ALTAMAHA HEALTHCARE CENTER
For profit - Corporation
62 Beds
BEACON HEALTH MANAGEMENT
Data: November 2025
Trust Grade
33/100
#241 of 353 in GA
Last Inspection: July 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Altamaha Healthcare Center has received a Trust Grade of F, indicating significant concerns and poor overall performance. It ranks #241 out of 353 nursing homes in Georgia, placing it in the bottom half of facilities in the state, but it is #2 of 3 in Wayne County, meaning only one local option is better. The facility's trend is improving, as it reduced its number of issues from 12 in 2024 to just 1 in 2025. However, staffing is a notable weakness with a 62% turnover rate, which is higher than the state average, and the RN coverage is concerning, being lower than 91% of Georgia facilities. Specific incidents included a resident falling during a bed bath due to inadequate assistance and failures in food safety practices that could expose residents to foodborne illnesses. Overall, while there are some improvements, families should weigh the serious issues against the facility's efforts to enhance care.
- Trust Score
- F
- In Georgia
- #241/353
- Safety Record
- Moderate
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 62% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ○ Average
- $4,017 in fines. Higher than 62% of Georgia facilities. Some compliance issues.
- Skilled Nurses ⚠ Watch
- Each resident gets only 12 minutes of Registered Nurse (RN) attention daily — below average for Georgia. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 20 deficiencies on record. Higher than average. Multiple issues found across inspections.
33/100
Bottom 32%
Needs review
12 → 1 violations
★☆☆☆☆
1.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★★☆☆☆
2.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 12 issues
2025: 1 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
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: 62%
16pts above Georgia avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $4,017
Below median ($33,413)
Minor penalties assessed
Chain: BEACON HEALTH MANAGEMENT
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is elevated (62%)
14 points above Georgia average of 48%
The Ugly 20 deficiencies on record
1 actual harm
Aug 2025
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
Based on observation, interview, record review, and review of the facility's policies titled Safe Smoking Standard and Fall Management, the facility failed to ensure an environment free from accident ...
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Based on observation, interview, record review, and review of the facility's policies titled Safe Smoking Standard and Fall Management, the facility failed to ensure an environment free from accident hazards for two of 42 sampled residents (R) (R51 and R6). Harm was identified to have occurred on 7/30/2025, when Certified Nursing Assistant (CNA)12 was independently providing a bed bath for R51, and the resident fell from the bed. It was determined that R51 required two-person assistance for bed mobility (turning from left to right in the bed). Findings included:A review of the facility's policy titled Fall Management, dated January 2025, indicated, The facility strives to reduce the risk of falls and injuries by promoting the implementation of the Risk Reduction: Falls and Injuries Program. Residents are assessed for the fall risk factors. The interdisciplinary team works with the residents and family to identify and implement appropriate interventions to reduce the risk of falls or injuries while maximizing dignity and independence. A review of the facility's policy titled Safe Smoking Standard, revised December 2022, indicated, No staff member, visitor, or resident is permitted to smoke inside the building at any time, this includes e-cigarettes and smokeless products such as chewing tobacco. The policy specified, Oxygen use is prohibited in the smoking area.1. A review of R51's admission Record revealed the facility admitted R51 on 7/3/2025. According to the admission Record, the resident had a medical history that included diagnoses of generalized muscle weakness and a need for assistance with personal care. A review of R51's admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date of 7/9/2025, revealed R51 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident was dependent on the staff for bathing. A review of R51's Care Plan Report included a focus area initiated 7/28/2025 that indicated the resident required assistance with activities of daily living (ADL) care related to activity intolerance, confusion, fatigue, impaired balance, and limited mobility. Interventions directed the staff to provide the resident with extensive assistance from one staff member with bathing/showering per schedule and as necessary, and that the resident required extensive assistance of two staff members to turn and reposition in bed as necessary. A review of R51's progress note dated 7/30/2025, during the provision of a bed bath by CNA12, when the resident was rolled, the resident's leg went off the side of the bed, which caused the resident to roll off the bed onto the floor. Per the progress note, the resident hit their head, which caused a laceration. The progress note indicated the resident was assessed by the Nurse Practitioner and subsequently transferred to the emergency room for further evaluation and treatment. A review of R51's hospital Visit Record dated 7/30/2025, indicated the resident fell out of the bed and hit their head while getting a bed bath. The record indicated the resident had a laceration to the scalp, a four-centimeter (cm) linear which was closed with skin glue and an adhesive. During an interview on 8/8/2025 at 2:49 pm, CNA12 stated she was told in the report when she started her shift for work about the needs of the residents, such as whether they needed one or two people for assistance. CNA12 stated she took care of R51 on 7/26/2025 before the fall, and the resident did not require two-person assistance, so she thought it was okay to give the resident a bed bath by herself. She stated the resident turned over onto their right side and just kept going. CNA12 stated that when the resident's leg went off the side of the bed, the resident slid off the bed. She stated the Director of Nursing (DON) and Administrator educated her to use two people with R51. CNA12 stated she did not mean for it to happen. During an interview on 8/8/2025 at 9:39 am, the Licensed Practical Nurse Unit Manager (LPN UM) stated that two people should be used for a bed bath if the resident required two people for bed mobility. The LPN UM stated that on 7/30/2025, when she entered R51's room, the resident was wrapped up in the covers and lying on the floor with the covers draped off the bed. The LPN UM stated the resident had a bleeding laceration to their forehead. During an interview on 8/8/2025 at 11:03 am, the DON stated the CNA should have two people for a bed bath if two people were needed for bed mobility. The DON stated the CNA was giving R51 a bath, unassisted, and when she turned the resident over, the resident just kept going off the side of the bed. She stated the resident got a laceration on their forehead, first aid was rendered, and the resident was transferred to the emergency room for further evaluation and treatment. According to the DON, CNA12 was in-serviced one-to-one to make sure she used two people when giving care. During an interview on 8/8/2025 at 11:30 am, the Administrator stated the staff should use two people for a bed bath if the resident required two persons to assist with bed mobility. The Administrator stated she was told the CNA was giving R51 a bed bath, and the resident rolled and fell out of the bed that was in a high position. She stated the CNA worked as needed, and she did not look for or ask how much assistance the resident needed. The Administrator stated she filed a state report, the CNA was educated, and an in-service was done. 2. A review of R6's admission Record revealed that the resident had a medical history that included a diagnosis of chronic obstructive pulmonary disease (COPD).A review of R6's Annual MDS assessment, with an ARD of 4/1/2025, revealed R6 had a BIMS score of 15, which indicated the resident had intact cognition. The MDS indicated the resident used oxygen therapy.A review of R6's Order Summary Report that contained active orders as of 8/5/2025, revealed an order dated 7/18/2024 for supplemental oxygen at three liters per minute by way of a nasal canula as tolerated every shift. A review of records revealed a Facility Incident Report Form, dated 11/19/2024, indicated residents reported today [11/19/2024] that [R6] was smoking in the smoking area with [his/her] oxygen on. Resident states that [his/her] oxygen was turned off. No one was hurt.A review of records revealed an Employee Interview Form, signed by the Activities Director (AD) and dated 11/19/2024, indicated, On smoke break today at 11:00 am the smokers reported to me that [R6] was outside on last night's smoke break with [his/her] oxygen on smoking. A review of records revealed a Witness Statement Form, signed by R6 and dated 11/19/2024, indicated the resident admitted they had one cigarette, they turned their supplemental oxygen off, CNA15 lit their cigarette, and once they finished their cigarette, they turned their supplemental oxygen back on. A review of records revealed, CNA15's Witness Statement Form, dated11/19/2024, indicated, I took [R6] out to smoke and forgot to leave the [his/her O2 [oxygen] tank inside, even still I turned it off, asked my nurse what should have been the best thing to do the next day and he said I should have left it by the door my mistake.A review of records revealed that CNA15's Separation Notice, signed by the Administrator and dated 11/21/2024, indicated CNA15's employment with the facility was terminated on 11/22/2024 for a violation of company policy. Per the Separation Notice, CNA15 placed residents in danger by allowing a resident to smoke with a supplemental oxygen tank. During an interview on 8/7/2025 at 2:15 pm, R6 stated they went out one time to smoke with their supplemental oxygen, and the CNA who let them go out lost their job. R6 stated that after that incident, they began to vape. Review of R6's progress note dated 5/20/2025 revealed that the CNAs approached R6 in the DON's office and informed nursing that a vape was found in the resident's room. Per the progress note, staff saw smoke in the resident's room and walked in and saw the vape. A review of R6's social service progress note dated 5/21/2025, indicated a vape device was found in the resident's possession after the resident was reportedly caught smoking. During an interview on 8/7/2025 at 9:10 am, the AD stated CNA15 let R6 go out during a smoke break with a supplemental oxygen tank on the back of the resident's wheelchair. During an interview on 8/7/2025 at 10:33 am, the DON stated she believed staff knew it was not okay to have supplemental oxygen outside for a smoke break. During a follow-up interview on 8/7/2025 at 3:57 pm, the DON stated that 5/20/2025 was the first time R6 was found with a vape in their room. The DON stated the vape was removed, and the resident was caught again with a vape on 5/24/2025 in their room. The DON stated that the risk of vaping in a resident's room was that it could potentially start a fire. During an interview on 8/7/2025 at 4:13 pm, the Administrator stated she thought she had heard a while ago that R6 was vaping in their room. She did not recall what was done after the incident and did not know how many times the resident was caught with a vape. The Administrator stated the resident was not allowed to vape in their room because the resident was on supplemental oxygen, and it was flammable. During a telephone interview on 8/9/2025 at 9:18 am, the former DON stated she was the DON at the time when CNA15 allowed R6 to go outside with a supplemental oxygen tank to smoke. According to the former DON, R6 wanted to go outside with the group, and CNA15 told the resident it was okay to go outside with the supplemental oxygen tank because he had turned it off. The former DON stated it scared the other residents, and they reported it the next day. Per the former DON, CNA15 admitted he made a mistake. During a telephone interview on 8/9/2025 at 10:18 am, the former Administrator stated he was the Administrator when CNA15 allowed R6 to go outside with a supplemental oxygen tank to smoke. The former Administrator stated that CNA15 was suspended, and then their employment was terminated. During an interview on 8/9/2025 at 1:54 pm, the DON stated her expectation was that all smoking materials were to be kept with the staff and no residents could have smoking materials in their room. The DON stated that staff were expected to report any found smoking materials to anyone in charge. During an interview on 8/9/2025 at 2:44 pm, the Administrator stated her expectation for vapes in a resident's room was that they were not allowed, and she expected them to be stored with cigarettes. The Administrator stated she expected staff to report to her, the DON, or a nurse if they found a resident with a vape. During an interview on 8/9/2025 at 2:46 pm, the Administrator stated her expectation was that there were to be no supplemental oxygen tanks outside while residents were smoking.
Jul 2024
12 deficiencies
CONCERN
(D)
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 observation, interview, record review, Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual (RAI) review, and policy review, the facility failed to revise the care plan to include fall interventions and ensure care conferences were held for one resident (Resident (R) 48) of 28 sample residents reviewed for care planning. The failure to revise the care plan could affect staff implementing interventions to prevent a future fall. Failure to conduct care plan conferences with the resident and/or their resident representatives could cause the resident to not be informed of care interventions as well as for the resident and/or the resident representative to ask questions about the resident's care.
Findings include:
Review of the facility's policy titled, RAI/Care Plan Management, dated August 2021, indicated Care Conferences are held after the MDS [Minimum Data Set] is completed but before the care plan is due for all new admissions. Conferences are also held quarterly and annually with each review. In addition, care plan reviews are conducted when a resident has a change of condition. Invitations are mailed to the family/responsible party one week prior to the conference date. Social Services invites each resident to the care conference personally on the morning of the care conference .If for some reason the resident, family or responsible party cannot attend the conference, an alternate method of communicating the information should be implemented .
Review of the Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual RAI, dated 10/01/24, indicated, 4-7 . The care plan must be reviewed and revised periodically, and the services provided or arranged must be consistent with each resident's written plan of care .
During an observation on 07/28/24 at 6:48 PM, R48 was in his room with his bed in a low position and a fall mat next to his bed.
During an observation on 07/31/24 at 11:17 AM, R48 was seated in a geri chair in the hallway near the nurses' station.
During an observation on 07/31/24 at 11:30 AM, R48's room revealed his bed against the wall and a fall mat was folded up next to the wall.
During an observation and interview on 07/31/24 at 10:50 AM, R48 was seated in a geri chair in hallway. The Regional Consultant Nurse stated that the resident appeared to be more comfortable in the geri chair. She could not remember when they started using the geri chair.
Review of R48's electronic medical record (EMR) Profile tab, indicated R48 was admitted on [DATE]. Further review of the EMR Progress Notes tab indicated that R48 returned from the hospital on [DATE]. Review of the EMR MDS with an Assessment Reference Date (ARD) of 05/26/24 revealed R48's Brief Interview for Mental Status (BIMS) score was 12 out of 15 indicating R48's cognition was moderately impaired.
Review of the Fall assessment provided by the Regional Operations Manager (ROM) revealed that on 07/24/24 and 07/27/24, the resident was found on a floor mat next to his bed.
During an interview on 07/31/24 at 10:53 AM, the Physical Therapist (PT) and the Certified Occupational Therapy Assistant (COTA) both stated that R48 started using the geri chair after he returned from the hospital on [DATE].
Review of R48's Care Plan, dated 12/05/23 and located in the EMR under the Care Plan tab, failed to identify the intervention of a floor mat next to bed, low bed, or geri chair.
During an interview on 07/31/24 at 11:51 AM, the MDS Coordinator (MDSC) reviewed R48's Care Plan and stated that she could not find that the care plan had been revised to include the interventions of low bed, geri chair, and fall mats.
Review of the EMR Documents tab revealed no evidence of care plan conferences since R48's admission to the facility.
During an interview on 07/30/24 at 9:33 AM, the MDSC confirmed R48 admission MDS was completed on 12/08/23 and he had a quarterly MDS on 03/09/24, 05/26/24, and 07/24/24.
During an interview on 07/30/24 at 2:00 PM, the MDS Coordinator confirmed she was unable to find any documentation that a care plan conference was held R48 and who attended.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0700
(Tag F0700)
Could have caused harm · This affected 1 resident
Based on observation, record review, and interview, the facility failed to ensure that three of three residents (Resident (R) 5, R38, and R3) reviewed for bed rail use out of a total of 28 sampled res...
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Based on observation, record review, and interview, the facility failed to ensure that three of three residents (Resident (R) 5, R38, and R3) reviewed for bed rail use out of a total of 28 sampled residents had bed rail assessments and attempted alternatives with documented reasons for the failure of the alternative prior to the use of the bed rails. This failure increased the potential risks associated bed rail use and could put the residents at risk for injury, entrapment, and/or death.
Findings include:
1. During an observation on 07/29/24 at 10:42 AM, R5 was asleep in bed with bilateral assist bars in the up position; on 07/29/24 at 12:27 PM, and 07/30/24 at 9:45 AM, R5 was asleep in bed with bilateral assist bars. On 07/29/24 at 12:30 PM, R5 was observed in bed eating lunch and the bilateral assist bars were in the up position on the bed.
Review of R5's admission Record from the electronic medical record (EMR) showed a facility admission date of 12/12/23 with medical diagnoses that included dementia, periprosthetic fracture around internal prosthetic left hip, peripheral vascular disease, generalized muscle weakness, and reduced mobility.
Review of R5's EMR Assessments tab showed three Bed Rail Evaluation forms:
a. effective date 12/12/23 at 3:51 PM that did not show any failed attempted alternatives to bed rails and recommended Side Rails/Assist Bar are indicated and serve as an enabler to promote independence.
b. effective date 03/12/24 at 10:48 AM that did not show any failed attempted alternatives to bed rails and recommended Side Rails/Assist Bar are not indicated at this time.
c. effective date 03/12/24 at 11:39 AM that did not show any failed attempted alternatives to bed rails and recommended Side Rails/Assist Bar are not indicated at this time.
2. During an observation on 07/28/24 at 7:45 PM R38 was in bed with bilateral assist bars and when asked if she used them R38 responded no. Observation on 07/29/24 at 11:25 AM showed R38 in bed napping with bilateral assist bars; and on 07/30/24 at 9:43 AM, R38 was out of her room but the bed was noted to have bilateral assist bars in place.
Review of R38's admission Record from the EMR Profile tab showed a facility admission date of 10/15/21 with medical diagnoses that included chronic kidney disease, atrial fibrillation, vascular dementia, glaucoma, history of cerebrovascular disease, type II diabetes, and Alzheimer's dementia.
Review of R38's EMR Assessments tab showed two Bed Rail Evaluation forms:
-Dated 10/15/21 at 5:07 PM showed no documented failed attempted alternatives and recommended Side Rails/Assist Bar are indicated and serve as an enabler to promote independence.
-Dated 02/12/23 at 9:45 AM showed no documented failed attempted alternatives and recommended Side Rails/Assist Bar are indicated and serve as an enabler to promote independence and The Resident has expressed a desire to have Side Rails/Assist Bars.
A request for alternatives attempted and the reason for failure was made to the Administrator on 07/30/24 at 5:45 PM and 07/31/24 at 10:00 AM with no documentation provided.
A request for a facility bed rail policy was made on 07/31/24 at 3:34 PM from the Regional Operations Manager (ROM), however, no policy was received.
During an interview on 07/31/24 at 7:45 PM, the Administrator confirmed no alternatives were attempted and stated that alternatives attempted to bed rails should have been documented prior to bed rail use; and an expectation that risk/benefits were advised and informed consents completed as part of the documentation for rail use.
3. Observation on 07/28/24 at 6:39 PM revealed R3 was in his room in bed with half side rails on both sides of his bed.
Review of R3's electronic medical record (EMR) Profile tab revealed admission date of 02/15/11. Review of the quarterly MDS with an ARD of 06/19/24 revealed a BIMS score of three out of 15 which indicated R3's cognition was severely impaired.
Review of R3's bed rail assessment in the Assessment tab of the EMR, revealed there was no bed rail assessment, dated 07/03/24. Review of the bed rail assessment in the EMR Assessment tab, revealed the assessment, dated 04/03/24, was blank and the EMR indicated the assessment was in progress. The bed rail assessment, dated 01/22/24, indicated the family requested the side rails.
During an interview on 07/31/24 at 11:31 AM, the Administrator stated that there are no recent bed rail assessments. The Administrator also confirmed that the 04/03/24 bed rail assessment was blank, the last bed rail assessment was dated 01/22/24 and the family requested the side rails.
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
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, the facility failed to ensure pharmacy provided medications timel...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, the facility failed to ensure pharmacy provided medications timely and residents received medications as ordered by the physician for one of six residents (Residents (R) 113) reviewed for medication administration out of 28 sample residents. The failure of the facility to ensure medications were provided from the pharmacy had the potential to affect all residents requiring administration of medications.
Findings include:
Review of the facility's policy titled, Medication Administration Guide, dated July 2023, revealed If a medication is not administered because the medication is not available, make every effort to locate the medication. If the medication cannot be located, check the interim or emergency kit for the medication so that the medication pass can be completed .Document unavailable medications appropriately per facility policy. Contact the pharmacy and arrange for delivery of the medication.
Review of R113's admission Record located in the Profile tab of the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with diagnoses including atherosclerotic heart disease and diabetes mellitus.
Review of R113's EMR under the Progress Notes tab revealed the resident was admitted on [DATE] at 1:03 PM with a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated intact cognition.
Review of R113's EMR under the Orders tab revealed an order, dated 07/12/24, for Atorvastatin Calcium Oral Tablet 40mg [milligrams], Give one tablet by mouth at bedtime for hyperlipidemia.
Review of the Medication Administration Record (MAR) revealed the medication was not administered on 07/12/24 at 9:00 PM. There was no follow-up documentation to indicate why the medication was not administered.
Review of R113's EMR under the Orders tab revealed an order, dated 07/12/24, for Ondansetron HCl [hydrochloride] Oral Tablet 8mg, give one tablet by mouth every six hours for nausea.
Review of the MAR revealed the medication was not administered on 07/12/24 at 11:00 PM, on 07/13/24 at 5:00 AM and 11:00 PM, on 07/16/24 at 11:00 PM, on 07/17/24 at 5:00 AM, on 07/18/24 at 11:00 PM, on 07/19/24 at 5:00 AM, on 07/22/24 at 11:00 PM, and on 07/23/24 at 5:00 AM. There was no follow-up documentation to indicate why the medication was not administered.
Review of R113's EMR under the Orders tab revealed an order, dated 07/12/24, for Carvedilol Oral Tablet 12.5 mg, give one tablet by mouth three times a day related to essential hypertension.
Review of the MAR revealed the medication was not administered on 07/12/24 at 9:00 PM. There was no follow-up documentation to indicate why the medication was not administered.
Review of R113's EMR under the Orders tab revealed an order, dated 07/12/24, for Metformin HCl Oral Tablet 1000 mg, give one tablet by mouth two times a day related to type 2 diabetes mellitus without complications.
Review of the MAR revealed the medication was not administered on 07/12/24 at 9:00 PM. There was no follow-up documentation to indicate why the medication was not administered.
Review of R113's EMR under the Orders tab revealed an order, dated 07/12/24, for Eliquis Oral Tablet 5 mg, give one tablet by mouth two times a day related to presence of aortocoronary bypass graft.
Review of the MAR revealed the medication was not administered on 07/12/24 at 9:00 PM. There was no follow-up documentation to indicate why the medication was not administered.
Review of R113's EMR under the Orders tab revealed an order, dated 07/13/24, for Levothyroxine Sodium Oral Tablet 50 mcg (microgram), Give one tablet by mouth in the morning related to hypothyroidism.
Review of the MAR revealed the medication was not administered on 07/13/24 or 07/17/24 at 5:00 AM. There was no follow-up documentation to indicate why the medication was not administered.
During an interview on 07/31/24 at 10:15 AM, Licensed Practical Nurse (LPN) 5 stated that when a new resident was admitted to the facility the admission staff, or the nurse would put the medication orders into the EMR. She stated that the medication orders were automatically sent to the pharmacy, and that the pharmacy delivered medications twice a day. LPN5 stated that the medications were usually delivered from the pharmacy early in the morning and late in the evening. She stated that if a resident was admitted in the afternoon or later, it was not uncommon for the pharmacy to not bring medications until the following morning. LPN5 stated that if a medication was not available, the nurse should pull medication from their emergency kit, if possible. She stated that if the MAR showed a 9 then look for a progress note, which should indicate a note in the EMR about why the medication was not given. She confirmed that only a checkmark on the MAR indicated the medication was given to the resident.
During an interview on 07/31/24 at 1:45 PM, the Director of Nursing (DON) stated that when residents were admitted , the pharmacy was made aware of the medications needed. She stated that the pharmacy usually had a cut off time, approximately 3:00 PM, to arrive on the next delivery. She stated that if a medication was not available, the facility had an emergency drug kit that carried the basic medications. She stated if a nurse did not have the medication to administer to the resident, they would code a 9, which meant that the nurse was aware the medication was not available, and that a progress note would be documented in the EMR to indicate what steps the nurse had followed. The DON stated that pharmacy had been a problem, and that there were instances when the medications had not arrived for delivery, the facility had contacted the pharmacy, and been given excuses. She confirmed that pharmacy deliveries had been difficult.
During an interview on 07/31/24 at 4:24 PM, the Medical Director stated that if a resident did not have their medications available on admission, the nursing staff should have called for the medication to be held until it arrived, or to use the local pharmacy to get the medications.
CONCERN
(D)
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, interview, and policy review, the facility nurses failed to document the behaviors that were occurring a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the facility nurses failed to document the behaviors that were occurring and what nonpharmacological interventions were attempted prior to the administration of antipsychotic medication, Seroquel Intramuscularly (IM) for one of five residents (Resident (R) 48) reviewed for unnecessary medications of 28 sample residents. The failure could result in the resident receiving unnecessary medication.
Findings include:
Review of the facility's policy titled, Behavior Management Standard, dated September 2021, indicated . Goals for use of psychoactive .The Interdisciplinary Team (IDT) will ensure the following have been completed before a psychoactive medication is administered .targeted behavior is identified; behavior monitoring sheets are initiated .Appropriate nonpharmacological interventions have been identified prior and implemented based on an individual resident assessment .
Review of R48's electronic medical record (EMR) Profile tab, indicated R48 was admitted on [DATE]. Further review of the EMR progress notes tab indicated that R48 returned from the hospital on [DATE]. Review of the EMR Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/26/24 revealed R48's Brief Interview for Mental Status (BIMS) score was 12 out of 15 indicating R48's cognition was moderately impaired.
Review of R48's EMR orders tab, dated 07/18/24, revealed, Haldol Injection Solution 5 MG/ML [milligrams/ milliliters] (Haloperidol Lactate), Inject 5 mg intramuscularly every 8 hours as needed for agitation.
Review of R48's July 2024 Medication Administration Record (MAR) located under the Orders tab of the EMR revealed that since R48 returned from hospital on [DATE], the MAR indicated what behaviors to monitor. Further review of the MAR revealed that R48 received Haldol (antipsychotic medication) 5 mg IM on 07/21/24, 07/25/24, and on 07/29/24 he received two doses of the medication. The MAR did not indicate any behaviors R48 displayed prior to receiving the Haldol IM injections.
During an interview on 07/31/24 at 4:46 PM, the Regional Operations Manager (ROM) reviewed R48's July 2024 MAR, the behaviors section of the MAR, and the Progress notes from 07/19/24 to 7/31/24. She was asked what behaviors R48 displayed and what nonpharmacological interventions were used prior to the administration of Haldol. The ROM confirmed there were no behaviors documented and that there was no documentation of nonpharmacological interventions. She stated, if it is not documented, then it wasn't done.
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 F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the facility nurse failed to follow the physician order and p...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the facility nurse failed to follow the physician order and provide the resident his insulin per the sliding scale order for one of seven residents (Resident (R) 3) reviewed during medication administration of 28 sample residents. Specifically, the resident did not have the insulin available for medication administration. This failure caused a significant medication error which could affect the management of R3's diabetes and glucose levels.
Findings include:
Review of the facility's policy titled, Medication Administration Guidelines dated August 2021, indicated, General and Specific Guidelines on Administration of Medications by Routes .c. Staff will compare the MAR [Medication Administration Record] with the label of each medication for the following: Right person, Right medication .e. Staff will compare the label with the MAR for a second time. G. Staff will compare the label on the medication to the MAR for a third time before administering the medication .
Review of R3's electronic medical record (EMR) Census tab indicated R3 was admitted on [DATE] with diagnosis of diabetes mellitus. Review of R3's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/02/24 revealed a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated R3's cognition was moderately impaired. The MDS indicated R3's active diagnosis of diabetes mellitus.
Review of the EMR Orders tab revealed an order, dated 06/19/24, for Humulin R Injection Solution 100 UNIT/ML [unit/ milliliter] (Insulin Regular (Human)) Inject as per sliding scale: if 151 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units, subcutaneously before meals and at bedtime related to TYPE 2 DIABETES MELLITUS WITH UNSPECIFIED COMPLICATIONS (E11.8) BS [blood sugars] greater than 401 call MD [Medical Doctor] for further instructions.
During an observation and interview on 07/29/24 at 11:50 AM, Registered Nurse (RN) 1 obtained R3's glucose reading of 258 and returned to the medication cart. RN1 reviewed the MAR and determined that R3 required six units of Humulin R insulin. RN1 searched throughout the medication cart and was unable to find R3's insulin. RN1 went to the medication room to obtain R3's insulin. RN1 returned to the medication cart with the insulin box and vial inside and prepared a syringe of six units of Humulin R. RN1 proceeded to R3's room and was asked by the surveyor to return to the medication cart. When asked why she was administering six unit of Humulin R insulin to R3 when the box indicated four units of Humulin R insulin for a blood glucose of 258. RN1 reviewed the MAR and showed the surveyor that the MAR indicated that six units of Humulin R insulin were to be administered. RN1 then reviewed the insulin and insulin box and determined that the insulin belonged to R50. RN1 stated that she reported the failure to have R3's Humulin R insulin to the Regional Operations Manager (ROM) and that she will order the insulin. R3 did not receive the insulin as ordered.
The Administrator provided documentation that the pharmacy sent the insulin on 07/29/24 at 10:44 PM.
Review of R3's July 2024 MAR revealed R3 did not receive any insulin on 07/29/24 at the 1100 (11:00 AM), 1600 (4:00 PM), and 2100 (9:00 PM) and on 07/30/24 at 0700 (7:00 AM) designated time periods. Review of the July MAR indicated that R3 routinely received sliding scale Humulin R insulin from 07/01/24 to 07/29/24 at the 7:00 AM Accu-Chek.
Review of R3's MAR, dated 07/30/24, indicated at the 11:00 AM Accu-Chek, R3's glucose level was 239 and required four units of Humulin R insulin.
During an interview on 07/31/24 at 1:40 PM, the Administrator stated that she was not aware of any delay in pharmacy providing the medications.
During an interview on 07/31/24 at 4:26 PM, the Medical Director stated that if there was delay in getting the insulin, the facility should have called him, and he would have called the insulin order into a local pharmacy so that the resident could receive it much sooner. He further stated that while waiting for the insulin, the nurses still should have performed the Accu-Chek to assess the resident's glucose level and notify him of any elevated glucose levels.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the facility failed to provide written information to five residents (Resi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the facility failed to provide written information to five residents (Resident (R) 48, R18, R12, R24, and R4) and/or their resident representative concerning the right to formulate an advance directive of 28 sample residents. The failure to discuss advance directive information with the resident and resident representative could potentially affect their ability to make informed decisions about their care.
Findings include:
Review of the facility's policy titled, Advance Directive, dated 08/09/22, indicated The facility must inform and provide written information to all adult residents concerning the right .to formulate an advance directive .Upon admission/readmission, the facility Social Service Director will inform and educate the resident, or POA [Power of Attorney] in writing about the right .to an advance directive . and upload to the resident's chart .
1. Review of R48's electronic medical record (EMR) Profile tab, indicated R48 was admitted on [DATE]. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/26/24 in the EMR under the MDS tab indicated a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated moderate cognitive impairment.
Review of the EMR revealed no documentation that the resident was provided written information concerning the right to formulate an advance directive.
2. Review of R18's EMR Profile tab, indicated R18 was admitted on [DATE] and that R18 was her own responsible party. Review of the annual MDS with an ARD of 06/18/24 in the EMR under the MDS tab indicated a BIMS score of 15 out of 15 which indicated R18's cognition was intact.
Review of the EMR revealed no documentation that the resident was provided written information concerning the right to formulate an advance directive.
During an interview on 07/30/24 at 4:04 PM, the Social Services Director (SSD) stated that she could not find any documentation that R48 and R18 were provided with written information about formulating an advance directive.
3. Review of R12's EMR Profile tab indicated R12 was admitted on [DATE]. Review of the quarterly MDS with an ARD of 07/08/24 in the EMR under the MDS tab indicated a BIMS score of one out of 15 which indicated cognition was severely impaired.
During an interview on 07/30/24 at 4:10 PM, the SSD confirmed she was unable to locate any documentation that R12's responsible party was provided written information concerning the right to formulate an advance directive.
4. Review of R24's undated admission Record located in R24's EMR under the Profile tab revealed R24 was admitted to the facility on [DATE].
Review of R24's EMR revealed no documentation that R24 had an advance directive or that the facility provided written information to the resident, or the resident representative concerning the right to accept or refuse medical or surgical treatment and/or formulate an advance directive.
5. Review of R4's admission Record from the EMR Profile tab showed a facility admission date of 01/05/16 and readmission on [DATE], with medical diagnoses that included convulsions, osteoporosis, intracranial injury, and dizziness.
Review of R4's electronic EMR Documents tab revealed no information regarding an advance directive or education regarding an advance directive. Review of the 2016 admission agreement for R4 showed no education regarding an advance directive.
Review of R4's annual MDS with an ARD of 06/04/24 revealed R4 had a BIMS score of 15 out of 15 which indicated the resident was cognitively intact.
During an interview on 07/31/24 at 11:30 AM, R4 confirmed he had been in the facility since 2016; that the SSD had provided the advance directive information the previous day and had not received this information prior to 07/30/24.
During an interview on 07/31/24 at 11:48 AM, the SSD confirmed she had found nothing in the EMR that R4 had presented previously during his admission.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected multiple residents
Based on personnel file review, interview, and policy review, the facility failed to follow their policy to obtain background and criminal checks at time of employment for four of nine employee files ...
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Based on personnel file review, interview, and policy review, the facility failed to follow their policy to obtain background and criminal checks at time of employment for four of nine employee files (Certified Nurse Aide (CNA) 1, CNA2, Licensed Practical Nurse (LPN) 2, and Dietary Aide (DA) 1) reviewed for background checks. The failure to obtain background and criminal checks had the potential to allow facility staff with criminal backgrounds to work with the residents.
Findings include:
Review of the facility's policy titled, Background and Criminal Checks, dated 12/21/23, indicated The facility .may investigate all statements contained in any documents, applications and/or resumes you have provided. A background check will be conducted . to include .criminal history .fingerprints .references .upon submitting an application of employment, you release the facility . from obtaining such information .
Review of four of nine personnel files revealed the Administrator was unable to provide background and criminal checks information for the following staff:
-CNA1's file revealed hire date of 09/08/20.
-CNA2's file revealed hire date of 04/17/24.
-LPN2's file revealed hire date of 02/01/21.
-DA1's file revealed hire date of 06/10/24.
During an interview on 07/31/24 at 1:45 PM, the Administrator confirmed she was unable to find the background and criminal history information for the above employees. She stated that the facility no longer had a Human Resource Director (HRD) who was responsible for uploading the information into the computer system.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the facility failed to ensure seven of seven residents and their represent...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the facility failed to ensure seven of seven residents and their representatives (Resident (R) 27, R29, R38, R48, R116, R112, and R44) reviewed for facility initiated emergent hospital transfer, from a total sample of 28 residents, were provided with written transfer/discharge notice that stated the reason for transfer, the place of transfer, other information regarding the transfer, and information on the right to appeal the transfer. This failure had the potential to affect the resident and their Resident Representative (RR) 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's policy titled, Discharge Plan/Transfers, revised 10/20/23, showed it did not address a written notice of transfer, the required contents, or the provision of the notice to the Resident and RR.
1. Review of R27's admission Record from the electronic medical record (EMR) Profile tab, showed a facility admission date of 10/24/23, readmission on [DATE], with medical diagnoses that included end stage renal disease, type II diabetes, seizures, atrial fibrillation, psychotic disorder, and Alzheimer's dementia.
Review of R27's EMR Census tab showed hospital leave on 06/26/24. Review of R27's Progress Notes tab showed nothing about a hospital transfer but did show a readmit progress note, dated 06/29/24 at 11:47 AM, that revealed resident back from hospital.
Further review of R27's EMR Progress Notes, Documents, and Assessments tabs did not reveal any evidence of the provision of a written transfer notice.
During an interview on 07/30/24 at 5:52 PM regarding receipt of any written documentation regarding the hospital transfer from the facility that stated why and where he was transferred and information on his right to appeal the transfer, R27 stated, No.
2. Review of R29's admission Record from the EMR Profile tab showed a facility admission date of 08/01/23, readmission on [DATE], with medical diagnoses that included toxic encephalopathy, congestive heart failure, chronic respiratory failure, end stage renal disease, chronic obstructive pulmonary disease, and anxiety disorder.
Review of R29's Progress Notes showed on 07/16/24 at 7:15 PM, R29 was admitted to hospital, from dialysis.
Further review of R29's EMR Progress Notes, Documents, and Assessments tabs did not reveal any evidence of the provision of a written transfer notice.
During an interview on 07/30/24 at 11:40 AM, the Director of Nursing (DON) remarked she was unsure who did the transfer notices.
3. Review of R38's admission Record from the EMR Profile tab showed a facility admission date of 10/15/21 with medical diagnoses that included chronic kidney disease, atrial fibrillation, vascular dementia, glaucoma, history of cerebrovascular disease, type II diabetes, and Alzheimer's dementia.
Review of R38's EMR Progress Notes tab showed on 04/14/24 at 3:12 PM that Resident transferred to hospital due to altered mental status. [Doctor name] notified. [R38's RR identified] notified and [name] DON notified as well.
Further review of R38's EMR Progress Notes, Documents, and Assessments tabs did not reveal any evidence of the provision of a written transfer notice.
During an interview on 07/30/24 at 5:42 PM regarding the facility process for an emergent transfer, Licensed Practical Nurse (LPN) 5 stated, When we find there is an issue, we call the doctor and let him know, get an order to transfer out. Call 911, let them know the issue, then call the hospital and give them report. Then, I print all the paperwork. [transfer/discharge record and medication administration record [MAR]. Then fill out all the paperwork on the computer, such as this E-transfer form [an E-Interact transfer form for the hospital] and do a change in condition, [an E-Interact form, both of which are saved in the EMR Assessment tab] call the family and let them know they are being or were transferred and why. Then write a progress note. When asked what was given to the Emergency Medical Services (EMS), LPN5 responded the E-transfer report and MAR. When queried if anything was provided to the resident or RR regarding the transfer, LPN5 stated, No.
During an interview on 07/31/24 at 8:08 PM, the Administrator stated an expectation regarding the provision of written transfer notices that the document is sent, a signature that they are made aware and document that it went to family / POA [Power of Attorney or RR] is aware. When asked on her expectation as to when the notice should be provided, the Administrator responded, When they go to leave the facility on way out or as soon as possible.
4. Review of R48's EMR Profile tab indicated R48 was admitted on [DATE]. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/26/24 in the EMR under the MDS tab indicated a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated moderate cognitive impairment.
Review of R48's EMR Progress Notes, dated 05/13/24 and 07/11/24, revealed R48 experienced a change in condition and was transferred to the hospital. There was no documentation in the EMR that the resident and the resident's responsible party were provided the transfer notice for either time R48 was transferred to the hospital.
5. Review of R116's EMR Profile tab indicated R116 was admitted on [DATE]. Review of the quarterly MDS with an ARD of 06/21/24 in the EMR under the MDS tab indicated a BIMS score of seven out of 15 which indicated severe cognitive impairment.
Review of R116's EMR Progress Notes, dated 07/09/24, indicated R116 was experiencing behavioral issues and was sent to the behavioral hospital. There was no documentation in the EMR that the resident and the resident's responsible party were provided the transfer notice when R116 was transferred to the hospital on [DATE].
6. Review of R112's EMR Profile tab indicated R112 was admitted on [DATE].
Review of R112's EMR Progress Notes, dated 02/14/24, indicated R112 experienced a change of condition and was sent to the hospital. There was no documentation in the EMR that the resident and the resident's responsible party were provided the transfer notice when R112 was transferred to the hospital on [DATE].
7. Review of the EMR Profile tab indicated R44 was admitted on [DATE]. Review of the quarterly MDS with an ARD of 07/10/24 in the EMR under the MDS tab indicated a BIMS score of one out of 15 which indicated severe cognitive impairment.
Review of R44's EMR Progress Notes, dated 07/17/24, indicated R44 experienced a change in condition and was sent to the hospital. There was no documentation in the EMR that the resident's responsible party was provided the transfer notice when R44 was transferred to the hospital on [DATE].
During an interview on 07/30/24 at 9:44 AM, the Social Service Director (SSD) stated that she would have to check with the Administrator to see who sent the transfer notices to the Ombudsman.
During an interview on 07/30/24 at 12:33 PM, the Administrator stated that there was no documentation that the transfer notice was provided to the resident and their resident representative when the residents were transferred to the hospital. The Administrator also stated that since becoming the Administrator at the end of November 2023, the facility had not been sending the transfer notices to the Ombudsman.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and review of facility policy, the facility failed to ensure seven of seven residents (Reside...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and review of facility policy, the facility failed to ensure seven of seven residents (Resident (R) 27, R29, R38, R48, R116, R112, and R44) reviewed for facility initiated emergent transfer to the hospital and/or their Resident Representative (RR) received a written bed hold notice that included all required information of 28 sample residents. This failure had the potential to contribute to possible denial of re-admission and loss of the resident's room following a hospitalization for residents transferred to the hospital.
Findings include:
Review of the facility policy titled Discharge Plan/Transfers, revised 10/20/23, showed: Policy: All Residents are given the option of reserving their bed when leaving the facility with the intent to return. This temporary absence may be for hospitalization or therapeutic leave. All Residents or their Responsible party are informed in writing about the facility's bed-hold policy at the time of admission. A copy of the bed hold agreement is also provided to the Resident or Responsible party prior to a resident's transfer to a hospital or start of a therapeutic leave. The bed hold policy provides written information detailing bed hold regulations for specific payers including Medicare regulations, the duration of the bed-hold policy under the specific State's Medicaid plan, if any, and private bed hold rules.
1. Review of R27's admission Record from the electronic medical record (EMR) Profile tab, showed a facility admission date of 10/24/23 with readmission on [DATE] and medical diagnoses that included end stage renal disease, type II diabetes, seizures, atrial fibrillation, psychotic disorder, and Alzheimer's dementia.
Review of R27's EMR Census tab showed hospital leave on 06/26/24. Review of R27's Progress Notes tab revealed nothing about a hospital transfer but did show a readmit progress note, dated 06/29/24 at 11:47 AM, that revealed resident back from hospital.
Further review of R27's EMR Progress Notes, Documents, and Assessments tabs did not reveal any evidence of the provision of a written bed hold notice.
During an interview on 07/30/24 at 5:52 PM regarding receipt of any written documentation regarding bed hold, R27 responded, The government pays for my bed. Clarified, if he had received anything regarding how long the government would pay to hold his bed, R27 stated, No they don't give me anything in writing.
2. Review of R29's admission Record from the EMR Profile tab showed a facility admission date of 08/01/23 with readmission on [DATE] and medical diagnoses that included toxic encephalopathy, congestive heart failure, chronic respiratory failure, end stage renal disease, chronic obstructive pulmonary disease, and anxiety disorder.
Review of R29's Progress Notes revealed on 07/16/24 at 7:15 PM, R29 was admitted to hospital, from dialysis.
Further review of R29's EMR Progress Notes, Documents, and Assessments tabs did not reveal any evidence of the provision of a written bed hold notice.
During a request for the provision of a written transfer notice on 07/30/24 at 11:40 AM, the Director of Nursing (DON) remarked she was unsure of the bed hold, she had been in long term care many years and her nurses did not do it; she thought perhaps Admissions did the bed hold.
3. Review of R38's admission Record from the EMR Profile tab revealed a facility admission date of 10/15/21 with medical diagnoses that included chronic kidney disease, atrial fibrillation, vascular dementia, glaucoma, history of cerebrovascular disease, type II diabetes, and Alzheimer's dementia.
Review of R38's EMR Progress Notes tab revealed on 04/14/24 at 3:12 PM that Resident transferred to hospital due to altered mental status. [Doctor name] notified. [R38's RR identified] notified and [name] DON notified as well.
Further review of R38's EMR Progress Notes, Documents, and Assessments tabs did not reveal any evidence of the provision of a written bed hold notice.
During an interview on 07/30/24 at 5:42 PM regarding the facility process for an emergent transfer, Licensed Practical Nurse (LPN) 5 stated, When we find there is an issue, we call the doctor and let him know, get an order to transfer out. Call 911, let them know the issue, then call the hospital and give them report. Then, I print all the paperwork . call the family and let them know they are being or were transferred and why. Then write a progress note. When queried if anything was provided to the resident or RR regarding the bed hold policy, LPN5 stated, No, nothing in writing to the Resident or Representative.
4. Review of R48's electronic medical record (EMR) Profile tab indicated R48 was admitted on [DATE]. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/26/24 in the EMR under the MDS tab indicated a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated moderate cognitive impairment.
Review of R48's EMR Progress Notes, dated 05/13/24 and 07/11/24, revealed R48 experienced a change in condition and was transferred to the hospital. There was no documentation in the EMR that the resident and the resident's responsible party were provided the bed hold policy for either time R48 was transferred to the hospital.
5. Review of R116's EMR Profile tab indicated R116 was admitted on [DATE]. Review of the quarterly MDS with an ARD of 06/21/24 in the EMR under the MDS tab indicated a BIMS score of seven out of 15 which indicated severe cognitive impairment.
Review of R116's EMR Progress Notes, dated 07/09/24, indicated R116 was experiencing behavioral issues and was sent to the behavioral hospital. There was no documentation in the EMR that the resident and the resident's responsible party were provided the bed hold policy when R116 was transferred to the hospital on [DATE].
6. Review of R112's EMR Profile tab indicated R112 was admitted on [DATE].
Review of R112's EMR Progress Notes, dated 02/14/24, indicated R112 experienced a change of condition and was sent to the hospital. There was no documentation in the EMR that the resident and the resident's responsible party were provided the bed hold policy when R112 was transferred to the hospital on [DATE].
7. Review of R44's EMR Profile tab indicated R44 was admitted on [DATE]. Review of the quarterly MDS with an ARD of 07/10/24 in the EMR under the MDS tab indicated a BIMS score of one out of 15 which indicated severe cognitive impairment.
Review of R44's EMR Progress Notes, dated 07/17/24, indicated R44 experienced a change in condition and was sent to the hospital. There was no documentation in the EMR that the resident responsible party was provided the bed hold notice when R44 was transferred to the hospital on [DATE].
During an interview on 07/30/24 at 9:44 AM, the Social Service Director (SSD) stated that she would have to check with the Administrator to see who sent the bed hold policy to the residents and their resident representatives.
During an interview on 07/30/24 at 12:33 PM, the Administrator stated that there was no documentation that the bed hold policy was provided to the resident and their resident representative when the residents were transferred to the hospital.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observations, interviews, and policy review, the facility failed to ensure food was not stored on the floor, expired foods were disposed of in a timely manner, ready-to-eat food was not touch...
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Based on observations, interviews, and policy review, the facility failed to ensure food was not stored on the floor, expired foods were disposed of in a timely manner, ready-to-eat food was not touched with bare hands, and moldy food was not stored for use in accordance with professional standards for food service safety as required for 52 census residents who received meals from the facility kitchen. These failures had the potential to lead to food-borne illness among facility residents.
Findings include:
Review of a facility policy titled, Nutrition Services Manual, dated 06/2015, revealed, The facility strives to promote good sanitation practices in order to protect its residents/patients and employees from foodborne illness. The facility sanitation system will ensure a clean, safe environment for its residents/patients and staff .The Nutrition Services staff follows infection control procedures including maintaining personal hygiene and handling foods to prevent contamination .Verify expiration dates are appropriate on individual cartons .Store delivered items immediately upon receipt.
During an observation on 07/31/24 at 10:53 AM, sixteen boxes of canned foods and perishables were observed resting directly onto the pantry floor.
During an interview on 07/31/24 at 10:54 AM, Cook1 stated that the food shipment had arrived the previous evening, but staff had not had time to properly store the food.
During observation of a reach-in refrigerator on 07/31/24 at 11:00 AM, there was one 46-ounce (oz.) thickened orange juice carton, opened with 07/09/24 written on it. A second 46oz. thickened pomegranate berry juice, opened with 07/16/24 written on it. Both cartons documented, After opening, may be kept up to 7 days under refrigeration. Also, a large, opened container of turkey lunch meat with 7/24-7/27 written on the side.
During an interview on 07/31/24 at 11:05 AM, Cook2 stated she was not aware that the opened thickened juices had to be disposed of after seven days. Cook2 also confirmed the turkey lunch meat was dated past acceptable use by date.
During lunch service observation on 07/31/24 from 12:00 PM through 12:15 PM, Cook1 was observed plating food from the steam table, touching the dinner rolls with her bare hands. Cook1 was observed to touch the meal trays, the tray rack, and again touched dinner rolls with her bare hands without handwashing.
During an observation on 07/31/24 at 3:58 PM, one moldy 16oz. carton of strawberries was found in a refrigerated reach-in.
During an interview on 07/31/24 at 3:58 PM, Dietary Aide (DA) 2 confirmed that there were moldy strawberries, and that staff had not always checked the produce when it arrived from the supplier to ensure it was still edible.
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
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, personnel file review, and policy review, the facility failed to 1. follow manuf...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, personnel file review, and policy review, the facility failed to 1. follow manufacturer's instructions regarding the cleaning and disinfecting of one of one glucometer between residents' use. 2. follow pre-employment and annual purified protein derivative (PPD) (skin test that determines if you have tuberculosis) guidelines of obtaining PPD 1st and 2nd step at the time of employment for six of nine personnel files (Administrator, Director of Nursing (DON), Certified Nurse Aide (CNA) 2, Licensed Practical Nurse (LPN) 2, Dietary Aide (DA) 1, and LPN3) reviewed, 3. obtain annual PPD test for two of nine personnel files (LPN1 and CNA1) reviewed, and 4. maintain a current infection surveillance program for 2024. Failure to follow infection control guidelines could result in the residents acquiring a blood-borne pathogen or infectious disease.
Findings include:
1. Review of the facility's policy titled, Diabetic Management. dated August 2021. indicated Guidelines .14. Clean and disinfect the glucometer per the facility's infection control protocol/manufacturer's instruction .
Review of the undated Evencare G3, Blood Glucose Monitoring System manufacturer's instructions for the glucometer and provided by the facility, revealed on page 11, The Evencare G3 Meter should be cleaned and disinfected between each patient .The following products have been approved for cleaning and disinfecting the Evencare G3 Meter .Medline Micro-Kill Bleach Germicidal Bleach Wipes . Further review of the manufacturer's instructions revealed on page 16, In-Service Training .Step6. Perform a blood glucose test 8. Clean and disinfect the meter .
During an observation on 07/29/24 at 11:50 AM Registered Nurse (RN )1 stood at the medication cart on the 100 unit, removed the glucometer out of her uniform pocket. Without cleaning and disinfecting the glucometer, attached the Accu-Chek test strip into the glucometer and entered R3's room. After obtaining R3's glucose reading, returned to the medication cart and placed the glucometer directly on top of the cart without first placing a clean barrier between the glucometer and the cart. RN1 reviewed the Medication Administration Record (MAR) and determined that R3 required insulin. RN1 searched throughout the medication cart and was unable to find R3's insulin. Without cleaning and disinfecting the glucometer, RN1 placed the glucometer in the medication cart and locked the cart. RN1 went to the medication room to obtain R3's insulin. RN1 returned to the medication cart and prepared a syringe of six units of Humulin R. At this time, RN1 did not remove the glucometer to clean and disinfect it.
During an interview on 07/29/24 at 12:28 PM, RN1 was asked what training she had received regarding the cleaning and disinfecting of the glucometer. RN1 stated at this time, I probably need to clean it. When asked what product she was to use, RN1 stated she was to use an alcohol wipe. RN1 removed the glucometer from the medication cart and cleaned it with an alcohol wipe. When asked what training the facility had provided regarding cleaning and disinfecting the glucometer between residents' use, RN1 stated that she had not received any training and just relied on her nursing knowledge.
Review of the diagnosis list provided by the Regional Operations Manager (ROM) for all the residents in the facility revealed no evidence of a resident having a bloodborne pathogen diagnosis.
Review of the list of residents with sliding scale orders per hallway and provided by the ROM revealed seven residents (R15, R48, R116, R18, R17, R30, and R3) on the 100 hallway.
During an interview on 07/31/24 at 1:37 PM, the Administrator stated that it was her expectation that the nurses followed the manufacturer's instruction and to use the Micro Kill product, which was in each medication cart to disinfect the glucometer.
During an interview on 07/31/24 at 4:35 PM, the ROM stated that they could not find any documentation that nurses, including RN1, had been trained on how to disinfect the glucometer prior to the incident on 07/29/24.
2. Review of the facility's undated document titled, Pre-Employment and Annual TB [Tuberculosis] Test Results indicated, Pre-employment requires a 2-step TB. Employee may not start working on the floor until 1st step is completed. 2nd step must be completed no later than 14 days after the 1st step. Annual TB test are a 1-Step .
Review of six of nine personnel files revealed the Administrator was unable to provide PPD information for the following staff:
-Administrator's file revealed hire date of 11/3/23
-Director of Nursing (DON) file revealed hire date of 07/08/24
-CNA2's file revealed hire date of 04/17/24
-LPN2's file revealed hire date of 07/0/2/24
-DA1's file revealed hire date of 06/10/24
-LPN3's file revealed hire date of 05/01/24
3. Review of two of two personnel files revealed the facility was unable to provide yearly PPD information for the following staff:
-LPN1's file revealed hire date of 02/01/21 and the last documentation of the PPD was dated 02/23.
-CNA1's file revealed hire date of 09/08/20 and the facility was unable to find documentation of the PPD for 09/23.
During an interview on 07/31/24 at 1:45 PM, the Administrator confirmed she was unable to find the PPD information for the above employees. She stated that the facility no longer had a Human Resource Director (HRD). She stated the HRD was responsible for uploading the information into the computer system.
4. Review of the facility policy titled Infection Surveillance, dated 09/23, showed: Overview. The facility will use a systematic method of collecting, consolidating, and analyzing data concerning the distribution and determining factors of a given disease or event. An outbreak may be defined as an increase in the incidence of a disease, complication, or event above the background rate. The facility will have baseline surveillance data on the incidence of
nosocomial infections in order to identify outbreaks. Following the collection and analysis of data, the information will be provided to the staff for educational purposes to strive to improve infection prevention/control outcomes. The facility will also use surveillance as follows . Procedure. 1. Gather information from each unit at least once per week. 2. Initiate a resident specific Infection Surveillance Worksheet if infection appears likely . 3. Summarize information from the Infection Surveillance Worksheet on the Monthly Line Listing Report .4. Tabulate infection data according to the following and document on the appropriate month on the Annual Infection Rate Summary .5. Calculate incidence rates and compare to previous rates within the facility. 6. Present the information at the next scheduled Infection Control/Prevention Team meeting .8. Implement an action plan as needed. Report to the Risk Management/ Quality Improvement Committee as needed. 9. Provide staff training as needed. 10. Review and revise action plan as needed.
During the Infection Control review in response to a request for infection tracking and trending (surveillance) documentation for 2024, the Director of Nursing (DON) provided a binder with numerous tabs and blank schematics. On 07/31/24 at 6:46 PM, the DON stated it might be in another book that was taken out of here. I know I can do the schematic for the trends for cross contamination, and I can show you what I'm going to do. When the last six months was requested, the DON stated, I wasn't here. I can go through more boxes and books. At 6:54 PM, the DON was going through boxes in her office and related I feel sure she [prior DON] was doing that stuff, I don't know why she put things in such strange places before she left. On 07/31/24 at 7:05 PM, the DON stated, I can't provide any documentation about an infection control program before my arrival. I am putting my program [in place] but it's not up and running yet. I've been here about two weeks, maybe the 8th or 9th, and I worked on the floor for the first 13 or 14 days.
During an interview on 07/31/24 at 7:08 PM, the Administrator [NAME] in a file for tracking and trending from 2023 but was unable to provide anything from 2024. The Administrator stated it was an expectation that the facility had an infection surveillance program.
MINOR
(C)
Minor Issue - procedural, no safety impact
Staffing Information
(Tag F0732)
Minor procedural issue · This affected most or all residents
Based on observation and interview, the facility failed to ensure that the daily nurse staffing was posted to accurately reflect the actual staff hours to care for the 52 current residents for three o...
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Based on observation and interview, the facility failed to ensure that the daily nurse staffing was posted to accurately reflect the actual staff hours to care for the 52 current residents for three of four survey days. This failure had the potential to inaccurately inform any resident, family member, or visitor of the available nursing staff caring for residents.
Findings include:
An observation throughout the facility on 07/28/24 at 6:43 PM revealed the daily nurse staffing was not posted.
Observations throughout the facility on 07/29/24 at 9:30 AM and at 10:40 AM revealed the daily nurse staffing was not posted.
An observation throughout the facility on 07/30/24 at 6:05 PM revealed the daily nurse staffing was not posted.
During an interview on 07/31/24 at 8:15 AM, the Administrator stated that the daily nurse staff posting should have been posted in the glass display window near the front of the facility each day. She confirmed the staffing had not been posted for three of the four survey days.
Jun 2022
3 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and review of policy titled Advance Directives/DNRO [Do Not Resuscitate Order] Log, the faci...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and review of policy titled Advance Directives/DNRO [Do Not Resuscitate Order] Log, the facility failed to ensure the resident's code/advanced directive status was promptly determined and documented in an easily accessible location in the medical record to facility staff's ability to honor the resident/responsible party's wishes for one (Resident [R] #154 of three sampled residents reviewed for advance directives.
Findings include:
Review of a facility policy titled, Advance Directives/DNRO [Do Not Resuscitate Order] Log, dated 02/2015, revealed, To assist in recording and managing Advance Directives information in the medical record. Responsible Person: Director of Social Services. When: Upon admission. Review and update quarterly. Review and update with change of condition. The policy also indicated, 3. Indicate presence of Advance Directives by referring to Advance Directives documents. Initial next to each one applicable. 4. Indicate if the resident/patient has a DNRO. 5. Indicate if the resident/patient does not have any Advance Directives.
Review of an admission Record revealed the facility admitted R#154 on [DATE] with diagnoses including ataxia (a degenerative disease of the nervous system that results in poor muscle control and can affect speech, balance, swallowing, and eye movements) and moderate protein-calorie malnutrition. The Advanced Directives section of the record was blank. Further review of the resident's medical record revealed there was no documentation of the resident's code status (determination of whether any emergent treatment was to be provided in the event of cessation of pulse or respirations). There was no evidence of any advance directive or code status order signed by the resident, the resident's power of attorney (POA), or the resident's physician.
On [DATE] at 3:02 PM, an interview was conducted with Director of Nursing (DON) AA. DON AA stated the code status should be documented in each resident's medical record but was unable to locate the code status for R#154. DON AA stated R#154's chart did not have the usual information, including a color-coded notice in the front of the chart. DON stated a green notice indicated cardiopulmonary resuscitation (CPR) would be provided and a red notice indicated no CPR was to be provided. DON AA stated there was also no physician's order for R#154's code status. DON AA stated that R#154's family wanted the resident's code status to be DNR [do not resuscitate], and that the family had been in the facility the day before to complete the paperwork. DON AA verified the paperwork was not readily available in the chart.
On [DATE] at 3:09 PM, an interview was conducted with Director of Social Work (DSW) BB, who stated Resident #154's POA was in the facility the day before and had discussed making the resident's code status DNR. DSW BB indicated she had just received the final go-ahead today ([DATE]). DSW BB stated she did not put the orders into the electronic medical record system upon admission; she just updated the file once a change of code status was received. The DSW stated the admission nurse would be the one to enter the initial code status.
On [DATE] at 3:14 PM, an interview was conducted with Licensed Practical Nurse (LPN) CC, the unit manager. LPN CC stated she was the admission nurse for R#154 and that she was not able to determine R#154's code status at the time of admission. She stated normally, if she was unable to determine the code status, she would put in an order for full code (indicating CPR would be provided). She would then verify with the family what the resident's wishes were. LPN stated, I just didn't do what I needed to do, and the chart did not reflect any code status.
On [DATE] at 9:20 AM, an interview was conducted with the Administrator, who stated the code status needed to be obtained at the time of admission and, until the physician signed the decision form, the resident would remain a full code. The Administrator stated his expectation was that, at the time of admission, the code status would be placed in the chart and, it is our responsibility to ensure that the code status is in place.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected multiple residents
3. Review of an admission Record revealed the facility admitted R#50 on 10/30/2019 with diagnoses including bipolar disorder and major depressive disorder.
Review of a PASRR Level 1 Assessment Form, ...
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3. Review of an admission Record revealed the facility admitted R#50 on 10/30/2019 with diagnoses including bipolar disorder and major depressive disorder.
Review of a PASRR Level 1 Assessment Form, dated 10/29/2019, revealed the screening did not reflect the resident's diagnoses of bipolar disorder and major depressive disorder.
During an interview on 6/23/2022 at 12:23 PM, the Business Office Manager (BOM) revealed the admission Coordinator (AC) initiated the PASRR level one process. The BOM stated the AC was responsible for getting all the information, including the history and physical. The BOM stated if the resident came from the hospital, the physician at the hospital completed the level one PASRR form, sent it to the facility, and the AC reviewed it for accuracy. The BOM stated the AC may consult with the Director of Nursing (DON) to ensure the level one PASRR was completed accurately. The BOM stated she did not know who completed the level one PASRR for R#50 in October 2019. The BOM stated there had been numerous people in the role of AC over the last three years. She stated the AC who completed R#44's level one PASRR had left employment with the facility about four weeks ago.
During an interview on 6/23/2022 at 2:41 PM, the AC revealed she had only been in the role of AC for two weeks. The AC stated it was her role to communicate with the case manager from the hospital after referral for a new admission and to ensure the hospital had completed a level one PASRR. The AC stated she reviewed the information to ensure it was complete, but she had not completed one on her own yet because she did not have access to the system to do them. The AC stated she had received training with the prior AC.
During an interview on 6/23/2022 at 2:52 PM, the Director of Nursing (DON) revealed she did not know the expectations for the AC regarding PASRR requirements. The DON stated she was unfamiliar with the PASRR process but expected that the information would be completed accurately to ensure additional services were provided if necessary.
During an interview on 6/23/2022 at 3:01 PM, the Minimum Data Set (MDS) Coordinator revealed when she completed an annual MDS, she reviewed the completed level one PASRR to ensure the correct diagnosis was listed but did not do so prior to the annual MDS.
During an interview on 6/23/2022 at 3:25 PM, Director of Social Work (DSW) BB revealed she was not trained to complete level one PASRRs and did not have access to the system to complete them.
During an interview on 6/24/2022 at 9:14 AM, the Administrator stated the AC received a referral from the hospital and checked to see if the level one PASRR was completed at the hospital or in the community. The Administrator stated he expected staff to ensure the level one PASRR I was accurately completed prior to submitting it to the state mental health authority for level two PASRR review.
Based on interviews and record review, the facility failed to ensure the level one Preadmission Screening and Resident Review (PASRR) accurately reflected diagnosed mental illnesses for three (Resident [R] #3, R#44, and R#50) of six sampled residents who were reviewed for PASRR.
Findings include:
During an interview on 6/24/2022 at 8:20 AM, the Administrator revealed the facility did not have a policy for PASRR.
1. A review of the admission Record for R#3 revealed the facility admitted the resident on 4/8/2019 with diagnoses of paranoid schizophrenia and bipolar disorder. A review of the PASRR Level I Assessment Form, dated 04/08/2019 revealed the screening did not reflect the resident's diagnosed mental illnesses.
Review of a Minimum Data Set (MDS) Care Area Assessment (CAA) Summary, dated 11/16/2021, revealed R#3 received psychoactive medications for diagnoses of schizophrenia, manic depression, depression, and anxiety disorders.
Review of a Care Plan, revised 4/16/2022, revealed R#3 had a cognitive deficit related to paranoid schizophrenia and bipolar disorder, was at risk for psychotropic adverse side effects related to diagnoses of paranoid schizophrenia and bipolar disorder, and used psychotropic medication.
Review of an Order Summary Report, printed 6/23/2022, revealed R#3 had active physician's orders for psychiatric evaluation and treatment as necessary and to monitor for behaviors, including delusions, hallucinations, and psychosis. The orders indicated the resident was prescribed divalproex sodium for bipolar disorder, citalopram for bipolar disorder, and risperidone for schizophrenia.
2. Review of an admission Record revealed the facility admitted R#44 on 5/27/2022 with diagnoses that included bipolar disorder and chronic kidney disease. Review of a PASRR Level I Assessment Form, dated 5/26/2022 revealed the screening did not reflect the resident's diagnosed mental illness.
A review of an Order Summary Report, printed 6/23/2022, revealed active orders for a psychiatric consult and indicated the resident was prescribed divalproex sodium for bipolar disorder, sertraline for depression, and Zyprexa (an antipsychotic agent) for depression.
Review of a Care Plan, dated 5/27/2022, revealed R#44 used antidepressant medication related to depression and used psychotropic medications related to bipolar disorder.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected multiple residents
Based on observation, staff interviews, record review, and review of policy titled Medication Administration Guidelines, the facility failed ensure the medication error rate was less than 5%. There we...
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Based on observation, staff interviews, record review, and review of policy titled Medication Administration Guidelines, the facility failed ensure the medication error rate was less than 5%. There were six medication errors with 25 opportunities, which resulted in a 24% medication error rate. This failure affected two residents, Resident (R) #41 and R#15.
Findings include:
A review of the facility document titled, Medication Administration Guidelines, dated September 2019, revealed, Medication Administration: Upon administering medication, the licensed nurse will compare the label on the medication to the MAR [Medication Administration Record] to ensure accuracy. All variances are to be reported to the pharmacy immediately. General and Specific Guidelines on Administration of Medication by Routes: A. General procedures completed before administering medication by any route: c. Staff will compare the MAR with the label of each medication for the following: i. Right Person ii. Right Medication iii. Right Date iv. Right Time v. Right Route. vi. Right Dose vii. Expiration date. D. If there is a discrepancy, the medication will not be administered. Instruction will be verified by contacting the physician/pharmacy.
1.Observations of medication administration were conducted on 6/22/2022 at 8:25 AM with Licensed Practical Nurse (LPN) DD. LPN DD administered medication to R#41 which included one tablet of Seroquel 25 milligrams (mg).
Following the medication pass, a medication reconciliation (a review of physician orders compared to medications given) was conducted. The physician orders for R#41, dated 5/23/2022, indicated three tablets of Seroquel 25 mg were to be given twice a day.
On 6/22/2022 at 4:00 PM, an interview with LPN DD revealed R#41 should have received three Seroquel tablets and he only gave one tablet during the medication administration at 8:25 AM. LPN DD stated that he made a mistake.
2.LPN DD was observed on 6/22/2022 at 9:00 AM to administer medication to R#15 which included the following medications:
- Vitamin D3 25 micrograms (mcg), three tablets;
- fexofenadine 180 mg, one tablet; and
- Vitamin C 500 mg, two tablets.
A medication reconciliation was conducted for R#15 and revealed the following physician orders on the Order Summary Report that were active orders as of 6/1/2022:
- cholecalciferol (vitamin D3) 1000 unit, one tablet daily;
- fexofenadine 60 mg, one tablet daily;
- docusate sodium tablet 100 mg, one tablet by mouth two times a day.
Physician orders written after 6/1/2022 were documented on the Medication Administration Record [MAR]. Review of the MAR revealed R#15 was to receive the following medications:
- Vitamin C 100 mg, give two tablets by mouth two times a day. The start date was 06/14/2022.
- Quercetin tablet 250 mg, one tablet by mouth two times a day. The start date was 06/14/2022.
Review of the records revealed R#15 did not receive docusate sodium, vitamin C, or Quercetin as ordered and scheduled.
On 6/23/2022 at 10:00 AM, LPN DD was interviewed regarding the medication administration for R#15. LPN DD verified that he gave R#15 medications from the stock bottles available. The fexofenadine dose was 180 mg, the vitamin C was only available in a 500 mg dose, and the Quercetin and the docusate sodium were available. LPN DD stated he usually followed the five rights of medication administration and was not able to explain why he administered the incorrect dose and omitted the doses of medication.
On 6/23/2022 at 2:12 PM, an interview was conducted with the Director of Nursing (DON), in the conference room. The DON was made aware of the medication errors and stated that her expectations were to educate the resident, provide the accurate dose to the right resident, and to check the medications available against the MAR. The DON further stated the nurses were expected to follow the five rights of medication administration.
On 6/24/2022 at 9:29 AM, an interview was conducted with the Administrator, in the conference room. The Administrator stated he was aware of the medication error rate and that it was his expectation that the nurses followed the five rights of medication administration. The Administrator further stated it was important for the residents to get the right medication in the correct dose because it was a safety concern.
May 2019
4 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
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 a policy/procedure titled, PASRR User Manualprovided by the facility, th...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review, staff interviews and review of a policy/procedure titled, PASRR User Manualprovided by the facility, the facility failed to ensure that Preadmission Screening/Resident Review (PASRR) Level I Assessment forms were completed accurately and timely for two residents of 33 residents (R#24 and R#15).
Findings include:
1. A review of the face sheet revealed that R#24 was admitted with diagnoses including but not limited to bipolar disorder, depression, anxiety, psychosis, diabetes mellitus, hypertension and coronary artery disease.
On the PASRR form dated 3/18/16 for R#24, number 1: Does the individual have a mental illness ., is answered NO; number 2: Primary Diagnosis of Serious Mental Illness, ., is answered NO and the diagnoses of Bipolar Disorder and Anxiety Disorder were marked as NO indicating that these were not current diagnoses for R#24 even though these diagnoses were present and listed on the face sheet at that time of admission.
A review of current physician orders revealed R#24 is receiving haloperidol deconate (Haldol), an antipsychotic injectable medication, intramuscularly every four weeks for bipolar disorder. This order was written 7/1/16. R#24 is also receiving mirtazapine (Remeron), an antidepressant medication, 15 milligrams (mg) orally every night at bedtime. This order was written 2/16/19.
On 5/14/19 at 3:15 p.m. during an interview with Marketing Director/Admissions Coordinator, AA she stated there was no system in place to track and check PASRRs. She stated the nurses and admissions should check the PASRR against resident diagnosis upon admission. She also stated she initiated an audit on March 15, 2019, but she has not done anything since that time on this concern.
2. Resident #15 (R#15) was admitted to the facility on [DATE], with diagnoses that included anxiety disorder, disorders of bone density, irritable bowel syndrome, bipolar disorder, gastro-esophageal reflux disease, obsessive-compulsive disorder and attention-deficit hyperactivity disorder.
Review of the PASRR form dated 2/13/19 for R#15, number 4: Primary Diagnosis of Serious Mental Illness, developmental disability or related condition, Bipolar Disorder was marked as NO and Anxiety Disorder was marked as NO indicating that these were not current diagnosis for this resident even though these diagnosis were present at that time of admission.
On 5/16/19 at 12:23 p.m. during an interview with the Social Worker BB from United Behavioral Services where he stated R#15 was not a client currently on his case load. However, he stated he and the staff at the facility have discussed the need to audit the PASRR's in the facility for needs or changes but there has been no mechanism in place to achieve this goal.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0773
(Tag F0773)
Could have caused harm · This affected 1 resident
Based on record review, staff interviews and review of a facility policy titled Lab Procedures and Other Services, the facility failed to obtain the lab results as ordered by the physician and failed ...
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Based on record review, staff interviews and review of a facility policy titled Lab Procedures and Other Services, the facility failed to obtain the lab results as ordered by the physician and failed to report the abnormal lab results to the physician for one resident of 33 Residents (R#45).
Findings include:
Review of a facility policy dated 7/1/2018 entitiled Lab Procedures & Other Services states It is the standard of this facility to provide laboratory and diagnostic studies for all residents in compliance with Federal and State requirements. All tests will be completed as ordered, results obtained and reported to the attending physician or Medical Director, and other members of the Interdisciplinary Team, as appropriate to assist in management of disease process. The General Guidelines state The Licensed Nurse receives the laboratory test order from the physician and notified the lab of the requested test. The Licensed Nurse ensures lab is drawn/conducted in a reasonable time frame (unless stat order). The Licensed Nurse communicates lab results to the physician.
R#45 was admitted with diagnoses including but not limited to epilepsy, manic episode, short stature due to endocrine disorder, cognitive communication deficit, diabetes mellitus, osteoarthritis of hip and right knee. Due to cognitive deficits, staff anticipate her needs and provide or assist with all activities of daily living including but not limited to bathing, dressing, grooming, eating, bed mobility, transfers and locomotion. She is non-ambulatory. A review of the Minimum Data Set (MDS), a resident assessment instrument with an assessment reference date of 4/8/19, R#45 has a Brief Inventory of Mental Status (BIMS) score of 99 indicating an inability to complete the interview.
A review of May 2019 physician's orders includes but is not limited to the following medications:
Lithium carbonate 300 mg tablet, take one tablet by mouth once daily for manic depression at 8AM
Lithium carbonate 600 mg cap, take one cap by mouth at bedtime for depression at 8PM
Phenobarbital 30 mg tablets, take three tablets by mouth at bedtime for seizures at 8PM
Divalproex DR 125 mg capsule 500 mg (4) capsules by mouth every morning at 8AM
Divalproex DR 125 mg capsule 750 mg (6) capsules by mouth every evening at 4PM
Levothyroxine 1,000 micrograms tablet, one tablet by mouth once daily for hypothyroidism at 8AM
The May 2019 physician's orders also include laboratory orders for the following:
Complete Blood Count (CBC) every six months (scheduled April and October)
Complete Metabolic Profile (CMP) every 6 months (scheduled April and October)
Depakote (drug) level every 6 months (scheduled April and October)
Thyroid Stimulating Hormone (TSH) every 6 months (scheduled April and October)
Phenobarbital (drug) level every 6 months (scheduled April and October)
Lithium (drug)level every 6 months (scheduled April and October)
A review of Nurse's Notes for the month of April 2019 reveal that staff were unable to draw R#45's blood on three occasions. The staff notified the physician who instructed them to attempt the labs the next scheduled lab draw day (5/1/19).
A review of lab results found in chart as of 5/13/19 at 3:00 p.m. included the drug level test results for lithium and pheobarbital drawn on 5/1/19. The forms have a fax receipt date of 5/5/19 at the top of the pages. None of these results were documented as reported to the physician in either the Nurse's Notes or on the lab reports themselves. There were no lab results for the valproic acid drug level, the TSH level, the CBC or the CMP. The 5/1/19 lab results for the lithium drug level (1.17 mmol/L) indicates it was within normal limits (0.60-1.20 mmol/L). The results for the phenobarbital drug level (12.2 mg/L) indicate is was below normal range (15.0-40.0 mg/L).
During an interview conducted on 5/14/19 at 9:00 a.m. with Licensed Practical Nurse (LPN) EE she confirmed that lab results are received via fax and the nurses will call the results to the physician's office. She further stated that the nurses usually document on the bottom of the lab results the date and time they contact the physician and any new orders given as a result. LPN EE stated that if the nurses don't document on the lab report the date and time they contacted the physician's office, they will document in the Nurse's Notes.
During an interview conducted on 5/14/19 at 10:10 a.m. with LPN EE, she confirmed that results for the CBC, CMP, TSH level and valproic acid drug level were not in the chart. She stated that she would have to contact the lab for the remaining results.
The remaining lab results from the 5/1/19 testing were provided by the nurse consultant DD on 5/14/19 at 2:34 p.m. including copies of the CBC, CMP and the valproic acid level. The forms had a fax receipt date of 5/14/19 at the top of the pages. The results for the valproic acid drug level (less than 10.0 ug/ml) indicates it was below normal range (50.0-120.0 ug/ml). The TSH level was within normal limits. The CMP results included but was not limited to a glucose level (55 mg/dl) that was below normal range (74-106 mg/dl), a creatinine level (0.40 mg/dl) that was below normal range (0.70-1.20 mg/dl), a sodium level (136 mmol/l) that was below normal range (137-145 mmol/l), and an albumin level (3.3 gm/dl) that was below normal range (3.5-5.0 gm/dl). The CBC results included but was not limited to a white blood cell count (4.76 K/UL) that was below normal range (4.80-10.80 K/UL), a red blood cell count (3.41 m/ul) that was below normal level (4.20-5.40 m/ul), There was no evidence to support that the results had been phoned or faxed to the attending physician.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on record review, review of the policy titled, Medication Administration Guidelines and staff interviews it was noted that the facility failed to ensure that complete and accurate documentation ...
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Based on record review, review of the policy titled, Medication Administration Guidelines and staff interviews it was noted that the facility failed to ensure that complete and accurate documentation of administration of medications were placed on the Medication Administration Records (MARs) for one of 33 residents reviewed (R#1).
Findings include:
During a review of the policy/Medication Administration Guidelines dated July 2018, it was noted under the section, Documentation of Medications, the second bullet states, Document signature or initials as required for medications administered on the MAR immediately following administration or per state standards. DO NOT pre-sign MAR prior to medication administration. Circle initials for those medications that were not administered and document reason for non-administration on the back of the MAR.
Record review revealed that Resident #1 was admitted to the facility with diagnoses that included of (not an all inclusive list): chronic obstructive pulmonary disease, epilepsy, diabetes, dysphagia, acute respiratory failure, Essential hypertension, bipolar disorder, anxiety disorder, psychosis, major depressive disorder and toxic encephalopathy.
Review of the MARs for March 2019, April 2019 and May 2019 revealed the following areas where medication administration was not signed or initialed and there was not any evidence of documentation on the back of the MARs as to the reason they were not administered, signed, or initaled.
March 2019 MAR
8:00 a.m.
3/16/19 levetiracetam 500 milligrams (mg), gabapentin 400 mg, buspirone HCL 15 mg, hydrocodone 7.5-325 mg
3/28/19 buspirone HCL 15 mg
3/28/19 lasix 20 mg
12:00 p.m.
3/16/19 hydrocodone 7.5-325 mg, gabapentin 400 mg
3/28/19 busprione HCL 15 mg, hydrocodone 7.5-325 mg
4:00 p.m.
3/28/19 buspirone HCL 15 mg
3/28/19 gabapentin 400 mg
8:00 p.m.
3/4/19 Levetiracetam 500 mg, levemir flextouch 20 units
3/12/19 trazodone 100 mg
3/22/19 levemir flextouch 20 units
3/23/19 hydrocodone 7.5-3.25 mg
April 2019 MAR
12 a.m.
4/15/19 hydrocodone 7.5-325 mg
6 a.m.
4/14/19 hydrocodone 7.5-32 5 mg
4/30/19 hydrocodone 7.5-325 mg
8:00 a.m.
12:00 p.m.
4/27 gabapentin 400 mg, buspirone HCL 15 mg
4 p.m.
4/29/19 docusate, gabapentin 400 mg
6 p.m.
4/29/19 hydrocodone 7.5 mg-325 mg
8:00 p.m.
4/1/19 Levetiracetam 500 mg
4/2/19 Levetiracetam 500 mg
4/11/19 levemir 20 units
4/15/19 Divalproex 500 mg, levetiracetam 500 mg, buspirone HCL 15 mg, trazodone 100 mg, fiberlax, levimir 20 units
4/26/19 fiber lax, trazodone 100 mg, levemir 20 units
4/29/19 Levetiracetam 500 mg, divalproex 500 mg, buspirone HCL 15 mg, trazodone 100 mg, levemir 20 units
May 2019 MAR
8:00 a.m.
buspirone 15 mg
12:00 p.m.
5/4/19 gabapentin 400 mg, hydrocodone 7.5-325 mg
4:00 p.m.
5/4/19 docusate 100 mg
6:00 p.m.
5/4/19 hydrocodone 7.5-325 mg
8:00 p.m.
5/4/19 divalproex 500 mg, levetiracetam 500 mg, gabapentin 400 mg, fiberlax, trazodone 100 mg
During an interview on 5/16/19 at 11:39 a.m. with LPN GG, she stated that she gave those medications on those dates but she just didn't sign them out like she should have. She stated she is very diligent about her care and services to the resident, but admits she is used to a computer system that flags those administrations times to be signed before you can move forward with medication administration.
During an interview on 5/16/19 at 11:42 a.m. with the Regional Nurse, DD, she stated that as of next week she will be the Director of Nursing (DON) at this facility. She expects the nurses to sign out all medications at the time they are given and validate all MARs before they leave their shift. The Unit Managers and the DON should follow-up daily to ensure that this documentation is completed. Going forward this concern will be managed daily.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observations, staff interviews, and review of two facility policies titled Food Storage and Pot and Pan Washing, the facility failed to store opened food items in secured or sealed containers...
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Based on observations, staff interviews, and review of two facility policies titled Food Storage and Pot and Pan Washing, the facility failed to store opened food items in secured or sealed containers in the dry storage room and failed to store clean pans in a dry, sanitary manner. This had the potential to affect 57 of 57 residents receiving an oral diet.
Findings include:
Review of an undated facility policy entitled Food Storage states 4. Metal or plastic containers with tight fitting covers must be used for storing cereals, cereal products, flour, sugar, dried vegetables, and broken lots of bulk foods. All containers must be legibly and accurately labeled.
Review of an undated facility policy entitled Pot and Pan Washing states 5. Pots and pans must be air dried on the drain board. Dish towels must never be used. After pot and pans are dry, they must be inspected and then stored in a clean, dry, protected area.
During the initial tour conducted on 5/13/19 at 10:50 a.m. with the Food Service Director (FSD), the dry storage area was found to contain seven individual bowls of dry cereal with loosely fitting disposable lids that did not seal. The seven bowls of cereal were on a tray labeled as prepared on 5/12/19 and use by 5/15/19.
During the initial tour conducted on 5/13/19 at 10:50 a.m. with the FSD, three stacks of various size and shaped pans were examined and three of three pans checked were wet. A tour of the kitchen conducted with the FSD on 5/15/19 at 12:20 p.m. revealed two stacks of various size and shaped pans were examined and two of two metal pans were wet. The FSD confirmed that the pans should not be stacked or nested when wet.
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
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • $4,017 in fines. Lower than most Georgia facilities. Relatively clean record.
Concerns
- • 20 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
- • Grade F (33/100). Below average facility with significant concerns.
- • 62% turnover. Above average. Higher turnover means staff may not know residents' routines.
Bottom line: Trust Score of 33/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Altamaha Healthcare Center's CMS Rating?
CMS assigns ALTAMAHA HEALTHCARE CENTER 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 Altamaha Healthcare Center Staffed?
CMS rates ALTAMAHA HEALTHCARE CENTER's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 62%, which is 16 percentage points above the Georgia average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 67%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Altamaha Healthcare Center?
State health inspectors documented 20 deficiencies at ALTAMAHA HEALTHCARE CENTER during 2019 to 2025. These included: 1 that caused actual resident harm, 18 with potential for harm, and 1 minor or isolated issues. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Altamaha Healthcare Center?
ALTAMAHA HEALTHCARE CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by BEACON HEALTH MANAGEMENT, a chain that manages multiple nursing homes. With 62 certified beds and approximately 53 residents (about 85% occupancy), it is a smaller facility located in JESUP, Georgia.
How Does Altamaha Healthcare Center Compare to Other Georgia Nursing Homes?
Compared to the 100 nursing homes in Georgia, ALTAMAHA HEALTHCARE CENTER's overall rating (1 stars) is below the state average of 2.6, staff turnover (62%) is significantly higher than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Altamaha Healthcare Center?
Based on this facility's data, families visiting should ask: "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "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 high staff turnover rate and the below-average staffing rating.
Is Altamaha Healthcare Center Safe?
Based on CMS inspection data, ALTAMAHA HEALTHCARE CENTER has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Georgia. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Altamaha Healthcare Center Stick Around?
Staff turnover at ALTAMAHA HEALTHCARE CENTER is high. At 62%, the facility is 16 percentage points above the Georgia average of 46%. Registered Nurse turnover is particularly concerning at 67%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Altamaha Healthcare Center Ever Fined?
ALTAMAHA HEALTHCARE CENTER has been fined $4,017 across 1 penalty action. This is below the Georgia average of $33,119. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Altamaha Healthcare Center on Any Federal Watch List?
ALTAMAHA HEALTHCARE CENTER is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.