Callaway Gardens Alzheimers Special Care Center.

This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website.

This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website.

Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . . Statement of Deficiencies License #: 2511 Compliance Determination # 31588 Plan of Correction Callaway Gardens Alzheimers Special Care Center Completion Date Based on observation, interview, and record review the facility failed to provide a modified diet of nothing by mouth (NPO) as per the Resident Care In-Service/Change in Plan of Care Record (temporary service plan) prior to a dental appointment for 1 of 1 resident (Resident 1). This failure contributed to Resident 1 aspirating (when food, liquid or saliva entering the lungs) during the dental procedure. Findings included… Review of Assisted Living Facility (ALF) policy titled, Communication of Resident Information dated, 11/01/2014, showed that the caregivers are responsible to read and be aware of each change on the Resident Service Plans [known as the Negotiated Service Agreement, NSA]. The notebooks will be placed in a central location that is easily accessible to all staff members. Each time there is a change in a Resident care approach or intervention, the change will be noted on a temporary service plan [Care In-Service/Change in Plan of Care Record] by a licensed nurse. Review of Resident 1’s Individual Service Plan (NSA), dated 07/14/2023, showed Resident 1 had a diagnosis of It also showed that Resident 1 was ambulatory without an assistive device and that during meals, Resident 1 needed cueing from staff to eat. Review of a Resident Care In-Service/Change in Plan of Care Record (temporary service plan), dated 10/11/2023, was filled out by Staff A, Medication Technician, to show that Resident 1 was to be NPO after 7:00 PM the night of /2023 until after their appointment on /2023. Review of a 24-hour report sheet (documentation to notify staff), dated 10/11/2023, showed that Resident 1 was going out to dental appointment on /2023 with pick up at 8:00 AM. “No food, No meds [medications].” Review of Resident 1’s meal attendance record for /2023 showed that breakfast intake was one hundred percent. Per ALF’s investigative document dated 10/17/2023 by Staff H, Caregiver, showed they were not aware that Resident 1 was not to have any food on /2023. Per ALF’s investigative document dated 10/17/2023 by Staff I, Caregiver, showed on /2023 they saw Resident 1 in the dining room and was also not aware that Resident 1 was not supposed to eat anything that morning. Review of Resident 1’s hospital records showed that Resident 1 was admitted to the hospital from /2023 through /2023, with a diagnosis of . Statement of Deficiencies License #: 2511 Compliance Determination # 31588 Plan of Correction Callaway Gardens Alzheimers Special Care Center Completion Date and treated with intravenous (in the vein) antibiotics. During an interview on 10/25/2023 at 11:08 AM, Staff B, Registered Nurse (RN) stated that staff are expected to read the 24-hour communication book and the Care In-Service/Change in Plan of Care Record before starting their shifts. Staff B also stated it was concerning to management to the lack of caregiver signatures on the Care In-Service/Change in Plan of Care Record form alerting staff of the temporary care plan changes for Resident 1. During an interview on 10/25/2023 at 11:54 AM, Staff A, stated they were notified by Collateral Contact 1 (CC1), resident representative, on the afternoon of 10/11/2023, that Resident 1 had a scheduled dental appointment on /2023 and Resident 1 needed to be NPO that night. Staff A said they wrote the communication on a bright orange Care In-Service/Change in Plan of Care Record form and hung it at the nurse’s station on the afternoon of 10/11/2023. Staff A stated they worked the day of Resident 1’s dental appointment and they administered Resident 1 medications in a “spoonful” of pudding. Staff A also stated that staff are expected to do a change of shift report and to read the communication book/alert charting book before they start their shift. During an interview on 10/25/2023 at 11:57 AM, Staff C, Caregiver stated that they were the caregiver for Resident 1 on the day Resident 1 was to be NPO. Staff A also denied seeing any communication posted about Resident 1 being NPO and they did not receive a verbal report from the night shift staff. During an interview on 10/25/2023 at 11:01 AM, Staff D, Health Services Director, stated that it was every caregiver’s responsibility to be aware of the changes with all of the ALF residents, regardless if those residents are assigned to that staff member or not. Staff D also stated that caregivers do not serve plates up for meals, only dietary staff do that. During an interview on 10/25/2023 at 12:36 PM, Staff F, Dietary Manager, they stated that they had received an NPO slip for Resident 1, hung it up in the kitchen and made their dietary staff aware of the communication. During an interview on 11/08/2023 at 11:25 AM Staff E, Caregiver, confirmed they saw the resident eating. Staff E was not aware of who served Resident 1 a plate, as kitchen staff are the only ones who are to plate the food. During an interview on 11/08/2023 at 4:05 PM, Collateral Contact (CC1), stated that when they went to pick up Resident 1, for the dentist appointment, they were told by an unnamed staff member that Resident 1 had not eaten anything. CC1 also stated that during the event CC1 was “frustrated and angry” that this happened to Resident 1 and “there was nothing I could do about it.” CC1 stated they felt the facility had a breakdown or lack of communication, and that staff should be told of resident changes the first thing when they come onto their shift. CC1 also indicated that Resident 1 laid in the hospital for . .