching done, items removed and given to family. During an observation on 1/13/2020 at 12:45 p.m. revealed R#65 sitting in a wheelchair in her room. She was noted to have a square shaped, opened packet in her hand and was coughing. An orange colored powder substance was observed on her lap. The packet was an Emergen-C Packet. During this time, a small three drawer plastic chest was observed next to R#65's bed. The drawers to the chest were clear allowing the ability to see inside without having to open the drawers. Inside the third drawer was a box of Emergen-C Packets that was not labeled with the resident's name or dated with an open date. The top of the box was observed to be open and there were unopened packets inside. During an observation on 1/14/2020 at 10:30 a.m., Emergen-C Packets box observed in the bottom drawer of the plastic chest sitting next to the bed of R#65. Review of the package insert information for Emergen-C Packet includes but is not limited to: Emergen-C is a nutritional supplement that contains vitamin C and other nutrients designed to boost your immune system and increase energy. It can be mixed with water to create a beverage and is a popular choice during cold and flu season for extra protection against infections. During an interview on 1/15/2020 at 10:00 a.m. with Licensed Practical Nurse (LPN) BB … | 2020-09-01 |
| 522 | 522 | A.G. RHODES HOME, INC, THE | 115275 | 350 BOULVARD, S.E. | ATLANTA | GA | 30312 | 2020-01-16 | 585 | D | 0 | 1 | 3CHC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident/staff interviews, and review of the facility policy titled, Grievances and Enforcement the facility failed to communicate and document grievance decisions to resident's family for two residents (R) (A and B) of 48 sampled residents. Findings Include: Review of the facility policy titled, Grievances and Enforcement dated (MONTH) 2014 revealed the Administrator or his/her designee shall act to resolve the complaint or shall respond to the complaint within three business days, including in the response a description of the review and appeal rights. 1. Review of the Grievance/ Concern Report dated 12/3/19 revealed family of R A filed a grievance with the facility. Corrective action included in-services for staff. The section of the grievance titled For Office Use Only was completely blank including notification of the date the facility responded to the person filing the grievance and if the complaint was resolved to the satisfaction of the resident/ resident's representative. Interview with the family of R A on 1/15/2020 at 12:20 p.m. revealed a grievance was filed. Family of R A denied receiving written or oral communication regarding the status or conclusion of the grievance. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed R A with a Brief Interview of Mental Status (BIMS) score of 7 indicating severely impaired cognition. 2. Interview with the family of R B on 1/15/2020 at 12:15 p.m. revealed a grievance was filed. Family of R B denied receiving written or oral communication regarding the status or conclusion of the grievance. Review of the MDS Significant Change assessment dated [DATE] revealed R B was unable to complete the BIMS assessment. Review of the Grievance Log from (MONTH) 2019 through (MONTH) 2020 revealed no documentation of associated grievances filed by the family of R B. All forms in the log did not address or specify what the status of grievances were, if the incidents had … | 2020-09-01 |
| 523 | 523 | A.G. RHODES HOME, INC, THE | 115275 | 350 BOULVARD, S.E. | ATLANTA | GA | 30312 | 2020-01-16 | 812 | F | 0 | 1 | 3CHC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and review of the facility policy titled, Food Storage and Handling, the facility failed to ensure opened frozen food items in the walk-in freezer and food items in the dry storage area were securely wrapped, labeled and dated; and failed to discard a food item by the use by date. In addition, the facility failed to maintain sanitary conditions of the two stand-alone ovens and the fryer. This practice had the potential to effect 127 of 131 residents receiving an oral diet. Findings Include: A review of the undated facility policy titled, Food Storage and Handling revealed that it is the policy of the Dining Services Department to cover, label, date, and store all foods in a safe, and appropriate manner to prevent food borne illness. Procedure: all cooked foods, pre-packaged open containers, protein-based salads, desserts and canned fruits are labeled, dated, and secure covered. Food Storage: unopened foods in refrigerator or dry storeroom, storage life is per manufacturer's guideline or supplier labeled guidelines (i.e. used by date). Procedure: Dating System for Open Foods, documented the facility will follow the U-Labeling P&P, to always securely cover food item. Using a label, complete the following: write the expiration date on the product using the guide, clearly write the products name, then return to designated storage (refrigeration, freezer or storeroom.) Check labels daily and discard outdated food. An initial observation and tour of the kitchen was conducted with the Food Service Director (FSD). The observational tour conducted on [DATE] from 9:50 a.m. to 10:20 a.m. of the kitchen and food storage areas revealed two ovens attached to the gas stove not in use. Two double stacked stand-alone ovens in use were dirty, containing old food debris and baked on grease on all shelves and the bottom of both ovens. The fryer oil appeared dirty with small particles of food debris floating in the oil. An o… | 2020-09-01 |
| 524 | 524 | A.G. RHODES HOME, INC, THE | 115275 | 350 BOULVARD, S.E. | ATLANTA | GA | 30312 | 2020-01-16 | 814 | F | 1 | 1 | 3CHC11 | > Based on observation, staff interview, and review of the facility policies titled, Grounds Cleanliness Policy and Disposal of Garbage and Refuse, the facility failed to ensure that trash was disposed of in a sanitary manner and failed to ensure that areas surrounding the compactor were free of trash debris. The facility census was 131. Findings include: A review conducted of the undated policies titled, Disposal of Garbage and Refuse revealed: Policy Explanation and Compliance Guidelines: 7. Refuse containers and dumpsters kept outside the facility shall be designed and constructed to have tightly fitting lids, doors, or covers. Surrounding areas shall be kept clean so that accumulation of debris and insect/rodent attractions are minimized. 8. Garbage should not accumulate or be left outside the dumpster. Review of the facility policy titled, Grounds Cleanliness Policy revealed: 5. The ground's crew clean the entire campus at least weekly. 6. Daily/weekly rounds are made by maintenance staff to make sure that grounds are clean and safe. An initial tour and observation was conducted on 1/13/2020 from 9:50 a.m. to 10:30 a.m. with the Food Service Director (FSD). The tour was of the kitchen, the kitchen back door area, the loading dock, the grease trap, and the garbage/refuse disposal area surrounding the compactor. The grease trap container located on the loading dock outside the back-kitchen door had a moderate amount of scrap wood and broken down/flat cardboard boxes lying on top of the trap. Access was blocked for any disposal of oil/or grease into the trap. Discarded plastic wrappings were observed on the floor behind the grease trap. The FSD explained that when the grease trap is full, she will call the vendor. She then confirmed the wood and cardboard should not be on the trap and she would have the Maintenance Director (MD) remove the items. Further observations of the kitchen loading dock revealed the trash compactor on the lower level. Observation of trash debris included but was not limited to the follo… | 2020-09-01 |
| 525 | 525 | A.G. RHODES HOME, INC, THE | 115275 | 350 BOULVARD, S.E. | ATLANTA | GA | 30312 | 2020-01-16 | 880 | D | 0 | 1 | 3CHC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interview, record review, and review of the Isolation - Notices of Transmission-Based Precautions, the facility failed to initiate contact precautions in a timely manner for one resident (R) (#86) on one of three floors. Findings include: During an interview on 1/15/2020 at 10:30 a.m. with R#86 she pulled her blouse away from her left shoulder to reveal blistering going down her shoulder. She stated she was diagnosed with [REDACTED]. During this time an observation was made of the resident's door, and outside the door, for a sign indicating to check with the nurse prior to entering, and there was no sign, and no Personal Protective Equipment (PPE) cart located outside of the room of R#86. During an interview on 1/15/2020 at 10:35 a.m. with Licensed Practical Nurse (LPN) DD she stated when someone is on transmission-based precautions there is a sign on the door stating, Check with nurse before entering room. She stated she was made aware that R#86 is on transmission-based precautions and confirmed there is no sign on the door and there is no PPE cart located outside the door. During an interview on 1/15/2020 at 10:40 a.m. with the DON he stated he was not made aware R#86 was diagnosed with [REDACTED]. During an interview on 1/15/2020 at 10:50 a.m. with the ADON and LPN CC, the ADON stated that he was made aware that R#86 was diagnosed with [REDACTED]. He stated putting a sign on the door would be a dignity issues so the staff advise visitors before they enter the room, they will need PPE. He stated that contact precautions should be considered and used on all residents and a PPE cart and sign was not needed. During an interview on 1/15/2020 at 11:10 a.m. with the DON he provided a copy of the facility isolation policy and stated that R#86 should have had a sign placed on the door and a PPE cart placed just outside the door when the [DIAGNOSES REDACTED]. During an interview on 1/16/2020 at 1:19 p.m. with… | 2020-09-01 |
| 3628 | 3628 | NANCY HART CENTER FOR NURSING AND HEALING LLC | 115686 | 2117 DOCTOR WARD ROAD | ELBERTON | GA | 30635 | 2020-01-16 | 580 | D | 0 | 1 | D2MI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff interviews and policy review titled Changes in a Resident's Condition or Status, the facility failed to promptly notify the Physician and responsible party for a change in condition for one resident (R) R# 25, who developed additional pressure ulcers on the toes of left foot . The sample size was 36. Findings include: Review of the policy titled Changes in a Resident's Condition or Status revised (MONTH) (YEAR) revealed: The facility shall promptly notify the resident, his/her attending Physician, and representative of changes in the resident's medical/mental condition and/or Status. Policy Interpretation: The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or on-call Physician when there has been 1 d. A significant change in the resident's physical/emotional/mental condition; 1 i. Instructions to notify the Physician of changes in the resident's condition. 4 b. Unless otherwise instructed by the resident, the Nurse Supervisor/Charge Nurse will notify the resident's family or representative: when there is a significant change in the resident's physical, mental or psychosocial status. 7. The Nurse Supervisor/Charge Nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. A review of the clinical record for R#25 revealed resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's Annual Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was assessed as 10, which indicated moderate cognitive impairment. Section G revealed that the resident was assessed for extensive assistance for bed mobility, transferring, locomotion on/off unit and toilet use. Section M revealed no skin breakdown. Review of Physician Phone Order (PO) dated 1/5/2020 revealed order to clean unstaged pressure areas to Lt/Rt (left and right) heel and to tip of L… | 2020-09-01 |
| 3629 | 3629 | NANCY HART CENTER FOR NURSING AND HEALING LLC | 115686 | 2117 DOCTOR WARD ROAD | ELBERTON | GA | 30635 | 2020-01-16 | 638 | E | 0 | 1 | D2MI11 | Based on record review and staff interview, the facility failed to complete a Quarterly Minimum Data Set (MDS) Assessment not less than every three (3) months for five (5) out of ten (10) residents reviewed (R#3, #4, #5, #9, #10). The sample size was 36 residents. Findings include: Review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.16, dated (MONTH) (YEAR) revealed: The Quarterly assessment is an OBRA (Omnibus Budget Reconciliation Act) non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type. It is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored. 1. Review of R#3's MDS Assessments revealed that a Annual MDS Assessment was completed on 9/9/19. Further review revealed there was no evidence that a Quarterly MDS assessment was completed in (MONTH) 2019. Review of the MDS calendar for (MONTH) 2019 revealed that the resident was scheduled for a Quarterly assessment on 12/10/19. 2. Review of R#4's MDS Assessments revealed that a Annual Assessment was completed on 9/17/19. Further review revealed there was no evidence that a Quarterly MDS assessment was completed in (MONTH) 2019. Review of the MDS calendar for (MONTH) 2019 revealed that the resident was scheduled for a Quarterly MDS assessment on 12/18/19. 3. Review of R#5's MDS Assessments revealed that a Admission MDS Assessment was completed on 9/25/19. Further review revealed there was no evidence that a Quarterly MDS assessment was completed in (MONTH) 2019. Review of the MDS calendar for (MONTH) 2019 revealed that the resident was scheduled for a Quarterly MDS assessment on 12/18/19. 4. Review of R#9's MDS Assessments revealed that a Quarterly MDS assessment was completed on 9/4/19. Further review revealed there was no evidence that a Quarterly MDS assessment was completed in (MONTH) 2019. Re… | 2020-09-01 |
| 3630 | 3630 | NANCY HART CENTER FOR NURSING AND HEALING LLC | 115686 | 2117 DOCTOR WARD ROAD | ELBERTON | GA | 30635 | 2020-01-16 | 640 | C | 0 | 1 | D2MI11 | Based on record review, staff interviews and policy review, the facility failed to ensure that Minimum Data Set (MDS) assessments were transmitted within 14 days of completion to CMS's (Centers for Medicare and Medicaid Services) Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) system for nine (9) residents (R) (R#1, #3, #4, #9, #10, #25, #37, #39 and #46). The sample size was 36. Findings include: Review of the undated facility policy titled MDS Procedures/Guidelines revealed the MDS Coordinator has a set schedule for assessments based on admitted and significant changes. Assessments are completed on admission, quarterly, annually and with significant changes. The assessment process is completed through an interdisciplinary team consisting of nursing home staff with varied clinical backgrounds, including resident's Physician. The assessment is completed through observations, information from all available services (medical records, the resident, direct care staff on all shifts, resident's family and/or guardian or other legally authorized representative.) 1. Review of R#1's completed and transmitted MDS records revealed that a Quarterly Assessment was completed on 12/3/19 and submitted on 1/13/2020; a Quarterly Assessment was completed on 9/2/19 and submitted on 9/23/19; an Annual Assessment was completed on 6/16/19, but not transmitted into the QIES System until 9/19/19. 2. Review of R#3's completed and transmitted MDS records revealed that an Annual Assessment was completed on 9/23/19 and submitted to QIES System on 10/21/19; A Quarterly Assessment was completed on 6/17/19 and not submitted to QIES System until 9/18/19. 3. Review of R#4's completed and transmitted MDS records revealed that a Quarterly Assessment was completed on 7/13/19 but not submitted into the QIES System until 10/1/19; a Quarterly Assessment was completed on 3/29/19 but not submitted into the QIES System until 4/12/19; a Quarterly Assessment was completed on 1/10/19 but not submitted into the QIES Sy… | 2020-09-01 |
| 3631 | 3631 | NANCY HART CENTER FOR NURSING AND HEALING LLC | 115686 | 2117 DOCTOR WARD ROAD | ELBERTON | GA | 30635 | 2020-01-16 | 641 | D | 0 | 1 | D2MI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interview the facility failed to ensure Minimum Data Set (MDS) assessments were accurate for two of 36 sampled residents R#49 and R#37. Findings Include: 1. Record review for R#49 revealed the resident was admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. Continued record review revealed the resident was transported to the hospital on [DATE] where the resident expired with [DIAGNOSES REDACTED]. An interview with Director of Nursing (DON) on [DATE] at 1:13 p.m. revealed the resident was a direct admit to hospital from a Physician office on the day of transfer on [DATE] and had expired at the hospital. Further interview confirmed that resident's Minimum Data Set ((MDS) dated [DATE] wass assessed incorrectly, as a death in the facility. 2. Record review revealed R#37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's Annual Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 15, which indicates no cognitive impairment. Review of MDS dated [DATE], section I-Active Diagnoses- did not indicate that resident had [DIAGNOSES REDACTED]. An interview on [DATE] at 2:08 p.m. with the Director of Nursing (DON), stated that the MDS nurse was the person who completed the MDS assessments. She stated that she signed that the MDS assessement's were completed, not that they were accurate. She stated that she does not know anything about completing the assessments, so she would not have known what to look for to make sure they were accurate. She verified that R#37 did not have MDS assessment for [MEDICAL CONDITIONS], PE or GERD. The DON further revealed that the facility has not had an MDS nurse since (MONTH) 2019. | 2020-09-01 |
| 3632 | 3632 | NANCY HART CENTER FOR NURSING AND HEALING LLC | 115686 | 2117 DOCTOR WARD ROAD | ELBERTON | GA | 30635 | 2020-01-16 | 656 | E | 0 | 1 | D2MI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interview, the facility failed to develop comprehensive care plans for multiple areas that triggered on their Care Area Assessment Summaries (CAAS) for six sampled residents (R) (R#4, R#5, R#25, R#46, R#7 and R#27). The sample size was 36 residents. Findings include: 1. Review of a listing of R#4's Minimum Data Sets (MDS) revealed that she was originally admitted to the facility from an acute hospital on [DATE]. Review of R#4's clinical record revealed that she had [DIAGNOSES REDACTED]. Review of R#4's Annual MDS dated [DATE] revealed that care areas that triggered on the CAAS as potential concerns with the decision to address in the care plan included ADL (Activity of Daily Living) Functional/Rehabilitation Potential; Urinary Incontinence; Falls; Dental Care; and Pressure Ulcer. In addition, Nutritional Status triggered, but the column on the CAAS Addressed in Care Plan was not selected. Further review of this Annual MDS revealed that R#4 received insulin and an anticoagulant all seven days of the assessment period, and that she was receiving [MEDICAL TREATMENT] services. Review of R#4's active clinical record revealed an Interim Care Plan with a date of admission of 10/16/18, which did not include that she was receiving [MEDICAL TREATMENT] services, nor that she was receiving insulin for diabetes and that she was on a blood thinner. Further review of her active clinical record revealed that no comprehensive care plan was found. Review of R#4's Physician order [REDACTED]. Further review of the Physician order [REDACTED]. Observation on 1/14/20 at 11:58 a.m. revealed that R#4's [MEDICAL TREATMENT] was in her right upper arm. Interview with R#4 at this time revealed that she was on a 1,500 mL (milliliter) per day fluid restriction, but that staff did not divide up her fluid allotment, and that she did not keep up with how much she was drinking. During interview with the Director of Nursin… | 2020-09-01 |
| 3633 | 3633 | NANCY HART CENTER FOR NURSING AND HEALING LLC | 115686 | 2117 DOCTOR WARD ROAD | ELBERTON | GA | 30635 | 2020-01-16 | 657 | E | 0 | 1 | D2MI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and staff interviews, the facility failed to revise the plans of care for eight residents (#28, #6, #21, #4, #5, #41, #25, and #46) and failed to invite and document, consistently, that the residents or resident representative to the care plan conferences of a sample of 36 residents. The Findings Include: Review of the Facility Policy Multidisciplinary Care Plans revealed A baseline careplan should be completed within the first forty-eight hours after admission by all departments to reflect the choices of the resident. Resident care plan meetings should be held weekly, as needed. Goals and objectives are reviewed and revised at least quarterly. 1. Review of R#28's Minimum Data Set (MDS) listing revealed that she was originally admitted to the facility on [DATE], and had an Annual MDS assessment completed 2/15/19, Quarterly MDSs completed on 5/18/19, 8/12/19, 11/12/19. Review of this Annual MDS revealed that R#28 had a Brief Interview for Mental Status (BIMS) score of 10 (a BIMS between 10 and 15 indicate no cognitive impairment). Review of R#28's care plans revealed that a comprehensive care plan had not been updated since 2/18/19 when the last annual MDS was completed. Review of a Care Plan Conference Sheet dated 02/21/19 revealed that R#28's care plan meeting was held, without any family attendance. There was no evidence on this form that R#28 was either at the meeting or had been invited and declined. Further review revealed that this was the only Care Plan Conference Sheet found in R#28's clinical record. 2. Review of R#6's Minimum Data Set (MDS) listing revealed that she was originally admitted to the facility on [DATE], and had an Admission MDS assessment completed 1/2/19, Quarterly MDSs completed on 4/17/19, 7/18/19, 10/22/19. Review of this Annual MDS revealed that R#6 had a Brief Interview for Mental Status (BIMS) score of 11 (a BIMS between 11 and 15 indicate no cognitive impairment). Review of… | 2020-09-01 |
| 3634 | 3634 | NANCY HART CENTER FOR NURSING AND HEALING LLC | 115686 | 2117 DOCTOR WARD ROAD | ELBERTON | GA | 30635 | 2020-01-16 | 686 | D | 0 | 1 | D2MI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, review of the facility policy titled Wound Care/Treatment Guidelines and staff interviews, the facility failed to prevent the development of further skin breakdown for one resident (R) (R#25) of 36 sampled residents. Findings include: Review of the facility's undated policy titled Wound Care/Treatment Guidelines the purpose is to provide excellent wound care to promote healing.[NAME]Numeral X. The dressing should be labeled with the nurse's initials, date and time.[NAME]Numeral XII. The must be a specific order for the treatment.[NAME]Numeral XIV. The care plan should reflect the current status of the wound and appropriate goals. A review of the clinical record for R#25 revealed resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's Annual Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 10, which indicated moderate cognitive impairment. Section G revealed that the resident was assessed for extensive assistance for bed mobility, transferring, locomotion on/off unit and toilet use. Section M revealed no skin breakdown. Review of Nurse's note dated 1/5/2020, indicated un-stageable pressure area noted to both heels/toes and Physician Orders received to clean with saline. There is no evidence documented that R#25 had additional breakdown on toes two through four on left foot, until 1/15/2020. Review of Physician Phone Order (PO) dated 1/5/2020 revealed order to clean unstaged pressure areas to left and right (Lt/Rt) heel and to tip of Lt/RT great toe with normal saline (NS), apply skin prep and dressing every day until resolved. Review of the Interim Care Plan for R#25, dated 3/1/19, revealed no evidence that R #25 had a care plan problem to include potential for alteration in skin breakdown or actual skin breakdown. An interview on 1/14/2020 at 3:12 p.m. with Licensed Practical Nurse (LPN) JJ, revealed that she did not u… | 2020-09-01 |
| 3635 | 3635 | NANCY HART CENTER FOR NURSING AND HEALING LLC | 115686 | 2117 DOCTOR WARD ROAD | ELBERTON | GA | 30635 | 2020-01-16 | 698 | D | 0 | 1 | D2MI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interview, the facility failed to consistently check vital signs, thrill and bruit, and condition of an AV (arteriovenous) graft before and after [MEDICAL TREATMENT], and failed to ensure an accurate accounting of the ordered fluid restrictions for one of one residents (R) (R#4) reviewed for [MEDICAL TREATMENT]. Findings include: Review of R#4's clinical record revealed that she was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of R#4's Annual Minimum Data Set ((MDS) dated [DATE] revealed that she had a Brief Interview for Mental Status (BIMS) score of 14 (a BIMS between 13 and 15 indicate no cognitive impairment), and that she received [MEDICAL TREATMENT] services. Review of R#4's care plans revealed that there was no comprehensive care plan done. Further review of the care plans revealed that an interim care plan was done that noted a date of (re)admission of 10/16/18, but no notation that R#4 was receiving [MEDICAL TREATMENT]. Review of R#4's (MONTH) 2020 Physician Orders revealed that there was no order for [MEDICAL TREATMENT]. Further review of these Physician Orders revealed a 1,500 mL (milliliter) per day fluid restriction. Review of a Nephrology Consultation dated 10/10/18 revealed a history of [MEDICAL CONDITION] on maintenance [MEDICAL TREATMENT], dialyzed on Monday, Wednesday, and Friday, and that she was admitted by vascular surgery for [REDACTED]. Observation on 1/14/20 at 11:58 a.m. revealed that R#4's [MEDICAL TREATMENT] was her right upper arm. Interview with R#4 at this time revealed that she was on a 1,500 mL fluid restriction, but that staff did not ration her fluids, and she did not keep up with how much she was drinking. A large insulated drinking mug was observed on her overbed table at this time, and felt like it was about half full when lifted. She stated during continued interview that her [MEDICAL TREATMENT] days were Mondays, W… | 2020-09-01 |
| 3636 | 3636 | NANCY HART CENTER FOR NURSING AND HEALING LLC | 115686 | 2117 DOCTOR WARD ROAD | ELBERTON | GA | 30635 | 2020-01-16 | 761 | D | 0 | 1 | D2MI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews, the facility failed to ensure multidose medication vials were dated when opened to determine the discard date in one of one medication storage rooms. Findings include: Observation and interview on 1/15/2020 at 9:25 a.m. with Licensed Practical Nurse (LPN) II, the medication storage room refrigerator revealed two opened multidose vials of Influenza vaccine. One of the opened vials was dated 10/19/19 and the other vial was not dated, as to when it was opened. LPN II revealed that the nurses are supposed to date all medications when they are opened. She further stated that vials are good for 30 days after opening. She stated it is every nurse's responsibility to keep the med storage room cleaned, including the refrigerator and medications. An interview on 1/15/2020 at 10:10 a.m. with Director of Nursing (DON) revealed that she thought the Influenza vials were good through the current Flu season. She called their Pharmacy to get clarification, and was informed that multi-dose vials should be discarded after 30 days of opening. She stated the facility does not have a policy on labeling biological's. Review of untitled document provided by the facility Pharmacy revealed a chart indicating: [MEDICAL CONDITION] vaccine once entered the multi-dose vial should be discarded after 28 days. Review of Long-Term Care Pharmacy Shipping Manifest dated 9/26/2019 to [NAME][NAME]Nursing Center revealed one 30 milliter (ml) vial of FLUCLVX QUAD INJ 2019-2020 was delivered and signed for on 9/26/2019. A telephone interview on 1/16/2020 at 9:36 a.m. with consultant Pharmacist OO, revealed that the Influenza vaccine vial was delivered to facility on (MONTH) 26, 2019. He stated that multi-dose vials of Influenza should be discarded 28 days after the vials were opened. | 2020-09-01 |
| 3637 | 3637 | NANCY HART CENTER FOR NURSING AND HEALING LLC | 115686 | 2117 DOCTOR WARD ROAD | ELBERTON | GA | 30635 | 2020-01-16 | 812 | F | 0 | 1 | D2MI11 | Based on observations, staff interviews and review of policies entitled Food Storage, Dish Machine Temperature Long, Resource: Sanitation of Dishes/Dish Machine, and Food Temperatures, the facility failed to properly maintain dish machine wash temperatures and rinse sanitizer; failed to properly label food products, and failed to ensure foods reached appropriate internal temperatures prior to serving, which had the potential to affect 51 of 51 residents receiving an oral diet. Findings include: During an observation and interview on 1/13/20 at 8:54 a.m. with the Dietary Supervisor (DM) the following was observed and verified by the DM: in the reach in refrigerator; a cucumber with dark blackish and white areas on it, a package of browning heads of lettuce, turkey gravy dated 1/12/20 with no 'use by' date; an unidentified, unlabeled plastic container with a green lid and orange/reddish substance inside; a container labeled tomatoes dated 1/12/20 with no 'use by' date; sliced cheese in a zip lock bag dated 1/8/20 with no 'use by' date; a meat thawing on the bottom shelf of the reach in refrigerator unlabeled; a container of buttermilk ranch dressing with an open date of 12/24/19, and a container of mayonnaise with an open date of 1/23/20, both with no 'use by' dates. Continued observation on 1/13/20 at 9:02 a.m. with the DM of the reach in freezer revealed an opened, unsealed and unlabeled bag of an unidentified food product; an unidentified, unlabeled food product in a blue plastic bag; an unidentified, unlabeled food product in a clear plastic bag; an unidentified, unlabeled meat product in a clear plastic bag; an unopened, unlabeled clear plastic bag of pancakes; and an opened, unsealed and an unlabeled bag of French fries. Further observation on 1/13/20 at 9:11 a.m. of the kitchen revealed an ice machine with cracks on the inside lower left wall of the bin. During an observation and interview on 1/15/20 at 9:15 a.m. with the DM, we observed the browning heads of lettuce remain in the reach in refrigerator, and … | 2020-09-01 |
| 3638 | 3638 | NANCY HART CENTER FOR NURSING AND HEALING LLC | 115686 | 2117 DOCTOR WARD ROAD | ELBERTON | GA | 30635 | 2020-01-16 | 835 | F | 0 | 1 | D2MI11 | Based on observation, record review, and staff interview, the facility administration failed to use its resources effectively and efficiently resulting in the failure to attain the highest practicable physical and psychosocial wellbeing of the residents. The facility failed to achieve employment for vacant Minimum Data Set (MDS) nurse, since (MONTH) 2019. This vacancy resulted in missing and/or late MDS assessments, inaccurate assessments and incomplete resident care plans and the omission of Quarterly care plan meetings. The facility census was 51. The findings include: During entrance conference with the Administrator on 1/13/2020 at 8:55 a.m., she stated that the facility did not employ an Minimum Data Set (MDS) nurse and has not had anyone in that position since (MONTH) of 2019. She further stated that the facility had been utilizing a MDS Consultant and the MDS Nurse from a sister facility, to help out with MDS responsibilities, until a nurse is hired for the position. Review of the Administrator Position Description number 6. Manages the ongoing functions of the facility by employing adequate numbers of appropriately trained professional and support personnel and by delegating duties appropriately; number 8. Coordinates and/or delegates Quality Assurance and Performance Improvement Activities; number 10. Reports to the CEO any pertinent issues regarding facility functioning. Interview on 1/16/2020 at 12:33 p.m. with the Administrator, stated the facility received a letter from Centers for Medicare and Medicaid Services (CMS) in (MONTH) 2019 indicating some concerns with MDS assessments. She further stated that she and the owner had a meeting with the MDS Coordinator about her job performance with the MDS assessments, and help was offered to her with a MDS consultant and the MDS nurse from a sister facility. During further interview, she stated the governing body and the Medical Director were aware of the situation of the MDS vacancy, but there was not a long-term plan in place, other than to utilize the MDS… | 2020-09-01 |
| 3639 | 3639 | NANCY HART CENTER FOR NURSING AND HEALING LLC | 115686 | 2117 DOCTOR WARD ROAD | ELBERTON | GA | 30635 | 2020-01-16 | 867 | F | 0 | 1 | D2MI11 | Based on observations, record review, staff interviews and review of the policy titled Quality Assurance and Improvement Committee, the facility failed to have an effective Quality Assurance and Performance Improvement Program and Committee (QAPI) process that identified concerns related to not having a qualified staff member to complete accurate Minimum Data Set (MDS) assessments and additional responsibilities of the MDS Coordinator. The facility census was 51 residents. Findings include: Review of undated facility policy titled Quality Assurance and Improvement Committee revealed the policy is to have a Quality Assurance and Improvement Committee. The committee will meet at least quarterly. The team will be responsible for collection for data for audits, evaluating quality indicators and reporting to the committee quarterly. During entrance conference on 1/13/2020 at 8:55 a.m. with Administrator, she stated that the facility has been without an Minimum Data Set (MDS) since (MONTH) of 2019. She further stated that the facility had been utilizing a MDS Consultant and the MDS Nurse from a sister facility. Interview on 1/15/2020 at 2:19 p.m with Director of Nursing (DON) stated that the facility has been without an MDS nurse since (MONTH) 2019. She stated that some departments help out a little, but the duties of the MDS were not distributed to other staff members, because there is no-one in the facility that is trained to complete MDS assessments. A telehhone interview on 1/16/2020 at 9:12 a.m. with Medical Director, stated that he attends the Quarterly QAPI meetings. During further interview, he stated he was aware that the facility did not have a MDS nurse, but they were looking to hire a person that would act as the Assistant Director of Nursing (ADON) and MDS nurse. Interview on 1/16/2020 at 12:33 p.m. with the Administrator, stated the the MDS nurse was not performing the duties of her job adequately. She stated the facility received a letter from Centers for Medicare and Medicaid Services (CMS) in (MONTH) 2… | 2020-09-01 |
| 3640 | 3640 | NANCY HART CENTER FOR NURSING AND HEALING LLC | 115686 | 2117 DOCTOR WARD ROAD | ELBERTON | GA | 30635 | 2020-01-16 | 868 | E | 0 | 1 | D2MI11 | Based on observation, record review, interviews and policy review, the facility's Quality Assurance and Performance Improvement (QAPI) team and the Quality Assurance Assessment (QAA) committee failed to meet at least quarterly with the required committee members: specifically the Administrator or another member of the leadership team (owner or board member) did not attend two (2) of the four (4) held meetings during past year. The facility census was 51. Findings include: Review of the undated policy titled Quality Assurance Committee revealed the committee shall conduct quarterly meetings to discuss, review and revise procedures, policies, protocols and facility practices. Members of the committee shall be Medical Director, Director of Nurse's, Administrator and other staff as indicated. Review of the QAA records for the past year revealed the committee meets quarterly. Review of the QAA sign-in sheets revealed that the Administrator or another member of the leadership team did not attend the 1/15/19 QAA Quarterly meeting or the 4/9/19 QAA Quarterly meeting. Interview on 1/16/2020 at 12:33 p.m. with the Administrator, stated the QAA Committee meets quarterly and Medical Director attends each meeting. During further interview with the Administrator, it was revealed that she did not attend the first two QAA quarterly meetings during the past year. She stated that this may have been during the time her family member was in the hospital and she was not able to attend. She was questioned about having the owner or a board member attend in her place, or postponing the meeting, and she replied I guess I didn't think about that. | 2020-09-01 |
| 3641 | 3641 | NANCY HART CENTER FOR NURSING AND HEALING LLC | 115686 | 2117 DOCTOR WARD ROAD | ELBERTON | GA | 30635 | 2020-01-16 | 919 | D | 0 | 1 | D2MI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interviews the facility failed to ensure that all components of the nurse call system in 3 of 50 resident shared room (for rooms: 200 and 202) were fully functional and the facility failed to ensure that there was a monitoring system in place to identify call light issues in resident rooms. Findings include: Record Review of Facility Policy Call Light Policy not dated revealed a Call light will be provided for each Resident in the facility. A standard call light is available at each bed. For Resident's that are handicapped and unable to use the standard call light, a handicapped style will be provided. Interview with Resident Council on 1/15/20 at 3:00 p.m. revealed that Resident Z reported to staff that her call light does not work. Resident Z stated the light outside her door will light up when the call button is pushed but, it does not light up and alert staff at the nurse's station. Resident Z stated she has reported this to staff on multiple occasions but that it has been an issue since she came to the facility about three (3) years ago. Observation of call light system on 1/15/20 at 4:00 p.m. revealed that room [ROOM NUMBER] and room [ROOM NUMBER] do not have properly functioning call lights. Surveyor verified that call light in both of those resident rooms signal the light at the resident door but they do not light up or indicate at the nurses station to alert staff. Interview with DON on 01/15/120 at 4:20 p.m. revealed that she was completely unaware there were any issues with any of the call light or the call light system. The DON stated they have not put in alternative means for residents to alert staff because DON was unaware there was a concern and a need for any alternate means for residents to alert staff. Interview with Maintenance Director on 01/15/20 at 4:45 p.m. revealed that he was aware that the call system was not functioning properly, and that room [ROOM NUMBER] & 202 are affected. Maintena… | 2020-09-01 |
| 2425 | 2425 | PIONEER HEALTH OF CENTRAL GEORGIA | 115564 | 712 PATTERSON STREET | BYROMVILLE | GA | 31007 | 2020-01-15 | 684 | D | 0 | 1 | N7S811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to follow Physician's order for supplement for one resident (R) #80) of four residents reviewed. Findings include: Review of R#80's medical record revealed a care plan indicating resident at risk for weight loss due to GI symptoms and noncompliance with an intervention that included serving diet as ordered. Further review of the medical record revealed Physician's Orders dated 1/2/2020 for Magic Cup by mouth three times daily. During observations of meals for R#80 on 1/14/2020 at 8:20 a.m., 1/14/2020 at 2:13 p.m., and 1/15/2020 at 8:28 a.m. there was no Magic Cup served with meals. During an observation on 1/15/2010 at 8:14 a.m. of the breakfast trays for West Unit residents there was no Magic Cup on the tray for R#80 as the meal cart left the kitchen. During an interview with the Dietary Manager on 1/15/2020 at 9:18 a.m. revealed that she had not been sending the Magic Cup on the meal tray for R#80 but confirmed that there is an order for [REDACTED].>During an interview on 1/15/2020 at 9:25 a.m. with the Administrator revealed that if there is an order for [REDACTED]. The Administrator revealed that the expectation is that the Magic Cup will be sent to resident until the order has been discontinued. | 2020-09-01 |
| 2426 | 2426 | PIONEER HEALTH OF CENTRAL GEORGIA | 115564 | 712 PATTERSON STREET | BYROMVILLE | GA | 31007 | 2020-01-15 | 689 | E | 0 | 1 | N7S811 | Based on observation and staff interviews the facility failed to ensure that trash was not placed in the self-extinguishing can that cigarette butts were disposed of on two of four days of smoking observations. Findings include: During an observation of smoke breaks on 1/12/2020 at 2 p.m., 1/12/2020 at 4:20 p.m., and 1/13/2020 at 9:26 a.m. staff observed throwing cigarette butts in red can for cigarette butts. It is noted that there was trash (paper towels and cups) in the red cans. On 1/13/20 at 9:42 a.m. a Dietary Aide was observed dumping a milky substance as well as a plastic cup into the red cigarette butt container. There were two red containers in the outside smoking area. One contained only cigarette butts while the larger container had a white Styrofoam cup in it. The larger red container had a sign on it saying, Empty every night. During an interview on 1/13/20 at 1:53 p.m. with the Administrator, she denied that there have been any residents burned while smoking and denies any fires as a result of the red containers catching on fire. The Administrator revealed that only cigarette butts should go into the red containers and that the red containers are supposed to be emptied daily. The Administrator reviewed a picture of the red containers and confirmed there were both trash and cigarette butts in the trash can. | 2020-09-01 |
| 2427 | 2427 | PIONEER HEALTH OF CENTRAL GEORGIA | 115564 | 712 PATTERSON STREET | BYROMVILLE | GA | 31007 | 2020-01-15 | 812 | F | 0 | 1 | N7S811 | Based on observation, interview, and policy review the facility failed to ensure that two kitchen staff had their hair covered with a hair covering (hairnet, cap, or hat) while in the kitchen. The facility failed to maintain sanitary conditions to prevent cross contamination by ensuring clean sanitation practices for the food prep equipment. This deficient practice had the potential to effect 76 of the 81 residents receiving an oral diet. Finding Include: Review of the Nutrition Services Manual Sanitation and Food Production policy dated 08/2015 revealed wear a hairnet and avoid touching hair or face when serving food. An observation on 1/12/2020 at 11:12 a.m. of the dietary staff revealed one of two dietary staff members did not have their hair nets fully covering their hair. One of the dietary aides had four long braids hanging down her back with the top of her hair covered with a hair net. An observation on 1/13/2020 at 1:45 p.m. of the dietary staff revealed two of four dietary staff members who did not have their hair nets fully covering their hair. One of the dietary aides had four long braids hanging down her back with the top of her hair covered with a hair net. The second dietary aide had long hair down her back and the top of her hair was covered with a hair net. An observation and interview on 1/13/2020 at 1:48 p.m. with the Dietary Manager confirmed the dietary staff was not properly wearing the hairnets. She revealed that all staff in the kitchen are to wear hair nets that completely cover their hair and have no hair exposed outside of the hairnet. An observation on 1/14/2020 at 11:35 a.m. revealed that Dietary Aide BB prepared the puree food. Once Dietary Aide BB finished with each puree food item she was observed to rinse the container in the meat only sink with water only. She used a towel and would ring the water out of the towel, wipe her arms and hands then proceed to prepare the next food item. After each food item was prepared Dietary Aide BB was observed to place the puree food on the steam … | 2020-09-01 |
| 2428 | 2428 | PIONEER HEALTH OF CENTRAL GEORGIA | 115564 | 712 PATTERSON STREET | BYROMVILLE | GA | 31007 | 2020-01-15 | 880 | E | 0 | 1 | N7S811 | Based on observation, record review, and staff interviews the facility failed to maintain sanitary conditions in two of four shower rooms and failed to administer medication in a sanitary manner for one medication opportuniy (R#8) out of 32 medication opportunities. Findings include: 1. On 1/12/20 at 11:24 a.m. in the West Unit Shower room there was a green shower chair with build-up on the back and sides. During tour with DON on 1/14/20 at 2:45 p.m. in the East male shower room there was a resident's brief on the floor. During an environmental tour with Maintenance Director and Housekeeping Supervisor (HSK) on 1/15/20 beginning at 8:19 a.m. revealed the following observations: [NAME] On 1/15/2020 at 8:42 a.m. in the male shower room on the East Unit there was a resident's brief and towels on the floor. HSK Supervisor and Maintenance Director both stated that these items do not belong on the floor. The Administrator was notified, and she also confirmed the towels and brief should not be on the floor. B. On 1/15/20 at 8:59 a.m. on the West unit shower room on the hallway HSK and Maintenance Director confirmed shower chair in the shower room with noted with buildup and bath cloths were on the floor and were hanging in the shower. During an interview on 1/15/20 at 9:05 a.m. with the Unit Manager, she revealed that shower chairs should be cleaned on the night shift. The Unit Manager explained that they are wiped and sanitized between all residents. However, upon observation of the shower chair with the Unit Manager she revealed that the shower chair would have to be removed from the bathroom. The Unit Manager further revealed that the bath cloths should not be left on rails or on the floor in the shower room. 2. Record Review of the facility's Medication Administration Guidelines dated (MONTH) (YEAR) under subtitle General and Specific Guidelines on Administration of Medication by Routes revealed the following: General and Specific Guidelines on Administration of Medication by Routes: Staff must begin by washing thei… | 2020-09-01 |
| 2429 | 2429 | PIONEER HEALTH OF CENTRAL GEORGIA | 115564 | 712 PATTERSON STREET | BYROMVILLE | GA | 31007 | 2020-01-15 | 914 | D | 0 | 1 | N7S811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to ensure that privacy curtains provided full visual privacy, for four (4) of 33 resident rooms. (Room numbers 102-B, 110-A, 209-A, 216-B). Findings include: Observations in room [ROOM NUMBER]A on 1/14/20 at 2:39 p.m. revealed track for privacy curtain is broken and privacy curtain cannot be pulled to assure 100% privacy. Observations in room [ROOM NUMBER]-A at 3:00 p.m. on 1/14/20 short privacy curtains observed in room. During environmental tour with Maintenance Director and Housekeeping Supervisor (HSK) on 1/15/20 at 8:19 a.m. the following was revealed and confirmed: 1. At 8:23 a.m. in room [ROOM NUMBER]B HSK Supervisor confirmed short track. She reported that housekeeping has been doing an audit of privacy curtains related to hooks, making sure they have no holes in them, and making sure the track is not falling, However, they have been not auditing to assure that privacy curtains assure full privacy. 2. At 8:26 a.m. in room [ROOM NUMBER] privacy curtain for bed A is short due to curtain sticking on the track. The privacy curtain for Bed B is short due to a nail stopping the curtain from being pulled all the way around the bed. 3. At 8:50 a.m. in room [ROOM NUMBER]B the ceiling track is hanging and call privacy curtain is short. The privacy curtains for beds A, B, and C are short. 4. At 8:55 a.m. in room [ROOM NUMBER] the privacy track is broken and will not allow for the privacy curtain to be fully pulled for Bed [NAME] | 2020-09-01 |
| 2430 | 2430 | PIONEER HEALTH OF CENTRAL GEORGIA | 115564 | 712 PATTERSON STREET | BYROMVILLE | GA | 31007 | 2020-01-15 | 925 | F | 0 | 1 | N7S811 | Based on observation, interview, and review of the facilities pest control contract and service records, the facility failed to maintain an effective pest control in the kitchen with the potential to affect all 76 out of 81 residents receiving oral feedings. Findings include: An observation and interview on 1/14/20 at 11:30 a.m. of small ants located near the dishwashing sink and the three compartment sink. Dietary aide BB observed and verified the small ants crawling on the wall, she and the Dietary manager stated that pest control comes by monthly, but the kitchen staff still has issues with small ants. Interview on 1/14/20 at 2:12 p.m. the Maintenance Director revealed he was unaware of the kitchen having issues with small ants he stated that pest control does come to the facility monthly. Interview on 1/15/20 at 11:55 a.m. with pest control staff member stated that he would have to use a sugar bait for the small ants in the kitchen. He stated the chemical used for other ants and insects doesn't work on the small ants. Review of the CPS management form dated (MONTH) 2019 - (MONTH) 2020 revealed pest control comes out monthly to treat the kitchen for German roaches and flies but not for ants. | 2020-09-01 |
| 2616 | 2616 | AUTUMN BREEZE HEALTH AND REHAB | 115580 | 1480 SANDTOWN ROAD SW | MARIETTA | GA | 30008 | 2020-01-15 | 584 | E | 1 | 0 | S0LW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, complainant and staff interviews, the facility failed to ensure that the facility was free of odors, on two (2) Halls (B and C), of five (5) Halls. Findings include: Observation on 1/14/19 at 9:00 a.m. revealed a strong urine odor upon entrance into the facility. A strong urine odor was throughout the facility on the B Hall, and near the conference room. Observation on 1/14/19 at 10:38 a.m. of a random check of resident's rooms for odor revealed the following: room [ROOM NUMBER] -strong urine odor B Hall rooms at 10:40 a.m. revealed: room [ROOM NUMBER]- strong odor Observation on 1/14/2020 at 10:50 a.m. on the B Hall of a random walk through of resident rooms revealed following; a strong odor at the end of the Hall B. Observation on 1/14/2020 at 11:00 a.m. of random check of resident lounge revealed strong pungent odor, five residents in room. Observation on 1/14/2020 at 2:25 p.m. of a random walk through on the C Hall revealed a strong urine odor, residents doors open, no ADL care being provided at this time. Observation on 1/15/2020 at 9:00 a.m. of a random walk through of the facility revealed a strong pungent, musty, smell in the hallway (C) around the Employee Lounge, the Business Office, the Conference Room, Rooms-134, 135, 136, and 137. A strong old urine odor in room [ROOM NUMBER]. Residents were not being changed at that time, residents doors open. Observation on 1/15/2020 at 10:09 a.m. revealed a strong (pungent) odor at end of hall (C) near conference room, business office and employee lounge. No incontinent care being provided at this time. Observation on 1/15/2020 at 10:11 a.m. of a random walkthrough of hall way (C) revealed a strong old urine smell around rooms # 131, and 132. No ADL care being provided at this time. Observation on 1/15/2020 at 3:30 p.m. of a walk through in the hall way (C) near room [ROOM NUMBER], the conference room, and the employee lounge, revealed a strong pungent odor. No ADL car… | 2020-09-01 |
| 3171 | 3171 | RIVER BROOK HEALTHCARE CENTER | 115635 | 390 SWEAT STREET | HOMERVILLE | GA | 31634 | 2020-01-15 | 623 | E | 0 | 1 | NFFF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to notify the resident and /or resident representative in writing of the reason for hospital transfer and/or discharge and the facility failed to notify the Ombudsman of hospital transfers for five residents (R) (R#71, R#58, R#59, R#1, and R#31,) reviewed of 121 residents discharged and/or transferred to the hospital since 7/24/2019. Findings include: 1. Record review revealed that R#71 was admitted with [DIAGNOSES REDACTED]. Review of a Nurse's Notes dated 12/18/2019 for R#71 revealed the resident was transferred to an acute care hospital on [DATE] for cough and low oxygen. Review of the clinical record for R#71 revealed that there was not any evidence of documentation that the reason for the discharge/transfer was provided to R#71, the resident's representative, or the Ombudsman. During an interview on 1/15/2020 at 09:10 a.m. with Licensed Practical Nurse (LPN) EE revealed the procedure for sending a resident to the hospital was to call the doctor and get an order to send the resident out, then complete a transfer form, fill out the bed hold form, call the resident's family and document this in the resident's chart. During an interview on 1/9/2020 at 09:48 a.m. with Business Office Manager (BOM) revealed Social Services is responsible for notifying the Ombudsman of transfers and discharges from the facility. During an interview on 1/15/2020 at 10:09 a.m. the Director of Nursing (DON) revealed he is not sure who is responsible for notifying the Ombudsman of resident transfers and discharges to hospital. During an interview on 1/15/2020 at 10:19 a.m. the Social Services Director (SSD) revealed she does a monthly report of residents that have been discharged or transferred to the hospital and did not return to the facility. The SSD stated she does not have to notify the Ombudsman if a resident is transferred to the hospital unless they do not return to the facility within one mon… | 2020-09-01 |
| 3172 | 3172 | RIVER BROOK HEALTHCARE CENTER | 115635 | 390 SWEAT STREET | HOMERVILLE | GA | 31634 | 2020-01-15 | 625 | E | 0 | 1 | NFFF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and review of the facility policy titled, Bed Hold the facility failed to provide a copy of the bed hold policy prior to transfer and/or discharge to the hospital for five residents (R) (R#71, R#58, R#59, R#1, and R#31,) reviewed of 121 residents discharged and/or transferred to the hospital since 7/24/2019. Findings include: Review of the facility policy titled, Bed Hold documents the following: All residents or their responsible party are informed in writing about the facility's bed-hold policy at the time of admission. A copy of the bed hold agreement is also provided to the resident or responsible party prior to a resident's transfer to a hospital or start of a therapeutic leave and to residents or families upon transfer or discharge to the hospital. Effective:12/01/2014. 1. Review of a Nurse's Note dated 12/18/2019 for R#71 revealed the resident was transferred to an acute care hospital on [DATE] for cough and low oxygen. Review of the clinical record for R#71 revealed that there was no evidence of documentation that the bed hold policy was provided to the resident and/or resident's representative for the resident's discharge to the hospital on [DATE]. During an interview on 1/15/2020 at 09:10 a.m. Licensed Practical Nurse (LPN) EE revealed the procedure for sending a resident to the hospital is to call the doctor and get an order to send out then fill out transfer form, fill out bed hold form, call family and document in the resident's chart. She stated she could not find a copy of the bed hold form for hospital transfer dated 12/18/2019. LPN EE stated she is not sure if the nurse completed a bed hold form or not because there is not one there. During an interview on 1/15/2020 at 10:09 a.m. the Director of Nursing (DON) revealed the nurses complete the bed hold forms. He stated they (staff) don't give bed hold forms to the residents when they are transferred and/or discharged to the hospital. 2.… | 2020-09-01 |
| 3173 | 3173 | RIVER BROOK HEALTHCARE CENTER | 115635 | 390 SWEAT STREET | HOMERVILLE | GA | 31634 | 2020-01-15 | 656 | D | 0 | 1 | NFFF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews and review of the facility policy titled, Resident Assessment Instrument (RAI)/Care Planning Management the facility failed to implement the care plan to notify the Physician of resident's refusal for a urinalysis and urine culture for one residents (R) (R#61). In addition, the facility failed to develop a care plan for [MEDICAL CONDITION] disorders for one of 37 residents (R#31) reviewed for care plans. Findings include: Review of the facility policy titled, RAI/Care Planning Management revealed: The comprehensive care plan is completed within seven days after the MDS is completed (at no time will time frame exceed 21 days), and reviewed quarterly thereafter, If modifications , deletions, additions are necessary, changes should be made at the time of occurrence. Modifications are made by deleting the item in the electronic medical record and adding the new information. Objective 1. To identify residents' individual needs and care requirements. 1. Record review revealed that R#61 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) for R#61 dated 12/16/2019 revealed the following: Section C- revealed a score of 99 indicating severe cognitive impairment. Review of Section G revealed a functional status of totally dependent for toileting with two person assist. Review of Section H revealed that R#61 was always incontinent. Review of R#61's care plans revealed: Resident is noncompliant with treatments related to refusing medications and treatments/declines incontinent care and blood draws -- notify Physician as needed or indicated. Review of R#61's medical record revealed a Physician's Order dated 1/6/2020 for a urinalysis and urine culture. Review of R#61's Nurse's Progress Note dated 1/6/2020 revealed a new order for a urinalysis and a urine culture, order was noted, faxed to the pharmacy, placed in the lab book and on the 24-hour communication sheet for… | 2020-09-01 |
| 3174 | 3174 | RIVER BROOK HEALTHCARE CENTER | 115635 | 390 SWEAT STREET | HOMERVILLE | GA | 31634 | 2020-01-15 | 689 | E | 0 | 1 | NFFF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, staff interviews, and review of the facility policy titled, Accidents and Supervision-Water Temperatures it was determined the facility failed to ensure comfortable hot water temperatures were maintained for two of 15 resident bathrooms (shared bathrooms in rooms B6/B8, A13/A15) and in one of two resident shower stalls. Findings include: Review of the undated facility policy titled, Accidents and Supervision-Water Temperatures documented the following: Ensure the resident environment remains as free of accident hazards as possible. Each resident receives adequate supervision and assistance devices to prevent accidents. The purpose of recording your water temperatures is to assure . the facility is remaining as free from [MEDICAL CONDITION] scalds as possible and that any issues are addressed in a prompt and consistent manner. Ensure residents room water temperatures are between 105 degrees and 115 degrees or by state regulation. Georgia state regulation indicates comfortable to touch but must not exceed 120 degrees. Water temperature checks; test and log the hot water temperatures weekly. Observation on 1/12/2020 starting at 11:40 a.m. during the initial tour and resident screening revealed hot water for the bathroom sinks for rooms B6/B8 and A13/A15 were extremely hot to the touch. Observation on 1/12/2020 at 12:43 p.m. with the Maintenance Director confirmed that the water was hot. The following temperatures were taken by the Maintenance Director with the facility's thermometer: The water for the shared bathroom sink for rooms B6/B8 was 123.2 degrees Fahrenheit (F). The water for shared bathroom for rooms A13/A15 bathroom sink was 131 degrees F. The water for shower room one shower stall was 123.0 degrees F. (There were no scheduled showers for 1/12/2020). This could have affected three residents that were able to use these bathrooms. Review of the facility incident log for last six months revealed no re… | 2020-09-01 |
| 3175 | 3175 | RIVER BROOK HEALTHCARE CENTER | 115635 | 390 SWEAT STREET | HOMERVILLE | GA | 31634 | 2020-01-15 | 770 | D | 0 | 1 | NFFF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and review of the facility policy titled, Physician Services the facility failed to notify the Physician of a lab refusal for one of 37 residents (R) (R#61) reviewed for labs. Findings include: Review of the facility policy titled, Physician Services dated (MONTH) (YEAR), documented: Physician's Orders 7. Physicians orders include: laboratory, radiology, other diagnostic procedures. Notation and Processing of Physician's Orders 1. Physician's Orders are to be noted by a licensed nurse at the time that the orders are written/approved by the physician or received verbally or by telephone from the physician. 2. The nurse who notes the order will transcribe the order onto the appropriate Medication Administration Record [REDACTED]. 5. A licensed nurse between the hours of 12:00 midnight and 6:00 a.m. will review all physician's verbal and /or telephone orders daily. Record review revealed that R#61 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) for R#61 dated 12/16/2019 revealed the following: Section C- revealed a score of 99 indicating severe cognitive impairment. Review of Section G revealed a functional status of totally dependent for toileting with two person assist. Review of Section H revealed that R#61 was always incontinent. Review of R#61's Nurse's Progress Note dated 1/6/2020 for R#61 revealed a new order for a urinalysis and a urine culture. The order was noted, faxed to the pharmacy, placed in the lab book and on the 24-hour communication sheet for collection. There was no further documentation in the progress note indicating the urine was collected or refused or that the Physician or family was notified. Review of the B Hall 24 Hour Report dated 1/6/2020 7 a.m.-7 p.m. revealed R#61: needs a urinalysis and urine culture collected. 7 p.m.-7a.m. indicated resident refused. Review of the Clinical Laboratory Services laboratory request form … | 2020-09-01 |
| 3176 | 3176 | RIVER BROOK HEALTHCARE CENTER | 115635 | 390 SWEAT STREET | HOMERVILLE | GA | 31634 | 2020-01-15 | 812 | F | 0 | 1 | NFFF11 | Based on observations, interviews, and record review the facility failed to provide maintenance services to one roof located over the kitchen that was necessary to maintain a sanitary interior environment during food preparations. This had the potential to effect 72 of 75 residents receiving oral meal. Findings include: 1. An observation on 1/12/2019 at 11:24 a.m. of the kitchen ceiling revealed a large hole in the ceiling with exposed wet insulation foam and open areas on the sides of the insulation that allowed dust, debris, and dirt to fall from the hole. Further observation revealed directly underneath the large hole in the ceiling were four resident food carts which were being used to transport the food trays for residents who were eating on the halls and the dining room. The dietary staff were observed loading the foods trays on five of five carts for the lunch meals. Also, to the left of the hole in the ceiling and directly beneath the hole was a preparation counter used to prepare the resident foods. Directly in front and across from the hole in the ceiling was the steam table where the dietary staff was observed plating residents' food. Record review of the Maintenance Log book revealed there had not been any repairs to the kitchen ceiling within the last six months from (MONTH) 2019 through (MONTH) 2020. Interview on 1/12/2020 at 1:00 p.m. with Dietary Assistant (DA) AA revealed that when it rains, she and the other dietary staff have to remove the food carts out the way. She revealed that due to the large opening in the ceiling dirt, debris, and water leaks everywhere in this area, especially when it is raining heavily. DA AA revealed that the hole has been there for the last three months. DA AA further stated that Maintenance has not been in the kitchen to make the needed repairs. Interview on 1/13/2020 at 9:55 a.m. with the Dietary Manager (DM) revealed that he was aware that the roof needed to be repaired and that the roof leaked during rainy weather. The DM stated that dietary staff were instructed… | 2020-09-01 |
| 3177 | 3177 | RIVER BROOK HEALTHCARE CENTER | 115635 | 390 SWEAT STREET | HOMERVILLE | GA | 31634 | 2020-01-15 | 867 | F | 0 | 1 | NFFF11 | Based on staff interviews and review of facility policy titled, The QAPI Performance Improvement Program (QAPI), the facility failed to have an effective Quality Assurance and Performance Improvement Program and Committee (QAPI) that identified concerns related to the hole in the kitchen ceiling that leaked water, debris, and dirt into the food preparation and resident meal cart loading area. The facility census was 75 Residents. Findings include: Record review of policy titled, The QAPI Performance Improvement Program (QAPI) dated (MONTH) 2019 revealed that it included a QAPI form titled, QAPI Tool Sanitation Score Card-Dietary listed areas that included: ceiling, walls, lights, clean and in good conditions at one of the check off areas for Dietary. Record review of the last QAPI Meetings were conducted on 8/19/2019, 9/17/2019, 10/21/2019, 11/19/2019, and 12/17/2019 revealed the hole in the kitchen ceiling were not discussed. Interview on 1/15/2020 at 12:03 p.m. with the Administrator revealed that he was unaware of the leaking into the kitchen area. The Administrator stated that he was under the impression the Maintenance Supervisor was making the necessary interior repairs to prevent leaking. The Administrator revealed that the Dietary Manager informed him approximately a month ago about the leakage in the kitchen. The Administrator stated that the last work on the roof was completed on 8/14/2019 and this was for the entire back section for the kitchen. When a leakage was identified a few months ago, the roofing company was contacted. This repair included a contract for shingles. The roofing company failed to return to the facility to caulk the leaking area on the roof. The Administrator reported that the process to do repairs is to obtain three bids from three vendors and submit to the Corporate Office. The Administrator stated that he had not yet obtained and submitted the bids. The Administrator stated this was an oversight on his part for not following up with the Corporate Office. The Administrator reveal… | 2020-09-01 |
| 897 | 897 | BOLINGREEN HEALTH AND REHABILITATION | 115346 | 529 BOLINGREEN DRIVE | MACON | GA | 31210 | 2020-01-09 | 578 | D | 0 | 1 | TXH811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility policy titled Skilled Inpatient Services Advanced Directive, and staff interviews, the facility failed to update the code status on one resident (R) (#30) of 41 sampled residents. Findings include: A review of a Physician order [REDACTED]. Further review of the clinical record revealed a Physicians Orders for Life Sustaining Treatment (POLST) document signed and dated by the resident on [DATE] indicating the resident wants to allow a natural death, comfort measures, and no artificial nutrition by tube. A review of R#3's care plan dated [DATE] revealed resident is a Full Code with the following goal: Advanced Directive decisions will be honored as applicable during the review period and interventions of follow advanced directives as written. The care plan further revealed under Care Area/Problem dated [DATE]: has POLST. In an interview on [DATE] at 3:39 p.m., the Social Services Director (SSD) revealed she changed his code status on [DATE] from full code to allow natural death. She reported she had forgotten to change his status back in (MONTH) (2019) when he signed the POLST. During an interview on [DATE] at 3:49 p.m., the Minimum Data Set (MDS) Coordinator MM verified R#3's last care plan meeting was held [DATE] which he did not attend. Following notification that R#3's POLST was signed on [DATE], the MDS Coordinator agreed that if the resident had experienced an event in this past month, the facility would have considered him a full code. During an interview on [DATE] at 11:58 a.m., the Director of Nursing (DON) reported that she expects the orders to be updated once the POLST in signed. DON stated the nurses check the POLST book at the nurse's station prior to starting Cardiopulmonary Resuscitation (CPR). In an interview on [DATE] at 1:12 p.m., the Administrator reported the ribbon (header of the electronic health care record) and care plan were not updated, and most likely CPR would have been don… | 2020-09-01 |
Advanced export
JSON shape: default, array, newline-delimited
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 );