Edgefield Post-Acute

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to maintain food service equipment and food storage areas in a clean and sanitary condition and failed to ensure sanitizing solutions were maintained at an effective concentration. Specifically, the facility failed to maintain kitchen equipment (including walk in refrigerators and freezers, reach in refrigerators, ice machine, handwashing sinks, and dish room drainage) in good repair and free from rust, mold, food debris, and leaks; and failed to ensure sanitizers were maintained at appropriate concentrations for effective sanitation. These deficient practices had the potential to affect 100 of 104 residents (excluding four residents on tube feedings) and had the potential to result in food contamination and foodborne illness.

Inspectors wroteBased on observation and interview, the facility failed to maintain resident rooms and bathrooms in good repair for 5 of 49 resident rooms sampled, (Rooms 129, 200/203, 225, 227, and 224/226). These failures included damaged air conditioning units, chipped and broken furniture, cracked drywall, bathroom fixtures in disrepair, and lack of a formal maintenance system. This resulted in an environment that was not consistently safe or well maintained.1. During an observation on 04/15/26 at 10:51 AM, of room [ROOM NUMBER] revealed the air conditioning unit was broken, the controller was filled with dust, and the metal cover was rusted and falling off with paint flecking. [...]

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to promote and maintain dignity during dining services for 3 of 21 Residents (R)61, R33, and R37, reviewed who ate in the Main Dining Room. This failure resulted in residents experiencing prolonged waits for meals and being assisted in a manner that did not preserve dignity.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure medications were not left at the bedside for a resident who was not assessed as able to self-administer medications, for 1 of 1 Resident (R)11. This failure placed the resident at risk for unsafe medication use and improper self administration.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure that 1 of 1 resident (Resident (R)85), reviewed for restraints out of a total sample of 49, was properly assessed for the use of positioning devices (pillows used as a restraint) intended to reduce the risk of rolling, crawling, or falling out of bed. In addition, the facility failed to ensure that informed consent was obtained and documented for the use of a chair alarm. (Cross Reference F684 and F689)

Inspectors wroteBased on record review, and interview, the facility failed to ensure 1 of 3 residents (Resident (R)12) and their resident representatives (RR), reviewed for emergent hospital transfer out of a total sample of 49 residents, were provided with a written bed hold policy and transfer notice that contained the appeal process. This failure had the potential to affect the resident 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 record review, interview, review of the Centers for Disease Control and Prevention (CDC) guidelines, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure 2 of 2 residents (Resident (R)94 and R109) out of 49 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 of the residents.(Cross Reference F883)

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to: 1. Ensure neurological checks were conducted as ordered by the medical provider after 1 of 2 residents (Resident (R)85) reviewed for falls, was found on the floor crawling (a potential unwitnessed fall) out of a survey sample of 49. This failure to complete neurological checks placed the resident at risk for potential neurological decline; 2.) Follow the facility's policy regarding the assessment and documentation of open areas for 1 of 1 resident (R9) reviewed for open skin areas in the sample of 49 residents. The failure to accurately assess and document the resident's open areas as indicated in the facility's policy had the potential to affect the notification of the provider for treatment when the open areas size increased or the areas showed signs of infection; [...]

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to complete a root cause analysis for a potential unwitnessed fall for 1 of 2 residents (Resident (R)85), reviewed for falls out of a total sample of 49. Without identifying why the resident was found on the floor, the cause of a potential fall (e.g., toileting needs, environmental hazards, medication effects, poor footwear, lack of assistance) was not identified, and the same risk factors remain unaddressed.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure residents received alternative measures prior to the installation of side rails; document discussion related to risk versus benefits; and obtain signed informed consent prior to bed rail use for 1 of 3 residents (Resident (R)64), reviewed for side rails out of 49 sampled residents. The lack of alternate side rail measures and proper assessment/consent could lead to a potential restraint or side rail entrapment.

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to ensure proper personal protective equipment (PPE), specifically ex-large disposable gloves were available for staff use prior to entering into a contact/droplet transmission-based precaution (TBP) room and/or failed to post proper TBP signage for contact/droplet precautions for 2 of 2 residents (Resident (R)87 and R75), reviewed for TBP out of a total sample of 49. This increased the likelihood that infectious organisms could be transmitted from residents to staff, other residents, or the environment.

Inspectors wroteBased on interview, record review and facility policy review, the facility failed to ensure an antibiotic was not used without the presence of a diagnosed infection for 1 of 1 resident (Resident (R)9) reviewed for antibiotic stewardship out of a total sample of 49. The failure had the potential to increase the risk of adverse events, including the development of antibiotic-resistant organism, from unnecessary or inappropriate antibiotic use.

Inspectors wroteBased on interview, record review, facility policy review, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to offer 2 of 5 residents (Residents (R)94 and R109) reviewed for flu/pneumonia vaccinations and/or their representatives, the opportunity for the residents to be vaccinated in accordance with nationally recognized standards. This practice had the potential to increase the risk for residents to contract pneumonia.

Inspectors wroteBased 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 (ADLs) that were necessary to maintain good grooming and personal hygiene for 2 (Resident #59 and Resident #8) of 3 sampled residents reviewed for ADL care. Specifically, Resident #59 and Resident #8 had fingernails that were long, jagged, and dirty.

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to ensure that a glucose meter (a device used to monitor blood glucose levels) was cleaned with an approved disinfectant wipe. This affected 1 (Resident #2) of 2 residents observed for blood glucose testing during the medication pass observation.