Lake Emory Post Acute Care

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and facility policy review, the facility failed to protect the resident's right to be free from physical abuse by a resident for one of four residents (Resident (R) 13) reviewed for abuse of 21 sample residents. This failure had the potential to affect resident safety.Findings include: Review of the facility's undated policy titled, Abuse, Neglect, Exploitation, or Mistreatment, revealed The facility's leadership prohibits neglect, mental, physical and/or verbal abuse. Types of abuse include but are not limited to: A. Physical assault/abuse: 1) Hitting 2) Slapping.Review of R13's Face Sheet located under the Resident-Face Sheet tab of the electronic medical record (EMR) revealed the resident was admitted on [DATE] with diagnoses which included Alzheimer's disease, vascular dementia, and major depressive disorder. Review of the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/14/25, located under the Resident Assessment Instrument (RAI) - MDS 3.0…

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, interview, and policy review, the facility failed to report an allegation of staff to resident physical abuse for one of two (Residents (R)18) abuse allegations reviewed in the sample of 21 residents to the State Agency (SA) immediately, but no later than 2 hours after the allegation was made when the incident involved abuse. This failure had the possibility to negatively impact all 83 residents currently residing at the facility.Findings include:Review of the facility's policy titled, Abuse, Neglect, Exploitation, or Mistreatment, revised 11/01/17, indicated, . The facility shall report immediately, but not later than two hours after the allegation is make if the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not result in serious bodily injury to the Administrator of the facility and to other officials (including to the State Survey Agency and adult…

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, record review, facility document review, and facility policy review, the facility failed to timely report a resident-to-resident abuse allegation to the State Agency for 1 (Resident (R)3) of 3 residents reviewed for abuse. Findings include: An undated facility policy titled, Abuse, Neglect, Exploitation, or Mistreatment, specified, 1. The facility's Leadership prohibits neglect, mental, physical and/or verbal abuse, use of a physical and/or chemical restraint not required to treat a medical condition, involuntary seclusion, corporal punishment, and misappropriation of a patient's/resident's property and/or funds and ensures that alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, and [sic] are reported immediately. 2. The Facility shall report immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, record review, and interview, the facility failed to notify the responsible party for Resident (R) 2 and R3, of an elopement, for 2 of 3 residents reviewed for elopement. Findings include: Review of the facility policy titled Elopement dated 11/01/17, documented, When the resident is located . The Director of Nurses or the designee notifies the Administrator/designee and notifies the appropriate community agencies, attending physician and the residents legal representative. Review of R2's Face Sheet revealed the facility admitted R2 on 09/13/22, with diagnoses including but not limited to: chronic obstructive pulmonary disease, vascular dementia, Alzheimer's Disease, and major depressive disorder. Review of R2's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/18/24, revealed R2 had a Brief Interview for Mental Status (BIMS) score of 6 out of 15, indicating R2 had severe cognitive impairment. Review of R3's Face Sheet revealed R3 was admitted to…

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, interviews, and a review of facility policy, the facility failed to ensure foods stored in the refrigerator, and nourishment kitchen were free from expiration. This failure had the potential to affect residents in the facility who consumed food from the kitchen and received food from the nourishment kitchen. Findings include: A review of the facility's policy titled, Nutrition policy and procedures on cleaning walk-in refrigerator with a complete revision date of 06/20/2023 states 2. Verify that all products are properly labeled and dated. On 07/16/2024 at 10:35 AM and 07/18/2024 at 04:45 PM, the following observations in the kitchen and nourishment kitchen were made with and verified by the Dietary Manager (DM): Main refrigerator/Cooler-Two clear bags, both with 6 heads of lettuce each with no open date and a use-by date of 06/17/2024 listed on the bag. All 12 heads of lettuce in the bags were brown with pink build-up surrounding the entire head of lettuce. An observation of the nourishment kitchen, located in B Hall on 7/18/2024 at 4:34 PM revealed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure Resident (R)6 was treated with dignity by failing to ensure his catheter bag was covered to promote privacy. Finding include: Review of the admission Record revealed R6 was admitted on [DATE] with diagnoses including but not limited to, major depressive disorder and Parkinson's disease. Review of R6's Minimum Data Set (MDS), located in the Electronic Medical Record (EMR) with an Assessment Reference Date (ARD) of 06/30/23, revealed R6 has a Brief Interview of Mental Status (BIMS) score of 12 out of 15, indicating the resident was moderately cognitively intact. During an observation, R6 was observed sitting up in bed on 08/24/23 at 12:25 PM. He appeared unkempt, with long facial hair, and his catheter bag was full without a privacy bag. The privacy bag was observed at 12:25 PM and 1:56 PM on 08/24/23. An interview on 08/24/23 at 1:56 PM with R6 revealed that he does prefer to have his face shaved and it has not been shaved today. He…

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 review of the facility's policy, observations, and interview, the facility failed to ensure the processing of clean and dirty laundry was separated in the laundry room; and failed to ensure accessibility for handwashing for laundry staff. This failure effected all laundered items and any of the facility's 83 residents who received laundered items. Findings include: Review of the facility's Infection Prevention and Control Policies and Procedures, Subject: Linen and Laundry Services, completed revision 09/2011. Laundry Facilities: 1. A. Laundry areas are housed away from patient/resident care areas. B. The soiled laundry area is separated from the clean, through either use of negative pressure for the soiled area, or by physical separation. C. Areas where laundry is processed have hand washing facilities, appropriate hand washing supplies and personal protective equipment available for staff use. On 02/03/23 at 10:55 AM, a tour of the laundry room was conducted with the Acting Laundry Supervisor (ALS). The laundry room had one door entry for the clean and dirty processing 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 review of the Resident Assessment Instrument Manual, record review, and interviews, the facility failed to complete a quarterly Minimum Data Set (MDS) assessment within the regulatory timeframe for one resident (R) 45 reviewed for Resident Assessments. Findings include: Review of the ''Resident Assessment Instrument [RAI] Manual,'' October 2019 edition, indicated that a quarterly MDS assessment was to be completed at least every 92 days when a comprehensive assessment was not required. R45 was originally admitted to the facility on [DATE]. A review of the MDS assessments for R45 revealed the most recent quarterly MDS completed had an assessment reference date (ARD) of 09/23/22. An interview and electronic medical record review was conducted with the MDS Coordinator on 02/03/23 at 5:37 PM. The MDS Coordinator confirmed R45's quarterly last quarterly MDS was on 09/23/22. The MDS Coordinator stated he was responsible for timely completion of MDS and that he had missed R45's quarterly MDS and it was late.…

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 review of the facility policy, record review, and interviews, the facility failed to follow the Preadmission Screening and Resident Review (PASARR) process for individuals prior to admission to the facility by failing to complete Level I screening for 2 of 2 residents (Resident (R)11 and R71) reviewed for PASARR. Findings include: Review of facility's policy title PASSR Documentation Policy dated 04/2022 revealed . GENERAL GUIDELINES FOR PASARR: PASARR requires that: All applicants to a Medicaid-certified nursing facility are evaluated for mental illness A. and or intellectual disability, prior to admission and, B. Offered the most appropriate setting for their needs which may be in the community, a nursing facility, or an acute care setting, and C. Receive necessary services in those settings to address any specific need related to the diagnosis of mental illness or intellectual disability. 1. Review of R11's admission record located in the Profile tab of the electronic medical record (EMR), revealed…

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 facility policy review, record review, and interviews, the facility failed to a ensure an end date was added to an as needed (PRN) psychotropic medication order, a medication that alters the mood or thought process for 1of 5 residents (Resident (R) 46) reviewed for unnecessary medications. The facility also failed to ensure a prescriber provided clinical rational for the continuation of a PRN medication beyond 14 days. This failure could have led to the resident remaining on a PRN psychotropic medication longer than necessary. Findings include: Review of the facility's policy dated 04/01/22, titled PSYCHOTROPIC DRUGS - USE OF revealed: A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: A. Anti-psychotic. B. Anti-depressant. C. Anti-anxiety, and D. Hypnotic. Further review of the policy revealed: D. PRN orders for psychotropic drugs are limited to 14 days. Except as…

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 review of facility policy, record review, observation, and interview, the facility failed to ensure that intravenous (IV, medication given through the vein) fluids administered were labeled with the date, time, and initials of the person who hung them according to facility policy for 1 resident observed on IV fluids (Resident (R)16). Findings include: Review of the facility's police number 6.4 titled Medication Labeling revised on 04/01/22 revealed, 1. The Facility shall ensure that the pharmacy provider labels medications dispensed in accordance with State and Federal regulations. 2. The Facility shall ensure that all medications are labeled appropriately. Further review of the policy revealed, .8. Nursing should ensure that infusion therapy labels include the medication name, volume, infusion rate, name and quantity of each additive, date of preparation, initials of compounder, date and time of administration, initials of person administering the medication, ancillary labeling and expiration date. Review of R16's physician orders located in the electronic medical record…

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.