Cartersville Center for Nursing and Healing

Inspectors wroteBased on observations, staff interviews, and review of the facilities policies titled, Food Preparation and Service, Food Brought by Family/Visitors, and Sanitization, the facility failed to ensure food was labeled, stored and prepared under sanitary conditions. In addition, the facility failed to ensure cleanliness of the kitchen and that equipment was working properly. The deficient practices created an unsanitary environment that increased the potential for cross contamination and food borne illness for the 109 of 112 residents receiving meals prepared in the kitchen.

Inspectors wroteBased on observations, staff and resident interviews, record review, and review of the facility's policies titled, Medication Administration, the facility failed to maintain a medication error rate below 5% (percent). The observed medication administration error rate was 17.24% with 5 errors of 29 opportunities for four residents (R) (R50, R15, R23, and R82) during medication administration. This deficient practice had the potential to cause health complications for residents on B hall.

Inspectors wroteBased on observations, record review, staff interviews, and review of the facility policy titled, Catheter Care, the facility failed to ensure residents were provided with privacy bags for the urinary drainage bag on the Foley catheter for two of eight Residents (R) (R119 and R128) with catheters. The deficient practice had the potential for infection for R119 and R128.

Inspectors wroteBased on record review, staff interviews, and review of the facility policy titled, MDS 3.0 Completion, the facility failed to properly code a resident for discharge furthermore there was no correction transmittal sent to Center for Medicaid Services (CMS) for one of two residents (R) (R116) reviewed for discharge.

Inspectors wroteBased on observations, staff and resident interviews, record review, and review of the facility's policy titled, Pharmacy Services, the facility failed to provide routine and emergency drugs and biologicals to the facility residents for one of four halls sampled, and specifically for resident (R) (R82). This deficient practice had the potential to cause serious complications with resident health.

Inspectors wroteBased on resident and staff interviews, record review, and facility policy review, the facility failed to provide written notice of a room change prior to changing residents' rooms within the facility, which affected 4 (Residents #1, #7, #11, and #12) of 4 residents reviewed for multiple room changes.

Inspectors wroteBased on resident attorney, medical records company representative, and staff interviews, record review, and facility policy review, the facility failed to provide a written copy of the residents' medical records within two working days of the initial written request for three (Residents #2, #9, and #10) of three residents reviewed for timely access to their medical records.

Inspectors wroteBased on observations, staff interviews, and review of the facility's policies titled, Sanitation, Refrigeration and Freezer, Food Receiving and Storage, and Food Preparation and Service, the facility failed to discard dry and frozen food by expiration dates, ensure proper food labeling, storage and dates, follow puree recipe, perform proper thawing procedure, and maintain proper sanitary conditions of two of two ice machines. The deficient practice had the potential to affect 108 residents who receive an oral diet from the kitchen. The facility census was 110 residents. Findings Include: Review of the facility policy titled Sanitation dated April 2024 revealed under 12. Ice machines and ice storage containers will be drained, cleaned, and sanitized per manufacturer's instructions and facility policy.16. [...]

Inspectors wroteBased on resident family and staff interviews, and record reviews, the facility failed to notify the responsible party (RP) of new medication orders for one of 63 sampled residents (R) (R315). The facility census was 110.

Inspectors wroteBased on observations, resident and staff interviews, record review, and review of facility's policy titled, Minimum Data Set, the facility failed to ensure accurate assessment for two of 63 sampled residents (R) (R413 and R68). The deficient practice had the potential to reflect an inaccurate status of the resident's current condition and progress.

Inspectors wroteBased on observations, resident and staff interviews, record review, and review of the facility policy titled, Activities of Daily Living (ADLs), the facility failed to provide scheduled showers/baths for two residents (R) (R10 and R45) dependent on staff for ADLs. The facility census was 110 residents.

Inspectors wroteBased on observations, resident and staff interviews, record review, and review of the facility's policy titled, Activities, the facility failed to develop and introduce an activities program for one of 63 sampled residents (R) (R 413). The deficient practice had the potential to place the resident at risk for a diminished quality of life.

Inspectors wroteBased on observations, staff and resident interviews, and record review, the facility failed to follow the physician's orders for ointment and compression stockings for one of 63 sampled residents (R) (R413). The deficient practice had the potential to place the resident at risk for medical complications, and a diminished quality of life.

Inspectors wroteBased on observations, staff interviews, and review of the facility policy titled, Oxygen (O2) Safety the facility failed to ensure O2 tanks were securely stored in a designated location to prevent accidents and hazards for one of eight residents (R) (R163) who use O2.

Inspectors wroteBased on observations, staff and resident interviews, record review, and review of the facility's policies titled, Medication Administration, and Pain Management, the facility failed to ensure pain management was provided for one of two residents (R) (R68) reviewed for pain management. The deficient practice had the potential of unmet needs and a diminished quality of life.

Inspectors wroteBased on observations, staff interview, and review of the facility's policy titled, Medication Storage, the facility failed to lock the medication cart for one of two medication carts; and found expired, used and new items co-mingled in bags, sink, and storage box in one of two medication storage rooms. The deficient practice had the potential for residents, unauthorized staff, and visitors to have access to medications and biologicals stored on the medication cart and staff to use contaminated items. The facility census was 110 residents.

Inspectors wroteBased on observations, staff and resident interviews, record review, and review of the facility policy titled, Documentation in Medical Record, the facility failed to maintain accurate documentation of care and services provided for one of 63 sampled residents (R) (R413).

Inspectors wroteBased on observations, record review, staff interviews, and review of the facility's policies titled, Catheterization of a Male, Infection Prevention and Control Program, and Transmission-Based Precautions, the facility failed to maintain infection control protocol during indwelling urinary catheter insertion for one of seven residents (R) (R15) with an indwelling catheter, to perform hand hygiene during medication administration for one resident (R53), and to keep doors closed for contact isolation in two of four residents (R23 and R25) on contact isolation. The deficient practice had the potential to cause infection and adverse health outcomes.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled, Handwashing and Hand Hygiene, the facility failed to follow proper infection control practices to prevent the spread of disease for one of seven sampled Residents (R) (R1). Specifically, staff entered R1's room, who was on contact isolation, without washing their hands or wearing gloves and a gown.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure the kitchen was maintained in a sanitary manner to prevent the potential spread of foodborne illness to all 104 facility residents. Concerns included improper dishwashing, inadequate sanitizer solutions, meat thawing, ice dispensing procedures, labeling, and food handling.

Inspectors wroteBased on observation, interview, record review, and facility policy, the facility failed to ensure three of eight residents (R) (R14, R97, and R43) were treated with dignity and respect in a manner to enhance quality of life and individuality. Specifically, residents were observed in clothing that was not their own and was too small, improperly dressed in view of other residents, and in soiled clothing.

Inspectors wroteBased on observations and interviews, the facility failed to ensure a clean, comfortable, and homelike environment for 10 of 33 sampled residents (R) (R48, R17, R45, R33, R257, R9, R31, R24, R59) and one supplemental resident (R155). Specifically, the facility had multiple rooms with holes in the walls, pieces of wall paneling coming off the walls, dirty bathrooms, missing bath bars for washcloths, towels, missing tiles, dirty/torn resident equipment, dirty air conditioner ducts, wall paneling being held together with duct tape, TV cables hanging down, and excessive noise.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide residents their showers as scheduled and nail care according to the Plan of Care ADL (Activities of Daily Living) for four of six residents (R) (R59, R14, R97, and R3) reviewed for ADL care in the sample of 33.

Inspectors wroteBased on observations, interviews, record reviews, and facility policy the facility failed to ensure five residents out six (R) (R307, R88, R308, R46 and R153) reviewed for advance directives had their code status consistently documented throughout their electronic medical record (EMR) for easy access to the clinical staff.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to have a system in place to ensure respiratory equipment was bagged when not in use, date/label oxygen tubing and humidifiers when changed out, and clean respiratory filters. The facility also failed to ensure respiratory care consistent with professional standards of practice was provided for four of four residents (R) (R43, R48, R84, and R46,) reviewed for respiratory care/oxygen therapy.

Inspectors wroteBased on observations, interview, record review, and policy review, the facility failed to ensure palatable food was served to nine out of 33 sampled (R) (R59, R47, R31, R97, R71, R43, R38, R30, R46) and residents who attended the resident council. Food was burnt, lacking in flavor, poorly prepared, cold, and condiments were not provided.

Inspectors wroteBased on observation, interview, record review and policy review the facility failed to ensure nine out of 104 total residents (R) (R59, R47, R31, R24, R97, R71 R43, R46, R102) and residents who attended the resident council were provided with choices about food and beverages.

Inspectors wroteBased on observations, interviews, facility policy review, and Pest Elimination Service Reports, the facility failed to ensure an effective pest control system was in place for six of 33 sampled residents (R) (R33, R38, R71, R47, R31, and R34). Specifically, the facility had sightings of live and dead roaches in resident rooms, staff bathrooms, and multiple complaints from residents.

Inspectors wroteBased on observations, interviews, record reviews, and facility policies, the facility failed to ensure one of one resident (R) (R308) reviewed for self-administration of medication had a physician's order to safely perform self-administration of medication. The facility's deficient practice had potential for medication errors to occur for R308.

Inspectors wroteBased on observations, record review, interviews, and facility policy review, the facility failed to ensure basic accommodation of needs for one of one sampled residents (R) (R257) reviewed for accommodation of needs were provided. Specifically, the facility failed to ensure R257's call light was within reach, and also failed to ensure the residents bed was in good working condition. The foot board to R257's bed was observed to be broken and hanging off the bed.

Inspectors wroteBased on observation, interview, record review and policy review, the facility failed to ensure an allegation of neglect was reported to the State Survey Agency for one of three residents (R) (R47) investigated for abuse. R47 reported having her call light taken away and placed out of her reach and her incontinence/toileting needs not being addressed for five hours. The incident was not reported to the State Survey Agency.

Inspectors wroteBased on observation, interview, record review and policy review, the facility failed to ensure an allegation of neglect was thoroughly investigated for one of three residents (R) (R47) investigated for abuse. R47 reported having her call light taken away and put out of her reach and her incontinence/toileting needs not being addressed for five hours.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure two of 33 sampled residents (R) (R256 and R52) had baseline care plans developed and implemented to address the resident's immediate needs within 48 hours of admission to the facility. R256 did not have a baseline care plan implemented. R52's baseline care plan did not address R52's dementia diagnoses.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure each resident had a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental and psychosocial needs for two of 33 sampled residents (R) (R3 and R41).

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to ensure one of 33 sampled residents (R) (R38) was being invited to regular care plan meetings. The facility also failed to have documentation to show the resident care plan meetings were being held regularly or with input from the resident. By not involving residents in their care, they are unaware of changes that may be made, or decisions made.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure resident's received care in accordance with nursing standards, specifically clarifying an order for an antibiotic without an end date and taking appropriate action when prescribed medications were not in stock, two out of 33 total sampled residents (R) (R59 and R46). R59 missed doses of an antibiotic prescribed by the physician and received the antibiotic for longer than the provider intended. R46 missed doses of a pain medication.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide services to one of four residents (R) (R64) reviewed for limitations in range of motion (ROM). The facility failed to ensure residents with ROM impairments were provided services to maintain function or prevent declines. In addition, the facility failed to implement established restorative programs for residents with programs in place.

Inspectors wroteBased on observations, interviews, record review, and facility policies the facility failed to provide nutrition management for one of one resident (R) (R308) reviewed for dialysis to meet her nutritional needs. Specially, the facility did not adjust meal schedule to provide nutrition prior to or during dialysis clinic appointments three days a week. The facility's deficient practice had potential to affect R308's nutritional intake and blood sugar values (low blood sugar).