cms_SC
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33 rows where "inspection_date" is on date 2012-02-29
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| Link | rowid ▼ | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 8241 | 8241 | THE METHODIST OAKS | 425131 | 151 LOVELY DRIVE | ORANGEBURG | SC | 29115 | 2012-02-29 | 225 | D | 0 | 1 | 5WM211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey based on interview and record review, the facility failed to report an injury of unknown origin to the appropriate State agency for 1 of 1 sampled residents reviewed with an injury of unknown origin. (Resident #5) The findings included: Resident #5 was re-admitted on [DATE] with [DIAGNOSES REDACTED]. Record review on 2/27/12 at approximately 2:15pm revealed a nursing note dated 1/3/12 which indicated that the resident was seated in wheelchair in doorway of room with skin tears to arms, knot noted on back of head - sent to ER (emergency room ). Review of Incident report on 2/28/12 at approximately 10:30am indicated that a nurse and CNA (Certified Nursing Assistant) entered room after a loud noise was heard. When asked what had happened, the resident stated he was trying to go downstairs to put out the fire. The incident report did not indicate where in the room the resident was located when found. Review of the resident's most recent Minimal Data Set of 2/14/12 indicated a BIMS (Brief Interview for Mental Status) of 7. A BIMS score of 0-7 indicates severe cognitive impairment. Interview on 2/28/12 with the Administrator indicated that the incident had not been reported any State agency. Communication with the Bureau of Certification Compliant Intake Officer verified that the incident had not been reported to the agency. Based on the information in the nursing notes and the incident report, the occurrence met the definition of an injury of unknown origin. Therefore, it should have been reported to the appropriate State agency within 24 hours of its occurrence and a further investigation should have occurred and been documented. | 2016-06-01 |
| 8242 | 8242 | THE METHODIST OAKS | 425131 | 151 LOVELY DRIVE | ORANGEBURG | SC | 29115 | 2012-02-29 | 280 | E | 0 | 1 | 5WM211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interview, the facility failed to review and revise care plans for 4 of 13 resident care plans reviewed. The facility failed to revise the CNA (Certified Nurses Aide) care plan to reflect implemented interventions to prevent falls for Resident #6, failed to update the comprehensive care plan to reflect a fall for Resident #6, failed to update the comprehensive care plan for Resident #5 to reflect implemented interventions to prevent falls, and failed to revise the care plans for Resident #9 and Resident #13 to reflect treated infections. The findings included: The facility admitted Resident #6 on 12/11/07 with [DIAGNOSES REDACTED]. Review of the Nurse's Notes dated 8/22/11 at 5:55 PM indicated Resident #6 sustained a fall to the floor after rolling out of bed. Review of the fall data provided by the facility entitled Falls Screened by Therapy PAR (Patients at Risk) committee revealed that recommendations following the fall included, Recommend resident not be left alone for meals. Further review of the Nurse's Notes dated 11/18/11 at 11:05 AM indicated Resident #6 was found on the floor in front of the wheelchair. The notation stated, Res (resident) appeared to have slide (sic) out of w/c. Record review indicated Resident #6 sustained a [MEDICAL CONDITION] tibia and fibula as a result of the incident. Review of the Therapy Screen dated 11/22/11 indicated interventions included recommend checking regularly for repositioning needs and Recommend Hoyer lift transfer to protect fx. Review of the Falls Screened by Therapy PAR committee data revealed Recommend not leaving resident alone but in-sight of caregivers to identify repositioning needs .Recommend also Hoyer transfers were recommended interventions to prevent further falls. Review of the Nurse's Notes dated 1/07/12 at 8:30 AM indicated, CNA was transferring res from wheelchair to bed when Res slipped and slid to ground on top of CNA. The T… | 2016-06-01 |
| 8243 | 8243 | THE METHODIST OAKS | 425131 | 151 LOVELY DRIVE | ORANGEBURG | SC | 29115 | 2012-02-29 | 315 | D | 0 | 1 | 5WM211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, interview and review of the facility's policy Catheter Care, the facility failed to ensure that 1 of 3 residents received appropriate catheter care. For Resident #3, Certified Nurse Assistant (CNA) failed to separate and cleanse the labia. The finding included: The facility admitted Resident #3 on 1-7-09 and was readmitted on [DATE] with [DIAGNOSES REDACTED]. On 2-29-12 at 11:38 AM, during an observation of Resident #3's Foley catheter care, CNA #4 anchored the catheter tubing at the urinary meatus with her left hand. She then used 3 sanitary swabs to wipe only the catheter tubing. The CNA did not separate the labia to assure thorough cleansing. On 2-29-12 at 11:49 AM, during an interview, CNA #4 verified she had only cleaned the catheter tubing. Review of the facility policy entitled Catheter Care states under Procedure, Female Residents: Spread the labia, using the first swab cleanse down the one side of the labia, second swab cleanse down the other side, use third swab, starting at the urinary meatus and clean down catheter tubing rotate swab and clean opposite side of the tubing. | 2016-06-01 |
| 8244 | 8244 | THE METHODIST OAKS | 425131 | 151 LOVELY DRIVE | ORANGEBURG | SC | 29115 | 2012-02-29 | 322 | D | 0 | 1 | 5WM211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification Survey, based on observation, interview and record review, the facility failed to administer the amount of tube feeding formula and water flush as ordered for 5 feedings over a 2 day period for Resident #2, 1 of 2 residents sampled for Percutaneous Gastrostomy Tube (PEG) feedings. The findings included: The facility admitted Resident #2 on 12/13/11 with [DIAGNOSES REDACTED]. On 2/28/12 at 9:52 AM, Licensed Practical Nurse (LPN) #3 was observed administering the tube feeding and water flush to Resident #2. After checking the Medication Administration Record, [REDACTED]. After washing her hands, donning gloves and verifying placement, the LPN flushed the PEG tube with 30 ml of water. She poured 60 ml of Glucerna 1.5 into the syringe and allowed to flow via gravity. She then poured an additional 60 ml into the syringe and allowed to flow, added an additional 5 ml of formula then followed with an additional 30 ml of water to flush the tube. Record review on 2/28/12 at 3:40 PM revealed a Physician's Telephone Order dated 1/31/12 that read Per Dietary Rec(ommendation) - (Change) TF (tube feeding) to bolus 1 can Glucerna 1.5 @ (at) 9A, 1P and 6P and follow with 125 cc (cubic centimeters) H2O (water) flush. Further review revealed the order had been carried over to the February 1-29 monthly physician's orders [REDACTED]. During an interview on 2/28/12 at 4:45 PM, LPN #3 confirmed that she had given a total of 125 ml of tube feeding and a total of 60 ml of water to flush. After reviewing the MAR indicated [REDACTED]. | 2016-06-01 |
| 8245 | 8245 | THE METHODIST OAKS | 425131 | 151 LOVELY DRIVE | ORANGEBURG | SC | 29115 | 2012-02-29 | 369 | D | 0 | 1 | 5WM211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and observation, the facility failed to provide adaptive feeding equipment for 1 of 1 sampled residents with orders for adaptive equipment. The facility did not provide Resident #6 with the angled spoon per physician's orders [REDACTED]. The findings included: The facility admitted Resident #6 on 12/10/07 with [DIAGNOSES REDACTED]. Review of the February 2012 physician's orders [REDACTED]. Further record review revealed a Physician's Telephone Order dated 5/23/11 for an angled spoon. Review of the Nutrition Risk assessment dated [DATE] indicated an angled spoon was listed as an adaptive device to be used for Resident #6. Observation of the lunch meal on 2/28/12 at approximately 12:30 PM and the dinner meal on 2/28/12 at approximately 5:45 PM revealed Resident #6 sitting at a table eating in the dining room. Observation indicated that Resident #6 was provided a built-up fork for both meals. This was the only eating utensil provided by staff for both of the meals. Review of the dietary tray card revealed a photo of adaptive equipment which did not include an adaptive spoon. On 2/29/12 at approximately 4:00 PM, the Certified Dietary Manager (CDM) reviewed the dietary card and order for angled spoon. The CDM confirmed that the dietary card did not correctly indicate that the angled spoon was to be provided. | 2016-06-01 |
| 8246 | 8246 | THE METHODIST OAKS | 425131 | 151 LOVELY DRIVE | ORANGEBURG | SC | 29115 | 2012-02-29 | 425 | D | 0 | 1 | 5WM211 | On the days of the survey, based on observation and interview, the facility failed to follow a procedure to ensure that expired medications were not stored in 1 of 3 medication rooms. The findings include: On 2/27/12 at approximately 10:45 AM, inspection of the Riverside (D Wing) medication room refrigerator revealed the following: -One opened vial of Novolog Insulin 100 U (units)/1 ml (milliliter), Lot AZF0366, Prescription 848, dispensed 1-19-12 and belonging to Resident A had not been labelled as to the date it was opened. -One opened vial of Novolog Insulin 100 U/1 ml, Lot AZF0333, Prescription 976, dispensed 12/15/11 and belonging to Resident B had not been labelled as to the date opened. These findings were verified by LPN (Licensed Practical Nurse # 2) who stated that they should have been dated when opened. The manufacturer, Novo Nordisk, states in the package insert that Novolog Insulin should be discarded 28 days after opening. | 2016-06-01 |
| 8247 | 8247 | THE METHODIST OAKS | 425131 | 151 LOVELY DRIVE | ORANGEBURG | SC | 29115 | 2012-02-29 | 441 | E | 0 | 1 | 5WM211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification Survey, based on observations, interviews and record review, the facility failed to implement all components of the infection control program. The facility failed to have a process to comply with State Laws and Regulations for reporting communicable diseases and outbreaks and failed to monitor that staff observed transmission based precautions. The facility also failed to ensure that expired instant hand sanitizers were not being stored in 2 of 3 medication rooms and were not being used during patient care on 3 of 6 medication carts. The findings included: Review of the facility's Policy and Procedure Manual revealed no list of Reportable Conditions or communicable diseases to be reported in accordance with State Laws and Regulations. During an interview on [DATE] at approximately 11:30 AM, the Infection Control Nurse stated she didn't know where the list might be. She stated she hadn't seen one and did not know what conditions or communicable diseases were reportable. Review of the infection surveillance logs indicated the facility had 4 ESBL (Extended-Spectrum Beta-Lactamase) infections in the month of January, 2012. The Infection Preventionist was not able to state whether that would constitute an outbreak of a communicable disease and stated she would have to research it. On [DATE] during initial tour, Resident #11 was noted to be on transmission-based precautions. Licensed Practical Nurse (LPN) #3 stated the resident was on contact isolation. Record Review on [DATE] at approximately 10:30 AM revealed the resident had a Culture and Sensitivity on [DATE] which was positive for [DIAGNOSES REDACTED] Pneumoniae ESBL and antibiotic therapy and isolation precautions were ordered on [DATE] when the results were received. At 6:15 PM on [DATE], Certified Nursing Assistant (CNA) #2 was observed delivering the evening meal in the resident's room without donning any PPE (Personal Protective Equipment) prior to enter… | 2016-06-01 |
| 8248 | 8248 | THE METHODIST OAKS | 425131 | 151 LOVELY DRIVE | ORANGEBURG | SC | 29115 | 2012-02-29 | 502 | D | 0 | 1 | 5WM211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation and interview, the facility failed to follow a procedure to ensure that expired laboratory products were not stored in 1 of 3 medication rooms. The findings include: On [DATE] at approximately 10:30 AM, inspection of the Piedmont (A Wing) medication room revealed the following: -Fourteen packages of BBL Culture Swab Collection and Transport System, Lot 029H43 L.YPT233, expiration ,[DATE] were found in a plastic biohazard bag located in the 2nd drawer from the right side of a storage cabinet. This finding was verified by LPN (Licensed Practical Nurse) #1 on [DATE] at approximately 11:35 AM. | 2016-06-01 |
| 8249 | 8249 | THE METHODIST OAKS | 425131 | 151 LOVELY DRIVE | ORANGEBURG | SC | 29115 | 2012-02-29 | 520 | F | 0 | 1 | 5WM211 | On the days of the survey, based on an interview with the Administrator and Infection Control Preventionist, the facility's Quality Assurance Committee failed to monitor the effect of implemented changes and making needed revisions to the action plans. The findings included: Interview on 2/29/12 at approximately 10:00am with the Administrator and Infection Control Preventionist concerning the facility Quality Assurance Program revealed that the committee was actively addressing concerns in the area of Falls, Weight Loss, Infections, Skin Tears, Medications among others. However, the committee was reviewing the concerns on a case by case basis. The committee had not developed a formal system wide plan of action addressing monitoring of the interventions put into place and the effectiveness of those interventions in relation to the operation of the facility and how it could benefit all who reside within the facility. The Infection Control Preventionist stated We don't connect the dots. | 2016-06-01 |
| 8394 | 8394 | KERSHAWHEALTH KARESH LONG TERM CARE | 425080 | 1315 ROBERTS STREET | CAMDEN | SC | 29020 | 2012-02-29 | 425 | D | 0 | 1 | T32311 | On the days of the survey, based on observation, record and interview, the facility failed to follow a procedure to ensure that expired medications were not stored with other medications. There were expired medications observed in the 2nd floor medication refrigerator and in the 3rd floor medication cart for rooms 362-373. The findings included: During the observation of the 2nd floor medication refrigerator, there were (two) 1 milliliter (ml) vials of Purified Protein Derivative (PPD) 5TU/0.1ml, provided by pharmacy for floor stock with a fill date of 1/24/12, which were open but did not have a puncture date marked on either of the bottles. An interview with Registered Nurse (RN) #1 on 2/27/12 at 4:12 PM revealed that both of the PPD bottles should have been dated when they were opened, but the bottles were not dated. RN # 1 stated the nurses were supposed to check the medications nightly. RN #1 did not know how often the medications were being checked. During the observation of the 3rd floor medication cart for rooms 362-373, there were 3 unopened packages of Albuterol Sulfate Inhalation Solution 0.083% 2.5mg/3ml with an expiration date of 12/11 and 4 single use ampules of Albuterol Sulfate Inhalation Solution 2.5mg/3ml by DEY with an expiration date of 12/11. Interviews were conducted with Licensed Practical Nurses (LPN) #1, #2, and #3 on 2/27/12 at 3:15 PM. Interview with LPN #1 revealed that the pharmacy checks the medication carts every month and it is usually the 1st week of the month. The facility has recently changed pharmacy services, which began at the beginning of the year. Interview with LPN #2 revealed that the nurses were to check the medication carts for expired medications, but there was not a set schedule. Interview with LPN #3 revealed the consulting pharmacy was at the facility in January 2012 and was also at the facility on February 6, 2012. | 2016-04-01 |
| 9223 | 9223 | ELLEN SAGAR NURSING HOME | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2012-02-29 | 157 | K | 1 | 0 | PX0Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Complaint and Extended Survey based on record review and interview, Immediate Jeopardy was identified existing in the facility as of 02/14/2012 related to the facility failure to notify the Physician and the Responsible Party (RP) of changes in condition. The facility failed to timely notify the Attending Physician/Medical Director of an allegation of sexual abuse. The facility also failed to contact 1 of 3 resident's responsible parties regarding an allegation of sexual abuse. The facility also failed to ensure 2 of 3 residents reviewed for blood sugar management had their physician notified of low blood sugars (Resident #1 and #7). The findings included: The facility admitted Resident #2 on with [DIAGNOSES REDACTED]. Review of the Social Services notes dated 02/15/2012 revealed: "DON (Director of Nurses) and SSD (Social Services Director) reviewed statements regarding sexual abuse allegations against another resident in facility, nurses statements included (Resident #2) involvement with separate incident involving same male CNA (certified nursing assistant) (CNA #1). Attempted family contact with daughter/RP (Responsible Party) at 9:50 AM and 3 PM. Home phone had no answer/no voicemail, cell had no answer no VM (voice mail) box set up, no response." Review of the facility obtained statement taken by Registered Nurse (RN) #1 on 02/14/2012 at 9:45 PM from Resident #2 revealed: "About 2 weeks ago, it's been a good while back, he sat down and had his "thang" out and then he put it back. He was out on the porch... I believe we were out on the porch and he pulled his britches down. - its been so long ago. I saw his penis, it was red looking. I left. I haven't spoken to him since. ...it was very embarrassing - I can't even face him." Further review of the Investigative File revealed the facility also did not contact the attending physician and the Medical Director until 02/15/2012. During an interview on 02/21/2012 at 12 PM, the… | 2015-06-01 |
| 9224 | 9224 | ELLEN SAGAR NURSING HOME | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2012-02-29 | 223 | K | 1 | 0 | PX0Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Complaint and Extended Survey, Substandard Quality of Care and Immediate Jeopardy was identified as it related to the facility failure to identify, report and thoroughly investigate allegations of sexual abuse for 3 of 3 residents reviewed for sexual abuse. Residents #1, #2 and #6 alleged allegations of sexual abuse against Certified Nursing Assistant (CNA) #1. The findings included: A complaint survey was conducted on 02/21/2012 as a result of a facility reported incident. Resident #1 reported during a telephone conversation to her daughter on the evening of 02/14/2012, an incident of alleged sexual abuse. Her daughter came to the facility and reported the incident to Registered Nurse #1(RN). In the following statement taken by RN #1 on 02/14/2012 at 9:25 PM Resident #1 stated, "About 2 weeks ago (CNA #1) pulled his penis out on weekend to (Resident #2) and showed it to her. She told him "get this thing off my hand." Resident #2 told Resident #1 that he did this to her. 2 or 3 days after he did it to her, he done it to me, it was in the evening. He came into (Resident #1's) room and pulled his penis out and put it in her hand. Resident was alone in the room. He acted very nervous during/after he done it. Resident told him she didn't want anything to do with another man and that she was old enough to be his grandmother. This is the 1st time (Resident #1) has mentioned it - has only happened once. Resident stated that she didn't' say anything because she was afraid that he would go out and give her a shot to knock her out. Resident stated that no threats were made by (CNA #1)..." The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the Annual Minimum (MDS) data set [DATE] revealed Resident #1 received a BIMS score of "13" and was independent with transfers and toilet use. No behaviors were coded as occurring during the assessment period. Review of Resident #1's Care Plan reviewed on 02/02/2012 revealed a pr… | 2015-06-01 |
| 9225 | 9225 | ELLEN SAGAR NURSING HOME | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2012-02-29 | 226 | K | 1 | 0 | PX0Y11 | On the days of the Complaint and Extended Survey based on record review and interview, Substandard Quality of Care and Immediate Jeopardy was identified existing in the facility as of 02/14/2012 related to the facility's failure to identify, investigate and report allegations of sexual abuse. The facility failed to follow it's policy regarding reporting, investigating and identifying potential abuse. The findings included: Cross Refer to F-223 as it relates to the facility failure to identify, investigate and report allegations of sexual abuse. Review of the facility policy on Alleged Violations of Mistreatment, Neglect and Abuse revealed the following: "Residents will be free from verbal, sexual and physical or mental abuse... Residents will not be subjected to abuse by anyone including but not limited to ...staff ..." "The facility will investigate all grievances/complaints, accidents/incidents, allegations of abuse..." "Sexual Abuse includes, but is not limited to sexual harassment, sexual coercion or sexual assault." "D. Prevention. The Administrator will identify, correct, and intervene in situations in which abuse, neglect and/or misappropriation of resident property is likely to occur... The Director of Nursing or designee reviews all aspects of accidents/incidents, medical interventions and documentation. Data is trended, analyzed and incorporated into the facility's quality assurance program." "E. Identification. The facility Administrator or designee will identify events, such as suspicious bruising of residents, occurrences, patterns and trends that may constitute abuse; and to determine the direction of the investigation. Methods may include but are not limited to tracking, trending and analysis of facility reports and grievances for occurrences, patterns and trends." "F. Investigation. The individual assigned to conduct the investigation will conduct a thorough investigation of the allegation. Areas/items that may be included as appropriate in the investigation include: ...b. Review the resident's me… | 2015-06-01 |
| 9226 | 9226 | ELLEN SAGAR NURSING HOME | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2012-02-29 | 250 | K | 1 | 0 | PX0Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Complaint and Extended Survey, Substandard Quality of Care and Immediate Jeopardy was identified as it related to the facility failure to provide medically related social services to three of three residents involved in allegations of sexual abuse. Residents #1, #2 and #6 alleged sexual abuse against Certified Nursing Assistant (CNA) #1. No Social Service interventions were put in place related to the allegations. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the Annual Minimum (MDS) data set [DATE] revealed Resident #1 received a BIMS score of "13" and was independent with transfers and toilet use. No behaviors were coded as occurring during the assessment period. Review of the Social Services notes dated 12/12/2011 and 01/31/2012 revealed the resident was depressed and did not want to come out of her room. On 02/17/2012, "Resident was admitted to (local hospital) today, family notified of bed hold policy and sent (with) transfer." Another noted date 02/17/2012 revealed: "Allegations were made by resident to her daughter by phone that CNA had been sexually inappropriate. SSD (social service director) was notified on 02/15/2012. Internal investigation is underway along with investigations from SLED (South Carolina Law Enforcement Division) and local sheriff's dept (department). Employee has been placed on leave until investigations are complete. 24 Hour report sent on 2/14 when nurse was notified. 5 day report will be sent on 2/21." The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum (MDS) data set [DATE] revealed the resident scored a BIMS of "3" and was independent with transfers, ambulation and toilet use. No behaviors were recorded a occurring. The resident was coded as having hallucinations and delusions during the assessment period. Review of the Social Services notes dated 02/15/2012 revealed: "DON (director of nurses) and SSD re… | 2015-06-01 |
| 9227 | 9227 | ELLEN SAGAR NURSING HOME | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2012-02-29 | 281 | K | 1 | 0 | PX0Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Complaint and Extended Surveys, Immediate Jeopardy was identified related to the facility staffs failure to identify and assess 3 of 3 residents involved in allegations of sexual abuse (Resident #1, #2 and #6). Facility staff also failed to identify and assess other residents for potential abuse. In addition, facility staff failed to recognize, follow up on and contact the physician regarding blood sugars consistently below 60 mg/dl for two of three residents reviewed receiving Insulin (Residents #1 and #7). The findings included: Review of the "Summary of Investigation on allegation of sexual abuse" dated 02/20/2012 revealed: "During the course of this investigation, another residents name (Resident #2) was mentioned as possibly being involved. (Resident #2's) name is mentioned by the original complainant as having experienced a similar with the employee (sic) in question prior to her experience. (Resident #2) is a close friend of (Resident #1) at the nursing home. At first it was thought that the incident in question had taken place on Tuesday night February 14, 2012, however, it turns out that this was not the case and that the incident happened 2-3 weeks ago with (Resident #2) and 2-3 days ago with (Resident #1). Social Service Director (SSD) and Director of Nursing (DON) have interviewed several employees and residents for similar incidents with the CNA in question. DON visited with (Resident #2) on Wednesday (2/15/12) and resident stated that nothing had happened to her. Resident was given the name of the CNA in question and all she said was "he is sweet and kind man, he does not to a lot for me but he is always appropriate, he has never touched me or asked me to do something." DON had a witness in the room at the time. DON also went back to see (Resident #2) in the afternoon to see if her story had changed, it had not. Later on in the week both SSD and DON went back to (Resident #2) and her story stayed the same. Tod… | 2015-06-01 |
| 9228 | 9228 | ELLEN SAGAR NURSING HOME | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2012-02-29 | 309 | E | 1 | 0 | PX0Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the surveys based on record review and interview, facility staff failed to provide the necessary care and services to maintain the highest practicable physical well-being, in accordance with the comprehensive assessment and plan of care. The facility staff failed to recognize, follow up on and contact the physician regarding blood sugars consistently below 60 mg/dl for two of three residents reviewed receiving Insulin (Residents #1 and #7). The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the Resident #1's Physician order [REDACTED]. The original order was written on 10/13/2011. Further review revealed the resident was to have finger stick blood sugars twice daily at 6 AM and 8 PM. Review of the Symptomatic Protocol signed by the Physician on 02/12/2010 revealed: "[DIAGNOSES REDACTED]/Insulin Reaction- Administer sweetened beverage and/or Glucostat. May administer [MEDICATION NAME] 1 amp/1 mg STAT PRN. If resident has symptoms of insulin reaction (diaphoresis, irritability or altered level of consciousness) and/or blood sugar below 55 may repeat [MEDICATION NAME] once PRN." Special Instructions: "a. Determine blood sugar by finger stick. b. Administer treatments as necessary. c. Re-check 30 minutes after treatment. d. Notify MD immediately if condition hasn't resolved after 30 minutes. Notify MD prior to next insulin or other hypoglycemic agent in order to discuss strategy to prevent recurrence. f. Contact provider if glucose level below 55." Review of the Finger Stick Blood Sugar (FSBS) Record from December 1, 2011 through February 17, 2012 revealed the following: 12/14/2011 at 6 AM FSBS= 46 given juice. No re check was documented. No nurses notes were documented and no physician notification was located; 12/19/2011 at 6 AM FSBS= 55, no intervention and no follow up was documented; 12/22/2011 at 6 AM, FSBS=55, no intervention and no follow up was documented; 12/23/2011 at 6 AM, FSBS… | 2015-06-01 |
| 9229 | 9229 | ELLEN SAGAR NURSING HOME | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2012-02-29 | 428 | E | 1 | 0 | PX0Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During the survey based on observations, record review and interview, the Consultant Pharmacist failed to report irregularities for 2 of 3 residents reviewed for blood sugar management. Resident #1 and #7's blood sugars were repeatedly low without interventions, documented rechecks and physician notification. No recommendations were made by the Consultant Pharmacist regarding the low blood sugars. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the Symptomatic Protocol signed by the Physician on 02/12/2010 revealed: "[DIAGNOSES REDACTED]/Insulin Reaction- Administer sweetened beverage and/or Glucostat. May administer Glucagon 1 amp/1 mg STAT PRN. If resident has symptoms of insulin reaction (diaphoresis, irritability or altered level of consciousness) and/or blood sugar below 55 may repeat Glucagon once PRN." Special Instructions: "a. Determine blood sugar by finger stick. b. Administer treatments as necessary. c. Re-check 30 minutes after treatment. d. Notify MD immediately if condition hasn't resolved after 30 minutes. Notify MD prior to next insulin or other hypoglycemic agent in order to discuss strategy to prevent recurrence. f. Contact provider if glucose level below 55." Review of the Finger Stick Blood Sugar (FSBS) Record from December 1, 2011 through February 17, 2012 revealed the following: 12/14/2011 at 6 AM FSBS= 46 given juice. No re check was documented. No nurses notes were documented and no physician notification was located; 12/19/2011 at 6 AM FSBS= 55, no intervention and no follow up was documented; 12/22/2011 at 6 AM, FSBS=55, no intervention and no follow up was documented; 12/23/2011 at 6 AM, FSBS=55, no intervention and no follow up was documented; 12/25/2011 at 6 AM, FSBS=55, no intervention and no follow up was documented; 12/28/2011 at 6 AM, FSBS=55, no intervention and no follow up was documented; 01/3/2012 at 6 AM, FSBS=55, "drink and cookies" were given, no follow up w… | 2015-06-01 |
| 9230 | 9230 | ELLEN SAGAR NURSING HOME | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2012-02-29 | 490 | K | 1 | 0 | PX0Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Complaint and Extended Survey based on record reviews and interviews, Immediate Jeopardy was identified existing in the facility as of 02/14/2012 related to the facility's failure to utilize its resources effectively and efficiently to attain or maintain the highest practicable well being of each resident. The facility's Administration failed to identify, report and thoroughly investigate allegations of sexual abuse. The findings included: A complaint survey was conducted on 02/21/2012 as a result of a facility reported incident. Resident #1 reported during a telephone conversation, an incident of alleged sexual abuse to her daughter, on the evening of 02/14/2012. Her daughter came to the facility and reported the incident to Registered Nurse (RN) #1. In the following statement taken by RN #1 on 02/14/2012 at 9:25 PM Resident #1 stated, "About 2 weeks ago (CNA #1) pulled his penis out on weekend to (Resident #2) and showed it to her. She told him "get this thing off my hand." Resident #2 told Resident #1 that he did this to her. 2 or 3 days after he did it to her, he done it to me, it was in the evening. He came into (Resident #1's) room and pulled his penis out and put it in her hand. Resident was alone in the room. He acted very nervous during/after he done it. Resident told him she didn't want anything to do with another man and that she was old enough to be his grandmother. This is the 1st time (Resident #1) has mentioned it - has only happened once. Resident stated that she didn't' say anything because she was afraid that he would go out and give her a shot to knock her out. Resident stated that no threats were made by (CNA #1)..." On 02/22/2012 the Administrator contacted the State Agency with additional information related to the investigation regarding Residents #1 and #2. A faxed report indicated, "Staff Assistant reported to nursing that she had reported to her supervisor and Social Services about a month ago that… | 2015-06-01 |
| 9231 | 9231 | ELLEN SAGAR NURSING HOME | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2012-02-29 | 501 | K | 1 | 0 | PX0Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Complaint and Extended Surveys based on record review and interview, Immediate Jeopardy was identified as existing in the facility as of 02/14/2012. Allegations of sexual abuse were made involving three residents and Certified Nursing Assistant (CNA)#1; the facility's Medical Director failed to implement policies related to identification, reporting and investigating allegations of sexual abuse, and failed to ensure each resident was assessed and protected from further potential abuse. The findings included: Review of the facility obtained statement taken by Registered Nurse (RN) #1 from Resident #1 on 02/14/2012 at 9:25 PM revealed: "About 2 weeks ago (CNA #1) pulled his penis out on weekend to (Resident #2) and showed it to her. She told him "get this thing off my hand." Resident #2 told Resident #1 that he did this to her. 2 or 3 days after he did it to her, he done it to me, it was in the evening. He came into (Resident #1's) room and pulled his penis out and put it in her hand. Resident was alone in the room. He acted very nervous during/after he done it. Resident told him she didn't want anything to do with another man and that she was old enough to be his grandmother. This is the 1st time (Resident #1) has mentioned it-has only happened once. Resident stated that she didn't' say anything because she was afraid that he would go out and give her a shot to knock her out. Resident stated that no threats were made by (CNA #1)..." Review of the facility obtained statement taken by RN #1 from Resident #2 on 02/14/2012 at 9:45 PM revealed: "About 2 weeks ago, it's been a good while back, he sat down and had his "thang" out and then he put it back. He was out on the porch. I believe we were out on the porch and he pulled his britches down, its been so long ago. I saw his penis, it was red looking. I left, I haven't spoken to him since....it was very embarrassing, I can't even face him." Further review of the Investigative Fil… | 2015-06-01 |
| 9234 | 9234 | BROOKVIEW HEALTHCARE CENTER | 425062 | 510 THOMPSON STREET | GAFFNEY | SC | 29340 | 2012-02-29 | 250 | F | 1 | 1 | F0R711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Complaint and Recertification Survey Substandard Quality of Care was identified related to the failure of the facility to provide medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility failed to identify potential neglect, abuse, and/or misappropriation of property when reported by residents, staff and /or Responsible Parties. Residents #4, 26, 27, 28, 30, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 45 and 46 were identified in the facility Grievance Log with concerns related to a lack of incontinent care "resident's complained they were left saturated in urine and/or feces", alleged abuse and misappropriation of resident property. The facility Social Services Department failed to ensure that resident, staff and Responsible Party concerns of potential neglect/abuse/misappropriation were thoroughly investigate and/or reported to the appropriate State Agency. The facility Social Services Department failed to following up on and document the resolutions of concerns found in the facility Grievance Log. The Social Services Department failed to ensure that Resident #19 had necessary clothing; Resident #16 social services notes were not documented at least quarterly (last notes 8/2011); Resident #17 failed to have eye or dental appointment scheduled. The findings included: During the Complaint Survey, related to allegations of grievances not thoroughly investigated and resolved, the facility's grievances were reviewed. Upon review, 19 grievances related to lack of incontinent care were noted. Of the 19 grievances related to incontinent care, none of the incidents were thoroughly investigated or reported to the State Survey and Certification Agency. Five of the nineteen potential neglect allegations had a staff member identified. The facility provided "teachable moments" to two of the five identified staff members and failed to pro… | 2015-06-01 |
| 9235 | 9235 | BROOKVIEW HEALTHCARE CENTER | 425062 | 510 THOMPSON STREET | GAFFNEY | SC | 29340 | 2012-02-29 | 441 | E | 1 | 1 | F0R711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, record review, and interviews, the facility failed to maintain an Infection Control Program to help prevent the development and transmission of disease and infection. The facility had incomplete/missing data relative to their surveillance and/or tracking and trending of infections in the facility. The facility failed to implement Contact Precautions for Resident #3, one of two sampled residents with MRSA (Methicillin Resistant Staph Aureus). Two of two sampled residents reviewed for pre-admission [DIAGNOSES REDACTED] screening (Residents #12 and #13) did not have their 1st step PPDs done prior to admission. Three CNAs were observed handling resident's food with their bare hands. The findings included: The facility has 3 units, Peach (100's), Dogwood (200's), and Magnolia (300's). During an interview on 2/28/12 at 4:25 PM, the Director of Nursing (DON) and 2 nurse consultants verified they were unable to locate documentation relative to surveillance and/or tracking and trending of infections relative to individual residents on the following units for the following months: August 2011- Peach, Dogwood, and Magnolia. September 2011- Dogwood. October 2011- Dogwood and Magnolia. November 2011- Dogwood. During an interview on 2/29/12 at 10:42 AM, the DON and the Regional Nurse Consultant were present. The DON stated she had been the Infection Control Coordinator in November, December, and January prior to taking the DON position. She stated she was responsible to ensure staff are inserviced on infection control issues. She stated that each month in their QA (Quality Assurance) meeting any trends are brought to the committee and discussed. She stated each unit manager maintains a running log of any residents with a potential and/or true infection. She stated they would log any residents with symptoms, tests pending to confirm or rule out an infection, or any resident on an antibiotic. She stated the U… | 2015-06-01 |
| 9236 | 9236 | BROOKVIEW HEALTHCARE CENTER | 425062 | 510 THOMPSON STREET | GAFFNEY | SC | 29340 | 2012-02-29 | 166 | F | 1 | 1 | F0R711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Complaint and Recertification Survey based on observations, record review, interview and review of the facility Grievance Policy, the facility failed to identify potential neglect, abuse, and/or misappropriation of property when reported by residents, staff and /or Responsible Parties. Residents #4, 26, 27, 28, 30, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 45 and 46 were identified in the facility Grievance Log with concerns related to a lack of incontinent care "resident's complained they were left saturated in urine and/or feces", alleged abuse and misappropriation of resident property. The facility failed to thoroughly investigate each incident and/or report potential neglect/abuse/misappropriation to the appropriate State Agency. The findings included: The facility Grievance Log was reviewed as part of a complaint survey, related to allegations that grievances were not thoroughly investigated and resolved. Upon review, 19 grievances related to lack of incontinent care were noted. Of the 19 grievances related to incontinent care, none of the incidents were thoroughly investigated or reported to the State Survey and Certification Agency. Five of the nineteen potential neglect allegations identified a staff member. The facility provided "teachable moments" to two of the five identified staff members and failed to provide education or disciplinary action to the other three identified staff members. Resident #26 alleged verbal abuse against a Certified Nurse Aide (CNA) which was not investigated. Resident #38 alleged a staff member took a gold necklace, this was not report to the appropriate State Agency; Resident #46's family alleged she failed to receive insulin on 2 different days there was no documentation of a resolution of the concern. Several different grievance forms were used. There was not consistent documentation of satisfactory resolution nor was there documentation of what the resolutions were. The facility ad… | 2015-06-01 |
| 9237 | 9237 | BROOKVIEW HEALTHCARE CENTER | 425062 | 510 THOMPSON STREET | GAFFNEY | SC | 29340 | 2012-02-29 | 224 | F | 1 | 1 | F0R711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Complaint and Recertification Survey Substandard Quality of Care was identified related to the failure of the facility to implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. The facility failed to identify potential neglect, abuse, and/or misappropriation of property when reported by residents, staff and /or Responsible Parties. Residents #4, 26, 27, 28, 30, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 45 and 46 were identified in the facility Grievance Log with concerns related to a lack of incontinent care "resident's complained they were left saturated in urine and/or feces", alleged abuse and misappropriation of resident property. The facility failed to thoroughly investigate each incident and/or report potential neglect/abuse/misappropriation to the appropriate State Agency. The findings included: The facility Grievance Log was reviewed as part of a complaint survey, related to allegations that grievances were not thoroughly investigated and resolved. Upon review, 19 grievances related to lack of incontinent care were noted. Of the 19 grievances related to incontinent care, none of the incidents were thoroughly investigated or reported to the State Survey and Certification Agency. Five of the nineteen potential neglect allegations identified a staff member. The facility provided "teachable moments" to two of the five identified staff members and failed to provide any education or disciplinary action to the other three identified staff members. Resident #26 alleged verbal abuse against a Certified Nurse Aide (CNA) which was not investigated. Resident #38 alleged a staff member took a gold necklace, this was not report to the appropriate State Agency; Resident #46's family alleged she failed to receive insulin on 2 different days there was no documentation of a resolution of the concern. The facility admitted Resident #4 with [DIA… | 2015-06-01 |
| 9238 | 9238 | BROOKVIEW HEALTHCARE CENTER | 425062 | 510 THOMPSON STREET | GAFFNEY | SC | 29340 | 2012-02-29 | 226 | F | 1 | 1 | F0R711 | On the days of the Complaint and Recertification Survey Substandard Quality of Care was identified related to the facility failure to follow their Abuse and Neglect Prohibition Policy related to the identification of potential neglect, to thoroughly investigate allegations of potential neglect, to report potential neglect and to protect residents from potential neglect. The findings included: Cross Refers to F-224 as it related to the failure of the facility to implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. The facility failed to identify potential neglect, abuse, and/or misappropriation of property when reported by residents, staff and /or Responsible Parties. Residents #4, 26, 27, 28, 30, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 45 and 46 were identified in the facility Grievance Log with concerns related to a lack of incontinent care "resident's complained they were left saturated in urine and/or feces", alleged abuse and misappropriation of resident property. The facility failed to thoroughly investigate each incident and/or report potential neglect/abuse/misappropriation to the appropriate State Agency. The facility's Grievance Log was reviewed as part of a complaint survey, related to allegations that grievances were not thoroughly investigated and resolved. Upon review, 19 grievances related to lack of incontinent care were noted. Of the 19 grievances related to incontinent care, none of the incidents were thoroughly investigated or reported to the State Survey and Certification Agency. Five of the nineteen potential neglect allegations identified a staff member. The facility provided "teachable moments" to two of the five identified staff members and failed to provide education or disciplinary action to the other three identified staff members. There was not consistent documentation of satisfactory resolution nor was there documentation of what the resolutions were. Resident #26 alleged verbal abuse agains… | 2015-06-01 |
| 9239 | 9239 | BROOKVIEW HEALTHCARE CENTER | 425062 | 510 THOMPSON STREET | GAFFNEY | SC | 29340 | 2012-02-29 | 490 | F | 1 | 1 | F0R711 | On the days of the Complaint and Recertification Survey Substandard Quality of Care was identified and the Administration was informed on 2/28/2012 at 9:50 AM related to the facility's Administration to effectively utilize it's resources to maintain the highest practicable well being of each resident. The facility Administrator failed to address reported grievances to ensure prompt resolution and to ensure actual/potential neglect/abuse/misappropriation of property had not occurred. The findings included: The facility Grievance Log was reviewed as part of a complaint survey, related to allegations that grievances were not thoroughly investigated and resolved. Upon review, 19 grievances related to lack of incontinent care were noted. Of the 19 grievances related to incontinent care, none of the incidents were thoroughly investigated or reported to the State Survey and Certification Agency. Five of the nineteen potential neglect allegations identified a staff member. The facility provided "teachable moments" to two of the five identified staff members and failed to provide education or disciplinary action to the other three identified staff members. Several different grievance forms were used. There was not consistent documentation of satisfactory resolution nor was there documentation of what the resolutions were. Resident #26 alleged verbal abuse against a Certified Nurse Aide (CNA) which was not investigated. Resident #38 alleged a staff member took a gold necklace, this was not report to the appropriate State Agency; Resident #46's family alleged she failed to receive insulin on 2 different days there was no documentation of a resolution of the concern. During an interview on 2/27/12 at 1:45 PM, the Social Worker (SW) stated that she was responsible for grievances. She stated that when a grievance was received she made the initial report. Then the concern goes to the Administrator for review to determine if it is a reportable incident. If not reportable the grievance goes to the appropriate department for inves… | 2015-06-01 |
| 9240 | 9240 | BROOKVIEW HEALTHCARE CENTER | 425062 | 510 THOMPSON STREET | GAFFNEY | SC | 29340 | 2012-02-29 | 520 | F | 1 | 1 | F0R711 | On the days of the Complaint and Recertification Survey, Substandard Quality of Care was identified and the Administration was informed on 2/28/2012 at 9:50 AM related to the facility's failure to provide medically related social services related the facility's grievance process. The facility failed to identify potential neglect, thoroughly investigate allegations of potential neglect, report potential neglect and protect residents from potential neglect. Resident #4, 26, 27, 29, 30, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 45 and 46 had grievances logged related to lack of incontinent care "resident's were left saturated in urine and or feces" and abuse/neglect. The facility social services department failed to thoroughly investigate each incident and failed to report potential abuse/neglect/misappropriation of property to the appropriate State Agency. The systematic failure was not identified as a concern by the facility Quality Assurance program. The findings included: During the Complaint Survey, related to allegations of grievances not thoroughly investigated and resolved, the facility's grievances were reviewed. Upon review, 19 grievances related to lack of incontinent care were noted. Of the 19 grievances related to incontinent care, none of the incidents were thoroughly investigated or reported to the State Survey and Certification Agency. Five of the nineteen potential neglect allegations had a staff member identified. The facility provided "teachable moments" to two of the five identified staff members and failed to provide education or disciplinary action to the other three identified staff members. Resident #26 alleged verbal abuse against a Certified Nurse Aide (CNA) which was not investigated. Resident #38 alleged a staff member took a gold necklace, this was not report to the appropriate State Agency; Resident #46's family alleged she failed to receive insulin on 2 different days there was no documentation of a resolution of the concern. The Social Services Department was responsible for the gri… | 2015-06-01 |
| 9989 | 9989 | BROOKVIEW HEALTHCARE CENTER | 425062 | 510 THOMPSON STREET | GAFFNEY | SC | 29340 | 2012-02-29 | 315 | D | 0 | 1 | F0R711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, interviews, record review, and review of the facility provided policy for Catheter Care, the facility failed to provide appropriate catheter care for 2 of 3 residents observed for catheter care. Facility Certified Nursing Assistants failed to practice acceptable infection control standards during catheter care for Residents #7 and #15. The findings included: The facility admitted Resident #15 on 5/18/11 with [DIAGNOSES REDACTED]. Catheter care was provided on 2/28/12 at approximately 2:15 PM by CNA (Certified Nursing Assistant) # 6 and CNA #5. Both CNA's knocked, entered the room, identified self and explained the procedure, provided privacy by closing the door and pulling the privacy curtain. They washed hands and gloved. CNA #6 used a disposable wipe to clean the right side of the tip of the penis downward toward the shaft and discarded the wipe. She then used a clean disposable wipe and cleaned the left side of the tip of the penis downward toward the shaft and discarded the wipe. CNA #6 then used a third disposable wipe and cleaned the catheter tubing avoiding the meatus, thus not cleaning the site of tube insertion into the urethra. CNA #6 bagged up the trash, removed the soiled gloves, washed hands and with assistance from CNA #5, the resident was repositioned and covered. CNA #6 then placed the trash in the soiled linen room and washed hands in another resident's room. On 2/29/12 at approximately 4:00 PM, during an interview with the Director of Nursing (DON) regarding expected practice of catheter care related to infection control standards, she confirmed the importance of cleaning the meatus and the catheter tubing at this site. The facility admitted Resident #7 on 3/19/10 with [DIAGNOSES REDACTED]. Record review on 2/28/12 revealed lab results from December 2011 through February 2012 documenting several UTI's (Urinary Tract Infections) for Resident #7. Observation of catheter care on… | 2014-08-01 |
| 9990 | 9990 | BROOKVIEW HEALTHCARE CENTER | 425062 | 510 THOMPSON STREET | GAFFNEY | SC | 29340 | 2012-02-29 | 279 | D | 0 | 1 | F0R711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification and Complaint Survey, based on record reviews and interviews, the facility failed to develop a comprehensive care plan for Resident #13, (1 of 1 with a Intr[DIAGNOSES REDACTED]c Defibrillator), that included measurable objectives and timetables to meet a resident's needs that were identified in the comprehensive assessment. The findings included: The facility admitted Resident #13 on 2/9/2012 with [DIAGNOSES REDACTED]. On 2/28/12 at 11:45 AM, record review for Resident #13 revealed that the resident had had an ICD placed prior to admission to the facility. Review of the Nursing Admission/Quarterly Evaluation Form dated 2/9/12 indicated that the resident was assessed as having "scars" on the upper right and left areas of his chest. The Nursing notes for 2/9/12 contained no documentation related to the areas. Review of the resident's care plan revealed the resident had no care plan for the ICD. During an interview on 2/29/12 at 8:55 AM, Licensed Practical Nurse (LPN) #5 verified that the resident did not have a care plan for the ICD. | 2014-08-01 |
| 9991 | 9991 | BROOKVIEW HEALTHCARE CENTER | 425062 | 510 THOMPSON STREET | GAFFNEY | SC | 29340 | 2012-02-29 | 280 | D | 0 | 1 | F0R711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the recertification and complaint survey, based on record review and interview, the facility failed to update a plan of care for 1 of 2 sampled residents reviewed [MEDICAL CONDITION] ([MEDICAL CONDITION] Resistant Staph Aureus). The care plan for Resident #3 was not updated related to the resident'[MEDICAL CONDITION] wound infection. The findings included: The facility admitted Resident #3 on 10/26/11 with Left Lower Lobe Pneumonia, History of Hypotensive Septic Shock, Urosepsis and Metabolic Acidosis. . Review of the resident's labs on 2/27/12 at 3:22 PM revealed a Wound Culture report dated 2/21/12 (faxed to Wound Center 2/24/12) which documented under Isolates and Sensitivity Results "Staphylococcus Aureus, [MEDICATION NAME] R (Resistant) = [MEDICAL CONDITION] Resistant Staph Aureus (MRSA). Strict Handwashing Technique and Isolation Recommended...Escherichia Coli (E. Coli)". A second Wound Culture report dated 12/27/11 (faxed to Wound Center 12/30/11) documented under Isolates and Sensitivity Results "Staphylococcus Aureus, [MEDICATION NAME] R (Resistant) = [MEDICAL CONDITION] Resistant Staph Aureus (MRSA). Strict Handwashing Technique and Isolation [MEDICATION NAME] Faecalis- (Group D). Review of Physician Telephone Orders dated 2/24/12 revealed an entry for "1. [MEDICATION NAME] 500 mg (1) per tube QID (Four times daily) X 10 days, 2. Keflex 500 mg (milligrams) (1) via tube QID X 10 days". According to the Wound Culture report dated 2/21/12, [MEDICATION NAME] was listed as being sensitive to Staph Aureus while Keflex was listed as being sensitive to the E. Coli. Review of Physician order [REDACTED]. If wound vac off replace in 2 hours, [MEDICATION NAME] 300 mg Q (every) 8 hrs (hours) X 6 weeks...Cont(inue) [DEVICE]". Review of facility Physician Telephone Orders revealed an entry dated 1/3/12 to "D/C Bactrim, Start [MEDICATION NAME] (1) via tube TID (Three Times Daily) X 6 weeks, ...". According to the Wound Culture report… | 2014-08-01 |
| 9992 | 9992 | BROOKVIEW HEALTHCARE CENTER | 425062 | 510 THOMPSON STREET | GAFFNEY | SC | 29340 | 2012-02-29 | 281 | D | 0 | 1 | F0R711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification and Complaint Survey, based on record reviews and interviews, the facility failed to provide services that met professional standards of quality for 3 of 14 sampled residents reviewed for medication administration. Resident #8 received no follow up related to a medication that was placed on hold on 11/29/11. Nursing staff inaccurately notified the Physician of a positive [MEDICAL CONDITION] lab result for Resident #3, resulting in an unnecessary treatment with [MEDICATION NAME]. Resident #7 was not provided Sliding Scale Insulin as ordered by the Physician. The findings included: The facility admitted Resident #8 on 2/18/10 with [DIAGNOSES REDACTED]. On 2/27/12, review of the Physician's Telephone Orders and Nurse's Notes dated 11/29/11 stated to "hold [MEDICATION NAME] until further notice". Communication from the [MEDICAL TREATMENT] Clinic stated "Phosphorus is low at 2.3-Hold [MEDICATION NAME]." The Resident's current Medication Administration Record [REDACTED]"Hold until further notice r/t (related to) phosphorus level 11-29-11 labs at DCI ([MEDICAL TREATMENT] Clinic)." The resident's lab results revealed that the facility had not obtained results since November 2011. In an interview on 2/27/12 with Licensed Practical Nurse (LPN) #6, she stated that she would have expected the order to hold the medication to be evaluated when the next lab results were received . She verified labs are drawn at the [MEDICAL TREATMENT] Clinic. LPN #6 and LPN #7 verified that the facility had not received lab results since November 2011 and agreed that they should have followed up on the order sooner. The facility admitted Resident #3 on 10/26/11 with [DIAGNOSES REDACTED]. Record review on 2/28/12 at approximately 11:00 AM revealed a lab result dated 2/1/12 for [MEDICAL CONDITION] which was reported as "negative". Review of Interdisciplinary Progress Notes on 2/29/12 revealed the following notes:-2/2/12 at 7:30 PM "Res(ident… | 2014-08-01 |
| 9993 | 9993 | BROOKVIEW HEALTHCARE CENTER | 425062 | 510 THOMPSON STREET | GAFFNEY | SC | 29340 | 2012-02-29 | 285 | D | 0 | 1 | F0R711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification and Complaint Survey, the facility failed to obtain a Preadmission Screening for Resident #13 prior to admission. (1 of 24 sampled residents reviewed for PASARR completion.) The PASARR for Resident # 13 was not completed until after the resident resided in the facility for six days. The findings included: The facility admitted Resident #13 on 2/9/2012 with [DIAGNOSES REDACTED]. On 2/28/12 at 10:40 AM, record review for Resident #13 revealed that he was admitted to the facility on [DATE] and that his PASARR was not completed until 2/14/12 at the facility. At the time of record review, Licensed Practical Nurse (LPN) #6 verified that the PASARR was dated 2/14/12 and should have been completed prior to the resident being admitted to the facility. | 2014-08-01 |
| 9994 | 9994 | BROOKVIEW HEALTHCARE CENTER | 425062 | 510 THOMPSON STREET | GAFFNEY | SC | 29340 | 2012-02-29 | 371 | E | 0 | 1 | F0R711 | On the days of the survey, based on observations and interviews, the facility failed to store, prepare, distribute and serve food under sanitary conditions. Dietary staff members were observed improperly wearing harinets. Food items stored in the freezer were unlabeled or stored in torn bags. Resident meal trays were cracked with metal exposed on the rims. The findings included: On 2/27/12 at 10:30 AM, two dietary staff members and the Dietary Manager (DM) were observed improperly wearing hair restraints. Hair was exposed and not restrained by the hair nets while the staff was observed in the food service area. The concern was not disputed by the DM. Observation of the facility's freezer revealed a bag of Chicken Cordon Bleu stored out of its original box with no label/date, and the bag was torn. There was also 1 large bag of meatballs and 1 large bag of diced ham which was not dated nor labeled. On 2/28/12 at 11:00 AM, an additional 2.5 large bags of tatter tots were observed in the freezer with no date/label and not in the original box (all unlabeled items were identified/verified by the DM). Meal trays which were being used to serve resident meals were observed with chipped sides, exposed metal on the edges. | 2014-08-01 |
| 9995 | 9995 | BROOKVIEW HEALTHCARE CENTER | 425062 | 510 THOMPSON STREET | GAFFNEY | SC | 29340 | 2012-02-29 | 425 | D | 0 | 1 | F0R711 | On the days of the survey, based on observation and interview, the facility failed to follow a procedure to ensure that expired medication (insulin) was not stored with other medications available for use in 2 of 6 medication carts. The findings included: On 2/29/12, review of the facility's medication carts revealed that the Peach (short hall cart) contained a 100 unit/milliliter (ml) vial of Lantus Insulin with an opened date of 1/22 and an expiration date of 2/19 and one 100 unit/ml vial of Regular Insulin with an expiration date of 2/15/12. Both of the insulins were available for staff use despite being past their expiration date. The (long hall) cart on the Peach Unit contained a 100 unit/ml vial of Lantus Insulin with an open date of 1/21/12 and an expiration date of 2/17/12 that should not have been available for resident use. Registered Nurse #1 verified the expiration dated of the Insulins on the short hall cart and Licensed Practical Nurse #4 verified the expiration date of the Insulin on the long hall cart. | 2014-08-01 |
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CREATE TABLE [cms_SC] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );