NHC Healthcare - Greenwood

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure food stored in the kitchen was labeled, dated, and not expired, and failed to ensure stored bags of food items were properly sealed or closed. Additionally, the facility failed to prevent cross-contamination by using the sanitizing compartment of a sink to rinse washcloths used to clean spilled food from the kitchen floor and subsequently placing the washcloths on a clean food preparation surface. These practices had the potential to result in food-borne illness for all 139 residents who received meals from the facility kitchen.

Inspectors wroteBased on interview and record review, the facility failed to ensure that as needed (PRN) psychotropic medication orders did not exceed 14 days in duration without a documented rationale and that target behaviors and side effect monitoring was documented for 1 of 5 residents (Resident (R)76) reviewed for unnecessary medications out of 37 sample residents. This failure had the potential to result in unnecessary medication use, adverse drug effects, and increased risk of oversedation for all residents receiving psychotropic medications in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure the pharmacist's Monthly Medication Reviews identified the potential inappropriate use of a psychotropic medication for 1 of 5 residents (Resident (R)76) reviewed for unnecessary medications out of 37 sample residents. This failure had the potential to result in unnecessary medication use, adverse drug effects, and increased risk of oversedation, and had the potential to affect all residents receiving psychotropic medications in the facility.

Inspectors wroteBased on record review, observation, interview, and facility policy review, the facility failed to follow infection control procedures during perineal care for 1 of 3 residents reviewed (Resident (R)12) and failed to ensure appropriate storage of oxygen tubing when not in use for 1 of 6 residents (R90) reviewed for oxygen use out of a total sample of 37 residents. These failures had the potential to increase the risk of infection transmission.

Inspectors wroteBased on interview, record review, and review of facility policy, the facility failed to ensure informed consent was obtained from the resident prior to the use of a psychotropic medication for one of five residents (Resident (R) 42) reviewed for unnecessary medications out of 20 sampled residents. This placed the resident at risk of not being informed of the possible side effects of the medication.

Inspectors wroteBased on interviews, record reviews, and review of the facility's policy, the facility failed to ensure two of two residents (Residents (R) 40 and R289) were afforded the right to participate in their care planning process. This failure placed the residents at risk of not being aware of the goals and outcomes of their care and for their care plan not to be person centered.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to report an allegation of physical abuse to the State Survey Agency (SSA) within two hours for an incident between residents (Resident (R)115 and R5).

Inspectors wroteBased on interviews and record review, the facility failed to ensure supervision while toileting for one of four residents (Residents (R) 112) reviewed for falls out of 30 sampled residents. This failure caused harm to R112 when he sustained a right hip fracture from a fall off the toilet. This failure placed residents at risk of further injury and a diminished quality of life.

Inspectors wroteBased on review of facility policy, record review, and interview, the facility failed to ensure Resident (R)1 was free of significant medication error, when R1 received another resident's medications, for 1 of 3 residents reviewed for significant medication error. On 09/11/24 at 5:20 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template, informing the facility IJ existed as of 04/29/24. The IJ was related to 42 CFR 483.45 - Pharmacy Services. On 09/12/24 the facility provided an acceptable IJ Removal Plan. On 09/12/24 the survey team, validated the facility's corrective actions and determined the facility put forth due diligence in addressing the noncompliance. The IJ is considered at Past Non-Compliance as of 04/30/24. [...]

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to develop and implement a comprehensive person-centered care plan for a resident with a history of falls with a fracture prior to admission and who was assessed as being at high risk for falls. The deficiency affected 1 (Resident (R)3) of 3 residents reviewed for accidents.

Inspectors wroteBased on observations, interviews, and facility policy review, the facility failed to ensure that kitchen staff wore hair nets that covered all their hair, failed to ensure that kitchen staff wore beard guards, and failed to ensure that kitchen staff did not touch food items with their bare hands and/or preformed hand hygiene after coming in contact with non-food items. In addition, the facility failed to ensure that 1 of 3 nutritional refrigerators had food items labeled and/or dated. This has the potential to affect 131 residents who received an oral diet from the kitchen.

Inspectors wroteBased on record review, interview, and Resident Assessment Instrument (RAI) manual review, the facility failed to follow the RAI's transmittal requirements, which indicated that within 14 days after a facility completed a resident's assessment, a facility must electronically transmit encoded, accurate, and complete Minimum Data Set (MDS) data to the Center for Medicare & Medicaid Services (CMS) System for 4 of 4 residents (Resident (R)22, R34, R67, and R35) of 28 sampled residents. Specifically, it has been over 120 days since the facility transmitted the 4 residents MDS to the CMS System.

Inspectors wroteBased on observation, record review, interviews, and test tray evaluation, the facility failed to serve food that was palatable and at a safe and appetizing temperature for 7 of 7 residents (Resident (R)3, R71, R73, R97, R56, R14, and R63) reviewed for food palatability. This failure had the potential to affect 131 residents who consumed food prepared from the facility's kitchen.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to assess 1 of 8 residents reviewed during medication pass (Resident (R)122) for self-administration of medications. This failure led to medications being left at the bedside where they could be accessed by other residents or the resident not taking the medications.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to develop comprehensive care plans related to indwelling urinary catheters and/or the use of Tubigrip stockings (compression stockings used to help manage edema) for 2 of 28 sampled residents (Resident (R)63 and R1).

Inspectors wroteBased on observation, record review, interviews, and facility policy review, the facility failed to ensure the resident care plan was revised to accurately reflect 1 of 28 sampled residents (Resident (R)72) current plan of care. In addition, the facility failed to ensure 1 of 28 sampled residents (R125) was invited to her quarterly care conference.

Inspectors wroteBased on observation, interview, and record review, the facility failed to apply Tubigrip stockings (compression stockings used to help manage edema) per physician orders for 1 of 28 sampled residents (Resident (R)7).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 28 sampled residents (Resident (R)14) was competent to perform suprapubic catheter care independently. The facility failed to conduct and document assessments and/or evaluations of R14's capabilities and obtain physician orders prior to allowing R14 to complete his own suprapubic catheter care.