Nurse Care Of Buckhead
NURSE CARE OF BUCKHEAD in ATLANTA, GA — inspection on August 1, 2024.
Found 24 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Findings included: During an interview on 7/17/2024 at 9:36 am, the Business Office Manager (BOM) stated that the residents do not have access to their funds on the weekends and have been like that since before she got here.
The residents were notified in a memo and resident council meeting by the previous Social Service Director.
The BOM stated the residents are provided funds on Fridays to cover their weekend spending.
When asked why this had been the process, the BOM stated it had been like this before the BOM's tenure at the facility.
They currently don't have someone secure enough to handle resident funds on the weekends.
In a phone interview on 7/22/2024 at 10:59 am the Former Administrator (FA) WWW stated that they had a Business Office Manager who had been at the facility for approximately six to seven years that resigned.
After their resignation, they did have difficulty securing another Business Office Manager.
The FA WWW continued that in the interim, they had a plan in place where funds were left with the receptionist.
Per the FM WWW, the facility did have a 24-hour seven-day-a-week receptionist until January 2024.
During an interview on 7/24/2024 at 10:47 am with Resident Council President, R48, it was revealed that the residents do not have access to their funds on the weekends.
When asked what they do when they want to access their funds on weekends, R48 stated they were notified to get enough funds for the weekend on Fridays.
In an observation on 7/23/2024 at 11:15 am, the business office hours were noted to be Monday through Friday 9:30 am to 4:30 pm.
These business office hours were posted on the door of Accounts Receivable.
In an interview on 7/16/2024 at 11:17 am, the Former Social Service Director (SSD) stated that residents didn't have access to withdraw their funds after 3:00 pm and on the weekends.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
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Nurse Care of Buckhead 2920 Pharr Court South NW Atlanta, GA 30305
through the third floor of the facility.
notable on that third floor. R48 stated that housekeeping does not perform deep cleaning of resident
Interview on 7/25/2024 at 2:08 pm, Housekeeping IIII stated they have worked all four floors at the facility.
Housekeeping IIII confirmed that there was a smell on the third floor, however, the housekeeping staff tried to manage it by washing the bases down.
An interview with Administrator AA on 8/1/2024 at 1:14 pm revealed when she first started at this facility, there were complaints about odors in the elevators and all the halls. At that time, they started doing deep cleaning on all the halls.
She was unaware of any current complaints on the third floor.
The third floor is scheduled for deep cleaning on Thursdays; however, no deep cleaning has been done since the surveyors were in the building.
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Nurse Care of Buckhead 2920 Pharr Court South NW Atlanta, GA 30305
During an interview on 7/22/2024, the Former Administrator WWW stated extensive issues with linens, laundry, and Registered Dietician nutritional services were suspended due to non-payment.
The Former Administrator WWW stated the facility acquired a third-party vendor in September 2023.
This vendor provided the facility staffing needs for the Housekeeping, Laundry, and Dietary departments.
Since that happened, a lot of issues with those specific departments.
The Former Administrator WWW also stated that the washing machine in the laundry was broken and took approximately three to four weeks to fix.
The Former Administrator also added that the dining room floors had initiated the floors to be fixed in August/September of 2023.
During an interview on 7/24/2024 at 10:47 am, the Resident Council President, R48, revealed that meals have been an issue for a very long time.
The portions are small the food is undercooked and served cold. R48 stated the residents have brought up the food issues for a long time and it doesn't seem to be getting resolved. R48 added that the food for about a week or two while the survey team was in the facility had improved but is curious to see what happens after the survey team leaves. R48 stated there is a lack of organization in the kitchen. As far as the laundry and linen issues, R48 stated the third shift do no get linens so when the residents have an accident at night they must wait till the morning for fresh linens. R48 stated, I don't know why they do that.
During an interview on 7/30/2024 at 11:13 am, Certified Medication Technician (CMT) LLLL stated they have issues with supplies regarding briefs and linens daily.
The staff must go to other floors to see if they have some extra supplies there.
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Nurse Care of Buckhead 2920 Pharr Court South NW Atlanta, GA 30305
Findings included: During a review of the facility's policy titled, 'Abuse, Neglect and Exploitation revised on 3/1/2024, it is documented that misappropriation of resident's property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of resident's belongings or money with the resident's consent.
A review of R32's Electronic Medical Record (EMR) revealed an original admission date of 5/13/2021 with multiple diagnoses of but not limited to chronic obstructive pulmonary disease, heart failure, anxiety hypertension, type II diabetes, and chronic pain. R32's Brief Interview for Mental Status (BIMS) was 15; indicating R32 was cognitively intact.
A review of the Facility Reportable Incident (FRI) dated 1/23/2024 revealed that R32 notified social services of unauthorized charges on their account. It is documented that R32 gave their FSA card to Former Activities Assistant (AA) OOOO to do some shopping for R32 at a local store. R32 states that Former AA OOOO did not return the FSA card.
Additionally, R32 noticed some cash app charges R32 did not authorize.
The investigation showed that Former AA OOOO linked their Cash app Kanary account to R32's card and subsequently a total of $830 was sent through the cash app. R32 called the FSA card and all transactions were reported to the fraud department.
During an interview on 7/10/2024 at 2:35 pm, the Administrator stated that the police came to interview them at the facility about the allegation regarding R32 in April 2024. To the Administrator's knowledge, the police did not have a final report yet and the incident happened in January 2024.
During an interview on 7/15/2024 at 10:43 am, the Former Social Service Director (SSD) revealed that the Former Activities Assistant (AA) OOOO connected their Cash app account to R32's bank account.
The Former SSD also revealed the Former AA OOOO never returned to the facility after it was brought to the facility's attention that Former AA OOOO misappropriated R32's funds.
Former AA OOOO told Former SSD over the phone R32 gave her permission.
When the Former SSD followed up with R32, s/he denied giving the Former AA OOOO permission for the amount taken from R32's account.
A record review of the Former AA OOOO employee file revealed that their employment was terminated on 1/23/2024.
During an interview on 7/16/2024 at 11:17 am, the Former SSD revealed that s/he conducted an in-service with employees and R32 after the investigation was completed and sustained.
The Former AA OOOO was also officially terminated.
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Nurse Care of Buckhead 2920 Pharr Court South NW Atlanta, GA 30305
During an interview on 7/17/2024 at 10:27 am, DON OOO revealed she was the DON for three weeks in January 2024 and that she was made aware that R11 was barricaded in his room when RR63 came to her visibly upset and made a formal complaint.
She stated that there were at least three wheelchairs in R11's room and she pulled out two of the three. DON OOO stated she did not know why staff had the wheelchairs in R11's room. DON OOO confirmed that she did not write the grievance and did not conduct a formal investigation.
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fail to pay their bills and when the facility fails to meet the Resident's needs.
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Nurse Care of Buckhead 2920 Pharr Court South NW Atlanta, GA 30305
suctioning, the oxygen saturation was at 95 percent, and they made sure his oxygen was on.
The
coarse or rhonchi, and after suctioning, they become clear. It didn't get to the point where they
An interview with Administrator AA on 8/1/2024 at 1:14 pm revealed the policy is when the supervisor is on the cart, then they are on the cart and not supervising. If the nurse calls out, the nursing supervisor should come in and work the floor. It is not acceptable to not have a nurse on each floor.
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residents who had experienced a bowel movement immediately or as soon as possible.
Administrator AA stated staff are expected to stop passing out trays and assist any resident who required assistance with incontinence care.
She was unaware R36 had been left soiled and stated she would have addressed the situation immediately had she been made aware.
Administrator AA stated she did not approve any delay in care at the facility.
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Nurse Care of Buckhead 2920 Pharr Court South NW Atlanta, GA 30305
the resident council president, R48 stated, that during meals residents were never offered sufficient
ice and water in between meals.
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Nurse Care of Buckhead 2920 Pharr Court South NW Atlanta, GA 30305
Findings included: A review of an updated facility policy titled, Enteral Feeding, revealed, .A resident who is fed by a gastrostomy tube shall receive the appropriate treatment and services to prevent aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities and to restore, if possible, normal eating skills .
A review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed that R53 was admitted to the facility on [DATE] with diagnoses that included dementia, urinary tract infection, and pressure ulcers.
A review of the Physician Orders located in the Orders tab of the EMR revealed, Enteral Feed .Jevity 1.5 at 66ml/hour for 20 hours, start at 6:00 am and stop at 10:00 PM Dated 5/21/2024.
A review of the quarterly Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 6/6/2024 revealed R53 had a feeding tube and was provided nutrition of greater than 501cc/day.
During an observation on 7/23/2024 at 8:15 am, R53 was observed lying in bed with her eyes closed.
The tube feeding pump was located next to the bed, and the tube feeding bag that was hanging was full, however, the pump was in the off position.
During an observation on 7/23/2024 at 10:00 am, the tube feeding pump was in the off position and the tube feeding bag was full.
During an observation on 7/23/24 at 12:15 pm, the tube feeding pump was on and running at 66ml/hr.
During an interview on 7/24/2024 at 11:34 am, the Director of Nursing (DON) was told about the observations with R53's tube feeding pump.
She stated, Staff must follow the physician's orders.
During an interview on 7/29/2024 at 9:48 am, the Administrator stated, My expectation is staff should follow physician orders.
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Nurse Care of Buckhead 2920 Pharr Court South NW Atlanta, GA 30305
pre-dialysis communication forms are to be filled out entirely and provided to the resident upon transfer to dialysis.
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Nurse Care of Buckhead 2920 Pharr Court South NW Atlanta, GA 30305
Findings included: A review of the facility policy titled, Staff Privileges, dated April 2024 revealed, .Each physician desiring to participate in staff privileges must abide by the following conditions .Provide medical information necessary to maintain continuous medical care and treatment .Provide the Center with medical information concerning the resident in accordance with admission policies .Prepare and maintain a complete medical record for each resident in accordance with current medical record policies and procedures .Provide regularly scheduled physician visits in accordance with physician services .
A review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed that R53 was admitted to the facility on [DATE] with a diagnosis of dementia.
A review of the Physician Visit Notes located in the Miscellaneous tab of the EMR revealed that the last physician visit was on 4/9/2024.
There was no physician visit note from 6/9/2024 to 6/19/2024, as required for the 60-day visit.
During an interview on 7/23/2024 at 8:00 am Medical Records EEEE was asked what her process was regarding ensuring timely physician visits.
Medical Records EEEE stated, When the physician comes in, we print them a list with the residents they see.
When they are done, they leave the list in my box, so I know the date they were seen.
Medical Records EEEE further stated that she does an audit on physician visits every 30-45 days.
Medical Records EEEE was asked if the physician's chart was in the facility's EMR.
Medical Records EEEE stated, No, only the Medical Director does, however, R53's physician will send us his notes after he visits.
Staff EEEE was asked why there was no physician visit documented or visit notes from June.
Staff EEEE stated, Well, I can call and have him send the notes.
Staff EEEE confirmed there was no documentation in the medical record of a physician visit after 4/9/2024.
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Nurse Care of Buckhead 2920 Pharr Court South NW Atlanta, GA 30305
During an interview on 7/17/2024 at 10:29 am, the Former Director of Nursing (DON) OOO revealed that s/he had made multiple attempts to reach out to the management company about the lack of staff and RN coverage for multiple shifts.
The Former DON OOO stated there were multiple days s/he had to work multiple shifts to ensure weekend RN coverage.
The Former DON OOO also added that there were multiple occasions no RN for the day shift.
During an interview on 7/17/2024 at 11:55 am, the Former SSD revealed that There were a couple of times when staff quit because they weren't paid.
The third-party vendor provided the staff with both dietary and housekeeping/laundry. In the last three months, they have lost two dietitians and three dietary managers, two of whom were terminated and one who quit.
The direct care staff for both departments worked and didn't get paid.
There are deficiencies in management and scheduling that are not the fault of the line staff.
A review of a facility document provided by the Administrator titled NCOB cleanup Crew Sing up sheet revealed that as recently as 7/8/2024, the staff is still signing to work additional hours in laundry or housekeeping.
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Nurse Care of Buckhead 2920 Pharr Court South NW Atlanta, GA 30305
Findings included: A review of the December 2023 and January 2024 Facility Two-Week Staffing Grid provided by the Staffing Coordinator and reviewed by the Administrator, revealed that there was no RN coverage for 1/6/2024, 1/7/2024, and 1/20/2024.
During an interview on 7/1/2024 at 1:43 pm, the Administrator stated the facility was using a lot of agency employees so a major goal when she began in March 2024 was to get rid of agency staff and hire full-time employees.
During an interview on 7/17/2024 at 10:29 am, the former Director of Nursing (DON) OOO revealed that s/he had made multiple attempts to reach out to the management company about the lack of staff and RN coverage on multiple shifts. DON OOO stated there were several days s/he had to work multiple shifts to ensure weekend RN coverage and confirmed that there were multiple occasions that no RN was available for the day shift.
During an interview on 7/18/2024 at 1:00 pm the Administrator confirmed that she was aware of the staffing issues at the facility but that this was the first time seeing it on paper.
During an interview on 7/31/2024 at 4:26 pm, the current Director of Nursing (DON) stated there should always be nursing coverage on every floor even if there is a Certified Mediation Technician (CMAT).
The DON confirmed that there was a current lack of nurses to cover each floor.
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Nurse Care of Buckhead 2920 Pharr Court South NW Atlanta, GA 30305
During an interview with the DON on 7/16/2024 at 9:49 am, X's on the Medication Administration
administered, blanks all we can assume is the medication was not administered.
A review of R32's eMAR dated January 2024 revealed a physician's order for methadone HCl Oral Tablet of 10 milligrams (mg) given by mouth three times a day for pain. On 1/2/2024, 1/3/2024, 1/5/2024, 1/10/2024, 1/12/2024, 1/15/2024, 1/16/2024, 1/17/2024, 1/18/2024, 1/19/2024, 1/21/2024, 1/25/2024, and 1/30/2024 the medication was not administered either once, twice or three times as ordered.
- A review of R67's Electronic Medical Record (EMR) revealed an original admission date of
8/8/2017 with multiple diagnoses of but not limited Idiopathic chronic gout, generalized edema, alcoholic cirrhosis of the liver, diabetes mellitus with hyperglycemia, hypo-osmolality, and hyponatremia. R67 Brief Interview for Mental Status (BIMS) was 15; indicating R67 was cognitively intact.
A review of R67's Grievance/complaint form dated 1/4/2024 documented that R67 reported not receiving his oxycontin and gabapentin for 6 days.
The complaint was investigated by the Former Director of Nursing (DON) OOO and it was documented that the medication had not been ordered promptly.
A review of R67's eMAR dated December 2023 revealed a physician's order for Gabapentin Oral Capsule 100 milligram (mg) given by mouth one time a day for an anticonvulsant.
The order date was 12/8/2023 and discontinued on 1/2/2024.
Medication was not given on 12/29/2023.
During an interview on 7/30/2024 at 11:13 am, Certified Medication Technician (CMT) LLLL revealed when the medication gets to the blue strip (approximately eight medications) on the card write it on the paper to give the Charge nurse to reorder or go to the DON. CMT LLLL stated she had tried to reorder medications but only nurses can do that. CMT LLLL stated she had been on the fourth floor for about a week so far and they always have issues with medication being out. CMT LLLL stated if the Administrator note says on order or not available not available is either 9 or 13 on eMAR.
During an interview on 7/30/2024 at 1:50 pm, the Unit Manager, Licensed Practical Nurse (UMLPN) RR there was a dark blue line on the blister packets and that's when nurses should reorder the medication. UMLPN stated some staff waits until it gets down to two to three pills.
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Nurse Care of Buckhead 2920 Pharr Court South NW Atlanta, GA 30305
During an interview on 7/23/2024 at 1:37 pm Certified Nursing Assistant (CNA) UUUU stated that about two weeks ago the food was late, due to staffing.
When we run into staffing problems in the kitchen, none of us are too good to go into the kitchen. CNA UUUU stated that the Sunday (6/23/2024) before surveyors entered the building, she had to help in the kitchen.
During an interview on 7/29/2024 at 1:20 pm Certified Medication Administration (CMA) VVVV stated that when the facility switched over to the new company, we didn't get paid on our pay date and it was very late in the day, and some staff members walked out. CMA VVVV stated that this occurred around January 2024 but stated that she wasn't in the facility at that time due to being on vacation at that time, but she heard about it when she came back. CMA VVVV further stated that the prior administrator and Director of Nursing (DON) were offering bonuses, and the new company did not give out the bonuses.
During the Quality Assurance Performance (QAPI) interview on 7/31/2024 at 10:06 am with Administrator AA revealed that issues that have been identified for the months of May, June, and July 2024 included laundry, linens, housekeeping, supplies and dietary issues.
During an interview on 7/31/2024 at 6:37 pm Central Supply (CS) XXXX stated that he orders supplies every week, and it is mostly briefs and wipes. CS XXXX stated that the staff were using too many briefs and wipes. CS XXXX stated that he would put out the briefs and wipes out on a Friday and when he would return on a Monday, the supplies would be gone.
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Nurse Care of Buckhead 2920 Pharr Court South NW Atlanta, GA 30305
Findings included: A review of the updated facility policy titled, Quality Assurance Performance Improvement Plan documented this facility's leadership intends to conduct an ongoing quality assurance/performance improvement program designed to systematically monitor and evaluate the quality and appropriateness of resident care, pursue opportunities to improve resident care, resolve identified programs and identify opportunities for improvement.
A review of Resident Council minutes dated 9/27/2023, 10/24/2023, 11/29/2023, 12/27/2023, 2/28/2024, 3/27/2024, 4/24/2024, and 5/29/2024 revealed continued concerns related to laundry, missing clothing items, linen, and diaper shortage, and shortage of personnel and supplies.
A review of the QA Committee Minutes for May 2024 revealed extra linen needed to be ordered.
Interview on 7/16/2024 at 11:17 am, the previous Social Services Director (SSD) NNN provided an account of several months where the facility experienced a linen shortage.
She stated it had been a problem since November 2023 and remained a constant problem until s/he left in June 2024.
Several grievances were provided to the housekeeping manager; however, they were never returned to the previous SSD NNN.
Grievances regarding personal clothing and linen were provided to the housekeeping manager during the morning report where the Administrator was present. SSD NNN provided details from her notes regarding the continued concerns related to linen shortage, missing personal clothing, and shortage of briefs from 2/3/2024 through 3/3/2024.
During an interview on 7/31/2024 at 10:06 am, Administrator AA stated that the issues identified in the May 2024, June 2024, and July 2024 QAPI meetings included laundry, linen, supplies, maintenance issues, and dietary issues.
She stated that based on what is in the QAPI meeting agenda, the issues identified in February 2024 included maintenance, and not responding timely to grievances. In January 2024, the issues identified included staffing issues due to them utilizing agency and linen issues.
During the interview on 7/31/2024 at 10: 25 am, Administrator AA revealed that supplies and linen shortage is still an issue and will be an issue till they figure out what is causing the inventory to be low.
Just recently someone threw 3 bags of clean linen in the trash.
Cross Refer F-F585 and F-F584.
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Nurse Care of Buckhead 2920 Pharr Court South NW Atlanta, GA 30305
During an interview on 7/29/2024 at 9:24 am the IP confirmed that she and the Unit managers on each floor are responsible for educating on EBP.
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Nurse Care of Buckhead 2920 Pharr Court South NW Atlanta, GA 30305
During an interview on 7/29/2024 at 9:24 am, the Administrator and Infection Preventionist were asked if the facility had readdressed the pneumonia vaccines with R55 since 2018.
The Administrator stated, No, we haven't.
Since we started in May of this year, we are still getting immunizations up and running and getting the documentation together.
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Nurse Care of Buckhead 2920 Pharr Court South NW Atlanta, GA 30305
Findings included: A review of facility policy titled, Testing of Resident and Staff for COVID-19, revised in May 2023 revealed, .It is the policy of [facility] to maintain and attain best practices in the prevention and spread of infection.
The facility follows all recommendations from CMS (Center for Medicare/Medicaid Services), CDC (Center for Disease Control), and state and local regulatory agencies .
A review of the electronic medical record (EMR) revealed that R28 was originally admitted to the facility on [DATE].
A review of the Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 5/26/2024 revealed R28 had a Brief Interview of Mental Status (BIMS) score of six out of 15 which indicated she was severely impaired in cognition for daily decision-making.
A review of the Immunization tab in the EMR revealed no documentation of the initial COVID-19 vaccines including any boosters for R28.
A review of the Miscellaneous tab in the EMR revealed no documentation that the R28 and/or legal representative were informed of the risks and/or benefits of the vaccines.
There was no documentation in the EMR of consent or refusal of vaccines.
A review of the Georgia Registry of Immunization Transactions and Services (GRITS), provided by the Administrator, revealed no immunization history for R28.
During an interview on 7/29/2024 at 9:24 am the Administrator confirmed that R28 had no documented COVID-19 vaccinations or consent/refusals in her medical record.
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Nurse Care of Buckhead 2920 Pharr Court South NW Atlanta, GA 30305
During an interview on 7/1/2024 at 3:50 pm, Licensed Practical Nurse (LPN) RR revealed that the ice
maintenance department was made aware.
They stated that the maintenance department takes several months for equipment to be repaired.
During an interview on 7/1/2024 at 4:07 pm, CNA TT revealed the ice machine on the Fourth Floor was inoperable and explained staff usually have to rely on the ice machine located on the First Floor, but now the First Floor icemaker was down and inoperable as well.
During an interview on 7/1/2024 at 4:01 pm, Maintenance Worker SS stated that they were aware that the ice machines on the Fifth Floor and Second Floors were inoperable.
- During observations on 7/11/2024 at 3:05 pm, the walk-in freezer in the kitchen revealed an
internal temperature of 25 degrees Fahrenheit (F).
During observations on 7/13/2024, the walk-in freezer in the kitchen revealed an internal temperature of 25 degrees F throughout the day.
During observations on 7/15/2024 at 8:49 am, the walk-in freezer in the kitchen revealed an internal temperature of 25 degrees F.
During observations on 7/16/2024 at 10:45 am, the walk-in freezer in the kitchen revealed an internal temperature of 23 degrees F.
During an interview on 7/31/2024 at 10:52 am, Dietary Manager GGGGG, confirmed that the walk-in freezer had not been able to keep the required holding temperatures.
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Nurse Care of Buckhead 2920 Pharr Court South NW Atlanta, GA 30305
able to complete the inspection of the handrails.
The Maintenance Director stated, We know there are
115129 08/01/2024
Nurse Care of Buckhead 2920 Pharr Court South NW Atlanta, GA 30305
During an interview on 7/1/2024 at 3:20 pm, Dietary Aide QQ stated there was evidence of mice in the kitchen. He stated that he observed mouse droppings in the pantry and on the kitchen floors.
During an interview on 7/1/2024 at 3:36 pm the Assistant Maintenance Director XX revealed the small dark droppings in the kitchen pantry showed mouse infestation was a concern.
During an observation on 7/2/2024 at 8:28 am the door to the kitchen leading outside towards the parking lot was propped open.
There was a rock used to prop it open.
During an observation on 7/02/2024 at 8:49 am the outside kitchen door was opened with a rock inside to keep it ajar.
During an interview on 7/2/2024 at 9:28 am Maintenance Director VV stated the facility had a pest control program, but he was not confident its ability to eliminate the flies.
During an observation on 7/2/2024 at 3:26 pm a dead fly was observed on the table in the conference room.
During an observation on 7/3/2024 at 12:40 pm a dead fly was observed on the table in the conference room.
During an observation on 7/5/2024 at 8:51 am the kitchen door that leads out to the parking lot was left ajar.
On 7/15/2024 at 9:50 am, a live fly was observed in the conference room.
Findings included:
A review of facility in-service training titled, Enhanced Barrier Precautions, dated March 2024, revealed, .
Enhanced Barrier Precautions (EBP)- include the use of gloves and gown when caring for residents with chronic wounds or indwelling medical devices during high-contact resident activities .Residents requiring EBP (gowns and gloves for care) include chronic wounds, wounds with dressings .
Gloves and gowns are to be worn when providing the following high-contact resident activities.
Dressing, bathing/showering, transferring, changing linen, providing hygiene, changing briefs, or assisting with toileting.
Any care that requires close contact .
A review of the Admission Record located in the Profile tab of the electronic medical record (EMR) revealed R53 was admitted to the facility on [DATE] with diagnoses that included a stage four pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle), a gastrostomy tube (a feeding tube which provides nutrition to people who cannot eat by mouth) and dementia.
A review of the quarterly Minimum Data Set (MDS) assessment located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 6/6/2024 revealed R53 was severely impaired in cognition, was dependent on staff for all activities of daily living (ADL) care, had one stage four pressure ulcer, and received nutrition via a gastrostomy tube.
During an observation on 7/23/2024 at 10:00 am, Certified Nursing Assistant (CNA) YYY and CNA GG were observed setting up supplies to give R53 a bed bath.
Neither CNA was observed to be wearing a gown. CNA YYY removed her gloves and left the room, upon returning to the bedside, she donned new gloves without using hand hygiene. CNA YYY removed R53's brief and with the same gloves, cleaned the front peri area. R53 was turned onto her right side by CNA GG and the soiled brief, with feces, was removed. CNA YYY did not remove her soiled gloves after she placed the soiled brief into the plastic bag.
With the same gloves, and without performing hand hygiene, CNA YYY removed the draw sheet, obtained a clean washcloth, and cleaned her buttocks. CNA YYY and CNA GG were asked if they had been in-serviced on EBP and what the requirements were when providing high-contact care, such as a bed bath. CNA YYY shrugged and stated, I don't know.
115129
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 115129 B.
Wing 08/01/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Nurse Care of Buckhead 2920 Pharr Court South NW Atlanta, GA 30305
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.