Accura Healthcare of Kenesaw

Inspectors wroteLicensure Reference Number 175 NAC 12-007.04CiBased on observation, record review, and interview the facility failed to develop and implement a plan to maintain required safe temperatures in resident rooms to prevent heat-related injury for facility residents. This affected 1 of 3 sampled residents (Resident 1). The facility census was 58. The facility Administrator was notified on 07/01/2026 at 12:45 PM of an Immediate Jeopardy (IJ) which began on 07/01/2026. The IJ was removed on 07/01/2026, as confirmed by surveyor onsite verification.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(I)Licensure Reference Number 175 NAC 12-006.09(I)(i)(1)Licensure Reference Number 175 NAC 12-006.09(I)(i)(3)Based on observation, record review, and interview the facility failed to ensure that residents were protected from injury for 1 of 5 residents (Resident 1); failed to ensure that interventions to prevent falls were implemented for 1 of 5 residents (Resident 2); and failed to develop fall prevention interventions related to causal factors for 1 of 5 residents (Resident 6). The facility census was 66.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.05(S)Based on record review, observation, and interview the facility failed to promote resident dignity by ensuring that resident body parts were not exposed to public view for 1 resident (Resident 7) and not knocking and announcing entry to residents' room for 1 resident (Resident 5). The facility census was 66.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.05(H)Based on record reviews and interviews, the facility failed to ensure that a resident was free from physical abuse for 1 resident (Resident 3). The facility census was 66.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.10(D)Based on observation, record review, and interviews, the facility failed to ensure a medication error rate of 5% or less with an actual observed medication error rate of 90%. This had the potential to affect all the residents residing and receiving medications administered by the facility. The facility census was 66.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.04(A)(iii)(2)Licensure Reference Number 175 NAC 12-006.02(H)Based on record review and interview, the facility failed to complete nurse aide registry checks prior to staff having possible/probable contact with residents for 3 of 6 sampled staff and failed to report an adverse event to the designated agencies as stated in facility policy for 1 resident (Resident 59) of 1 sampled residents. The facility census was 67. Findings Are:A.Review of a facility policy titled Pre-Employment Background Screening and dated 02/01/2024 revealed applicants for employment will receive job offers contingent upon the satisfactory completion of a background screening. A record review of a facility document titled General Orientation Check List dated 08/15/2025 revealed a date of hire for Nurse Aide (NA)-F of 07/30/2025. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.04(A)(ii)Licensure Reference Number 175 NAC 12-006.18 Based on observation, interview, and record review the facility failed to ensure employee health screens were reviewed prior to the start of employment for 4 of 5 sampled employees and failed to complete hand hygiene per professional standards. These had the potential to affect all residents residing within the facility. The facility census was 67.

Inspectors wroteLicense Reference Number 175 NAC 1-005.06(C) Based on record review and interview, the facility failed to follow Antibiotic Stewardship standards for antibiotic surveillance and monitoring for 1 (Resident 10) of 2 sampled residents. The facility census was 67.

Inspectors wroteBased on interviews and record reviews, the facility failed to notify 1 resident in writing before the resident's room in the facility changed. This affected 1 of 1 sampled resident (Resident 32). The facility census was 67.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(D) Based on record review and interview, the facility failed to accurately code the Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and help nursing home staff identify health problems) for 2 (Residents 7 and 59) of 17 sampled residents. The facility census was 67.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(I) Based on observation, interview, and record review the facility failed to prevent accidents and or incidents from occurring for 1 resident (Resident 62) of 1 sampled residents. The facility census was 67.

Inspectors wroteBased on record review and interview the facility failed to ensure that residents were provided their required 30-day physician visit for 2 (Residents 47 and 63) of 4 sampled residents. This prevented the residents from receiving a thorough physician assessment of the resident for developing the resident's comprehensive care plan (a written interdisciplinary comprehensive plan to meet the resident's needs), including verifying initial orders and prescribing medication and treatments for the residents. The facility census was 67.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.10(D) Based on observation, record review, and interview the facility failed to ensure a medication error rate of 5% or less with an actual observed medication error rate of 12%. This affected 1 (Resident 4) of 5 sampled residents. The facility census was 67.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(I)(i)(1) Based on record review, observations, and interviews, the facility failed to identify causal factors for falls and failed to implement interventions for the prevention of new falls following each new incident. This affected 3 (Residents 3,7, and 11) of 3 sampled residents. The facility census was reported to be 60. The facility Administrator was notified on 3/17/2025 at 5:44 PM of an Immediate Jeopardy (IJ) which began on 12/01/2024. The IJ was removed on 3/17/2025, as confirmed by surveyor onsite verification.

Inspectors wroteBased on record review and interivews, the facility failed to ensure that all residents were seen by a physician every 30 to 60 days. This had the potential to affect 5 of 5 sampled residents (Residents 3,7,11,13, and 15.) The facility census was 60.

Inspectors wroteLICENSURE REFERENCE NUMBER NAC 175 12-006.11(E) The facility failed to ensure foods were not outdated and were labeled to prevent the potential for food-borne illness for all 62 residents served out of the kitchen. The facility identified a census of 62. An observation on 7/29/24 from 8:35 AM to 9:15 AM during the initial kitchen tour revealed the following: - 5 bags of opened cereal on a metal cart that with no label or date on them. - The upright refrigerator with 12 half chicken salad sandwiches with no label or date, and Med Pass nutritional shake open without a date with the manufacturers label instructing to use within 4 days of opening. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09B Based on observation, record review and interview the facility failed to ensure accuracy of the Minimum Data Set (MDS - a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care) assessment for 2 (Residents 33 and 16) of 6 sampled residents related to Stage 2 pressure injury wounds (loss of partial thickness of the skin including epidermis and part of the superficial dermis) for (Resident 33) and for hospice services for (Resident 16). The facility census was 62.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H)(v) Based on record review, interview and observation the facility failed to provide restorative therapy and an assistance device for contractures (abnormal shortening of muscle tissue making it highly resistant to stretching and eventually causing permanent disability) for 1 (Resident 58) of 3 sampled residents. The facility census was 62.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(l) Based on observations, interviews, and record review, the facility failed to evaluate a Broda chair (a specialty wheelchair that can be used for positioning and can be placed in a reclining position with the foot rest up) for safety prior to use for 1( Resident 16) of 1 sampled resident. The facility staff identified a census of 62.

Inspectors wroteLicensure Reference Number 175 NAC 12-0006.09(H) Based on interviews and record reviews the facility failed to ensure non-pharmacological interventions were provided prior to administering the PRN (as needed) Xanax (a medication used to treat anxiety) for one (Resident 53) of 5 sampled residents. The facility identified a census of 62. Findings Are: A record review of the admission Record ran on 7/30/24 revealed Resident 53 had been accepted into the facility on 6/7/24 and readmitted on [DATE] with a primary diagnosis of Sepsis (an infection trigger inflammation throughout the body) and Pulmonary Embolism with Acute Cor Pulmonale (a blood clot gets stuck in an artery in the lung). [...]

Inspectors wroteLicensure Reference Number 175 NAC 12.006.19(A) Based on observation and interview, the facility failed to ensure the emergency entrance/exit door at the south end of the 100-hallway functioned correctly. The total facility census was 64.

Inspectors wroteLicensure Reference Number NAC 12-006.04D2 Based on record review and interview, the facility failed to have a qualified director of food and nutrition services. This had the potential to affect all 59 resident that consumed food from the kitchen. The facility census was 59.

Inspectors wroteLicensure Reference Number NAC 12-006.11D Based on observations, interviews and record reviews the facility failed to provide food that is palatable and at a safe and appetizing temperature. This had the potential to affect all 59 resident that consumed food from the kitchen. The facility census was 59.

Inspectors wroteLicensure Reference Number NAC 12-006.11E Based on observations, interviews, and record review, the facility failed to store, prepare, and serve food in a manner to prevent cross contamination and food borne illness to all 59 residents served from the kitchen.

Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12-006.17B LICENSURE REFERENCE NUMBER 175 NAC 12-006.17D Based on observation, interview and record review the facility failed to have a Legionella Plan, failed to perform hand hygiene during wound care for 1 (Resident 18) of 1 sampled residents and failed to properly clean and store respiratory equipment for 2 (Residents 29 and 50) of 2 sampled residents. The facility identified a census of 59. Findings Are: A. Record Review of the Legionella Plan Binder received from Maintenance Director was not a legionella plan for this facility but rather an example of a different facility and the CDC toolkit for writing a legionella plan. [...]

Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12-006.09D Based on record review and interview the facility failed to ensure residents were free from unnecessary psychotropic medications related to the lack of behavior monitoring for 2 residents (Residents 29,32, 11 and 52) of 5 sampled residents. The facility identified a census of 59. Findings Are; A. A record review of the demographic information revealed Resident 29 had been admitted on [DATE]. A record review of the Progress Notes dated 2/22/23 through 8/23/23 revealed Resident 29 was alert and oriented to person, place, and time. [...]

Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12-006.05(4) Based on record review and interview the facility failed to ensure residents received a bath at least one time weekly for 1 resident (Resident 162) of 5 sampled residents. The facility identified a census of 59. Findings Are; A record review of the demographic information revealed Resident 162 admitted to the facility on [DATE]. A record review of the running, undated Comprehensive Care Plan (CCP- written instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care) for Resident 162 revealed it did not indicate the frequency of baths that Resident 162 had wished to receive. A record review of the untitled documents dated December 2022, January 2023, and February 2023 for Resident 162 related to bathing, revealed the following; December 2022 ,Intervention/task: [...]

Inspectors wroteLicensure Reference Number 175 NAC 12.006.09D2b Based on observation, interview, and record review, the facility failed to ensure wound care was completed for 2(Resident 7 and 18) of 5 sampled residents as ordered by the practitioner. The total facility census was 59.

Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2A Based on observations, record review and interview; the facility staff failed to implements assessed intervention to prevent pressure ulcers development and promote healing for 1 (Resident 52) of 4 sampled residents. The census was 59.

Inspectors wroteLicensure Reference Number 175 NAC 12.006.09D3 Based on interview and record review, the facility failed to ensure interventions for toileting were completed timely for 1 (Resident 161) of 3 sampled residents. The total facility census was 59.