Peachtree Centre

Inspectors wroteBased on observation, interview, document review and record review, the facility failed to ensure that the planned menu was followed to meet the nutritional needs of five of five residents (R)2, R151, R108, R168, and R37) reviewed for nutrition. Specifically, the Dietary Aide (DA)2 served smaller portions to R2, R151, R108, R168 and R37 than the portion size the menu indicated. In addition, the residents on one of four floors (third floor) were served a different vegetable that what was indicated on the menu.

Inspectors wroteBased on observation, interview, document review and policy review, the facility failed to ensure personal protective equipment (PPE) was available for laundry staff in one of one laundry rooms to use while sorting soiled resident clothing and bed linens. This failure had the potential to infect the staff and/or all residents with pathogens which could potentially lead to the development of infectious diseases.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to maintain a safe, clean, comfortable, and homelike environment on two of the four floors (first and third floors). Specifically, the floor in the dining/activity area and hallways on the third floor were observed to be sticky. Additionally, four tables on the third-floor dining/activity area were chipped and exposed the wood underneath. The sticky floor posed a potential risk for residents who ambulate, as it could contribute to loss of balance of falls. The chipped condition of the tables had the potential to create an infection control issue.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to develop person-centered, comprehensive care plans with measurable goals and interventions for two residents (Resident (R) 110 and R73) of two residents reviewed for care plans out of a sample of 54 residents. Specifically, the failure placed R110 at risk for unmet nutritional needs and for R73's unmet mental health treatment needs. These failures placed the residents at risk for unmet care needs, and the inability meet their maximum practicable level of functioning.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain good grooming. Specifically, the facility failed to provide nail care for one of one resident (R)109) in the sample of 54 residents who was observed with long, dirty fingernails. This deficient practice has the potential to affect the resident's quality of life

Inspectors wroteBased on observations, interviews, record reviews, and facility policy reviews, the facility failed to ensure one out seven residents (Resident (R) 46) out of a survey sample 54, by failing to cover a heavily scraped painted wall by R46's bed, who had a history of putting non-food items in her mouth. The resident had the potential for choking, gastrointestinal issues, and toxic exposure.

Inspectors wroteBased on record review, observations, interviews and policy review, the facility failed to ensure a medication error rate of less than five percent (5%). Two errors out of a total of 28 opportunities for error related to two (Residents (R) 18 and R82) of six residents observed during medication administration, resulting in a medication error rate of 7.14%. The facility's failure to ensure a medication error rate of less than five percent created the potential for residents to experience negative physical and/or psychosocial effects related to medication errors.

Inspectors wroteBased on observation and interview, the facility failed to store and dispense food and ice under sanitary conditions for one of four nourishments rooms (second-floor nourishment room). This failure had the potential to cause residents' food borne illness.

Inspectors wroteBased on record review and interviews, the facility failed to ensure resident assessments were accurately documented for two (2) residents (R)42 and R100.

Inspectors wroteBased on review of the facility policy, record review, observations, and interviews, the facility failed to ensure that respiratory equipment was appropriately stored according to professional standards of practice for one (1) of one (1) resident sampled for respiratory care, Resident (R)54.

Inspectors wroteBased on observation, interview, record review, review of the Food Code U.S. Food and Drug Administration, manufacturer's guidance and facility policy review, the facility failed to ensure the kitchen was maintained in a sanitary manner and sanitation practices were in place to prevent the potential spread of food borne illness to 92 out of 93 residents (one resident received nutrition via a feeding tube). Specifically, dietary carts, buckets, garbage can had a heavy accumulation of food or grime; a plastic basin, located under the handwashing sink had an accumulation of dirt and green tinged water within the basin; shelves for the storage of clean pots were rusted; plastic bags of leftovers were in the refrigerator were not labeled with the food item in the bag or the date the food was placed in the refrigerator; [...]

Inspectors wroteBased on observations, interview, record review, and facility policy review, the facility failed to ensure food was palatable for 9 out of 93 residents (Residents (R)76, R36, R38, R91, R89, R60, R69, and two residents who received pureed diets R59 and R44). Specifically, the vegetables for the regular diet were faded and soggy in appearance and residents did not receive salt, pepper, or margarine for their rolls. The pureed food was bland, pasty and lacked flavor. Residents reported the food was not served hot, the vegetables were overcooked, and condiments and margarine were not served.

Inspectors wroteBased on interview, record review and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure three of three residents (Resident (R)7, R52, and R78) reviewed for no Minimum Data Set (MDS) assessment in over 120 days had a quarterly assessment successfully transmitted and accepted within the allotted time frame as stated in the RAI manual.

Inspectors wroteBased on interview, record review, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to provide an accurate resident assessment regarding a Level II screening of a Pre-admission Screening and Resident Review (PASRR) on an admission Minimum Data Set (MDS) assessment for 1 of 2 residents (Resident (R) 28) reviewed for PASRR.

Inspectors wroteBased on record review, review of facility policy, review of the Resident Assessment Instrument (RAI) Manual and interviews, the facility failed to develop and implement a person-centered comprehensive plan of care with measurable goals and plans for 1 of 27 residents reviewed for care plans. Specifically, the facility failed to develop a care plan that addressed cognition/dementia health problems for Resident (R)76. Failure to develop the care plan could result in the resident not receiving care and services.

Inspectors wroteBased on observation, interview, record review and review of facility policy, the facility failed to ensure 1 (Resident (R)88) of 4 dependent residents reviewed for activities of daily living (ADL), was provided with adequate nail care.

Inspectors wroteBased on observation, interview, and manufacturer's instructions for use (MIFU), the facility failed to ensure a medication administration error rate under five percent, with 2 errors for 2 (Residents (R)11 and R68) out of a possible 25 opportunities. This resulted in an error rate of 8 percent (%). Specifically, 2 Licensed Practical Nurses (LPN)1 and LPN2 failed to prime (to remove any bubbles from the needle and cartridge to ensure that the pen is working correctly so the insulin given is not too much or too little) insulin injection pens prior to the administration of the insulin.

Inspectors wroteBased on interview, record review, facility policy review, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to offer 2 of 5 residents reviewed for pneumonia vaccinations (Resident (R) 21 and R60) and/or their representatives, the opportunity to be vaccinated in accordance with nationally recognized standards. Specifically, the facility failed to offer R21 and R60 the opportunity to be vaccinated with Pneumococcal 15-valent Conjugate Vaccine (PCV15) or one dose of Prevnar 20 (PCV 20) in accordance with nationally recognized standards. The failed practice had the potential to increase the risk for these residents to contract pneumonia.