NHC Healthcare, Ft Sanders

In the surveyor’s words

From the most serious findings on record at NHC Healthcare, Ft Sanders, in the surveyor’s own words.

• Actual harm, isolatedF689Nov 8, 2023

  Based 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. Findings include: 1.Review of facility-reported incident, provided to the survey team by the Administrator, dated 7/5/2023, revealed the following: [Certified Nursing Assistant (CNA)12] reported that on 6/26/2023, she was attempting to transfer [R13] from her bed to her wheelchair using the sit-to-stand lift when the patient became weak and slid back against the lift… […]

• No harm, potential for more than minimal, patternF677Nov 8, 2023

  Based 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. Findings include: 1. Observation of R27 on 10/9/2023 at 12:13 PM revealed he had long fingernails with a dark substance underneath each fingernail. […]

• No harm, potential for more than minimal, patternF684Nov 8, 2023

  Based 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. Findings include: 1. Review of R1's electronic medical record (EMR) revealed under the Resident tab, revealed the Face Sheet indicated that R1 was admitted on [DATE] and readmitted to the facility on [DATE] after an admission to the hospital from 6/30/2022 to 7/05/2022. Review of R1's EMR under the Resident tab revealed Progress notes indicated: 06/30/22 at 8:41AM, Resident labs were drawn this morning, labs were critical. […]

• No harm, potential for more than minimal, patternF804Nov 8, 2023

  Based 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. Findings include: 15406 Review of the Week at a Glance Week 3 Menu, provided by the facility, revealed the lunch meal on 10/10/2023 consisted of pulled pork with barbeque sauce, barbequed beans, creamy coleslaw, grilled Texas toast, and chocolate fudge pie. Observations were made in the kitchen on 10/10/2023 from 10:43 AM through 11:20 AM with the Dietary Manager (DM). The DM stated meal service for lunch began around 11:00 AM. […]

• No harm, potential for more than minimal, patternF925Nov 8, 2023

  Based 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. Findings include: During an interview on 10/9/2023 at 3:42 PM. Certified Nurse Aide (CNA)4 stated she had seen cockroaches in the housekeeping supply room where they put trash bags from resident rooms. CNA4 also stated in the supply room, there is a sign posted where housekeeping can document if they see roaches and other bugs. During an interview on 10/11/2023 at 8:08 AM, Licensed Practical Nurse (LPN)9 stated she has seen cockroaches in resident rooms and in the common areas. […]