Parkside Center for Nursing and Rehab at Ellijay

Inspectors wroteBased on observations, record review, staff interviews, and review of the facility's policy titled Administration of Insulin, the facility failed to ensure professional standards were followed when preparing and administering insulin for one of 17 residents (R) (R142) receiving insulin from a pen device. The deficient practice had the potential to result in the resident receiving an incomplete insulin dose, which could lead to ineffective blood glucose control, and adverse clinical outcomes.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policy titled Oxygen Administration, the facility failed to ensure that oxygen (O2) therapy was administered according to physician's orders for one of 17 residents (R) (R69) receiving oxygen. The deficient practice had the potential to place R69 at risk for respiratory complications, adverse clinical outcomes, and diminished quality of life.

Inspectors wroteBased on observations, record review, staff interviews, and review of the facility's policy titled Medication Administration, the facility failed to ensure a medication error rate of less than five percent. Two medication errors were identified out of 31 opportunities observed, resulting in a medication error rate of 6.45 percent. This deficient practice had the potential to place resident (R) (R123) at risk for medical complications and a diminished quality of life.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policy titled Medication Administration, the facility failed to ensure that one of six residents (R) (R140) reviewed for medication administration was free from significant medication errors. Specifically, the facility failed to ensure medications were administered to the correct resident, resulting in R140 receiving medications intended for another resident. This deficient practice had the potential to place the resident at risk for adverse drug reactions, medication side effects, and adverse clinical outcomes.

Inspectors wroteBased on observations, staff interviews, and review of the facility's policies titled Enhanced Barrier Precautions and Cleaning and Disinfection of Resident-Care Equipment, the facility failed to consistently implement enhanced barrier precautions (EBP) and sanitize shared medical equipment (blood pressure machine and glucometer) between resident uses in four of 13 medication administration observations. This deficient practice had the potential to expose residents to harmful pathogens, increasing the risk of cross contamination, and spread of infections.

Inspectors wroteBased on record review, resident and staff interview, and facility policy review, the facility failed to ensure three of five residents (Resident (R) 8, R18, and R91) and/or their resident representatives (RR) out of a sample of 23 residents reviewed for facility initiated emergent hospital transfer were provided with written transfer notice that contained all required information. This failure has the potential to affect the residents and their RRs 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 complete the comprehensive care plan to include the use of oxygen for one of 23 sample residents (Resident (R) 20) reviewed for care planning. The failure had the potential for R20's medical, nursing, mental, and psychosocial needs not being met.

Inspectors wroteThe facility failed to ensure medications were received in a manner that allowed administration for one of one resident (Resident (R) 91) reviewed for medication administration of 23 sample residents. This failure has the potential to cause R91 not to receive the therapeutic benefits of their prescribed medications.

Inspectors wroteBased on observations, record review, resident and staff interviews, and facility policy review, the facility failed to identify target behaviors for monitoring effectiveness of antipsychotic medication for one of five residents (Resident (R) 48) reviewed for unnecessary medications of 23 sample residents. This failure had the potential to contribute to unnecessary antipsychotic medication use in R48 who used the medication to treat behavioral symptoms of anxiety.

Inspectors wroteBased on observations, staff interviews, and record review, the facility failed to hire qualified dietary staff certified to serve food in a clean, safe and sanitary manner. The potential for foodborne illnesses could affect 84 of 85 residents.

Inspectors wroteBased on observations, resident and staff interviews, and record review, the facility failed to serve the appropriate quantities of food according to the prescribed dietary recipe. The deficient practice had the potential for malnutrition and could affect 84 of 85 residents receiving an oral diet from the kitchen. Findings Include: Observation on 3/5/2024 from 11:46 pm to 12:02 pm, the Dietary [NAME] placed chicken and dumplings, and peas on two resident's plates using a 3-ounce (oz) sized ladle for the chicken and dumplings. When asked about the size of the serving ladle, the Dietary [NAME] immediately grabbed a 4 oz ladle. She stated that the 4 oz ladle will be used to serve the meal/meat, then the 3 oz ladle will be used to fill the bowl with just the liquid. The Dietary [NAME] added This is how the chicken and dumplings are served. [...]

Inspectors wroteBased on observations, resident and staff and complainant interviews, and record reviews, and review of the facility policy titled, Temperature for Food Safety, the facility failed to serve food that is palatable, attractive and at required temperatures. The deficient practice had the potential to affect 84 of 85 residents utilizing dining services. Findings Include: Review of the facility policy titled Temperature for Food Safety dated 3/6/2024 indicated 135 [degrees] F [Fahrenheit] minimum temperature for holding hot food. Danger Zone 41 [degrees] -135 [degrees] F Rapid Bacteria Growth Zone. On 3/4/2024 at 5:15 pm, a test tray of Monday's menu Week 4 Dinner was served to this Surveyor, which included stuffed cabbage soup, roast beef sandwich, carrot raisin salad, and mixed melon salad. The stuffed cabbage was flavorless and not edible. [...]

Inspectors wroteBased on observations, resident and staff interviews, and record review, the facility failed to serve residents their preferences and alternative meals. The deficient practice had the potential to affect 84 of 85 residents receiving meals from the kitchen.

Inspectors wroteBased on observations, staff interviews and record reviews, the facility failed to recognize the dish machine was malfunctioning and producing temperatures too low to kill bacteria and germs for the last 10 months. The potential for foodborne illnesses could affect 84 of 85 residents.

Inspectors wroteBased on observations, resident and staff interviews, record review, and review of the policy titled Comprehensive Care Plans, the facility failed to implement appropriate interventions on the care plan for two of 45 sampled residents (R) (R#39 and R#20) related to (1) pain management during wound care for R#39 resulting in harm; and (2) assessment of the arteriovenous fistula (AVF) access site after dialysis treatment for R#20.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop, and implement a plan related to effective communication goals for one of 45 sampled residents (R) (R#55) as it relates to provide care and services for activities of daily living as it related to communication and offering a functional communication system. This failure resulted in psychosocial harm related to R#55 experiencing emotional distress, crying often, and frustrated when she was not able to communicate daily needs with facility staff.

Inspectors wroteBased on observation, record review, interview, and review of facility policy Pain Management the facility failed to stop and address verbal expression of pain during wound care for one of three residents (R) (R#39) observed for wound care. The facility staff failed to recognize the need for modified approaches/interventions when R#39 experienced severe pain during wound care treatment resulting in harm for R#39.

Inspectors wroteBased on observation, staff interviews, and recipe review, the facility failed to ensure puree recipes were followed to conserve nutrient value of puree vegetable and puree chicken strips for six of six resident receiving puree consistency.

Inspectors wroteBased on observations, staff interviews, and policy review the facility failed to ensure the pipes to the fire suppression system under exhaust hood were clean and free from grease build-up; failed to ensure pans were stored dry to prevent wet nesting; failed to proper store foods in dry storage area; failed to ensure label, date, and securely wrap opened food items in the kitchen and resident nourishment room; failed to ensure kitchen equipment was properly cleaned to prevent cross contamination; failed to ensure food spills were cleaned from walls; and failed to ensure dietary staff wore hair restraint while in the kitchen. This had the potential to affect 90 residents receiving an oral diet.

Inspectors wroteBased on observations and staff interviews the facility failed to ensure that the dumpsters doors/lids were closed at all times and failed to ensure the area surrounding the dumpsters was free from trash debris. This had the potential to affect all 91 residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility (1) failed to ensure proper infection control practices during wound care for two of three residents (R) (R#39 and R#86); (2) failed to ensure staff wore Personal Protective Equipment (PPE) into Transmission Based Precaution (TBP) rooms and that appropriate signage was on the door for two of three residents (R#5 and R#9) on TBP; and (3) failed to develop an updated water management program plan for the prevention of Legionella for 91 of 91 residents in the building.

Inspectors wroteBased on interviews, record review, and a review of facility's policy titled, Baseline Care Plan, the facility failed to develop a 48-hour base line care plan for 16 of 45 sampled residents (R) (R#48, R#241, R#242, R#192, R#49, R#246, R#87, R#240, R#68, R#195, R#340, R#342, R#245, R#341, R#244, and R#247).

Inspectors wroteBased on interviews, record review, and review of the facility policy titled, Nutritional Management, the facility failed to complete a Comprehensive Nutritional Assessment for nine of 45 sampled residents (R) (R#86, R#20, R#10, R#70, R#77, R#25, R#192, R#38, and R#16).

Inspectors wroteBased on observations, resident and staff interviews, record review, and review of the policy titled Hemodialysis, the facility failed to ensure that one of two residents (R) (R#20) receiving dialysis treatment received care and services consistent with professional standards of practice related to assessing the arteriovenous fistula (AVF) access site and documenting findings daily and after dialysis treatments and providing documented communication between the facility and the dialysis center before and after dialysis appointments.

Inspectors wroteBased on staff interview, record review, and review of the facility policy titled Use of Psychotropic Medication, the facility failed to ensure a stop date was implemented, not to exceed 14 days, for as-needed (PRN) psychotropic medications for one of five residents (R) (R#41) reviewed for unnecessary medications.