BOLINGREEN HEALTH AND REHABILITATION
Non profit - Other
121 Beds
CLINICAL SERVICES, INC.
Data: November 2025
Trust Grade
38/100
#174 of 353 in GA
Photo by Bolingreen Health & Rehabilitation
Photo by Bolingreen Health & Rehabilitation
Photo by Bolingreen Health & Rehabilitation
1 / 5 photos
Last Inspection: February 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Bolingreen Health and Rehabilitation has received a Trust Grade of F, indicating significant concerns about the quality of care provided. They rank #174 out of 353 facilities in Georgia, placing them in the top half, but they are #3 out of 3 in Monroe County, meaning there are no better local options. The facility is improving, having reduced their issues from 13 in 2024 to 5 in 2025, but still faces serious shortcomings, including $16,800 in fines, which is higher than 76% of facilities in Georgia. Staffing ratings are average with a turnover of 47%, while RN coverage is also average, which means there is some consistency in care. However, there have been serious incidents where a resident was not properly treated for pressure ulcers, leading to hospitalization, and another resident experienced pain during wound care because pain management was not followed, showcasing both the facility's efforts to improve and the critical areas that need attention.
- Trust Score
- F
- In Georgia
- #174/353
- Safety Record
- Moderate
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 47% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- $16,800 in fines. Lower than most Georgia facilities. Relatively clean record.
- Skilled Nurses ○ Average
- Each resident gets 32 minutes of Registered Nurse (RN) attention daily — about average for Georgia. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 21 deficiencies on record. Higher than average. Multiple issues found across inspections.
38/100
Top 49%
Needs review
13 → 5 violations
★★☆☆☆
2.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★☆☆
3.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 13 issues
2025: 5 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
2-Star Overall Rating
Below Georgia average (2.6)
Below average - review inspection findings carefully
Staff Turnover: 47%
Near Georgia avg (46%)
Higher turnover may affect care consistency
Federal Fines: $16,800
Below median ($33,413)
Minor penalties assessed
Chain: CLINICAL SERVICES, INC.
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 21 deficiencies on record
2 actual harm
Feb 2025
5 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation, interview, and facility policy review, the facility failed to ensure over the counter (OTC) medications were securely stored. This failure had the potential for unauthorized peop...
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Based on observation, interview, and facility policy review, the facility failed to ensure over the counter (OTC) medications were securely stored. This failure had the potential for unauthorized people to access the medication.
Findings include:
Review of the facility's policy titled, Medication Labeling and Storage, dated 2001, indicated under the section, .The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. Indicated under section .Medication storage; 2. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner .
Observation and interview on 2/25/2025 at 8:05 am with the Central Supply Supervisor (CSS) of the central supply stockroom revealed the room contained a supply cart which contained a 100-tablet count unopened bottle of acetaminophen 500 milligram (MG) in the cart. The CSS confirmed the cart contained the bottle of unopened acetaminophen and stated she did not have room in the medication rooms on the hall to store the acetaminophen. The CSS stated, I don't normally keep meds [medications] in here like this. We have a locked storage cabinet in the next room where all the overstock meds are kept. They're in this cart this time because I fill the cart with all my supplies like briefs, wipes, personal protective equipment (PPE), overstock meds, and whatever else is needed and deliver them to the halls. Sometimes I have extras that there isn't room for, and I leave them in the cart to take back down to central supply and put them away when I get a chance.
During an interview on 2/25/2025 at 9:10 am, the Director of Nursing (DON) stated, That shouldn't happen. I know the CSS collects all her supplies together and delivers them all at once, and she handles all our overstock over the counter meds. All medications should be locked up, including all the overstock and over the counter drugs. I'll be re-educating her right away.
During an interview on 2/25/2025 at 9:15 am, the Administrator stated, That shouldn't be happening. I'm going down there right now to fix this. Staff know this isn't acceptable practice.
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 F0808
(Tag F0808)
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 failed to provide a therapeutic diet as ordered ...
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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 failed to provide a therapeutic diet as ordered for one resident (Resident (R) 59) of six residents reviewed for nutrition and/or food out of a total sample of 22 residents. This failure created a potential choking or swallowing hazard for R59, who had a diagnosis of dysphagia (difficulty with swallowing).
Findings include:
Review of the facility's policy titled, Meal Service, provided by the facility and dated 12/27/2024, indicated, It is the intent of the center to provide an enjoyable meal service in a safe, sanitary, and comfortable environment while focusing on patient centered care . Therapeutic diets and alternatives should be provided as needed.
Review of R59's Diagnosis Sheet, provided by the facility, revealed the resident was admitted to the facility on [DATE] with diagnoses which included dysphagia, flaccid hemiplegia affecting right dominant side, and aphasia following cerebral infarction.
Review of R59's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/11/2024, located in the electronic medical record (EMR) under the MDS, tab revealed R59 did not have a Brief Interview for Mental Status (BIMS) conducted, had short term and long-term memory problems, severely impaired cognitive skills for daily decision making and received a mechanically altered diet.
Review of R59's current Care Plan, provided by the facility, contained the following Care Area/Problem, dated 1/15/2025, Risk for altered nutritional status Related To Dysphagia. Care Plan interventions included, Observe for worsening swallowing and/or chewing . Provide diet as prescribed . Provide meal alternates as needed.
Review of R59's Speech Therapist (ST) notes, provided by the facility, revealed a 2/12/2025 ST note that specified the ST observed R59 having difficulty eating cornbread during the lunch meal and cornbread was discontinued from the resident's diet.
Review of R59's current Physician's Orders, located in the resident's EMR under the Orders tab, revealed an order with a start date of 2/12/2025 for a regular diet with no cornbread.
Observation on 2/23/2025 at 12:35 pm revealed R59 was seated in his room independently eating his lunch meal without staff present. Observation of the food R59 was served at this meal revealed he was served cornbread. Review of R59's tray slip served with this meal specified he was not to be served cornbread.
Observation on 2/23/2025 from 12:35 pm to 1:07 pm revealed that R59 continued to independently eat his lunch meal in his room, and staff checked in on him periodically to encourage him to eat.
Observation on 2/23/2025 at 1:07 pm revealed R59 had finished eating his lunch meal. R59 did not eat the cornbread that was served at this meal.
During an interview on 2/23/2025 at 1:10 pm, the Dietary Manager (DM) confirmed R59 was served cornbread with his lunch meal. The DM stated R59 should not have been served cornbread at this meal and should have received a roll instead. The DM stated that ST had previously informed the dietary staff to restrict cornbread from R59's diet, and this restriction was placed on the resident's meal tray slip. The DM stated the dietary staff needed to read the resident meal tray slips more closely to ensure resident diets were followed.
During an interview on 2/24/2025 at 1:29 pm, Certified Nursing Assistant (CNA) 1 stated R59 was able to independently feed himself after staff set up his meal tray.
During an interview on 2/26/2025 at 11:05 am, the ST stated she worked with R59 twice a week from 2/3/2025 to 02/23/25 to determine if his diet could be upgraded from a chopped meat diet to a regular diet. The ST stated when she observed R59 eating his lunch meal on 2/12/2025, the resident began coughing as he ate cornbread, and it took him several minutes to recover. The ST stated she wrote the order for R59 not to receive cornbread with his meals. The ST confirmed R59 was able to independently feed himself a regular diet, but he should not have been served cornbread with his 2/23/2025 lunch meal.
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 observation, interview, and facility policy review, the facility failed to date, label, and/or cover bread products stored in the kitchen, and failed to keep the kitchen's two ovens, large ma...
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Based on observation, interview, and facility policy review, the facility failed to date, label, and/or cover bread products stored in the kitchen, and failed to keep the kitchen's two ovens, large manual can opener and its table base attachment, and food preparation pans clean. The facility also failed to discard two opened containers of thickened beverages stored in resident refrigeration for greater than seven days. This failure had the potential to create an environment for food-borne illnesses, which could affect 80 of 80 residents who consumed food prepared from the facility's kitchen.
Findings include:
Review of the facility's policy titled, Storage Areas, dated 12/27/2024, indicated, It is the intent of this center to store food in a manner that maintains quality and safety . First in first out (FIFO) should be followed . Refrigerator Food codes and internal tools may be used as a reference for proper dating.
Review of the facility's policy titled, Cleaning and Sanitizing, dated 12/27/2024, indicated, It is the intent of this center to clean and sanitize utensils, dishware, pots and pans, workspace, and equipment to minimize the risk of food-borne illnesses . All small ware equipment should be in a self-draining position that allows it to air dry . Items should be washed, rinsed, and sanitized . Fixed equipment Items should be washed, rinsed, and sanitized appropriately .
1. Observation on 2/23/2025 from 8:05 am to 8:30 am, during the initial kitchen inspection with the Dietary Manager (DM) present, of bread products stored on the kitchen's bread storage racks revealed eight unopened and undated loaves of thawed bread, two unopened and undated packages of thawed hamburger buns, one opened and undated package of thawed hamburger buns, that was open to air and contained six buns that were very hard, and one 18 ounce package of hot dog buns, with an expired hand written use by date of 1/31/2025 on the package which had three buns with mold growth.
During an interview on 2/23/2025 at 8:30 am, the DM confirmed the concerns observed with how bread products were stored in the kitchen. The DM stated bread products should be dated by staff when taken out of freezer storage to thaw and utilized within fourteen days after they are thawed. The DM stated bread products should be completely closed when stored and should be discarded if not utilized within fourteen days or have signs of spoilage.
2. Observation on 2/23/2025 from 8:05 am to 8:30 am, during the initial kitchen inspection with DM present, revealed the kitchen's two ovens were unclean with heavy accumulated blackened and dried food spills on its interior cooking compartment, the large manual can opener's blade and table base attachment were unclean with accumulated dried and sticky substances, and five food preparation pans were stored stacked together and ready for use with food residue, grease residue, and moisture on them.
During an interview on 2/23/2025 at 8:30 am, the DM confirmed the kitchen's ovens, manual can opener and its' base attachment, and food preparation pans were unclean. The DM stated the kitchen's two ovens were scheduled to be cleaned weekly, but staff had been unable to clean them weekly because of staffing shortages, and the kitchen's manual can opener and food preparation pans should be stored clean and free of moisture.
3. Observation on 2/24/2025 at 11:05 am of food and beverages stored in the resident refrigerator for the facility's 400 and 500 hallways revealed one opened forty-six container of thickened cranberry juice and one opened forty-six-ounce container of thickened apple juice. Observed on both containers was a handwritten date of 2/4/2025. The manufacturer's directions printed on both containers indicated, Refrigerate after opening. After opening, may be kept seven days under refrigeration.
During an interview on 2/24/2025 at 11:15 am, the Regional Nurse Consultant (RNC) confirmed the containers of thickened cranberry juice and apple juice stored in the resident 400/500 hallway refrigerator were opened and dated 2/4/2025. The RNC confirmed the two opened containers of thickened juice had been stored in refrigeration for more than seven days and discarded both containers.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
Based on observations, interviews, and policy review, the facility failed to maintain a clean environment by storing unwashed and unsanitized mattresses next to racks of clean resident clothing in the...
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Based on observations, interviews, and policy review, the facility failed to maintain a clean environment by storing unwashed and unsanitized mattresses next to racks of clean resident clothing in the shared clean laundry room and central supply room. This failure had the potential for residents being subject to the spread of infections within a facility, leading to more serious illnesses.
Findings include:
Review of the facility's policy titled, Cleaning and Disinfection of Resident-Care Items and
Equipment, revised 2022, indicated .Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard .
Observation on 2/25/2025 at 7:54 am in the shared clean laundry room and central supply room revealed four unwashed and unsanitized mattresses being stored side by side leaning next to a rack of lost and found clothes. The Housekeeping Supervisor (HSKS) confirmed the mattresses were being stored unwashed, touching the rack of hanging clean clothes.
During an interview on 2/25/2025 at 7:55 am, HSKS stated, Those clothes are lost and found items and should have a cover draped over them to keep them clean. Once a month, we take the clothes to the 400 hall and let the residents and families go through them to find any lost clothes. The mattress is cleaned whenever maintenance needs a replacement prior to putting on a resident's bed.
During an interview on 2/25/2025 at 8:05 am, the Central Supply Supervisor (CSS) stated, We store a few mattresses down here until they're needed. Maintenance will come down here and get them when they're needed and clean and disinfect them before they put them on the resident's bed. We should clean them when we store them.
During an interview on 2/25/2025 at 9:10 am, the Director of Nursing (DON) stated, Those mattresses should all be cleaned. They know they can't store dirty with clean. We will be reeducating all staff.
During an interview on 2/25/2025 at 9:15 am, the Administrator stated, That shouldn't be happening. I'm going down there right now to fix this. Staff know this isn't acceptable practice.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected most or all residents
Based on observation, interview, and policy review, the facility failed to ensure the laundry dryers were maintained to ensure safe operating conditions. This failure placed the facility at an increas...
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Based on observation, interview, and policy review, the facility failed to ensure the laundry dryers were maintained to ensure safe operating conditions. This failure placed the facility at an increased risk of fire and had the potential to affect all residents who resided at the facility.
Findings include:
Review of the manufacturer's manual titled UniMac Tumble Dryer Operational/Maintenance by Alliance Laundry Systems, dated January 2020, revealed . Maintenance .Daily 2. End of Day: a. Clean lint filter to maintain proper airflow and avoid overheating. Monthly 3. Remove lint filter and thoroughly vacuum exhaust duct. 4. Inspect fan, remove any accumulated lint or debris from fan to maintain proper airflow and avoid overheating .
During an observation on 2/25/2025 at 7:54 am with the Housekeeping Supervisor (HSKS) of the laundry room revealed one dryer vent filter had two layers of lint built up, each shaded with a different color. Observation of the bottom compartment inside of the dryer revealed approximately one inch thick of lint lying on the bottom compartment inside of dryer. Observation of the second dryer vent filter revealed the filter had three layers of lint build up, each shaded a different color, and there was also lint hanging loose from the filter. Observation of the bottom compartment inside the dryer revealed approximately one and a half inches of lint lying on the bottom compartment inside of the dryer. The HSKS stated, The dryer lint filters should have been cleaned last night at the end of the shift, before the laundry aide left. They're supposed to be cleaned after every two dryer loads. She will be retrained because it's a fire hazard. The evening laundry aide has worked here for two months, but she should have known better and cleaned the dryer lint out after every two loads and every night before the end of her shift. We keep a check-off schedule of when they're checked and cleaned, but I can't find it right now.
During an interview on 2/25/2025 at 9:10 am, the Administrator stated, The dryer vent filters should be cleaned at the end of every day. We don't know where the cleaning schedule check-off sheets are to show when they were cleaned. We're looking into it.
During an observation on 2/25/2025 at 10:35 am with the Maintenance Director (MD) of the laundry room revealed the back of the dryers and floor were covered in an accumulation of approximately a half to one inch thickness layer of lint and dust mixture as well stringy lint from the pipes of the ceiling. Observation looking from the ground up to the dryer ductwork (approximately 40 feet) revealed an accumulation of approximately two inches of lint built up from under the dryer hood.
During an interview on 2/25/2025 at 10:36 am, the MD stated, We take turns and clean the back of the dryers every three months using a hand vacuum and wiping it down. I believe the dryer duct on top of the roof was last cleaned three months ago. I don't keep a record of when we clean it, we just clean it every three months.
During an interview on 2/25/2025 at 10:55 am, the Regional Maintenance Supervisor stated, The last time the dryer duct on the rooftop was cleaned was back in November 2024. I kept the date of when I cleaned it in my phone, but I can't find it now. It was horrible and covered completely. I cleaned under the hood and then inside the exhaust pipe. Before that, I can't tell you when it was ever cleaned.
During an interview on 2/25/2025 at 11:00 am, the Administrator stated, I don't know when the dryer exhaust gets cleaned. Maintenance has always taken care of it. I'm not able to reach the laundry aide that may have taken the cleaning schedule check off sheets home. She may have them with her. I can't say they exist because I can't produce them, but I'm fairly certain that they do exist, and she has them with her.
Review of the facility's Dryer Filter Log Binder, provided by the facility revealed the binder contained sheets for documenting Clean filters every two hours. The binder contained eight days of checks during the month of November 2024 only. No other documentation of the dryer vent filters being cleaned was received.
Review of the facility's Dryer Lint Removal Sign Off sheets dated for November 2024, December 2024, and January 2025, provided by the facility the day after they were requested, revealed when comparing the sign off sheets to the Dryer Filter Log Binder, dates and times of the two documents did not match and they should have.
Feb 2024
13 deficiencies
2 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
Pressure Ulcer Prevention
(Tag F0686)
A resident was harmed · This affected 1 resident
Based on record reviews and staff interviews, the facility failed to ensure one Resident (R)180, with pressure ulcers, received treatment and services to promote healing. Actual harm was identified wh...
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Based on record reviews and staff interviews, the facility failed to ensure one Resident (R)180, with pressure ulcers, received treatment and services to promote healing. Actual harm was identified when a statin (STAT) lab order on 11/5/2023 was not followed up on by staff, and twelve days later, on 11/17/2023, R180 was admitted to the hospital with sepsis due to a wound infection.
Findings include:
Record review of the most recent admission Minimum Data Set (MDS) assessment for R180, dated 12/2/2023, revealed that he had a Brief Interview for Mental Status Score (BIMS) of 15, indicating intact cognition. Exhibited no negative behaviors. Dependent on staff for all Activities of Daily Living. Has an indwelling catheter and is always incontinent of bowel and bladder. Active diagnoses, including but not limited to wound infection (other than foot), Diabetes Mellitus, and hemiplegia. Has a stage 1 or greater unhealed pressure ulcer, a scar over bony prominence, or a non-removable dressing/device and 1 stage 4, full thickness tissue loss with exposed bone, tendon, or muscle that slough, or eschar may be present on some parts of the wound bed that often includes undermining or tunneling. Care Area Assessment Summary (CAAS) triggered Activities of Daily Living (ADL) Function, urinary catheter, nutritional status, feeding tube, dehydration/fluid maintenance, and pressure ulcer.
Record review of the 11/13/2023 care plan for R180 revealed a concern of skin breakdown related to being at risk for/actual pressure ulcer, type 2 diabetes mellitus, cerebral infarction, hemiplegia. Goals include breakdown/further breakdown to the area through the review period, patient's pressure ulcer(s) will have signs of improvement through the review period, open area will be healed during the review period, and skin tear to the left upper arm will resolve during the review period. As evidenced by G-tube to left mid abdomen (9/28/2023), stage II to left upper back at the shoulder (9/28/2023) RESOLVED, Resident has pressure ulcers/injuries, this increases the potential risk for developing additional pressure ulcers/injuries (10/17/2023), staff reports resident is always incontinent (10/17/2023), stage II to left hip (9/28/2023) RESOLVED- New unstageable on this healed area, Deep Tissue Injury (DTI) to bilateral buttocks with open area at the coccyx (9/28/2023) DECLINE to unstageable - BONE EXPOSED (Onset 9/28/2023 - Admission), skin tear to the left upper arm (11/11/2023), pressure area (9/28/2023). Interventions: application of ointments/medication to skin (other than to feet) (9/28/2023), apply protective or barrier lotion after incontinence (9/28/2023), assist patient to turn and reposition frequently (9/28/2023), assist with bed mobility as needed (10/17/2023), avoid prolonged sitting (10/15/2023), incontinence care as needed (10/17/2023), inspect skin during care and bathing, and report any changes to charge nurse (9/28/2023), inspect wound at each dressing change for signs and symptoms (s/s) of infection (11/11/2023), low air loss mattress in place (10/24/2023), maintain adequate nutrition and hydration (10/15/2023), off load heels (10/24/2023), patient on a turning/repositioning program per the HANDs program (9/28/2023), position patient properly; use pressure-distribution or pressure-relieving devices (e.g. pillows, positioning wedges, and specialty mattress) if indicated (9/28/2023), pressure redistribution device to bed (9/29/2023), pressure redistribution device to chair (10/5/2023), provide incontinence care after voiding or bowel movement (9/28/2023), treatments / dressings as ordered per physician (9/28/2023), turning/repositioning program (9/29/2023).
Record review of the physician order dated 10/30/2023 for R180 revealed an order for wound care consult for coccyx and wound evaluation entered by Wound Care Nurse (WCN) AA.
Record review of the physician order dated 11/5/2023 at 18:16:57 (6:16 pm) revealed Registered Nurse (RN) EE entered a STAT order for a Complete Blood Count (CBC) with Auto Differential one time only and at 18:16:58 (6:16 pm) RN EE ordered a Comprehensive Metabolic Panel (CMP) one time only.
Record review of wound care note dated 10/30/2023 by Wound Care Nurse (WCN) AA revealed during routine wound care this morning, it was noted amount of slough in the wound was decreased and the wound bed was visible, and the bone was exposed. Family Nurse Practitioner (FNP) MM was in the facility and notified. An order to get a wound consult at a wound care clinic was given, and the order was put in the system. The writer is in progress with the paperwork and will send it to the Wound Clinic for an appointment as soon as possible (ASAP) due to exposed bone. The resident's family was notified as well. Will continue to monitor skin for changes. The area on the left knee has improved from last week.
A review of wound care note dated 10/31/2023 by WCN AA revealed writer received call back from wound clinic and appointment is made for November 17, 2023, at 9:00 am. The resident's family called this am and wanted to know about the father's wounds. Updated on all wound issues, and about new Low Air Loss (LAL) mattress and recent appointments with the wound care clinic. The resident's family member will be meeting the resident at the wound care appt. Appointment was put in the resident's schedule, and Social Services was notified to make the transportation.
Record review of the wound care note dated 11/1/2023 by WCN AA revealed the family member called that day and stated she would be meeting another family member at wound care appointment on November 17, 2023.
A review of Nurses Note dated 11/5/2023 by Licensed Practical Nurse (LPN) LL revealed the resident's temporal temp 99.2, As Needed (PRN) x1 dose Tylenol given. Sacral wound noted with a foul odor. Wound care is complete. On the call, the FNP was notified. Order for CBC STAT collected per orders. The family member was made aware.
A review of the wound care note dated 11/9/2023 by WCN AA revealed coccyx and left hip continue to decline. The resident eats very little of the pleasure trays and will sip only a small amount of water. The order changed to daily this day, and the resident still has a wound consult on 11/17/2023. Tube feeding time will increase for increased caloric needs. FNP MM and the family member of R180 were notified as well.
A review of the wound care note dated 11/12/2023 by WCN AA revealed the writer attempted to contact the family of R180 to give an update on the resident's wounds. A message was left to let the family member know that dressing changes have moved to daily due to wounds not healing and to let her know the resident will go to a wound consult on 11/17/2023.
A review of the wound care note dated 11/17/2023 by WCN AA revealed a callback from the family. The resident is being admitted to the hospital due to a coccyx wound. The writer and Director of Nursing (DON) talked with the family member to follow up on any concerns. She wanted to know what was done for R180. A family member was in the room on speakerphone with another family member. The writer explained everything had been done regarding wound care and had contacted the family with every change in skin or change in orders. Also reminded them about the insurance decline, and honey was continued to be used until the wound appointment. Explained area around the wound was intact no maceration noted, and the resident was not eating or drinking much and had notified family of all changes. A wound consult was made, and no sooner time could be given as they were fully scheduled. The family was made aware of this also, and I encouraged the family to make sure someone was with the resident because they would not see the resident if the family was not there, and I didn't know how long it would take to make another appointment. We had talked about all that. The family member stated, I have no problems with the care you gave R180. You did everything you could have done with his wound care, and we appreciate you, but there are some other concerns we have. DON took over and talked with the family member about the other concerns she had.
A review of the nurse's note dated 11/20/2023 by WCN AA revealed called and spoke with the nurse at the hospital. Diagnosis: sepsis--sacral wound infection--- antibiotic therapy merrem and vancomycin iv. Started on feeds will increase to a goal of 50 cc hr. Puree thin liquid diet-- takes only small sips. Debridement of sacral wound 11/17/2023. No discharge plans at present.
Interview on 2/3/2024 at 10:07 am with WCN AA revealed R180 was admitted with a stage 2 pressure ulcer and DTI. On 10/23/2023, the order changed from honey gel to Santyl. A low-air loss mattress was ordered. The Registered Dietitian (RD) was notified that the resident might need a high calorie feeding. On 10/24/2023, an air mattress arrived. On 10/24/2023 Santyl was still not available and continued use of Honey Gel. On 10/25/2023, insurance denied payment for Santyl. Spoke with FNP MM, and she ordered the one-time Debrisoft Lolly to remove the slough since Santyl denied it and continued to monitor. Debrisoft Lolly came in on 10/27/2023; on the same day it came in, she used an R180, as best she can remember. On 10/30/2023, during routine wound care, the wound was noted to have slough broken up, and the bone was visible; FNP MM was notified, and a wound consult was ordered. The consult, which is seven pages long, was filled out and sent to the wound clinic on 10/30/2023. On 10/31/2023, a call was received from the wound clinic, and the earliest appointment was on 11/17/2023. The family of R180 was notified and stated they would meet him at the wound clinic for the appointment. The family was notified on 11/1/2023. On 11/5/2023, a foul odor was noted by a weekend nurse. On 11/9/2023, the hip continued to decline, and eating by R180 declined. The decline was discussed in the morning meeting, and the Registered Dietician (RD) ordered a change in the feeding to Nutren 1.5/0.07-gram (g)-1.5 kilocalories (kcal)/milliliter (mL) liquid for tube feed. 55-milliliter feeding tubes every 24 hours to provide 1815 kcals, 82g protein, and 924 ml of free water. RD was involved and continued to increase nutritional needs as the resident's needs arose. On 11/12/2023, Dressing changes changed to daily due to the wound not healing. During this time, the WCN was asked about the note on 11/5/2023 related to the nurse documenting the wound now having a foul odor, calling the FNP, and the order for the Stat CBC. She stated that she could not find the CBC in the medical record and that there was no documentation indicating it was received by the FNP or Medical Director and no new orders, but she would need to speak with the Assistant Director of Nursing (ADON) to find out where the CBC is. She stated the wound clinic could not see the resident until 11/17/2023 but added that with the wound worsening and with fever, the resident could have been sent out to the hospital in the meantime if needed.
Interview on 2/3/2024 at 12:04 pm, the ADON stated she searched the medical record and could not locate the STAT (immediately) labs ordered on 11/5/2023 and found no documentation indicating the labs had been relayed to the FNP and added that she called the local hospital and had the lab fax over the STAT labs ordered for R180 on 11/5/2023 and provided a copy of the results. A review of the results at this time revealed a [NAME] Blood Cell (WBC) count of 16.97 with a reference range of 4.00-11.00.
A telephone interview on 2/03/2024 at 12:15 pm with FNP MM revealed if she had been made aware of the lab results on R180 on 11/5/2023 she would have considered sending R180 out sooner. She stated the facility was going through many changes, and the results never reached her. FNP MM revealed it wasn't caught, and the results never got to her or the Medical Directors hands. She stated she could not explain that, but had she seen the results, she may have sent him to the hospital or may have started him on an antibiotic. She added that had she known, she could have intervened. FNP MM further revealed the note on 11/5/2023 revealed the on-call FNP was notified and suggested that LPN LL be called to verify who she spoke with about the wound on 11/5/2023.
Interview on 2/03/2024 at 12:45 pm with LPN LL revealed she cannot remember who the on-call FNP was she spoke with on 11/5/2023 about R180. She stated she was off the following two days and does not know who got the lab report as it did not get reported to the facility until after her shift was over at 7:00 pm. LPN LL revealed that she is sure she would have told the oncoming nurse of the pending STAT labs for R180.
Interview on 2/03/2024 at 1:15 pm with RN EE revealed she was aware there was a STAT lab ordered for R180 on 11/5/2023 but added that the labs may not have been reported out prior to her leaving the facility at 7:00 p.m. She stated that the process for STAT labs is that the facility draws the labs, the courier picks them up and takes them to the hospital, and when they are completed, the lab faxes the results to one of three fax machines in the facility. RN EE revealed if she knows there is a STAT lab to be on the lookout for when she arrives at the facility, she will check the fax machines right away. Otherwise, she will check them after her rounds.
A review of the STAT lab results dated 11/5/2023 for R180 revealed they were collected on 11/5/2023 at 6:17 pm, received at 7:49 pm, and verified on 11/5/2023 at 7:53 pm.
A telephone interview on 2/3/2024 at 2:05 pm with the Director of Nursing (DON) revealed it is her expectation of staff when a STAT lab is pending or has not come back that they follow up to ensure the lab results have been received and the provider has been notified of those results. During this time, the DON was asked about the elevated white count not being reported to the FNP or the Medical Director on 11/5/2023 and that R180 went an additional 12 days in the facility until his appointment with the wound clinic on 11/17/2023 with no treatment for a wound infection. DON stated she has not worked in the facility for very long but that she does expect any STAT labs to be followed up on to ensure the results are received by the ordering provider.
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
Deficiency F0697
(Tag F0697)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and review of facility policy Pain Assessment, the facility failed to stop and a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and review of facility policy Pain Assessment, the facility failed to stop and address verbal and facial expressions of pain during wound care for one resident (R) (R286) observed for wound care. Actual harm was identified on 2/2/2024 when Registered Nurse (RN) AA failed to assess and administer pain medication to R286 prior to providing wound care treatment, which resulted in pain during the treatment.
Findings include:
A review of the Policy titled Pain Assessment, review date 12/30/2022, revealed Guideline; pain evaluation utilizing the 0-10 pain scale should be completed and documented on the Treatment Administration Record prior to any treatment.
A review of the clinical record revealed that R286 was admitted to the facility on [DATE] with diagnoses, including but not limited to, acquired absence of right leg above knee.
A review of the baseline care plan revealed R286 has pain. Interventions include administer pain medications as ordered. Assess characteristics of pain: location, severity, on a scale 1-10, type of pain, frequency, precipitating factors, and relief factors. Give pain medications before pain becomes severe.
A review of the physician orders revealed R286 had current orders for oxycodone 5 milligram.
(mg) capsule by mouth every 8 hours As Needed PAIN Dx: Acquired absence of right leg above knee.
During an observation on 2/2/2024 at 9:14 am of wound care provided by Registered Nurse (RN) AA for R286, while RN AA was removing the soiled dressing that was stuck to the staples to R286 Right Below the Knee Amputation (RBKA), R286 yelled Ouch, Oh Lord . R286 was observed to have facial grimaces and frowning at this time. RN AA continued to pour some normal saline onto the soiled dressing and continued to remove the dressing and did not assess for pain. When surveyor asked if R286 was assessed for pain, RN AA replied she usually does not do that. RN AA was then asked if R286 was assessed for pain and or received pain medication prior to wound care. RN AA stated what do you want me to do, do you want me to stop and ask the nurse if she has something for pain? RN AA then asked R286 if she was in pain, R286 stated yes. RN AA continued with wound care applying xeroform dressings covering the area on R286 right below the knee amputation. RN AA stated she would ask the charge nurse to give R286 something for pain. RN AA stated that she was not going to put the dressing on until after R286 receives pain medication. She stated that she was going to wait for 30 minutes and then come back and put the dressing on it. RN AA exited the room and returned with Licensed Practical Nurse (LPN) BB. LPN BB administered R286 pain medication at 9:39 am. LPN AA wrapped the area with a cling dressing. RN AA informed R286 that she would be back in 30 minutes to put the dressing on her wound.
Interview with RN AA on 2/2/2024 at 8:43 am revealed she did not assess the R286 for pain prior to wound care. RN AA stated that she should have assessed her before she started wound care. RN AA stated that the R286 normally does not cry out in pain like that. She stated that she
was trying to show R286 son her area. RN AA stated that she was just nervous because the son was in the room watching her and she had not met him before.
Interview with LPN BB on 2/2/2024 at 9:39 am revealed the last time a pain medication was signed out for R286 was on 1/30/2024 at 3:00 pm. LPN BB stated that he administered the pain medication to R286 at that time.
Interview with the Assistant Director of Nursing (ADON) on 2/4/2024 at 7:55 am revealed RN AA should have assessed R286 prior to beginning wound care. She stated that if R286 was crying out in pain RN AA should have stopped and assessed her pain.
Phone interview with the Director of Nursing (DON) on 2/4/2024 at 1:33 pm revealed residents should be assessed for pain and offered pain medication prior to wound care. DON stated that it is her expectation that residents are assessed for pain prior to treatment.
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
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Based on staff interview, record review, and a review of the facility policy titled Changes in a Patient's Condition, the facility failed to notify the family/health agent of a significant change rela...
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Based on staff interview, record review, and a review of the facility policy titled Changes in a Patient's Condition, the facility failed to notify the family/health agent of a significant change related to weight loss for one of 27 sampled Residents (R) (R36).
Findings Include:
A review of the facility's policy titled Changes in a Patient's Condition, dated 12/30/2022, revealed it is the intent of the facility to notify the patient, his/her attending physician, and responsible party/patient representative of changes in the patient's condition and/or status. Guideline: Nursing services is responsible for notifying the patient's attending physician when: There is a significant change in the patient's physical, mental, or emotional status. Nursing services is responsible for notifying the patient, his/her next-of-kin, or responsible party/patient representative when: There is a significant change in the patient's physical, mental, or emotional status. Notifications, other than for medication emergency, should be made as soon as practical, but should not exceed twenty-four (24) hours. Changes in the patient's medical condition should be promptly recorded in the patient's medical record, including notifications to whom, by which staff, and when.
Record review of the Electronic Medical Record (EMR) for R36 revealed that on 1/8/2024, the resident weighed 165 lbs. (pounds). On 10/07/2023 resident weighed 180 lbs. On 7/7/2023 resident weighed 184.6 lbs. The above-mentioned weights triggered a significant weight loss of 8.33% in 90 days and 10.62 % weight loss in 180 days.
Record review of the EMR for R36 revealed there was no evidence that the family/health agent or physician had been notified related to his significant weight loss.
A review of the progress note dated 2/1/2024 indicated that the Nurse Practitioner (NP) and the residents' family member was not notified of R36's gradual weight loss (24 days later). A new order was received for Mirtazapine 7.5 milligrams, 1 tablet by mouth daily. The documentation did not indicate the NP or the resident's family member were informed that R36 had a significant weight loss.
Interview 2/4/2024 at 9:22 am with Divisional Nurse Consultant verified R36 triggered for a 3- and 6-month weight loss on the first of January 2024. The Divisional Nurse Consultant stated that the resident's family should have been notified when the significant weight loss was identified. She verified there was no documentation of family or physician notification until 2/1/2024.
During a telephone interview on 2/4/2024 at 9:28 am with the Director of Nursing (DON), it was revealed the Dietary Manager (DM) is responsible for documenting the PAR meeting notes, weekly weights, and making notifications in the record. The DON stated that she does not audit records to ensure weekly documentation and weights are documented.
Interview on 2/4/2024 at 9:42 am with the DM revealed that she was aware R36 triggered a significant weight loss. The DM further stated she had fallen behind on documentation due to staffing issues in the kitchen. DM verified she did not call the Registered Dietitian, physician, or notify resident's family of R36's regarding weight loss.
Cross Reference F692
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 F0645
(Tag F0645)
Could have caused harm · This affected 1 resident
Based on staff interviews, record review, and review of the facility policy titled Best Practices for PASRR, the facility failed to perform Level II PASRR (Preadmission Screening and Resident Review) ...
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Based on staff interviews, record review, and review of the facility policy titled Best Practices for PASRR, the facility failed to perform Level II PASRR (Preadmission Screening and Resident Review) for evaluation and determination of specialized services for one of 27 sampled residents (R) (R52) diagnosed with a mental disorder. This failure had the potential for residents with mental disorders not to receive identified specialized services.
Findings include:
A review of the undated facility policy titled Best Practices for PASRR revealed:
There are two areas a person can be a PASRR patient: Significant Mental Illness and Intellectual Disability/Developmental Disability.
Record review of the medical record for R52 revealed diagnoses that include but are not limited to bipolar disorder and unspecified intellectual disabilities.
Record review of the most recent admission Minimum Data Set (MDS) for R52, dated 10/29/2023, revealed:
Section A-No PASRR level 2
Section C-Cognition: Brief Interview of Mental Status score of seven (7) indicating poor cognition.
Section D-Mood: score of 0
Section E-Behavior: no behaviors identified.
Record review of the care plans for R52 revealed:
Cognitive deficit, memory related to bipolar depression, and intellectual disabilities.
Behaviors related to crying and impulsiveness.
Record review of the current medications for R52 revealed (partial list):
Buspirone 15 mg (milligrams) tablet 1 tablet by mouth 2 times per day for bipolar disorder.
Divalproex 125 mg capsule, delayed release sprinkle 2 capsules, delayed release sprinkle by mouth at bedtime for bipolar disorder.
Divalproex 125 mg capsule, delayed release sprinkle 4 capsules, delayed release sprinkle by mouth 1 time per day for bipolar disorder.
Seroquel 100 mg tablet 1 tablet by mouth 2 times per day for bipolar disorder.
Record review revealed an approved PASARR Level I for R52 dated 9/23/2022.
Record review revealed that R52 was not receiving psych services.
A review of the facility list of residents who have a level II PASRR in place and a list of residents who are receiving psych services revealed that R52 was not on either of the lists.
Interview on 2/4/2024 at 8:03 am with the Social Service Coordinator revealed she reviews the new admissions to ensure they have a level one. She indicated she did not have a process for reevaluating the residents for the need for a level II PASRR after admission. She indicated the resident does not have a level II PASRR and does not receive any type of psychiatric services.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of the facility policy titled Patient's Plan of Care, the facility failed to...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of the facility policy titled Patient's Plan of Care, the facility failed to develop care plans for diabetes and insulin use, as well as antianxiety and diuretic use, for one resident (R) (R 50). In addition, the facility failed to develop an individualized care plan for the behaviors related to pacing, delusions, and combativeness of one resident (R 72). The facility also failed to follow a care plan for one resident (R) 68 related to ADL care. The deficient practice had the potential to cause R50, R72, and R68 to not receive treatment and/or care according to their needs and to place them at risk for adverse consequences. The sample size was 27 residents.
Findings include:
Review of the facility policy titled, Patient's Plan of Care, with a review date of 12/30/2022, revealed under Guideline: Each patient will have a person-centered comprehensive care plan developed and implemented to meet his or her preferences and goals, and address the patient's medical, physical, mental, and psychological needs.
1. Record review of R50's clinical record revealed that he had diagnoses including anxiety, diabetes mellitus, and congestive heart failure (CHF).
Record review of the most recent Quarterly Minimum Data Set (MDS) for R50 dated 12/26/2024 revealed he received insulin therapy 7 out of 7 days of the assessment period and received an antianxiety and diuretic medication. Review of R 50's Physician's Orders revealed that he was receiving Novolin 70/30 U-100 Insulin 100 unit/mL (milliliter) subcutaneous suspension (insulin NPH human isophane/insulin regular, human) 30 Unit/Units Subcutaneous 2 times per day for diabetes mellitus, Novolog Flexpen U-100 Insulin aspart 100 unit/mL (3 mL) subcutaneous (INSULIN ASPART) Units Per Sliding Scale Subcutaneous before meals and at bedtime for diabetes mellitus, Buspirone 15 mg tablet (BUSPIRONE HCL) 1 tablet by mouth 2 times per day for anxiety, and Furosemide 40 mg tablet (FUROSEMIDE) 1 tablet by mouth 1 time per day for CHF.
Record review of the care plan for R50 revealed there were no care plans developed for the insulin, antianxiety, or diuretic medications he was receiving, and no individualized interventions to address the monitoring and possible side effects from these drugs, nor to monitor for progress towards a therapeutic goal.
A review of the facility's Interdisciplinary Team (IDT) care plan conference on 1/8/2024 for R50 revealed to review R50's plan of care. The Care Plan Conference V2.0 Form indicated resident's medication and care plans were reviewed during this meeting.
Interview on 2/3/2024 at 11:40 AM with Assistant Director of Nursing (ADON) revealed she does attend the care plan conferences. ADON further stated medications are reviewed during the care plan conferences, but she does not look at the care plan to verify if a care plan had been developed for each medication.
Interview 2/3/2024 at 11:48 AM with Resident Assessment Instruments (RAI) Coordinator HH revealed R50's care plans were updated 1/8/2024. She further stated that the IDT is required to review medications and update and generate new care plans if needed during the care plan meetings. RAI Coordinator verified that R50 did not have care plans related to diabetes diagnosis and insulin use, anxiety and antianxiety use, and CHF and diuretic use. The RAI Coordinator stated she would develop the care plans right away.
2. Record review of the clinical record revealed that R68 was admitted to the facility on [DATE] and had diagnoses including, but not limited to, unspecified dementia, need for assistance with personal care, and other specified arthritis.
Record review of the care plan for R68 revealed that the resident presented with a self-care deficit for ADL care. R68 required assistance with ADL care.
Record review of the most recent 5 Day Minimum Data Set (MDS) assessment dated [DATE] revealed that R68 required substantial/maximal assistance with personal hygiene. This coding indicated the staff does more than half the effort. The staff lifts or hold trunk or limbs and provides more than half the effort.
Observations on 2/2/2024 at 8:51 am, 2/3/2024 at 9:09 am and 1:11 pm, and on 2/4/2024 at 8:55 am, R68 was observed in bed, not shaven with long, uneven facial hair.
During an interview and walking rounds on 2/4/2024 at 9:18 am with Weekend Registered Nurse (RN) Supervisor EE, revealed Certified Nursing Assistants (CNA) are required to report any resident refusal of care to the primary nurse or her. Weekend RN Supervisor EE further stated the goal is to get the resident to comply and receive the needed care. Weekend RN Supervisor EE informed the surveyor that she had not received a report of R68 refusing to be shaved or being combative. During walking rounds, the RN EE verified the long facial hair and stated that R68 should have been shaved during ADL care.
3. Record review of the most recent Quarterly Minimum Data Set (MDS) for R72 dated 1/10/2024 revealed a Brief Interview for Mental Status Score (BIMS) of 7, indicating severe cognition. Exhibited no behaviors. Independent for Activities of Daily Living (ADLs). Occasionally, there is incontinence of the bladder but always continent of the bowel. Active diagnosis of non-Alzheimer's dementia. No swallowing disorder and no weight loss. Is on no antipsychotic, antidepressant, or antianxiety medication.
Record review of the care plan dated 11/4/2023 for R72 revealed concern of cognitive Impairment related to Vascular Dementia, Hypothyroidism, and chronic kidney disease with a goal that the patient's safety and needs will be maintained during the review period, as evidenced by the resident has short term memory difficulties, has long term memory difficulties, sometimes understood by others, ability is limited to making concrete requests, sometimes understands others, responds adequately to simple, direct communication only, sometimes has unclear speech, slurred or mumbled words, staff reports resident experiences incontinence episodes, has minimal hearing difficulty, difficulty in some environments (e.g., when person speaks softly or setting is noisy), has impaired vision, sees large print, but not regular print in newspapers/books. Interventions include allowing the patient ample time to absorb and respond to information, explaining all procedures and treatments to the patient in easy-to-understand terms, provide a consistent routine.
Observation on 2/2/2024 at 10:00 am revealed while in the room of R72, he was pacing about his room and was upset. R72 stated he had just come to this place last night wearing clothes that didn't belong to him because his clothes were soaking wet. At this time, it was noted that the sweatpants he had on were on backwards with the tie in the back. R72 reported that he does not know how he ended up at this facility.
Review of nurse note dated 12/26/2023 revealed resident awake and pacing up and down hall in underwear. Could not redirect resident back to room. Resident states that there was a woman in the woods in a car waiting on him. Tried to tell the resident that he was most likely dreaming. Resident then came combative. Holding fist up trying to swing at staff.
Interview on 2/04/2024 at 10:34 pm with the Assistant Director of Nursing (ADON) revealed that upon her review of the chart for R72, there is no care plan in place related to behaviors for R72 and that a care plan should have been added. The ADON further revealed the facility will be putting one in place today and has begun staff education. She confirmed the care plan does not mention a need for Psychiatric Services that was ordered on 1/22/2024.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Observation on 2/2/2024 at 8:51 am, 2/3/2024 at 9:09 am and 1:11 pm, and on 2/4/2024 at 8:55 am, R68 was observed in bed, not...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Observation on 2/2/2024 at 8:51 am, 2/3/2024 at 9:09 am and 1:11 pm, and on 2/4/2024 at 8:55 am, R68 was observed in bed, not shaven with a full and uneven beard.
Record review of the Electronic Medical Record (EMR) revealed that R68 was admitted to the facility on [DATE] and had diagnoses including, but not limited to, unspecified dementia, need for assistance with personal care, and other specified arthritis.
Record review of the most recent 5-Day Minimum Data Set (MDS) assessment dated [DATE] revealed that R68 required substantial/maximal assistance with personal hygiene.
Record review of the care plan for R68 revision date of 1/3/2024 revealed that R68 presented with a self-care deficit for ADL care. R68 required assistance with ADL care.
Record review of the EMR for R68 revealed no documentation that the resident refused to be shaved. This was verified by the Weekend RN Supervisor.
Interview on 2/3/2024 at 1:28 on with CNA FF revealed R68 is total care. CNA FF stated that the resident should have been shaved but is combative at times, and she can't shave him. CNA FF further stated that when R68 is combative, she notifies the nurse. CNA FF confirmed that she provided ADL care for the resident today but did not shave him.
Interview on 2/4/2024 at 8:58 am with Social Service Director (SSD) revealed that she was not aware of R68 being resistant to care or combative.
During a follow-up interview on 2/4/2024 at 9:07 am with CNA FF revealed she had already performed ADL care for R68 this morning. CNA FF further stated she did not attempt to shave resident this morning but had reported the refusal of care to RN GG on 2/3/2024.
During an interview 2/4/2024 at 9:12 AM with RN GG revealed she had worked in the facility from 2/2/2024 through 2/4/2024, and there had not been any reports of R68 refusing to be shaved or ADL care. RN GG further stated if the resident had refused care, she would have tried to persuade him to comply, and if he continued to refuse care, she would have documented the refusal in the medical record.
Cross Referenced F656
Based on observation, staff interviews, and record reviews, the facility failed to provide Activities of Daily Living (ADL) care for two of 27 Residents (R) (R52 and R68) related to incontinence care and personal hygiene.
Findings include:
1. The survey team requested a policy for ADL care/assistance on 2/4/2024, and per the Administrator and Nurse Consultant, the facility did not have a policy related to ADL care.
A review of the facility's Job Description, Certified Nursing Assistant for Skilled Nursing Services, revealed staff were to assist residents in using the bathroom and/or bedpan and peri-care.
A continued review revealed the staff were to assist patients to and from activities as requested.
Observation of the dining service on 2/4/2024 at 7:47 am, R57 told the Certified Nursing Assistant (CNA DD), I have to pee. CNA DD responded, You need to go tell someone you need help because I can't leave this room.
Observation of R52 at 7:47 am revealed that R52 began to propel herself down the hallway, loudly repeating, I need to pee. At 7:55 am, the resident turned onto the 100-hall, announcing, I have to pee. The SW heard the resident and told her she would assist her to her room and have someone help her. At 7:56 am, the SW found a tech and had them assist the resident to the bathroom in her room.
Record review of the most recent Minimum Data Set (MDS) OBRA admission Assessment, dated 10/29/2023, revealed R52 had a Brief Interview for Mental Status (BIMS) of 07. She was frequently incontinent of bowel and bladder and required substantial assistance with toileting.
Record review of the physician order dated 10/23/23 revealed that R52 received 40 mg of furosemide by mouth daily.
Record review of the care plan for R52 revealed staff were to provide incontinent care as requested by the resident, before and after meals, and at bedtime. Additionally, the care plan indicated the resident required assistance with toileting and received a diuretic.
Interview on 2/4/2024 at 7:48 am, with CNA DD confirmed that she told R52 to find another staff member to help her with toileting. The CNA stated she was instructed that once she was in the dining room, she was not supposed to leave the area, so she could not assist R52.
Interview on 2/4/2024 at 8:03 am, with Registered Nurse Supervisor (RNS EE) stated the staff assisting in the dining room were supposed to stay in the dining room; however, she said if a resident needed to use the toilet or needed to be changed, the staff was supposed to assist them to another staff member to ensure they received help. She added the CNA should have taken R52 to the 100/200 Hall Nurse's Station to ask staff for assistance with R52, or she should have ensured a staff member helped R52 to her room for toileting assistance.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
Based on observations, staff and resident interviews, record review, and a review of the facility policy titled Restorative, the facility failed to ensure one of 27 sampled Residents (R) (R19) reviewe...
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Based on observations, staff and resident interviews, record review, and a review of the facility policy titled Restorative, the facility failed to ensure one of 27 sampled Residents (R) (R19) reviewed for limited range of motion received passive range of motion exercises and splint application as needed to address limited range of motion in her right upper extremity. This failure created a potential for worsening contracture (fixed resistance to passive stretch), pain, or skin breakdown.
Findings include:
A review of facility's policy titled Restorative dated 12/30/2022 indicated it is the intent of the facility to provide a formalized restorative care plan to be implemented by appropriately trained staff and overseen by a restorative nursing supervisor. Procedure: The Restorative Team or Skilled therapy may develop the restorative program. The plan of care will be outlined in electronic medical record (eMAR) and will be followed by staff trained in restorative care. Inability to provide care per the plan of care should be communicated to the Restorative Nurse (s).
Observation on 2/2/2024 at 9:55 am revealed R19 out of bed to a wheelchair. Observation revealed that R19 had an impairment on the right side, including a right-hand contracture. R19's right hand was closed with fingers contracted to the palm. R19 stated that she had received therapy in the past but no longer does, and she does not receive exercises on the affected side.
Observations on 2/3/2024 at 8:34 am and 9:06 am revealed that R19 was in the room sitting in a wheelchair without anything in her right hand for contracture management.
Observation on 2/3/2024 at 11:38 am revealed R19 is out of bed to the wheelchair in the dining room awaiting to eat. The right hand is closed without anything in the right hand, and she was not using a splint/brace.
Observation and interview on 2/3/2024 at 1:36 pm with R19 revealed the resident sitting in the wheelchair in the hallway with their right hand clenched. R19 stated that no one had performed exercises on her hand or applied a splint today. R19 further stated that she once had a splint but had not had it on in a long time.
Observation on 2/3/2024 at 2:13 pm revealed R19 in a wheelchair in front of the nurse's station; Weekend RN Supervisor EE verified the resident's right hand was clenched closed, and the resident was not wearing a splint or had anything in the hand for contracture management.
Record review of the Electronic Medical Record (EMR) for R19 revealed a diagnosis including but not limited to hemiplegia and hemiparesis following cerebral infarction affecting an unspecific side.
Record review of the most recent Quarterly Minimum Data Set (MDS) for R19 dated 12/2/2023 revealed resident required substantial maximal assistance with toileting and showers and partial/moderate assistance with personal hygiene. R19 had a limited range of motion on one side in the upper and lower extremities. Section O revealed that the resident received a passive range of motion and splint/brace for three of seven days.
A record review of the care plan initiated on 12/13/2023 for R19 revealed the resident had limited mobility related to a cardiovascular accident (CVA), dementia, and contracture of the right hand.
Record review of R19 's active physician orders, located in the Orders tab of the EMR, revealed there was not an order for passive range of motion, splinting, or restorative services.
A review of R19's Restorative Care, located in the Restorative tab of the EMR, revealed a plan of care for splint/brace assistance with a start date of 3/29/2023 once a day for seven days a week. Intervention: Gentle stretch to right hand and wrist to extension with 30 sec holds for each stretch at affected joint for (2 sets and 10 reps). Then, perform a thorough skin inspection of involved joint, and if no signs/symptoms of skin integrity compromise, apply the recommended splint/brace to right hand. The patient is to wear a splint/brace for 6-8 hours daily. Upon removal, skin inspection of the involved joint should be completed, and note any signs/symptoms of compromised skin integrity.
Interview on 2/3/2024 at 11:38 am with CNA II revealed she was assigned to care for R19 but had not been informed she was responsible for the resident's restorative plan of care. CNA II further stated she had not received any training on performing passive range of motion or splint application.
Interview on 2/3/2024 at 1:40 pm with Assistant Director of Nursing (ADON) revealed that the Certified Medical Assistants (CMA's) are responsible for resident's restorative plan of care on the halls to which they are assigned.
Interview on 2/3/2024 at 1:44 pm with RN Weekend Supervisor EE revealed the CMA scheduled for R19's hall was reassigned to care for residents on the hall due to a staffing issue. Therefore, the CNA assigned to resident is responsible for the restorative plan of care. The RN Supervisor further stated that she had not informed the assigned CNA that she was responsible for R19's restorative plan of care.
Interview on 2/3/2024 at 1:51 pm with RN GG revealed that R19 was recently moved to the 200 Hall, but since being on the 200 hall she had not observed R19 wearing a splint. RN GG stated that she knew the resident had a right-hand contracture.
Interview on 2/3/2024 at 1:55 pm with CMA JJ revealed R19 was not assigned to her for restorative caseload. Therefore, she had not performed the restorative plan of care for the resident. CMA JJ further stated that she had not witnessed R19 wearing a splint to her right hand, and there was not a splint in her room.
Interview on 2/3/2024 at 2:02 pm with CMA KK revealed R19 was not assigned to her. Therefore, she had not performed PROM exercises or splinting for the resident. CMA KK also stated she was not sure who was responsible for R19's restorative plan at this time because the nurse over the program no longer worked at the facility. CMA KK further stated that R19 was on the 400 Hall prior to transferring to the 200 Hall, but no one updated the assignment, so no one was currently assigned to perform residents' restorative care.
During a telephone interview on 2/3/2024 at 2:56 pm with DON revealed she is now ultimately responsible for the restorative program, but she had very minimal knowledge of the program. The DON stated that the CMAs are trained and responsible for all the restorative plans of care. DON further stated that it was her expectation for CMAs to notify the nurse if splints were missing so that they could be replaced. DON further stated that it was her responsibility to update the CMA assignment to include R19 after she was transferred to another location in the facility. DON confirmed she had not reassigned resident care.
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 F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and review of the facility policy titled, Weight and Nutrition Management, the facilit...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and review of the facility policy titled, Weight and Nutrition Management, the facility failed to provide nutritional care and services for one of 27 sampled Residents (R) (R36) with a significant weight loss. This deficient practice had the potential to facilitate further weight loss.
Findings Included:
A review of the facility's policy titled Weight and Nutrition Management, dated 12/30/2022, revealed under the section titled, Guideline: The center should identify significant weight changes. The center should discuss and document the risk for significant weight changes, nutritional issues, needs, and goals in the context of the patient's overall condition and plan of care through a collaborative interdisciplinary team (IDT) environment.
Record review of the Electronic Medical Record (EMR) for R36 revealed the resident was admitted to the facility on [DATE] with a diagnosis that included but was not limited to cerebral infarction without residual deficits, diverticulosis of the intestine, part unspecified, and type 2 diabetes mellitus.
Record review of the most recent Minimum Data Set (MDS) Assessment for R36 dated 1/9/2024 revealed that the resident required partial/moderate assistance with eating and had experienced a weight loss of 5% or more in the last month or loss of 10% or more in last six months and was not on a physician prescribed weight-loss regimen.
Record review of physician orders for R36 revealed the resident was receiving a mechanical soft ground meats diet /large portion since 12/26/2023. R36 also had orders for a nutritional shake, 1 carton by mouth with meals, with a start date of 8/7/2023.
A review of R36's EMR revealed that on 1/8/2024, the resident weighed 165 lbs. (pounds). On 10/07/2023 resident weighed 180 lbs. On 7/7/2023 resident weighed 184.6 lbs. The above-mentioned weights triggered a significant weight loss of 8.33% in 90 days and 10.62 % weight loss in 180 days.
Record review of the EMR for R36 revealed the resident did not have documented weekly weight monitoring on the record after the significant weight loss was identified with the 1/08/2024 weight.
Record Review of the EMR for R36 revealed there was not a documented Patient at Risk (PAR) progress note addressing the resident's significant weight loss until 1/21/2024. This progress note indicated R36 had weight changes /weight loss. The previous interventions implemented listed: continue nutritional shake 1 carton and weekly weights. Further review of the record revealed no additional PAR notes in the resident's record.
Record review of the EMR for R36 revealed no additional interventions were added when the significant weight loss occurred on 1/8/2023.
Record review of the EMR for R36 revealed a Registered Dietitian (RD) Nutritional assessment dated [DATE] for a significant change (23 days after the weight loss was identified).
A review of the progress note dated 2/1/2024 revealed that the Nurse Practitioner (NP) and the resident's family members were not notified of R36's weight loss until that time. A new order was received for Mirtazapine 7.5 milligrams, 1 tablet by mouth daily.
During an interview on 2/4/2024 at 9:22 am with the Divisional Nurse Consultant, it verified R36 triggered for a three and six month weight loss on the first of January 2024. She stated that the facility's protocol requires residents who are identified as having significant weight loss to be weighed weekly and discussed in the weekly PAR meetings. The Divisional Nurse Consultant further stated the documentation should be in the electronic record. The Divisional Nurse Consultant reviewed R36's record and verified there was no intervention added when the resident's weight loss was identified, weekly documentation of resident progress was not documented, weekly weights were not obtained and documented since significant weight loss and the Registered Dietitian (RD) was not contacted until her routine monthly visit. The Divisional Nurse Consultant verified no family or physician notification documentation until 2/1/2024.
A telephone interview on 2/4/2024 at 9:28 am with the Director of Nursing (DON) revealed that all residents with significant weight loss are discussed weekly in the PAR meetings until the resident's weight stabilizes. DON further stated that interventions are put into place, and residents are seen monthly by the RD. DON confirmed that residents who trigger a three and six month weight loss should also be discussed in the weekly PAR meetings and placed on weekly weights. DON revealed the Dietary Manager is responsible for documenting the PAR meeting notes, weekly weights, and notifications in the record. DON stated that she does not audit records to ensure weekly documentation and weights are documented.
During an interview on 2/4/2024 at 9:42 am with the Dietary Manager (DM), she revealed that she was aware R36 triggered significant weight loss. DM further stated she had fallen behind on documentation due to staffing issues in the kitchen. DM verified that the RD is available via phone related to a resident's weight loss if needed. DM verified she did not call the RD or notify the resident's family members of R36's weight loss.
Cross Reference F580
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of R2's Electronic Medical Record (EMR) revealed she was admitted with diagnoses that included chronic obstructive pul...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of R2's Electronic Medical Record (EMR) revealed she was admitted with diagnoses that included chronic obstructive pulmonary disease (COPD), pleural effusion, sleep apnea, pulmonary chronic diastolic congestive heart failure, panlobular emphysema, asthma, and respiratory failure.
Review of R2's Quarterly MDS dated [DATE], located in the resident's EMR under the MDS tab, revealed Section C-Cognitive Patterns, the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of nine out of 15 which indicated she was moderately impaired.
Review of R2's Physician Orders located in the EMR under the Orders tab revealed an order dated 2/4/2024 for Oxygen: Nasal Cannula two liters per minute nasally every eight hours as needed for shortness of breath.
Observation on 2/3/2024 at 9:10 am revealed R2's nasal cannula was attached to the oxygen concentrator with the other end of the tubing touching the floor and not stored in a plastic bag.
Observation and interview conducted on 2/4/2024 at 7:50 am with the Assistant Director of Nursing (ADON) who confirmed R2's nasal cannula was connected to the oxygen concentrator with the other end of the tubing touching the floor and not stored in a plastic bag. ADON stated her expectations were for the nurses to make sure all oxygen tubing was stored properly and covered when not in use.
Based on observations, staff interview, record review and review of the facility's policy titled, Oxygen Therapy, the facility failed to maintain proper storage of respiratory equipment when not in use to prevent cross contamination related to a nasal cannula for three Residents (R) (R2, R10, and R64) who received oxygen therapy, a nebulizer mask for one resident (R10) who receive nebulizer treatments, and an oral suctioning device for one resident (R10) of 15 total residents.
Findings include:
Review of the facility's policy titled, Oxygen Therapy, dated 12/30/2022, under section titled, Oxygen administration revealed, Keep oxygen cannula and tubing use as needed (PRN) in a plastic bag when not in use. Under section titled Medication Nebulizers/Continuous Aerosol revealed, Use caution not to contaminate internal nebulizer tubes and Store circuit in plastic bag, between uses.
1. Review of R10's diagnoses included but not limited to chronic obstructive pulmonary disease (COPD) and acute respiratory failure with hypoxia.
Review of R10's Quarterly Minimum Date Set (MDS) dated [DATE] revealed:
Section C-Cognition: Brief Interview of Mental Status (BIMS) 9 indicating moderate cognitive deficit. R10's functional status indicated dependent for self-care and mobility. Special treatments in Section O indicated oxygen, hospice, and respiratory treatments.
Review of R10's Physicians orders revealed:
Oral Suction as needed for cough related to dysphagia.
Oxygen via nasal cannula 2 Liter per minute (l/m) nasally related to COPD.
Ipratropium 0.5 milligrams (mg) -albuterol 3 mg (2.5 mg base)/3 ml nebulization solution 1 VIAL inhalation every 6 hours related to shortness of breath.
Observation on 2/3/2024 at 9:18 am of R10 revealed a suction machine with an undated oral suctioning device attached to the tubing, not secured in a bag, and was on the bedside dresser. An oxygen machine was on and was set at 2 l/m. The undated nasal cannula was on the floor and not secured in a bag. There was not a bag available for storage. A nebulizer machine was on his bedside table next to R10's breakfast tray. The tubing and mask were not labeled or dated and not secured in a bag. The mask was sitting on top of the machine.
2. Review of R64's diagnoses include but not limited to COPD.
Review of R64's quarterly MDS dated [DATE] revealed the following:
Section C-Cognition: BIMS 8 indicating moderate cognitive deficit.
Section O-Special Treatments: Oxygen
Review of R64's Physician orders revealed:
nasal cannula 2 Liter per minute nasally as needed for shortness of breath/wheezing for COPD.
Observation on 2/2/2024 at 8:59 am revealed R64 in bed and asleep. Observation of the oxygen nasal cannula revealed the tubing was not labeled or secured in a bag and the tubing was draped over the machine and the nasal cannula was touching the floor. There was not a bag to secure the tubing in when not in use.
Observation on 2/3/2024 at 9:00 am revealed R64 in bed and asleep. Observation of the oxygen machine revealed oxygen was on, but the nasal cannula was wrapped around the bed rail and nasal part was touching the floor. There was not a bag to secure the tubing in when not in use.
An interview on 2/3/2024 at 12:54 pm with Certified Medication Aid (CMA) KK revealed residents who have oxygen should have their oxygen tubing stored in a bag. She indicated if she sees the oxygen tubing's on the floor, she will throw it away and get a new one.
An interview on 2/3/2024 at 12:58 pm with the Registered Nurse (RN) weekend supervisor RN EE revealed when a resident is on oxygen, has a nebulizer, c-pap/bi-pap or has a suction machine all equipment should be stored in a sanitary manner and all tubing should be stored in a blue bag that is provided by the facility. RN EE further reported that the tubing is changed weekly and as needed.
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 F0742
(Tag F0742)
Could have caused harm · This affected 1 resident
Based on observations, staff and resident interviews, clinical record review, and review of the facility policy Behavior Health the facility failed to ensure behavioral health services were received a...
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Based on observations, staff and resident interviews, clinical record review, and review of the facility policy Behavior Health the facility failed to ensure behavioral health services were received and failed to monitor/document behaviors for one resident (R) 72, as it relates to administration of Ativan 2mg intramuscular on 1/2/2024 and Buspirone 5mg on 1/22/2024. The sample size was 27 residents.
Findings include:
Review of the facility policy Behavior Health revised 12/30/2022 revealed it is the intent of this center for each patient to receive the necessary behavioral health care and services to attain or maintain their highest practical physical, mental, and psychosocial well-being based on the comprehensive assessment and plan of care. The policy further revealed patients will be monitored for indications of distress, concerns identified will be assessed and care planned, changes will be documented, including frequency of occurrence and potential triggers, concerns, follow-up assessment and potential modifications are discussed with the interdisciplinary team.
Review of the 1/10/2024 Quarterly Minimum Data Set (MDS) for R72 revealed a Brief Interview for Mental Status Score (BIMS) of 7 indicating severe cognitive impairment, with no behaviors identified. The assessment further revealed that R72 was independent for Activities of Daily Living (ADLs) but was occasionally incontinent of bladder but always continent of bowel. Active diagnosis included non-Alzheimer's dementia and medication use included antipsychotic, antidepressant, or antianxiety medications.
Review of the care plan dated 11/4/2023 for R72 revealed a concern of cognitive Impairment related to vascular dementia, hypothyroidism, CKD with a goal that the patient's safety and needs will be maintained during review period as evidenced by the resident has short term memory difficulties, has long term memory difficulties, sometimes understood by others, ability is limited to making concrete requests, sometimes understands others, responds adequately to simple, direct communication only, sometimes has unclear speech, slurred or mumbled words, staff reports resident experiences incontinence episodes, has minimal hearing difficulty, difficulty in some environments (e.g., when person speaks softly or setting is noisy), has impaired vision, sees large print, but not regular print in newspapers/books. Interventions include allowing the patient ample time to absorb and respond to information, explain all procedures and treatments to patient in easy-to-understand terms, provide consistent routine.
Review of Care Plan Conference dated 1/18/2024 revealed diagnoses that include but is not limited to vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, unspecified dementia, unspecified severity, with agitation.
Review of a Physician order dated 1/22/2024 revealed a referral to behavioral health/psych services. Diagnoses: Vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, with no end date.
Review of nurse note dated 12/26/2023 revealed resident awake and pacing up and down hall in underwear. Could not redirect resident back to room. Resident states that there was a woman in the woods in a car waiting on him. Tried to tell the resident that he was most likely dreaming. Resident then came combative. Holding fist up trying to swing at staff. On call Nurse Practitioner (NP) notified to get order for a one-time dose of Ativan 2mg/ml. Pharmacy notified. The pharmacy tried to contact Medical Director with no answer. On call Pharmacist contacted on call NP. Ativan 2mg/ml given in right deltoid intramuscularly (IM). Will continue to monitor.
Review of the Behavior Monitoring Screen in the Electronic Medical Record (EMR) revealed R72 received medications for behaviors on 1/2/2024 that included Ativan 2 milligram (mg)/milliliter (mL) injection solution (LORAZEPAM) 2 Milligram Intramuscular one time only. On 1/22/24 R72 received: buspirone 5 mg tablet (BUSPIRONE HCL) 1 tablet by mouth one time only. There was no documentation detailing while the medication was used or the effects of using the medication.
Review of the 1/12/2024 Comprehensive Social Assessment (in part) revealed under Summary: Resident is alert and oriented. No mood or behavior problems noted.
Review of the Psychoactive Medication Consent form dated 1/22/24 revealed the condition to be treated is Anxiety and Dementia with Psychotic features. Beneficial effects from the medication include its use results in maintenance or improvement in the resident's functional status. Side effects of the medication are explained and is signed by the nurse, a listed contact person, and dated 1/22/23.
There are no psychiatric notes in the medical record.
There is no documentation in the medical record for R72 that reveals the behavior/reason he received Ativan 2mg IM on 1/2/2024 or Buspirone 5mg on 1/22/2024.
Review of the 1/30/2024 Initial Change of Condition (COC) Report to Medical Doctor (MD) revealed LPN made MD aware of skin tear after incident with roommate on 1/31/2024 with attached nurse note dated 1/31/2024. MD response was skin tear treatment per protocol. R72 behaviors were not addressed.
Review of nurse note dated 1/31/2024 at 1:42 am revealed resident was upset because roommate would not go to sleep and wondered throughout the room. Resident waited until roommate left the room and he took the bedside table and pushed it against the door to barricade it preventing roommate from going back in. Resident scraped his left arm causing a skin tear to it while barricading the door. First aid given. NP notified and roommate was moved to another room.
Observation on 2/2/2024 at 10:00 am revealed R72 in his room. He was clean and groomed with no odors present. He was walking about his room anxious and very upset, stating he had just come to this place last night and now he is wearing clothes that do not belong to him because his were soaked. At this time, it was noted that the sweatpants he had on were on backwards with the tie in the back. He picked up his wallet on his nightstand and opened it. It had many one-dollar bills, and the money and wallet were wet. He took surveyor around his room and told about how the things in the room were his belongings, but he came from Florida and is trying to get to South Carolina and does not know how he ended up here or how all his things got here. He continued to walk about the room picking up items in a very anxious manner. R72 stated he needed to get to the bottom of what is going on and stated he was so sleepy and needed to sleep but he needed to get to the root of what was going on first. During this time a staff member came into the room of R72 and brought a bed sheet and made his bed. She told the resident he could lay down and rest. R72 continued to anxiously walk around the room stating he had to find out what was going on.
Interview on 2/4/2024 at 9:31 am with the Assistant Director of Nursing (ADON) revealed she does not know why the Ativan 2mg IM on 1/2/2024 or Buspirone 5mg by mouth was given on 1/22/2024. She stated she would review the record of R72 and get back with surveyor about these medications.
Interview on 2/4/2024 at 10:34 am with the ADON revealed that upon her review of the chart for R72 there is no documentation as to why Ativan was given to R72 on 1/2/2024 nor as to why Buspirone was given to R72 on 1/22/2024. After further review of the chart, ADON confirmed that there was no evidence to support that R72 had been seen for any behavioral/psychiatric services.
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
Food Safety
(Tag F0812)
Could have caused harm · This affected 1 resident
Based on observations, interviews, and facility policy Labeling and Dating Tool, the facility failed to ensure that opened food items in the walk-in refrigerator, freezers, and dry storage area areas ...
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Based on observations, interviews, and facility policy Labeling and Dating Tool, the facility failed to ensure that opened food items in the walk-in refrigerator, freezers, and dry storage area areas were labeled and dated. The facility census was 78, with 78 residents receiving an oral diet.
Findings include:
A review of the facility policy, Labeling and Dating Tool, dated 8/2023, revealed all items should have an open date and use by date.
An observation on 2/2/2024 at 7:50 am of the walk-in refrigerator revealed the following items:
1. A bag of shredded cabbage, no weight, revealed the cabbage was open, unlabeled, and undated.
2. A package of American cheese slices revealed the package was open, unlabeled, and undated.
3. A bag of parmesan cheese, no weight, revealed the cheese was open, unlabeled, and undated.
4. A block of Swiss cheese revealed the cheese was open, unlabeled, and undated.
5. A bag of pepperoni revealed the bag was open to the air, unlabeled, and undated.
6. A large package of raw ground hamburger, weighing approximately four pounds, revealed the meat was opened, unlabeled, and undated.
7. Two large bags of raw chicken breasts, weighing approximately ten pounds, revealed the meat was open, unlabeled, and undated.
8. Three stalks of celery were noted on a meal tray on a shelf in the refrigerator. The stalks appeared wilted and exposed to the air.
9. There was one 48-ounce jar of grape jelly revealed the jar was open, unlabeled, and undated.
On 2/2/2024 at 8:10 am, an observation of standing freezer number one revealed the following items:
1. There was one bag of chicken tenders that was open, unlabeled, and undated.
2. There was a box of raw biscuits that was open, unlabeled, and undated.
3. There were five pancakes in a clear plastic wrap that were unlabeled and undated.
An observation of standing freezer number two on 2/2/2024 at 8:20 am revealed:
1. There was a bag of chicken tenders that were opened, unlabeled, and undated.
2. There was a box of beef franks that was opened, unlabeled, and undated.
3. There was a box of pork chops that was opened, unlabeled, and undated.
4. There was a box of beef steaks that were open to air, unlabeled, and undated.
An observation of the dry goods on 2/2/2024 at 8:35 am revealed a five-pound bag of grits that had been opened but was unlabeled and undated.
During an interview with the Dietary Manager (DM) on 2/2/2024 at 8:40 am, she stated she expected her staff to secure, label, and date all food items after opening. The DM acknowledged the items in the walk-in refrigerator, freezers, and dry goods had not been labeled or dated after opening.
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
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected 1 resident
Based on observations, staff interviews, and review of the facility's policy titled Skilled Nursing Services: Storage Areas, the facility failed to ensure that the dumpster area was free of trash and ...
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Based on observations, staff interviews, and review of the facility's policy titled Skilled Nursing Services: Storage Areas, the facility failed to ensure that the dumpster area was free of trash and food debris and dumpster lids and doors were closed for two of two dumpsters. This practice had the potential to harbor pests, insects, and organisms. The facility census was 78 residents.
Findings include:
Review of the facility's policy titled Skilled Nursing Services: Storage Areas, dated 12/30/2022, Intent statement revealed, Under the section titled Guideline and subsection Dumpster Area revealed, Area should be free of trash and debris and Containers should be kept in good condition and covered.
Observation on 2/3/2024 at 11:40 am of the facility's dumpsters revealed two dumpsters positioned side by side. Both dumpster's doors and lids were open and not covered. The dumpster area had trash and food debris around it.
Interview on 2/3/2024 at 11:50 am with the Maintenance Director revealed that the dietary department were responsible for ensuring the outside dumpsters were free of trash, debris and ensuring that the lids and side doors were closed.
An observation and interview were conducted on 2/3/2024 at 1:45 pm with the Dietary Manager (DM) who verified that she was responsible for making sure the dumpster lids and doors were closed and the dumpster area was free of trash and debris. DM stated she usually checked the dumpsters everyday but had not had a chance to do so. She confirmed that both dumpster lids and doors were open, food debris and trash was in the dumpster area. She stated she did not know why it had been left like that, but she would take care of it.
Interview on 2/4/2024 at 8:45 am with the Administrator reviewed photos of the dumpsters with the surveyor. The Administrator confirmed the deficient practice. The Administrator reported that his expectations were for all staff taking trash to the dumpster to make sure the dumpster lids were closed with no food or trash on the ground.
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
2. Review of policy titled Infection Prevention and Control Program, dated 12/30/2022, revealed the following: SCOPE - Prevention of Infections: Policies, procedures and aseptic practices are followed...
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2. Review of policy titled Infection Prevention and Control Program, dated 12/30/2022, revealed the following: SCOPE - Prevention of Infections: Policies, procedures and aseptic practices are followed by personnel when performing procedures and disinfecting equipment.
Review of policy titled COVID 19 dated 7/17/2023 revealed: Purpose: To prevent transmission of COVID -19 in the center between patients and associates. Patients with positive test must remain on Transmission Based Precautions (TBP) at least 10 days since symptoms first appeared. Caring for Patient with COVID-19: Place patient with suspected or confirmed COVID-19 infection in a private room. The door should be kept closed (if it is safe to do so). Personal Protective Equipment (PPE) - Associates who enter the room of patient with suspected or confirmed COVID-19 infection should use: N-95 mask, eye protection, gown, and gloves.
Signage on R50's door revealed the following: STOP: Aerosol Contact Precautions. Everyone must: including visitors, doctors, and staff.
Clean hands when entering and leaving patient room.
Respirator: Use a N-95 or equivalent especially during aerosolizing procedures
Wear eye protection (face shield or goggles)
Gown and glove at door.
Keep door closed.
Use patient dedicated or disposable equipment. Clean and disinfect shared equipment.
Review of R50's record revealed a progress noted dated 1/26/2024 that read: Responsible Party (RP) notified resident is positive for COVID.
Revied of R50's care plan initiated 2/2/2024 indicated resident has signs and symptoms of COVID 19 infection evidenced by a positive COVID 19 test. Interventions included: conduct daily COVID 19 screenings and maintain isolation precautions as directed.
During an interview an observation 2/2/2024 at 9:19 am revealed R50's room door open. There was a supply of PPE on the door and signage which indicated resident was on aerosol contact precautions. Further observation revealed signage on the left side of the door which indicated resident was on enhanced barrier precautions. During an interview with R50, he verified that he had tested positive for COVID a few days prior and was having cold like symptoms. Observations of the room revealed there were not any containers in the room for staff to doff PPE. Further observations revealed a housekeeper and nurse entering R50's room without donning PPE prior to entry. The room door remained open.
Observation 2/2/2024 at 12:12 pm revealed R50's room door opened at this time. R50 observed lying on the bed.
Observations 2/3/2024 at 8:42 am revealed R50's room door is opened wide. Staff and residents were observed in the hallway passing R50's room. CNA II observed entering resident's room to deliver a breakfast tray. CNA II did not don gown or gloves prior to entering or exiting resident's room. CNA II reentered R50's room again at 9:04 am without donning PPE. CNA II exited the room and entered room without washing or sanitizing her hands. CNA II was observed not changing face covering between COVID positive and COVID negative residents.
Observation 2/3/2024 at 8:46 am revealed Registered Nurse (RN) GG assisting with delivering breakfast trays to residents on the hall. RN GG walked past R50's room several times, looking into resident's room and did not close the open door.
Observation 2/3/2024 at 9:17 am of Certified Mediccation Aide (CMA) DD who entered R50's room with a cup of coffee. CMA DD was wearing an N95 mask and prescription glasses without side shields. CMA DD did not don gloves or gown prior to entering resident's room. CMA DD exited the room and did not wash or sanitize her hands nor did she close the room door upon exiting the room.
Observation 2/3/204 at 9:35 am revealed RN GG applied a pair of gloves and entered R50's room with a rolling blood pressure device. RN GG was observed applying the blood pressure cuff to R50's arm, obtained the blood pressure, and exiting the room to the hall wearing the gloves and placing the rolling blood pressure device in the hall without disinfecting it. RN GG doffed gloves at the medication cart, sanitized hands, prepared medications, and reentered resident's room to administer medications without gloves or gowns. RN GG exited the room after administering medications leaving the room door open returned to the medication cart and did not sanitize hands.
During an interview 2/3/2024 at 9:54 am with RN GG revealed that she did not know R50 was still in isolation. RN GG stated she was aware if a resident was placed in isolation for COVID the room door should remain closed, and staff are required to don full PPE prior to entering the room. RN GG furthers stated that R50's door was open when she arrived at work at 7 am so she did not close it. RN GG acknowledged that she did not don full PPE when entering R50's room today and did not disinfect the equipment taken into the room after use. RN GG also verified the R50's room door remained open and there were not any containers in the room to dispose of contaminated PPE or to contain contaminated linen. RN GG stated that she did not recall assessing or documented R50's condition in the record after he tested positive for COVID.
During an interview 2/3/2024 at 9:58 am with CNA II revealed she was aware that if a resident was COVID positive she was required to wear full PPE prior to entering the room, the room door should remain closed, and she should doff PPE prior to exiting the room. CNA II acknowledged that she was in and out of R50's room without proper PPE. CNA II further stated she thought R'50 was off of isolation but confirmed no one had told her resident was off of isolation. CNA II confirmed the signage on R50's room door and explained that she did not pay any attention to it.
During an interview 2/3/2024 at 10:01am with the Weekend RN Supervisor EE revealed she was given the names of COVID positive residents at the beginning of her shift. RN EE stated she made walking rounds at the top of the shift and the room door was closed. RN stated that the room door should have remained closed, and R50 prefers his door closed. RN Weekend Supervisor EE further stated nurses should have evaluated and documented on residents condition every shift after testing positive for COVID. RN EE verified there was not any follow up documentation after R50 tested positive for COVID on 1/26/2024. RN EE stated R50 should remain in isolation for 14 days after testing positive for COVID.
During an interview 2/3/2024 at 10:14 am with CMA DD revealed she was not aware R50 was COVID positive. CMA DD acknowledges she did not wear proper PPE prior to entering the room or wash/ sanitize hands upon exiting the room. CMA DD stated she was moving fast and did not notice the sign on the door.
During an interview 2/3/2024 at 10:35 am with Divisional Nurse Consultant revealed it is her expectation that the staff follow the facility's protocol related to infection control practices of COVID positive residents. She further stated staff should be donning proper PPE prior to entering the room, the room door should be closed, there should be containers in the room, there should be dedicated equipment in the room to reduce the risk of cross contamination, and there should be follow up documentation. The Divisional Nurse Consultant verified there was not any follow up documentation or assessments of R50's condition related to COVID in the electronic record.
During an interview 2/3/2024 at 10:51 am with the Assistant Director of Nursing (ADON) who revealed the Infection Control Preventionist (ICP) nurse was conducting infection surveillance rounds to ensure compliance, but the ICP nurse resigned a week and a half ago. ADON further stated the Director of Nursing (DON) had stepped into the ICP role since that time, but DON is presently out on medical leave. ADON stated that it was her responsibility to ensure that infection control compliance was being met in the facility at this time. ADON stated she was not aware R50's room door was being left open and that staff were not utilizing proper PPE. ADON further stated typically, R50 should remain in isolation for 10 days after testing positive for COVID. ADON stated that resident should have documentation related to COVID symptoms document symptomatic and asymptomatic. ADON verified that there was no documentation in the record.
During interview 2/3/2024 at 11:17 am with the Administrator who reported that anyone entering R50's room should wear PPE per the guidance on the door and CDC guidelines. The Administrator stated he would begin re-education of the staff immediately.
Based on observations, interviews, and review of policy titled Infection Prevention and Control Program and COVID-19, the facility failed to ensure infection control practices to prevent cross contamination related to entering/exiting a resident (R50) room
without use of proper personal protection equipment (PPE), falling to keep the door of COVID positive resident closed, failing to ensure equipment used in a COVID positive resident's room was disinfected after use, and failing to ensure receptacles for trash and linen were located in an isolation room (COVID). In addition, the facility failed to place signage on the entrance door informing staff, family, and visitors of the COVID outbreak in the facility. This deficient practice had the potential to spread infection to staff and other residents residing in the facility.
Findings:
1. Review of CDC guidelines titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic dated 5/8/2023 under section titled, Recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic revealed, .1. Post visual alerts (e.g., signs, posters) at the entrance and in strategic places (e.g., waiting areas, elevators, cafeterias). These alerts should include instructions about current IPC recommendations. Establish a process to make everyone entering the facility aware of recommended actions to prevent transmission to others if they have any of the following three criteria: 1) a positive viral test for SARS-CoV-2 2) symptoms of COVID-19, or 3) close contact with someone with SARS-CoV-2 infection (for patients and visitors) or a higher-risk exposure (for healthcare personnel (HCP).
Review of the facility's Matrix revealed one resident at the facility with COVID-19.
Observations on 2/3/2024 at 7:35 am and at 8:42 am revealed there were no COVID-19 signs posted on the two entrance (front and side) exterior doors.
Observations on 2/4/2024 at 7:33 am and at 7:35 am revealed there were no COVID-19 signs posted on the two entrance (front and side) exterior doors.
Observations during the survey period on 2/3/2024 through 2/4/2024 revealed multiple staff and visitors were observed utilizing the two entrance (front and side) doors that did not have COVID-19 signs posted.
Observation on 2/4/2024 at 7:45 am with the Assistance Director of Nursing (ADON) of the front entrance exterior door and side entrance exterior door revealed there were no COVID-19 signs posted on the two entrance doors. An interview was conducted during this time with the ADON and she confirmed there were no COVID-19 signs posted. ADON reported it was the Director of Nursing responsibility for ensuring COVID-19 signs were posted on the entrance doors. She confirmed there were two entrance (front and side) doors and that the facility had active COVID-19 in the facility. She acknowledged there should be COVID-19 signs posted on both entrance doors.
Jan 2023
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and a review of the facility policy titled, Skilled Inpatient Services- Environmental S...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and a review of the facility policy titled, Skilled Inpatient Services- Environmental Services, and Housekeeping, the facility failed to maintain a safe, clean, sanitary environment related to a heavy build-up of dust on the vent covers, peeling paint around ceiling vents, and cracked caulking around one sink in six of six adjoining bathrooms in resident rooms (101/103, 102/104, 105/107, 106/108, 109/111) and one leaking shower hose in the shower room on the 100 Hall. This failure had the potential to affect 13 residents currently residing in the 100 hall.
Findings include:
Review of policy titled, Environmental Services and Housekeeping the purpose was to ensure best practices for maintaining a clean environment to prevent and reduce the spread of infection and use checklists to provide daily and terminal cleaning. The stated intent was to maintain a clean and sanitary facility, free from odor and other environmental factors that may affect the quality of life of residents, and the center should be cleaned in a manner consistent with protocols and recommendations.
Observations during the initial tour and screening of residents on 1/10/2023 starting at 9:15 a.m., and additional observations on 1/11/2023 and 1/12/2023, revealed a heavy build-up of dust on the ceiling vent covers in resident's adjoining bathroom, cracked caulking around one sink, and peeling paint around ceiling vents on the 100 hall. A leaking shower hose was reported during the Resident Council meeting on 1/11/2023 and the following was verified, as follows:
room [ROOM NUMBER]/103 dusty ceiling vent, peeling paint around two ceiling vents, and cracked caulking around the bathroom sink.
room [ROOM NUMBER]/104 dusty vent cover.
room [ROOM NUMBER]/107 dusty vent cover and peeling paint around the ceiling vent.
room [ROOM NUMBER]/108 dusty vent cover and peeling paint around the ceiling vent.
room [ROOM NUMBER]/111 dusty vent cover.
room [ROOM NUMBER]/112 dusty vent cover.
The shower hose in the Spa shower room on 100 hall, leaking hose with water spewing uncontrollably, causing poor water pressure, and a slippery, wet floor.
During a walk-through on 1/12/2022 with the Maintenance Director and Administrator, revealed that the ceiling vent covers were dirty with a heavy build-up of dust in adjoining bathrooms. Additional environmental concerns needing repair were confirmed as follows:
room [ROOM NUMBER]/103 at 8:34 a.m. dusty ceiling vent, peeling paint around two ceiling vents, and busted caulking around the sink.
room [ROOM NUMBER]/107 at 8:36 a.m. dusty vent cover and peeling paint around the ceiling vent.
room [ROOM NUMBER]/104 at 8:38 a.m. dusty vent cover.
room [ROOM NUMBER]/111 at 8:40 a.m. dusty vent cover.
room [ROOM NUMBER]/112 at 8:41 a.m. dusty vent cover.
room [ROOM NUMBER]/108 at 8:42 a.m. dusty vent cover and peeling paint around the ceiling vent.
Shower hose in Spa shower on 100 hall.
Interview on 1/12/2023 at 8:00 a.m. with the floor tech revealed it was the responsibility of Maintenance or Environmental Services (Housekeeping) to clean the vents.
Interview on 1/12/2023 at 8:32 a.m. with the Maintenance Director (MD) revealed that a contractor came to the facility approximately in November 2022 and did some work on the intake vents and cleaned the vents. The MD revealed that the intake vents serviced by the contractor were not in use at this time. The MD confirmed that the vents were not sanitary and needed cleaning or removal.
Interview on 1/23/2023 at 9:31 a.m. with the Administrator revealed that maintenance is responsible for cleaning the vents, and they follow a routine cleaning schedule. The Administrator's expectation was that the facility is safe, clean, and sanitary and that all equipment is in proper working order.
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
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, and the facility's policy titled, Skilled Inpatient Services MDS Compliance, the facil...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, and the facility's policy titled, Skilled Inpatient Services MDS Compliance, the facility failed to ensure a resident received an accurate assessment that reflected the resident's status at the time of the assessment for one of 15 sampled residents (R) #24 reviewed for accuracy of assessments related to Pre-admission Screening and Resident Review (PASRR). This failure had the potential to cause the resident's medical record to reflect inaccurate data related to disposition.
Findings Include:
Review of the policy titled Skilled Inpatient Services MDS Compliance with review date 12/4/2021 revealed: Policy statement: To ensure that the Resident Assessment Instrumental (RAI) is used, in accordance with specified format and timeframes, to develop a comprehensive care plan, to provide the appropriate care and services for each resident, and to modify the care plan and care/services based on the resident's status.
Record review of the electronic medical record (EMR) for R#24 revealed that the resident was admitted to the facility on [DATE] with a diagnosis but not limited to schizoaffective and major depressive disorder.
Further record review for R#24 revealed a Georgia PASRR Level II assessment dated [DATE] indicating evidence of serious mental illness (SMI) and needs specialized services for SMI.
Record review of the Annual Minimum Data Set (MDS) dated [DATE] documented: No, on the PASRR section indicating that R#24 had not been reviewed for Level II PASRR.
Interview on 1/12/2023 at 12:30 p.m. with the Minimum Data Set (MDS) nurse, revealed that R#24 had a Level II PASRR. The MDS nurse confirmed she made a coding error on his 11/4/2022 Annual MDS assessment. She reported that she would make the correction.
Interview on 1/12/2023 at 12:35 p.m. with the Director of Nursing (DON) revealed her expectations of staff to complete the MDS assessment accurately and in a timely manner.
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 F0676
(Tag F0676)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, and record review, the facility failed to provide showers as scheduled for...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, and record review, the facility failed to provide showers as scheduled for two of 29 sampled residents (R) R#1 and R#43. This failure had the potential to impact residents' quality of life negatively.
Findings include:
R#43 was admitted to the facility on [DATE] with a primary admitting diagnosis (Dx) of end stage renal disease (ESRD. The resident was admitted to hospice on 9/14/2022
Review of the most recent quarterly Minimum Data Set (MDS) assessment for R#43 dated 12/10/2022 documented Section- C, cognition-Brief Interview of Mental Status (BIMS) score of 99, indicating cognition severely impaired. Section G, functional status documented extensive assistance, two-person physical help for bathing, and personal hygiene.
Record review of the care plan for R#43 updated 7/15/2022 included a risk for actual skin breakdown, the risk for problems with the elimination of bladder and bowels (B&B), always incontinent, hospice services for palliative care related to terminal diagnoses-nursing aide as scheduled.
Record review of the documentation revealed R#43 received a bath on the following dates in September, October, November, December, and January 3, 2023, five were by hospice: 9/27/2022, 9/29/2022, 10/6/2022 by hospice, 10/18/2022 by hospice, 10/25/2022, 11/8/2022 by hospice, 11/10/2022 by hospice, 11/15/2022, 11/24/2022, 12/3/2022, 12/8/2022, 12/10/2022, 12/17/2022, 12/20/2022, 12/22/2022 by hospice, 12/29/22/2022, and 1/3/2023. Two bath sheets had resident refused with no date on the bath sheets.
R#1 was admitted to the facility on [DATE] with current primary diagnoses (Dx) of hypertensive heart and chronic kidney disease stage two.
Review of the most recent quarterly Minimum Data Set (MDS) assessment for R#1 dated 10/14/2022 documented section-C, cognition-Brief Interview of Mental Status (BIMS) score of 11, indicating mild cognition impairment; section-E, section-G, functional status documented extensive assistance for personal hygiene, limited assist for toileting, and total dependence one-person physical help for bathing.
Review of the care plan dated 1/10/2023 included self-care deficit-assist with activities of daily living (ADL) as needed, the risk for problems with the elimination of bladder and bowels, risk for actual skin breakdown, history of fall transferring from wheelchair to shower chair.
Record review of the documentation revealed R#1 received a bath on the following dates in September, October, November, December, and thru January 11, 2023: 9/2/2022, 9/16/2022, 9/23/2022, 9/26/2022, 10/12/2022, 10/17/2022, 10/21/2022,10/31/2022, 11/2/2022, 11/11/2022, 11/14/2022, 11/16/2022, 11/18/2022, 12/2/2022, 12/7/2022, 12/14/2022, 12/21/2022, 12/28/2022, 12/30/2022, 1/4/2023, 1/9/2023.
During Resident Council (RC) meeting on 1/11/2023 beginning at 10:00 a.m. R#1, R#14, and R#54 revealed they are scheduled for a bath three times a week but are lucky to get a shower one day a week. R#1 revealed that frequently the certified nursing assistant (CNA) wakes her up between 10:00 p.m. and 10:30 p.m. to get a shower while she is sleeping. If R#1 doesn't want to get up, the aides state that R#1 refused. R#54, the RC vice-president, was in attendance for the RC meeting and stated he has started washing in the bathroom sink to avoid fooling with the staff.
Review of the shower record notebook revealed that baths are scheduled one week Monday, Wednesday, Friday, or Tuesday, Thursday, and Saturday, divided between different shifts. There were three completed bath sheets for October, four bath sheets for November, approximately ten bath sheets completed for December, and one bath sheet completed for January 4, 2023. Further review revealed that at least half the bath sheets had refused documented.
Review of the Grievance reports revealed complaints about not getting showers on scheduled days. Staff was in-serviced on following bathing schedules.
Interview on 1/12/23 at 1:30 p.m. with the Director of Nursing (DON) revealed that she found some bath sheets but was unable to locate the rest of the bath sheets. The DON further revealed bath sheets are to be completed by the CNA with any skin changes or refusal, signed, and given to the nurse. If the resident refused, the nurse should document the refusal in the clinical record. If showers are missed, they should be offered the next shift or the next day. The DON's expectation is that residents are getting all their care and needs met and bathed three times a week.
Interview on 1/12/23 at 1:33 p.m. with CNA BB revealed that when she is unable to provide a shower on the resident's scheduled day, she tries to complete the showers on the next day that she works.
Interview on 1/12/23 at 2:20 p.m. with the Administrator revealed her expectation was that residents are clean, get their baths as scheduled, and whenever they request one.
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
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • 21 deficiencies on record, including 2 serious (caused harm) violations. Ask about corrective actions taken.
- • $16,800 in fines. Above average for Georgia. Some compliance problems on record.
- • Grade F (38/100). Below average facility with significant concerns.
Bottom line: Trust Score of 38/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Bolingreen's CMS Rating?
CMS assigns BOLINGREEN HEALTH AND REHABILITATION an overall rating of 2 out of 5 stars, which is considered 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 Bolingreen Staffed?
CMS rates BOLINGREEN HEALTH AND REHABILITATION's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 47%, compared to the Georgia average of 46%.
What Have Inspectors Found at Bolingreen?
State health inspectors documented 21 deficiencies at BOLINGREEN HEALTH AND REHABILITATION during 2023 to 2025. These included: 2 that caused actual resident harm and 19 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Bolingreen?
BOLINGREEN HEALTH AND REHABILITATION is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility is operated by CLINICAL SERVICES, INC., a chain that manages multiple nursing homes. With 121 certified beds and approximately 76 residents (about 63% occupancy), it is a mid-sized facility located in MACON, Georgia.
How Does Bolingreen Compare to Other Georgia Nursing Homes?
Compared to the 100 nursing homes in Georgia, BOLINGREEN HEALTH AND REHABILITATION's overall rating (2 stars) is below the state average of 2.6, staff turnover (47%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Bolingreen?
Based on this facility's data, families visiting should ask: "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?" "Can I speak with family members of current residents about their experience?"
Is Bolingreen Safe?
Based on CMS inspection data, BOLINGREEN HEALTH AND REHABILITATION 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 2-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 Bolingreen Stick Around?
BOLINGREEN HEALTH AND REHABILITATION has a staff turnover rate of 47%, which is about average for Georgia nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Bolingreen Ever Fined?
BOLINGREEN HEALTH AND REHABILITATION has been fined $16,800 across 3 penalty actions. This is below the Georgia average of $33,247. 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 Bolingreen on Any Federal Watch List?
BOLINGREEN HEALTH AND REHABILITATION 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.