Powder Springs Center for Nursing & Healing

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policies titled, Food Receiving and Storage and Appendix 14: Emergency Water Supply, the facility failed to ensure emergency drinking water was stored in safe and sanitary manner for residents in the facility. This deficient practice had the potential to cause contamination and compromise all facility resident's safety. The facility census was 195 residents.

Inspectors wroteBased on observations, staff interviews, and review of the facility policy titled, Smoking Debris Protocol/Procedures, the facility failed to dispose of cigarette butts in the appropriate receptacle in the outdoor designated smoking area. This deficiency had the potential to cause a fire. The sample size was five residents reviewed for smoking.

Inspectors wroteBased on staff interviews, record review and review of the facility's policy titled, Binding Arbitration Agreements, the facility failed to ensure the arbitration agreement specifically provided for the selection of a convenient venue: a location in which to carry out arbitration proceedings which should be agreed upon and was convenient and suitable to both parties for three of three residents (R) R246, R140 and R251 reviewed for arbitration.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled, Personal Protective Equipment (PPE), the facility failed to follow infection control protocol related to disposal of PPE in two out of five rooms with residents on Droplet Precautions (infection control measures used to prevent the spread of respiratory infections). The census was 183.

Inspectors wroteBased on record review, interviews, and review of the facility policy titled Urinary Tract Infections/Bacteriuria-Clinical Protocol, the facility failed to provide appropriate treatment and services to prevent a catheter associated urinary tract infection from worsening for one of 57 sampled residents (R) (R10). The failure caused R10 to be sent to an acute care hospital with the diagnosis of shock, sepsis, and metabolic crisis (including acute kidney injury and acute renal failure). R10 expired in the hospital on [DATE]. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator was informed of the Immediate Jeopardy (IJ) for F690 and F770 on [DATE] at 10:08 a.m. [...]

Inspectors wroteBased on record review, interviews, and review of the facility's policy titled Laboratory Services and Reporting, the facility failed to provide critical laboratory tests for one of 57 sampled residents (R) (R10). The Nurse Practitioner ordered urine culture sensitivity (UA and CS) tests on [DATE]. The failure caused R10 to be sent to an acute care hospital with the diagnosis of shock, sepsis, and metabolic crisis (including acute kidney injury and acute renal failure). R10 expired in the hospital on [DATE]. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's administrator was informed of the Immediate Jeopardy (IJ) for F690 and F770 on [DATE] at 10:08 a.m. [...]

Inspectors wroteBased on observation, interviews, and review of the facility's policy titled, Food Receiving and Storage, the facility failed to ensure the vents directly over the steam table were free from dirt and debris, a fan used in the kitchen area was clean, the frozen food items are kept off the freezer floor, and that hair nets were worn in the kitchen. The census was 178 residents.

Inspectors wroteBased on observation, interviews, and review of the facility policy titled, Food-Related Garbage and Rubbish Disposal, the facility failed to ensure that the facility's outside garbage disposal area was free from trash and debris. The census was 178 residents.

Inspectors wroteBased on record review, policy review, and interviews, the facility failed to maintain the tracking and trending of the Infection Control Program. The census was 178 residents.

Inspectors wroteBased on record review, policy review, and interviews, the facility failed to ensure that residents were offered and/or consented to the pneumoccal vaccination for three of six residents (R) (R25, R44, and R46) reviewed for immunizations.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policies titled, Medication Storage and Medication Administration, the facility failed to ensure medications securely stored and ensure expired medications were discarded appropriately on two of three Units (East Unit and Secured Memory Unit).

Inspectors wroteBased on record reviews, observations, staff and resident interviews, and a review of the facility's policy titled Activities of Daily Living (ADLs), the facility failed to promote dignity and independence for one of ten sampled residents (R) (R20) related to providing incontinence pull ups.

Inspectors wroteBased on record reviews, staff interviews, and a review of the facility policy titled Resident and Family Grievances the facility failed to resolve a grievance related to missing glass for one of six sampled residents (R) (R17).

Inspectors wroteBased on record review, staff interview, and review of the facility's policy titled Medication Administration, the facility failed to follow the physician orders to administer medications for one of three sampled residents (R) (R41).

Inspectors wroteBased on record review, interviews, and review of the facility's policies titled, Fall Prevention Program and High Risk Medications- Anticoagulants, the facility failed to ensure that residents were supervised, fall incidents were documented, and neuro checks were completed for unwitnessed fall incidents for two of four sampled residents (R) (R4, and R17).

Inspectors wroteBased on interviews and record review, the facility failed to keep accurate medical record of health status for one of 57 sampled residents (R) (R17).

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that the nursing call system was functional for one of three sampled residents (R) (R37).

Inspectors wroteBased on record review, interviews and review of policy titled, Antibiotic Stewardship Program, the facility failed to provide evidence of a monitoring system to track and trend antibiotic use for seven months (September 2021 through March 2022) or the past 12 months reviewed.

Inspectors wroteBased on a review of the facility policy titled, Empire Care Centers Testing Plan/Policy, facility policy titled, Facility Testing Requirements for Staff and Residents, testing records and interviews, the facility failed to ensure consistent testing throughout the facility for residents and staff as required by the Center for Medicare and Medicaid (CMS) while the facility was experiencing an outbreak of COVID-19.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure all components of the nurse call system was functional for one of two wings (West Wing).

Inspectors wroteBased on a review of the facility policies, employee records, resident records and staff interviews, the facility failed to ensure all staff reporting for duty were screened for Coronavirus (COVID)-19 prior to working their shift and failed to ensure residents were screened daily for signs and symptoms of Covid-19 for five of 50 sampled residents (R) (R#582, R#577, R#623, R#580, R#625).

Inspectors wroteBased on record review, interviews, and review of the facility Policy (name) Automated Medication Cabinet Services, the facility failed to ensure one of 50 sampled residents (R) (R#228) received his pain medication as ordered.

Inspectors wroteBased on observations, record review, staff interviews, and review of the policy titled Oxygen Administration, the facility failed to provide respiratory care consistent with professional standards of practice for two of 35 sampled residents (R) (R#573, R#585) related to ensuring humidification was provided and ensuring that humidification bottles and oxygen tubing were dated.

Inspectors wroteBased on observation, record review, review of facility policy titled Medication Administration, and staff interviews, the facility failed to ensure the medication error rate was less than five percent (5%). A total number of 27 medication opportunities were observed, and there were three errors for three of five residents (R) (R#90, R#31, and R#96) for an error rate of 11.11%.