Buckhead Center for Nursing & Healing

Inspectors wroteBased on observations, staff interviews, and record review, the facility failed to maintain food storage, preparation, and service areas in a sanitary manner by failing to remove food products that exceeded their use-by date and by failing to maintain kitchen floors and equipment in a clean condition to prevent the accumulation of food debris and other contaminants. This deficient practice had the potential to affect 136 out of 148 residents who received nourishment from the facility kitchen.

Inspectors wroteBased on resident and staff interviews, record review, and review of the facility's policy titled, Comprehensive Care Plan, the facility failed to ensure the right to participate in their care planning process for two of 41 residents (R) (R101 and R30). The deficient practice placed the residents at risk of not being aware of the goals and outcomes of their care and for their care plan not to be person centered.

Inspectors wroteBased on staff interview, record review, and review of facility policies titled, Transfer and Discharge and Bed Hold Prior to Transfer, the facility failed to provide the resident or resident representative with a written notice of transfer or discharge and failed to provide a notice of bed-hold policy and return before transfer to hospital for one of four residents (R) (R175) reviewed for discharge.

Inspectors wroteBased on staff interviews, record review, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure the Minimum Data Set (MDS) assessments were transmitted within the timeframes specified in the RAI manual for one of three residents (R) (R76) whose MDS submissions were reviewed. This failure had the potential for the discharged resident not to be able to receive services elsewhere because Medicare was not aware of the discharge status and for an inappropriate payment for services to the facility.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policies titled, Comprehensive Care Plan and Proper Use of Bed Rails, the facility failed to develop and implement a comprehensive person-centered care plan for the two of 44 sampled residents (R) (R5 and R154). Specifically, the care plan did not include measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs specifically related to the resident's use of bed rails and activities. This failure had the potential to affect the accuracy and complexity of resident care.

Inspectors wroteBased on observations, resident and staff interviews, record review, and review of the facility policy titled, Resident Smoking, the facility failed to provide adequate supervision to ensure residents smoked safely and only in designated smoking areas for one of three residents (R) (R77) reviewed for smoking practices. The facility's failure to adequately monitor and supervise R77's smoking activities placed the resident at risk for serious injury and had the potential to jeopardize the health and safety of current residents and staff.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled, Proper Use of Bed Rails, the facility failed to ensure assessments included attempted alternatives with documented failures to bed/side rail or assist rail usage prior to the installation and use of rails for one of one resident (R) (R5) reviewed for bed/side rails out of a total sample of 44 residents. This failure had the potential to increase the risk of resident accidental entrapment or injury.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled, Enhanced Barrier Precautions, the facility failed to ensure infection prevention and control practices were implemented for two of 71 sampled residents (R) (R12 and R140). Specifically, the facility failed to ensure appropriate personal protective equipment (PPE) was worn by staff while performing activities of daily living (ADLs) for a vulnerable resident (R12) and failed to properly disinfect a shared glucometer between resident uses. This failure has the potential to expose residents to cross contamination and the transmission of infectious organisms, including bloodborne pathogens.

Inspectors wroteBased on observations and staff interview, the facility failed to maintain a safe and functional kitchen environment. The facility failed to ensure the kitchen flooring was maintained in a manner that provided stable placement of equipment, resulting in the potential for equipment instability and increasing the risk of staff injury while working in the kitchen.

Inspectors wroteBased on observations and staff interviews, the facility failed to ensure that four of six resident shower rooms were free of hazards. Specifically, razors were found on the floor, dirty gloves found on a shower bed, opened bottles of bath soap were found, a bottle of chemical resistant spray was found, and a razor and hair clippers were found in a bag on the floor of a shower room. The deficient practice had the potential to cause injury to cognitively impaired residents and the possibility of the spread of infection to residents using the shower rooms.

Inspectors wroteBased on observations and staff interviews, the facility failed to ensure that the staff followed standard and transmission-based precautions to prevent the spread of infection when dispensing ice to the residents on two of four floors (3rd and 4th floor).

Inspectors wroteBased on observation and interview, the facility failed to properly label and date several items in the refrigerator. This failure had the possibility to expose 116 of 128 residents residing at the facility to food items that may have been spoiled.

Inspectors wroteBased on staff interviews, record review, and facility policy review, the facility failed to monitor and follow up on weight loss for three of six sampled residents (Resident (R) 9, R10, and R23) reviewed for weight loss. This deficient practice had the potential to allow residents to continue to lose weight and not be monitored for supplements or change in diet.

Inspectors wroteBased on observations, resident and staff interview, record review, and facility policy review, the facility failed to provide a dignified dining experience for one of five residents observed for nutrition (Resident (R) 15. This failure had the potential to negatively impact quality of life and self-esteem of R15.

Inspectors wroteBased on record review, resident and staff interviews, and review of the facility's policy, the facility failed to ensure two (Residents (R5) and R1) of a survey sample of 33 residents were invited to participate in the quarterly care plan meeting. This failure has the potential to violate resident rights, including the care plan not reflecting their preferences.

Inspectors wroteBased on observations, resident and staff interviews, record review, and facility policy review, the facility failed to ensure the call light was accessible for one of 33 residents (Resident (R) 99) observed in the Initial Pool. This failure placed R99 at risk of falling and injuries or distress when he could not access the call light to alert staff of an emergency or unmet needs.

Inspectors wroteBased on observations, resident, resident responsible party, and staff interviews, and record review, the facility failed to provide adequate Activities of Daily Living (ADL) care for one (R128) out of 33 sampled residents. This failure had the potential to negatively affect R128.

Inspectors wroteBased on observations, records review, and facility policy review, the facility failed to ensure two residents (Resident (R) 131, R152) were free from significant medication errors out of a total of 33 sample residents during one of the two residents' insulin administration observation and record reviews. These failures had the potential to cause hyperglycemia or hypoglycemia episodes in insulin-dependent residents.

Inspectors wroteBased on observations, resident and staff interviews, record review, and facility policy review, the facility failed to ensure that food preferences were honored for one out one of 33 sampled residents (Resident (R) 49).

Inspectors wroteBased on observations, interviews, record review and review of facility policies and manufacturer guidelines, the facility failed to ensure the glucometer disinfection procedure and infection control practice for hand hygiene were followed during a medication administration observation for blood glucose (BG) check for one resident (Resident (R)131) and during a wound care observation for one R59 observed out of 33 sample residents. These failures placed residents and staff at risk of cross contamination and infection.

Inspectors wroteBased on observations, staff interview, and review of the facility policy titled, Food Preparation and Service, the facility failed to ensure that the temperature for cold food was maintained at a temperature of 41 degrees Fahrenheit (F) or less. This deficient practice had the potential to promote the growth of pathogens that cause foodborne illnesses and to affect 142 of 153 residents receiving an oral diet.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facilty job description for the Business Office Manager (BOM), the facility failed to ensure clinical staff were trained and competent to provide ADL care for one of four residents (R) (R7) reviewed for ADL care. The deficient practice had the potential to adversely affect the care given to all residents in the facility. The facility census was 144.

Inspectors wroteBased on record review, observations, and interviews, the facility failed to ensure that two of six residents (R) (R56 and R63) reviewed for pressure ulcers received consistent care and services. The facility failed to implement repositioning and offloading pressure devices resulting in harm when R56 acquired a stage 4 sacral wound and an unstageable right lower leg wound.

Inspectors wroteBased on interviews, record review, and review of the facility's policies titled Controlled Substance Administration and Accountability and Abuse, Neglect, and Exploitation, the facility failed to ensure two of seven residents (R) (R115 and R226) were free from misappropriation of medication when 49 oxycodone (a narcotic) pills were unaccounted for during a narcotic count.

Inspectors wroteBased on record review, interview, and a review of the facility policies titled High-Risk Medications - Anticoagulants and Comprehensive Care Plans, the facility failed to develop care plans with resident-specific goals and interventions for one of 32 sampled residents (R) (R45) reviewed for care plans.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to consistently apply knee splints for prevention of further decrease in range of motion (ROM) for one of three residents (R) (R56) reviewed for limited ROM.

Inspectors wroteBased on observation, interview, record review, and review of the facility policy titled Nebulizer Therapy, the facility failed to properly store a nebulizer mask to prevent cross-contamination for one of three residents (Resident (R) 53) reviewed for respiratory care.