NHC HealthCare - North Augusta

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, interview, and record review, the facility failed to ensure Resident (R)12 received his nasal spray, based on physician orders, for three consecutive days, for 1 of 3 residents reviewed.Findings Include:Review of the facility policy, Preparation and General Guidelines: Medication Administration - Guidelines, with a revision date of 01/01/19, revealed, Policy.Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. D. Documentation.7) If a dose of regularly scheduled medication is withheld, refused, not available, or given at a time other than the scheduled time (e.g., the resident is not in the facility at the scheduled dose time, or a starter dose of antibiotic is needed), the space provided on the MAR for that dosage administration is initialed and circled if using a paper MAR, if electronic MAR follow manual's direction for documentation of such.Review of R12's Face Sheet revealed he…

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, record review, and interviews, the facility failed to ensure pharmaceutical services were provided to meet Resident (R)12's needs for 1 of 1 resident reviewed. Specifically, R12's Afrin nasal spray and Saline nasal spray was ordered by the physician on 02/21/26 and was not administered for three days due to unavailability.Findings Include: Review of the facility policy, titled Preparation and General Guidelines: Medication Administration - Guidelines, last revised January 01, 2019, documented, Policy: Medications are administered as prescribed in accordance with good nursing principles . 12) If a medication with a current, active order cannot be located in the medication cart/drawer, other areas of the medication cart, medication room, and facility are searched, if possible. If the medication cannot be located. the pharmacy is contacted or medication removed from the night box/emergency kit.Review of R12's Face Sheet revealed he was originally admitted to the facility on…

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 review, and review of facility policies, the facility failed to ensure the environment remained free from potential accident hazards for 4 of 5 residents, related to medications at bedside. Specifically, the facility failed to ensure the environment for Resident (R)33, R389, R38, and R69, was free of medication that was required to be properly monitored and stored, to prevent accidental hazards. Findings include: Review of the facility policy, revised 01/01/2019, titled, Medication Storage in the Facility policy states, Medications and biologicals are stored safely, securely and properly manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Under Procedures, B. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medication are permitted to access medication. Medication rooms, carts,…

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 review, and policy review, the facility failed to provide respiratory care in accordance with professional standards. Specifically, the facility failed to ensure the nebulizer machines mask for Resident (R)69 and R389 were clean, labelled, and bagged when not in use. Findings include: Review of the policy titled Jet Nebulizer Treatment revised 09/07 reveals under procedure,10. When treatment is completed remove the nbulizer to the sink area, empty any remaining medication, rinse with water, and return setup to bag. Note change nebulizer setups weekly, date and initial equipment. Review of Review of Resident 69's face sheet revealed that resident was current admitted to the facility on [DATE] with the diagnoses listed but not limited to dementia, Alzheimer's disease, major depressive disorder, chronic obstructive pulmonary disease, hypertensive heart disease with heart failure, atherosclerotic heart disease, left bundle block, benign prostatic hyperplasia, and unqualified…

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 the facility policy titled, Specific Medication Administration Procedures IIB1: Administration Procedures for All Medications, observations and interviews, the facility failed to ensure Resident (R)95 was free from significant medication errors. Specifically, ertapenem reconstituted solution 1 gram infused with 100mL of normal saline intravenous (IV) in a safe manner and in accordance with professional standards of medication administration via peripherally inserted central catheter (PICC or PICC line). The findings include: Review of the facility policy titled, Specific Medication Administration Procedures IIB1: Administration Procedures for All Medications, states under the Policy Statement, To administer medications in a safe and effective manner. An observation on 10/17/2024 at 1:08 PM revealed ertapenem intravenous administration for R95. Licensed Practical Nurse (LPN)1 failed to ensure R95 safely received antibiotic therapy via PICC line by improperly managing the IV line once primed to reduce the risk of contamination before going to the patient. The primed uncapped…

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, record review, observation and interview the facility failed to provide 1 of 4 residents (R95) and 1 of 34 medication opportunities given by 4 nurses, medication administration without possibility of cross contamination. Specifically, ertapenem reconstituted solution 1 gram infused with 100mL of normal saline intravenous in accordance with infection control and prevention standards of medication administration via peripherally inserted central catheter (PICC or PICC line). Findings include: Review of the facility policy titled, Specific Medication Administration Procedures IIB1: Administration Procedures for All Medications, states under the Policy Statement, To administer medications in a safe and effective manner. Review of the facility policy titled, PICC and Midline Catheter Flushing, states under general guideline, 3. Consult state Nurse Practice Act for RN/LPN scope of practice and function. Review of Competency standard skills checklist PICC lines with DON name,…

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 Center for Medicare and Medicaid Services (CMS) QSO-20-38-NH Revised, and policy review, interviews, and record reviews, the facility failed to perform COVID-19 testing immediately for all staff and residents regardless of vaccination status when an outbreak was identified and failed to retest every three to seven days until no additional cases were identified for 14 days. The facility failed to perform thorough contact tracing when staff tested positive for COVID-19 to determine residents and staff with higher exposure which added to the noncompliance with staff and resident testing in an outbreak. This noncompliance resulted in 17 residents (Resident (R) 18, R56, R69, R78, R83, R110, R120, R154, R155, R255, R258, R259, R260, R261, R262, R263, and R264) and 17 staff members contracting COVID-19 and increased likelihood for additional serious infections and potential hospitalizations and death due to transmission of COVID-19 between staff members and residents. Findings include: Review of 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 the facility's policy, record review, observations, and staff interviews, the facility failed to check for placement of a gastrostomy (g)-tube prior to administering medications for 1 resident (Resident (R) 38) of 5 residents reviewed during medication administration. Findings include: Review of the facility's undated Feeding/Enteral Tube Medication Administration Procedure read, in pertinent part, Check tube placement by aspirating gastric contents (prior to water flush and medication administration). Review of R38's undated Resident Face Sheet, found in the electronic medical record (EMR) under the Face Sheet tab revealed R38 was admitted to the facility on [DATE] with diagnoses including schizophrenia, dementia with behaviors, dysphagia (difficulty swallowing), adult failure to thrive, and encounter for attention to gastrostomy tube (G-Tube-a tube surgically placed into the stomach through the abdomen used for hydration, nutrition, and medication administration). Review of R38'sPhysician…

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, record review, and staff interviews, the facility failed to ensure the appropriate use of side rails for 2 Residents (R), R7 and R38 of 4 residents reviewed for accidents. Findings include: The facility's side rail policies were requested on 09/01/22 at 10:34 AM and were not received prior to facility exit. In an interview conducted with the Director of Nursing (DON) at the time of the request, she indicated side rails were addressed for each resident specifically as part of each resident's individualized plan of care. 1. Review of R38's undated Resident Face Sheet, found in the electronic medical record (EMR) under the Face Sheet tab, revealed R38 was admitted to the facility on [DATE] with diagnoses including schizophrenia and dementia with behaviors. Review of R38's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/22/22 indicated R38 was dependent upon two or more staff for all mobility, including mobility within her bed and transfers in…

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 policy review and interview, the facility failed to ensure that 2 of 8 staff (Certified Nursing Assistant (CNA)7 and CNA8) reviewed for COVID-19 vaccination status were fully vaccinated. This failure increases the risk of transmission of COVID-19 to residents and other staff members. Findings include: Review of the facility's policy titled Human Resources Policies and Procedures CMS Emergency Regulation- Mandatory COVID-19 Vaccine, revised 03/18/22, stated Our company requires all employees to receive the COVID-19 vaccine .If you are hired, the company will require you to prove that you have received the COVID-19 vaccine or have a valid medical or religious reason not to be vaccinated .New hires will be subject to the same requirements as current staff and must have received, at a minimum, the first dose of a two-dose COVID-19 vaccine or a one-dose COVID-19 vaccine prior to providing any care, treatment, or other services for the center/agency and/or its patients .The employer shall require and maintain documentation for each eligible individual (including new hires) proof…

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.