cms_SC
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82 rows where scope_severity = "L"
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Suggested facets: facility_name, facility_id, address, city, zip, inspection_date, deficiency_tag, complaint, standard, eventid, filedate, inspection_date (date), filedate (date)
| Link | rowid ▼ | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1309 | 1309 | COMMANDER NURSING CENTER | 425119 | 4438 PAMPLICO HIGHWAY | FLORENCE | SC | 29505 | 2018-07-31 | 600 | L | 0 | 1 | Q5Q411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of the facility's Abuse, Neglect and Exploitation Policy, the facility failed to ensure that all residents remained free of abuse/neglect. The facility failed to identify allegations/complaints as abuse/neglect, immediately implement safeguards to prevent further violations, report the allegations to appropriate authorities within the required timeframes, and failed to conduct thorough investigations for 3 of 3 sampled residents who reported abuse/neglect. Staff failed to assist Resident #58 with proper toileting procedures as requested and instructed her/him to use her/his disposable brief which would reasonably result in shame/humiliation. Staff were rough and spoke abusively at times to Resident #56. Staff failed to provide incontinent care to Resident #131 over a 9 hour period. The findings included: The facility admitted Resident #58 on 10/19/17 with [DIAGNOSES REDACTED]. Review of the 10-25-17 Admission and 4-27-18 Quarterly Minimum Data Set Assessments revealed that the resident had a consistent Brief Interview for Mental Status (BIMS) score of 15, indicating s/he was cognitively intact. On 7-12-18, during an investigation of responses to concerns addressed during the Resident Council meeting on 7/11/18 at 10:30 AM, the Grievance Log was reviewed. The investigation file noted that Resident #58 reported an incident that occurred on 12-18-17 to Social Services on 12-19-17. According to the 12-19-17 Social Service note, the resident stated s/he put the call light on at 8:30-9 PM because s/he needed to go to the bathroom. When Certified Nursing Assistant (CNA) #3 answered the light, s/he told her (him) to go in her (his) brief. When the resident stated she (he) would be wet, the CNA told her/him to just do it. She (He) stated she (he) did wet her/himself. The resident also reported that CNA #3 was very short with her (him), but stated this is not the first time she (he) has been ugly to her (h… | 2020-09-01 |
| 1310 | 1310 | COMMANDER NURSING CENTER | 425119 | 4438 PAMPLICO HIGHWAY | FLORENCE | SC | 29505 | 2018-07-31 | 607 | L | 0 | 1 | Q5Q411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of the facility's Abuse, Neglect and Exploitation Policy, the facility failed to implement established policies related to identification, investigation, protection, and/or reporting of abuse/neglect for 3 of 3 sampled residents reviewed who had voiced allegations of abuse/neglect. When staff failed to provide necessary care related to toileting and instructed Resident #58 to go in her/his disposable brief, staff failed to assist Resident #58 with proper toileting procedures as requested and instructed her/him to use her/his disposable brief, failed Resident #56 by being rough and speaking abusively at times to him/her and failed Resident #131 by not changing his/her brief all day and allowing the resident to remain wet for several hours, facility policies were not followed regarding implementation of safeguards to prevent further violations, reporting the allegation to appropriate authorities within the required timeframes, and conducting a thorough investigation. The findings included: The facility admitted Resident #58 on 10/19/17 with [DIAGNOSES REDACTED]. Review of the 10-25-17 Admission and 4-27-18 Quarterly Minimum Data Set Assessments revealed that the resident had a consistent Brief Interview for Mental Status (BIMS) score of 15, indicating s/he was cognitively intact. Review of the reportable investigation file noted that Resident #58 reported an incident that occurred on 12-18-17 to Social Services on 12-19-17. According to the 12-19-17 Social Service note, the resident stated s/he put the call light on at 8:30-9 PM because s/he needed to go to the bathroom. When Certified Nursing Assistant (CNA) # 3 answered the light, s/he told her (him) to go in her (his) brief. When the resident stated she (he) would be wet, the CNA told her/him to just do it. She (He) stated she (he) did wet her/himself. The resident also reported that CNA #3 was very short with her (him), but stated this is not t… | 2020-09-01 |
| 1311 | 1311 | COMMANDER NURSING CENTER | 425119 | 4438 PAMPLICO HIGHWAY | FLORENCE | SC | 29505 | 2018-07-31 | 609 | L | 0 | 1 | Q5Q411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of the facility's Abuse, Neglect and Exploitation Policy, the facility failed to ensure that all allegations of abuse/neglect were immediately reported to the State Agency according to required timeframes. The facility failed to identify 2 of 3 resident-reported allegations/complaints reviewed as abuse/neglect and failed to report 3 of 3 abuse/neglect allegations to the proper authorities as required. Staff failure to assist Resident #58 with proper toileting procedures as requested and instruction to use her/his brief, failed Resident #56 by being rough and speaking abusively at times to him/her and failed Resident #131 by not changing his/her brief all day and allowing the resident to remain wet for several hours, facility policies were not followed for reporting the allegation to appropriate authorities within the required timeframes, and conducting a thorough investigation. The allegations were not reported to the State Agency within 2 hours as required. The findings included: The facility admitted Resident #58 on 10/19/17 with [DIAGNOSES REDACTED]. Review of the 10-25-17 Admission and 4-27-18 Quarterly Minimum Data Set Assessments revealed that the resident had a consistent Brief Interview for Mental Status (BIMS) score of 15, indicating s/he was cognitively intact. On 7-12-18, during an investigation of responses to concerns addressed during the Resident Council meeting on 7/11/18 at 10:30 AM, the Grievance Log was reviewed. The investigation file noted that Resident #58 reported an incident that occurred on 12-18-17 to Social Services on 12-19-17. According to the 12-19-17 Social Service note, the resident stated s/he put the call light on at 8:30-9 PM because s/he needed to go to the bathroom. When Certified Nursing Assistant (CNA) #3 answered the light, s/he told her (him) to go in her (his) brief. When the resident stated she (he) would be wet, the CNA told her/him to just do it. She (H… | 2020-09-01 |
| 1312 | 1312 | COMMANDER NURSING CENTER | 425119 | 4438 PAMPLICO HIGHWAY | FLORENCE | SC | 29505 | 2018-07-31 | 610 | L | 0 | 1 | Q5Q411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of the facility's Abuse, Neglect and Exploitation Policy, the facility failed to ensure that 3 of 3 reported allegations of abuse/neglect were thoroughly investigated. The facility failed to identify allegations/complaints as abuse/neglect, immediately implement safeguards to prevent further violations while the investigations were in process,and take appropriate corrective action to prevent recurrence for 3 of 3 sampled residents who reported abuse/neglect. The facility failed to conduct a thorough investigation and put procedures in place to prevent further abuse/neglect after Resident #58 complained that staff did not assist her/him with proper toileting procedures as requested, failed Resident #56 by being rough and speaking abusively at times to him/her and failed Resident #131 by not changing his/her brief all day and allowing the resident to remain wet for several hours. Facility policies were not followed for reporting the allegation to appropriate authorities within the required timeframes, and conducting a thorough investigation. The findings included: The facility admitted Resident #58 on 10/19/17 with [DIAGNOSES REDACTED]. Review of the 10-25-17 Admission and 4-27-18 Quarterly Minimum Data Set Assessments revealed that the resident had a consistent Brief Interview for Mental Status (BIMS) score of 15, indicating s/he was cognitively intact. On 7-12-18, during an investigation of responses to concerns addressed during the Resident Council meeting on 7/11/18 at 10:30 AM, the Grievance Log was reviewed. The investigation file noted that Resident #58 reported an incident that occurred on 12-18-17 to Social Services on 12-19-17. According to the 12-19-17 Social Service note, the resident stated s/he put the call light on at 8:30-9 PM because s/he needed to go to the bathroom. When Certified Nursing Assistant (CNA) #2 answered the light, s/he told her (him) to go in her (his) brief. When th… | 2020-09-01 |
| 1328 | 1328 | COMMANDER NURSING CENTER | 425119 | 4438 PAMPLICO HIGHWAY | FLORENCE | SC | 29505 | 2018-07-31 | 835 | L | 0 | 1 | Q5Q411 | Based on record reviews and interviews, the administration of the facility failed to ensure that resident care policies regarding abuse/neglect were followed. Two of 3 allegations of abuse/neglect were not identified as such. Three (3) of 3 were not investigated and/or reported to appropriate authorities within the required timeframes. In 3 of 3 cases, management failed to immediately implement safeguards to protect these and other residents from recurrence of the abuse/neglect. The findings included: On 7-12-18, during an investigation of responses to concerns addressed during the Resident Council meeting on 7/11/18 at 10:30 AM, the Grievance Log was reviewed. Resident #58 reported an incident of abuse/neglect that occurred on 12-18-17 when Certified Nursing Assistant (CNA) #3 instructed the resident to go in her/his brief. The named grievance official, the Director of Nurses (DON), did not report to the State Agency in a timely manner or thoroughly investigate the incident. During an interview on 7/12/18 at 2:01 PM, the DON stated that the Administrator made the decisions related to disciplinary action. In this case, management failed to immediately implement safeguards to protect these and other residents from recurrence of the abuse/neglect by the alleged perpetrator. The only action taken was counseling/education. Resident #56 reported rough handling and possible verbal abuse by the same CNA #3 to the Social Worker (SW) on 5-3-18. The DON failed to identify the incident as possible abuse and implement reporting and investigation policies. During an interview on 7/13/2018 at approximately 10:40 AM when questioned about the incident, the resident confirmed the allegations and began to cry. On 5-8-18, Resident #131 reported staff failure to provide incontinent care over a 9 hour period on 4-28-18. The DON failed to identify the incident as an allegation of abuse/neglect and implement reporting and investigation policies. The DON failed to identify the incident as possible abuse and implement reporting and inves… | 2020-09-01 |
| 3773 | 3773 | VETERANS VICTORY HOUSE | 425386 | 2461 SIDNEY ROAD | WALTERBORO | SC | 29488 | 2018-12-14 | 607 | L | 1 | 0 | 8Q9W11 | > Based on record review and interviews, the facility failed to implement their abuse policy on investigating and protecting residents from abuse for 16 of 16 Facility Reported Incidents of abuse/neglect and injury of unknown origin. The findings included: Cross refer to F610- Thoroughly Investigating Allegations of Abuse/Neglect Review of the facility investigation for Resident #14 dated 9/27/18 revealed Resident reported to staff a Certified Nursing Assistant (CNA) had touched him/her with closed hands in his/her stomach. Review of the facility investigation for Resident #14 dated 10/27/18 revealed Resident #14 with a BIMS score of 3 stated to nurse that one of the CNAs beat up her/his roommate last night then came over and hit her/him. Resident #14 reports s/he does not know the name and is scared to get anyone in trouble. The facility investigation dated 10/27/18 failed to identify the CNA assigned to the resident or her/his roommate. In addition, the facility investigation failed to show time cards or staff assignments to show who had worked at the time of the alleged incident in order to determine if abuse actually accrued. Review of the facility investigation for Resident #16 and Resident #15 dated 9/26/18 revealed that staff observed Resident #15 making contact with Resident #16's neck with an open hand and contact with her/his chest with a closed hand Resident #16 was noted to have red marks on her/his neck. The Facility Investigation for Resident #16 and Resident #15 failed to contain an accurate representation of the incident dated 9/26/18. Review of the facility investigation for Resident #18 for injury of unknown origin dated 8/27/18 revealed Resident had pain with ROM (range of motion). X-ray of right hip revealed acute right femoral fracture. The facility investigation contained a statement from CNA #7. CNA #7 stated s/he had taken care of Resident #18 on 8/25/18 and that Resident #18 was guarding her/his right hip during ADL care. CNA #7 reported to the nurse that Resident #18 was not acting right… | 2020-09-01 |
| 3774 | 3774 | VETERANS VICTORY HOUSE | 425386 | 2461 SIDNEY ROAD | WALTERBORO | SC | 29488 | 2018-12-14 | 610 | L | 1 | 0 | 8Q9W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, review of facility files and interviews, the facility failed to conduct thorough investigations for 16 of 16 reportable incidents. The findings included: Review of the Facility Investigation for Resident #14 dated 9/27/18 revealed Resident reported to staff a Certified Nursing Assistant (CNA) had touched him/her with closed hands in his/her stomach. Resident with a Brief Interview for Mental Status (BIMS) score of 3 out of 15. Upon completion of investigation to include staff and resident interviews, the allegation of abuse was not substantiated. Review of the 5 day report for Resident #14 revealed the CNA had been suspended pending investigation. CNA received re-education on abuse policy and customer service. The Resident's statement dated 9/27/18 stated, Resident stated that on Monday, 9/24/18, after midnight, girl (meaning CNA) came in her/his room and tried to take her/his clothes off. S/He said that s/he told her (CNA) to leave her/him alone because s/he had already had a shower and her/his clothes were clean. S/He said, that girl got mad and hit her/him in the stomach. Girl then went to check on her/his roommate and that was the last time s/he saw her that night. S/He then said the same girl gave her/him a shower today. Licensed Practical Nurse (LPN) #4 wrote a statement dated 9/27/18 which stated Resident #14 told her/him, the CNA hit the resident all over her/his body. The nurse looked her/him over and found no discolorations or marks on the resident. The investigation did not include who the CNA was who had been suspended. The 5 day Report Form stated the alleged perpetrator was CNA #4. CNA #4 had given a statement dated 9/27/18. CNA #4 stated s/he did not work on 9/24/18 on the 11/7 shift. S/he worked on the 7-3 shift on another unit and had no knowledge of the alleged accusation. The facility investigation for Resident #14 failed to show time cards or staff assignments to show who had worked at the time of… | 2020-09-01 |
| 3775 | 3775 | VETERANS VICTORY HOUSE | 425386 | 2461 SIDNEY ROAD | WALTERBORO | SC | 29488 | 2018-12-14 | 835 | L | 1 | 0 | 8Q9W11 | > Based on review of facility files and interview, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. During the survey, surveyors reviewed 16 reportable incidents. Review of the facility's investigative files for those incidents revealed the incidents were not thoroughly investigated. The findings included: Cross refer to CMS 2567 F0607, F0610 and F0842 related to concerns identified related to the facility not thoroughly investigating allegations of abuse. Review of facility investigative files revealed that allegations were not thoroughly investigated. There were allegations that did not contain staff statements that were assigned to the unit at the time of incident and may have knowledge of the incident. Staff statements that were obtained did not contain enough information to know what happened for incidents that were witnessed by staff. The investigation summaries and notes within the medical records do not contain an accurate representation of the actual experiences of the resident and resident outcomes. During an interview with the facility Administrator on 12/13/18 at approximately 6:15 PM, the Administrator stated the facility staff have been taught that anything they document needs to be factual. The Administrator stated the Staff should be objective in documentation, some words could be subjective. The Administrator stated that Punch would be subjective, slap would be subjective. The administrator stated that If you have an open hand and make contact that is more descriptive than strike or slap. The administrator stated s/he generally reviews every 24 hour report and 5 day. During the interview the surveyor asked the Administrator how do you know when touch is documented if it is a friendly touch or a slap which is defined as abuse in the facility abuse policy? The Administrator stated that if staff witnesses an event, if they do… | 2020-09-01 |
| 3776 | 3776 | VETERANS VICTORY HOUSE | 425386 | 2461 SIDNEY ROAD | WALTERBORO | SC | 29488 | 2018-12-14 | 837 | L | 1 | 0 | 8Q9W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interviews, the facility failed to have a governing body that is legally responsible for establishing and implementing policies regarding the management and operation of the facility. Review of 16 reportable incidents revealed allegations of abuse were not thoroughly investigated. Review of staff statements related to the incidents did not provide detail about the incidents. The findings included: Cross refer to CMS 2567 F0607, F0610 and F0842 related to concerns identified related to the facility not thoroughly investigating allegations of abuse. Also, cross refer to CMS 2567 F 835 related to administration of the facility regarding documentation of incidents that occurred at the facility. Review of Registered Nurse (RN) #1's employee file revealed a One on One In-Service education sheet dated 7/12/18 by Instructor RN #2 related to Nursing Documentation. Under the topic to discussed section see attached was indicated. The attachment titled Nursing Documentation revealed Nurse's notes are not the place to put a summary of your thoughts, opinions, or judgements of a resident and their medical status or condition. You should not be placing recommendations for care in the nurse's notes. Nurse's notes should capture what you actually saw, what you did, and the resident's response. Notes should not include hard words such as hit, punched, shoved, etc. They should include soft words such as touched or made contact with. Please understand that while your opinions and observations may be helpful in providing care to our residents and we would like to be made aware of your findings, the nurse's notes are not the appropriate place to communicate this type of information. Notification via phone call to the nursing supervisor or by listing it on the 24 hour report is sufficient. Review of the facility's Abuse Policy revealed physical abuse includes, but is not limited to, hitting, slapping, pinching, and kicking. I… | 2020-09-01 |
| 3777 | 3777 | VETERANS VICTORY HOUSE | 425386 | 2461 SIDNEY ROAD | WALTERBORO | SC | 29488 | 2018-12-14 | 842 | L | 1 | 0 | 8Q9W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, review of facility files and interviews, the facility failed to maintain medical records that were complete and accurately documented. Medical Record Documentation was misleading and unclear for 18 of 18 medical records reviewed for reportable incidents. Physical contact was described in incidents as touched, came in contact with, open hand or closed hand. The investigation summaries and notes within the medical records did not contain complete and accurate representation of the actual experiences of the residents. Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #15, #16, #17 and #18. The findings included: The facility admitted Resident #14 on 2/13/18 with [DIAGNOSES REDACTED]. Review of the Facility Investigation for Resident #14 dated 9/27/18 revealed Resident reported to staff a Certified Nursing Assistant (CNA) had touched him/her with closed hands in his/her stomach. Resident with a Brief Interview for Mental Status (BIMS) score of 3 out of 15. Review of the 5 day report for Resident #14 revealed the Resident's statement dated 9/27/18 stated, Resident stated that on Monday, 9/24/18, after midnight, girl (meaning CNA) came in her/his room and tried to take her/his clothes off. S/He said that s/he told her (CNA) to leave her/him alone because s/he had already had a shower and her/his clothes were clean. S/He said, that girl got mad and hit her/him in the stomach. Girl then went to check on her/his roommate and that was the last time s/he saw her that night. S/He then said the same girl gave her/him a shower today. Licensed Practical Nurse (LPN) #4 wrote a statement dated 9/27/18 which stated Resident #14 told her/him, the CNA hit the resident all over her/his body. The nurse looked her/him over and found no discolorations or marks on the resident. The investigation did not include who the CNA was who had been suspended. The 5 day Report Form stated the alleged perpetrator was CNA #4. CNA #4 had … | 2020-09-01 |
| 4703 | 4703 | COMPASS POST ACUTE REHABILITATION | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2016-04-21 | 224 | L | 0 | 1 | 1ROG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews and facility files, the facility failed to protect residents from abuse for one of one resident's (#178) coerced without an investigation or report to state agencies. One of one residents (resident #69) with misappropriation of funds, without a thorough investigation and 2 residents with allegations of abuse that were not reported to state agency. The findings included: During the Recertification and Complaint Survey, on 4/21/16 the Department of Health and Environmental Control (DHEC) Certification State Agency office received an additional eight (8) allegations of abuse/neglect. Review of the allegations revealed the facility had identified a concern related to the allegation that involved resident # 178. The facility admitted resident # 178 with [DIAGNOSES REDACTED]. The resident had a Brief Interview for Mental Status Score of 15. S/he was alert and oriented and able to make decisions regarding his/her ability to make decisions regarding activities of daily living. Review of the additional allegations revealed an allegation of 3/16/16 related to resident #178. Per the allegation, the resident had complained that a nurse had snatched off a neck brace. Review of the facility's grievance files revealed a grievance of the allegation. Through the facility investigation of the allegation, the resident had stated the nurse had startled him/her when removing the neck brace and was not abused. The Administrator, Director of Nursing (DON), Director of Nursing in Training (DON in training), and Social Services (SS) were interviewed by the surveyor on 4/21/16 at approximately 11:30 AM. During the interview the Administrator and DON stated that a note was left under the administrator's door, signed by the resident. The administrator provided the note for review. The note stated, I will (sic) like to speak to the Patient Avocate about my collar being snatched off by male nurse. Please call them for me, thanks for aski… | 2019-09-01 |
| 4704 | 4704 | COMPASS POST ACUTE REHABILITATION | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2016-04-21 | 226 | L | 0 | 1 | 1ROG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews and facility files, the facility failed to follow their policy to complete a thorough investigation and report immediately to state agencies any allegations of abuse, neglect and misappropriation of funds. The facility failed to conduct a thorough investigation for 1 of 1 allegations of misappropriation of funds (resident #69). The facility failed to conduct an investigation and report allegations of abuse for 1 of 1 residents the facility identified a concern with (resident # 178). The facility failed to report and provide a thorough investigation of 2 of 2 random allegations of abuse reported to them by the surveyor. The findings included: Cross refer to F 224. Preventing, investigating and reporting allegations of abuse, neglect and misappropriation of funds/personal property. Resident #178 reported someone had entered their room in the middle of the night and had him/her sign a paper. The resident did not know who the person was or what was on the paper. The resident was told not to mention the letter and not to tell anyone that the resident had a visitor. The facility also received reports the person that entered the building in the middle of the night made copies of medical records. No investigation had been conducted nor were the allegations reported to the state agencies. Resident # 69 reported to the facility that a Certified Nursing Assistant (CNA) had his/her bank card and had used the card without the resident's authorization. The CNA had the resident's car as well. The facility did not have a thorough investigation of the allegations. The facility's investigation did not included an official statement from the resident. There were no interviews/statements of other resident's that may have been affected by the CNA's practice. There were no statements obtained from the staff. During the Recertification/Complaint Survey, the facility Administration was notified by the surveyor of two allegations of… | 2019-09-01 |
| 4710 | 4710 | COMPASS POST ACUTE REHABILITATION | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2016-04-21 | 323 | L | 0 | 1 | 1ROG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to provide supervision for the safety of the residents. Resident #178 was visited in the middle of the night by someone s/he did not know, and instructed to sign a paper. The resident was told to not tell anyone about the paper and not to tell ayone about the visit. The findings included: Cross refer to F224- Prevention, investigation and reporting abuse/neglect and misappropriation of funds. The facility admitted resident # 178 with [DIAGNOSES REDACTED]. The resident had a Brief Interview for Mental Status Score of 15. S/he was alert and oriented and able to make decisions regarding his/her ability to make decisions regarding activities of daily living. Review of the additional allegations revealed an allegation of 3/16/16 related to resident #178. Per the allegation, the resident had complained that a nurse had snatched off a neck brace. Review of the facility's grievance files revealed a grievance of the allegation. Through the facility investigation of the allegation, the resident had stated the nurse had startled him/her when removing the neck brace and was not abused. The Administrator, Director of Nursing (DON), Director of Nursing in Training (DON in training), and Social Services (SS) were interviewed by the surveyor on 4/21/16 at approximately 11:30 AM. During the interview the Administrator and DON stated that a note was left under the administrator's door, signed by the resident. The administrator provided the note for review. The note stated, I will (sic) like to speak to the Patient Avocate about my collar being snatched off by male nurse. Please call them for me, thanks for asking about my care. I was informed S/he is Ombudsman ---- (name of person). The administrator went to the resident and was told by the resident that someone had come in his/her room at 3:00 AM, wearing a hoodie and had him/her sign a paper. The resident did not know who the person was or what was o… | 2019-09-01 |
| 4717 | 4717 | COMPASS POST ACUTE REHABILITATION | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2016-04-21 | 490 | L | 0 | 1 | 1ROG11 | Based on review of facility files and interviews, the facility failed to Administer in a way to maintain safety of residents named in allegations of abuse/neglect misappropriation of funds. The findings included: Cross refer to F224- Prevent, investigate and report allegations of abuse/neglect, misappropriation of funds Cross Refer to F226: Developing Policies and Procedures for Abuse/Neglect and Misappropriation of funds/personal property. Cross refer to F323: Supervision to prevent accidents/incidents. Supervision not provided to prevent unknown person entering facility and resident's rooms when sleeping. | 2019-09-01 |
| 4721 | 4721 | COMPASS POST ACUTE REHABILITATION | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2016-04-21 | 516 | L | 0 | 1 | 1ROG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to maintain the safety and confidentiality of resident records and failed to safeguard clinical record information against unauthorized use. It was determined on 4/21/16 at approximately 4:20 PM Immediate Jeopardy and/or Substandard Quality of Care existed in the facility as of 3/17/2016. The findings included: Cross refer to F224- Prevent, investigate and report allegations of abuse/neglect, misappropriation of funds related to Resident #178. Cross refer to F226-Developing Policies and Procedures for Abuse/Neglect and Misappropriation of funds/personal property related to Resident #178. Cross refer to F-323 Supervision to prevent accidents/incidents related to Resident #178. During the Recertification and Complaint Survey, on 4/21/16 the Department of Health and Environmental Control (DHEC) Certification State Agency office received an additional eight (8) allegations of abuse/neglect. Review of the allegations revealed the facility had identified a concern related to the allegation that involved resident # 178. The administrator went to the resident (#178) and was told by the resident that someone had come in his/her room at 3:00 AM, wearing a hoodie and had him/her sign a paper. The resident did not know who the person was or what was on the paper that s/he signed. The resident stated s/he did not write the note and did not want to talk to the patient advocate. The DON stated the same person seen in Resident #178's room was seen on the same night by staff members copying resident charts. The DON stated when s/he came in, the person had already left the facility. During the interview the Administrator and DON and DON in training stated the person that had entered the facility during the night was an employee, a Licensed Practical Nurse (LPN), who worked the 7A-7P shift. The employee was out on medical leave at the time of the survey. The Administrator was asked by the surveyor, what… | 2019-09-01 |
| 4723 | 4723 | COMPASS POST ACUTE REHABILITATION | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2016-04-21 | 520 | L | 0 | 1 | 1ROG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on full and/or limited record reviews, interviews, and review of facility policies, it was determined on 4/21/16 at approximately 4:20 PM Immediate Jeopardy and/or Substandard Quality of Care existed for CFR483.75 F-520 which was identified at a scope and severity level of (L). The facility failed to identify quality deficiencies related to prevention of abuse/neglect, proper implementation of abuse/neglect policies, provision of supervision to ensure resident safety, and provision of medical record security. Failure of the Quality Assurance (QA) Committee to identify and implement action plans related to these quality deficiencies resulted in Immediate Jeopardy for Resident #69 and Resident #178. The findings included: Based on record reviews and interviews, the facility failed to identify concerns related to prevention of abuse/neglect, provision of supervision to ensure resident safety, and provision of medical record security. During an interview on 4/28/16, the Administrator and Director of Nursing stated and confirmed that the QA Committee had not identified and had not implemented action plans related to the concerns identified for Resident #69 and Resident #178. Based on full and/or limited record reviews, interviews, and review of facility policies, it was determined on 4/21/16 at approximately 4:20 PM Immediate Jeopardy and/or Substandard Quality of Care existed in the facility as of 3/17/2016. The facility Administrator, Director of Nursing, and Director of Nursing in Training were informed of the Immediate Jeopardy on 4/21/16 at approximately 5:20 PM. The facility provided an Allegation of Compliance (A[NAME]) that was acceptable on 4/28/16 at 2:05 PM, and the Immediate Jeopardy at F-224, F-226, F-323, F490, F516 and F-520 was removed but the citations remained at a lower scope and severity. The A[NAME] included the following: A[NAME]: It has been alleged in the context of the pending survey process that the Facility's respo… | 2019-09-01 |
| 4733 | 4733 | ELLENBURG NURSING CENTER, INC | 425047 | 611 EAST HAMPTON STREET | ANDERSON | SC | 29624 | 2016-03-25 | 323 | L | 0 | 1 | 4J2O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a safe environment for residents. Water temperatures were above accepted parameters on 3 of 4 units. Water temperatures exceeded 140 degrees Fahrenheit on the locked Alzheimer's Unit. The facility's Maintenance Director and Administrator were aware the water temperatures exceeded a safe range. The Maintenance Director did not have a system of recording water temperatures and was unaware of how to calibrate a thermometer. These findings resulted in Immediate Jeopardy existing in the facility at the time of discovery on 3/21/16. The facility Administrator was informed of the Immediate Jeopardy on 3/21/16 at 7:00 PM. Additionally, interventions were not implemented following falls to prevent recurrence for 1 of 4 residents reviewed for accidents (Resident #166). The findings included: Observation on Unit 1 in Room 113 on 3/21/2016 at 3:42 PM revealed the water temperature in the sink was 127 degrees Fahrenheit. Resident #190 indicated the water temperature gets hot sometimes. Random observation in other rooms on Unit 1 on 3/21/2016 at approximately 4:15 PM revealed the following water temperatures: 124 degrees Fahrenheit in Room 123, 124 degrees Fahrenheit in Room 124, and 125 degrees Fahrenheit in the Unit 1 shower room. Observation on Unit 4 in Room 119 on 3/21/2016 at approximately 4:30 PM revealed the water temperature at the sink was 147.6 degrees Fahrenheit. Observation on Unit 1 in Room 115 on 3/21/2016 at 4:39 PM revealed the water temperature was 126 degrees Fahrenheit. Interview with the Maintenance Director on 3/21/2016 at 5:05 PM revealed (s)he checked water temperatures on Mondays and Fridays. (S)he stated the water heaters/mixers were checked six days each week and were maintained at a setting of 120 degrees Fahrenheit. (S)he stated the water in Unit 3 had to run awhile before it would get warm. (S)he stated Units 1 and 2 had a circulating pump. The… | 2019-08-01 |
| 4735 | 4735 | ELLENBURG NURSING CENTER, INC | 425047 | 611 EAST HAMPTON STREET | ANDERSON | SC | 29624 | 2016-03-25 | 490 | L | 0 | 1 | 4J2O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews, the Administrator failed to provide proper training for the facility Maintenance Director and failed to ensure on-going preventive maintenance policies were developed and followed to ensure safety of residents related to hot water temperatures which contributed to immediate jeopardy and/or substandard quality of care. Water temperatures exceeded 140 degrees Fahrenheit on the locked Alzheimer's Unit. The facility's Maintenance Director and Administrator were aware the water temperatures exceeded a safe range. The Maintenance Director did not have a system of recording water temperatures and was unaware of how to calibrate a thermometer. These findings resulted in Immediate Jeopardy existing in the facility at the time of discovery on 3/21/16. The facility Administrator was informed of the Immediate Jeopardy on 3/21/16 at 7:00 PM. The findings included: Cross refer CFR 483.25 F-323 Free of Accident Hazards During an interview on 3/21/2016 at 5:05 PM, the Maintenance Director stated that s/he checked hot water temperatures on Mondays and Fridays but had kept no records of which rooms were checked and no temperatures had been recorded. S/he stated s/he used to record the water temperatures but no longer did so. The Maintenance Director had been aware that the last two rooms on Unit 4 (418, 419) ran off the same water heater as the laundry below them since the 1980's when laundry service began. Unit 4 was a locked unit specifically used for cognitively impaired self-mobile residents who were at much greater risk for injury. On 3/21/2016 at 6:18 PM, the Maintenance Director was unable to demonstrate proper use/calibration of the thermometer with which to measure hot water temperatures. Interview with the Administrator on 3/22/2016 at 4:13 PM revealed that the Maintenance Director had stated several months previously that the rooms over the laundry needed their own water heater. Although the Admi… | 2019-08-01 |
| 4736 | 4736 | ELLENBURG NURSING CENTER, INC | 425047 | 611 EAST HAMPTON STREET | ANDERSON | SC | 29624 | 2016-03-25 | 520 | L | 0 | 1 | 4J2O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on full and/or limited record reviews, interviews, and review of the facility policies, it was determined on 6/2/15 at approximately 5:02 PM Immediate Jeopardy and/or Substandard Quality of Care existed for CFR 483.75 F-520 which was identified at a scope and severity level of (L). The facility failed to ensure that the Quality Assurance (QA) process was utilized to identify, monitor and implement a plan of action to ensure routine monitoring of water temperatures to prevent potential injuries to residents. Water temperatures exceeded 140 degrees Fahrenheit on the locked Alzheimer's Unit. The facility's Maintenance Director and Administrator were aware the water temperatures exceeded a safe range. The Maintenance Director did not have a system of recording water temperatures and was unaware of how to calibrate a thermometer. These findings resulted in Immediate Jeopardy existing in the facility at the time of discovery on 3/21/16. The facility Administrator was informed of the Immediate Jeopardy on 3/21/16 at 7:00 PM. The findings included: Cross refer CFR 483.25 F-323 Free of Accident Hazards CFR 483.25 F-323 was identified at a scope and severity level of (L). The Immediate Jeopardy existed on 3/21/15 when water temperatures were checked in resident rooms on Units 1 and 4 and observed to be greater than 120 degrees. On 3/21/15 beginning at 3:42 PM surveyors thermometers were used to check rooms throughout the facility. During an interview on 3/21/2016 at 5:05 PM, the Maintenance Director revealed that s/he checked hot water temperatures on Mondays and Fridays but had kept no records of which rooms were checked and no temperatures had been recorded. S/he stated s/he used to record the water temperatures but did not do so any longer. The Maintenance Director had been aware that the last two rooms on Unit 4 (118, 119) ran off the same water heater as the laundry below them since the 1980's when laundry service began. Unit 4 was a locked … | 2019-08-01 |
| 5490 | 5490 | VIBRA HOSPITAL OF CHARLESTON -TCU | 425405 | 1200 HOSPITAL DR 2ND FL | MOUNT PLEASANT | SC | 29464 | 2015-12-16 | 520 | L | 1 | 0 | MUQO11 | > Based on resident record review, policy and procedure review and staff interviews, it was determined that the facility Quality Assessment and Assurance Committee failed to adequately identify and failed to put systemic measures in place to ensure that residents were protected following allegations of abuse. The facility's Quality Assurance and Assessment Committee failed to assure a licensed Administrator was overseeing the daily operations of the facility. The Quality Assurance Committee did not meet until 10/1/2015 to review an incident that occurred on 7/27/2015 of alleged abuse. The Committee failed to thoroughly identify the deficient practice that the alleged perpetrators were allowed to continue to work for three days following the Chief Executive Officer becoming aware of the allegation, placing all facility residents at risk for further abuse. The QAA Committee failed to provide an action plan to prevent any further occurrence. The systemic failures of the facility's Quality Assurance and Assessment Committee led to the findings of Immediate Jeopardy and Substandard Quality of Care existing in the facility as of 7/28/15. The facility was informed of the Immediate Jeopardy on 12/15/15 at 11:45 AM. The findings included: 1. Review of the facility Quality Assessment and Assurance Committee policy effective 12/16/15 revealed: the Facility failed to designate a Quality Assurance Coordinator. 2. Six months of Quality Assurance Minutes were not available. The facility was able to produce minutes for June, (MONTH) and (MONTH) (YEAR). Quarterly meetings should have included (MONTH) (YEAR) minutes. The facility stated they were not able to locate the requested information. 3. Review of the facility Nursing Policy Manual and Infection Control Manual on 12/15/15, during the extended survey, revealed there was no evidence the facility policies had been reviewed through the QA/QI Committee for approval during the past year. The Chief Clinical Officer (CCO) stated the policies and procedures were on the computer, whe… | 2018-12-01 |
| 5612 | 5612 | WOODRUFF MANOR | 425179 | 1114 EAST GEORGIA ROAD | WOODRUFF | SC | 29388 | 2015-06-04 | 323 | L | 0 | 1 | 02VR11 | Based on observations, record reviews and interviews the facility failed to assure safe water temperatures for 13 of 13 resident bathrooms on Unit 2 (Hall 200). The Maintenance Director failed to have adequate knowledge for checking temperatures and calibrating thermometers and there was no scheduled monitoring of water temperatures. The findings include: On 6/2/15 at approximately 9:00 AM during initial tour of the facility water temperatures were checked by hand in thirteen resident bathrooms on Unit 2 and observed to be too hot. On 6/2/15 at approximately 9:30 AM Surveyor Team thermometers were used to check all facility bathrooms. Thirteen resident bathrooms on Unit 2 were found to have hot water temperatures of approximately 121-124 degrees F (Fahrenheit). On 6/2/15 at approximately 9:55 AM the Maintenance Director was asked to provide a water temperature log and to take water temperatures for the Unit 2 resident bathrooms. He/she stated that no log was kept and obtained a(NAME)stick thermometer from the kitchen. When asked about calibration he/she stated that the thermometer had been calibrated yesterday. The Surveyor asked for the thermometer to be calibrated again and the Maintenance Director took the thermometer to the kitchen and asked the Dietary Manager to calibrate. On 6/2/15 at approximately 10:10 AM the Maintenance Director used the kitchen thermometer calibrated by the Dietary Manager to check bathroom water temperatures on Unit 2. Water temperatures were check in bathrooms for room 201/203, 204/206, 209, 211/213, 216 and 215/217. The results obtained by the Maintenance Director were between approximately 100-110 degrees F. The Maintenance Director demonstrated considerable variability in technique when taking temperatures and stated several times that the water sure feels a lot hotter than this. The thermometer was held under the hot water stream at varying angles and the entire temperature sensitive portion of the thermometer was not exposed to the water. The Surveyor temperature reading taken a… | 2018-11-01 |
| 5616 | 5616 | WOODRUFF MANOR | 425179 | 1114 EAST GEORGIA ROAD | WOODRUFF | SC | 29388 | 2015-06-04 | 490 | L | 0 | 1 | 02VR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews the Administrator failed to train and/or provide a job description for the facility Maintenance Director which contributed to immediate jeopardy and/or substandard quality of care. The findings include: Cross refer CFR 483.25 F-323 Free of Accident Hazards On 6/3/15 at approximately 10:00 AM a review of the Maintenance Director personnel file revealed the Date of Hire as Floor Tech: 8/16/13 and Promoted to Maintenance Director/Housekeeping Supervisor: 9/26/14. Further review failed to show a job description or evidence of training for the Maintenance Director. The Administrator stated that s/he was unable to locate a Maintenance Director job description or a record of training for the Maintenance Director. The Administrator was notified at approximately 5:00PM on 6/2/2015 of the Immediate Jeopardy and/or Substandard Quality of Care related to excessive hot water temperatures in resident rooms. An Allegation of Compliance (A[NAME]) was submitted by the facility on 6/3/15 at approximately 8:45 AM. The actions listed in the A[NAME] included the following: I. Corrective Action taken to remove the Immediate Jeopardy: On 6/2/2015 at approximately 5:00pm (sic), the survey team notified the facility that an Immediate Jeopardy situation was present in regards to Hot Water Temperatures on the 200 Unit. The survey team stated that resident room temperatures on the 200 Unit were in excess of 120 degrees (highest temperature reported was 124 degrees). It was stated by the survey team leader that excessive temperatures were limited to the 200 Unit and that the other Unit's temperatures (100 Unit) were in compliance. The Administrator informed the nursing staff on the 200 Unit to cease using hot water on 6/2/15 at approximately 5:20pm (sic) until the situation was resolved. On 6/2/15 The DON, in coordination with the Licensed Nursing Staff completed 100% body audits on all residents on both units to ensur… | 2018-11-01 |
| 5619 | 5619 | WOODRUFF MANOR | 425179 | 1114 EAST GEORGIA ROAD | WOODRUFF | SC | 29388 | 2015-06-04 | 520 | L | 0 | 1 | 02VR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on full and/or limited record reviews, interviews, and review of the facility policies, it was determined on 6/2/15 at approximately 5:02 PM Immediate Jeopardy and/or Substandard Quality of Care existed for CFR 483.75 F-520 which was identified at a scope and severity level of (L). The facility failed to ensure that the Quality Assurance (QA) process was utilized to identify, monitor and implement a plan of action to ensure routine monitoring of water temperatures to prevent potential injuries to residents. The findings included: Cross refer CFR 483.25 F-323 Free of Accident Hazards CFR 483.25 F-323 was identified at a scope and severity level of (L). The Immediate Jeopardy existed on 6/2/15 when water temperatures were checked on initial tour in thirteen resident bathrooms on Unit 2 and observed to be too hot. On 6/2/15 at approximately 9:30 AM Surveyor Team thermometers were used to check all facility bathrooms. Thirteen resident bathrooms on Unit 2 were found to have hot water temperatures of approximately 121-124 degrees F (Fahrenheit). During an interview on 6/4/15 at approximately 5:30 PM, the facility Administrator confirmed the facility had not identified the water temperatures as being a concern. The Administrator stated the facility had no QA in process relative to the concern. The Administrator stated that the QA Committee identified concerns through the Quality Measures, Bench Mark Reports the 24 Hour Reports, Incident Reports, Grievances, Customer Satisfaction Surveys, the Guardian Angel Program, and the Interact Stop and Watch to identify residents' changes in condition to prevent re-hospitalization s. The Administrator was notified at approximately 5:00PM on 6/2/2015 of the Immediate Jeopardy and/or Substandard Quality of Care related to excessive hot water temperatures in resident rooms. An Allegation of Compliance (A[NAME]) was submitted by the facility on 6/3/15 at approximately 8:45 AM. The actions listed in the A[NAM… | 2018-11-01 |
| 5941 | 5941 | BLUE RIDGE IN THE FIELDS, LLC | 425158 | 117 BELLEFIELD ROAD | RIDGEWAY | SC | 29130 | 2015-08-03 | 250 | L | 0 | 1 | KHE011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to provide medically related social services with interventions and treatment to promote the psychosocial well-being for 12 of 12 residents reviewed for psychiatric services. The facility failed to adequately assess, monitor and evaluate Resident #32's psychosocial needs related to a physician's orders [REDACTED].#38; Resident #74 exhibiting inappropriate behaviors failed to have consistent coordination of care with facility staff, mental health staff, physician and the responsible party to ensure appropriate treatment was administered; Resident #79, with a physician's orders [REDACTED].#25, #35, #57, #58, #62, #77, #82, & #116 noted with [DIAGNOSES REDACTED]. The findings included: Cross Refer to F-406 as it relates to the facility failure to provide medically related social services to attain or maintain the highest practicable physical, mental and psychosocial well being of each resident. The facility admitted Resident #32 with [DIAGNOSES REDACTED]. During record review of the progress notes on 7/28/15 at approximately 3:15 PM, it was revealed that Resident #32 had long and short term memory loss, was unhappy, sad, with confusion at times but was able to make needs known to the staff. Multiple observations were made 7/28/15 and 7/29/15 at different times revealing Resident #32 was participating in activities with bingo and church services. An interview was conducted on 7/29/15 at approximately 9:35 AM with the resident's daughter present. Resident #32 revealed he/she had a panic attack. He/she stated, I turned on the light and no one came. When they finally came the CNA (Certified Nursing Assistant) turned off the call light and told me he/she would be back in a few minutes. S/he never came back. Resident #32 went on to say, I was soiled and had to call my daughter to get some help months ago around February/March (YEAR). I called my son about the CNA not putting cr… | 2018-07-01 |
| 5948 | 5948 | BLUE RIDGE IN THE FIELDS, LLC | 425158 | 117 BELLEFIELD ROAD | RIDGEWAY | SC | 29130 | 2015-08-03 | 280 | L | 0 | 1 | KHE011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to review and revise the care plans for multiple residents with changes in behavior, Activities of Daily Living (ADLs), psychiatric services, and increased depression. Eleven of 38 residents sampled had care plans not reviewed and revised for these issues, including Resident #32 with changes in anxiety/depression that required a psych eval and follow-up, Resident #38 with behavior change with increased depression, Residents #57, #116, #25, #35, #58, #62 & #77 receiving mental health services with no care plan related to current treatment or possible interventions, Resident #27 with improvement in ADLs, and Resident #108 with decline in ADLs. The findings included: Cross Refer to F406/F250 as it relates to residents seen by mental health services with no coordination of care and facility failure to revise care plans to allow for staff to adequately address identified concerns. The facility admitted Resident #32 with [DIAGNOSES REDACTED]. A record review on 7/28/15 at approximately 3:15 PM revealed a physician's orders [REDACTED]. The order was to have Resident #32 evaluated by psychiatric services. Even though the order was written on 9/10/14 there was no documentation in the chart to indicate that the resident was seen or evaluated for mental health services before 1/12/15, four months after the initial order. Progress notes documenting mental health visits were not found in the resident's clinical record or available to staff for use in treating Resident #32. The visits and notes had to be requested from mental health services and faxed to the facility. During an interview on 7/29/15 at approximately 8:00 AM, Resident #32 stated s/he was having panic attacks 2 times a week when she would get upset with staff for not answering her call light and meeting her needs timely. The panic attacks started happening in (MONTH) or (MONTH) (YEAR) with an incident of not getting cleaned up timely f… | 2018-07-01 |
| 5954 | 5954 | BLUE RIDGE IN THE FIELDS, LLC | 425158 | 117 BELLEFIELD ROAD | RIDGEWAY | SC | 29130 | 2015-08-03 | 406 | L | 0 | 1 | KHE011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews and review of facility policies, it was determined on 7/30/15 at approximately 5:20 PM Immediate Jeopardy was identified at a scope and severity level of (L). The facility failed to provide mental health services timely for 4 of 12 sampled residents with physician ordered mental health evaluations/treatments. Residents #32, #38, #74 and #79 were not provided mental health services timely. The findings included: The facility admitted Resident #32 with [DIAGNOSES REDACTED]. A review of the medications revealed that Resident #32 was on [MEDICATION NAME] 0.25 mg one po (by mouth) every 6 hours prn (as needed) anxiety (ordered (MONTH) (YEAR)), [MEDICATION NAME] 50 mg. one tab tid (three times a day). A physician's progress note indicated that Resident #32 had long and short term memory loss. The progress note further indicated the resident was unhappy, sad, and confused at times. A record review on 7/28/15 at approximately 3:15 PM revealed a physician's orders [REDACTED]. The order was to have Resident #32 evaluated by psychiatric services. Even though the order was written on 9/10/14 there was no documentation in the chart to indicate that the resident was seen or evaluated for mental health services before 1/12/15, four months after the initial order. Progress notes documenting mental health visits were not found in the resident's clinical record or available to staff for use in treating Resident #32. The visits and notes had to be requested from mental health services and faxed to the facility. A psychiatric note dated 1/12/15 indicated Resident #32 had a [DIAGNOSES REDACTED]. A second psychiatric note dated 1/21/15 indicated the resident had [DIAGNOSES REDACTED]. A physician's progress note dated 1/26/15 indicated the resident was not acting right. There was no documentation to indicate a referral was made to social services or that social services intervened to ensure mental health services were followed th… | 2018-07-01 |
| 5957 | 5957 | BLUE RIDGE IN THE FIELDS, LLC | 425158 | 117 BELLEFIELD ROAD | RIDGEWAY | SC | 29130 | 2015-08-03 | 490 | L | 0 | 1 | KHE011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews and review of facility policies, the facility Administration failed to implement its resources effectively and efficiently to attain or maintain the highest practicable mental and psychosocial well being for Resident #32, #38, #74, & #79, who did not receive mental health services timely. The facility further failed to identify additional residents who did not receive medically related social services through effective coordination of mental health services (Residents #25, #35, #57, #58, #62, #77, #82, & #116). The findings included: Cross Refer Social Services, F-250. The facility failed to provide medically related social services to attain or maintain the highest practicable physical, mental and psychosocial well being of each resident. The facility failed to adequately assess, monitor and evaluate Resident #32's psychosocial needs related to a physician's orders [REDACTED]. A psychological evaluation was ordered 9/10/14 and there was no documentation to indicate services were provided until 1/12/15; failed to ensure the physician was notified of an increase in depression score and a recommendation for a psych evaluation for Resident #38; Resident #74 exhibiting inappropriate behaviors failed to have consistent coordination of care with facility staff, mental health staff, physician and the responsible party to ensure appropriate treatment was administered; Resident #79, with a physician's orders [REDACTED].#25, #35, #57, #58, #62, #77, # 82, & #116 noted with [DIAGNOSES REDACTED]. Care Plan, F-280. The facility failed to update, review and revise Resident #32, #25, #35, #38, #57, #58, #62, #77, & #116's Plan of Care related to physician ordered mental health services to include goals and coordination of care interventions. Provision of Services, F-406. The facility failed to ensure that physician ordered mental health services were provided timely and/or coordinated as part of the plan of care for Resid… | 2018-07-01 |
| 5958 | 5958 | BLUE RIDGE IN THE FIELDS, LLC | 425158 | 117 BELLEFIELD ROAD | RIDGEWAY | SC | 29130 | 2015-08-03 | 501 | L | 0 | 1 | KHE011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, review of facility policy and record review, the Medical Director failed to ensure implementation of facility policies and coordinate mental health services in an effective and efficient manner to maintain the highest practicable physical, mental, and psychosocial well-being for residents in the facility with physician ordered psychological evaluations and treatment for 12 of 12 residents reviewed for mental health services. The findings included: Cross Refer Social Services, F-250. The facility failed to provide medically related social services to attain or maintain the highest practicable physical, mental and psychosocial well being of each resident. The facility failed to adequately assess, monitor and evaluate Resident #32's psychosocial needs related to a physician's order for mental health services that was not provided timely. A psychological evaluation was ordered 9/10/14 and there was no documentation to indicate services were provided until 1/12/15; failed to ensure the physician was notified of an increase in depression score and a recommendation for a psych evaluation for Resident #38; Resident #74 exhibiting inappropriate behaviors failed to have consistent coordination of care with facility staff, mental health staff, physician and the responsible party to ensure appropriate treatment was administered; Resident #79, with a Physician's order for a Psych eval related to a gradual dose reduction of medication, failed to be evaluated until 6 months after the order; Resident #25, #35, #57, #58, #62, #77, # 82, & #116 noted with [DIAGNOSES REDACTED]. Cross refer Provision of Services, F-406. The facility failed to ensure that physician ordered mental health services were provided timely and/or coordinated as part of the plan of care for Residents #32, #38, #74, & #79. Cross refers to F-520 Quality Assurance. The facility failed to ensure the Quality Assurance process was utilized to identify, clarify, and implemen… | 2018-07-01 |
| 5960 | 5960 | BLUE RIDGE IN THE FIELDS, LLC | 425158 | 117 BELLEFIELD ROAD | RIDGEWAY | SC | 29130 | 2015-08-03 | 520 | L | 0 | 1 | KHE011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews and review of facility policies the facility failed to identify quality deficiencies to ensure medically related Social Services were provided timely and consistently. The facility failed to identify, clarify, and implement a plan of action related to physician's orders [REDACTED]. Medically related Social Services failed to implement, coordinate and ensure mental health services were provided as needed. The findings included: Cross Refer Social Services, F-250. The facility failed to provide medically related social services to attain or maintain the highest practicable physical, mental and psychosocial well being of each resident. The facility failed to adequately assess, monitor and evaluate Resident #32's psychosocial needs related to a physician's orders [REDACTED]. A psychological evaluation was ordered 9/10/14 and there was no documentation to indicate services were provided until 1/12/15; failed to ensure the physician was notified of an increase in depression score and a recommendation for a psych evaluation for Resident #38; Resident #74 exhibiting inappropriate behaviors failed to have consistent coordination of care with facility staff, mental health staff, physician and the responsible party to ensure appropriate treatment was administered; Resident #79, with a physician's orders [REDACTED].#25, #35, #57, #58, #62, #77, # 82, & #116 noted with [DIAGNOSES REDACTED]. Cross Refer Care Plan, F-280. The facility failed to update, review and revise Resident #32, #25, #35, #38, #57, #58, #62, #77, & #116's Plan of Care related to physician ordered mental health services to include goals and coordination of care interventions. Cross Refer Provision of Services, F-406. The facility failed to ensure that physician ordered mental health services were provided timely and/or coordinated as part of the plan of care for Residents #32, #38, #74, & #79. Based on record reviews and interviews, the facility faile… | 2018-07-01 |
| 7446 | 7446 | COMPASS POST ACUTE REHABILITATION | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2016-04-28 | 224 | L | 0 | 1 | 1ROG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews and facility files, the facility failed to protect residents from abuse for one of one resident's (#178) coerced without an investigation or report to state agencies. One of one residents (resident #69) with misappropriation of funds, without a thorough investigation and 2 residents with allegations of abuse that were not reported to state agency. The findings included: During the Recertification and Complaint Survey, on 4/21/16 the Department of Health and Environmental Control (DHEC) Certification State Agency office received an additional eight (8) allegations of abuse/neglect. Review of the allegations revealed the facility had identified a concern related to the allegation that involved resident # 178. The facility admitted resident # 178 with [DIAGNOSES REDACTED]. The resident had a Brief Interview for Mental Status Score of 15. S/he was alert and oriented and able to make decisions regarding his/her ability to make decisions regarding activities of daily living. Review of the additional allegations revealed an allegation of 3/16/16 related to resident #178. Per the allegation, the resident had complained that a nurse had snatched off a neck brace. Review of the facility's grievance files revealed a grievance of the allegation. Through the facility investigation of the allegation, the resident had stated the nurse had startled him/her when removing the neck brace and was not abused. The Administrator, Director of Nursing (DON), Director of Nursing in Training (DON in training), and Social Services (SS) were interviewed by the surveyor on 4/21/16 at approximately 11:30 AM. During the interview the Administrator and DON stated that a note was left under the administrator's door, signed by the resident. The administrator provided the note for review. The note stated, I will (sic) like to speak to the Patient Avocate about my collar being snatched off by male nurse. Please call them for me, thanks for aski… | 2017-03-01 |
| 7447 | 7447 | COMPASS POST ACUTE REHABILITATION | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2016-04-28 | 226 | L | 0 | 1 | 1ROG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews and facility files, the facility failed to follow their policy to complete a thorough investigation and report immediately to state agencies any allegations of abuse, neglect and misappropriation of funds. The facility failed to conduct a thorough investigation for 1 of 1 allegations of misappropriation of funds (resident #69). The facility failed to conduct an investigation and report allegations of abuse for 1 of 1 residents the facility identified a concern with (resident # 178). The facility failed to report and provide a thorough investigation of 2 of 2 random allegations of abuse reported to them by the surveyor. The findings included: Cross refer to F 224. Preventing, investigating and reporting allegations of abuse, neglect and misappropriation of funds/personal property. Resident #178 reported someone had entered their room in the middle of the night and had him/her sign a paper. The resident did not know who the person was or what was on the paper. The resident was told not to mention the letter and not to tell anyone that the resident had a visitor. The facility also received reports the person that entered the building in the middle of the night made copies of medical records. No investigation had been conducted nor were the allegations reported to the state agencies. Resident # 69 reported to the facility that a Certified Nursing Assistant (CNA) had his/her bank card and had used the card without the resident's authorization. The CNA had the resident's car as well. The facility did not have a thorough investigation of the allegations. The facility's investigation did not included an official statement from the resident. There were no interviews/statements of other resident's that may have been affected by the CNA's practice. There were no statements obtained from the staff. During the Recertification/Complaint Survey, the facility Administration was notified by the surveyor of two allegations of… | 2017-03-01 |
| 7453 | 7453 | COMPASS POST ACUTE REHABILITATION | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2016-04-28 | 323 | L | 0 | 1 | 1ROG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to provide supervision for the safety of the residents. Resident #178 was visited in the middle of the night by someone s/he did not know, and instructed to sign a paper. The resident was told to not tell anyone about the paper and not to tell ayone about the visit. The findings included: Cross refer to F224- Prevention, investigation and reporting abuse/neglect and misappropriation of funds. The facility admitted resident # 178 with [DIAGNOSES REDACTED]. The resident had a Brief Interview for Mental Status Score of 15. S/he was alert and oriented and able to make decisions regarding his/her ability to make decisions regarding activities of daily living. Review of the additional allegations revealed an allegation of 3/16/16 related to resident #178. Per the allegation, the resident had complained that a nurse had snatched off a neck brace. Review of the facility's grievance files revealed a grievance of the allegation. Through the facility investigation of the allegation, the resident had stated the nurse had startled him/her when removing the neck brace and was not abused. The Administrator, Director of Nursing (DON), Director of Nursing in Training (DON in training), and Social Services (SS) were interviewed by the surveyor on 4/21/16 at approximately 11:30 AM. During the interview the Administrator and DON stated that a note was left under the administrator's door, signed by the resident. The administrator provided the note for review. The note stated, I will (sic) like to speak to the Patient Avocate about my collar being snatched off by male nurse. Please call them for me, thanks for asking about my care. I was informed S/he is Ombudsman ---- (name of person). The administrator went to the resident and was told by the resident that someone had come in his/her room at 3:00 AM, wearing a hoodie and had him/her sign a paper. The resident did not know who the person was or what was o… | 2017-03-01 |
| 7460 | 7460 | COMPASS POST ACUTE REHABILITATION | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2016-04-28 | 490 | L | 0 | 1 | 1ROG11 | Based on review of facility files and interviews, the facility failed to Administer in a way to maintain safety of residents named in allegations of abuse/neglect misappropriation of funds. The findings included: Cross refer to F224- Prevent, investigate and report allegations of abuse/neglect, misappropriation of funds Cross Refer to F226: Developing Policies and Procedures for Abuse/Neglect and Misappropriation of funds/personal property. Cross refer to F323: Supervision to prevent accidents/incidents. Supervision not provided to prevent unknown person entering facility and resident's rooms when sleeping. | 2017-03-01 |
| 7464 | 7464 | COMPASS POST ACUTE REHABILITATION | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2016-04-28 | 516 | L | 0 | 1 | 1ROG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to maintain the safety and confidentiality of resident records and failed to safeguard clinical record information against unauthorized use. It was determined on 4/21/16 at approximately 4:20 PM Immediate Jeopardy and/or Substandard Quality of Care existed in the facility as of 3/17/2016. The findings included: Cross refer to F224- Prevent, investigate and report allegations of abuse/neglect, misappropriation of funds related to Resident #178. Cross refer to F226-Developing Policies and Procedures for Abuse/Neglect and Misappropriation of funds/personal property related to Resident #178. Cross refer to F-323 Supervision to prevent accidents/incidents related to Resident #178. During the Recertification and Complaint Survey, on 4/21/16 the Department of Health and Environmental Control (DHEC) Certification State Agency office received an additional eight (8) allegations of abuse/neglect. Review of the allegations revealed the facility had identified a concern related to the allegation that involved resident # 178. The administrator went to the resident (#178) and was told by the resident that someone had come in his/her room at 3:00 AM, wearing a hoodie and had him/her sign a paper. The resident did not know who the person was or what was on the paper that s/he signed. The resident stated s/he did not write the note and did not want to talk to the patient advocate. The DON stated the same person seen in Resident #178's room was seen on the same night by staff members copying resident charts. The DON stated when s/he came in, the person had already left the facility. During the interview the Administrator and DON and DON in training stated the person that had entered the facility during the night was an employee, a Licensed Practical Nurse (LPN), who worked the 7A-7P shift. The employee was out on medical leave at the time of the survey. The Administrator was asked by the surveyor, what… | 2017-03-01 |
| 7466 | 7466 | COMPASS POST ACUTE REHABILITATION | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2016-04-28 | 520 | L | 0 | 1 | 1ROG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on full and/or limited record reviews, interviews, and review of facility policies, it was determined on 4/21/16 at approximately 4:20 PM Immediate Jeopardy and/or Substandard Quality of Care existed for CFR483.75 F-520 which was identified at a scope and severity level of (L). The facility failed to identify quality deficiencies related to prevention of abuse/neglect, proper implementation of abuse/neglect policies, provision of supervision to ensure resident safety, and provision of medical record security. Failure of the Quality Assurance (QA) Committee to identify and implement action plans related to these quality deficiencies resulted in Immediate Jeopardy for Resident #69 and Resident #178. The findings included: Based on record reviews and interviews, the facility failed to identify concerns related to prevention of abuse/neglect, provision of supervision to ensure resident safety, and provision of medical record security. During an interview on 4/28/16, the Administrator and Director of Nursing stated and confirmed that the QA Committee had not identified and had not implemented action plans related to the concerns identified for Resident #69 and Resident #178. Based on full and/or limited record reviews, interviews, and review of facility policies, it was determined on 4/21/16 at approximately 4:20 PM Immediate Jeopardy and/or Substandard Quality of Care existed in the facility as of 3/17/2016. The facility Administrator, Director of Nursing, and Director of Nursing in Training were informed of the Immediate Jeopardy on 4/21/16 at approximately 5:20 PM. The facility provided an Allegation of Compliance (AOC) that was acceptable on 4/28/16 at 2:05 PM, and the Immediate Jeopardy at F-224, F-226, F-323, F490, F516 and F-520 was removed but the citations remained at a lower scope and severity. The AOC included the following: AOC: It has been alleged in the context of the pending survey process that the Facility's response to event… | 2017-03-01 |
| 7832 | 7832 | MARION NURSING CENTER, INC. | 425015 | 2770 SOUTH HIGHWAY 501 | MARION | SC | 29571 | 2013-10-03 | 281 | L | 1 | 0 | 1P0111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint and extended survey, based on observations, interviews, record reviews, review of the facility Prevention of Pressure Ulcer policy, review of the South Carolina Board of Nursing, Advisory Opinion #46, review of the July 2013 South Carolina Nurse Aide Candidate Handbook, and review of the facility policy entitled Incontinence Care, 2006, the facility licensed staff failed to evaluate pressure ulcer risk factors and implement interventions to reduce or remove the underlying risk factors; assess residents to identify the development of new pressure sores and provide appropriate care and assessments of wounds, in accordance with recognized standards of practice to promote healing and prevent infection for Resident #1, #2, #3, and #5 did not have pressure sore dressings in place per physician order. The facility failed to provide appropriate treatment and services for five of five residents (Residents #21, #17, A, B and C) noted with urinary incontinence who were reviewed for skin integrity. Staff failed to apply relevant policies and procedures to manage urinary incontinence. Care was not provided when residents were noted to be incontinent, thus increasing the risk of skin breakdown. The findings included: Cross refers to F-314 as it relates to the failure of the facility to evaluate pressure sore risk factors and implement interventions to reduce or remove the underlying risk factors, assess residents to identify the development of new pressure sores and provide appropriate care and assessments of wounds, in accordance with recognized standards of practice, to ensure the healing and prevent infection to residents with pressure sores. Cross refers to F-315 as it relates to the failure of the facility to provide appropriate incontinence care to residents with or at risk for skin breakdown Cross refers to F-490 as it relates to the failure of the facility administration to implement its resources effectively and effici… | 2016-10-01 |
| 7836 | 7836 | MARION NURSING CENTER, INC. | 425015 | 2770 SOUTH HIGHWAY 501 | MARION | SC | 29571 | 2013-10-03 | 314 | L | 1 | 0 | 1P0111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint and extended survey, based on observations, interviews, record reviews, review of the facility Prevention of Pressure Ulcer policy and review of the South Carolina Board of Nursing, Advisory Opinion #46, the facility licensed staff failed to evaluate pressure ulcer risk factors and implement interventions to reduce or remove the underlying risk factors; assess residents to identify the development of new pressure sores and provide appropriate care and assessments of wounds, in accordance with recognized standards of practice to promote healing and prevent infection for Residents #1, #2, #3, #5, #21 and #19. The findings included: Resident #1 was observed with the surveyor and Certified Nurse Aide (CNA) #2 on 9/21/2013 at approximately 2:15 PM. The resident was positioned on her/his back, with the head of the bed elevated, a tube feeding was in progress, a towel was observed on top of the drawsheet, and under the resident. The dressing on the peg tube insertion site was soiled with a dark brown stain and the dressing was not dated. When the resident was turned to her/his left side and the brief was removed, the entire back of the brief was wet and stained a tan color. There was an odor noted coming from the wound. Resident #1 did not have any type of dressing on her/his sacral pressure ulcer. The absence of a dressing was confirmed by CNA #2 who stated s/he had not provided care to the resident until now and s/he was unable to say for sure who had provided care earlier in the day. The sacral pressure ulcer was noted by the surveyor to be clean with a pink wound base. A small amount of brown slough was observed at the 12:00 o'clock position of the wound. The wound appeared to be a Stage IV on observation. Licensed Practical Nurse #4 was outside of the resident's room and came in immediately to assist CNA #2. LPN #4 stated when asked by the surveyor, Who does the wound care? that the nurses on the units did the wound… | 2016-10-01 |
| 7843 | 7843 | MARION NURSING CENTER, INC. | 425015 | 2770 SOUTH HIGHWAY 501 | MARION | SC | 29571 | 2013-10-03 | 490 | L | 1 | 0 | 1P0111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint and extended survey, based on observations, interviews, and record reviews, the facility Administration failed to implement its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well being of each resident. The facility's administration failed to identify and implement a plan of action to ensure residents with pressure sores received the necessary treatments and services to promote healing, prevent infection and prevent new sores from developing; failed to adequately protect residents assessed as smokers; failed to designate an Infection Control Preventionist when the current Preventionist left due to illness the week of September 9, 2013; failed to employ a Registered Dietician since December 10, 2012. This deficiency was cited at K during the Recertification and Extended Survey conducted 08/08 - 08/14/2013. The facility continued to be out of compliance as of 10/03/2013 when a second extended survey was conducted and the deficiency was elevated to L related an Immediate Jeopardy involving pressure sore and the failure to supervise resident assessed as smokers. The findings included: Cross refers to F-279 as it relates to the failure of the facility to develop care plans for residents identified as smokers. Cross refers to F-280 as it relates to the failure of the facility to review and revise the comprehensive care plan for residents assessed at risk for skin breakdown and/or with existing breakdown. Cross refers to F-281 as it relates to the failure of the facility staff to evaluate pressure sore risk factors and implement interventions to reduce or remove the underlying risk factors; assess residents to identify the development of new pressure sores and provide appropriate care and assessments of wounds, to promote healing and prevent infection to residents who had pressure sores, in accordance with recognized standards of practice. Cross refe… | 2016-10-01 |
| 7844 | 7844 | MARION NURSING CENTER, INC. | 425015 | 2770 SOUTH HIGHWAY 501 | MARION | SC | 29571 | 2013-10-03 | 493 | L | 1 | 0 | 1P0111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint and extended survey based on observations, interviews and review of the facility Governing Body failed to provide evidence of ongoing oversight, establish and/or implement policies regarding the management and operation of the facility. The findings included: Cross refers to F-279 as it relates to the failure of the facility to develop care plans for residents identified as smokers. Cross refers to F-280 as it relates to the failure of the facility to review and revise the comprehensive care plan for residents assessed at risk for skin breakdown and/or with existing breakdown. Cross refers to F-281 as it relates to the failure of the facility staff to evaluate pressure sore risk factors and implement interventions to reduce or remove the underlying risk factors; assess residents to identify the development of new pressure sores and provide appropriate care and assessments of wounds, to promote healing and prevent infection to residents who had pressure sores, in accordance with recognized standards of practice. Cross refers to F-314 as it relates to the failure of the facility staff to evaluate pressure sore risk factors and implement interventions to reduce or remove the underlying risk factors, assess residents to identify the development of new pressure sores and provide appropriate care and assessments of wounds, to ensure the healing and prevent infection to residents with pressure sores. Cross refers to F-323 as it relates to the failure of the facility failed to provide safety devices and adequate supervision to ensure the safety of residents while smoking. Resident #10 had visible tremors of the hands and no fire retardant apron on while smoking, 4 residents were observed smoking in a non-designated smoking area and left unattended, and there was no fire extinguisher in the designated smoking area. Resident's #11 and #12 were found to have no comprehensive care plan in the clinical record; Residents #10 an… | 2016-10-01 |
| 8211 | 8211 | CHESTER NURSING CENTER | 425061 | 1 MEDICAL PARK DRIVE | CHESTER | SC | 29706 | 2012-05-03 | 223 | L | 0 | 1 | WII411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** July 17, 2012 - Ammended to reflect change of original Scope and Severity Lowered to K and lowered Scope and Severity to E On the days of the Recertification and Extended Survey, based on observations, record review, and interviews, the facility failed to ensure the staff monitored visitors/sitters interactions with residents to ensure the safety and well being of residents in the facility. Resident #18 was allegedly verbally abused by Resident #11's visitor/sitter. The findings included: Cross refers to F-226 as it relates to the failure of the facility to follow policy to identify abuse and neglect, report allegations of abuse/neglect as well as protect residents from further abuse/neglect once an allegation was reported. Cross refers to F-490 as it related to the failure of the facility Administration to provide the necessary oversight to ensure policies and procedures related to protecting residents from abuse/neglect by reporting and intervening to prevent further abuse/neglect was implemented properly. The Administration was not aware paid sitters were operating in the building and the facility had no policies in place to ensure sitters were aware of facility policies and procedures and met regulatory requirements. Cross refers to F-520 as it relates to the failure of the facility to be aware that paid sitters were operating in the building and the facility had no policies in place to ensure sitters were aware of facility policies and procedures. The facility admitted Resident #18 with [DIAGNOSES REDACTED]. Record review revealed an Annual MDS (Minimum Data Set) dated 6/17/11 that indicated the resident had a BIMS (Brief Interview for Mental Status) of 3 indicating she was cognitively impaired. Review of the MDS dated [DATE] indicated Resident #18 had long and short-term memory with severe cognitive impairment in daily living skills. The MDS further indicated the resident had the ability to respond adequately to simple direction; no beh… | 2016-06-01 |
| 8212 | 8212 | CHESTER NURSING CENTER | 425061 | 1 MEDICAL PARK DRIVE | CHESTER | SC | 29706 | 2012-05-03 | 225 | L | 0 | 1 | WII411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** July 17, 2012 - Ammended to reflect change to original Scope and Severity to J and lowered Scope and Severity to D On the days of the Recertification and Extended survey, based on record reviews, interviews and incident logs, the facility failed to ensure that all alleged violations involving mistreatment, neglect, or abuse, were reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). Application of heat by a licensed staff member to the leg of Resident #11, 1 of 3 residents reviewed for heat treatments, was applied improperly and not monitored resulting in a second degree burn to the resident. The incident was not reported as possible neglect to the State Agency. The findings included: Cross refers to F-226 as it relates to the failure of the facility to follow policy to identify neglect, report allegations of neglect as well as protect residents from further neglect once an allegation was reported. Cross Refers to F-281 as it relates to the failure of the facility Nursing staff to verify the physician's orders [REDACTED]. The failure placed Resident #11 at risk of serious harm. Cross Refers to F-323 as it relates to the failure of the facility to provide necessary care for Resident #11 when a licensed staff member used a microwave to heat a compress and placed the heated compress directly on the resident's leg without using a barrier between the resident's leg and the compress. This action resulted in a second degree burn to the resident's leg. Cross Refers to F-490 as it relates to the failure of the Administrator to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The administrator was aware that a licensed nurse used a microw… | 2016-06-01 |
| 8213 | 8213 | CHESTER NURSING CENTER | 425061 | 1 MEDICAL PARK DRIVE | CHESTER | SC | 29706 | 2012-05-03 | 226 | L | 0 | 1 | WII411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** July 17, 2012 - Ammended to reflect change to original Scope and Severity to K and lowered Scope and Severity to E On the days of the Recertification and Extended survey, based on interviews, record reviews, and review of the facility Abuse and Neglect Policy the facility failed to follow its policies and procedures that prohibit mistreatment, neglect, and abuse of residents. The facility staff failed to report neglect involving Resident #11 who suffered a burn related to a heat treatment which was applied incorrectly. The incident was not investigated and reported to the State Agency. The facility staff failed to respond when a sitter for Resident #11 yelled at her roommate Resident #18; multiple staff members were observed by the surveyor standing by when the incident occurred. The findings included: Cross Refers to F-223 as it relates to the failure of the facility to ensure that staff monitored visitors/sitters interactions with residents to ensure the residents safety and well being in the facility. Resident #18 was allegedly verbally abused by Resident #11's visitor/sitter. Cross Refers to F-225 as it relates to the failure of the facility to report and thoroughly investigate an incident in the facility as possible neglect due to a nurse's inappropriate approach to applying heat to Resident #11's leg that resulted in a burn. Cross Refers to F-281 as it relates to the failure of the facility Nursing staff to verify the physician's orders [REDACTED]. The failure placed Resident #11 at risk of serious harm. Cross Refers to F-323 as it relates to the failure of the facility to provide necessary care for Resident #11. The resident was burned when a nurse used a microwave to heat a compress and placed it directly on the resident's leg without using an appropriate barrier between the resident's leg and the heated compress. This action resulted in a second degree burn to the resident's leg. Cross Refers to F-490 as it relates to the failure of … | 2016-06-01 |
| 8223 | 8223 | CHESTER NURSING CENTER | 425061 | 1 MEDICAL PARK DRIVE | CHESTER | SC | 29706 | 2012-05-03 | 490 | L | 0 | 1 | WII411 | July 17, 2012 - Ammended to reflect changes to the original Scope and Severity to K and lowered Scope and Severity to E. On the days of the Recertification and Extended survey, based on record reviews, interviews and review of facility policy and procedures related to providing heat treatments, the facility administration failed to effectively and efficiently utilize resources to prevent one of one sampled resident from harm due to inappropriate application of a warm compress treatment. The facility failed to obtain clarification orders related on how to apply heat to a resident and failed to monitor the treatment which resulted in a burn to a resident. The facility failed to complete a thorough investigation of the burn incident and failed to report the injury as neglect to the State survey and certification agency. In addition the facility failed to develop policies on using paid sitters in the facility and were unaware of sitters currently working in the facility at the time of survey. The findings included: Cross Refers to F-223 as it relates to the failure of the facility to ensure that staff monitored visitors/sitters interactions with residents to ensure the residents safety and well being in the facility. Cross Refers to F-225 as it relates to the facility's failure to report an allegation of neglect to the State survey and certification agency. Cross Refers to F-226 as it relates to the facility's failure to ensure that staff was adequately trained to define, recognize and report allegations of abuse/neglect. Cross Refers to F-281 as it relates to the facility's failure to ensure that the licensed staff received adequate training to request clarification orders on applying a warm compress treatment and the monitoring of the treatment to prevent injury. Cross Refers to F-323 as it relates to the facility failure to prevent accidents and hazards for a resident that was burned during a warm compress treatment. Cross Refers to F-520 as it relates to the facility's failure to ensure each resident receiving wa… | 2016-06-01 |
| 8224 | 8224 | CHESTER NURSING CENTER | 425061 | 1 MEDICAL PARK DRIVE | CHESTER | SC | 29706 | 2012-05-03 | 520 | L | 0 | 1 | WII411 | July 17, 2012 - Ammended to reflect changes to the original Scope and Severity to K and lowered Scope and Severity to E. On the days of the Recertification and Extended survey, based on record reviews and interviews, the facility failed to develop, implement and monitor an action plan for identified concerns related to a nurse placing a hot compress in a microwave, placing it on a resident's skin without monitoring progression of the treatment and resulting in a second degree burn to the resident. The injury noted on 3/27/12 and no review of current policy or re-education was provided to nursing staff to prevent further injuries related to heat treatments. The facility staff failed to recognize verbal abuse and failed to act to protect the resident at the time the abuse took place. In addition, the facility failed to have any policies on using paid sitters in the facility and were unaware of sitters currently working in the facility at the time of survey. The findings included: Cross Refers to F-223 as it relates to the facility's failure to recognize verbal abuse, protect the resident abused, and have policies in place for paid sitters in the facility. Cross Refers to F-225 as it relates to the facility's failure to report an allegation of neglect to the State survey and certification agency. Cross Refers to F-226 as it relates to the facility's failure to ensure that staff was adequately trained to define, recognize and report allegations of abuse/neglect. Cross Refers to F-281 as it relates to the facility's failure to ensure that the licensed staff received adequate training to request clarification orders on applying a warm compress treatment and the monitoring of the treatment to prevent injury. Cross Refers to F-323 as it relates to the facility failure to prevent accidents and hazards for a resident that was burned during a warm compress treatment. Cross Refers to F-490 as it relates to the failure of the facility's Administration to provide the necessary oversight to ensure policies and procedures relate… | 2016-06-01 |
| 8300 | 8300 | AGAPE REHABILITATION OF CONWAY | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2012-05-02 | 441 | L | 0 | 1 | YK4D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification, Extended, and Complaint Surveys, based on record reviews, observations, interviews, and review of facility infection control policies and procedures and tracking documents, the facility failed to implement treatment and contact precautions in a timely manner, and/or failed to ensure contact precautions were maintained, and/or failed to ensure accurate monitoring and tracking of infections for 7 of 9 residents reviewed who had positive test results for Clostridium Difficile (C-Diff), (Residents #1, #4, #5, #6, #8, #10, and #12). The physician was not notified of the onset of gastrointestinal signs and symptoms of Clostridium Difficile (C-Diff) in a timely manner for four of nine sampled residents reviewed with[DIAGNOSES REDACTED] (Residents #1, #4, #8, #12). Three of these four developed symptoms after admission to the facility (Residents #1, #4, #12). This failure to notify the physician in a timely manner resulted in significant delays in treatment and increased risk/potential for transmission of infection. The facility failed to ensure contact precautions were maintained appropriately for Residents #1, #4, #5, #6, #8, #10. Infection surveillance data was inaccurate/missing for residents who had positive test results for[DIAGNOSES REDACTED] (Residents #1, #4, #6, #8, #10, and #12). The Infection Preventionist (IP) was not knowledgeable of job duties and responsibilities for the infection control program. The facility failed to ensure that surveillance data was reviewed frequently enough to identify, investigate, and address the causes of any trends. Facility staff failed to identify an outbreak of[DIAGNOSES REDACTED] and notify the local office of the Department of Health and Environmental Control. Procedures were not in place and/or followed to ensure that facility laundry was hygienically cleaned. Procedures were not in place and/or followed to ensure appropriate daily and terminal cleaning of isolation … | 2016-06-01 |
| 8301 | 8301 | AGAPE REHABILITATION OF CONWAY | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2012-05-02 | 490 | L | 0 | 1 | YK4D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification, Extended, and Complaint Survey, based on observation, record review and interviews, facility administration failed to ensure that policies and procedures were in place/followed to prevent, recognize, and control the onset and spread of infection within the facility. The findings included: On 5-2-12, review of the facility policy entitled Infection Control Committee - Duties and Responsibilities (Revised June, 2010) revealed that The Administrator will be responsible for oversight of the Infection Control Program. During an interview on 5-1-12 at 11:45 AM, the Administrator stated that the Infection Control Committee was not a separate entity but was part of the QAA Committee. He presented an action plan for November 2011 that noted the opportunity for improvement as Proper infection control methods that were in place before are currently not in place. He stated that this was based on general observations of resident care. Steps to correct/improve included: Inservices to be provided to nursing staff by 12-7-11; Compliance rounds to be done daily; and random audits to be done to ensure that infection control procedures were followed. Review of information provided by the facility staff on 5-2-12 revealed that 12 nurses and 1 CNA were inserviced on basic infection control on 11-15-11. Twelve CNAs and two nurses attended an inservice on 11-28-11 on infection control: room set-up/isolation equipment/drawers. Compliance rounds were only documented as completed twice (12-14-11 with 6 residents on isolation, 12-20-11 with 4 residents on isolation). Although additional information regarding completion of the plan and ongoing monitoring/audits were requested, none were provided. Additional inservice records were provided but not all departments/staff were in attendance. There was no evidence that the committee reviewed the implementation of the plan, monitored the outcome, or made needed revisions. During an intervie… | 2016-06-01 |
| 8303 | 8303 | AGAPE REHABILITATION OF CONWAY | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2012-05-02 | 501 | L | 0 | 1 | YK4D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification, Extended, and Complaint Surveys, based on record reviews, observation, and interviews, the Medical Director failed to coordinate medical care in the facility to ensure that resident care was consistent with established infection control policies and procedures. The facility failed to involve the Medical Director in the ongoing evaluation of monitoring infections within the facility and implementation of infection control policies and procedures. The findings included: Based on record reviews and interviews, the physician was not notified of the onset of gastrointestinal signs and symptoms of [MEDICAL CONDITIONS] in a timely manner for four of nine sampled residents reviewed with [MEDICAL CONDITION] (Residents #1, #4, #8, #12). Three of these four developed symptoms after admission to the facility (Residents #1, #4, #12). This failure to notify the physician in a timely manner resulted in significant delays in treatment and increased risk/potential for transmission of infection. The facility failed to ensure contact precautions were maintained appropriately for Residents #1, #4, #5, #6, #8, #10. Infection surveillance data was inaccurate/missing for residents who had positive test results for [MEDICAL CONDITION] (Residents #1, #4, #6, #8, #10, and #12). The Infection Preventionist (IP) was not knowledgeable of job duties and responsibilities for the infection control program. The facility failed to ensure that surveillance data was reviewed frequently enough to identify, investigate, and address the causes of any trends. Facility staff failed to identify an outbreak of [MEDICAL CONDITION] and notify the local office of the Department of Health and Environmental Control. Procedures were not in place and/or followed to ensure that facility laundry was hygienically cleaned. Procedures were not in place and/or followed to ensure appropriate daily and terminal cleaning of isolation rooms, including those rooms of… | 2016-06-01 |
| 8304 | 8304 | AGAPE REHABILITATION OF CONWAY | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2012-05-02 | 520 | L | 0 | 1 | YK4D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification, Extended, and Complaint Surveys, based on review of quality improvement documents, record reviews, and interviews, the facility failed to identify ongoing quality deficiencies related to monitoring and implementing infection control policies and procedures. The QAA Committee failed to conduct ongoing reviews of the processes involved in infection control surveillance and monitoring. Staff failed to follow a plan of action established in November 2011 related to ongoing monitoring of compliance with infection control procedures. The findings included: During an interview on 5-1-12 at 11:45 AM, the Administrator stated that the Infection Control Committee was not a separate entity but was part of the QAA Committee. He presented an action plan for November 2011 that noted the opportunity for improvement as Proper infection control methods that were in place before are currently not in place. He stated that this was based on general observations of resident care. Steps to correct/improve included: Inservices to be provided to nursing staff by 12-7-11; Compliance rounds to be done daily; and random audits to be done to ensure that infection control procedures were followed. Review of information provided by the facility staff on 5-2-12 revealed that 12 nurses and 1 CNA were inserviced on basic infection control on 11-15-11. Twelve CNAs and two nurses attended an inservice on 11-28-11 on infection control: room set-up/isolation equipment/drawers. Compliance rounds were only documented as completed twice (12-14-11 with 6 residents on isolation, 12-20-11 with 4 residents on isolation). Although additional information regarding completion of the plan and ongoing monitoring/audits were requested, none were provided. Additional disservice records were provided but not all departments/staff were in attendance. There was no evidence that the committee reviewed the implementation of the plan, monitored the outcome, or ma… | 2016-06-01 |
| 8456 | 8456 | SUMMIT HILLS SKILLED NURSING FACILITY | 425390 | 110 SUMMIT HILLS DRIVE | SPARTANBURG | SC | 29307 | 2012-08-02 | 272 | L | 0 | 1 | SQR511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification and Extended Survey, based on observations, record review and interviews, the facility failed to make comprehensive assessments of resident's needs related to 7 of 7 residents reviewed for pressure sores (Residents #14, #1, #4, #10, #3, #2 and #9). The findings included: Cross refers to F-280 as it relates to the failure of the facility to review and revise the comprehensive care plan for residents with pressure sores, Resident #14, #1, #4, #3 and #9. Cross refers to F-281 as it relates to the failure of the facility to evaluate pressure sore risk factors and implement interventions to reduce or remove the underlying risk factors, assess residents to identify the development of new pressure sores and provide appropriate care and assessments of wounds, in accordance with recognized standards of practice, to promote healing and prevent infection to residents who had pressure sores, Residents #14, #1, #4, #10, #3, #2, and #9. Cross refers to F-314 as it relates to the failure of the facility to evaluate pressure sore risk factors and implement interventions to reduce or remove the underlying risk factors, assess residents to identify the development of new pressure sores and provide appropriate care and assessments of wounds, in accordance with recognized standards of practice, to ensure the healing and prevent infection to residents with pressure sores, Residents #14, #1, #4, #10, #3, #2, and #9. Cross refers to F-490 as it relates to the failure of the facility administration to implement its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well being of each resident. The facility's administration failed to identify and implement a plan of action to ensure residents with pressure sores received the necessary treatments and services to promote healing, prevent infection and prevent new sores from developing. Cross refers to F-520 as it relat… | 2016-04-01 |
| 8458 | 8458 | SUMMIT HILLS SKILLED NURSING FACILITY | 425390 | 110 SUMMIT HILLS DRIVE | SPARTANBURG | SC | 29307 | 2012-08-02 | 280 | L | 0 | 1 | SQR511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification and Extended Survey, based on observations, interviews, and record review the facility failed to review and revise the comprehensive care plan for 5 of 7 residents reviewed with pressure sores (Residents #14, #1, #4, #3 and #9). The findings included: Cross refers to F-272 as it relates to the failure of the facility to make comprehensive assessments of resident's needs related to pressure sores. Cross refers to F-281 as it relates to the failure of the facility to evaluate pressure sore risk factors and implement interventions to reduce or remove the underlying risk factors, assess residents to identify the development of new pressure sores and provide appropriate care and assessments of wounds, in accordance with recognized standards of practice, to promote healing and prevent infection to residents who had pressure sores. Cross refers to F-314 as it relates to the failure of the facility to evaluate pressure sore risk factors and implement interventions to reduce or remove the underlying risk factors, assess residents to identify the development of new pressure sores and provide appropriate care and assessments of wounds, in accordance with recognized standards of practice, to ensure the healing and prevent infection to residents with pressure sores. Cross refers to F-490 as it relates to the failure of the facility administration to implement its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well being of each resident. The facility's administration failed to identify and implement a plan of action to ensure residents with pressure sores received the necessary treatments and services to promote healing, prevent infection and prevent new sores from developing. Cross refers to F-520 as it relates to the failure of the facility to implement a plan of action and follow up on concerns related to pressure sore treatment. The facility admit… | 2016-04-01 |
| 8459 | 8459 | SUMMIT HILLS SKILLED NURSING FACILITY | 425390 | 110 SUMMIT HILLS DRIVE | SPARTANBURG | SC | 29307 | 2012-08-02 | 281 | L | 0 | 1 | SQR511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification and Extended Survey, based on observations, interviews, record reviews, review of the facility Skin Care Guidelines and review the U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, treatment of [REDACTED]. pressure sores (Residents #14, #1, #4, #10, #3, #2, and #9). The findings included: Cross refers to F-272 as it relates to the failure of the facility to make comprehensive assessments of resident's needs related to pressure sores (Residents #14, #1, #4, #10, #3, #2 and #9). Cross refers to F-280 as it relates to the failure of the facility to review and revise the comprehensive care plan for residents with pressure sores. Cross refers to F-314 as it relates to the failure of the facility to evaluate pressure sore risk factors and implement interventions to reduce or remove the underlying risk factors, assess residents to identify the development of new pressure sores and provide appropriate care and assessments of wounds, in accordance with recognized standards of practice, to ensure the healing and prevent infection to residents with pressure sores (Residents #14, #1, #4, #10, #3, #2, and #9). Cross refers to F-490 as it relates to the failure of the facility administration to implement its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well being of each resident. The facility's administration failed to identify and implement a plan of action to ensure residents with pressure sores received the necessary treatments and services to promote healing, prevent infection and prevent new sores from developing. Cross refers to F-520 as it relates to the failure of the facility to implement a plan of action and follow up on concerns related to pressure sore treatment. The facility admitted Resident #14 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set ((MDS) date… | 2016-04-01 |
| 8462 | 8462 | SUMMIT HILLS SKILLED NURSING FACILITY | 425390 | 110 SUMMIT HILLS DRIVE | SPARTANBURG | SC | 29307 | 2012-08-02 | 314 | L | 0 | 1 | SQR511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification and Extended Survey, based on observations, interviews, record reviews, and review of the U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, treatment of [REDACTED].#14, #1, #4, #10, #3, #2, and #9). In addition, Resident #9, 1 of 3 residents with wound treatments observed, failed to receive pressure sore treatment per physician instructions. The findings included: Cross refers to F-272 as it relates to the failure of the facility to make comprehensive assessments of resident's needs related to pressure sores (Residents #14, #1, #4, #10, #3, #2 and #9). Cross refers to F-280 as it relates to the failure of the facility to review and revise the comprehensive care plan for residents with pressure sores (Resident #14, #1, #4, #3 and #9). Cross refers to F-281 as it relates to the failure of the facility to evaluate pressure sore risk factors and implement interventions to reduce or remove the underlying risk factors, assess residents to identify the development of new pressure sores and provide appropriate care and assessments of wounds, in accordance with recognized standards of practice, to promote healing and prevent infection to residents who had pressure sores (Residents #14, #1, #4, #10, #3, #2, and #9). Cross refers to F-490 as it relates to the failure of the facility administration to implement its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well being of each resident. The facility's administration failed to identify and implement a plan of action to ensure residents with pressure sores received the necessary treatments and services to promote healing, prevent infection and prevent new sores from developing. Cross refers to F-520 as it relates to the failure of the facility to implement a plan of action and follow up on concerns related to pressure sore treatment. Nur… | 2016-04-01 |
| 8468 | 8468 | SUMMIT HILLS SKILLED NURSING FACILITY | 425390 | 110 SUMMIT HILLS DRIVE | SPARTANBURG | SC | 29307 | 2012-08-02 | 490 | L | 0 | 1 | SQR511 | On the days of the Recertification and Extended Survey, based on observations, interviews, and record reviews, the facility Administration failed to implement its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well being of each resident. The facility's administration failed to identify and implement a plan of action to ensure residents with pressure sores received the necessary treatments and services to promote healing, prevent infection and prevent new sores from developing. The findings included: Cross refers to F-272 as it relates to the failure of the facility to make comprehensive assessments of resident's needs related to pressure sores (Residents #14, #1, #4, #10, #3, #2 and #9). Cross refers to F-280 as it relates to the failure of the facility to review and revise the comprehensive care plan for residents with pressure sores (Resident #14, #1, #4, #3 and #9). Cross refers to F-281 as it relates to the failure of the facility staff to evaluate pressure sore risk factors and implement interventions to reduce or remove the underlying risk factors; assess residents to identify the development of new pressure sores and provide appropriate care and assessments of wounds, to promote healing and prevent infection to residents who had pressure sores, in accordance with recognized standards of practice (Residents #14, #1, #4, #10, #3, #2, and #9). Cross refers to F-314 as it relates to the failure of the facility staff to evaluate pressure sore risk factors and implement interventions to reduce or remove the underlying risk factors, assess residents to identify the development of new pressure sores and provide appropriate care and assessments of wounds, to ensure the healing and prevent infection to residents with pressure sores (Residents #14, #1, #4, #10, #3, #2, and #9). Cross refers to F-496 as it relates to the failure of the facility to verify certification before the date of hire for four of eleven Certified Nursing Assistants reviewed… | 2016-04-01 |
| 8471 | 8471 | SUMMIT HILLS SKILLED NURSING FACILITY | 425390 | 110 SUMMIT HILLS DRIVE | SPARTANBURG | SC | 29307 | 2012-08-02 | 520 | L | 0 | 1 | SQR511 | On the days of the Recertification and Extended Survey, based on observations, interviews, and record reviews the facility failed to implement a plan of action and follow up on concerns related to pressure sore treatment. The findings included: Cross refers to F-272 as it relates to the failure of the facility to make comprehensive assessments of resident's needs related to pressure sores (Residents #14, #1, #4, #10, #3, #2 and #9). Cross refers to F-280 as it relates to the failure of the facility to review and revise the comprehensive care plan for residents with pressure sores (Resident #14, #1, #4, #3 and #9). Cross refers to F-281 as it relates to the failure of the facility staff to evaluate pressure sore risk factors and implement interventions to reduce or remove the underlying risk factors; assess residents to identify the development of new pressure sores and provide appropriate care and assessments of wounds, to promote healing and prevent infection to residents who had pressure sores, in accordance with recognized standards of practice (Residents #14, #1, #4, #10, #3, #2, and #9). Cross refers to F-314 as it relates to the failure of the facility staff to evaluate pressure sore risk factors and implement interventions to reduce or remove the underlying risk factors, assess residents to identify the development of new pressure sores and provide appropriate care and assessments of wounds, to ensure the healing and prevent infection to residents with pressure sores (Residents #14, #1, #4, #10, #3, #2, and #9). Cross refers to F-490 as it relates to the failure of the facility Administration to implement its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well being of each resident. The facility's administration failed to identify and implement a plan of action to ensure residents with pressure sores received the necessary treatments and services to promote healing, prevent infection and prevent new sores from developing. During an int… | 2016-04-01 |
| 8637 | 8637 | AZALEAWOODS REHAB & NURSING CENTER | 425014 | 123 DUPONT DR | AIKEN | SC | 29801 | 2011-10-26 | 323 | L | 0 | 1 | N62S11 | On the days of the survey, based on observation and interview, the facility failed to ensure that the resident's environment was free from accident hazards as possible. The facility was observed to store medications in an unsecured area while having knowledge that cognitively impaired mobile residents resided on the unit, thereby placing the residents at risk for serious harm. The findings included: On 10/25/11 at 3:20 PM, Licensed Practical Nurse #2 stated that stock medications were kept in the nursing office. The Director of Nurses (DON) revealed an unlocked metal cabinet in her office where medications were stored. The DON confirmed the cabinet was unlocked and her office door open. Inspection of the cabinet revealed over the counter (OTC) medications and bottles of liquid medications including Aspirin, Acetaminophen, Vitamins, Laxatives, Antidiarrheals, Zantac and Carafate, a bottle of 1200 milliliters of Potassium Chloride and (8) - 900 milliliter bottles of Tegretol (100 milligrams per 5 milliliters). In 2 other boxes were additional resident prescription medications. At 3:50 PM, Registered Nurse (RN) #1 was asked to open the DON's office door. The RN opened the unlocked door and, upon request, opened the 2 door metal cabinet to reveal the stock drugs. When the surveyor asked if there wasn't a lock, the RN stated the cabinet had never been locked as long as I have been here and informed the surveyor she had been there for 2 and 1/2 years. She also stated that residents went in and out of the office all the time. At 4:10 PM, an inventory of the cabinet was conducted by 2 surveyors and witnessed by the DON. In addition to the above listed OTC medication the inventory revealed 94 boxes and 24 vials of residents' prescriptions including: Acetylcysteine, Apresoline, Aricept, Clonidine, Cozaar, Creon, Depakote tablets and sprinkles, Ditropan, Duonebs, Effexor, Hydrochlorothiazide, KDur, Lasix, Lipitor, Lisinopril, Lopressor, Lotrel, Meloxicam, Metformin, Namenda, Norvasc, Pepcid, Potassium, Sinemet, Reglan, Topr… | 2016-01-01 |
| 8640 | 8640 | AZALEAWOODS REHAB & NURSING CENTER | 425014 | 123 DUPONT DR | AIKEN | SC | 29801 | 2011-10-26 | 431 | L | 0 | 1 | N62S11 | On the days of the Recertification and Extended Survey, based on observations, interviews, and review of the facility's Policy and Procedure entitled Pharmacy Services Policy and of the Medical Arts Pharmacy Policy and Procedures entitled IA2: Consultant Pharmacist Services Provider Requirements, the facility failed to store all medications in a locked storage area and to limit access to authorized personnel. The facility stored multiple Over The Counter (OTC) medications and resident Prescription medications unsecured in the office of the Director of Nursing (DON). The findings included: On 10/25/11 at 3:20 PM, inspection of an unlocked cabinet in the Director of Nursing office, (with an unlocked door) revealed stock OTC medications and bottles of liquid medications including Aspirin, Acetaminophen, Vitamins, Laxatives, Antidiarrheals, Zantac and Carafate, a bottle of 1200 milliliters of Potassium Chloride and (8) - 900 milliliter bottles of Tegretol (100 milligrams per 5 milliliters). In 2 other boxes were additional resident prescription medications. The DON stated she had moved the medications into her office so that she could monitor expiration dates to ensure no expired medications were administered to residents. At 3:50 PM, Registered Nurse (RN) #1 opened the unlocked door of the Director of Nursing office and, upon request, opened the 2 door metal cabinet to reveal the stock drugs. When the surveyor asked about a lock, the RN stated the cabinet had never been locked as long as I have been here. She stated she had worked at the facility for 2 and 1/2 years. RN # 1 also stated that residents went in and out of the office all the time. At 4:10 PM, an inventory of the cabinet was conducted by 2 surveyors and witnessed by the DON. In addition to the above listed OTC medication the inventory revealed 94 boxes and 24 vials of residents' prescription medications including: Acetylcysteine, Apresoline, Aricept, Clonidine, Cozaar, Creon, Depakote tablets and sprinkles, Ditropan, Duonebs, Effexor, Hydrochlorothiazide… | 2016-01-01 |
| 8641 | 8641 | AZALEAWOODS REHAB & NURSING CENTER | 425014 | 123 DUPONT DR | AIKEN | SC | 29801 | 2011-10-26 | 490 | L | 0 | 1 | N62S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification and Survey, based on observations and interviews and review of the facility's Policy and Procedure entitled Pharmacy Services Policy and of the Medical Arts Pharmacy Policy and Procedures entitled IA2: Consultant Pharmacist Services Provider Requirements, the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility Administration failed to ensure policies and procedures were monitored and followed to ensure safe and secure storage of all medications. The failure to do so placed residents at significant risk for serious harm. The findings included: On 10/25/11 at 3:20 PM, while checking the stock medications, the DON revealed an unlocked metal cabinet in her office. The DON confirmed the cabinet was unlocked and her door was open. An inventory of the contents of the cabinet revealed multiple Over the Counter and Prescription medications. Review of the facility's Policy and Procedure, dated October 18, 2010, entitled Pharmacy Services Policy 483.60 revealed the following All drugs and biologicals are stored in locked compartments under proper temperature controls. Only authorized personnel are permitted to have access to the medication keys. Review of the Medical Arts Pharmacy Policy and Procedures entitled IA2: Consultant Pharmacist Services Provider Requirements, revealed Section F. Specific activities that the consultant pharmacist performs includes, but is not limited to: .4) Checking the medication storage areas, and the medication carts, for proper storage and labeling of medications, . 6) Submitting a written report and recommendations for each review of medication storage which may be performed by a consultant or consultant agent (see Form 5: MEDICATION ROOM INSPECTION/NURSING STATION INSPECTION REPORT). On 10/26/11 at 11:30, t… | 2016-01-01 |
| 8642 | 8642 | AZALEAWOODS REHAB & NURSING CENTER | 425014 | 123 DUPONT DR | AIKEN | SC | 29801 | 2011-10-26 | 501 | L | 0 | 1 | N62S11 | On the days of the Recertification and Extended Survey, based on observation and interviews, the Medical Director failed to implement and coordinate policies and procedures that reflect current standards of practice related to safe drug storage. The findings included: At 11:15 AM on 10/26/11, a telephone interview was conducted with the Medical Director. He stated this was his second year as Medical Director. He stated he was involved with resident care policies and confirmed he was aware of the medication storage policy and procedure. The Medical Director stated that he was aware that medications were stored in the office of the Director of Nurses (DON) but was not aware that they were not secured. He further stated he received the Pharmacy reports but medication storage was not addressed in the reports to my recollection. The Medical Director stated that the outcome of a resident's accidental ingestion of the medications would depend on the medication. On 10/26/11 at 11:30, the Nursing Home Administrator (NHA) was interviewed and stated that the corporate office developed any policies and procedures and that the NHA was responsible for implementing them. He confirmed that the Medical Director was not really involved in the development of the policies and procedures. On 10/25/11 at 5:15 PM the facility was notified that Immediate Jeopardy related to the facility's failure to secure all medications in a locked storage area, which posed a significant risk of accidental ingestion of medications that, could result in the potential for clinically significant adverse consequences. On 10/26/11 an acceptable allegation of compliance was submitted, reviewed, and accepted by the survey team. On 10/26/11 prior to exiting the facility, the allegation of compliance was verified based on observation and interview and the Immediate Jeopardy citations of F323, F431, F490, and F501 were reduced in scope and severity from L to an E. Cross refer to F 323 as it relates to the accessibility of medications to cognitively impaired, mo… | 2016-01-01 |
| 8766 | 8766 | ST GEORGE HEALTHCARE CENTER | 425143 | 905 DUKE STREET | SAINT GEORGE | SC | 29477 | 2012-12-18 | 281 | L | 1 | 0 | Q5B511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification Survey and Complaint Inspection, the facility failed to provide services that meet professional standards of practice. Licensed Practical Nurse (LPN) #1 left her/his assigned unit, Stone Unit, multiple times during her/his shifts from 7:00 PM on 11/9/12 through 7:00 AM on 11/12/12 leaving the residents unattended, sometimes for extended periods. Certified Nursing Assistants (CNA) were unable to locate the nurse assigned to the unit when Resident #18 was found unresponsive requiring LPN #2 from Rogers Unit to leave her/his unit unattended for a period of 1 hour to respond to the emergency on Stone Unit. On 12-18-12 at 10:35 AM the Administrator was notified that Immediate Jeopardy was Identified at F-281. Immediate Jeopardy existed in the facility on 11-11-12 related to the actions of facility staff as noted above. The findings included: On 12/4/12 at approximately 3:15 PM review of the Five-Day Follow-up related to a Facility Reported Incident received by this office revealed the facility had reported to the State agency that LPN #1 had been absent from her assigned unit multiple times during her shifts from 7:00 PM on 11/09/12 to 7:00 AM on 11/12/12. The report revealed the facility had camera videos and a time line was developed for LPN #1 during that time period and included a copy of the time line. Review of the time line revealed LPN #1 left the building 9 times between 7:00 PM and 7:25 AM on 11/09/12: 8:17 PM, 8:35 PM, 9:31 PM, 9:33 PM, 10:25 PM, 1:15 AM, 2:35 AM, 3:21 AM, and 5:09 AM. In addition, LPN #1 was seen coming back into the building at 4:30 AM but the facility was unable to determine when s/he exited. On 11/10/12, s/he exited the building 12 times that the exit and entrance times could be determined: 7:07 PM, 8:02 PM, 9:10 PM, 10:09 PM, 10:45 PM, 11:03 PM, 11:57 PM, 1:21 AM, 2:08 AM, 3:20 AM, 3:55 AM,and 6:49 AM. Additionally, at 4:59 LPN #1 was seen exiting the building. LPN #1 was not seen… | 2015-12-01 |
| 8767 | 8767 | ST GEORGE HEALTHCARE CENTER | 425143 | 905 DUKE STREET | SAINT GEORGE | SC | 29477 | 2012-12-18 | 309 | L | 1 | 0 | Q5B511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification Survey and Complaint Inspection, based on record review, interviews, and review of the facility's files made in reference to a complaint received by this office, the facility failed to provide care and services in a manner that reduced the residents' risk for harm. Licensed Practical Nurse (LPN) #1 left her/his assigned unit, Stone Unit, multiple times during her/his shifts from 7:00 PM on 11/9/12 through 7:00 AM on 11/12/12 leaving the residents on that unit unattended. Certified Nursing Assistants (CNA) were unable to locate the nurse assigned to the unit when Resident #18 was found unresponsive requiring LPN #2 from Rogers Unit to leave her/his unit unattended for a period of 1 hour to respond to the emergency on Stone Unit. In addition, a Reportable Incident was received by this office that unidentified medications were administered to Resident #10 by a Certified Nursing Assistant (CNA), not the staff nurse, following the residents repeated request for pain medications. On 12-18-12 at 10:35 AM the Administrator was notified that Substandard Quality of Care and Immediate Jeopardy was Identified at F-309. The Substandard Quality of Care and Immediate Jeopardy existed in the facility on 11-11-12 related to the failure of the facility to provide appropriate care and services The findings included: On 12/4/12 at approximately 3:15 PM review of the Five-Day Follow-up related to a Facility Reported Incident received by this office revealed a statement from LPN #2 on 11/13/12. LPN #2 indicated in the statement that s/he was called from her/his assignment on Rogers Unit to Stone Unit on 11/11/12 (actually AM of 11/12/12) by a CNA (Certified Nursing Assistant) who informed her/his there was something wrong with Resident #18. Upon entering the room at 3:00 AM, the resident was found unresponsive. LPN #2 checked the residents's blood sugar and found s/he had a critically low level of 21. The statement further stated… | 2015-12-01 |
| 8769 | 8769 | ST GEORGE HEALTHCARE CENTER | 425143 | 905 DUKE STREET | SAINT GEORGE | SC | 29477 | 2012-12-18 | 490 | L | 1 | 0 | Q5B511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification, Complaint and Extended Surveys, based on record review, interviews and review of the facility's files made in reference to a complaint received by this office, the facility failed to effectively utilize resources to ensure that necessary care and services were provided to reduce the residents' risk for harm and that services provided met professional standards. The nurse assigned to Stone Unit left the building multiple times during the 7:00 PM-7:00 AM shift on 11/9/12, 11/10/12 and 11/11/12. On 12-18-12 at 10:35 AM the Administrator was notified that Immediate Jeopardy was Identified at F-490 and that Substandard Quality of Care and/or Immediate Jeopardy existed in the facility on 11-11-12 related to the failure of the facility to provide appropriate care and services. The findings included: On 11/13/12 a report was received by this office from the facility alleging neglect by LPN (Licensed Practical Nurse) #1 who had left Stone Unit multiple times during the 7:00 PM to 7:00 AM shift on 11/9 through 11/11/12. Review of the Five Day Follow-up report received by this office on 11/19/12 revealed Resident #18 was found unresponsive by CNA #1 at approximately 3:00 AM on 11/12/12. The CNA called Rogers Unit and requested the LPN #2 come to Stone Unit. Upon arrival to Stone Unit, LPN #2 obtained a blood sugar which was critically low at 21. S/he initiated the facility's protocol for [DIAGNOSES REDACTED] and stayed on Stone Unit from approximately 3:00 AM until LPN #1 returned at 4:05 AM, leaving Rogers Unit unattended during that time. During an interview on 12/5/12 at 7:58 AM, LPN #2 stated s/he did not call the on-call nurse to report that LPN #1 was not on her/his assigned unit from 3:00 AM to 4:04 AM. During an interview on 12/5/12 at 7:35 AM, CNA #1 stated that s/he told LPN #2 that LPN #1 had been outside most of the night. S/he further stated that LPN #2 did not respond. In a facility-obtained statement da… | 2015-12-01 |
| 8772 | 8772 | ST GEORGE HEALTHCARE CENTER | 425143 | 905 DUKE STREET | SAINT GEORGE | SC | 29477 | 2012-12-18 | 520 | L | 1 | 0 | Q5B511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interview, the facility failed to to identify issues with respect to which quality assessment and assurance activities are necessary; and develop and implement an appropriate plan of action to correct identified concerns. On 12-18-12 at 10:35 AM the Administrator was notified that Immediate Jeopardy was Identified at F-520 and that Substandard Quality of Care and/or Immediate Jeopardy existed in the facility on 11-11-12. The facility was aware of resident and staff reported concerns but failed to fully explore the full outcome and consequences of the reported behavior. Additionally, the facility failed to develop an action plan to identify and or prevent reoccurrence. The findings included: During an interview on 12/5/12 at approximately 3:30 PM, the Nursing Home Administrator stated that Certified Nursing Assistant #1 (CNA) had reported on the morning of 11/12/12 at the end of her shift that there had problems over the week-end with Licensed Practical Nurse (LPN) #1, assigned to the Stone Unit. The Administrator further stated that s/he investigated and found that LPN #1 had signed off all the medications and completed the documentation necessary and had not investigated further. S/he was not aware of any other problems until Resident #10 reported that he/she had to wait several hours to get his/her medications and that the nurse was not doing her/his job per his/her facility-obtained statement. The Administrator further stated that s/he had reviewed camera videos to verify that LPN #1 had been out of the building as reported only for the time frame of 11/9/12 through 11/12/12. S/he stated that s/he felt that was enough information to terminate LPN #1 and had not reviewed any other time frames. The Administrator also stated that all staff had been instructed in the past to call her/him if they didn't get an appropriate response from the on call nurse and had provided the cell phone number… | 2015-12-01 |
| 9006 | 9006 | BROOKVIEW HEALTHCARE CENTER | 425062 | 510 THOMPSON STREET | GAFFNEY | SC | 29340 | 2012-06-14 | 224 | L | 1 | 0 | NLW111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the Complaint and Extended Survey, the facility failed to ensure that each resident provided the necessary good and services to avoid physical harm. Residents #1 and #4 were identified during the investigation as having negative outcomes. Licensed Practical Nurse (LPN) #1 failed to assess, intervene and provide the necessary information to the physician for Resident #1's acute change in condition. The facility failed to notify Resident #4's physician regarding an acute change in condition, delaying the necessary medical care. The findings included: F-224 previously cited as part of the Recertification Survey conducted [DATE] and corrected on the follow up survey conducted [DATE]. On [DATE] F-224 was cited at a "D" and elevated to Substandard Quality of Care and Immediate Jeopardy at "L" on [DATE] related to an allegation of neglect. Cross refers to F-226 as it relates to the failure of the facility to implement their policy on abuse/neglect related to the identification of alleged neglect, to thoroughly investigate an allegation of neglect, to report timely potential neglect and to protect residents from potential neglect. Licensed Practical Nurse (LPN) #1 allegedly failed to provide Resident #1 with the necessary care and services to prevent harm. The potential neglect was reported to the State Agency as unsubstantiated. The facility failed to notify Resident #4's physician regarding an acute change in condition and identify the delay in treatment as potential neglect. Cross refers to F-281 as it relates to the failure of the facility to provide accurate, current and appropriate assessments, interventions and re-assessments to residents with acute changes in condition. Resident #1 and #4 were identified during the investigation with negative outcomes. Licensed Practical Nurse #1 failed to assess, intervene and provide the necessary information to the physician for Resident #1's acute change in condition. The physician was not n… | 2015-08-01 |
| 9007 | 9007 | BROOKVIEW HEALTHCARE CENTER | 425062 | 510 THOMPSON STREET | GAFFNEY | SC | 29340 | 2012-06-14 | 226 | L | 1 | 0 | NLW111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the Complaint and Extended Survey based on record review, information provided by the facility and review of the Policy on Abuse and Neglect Prohibition the facility failed to implement their policy on abuse/neglect related to the identification of alleged neglect, to thoroughly investigate an allegation of neglect, to report timely potential neglect and to protect residents from potential neglect. Licensed Practical Nurse (LPN) #1 allegedly failed to provide Resident #1 with the necessary care and services to prevent harm. The potential neglect was reported to the State Agency as unsubstantiated. The findings included: F-226 previously cited as part of the Recertification Survey conducted 2/29/12 and not corrected on the follow up survey conducted 4/26/12. On 5/24/12 F-226 was cited at a "D" and elevated to Substandard Quality of Care and Immediate Jeopardy at "L" on 6/14/12 related to the failure of the facility to follow their abuse policy. Cross Refer to F-224 as it relates to the failure of the facility to ensure that each resident's provided the necessary goods and services to avoid neglect. Residents #1 was identified as having a negative outcome due to a lack of appropriate assessment, intervention, re-assessment and timely physician notification that resulted in a delay in obtaining the necessary medical interventions. Licensed Practical Nurse #1 failed to assess, intervene, re-assess and provide necessary information to the physician related to Resident #1's acute change in condition. The facility failed to notify Resident #4's physician regarding an acute change in condition and identify the delay in treatment as potential neglect. Cross refers to F-309 as it relates to the failure of the facility to ensure each resident received the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being for 2 of 3 residents reviewed with an acute change in condition. Res… | 2015-08-01 |
| 9008 | 9008 | BROOKVIEW HEALTHCARE CENTER | 425062 | 510 THOMPSON STREET | GAFFNEY | SC | 29340 | 2012-06-14 | 281 | L | 1 | 0 | NLW111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the Complaint and Extended Survey, the facility staff failed to provide accurate, current and appropriate assessments, interventions and re-assessments to residents with acute changes in condition. Resident #1 and #4 were identified during the investigation with negative outcomes. Licensed Practical Nurse #1 failed to assess, intervene and provide the necessary information to the physician for Resident #1's acute change in condition. The physician was not notified timely, when Resident #4 had an acute change in condition, delaying necessary medical care. The findings included: F-281 previously cited as part of the Recertification Survey conducted [DATE] and not corrected on the follow up survey conducted [DATE]. On [DATE] F-281 was cited at a "G" and elevated to an Immediate Jeopardy at a "L" on [DATE] related to the failure of the facility to follow acceptable standards of practice. Cross Refer to F-224 as it relates to the failure of the facility to ensure that each resident's provided the necessary goods and services to avoid neglect. Residents #1 was identified as having a negative outcome due to a lack of appropriate assessment, intervention, re-assessment and timely physician notification that resulted in a delay in obtaining the necessary medical interventions. Licensed Practical Nurse #1 failed to assess, intervene, re-assess and provide necessary information to the physician related to Resident #1's acute change in condition. The facility failed to notify Resident #4's physician regarding an acute change in condition and identify the delay in treatment as potential neglect. Cross refers to F-226 as it relates to the failure of the facility to implement their policy on abuse/neglect related to the identification of alleged neglect, to thoroughly investigate an allegation of neglect, to report timely potential neglect and to protect residents from potential neglect. Licensed Practical Nurse (LPN) #1 allegedly failed to pr… | 2015-08-01 |
| 9009 | 9009 | BROOKVIEW HEALTHCARE CENTER | 425062 | 510 THOMPSON STREET | GAFFNEY | SC | 29340 | 2012-06-14 | 309 | L | 1 | 0 | NLW111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the Complaint and Extended Survey, based on record review and interview the facility failed to ensure each resident received the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being for 2 of 3 residents reviewed with an acute change in condition. Resident #1 failed to have the necessary care and services required related to an acute change in condition, the resident was not assessed, vital signs were not obtained and the physician was not notified timely of an acute change in condition. Resident #4 had a delay in physician notification of an acute change in condition. The findings included: F-309 previously cited on [DATE] at a "G" was cited again on [DATE] at Substandard Quality of Care and Immediate Jeopardy at a "L" related to the failure of the facility to provide the necessary care and services for 2 of 3 residents. Cross Refer to F-224 as it relates to the failure of the facility to ensure that each residents provided the necessary goods and services to avoid neglect. Residents #1 was identified as having a negative outcome due to a lack of appropriate assessment, intervention, re-assessment and timely physician notification that resulted in a delay in obtaining the necessary medical interventions. Licensed Practical Nurse #1 failed to assess, intervene, re-assess and provide necessary information to the physician related to Resident #1's acute change in condition. The facility failed to notify Resident #4's physician regarding an acute change in condition and identify the delay in treatment as potential neglect. Cross refers to F-226 as it relates to the failure of the facility to implement their policy on abuse/neglect related to the identification of alleged neglect, to thoroughly investigate an allegation of neglect, to report timely potential neglect and to protect residents from potential neglect. Licensed Practical Nurse (LPN) #1 allegedly failed to p… | 2015-08-01 |
| 9010 | 9010 | BROOKVIEW HEALTHCARE CENTER | 425062 | 510 THOMPSON STREET | GAFFNEY | SC | 29340 | 2012-06-14 | 490 | L | 1 | 0 | NLW111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the Complaint and Extended Survey the facility Administration failed to implement its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The facility Administration failed to identify, implement a plan of action, and follow up on allegations that Licensed Practical Nurse (LPN) #1 acted negligently. The facility also failed to identify, report and follow up on another potential allegation of neglect related to Resident #4. The findings included: F-490 previously cited as part of the Recertification Survey conducted [DATE] and not corrected on the follow up survey conducted [DATE]. On [DATE] F-490 was cited at Immediate Jeopardy "L" related to an allegation of neglect. Cross Refer to F-224 as it relates to the failure of the facility to ensure that each residents provided the necessary goods and services to avoid neglect. Residents #1 was identified as having a negative outcome due to a lack of appropriate assessment, intervention, re-assessment and timely physician notification that resulted in a delay in obtaining the necessary medical interventions. Licensed Practical Nurse #1 failed to assess, intervene, re-assess and provide necessary information to the physician related to Resident #1's acute change in condition. The facility failed to notify Resident #4's physician regarding an acute change in condition and identify the delay in treatment as potential neglect. Cross refers to F-226 as it relates to the failure of the facility to implement their policy on abuse/neglect related to the identification of alleged neglect, to thoroughly investigate an allegation of neglect, to report timely potential neglect and to protect residents from potential neglect. Licensed Practical Nurse (LPN) #1 allegedly failed to provide Resident #1 with the necessary care and services to prevent harm. The potential neglect was reported to the State Agency… | 2015-08-01 |
| 9011 | 9011 | BROOKVIEW HEALTHCARE CENTER | 425062 | 510 THOMPSON STREET | GAFFNEY | SC | 29340 | 2012-06-14 | 520 | L | 1 | 0 | NLW111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the Complaint and Extended Survey based on record reviews, interviews and observations, the facility failed to successfully develop, implement and monitor an action plan for identified concerns related to the accurate assessment, notification of the physician and reporting of alleged neglect. Despite the initiation of plan(s) by the facility to address resident assessment, care and services and reporting of abuse/neglect concerns were identified during the survey for two of seven residents sampled during the survey. The findings included: F-520 previously cited as part of the Recertification Survey conducted [DATE] and corrected on the follow up survey conducted [DATE]. On [DATE] F-520 was cited at Immediate Jeopardy "L" related to an allegation of neglect. Cross Refer to F-224 as it relates to the failure of the facility to ensure that each resident's provided the necessary goods and services to avoid neglect. Residents #1 was identified as having a negative outcome due to a lack of appropriate assessment, intervention, re-assessment and timely physician notification that resulted in a delay in obtaining the necessary medical interventions. Licensed Practical Nurse #1 failed to assess, intervene, re-assess and provide necessary information to the physician related to Resident #1's acute change in condition. The facility failed to notify Resident #4's physician regarding an acute change in condition and identify the delay in treatment as potential neglect. Cross refers to F-226 as it relates to the failure of the facility to implement their policy on abuse/neglect related to the identification of alleged neglect, to thoroughly investigate an allegation of neglect, to report timely potential neglect and to protect residents from potential neglect. Licensed Practical Nurse (LPN) #1 allegedly failed to provide Resident #1 with the necessary care and services to prevent harm. The potential neglect was reported to the State Agency as… | 2015-08-01 |
| 9282 | 9282 | GREENWOOD TRANSITIONAL REHABILITATION UNIT | 425388 | 1530 PARKWAY | GREENWOOD | SC | 29646 | 2012-06-12 | 490 | L | 0 | 1 | 4KJK11 | On the days of the survey, based on observation, interview, and review of the the facility provided policy for Abuse, facility administration failed to assure facility polices and procedures were implemented for the prevention of blood borne pathogens related to cleaning and disinfecting multi-resident use glucometer's between each resident receiving Finger Stick Blood Sugars (FSBS). Additionally, administration failed to fully develop and implement policies related to Abuse. The findings included: On 6/11/12 Patient Care Technician/Certified Nursing Assistant (PCT/CNA) #1 was observed and verbally verified she had failed to clean a multi-resident use glucometer between use with residents. She stated the wipes required to clean/sanitize were "locked up". In an interview on 6/11/12 with the NHA (Nursing Home Administrator) and DNO (Director of Nursing Operations), both stated they were not sure why the sanitizing wipes were kept in a locked cabinet. Cross refer to F 441 as it relates to the failure to clean multi-resident use glucometer's between resident use. 483.75 Administration F-490 was identified at Immediate Jeopardy at a scope and severity level of "L". The facility Administration failed to assure that appropriate polices and procedures in place were implemented related to the cleaning of the Glucometer used for multiple residents. The systemic failure of the facility to effectively clean the Glucometers placed the residents at risk at for serious harm. exist on 6/11/12 at 5:30 PM . The Allegation of Compliance was submitted by the facility on 6/12/11. The actions listed in the Allegation of Compliance included the following: The purpose of this document is to provide detailed information regarding immediate actions taken in response to the finding of a glucometer not being cleaned properly following resident treatment, thus increasing the potential spread of infection. Two (2) residents were found to have been affected by the deficient practice. The following actions were taken for not only those two resi… | 2015-06-01 |
| 9415 | 9415 | HERITAGE HEALTHCARE OF PICKENS | 425306 | 163 LOVE & CARE ROAD | SIX MILE | SC | 29682 | 2012-01-26 | 224 | L | 1 | 0 | OHFM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Complaint and Extended Survey, the facility failed to ensure each resident was provided the necessary goods and services to avoid neglect. Residents #2, #3, #4 and #5 were identified during the facility investigation process as having physician's orders [REDACTED]. All residents currently residing in the facility had the potential of incurring harm related to an allegation that Licensed Practical Nurse (LPN) #1's disposed of resident medical record information. On 01/10/2012 physician's orders [REDACTED].#3, #4 and #5 were found in a shred bin. The physician orders [REDACTED]. During the facility investigation statements from 7 staff members alleged that LPN #1 removed resident information from the facility and/or signed physician's name to orders and/or altered and/or destroyed documentation. The findings included: The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Review of the closed medical record for Resident #2 documented she received Hospice Services. On 12/27/2011, Resident #2 finished a prescribed course of antibiotics for a Urinary Tract Infection. On 12/29/2011, the Hospice Nurse assessed the resident and ordered "Bactrim 400 mg daily x 10 days for urinary tract infection". The 400 mg had been crossed out and 20 mg was written above. (It was unknown who crossed out the 400 mg). On 1/10/2012 the order was found in the shred bin located under the nurses station desk. Further review of Resident #2's closed medical record revealed the order was not transcribed or implemented. Review of the Nurse's Notes revealed on 12/29/2011 at 10:30 AM, the resident was "rubbing lower abdomen, voided incontinently though still some lower abdominal distension, NO (nurses order) received #18 Foley Catheter inserted with immediate return of yellow urine..." On 12/30/2011 at 2:05 AM, "Res(ident) c (with) confusion and decreased sensation on right side of body." At 6 PM, "Medicated (one time) this shift c [MEDICATION NAME] r/t… | 2015-05-01 |
| 9416 | 9416 | HERITAGE HEALTHCARE OF PICKENS | 425306 | 163 LOVE & CARE ROAD | SIX MILE | SC | 29682 | 2012-01-26 | 225 | L | 1 | 0 | OHFM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Complaint Inspection and Extended Survey the facility failed to ensure that staff members reported allegations of abuse, neglect and suspicions of criminal activity. The facility failed to report and/or thoroughly investigate recurring staff allegations that Licensed Practical Nurse's (LPN) #1's removed resident information from the facility and/or signed physician's name to orders and/or altered and/or destroyed documentation. The findings included: Review of the facility investigative files revealed a 24 hour report that was sent to the State Survey and Certification Agency on 1/12/2012. The facility Administrator was made aware of the alleged disposal of medical records on 1/10/2011. Further review of the investigation revealed facility obtained statements from the staff that alleged that Licensed Practical Nurse (LPN) #1 disposed of protected health information (including physician orders) in a "shred" bin located under a desk at the nurse's station. A large locked shred bin located on facility grounds was removed and emptied by the company contracted to do facility shredding on 1/10/2012 without first being checked as part of the facility investigation of the allegations. In addition to the disposal of resident medical records information, the facility was also made aware of allegations that LPN #1 removing protected health information from the premises. Facility staff failed to report the incidents to the current administration. As of 1/19/2012 the facility had audited 11 records (open and closed). Also at the time of exit, the facility investigation had not been completed. The residents identified as having physician's orders [REDACTED]. Resident #2 had a 4 day delay in treatment for [REDACTED]. Resident #3's [MEDICATION NAME] order was altered from every 4 hours to every 2 hours. Resident #4 had physician signed telephone orders for lab work as part of anticoagulant therapy that was disposed of improperly. Resident … | 2015-05-01 |
| 9417 | 9417 | HERITAGE HEALTHCARE OF PICKENS | 425306 | 163 LOVE & CARE ROAD | SIX MILE | SC | 29682 | 2012-01-26 | 226 | L | 1 | 0 | OHFM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Complaint and Extended Survey the facility failed to implement their Abuse Policy related to reporting allegations of abuse, neglect and criminal activity by not conducting a thorough and timely investigation related to an allegation that Licensed Practical Nurse (LPN) #1 disposed of protected health information in a shred bin located under the desk at the nurses station. During the facility investigation statement from 7 staff members alleged that LPN #1 removed resident information from the facility and/or signed physician's name to orders and/or altered and/or destroyed documentation. The findings included: Review of the investigative files revealed a 24 hour report that was sent to the State Survey and Certification Agency on 1/12/2012 alleging the disposal of protected health information by a facility employee. Further review of the investigation revealed facility obtained statements from the staff that alleged that Licensed Practical Nurse (LPN) #1 disposed of protected health information (including physician orders) in a "shred" bin located under the desk at the nurses station. In addition to the disposal of medical records, the facility was also made aware of allegations that LPN #1 removing protected health information from the premises, altered and destroyed documentation in the resident's medical records. As of 1/19/2012 the facility had audited 5 of 42 open medical records and 6 closed medical records [REDACTED]. During an interview on 1/19/2012 at 11 AM, the Administrator stated that on 1/11/2012 LPN #1 was suspended and on 1/12/2012 a 24 hour report was sent to the State Survey and Certification agency. The Administrator stated that as of 1/19/2012, 11 records had been audited. She stated that she planned to be finished with the audits by the end of next week. The Administrator also confirmed that staff had been trained on reporting incidents to their superiors and should have reported any and all incidents re… | 2015-05-01 |
| 9418 | 9418 | HERITAGE HEALTHCARE OF PICKENS | 425306 | 163 LOVE & CARE ROAD | SIX MILE | SC | 29682 | 2012-01-26 | 281 | L | 1 | 0 | OHFM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Complaint and Extended Survey the facility staff failed to provide timely prescribed physician care to Resident #2, #3, #4 and #5 whose medical records were disposed of improperly. Licensed Practical Nurse (LPN) #1 allegedly removed resident information from the facility and/or signed physician's name to orders and/or altered and/or destroyed documentation. The facility staff also failed to provide 15 minute checks for Resident #1 with a history of smoking in the building. The findings included: Resident #2 had a 4 day delay in treatment for [REDACTED]. Resident #3's [MEDICATION NAME] order was altered from every 4 hours to every 2 hours. Resident #4 had physician signed telephone orders for lab work that was disposed of improperly. Resident #5 had a restraint order disposed of improperly. Review of the facility obtained statement from the Financial Counselor (FC) revealed "I (FC) have seen (LPN #1) walked out building, getting in his car with manuals and things he had work on from this facility. I ask him why he was carry stuff home and he said he had to work on it." During an interview on 1/19/12 at 2:10 PM, the FC confirmed her statement as written. The FC also stated that a previous administrator would let him get away with a lot and asked the FC "you want your job?" She stated that LPN #1 threw keys and shouted. She stated that LPN #1 would take manuals and documents home. She also stated that LPN #1 told staff to "stall DHEC" because it was at home. Review of the facility obtained statement from the Minimum Data Set (MDS) Nurse revealed: "On Monday, January 9, 2012 I wrote an order for [REDACTED]. I saw that another order written for the same resident for a different restraint order had been written. I asked did I need to d/c (discontinue) the order I had previously written on January 9, 2012 and was told no that it was taken care of. Later that day I asked the DHS (DON) to check to make sure I didn't need to write a … | 2015-05-01 |
| 9420 | 9420 | HERITAGE HEALTHCARE OF PICKENS | 425306 | 163 LOVE & CARE ROAD | SIX MILE | SC | 29682 | 2012-01-26 | 490 | L | 1 | 0 | OHFM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Complaint and Extended Survey the facility Administration failed to implement it's resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The facility's administration failed to identify, implement a plan of action, and follow up on allegations that Licensed Practical Nurse (LPN) #1 removed resident information from the facility and/or signed physician's name to orders and/or altered and/or destroyed documentation. (Residents #2, #3, #4, & #5) The Administration also failed to implement and follow up on imposed interventions related to Resident #1's known smoking in the facility. The findings included: Review of the investigative files revealed a 24 hour report that was sent to the State Survey and Certification Agency on 1/11/2012. Further review of the investigation revealed Licensed Practical Nurse (LPN) #1 disposed of protected health information (including physician orders) in a "shred" bin located under desk at the nurse's station. The facility was first made aware of the alleged disposal of medical records on 1/9/2011. In addition to the disposal of medical records, the facility was also made aware of an allegation that LPN #1 removing protected health information from the premises. At the time of exit, the facility investigation had not been completed. The residents identified with physician's orders [REDACTED]. Resident #2 had a 4 day delay in treatment for [REDACTED]. Resident #3's [MEDICATION NAME] order was altered from every 4 hours to every 2 hours. Resident #4 had physician signed telephone orders for lab work as part of anticoagulant therapy that was disposed of improperly. Resident #5 had a restraint order disposed of improperly. Facility staff alleged LPN #1 removed protected health information from the premises on multiple occasions. Facility staff failed to report the incidents to the current administration. Durin… | 2015-05-01 |
| 9421 | 9421 | HERITAGE HEALTHCARE OF PICKENS | 425306 | 163 LOVE & CARE ROAD | SIX MILE | SC | 29682 | 2012-01-26 | 516 | L | 1 | 0 | OHFM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Complaint and Extended Survey the facility failed to safeguard clinical record information against destruction or unauthorized use. Licensed Practical Nurse (LPN) #1 allegedly removed resident information from the facility and/or signed physician's name to orders and/or altered and/or destroyed documentation. During the facility investigation resident information was located in a shred box at the nurse's desk for Residents #2, #3, #4, and #5. The findings included: Review of the investigative files revealed Licensed Practical Nurse (LPN) #1 allegedly disposed of protected health information (including physician orders) in a "shred" bin located under a desk at the nurse's station. The facility was first made aware of the alleged disposal of medical records on 1/10/2012. In addition to the disposal of medical records, the facility was also made aware that LPN #1 allegedly removing protected health information from the premises. The residents identified with physicians orders found in a shred box are as follows: The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Resident #2 received Hospice Services. On 12/27/11, Resident #2 finished a prescribed course of antibiotics for a Urinary Tract Infection. On 12/29/2011, the Hospice Nurse assessed the resident and ordered " Bactrim 400 mg daily x 10 days for urinary tract infection. The 400 mg had been crossed out and 20 mg was written above. (It was unknown who crossed out the 400 mg). On 1/10/2012 the Director of Nurses (DON) found the order in the shred bin located under the nurse's station desk. Further review of the record revealed the order was not transcribed nor implemented. Review of the Nurse's Notes revealed on 12/29/2011 at 10:30 AM, the resident was "rubbing lower abdomen, voided incontinently though still some lower abdominal distension, NO (nurses order) received #18 Foley Catheter inserted with immediate return of yellow urine..." On 12/30/2011 at 2:05 AM, "R… | 2015-05-01 |
| 9422 | 9422 | HERITAGE HEALTHCARE OF PICKENS | 425306 | 163 LOVE & CARE ROAD | SIX MILE | SC | 29682 | 2012-01-26 | 520 | L | 1 | 0 | OHFM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Complaint and Extended Survey the facility failed to investigate, implement and follow up on identified concerns related to alleged resident negligence (Residents #2, #3, #4, and #5) and related to Resident #1 smoking in his room. The findings included: Review of the investigative files revealed a 24 hour report that was sent to the State Survey and Certification Agency on 1/11/2012. Further review of the investigation revealed allegations that Licensed Practical Nurse (LPN) #1 disposed of protected health information (including physician orders) in a shred bin located under a desk at the nurse's station. The facility was first made aware of the alleged disposal of medical records on 1/10/2012. In addition to the disposal of medical records, the facility was also made aware of allegations that LPN #1 removing protected health information from the premises. The residents identified with outcomes are as follows: Resident #2 had a 4 day delay in treatment for [REDACTED]. Resident #3's [MEDICATION NAME] order was altered from every 4 hours to every 2 hours. Resident #4 had physician signed telephone orders for lab work as part of anticoagulant therapy that was disposed of improperly. Resident #5 had a restraint order disposed of improperly. During an interview on 1/18/2012 at 4:10 PM, the Administrator and Director of Nurses (DON) confirmed that the DON found orders on 1//10/2012 for Residents #2, #3, #4, and #5 in the shred bin. During an interview on 1/19/12 at 11 AM, the Administrator stated that as of 1/19/2012, 11 records had been audited related to the allegation that physician's orders [REDACTED]. She stated that no employee had reported anything to her about LPN #1 until after 1/11/2012. She stated that the "general consensus was I got to work." The Administrator confirmed that the Ombudsman, State Law Enforcement and the Attorney General had not been contacted regarding the allegations. The Administrator stated that on… | 2015-05-01 |
| 9626 | 9626 | SUMMIT HILLS SKILLED NURSING FACILITY | 425390 | 110 SUMMIT HILLS DRIVE | SPARTANBURG | SC | 29307 | 2011-11-08 | 281 | L | 1 | 1 | 8MQE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification, Complaint and Extended Survey, based on observations, record review, interview and review of the facility's policy on Medication Administration, Immediate Jeopardy was identified on 11/08/2011 related to the facility staff's failure to administer medications per the physician's orders [REDACTED].#16 received a Benzodiazepine without a physician's orders [REDACTED].#19, #20, #21, #22, #23, and #24 failed to receive controlled substances as ordered; Resident #7 documented to receive the wrong dose of medication on the Medication Administration Record. In addition, the facility failed to adhere to accepted standards of practice for two of two sampled residents reviewed with Sliding Scale Insulin. Nursing Staff failed to administer the physician ordered amount of Sliding Scale Insulin as per Finger Stick Blood Sugar results for Residents #2 and #7. (2 of 2 sampled residents reviewed for professional standards related to administration of sliding scale insulin) The findings included: The facility admitted Resident #16 with [DIAGNOSES REDACTED]. Resident #16 was discharged on [DATE] to an acute care hospital. Resident #16's closed medical record was reviewed due to a complaint received by the Department of Health and Environmental Control, that a Benzodiazepine medication was found during a Toxicology Screen at a hospital on [DATE]. In an interview on 10/31/2011 at 11:45 AM, the Director of Nurses (DON) stated that Resident #16's family member informed the facility of the positive Toxicology Screen and that the resident was not prescribed any Benzodiazepines. The facility did not have or attempt to obtain proof of the toxicology report. Review of the Clean Catch Urine Toxicology Screen dated 9/17/2011 at 9:49 PM revealed Resident #16 was "POS" (positive) for Benzodiazepines. Review of the physician's orders [REDACTED].#16 was not prescribed Benzodiazepines. The facility admitted Resident #17 with [DIAGNOSES REDAC… | 2015-03-01 |
| 9627 | 9627 | SUMMIT HILLS SKILLED NURSING FACILITY | 425390 | 110 SUMMIT HILLS DRIVE | SPARTANBURG | SC | 29307 | 2011-11-08 | 333 | L | 1 | 1 | 8MQE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification, Complaint and Extended Survey, based on record review, interview, and review of the policy provided by the facility entitled "Documentation Standards", Substandard Quality of Care and Immediate Jeopardy was identified on [DATE] related to the administration of controlled substances for 7 of 8 residents on scheduled controlled substances and 1 of 1 resident that received a controlled medication in error. Resident #16 received a Benzodiazepine without a physician's orders [REDACTED].#19, #20, #21, #22, #23, and #24's controlled substances were not administered per the physician's orders [REDACTED]. Resident #2 did not receive [MEDICATION NAME] as ordered. There was also no documentation of a pulse having been checked prior to the administration of [MEDICATION NAME] with orders which stated the medication "lower(s) HR (Heart Rate) may hold if below 40", Resident #7 did not receive [MEDICATION NAME] as ordered and there was no documentation of Blood Pressure checks prior to the administration of a Blood Pressure medication for Resident #4 with orders to hold for certain parameters. The findings included: The facility admitted Resident #16 with [DIAGNOSES REDACTED]. Resident #16 was discharged on [DATE] to an acute care hospital. Review of the Nurse's Notes revealed on [DATE] (no time given), Licensed Practical Nurse (LPN) #3 documented "Resident went to hospital per transport per request of family members. BP ,[DATE], P 76, R 18, T 97.2. Skin W+D (warm and dry). (Patient) did not c/o (complain) until family came at 5 PM. Tylenol tabs 2 given to pt prior to family visit per request of pt (patient) per request of back pain." LPN #3 was noted to work ,[DATE] PM shift. Review of the Clean Catch Urine Toxicology Screen dated [DATE] at 9:49 PM revealed Resident #16 was "POS" (positive) for Benzodiazepines. Review of the physician's orders [REDACTED].#16 was not prescribed Benzodiazepines. During an interview on [DATE… | 2015-03-01 |
| 9628 | 9628 | SUMMIT HILLS SKILLED NURSING FACILITY | 425390 | 110 SUMMIT HILLS DRIVE | SPARTANBURG | SC | 29307 | 2011-11-08 | 428 | L | 1 | 1 | 8MQE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification, Complaint and Extended Survey based on observations, record review, interview and review of the Pharmacy Reports, Immediate Jeopardy was identified on 11/08/2011 related to the facility's failure to assure controlled substances were reconciled monthly. The Pharmacy Consultant failed to assure 7 of 8 residents (#17, #19, #20, #21, #22, #23 and #24) receiving scheduled controlled medications received them as ordered. The findings included: Review of the October 2011, Drug Count Verification Sheet revealed blanks where both nurses did not sign at change of shift narcotic count. During an interview on 10/31/2011 at approximately 2 PM, RN #3 stated that at shift change both nurses counted the narcotics and then signed the sheet. RN #3 confirmed the blanks and stated that she had not signed for her shift as of 2 PM. During an interview on 10/31/2011 at 5:30 PM, Consultant Pharmacist #1 stated that she was not assigned to the facility but was aware of what the procedure entailed. She stated that during the monthly medication review controlled substances should be reconciled by checking the narcotic sheets to the actual count. Comparing routine medications and as needed medications, risk assessments, blanks on the Medication Administration Record [REDACTED]. She stated that if there was an excess of medication she would look to see if the resident was refusing the medication. She stated that she would also train staff on administration and documentation. During an interview on 10/31/2011 at 5:45 PM, the Director of Nurses stated that she was not aware of any concerns related to controlled substances. She stated that on 10/24/11, the Quarterly Quality Assurance Review was conducted by Pharmacy. She stated that no concerns were found during the review related to controlled substance administration. She also stated that the pharmacist did not inform her of any concerns during the monthly review related to controlled s… | 2015-03-01 |
| 9629 | 9629 | SUMMIT HILLS SKILLED NURSING FACILITY | 425390 | 110 SUMMIT HILLS DRIVE | SPARTANBURG | SC | 29307 | 2011-11-08 | 490 | L | 1 | 1 | 8MQE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification, Complaint and Extended Survey based on observations, record review and interview, Immediate Jeopardy was identified at the facility related to the failure to ensure medication administration policies and procedures were followed for seven of eight residents with pain and/or antianxiety medications (controlled substances) and one of one resident that received a Benzodiazepines without an order. The findings included: Cross Refers to F-226 Abuse Neglect Policy, as it relates to the facility's failure to investigate an allegation of neglect related to Resident #16 receiving a Benzodiazepines without a physician's orders [REDACTED]. Cross Refers to F-281 Professional Standards of Practice, as it relates to the facility's staff failure to properly administer controlled medications per the physician's orders [REDACTED]. Cross Refers to F-333 Significant Medication Errors, as it relates to the facility's failure to ensure 7 of 8 residents received controlled substances as ordered. One of one residents received a Benzodiazepines without a physician's orders [REDACTED]. Cross Refers to F-428 Pharmacy Review, as it relates to the facility's failure to ensure each resident's controlled medications were reconciled monthly. Cross Refers to F-514 Resident Records, as it relates to the facility's failure to maintain clinical records in accordance with accepted professional standards and practices. Cross Refers to F-520, Quality Assurance, as it relates to the facility's failure to identify, develop and implement a plan of action related to medication administration of controlled substances. The facility Administrator and Director of Nursing were present on 11/08/2011 at 9:40 AM when advised by the surveyor that Substandard Quality of Care and/or Immediate Jeopardy was identified during the Recertification and Complaint Survey related to the staffs failure to administer medication per physician's orders [REDACTED]. The all… | 2015-03-01 |
| 9630 | 9630 | SUMMIT HILLS SKILLED NURSING FACILITY | 425390 | 110 SUMMIT HILLS DRIVE | SPARTANBURG | SC | 29307 | 2011-11-08 | 514 | L | 1 | 1 | 8MQE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification, Complaint and Extended Survey based on observations, record review and interview, Immediate Jeopardy was identified at the facility related to the failure to maintain clinical records in accordance with accepted professional standards and practices for seven of eight residents (#17, #19, #20, #21, #22, #23 and #24) with pain and/or antianxiety medications (controlled substances) and one of one resident (#16) that received a Benzodiazepines without an order. Two residents (#2 and #7) with physician's orders [REDACTED]. The findings included: Cross Refers to F-281 Professional Standards of Practice, as it relates to the facility's staff failure to properly administer controlled medications per the physician's orders [REDACTED]. Cross Refers to F-333 Significant Medication Errors, as it relates to the facility's failure to ensure 7 of 8 residents received controlled substances as ordered. One of one residents received a Benzodiazepines without a physician's orders [REDACTED]. Cross Refers to F-490 Administration, as it relates to the facility's failure to ensure policies and procedures were implemented related to controlled substances. Cross Refers to F-520, Quality Assurance, as it relates to the facility's failure to identify, develop and implement a plan of action related to medication administration of controlled substances. The facility Administrator and Director of Nursing were present on 11/08/2011 at 9:40 AM when advised by the surveyor that Substandard Quality of Care and/or Immediate Jeopardy was identified during the Recertification and Complaint Survey related to the staffs failure to administer medication per physician's orders [REDACTED]. The allegation of compliance stated that an investigation of the alleged neglect related to the administration of the wrong drug to Resident #16 was initiated. On 11/08/2011 all staff currently on duty was inserviced on the grievance policy. All staff, new hires… | 2015-03-01 |
| 9631 | 9631 | SUMMIT HILLS SKILLED NURSING FACILITY | 425390 | 110 SUMMIT HILLS DRIVE | SPARTANBURG | SC | 29307 | 2011-11-08 | 520 | L | 1 | 1 | 8MQE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification, Complaint and Extended Survey based on observations, record review and interview, Immediate Jeopardy was identified related to the facility's failure to identify, develop and implement a plan of action related to the administration of pain and / or antianxiety medications (controlled substances). Seven of eight residents did not receive controlled substances per the physician's orders [REDACTED]. The findings included: On 10/31/11 between 2 PM and 4 PM, the Director of Nurses confirmed that there was an excess of controlled substances for the residents. She agreed that the facility nurses were not giving the prescribed controlled substances to the residents as ordered. The DON also confirmed that she was aware of possible medication errors but stated that she did not have any direct evidence. The DON also could not provide any evidence of investigation, re-education or termination for any nurse involved in potential drug errors. The DON stated that there was not an Action Plan initiated related to medication errors or controlled substances. She also stated that she was unaware of any concerns with controlled substances and had not been notified by the Pharmacy Consultant of any concerns. Review of the Quarterly Quality Assurance Review dated 10/24/2011 revealed the Pharmacist identified the shift to shift narcotic counts were not signed by both nurses for each shift. No other concerns were noted related to controlled substances. During an interview on 11/8/2011 at 2:10 PM, the Consultant Pharmacist #2 stated that during her monthly reviews she did not notice any trends related to controlled substance administration. The Consultant Pharmacist #2 stated that she did a 20% detailed medication review every month and had not noticed any concerns or trends related to controlled substance administration. Cross Refers to F-226 Abuse Neglect Policy, as it relates to the facility's failure to investigate an allegatio… | 2015-03-01 |
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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 );