cms_GA
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| Link | rowid ▲ | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 10655 | 10655 | FOUNTAINVIEW CTR FOR ALZHEIMER | 115697 | 2631 NORTH DRUID HILLS ROAD N E | ATLANTA | GA | 30329 | 2010-09-21 | 323 | G | GYV611 | Based on resident medical record review, staff interview, facility Investigative Report review, and hospital Discharge Summary review, the facility failed to ensure a safe transfer, per facility policy and the plan of care, for one (1) resident (#1) from five (5) sampled residents. This resulted in actual harm to the resident, with the resident sustaining bleeding lacerations to the left eyebrow area and left side of the forehead, a hematoma on top of the head, and a skin tear on the right hand, with bruising. Findings include: Medical record review for Resident "A" revealed a Care Plan entry dated 05/28/2010 which indicated that resident required the assistance of two (2) persons with total lift transfers. A Nurse's Note of 09/01/2010 timed at 4:00 p.m. documented the nurse had been called to the room of Resident "A" at around 2:35 p.m. by Certified Nursing Assistant (CNA) "CC" and observed the resident with bleeding lacerations to the left eyebrow area and left side of the forehead, a hematoma on top of the head, and an approximate 2 centimeter (cm.) by 2 cm. skin tear on the right hand, with bruising. This Note documented that the physician was notified, Emergency Medical Services was called, and the resident was transported the to the hospital around 3:00 p.m. A review of hospital Discharge Summary record dated 09/13/2010 for Resident "A" revealed documentation that the resident did not receive fractures and had no orbital damage, but had received sutures to the left forehead. The facility conducted an investigation into this resident's injury and obtained a statement from CNA "CC", who was the CNA who had been caring for the resident during the shift at the time of the discovery of the resident's injury on 09/01/2010. CNA "CC" gave a written statement in which she documented that she and another staff member had put Resident "A" in the bed, changed the resident's diaper, then left the room to assist another resident. The CNA documented that the family of Resident "B", the roommate of Resident "A", then came … | 2014-01-01 | ||
| 10654 | 10654 | CARTERSVILLE HEIGHTS | 115571 | 78 OPAL STREET | CARTERSVILLE | GA | 30120 | 2010-09-27 | 309 | D | DI8T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to provide wound care as ordered by the physician for two (2) residents (#5 and #7) in a survey sample of eight (8) residents. Findings include: 1. Record review for Resident #5 revealed a 07/15/2010 Minimum Data Set assessment which indicated that the resident had no pressure ulcers or stasis ulcers at that time, but did have a [DIAGNOSES REDACTED]. Further record review for Resident #5 revealed a current physician's orders [REDACTED]. However, review of the September 2010 treatment record referenced above revealed no documented evidence to indicate that the treatment was done on Sunday, 09/26/2010. During an interview with Treatment Nurse "BB" conducted on 09/27/2010 at 2:00 p.m., this nurse acknowledged that the treatment was not done on 09/26/2010 as ordered. 2. Record review for Resident #7 revealed a 09/23/2010 Minimum Data Set assessment which indicated that the resident had [DIAGNOSES REDACTED]. A current physician's orders [REDACTED]. However, review of the September 2010 treatment record revealed no documented evidence to indicate that the treatment was done on Sunday, 09/26/2010. During an interview with Treatment Nurse "BB" conducted on 09/27/2010 at 2:15 p.m., this nurse acknowledged that the treatment was not done as ordered on [DATE]. | 2014-01-01 | ||
| 10653 | 10653 | CARTERSVILLE HEIGHTS | 115571 | 78 OPAL STREET | CARTERSVILLE | GA | 30120 | 2010-09-27 | 314 | D | DI8T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, it was determined that the facility failed to provide pressure sore treatments as ordered by the physician for two (2) residents (#2 and #6) in a survey sample of eight (8) residents. Findings include: 1. Record review for Resident #2 revealed an 08/13/2010 Minimum Data Set assessment which indicated that the resident had one Stage IV pressure sore, with an open lesion on the foot. The resident's Pressure Ulcer Documentation Form indicated that the resident had a left heel pressure sore. Additionally, the resident's September 2010 treatment record documented that the resident had [DIAGNOSES REDACTED]. A current physician's orders [REDACTED]. with Kling every day. However, review of the September 2010 treatment record referenced above revealed no documented evidence to indicate that the dressing change was done on Sunday, 09/26/2010, as ordered. During a treatment observation for Resident #2 conducted on 09/27/2010 at 11:45 a.m., when Treatment Nurse "BB" began the treatment procedure and removed the existing dressing on the resident's left heel pressure sore, this nurse stated that the dressing removed from the left heel wound was dated 9/25/2010, and that the dressing had not been done on 09/26/2010, as ordered. 2. Record review for Resident #6 revealed a 09/02/2010 Minimum Data Set assessment which indicated that the resident had [DIAGNOSES REDACTED]. A current physician's orders [REDACTED]. However, review of the September 2010 treatment record revealed no documented evidence to indicate that the dressing was changed on 09/26/2010, as ordered. Additionally, during a treatment observation for Resident #6 conducted on 09/27/2010 at 3:15 p.m., the existing dressing on the upper back of Resident #6 was dated 09/25/2010. During an interview with Treatment Nurse "BB" conducted on 09/27/2010 at 3:15 p.m., this nurse acknowledged that the dressing was not changed on 09/26/2010 as ordered. | 2014-01-01 | ||
| 10652 | 10652 | POWDER SPRINGS NURSING & REHAB CENTER | 115538 | 3460 POWDER SPRINGS ROAD | POWDER SPRINGS | GA | 30127 | 2009-06-17 | 372 | C | 5ICH11 | Based on observation and staff interview, the facility failed to ensure refuse containers were in good condition for the garbage compactor. The findings include: Observation on 6/15/09 at 11:45 a.m. revealed the garbage compactor to be dripping a dark liquid from the roller end. The liquid was sufficient in quantity to cause a oily, milky runoff three (3) feet wide by sixteen (16) feet long. Interview on 6/15/09 at 3:35 p.m. with the Maintenance Director confirmed that the compactor was leaking and needed repair. | 2014-01-01 | ||
| 10651 | 10651 | POWDER SPRINGS NURSING & REHAB CENTER | 115538 | 3460 POWDER SPRINGS ROAD | POWDER SPRINGS | GA | 30127 | 2009-06-17 | 363 | D | 5ICH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to provide fruit juice as planned on the menu for breakfast for one (1) resident, resident "D" on a sample of thirty (30) residents. The findings include: Review of the physician orders [REDACTED]. Review of the prepared and planned menu for 6/16/2009 revealed that the resident should have received four (4) ounces of a juice with breakfast. Observation of the resident on 6/16/2009 at 7:50 a.m. revealed that the resident received the pureed food as ordered but not the juice as indicated on the meal plan. The resident told the surveyor that they liked juice. Observation of the resident on 6/17/2009 at 7:40 a.m. revealed that the resident did not receive any juice for breakfast. Interview with Certified Nursing Assistant (CNA) "BB" at that time revealed she did not know why the resident had not received juice. It was observed that other residents in the dining room did receive juice with their breakfast. Review of the resident's diet card did not list juice as a dislike. | 2014-01-01 | ||
| 10650 | 10650 | POWDER SPRINGS NURSING & REHAB CENTER | 115538 | 3460 POWDER SPRINGS ROAD | POWDER SPRINGS | GA | 30127 | 2009-06-17 | 253 | B | 5ICH11 | Based on observation and staff interview the facility failed to provide housekeeping services to maintain a sanitary and comfortable interior related to dirty floors and furniture in need of repair on two (2) of three (3) Wings (East and West) and one (1) of two (2) solariums. The findings include: During intial tour of the East Wing on 6/15/09 at 11:30 a.m. the floors of the hallways were observed to be dirty with a black substance waxed into the tile floor. General observation tour on 6/16/2009 at 9:30 a.m. revealed that the three (3) hallways that make-up the East Wing of the building were in need of stripping and rewaxing. Additional observations at that time: Room 204- The door frame to the bathroom was scuffed and missing paint. The inside of the bathroom door was scuffed and the paint was peeling in a one (1) foot by eight (8) inch section. Room 236- The bedside table for the resident in the second bed was marred and scraped and had missing veneer across the entire front and at the bottom corners. Room 247- The floor was marred with the wax scraped as if someone had pulled something heavy across the floor. Interview with the Administrator on 6/16/2009 at 3:15 p.m. revealed that she was aware the hallways were in need of stripping and waxing. Observation on the West wing on 6/16/09 at 7:25 a.m. revealed the following: Room 302 - Bed A nightstand was missing the trim strip around the top of the stand. Room 326 - The foot board was missing the side strips, exposing bare wood or fiber board. Room 335 - Bed A footboard was scuffed on the edges and was missing the finish. Room 337 - A water stain was on the wall to the right of the air conditioner and was visible from the hallway. One of two (1 of 2) solariums had peeling wallpaper at the air conditioner and window sill. The pink sofa's vinyl was darkened in spots making the sofa appear dirty. One of two (1 of 2) green benches in the hallway had vinyl that had was discolored. Interview on 6/16/09 at 2:00 p.m. with the Maintenance and Housekeeping Supervisors con… | 2014-01-01 | ||
| 10649 | 10649 | POWDER SPRINGS NURSING & REHAB CENTER | 115538 | 3460 POWDER SPRINGS ROAD | POWDER SPRINGS | GA | 30127 | 2009-06-17 | 364 | E | 5ICH11 | Based on observation, resident and staff interview the facility failed to serve food using methods that conserve the nutritional value for all residents consuming food (total = 187). The findings include: Observation of the kitchen on 6/15/09 at 10:00 a.m. revealed ground pork chops, gravy, potatoes and rutabagas were being held hot on trayline. Interview with the Food Service Director (FSD) at that time revealed staff were served at 11:00 a.m. and residents were served at noon. Observation on 6/16/09 at 7:30 a.m. revealed a large pan of green beans boiling on the stove. The FSD stated the beans were for lunch at noon. At 9:55 a.m. the trayline held chicken stew, mashed potatoes, gravy and beef steak also for lunch. Interview with resident "H" on 6/16/09 at 3:00 p.m. revealed the green beans were always over cooked. | 2014-01-01 | ||
| 10648 | 10648 | POWDER SPRINGS NURSING & REHAB CENTER | 115538 | 3460 POWDER SPRINGS ROAD | POWDER SPRINGS | GA | 30127 | 2009-06-17 | 371 | F | 5ICH11 | Based on observation, record review and staff interview the facility failed to store and prepare food under sanitary conditions for all residents consuming food (total = 187). The findings include: Observation of the kitchen on 6/15/09 at 10:00 a.m. revealed: The microwave was soiled inside with food particles on all sides, particularly the top and bottom. A pan of pureed bread was sitting on top of the stove ledge. The Food Service Director (FSD) confirmed it was for the lunch meal and should be refrigerated or held at 135 degrees Fahrenheit (F). In the dishmachine area the tile floor was wet and soapy. The FSD stated staff washed the floor a few times each day and used a hose with a sprayer attachment. Observation revealed the water from the floor was being sprayed onto clean dished that were stacked on carts. The can opener in the food preparation area had a thick, dark gummy substance built up on the blade. The microwave in the dining room was dirty on all six (6) sides. Observation on 6/16/09 at 7:05 a.m. revealed: Three (3) items in the cooler did not register a temperature of 41 degrees F or less. The facility thermometer was calibrated twice to ensure accuracy. Pork chops were 47 degrees, black eyed peas were 49 and buttermilk was 48 degrees F. These items were in the cooler over eighteen (18) hours. The tile floor throughout the kitchen needed repair including grout cleaning and replacement. Interview with the Administrator and Maintenance Director on 6/17/09 at 9:00 a.m. revealed they were aware of the tile problems but did not have a specific plan for repairs at this time. Review of the Daily Cleaning Assignments for kitchen staff provided by the facility and signed by staff for 5/11/09 to 6/07/09 revealed cleaning the microwave was not listed under any assignments. | 2014-01-01 | ||
| 10647 | 10647 | POWDER SPRINGS NURSING & REHAB CENTER | 115538 | 3460 POWDER SPRINGS ROAD | POWDER SPRINGS | GA | 30127 | 2009-06-17 | 309 | D | 5ICH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to follow physician's orders for blood glucose monitoring for one (1) resident (#7) and follow up appointments after an injury for one (1) resident (#13) and on a sample of thirty (30) residents. The findings include: 1. Record review revealed resident #7 to have a [DIAGNOSES REDACTED]. In addition to the routine insulin, the resident was to receive additional insulin as needed based on blood glucose monitoring at 6:30 a.m. and 4:30 p.m. Physician orders included to notify the physician for blood glucose values greater than 400. Review of the facility policy [MEDICAL CONDITION] (elevated blood glucose), the clinical record should have included the resident's symptoms, blood sugar results, the resident's oral intake, notification of the physician and family, and the resident's response to treatment. A review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Interview with Licensed Practical Nurse "EE" on 6/16/09 at 12:30 p.m. confirmed that the physician was not made aware of this elevated blood sugar. Interview on 6/16/09 at 4:00 p.m. with the Director of Nursing revealed the nurse should have documented the blood sugar, the resident's symptoms and that the physician was notified. 2. Review of a Nurse's Note dated 5/22/0 at 5:30 p.m. revealed resident #13 returned to the facility from the emergency room with a [DIAGNOSES REDACTED]. There was no documentation that the resident had a follow up physician visit after this injury. Interview with the Assistant Director of Nurses on 6/17/09 at 8:20 a.m. confirmed that a follow up physician visit had not been conducted. | 2014-01-01 | ||
| 10646 | 10646 | POWDER SPRINGS NURSING & REHAB CENTER | 115538 | 3460 POWDER SPRINGS ROAD | POWDER SPRINGS | GA | 30127 | 2009-06-17 | 431 | B | 5ICH11 | Based on staff interview, it was determined that the facility failed to establish a system of records of receipt and disposition of all controlled drugs. The findings include: During an interview with the Director of Nurses, on 6/17/09 at 7:45 a.m., she stated that the facility did not have any system of reconciliation of controlled drugs and the facility relied on proof of use sheets utilized during shift to shift controlled drug counts done by staff nurses. | 2014-01-01 | ||
| 10645 | 10645 | POWDER SPRINGS NURSING & REHAB CENTER | 115538 | 3460 POWDER SPRINGS ROAD | POWDER SPRINGS | GA | 30127 | 2009-06-17 | 225 | D | 5ICH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and resident interview the facility failed to ensure that an injury of unknown origin was investigated and immediately reported to the State Survey and Certification Agency for one (1) resident ("A") on a sample of thirty (30) residents. The findings include: Review of a Nurse's Note dated 5/22/0 at 5:30 p.m. revealed that resident "A" complained of chest pain since 5/21/09 and had received an antacid and pain medication without relief. The physician was notified and orders were obtained to send the resident to the hospital emergency room for evaluation. Review of a Nurse's Note dated 5/23/09 at 2:15 a.m. revealed the resident returned from the hospital with a [DIAGNOSES REDACTED]. The 24 Hour Report/Change of Condition Report dated 5/22/09 included a notation that the resident had returned to the facility at 2:00 a.m. with a fractured right rib. Interview with the Licensed Practical Nurse Unit Manager (LPN) "EE" on 6/15/09 at 2:05 p.m. revealed she was unaware that the resident had a fractured rib and would obtain the report from the hospital. Review of the Radiologist Report with an order date of 5/22/09 documented there was a subacute [MEDICAL CONDITION] posterior 12th rib. Review of the Minimal Data Set assessment revealed resident "A" had short term memory loss, however interview with the resident on 6/15/09 at 11:30 a.m. revealed the resident was able to state place of residence, day of the week, month and year of admission, and family information. During interview with the resident on 6/15/09 at 3:10 p.m. he/she remember having severe pain in the chest area and he/she was told of the rib fracture a few days ago but could not remember which day. Interview with the Director of Nurses (DON) on 6/16/09 at 7:22 a.m. revealed she was unaware that the resident had a fractured rib and therefore it had not been been investigated or reported to the State Agency. Further interview with the DON on 6/16/09 at 9:30 a.m.… | 2014-01-01 | ||
| 10644 | 10644 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2011-03-10 | 325 | D | 82I011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to ensure nutritional parameters were maintained for two (2) residents ("B" and #11) from a sample of nineteen (19) residents. Findings include: 1. Review of the physician orders [REDACTED]. She was ordered Carnation Instant Breakfast 120 milliliters three (3) times a day on 2/22/11. Observation of the lunch meal on 3/08/11 at 12:20 p.m. revealed that resident #24 was served chopped meat, white rice, sweet potatoes, brussel sprouts, a roll, fruit, tea, water and coffee. Interview with Licensed Practical Nurse (LPN) Clinical Manager at that time revealed that the rice was considered to be a fortified food item. The resident was observed to quickly eat the meat, rice and tea but no other food items. No substitutes or second servings were offered. Interview with the resident at that time revealed she did not have much of an appetite and had lost weight since admission to the facility. She decribed herself as a picky eater at times but does like the vanilla drink she receives with her medications. Record review revealed an admission weight, dated 9/22/10, of 178.8 pounds and a height of 61 inches. Following monthly weights were: 10/2010=177 pounds; 12/2010=165 pounds; 1/08/11=155 pounds. Review of the medical record for resident #24 revealed that no care plan had been developed for this resident. There was no individualized plan of care related to nutrition or weight loss for the resident. Interview with the LPN Manager revealed she considered the weight loss for this resident as beneficial. 2. A review of the clinical record of resident #11 revealed that she had experienced significant weight loss as follows: 03/01/2011; Weight: 117 (12.7% loss in 3 months) 01/13/2011; Weight: 127 (5.2% loss in 1 month) 12/20/2010; Weight: 134 (baseline weight) Further record review revealed the resident's care plan regarding the potential alteration in nutrition status had not been revi… | 2014-01-01 | ||
| 10643 | 10643 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2011-03-10 | 490 | K | 82I011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observation, record review and staff interviews, the facility failed to be administered in a manner that ensured staff members were trained appropriately regarding the need to clean and disinfect glucometers between each resident. This affected 21 residents currently in the facility who received daily monitoring of blood glucose levels where mult-use glucometers are used. This failure resulted in the likelihood of an immediate and serious threat to resident health and safety for those 21 residents. Therefore, it was determined that the likelihood of an immediate and serious threat to resident health and safety existed from March 8, 2011 until March 10, 2011 when a plan of correction was implemented by the facility to remove the jeopardy situation. Findings include: Interview on 3/8/11 at 1:00 p.m. with the Administrator, Director of Nursing (DON) and the Clinical Education Director revealed that the DON was unaware of the revision to F441 dated July 17, 2009 and was that the DON and the Clinical Education Director were not familiar with the facility Policy for cleaning and disinfecting of the blood glucose monitors. Review of the facility policy Cleaning/Disinfecting Glucometers with creation date of 4/30/10 and fax date of 3/08/11, from the corporate office, revealed that alcohol should never be used, as it can damage the LED (light emitting diode) readout and the machine, if no visible soil is present, should be disinfected after each use following the manufacture direction or wipe with a cloth damped with EPA (environmental protection agency) registered detergent/germicide that has a TB ([MEDICAL CONDITION]), HBV ([MEDICAL CONDITION]),[MEDICAL CONDITION](human immunodeficiency virus) label or dilute beach solution of 1:10 concentration, and allow to self dry. At this time the DON revealed that he had an in-serviced and instructed all professional staff to clean the blood glucose monitors with an alcohol wipe before and after use… | 2014-01-01 | ||
| 10642 | 10642 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2011-03-10 | 463 | E | 82I011 | Based on record review, observation and staff interview, the facility failed to ensure that two (2) call lights in resident's bathrooms (#24 and a randomly observed resident) on the C-hall was maintained in functioning order. Findings include: During facility environmental rounds on 3/08/11 at 11:08 a.m., in bathroom C-14, there was no pullcord and/or toggle on the call light system. However, there was a 4 inch x 4 inch orange sign that reminded the resident to call for assistance, "we don't want you to fall". Staff interview with the Maintenance Supervisor on 3/09/11 at 9:10 a.m., revealed the toggle for the bathroom call system had been fixed the day before. He indicated that if a resident was using that particular restroom and needed help, than the resident would have to verbally call for help. A log was kept at the nursing station for staff to enter maintenance requests which he checks at the beginning of the shift and throughout the day. In addition, he does room rounds daily and facility wide rounds monthly. Review of the nursing station repair request log for February and March 2011 revealed no reference of call light problem in bathroom C-14. During the initial observation of resident #24's room on 3/07/2011 at 12:14 p.m. there was no toggle or call light cord in the resident's bathroom. There were signs posted in the bathroom that stated please call for assistance, "we don't want you to fall". On 3/08/2011 at 11:15 a.m. Licensed Practical Nurse (LPN"BB") was observed to wash her hands in this bathroom. When questioned by the surveyor the nurse stated that there was no way to use the call light in this bathroom. | 2014-01-01 | ||
| 10641 | 10641 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2011-03-10 | 441 | K | 82I011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of manufacturer's recommendations and staff interview, the facility failed to ensure an Infection Control Program designed to ensure a safe environment to prevent the development and transmission of disease and infection by failing to ensure the cleaning and sanitizing of glucometers between each resident use. This affected two (2) sampled residents, (#17 and #36) and nineteen (19) residents who received blood glucose monitoring on a daily basis via a multiple resident use glucometers. This failure resulted in the likelihood of an immediate and serious threat to resident health and safety for these twenty-one (21) residents. Therefore, it was determined that the likelihood of an immediate and serious threat to the resident health and safety existed from March 8, 2011 related to glucometers not being cleaned and disinfected when used for multiple residents until March 10, 2010, when a plan of correction was implemented by the facility to remove the jeopardy situation. Additional concerns, not related to jeopardy, were identified regarding hand washing during the medication pass observation. Findings include: 1. During medication pass on the A-Hall with LPN, "CC", on 3/08/11 from 11:51 a.m. she donned her gloves, took the glucometer out of the medication cart drawer, used the meter to check resident #17's blood glucose level. The nurse returned the glucometer to the medication cart drawer, but did not clean or disinfect the meter after use. In addition, LPN continue to draw up insulin and administer the injection without changing the gloves or washing her hands. Interview with LPN, "CC", on 3/08/11 at 12:08 p.m. revealed she did not clean the glucometer before she went into the resident #17 room, stating that she thinks she might have cleaned it after the last resident, but was unsure. 2. During medication pass task on the B-Hall on 3/08/11 at 12:40 a.m. with LPN "AA" revealed prior to checking a rand… | 2014-01-01 | ||
| 10640 | 10640 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2011-03-10 | 309 | D | 82I011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and staff interview, the facility failed to ensure that physician orders [REDACTED]. Findings include: Record review for resident #36 revealed that she was admitted with a [DIAGNOSES REDACTED]. Review of the March Physician order [REDACTED]. The resident was to receive [MEDICATION NAME] (type of insulin) ten (10) units before meals. During the medication pass observation on the C-hall with Licensed Practical Nurse (LPN), "BB", on 3/07/11 from 12:44 a.m.-12:55 p.m., LPN "BB" was observed to complete a blood glucose (BG) level then to administer [MEDICATION NAME] (insulin) ten (10) units. Interview with the LPN "BB" on 3/07/11 at 12:55 p.m. revealed that the resident had eaten lunch prior to resident's BG being checked and/or insulin being administered. Interview with the Director of Nursing (DON) on 3/09/11 at 2:45 p.m. revealed expectations were that the physicians order would be followed. Review of the March 2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]" signed that the accucheck was completed at 11:30 a.m. and also, that insulin was administered at the same time, documenting the insulin was administered prior to the lunch meal and not after the meal. | 2014-01-01 | ||
| 10639 | 10639 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2011-03-10 | 287 | F | 82I011 | Based upon observation, record review and staff interviews the facility failed to ensure that Minimum Data Set (MDS) 3.0 transmitted and accepted since 10/01/11. Findings include: Upon entrance to facility it was determined the facility had a census of ninety two (92) but after reconciliation it was discovered that the resident census pool contained twenty three (23) residents. A telephone interview with the Georgia State MDS Coordinator on 3/08/11 at 9:34 a.m. revealed that since 10/01/10, only eleven (11) MDS 3.0 had been submitted and accepted from the facility. An interview with the Administrator on 3/07/11 at 12:00 p.m. revealed she was aware there had been issues with rejection of 3.0 MDS at submission. Interview on 3/08/11 at 8:45 a.m. with the Administrator and MDS coordinator revealed they were unaware that only eleven (11) MDS 3.0 had been accurately transmitted and accepted since 10/01/11. | 2014-01-01 | ||
| 10638 | 10638 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2011-03-10 | 281 | D | 82I011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to meet professional standards of quality of care related to obtaining a blood sugar and administering insulin before meals for one (1) resident (#36) from a sample of nineteen (19) residents. Findings include: During the medication pass observation on 3/07/11 at 12:44 p.m. and 12:55 p.m. Licensed Practical Nurse (LPN), "BB" was observed to check the resident's blood glucose (BG) level and then to administer a routine dose of insulin ([MEDICATION NAME] 10 units). Interview with the Licensed Practical Nurse (LPN),"BB", at 12:55 p.m. on 3/07/11 revealed she was aware that the resident had already eaten lunch prior to the BG being checked and the insulin being administered. Review of the March 2011 Physician order [REDACTED]. A later review of the March 2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]" had signed that the blood glucose check was completed at 11:30 a.m. and that that insulin was administered at this time (11:30 a.m). Reference: The Georgia Nurse Practice Act 943-26-1;Article 2; subsection 2.3.2- Standards Related to Licensed Practical Nurse Professional Accountability revealed that the practice practical nursing as a Licensed Practical Nurse (LPN) by performing for compensation acts authorized by the board related to the maintenance of health and prevention of illness through acts, which shall include: administering treatments and medication as ordered by a physician. 2.3.1 B. Demonstrates honesty and integrity in nursing practice. Cross Refer to F-309 | 2014-01-01 | ||
| 10637 | 10637 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2011-03-10 | 280 | D | 82I011 | Based on record review and staff interview the facility failed to revise a Plan of Care to reflect the change in condition of one (1) resident (#11) and the dental needs for one (1) resident ("A") from a sample of nineteen (19) residents. Findings include: 1. A review of the clinical record of resident #11 revealed that she had experienced significant weight loss as follows: 03/01/2011; Weight: 117 (12.7% loss in 3 months) 01/13/2011; Weight: 127 (5.2% loss in 1 month) 12/20/2010; Weight: 134 (baseline weight) Further record review revealed the resident's care plan regarding the potential alteration in nutrition status had not been reviewed or revised since 12/24/10. An interview with the facility's Care Plan Coordinator on 3/08/11 at 3:00 p.m. revealed the care plan had not been revised to reflect this weight loss. Although the care plan did not reflect the resident's weight loss, review of Dietary Notes revealed the weight loss was identified and interventions in place to address the weight loss. 2. A family interview for resident "A" on 3/07/11 at 7:30 p.m., revealed the resident had lost weight since admission and the resident's dentures no longer fit properly. Review of the resident's care plan revealed a care plan that addressed nutrition but that had not been updated to reflect the ill fitting dentures. Interview with the Minimum Data Set (MDS) Coordinator on 3/08/11 revealed she had not been made aware of a denture problem for resident "A", therefore, the care plan had not been revised. Interview with the Social Worker on 3/08/11 at 10:13 a.m. revealed she was aware of the resident's ill fitting dentures but had not been able to arrange for a dental visit. She agreed the care plan has not been updated to reflect the ill fitting dentures. | 2014-01-01 | ||
| 10636 | 10636 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2011-03-10 | 279 | D | 82I011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to develop a comprehensive plan of care that included measurable objectives and timetables to meet a resident's medical needs related to weight loss and antianxiety medications for one (1) resident, (#24) on a sample of nineteen (19) residents. Findings include: 1. Review of the physician orders [REDACTED]. She was ordered Carnation Instant Breakfast 120 milliliters three (3) times a day on 2/22/11. Observation of the lunch meal on 3/08/11 at 12:20 p.m. revealed that resident #24 was served chopped meat, white rice, sweet potatoes, brussel sprouts, a roll, fruit, tea, water and coffee. Interview with Licensed Practical Nurse (LPN) Clinical Manager at that time revealed that the rice was considered to be a fortified food item. Record review revealed an admission weight, dated 9/22/10, of 178.8 pounds and a height of 61 inches. Following monthly weights were: 10/2010=177 pounds; 12/2010=165 pounds; 1/08/11=155 pounds. Review of the medical record for resident #24 revealed that no care plan had been developed for this resident. The Minimum Data Set (MDS) assessment from her admission on 9/22/10 were on the medical record and the RAP summaries. However, there was no individualized plan of care related to nutrition or weight loss for the resident. On 3/08/11 at 4:00 p.m., interview with the MDS Coordinator revealed that resident #24 did not have a care plan that addressed her nutritional status. 2. Review of the Physician order [REDACTED]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The most recent quarterly MDS 3.0 assessment documented that the resident was receiving an antianxiety medication daily. On 3/8/2011 at 4:15 p.m. review of resident #24's medical record revealed that there was no developed plan of care related to antianxiety medications. Interview with the MDS Coordinator on 3/08/2011 at 4:00 p.m. revealed… | 2014-01-01 | ||
| 10635 | 10635 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2011-03-10 | 164 | E | 82I011 | Based on observation and staff interview, the facility failed to provide privacy during medication pass for three (3) observed residents on two (2) of three (3) halls with three (3) of three (3) nurses. Findings include: During medication pass with LPN "BB" from 12:44 p.m.- 12:55 p.m., she was observed to close the mini blinds in a resident's room but left the door open to the hallway. While administering an insulin injection into the resident's abdominal area, one (1) person was observed walking by the open door. Also, the privacy curtain between the beds was not pulled and the resident's roommate was in their bed. During observation of med pass with LPN "AA" at 11:35 a.m. on 3/09/11, she did not close the resident's door, pull the privacy curtain or close the mini blinds during a blood sugar (BS) check and the administration of an injection in the resident's abdomen area. The resident's roommate was in the room. On 3/09/11 at 11:55 a.m., LPN "CC" was observed obtain a blood sample to monitoring a resident's blood sugar. LPN "CC did not close the resident's door during the blood glucose check. Three persons were observed to walk by the resident's door. Interview with the Director of Nursing (DON) on 3/08/11 at 1:30 p.m. confirmed that privacy should include closing the resident's bedroom door, window blinds, and privacy curtains. When giving an injection a resident should be provided privacy. | 2014-01-01 | ||
| 10634 | 10634 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2011-03-10 | 160 | E | 82I011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to convey within thirty (30) days the balance of resident trust funds, and a final accounting of those funds, to the individual administering the resident's estate. This affected four (4) randomly reviewed trust fund accounts belonging to deceased residents. Findings include: A review of resident trust fund accounts managed by the facility revealed that the following trust fund account disbursements made to the estates of deceased residents exceeded 30 days: ? Resident expired on [DATE], disbursement made on [DATE] ? Resident expired on [DATE], disbursement made on [DATE] ? Resident expired on [DATE], disbursement made on [DATE] ? Resident expired on [DATE], disbursement made on [DATE] This information was confirmed by Office Manager "DD" in an interview on [DATE] at 10:15 a.m. | 2014-01-01 | ||
| 10633 | 10633 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2010-09-02 | 162 | E | 42L211 | Based on record review and staff interview, the facility failed to appropriately manage resident accounts for fifteen (15) residents (#s 5, 6, 7, 9, 11, 12, 14, 15, 16, 17, 19, 20, 22, 23 and 24) in a survey sample of twenty-four (24) residents, related to charging and deducting a fee for laundry service from the resident trust fund account, but for which payment had already been made under Medicaid. Finding include: Review of the facility's resident trust fund Patient Activity Report revealed the following: 1. For Resident #5, the facility deducted a charge of $31 from the resident trust fund on 05/31/2010 for laundry service. 2. For Residents #9, #17, and #19, the facility deducted a charge of $31 from the resident trust fund on 03/31/2010 and 07/31/2010 for laundry service. Review of the August 2010 Account Statements for these residents revealed that the facility did credit $31 for that month to these residents' accounts on 08/26/2010, after the initiation of this complaint survey during which the issue was identified. 3. For Residents #6, #7, #11, #12, #22, and #23, the facility deducted a charge of $31 from the resident trust fund on 03/31/2010 for laundry service. 4. For Residents #14, #15, #16, #20, and #24, the facility deducted a charge of $31 from the resident trust fund on 03/31/2010 and 07/31/2010 for laundry service. During an interview with Staff Member "BB" conducted on 08/24/2010 at 3:30 p.m., this staff member stated that she/he was aware that some residents had been charged the laundry fee incorrectly. Staff Member "BB" also acknowledged that there was no system in place to ensure that residents who were charged the laundry fee were identified and that the money was reimbursed back into the account. | 2014-01-01 | ||
| 10632 | 10632 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2010-09-02 | 157 | D | 42L211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to immediately inform the family member of one (1) resident (#1), in a survey sample of twenty four (24) residents, of the development of a pressure sore. Findings include: A review of Resident #1's Nurse's Notes dated 4/26/2010 revealed documentation that the family member was notified of the resident's excoriated gluteal cleft and buttocks and of a treatment order for [MEDICATION NAME] cream. On 6/20/2010, documentation in the Treatment Record revealed that the left upper buttock had developed a sheet sheared area that was turning necrotic with eschar and slough measuring 4.0 by 1.0 centimeters. It was also documented that the area was treated with Santyl. However, there was no documentation to indicate that the responsible party of the resident was notified of the wound and treatment. During interview with Nurse "AA" conducted on 08/24/2010 at 2:45 p.m., this nurse acknowledged that there was no documentation to indicate that the responsible party was notified of the progression of the wound. | 2014-01-01 | ||
| 10631 | 10631 | HERITAGE HEALTHCARE OF LAFAYETTE | 115304 | 205 ROADRUNNER BOULEVARD | LAFAYETTE | GA | 30728 | 2009-05-13 | 502 | D | L1C411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the February 2009 Pharmacist consultant report and staff interview the facility failed to ensure that a Comprehensive Metabolic Panel was obtained in a timely manner for one (1) resident (#1) from a sample of seventeen (17) residents. Findings include: Review of the medical record for resident #1 revealed a physician's orders [REDACTED]. Further review revealed no laboratory results in the record. Review of the Monthly Pharmacist Reviews dated February 2009 indicated a CMP was due in February and then every 6 months. Interview with Unit Manager "EE" on 5/12/09 at 1:00pm revealed that when laboratory test are ordered there is one drawn at the time of order as a baseline and then as frequent as ordered by the physician. "EE" further revealed the first/base line or any CMP had not been done after the 2/23/09 physician's orders [REDACTED]. | 2014-01-01 | ||
| 10630 | 10630 | HERITAGE HEALTHCARE OF LAFAYETTE | 115304 | 205 ROADRUNNER BOULEVARD | LAFAYETTE | GA | 30728 | 2009-05-13 | 322 | D | L1C411 | Based on observations, staff interviews, and review of facility policy, the facility failed to provide appropriate positioning, during incontinence care, for two residents (2) residents (#4, #9) receiving gastrostomy tube feeding from a sample of seventeen (17) residents. Findings include: 1. Observation on 5/13/09 at 8:15 am of CNA "BB" providing incontinence care to resident # 9 revealed that tube feeding was being administered via a pump at 55 cc per hour. During the care the head of the resident's bed was flat and the tube feeding continued to infuse. Interview on 5/13/09 at 8:35 am with CNA "BB" revealed that the she was suppose to keep the head of the bed up during incontinent care or get the nurse to turn the tube feeding off. "BB" acknowledge that the feeding continued to infuse while the resident was flat in bed. 2. Observation on 5/11/09 at 1:30pm. of CNA "BB" providing incontinence care to resident #4, revealed that tube feeding was infusing via pump and she lowered the head of the bed to lower tha thirty (30) degrees. The CNA did not pause or stop the feeding while providing care. Interview on 5/11/09 at 1:35pm with CNA "BB" revealed that she was never instructed to stop or pause the feeding pump when providing care. She further revealed that she never notified the nurse prior to care or lowering the head of the bed. Interview with Director of Nursing (DON) "CC" on 5/11/09 at 3:10pm revealed that she was not aware of a policy to stop or pause the feeding pump when head of the bed is lowered. Review of the facility policy for Tube Feeding indicated that a resident's head will be elevated at least 30-45 degrees at all times with continuous feedings unless temporarily stopped when the head is lowered to render care. | 2014-01-01 | ||
| 10629 | 10629 | HERITAGE HEALTHCARE OF LAFAYETTE | 115304 | 205 ROADRUNNER BOULEVARD | LAFAYETTE | GA | 30728 | 2009-05-13 | 203 | D | L1C411 | Based on record review and staff interview, the facility failed to issue a written notice of discharge/transfer at least 30 days before the discharge or transfer for one (1) resident from seventeen (17) sampled residents. Findings includes: Record review for resident #16 revealed a nurse's note dated 4/30/09 that indicated the resident was discharge to another nursing home. Further review revealed a social service note dated 4/20/09 that the social service staff spoke with the resident's son regarding that the resident had been observed smoking in the room and that cigarettes were found in the room. No other written notification related to the resident's discharge was found in the resident's medical record. Interview with Social Worker "AA" on 5/13/09 at 10:10 am revealed that she did not issue a written notice related to discharge of this resident to another nursing home. | 2014-01-01 | ||
| 10628 | 10628 | GOLDEN LIVINGCENTER - DUNWOODY | 115270 | 5470 MERIDIAN MARK ROAD, BLDG E | ATLANTA | GA | 30342 | 2010-09-01 | 225 | D | 7R0511 | Based on record review and staff interview, it was determined that the facility failed to immediately report an injury of unknown origin to the state regulatory agency for one (1) resident #1 in a survey sample of four (4) residents. Finding include: The Interdisciplinary Progress Note dated 8/8/2010 documentation revealed that at 7:40 a.m. resident #1 was noted by the oncoming nurse to have a swollen right eye and the physician was notified. The Physician's Progress Note dated 8/8/2010 revealed that the resident had a bruise to the right eye that was identified as an ocular contusion. Review of the letter sent to the state regulatory agency dated 8/17/2010, revealed that the bruise of unknown origin to the eye of the resident was reported on 8/10/2010, two days after the bruise was noted by the physician on 8/8/2010 rather than immediately as required During an interview with the Director of Nursing on 9/1/2010 at 10:45 a.m., it was confirmed that the injury of unknown origin was not reported to the state until 8/10/2010. A phone interview with the Director of Nursing on 9/9/2010 at 2:20 p.m. revealed that the Physician's Progress note identified the bruise to the right eye as an ocular contusion that indicated an injury of unknown origin. It was further confirmed that the injury should have been reported that day to the state regulatory agency and an investigation immediately started. | 2014-01-01 | ||
| 10627 | 10627 | MUSCOGEE MANOR & REHAB CENTER | 115146 | 7150 MANOR RD | COLUMBUS | GA | 31907 | 2010-09-01 | 514 | D | 4BQ511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to ensure that the clinical record was complete for one (1) resident (#2) from a survey sample of eight (8) residents. Findings include: Record review revealed that Resident #2 had a 07/13/2010 physician's orders [REDACTED]. However, there was no documentation of any signs or symptoms of [MEDICAL CONDITION] in the Nurses Progress Notes, or elsewhere in the clinical record. Resident #2 also had a 07/27/2010 physician's orders [REDACTED]. However, there was no documentation of any signs or symptoms or the reason for this new treatment regimen in the Nurses Progress Notes or anywhere else in the clinical record. This was acknowledged by licensed staff member "AA" on 08/25/2010 at 4:30 p.m. | 2014-01-01 | ||
| 10626 | 10626 | MUSCOGEE MANOR & REHAB CENTER | 115146 | 7150 MANOR RD | COLUMBUS | GA | 31907 | 2010-09-01 | 157 | D | 4BQ511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to ensure that the physician was consulted in a timely manner for two (2) residents (#s 1 and 2 ), who had experienced significant changes in condition related to urinary tract symptoms, from a survey sample of eight (8) residents. Findings include: 1. Record review for Resident #1 revealed a Nurses Progress Note of 07/30/2010 at 9:45 p.m. which documented that the resident was noted to have cloudy and foul smelling urine. However, further record review revealed no evidence to indicate that the physician was consulted regarding this resident's significant change in physical condition until a Nurse's Progress Note of 08/03/2010 at 1:30 p.m. documented that a new order had been received. An order signed by the nurse practitioner, and dated 08/03/2010 at 8:50 a.m., specified that urine be collected for a urinalysis with culture and sensitivity. This represented an approximate three (3) day delay in physician consultation. A urinalysis laboratory report for Resident #1 dated as collected on 08/04/2010 documented urine with a positive [MEDICATION NAME], three (3) plus abnormal white blood cells, and one (1) plus abnormal protein. A physician's telephone order of 08/06/2010 specified that the resident receive the [MEDICATION NAME] milligrams twice daily for three weeks for a urinary tract infection. 2. Record review for Resident #2 revealed a Nurse's Progress Note of 08/16/2010 at 6:30 a.m. which documented that during a urinary catheter change, thick and milky white secretions were noted in the resident's peri-area. A foul odor was also noted. This Note did not document physician consultation regarding the resident's significant change in status at that time, but rather documented that the resident had been added to physician rounds for evaluation and treatment. A Nurse's Progress Note of 08/24/2010 at 7:30 p.m. documented that upon assessment of the resident's … | 2014-01-01 | ||
| 10625 | 10625 | D SCOTT HUDGENS CENTER FOR SKILLED NURSING, THE | 115690 | 3500 ANNANDALE LANE | SUWANEE | GA | 30024 | 2010-07-15 | 371 | F | DUNS11 | Based on observation and staff interview the facility failed to ensure that foods being served to residents in the facility's main dining room were held at a temperature necessary to prevent the likelihood of foodborne illnesses. This affected all residents in the facility (census = 15). Findings include: Observation on 7/13/10 at 12:15 p.m., with dietary employee "EE", in the serving kitchen of the dining room revealed a stainless steel pan full of tossed green salad was sitting unrefrigerated on a cart in the serving area. Continued observation revealed that the pan of salad was sitting in another pan containing ice. A temperature check of the tossed salad, using a digital thermometer, revealed that the temperature was 62 degrees Fahrenheit, well above the safe holding temperature of 41 degrees Fahrenheit. Further observation revealed a small stainless steel pan of chopped ham, being used to make chef salads, sitting on the cart. The pan of chopped ham was being held at room temperature without any means of keeping the ham cold. The temperature of the chopped ham was measured with a digital thermometer at 61 degrees Fahrenheit. | 2014-02-01 | ||
| 10624 | 10624 | GOLD CITY CONVALESCENT CENTER | 115689 | 222 MOORE DRIVE | DAHLONEGA | GA | 30533 | 2010-10-27 | 203 | D | 0EJX11 | Based on record review and staff interview, it was determined that the facility failed to notify three (3) of four (4) sampled residents (#2, #3, and #4), and family members of these residents, in writing of the residents' transfer to the hospital and of additional information as required. Findings include: Record review revealed Nurse's Notes dated 10/17/2010 at 7:00 pm. for Resident #2, 10/21/2010 at 5:30 p.m. for Resident #3, and 10/11/2010 at 10:50 a.m. for Resident #4 which documented that each resident had been transferred to the hospital. However, for each of these residents, there was no evidence to indicate that either before hospital transfer, at the time of hospital transfer, or since hospital transfer, each resident and the resident's family had received a written notice of the transfer indicating the reason for the transfer, the date of the transfer, the location to which the resident was being transferred, a statement that the resident had the right to appeal the action to the State, and the State Ombudsman's name, address and telephone number. During an interview conducted on 10/27/2010 at 12:46 p.m., the facility's Director of Nursing acknowledged that there was no evidence of a written notice of transfer containing the required information specified above having been issued/provided to Resident #2, #3, and #4, and to resident family members, regarding the residents' hospital transfers. | 2014-02-01 | ||
| 10623 | 10623 | PALMYRA NURSING HOME | 115628 | 1904 PALMYRA ROAD | ALBANY | GA | 31702 | 2010-10-15 | 315 | D | E1CR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and staff interviews, it was determined that the facility had failed to ensure the appropriate care to prevent urinary tract infections for one resident, Resident #2, from a sample of five residents. Findings include: Resident #2 was observed on 10/15/10 at 3:10 p.m. in bed with smeared, dried bowel movement (BM) on the right buttock and in the perineal area. At that time, the resident was not having a bowel movement. Both licensed staff member "AA" and certified nursing assistant "'BB", who were in the room during the observation, acknowledged that this was old bowel movement and that the resident had not been cleaned thoroughly after her last bowel movement. A review of a culture and sensitivity reports from Doctors Laboratory, Inc. revealed documentation showing that the resident had a urinary tract infection on 4/23/10 with a positive [MEDICATION NAME] and over 100,000 colonies/milliliter of Eschericia Coli (E. Coli) and another urinary tract infection with a positive [MEDICATION NAME] and over 100,000 colonies/milliliter of E. Coli on 8/10/10. | 2014-02-01 | ||
| 10622 | 10622 | PALMYRA NURSING HOME | 115628 | 1904 PALMYRA ROAD | ALBANY | GA | 31702 | 2010-10-15 | 314 | D | E1CR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations and staff interview, it was determined that the facility failed to provide the treatment as ordered for healing for one resident, Resident #2, out of a sample of four residents with pressure sores, from a total sample of five residents. Findings include: Based on review of the documentation on the facility's Wound Record for Resident #2, revealed an unknown stage pressure sore to the right heel, which was facility acquired and first identified on 7/16/10. A review documentation on the Treatment Record revealed there was a treatment order, to cleanse the right heel with normal saline, apply [MEDICATION NAME] and dry dressing, and to change every three days. This order was discontinued on 10/11/10 when a new physician's orders [REDACTED]. However, during an observation of the resident's right heel and dressing on 10/15/10 at 3:10 p.m. with licensed staff member "AA" revealed that the dressing over the right heel pressure sore was the [MEDICATION NAME] dressing. The [MEDICATION NAME] was then reapplied at that time. Another observation of the resident's right heel with licensed staff member "AA" at 4:40 p.m. on 10/15/10 revealed that the [MEDICATION NAME] dressing was in place over the pressure sore on the right heel. This was confirmed by licensed staff "AA" at 3:10 p.m. and 4:40 p.m. during interview. A review of the documentation on the October 2010 treatment record on 10/15/10 at 3:45 p.m. revealed that the old treatment order to cleanse the right heel with normal saline, apply [MEDICATION NAME] and dry dressings, and to change every three days, was still being documented as done from 10/11/10 through 10/15/10. There no documentation that the new treatment order of 10/11/10 had been transcribed nor implemented by staff to cleanse the right heel with normal saline, apply Santyl and dry dressings, and to change every other day. This was acknowledged by licensed staff "AA" at 5:20 p.m. during an interview. | 2014-02-01 | ||
| 10621 | 10621 | CRESTVIEW HEALTH & REHAB CTR | 115525 | 2800 SPRINGDALE ROAD | ATLANTA | GA | 30315 | 2010-10-27 | 157 | D | CU8M11 | Based on record review and staff interview, the facility failed to promptly consult with the physician, and immediately notify the family, regarding a significant change in the physical status of one (1) resident (#1) of thirteen (13) sampled residents Findings include: Record review for Resident #1 revealed Nurse's Note of 09/17/2010 at 11:22 a.m. which documented that the resident was alert and responsive, with no distress observed. Then, a Nurse's Note of 09/17/2010 at 5:30 p.m. documented that staff had noted softness and puffiness of the resident's left hand. There was no evidence to indicate that the physician was consulted or that the family of the resident was notified of this change in status at that time. A Nurse's Note of 09/25/2010 at 9:30 a.m. documented that the resident left arm had been elevated with a pillow roll and the left leg was elevated due to swelling. There was no evidence to indicate that the physician was consulted or that the family of the resident was notified of this change in status at that time. A Nurse's note of 10/19/2010 at 6:30 p.m. documented that the resident's family was concerned about the resident having left arm swelling. This Note documented that the physician was notified at that time, and that orders were received for a chest x-ray and Doppler studies of the left arm. During an interview conducted on 10/26/2010 at 2:15 p.m., the Director of Nursing stated that she called the doctor as soon as the family told her the resident's arm was swollen. | 2014-02-01 | ||
| 10620 | 10620 | GLENN-MOR NURSING HOME | 115480 | 10629 U.S. HIGHWAY 19 SOUTH | THOMASVILLE | GA | 31792 | 2010-08-26 | 323 | D | S0VI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, it was determined that the facility failed to evaluate the effectiveness of or develop new interventions to prevent injury from the bed siderails for one resident (#3) from a total sample of 15 residents. Findings include: Resident #3 had [DIAGNOSES REDACTED]. He/She sustained a moderately displaced and mildly angulated spiral fracture to his/her left distal tibia and fibula that was identified by an x-ray report on 2/8/10. Licensed nursing staff documented in the 2/5/10 at 4:17 a.m. nursing notes that a certified nursing assistant (CNA) observed that the resident's left ankle had edema (swelling) and was painful with movement. However, review of the resident's record revealed no known etiology (cause) for the fracture. During an interview on 8/25/10 at 9:50 a.m., the Director of Nursing (DON) stated that the facility did not complete an investigation into the cause of the resident's fracture. He/she stated that the resident had probably hit his/her leg on the side rail of the bed and it had fractured because of having osteopenia. However, the 2/8/10 x-ray report noted "diffuse osteopenia" only in the resident's left ankle. The resident was observed in bed on 8/24/10 at 11:50 a.m., 12:40 p.m., 2:40 p.m., on 8/25/10 at 11:00 a.m., 12:00 p.m. and on 8/26/10 at 7:55 a.m. with 3/4 siderails up. There was not any padding on them. During an interview on 8/26/10 at 11:30 a.m., the DON stated that padded siderails had been tried after the resident's fracture but, the resident had removed them. He/she stated that there was no documentation related to the resident having had padding on his/her siderails or about the resident's behavior of removing them. She said that there were not any other interventions that had been put in place. During an interview on 8/26/10 at 9:45 a.m., CNA "CC" stated that he/she had not seen padding on the resident's siderails after the resident's 2/2010 fracture. There … | 2014-02-01 | ||
| 10619 | 10619 | GLENN-MOR NURSING HOME | 115480 | 10629 U.S. HIGHWAY 19 SOUTH | THOMASVILLE | GA | 31792 | 2010-08-26 | 225 | D | S0VI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to investigate the cause of a fracture for one resident (#3) from a total sample of 15 residents. Findings include: Resident #3 sustained a moderately displaced and mildly angulated spiral fracture to his/her left distal tibia and fibula that was identified by an x-ray report on 2/8/10. Licensed nursing staff documented in the 2/5/10 at 4:17 a.m. nursing notes that a certified nursing assistant (CNA) had observed that the resident's left ankle had [MEDICAL CONDITION] (swelling) and was painful with movement. However, review of the resident's record revealed no known etiology (cause) for the fracture. The licensed nurse coded the resident as requiring extensive assistance of one staff member (3/2) for bed mobility and dressing on the 12/8/09 quarterly Minimum Data Set (MDS) assessment. During an interview on 8/25/10 at 9:50 a.m., the Director of Nursing confirmed that the facility did not conduct a thorough investigation to determine the cause of the resident's fracture. | 2014-02-01 | ||
| 10618 | 10618 | GLENN-MOR NURSING HOME | 115480 | 10629 U.S. HIGHWAY 19 SOUTH | THOMASVILLE | GA | 31792 | 2010-08-26 | 164 | D | S0VI11 | Based on observation, it was determined that the facility failed to provide personal privacy during incontinence care for one resident (#3) from a total sample of 15 residents. Findings include: During an observation of incontinence care being provided on 8/25/10 at 4:20 p.m., certified nursing assistant (CNA) "BB" failed to close the privacy curtain between the A and B beds in the room. Resident #3 was exposed from the waist down and his/her roommate was present in the room. | 2014-02-01 | ||
| 10617 | 10617 | GLENN-MOR NURSING HOME | 115480 | 10629 U.S. HIGHWAY 19 SOUTH | THOMASVILLE | GA | 31792 | 2010-08-26 | 387 | D | S0VI11 | Based on record review, staff interview, and review of the facility's Quality Assurance committee meeting minutes, it was determined that one resident (#1) was not seen by a physician at least once every 60 days in a sample of 15 residents. Findings include: Resident #1 had a 1/14/10 physician's progress note signed by his/her attending physician. However, there was not another physicians's progress note or evidence of a physician's visit to the resident until a 7/19/10 progress note signed by the Medical Director. During an interview on 8/25/10 at 11 a.m., the Director of Nursing (DON) stated that the facility had identified that the resident's attending physician had not visited him/her since January, 2010. She said that the problem had been discussed in the April Quality Assurance meeting and a corrective action plan was developed. She said that as of July, the attending physician had still not visited the resident so, the Medical Director visited him/her. However, despite the facility having identified the lack of physician's visits to resident #1 in April, a physician did not visit the resident until 7/19/10. | 2014-02-01 | ||
| 10616 | 10616 | GLENN-MOR NURSING HOME | 115480 | 10629 U.S. HIGHWAY 19 SOUTH | THOMASVILLE | GA | 31792 | 2010-08-26 | 315 | D | S0VI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to ensure that one resident (#1) had a medical [DIAGNOSES REDACTED]. Findings include: Resident #1 had an indwelling urinary catheter since at least 12/14/09. However, review of the resident's medical record revealed [REDACTED]. During an interview on 8/25/10 at 2:00 p.m., the Director of Nursing (DON) stated that the resident had the catheter because the resident's family had requested it. | 2014-02-01 | ||
| 10615 | 10615 | GLENN-MOR NURSING HOME | 115480 | 10629 U.S. HIGHWAY 19 SOUTH | THOMASVILLE | GA | 31792 | 2010-08-26 | 253 | D | S0VI11 | Based on observations, it was determined that the facility failed to maintain an environment that was free from dust, dirt, improperly fitting vents, stained ceiling tiles, missing light bulbs and light covers and broken air conditioner vent covers in nine of 31 residents' rooms on both halls (100 and 200) of the facility. Findings include: Observations were made on 8/24/10 between 9:30 a.m. and 10:35 a.m. 100 Hall 1. The bathroom's ceiling tiles did not fit so, there were gaps in the ceiling in room 108. 2. There were two dried brown stained ceiling tiles in room 103. 200 Hall 1. There was a dried brown stained ceiling tile in the bathrooms in rooms 201 and 212. 2. The bathroom ceiling light fixture was missing a bulb and light cover in room 205. 3. The air conditioner vent covers had a build up of dust in rooms 207, 209, 211 and 214. 4. The bathroom's ceiling vent was loose in room 209. 5. A part of the air conditioner's plastic vent cover was broken off in room 207. | 2014-02-01 | ||
| 10614 | 10614 | GLENN-MOR NURSING HOME | 115480 | 10629 U.S. HIGHWAY 19 SOUTH | THOMASVILLE | GA | 31792 | 2010-08-26 | 502 | D | S0VI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to obtain laboratory tests as ordered for two residents ( #6 and #10) from a total sample of 15 residents. Findings include: 1. Resident #6 had a 4/6/10 pharmacy recommendation for a lipid panel and a HgbA1c now and every 12 months to monitor his/her use of [MEDICATION NAME]. The resident's attending physician approved that recommendation on 5/3/10 and ordered that those laboratory tests be obtained on 5/5/10 and then annually. However, the laboratory tests were not obtained as ordered until 8/25/10, after surveyor inquiry. During an interview on 8/25/10 at 10:50 a.m., licensed nurse "AA" confirmed that nursing staff had failed to obtain the laboratory tests as ordered. 2. Resident #10 was admitted on [DATE]. There was an 8/9/10 physician's orders [REDACTED].) and a Liver Function Test (LFT) to be obtained the week of admission and then every 6 months thereafter with a start date of 8/11/10. The order included that a Potassium level was to be obtained the week of admission and then once a month thereafter with a start date of 8/11/10. However, those laboratory tests were not obtained until 8/26/10, after surveyor inquiry. On 8/26/10 at 11:20 a.m., the Director of Nurses provided a copy of the laboratory results and confirmed that those laboratory tests had not been obtained until that day (8/26/10). Resident #10 had a critical high [MEDICATION NAME] time (PT) level of 44 seconds (normal range of 9.5 - 11.8 seconds) and a critical high International Normalized Ratio (INR) of 4.5 ( normal range 2 - 3) on 8/11/10. The physician ordered that nursing staff hold the resident's [MEDICATION NAME] for two days and then recheck the resident's PT and INR levels again on 8/13/10. However, nursing staff failed to obtain the PT and INR levels until 8/16/10. On 8/16/10, the laboratory results form noted that the resident's PT was high at 17 seconds and the physician was n… | 2014-02-01 | ||
| 10613 | 10613 | ANDERSON MILL HEALTH AND REHABILITATION CENTER | 115145 | 2130 ANDERSON MILL RD | AUSTELL | GA | 30106 | 2010-10-13 | 309 | D | Y3K611 | Based on record review and staff interview, it was determined that the facility failed to provide care, in accordance with a physician's order for a surgical consultation, for one (1) resident (#1) in a survey sample of four (4) residents. Findings include: Record review for Resident #1 revealed a Physician's Telephone Order of 08/20/2010 which specified that the resident was to have an x-ray of the right hip prior to the a physician's appointment scheduled on 09/17/2010. A Radiology Report dated 09/02/2010 documented that the impression was a dislocation of the resident's right arthroplasty. A Nursing Daily Skilled Summary dated 09/02/2010 at 10:30 p.m. documented that the resident's attending physician had been made aware of the x-ray result which was positive for a dislocation of the right hip arthroplasty, and documented that the attending physician ordered for staff on the 7:00 a.m.-3:00 p.m. shift to follow-up with the surgeon the next morning. However, further record review, to include review of the Nursing Daily Skilled Summary, revealed no evidence to indicate that the surgeon was notified of the x-ray results, as specified by the resident's attending physician's order. During an interview with the Director of Nursing (DON) conducted on 10/13/2010 at 11:10 a.m., the DON acknowledged that the surgeon was not notified of the results of the x-ray, as specified by the attending physician's order. | 2014-02-01 | ||
| 10612 | 10612 | ANDERSON MILL HEALTH AND REHABILITATION CENTER | 115145 | 2130 ANDERSON MILL RD | AUSTELL | GA | 30106 | 2010-10-13 | 157 | D | Y3K611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to immediately notify the family of a dislocated right hip arthroplasty for one (1) resident (#1) in a survey sample of four (4) residents. Findings include: Record review for Resident #1 revealed an Accumulative [DIAGNOSES REDACTED]. A physician's note referencing a physician's visit of 08/21/2010 documented that Resident #1 had experienced a dislocation of the right hip and had undergone a closed reduction in the hospital on [DATE], and was then admitted to the nursing facility on 08/20/2010. A Physician's Telephone Order of 08/20/2010 specified that the resident was to have an x-ray of the right hip prior to the a physician's appointment scheduled on 09/17/2010. A Radiology Report dated 09/02/2010 documented that the impression was a dislocation of the right arthroplasty. A Nursing Daily Skilled Summary dated 09/02/2010 at 10:30 p.m. documented that the x-ray result had been received and was positive for a dislocation of the right hip arthroplasty, and that the resident's physician was notified of the results. However, further record review, to include review of the Nursing Daily Skilled Summary, revealed no evidence to indicate that the resident's family had been notified of this resident's significant change in physical status. During an interview with the Director of Nursing (DON) conducted on 10/13/2010 at 11:10 a.m., the DON acknowledged that the resident's family was not notified of the results of the x-ray done on 09/02/2010 that indicated a dislocation of the resident's right hip arthroplasty. | 2014-02-01 | ||
| 10611 | 10611 | TOWER ROAD HEALTHCARE AND REHABILITATION CENTER | 115115 | 26 TOWER RD | MARIETTA | GA | 30060 | 2010-10-18 | 225 | D | DMLD11 | Based on family interview and staff interview, it was determined that the facility failed to investigate allegations of misappropriation of resident property reported to facility staff by the family of one (1) resident ("A") in a survey sample of five (5) residents. Findings include: During an interview with a family member of Resident "A" conducted on 10/12/2010 at 3:45 p.m., the family member stated that it had been reported to the Administrator that someone in a white uniform had been observed by the resident standing in front of an opened drawer and had started to pull things out, at which time the resident screamed and the person left the room. The family member stated that another allegation had been reported to the Administrator in which perfume was allegedly stolen from the resident's room. During an additional interview with the family of Resident "A" conducted by telephone on 10/14/2010 at 6:15 p.m., the family member alleged that the stolen perfume referenced above was valued at $110.00. The family member also alleged that a pair of earrings had been stolen from the resident's jewelry box, and that this allegation was also reported to the Administrator. During an interview with the Administrator conducted on 10/12/2010 at 4:10 p.m., the Administrator acknowledged that there was an allegation reported by the resident's family of an intruder in the resident's room attempting to steal something, but further acknowledged that neither this allegation, nor the allegation regarding the stolen perfumed, were investigated or reported to the State regulatory agency by the facility. During an additional interview with the Administrator conducted on 10/18/2010 at 11:55 a.m., the Administrator stated that the allegation regarding missing earrings was not investigated or reported to the State survey agency. | 2014-02-01 | ||
| 10610 | 10610 | MILLER NURSING HOME | 115039 | 206 GRACE ST | COLQUITT | GA | 39837 | 2010-10-19 | 157 | D | NOYT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to immediately consult with the physician and notify the family when there was a significant change in the physical status of one (1) resident (#1) from a survey sample of four (4) residents. Findings include: Record review for Resident #1 revealed the resident's September 2010 Physician order [REDACTED]. An original Admissions Nursing Assessment documented that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An Alteration In Skin Integrity Report of 08/28/2010 specifically documented that the resident had a right above-the-knee amputation and a left below-the-knee amputation, but documented no problem related to the left knee. A later Alteration In Skin Integrity Report of 09/04/2010 documented that by that time, bruising and [MEDICAL CONDITION], with discoloration, were noted to the left knee. Additionally, documentation on the September 2010 General Notes indicated that the resident was medicated with [MEDICATION NAME] 5-500 milligrams for specific complaints of pain in the left leg on 09/04/2010 at 3:00 a.m., 09/07/2010 at 4:00 a.m., and 09/08/2010 at 5:30 a.m.. However, further record review revealed no evidence to indicate that the physician and the family were notified about this significant change status of the resident's left knee, as indicated by bruising, discoloration, [MEDICAL CONDITION], and continued complaints of pain, until a Nurse's Note of 09/10/2010 at 2:40 p.m. documented that the nurse was called to the room of the resident by a certified nursing assistant. This Note documented that the nurse noted ischemic skin breakdown to the resident's left knee, and documented that the physician was notified of the observed breakdown at that time. A Nurse's Note of 09/10/2010 at 2:50 p.m. documented that the family was notified. The above was acknowledged by licensed staff member "AA" during an interview conducted on… | 2014-02-01 | ||
| 10609 | 10609 | FORT GAINES HEALTH AND REHAB | 115696 | 101 HARTFORD ROAD, WEST | FORT GAINES | GA | 39851 | 2010-11-17 | 407 | D | 9ZTI11 | Based on record review and staff interview, it was determined that the facility failed to obtain a physician's order prior to a psychiatric evaluation to determine the appropriateness of inpatient psychiatric care for one resident (#1) from at total sample of five residents. Findings include: A social service note entry dated 9/9/10 documented that a staff person from the geri-psychiatric unit at Barbour Medical Center was at the facility to evaluate resident #1's behavioral problems in order to determine if he/she met the criteria for placement at the geripsychiatric unit.. However, a review of the clinical record revealed that there was not a physician's order for that psychiatric evaluation. The Social Service Director stated on 11/17/10 at 2:05 p.m., that the Director of Nursing told her to contact Barbour Medical Center geri-psychiatric services to evaluate the resident. The resident's physician stated on 11/17/10 at 3:05 p.m. that she was not aware that an (psychiatric) evaluation and had not ordered one to be done. | 2014-03-01 | ||
| 10608 | 10608 | FORT GAINES HEALTH AND REHAB | 115696 | 101 HARTFORD ROAD, WEST | FORT GAINES | GA | 39851 | 2010-11-17 | 205 | D | 9ZTI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to ensure that, two residents (#1 and #2) of three residents who were transferred out of the facility, their family members were provided written information which specified the duration of the facility's bed hold policy from a total sample of five residents. Findings include: The facility's Admission Agreement included a policy on bed holds. The agreement documented the resident and a family member or legal representative would be given notice of the bed hold option at the time of hospitalization or therapeutic leave. The Social Service Director stated during an interview on 11/17/10 at 2:05 p.m., that the bed hold policy was supposed to be sent with residents during transfers out of the facility. However, she said that she did not know if it was being done. She was not sure who was assigned responsibility for sending out the notices. She stated that if the facility was sending it, should have been documented "somewhere." 1. There was a 9/10/10 physician's orders [REDACTED]. However, there was no evidence to indicate that the resident and family had been given written notice which specified the duration of the facility's bed hold policy at the time he/she left the facility. 2. Resident #2 was hosptalized on [DATE] and again on 10/12/10 due to an acute change in condition. However, there was no evidence that the resident and family were given written notice which specified the duration of the facility's bed hold policy at the time the resident left the facility. | 2014-03-01 | ||
| 10607 | 10607 | FORT GAINES HEALTH AND REHAB | 115696 | 101 HARTFORD ROAD, WEST | FORT GAINES | GA | 39851 | 2010-11-17 | 203 | D | 9ZTI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility discharged on e(#1) of three residents without notifying the resident and the resident's family in writing about the specific reason for the discharge and any of the other required information in a total sample of five residents. Findings include: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. There was a physician's orders [REDACTED]. A nurse's note entry on 9/10/10 at 2 p.m. documented the resident as being transferred to Medical Center Barbour psychiatric ward for behavior problems, the family was aware of it and that the physician had been notified. A social service note dated 9/10/10 described the resident as having become combative and very agitated so, he/she was being transferred to the Geripsych unit at Barbour Medical Center. The note indicated that the resident's family and physician were notified. The resident was discharged from the facility on 9/10/10. The administrator stated on 11/17/10 at 10:10 a.m. that the resident was discharged from the facility for safety concerns. The Director of Nursing stated on 11/17/10 at 1:55 p.m., that the resident was transferred and discharged from the facility because of his/her wandering behaviors. However, there was no documentation in the clinical record that the facility had provided written notice to the resident and his family about the discharge, the reason for the discharge, the effective date of the discharge, the location to which the resident was being discharged , or the resident's right to appeal the action to the State, and provide the State long term care ombudsman's name, phone number or address. | 2014-03-01 | ||
| 10606 | 10606 | FORT GAINES HEALTH AND REHAB | 115696 | 101 HARTFORD ROAD, WEST | FORT GAINES | GA | 39851 | 2010-11-17 | 202 | D | 9ZTI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to ensure that a physician documented the necessity of a transfer and discharge from the facility for one resident (#1) of three residents reviewed for transfers/discharges from a total sample of five residents. Findings include: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. There was a physician's orders [REDACTED]. A nurse's note entry on 9/10/10 at 2 p.m. documented the resident as stable upon being transferred by car to Medical Center Barbour psychiatric ward for behavior problems. The nurse wrote that the family was aware and the physician was notified. A social service note dated 9/10/10 described the resident's behavior as having become combative and very agitated. The social service staff noted that the resident was being transferred to the Geripsych unit at Barbour Medical Center and that the family and physician were notified. The resident was discharged from the facility on 9/10/10. The Director of Nursing (DON) stated on 11/17/10 at 1:55 p.m., that the resident's physician and medical director had been contacted by the Assistant Director of Nursing (ADON) about transferring the resident on 9/10/10. The physician stated, on 11/17/10 at 3:05 p.m., that the facility had legitimate concerns about the resident's attempting to leave the facility. However, there was not any documentation by the resident's attending physician or another physician about the specific reason for the resident's immediate transfer and discharge to the Medical Center. | 2014-03-01 | ||
| 10605 | 10605 | GOLD CITY CONVALESCENT CENTER | 115689 | 222 MOORE DRIVE | DAHLONEGA | GA | 30533 | 2009-09-24 | 282 | D | MGH611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to ensure for two(2) residents (#9 & 12) on a sample of nineteen (19) residents, that care plans were followed related to the use of chair alarms, safety floor pad and self release seat belts. Findings include: Record review for resident #9 revealed that the resident fell on [DATE], 5/12/09, 5/16/09, 5/31/09, 6/8/09, 6/12/09, 6/15/09, 7/15/09, 7/20/09, and 8/22/09. The care plan dated 9/3/09 indicated that the resident was at risk for falls and was care planned to have a low bed with a safety pad and a self release belt when the resident is in the wheelchair. During an observation on 9/24/09 at 12:58 p.m. and on 9/25/09 at 8:15 a.m. the resident was observed in a high back wheelchair and a self release belt was not in place. An interview on 9/25/09 at 8:15 a.m. with Certified Nursing Assistant "AA" confirmed that a self release belt was not in place. During an observation on 9/26/09 at 8:50 a.m. the resident was observed in bed and a safety pad was not placed beside the bed. During an interview with Licensed Practical Nurse "BB" on 9/26/09 at 9:10 a.m. she confirmed that the safety pad was not beside the bed. Review of the comprehensive care plan for resident #12 revealed a care plan was developed to address the risk for falls. The care plan was reviewed in the care plan meeting on 7/27/09. An intervention added on 5/12/09 indicated the resident should have a tab alarm applied to her wheelchair. During an observation on 9/23/09 at 2:30 p.m., the resident was observed up in the wheelchair with no tab alarm in place. During an interview on 9/23/09 at 3:10 p.m. the Minimum Data Set (MDS) Coordinator "AA" stated the resident was supposed to have the tab alarm, however, she had no explanation as to why it had not been applied. | 2014-03-01 | ||
| 10604 | 10604 | GOLD CITY CONVALESCENT CENTER | 115689 | 222 MOORE DRIVE | DAHLONEGA | GA | 30533 | 2009-09-24 | 323 | D | MGH611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to ensure that three (3) residents (#6, #9, and #12) of nineteen (19) sampled residents at risk for falls had appropriate safety devices in use. Findings include: Review of the quarterly Minimum Data Set (MDS) for resident #12 dated 7/29/09 revealed the resident had fallen in the past thirty (30) days as well as in the past thirty-one (31) to sixty (60) days. Review of the care plan developed to address the risk for falls revealed the resident had an intervention to have an alarm on her wheelchair. During an observation on 9/23/09 at 2:20 p.m. the resident was observed up in the wheelchair, however, there was no alarm in place. During an interview on 9/24/09 at 9:00 a.m. the Director of Nursing (DON) confirmed that the resident should have an alarm when the resident is in her wheel chair. She further stated that the Certified Nursing Assistant (CNA) responsible for restorative nursing had a book with a list of residents who required alarms and safety devices, and she checks these devices daily for their appropriate use. She added, that the use of an alarm on this resident's wheelchair was not listed in the book and must have been left off. Record review for resident #9 revealed that the resident had a history of [REDACTED]. During an observation on 9/24/09 at 12:58 p.m. and on 9/25/09 at 8:15 a.m. the resident was observed in a high back wheelchair and a self release belt was not in place. An interview on 9/25/09 at 8:15 a.m. with Certified Nursing Assistant (CNA) "AA" confirmed that a self release belt was not in place. During an observation on 9/26/09 at 8:50 a.m. the resident was observed in bed and a safety pad was not placed beside the bed. During an interview with Licensed Practical Nurse "BB" on 9/26/09 at 9:10 a.m. she confirmed that the safety pad was not beside the bed. During an interview on 9/26/09 at 10:45 a.m. Restorative LPN "EE" stated the restorative … | 2014-03-01 | ||
| 10603 | 10603 | CANTON NURSING CENTER | 115606 | 321 HOSPITAL ROAD | CANTON | GA | 30114 | 2010-11-30 | 309 | D | LIVR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to administer medications as ordered by the physician for one (1) resident (#1) in a survey sample of six (6) residents. Findings include: Record review for Resident #1 revealed a Social Progress Notes entry of 10/11/2010 which documented that the resident had been admitted to the facility on that date. The resident's admission physician's orders [REDACTED]. However, further record review, to include review of the October 2010 Medication Record, revealed no evidence to indicate that the medication was administered, as ordered and scheduled, on 10/16/2010 at 8:00 a.m., 10/17/2010 at 8:00 p.m., and 10/24/2010 at 8:00 a.m. During an interview with the Director of Nursing (DON) conducted on 11/18/2010 at 1:20 p.m., the DON acknowledged there was no evidence to indicate that the medication doses were administered as ordered. Additional review of the 10/11/2010 physician's orders [REDACTED]. During an interview with the DON at 1:15 p.m. on 11/18/2010, the DON acknowledged there was no evidence to indicate that the medication was administered as ordered. | 2014-03-01 | ||
| 10602 | 10602 | AUTUMN BREEZE HEALTH CARE CTR | 115580 | 1480 SANDTOWN ROAD | MARIETTA | GA | 30008 | 2010-11-17 | 224 | D | C9BJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and hospital document review, the facility failed to provide the services necessary to assess and obtain timely treatment for one (1) resident ("C") from a survey sample of three (3) residents. Findings include: Record review for Resident "C" revealed a 04/20/2010 Physician's Admission History and Physical which documented that the resident's breast exam had been deferred. A physician's Progress Note dated 10/25/2010 documented that during the April 2010 History and Physical, the palpation portion of the breast exam had been deferred, but that visualization for asymmetry and assessment for nipple drainage had been unremarkable. Further review of the resident's record revealed documentation indicating that weekly assessments had been done, with no notations indicating that staff had either identified or documented any changes or dimpling of the right breast. However, a Nurse's Note of 10/24/2010 at 6:00 p.m. documented that the resident's family member had reported a lump in the resident's right breast. This Note documented that upon assessment, a lump approximately the size of a golf ball was palpated on the inner portion, and extending toward the middle, of the resident's right breast, with indentation observed. This Note further documented that the physician was notified, and an order was received to send the resident to the hospital emergency room . A hospital ED Record of 10/24/2010 documented that Resident "C" was diagnosed with [REDACTED]. A Physician's Progress Note of 10/27/2010 documented that a breast exam had revealed considerable induration with skin retraction. During an interview with the Assistant Director of Nursing (ADON) conducted on 11/17/2010 at 1:20 p.m., she stated that she expected staff to do a head-to-toe assessment and to report any changes or abnormal findings. The ADON stated that she had examined Resident "C"'s breasts and noted that the right breast looked dif… | 2014-03-01 | ||
| 10601 | 10601 | MEADOWBROOK HEALTH AND REHAB | 115561 | 4608 LAWRENCEVILLE HIGHWAY | TUCKER | GA | 30084 | 2010-11-17 | 203 | D | IU2W11 | Based on record review and staff interview the facility failed to issue a discharge notice to the resident and family member of the resdient of the discharge and the reasons for the move in writing for one (1) resident, Resident #1, in a survey sample of eight (8) resdients. Findings include: Based on review of the medical record of resident #1, there was no documentation in the resident's medical record that showed the facility provided a discharge notice as soon as practical to the resident and/or family member as required. This notice should include the reason for the transfer/discharge; the effective date of the transfer or discharge; the location to which the resident was transferred or discharged ; the right of appeal, and how to notify the ombudsman (name, address, and telephone number). During an interview with the administrator on 11/17/2010 at 12:45 p.m., the administrator said he had told the complainant about the injured staff member and said that the resident could not return to the facility. However, the administrator said that this conversation with the family member had not been documented. | 2014-03-01 | ||
| 10600 | 10600 | MEADOWBROOK HEALTH AND REHAB | 115561 | 4608 LAWRENCEVILLE HIGHWAY | TUCKER | GA | 30084 | 2010-11-17 | 202 | D | IU2W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to document the reason for one (1) resident's discharge, Resident #1, from a survey sample of eight (8) residents. Findings include: A review of the medical record for resident #1 revealed the resident was discharged to the hospital on [DATE] due to dangerous aggressive behaviors to others. There was no documentation noted in the medical record by the attending physician or extender as to an inability to meet the resident's needs in the facility or of plans for discharge. A telephone interview conducted on 11/17/10 at 12:26 p.m. with the physician, revealed he had told the discharge planner at the hospital that the resident could not return to the facility because she was dangerous to self and others. The physician further confirmed that he had not documented in the resident's medical record nor had he informed the family that the resident could not return to the facility. | 2014-03-01 | ||
| 10599 | 10599 | CORDELE HEALTH AND REHABILITATION | 115429 | 1106 NORTH 4TH STREET | CORDELE | GA | 31015 | 2010-09-01 | 428 | D | W2R511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the consultant pharmacist failed to identify that the frequency of administering a hypnotic had been changed without a physician's orders [REDACTED]. Findings include Resident #8 had a physician's orders [REDACTED]. However, a review of the resident's June 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. However, review of the clinical record revealed that there was no evidence of a physician's orders [REDACTED]. During an interview on 8/31/10 at 3:30 p.m., licensed nurse "AA" confirmed that there was not a physician's orders [REDACTED]. However, nursing staff administered Ambien to the resident every night in June and July and 30 of 31 nights in August, 2010. Although the consultant pharmacist reviewed the resident's drug regimen in July and August 2010, she failed to identify the change in the the frequency of administration of Ambien without a physician's orders [REDACTED]. See F309 for additional information regarding resident #8. | 2014-03-01 | ||
| 10598 | 10598 | CORDELE HEALTH AND REHABILITATION | 115429 | 1106 NORTH 4TH STREET | CORDELE | GA | 31015 | 2010-09-01 | 463 | E | W2R511 | Based on observations, and resident and staff interviews, it was determined that the facility failed to properly maintain the call light system for seven beds on one of two halls (200). Findings include: 1. During the group interview on 8/30/10 at 1:50 p.m., one resident ("B") of the four residents in attendance complained that the call light in his/her room did not always work. During an observation on 9/1/10 at 8:30 a.m., seven of the call lights(rooms 204 bed 3, 203 bed 3, 201 beds 1 and 2 , 219 bed 2, 200 bed 3, 205 bed 3) in residents' rooms on the 200 hall were not working. Residents "E" and "D" stated that the call lights had not worked correctly for about the last one to two weeks. They stated that sometimes the light would turn on (light up) without either of them pushing the button. They stated that the staff had told them they did not know what was wrong with the call light system. During an interview on 9/1/10 at 9:30 a.m., the Administrator stated that the facility had recently had a problem with a call light on the 100 hall but, she was not aware of any problems with call lights on the 200 hall. She provided documentation on 8/19/10 that the facility had requested another service visit from their contractor for problems with the system in one room on 100 hall and a lot (of rooms) on the North side. According to that request, there had been a service visit on Monday (August16, 2010). Although the facility was aware of problems with the call light system, there was no evidence of continued monitoring of the call light system to determine its operational status. When the administrator contacted the Maintenance Director on 9/11/10 at 9:39 a.m., he confirmed that he had not performed any random checks of the call light system. At 10:20 a.m., the Administrator provided a list of the call lights on the 200 hall that had been checked by the Maintenance Supervisor. He identified two call lights that were not functioning properly. The Administrator reported that the Maintenance Director said that he had found… | 2014-03-01 | ||
| 10597 | 10597 | CORDELE HEALTH AND REHABILITATION | 115429 | 1106 NORTH 4TH STREET | CORDELE | GA | 31015 | 2010-09-01 | 514 | D | W2R511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, it was determined that the facility failed to ensure that licensed nurses documented administration of two medications on the August Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Findings include: Resident #9's physician had ordered 400 milligrams (mg) of [MEDICATION NAME] be administered twice daily through the gastrostomy tube. [MEDICATION NAME] was scheduled to be administered at 5:00 a.m. and 5:00 p.m. However, licensed nursing staff failed to document that the 5:00 p.m. dose of [MEDICATION NAME] had been administered on 8/27/10, 8/28/10, 8/29/10, 8/30/10 and 8/31/10. There was a 8/25/10 physician's orders [REDACTED]. However, licensed nursing staff failed to document that [MEDICATION NAME] had been administered on 8/27/10, 8/29/10 and 8/30/10. | 2014-03-01 | ||
| 10596 | 10596 | CORDELE HEALTH AND REHABILITATION | 115429 | 1106 NORTH 4TH STREET | CORDELE | GA | 31015 | 2010-09-01 | 253 | E | W2R511 | Based on observations, it was determined that the facility failed to repair chipped and/or broken shower tiles in two of two shower rooms, failed to repair a leaking sink in the floor pantry, failed to clean dust from an oscillating fan in one room, failed to maintain a clean microwave on station II, and failed to replace a light switch cover in one room, failed to maintain intact double doors on one hall from a review of both wings. Findings include: The following observations were made during the Initial Tour of the facility on 8/30/10 from 8:45 a.m. to 10:30 a.m. and during the General Observations Tour on 9/1/10 from 10:45 a.m. to 11:25 a.m.: 1. There was a dusty oscillating fan in room 105. 2. The light switch cover was missing in the bathroom of room 106. 3. Tere was a small trash can containing dirty gloves outside of the doors at the end of 200 hall. There was mold growing inside it. 4. There was dried food debris on the inside of a microwave on Station II. 5. Three shower stalls in the women's bath had chipped and/or broken tiles with dull edges. 6. One shower stall in the men's bath had chipped and/or broken tile. 7. The floor was stained around the base of the commode in the men's common bath. 8. The plumbing under the sink in the floor pantry was leaking. 9. It was observed on 8/31/10 at 12:40 p.m. that double doors at the end of North Hall had not been maintained. The bottom of of the North Hall egress double door was not flush with the floor which left an opening to the exterior of the building. Although the double doors met in the center of the door frame, a section at the center of each door had been gouged which resulted in a hole when the doors were closed. The hole provided an opening to the exterior of the building. See F469 example #8 for additional information about the doors at the end of North Hall. | 2014-03-01 | ||
| 10595 | 10595 | CORDELE HEALTH AND REHABILITATION | 115429 | 1106 NORTH 4TH STREET | CORDELE | GA | 31015 | 2010-09-01 | 469 | F | W2R511 | Based on observations and interviews with residents and staff, it was determined that the facility failed to maintain an effective pest control program so that the facility was free of flies in the dining rooms, and the 200 hallway. Findings include: 1. During the group interview held after lunch on 8/30/10 at 1:50 p.m., all four residents in attendance complained about flies in the dining room, residents' rooms and hallways of the facility. Resident "A" had a fly swatter with him/her at the meeting and several flies landed on his/her shirt during the meeting. Resident "U" stated that the flies were awful this year and pointed out two lights in the dining room that he/she stated were purchased by the facility to help get rid of the flies. One of those lights was turned on at that time but, the other one was unplugged. Several flies were seen in the room during the meeting. 2. On 8/30/10 at 12:50 p.m., several flies were observed in the large dining room while the residents were being served lunch. One fly was on a resident's head. One was crawling on the floor. Staff members, who were assisting residents with their meals, were swatting the flies away with their hands. 3. During an interview on 8/31/10 at 5:30 p.m., the Administrator stated that the bug lights were purchased to help get rid of flies. She said that she had been advised by the Pest control company that the lights were supposed to stay off until meal time so they would attract the flies during the meal times. However, it had been observed on 8/30/10 at 1:50 p.m. that one of the bug lights was on after the mid-day meal in the large dining room. However, on 8/31/10 at 8:25 a.m. and 12:20 p.m. during the meals, the bug light in the small dining room on the 200 hall had not been turned on by staff but, the two in the main dining room had been. At 12:40 p.m., two flies were observed in the large dining room. There were flies in the 200 hallway and outside of room 214. 5. During an interview on 9/1/10 at 10:45 a.m. resident "F" stated that he/she ate all m… | 2014-03-01 | ||
| 10594 | 10594 | CORDELE HEALTH AND REHABILITATION | 115429 | 1106 NORTH 4TH STREET | CORDELE | GA | 31015 | 2010-09-01 | 371 | D | W2R511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and record review, it was determined that the facility failed to dispose of 11 bottles of expired [MEDICATION NAME] enteral nutrition. Findings include: On 9/1/10 at 11:15 a.m., 11 bottles of [MEDICATION NAME] enteral nutrition were observed being stored in a cabinet in the floor pantry. They had an expiration date of 7/1/2010. During an interview on 9/1/10 at 11:45 a.m., the Director of Nursing stated that were not any residents receiving [MEDICATION NAME] at that time. She stated that she was not sure who was responsible for checking the expiration dates on supplements and enteral feedings. | 2014-03-01 | ||
| 10593 | 10593 | CORDELE HEALTH AND REHABILITATION | 115429 | 1106 NORTH 4TH STREET | CORDELE | GA | 31015 | 2010-09-01 | 225 | D | W2R511 | Based on record review, it was determined that the facility failed to thoroughly investigate the past histories of two of ten newly hired employees. Findings include: A review of ten (10) newly hired employees' files revealed that two did not contain evidence of the results of a criminal background check. 1. A certified nursing assistant began working at the nursing facility on 8/16/10 after transferring from another one. However, the facility failed to obtain a new criminal background check. The previous criminal background check results had been obtained on 10/4/05. 2. A certified nursing assistant was hired on 6/10/10. The facility originally requested a background check on 6/2/10. However, there was no evidence that the results were obtained until another request was made on 8/31/10. | 2014-03-01 | ||
| 10592 | 10592 | CORDELE HEALTH AND REHABILITATION | 115429 | 1106 NORTH 4TH STREET | CORDELE | GA | 31015 | 2010-09-01 | 323 | E | W2R511 | Based on observation and record review, it was determined that the facility failed to safely store hazardous chemicals to prevent residents' access in two of two common shower rooms(women's and men's). Findings include: During the General Observations Tour of the facility on 9/1/10 from 10:45 a.m. to 11:25 a.m., the following observations were made: 1. The Women's Shower was unlocked and unsupervised. Staff had not locked a cabinet in that shower which contained a spray bottle of Germicidal Cleaner. The bottle had the printed manufacturer's recommendation "to keep out of reach of children, may cause eye or skin irritation." There was also a container of Cavi Wipes with a cautionary label that it was harmful if absorbed through the skin and caused moderate eye irritation. 2. The Men's Shower room was unlocked and unsupervised. Staff had left a spray bottle of Germicidal Cleaner hanging on the handrail in one of the shower stalls with a manufacturer's recommendation to keep out of reach of children and may cause eye or skin irritation. | 2014-03-01 | ||
| 10591 | 10591 | CORDELE HEALTH AND REHABILITATION | 115429 | 1106 NORTH 4TH STREET | CORDELE | GA | 31015 | 2010-09-01 | 328 | E | W2R511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and record review, it was determined that the facility failed to ensure that oxygen tubing and nasal cannulas were appropriately stored when not in use for three residents (#12 and two randomly observed residents), that nebulizer masks and tubing were appropriately stored when not in use for four residents (#9 and three randomly observed residents), that the humidifier bottle was filled with water for one resident (#9), and that an oxygen cannister was appropriately secured for one randomly observed resident from four sampled residents and 13 total resident receiving respiratory treatment. Findings include: According to the facility's Resident Census and Conditions of Resident from (dated 8/30/10), 13 residents were receiving respiratory treatment. 1. During an observation of resident #9 on 8/30/10 at 11:15 a.m., his/her nebulizer mask and tubing had been inappropriately stored uncovered on top of the nebulizer compressor. Resident #9 received oxygen continuously at 2 liters per minute through a nasal cannula. It was observed on 8/30/10 at 11:15 a.m., 1:15 p.m. and 2:40 p.m., and on 8/31/10 at 9:00 a.m., 12:35 p.m., 1:30 p.m., and 3:15 p.m. that the humidifier bottle on the oxygen concentrator was empty. During an interview on 9/1/10 at 11:20 a.m., the Director of Nursing (DON) stated that the nurses were responsible for ensuring that there was water in the humidifier bottles on the oxygen concentrators. On 9/1/10 at 11:40 a.m., licensed nurse "BB" stated that water was not added to the humidifier bottles but, the bottles were changed out weekly. However, the facility's policy on Use of Oxygen instructed nursing staff that if a reusable humidifier was used, it should be emptied, rinsed, dried and refilled with sterile water daily. 2. The front panel of resident #12's oxygen concentrator was dusty . The oxygen tubing and nasal cannula were uncovered and draped over the night stand on 8/31/10 at 3:40 p.m. a… | 2014-03-01 | ||
| 10590 | 10590 | CORDELE HEALTH AND REHABILITATION | 115429 | 1106 NORTH 4TH STREET | CORDELE | GA | 31015 | 2010-09-01 | 164 | D | W2R511 | Based on observations and resident interviews, it was determined that the facility failed to provide privacy while bathing and assistance with dressing for two residents ("A" and "B") of five residents interviewed. Findings include: During the group interview on 8/30/10 at 1:50 p.m., two of the four residents in attendance complained that they did not like the nursing staff allowing other residents to be in the shower room while they were receiving care. On 8/31/10 at 10:20 a.m. and at 3:40 p.m., it was observed that the common shower room had a key pad lock on the outside of the door but, the door was not completely closed. Upon entering the shower room, there was a central area with a commode and sink, which was surrounded by three (3) shower stalls and one tub stall. Each of those stalls had privacy curtains to provide personal privacy for a resident while being bathed. During an interview on 8/31/10 at 10:20 a.m., Certified Nursing Assistant (CNA) " RR" stated each CNA baths assigned residents. "RR" said that the shower room door should be locked so, other residents could not come. He/she stated that residents were dressed in the central area of the shower room after they received a shower. It was observed at that time that there was not a means to ensure personal privacy in the central area where residents were dressed. During an interview on 9/1/10 at 11:00 a.m., the Administrator stated that the shower room door did not automatically lock when closed. She said that there was a "lock" button on the outside that had to be pushed before the door was locked. She said that several residents preferred to use the commodes in the common shower room rather than the bathrooms in their own rooms. Resident "A" stated on 8/30/10 at 1:50 p.m. that during his/her shower in the common shower room, the privacy curtain was pulled around the shower stall but the shower room door was not locked and several residents came into the room to use the toilet. The resident said that he/she felt uncomfortable with other residents com… | 2014-03-01 | ||
| 10589 | 10589 | CORDELE HEALTH AND REHABILITATION | 115429 | 1106 NORTH 4TH STREET | CORDELE | GA | 31015 | 2010-09-01 | 312 | D | W2R511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, it was determined that the facility failed to ensure that oral hygiene was performed as needed for one resident (#9), from a total sample of 16 residents. Findings include: Resident #9 had medical [DIAGNOSES REDACTED]. On the 6/9/10 significant change of status Minimum Data Set (MDS) assessment, licensed nursing staff coded resident #9 as having been dependent on staff for hygiene and bathing. Resident #9 only received nutrition (enteral formula) through a gastrostomy tube. It was observed on 8/30/10 at 11:15 a.m., 1:15 p.m., and 2:15 p.m. that nursing staff had not provided oral care and the resident had a heavy build-up of a thick, white substance on his/her lips. | 2014-03-01 | ||
| 10588 | 10588 | CORDELE HEALTH AND REHABILITATION | 115429 | 1106 NORTH 4TH STREET | CORDELE | GA | 31015 | 2010-09-01 | 309 | D | W2R511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to administer medication as ordered for one resident (#6) and failed to obtain a physician's orders [REDACTED].#8), from a total sample of 16 residents. Findings include: 1. Resident #8 had a physician's orders [REDACTED]. A review of the resident's June 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. However, review of the clinical record revealed that there was no evidence of a physician's orders [REDACTED]. During an interview on 8/31/10 at 3:30 p.m., licensed nurse "AA" confirmed that there was not a physician's orders [REDACTED]. Licensed nurse "AA" stated on 8/31/10, after surveyor inquiry, that she had clarified the order with the physician, who wanted it to be administered routinely. 2. Resident #6 had been receiving 3.5 milligrams (mg) of [MEDICATION NAME] daily since 7/23/10. On 7/29/10, the physician ordered 100 milligrams (mg) of [MEDICATION NAME] (an antibiotic) twice daily for ten days to treat a urinary tract infection. There was an 8/2/10 physician's orders [REDACTED]. PT and INR levels were obtained on 8/5/10. The results were available on 8/6/10. The resident's PT and INR levels were reported as having been abnormally high at 25.1 ( normal range 9.5 to 11.8 seconds) and 4.29 respectively. There was a handwritten physician's orders [REDACTED]. However, a review of the August 2010 MAR indicated [REDACTED]. Another PT and INR level was obtained on 8/8/10 with the results available on 8/8/10. The PT and INR levels had increased and were reported as having been critically high at 31.4 and 5.42 respectively. At that time, [MEDICATION NAME] was ordered to be held and then the other orders for reducing the dosage of [MEDICATION NAME] and obtaining PT/INR levels were followed. | 2014-03-01 | ||
| 10587 | 10587 | CORDELE HEALTH AND REHABILITATION | 115429 | 1106 NORTH 4TH STREET | CORDELE | GA | 31015 | 2010-09-01 | 241 | D | W2R511 | Based on observation, it was determined that the facility failed to provide care in a dignified manner for one resident (#9) from a total sample of 16 residents. Findings include: On the 6/9/10 significant change of status Minimum Data Set (MDS) assessment, licensed nursing staff coded resident #9 as being dependent on staff for bed mobility, dressing, personal hygiene and toileting. During the provision of incontinence care by CNA "MM" on 8/30/10 at 2:40 p.m., the resident's draw sheet and fitted sheet were observed to be wet with urine. After applying a clean brief, certified nursing assistant (CNA) "MM" did not remove or change those wet sheets. At that time, CNA "MM" stated that the hospice CNA was in the building and would be returning to give the resident a bed bath. However, it was observed that the resident laid on the wet sheets until at least one hour later, at 3:40 p.m., when the hospice CNA was bathing the resident and then changed the wet sheets. | 2014-03-01 | ||
| 10586 | 10586 | OXLEY PARK HEALTH AND REHABILITATION | 115387 | 181 OXLEY DRIVE | LYONS | GA | 30436 | 2009-10-22 | 323 | D | B8MH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and record review, it was determined that the facility failed to ensure that one resident (#11) of 13 residents dependent on staff for transfers was appropriately transferred from the wheelchair to the bed from a total sample of 18 residents. Findings include: Resident #11 had a [DIAGNOSES REDACTED]. His/her care plan did not include any interventions to address his/her need for staff assistance to transfer. On 10/20/09 at 1:25 p.m., during an observation of the resident being transferred from his/her wheelchair to the bed, two certified nursing assistants (CNAs) inappropriately lifted the resident under his/her arms and by the waistband of the resident's pants. | 2014-03-01 | ||
| 10585 | 10585 | MAGNOLIA MANOR OF COLUMBUS NURSING CENTER - EAST | 115124 | 2010 WARM SPRINGS RD | COLUMBUS | GA | 31904 | 2010-11-10 | 281 | D | Inf | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, staff interview, review of a facility nurse's written statement, and review of the Model Nurse Practice Act/Model Nursing Administrative Rules, the facility failed to ensure that services, regarding medication administration, were provided in accordance with professional standards of quality and a physician's orders [REDACTED]. Findings include: As specified in the Model Nurse Practice Act/Model Nursing Administrative Rules, Chapter Two - Standards of Nursing Practice, Part 2.3.2 (J), Standards Related to Licensed Practical/Vocational Nurse, the nurse will administer medications accurately. Record review for Resident #1 revealed a current November 2010 physician's orders [REDACTED]. However, observation of Resident #1 conducted on 11/09/2010 at 4:30 p.m. revealed two [MEDICATION NAME]es applied to the resident's back. One [MEDICATION NAME] was dated as having been applied on 11/08/2010 and was on the resident's right back shoulder area. The second patch had an illegible date of application and was on the resident's right mid-back. This was acknowledged by Nurse "AA" and the Director of Nursing (DON), both of whom were in attendance at the time of this observation. During an interview with the DON conducted on 11/09/2010 at 4:40 p.m., the DON acknowledged that only one [MEDICATION NAME] should have been applied to Resident #1. In a written statement dated 11/11/2010 provided by Nurse "BB", Nurse "BB" documented that on 11/08/2010, she had removed a [MEDICATION NAME] dated 11/05/2010 from the left chest of Resident #1, and had then applied a new [MEDICATION NAME]. The nurse further documented that during the application of the [MEDICATION NAME] on 11/08/2010, the resident had exhibited some agitation, and that during the process of providing the resident comfort, she did not recall taking the removed [MEDICATION NAME] off the bed and discarding it. The nurse then indicated in her statement that this… | 2014-03-01 | ||
| 10584 | 10584 | TOWER ROAD HEALTHCARE AND REHABILITATION CENTER | 115115 | 26 TOWER RD | MARIETTA | GA | 30060 | 2010-11-14 | 309 | D | K6XU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, it was determined that the facility failed to administer a medication, [MEDICATION NAME] (blood thinner) as ordered for one (1) resident #1 in a survey sample of six (6) residents. Findings include: A review of the 10/27/2010 physician's orders [REDACTED]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. During an interview with the Director of Nursing on 11/14/2010 at 1:00 p.m., it was confirmed that the medication was not administered on 10/27/2010. In addition, an interview and observation with the Director of Nursing at 2:00 p.m. revealed that the [MEDICATION NAME] was at the facility on 10/27/2010 and available to be administered. | 2014-03-01 | ||
| 10583 | 10583 | NEW LONDON HEALTH CENTER | 115771 | 2020 MCGEE ROAD | SNELLVILLE | GA | 30078 | 2009-09-24 | 323 | D | W1TL11 | Based on observation and staff interview, the facility failed to maintain an environment that remained free of accidents hazards as is possible. This was evidenced by the failure to ensure safe storage of drugs and therapeutic agents, to prevent access by cognitively impaired residents for one of five (1 of 5) medication carts. Findings include: Observation on 9/22/09 at 3:35 p.m. revealed that the medication cart on the A Hall was unlocked. All drawers (except the narcotic box) were able to be opened. No staff was in attendance, or in the vicinity. The Nurse's Station was approximately 50-60 feet away. Licensed Practical Nurse (LPN) "GG" was observed approaching the cart from the Nurse's Station. In an interview with LPN "GG" on 9/22/09 at 3:40 p.m. she acknowledged that the medication cart should be locked when leaving it unattended. | 2014-04-01 | ||
| 10582 | 10582 | NEW LONDON HEALTH CENTER | 115771 | 2020 MCGEE ROAD | SNELLVILLE | GA | 30078 | 2009-09-24 | 314 | D | W1TL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews, it was determined that for three (3) of the twenty-four (24) sampled residents, #1, #6 and #19, the facility failed to prevent pressure ulcers from forming for residents not previously having pressure ulcers and failed to treat pressure ulcers appropriately to promote healing and prevent new ulcers from forming. Findings include: Review of the clinical record for resident #1 revealed a Minimum Data Set ((MDS) dated [DATE] that indicated the resident had intact skin, with no breakdown. Section M5 of this document also indicated that staff was not using any protective or preventive skin care. However, review of the Master Care Plan revealed that the resident was assessed as being at risk for pressure ulcers. A progress note by the Nurse Practitioner and attending physician, dated 09/17/09 described a Stage II ulcer behind her left ear. Observation of this pressure ulcer on 09/22/09 at 2:15 a.m. revealed that the resident was wearing eye glasses and had plastic tubing around her ears for receiving supplemental oxygen. There was also a dressing in place behind her left ear. Interview with the Director of Nurses on 09/23/09 at 7:45 a.m. indicated that she was unaware of any preventive measures that had been put into place to prevent this pressure ulcer from forming. Record review for resident #6 revealed the resident a care plan dated 12/31/08 that indicated the resident had a potential for skin breakdown. A Nurse's Note dated 9/11/09 indicated the resident had received a skin shear to the right buttock. This was described as a Stage II pressure area measuring 0.2 centimeter in diameter. The Treatment Record for September 2009 described this Stage II wound on the right buttock as a skin shear. During an observation of the resident receiving incontinent care on 9/22/09 at 2:30 p.m., the Stage II pressure sore on the right buttock was not covered by a dressing, but the skin was intact. The re… | 2014-04-01 | ||
| 10581 | 10581 | NEW LONDON HEALTH CENTER | 115771 | 2020 MCGEE ROAD | SNELLVILLE | GA | 30078 | 2009-09-24 | 221 | D | W1TL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to apply a restraint as ordered for one (1) resident (#12) on a sample of twenty four (24) residents. Findings include: Review of the clinical record for resident #12 revealed a physician's orders [REDACTED]. Observation of this resident on 9/22/09 at 11:50 a.m. and 12:35 p.m. and 9/23/09 at 7:30 a.m. and 11:15 a.m. revealed the resident was in his wheelchair with a full lap table and wearing the left hand mitten. Interview with the Director of Nursing (DON) on 9/23/09 at 11:00 a.m. revealed the resident has the mitten because he continually touches his gastrostomy tube and pulled it out 7/16/09. She also stated he does wear an abdominal binder at all times in the wheelchair. There was no indication why the resident was also wearing the left hand mitten while in his wheelchair, since this device was ordered for use in the bed. The DON added at that time, that with the abdominal binder and a full lap tray the resident would have difficulty accessing the gastrostomy tube while in the wheelchair. She confirmed that the mitten should not be applied. | 2014-04-01 | ||
| 10580 | 10580 | NEW LONDON HEALTH CENTER | 115771 | 2020 MCGEE ROAD | SNELLVILLE | GA | 30078 | 2009-09-24 | 371 | F | W1TL11 | Based on observation, record review and staff interview the facility failed to store, prepare and serve food under sanitary conditions for all residents consuming food (total = 132). Findings include: Observation during initial tour of the kitchen on 9/22/09 at 9:35 a.m. revealed the wall around the stainless steel counter near the dishmachine was soiled with a black substance in the grout and on the wall and continued under the counter. This wall area also had a build up of substances that were dried and sticky. Three (3) used dishcloths were observed on the bottom shelf of a cart next to clean serving trays. Observation of the right reach-in cooler revealed two (2) fat-free milks with a use-by date of 9/20/09. The walk-in cooler had two (2) containers of buttermilk with use-by dates of 9/04/09 and 9/16/09. Also in this walk-in cooler were prepared ground sausage, pureed sausage and pureed eggs dated 9/23/09. Interview with the Dietary Manager (DM) at this time revealed these items were prepared 9/22/09 to be served for breakfast on 9/23/09. She stated these items were prepared ahead of time instead of on the day of service because staff often came in late in the mornings. Observation on 9/23/09 at 7:25 a.m. revealed dietary staff "AA" operating the three (3) compartment sink. She was washing and sanitizing items in full sinks of water. However, she was rinsing items under running water without submerging in a full sink of rinse water as required. Interview with the DM at this time revealed she agreed the correct procedure was not being followed. Observation at 9:50 a.m. revealed a bucket with several dishcloths immersed in water. The DM stated the facility used chlorine in the bucket as a sanitizer but she twice attempted to test the sanitizer level with the wrong chemical strips. When she used the correct chlorine test strip, chlorine did not register as present in the solution. Observation at 10:00 a.m. revealed packaged turkey in a pan of water on a preparation counter. The DM stated it was being thawed. Obs… | 2014-04-01 | ||
| 10579 | 10579 | NEW LONDON HEALTH CENTER | 115771 | 2020 MCGEE ROAD | SNELLVILLE | GA | 30078 | 2009-09-24 | 363 | E | W1TL11 | Based on observation, record review and staff interview the facility failed to follow menus for two (2) meals during the survey. This had the potential to affect most residents consuming food (total = 132). Findings include: Review of the menus provided by the facility revealed pancakes or waffles were to be served for breakfast 9/23/09. Observation of the breakfast meal revealed neither were served to residents, they received toast instead. During an interview with the Dietary Manager (DM) on 9/23/09 at 10:20 a.m. she stated the facility did not serve pancakes or waffles because one (1) or two (2) years ago residents complained the items were served cold and/or hard. Review of the four (4) week cycle menu provided by the facility revealed a variety of starch-based food items were listed contributing to the menu variety. These items included muffins, biscuits, french toast, pancakes, Danish, waffles and cinnamon rolls. Interview with the DM at 2:20 p.m. revealed the facility did not serve any of these products but always served toast instead. The menu also called for lettuce and tomato to be served as part of the dinner meal on 9/23/09. Interview with the DM on 9/23/09 at 8:30 a.m. and 10:30 a.m. revealed they were not serving lettuce but only diced tomatoes. She stated residents can choke on lettuce and that it was also a food waste issue. Review of the grievance file and resident council minutes since 10/2008 revealed no notation about pancakes, waffles or lettuce. | 2014-04-01 | ||
| 10578 | 10578 | NEW LONDON HEALTH CENTER | 115771 | 2020 MCGEE ROAD | SNELLVILLE | GA | 30078 | 2009-09-24 | 161 | E | W1TL11 | Based on record review and staff interview, the facility failed to maintain a surety bond of equal or greater value, than the balance in the residents' trust fund accounts. The facility managed seventeen (17) resident accounts. Findings include: Record review with the Nursing Home Administrator and Business Office Manager on 9/24/09 revealed that the residents' trust fund account balance was $11,478.00. Further review revealed bank statements with average ending balances ranging between 12,300.04 to 10,308.17 for the months of May, June, July, and August 2009. The facility's surety bond was in the amount of $10,000.00. In an interview with the Nursing Home Administrator on 9/24/09 at 8:30 a.m., he acknowledged that the surety bond amount was insufficient. | 2014-04-01 | ||
| 10577 | 10577 | PRUITTHEALTH - AUGUSTA HILLS | 115672 | 2122 CUMMING ROAD | AUGUSTA | GA | 30904 | 2010-09-23 | 463 | E | 5C5911 | Based on observation and staff interview the facility failed to ensure that all call lights located in resident rooms were functioning properly. Eight (8) of forty-five (45) call lights tested were found to be defective. Findings include: During the course of the standard survey investigative process, 45 call lights were tested to see if they were functional. The following resident rooms contained call lights that were not working: 107A; 201 bathroom; 313A; 313B; 313C; 315A; 315B; and 315C. This information was confirmed by Licensed Practical Nurse "JJ" at the time of observation on 9/21/10 at 1:50 p.m. | 2014-04-01 | ||
| 10576 | 10576 | PRUITTHEALTH - AUGUSTA HILLS | 115672 | 2122 CUMMING ROAD | AUGUSTA | GA | 30904 | 2010-09-23 | 248 | D | 5C5911 | Based on observation, record review and staff interview the facility failed to provide an activity program that met the needs of one (1) resident, #58, from a sample of twenty-seven (27) residents. Findings include: Record review of resident #58 revealed that she had experienced a recent mental and physical decline and spent her days in her room because she did not feel like attending group activities. The resident also ate all of her meals in her room. Observations of the resident during the course of a standard survey conducted on September 20-23, 2010 confirmed that the resident remained in her room during this period of time. There were no observed visits by the Activity Department staff to the resident during this time frame. There was also no Activity Calendar posted in the resident's room. A review of the resident's Care Plan dated 7/05/10 and updated on 9/15/10 revealed that the resident was at risk for social isolation and her Care Plan had interventions which included the provision of 1:1 in room visits by the activity staff as well as the provision of activity supplies for the resident. The interventions also provided for an Activity Calendar to be posted in the resident's room. An interview with the facility's Activity Director (AD) on 9/22/10 at 3:00 p.m. revealed that the resident was placed on an activity plan in July 2010 that provided her with 1:1 visits at least twice per week. These personal visits were to include reading, massages, nail care, aroma therapy and social visits. However, the AD confirmed in the interview that the resident had not been provided with an individualized program and that she had not been provided with any in-room activities as planned. | 2014-04-01 | ||
| 10575 | 10575 | PRUITTHEALTH - AUGUSTA HILLS | 115672 | 2122 CUMMING ROAD | AUGUSTA | GA | 30904 | 2010-09-23 | 372 | E | 5C5911 | Based on observation and staff interview the facility failed to ensure that trash and garbage was transported from the main kitchen to dumpsters located outside of the building in a manner to prevent potential contact with residents. Findings include: Observations on 9/21/10 at 10:45 a.m., 9/22/10 at 10:50 a.m., and 9/22/10 at 2:25 p.m. revealed that staff from the facility's kitchen were transporting trash and garbage in open receptacles that were not covered with lids. The observations further revealed that food scraps from resident meals and trash from the kitchen were in these open, unlidded garbage receptacles and that the garbage bags inside the receptacles were not tied to secure their contents. The garbage was transported from the kitchen through the main dining room, through the main facility lobby and then down the 200 hall corridor. The emptied garbage receptacles were returned from the trip to the dumpsters back to the kitchen via the same reverse route. This information was confirmed in an interview with the facility's Food Service Director (FSD) on 9/23/10 at 11:30 a.m. | 2014-04-01 | ||
| 10574 | 10574 | PRUITTHEALTH - AUGUSTA HILLS | 115672 | 2122 CUMMING ROAD | AUGUSTA | GA | 30904 | 2010-09-23 | 279 | D | 5C5911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to developed a care plan for one (1) resident (#164) on a sample of twenty seven (27) residents when the resident had a change in condition that required a defibrillator implant. Findings include. Review of the discharge summary dated 6/01/10 for resident #164 revealed the resident was discharged from the hospital to the nursing home with a [DIAGNOSES REDACTED]. Review of Nurses Notes dated 6/23/10 revealed the resident was sent to the hospital for a cardiac defibrillator implant. He returned to the facility on [DATE] with the defibrillator to his left chest with steri-strips intact. There was no evidence in the record that a care plan was developed related to the care and monitoring of the defibrillator implant. Interview with the Licensed Practical Nurse (LPN) Minimal Data Set Assessment Coordinator on 9/22/10 at 8:25 a.m. confirmed there was no care plan for the resident's defibrillator and interventions should have been put into place when the resident returned with the defibrillator implant. | 2014-04-01 | ||
| 10573 | 10573 | PRUITTHEALTH - AUGUSTA HILLS | 115672 | 2122 CUMMING ROAD | AUGUSTA | GA | 30904 | 2010-09-23 | 309 | D | 5C5911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff, and family interview the facility failed to ensure that physician orders [REDACTED]. Findings include: Review of a Nurses Note dated 5/30/10 documented that a resident's ("C") family member requested that the resident be given medications for constipation, a problem the resident had had since admission to the facility. Review of the Physician order [REDACTED]. On 5/31/10 there was a Physician order [REDACTED]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the Activities of Daily Living Care Plan sheets for July 2010 revealed there was no documentation that the resident had a bowel movement between 7/16/10 and 7/22/10 (6 days). On 7/22/10 a Physician order [REDACTED]. Review of the August 2010 physician's orders [REDACTED]. The August 2010 MAR documented the [MEDICATION NAME] was given as ordered. The September 2010 Physician order [REDACTED]. A physician's orders [REDACTED].[REDACTED] Interview with the resident's family member on 9/22/10 at 10:45 am revealed that when the facility stopped giving the resident the [MEDICATION NAME] and [MEDICATION NAME] in July 2010 and the resident became impacted, was having abdominal pain and nausea. She stated the staff only addressed this problem after she brought it to their attention. Interview with the DON on 9/22/10 at 11:10 am revealed she received the Physician order [REDACTED]. She confirmed that the [MEDICATION NAME] and the [MEDICATION NAME] were documented as being given in June 2010 even though there was an order to discontinue it on 5/31/10. She also revealed that after the [MEDICATION NAME] and [MEDICATION NAME] was reordered on [DATE] neither medication was carried over on the September 2010 Physician order [REDACTED]. | 2014-04-01 | ||
| 10572 | 10572 | PRUITTHEALTH - AUGUSTA HILLS | 115672 | 2122 CUMMING ROAD | AUGUSTA | GA | 30904 | 2010-09-23 | 282 | D | 5C5911 | Based on record review and staff interview the facility failed to ensure that a care plan related to constipation was followed for one (1) resident ("C") on a sample of twenty seven (27) residents. Findings include: Review of the care plan developed for a problem of constipation for resident "C" included interventions of assess the resident's bowel elimination pattern, monitor for signs and symptoms of constipation such as no bowel movement in three days and to administer laxatives as ordered. Review of the Activities of Daily Living Care Plan Sheet for July 2010 revealed that between 7/15/10 and 7/22/10 (6 days) there was no documentation that the resident was having bowels movements. Interview with the resident's family on 9/22/10 at 10:45 am revealed that the resident was having symptoms of nausea, spitting up as well as abdominal and rib pain during this time and the facility did nothing until they brought it to their attention. Interview with Director of Nursing (DON) on 9/23/10 at 8:55 am revealed that the care plan was not followed related to the resident's bowel elimination problem. Cross refer to F309 | 2014-04-01 | ||
| 10571 | 10571 | GOLDEN LIVINGCENTER - KENNESTONE | 115660 | 613 ROSELANE STREET | MARIETTA | GA | 30064 | 2010-12-13 | 203 | D | JYL811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, it was determined that before transfer/discharge, the facility failed to notify the resident and a family member/legal representative of the transfer/discharge, and of the required information, in writing for one (1) resident (#1) from a survey sample of six (6) residents. Findings include: Record review for Resident #1 revealed a 10/07/2010 physician's orders [REDACTED]. During a telephone interview conducted on 11/01/2010 at 11:30 a.m. with Staff Member "AA", this staff member stated that upon review after the resident's hospital transfer, it was determined that the facility could not meet the resident's needs and the decision was made to not readmit the resident. However, further record review revealed no evidence to indicate that the resident and the family member/legal representative were notified, in writing, of the transfer/discharge, the reasons for the transfer/discharge, the effective date of the transfer/discharge, the location to which the resident was transferred/discharged , a statement that the resident had the right to appeal the action to the State, and the name, address and telephone number of the State long term care ombudsman. During an interview with Administrative Staff "BB" conducted on 12/13/2010 at 9:45 a.m., this staff member acknowledged that a transfer/discharge notice letter had not been sent. | 2014-04-01 | ||
| 10570 | 10570 | PRUITTHEALTH - GREENVILLE | 115658 | 99 HILLHAVEN RD. | GREENVILLE | GA | 30222 | 2009-08-05 | 514 | E | DOSV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and record reviews, the facility failed to ensure that physician's progress notes were in the resident's medical record for ten (10) residents (#3, #4, #6, #7, #8, #9, #10, #15, #16, and #20) and that physician's orders [REDACTED]. Findings include: 1. Record reviews for residents #3,#4, #6, #7, #8, #9, #10, #15, #16, and #20 revealed missing physician's progress notes. Interview on 8/4/09 at 3:40 pm with the physician revealed that there has been a problem with progress notes missing from resident's medical records. The physician indicated that she brings her progress notes and facility staff is suppose to place the notes in the residents' records. She further indicated that she has had problems with missing progress notes since October 2008. Interview of 8/5/09 at 9:45 am with the Director of Health Services revealed that the physician's progress notes were missing from resident's medical records. She further revealed that the physician's visits at least once a week but there are no progress notes and that medical records staff are responsible for placing progress notes in the records. 2. Record review for resident # 1 revealed that a [MEDICATION NAME] order written on 7/26/09 by a nurse indicated an "increase" in the [MEDICATION NAME] dose to 100mgs. three times a day (t.i.d.). Further record review revealed that on 7/23/09 the [MEDICATION NAME] was ordered 100mgs every six hours (q6h), which is four times a day. The order on 7/26/09 did not reflect an "increase" Review of the July 2009 MAR for resident #1 revealed that [MEDICATION NAME] is written as " [MEDICATION NAME] 4mls (100mgs) per tube q6h t.i.d. with hours of administration as 9am, 3pm, and 9pm. Every six hours (q6h) is not the same as t.i.d. During post survey review of the June 2009 MAR for resident #1 revealed that [MEDICATION NAME] two (2) capsules via tube twice a day (b.i.d) had been marked through and [MEDICATION NAME] 125 mgs/5mls. suspension 4 ml… | 2014-04-01 | ||
| 10569 | 10569 | PRUITTHEALTH - GREENVILLE | 115658 | 99 HILLHAVEN RD. | GREENVILLE | GA | 30222 | 2009-08-05 | 333 | D | DOSV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and review of the Medication Adminisrtation Record (MAR) the facility failed to administer [MEDICATION NAME] according to physician's orders for one (1) resident (#1) on a sample of twenty one (21) residents. The findings include: Review of the clinical record for resident #1 revealed that on 7/23/09 the [MEDICATION NAME] was changed from 100 milligrams (mgs.) two (2) capsules twice a day (b.i.d.)to [MEDICATION NAME] 4mgs (100mgs) suspension per tube every six (6) hours (q6h). The resident has a history of [MEDICAL CONDITION] disorder according to the facility's admission history and physical. Review of the July 2009 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The July MAR indicated [REDACTED]. Further review of the July MAR indicated [REDACTED]. Further review of the medical record revealed a physician's order dated 7/26/09 to "increase [MEDICATION NAME] to 100mgs three times a day (t.i.d.). The July MAR indicated [REDACTED].i.d. with the times of administration as 9am, 3pm, and 9pm. The dates that for administration are 7/23/09 to 7/31/09. There is no evidence that the [MEDICATION NAME] was given on the following dates and times: 7/24 at 9am and 3pm; 7/26 at 9am; and 7/31 at 9am and 3pm. Record review revealed a nurses' note dated 8/3/09 that the physician's and responsible party were notified of the missed [MEDICATION NAME] dosages. The physician ordered a [MEDICATION NAME] level. The results of the [MEDICATION NAME] level was 2.5 ml, which was below the normal range of 10.0 - 20.0. The physician was notified of of this results and ordered the [MEDICATION NAME] be changed to 100mgs every am (Qam), and every pm (Qpm) and 200mgs at bedtime (Qhs). | 2014-04-01 | ||
| 10568 | 10568 | PRUITTHEALTH - GREENVILLE | 115658 | 99 HILLHAVEN RD. | GREENVILLE | GA | 30222 | 2009-08-05 | 226 | D | DOSV11 | Based on staff interviews, review of facility policy and records, the facility failed to ensure that two (2) Certified Nurses Assistants (CNA) of five (5) CNAs interviewed had received training on abuse prohibition. Findings include: Review of the facility's Abuse Policy for staff training indicated that training on abuse will be done during initial orientation for all new staff and volunteers. This will include oriented to the facility policy related to abuse prohibition including what constitutes abuse, what to do if they hear or see abuse, and the appropriate interventions to deal with aggressive and/or catatropic reactions of residents/patients,including burnout, stress management and conflict resolution. Interview on 8/4/09 at 3:30 pm with CNA "ZZ" revealed that when she was asked about what training she had received related to abuse and neglect, she indicated that she had not received any training at this facility. She further revealed that she had been employed for four (4) months. Interview on 8/4/09 at 3:35 pm with CNA "XX" revealed that she has not had any training regarding abuse and that she had not received any facility orientation. She was unaware of who in the facility was responsible for abuse prevention. She further revealed that she had been working for four (4) days. Interview on 8/4/09 at 4:15 pm with the Staff Development Coordinator revealed that she had been at the facility for three (3) weeks and had not conducted any inservices. She further revealed that the facility policy is to teach abuse training during orientation Interview on 8/5/09 at 8:30 am with the Director of Health Services revealed that the last three (3) employees hired and currently working had not had any orientation or abuse training. During review of abuse investigations conducted by the facility and reported to the state agency, revealed two (2) incidents of residents allegations of verbal abuse by CNAs | 2014-04-01 | ||
| 10567 | 10567 | PRUITTHEALTH - GREENVILLE | 115658 | 99 HILLHAVEN RD. | GREENVILLE | GA | 30222 | 2009-08-05 | 520 | E | DOSV11 | Based on staff interviews and review of facility quality assurance records, the facility failed to ensure that the performance improvement plan for missing physician's progress notes was effective for ten (10) residents (#3, #4, #6, #7, #8, #9, #10, #15, #16, and #20) from a sample of twenty-one (21) residents. Findings include: Record reviews for residents #3,#4, #6, #7, #8, #9, #10, #15, #16, and #20 revealed missing physician's progress notes. Interview on 8/4/09 at 3:40 pm with the physician revealed that there has been a problem with progress notes missing from resident's medical records. She further indicated that she has had problems with missing progress notes since October 2008. Interview of 8/5/09 at 9:45 am with the Director of Health Services revealed that the physician's progress notes were missing from resident's medical records. Review of the quality assurance improvement action plan revealed that the facility identified the problem with missing progress notes in February 2009. The plan revealed that physician's progress notes were discussed in the 3/20/09 and 6/29/09 meetings. Each meeting indicated that notes were still missing from medical records. There was no evidence that the approaches developed to resolve the missing progress notes have been effective. According to the plan the last approach was to involve corporate, with a target date of 8/30/09. | 2014-04-01 | ||
| 10566 | 10566 | PRUITTHEALTH - GREENVILLE | 115658 | 99 HILLHAVEN RD. | GREENVILLE | GA | 30222 | 2009-08-05 | 365 | D | DOSV11 | Based on observation, record review and staff interview the facility failed to provide the correct consistency diet to meet the needs of one (1) resident (#1) from a sample of twenty one (21) residents. The findings include: Review of the clinical record for resident #1 revealed that on June 24, 2009 the resident's diet was changed to mechanical soft. On June 25, 2009 this diet order was clarified to a Liberalized Diabetic, Mechanical Soft with nectar thick liquids. Observation of the resident's meal on 08/03/09 at 12:50 p.m. revealed the resident received a pureed diet with nectar thick liquids. Observation of the breakfast meal on 08/04/09 at 7:45 a.m. revealed the resident received a pureed diet with nectar thick liquids again. Interview with the Dietary Manager on 08/04/09 at 7:50 a.m. revealed the dietary department did not receive the diet change from the nursing department. | 2014-04-01 | ||
| 10565 | 10565 | PRUITTHEALTH - GREENVILLE | 115658 | 99 HILLHAVEN RD. | GREENVILLE | GA | 30222 | 2009-08-05 | 323 | D | DOSV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interview the facility failed to ensure that an intervention, clip alarm, to prevent falls was implemented for one (1) resident (#1) from a sample of twenty one (21) residents. The findings include: Observations of resident #1 conducted 08/03/09 at 10:55 a.m. and 12:50 p.m. revealed the resident had no clip alarm on the bed. Further observation on 08/04/09 at 7:55 a.m. revealed there was no alarm on the bed. A second observation on 8/04/09 at 10:30 a.m. revealed the resident was in bed and no clip alarm was on. Interview with Licensed Practical Nurse ( LPN) "BB" on 8/4/09 at 11:00 a.m. revealed an clip alarm was located and applied to the resident. Review of the clinical record for resident #1 revealed he was admitted [DATE]. Review of Nurse's Notes revealed he had three (3) falls since admission. These falls occurred on 06/13/09, 07/25/09 and 07/27/09 and were a results of the resident attempting to toilet himself. Following the 07/27/09 fall, the facility added an intervention of a bed clip alarm. Review of the care plan for resident #1 revealed he was care planned for the risk for falls on 05/09/09. On 7/27/09 the care plan was updated to include a clip alarm to bed. | 2014-04-01 | ||
| 10564 | 10564 | PRUITTHEALTH - GREENVILLE | 115658 | 99 HILLHAVEN RD. | GREENVILLE | GA | 30222 | 2009-08-05 | 371 | F | DOSV11 | Based on observations, record review and staff interview the facility failed to prepare food under sanitary conditions for all residents consuming food (facility census 89.) The findings include: Observation of the kitchen on 08/03/09 at 9:00 a.m. revealed the can opener blade contained a thick build-up of a dark, sticky substance. Review of the Daily and Weekly Cleaning Assignments revealed that washing and sanitizing of the can opener blade was not listed. Observation on 08/04/09 at 10:50 a.m. revealed multiple raw chicken pieces in a preparation sink under cold, running water. The water was running over the raw chicken and draining down the sink. Interview with a dietary staff member "AA" at this time revealed she did not know that raw meat must also be submerged in water for proper thawing by this method. Interview with the dietary manager on 8/4/09 at 2:35 p.m. revealed she also was not aware this requirement. | 2014-04-01 | ||
| 10563 | 10563 | PINEWOOD NURSING CENTER | 115607 | 433 NORTH MCGRIFF STREET | WHIGHAM | GA | 39897 | 2010-12-01 | 225 | D | YYPJ11 | Based on facility document review, it was determined that the facility had failed to report allegations of neglect and mistreatment to the State survey and certification agency for one (1) resident (#1) from a survey sample of five (5) residents. Findings include: A 10/29/2010 facility complaint form which referenced Resident #1 documented that Resident #1 alleged via an e-mail to facility staff, including the Director of Nursing, that on 10/23/2010 at approximately 4:50 a.m., a certified nursing assistant (CNA) on the 11:00 p.m. - 7:00 a.m. shift told the resident that if she had to provide care at that time, then she would not get the resident up in the morning. The resident also alleged that the CNA then "snatched the call light" and "snatched the pillows from underneath" the resident's legs. Review of the facility's investigation revealed that the facility did conduct an investigation into these allegations of neglect and mistreatment, but there was no evidence to indicate that the allegations had been reported to the State survey and certification agency. | 2014-04-01 | ||
| 10562 | 10562 | PINEWOOD NURSING CENTER | 115607 | 433 NORTH MCGRIFF STREET | WHIGHAM | GA | 39897 | 2010-12-01 | 312 | D | YYPJ11 | Based on observation, record review, and staff interview, it was determined that the facility failed to ensure the provision of the appropriate incontinence care for one (1) resident (#5) from a survey sample of five (5) residents. Findings include: Record review for Resident #5 revealed the resident's Care Plan of 10/26/2010 indicated that the resident was totally dependent on staff for all activities of daily living care, including incontinence care. During an observation of incontinence care for Resident #5 at 12:35 p.m. on 12/01/2010, two (2) certified nursing assistants (CNAs) initially cleaned the resident with a disposable blue pad that had been dampened with water. However, these CNAs failed to wash any portion of the resident's penis. It was observed that the resident had been incontinent of urine. Licensed Staff "AA" was in the room during this observation and acknowledged that this incontinence care was not performed appropriately. | 2014-04-01 | ||
| 10561 | 10561 | PINEWOOD NURSING CENTER | 115607 | 433 NORTH MCGRIFF STREET | WHIGHAM | GA | 39897 | 2010-12-01 | 253 | E | YYPJ11 | Based on observation, resident interview, and staff interview, it was determined that the facility had failed to maintain an orderly environment on one (1) hall (200 hall) of two (2) halls observed. The findings include: During interview with Resident "A" conducted on 12/01/2010 at 2:30 p.m., the resident stated that there were leaks in rooms 209, 208 and 207. Observations of rooms 210, 209, 208 and 207 on 12/01/2010 at 3:45 p.m. revealed the following: 1. In room 210, there was a stained, wet and bulging ceiling tile over the lavatory. 2. In room 209, there were two missing ceiling tiles over where the "A" bed should have been. The insulation in the ceiling was saturated and a dark substance was observed in the area around the wet insulation. There was a large bedspread on the floor under this area. 3. In room 208, there was a missing ceiling tile over the bedside table at the "A" bed. The ceiling tiles around this area were soaked and bulging. 4. In room 207, there were bulging and wet ceiling tiles at the fluorescent light at the foot of the "A" bed and in front of the closets. During an interview with the Assistant Maintenance Director, who had worked at the facility since August of 2009, he stated that there had been leaks on the 200 hall since he had been at the facility. Some of the leaks had been in rooms 207 and 212. He provided a current receipt, dated 11/17/10, for Lexel to fix the leaks in the rooms on the 200 hall. He stated that he had used such things as Lexel, Mastic and other caulking to try to repair the leaks in these rooms and on this hall, however, these measures had only fixed the leaks temporarily. | 2014-04-01 | ||
| 10560 | 10560 | RIVER TOWNE CENTER | 115566 | 5131 WARM SPRINGS RD | COLUMBUS | GA | 31909 | 2010-12-10 | 361 | K | WE6B11 | Based on review of facility records, review of resident medical records, observations, and staff interviews, the facility failed to ensure that menus for residents having physicians ' orders for ground consistency specified the amount and consistency of meat to be served, and failed to ensure that staff were knowledgeable about proper procedures for food preparation and service regarding food form, for five (5) residents (#s 2, 3, 4, 6 and 7), who had physicians ' orders for ground meat diets or house ground diets, of thirteen (13) sampled residents. This failure resulted in a high potential for serious harm for these five (5) sampled residents. Further, residents were identified at risk based on review of the Centers for Medicare and Medicaid Services Form 672, which denoted that sixty-five (65) residents required mechanically altered diets, either pureed or all-chopped food. According to review of the facility ' s Diet Listing, fifty-two (52) of these sixty-five (65) residents required ground meat and/or foods, thus placing all fifty-two (52) residents at potential risk for serious harm. It was therefore determined that an immediate and serious threat to resident health and safety existed as of 10/30/2010, and was removed on 12/09/2010, at which time a plan was implemented by the facility to remove the immediate jeopardy situation. Findings include: A review of the facility's Saturday Week #3 Fall-Winter Menus revealed that on October 30, 2010, the planned supper menu for residents receiving regular diets listed the meat being served as beef tips over noodles. For the ground diets, the meat was to be three ounces of ground beef tips. On December 7, 2010, the Tuesday Week #1 Fall-Winter Menus had a planned supper menu of homemade beef stew listed as the meat for regular diets. The menu for "ground" consistency read 6 ounces (soft veggies) and did not denote the amount nor the consistency of meat to be served. Interview with dietary staff "AA" on 12/8/10 at 4:35 p.m. revealed that she had prepared the evening mea… | 2014-04-01 | ||
| 10559 | 10559 | RIVER TOWNE CENTER | 115566 | 5131 WARM SPRINGS RD | COLUMBUS | GA | 31909 | 2010-12-10 | 365 | K | WE6B11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility records, resident medical records review, interviews with family, emergency medical technicians, and staff, it was determined the facility failed to provide food in a form that met the individual needs of six (6) sampled residents ("A", #2, #3, #4, #6 and #7) of 13 sampled residents. This failure resulted in serious harm (death) for Resident "A" and had a high potential for serious harm for the five sampled residents who had orders for ground meat diets or house ground diets that were reviewed. Additionally, further residents were identified at risk based on review of the Centers for Medicare and Medicaid Services (CMS), Form 672, that denoted 65 residents in the facility required mechanically altered diets, either pureed or all chopped food. Of these 65, according to review of the facility's Diet Listing, 52 residents required gound meat and/or foods, thus all 52 of these residents would be at potential risk for serious harm. It was determined that an immediate and serious threat to resident health and safety existed as of 10/30/10 and was removed on 12/09/10, at which time a plan was implemented by the facility to remove the immediate jeopardy situation. Findings include: A review of the facility's Saturday Week #3 Fall-Winter Menus revealed that on October 30, 2010, the planned supper menu for residents receiving regular diets listed the meat being served as beef tips over noodles. For the ground diets, the meat was to be three ounces of ground beef tips. On December 7, 2010, the Tuesday Week #1 Fall-Winter Menus had a planned supper menu of homemade beef stew listed as the meat for regular diets. The menu for "ground" consistency read 6 ounces (soft veggies) and did not denote the amount nor the consistency of meat to be served. The Registered Dietician stated during an interview on 12/10/10 at 3:00 p.m., that since 12/8/10, she had revised the menu for homemade beef stew, for ground diets, to read 6 ounces of … | 2014-04-01 | ||
| 10558 | 10558 | JONESBORO NURSING AND REHABILITATION CENTER | 115545 | 2650 HIGHWAY 138 SE | JONESBORO | GA | 30236 | 2009-07-22 | 469 | D | LY2811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interviews, the facility failed to ensure that one (1) resident ( "Z" ) from a sample of twenty-four (24) residents was free of pests. Findings include: Observation on 7/22/09 at 8:15 am revealed tiny insects crawling on resident "Z's " right hand and lower part of arm. Further observation revealed tiny insects crawling on the resident's bed on the right side rail and on the call light. Further observation at 8:30 am revealed tiny insects crawling on a bottle of baby powder on the bedside table near the resident's bed and the insects were crawling on the call light cord from the wall to the bed. During an interview with charge nurse "EE" on 7/20/09 at 8:30 am, revealed that the tiny insects were ants and that the ants were also on the bedside table. During an interview with resident "Z" on 7/20/09 at 9:00 am revealed that the resident had problems with ants before in the past, but has never been bitten. She further indicated that she has never had ants on her or in her bed before. Interview with maintenance staff "GG" on 7/22/09 at 9:35 am revealed that there had been no problens in this room with ants, however; ants had been a problem in resident room 128 in the past. A review of the pest management invoice dated 7/15/09 revealed resident room 128 was treated for [REDACTED]. Further interview with maintenance staff "GG" on 7/22/09 at 3:15 pm revealed that the Pest Control Company had determined that the ants in resident's "Z" room were coming in from the outside due to a crack in the wall near the air conditioner unit. | 2014-04-01 | ||
| 10557 | 10557 | JONESBORO NURSING AND REHABILITATION CENTER | 115545 | 2650 HIGHWAY 138 SE | JONESBORO | GA | 30236 | 2009-07-22 | 356 | B | LY2811 | Based on observations and review of the facility posted staffing data forms, the facility failed to post the daily census for three (3) days of the survey (7/20/09 through 7/22/09). Findings include: Observations of the staffing data forms posted on 7/20/09 through 7/22/09, at 1:00pm each day, revealed no resident census posted on the staffing data form. | 2014-04-01 | ||
| 10556 | 10556 | JONESBORO NURSING AND REHABILITATION CENTER | 115545 | 2650 HIGHWAY 138 SE | JONESBORO | GA | 30236 | 2009-07-22 | 315 | D | LY2811 | Based on a review of the Resident Census and Condition report, facility's policy/procedure for Bladder Retraining, Bowel and Bladder Elimination Pattern Assessment tool, resident and staff interviews, the facility failed to restore/maintain as much normal bladder function for one (1) resident ( "Y" ) from a sample of twenty four (24) residents. Findings include: During an interview with resident "Y" on 7/21/09 at 10:30 am, revealed that she was continent during the day but uses a brief at night. She further revealed that she occasionally has accidents if she does not get to the toilet fast enough. She indicated that the Certified Nursing Assistants ( CNAs) check and change her when she wears the briefs at night. During a review of the admission MDS ( Minimum Data Set ) assessment for resident "Y" dated 8/20/08, and quarterly assessments dated 1/16/09 and 7/1/09 revealed the resident was assessed as being continent of bladder but required extensive assistance with transfers. Record review revealed a Bladder Elimination Assessment form dated 3/7/08 through 3/13/08, which was to determine the resident's bladder function/toileting schedule, was incomplete. A review of the facility policy/procedure for Bladder Independence/Retraining that was in effect since 11/03 revealed the following criteria: Assess the resident for factors that would create difficulty for the resident to toilet safely. Establish interventions to meet individual resident's goals. Maintain a voiding schedule that is based on the resident's voiding assessment Further record review revealed the facility had failed to follow their policy/procedure to assess/maintain this residents' bladder function. Interview with the Director of Nursing (DON) on 7/22/09 at 11:15am revealed that the facility had continued to use a three (3) day voiding and bowel assessment for residents on admission. She further revealed that the last assessment for a resident for a bowel and bladder program was October 2008. There are no residents currently on a Bowel and Bladder Ret… | 2014-04-01 |
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CREATE TABLE [cms_GA] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );