Emanuel County Nursing Home

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews, record review, review of the American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHREA) and Centers for Disease Control and Prevention (CDC) guidelines, and review of the facility document titled, Water Management Program for [NAME] County Nursing Home, the facility failed to have an adequate water management program. The facility's water management program was incomplete and was not consistent with the current ASHRAE Guideline, which specifically called for design and maintenance procedures for the potential exposure of Legionnaires' disease (a serious pneumonia infection) within a healthcare facility. This failure created the potential for the facility residents to be infected by Legionella. Findings include: Review of a website for ASHRAE titled Successfully Managing the Risk of Legionellosis dated 4/7/2021 indicated . Legionellae the biological classification name for a [NAME] of bacteria.is the plural, referring to more than one Legionella…

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 staff interviews, record review, and review of the facility policy titled, Reference 8: Behavior Monitoring Procedure, the facility failed to ensure that three of five residents (R) (R17, R21, and R40) sampled for unnecessary medications were monitored for behaviors, side effects and efficacy of antipsychotic medications. This failure to monitor for adverse effects and efficacy had the potential to place R17, R21, and R40 at risk of medical complications and unmet needs. Findings Include: Review of the facility's undated policy titled, Reference 8: Behavior Monitoring Procedure, revealed 1. Each MAR (Medication Administration Record) will have three major lines (one for each shift), with four subdividing minor lines within each major line. 2. Inside the frequency column of each minor line will have directions. a. Line 1-will indicate the shift. This is where the nurse will enter her initials. b. Lines 2-4 will state Behaviors =__. In the blank, a number is to be entered, that corresponds to a behavior…

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, staff interviews, record review, and review of the facility policies titled, titled, Medications - Administration and Preparation and Policy and Procedure for Expired Drugs, the facility failed to ensure one of six residents (R) (R7) observed during medication pass medications were not expired. This deficient practice increased R7's risk of infection and exacerbation of R7's compromised respiratory status related to chronic obstructive pulmonary disease. Findings include: Review of facility-provided policy, revised 04/22/2024, titled, Medications - Administration and Preparation revealed . 15. check all medications .for expiration dates. Review of a facility-provided policy, reviewed and approved dated 04/22/2024, titled, Policy and Procedure for Expired Drugs, revealed, .During each medication pass, it is the nurse's responsibility to check medication labels for expiration dates, before dispensing drug.3. Any expired drugs will be removed from medication chart and be re-ordered . Review…

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 staff interview, record review, review of the facility policy titled Immunizations, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to offer one of five residents (R) (R28) reviewed for flu and pneumonia vaccinations and/or their representatives the opportunity for the residents to be vaccinated in accordance with nationally recognized standards of 44 sample residents. In addition, the facility failed to update their immunization to reflect current CDC recommendations. These deficient practices had the potential to place R28 at risk of contracting pneumonia and other residents at risk of not being offered immunizations based on current CDC guidelines. Findings include: Review of the facility policy titled Immunizations, dated 5/22/2024, indicated .To provide guideline for administering Pneumococcal Vaccine - PCP13 (Previnar) [sic] pr PPSV23 (Pneumovacc) [sic]. Review of the CDC website titled,…

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, and policy review, the facility failed to ensure that opened food items were labeled and dated in two walk-in refrigerators, the walk-in freezer, and the dry storage area. The facility census was 46, with 44 residents receiving an oral diet. Findings include: A review of facility policy, Labeling, Dating, and Storage, revised 1/8/21, revealed food items, once opened, would be stored in their original packaging or wrapped tightly with film and/or foil and clearly labeled with the name of the item and the date opened. A further review revealed that opened refrigerated items would be labeled and dated. An observation on 3/17/23 at 8:10 a.m. of the walk-in refrigerator #1 revealed a plastic container with approximately five pickles. The container was unlabeled and undated. An observation on 3/17/23 at 8:18 a.m. of the walk-in refrigerator #2 revealed a box of breakfast sausage. Inside the box was an opened bag of breakfast sausage that had not been labeled or dated with an opened date. Additionally, the breakfast sausage was in an unsealed bag, and 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 staff interviews, record review, and review of policy titled Bed Holds During Hospital Stays and Therapeutic Leaves, the facility failed to provide written documentation of bed hold to resident/family upon discharge to hospital for one of eight residents (R# 2) who was transferred to the hospital. Policy on Bed Holds During Hospital Stays and Therapeutic Leaves last revised 1/20/23: 1. Hospital stays: Medicaid will provide payment to hold the Resident's bed for a period of seven days while the Resident is hospitalized . List of transfers December 2022 through March 2023 indicated eight residents had been transferred during the identified time period. Electronic record review for R#2 revealed hospital leaves on 12/22/22 and 3/14/23. Review of the electronic medical record and the hard chart record did not reveal any evidence of the resident/family being notified in writing of the bed hold policy. During interviews on 3/17/23 at 10:55 a.m. with Licensed Practical Nurse (LPN) AA, LPN BB, and LPN CC who all reported that when a resident has to go out to the hospital there are…

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 staff interviews, the facility failed to ensure that the staff designated as Dietary Manager (DM) was a Certified Dietary or Food Service Manager or had a similar food service management certification or degree. This had the potential to affect 37 residents receiving an oral diet. Findings include: Review of the job description in the employee file of the DM documented Food Service Manager (FSM) and did not indicate the requirement of a certification. During a tour of the kitchen and interview on 8/31/21 at 11:21 a.m., the DM revealed his present food certification status as ServSafe certified and not certification as a Certified Dietary Manager. He stated that he is enrolled in a CDM course but could not provide a start date or a target date for completion of the CDM certification course. Review of the employee file for the DM revealed a hire date of March 2021. Record review of the DM's resume revealed no certification or education degree in culinary art or any other food service management degree. During an interview on 9/2/21 at 12:10 p.m., 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 observations and staff interviews, the facility failed to maintain the cleanliness of one ice machine, label and date food items, discard expired food, prepare food in a sanitary manner, store food to prevent food borne illness, maintain a pest free environment, and ensure staff wear hair nets appropriately while in the kitchen. This had the potential to effect 37 residents that received an oral diet. Findings include: During the initial walk-through of the kitchen with the Dietary Manager (DM) on 8/31/21 at 9:29 a.m. through 10:33 a.m., the following concerns /issues were observed: 1. Observation of the ice machine revealed sticky dark watery brown substances on the inside panels of the ice machine. At the time of the observation, (the DM wiped the inside panel with a white cloth), the DM identified the substances as mildew. The DM could not provide a log date for the cleaning schedule for the ice machine. Record review showed the ice machine was cleaned on 3/20/21. 2. Observation of Refrigerator #1 revealed five ham sandwiches contained in a Ziploc bag, with no open 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.

Based on observation, record review, staff interviews, and review of the facility policy titled, Quality Assurance and Performance Improvement (QAPI) Plan, the facility failed to implement corrective action plans that effectively addressed kitchen concerns including discarding expired food items and appropriately wearing hairnets in food preparation areas. The census was 37 residents. Findings include: Review of the facility policy titled QAPI Plan revised 4/7/2020 revealed: Purpose - all staff will participate in ongoing QAPI efforts which support our mission to enhance quality of life. Performance Improvement Projects - the QAPI team will review sources of information to determine if gaps or patterns exist in our systems that could potentially result in quality-of-care issues or if there are opportunities for improvement. QAPI Goals - the nursing home supports performance improvement by encouraging each staff member to be accountable for their own professional performance and practice. Observations of the kitchen on 11/8/2021 at 9:45 a.m. through 10:30 a.m. revealed expired food…

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 staff interviews, the facility failed to obtain a concurring Physician's signature for a Physician Orders for Life Sustaining Treatment (POLST) for Do Not Resuscitate (DNR) consent for one of 16 residents (R) reviewed (R A). Findings include: Review of the document titled Guidance for Completing the POLST Form revealed the following: 5. If the patient lacks decision making capacity, the POLST form may be signed by an authorized person which includes, in the order of priority: a. the agent named on the patient's durable power of attorney for health care, or a health care agent named on the patient's advance directive for health care. b. spouse c. a court-appointed guardian d. son or daughter (age 18 or older) e. parent f. brother or sister (age 18 or older) When a POLST is signed by an authorized person and attending Physician: if section A indicated allow natural death - do not attempt resuscitation . a concurring Physician signature is required. Review of the medical record for R A…

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.