NHC Healthcare - Mauldin

Based on review of facility policy, observation and interview, the facility failed to store, prepare and distribute food under professional standards of food safety. This had the potential to affect 167 of 167 residents who resided at the facility and increased the risk of food-borne illnesses. Findings include: Review of the facility's policy titled, Safety & Sanitation Best Practice Guidelines, under the subtitle Sanitation, Manual Warewashing, dated 11/2017 revealed, on item b A chemical sanitizing solution at the proper concentration and at the correct temperature for the sanitizer used. The policy goes onto to state (see chemical sanitizing on page C28-C29). These policy/pages were not available to the surveyor during the survey. Review of the facility's policy titled, Safety & Sanitation Best Practice Guidelines, dated 11/2017, revealed no process for loading and unloading the dishwasher and only referenced to the state food code for further instruction. Observations on 03/06/25 at 8:30 AM with Food Service Director (FSD)1 revealed [NAME] 2 washing dishes in 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 observation, interview, and review of facility menus and meal cards, the facility failed to follow menus for seven of 167 residents (Resident (R) 145, R13, R29, R80, R135, R149, and R67) whose meal service was observed. This failure had the potential to cause increased blood sugar levels and/or affect the residents' cardiac status. Findings include: 1. Review of the facility's menu for the noon meal on 03/06/25, provided by the facility, revealed residents with diet orders of a consistent carbohydrate diet were to receive one half-piece of frosted peanut butter sheet cake for dessert. During an observation on 03/06/25 at 11:52 AM, R145's meal card was noted to read the resident was to receive a consistent carbohydrate diet. R145 was observed to receive one whole piece of frosted peanut butter sheet cake. During an observation on 03/06/25 at 12:25 PM, R13's meal card was noted to read the resident was to receive a consistent carbohydrate diet. R13 was observed to receive one whole piece of frosted peanut butter sheet cake. During an observation on 03/06/25 at 12:45 PM, R29's…

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, record, and policy review, it was determined the facility failed to conduct medication self-administration assessments and have physician orders for self-administration of medications for one of one resident (Resident (R) 63) reviewed for self-administration of medications out of a total sample of 33. This had the potential to cause harm to R63 through medication administration errors. Findings include: Review of the facility's policy titled, Self-Administration of Medications, revised 02/25/25, revealed, . If a resident desires to self-administer medications, a physician's order should be obtained then an assessment is conducted by a member of the interdisciplinary team of the resident's cognitive (including orientation to time), physical and visual ability to carry out the responsibility. For those residents who self-administer, a member of the interdisciplinary team verifies the resident's ability to self-administer medications by means of a skill assessment on a quarterly…

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 interview, record review, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to ensure the Minimum Data Set (MDS) was coded accurately for three of 33 residents (Residents (R) 95, R74, R42) whose clinical records were reviewed. The facility failed to accurately code a quarterly assessment for hospice services for R95 and for therapy services for R42. In addition, the facility failed to accurately code the use of antipsychotic medication for R74. These failures placed the residents at risk of unmet care needs and a diminished quality of life. Findings included. Review of the October 2024 RAI manual, page 1-5 revealed, . An accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations . It is important to note here that information obtained should cover the same observation period as specified by the MDS (minimum data set) items on the assessment, and should be validated for accuracy (what the resident's actual status…

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 review of the facility policy, observation and interview, the facility failed to ensure a specialized wheelchair was clean and sanitary for one of one resident (Resident (R) 131) reviewed for specialized wheelchairs in a total sample of 33. This failure placed the resident at risk for a diminished quality of life and dignity. Findings include: Review of an undated facility policy titled, Noncritical Patient Care Equipment-Cleaning Procedure Summary revealed, . Dedicated equipment-when dedicated to a particular patient during their stay . Frequency . Consistent with cleaning frequency for patient area, and as needed . Person Responsible . Cleaning Partners . Clean and disinfect with a rapid multi surface disinfectant and cleaner or disinfecting wipes . Review of R131's Face Sheet, located in the Face Sheet tab of the electronic medical record (EMR), revealed R131 was admitted to the facility on [DATE] with diagnoses including but not limited to: multi-system degeneration of the autonomic nervous system.…

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 review of the facility policy, observations and interviews, the facility failed to ensure the removal of expired supplies from 3 of 6 medications carts, 1 of 1 treatment cart and 1 of 2 storage rooms. Findings include: Review of the facility's policy titled, Medication Storage in The Facility revised January 2019, revealed, Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock and returned to pharmacy if appropriate or disposed of on the units. During an observation on 01/31/24 at 11:44 AM of the Medication Cart #3 on Unit 3 revealed: 1 expired BinaxNOW COVID test kit with expiration date of 06/07/23. During an observation on 01/31/24 at 11:50 AM of the Treatment Cart on Unit 3 revealed: 2 boxes of Sureprep Rapid Dry No Sting - Barrier wipes with an expiration date of July 2023, 1 package of Calcium Alginate dressing with an expiration date of 06/28/23, 1 Telfa Non-Adherent dressing with an expiration date of October 2023 and 1 opened package of sterile gauze.…

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 policy, the facility failed to ensure foods that are stored in the freezer and 2 of 3 unit refrigerators were labeled, dated with a use by date and/or discarded after the manufacturer's expiration date. Findings include: Review of the facility's policy titled, Safety and Sanitation Best Practices Guidelines-Refrigerator and Freezer storage, dated 11/2017 indicated: 9a. Foods will be stored in their original container, or an NSF approved container or wrapped tightly in moisture-proof film, foil, etc. Clearly labeled with the contents and the use by date. (Food Code 3-501.17). During an observation and interview on 01/29/23 at 12:03 PM, of the kitchen freezer revealed: a 32 ounce (oz) bag of [NAME] Shrimp unlabeled without a use by date and a 7 pound (lbs) bag of Cold-Water Shrimp unlabeled without a use by date. The Dietary Manager (DM) acknowledged the shrimp were not in their original package and did not have a use by date. Further observation of the freezer revealed: a bag of whole cranberries dated 2017. The Dietary…

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, record reviews, review of facility policy and review of manufacturer's guidelines, the facility failed to clean and disinfect a blood glucose meter per device and manufacturer's instructions before and after use for 1 of 1 resident, Resident (R)146. Additionally, the facility failed to ensure that its staff demonstrated proper hand hygiene while assisting a resident during meal time. Findings include: Review of the facility's policy titled, Blood Glucose Monitoring Technique revised 11/13/18, revealed, 15. Clean glucometer with alcohol wipe and place on barrier to air dry. 18. Place clean meter into storage box and return the storage box to the drawer or closet. Review of the Manufacturer's Guidelines titled, Cleaning and Disinfecting the Assure Prism multi-Blood Glucose Monitoring System (BGMS) revised September 2019, revealed, The meter will be cleaned and disinfected after use on each patient. Review of R146's Medication Administration Record (MAR) dated 01/31/24 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.