Inspection Reports for
Anderson Mill Center for Nursing and Healing LLC

The survey identified deficiencies including failure to provide routine drugs for one resident due to pharmacy issues with a schedule IV-controlled substance, and failure to establish an infection prevention and control program evidenced by improper use of personal protective equipment and hand hygiene during medication administration for two residents.

Multiple complaint intake numbers were investigated in conjunction with the standard survey, revealing noncompliance with federal regulations.

The facility was found not in substantial compliance with regulations, with deficiencies including failure to provide routine drugs due to pharmacy issues, medication errors exceeding 5% for one resident, and failure to implement proper infection prevention and control practices including inadequate use of PPE and hand hygiene during medication administration.

The facility failed to provide a prescribed schedule IV-controlled medication to a resident due to pharmacy and nursing communication issues, resulting in medication errors. Additionally, the medication error rate exceeded 5%, and infection prevention protocols, including proper use of PPE and hand hygiene during medication administration, were not consistently followed.

Complaints GA00235938, GA00236201, GA00236573, GA00236660, and GA00238554 were unsubstantiated. Complaint GA00239662 was substantiated with deficiency related to incontinence care.

The investigation found that five complaints were unsubstantiated, while one complaint (GA00239662) was substantiated with a deficiency related to failure to provide timely and appropriate incontinence care for one resident, which had the potential to promote infection.

The facility failed to provide timely and appropriate incontinence care for one of four residents reviewed, specifically resident R7, which had the potential to promote infection. Observations and interviews revealed inadequate incontinence care during pressure ulcer treatment.

The complaint investigation found that the staff failed to provide frontal incontinence care after a bowel movement. Interviews with the Wound Care Nurse and Director of Nursing confirmed that staff should clean front to back and provide frontal care if stool is present.

The facility failed to provide timely and appropriate incontinence care for one resident, which had the potential to promote infection. Observations and interviews revealed inadequate cleaning practices during pressure ulcer care and incontinence management.

The facility did not report complete COVID-19 data to the NHSN between 04/17/2023 and 04/23/2023 as required by CMS and CDC regulations, which could potentially cause more than minimal harm to residents.

The facility failed to report complete COVID-19 information to the NHSN between 04/10/2023 and 04/16/2023 as required by CMS and CDC regulations, which has the potential to cause more than minimal harm to all residents.

The facility was found deficient in medication storage practices, infection control procedures, and environmental cleanliness. Specific issues included unlocked medication carts, unlabeled and expired medications, failure to clean reusable resident equipment and surfaces between residents, inadequate hand hygiene, and unsanitary conditions in multiple resident rooms and restrooms.

Multiple complaint intake numbers were investigated in conjunction with the standard survey as listed in the report.

The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to ensure resident dignity and respect, failure to assess resident self-administration of medications, failure to maintain a safe and sanitary environment in multiple resident rooms, failure to submit PASARR Level II screenings for two residents, failure to administer oxygen therapy according to physician orders, failure to properly store and label medications, and failure to ensure appropriate infection control practices.

The facility was found deficient in multiple areas including resident dignity and respect, medication self-administration, environmental cleanliness, PASARR screening, respiratory care, medication storage and labeling, and infection control practices. Several residents were affected by these deficiencies, with issues ranging from failure to honor privacy, improper medication handling, unsanitary conditions, incomplete mental health screenings, and inadequate infection prevention.

The facility was found deficient in multiple areas including resident dignity and respect, medication self-administration, environmental cleanliness, PASARR screening, respiratory care, medication storage and labeling, and infection control practices. Several residents were affected by these deficiencies, with issues ranging from failure to honor privacy rights to improper medication handling and inadequate infection prevention.

The facility was found not in substantial compliance with life safety requirements, including issues with cooking facility safety devices, corridor door latching, and electrical panel labeling. These deficiencies affected 1 of 6 smoke compartments.