Sadie G. Mays Health & Rehabilitation Center
SADIE G. MAYS HEALTH & REHABILITATION CENTER in ATLANTA, GA — inspection on June 26, 2024.
Found 16 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
During a post-survey interview on 7/1/2024 at 8:08 am, Licensed Practical Nurse (LPN) NN stated that R8's bath days were Tuesday, Thursday, and Saturday on the 3:00 pm-11:00 pm shift.
She stated the CNA Bath Skin Sheets should be completed with each shower/bath and the sheets should be provided to the charge nurse who signs off verifying completion.
115542 06/26/2024
Sadie G.
Mays Health & Rehabilitation Center 1821 Anderson Avenue NW Atlanta, GA 30314
Services Director stated he was not responsible for ordering the linen. He stated he only alerted the
An interview and observation on 5/22/2024 at 2:50 pm of Laundry Aide XX filling the linen closets on
sheets, fitted sheets, and pillowcases.
The Laundry Aide stated the department washes what was taken in and then divides what they put out by the three laundry closets.
The Laundry Aide was asked if she thought fifteen washcloths, towels, flat sheets, fitted sheets, and pillowcases were enough linen for sixty-two residents on the A/B unit.
The Laundry Aide responded, No.
115542 06/26/2024
Sadie G.
Mays Health & Rehabilitation Center 1821 Anderson Avenue NW Atlanta, GA 30314
Background and criminal checks are initiated within two days of an offer of employment and completed before employment.
A review of the Director of Human Resource job description revealed: Conduct pre-employment screening for the Centers for Medicare and Medicaid Services (CMS) disqualification, criminal background check, abuse registry check, and licensure (if applicable) in accordance with state/federal law and facility policies.
A review of RN GG employee file revealed a hire date of 9/21/2023 as a full-time RN Supervisor.
Further review of the employee's file revealed that there was no documentation that a criminal background check was conducted.
A review of RN HH employee file revealed a hire date of 11/3/2023 as a full-time RN Supervisor.
Further review of the employee's file revealed that there was no documentation that a criminal background check was conducted.
During an interview on 5/17/2024 at 10:47 am, the Human Resources Director (HRD) stated that criminal background checks and fingerprint checks are completed before the employee starts work.
The HRD confirmed that RN GG and RN HH did not have a criminal background check conducted.
The HRD stated moving forward she will ensure that all staff have the required criminal background check, or the fingerprint check completed prior to employment.
115542 06/26/2024
Sadie G.
Mays Health & Rehabilitation Center 1821 Anderson Avenue NW Atlanta, GA 30314
Findings included: A review of the facility policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating dated September 2022 revealed that all reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management.
Findings of all investigations are documented and reported.
Reporting Allegations to the Administrator and Authorities. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and other officials according to state law.
Immediately is defined as within two hours of an allegation involving abuse or results in serious bodily injury; or within 24 hours of an allegation that does not involve abuse or result in serious bodily injury.
During an interview on 6/7/2024 at 12:20 pm, the Director of Health Services (DHS) stated on 2/2/2024, the day shift nurse reported that two residents (R17 and R18) narcotic count sheet along with the narcotics were missing.
She stated that R17 was receiving Oxycodone 10 milligram (mg) daily, and R18 was receiving Oxycodone/APAP 5/325 mg as needed.
The DHS stated the facility immediately started investigating.
She stated the facility camera was viewed and Licensed Practical Nurse (LPN) RR was observed removing the medications and narcotic count sheets from the medication cart.
The DHS stated the police were notified and came to the facility.
The nurse was terminated and reported to the state board of nursing.
The DHS stated the pharmacy was notified and the medication for R17 and R18 was replaced.
The DHS stated she was not aware that the misappropriation of a resident's medicine had to be reported to the SSA.
During an interview on 6/7/2024 at 12:30 pm, the Executive Director stated the misappropriation of R17 and R18 medication would be reported immediately to the SSA.
115542 06/26/2024
Sadie G.
Mays Health & Rehabilitation Center 1821 Anderson Avenue NW Atlanta, GA 30314
with all ADLs. ADL Functional/Rehabilitation Potential triggered as an area of concern on the CAAS.
plan for ADLs, oxygen, or the BiPAP/CPAP machine. MDS Coordinator AAA stated the resident should have a care plan for ADLs, oxygen, and the BiPAP/CPAP machine.
In an interview on 6/7/2024 at 11:59 am, MDS Coordinator BBB stated all residents should have a care plan for ADLs and confirmed R9 did not have an ADL care plan.
In an interview on 6/11/2024 at 1:15 pm, MDS Coordinator ZZ confirmed the MDS Department had not developed a comprehensive, person-centered care plan for ADLs for R3, R7, R8, R9, and R16, a care plan for fracture for R3, or a care plan for falls for R3 and R7.
Cross-Reference F-F677
115542 06/26/2024
Sadie G.
Mays Health & Rehabilitation Center 1821 Anderson Avenue NW Atlanta, GA 30314
Findings included: A review of the facility policy titled Activities of Daily Living (ADL), Supporting, with a revised date of March 2018 revealed that residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs).
Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene.
Appropriate care and services will be provided for residents who are unable to carry out ADL care independently, with the consent of the resident, and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming, and oral care).
A review of the admission Record for R9 revealed he was readmitted to the facility on [DATE] with diagnoses of, but not limited to, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, contracture of muscle right upper arm, contracture of right ankle, and vascular dementia.
A review of R9's most recent comprehensive Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of seven, indicating severe cognitive impairment. It was further documented that R9 required partial/moderate assistance for upper body dressing and substantial/maximal assistance for lower body dressing.
Functional Abilities (Self-Care and Mobility) triggered as an area of concern on the Care Area Assessment Summary (CAAS).
An observation on 5/3/2024 at 2:19 pm revealed R9 propelling himself down Unit A.
The resident stopped the surveyor and pointed to his clothing.
His speech was not understood.
Observation revealed the resident had remnants of food on his pants and shirt.
The resident nodded his head up and down when asked if he needed help with changing his clothes.
Charge Nurse KK and Charge Nurse MM were notified that the resident needed assistance with changing his clothes.
An observation on 5/3/2024 at 3:25 pm revealed R9 sitting in a wheelchair in his room.
Further observation revealed that R9 stopped Certified Nursing Assistant (CNA) CCC and asked for assistance with changing his clothes and getting in the bed. He was still observed with remnants of food on his pants and shirt.
In an interview on 5/3/2024 at 3:30 pm, Unit Manager (UM) JJ confirmed that R9 had food on his shirt and pants and that the charge nurses should have assisted R9 with changing his clothes.
She stated the resident should not have had to wait over an hour for assistance.
Cross-Reference F-F656
115542 06/26/2024
Sadie G.
Mays Health & Rehabilitation Center 1821 Anderson Avenue NW Atlanta, GA 30314
During an interview on 5/9/2024 at 11:54 am, UM JJ stated she was not aware of the gnat problem until the surveyor brought it to her attention on 5/2/2024 and 5/3/2024 and that she immediately reported the gnats to the Maintenance Department.
During an interview on 5/15/2024, the DHS stated that she expects the nurses to assess the residents and notify the physician as needed.
She stated that R6 was more relaxed since his pain medication had been adjusted.
115542 06/26/2024
Sadie G.
Mays Health & Rehabilitation Center 1821 Anderson Avenue NW Atlanta, GA 30314
Findings included: A review of the State of Georgia Nurse Aide Registry Nurse Aide Certification Renewal revealed that to remain on the Registry and to be eligible to work in a licensed Medicaid & Medicare facility, you must meet the requirements for Re-Certification.
Failure to return the Application for Renewal as a Certified Nurse Aide will result in your name being removed from the Georgia Nurse Aide Registry and will not be eligible to work as a nurse aide by a licensed Medicaid facility.
- A review of CNA TT's employee file revealed the original certification date of [DATE].
The employee certification expired on [DATE].
The employee worked twenty-two weeks before the facility identified that the employee's certification had lapsed.
The employee certification was not renewed until [DATE].
During an interview on [DATE] at 10:27 am, CNA TT stated that the facility has a person who usually reminds the staff when certification needs to be renewed.
The CNA stated she was not sure what happened last year and why she did not receive a reminder.
She stated she worked for several months without her certification being renewed and as soon as the facility realized the certification needed to be renewed, it was taken care of.
- A review of CNA UU's employee file revealed an original certification date of [DATE].
The employee certification expired on [DATE].
The employee worked four weeks before the facility identified that the employee's certification had lapsed.
The employee certification was not renewed until [DATE].
During an interview on [DATE] at 12:30 pm, CNU UU confirmed that she did work for about a month without her certification being renewed.
She stated as soon as it was discovered the facility assisted her with getting the certification renewed.
During an interview on [DATE] at 10:47 am, the Human Resources Director (HRD) confirmed that CNA TT worked for six months without her certification being renewed.
She stated CNA UU worked for approximately one month without her certification being renewed.
The facility identified that both employees' certifications had lapsed on [DATE].
She stated when the issue was identified, both CNAs were pulled from resident care until their certification was updated.
The HRD stated previous Education Coordinator was responsible for ensuring the license and certifications were updated and was not performing their job duties.
115542 06/26/2024
Sadie G.
Mays Health & Rehabilitation Center 1821 Anderson Avenue NW Atlanta, GA 30314
Nurse Consultant stated she has not completed a medication cart audit on R15.
She stated that the
audit on the residents that are currently in the facility.
Cross-refer to F-Tag 684 and 757
115542 06/26/2024
Sadie G.
Mays Health & Rehabilitation Center 1821 Anderson Avenue NW Atlanta, GA 30314
115542 06/26/2024
Sadie G.
Mays Health & Rehabilitation Center 1821 Anderson Avenue NW Atlanta, GA 30314
Findings included: A review of the facility policy titled Background Screening Investigations dated April 2021, revealed that any licensed professional applying for a position that may involve direct contact with residents, his/her respective licensing board is contacted to determine if any sanctions have been assessed against the applicant's license.
A review of the facility policy titled Hiring Process dated 1/21/2024 revealed that this policy provides guidance for the hiring of team members.
The Human Resources Director is responsible for overseeing all aspects of the hiring process, which includes: Human Resources will obtain copy of two forms of identification and will verify license or certification prior to an offer being made.
A review of the employee files revealed RN HH was hired on 11/3/2023.
However, a review of her personnel file revealed the Professional Licensing status of the RN license had lapsed.
The lapsed Georgia license was not identified prior to hire by Human Resources staff.
A review of RN HH's Team Member Information revealed she was hired as an RN Supervisor.
A review of RN HH's Time-Card revealed she worked in the facility on 11/2/2023 for 7.67 hours.
In an interview on 5/17/2024 at 10:47 am, the Executive Director, Assistant Executive Director, and Human Resources Director (HRD) revealed the facility was unaware that RN HH's RN license had lapsed at the time of the interview and hire date.
The HRD stated the employee only worked one day and did not return.
The HRD stated RN HH quit without providing the facility with a notice.
The HRD further stated it was her responsibility to conduct the final check of the potential employee's application.
She stated she was responsible for checking the applications for completeness, which included initiating the Team Member Information, completing the Employment Eligibility Verification and the I-9 information, verifying professional license and certifications, and ensuring that the criminal background checks and fingerprint records check were completed before the employee began work.
The Executive Director stated there were very few controls in place and that the staff that were employed was circumventing the system.
She stated that is why the current HRD was hired to put policies and procedures in place to ensure the facility was following State and Federal requirements.
115542 06/26/2024
Sadie G.
Mays Health & Rehabilitation Center 1821 Anderson Avenue NW Atlanta, GA 30314
Findings included: A review of the policy titled Cleaning and Disinfection of Resident-Care Items and Equipment with a revised date of September 2022, revealed that resident-care equipment, including reusable items and durable medical equipment, will be cleaned and disinfected according to current Centers for Disease Control and Prevention (CDC) recommendations for disinfection and the OSHA Bloodborne Pathogens Standard. It is further noted that reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, and durable medical equipment).
A review of the policy titled Administering Medications with a revised date of April 2019, revealed that medication is administered in a safe and timely manner, and as prescribed. It is further noted that staff is required to follow established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) during the administration of medications.
During a medication administration observation on 6/20/2024 at 9:52 am, Registered Nurse (RN) SS obtained R19's blood pressure with a wrist blood pressure monitor. RN SS then used the same wrist blood pressure monitor and obtained R6 blood pressure.
The wrist blood pressure machine was not cleaned and disinfected after use between residents. As the observation continued, RN SS assisted a resident out of the way by touching the wheelchair.
The RN did not perform hand hygiene after this encounter and proceeded to pick up R6's medication and enter the room.
While in the room, an item fell off the resident's overbed table onto the floor. RN SS picked the item up off the floor, took R6's blood pressure, and administered the resident's medication.
The RN did not perform hand hygiene at all during this observation.
During an interview on 6/20/2024 at 10:00 am, RN SS stated the wrist blood pressure monitor should have been clean after obtaining R19's blood pressure and confirmed that she did not use appropriate hand hygiene during the medication observation.
During an interview on 6/20/2024 at 10:05 am, the Director of Health Services (DHS) stated that the staff should always clean and disinfect resident equipment after use between residents.
The DHS stated hand hygiene should be conducted to prevent the spread of germs.
115542 06/26/2024
Sadie G.
Mays Health & Rehabilitation Center 1821 Anderson Avenue NW Atlanta, GA 30314
During an interview on 6/5/2024 at 11:08 am, the Director of Health Services (DHS) stated education should be provided before a resident receives any vaccine.
She further stated that after the education is completed, consent should be obtained before administering the vaccine.
The DHS confirmed that R1 and R10 did not have a signed consent form for the COVID-19 vaccines that were administered.
115542 06/26/2024
Sadie G.
Mays Health & Rehabilitation Center 1821 Anderson Avenue NW Atlanta, GA 30314
During an interview on 5/8/2024 at 2:55 pm, Licensed Practical Nurse (LPN) LL stated that she has never heard of a pest control logbook and that she reports all maintenance concerns through the electronic maintenance system.
During an interview on 5/9/2024 at 11:50 am, LPN OO stated that the facility had been having problems with gnats for the last two years, but she did not realize it was as bad as it was in R6's room.
The LPN also confirmed the live black gnats in the bathroom shared by rooms B14 and B16.
Findings included:
A review of the facility policy titled Administering Medications dated April 2019 that medications are administered in a safe and timely manner, and as prescribed; only persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so; the Director of Nursing Services supervises and directs all personnel who administer medications and/or have related functions; medications are administered in accordance with prescriber orders, including any required time frame; if a dosage is believed to be inappropriate or excessive for a resident, or medication has been identified as having potentially adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's attending physician or the facility's medical director to discuss the concerns; and the individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication.
A review of the facility policy titled Pain Assessment and Pain Management dated October 2022 revealed that the purposes of this procedure are to help the staff identify pain in the resident and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain.
Pain management is a multidisciplinary care process that includes the following: a.
Assessing the potential for pain; b.
Recognizing the presence of pain; d.
Addressing the underlying causes of the pain.
Review the resident's clinical record to identify conditions or situations that may predispose the resident to pain, including: a. musculoskeletal conditions: (1) degenerative joint disease; (2) rheumatoid arthritis.
Contact the prescriber immediately if the resident's pain or medication side effects are not adequately controlled.
A review of the facility policy titled Pressure Ulcer/Skin Breakdown, with a revision date of April 2018, revealed that the physician will assist the staff in identifying the type (for example, arterial or stasis ulcer) and characteristics (presence of necrotic tissue, status of wound bed, etc.) of an ulcer.
The physician will help identify and define any complications.
A review of the facility policy titled Pest Control dated May 2008 revealed that the facility shall maintain an effective pest control program.
Policy Interpretation and Implementation.
This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents.
115542
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 115542 B.
Wing 06/26/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Sadie G.
Mays Health & Rehabilitation Center 1821 Anderson Avenue NW Atlanta, GA 30314
Findings included:
A review of the facility policy titled Activities of Daily Living (ADL), Supporting, with a revised date of March 2018 revealed that residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs).
Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene.
Appropriate care and services will be provided for residents who are unable to carry out ADL care independently, with the consent of the resident, and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming, and oral care).
A review of the Admission Record for R9 revealed he was readmitted to the facility on [DATE] with diagnoses of, but not limited to, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, contracture of muscle right upper arm, contracture of right ankle, and vascular dementia.
A review of R9's most recent comprehensive Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of seven, indicating severe cognitive impairment. It was further documented that R9 required partial/moderate assistance for upper body dressing and substantial/maximal assistance for lower body dressing.
Functional Abilities (Self-Care and Mobility) triggered as an area of concern on the Care Area Assessment Summary (CAAS).
An observation on 5/3/2024 at 2:19 pm revealed R9 propelling himself down Unit A.
The resident stopped the surveyor and pointed to his clothing.
His speech was not understood.
Observation revealed the resident had remnants of food on his pants and shirt.
The resident nodded his head up and down when asked if he needed help with changing his clothes.
Charge Nurse KK and Charge Nurse MM were notified that the resident needed assistance with changing his clothes.
An observation on 5/3/2024 at 3:25 pm revealed R9 sitting in a wheelchair in his room.
Further observation revealed that R9 stopped Certified Nursing Assistant (CNA) CCC and asked for assistance with changing his clothes and getting in the bed. He was still observed with remnants of food on his pants and shirt.
In an interview on 5/3/2024 at 3:30 pm, Unit Manager (UM) JJ confirmed that R9 had food on his shirt and pants and that the charge nurses should have assisted R9 with changing his clothes.
She stated the resident should not have had to wait over an hour for assistance.
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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.