cms_SC
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 10223 | 10223 | MAGNOLIA MANOR - INMAN | 425032 | 63 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2010-11-17 | 164 | D | JNTL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, interview, and review of facility protocol entitled "Survey Readiness", the facility failed to provide privacy to 1 of 3 residents observed for wound care and 1 resident randomly observed in the bathroom during the same wound care procedure. Resident # 3 was exposed during wound care to the buttock when a Certified Nursing Assistant (CNA) entered the room without knocking. The Licensed Practical Nurse (LPN) entered an occupied bathroom without knocking during this same treatment. The findings included: The facility admitted Resident #3 on 6/23/10 with a [DIAGNOSES REDACTED]. During observation of wound treatment for [REDACTED].#3 entered the room through the closed bathroom door without knocking, left the bathroom door open while she got the lift and then left the room through the same bathroom door. The wound care treatment was in progress with Resident #3's buttock exposed and the privacy curtain was not pulled at the foot of the bed. During observation of the same wound treatment for [REDACTED].#3 entered the bathroom to wash her hands and did not knock. A resident was using the bathroom at the time when the nurse entered without knocking. During an interview with LPN #3 on 11-17-10 at 12:40 PM, the nurse verified that she did enter the occupied bathroom without knocking. She also verified that CNA #3 entered the room without knocking while Resident #3 was exposed. On 11-17-10 at 1:05 PM, the Staff Development Coordinator (SDC) provided a document entitled "Survey Readiness" which stated: "Remember Privacy: Knock on each door, close the door, pull the privacy curtain, and close the blinds." The SDC stated that she goes over this information with new hires and periodically as needed. During a discussion with the Director of Nursing (DON) related to privacy issues identified during treatments on 11-17-10 at 1:00 PM, the DON said she had in-serviced the staff on closing blinds, pulling curtains… | 2014-03-01 | ||
| 10224 | 10224 | MAGNOLIA MANOR - INMAN | 425032 | 63 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2010-11-17 | 315 | D | JNTL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, interview, record review, review of the facility policy entitled "Suprapubic Catheter Care", and review of the training manual "Assisting in Long Term Care, Second Edition", the facility failed to provide appropriate treatment and services to prevent Urinary Tract Infections for 2 of 4 sampled residents reviewed with indwelling catheters. Resident #3 had the catheter anchored inappropriately during catheter care causing a potential for trauma. Resident # 14's catheter tubing was on the floor throughout catheter care observation. The findings included: The facility admitted Resident #3 on 6/23/10 with a [DIAGNOSES REDACTED]. On 11-17-10 at 10:45 AM during observation of suprapubic catheter care for Resident # 3, Licensed Practical Nurse (LPN) #3 anchored the catheter tubing approximately 4 inches away from the insertion site and cleansed the tubing from the insertion site in an outward motion causing potential trauma. Review of the facility policy entitled "Suprapubic Catheter Care" step # 12 stated: 'With the third wipe, clean the catheter tubing about 4 inches, while holding the catheter securely." The facility admitted Resident # 14 on 6/12/09 with [DIAGNOSES REDACTED]. During observation of suprapubic catheter care by Registered Nurse (RN) # 5 on 11-17-10 at 10:30 AM, the catheter tubing was noted to be lying on the floor upon entering the room and remained there during the entire procedure. After completion of the procedure, RN #5 was questioned about the cloudy character of the urine. The nurse stated that the resident was currently being treated for [REDACTED]. Record review revealed a Physician's Telephone Order dated 11/14/10 which stated: "Keflex 250 mg. (milligrams) po (by mouth) TID (three times daily) X 10 days for positive urinalysis." RN # 5 confirmed that the tubing was on the floor during an interview held on 11-17-10 at 12:30 PM. The nurse verified that she was aware that the t… | 2014-03-01 | ||
| 10225 | 10225 | J F HAWKINS NURSING HOME | 425035 | 1330 KINARD STREET | NEWBERRY | SC | 29108 | 2010-11-18 | 225 | D | PITJ11 | On the day of the inspection, based on record review and review of facility files, the facility failed to ensure that all allegations of neglect were reported within twenty-four hours to the State survey and certification agency for 1 of 1 allegation of neglect reported (Resident #1). The findings included: On 10/22/10, after Resident #1 complained of pain in her right ankle, the physician found a dressing dated 9/27/10 on her ankle. The dressing had originally covered a callus. When the physician removed the dressing, he found the resident's ankle red and swollen with an open and infected ulcer. Review of the medical record revealed the resident was to have a DuoDerm dressing to the site, changed every three days. The facility reported this allegation of neglect to the State survey and certification agency on 10/25/10, which exceeded the twenty-four hours allowed. | 2014-03-01 | ||
| 10226 | 10226 | J F HAWKINS NURSING HOME | 425035 | 1330 KINARD STREET | NEWBERRY | SC | 29108 | 2010-11-18 | 281 | G | PITJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the inspection, based on record review, interviews, and review of facility files, the facility failed to ensure that services provided by the facility met professional standards of quality for 1 of 1 resident who developed redness, swelling, pain, and an open area under a [MEDICATION NAME] dressing that was not changed for 23 days (Resident #1). Facility staff failed to ensure the resident's treatment order was carried forward to the new month, and failed to thoroughly assess and accurately document the resident's changing skin condition. The findings included: Resident #1 with [DIAGNOSES REDACTED]. The physician found an occlusive dressing on the right lateral ankle dated 09/27/10. There was pus underlying the dressing and an infected open area measuring 1 X 1 cm (centimeter) surrounded by a 3 by 3 cm area of [MEDICAL CONDITION]. The physician ordered wet to dry dressings, and antibiotic treatment with [MEDICATION NAME] 250 milligrams three times a day for ten days. Review of the medical record and the facility's investigative materials revealed none of the staff providing care to the resident (five nurses and thirteen nursing assistants), from 9/27/10 to 10/22/10, noticed the unchanged dressing and the developing decline in the resident's skin condition. CNAs (Certified Nursing Assistants) doing daily skin inspections noted the resident's skin was "clear." Licensed staff documented on the weekly body audits that the resident had a callus on her right ankle. The licensed staff failed to update the monthly cumulative orders for October 2010 to show the dressing change order for DuoDerm to the right ankle every three days. This order was initiated on 6/30/10. Licensed staff failed to realize the omission of the order and therefore, failed to provide the resident with the treatment. The staff also failed to provide the appropriate care and ongoing assessment required to manage the resident's skin care. Cross refer to F-314 related… | 2014-03-01 | ||
| 10227 | 10227 | J F HAWKINS NURSING HOME | 425035 | 1330 KINARD STREET | NEWBERRY | SC | 29108 | 2010-11-18 | 314 | G | PITJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the inspection, based on record review and interview, the facility failed to ensure that a resident received treatment to promote healing, prevent infection, and prevent new sores from developing for 1 of 1 resident reviewed who developed an infected sore when facility staff left a protective dressing in place from 9/27/10 to 10/22/10 (Resident #1). The resident did not have her dressing changed because the treatment order was omitted from the October 2010 orders and treatment record. Facility staff failed to recognize the omission. As the resident's ankle declined in condition, the staff failed to thoroughly assess and accurately document her condition in the medical record. The daily skin inspection and weekly body audit documentation showed no changes in the condition of the resident's ankle. These failures lead to a lack of appropriate interventions. The findings included: Resident #1 with [DIAGNOSES REDACTED]. The physician's progress note, dated 10/22/10 and signed on 11/18/10, stated he found an occlusive dressing on the right lateral ankle "which was dated 09/27 and had pus underlying the dressing." Under the dressing was "a 3 X 3 cm (centimeter) stage 2 ulceration and a 1 X 1 cm stage 3 ulceration with surrounding [MEDICAL CONDITION]." The physician ordered wet to dry dressings, and antibiotic treatment with [MEDICATION NAME] 250 milligrams three times a day for ten days. According to the physician's progress note, it was his understanding the Wound Care team was assessing this wound at least weekly. The physician wanted to know why the dressing had "apparently not been changed for 23 days." He showed the wound to the Unit Manager and wanted to know why the dressing had not been changed. The facility began an investigation to answer the physician's questions. Review of the medical record revealed the resident had an ulcer on her right lateral ankle in February 2010. The pressure ulcer was treated with antibiotics for tw… | 2014-03-01 | ||
| 10228 | 10228 | J F HAWKINS NURSING HOME | 425035 | 1330 KINARD STREET | NEWBERRY | SC | 29108 | 2010-11-18 | 514 | G | PITJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the inspection, based on record review, the facility failed to ensure medical records were complete and accurately documented for 1 of 1 resident who developed an infected open area under a [MEDICATION NAME] dressing that was not changed for 23 days (Resident #1). On 11/18/10, the physician's progress note of 10/22/10 was not on the record. Facility staff failed to ensure monthly cumulative orders were complete related to treatments ordered, and failed to accurately document the resident's changing skin condition. The findings included: Resident #1 with [DIAGNOSES REDACTED]. On 10/22/10, the resident complained to the physician of pain in her ankle. While examining the resident, the physician found a DuoDerm dressing on the ankle 9/27/10. Under the dressing was an open and infected ulcer. Review of the resident's medical record on the morning of 11/18/10 failed to show a physician progress notes [REDACTED]. The physician signed and sent his progress note for 10/22/10 via facsimile on the afternoon of 11/18/10. Review of the Nurse's Notes for 10/22/10 showed no descriptive documentation of the resident's right ankle. The redness, swelling, and open area found by the physician was not included in the nurse's note. The pressure ulcer's characteristics were documented in the Skin Condition Report, but other than the physician's progress note, the medical record did not show that a dressing dated 9/27/10 was found on the resident on 10/22/10. Facility staff failed to note the omission of the DuoDerm treatment order on the printed cumulative orders for October 2010. Therefore, the order was not listed on the Documentation Sheet for treatments and the resident did not receive the DuoDerm treatment 10/1-22/10. Review of the CNA Daily Skin Inspection Record and the Body & Skin Audits done by the nurses on a weekly basis revealed documentation for September 2010 and up to October 22, 2010 showing no changes in the resident's condition alt… | 2014-03-01 | ||
| 10229 | 10229 | C M TUCKER NURSING CARE CENTER / STONE & FEWELL | 425074 | 2200 HARDEN STREET | COLUMBIA | SC | 29203 | 2010-11-30 | 225 | D | 5NE411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection based on record review, interviews, and review of the facility's policy on Abuse and Neglect, the facility failed to provide evidence that an incident involving the care of Resident #1 was thoroughly investigate. The facility failed to interview and obtain witness statements from the Certified Nursing Aide (CNA) assigned to Resident #1 at the time of the incident and the Registered Nurse (RN) on duty at the time of the incident; Resident #2's family's concern about his eye was not investigated and reported to the state agency. (2 of 5 sampled residents reviewed). The findings included: The facility admitted Resident #1 on 5/12/2010 with [DIAGNOSES REDACTED]. Review of the Nurses' Note dated 11/08/2010 at 10:40 AM stated, "Called to room Resident on floor matt with laceration to right forehead measuring 1.5 cm (centimeters)..." Review of the facility investigation file revealed a facility accident/incident report dated 11/08/2010 at 11:22 AM Section One: To be completed by person reporting/witnessing the incident. CNA #1 described the incident as follows: "staff turn back and res (resident) rolled over and hit head on closet. Section Two: To be completed by a licensed nurse dated 11/08/2010 at 1500 under Corrective/preventive measures RN #1 stated, "Resident receiving AM care staff turned and resident rolled OOB (out of bed) struck head on closet. Orders written to pad closet and nightstand to prevent this type of injury. Matts were on floor..." The facility investigation included incident witness statements from three staff members who stated they were unaware of the incident; there were no credentials/job titles to identify the three witnesses. The facility failed to obtain interview statements from CNA #1 and RN #1. In an interview on 11/17/2010 at 10:40 AM the Director of Nurses confirmed there were no witness statements completed by CNA #1 and RN #1. The facility admitted Resident #2 on 11/29/2004 w… | 2014-03-01 | ||
| 10230 | 10230 | C M TUCKER NURSING CARE CENTER / STONE & FEWELL | 425074 | 2200 HARDEN STREET | COLUMBIA | SC | 29203 | 2010-11-30 | 282 | G | 5NE411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on record review and interviews the facility failed to ensure that care plans were followed for 1 of 5 sampled residents reviewed. Resident #1 care planned as a total assist with two care givers with bathing, dressing and grooming, was injured on 11/08/2010 when Certified Nurse Aide #1 provided care unassisted. The findings included: The facility admitted Resident #1 on 5/12/2010 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] and 11/04/2010 coded the resident as having short and long-term memory problems with moderately impaired cognitive skills for daily decision-making. The MDS coded the resident as being totally dependent on staff for transfer, hygiene and dressing. Review of the Nurses' Note dated 11/08/2010 at 10:40 AM stated, "Called to room Resident on floor matt (sic) with laceration to right forehead measuring 1.5 cm (centimeters)..." Review of the care plan with a start dated of 05/31/2010 identified as Problem #6 "Self care deficit r/t (related to) Alzheimer's dementia with inability to follow directions, impaired mobility..." Interventions included, "1. Requires total assistance of two care givers with bathing, dressing and grooming needs..." In an interview with the surveyor on 11/17/2010 at 10:05 AM Certified Nurse Aide (CNA) #1 stated that on 11/08/2010 Resident #1 rolled over and fell from the bed when she turned around "to grab things" while providing care. CNA #1 stated, "I turned away for a few seconds and the resident rolled out of bed." CNA #1 stated she was the only CNA providing care. In an interview with the surveyor on 11/17/2010 at 10:20 AM Registered Nurse (RN) #1 stated that when he entered the room the resident was lying in bed on he back and he noted an injury to the right side of the resident's forehead. RN #1 stated that CNA #1 told him she went to the closet and the resident fell . RN #1 stated that CNA #1 was the only CNA … | 2014-03-01 | ||
| 10231 | 10231 | C M TUCKER NURSING CARE CENTER / STONE & FEWELL | 425074 | 2200 HARDEN STREET | COLUMBIA | SC | 29203 | 2010-11-30 | 323 | G | 5NE411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on observations, record review and interviews the facility failed to ensure that Resident #1's environment remains as free of accident hazards as possible. Resident #1 injured on 11/08/2010 when a Certified Nurse Aide (CNA) bathed him alone, was care planned to have two people with bathing. The review of the Nursing Guide To Care sheet, the CNA care guide, dated 10/01/2010 did not include the number of caregivers required for care. Following the injury the care plan was updated on 11/09/2010 to include padded edges to the nightstand and closet, observation on 11/17/2010 revealed no padded edges. The findings included: The facility admitted Resident #1 on 5/12/2010 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] and 11/04/2010 coded the resident as having short and long-term memory problems with moderately impaired cognitive skills for daily decision-making. The MDS coded the resident as being totally dependent on staff for transfer, hygiene and dressing. Review of the Nurses' Note dated 11/08/2010 at 10:40 AM stated, "Called to room Resident on floor matt (sic) with laceration to right forehead measuring 1.5 cm (centimeters)..." Review of the care plan with a start dated of 05/31/2010 identified as Problem #6 "Self care deficit r/t (related to) Alzheimer's dementia with inability to follow directions, impaired mobility..." Interventions included, "1. Requires total assistance of two care givers with bathing, dressing and grooming needs..." On 11/09/2010 the care plan was updated with an intervention to include "Pad night stand and closet." Review of the Nursing Guide To Care sheet, the CNA care guide, dated 10/01/2010 did not include the number of caregivers required for care. In an interview with the surveyor on 11/17/2010 at 10:05 AM Certified Nurse Aide (CNA) #1 stated that on 11/08/2010 Resident #1 rolled over and fell from the bed when she turned aroun… | 2014-03-01 | ||
| 10232 | 10232 | UNIHEALTH POST ACUTE CARE - AIKEN, LLC | 425145 | 830 LAURENS STREET NORTH | AIKEN | SC | 29801 | 2010-11-22 | 153 | G | 6LCC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the inspection, based on record review and interviews, the facility failed to provide access to all medical records for 1 of 4 residents sampled for the request of medical records (Resident #1). A written request made by the wife (personal representative) of Resident #1 made initially to the facility on [DATE] and then again on [DATE] was denied. The Regional Ombudsman, after numerous attempts to assist the resident's wife in obtaining the medical records of Resident #1, filed a complaint with the State Survey Agency on [DATE]. Nurses' Notes documented that the facility notified Resident #1's wife with any change in condition and acknowledged her as his personal representative. The facility failed to acknowledge the Health Care Consent Act (SC Code [DATE] et. esq.) and failed to recognize Resident #1's wife as his personal representative when she requested copies of his medical record. The findings included: On [DATE] the facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] and Quarterly MDS assessment dated [DATE] coded the resident as having short-term and long-term memory problems with severely impaired cognitive skills for daily decision-making. Resident #1 required extensive to total assistance for all activities of daily living on the Admission and Quarterly MDS. Review of the current medical record revealed a Do Not Resuscitate (DNR) Authorization for Patient/Resident Without Decision-Making Capacity for Resident #1 signed [DATE] by two physicians and by the resident's wife ([DATE]). During an onsite visit to the facility on [DATE], Resident #1 was sampled as a result of a complaint received by the State Agency on [DATE]/2010, which alleged that the resident's wife failed to receive requested medical records. The allegation stated that the Ombudsman had worked since [DATE] to resolve a complaint filed against the facility related to the denial of … | 2014-03-01 | ||
| 10233 | 10233 | MAGNOLIA MANOR - ROCK HILL | 425165 | 127 MURRAH DR | ROCK HILL | SC | 29732 | 2010-11-23 | 225 | D | FIPL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection based on record review, interview, the facility's "Patient/Resident Incident/Accident Investigation Worksheet" and review of the facility's policy on Abuse and Neglect, the facility failed to report injuries of unknown origin to the State survey and certification agency related to Resident #1. Resident #1 with injuries of unknown origin; a bruise to her right lower jaw on 10/27/2010 and a bruise to her left knee/leg on 11/04/2010 that were not reported to the state agency. (1 of 3 sampled residents reviewed) The findings included: The facility admitted Resident #1 on 5/09/1907 with [DIAGNOSES REDACTED]. Review of the medical record revealed a Quarterly Minimum Data Set ((MDS) dated [DATE] that indicated the resident had short and long-term memory problems with severely impaired cognitive skills for daily decision-making. Range of motion showed limitation on both side for neck, arm, hands and leg with partial voluntary movement. Review of a 10/27/2010 "Patient/Resident Incident/Accident Investigation Worksheet" indicated "2 cm (centimeter) bruise noted to RT (right) v (lower) jaw. doesn't flinch when touch. Unable to communicate to tell what happened D/T (due to) mentality." Review of an 11/04/10 "Patient/Resident Incident/Accident Investigation Worksheet" indicated "8 AM called to Room CNA (Certified Nurse Aide) states every time I move her left leg she hollers. In to exam Resident noted to have light purple bruise appx (approximately) 3x (times) 3 in (inches) area (just above left outer knee)..." In an interview with the surveyor on 11/23/2010 at 11:50 AM the Director of Nursing (DON) revealed she did not report the 10/27/2010 or the 11/04/2010 incidents to State survey and certification agency. An interview on 11/23/10 at 12: 20 PM with the Interim Administrator revealed the unwitnessed incidents were not reported because he believed the facility had within 24 hours to determine the cause of the incide… | 2014-03-01 | ||
| 10234 | 10234 | MAGNOLIA MANOR - ROCK HILL | 425165 | 127 MURRAH DR | ROCK HILL | SC | 29732 | 2010-11-23 | 323 | D | FIPL11 | On the day of the compliant inspection, based on an observations, interviews and record reviews, the facility failed to ensure that Resident A received adequate assistive devices to prevent accidents. Resident A had padded side rails; the pads did not cover the entire length of the side rails and were not securely attached to the side rails. The findings included: An observation and interview on 11/23/10 at 11:15 AM with the DON (Director of Nursing) revealed Resident A had padded side rails, the pads did not cover the entire length of the side rails and were not stable. The DON showed how easily the padded side rails moved back/forth and confirmed the pad would not protect the resident from injury if she rolled against the uncovered side rails. | 2014-03-01 | ||
| 10235 | 10235 | LAKE EMORY POST ACUTE CARE | 425303 | 59 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2010-11-16 | 157 | D | SPEH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record reviews and interviews, the facility failed to notify the physician, or failed to notify the physician timely, of changes in status for 3 of 11 residents reviewed for notification. The facility failed to notify the physician of a positive stool hemoccult test for Resident #1 and failed to notify the physician timely of complaints of pain for Resident #11. In addition, the facility failed to notify the physician of blood noted in Resident #9's brief and also failed to notify the family of the blood or of an order for [REDACTED]. The findings included: At 5:28 PM on 11/15/10, record review for Resident #9 revealed a physician's orders [REDACTED]." Review of the Progress Notes revealed a note by the FNP (Family Nurse Practitioner) dated 9/27/10 regarding debridement of eschar from the right heel wound. On 11/16/10 at 9:29 AM review of the Nurse's Notes revealed a note dated 9/27/10 at 2:00 PM that the wound had been debrided per the FNP. No documentation of family notification of the FNP evaluation or debridement was found in the record. On 11/16/10 at 9:29 AM, record review for Resident #9 revealed a Nurse's Note dated 9/22/10 of a late entry for 9/21/10 at 3:40 PM stating "noted dark red blood on brief + (and) penis size of quarter." Review of the physician's orders [REDACTED]. No new orders were initiated. The Nurse's Notes also revealed a note dated 9/24/10 at 12:00 noon "Res(ident) had another episode of small amt (amount) of dark rusty blood p (after) he voided clear urine." There was no documentation of physician notification of the second episode of blood in the resident's brief and there was no documentation that the family was notified of either episode. During an interview at 1:47 PM on 11/16/10, LPN (Licensed Practical Nurse) #4 confirmed there was no documentation that Resident #9's family was notified of the evaluation and debridement of his wound or of the blood in his brief. She also ver… | 2014-03-01 | ||
| 10236 | 10236 | LAKE EMORY POST ACUTE CARE | 425303 | 59 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2010-11-16 | 225 | D | SPEH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey based on record review, interviews and review of the facility's Abuse policy, the facility staff failed to immediately report an allegation of abuse to the administrator of the facility. Resident #11 reported an injury to her ankle on 9/23/2010 to her Certified Nursing Assistant (CNA). The CNA failed to report the injury to the nurse. An allegation of abuse was made to the Licensed Practical Nurse (LPN) the next morning. The LPN waited 6 hours before contacting the administration of the allegation. The findings include: Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] and a re-admission on 8/30/2010. [DIAGNOSES REDACTED]. Review of the Nurses' Progress Notes dated 9/24/2010 at 9:15 AM documented: "This nurse (LPN (Licensed Practical Nurse #1) brought to the DON (Director of Nurses) office by res(ident) and granddaughter and also an employee @ facility. Res in DON office in w/c (wheelchair) accompanied by res nurse. This nurse approached res and res stated, "the CNA was rough with me last night." Then res stated the CNA offered to use lift to stand resident. Res states, "I said hell no." Res c/o (complains of) L(eft) ankle pain. Res nurse reported pain pill just given to Res @ 9 AM r/t (related to) same. No further complaints noted. This nurse told res that a different CNA would take care of her from now on. Resident stated "ok" and seemed pleased." A Nurses' Note dated 9/24/2010 at 3:30 PM, indicated "Res. daughter noted standing at desk talking with nursing staff. This nurse approached res. daughter and daughter states res ankle is hurting her and may need an x-ray." At 5:00 PM a nurses note documented "Reported res complaints of L ankle pain to Dr. Patterson. New orders to get x-ray of L ankle." Review of the Incident Report dated 9/24/2010 at 9:15 AM revealed "res stated to this nurse "the CNA was rough with me last night." Then resident stated the CNA offered to use lift t… | 2014-03-01 | ||
| 10237 | 10237 | LAKE EMORY POST ACUTE CARE | 425303 | 59 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2010-11-16 | 280 | D | SPEH11 | **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 assure that 1 of 11 residents reviewed had their care plans reviewed and revised to reflect the care needs of each resident. Resident #11's care plan did not reflect the specific transfer devices needed. Resident #11 was recommended to use a sliding board, rolling walker and gait belt for safe transfers. The care plan did not reflect the recommendations. The findings include: Review of the medical record revealed Resident #11's was admitted to the facility on [DATE] and a re-admission on 8/30/2010. [DIAGNOSES REDACTED]. Review of the Nurses' Progress Notes dated 10/1/2010 indicated that the Nurse Practitioner and the Physical Therapist assessed Resident #11's decreased Range of Motion and functional ability of the left ankle and recommended it was "safest for res. to use slide board to transfer and use BSC (bedside commode) after standing from w/c." Review of the Physical Therapy notes revealed on 10/1/2010 "...sliding board transfer to w/c and standing pivot transfer with walker for w/c recliner transfer. No more toilet transfer and used bedside commode..." A Physical Therapy inservice was conducted with 4 CNA's related to safe transfers for Resident #11. The inservice indicated the staff was to use a gait belt and rolling walker for transfers. Another Physical Therapy inservice was conducted with the Ambustar staff related to safe transfers for Resident #11. The education provided indicated the resident was to be transferred using a gait belt and rolling walker with "no ankle lock on floor." Review of the care plan revealed assistance with ADL's was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included "bed mobility: assist of 1, extensive, eating: assist of 1, for set up at times, toileting: assist of 1, extensive, Transfer: assist of 1, extensive, Dressing, assist of 1, extensive." T… | 2014-03-01 | ||
| 10238 | 10238 | LAKE EMORY POST ACUTE CARE | 425303 | 59 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2010-11-16 | 323 | D | SPEH11 | **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 assure Resident #11's range of motion was appropriately assessed and the appropriate interventions were put in place related to safe transfers. Resident #11 did not have a current range of motion assessment in place, did not have documented the safe handling devices that were recommended by the nurse practitioner and the physical therapist and staff were not consistent/aware of the recommendations for safe transfers. The findings included: Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] and a re-admission on 8/30/2010. [DIAGNOSES REDACTED]. Further review of the medical record revealed the Admission Minimum Data Set ((MDS) dated [DATE] and the Quarterly MDS dated [DATE] coded Resident #11 as needing extensive one person assist with bed mobility, transfers, walking in and out of the room and locomotion on the unit. Resident #11 also needed extensive one person assist with toileting, hygiene, bathing and dressing. Resident #11's functional range of motion was coded as one sided partial loss of the leg. Review of the care plan revealed assistance with ADL's was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included "bed mobility: assist of 1, extensive, eating: assist of 1, for set up at times, toileting: assist of 1, extensive, Transfer: assist of 1, extensive, Dressing, assist of 1, extensive." There were no approaches related to the type of transfer devices needed or what was the safest way to transfer the resident. The CNAs used the same care plan as the nurses. The care plan was located in the resident's chart at the nurse ' s station. There was no documentation on the resident's care plan that indicated what the specific care needs of Resident #11's were (i.e. slide boards, rolling walker, gait belt etc) Review of the Nurses' Progress Notes da… | 2014-03-01 | ||
| 10239 | 10239 | ANCHOR HEALTH & REHAB OF AIKEN | 425311 | 550 EAST GATE DRIVE | AIKEN | SC | 29803 | 2010-11-15 | 280 | D | RSFH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the inspection based on record review and interviews, the facility failed to review and revise one of four resident's care plans. Resident #1 had a significant weight loss that was not identified or updated on the care plan. The care plan also did not reflect the resident's diarrhea. The findings included: Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with a readmission date of [DATE]. [DIAGNOSES REDACTED]. Further review of the medical record revealed the Initial Minimum Data Set ((MDS) dated [DATE] coded the resident's weight as 157 pounds with no weight changes. The Medicare 14 day MDS dated [DATE] coded the resident weight was 152 pounds with no weight changes. Review of the daily weights revealed her admission weight of 151.6 pounds on 7/13/2010. On 7/17/2010 Resident #1 weighed 148.4 pounds. On 7/25/2010 she weighed 140.2 pounds. Resident #1 had a steady rapid weight loss during that week of 8.2 pounds in 8 days. On 8/2/2010 she weighed 135.6 pounds. On 8/5/2010 she weighed 134.8 pounds. A total weight loss of 15.4 pounds or an 11.4% weight loss in 3 weeks. Review of the Physicians Orders revealed an order to "Notify MD (medical doctor) of weight change > (greater than) 5 pounds." Review of the care plan revealed expected weight loss related to diuretic therapy was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included "dietician to evaluate nutritional status, weigh per order..." The care plan had not been updated with the actual significant weight loss, or the supplements that had been added. During an interview on 11/15/2010 at 1 PM, the Care Plan Coordinator confirmed that Resident #1's care plan was not updated to reflect the resident's significant weight loss. She also confirmed that interventions should have been put in place to address the weight loss. She stated that she routinely updated care plans, h… | 2014-03-01 | ||
| 10240 | 10240 | HEARTLAND OF COLUMBIA REHAB AND NURSING CENTER | 425008 | 2601 FOREST DRIVE | COLUMBIA | SC | 29204 | 2011-09-21 | 314 | E | MKPP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, interview and review of a facility provided article from " Primary Intention" which included a reference from Barr J." Principals of Wound Cleansing" and an facility provided article printed from the Internet related to Management of Pressure Ulcers, the facility failed to provide appropriate wound care. The Pressure ulcers for Resident #2 & #3 were not appropriately cleaned. during the observation of wound care. (2 of 3 pressure ulcer care observed). The findings included: The facility readmitted Resident #3 on 08/18/2011 with [DIAGNOSES REDACTED]. On 9/20/11 at !0:05 AM, during observation of wound care for Resident # 3, the Wound Nurse sprayed wound cleanser on the sacral ulcer and wiped the ulcer edges with a four by four gauze four times, using a clean gauze each time, but failed to clean the wound bed. The resident was then turned and repositioned on the left side and wound care to the right hip was observed. The Wound Nurse sprayed the ulcer and wiped the wound bed three times using a separate four by four gauze each time but failed to clean the periwound tissue. The facility admitted Resident # 2 on 3/14/07 with the following Diagnosis: [REDACTED]. On 9/20/11 at 3:30 PM, during observation of wound care for Resident # 2, the Wound Care Nurse (WCN) cleaned the wound from side to side. During a interview with the WCN on 9/20/11 at 2:00 PM when ask about wiping/swabbing the wound from side to side she stated " I was told not to clean it from the center, because you don't know where you started." When ask how she was taught to clean a wound, she stated from the center outward. The wound care nurse was observed during the survey to clean three pressure ulcers. Her methodology varied during all three procedures. The facility Nurse Consultant provided this surveyor with documentation of an article titled "Wound Cleansing: sorely neglected? " ( Primary Intentions Volume 14 Number 4 November 200… | 2014-02-01 | ||
| 10241 | 10241 | HEARTLAND OF COLUMBIA REHAB AND NURSING CENTER | 425008 | 2601 FOREST DRIVE | COLUMBIA | SC | 29204 | 2011-09-21 | 315 | D | MKPP11 | **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 provide appropriate catheter care for Resident # 12. (1 of 2 catheter care observations conducted.) The findings included: The facility admitted Resident # 12 on 9/29/10 with the following Diagnosis: [REDACTED]. During the observation of the catheter care provided by Certified Nursing Assistant (CNA) #1 on 9/19/11 at 1:35 PM, the CNA lifted the penis by raising the catheter tubing. The catheter tubing was held approximately 2 inches from the urinary meatus. While securing the penis in an upright position by holding the catheter tubing, she then cleaned the penis using downward [MEDICAL CONDITION] from tip to the base of the penile shaft. During a interview with the CNA on 9/21/11 at 9:45 AM she did not dispute the observation. | 2014-02-01 | ||
| 10242 | 10242 | KERSHAWHEALTH KARESH LONG TERM CARE | 425080 | 1315 ROBERTS STREET | CAMDEN | SC | 29020 | 2010-10-29 | 225 | D | CXO111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the survey, based on review of facility files related to an allegation of abuse and misappropriation of resident property, the facility failed to report the allegation to the State survey and certification agency for 1 of 1 allegation reviewed. On 5/5/10, Resident #1's [MEDICATION NAME] ([MEDICATION NAME]) patch was missing. All staff on duty were drug tested that day. Laboratory test results reported to the facility on [DATE] confirmed the presence of the drug in Certified Nursing Assistant (CNA) #1's system. The findings included: Resident #1 arrived at the facility on 1/22/03. His [DIAGNOSES REDACTED]. The resident suffered from chronic pain and received [MEDICATION NAME] 25 micrograms per hour via [MEDICATION NAME]. The patch was changed every 72 hours. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the investigative materials revealed LPN #1 went to the resident on the morning of 5/5/10 and applied a new [MEDICATION NAME]. She secured the patch with a dated piece of tape. The LPN was unable to find the old patch for removal. LPN #1 tried to find the old patch again at approximately 10 AM and could not. She made another attempt at 12 noon only to discover the 8 AM patch was missing. A search of the resident, his bed, and his room failed to locate the [MEDICATION NAME]. LPN #1 reported her findings to Administration. The facility conducted searches of all employees on duty. The employees were also held for drug testing. Only one employee's drug test returned with positive results for [MEDICATION NAME], CNA #1. The Bureau of Drug Control was called to investigate. CNA #1 was terminated on 5/29/10. The facility could not provide any evidence showing they reported this incident to the State survey and certification agency. | 2014-02-01 | ||
| 10243 | 10243 | RIVERSIDE HEALTH AND REHAB | 425082 | 2375 BAKER HOSP BLVD | CHARLESTON | SC | 29405 | 2010-10-12 | 225 | E | 8JQP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the survey, based on limited record review, interview, and review of the facility's reportable file since 4/9/10, the facility failed to report to the State survey and certification agency 4 of 8 allegations of misappropriation of resident property (Residents A, B, C, D), failed to report timely 3 of 4 allegations of misappropriation (Residents #1, E, F), and failed to thoroughly investigate 4 of 8 allegations of misappropriation (Residents A, B, C, and D). The findings included: Resident #1 reported to the facility on [DATE] that her wallet was missing. The Complaint/Grievance Report stated the resident reported that approximately $30.00 was in the wallet. The facility's initial 24 hour report also noted the resident's debit card was taken and that there had been some activity on the resident's debit card account. The initial report to the State survey and certification agency was dated 9/28/10, which exceeded the 24 hour deadline for reporting allegations of misappropriation. Review of the facility's grievance files revealed three addition allegations of misappropriation around the same time Resident #1 made her complaint. Resident A reported $4.00 missing on 9/24/10. Resident B reported $14.00 missing on 9/27/10. Resident C reported $9.00 missing on 9/28/10. Residents B and C had notations on their grievance stating "resolved by personnel action (secondary to) cluster of similar events on Unit 200." None of these allegations was reported to the State survey and certification agency or thoroughly investigated. Continued review of the facility reportable incidents revealed another cluster of allegations concerning misappropriation of resident property in April 2010. Resident E reported on 4/10/10 that $63.00 was missing. The resident's allegation was not reported until 4/12/10. Resident F reported on 4/16/10 that $20.00 was missing. The allegation was reported to State agency on 4/20/10. Resident D reported "missing $" on 4/16/… | 2014-02-01 | ||
| 10244 | 10244 | WHITE OAK MANOR - ROCK HILL | 425088 | 1915 EBENEZER RD | ROCK HILL | SC | 29732 | 2010-10-19 | 225 | D | YPDS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the inspection based on record reviews and interviews the facility failed to ensure that all allegations of abuse/neglect were thoroughly investigate to prevent further abuse to residents #1 and #5. There was no documentation that the facility interviewed all staff on duty at the time of the incident (2 of 5 sample residents reviewed) The findings included: The facility admitted Resident #1 on 06/25/2010 and readmitted the resident on 07/30/2010 with [DIAGNOSES REDACTED]. Review of the facility investigation regarding a facility reported incident involving Resident #1 on 07/23/2010 revealed a statement written by Licensed Practical Nurse #1 that stated, "...I asked her when it started hurting she said yesterday at white guy help me from my bed to my chair he was in white uniform - he was with other workers. He picked me up under my arms and lifted me to the w/c (wheelchair) - felt a little pain not much..." The witness statement indicated the resident informed the facility staff that "he was with other workers". A review of the facility investigation revealed no interviews were done with the staff working at the time of the incident. The Social Services Director (SSD) stated that the facility did not have statements from staff on the unit at the time of the incident with Resident #1. The facility admitted Resident #5 on 12/20/2005 with [DIAGNOSES REDACTED]. Record review revealed a Quarterly MDS (Minimum Data Set) dated 06/17/2010 that indicated the resident had memory problems but had no cognitive problems with daily decision making. Review of the facility grievance log revealed Resident #5 informed the facility on 08/05/2010 that a nurse, in the presence of three CNAs (certified nurse aides), grabbed her wrist and told her to move. There was no documentation the facility investigated the allegation and reported to the State Survey Agency. In an interview on 10/19/2010 at approximately 11:30 PM the DON (Director of Nursing) and… | 2014-02-01 | ||
| 10245 | 10245 | SPRINGDALE HEALTHCARE CENTER | 425169 | 146 BATTLESHIP ROAD | CAMDEN | SC | 29020 | 2010-10-27 | 157 | D | K6DC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on record review and interview, the facility failed to notify the physician and family promptly of a change in condition which potentially required physician intervention. Resident #4, one of four residents reviewed for notification, had a temperature of 103.2 without timely physician/family notification of a change in condition. The findings included: The facility admitted Resident #4 on 6/18/10 and readmitted the resident on 7/28/10 with [DIAGNOSES REDACTED]. Review of Interdisciplinary Progress Notes on 10/27/10 at 10:20 AM revealed a note dated 7/20/10 at 1:50 PM that stated "130/76, 100.3, 78, 18. Prn (As needed) Tyl(enol) admin(istered) (with) f/u (follow up) temp (temperature) of 98.8. Pt (Patient) total care continues. Up in w/c (wheelchair) daily max assist (with) mech(anical) lift. Skin warm-tx (treatment) to sacral area continues. Moderate drainage noted (with) scant odor. Will cont(inue) to monitor...". The next note was dated 7/21/10 at 3 AM and stated "At 1 AM resident had rapid breathing, skin warm & moist. VS (Vital Signs) as follows 103.2, 98, 24, 136/92. PRN (As Needed) Tylenol given for (increased) temp. Recheck temp @ 3 A(M) (down) to 99.9. Respiration(s) even + nonlabored...". There was no mention that the physician or family had been notified of the change in condition for this resident when her temperature, heart rate, and respiratory rate increased at 1 AM. The next entry was dated 7/21/10 at 10:40 AM and stated "@ 9 am, pt alert, responsive-meds (medications) given per g-(gastrostomy) tube (without) difficulty. g tube patent (with no residual). HOB (Head of Bed) elevated per norm. Tyl(enol) PRN admin(istered) @ this time prior to wound care tx (treatment). @ 9:55 called to pt rm (room) d/t (due to) pt lethargic et facial drooping upon assessment noted pt (with) L(eft) side facial drooping, open mouth breathing-labored respirations @ 26. Lungs full, SpO2 @ 90% RA (Room Air… | 2014-02-01 | ||
| 10246 | 10246 | SPRINGDALE HEALTHCARE CENTER | 425169 | 146 BATTLESHIP ROAD | CAMDEN | SC | 29020 | 2010-10-27 | 166 | D | K6DC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on record review, interview, and review of the policy provided by the facility entitled "Grievances & Complaints", the facility failed to actively work towards resolution of a complaint/grievance for one of one sampled residents with a grievance. Family member concerns regarding the care of Resident #4 were not addressed by the facility. The findings included: The facility admitted Resident #4 on 6/18/10 and readmitted the resident on 7/28/10 with [DIAGNOSES REDACTED]. A complaint faxed to DHEC (Department of Health and Environmental Control) Certification was reviewed on 10/26/10 prior to the survey. The complaint included a letter dated 7/29/10 addressed to the Admissions Director and Marketing Director of Springdale Health Care Center. It contained the following: "Gentlemen: (Resident #4) is back at Springdale, as you know, and I'd like to review with you the matters regarding her care that we discussed recently. (Marketing Director) informed us that she would be placed on the "100" wing/hall with different nurses/staff caring for her. (Admissions Director) addressed personally taking care of/supervising her wound care, including the "wound vac". To prevent dehydration, her feeding tube is to be flushed multiple times daily. Insuring that the feeding tube area remains clean. Monitoring excessive therapy (exercise) on her left arm. To make sure that she isn't sitting on the affected area for prolonged periods, and that she is turned on a regular basis. That someone communicates with Dr. --, myself and/or my (other family member) for any change in her condition or care. FYI, her home caregiver --, will continue to make regular visitations with (Resident #4). I am optimistic that the "situation" that occurred last week has been resolved, corrected, and that (Resident #4's) care will be the best that Springdale has to offer. Please contact me immediately if any of the foregoing is incorrect or mis… | 2014-02-01 | ||
| 10247 | 10247 | SPRINGDALE HEALTHCARE CENTER | 425169 | 146 BATTLESHIP ROAD | CAMDEN | SC | 29020 | 2010-10-27 | 253 | D | K6DC11 | On the days of the complaint inspection, based on observation, the facility failed to provide a safe, clean, comfortable and homelike environment for 3 of 6 resident rooms observed. Soiled and malodorous carpets were observed in 3 of 6 resident rooms on Unit 2. The findings included: Observations on 10/26/2010 at 10:10 AM of room 209 revealed 3 large grayish brown spots on the floor under the tube feeding pole and pump; room 213 was noted with a large amount of clothes piled on a chair and a pair of bedroom shoes on the floor; both room had a musty odor throughout. Observations on 10/26/10 at 12:02 PM revealed a fly light position on the floor in room 212B near the window, the ionizer contained approximately 15 dead flies on the base, under the light. There was also a musty odor noted throughout the room. The tan carpet on the floor was worn and had stains along with darker areas that looked like black scuff marks. At 12:24 the Director of Nursing verified the findings but stated she could not smell any odors. She stated that there might be an odor, but that she smoked and didn't have a good sense of smell. | 2014-02-01 | ||
| 10248 | 10248 | SPRINGDALE HEALTHCARE CENTER | 425169 | 146 BATTLESHIP ROAD | CAMDEN | SC | 29020 | 2010-10-27 | 279 | D | K6DC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on observation, record review and interview, the facility failed to development comprehensive plans of care, which addressed the needs of 1 of 6 sampled residents. Resident #3 with a [DIAGNOSES REDACTED]. The findings included: The facility admitted Resident #3 on 10/15/2010 with [DIAGNOSES REDACTED]. Review of the current medical record on 10/26/2010 for Resident #3 revealed a Interdisciplinary Progress Note dated 10/23/2010 at 1:00 PM that stated, "Res (resident) noted with nephrostomy valve leaking. Supervisor notified and MD made aware. MD order given to tape around valve to seal and to monitor until Monday and let nephrologist address then. Urine draining in nephrostomy bag without problems..." A care plan dated 10/25/2010, noted the following problem area: "Is at risk for injury related to falls as evidence by...has nephrostomy with drng (drainage) bag and suprapubic cath (catheter)"; "Admits related to weakness from acute hospital stay...suprapubic cath and groin pain"; "Potential for pain related to [DIAGNOSES REDACTED]. staff for ADL's (activities of daily living) related to: suprapubic cath in place..." The care plan identified the left nephrostomy tube as a suprapubic catheter. The plan of care did not document that Resident #3 had a left nephrostomy tube in place or the need to monitor on a routine bases the care of the tube and insertion site. The Director of Nursing verified the resident was not care plan for a left nephrostomy tube. | 2014-02-01 | ||
| 10249 | 10249 | SPRINGDALE HEALTHCARE CENTER | 425169 | 146 BATTLESHIP ROAD | CAMDEN | SC | 29020 | 2010-10-27 | 309 | D | K6DC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on record review, interviews and observation, the facility failed to assure each resident received care and services in accordance with the plan of care as ordered by the physician. Resident #1 had current physician orders [REDACTED]. Resident #3 with an order documented in the Interdisciplinary Progress Notes for a follow-up with the nephrologist related to a leaking nephrostomy tube that was not transcribed and carried out. (2 of 6 sampled residents reviewed for care and services related to following physician orders.) The findings included: The facility admitted Resident #1 on 10/04/2010 with [DIAGNOSES REDACTED]. As a result of a complaint the closed medical record for Resident #1 was reviewed on 10/26/2010, a physician's orders [REDACTED].#1 complained of loose stools through the night and the standing order for Immodium was initiated, there was no further documentation related to loose stools until 10/10/2010. A late entry dated 10/12/2010 at 8:00 PM for 10/10/2010 4:00 PM stated, "Resident c/o (complains of) loose stool. Medicated with Immodium, ineffective continues to have loose stool. MD aware n/o (new order) received: obtain stool sample, decrease TF (tube feed) 50 cc/hr (centimeters/hour); have dietician assess." On 10/10/2010 the Resident #1 was transferred to the hospital at the request of the family due to their concerns related to her having loose stools. Review of the Activities of Daily Living (ADL) Flow Record showed Resident #1 had extra large stools on all three shifts 10/08/2010; had no stool on the 11-7 shift, an extra large stool on the 7-3 shift and a small stool on the 3-11 on 10/09/2010; had extra large stools on all three shift on 10/10/2010. Review of the 24 hour report from 10/08/2010 thru 10/10/2010 documented on 10/08/2010 for the "Day" shift (7-3) "c/o loose stools, initiated s.o. (standing order) Immodium..."; the 24 hours reports revealed no further documentatio… | 2014-02-01 | ||
| 10250 | 10250 | HERITAGE HEALTHCARE OF PICKENS | 425306 | 163 LOVE & CARE ROAD | SIX MILE | SC | 29682 | 2010-10-26 | 157 | D | M5SK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on interview, closed record review, and review of facility policy titled Condition Change (9/03) and Documentation (4/06) the facility failed to provide evidence that the resident's physician and legal representative were notified when Resident # 11 experienced a significant change in his condition. The resident's temperature was significantly elevated to 103.9 and the resident was vomiting brown emesis with a foul odor. The findings included: The facility admitted Resident # 11 on 12/1/08. The resident's [DIAGNOSES REDACTED]. On 10/24/10, a review of the closed medical record revealed the resident was documented as having an elevated temperature of 103.9 on 10/1/10 at 2:30PM. The resident vomited twice. The emesis was noted to be brown, watery with a foul odor. There was no documentation that the attending physician was notified but rather standing orders were initiated which included [MEDICATION NAME] and Tylenol. There was no documentation that the responsible party was notified. During an interview with the facility Director of Nursing on 10/24/10 at 8:30PM, she indicated she felt the nurse had initiated the standing orders appropriately. When questioned about the brown emesis with a foul odor, she stated the resident constantly chewed tobacco and felt that was the cause of the foul odor and brown color. The Director of Nurses did not dispute there was no evidence that the family had been notified. On 10/25/10, at 5PM, during an interview with the attending physician, he stated he did not recall being aware of the resident's illness while in the building. He further stated that if he did see him that day it would have been because the resident was seated in the hallway per his usual custom. On 10/25/10 at approximately 5:45PM, during an interview with Licensed Practical Nurse # 1, she stated that the physician was in the building and was informed of the resident's condition and saw the resident. She stated… | 2014-02-01 | ||
| 10251 | 10251 | HERITAGE HEALTHCARE OF PICKENS | 425306 | 163 LOVE & CARE ROAD | SIX MILE | SC | 29682 | 2010-10-26 | 281 | D | M5SK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey based on record review, interview and review of the facility provided policy for documentation, the facility failed to meets professional standards of quality. Resident # 11 was documented as having a rapid onset of illness with elevated temperature and foul smelling emesis at 2:45PM. At 6PM, a facility staff member documented the effect of medications administered. There was no further documentation of the resident until 355AM, the following morning when the resident was mottled, with unstable vitals signs and transferred to acute care. A History and Physical completed by the attending physician failed to address a complete assessment of the resident. The findings included: The facility admitted Resident # 11 on [DATE]. The resident's [DIAGNOSES REDACTED]. On [DATE], a review of the closed medical record revealed the resident was documented as having an elevated temperature of 103.9 on [DATE] at 2:30PM. The resident vomited twice. The emesis was noted to be brown, watery with a foul odor. Licensed Practical Nurse # 1 documented she administered [MEDICATION NAME] two times that day (at 8:30AM and 2PM) and Tylenol at 2PM for and elevated temperature. The last documented complete physical assessment of the resident was at 2:45PM on [DATE]. Review of the 24 hour report and nursing worksheet contained no additional information. Licensed Practical Nurse # 2 documented on the back side of the Medication Record that Tylenol and [MEDICATION NAME] were repeated at 6PM and were "effective." No further documentation of the resident's condition was found. The next documentation of an assessment of the resident's condition occurred at 3:55AM on [DATE] when the resident was transferred to acute care and admitted to the hospital. The admission History and Physical obtained from the hospital stated the resident was to be admitted with [DIAGNOSES REDACTED]. The resident expired while in the hospital on [DATE]. The Discharge summary s… | 2014-02-01 | ||
| 10252 | 10252 | HERITAGE HEALTHCARE OF PICKENS | 425306 | 163 LOVE & CARE ROAD | SIX MILE | SC | 29682 | 2010-10-26 | 428 | D | M5SK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interview, the consulting pharmacist failed to identify that Resident # 11 with known bradycardia was not having a pulse taken prior to administration of the medication. The findings included: The facility admitted Resident # 11 on 12/1/08. The resident's [DIAGNOSES REDACTED]. On 10/24/10, a review of the closed medical record revealed the resident was documented as having known Bradycardia. The resident was ordered by the physician to receive Metoprolol 12.5 milligrams daily. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The pharmacist was questioned as to why there had not been a previous recommendation to take the resident's pulse prior to the administration of the medication, especially since she had acknowledged the resident's known bradycardia. The pharmacist stated that some facilities had policies which required a pulse be obtained prior to the administration of this class of drug, but this facility did not. On 10/25/10 at 5PM, during an interview with the attending physician, he stated he was not aware the resident's pulse was not being taken prior to the administration of the medication. The Nursing Drug Handbook 2011 Edition available as a resource for the nurses on the nursing unit, stated on page 383: "Always check patient's apical pulse rate before giving drug. If it's slower than 60 beats/minute, withhold drug and call prescriber immediately." There was no documentation found that the resident's pulse was being obtained prior to the administration of the Metoprolol or that the consulting pharmacist had reported the irregularity to the physician. | 2014-02-01 | ||
| 10253 | 10253 | HERITAGE HEALTHCARE OF PICKENS | 425306 | 163 LOVE & CARE ROAD | SIX MILE | SC | 29682 | 2010-10-26 | 156 | B | M5SK11 | On the days of the survey, based on record review and interview, the facility failed to provide timely Notice of Medicare Provider Non-Coverage notification for 4 of 5 residents reviewed for Change in Pay Source. The findings Included: Review of residents files for change in pay source revealed four of five residents had not received timely notification of Medicare Provider Non-Coverage. Resident A's Notice of Medicare Provider Non-Coverage indicated that effective 1/11/2010 his/her coverage of current skilled nursing services would end. Further review revealed the resident had not received notification of the change in pay source until 1/11/2010. Resident B's Notice of Medicare Provider Non-Coverage indicated that effective 6/11/2010 his/her coverage of current skilled nursing services would end. Further review revealed the resident had not received notification of the change in pay source until the 6/11/10. Resident C's Notice of Medicare Provider Non-Coverage indicated that effective 6/11/2010 his/her coverage of current skilled nursing services would end. Further review revealed the resident had not received notification of the change in pay source until the 6/11/2010. Resident D's Notice of Medicare Provider Non-Coverage indicated that effective 1/14/2010 his/her coverage of current skilled nursing services would end. Further review revealed the resident had not received notification of the change in pay source until the 1/14/2010. During an interview with the Business Office Manager (BOM) on 10/25/10 at approximately 3:30 PM he/she stated " They wanted to go home that day, so we did not have time to give notice". The medical records for residents B and C showed a form titled Notification of Therapy Change which was dated 6/2/10 for resident C. (7 days in advance). and Resident B's form was dated 6/7/10. (4 days in advance). The BOM stated when asked what this form was for, "that is how they let us know the time is ending." | 2014-02-01 | ||
| 10254 | 10254 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2010-10-12 | 157 | G | GYKK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection, based on record review and interview, the facility failed to consult with the resident's physician when there was a significant change in the resident's condition. Resident #6 had clinical record documentation on 07/24/2010 at 0615 as sweaty, which required a linen and clothing change, later in the day he was described as lethargic. The next day (07/25/2010) at 2:00 AM it was documented that he had a temperature of 100 degrees and twitching of his extremities when touched; at 4:00 AM the twitching continued; at 6:00 AM he pulled away when care was provided and would not take fluids. The documentation indicated that the resident was lethargic at 10:50 AM and was sent to the emergency room at his daughter's request. There was no evidence the resident's physician was notified of the change in condition. (One of six sampled residents reviewed for notification) The findings included: The facility admitted Resident #6 with [DIAGNOSES REDACTED]. On 10/12/2010 a review of the resident's closed medical record revealed the following Nurse's Notes from 07/24/2010 thru 07/25/2010: "07/24/2010 0615 Res (resident) has been sweaty this shift requiring linen and night clothing change. Hair damp skin cool and pale, clammy to touch. VS (vital signs) @ present BP (blood pressure) 141/72 p (pulse) 85, resp (respirations) 22 temp (temperature) 97.5 (A) (axillary), BS (blood sugar) 182. Hands to (sic) cool for O2 (oxygen) sat (saturation) to register. No s/s (signs/symptoms) of pain/discomfort. No acute apparent distress. Orderly up and showered. On top of bed resting now. Alert with eyes open. Will pass to next shift to monitor. 1:35 PM Resident was lethargic at breakfast could not wake up enough to eat. Ate 100 % of lunch. Has been holding head down and drooling excessively all day. Afebrile with VS WNL (within normal limits). Will cont. (continue) to monitor. 2300 Remains in bed. Skin cool to touch and dry at this time. N… | 2014-02-01 | ||
| 10255 | 10255 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2010-10-12 | 281 | G | GYKK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection, based on record reviews and interviews, the facility staff failed to meet professional standards of quality for 1 of 6 residents reviewed for an acute change in condition. The physician was not consulted when Resident #6, treated [MEDICATION NAME] for recurrent urinary tract infections and recently treated with a course of antibiotics for a urinary tract infection, showed evidence of a change in condition. On 07/24/2010 at 6:15 AM he was noted with sweating; blood pressure 141/72, temperature 97.5, pulse 85 and respirations 22, he was described as lethargic at breakfast there was no other documentation until 11:00 PM when it was stated that no twitching of extremities was noted. On 07/25/2010 at 2:00 AM his blood pressure was not noted, temperature 100, pulse 100, respirations 18 and twitching of extremities when touched was noted; "opens eyes when spoken to with no awareness of staff. At 4:00 AM twitching when touched was again documented; at 6:00 AM his blood pressure was 110/50, temperature 99.9, pulse 180, fluids not accepted; at 10:50 AM he was lethargic, unresponsive; his BP was 110/80, temperature 97.5, pulse 115, respirations 20. Resident #6 was transferred to the emergency room . The findings included: The facility admitted Resident #6 with [DIAGNOSES REDACTED]. On 10/12/2010 a review of the resident's closed medical record revealed the following Nurse's Notes from 07/24/2010 thru 07/25/2010: "07/24/2010 0615 Res (resident) has been sweaty this shift requiring linen and night clothing change. Hair damp skin cool and pale, clammy to touch. VS (vital signs) @ present BP (blood pressure) 141/72 p (pulse) 85, resp (respirations) 22 temp (temperature) 97.5 (A) (axillary), BS (blood sugar) 182. Hands to cool for O2 (oxygen) sat (saturation) to register. No s/s (signs/symptoms) of pain/discomfort. No acute apparent distress. Orderly up and showered. On top of bed resting now. Alert with eyes open. Wil… | 2014-02-01 | ||
| 10256 | 10256 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2010-10-12 | 312 | D | GYKK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint survey based on observations, record review and interviews, the facility failed to ensure that care and services necessary to maintain or attain the highest practical physical well being related to grooming and personal hygiene was provided for Resident #3 observed on 10/12/2010 with blood on the left side of the nose; with long fingernails on both hands and what appeared to be blood under her fingernails. The findings included: The facility admitted Resident #3 with [DIAGNOSES REDACTED]. Resident #3 observed at 11:00 AM seated in the day room on Unit 3 with dried blood on the left side of her nose; her fingernails on both hands, were noted to be long, with what appeared to be blood under the index finger and on the thumb of the right hand. At 11:10 AM Resident #3 was rolled in her Geri-chair to her room and transferred to her bed for incontinent care. CNA #2 stated that the resident preferred her nails long and that nails were done on Tuesday. Review of the Weekly Nursing Assessment from 06/19/2010, 09/11/2010,09/25/2010, and 10/09/2010 documented a scab in the crease of the resident's nose on the left side and stated, "scratches won't leave band aid on." On 10/12/2010 at 11:30 AM Resident #3's fingernails were observed with the Director of Nurses, at that time the nails had been cut and cleaned, but were still uneven and rough. The Director of Nurses confirmed that Resident #3 still needed nail care, which should include filing. | 2014-02-01 | ||
| 10257 | 10257 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2010-10-12 | 280 | D | GYKK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection, based on record review and interview, the facility failed to revise and update the Care Plan for 1 of 6 sampled residents reviewed for Comprehensive Care Plans. Resident #1 had 4 reported incidents where she "slid" out of chairs to the floor without changes to the approaches used to address her falls. The findings included: The facility admitted Resident #1 on 08/16/2010 with [DIAGNOSES REDACTED]. Resident #1 was included in the sample due to an incident reported by the facility which prompted the complaint investigation. Review of the closed medical record on 10/12/2010 revealed an Incident/Accident Report for Resident #1 dated "8-22-10 at 7:45 AM". Under "Describe exactly what happened; why it happened; what the causes were. If an injury, state part of body injured. If property or equipment damaged, describe damage." was a handwritten note. "Resident was in shower chair-it tilted forward + she slid out on the BR (Bathroom) floor...". The "Additional comments and/or steps taken to prevent recurrence:" revealed "Morse Fall Scale". Review of a 2nd Incident/Accident Report dated 09/1/2010 revealed that Resident #1 had been "..sitting in w/c (wheelchair)- nurse went to ck (check) on another res(ident)-this res(ident) sitting on carpet in front of upright w/c. States she "slid out". She was out of site for app(roximately) 2 minutes". The "Additional comments and/or steps taken to prevent recurrence:" revealed "Morse Fall Scale completed, w/c alarm in place but didn't sound-magnet was still in place. Alarm ...". Review of a 3rd Incident/Accident Report dated 09/13/2010 revealed "Resident found sitting on floor in front of chair". The "Additional comments and/or steps taken to prevent recurrence:" revealed "Morse Fall". Review of a 4th Incident/Accident Report dated 09/14/2010 revealed "Sitting in w/c trying to push nurse away, slipped to floor from w/c. Also hitting at nurse". There were no additional commen… | 2014-02-01 | ||
| 10258 | 10258 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2010-10-12 | 272 | G | GYKK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection, based on observations, record review, and interviews, the facility failed to ensure two of four sampled residents were assessed for transfers. Certified Nursing Assistants used a mechanical lift on Residents #1 and #2 without documented assessments as to the appropriateness of the lift device for each resident. Resident #3's CNA Care Plan Guide revealed no mention of the level of assistance required for transfers or the mode of transfer. The findings included: The facility admitted Resident #1 on 08/16/2010 with [DIAGNOSES REDACTED]. Resident #1 was included in the sample due to an incident reported by the facility, which prompted the complaint investigation. Review of the facility investigation revealed that Resident #1 had been sent to the emergency roiagnom on [DATE] for pain, swelling, warmth, decreased range of motion, and a "fading discoloration" around and below the left knee. According to the physician's statement included in those records, the resident had been admitted to the hospital on [DATE] with a [MEDICAL CONDITIONS] and tib-fib (tibia-fibula) [MEDICAL CONDITION] leg. In a letter dated 10/1/2010 from the facility's Director of Nursing (DON), the facility reported that "During the investigation it was noted that on September 25, 2010 (Resident #1's) left foot had slipped forward while being lifted with the "stand-up" lift. The lift procedure was stopped, another Certified Nursing Assistant (CNA) joined the aide caring for (Resident #1). Her left foot was moved approx.(approximately) three inches back into the proper position, and the lift and care proceeded. I had the CNAs demonstrate the procedure for me. I did not observe anything that would cause injury". Review of the closed medical record conducted on 10/12/2010 revealed the following: Review of the cumulative physician's orders [REDACTED]. During an interview at 12:15 PM, Licensed Practical Nurse #1 verified this and stated that the … | 2014-02-01 | ||
| 10259 | 10259 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2010-10-12 | 225 | E | GYKK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection, based on interviews, observation and record review, the facility failed to thoroughly investigate and/or report two incidents involving Resident #1, two incidents involving Resident #2, one incident involving Resident #3 and one incident involving Resident #5. These residents were 4 of 6 sampled residents reviewed for reportable incidents. The findings included: The facility admitted Resident #1 on 08/16/2010 with [DIAGNOSES REDACTED]. Resident #1 was included in the sample due to an incident reported by the facility which prompted the complaint investigation. Review of the closed medical record on 10/12/2010 revealed an Incident/Accident Report for Resident #1 dated "8-22-2010 at 7:45 AM". Under "Describe exactly what happened; why it happened; what the causes were. If an injury, state part of body injured. If property or equipment damaged, describe damage." was a handwritten note. "Resident was in shower chair-it tilted forward + she slid out on the BR (Bathroom) floor...". During an interview with the surveyor on 10/12/2010 at 4:15 PM, the Director of Nursing (DON) stated there had been no investigation conducted since the incident had been witnessed. When asked if she knew what had happened to cause the shower chair to tilt forward she did not know. Review of a 2nd Incident/Accident Report for Resident #1 dated 09/1/2010 revealed that she had been "..sitting in w/c (wheelchair)- nurse went to ck (check) on another res(ident)-this res(ident) sitting on carpet in front of upright w/c. States she "slid out". She was out of site for app(roximately) 2 minutes". The "Additional comments and/or steps taken to prevent recurrence:" revealed "Morse Fall Scale completed, w/c alarm in place but didn't sound-magnet was still in place. Alarm ...". During an interview with the surveyor on 10/12/2010 at 4:15 PM, the DON verified an investigation had not taken place. She stated the resident had been in the Day Room … | 2014-02-01 | ||
| 10260 | 10260 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2010-10-12 | 253 | D | GYKK11 | On the day of the complaint inspection, based on observations and interviews the facility failed to provide housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior for 1 of 1 Unit reviewed. There were 2 blue wheelchair with cracked, rough and peeling arm supports; 2 black wheelchairs with soiled seats and frames with food particles; 1 Geri-chair with a cracked arm support frame and torn upholstery on the back of the back support at the top. The findings included: Observations on 10/12/2010 at approximately 10:40 AM revealed maintenance issues on Unit 3. The Director of Nurses confirmed the following at 11:30 AM: One Geri-chair with a crack approximately 10 inches long on Resident #3's Geri-chair, right arm support frame; back support, top right back with exposed foam. Resident #2 seated in a blue wheelchair with both armrests torn and cracked. A blue wheelchair with both arm rests torn and cracked; 2 black wheelchairs with soiled seats and frames with food particles. Review of Schedule of Events/Activities revealed that Gerri Chairs and Wheelchairs were to be cleaned once a week and as needed; there was no cleaning log maintained. | 2014-02-01 | ||
| 10261 | 10261 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2010-10-12 | 323 | G | GYKK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection, based on observations, record review, and interviews, the facility failed to ensure that the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents. Certified Nursing Assistants used a mechanical lift on Residents #1 and #2 without documented assessments as to the appropriateness of the lift device. The findings included: The facility admitted Resident #1 on 08/16/2010 with [DIAGNOSES REDACTED]. Resident #1 was included in the sample due to an incident reported by the facility, which prompted the complaint investigation. Review of the facility investigation revealed that Resident #1 had been sent to the emergency roiagnom on [DATE] for pain, swelling, warmth, decreased range of motion, and a "fading discoloration" around and below the left knee. According to the physician's statement included in those records, the resident had been admitted to the hospital on [DATE] with a Deep Vein Thromboses (DVT) and tib-fib (tibia-fibula) fracture of the left leg. In a letter dated 10/1/10 from the facility's Director of Nursing (DON), the facility reported, "During the investigation it was noted that on September 25, 2010 (Resident #1's) left foot had slipped forward while being lifted with the "stand-up" lift. The lift procedure was stopped, another Certified Nursing Assistant (CNA) joined the aid caring for (Resident #1). Her left foot was moved approx. (approximately) three inches back into the proper position, and the lift and care proceeded. I had the CNAs demonstrate the procedure for me. I did not observe anything that would cause injury". Review of the closed medical record on 10/12/2010 revealed the following: Review of the cumulative physician's orders [REDACTED]. During an interview at 12:15 PM, Licensed Practical Nurse #1 verified this and stated that the physician deferred the issue of transfers… | 2014-02-01 | ||
| 10262 | 10262 | MAGNOLIA PLACE - GREENVILLE | 425361 | 35 SOUTHPOINT DRIVE | GREENVILLE | SC | 29607 | 2010-10-18 | 280 | D | DFY111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint survey, based on record review and interview, the facility failed to revise and update the Care Plan for 1 of 4 sampled residents reviewed for Comprehensive Care Plans. Resident #1's Care Plan had not been updated regarding approaches used for proper positioning and to prevent and/or care for Pressure Ulcers. The findings included: The facility admitted Resident #1 on 09/06/2002 and readmitted her on 12/10/2004 with [DIAGNOSES REDACTED]. Observation on 10/18/2010 at 12:35 PM revealed the resident lying on a specialty mattress with the head of bed elevated. Review of the cumulative Physician order [REDACTED]. Review of the Physician/Nurse Practitioner Progress Notes on 10/18/2010 at 1:15 PM revealed the following: 06/16/2010- "S(ubjective): Resident had an area of skin compromise noted to her sacrum. Initial treatment was the use of [MEDICATION NAME] although wound treatment nurse reports the skin was intact at that time. However, we were called to see the resident today due to changes in the sacral wound...P(lan): ...Also, initiate a specialty mattress surface for the resident to minimize skin breakdown and to offload this area". 07/12/2010- "Patient is an elderly white female with a known history of advanced dementia, ... and essentially total care for activities of daily living (ADLs) and instrumental activities of daily living (IADLs)...". 07/14/2010- "Chief Complaint: Pressure Area. S(ubjective): Resident is frail and debilitated, cachectic, with wound on her sacrum...O(bjective): The wound is open...Heels are intact... P(lan): ...Keep resident turned and positioned...". 07/28/2010- "P(lan): She is on double shot protein q.i.d. (4 Times daily)...Heels are intact...Encourage turning and repositioning". 08/09/2010- "P(lan): ...Keep resident turned and repositioned". 08/30/2010- "P(lan):...Encourage turning and repositioning, although due to her frailty and debility would contribute greatly to poor wound healing.… | 2014-02-01 | ||
| 10263 | 10263 | MAGNOLIA PLACE - GREENVILLE | 425361 | 35 SOUTHPOINT DRIVE | GREENVILLE | SC | 29607 | 2010-10-18 | 157 | D | DFY111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on observation, record review, interview, and review of the policy provided by the facility entitled "Physician Communication Grid", the facility failed to notify the physician with changes related to pressure ulcers for 2 of 4 sampled residents reviewed with pressure ulcers. Residents #3 and #4 had pressure ulcers worsen without physician notification. The findings included: The facility admitted Resident #3 on 07/06/2010 with [DIAGNOSES REDACTED]. Record Review on 10/18/2010 revealed a Wound Treatment & Progress Record dated for September 2010. On the front was an order dated "9-15-10" that stated "Cleanse sacral area (with) wound cleanser, pack (with) calcium alginate & cover (with) adhesive foam dsg.(dressing), (Change) qd (daily) & PRN (When needed)". Under this was written "crush [MEDICATION NAME] 500 mg (milligrams) (1) tab(let) into wound on coccyx qd". On the back of the sheet were 3 entries. One of the entries, dated 09/22/2010 revealed that the wound had measured "Length 5.0, Width 8.0, depth 1.0, Undermining 3.9". On 9/29/10 the wound had increased in size to "Length 5.9, Width 8.0, Depth 1.6, and Undermining 4.1". Another Wound Treatment and Progress Record dated October 2010 revealed two entries, one dated for 10/07/2010 that stated the wound measured "Length 6.1, Width 8.0, Depth 1.5, Undermining 3.8"; and one dated 10/14/2010 that stated "Length 6.5, Width 8.0, Depth 1.5, Undermining 4.1". Review of the Physician/Nurse Practitioner Progress Notes revealed the last note in the chart was dated 09/06/2010 and did not mention the sacral wound. Review of Physician order [REDACTED]. Review of the Nurse's Notes for September and October 2010 revealed no mention that the Physician or Nurse Practitioner had been notified that the Pressure Ulcer had gotten bigger. During an interview on 10/18/2010 at 8:42 AM, the Wound Care Nurse (LPN #1) stated that the facility used a Nurse Practitioner (… | 2014-02-01 | ||
| 10264 | 10264 | MAGNOLIA PLACE - GREENVILLE | 425361 | 35 SOUTHPOINT DRIVE | GREENVILLE | SC | 29607 | 2010-10-18 | 514 | E | DFY111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on record reviews, the facility failed to ensure that nursing staff initialed treatments when completed for 2 of 4 sampled residents reviewed for completeness and accuracy of clinical records. Residents #3 and #4 had blanks on their treatment record where the nurse failed to initial the treatment as having been completed. Review of the Narcotics Log and Medication Administration Records for the Blue Wing revealed inaccuracies in documentation of narcotic/hypnotic medication administration for Residents A, B, C, D, E, and F. The findings included: The facility initially admitted Resident #4 on 08/11/2009 and readmitted him on 03/07/2010 with [DIAGNOSES REDACTED]. Review of Wound Treatment and Progress Records for July, August, September, and October 2010 revealed the following blanks indicating that the nurse had not initialed the treatment as having been completed: -physician's orders [REDACTED]. (Change) qd (daily) & PRN (As needed)". Blank spaces were noted for 10/2, 10/3, 10/6, 10/8, 9/4, 9/6, 9/12, 9/13, 9/21, 8/1, 8/24, 8/25, 8/30, 8/31, 7/9, and 7/11/2010. -physician's orders [REDACTED]. Secure (with) tape. May cover loosely (with) gauze. (Change) qd and PRN". Blank spaces were noted for 10/6 and 9/21/2010. -physician's orders [REDACTED]. Wrap (with) Kerlix. (Change) qd & PRN". A blank space was noted for 10/01/2010. The Treatment Nurse on 10/18/2010 verified the blanks for September and October 2010. The facility admitted Resident #3 on 07/06/2010 with [DIAGNOSES REDACTED]. Review of Wound Treatment and Progress Records for August and October 2010 revealed the following blanks indicating that the nurse had not initialed the treatment as having been completed: -physician's orders [REDACTED]. (Change) qd & PRN". A blank space was noted for 10/06/2010. -physician's orders [REDACTED]. (Change) qd & PRN". Blank spaces were noted for 8/24 and 8/29/2010. The Director of Nursing on 10/18/2010 veri… | 2014-02-01 | ||
| 10265 | 10265 | MAGNOLIA PLACE - GREENVILLE | 425361 | 35 SOUTHPOINT DRIVE | GREENVILLE | SC | 29607 | 2010-10-18 | 314 | D | DFY111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on observation, record review, interview, and review of the policy provided by the facility entitled "Physician Communication Grid", the facility failed to assess and address with the physician changes related to pressure ulcers for 2 of 4 sampled residents reviewed with pressure ulcers. Residents #3 and #4 had pressure ulcers worsen without physician notification. The findings included: The facility admitted Resident #3 on 07/06/2010 with [DIAGNOSES REDACTED]. Record Review on 10/18/2010 revealed a Wound Treatment & Progress Record dated for September 2010. On the front was an order dated "9-15-10" that stated "Cleanse sacral area (with) wound cleanser, pack (with) calcium alginate & cover (with) adhesive foam dsg.(dressing), (Change) qd (daily) & PRN (When needed)". Under this was written "crush [MEDICATION NAME] 500 mg (milligrams) (1) tab(let) into wound on coccyx qd". On the back of the sheet were 3 entries. One of the entries, dated 09/22/2010 revealed that the wound had measured "Length 5.0, Width 8.0, depth 1.0, Undermining 3.9". On 9/29/10 the wound had increased in size to "Length 5.9, Width 8.0, Depth 1.6, and Undermining 4.1". Another Wound Treatment and Progress Record dated October 2010 revealed two entries, one dated for 10/07/2010 that stated the wound measured "Length 6.1, Width 8.0, Depth 1.5, Undermining 3.8"; and one dated 10/14/2010 that stated "Length 6.5, Width 8.0, Depth 1.5, Undermining 4.1". Review of the Physician/Nurse Practitioner Progress Notes revealed the last note in the chart was dated 09/06/2010 and did not mention the sacral wound. Review of Physician order [REDACTED]. Review of the Nurse's Notes for September and October 2010 revealed no mention that the Physician or Nurse Practitioner had been notified that the Pressure Ulcer had gotten bigger. During an interview on 10/18/2010 at 8:42 AM, the Wound Care Nurse (LPN #1) stated that the facility used a Nurse Pr… | 2014-02-01 | ||
| 10266 | 10266 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2010-04-14 | 281 | D | THIH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record reviews, interviews and review of acceptable standards of practice for licensed staff , the facility failed to assure for 1 of 2 residents reviewed for accurate documentation related to a [MEDICAL TREATMENT] site that the documentation was thorough and accurate as entered. Resident #4 had documentation of thrill and bruit checks after the shunt site was changed and the physician discontinued the order. The findings included: The facility admitted Resident #4 on 6/26/09 with the following Diagnoses: [REDACTED]. The record review on 4/12/10 revealed a physician's orders [REDACTED]. Further review revealed another order written on 11/5/09 for removal of infected [MEDICAL TREATMENT] catheter and replacement of [MEDICAL TREATMENT] catheter- a tummeled catheter due to permanent placement access. During an interview with Registered Nurse (RN) #1 on 4/12/10 he/she stated " a thrill and bruit is not checked because the resident has a catheter in her right chest, the other site was removed." The nurse's notes revealed that Licensed Practical Nurse (LPN) # 2 documented in the notes "thrill felt and bruit heard" on the following dates 3/11/10, 3/13/10, 3/27/10 and 4/10/10. LPN #1 documented in the nurse's notes on 3/13/10 "bruit and thrill felt". LPN #3 documented in the nurse notes on 3/30/10 "thrill felt and bruit heard". During an interview with LPN #1 on 4/12/10 at 4 PM, when asked how he/she checked for a thrill and bruit, he/she stated "I just put the stethoscope above the catheter and hear a "LUB-DUB". During an interview with LPN #2 on 4/12/10 at 4:15 PM when asked how he/she checked for a thrill and bruit, he/she stated " you have to check that in the arm, but hers is in the chest". When ask why he/she documented that the thrill and bruit was checked, the LPN stated "I don't know". | 2014-01-01 | ||
| 10267 | 10267 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2010-04-14 | 315 | D | THIH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation and review of facility policy and procedure, the facility failed to provide appropriate catheter care for one of one catheter treatments observed. The Registered Nurse (RN) failed to properly anchor the catheter tubing during Resident # 3's catheter care. The findings included: The facility admitted Resident #3 on 7/27/09 with the following Diagnoses: [REDACTED]. During the catheter care observation on 4/13/10 at 9:15 AM RN #2 failed to secure the tubing to prevent pressure from tugging of the suprapubic catheter while cleaning, then drying the tube. At 9:20 AM on 4/13/10 during an interview with RN #2 he/she stated when ask about anchoring the tube "I didn't anchor it because its in the stomach." The facility policy titled Catheter Care, Suprapubic, stated under Procedure #11 "Gently grasp the catheter with non-dominant hand and use clean wash cloth to work down the tubing approximately 6 inches" | 2014-01-01 | ||
| 10268 | 10268 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2010-04-14 | 323 | E | THIH11 | On the days of the survey, based on observations and interviews, the facility failed to ensure that the resident environment remains as free of accident hazards as is possible. Three bathrooms in the common area observed to be used by residents had no call light system in place. The findings included: A random observation on 4/12/10 revealed a female resident in a wheelchair coming out of the bathroom unsupervised directly across from the main dining room. Another random observation on 4/13/10 revealed a male resident in a wheelchair coming out of the bathroom unsupervised directly across from the main dining room. An inspection of the bathrooms 1. located on the back hall next to the main dining room, 2. the bathroom directly across from the main dining room and 3. the bathroom located between the beauty shop and the activity room, all revealed no call light system in place. During an interview with the Director of Nursing (DON) on 4/13/10 at 11:40 AM, he/she confirmed that "these bathrooms are used by everyone, staff, visitors and residents". The DON stated that "the residents are assisted". When he/she was informed of the observations of residents using the bathroom alone, he/she stated "well we do have some that can go by themselves." | 2014-01-01 | ||
| 10269 | 10269 | HEARTLAND OF COLUMBIA REHAB AND NURSING CENTER | 425008 | 2601 FOREST DRIVE | COLUMBIA | SC | 29204 | 2010-09-14 | 279 | D | 916711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on record review, observations and interviews, the facility failed to develop and implement care plans with interventions to prevent aspiration for Residents #1, #2, #3 and #4 prescribed mechanically altered diets with nectar thick liquids and assessed as at risk for aspiration. The findings included: The facility admitted Resident #1 on 08/20/2008 with [DIAGNOSES REDACTED]. Observation on 09/13/2010 at approximately 3:00 PM of Resident #1's room revealed a white Styrofoam cup dated 09/11/2010 filled with water. In an interview with the surveyor on 09/13/2010 at 3:30 PM Licensed Practical Nurse #1 confirmed the date on the cup and the liquid. LPN #1 stated that a Speech Therapist had been working with Resident #1 and she was to have thickened liquids only. "The cup must have been left by the weekend staff." Record review on 09/13/2010 revealed a hospital transfer summary dated 08/23/2010 with discharge [DIAGNOSES REDACTED]. The physician ordered on [DATE] Speech-Language Pathology 5 days per week daily with precaution listed as aspiration; a pureed diet with nectar thick liquids was prescribed. Review of Resident #1's care plan revised 08/31/2010 listed as a focus area "Alteration in nutritional status r/t (related to) therapeutic mechanically altered diet with thicken liquids. Has severe dysphagia with high aspiration risk, family declines feeding tube." Interventions listed "will provided diet/snacks as ordered, will report hypo/hyper glycemia, will honor food preferences, will provide OHA's (oral hypoglycemic agents) as ordered". The facility admitted Resident #2 on 03/10/2008 with [DIAGNOSES REDACTED]. Record review on 09/14/2010 revealed physician's orders [REDACTED]. Review of Resident #2's care plan revised 09/13/2010 listed as a focus area "History of weight loss r/t receives daily diuretic and has dx (diagnosis) of dysphagia..." Interventions included "will provide honey thick liquids as… | 2014-01-01 | ||
| 10270 | 10270 | HEARTLAND OF COLUMBIA REHAB AND NURSING CENTER | 425008 | 2601 FOREST DRIVE | COLUMBIA | SC | 29204 | 2010-09-14 | 315 | G | 916711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection based on record review and interviews the facility failed to provide appropriate treatment and services to prevent urinary tract infections for 2 of 3 residents reviewed for urinary tract infections. On 08/13/2010 the physician ordered a STAT urinalysis and culture/sensitivity for Resident #1 to be done on 08/14/2010; the urine obtained by an in and out catheterization was left in the refrigerator, the test was not performed and treatment was delayed. Resident #1 was admitted to the hospital on [DATE] with a urinary tract infection. Resident #3's with increased blood sugars and a low grade temperature had a urinalysis and culture/sensitivity done on 08/05/2010, which was carried to the wrong lab, treatment was delayed for 4 days. The findings included: The facility admitted Resident #1 on 08/20/2008 with [DIAGNOSES REDACTED]. Record review on 09/13/2010 revealed the following Nurse's Note: 08/13/2010 at 6:00 PM that stated, "Speech only slightly garbled today. Hx (history) UTI (urinary tract infection) in the past. New order received for UA/CS (urinalysis/culture and sensitivity) Stat in AM.... 08/14/201 at 6:50 AM In and out cath (catheterization) to obtain urine specimen for UA and CS state in AM; pt tolerated procedure well... 08/15/2010 at 2:00 PM Pt with garble speech appears confused unable to coordinate hands to mouth. Placing hands in plate rather than spoon to eat with. Chest congested. BP (blood pressure) 114/63 p (pulse) 68 R (respirations) 18 unlabored. MD notified ordered [MEDICATION NAME] Bid (twice a day) and chest x-ray given. Schedule CT of head at hospital... Late entry for 08/15/2010 12:30 AM MD here to see resident... 08/16/2010 11:40 AM Resident unable to coordinate hand movement. Garbled like speech. Tongue hanging out of mouth. Resident not herself call RP. RP would like for resident to be evaluated. MD notified. Resident sent to hospital..." Record review on 09/13/2010 of the hos… | 2014-01-01 | ||
| 10271 | 10271 | HEARTLAND OF COLUMBIA REHAB AND NURSING CENTER | 425008 | 2601 FOREST DRIVE | COLUMBIA | SC | 29204 | 2010-09-14 | 281 | G | 916711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on observations, record review and interviews, the facility failed to provide care that met professional standards of practice for 2 of 3 sampled residents reviewed for standards of practice related to urinary tract infections and for 4 of 4 sampled residents reviewed for standards of practice related to aspiration precautions. The findings included: The facility admitted Resident #1 on 08/20/2008 with [DIAGNOSES REDACTED]. Record review on 09/13/2010 revealed the following Nurse's Note: 08/13/2010 at 6:00 PM that stated, "Speech only slightly garbled today. Hx (history) UTI (urinary tract infection) in the past. New order received for UA/CS (urinalysis/culture and sensitivity) Stat in AM.... 08/14/201 at 6:50 AM In and out cath (catheterization) to obtain urine specimen for UA and CS STAT in AM; pt (patient) tolerated procedure well... 08/15/2010 at 2:00 PM Pt with garble speech appears confused unable to coordinate hands to mouth. Placing hands in plate rather than spoon to eat with. Chest congested. BP (blood pressure) 114/63 p (pulse) 68 R (respirations) 18 unlabored. MD (medical doctor) notified ordered [MEDICATION NAME] Bid (twice a day) and chest x-ray given. Schedule CT (computerized tomography) of head at hospital... Late entry for 08/15/2010 12:30 AM MD here to see resident... 08/16/2010 11:40 AM Resident unable to coordinate hand movement. Garbled like speech. Tongue hanging out of mouth. Resident not herself call RP (responsible party). RP would like for resident to be evaluated. MD notified. Resident sent to hospital..." Record review on 09/13/2010 of the hospital admission history and physical dated 08/16/2010 at 3:33 PM revealed an admission assessment and plan that stated, "Urinary tract infection..." On 09/13/2010 a review of the laboratory studies revealed no results for the STAT UA/CS ordered by the physician for the AM of 08/14/2010. In an interview with the surveyor on 09/14/… | 2014-01-01 | ||
| 10272 | 10272 | MAGNOLIA MANOR - INMAN | 425032 | 63 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2010-09-16 | 328 | D | UGRJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection based on observations, interviews and record review the facility failed to ensure residents received timely foot care. The physician saw resident #2 and prescribed an antibiotic and cleaning to the right toenail bed until seen by the podiatrist related to redness of the toenail bed; resident #2 had a history of [REDACTED]. The findings included: The facility admitted Resident #2 on 08/21/2009 with [DIAGNOSES REDACTED]. Resident #2 was sampled as a result of a complaint related to skin care. Review of the current medical record on 09/16/2010 revealed the most recent Podiatry visit as 01/20/2010. A review of the nurse's notes revealed documentation that the podiatrist on 01/10/2010 for routine care saw Resident #2. On 03/10/2010 the physician saw Resident #2 due to pain in the left great toe and ordered triple antibiotic ointment for 7 days and Keflex 250 milligrams for 10 days. Nurse's notes from 03/11, 03/12, and 03/13/2010 documented a purulent yellow discharge from the left great toe. The Nurse's notes on 03/14/2010 at 3:45 PM stated, "CNA (certified nurse aide) reported to me Res (resident) in need of toenail trim. Removed bil (bilateral) bunny boots and both feet extremely dry and cracked no open areas noted. Velcro closure of top of (L) foot has rubbed reddened area to skin but intact. Attempted to trim toenail of (L) great ft (foot) and pus actively comin (sic) out. Toenail fell off. Trimmed all toenails and all came off either whole or crumbled. Skin underneath old nail pink and very healthy in appearance. Cleansed feet multiple times with warm water at bedside... Has had trx (treatment) ongoing to (L) great toes for inf (infection) with TAO. Had foul odor and purulent pus before cleaning. At present no active bleeding. Continued review of the nurse's notes revealed the physician was not notified about the drainage on 03/11, 03/12 and 03/13/2010 or that during care the toenails came off on 03/14/2… | 2014-01-01 | ||
| 10273 | 10273 | MAGNOLIA MANOR - INMAN | 425032 | 63 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2010-09-16 | 157 | D | UGRJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the survey, based on record review the facility failed to notify the physician of changes for one of five residents reviewed for foot care. Resident #2 with prescribed antibiotics for an infection of the left great toe developed "a purlent (sic) yellow discharge" that was not reported timely to the physician. The findings included: The facility admitted Resident #2 on 08/21/2009 with [DIAGNOSES REDACTED]. Resident #2 was sampled as a result of a complaint related to foot care. A review of the nurse's notes revealed documentation that the podiatrist on 01/10/2010 for routine care saw Resident #2. On 03/10/2010 the physician saw Resident #2 due to pain in the left great toe and ordered triple antibiotic ointment for 7 days and Keflex 250 milligrams for 10 days. Nurse's notes from 03/11, 03/12, and 03/13/2010 documented a purulent yellow discharge from the left great toe. The Nurse's notes on 03/14/2010 at 3:45 PM stated, "CNA (certified nurse aide) reported to me Res (resident) in need of toenail trim. Removed bil (bilateral) bunny boots and both feet extremely dry and cracked no open areas noted. Velcro closure of top of (L) foot has rubbed reddened area to skin but intact. Attempted to trim toenail of (L) great ft (foot) and pus actively comin (sic) out. Toenail fell off. Trimmed all toenails and all came off either whole or crumbled. Skin underneath old nail pink and very healthy in appearance. Cleansed feet multiple times with warm water at bedside... Has had trx (treatment) ongoing to (L) great toes for inf (infection) with TAO. Had foul odor and purulent pus before cleaning. At present no active bleeding. Continued review of the nurse's notes revealed the physician was not notified about the drainage on 03/11, 03/12 and 03/13/2010 or that during foot care the toenails came off on 03/14/2010. The physician examined Resident #2's toes on 03/16/2010. | 2014-01-01 | ||
| 10274 | 10274 | UNIHEALTH POST ACUTE CARE ORANGEBURG, LLC | 425085 | 755 WHITMAN STREET SE | ORANGEBURG | SC | 29115 | 2010-09-29 | 225 | D | LLC411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review, observations, interviews, and review of facility documents, the facility failed to report an injury of unknown origin within the allowed time frame, failed to promptly begin an investigation into the injury, and failed to thoroughly investigate the resident's injury for a possible explanation of how it occurred for 1 of 1 resident reviewed who had an injury of unknown origin (#3). The findings included: Resident #3 with [DIAGNOSES REDACTED]. Review of the annual Resident Assessment Instruments of 5/14/09 and 4/23/10 showed the resident had short and long term memory problems with moderately impaired decision making ability. Communication was sometimes understood. The resident required total care from the staff for all activities of daily living. Staff transferred the resident by mechanical lift. The resident received nutrition and hydration via feeding tube and maintained a steady weight (206 pounds recorded on the 5/14/09 assessment and 204 pounds on the later assessment.) Resident Assessment Protocol (RAP) notes revealed the resident had left side weakness from the stroke. She could mumble some words and was able to relay simple messages at times. The resident understood simple communication and followed simple commands. Two staff members assisted with bed mobility and transfers with the mechanical lift. Review of the medical record and facility documents showed the resident first showed signs of injury on 7/13/10 when a bruise was discovered after the resident's shower. Review of the Change Of Condition Nurses Notes and Resident Incident Report showed the discoloration was to the left back. There was no inflammation or [MEDICAL CONDITION] noted to the area. The facility did not report this injury of unknown origin or begin any investigation into the injury's possible origin. The facility did report to the State survey and certification agency on 7/15/10 that the resident's weekly skin audi… | 2014-01-01 | ||
| 10275 | 10275 | UNIHEALTH POST ACUTE CARE ORANGEBURG, LLC | 425085 | 755 WHITMAN STREET SE | ORANGEBURG | SC | 29115 | 2010-09-29 | 496 | D | LLC411 | On the days of the survey, based on review of employee information provided, the facility failed to ensure that registry verification was completed before allowing an individual to serve as a Certified Nursing Assistant (CNA) for 2 of 3 employees reviewed who were hired in 2010 as CNAs. The findings included: During the complaint investigation, information concerning the staff on duty around the time of an injury of unknown origin was requested from the facility. The information provided failed to show that two of the CNAs had registry verification checks done prior to hire. The Director of Nurses (DON) was asked for this information on 9/28/10. On 9/29/10, the DON stated she knew the registry verification checks were done before hire, but Human Resources could not produce evidence of this. | 2014-01-01 | ||
| 10276 | 10276 | UNIHEALTH POST ACUTE CARE ORANGEBURG, LLC | 425085 | 755 WHITMAN STREET SE | ORANGEBURG | SC | 29115 | 2010-09-29 | 514 | D | LLC411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record reviews, the facility failed to ensure that resident records were complete and accurately documented for 1 of 3 resident records reviewed (#3). Documentation in the medical record concerning Resident #3's injury of unknown origin was incomplete and inaccurate. The findings included: Resident #3 with [DIAGNOSES REDACTED]. Review of the Change Of Condition Nurses Notes showed staff found a discoloration on the resident's left back. The area was without inflammation or [MEDICAL CONDITION]. The nurse's note by LPN #1 did not describe the discoloration's size, shape, color, or specific location on the resident's left back. Certified Nursing Assistant (CNA) #3 found the area on 7/13/10 after the resident's shower and reported it to the nurse for assessment. This CNA was interviewed on 9/28/10 at 4:20 PM and stated what he saw was an area under the resident's left axilla extending to the left breast, it was blackish blue in color, and was approximately 4 by 4 centimeters big. LPN #1 was interviewed on 9/29/10 at 10:35 AM. She stated that on 7/13/10, she observed an elongated; approximately 3 inches by 1 inch, reddish purple area on the resident's upper back at the axilla level. LPN #1 denied seeing a blackish bruise under the resident's arm, extending under the left breast. Documentation in the Change of Condition Nurses Notes on 7/14/10 by LPN #1 described the "left flank discoloration" as not as large as yesterday. The medical record showed no information of any discolored area on the resident's flank. LPN #1 did not reference the resident's left flank in either her interview or in her statement. The information at the top of the page on the 7/15/10 Change of Condition Nurses Notes showed the resident's bruise on the left back was not as large. Purple discoloration was noted on the upper anterior left arm and left chest. Farther down the page, under the Current Care Plan Interventions and physician's orde… | 2014-01-01 | ||
| 10277 | 10277 | UNIHEALTH POST ACUTE CARE ORANGEBURG, LLC | 425085 | 755 WHITMAN STREET SE | ORANGEBURG | SC | 29115 | 2010-09-29 | 323 | D | LLC411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review, observations, interviews, and review of facility documents, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 1 resident reviewed who had an injury of unknown origin (#3). The findings included: Resident #3 with [DIAGNOSES REDACTED]. Review of the annual Resident Assessment Instruments of 5/14/09 and 4/23/10 showed the resident had short and long term memory problems with moderately impaired decision making ability. Communication was sometimes understood. The resident required total care from the staff for all activities of daily living. Staff transferred the resident by mechanical lift. The resident received nutrition and hydration via feeding tube and maintained a steady weight (206 pounds recorded on the 5/14/09 assessment and 204 pounds on the later assessment.) Resident Assessment Protocol (RAP) notes revealed the resident had left side weakness from the stroke. She could mumble some words and was able to relay simple messages at times. The resident understood simple communication and followed simple commands. Two staff members assisted with bed mobility and transfers with the mechanical lift. Review of the medical record and facility documents showed the resident first showed signs of injury on 7/13/10 when a bruise was discovered after the resident's shower in the left axilla area. On 7/15/10, the resident's weekly skin audit on 7/15/10 showed purple discoloration on the upper anterior left arm and chest. The resident grimaced when the left arm was manipulated. X-ray and assessment at the hospital showed a fractured left humeral head. The facility began an investigation into the resident's injury at that time. The Five-Day Follow-Up Report dated 7/20/10 stated the area found on 7/13/10 was a discoloration to the left flank. Review of the facility's investigative materials showed on their final report: "Res. wa… | 2014-01-01 | ||
| 10278 | 10278 | WHITE OAK MANOR - YORK | 425089 | 111 SOUTH CONGRESS STREET | YORK | SC | 29745 | 2010-07-28 | 425 | E | 1BYP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record review and interviews, the pharmacy, supplying medications to the facility, failed to assure the accurate administration of all drugs for 1 of 6 residents observed during medication pass. Resident A with a physician's orders [REDACTED]. The findings included: On 7/27/10 at 8:50 AM during observation of medication pass for Resident A, Licensed Practical Nurse (LPN) #4 was observed to measure Miralax Powder to the 15 milliliter mark in a medication cup used to measure liquid medications. The Miralax Powder was dissolved in 7 ounces of water and administered to the resident along with 8 other medications. Reconciliation of medication pass for Resident A revealed a current physician's orders [REDACTED]. DX (diagnosis) CONSTIPATION". The identical physician's orders [REDACTED]. All of the orders were signed by the physician without clarifying the ambiguous dosage. Further review revealed that the Physician's admission orders [REDACTED]. Dx Constipation". During an interview on 7/28/10 at 8:40 AM, the pharmacist at the pharmacy supplying the medications to the facility, stated that the pharmacy did not have the original order for the Miralax Powers (written 1/20/04) on hand. She/he stated that, on the pharmacy side, they have 17 Gms in 8 ounces of water as the standard (manufacturer's recommended) dose for Miralax and confirmed that the dosage on the monthly orders, printed by the pharmacy, was not clear. She/he further stated that, if there was an error, it was the pharmacy's fault. During an interview on 7/28/10 at 8:47 AM, LPN #4 stated that the pharmacist came to the facility yesterday (7/27/10) at about 5 PM, after the observation of medication by this surveyor the morning of the same day, and changed the dose for the Miralax on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. | 2014-01-01 | ||
| 10279 | 10279 | WHITE OAK MANOR - YORK | 425089 | 111 SOUTH CONGRESS STREET | YORK | SC | 29745 | 2010-07-28 | 314 | D | 1BYP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record review, interview and review of the product insert sheet for Santyl/facility policy for the application of a [MEDICATION NAME] product, the facility failed to assure that one of two sampled resident's reviewed for pressure ulcer care received appropriate treatment and services. During observation of the pressure ulcer treatment for [REDACTED]. Facility staff was unaware if the pressure relieving mattress in use was appropriately set for the resident's use. The findings included: The facility last admitted Resident # 3 on 7/24/10. The resident's [DIAGNOSES REDACTED]. On 7/27/10 at 9:10am, an observation of the resident's pressure ulcer treatment was conducted. During the the procedure, the wound care nurse was observed to clean the outside raised edge of the pressure ulcer but not clean the wound bed itself. The wound bed was noted to contain slough and tunneling was noted. Following the treatment, the wound care nurse was questioned as to why the wound bed was not cleaned. S/he stated s/he did not want the spray the "collect" where the wound was undermined and did not want to injure the wound bed by having to pat it dry. S/he also stated s/he felt the use of Santyl cleaned the wound bed when the previous dressing was removed. Review of the product insert sheet from Santyl revealed the manufacturers recommendation stated to clean the wound bed prior to the application of Santyl. The instructions stated the wound bed should be cleansed prior to application.. remove as much loose debris as possible, gently cleanse the wound bed with saline or wound cleanser followed by saline each time the dressing is changed. Additionally, the facility policy also stated the wound bed should be cleansed prior to the application of a [MEDICATION NAME] product. Also following the completion of the treatment, the facility wound care nurse was questioned related to the use of the pressure relieving mattress wh… | 2014-01-01 | ||
| 10280 | 10280 | WHITE OAK MANOR - YORK | 425089 | 111 SOUTH CONGRESS STREET | YORK | SC | 29745 | 2010-07-28 | 373 | D | 1BYP11 | On the days of the survey, based on observation, interview and record review, the facility failed to identify the use of a paid feeding assistant program and failed to implement the approved program consistent with State law. The findings included: On 7/26/10, upon entrance to the facility, the Administrator stated the facility did not utilize a paid feeding assistant program. On 7/27/10, at approximately 1:30pm, the Administrator and Nurse Consultant again stated the facility did not have or use a paid feeding assistant program. During random observations during the evening meal on 7/26/10, two activity staff members were observed feeding residents in the "B" building. One resident was being fed in a small alcove in the "B" building and another resident was being fed in his/her room. Both staff members stated they were not Certified Nursing Assistants. During the noon meal on 7/27/10, the activity members were again observed feeding residents either in their rooms (building "B") or dining room (main building). Further investigation revealed the facility did have an state approved feeding assistant program. On 7/27/10 at 2PM, during an interview with the Staff Development Coordinator (SDC) , s/he stated s/he had not taught the feeding assistant program since her return to the facility 12/09 but s/he previously had taught it at the facility. S/he stated an awareness that both activity personnel had previously completed the feeding assistant program. When asked which residents a staff member who had completed the program could feed, the SDC stated they would feed "easier" residents. S/he further stated one particular activity staff member would feed "anyone she felt comfortable with...s/he would not step out of her comfort zone." A review of personnel files revealed both staff members had completed the paid feeding assistant program at the facility (in 2005 and 2007). On 7/28/10, during an interview with the Administrator it was verified that the facility was not cognizant that using trained staff members to feed r… | 2014-01-01 | ||
| 10281 | 10281 | WHITE OAK MANOR - YORK | 425089 | 111 SOUTH CONGRESS STREET | YORK | SC | 29745 | 2010-07-28 | 441 | E | 1BYP11 | **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 maintain an infection control program to help prevent the development and transmission of disease and infection. Interview and observation of the Laundry Department revealed a lack of knowledge of appropriate infection control practice. Personal Laundry was not being sanitized. Following observation of catheter care for Resident # 3, handwashing concerns were identified. The findings included: On 7/27/10 at 11AM, an observation of the facility laundry department was conducted. Laundry worker # 1 was observed placing soiled laundry into a washing machine. After the soiled laundry was placed, s/he was observed to remove the protective gown by pulling it over his/her head when unable to untie the strings. The same laundry worker was asked to explain the process on how to handle laundry from an infected resident. Both Laundry worker # 1 and # 2 stated they would wear two pair of gloves and put on two gowns for protection. When asked how the two gowns would be applied, they stated one frontward and one backward. A box containing 3 pillows (1 cloth and 2 vinyl covered) was observed in the soiled area. When asked how the pillows would be cleaned, Laundry worker # 1 stated one pillow would be discarded because it was torn. The other two pillows would would be cleaned the same by spraying and wiping off with a disinfectant cleaner and then dried with a towel. Review of the label of the product indicated would be used stated it was to be used for non-porous surfaces. Further interview revealed that no bleach or other disinfecting chemical was used when washing the resident's personal laundry. The facility water temperature for personal laundry was identified as cold/warm. Appropriate chemical sanitization was used for bedding and other linens when washed. On 7/27/10 at 11:25AM, an interview was conducted with the Maintenance Supervisor, identified as in charge of the … | 2014-01-01 | ||
| 10282 | 10282 | WHITE OAK MANOR - YORK | 425089 | 111 SOUTH CONGRESS STREET | YORK | SC | 29745 | 2010-07-28 | 156 | D | 1BYP11 | **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 ensure a Resident's responsible party's stated interest in a Do Not Resuscitate order was acted upon timely. Resident # 11's responsible party expressed interest in formulating an Advanced Directive. After the Resident was determined to lack capacity for healthcare decisions, the facility took no further action. (1 of 13 sampled resident's reviewed for Advanced Directives) The findings included: The facility last admitted Resident # 11 on 7/7/10. The resident's [DIAGNOSES REDACTED]. On 7/26/10 a review of the current medical record revealed a Social progress note dated 7/8/10 which stated: "Res (resident) has POA (Power of Attorney) copy placed on chart and no living will. RP (Responsible party) is interested in DNR (Do not Resuscitate)." On 7/14/10 two physicians documented the resident lacked capacity to make healthcare decisions. Additional Social progress notes were documented on 7/16 and 7/19/10 noting resident behaviors and family visits/contacts. However, there was no further documentation related to the resident's advanced directive status. On 7/26/10 at 4:10pm, during an interview with the nurse consultant, s/he stated the resident was a "full code." On 7/27/10 at 11am, during an interview with social services employee # 1, s/he stated once a resident's capacity has been determined, appropriate action related to the residents/responsible party stated wishes for advanced directives should "happen quickly". S/he verified no action had been taken by the facility after the resident's capacity has been determined. S/he further stated the RP had been contacted and would be coming to the facility "today" to sign the paperwork for the resident's Do Not Resuscitate status. | 2014-01-01 | ||
| 10283 | 10283 | HEARTLAND OF LEXINGTON REHAB AND NURSING CENTER | 425105 | 2416 SUNSET BOULEVARD | WEST COLUMBIA | SC | 29169 | 2010-09-22 | 281 | D | OR4T11 | **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 clarify and follow a Physicians order related to discontinuing [MEDICATION NAME] for Resident # 12, 1 of 1 resident reviewed on anticoagulant therapy. The findings included: Resident # 12 was admitted by the facility on 3/16/10 with [DIAGNOSES REDACTED]. The record review on 9/21/10 revealed a physician's orders [REDACTED].= 2.0". Further record review revealed an INR drawn on 9/13/10 was 4.05 and on 9/14/10 the INR was 3.03. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The INR results dated 9/9/10 had an order written [REDACTED].> 2). On 9/21/10 at 1:00 PM Licensed Practical Nurse (LPN) # 2 stated during an interview that "the order should have been clarified, because the orders are not the same. Someone should have called the doctor and asked about it, I think it should be stopped after it is greater than 2.0." The Unit Manager for the 100 hall stated during an interview on 9/21/10 at 2:00 PM " It (the [MEDICATION NAME]) should have been stopped when they got a INR of 2.0 or greater." During a telephone interview with LPN # 3 on 9/22/10 at 10:40 AM she confirmed that she took the order and stated " they were to stop the [MEDICATION NAME] when the INR is 2.0 or greater, I don't know why I would have written equal, that is just a slip of the pen or something, but it should be stopped when the INR is 2.0 or greater.". LPN # 2 called the Physician and received a clear order on 9/21/10 at 1:00 PM which reads "D/C [MEDICATION NAME] when INR greater than or equal to 2.0". | 2014-01-01 | ||
| 10284 | 10284 | HEARTLAND OF LEXINGTON REHAB AND NURSING CENTER | 425105 | 2416 SUNSET BOULEVARD | WEST COLUMBIA | SC | 29169 | 2010-09-22 | 329 | E | OR4T11 | **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 decrease [MEDICATION NAME] as ordered for Resident # 12. The resident received 30 mg (milligrams) of [MEDICATION NAME] instead of 15 mg as ordered. The findings included: Resident # 12 was admitted by the facility on 3/16/10 with [DIAGNOSES REDACTED]. The record review on 9/21/10 revealed an order written [REDACTED]. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Licensed Practical Nurse (LPN) # 2 stated during a interview on 9/21/10 that "the nurse who checked the MAR indicated [REDACTED]." The Unit Manager for Hall 100 stated during an interview on 9/21/10 " I checked those MAR's and I missed that, it is a problem." Both nurses stated " we will need to do a medication error report on this." | 2014-01-01 | ||
| 10285 | 10285 | HEARTLAND OF LEXINGTON REHAB AND NURSING CENTER | 425105 | 2416 SUNSET BOULEVARD | WEST COLUMBIA | SC | 29169 | 2010-09-22 | 502 | D | OR4T11 | **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 ensure that laboratory services were provided in a timely manner for 1 of 13 residents (Resident #4) reviewed for laboratory services. The findings included: The facility admitted Resident # 4 on 6/18/10 with the following Diagnoses: [REDACTED]. The record review on 9/20/10 revealed an order for [REDACTED]. On the bottom of this report a note/recommendation was made that stated " Mixed culture: 3 or more organisms isolated suggest repeat culture to rule out contamination." No other reports were found on the medical record. During an interview with Licensed Practical Nurse # 2 she stated " we should get another urine sample". This resident does have a Foley catheter and a history of Urinary Tract Infections with the last one documented and treated in July 2010. | 2014-01-01 | ||
| 10286 | 10286 | BRIAN CENTER NURSING CARE - ST ANDREWS | 425129 | 3514 SIDNEY ROAD | COLUMBIA | SC | 29210 | 2010-12-08 | 441 | E | R42P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, interview and review of facility policies, the facility failed to develop and maintain an infection control program which prevented the spread of infection. During three of four pressure ulcer treatment observations, concerns were identified related to glove use or handwashing. (Resident's # 1, #2, and #5) During observation of three of three gastric tube flushes, the nursing staff failed to clean the stethoscope either before or following the treatment. (Resident's #2, #3, and #8) In two of three medication rooms, supplies were found stored beyond the manufacturer's expiration date. (One hundred and three hundred units) The findings included: The facility last admitted Resident # 1 with [DIAGNOSES REDACTED]. On [DATE] at 10:45AM, Licensed Practical Nurse (LPN) # 5 was observed performing wound care for the resident. LPN # 5 was observed to remove the soiled dressing from the residents left hip area, and without changing gloves proceeded to clean the wound using clean supplies. The facility last admitted Resident # 5 with [DIAGNOSES REDACTED]. On [DATE] at approximately 11AM, Licensed Practical Nurse # 5 was observed performing pressure ulcer care. LPN # 5 removed the soiled dressing from the residents sacrum and without changing gloves proceeded to clean the Stage IV pressure area with clean supplies. After cleaning the area with normal saline and drying the area, LPN #5 removed her gloves, washed her hands and donned clean gloves. The nurse then skin prepped the perimeter of the wound, fanned the area dry, applied Santyl to the areas containing slough, wet a dressing with saline, unfolded it, folded it into a smaller size and placed it directly onto the wound. A cover dressing was applied. LPN #5, continuing to wear the same gloves, reached into her uniform pocket, removed a pen and tape which were used to initial and date the dressing. After moving the bedside table away from the bed, the nu… | 2014-01-01 | ||
| 10287 | 10287 | BRIAN CENTER NURSING CARE - ST ANDREWS | 425129 | 3514 SIDNEY ROAD | COLUMBIA | SC | 29210 | 2010-12-08 | 520 | E | R42P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record review, and interview, the facility failed to fully identify quality concerns related to restraints. Resident # 2 with a known restraint, had no quarterly assessment to determine if the restraint was the least restrictive device and whether or not the restraint continued to be necessary. The facility conducted weekly restraint quality assurance reviews and failed to fully identify missing documentation related to the restraint. The findings included: The facility admitted Resident # 20 with a primary [DIAGNOSES REDACTED]. During the initial tour of the facility on 12/6/10 the resident was identified as wearing a hand mitt restraint, "at the families request." The resident was observed with an oven mitt with a splint applied over the mitt on the right hand. On 12/8/10, record review revealed an order was written on 2/2/10 for: "Oven mitt to right hand(with) left hand Spica. Remove for ADL's (Activities of Daily Living) + (and) check skin integrity Q (every) shift d/t (due to) restlessness, Dementia, playing in feces and self scratching." Further review revealed a Quarterly Restraint Review dated 1/8/10 (before the restraint order) which stated: ' Continue current restraint order. ...Look for alternative to mitt that is less restrictive." The quarterly physical restraint review was completed thirteen times, each time recommending the continued use of the restraint. On 12/8/10 from 10AM to approximately 11:15AM, interviews were conducted with the Director of Rehabilitation who stated she was responsible for restraint documentation and the Physical therapist. It was questioned what follow up was done to obtain an alternative which was less restrictive and or whether the resident still required the use the use of the restraint. In reviewing the nurses notes, there was no documentation of the resident scratching or attempting to play in feces when the restraint was released for ADL's. The last… | 2014-01-01 | ||
| 10288 | 10288 | BRIAN CENTER NURSING CARE - ST ANDREWS | 425129 | 3514 SIDNEY ROAD | COLUMBIA | SC | 29210 | 2010-12-08 | 164 | D | R42P11 | **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 ensure 1 of 3 residents received privacy during wound care. (Resident # 2) The findings included: The facility admitted Resident # 2 on 12-30-08 with [DIAGNOSES REDACTED]. During observation of wound care on 12-7-10 at approximately 1:30 PM, the Licensed Practical Nurse (LPN # 1) entered the room, pulled the privacy curtain between the beds to the foot of the bed, and asked the room mate if she wanted to leave the room while care was being given to Resident # 2. The room mate declined to leave the room, and was moving around her side of the room in her wheelchair. The privacy curtain which could have surrounded Resident # 2's bed was left at the head of her bed and not pulled around her bed. During the treatment LPN # 1 used up all of the supplies and stated to this surveyor, that he needed to leave the room to obtain more supplies to complete the treatment. At that time, Resident # 2 was lying on her side facing the door, with her brief unfastened and her entire backside exposed to view. When LPN # 1 left the room, the door was left ajar and unidentified persons were noted to be walking in the hall past the door. | 2014-01-01 | ||
| 10289 | 10289 | BRIAN CENTER NURSING CARE - ST ANDREWS | 425129 | 3514 SIDNEY ROAD | COLUMBIA | SC | 29210 | 2010-12-08 | 315 | D | R42P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, interview, review of the South Carolina Nurse Aide Candidate Handbook, and review of the facility policy on catheter care, the facility failed to provide appropriate treatment for 1 of 1 resident observed for catheter care. During observation of catheter care for Resident # 7, the Certified Nursing Assistant failed to secure the catheter close to the meatus to prevent tension or pressure on the bladder wall when cleaning the catheter tubing. The findings included: The facility admitted Resident # 7 on 6-7-10 with [DIAGNOSES REDACTED]. ,During observation of catheter care on 12-7-10 at approximately 10:00 AM, Certified Nursing Assistant (CNA # 1) knocked, entered the room, provided privacy, washed hands and gloved. CNA # 1 then set up the supplies on the over the bed table: 3 separate cups, one containing soapy water and gauze wipes, one containing clear water and gauze wipes, and the third containing dry gauze wipes. After Resident # 7 was positioned for the treatment, CNA # 1 again washed hands and gloved. CNA # 1 then positioned her left hand to separate the labia and secure the catheter. Using her right hand she used a soapy gauze wipe to clean around the left side of the labia, and discarded the gauze wipe, then repeated the procedure on the right side. CNA # 1 then used the third soapy gauze wipe to clean the catheter, beginning at the entry point of the catheter into the body, she wrapped the gauze around the catheter and pulled away from the body to where the fingers of her left hand secured the catheter (about 4 inches from the body). Tension was observed when the catheter was being cleaned. This entire process was repeated with the clear water rinse, and in drying. Review of the facility policy revealed the following: "Female residents: Separate labia with one hand. With the soapy gauze, cleanse from front to back one stroke down one side, discard the used gauze then stroke down the ot… | 2014-01-01 | ||
| 10290 | 10290 | UNIHEALTH POST-ACUTE CARE - NORTH AUGUSTA | 425296 | 1200 TALISMAN DRIVE | NORTH AUGUSTA | SC | 29841 | 2012-02-01 | 251 | C | 2C1L11 | On the days of the survey, based on interviews and review of the "South Carolina Code of Laws Title 40-Professions and Occupations Chapter 63: Social Workers", the facility, with more than 120 beds, failed to employ a Licensed Social Worker as required by state law. The facility Social Worker had a Bachelor's Degree and had not been licensed. The findings included: During an interview on 02-01-12 with the facility Social Worker, she revealed she had a Bachelor's degree and had not been licensed. During an interview on 02-01-12 with the Administrator, she revealed she did not know a Licensed Social Worker was required. She stated the facility would contract with a Licensed Social Worker as a Consultant to oversee the facility Social Worker at least 20 hours per month. Review of the "South Carolina Code of Laws Unannotated, Current through the end of the 2011 Session, Title 40-Professions and Occupations, Chapter 63: Social Workers" revealed in Section 40-63-30: License as prerequisite to practice or offer to practice; providing social work services through telephone or electronic means. A) No individual shall offer social work services or use the designation "Social Worker", "Licensed Baccalaureate Social Worker", "Licensed Masters Social Worker", "Licensed Independent Social Worker-Clinical Practice", "Licensed Independent Social Worker-Advanced Practice", or the initials "LBSW", "LMSW", or "LISW" or any other designation indicating licensure status or hold themselves out as practicing social work or as a Baccalaureate Social Worker, Masters Social Worker, or Independent Social Worker unless licensed in accordance with this chapter". | 2014-01-01 | ||
| 10291 | 10291 | UNIHEALTH POST-ACUTE CARE - NORTH AUGUSTA | 425296 | 1200 TALISMAN DRIVE | NORTH AUGUSTA | SC | 29841 | 2012-02-01 | 252 | E | 2C1L11 | On the days of the survey, based on observation and interviews, the facility failed to ensure that the residents' room and care equipment were clean and sanitary for 1 out of 3 units observed for cleanliness. Resident rooms that contained feeding pumps were noted with soiled areas; stains were noted on ceiling tiles; dust was apparent under resident beds and a base board was not intact. The findings included: Observation during the initial tour on 1/30/2012 at 11:00 AM and follow up observation on 1/31/2012 at 9:30 AM on the Ventilator Unit revealed the following concerns. -12-A---tube feeding spills in bathroom; on grab bar; and shower chair. -12-B-- tube feeding noted at the base of the feeding pump. -12-D--wall at the head of the bed had dried spills. -13-C--tube feeding noted on the floor and wall behind the bed. -14-- noted stained ceiling tiles. -14-B---tube feeding noted on feeding pump. -14-D-- tube feeding noted on feeding pump. -15-C-- tube feeding noted on feeding pump and dust under the bed -15-D-- tube feeding noted on feeding pump and dust the under the bed. -16-A-- tube feeding noted on feeding pump and dust under the bed. -17-A-- dust particles noted behind the bed. -17-B-- tube feeding noted on the feeding pump. -18--wall and floor noted with spills. -19--dust noted behind the bed and portion of the base board was not intact. During an interview with the Unit Manager on 1/31/2012 at 3:15 PM, she stated that all staff were responsible for keeping the resident's care equipment and room clean. The Housekeeping and Laundry Supervisor verified all of the following listed above during a walking tour on 1/31/2012 at 4:00 PM. The Housekeeping and Laundry Supervisor stated that is was the responsibility of everyone to ensure all equipment and rooms are kept clean and sanitary. | 2014-01-01 | ||
| 10292 | 10292 | L.M.C.- EXTENDED CARE | 425321 | 815 OLD CHEROKEE ROAD | LEXINGTON | SC | 29072 | 2010-09-30 | 441 | F | IK8X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record reviews and interviews, the facility failed to provide Tracheostomy care for one of one resident reviewed for tracheostomy care in a manner that would prevent possible infection on Resident #11. In addition the facility failed to track/trend infectious organisms and failed to adequately notify visitors of contact precautions. The findings included: The facility admitted Resident #11 on 5/12/10 with [DIAGNOSES REDACTED]. Review of the September 2010 cumulative physician's orders [REDACTED]. Observation on 9/28/10 at approximately 4:50 PM revealed Licensed Practical Nurse (LPN) #5 entered the resident's room. After assessing the resident, he put on a pair of clean gloves and suctioned inside and around the tip of the tracheostomy opening with a [MEDICATION NAME] suction catheter. He did not wash his hands prior to putting on the gloves. With the same gloved hands that he had used to suction with the [MEDICATION NAME] catheter, he opened a new inner cannula from a box container, removed the inner cannula from the resident's tracheostomy, and inserted the new inner cannula into the tracheostomy. With the same gloved hands, he then opened the drawer to the bedside table and removed a sterile suction kit. He put one sterile glove on his left hand without removing the other gloves and proceeded to perform endotracheal suctioning to the resident. During an interview on 9/29/10 at 5:13 PM, LPN #5 verified he put on gloves without washing his hands first, put on a sterile glove over a dirty one, and touched the drawer handle and supplies with the same gloved hands used for suctioning. He stated that the reason he put the sterile glove over the dirty one was that the sterile gloves were too small and ripped causing mucus to get on his hands. Review of the policy provided by the facility entitled "Suctioning of Tracheostomy" (dated 11/25/97) on 9/29/10 at 12:58 revealed under Procedure..."3. Assembl… | 2014-01-01 | ||
| 10293 | 10293 | L.M.C.- EXTENDED CARE | 425321 | 815 OLD CHEROKEE ROAD | LEXINGTON | SC | 29072 | 2010-09-30 | 225 | D | IK8X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on interview and review of the policy provided by the facility entitled "Alleged Abuse/Incident of Unknown Origin/Accident-Injury Complaint, Complaint Responsibilities" dated 8/7/09, the facility failed to report to the state agency and investigate the alleged verbal abuse of Resident #13, one of 18 residents reviewed for abuse and neglect; the facility failed to complete an incident report related to a skin tear on Resident #30. The findings included: The facility admitted Resident #13 on 6/27/07 with [DIAGNOSES REDACTED]. During an individual interview on 9/29/10 at 11:05 AM, Resident #13 stated that she was lying on her side when a Certified Nursing Assistant (CNA) laughed and made an unprofessional/inappropriate remark related to the resident's size.. Resident #13 stated the CNA pushed her so hard she almost pushed her out of the bed. The resident stated that it had not been long since the incident occurred. She stated she had asked that the CNA not be allowed to take care of her and stated that the CNA had been taken off the floor. During an interview on 9/29/10, the Assistant Director of Nursing (ADON) stated she was unaware of the incident and it had not been reported to her. During an interview on 9/30/10 at approximately 11:00 AM, Nurse A stated she was aware of the incident, but hadn't been on duty at the time the incident occurred. Nurse A stated she had reported the incident to her supervisor, RN #2. Nurse A stated the CNA involved in the incident had requested to be moved off the floor, and had not been moved as a result of any disciplinary action. During an interview on 9/30/10 at approximately 11:30 AM, RN #2 denied any knowledge of the incident and stated that the nurse must have reported the incident to another nursing supervisor. During an interview on 9/30/10 at 12:00 Noon, the Director of Nursing (DON) stated she was unaware of the incident. After reviewing the CNA's personnel record, the D… | 2014-01-01 | ||
| 10294 | 10294 | L.M.C.- EXTENDED CARE | 425321 | 815 OLD CHEROKEE ROAD | LEXINGTON | SC | 29072 | 2010-09-30 | 280 | D | IK8X11 | **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 update the Care Plans for 2 of 18 sampled residents reviewed for comprehensive Care Plans. Resident #13's Care Plan was not updated related to [MEDICAL CONDITION] and drug seeking behaviors; Resident #30's Care plan was not updated related to skin tears. The findings included: The facility admitted Resident #13 on 6/27/07 with [DIAGNOSES REDACTED]. During an interview on 9/30/10 at approximately 12:15 PM, Registered Nurse (RN) #2 stated Resident #13 had been exhibiting drug seeking behavior. According to the nurse, the resident told the physician on 9/20/10 that the [MEDICATION NAME] wasn't working any more and he subsequently discontinued it. Review of the physician's orders [REDACTED]. The nurse stated that the resident kept asking for the [MEDICATION NAME] again, so the nursing staff had to call the on-call physician that same night who gave an order for [REDACTED]. MD (physician) will evaluate in AM". When asked what was being done to address this issue, the nurse stated the resident had been seen by Psychiatry and had a trial of [MEDICATION NAME]. Review of the "Psych Consult and Progress Notes" dated 3/10/10 revealed that Resident #13 had been diagnosed with [REDACTED]. According to the note "Case discussed with staff. Pt. (Patient) had been refusing q (every) hs (Bedtime) [MEDICATION NAME] (Secondary) to "SE" (Side Effects) Upset stomach, [MEDICAL CONDITION] of feet which attributed to (increased) dose. Pt. would like to try another medicine & asks for [MEDICATION NAME]. I explain(ed) to her that this will not help (with) depression & Pt. is already taking [MEDICATION NAME] which is similar. Pt denies SI (Suicidal ideation). She has been cooperating with care. (No) voiced [MEDICAL CONDITION]. Pt is oriented x3. Meds (Medications) [MEDICATION NAME] 1 mg (milligram) PO (By Mouth) Q (every) AM. [MEDICATION NAME] 60 mg PO Q AM, [MEDICATION NA… | 2014-01-01 | ||
| 10295 | 10295 | BMC SUBACUTE REHAB CENTER | 425340 | 1330 TAYLOR AT MARION STREET | COLUMBIA | SC | 29203 | 2011-06-07 | 371 | F | VIJL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the recertification survey, based on observation, record review, review of the facility's policy entitled HACCP/FOOD SAFETY PROGRAM and interviews, the facility failed to store, prepare, distribute, and serve food under sanitary conditions. The facility failed to dispose of expired foods, failed to label foods in storage to ensure expired foods could be identified and failed to implement policies and procedures to ensure expired items were discarded appropriately. The facility also failed to sanitize the thermometer between foods while testing temperatures on the tray line. In addition, the facility failed to develop and implement a policy for thawing meat to ensure that previously frozen, thawed meats were not refrigerated for extended periods prior to cooking. The findings included: Initial tour of the kitchen was conducted on 6/7/11 beginning at 9:15 AM with the Store Room Manager, the Certified Dietary Manager (CDM) and the Executive Chef. Tour of the dry food storage area revealed a box of [MEDICATION NAME] Extra with an expiration date of 4/11 and a box of muffin mix with an expiration date of 2/16/11. In addition there were 6 boxes of corn muffin mix and 8 boxes of buttermilk biscuit mix with no expiration dates and an opened bag of macaroni with no label. During the tour, the Store Room Manager confirmed there were multiple items without expiration dates and confirmed the items should have been labeled when removed from the case boxes. During an interview at approximately 12:00 PM, the Store Room Manager stated dry goods were rotated with each delivery to ensure "first in, first out." He stated that he doesn't "pay attention" to items already on the shelf if he hasn't ordered any of that item but also stated "I guess I should." He also stated he did not know if there was a policy stating how often the store room should be checked for expired food items. Review of the facility's Operational Standard: Food Storage, dated A… | 2014-01-01 | ||
| 10296 | 10296 | AGAPE NURSING & REHAB CENTER | 425379 | 300 AGAPE DRIVE | WEST COLUMBIA | SC | 29169 | 2010-09-14 | 328 | E | DZ1T11 | **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 ensure that residents received treatments as ordered by the physician for 1 of 2 residents reviewed who had nebulizer treatments ordered (#2). Resident #2 did not receive the nebulizer treatments ordered on [DATE] until 8/17/10. The findings included: Resident #2 with [DIAGNOSES REDACTED]. Review of the Daily Skilled Nurses Notes revealed a note on 8/12/10 at 10:15 PM stating: "Resident noted to have cough (with) congestion. Notified MD." The physician saw the resident on 8/13/10 and wrote in his progress note that the resident was "... quite short of breath and feeling terrible. ..." A treatment plan was documented in the progress note including "Start [MEDICATION NAME] solution 2.5 mg/3mL (2.5 milligrams per 3 milliliters), (0.083%), 3 mL, Q 4 hrs. (every four hours) while awake x (times) 5 days, then prn (as needed for) wheeze. ..." Antibiotics, nasal oxygen, a chest x-ray, and a speech therapy consult were also ordered for suspected aspiration pneumonia. The 8/13/10 Daily Skilled Nurses Note at 6 PM documented that the resident was coughing but had no complaint of pain. He was resting in bed. The nurse's note documented that the physician wrote new orders for oxygen, nebulizer treatments, and a chest x-ray. The chest x-ray was done and no infiltrates were noted. Speech Therapy evaluated the resident and changed his diet. A swallow study was scheduled for 8/16/10. The nurse's note ended with "... No distress when eating supper. Will monitor." Review of the physician's orders [REDACTED]. "Chest x-ray Re: poss (possible) aspiration pneumonia "[MEDICATION NAME] 100 mg PO (by mouth) BID (two times a day) x 10 days, 1st dose STAT "[MEDICATION NAME] 500 mg PO BID x 10 days, 1st dose STAT "[MEDICATION NAME] 2.5mg/3mL via neb q 4 (hours) while awake x 1 week, then PRN "Oxygen 2 L/min (liters per minute) via nasal cannula" This order was signed by the physician … | 2014-01-01 | ||
| 10297 | 10297 | WILDEWOOD DOWNS NURSING AND REHABILITATION CENTER | 425385 | 1215 WILDEWOOD DOWNS CIRCLE | COLUMBIA | SC | 29223 | 2010-09-20 | 272 | D | 9EZH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the survey, based on record reviews, the facility failed to ensure that residents were comprehensively assessed related to a history of falls for 2 of 2 residents reviewed who had repeated falls (#1 and #3). Both residents had a history of [REDACTED]. The findings included: Resident #1 with [DIAGNOSES REDACTED]. No fractures were diagnosed at the hospital. The resident went to the facility for short term rehabilitation. She was discharged home on[DATE]. The admission nursing fall assessment showed a score of 20. A score above 10 indicated risk for falls. Review of the Resident Assessment Instrument (RAI) for 7/12/10 showed the resident had short and long term memory problems with moderately impaired decision making ability. The resident needed extensive assistance of one person for bed mobility, transfer, dressing, and bathing. She required total assistance for toilet use and hygiene. The resident was incontinent of bowel and bladder. A fall in the last 30 days was noted. Review of the Resident Assessment Protocol (RAP) notes revealed the resident was at risk for falls. "She is at risk for falls related to Hx (history of) falls and Dx ([DIAGNOSES REDACTED]. The note failed to provide any history of the resident's falls, and therefore there was no evaluation of any pattern or possible triggers for the falls. The RAP note did not evaluate the resident's internal or external risk factors. The resident fell three times while at the facility, 7/27/10, 7/28/10, and 8/22/10. One fall, the one on 7/28/10, resulted in a fractured distal right clavicle. Review of the medical record revealed the resident was independent and wanted to do for herself. She also participated in therapy with improving functional status. However, the facility failed to use this information to adapt to the resident's changing status in an effort to prevent accidents. There was no evidence of a comprehensive assessment of the resident's falls either on admission o… | 2014-01-01 | ||
| 10298 | 10298 | WILDEWOOD DOWNS NURSING AND REHABILITATION CENTER | 425385 | 1215 WILDEWOOD DOWNS CIRCLE | COLUMBIA | SC | 29223 | 2010-09-20 | 280 | G | 9EZH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the survey, based on record reviews, the facility failed to ensure that residents' care plans were periodically reviewed an updated to reflect changing status for 2 of 2 residents reviewed who had repeated falls (#1 and #3). The findings included: Resident #1 with [DIAGNOSES REDACTED]. The resident was hospitalized after a fall for evaluation of hip pain. No fractures were diagnosed at the hospital. The resident went to the facility for short term rehabilitation after hospitalization . She was discharged home on[DATE]. Review of the Resident Assessment Instrument (RAI) for 7/12/10 showed a fall in the last 30 days. Review of the Resident Assessment Protocol (RAP) noted revealed the resident was at risk for falls related to her history of falls. Review of the plan of care dated 7/15/10 showed a problem of risk for falls with interventions of: gather information about past falls; keep call light in reach; anticipate and meet needs; provide safe environment; physical therapy evaluation and treatment; adaptive equipment as needed; and proper footwear. The resident fell three times while at the facility. One of the falls resulted in a fractured distal right clavicle. Review of the care plan showed it was not updated to show the falls and no new interventions were planned to assist the resident in fall prevention. Resident #3 with [DIAGNOSES REDACTED]. An admission nursing assessment for falls revealed a score of 22, any score above 10 indicated a risk for falls. The facility physician's history and physical dated 7/22/10, the resident had had multiple falls. Review of the RAI of 7/25/10 showed no falls. Review of the RAP notes of 7/28/10 showed the resident triggered for falls related to daily use of an antidepressant. Review of the care plan dated 8/3/10 revealed a problem of "high risk for falls related to Hx (history of) falls, decreased mobility." Interventions included: gather information on past falls; be sure call light is in … | 2014-01-01 | ||
| 10299 | 10299 | WILDEWOOD DOWNS NURSING AND REHABILITATION CENTER | 425385 | 1215 WILDEWOOD DOWNS CIRCLE | COLUMBIA | SC | 29223 | 2010-09-20 | 323 | G | 9EZH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the survey, based on record reviews, the facility failed to ensure that residents received adequate supervision and assistance devices to prevent accidents for 2 of 2 residents reviewed who had repeated falls (#1 and #3). The findings included: Resident #1 with [DIAGNOSES REDACTED]. No fractures were diagnosed at the hospital. Resident #1 went to the facility for short term rehabilitation. Review of the admission nursing assessment showed a fall risk score of 20. A score above 10 indicated risk for falls. Review of the Resident Assessment Instrument (RAI) for 7/12/10 showed the resident had short and long term memory problems with moderately impaired decision making ability. The resident needed extensive assistance of one person for bed mobility, transfer, dressing, and bathing. She required total assistance for toilet use and hygiene. The resident was incontinent of bowel and bladder. A fall in the last 30 days was noted. Review of the Resident Assessment Protocol (RAP) noted revealed the resident was at risk for falls related to her history of falls. The note did not provide any history of the past falls. There was no evaluation of any pattern or triggers for the falls. Review of the plan of care dated 7/15/10 showed a problem of risk for falls with interventions of: gather information about past falls; keep call light in reach; anticipate and meet needs; provide safe environment; physical therapy evaluation and treatment; adaptive equipment as needed; and proper footwear. The resident fell three times while at the facility: 1. A Nurse's Note on 7/27/10 at 7 AM stated the resident was found lying on the floor in her bathroom. The resident could not explain how she got on the floor. A small skin tear on the left elbow resulted from the fall. There was no evidence the facility changed or added interventions to the resident's care plan after this fall. 2. On 7/28/10, at 7 PM, the Nurse ' s Note said her Certified Nursing Assistan… | 2014-01-01 | ||
| 10300 | 10300 | WILDEWOOD DOWNS NURSING AND REHABILITATION CENTER | 425385 | 1215 WILDEWOOD DOWNS CIRCLE | COLUMBIA | SC | 29223 | 2010-09-20 | 496 | D | 9EZH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the survey, based on review of a Certified Nursing Assistant's employee file and interview, the facility failed to ensure that information was sought from every State registry before allowing an individual to serve as a nurse aide for 1 of 1 employee file reviewed. The findings included: The employee file of a Certified Nursing Assistant (CNA) who was assigned to a resident who fell and was later diagnosed with [REDACTED]. The facility checked the South Carolina CNA Registry for information prior to hire, but failed to check with the Massachusetts CNA Registry. The Assistant Director of Nurses confirmed this after she spoke with Human Resources personnel. | 2014-01-01 | ||
| 5 | 5 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2018-03-01 | 550 | D | 0 | 1 | JK8711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews the facility failed to provide dignity and privacy for Resident # 41 by not covering the resident's catheter bag when it was in sight of other people. ( 1 of 2 residents observed with catheters) The findings included: The facility admitted Resident # 41 with [DIAGNOSES REDACTED]. On three days of the survey the resident was observed in bed in his/her room with the catheter tubing hanging uncovered on the side of the bed facing the door. The bag could be seen by anyone walking by the door or out in the dining area. Interview with the resident's spouse revealed the staff usually covered the bag but he/she had not seen the bag covered at all this week. Interview with Certified Nursing Assistant # 1 ( CNA) on 2/28/18 @ 10:15 AM revealed that the catheter bags were covered any time a resident was up or catheter bag was in view of other people to protect the privacy and dignity of the resident. When asked what he/she saw when he/she looked into this resident's room. He/she stated the catheter bag uncovered. The CNA confirmed the resident's privacy and dignity was not being protected. The CNA further stated, The cover was removed the other day and not replaced. There have not been any covers in the closet or in the cottage at all this week. The Licensed Practical Nurse #1 also responded that there were no covers in the cottage and that he/she would order some. | 2020-09-01 |
| 6 | 6 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2018-03-01 | 659 | D | 0 | 1 | JK8711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to provide care per the Care Plan for Resident #18, 1 of 7 sampled residents reviewed for Falls. Resident #18 was care planned for the bed to be in low position and to remove bed controls due to the resident being a high fall risk. Cross refer to F689 The findings included: The facility admitted Resident #21 with [DIAGNOSES REDACTED]. Resident #21 was observed in bed with the bed in normal position (not low) on 2/26/2018 at 10:59 AM, 2/27/2018 at 3:56 PM and 2/28/2018 at 3:06 PM. Record review of the Care Plan on 2/28/2018 at 3:23 PM, revealed a focus area indicating Resident #21 was at risk for fall related injuries. Interventions listed for the focus area were to keep the bed in lowest position and to remove the bed controls when the bed is in lowest position so the resident can't raise bed to a high position. In addition, the Care Plan indicated the resident was a high fall risk. During an observation and interview with Certified Nursing Assistant (CNA) #2 on 2/27/2018 at 3:58 PM, Resident #18 was observed in bed with the bed in normal position. In addition, the bed controls were observed on the bed, within reach of the resident. CNA #2 stated that the resident was care planned to have the bed low, but she/he did not like the bed in low position. CNA #2 stated that the resident can become very agitated when the bed is in low position and will crawl out of the bed and then be found on the floor in the room. CNA #2 stated that when the bed is in normal position the resident is calm and content. Upon leaving the room, CNA #2 left the bed in normal position with the bed controls within reach of the resident. During an interview with Licensed Practical Nurse (LPN) #5 on 2/28/2017 at 3:06 PM, LPN #5 verbalized fall prevention interventions for Resident #18, including keeping the bed in lowest position. In addition, LPN #5 stated the resident is cognitively intact enough to op… | 2020-09-01 |
| 7 | 7 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2018-03-01 | 679 | D | 0 | 1 | JK8711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview, the facility failed to provide a structured program of activities for 1 of 1 sampled resident reviewed/triggered for activities. Resident #82 was observed in bed in his/her room with no structured activities in progress. The findings included: The facility admitted Resident #82 with [DIAGNOSES REDACTED]. Observations on 2/26/18 from 10 AM to 1 PM revealed Resident in room in bed with no structured program of activities provided. A record review on 2/26/18 at approximately 11:28 PM revealed documentation on a physician's capacity statement that Resident #82 was admitted on [DATE] and physician's cumulative orders that the resident was admitted on [DATE]. A social note dated 2/06/18 indicated the resident scored 15 cognition indicating cognition was intact and resident able to voice needs. Further record review revealed no activity evaluation was completed and there was no documentation on the paper charting or electronic record to indicate a structured program of activities were provided. An observation on 2/27/18 at approximately 11:33 PM to 1 PM revealed the resident in his/her room with no structured program of activities in place. A nurse's noted dated 2/06/18 indicated Resident #82 refused medication and verbally expressed he/she wanted to die. An interview on 2/28/18 at approximately 8:30 AM with Social Services Assistant #1 revealed the resident received psych services on 2/13/18. A review of the psych results revealed the resident depressed with a recommendation for staff to encourage residents to participate in activities. An interview on 2/28/18 at approximately 10:15 AM with the Activity Director (AD) confirmed the activity assessment/evaluation was not complete and there was no documentation in the medical record (paper/electronic) of activities being provided. | 2020-09-01 |
| 8 | 8 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2018-03-01 | 684 | D | 0 | 1 | JK8711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide the necessary care and services for 1 of 6 residents reviewed for unnecessary medications. Resident #115's elevated blood sugars were not reported to the physician as ordered. The findings included: Resident #115 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. Review of Medication Administration Records for Resident #115 on 2/28/18 at approximately 11:12 AM revealed the resident had an elevated blood sugar of 410 on 2/23/18. Review of Resident #115's Progress Notes on 2/28/18 at approximately 11:50 AM revealed no documentation that the physician was notified of elevated blood sugar on 2/23/18. Interview with Director of Nursing (DON) on 2/28/18 at approximately 1:26 PM confirmed that there was no documentation that the elevated blood sugar on 2/23/18 was relayed to the physician. | 2020-09-01 |
| 9 | 9 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2018-03-01 | 689 | D | 0 | 1 | JK8711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to implement fall prevention interventions for Resident #18, 1 of 7 sampled residents reviewed for falls. The facility failed to maintain the resident's bed in the lowest position and remove the bed controls per the Care Plan. Resident #18 has a history of multiple falls. Cross refer to F659 The findings included: The facility admitted Resident #21 with [DIAGNOSES REDACTED]. Resident #21 was observed in bed with the bed in normal position (not low) on 2/26/2018 at 10:59 AM, 2/27/2018 at 3:56 PM and 2/28/2018 at 3:06 PM. Record review of the Nurse's Notes on 2/28/2018 at 2:23 PM revealed that the resident had unwitnessed falls in her/his room on 10/30/2017, 11/25/2017, 12/27/2017 and 2/9/2018. In each case the resident was found on the floor near her/his bed. Record review of the Care Plan on 2/28/2018 at 3:23 PM, revealed a focus area indicating Resident #21 was at risk for fall related injuries. Interventions listed for the focus area were to keep the bed in lowest position and to remove the bed controls when the bed is in lowest position so the resident can't raise bed to a high position. In addition, the Care Plan indicated the resident was a high fall risk. Review of the Certified Nursing Assistant task sheet for Resident #18 on 3/1/2018 at 10:25 AM, revealed a task to keep the resident's bed in low position. Removing the resident's bed controls was not listed on the task sheet. During an observation and interview with Certified Nursing Assistant (CNA) #2 on 2/27/2018 at 3:58 PM, Resident #18 was observed in bed with the bed in normal position. In addition, the bed controls were observed on the bed, within reach of the resident. CNA #2 stated that the resident was care planned to have the bed low, but she/he did not like the bed in low position. CNA #2 stated that the resident can become very agitated when the bed is in low position and will crawl out of the bed and th… | 2020-09-01 |
| 10 | 10 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2018-03-01 | 732 | C | 0 | 1 | JK8711 | Based on observations, interviews and review of the facility's posting information, the facility failed to complete daily posting information that addressed nursing staff per shift. The posting did not identify whether nurse was registered or licensed and certified nursing to resident coverage was not included. 12 of 12 cottages. The findings included: During initial tour on 2/26/18 of the Forsythia Cottage at approximately 9:30 AM and the Rose Cottage at approximately 9:38 AM review of the hand written staff posting had no documentation of staff coverage related to the second shift (7 PM - 7:30 AM). Random observation on 2/27/18 at approximately 9 AM of the Rose Cottage and 9:30 AM of the Forsythia Cottage revealed the hand written staff posting noted on the wall with no second shift (7 PM - 7:30 AM) staff posted. An interview on 2/27/18 at approximately 12:15 PM with the Director of Nursing (DON) and Facility Administrator confirmed the second shift staff documentation was not posted for any of the cottages until the second shift staff arrived to the facility. Further review of hand written staff postings on the cottage revealed staff posting for 2/24/18 (Saturday) Rose Cottage first shift (7 AM - 7:30 PM) had no documentation of nursing staff coverage and the hand written on 2/25/18 (Sunday) Rose Cottage had no first shift staff coverage. The hand written staff posting for 2/25/18 (Sunday) Forsythia Cottage had no documentation of staff coverage. Review of the hand written posting indicated staff worked 12 and half hours shifts. During the survey, two family members expressed concerns about lack of evening and weekend staff coverage. During group interview on 2/27/18 at approximately 11 AM three of 5 residents who attend resident council regularly expressed concerns about staff coverage at nights and on weekends. A review of a computerized accounting of staff coverage for the past three months on 3/01/18 at 8:40 AM revealed a listing of staff coverage that was not accessible to residents/visitors/families. The… | 2020-09-01 |
| 11 | 11 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2018-03-01 | 745 | D | 0 | 1 | JK8711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the communication sheet and interview, the facility failed to arrange and provide transportation to a medical appointment for Resident #121, 1 of 1 sampled resident reviewed for medically-related social services. Resident #121 missed a doctor's appointment due to the facility not arranging transportation. The findings included: The facility admitted Resident #121 with [DIAGNOSES REDACTED]. During an interview with Resident #121 and family member on 2/26/2018 at 10:00 AM, Resident #121 stated she/he had an upcoming appointment with his/her Oncologist on 2/28/2018. The family member stated she/he was concerned because the facility had provided no confirmation of transportation to the appointment. Resident #121 produced a form from his doctor with a list of upcoming appointments, including appointments on 2/28/2018 and 3/7/2018. During an interview with Licensed Practical Nurse (LPN) #3 on 2/26/2018 at 10:13 AM, LPN #3 was made aware of Resident #121 's and the family member's concerns related to the upcoming appointment on 2/28/2018. LPN #3 stated she/he would take care of the arrangements. On 2/28/2018 at 12:12 PM, LPN #4 was observed talking to another staff member about Resident #121's Oncology appointment. The staff member told LPN #4 that the Oncologist's office was calling asking why Resident #121 had not shown up for his/her appointment. LPN #4 then called the transporter (person in charge of setting up transportation). After the call, LPN #4 was interviewed and stated that transportation had not been arranged for the resident's appointment. LPN #4 stated transportation had been set up for an appointment on 3/7/2018, but not for today. During an interview with the Director of Nursing on 2/28/2018 at 2:00 PM, the DON confirmed that transportation had not been set up for the resident's appointment today. The DON stated LPN #3 reported to her/him that she/he called the transporter on 2/26 to see if transportation had been… | 2020-09-01 |
| 12 | 12 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2018-03-01 | 758 | D | 0 | 1 | JK8711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to monitor antipsychotic usage for 1 of 6 residents reviewed for unnecessary medications. Resident #115 was on antipsychotics and the facility failed to monitor him/her for side effects, behaviors, and nonpharmaceutical interventions. The findings included: Resident #115 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #115's Medication Administration Record [REDACTED]. Interview with the Director of Nursing (DON) on 2/28/18 at approximately 12:54 PM revealed the order for antipsychotic monitoring was discontinued by the physician. The DON was unable to clarify why the order had been discontinued. Interview with the DON on 2/28/18 at approximately 1:26 PM revealed the facility had resumed monitoring for antipsychotic medications. | 2020-09-01 |
| 13 | 13 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2018-03-01 | 842 | D | 0 | 1 | JK8711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to accurately document a medical record (paper/electronic) for 1 of 42 sampled residents reviewed for advanced directives and clinical accuracy. Resident #82 paper charting was noted with full size red sheet of paper that indicated Do Not Resuscitate (DNR) and the electronic documentation indicated Cardiopulmonary Resuscitation (CPR). There was an inconsistency in the resident's admitted . The findings included: The facility admitted Resident #82 with [DIAGNOSES REDACTED]. A review of the paper charting and electronic charting on [DATE] at approximately 11:28 AM revealed the resident's chart for advanced directive was coded as DNR and CPR. The paper charting was noted with a red sheet of paper that indicated DNR. The electronic record indicated the resident's advance directive was CPR (full code). Further review of the medical record review that one physician's signed resident's inability to consent on [DATE] and the second physician signed the inability to consent on [DATE]. The decisional capacity forms indicated Resident #82 was admitted on [DATE] and the Cumulative physician's orders [REDACTED]. An interview on [DATE] at approximately 12:09 PM with Licensed Practical Nurse (LPN) #2 confirmed the findings that the paper chart indicated DNR and the computer documentation was CPR. | 2020-09-01 |
| 14 | 14 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2019-05-16 | 550 | D | 0 | 1 | Y5WG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interview, the facility failed to ensure that residents were treated with respect and dignity in three of 12 Cottages observed. Staff and/or contractor were observed entering residents' rooms without knocking. (Forsythia, Dogwood and Azalea) The findings included: An observation in the Forsythia Cottage on 5/13/19 at approximately 11:30 AM revealed Licensed Practical Nurse (LPN) #1 entering Resident #367 room without knocking. The resident was observed sitting in a wheelchair in his/her room. During an interview on 5/13/19 at approximately 11:33 AM with LPN #1 confirmed the observation. LPN #1 then smiled and knocked on the resident bedside table and playfully stated I have knocked now. A random observation in the Dogwood Cottage on 5/13/19 at approximately 3:13 PM revealed Activity staff entering room [ROOM NUMBER] without knocking. The resident was in the room in bed when the staff member entered the room. During an interview on 5/13/19 at approximately 3:18 PM with the Activity staff confirmed the observation. The Activity staff stated he/she does not generally knock on the resident's door if the door is opened and the resident is looking out toward the door. A random observation in the Azalea Cottage on 5/14/19 at approximately 12:05 PM revealed a nurse entering room [ROOM NUMBER] without knocking. The resident was in the room in bed. A random observation in the Azalea Cottage on 5/14/19 at approximately 12:21 PM revealed someone testing the alarms entering multiple residents' rooms without knocking. During an interview on 5/14/19 at approximately 12:25 PM revealed the alarm tester to be an Outside Fire Contractor who was entering the resident's rooms without knocking. | 2020-09-01 |
| 15 | 15 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2019-05-16 | 565 | E | 0 | 1 | Y5WG11 | Based on interviews and review of the Resident Council Minutes, the facility failed to ensure residents grievance were addressed related to staff being accessible in the cottages. Eight of eight group members and four months of resident council minutes. The findings included: During the agency group interview on 5/14/19 at approximately 10:32 AM eight of eight residents deemed alert, oriented and interview-able by the facility expressed concerns about staff being accessible in the cottages when needed. One resident stated that it takes several hours to see a nurse when needed because there may be one nurse at times who was responsible for rotating between three cottages. Another resident agreed that it takes staff a long time to address needs because staff rotate to other cottages. The resident who expressed concerns about one nurse covering three cottages stated he/she was not sure if one certified nursing aide had to cover three cottages as well. The residents stated they have addressed their concerns in resident council meetings. A review of the resident council minutes on 5/14/19 revealed at the 4/25/19 meeting there were concerns of getting medicine late due to nurse being in another cottage, certified nursing aides (CNA) on cells phone and certified nursing aides cutting off call lights saying they will return, and they do not return. The 3/27/19 resident meetings indicated medication was still being provided late, there are still issues with the certified nursing aides and staff not available to answer phones at night when family members are trying to contact the resident. The 2/28/19 resident meeting indicated concerns with late medications, CNA on cell phones. The (MONTH) 2019 minutes indicated concerns with late medications, cottages being un-staffed at night and CNAs telling residents they are alone in the cottages and unable to answer call lights. During an interview on 5/16/19 at approximately 8:16 AM with the Administrator revealed he/she was aware of the residents' concerns regarding staffing and t… | 2020-09-01 |
| 19 | 19 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2019-05-16 | 725 | D | 0 | 1 | Y5WG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide sufficient staffing for 2 of 12 cottages. Staff and residents expressed that the structure and layout of the cottages along with the insufficient staffing led to long wait times and inadequate care of residents. The findings included: Brushy Creek Rehabilitation and Healthcare Center consists of 12 cottages each with 12 beds. The only way to move between cottages is to traverse outside. Review of Grievance Log for Resident #67 on 5/15/19 at approximately 12 PM revealed that on 4/4/19 at approximately 2 PM the resident had rung his/her call light for assistance and walked away. The resident changed his/her own brief and filed a grievance. Review of Resident Council Minutes on 5/15/19 at approximately 12 PM revealed the following: 1. (MONTH) concerns expressed regarding CNA staffing 2. (MONTH) concerns regarding lack of CNAs in nurses and cottages; CNAs continue to tell the residents they are alone in the cottage and thus unable to answer the call button 3. (MONTH) concerns regarding nurses doing a good job but needed more help; CNAs are being split between cottages and care is limited at times and not enough CNAs for residents During an interview with Certified Nursing Aide (CNA) #1 on 5/15/19 at approximately 3 PM revealed during night shifts there often may be just one staff member (CNA) in a building because the nurse is attending to another cottage. During an interview with Licensed [MEDICATION NAME] Nurse (LPN) #2 on 5/16/19 at approximately 9 AM revealed the following: 1. Sometimes during the night shift residents may fall because the CNA is busy with another resident in the cottage while the nurse is in another cottage and unable to assist. 2. During night shift, when two staff members are required for care s/he stated, If the nurse has two cottages they're called over. If they have three cottages they're called over, but it may take longer. 3. LPN #2 stated she has exp… | 2020-09-01 |
| 20 | 20 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2019-05-16 | 812 | E | 0 | 1 | Y5WG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and policy review, the facility failed to ensure that food was stored, prepared and distributed in an appropriate manner for 5 of 12 Cottages observed for kitchen services. Holly, Magnolia, and Rose Cottages had expired food and foods that were opened with no open date. Magnolia and Rose Cottages were observed with resident's personal food in the refrigerator used by the cook which was against facility policy. The Dogwood Cottage Kitchen had staff preparing meals with facial hair uncovered (thick mustache). The Azalea Cottage Kitchen had staff preparing meals with large trash can with no lid available. The findings included: During the initial tour of Holly Cottage with the Registered Dietitian (RD) on [DATE] at approximately 10:10 AM, butter was observed in the freezer with an expiration date of [DATE]. The expiration date was verified by the RD at the time of the observation. During the initial tour of Magnolia Cottage with the RD on [DATE] at approximately 10:40 AM, Lemon juice was observed in the kitchen area with an expiration date of [DATE]. Also, during the tour, cooking spray, granulated garlic, and ground cinnamon were observed in the kitchen area without dates opened for use. As the tour continued, Paprika had an opened-on date of [DATE], steak seasoning had an opened-on date of [DATE], basil had an opened-on date of [DATE] and vanilla extract had an opened-on date of [DATE]. The expiration date of the lemon juice was verified by the RD at the time of observation. The lack of opened-on dates for the cooking spray, granulated garlic, and ground cinnamon was verified by the RD at the time of observation. When asked about the older opened-on dates, the RD stated that the items should have been thrown out after a year or at expiration. A resident's personal food was observed in the kitchen refrigerator of Magnolia Cottage. This was verified by the RD at the time of observation. During the initial tour … | 2020-09-01 |
| 25 | 25 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2016-12-01 | 282 | D | 0 | 1 | OHU211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to follow the nutrition care plan for 1 of 1 sampled resident for hospice. Dietary approaches for a low fiber diet with ground meat and nectar-thickened liquids was not followed for Resident #265. The findings included: The facility admitted Resident #265 with [DIAGNOSES REDACTED]. Review of nutrition care plan on 11/29/2016 revealed approaches for a low fiber diet with ground meat and nectar-thickened liquids. Record review on 11/29/2016 revealed Physicians Orders for low fiber diet with ground meat and nectar liquids with no straws. Review on 11/29/2016 of nutrition care plan revealed approaches for a low fiber diet with ground meat and nectar-thickened liquids. Observation on 11/29/2016 at 12:40 PM revealed that Resident #265 was served a wheat roll, chopped ham with gravy, mashed potatoes, mixed vegetables (peas, carrots, and lima beans), peaches, and nectar-thickened liquids. Certified Nursing Assistant (CNA) #2 was assisting with feeding the Resident and confirmed what was on the Residents tray. Observation on 11/30/2016 at 1:03 PM revealed Resident #265 was served rice, squash, coconut cake, nectar-thickened tea, and a white roll. CNA #1 was assisting with feeding the Resident and confirmed what was on the Residents tray. During an interview on 11/30/2016 at 1:15 PM CNA #1 pointed out dietary instructions for a low fiber diet for Resident #265 located in a notebook in the dining area. Dietary instructions included that the Resident was not to receive all beans, peas, whole wheat products, and coconut. | 2020-09-01 |
| 26 | 26 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2016-12-01 | 309 | D | 0 | 1 | OHU211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure integration of Hospice and facility services to provide continuity of care for 1 of 1 sampled resident reviewed for Hospice. Complete documentation could not be found in Resident #265's medical record for Hospice services provided and there was no evidence of communication between Hospice and the facility to establish an agreed upon/coordinated plan of care. The findings include: The facility admitted Resident #265 with [DIAGNOSES REDACTED]. Review on 11/29/2016 of Hospice documentation, kept in a separate notebook from the medical chart, revealed the Hospice Care Plan for Nurse visits weekly, Aide visits three times a week, Chaplin visits once a month, and Social Worker visits once a month. Record review on 11/29/2016 revealed incomplete documentation for Hospice Aide visits between 08/23/2016 and 11/17/2016, incomplete documentation for Chaplin visits for (MONTH) (YEAR), and incomplete documentation for Social Worker visits for (MONTH) (YEAR). During an interview on 11/29/2016 at 4:04 PM the Director of Social Services verified missing Hospice documentation. The Director of Social Services verified that at the time of services, Hospice notes were to be documented in Resident #265 ' s Hospice record. Review on 11/29/2016 of the Skilled Nursing Facility Service Agreement with the Hospice provider verified each party is responsible for documenting such communication in its respective clinical records to ensure that the need of hospice patients are met twenty-four hours per day. During an interview on 11/30/2016 at 12:15 PM revealed no evidence of care plan integration. Registered Nurse (RN) #1 verified that the facility staff did not review the Hospice care plan and that Hospice was only included in the facility care plan interventions under nutrition. RN #1 verified that Hospice services were not included in the interdisciplinary care plan and that Hospice did not attend the … | 2020-09-01 |
| 27 | 27 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2016-12-01 | 323 | D | 0 | 1 | OHU211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to ensure that the planned fall prevention measures were in place and/or changed/added to prevent reoccurrence and minimize potential injury for 1 of 2 sampled Residents for accidents. The findings included: The facility admitted Resident #265 with [DIAGNOSES REDACTED]. Review of fall risk assessment on 11/28/2016 revealed that Resident #265 was a high fall risk. Fall assessment dates and scores; 08/05/2016 score 10, 08/25/2016 score 10, 11/16/16 score 16. Review of Nurses notes, incident reports, and care plan revealed that Resident #265 had falls on the following dates: 9/28/16- Fall in bedroom. My knees are red but my ROM is WNL. Please place laser alarm on floor for poor safety awareness. 10/13/16- I lost balance in bathroom going into room CNA lowered me to floor. 10/23/16- Continue bed/chair alarms non skid socks. 10/28/16- Fall in bedroom Laser alarm by bed, re-educate on not turning off alarms and calling for assistance with any transfers. Nurses notes dated 10/28/2016 stated alarm not sounding r/t elder shuts it off. 11/8/16- I slid down to floor when trying to transfer self from WC to chair; no injury noted. 11/16/16- Slid out of bed onto floor with no injury noted. Implement fall mat, ensure alarms are functioning Q shift. 11/21/16- New alarms to bed and chair with no turn off switch. Observation on 11/28/2016 at 12:00 PM revealed no fall mat in Resident #265 ' s room, bed alarm with turn off switch, and laser alarm was turned off. The resident was lying in bed. Observation on 11/29/2016 at 12:35 PM revealed no fall mat in Resident #265 ' s room, and bed alarm with turn off switch. The resident was lying in bed. Observation on 11/30/2016 at 12:00 PM revealed no fall mat in resident #265 ' s room, bed alarm with turn off switch, and wheel chair alarm with turn off switch. Resident #265 was sitting in wheelchair in common area. The Director of Nursing (DON) and Re… | 2020-09-01 |
| 28 | 28 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2016-12-01 | 329 | D | 0 | 1 | OHU211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that 1 of 1 sampled resident reviewed for Hospice had documented clinical reason for medication administration and/or were monitored for effectiveness of medication for Resident #265. Resident #265 was prescribed medication for which there was no documented evidence of clinical need. The findings included: The facility admitted Resident #265 with [DIAGNOSES REDACTED]. Record review on 11/30/2016 at 9:30 AM revealed physician's orders [REDACTED]. 4 hours , [MEDICATION NAME] 0.5 mg tablet one tablet every 6 hours as needed , and Vitamin D3 1,000 units tablet 2 tablets daily . Continued review revealed no clinical indication for Vitamin D3 to treat the Resident's assessed condition. There were no laboratory reports to substantiate Vitamin D3 deficiencies or reason for continued use. No documented evaluation of the underlying cause of behaviors prior to the start of psychiatric medications. No pain measurement tool documented prior to [MEDICATION NAME] administration and after administration to measure effectiveness. No documentation of behaviors prior to administrating [MEDICATION NAME] and [MEDICATION NAME]. Review of the Medication Administration Records (MARs) revealed that from 09/01/2016 through 11/27/2016 Resident #265 received 18 doses of as needed [MEDICATION NAME] 0.5mg tab, 7 doses of as needed [MEDICATION NAME] 5mg/ml 0.5 ml, and 100 doses of as needed [MEDICATION NAME] 50 mg tab. Review of Progress Notes and MARs revealed that no reason for administration and/or effectiveness of PRN (as needed) medication were documented. Continued review revealed no evidence of evaluation of underlying cause of behaviors prior to starting routine psychiatric medications. During an interview on 11/30/2016 at 9:40 AM with the Director of Nursing (DON) information was requested to provide clinical reasons for the use of Vitamin D3. The DON stated they had reviewed the medical records a… | 2020-09-01 |
| 29 | 29 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2016-12-01 | 367 | D | 0 | 1 | OHU211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to assure that 1 of 1 sampled Residents reviewed for Hospice received the diet that was prescribed by the Physician. Resident #265 ' s physician's order [REDACTED]. The findings included: The facility admitted Resident #265 with [DIAGNOSES REDACTED]. Record review on 11/29/2016 revealed Physicians Orders for low fiber diet with ground meat and nectar liquids with no straws. Review on 11/29/2016 of nutrition care plan revealed approaches for a low fiber diet with ground meat and nectar-thickened liquids. Observation on 11/29/2016 at 12:40 PM revealed that Resident #265 was served a wheat roll, chopped ham with gravy, mashed potatoes, mixed vegetables (peas, carrots, and lima beans), peaches, and nectar-thickened liquids. Certified Nursing Assistant (CNA) #2 was assisting with feeding the Resident and confirmed what was on the Residents tray. Observation on 11/30/2016 at 1:03 PM revealed Resident #265 was served rice, squash, coconut cake, nectar-thickened tea, and a white roll. CNA #1 was assisting with feeding the Resident and confirmed what was on the Residents tray. During an interview on 11/30/2016 at 1:15 PM CNA #1 pointed out dietary instructions for a low fiber diet for Resident #265 located in a notebook in the dining area. Dietary instructions included that the Resident was not to receive all beans, peas, whole wheat products, and coconut. | 2020-09-01 |
| 30 | 30 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2016-12-01 | 371 | E | 0 | 1 | OHU211 | Based on observation and interview, the facility failed to assure foods were held at appropriate temperatures prior to serving in 2 of 2 cottages. In the Dogwood cottage, staff failed to calibrate the thermometer. In the Azalea cottage staff served foods that had been held at improper temperatures. Observation of the Azalea cottage at approximately 12:10 to 12:20 PM on 11/29/16 revealed Cook #1 measured the temperature of peaches, a cold food item, to be 49 degrees Fahrenheit. The cook did not alert the Certified Nursing Assistant (CNA) #3, who was serving, that the cold food item did not reach appropriate temperatures. Observation of the Azalea cottage at approximately 12:50 on 11/29/16 revealed that during the meal, the cold food item was held on the table without refrigeration or insulation. When CNA #3 plated four helpings of peaches and began serving, she was stopped and informed that they were not held at appropriate temperatures. Observation on 11/28/16 at 12:03 PM revealed Certified Nursing Assistant (CAN) #2 and Licensed Practical Nurse (LPN) #1 starting to plate lunch without taking food temperatures. When asked if food temperatures had been taken the staff were unaware that this had to be done. Observation on 11/28/2016 at 12:10 PM Dietary Aide #1 checked the temperature of the fish, without calibrating the thermometer. When asked Dietary Aide #1 stated that she/he calibrated the thermometer by placing it in ice water. When asked what temperature, the thermometer should be calibrated to she/he stated till it reads 0 degrees Fahrenheit. Cook #1 stated that after the thermometer was placed in ice water, it should read 32 degrees Fahrenheit. Observation on 11/28/2016 at 12:17 PM, Dietary Aide #1 filled a cup with ice and water and inserted the thermometer. When checked by Cook #1 the thermometer read 42 degrees Fahrenheit. She/He stated that the thermometer was calibrated earlier in the day and read 41.5 degrees Fahrenheit. Cook #1 stated that the Certified Dietary Manager (CDM) would need to be contacted… | 2020-09-01 |
| 33 | 33 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2017-07-26 | 281 | E | 0 | 1 | LLSR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a random observation, record reviews and interviews the Facility failed to follow procedures to assure that Resident 62 was free of significant medication errors related to medicine to which allergic. The Facility admitted Resident 62 on 1/27/11 with [DIAGNOSES REDACTED]. (cross reference F333 and F425) The findings include: On 7/23/17 at approximately 1:57 PM during chart review it was noted that Resident 62 had a physician's order for [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME]-[MEDICATION NAME]) Ophthalmic Ointment to be instilled inside lower lids of both eyes at bedtime and that Resident 62 was listed as allergic to [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME]-[MEDICATION NAME]). [MEDICATION NAME] and [MEDICATION NAME] are common ingredients in both [MEDICATION NAME] and [MEDICATION NAME]. On 7/23/17 at approximately 2:05 PM LPN (Licensed Practical Nurse) # 2 stated that the Resident was receiving [MEDICATION NAME] for red eyes with itching. (cross reference F333 and F425) On 7/24/17 at approximately 3:10 PM to 5:00 PM record reviews revealed the following: -Resident 62 was admitted with a listed allergy to [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME]-[MEDICATION NAME]) and multiple doses of [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME]-[MEDICATION NAME]) Ophthalmic Ointment were administered to Resident 62 between 1/27/11 and 7/24/17. (refer to F333) -A review of the Facility Policy and Procedures IB1: PRESCRIBER MEDICATION ORDERS states Any dose or order that appears inappropriate considering the resident's age, condition, allergies [REDACTED]. and The prescriber is contacted to verify or clarify an order (e.g. (for example) when the resident has allergies [REDACTED]. The DON acknowledged in an interview on 7/24/17 at approximately 5:15 PM that the facility, pharmacy and nursing staff had failed to prevent Resident 62 from receiving multiple doses of [MEDICATION NAME] ([MEDICATION NAME]-… | 2020-09-01 |
| 34 | 34 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2017-07-26 | 333 | E | 0 | 1 | LLSR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a random observation, record reviews and interviews the Facility failed to assure that Resident 62 was free of significant medication errors related to medicine to which allergic. The Facility admitted Resident 62 on 1/27/11 with [DIAGNOSES REDACTED]. (cross reference F281 and F425) The findings include: On 7/23/17 at approximately 1:57 PM during chart review it was noted that Resident 62 had a physicians order for [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME]-[MEDICATION NAME]) Ophthalmic Ointment to be instilled inside lower lids of both eyes at bedtime and that Resident 62 was listed as allergic to [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME]-[MEDICATION NAME]). [MEDICATION NAME] and [MEDICATION NAME] are common ingredients in both [MEDICATION NAME] and [MEDICATION NAME]. On 7/23/17 at approximately 2:05 PM LPN (Licensed Practical Nurse) # 2 stated that the Resident was receiving [MEDICATION NAME] for red eyes with itching. On 7/24/17 at approximately 3:10 PM to 5:00 PM record reviews revealed the following: -Physician order dated 1/27/12 (date of admission) listed [MEDICATION NAME] as an allergy. -Physician order dated 6/11/12 stated D/C (discontinue) [MEDICATION NAME] -Physicians order dated 8/23/12 stated [MEDICATION NAME] ung (ointment) sig (give) instill inside lower eye lids ou (both eyes) q PM (every evening) x 7 days and then use PRN (as needed) for itching. - MAR (medication administration record) review January- December, 2012 showed approximately 61 scheduled plus PRN doses of [MEDICATION NAME] Ophthalmic Ointment had been administered -Physician order dated 6/3/13 stated Add allergy to [MEDICATION NAME] and tenoretic. -MAR review [REDACTED]. -January - September, 2013 MAR indicated [REDACTED]. -Physician order dated 9/17/13 stated change [MEDICATION NAME] Oint (ointment) to q hs (every bedtime) -MAR review [REDACTED]. -MAR review [REDACTED]. -MAR review [REDACTED]. -Consultant Pharmacist Report dated… | 2020-09-01 |
| 36 | 36 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2017-07-26 | 425 | E | 0 | 1 | LLSR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a random observation, record reviews and interviews the Pharmacy failed to follow procedures to assure that Resident 62 was free of significant medication errors related to medicine to which allergic. The Facility admitted Resident 62 on 1/27/11 with [DIAGNOSES REDACTED]. (cross reference F281 and F333) The findings include: On 7/23/17 at approximately 1:57 PM during chart review it was noted that Resident 62 had a physicians order for Maxitrol (Neomycin-Polymyxin-Dexamethasone) Ophthalmic Ointment to be instilled inside lower lids of both eyes at bedtime and that Resident 62 was listed as allergic to Neosporin (Neomycin-Bacitracin-Polymyxin). Neomycin and Polymyxin are common ingredients in both Maxitrol and Neosporin. On 7/23/17 at approximately 2:05 PM LPN (Licensed Practical Nurse) # 2 stated that the Resident was receiving Maxitrol for red eyes with itching. On 7/24/17 at approximately 3:10 PM to 5:00 PM record reviews revealed the following: -Resident 62 was admitted with a listed allergy to Neosporin (Neomycin-Bacitracin-Polymyxin) and multiple doses of Maxitrol (Neomycin-Polymyxin-Dexamethasone) Ophthalmic Ointment were administered to Resident 62 between 1/27/11 and 7/24/17. (refer to F333) -A review of the Facility Policy and Procedures IB1: PRESCRIBER MEDICATION ORDERS states Any dose or order that appears inappropriate considering the resident's age, condition, allergies [REDACTED]. and The prescriber is contacted to verify or clarify an order (e.g. (for example) when the resident has allergies [REDACTED]. The DON acknowledged in an interview on 7/24/17 at approximately 5:15 PM that the facility, pharmacy and nursing staff had failed to prevent Resident 62 from receiving multiple doses of Maxitrol (Neomycin-Polymyxin-Dexamethasone) Ophthalmic Ointment to which Resident 62 was listed as allergic to Neosporin (Neomycin-Bacitracin-Polymyxin). The Consultant Pharmacist verified in an interview on 7/25/17 at approximately 12:0… | 2020-09-01 |
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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 );