DECATUR, GA- GLENWOOD HEALTH CENTER BY HARBORVIEW

The Department of Health & Human Services conducted an inspection of the facility. The following highlighted decencies listed below were found in a public survey, that can be found by clicking on “Full State Report” at the bottom.

Make sure that a working call system is available in each resident’s bathroom and bathing area.

Based on observations, staff interviews, and review of the facility’s policy titled, Answering the Call Light the facility failed to ensure resident call lights were within reach to allow the residents to call for staff assistance in seven of 22 rooms (101, 106, 105, 103, 104, 111, 107) on the memory care unit (Magnolia). This failure placed the residents at risk of accidents, injuries, and/or unmet needs.

Develop and implement a complete care plan that meets all the resident’s needs, with timetables and actions that can be measured.

Based on observations, record review, resident and staff interviews, and review of the policy titled
Comprehensive Care Plans, the facility failed to develop and/or implement the person-centered care plan for six residents (R) (R71, R266, R19, R25, R111, R118) reviewed for smoking. In addition, the facility failed to develop a care plan for one resident (R172) related to Post Traumatic Stress Disorder (PTSD). The facility’s failures created potential risks for the safety and well-being of the residents. The sample size was 102 residents.

On 10/9/2024, a determination was made that a situation in which the facility’s noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents.

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Based on observations, record review, resident and staff interviews, and review of the facility’s policy titled Smoking Policy – Residents, and Resident Smoking and Banned Item List and Safe Water Temperatures and Oxygen Storage, the facility failed to ensure that the environment and facility were free from potential accident hazards for residents and staff. Specifically: 1. Immediate Jeopardy was identified for facility’s failure to enforce the smoking policy and Banned Item List for eight of 44 sampled residents reviewed for smoking (R) (R71, R266, R145, R365, R25, R111, R118, R19); 2. Failed to ensure three residents (R83, R60, and R91) were not allowed to keep hazardous materials in their rooms; 3. Failed to maintain safe and comfortable water temperatures below 120 degrees Fahrenheit in 18 rooms on five of five units (E111, E112, E108, E107, E102, E101, W134, W129, W124, G217, G224, G229, D215, D206, D203, M109, M101, M118); and 4. Failed to properly secure a portable oxygen cylinder in one resident room (W132). The facility’s failures created potential risks for the safety and well-being of the residents, staff, and any visitors in the building.

On 10/9/2024, a determination was made that a situation in which the facility’s noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents.

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident’s well being.

Based on observations, staff interviews, and review of the facility’s policy titled Sufficient and Competent Nursing, the facility failed to ensure nursing staff provided supervision and oversight for residents, as evidenced by nursing staff sleeping and watching videos during a third shift observation. The census was 210.

Observation on 10/3/2024 at 3:50 am, revealed on the Magnolia Hall (dementia care unit) staff members were behind the nurse’s station on their personal phone, sleeping, and watching movies on a laptop. Specifically, Certified Nurse Assistant (CNA) GGGG was sleeping at the nurse station with her head down; CNA HHH and CNA HHHH were both in the resident dining room with their back turned away from the resident’s rooms watching a movie on a laptop computer; Licensed Practical Nurse (LPN) IIII was nodding at the nurse station and Infection Preventionist (IP) was scrolling on her phone at the nurse’s station.

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Based on observations, staff interviews, and review of the  facility policies titled Medication Administration, and Medication Storage, the facility failed to maintain the correct narcotic count in one of five medication carts (West Wing); failed to ensure one of five medication carts (Dogwood Hall) was locked when not in use, and that medications were not left on top of cart, accessible to residents and non-licensed staff; and failed to ensure expired medications were removed from one of five med carts (Dogwood Hall). The facility census was 210.

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Based on observations, record review, interviews, review of the Administrator Job Description and Director of Nursing Job Description, and review of the policy titled Smoking Policy – Residents, the facility administration failed to provide oversight and monitoring of the facility operations related to enforcement of its smoking policy and failed to ensure that licensed nursing staff were knowledgeable and competent to assess residents and implement care plans for smoking. The facility’s failures created potential risks for the safety and well-being of the residents. The census was 210 residents.