CHATUGE REGIONAL NURSING HOME
Non profit - Corporation
112 Beds
Independent
Data: November 2025
5 Immediate Jeopardy citations
Trust Grade
0/100
#260 of 353 in GA
Photo by Chatuge Regional Nursing Home
Photo by Chatuge Regional Nursing Home
Photo by Chatuge Regional Nursing Home
1 / 5 photos
Last Inspection: June 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Chatuge Regional Nursing Home has received a Trust Grade of F, indicating significant concerns about the facility's overall quality and care. It ranks #260 out of 353 nursing homes in Georgia, placing it in the bottom half, though it is the only option in Towns County. The facility's situation is worsening, with issues increasing from 8 in 2022 to 19 in 2024. Staffing is an average strength, rated 3 out of 5 stars, with a turnover rate of 40%, which is better than the state average. However, the home has accumulated $64,214 in fines, which is higher than 92% of facilities in Georgia and suggests ongoing compliance problems. Recent inspections revealed critical failures, including the administration's inability to address allegations of staff abuse towards residents, risking their safety and well-being. There were also findings of residents being subjected to physical and verbal abuse by staff, highlighting serious concerns regarding resident protection and care. While the home has some staffing stability, the critical incidents and overall poor ratings suggest families should approach with caution.
- Trust Score
- F
- In Georgia
- #260/353
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ○ Average
- 40% turnover. Near Georgia's 48% average. Typical for the industry.
- Penalties ⚠ Watch
- $64,214 in fines. Higher than 89% of Georgia facilities, suggesting repeated compliance issues.
- Skilled Nurses ○ Average
- Each resident gets 30 minutes of Registered Nurse (RN) attention daily — about average for Georgia. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 31 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 27%
Review needed
8 → 19 violations
★☆☆☆☆
1.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★☆☆☆
2.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2022: 8 issues
2024: 19 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (40%)
8 points below Georgia average of 48%
Facility shows strength in fire safety.
The Bad
1-Star Overall Rating
Below Georgia average (2.6)
Significant quality concerns identified by CMS
Staff Turnover: 40%
Near Georgia avg (46%)
Typical for the industry
Federal Fines: $64,214
Above median ($33,413)
Moderate penalties - review what triggered them
The Ugly 31 deficiencies on record
5 life-threatening
Jun 2024
19 deficiencies
5 IJ (1 facility-wide)
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Free from Abuse/Neglect
(Tag F0600)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of policy titled Abuse Reporting and Investigation, the facility failed to protec...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of policy titled Abuse Reporting and Investigation, the facility failed to protect the resident's right to be free from abuse from by facility staff. Specifically, the facility failed to protect two residents (R) (R78 and R107) of 27 total sampled residents from physical, mental, and verbal abuse from Certified Nursing Assistant (CNA) staff. Due to the vulnerable nature of the nursing home population and the likelihood of resident abuse in the facility, immediate action was required to prevent further events of abuse.
On 6/7/2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents.
The facility's Administrator and Director of Nursing (DON) were informed of two Immediate Jeopardy's (IJ) on 6/7/2024 at 8:49 am. The noncompliance related to the first Immediate Jeopardy was identified to have existed on 3/22/2024 when the facility failed to protect two residents (R) (R78 and R107) from physical, mental, and verbal abuse.
A Credible Allegation of Compliance was received on 6/7/2024. Based on observations, record review, resident and staff interviews, and review of facility policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed as of 6/8/2024.
Findings include:
Review of the policy titled Abuse Reporting and Investigation, revised March 2017, revealed Facility will not permit residents to be subjected to abuse by anyone, visitors, other residents, staff members, volunteers, and/or other agency working inside facility. Forms of abuse consist of verbal, sexual, physical, mental, neglect, exploitation/misappropriation of resident property, mistreatment, and injuries of unknown origin.
1. Review of R78's Record of Admission located under the Clinical tab of the electronic medical record (EMR), revealed an admission date of 2/2/2023 with a diagnosis of dementia.
Review of R78's significant change Minimum Data Set (MDS) dated of 3/21/2024 revealed a Brief Interview of Mental Status (BIMS) score of a zero out of 15 which indicated R78 was severely cognitively impaired.
Review of the Facility Reported Incident (FRI) dated 3/22/2024, completed by the Administrator/Abuse Coordinator, revealed a report of verbal abuse. The report stated, allegation was reported by another CNA [CNA3] that a staff member [CNA2] spoke harshly to the resident during her shower.
The FRI further revealed that Human Resource (HR) staff was interviewed and stated that CNA 3 reported the above incident to her. The HR staff stated CNA 3 submitted a written statement of the incident and it was provided to the administrator.
The FRI included an interview with the Director of Nursing (DON) where she stated that she provided verbal training to staff to always be mindful of your tone of voice.
Review of CNA 2's personnel file revealed no evidence of abuse training other than a statement on how to report elder abuse under the Elder Justice Act. CNA 2 was suspended with pay for three days. The facility could not provide a facility investigation that determined the outcome of the incident. CNA 2 continued to provide direct care to R78, 16 times since this incident occurred, as recently as 6/5/2024.
During an interview on 6/6/2024 at 9:20 am, the Administrator stated he had misplaced all
documentation related to this incident.
During an interview on 6/6/2024 at 9:55 am, CNA 3 stated she provided a verbal and written statement that CNA 2 was rough with R78 during a shower by throwing the resident into the shower chair. CNA 3 said R78 began gagging and crying. She stated R78 said l am going to vomit. She stated that CNA 2 told the resident if you vomit on me, I am going to punch you. CNA 3 proceeded to say that CNA 2 sprayed water in R78's face.
2. Review of R107's Record of Admission, located under the Clinical tab of the EMR, revealed R107 was admitted to the facility on [DATE] with a diagnosis of Hemiparesis.
Review of R107's Discharge MDS dated [DATE] revealed a BIMS score of 15 out of 15 which indicated R107 was cognitively intact. The resident required supervision for lower body and toileting.
Review of a Grievance Form dated 4/22/2024 documented that R107 submitted a grievance form to Social Services Director (SSD). The grievance read, SS (social services) received a message from resident's granddaughter that the resident was not allowed to use the bathroom over the weekend. SS spoke with resident who advised when resident asked to get up for bedside toilet the CNA told the resident to use her pull up. Resident advised that the CNA did not get her up, did not take her to the bedside toilet, and kept her in bed all weekend. Resident said she did not get up out of the bed until Monday 4/22/2024. Resident advised that she was given an enema Friday, and it did not feel right to her to be made to use the bathroom on herself. The Investigation portion of the Grievance Form read Spoke with the staff member in charge of resident. She stated that resident asked her to help her get on BSC (bed side commode). Staff member then informed resident that since she just had an enema, they [sic] may not make it to the toilet. Staff member also reported that resident did not go to sleep until after 4:00 am and she voiced she was tired. The Action Taken included no documentation. The investigating employee was the Director of Nursing (DON), dated 4/24/2024 and the Administrator signed the document on 5/1/2024.
During an interview on 6/6/2024 at 5:30 pm, the DON revealed she had talked to CNA 2 but did not document anything. The DON confirmed that CNA 2 who was named in the allegation had continued working since the event occurred.
During an interview on 6/6/2024 at 7:30 pm, the Administrator revealed he had suspended CNA 2 and has since been terminated.
During an interview on 6/8/2024 at 3:15 pm, the Administrator revealed the police had been notified regarding the incident.
An attempt to interview CNA 2 was unsuccessful.
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Deficiency F0602
(Tag F0602)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of policy titled Abuse Reporting and Investigation, the facility failed to protec...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of policy titled Abuse Reporting and Investigation, the facility failed to protect one resident (R) (R71) out of a total sample of 27 from exploitation perpetrated by Certified Nurse Aide (CNA)1. Due to the vulnerable nature of the nursing home population, a potential for serious exploitation existed, and the likelihood of CNA 1 exploiting other residents in the facility required immediate action to prevent further events of exploitation.
On 6/7/2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents.
The facility's Administrator and Director of Nursing (DON) were informed of two Immediate Jeopardy's (IJ) on 6/7/2024 at 8:49 am. The noncompliance related to the second Immediate Jeopardy was identified to have existed on 7/12/2023 when the facility failed to protect R71 from exploitation by CNA 1.
A Credible Allegation of Compliance was received on 6/7/2024. Based on observations, record review, resident and staff interviews, and review of facility policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed as of 6/8/2024.
Findings include:
Review of the policy titled Abuse Reporting and Investigation, revised March 2017, indicated the Procedure is the facility will not permit residents to be subjected to abuse by anyone, visitors, other residents, staff members, volunteers, and/or other agency working inside facility. Forms of abuse consist of verbal, sexual, physical, mental, neglect, exploitation/misappropriation of resident property, mistreatment, and injuries of unknown origin. Implementation: Number 8. Employees of this facility who have been accused of resident abuse will be suspended immediately pending the outcome of the investigation.
Review of R71's Record of Admission located under the Clinical tab of the electronic medical record (EMR), revealed an admission date of 9/21/2022 with a diagnosis of dementia and delusions.
Review of R71's quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 11 out of 15 which indicated R71 was moderately cognitively impaired.
Review of an untitled document dated 7/12/2023, written by the Administrator documented CNA 1 was spending time with R71. The document revealed CNA 1 was staying with the resident in the facility until 2:00 am. The document revealed that facility staff observed CNA 1 holding hands with R71 in his room during this time. Further review of the document revealed the Administrator spoke with CNA 1 regarding the relationship with R71 and she denied any involvement. The Administrator discussed concerns that CNA 1 was spending so much time with R71 while other residents assigned to her required assistance, which had to be provided by other CNA's. The Administrator informed CNA 1 that personal relationships between resident and employees crossed professional boundaries and would not be tolerated. ln this document, he indicated he was reassigning CNA 1 to another hall and that she was no longer allowed to cross over to R71's hall.
Review of a report filed to the Adult Protective Services (APS), by the Business Office Manager dated 5/30/2024, revealed R71 left Against Medical Advice (AMA). Review of additional information in the report filed to the APS revealed R71 came to the business office to pay his bill and R71 presented three debit cards that were all declined. He stated I don't know who is spending all my money.
Review of an untitled document, dated 6/3/2024, written by the Administrator revealed R71 returned from the hospital with his medical record. The medical record revealed that CNA 1 was listed as his emergency contact. The Administrator spoke with the staff member about her being listed as the emergency contact on the hospital medical records for R71. He reiterated to her their prior conversation from 7/12/2023. CNA 1 would not respond to the Administrator during this conversation. CNA 1 then requested a piece of paper from the Administrator and proceeded to write her resignation letter and presented it to the administrator.
During an interview on 6/6/2024 at 10:48 pm, the Administrator confirmed he did not thoroughly investigate the allegations of exploitation of R71 by CNA 1 as he felt they were rumors and had no further information to provide.
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Report Alleged Abuse
(Tag F0609)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of policy titled Abuse Reporting and Investigation, the facility failed to ensure...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of policy titled Abuse Reporting and Investigation, the facility failed to ensure allegations of abuse, an injury of unknown origin that resulted in a hip fracture, and an allegation of employee to resident exploitation were reported to the State Survey Agency (SSA). Specifically, residents (R) (R71 and R107) were verbally abused by staff; R71 sustained an injury of unknown origin and potential exploitation by facility staff. The failure of the facility to report these incidents has the likelihood to lead to future unreported injuries of unknown origin, exploitation, and mental and verbal abuse against residents. The sample size was 27.
On 6/7/2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents.
The facility's Administrator and Director of Nursing (DON) were informed of two Immediate Jeopardy's (IJ) on 6/7/2024 at 8:49 am. The noncompliance related to the Immediate Jeopardy was identified to have existed on 7/12/2023 related to the failure to report exploitation by Certified Nursing Aide (CNA) CNA 1 to R71, failed to report an injury of unknown origin for R71, and failed to report employee to resident abuse for R107.
A Credible Allegation of Compliance was received on 6/7/2024. Based on observations, record review, resident and staff interviews, and review of facility policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed as of 6/8/2024.
Findings include:
Review of the facility policy titled Abuse Reporting and Investigation, revised March 2017, indicated Implementation: Number 14. The Administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the State Survey and Certification Agency, the local police department, the Ombudsman, and others as may be required by state or local laws, within five (5) working days of the reported incident.
1. Review of R71's Record of Admission located under the Clinical tab of the electronic medical record (EMR), revealed an admission date of 9/21/2022 with a diagnosis of dementia and delusions.
Review of R71's quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 11 out of 15 which indicated R71 was moderately cognitively impaired.
Review of an untitled document dated 7/12/2023, written by the Administrator, summarizes a situation between CNA 1 and R71. CNA 1 would spend time in R71's room while neglecting her other assigned residents and was observed to be holding hands with R71. The Administrator spoke with CNA 1 regarding personal relationships between residents and employees that crossed professional boundaries and would not be tolerated. She denied any involvement with R71. She was reassigned to another hall, informed her that she was no longer allowed to cross over to R71's hall. There was no evidence this incident was reported to the SSA.
Review of the Adult Protective Services (APS) report dated 5/30/2024 filed by the Business Office Manager revealed R71 left facility Against Medical Advice (AMA). Review of additional information in the report revealed R71 attempted to pay his bill and R71 presented three debit cards that were all declined. Resident stated, I don't know who is spending all my money. There was no evidence this incident was reported to the SSA.
Cross Refer F602.
Review of the Progress Notes dated 3/8/2024 indicated resident was on a leave of absence (LOA) from the facility 3/5/2024 through 3/7/2024. Upon his return, the resident reported that he had a fall while on LOA and thought he had a broken right leg/hip. This note further revealed R71 was not able to move his leg on that side and knee and foot appeared very swollen. R71 was immediately sent to the emergency room. On 3/12/2024, the resident returned to the facility from the hospital. He had a fractured right femur that had been repaired in surgery. There was no evidence that the injury of unknown origin was reported to the SSA.
2. Review of R107's Record of Admission, located under the Clinical tab of the EMR revealed R107 was admitted to the facility on [DATE] with a diagnosis of Hemiparesis.
Review of the Discharge MDS dated [DATE] revealed a BIMS score of 15 out of 15 which indicated R107 was cognitively intact. The resident required supervision for lower body and toileting.
Review of the Grievance Form dated 4/22/2024 revealed that R107 submitted a grievance form when the facility received a message from resident's granddaughter that the resident was not allowed to use the bathroom over the weekend. When Social Services spoke with R107 he advised that that CNA 2 would not assist him to the bathroom and told him to go in his pull up. He further stated CNA 2 did not get him up all weekend. There was no evidence the incident was reported to the SSA.
During an interview on 6/5/2024 at 2:50 pm, the Administrator confirmed the exploitation, injury of unknow origin, and verbal abuse were not reported to the SSA.
Cross Reference F600.
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Investigate Abuse
(Tag F0610)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of the policy titled Abuse Reporting and Investigation, the facility failed to en...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of the policy titled Abuse Reporting and Investigation, the facility failed to ensure that allegations of abuse, allegations of exploitation, and an injury of unknown origin, were thoroughly investigated for three residents (R) (R78, R71, and R107) reviewed out of a total sample of 27 residents. Specifically, the facility failed to investigate allegations of employee to resident abuse for R78 and R107, perpetrated by Certified Nurse Aide (CNA) 2. In addition, the facility failed to investigate an injury of unknown origin that resulted in a hip fracture and failed to investigate allegations of exploitation for R71 perpetrated by CNA 1. The failure of the Administrator to investigate these incidents have the likelihood to lead to future unreported allegations of abuse and exploitation as well as injuries of unknown origin.
On 6/7/2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents.
The facility's Administrator and Director of Nursing (DON) were informed of two Immediate Jeopardy's (IJ) on 6/7/2024 at 8:49 am. The noncompliance related to the second Immediate Jeopardy was identified to have existed on 7/12/2023 when the facility became aware CNA 1 was in a personal relationship with R71 and potentially exploited is money.
A Credible Allegation of Compliance was received on 6/7/2024. Based on observations, record review, resident and staff interviews, and review of facility policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed as of 6/8/2024.
Findings include:
Review of the facility policy titled Abuse Reporting and Investigation, revised March 2017, indicated the Statement Of Purpose is that all reports of resident abuse, neglect, and injuries of unknown source shall be thoroughly and promptly investigated by the facility. Implementation: Number 1. Should an incident or suspected incident of resident abuse, mistreatment, neglect, or injury of unknown source be reported, the Administrator and/or the Director of Nursing (DON), will appoint a member of management to investigate the alleged incident. Number 14. The Administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency, the local police department, the ombudsman, and other as may be required by state and local laws, within five working days of the reported incident.
1. Review of R71's Record of Admission located under the Clinical tab of the electronic medical record (EMR), revealed an admission date of 9/21/2022 with diagnoses of dementia and delusions.
Review of R71's quarterly Minimum Data Set (MDS) dated [DATE] revealed a BIMS score of 11 out of 15 which indicated R71 was moderately cognitively impaired.
The Administrator submitted a written document dated 7/12/2023 that documented a suspected situation with CNA 1 and R71 being involved in a relationship with each other. The document continued to indicate that CNA 1 would neglect the other residents on her assignment, while she would be spending time in R71's room. CNA 1 was reassigned to another hall, and she was no longer allowed to go to R71's hall. There was no evidence this incident was thoroughly investigated by the facility.
Review of the Adult Protective Services (APS) report dated 5/30/2024 filed by the Business Office Manager revealed R71 left facility Against Medical Advice (AMA). Review of additional information in the report revealed R71 attempted to pay his bill and he presented three debit cards that were all declined. Resident stated, I don't know who is spending all my money. There was no evidence this incident was reported to the SA.
Review of the Progress Notes dated 3/8/2024 indicated resident was on a leave of absence (LOA) from the facility 3/5/2024 through 3/7/2024. Upon his return, the resident reported that he had a fall while on LOA and thought he had a broken right leg/hip. This note further revealed R71 was not able to move his leg on that side and knee and foot appeared very swollen. R71 was immediately sent to the emergency room. On 3/12/2024, the resident returned to the facility from the hospital. He had a fractured right femur that had been repaired in surgery. There was no evidence that the injury of unknown origin was investigated by the facility.
During an interview with the Administrator on 6/6/2024 at 10:48 pm, he confirmed the above incidents involving R71 were not thoroughly investigated.
3. Review of R78's Record of Admission located under the Clinical tab of the EMR revealed an admission date of 2/2/2023 with a diagnosis of dementia.
Review of R78's significant change MDS dated of 3/21/2024 revealed a BIMS score of a zero out of 15 which indicated R78 was severely cognitively impaired.
Review of the Facility Reported Incident (FRl) dated 3/22/2024, completed by the administrator/abuse coordinator, revealed a report of verbal abuse to R78 by CNA 2. Further review of this FRI revealed no documentation of an investigation.
During an interview on 6/6/2024 at 9:20 am, the Administrator revealed he had investigated the issue but misplaced all documentation related to this incident. He was unable to provide or report the outcome of the investigation and confirmed CNA 2 continued to provide care to R78 and other residents.
4. Review of R107's Record of Admission, located under the Clinical tab of the EMR revealed R107 was admitted to the facility on [DATE] with a diagnosis of Hemiparesis.
Review of R107's discharge MDS dated [DATE] revealed a BIMS score of 15 out of 15 which indicated R107 was cognitively intact. The resident required supervision for lower body and toileting.
Review of the Grievance Form dated 4/22/2024 revealed that R107 submitted a grievance when the facility received a message from resident's granddaughter stating that the resident was not allowed to use the bathroom over the weekend. When Social Services spoke with R107 he advised that that CNA 2 would not assist him to the bathroom and told him to go in his pull up. He further stated she did not get him up all weekend. There was no evidence the incident was investigated by the facility.
During an interview on 6/5/2024 at 2:50 pm, the Administrator confirmed there was an allegation of abuse reported by R107 against CNA 2 and the facility did not complete a thorough investigation of the abuse.
CRITICAL
(L)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Administration
(Tag F0835)
Someone could have died · This affected most or all residents
⚠️ Facility-wide issue
Based on record review, interviews, review of the Administrator Job Description, and review of the policy titled Abuse Reporting and Investigation, the facility Administration failed to provide protec...
Read full inspector narrative →
Based on record review, interviews, review of the Administrator Job Description, and review of the policy titled Abuse Reporting and Investigation, the facility Administration failed to provide protective oversight to attain the highest practicable physical and psychosocial wellbeing of the residents. Specifically, Administration failed to take appropriate action on allegations of employee-to-resident abuse, exploitation, and injury of unknown origin, which were reported to him. The failure of the Administrator to take appropriate action which was reported to him has the likelihood to lead to future allegations of abuse, exploitation, and injury of unknown origin that are not identified, reported, or investigated.
On 6/7/2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents.
The facility's Administrator and Director of Nursing (DON) were informed of two Immediate Jeopardy's (IJ) on 6/7/2024 at 8:49 am. The noncompliance related to the Immediate Jeopardy's was identified to have existed on 3/22/2024 when the facility failed to protect two residents (R) (R78 and R107) from physical, mental, and verbal abuse. A second Immediate Jeopardy was identified to have existed on 3/22/2024 when Certified Nurse Aide (CNA)1 began a personal relationship with R71.
A Credible Allegation of Compliance was received on 6/7/2024. Based on observations, record review, resident and staff interviews, and review of facility policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed as of 6/8/2024.
Findings include:
Review of the undated document titled Nursing Home Administration Job Description/Performance Evaluation documented the Administrator of the Nursing Home shall be responsible for the planning, controlling, and directing the overall program and shall be responsible for direct supervision of all departments of the Nursing Home. The Administrator of the Nursing Home is an experienced professional who ensures that the facility meets the age specific needs of adults and geriatrics as well the physical, psychosocial, and cultural needs of the residents. Functions and duties include:
Assist with planning, organizing, controlling, and directing a viable program of services at Nursing Home.
Manage a program of patient services that allows resident the opportunity for input into the facility's operation
and to promote an environment that is conducive to the social, physical, psychological, and cultural health of
the patient population.
Ensure the facility's physical plan is maintained to OSHA guidelines and standards and that the physical
environment remains attractive and pleasant to residents and visitors.
Ensure compliance with State and Federal guidelines regarding Nursing Home operations.
Monitor in-service training and ensure that it is carried out on an on-going basis and encourage staff
development.
Attend organizational meetings, board meetings, and represent the Nursing Home in all matters.
Review of a policy titled Abuse Reporting and Investigation, last revised March 2017 revealed Implementation: Number 3.c. Interview the person(s) reporting the incident; d. Interview any witnesses to the incident; e. Interview the resident; f. and interview the resident's attending physician as needed to determine the resident's current level of cognitive function and medical condition; g. Interview staff members on all shifts who have had contact with the resident during the period of the alleged incident; i. interview other residents to whom the accused employee provides care or services; j. and review all events leading up to the alleged incident, and obtain the interviews in writing by the staff member or the administrator/abuse coordinator, notify the ombudsman, suspend the employee pending the progress/findings of the investigation. Number 5. Witness reports will be obtained in writing. Number 14. The Administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency.
1. On 7/12/2023, an allegation of exploitation was reported to the Administrator regarding a staff to resident personal relationship between CNA 1 and R71. The Administrator failed to identify this personal relationship as potential exploitation and did not investigate or report this allegation.
Cross Refer F602
2. On 3/8/2024, the Administrator was made aware of an injury of unknown origin for R71 and failed to investigate and report this incident.
Cross Refer F609 and F610
3. On 3/22/2024, the Administrator became aware of an allegation of employee to resident abuse towards R78, perpetrated by CNA 2. The Administrator did not identify this situation as abuse, did not protect R78 from CNA 2, failed to investigate this allegation, and failed to report the incident accurately.
Cross Reference F600 , F609 and F610
4. On 4/22/2024 the facility became aware of an allegation of mental and verbal abuse from CNA 2 to R107 and did not report or investigate the incident.
Cross Refer F600, F609, and F610
During an interview on 6/6/2024 at 9:20 am, the Administrator confirmed the incidents listed above were indicative of abuse to the residents, and were either not reported timely, and/or investigated thoroughly. He indicated he had misplaced the documentation related to the incidents.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to assist one resident (R) (R56) in obtaining identification for voti...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to assist one resident (R) (R56) in obtaining identification for voting purposes out of total sample of 27 residents reviewed for resident rights. This had the potential for a diminished quality of life and the failure to promote the resident's right to vote.
Findings include:
Review of R56's Record of Admission, located under the Clinical tab of the electronic medical record (EMR), revealed R56 was admitted to the facility on [DATE].
Review of R56's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/28/2024 and located under the Clinical tab of the EMR, revealed R56 scored 15 out of 15 on the Brief interview for Mental Status (BIMS), which indicated R56 was cognitively intact.
During an interview on 6/4/2024 at 11:42 am, R56 stated he needed assistance getting his license so he could vote. R56 stated when he went to vote last time, he only had a copy of his identification card, and they would not accept the copy, so his vote did not count. He indicated that it was important to him that he vote as he has never missed a vote in his life. R56 said the facility is aware of what he needs but no one has helped him.
During an interview on 6/5/2024 at 4:30 pm, the Activities Director (AD) stated he was aware that R56 needed to renew his identification card but confirmed he had not done anything about it.
During an interview on 6/6/2024 at 5:15 pm, the AD revealed he had taken R56 to get his identification card.
During an interview on 6/7/2024 at 2:00 pm, the Social Services Director (SSD) and the Director of Nursing (DON) verified that the AD would have been responsible for ensuring R56 had his identification card updated.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
Based on record review, interviews, and review of the policy titled Resident Transfer and Discharge Rights Policy and Procedure, the facility failed to ensure three of five residents (R1, R72, and R10...
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Based on record review, interviews, and review of the policy titled Resident Transfer and Discharge Rights Policy and Procedure, the facility failed to ensure three of five residents (R1, R72, and R101) and/or their representatives reviewed for facility initiated emergent hospital transfer were provided with written transfer notice that contained all required information. This failure has the potential to affect the resident and their representatives by not having the knowledge of where and why a resident was transferred, and/or how to appeal the transfer, if desired.
Findings include:
Review of the facility policy titled Resident Transfer and Discharge Rights Policy and Procedure, revised 6/2024 indicated the policy is to ensure that prior to resident transfer or discharge, whether voluntary or involuntary, resident transfer or discharge is necessary and if so, facility is in compliance with all regulatory requirements. Procedure: Number 6. Written Transfer Notification must include the following:
a. Notification must be an advance notice (either 30 days or as soon as practicable, depending on the reason for the transfer/discharge:
b. Reason for transfer/discharge
c. The effective date of the transfer or discharge
d. The location to which the resident was transferred or discharged
e. Statement that the resident has a right to appeal the action to the State of Georgia (facility will not discharge or transfer resident when an appeal is pending unless failure to transfer or discharge would endanger the health or safety of the resident or other individuals in the facility
f. Name, address, and telephone number of the State Long Term Care Ombudsman.
1. Review of R1's Face Sheet from the electronic medical record (EMR) Face Sheet report tab showed a facility admission date of 11/5/2008.
Review of R1's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 4/12/2024 showed a Brief Interview for Mental Status (BIMS) of 15, indicative of being cognitively intact.
During an interview on 6/5/2024 at 10:37 am, R1 stated he had just come back from the hospital, he thought it was for a urinary tract infection.
Review of R1's EMR Progress Notes revealed on 5/13/2024 at 2:17 pm, R1 was experiencing a change in mental status, increased weakness, and slurred speech; the physician was contacted and an order to send to the emergency room (ER) was received; emergency services were called for transport to the ER.
Further review of the EMR did not show any documentation of a written notice of transfer provided to R1 or his representative.
During an interview on 6/6/2024 at 5:55 pm, the Director of Nursing (DON) revealed she was not aware a transfer notice was required in writing and needed to be given to the resident and/or their representative. She revealed they call the doctor, EMS [Emergency Medical Services], and call the family to let them know.
During an interview on 6/7/2024 at 1:50 pm, with the representative of R1 revealed she was with him at a doctor's appointment, and she called and told the nurse his symptoms. When we got back to the facility the doctor was there and gave orders to send him to the hospital. The representative stated she did not receive anything in writing about the transfer.
2. Review of R72's Face Sheet from the EMR Face Sheet from the Report tab showed a facility admission date of 9/28/2022.
Review of R72's EMR Progress Note revealed on 5/30/2024 at 6:59 pm the nurse documented a change in mental status, decreased intake, increased sleeping, and a lack of response to stimuli; the physician was notified and an order to send to the ER was received; and R72's representative was notified by phone.
Further review of the EMR did not show any documentation of a written notice of transfer provided to R72 or her representative.
During a telephone interview on 6/7/2024 at 8:06 pm, the representative for R72 stated he had not been given a written transfer notice, was notified (by phone) and was at the hospital when R72 arrived.
3. Review of R101's Face Sheet from the EMR Reports tab showed a facility admission date of 3/19/2024.
Review of R101's Progress Note revealed on 3/15/2024 at 6:47 pm the nurse noted labored breathing and a decrease in his oxygen saturation. The nurse contacted the physician and received an order to send the resident to the ER for evaluation and treatment; the nurse contacted EMS for transport to the hospital.
Further review of the EMR did not show any documentation of a written notice of transfer provided to R101 or his representative.
During an interview on 6/7/2024 at 7:10 pm, the DON stated she would expect that we follow the regulations.
During an interview on 6/7/2024 at 8:10 pm regarding the emergent transfer process, Licensed Practical Nurse (LPN) 6 stated We tell them [resident], and we call the family. When specified if anything in writing was given to the resident or family, LPN 6 stated, No.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
MDS Data Transmission
(Tag F0640)
Could have caused harm · This affected 1 resident
Based on record review, interviews, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to ensure an annual Minimum Data Set (MDS) assessment was submitted within 14 day...
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Based on record review, interviews, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to ensure an annual Minimum Data Set (MDS) assessment was submitted within 14 days of completion to Centers for Medicare and Medicaid Services (CMS) Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) System for one resident (R) (R58) reviewed out of a total sample of 27. This failure had the potential to adversely affect the care planning and care provision for any resident that may not have received a comprehensive assessment.
Findings include:
Review of the October 2023 RAI Manual page 2-24 showed:
The ARD . must be set within 366 days after the ARD of the previous . comprehensive assessment (ARD of previous comprehensive assessment + 366 calendar days) AND within 92 days since the ARD of the previous . Quarterly . (ARD of previous . Quarterly assessment + 92 calendar days).
Review of R58's electronic medical record (EMR) Face Sheet from the Face Sheet tab showed a facility admission date of 9/28/2022.
Review of the MDS assessments received by Centers for Medicare and Medicaid Services (CMS) showed the last MDS received had an assessment reference date (ARD) of 1/15/2024.
The MDS Coordinator (MDSC) provided documentation for R58 of . Final Validation Report dated 5/30/2024 that the ARD of 4/11/2024 annual (comprehensive) MDS was not submitted until 5/30/2024 and, on page 4 of 52, showed Message: Record Submitted Late: The submission date is more than 14 days after V0200C2 on this new comprehensive assessment.
During an interview on 6/6/2024 at 10:50 am, the MDSC confirmed R58's assessment was submitted late, stating, The assessment was closed, and the care plan signature was in there, but the last audit was not done to actually close it and I didn't notice it.
In a follow-up interview on 6/6/2024 at 6:12 pm, the MDSC stated the facility did not have a policy regarding timely submission of assessments. She stated, We use the RAI Manual and follow that.
During an interview on 6/7/2024 at 7:00 pm, the Director of Nursing (DON) stated the expectation is that MDS assessments would be submitted within the RAI guidelines and confirmed the facility did not have a policy and used the RAI Manual.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of the policy titled Care Plan Meetings, the facility failed to ensure that three...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of the policy titled Care Plan Meetings, the facility failed to ensure that three residents (R) (R56, R44, and R17) of 27 sampled residents had scheduled care plan conferences after each assessment. In addition, the facility failed to ensure updated interventions were included on the comprehensive care plan for one resident (R3). This failure had the potential for residents not to be involved with their care decisions and potential unmet care needs.
Findings include:
Review of the undated policy titled Care Plan Meetings, revealed the policy is that each resident will have an individualized interdisciplinary care plan in place. The care plan will be ongoing, focusing on each individual resident as a unitary unit. Resident and their representative will play an active role in the development of goals and implementation of the residents Comprehensive care plan. Procedure: Number 5. The resident, resident representative, and IDT team members will sign attendance sheet at each comprehensive care plan meeting and this form will be scanned into the residents EMR. Number 7. The comprehensive care plan will be revised as needed and goals updated as appropriate.
1. Review of R56's Record of Admission, located under the Clinical tab of the electronic medical record (EMR), revealed R56 was admitted to the facility on [DATE] with a diagnosis of hemiparesis.
Review of R56's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/28/2024 revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated R56 was cognitively intact.
Review of the Care Plan Attendance Sheet provided by the MDS Coordinator (MDSC) dated 11/8/2023 revealed that R56 and a friend attended. The form did not indicate the type of assessment. This was the only care plan conference that was held since R56's admission.
Interview on 6/4/2024 at 11:42 am, R56 said he was never involved in planning his care but would like to be.
2. Review of R44's Record of Admission, located under the Clinical tab of the EMR revealed R44 was admitted to the facility on [DATE] with a diagnosis of dementia and seizure disorder.
Review of R44's quarterly MDS with an ARD of 2/26/2024 and located under the Clinical tab of the EMR, revealed a BIMS of 15 which indicated R44 was cognitively intact.
Review of the Care Plan Attendance Sheets dated 5/4/2023 and 8/31/2023 revealed that R44 attended. The form indicated the type of assessment was a quarterly assessment. These were the only care plan conferences that were held for R44 since admission.
3. Review of R17's Record of Admission, located under the Clinical tab of the EMR revealed R17 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's Disease.
Review of R17's significant change MDS with an ARD of 2/16/2024 and located under the Clinical tab of the EMR, revealed a BIMS score of 11 which indicated R17 was moderately impaired.
Review of the Care Plan Attendance Sheet dated 2/10/2023 revealed that R17 and two other unknown individuals attended. The form did not indicate the type of assessment. This was the only care plan conference that was held for R17 since admission.
During a group interview on 6/6/2024 at 10:00 am, members of the Resident Council (R88, R15, R17, R2, R44, R94 and R8), all seven residents revealed they had never been invited to a care plan conference and did not know that care plan conferences existed. R44 and R17 stated it would be important to them to be involved in planning their care. 4. Review of R3's Record of Admission, located under the Clinical tab of the EMR), revealed R3 was admitted on [DATE] with diagnosis of cerebral palsy.
Review of R3's quarterly MDS with an ARD of 3/12/2024 located under the MDS tab revealed the resident did not have a BIMS score.
Review of R3's June 2024 Physician Orders, revealed the following order dated 9/21/2023: Bilateral body pillows to be in place under fitted sheet when resident in bed for torso support Resident having no upper body core strength and having gastric feeding tube in place resident needs for support in attempt to keep resident upright and aide in possible prevention of aspiration.
Review of the care plan dated 12/23/2020 revealed R3 had impaired bed mobility. Interventions to care include assess for changes quarterly and as needed. The care plan did not address the resident's order for body pillows under the fitted sheet.
Observations on 6/5/2024 at 10:34 am, 6/5/2024 at 1:27 pm, 6/5/2024 at 5:14 pm, and 6/6/2024 at 8:30 am, revealed R3 was observed in bed without pillows under the fitted sheet.
During an interview on 6/6/2024 at 12:25 pm, MDS Coordinator (MDSC) stated she was currently working on the care plan conference process. She revealed since COVID the facility has not had care plan conferences. She said their new process would start today and they would be starting a Performance Improvement Plan (PIP) on this date. The MDSC said usually when it is time for R56's care conference, they do not invite him, only his responsible party.
During an interview on 6/7/2024 at 2:15 pm, R97's Family Members (FM)1 and FM 2 stated they are rarely informed about the status of R97 and were uncertain about the process. The family members indicated they would appreciate a care plan conference, so they would know more about what was going on with R97.
During an interview on 6/7/2024 at 3:35 pm, the Director of Nursing (DON) stated she was not aware that care plan conferences were not being conducted until R56 was discussed the day before. She said moving forward care conferences will happen because they are important.
Cross Refer F684
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff interviews, and review of the policy titled Physician Orders Policy and Procedure, t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff interviews, and review of the policy titled Physician Orders Policy and Procedure, the facility failed to follow the physician orders for one resident (R) (R3) related to using body pillows for positioning. This failure had the potential to put the resident at risk of aspirating. The sample size was 27.
Findings include:
Review of the policy titled Physician Orders Policy and Procedure revised 6/2024, revealed the nurse will carry out all physician orders within a timely manner. The nurse will notify the physician with any delay.
Review of R3's Record of Admission, located under the clinical tab of the electronic medical record (EMR), revealed R3 was admitted to the facility on [DATE] with a diagnosis of cerebral palsy.
Review of R3's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/12/2024 revealed the Brief Interview for Mental Status (BIMS) was not completed. The section to enter the BIMS was blank. It was documented the resident was rarely/never understood.
Review of R3's Physician Orders, revealed an order dated 9/21/2023 for bilateral body pillows to be in place under fitted sheet when resident in bed for torso support, resident having no upper body core strength, and having gastric feeding tube in place. Resident needs support in attempt to keep resident upright and aide in possible prevention of aspiration.
Review of the Kardex Summary located in the EMR under the Clinical tab revealed for fall interventions bilateral body pillows in place under fitted sheet for torso support.
During observations on 6/5/2024 at 10:34 am, 6/5/2024 at 1:27 pm, 6/5/2024 at 5:14 pm, and 6/6/2024 at 8:30 am, the resident was observed in bed without body pillows under the fitted sheet.
During an interview on 6/5/2024 at 5:16 pm, Certified Nurse Aide (CNA) 5 stated, he did not use pillows under the fitted bed sheet. He revealed he was not aware of the physician order to have pillows under the resident's fitted sheet.
During an interview on 6/5/2024 at 5:38 pm, Licensed Practical Nurse (LPN) 3 stated, she was not aware of the physician order for pillows under the fitted sheet and, she had never placed them under R3's sheet.
During an interview on 6/6/2024 at 11:10 am, LPN 5 confirmed she was aware of the physician orders for R3 to have pillows under his fitted sheet. She stated she did not know why the pillows were not in place or when they were removed. The LPN verified the pillows were not in place.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interviews, and review of the policy titled Departmental (Respiratory Therapy) - Preventio...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interviews, and review of the policy titled Departmental (Respiratory Therapy) - Prevention of Infection, the facility failed to provide respiratory care in accordance with professional standards for one resident (R) (R48) of two residents reviewed for respiratory care out of a total sample of 27 residents. Specifically, respiratory equipment was not stored in a sanitary manner. This had the potential for the resident to have possible respiratory infections.
Findings include:
Review of the policy titled Departmental (Respiratory Therapy) - Prevention of Infection, dated 2001, revealed the policy is to guide prevention of infection associated with Respiratory tasks and equipment. Infection Control Considerations . Medications: Number 3. After completion of therapy: a. remove the nebulizer container; b. rinse the container with fresh tap water; c. dry on a clean paper towel or gauze sponge. Number 4. Reconnect to the administration set-up when air dried. Number 5. Take care not to contaminate internal nebulizer tubes. Number 6. Wipe the mouthpiece with damp paper towel or gauze sponge. Number 7. Store the circuit in plastic bag, marked with date and resident's name, between uses.
Review of R48's Record of Admission revealed R48 was admitted to the facility on [DATE] with diagnosis of chronic obstructive pulmonary disease (COPD).
Review of the quarterly Minimum Data Set (MDS) for R48 with an Assessment Reference Date (ARD) of 4/25/2024 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating resident was cognitively intact.
Review of June 2024 Physician Orders revealed the following order dated 2/14/2024 for ipratropium bromide-albuterol sulfa (Albuterol Sulfate/Ipratropium Bromide 3 milligrams/milliter-0.5 MG/3 ML solution) 1 vial inhalation twice daily for COPD.
Observation on 6/5/2024 at 1:17 pm, revealed R48's nebulizer medication chamber still had medication in it. It had not been rinsed and was not stored in the plastic storage bag.
Interview on 6/5/2024 at 2:44 pm, R48 stated staff placed the medication chamber and tubing in the basket behind her bed and did not rinse it out. She revealed when she first received the device, the instructions indicated to boil the mouthpiece and medication chamber for five minutes after use.
Interview on 6/5/2024 at 2:52 pm, Registered Nurse (RN) 1 verified that medication was still in the medication chamber and, the medication chamber, mask and tubing were not bagged. She stated she should have rinsed the medication chamber after the medication was administered, and the equipment should have been rinsed, dried, and placed in the plastic bag.
Interview on 6/5/2024 at 3:29 pm, the Director of Nursing (DON) stated the nurses administering the nebulized breathing treatments should wash the equipment after each use with soap and water, dry it with a paper towel, and then place the items in the storage bag.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and review of the policy titled 10.b Medication Regimen Review, the consultant pharmac...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and review of the policy titled 10.b Medication Regimen Review, the consultant pharmacist failed to identify and report irregularities regarding an order for PRN (as needed) lorazepam (antianxiety medication) beyond 14 days and to include a written rationale and duration for continuing its use, for one resident (R) (R24) reviewed for psychotropic medications from a total of 27 sampled residents.
Findings include:
Review of the policy titled 10.b Medication Regimen Review revised 5/2020 revealed Procedure: A. The consultant pharmacist will conduct medication regimen reviews (MRRs) if required under a pharmacy consultant agreement and will make recommendations based on the information available in the residents health record.
Review of the clinical record revealed was admitted to the facility on [DATE] with diagnosis of dementia.
The resident's annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was coded as 15, which indicated no cognitive impairment. Section N revealed that the resident received antianxiety medications.
Review of the June 2024 Physician Orders revealed an order dated 5/9/2023 for lorazepam 0.5 milligrams (mg) tablet, one tablet by mouth as needed [PRN] TID [three times a day] for anxiety.
Review of R24's Medication Regimen Review (MRR) from 5/2023 through 5/2024 provided by the Director of Nursing (DON) did not reveal any recommendations from the pharmacist to address the lack of a 14-day stop date or for the physician to provide a rationale to continue the lorazepam.
Review of R24's EMR revealed no documentation by the resident's physician regarding the clinical rationale for continued use of lorazepam.
During a phone interview on 6/7/2024 at 10:47 am, Physician (PHY) 1 was contacted regarding the lorazepam order. He confirmed he did not document the rationale for the continued use of lorazepam.
During an interview on 6/7/2024 at 11:35 am, Licensed Practical Nurse (LPN) 1 stated they did not have any documentation showing pharmacy recommendations regarding the resident's lorazepam.
During an interview on 6/7/2024 at 11:47 am, the Pharmacist verified the monthly MRRs did not address the lorazepam and no recommendations were made.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and review of the policy titled Physician Orders Policy and Procedure, the facility fa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and review of the policy titled Physician Orders Policy and Procedure, the facility failed to ensure that as needed (PRN) order for antianxiety medication was limited to 14 days and failed to document the rationale for the extended duration for the PRN order for one of five residents (R) (R24) reviewed for unnecessary medications.
Findings include:
Review of the policy titled Physician Orders Policy and Procedure revised 6/2024 revealed Procedure Number 4. All medication orders must have a route, dose, frequency, and diagnosis. Time frames, stop dates, and quantities must be specific. Number 5. The Physician will be notified of any need for clarification or additional orders if needed.
Review of R24's Record of Admission revealed resident was admitted to the facility on [DATE] with diagnosis of dementia in other diseases classified elsewhere, mild, with psychotic disturbance.
Review of the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/27/2024 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R24 was cognitively intact.
Review of the June 2024 Physician Orders revealed the following order dated 5/9/2023 for lorazepam 0.5 milligrams (mg) tablet, one tablet by mouth as needed [PRN] TID [three times a day] for anxiety.
Review of the care plan dated 4/5/2024 indicated resident is at risk for side effects from psychotropic medication - receives antidepressant medication. Interventions to care include allow the resident to express feelings of sadness/anxiety and be a good listener, behavioral health services as needed, antipsychotic, antidepressant, and anti-anxiety medications as ordered. Ativan was added 4/21/2024.
Review of R24's EMR revealed there was no documentation by the resident's physician of the clinical rationale for the continued use of lorazepam, PRN.
Interview on 6/7/2024 at 10:26 am, Registered Nurse (RN) 1 stated she was aware that there needed to be a 14-day stop date for all antianxiety and antipsychotic medications that are ordered PRN. During further interview, she stated she was not aware the physician needed to provide a rationale if the medication was going to be continued.
During a phone interview on 6/720/24 at 10:47 am, Physician 1 was contacted regarding the lorazepam order. He stated due to the diagnosis Parkinson's disease and the anxiety related to that diagnosis he felt the continued use greater than 14 days was warranted and justified. He stated he was aware the rationale should be documented in his progress note.
During an interview on 6/7/2024 at 11:35 am, Licensed Practical Nurse (LPN) 1 verified they did not have any documentation showing a 14-day stop date regarding the resident's PRN lorazepam.
During an interview on 6/7/2024 at 11:47 am, the Pharmacist stated R24 began having behaviors in May and the lorazepam was added for PRN use. During further interview, the Pharmacist stated she was aware of the 14-day stop date requirement but did not provide an explanation of why it was not addressed.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0700
(Tag F0700)
Could have caused harm · This affected multiple residents
Based on observations, record review, interviews, and review of the policy titled Proper Use of Side Rails, the facility failed to ensure that informed consents were signed prior to the use of bedrail...
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Based on observations, record review, interviews, and review of the policy titled Proper Use of Side Rails, the facility failed to ensure that informed consents were signed prior to the use of bedrails for four of 27 sampled residents (R) (R1, R45, R72, and R78) reviewed for bed rail use. The failure had the potential for risks of injury, entrapment, and/or death.
Findings include:
Review of the policy titled Proper Use of Side Rails, revised December 2016, revealed the policy is to ensure the safe use of side rails as resident mobility aids. General Guidelines: Number 9. Consent for side rail use will be obtained from the resident or legal representative, after presenting potential benefits and risks.
1. Review of R1's Face Sheet from the electronic medical record (EMR) Face Sheet report tab showed a facility admission date of 11/5/2008.
The residents quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 4/12/2024 revealed a Brief Interview for Mental Status score of 15 out of 15, indicative of being cognitively intact.
Review of the care plan for R1 dated 12/17/2021 documented resident has impaired bed mobility and uses bilateral upper quarter-length side rail to assist with bed mobility, turning, and repositioning. Interventions to care include monitor for safety, provide frequent visual checks, assist in turning, repositioning, pulling up in bed as needed, and assess for changes quarterly.
Review of the 8/22/2020 (first) and 4/10/2024 (most recent) bed rail assessments showed bed rail precautions and alternatives to siderails had been discussed with R1 for the first assessment and the family/resident representative for the most recent.
Review of the 12/14/2020 quarterly restorative Interdisciplinary Progress Notes (IPN) written by Registered Nurse (RN) RN3 documented Resident has order for one bed rail but has requested two bed rails with turning and repositioning in bed, risks and benefits of bed rail use discussed with resident and resident wife. However, there wasn't an informed consent signed located in the EMR.
During an observation and interview on 6/5/2024 at 10:40 am, R1 was noted to have bilateral upper quarter rails on his bed. When asked if he used them, R1 responded I hate these damn things, they antagonize me. When asked if he had been advised of the risks/benefits of the rails, he stated, No risk/benefits - I hate them damn things.
2. Review of R45's Face Sheet from EMR Face Sheet report tab showed a facility admission date of 12/16/2020.
The residents quarterly MDS with an ARD of 3/11/2024 revealed a Brief Interview for Mental Status score of 15 out of 15, indicative of being cognitively intact.
Review of the care plan for R45 dated 12/16/2020 documented resident has impaired bed mobility and uses bilateral upper quarter-length side rail to assist with bed mobility, turning and repositioning, and to access his bed controls. Interventions to care include monitor for safety while in bed, provide frequent visual checks, assist in turning, repositioning, pulling up in bed as needed, and assess for changes quarterly.
Review of the 12/28/2020 (first) and 2/14/2024 (most recent) bed rail assessments for R45 showed siderail precautions and alternatives to siderails had been discussed with family/representative. However, there was no signed consent form found in the EMR.
Review of the 12/28/2020 restorative IPN written by RN3 documented resident has bilateral upper bedrails and risks/benefits had been discussed with the resident and wife. However, there was no signed consent form found in the EMR.
During an interview and observation on 6/420/24 at 2:14 pm, it was observed that R45 had one upper quarter bed rail on the window side of the bed. When asked if anyone had reviewed the risks and/or benefits of the bed rail, R45 stated, No, not said anything to me.
3. Review of R72's Face Sheet from the EMR Face Sheet report tab showed a facility admission date of 9/28/2022.
The residents quarterly MDS with an ARD of 3/19/2024 revealed no BIMS score and the resident was rarely or never understood.
Review of the care plan for R72 dated 9/30/2022 documented resident has impaired bed mobility and uses bilateral upper quarter-length side rail to assist with bed mobility and turning and repositioning. Interventions to care include monitor for safety while in bed, provide frequent visual checks, assist in turning, repositioning, pulling up in bed as needed, and assess for changes quarterly.
Review of the 9/30/2022 (first) and 3/5/2024 (most recent) bed rail assessments for R72 showed siderail precautions and alternatives to siderails had been discussed with family/representative. However, there was no informed consent found with the family and/or representative in the EMR.
During an observation on 6/4/2024 at 12:09 pm, R72 was out of the room but the bed had one upper quarter rail in the up position on the window side of the bed.
During an observation of R72's bed on 6/7/2024 at 10:54 am, bilateral upper quarter rails now wrapped in pipe insulation padding. Registered Nurse (RN)1 was outside the door and said, The padding was added yesterday because she fell out of bed and hit her cheek on the siderail. When asked if R72 used the rails, RN1 replied Yes - to turn and reposition, that's how she fell out of the bed.
4. Review of R78's Face Sheet from the EMR Face Sheet report tab showed a facility admission date of 2/2/2023.
Review of the significant change of status MDS with an ARD of 3/21/2024 revealed a BIMS score could not be obtained and the resident was rarely or never understood.
Review of the care plan for R78 dated 2/14/2024 documented resident has impaired bed mobility and uses 1-2 upper quarter-length side rail(s) to assist with bed mobility, turning and repositioning, and bed controls. Interventions to care include monitor for safety while in bed, provide frequent visual checks, assist in turning, repositioning, pulling up in bed as needed, and assess for changes quarterly.
Review of the 2/2/2023 (first) and 3/4/2024 (most recent) bed rail assessments for R78 showed siderail precautions and alternatives to siderails had been discussed with family or representative.
Review of the 4/20/2023 restorative IPN written by RN4 documented resident demonstrates proper use of upper bilateral quarter length side rails for turning, and repositioning. There was no signed consent form found in the EMR.
During an observation of R78's room on 6/4/2024 at 10:15 am, the bed had bilateral upper quarter rails in the up position.
During an interview on 6/7/2024 at 7:19 pm, the Director of Nursing (DON) stated the expectation was that the facility would attempt alternatives before side rails were used and that they do assess the resident; that risk/benefits would be advised, and it is documented who is being advised.
No signed consents were provided for any of the four residents above by the time of the exit conference.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on observations, interviews, and review of the policy Titled Copy of 5.d Storage and Expiration of Medications, Biologicals, Syringes, and Needles, the facility failed to ensure expired medicati...
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Based on observations, interviews, and review of the policy Titled Copy of 5.d Storage and Expiration of Medications, Biologicals, Syringes, and Needles, the facility failed to ensure expired medications were removed from one of two medication carts, failed to remove expired phlebotomy supplies for one of two phlebotomy carts, and one of two medication rooms. This had the potential to affect any resident who might be administered expired medications/use of expired supplies. The census was 104.
Findings include:
Review of the undated policy titled Copy of 5.d Storage and Expiration of Medications, Biologicals, Syringes, and Needles revealed Procedure: C.9. Nursing staff will monitor for expired drugs and cleanliness of medication room/medication carts once weekly. Procedure: D. Facility should ensure that medications and biologicals: (1) have an expiration date on the label; (2) have been retained longer than recommended by the manufacturer or supplier guidelines; or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the pharmacy or supplier.
1. Observation on 6/6/2024 at 9:27 am in the Blue Hall medication room, the following expired items were found:
One bottle Pro- Stat (protein) expired 4/2024
One bottle Pro-Stat expired 3/2024
One bottle Co-Q-10 100 milligrams (mg) tabs expired 5/2024
One bottle Zinc Sulfate 220 mg expired 4/2024
One bottle Zinc Sulfate 220 mg expired 3/2024
One box L-Methylfolate Calcium Tablets expired 4/2024
One box L-Methylfolate Calcium Tablets expired 10/2023
Seven boxes of Omeprazole 20 mg tablets expired 5/2024
One box Omeprazole 20 mg tablets expired 12/2023
One box Omeprazole 20 mg tablets expired 2/2024
One box Pink Bismuth anti-diarrheal 30 chewable tablets expired 5/2024
Four boxes of Omeprazole acid reducer 20 mg tablets expired 5/2024
One box Saccharomyces Boulardii (probiotic) 250 mg capsules expired 5/2024
One bottle Iron supplement liquid expired 2/2023
One bottle Centrum Adults expired 2/2024
Interview on 6/6/2024 at 9:27 am, Registered Nurse (RN) 2 verified the expiration dates and, confirmed that the medications were still available for resident use. She stated the expired medications should be given to the Director of Nursing (DON) for destruction.
Interview on 6/6/2024 at 9:50 am, Licensed Practical Nurse (LPN) 4 stated the expiration dates should be checked upon receiving the medications from the pharmacy. The LPN stated the night shift nurses were responsible for checking the medication room for expired medications.
2. Observation and interview on 6/6/2024 at 2:07 pm, the phlebotomy cart located at the nurses' station between the pink and green halls revealed one black top vacutainer tube that expired on 6/2/2024; one container (85 tubes) of light blue top vacutainer tubes expired on 12/31/2023. RN 1 verified the expiration dates and confirmed they were still available to be used.
3. Observation on 6/6/2024 at 2:10 pm, the Green Hall medication cart was inspected with LPN 5 and revealed one card of discontinued oxycodone (narcotic pain medication) 15 mg with 78 tablets was on the cart. The LPN stated that discontinued narcotics should be removed from the cart the day they are discontinued. LPN 5 verified the oxycodone medication was discontinued.
Interview on 6/6/2024 at 2:20 pm, the DON stated expired medications should not be available for use on medication carts or in the medication room. She stated they should be removed immediately.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0809
(Tag F0809)
Could have caused harm · This affected multiple residents
Based on observations and resident and staff interviews, the facility failed to ensure that meals were served according to resident preferences and designated meal times for 50 residents on the green ...
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Based on observations and resident and staff interviews, the facility failed to ensure that meals were served according to resident preferences and designated meal times for 50 residents on the green and pink halls.
Findings include:
Interview on 6/4/2024 at 9:30 am, the Registered Dietician (RD) and the Dietary Manager (DM) stated the designated meal times were: Breakfast was to be served at 8:00 am, Lunch to be served at 12:00 pm, and Dinner was to be served at 5:00 pm.
Interview on 6/4/2024 at 1:39 pm, R48 stated she had not received her lunch yet. At that moment, a staff member entered the room with her tray. R48 stated the trays should be there at noon or 12:30 pm. Her roommate also did not have a tray and revealed it was supposed to be noon.
Interview on 6/4/2024 at 2:08 pm, R45 stated he had not received his lunch tray. The interview ended at 2:25 PM and the lunch tray had still not arrived.
During a group interview on 6/6/2024 at 10:00 am with members of the Resident Council (R88, R15, R17, R2, R44, R94 and R8), residents confirmed meal delivery was consistently late. R88 and R15 said dinner was sometimes so late it affected their acid reflux. R17 and R55 expressed concerns about having lunch so late because they were diabetics and received insulin. R17 stated sometimes lunch is served as late as 2:15 pm.
Observation on 6/6/2024 at 1:31 pm (an hour and a half after the scheduled time), lunch trays for 24 residents were observed to arrive on the pink hall. Continued observation revealed the last tray on the hall was served at 1:51 pm.
Interview on 6/6/2024 at 1:57 pm, Certified Nurse Aide (CNA) 9 revealed room trays always come late. She said she has seen them come as late as 3:00 pm.
Interview on 6/6/2024 at 2:00 pm, CNA10 confirmed that room trays always come late. She said they are supposed to make round on their residents between 2:00 pm - 4:00 pm daily and it is difficult when lunch is served so late.
Interview on 6/6/2024 at 2:12 pm, CNA 11 said lunch trays always come around this time or later. She said when trays come so late it makes it difficult to complete other work because residents are eating. She said residents frequently complain about how long it takes to get their meals.
Interview on 6/7/2024 at 1:30 pm, R45 stated he had not yet received his lunch tray.
Observation on 6/7/2024 at 1:45 pm (an hour and 45 minutes after the scheduled time), lunch trays for 26 residents were observed to arrive on the green hall. Continued observation revealed the last tray on the hall was served at 2:19 pm.
Observation on 6/7/2024 at 1:50 pm, eight residents were observed on the green hall, sitting outside their rooms, waiting for their lunch. R81 said we always eat lunch late. R52 agreed saying, usually we don't get lunch earlier than 2:00 pm. R52 stated she was hungry since breakfast was served earlier this morning.
Observation and interview on 6/7/2024 at 2:15 pm, family members (FM) 1 and FM 2 for R97 were observed giving him a protein shake. FM 2 revealed the lunch trays were always served late and they were not sure why. They said that's too late for lunch, and R97 agreed.
Interview on 6/7/2024 at 6:54 pm, the DM said room trays are late because of the lack of communication between nursing and dietary staff. He said having a list of who is coming into the dining room would help with room trays being served earlier.
Interview on 6/7/2024 at 7:06 pm, the Director of Nursing (DON) stated the expectation is that meal service would be timely, all day should be timely.
Interview on 6/8/2024 at 11:27 am, License Practical Nurse (LPN) 4, the Unit Manager for Pink Hall and LPN 2, the Unit Manager for [NAME] Hall, stated they were not aware that meals were served as late as 2:00 pm at times. They both agreed that receiving meals at 2:00 pm was too late and said serving a meal late impacts other resident care that staff need to complete.
A policy for meal service and/or mealtimes was requested. The policy was never provided.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0909
(Tag F0909)
Could have caused harm · This affected multiple residents
Based on interviews, review of facility's Nursing Home Inspection Report Upon Receipt of Equipment, review of the Food and Drug Administration (FDA) guidelines, and review of the policy titled Proper ...
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Based on interviews, review of facility's Nursing Home Inspection Report Upon Receipt of Equipment, review of the Food and Drug Administration (FDA) guidelines, and review of the policy titled Proper Use of Side Rails, the facility failed to ensure bed rails were inspected for safety to minimize the risks of possible entrapment or resident injury for 90 resident beds out of 104. This failure had the potential to cause serious injury to all 90 residents in the facility using a bed with bed rails attached.
Findings include:
Review of the policy titled Proper Use of Side Rails, revised in December 2016, revealed the policy is to ensure the safe use of side rails as resident mobility aids. General Guidelines: Number 13. When side rail usage is appropriate, the facility will assess the space between the mattress and side rails to reduce the risk of entrapment (the amount of safe space may vary depending on the type of bed and mattress used).
Review of the Nursing Home Inspection Report Upon Receipt of Equipment provided by the facility and completed annually, documented items inspected included electrical and bed function. There was nothing noted regarding the review of the bed rails for secure attachment and/or gaps that the US Department of Health and Human Services: FDA guidelines dated 3/10/2006 that showed the measurements for the bed rails to reduce the chance of resident entrapment when using bed rails.
During an interview on 6/7/2024 at 9:55 am, Maintenance Worker (MW) confirmed that they did not perform safety checks on resident beds with side rails.
Review of a resident list compiled by Restorative Nurse Aide (RNA) on 6/7/2024 at 8:05 pm revealed that 90 of 104 residents in the facility have one or two side rails on their beds.
During an interview on 6/7/2024 at 7:14 pm, the Director of Nursing (DON) stated the expectation was that maintenance would inspect the beds, including bedrails for safety and security.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected most or all residents
Based on record review, interview, and review of the policy titled Grievance Policy, the facility failed to ensure that grievances were promptly and thoroughly resolved and/or responded to for one res...
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Based on record review, interview, and review of the policy titled Grievance Policy, the facility failed to ensure that grievances were promptly and thoroughly resolved and/or responded to for one resident (R) (R107) out of 27 sampled residents. Additionally, the facility failed to have a process in place for residents to file a grievance anonymously. This had the potential to affect all of the residents of the facility.
Findings include:
Review of the facility's policy titled, Grievance Policy, dated May 2022 revealed the policy of the facility is to assist residents and their family members or advocates in filing grievances when such requests are made. Procedure: Number 1. Any resident, his/her representative, family member, or advocate may file a grievance concerning his/her treatment, medical care, behavior of other residents, staff members, theft of property, etc. without fear of threat or reprisal in any form. Number 3. The Administrator has delegated the responsibility of the grievance investigation to the Social Services department. Number 4. Upon receipt of the grievance the social worker will determine which department head or heads need to investigate the allegations and submit a written report of such findings to the Administrator within five working days of receiving the grievance. Number 6. The resident, or person filing the grievance will be informed of the findings f the investigation and the actions that will be taken to correct any identified problems.
Review of a Grievance Form dated 4/22/2024 documented that R107 submitted a grievance form to Social Services Director (SSD). The grievance read, SS (social services) received a message from resident's granddaughter that the resident was not allowed to use the bathroom over the weekend. SS spoke with resident who advised the Certified Nurse Aide (CNA) when resident asked to get up for bedside toilet the CNA told the resident to use her pull up. Resident advised that the CNA did not get her up, did not take her to the bedside toilet, and kept her in bed all weekend. Resident said she did not get up out of the bed until Monday 4/22/2024. Resident advised that she was given an enema Friday, and it did not feel right to her to be made to use the bathroom on herself. The Investigation portion of the Grievance Form read Spoke with the staff member in charge of resident. She stated that resident asked her to help her get on BSC (bed side commode). Staff member then informed resident that since she just had an enema, they [sic] may not make it to the toilet. Staff member also reported that resident did not go to sleep until after 4:00 am and she voiced she was tired. The Action Taken was blank. The Person making the complaint has been informed of results was blank. The investigating employee was the Director of Nursing (DON), dated 4/24/2024 and the Administrator signed the document on 5/1/2024.
During an interview on 6/6/2024 at 3:23 pm, the Administrator said the incident, from 4/22/2024, when CNA spoke rudely to R107 was documented on a grievance form and then staff completed education. He said the CNA should always report something like that and then it should be documented on a grievance form. The Administrator said he was typically the grievance coordinator. He said that any grievance should go to the correct department who can address the grievance and then they should follow up with the resident and the family. He said when a grievance comes up in a Resident Council meeting then the Activity Director (AD) should write it on the grievance form and get them to the right department. He confirmed he currently didn't have a grievance form that residents and family members could access and submit anonymously if they chose to.
During an interview on 6/7/2024 at 3:35 pm, the Director of Nursing (DON) stated that completing a grievance form was important. She indicated if the grievance involved nursing then she would be involved with the investigation. She stated the SSD will be involved in every grievance.
Cross Reference F600.
MINOR
(C)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Minor Issue - procedural, no safety impact
Staffing Information
(Tag F0732)
Minor procedural issue · This affected most or all residents
Based on observation and staff interviews, the facility failed to ensure that the daily nurse staffing posted included the name of the facility, the facility census, and the total number and the actua...
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Based on observation and staff interviews, the facility failed to ensure that the daily nurse staffing posted included the name of the facility, the facility census, and the total number and the actual hours worked by the licensed and unlicensed nursing staff directly responsible for resident care per shift. display contained the required information for residents, visitors, and/or staff. This failure could affect the knowledge of the family members or representatives of the 104 residents in the facility.
Findings include:
During an observation on 6/4/2024 at 9:15 am of the nursing staff posting on the wall in the lobby of the facility revealed a grid chart with all 30 days of June with the first three days filled out with the numbers of staff for each of the following staffing categories for each of three eight-hour shifts (days, evenings, nights - no ward clerk):
*Registered Nurse (RN)
*Licensed Practical Nurse (LPN)
*Certified Nurse Aide (CNA)
*Ward Clerk (WC)
The staff posting did not show the name of the facility, the census for each shift, or the total number of hours for each category.
Review of the April and May 2024 staff posting documents provided by the facility showed the entire months and the number of staff for each category, but not the facility name, census, or total number of hours worked for each staffing category.
During an interview on 6/7/2024 at 9:33 am Human Resources (HR) staff stated she was responsible for the staff posting, and stated it may not be every day, the numbers are not the day of, but usually the day after. At 4:12 pm, the HR staff stated there was no policy regarding the nurse staff posting.
During an interview on 6/7/2024 at 7:03 pm, the Director of Nursing (DON) stated the expectation was that the staff posting would contain all the required elements. The DON confirmed the posting did not contain all the required elements.
Dec 2022
8 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, family and staff interviews, and review of the policy titled Abuse Reporting and Investigation , the fac...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, family and staff interviews, and review of the policy titled Abuse Reporting and Investigation , the facility failed to report an injury of unknown source for one resident (R) of four residents, (R#25). Specifically, the facility failed to submit a report of an injury of unknown source involving R#25, to the State Agency within two hours of discovery.
Findings include:
Review of the policy titled, Abuse Reporting and Investigation dated March 2017 indicated,
Statement of Purpose:
All reports of resident abuse, neglect and injuries of unknown source shall be thoroughly and promptly investigated by the facility.
Implementation:
1.
Should an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source be reported, the Administrator and/or Director of Nursing (DON), will appoint a member of management to investigate the allege incident
2.
The Administrator/DON will provide any supporting documents relative to the alleged incident to the person in charge of the investigation.
14. The Administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency, the local police department, the ombudsman, and others as may be required by state of local laws, within five working days of the reported incident.
Review of the Electronic Medical Record (EMR) for R#25, revealed a most recent Minimum Data Set (MDS) assessment dated [DATE]. Further review of the MDS revealed a Brief Interview for Mental Status (BIMS) score of 99 which indicated that R#25 is cognitively impaired. R#25 has diagnoses that include but are not limited to There were no behaviors noted. R#25 requires extensive assistance for all activities of daily living (ADLs) and limited assist for meals. R#25 is incontinent of bowel and bladder and receives restorative range of motion.
Review of incident reports and the file of facility reportable incidents revealed that a report was not filed regarding the incident / injury with unknown source which occurred in January of 2022 involving R#25.
Interview on 12/14/2022 at 1:30p.m., Registered Nurse (RN) CC revealed that there was no evidence that a report regarding R#25's injury was filed or that it was investigated. She confirmed that the report should have been filed within the first two hours of discovery.
Interview on 12/14/2022 at 2:30 p.m., the Director of Nursing (DON) revealed when a resident is discovered to have an injury, a report must be filed with state within two hours of discovering the injury. The DON revealed there was no record of the injury being reported to the state.
Interview on 12/15/2022 at 10:00 a.m., the Administrator revealed that he usually did the reporting, but the nursing staff have been educated in state reporting as well. He stated that the expectation is that it should be done within two hours of discovery.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, family and staff interviews, and review of the facility policy titled, Abuse Reporting and Investigation...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, family and staff interviews, and review of the facility policy titled, Abuse Reporting and Investigation , the facility failed to investigate and report an injury of unknown source for one of four residents (R) R#25. Specifically, the facility failed to conduct an investigation of an injury of unknown source for R#25 as required.
Findings include:
Review of the facility policy titled, Abuse Reporting and Investigation dated March 2017 indicated under,
Statement of Purpose:
All reports of resident abuse, neglect and injuries of unknown source shall be thoroughly and promptly investigated by the facility.
Implementation:
1. Should an incident or suspected incident of resident abuse, mistreatment, neglect, or injury of unknown source be reported, the Administrator and/or Director of Nursing (DON), will appoint a member of management to investigate the allege incident.
9. The individual in charge of the investigation will consult daily with the Administrator concerning the progress/ findings of the investigation.
10. The Administrator will keep the resident and his/her representative informed of the progress of the investigation.
11. The results of the investigation will be recorded on approved documentation forms.
A review of the residents Electronic Medical Record (EMR) revealed R#25 is an [AGE] year-old year old female with diagnoses to include but not limited to- Alzheimer's Dementia, weakness, Adult failure to thrive, and Contracture of the left hand. Review of Minimum Data Set (MDS) Annual review dated 11/8/2022 Section C (Cognitive Pattern) revealed Brief Interview of Mental Status (BIMS) score of 99 indicating resident was cognitively impaired, Section E (Behaviors) No behaviors noted, Section G (Functional Status) Requires extensive assist for all ADL's.
Review of an incident report for R#25 revealed the report was completed on 1/20/2022 at 11:07 p.m. with documentation of a Certified Nursing Assistant (CNA) reported to a nurse that the resident was rubbing her forehead saying it hurt. The nurse assessed resident; resident had a golf ball size knot between her eyebrows on her forehead with slight purple discoloration. The CNA stated she did not know where the bruise came from and that nothing happened while she was in resident's room. Medical Doctor (MD) was made aware at 11:10 p.m. that resident had bruise and Knot on forehead of unknown origin. MD gave orders to apply ice pack two times for 15 minutes each time. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) to be notified in the AM. Continued review of the incident report revealed that abuse nor neglect was not indicated, and there was no indication the incident was investigated or reported to State Agency.
A review of the facility reported Incidents for 2022 revealed there was not a report filed regarding the incident / injury with unknown source for R#25 which occurred in January of 2022.
Interview on 12/14/2022 at 12:25p.m. with CNA DD revealed the family had concerns about the bruise and knot on her head in January because they did not know what caused it. Continued interview revealed that R#25 does not climb out of bed and cannot turn over or reposition herself independently. Further interview also revealed the family was concerned with the failure of the facility to report the incident to the state or investigate.
Interview on 12/14/2022 at 1:30 p.m. with Registered Nurse (RN) CC revealed she had looked for a state report regarding R#25's injury but had not found any evidence a report was ever filed. Further interview also revealed the report should have been done within the first two hours and all nurses have been trained to file state reports.
Interview on 12/14/2022 at 2:30 p.m. with the DON revealed when a resident is discovered to have an injury it should be investigated, and a report filed with the state within two hours. Continued interview revealed all nursing staff have received education to fill out reports if the Administrator or DON is not available and then to make sure they reported it to the Administrator who serves as the facility abuse coordinator. The DON revealed there was no record of the injury being reported to the state.
Interview on 12/15/2022 at 10:00 a.m. an interview with the Administrator revealed he is the abuse coordinator for the facility and usually did the reporting, but the nursing staff have been educated on state reporting and it should be done within two hours of discovery. Continued interview revealed it is his expectation that incidents be reported as soon as possible but, the incident in January involving R# 25 was never reported to the State or investigated.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interview the facility failed to ensure that one resident (R) of 25 residents, R#53, was refer...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interview the facility failed to ensure that one resident (R) of 25 residents, R#53, was referred to the appropriate state designated authority for a Preadmission Screening and Resident Review (PASARR) Level II for the evaluation and determination of specialized services. This deficient practice had the potential to affect the appropriate level of care and services provided for R#53.
Findings include:
The facility did not have a policy, procedure, or formal guidance for PASARR Level II.
Review of the electronic medical record (EMR) for R#53 revealed an admission date of 6/11/2020.
Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 99 (indicating resident was unable to complete the interview). The MDS revealed R#53 required extensive assistance to total dependence for all ADLs (activities of daily living). The assessment revealed that the resident had diagnoses that included, but not limited to anxiety, depression, and post-traumatic stress disorder (PTSD). The resident received antianxiety (Ativan 0.5mg. three times a day), antidepressant (Zoloft 50mg every day) and opioid (Norco 325mg/5mg for pain) medications seven days of the assessment seven day look back period.
Review of the care plan dated 11/18/2022 revealed R#52 had potential for altered mood and increased anxiety, diagnosis of depression and resident is afraid of the dark.
Interventions included to administer medications as ordered, notify physician immediately for suicidal behaviors, self-harm, or harm behaviors to others, ensure resident has night light on at night.
Review of the EMR revealed a PASARR Level I request was dated 6/11/2020. Additional review reveled there was no PASARR Level II for R#53.
Interview on 12/14/2022 at 2:20 p.m., the Director of Nursing (DON) and Registered Nurse (RN) CC verified that R#53 was admitted on [DATE] and received physician's diagnoses of PTSD and anxiety on 11/13/2021. Both confirmed the absence of PASARR Level II in resident's EMR and stated that a referral for a PASARR Level II should have been made within one month of the diagnosis of PTSD. The DON and RN CC revealed new diagnoses are normally discussed at weekly meetings and R#53's diagnosis of PTSD must have gone unnoticed. RN CC stated that a referral was sent on 12/14/2022.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, resident and staff interviews, and review of the facility policy titled, Initial admission...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, resident and staff interviews, and review of the facility policy titled, Initial admission Care Plan Policy and Procedure, the facility failed to follow the care plan for activities of daily living (ADLS), specifically related to showers and nail care, for one resident (R) (R#8), The sample size was 25. This deficient practice had the potential to affect the delivery of the proper care and services provided to R#8
Findings include:
Review of the policy titled Initial admission Care Plan Policy and Procedure with a revision date of 4/2020 revealed:
Policy: The facility will develop a baseline care plan to ensure proper resident center care is provided.
Procedure:
a. The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care.
Review of the electronic medical record (EMR) for R#8 revealed an admission date of 5/15/2019 with diagnoses that included but are not limited to, major depressive disorder, weakness, bipolar disorder, heart failure, type 2 diabetes mellitus with diabetic polyneuropathy idiopathic gout, macular degeneration.
Review of the most recent quarterly Minimum Data Set (MDS) dated [DATE], revealed Brief Interview for Mental Status (BIMS) coded as 15, indicating is cognitively intact. The MDS assessment also revealed R#8 required extensive assist of two persons for all ADLs including personal hygiene and required total assistance for bathing.
Review of the care plan dated 3/31/2021, revealed R#8 had ADL/self-care deficit due to functional losses and required assisted care to meet needs. Interventions included to provide assistance with ADL care needs to the extent needed.
Review of the EMR for R#8 did not reveal evidence of documented refusals of care in the nurse's notes during the last three months.
Review of the shower/bath documentation for R#8 revealed she received a shower three times from 9/12/2022 to 9/30/2022, five times from 10/120/22 to 10/31/2022, seven times from 11/1/22 to 11/30/2022 and 2 times from 12/1/2022 to 12/14/2022.
Observations on 12/13/2022 at 10:15 a.m., 12/14/2022 at 8:15 a.m., and 12/14/2022 at 12:22 p.m. revealed R#8 had long, jagged, and dirty fingernails.
Observation and interview on 12/14/2022 at 12:30 p.m. Licensed Practical Nurse (LPN) BB verified R#8 fingernails were long, jagged, and dirty.
Interviews on 12/13/2022 at 10:15 a.m., 12/14/2022 at 8:15 a.m., and 12/14/2022 at 12: 22 p.m. revealed R#8 stated she is scheduled for a shower two times per week, but does not receive them as scheduled. R#8 further revealed that she asked staff to clean and trim her nails, but staff had not done so.
Interview on 12/14/2022 at 8:25 a.m., Certified Nursing Assistant (CNA) AA revealed residents are scheduled to receive a shower or bath two times a week and revealed nail care is included in ADL cares. She also revealed showers and baths are documented in the EMR and refusal of care is reported to the nurse and also documented in the EMR. She stated that there is a shower team of CNAs, and they are often assigned to other areas of care.
Interview on 12/14/2022 at 11:35 a.m., Licensed Practical Nurse (LPN) BB revealed R#8 required extensive assist for ADLs including showers or baths. LPN BB also revealed that CNAs are required to document ADL care and refusal of care in the EMR and are to report refusal of care to the nurse.
Interview on 12/14/2022 at 2:00 p.m., the Director of Nursing (DON) revealed residents are scheduled to have a bath or shower two times a week and that nail care included on bath/shower days and as needed. She confirmed that R#8 did not have a bath or shower two times a week for the time period of 9/12/22 through 12/14/22 and there was no documented refusal of cares.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, resident and staff interviews, and review of the facility policy, Activities of Daily Livi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, resident and staff interviews, and review of the facility policy, Activities of Daily Living Policy and Procedure, the facility failed to ensure activities of daily living (ADL) were provided for one resident (R) of 25 residents, R#8, reviewed for ADL care. Specifically, the facility failed to ensure that scheduled showers and nail care were completed for R#8.
Findings include:
A review of the policy titled Activities of Daily Living Policy and Procedure dated 4/2020 revealed:
Policy: To ensure that each resident's basic needs for care are being met.
Procedure: Each resident's needs are assessed, and a care plan written to meet the resident's needs. Care directives will be put in the charting system for the certified nursing assistants (CNA), so they will have an understanding of what is needed for each resident.
Review of the electronic medical record (EMR) for R#8 revealed an admission date of 5/15/2019 with diagnoses that included but are not limited to, major depressive disorder, weakness, bipolar disorder, heart failure, type 2 diabetes mellitus with diabetic polyneuropathy idiopathic gout, macular degeneration.
Review of the most recent quarterly Minimum Data Set (MDS) dated [DATE], revealed Brief Interview for Mental Status (BIMS) coded as 15, indicating is cognitively intact. The MDS assessment also revealed R#8 required extensive assist of two persons for all ADLs including personal hygiene and required total assistance for bathing.
Review of the care plan dated 3/31/2021, revealed R#8 had ADL/self-care deficit due to functional losses and required assisted care to meet needs. Interventions included to provide assistance with ADL care needs to the extent needed.
Review of the EMR for R#8 did not reveal evidence of documented refusals of care in the nurse's notes during the last three months.
Review of the shower/bath documentation for R#8 revealed she received a shower three times from 9/12/2022 to 9/30/2022, five times from 10/120/22 to 10/31/2022, seven times from 11/1/22 to 11/30/2022 and 2 times from 12/1/2022 to 12/14/2022.
Observations on 12/13/2022 at 10:15 a.m., 12/14/2022 at 8:15 a.m., and 12/14/2022 at 12:22 p.m. revealed R#8 had long, jagged, and dirty fingernails.
Observation and interview on 12/14/2022 at 12:30 p.m. Licensed Practical Nurse (LPN) BB verified R#8 fingernails were long, jagged, and dirty.
Interviews on 12/13/2022 at 10:15 a.m., 12/14/2022 at 8:15 a.m., and 12/14/2022 at 12: 22 p.m. revealed R#8 stated she is scheduled for a shower two times per week and normally does not receive two showers per week. R#8 also revealed that she is aware her fingernails are long and dirty. She further revealed that she asked staff to clean and trim them, but staff had not done so. R#8 stated that she would like to receive two showers a week and would like to have fingernail care with each shower.
Interview on 12/14/2022 at 8:25 a.m., Certified Nursing Assistant (CNA) AA revealed residents are scheduled to receive a shower or bath two times a week and revealed nail care is included in ADL cares. She also revealed showers and baths are documented in the EMR and refusal of care is reported to the nurse and also documented in the EMR. She stated that there is a shower team of CNAs, and they are often assigned to other areas of care. She also stated that when the shower CNAs are reassigned, CNAs assigned to the floor are responsible for providing showers and baths. She revealed R#8 requires assistance of two persons and requires the Hoyer lift for transfers.
Interview on 12/14/2022 at 11:35 a.m. with Licensed Practical Nurse (LPN) BB revealed R#8 required extensive assist for ADLs including showers or baths. LPN BB also revealed that CNAs are required to document ADL care and refusal of care in the EMR and are to report refusal of care to the nurse.
Interview on 12/14/2022 at 2:00 p.m. with the Director of Nursing (DON) revealed residents are scheduled to have a bath or shower two times a week and that nail care included on bath/shower days and as needed. She revealed her expectations are for residents to receive baths/showers as scheduled and that nail care should always be included in ADL care. She further revealed all refusal of cares should be reported to the nurse and documented in the EMR. After reviewing the shower/bath documentation for R#8 during with the DON, she confirmed that R#8 did not have a bath or shower two times a week for the time period of 9/12/22 through 12/14/22 and there was no documented refusal of cares. The DON revealed she had spoken to LPN BB and was aware of R#8 having long, dirty, and jagged fingernails.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interviews, facility failed to provide restorative nursing services to maintain the highest pr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interviews, facility failed to provide restorative nursing services to maintain the highest practicable physical, mental, and psychosocial well- being for one resident (R) of 25 sample residents, (R#44). This failure had the potential to cause a decline in the resident's functional ability.
Findings:
Review of the electronic medical record (EMR) revealed that R#44 was initially admitted to the facility on [DATE], with a recent re-admission date of 7/7/2022. R#44 diagnoses included stroke, anemia, hypertension, hemiplegia/hemiparesis, and dementia.
Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated that the resident is cognitively intact. Further review of the MDS assessment, revealed that R#44 has not received any speech, occupational, physical, or respiratory therapies in the 7 day look back period.
Review of the EMR for R#44 revealed that resident was to have restorative nursing for Splint, bed mobility and transfers.
Review of EMR, revealed that placing splint is the responsibility of nurses.
Review of the care plan for R#44 revealed the following: RNP Program: Splint and Bed Mobility. 12/14/2022, resident frequently refuses to wear his splint.
Review of the splint documentation in the EMR for R#44 revealed that the resident refuses the splint often.
Interview on 12/14/2022 01:38 p.m., the Director of Nursing (DON) revealed that due to staffing, they do not have a Restorative program. She stated that certified nursing assistants (CNA's) are trained to do range of motion (ROM). She also stated that nurses will place braces/splint on the residents, and the therapy department helps with maintenance. She revealed that they only have restorative dining for Breakfast and Lunch. She also revealed that the facility does have two restorative CNAs and she was the restorative nurse. The DON stated that the CNAs were not available to do restorative because they were short staffed, and they were needed for resident care.
Interview on 12/15/2022 at 4:00 p.m., the DON revealed that if the CNAs provide restorative services, there is no way for them to chart it in the EMR. She further revealed that she has discussed changing the charting system because of the inability to document restorative services with higher management.
Interview on 12/15/2022 at 4:15 p.m., CNA AA revealed that if she was able to do restorative services, she was not showed how to chart it the EMR.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and staff interview, the facility failed to ensure that one resident (R) of 25 sampled res...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and staff interview, the facility failed to ensure that one resident (R) of 25 sampled residents, R#15, was administered oxygen therapy in accordance with the physician orders. This deficient practice had the potential to affect the resident's ability to maintain an oxygen level of 90% or greater.
Findings include:
Review of the electronic medical record (EMR) for R#15 revealed she was admitted to the facility on [DATE] with diagnoses that included but not limited to chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), encounter for attention to tracheostomy, personal history of malignant neoplasm of larynx, gastrostomy.
Review of the care plan initiated on 11/17/2021, revealed that resident has a tracheostomy and is at risk for impaired breathing. Interventions include, a nurse will assess respiratory status at least once a shift and as needed.
Review of physician order (PO) dated 8/26/2022 revealed, 02 at 6 L per trach collar to maintain 02 @ 90% or Greater.
Observation on 12/13/2022 at 10:30 a.m. revealed oxygen concentrator set on eight liters being delivered via Trach collar mask.
Observation on 12/15/2022 at 1:30 p.m. revealed oxygen concentrator flow rate set at 9.5 liters, being delivered via Trach collar mask.
Interview on 12/15/2022 at 1:31 p.m., Licensed Practical Nurse (LPN) AA revealed that that I think that the oxygen should be at 6 liters. She also stated that she does not check the oxygen and adjust it. She stated that it was adjusted by respiratory therapist from the hospital. The rate of nine and half liters was confirmed by LPN AA.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observations, interviews, and review of the facility policy titled, Storage and Expiration of Medications, Biologicals, Syringes, and Needles, the facility failed to ensure that two of three ...
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Based on observations, interviews, and review of the facility policy titled, Storage and Expiration of Medications, Biologicals, Syringes, and Needles, the facility failed to ensure that two of three medication carts were locked and secured when the carts were out of view of the nurse. The deficient practice had the potential to allow unauthorized residents, visitors, and staff access to unattended medications.
Findings include:
Review of the facility policy titled, Storage and Expiration of Medications, Biologicals, Syringes, and Needles, dated May 2020 and last approved December 2022 revealed under policy procedure C. General Storage number three. Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors.
Observation on 12/14/2022 at 8:38 a.m.- 8:45 a.m. during a medication pass with Licensed Practical Nurse (LPN) BB, Charge Nurse for the [NAME] Hall, revealed LPN BB left the medication cart unlocked and out of view with a bottle of Tums, a bottle of multivitamins, and a bottle of Aspirin left on top of the medication cart unattended.
Observation on 12/14/2022 at 9:30 a.m. - 9:40a.m. revealed the medication cart on the purple hall was unattended and unlocked.
Interview on 12/14/2022 at 8:45 a.m., LPN BB revealed nurse acknowledged that the cart should be locked when not within sight and no medications should be left out on top of the cart. During interview LPN BB stated, I know the cart should be locked and the medications should be off the cart, but I guess I was nervous.
Interview on 12/14/2022 at 9:40 a.m., LPN EE revealed she was assigned to the cart on the purple hall, and confirmed the cart was unlocked and had been left unattended. Continued interview also revealed that the cart should have been locked while she was away administering medications.
Interview on 12/14/2022 at 10:15 a.m. with the Director of Nursing (DON) revealed her expectations are for all medication carts to be locked and always secured when left unattended.
Oct 2019
4 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on record review, interviews, and review of the facility policy, the facility failed to administer medications as ordered by the Physician for two residents (R) (#95 and #91) of 47 sampled resid...
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Based on record review, interviews, and review of the facility policy, the facility failed to administer medications as ordered by the Physician for two residents (R) (#95 and #91) of 47 sampled residents.
Findings include:
1. During an interview on 10/08/19 at 11:39 a.m., R#95 stated he had not received his Lyrica (medication for nerve pain) for the past three days.
Review of the clinical record revealed R#95 has diagnosis of polyneuropathy. There was a Physician's Order with a start date of 10/29/18 for Lyrica 200 milligrams (mg), one capsule twice per day.
Review of the electronic Medication Administration Record (EMAR) revealed the medication, Lyrica, was not given on 10/5/19 through 10/7/19, which was documented as not available.
A review of electronic nursing documentation indicated that on 10/7/19 the facility was waiting on R#95's Medical Doctor (MD) to transcribe a new script related to the Lyrica medication due to a recent change in pharmacy services after the attempt to get the medication from the pharmacy.
The resident received the Lyrica on 10/8/19 when the pharmacy brought a replacement Emergency kit (E-kit) that contained the Lyrica for the morning dose. A review the MD's progress note dated 10/9/19 regarding the missed doses of the Lyrica indicated no major negative outcomes for R#95.
During an interview on 10/8/19 at 3:30 p.m., the Director of Nursing (DON) stated that she had contacted the nurse from the weekend shift and that the nurse reported she had contacted the MD on Saturday related to the need for the Lyrica script, but she did not document this information. Further interviews conducted with DON and Assistant Director of Nursing (ADON) related to the medication reflected that the nurse should have notified them and/or the Medical Director regarding the inability to get a new script for the Lyrica from the new pharmacy on Saturday. In addition, they stated that the nurse should have documented what attempts and follow ups were done related to the needed medication.
2. On 10/08/19 at 3:05 p.m., R#91 stated that she had pneumonia and that she did miss a couple doses of her cough medication due to what she understood as insurance concerns. She stated that she did not have much coughing or pain during that time.
Review of the clinical record revealed R#91 has diagnoses of cough and lower lobe pneumonia. There was a Physician's Order with a start date of 7/16/19 for codeine-guaifenesin (cough syrup) 5 milliliters (ml) every 8 hours. Review of the EMAR revealed the medication was not given on 10/1/19 at 2:00 p.m. and 10/2/19 at 6:00 a.m., which documented not done equipment/supplies not available.
Review of the nursing documentation for 10/1/19 and 10/2/19 did not reveal any documentation related to the missed medication being unavailable. However, on 10/1/19 at 9:42 p.m., insurance eligibility verification was documented.
Review of facility policy title, 7. a Medication Shortage/Unavailable Medications, dated 10/1/19 indicated that upon discovery of an inadequate supply of medication to administer to a resident, facility staff should immediately initiate action to obtain the medication from pharmacy.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on observation, record review, staff interviews, and review of facility policy titled, Medication Administration, the facility failed to sign out a controlled medication at time of administratio...
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Based on observation, record review, staff interviews, and review of facility policy titled, Medication Administration, the facility failed to sign out a controlled medication at time of administration for one resident (R) (#107) and failed to sign out a controlled medication accurately for one resident, R#3, on one of three medication carts.
Findings Include:
1. Observation on 10/9/19 at 9:49 a.m. of the Blue Hall medication cart Controlled Substance Proof of Use narcotic medication staff sign out sheet revealed R#107 was missing one tablet of Hydrocodone-Acetaminophen (an opioid pain reliever with Tylenol used to relieve moderate to severe pain) 5-325 milligrams (mg). An empty bubble pack was found. The last documented sign out was for one tablet on 10/7/19 at 5:30 a.m. by nurse LPN GG, documentation reflecting one tablet available/left.
Review of the physician's order with a start date of 9/9/19 revealed an order for Hydrocodone-Acetaminophen 5-325 mg, take one tablet by mouth four times daily while awake for pain related to spinal stenosis.
2. A continued review of narcotic sign out sheets documented that for R#3, Lorazepam (a medication commonly used to treat anxiety disorders) 0.5 mg tablet was ordered to take 0.25mg (1/2) tablet by mouth three times daily, take 0.5mg (1) tablet by mouth at bedtime. The last documented sign out was on 10/8/19 at 5:19 p.m. by LPN HH, reflecting one tablet used, with 19 tablets remaining; however only 18 were found left in the bubble pack.
In addition, for R#3, Lorazepam 0.5 mg ½ tablet (0.25mg) ordered to take 0.25mg (1/2) tablet by mouth three times daily, take 0.5mg (1) tablet by mouth at bedtime is documented on another sign out sheet as given on 10/8/19 at 7:43 a.m. one tablet, with nine tablets remaining, signed out by LPN II, reflecting one tablet used; however 10 tablets were found available/left in the bubble packet.
Review of the physician's order with a start date of 5/29/19 reflected an order for Lorazepam 0.25 mg oral, TID (three times per day), routine. Lorazepam 0.25 three times per day at 9 a.m., 1 p.m., and 9 p.m please monitor for and document any increase in crying .has different dosage for 5p.m.-separate order.
Review of the physician's order with a start date of 5/30/19 reflected an order for Lorazepam 0.5 mg, oral, daily, routine. Lorazepam 0.5 mg daily at 5pm.
A brief interview was conducted on 10/9/19 at 4:23 p.m. with LPN/Unit Manager EE, where she explained they had contacted the two nurses involved in the narcotic count being off. She stated that LPN II had confirmed to her that she had given the Hydrocodone-Acetaminophen at 7:27 a.m. today but did not sign it out. She explained that LPN HH on the 11-7 a.m. shift told her that she had given the correct dose but signed it out on the wrong Lorazepam dose sign out sheet.
An interview was conducted with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) on 10/10/19 at 2:30 p.m. where the DON confirmed that the expectation is for the narcotic reconciliation/count to be correct.
A review was conducted of the facility policy titled, Medication Administration revised 12/2014. The policy and procedure documented the following: 1. Policies and procedures related to medication administration are being followed (i.e. MAR verified with MD orders, MAR used to prepare and administer medications signed off as given, VS taken prior to administration if applicable, controlled medication count verified and signed out prior to administration). 12. Documentation of medication administration is completed accurately and charted consistently (before or after), controls signed out immediately after removing from packaging.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on observation, interview and policy review, the facility failed to ensure over the counter medications were dated appropriately when opened to determine the discard date, in two of three medica...
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Based on observation, interview and policy review, the facility failed to ensure over the counter medications were dated appropriately when opened to determine the discard date, in two of three medication carts; and failed to ensure that two of two medication cabinets, containing over the counter medications, remained locked.
Findings include:
An observation was conducted on 10/7/19 at 10:10 a.m. of the A Wing (Pink & [NAME] Hall) nursing station medication cabinet. The large black metal cabinet containing over the counter medications (OTC) was found unlocked. No staff was found at the nursing station.
An observation was conducted on 10/7/19 at 10:35 a.m. on the B Wing (Blue Hall) of the nursing station medication cabinet. The large black metal cabinet containing OTC medications was found unlocked. No staff was found at the nursing station. The Blue Hall has two known residents that wander. Resident #66 was observed wandering in the Blue Hall at time of cabinet observation, with obvious confusion when approached. The resident has a history of wandering and is cognitively impaired.
An observation of the Blue Hall OTC medication cabinet was conducted on 10/7/19 at 2:18 p.m., two staff members were observed on computers sitting at the nursing station. The medication cabinet was unlocked. Two swing doors are located at each end of the nurse's station, with the ability for easy access into the nursing station area by residents and guests.
An observation of the Pink Hall OTC medication cabinet conducted on 10/7/19 at 2:35 p.m., no staff was observed at the nursing station. The medication cabinet was unlocked. Two swing doors are located at each end of the nurse's station, with the ability for easy access into the nursing station area by residents and guests.
An observation was conducted on 10/8/19 at 5:00 a.m. of the A Wing (Pink & [NAME] Hall) nursing station medication cabinet. The large black metal cabinet containing over the counter medications (OTC) was found unlocked. No staff was found at the nursing station.
During an observation on 10/8/19 at 5:15 a.m. of the metal cabinet, on Blue Hall, located behind the nurse's station revealed that floor stock medication is kept inside, and the door was not locked. During this time R#37 was observed sitting in a wheelchair outside the nursing station. He was observed to be able to propel himself in the wheelchair. There was no staff observed at the nursing station and the doors on both sides of the nursing station do not have a lock and the station is easily accessible to staff and is noted to be large enough for a wheelchair to get through.
During a follow-up observation of the A Wing (Pink & [NAME] Hall) OTC medication cabinet conducted on 10/8/19 at 9:15 a.m., the cabinet was locked.
During a follow-up observation of the B Wing (Blue Hall) OTC medication cabinet conducted on 10/8/19 at 9:25 a.m., the cabinet was locked.
On 10/8/19 at 3:21 p.m. Medication Cart#1 for the Pink Hall was checked with LPN CC, two opened liquid containers were found to be partially full but not dated when first opened for use as follows: Milk of Magnesia 1200 milligrams (mg)/15 milliliters (ml), and Ferrous Sulfate (iron supplement) 220 mg/5 ml.
On 10/8/19 at 3:46 p.m. an observation and check of Medication Cart #2 for the [NAME] Hall was conducted with Registered Nurse (RN) DD, three opened liquid containers were found to be partially used but not dated when first opened for use as follows: Lactulose (an ammonia reducer and laxative) 10 gm/15 ml, Tussin DM (a cough and congestion relief) 20 mg/10 ml, and Levetiracetam (anticonvulsant) 10 mg/ml.
A brief interview was conducted with the Director of Nurses (DON) with the Assistant Director of Nursing (ADON) present on 10/10/19 at 2:30 p.m. where the DON stated it was her expectation that the nursing staff keep the medication room and metal cabinet for OTC medications locked.
A review of the facility policy titled, Storage and Expiration of Medications, Biologicals, Syringes and Needles effective date 10/1/19 documented the following: 3c. Facility should ensure that all medications and biologicals, including treatment items, are stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. 5. Once a medication or biological package is opened, facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the medication container and when the medication has a shortened expiration date once opened. 5a. Facility staff may record the calculated expiration date based on the date opened on the medication container.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected most or all residents
Based on observations, interview and policy review, the facility failed to ensure the garbage disposal area was free of refuse. The facility census was 109.
Findings include:
On 10/7/19 at 10:17 a.m. ...
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Based on observations, interview and policy review, the facility failed to ensure the garbage disposal area was free of refuse. The facility census was 109.
Findings include:
On 10/7/19 at 10:17 a.m. during the observation of waste disposal area, food and trash was noted outside of the compactor. The Dietary Manager (DM) was present and stated that someone from dietary should have cleaned this up. Further observation at 10:40 a.m. revealed blue rubber gloves, an empty soda can, bottle lids, straws, paper items and what appeared to be some type of macaroni leftovers are on the ground.
Review of the undated facility policy titled, Dietary: Handling and Disposal of Waste Materials revealed that the dietary department is responsible for the safe and sanitary removal of all waste materials from the department.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "What safeguards are in place to prevent abuse and neglect?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • 40% turnover. Below Georgia's 48% average. Good staff retention means consistent care.
Concerns
- • Multiple safety concerns identified: Federal abuse finding, 5 life-threatening violation(s), Special Focus Facility, $64,214 in fines. Review inspection reports carefully.
- • 31 deficiencies on record, including 5 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $64,214 in fines. Extremely high, among the most fined facilities in Georgia. Major compliance failures.
- • Grade F (0/100). Below average facility with significant concerns.
Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.
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About This Facility
What is Chatuge Regional's CMS Rating?
CMS assigns CHATUGE REGIONAL NURSING HOME an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Georgia, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Chatuge Regional Staffed?
CMS rates CHATUGE REGIONAL NURSING HOME's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 40%, compared to the Georgia average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Chatuge Regional?
State health inspectors documented 31 deficiencies at CHATUGE REGIONAL NURSING HOME during 2019 to 2024. These included: 5 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 25 with potential for harm, and 1 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Chatuge Regional?
CHATUGE REGIONAL NURSING HOME is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility operates independently rather than as part of a larger chain. With 112 certified beds and approximately 85 residents (about 76% occupancy), it is a mid-sized facility located in HIAWASSEE, Georgia.
How Does Chatuge Regional Compare to Other Georgia Nursing Homes?
Compared to the 100 nursing homes in Georgia, CHATUGE REGIONAL NURSING HOME's overall rating (1 stars) is below the state average of 2.6, staff turnover (40%) is near the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Chatuge Regional?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's Immediate Jeopardy citations and the substantiated abuse finding on record.
Is Chatuge Regional Safe?
Based on CMS inspection data, CHATUGE REGIONAL NURSING HOME has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). Inspectors have issued 5 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility is currently on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes nationwide). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Georgia. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Chatuge Regional Stick Around?
CHATUGE REGIONAL NURSING HOME has a staff turnover rate of 40%, which is about average for Georgia nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Chatuge Regional Ever Fined?
CHATUGE REGIONAL NURSING HOME has been fined $64,214 across 1 penalty action. This is above the Georgia average of $33,721. Fines in this range indicate compliance issues significant enough for CMS to impose meaningful financial consequences. Common causes include delayed correction of deficiencies, repeat violations, or care failures affecting resident safety. Families should ask facility leadership what changes have been made since these penalties.
Is Chatuge Regional on Any Federal Watch List?
CHATUGE REGIONAL NURSING HOME is currently an SFF Candidate, meaning CMS has identified it as potentially qualifying for the Special Focus Facility watch list. SFF Candidates have a history of serious deficiencies but haven't yet reached the threshold for full SFF designation. The facility is being monitored more closely — if problems continue, it may be added to the official watch list. Families should ask what the facility is doing to address the issues that led to this status.