Cartersville Crossing of Journey LLC

Inspectors wroteBased on observations, resident and staff interviews, record review, and review of the facility's policy, the facility failed to ensure residents were served food that was palatable to seven of seven residents (Resident (R) 10, R24, R39, R7, R58, R46, and R29) reviewed for food palatability out of 28 sampled residents. This failure had the potential to affect 71 residents who consumed food prepared from the facility's kitchen and could result in residents skipping meals and experiencing weight loss.

Inspectors wroteBased on staff interview, record review, and review of the facility's policy, the Quality Assurance and Performance Improvement (QAPI) committee failed to ensure the required members of the committee attended the quarterly meetings. This failure had the potential to affect all 71 residents who currently live in the facility.

Inspectors wroteBased on staff interviews, record review, and review of the facility's policy, the facility failed to ensure the resident and/or their Resident Representative (RR) received the required written notice of transfer and a bed hold notice which included all the required information upon their emergent transfer to the hospital for four of 47 sampled residents (R) (R6, R7, R38, and R3). This failure had the potential to affect all residents and their RRs of the facility by not having the knowledge of how to appeal the transfer, if desired, and the mailing address of the Ombudsman which could contribute to the possibility of denial of re-admission and loss of the resident's home following hospitalization for any resident transferred to the hospital from the facility.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure resident assessments were accurately completed for one of 47 sampled residents (Resident (R) 80). R80's Minimum Data Set (MDS) assessment did not reflect the resident's hospice status. This deficient practice had the potential to lead to inaccurate reimbursements and unmet care needs for the resident.

Inspectors wroteBased on observation, staff interview, and review of the facility policies titled, Sanitation Inspection, Food Safety Requirements, and Resident Refrigerators, the facility failed to keep the kitchen's convection oven, two conventional ovens, stove top's spill pan, and large manual can opener and its base attachment clean. The facility failed to date bread products stored in the kitchen's dry storage area and cover opened food stored in the kitchen's walk-in freezer. In addition, the facility failed to date thawed nutritional supplements and discard food that was spoiled or had expired use by dates that were stored in the facility's kitchen and in the 300-hallway resident refrigerator. This failure had the potential to affect 64 residents who consumed food prepared in the facility's kitchen.

Inspectors wroteBased on staff interview, record review, and review of the facility policy titled, Transfer and Discharge (including AMA [against medical advice], the facility failed to issue two of two residents (Resident (R) 9 and R24) or their responsible party transfer paperwork or to notify the long-term care ombudsman of hospital transfers out of 19 sample residents. This failure could affect the resident and or representative by not receiving the information for the reason of transfer and the resident's right to return to the facility.

Inspectors wrote2. Review of R24's admission Record in the Profile tab of the EMR revealed an admission date of 07/09/24. Review of R24's five-day MDS with an ARD of 08/02/24 and located in the MDS tab of the EMR revealed a BIMS score of five out of 15 which indicated the resident was severely cognitively impaired. Review of R24's Nursing Note, dated 08/30/24 at 5:57 PM and located in the Progress Notes tab of the EMR, revealed Labs reviewed with NP [Nurse Practitioner], new orders received to send to ER [emergency room] for evaluation, spoke with responsible party and is agreeable with plan of care. Review of R24's Nursing Note, dated 08/30/24 at 6:15 PM and located in the Progress Notes tab of the EMR, revealed emergency medical services (EMS) called and here to transport resident to hospital via stretcher in stable condition. [...]

Inspectors wroteBased on observations, resident, family member, and staff interviews, record review, and review of the facility policy titled, Weight Monitoring Program, the facility failed to obtain an admission weight, perform re-weights for weight losses of five percent or greater and be evaluated and assessed by the facility's Consultant Registered Dietitian (CRD) and Interdisciplinary Team after experiencing an unplanned significant weight loss for one of two residents (Resident (R) 17) reviewed for nutritional status out of 19 sample residents. The facility's failure placed the resident at risk for further unplanned weight loss.

Inspectors wroteBased on observations, resident and staff interviews, record review, and review of the facility policy titled, Therapeutic Diet Orders, the facility failed to provide food in a form that met the needs which included yogurt at meals as requested for one of two residents (Resident (R) 14) reviewed for food out of 19 sample residents. The facility's failure to provide food in the appropriate form to meet a resident's needs could result in decreased intake and an increased risk of choking.

Inspectors wroteBased on observations, policy review, and staff interview, the facility failed to ensure facial hair was covered with beard guards; failed to ensure opened food items in the dry storage area were securely covered, labeled, and dated; failed to maintain sanitary conditions of the kitchen area and equipment. In addition, the facility failed to maintain the sanitary conditions of the resident diet kitchen on the nursing unit. The census was 73.

Inspectors wroteBased on observations, interviews, and review of facility policies, the facility failed the ensure that essential kitchen equipment was maintained in proper working condition. Specifically, the walk-in freezer was not holding temperature as evidenced by foods not being frozen upon inspection during initial tour of the kitchen; the low temperature dish machine did not reach the proper temperature during the wash cycle after three cycles. The facility census was 73.

Inspectors wroteBased on observations and interviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment throughout the facility related to delay in repairing damaged ceilings in the kitchen dish-room, the resident shower room, and on the 400 Hall. The facility census was 73.

Inspectors wroteBased on observation, facility policy, and interviews, it was determined the facility failed to ensure a homelike and comfortable environment for 15 (202, 205, 206, 207, 210, 143, 214, 405, 305, 515, 403, 407, 408, 409, 410) of 44 resident's rooms and one shower room.

Inspectors wroteBased on facility policy, medical record review, and staff interviews, it was determined the facility failed to develop a person-centered comprehensive care plan for six of 26 sampled residents (R) (R#54, R#1, R#40, R#16, R#32, and R#57).

Inspectors wroteBased on observation, record review, and staff interviews, the facility failed to ensure that Minimum Data Set (MDS) assessments were accurate for one of 26 sampled residents (R) (R#13) related to the use of oxygen.

Inspectors wroteBased on observations, record review, staff interviews, and facility policy 'Oxygen Concentrator', the facility failed to administer oxygen therapy as ordered for one of seven residents (R)(R#32).

Inspectors wroteBased on observations, staff interviews, and review of the policy titled Disposal of Garbage and Refuse, the facility failed to ensure the outdoor garbage and refuse area was maintained in a sanitary manner, creating the potential for harboring pests and insects. Specifically, the side door was open, a blue trash bin was overflowing with bagged garbage, bagged garbage on top of the dumpster, garbage and debris was strewn on the ground and behind the dumpster. The facility census was 73.

Inspectors wroteBased on observations, record review, staff interviews, and policy review, the facility failed to implement an effective Infection Control Program (ICP) to prevent the spread of infections by not ensuring Certified Nursing Assistant (CNA) CC washed/sanitized her hands before and after glove removal during the provision of catheter care, for one of three residents (R) (R#14) with indwelling urinary catheter. In addition, the facility failed to properly store resident personal care equipment.