Piedmont Gardens Health Facility

Based on observation, interview and record review, the facility staff did not have comprehensive care plan for bed alarms and chair alarm as fall prevention for 3 out of 8 sampled residents(Resident 36, 55 and 44.) The failure to not care plan interventions for bed alarm use under fall risk for Resident 36, 55 and 44 has the potential to not provide direct or limited staff supervision for resisdents and also to not accurately monitor, provide care, and reassess the effectiveness of the bed alarms. Findings: During an observation on 1/27/25 at 10:15 a.m. in Resident 44's room, Resident 44 was had a bed alarm strapped to the siderail of her bed while she was asleep in bed. During an observation on 1/27/25 at 10:27 a.m., in Resident 55's room, Resident 55 was up in a wheelchair with family husband and daughter visiting at her bedside. Resident 55 had a white portable position alarm on her wheelchair and a green portable bed alarm strapped to the siderail of Resident 55's bed. During an observation and an interview with Resident 36 on 1/27/25 at 10:43 a.m. in Resident 36's room,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation ,interview record review, facility staff including Certified Nursing Assistant (CNA), Licensed Nurses (LNs), and Maintenance Staff did not perform hand hygiene while providing care to one of five sampled residents (Resident 42) when : 1.CNA 3 did not perform hand hygiene before and after putting in hearing aides in Resident 42 's ears and before donning gloves for incontinence care. 2.LNs did not sanitize/disinfect glucometer and flat surfaces to keep medication tray during medication administration. This failure placed all residents at risk for spread of in infection. 1. Findings: During an observation on 01/29/25 at 09:45 a.m. without performing hand hygiene, CNA 3 entered Resident 42's room, placed Resident 42's hearing aid in both ears with bare hands, without performing hand hygiene, CNA 3 donned gloves and provided incontinence care to Resident 42. During an interview on 01/29/25 at 12:07 p.m. CNA 3 stated hand hygiene includes gel in, gel out and hand washing with soap and water when hands or gloves are visible soiled. CNA 3 stated should have completed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review facility did not promptly investigate and act upon complaints of one of one sampled resident's (Resident 11) missing personal belongings (sweatpants). This failure resulted in the Resident 11 feeling angry. Findings: During a record review of Resident 11's admission record, the admission record indicated, Resident 11 was admitted to the facility in August 2024 and family representative (FR1) was the responsible party. During record review of Resident 11's Inventory of Personal Effects, dated 08/20/24,the record indicated two pair of sweatpants were listed as items acquired. During an interview on 01/28/25 at 09:40 a.m. FR1 stated, Resident 11 had lost around two- three sweatpants over time, since admission. FR1 stated he had made one or two Certified nursing assistants (CNA) aware of missing items at the time items went missing. During an observation on 01/28/25 at 10:04 a.m. FR1 gave CNA1 a verbal description of two missing sweatpants. During an interview on 01/30/25 at 09:31 a.m. CNA1 stated she told the SSD about Resident 11's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, for one of five (Resident 259) sampled residents reviewed for unnecessary medications, the facility failed to provide treatment and care in accordance with professional standards of practice and the comprehensive care plan when the physician was not notified as ordered when Resident 259's blood sugar level exceeded 400 milligrams per deciliter (mg/dL). This failure increased the risk for Resident 259 of developing complications related to severely elevated blood glucose levels, like diabetic ketoacidosis (life-threatening complication of diabetes when the build-up of acids in the body occurs when the blood sugar is too high for too long) or coma. Findings: Review of Resident 259's Face Sheet indicated Resident 259 was admitted to the facility with diagnoses that included diabetes mellitus with hyperglycemia (condition of uncontrolled, elevated blood glucose levels). Review of Resident 259's Physician's Orders dated 7/2/22 indicated to administer insulin (treats diabetes) lispro per sliding scale ( insulin dosage varies based on blood glucose…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interviews, and record review, the facility failed to follow proper sanitation and food storage practices when: - The High temperature dishwasher was not within the required temperature range - Kitchen floor tiles had brownish residual discoloration, - Two food steamers had brownish food debris on the bottom shelf and around the steamer areas - Bowl of lettuce, bowl of tomatoes in refrigerator were not labeled or dated - Two opened milk cartons in the walk in refrigerator were not label or dated - Bowl of sliced ham in the refrigerator had use by date 11/10/22 -Two food mixers had brownish discoloration and debris around the edges - Plate covers were faded and discolored - Three compartment sink air gap drain area had yellow residue - Ice machine cover had debris and crumbs - Ice machine air-gap drain area with yellowish residual - [NAME] trays with thick blackish brown crusts around the edges - Double door panel to the kitchen/dumpster area with black discoloration on the surface These deficient practices had the potential to result in foodborne illness.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, for one of two sampled residents (Resident 2), the facility failed to provide devices to ensure Resident 2's activities of daily living (ADL) did not diminish when Resident 2 was not provided with an assistive device to stay upright during meals. This failure resulted in Resident 2's inability to feed self independently and had the potential to result in decreased oral intake. Findings: Review of Resident 2's Face Sheet indicated Resident 2 had been known to the facility since 1/20/21 with diagnoses that included acute transverse demyelinating disease (inflammation of both sides of the spinal cord) of the central nervous system, spinal stenosis (narrowing of the spinal canal which then puts pressure on the spinal cord) of the cervical (neck) region, and need for assistance with personal care. Review of Resident 2's comprehensive Minimum Data Set (assessment tool used to direct resident care) assessment dated [DATE] indicated Resident 2 required staff…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews and record review, the facility failed to ensure the Consultant Pharmacist's (CP) monthly Medication Regimen Review (MRR) reported a medication irregularity for two (Residents 18 and 27) sampled residents. For Resident 18, CP did not address the duration for the administration of Macrobid (antibiotic medication) for the prevention of Urinary Tract Infection (UTI). For Resident 27, the duration of Keflex (antibiotic) for UTI was not identiied for more than one year. These deficient practices had the potential for residents to receive unnecessary drugs and future antibiotic resistant infections due to prolong use Findings: Review of the physician order dated 8/16/22 indicated Resident 18 was to receive Macrobid 100 mg (milligram) capsule every morning for UTI prophylaxis, indefinite. Review of Resident 18's Medication Administration Record (MAR) for October 1 through November 16, 2022, indicated Resident 18 was administered Macrobid 100 mg capsule by mouth every morning as ordered by the physician. During an interview on 11/17/22 at 8:08 a.m., the Director of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure appropriate use of antibiotic (medication for infection) for one of five residents reviewed (Resident 27) when they did not monitor appropriate use and improved outcomes. This failure had the potential for Resident 27 to take unnecessary antibiotics which could lead to antibiotic resistance. Findings: During a concurrent interview and record review, on 11/16/22 at 10:43 a.m., with the Infection Preventionist (IP), Resident 27's Physician Order Sheet (POS), dated November 2022 was reviewed. The POS indicated an order start date of 06/28/21, for Keflex (an antibiotic), indicated for urinary tract infection (UTI) prophylaxis (action taken to prevent disease). IP stated, there was no documentation on the POS dated November 2022 that indicated Resident 27's Keflex had a stop date. During an interview and concurrent record review, on 11/16/22 at 10:43 a.m., IP stated she could only find documentation that their antibiotic stewardship for Resident 27 was done in February, May and November of 2022. IP stated she could not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure drugs used in the medication room were not expired when one Ekit (An emergency container with equipment, supplies, and medications needed to provide care and manage life-threatening conditions) had expired medications in the refrigerator. This deficient practice had the potential to affect the potency and safety of the medication that could have harmful effects for all 70 residents in the facility. Findings: During an observation of the third floor medication room, on 04/10/19 at 12:55 P.M., an Ekit inside the medication's refrigerator included three tablets of lorazepam (antianxiety) 2 mg/ml (milligram/milliliter) that expired on 12/18 (December 2018). During an interview with the Registered Nurse 1 (RN 1) on 04/10/19 at 12:55 P.M., RN 1 confirmed the expired Ekit and stated the expired medication should not be stored in the medication room and they (staff) forgot to return the Ekit to the pharmacy. During a review of the policy and procedure, DISPOSAL OF MEDICATIONS dated 2007 indicated: . 8.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to update the plan of care for two of two sampled residents (Residents 47 and 62). Resident 47's hearing aids were missing and Resident 62 had untreated pain with movement. These failures resulted in a lack of comprehensive care plans for hearing and pain management that did not meet resident care needs. Findings: 1. Record review of the admission Record showed the facility admitted Resident 47 on 2/8/19. Record review of Resident 47's plan of care dated 1/23/19 showed, The resident has a communication problem r/t (related to) hearing deficit .Hearing Aid provided .hearing aids are kept with the nurses cart and given to resident each morning. In an interview on 4/8/19 at 10:34 a.m., Resident 47 stated she has difficulty hearing and wanted to know where her hearing aids were located. In a concurrent interview, Registered Nurse 1 (RN 1) stated Patient 47's hearing aids were lost during the time she was in and out of the hospital and were not stored in the medication cart. There was no updated care plan and interventions for the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility did not manage the pain for one (Resident 62) of two sampled residents in a timely manner. Resident 62 complained of pain when staff turned him in bed and during assistance with activities of daily living (or ADLs: bathing, toileting, feeding). This failure resulted in Resident 62 experiencing unnecessary pain and discomfort. Findings: Record review of theadmission Record showed the facility admitted Resident 62 on 3/9/19. The diagnoses included muscle wasting and atrophy (gradual deterioration). Record review of the Minimum Data Set - Resident Assessment and Care Screening, dated 3/16/19, showed Resident 62 had clear speech, understood what others said to him, and was able to express his ideas and wants. In an interview on 4/8/19 at 10:42 a.m., Resident 62 stated he had a significant amount of pain in his shoulders when staff assisted him with his ADLs and turning in bed. In an interview on 4/9/19 at 2:30 p.m., the Physical Therapist 1 (PT 1) stated Resident 62 reported to him that he had pain in his shoulders when…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.