A.g. Rhodes Home, INC - Cobb

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and resident and staff interviews, the facility failed to update resident (R) care plans when significant events occurred for one of 27 sampled residents (R) (R84). Specifically, the facility failed to update/revise the care plan after instances of communication did not work for R84.Findings include:Review of the electronic medical record (EMR) revealed resident (R)84 was admitted to the facility with pertinent diagnoses including but not limited to deaf nonspeaking, not elsewhere classified, contracture, left hand, stroke.Review of R84's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 06, which indicates R84 had severe cognitive impairment. Section GG, functional status, revealed R84 required extensive assistance for activities of daily living (ADLs) with one or more-person assistance. Impairment on one side of upper/lower extremities, benefits from the use of a wheelchair. Self Care: setup/clean up assistance with…

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, staff interviews, and review of the facility's policy titled, Routine Cleaning and Disinfection and Infection Prevention and Control Program Policy, the facility failed to ensure that there was a clean and comfortable environment to prevent transmission of infection as evidenced by unbagged and unlabeled urinals in four of 19 resident bathrooms on the third floor of the Legacy building. This deficient practice had the potential to place residents at risk for infection. Findings include: Review of the facility policy titled Routine Cleaning and Disinfection revised date of February 2025, revealed under Policy: To ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible. Review of the facility policy titled Infection Prevention and Control Program Policy revised date of July 10, 2023 revealed under Policy: This community has established and maintains 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 staff interviews, record review, and review of the facility policies titled, Incident and Accidents and Abuse Prohibition Policy, the facility failed to ensure allegations of potential abuse were thoroughly investigated for one of three residents (R) (R6) who had an allegation of abuse.Findings include: Review of the facility policy titled Incident and Accidents last revised 8/28/2023, documented under Compliance Guidelines: .4. Incidents that rise to the level of abuse, misappropriation, or neglect, will be managed and reported according to the community's abuse and prevention policy.Review of the facility policy titled Abuse Prohibition Policy last revised 5/22/2023 revealed under Policy Explanation and Compliance Guidelines: 1. The facility will develop and implement written policies and procedures that: .b. Establish policies and procedures to investigate any such allegations.V. Investigation of Alleged Abuse, Neglect and Exploitation.4. Identify and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses and others who might have…

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, staff interviews, and review of the facility policy titled, Food and Supply Storage, the facility failed to discard frozen/refrigerated food items by expiration date, failed to label and date items in two of three reach in refrigerator units, and failed to maintain proper sanitary conditions by ensuring kitchen staff wore hairnets and beard guards while preparing food for residents. The deficient practice had the potential to affect 99 residents who received an oral diet from the kitchen. The facility census was 105 residents. Findings Include: Review of facility policy titled Food and Supply Storage date revised January 2024 under Procedures revealed: Cover, label, and date unused portions and open packages. Complete all sections on a 'company name' orange label or use 'company names' labeling system. Products are good through the close of business on the date noted on the label. Date and rotate items; first in, first out (FIFO). Discard food past the use-by or expiration date. Review 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff interviews, the facility failed to keep potentially hazardous materials in a secured area. Specifically, the janitorial room on one of three floors (third floor) was unlocked and taped open, and treatment solution was left in the room on the nightstand of one resident (R) (R309) in room [ROOM NUMBER] of 24 rooms on the third floor where 23 residents with severe cognitive impairment resided. The deficient practice had the potential for residents residing on the third floor to come in contact with hazardous chemicals and waste. The facility census was 105 residents. Findings include: Review of the electronic medical record (EMR) for R309 revealed diagnoses including but not limited to unspecified dementia, unspecified severity, without behavioral disturbances, psychotic disturbance, mood disturbance, and anxiety, heart failure, unspecified, personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits, altered mental status,…

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 properly keep a complete record of the controlled drug shift audit, as evidenced by missing signatures on audit sheets for eight of twelve medication carts. This had the potential to cause residents to go without prescribed medications. The facility census was 105. Findings included: On 7/24/2024 starting at 8:32 am, a medication administration observation was conducted. The observation included a Licensed Practical Nurse (LPN) or a Certified Medication Aide (CMA) on each of the five floors. On 7/24/2024 at 9:40 am, on the Starvine medication cart, it was observed that there was one shift nurse's signature missing on the controlled drug shift audit sheet for 7/21/2024, on the 11:00 pm to 7:00 am shift. On 7/24/2024 at 9:45 am, on the Trilluim medication cart, it was observed that there were 15 signatures missing from the Controlled Drug Shift Audit sheet, between the dates of 7/1/2024 through 7/14/2024. On 7/24/2024, 2024 at 9:55 am, on the Dogwood medication cart, it was observed that there were 11…

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, staff interview, record review, and review of the facility policy titled, Oxygen Concentrator, the facility failed to properly care for the oxygen concentrator (machine that produces oxygen from room air) of one of eight residents (R) (R77) that use oxygen. Specifically, oxygen concengtrator filters were not cleaned timely. Findings included: Review of the facility policy titled Oxygen Concentrator with a revision date of 6/23/2023 revealed that the Purpose of the policy is to establish responsibilities for the care and use of oxygen concentrators. The definition of an oxygen concentrator as defined by the policy, is a medical device that extracts oxygen from room air by filtering out or separating the nitrogen from the oxygen, by passing through a filter. Review of the compliance guidelines, . 5. Care of the concentrator: a. Clean filters as needed or directed by the supplier. Review of the electronic medical record (EMR) for R77 revealed that she was admitted to the facility with…

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 staff interviews, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the diagnosis of multiple sclerosis for one resident (R) R#20 of 56 residents whose MDS was reviewed. Specifically, the facility failed to ensure R#20 used a splint or brace before indicating the resident utilized one on the MDS. Findings include: Review of the clinical record revealed R#20 was admitted to the facility on [DATE] with a diagnosis of multiple sclerosis. The resident's most recent quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 15, which indicates no cognitive impairment. Section G revealed resident required extensive assistance with bed mobility, dressing, toilet use and personal hygiene, total dependence with transfers and bathing. Section 0 revealed resident received at least 15 minutes of splint or brace assistance through a restorative nursing program for two out of seven days during the assessment…

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 review, interviews, and policy review, the facility failed to ensure care and services were provided in accordance with physician orders for one resident (R) (R#321) of one sampled resident reviewed for treatment of swelling and thrombosis (blood clot) to the legs. Specifically, the facility failed to ensure staff applied compression stockings (TED hose) and elevate the lower extremities to reduce swelling. Findings include: Review of the undated policy titled, Policy for Edema/TED Hose, revealed edema (swelling) is a result of excess fluids collecting in the tissues, often caused by an underlying disease process that interfered with circulation (decreased blood perfusion) to the legs and feet. Edema is treated by medications or nonpharmacological approaches, such as elevation of extremities, TED (thromboembolic disease) hose, etc. [et cetera]. TED hose (or anti-embolic stockings) exert pressure on the veins to promote venous blood return to the heart. Procedure 1. The patient with…

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 review, interviews, and policy review, the facility failed to ensure fall prevention interventions were added to the care plan and consistently implemented for one resident (R) (R#95) of three residents reviewed for accidents/hazards. Findings include: Review of the facility policy titled Fall Prevention Policy and Procedure dated 4/1/21, revealed the policy is 1. The facility will identify each resident who is at risk for falls and will plan care and implement interventions to assist in fall prevention. The facility will attempt to prevent falls by providing an environment that is free from potential hazards. 2. Nursing will complete the fall risk assessment. 3. A resident's fall prevention program will be implemented that educates staff in creative, functional strategies while recognizing residents and their need to maintain the highest practical level of function. Procedure: 1. Nursing assesses all residents for fall risk through the fall risk assessment upon admission,…

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.