Emory L Bennett Memorial Veterans Nursing Home

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on kitchen food service observations, staff interviews, and facility policy and procedure review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness, with the potential to affect all residents who consumed foods from the facility's nourishment rooms, by failing to seal and date mark open food products in the nourishment rooms, clean residue build up in the ice machine drain hose and coffee dispenser hood, and clean in and around the ice machine dispenser ports and tray. Food handling and sanitation are important in health care settings serving nursing home residents. Unsafe food handling practices represent a potential source of pathogen exposure. The findings include: A tour of the kitchen was conducted on 10/16/2024 at 11:29 AM. During the tour, observations of the nourishment room on the Delta Hall unit revealed one jar of open peanut butter on the plastic bin shelf, and one open bundle of bread on the plastic bin shelf with no date…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to ensure that one resident (#2) who was visually impaired, from a total survey sample of 31 residents, received reasonable accommodation of needs for his call light. Failure to ensure that a resident who is visually impaired has the appropriate means to call for assistance can pose a safety risk to that resident. The findings include: During a facility tour on 10/15/24 at 10:28 a.m., Resident #2 was observed lying in bed. His call light was not within his reach. (Photographic evidence obtained) In an interview on 10/15/24 at 10:30 a.m., Resident #2 stated he was legally blind. When asked how he called for assistance, he stated there was a call light to use but he didn't know where it was. He usually waited until someone came in his room to ask for help. He further stated the staff did not introduce themselves when they came in his room. On 10/15/24 at 11:07 a.m., Licensed Practical Nurse (LPN) A was observed dressing a skin tear on the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, interviews, and a review of the facility's policy and procedure, the facility failed to ensure that residents were properly screened for a mental disorder (MD) or intellectual disability (ID) prior to admission, and that individuals identified with a MD or ID were evaluated and received care and services appropriate to their needs for one (Resident #48) of a total survey sample of 31 residents. Resident #48's Pre-admission Screening and Resident Review (PASRR) was incomplete with numerous areas of the form left blank. Incomplete PASRR forms can result in residents not receiving appropriate help/services and/or could create a delay in the process. The findings include: A record review was conducted for Resident #48 noting an admission date of 11/26/2021 and a previous admission date of 04/13/2018. His diagnoses included anxiety, depression (other than bipolar), manic depression (bipolar disease), and post traumatic stress disorder (PTSD). The resident's Quarterly minimum data set (MDS) assessment, dated 09/27/2024, revealed that the resident had a Brief…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure that one (Resident #89) of a total survey sample of 31 residents, received care and services timely, in accordance with professional standards of practice, by failing to schedule physician-ordered magnetic resonance imaging (MRI). Failure to provide care timely poses a risk to residents' health due to delayed interventions. The findings include: During a facility tour on 10/15/2024 at 10:39 a.m., Resident #89 was observed seated in his wheelchair outside his room. He asked to be put back in bed. He stated he was always sleepy and fatigued and did not know what was wrong with him. A review of the resident's medical record revealed that he was admitted to the facility on [DATE] with diagnoses including dementia, Parkinson's disease, psychotic disorders with hallucinations due to unknown physiological condition, major depressive disorder, anxiety disorder, insomnia, and other fatigue and tiredness. A review of the active physician's orders…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews and record review, the facility failed to provide food that accommodated resident preferences, by failing to provide options of similar nutritive value to residents who requested a different meal/snack choice for one (Resident #91) of four residents reviewed for nutrition, from a total survey sample of 31 residents. Resident #91, diagnosed with type 2 diabetes and blood sugar readings at times reaching 219 mg/dL, expressed a desire for sugar-free foods and snacks; however, they were not provided. The findings include: During a tour of the facility on 10/15/2024 at 10:27 AM, Resident #91 was observed sitting up in her bed fully dressed and watching television. She complained that the facility had no diabetic food or desserts, and she stated she had been asking for sugar free items. They push ice cream a lot. A review of the resident's medical record revealed an admission date of 09/12/2022 and diagnoses including type 2 diabetes mellitus w/other specified complications: chronic kidney disease, stage 4 (severe), and hyperglycemia. A review of the Quarterly minimum…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, staff interviews, and facility policy review, the facility failed to store all drugs and biologicals in locked compartments. This failure involved the Delta 5 hallway medication cart, Delta 5 hallway treatment cart, Delta 3 hallway medication cart, Alpha 5 hallway treatment cart, Alpha 5 hallway medication cart, Alpha 3 hallway medication cart, and four separate nurses on two different shifts during three different days. The findings include: On 11/28/22 at 3:08 pm, the medication cart on Delta 5 hallway was observed to be unlocked as evidenced by the locked popped open. The first two drawers were opened and bottles of prescription medications were observed. (Photographic evidence obtained) No staff were observed in the area of this medication cart. On 11/29/22 at 3:50 pm, the treatment cart on Delta unit was observed to be unlocked and unattended. (Photographic evidence obtained) At this same time, the medication cart on Delta 3 was observed to be unlocked and unattended. The cart was observed to be unattended and unlocked for two full minutes. (Photographic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews, the facility failed to ensure the resident environment remained as free of accident hazards as was possible, and failed to provide adequate supervision for four (Residents #19, #25, #3, and #26) of four residents who smoked, kept their lighters in their rooms, and either used oxygen or were near oxygen concentrators. This practice endangered residents, staff and other building occupants. The findings include: On 11/28/2022 at 12:32 PM, Resident #19 was observed wearing a nasal cannula (tubing used to deliver oxygen through the nose) connected to an O2 (oxygen) concentrator. When asked if he knew what his O2 flow rate was supposed to be, he said he took care of it himself and didn't need the staff, but he didn;t provide a flow rate setting. The concentrator was running at 5 LPM (liters per minute). Additionally, a cigarette lighter was observed between the bed and the oxygen concentrator on the floor on top of a fall mat. Resident #19 was asked if he was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to provide three (Residents #11, #18, and #36) of three samped residents, notices of non-coverage to allow residents the opportunity to make informed decisions about continued services and/or the right to an expedited review by a Quality Improvement Organization. The findings include: A review of the facility's Beneficiary Protection Notification and Notice of Medicare Non-Coverage (NOMNC), conducted on 11/30/2022 at 11:30 AM, revealed two (Residents #11 and #18) of three sampled residents were not provided a NOMNC with a written statement that said the facility was unaware of the need for the form. On 11/30/2022 at 11:35 AM, a record review revealed that one (Resident #36) of three sampled residents was not provided a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage with a written statement that said the resident did not want to continue service. Photographic evidence was obtained. An interview was conducted on 11/30/2022 at 12:27 PM with the Social Services Director (SSD) regarding why Form CMS-10055 and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, staff and resident interviews, medical record review, and facility policy and procedure review, the facility failed to ensure that one (Resident #39) of 21 residents receiving respiratory care, were provided such care per physician's orders. The findings include: On 11/28/22 at 1:00 PM, Resident #39 was observed lying in bed. In an interview, he stated he had a CPAP (Continuous Positive Airway Pressure) device that was brought here by his wife, but that the CPAP was broken, and he never got to use it. The resident further stated he had been waiting for a new CPAP for over two months. He was asked if his sleep was disturbed from not having his CPAP. He stated he didn't sleep well without the CPAP. No CPAP device was observed in his room. On 11/30/22 at 9:10 AM, Resident #39 was observed lying in bed. He stated he hadn't heard anything about his CPAP device yet. He further stated he didn't get a good night's rest and he slept off and on throughout the night. He stated again that he slept better with his CPAP. A medical record review for Resident #39 revealed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, medical record review, and facility policy review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for one resident (Resident #194) of seven residents requiring urinary catheter care, from a total sample of 27 residents. The findings include: On 11/29/22 at 9:22 am, Resident #194 was observed lying in bed. A urinary catheter bag was observed on the door side of his bed, was not covered with a dignity bag, and was approximately half full of clear, yellow urine. The bag was touching the floor. (Photographic evidence obtained) On 11/30/22 at 2:50 pm, Resident #194's urinary catheter bag was observed uncovered with clear, yellow urine. It was lying against the bed frame and floor of his room. (Photographic evidence obtained) Registered Nurse (RN) J entered the room to answer the call light. She did not address the urinary catheter bag lying against the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on kitchen food service observations, staff interviews, facility document review, and facility policy and procedure review, the facility failed to follow proper sanitation, food distribution and service practices to prevent the outbreak of foodborne illness with the potential to affect all of the residents in the facility. The facility failed to ensure that the dietary staff implemented the facility policy for the proper procedures for hand hygiene, disposable glove use, and proper sanitation practices in the kitchen when staff failed to change gloves when they became contaminated, and to wash their hands between glove changes during the lunch meal service. The findings include: On 4/19/2021 at 10:25 AM, the initial tour of the kitchen was conducted. A smoking device identified as a Vape was observed on the prep table across from the steamers and the fryer in the kitchen (Photographic evidence obtained). The Dietary Manager stated the vape belonged to Employee K, Dietary Staff, and she asked him to remove the device. The three-compartment sink was set up with a pan soaking in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on kitchen food service observations, staff interviews, and facility policy and procedure review, the facility failed to ensure all essential kitchen equipment was maintained in safe operating condition by not ensuring proper maintenance of the mechanical, high temperature dishwashing machine and walk-in freezer. The findings include: On 4/19/2021 at 10:25 AM, the initial kitchen tour was conducted. Employee J was asked to run the high temperature mechanical dish machine. He ran the machine a couple of times to get the machine up to the right temperature. When asked what the temperature of the wash cycle and final rinse cycle should be, he stated the wash cycle temperature should be 160'F (Fahrenheit) to 180'F and the final rinse cycle should be 180'F. He ran the dish machine and the actual temperature for the wash cycle was 158'F-159'F and the temperature for the final rinse cycle was 183'F-184'F. On 4/22/201 at 9:20 AM, a second operation of the dish machine was observed. Employee M was operating the dish machine. She rinsed and loaded dirty dishes onto racks and pushed them…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record reviews and staff interviews, the facility failed to send notification to the Office of the State Long-term Care Ombudsman of resident transfers and discharges for two (Residents #5 and #75) of three residents sampled for a review of transfer and discharges, from a total sample of 36 residents. The findings include: 1. A record review was conducted for Resident #5, which noted an initial admission date of 6/12/2019. On 4/19/2021, the resident was transferred/discharged to an acute care hospital's emergency department. As of 4/21/21, Resident #5 was still in the hospital. No evidence was found of notification to the Office of the State Long-Term Care Ombudsman. 2. A record review was conducted for Resident #75, which noted an initial admission date of 8/30/2019. On 2/25/2021, the resident was transferred to the hospital. On 3/9/2021, Resident #75 returned to the facility from the hospital. No evidence was found of notification to the Office of the State Long-Term Care Ombudsman. During an interview conducted on 4/22/2021 at 10:45 AM with the Social Services…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview and policy and procedure review, the facility failed to monitor resident behaviors and potential side effects related to the use of psychotropic medication for one (Resident #74) of five residents reviewed for unnecessary medications from a total of 36 residents in the sample. The findings include: A record review for Resident #74 revealed he was admitted on [DATE], with the following diagnoses: history of alcohol use, major depressive disorder recurrent episode, suicidal in the past, and adjustment diagnosis of mixed anxiety and depression. A review of the physician orders on 4/22/21, revealed an order for Sertraline 150 mg (milligram) by mouth daily for major depression. Behavior monitoring documentation and/or side effect monitoring documentation was not found in the medical record. An interview was conducted with the Director of Nursing (DON) on 4/22/21 at 12:54 PM. The DON confirmed there was no documentation for behavior monitoring for Resident #74 related to the use…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.