Inman Healthcare

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and facility policy review, the facility failed to ensure palatability for residents' food being served at an appropriate temperature for 3 of 3 residents (Resident (R)29, R31, and R30) out of 13 sampled residents. This failure had the potential to affect all 34 residents (2 puree, 11 mechanical textures, and 21 regular) in the facility, who received food that was cold and undesirable to eat. This had the potential to create dissatisfaction with meals and decrease the residents' quality of life. Findings include: Review of the facility's undated policy titled, Food Temperatures, indicated, Foods will be maintained at proper temperature to ensure food safety. The point of service temperature to residents will be within the range of 120-140 degrees based on the resident's preference. The following range of temperatures is recommended for food at point of tray assembly. Broth, soup, hot beverages 180-190 degrees F [Fahrenheit] 160 Meat, portioned for service degrees…

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 facility policy review, the facility failed to ensure a handwashing sink was available, personal protective equipment (PPE) was available, failed to maintain the wall space around the dryer vents which left openings in the wall large enough for pests or small rodents to enter, failed to prevent cross contamination from dirty areas to clean areas within the laundry room, failed to provide a system to enable staff to fold clothing on a surface that could be sanitized, failed to store clean clothing, assorted pillows, and towels in an area to maintain cleanliness, and failed to maintain cleanliness and maintenance of two washing machines for one of one laundry room. This failure had the potential to affect infection control measures for 34 of 34 census residents. Findings include: Review of the facility's policy titled, Laundry with a review date of 07/14/24, indicated: 1. Aligning with principles of standard precautions, staff should consider all previously worn clothing and used linens as potentially contaminated. 2. The facility's laundry area…

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, refrigerators and dry food storage were appropriately sealed, labeled, dated with a use by date and/or discarded after the manufacturer's expiration date. Findings include: Review of the facility's undated policy titled, Food Safety Requirements, showed that food will be stored, prepared, distributed and served in accordance with professional standards for food service safety. Policy Explanation and Compliance guidelines: Storage of food in a manner that helps prevent deterioration or contamination of the food, including from growth of microorganisms. Facility staff shall inspect all food, food products, and beverages for safe transport and quality upon delivery/receipt and ensure timely and proper storage. Labeling, dating, and monitoring refrigerated food, including but not limited to leftovers, so it is used by its use-by date, or frozen (where appl)/discarded. During an observation on 03/05/24 at 10:58 AM, the kitchen refrigerator revealed one…

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 facility policy, record review and interviews the facility failed to provide written notices of hospitalization to the Responsible Party (RP) and/or the Resident (R) and failed to ensure that the Ombudsman was notified for (R)3 in a timely manner for 1 of 2 residents reviewed for hospitalizations. The findings include: The facility admitted R3 with diagnoses including but not limited to, cirrhosis of liver, dementia, and history of falling. Review of Nurses Notes for hospitalizations on 02/28/24 revealed documentation from 06/28/2023 at 6:24 PM, Resident stated she wanted to be sent to Emergency Department (ED). This nurse and [another] nurse assessed [patient] pt. Abnormal [vital signs] v/s. Resident states I don't feel good she also stated that her body was aching all over. Resident was slurring her speech and had periodic episodes of rolling her eyes back and screaming I want to go now. Showing [signs and symptoms] s/s of anxiety while waiting on [Emergency Medical Service] EMS. Resident have been…

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 facility policy, record review, and interviews, the facility failed to provide the bed hold document to Resident (R)3 and/or Resident Representative (RR) in a timely manner for 1 of 2 reviewed for hospitalization. Findings include: Review of the facility policy titled, Bed Hold and Therapeutic Leave Policy, undated, revealed Before the Center transfers a Resident to a hospital ., the Center must provide this written information to the Resident or the Resident Representative that specifies the Center's bed hold and therapeutic/temporary leave policy. The following applies to all residents. Medicaid Residents-Bed Hold: If the Resident leaves the Center for hospitalization, the Center will reserve or hold a bed available for the Resident for up to ten (10) consecutive calendar days per medically necessary hospital stay when the Resident is expected to return to the Center per South Carolina Medicaid. If the Resident is hospitalized for a period longer than ten (10) days, the Resident will be discharged .…

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, record review, and facility policy review, the facility failed to provide services to residents who were unable to carry out activities of daily living (ADL) necessary to maintain good grooming and personal hygiene for Resident (R)9; 1 of 4 reviewed for assistance with ADL care. Findings include: Reviewed the facility's undated policy titled, Activities of Daily Living (ADLs), revealed, Policy Explanation and Compliance Guidelines 3. a resident who is unable to carry out activities of daily living will receive necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Review the facility's undated policy, titled, Nail Care, revealed, Policy Explanation and Compliance Guidelines: 3. Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis. 4. Routine nail care, to include trimming and filing, will be provided on a regular schedule (such as weekly on Wednesday 3-11 shift). Nail care will be provided between scheduled occasions as the need arises. Review of the face sheet revealed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations, interviews, and record review, the facility failed to administer oxygen per physician's orders for 1 of 1 residents reviewed for respiratory care, Resident (R)17. Findings include: Review of the facility's policy titled, Oxygen Administration dated 2024 revealed, Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and resident's goals and preferences. Definitions: 'Oxygen therapy' is the administration of oxygen at concentrations greater than that in ambient air (20.9%) with the intent of treating or preventing the symptoms and manifestations of hypoxia. 'Hypoxia' means decreased perfusion of oxygen to the tissues. Policy Explanation and Compliance Guidelines: 1. Oxygen is administered under orders of a physician . 2. Personnel authorized to initiate oxygen therapy include physicians, RNs, LPNs, and respiratory therapists. 3. Staff shall document the initial 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 observation, record reviews, and interviews the facility failed to provide an appropriate alternative to the normal menu. Findings Include: A review of the four (4)-week menu for the facility showed there were no food alternatives shown for the main menu. A review of the policy/procedure titled Dietary Services - Menus and Nutritional Adequacy (no date) showed l. Specially prepared or alternative food requested instead of the food and meals generally prepared by the facility. During an interview on 2/17/2022 at 2:39 p.m., Resident #28 who stated that the food is the biggest complaint of the meetings. She stated that nothing has changed with the complaints, and no one has given them any resolution to their complaints. During an interview on 2/17/2022 at 3:02 p.m., Resident #19 stated that there are times when she/he does not want the food, but most times will not eat the alternative and will just not eat at all. During an interview on 2/18/22 at 9:32 a.m., Activities Director (AD) stated that when residents request an alternative, they have the option of a peanut butter 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 observation and interviews, the facility failed to follow proper sanitation and food handling practices by maintaining kitchen equipment in a clean and sanitary manner and the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness. The findings included: During the initial tour of the facility on 2/15/22 at 10:03 a.m., it was observed that a dust build up was on the range hood. The range hood cleaning sticker showed the hood was last cleaned in May 2021 and was scheduled to be cleaned again in November 2021. Dust particles were observed along the edge of the hood. During the initial tour of the kitchen on 2/15/22 at 10:13 a.m., an observation of the reach in freezer showed that sausage patties, chopped grilled chicken, and sliced carrots were not stored in closed containers and were not dated and labeled. A request was made twice for a cleaning schedule for the kitchen but was not received. A review of the policy entitled Safety (Revised 8/2013) under the portion entitled Safety Guidelines showed that equipment…

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 reviews the facility failed to ensure that dietary services demonstrated their response to grievances filed by the Resident Council group and residents, and the rationale for such response. Findings include: A review of the policy/procedure with the subject of Resident Right-Grievance (no date) showed that the resident has the right to and the facility will make prompt efforts by the facility to resolve grievances the resident may have, in accordance with this paragraph. A review of the policy/procedure with the subject of Dietary Services - Menus and Nutritional Adequacy (no date) showed that Menus will: (4) Reflect, based on a facility's reasonable efforts, the religious, cultural and ethnic needs of the resident population, as well as input received from residents and resident groups. A review of the four (4)-week menu for the facility showed that there was no bacon offered as part of the menu for breakfast throughout the entirety of the menu cycle. A review of the Resident Council Meeting Minutes showed that on 9/14/21, residents stated that they…

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, record review, and policy review, the facility failed to ensure controlled substance medications were secured under double lock and key to prevent the potential for residents accidentally ingesting the medications or drug diversion if staff confiscates the medications. Findings include: Review of the facility policy titled, Storage and Expiration Dating of Medications, Biologicals revised 1/1/22, revealed: Store all drugs and biologicals in locked compartments, including Schedule II-V medications in separately locked permanently affixed compartments, permitting only authorized personnel to have access. On 2/15/22 at 9:05 a.m., the Survey Team entered the facility to conduct a Recertification Survey and was directed to work in the Administrator's Office. The office door remained unlocked to allow the team to enter and exit the office as needed. When Registered Nurse (RN) #2 started his/her shift later that day, he/she discovered some resident-controlled medications that needed to be destroyed as the resident had been discharged that day with no…

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.