Douglasville Center for Nursing and Healing LLC

Based on record review, staff interviews, and review of the facility's policy titled, Abuse Prevention, the facility failed to ensure that the hiring of staff was proceeded by a completed background check to ensure that individuals who have been hired have not been found guilty of abuse, neglect, exploitation, misappropriation of property or mistreatment in a court of law. Specifically, the Dietary Manager (DM) was allowed to continue working at the facility after two unsatisfactory criminal background checks. Findings include: Review of the facility's policy titled Abuse Prevention with a revised date January 2025 documented under Policy: The facility is committed to protecting the residents from abuse by anyone including but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individuals. Under the section A, Steps to Prevent, Detect and Report: Screening . 3. The facility will pre-screen all…

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 staff interviews, record review, and review of the facility policy titled, Abuse Prevention, the facility failed to report injuries of unknown origin to the State Survey Agency (SSA) within the required timeframe for one resident (R) (R512) reviewed for abuse and neglect. The deficient practice had the potential for future unreported injuries of unknown origin, with the potential to affect residents' quality of life. Findings include: Review of the facility policy titled Abuse Prevention revised January 2025 revealed under Policy: The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual. Alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after…

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 staff interviews, record review, and a review of the facility policy titled, PASRR (Preadmission Screening and Resident Review) Screening for Mental Disorder or Intellectual Disability, the facility failed to submit a PASARR Level II for one of two residents (R) (R153) reviewed for a mental illness diagnosis. This deficient practice had the potential to affect the appropriate level of care and services provided for R153. Findings include: A review of the facility policy titled PASRR Screening for Mental Disorder or Intellectual Disability dated July 2024, revealed the Policy stated, It I the policy of the Facility for each resident to be screened for Mental Disorder (MD) as defined or Intellectual Disability (ID) prior to admission and the individuals identified with MD or ID are evaluated by the State Mental Health Authority and receive care with services appropriate to their need. Referring all Level II with new MD, ID, or related conditions a review upon a significant change in status assessment. A…

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 observations, staff interviews, record review, and review of the facility policy titled, Oxygen Therapy, the facility failed to deliver oxygen (O2) per physician order for one of 37 residents (R) (R76) receiving O2 therapy. The deficient practices had the potential to cause respiratory distress. Findings include: Review of the facility policy titled Oxygen Therapy revised 8/14 revealed under Policy: Oxygen (O2) is administered to promote adequate oxygenation and provide relief of symptoms of respiratory distress. Under Procedure: Oxygen therapy is to be provided under the direction of a written physician's order. A Physician's Order for O2 therapy is to contain liter flow per minute via mask or cannula/timeframe. Review of the electronic medical record (EMR) for R76 revealed she admitted to the facility with diagnoses including chronic obstructive pulmonary disease (COPD), cough, and pleural effusion Review of the Physician Orders for R76 dated 10/18/2024 revealed an order for continuous humidified Oxygen 2-4 L (liters) via NC (nasal canula) Observation on 6/23/2025 at 2:12…

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 record review, staff interviews, and review of the facility's policy titled, Abuse Prevention, the facility administration failed to provide oversight to ensure one employee was free from adverse action on the criminal background check while working in the facility. Findings include: Review of the facility's policy titled Abuse Prevention with a revised date January 2025 documented under Policy: The facility is committed to protecting the residents from abuse by anyone including but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individuals. Under Procedure: A. Steps to Prevent, Detect and Report: Screening .3. The facility will pre-screen all potential new employees, volunteers, and residents for a history of abusive behavior. Review of the Georgia Background Checks (G-CHECKS) dated 11/21/2022 and 2/11/2025 documented as unsatisfactory for the Dietary Manager (DM). During an interview on…

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 observations, staff interviews, record review, and review of the facility's policy titled Telephone Orders, the facility failed to ensure accurate and complete medical records were maintained for one of three sampled residents (R) (R4). Findings include:Review of the facility's policy titled Telephone order updated 7/2025, revealed the Policy section stated, Orders received via telephone from a physician must be entered into the electronic software and co-signed by physician within the required time. The Procedure section included, 1. Whenever telephone orders are received from a physician, the order is to be entered into the electronic medical record and indicated as a telephone order.5. The telephone will be signed within the required time electronically or printed out for physicians who do not utilize electronic signatures. Post obtaining the MD signature, the order will be scanned into the electronic medical record following the active order of the electronic medical record guide (A.14d ). 6. A paper copy telephone order will be utilized if the electronic software is…

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 observations, staff interviews, record review, and review of the manufacturer's instructional sheet titled, How to clean and disinfect your Blood Glucose Meter, the facility failed to ensure proper cleaning technique for a glucometer during routine fasting blood sugar checks on one resident (R) (R44). The deficient practice had the potential to put residents at risk for a possible bloodborne pathogen. Findings include: Review of the Manufacturers' recommendation for the Assure Platinum blood glucose monitoring system on page 47 on cleaning and disinfecting guidelines revealed: Critical item-glucometer. Healthcare professionals should wear gloves when cleaning the Assure Platinum meter. Wash hands after taking off gloves. Contact with blood presents a potential infection risk. We suggest cleaning and disinfecting the meter between patient use. Cleaning and disinfecting can be completed by using a commercially available EPA Environmental Protection Agency)-registered disinfectant, detergent or germicide wipe. Many wipes act as both cleaner and disinfectant, though if blood is…

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 record review, staff interview, and review of the facility policy titled, Care Plans, the facility failed to include seizure medication in the care plan for one of nine sampled residents (R) (R1) reviewed. The deficient practice had the potential for R1 not to receive treatment and/or care according to their needs. Findings include: Review of the facility policy titled Care Plans revealed under Policy: Each resident will have a plan of care to identify problems, needs and strengths that will identify how the team will provide care. Review of the Medication Administration Record (MAR) form dated February 2025 indicated a medication order for carbamazepine suspension 100 mg (milligrams)/5 ml (milliliters). Give 10 ml via Peg-Tube (feeding tube in abdomen) every 12 hours related to Other Seizures - start date 01/06/2025 2100-D/C (discontinuation) date- 02/07/2025. Further review indicated an order for carbamazepine oral suspension 100 mg/5ml (carbamazepine). Give 10 ml via Peg-Tube every 12 hours for prophylaxis (preventative) relating to other Seizures. Start date 02/19/2025.…

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 complainant, family member and staff interviews, record review, and review of the facility policy titled, Prescriber Medication Orders, the facility failed to transfer a medication order and failed to give the medication as ordered for one of nine sampled residents (R) (R1). The deficient practice caused R1 not to receive ordered seizure medication. Findings include: Review of the facility policy titled Prescribed Medication Orders indicated under Procedure: . 2. A. Documentation: Each medication order is documented in the resident's medical record with the date, time, and signature of the person receiving the order. Review of the medical diagnosis for R1 indicated diagnoses but not limited to epilepsy, unspecified not intractable without status epilepticus (2/22/2025), iron deficiency anemia (2/22/2025), other seizures, unspecified, urinary tract infection, site unspecified (2/29/2025), chronic respiratory failure with hypercapnia (12/20/2024). Review of Nurses Note dated 2/14/2025 at 10:32:00 am indicated resident (R1) presents with HR of 140 BP (blood pressure) 140/68 T…

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 observations, record reviews, and interviews, the facility failed to provide services with reasonable accommodation of needs for one of 28 sampled residents (R) (R6) related to scheduled appointments. Findings included: 1. A review of R6's undated admission Record revealed R6 was admitted to the facility with diagnoses including but not limited to chronic obstructive pulmonary disease (COPD). A review of R6's quarterly Minimum Data Set (MDS) dated [DATE] revealed R6 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS further revealed R6 was dependent on staff for toileting and chair/bed-to-chair transfers. An observation and interview on 10/7/2024 at 12:40 pm with R6 in her room revealed the resident was in bed and a large personal wheelchair was inside the room. R6 stated that she missed her appointment last week with her pulmonologist (lung doctor) because her wheelchair did not fit inside the transportation van. R6 further stated that there was a…

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 observations, interviews, and record reviews, the facility failed to provide toileting assistance and assessment and treatment of a bleeding right leg to one of three sampled residents (R) (R7). Findings included: A review of the undated facility's policy and procedure titled, Subject: Abuse Prevention, indicated: Policy: The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual. Definitions: . f) Neglect: A failure of the facility, its employees, or service providers to provide goods and services necessary to avoid physical harm, mental anguish, emotional distress, or pain . IDENTIFICATION: . 2. The Executive Director and Director of Nursing Services must be promptly notified of suspected abuse or incidents of abuse. If such…

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 observations, resident and staff interviews, record review, and review of the facility policy titled Abuse Prevention, the facility failed to ensure that an allegation of sexual abuse was thoroughly investigated to rule out abuse for two of 28 sampled residents (R) (R11 and R12). Findings included: A review of the facility policy titled Abuse Prevention dated October 2022 included definitions of different types of abuse. The policy defined, Sexual Abuse: This included, but is not limited to sexual harassment, sexual coercion or sexual assault, or non-consensual sexual contact of any type with a resident. The policy also indicated the facility would initiate an investigation at the time of any finding of potential abuse or neglect allegation to determine cause and effect and provide protection to any alleged victims to prevent harm during the investigation. A review of R11's electronic medical record (EMR) revealed they were admitted to the facility with multiple diagnoses, one of which included…

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 record review, and resident and staff interviews, the facility failed to ensure that the resident environment remained free of accident hazards for one of four residents (R) (R16) related to receiving adequate supervision and assistance devices to prevent accidents. Findings included: A review of the facility's undated policy titled INVACARE TOTAL LIFT noted the Invacare Total Lift is to be used for total lifts and/or to obtain a resident's weight from bed to chair, chair to bed, or from the floor. Maintain contact with the resident in order to guide or steady the resident during lift, as necessary. A review of the Electronic Medical Record (EMR) revealed that R16 was admitted on [DATE] and re-admitted on [DATE] with diagnoses including bipolar disorder, current episode mixed, mild, unspecified psychosis not due to a substance or known physiological condition, type two (2) diabetes mellitus with hyperglycemia, other specified disorders of the skin and subcutaneous tissue, and unspecified open wound, and…

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 observations, staff interviews, and record review, the facility failed to maintain a clean, comfortable, homelike environment as evidenced by dirty PTAC (packaged terminal air conditioner) filters and broken slats, loose call light panels, and oversized ceiling light fixtures which covered or partially covered the return air vents in six of 141 occupied resident rooms (TC101, TC104, W31, W33, W34, and W36). Findings include: Review of the electronic system for maintenance and repair requests and tracking, instructions for HVAC [heating, ventilation, air conditioning]: Through-Wall Units: Clean air filters, #2. Remove air filter and inspect for cleanliness. If filter is dirty, either wash or replace depending on type of filter. If clean, reinstall filter. #6. At a minimum, air filters are to be replaced or thoroughly cleaned depending on type of filter every three months. Observation of resident rooms beginning on 2/7/2024 at 3:00 pm revealed dusty PTAC filters in rooms TC101, TC104, W31(+ broken slats), and W33. In addition, room W32 contained a loose emergency call light…

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 3. Review of R647's quarterly MDS dated [DATE] revealed section I (Active Diagnosis): chronic respiratory failure, chronic obstructive pulmonary disease (COPD), obstructive sleep apnea, shortness of breath (SOB), section O (Special Treatments, Procedures, Programs): receives oxygen therapy. Review of the care plan for R647 dated 6/9/2021 revealed a Focus of the resident uses oxygen/nebulizer for COPD. The Goal was that R647 will have the effectiveness of oxygen/nebulizers through the next review on 7/21/2023. Monitor for signs and symptoms of respiratory distress, and monitor vital signs as needed or according to the facility's policy. A review of the physician's orders for R647 revealed an order dated 11/3/2023 for O2 at 2 LPM via NC. Observation on 2/6/2024 at 12:39 pm revealed R647's O2 was set at 5 LPM. Observation on 2/7/2024 at 12:00 pm revealed R647's O2 was set at 5 LPM on the concentrator's flow meter with no humidifier. Interview on 2/8/2024 at 10:40 am with LPN HH, she verified R647's O2 flowmeter was…

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 observations, staff interviews, and record review, the facility failed to maintain dignity by ensuring a urinary catheter dignity bag was provided for two of 45 sampled residents (R) (R654 and R657). This failure had the potential to diminish the resident's quality of life in an environment that promotes the maintenance or enhancement of each resident's quality of life. Findings include: R657 was admitted to the facility with diagnoses that included but not limited to acute kidney failure. Review of R657's electronic medical record (EMR) revealed the Minimum Data Set (MDS) assessment was not yet completed due to the resident's recent admission date of 2/5/2024. Review of the physician's orders for R567 revealed an order dated 2/6/2024 for an indwelling catheter for neurogenic bladder. Observation on 2/6/2024 at 1:57 pm of R657 revealed an indwelling catheter bag on the side of the bed nearest the door without a dignity bag to cover it. Observation on 2/7/2024 at 1:15 pm of R657 revealed an indwelling catheter bag was visible from the hallway when the door was opened, and…

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 observations, resident and staff interviews, record review, and review of the facility's policy titled, Comprehensive Person-Centered Care Plans, the facility failed to develop and implement a care plan for two of 45 Residents (R) (R82 and R126). Specifically, R82 had no care plan for psychotropic medication and R126 had no care plan for Hospice care or for oxygen (O2). Findings include: Review of the facility's policy titled Comprehensive Person-Centered Care Plans documented under Procedure 5. For each problem, need, or strength, a resident-centered goal is developed. Goals should be measurable (i.e. walk from nurses' station to room by (date). R82 was admitted with diagnoses that included but not limited to depression and anxiety. Review of R82's care plan revealed there was no care plan in place for use of psychotropic medication. Interview on 2/8/2024 at 11:14 am with the MDS Coordinator regarding a care plan for R82 on use of psychotropic medication, she acknowledged that there was no care plan developed for use of psychotropic medication for R82. When asked what…

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 record review, observations, staff interviews, and the undated facility's policies titled, Controlled Medications Administrations and the undated Medication Administration General Guidelines revealed two of 56 sampled residents (R) (R8 and R7) medication was not administered timely. Findings included: A review of the undated facility's policy titled, Controlled Medications Administrations revealed When administering controlled medication, the authorized personnel record the administration on the MAR (medical administration record) eMAR (electronic medical administration record) and enters all of the following information on the Controlled Drug Record: a. Date and time of administration b. Amount administered c. Signature of the person preparing the dose, and d. Quantity reconciled. A review of the undated facility's policy titled Medication Administration General Guidelines revealed Medications are administered within the identified block of time per facility defined parameters. One hour before and one…

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 policy and record review, observations and resident and staff interview the facility failed to follow infection control processes and procedures to prevent the spread of infections and contamination on four of five units (300 Unit, Central Unit, Magnolia Terrace, and Transition Pulmonary Unit). Findings included: A review of the facility policy titled, Standard Precautions, dated August 2003, October 2009, and September 2019. Standard precautions will be utilized to provide a primary strategy for the prevention of healthcare-associated agents among patients and healthcare personnel. Linen-handle, transport and process used soiled linen in a manner to prevent contamination of clothing and avoids transfer of microorganisms to the environment and others. #10 Follow procedures for disposal of regulated infectious waste when items are saturated with blood and meet the definitions of Regulated Infectious Waste. A review of facility policy titled, Coronavirus (COVID-19) dated June 2023, it shall be the policy…

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 observations and interviews, the facility failed to provide residents with a comfortable and homelike atmosphere on three of five Units (Transition Pulmonary Unit, Magnolia Terrace, and 300 Unit) related to not having an adequate supply of bed and bath linens, dirty rooms, used pest traps and trash on floors, soiled privacy curtains, and urine odors. Findings included: 1. During a tour of the facility on 9/11/2023 at 9:48 am, the Transition Pulmonary Unit (TPU) linen closet was observed to have 14 top sheets, nine bottom sheets, seven pillowcases, and four blankets. There were no washcloths, towels or gowns observed. During an interview on 9/11/2023 at 9:48 am, Certified Nursing Assistant (CNA) OO stated that the linen closet was the only linen closet for the unit, and they frequently run out of linen. During an observation on 9/11/2023 at 11:41 am, the 300 Unit linen closet was observed to have five blankets, 16 top sheets, 10 washcloths, one gown, and 24 fitted sheets. There were no towels observed.…

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 record review, observations, and interviews, the facility failed to provide Activities of Daily Living (ADL) care to seven of 54 sampled residents (R) (R7, R21, R26, R38, R30, R39, and R15) related to scheduled showers/baths, incontinence care, and nail care. Findings included: A review of the facility policy titled, BATH/SHOWER - DEPENDENT., dated [DATE]; A bath (shower/tub) for cleanliness and comfort is scheduled at least weekly for each resident. A review of the facility policy titled, BED BATH, dated [DATE]; Bedfast residents will receive a bed bath daily. A bed bath also provides a mild form of exercise and allows observation of the resident to meet his psychosocial and physical needs. A review of the facility policy titled, Fingernails/Toenails Care dated [DATE], [DATE]; The purpose of this procedure is to clean the nail bed, to keep nails trimmed, and to prevent infections. Key Procedural: Nails can be partially cleaned during bath care. Nursing Assistants do not trim the nails of diabetic…

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 review of the facility's policy for food and nutrition, the facility failed to ensure opened food items were securely wrapped, labeled, and dated, failed to discard food items by the expiration date, failed to store food items properly in the freezer, and failed to maintain a sanitary functional kitchen equipment in the kitchen. The facility census was 199. Findings included: A review of the kitchen manual titled Guideline & Procedure Manual 2016 Edition, revealed the following: Food shall be stored on shelves in a clean, dry area, free from contaminants. Food shall be stored at appropriate temperatures; use appropriate methods to ensure the highest level of food safety. General storage guidelines to be followed: a. Label food items held for longer than 24 hours. The label should include the name of the food, if not in original packaging, the date by which it should be sold, consumed, or discarded. c. Discard food that has passed the expiration date, and discard food that has been prepared in the facility after seven days of storing under proper…

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 observations and interviews, the facility failed to maintain a Safe, Functional, Sanitary, and Comfortable Environment for three of five units (Magnolia Terrace, Central Unit, and 300 Unit). Findings included: On 9/11/2023 at 9:30 am, an observation on Magnolia Terrace of room [ROOM NUMBER] revealed a dirty floor to include food particles and dirt. Also, there was a fly strip that had numerous pests from the top of the strip to the bottom of it. On 9/11/2023 at 9:39 am, an observation on Magnolia Terrace of room [ROOM NUMBER] revealed a door missing off the closet. The privacy curtain was soiled with a brownish looking substance. The molding was missing off the bottom of the wall around the first bed. On 9/11/2023 at 9:40 am, an observation on Magnolia Terrace of room [ROOM NUMBER] revealed a dirty floor with various items on the floor to include clothes and trash. Privacy curtain was soiled with brownish color substance. There was a strong smell of urine in the room seeping out into the hall. On…

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 maintain an effective pest control program on two of five units (Magnolia Terrace and 300 Unit). Findings included: Observation on 9/12/2023 at 8:00 am of Magnolia Terrace revealed three rooms with gnats flying around residents faces while they were lying in bed. Observations on 300 Unit revealed two rooms that had fly tape hanging down from the ceiling on the right-side head of bed near the corner of the room. Also observed was another fly tape that had fallen and was lying coiled up on the floor. During an interview with R9's family member on 9/12/2023 at 1:33 pm, the family member stated that during visits with her grandmother she has seen large roaches in the room as well as flies. The family member stated that the facility was often dirty with overflowing trash cans and trash on the floor of the room. During an interview with LPN NN on 9/18/2023 at 10:30 am, the LPN stated that she has seen flies and the large bugs that everyone calls roaches. During an interview with Staff Member AA on 9/18/2023 at…

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 policy reviews, record reviews and interviews, the facility failed to provide residents with a grievance process that provided residents with the solutions for grievances that were filed for three of 54 sample residents (R) (R16, R17, and R18). Findings included: A review of the undated facility's policy titled, Grievance/Missing Property, revealed that the Social Service is responsible for notifying resident representative, family/next of kin and ombudsman, as appropriate, of resolution, Supervisory personnel shall be responsible for notifying resident of resolution and so indicate on grievance form, should resolution(s) not be satisfactory and/or grievance(s) reoccur, Social Services will notify the Grievance Official and Executive Director; and schedule a meeting with the involved parties. Grievances pertaining to missing items and/or property may also be presented to any staff member. If the missing item is not found on an initial search, the Missing Property Report will be completed and forwarded…

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 record review and interviews, the facility failed to fully investigate an allegation of abuse for one of 56 residents (R) (R32). Findings included: A review of the Abuse Prevention Policy (Review date of August 2014) under the section of definitions, sexual abuse is defined as, including, but not limited to sexual harassment, sexual coercion or sexual assault, or non-consensual sexual contact of any type with a resident. Under the section of investigation, the Abuse Prevention Policy states, the facility will initiate at the time of any finding of potential abuse or neglect an investigation to determine cause and effect and provide protection to any alleged victims to prevent harm during the continuance of the investigation. The Executive Director, or designee, shall report any allegation of abuse, neglect, or misappropriation of resident property as well as report any reasonable suspicion of crime in accordance with Section 150B of the Social Security Act to the Department of Health as required. A…

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 record review, observations, interviews, and the facility's policy titled, Tracheostomy Care the facility Respiratory Therapist (RTs) failed to provide a safe and sanitary environment during tracheostomy (trach)care for three four residents (R) (R15, R31, and R33) reviewed for trach care. Findings included: A review of the undated facility's policy titled, Tracheostomy Care revealed .Residents who have a tracheostomy will have trach (change drain sponge stoma site and check inner cannula for obstruction) suction if indicated, trach ties will be changed once daily or prn [as needed]. Completed trach care will be performed daily (inner cannula changed or cleaned). Disposable inner cannulas will be changed once a day or prn for mucus plugs .Equipment: 1. Tracheostomy kit with pipe cleaners, brush, 4x4 dressings, slit 4x4 dressing trach ties, sterile gloves (two pairs) and Q-tips .Procedure: 4. Apply gloves 5. Keep one hand clean and one dirty. Your dominant hand should be clean. 1. A review of the medical…

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 record review, observations, and staff interviews, the facility failed to ensure that one of six treatment carts (300 Unit Treatment Carts) were secured and inaccessible to residents. Findings included: A review of policy titled, MEDICATION STORAGE, dated April 2006; October 2009; Medication supply must be accessible only to licensed nursing personnel, or staff members lawfully authorized to administer medications. All drugs, treatments, and biologicals must be stored securely and following the manufacturer's labeled recommendations, or per facility policy. Medication rooms, carts, and medication supply rooms are kept locked at all times or must be attended by authorized personnel. An observation on 9/11/2023 at 10:05 am revealed a treatment cart parked in hallway outside of the rehabilitation therapy suite on 300 Unit, unattended and unlocked. The surveyor pulled a drawer to see if the cart was secured and found it to be unlocked and unattended. The bottom drawer contained a prescription medication of chlorhexidine, belonging to resident (R) 57 that was filled on…

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 policy review, the facility failed to provide a clean and sanitary environment for one of five nursing units (Magnolia [NAME]). Food, trash, dirt and debris were found on the floors in multiple rooms for multiple days, and bedside tables were found not cleaned for multiple days with dried food substances on bedside tables, creating an unsanitary environment. Finding include: Observation on 07/25/22 at 12:12 PM revealed room [ROOM NUMBER] with brown loose substance on the floor and a plastic spoon. room [ROOM NUMBER] window bed with food on the floor (appears to be salad) and trash on the floor (plastic wraps). room [ROOM NUMBER] with dirt and debris including what appears to be cotton on the floor. room [ROOM NUMBER] with trash (napkin and disinfectant wipe under the bed). The floor is very sticky. room [ROOM NUMBER] with food and debris (white specks) on the floor under the bed. room [ROOM NUMBER] with trash on the floor (plastic wraps). Observation on 07/25/22 at 2:57 PM…

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 interview, record review, and facility policy review, the facility failed to notify the physician/nurse practitioner timely of culture and sensitivity results for a urinary tract infection (UTI) requiring treatment for one of 35 sampled residents (R) (R22). Delay in notifying the physician/nurse practitioner timely resulted in a delay in initiating antibiotics. Findings include: Review of the facility's policy titled, Laboratory Test, revised November 2017, revealed . The Physician or physician extender will be promptly notified of abnormal results according to facility policy . Review of the facility's policy titled, Notification of a Change in Resident's Status, revised November 2017, revealed The attending physician/physician extender (Nurse Practitioner, Physician Assistant, or Clinical Nurse Specialist) and the resident representative will be notified of a change in the resident's condition . Guidelines for notification of physician . abnormal lab findings. During an observation on 07/25/22 at 1:28…

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, the facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for two of 35 sampled residents (R) (R189 and R205). The facility failed to accurately assess R205's catheter status and failed to allow R189 to complete the section for preferences and customary routine activities (section F). This failure placed the residents at risk for a decreased quality of life. Findings included: Review of the Resident Assessment Instrument (RAI) Manual 3.0, dated 10/2019 revealed, . If an MDS assessment is found to have errors that incorrectly reflect the resident's status, then that assessment must be corrected. Section F: Preferences for Customary Routine and Activities . The intent of items in this section is to obtain information regarding the resident's preferences for his or her daily routine and activities. This is best accomplished when the information is obtained directly through the resident . Nursing homes should use this as a guide to create an…

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 staff maintained appropriate infection control measures for the safe handling and monitoring of respiratory equipment for three residents of three residents (R) (R101, R64, and R13) reviewed for respiratory care in a total sample of 69 residents. Findings include: 1. Record review of the physician order tab located in electronic medical record (EMR), revealed R101 was admitted by the facility on 10/24/20 with diagnoses to include cerebral infarction, dysphagia, cerebral ischemia, cervical disc degeneration, acute respiratory failure with hypoxia, acute diastolic congestive heart failure, mild intermittent asthma with acute exacerbation, and dependence on supplemental oxygen. Review of the Physician Order, dated 07/30/21, indicated, Resident was ordered to be placed on 2liters of oxygen via nasal cannula continuous. During the initial tour of the facility on 07/25/22 at 12:00 PM, R101 was observed to be receiving oxygen per nasal cannula at 2liters per minute, the nasal cannula tube was dated for…

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, and policy review, the facility failed to ensure the kitchen was maintained in a sanitary manner to prevent the potential spread of foodborne illness to all residents. Clean serving pans were observed to be stacked wet. Findings include: Review of the facility policy titled, Dishwashing: Machine Operation, dated 2016, revealed, .use clean, washed hands to pull out clean racks, and allow to air dry before putting dishes away for storage. During an initial tour of the kitchen on 07/25/22 at 11:56 AM, an observation was made of clean ready-for use metal serving pans. The top pan on four of the stacks of clean pans was observed to have moisture accumulated. Interview with Dietary Aide (DA) 1 and the Dietary Manager during the initial tour, DA1 stated the pans had been washed that morning via the automatic dish machine. DA1 and the Dietary Manager confirmed that dishes should be allowed to dry before being stacked for use. The Dietary Manager stated that a new employee had been in charge of putting away clean dishes from the dish machine…

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 and interview, the facility failed to provide a safe, functional, sanitary, and comfortable environment for one of four survey units. Specifically, the facility failed to ensure the resident's rest rooms floor tiles, ceiling tiles, and toilets were in good repair. Findings include: During the surveyor's initial tour of the Magnolia Terrace hallways on 07/25/22 at 2:05 PM the following concerns were observed in the bathroom in room [ROOM NUMBER] - the bathroom floor was observed to be very darkly discolored, two broken tiles were observed on the floor, the toilet bowl screws to the floor were not covered and exposed, the right screw was observed to be approximately 2 inches and the left screw was observed to be approximately one inch in length. Both toilet bowl screws were observed to be red in color and rusty. The ceiling tiles were observed to be discolored with holes observed around the fire sprinkler on the ceiling. Observation of the bathroom in room [ROOM NUMBER] on 07/25/22 at 12:25 PM…

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.