Bishop Gadsden Episcopal Health Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, policy review, and staff interview, the facility failed to individualize comprehensive plans for urinary catheter bulb size for two (2) of two (2) residents reviewed for catheter care (Resident (R)11 and R123). This failure could place the residents at risk for discomfort and/or pain. Findings include: A review of the facility policy titled Physician Orders, with a revision date of October 2024, documented: 1. Policy It is the policy of [NAME] to obtain, document, and implement physician (or other licensed practitioner) orders in accordance with federal and state regulations, facility protocols, and standards of clinical practice. It is the policy of [NAME]'s SNF [skilled nursing facility] to review charts for any changes in Physician Orders. This will be done by the charge nurse every shift using the 24-hour alerts or 'Display New Orders' feature. 2. Procedure Order Documentation All orders must be documented in the resident's medical record, either electronically or in written…

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, interviews, review of facility policy and clinical records, the facility failed to monitor and/or document the use of a wander guard device according to standards of practice for one (1) of one (1) sampled resident (Resident (R)3), and toprovide care and services consistent with professional standards for the management of pain related to a resident's frequent request for an opioid pain medication prescribed as needed (PRN) and or to ensure the consistent administration of pain medication for one (1) of two (2) residents (R4) sampled for pain. Findings include: 1.) A review of facility policy titled, Wander Management System, reviewed September 2024, revealed 1. Policy- A wander management system will be used for those residents/patients who are assessed to be an elevated risk to wander or elope. 2. Procedure 1. A tag will be assigned to each resident/patient who qualifies for increased monitoring, per wrist band if ambulatory or to wheelchair if unable to ambulate. 2. The system function…

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, clinical record review, and staff interview, the facility failed to follow physician orders for oxygen therapy prescribed for one (1) of one (1) sampled resident (Resident (R)14). Findings included: A review of the clinical record revealed that R14 was most recently admitted to the facility on [DATE], with diagnoses to include Acute and Chronic Respiratory Failure with Hypoxia, chronic obstructive pulmonary disease (COPD), Acute Pulmonary Manifestations Due to Radiation, Pneumonia, and Influenza. Review of an admission Minimum Data Set (MDS) dated [DATE], revealed Section O, Special Treatments, Procedures, and Programs, revealed that the resident was receiving oxygen therapy. A review of the R14's Care Plan revealed a focused area for oxygen therapy, date initiated April 8, 2025, with interventions to include give medications as ordered by physician, monitor for signs/symptoms of respiratory distress and report to Medical Doctor (MD) as needed, and oxygen settings via nasal cannula (NC) at…

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, interview, and policy review, the facility failed to ensure the kitchens were maintained and operated in a safe manner to minimize the chances for potential spread of foodborne illness to all 21 residents in the facility. Failures included not storing food properly, handling ready to eat foods with gloves that had been in contact with potentially contaminated surfaces, failure to air dry pans and food containers before storage, and failure to ensure employee hair restraint while in the kitchens. Findings include: Review of the facility's policy titled Storing Staples, revised September 2016, revealed: .2. Procedure.2.1 All dry staples food items are stored in the dry storage area. Certain food items are stored off the floor on clean racks for ventilation and cleaning purposes. 2.2 Other staple items are stored in containers to be protected from splashes and other contamination. 2.3 Food items are rotated frequently. New stock is stored behind older stock to prevent deterioration 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and interviews the facility failed to assure a medication error rate of less than 5% (percent) based on medication pass observations for 1 of 3 residents. There were two medication administration errors resulting in an error rate of 7.67%. related to medication administration to Resident (R)224 who was admitted to the facility on [DATE] with diagnoses including, but not limited to acute respiratory failure with hypoxia. Findings include: During observation of Medication Administration on 03/18/24 at approximately 4:00 PM, Registered Nurse (RN)1 stated she was going to give Azelastine Nasal Spray to R224 and took a pharmacy labeled dispensing vial for R224 from the medication cart which had been labeled by pharmacy as Azelastine Nasal Spray for R224. RN1 then removed a container of Fluticasone Nasal Spray from the pharmacy labeled Azelastine vial. After punching other medications for R224 from medicine cards, she started toward the resident's room when the Surveyor stopped…

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, record review, staff interview, manufacturer' guidelines and review of the facility's policy and procedures, the facility failed to ensure the Medical Director worked with the facility to completely assess 1 of 5 residents (Resident (R)75) for unnecessary medications. Specifically, an antipsychotic and psychoactive medication was used by the facility without an attempted gradual dose reduction (GDR), proper medical rationale or proper indication for use. Findings include: Review of the facility's policy titled Psychotropic Medication Guideline revised March 2022 revealed, The Medical Director will act in an administrative and supervisory capacity by A. Contributing to the establishment of the Medical Policies in to the establishment of the Medical Policies B. Supervising the medical care given C. Ensuring that the medical policies are carried out D. Participating in the Quality Improvement Program to identify areas of improvement of patient care E. Approving medical care procedures as set…

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, record reviews, interview and facility Departmental Procedure, the facility failed to ensure expired medications were removed from active storage in 1 of 1 medications rooms. The findings include: On 2/14/22 at approximately 10:38 AM, inspection of the medication room refrigerator revealed one opened vial of Tuberculin, Purified Protein Diluted, Diluted, Aplisol by Par Pharmaceuticals 5 TU (test units)/0.1 ml (milliliter) 1ml (10 tests) approximately 1/4 full, dated as opened by the facility on 1/9/22. This medication was labeled by the manufacturer Once entered, vial should be discarded after 30 days and the manufacturer package insert states Vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency. The Departmental Procedure, revised October 2021, states under 2.3 Expired or discontinued medication shall not be stored with current medications. On 2/14/22 at approximately 10:48 AM, these findings were confirmed by Registered Nurse 1 and on 2/17/22 at approximately 9:05 AM, the Director of Nursing…

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 review of the facility Departmental Procedure, Food Storage in Country Kitchen Refrigerator, the facility failed to ensure an expired item was removed from the reach in cooler and failed to ensure open items in the cooler, freezer and the dry storage were labeled with an open date and resealed. The facility further failed to ensure food splatter was removed from the microwave in the Bistro and failed to ensure a covered trash receptacle was provided at the hand washing sink in the Bistro. This deficient practice has the potential to affect all 34 residents eating foods prepared and stored in the Bistro. The findings included: An observation on 2/24/22 at 10:40 AM during initial tour of the Bistro revealed the following: Food splatter in the top of the microwave. A covered trash receptacle not provided at the hand washing sink in the Bistro. A small carton of milk in the reach in cooler with an expired date of 2/12/22. A tub of mixed fruit opened and not labeled with an open date. An open bag of 2 frozen hamburger patties in the reach in freezer…

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 review, staff interview, review of the manufacturer's guidelines for medication use, and review of the facility's policy and procedure, the facility failed to ensure that one of five residents (Resident (R) R10) reviewed for unnecessary medication use did not receive psychoactive medication without a clinical risk versus benefit assessment and analysis, appropriate indication for use of the medication, attempting gradual dose reductions, identifying and routinely monitoring specific target behavior, and developing and implementing resident specific non-pharmacological interventions. This deficient practice had the potential for serious harm and/or death for all residents who reside in the facility. Findings include: Review of the facility's policy titled, Psychotropic Medication Guidelines dated May 2021, revealed the facility was to ensure that .Residents who have not used psychotropic medications would not be prescribed psychotropic medications unless the medication was necessary…

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.