Anderson County Hospital Ltcu

The facility identified a census of 27 residents. The sample included 12 residents. Based on observation, record review, and interviews, the facility failed to provide direct, interactive activities based on resident preferences for the residents on weekends. This deficient practice placed the affected residents at risk for decreased psychosocial well-being, boredom, and isolation. Findings Included: - A review of the facility's Activity Calendars for December 2024, January 2025, and February 2025 was completed. The calendars revealed religious services provided at 09:00 AM and 03:15 PM for Saturdays but lacked staff-led activities. The calendars revealed a devotional group was held at 09:00 AM on Sundays. The calendar revealed the residents were provided music and coloring pages on Sundays but lacked staff-led activity groups. The council reported the weekends were sometimes slow without activities. On 02/11/25 at 10:30 AM, the facility provided manicures for the residents. On 02/12/25 at 11:40 AM, the facility's Resident Counsel reported that staff-led activities rarely occurred…

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.

The facility had a census of 27 residents. The sample included 12 residents, with two reviewed for accidents. Based on observation, record review, and interview, the facility failed to secure 15 pressurized medical oxygen tanks in a safe, locked area, and out of reach of the nine cognitively impaired independently mobile residents. This deficient practice placed the residents at risk for preventable accidents and injuries. Findings Included: - On 02/11/25 at 07:20 AM, an inspection of the facility's oxygen storage room revealed that the door was not secured. An inspection of the room revealed 15 full supplemental oxygen cylinders in the storage rack. The door closed and locked upon exit. On 02/13/25 at 08:22 AM the facility identified it had nine cognitively impaired independently mobile residents. On 02/13/25 at 12:01 PM, Certified Nurse's Aide (CNA) M stated the room was to be locked at all times due to the oxygen tanks. She stated the door had an electronic lock and staff were to ensure the door was fully closed and locked upon exiting the room. On 02/13/25 at 12:30 PM,…

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 The facility identified a census of 27 residents. The sample included 12 residents, with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure the Consultant Pharmacist (CP) recommendations were acknowledged and/or acted upon for Resident (R) 2, R20, and R25. The facility failed to ensure the CP identified and reported the non-approved indication for R10's antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication. These deficient practices placed the residents at risk for unnecessary medication use and physical complications. Findings included: - R2's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of dementia (a progressive mental disorder characterized by failing memory), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest and confusion), and short-term memory loss. The Significant Change Minimum Data…

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.

The facility identified a census of 27 residents. The facility identified four residents on Enhanced Barrier Precautions (EBP - infection control interventions designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact care). Based on record reviews, observations, and interviews, the facility failed to implement adequate hand hygiene. This deficient practice placed the residents at risk for infectious diseases. Findings included: - On 02/11/25 at 08:33 AM, Certified Nurse Aide (CMA) R failed to perform hand hygiene and donned a pair of gloves, CMA R removed R10's hearing aids from the medication cart. CMA R changed the battery in one hearing aid. CMA R placed R10's hearing aids in each ear at the dining room table. CMA R doffed her gloves and failed to perform hand hygiene. CMA R pushed R10 into an area across from the dining room. CMA R failed to perform hand hygiene and donned a pair of gloves from her uniform pocket. CMA R then administered R10's inhalation medication by assisting R10 with one puff into each nostril. CMA R…

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 The facility identified a census of 27 residents. The sample included 12 residents, with two residents sampled for discharge. Based on observation, record review, and interview, the facility failed to provide a written notice of transfer as soon as practicable to Resident (R) 13 and their representative. This deficient practice had the risk of miscommunication between the facility and resident/family and possible missed opportunities for healthcare service for R13. Findings Included: - The electronic medical record (EMR) for R13 documented diagnoses of congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid), hypertension (high blood pressure), confusion, adult failure to thrive (includes not doing well, feeling poorly, weight loss, and poor self-care that could be seen in elderly individuals), weakness, hyperkalemia (greater than normal amount of potassium in the blood), hypokalemia (low level of potassium in the blood), and dementia (a progressive mental…

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 The facility identified a census of 27 residents. The sample included 12 residents with two residents sampled for discharge. Based on observation, record review, and interview, the facility failed to provide a bed hold with the required information to Resident (R) 13 or their family representative when R13 transferred to the hospital. This deficient practice placed R13 at risk for impaired ability to return to the facility or his same room. Finding include: - The electronic medical record (EMR) for R13 documented a diagnoses of congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid), hypertension (high blood pressure), confusion, adult failure to thrive (includes not doing well, feeling poorly, weight loss, poor self-care that could be seen in elderly individuals), weakness, hyperkalemia (greater than normal amount of potassium in the blood), hypokalemia (low level of potassium in the blood), and dementia (a progressive mental disorder characterized by failing…

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.

The facility identified a census of 27 residents. The sample included 12 residents, with one reviewed for dementia (a progressive mental disorder characterized by failing memory, and confusion) care. Based on interviews, record reviews, and observations, the facility failed to provide dementia-related care services for Resident (R) 10 to promote the resident's highest practicable level of well-being. This deficient practice placed R10 at risk for decreased quality of life, isolation, and impaired dignity. Findings Included: - The Medical Diagnosis section within R10's Electronic Medical Records (EMR) included diagnoses of Parkinson's Disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), generalized weakness, dementia, chronic heart failure, hypertension (high blood pressure), and osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain) in both knees. R10's Quarterly Minimum Data Set (MDS) dated 12/06/24 documented 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 The facility identified a census of 27 residents. The sample included 12 residents, with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure a gradual dose reduction (GDR) was attempted or documented as contraindicated by the physician with a supporting rationale for risk versus benefit for Resident (R) 20 and R25's antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication. The facility also failed to ensure R10's antipsychotic medication had a Centers for Medicare and Medicaid (CMS) approved indication or the required risk versus benefit physician documentation. These deficient practices placed these residents at risk for unnecessary medications and adverse side effects. Findings included: - R20's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory…

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.

The facility identified a census of 27 residents. The sample included 12 residents, with two residents reviewed for hospice. Based on observation, record review, and interviews, the facility failed to ensure a coordinated plan of care, which coordinated care and services provided by the facility with the care and services provided by hospice, was developed and available for Resident (R) 22. This placed the resident at risk for inappropriate end-of-life care. Finding Included: - R22's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of assistance with personal needs, urinary retention, diabetes mellitus (when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), sinus tachycardia(normal rhythm, heart beating too fast), dysphagia (swallowing difficulty), and anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues). The Significant Change in Status Minimum Data Set (MDS) for R22 dated 11/26/24 recorded a Brief Interview for Mental Status (BIMS) score of 14, which indicated…

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.

The facility reported a census of 20 residents and identified 12 of those residents with controlled medications stored in the medication cart. Based on interview and record review, the facility failed to perform an accurate system for the count of the number of controlled medications (medications that can cause physical and mental dependence) in the medication cart, increasing the risk for diversion of the medications. Findings included: - On 09/16/21 at 03:50 PM, the record used for the shift to shift count of controlled medications lacked a place for the staff to document the number of controlled medications in the medication cart. On 09/16/21 at 03:52 PM, Licensed Nurse (LN) G stated that all controlled medications were stored in the medication cart and a count was done with the off going/on coming staff that was taking over the medication cart. During the count process the staff counted the number of pills in the cards or amount of liquid in a bottle. LN G stated that the number of controlled medications in the cart were not counted during the count process. On 09/16/21 at 04:11…

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.

The facility reported a census of 20 residents with 12 selected for review, including five residents reviewed for influenza vaccinations. Based on interview and record review, the facility failed to provide consent forms to allow the resident or the resident's representative the opportunity to refuse the influenza immunization for the five residents, Resident (R)1, R5, R8, R11, and R19. Findings included: - The electronic medical record (EMR), indicated that Resident (R)19 received an influenza vaccine on 09/17/20. The other four reviewed residents' EMRs, indicated that R1, R5, R8, and R11 received an influenza vaccine on 10/14/20. The EMRs all lacked consent forms for the influenza vaccination for these five residents. On 09/21/21 at 11:48 AM, Administrative Nurse F stated that the nurse providing the vaccine would supply the vaccine information sheet and have the consent filled out. On 09/21/21 at 03:50 PM, Administrative Nurse D stated the facility does a blanket consent for treatment that the resident/representative signs and there was not a consent form provided before…

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 The facility reported a census of 20 residents. The sample contained 12 residents, with one resident reviewed for limited range of motion. Based on observation, interview, and record review, the facility failed to provide interventions to promote maintenance of range of motion and prevent decline in the right hand, for the one sampled resident, Resident (R) 8. Findings included: - The signed Physician Order Sheet (POS), dated 09/09/21, documented R8's diagnoses included cataract (clouding of the lens of the eye) of unspecified eye, vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), irritable bowel syndrome (abnormally increased motility of the small and large intestines), and stroke (damage to tissues in the brain due to a loss of oxygen to the area). An annual Minimum Data Set (MDS), dated [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 The facility reported a census of 20 residents. The sample contained 12 residents, with two residents reviewed for accidents. Based on observation, interview and record review, the facility failed to ensure safe mobility to prevent accidents when the facility failed to provide foot pedals to the wheelchair, while transporting one of the two sampled residents, dependent Resident (R) 9. Findings included: - The signed Physician Order Sheet (POS), dated 07/28/21, documented R9 had a diagnosis of bilateral (affecting both sides) osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain) of the knee. An annual Minimum Data Set (MDS), dated [DATE], documented R9's Brief Interview for Mental Status (BIMS) score was 11, indicating moderate cognitive impairment. R9 required limited assistance with locomotion on the unit. A Cognitive Loss Care Area Assessment (CAA), dated 03/17/21, documented R9's primary language was Japanese and confusion resulted when she did not understand. An…

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 The facility reported a census of 20 residents with twelve selected for review, including one Resident (R)5, reviewed for respiratory care. Based on observation, interview, and record review, the facility failed to change R5's oxygen tubing in a timely manner. This practice increased the risk of Resident (R)5 developing a respiratory infection. Findings included: - The Problem List, located in the electronic medical record (EMR), for Resident (R)5, included diagnoses of pulmonary fibrosis (lung tissue becomes damaged and thickened leading to shortness of breath), obstructive sleep apnea (intermittent airflow blockage during sleep), and chronic cough. The Quarterly Minimum Data Set (MDS), dated [DATE], assessed R5 with a Brief Interview of Mental Status (BIMS) score of 15, indicating intact cognition. He did not experience shortness of breath with exertion, lying flat, or at rest, and did require oxygen. The Annual MDS, dated 08/25/21, did not reveal any changes to R5's BIMS score, oxygen use, or shortness of…

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.