Anderson Mill Center for Nursing and Healing LLC

Inspectors wroteBased on staff interviews, record review, and review of the facility policy titled, Transfer and Discharge (including AMA [Against Medical Advice], the facility failed to ensure six of 41 sampled residents (Resident (R) 3, R7, R149, R4, R15, and R72) and their resident representatives (RR) reviewed for emergency hospital transfer, were provided with a written transfer/discharge notice which contained the appeal process. This failure had the potential to affect the residents and their RR by not having the knowledge of how to appeal the transfer, if desired, and had the potential to contribute to the possible denial of re-admission and loss of the resident's home following hospitalization for residents transferred to the hospital.

Inspectors wroteBased on resident and staff interviews, record review, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure one of two residents (Resident (R) 31) out of 41 sampled residents had an accurate Minimum Data Set (MDS) assessment. Failure to code the MDS correctly could potentially lead to inaccurate federal reimbursements and inaccurate assessment and care planning of the residents. (Cross Reference F656)

Inspectors wroteBased on resident and staff interviews, record review, and review of the facility policy titled, Comprehensive Care Plans, the facility failed to develop a person-centered comprehensive plan of care with measurable goals and interventions for one of one resident (Resident (R) 31) reviewed for mental health, specifically for post-traumatic stress disorder (PTSD). This failure had the potential for staff to provide inconsistent and incomplete care related to the resident's PTSD.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled, Weight Monitoring, the facility failed to ensure weekly weights were implemented for one of one resident (Resident (R) 59) reviewed for nutrition out of a survey sample of 41. This lack of monitoring of residents' weight loss/gain can delay in identifying potential nutritional problems.

Inspectors wroteBased on staff interview and review of the facility policy titled, Infection Preventionist, the facility failed to ensure the designated Infection Preventionist (IP) (IP6) completed specialized training in infection prevention and control. This failure had the potential to affect the well-being of any of the 138 residents and/or the staff by not ensuring all current infection prevention and control measures were being instituted.

Inspectors wroteBased on staff interview, record review, review of the facility policy titled, Pneumococcal Vaccine (Series), and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to offer one of seven residents (Residents (R) 74) reviewed for flu/pneumonia vaccinations and/or their representatives, the opportunity for the residents to be vaccinated in accordance with nationally recognized standards. This deficient practice had the potential to increase the risk for residents to contract pneumonia.

Inspectors wroteBased on observations, staff and resident interviews, record review, and review of the facility's policy titled, Assessment: Nursing, the facility failed to ensure that the care plan was updated for one of three sampled residents (R) (R3). This deficient practice placed the resident at risk for unmet care needs and delayed interventions because the care plan remained inaccurate regarding the level of assistance required.

Inspectors wroteBased on observations, record review, review of facility policy, and interview with facility staff, the facility failed to provide routine drugs or obtain them under an agreement for one of 32 sampled residents (R) R#119. Additionally, the facility's Pharmacy failed to notify nursing of the need for additional information in order to supply a schedule IV-controlled substance.

Inspectors wroteBased on observations, record review, review of facility policy, and interviews with facility staff, the facility failed to ensure the medication error rate was not five percent or greater for one of three residents (R) #119. There were two medications errors in 29 opportunities during observation of medication administration to three residents for a medication error rate of 6.89% (percent).

Inspectors wroteBased on observations, staff interviews, and review of the facility's policy, the facility failed to establish an infection prevention and control program (IPCP) that included preventing and controlling infections and communicable disease for all residents, staff and other individuals by not utilizing proper personal protective equipment (PPE) and hand sanitization during administration of medications for two of three residents during observation of medication administration to Resident (R)#119 and R#53.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled, Incontinence, the facility failed to provide timely and appropriate incontinence care for one of four residents (R) (R7) reviewed for incontinence care. The deficient practice had the potential to promote infection.

Inspectors wroteBased on observations, interviews and review of policies titled Medication Storage, Administration of Eye Drops or Ointments, document provided by the facility titled Insulin Storage and Dispensing Info, and manufacturer's recommendations, the facility failed to ensure medication was stored properly on 3 of 6 medication carts (300 Hall Medication Cart, 500 Hall Medication Cart, and 600 Hall Medication Cart). Specifically the facility failed to ensure that the 500 Hall and 600 Hall medication cart were locked and secured when out of the sight of a nurse; failed to ensure eight containers of ophthalmic solutions were labeled when opened; failed to ensure three oral inhaled medication were labeled when opened; failed to ensure one nasal spray was labeled when opened; failed to ensure three multi-dose vials of Insulin and one multi-dose Insulin pen were labeled when opened; [...]

Inspectors wroteBased on observations, interviews, record reviews and policy reviews, the facility failed to ensure appropriate infection control practices for 17 of 64 sampled residents (R#90, R#336, R#337, R#87, R#83, R#45, R#1, R#338, R#6, R#28, R#65, R#7, R#96, R#101, R#8, R#41, and R#119). Specifically staff failed to clean or disinfect reusable resident equipment (a blood pressure cuff) between R#90, R#336, R#337, R#87, R#83, R#45, R#1, R#338, R#6, R#28, R#65; failed to ensure a clean surface area for equipment use (failed to use a barrier or clean resident's table tops or medication cart surface before placing glucometer and supplies on them) between R#7, R#96, R#101, and R#8; failed to use appropriate hand hygiene between performing glucometer checks for R#7, R#96, R#101, and R#8; failed to use appropriate hand hygiene during wound care for R#41; [...]

Inspectors wroteBased on observations, interviews, record review, and policy review, the facility failed to ensure resident right to dignity and respect was honored related for 19 of 64 sampled residents (R#44, R#90, R#336, R#337, R#87, R#83, R#45, R#1, R#338, R#6, R#10, R#86, R#89, R#61, R#60, R#77, R#21, R#28, and R#65) related (1) ensuring that the catheter was placed in a privacy bag for R#44; (2) ensuring staff knocked on resident doors before entering for R#90, R#336, R#337, R#87, R#83, R#45, R#1, R#338, R#6, R#10, R#86, R#89, R#61, R#60, R#77, R#21, R#28, and R#65.

Inspectors wroteBased on observations, interviews, record review and review of the policy titled Medication: Self Administration, the facility failed to ensure one of 64 sampled residents (R) (#97) was assessed to self-administer medications.

Inspectors wroteBased on observations, staff interviews, and review of facility documents, the facility failed to maintain a safe, clean, sanitary environment in 13 of 76 resident rooms (310, 306, 501, 502, 503, 504, 505, 506, 507, 508, 510, 512, and 514). Specifically, observations revealed buildup of brown fuzzy material on the heating and cooling units located in resident rooms on the 500 Hall (rooms 501,502, 504, 506, 508); buildup of white fuzzy material on ceiling ventilation covers in resident restrooms on the 500 Hall (rooms 501/503 (shared), 502/504 (shared), 506/508 (shared), 510/512 (shared), 505, 507, 514); black substance surrounding the base of the toilets in resident restrooms on the 500 Hall (rooms 501/503 (shared), 510/512 (shared), 505); one heating and cooling unit cover lying on the floor in room [ROOM NUMBER]; [...]

Inspectors wroteBased on observations, record review, staff interviews, and review of the undated policy titled Resident Assessment - Coordination with PASARR Program the facility failed to submit an application for PASARR Level II (Preadmission Screening and Resident Review) screening for evaluation and determination of specialized services for two of 64 sampled residents (R) (R#102 and R#61). Findings Included: A review of the undated policy titled Resident Assessment - Coordination with PASARR Program revealed a policy of: This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives services in the most integrated setting appropriate to their needs. The policy explanation and compliance guidelines sections line numbered 9 revealed: 9. [...]

Inspectors wroteBased on observations, record review, review of policy titled Oxygen Administration dated December 2022 and staff interview, the facility failed to ensure that one of 64 sampled residents (R) (R#49) were administered oxygen therapy in accordance with the physician orders and failed to date and label oxygen tubing.