Bishop Gadsden Episcopal Health Care Center

In the surveyor’s words

From the most serious findings on record at Bishop Gadsden Episcopal Health Care Center, in the surveyor’s own words.

• Immediate jeopardy, patternF880Feb 17, 2022

  Based on observation, staff interview, record review, and facility policy review the facility failed to maintain an effective infection control and prevention program by failing to monitor COVID 19 screening process logs to ensure accurate and within normal limit temperature measurements of 97 degrees Fahrenheit (F) to 99.5 degrees F. Specifically, all residents, staff members, vendors, and visitors entering the facility campus were checked for an increase in temperature over 99.5 F. and symptoms of COVID 19. Review of the temperature measurements recorded on the screening process logs revealed there were temperature measurements out of normal range that could indicate a symptom of COVID 19 illness. […]

• No harm, potential for more than minimal, widespreadF812Mar 20, 2024

  Based on observation, interview, and policy review, the facility failed to ensure the kitchens were maintained and operated in a safe manner to minimize the chances for potential spread of foodborne illness to all 21 residents in the facility. Failures included not storing food properly, handling ready to eat foods with gloves that had been in contact with potentially contaminated surfaces, failure to air dry pans and food containers before storage, and failure to ensure employee hair restraint while in the kitchens. Findings include: Review of the facility's policy titled Storing Staples, revised September 2016, revealed: .2. Procedure.2.1 All dry staples food items are stored in the dry storage area. […]

• No harm, potential for more than minimal, widespreadF761Feb 17, 2022

  Based on observations, record reviews, interview and facility Departmental Procedure, the facility failed to ensure expired medications were removed from active storage in 1 of 1 medications rooms. The findings include: On 2/14/22 at approximately 10:38 AM, inspection of the medication room refrigerator revealed one opened vial of [MEDICATION(S)], Purified Protein Diluted, Diluted, [MEDICATION(S)] by Par Pharmaceuticals 5 TU (test units)/0.1 ml (milliliter) 1ml (10 tests) approximately 1/4 full, dated as opened by the facility on 1/9/22. […]

• No harm, potential for more than minimal, widespreadF812Feb 17, 2022

  Based on observations, interviews and review of the facility Departmental Procedure, Food Storage in Country Kitchen Refrigerator, the facility failed to ensure an expired item was removed from the reach in cooler and failed to ensure open items in the cooler, freezer and the dry storage were labeled with an open date and resealed. The facility further failed to ensure food splatter was removed from the microwave in the Bistro and failed to ensure a covered trash receptacle was provided at the hand washing sink in the Bistro. […]

• No harm, potential for more than minimal, isolatedF656Aug 5, 2026

  Based on review of facility policy, record review, observation, and interview, the facility failed to implement care plan interventions for Resident (R)39, for 1 of 2 residents reviewed for falls.Findings include:Review of the facility policy titled, Fall Management Policy with a revision date of 03/22, revealed, Policy . We assess each resident/patient for his or her fall risk, design a plan for care, and implement procedures to minimize falls and/or injury. The policy also stated, Procedure . Interventions to prevent falls are listed on the plan of care.Review of R39's medical diagnoses list revealed he was admitted to the facility on [DATE]. […]