Etowah Landing

Inspectors wroteBased on observation, interviews, record review, and a review of the facility policy titled Cleaning and Disinfection of Resident-Care Items and Equipment, the facility failed to implement infection prevention and control practices for two of five sampled residents (R) (R50 and R23). In addition, the facility failed to ensure proper cleaning, disinfection, and separation of reusable resident care equipment for two of two units. This failure created the potential for cross-contamination and transmission of infection.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a clean and homelike environment on two of three units (Meadows Unit and the Springs Unit) related to an unclean room and broken bathroom tissue holder, lack of use of proper bed linen, unclean packaged terminal air condition (PTAC) units, and lingering malodorous odors. The deficient practice had the potential to affect resident comfort and safety.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure that three of seven medication and treatment carts (Springs Medication Cart #1, Springs Medication Cart #2, and Meadows Treatment Cart #1) were locked and secure when not in use. The deficient practice increased the risk of unauthorized access to medications and diversion.

Inspectors wroteBased on observations, staff and resident interviews, record review, and review of the facility policy titled Care of Fingernails/Toenails, the facility failed to ensure Activities of Daily Living (ADL) care was provided for two of eight sampled residents (R) (R2 and R9) related to fingernail care. The deficient practice placed R2 and R9 at risk of diminished quality of life.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled Restorative Nursing Policy and Procedure, the facility failed to ensure that one of two sampled residents (R) (R2) received restorative services to prevent contractures and/or to prevent a decrease in range of motion (ROM) mobility. The deficient practice increased the risk that R2 would experience worsening contractures.

Inspectors wroteBased on record review, resident and staff interviews, and facility policy review, the facility failed to send a written notification of hospital transfer to the resident and/or resident representative (RR) for three of three residents (Resident (R) 22, R56, and R62) reviewed for hospital transfer of 27 sample residents. This failed practice had the potential to affect the residents and their RR by not having the knowledge of where and why a resident was transferred and/or how to appeal the transfer, if desired.

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility failed to ensure one 27 sampled residents (R) (R287) was free from significant medication errors when R287 did not receive diltiazem (Cardizem), a blood pressure medication, as ordered by the physician on 10 days. This failure had the potential to cause adverse reactions of high blood pressure.

Inspectors wroteBased on observations, record review, interviews, and review of the policy titled Care Plans, Comprehensive Person-Centered, the facility failed to follow the care plan related to trach supplies for three residents (R) (R68, R70, R76). In addition, the facility failed to develop a person-centered care plan for three residents (R23) for Post Traumatic Stress Disorder (PTSD) and anti-coagulant use; R38 for the use of psychotropic medications, and R51 for PTSD. The sample size was 37. On February 9, 2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on February 9, 2024, at 2:39 pm. [...]

Inspectors wroteBased on observations, record review, staff interviews, review of the Policies and Procedures for Nursing Facility Services, the facility failed to ensure emergency tracheostomy supplies were at the bedside for three of 15 sampled residents (R) (68, 70, 76). In addition, facility failed to change the oxygen nasal cannula (N/C) tubing per physician orders or as needed for R49, failed to provide ongoing training for staff working on the ventilator unit, and failed to ensure a Registered Nurse (RN) worked on the ventilator unit for at least 12 hours per day. On February 9, 2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents. [...]

Inspectors wroteBased on observations, record review, staff interviews, review of Policies and Procedures for Nursing Facility Services and review of job descriptions for the Administrator and the Director of Respiratory Operations (DORT), the facility administration failed to provide monitoring and oversight for the Mechanical Ventilation Unit (MVU) by ensuring the respiratory ventilator equipment was functioning appropriately with audible alarms, and monitoring end title carbon dioxide (ETCO2) for six of six sampled ventilator dependent residents (R) (R281, E, F, R68, R70, R76). In addition, administration failed to ensure emergency tracheostomy supplies were available at the bedside for three of 15 residents (R) (R 68, R70, R76) reviewed for tracheostomy care. [...]

Inspectors wroteBased on observations, record review, interviews, and review of the Policies and Procedures for Nursing Facility Services, the facility failed to ensure that ventilator machines had properly functioning heart rate and pulse oximetry alarms that were audible outside resident rooms. In addition, the facility failed to ensure end tidal carbon dioxide (ETCO2) analyzers were implemented for measuring ETCO2 of ventilator residents This deficient practice affected six of six residents (R) (R281, RE, RF, R70, R68, R76) sampled for mechanical ventilators and CO2 monitors. On February 9, 2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents. [...]

Inspectors wroteBased on observations, staff interviews, and review of the facility's policies, the facility failed to have a hands-free trash receptacle at the hand washing sink, failed to ensure the exhaust hood filters were clean and free from grease build-up, and failed to properly label and date opened food items. These failures had the potential to affect 69 residents receiving an oral diet.

Inspectors wroteBased on observations, staff interviews, review of the Policies and Procedures for Nursing Facility Services, and review of the policy titled Healthcare Management-Legionella Infection Control, the facility failed to develop and implement a water management plan to include policies and procedures for the prevention and spread of Legionella and other opportunistic pathogens in the building water system. In addition, the facility failed to designate a clean and dirty room on the ventilator unit to reduce the cross contamination of respiratory therapy equipment. The census was 93.

Inspectors wroteBased on observations, interviews, and review of the policy titled Cleaning and Disinfection of Resident Care Items and Equipment, the facility failed to ensure that it maintained a clean and comfortable home-like environment for two of 30 sampled residents (R) (R54 and R63). Specifically, the facility failed to upkeep the cleanliness of resident wheelchairs related to dirt and hair build up.

Inspectors wroteBased on observation and interviews, the facility failed to ensure the environment was free from potential accident hazards by not ensuring that a portable oxygen tank was stored securely in resident (R) 233's room of 43 resident rooms.

Inspectors wroteBased on record review, staff interview, and review of the policy titled Antipsychotic Medication Use, the facility failed to ensure that psychotropic medications including antianxiety medications were not ordered as needed (PRN) beyond 14 days unless clinically indicated for two of five residents (R) (R8 and R38) reviewed for unnecessary medications.