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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 101 | 101 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2017-08-16 | 225 | G | 1 | 0 | MGP911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, the facility failed to ensure that all alleged violations involving abuse or neglect were reported immediately, but not later than 2 hours after the allegation was made. The facility also failed to have evidence that all alleged violations were thoroughly investigated. Resident #1 was noted to have complaints of pain on 8/1/17 and the allegation of neglect was not reported to the State Agency until 8/3/17. Review of the facility's investigation revealed statements from three staff members, the Registered Nurse (RN) Supervisor on the unit (RN #1), the wound care nurse (RN #3) and Certified Nursing Assistant (CNA) #1. It was noted on the Daily Assignment Sheet for 8/1/17 that CNA #1 was not assigned to Resident #1. There were no statements from the staff assigned to care for the resident on the days surrounding the incident. One of two residents reviewed for reportable incidents. The findings included: The facility reported an allegation of neglect to the State Agency for Resident #1 by CNA #1 on 8/3/17. Review of the facility's Five-Day Follow-Up Report dated 8/8/17 indicated after investigation, Resident #1 was found to have right knee fracture from attempted transfer to wheelchair without lift or two-person assist. The Initial 24-hour Report dated 8/3/17 revealed Resident #1 stated that while being pivoted by CNA #1, the CNA assisted him/her to slide to the floor and at that time his/her right knee popped. Further review of the medical record revealed the Annual Minimum Data Set ((MDS) dated [DATE] coded Resident #1 as having a Brief Interview for Mental Status score of 6. The Quarterly MDS dated [DATE] coded the resident as having a Brief Interview for Mental Status score of 5. The Quarterly MDS coded Resident #1 as totally dependent for transfers. Review of the care plan revealed resident needs moderate to max assistance with ADLs was identified as a problem area. Interventions and approac… | 2020-09-01 |
| 102 | 102 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2017-08-16 | 309 | G | 1 | 0 | MGP911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Resident #1 was noted to have complaints of pain on 8/1/17 and there was no documentation that the resident was monitored for pain. Resident #1 was found to have a right femur fracture on 8/3/17. One of three residents reviewed for fracture. The findings included: The facility reported an allegation of neglect to the State Agency for Resident #1 by Certified Nursing Assistant (CAN) #1 on 8/3/17. Review of the facility's Five-Day Follow-Up Report dated 8/8/17 indicated after investigation, Resident #1 was found to have right knee fracture from attempted transfer to wheelchair without lift or two-person assist. The Initial 24-hour Report dated 8/3/17 revealed Resident #1 stated that while being pivoted by CNA #1, the CNA assisted him/her to slide to the floor and at that time his/her right knee popped. Further review of the medical record revealed the Annual Minimum Data Set ((MDS) dated [DATE] coded Resident #1 as having a Brief Interview for Mental Status score of 6. The Quarterly MDS dated [DATE] coded the resident as having a Brief Interview for Mental Status score of 5. The Quarterly MDS coded Resident #1 as totally dependent for transfers. Review of the care plan revealed resident needs moderate to max assistance with ADLs was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included resident transfers with assist of mechanical lift. Review of the Nurses' Progress Notes dated 8/2/17 indicated called to room by CNA to look at resident's leg. Right leg is swollen. States had pain in leg while receiving peri-care. RN supervisor notified who also looked at leg. Resident's socks removed and legs elevated. The previous note was dated 7/21/17 and noted week… | 2020-09-01 |
| 103 | 103 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2017-08-16 | 496 | D | 1 | 0 | MGP911 | > Based on review of facility files and interview, the facility failed to ensure that information from every State registry was received before allowing an individual to serve as a nurse aide. Certified Nurse Aide (CNA) #1 started working for the facility prior to his/her South [NAME]ina Nurse Aide Registry Verification being checked. One of one nurse aides reviewed. The findings included: The facility reported an allegation of neglect to the State Agency for Resident #1 by CNA #1. Review of the facility's Five-Day Follow-Up Report dated 8/8/17 indicated after investigation, Resident #1 was found to have a right knee fracture from attempted transfer to wheelchair without lift or two-person assist. The Initial 24-hour Report dated 8/3/17 revealed Resident #1 stated that while being pivoted by CNA #1, the CNA assisted him/her to slide to the floor and at that time his/her right knee popped. Review of CNA #1's employee file revealed a South [NAME]ina Nurse Aide Registry Verification dated 7/10/17. CNA #1 was noted with a hire date of 7/5/17. In an interview with the surveyor on 8/16/17 at approximately 10:15 AM, Registered Nurse (RN) #2 (Director of Education) stated the only registry verification was the one checked on 7/10/17. RN #2 confirmed CNA #1's date of hire was 7/5/17. RN #3 confirmed the registry verification was done after the employee's date of hire. | 2020-09-01 |
| 104 | 104 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2017-08-16 | 526 | D | 1 | 0 | MGP911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to obtain the most recent hospice plan of care specific to the resident, the hospice election form, and documentation of the communication between the facility and the hospice provider to ensure that the needs of the resident are addressed and met 24 hours per day. Resident #3 was noted to be receiving hospice services at the facility from [DATE]-[DATE] at which time the resident expired. Review of the resident's closed medical record on ,[DATE]-[DATE] revealed there was no documentation in the resident's medical record from the hospice agency. One of one residents reviewed for hospice. The findings included: Review of Resident #3's medical record revealed the Nurse's Progress Note dated [DATE] at 9:55 AM indicated the nurse practitioner rounded and new orders were written for hospice to evaluate and treat the resident related to [MEDICAL CONDITION]. Review of the Physician order [REDACTED]. Review of Resident #3's closed medical record on [DATE] and [DATE] revealed no documentation from the hospice agency. The medical records staff was asked about the missing documentation. In an interview with the surveyor on [DATE] at approximately 1:55 PM, medical records stated the hospice documentation was faxed over today, there was no information in the resident's medical record from the hospice agency. | 2020-09-01 |
| 105 | 105 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2018-08-16 | 578 | D | 0 | 1 | PLLD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure residents were afforded the opportunity to formulate their own decisions regarding health care for 1 of 2 residents reviewed for Advanced Directives. Resident # 26 was not provided the opportunity to update his/her healthcare decision. The findings included: Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Medical Record on 08/14/2018 at 11:53 AM revealed Resident #26 Advance Directive status was Do Not Resuscitate (DNR). Further review revealed the document was not signed by Resident #26. Continued review revealed the document was signed by the legal representative in (YEAR). Review of the Progress Note Addressing Decisional Capacity dated 9/16/16 revealed This patient DOES possess the decisional capacity to make healthcare decisions for self. Interview with Registered Nurse #1 on 08/15/2018 at approximately 2:30pm revealed when the resident is sent out to the Hospital the facility supplies Emergency Medical Services with the DNR order. Further interview revealed the capacity to make healthcare decisions needs to be updated to reflect resident's current wishes. | 2020-09-01 |
| 106 | 106 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2018-08-16 | 582 | D | 0 | 1 | PLLD11 | Based on record review and interview, the facility failed to issue the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN)/ Centers for Medicare/Medicaid (CMS) and CMS forms for 2 of 3 residents reviewed for Medicare Part A Services. Resident #33 was not issued the CMS timely, Resident #87 did not receive the required SNFABN/CMS . The findings included: Review of the Medicare non coverage notices on 08/16/2018 at approximately 11:00 am revealed Resident #87 had services ended with additional days left for services. Continued review revealed Resident #87 had not been provided the CMS form . Review of the Medicare non coverage notices on 8/16/2018 at approximately 11:00 am revealed the CMS indicated the resident services would end for Resident # 33 on 05/29/2018. Continued review revealed Resident #33 was provided notice on 05/28/2018. Interview with the Business Manager on 08/16/2018 at approximately 11:30 am confirmed CMS notices were not distributed as required. | 2020-09-01 |
| 107 | 107 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2018-08-16 | 584 | D | 0 | 1 | PLLD11 | Based on record review and interview, the facility failed to exercise reasonable care for the protection of resident property from loss or theft for 1 of 2 residents reviewed for Personal Property. Resident #55 was not reimbursed for several missing clothing items. The findings included: Interview with Resident # 55 on 8/14/2018 at approximately 11:40 am revealed he/she has had several clothing items that do not return from laundry. Further interview revealed he/she had not been replaced nor was he/she reimbursed for any of the missing clothing items. Resident #55 stated he/she informed facility staff to include the Social Worker of the missing items. Interview with Resident #55 on 8-16-18 at 11:15 am revealed he/she had a closet full of clothing that went missing which had not been replaced nor had he/she been reimbursed for the items. Resident #55 further stated he/she wore his/her (roommates) clothes. Resident #55 stated see, as he/she proceeded to show the written name of another resident inside the clothing he/she was wearing. Review of purchase receipts supplied by the facility Administrator on 8/15 and 08/16/2018 revealed no receipt of clothing purchase for Resident #55. Review of Policy #200.128 - Resident Valuables or Belongings revealed Procedure IV- If ESNC is notified that a resident's personal effects are missing, we shall attempt to locate the missing item but are not assuming responsibility for replacement of the lost or stolen property. Interview with Social Worker #1 on 08/16/2018 at approximately 11:30 am revealed items were replaced but could not provide documentation to support this. Social Worker #1 further stated he/she gave Resident #55 two pair of pants on 08-13-2018 but did not document this. | 2020-09-01 |
| 108 | 108 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2018-08-16 | 623 | E | 0 | 1 | PLLD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to give a written notice of transfer to the resident or the resident's representative when Resident #17 was transferred out of the facility for evaluation after a fall. The findings included: The facility admitted Resident #17 on 2/1/18 with [DIAGNOSES REDACTED]. Review of the Nurse's Progress Record revealed the notation dated 6/27/18 at 1130 indicated the resident was sent to the hospital for evaluation. The notation stated, R/P (representative) notified. The notation dated 6/27/18 at 2000 indicated the resident returned to the facility. The Nurse's Progress note dated 6/29/18 at 1925 indicated staff sent Resident #17 to the hospital for evaluation following a fall. The notation indicated that staff notified a family member. The notation dated 6/29/18 at 2230 indicated the resident returned to the facility. Review of the Social Services notes revealed no documentation that staff sent a written Notice of Transfer with the resident or to the resident's representative on those dates. During an interview on 8/16/18 at approximately 2:00 PM, Social Services Staff #1 reviewed the Nurse's Progress Notes and Social Services notations and confirmed these findings. | 2020-09-01 |
| 109 | 109 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2018-08-16 | 657 | D | 0 | 1 | PLLD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure all required members of the Interdisciplinary Team participated in the development of care plans and/or reviewed and revised the care plan for 3 of 21 residents reviewed for care plans. (Residents #6, #17, and #35) The findings included: The facility admitted Resident #6 on 11/1/00 with [DIAGNOSES REDACTED]. Review of the medical record revealed the care plan conference attendance sheets contained space for signatures of staff participating in the care plan meeting. Review of the attendance sheet dated 5/11/18 revealed no signature of a Certified Nurse Aide (CNA) to indicate participation in development of the care plan. The facility admitted Resident #17 on 2/1/18 with [DIAGNOSES REDACTED]. Review of the medical record revealed the care plan conference attendance sheets contained space for signatures of staff participating in the care plan meeting. Review of the attendance sheet dated 5/17/18 revealed no signature of a Certified Nurse Aide (CNA) to indicate participation in development of the care plan. The facility admitted Resident #35 on 1/16/66 with [DIAGNOSES REDACTED]. Review of the medical record revealed the care plan conference attendance sheets contained space for signatures of staff participating in the care plan meeting. Review of the attendance sheets dated 3/15/18 and 6/14/18 revealed no signature of a Certified Nurse Aide (CNA) to indicate participation in development of the care plan. During an interview on 8/16/18 at approximately 2:00 PM, Social Services Staff #1 and MDS Staff #1 reviewed the attendance forms and confirmed that there was no CNA signature on the care plan attendance sheets for these residents. | 2020-09-01 |
| 110 | 110 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2018-08-16 | 755 | E | 0 | 1 | PLLD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interviews and review of manufacture's recommendations, the facility's Consulting Pharmacist failed to assure that the Pharmaceutical service oversight for which it was contracted to provide, continued to identify, evaluate and prevent the improper storage of medications for 1 of 3 medication storage rooms reviewed. There was no immediate action documented which indicated the Pharmacy addressed the improperly stored medications at the time of the inspection of the Unit 1 medication storage room, educated the nursing staff as to the proper procedure to follow nor documented follow up to assure a concern was immediately corrected. (cross refer to F761) The findings included: On 8/13/18 at approximately 10:25 AM, an observation of the Unit 1 medication storage room with Licensed Practical Nurse (LPN) #1 revealed the temperature of the medication refrigerator was 32 degrees Fahrenheit (F) which was confirmed by LPN #1. The contents of the refrigerator was: 1.) (4) containers of Lananoprost Opthalmic Solution .0005% 125ug/2.5 ml. 2.) (38) vials of [MEDICATION NAME] 20 mcg. / 2 ml. 3.) (2) 10 ml. vials [MEDICATION NAME] R insulin 100 u/ml. 4.) (1) 10 ml. vial [MEDICATION NAME] R insulin 100 u/ml. 5.) (1) 2 mg. / ml. bottle of Lorazapam oral concentrate 6.) (2) 10 ml. vials Humalog insulin 100 u/ml. 7.) (5) 10 ml. vials of [MEDICATION NAME] 100 u/ml. 8.) (2) 12.5 mg. injections of [MEDICATION NAME] Consta 9.) (2) vials of [MEDICATION NAME]100 u/ml. The (MONTH) (YEAR) Unit Drug Refrigerator Temperature Log on top of the refrigerator revealed 5 dates (August 2, 3, 4, 5, 6) had been recorded On 8/13/18 at approximately 11:30 AM, during a review of the Unit 1's medication storage refrigerator's logs revealed in (MONTH) (18) days, (MONTH) (6) days, (MONTH) (14) days, and (MONTH) (5) days had temperature readings below 36 degrees F. On 8/14/18 at 12:30 PM, a review of the (MONTH) Monthly QA Consultant Pharmacy Report d… | 2020-09-01 |
| 111 | 111 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2018-08-16 | 757 | E | 0 | 1 | PLLD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a drug regimen free from unnecessary drugs for 1 of 6 sampled residents reviewed for unnecessary medications. An antipsychotic was initiated for Resident #41 without justification and/or non-pharmacological attempts. The findings included: The facility admitted Resident #41 on 03/26/2015 with [DIAGNOSES REDACTED]. Review of the medical record on 08-15-2018 at approximately 5:30 pm revealed he/she was prescribed [MEDICATION NAME] 05-16-2018. Further review revealed no adequate indication for it's use. Continued review of the record revealed no documentation of inappropriate behavior for Resident #41 and there was no indication staff received Dementia management training/techniques. Nurses Note dated 05-16-2018 revealed New order for [MEDICATION NAME] 25 mg (milligrams), po (by mouth), daily at 1700 for agitation and anxiety. Further review of Nurses Notes revealed no documentation of inappropriate behavior. Review of Pharmacy Consultant Report dated 6-14-2018 revealed receives an antipsychotic [MEDICATION NAME] but does not have a supporting indication for use documented. Further review revealed Dementia with behaviors written under Physician's Response dated 06-18-2018. Review of the Medication Administration Record [REDACTED]. Interview with the Director of Nursing (DON) on 08/16/2018 revealed no behaviors had been documented for Resident # 41. Further interview revealed the Nurse Practitioner (NP) was seated at the Nursing Station one day and saw Resident # 41 looking as if he/she was agitated and headed for the door and the order for [MEDICATION NAME] was written. | 2020-09-01 |
| 112 | 112 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2018-08-16 | 760 | D | 0 | 1 | PLLD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and review of manufacture's recommendations, the facility failed to administer the correct amount medication for 1 of 1 resident reviewed for TB [MEDICATION NAME], Purified Protein Derivative (PPD) medication administration. Resident #449 did not receive the correct amount of physician ordered PPD during medication administration. The findings included: On [DATE] at approximately 10:45 AM, an observation of the medication refrigerator in the Director of Nursing's (DON's) office with the DON revealed (1) 1 milliliter (ml), 10 test, vial of [MEDICATION NAME] Purified Protein Derivative (PPD) (Mantoux) (Lot # 0) which was opened (,[DATE] empty) with a puncture date of [DATE] recorded on the vial, and an expiration date of [DATE] on the pharmacy bottle that the vial was stored in. Following the observation of the PPD vial, the DON verified the vial of PPD was opened on [DATE] and expired on [DATE]. On [DATE] at approximately 1:30 PM, during an interview with the Director of Nursing (DON), the DON verified the vial of PPD (Lot # 0) was in use after the manufactures recommended expiration date and revealed that Resident #449 received PPD on [DATE] which was after the expiration date of [DATE]. Review of the manufacture's recommendations for [MEDICATION NAME] Purified Protein Derivative, (Mantoux) (PPD) ([MEDICATION NAME]) states under section Storage, A vial of [MEDICATION NAME] which has been entered and in use for 30 days should be discarded. Do not use after the expiration date. | 2020-09-01 |
| 113 | 113 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2018-08-16 | 761 | E | 0 | 1 | PLLD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, review of the facility policy, Medication Storage in the Facility, and review of manufacture's recommendations, the facility failed to follow a procedure to ensure that recommended temperatures were maintained in 1 of 3 medication storage refrigerators and expired medication was removed in 1 of 3 medication storage rooms reviewed. Medications were stored in the Unit 1 medication storage room below the FDA (Food and Drug Administration) approved package inserts and manufacturer package labeling, and expired medication was in the Director of Nursing's (DON's) medication storage room refrigerator,. The findings included: On [DATE] at approximately 10:25 AM, an observation of the Unit 1 medication storage room with Licensed Practical Nurse (LPN) #1 revealed the temperature of the medication refrigerator was 32 degrees Fahrenheit (F) which was confirmed by LPN #1. The contents of the refrigerator was: 1.) (4) containers of Lananoprost Opthalmic Solution .0005% 125ug/2.5 ml. 2.) (38) vials of [MEDICATION NAME] 20 mcg. / 2 ml. 3.) (2) 10 ml. vials [MEDICATION NAME] R insulin 100 u/ml. 4.) (1) 10 ml. vial [MEDICATION NAME] R insulin 100 u/ml. 5.) (1) 2 mg. / ml. bottle of Lorazapam oral concentrate 6.) (2) 10 ml. vials Humalog insulin 100 u /ml. 7.) (5) 10 ml. vials of [MEDICATION NAME] 100 u /ml. 8.) (2) 12.5 mg. injections of [MEDICATION NAME] Consta 9.) (2) vials of [MEDICATION NAME]100u /ml. The (MONTH) (YEAR) Unit Drug Refrigerator Temperature Log on top of the refrigerator revealed 5 dates ([DATE], 4, 5, 6) had been recorded On [DATE] at approximately 11:00 AM, during an interview with Maintenance Director and LPN #1, the surveyor's thermometer was placed in the Unit 1's medicine refrigerator which read 31 degrees F. Both thermometers (facility's and surveyors) were then tested for accuracy with the Maintenance Directors thermometer which all read the same temperature. The Maintenance Director verified the ther… | 2020-09-01 |
| 114 | 114 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2019-10-18 | 600 | E | 1 | 0 | CCZ611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to ensure that each resident has the right to be free from mistreatment, abuse or neglect for 5 out of 14 resident-to-resident altercations. The findings included: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of complaint records indicated Resident #2 was involved in five incidents of resident-to-resident altercations between November 2018 and September 2019 in which Resident #2 was the physical aggressor. Review of Resident #2's medical book revealed there were no interventions and no direct care plans to prevent Resident #2 from being physically aggressive towards other residents. During an interview on 10/16/2019 at approximately 2:20 PM, the Director of Nursing (DON) stated that Resident #2 was being picked on by others residents which caused Resident #2 to get upset and act out by having altercations with other residents. The DON stated that Resident #2 was on informal 15 minutes checks, and we have him/her stay around the nursing station because we can keep him/her in our sights. Also, the DON stated that Resident #2 doesn't have a care plan to address his/her altercations with other residents and there was no documentation for the 15 minutes checks because the DON decided that Resident #2 was being picked on, which makes him/her agitated. On 10/16/19 at approximately 3:30 PM, review of the facility policy entitled Adult or Elder Abuse, Mistreatment and Neglect revealed: It is facility policy to protect residents from abuse, neglect, mistreatment or exploitation from anyone, including staff members, students, volunteers, other residents, consultants' staff or other agencies serving the resident, family members, legal guardians, friends, or visitors. | 2020-09-01 |
| 115 | 115 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2019-10-18 | 607 | E | 1 | 0 | CCZ611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, facility failed to implement written policies and procedures that would prohibit or prevent each resident from mistreatment, abuse or neglect. The finding included: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of complaint records indicated Resident #2 was involved in five incidents of resident-to-resident altercations between November 2018 and September 2019 in which Resident #2 was the physical aggressor. On 10/16 at approximately 3:30 PM, reviewed of Resident #2 medical book revealed there was no care plan for Resident #2's behaviors. Also there was no documentation on Resident #2 being picked on by other residents. During an interview on 10/16/2019 at approximately 2:20 PM, the Director of Nursing (DON) stated that Resident #2 was being picked on by others residents which caused Resident #2 to get upset and act out by having altercations with other residents. The DON stated that Resident #2 was on informal 15 minutes checks and we have him/her stay around the nursing station because we can keep him/her in our sights. Also, the DON stated that Resident #2 does not have a care plan to address his/her altercations with other residents and there was no documentation for the 15 minutes checks because the DON decided that Resident #2 was being picked on, which makes him agitated. On 10/16/19 at approximately 3:30 PM, review of the facility policy entitled Adult or Elder Abuse, Mistreatment and Neglect revealed: It is facility policy to protect residents from abuse, neglect, mistreatment or exploitation from anyone, including staff members, students, volunteers, other residents, consultants' staff or other agencies serving the resident, family members, legal guardians, friends, or visitors. | 2020-09-01 |
| 116 | 116 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2019-10-18 | 610 | E | 1 | 0 | CCZ611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to take action in response to an alleged violation of abuse, neglect, exploitation or mistreatment for 5 out 14 resident-to-resident altercations. The findings included: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of complaint records indicated Resident #2 was involved in five incidents of resident-to-resident altercations between November 2018 and September 2019. In each complaint, Resident #2 was the physical aggressor. Review of Resident #2's medical book revealed there were no interventions and no direct care plans to prevent Resident #2 from being physically aggressive towards other residents. During an interview on 10/16/19 at approximately 10:43 AM, Licensed Practical Nurse (LPN) #2 stated there was no formal care plan for Resident #2's behaviors. LPN #2 stated that they keep watch on Resident #2 every 15 minutes and she/he likes to play country music for him/her, offer him/her snacks, and offer to take him/her outside. During an interview on 10/16/19 at 10:50 AM, LPN #1 stated there no formal care plan for Resident #2 and also stated that they keep watch on him/her every 15 minutes and staff is instructed to redirect Resident #2 with snacks and drinks when Resident #2 appears to be agitated. On 10/16/19 at approximately 3:30 PM, review of the facility policy entitled Adult or Elder Abuse, Mistreatment and Neglect revealed: It is facility policy to protect residents from abuse, neglect, mistreatment or exploitation from anyone, including staff members, students, volunteers, other residents, consultants' staff or other agencies serving the resident, family members, legal guardians, friends, or visitors. | 2020-09-01 |
| 117 | 117 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2019-10-18 | 657 | E | 1 | 0 | CCZ611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to ensure that the comprehensive care plan was reviewed and revised by an interdisciplinary team composed of individuals with knowledge of the resident and his/her needs for 1 of 18 resident care plans reviewed (Resident #2). The findings included: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of complaint records indicated Resident #2 was involved in five incidents of resident-to-resident altercations between November 2018 and September 2019 in which Resident #2 was the physical aggressor. Review on 10/16/2019 at approximately 10:00 AM of Resident #2's comprehensive care plan revealed it did not address behavior for Resident #2. During an interview on 10/16/19 at 10:50 AM, Licensed Practical Nurse (LPN) #1 stated there was no formal behavior care plan for Resident #2. LPN #1 stated that they keep watch on him/her every 15 minutes and staff was instructed to redirect Resident #2 with snacks and drinks when Resident #2 appears to be agitated. During an interview on 10/16/2019 at approximately 2:45 PM, the Administrator stated that each discipline writes their own care plans and makes sure their care plans are completed. During an interview on 10/16/ 2019 at approximately 3:10 PM, the Director of Nursing stated that when it comes to making any care plan changes, the nurses will write in their own care plans without having a meeting or letting other disciplines know. On 10/16/2019 at approximately 3:15 PM, LPN #1 stated that he/she wrote in Resident #2's care plan about having 15 minutes checks and also will continue to use the paper system to record each time. LPN #1 stated that it was the Administrator who told her/him to write the care plans. Also, LPN #1 stated that she/he has never been to a care plan meeting or been trained on how to write a care plan. | 2020-09-01 |
| 118 | 118 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2019-10-18 | 658 | D | 1 | 0 | CCZ611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to provide nursing services according to professional standards of quality for 1 of 1 resident reviewed for [MEDEQUIP] tube. Facility staff performed a [MEDEQUIP] tube flush for Resident #11 which was outside their scope of practice. The findings included: The facility admitted Resident #11 on 5/20/19 with [DIAGNOSES REDACTED]. Review of the medical record revealed a facility-reported incident dated [DATE] which indicated that staff performed a skill outside of scope of practice. Review of the facility's investigative file revealed the Five-Day Report indicated that the Director of Nursing (DON) spoke with Certified Nurses Aide (CNA) #1 regarding a report that he/she had proceeded to put water in the residents feeding tube. Documentation indicated that CNA #1 stated that (he/she) had asked the charge nurse if she could disconnect resident's feeding tube so she could put the resident to bed. Charge nurse (sic) stated that he/she could disconnect to put resident to bed. I asked (CNA#1) if (Charge Nurse) authorized her to put water in residents feeding tube. (CNA#1) stated that she did not. Further documentation by the DON indicated, (CNA#1) did admit to putting water in the feeding tube.I told (CNA#1) by disconnecting and putting water in (Resident #11's) feeding tube was out of (his/her) scope of practice. Further documentation indicated the DON spoke with the Charge Nurse. Documentation indicated that the Charge Nurse was unaware that CNA #1 performed a tube flush for Resident #11. Further documentation indicated that the Charge Nurse did give (CNA #1) permission to disconnect the tubing to put resident to bed. I (DON) told (Charge Nurse) that allowing the C.N.A. to disconnect the tubing was out of the C.N.A.'s scope of practice. Further review of the Five-Day Follow-Up report indicated it was confirmed that the C.N.A. did a peg flush of approximately 400 cc's of water after putting … | 2020-09-01 |
| 119 | 119 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2019-11-10 | 550 | D | 0 | 1 | NAMT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to protect the dignity of one of 37 residents (Resident #41). Signs were observed posted in the resident's room containing personal information. The findings included: Resident #41 was admitted on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #41's care plan noted a concern for assistance with activities of daily living dated 02/04/19. A concern for end stage [MEDICAL CONDITION] listed a 1500 milliliter per day fluid restriction. A review of the Annual Minimum Data Set (MDS) assessment dated [DATE] noted that Resident #41 was totally dependent on one staff member for eating assistance. Resident #41 was noted to have a Brief Interview for Mental Status score of 3, indicating severe cognitive impairment. On 11/08/19 at 12:09 PM, a sign was noted taped to the wall over the head of the bed documenting 1500 cc (milliliter) a day fluid restriction and a second sign that Resident #41 needed thickened liquids. On 11/09/19 at 3:49 PM, an interview was completed with the Director of Nurses (DON). We try not to have much signage, it looks tacky. We try to keep it to a minimum. We have colored bracelets that would show swallowing difficulty. I don't know who put the sign up there, but we wouldn't normally put that up. We don't usually put up fluid restrictions. That would be on the MAR (medication administration record). | 2020-09-01 |
| 120 | 120 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2019-11-10 | 656 | D | 0 | 1 | NAMT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and staff interviews, the facility failed to implement the care plan for pressure ulcer risk and activities of daily living care for one of 20 sampled residents reviewed (Resident #37). The findings included: 1. Resident #37 had [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment, dated 09/11/19, documented the resident's cognition was severely impaired and was totally dependent on staff for bed mobility, transfer, dressing, toilet use, and hygiene. The resident was always incontinent of bowel and bladder. A care plan last updated 11/07/19 documented the resident was at risk for impaired skin integrity related to immobility and incontinence of bowel and bladder. Interventions included to keep skin clean and dry and assist with turning as needed. A second care plan, last updated 11/07/19, documented the resident was an extensive assist and dependent with activities of daily living. The interventions included to assist with repositioning for comfort and to maintain skin integrity. On 11/08/19 at 9:45 AM, the resident was observed in his room working with therapy. The therapist stated they were about finished with him and would bring him out of his room when they were completed. At 10:30 AM, the resident was observed in the common area of unit two in front of the television. At 10:45 AM, a staff member was observed giving the resident a drink. After giving the drink the staff member left. From 10:45 AM through 12:05 PM, the resident remained in the common area. Staff was observed passing by the resident and taking other residents into the dining room for the noon meal. No staff was observed stopping and checking on the resident, repositioning him and/or taking him to provide care. At 12:05 PM, the therapist approached the resident, removed a towel from behind his head, and stated she would bring back a new one. She did not check the resident, reposition him or take the resident to his room to… | 2020-09-01 |
| 121 | 121 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2019-11-10 | 677 | D | 0 | 1 | NAMT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and staff interviews, the facility failed to provide activities of daily living (ADL) care for two of 20 residents reviewed for ADL care. (Residents #37 and #41) The findings included: 1. Resident #37 had [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment, dated 09/11/19, documented the resident's cognition was severely impaired and was totally dependent on staff for bed mobility, transfer, dressing, toilet use, and hygiene. The resident was always incontinent of bowel and bladder. There was no documentation on the assessment the resident had any skin breakdown or issues. Weekly skin audit sheets dated 10/28/19 and 11/04/19 documented the resident's skin was intact. A care plan last updated 11/07/19 documented the resident was at risk for impaired skin integrity related to immobility and incontinence of bowel and bladder. Interventions included to keep skin clean and dry and assist with turning as needed. A second care plan, last updated 11/07/19, documented the resident was an extensive assist too dependent with activities of daily living. The interventions included to assist with repositioning for comfort and to maintain skin integrity. A weekly skin audit sheet, dated 11/09/19, documented the resident had shearing to the right buttocks. There was no documentation the resident had any skin issues related to moisture. On 11/08/19 at 9:45 AM, the resident was observed in his room working with therapy. The therapist stated they were about finished with him and would bring him out of his room when they were completed. At 10:30 AM, the resident was observed in the common area of unit two in front of the television. At 10:45 AM, a staff member was observed giving the resident a drink. After giving the drink the staff member left. From 10:45 AM through 12:05 PM, the resident remained in the common area. Staff was observed passing by the resident and taking other residents into the dining room … | 2020-09-01 |
| 122 | 122 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2019-11-10 | 684 | D | 0 | 1 | NAMT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews, it was determined the facility failed to implement care for a dependent resident which resulted in moisture related skin issues for one of two residents reviewed for skin integrity (Resident #37). The facility identified 36 residents who were frequently incontinent of bladder. The findings included: Resident #37 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 09/11/19, documented the resident's cognition was severely impaired and was totally dependent on staff for bed mobility, transfer, dressing, toilet use, and hygiene. The resident was always incontinent of bowel and bladder. There was no documentation on the assessment the resident had any skin breakdown or issues. Weekly skin audit sheets dated 10/28/19 and 11/04/19 documented the resident's skin was intact. A care plan last updated 11/07/19 documented the resident was at risk for impaired skin integrity related to immobility and incontinence of bowel and bladder. Interventions included to keep skin clean and dry and assist with turning as needed. A second care plan, last updated 11/07/19, documented the resident was an extensive assist and dependent with activities of daily living. The interventions included to assist with repositioning for comfort and to maintain skin integrity. A weekly skin audit sheet, dated 11/09/19, documented the resident had shearing to the right buttocks. There was no documentation the resident had any skin issues related to moisture. On 11/08/19 at 9:45 AM, the resident was observed in his room working with therapy. The therapist stated they were about finished with him and would bring him out of his room when they were completed. At 10:30 AM, the resident was observed in the common area of unit two in front of the television. At 10:45 AM, a staff member was observed giving the resident a drink. After giving the drink the staff member left. From 10:45 AM through 12:05 PM, the resident remained in the… | 2020-09-01 |
| 123 | 123 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2019-11-10 | 686 | D | 0 | 1 | NAMT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to identify and treat a wound on the coccyx as a pressure ulcer for one of two residents reviewed for pressure ulcers (Resident #82). The findings included: On 11/09/19 at 11:30 AM, wound care was observed on Resident #82 with Registered Nurse/Wound Care (RN #21) and Certified Nurse Assistant (CNA #53). The wound was located on the coccyx with an open area on the right buttocks. The skin surrounding the open area showed scarring from a healed pressure ulcer. The open area was approximately 3 centimeters (cm) long x 0.25 cm wide X 0.02 cm deep. The area on the left buttocks was superficial but reddened. RN #21 applied a skin barrier ointment to the area. No drainage or odor were noted. When asked if the resident felt pain at the site, she stated, It's pretty sore. An interview with RN #21 on 11/09/19 at 1:35 PM revealed that she identified the wound as shearing rather than a pressure ulcer. She stated that the resident stayed up in her wheelchair most of the day. She stated that she encouraged the resident to stay off of that area as much as possible by lying down in bed instead of in her wheelchair. She stated that she had tried multiple forms of treatment based on standing orders. She stated that she had discussed it with the physician and the nurse practitioner but neither of them had visualized the wound. The wound was first noted on 09/24/19. RN #21 stated that she became aware of the open area when the resident asked her to look at her buttocks because she was having pain. RN #21 stated that she had not asked the physician or the nurse practitioner to observe the wound. She stated that there was no order or policy for when the physician or nurse practitioner should be asked to visualize the wound when it was not improving. A second interview with RN#21 on 11/10/19 at 10:40 AM revealed that Resident #82 had been put on the list to be seen by the nurse practiti… | 2020-09-01 |
| 124 | 124 | PRUITTHEALTH- COLUMBIA | 425013 | 2451 FOREST DRIVE | COLUMBIA | SC | 29204 | 2019-03-22 | 610 | D | 1 | 0 | U4GQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to ensure all allegations were thoroughly investigated for 1 out of 2 complaints reviewed. The findings included: Resident #545 was admitted to the facility with [DIAGNOSES REDACTED]. Resident #545's family alleged that on 10/07/18 that Resident #545 was found by his/her family seated in his/her wheelchair in urine. Review of facility documentation for Resident #545 on 03/21/19 at 2:01 PM revealed the Certified Nursing Assistant (CNA) Care Interventions Record Form revealed the section related to elimination needs was left blank and the CNA-ADL (Activities of Daily Living) Flow Sheet Form was coded as fully incontinent on 10/05/18, 10/06/18, and 10/07/18; however, the number of times the resident urinated during the shift was not documented. Review of the facility internal investigation of the incident on 03/21/19 at 12:47 PM revealed the blank section of the CNA Care Interventions Record Form and CNA-ADL missing documentation were not investigated. In an interview on 03/21/19 at 11:14 AM, the facility Director of Nursing confirmed the missing information on the CNA Care Interventions Record Form and CNA-ADL missing documentation were not investigated. | 2020-09-01 |
| 125 | 125 | PRUITTHEALTH- COLUMBIA | 425013 | 2451 FOREST DRIVE | COLUMBIA | SC | 29204 | 2019-03-22 | 623 | D | 0 | 1 | U4GQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the contents of the written notice upon transfer to the resident and/or resident representative included all required information for Resident #89 (1 of 2 sampled residents reviewed for hospitalization ). The findings included: The facility admitted Resident #89 with [DIAGNOSES REDACTED]. Record review on 03/20/19 at approximately 1:08 PM revealed a physician's orders [REDACTED].#89 to the hospital due to shortness of breath, [MEDICAL CONDITION] and increased blood pressure. No documentation of the written notice upon transfer was found in the medical record, but the written notice was provided by the Director of Health Services (Nursing) and the Business Manager. Review of the written notice revealed it did not include all of the required information such as the reason for the transfer, place of transfer, and contact information for the state agency and local ombudsman. In an interview on 03/20/19 at approximately 2:40 PM, the Director of Health Services (Nursing), the Administrator, and Business Manager confirmed that the facility notice did not include the reason for the transfer, place of transfer, and contact information for the state agency and local ombudsman. | 2020-09-01 |
| 126 | 126 | PRUITTHEALTH- COLUMBIA | 425013 | 2451 FOREST DRIVE | COLUMBIA | SC | 29204 | 2019-03-22 | 657 | E | 1 | 0 | U4GQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to ensure Care Plans were revised in a timely manner for 1 out of 5 residents reviewed for Unnecessary Medications (Resident 67). The findings included: Resident #67 was admitted to the facility with [DIAGNOSES REDACTED]. Review of Resident #67's Psychotherapy notes on 03/19/19 at 12:42 PM revealed a note dated 12/19/18 which noted an initial mental health examination by the Nurse Practitioner recommending starting [MEDICATION NAME] 7.5 milligrams twice daily for agitation. Review of Resident #67's physician's orders [REDACTED]. In an interview on 03/21/19 at 10:18 AM, the Director of Nursing confirmed Resident #67's [MEDICATION NAME] 7.5 milligrams twice daily was not started in a timely manner. | 2020-09-01 |
| 127 | 127 | PRUITTHEALTH- COLUMBIA | 425013 | 2451 FOREST DRIVE | COLUMBIA | SC | 29204 | 2018-03-23 | 636 | D | 0 | 1 | LL0111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and limited record reviews, the facility failed to complete a comprehensive Minimum Data Set (MDS) 3.0 assessment within the timeframe required by the Centers for Medicare and Medicaid (CMS) for 1 of 1 resident reviewed for pressure ulcers. Resident #16 did not have a comprehensive (annual or significant change in status) MDS assessment completed as required within 92 days of the prior Omnibus Budget Reconciliation Act (OBRA) MDS quarterly assessment with Assessment Reference Date (ARD) of 8/22/17. The findings included: Resident #16 was admitted to facility with the following [DIAGNOSES REDACTED]. Record review on 3/23/18 at approximately 9:00 AM revealed that Resident #16 had a Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 8/22/17 completed. Further review of the medical record on 3/23/18 revealed that the next MDS completed was a Significant Change in Status (SCSA) MDS assessment with an ARD of 12/5/17. Additional review revealed that the prior comprehensive MDS assessment was completed with an ARD of 11/24/16 and identified as an annual MDS assessment. The ARD for the SCSA (12/5/17) was ARD + 105 calendar days from the prior quarterly assessment (8/22/17) and was ARD + 377 calendar days from the prior annual MDS assessment (11/24/16). Review on 3/23/18 at of the MDS Resident Assessment Instrument (RAI) Manual version 1.15 effective date 10/1/2017; Chapter 2 page 2-22 revealed the following: The ARD (Item A2300) must be set within 366 days after the ARD of the previous OBRA comprehensive assessment (ARD of previous comprehensive assessment +366 calendar days AND within 92 days since the ARD of the previous OBRA quarter or Significant Correction to Prior Quarterly assessment (ARD of previous Quarterly assessment + 92 calendar days). MDS nurses #1 and #2 verified during interviews on 3/23/18 that a annual MDS had not been completed as originally scheduled with an ass… | 2020-09-01 |
| 128 | 128 | PRUITTHEALTH- COLUMBIA | 425013 | 2451 FOREST DRIVE | COLUMBIA | SC | 29204 | 2018-03-23 | 637 | D | 0 | 1 | LL0111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and limited record reviews, the facility failed to complete a Significant Change in Status (SCSA) Minimum Data Set (MDS) 3.0 assessment within the timeframe required by the Centers for Medicare and Medicaid (CMS) for 1 of 1 resident reviewed for pressure ulcers. Resident #16 did not have a SCSA MDS assessment completed as required within 14 days after admission to hospice services effective 11/22/2017. The findings included: Resident #16 was admitted to facility with the following [DIAGNOSES REDACTED]. Record review on 3/23/18 at approximately 9:00 AM revealed that Resident #16 was admitted to hospice services with start of care date effective 11/22/2017. Additional review revealed that Resident #16 had a Significant Change in Status (SCSA) MDS assessment with an ARD of 12/5/17 completed and signed by RN on 12/19/2017. Review on 3/23/18 at of the MDS Resident Assessment Instrument (RAI) Manual version 1.15 effective date 10/1/2017; Chapter 2 page 2-23 revealed the following: The MDS completion date (Item Z0500B) must be no later than 14 days from the ARD (ARD + 14 calendar days) and no later than 14 days after the determination that the criteria for a SCSA were met. MDS nurses #1 and #2 verified during interviews on 3/23/18 that the significant change in status assessment initiated when Resident #16 was admitted to hospice services on 11/22/17 was not completed within required time frame. They verified that the ARD for SCSA was 12/5/17 and item Z0500B was signed by RN to signify assessment as complete on 12/19/17, which was 27 calendar days after admission to hospice services. | 2020-09-01 |
| 129 | 129 | PRUITTHEALTH- COLUMBIA | 425013 | 2451 FOREST DRIVE | COLUMBIA | SC | 29204 | 2018-03-23 | 638 | D | 0 | 1 | LL0111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and limited record reviews, the facility failed to complete a quarterly Minimum Data Set (MDS) assessment within the required time frame as outlined in the MDS 3.0 Resident Assessment Instrument (RAI) manual for 1 of 1 resident reviewed for pressure ulcers. Resident #16's quarterly MDS was not completed with an Assessment Reference Date (ARD) within 92 calendar days of the ARD of the most recent Omnibus Budget Reconciliation Act (OBRA) assessment, a Significant Change in Status Assessment (SCSA) with ARD of 12/5/17. The findings included: Resident #16 was admitted to facility with the following [DIAGNOSES REDACTED]. Record review on 3/23/18 at approximately 9:00 AM revealed that Resident #16 had a Significant Change in Status (SCSA) Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 12/5/17 completed related to admission to hospice care services. Further review of the medical record on 3/23/18 revealed that there was not a quarterly MDS assessment completed as required on or before 3/7/18. Additionally, the only MDS with an ARD after 12/5/17 was a SCSA MDS that was currently in the process of being completed with an ARD of 3/15/18. Review on 3/23/18 at of the MDS Resident Assessment Instrument (RAI) Manual version 1.15 effective date 10/1/2017; Chapter 2 page 2-32 revealed the ARD of an assessment drives the due date of the next assessment. The next non-comprehensive assessment is due within 92 days after the ARD of the most recent OBRA assessment (ARD of the previous OBRA assessment- Admission, Annual, Quarterly, Significant Change in Status, or Significant Correction assessment + 92 calendar days). MDS nurses #1 and #2 verified during interviews on 3/23/18 that a quarterly MDS had not been completed as originally scheduled with an assessment reference date of 3/6/18 due to hospice services being discontinued effective 3/8/2018. Further discussion revealed that MDS nurse #2 had initi… | 2020-09-01 |
| 130 | 130 | PRUITTHEALTH- COLUMBIA | 425013 | 2451 FOREST DRIVE | COLUMBIA | SC | 29204 | 2018-03-23 | 640 | D | 0 | 1 | LL0111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to complete and/or transmit Minimum Data Set (MDS) 3.0 information within required 14 day timeframe as required by CMS (Centers for Medicare and Medicaid Services) and the State for 4 of 6 residents identified on Certification and Survey Provider Enhanced Reporting (CASPER) Minimum Data Set (MDS) 3.0 Missing Omnibus Budget Reconciliation Act (OBRA) Report generated on 3/14/2018. The findings included: Resident #382 had an assessment target date of 01/08/2018 which was the last transmitted Minimum Data Set (MDS) assessment per the CASPER (Certification and Survey Provider Enhanced Reporting) MDS 3.0 Missing OBRA (Omnibus Budget Reconciliation Act) Assessment Report generated on 03/14/2018. Resident #382 was discharged from facility on 1/12/2018 which was signed as complete by the Registered Nurse on 3/19/2018 which was not within the required 14 day time frame from the Assessment Reference Date (ARD) of 1/12/2018 as required by regulatory guidelines. The documentation provided for review by MDS Nurse #1 on 3/21/2018 at 11:30 AM revealed a Final Validation Report (FVR) with the submission Identification (ID) of 823 that was completed on 3/20/2018 at 12:55: 21 PM. Record #11 identified Resident #382's Discharge MDS assessment which was signed as complete on 3/19/2018 and submitted on 3/20/2018 was accepted into the CMS database and subsequently identified as Assessment Completed late: Z0500B (assessment completion date) is more than 14 days after A2300 (assessment reference date) . Resident #1 had an assessment target date of 10/10/2017 which was the last transmitted Minimum Data Set (MDS) assessment per the CASPER (Certification and Survey Provider Enhanced Reporting) MDS 3.0 Missing OBRA (Omnibus Budget Reconciliation Act) Assessment Report generated on 03/14/2018. Resident #1 was not discharged from facility and a quarterly MDS with an Assessment Reference Date (ARD) of 1/9/2018 was si… | 2020-09-01 |
| 131 | 131 | PRUITTHEALTH- COLUMBIA | 425013 | 2451 FOREST DRIVE | COLUMBIA | SC | 29204 | 2018-03-23 | 641 | D | 0 | 1 | LL0111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to code 1 of 1 resident reviewed on hospice accurately for the Health Conditions Prognosis. Resident #49 was not coded in Section J Health Conditions with the accurate life expectancy. The findings included: The facility admitted Resident #49 with [DIAGNOSES REDACTED]. On 3/21/18 at 5:23PM, review of the Minimum Data Set (MDS) assessment dated [DATE] for significant change and 1/5/18 for Quarterly Assessment revealed Section J Health Conditions: J1400 Prognosis: life expectancy of less than 6 months marked No. On 3/21/18 at 5:59 PM, review of the Hospice Certification and Plan of Care revealed the Start Date of Care was 9/23/17. Further record review from the hospice company revealed, Order date 12/7/17 Order Description: I recertified that patient is terminally ill with a life expectancy of Six (6) months or less if the disease process runs it's normal course. During an interview on 3/23/18 at 10:34 AM with MDS Coordinator #1 is familiar with Resident #49 and confirmed the inaccurate coding for Health Conditions Prognosis. S/he stated was just educated on 3/22/18 by a State Agency Surveyor on coding residents on Hospice. | 2020-09-01 |
| 132 | 132 | PRUITTHEALTH- COLUMBIA | 425013 | 2451 FOREST DRIVE | COLUMBIA | SC | 29204 | 2018-03-23 | 657 | D | 0 | 1 | LL0111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, records review and staff interview, the facility failed to reassess and revise the comprehensive resident-centered care plan to make sure that resident's current nutrition status reflects the discontinuation of enteral feeding therapy. The facility also failed to update the care plan regarding the percutaneous endoscopic gastrostomy (PEG) status and percentage of by mouth (PO) intake for one of six sampled resident reviewed for nutrition. The findings included: Resident #62 was admitted to the facility with [DIAGNOSES REDACTED]. During the initial tour on 03/19/18 at approximately 2:30 PM Resident #62 was observed laying on his/her bed without signs or symptoms of distress. The resident's room was free of enteral nutrition supplies or equipment and the resident's PEG off sight. Nurse's notes reviewed on 03/22/18 at approximately 2:50 PM revealed that on 02/14/18 the Physician wrote and ordered to discontinue current enteral feeding therapy (tube-feeding) and flush. S/he also wrote an order to have the gastrostomy tube ([DEVICE]) flush with 100 ml of water twice per day for tube patency. Medicine administration regiment reviewed 03/22/18 at approximately 3:00 PM revealed that the nutritional supplement [MEDICATION NAME] 1.5-237 ml bolus five times per day was discontinued on 2/14/18. The care plan review on 03/22/18 at 3:19 AM stated that the resident has the potential for nutrition and hydration deficits and aspiration related to [DEVICE] feeding. The care plan goal includes to nourish and adequately hydrate. The intervention includes administration of H2O flush as ordered per Hierarchical Condition Categories (HCC) protocol, monitor residual volume as ordered, and to care for PEG site daily and as needed. During an interview with Minimum Date Set coordinator (MDS) #1 conducted on 03/23/18 at 10:12 AM s/he confirmed that the care plan is not updated to include improvement in PO intake and discontinuation of PEG tube feed… | 2020-09-01 |
| 133 | 133 | PRUITTHEALTH- COLUMBIA | 425013 | 2451 FOREST DRIVE | COLUMBIA | SC | 29204 | 2018-03-23 | 761 | E | 0 | 1 | LL0111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, limited record reviews, interviews, and review of the facility policy, the facility failed to ensure that medications were properly labeled in 2 of 7 medication carts reviewed for medication storage. In addition, the facility failed to ensure controlled substances medication was accounted for in 1 of 1 emergency narcotics box reviewed for medication storage. The findings included: During the medication storage review, conducted in part on 3/22/18 at approximately 09:50 AM with Licensed Practical Nurse (LPN) #1, two packages of [MEDICATION NAME] 10 milligrams (mg) oral tablets (thirty tablets per package) were found with a discard date of 1/12/19 and a manufacturer expiration date of 1/29/18 for Resident #48. One package was in use and the other package was unopened. LPN #1 stated, I use the discard date as the expiration date. I never look on the back of the package. LPN #6, also present on the unit, stated, I just use the discard date as the expiration date. During continuation of the medication storage review on 3/22/18 at approximately 1:35 PM with LPN #4, one unopened package of [MEDICATION NAME] 10 mg oral tablets (thirty tablets) was found with a discard date of 1/1/19 and a manufacturer expiration date of 1/29/18 for Resident #72. LPN #4 stated, I was trained on checking the discard date only. LPN #2, also present on the unit, stated, We use the discard date as the expiration date. In a telephone interview with Pharmacist #2 on 3/22/18 at approximately 10:20 AM, s/he stated, There was an error on the pre-pack label for the [MEDICATION NAME] dispensed with the manufacturer lot # 59[NAME] The expiration date should be 1/29/19 not 1/29/18. S/he also stated, There is no policy for how to check the expiration date of a medication. We train the staff to use whichever date comes first, the discard date or the expiration date. The expectation is they will call us if they find a discrepancy. During an interview on 3/23/18… | 2020-09-01 |
| 134 | 134 | PRUITTHEALTH- COLUMBIA | 425013 | 2451 FOREST DRIVE | COLUMBIA | SC | 29204 | 2018-03-23 | 801 | F | 0 | 1 | LL0111 | Based on observation, record review and interview the facility failed to employ sufficient qualified staff with the appropriate competencies and skill set forward to carry out food and nutritional services in accordance to the Centers for Medicare and Medicaid Services (CMS) regulations and the state of South[NAME]nutritional professional standards for one of one kitchen sample reviewed for qualified food and nutrition service staff. The findings included: On 03/19/18 at 10:43 AM during the initial tour of the facility's kitchen the dietary manager #1 revealed that s/he has been functioning as one of the dietary managers for three years now. S/he also stated s/he has not yet taken/passed the nationally recognized credentialing exam needed to obtain/maintain certified status. When asked if the facility has a registered dietitian or food and nutrition services director s/he stated that the facility has a consultant registered dietitian that comes to the facility three to four times per month. At approximately 04:21 PM on the same day during the continuation of kitchen tour the dietary manager #2 stated that s/he has a bachelor degree in food management and culinary art. S/he also stated that s/he is eligible for the Certified Dietary Manager (CDM) exam and that s/he was currently enrolled in the class. However, s/he has not yet taken/pass the exam to obtain/maintain certification status. On 03/20/18 the work schedule for the dietary managers and registered dietitian was requested. However, the facility administrator stated that s/he does not have formal/hard copy work scheduled for the dietary staff. S/he provides a handwritten note stating that the dietary manager #1 works from Sunday through Thursday for 8 hours per day. The dietary manager #2 works Mondays through Fridays for 8 hours. The written note also states that the consultant register dietitian worked (MONTH) 6th, 7th, and 8th, (MONTH) 22nd, 23rd, 24th (MONTH) 13th, 14th, 15th and 16th for 8 hours each day. The registered dietitian #2 works approximately … | 2020-09-01 |
| 135 | 135 | PRUITTHEALTH- COLUMBIA | 425013 | 2451 FOREST DRIVE | COLUMBIA | SC | 29204 | 2018-03-23 | 812 | F | 0 | 1 | LL0111 | Based on observation, interview, and review of the facility's policy titled Food Storage, the facility failed to ensure that the kitchen's walkin cooler was kept in good working condition to guarantee cold food items were kept at 41F degrees or lower to prevent the growth of pathogenic microorganisms that can cause foodborne illness. The findings included: During the initial kitchen tour on 03/19/18 at 10:49 AM the thermometer in the walkin cooler read 49F degrees. At approximately 11:20 AM a brand new thermometer was observed in the same walkin cooler, and it read 60F degrees at the time. The dietary manager stated the thermometer was just put in and that it needed some time to adjust. At 04:21 PM on the same day the walkin cooler temperature was reading 49F degrees. At 4:51 PM the temperature of 236 ml carton of 2% milk that was placed on dinner tray at the kitchen read 48F degrees. The milk was taken off the tray and discarded. At approximately 5:08 PM on the same day the walkin cooler temperature log was requested. It was provided. However, it was incomplete and some areas white out. At approximately 5:15 PM on the same day dietary manager #2 stated that the maintenance person was on his/her way to the facility to take a look at the walkin cooler. At approximately 5:20 PM the administrator acknowledged that the walkin cooler was not working properly and s/he stated that the food items in it were not maintained at 41F degrees or lower. S/he also stated that all the food items in the walkin cooler that have the potential for bacterial growth and the potential to cause harm was going to be discarded. At approximately 5:30 PM the surveyor observed the administrator, dietary manager, and kitchen staff throw the following items into a large trash can: 600 of individual cartons of milk (236 ml of whole, 2%, 1% milk carton), one gallon of 2% milk, one container of chy salad, three containers of pimento cheese, two containers of cottage cheese, two pounds of sliced turkey, one container of gravy, one bag of parmesan c… | 2020-09-01 |
| 136 | 136 | PRUITTHEALTH- COLUMBIA | 425013 | 2451 FOREST DRIVE | COLUMBIA | SC | 29204 | 2017-06-20 | 278 | D | 1 | 0 | 5BIF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interviews the facility failed to accurately assess 1 of 3 residents reviewed for assessments. Resident #2's assessment did not have a cognitive assessment. The resident had been assessed as having a [MEDICAL CONDITION], which was actually a fistula. The findings included: The facility admitted resident #2 with [DIAGNOSES REDACTED]. Review of the medical record revealed a Quarterly Minimum Data Set (MDS) of 2/17/17 revealed the resident's cognition was not coded. No mood or behavior problems. Functional status was total care with Activities of Daily Living, non-ambulatory. S/he was incontinent of bowel and bladder. Weight was 84 lbs. A Significant Change Minimum Data Set (MDS) of 5/10/17 had the resident coded to have no memory problems and was able to make decisions. There were no mood or behavior problems. Functional ability- S/he required total care with all aspects of Activities of Daily Living (ADL's), non-ambulatory. Resident had an indwelling foley and an ostomy for waste elimination. She was 67 inches tall and weighed 84 lbs. Mechanically Altered Therapeutic Diet. One stage III pressure sore, present on admission. 04.0 x 03.5 x 00.1, granulation tissue present in wound bed. The resident received pressure ulcer care and was on pressure reducing devices for bed and chair. On 6/20/17 at 9:20 AM: Registered Nurse (RN), (wound nurse) was interviewed by the surveyor. Resident #2 no longer here. S/he had a sacral wound, stage III. We were doing daily treatments. S/he had a groin wound and was going to the wound clinic for it. S/he had a flesh-eating bacteria, before s/he came here. S/he was an established patient when I became wound nurse. We found out that the groin area was actually a fistula. It wasn't infected, stool was coming through it. It had the risk of being infected. I assessed her/him and sent her/him out. They were using a [MEDICAL CONDITION] device, but s/he did not have a [MEDICAL CONDITION]. They … | 2020-09-01 |
| 137 | 137 | PRUITTHEALTH- COLUMBIA | 425013 | 2451 FOREST DRIVE | COLUMBIA | SC | 29204 | 2017-06-20 | 279 | D | 1 | 0 | 5BIF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interviews the facility failed to provide an accurate care plan for 1 of 3 residents care plans reviewed. Resident #2's plan of care did not address the fistula or possible complications. The findings included: The facility admitted resident #2 with [DIAGNOSES REDACTED]. Review of the care plan dated 3/26/15, updated 5/17/17 revealed a problem of Self-care deficit in activities of daily living (ADL's). Requires total care with all ADL's related to Cerbralvascular Accident ([MEDICAL CONDITION]), has a foley catheter and a [MEDICAL CONDITION]. Intervention included to provide [MEDICAL CONDITION] care. Review of the Nurse's Notes revealed: On 4/20/17 Upon assessment of groin wound, brown loose stool noted oozing from left groin wound. Family and physician notified. New orders to send resident to ER for further evaluation and treatment. 5/3/17 returned from hospital with a [MEDICAL CONDITION] bag over left abd fold with brown liquid in bad. BM in diaper. Resident on [MEDICATION NAME] for [MEDICAL CONDITION] and on a [MEDICATION NAME]. 5/5/17 at 11:45 AM Labia noted with excoriation related to excessive stools. Review of the Hospital Discharge Summary dated 4/28/17 revealed the resident was admitted to the hospital with [REDACTED]. On 6/20/17 at 9:20 AM: Registered Nurse (RN), (wound nurse) was interviewed by the surveyor. Resident #2 no longer here. S/he had a sacral wound, stage III. We were doing daily treatments. S/he had a groin wound and was going to the wound clinic for it. S/he had a flesh-eating bacteria, before s/he came here. S/he was an established patient when I became wound nurse. We found out that the groin area was actually a fistula. It wasn't infected, stool was coming through it. It had the risk of being infected. I assessed her/him and sent her/him out. They were using a [MEDICAL CONDITION] device, but s/he did not have a [MEDICAL CONDITION]. They used an ostomy device. | 2020-09-01 |
| 138 | 138 | PRUITTHEALTH- COLUMBIA | 425013 | 2451 FOREST DRIVE | COLUMBIA | SC | 29204 | 2016-12-15 | 253 | E | 0 | 1 | UWQ711 | Based on observation and interview, the facility failed to ensure housekeeping and maintenance services provided an orderly and comfortable interior for the residents. The findings included: During a tour of the facility the following issues and concerns were noted: 1. In the 700 hall the handrails and walls below the handrails had chipped and missing paint. 2. In room 705, there was a broken nightstand, the faucet on the sink leaks, there was black build up on the tile seams, one bed did not have a privacy curtain, and the paint was gouged behind 1 bed. 3. In room 711, 1 dresser was missing wood laminate, a dresser handle was missing, and the baseboard was pulling away from the wall. 4. In the bathroom attached to room 711, there was a brown build up on the pipe leading to the sink and paint chipped away from the wall. 5. In room 715, the clothing lockers were damaged and in poor repair, paint was chipped away from the wall, there was no call light for 1 occupied bed, and 1 bed did not have a privacy curtain. 6. In room 102, the nightstand was missing laminate. 7. In the bathroom attached to room 102, the paint was chipped away from the wall and there was a gap around the pipe leading from the wall to the toilet . 8. In room 107, 1 dresser and 1 nightstand were missing laminate. 9. In room 111, 1 nightstand was missing laminate, the call light box was pulled away from the wall, and the paint behind the bed was gouged. 10. In room 112, 1 nightstand was missing a drawer pull and the paint was chipped away from the wall. 11. In room 125, the closet doors were damaged, 1 dresser and 2 nightstands were missing laminate, and the paint was chipped away from the wall. 12. In the bathroom attached to room 125, there was a gap between the wall and the baseboard. 13. In the dining area on the 200 floor, there was missing laminate from the handrails and rust colored staining on the wallpaper. 14. In room 202 1 nightstand had a missing handle and 1 dresser had missing laminate. 15. In the bathroom attached to room 202 there … | 2020-09-01 |
| 139 | 139 | PRUITTHEALTH- COLUMBIA | 425013 | 2451 FOREST DRIVE | COLUMBIA | SC | 29204 | 2016-12-15 | 371 | E | 0 | 1 | UWQ711 | Based on initial tour observation, interview and review of the facility policy Labeling, Dating, and Storage, the facility failed to store foods under sanitary conditions in 1 of 1 kitchen. Dietary staff failed to ensure expired foods were removed from the walk in refrigerator. Freezer food items open and unlabeled. The findings included: During initial tour of the kitchen on 12/12/16 at 10:40 AM with Certified Dietary Manager (CDM) revealed the walk-in refrigerator with 2 containers of 5 lbs. (pound) wholesome foods sour cream had expired on 12/3/16. In the walk-in freezer a bag of full cooked sausage, 1 box of Nordica breaded flounder fillets, and 1 box Baker Source waffles were opened and unlabeled. During the review of the facility policy Labeling, Dating, and Storage: Procedure: 1. Food and/or beverage items will be properly labeled with the name of the item, an open date, and a discard date. | 2020-09-01 |
| 140 | 140 | PRUITTHEALTH- COLUMBIA | 425013 | 2451 FOREST DRIVE | COLUMBIA | SC | 29204 | 2016-12-15 | 441 | D | 0 | 1 | UWQ711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and review of the facility policy titled, Indwelling Urinary Catheter Care and Management, and Transporting and sorting Soiled Linen, the facility failed to ensure proper perineal care during Foley catheter care for Resident #4 for 1 of 3 residents reviewed for Urinary Incontinence. The facility further failed to handle soiled laundry in a manner to prevent the spread of infections for 1 of 1 laundry rooms observed. The findings included: The facility admitted Resident #4 with [DIAGNOSES REDACTED]. Review on 12/14/2016 at approximately 12:24 PM of the physician's orders revealed an order for [REDACTED]. And an additional physician's order to use a #18 French Foley catheter with a 5-10 milliliter bulb and to change it monthly and as needed for leakage and occlusion. Observation on 12/14/2016 at approximately 1:55 PM of Foley Catheter Care revealed Certified Nursing Assistant (CNA) #1 as he/she knocked on Resident #4's door and asked permission to enter. Resident #4 did not answer. CNA #1 explained the procedure to Resident #4, provided privacy and then washed his/her hands. This surveyor asked for permission to observe the CNA performing Foley catheter care and Resident #4 was unable to answer. After CNA #1 washed his/her hands, he/she proceeded to apply 2 pairs of gloves, removed the brief with the same gloves applied a cleanser to a wipe and cleansed the right outside of the labia with 1 swipe. CNA #1 then did the same for the left side outside the labia. He/she then proceeded to cleanse the catheter tubing from the labia to approximately 2 inches down the tubing. CNA #1 never cleansed the inside of the labia nor did he/she cleanse around the Foley catheter insertion site. The room had a strong urine odor noted on all days of the survey and was brought to the attention of the Nurse Manager for the 400 Unit. During an interview on 12/14/2016 at approximately 2:10 PM with CNA #1, he/she confirmed that he/she h… | 2020-09-01 |
| 141 | 141 | PRUITTHEALTH- COLUMBIA | 425013 | 2451 FOREST DRIVE | COLUMBIA | SC | 29204 | 2016-12-15 | 456 | D | 0 | 1 | UWQ711 | Based on observations, interviews and review of the facility policy titled, Cleaning of Laundry Equipment, the facility failed to ensure an excessive large amount of lint was removed from the lint baskets, inside the upper dryer walls and from behind 4 of 4 clothes dryers. The facility further failed to ensure stagnant water was not standing behind the clothes washers and draining properly for 1 of 1 laundry rooms observed. The findings included: An observation on 12/15/2016 at approximately 8:30 AM of the laundry room revealed the clothes dryers with an excessive large amount of lint in the lint baskets, inside the upper dryer walls, and behind 4 of 4 clothes dryers. During an interview on 12/15/2016 at approximately 8:30 AM with the Laundry Supervisor, he/she confirmed the findings and stated, The lint baskets, the upper inside walls of the clothes dryers and behind the clothes dryers are cleaned every 2 weeks. Review on 12/15/2016 at approximately 9:00 AM of the facility policy titled, Cleaning of the Laundry Equipment, states under, Dryers: It is important that dryer filters be cleaned after every load. The frame should be cleaned daily, or as needed, with a disinfectant. At the end of the day, the door should be left open to allow the gasket to reshape. Items to be cleaned on the machines are, but not limited to: Dryer filter, shelf above the filter and the floor under the filter At least weekly the combustion chambers must be vacuumed to remove lint build-up. At least quarterly the front of dryers are to be removed and the interior vacuumed to remove lint build-up. Inspect and clean as necessary the dryer exhaust ducts. The area around the thermocouple must be lint free. Lint and heat causes fire. An observation on 12/15/2016 at approximately 8:35 AM of the clothes washers revealed stagnant water standing behind the clothes washers. There were towels around the outside of the area to soak up overflow. Water was pouring into the drain and none was moving out via the drain. An interview on 12/15/2016 at appro… | 2020-09-01 |
| 142 | 142 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2020-01-22 | 689 | D | 1 | 0 | E8OZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to provide adequate supervision to prevent resident to resident altercations for one of 17 residents (Resident #16) reviewed for altercations. Resident #16 continued to wander about the facility, including into other resident rooms, following four resident to resident altercations. The findings included: Review of Resident #16's Face Sheet, provided by the facility on 01/20/20, revealed s/he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #16's Quarterly Minimum Data Assessment (MDS) with an Assessment Reference Date of 11/08/19 revealed he/she was unable to complete the Brief Interview of Mental Status (BI[CONDITION]) interview but was assessed by staff to have moderately impaired decision-making abilities; had no behavioral symptoms directed at others; did not wander; and ambulated independently. Review of facility investigations of resident to resident altercations revealed Resident #16 was involved in four of these incidents between 11/15/19 and [DATE]: On 11/15/19 at 04:00 PM, Resident #16 entered Resident #15's room and got into Resident #15's bed while Resident #15 was out of the room. When Resident #15 returned to the room and found Resident #16 in the bed, s/he asked Resident #16 to leave, and Resident #16 hit him/her in the face. On 11/20/19 at 06:00 PM, Resident #16 was again in Resident #15's bed. When Resident #15 asked Resident #16 to leave, Resident #16 hit Resident #15 with his/her shoe. The facility sent Resident #16 to the emergency room , where his/her [MEDICATION NAME] dosage was increased from 0.5 milligrams (mg) three times daily to 1 mg three times daily. On 11/25/19 at 02:15 PM, Resident #16 was ambulating in the hallway near the nurse's station, turned a corner, and encountered Resident #17, who was pacing near the nurse's station. Resident #16 struck Resident… | 2020-09-01 |
| 143 | 143 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2020-01-22 | 758 | D | 1 | 0 | E8OZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review, and review of the facility's policy, it was determined the facility failed to identify and monitor specific target behaviors for residents taking [MEDICAL CONDITION] medications. This was true for one of seventeen residents (Resident #16) sampled for [MEDICAL CONDITION] medication use. The findings included: Review of Resident #16's Face Sheet, provided by the facility on 01/20/20, revealed he/she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #16 Admission physician's orders [REDACTED]. [MEDICATION NAME] (an antipsychotic medication), 5 milligrams (mg) twice daily for a [DIAGNOSES REDACTED]. [MEDICATION NAME] (a benzodiazepine), 2 mg three times daily beginning 08/05/19; and [MEDICATION NAME] (an antipsychotic), 1 mg twice daily beginning 08/05/19. Physician's telephone orders located in the Orders tab of Resident #16's paper clinical record revealed: 08/06/19, decrease [MEDICATION NAME] to 2.5 mg twice daily and decrease [MEDICATION NAME] to 0.5 mg three times daily; 11/21/19, increase [MEDICATION NAME] to 1 mg three times daily; [DATE], increase [MEDICATION NAME] to 5 mg twice daily; 12/05/19, decrease [MEDICATION NAME] to 0.5 mg three times daily. Review of Resident #16's Quarterly Minimum Data Assessment (MDS) with an Assessment Reference Date of 11/08/19 revealed he/she was unable to complete the Brief Interview of Mental Status (BI[CONDITION]) interview but was assessed by staff to have moderately impaired decision-making abilities; had no behavioral symptoms directed at others; and ambulated independently. On 01/21/20 at 10:15 AM, an interview with the Director of Nursing Services (DNS) revealed the facility monitored behaviors for [MEDICAL CONDITION] medications on the Medication Administration Record [REDACTED]. Review of Resident #16's MAR for November and December 2019 and January 2020 revealed, Monitor Resident every shift for behaviors and side effects re… | 2020-09-01 |
| 144 | 144 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2016-09-09 | 226 | D | 0 | 1 | LUPR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, review of an abuse incident investigation, record review, observation, and a review of the facility's policy and procedure for abuse, including protection, the facility failed to ensure that 1 of 35 sampled residents was protected against future abuse incidents, Resident #2. The findings include: Review of the Abuse Prevention, Investigation and reporting policy (Carlyle Senior Care) approval date 8/25/2016: Policy Statement: The resident has the right to be free from verbal, sexual, physical, and mental abuse, neglect, involuntary seclusion and misappropriation of personal property. Policy Interpretation and Implementation: Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. 1. Screening 2. Training 3. Prevention 4. Identification 5. Investigation 6. Protection The facility protects residents from harm during an investigation. A representative or designee from the Social Services department assesses the resident ' s emotions concerning the incident as well as the residents' reactions to his/her involvement in the investigation. Appropriate steps are taken for protection of the resident from additional harm during the investigation. Unless otherwise requested by the resident, the social service representative or designee will provide the administrator and the director of nursing services with a report of his/her findings. Employees of this facility who have been accused of resident abuse will be reassigned or suspended until the results of the investigation have been reviewed by the administrator. 7. Reporting/Response The facility analyzes the occurrences to determine what changes are needed, if any, to policies and procedures to prevent further occurrences. Resident #2 was admitted in 2000 and readmitted on [DATE… | 2020-09-01 |
| 145 | 145 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2016-09-09 | 253 | D | 0 | 1 | LUPR11 | Based on observations in the main dining room, 1 of 2 dining areas in the facility, an interview with an unsampled resident, and an interview with the administrator, the facility failed to ensure the main dining room was maintained in a sanitary, orderly and comfortable interior to ensure a pleasant dining environment for the many residents that eat breakfast, lunch, and dinner in the main dining room. The findings include: Observations in the main dining room on 09/08/2016 at 12:33 PM it was noted that both of the cathedral type ceiling, closest to the kitchen, had the following concerns: 1. The overhead vent located on the cathedral ceiling closest to the steam table had peeling plaster/paint peeling on one side of the vent. The area with the peeling plaster/paint was approximately 6 inches by 15 inches long. Approximately 4 inches of plaster/paint was also hanging from this area, resembling icicles. There was a table with a tablecloth located directly under this area of the peeling plaster/paint. Two residents were at the table waiting for their meal. At least 5 ceiling tiles located in this same area appeared with a beige looking stain, possibly indicating a wet appearance. At least 3 tiles were bowed in appearance. There were at least 2 plastic 5 gallon size buckets located under the front of the steam table, not coming into direct contact with the foods being served. There was additional buckets located near the entry to the dining room. Two of the 4 borders had peeling paint on the surface that edged the cathedral ceiling. There were 6 other ceiling tiles that are darker in appearances then the white tiles located next to them. They appear wet (beige looking stain) and bowed. Some of this area also had peeling plaster/paint hanging down. 2. On the cathedral ceiling located near the entrance of the dining room there are numerous ceiling tiles with a beige looking stain, possibly indicating long-term water damage. 3. A red painted wall in the dining room, to the right facing the kitchen/serving line, had sta… | 2020-09-01 |
| 146 | 146 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2017-10-11 | 155 | D | 1 | 1 | SACF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and review of the facility policy, the facility failed to observe resident's Advanced Directive rights for 1 of 12 residents reviewed for Advanced Directives. The facility did not ensure the correct code status for Resident #67. The findings included: The facility admitted Resident #67 with a [DIAGNOSES REDACTED]. On [DATE] at 11:10 AM, during record review, a signed and notarized Advanced Directive dated (MONTH) 1, (YEAR), prior to the Resident's admission on [DATE], revealed the Resident requested DNR status. The Physician's admission documentation for Resident #67 stated the Resident did not want CPR and was discussed with the Resident's daughter who is also the Responsible Party. On [DATE] 1:36 PM an interview with the Social Services Director revealed s/he agrees with documentation in the chart stating Resident #67 should be a DNR. S/he also discovered a signed DNR order in the file cabinet in Social Services office for the Resident that was not in the chart. On [DATE] 1:48 PM The Social Services Director stated, I will be changing the code status to DNR immediately for this resident. S/he also stated, I should have caught it; I used to work for DHEC. This surveyor witnessed the Social Services Director remove the FULL CODE page and replace it with the DNR page in Resident #67's chart. On [DATE] 2:05 PM Review of Facility Policy, DO NOT RESUSCITATE- POLICY, Policy Interpretation and Implementation #5 states: If the decision has been made for a natural death, the physician shall be notified and a DNR (DO NOT RESUSCITATE) order will be obtained as well as documented in the clinical records. | 2020-09-01 |
| 147 | 147 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2017-10-11 | 323 | G | 1 | 1 | SACF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interviews, and observations, the facility failed to provide the care and services necessary to prevent accidents for 1 of 3 residents reviewed for accidents. The facility failed to provide Mechanical Lift for all transfers to have assist of two people required for use of lift for Resident #16. The findings included: Record review revealed Resident #16 was admitted [DATE] with [DIAGNOSES REDACTED]. Non ambulatory and very frail with muscle loss. Observation revealed Resident #16 who has contractures to all the extremities, fingers, with foot drop on both feet. Call bell was observed by her right hand, and the call bell is a squeezable, round-shape that can be rung using her fingers. Resident requires total assistance for all ADL skills and requires a two staff transfer Resident#16's bedroom revealed low bed, bed alarm and floor mat in place. Resident #16 declined to be interviewed. A review of the nurse's notes revealed the following entries; 09/20/2017-- At 8:30pm, CNA called the nurse to Resident #16's room. Nurse observed Resident #16 had a right knee swollen and bruise with knee dislocated. Notified Doctor, DON, and family. 09/21/2017 - Resident #16 returned from the hospital at 12:30 am -- ER reported femur fracture -X-ray reported. Pain meds were given and leg splint in place. Continue to monitor. Review of the Physicians Orders revealed dated 09/20/2017 -Order (R) knee immobilizer Apply to (R) leg Check skin and circulation, shift R/T fracture. A review of the resident's Care Plans revealed the following; Resident #16 will have reduced risk of falls with injury thru the 90 days. Attend to lower extremities during daily care. Evaluate falls risk quarterly and prn. Attend to resident's needs promptly. Keep bed in lowest position. When care isn't being provided, ensure call bell is within reach. Mechanical Lift for all transfers. Assist of two people required for use of lift (05/02/2016). Place in supervised area… | 2020-09-01 |
| 148 | 148 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2017-10-11 | 441 | D | 1 | 1 | SACF11 | > Based on observation and interview, the facility failed to follow manufacturer's instructions for disinfecting a multi-use glucometer during 1 of 1 observation of a Finger Stick Blood Sugar. The findings included: On 10/10/2017 at 4:18 PM Licensed Practical Nurse (LPN) #1 was observed performing a Finger Stick Blood Glucose on Resident # 1. The LPN washed her/his hands, placed the glucometer inside a glove and pinched an opening into the glove. After obtaining the specimen and completing the procedure the LPN removed the glucometer from glove, removed her/his gloves, sanitized her/his hands and signed the procedure off on the Medication Administration Record. LPN #1 cleaned the glucometer with an Alclavis Bleach-Wipe for approximately 10 seconds. During an interview at that time, the LPN stated s/he cleaned the glucometer for about 5 seconds. The LPN confirmed s/he was not aware manufacturer's instructions were to keep the device visibly wet for 5 minutes to be effective against Clostridium Difficile. In addition, the LPN stated s/he usually used the other (Microdot) bleach wipe and just wipes it down good and allows it to air dry and stated that was the policy. Review of the Microdot instructions at that time revealed the instructions indicated a 3 minute contact time for Clostridium Difficile. The nurse also stated that it was policy to clean the device after use, not before. During an interview at 4:37 PM, the Director of Nursing (DON) stated each cart had 2 glucometers, one to be used will the other is air drying. Three additional nurses were interviewed regarding the policy for cleaning the glucometer and all 3 stated the device needed to have a contact time of 3-5 minutes. Review of the policy revealed 2. Sanitize the glucometer with the appropriate product (i.e. (that is) Sani cloth, Glucometer Wioe, etc (et cetera) .) as long as the product contains bleach. 3. Allow the glucometer to completely air dry before storage or use. During an interview on 10/11/17 at 2:14 PM, the DON confirmed the instructions … | 2020-09-01 |
| 149 | 149 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2018-11-30 | 573 | E | 0 | 1 | JLSM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy titled Resident Rights and interview, the facility failed to provide copies of medical records to 5 of 5 residents who had requested them. Four of 10 residents in the Group Meeting (Residents #7, #31, #73, and #77) and Resident #43 stated they had requested copies of their medical records and had not received them. The findings included: On 11/28/18 at approximately 10:36 AM, a Resident Council meeting was held with the surveyor, attended by 10 interviewable residents, all with Brief Interview for Mental Status scores ranging from 10-15. During the group interview, 4 of the 10 residents expressed that multiple requests had been made in attempts to obtain their medical records from the facility. Resident #s 7, 31, 73, and 77 all expressed they had made multiple requests to the Administrator and to their direct care staff. Review of the grievance log on 11/28/18 at approximately 3:00 PM revealed there were no references to requests made. During an interview with the Administrator and Social Services Director on 11/29/2018 at 9:45 AM, the Administrator indicated s/he was unaware of any requests and if there had been, they would have been taken care of. However, upon further interview, s/he indicated there was no documentation available proving or disproving the requests were made. Review of the facility's admission packet section labeled Resident Rights states: The resident has the right to access personal and medical records pertaining to him or herself. The facility admitted Resident #43 with [DIAGNOSES REDACTED]. Record review on 11/30/18 at 7:50 AM revealed that the resident was hospitalized from 8-31-18 to 9-6-18 Urinary Tract Infection, Hydro[DIAGNOSES REDACTED], [MEDICAL CONDITION], Dehydration, and Acute Kidney Injury. S/he was also hospitalized from 9-25-18 to 9-26-18 for [MEDICAL CONDITION] Calculus, Hydro[DIAGNOSES REDACTED], and Recurrent [MEDICATION NAME]. During an interview on 11/26/18 at 4:1… | 2020-09-01 |
| 150 | 150 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2018-11-30 | 578 | D | 0 | 1 | JLSM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility policy titled Resident Right to Formulate Advance Directives, the facility failed to ensure accuracy for 2 of 2 residents reviewed for advance directives. The findings included: Resident #51 was admitted to the facility on [DATE]. Review of his/her medical record on [DATE] showed that on [DATE] the Patient Self-Determination Act was signed by the Responsible Party (RP) indicating desires to have a living will or medical proxy. Additional review showed only an Emergency Medical Services Do Not Resuscitate Order signed on [DATE]. An interview with the Director of Nursing (DON) on [DATE] at 3:49 PM indicated there was no Physician's Order for a DNR nor was there any documentation indicating the Resident's inability to make health care decisions. Review of the facility's policy titled, Resident Right to Formulate Advance Directives, on [DATE] indicated the facility will periodically assess the resident for decision-making abilities and approach the health care proxy or legal representative if the resident is determined not to have decision making capabilities. The facility admitted Resident #135 on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission 5-day Minimum Data Set assessment revealed the resident had both short- and long-term memory problems with severely impaired decision-making ability. Record review on [DATE] at 8:53 AM revealed a full-page bright green form noting FULL CODE in the front of the medical record. Physician's Orders also noted the resident as a full code. Review of the Care Plan on [DATE] at 9:48 AM revealed Problem/Need #1: I desire advanced directives/DNR (Do Not Resuscitate) as of [DATE]. Approaches included to Honor my request for DNR status and Do not perform CPR (Cardiopulmonary Resuscitation) on me. During an interview on [DATE] at 11:38 AM, when asked individually how they would determine a resident's code status in case of an emergency, Licensed P… | 2020-09-01 |
| 151 | 151 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2018-11-30 | 580 | D | 0 | 1 | JLSM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure written notice of room/roommate change was provided to 2 of 2 residents reviewed for notification of change (Residents #51 and #11). The findings included; Review of the medical record on 11/29/2018 at 4:47 PM revealed that Resident #51 was moved from room [ROOM NUMBER]A to 151A on 11/26/2018. The Social Services Notes dated 11/26/2018 stated that the family was notified by telephone. Additionally, review of Resident #11's medical record on 11/28/2018 indicated s/he had a last documented roommate change on 7/13/2017 by Social Services. However, the resident received a new roommate on 11/26/2018 and indicated to this surveyor during an interview on 11/26/2018 that s/he had not been informed of the change. S/he stated the new roommate just showed up with his/her belongings and no one told me anything. Review of the Social Services Notes revealed no documentation related to the recent roommate change. During an interview on 11/28/18 at 12 PM, the Social Services Director stated that written notices were not sent out and notifications of room/roommate changes were made only by telephone calls. Review of the facility's policy titled, Resident Rights/ Room and/or Roommate Change states, The resident and/or family have the right to be informed in advance and in writing, to include the reason for the change, before the room or roommate in the facility is changed, unless it is an emergent situation for resident safety. | 2020-09-01 |
| 152 | 152 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2018-11-30 | 583 | E | 0 | 1 | JLSM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to protect the privacy of medical records for 3 of 3 sampled residents reviewed for Baseline Care Plans (Residents #51, #65, and #135). The findings included: The facility admitted Resident #135 on 11-8-18 with [DIAGNOSES REDACTED]. Dementia with Behavioral Disturbance, [MEDICAL CONDITIONS] Fibrillation, [MEDICAL CONDITION], Hypertension, [MEDICAL CONDITION], Reflux, [MEDICAL CONDITION] Left Lower Extremity, and Acute Kidney Injury. Review of the 11/8/18 Baseline Care Plan on 11/28/18 at 9:48 AM revealed documentation that the plan was verbally reviewed with the Resident Representative on 11/9/18. There was no evidence in the record that a summary or copy of the Baseline Care Plan was provided. During an interview on 11/28/18 at 4:31 PM, the Minimum Data Set (MDS) Coordinator stated that if the resident and family were not able to attend the Baseline Care Plan meeting and s/he was unable to reach them by phone, s/he documented and left a copy in the resident's room in an envelope. Resident #65 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #51 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Record review for Residents #65 and #51 revealed no evidence that the facility had provided summaries or copies of the Baseline Care Plans to the residents or their representatives. During an interview on 11/28/18 at 4:31 PM, the Minimum Data Set (MDS) Coordinator stated s/he did not mail out the summaries or copies. S/he stated s/he left them in the resident's room in an envelope and called the family to let them know s/he left it in the room if s/he could get hold of them. The facility's Baseline Care Plan and Form Policy states, The facility must provide the resident and their representative with a summary of the baseline care plan . | 2020-09-01 |
| 153 | 153 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2018-11-30 | 584 | E | 0 | 1 | JLSM11 | Based on observations and interviews, the facility failed to ensure corridor wall coverings and baseboards were in good repair primarily on 1 of 4 halls. The findings included: On all days of the survey,[NAME]Hall wall coverings were noted to be permanently stained with what appeared to be some type of liquid that had been sprayed, run down the walls, and dried. Baseboards were darkly scarred throughout and chipped in multiple places. Housekeeping contracted management was observed cleaning the walls on 11/27/18 and 11/28/18 in unsuccessful attempts to remove the wall stains. On 11/27/18 at 1:38 PM, the Assistant Director of Nurses verified that wall coverings were discolored and stated, It looks like it has been sprayed with something. On 11/27/18 at 5:30 PM, the Administrator and Housekeeping Contract Manager stated the walls had been cleaned but the stains would not come out. On 11/28/18 at 8:51 AM, the Housekeeping Contract Manager stated the walls must have been cleaned with an inappropriate chemical. | 2020-09-01 |
| 154 | 154 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2018-11-30 | 604 | D | 0 | 1 | JLSM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to ensure the resident is free from unnecessary physical restraint. The facility did not afford the resident the opportunity to be free from the restraint when in close view of the staff or when participating in activities in the presence of the activity coordinator, other staffs and residents. The facility also failed to appropriately implement attempts to discontinue the restraint for one of six sample residents reviewed for restraints. The findings included: The facility admitted Resident #66 on 6/9/17 with [DIAGNOSES REDACTED]. During the initial survey tour on 11/26/18 at 10:45 AM Resident #66 seat on his/her wheelchair in the dining/activity room, lap belt in place, attempting to take off arm skin protector, at which time a certified nursing assistant (C.N.A) took the resident back to his/her room. On 11/27/18 the resident was seated at the nurse's station again and half an hour later in the activity room, lap belt in place at both observations. Resident's room observation on 11/28/18 at 10:42 AM revealed bed in low position, side rails in place and large floor mats at both side of the bed. Nurse's notes reviewed on 11/27/18 at 1:13 PM revealed that the resident has a lap belt restraint that is released every two hours, during activity and meal times. However, this intervention did not occur during surveying hours. According to the care plan reviewed on 11/28/18 at approximately 11:00 AM on 11/13/18 the facility put a three day restraint reduction attempt in placed, Lap belt removed and resident situated in the common area for easy viewing. But the restraint reduction documentation showed that after releasing the lap belt if the resident tried to get up from his/her wheelchair the staff would place the lap belt back on. During an interview with the care plan coordinator and director of nursing (DON) on 11/28/18 at approximately 11:30 AM confirmed that the three … | 2020-09-01 |
| 155 | 155 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2018-11-30 | 607 | D | 0 | 1 | JLSM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement the policy related to Abuse for one incident of resident to resident abuse reviewed. The findings include; Res #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 11/26/2018 at approximately 2:43 PM during a resident interview with this surveyor, Resident #11 indicated that s/he had been kicked on last week by another resident and nothing was done about it. Further interview, the resident explained a male resident had approached him/her, kicked and walked away. After the incident, s/he told Registered Nurse (RN) #2 who then was believed to have told the Director of Nursing (DoN). Further interview with RN #2, s/he stated s/he had told the DoN but had not personally done anything to alleviate or investigate the incident. During record review on 11/28/18 at 9:15 AM, there was no documentation of the alleged incident noted. During an interview with RN#2 on 11/28/18 at 12:28 PM, s/he indicated that s/he had not visibly witnessed the incident, but the resident had made him/her aware and s/he told his/her direct supervisor, the DoN. On 11/28/2018 at 3:26 PM, during an interview with the DoN, s/he stated this was his/her first time hearing of the incident. Review of the facility's policy titled, Resident Rights- Abuse and Abuse Prevention, Neglect and Exploitation provided by the DoN on 11/28/18 at 3:30 PM states response and reporting of abuse, neglect and exploitation- anyone in the facility can report suspected abuse to the abuse agency hotline, when abuse, neglect or exploitation is suspected, the Licensed Nurse should: respond to the needs of the resident and protect them from further incident (Document), notify the Director of Nursing and Administrator (document), and initiate an investigation immediately . | 2020-09-01 |
| 156 | 156 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2018-11-30 | 609 | D | 0 | 1 | JLSM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to report an allegation of resident-resident abuse in a timely manner. The findings included; Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 11/26/2018 at approximately 2:43 PM during a resident interview with this surveyor, Resident #11 indicated that s/he had been kicked on last week by another resident and nothing was done about it. Further interview, the resident explained a male resident had approached him/her, kicked and walked away. After the incident, s/he told Registered Nurse (RN) #2 who then was believed to have told the Director of Nursing (DoN). During record review on 11/28/18 at 9:15 AM, there was no documentation of the alleged incident noted. During an interview with RN#2 on 11/28/18 at 12:28 PM, s/he indicated that s/he had not visibly witnessed the incident, but the resident had made him/her aware and s/he told his/her direct supervisor, the DoN. On 11/28/2018 at 3:26 PM, during an interview with the DoN, s/he stated this was his/her first time hearing of the incident. Review of the facility's policy titled, Resident Rights- Abuse and Abuse Prevention, Neglect and Exploitation provided by the DoN on 11/28/18 at 3:30 PM states response and reporting of abuse, neglect and exploitation- anyone in the facility can report suspected abuse to the abuse agency hotline, when abuse, neglect or exploitation is suspected, the Licensed Nurse should: respond to the needs of the resident and protect them from further incident (Document), notify the Director of Nursing and Administrator (document), and initiate an investigation immediately . | 2020-09-01 |
| 157 | 157 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2018-11-30 | 610 | D | 0 | 1 | JLSM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to report an allegation of resident-resident abuse in a timely manner. The findings included; Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 11/26/2018 at approximately 2:43 PM during a resident interview with this surveyor, Resident #11 indicated that s/he had been kicked on last week by another resident and nothing was done about it. Further interview, the resident explained a male resident had approached him/her, kicked and walked away. After the incident, s/he told Registered Nurse (RN) #2 who then was believed to have told the Director of Nursing (DoN). During record review on 11/28/18 at 9:15 AM, there was no documentation of the alleged incident noted. During an interview with RN#2 on 11/28/18 at 12:28 PM, s/he indicated that s/he had not visibly witnessed the incident, but the resident had made him/her aware and s/he told his/her direct supervisor, the DoN. On 11/28/2018 at 3:26 PM, during an interview with the DoN, s/he stated this was his/her first time hearing of the incident. S/he then verified there was no investigation started at the time or any information documented regarding the incident. Review of the facility's policy titled, Resident Rights- Abuse and Abuse Prevention, Neglect and Exploitation provided by the DoN on 11/28/18 at 3:30 PM states response and reporting of abuse, neglect and exploitation- anyone in the facility can report suspected abuse to the abuse agency hotline, when abuse, neglect or exploitation is suspected, the Licensed Nurse should: respond to the needs of the resident and protect them from further incident (Document), notify the Director of Nursing and Administrator (document), and initiate an investigation immediately .Additionally the policy states when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur, an investigation is immediately warranted. Onc… | 2020-09-01 |
| 158 | 158 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2018-11-30 | 623 | D | 0 | 1 | JLSM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview , the facility failed to provide written notice of facility-initiated transfer to the Residents' Representatives and/or Ombudsman for 2 of 5 sampled residents reviewed for hospitalization (Residents #67 and #70) . The findings included: The facility admitted Resident #67 with [DIAGNOSES REDACTED]. Record review on 11/28/18 at 2:31 PM revealed the resident was transferred to the hospital on 9-25-18 for Aspiration Pneumonia. Further review revealed no evidence of written notification of the transfer to the Resident Representative. During an interview on 11/30/18 at 12:12 PM, when asked about notification of the family, Social Services stated there should be documentation in the record that the family was called. S/he was unaware of the requirement for a written notice to be sent. The facility admitted Resident #70 with [DIAGNOSES REDACTED]. Record review on 11/27/18 at 12:53 PM revealed the resident was hospitalized from [DATE] to 10/26/18 for Agitation, Combativeness, and [DIAGNOSES REDACTED]. Further review revealed no evidence of written notification of the transfer to the Resident Representative or Ombudsman. During an interview on 11/30/18 at 12:18 PM, Social Services reviewed her/his documentation of monthly reports and stated s/he had not sent transfer notifications to the Ombudsman for the month of October. S/he was unaware of the requirement for a written notice of transfer to be sent to the Resident Representative. | 2020-09-01 |
| 159 | 159 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2018-11-30 | 625 | D | 0 | 1 | JLSM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide written notice of bed-hold to the Residents' Representatives upon facility-initiated transfer for 2 of 5 sampled residents reviewed for hospitalization (Residents #67 and #70). The findings included: The facility admitted Resident #67 with [DIAGNOSES REDACTED]. Record review on 11/28/18 at 2:31 PM revealed the resident was transferred to the hospital on 9-25-18 for Aspiration Pneumonia. Further review revealed no evidence of written notification of the facility's bed-hold policy supplied to the Resident Representative upon transfer. During an interview on 11/30/18 at 9:18 AM, the Director of Nurses (DON) reviewed the record, was unable to locate any information about bed-hold notification, and referred the surveyor to Social Services. During an interview on 11/30/18 at 12:12 PM, Social Services reviewed the record and was unable to locate any information about bed-hold notification. S/he was unsure who was responsible for bed-hold notification upon transfer. The facility admitted Resident #70 with [DIAGNOSES REDACTED]. Record review on 11/27/18 at 12:53 PM revealed the resident was hospitalized from [DATE] to 10/26/18 for Agitation, Combativeness, and [DIAGNOSES REDACTED]. Further review revealed no evidence of written notification of the facility's bed-hold policy supplied to the Resident Representative upon transfer. During an interview on 11/30/18 at 9:18 AM, the Director of Nurses (DON) reviewed the record, was unable to locate any information about bed-hold notification, and referred the surveyor to Social Services. During an interview on 11/30/18 at 12:18 PM, Social Services reviewed the record and was unable to locate any information about bed-hold notification. S/he was unsure who was responsible for bed-hold notification upon transfer. | 2020-09-01 |
| 160 | 160 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2018-11-30 | 641 | E | 0 | 1 | JLSM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to assure the accuracy of assessments for 7 of 23 sampled residents reviewed for accuracy of Minimum Data Set (MDS) assessments (Residents #23, #52, #57, #66, #67, #70, and #135) and for 2 of 2 residents noted on the MDS 3.0 Missing OBRA Assessment report (Residents #40 and #60). The findings included: The facility admitted Resident #23 with [DIAGNOSES REDACTED]. Review of the 8-29-18 Admission/5-Day and the 9/7/18 14-Day MDS assessments on 11/29/18 at 11:23 PM revealed the following: (1) Section B of both assessments noted that the resident was sometimes understood and sometimes understands. However, the Section C Brief Interview for Mental Status (BIMS) and the Section D Mood interviews were not conducted. The reasons recorded were that the resident was rarely/never understood. (2) The 9/7/18 14-Day assessment only had one fall coded. Review of Incident/Accident Reports on 11/30/18 at 9:34 AM revealed the resident had sustained 2 falls during the 7-day look-back period (on 9/1/18 and 9/5/18). During an interview on 11/30/18 at 10:19 AM, the MDS Coordinator stated that Sections C and D were completed by Social Services. S/he verified that the coding for not conducting the interview because the resident was rarely/never understood was not consistent with the coding in Section B. S/he reviewed the record, verified the falls noted in the Nurses Notes and on the Care Plan, and confirmed that the number of falls coded on the 14-Day MDS was incorrect. The facility admitted Resident #52 with [DIAGNOSES REDACTED]. Hypertension, [MEDICAL CONDITION], Dementia, Aspiration Pneumonia, Dysphagia, Gastro-[MEDICAL CONDITION] Reflux Disease, B-12 Deficiency, and Multiple [MEDICAL CONDITION]. Review of the 2-6-18 Significant Change and the 10-21-18 Quarterly MDS assessments on 11/27/18 at 7:48 PM revealed the following: (1) Section B of both assessments noted that the resident was usually understood an… | 2020-09-01 |
| 161 | 161 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2018-11-30 | 644 | D | 0 | 1 | JLSM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to complete a Preadmission Screening and Resident Review (PASRR) Level II for a resident with a positive PASRR level I and a history of psychiatric hospitalization at the time of admission to the facility for one of one sampled resident reviewed for PASRR. Findings: The facility admitted Resident #15 on 12/1/14 with [DIAGNOSES REDACTED]. During an observation on 11/26/18 at 3:34 PM the resident seems to get agitated very easy when greeted in the hallway s/he responded in a distrustful manner. The next day, during lunch in the dining room s/he did not want the certified nursing assistant (C.N.A) to help him/her with the food protector. Nurse's notes reviewed on 11/29/18 at 2:36 PM indicated that the resident could verbalize some need to staff. However, his speech is unclear and incoherent and often refuses care, gets combative and yells out loud. Record reviewed on 11/29/18 at approximately 3:00 PM revealed a PASRR level I completed on 11/18/14 (prior admission) indicated that the resident had a history of [REDACTED]. During an interview with the DON on 11/29/18 at 4:00 PM she stated that the resident had not had any incidents for the last three months. She also noted that the resident had not had a PASARR Level II because according to his/her interpretation of the regulation the resident did not need one. The DON later acknowledged that the resident should have had a level II PASRR and possibly psychiatric services. | 2020-09-01 |
| 162 | 162 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2018-11-30 | 655 | E | 0 | 1 | JLSM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation,record review and interview the facility failed to provide evidence of Baseline care plan development and provided summaries for 3 of 3 residents reviewed for baseline care plans. The findings included: Resident #65 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #51 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Record review for Residents #65 and #51 revealed the facility had not provided copies of the summary of the baseline care plans to the residents or their representatives. During an interview on 11/28/18 at 4:31 PM, the Minimum Data Set (MDS) Nurse indicated s/he does not mail out the summaries, s/he leaves it in the room in an envelope and calls the family to let them know s/he left it in the room if s/he can get a hold of them. A review of the facility's MDS Policy- Baseline Care Plan and Form Policy on 11/30/2018 at 12:47 PM states, the facility must provide the resident and their representative with a summary of the baseline care plan . The facility admitted Resident #135 on 11-8-18 with [DIAGNOSES REDACTED]. Dementia with Behavioral Disturbance, [MEDICAL CONDITIONS] Fibrillation, [MEDICAL CONDITION], Hypertension, [MEDICAL CONDITION], Reflux, [MEDICAL CONDITION] Left Lower Extremity, and Acute Kidney Injury. Review of the 11/8/18 Baseline Care Plan on 11/28/18 at 9:48 AM revealed documentation that the plan was verbally reviewed with the Resident Representative on 11/9/18. There was no evidence in the record that a summary or copy of the Baseline Care Plan was provided. During an interview on 11/28/18 at 4:31 PM, the Minimum Data Set (MDS) Coordinator stated that if the resident and family were not able to attend the Baseline Care Plan meeting and s/he was unable to reach them by phone, s/he documented and left a copy in the resident's room in an envelope. The Minimum Data Set (MDS) Coordinator stated s/he never mailed a summary or copy of the Baseline Care Plan… | 2020-09-01 |
| 163 | 163 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2018-11-30 | 656 | D | 0 | 1 | JLSM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to develop/implement the care plan interventions related to proper positioning during enteral feeding therapy for one of two sampled residents reviewed for tube feeding. Findings: The facility admitted Resident #33 on 3/11/18 with [DIAGNOSES REDACTED]. During the initial survey tour on 11/26/18 at 4:22 PM observed Resident #33 in a low bed with the head of it slightly raised and the resident slid down to the lower part of the bed while receiving enteral feeding. On 11/27/18 at 11:03 AM, 11/29/18 at 2:57 PM, and 11/29/18 at 4:05 PM observed the resident in a similar position. At no point during the survey, from 11/26 through 11/30, the surveyor saw any of the facility staff turning or repositioning the resident. The care plan reviewed on 11/29/18 at 3:40 PM indicated that the head of the resident's bed should be up 30-45 degrees during feeding therapy. The care plan also stated that the certified nursing assistant would turn and reposition the resident every 2 hours to prevent skin breakdown related to impaired bed mobility. The care plan did not address the resident actual or inappropriate positioning during feeding therapy. During an interview on 11/29/18 at 4:05 PM the unit manager confirmed that the resident slid down in his/her bed during feeding and stated that as an intervention to prevent complication the resident gets repositioned every 2 hours, however, s/he was not able to provide supporting evidence/documentation to indicate that the resident is being turned and repositioned every 2 hours. | 2020-09-01 |
| 164 | 164 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2018-11-30 | 657 | D | 0 | 1 | JLSM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to update the Care Plan for one of two sampled residents reviewed for abuse. The Care Plan for Resident #135 was not updated to include an incident of resident-to-resident abuse. The findings included: The facility admitted Resident #135 on 11-8-18 with [DIAGNOSES REDACTED]. Dementia with Behavioral Disturbance, [MEDICAL CONDITIONS] Fibrillation, [MEDICAL CONDITION], Hypertension, [MEDICAL CONDITION], Reflux, [MEDICAL CONDITION] Left Lower Extremity, and Acute Kidney Injury. Record review on 11/28/18 at 10:07 AM revealed an entry in Nurse's Notes at 12:57 PM on 11/15/18: Notified by (Licensed Practical Nurse #1) that resident was found by two CNAs (Certified Nursing Assistants) hitting another resident in his back while he was resting in his bed . Review of the 11/8/18 Baseline Care Plan and the 11/22/18 Interdisciplinary Care Plan on 11/28/18 at 9:48 AM revealed no mention of the behavior/incident. During an interview on 11/28/18 at 4:08 PM, the Director of Nurses verified that neither the Baseline nor Interdisciplinary Care Plan had been updated to include the resident-to-resident abuse incident on 11/15/18. | 2020-09-01 |
| 165 | 165 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2018-11-30 | 686 | D | 0 | 1 | JLSM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview , the facility failed to provide appropriate care and services to promote healing and prevent infection for one of two sampled residents observed for pressure ulcer treatments. The nurse failed to clean the scissors prior to cutting off the soiled dressing during observation of a pressure ulcer treatment for [REDACTED]. The findings included: During observation of a pressure ulcer treatment to the left heel on 11/27/18 at 2:08 PM, Registered Nurse (RN) #1 removed a scissors from her/his pocket. Without sanitizing it, s/he cut the undated soiled dressing from the unstageable malodorous wound (at least 3 inches in diameter eschar) on the heel. During an interview following the treatment, RN #1 verified s/he had taken the scissors from her/his pocket and used it to cut the dressing off without cleansing it. The RN stated s/he should have cleaned it with bleach wipes. | 2020-09-01 |
| 166 | 166 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2018-11-30 | 692 | D | 0 | 1 | JLSM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to complete a nutritional assessment and implement recommendations in a timely manner for Resident #67, one of 2 sampled residents reviewed for nutrition. The findings included: The facility admitted Resident #67 with [DIAGNOSES REDACTED]. Review of weights on 11/26/18 at 1:55 PM revealed the resident sustained [REDACTED].#) to 11/6/18 (148#), equivalent to 10.3%. Record review on 11/28/18 at 2:31 PM revealed a 10/11/18 physician's orders [REDACTED]. Review of Dietary Notes on 11/28/18 at 3:33 PM revealed that the Licensed Dietitian did not complete the assessment until 10/24/18, 13 days later. A recommendation to increase the resident's tube feeding of Fibersource HN from 58 milliliters (ml) per hour to 77 ml per hour over a 12 hour period to promote weight maintenance was not ordered or implemented until 10/26/18. During an interview on 11/29/18 at 2:54 PM, the Director of Nurses verified the above information. | 2020-09-01 |
| 167 | 167 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2018-11-30 | 693 | D | 0 | 1 | JLSM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to ensure that the resident maintained proper position during administration of enteral feeding for one of two sample residents reviewed for tube feeding. Findings: The facility admitted Resident #33 on 3/11/18 with [DIAGNOSES REDACTED]. During the initial survey tour on 11/26/18 at 4:22 PM observed Resident #33 in a low bed with the head of it slightly raised, and the resident slides down to the lower part of the bed while receiving enteral feeding. On 11/27/18 at 11:03 AM, 11/29/18 at 2:57 PM, and 11/29/18 at 4:05 PM observed the resident in a similar position. The care plan reviewed on 11/29/18 at 3:40 PM indicated that the head of the resident's bed should be up 30-45 degrees during feeding therapy. During an interview on 11/29/18 at 4:05 PM the unit manager confirmed that the resident slides down his/her bed during feeding. | 2020-09-01 |
| 168 | 168 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2018-11-30 | 755 | E | 0 | 1 | JLSM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure that medications were started in a timely manner for 1 of 5 sampled residents reviewed for unnecessary medication. [MEDICATION NAME] and [MEDICATION NAME] were not available for administration so as to be started in a timely manner for Resident #67. The findings included: The facility admitted Resident #67 with [DIAGNOSES REDACTED]. Record review on 11/28/18 at 2:31 PM revealed 11/1/18 physician's orders [REDACTED]. Review of the Medication Administration Records (MARs) on 11/28/18 revealed that the [MEDICATION NAME] was not started until 11/4/18 and was omitted on 11/7/18 due to awaiting med from pharmacy. Review of physician's orders [REDACTED].#67 had an order for [REDACTED]. Nurses Notes indicated that Registered Nurse (RN) #2 contacted the pharmacy representative who instructed her/him to access the Cubex system (emergency drug supply) for the medication. RN #2 documented that the medication was not available for administration. Review of the Medication Administration Records on 11/28/18 revealed that the [MEDICATION NAME] was not started until 9/29/18. During an interview on 11/29/18 at approximately 10 AM, RN #2 verified that the [MEDICATION NAME] was not available to be given as ordered. When asked about the availability of [MEDICATION NAME], the RN stated s/he remembered running low in Cubex. During an interview on 11/29/18 at 10:44 AM, the Director of Nurses stated the [MEDICATION NAME] was increased due to an exascerbation of the Bullous Disorder and verified the documentation in the Nurses Notes and MAR. During an interview on 11/29/18 at 10:09 AM, the RN Consultant provided a copy of the contents of the Cubex system which noted both [MEDICATION NAME] and [MEDICATION NAME] should have been available for administration. | 2020-09-01 |
| 169 | 169 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2018-11-30 | 757 | E | 0 | 1 | JLSM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to document the necessity for and effectiveness of PRN (as needed) medication administered for pain for 1 of 5 sampled residents reviewed for unnecessary medication. Resident #67 received [MEDICATION NAME] five times in 11/18 with no documented reason or results. The findings included: The facility admitted Resident #67 with [DIAGNOSES REDACTED]. Record review on 11/28/18 at 2:31 PM revealed a physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. There was no documentation found to show pain level or location at the time the medication was administered or monitoring to determine effectiveness after administration. During an interview on 11/29/18 at 10:44 AM, the Director of Nurses (DON) reviewed the record and verified the lack of documentation for [MEDICATION NAME] administration. The DON stated s/he would expect the documentation to be on the MAR. | 2020-09-01 |
| 170 | 170 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2018-11-30 | 880 | D | 0 | 1 | JLSM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews, the facility failed to ensure that appropriate handwashing procedures were implemented following completion of one of two pressure ulcer treatments observed (Resident #67). The findings included: The facility admitted Resident #67 with [DIAGNOSES REDACTED]. Following a pressure ulcer treatment for [REDACTED].#2 sanitized her/his hands and exited the resident's room. S/he entered the shower room, opened the bin with her/his hand, and disposed of the bag of trash from the treatment. The nurse then left the room without washing/sanitizing her/his hands and headed toward the nursing station. When asked about washing her/his hands after touching the trash bin lid, RN #2 stated s/he would go to the nurse's desk to sanitize her/his hands or to the bathroom located near there. No sanitizer was observed at the nurses station. When washing hands in the bathroom was discussed, the nurse admitted s/he would contaminate the key and doorknob prior to being able to wash hands in that location. The Assistant Director of Nurses (ADON) observed the procedure and stated that RN #2 should have washed her/his hands in shower. The DON stated the nurse should have washed hands in the shower where a sink was readily available. | 2020-09-01 |
| 171 | 171 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2018-11-30 | 924 | D | 0 | 1 | JLSM11 | Based on observation and interview, the facility failed to ensure that handrails were installed as required on one of 4 halls. The findings included: Observations on all days of the survey revealed 3 sections of handrails missing on[NAME]Hall. Two sections were missing, one on either side of the Conference room, and one section was missing between the patio exit (across from the Conference Room) and the fire doors. During an interview on 11/28/18 at 8:16 AM, the Maintenance Supervisor and Administrator were measuring the walls and verified that (2) 4' and (1) 8' sections of handrails had not been installed. | 2020-09-01 |
| 172 | 172 | LINLEY PARK REHABILITATION AND HEALTHCARE CENTER, | 425016 | 208 JAMES STREET | ANDERSON | SC | 29625 | 2018-06-27 | 812 | F | 0 | 1 | Z84K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of facility policy and procedure the facility failed to ensure 1)Foods stored in refrigerator were stored appropriately to prevent cross- contamination in 1 of 1 kitchen and 2)Expired bottled juice which was stored in the Nourishment Refrigerator was discarded on or before the expiration date in 1 of 2 Nourishment Refrigerators. The findings included: During an observation made while in the Walk-In Refrigeration Unit on [DATE] at 4:45 PM, an aluminum sheet pan located on the bottom shelf of a shelving rack contained 2, 10 pound rolls of frozen ground beef and 5 bags of frozen assorted chicken pieces. One of the 10 pound rolls of ground beef was on one side of the pan and the other 10 pound roll was on the other side of the same pan, the 5 bags of assorted chicken pieces were sandwiched between the two rolls of ground beef. This observation was verified by the Kitchen Manager and the Certified Dietary Manager (CDM). When the CDM was asked should the ground beef and chicken be stored on the same tray together, he/she said, No and then told the Kitchen Manager to get a pan and move the bags of chicken pieces to a separate pan. The Kitchen Manager had already begun to move the bags of chicken pieces to a separate pan and relocated the pan which now contained the bags of chicken pieces on the same shelf and beside the ground beef which was now on the same pan which previously had shared space with the bags of thawing chicken. On [DATE] at 9:30 AM, the Kitchen Manager provided a copy of the Inservice titled, Cross Contamination, which was Given By: CDM and the Kitchen Manager, to the dietary staff, 10 team members signed the inservice on [DATE] after the discovery of thawing ground beef and chicken on the same pan in the Walk- In Cooler. The form titled, Cross Contamination, states, .Raw meat, poultry and seafood should be stored in containers or sealed plastic bags to prevent their juices from dipping on… | 2020-09-01 |
| 173 | 173 | LINLEY PARK REHABILITATION AND HEALTHCARE CENTER, | 425016 | 208 JAMES STREET | ANDERSON | SC | 29625 | 2019-08-01 | 578 | D | 0 | 1 | 5ZED11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to give 2 of 2 residents reviewed an opportunity to formulate an advance directive. Residents #11 and #14 were judged as mentally capable by physicians, yet were not involved in their own advance directive. The findings included: Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent brief interview for mental status (BIMS) yielded a score of 13. Review of Resident #11's chart on 7/29/19 at approximately 2:50 PM revealed two physicians had judged Resident #11 to be mentally capable, but Resident #11 did not sign his/her advance directive. During an interview with the Director of Nursing (DON) on 7/30/19 at approximately 2:58 PM s/he confirmed that Resident #11 is capable of formulating an advance directive but did not sign off on it. The DON stated when the physicians declared him/her capable, they should have reapproached the resident regarding his/her advance directive. The facility admitted Resident #14 with [DIAGNOSES REDACTED]. Record review of Resident #14's Resident/Family Consent for Cardiopulmonary Resuscitation form on 7/29/19 at 3:54 PM, revealed do not resuscitate (DNR) status had been selected for the resident on 1/31/19. The form was signed by the resident's representative. Record review of Resident #14's Physicians Determination of Capacity form, dated 2/17/19, on 7/29/19 at 3:55 PM, revealed Resident #14 had decisional capacity to make his/her own healthcare decisions. Record review of Resident #14's Telephone Orders on 7/29/19 at 3:55 PM, revealed a DNR order for the resident, dated 2/17/19. There was no documentation indicating it was Resident #14's choice to be DNR status. During an interview with Registered Nurse (RN) #3 on 7/30/19 at 2:24 PM, RN #3 stated Resident #14 was unable to sign the DNR consent form on admission and the family signed it for him/her. RN #3 confirmed the physician determined the resident had … | 2020-09-01 |
| 174 | 174 | LINLEY PARK REHABILITATION AND HEALTHCARE CENTER, | 425016 | 208 JAMES STREET | ANDERSON | SC | 29625 | 2019-08-01 | 641 | D | 0 | 1 | 5ZED11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to accurately complete the Minimum Data Set (MDS) assessment for 1 of 4 sampled resident reviewed for nutrition (Resident #49). The findings included: The facility admitted Resident #49 on 01/16/15 with [DIAGNOSES REDACTED]. Review of Resident #49's 07-03-19 5-day Minimum Data Set (MDS) assessment revealed under section K under K0300 Weight Loss the code entered is 1. Yes, on a physician-prescribed weight-loss regimen. Review of Resident #49's orders on 07/30/19 at approximately 11:15 AM revealed the resident did not have orders for weight loss. During an interview on 08/01/19 at 09:58 AM, the Certified Dietary Manger stated that the MDS had been coded wrong. S/he would reopen it (MDS) and change the information. | 2020-09-01 |
| 175 | 175 | LINLEY PARK REHABILITATION AND HEALTHCARE CENTER, | 425016 | 208 JAMES STREET | ANDERSON | SC | 29625 | 2019-08-01 | 755 | D | 1 | 1 | 5ZED11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to obtain and provide routine medications for Resident #174, 1 of 7 sampled residents reviewed for Abuse/Neglect. Routine medications were not provided in a timely manner after admission to the facility. The findings included: The facility admitted Resident #174 on 5/3/19 with [DIAGNOSES REDACTED]. Record review of Resident #174's Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. In addition, the MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Review of Resident #174's Nurse's Notes on 8/1/19 at 9:16 AM, revealed the [MEDICATION NAME] and [MEDICATION NAME] were not given as ordered due to the medications had not been received from the pharmacy. During an interview with the Director of Nursing (DON) on 8/1/19 at 9:16 AM, the DON Confirmed Resident #174 did not receive the [MEDICATION NAME] and [MEDICATION NAME] as ordered. The DON stated the pharmacy delivered all other medications for the resident, but wasn't sure why these medications were not delivered. The DON stated the facility does have a back up pharmacy, but use of the back up pharmacy has to be initiated by the primary pharmacy when there are issues with delivery of medications. The DON was not sure why the back up pharmacy wasn't used and was waiting to hear from the primary pharmacy to find out what happened. The DON provided documentation revealing the facility followed their protocol for medication requisition when Resident #174 was admitted on [DATE]. During an interview with Registered Nurse (RN) #3 on 8/1/19 at 12:12 PM, RN #3 was on the phone with the pharmacy. When s/he got off the phone, RN #3 stated the pharmacy said the [MEDICATION NAME] order was cancelled by the pharmacy for unknown reasons. The [MEDICATION NAME] order was not delivered due to a possible drug interaction. The [MEDICATION NAME] was not delivered because … | 2020-09-01 |
| 176 | 176 | LINLEY PARK REHABILITATION AND HEALTHCARE CENTER, | 425016 | 208 JAMES STREET | ANDERSON | SC | 29625 | 2017-10-11 | 159 | F | 1 | 0 | TBH011 | > Based on review of facility files and interview, the facility failed to act as a fiduciary of the resident's funds and hold, safeguard, manage, and account for the personal funds of the resident deposited with the facility. The facility's Business Office Manager removed $600.00 from the resident petty cash fund. An audit completed after the incident revealed the receipt book had signatures with questionable validity totaling $1899.00. One of one staff reviewed for mishandling resident funds. The findings included: The facility reported an allegation of misappropriation of resident property to the State Agency on 8/11/17 and identified three residents affected. Review of the facility's Five-Day Follow-Up Report dated 8/16/17 indicated at the completion of the investigation the $600.00 was removed and replaced by the Business Office Manager. Results of the investigation also revealed 11 additional residents had signatures with questionable validity totaling $1899.00. Review of facility files revealed on 8/11/17 at 4:40 PM, the assistant Business Office Manager (BOM) reported to the administrator that there were questionable receipts in the resident trust petty cash book. The administrator interviewed the Business Office Manager at 5:05 PM and s/he admitted after questioning to taking $600.00. The Business Office Manager left the facility to go to the bank and returned with money to replace what s/he had taken. In an interview with the surveyor on 9/18/17 at approximately 4:00 PM, the facility administrator stated the assistant BOM came to him/her on 8/11/17 and said that were receipts in the resident trust petty cash book that didn't add up. They had the assistant BOM's name and social services staff's name as the two signatures. The assistant BOM stated s/he didn't sign those receipts. The assistant BOM was trying to balance the cash box and it didn't balance. The cash box should be balanced every Friday. The assistant BOM did not balance the cash box the previous Friday because s/he didn't have a chance because… | 2020-09-01 |
| 177 | 177 | LINLEY PARK REHABILITATION AND HEALTHCARE CENTER, | 425016 | 208 JAMES STREET | ANDERSON | SC | 29625 | 2017-10-11 | 224 | F | 1 | 0 | TBH011 | > Based on review of facility files and interview, the facility failed to ensure each resident remained free from misappropriation of resident property. The facility's Business Office Manager removed $600.00 from the resident petty cash fund. An audit completed after the incident revealed the receipt book had signatures with questionable validity totaling $1899.00. One of one staff reviewed for misappropriating resident funds. The findings included: The facility reported an allegation of misappropriation of resident property to the State Agency on 8/11/17 and identified three residents affected. Review of the facility's Five-Day Follow-Up Report dated 8/16/17 indicated at the completion of the investigation the $600.00 was removed and replaced by the Business Office Manager. Results of the investigation also revealed 11 additional residents had signatures with questionable validity totaling $1899.00. Review of facility files revealed on 8/11/17 at 4:40 PM, the assistant Business Office Manager (BOM) reported to the administrator that there were questionable receipts in the resident trust petty cash book. The administrator interviewed the Business Office Manager at 5:05 PM and s/he admitted after questioning to taking $600.00. The Business Office Manager left the facility to go to the bank and returned with money to replace what s/he had taken. In an interview with the surveyor on 9/18/17 at approximately 4:00 PM, the facility administrator stated the assistant BOM came to him/her on 8/11/17 and said that there were receipts in the resident trust petty cash book that didn't add up. They had the assistant BOM's name and social services staff's name as the two signatures. The assistant BOM stated s/he didn't sign those receipts. The assistant BOM was trying to balance the cash box and it didn't balance. The cash box should be balanced every Friday. The assistant BOM did not balance the cash box the previous Friday because s/he didn't have a chance because of admissions, so she was reviewing 2 weeks on 8/11/17. When … | 2020-09-01 |
| 178 | 178 | WHITE OAK MANOR - LANCASTER | 425017 | 253 CRAIG MANOR ROAD | LANCASTER | SC | 29720 | 2020-01-16 | 607 | D | 1 | 1 | FL9111 | > Based on record review, interview, and review of the facility's policy Protocol for Reporting Abuse the facility failed to follow policy to report an allegation of abuse within the required timeframe for Resident #98, 1 of 7 reviewed for abuse. CNA #3 allegedly witnessed CNA #2 physically abuse Resident #98 on 1/30/19. The allegation was not reported to the State Agency until 2/6/19. The findings included: The facility reported an allegation of physical abuse for Resident #98 by CNA #2 to the State Agency. On 1/14/20 at 12:13 PM, review of the Initial 2/24-Hour revealed it was faxed to the State Agency on 2/6/19 at 09:34 AM. The Initial 2/24-Hour Report indicated Resident #98 was physically abused by CNA #2 and indicated the date/time of incident as 2/6/19 at 07:40. The report indicated there was an allegation that while two CNAs were providing care to resident, resident became combative and hit a CNA. There is an allegation that CNA may have physically retaliated. Further review revealed a Five-Day Report dated 2/8/19 that indicated the incident occurred on 1/30/19 at 08:50 PM at which time an incident report was done. The summary indicated physical abuse not substantiated by facility. CNA #3 reported that CNA #2 struck Resident #98 on the arm after the resident struck him/her and was forceful when turning the resident. At 12:33 PM on 1/14/20, review of the Occurrence Report also indicated the incident occurred on 1/30/19 and indicated the resident had 2 skin tears measuring 2.5x1.0 and 4.0x3.5 cm and was completed by LPN #2. On 1/30/19, CNA #3's statement on the Occurrence Report stated s/he was changing Resident #98 and observed a skin tear abrasion on (his/her) left arm. (S/he) was combative during care and hitting and grabbing at us. There was no statement obtained from CNA #2. Review of the Occurrence Report also indicated a 24 hour follow-up was done by Unit Manager RN #1 on 1/31/19 and was also signed by the Director of Nursing on 2/1/19. LPN #3's facility-obtained statement dated 2/6/19 indicated s/he … | 2020-09-01 |
| 179 | 179 | WHITE OAK MANOR - LANCASTER | 425017 | 253 CRAIG MANOR ROAD | LANCASTER | SC | 29720 | 2020-01-16 | 609 | D | 1 | 1 | FL9111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to report an allegation of abuse within the required timeframe for Resident #98, 1 of 7 reviewed for abuse. CNA #3 allegedly witnessed CNA #2 physically abuse Resident #98 on 1/30/19. The allegation was not reported to the State Agency until 2/6/19. The findings included: The facility admitted Resident #98 on 11/21/18 with [DIAGNOSES REDACTED]. On 1/14/20 at 12:13 PM, review of the Initial 2/24-Hour revealed it was faxed to the State Agency on 2/6/19 at 09:34 AM. The Initial 2/24-Hour Report indicated Resident #98 was physically abused by CNA #2 and indicated the date/time of incident as 2/6/19 at 07:40. The report indicated there was an allegation that while two CNAs were providing care to resident, resident became combative and hit a CNA. There is an allegation that CNA may have physically retaliated. Further review revealed a Five-Day Report dated 2/8/19 that indicated the incident occurred on 1/30/19 at 08:50 PM at which time an incident report was done. The summary indicated physical abuse not substantiated by facility. CNA #3 reported that CNA #2 struck Resident #98 of the arm after the resident struck him/her and was forceful when turning the resident. At 12:33 PM on 1/14/20, review of the Occurrence Report also indicated the incident occurred on 1/30/19 and indicated the resident had 2 skin tears measuring 2.5x1.0 and 4.0x3.5 cm and was completed by LPN #2. On 1/30/19, CNA #3's statement on the Occurrence Report stated s/he was changing Resident #98 and observed a skin tear abrasion on (his/her) left arm. (S/he) was combative during care and hitting and grabbing at us. There was no statement obtained from CNA #2. Review of the Occurrence Report also indicated a 24 hour follow-up was done by Unit Manager RN #1 on 1/31/19 and was also signed by the Director of Nursing on 2/1/19. LPN #2's facility-obtained statement dated 2/6/19 indicated s/he was notified by CNA #3 that Residen… | 2020-09-01 |
| 180 | 180 | WHITE OAK MANOR - LANCASTER | 425017 | 253 CRAIG MANOR ROAD | LANCASTER | SC | 29720 | 2020-01-16 | 625 | D | 1 | 1 | FL9111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to provide the resident or the resident's representative with the written bed-hold policy prior to a facility initiated hospital transfer/discharge for one of three sampled residents reviewed for hospitalization . Resident #118 was sent to the hospital on [DATE] and [DATE] and the facility did not provide written information that specified the bed-hold policy. The findings included: The facility admitted Resident #118 on 7/26/19 with [DIAGNOSES REDACTED]. Review of Resident #118's Quarterly Minimum (MDS) data set [DATE] revealed the resident was coded as having short-term and long-term memory problems with severely impaired cognitive skills for daily decision-making. Nurse's notes reviewed on 1/16/20 at 8:16 AM revealed that the facility sent Resident #118 to the hospital emergency roiagnom on [DATE] with difficulty breathing, wheezing, pneumonia and foul smelling urine. Resident #118 was admitted back to the facility on [DATE]. The nurse's notes also revealed that Resident #118 went back to the hospital emergency room again on [DATE] for increased respiratory distress. Resident #118 returned to the facility on [DATE]. In an interview with the social worker on 1/16/20 at 8:32 AM s/he stated that the facility did not provide/discuss the bed-hold policy with the resident or the resident's representative for the two hospital transfers that occurred during December 2019. | 2020-09-01 |
| 181 | 181 | WHITE OAK MANOR - LANCASTER | 425017 | 253 CRAIG MANOR ROAD | LANCASTER | SC | 29720 | 2020-01-16 | 908 | F | 1 | 1 | FL9111 | > Based on observations and interviews, the facility failed to maintain all mechanical and electrical equipment in safe operating condition. The kitchen ice machine condensation draining pipes were not clean and in place. The facility was unable keep the floor behind and underneath the ice-maker clean and free from debris for one of one kitchen observed. The findings included: During the initial kitchen observation on 1/13/20 at 10:39 AM and in the presence of the registered dietitian/quality improvement support person, the surveyor noticed cups, some of which were Styrofoam on the floor behind the ice-maker. There was also paper trash on the floor and the floor appeared soiled (dark brown and oily). On 1/15/20 at 9:24 AM, during a second observation of the ice-machine, in the presence of the registered dietitian/quality support person, the surveyor observed the same cups (including Styrofoam), and paper-trash on the floor behind the ice-maker. The floor still appeared soiled (dark brown and oily). On 1/15/20, at approximately 9:25 AM, the registered dietitian got on his/her knees and attempted to remove the cups and paper-trash. At this time, the surveyor looked underneath the ice-machine and noticed two condensation draining pipes covered with black matter and the pipes were not aligned with the drainage underneath the ice-machine. The pipes were touching the floor. In a brief interview with the registered dietitian/quality improvement support person on 1/15/20 at approximately 9:27 AM (s/he) acknowledged that the floor and pipes were dirty and that the condensation draining pipes were touching the floor underneath the ice-machine. | 2020-09-01 |
| 182 | 182 | WHITE OAK MANOR - LANCASTER | 425017 | 253 CRAIG MANOR ROAD | LANCASTER | SC | 29720 | 2017-06-15 | 225 | D | 0 | 1 | HKAH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility files, interview, and review of the facility's policy titled, Neglect, Abuse, Mistreatment, Threatened or Alleged Abuse of Residents, the facility failed to ensure that all alleged violations including resident to resident altercations were reported to the State Health Agency. Resident # 9 involved in an altercation that resulted with an injury for 1 of 3 residents reviewed for accidents. The findings included: The facility admitted Resident #9 with [DIAGNOSES REDACTED]. During record review of the facility's occurrence reports on 06/15/17 at 9:21 AM, revealed Resident # 9 had resident to resident altercations on 4/12/17, 4/29/17, and 5/2/17. Report for 4/12/17 revealed Resident #9 was trying to enter in the TV room and Resident #41 would not move. Resident #9 began hitting the Resident #41 there were no injuries. Report for 4/29/17 Resident #9 entered into Resident #92's room and began hitting the resident. Resident #92 had redness on the right side of the face. Report for 5/2/17 Resident #9 wandered into Resident # 38's room and starting grabbing him. Resident#9 stated she can go anywhere she wants. Resident #9 suffered with bruises on the face and hematoma. Staff separated Resident #9 from the 3 incidents that occurred. There was no documentation of the incidents being reported in the section for Reported to State Agency. During an interview on 06/15/17 at 9:15 AM with the Administrator, Director of Nursing, and the facility's consultants it was confirmed the incidents that occurred were not reported. It was also stated it was not required to report to the health agency if it was a resident to resident altercation. Review of the facility's policy, Neglect, Abuse, Mistreatment, Threatened or Alleged Abuse of Residents, revealed under VII. Reporting/Response Section B: Upon receipt of allegation of abuse or neglect, the Administrator or designee will notify the appropriate State agency as soon as practicable, … | 2020-09-01 |
| 183 | 183 | WHITE OAK MANOR - LANCASTER | 425017 | 253 CRAIG MANOR ROAD | LANCASTER | SC | 29720 | 2017-06-15 | 278 | D | 0 | 1 | HKAH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to assure that 2 out of 3 residents reviewed for nutrition, 1 out of 3 residents reviewed for activities of daily living, dental, vision, and accidents and 1 out of 1 resident reviewed for pressure ulcers received accurate assessments. Residents #18 and #48. The Findings Included: Review of the medical record conducted on 6/14/2017 revealed that the facility admitted Resident #18 with [DIAGNOSES REDACTED]. Record review of Resident #18's Annual Comprehensive Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 5/25/2017 on 6/14/17 revealed Section B (Hearing, Speech Vision) item B1200 (Corrective lenses) was coded 0=no. Further review of medical record revealed documentation on Daylight IQ Assessments (COMS) entered on 5/20/2017 at 6:19 PM and 5/22/17 T 12:58 am which both reflects EENT Vision Corrective: Glasses indicating that resident utilized corrective lenses during the 7 day assessment window prior to the ARD of 5/25/17 of the Comprehensive MDS. During group interview on 6/14/17 at 3:45 PM, when asked if Resident #18 wore glasses when awake, Licensed Practical Nurse) LPN #1, LPN # 2, and Certified Nursing Assistant (C.N.[NAME]) #1 all replied Yes. When LPN #1 was asked if s/he could recall how long Resident #18 has worn glasses, s/he replied as long as I can remember. During an interview on 6/15/17 at 10:00 AM, MDS Nurse #1 agreed that item B1200 (corrective lenses) was incorrectly coded as 0=no and should have been coded as 1=yes. Additional record review on 6/14/2017 of Resident #18's Annual Comprehensive MDS assessment with ARD of 5/25/2017 revealed Section G (Functional Status) items G0110A2 (Bed mobility: support provided), G0110H2 (Eating: support provided), and G0110I2 (Toilet use: support provided) were all coded as 2=one person physical assist and item G0110H1 (Eating: self-performance) was coded as 2=limited assistance-resident highly … | 2020-09-01 |
| 184 | 184 | WHITE OAK MANOR - LANCASTER | 425017 | 253 CRAIG MANOR ROAD | LANCASTER | SC | 29720 | 2017-06-15 | 279 | D | 0 | 1 | HKAH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to develop and implement a care plan to meet the medical, nursing, and mental/ psychosocial needs for Resident #48. A care plan was not developed to address [DIAGNOSES REDACTED]. A care plan was not developed to address presence of actual contractures in upper and lower extremities in one of three residents reviewed for range of motion. A care plan was not developed or implemented to address presence of sacral pressure ulcer that was identified on 2/13/17 and resolved on 4/12/17 for one of one resident reviewed for pressure ulcer. The Findings Included: The facility admitted Resident #48 with [DIAGNOSES REDACTED]. Review of the Comprehensive Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 10/20/16 revealed that Items G0400A (Functional Limitation in Range of Motion {FROM} of upper extremities) and G0400B (FROM of lower extremities) were coded as 2=impairment on both sides. Further review revealed that Items I3300 ([MEDICAL CONDITION]) and I4800 (non-Alzheimer's dementia) were both checked. Additionally, presence of limitations in range of motion in upper and lower extremities identified in nursing notes on 10/17/16 at 10:09 PM. Review of (MONTH) (YEAR) monthly Physician orders [REDACTED].#48 was prescribed the medications [MEDICATION NAME] for [DIAGNOSES REDACTED]. Additional review of medical record on 6/14/17 revealed pressure ulcer reports for sacral pressure ulcer that was identified on 2/13/17 and reported as resolved on 4/12/2017. Review of Resident #48's care plan (pages 1-20 of 20) on 6/14/17 revealed that the care plan did not address the [DIAGNOSES REDACTED]. Additionally, review of page 4 of 20 on Resident #48's care plan revealed that FROM in bilateral extremities/ contractures were not addressed as a current problem, with impaired physical mobility attributed only to cervical stenosis with [DIAGNOSES REDACTED] and goal for resident to .develop no… | 2020-09-01 |
| 185 | 185 | WHITE OAK MANOR - LANCASTER | 425017 | 253 CRAIG MANOR ROAD | LANCASTER | SC | 29720 | 2018-09-27 | 550 | E | 0 | 1 | 52MP11 | Based on observations, interview, and review of the facility policy, the facility failed to maintain the dignity of residents with catheter bags for 1 of 1 resident reviewed for catheters. Resident #25's catheter bag was exposed on the 100 hall. The findings included: On 9/24/18 at approximately 1:16 PM, an observation on the 100 hall of Resident #25's catheter bag hanging on the right side of the bed facing the hallway and was approximately 1/2 full of urine. The catheter bag was not covered and in full view from the hallway. On 9/24/18 at approximately 3:32 PM, an observation on the 100 hall of Resident #25's catheter bag hanging on the right side of the bed facing the hallway. The catheter bag was not covered and in full view from the hallway. On 9/25/18 at approximately 8:59 AM, an observation on the 100 hall of Resident #25's catheter bag hanging on the right side of the bed and was approximately 1/4 full of urine. The catheter bag was not covered and in full view from the hallway. On 9/25/18 at approximately 5:20 PM, an observation with Licensed Practical Nurse (LPN) #1 on the 100 hall of Resident #25's catheter bag hanging on the right side of the bed that was approximately 1/4 full of urine. The catheter bag was not covered and in full view from the hallway. On 9/25/18 at approximately 5:20 PM, during an interview LPN #1 verified the catheter bag was in full view from the hallway and indicated the bag should be placed in a privacy bag on the side of the bed away from view from the hallway. Review of the facility policy, Closed Urinary Drainage states under procedure (3.) Attach drainage bag to bed frame, below level of resident's bladder, not touching floor; cover with dignity bag (unless fig leaf bag used). | 2020-09-01 |
| 186 | 186 | WHITE OAK MANOR - LANCASTER | 425017 | 253 CRAIG MANOR ROAD | LANCASTER | SC | 29720 | 2018-09-27 | 580 | E | 0 | 1 | 52MP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of the facility policy titled, Standard Of Care, the facility failed to ensure the physician and the personal representative for Resident #5, #105, #82 and #56 was notified of refusal of multiple medications on multiple days. The facility further failed to ensure the physician was notified of falls/falls with injury for Resident #30 for 5 of 5 residents reviewed for Notification. The findings included: The facility admitted Resident #5 with [DIAGNOSES REDACTED]. Review on 9/26/2018 at approximately 1:24 PM of the medical record for Resident #5 revealed on multiple days multiple medications were refused by Resident #5. Resident #5 had refused medications on 5/2/2018, 5/16/2018, 5/29/2018, 5/30/2018, 5/31/2018, 6/3/2018, 6/4/2018, 6/6/2018, 6/15/2018, 7/24/2018, 7/27/2018, 8/6/2018, 8/9/2018, 8/10/2018, 8/15/2018, 8/16/2018, 8/22/2018, 8/28/2018, 9/5/2018 and 9/21/2018. No documentation could be found in the medical record for Resident #5 to ensure the physician or the personal representative was notified of the refusal of medications. The facility admitted Resident #30 with [DIAGNOSES REDACTED]. Review on 9/27/2018 at approximately 2:00 PM of the medical record for Resident #30 revealed a fall on 7/12/2018 and 7/14/2018. No documentation could be found in the medical record for Resident #30 to ensure the physician was notified. Review on 9/27/2018 at approximately 2:30 PM of the, Occurrence Report, for Resident #30 dated 7/12/2018 revealed a fall with a laceration above right eye and discoloration to the right outer calf. Further review on 9/27/2018 at approximately 2:30 PM of a second Occurrence Report for Resident #30 dated 7/14/2018 revealed a fall from the bed with no injury assessed. No documentation could be found in the medical record nor on the Occurrence report to ensure the physician was notified of either fall. During interview on 9/27/2018 at approximately 2:40 PM with LPN (Licensed Prac… | 2020-09-01 |
| 187 | 187 | WHITE OAK MANOR - LANCASTER | 425017 | 253 CRAIG MANOR ROAD | LANCASTER | SC | 29720 | 2018-09-27 | 656 | D | 0 | 1 | 52MP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a Comprehensive Plan of Care was developed for Resident #5 related to refusal of medications. The findings included: The facility admitted Resident #5 with [DIAGNOSES REDACTED]. Review on 9/26/2018 at approximately 1:24 PM of the medical record for Resident #5 revealed on multiple days multiple medications were refused by Resident #5. Resident #5 had refused medications on 5/2/2018, 5/16/2018, 5/29/2018, 5/30/2018, 5/31/2018, 6/3/2018, 6/4/2018, 6/6/2018, 6/15/2018, 7/24/2018, 7/27/2018, 8/6/2018, 8/9/2018, 8/10/2018, 8/15/2018, 8/16/2018, 8/22/2018, 8/28/2018, 9/5/2018 and 9/21/2018. Review on 9/26/2018 at approximately 3:10 PM of the Plan of Care for Resident #5 revealed no problem, goals or interventions for refusal of medications. An interview on 9/26/2018 at approximately 3:15 PM with the Care Plan Coordinator confirmed that there was no care plan developed for refusal of medications. | 2020-09-01 |
| 188 | 188 | WHITE OAK MANOR - LANCASTER | 425017 | 253 CRAIG MANOR ROAD | LANCASTER | SC | 29720 | 2018-09-27 | 686 | D | 0 | 1 | 52MP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and review of the facility policy titled, Dressing - Non-Sterile, the facility failed to follow a procedure during wound care for Resident #8 and #24 consistent with professional standards of practice to promote healing and prevent infection for 2 of 3 residents reviewed for wound care. The findings included: The facility admitted Resident #8 with [MEDICAL CONDITION], Pneumonia, Heart Failure, Pain and Pressure Ulcers. An observation on 9/26/2018 at approximately 10:30 AM during wound care for Resident #8, revealed a pair of scissors on the over the bed table. The scissors were not observed to be cleaned by RN (Registered Nurse) #3 prior to cutting a small amount of calcium alginate for placement on wound beds for Resident #8 during wound care. An additional observation on 9/26/2018 at approximately 10:40 AM, during wound care, revealed RN #3 removing gloves from his/her pocket to use for the dressing changes for Resident #8 after each time cleansing his/her hands. The facility admitted Resident #24 with [DIAGNOSES REDACTED]. An observation on 9/26/2018 at approximately 11:10 AM, during wound care for Resident #24, revealed RN #3 removing a pair of scissors from his/her pocket and cutting a piece of Calcium Alginate with Silver for the wound beds. An additional observation on 9/26/2018 at approximately 11:10 AM , during wound care for Resident 24, revealed RN #3 removing gloves from his/her pocket and applying them each time he/she removed the soiled gloves and after washing his/her hands. During an interview on 9/26/2018 at approximately 11:35 AM with RN #3 confirmed that he/she had not cleaned the scissors prior to wound care and had removed gloves from his/her pocket for use during wound care for Resident #24 and #8. Review on 9/26/2018 at approximately 11:50 AM of the facility policy titled, Dressing - Non Sterile, states under Objective: number 1. states, To protect wound from contamination and/or injury.… | 2020-09-01 |
| 189 | 189 | WHITE OAK MANOR - LANCASTER | 425017 | 253 CRAIG MANOR ROAD | LANCASTER | SC | 29720 | 2018-09-27 | 690 | D | 1 | 0 | 52MP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview the facility failed to provide follow up and appropriate treatment and services to prevent urinary tract infection to a resident with signs and symptoms of urinary tract infection for one of one sample resident reviewed for bowel and bladder incontinent. Findings: Resident # 56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Nurse's notes reviewed on 9/25/18 at 2:57 PM revealed that on 6/7/18 Resident #56 on 6/7/18 complained of dysuria and also had some foul smelling urine. According to the nurse's notes, the nurse notified the physician. However, there is no documentation to support that the physician or the facility staff took any further action or performed a urinalysis to rule out urinary tract infection [MEDICAL CONDITION]. On 6/9/18 the nurse's notes indicated that the resident wanted to get out of the facility. S/he has thrown his/her cover on the floor and was attempting to get out of bed. On 6/13/18 the facility found the resident on the floor with his/her back against the bedside commode. On 6/20/18 the facility sent the resident at the hospital where s/he was treated for [REDACTED]. During an interview with the director of nursing (DON) and registered nurse consultant on 9/26/18 at 9:23 AM the DON confirmed that the facility did not perform a urinalysis to rule out UTI. | 2020-09-01 |
| 190 | 190 | WHITE OAK MANOR - LANCASTER | 425017 | 253 CRAIG MANOR ROAD | LANCASTER | SC | 29720 | 2018-09-27 | 759 | D | 0 | 1 | 52MP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and review of the facility policy, the facility failed to maintain a medication error rate of less than 5%. There were 3 errors out of 31 opportunities for error, resulting in a medication error rate of 9.68%. The findings included: Error #1 and #2 On 9/26/18 at approximately 8:50 AM, during an observation of Resident #5's medication administration on the 100 hall, Registered Nurse (RN) #1 crushed [MEDICATION NAME] 10 meq. and [MEDICATION NAME] HCL 10 mg. and placed the medication in applesauce and attempted to administer the medication to Resident #5. RN #1 was stopped before administering the medication and was asked to review Resident #5's physicians orders which stated, [MEDICATION NAME] 10 MEQ Tablet- Give one tablet by mouth twice daily with or after meals and with at least 4 oz of liquid.***Do not crush***, also [MEDICATION NAME] HCL 10 MG Capsule- Give 1 capsule by mouth daily. **Do not crush**. Following the review of Resident #5's physician's orders RN #1 verified s/he crushed [MEDICATION NAME] and [MEDICATION NAME] and indicated s/he should not have. Error #3 On 9/26/18 at approximately 8:55 AM, during an observation of Resident #5's medication administration on the 100 hall, Registered Nurse (RN) #1 administered (1) drop of Artificial Tears into each of the residents' eyes. RN #1 then returned to the cart and placed the Artificial Tears back into the Resident #5's drawer in the medication cart, and signed the medication off as given. On 9/26/18 at 9:00 AM, during reconciliation of Resident #5's med pass, a review of the Medication Administration Record [REDACTED]. On 9/26/18 at 9:00 AM, during an interview with RN #1, s/he verified giving only 1 drop per eye of Artificial Tears instead of 2 drops per eye. Review of the facility policy, Oral Medication Administration Procedure states under procedure (6.b.) Medications, not otherwise indicated may be crushed. If Do Not Crush is added t… | 2020-09-01 |
| 191 | 191 | WHITE OAK MANOR - LANCASTER | 425017 | 253 CRAIG MANOR ROAD | LANCASTER | SC | 29720 | 2018-09-27 | 761 | D | 0 | 1 | 52MP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and review of the facility policy titled, Medication Storage In The Facility, the facility failed to ensure medications were secured and out of reach of residents that were capable of obtaining them on Unit 200 for 1 of 3 units observed. The findings included: An observation on 9/25/2018 at approximately 9:10 AM revealed unsecured medications on the top of a treatment cart on the 200 Unit. The medications consisted of [MEDICATION NAME] Powder, [MEDICATION NAME] Cream and Santyl. Residents were observed sitting in wheel chairs approximately 3 feet from the treatment cart and others were observed walking by the cart on the unit. An interview on 9/25/2018 at approximately 9:10 AM with LPN (Licensed Practical Nurse) #2 confirmed the findings and stated, these medications came in during the night and were left on the cart. LPN #2 went on to say that the medications should have been secured in the treatment cart and not stored on the top of it. Review on 9/25/2018 at approximately 10:00 AM of the facility policy titled, Medication Storage In The Facility, states, Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. | 2020-09-01 |
| 192 | 192 | WHITE OAK MANOR - LANCASTER | 425017 | 253 CRAIG MANOR ROAD | LANCASTER | SC | 29720 | 2018-09-27 | 804 | D | 0 | 1 | 52MP11 | Based on observation, and interview the facility failed to provide food prepared at an appetizing temperature for 2 of 2 residents reviewed during lunch meal. Two Residents on the 300 unit were served melted ice cream. The findings included: On 9/25/18 at 1:57 PM, an observation of the meal service on the 300 hall revealed the meal trays were placed on the hall at 12:15 PM. The last 2 trays were removed from the uncovered food cart at 12:57 PM. Certified Nursing Assistant (CNA) #1 and CNA #2 removed the last 2 trays from the cart and verified the ice cream on the tray was melted. | 2020-09-01 |
| 193 | 193 | FLEETWOOD REHABILITATION AND HEALTHCARE CENTER | 425018 | 200 ANNE DRIVE | EASLEY | SC | 29640 | 2016-10-05 | 241 | D | 0 | 1 | WRBU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to ensure that dignity in dining was enhanced for residents who required assistance with eating during meals. Two random meal observations in 1 of 3 dining rooms. (Section 1) The findings included: During a random lunch observation on 10/03/16 at approximately 12 PM revealed four dining tables with two to five residents seated at each table. The residents seated at three of the four tables were served. There were three residents seated at a table close to room [ROOM NUMBER]. None of the residents seated at the table were served while the other residents in the dining room were served and eating independently or being fed by family members. Staff was observed delivering food to residents in their rooms while the three residents in the dining room were not served or eating. Further meal observation in the dining room on 10/03/16 revealed Certified Nursing Aide (CNA) #3 touching two residents bread with bare hands and putting butter on it. At approximately 12:17 PM staff was observed feeding the residents at the fourth table near room [ROOM NUMBER]. Random observation of meal service down the hallway on 10/03/16 at approximately 12:20 PM near medical records revealed a Certified Nurse Aide (CNA) in a room texting on his/her phone; while a resident that required assistance with eating was in bed with a food tray on a bedside table. A random observation of meal delivery on 10/04/16 at approximately 11:56 AM revealed four tables in the dining room. There was a long table with six residents present. Staff was observed serving residents at two other tables before serving all the residents at the long table. Staff was observed serving some residents in their rooms before serving all the residents in the dining room. During meal observation down the hallway on 10/04/16 at approximately 12:12 PM revealed two residents in Rooms #22, #17 and #15 with one resident with a food tray and eating while t… | 2020-09-01 |
| 194 | 194 | FLEETWOOD REHABILITATION AND HEALTHCARE CENTER | 425018 | 200 ANNE DRIVE | EASLEY | SC | 29640 | 2016-10-05 | 431 | D | 0 | 1 | WRBU11 | Based on observation and interview the facility failed to maintain medication (med) storage rooms free of expired medications on 1 of 3 nursing stations. Magic Mouthwash was stored in the refrigerator in the Station 1 med room and had expired. The findings included: During an observation of the Station 1 med room on 10/5/2016 at 9:05 AM, a bottle of Magic Mouthwash with Lidocaine was found in the refrigerator. The medicine was ordered to be used 3 times daily as needed for mouth pain. The medication was dispensed on 9/16/2016 and had a hand written expiration date of 9/30/2016 on the label. During an interview with RN (Registered Nurse) #1 on 10/5/2016 at 9:05 AM, RN #1 confirmed the hand written date of 9/30/2016 appeared to be the expiration date of the Magic Mouthwash. RN #1 called the pharmacist for clarification on the expiration date. Per RN #1, the pharmacist confirmed that the magic mouthwash was a compounded medication with a 14 day shelf life and did expire on 9/30/2016. Review of the Medication Administration Records revealed that the resident did not receive any of the Magic Mouthwash after 9/30/2016. | 2020-09-01 |
| 195 | 195 | FLEETWOOD REHABILITATION AND HEALTHCARE CENTER | 425018 | 200 ANNE DRIVE | EASLEY | SC | 29640 | 2017-10-06 | 157 | D | 1 | 1 | NTTE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to notify the physician of significant changes in blood glucose levels for 1 of 5 sampled residents reviewed for unnecessary medication. The physician was not notified of multiple blood sugar results greater than 400 as ordered for Resident #2. The findings included: The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Record review on 10/6/17 revealed 6/29/2017 physician's orders [REDACTED].= 3 units; 251-300 = 5 units; 301-350 = 8 units; 351-400 = 10 units; 401-450 = 13 units. Notify provider; 451-500 = 15 units subcutaneously before a meal and at bedtime for diabetes. Notify provider if BG >400 and Review of the 7/17 Medication Administration Record [REDACTED]= 433 at 1630h(ou)rs and 429 at 2100hrs, 7/3 = 454 at 1630hrs, 542 at 2100hrs, 7/7 = 4[AGE] at 2100hrs, 7/13 = 426 at 2100, 7/15 = 406 at 2100, 7/17 = 499 at 2100hrs, 7/20 = 426 at 1630hrs and 458 at 2100hrs, 7/21 = 415 at 0700hr, 7/22 = 414 at 2100hrs, 7/28 = 422 at 2100, and 7/29 = 458 at 2100. Continuing review of the 8/17 MARs revealed that Resident #2's blood glucose was 405 on 8/1, 413 on 8/3 at 1630hrs, 402 on 8/4, 432 on 8/8 at 2100hrs, 448 on 8/9 at 1630hrs, 478 on 8/12 at 2100hrs, 427 on 8/17, 415 on 8/18 at 1630hrs, 414 on 8/24 at 2100hrs, and 416 on 8/29 at 1630hrs. Review of 9/17 MARs revealed that Resident #2's blood glucose was 407 on 9/4 at 2100hrs, 427 on 9/6 at 1630hrs, 402 on 9/8, 401 on 9/9, 525 on 9/12/17, 410 on 9/18, 504 on 9/25 at 2100hrs, and 468 on 9/26 at 0700hrs. Review of Nurse's Notes on 10/05/2017 at 9:45 AM for the months of July, August, and September, 2017 revealed no documentation regarding notifying the physician of blood sugar results greater than 400. During an interview on 10/05/2017 at 9:09 AM, Licensed Practical Nurse (LPN) #4 could not locate any documentation on either the computerized records or the resident's medical record that stated the physician had been notified of any… | 2020-09-01 |
| 196 | 196 | FLEETWOOD REHABILITATION AND HEALTHCARE CENTER | 425018 | 200 ANNE DRIVE | EASLEY | SC | 29640 | 2017-10-06 | 274 | D | 1 | 1 | NTTE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to complete a Significant Change in Status Assessment (SCSA) in a timely manner for 1 of 5 residents reviewed for Hospice services. The facility did not complete the SCSA within 14 days following revocation of Hospice for Resident #8. The findings included: The facility admitted Resident #8 with [DIAGNOSES REDACTED]. Review of the medical record on 10/5/17 at 1:50 PM revealed that there was an order for [REDACTED]. Further review of the medical record revealed that resident was transferred to the hospital on [DATE] after the revocation of hospice services and returned to facility on 2/3/17. Review of the Minimum Data Set (MDS) assessments indicated the SCSA was not initiated with an assessment reference date until 2/13/17. Further review revealed that items Z0500B, V0200B2 and V0200C2 were all signed, which reflected the completion of the assessment on 2/21/17. The significant change in status assessment was not completed within 14 days of Hospice admission as required. During an interview on 10/6/17 at 3:17 PM, MDS Nurse #1 reviewed the medical record for Resident #8 and confirmed that hospice services were discontinued prior to hospitalization , and that a SCSA was not completed within 14 days of Resident #8 ' s return to facility, identified as the date a SCSA was indicated, as required. | 2020-09-01 |
| 197 | 197 | FLEETWOOD REHABILITATION AND HEALTHCARE CENTER | 425018 | 200 ANNE DRIVE | EASLEY | SC | 29640 | 2017-10-06 | 278 | B | 1 | 1 | NTTE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, and interview, the facility failed to accurately code the Minimum Data Set (MDS) for 1 of 2 sampled residents reviewed for contractures. Resident #94's MDS was not coded accurately to reflect the functional limitation of range of motion for the upper extremity contractures. The findings included: Resident #94 was admitted with [DIAGNOSES REDACTED]. During an observation on 10/3/17 at 10am, Resident #94 was observed to have contractures of her/his wrists and hands. Record review on 10/5/17 at 10am of hospice Interdisciplinary Team (IDT) Note on 3/8/17 stated, She (he) has bilateral hand contractures, and all extremities have fixed contractures and no purposeful use. Further record review of a Skilled Nursing (SN) Clinical Note dated 6/1/17 stated, All extremities with fixed contractures. Review of the MDS on 10/5/17 at 9am revealed the MDS with review dates of 6/6/17 and 8/31/17 was coded a 0-no impairment under Functional Limitation of Range of Motion, Section G0400, A- Upper Extremity. During an interview on 10/5/2017 at 12:50pm, MDS #1 verified that the 6/6/17 and 8/31/17 MDS was not coded correctly to reflect the upper extremity contractures. | 2020-09-01 |
| 198 | 198 | FLEETWOOD REHABILITATION AND HEALTHCARE CENTER | 425018 | 200 ANNE DRIVE | EASLEY | SC | 29640 | 2017-10-06 | 323 | D | 1 | 1 | NTTE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record review and staff interview, the facility failed to ensure one of three residents reviewed for accidents received adequate supervision and assistance devices to prevent accidents. Facility staff used an improper lift during care resulting in Resident #8 being lowered to floor. The Findings Include The facility admitted Resident #8 with [DIAGNOSES REDACTED]. Review of the Certified Nursing Assistant (C.N.A.) Care Card for Resident #8 was completed on 10/5/17 at 10:00 AM. The C.N.A. Care Card identified that a sling lift and 2 staff assist were required for transfers. Further review of the Lift Evaluation Form completed on 8/11/17, revealed that Resident #8 was not able to bear weight, did not have upper body strength, and that a total body lift was indicated. Observations on 10/3/17 and 10/5/17 revealed that two staff members used a total lift / sling lift to transfer Resident #8 to and from bed to Geri-chair with no concerns identified related to the transfer procedures. During interview with C.N.A. #1 on 10/5/17 at 2:00 PM, s/he reviewed her/his written statement regarding an incident related to Resident #8 being lowered to the floor that occurred on 9/11/17 and verified that the statement resident had soiled self I took her to shower room placed on stand lift to clean her. Resident raised her arms and began to fall. I got behind her and lowered her to the floor was correct. When asked how s/he was made aware of what each resident ' s specific care needs were, s/he identified the C.N.A. Care Card. When asked if s/he could indicate where on the C.N.A. Care Card it identified the use of a sit-to-stand lift, s/he could not. When asked how Resident #8 currently was transferred, s/he replied with the total lift. When asked how many staff members were required to assist with transfers for Resident #8, s/he replied 2 . During an interview on 10/5/17 at 2:12 PM with C.N.A. #2, s/he stated that s/he was familiar with Re… | 2020-09-01 |
| 199 | 199 | FLEETWOOD REHABILITATION AND HEALTHCARE CENTER | 425018 | 200 ANNE DRIVE | EASLEY | SC | 29640 | 2018-11-09 | 577 | C | 0 | 1 | NICZ11 | Based on observations and interview, the facility failed to post notice of the latest survey report in a prominent place in all areas of the facility. In addition, the facility failed to post notice of the availability of the results of the preceding 3 years survey reports in a place readily accessible to residents and the public. The findings included: During the Recertification Survey, a Group Interview was held with 8 residents on 11/7/18 at approximately 4:00 PM. At that time, residents were asked if they knew where the latest State survey inspection report was located. The participants were unable to answer this question and indicated that they were unaware of this information. Observations during the survey indicated the survey report was located in a binder placed in a holder on the wall outside the Administrator's office near the entrance to the facility. Observations of the first and second floor units revealed no signage indicating the location of the survey report. Observation revealed the past year's survey report was located in the binder. Further observation revealed there was no signage to indicate that the preceding 3 years survey reports were available for review upon request. During an interview on 11/9/18, the Administrator reviewed the contents of the survey binder and confirmed these findings at that time. | 2020-09-01 |
| 200 | 200 | FLEETWOOD REHABILITATION AND HEALTHCARE CENTER | 425018 | 200 ANNE DRIVE | EASLEY | SC | 29640 | 2018-11-09 | 584 | E | 0 | 1 | NICZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to provide housekeeping and maintenance services to maintain a clean, safe and comfortable environment on 11/6/2018 through 11/8/2018 on 3 of 3 units. The findings included: The following concerns were identified during the Initial Pool Process on 11/6/2018 and 11/7/2018 and confirmed during and environmental tour with facility administrator and housekeeping supervisor on 11/08/18 beginning at approximately 2:23 PM. (1)room [ROOM NUMBER] hall 3-A- floors and bathroom with dirt and residue buildup, cluttered with boxes on the floor (2) room [ROOM NUMBER] hall 3-B cluttered items on the floor, dirty/torn baseboards on the wall at the head of the bed (3) room [ROOM NUMBER] hall 12-W dirt and residue buildup on the baseboards in the bathroom and baseboards to the left side of the residents bed (4) room [ROOM NUMBER] hall 2-C cluttered items on the floor, underneath bed dirt and residue buildup, dirty brown substance build up in the toilet, and underneath the sink with moderate dirt and buildup (5) room [ROOM NUMBER] hall 6-D closet door with large scrapes and missing paint, missing paint around the sink with appearance of dried coating (6) room [ROOM NUMBER] hall 13-A dirt and residue buildup on floor and walls, overbed table dirty with build up on the rolling base support, and bedframe with splatter of sticky light brown substance (7) room [ROOM NUMBER] hall 7-W closet doors with large scrapes and scuffs and missing paint, cluttered items on the floor (8) room [ROOM NUMBER] hall 11-W bathroom with black spatter substance appears with grime and build up, clothing closet with large scrapes and missing paint, light bulb apparatus with missing cover (9) room [ROOM NUMBER] hall 13-W privacy curtain dirty with streaks of red substance, dirt build up on walls, baseboards and shelves, cluttered items on the floor (10) room [ROOM NUMBER] hall 15-C floors, baseboards, walls with dirt build up, and … | 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 );