AIKEN, SC - Anchor Rehab and Healthcare Center of Aiken faced citations from federal inspectors in July for multiple violations affecting resident care, including improper medication management, food safety concerns, and inadequate infection control practices.
Medication Management and Psychiatric Drug Oversight Failures
Federal inspectors found significant problems with the facility's oversight of psychiatric medications, particularly regarding required dose reductions for antipsychotic drugs. In one case, a resident continued receiving an unnecessarily high dose of Seroquel (quetiapine) for over two months after a pharmacist recommended reducing the medication.
The resident in question had been prescribed 50 milligrams of Seroquel daily for agitation. In April, the facility's consulting pharmacist recommended reducing the dose to 25 milligrams as part of a gradual dose reduction (GDR) protocol. While the physician approved and signed the recommendation on April 11, the actual medication order wasn't entered into the system until June 29 - more than 60 days later.
This delay is particularly concerning because antipsychotic medications carry significant risks for nursing home residents, including increased fall risk, sedation, and potential cardiac complications. Federal regulations require facilities to attempt dose reductions every six months for residents on these medications, with the goal of using the lowest effective dose or discontinuing the medication entirely when possible.
The Assistant Director of Nursing acknowledged the system breakdown, explaining that while physicians signed the pharmacy recommendations, the orders weren't properly entered into the electronic medical record system. When asked about oversight of these signed recommendations, staff indicated no one was reviewing them to ensure implementation.
This type of medication management failure can leave vulnerable residents on higher doses of psychotropic drugs than medically necessary, potentially exposing them to preventable side effects and complications that could impact their quality of life and overall health.
Food Safety and Temperature Control Violations
The facility's kitchen operations revealed multiple food safety violations that directly affected meal quality and potentially resident health. During inspection, temperatures of served food fell well below safe standards, with some items reaching dangerous temperature zones.
When inspectors measured food temperatures at the point of service, they found concerning results. Pork loin with gravy dropped to 138.8 degrees Fahrenheit, fried potatoes reached only 122.3 degrees, and lima beans measured just 111.8 degrees. Food safety standards require hot foods to be maintained at 140 degrees Fahrenheit or higher to prevent bacterial growth.
Multiple residents complained about the quality of their meals during a group meeting with inspectors. "The potatoes were served cold and had no seasoning," residents reported about their lunch. One resident noted that "the lima beans were cold and had no taste to them," while another stated "the grits were served cold and stiff."
The temperature problems appeared systemic rather than isolated incidents. Residents explained that food carts sat in hallways for extended periods before being served, contributing to the cooling problem. Historical resident council meeting minutes dating back months showed ongoing "dietary concerns" that had not been adequately addressed.
Food temperature control is critical in nursing homes because residents often have compromised immune systems that make them more susceptible to foodborne illnesses. When hot foods fall below 140 degrees Fahrenheit, they enter the "danger zone" where harmful bacteria can multiply rapidly. Additionally, cold, unappetizing food can lead to poor nutrition and unintended weight loss among residents who already face challenges maintaining adequate nutritional intake.
Kitchen Hygiene and Contamination Risks
Beyond temperature issues, inspectors documented multiple hygiene violations in the kitchen that posed contamination risks. The ice machine contained a pink, slimy substance on interior surfaces, and staff had inappropriately stored a beverage bottle directly in the ice that residents would consume.
A cook was observed working without required facial hair protection, then later touching his face and beard guard while wearing gloves that he subsequently used to handle food items. Proper hand hygiene protocols were also violated when the same staff member turned off water faucets with bare hands after washing, potentially recontaminating clean hands.
These hygiene lapses create multiple pathways for bacterial and viral contamination of food. Ice machines are particularly concerning because they can harbor harmful microorganisms that multiply in moist environments, and contaminated ice can spread pathogens to beverages and food preparation areas throughout the facility.
The Dietary Manager confirmed that beard guards should always be worn and that the ice machine should be cleaned daily, but acknowledged the unit had not been cleaned on the day it was found contaminated. Staff should have followed proper handwashing techniques, including using paper towels to turn off faucets and maintaining separation between clean and dirty surfaces.
Infection Control Deficiencies
Perhaps most concerning were violations of infection control protocols designed to prevent the spread of dangerous antibiotic-resistant bacteria. Inspectors observed staff failing to follow proper procedures when caring for residents with enhanced barrier precautions (EBP), which are implemented for patients colonized with multidrug-resistant organisms.
During catheter care for one resident with a documented E. coli infection that showed resistance to multiple antibiotics, staff failed to change gloves when moving from contaminated to clean areas of the resident's body. The caregiver wiped around the catheter and genital area, then without changing gloves, moved to cleaning the anal area where brown material was observed on the wipes, and then continued to provide care and adjust bedding.
After completing the care, the staff member removed gloves but failed to perform hand hygiene before leaving the room - a critical step in preventing the spread of resistant bacteria to other residents and areas of the facility.
Additionally, three residents on enhanced barrier precautions requiring both gloves and gowns received care from staff wearing only gloves. One staff member stated, "We don't have to gown up for her," indicating confusion about isolation protocols. Another nurse explained they only wore gowns for activities lasting more than two or three minutes, which contradicts proper infection control guidelines.
Enhanced barrier precautions exist specifically to contain dangerous antibiotic-resistant organisms that can cause life-threatening infections, particularly in vulnerable nursing home populations. When these protocols aren't followed correctly, resistant bacteria can spread throughout a facility, potentially causing outbreaks that are difficult to treat and can result in serious complications or death.
Transfer Documentation and Resident Rights Issues
The facility also failed to provide proper written documentation when transferring residents to hospitals, violating regulations designed to protect resident rights and keep families informed. Three residents who required emergency hospital transfers either never received written transfer notices or received incomplete documents missing required information about ombudsman contacts and appeal rights.
One resident reviewed the transfer documents and responded, "First time I seen this paper. They never gave me this paper. My daughter never got one either." A family member of another resident confirmed by phone: "No, I never received anything in writing, they called."
Proper transfer documentation ensures families understand why their loved one was moved, where they went, and what options they have if they disagree with the facility's decision. This paperwork also provides important legal protections and ensures continuity of care information reaches the receiving hospital.
Additional Issues Identified
Beyond these major violations, inspectors documented other concerning practices including incomplete fall prevention measures, where a resident at high risk for falls was missing required floor mats on one side of their bed, and inadequate reporting of alleged staff misconduct toward residents.
These violations collectively paint a picture of systemic issues affecting multiple aspects of resident care and safety. Each violation represents a breakdown in protocols designed to protect some of society's most vulnerable individuals, who depend on nursing homes for essential daily care and medical oversight.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Anchor Rehab and Healthcare Center of Aiken, LLC from 2024-07-02 including all violations, facility responses, and corrective action plans.
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