Both the State of Georgia and the Centers for Medicare and Medicaid Services (CMS) conduct routine surveys and investigations of every nursing facility statewide. Their efforts help to identify safety hazards, substandard care, deficiencies and violations that could harm or have harmed their residents. These facilities are required to make necessary improvements and revise their problematic policies and procedures promptly.
Some serious cases involve egregious violations. When this occurs, the regulators will designate the facility a Special Focus Facility (SFF). This designation means that the nursing home is placed on a national Medicare watch list and must undergo many more inspections than normal. If the nursing home was unable or unwilling to make changes, they could lose their contract to provide care, services, and assistance to Medicaid and Medicare-funded patients.
In 2017, both the state and federal nursing home regulatory agencies designated Windermere Health and Rehabilitation Center as a Special Focus Facility. Now that the nursing home has been added to the federal watch list, surveyors will be keeping a watchful eye on the improvements the facility makes to ensure the health and well-being of every resident are maintained. Some serious violations, deficiencies and health hazards concerning the facility are detailed below.
This facility is a ‘for profit’ 120-certified-bed Long Term Care Center providing cares and services to residents of Augusta and Richmond County, Georgia. The Home is located at:
3618 J Dewey Gray Circle
Augusta, GA 30909
(706) 860-7572
In addition to providing skilled nursing care, the senior-affiliated nursing home also offers rehabilitation services, dementia care, bariatric care, respiratory therapy and intervenous (IV) therapy.
State and Federal Regulators are legally authorized to levy monetary penalties on every nursing facility in Georgia that are identified with serious deficiencies and violations. These fines are meant to serve as a public announcement and alert the nursing home that Medicare and Medicaid will no longer tolerate substandard care.
Within the last three years, Windermere Health And Rehabilitation Center has received three fines including a $69,550 monetary penalty on January 6, 2015, another on March 26, 2015, for $7020, and a massive monetary fine of $419,893 on August 5, 2016. When the last monetary fine was imposed, Medicare denied a payment request from the facility due to substandard care. Over the last 36 months, there were 24 formally filed complaints and seven facility-reported issues that all resulted in citations.
To ensure families are fully informed of the level of care every nursing home provides, the state of Georgia routinely updates their long-term care home database system. This information reflects a complete list of incident inquiries, dangerous hazards, filed complaints, health violations, safety concerns, and opened investigations that can be found on numerous sites including Medicare.gov.
Currently, Windermere Health And Rehabilitation Center maintains an overall one out of five stars compared to all nursing homes in the United States. This ranking includes one out of five stars for health inspections, one out of five stars for staffing issues, and one star for quality measures. Some egregious violations and serious deficiencies concerning this facility include:
In a summary statement of deficiencies dated August 5, 2016, the state investigator noted the facility’s failure to “notified the physician of the resident’s status change as evidenced by a failure to obtain physician’s orders… and a failure to “notify the position of pain for the resident.”
Surveyors also documented that the facility had failed to “notify the physician that an ordered antibiotic was not administered until two days after it was ordered for [a resident].” The determination “was made that the facility’s noncompliance with one or more requirements of participation had caused, or had a likelihood of causing a serious injury, harm, impairment, or death to residents.”
In a summary statement of deficiencies dated August 5, 2016, the state investigator noted the facility’s failure to open ensure that residents with pressure ulcers and other skin conditions receive services necessary to identify, report and obtain physician’s orders.” This deficiency affected six residents at the facility.
The surveyors also noted the facility’s failure “to ensure that one resident identified with elopement risk on admission received the services necessary to prevent the elopement, the resident eloped from the facility four days after admission.” A determination by the state surveyor “was made of the facility’s noncompliance with one or more requirements of participation had caused, or had a likelihood to cause, serious injury, harm, impairment, or death to residents.”
In one incident, the state surveyor notified the Corporate Area Vice President that any Immediate Jeopardy existed. The surveyors determined that the Immediate Jeopardy was identified when it was revealed that a resident “was admitted to the facility after a hospital stay from home from urinary tract infection.” The resident has a “history of falls, you and legs with a walker, with impaired cognition [was] discharge from the hospital to the facility with fluid-filled blisters on bilateral appeals and a reddened sacral area.”
The facility failed to develop an Interim Care Plan to address the pressure ulcers. The resident was found unresponsive [at the facility] and transferred to the hospital in septic shock.” The resident’s Georgia Death Certificate “revealed the immediate cause of death for [the resident] was septic shock secondary to decubitus [ulcers].”
The surveyor reviewed the resident’s Treatment Administration Records (TAR) revealed “that there was no evidence that treatments were completed as ordered to the heels. The May 2016 TAR revealed that “there was no evidence that treatment of the heels was completed [and continued] review revealed no evidence that staff performed any treatment to the resident sacral pressure sore [on numerous dates].”
In a summary statement of deficiencies dated August 5, 2016, the state investigator noted that the facility had failed to “conduct pre-employment reference checks for [1 of 9] employee files reviewed.” Also, the facility had failed to “thoroughly investigate and report an allegation of misappropriation of property for [a resident] and an allegation of staff to resident physical abuse” involving one resident.
The surveyor also noted the facility’s failure “to report to the State Survey Agency two allegations of resident-to-resident sexual abuse” involving four residents “and visitor-to-resident verbal abuse for [one resident].” A review of a facility sometime reported the incident “reveal an allegation of verbal abuse by a family member to [a resident] on July 6, 2016. In this incident, a resident “was found lying naked in the female resident’s bed on March 27, 2016. While the initial report was filed in March 30, 2016, the five-day follow-up completed investigation was faxed to the State Survey Agency on April 8, 2016.”
A review of the facility’s grievance log revealed that a resident “reported that a staff member on the second shift on May 15, 2016, was rough with him when giving care and that he was hit in the stomach by the male Certified Nursing Assistant (CNA).” The Executive Director stated that “there was no documentation of an investigation into this allegation that could be found.”
In a summary statement of deficiencies dated August 5, 2016, the state investigator noted that upon review a facility self-reported incident, there was “an allegation of sexual abuse involving [two residents]” revealed that the allegation occurred on July 11, 2016.
In a summary statement of deficiencies dated August 5, 2016, surveyors documented that a self-reported incident “regarding an allegation of sexual abuse involving [two residents] revealed that the allegation occurred on July 11, 2016. Further review of the facility’s investigative documents revealed that the initial report of the allegation was sent to the State Survey Agency on July 12, 2016.” However, “the final investigation was not sent to the Agency until July 27, 2016,” more than two weeks after the initial report.
This incident involved the review of the facility Call Light Policy and interviews with staff members and residents. The surveyor noted that the facility failed “to knock before entering a residents’ room.” This deficiency involved three residents at the facility. Additionally, “the facility failed to respond to call light in a timely and courteous manner for [one resident]. The facility also “failed to maintain an environment which [there were] no signs posted in the resident’s room that contain clinical information that can be seen by other residents and visitors.”
In one incident, a resident “stated on the night shift [they] will press the call light, staff to say that they will be right back, but it takes about 45 minutes for them to return. The resident stated that one morning at 5:00 AM, [they] woke up and realized they were wet, and press the call light, but [they] were not assisted until 6:30 AM.”
In a summary statement of deficiencies dated July 27, 2017, the state investigator noted the facility’s failure “to clean a glucometer in a manner to ensure that it was disinfected between each resident.” This deficiency involved three residents on the 500 Hall who “received a finger stick blood sugar on the evening shift of July 25, 2017.”
An observation was made of a Licensed Practical Nurse on the evening of July 25, 2017, while “cleaning the glucometer with only an alcohol wipe after performing a finger stick blood sample for [a resident]. During the interview, the Licensed Practical Nurse stated she only used alcohol to clean the glucometer as she was allergic to bleach wipes and would break out in hives if she used the bleach.”
The state investigator interviewed the Director Clinical Education the following day stated, “that the facility staff was expected to use Clorox whites to disinfect the glucometer, and that alcohol alone would not be sufficient.”
In a summary statement of deficiencies dated August 5,016, the state investigator noted the facility’s failure “to update the Care Plan with an intervention for a ‘wander guard’ bracelet for a resident at risk of elopement [wandering away from the facility].” The state surveyor reviewed the resident’s Quarterly Minimum Data Set (MDS) that revealed that “she wanted one to three days during the assessment. Review of the risk for elopement Care Plan initiated July 23, 2013, revealed there was no intervention listed for the ‘wander guard’ bracelet.”
The surveyor reviewed the facility’s September 1, 2015 Incident Reporting Form that revealed that the resident was “approximately 300 yards off the facility property.” A review of the facility’s five-day follow-up investigation concerning the elopement noted that “the resident was assessed on admission and Care Plan as a risk for elopement and a ‘wander guard” device placed for the resident’s protection.”
However, a review of “the facility’s Elopement Guideline noted that the documentation should include a Care Plan that addresses the potential to wander or exit living Center and the measurements are taken to prevent wandering/elopement.” The guidelines should also have shown that “the bracelet alarm/device was in place and functioning.” The surveyor interviewed the facility’s Director Nursing Services on the morning of August 4, 2016, who verified “that the ‘wander guard” was not an intervention on the Care Plan for [that resident].”
If you believe that your loved one suffered abuse, mistreatment or neglect while a patient at Windermere Health and Rehabilitation Center, or any nursing home, call a personal injury attorney now. With legal representation, your family can be assured of receiving financial compensation for your damages. A law firm can build your case, file your claim, negotiate your settlement and present the evidence at a jury trial, if necessary.
Contact us today! No upfront payments are necessary because personal injury law firms accept every wrongful death lawsuit and nursing home neglect claim for compensation through contingency fee agreements. This arrangement allows you immediate legal representation without making a payment until your cases financially resolved.
Attorney Lance D. Lourie
Licensed in Georgia
Chicago Nursing Home Injury Attorney Nursing Home Law Center LLC Home