Emory L Bennett Memorial Veterans Nursing Home

In the surveyor’s words

From the most serious findings on record at Emory L Bennett Memorial Veterans Nursing Home, in the surveyor’s own words.

• Actual harm, isolatedF684Apr 22, 2021

  Based on observation, resident interview, clinical record review, staff interview and facility policy and procedure review, the facility failed to provide care and treatment in a timely manner, in accordance with professional standards of practice, the plan of care and the resident's choices for pain management and identifying a change of condition after a fall for 1 (#47) out of 4 residents sampled for accidents, from a total of 36 sampled residents. Resident #47 sustained a fracture of the hip and femur bones when he fell , but the first x-rays indicated no fractures. Three days later the resident requested transfer to the hospital due to extreme pain. […]

• No harm, potential for more than minimal, widespreadF761Dec 1, 2022

  Based on observations, staff interviews, and facility policy review, the facility failed to store all drugs and biologicals in locked compartments. This failure involved the Delta 5 hallway medication cart, Delta 5 hallway treatment cart, Delta 3 hallway medication cart, Alpha 5 hallway treatment cart, Alpha 5 hallway medication cart, Alpha 3 hallway medication cart, and four separate nurses on two different shifts during three different days. The findings include: On 11/28/22 at 3:08 pm, the medication cart on Delta 5 hallway was observed to be unlocked as evidenced by the locked popped open. The first two drawers were opened and bottles of prescription medications were observed. (Photographic evidence obtained) No staff were observed in the area of this medication cart. […]

• No harm, potential for more than minimal, widespreadF812Apr 22, 2021

  Based on kitchen food service observations, staff interviews, facility document review, and facility policy and procedure review, the facility failed to follow proper sanitation, food distribution and service practices to prevent the outbreak of foodborne illness with the potential to affect all of the residents in the facility. The facility failed to ensure that the dietary staff implemented the facility policy for the proper procedures for hand hygiene, disposable glove use, and proper sanitation practices in the kitchen when staff failed to change gloves when they became contaminated, and to wash their hands between glove changes during the lunch meal service. The findings include: On [DATE] at 10:25 AM, the initial tour of the kitchen was conducted. […]

• No harm, potential for more than minimal, widespreadF908Apr 22, 2021

  Based on kitchen food service observations, staff interviews, and facility policy and procedure review, the facility failed to ensure all essential kitchen equipment was maintained in safe operating condition by not ensuring proper maintenance of the mechanical, high temperature dishwashing machine and walk-in freezer. The findings include: On 4/19/2021 at 10:25 AM, the initial kitchen tour was conducted. Employee J was asked to run the high temperature mechanical dish machine. He ran the machine a couple of times to get the machine up to the right temperature. When asked what the temperature of the wash cycle and final rinse cycle should be, he stated the wash cycle temperature should be 160'F (Fahrenheit) to 180'F and the final rinse cycle should be 180'F. […]

• No harm, potential for more than minimal, patternF812Oct 17, 2024

  Based on kitchen food service observations, staff interviews, and facility policy and procedure review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness, with the potential to affect all residents who consumed foods from the facility's nourishment rooms, by failing to seal and date mark open food products in the nourishment rooms, clean residue build up in the ice machine drain hose and coffee dispenser hood, and clean in and around the ice machine dispenser ports and tray. Food handling and sanitation are important in health care settings serving nursing home residents. […]