NHC Healthcare, Ft Sanders

Inspectors wroteBased on medical record review, observations, and interview, the facility failed to maintain resident dignity when urinary drainage bags were uncovered for 2 residents (Residents #14 and #2) of 6 residents reviewed with indwelling urinary catheters.

Inspectors wroteBased on facility policy review, medical record review, observation, and interview, the facility failed to provide a clean and sanitary environment to ensure cleanliness of personal fans for 2 residents (Residents #92 and #40) of 134 residents reviewed for a clean and sanitary environment.

Inspectors wroteBased on medical record review and interview, the facility failed to resubmit a Pre-admission Screening and Resident Review (PASRR) for Level II Evaluation after new mental health diagnoses were identified for 1 resident (Resident #6) of 5 residents reviewed for accurate PASRR.

Inspectors wroteBased on review of medical records, observations, and interviews, the facility failed to provide nail care to 1 resident (Resident #26) of 134 residents reviewed.

Inspectors wroteBased on facility policy review, medical record review, facility documentation review, observations, and interviews, the facility failed to follow Physician Orders for 2 residents (Residents #3 and #77) of 134 residents reviewed. The facility was cited at F-684 as Past Non-Compliance (PNC). Non-compliance began on 11/14/2025 and ended on 12/15/2025.

Inspectors wroteBased on facility policy review, medical record review, observation, and interview, the facility failed to ensure that medications were secure for 1 resident (Resident #84) of 134 residents reviewed. Review of the facility policy titled, Medication Storage In The Facility, dated 2/25/2025, revealed .Medications .are stored safely securely, and properly, following manufacturer's recommendations .the medication supply is accessible only to licensed nursing personnel .stored in a medication cart or other designated area . Review of the medical record revealed Resident #84 was admitted to the facility on [DATE], with diagnoses including Diabetes and Acute Metabolic Acidosis (electrolyte disorder causing too much acid in the blood). [...]

Inspectors wroteBased on facility policy review, medical record review and interviews, the facility failed to ensure ongoing communication between the facility and the offsite dialysis center had been completed for 1 resident (Resident #64) of 3 residents reviewed for dialysis.

Inspectors wroteBased on review of the Tennessee Mock Skills Testing Booklet, facility policy review, medical record review, observation and interview, the facility failed to follow appropriate hand hygiene and glove changing standards during a bed bath, dressing and oral care for 1 resident (Resident #107) of 1 resident observed.

Inspectors wroteBased on review of facility documents, interview, medical record review, and policy review, the facility failed to provide adequate supervision to prevent accidents for two of four residents (Resident (R)13 and R7) reviewed for accidents in a total sample of 41 residents. The facility's failure to utilize two staff, during the use of a mechanical lift, resulted in harm when R13 sustained a distal right femur (leg) fracture.

Inspectors wroteBased on observation, interview, medical record review and policy review, the facility failed to ensure each resident received assistance with their Activities of Daily Living (ADLs) for bathing/showers, fingernail trimming and cleaning under the fingernails and grooming of facial hair. This deficient practice affected four residents (Resident (R )27, R21, R23 and R6) in the sample of 41 residents.

Inspectors wroteBased on interview, medical record review, facility documents, facility policies and protocols review, the nursing staff failed to complete ongoing nursing assessments for vomiting, bowel movements, or falls for 3 of 3 residents (Resident (R)1, R21, and R7, respectively) in a total sample of 41 residents.

Inspectors wroteBased on observation, interview, facility record review, and tasting of food served on a requested test tray due to eight resident and/or family complaints (F13, R33, R2, R34, F5, R24, R26, and R27) out of a total sample of 41 residents, the facility failed to serve food that was palatable and hot.

Inspectors wroteBased on observations, interviews, facility documentation review, and review of the facility's policy, the facility failed to maintain an effective pest control system to ensure the residents' environment was free of pests. This failure had the potential to affect all residents of the facility.

Inspectors wroteBased on medical record review, interview and review of the facility's policies, the facility's nursing staff failed to notify the resident's physician and family with a change in condition for 1 of 1 resident (Resident (R)1) reviewed for change of condition out of a total sample of 41 residents.

Inspectors wroteBased on medical record review, review of facility documents, interview and review of the facility's policy, the facility failed to protect the resident's right to be free from physical abuse by a resident for 1 of 3 residents (Resident (R)9) reviewed for abuse out of a total sample of 41 residents. On 1/28/2023, R11 took R9's call light/bed remote and repeatedly struck R9 on his left arm causing discolored areas.

Inspectors wroteBased on record review and interview, the facility failed to revise the care plan with interventions after a Gastrojejunostomy (GJ) (gastrojejunostomy tube is a type of feeding tube used to administer nutrition, liquids, and medications and can also be used for venting, to let gas out of the stomach) had been dislodged seven times resulting in replacement of the tube in the emergency room (ER) for one resident (Resident (R) 3) of 41 resident care plans reviewed.

Inspectors wroteBased on medical record review and interview, the facility's nursing staff failed to implement interventions to anchor the Gastrojejunostomy (GJ) (gastrojejunostomy tube is a type of feeding tube used to administer nutrition, liquids, and medications and can also be used for venting, to let gas out of the stomach) tube properly, in order to prevent repeated dislodgement of the GJ tube, which then required the resident to be transferred to the emergency room (ER) to have the GJ tube replaced for 1 of 1 resident (Resident (R)3) out of a total sample of 41 residents.

Inspectors wroteBased on observations, interview, and medical record review and review of facility documents, the facility failed to have pharmacy systems in place to ensure medications were administered accurately to two out four sampled residents (Resident (R)4, R31) out of a total sample of 41 residents. R4 was administered a pain medication in pill form that had been discontinued six days earlier due to the resident's decreased ability to swallow pills; consequently R4's sublingual (under the tongue) pain medication was not administered. R31 was administered her roommate's (R32's) medications.

Inspectors wroteBased on interviews, medical record review, review of facility documents and review of the facility's policy, the facility failed to ensure 1 of 4 sampled residents (Resident (R)31) was free from significant medication errors out of a total sample of 41 residents. On 8/19/2023, the facility administered R31 duplicate doses of her physician ordered insulin. This medication error had the potential to cause the resident to become hypoglycemic (low blood sugar).

Inspectors wroteBased on facility policy review, medical record review, observation, and interview, the facility failed to ensure adequate supply of medications were available for 1 resident (Resident #285) of 5 residents reviewed for medication administration, resulting in staff borrowing pain medication from Resident #59 to administer to Resident #285.

Inspectors wroteBased on review of the facility policy, medical record review, observation, and interview, the facility failed to follow infection control guidelines for 1 resident (Resident #89) of 3 residents reviewed for isolation precautions.