CMS-Nursing-Home-Full-Deficiencies
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| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 101 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2017-08-16 | 225 | G | 1 | 0 | MGP911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, the facility failed to ensure that all alleged violations involving abuse or neglect were reported immediately, but not later than 2 hours after the allegation was made. The facility also failed to have evidence that all alleged violations were thoroughly investigated. Resident #1 was noted to have complaints of pain on 8/1/17 and the allegation of neglect was not reported to the State Agency until 8/3/17. Review of the facility's investigation revealed statements from three staff members, the Registered Nurse (RN) Supervisor on the unit (RN #1), the wound care nurse (RN #3) and Certified Nursing Assistant (CNA) #1. It was noted on the Daily Assignment Sheet for 8/1/17 that CNA #1 was not assigned to Resident #1. There were no statements from the staff assigned to care for the resident on the days surrounding the incident. One of two residents reviewed for reportable incidents. The findings included: The facility reported an allegation of neglect to the State Agency for Resident #1 by CNA #1 on 8/3/17. Review of the facility's Five-Day Follow-Up Report dated 8/8/17 indicated after investigation, Resident #1 was found to have right knee fracture from attempted transfer to wheelchair without lift or two-person assist. The Initial 24-hour Report dated 8/3/17 revealed Resident #1 stated that while being pivoted by CNA #1, the CNA assisted him/her to slide to the floor and at that time his/her right knee popped. Further review of the medical record revealed the Annual Minimum Data Set ((MDS) dated [DATE] coded Resident #1 as having a Brief Interview for Mental Status score of 6. The Quarterly MDS dated [DATE] coded the resident as having a Brief Interview for Mental Status score of 5. The Quarterly MDS coded Resident #1 as totally dependent for transfers. Review of the care plan revealed resident needs moderate to max assistance with ADLs was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included resident transfers with assist of mechanical lift. Review of the Nurses' Progress Notes dated 8/2/17 indicated called to room by CNA to look at resident's leg. Right leg is swollen. States had pain in leg while receiving peri-care. RN supervisor notified who also looked at leg. Resident's socks removed and legs elevated. The previous note was dated 7/21/17 and noted weekly summary and body audit completed. The next note was noted as a late entry for 8/1/17 and indicated resident complained in wheelchair that right knee popped while being transferred to bed. Some slight [MEDICAL CONDITION] noted, daughter present. Daughter stated possible the footrest (missing) may have caused pain and [MEDICAL CONDITION]. Replaced footrest. Reported to nurse to get something for pain and monitor. The note was completed by RN #1. The Nurses' Progress Note dated 8/3/17 at 3:00 AM indicated the resident had complaints of pain and swelling to the right knee and warm to touch. Ice pack applied and elevated. As needed Tylenol given related to pain. On 8/3/17 at 5:00 AM the Nurses' Note indicated Tylenol was effective. Resident states My knee still hurts but feels a lot better since that ice. Ice appears to be effective. Swelling slightly reduced in size and less warm to touch. Resident now resting quietly. At 10:10 AM the note indicated the physician was asked to see the resident related to right knee pain. X-ray and CBC ordered stat. The Nurses' Progress Note dated 8/3/17 at 6:40 PM indicated the nurse practitioner was notified of the x-ray results and a new order was received to send the resident to the emergency room for evaluation and treatment related to complaints of pain. There was no additional documentation related to monitoring the resident for complaints of pain or assessing the resident's knee. Review of Resident #1's (MONTH) Medication Administration Record [REDACTED]. The resident did not receive the as needed medication any other time during the month of August. Resident #1 received scheduled Tylenol 2 tablets (650 mg) three times daily for pain at 8:00 AM, 4:00 PM, and 8:00 PM. Review of the physician progress notes [REDACTED]. Apparently the other day during the transfer his/her knee was some way twisted. The exact mechanism of action was unknown, and from conversation with the facility staff history does not seem to be consistent with another. Resident #1 is a poor historian. The physician ordered an x-ray. The note was signed 8/3/17 at 4:24 PM. Review of the Mobilex Radiology Report dated 8/3/17 revealed the conclusion was noted as possible non-displaced fracture through the medial femoral condyle. Further evaluation with oblique views was recommended. RN #1's facility-obtained statement dated 8/1/17 indicated at approximately 8:40 AM, resident's niece reported that the resident's right leg hurt and that s/he needed his/her foot rest on the wheel chair. RN #1 assessed the resident's right and left legs. Resident stated hurts more with movement, grimaced. Resident also reported it happened while being put to bed. Niece stated she felt like it was because the resident had been up in wheelchair without a foot rest. RN #1 and CNA #1 found the foot rest. CNA #1 replaced them on the wheelchair. RN #1 reported to the primary nurse and asked if resident could get something for pain and to continue to monitor his/her leg. RN #1's facility-obtained statement dated 8/4/17 indicated when s/he arrived to work on 8/3/17 s/he was made aware that Resident #1 was in the hospital with a fracture. It had been reported to another RN that CNA #1 had dropped the resident while transferring without a lift. When CNA #1 was called to the office to investigate the incident, s/he stated s/he never lifted the resident without a lift. CNA #1 did observe the resident in the wheelchair without a foot rest with the resident's leg stuck behind the front wheel and had to lift the chair up and get the resident's leg free. RN #1 explained to CNA #1 that this was considered an incident and should have been reported to the primary nurse. RN #1's facility-obtained statement dated 8/7/17 indicated upon entering Resident #1's room since return from the hospital s/he asked the resident how s/he hurt his/her leg. Resident #1 replied That (boy/girl) holding me up made me slide into the floor. Asked how s/he had picked the resident up and if s/he had used the lift. Resident #1 replied no, s/he had him/her under his/her arms. Resident #1 stated (s/he) picked me up under my arms and put me in the chair. In an interview with the surveyor on 8/15/17 at approximately 2:20 PM, RN #1 stated s/he is the unit manager for Unit 1. RN #1 stated that the resident's niece said his/her leg was hurting out in the lobby. RN #1 went and assessed the resident's leg and it was painful. Resident #1 didn't have petals on his/her wheelchair and his/her niece felt that may be what was causing the resident's leg to hurt. Normally the resident had petals but staff said they couldn't find them that day. RN #1 walked down the hall and found them on another wheelchair. The CNA said they looked like the resident's and the CNA checked and they fit Resident #1's wheelchair. The petals were on an extra wheelchair that was on the hall. Resident #1's knee had slight [MEDICAL CONDITION]. RN #1 stated s/he had the resident's nurse give the resident his/her pain medication. RN #1 stated s/he was not assigned to the resident, s/he was on as unit manager. The niece thought the resident's leg might be bothering him/her because it was not supported by the petal. RN #1 told the resident's nurse to monitor the resident's leg and let him/her know if there were any additional complaints of pain. RN #1 stated s/he did not hear anything else about the resident's leg until s/he heard the resident went out to the hospital with a fracture. RN #1 works days Monday-Friday. RN #1 stated Resident #1 was a total lift prior to the incident. RN #3's facility-obtained statement dated 8/1/17 indicated on 8/1/17 at 8:45 AM, the resident's niece reported to RN supervisors, RN #3 and RN #1, the resident complained of pain to the right knee. Resident states It happened when I was put back to bed. Assessment findings of slight [MEDICAL CONDITION] noted to right knee and pain with movement. Niece states It might be from sitting up in wheelchair without a foot rest. Foot rest placed by CNA, RN to monitor. In an interview with the surveyor on 8/15/17 at approximately 2:35 PM, RN #3 stated s/he is the wound care nurse. RN #1 stated the resident's niece told them about the resident complaining of pain. RN #1 stated s/he does not remember anything about the incident. In an interview with the surveyor on 8/15/17 at approximately 2:45 PM, Licensed Practical Nurse (LPN) #1 stated the resident's family member stated the resident was complaining his/her leg hurt. LPN #1 stated s/he gave him some Tylenol. The resident doesn't usually complain about anything. Resident #1 said s/he was hurting. LPN #1 didn't look at the resident's leg. LPN #1 worked 7 AM-7 PM. CNA #1's facility-obtained statement dated 8/4/17 indicated on the afternoon of 8/1/17 at approximately 11:30 AM, Resident #1 was transferred from the bed to the chair using the lift. Resident #1's wheel chair only had one left pedal attached to it. When the resident was in the hallway his/her right leg twisted under the chair. Resident #1 called out and said that his/her leg was stuck. CNA #1 then began to undo the resident's leg. RN #1 walked up and said that Resident #1 needed two pedals on his/her wheelchair. They began to look throughout the facility for another pedal to add to the resident's wheelchair. After they found a right pedal that would fit, RN #1 and CNA #1 put the pedal on the right side of the wheelchair. The day in question, the resident did not complain of any pain or discomfort and his/her leg was not swollen. After Resident #1's wheelchair was adjusted his/her sister took over and pushed the resident to the lobby. In an interview with the surveyor on 8/16/17 at approximately 10:15 AM, RN #2 (Director of Education) stated the only registry verification for CNA #1 was the one checked on 7/10/17. CNA #1's date of hire was 7/5/17. RN #2 confirmed the registry verification was done after the employee's date of hire. In an interview with the surveyor on 8/16/17 at approximately 1:50 PM, the Director of Nursing (DON) stated s/he was not at the facility when the incident happened with Resident #1. The DON stated s/he usually goes back to interview staff who worked with the resident prior to the incident. The DON stated s/he would have looked back to try to find out when the pain started. The DON stated Resident #1 did not usually complain of pain. The DON stated the resident could tell you what happened. The DON stated s/he would expect the nurses to monitor a resident for a new complaint of pain. Review of the Disciplinary Action Form dated 8/4/17 revealed the facility placed CNA #1 on administrative leave pending results of investigation for resident care. Review of an email dated 8/14/17 from Spartanburg Regional to staffing agency that CNA #1 was employed by revealed due to the current issue involving (CNA #1), managers are terminating his/her contract effective immediately. There was no documentation in any emails provided that the facility notified the staffing agency about the incident that led to the termination of CNA #1's contract. | 2020-09-01 |
| 102 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2017-08-16 | 309 | G | 1 | 0 | MGP911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Resident #1 was noted to have complaints of pain on 8/1/17 and there was no documentation that the resident was monitored for pain. Resident #1 was found to have a right femur fracture on 8/3/17. One of three residents reviewed for fracture. The findings included: The facility reported an allegation of neglect to the State Agency for Resident #1 by Certified Nursing Assistant (CAN) #1 on 8/3/17. Review of the facility's Five-Day Follow-Up Report dated 8/8/17 indicated after investigation, Resident #1 was found to have right knee fracture from attempted transfer to wheelchair without lift or two-person assist. The Initial 24-hour Report dated 8/3/17 revealed Resident #1 stated that while being pivoted by CNA #1, the CNA assisted him/her to slide to the floor and at that time his/her right knee popped. Further review of the medical record revealed the Annual Minimum Data Set ((MDS) dated [DATE] coded Resident #1 as having a Brief Interview for Mental Status score of 6. The Quarterly MDS dated [DATE] coded the resident as having a Brief Interview for Mental Status score of 5. The Quarterly MDS coded Resident #1 as totally dependent for transfers. Review of the care plan revealed resident needs moderate to max assistance with ADLs was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included resident transfers with assist of mechanical lift. Review of the Nurses' Progress Notes dated 8/2/17 indicated called to room by CNA to look at resident's leg. Right leg is swollen. States had pain in leg while receiving peri-care. RN supervisor notified who also looked at leg. Resident's socks removed and legs elevated. The previous note was dated 7/21/17 and noted weekly summary and body audit completed. The next note was noted as a late entry for 8/1/17 and indicated resident complained in wheelchair that right knee popped while being transferred to bed. Some slight [MEDICAL CONDITION] noted, daughter present. Daughter stated possible the footrest (missing) may have caused pain and [MEDICAL CONDITION]. Replaced footrest. Reported to nurse to get something for pain and monitor. The note was completed by RN #1. The Nurses' Progress Note dated 8/3/17 at 3:00 AM indicated the resident had complaints of pain and swelling to the right knee and warm to touch. Ice pack applied and elevated. As needed Tylenol given related to pain. On 8/3/17 at 5:00 AM the Nurses' Note indicated Tylenol was effective. Resident states My knee still hurts but feels a lot better since that ice. Ice appears to be effective. Swelling slightly reduced in size and less warm to touch. Resident now resting quietly. At 10:10 AM the note indicated the physician was asked to see the resident related to right knee pain. X-ray and CBC ordered stat. The Nurses' Progress Note dated 8/3/17 at 6:40 PM indicated the nurse practitioner was notified of the x-ray results and a new order was received to send the resident to the emergency room for evaluation and treatment related to complaints of pain. There was no additional documentation related to monitoring the resident for complaints of pain or assessing the resident's knee. Review of Resident #1's (MONTH) Medication Administration Record [REDACTED]. The resident did not receive the as needed medication any other time during the month of August. Resident #1 received scheduled Tylenol 2 tablets (650 mg) three times daily for pain at 8:00 AM, 4:00 PM, and 8:00 PM. Review of the physician progress notes [REDACTED]. Apparently the other day during the transfer his/her knee was some way twisted. The exact mechanism of action was unknown, and from conversation with the facility staff history does not seem to be consistent with another. Resident #1 is a poor historian. The physician ordered an x-ray. The note was signed 8/3/17 at 4:24 PM. Review of the Mobilex Radiology Report dated 8/3/17 revealed the conclusion was noted as possible non-displaced fracture through the medial femoral condyle. Further evaluation with oblique views was recommended. Registered Nurse (RN) #1's facility-obtained statement dated 8/1/17 indicated at approximately 8:40 AM, resident's niece reported that the resident's right leg hurt and that s/he needed his/her foot rest on the wheel chair. RN #1 assessed the resident's right and left legs. Resident stated hurts more with movement, grimaced. Resident also reported it happened while being put to bed. Niece stated she felt like it was because resident had been up in wheelchair without foot rest. RN #1 and CNA #1 found the foot rest. CNA #1 replaced them on the wheelchair. RN #1 reported to the primary nurse and asked if resident could get something for pain and to continue to monitor his/her leg. RN #1's facility-obtained statement dated 8/4/17 indicated when s/he arrived to work on 8/3/17 s/he was made aware that Resident #1 was in the hospital with a fracture. It had been reported to another RN that CNA #1 had dropped the resident while transferring without a lift. When CNA #1 was called to the office to investigate the incident, s/he stated s/he never lifted the resident without a lift. CNA #1 did observe the resident in the wheelchair without a foot rest with the resident's leg stuck behind the front wheel and had to lift the chair up and get the resident's leg free. RN #1 explained to CNA #1 that this was considered an incident and should have been reported to the primary nurse. RN #1's facility-obtained statement dated 8/7/17 indicated upon entering Resident #1's room since return from the hospital s/he asked the resident how s/he hurt his/her leg. Resident #1 replied That (boy/girl) holding me up made me slide into the floor. Asked how s/he had picked the resident up and if s/he had used the lift. Resident #1 replied no, s/he had him/her under his/her arms. Resident #1 stated (s/he) picked me up under my arms and put me in the chair. In an interview with the surveyor on 8/15/17 at approximately 2:20 PM, RN #1 stated s/he is the unit manager for Unit 1. RN #1 stated that the resident's niece said his/her leg was hurting out in the lobby. RN #1 went and assessed the resident's leg and it was painful. Resident #1 didn't have petals on his/her wheelchair and his/her niece felt that may be what was causing the resident's leg to hurt. Normally the resident had petals but staff said they couldn't find them that day. RN #1 walked down the hall and found them on another wheelchair. The CNA said they looked like the resident's and the CNA checked and they fit Resident #1's wheelchair. The petals were on an extra wheelchair that was on the hall. Resident #1's knee had slight [MEDICAL CONDITION]. RN #1 stated s/he had the resident's nurse give the resident his/her pain medication. RN #1 stated s/he was not assigned to the resident, s/he was on as unit manager. The niece thought the resident's leg might be bothering him/her because it was not supported by the petal. RN #1 told the resident's nurse to monitor the resident's leg and let him/her know if there were any additional complaints of pain. RN #1 stated s/he did not hear anything else about the resident's leg until s/he heard the resident went out to the hospital with a fracture. RN #1 works days Monday-Friday. RN #1 stated Resident #1 was a total lift prior to the incident. RN #3's facility-obtained statement dated 8/1/17 indicated on 8/1/17 at 8:45 AM, the resident's niece reported to RN supervisors, RN #3 and RN #1, the resident complained of pain to the right knee. Resident states It happened when I was put back to bed. Assessment findings of slight [MEDICAL CONDITION] noted to right knee and pain with movement. Niece states It might be from sitting up in wheelchair without a foot rest. Foot rest placed by CNA, RN to monitor. In an interview with the surveyor on 8/15/17 at approximately 2:35 PM, RN #3 stated s/he is the wound care nurse. RN #1 stated the resident's niece told them about the resident complaining of pain. RN #1 stated s/he does not remember anything about the incident. In an interview with the surveyor on 8/15/17 at approximately 2:45 PM, Licensed Practical Nurse (LPN) #1 stated the resident's family member stated the resident was complaining his/her leg hurt. LPN #1 stated s/he gave him some Tylenol. The resident doesn't usually complain about anything. Resident #1 said s/he was hurting. LPN #1 didn't look at the resident's leg. LPN #1 worked 7 AM-7 PM. CNA #1's facility-obtained statement dated 8/4/17 indicated on the afternoon of 8/1/17 at approximately 11:30 AM, Resident #1 was transferred from the bed to the chair using the lift. Resident #1's wheel chair only had one left pedal attached to it. When the resident was in the hallway his/her right leg twisted under the chair. Resident #1 called out and said that his/her leg was stuck. CNA #1 then began to undo the resident's leg. RN #1 walked up and said that Resident #1 needed two pedals on his/her wheelchair. They began to look throughout the facility for another pedal to add to the resident's wheelchair. After they found a right pedal that would fit, RN #1 and CNA #1 put the pedal on the right side of the wheelchair. The day in question, the resident did not complain of any pain or discomfort and his/her leg was not swollen. After Resident #1's wheelchair was adjusted his/her sister took over and pushed the resident to the lobby. In an interview with the surveyor on 8/16/17 at approximately 10:15 AM, RN #2 (Director of Education) stated the only registry verification for CNA #1 was the one checked on 7/10/17. CNA #1's date of hire was 7/5/17. RN #2 confirmed the registry verification was done after the employee's date of hire. In an interview with the surveyor on 8/16/17 at approximately 1:50 PM, the Director of Nursing (DON) stated s/he was not at the facility when the incident happened with Resident #1. The DON stated s/he usually goes back to interview staff who worked with the resident prior to the incident. The DON stated s/he would have looked back to try to find out when the pain started. The DON stated Resident #1 did not usually complain of pain. The DON stated the resident could tell you what happened. The DON stated s/he would expect the nurses to monitor a resident for a new complaint of pain. Review of the Disciplinary Action Form dated 8/4/17 revealed the facility placed CNA #1 on administrative leave pending results of investigation for resident care. Review of an email dated 8/14/17 from Spartanburg Regional to staffing agency that CNA #1 was employed by revealed due to the current issue involving (CNA #1), managers are terminating his/her contract effective immediately. There was no documentation in any emails provided that the facility notified the staffing agency about the incident that led to the termination of CNA #1's contract. | 2020-09-01 |
| 103 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2017-08-16 | 496 | D | 1 | 0 | MGP911 | > Based on review of facility files and interview, the facility failed to ensure that information from every State registry was received before allowing an individual to serve as a nurse aide. Certified Nurse Aide (CNA) #1 started working for the facility prior to his/her South [NAME]ina Nurse Aide Registry Verification being checked. One of one nurse aides reviewed. The findings included: The facility reported an allegation of neglect to the State Agency for Resident #1 by CNA #1. Review of the facility's Five-Day Follow-Up Report dated 8/8/17 indicated after investigation, Resident #1 was found to have a right knee fracture from attempted transfer to wheelchair without lift or two-person assist. The Initial 24-hour Report dated 8/3/17 revealed Resident #1 stated that while being pivoted by CNA #1, the CNA assisted him/her to slide to the floor and at that time his/her right knee popped. Review of CNA #1's employee file revealed a South [NAME]ina Nurse Aide Registry Verification dated 7/10/17. CNA #1 was noted with a hire date of 7/5/17. In an interview with the surveyor on 8/16/17 at approximately 10:15 AM, Registered Nurse (RN) #2 (Director of Education) stated the only registry verification was the one checked on 7/10/17. RN #2 confirmed CNA #1's date of hire was 7/5/17. RN #3 confirmed the registry verification was done after the employee's date of hire. | 2020-09-01 |
| 104 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2017-08-16 | 526 | D | 1 | 0 | MGP911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to obtain the most recent hospice plan of care specific to the resident, the hospice election form, and documentation of the communication between the facility and the hospice provider to ensure that the needs of the resident are addressed and met 24 hours per day. Resident #3 was noted to be receiving hospice services at the facility from [DATE]-[DATE] at which time the resident expired. Review of the resident's closed medical record on ,[DATE]-[DATE] revealed there was no documentation in the resident's medical record from the hospice agency. One of one residents reviewed for hospice. The findings included: Review of Resident #3's medical record revealed the Nurse's Progress Note dated [DATE] at 9:55 AM indicated the nurse practitioner rounded and new orders were written for hospice to evaluate and treat the resident related to [MEDICAL CONDITION]. Review of the Physician order [REDACTED]. Review of Resident #3's closed medical record on [DATE] and [DATE] revealed no documentation from the hospice agency. The medical records staff was asked about the missing documentation. In an interview with the surveyor on [DATE] at approximately 1:55 PM, medical records stated the hospice documentation was faxed over today, there was no information in the resident's medical record from the hospice agency. | 2020-09-01 |
| 105 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2018-08-16 | 578 | D | 0 | 1 | PLLD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure residents were afforded the opportunity to formulate their own decisions regarding health care for 1 of 2 residents reviewed for Advanced Directives. Resident # 26 was not provided the opportunity to update his/her healthcare decision. The findings included: Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Medical Record on 08/14/2018 at 11:53 AM revealed Resident #26 Advance Directive status was Do Not Resuscitate (DNR). Further review revealed the document was not signed by Resident #26. Continued review revealed the document was signed by the legal representative in (YEAR). Review of the Progress Note Addressing Decisional Capacity dated 9/16/16 revealed This patient DOES possess the decisional capacity to make healthcare decisions for self. Interview with Registered Nurse #1 on 08/15/2018 at approximately 2:30pm revealed when the resident is sent out to the Hospital the facility supplies Emergency Medical Services with the DNR order. Further interview revealed the capacity to make healthcare decisions needs to be updated to reflect resident's current wishes. | 2020-09-01 |
| 106 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2018-08-16 | 582 | D | 0 | 1 | PLLD11 | Based on record review and interview, the facility failed to issue the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN)/ Centers for Medicare/Medicaid (CMS) and CMS forms for 2 of 3 residents reviewed for Medicare Part A Services. Resident #33 was not issued the CMS timely, Resident #87 did not receive the required SNFABN/CMS . The findings included: Review of the Medicare non coverage notices on 08/16/2018 at approximately 11:00 am revealed Resident #87 had services ended with additional days left for services. Continued review revealed Resident #87 had not been provided the CMS form . Review of the Medicare non coverage notices on 8/16/2018 at approximately 11:00 am revealed the CMS indicated the resident services would end for Resident # 33 on 05/29/2018. Continued review revealed Resident #33 was provided notice on 05/28/2018. Interview with the Business Manager on 08/16/2018 at approximately 11:30 am confirmed CMS notices were not distributed as required. | 2020-09-01 |
| 107 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2018-08-16 | 584 | D | 0 | 1 | PLLD11 | Based on record review and interview, the facility failed to exercise reasonable care for the protection of resident property from loss or theft for 1 of 2 residents reviewed for Personal Property. Resident #55 was not reimbursed for several missing clothing items. The findings included: Interview with Resident # 55 on 8/14/2018 at approximately 11:40 am revealed he/she has had several clothing items that do not return from laundry. Further interview revealed he/she had not been replaced nor was he/she reimbursed for any of the missing clothing items. Resident #55 stated he/she informed facility staff to include the Social Worker of the missing items. Interview with Resident #55 on 8-16-18 at 11:15 am revealed he/she had a closet full of clothing that went missing which had not been replaced nor had he/she been reimbursed for the items. Resident #55 further stated he/she wore his/her (roommates) clothes. Resident #55 stated see, as he/she proceeded to show the written name of another resident inside the clothing he/she was wearing. Review of purchase receipts supplied by the facility Administrator on 8/15 and 08/16/2018 revealed no receipt of clothing purchase for Resident #55. Review of Policy #200.128 - Resident Valuables or Belongings revealed Procedure IV- If ESNC is notified that a resident's personal effects are missing, we shall attempt to locate the missing item but are not assuming responsibility for replacement of the lost or stolen property. Interview with Social Worker #1 on 08/16/2018 at approximately 11:30 am revealed items were replaced but could not provide documentation to support this. Social Worker #1 further stated he/she gave Resident #55 two pair of pants on 08-13-2018 but did not document this. | 2020-09-01 |
| 108 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2018-08-16 | 623 | E | 0 | 1 | PLLD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to give a written notice of transfer to the resident or the resident's representative when Resident #17 was transferred out of the facility for evaluation after a fall. The findings included: The facility admitted Resident #17 on 2/1/18 with [DIAGNOSES REDACTED]. Review of the Nurse's Progress Record revealed the notation dated 6/27/18 at 1130 indicated the resident was sent to the hospital for evaluation. The notation stated, R/P (representative) notified. The notation dated 6/27/18 at 2000 indicated the resident returned to the facility. The Nurse's Progress note dated 6/29/18 at 1925 indicated staff sent Resident #17 to the hospital for evaluation following a fall. The notation indicated that staff notified a family member. The notation dated 6/29/18 at 2230 indicated the resident returned to the facility. Review of the Social Services notes revealed no documentation that staff sent a written Notice of Transfer with the resident or to the resident's representative on those dates. During an interview on 8/16/18 at approximately 2:00 PM, Social Services Staff #1 reviewed the Nurse's Progress Notes and Social Services notations and confirmed these findings. | 2020-09-01 |
| 109 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2018-08-16 | 657 | D | 0 | 1 | PLLD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure all required members of the Interdisciplinary Team participated in the development of care plans and/or reviewed and revised the care plan for 3 of 21 residents reviewed for care plans. (Residents #6, #17, and #35) The findings included: The facility admitted Resident #6 on 11/1/00 with [DIAGNOSES REDACTED]. Review of the medical record revealed the care plan conference attendance sheets contained space for signatures of staff participating in the care plan meeting. Review of the attendance sheet dated 5/11/18 revealed no signature of a Certified Nurse Aide (CNA) to indicate participation in development of the care plan. The facility admitted Resident #17 on 2/1/18 with [DIAGNOSES REDACTED]. Review of the medical record revealed the care plan conference attendance sheets contained space for signatures of staff participating in the care plan meeting. Review of the attendance sheet dated 5/17/18 revealed no signature of a Certified Nurse Aide (CNA) to indicate participation in development of the care plan. The facility admitted Resident #35 on 1/16/66 with [DIAGNOSES REDACTED]. Review of the medical record revealed the care plan conference attendance sheets contained space for signatures of staff participating in the care plan meeting. Review of the attendance sheets dated 3/15/18 and 6/14/18 revealed no signature of a Certified Nurse Aide (CNA) to indicate participation in development of the care plan. During an interview on 8/16/18 at approximately 2:00 PM, Social Services Staff #1 and MDS Staff #1 reviewed the attendance forms and confirmed that there was no CNA signature on the care plan attendance sheets for these residents. | 2020-09-01 |
| 110 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2018-08-16 | 755 | E | 0 | 1 | PLLD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interviews and review of manufacture's recommendations, the facility's Consulting Pharmacist failed to assure that the Pharmaceutical service oversight for which it was contracted to provide, continued to identify, evaluate and prevent the improper storage of medications for 1 of 3 medication storage rooms reviewed. There was no immediate action documented which indicated the Pharmacy addressed the improperly stored medications at the time of the inspection of the Unit 1 medication storage room, educated the nursing staff as to the proper procedure to follow nor documented follow up to assure a concern was immediately corrected. (cross refer to F761) The findings included: On 8/13/18 at approximately 10:25 AM, an observation of the Unit 1 medication storage room with Licensed Practical Nurse (LPN) #1 revealed the temperature of the medication refrigerator was 32 degrees Fahrenheit (F) which was confirmed by LPN #1. The contents of the refrigerator was: 1.) (4) containers of Lananoprost Opthalmic Solution .0005% 125ug/2.5 ml. 2.) (38) vials of [MEDICATION NAME] 20 mcg. / 2 ml. 3.) (2) 10 ml. vials [MEDICATION NAME] R insulin 100 u/ml. 4.) (1) 10 ml. vial [MEDICATION NAME] R insulin 100 u/ml. 5.) (1) 2 mg. / ml. bottle of Lorazapam oral concentrate 6.) (2) 10 ml. vials Humalog insulin 100 u/ml. 7.) (5) 10 ml. vials of [MEDICATION NAME] 100 u/ml. 8.) (2) 12.5 mg. injections of [MEDICATION NAME] Consta 9.) (2) vials of [MEDICATION NAME]100 u/ml. The (MONTH) (YEAR) Unit Drug Refrigerator Temperature Log on top of the refrigerator revealed 5 dates (August 2, 3, 4, 5, 6) had been recorded On 8/13/18 at approximately 11:30 AM, during a review of the Unit 1's medication storage refrigerator's logs revealed in (MONTH) (18) days, (MONTH) (6) days, (MONTH) (14) days, and (MONTH) (5) days had temperature readings below 36 degrees F. On 8/14/18 at 12:30 PM, a review of the (MONTH) Monthly QA Consultant Pharmacy Report dated 8/9/18 revealed Consultant Pharmacist #1 reviewed the Unit 1 medication storage room and refrigerator log. On the Medication Storage Audit Consultant Pharmacist #1 noted under C. Refrigerator: Medication refrigerator log completed daily, and Medications stored per manufacture's recommendations, were both checked as Met, and did not make any recommendations for the facility or identify any temperature concerns even though 5 dates (August 2, 3, 4, 5, 6) had been recorded On 8/13/18 at 1:25 PM, a review of the facility policy entitled, Safe and Sanitary Handling, Storage, Wastage, and Controlled Substance Management Medication Storage in the Facility stated under procedure (1.b) Medications are stored to ensure stability, This includes: 1.) Storing medications at proper temperatures. Review of the manufacture recommendations for insulin, Lorazapam, Lantanoprost, [MEDICATION NAME], and [MEDICATION NAME] Consta, state refrigerated storage temperatures between 36-46 degrees F. | 2020-09-01 |
| 111 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2018-08-16 | 757 | E | 0 | 1 | PLLD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a drug regimen free from unnecessary drugs for 1 of 6 sampled residents reviewed for unnecessary medications. An antipsychotic was initiated for Resident #41 without justification and/or non-pharmacological attempts. The findings included: The facility admitted Resident #41 on 03/26/2015 with [DIAGNOSES REDACTED]. Review of the medical record on 08-15-2018 at approximately 5:30 pm revealed he/she was prescribed [MEDICATION NAME] 05-16-2018. Further review revealed no adequate indication for it's use. Continued review of the record revealed no documentation of inappropriate behavior for Resident #41 and there was no indication staff received Dementia management training/techniques. Nurses Note dated 05-16-2018 revealed New order for [MEDICATION NAME] 25 mg (milligrams), po (by mouth), daily at 1700 for agitation and anxiety. Further review of Nurses Notes revealed no documentation of inappropriate behavior. Review of Pharmacy Consultant Report dated 6-14-2018 revealed receives an antipsychotic [MEDICATION NAME] but does not have a supporting indication for use documented. Further review revealed Dementia with behaviors written under Physician's Response dated 06-18-2018. Review of the Medication Administration Record [REDACTED]. Interview with the Director of Nursing (DON) on 08/16/2018 revealed no behaviors had been documented for Resident # 41. Further interview revealed the Nurse Practitioner (NP) was seated at the Nursing Station one day and saw Resident # 41 looking as if he/she was agitated and headed for the door and the order for [MEDICATION NAME] was written. | 2020-09-01 |
| 112 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2018-08-16 | 760 | D | 0 | 1 | PLLD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and review of manufacture's recommendations, the facility failed to administer the correct amount medication for 1 of 1 resident reviewed for TB [MEDICATION NAME], Purified Protein Derivative (PPD) medication administration. Resident #449 did not receive the correct amount of physician ordered PPD during medication administration. The findings included: On [DATE] at approximately 10:45 AM, an observation of the medication refrigerator in the Director of Nursing's (DON's) office with the DON revealed (1) 1 milliliter (ml), 10 test, vial of [MEDICATION NAME] Purified Protein Derivative (PPD) (Mantoux) (Lot # 0) which was opened (,[DATE] empty) with a puncture date of [DATE] recorded on the vial, and an expiration date of [DATE] on the pharmacy bottle that the vial was stored in. Following the observation of the PPD vial, the DON verified the vial of PPD was opened on [DATE] and expired on [DATE]. On [DATE] at approximately 1:30 PM, during an interview with the Director of Nursing (DON), the DON verified the vial of PPD (Lot # 0) was in use after the manufactures recommended expiration date and revealed that Resident #449 received PPD on [DATE] which was after the expiration date of [DATE]. Review of the manufacture's recommendations for [MEDICATION NAME] Purified Protein Derivative, (Mantoux) (PPD) ([MEDICATION NAME]) states under section Storage, A vial of [MEDICATION NAME] which has been entered and in use for 30 days should be discarded. Do not use after the expiration date. | 2020-09-01 |
| 113 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2018-08-16 | 761 | E | 0 | 1 | PLLD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, review of the facility policy, Medication Storage in the Facility, and review of manufacture's recommendations, the facility failed to follow a procedure to ensure that recommended temperatures were maintained in 1 of 3 medication storage refrigerators and expired medication was removed in 1 of 3 medication storage rooms reviewed. Medications were stored in the Unit 1 medication storage room below the FDA (Food and Drug Administration) approved package inserts and manufacturer package labeling, and expired medication was in the Director of Nursing's (DON's) medication storage room refrigerator,. The findings included: On [DATE] at approximately 10:25 AM, an observation of the Unit 1 medication storage room with Licensed Practical Nurse (LPN) #1 revealed the temperature of the medication refrigerator was 32 degrees Fahrenheit (F) which was confirmed by LPN #1. The contents of the refrigerator was: 1.) (4) containers of Lananoprost Opthalmic Solution .0005% 125ug/2.5 ml. 2.) (38) vials of [MEDICATION NAME] 20 mcg. / 2 ml. 3.) (2) 10 ml. vials [MEDICATION NAME] R insulin 100 u/ml. 4.) (1) 10 ml. vial [MEDICATION NAME] R insulin 100 u/ml. 5.) (1) 2 mg. / ml. bottle of Lorazapam oral concentrate 6.) (2) 10 ml. vials Humalog insulin 100 u /ml. 7.) (5) 10 ml. vials of [MEDICATION NAME] 100 u /ml. 8.) (2) 12.5 mg. injections of [MEDICATION NAME] Consta 9.) (2) vials of [MEDICATION NAME]100u /ml. The (MONTH) (YEAR) Unit Drug Refrigerator Temperature Log on top of the refrigerator revealed 5 dates ([DATE], 4, 5, 6) had been recorded On [DATE] at approximately 11:00 AM, during an interview with Maintenance Director and LPN #1, the surveyor's thermometer was placed in the Unit 1's medicine refrigerator which read 31 degrees F. Both thermometers (facility's and surveyors) were then tested for accuracy with the Maintenance Directors thermometer which all read the same temperature. The Maintenance Director verified the thermometers had the same reading and were accurate. On [DATE] at approximately 11:30 AM, during a review of the Unit 1's medication storage refrigerator's logs revealed in (MONTH) (18) days, (MONTH) (6) days, (MONTH) (14) days, and (MONTH) (5) days had temperature readings below 36 degrees F. On [DATE] at 1:25 PM, a review of the facility policy entitled, Safe and Sanitary Handling, Storage, Wastage, and Controlled Substance Management Medication Storage in the Facility stated under procedure (1.b) Medications are stored to ensure stability, This includes: 1.) Storing medications at proper temperatures. Review of the manufacture recommendations for insulin, Lorazapam, Lantanoprost, [MEDICATION NAME], and [MEDICATION NAME] Consta, state refrigerated storage temperatures between ,[DATE] degrees F. On [DATE] at approximately 10:45 AM, an observation of the medication refrigerator in the Director of Nursing's (DON's) office with the DON revealed (1) 1 milliliter (ml), 10 test, vial of [MEDICATION NAME], Tuber-culin Purified Protein Derivative (PPD) (Mantoux) (Lot # 0) which was opened (,[DATE] empty) with a puncture date of [DATE] recorded on the vial, and an expiration date of [DATE] on the pharmacy bottle that the vial was stored in. Following the observation of the PPD vial, The DON verified the vial of PPD was opened on [DATE] and expired on [DATE]. Review of the [MEDICATION NAME] Purified Protein Derivative (PPD) (Mantoux) packet insert manu-facture recommendations #262 stated, A vial of [MEDICATION NAME] which has been entered and in use for 30 days should be discarded. | 2020-09-01 |
| 114 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2019-10-18 | 600 | E | 1 | 0 | CCZ611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to ensure that each resident has the right to be free from mistreatment, abuse or neglect for 5 out of 14 resident-to-resident altercations. The findings included: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of complaint records indicated Resident #2 was involved in five incidents of resident-to-resident altercations between November 2018 and September 2019 in which Resident #2 was the physical aggressor. Review of Resident #2's medical book revealed there were no interventions and no direct care plans to prevent Resident #2 from being physically aggressive towards other residents. During an interview on 10/16/2019 at approximately 2:20 PM, the Director of Nursing (DON) stated that Resident #2 was being picked on by others residents which caused Resident #2 to get upset and act out by having altercations with other residents. The DON stated that Resident #2 was on informal 15 minutes checks, and we have him/her stay around the nursing station because we can keep him/her in our sights. Also, the DON stated that Resident #2 doesn't have a care plan to address his/her altercations with other residents and there was no documentation for the 15 minutes checks because the DON decided that Resident #2 was being picked on, which makes him/her agitated. On 10/16/19 at approximately 3:30 PM, review of the facility policy entitled Adult or Elder Abuse, Mistreatment and Neglect revealed: It is facility policy to protect residents from abuse, neglect, mistreatment or exploitation from anyone, including staff members, students, volunteers, other residents, consultants' staff or other agencies serving the resident, family members, legal guardians, friends, or visitors. | 2020-09-01 |
| 115 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2019-10-18 | 607 | E | 1 | 0 | CCZ611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, facility failed to implement written policies and procedures that would prohibit or prevent each resident from mistreatment, abuse or neglect. The finding included: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of complaint records indicated Resident #2 was involved in five incidents of resident-to-resident altercations between November 2018 and September 2019 in which Resident #2 was the physical aggressor. On 10/16 at approximately 3:30 PM, reviewed of Resident #2 medical book revealed there was no care plan for Resident #2's behaviors. Also there was no documentation on Resident #2 being picked on by other residents. During an interview on 10/16/2019 at approximately 2:20 PM, the Director of Nursing (DON) stated that Resident #2 was being picked on by others residents which caused Resident #2 to get upset and act out by having altercations with other residents. The DON stated that Resident #2 was on informal 15 minutes checks and we have him/her stay around the nursing station because we can keep him/her in our sights. Also, the DON stated that Resident #2 does not have a care plan to address his/her altercations with other residents and there was no documentation for the 15 minutes checks because the DON decided that Resident #2 was being picked on, which makes him agitated. On 10/16/19 at approximately 3:30 PM, review of the facility policy entitled Adult or Elder Abuse, Mistreatment and Neglect revealed: It is facility policy to protect residents from abuse, neglect, mistreatment or exploitation from anyone, including staff members, students, volunteers, other residents, consultants' staff or other agencies serving the resident, family members, legal guardians, friends, or visitors. | 2020-09-01 |
| 116 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2019-10-18 | 610 | E | 1 | 0 | CCZ611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to take action in response to an alleged violation of abuse, neglect, exploitation or mistreatment for 5 out 14 resident-to-resident altercations. The findings included: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of complaint records indicated Resident #2 was involved in five incidents of resident-to-resident altercations between November 2018 and September 2019. In each complaint, Resident #2 was the physical aggressor. Review of Resident #2's medical book revealed there were no interventions and no direct care plans to prevent Resident #2 from being physically aggressive towards other residents. During an interview on 10/16/19 at approximately 10:43 AM, Licensed Practical Nurse (LPN) #2 stated there was no formal care plan for Resident #2's behaviors. LPN #2 stated that they keep watch on Resident #2 every 15 minutes and she/he likes to play country music for him/her, offer him/her snacks, and offer to take him/her outside. During an interview on 10/16/19 at 10:50 AM, LPN #1 stated there no formal care plan for Resident #2 and also stated that they keep watch on him/her every 15 minutes and staff is instructed to redirect Resident #2 with snacks and drinks when Resident #2 appears to be agitated. On 10/16/19 at approximately 3:30 PM, review of the facility policy entitled Adult or Elder Abuse, Mistreatment and Neglect revealed: It is facility policy to protect residents from abuse, neglect, mistreatment or exploitation from anyone, including staff members, students, volunteers, other residents, consultants' staff or other agencies serving the resident, family members, legal guardians, friends, or visitors. | 2020-09-01 |
| 117 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2019-10-18 | 657 | E | 1 | 0 | CCZ611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to ensure that the comprehensive care plan was reviewed and revised by an interdisciplinary team composed of individuals with knowledge of the resident and his/her needs for 1 of 18 resident care plans reviewed (Resident #2). The findings included: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of complaint records indicated Resident #2 was involved in five incidents of resident-to-resident altercations between November 2018 and September 2019 in which Resident #2 was the physical aggressor. Review on 10/16/2019 at approximately 10:00 AM of Resident #2's comprehensive care plan revealed it did not address behavior for Resident #2. During an interview on 10/16/19 at 10:50 AM, Licensed Practical Nurse (LPN) #1 stated there was no formal behavior care plan for Resident #2. LPN #1 stated that they keep watch on him/her every 15 minutes and staff was instructed to redirect Resident #2 with snacks and drinks when Resident #2 appears to be agitated. During an interview on 10/16/2019 at approximately 2:45 PM, the Administrator stated that each discipline writes their own care plans and makes sure their care plans are completed. During an interview on 10/16/ 2019 at approximately 3:10 PM, the Director of Nursing stated that when it comes to making any care plan changes, the nurses will write in their own care plans without having a meeting or letting other disciplines know. On 10/16/2019 at approximately 3:15 PM, LPN #1 stated that he/she wrote in Resident #2's care plan about having 15 minutes checks and also will continue to use the paper system to record each time. LPN #1 stated that it was the Administrator who told her/him to write the care plans. Also, LPN #1 stated that she/he has never been to a care plan meeting or been trained on how to write a care plan. | 2020-09-01 |
| 118 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2019-10-18 | 658 | D | 1 | 0 | CCZ611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to provide nursing services according to professional standards of quality for 1 of 1 resident reviewed for [MEDEQUIP] tube. Facility staff performed a [MEDEQUIP] tube flush for Resident #11 which was outside their scope of practice. The findings included: The facility admitted Resident #11 on 5/20/19 with [DIAGNOSES REDACTED]. Review of the medical record revealed a facility-reported incident dated [DATE] which indicated that staff performed a skill outside of scope of practice. Review of the facility's investigative file revealed the Five-Day Report indicated that the Director of Nursing (DON) spoke with Certified Nurses Aide (CNA) #1 regarding a report that he/she had proceeded to put water in the residents feeding tube. Documentation indicated that CNA #1 stated that (he/she) had asked the charge nurse if she could disconnect resident's feeding tube so she could put the resident to bed. Charge nurse (sic) stated that he/she could disconnect to put resident to bed. I asked (CNA#1) if (Charge Nurse) authorized her to put water in residents feeding tube. (CNA#1) stated that she did not. Further documentation by the DON indicated, (CNA#1) did admit to putting water in the feeding tube.I told (CNA#1) by disconnecting and putting water in (Resident #11's) feeding tube was out of (his/her) scope of practice. Further documentation indicated the DON spoke with the Charge Nurse. Documentation indicated that the Charge Nurse was unaware that CNA #1 performed a tube flush for Resident #11. Further documentation indicated that the Charge Nurse did give (CNA #1) permission to disconnect the tubing to put resident to bed. I (DON) told (Charge Nurse) that allowing the C.N.A. to disconnect the tubing was out of the C.N.A.'s scope of practice. Further review of the Five-Day Follow-Up report indicated it was confirmed that the C.N.A. did a peg flush of approximately 400 cc's of water after putting the resident in bed. Resident did not suffer any adverse effects from the incident. The C.N.A. was terminated from (his/her) employment. In addition, the report indicated the facility educated the nurse that (he/she) allowed the C.N.A. to do a procedure outside of (his/her) scope. Disciplinary action was done on both the C.N.A. and (Charge Nurse). Review of the facility's Investigative File revealed CNA #1 confirmed in his/her facility-obtained written statement that he/she had disconnected the tube feeding and put water in the bag. The statement further indicated that I done what I have done and was taught to at other facilities and put water in the bag and disconnected it. During an interview on 10/17/19 at approximately 9:00 AM, the DON confirmed that both staff members had been disciplined and that CNA #1 was no longer employed at the facility. | 2020-09-01 |
| 119 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2019-11-10 | 550 | D | 0 | 1 | NAMT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to protect the dignity of one of 37 residents (Resident #41). Signs were observed posted in the resident's room containing personal information. The findings included: Resident #41 was admitted on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #41's care plan noted a concern for assistance with activities of daily living dated 02/04/19. A concern for end stage [MEDICAL CONDITION] listed a 1500 milliliter per day fluid restriction. A review of the Annual Minimum Data Set (MDS) assessment dated [DATE] noted that Resident #41 was totally dependent on one staff member for eating assistance. Resident #41 was noted to have a Brief Interview for Mental Status score of 3, indicating severe cognitive impairment. On 11/08/19 at 12:09 PM, a sign was noted taped to the wall over the head of the bed documenting 1500 cc (milliliter) a day fluid restriction and a second sign that Resident #41 needed thickened liquids. On 11/09/19 at 3:49 PM, an interview was completed with the Director of Nurses (DON). We try not to have much signage, it looks tacky. We try to keep it to a minimum. We have colored bracelets that would show swallowing difficulty. I don't know who put the sign up there, but we wouldn't normally put that up. We don't usually put up fluid restrictions. That would be on the MAR (medication administration record). | 2020-09-01 |
| 120 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2019-11-10 | 656 | D | 0 | 1 | NAMT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and staff interviews, the facility failed to implement the care plan for pressure ulcer risk and activities of daily living care for one of 20 sampled residents reviewed (Resident #37). The findings included: 1. Resident #37 had [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment, dated 09/11/19, documented the resident's cognition was severely impaired and was totally dependent on staff for bed mobility, transfer, dressing, toilet use, and hygiene. The resident was always incontinent of bowel and bladder. A care plan last updated 11/07/19 documented the resident was at risk for impaired skin integrity related to immobility and incontinence of bowel and bladder. Interventions included to keep skin clean and dry and assist with turning as needed. A second care plan, last updated 11/07/19, documented the resident was an extensive assist and dependent with activities of daily living. The interventions included to assist with repositioning for comfort and to maintain skin integrity. On 11/08/19 at 9:45 AM, the resident was observed in his room working with therapy. The therapist stated they were about finished with him and would bring him out of his room when they were completed. At 10:30 AM, the resident was observed in the common area of unit two in front of the television. At 10:45 AM, a staff member was observed giving the resident a drink. After giving the drink the staff member left. From 10:45 AM through 12:05 PM, the resident remained in the common area. Staff was observed passing by the resident and taking other residents into the dining room for the noon meal. No staff was observed stopping and checking on the resident, repositioning him and/or taking him to provide care. At 12:05 PM, the therapist approached the resident, removed a towel from behind his head, and stated she would bring back a new one. She did not check the resident, reposition him or take the resident to his room to provide any care. At 12:10 PM, the therapist placed a new rolled towel behind his head and immediately left. From 12:10 PM through 1:35 PM, the resident continued to be observed up in the common area without staff checking on him, repositioning or taking him to provide care. The resident had a strong odor of urine that was permeating from his body during the observation. The resident was observed up in the common area for three hours and five minutes without being repositioned, checked or provided care. At 2:15 PM, Certified Nurse Assistant (CNA) #49 stated the resident was incontinent, required care to be provided every two hours and needed to be checked on frequently for positioning. At 2:57 PM, CNA #80 stated the resident was incontinent and required assistance with repositioning. He stated the resident was not able to communicate his needs and required staff to check on him and provide all care. He stated the resident should have care provided at least every two hours. The aide stated the last time he changed the resident was just prior to therapy working with him in the morning which was sometime around 10:00 AM. He stated after the noon meal he offered to take the resident back to his room but was told by the nurse he was alright being up in the common area. The aide continued by saying not being changed for three hours was too long. When asked if the resident had any skin break down he shook his head side to side and then stated, No. At 3:16 PM, CNA #80 was observed taking the resident from the common area to his room. He stated he was going to get CNA #49 to help transfer him to bed and provide care. On 11/09/19 at 9:28 AM, Licensed Practical Nurse (LPN) #26 stated the resident was incontinent, was dependent on staff for positioning and could only answer yes and no questions. She stated that someone should be checking on him at least every two hours and provide a brief change. She was made aware of the observation from the previous day and the nurse stated the care plan was not being followed when he sat without care for over three hours. When asked if the resident had any skin breakdown she stated he did not. At 9:42 AM, the Director of Nursing (DON) stated the resident was totally dependent on staff for all care. She stated the resident was incontinent of bowel and bladder and required to be changed every two hours and more often if needed. She stated staff should be checking on him about every hour between the changes to make sure he was positioned and to see if he needed any additional care. When told about the observation she stated the resident's care plan was not being followed and implemented. | 2020-09-01 |
| 121 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2019-11-10 | 677 | D | 0 | 1 | NAMT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and staff interviews, the facility failed to provide activities of daily living (ADL) care for two of 20 residents reviewed for ADL care. (Residents #37 and #41) The findings included: 1. Resident #37 had [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment, dated 09/11/19, documented the resident's cognition was severely impaired and was totally dependent on staff for bed mobility, transfer, dressing, toilet use, and hygiene. The resident was always incontinent of bowel and bladder. There was no documentation on the assessment the resident had any skin breakdown or issues. Weekly skin audit sheets dated 10/28/19 and 11/04/19 documented the resident's skin was intact. A care plan last updated 11/07/19 documented the resident was at risk for impaired skin integrity related to immobility and incontinence of bowel and bladder. Interventions included to keep skin clean and dry and assist with turning as needed. A second care plan, last updated 11/07/19, documented the resident was an extensive assist too dependent with activities of daily living. The interventions included to assist with repositioning for comfort and to maintain skin integrity. A weekly skin audit sheet, dated 11/09/19, documented the resident had shearing to the right buttocks. There was no documentation the resident had any skin issues related to moisture. On 11/08/19 at 9:45 AM, the resident was observed in his room working with therapy. The therapist stated they were about finished with him and would bring him out of his room when they were completed. At 10:30 AM, the resident was observed in the common area of unit two in front of the television. At 10:45 AM, a staff member was observed giving the resident a drink. After giving the drink the staff member left. From 10:45 AM through 12:05 PM, the resident remained in the common area. Staff was observed passing by the resident and taking other residents into the dining room for the noon meal. No staff was observed stopping and checking on the resident, repositioning him and/or taking him to provide care. At 12:05 PM, the therapist approached the resident, removed a towel from behind his head, and stated she would bring back a new one. She did not check the resident, reposition him or take the resident to his room to provide any care. At 12:10 PM, the therapist placed a new rolled towel behind his head and immediately left. From 12:10 PM through 1:35 PM, the resident continued to be observed up in the common area without staff checking on him, repositioning or taking him to provide care. The resident had a strong odor of urine that was permeating from his body during the observation. The resident was observed up in the common area for three hours and five minutes without being repositioned, checked or provided care. At 2:15 PM, Certified Nurse Assistant (CNA) #49 stated she had been working half of the resident's hall and she had not provided any care to him since she arrived at 6:50 AM. She stated CNA #80 was responsible for the care of the resident. She stated the resident was incontinent, required care to be provided every two hours and needed to be checked on frequently for positioning. She stated she did check on the resident about 10:00 AM, and therapy was working with him and no care was provided. She stated the last brief change was when CNA #80 got the resident up for the day. At 2:57 PM, CNA #80 stated the resident was incontinent and required assistance with repositioning. He stated the resident was not able to communicate his needs and required staff to check on him and provide all care. He stated the resident should have care provided at least every two hours. The aide stated the last time he changed the resident was just prior to therapy working with him in the morning which was sometime around 10:00 AM. He stated after the noon meal he offered to take the resident back to his room but was told by the nurse he was alright being up in the common area. The aide continued by saying not being changed for three hours was too long. When asked if the resident had any skin break down he shook his head side to side and then stated, No. At 3:16 PM, CNA #80 was observed taking the resident from the common area to his room. He stated he was going to get CNA #49 to help transfer him to bed and provide care. At 3:34 PM, CNA #80 stated they had changed the resident's brief and he had urinated more than once. He then stated the resident was wet enough the brief was heavy. He then stated the resident had a small open area when he changed the brief. At 3:39 PM, CNA #49 confirmed the resident had urinated two or three times and the brief was heavy with urine. She then stated she did not notice any skin break down, but the other CNA may have had a better view. On 11/09/19 at 9:28 AM, Licensed Practical Nurse (LPN) #26 stated the resident was incontinent, was dependent on staff for positioning and could only answer yes and no questions. She stated the someone should be checking on him at least every two hours and provide a brief change. She was made aware of the observation from the previous day and the nurse stated the care plan was not being followed when he sat without care for over three hours. When asked if the resident had any skin breakdown she stated he did not. At 9:42 AM, the Director of Nursing (DON) stated the resident was totally dependent on staff for all care. She stated the resident was incontinent of bowel and bladder and required to be changed every two hours and more often if needed. She stated staff should be checking on him about every hour between the changes to make sure he was positioned and to see if he needed any additional care. When told about the observation she stated the resident's care plan was not being followed and implemented. She then stated the resident did not have any skin issues. At 9:53 AM, the resident's skin was observed after care was provided. The resident had a bowel movement and his brief had urine that was to the small of his back. The resident's buttocks were red and there was small open area. Present during the observations was the Wound Nurse, Director of Education, and LPN #26. The Wound Nurse confirmed the resident had a small open area. On 11/09/19 at 1:35 PM, LPN #26 stated the resident's brief was saturated with urine that morning when the skin was observed. She stated the resident had a small area of skin break down about the size of a dime due to moisture and sitting in soiled briefs a long time. She stated she found out the last time the aide provided care was at 7:00 AM, almost three hours before the skin observation. 2. Resident #41 was admitted on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #41's care plan noted a concern for assistance with activities of daily living dated 02/04/19. Interventions for facial hair were not included. A review of the Annual MDS assessment dated [DATE] noted that Resident #41 was totally dependent on staff for personal hygiene and dressing, requiring one staff person for assistance. Resident #41 was noted to have a Brief Interview for Mental Status score of 3, indicating severe cognitive impairment. On 11/08/19 at 9:26 AM, an observation of Resident #41 was completed. She was noted to have a mole on the right side of her chin with long hairs growing out. The hairs were approximately 1 inch long. On 11/09/19 at 3:08 PM, an interview was completed with CNA #62. I saw those long hairs. I don't do anything with them. I'm not sure what we would do. I guess I'd have to ask the nurse. They are so long, I'm not sure if you can pluck them out. An interview was completed with the DON on 11/09/19 at 3:56 PM. It would be difficult to trim the hair. She shakes a lot. We try normally to get the chin hair removed (for other residents). We can try with her, but we would have to be very careful. I'm not sure if anyone has tried. On 11/09/19 at 4:10 PM, an interview was completed LPN #24. LPN #24 stated that she was familiar with Resident #41. She's always had that (chin hair) and I've worked with her about 3 years. I don't know that anyone's ever tried to remove the chin hair. | 2020-09-01 |
| 122 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2019-11-10 | 684 | D | 0 | 1 | NAMT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews, it was determined the facility failed to implement care for a dependent resident which resulted in moisture related skin issues for one of two residents reviewed for skin integrity (Resident #37). The facility identified 36 residents who were frequently incontinent of bladder. The findings included: Resident #37 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 09/11/19, documented the resident's cognition was severely impaired and was totally dependent on staff for bed mobility, transfer, dressing, toilet use, and hygiene. The resident was always incontinent of bowel and bladder. There was no documentation on the assessment the resident had any skin breakdown or issues. Weekly skin audit sheets dated 10/28/19 and 11/04/19 documented the resident's skin was intact. A care plan last updated 11/07/19 documented the resident was at risk for impaired skin integrity related to immobility and incontinence of bowel and bladder. Interventions included to keep skin clean and dry and assist with turning as needed. A second care plan, last updated 11/07/19, documented the resident was an extensive assist and dependent with activities of daily living. The interventions included to assist with repositioning for comfort and to maintain skin integrity. A weekly skin audit sheet, dated 11/09/19, documented the resident had shearing to the right buttocks. There was no documentation the resident had any skin issues related to moisture. On 11/08/19 at 9:45 AM, the resident was observed in his room working with therapy. The therapist stated they were about finished with him and would bring him out of his room when they were completed. At 10:30 AM, the resident was observed in the common area of unit two in front of the television. At 10:45 AM, a staff member was observed giving the resident a drink. After giving the drink the staff member left. From 10:45 AM through 12:05 PM, the resident remained in the common area. Staff was observed passing by the resident and taking other residents into the dining room for the noon meal. No staff was observed stopping and checking on the resident, repositioning him and/or taking him to provide care. At 12:05 PM, the therapist approached the resident removed a towel from behind his head and stated she would bring back a new one. She did not check the resident, reposition him or take the resident to his room to provide any care. At 12:10 PM, the therapist placed a new rolled towel behind his head and immediately left. From 12:10 PM through 1:35 PM, the resident continued to be observed up in the common area without staff checking on him, repositioning or taking him to provide care. The resident had a strong odor of urine that was permeating from his body during the observation. The resident was observed up in the common area for three hours and five minutes without being repositioned, checked or provided care. At 2:15 PM, Certified Nurse Assistant (CNA) #49 stated she had been working half of the resident's hall and she had not provided any care to him since she arrived at 6:50 AM. She stated CNA #80 was responsible for the care of the resident. She stated the resident was incontinent, required care to be provided every two hours and needed to be checked on frequently for positioning. She stated she did check on the resident about 10:00 AM, and therapy was working with him and no care was provided. She stated the last brief change was when CNA #80 got the resident up for the day. At 2:57 PM, CNA #80 stated the resident was incontinent and required assistance with repositioning. He stated the resident was not able to communicate his needs and required staff to check on him and provide all care. He stated the resident should have care provided at least every two hours. The aide stated the last time he changed the resident was just prior to therapy working with him in the morning which was sometime around 10:00 AM. He stated after the noon meal he offered to take the resident back to his room but was told by the nurse he was alright being up in the common area. The aide continued by saying not being changed for three hours was too long. When asked if the resident had any skin break down he shook his head side to side and then stated, No. At 3:16 PM, CNA #80 was observed taking the resident from the common area to his room. He stated he was going to get CNA #49 to help transfer him to bed and provide care. At 3:34 PM, CNA #80 stated they had changed the resident's brief and he had urinated more than once. He then stated the resident was wet enough the brief was heavy. He then stated the resident had a small open area when he changed the brief. At 3:39 PM, CNA #49 confirmed the resident had urinated two or three times and the brief was heavy with urine. She then stated she did not notice any skin break down, but the other CNA may have had a better view. On 11/09/19 at 9:28 AM, LPN #26 stated the resident was incontinent, was dependent on staff for positioning and could only answer yes and no questions. She stated the someone should be checking on him at least every two hours and provide a brief change. She was made aware of the observation from the previous day and the nurse stated the care plan was not being followed when he sat without care for over three hours. When asked if the resident had any skin breakdown she stated he did not. At 9:42 AM, the Director of Nursing (DON) stated the resident was totally dependent on staff for all care. She stated the resident was incontinent of bowel and bladder and required to be changed every two hours and more often if needed. She stated staff should be checking on him about every hour between the changes to make sure he was positioned and to see if he needed any additional care. When told about the observation she stated the resident's care plan was not being followed and implemented. She then stated the resident did not have any skin issues. At 9:53 AM, the resident's skin was observed after care was provided. The resident had a bowel movement and his brief had urine that was to the small of his back. The resident's buttocks was red and there was a small open area. Present during the observations was the wound nurse, director of education, and LPN #26. The wound nurse confirmed the resident had a small open area. On 11/09/19 at 1:35 PM, LPN #26 stated the resident's brief was saturated with urine that morning when the skin was observed. She stated the resident had a small area of skin break down about the size of a dime due to moisture and sitting in soiled briefs a long time. She stated she found out the last time the aide provided care was at 7:00 AM. At 2:15 PM, the Wound Nurse stated during the skin observation the resident had a scaly callused area that opened. She stated when the resident's brief was changed it had enough urine in it to indicate he had urinated two or three times. She stated the open area was probably caused by being wet and soiled and moving up and down in the bed. She then stated she was not aware the resident had an open area on the previous day. When asked about the documentation of the area being shearing, she stated she should have documented the wound was related to moisture and needed to do better documentation. | 2020-09-01 |
| 123 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2019-11-10 | 686 | D | 0 | 1 | NAMT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to identify and treat a wound on the coccyx as a pressure ulcer for one of two residents reviewed for pressure ulcers (Resident #82). The findings included: On 11/09/19 at 11:30 AM, wound care was observed on Resident #82 with Registered Nurse/Wound Care (RN #21) and Certified Nurse Assistant (CNA #53). The wound was located on the coccyx with an open area on the right buttocks. The skin surrounding the open area showed scarring from a healed pressure ulcer. The open area was approximately 3 centimeters (cm) long x 0.25 cm wide X 0.02 cm deep. The area on the left buttocks was superficial but reddened. RN #21 applied a skin barrier ointment to the area. No drainage or odor were noted. When asked if the resident felt pain at the site, she stated, It's pretty sore. An interview with RN #21 on 11/09/19 at 1:35 PM revealed that she identified the wound as shearing rather than a pressure ulcer. She stated that the resident stayed up in her wheelchair most of the day. She stated that she encouraged the resident to stay off of that area as much as possible by lying down in bed instead of in her wheelchair. She stated that she had tried multiple forms of treatment based on standing orders. She stated that she had discussed it with the physician and the nurse practitioner but neither of them had visualized the wound. The wound was first noted on 09/24/19. RN #21 stated that she became aware of the open area when the resident asked her to look at her buttocks because she was having pain. RN #21 stated that she had not asked the physician or the nurse practitioner to observe the wound. She stated that there was no order or policy for when the physician or nurse practitioner should be asked to visualize the wound when it was not improving. A second interview with RN#21 on 11/10/19 at 10:40 AM revealed that Resident #82 had been put on the list to be seen by the nurse practitioner the following day when making rounds. She also stated that the resident had a cushion in her WC before the breakdown occurred, but a different type was ordered after the breakdown. An interview was done with the Director of Nursing (DON) and the nursing home administrator (NHA) about the wound on 11/09/19 at 2:20 PM. The NHA is also an RN. Both the NHA and the DON stated that they had not observed the wound on Resident #82. A review of the medical records showed the following physician orders [REDACTED].#21 and signed by either the physician or the nurse practitioner: 09/24/19 - Apply Duoderm to right buttocks/sacral area. Change q (every) 5 days and PRN (as needed) soiled. 09/26/19 - 1) Discontinue PRN order for buttock wound care. 2) Start: Apply foam dressing to open wound and secure (with) tape/bandaid, change every 3 days and PRN if soiled. 3) Place Geomat 4 WC (wheelchair) cushion in WC. 10/02/19 - 1) Discontinue prior R (right buttock wound orders. 2) Start: Clean with saline and pat dry. 2) Apply skin prep to periphery. Apply small border foam drsg (dressing). Change on shower days and PRN if soiled or non-occlusive. 3) Continue 4 Geomat WC cushion when in WC. 10/06/19 - Body wedge for positioning and coccyx pressure relief while in bed. 10/09/19 - 1) Discontinue all previous wound care. 2) Start: Wound care to buttocks every 3 days and PRN if soiled. Clean with saline and pat dry. Apply [MEDICATION NAME] (cut to size) to each area. Secure with [MEDICATION NAME] tape. 3) Start wound care to left anterior lower every 7 days and PRN if non-occlusive. Clean with NS (normal saline) and pat dry. Apply skin prep to periphery. Apply [MEDICATION NAME]. 4) Left elbow healed - maintain [MEDICATION NAME] x 1 wk (week) then DC. 10/16/19 - D/C previous tx (treatment) to buttocks. Tx to (upper) buttocks fold: Duoderm q 7 ds (days) and PRN soiled. 11/07/19 - 1) Discontinue all prior wound care to buttocks. 2) Start 2xday (twice a day): Clean areas with soap and water. Pat dry. Apply [MEDICATION NAME] paste. 3) Cont care to RLE (right lower extremity) as ordered. Most recent wound documentation sheet stated: 11/07/19 - location L & R buttocks areas on both sides of natural fold. Will use barrier cream as no success with [MEDICATION NAME]. Resident encouraged to stay off back and to take breaks from WC during the day. Wound type: shearing. Exudate: serous. Wound bed: normal for skin. Surrounding skin color: Normal for skin. Wound Edges/Surrounding tissue: Harness/induration. Weekly Nursing Summary: 10/27/19 Skin Condition: Pressure Ulcers (was checked), Location: BLE (bilateral lower extremities). 10/16/19 Area identified (upper) buttocks fold Description: R (right) 6 cm x 4 cm 'crusted'/open area, L (left) 1) 3 cm x 2 cm blistered area 3) 3 cm x 2 cm blistered area 2) 2.5 cm x 2 cm blister. 10/09/19(left side buttock marked) shearing 0.5 x 0.5 x 0.0; no odor, wound bed gray, surrounding skin dark red/purple blanchable Wound edges/surrounding tissue hardness/induration. 10/09/19 (right buttock marked) wound is macerated. Shearing and pinching (buttock to buttock) keeping area agitated. Encouraged resident to get out of WC q2h (every 2 hours) and to sleep on her side at night. She has a wedge for positioning. Cleaned and [MEDICATION NAME] applied/secured with [MEDICATION NAME] tape. Wound bed - slough yellow Wound Edges/Surrounding tissue - Hardness/induration, maceration. 09/26/19 (right buttock marked) - R of natural fold on buttock. Open area unchanged. Area just below is soft this AM (morning). Underside of right thigh and buttock does have a bruised appearance this AM. Foam bandage every 3 days and PRN. Will use 4 Geomat in WC. The most recent quarterly Minimum Data Set (MDS), dated [DATE], was not coded for a pressure ulcer. It was coded Moisture associated skin damage. | 2020-09-01 |
| 124 | PRUITTHEALTH- COLUMBIA | 425013 | 2451 FOREST DRIVE | COLUMBIA | SC | 29204 | 2019-03-22 | 610 | D | 1 | 0 | U4GQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to ensure all allegations were thoroughly investigated for 1 out of 2 complaints reviewed. The findings included: Resident #545 was admitted to the facility with [DIAGNOSES REDACTED]. Resident #545's family alleged that on 10/07/18 that Resident #545 was found by his/her family seated in his/her wheelchair in urine. Review of facility documentation for Resident #545 on 03/21/19 at 2:01 PM revealed the Certified Nursing Assistant (CNA) Care Interventions Record Form revealed the section related to elimination needs was left blank and the CNA-ADL (Activities of Daily Living) Flow Sheet Form was coded as fully incontinent on 10/05/18, 10/06/18, and 10/07/18; however, the number of times the resident urinated during the shift was not documented. Review of the facility internal investigation of the incident on 03/21/19 at 12:47 PM revealed the blank section of the CNA Care Interventions Record Form and CNA-ADL missing documentation were not investigated. In an interview on 03/21/19 at 11:14 AM, the facility Director of Nursing confirmed the missing information on the CNA Care Interventions Record Form and CNA-ADL missing documentation were not investigated. | 2020-09-01 |
| 125 | PRUITTHEALTH- COLUMBIA | 425013 | 2451 FOREST DRIVE | COLUMBIA | SC | 29204 | 2019-03-22 | 623 | D | 0 | 1 | U4GQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the contents of the written notice upon transfer to the resident and/or resident representative included all required information for Resident #89 (1 of 2 sampled residents reviewed for hospitalization ). The findings included: The facility admitted Resident #89 with [DIAGNOSES REDACTED]. Record review on 03/20/19 at approximately 1:08 PM revealed a physician's orders [REDACTED].#89 to the hospital due to shortness of breath, [MEDICAL CONDITION] and increased blood pressure. No documentation of the written notice upon transfer was found in the medical record, but the written notice was provided by the Director of Health Services (Nursing) and the Business Manager. Review of the written notice revealed it did not include all of the required information such as the reason for the transfer, place of transfer, and contact information for the state agency and local ombudsman. In an interview on 03/20/19 at approximately 2:40 PM, the Director of Health Services (Nursing), the Administrator, and Business Manager confirmed that the facility notice did not include the reason for the transfer, place of transfer, and contact information for the state agency and local ombudsman. | 2020-09-01 |
| 126 | PRUITTHEALTH- COLUMBIA | 425013 | 2451 FOREST DRIVE | COLUMBIA | SC | 29204 | 2019-03-22 | 657 | E | 1 | 0 | U4GQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to ensure Care Plans were revised in a timely manner for 1 out of 5 residents reviewed for Unnecessary Medications (Resident 67). The findings included: Resident #67 was admitted to the facility with [DIAGNOSES REDACTED]. Review of Resident #67's Psychotherapy notes on 03/19/19 at 12:42 PM revealed a note dated 12/19/18 which noted an initial mental health examination by the Nurse Practitioner recommending starting [MEDICATION NAME] 7.5 milligrams twice daily for agitation. Review of Resident #67's physician's orders [REDACTED]. In an interview on 03/21/19 at 10:18 AM, the Director of Nursing confirmed Resident #67's [MEDICATION NAME] 7.5 milligrams twice daily was not started in a timely manner. | 2020-09-01 |
| 127 | PRUITTHEALTH- COLUMBIA | 425013 | 2451 FOREST DRIVE | COLUMBIA | SC | 29204 | 2018-03-23 | 636 | D | 0 | 1 | LL0111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and limited record reviews, the facility failed to complete a comprehensive Minimum Data Set (MDS) 3.0 assessment within the timeframe required by the Centers for Medicare and Medicaid (CMS) for 1 of 1 resident reviewed for pressure ulcers. Resident #16 did not have a comprehensive (annual or significant change in status) MDS assessment completed as required within 92 days of the prior Omnibus Budget Reconciliation Act (OBRA) MDS quarterly assessment with Assessment Reference Date (ARD) of 8/22/17. The findings included: Resident #16 was admitted to facility with the following [DIAGNOSES REDACTED]. Record review on 3/23/18 at approximately 9:00 AM revealed that Resident #16 had a Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 8/22/17 completed. Further review of the medical record on 3/23/18 revealed that the next MDS completed was a Significant Change in Status (SCSA) MDS assessment with an ARD of 12/5/17. Additional review revealed that the prior comprehensive MDS assessment was completed with an ARD of 11/24/16 and identified as an annual MDS assessment. The ARD for the SCSA (12/5/17) was ARD + 105 calendar days from the prior quarterly assessment (8/22/17) and was ARD + 377 calendar days from the prior annual MDS assessment (11/24/16). Review on 3/23/18 at of the MDS Resident Assessment Instrument (RAI) Manual version 1.15 effective date 10/1/2017; Chapter 2 page 2-22 revealed the following: The ARD (Item A2300) must be set within 366 days after the ARD of the previous OBRA comprehensive assessment (ARD of previous comprehensive assessment +366 calendar days AND within 92 days since the ARD of the previous OBRA quarter or Significant Correction to Prior Quarterly assessment (ARD of previous Quarterly assessment + 92 calendar days). MDS nurses #1 and #2 verified during interviews on 3/23/18 that a annual MDS had not been completed as originally scheduled with an assessment reference date of 11/24/17 but changed due to Resident #16 being admitted to hospice services 11/22/17. Further discussion revealed that MDS nurse #2 had initiated a significant change in status assessment with an ARD of 12/5/17 to replace the annual assessment. S/he verified during interview that s/he was not aware that the time frame for the required comprehensive MDS had lapsed and that was due with ARD no later than 11/21/17 related to the date of the prior OBRA Quarterly MDS ARD (8/22/17) +92 calendar days. | 2020-09-01 |
| 128 | PRUITTHEALTH- COLUMBIA | 425013 | 2451 FOREST DRIVE | COLUMBIA | SC | 29204 | 2018-03-23 | 637 | D | 0 | 1 | LL0111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and limited record reviews, the facility failed to complete a Significant Change in Status (SCSA) Minimum Data Set (MDS) 3.0 assessment within the timeframe required by the Centers for Medicare and Medicaid (CMS) for 1 of 1 resident reviewed for pressure ulcers. Resident #16 did not have a SCSA MDS assessment completed as required within 14 days after admission to hospice services effective 11/22/2017. The findings included: Resident #16 was admitted to facility with the following [DIAGNOSES REDACTED]. Record review on 3/23/18 at approximately 9:00 AM revealed that Resident #16 was admitted to hospice services with start of care date effective 11/22/2017. Additional review revealed that Resident #16 had a Significant Change in Status (SCSA) MDS assessment with an ARD of 12/5/17 completed and signed by RN on 12/19/2017. Review on 3/23/18 at of the MDS Resident Assessment Instrument (RAI) Manual version 1.15 effective date 10/1/2017; Chapter 2 page 2-23 revealed the following: The MDS completion date (Item Z0500B) must be no later than 14 days from the ARD (ARD + 14 calendar days) and no later than 14 days after the determination that the criteria for a SCSA were met. MDS nurses #1 and #2 verified during interviews on 3/23/18 that the significant change in status assessment initiated when Resident #16 was admitted to hospice services on 11/22/17 was not completed within required time frame. They verified that the ARD for SCSA was 12/5/17 and item Z0500B was signed by RN to signify assessment as complete on 12/19/17, which was 27 calendar days after admission to hospice services. | 2020-09-01 |
| 129 | PRUITTHEALTH- COLUMBIA | 425013 | 2451 FOREST DRIVE | COLUMBIA | SC | 29204 | 2018-03-23 | 638 | D | 0 | 1 | LL0111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and limited record reviews, the facility failed to complete a quarterly Minimum Data Set (MDS) assessment within the required time frame as outlined in the MDS 3.0 Resident Assessment Instrument (RAI) manual for 1 of 1 resident reviewed for pressure ulcers. Resident #16's quarterly MDS was not completed with an Assessment Reference Date (ARD) within 92 calendar days of the ARD of the most recent Omnibus Budget Reconciliation Act (OBRA) assessment, a Significant Change in Status Assessment (SCSA) with ARD of 12/5/17. The findings included: Resident #16 was admitted to facility with the following [DIAGNOSES REDACTED]. Record review on 3/23/18 at approximately 9:00 AM revealed that Resident #16 had a Significant Change in Status (SCSA) Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 12/5/17 completed related to admission to hospice care services. Further review of the medical record on 3/23/18 revealed that there was not a quarterly MDS assessment completed as required on or before 3/7/18. Additionally, the only MDS with an ARD after 12/5/17 was a SCSA MDS that was currently in the process of being completed with an ARD of 3/15/18. Review on 3/23/18 at of the MDS Resident Assessment Instrument (RAI) Manual version 1.15 effective date 10/1/2017; Chapter 2 page 2-32 revealed the ARD of an assessment drives the due date of the next assessment. The next non-comprehensive assessment is due within 92 days after the ARD of the most recent OBRA assessment (ARD of the previous OBRA assessment- Admission, Annual, Quarterly, Significant Change in Status, or Significant Correction assessment + 92 calendar days). MDS nurses #1 and #2 verified during interviews on 3/23/18 that a quarterly MDS had not been completed as originally scheduled with an assessment reference date of 3/6/18 due to hospice services being discontinued effective 3/8/2018. Further discussion revealed that MDS nurse #2 had initiated a significant change in status assessment with an ARD of 3/15/18 to replace the quarterly assessment. S/he verified during interview that s/he was not aware that the time frame for the required quarterly MDS had lapsed and that was due with ARD no later than 3/7/18. MDS Nurse #2 reported that s/he had initiated an assessment using the previously scheduled ARD of 3/6/18 to be completed and transmitted to the state, but verbalized that it was considered late. | 2020-09-01 |
| 130 | PRUITTHEALTH- COLUMBIA | 425013 | 2451 FOREST DRIVE | COLUMBIA | SC | 29204 | 2018-03-23 | 640 | D | 0 | 1 | LL0111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to complete and/or transmit Minimum Data Set (MDS) 3.0 information within required 14 day timeframe as required by CMS (Centers for Medicare and Medicaid Services) and the State for 4 of 6 residents identified on Certification and Survey Provider Enhanced Reporting (CASPER) Minimum Data Set (MDS) 3.0 Missing Omnibus Budget Reconciliation Act (OBRA) Report generated on 3/14/2018. The findings included: Resident #382 had an assessment target date of 01/08/2018 which was the last transmitted Minimum Data Set (MDS) assessment per the CASPER (Certification and Survey Provider Enhanced Reporting) MDS 3.0 Missing OBRA (Omnibus Budget Reconciliation Act) Assessment Report generated on 03/14/2018. Resident #382 was discharged from facility on 1/12/2018 which was signed as complete by the Registered Nurse on 3/19/2018 which was not within the required 14 day time frame from the Assessment Reference Date (ARD) of 1/12/2018 as required by regulatory guidelines. The documentation provided for review by MDS Nurse #1 on 3/21/2018 at 11:30 AM revealed a Final Validation Report (FVR) with the submission Identification (ID) of 823 that was completed on 3/20/2018 at 12:55: 21 PM. Record #11 identified Resident #382's Discharge MDS assessment which was signed as complete on 3/19/2018 and submitted on 3/20/2018 was accepted into the CMS database and subsequently identified as Assessment Completed late: Z0500B (assessment completion date) is more than 14 days after A2300 (assessment reference date) . Resident #1 had an assessment target date of 10/10/2017 which was the last transmitted Minimum Data Set (MDS) assessment per the CASPER (Certification and Survey Provider Enhanced Reporting) MDS 3.0 Missing OBRA (Omnibus Budget Reconciliation Act) Assessment Report generated on 03/14/2018. Resident #1 was not discharged from facility and a quarterly MDS with an Assessment Reference Date (ARD) of 1/9/2018 was signed as complete by the Registered Nurse on 1/16/2018, however, the MDS was not transmitted to the Centers for Medicare and Medicaid (CMS) database and accepted within the 14 day time frame as required by CMS. The documentation provided for review by MDS Nurse #1 on 3/21/2018 at 11:30 AM revealed a Final Validation Report (FVR) with the submission Identification (ID) of 823 that was completed on 3/20/2018 at 12:55: 21 PM. Record #12 identified Resident #1's quarterly MDS assessment which was signed as complete on 1/23/2018 and submitted on 3/20/2018 was accepted into the CMS database and subsequently identified as Record Submitted Late. Resident #2 had an assessment target date of 10/24/2018 which was the last transmitted Minimum Data Set (MDS) assessment per the CASPER (Certification and Survey Provider Enhanced Reporting) MDS 3.0 Missing OBRA (Omnibus Budget Reconciliation Act) Assessment Report generated on 03/14/2018. Resident #2 was not discharged from the facility and a quarterly MDS with an ARD of 1/22/2018 was signed as complete by the Registered Nurse on 02/05/2018; however, the MDS was not transmitted to the Centers for Medicare and Medicaid (CMS) database and accepted within the 14 day time frame as required by CMS. The documentation provided for review by MDS Nurse #1 on 3/21/2018 at 11:30 AM revealed a FVR with the submission Identification (ID) of 823 that was completed on 3/20/2018 at 12:55: 21 PM. Record #31 identified Resident #2's quarterly MDS assessment which was signed as complete on 2/5/2018 and submitted 3/20/2018 was accepted into the CMS database and subsequently identified as Record Submitted Late. Resident #2 had an assessment target date of 10/24/2018 which was the last transmitted Minimum Data Set (MDS) assessment per the CASPER (Certification and Survey Provider Enhanced Reporting) MDS 3.0 Missing OBRA (Omnibus Budget Reconciliation Act) Assessment Report generated on 03/14/2018. Resident #383 admitted to the facility on [DATE] and an admission MDS with an ARD of 1/09/2018 was signed as complete by the Registered Nurse on 01/16/2018; however, the MDS was not transmitted to the Centers for Medicare and Medicaid (CMS) database within the 14 day time frame as required by CMS. The documentation provided for review by MDS Nurse #1 on 3/23/2018 at 11:01 AM revealed a FVR with the submission Identification (ID) of 095 that was completed on 3/21/2018 at 13:13:51. Record # 14 identified Resident #383's admission MDS assessment which was signed as complete on 1/16/2018 and submitted 3/21/2018 was accepted into the CMS database and subsequently identified as Record Submitted Late. During interview with MDS nurse #1 on 3/22/18 at 12: 45 PM , s/he verified that Resident #1's Quarterly MDS with ARD 1/9/2018 was submitted late, Resident #2's Quarterly MDS with ARD of 1/22/18 was submitted late. S/he further verified that Resident #382's discharge MDS assessment with ARD 1/12/18 was completed late as evidenced by date of RN signature reflecting completion of assessment of 3/19/2018 on Z0500B which was ARD + 66 days, which is outside the regulatory time frame of no later than 14 days after the assessment reference date. After receipt of FVR for Resident #383's admission MDS with ARD of 1/09/2018 on 3/23/2018/ at 11:01 AM, MDS Nurse #1 verified that the MDS was submitted late as it was sent greater than 14 days after it was initially completed on 1/16/2018. | 2020-09-01 |
| 131 | PRUITTHEALTH- COLUMBIA | 425013 | 2451 FOREST DRIVE | COLUMBIA | SC | 29204 | 2018-03-23 | 641 | D | 0 | 1 | LL0111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to code 1 of 1 resident reviewed on hospice accurately for the Health Conditions Prognosis. Resident #49 was not coded in Section J Health Conditions with the accurate life expectancy. The findings included: The facility admitted Resident #49 with [DIAGNOSES REDACTED]. On 3/21/18 at 5:23PM, review of the Minimum Data Set (MDS) assessment dated [DATE] for significant change and 1/5/18 for Quarterly Assessment revealed Section J Health Conditions: J1400 Prognosis: life expectancy of less than 6 months marked No. On 3/21/18 at 5:59 PM, review of the Hospice Certification and Plan of Care revealed the Start Date of Care was 9/23/17. Further record review from the hospice company revealed, Order date 12/7/17 Order Description: I recertified that patient is terminally ill with a life expectancy of Six (6) months or less if the disease process runs it's normal course. During an interview on 3/23/18 at 10:34 AM with MDS Coordinator #1 is familiar with Resident #49 and confirmed the inaccurate coding for Health Conditions Prognosis. S/he stated was just educated on 3/22/18 by a State Agency Surveyor on coding residents on Hospice. | 2020-09-01 |
| 132 | PRUITTHEALTH- COLUMBIA | 425013 | 2451 FOREST DRIVE | COLUMBIA | SC | 29204 | 2018-03-23 | 657 | D | 0 | 1 | LL0111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, records review and staff interview, the facility failed to reassess and revise the comprehensive resident-centered care plan to make sure that resident's current nutrition status reflects the discontinuation of enteral feeding therapy. The facility also failed to update the care plan regarding the percutaneous endoscopic gastrostomy (PEG) status and percentage of by mouth (PO) intake for one of six sampled resident reviewed for nutrition. The findings included: Resident #62 was admitted to the facility with [DIAGNOSES REDACTED]. During the initial tour on 03/19/18 at approximately 2:30 PM Resident #62 was observed laying on his/her bed without signs or symptoms of distress. The resident's room was free of enteral nutrition supplies or equipment and the resident's PEG off sight. Nurse's notes reviewed on 03/22/18 at approximately 2:50 PM revealed that on 02/14/18 the Physician wrote and ordered to discontinue current enteral feeding therapy (tube-feeding) and flush. S/he also wrote an order to have the gastrostomy tube ([DEVICE]) flush with 100 ml of water twice per day for tube patency. Medicine administration regiment reviewed 03/22/18 at approximately 3:00 PM revealed that the nutritional supplement [MEDICATION NAME] 1.5-237 ml bolus five times per day was discontinued on 2/14/18. The care plan review on 03/22/18 at 3:19 AM stated that the resident has the potential for nutrition and hydration deficits and aspiration related to [DEVICE] feeding. The care plan goal includes to nourish and adequately hydrate. The intervention includes administration of H2O flush as ordered per Hierarchical Condition Categories (HCC) protocol, monitor residual volume as ordered, and to care for PEG site daily and as needed. During an interview with Minimum Date Set coordinator (MDS) #1 conducted on 03/23/18 at 10:12 AM s/he confirmed that the care plan is not updated to include improvement in PO intake and discontinuation of PEG tube feeding. | 2020-09-01 |
| 133 | PRUITTHEALTH- COLUMBIA | 425013 | 2451 FOREST DRIVE | COLUMBIA | SC | 29204 | 2018-03-23 | 761 | E | 0 | 1 | LL0111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, limited record reviews, interviews, and review of the facility policy, the facility failed to ensure that medications were properly labeled in 2 of 7 medication carts reviewed for medication storage. In addition, the facility failed to ensure controlled substances medication was accounted for in 1 of 1 emergency narcotics box reviewed for medication storage. The findings included: During the medication storage review, conducted in part on 3/22/18 at approximately 09:50 AM with Licensed Practical Nurse (LPN) #1, two packages of [MEDICATION NAME] 10 milligrams (mg) oral tablets (thirty tablets per package) were found with a discard date of 1/12/19 and a manufacturer expiration date of 1/29/18 for Resident #48. One package was in use and the other package was unopened. LPN #1 stated, I use the discard date as the expiration date. I never look on the back of the package. LPN #6, also present on the unit, stated, I just use the discard date as the expiration date. During continuation of the medication storage review on 3/22/18 at approximately 1:35 PM with LPN #4, one unopened package of [MEDICATION NAME] 10 mg oral tablets (thirty tablets) was found with a discard date of 1/1/19 and a manufacturer expiration date of 1/29/18 for Resident #72. LPN #4 stated, I was trained on checking the discard date only. LPN #2, also present on the unit, stated, We use the discard date as the expiration date. In a telephone interview with Pharmacist #2 on 3/22/18 at approximately 10:20 AM, s/he stated, There was an error on the pre-pack label for the [MEDICATION NAME] dispensed with the manufacturer lot # 59[NAME] The expiration date should be 1/29/19 not 1/29/18. S/he also stated, There is no policy for how to check the expiration date of a medication. We train the staff to use whichever date comes first, the discard date or the expiration date. The expectation is they will call us if they find a discrepancy. During an interview on 3/23/18 at approximately 8:50 AM, the Director of Nurses (DON), also known as the Director of Health Services (DHS) stated, The discard date is used as an expiration date. The new staff are trained on medication administration and storage in a video they are shown when they are hired. The pharmacy consultant also does occasional in-services. In addition, during controlled medication storage review on 3/22/18 at approximately 4:00 PM with Unit Manager #1, the Emergency Narcotic Medication Log was found incomplete. The Emergency Narcotic Box has an inventory including the following controlled medications: [REDACTED]. Unit Manager #1 verified that the Controlled Drug Shift Audit Form - 12 Hour Shifts with dates from 3/5/18 - 3/22/18, had 4 of 35 shifts with the required signatures documenting the medications were counted and the lock code numbers were recorded as required by the facility policy. Unit Manager #1 stated, They should be counting this with their narcotic count every shift and recording the code on the security ties. Review of the facility policy entitled Controlled Substances for Healthcare Centers on 3/23/18 at approximately 9:00 AM revealed: Policy Statement: Medications listed as controlled substances (Schedules I-V) under federal or state regulations will be properly stored with maintained accountability. Reconciliation of controlled substances will be performed at the end of each shift by licensed professional nurses. The healthcare center will obtain and keep on file any permits related to ordering and storing controlled substances required by state or federal agencies. Also revealed under South [NAME]ina (SC Code Ann. Reg 61-4 Part 5, Section 508): Accounting: 1. A physical inventory of all controlled substances is conducted at each shift change by the oncoming and outgoing licensed professional nurses. 2. The inventory is documented on the Controlled Drug Shift Audit Sheet. 3. During the Shift Change Inventory, the controlled drug emergency kit is also checked for security of contents and recorded on the audit record. Any apparent tampering or theft of the contents will be recorded on the audit sheet. | 2020-09-01 |
| 134 | PRUITTHEALTH- COLUMBIA | 425013 | 2451 FOREST DRIVE | COLUMBIA | SC | 29204 | 2018-03-23 | 801 | F | 0 | 1 | LL0111 | Based on observation, record review and interview the facility failed to employ sufficient qualified staff with the appropriate competencies and skill set forward to carry out food and nutritional services in accordance to the Centers for Medicare and Medicaid Services (CMS) regulations and the state of South[NAME]nutritional professional standards for one of one kitchen sample reviewed for qualified food and nutrition service staff. The findings included: On 03/19/18 at 10:43 AM during the initial tour of the facility's kitchen the dietary manager #1 revealed that s/he has been functioning as one of the dietary managers for three years now. S/he also stated s/he has not yet taken/passed the nationally recognized credentialing exam needed to obtain/maintain certified status. When asked if the facility has a registered dietitian or food and nutrition services director s/he stated that the facility has a consultant registered dietitian that comes to the facility three to four times per month. At approximately 04:21 PM on the same day during the continuation of kitchen tour the dietary manager #2 stated that s/he has a bachelor degree in food management and culinary art. S/he also stated that s/he is eligible for the Certified Dietary Manager (CDM) exam and that s/he was currently enrolled in the class. However, s/he has not yet taken/pass the exam to obtain/maintain certification status. On 03/20/18 the work schedule for the dietary managers and registered dietitian was requested. However, the facility administrator stated that s/he does not have formal/hard copy work scheduled for the dietary staff. S/he provides a handwritten note stating that the dietary manager #1 works from Sunday through Thursday for 8 hours per day. The dietary manager #2 works Mondays through Fridays for 8 hours. The written note also states that the consultant register dietitian worked (MONTH) 6th, 7th, and 8th, (MONTH) 22nd, 23rd, 24th (MONTH) 13th, 14th, 15th and 16th for 8 hours each day. The registered dietitian #2 works approximately 3 hours per week based on the volume of new admission. The registered dietitian #2 worked 5.5 hours in December, 11.15 hours in January, 6.15 hours in February, and 3.45 hours in March. On 03/22/18 at 11:49 PM during an interview with the administrator and consultant registered dietitian #1 they both stated that according to their interpretation of the regulation the dietary manager #2 has the credential to perform as dietary manager without the CDM. The administrator stated that s/he is enrolled in the course and will eventually take the test. However, they both feel that if an individual has an associate degree or higher education s/he can form as a dietary manager without CDM credentials. The surveyor explained to both that according to CMS regulation, professional qualification/standard, and the state law the individual that performs as a dietary manager without a full time registered dietitian or food service director need to be a certified dietary manager (CDM). | 2020-09-01 |
| 135 | PRUITTHEALTH- COLUMBIA | 425013 | 2451 FOREST DRIVE | COLUMBIA | SC | 29204 | 2018-03-23 | 812 | F | 0 | 1 | LL0111 | Based on observation, interview, and review of the facility's policy titled Food Storage, the facility failed to ensure that the kitchen's walkin cooler was kept in good working condition to guarantee cold food items were kept at 41F degrees or lower to prevent the growth of pathogenic microorganisms that can cause foodborne illness. The findings included: During the initial kitchen tour on 03/19/18 at 10:49 AM the thermometer in the walkin cooler read 49F degrees. At approximately 11:20 AM a brand new thermometer was observed in the same walkin cooler, and it read 60F degrees at the time. The dietary manager stated the thermometer was just put in and that it needed some time to adjust. At 04:21 PM on the same day the walkin cooler temperature was reading 49F degrees. At 4:51 PM the temperature of 236 ml carton of 2% milk that was placed on dinner tray at the kitchen read 48F degrees. The milk was taken off the tray and discarded. At approximately 5:08 PM on the same day the walkin cooler temperature log was requested. It was provided. However, it was incomplete and some areas white out. At approximately 5:15 PM on the same day dietary manager #2 stated that the maintenance person was on his/her way to the facility to take a look at the walkin cooler. At approximately 5:20 PM the administrator acknowledged that the walkin cooler was not working properly and s/he stated that the food items in it were not maintained at 41F degrees or lower. S/he also stated that all the food items in the walkin cooler that have the potential for bacterial growth and the potential to cause harm was going to be discarded. At approximately 5:30 PM the surveyor observed the administrator, dietary manager, and kitchen staff throw the following items into a large trash can: 600 of individual cartons of milk (236 ml of whole, 2%, 1% milk carton), one gallon of 2% milk, one container of chy salad, three containers of pimento cheese, two containers of cottage cheese, two pounds of sliced turkey, one container of gravy, one bag of parmesan cheese, 32 sandwiches, 12 cup of yogurt, 20lbs of ground beef, 30 sausage patties, 15lbs of bacon, and 20 pack tortillas. On 3/20/18 at approximately 8:45 AM the walkin cooler temperature was 39F degrees. During an interview with the administration on the same day at approximately 10:00 AM s/he stated that the maintenance person did not find any mechanical problem with the cooler but s/he found a plastic wrap from food on the vent blocking air flow. The plastic wrap was removed, and the cooler temp was back to normal. | 2020-09-01 |
| 136 | PRUITTHEALTH- COLUMBIA | 425013 | 2451 FOREST DRIVE | COLUMBIA | SC | 29204 | 2017-06-20 | 278 | D | 1 | 0 | 5BIF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interviews the facility failed to accurately assess 1 of 3 residents reviewed for assessments. Resident #2's assessment did not have a cognitive assessment. The resident had been assessed as having a [MEDICAL CONDITION], which was actually a fistula. The findings included: The facility admitted resident #2 with [DIAGNOSES REDACTED]. Review of the medical record revealed a Quarterly Minimum Data Set (MDS) of 2/17/17 revealed the resident's cognition was not coded. No mood or behavior problems. Functional status was total care with Activities of Daily Living, non-ambulatory. S/he was incontinent of bowel and bladder. Weight was 84 lbs. A Significant Change Minimum Data Set (MDS) of 5/10/17 had the resident coded to have no memory problems and was able to make decisions. There were no mood or behavior problems. Functional ability- S/he required total care with all aspects of Activities of Daily Living (ADL's), non-ambulatory. Resident had an indwelling foley and an ostomy for waste elimination. She was 67 inches tall and weighed 84 lbs. Mechanically Altered Therapeutic Diet. One stage III pressure sore, present on admission. 04.0 x 03.5 x 00.1, granulation tissue present in wound bed. The resident received pressure ulcer care and was on pressure reducing devices for bed and chair. On 6/20/17 at 9:20 AM: Registered Nurse (RN), (wound nurse) was interviewed by the surveyor. Resident #2 no longer here. S/he had a sacral wound, stage III. We were doing daily treatments. S/he had a groin wound and was going to the wound clinic for it. S/he had a flesh-eating bacteria, before s/he came here. S/he was an established patient when I became wound nurse. We found out that the groin area was actually a fistula. It wasn't infected, stool was coming through it. It had the risk of being infected. I assessed her/him and sent her/him out. They were using a [MEDICAL CONDITION] device, but s/he did not have a [MEDICAL CONDITION]. They used an ostomy device. | 2020-09-01 |
| 137 | PRUITTHEALTH- COLUMBIA | 425013 | 2451 FOREST DRIVE | COLUMBIA | SC | 29204 | 2017-06-20 | 279 | D | 1 | 0 | 5BIF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interviews the facility failed to provide an accurate care plan for 1 of 3 residents care plans reviewed. Resident #2's plan of care did not address the fistula or possible complications. The findings included: The facility admitted resident #2 with [DIAGNOSES REDACTED]. Review of the care plan dated 3/26/15, updated 5/17/17 revealed a problem of Self-care deficit in activities of daily living (ADL's). Requires total care with all ADL's related to Cerbralvascular Accident ([MEDICAL CONDITION]), has a foley catheter and a [MEDICAL CONDITION]. Intervention included to provide [MEDICAL CONDITION] care. Review of the Nurse's Notes revealed: On 4/20/17 Upon assessment of groin wound, brown loose stool noted oozing from left groin wound. Family and physician notified. New orders to send resident to ER for further evaluation and treatment. 5/3/17 returned from hospital with a [MEDICAL CONDITION] bag over left abd fold with brown liquid in bad. BM in diaper. Resident on [MEDICATION NAME] for [MEDICAL CONDITION] and on a [MEDICATION NAME]. 5/5/17 at 11:45 AM Labia noted with excoriation related to excessive stools. Review of the Hospital Discharge Summary dated 4/28/17 revealed the resident was admitted to the hospital with [REDACTED]. On 6/20/17 at 9:20 AM: Registered Nurse (RN), (wound nurse) was interviewed by the surveyor. Resident #2 no longer here. S/he had a sacral wound, stage III. We were doing daily treatments. S/he had a groin wound and was going to the wound clinic for it. S/he had a flesh-eating bacteria, before s/he came here. S/he was an established patient when I became wound nurse. We found out that the groin area was actually a fistula. It wasn't infected, stool was coming through it. It had the risk of being infected. I assessed her/him and sent her/him out. They were using a [MEDICAL CONDITION] device, but s/he did not have a [MEDICAL CONDITION]. They used an ostomy device. | 2020-09-01 |
| 138 | PRUITTHEALTH- COLUMBIA | 425013 | 2451 FOREST DRIVE | COLUMBIA | SC | 29204 | 2016-12-15 | 253 | E | 0 | 1 | UWQ711 | Based on observation and interview, the facility failed to ensure housekeeping and maintenance services provided an orderly and comfortable interior for the residents. The findings included: During a tour of the facility the following issues and concerns were noted: 1. In the 700 hall the handrails and walls below the handrails had chipped and missing paint. 2. In room 705, there was a broken nightstand, the faucet on the sink leaks, there was black build up on the tile seams, one bed did not have a privacy curtain, and the paint was gouged behind 1 bed. 3. In room 711, 1 dresser was missing wood laminate, a dresser handle was missing, and the baseboard was pulling away from the wall. 4. In the bathroom attached to room 711, there was a brown build up on the pipe leading to the sink and paint chipped away from the wall. 5. In room 715, the clothing lockers were damaged and in poor repair, paint was chipped away from the wall, there was no call light for 1 occupied bed, and 1 bed did not have a privacy curtain. 6. In room 102, the nightstand was missing laminate. 7. In the bathroom attached to room 102, the paint was chipped away from the wall and there was a gap around the pipe leading from the wall to the toilet . 8. In room 107, 1 dresser and 1 nightstand were missing laminate. 9. In room 111, 1 nightstand was missing laminate, the call light box was pulled away from the wall, and the paint behind the bed was gouged. 10. In room 112, 1 nightstand was missing a drawer pull and the paint was chipped away from the wall. 11. In room 125, the closet doors were damaged, 1 dresser and 2 nightstands were missing laminate, and the paint was chipped away from the wall. 12. In the bathroom attached to room 125, there was a gap between the wall and the baseboard. 13. In the dining area on the 200 floor, there was missing laminate from the handrails and rust colored staining on the wallpaper. 14. In room 202 1 nightstand had a missing handle and 1 dresser had missing laminate. 15. In the bathroom attached to room 202 there was a gap around the pipe leading from the wall to the toilet and a gap in the wall around the soap dispenser. 16. On the 300 floor, a piece of the mounted Wanderguard system was hanging off of the wall. 17. In the dining area on the 300 floor there was a large seam in the wallpaper that was pulled apart. 18. In the hall bathroom on the 300 floor, there were large rust colored stains on the walls and the paint was chipped away from the wall. 19. In room 300, 1 dresser had missing laminate and the closet doors had been written on with a black marker. 20. In room 301, there was chipped paint along the entire wall beneath the window. 21. In the bathroom attached to room 301, the adaptive toilet seat had rust colored marks on the metal and the bathroom sink had missing laminate. 22. In room 305, there was a gap between the hall flooring and the room flooring at the threshold to the door. 23. In room 313, there was a gouge in the bathroom door, 1 dresser had missing laminate, the paint was chipped away from the wall, the closet doors were damaged, there were rust colored spots on the ceiling, and there was a hole in the wall behind the door that was approximately 12 inches by 8 inches. 24. In room 317 there was a large area gouged from the bathroom door, 1 dresser had missing laminate, paint was chipped away from the walls, 1 nightstand was missing a drawer pull, and the closet doors were marred with missing stain. 25. In the bathroom attached to room 317, there was a large gap around the pipe leading from the wall to the toilet. 26. In the dining area on the 400 floor, a large vent was bent and pulled away from the wall. 27. In room 406, 1 nightstand was missing a drawer pull. 28. In room 406, 1 nightstand was missing a drawer pull. During a tour on 12/15/16 starting at 10:25 AM, the facility maintenance manager confirmed the above noted issues and concerns. | 2020-09-01 |
| 139 | PRUITTHEALTH- COLUMBIA | 425013 | 2451 FOREST DRIVE | COLUMBIA | SC | 29204 | 2016-12-15 | 371 | E | 0 | 1 | UWQ711 | Based on initial tour observation, interview and review of the facility policy Labeling, Dating, and Storage, the facility failed to store foods under sanitary conditions in 1 of 1 kitchen. Dietary staff failed to ensure expired foods were removed from the walk in refrigerator. Freezer food items open and unlabeled. The findings included: During initial tour of the kitchen on 12/12/16 at 10:40 AM with Certified Dietary Manager (CDM) revealed the walk-in refrigerator with 2 containers of 5 lbs. (pound) wholesome foods sour cream had expired on 12/3/16. In the walk-in freezer a bag of full cooked sausage, 1 box of Nordica breaded flounder fillets, and 1 box Baker Source waffles were opened and unlabeled. During the review of the facility policy Labeling, Dating, and Storage: Procedure: 1. Food and/or beverage items will be properly labeled with the name of the item, an open date, and a discard date. | 2020-09-01 |
| 140 | PRUITTHEALTH- COLUMBIA | 425013 | 2451 FOREST DRIVE | COLUMBIA | SC | 29204 | 2016-12-15 | 441 | D | 0 | 1 | UWQ711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and review of the facility policy titled, Indwelling Urinary Catheter Care and Management, and Transporting and sorting Soiled Linen, the facility failed to ensure proper perineal care during Foley catheter care for Resident #4 for 1 of 3 residents reviewed for Urinary Incontinence. The facility further failed to handle soiled laundry in a manner to prevent the spread of infections for 1 of 1 laundry rooms observed. The findings included: The facility admitted Resident #4 with [DIAGNOSES REDACTED]. Review on 12/14/2016 at approximately 12:24 PM of the physician's orders revealed an order for [REDACTED]. And an additional physician's order to use a #18 French Foley catheter with a 5-10 milliliter bulb and to change it monthly and as needed for leakage and occlusion. Observation on 12/14/2016 at approximately 1:55 PM of Foley Catheter Care revealed Certified Nursing Assistant (CNA) #1 as he/she knocked on Resident #4's door and asked permission to enter. Resident #4 did not answer. CNA #1 explained the procedure to Resident #4, provided privacy and then washed his/her hands. This surveyor asked for permission to observe the CNA performing Foley catheter care and Resident #4 was unable to answer. After CNA #1 washed his/her hands, he/she proceeded to apply 2 pairs of gloves, removed the brief with the same gloves applied a cleanser to a wipe and cleansed the right outside of the labia with 1 swipe. CNA #1 then did the same for the left side outside the labia. He/she then proceeded to cleanse the catheter tubing from the labia to approximately 2 inches down the tubing. CNA #1 never cleansed the inside of the labia nor did he/she cleanse around the Foley catheter insertion site. The room had a strong urine odor noted on all days of the survey and was brought to the attention of the Nurse Manager for the 400 Unit. During an interview on 12/14/2016 at approximately 2:10 PM with CNA #1, he/she confirmed that he/she had not cleansed the inside of the labia nor the Foley catheter insertion site. Review on 12/14/2016 at approximately 2:30 PM of the facility policy titled,Indwelling Urinary Catheter (Foley) Care and Management, states under, Implementation, bullet 12 reads, Provide routine hygiene for meatal care. The clinical alert reads, Clean the periurethral area carefully, . An observation on 12/15/2016 at approximately 9:50 AM a laundry worker applied a gown and gloves and sorted soiled linen and placed it in a clothes washer. After closing the washer the laundry worker proceeded to start the washer without removing the soiled gloves, and then went over to the laundry room exit door, opened the door and exited into the soiled laundry room and continued to wear the soiled gloves. During an interview on 12/15/2016 at approximately 9:55 AM with Laundry Worker #1, he/she confirmed that he/she had not removed the soiled gloves and started the washer and opened the door and exited without removing the soiled gloves. When asked the Laundry Worker stated the outside of the washers are cleansed in the AM and at around 2:00 PM before the next shift arrives. Review on 12/15/2016 at approximately 10:30 AM of the facility policy titled, Transporting & Sorting Soiled Linen, states under, Policy: This process is a crucial part of infection control requirements. Inservices and constant supervision are necessary to stay within guidelines. Under the section titled, Loading Machines: #1 states, Do not over/under fill machines. Number 2 states, Shut the washer door and select correct programming cycles, start machine. Number 4 states, Remove gloves and wash hands. | 2020-09-01 |
| 141 | PRUITTHEALTH- COLUMBIA | 425013 | 2451 FOREST DRIVE | COLUMBIA | SC | 29204 | 2016-12-15 | 456 | D | 0 | 1 | UWQ711 | Based on observations, interviews and review of the facility policy titled, Cleaning of Laundry Equipment, the facility failed to ensure an excessive large amount of lint was removed from the lint baskets, inside the upper dryer walls and from behind 4 of 4 clothes dryers. The facility further failed to ensure stagnant water was not standing behind the clothes washers and draining properly for 1 of 1 laundry rooms observed. The findings included: An observation on 12/15/2016 at approximately 8:30 AM of the laundry room revealed the clothes dryers with an excessive large amount of lint in the lint baskets, inside the upper dryer walls, and behind 4 of 4 clothes dryers. During an interview on 12/15/2016 at approximately 8:30 AM with the Laundry Supervisor, he/she confirmed the findings and stated, The lint baskets, the upper inside walls of the clothes dryers and behind the clothes dryers are cleaned every 2 weeks. Review on 12/15/2016 at approximately 9:00 AM of the facility policy titled, Cleaning of the Laundry Equipment, states under, Dryers: It is important that dryer filters be cleaned after every load. The frame should be cleaned daily, or as needed, with a disinfectant. At the end of the day, the door should be left open to allow the gasket to reshape. Items to be cleaned on the machines are, but not limited to: Dryer filter, shelf above the filter and the floor under the filter At least weekly the combustion chambers must be vacuumed to remove lint build-up. At least quarterly the front of dryers are to be removed and the interior vacuumed to remove lint build-up. Inspect and clean as necessary the dryer exhaust ducts. The area around the thermocouple must be lint free. Lint and heat causes fire. An observation on 12/15/2016 at approximately 8:35 AM of the clothes washers revealed stagnant water standing behind the clothes washers. There were towels around the outside of the area to soak up overflow. Water was pouring into the drain and none was moving out via the drain. An interview on 12/15/2016 at approximately 9:00 AM with the Laundry Supervisor revealed and confirmed that there was stagnant water standing in the drain behind the clothes washers and not properly draining. The Laundry Supervisor went on to say that he/she would have the maintenance department look at it. | 2020-09-01 |
| 142 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2020-01-22 | 689 | D | 1 | 0 | E8OZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to provide adequate supervision to prevent resident to resident altercations for one of 17 residents (Resident #16) reviewed for altercations. Resident #16 continued to wander about the facility, including into other resident rooms, following four resident to resident altercations. The findings included: Review of Resident #16's Face Sheet, provided by the facility on 01/20/20, revealed s/he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #16's Quarterly Minimum Data Assessment (MDS) with an Assessment Reference Date of 11/08/19 revealed he/she was unable to complete the Brief Interview of Mental Status (BI[CONDITION]) interview but was assessed by staff to have moderately impaired decision-making abilities; had no behavioral symptoms directed at others; did not wander; and ambulated independently. Review of facility investigations of resident to resident altercations revealed Resident #16 was involved in four of these incidents between 11/15/19 and [DATE]: On 11/15/19 at 04:00 PM, Resident #16 entered Resident #15's room and got into Resident #15's bed while Resident #15 was out of the room. When Resident #15 returned to the room and found Resident #16 in the bed, s/he asked Resident #16 to leave, and Resident #16 hit him/her in the face. On 11/20/19 at 06:00 PM, Resident #16 was again in Resident #15's bed. When Resident #15 asked Resident #16 to leave, Resident #16 hit Resident #15 with his/her shoe. The facility sent Resident #16 to the emergency room , where his/her [MEDICATION NAME] dosage was increased from 0.5 milligrams (mg) three times daily to 1 mg three times daily. On 11/25/19 at 02:15 PM, Resident #16 was ambulating in the hallway near the nurse's station, turned a corner, and encountered Resident #17, who was pacing near the nurse's station. Resident #16 struck Resident #17 in the face. On 1[DATE] at 07:30 PM, Resident #16 was sitting on a sofa in the facility's lobby, where Resident #20 was sitting nearby in his/her wheelchair hitting the sofa cushions. Resident #16 struck Resident #20 on the cheek. On 01/20/19 at 3:30 PM, an interview with Registered Nurse (RN) #1 revealed he/she worked with Resident #16 regularly and was caring for the resident at the time of one of the resident to resident altercations. RN #1 stated he/she was not aware of any other resident to resident altercations for Resident #16, and unaware there may be any need to be aware of his/her whereabouts or proximity to other residents. RN #1 stated it was not uncommon for Resident #16 to wander into other resident rooms, and he/she was not easy to redirect once he/she was in another room. On 01/20/19 at 4:00 PM, an interview with Certified Nursing Assistant (CNA) #1 revealed he/she regularly cared for Resident #16 and was aware of at least two of the altercations. CNA #1 stated it was not unusual for Resident #16 to become agitated with other residents and to wander into other resident rooms. CNA #1 stated Resident #16 could be easily redirected with candy or reading materials if s/he was discovered before s/he entered another resident room, but once s/he was in a resident room it was best to wait until s/he had completed whatever it was s/he thought s/he had to do and leave on his/her own. On 01/20/20 at 4:10 PM, Resident #16 was observed in the hallway outside his/her room, ambulating towards the end of the hallway away from the nurse's station. He/she tried to open the doorway at the end of the hall, which was locked. Resident #16 turned around, ambulated to the other end of the hallway, past the nurse's station in the lobby and several offices where staff were present, past the nurse's station on the back hallway, down the hall to the end where he/she entered another resident's room. When the resident in the room made a noise, Resident #16 left the room, slamming the door shut behind him/her and returning on his/her path. At 4:36 PM, Resident #16 returned to the lobby where he/she sat on a sofa. On 01/21/20 at 09:30 AM, an interview with Licensed Practical Nurse (LPN) #1 revealed he/she worked on what the facility called the back hallway, which was on the opposite end of the facility from where Resident #16 resided. The back hallway included the resident room Resident #16 was observed to enter on 1/20/20 at 4:10 PM. LPN #1 stated he/she was aware of Resident #16 because he/she wanders back here every day. LPN #1 stated it was common for Resident #16 to go into other residents' rooms. LPN #1 stated at times when staff attempted to redirect Resident #16 from those rooms, he/she became agitated and it was best to leave him/her until he/she came out on his/her own. LPN #1 stated he/she was unaware that Resident #16 had had any resident to resident altercations and was unaware of the need for any additional supervision when he/she was wandering. On 01/21/20 at 10:15 AM, an interview with the Director of Nursing Services (DNS) and the Administrator revealed the facility considered the room changes and medication changes to be at the root of Resident #16's resident to resident altercation and had not implemented increased supervision. The DNS stated he/she would expect all staff caring for Resident #16 to be aware of his/her history of resident to resident altercations and automatically redirect him/her if he/she was wandering into other resident rooms. Review of the facility's policy titled, Accidents and Supervision - Policy, dated 10/23/19, revealed, .each resident receives adequate supervision.to prevent accidents.This includes.1. Identifying hazard(s) and risk(s).3. Implementing interventions to reduce hazard(s) and risk(s). | 2020-09-01 |
| 143 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2020-01-22 | 758 | D | 1 | 0 | E8OZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review, and review of the facility's policy, it was determined the facility failed to identify and monitor specific target behaviors for residents taking [MEDICAL CONDITION] medications. This was true for one of seventeen residents (Resident #16) sampled for [MEDICAL CONDITION] medication use. The findings included: Review of Resident #16's Face Sheet, provided by the facility on 01/20/20, revealed he/she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #16 Admission physician's orders [REDACTED]. [MEDICATION NAME] (an antipsychotic medication), 5 milligrams (mg) twice daily for a [DIAGNOSES REDACTED]. [MEDICATION NAME] (a benzodiazepine), 2 mg three times daily beginning 08/05/19; and [MEDICATION NAME] (an antipsychotic), 1 mg twice daily beginning 08/05/19. Physician's telephone orders located in the Orders tab of Resident #16's paper clinical record revealed: 08/06/19, decrease [MEDICATION NAME] to 2.5 mg twice daily and decrease [MEDICATION NAME] to 0.5 mg three times daily; 11/21/19, increase [MEDICATION NAME] to 1 mg three times daily; [DATE], increase [MEDICATION NAME] to 5 mg twice daily; 12/05/19, decrease [MEDICATION NAME] to 0.5 mg three times daily. Review of Resident #16's Quarterly Minimum Data Assessment (MDS) with an Assessment Reference Date of 11/08/19 revealed he/she was unable to complete the Brief Interview of Mental Status (BI[CONDITION]) interview but was assessed by staff to have moderately impaired decision-making abilities; had no behavioral symptoms directed at others; and ambulated independently. On 01/21/20 at 10:15 AM, an interview with the Director of Nursing Services (DNS) revealed the facility monitored behaviors for [MEDICAL CONDITION] medications on the Medication Administration Record [REDACTED]. Review of Resident #16's MAR for November and December 2019 and January 2020 revealed, Monitor Resident every shift for behaviors and side effects related to [MEDICAL CONDITION] medication use. The MAR indicated [REDACTED]. An interview with the DNS on 01/21/20 at 02:30 PM revealed the facility had not identified a specific behavior for Resident #16, but he/she was known to wander, become agitated with staff and others, and resist care. The DNS stated the facility did not review the behavior monitors and did not use them when coordinating with the physician or Nurse Practitioner (NP) when discussing [MEDICAL CONDITION] medication dosages or changes. The DNS stated Resident #16's medication changes had all been because he/she either appeared to be over medicated or had engaged in altercations with other residents. An interview with Resident #16's NP on 01/21/20 at 02:45 PM revealed he/she had decreased Resident #16's [MEDICAL CONDITION] medications when he/she saw him/her the day after he/she was admitted because he/she appeared to be so overly sedated and he/she was drooling. The NP stated he/she had made the remainder of the [MEDICAL CONDITION] medication changes based on what he/she saw of Resident #16 when he/she was in the facility, based on staff report, or based on resident to resident altercations. Review of the facility's policy titled, Behavior Management Plan and Form - Policy, dated 03/18/19, indicated, .4. Behaviors should be documented clearly and concisely by facility staff. Documentation should include specific behaviors, time and frequency of behaviors, observations of what may be triggering behaviors, what interventions were utilized, and the outcomes of the interventions.8. Behavior monitoring will be completed through the electronic medical record process. | 2020-09-01 |
| 144 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2016-09-09 | 226 | D | 0 | 1 | LUPR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, review of an abuse incident investigation, record review, observation, and a review of the facility's policy and procedure for abuse, including protection, the facility failed to ensure that 1 of 35 sampled residents was protected against future abuse incidents, Resident #2. The findings include: Review of the Abuse Prevention, Investigation and reporting policy (Carlyle Senior Care) approval date 8/25/2016: Policy Statement: The resident has the right to be free from verbal, sexual, physical, and mental abuse, neglect, involuntary seclusion and misappropriation of personal property. Policy Interpretation and Implementation: Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. 1. Screening 2. Training 3. Prevention 4. Identification 5. Investigation 6. Protection The facility protects residents from harm during an investigation. A representative or designee from the Social Services department assesses the resident ' s emotions concerning the incident as well as the residents' reactions to his/her involvement in the investigation. Appropriate steps are taken for protection of the resident from additional harm during the investigation. Unless otherwise requested by the resident, the social service representative or designee will provide the administrator and the director of nursing services with a report of his/her findings. Employees of this facility who have been accused of resident abuse will be reassigned or suspended until the results of the investigation have been reviewed by the administrator. 7. Reporting/Response The facility analyzes the occurrences to determine what changes are needed, if any, to policies and procedures to prevent further occurrences. Resident #2 was admitted in 2000 and readmitted on [DATE]. The resident's current Diagnoses: [REDACTED]. On 9/07/2016 at 2:28 PM an incident report concerning substantiated abuse involving Resident #2 was reviewed and revealed the following: On 6/26/16 at 7 PM several staff members and residents witnessed a CNA hand a small spiral bound index card book to a confused resident and instructed the resident to throw it at Resident #2. The intended target whose book it was asked the CNA why you did that and the CNA stated because you're a pervert, pervert, pervert. The confused resident had picked up Resident #2's spiral bound index card book and a card and carried them away at 6:55 PM and Resident #2 activated their call light and began to yell for help. A nursing assistant answered the call light and the resident explained what happened. The nursing assistant stepped out of the room and noted the CNA, with the book and the card and asked, Is that Resident #2's book? The CNA said, No, it is not his/hers and went to the dining area to sit at the table. The charge nurse approached the CNA and asked her to return the items to Resident #2. The CNA stated, Leave it here and let him/her throw a fit. The charge nurse corrected the CNA by stating, No, you take it back, you cannot let him/her get upset more than he/she already is because someone took his/her property. The CNA took the confused resident by the hand and guided him to Resident #2's doorway and instructed the confused resident to throw it at him/her (Resident #2), hit him/her in the face with it. A statement from the CNA revealed that she had instructed the confused resident to throw the spiral notebook at Resident #2. A review of the facility investigation revealed the facility did remove the CNA from the situation immediately per the Director of Nursing's orders on the evening of 6/26/16. After the facility investigated, it was determined the CNA had violated the resident and was terminated from employment on 6/30/2016 after the incident occurred. A review of the resident's care plan #5 noted the problem was potential for alterations in thought process and difficulty with communication - often has difficulty with finding words to complete sentences, at time runs his words together due to talking very fast. Periods of forgetfulness but often recalls after being reminded related to past head injury Updates: 6/29/16 - request a stop sign be placed in his doorway to prevent residents from entering his room 8/31/16 - Roommate passed away 9/1/16 - Cont. with current care plan Observations of the resident's doorway on 9/6/2016 at approximately 1:15 PM did not reveal any stop sign at the entrance to the resident's room. Apparently the Stop Sign, which was in the care plan as requested by the resident, has been removed but at whose request - it is unknown. The resident is OK with the Stop Sign not here - in honor of his new roommate which is wheeled in and out daily by staff. Observation of the resident on 9/6/2016 at approximately 2 PM revealed the resident in bed stating he/she was doing good . Staff take care of his/her needs. There was on the over the bed table a very small spiral notebook which he/she said was very important to him/her - this notebook was involved in the abuse incident. The resident did state he/she had residents coming in and out of their room - that's what occurred when the resident came in his/her room and took their spiral notebook. Then the staff had him throw it at Resident #2. Interview with the resident on 9/6/16 and 9/7/16 at 1:15 PM revealed the resident confirmed the incident occurred however he/she has no feelings of not being safe. The resident feels the facility takes good care of him/her. Since their admission in 2000 due to [MEDICAL CONDITION] related to a MVA (Motor vehicle accident) the resident has not had any issues like what happened in June. The resident further stated he/she doesn't like people messing with their things. The facility was unable to provide documentation in resident's clinical record, nurse's notes, plan of care, and social services, of the substantiated abuse incident, which was reported by the facility to the state agency. There was a 24 hour report filed with the State of South [NAME]ina and a final report completed by the Director of Nursing on 6/30/16 as a part of the investigation. However there was no documented evidence of effort by the facility to ensure the resident was protected, based on #6 Protection of their Abuse, Prevention, Investigation and Reporting Policy and Procedure located in the facility's Operations Manual approved on 8/25/2016. On 9/07/2016 at 3:15 PM an interview with the DON revealed she was not able to locate any further notes about the incident in the clinical record and was not able to reveal why the incident wasn't documented in the resident's clinical record. An interview with the Social Services Director on 9/09/2016 at 10:14 AM revealed she had documented the incident of abuse but put it somewhere else - not in the clinical record. The facility failed to address the resident psychosocial well-being at the time of the incident and to monitor his/her well-being after the abuse incident occurred to ensure the resident had no further issues. This was also a missed opportunity to monitor the resident's private space and to ensure staff understood how important his/her private space was to Resident #2 by development of a plan of care for Quality of Life. The facility failed to follow their policy and procedure, including documentation of the resident's reactions to his/her involvement in the investigation, to ensure the resident was protected from future abusive incidents. | 2020-09-01 |
| 145 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2016-09-09 | 253 | D | 0 | 1 | LUPR11 | Based on observations in the main dining room, 1 of 2 dining areas in the facility, an interview with an unsampled resident, and an interview with the administrator, the facility failed to ensure the main dining room was maintained in a sanitary, orderly and comfortable interior to ensure a pleasant dining environment for the many residents that eat breakfast, lunch, and dinner in the main dining room. The findings include: Observations in the main dining room on 09/08/2016 at 12:33 PM it was noted that both of the cathedral type ceiling, closest to the kitchen, had the following concerns: 1. The overhead vent located on the cathedral ceiling closest to the steam table had peeling plaster/paint peeling on one side of the vent. The area with the peeling plaster/paint was approximately 6 inches by 15 inches long. Approximately 4 inches of plaster/paint was also hanging from this area, resembling icicles. There was a table with a tablecloth located directly under this area of the peeling plaster/paint. Two residents were at the table waiting for their meal. At least 5 ceiling tiles located in this same area appeared with a beige looking stain, possibly indicating a wet appearance. At least 3 tiles were bowed in appearance. There were at least 2 plastic 5 gallon size buckets located under the front of the steam table, not coming into direct contact with the foods being served. There was additional buckets located near the entry to the dining room. Two of the 4 borders had peeling paint on the surface that edged the cathedral ceiling. There were 6 other ceiling tiles that are darker in appearances then the white tiles located next to them. They appear wet (beige looking stain) and bowed. Some of this area also had peeling plaster/paint hanging down. 2. On the cathedral ceiling located near the entrance of the dining room there are numerous ceiling tiles with a beige looking stain, possibly indicating long-term water damage. 3. A red painted wall in the dining room, to the right facing the kitchen/serving line, had stains on it that resembled old moisture drippings. 4. An interview on 9/08/2016 12:39 PM with the dietary manager revealed the issues of the ceiling had come up before. She added the facility management has made an effort to fix the roof which was suspected as the cause of the ceiling disrepair however their attempts have not worked. The facility has a flat roof that has been known to leak when it rains. 5. An observation and an interview with the administrator on 9/08/2016 1:01 PM revealed he was aware of the ceiling and they had someone coming out to look at it. There was no evidence that the facility had made additional effort to repair the roof which may or may not solve the environmental issues on the main dining room ceiling. 6. An interview on 9/8/2016 at approximately 5:05 PM with an alert and oriented resident in the main dining room revealed the roof leaks when it rains. The resident further stated the buckets are used to catch the rain water; the roof leaks. | 2020-09-01 |
| 146 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2017-10-11 | 155 | D | 1 | 1 | SACF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and review of the facility policy, the facility failed to observe resident's Advanced Directive rights for 1 of 12 residents reviewed for Advanced Directives. The facility did not ensure the correct code status for Resident #67. The findings included: The facility admitted Resident #67 with a [DIAGNOSES REDACTED]. On [DATE] at 11:10 AM, during record review, a signed and notarized Advanced Directive dated (MONTH) 1, (YEAR), prior to the Resident's admission on [DATE], revealed the Resident requested DNR status. The Physician's admission documentation for Resident #67 stated the Resident did not want CPR and was discussed with the Resident's daughter who is also the Responsible Party. On [DATE] 1:36 PM an interview with the Social Services Director revealed s/he agrees with documentation in the chart stating Resident #67 should be a DNR. S/he also discovered a signed DNR order in the file cabinet in Social Services office for the Resident that was not in the chart. On [DATE] 1:48 PM The Social Services Director stated, I will be changing the code status to DNR immediately for this resident. S/he also stated, I should have caught it; I used to work for DHEC. This surveyor witnessed the Social Services Director remove the FULL CODE page and replace it with the DNR page in Resident #67's chart. On [DATE] 2:05 PM Review of Facility Policy, DO NOT RESUSCITATE- POLICY, Policy Interpretation and Implementation #5 states: If the decision has been made for a natural death, the physician shall be notified and a DNR (DO NOT RESUSCITATE) order will be obtained as well as documented in the clinical records. | 2020-09-01 |
| 147 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2017-10-11 | 323 | G | 1 | 1 | SACF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interviews, and observations, the facility failed to provide the care and services necessary to prevent accidents for 1 of 3 residents reviewed for accidents. The facility failed to provide Mechanical Lift for all transfers to have assist of two people required for use of lift for Resident #16. The findings included: Record review revealed Resident #16 was admitted [DATE] with [DIAGNOSES REDACTED]. Non ambulatory and very frail with muscle loss. Observation revealed Resident #16 who has contractures to all the extremities, fingers, with foot drop on both feet. Call bell was observed by her right hand, and the call bell is a squeezable, round-shape that can be rung using her fingers. Resident requires total assistance for all ADL skills and requires a two staff transfer Resident#16's bedroom revealed low bed, bed alarm and floor mat in place. Resident #16 declined to be interviewed. A review of the nurse's notes revealed the following entries; 09/20/2017-- At 8:30pm, CNA called the nurse to Resident #16's room. Nurse observed Resident #16 had a right knee swollen and bruise with knee dislocated. Notified Doctor, DON, and family. 09/21/2017 - Resident #16 returned from the hospital at 12:30 am -- ER reported femur fracture -X-ray reported. Pain meds were given and leg splint in place. Continue to monitor. Review of the Physicians Orders revealed dated 09/20/2017 -Order (R) knee immobilizer Apply to (R) leg Check skin and circulation, shift R/T fracture. A review of the resident's Care Plans revealed the following; Resident #16 will have reduced risk of falls with injury thru the 90 days. Attend to lower extremities during daily care. Evaluate falls risk quarterly and prn. Attend to resident's needs promptly. Keep bed in lowest position. When care isn't being provided, ensure call bell is within reach. Mechanical Lift for all transfers. Assist of two people required for use of lift (05/02/2016). Place in supervised area when up as necessary. On 10/11/2017 at approximately 8:37 am, this surveyor interviewed the Director of Nursing (DON), who stated that Certified Nursing Assistant (CNA #1) was involved in the incident with Resident #16. The DON stated that the CNA's first written statement was not true because the CNA claimed that she and another CNA lifted Resident #16 from the geri chair to the bed, but when asked for the other CNA's name, CNA #1 recanted and stated that she was alone and did the pivoting of Resident #1 by herself/himself from the geri chair to the bed. On 10/11/2017 at approximately 10:30am, this surveyor interviewed the CNA #1 by telephone, who stated that she picked-up Resident #16 from her geri-chair to her bed. When changing the resident, the CNA removed the resident's pants and noticed a bump that had a shape of a light bulb. CNA #1 asked a CNA to get a nurse. Two nurses looked at the resident and decided to send Resident #16 to the hospital. CNA #1 stated that she did not know Resident #16 required a two person transfer. She did not see the policy on the two person transfer because it was hidden behind the closet door. CNA #1 further stated that Resident #16 was not CNAs' resident, and CNA #1 was just helping out. When asked about the first statement which said there was another CNA involved, CNA #1 stated that she was confused. | 2020-09-01 |
| 148 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2017-10-11 | 441 | D | 1 | 1 | SACF11 | > Based on observation and interview, the facility failed to follow manufacturer's instructions for disinfecting a multi-use glucometer during 1 of 1 observation of a Finger Stick Blood Sugar. The findings included: On 10/10/2017 at 4:18 PM Licensed Practical Nurse (LPN) #1 was observed performing a Finger Stick Blood Glucose on Resident # 1. The LPN washed her/his hands, placed the glucometer inside a glove and pinched an opening into the glove. After obtaining the specimen and completing the procedure the LPN removed the glucometer from glove, removed her/his gloves, sanitized her/his hands and signed the procedure off on the Medication Administration Record. LPN #1 cleaned the glucometer with an Alclavis Bleach-Wipe for approximately 10 seconds. During an interview at that time, the LPN stated s/he cleaned the glucometer for about 5 seconds. The LPN confirmed s/he was not aware manufacturer's instructions were to keep the device visibly wet for 5 minutes to be effective against Clostridium Difficile. In addition, the LPN stated s/he usually used the other (Microdot) bleach wipe and just wipes it down good and allows it to air dry and stated that was the policy. Review of the Microdot instructions at that time revealed the instructions indicated a 3 minute contact time for Clostridium Difficile. The nurse also stated that it was policy to clean the device after use, not before. During an interview at 4:37 PM, the Director of Nursing (DON) stated each cart had 2 glucometers, one to be used will the other is air drying. Three additional nurses were interviewed regarding the policy for cleaning the glucometer and all 3 stated the device needed to have a contact time of 3-5 minutes. Review of the policy revealed 2. Sanitize the glucometer with the appropriate product (i.e. (that is) Sani cloth, Glucometer Wioe, etc (et cetera) .) as long as the product contains bleach. 3. Allow the glucometer to completely air dry before storage or use. During an interview on 10/11/17 at 2:14 PM, the DON confirmed the instructions on both products and stated s/he would expect the nurse to read the directions. The DON also stated that s/he would expect the device to be kept wet for the longest amount of contact time specified in the directions. The DON further stated that 40 new glucometers had been ordered so each resident that needs it will have their own dedicated device and provided a copy of the purchase order dated 10/02/17. | 2020-09-01 |
| 149 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2018-11-30 | 573 | E | 0 | 1 | JLSM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy titled Resident Rights and interview, the facility failed to provide copies of medical records to 5 of 5 residents who had requested them. Four of 10 residents in the Group Meeting (Residents #7, #31, #73, and #77) and Resident #43 stated they had requested copies of their medical records and had not received them. The findings included: On 11/28/18 at approximately 10:36 AM, a Resident Council meeting was held with the surveyor, attended by 10 interviewable residents, all with Brief Interview for Mental Status scores ranging from 10-15. During the group interview, 4 of the 10 residents expressed that multiple requests had been made in attempts to obtain their medical records from the facility. Resident #s 7, 31, 73, and 77 all expressed they had made multiple requests to the Administrator and to their direct care staff. Review of the grievance log on 11/28/18 at approximately 3:00 PM revealed there were no references to requests made. During an interview with the Administrator and Social Services Director on 11/29/2018 at 9:45 AM, the Administrator indicated s/he was unaware of any requests and if there had been, they would have been taken care of. However, upon further interview, s/he indicated there was no documentation available proving or disproving the requests were made. Review of the facility's admission packet section labeled Resident Rights states: The resident has the right to access personal and medical records pertaining to him or herself. The facility admitted Resident #43 with [DIAGNOSES REDACTED]. Record review on 11/30/18 at 7:50 AM revealed that the resident was hospitalized from 8-31-18 to 9-6-18 Urinary Tract Infection, Hydro[DIAGNOSES REDACTED], [MEDICAL CONDITION], Dehydration, and Acute Kidney Injury. S/he was also hospitalized from 9-25-18 to 9-26-18 for [MEDICAL CONDITION] Calculus, Hydro[DIAGNOSES REDACTED], and Recurrent [MEDICATION NAME]. During an interview on 11/26/18 at 4:19 PM, Resident #43 stated s/he had requested to see her medical records related to the kidney problems s/he had experienced. S/he stated s/he had requested them from Licensed Practical Nurse (LPN) #2 four times. When asked what the nurse's response was, the resident stated, She (He) says she (he) can't find them. During an interview on 11/29/18 at 4:13 PM, LPN #2 stated s/he did not remember discussing a medical records request with the resident. When asked, the nurse initially stated that if the resident requested medical records, s/he would have told her/him that her/his daughter would need to go to the physician and request them. When the surveyor noted the resident's cognitive status, the nurse stated s/he would have obtained them for the resident. Following the interview, LPN #2 and the surveyor went to the resident's room. The resident confirmed that this nurse was the one from whom s/he had requested the records. The resident stated s/he had handed the records to LPN #2 in an envelope when s/he returned from her/his urology appointment. After visiting with Resident #43, LPN #2 stated, She (He) probably has me mixed up with (LPN #3). Record review on 11/30/18 at 8:25 AM revealed a 10/18/18 Nurses Note at 2:56 PM signed by LPN #2 which stated, Resident returned from Dr.---, urology. | 2020-09-01 |
| 150 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2018-11-30 | 578 | D | 0 | 1 | JLSM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility policy titled Resident Right to Formulate Advance Directives, the facility failed to ensure accuracy for 2 of 2 residents reviewed for advance directives. The findings included: Resident #51 was admitted to the facility on [DATE]. Review of his/her medical record on [DATE] showed that on [DATE] the Patient Self-Determination Act was signed by the Responsible Party (RP) indicating desires to have a living will or medical proxy. Additional review showed only an Emergency Medical Services Do Not Resuscitate Order signed on [DATE]. An interview with the Director of Nursing (DON) on [DATE] at 3:49 PM indicated there was no Physician's Order for a DNR nor was there any documentation indicating the Resident's inability to make health care decisions. Review of the facility's policy titled, Resident Right to Formulate Advance Directives, on [DATE] indicated the facility will periodically assess the resident for decision-making abilities and approach the health care proxy or legal representative if the resident is determined not to have decision making capabilities. The facility admitted Resident #135 on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission 5-day Minimum Data Set assessment revealed the resident had both short- and long-term memory problems with severely impaired decision-making ability. Record review on [DATE] at 8:53 AM revealed a full-page bright green form noting FULL CODE in the front of the medical record. Physician's Orders also noted the resident as a full code. Review of the Care Plan on [DATE] at 9:48 AM revealed Problem/Need #1: I desire advanced directives/DNR (Do Not Resuscitate) as of [DATE]. Approaches included to Honor my request for DNR status and Do not perform CPR (Cardiopulmonary Resuscitation) on me. During an interview on [DATE] at 11:38 AM, when asked individually how they would determine a resident's code status in case of an emergency, Licensed Practical Nurse (LPN) #1 and Registered Nurse (RN) #1 opened the medical record to the bright green page indicating the resident was a full code. Both nurses verified there was no documentation under the advance directives tab in the medical record. RN #1 reviewed the Care Plan and confirmed that it noted that a DNR advance directive was effective [DATE]. After further record review, the RN also confirmed there was no Physician's Order for DNR. During an interview on [DATE] at 11:58 AM, the Director of Nurses (DON) reviewed and verified the Care Plan and full code form. On [DATE] at 9:29 AM, the DON stated, They should not have added DNR to the Care Plan until the certification by 2 physicians of inability to make health care decisions had been completed. | 2020-09-01 |
| 151 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2018-11-30 | 580 | D | 0 | 1 | JLSM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure written notice of room/roommate change was provided to 2 of 2 residents reviewed for notification of change (Residents #51 and #11). The findings included; Review of the medical record on 11/29/2018 at 4:47 PM revealed that Resident #51 was moved from room [ROOM NUMBER]A to 151A on 11/26/2018. The Social Services Notes dated 11/26/2018 stated that the family was notified by telephone. Additionally, review of Resident #11's medical record on 11/28/2018 indicated s/he had a last documented roommate change on 7/13/2017 by Social Services. However, the resident received a new roommate on 11/26/2018 and indicated to this surveyor during an interview on 11/26/2018 that s/he had not been informed of the change. S/he stated the new roommate just showed up with his/her belongings and no one told me anything. Review of the Social Services Notes revealed no documentation related to the recent roommate change. During an interview on 11/28/18 at 12 PM, the Social Services Director stated that written notices were not sent out and notifications of room/roommate changes were made only by telephone calls. Review of the facility's policy titled, Resident Rights/ Room and/or Roommate Change states, The resident and/or family have the right to be informed in advance and in writing, to include the reason for the change, before the room or roommate in the facility is changed, unless it is an emergent situation for resident safety. | 2020-09-01 |
| 152 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2018-11-30 | 583 | E | 0 | 1 | JLSM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to protect the privacy of medical records for 3 of 3 sampled residents reviewed for Baseline Care Plans (Residents #51, #65, and #135). The findings included: The facility admitted Resident #135 on 11-8-18 with [DIAGNOSES REDACTED]. Dementia with Behavioral Disturbance, [MEDICAL CONDITIONS] Fibrillation, [MEDICAL CONDITION], Hypertension, [MEDICAL CONDITION], Reflux, [MEDICAL CONDITION] Left Lower Extremity, and Acute Kidney Injury. Review of the 11/8/18 Baseline Care Plan on 11/28/18 at 9:48 AM revealed documentation that the plan was verbally reviewed with the Resident Representative on 11/9/18. There was no evidence in the record that a summary or copy of the Baseline Care Plan was provided. During an interview on 11/28/18 at 4:31 PM, the Minimum Data Set (MDS) Coordinator stated that if the resident and family were not able to attend the Baseline Care Plan meeting and s/he was unable to reach them by phone, s/he documented and left a copy in the resident's room in an envelope. Resident #65 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #51 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Record review for Residents #65 and #51 revealed no evidence that the facility had provided summaries or copies of the Baseline Care Plans to the residents or their representatives. During an interview on 11/28/18 at 4:31 PM, the Minimum Data Set (MDS) Coordinator stated s/he did not mail out the summaries or copies. S/he stated s/he left them in the resident's room in an envelope and called the family to let them know s/he left it in the room if s/he could get hold of them. The facility's Baseline Care Plan and Form Policy states, The facility must provide the resident and their representative with a summary of the baseline care plan . | 2020-09-01 |
| 153 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2018-11-30 | 584 | E | 0 | 1 | JLSM11 | Based on observations and interviews, the facility failed to ensure corridor wall coverings and baseboards were in good repair primarily on 1 of 4 halls. The findings included: On all days of the survey,[NAME]Hall wall coverings were noted to be permanently stained with what appeared to be some type of liquid that had been sprayed, run down the walls, and dried. Baseboards were darkly scarred throughout and chipped in multiple places. Housekeeping contracted management was observed cleaning the walls on 11/27/18 and 11/28/18 in unsuccessful attempts to remove the wall stains. On 11/27/18 at 1:38 PM, the Assistant Director of Nurses verified that wall coverings were discolored and stated, It looks like it has been sprayed with something. On 11/27/18 at 5:30 PM, the Administrator and Housekeeping Contract Manager stated the walls had been cleaned but the stains would not come out. On 11/28/18 at 8:51 AM, the Housekeeping Contract Manager stated the walls must have been cleaned with an inappropriate chemical. | 2020-09-01 |
| 154 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2018-11-30 | 604 | D | 0 | 1 | JLSM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to ensure the resident is free from unnecessary physical restraint. The facility did not afford the resident the opportunity to be free from the restraint when in close view of the staff or when participating in activities in the presence of the activity coordinator, other staffs and residents. The facility also failed to appropriately implement attempts to discontinue the restraint for one of six sample residents reviewed for restraints. The findings included: The facility admitted Resident #66 on 6/9/17 with [DIAGNOSES REDACTED]. During the initial survey tour on 11/26/18 at 10:45 AM Resident #66 seat on his/her wheelchair in the dining/activity room, lap belt in place, attempting to take off arm skin protector, at which time a certified nursing assistant (C.N.A) took the resident back to his/her room. On 11/27/18 the resident was seated at the nurse's station again and half an hour later in the activity room, lap belt in place at both observations. Resident's room observation on 11/28/18 at 10:42 AM revealed bed in low position, side rails in place and large floor mats at both side of the bed. Nurse's notes reviewed on 11/27/18 at 1:13 PM revealed that the resident has a lap belt restraint that is released every two hours, during activity and meal times. However, this intervention did not occur during surveying hours. According to the care plan reviewed on 11/28/18 at approximately 11:00 AM on 11/13/18 the facility put a three day restraint reduction attempt in placed, Lap belt removed and resident situated in the common area for easy viewing. But the restraint reduction documentation showed that after releasing the lap belt if the resident tried to get up from his/her wheelchair the staff would place the lap belt back on. During an interview with the care plan coordinator and director of nursing (DON) on 11/28/18 at approximately 11:30 AM confirmed that the three days restraint reduction attempt not done correctly according to documentation. | 2020-09-01 |
| 155 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2018-11-30 | 607 | D | 0 | 1 | JLSM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement the policy related to Abuse for one incident of resident to resident abuse reviewed. The findings include; Res #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 11/26/2018 at approximately 2:43 PM during a resident interview with this surveyor, Resident #11 indicated that s/he had been kicked on last week by another resident and nothing was done about it. Further interview, the resident explained a male resident had approached him/her, kicked and walked away. After the incident, s/he told Registered Nurse (RN) #2 who then was believed to have told the Director of Nursing (DoN). Further interview with RN #2, s/he stated s/he had told the DoN but had not personally done anything to alleviate or investigate the incident. During record review on 11/28/18 at 9:15 AM, there was no documentation of the alleged incident noted. During an interview with RN#2 on 11/28/18 at 12:28 PM, s/he indicated that s/he had not visibly witnessed the incident, but the resident had made him/her aware and s/he told his/her direct supervisor, the DoN. On 11/28/2018 at 3:26 PM, during an interview with the DoN, s/he stated this was his/her first time hearing of the incident. Review of the facility's policy titled, Resident Rights- Abuse and Abuse Prevention, Neglect and Exploitation provided by the DoN on 11/28/18 at 3:30 PM states response and reporting of abuse, neglect and exploitation- anyone in the facility can report suspected abuse to the abuse agency hotline, when abuse, neglect or exploitation is suspected, the Licensed Nurse should: respond to the needs of the resident and protect them from further incident (Document), notify the Director of Nursing and Administrator (document), and initiate an investigation immediately . | 2020-09-01 |
| 156 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2018-11-30 | 609 | D | 0 | 1 | JLSM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to report an allegation of resident-resident abuse in a timely manner. The findings included; Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 11/26/2018 at approximately 2:43 PM during a resident interview with this surveyor, Resident #11 indicated that s/he had been kicked on last week by another resident and nothing was done about it. Further interview, the resident explained a male resident had approached him/her, kicked and walked away. After the incident, s/he told Registered Nurse (RN) #2 who then was believed to have told the Director of Nursing (DoN). During record review on 11/28/18 at 9:15 AM, there was no documentation of the alleged incident noted. During an interview with RN#2 on 11/28/18 at 12:28 PM, s/he indicated that s/he had not visibly witnessed the incident, but the resident had made him/her aware and s/he told his/her direct supervisor, the DoN. On 11/28/2018 at 3:26 PM, during an interview with the DoN, s/he stated this was his/her first time hearing of the incident. Review of the facility's policy titled, Resident Rights- Abuse and Abuse Prevention, Neglect and Exploitation provided by the DoN on 11/28/18 at 3:30 PM states response and reporting of abuse, neglect and exploitation- anyone in the facility can report suspected abuse to the abuse agency hotline, when abuse, neglect or exploitation is suspected, the Licensed Nurse should: respond to the needs of the resident and protect them from further incident (Document), notify the Director of Nursing and Administrator (document), and initiate an investigation immediately . | 2020-09-01 |
| 157 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2018-11-30 | 610 | D | 0 | 1 | JLSM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to report an allegation of resident-resident abuse in a timely manner. The findings included; Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 11/26/2018 at approximately 2:43 PM during a resident interview with this surveyor, Resident #11 indicated that s/he had been kicked on last week by another resident and nothing was done about it. Further interview, the resident explained a male resident had approached him/her, kicked and walked away. After the incident, s/he told Registered Nurse (RN) #2 who then was believed to have told the Director of Nursing (DoN). During record review on 11/28/18 at 9:15 AM, there was no documentation of the alleged incident noted. During an interview with RN#2 on 11/28/18 at 12:28 PM, s/he indicated that s/he had not visibly witnessed the incident, but the resident had made him/her aware and s/he told his/her direct supervisor, the DoN. On 11/28/2018 at 3:26 PM, during an interview with the DoN, s/he stated this was his/her first time hearing of the incident. S/he then verified there was no investigation started at the time or any information documented regarding the incident. Review of the facility's policy titled, Resident Rights- Abuse and Abuse Prevention, Neglect and Exploitation provided by the DoN on 11/28/18 at 3:30 PM states response and reporting of abuse, neglect and exploitation- anyone in the facility can report suspected abuse to the abuse agency hotline, when abuse, neglect or exploitation is suspected, the Licensed Nurse should: respond to the needs of the resident and protect them from further incident (Document), notify the Director of Nursing and Administrator (document), and initiate an investigation immediately .Additionally the policy states when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur, an investigation is immediately warranted. Once the resident is cared for and intial reporting has occurred, an investigation should be conducted. | 2020-09-01 |
| 158 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2018-11-30 | 623 | D | 0 | 1 | JLSM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview , the facility failed to provide written notice of facility-initiated transfer to the Residents' Representatives and/or Ombudsman for 2 of 5 sampled residents reviewed for hospitalization (Residents #67 and #70) . The findings included: The facility admitted Resident #67 with [DIAGNOSES REDACTED]. Record review on 11/28/18 at 2:31 PM revealed the resident was transferred to the hospital on 9-25-18 for Aspiration Pneumonia. Further review revealed no evidence of written notification of the transfer to the Resident Representative. During an interview on 11/30/18 at 12:12 PM, when asked about notification of the family, Social Services stated there should be documentation in the record that the family was called. S/he was unaware of the requirement for a written notice to be sent. The facility admitted Resident #70 with [DIAGNOSES REDACTED]. Record review on 11/27/18 at 12:53 PM revealed the resident was hospitalized from [DATE] to 10/26/18 for Agitation, Combativeness, and [DIAGNOSES REDACTED]. Further review revealed no evidence of written notification of the transfer to the Resident Representative or Ombudsman. During an interview on 11/30/18 at 12:18 PM, Social Services reviewed her/his documentation of monthly reports and stated s/he had not sent transfer notifications to the Ombudsman for the month of October. S/he was unaware of the requirement for a written notice of transfer to be sent to the Resident Representative. | 2020-09-01 |
| 159 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2018-11-30 | 625 | D | 0 | 1 | JLSM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide written notice of bed-hold to the Residents' Representatives upon facility-initiated transfer for 2 of 5 sampled residents reviewed for hospitalization (Residents #67 and #70). The findings included: The facility admitted Resident #67 with [DIAGNOSES REDACTED]. Record review on 11/28/18 at 2:31 PM revealed the resident was transferred to the hospital on 9-25-18 for Aspiration Pneumonia. Further review revealed no evidence of written notification of the facility's bed-hold policy supplied to the Resident Representative upon transfer. During an interview on 11/30/18 at 9:18 AM, the Director of Nurses (DON) reviewed the record, was unable to locate any information about bed-hold notification, and referred the surveyor to Social Services. During an interview on 11/30/18 at 12:12 PM, Social Services reviewed the record and was unable to locate any information about bed-hold notification. S/he was unsure who was responsible for bed-hold notification upon transfer. The facility admitted Resident #70 with [DIAGNOSES REDACTED]. Record review on 11/27/18 at 12:53 PM revealed the resident was hospitalized from [DATE] to 10/26/18 for Agitation, Combativeness, and [DIAGNOSES REDACTED]. Further review revealed no evidence of written notification of the facility's bed-hold policy supplied to the Resident Representative upon transfer. During an interview on 11/30/18 at 9:18 AM, the Director of Nurses (DON) reviewed the record, was unable to locate any information about bed-hold notification, and referred the surveyor to Social Services. During an interview on 11/30/18 at 12:18 PM, Social Services reviewed the record and was unable to locate any information about bed-hold notification. S/he was unsure who was responsible for bed-hold notification upon transfer. | 2020-09-01 |
| 160 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2018-11-30 | 641 | E | 0 | 1 | JLSM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to assure the accuracy of assessments for 7 of 23 sampled residents reviewed for accuracy of Minimum Data Set (MDS) assessments (Residents #23, #52, #57, #66, #67, #70, and #135) and for 2 of 2 residents noted on the MDS 3.0 Missing OBRA Assessment report (Residents #40 and #60). The findings included: The facility admitted Resident #23 with [DIAGNOSES REDACTED]. Review of the 8-29-18 Admission/5-Day and the 9/7/18 14-Day MDS assessments on 11/29/18 at 11:23 PM revealed the following: (1) Section B of both assessments noted that the resident was sometimes understood and sometimes understands. However, the Section C Brief Interview for Mental Status (BIMS) and the Section D Mood interviews were not conducted. The reasons recorded were that the resident was rarely/never understood. (2) The 9/7/18 14-Day assessment only had one fall coded. Review of Incident/Accident Reports on 11/30/18 at 9:34 AM revealed the resident had sustained 2 falls during the 7-day look-back period (on 9/1/18 and 9/5/18). During an interview on 11/30/18 at 10:19 AM, the MDS Coordinator stated that Sections C and D were completed by Social Services. S/he verified that the coding for not conducting the interview because the resident was rarely/never understood was not consistent with the coding in Section B. S/he reviewed the record, verified the falls noted in the Nurses Notes and on the Care Plan, and confirmed that the number of falls coded on the 14-Day MDS was incorrect. The facility admitted Resident #52 with [DIAGNOSES REDACTED]. Hypertension, [MEDICAL CONDITION], Dementia, Aspiration Pneumonia, Dysphagia, Gastro-[MEDICAL CONDITION] Reflux Disease, B-12 Deficiency, and Multiple [MEDICAL CONDITION]. Review of the 2-6-18 Significant Change and the 10-21-18 Quarterly MDS assessments on 11/27/18 at 7:48 PM revealed the following: (1) Section B of both assessments noted that the resident was usually understood and sometimes understands. However, the Section D Mood and Section F Preferences for Customary Routines and Activities interviews were not conducted. The reasons recorded were that the resident was rarely/never understood. (2) On the 2/6/28 MDS, J1400 was coded that the resident did not have a life expectancy of less than 6 months. Record review on 11/29/18 at 12:32 PM revealed physician's orders [REDACTED]. During an interview on 11/29/18 at 3:05 PM, the MDS Coordinator stated that Section D was completed by Social Services. S/he verified that the coding for not conducting the interview because the resident was rarely/never understood was not consistent with the coding in Section B. S/he reviewed the record and verified that J1400 should have been coded that the resident's life expectancy was less than 6 months. S/he stated that Section F, usually completed by the Activity Director, should have been completed with the resident's/family's input as the spouse came 3 times per week. The facility admitted Resident #57 with [DIAGNOSES REDACTED]. Review of the 10-21-18 Annual MDS assessment on 11/29/18 at 11:43 PM revealed the following: The Section F Preferences for Customary Routines and Activities interviews were not conducted. The reason recorded was that the resident was rarely/never understood. Section B noted the resident was usually understood and understands. During an interview on 11/30/18 at 11:46 AM, the MDS Coordinator confirmed that the Section F interviews had not been conducted and that the coding for not conducting the interview because the resident was rarely/never understood was not consistent with the coding in Section B. The facility admitted Resident #67 with [DIAGNOSES REDACTED]. Review of the 6-3-18 Quarterly and the 10-26-18 30-Day Quarterly MDS assessments on 11/26/18 at 1:59 PM revealed the following: (1) The 6-3-18 Quarterly MDS noted that the resident had both a weight loss and a weight gain. (2) The 10-26-18 30-Day Quarterly MDS noted that there was a weight loss but that the resident was on a physician prescribed weight loss program. During an interview on 11/30/18 at 11:51 AM, the MDS Coordinator confirmed that the resident had no significant weight gain during the period in review by the 6-3-18 MDS and that the resident had never been on a physician prescribed weight loss program. The facility admitted Resident #70 with [DIAGNOSES REDACTED]. Review of the 12-3-17 Annual and the 11-2-18 Significant Change MDS assessments on 11/27/18 at 6:22 PM revealed the following: (1) The pain interviews in Section J were not conducted for either assessment. (2) The 12-3-17 Annual MDS noted the resident's weight at 221 pounds and indicated s/he was on a physician prescribed weight gain program. (3) The 11-2-18 Significant Change MDS noted the resident's weight at 198 pounds and indicated s/he was on a physician prescribed weight loss program. During an interview on 11/29/18 at 03:13 PM, the MDS Coordinator verified that the pain interviews had not been conducted. S/he stated that the resident had not been on any physician-prescribed weight loss or gain programs. During an interview on 11/29/18 at 4:20 PM, the Dietary Manager stated s/he had hit the wrong button. The facility admitted Resident #135 on 11-8-18 with [DIAGNOSES REDACTED]. Dementia with Behavioral Disturbance, [MEDICAL CONDITIONS] Fibrillation, [MEDICAL CONDITION], Hypertension, [MEDICAL CONDITION], Reflux, [MEDICAL CONDITION] Left Lower Extremity, and Acute Kidney Injury. Review of the 11-15-18 Admission/5 day MDS on 11/28/18 at 9 AM revealed the following: (1) [DIAGNOSES REDACTED]. (2) Inattention, disorganized thinking, and physical behavior toward others were not coded for this resident. The resident was admitted with information from the hospital stating that s/he was exit-seeking and incapable of reality-based thinking. Review of Nurses Notes on 11/28/18 at 10:07 AM revealed the resident was combative when redirected, aimlessly ambulated in the hall, and remained seated for short times only. S/he struck another resident while s/he was asleep on 11-15-18. During an interview on 11/29/18 at 03:30 PM, the MDS Coordinator verified that the [DIAGNOSES REDACTED]. S/he also noted that the resident-to-resident abuse should have been coded because the incident occurred on the assessment reference date. Review of the MDS 3.0 Missing OBRA Assessment report with the MDS Coordinator on 11-29-18 revealed that (1) the facility had completed/transmitted an assessment for Resident #40 with the wrong gender, and (2) for Resident #60, the facility had entered the wrong birth date. The facility admitted Resident # 66 on 6/9/17 with [DIAGNOSES REDACTED]. Nurse's notes reviewed on 11/27/18 at 1:13 PM revealed that on 8/9/18 the facility placed a self-release lab belt restraint on the resident, related to many falls. On 8/14/18 the facility had the resident evaluated for hospice services. The resident started hospice care on 8/15/18. The Minimum Data Set (MDS) reviewed on 11/27/18 at 2:39 PM indicated that the MDS coordinator conducted a significant change assessment on 8/15/18. However, s/he did not note the restraint or hospice services. During an interview on 11/28/18 at 9:38 AM the DMS coordinator confirmed the above findings. | 2020-09-01 |
| 161 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2018-11-30 | 644 | D | 0 | 1 | JLSM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to complete a Preadmission Screening and Resident Review (PASRR) Level II for a resident with a positive PASRR level I and a history of psychiatric hospitalization at the time of admission to the facility for one of one sampled resident reviewed for PASRR. Findings: The facility admitted Resident #15 on 12/1/14 with [DIAGNOSES REDACTED]. During an observation on 11/26/18 at 3:34 PM the resident seems to get agitated very easy when greeted in the hallway s/he responded in a distrustful manner. The next day, during lunch in the dining room s/he did not want the certified nursing assistant (C.N.A) to help him/her with the food protector. Nurse's notes reviewed on 11/29/18 at 2:36 PM indicated that the resident could verbalize some need to staff. However, his speech is unclear and incoherent and often refuses care, gets combative and yells out loud. Record reviewed on 11/29/18 at approximately 3:00 PM revealed a PASRR level I completed on 11/18/14 (prior admission) indicated that the resident had a history of [REDACTED]. During an interview with the DON on 11/29/18 at 4:00 PM she stated that the resident had not had any incidents for the last three months. She also noted that the resident had not had a PASARR Level II because according to his/her interpretation of the regulation the resident did not need one. The DON later acknowledged that the resident should have had a level II PASRR and possibly psychiatric services. | 2020-09-01 |
| 162 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2018-11-30 | 655 | E | 0 | 1 | JLSM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation,record review and interview the facility failed to provide evidence of Baseline care plan development and provided summaries for 3 of 3 residents reviewed for baseline care plans. The findings included: Resident #65 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #51 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Record review for Residents #65 and #51 revealed the facility had not provided copies of the summary of the baseline care plans to the residents or their representatives. During an interview on 11/28/18 at 4:31 PM, the Minimum Data Set (MDS) Nurse indicated s/he does not mail out the summaries, s/he leaves it in the room in an envelope and calls the family to let them know s/he left it in the room if s/he can get a hold of them. A review of the facility's MDS Policy- Baseline Care Plan and Form Policy on 11/30/2018 at 12:47 PM states, the facility must provide the resident and their representative with a summary of the baseline care plan . The facility admitted Resident #135 on 11-8-18 with [DIAGNOSES REDACTED]. Dementia with Behavioral Disturbance, [MEDICAL CONDITIONS] Fibrillation, [MEDICAL CONDITION], Hypertension, [MEDICAL CONDITION], Reflux, [MEDICAL CONDITION] Left Lower Extremity, and Acute Kidney Injury. Review of the 11/8/18 Baseline Care Plan on 11/28/18 at 9:48 AM revealed documentation that the plan was verbally reviewed with the Resident Representative on 11/9/18. There was no evidence in the record that a summary or copy of the Baseline Care Plan was provided. During an interview on 11/28/18 at 4:31 PM, the Minimum Data Set (MDS) Coordinator stated that if the resident and family were not able to attend the Baseline Care Plan meeting and s/he was unable to reach them by phone, s/he documented and left a copy in the resident's room in an envelope. The Minimum Data Set (MDS) Coordinator stated s/he never mailed a summary or copy of the Baseline Care Plan to the Resident Representative. | 2020-09-01 |
| 163 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2018-11-30 | 656 | D | 0 | 1 | JLSM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to develop/implement the care plan interventions related to proper positioning during enteral feeding therapy for one of two sampled residents reviewed for tube feeding. Findings: The facility admitted Resident #33 on 3/11/18 with [DIAGNOSES REDACTED]. During the initial survey tour on 11/26/18 at 4:22 PM observed Resident #33 in a low bed with the head of it slightly raised and the resident slid down to the lower part of the bed while receiving enteral feeding. On 11/27/18 at 11:03 AM, 11/29/18 at 2:57 PM, and 11/29/18 at 4:05 PM observed the resident in a similar position. At no point during the survey, from 11/26 through 11/30, the surveyor saw any of the facility staff turning or repositioning the resident. The care plan reviewed on 11/29/18 at 3:40 PM indicated that the head of the resident's bed should be up 30-45 degrees during feeding therapy. The care plan also stated that the certified nursing assistant would turn and reposition the resident every 2 hours to prevent skin breakdown related to impaired bed mobility. The care plan did not address the resident actual or inappropriate positioning during feeding therapy. During an interview on 11/29/18 at 4:05 PM the unit manager confirmed that the resident slid down in his/her bed during feeding and stated that as an intervention to prevent complication the resident gets repositioned every 2 hours, however, s/he was not able to provide supporting evidence/documentation to indicate that the resident is being turned and repositioned every 2 hours. | 2020-09-01 |
| 164 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2018-11-30 | 657 | D | 0 | 1 | JLSM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to update the Care Plan for one of two sampled residents reviewed for abuse. The Care Plan for Resident #135 was not updated to include an incident of resident-to-resident abuse. The findings included: The facility admitted Resident #135 on 11-8-18 with [DIAGNOSES REDACTED]. Dementia with Behavioral Disturbance, [MEDICAL CONDITIONS] Fibrillation, [MEDICAL CONDITION], Hypertension, [MEDICAL CONDITION], Reflux, [MEDICAL CONDITION] Left Lower Extremity, and Acute Kidney Injury. Record review on 11/28/18 at 10:07 AM revealed an entry in Nurse's Notes at 12:57 PM on 11/15/18: Notified by (Licensed Practical Nurse #1) that resident was found by two CNAs (Certified Nursing Assistants) hitting another resident in his back while he was resting in his bed . Review of the 11/8/18 Baseline Care Plan and the 11/22/18 Interdisciplinary Care Plan on 11/28/18 at 9:48 AM revealed no mention of the behavior/incident. During an interview on 11/28/18 at 4:08 PM, the Director of Nurses verified that neither the Baseline nor Interdisciplinary Care Plan had been updated to include the resident-to-resident abuse incident on 11/15/18. | 2020-09-01 |
| 165 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2018-11-30 | 686 | D | 0 | 1 | JLSM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview , the facility failed to provide appropriate care and services to promote healing and prevent infection for one of two sampled residents observed for pressure ulcer treatments. The nurse failed to clean the scissors prior to cutting off the soiled dressing during observation of a pressure ulcer treatment for [REDACTED]. The findings included: During observation of a pressure ulcer treatment to the left heel on 11/27/18 at 2:08 PM, Registered Nurse (RN) #1 removed a scissors from her/his pocket. Without sanitizing it, s/he cut the undated soiled dressing from the unstageable malodorous wound (at least 3 inches in diameter eschar) on the heel. During an interview following the treatment, RN #1 verified s/he had taken the scissors from her/his pocket and used it to cut the dressing off without cleansing it. The RN stated s/he should have cleaned it with bleach wipes. | 2020-09-01 |
| 166 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2018-11-30 | 692 | D | 0 | 1 | JLSM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to complete a nutritional assessment and implement recommendations in a timely manner for Resident #67, one of 2 sampled residents reviewed for nutrition. The findings included: The facility admitted Resident #67 with [DIAGNOSES REDACTED]. Review of weights on 11/26/18 at 1:55 PM revealed the resident sustained [REDACTED].#) to 11/6/18 (148#), equivalent to 10.3%. Record review on 11/28/18 at 2:31 PM revealed a 10/11/18 physician's orders [REDACTED]. Review of Dietary Notes on 11/28/18 at 3:33 PM revealed that the Licensed Dietitian did not complete the assessment until 10/24/18, 13 days later. A recommendation to increase the resident's tube feeding of Fibersource HN from 58 milliliters (ml) per hour to 77 ml per hour over a 12 hour period to promote weight maintenance was not ordered or implemented until 10/26/18. During an interview on 11/29/18 at 2:54 PM, the Director of Nurses verified the above information. | 2020-09-01 |
| 167 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2018-11-30 | 693 | D | 0 | 1 | JLSM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to ensure that the resident maintained proper position during administration of enteral feeding for one of two sample residents reviewed for tube feeding. Findings: The facility admitted Resident #33 on 3/11/18 with [DIAGNOSES REDACTED]. During the initial survey tour on 11/26/18 at 4:22 PM observed Resident #33 in a low bed with the head of it slightly raised, and the resident slides down to the lower part of the bed while receiving enteral feeding. On 11/27/18 at 11:03 AM, 11/29/18 at 2:57 PM, and 11/29/18 at 4:05 PM observed the resident in a similar position. The care plan reviewed on 11/29/18 at 3:40 PM indicated that the head of the resident's bed should be up 30-45 degrees during feeding therapy. During an interview on 11/29/18 at 4:05 PM the unit manager confirmed that the resident slides down his/her bed during feeding. | 2020-09-01 |
| 168 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2018-11-30 | 755 | E | 0 | 1 | JLSM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure that medications were started in a timely manner for 1 of 5 sampled residents reviewed for unnecessary medication. [MEDICATION NAME] and [MEDICATION NAME] were not available for administration so as to be started in a timely manner for Resident #67. The findings included: The facility admitted Resident #67 with [DIAGNOSES REDACTED]. Record review on 11/28/18 at 2:31 PM revealed 11/1/18 physician's orders [REDACTED]. Review of the Medication Administration Records (MARs) on 11/28/18 revealed that the [MEDICATION NAME] was not started until 11/4/18 and was omitted on 11/7/18 due to awaiting med from pharmacy. Review of physician's orders [REDACTED].#67 had an order for [REDACTED]. Nurses Notes indicated that Registered Nurse (RN) #2 contacted the pharmacy representative who instructed her/him to access the Cubex system (emergency drug supply) for the medication. RN #2 documented that the medication was not available for administration. Review of the Medication Administration Records on 11/28/18 revealed that the [MEDICATION NAME] was not started until 9/29/18. During an interview on 11/29/18 at approximately 10 AM, RN #2 verified that the [MEDICATION NAME] was not available to be given as ordered. When asked about the availability of [MEDICATION NAME], the RN stated s/he remembered running low in Cubex. During an interview on 11/29/18 at 10:44 AM, the Director of Nurses stated the [MEDICATION NAME] was increased due to an exascerbation of the Bullous Disorder and verified the documentation in the Nurses Notes and MAR. During an interview on 11/29/18 at 10:09 AM, the RN Consultant provided a copy of the contents of the Cubex system which noted both [MEDICATION NAME] and [MEDICATION NAME] should have been available for administration. | 2020-09-01 |
| 169 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2018-11-30 | 757 | E | 0 | 1 | JLSM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to document the necessity for and effectiveness of PRN (as needed) medication administered for pain for 1 of 5 sampled residents reviewed for unnecessary medication. Resident #67 received [MEDICATION NAME] five times in 11/18 with no documented reason or results. The findings included: The facility admitted Resident #67 with [DIAGNOSES REDACTED]. Record review on 11/28/18 at 2:31 PM revealed a physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. There was no documentation found to show pain level or location at the time the medication was administered or monitoring to determine effectiveness after administration. During an interview on 11/29/18 at 10:44 AM, the Director of Nurses (DON) reviewed the record and verified the lack of documentation for [MEDICATION NAME] administration. The DON stated s/he would expect the documentation to be on the MAR. | 2020-09-01 |
| 170 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2018-11-30 | 880 | D | 0 | 1 | JLSM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews, the facility failed to ensure that appropriate handwashing procedures were implemented following completion of one of two pressure ulcer treatments observed (Resident #67). The findings included: The facility admitted Resident #67 with [DIAGNOSES REDACTED]. Following a pressure ulcer treatment for [REDACTED].#2 sanitized her/his hands and exited the resident's room. S/he entered the shower room, opened the bin with her/his hand, and disposed of the bag of trash from the treatment. The nurse then left the room without washing/sanitizing her/his hands and headed toward the nursing station. When asked about washing her/his hands after touching the trash bin lid, RN #2 stated s/he would go to the nurse's desk to sanitize her/his hands or to the bathroom located near there. No sanitizer was observed at the nurses station. When washing hands in the bathroom was discussed, the nurse admitted s/he would contaminate the key and doorknob prior to being able to wash hands in that location. The Assistant Director of Nurses (ADON) observed the procedure and stated that RN #2 should have washed her/his hands in shower. The DON stated the nurse should have washed hands in the shower where a sink was readily available. | 2020-09-01 |
| 171 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2018-11-30 | 924 | D | 0 | 1 | JLSM11 | Based on observation and interview, the facility failed to ensure that handrails were installed as required on one of 4 halls. The findings included: Observations on all days of the survey revealed 3 sections of handrails missing on[NAME]Hall. Two sections were missing, one on either side of the Conference room, and one section was missing between the patio exit (across from the Conference Room) and the fire doors. During an interview on 11/28/18 at 8:16 AM, the Maintenance Supervisor and Administrator were measuring the walls and verified that (2) 4' and (1) 8' sections of handrails had not been installed. | 2020-09-01 |
| 172 | LINLEY PARK REHABILITATION AND HEALTHCARE CENTER, | 425016 | 208 JAMES STREET | ANDERSON | SC | 29625 | 2018-06-27 | 812 | F | 0 | 1 | Z84K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of facility policy and procedure the facility failed to ensure 1)Foods stored in refrigerator were stored appropriately to prevent cross- contamination in 1 of 1 kitchen and 2)Expired bottled juice which was stored in the Nourishment Refrigerator was discarded on or before the expiration date in 1 of 2 Nourishment Refrigerators. The findings included: During an observation made while in the Walk-In Refrigeration Unit on [DATE] at 4:45 PM, an aluminum sheet pan located on the bottom shelf of a shelving rack contained 2, 10 pound rolls of frozen ground beef and 5 bags of frozen assorted chicken pieces. One of the 10 pound rolls of ground beef was on one side of the pan and the other 10 pound roll was on the other side of the same pan, the 5 bags of assorted chicken pieces were sandwiched between the two rolls of ground beef. This observation was verified by the Kitchen Manager and the Certified Dietary Manager (CDM). When the CDM was asked should the ground beef and chicken be stored on the same tray together, he/she said, No and then told the Kitchen Manager to get a pan and move the bags of chicken pieces to a separate pan. The Kitchen Manager had already begun to move the bags of chicken pieces to a separate pan and relocated the pan which now contained the bags of chicken pieces on the same shelf and beside the ground beef which was now on the same pan which previously had shared space with the bags of thawing chicken. On [DATE] at 9:30 AM, the Kitchen Manager provided a copy of the Inservice titled, Cross Contamination, which was Given By: CDM and the Kitchen Manager, to the dietary staff, 10 team members signed the inservice on [DATE] after the discovery of thawing ground beef and chicken on the same pan in the Walk- In Cooler. The form titled, Cross Contamination, states, .Raw meat, poultry and seafood should be stored in containers or sealed plastic bags to prevent their juices from dipping onto other foods. Liquids from raw meat, poultry, and seafood can contain harmful bacteria. Always store raw meat, poultry and seafood on the bottom shelf of the refrigerator to prevent the liquids from contaminating other items. On [DATE] at 9:30 AM, the Kitchen Manager provided a copy of Policy 019, Food Storage: Cold Foods, which states:, Policy Statement, All Time/Temperature Control for Safety (TCS) foods, frozen and refrigerate, will be appropriately stored in accordance with guidelines of the FDA (Federal Food and Drug Administration) Food Code Procedures .5. All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross-contamination. On [DATE] at approximately 9:30 AM, the Kitchen Manager said the chicken and ground beef were placed on the pan together in the walk-in refrigerator by the cook on [DATE] prior to leaving for the day. The Kitchen Manager said that he/she could not locate in the policies and procedures that raw chicken pieces and raw ground beef could not share the same space/tray for thawing. Review of the Food Code, U. S. Public Health Service, FDA, U. S. Food & Drug Administration (YEAR), US. Department of Health and Human Services, page 421, Section titled, Preventing Food and Ingredient Contamination, ,[DATE].11, Packaged and Unpackaged Food-Separation, Packaging, and Segregation, states: .With regard to the storage of different types of raw animal foods as specified under subparagraph ,[DATE].11 (A) (2), it it the intent of this Code to require separation based on anticipated microbial load and raw animal food type (species). Separating different types of raw animal foods from one another during storage, preparation, holding and display is based on as succession of cooking temperatures as specified under ,[DATE].11. During an observation on [DATE] at 05:58 PM of the Nourishment Refrigerator located on the A Unit, there was a bottle of juice with initials and room number written on the top and side of the bottle for Resident #39. The bottle of juice had an expiration date, stamped on the label, [DATE]. This observation was verified by the Housekeeping Supervisor and the Unit Manager/LPN #1. LPN #1 said that he/she had just checked the refrigerator this morning and this bottle of juice was not in the refrigerator. He/She said that he/she checks the refrigerator daily for expired products. LPN#1 stated that the family member most likely brought in today and wrote the resident's initials and room number on the bottle. The bottle of juice was then discarded. The Administrator immediately began placing signage on the refrigerators to inform the family/residents of the policy/procedure to notify a member of nursing or activities of foods they are bringing in for the residents. The Administrator provided a copy of form titled, Policy 031, Food: Safe Handling for Foods from Visitors, Policy Statement which states: Residents will be assisted in properly storing and safely consuming food brought into the facility for residents and visitors. Procedures, 1. The facility staff will request that visitors bringing in food, and/or residents that receive food, must notify a member of the nursing or activities departments. 2. The responsible facility staff will determine whether the food item is for immediate consumption or to be stored for later use .4. When food items are intended for later consumption, the responsible facility staff member will: Label foods with the resident name and current date 5. Refrigerators/freezers for storage of foods brought in by visitors will be properly maintained and: .Daily monitoring for refrigerated storage duration and discard of any food items that have been stored for greater than or equal to 7 days. | 2020-09-01 |
| 173 | LINLEY PARK REHABILITATION AND HEALTHCARE CENTER, | 425016 | 208 JAMES STREET | ANDERSON | SC | 29625 | 2019-08-01 | 578 | D | 0 | 1 | 5ZED11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to give 2 of 2 residents reviewed an opportunity to formulate an advance directive. Residents #11 and #14 were judged as mentally capable by physicians, yet were not involved in their own advance directive. The findings included: Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent brief interview for mental status (BIMS) yielded a score of 13. Review of Resident #11's chart on 7/29/19 at approximately 2:50 PM revealed two physicians had judged Resident #11 to be mentally capable, but Resident #11 did not sign his/her advance directive. During an interview with the Director of Nursing (DON) on 7/30/19 at approximately 2:58 PM s/he confirmed that Resident #11 is capable of formulating an advance directive but did not sign off on it. The DON stated when the physicians declared him/her capable, they should have reapproached the resident regarding his/her advance directive. The facility admitted Resident #14 with [DIAGNOSES REDACTED]. Record review of Resident #14's Resident/Family Consent for Cardiopulmonary Resuscitation form on 7/29/19 at 3:54 PM, revealed do not resuscitate (DNR) status had been selected for the resident on 1/31/19. The form was signed by the resident's representative. Record review of Resident #14's Physicians Determination of Capacity form, dated 2/17/19, on 7/29/19 at 3:55 PM, revealed Resident #14 had decisional capacity to make his/her own healthcare decisions. Record review of Resident #14's Telephone Orders on 7/29/19 at 3:55 PM, revealed a DNR order for the resident, dated 2/17/19. There was no documentation indicating it was Resident #14's choice to be DNR status. During an interview with Registered Nurse (RN) #3 on 7/30/19 at 2:24 PM, RN #3 stated Resident #14 was unable to sign the DNR consent form on admission and the family signed it for him/her. RN #3 confirmed the physician determined the resident had the capacity to make healthcare decisions on 2/17/19 and a DNR order was written. RN #3 stated at that time, Resident #14 should have been given the opportunity to select resuscitation status and sign the Resident/Family Consent for Cardiopulmonary Resuscitation. RN #3 stated this was not done. RN #3 stated s/he had spoken with Resident #14 today and s/he selected DNR status and signed the Resident/Family Consent for Cardiopulmonary Resuscitation. | 2020-09-01 |
| 174 | LINLEY PARK REHABILITATION AND HEALTHCARE CENTER, | 425016 | 208 JAMES STREET | ANDERSON | SC | 29625 | 2019-08-01 | 641 | D | 0 | 1 | 5ZED11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to accurately complete the Minimum Data Set (MDS) assessment for 1 of 4 sampled resident reviewed for nutrition (Resident #49). The findings included: The facility admitted Resident #49 on 01/16/15 with [DIAGNOSES REDACTED]. Review of Resident #49's 07-03-19 5-day Minimum Data Set (MDS) assessment revealed under section K under K0300 Weight Loss the code entered is 1. Yes, on a physician-prescribed weight-loss regimen. Review of Resident #49's orders on 07/30/19 at approximately 11:15 AM revealed the resident did not have orders for weight loss. During an interview on 08/01/19 at 09:58 AM, the Certified Dietary Manger stated that the MDS had been coded wrong. S/he would reopen it (MDS) and change the information. | 2020-09-01 |
| 175 | LINLEY PARK REHABILITATION AND HEALTHCARE CENTER, | 425016 | 208 JAMES STREET | ANDERSON | SC | 29625 | 2019-08-01 | 755 | D | 1 | 1 | 5ZED11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to obtain and provide routine medications for Resident #174, 1 of 7 sampled residents reviewed for Abuse/Neglect. Routine medications were not provided in a timely manner after admission to the facility. The findings included: The facility admitted Resident #174 on 5/3/19 with [DIAGNOSES REDACTED]. Record review of Resident #174's Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. In addition, the MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Review of Resident #174's Nurse's Notes on 8/1/19 at 9:16 AM, revealed the [MEDICATION NAME] and [MEDICATION NAME] were not given as ordered due to the medications had not been received from the pharmacy. During an interview with the Director of Nursing (DON) on 8/1/19 at 9:16 AM, the DON Confirmed Resident #174 did not receive the [MEDICATION NAME] and [MEDICATION NAME] as ordered. The DON stated the pharmacy delivered all other medications for the resident, but wasn't sure why these medications were not delivered. The DON stated the facility does have a back up pharmacy, but use of the back up pharmacy has to be initiated by the primary pharmacy when there are issues with delivery of medications. The DON was not sure why the back up pharmacy wasn't used and was waiting to hear from the primary pharmacy to find out what happened. The DON provided documentation revealing the facility followed their protocol for medication requisition when Resident #174 was admitted on [DATE]. During an interview with Registered Nurse (RN) #3 on 8/1/19 at 12:12 PM, RN #3 was on the phone with the pharmacy. When s/he got off the phone, RN #3 stated the pharmacy said the [MEDICATION NAME] order was cancelled by the pharmacy for unknown reasons. The [MEDICATION NAME] order was not delivered due to a possible drug interaction. The [MEDICATION NAME] was not delivered because the pharmacy stated they did not receive a prescription for it. RN #3 stated the pharmacy told her/him someone from the pharmacy should have contacted the facility about the discrepancies, but did not. During an interview with the DON on 8/1/19 at 12:41 PM, the DON provided documentation indicating the nurse had called the pharmacy on 5/4/19 to report all of the resident's medications had not been delivered. Review of Resident #174 pain assessments revealed the resident's pain was well controlled. The resident had as needed pain medication available, but did not use any. Review of Nurse's Notes, Nursing assessments and Physical Therapy assessments from 5/3 and 5/4/19 revealed the resident was stable and in no distress. Resident #174 left the facility against medical advice the morning of 5/5/19. The Medical Director was not present on 8/1/19, but provided a written statement regarding the missed doses of [MEDICATION NAME] and [MEDICATION NAME]. In the statement the Medical Director wrote These single missed doses could do no harm to the patient. | 2020-09-01 |
| 176 | LINLEY PARK REHABILITATION AND HEALTHCARE CENTER, | 425016 | 208 JAMES STREET | ANDERSON | SC | 29625 | 2017-10-11 | 159 | F | 1 | 0 | TBH011 | > Based on review of facility files and interview, the facility failed to act as a fiduciary of the resident's funds and hold, safeguard, manage, and account for the personal funds of the resident deposited with the facility. The facility's Business Office Manager removed $600.00 from the resident petty cash fund. An audit completed after the incident revealed the receipt book had signatures with questionable validity totaling $1899.00. One of one staff reviewed for mishandling resident funds. The findings included: The facility reported an allegation of misappropriation of resident property to the State Agency on 8/11/17 and identified three residents affected. Review of the facility's Five-Day Follow-Up Report dated 8/16/17 indicated at the completion of the investigation the $600.00 was removed and replaced by the Business Office Manager. Results of the investigation also revealed 11 additional residents had signatures with questionable validity totaling $1899.00. Review of facility files revealed on 8/11/17 at 4:40 PM, the assistant Business Office Manager (BOM) reported to the administrator that there were questionable receipts in the resident trust petty cash book. The administrator interviewed the Business Office Manager at 5:05 PM and s/he admitted after questioning to taking $600.00. The Business Office Manager left the facility to go to the bank and returned with money to replace what s/he had taken. In an interview with the surveyor on 9/18/17 at approximately 4:00 PM, the facility administrator stated the assistant BOM came to him/her on 8/11/17 and said that were receipts in the resident trust petty cash book that didn't add up. They had the assistant BOM's name and social services staff's name as the two signatures. The assistant BOM stated s/he didn't sign those receipts. The assistant BOM was trying to balance the cash box and it didn't balance. The cash box should be balanced every Friday. The assistant BOM did not balance the cash box the previous Friday because s/he didn't have a chance because of admissions, so she was reviewing 2 weeks on 8/11/17. When the spreadsheet and the cash box did not balance s/he went to the receipt book and started balancing from those. That is when s/he saw the receipts with his/her name that were not his/her signature. The administrator stated there is $250.00 in petty cash, when a resident comes and gets money then the BOM writes a check to the administrator Heritage -petty cash. The administrator goes to the bank, cashes the check and the money is replenished back in to the petty cash box. The administrator went to the social services staff and asked if it was his/her signature on the petty cash receipt and s/he said no. The administrator called the Business Office Manager and asked him/her to come in, s/he had already left for the day. The BOM came in around 5:05 PM and the administrator told him/her there were some questionable receipts. The BOM said I will be honest with you, I took the money. The BOM said s/he would do whatever to make it right, s/he had the money in his/her account. The BOM left and went to the bank and brought $600 cash back to the facility around 5:30 PM. The administrator stated the regional business office coordinator came in that evening around 7:00 PM and started auditing. The regional business office coordinator had found some receipts signed by the assistant BOM while s/he was out on medical leave. S/he audited the resident trust account and found some signatures that did not match. There were also receipts that had the social services staff's name that s/he had not signed for. The administrator called the BOM on 8/15/17 and told him/her that some signatures were in question. The BOM stated s/he had signed the assistant BOM's and social services staff's name and s/he assumed the assistant BOM knew. The BOM stated social services staff didn't know s/he was signing their name. The administrator asked the BOM on 8/11/17 if s/he had taken any other money and s/he stated no, it was the first time. In an interview with the surveyor on 9/18/17 at approximately 4:50 PM, social services staff stated the administrator told him/her s/he needed to look at the receipt book to see if they were his/her signatures. The ones s/he saw were not his/her signatures. The social services staff stated s/he use to work in the business office in 2012 and s/he would have signed the petty cash receipts then. S/he has not signed any receipts for money in a long time. S/he sated s/he does not have anything to do with the facility shopping trips. The Assistant Business Office Manager's facility-obtained statement indicated on 8/11/17, s/he was beginning to count the cash box for the Resident Fund Management System and fill out the weekly form to make sure the box was balanced. As s/he was filling out the form while using the petty cash disbursement log spreadsheet, s/he noticed that the box was not balancing. The Assistant Business Office Manager went to get the withdrawal receipt book to ensure all the withdrawals that had happened for the week were accounted for on the spreadsheet. Upon looking in the receipt book, s/he noticed several withdrawals that s/he was not aware of and that had his/her name signed to them but it was not his/her signature. After finding this, s/he took the receipt book to the administrator and showed him/her the withdrawals that s/he had not witnessed with his/her name signed to them. In an interview with the surveyor on 9/18/17 at approximately 5:15 PM, the assistant BOM, stated s/he was doing the cash box count and realized that the totals were off. The assistant BOM went and got the receipt book and saw that there were several receipts where money had been withdrawn that s/he didn't know about. The assistant BOM saw his/her name and it was not his/her signature. Some of the residents never take out money or not that much at a time. The assistant BOM took the information to the administrator. The assistant BOM states s/he normally is the person who does the cash box count. In an interview with the surveyor on 9/18/17 at approximately 5:35 PM, the regional business office coordinator stated s/he was told there was an issue with the resident trust and they would need to investigate that and do an audit. The regional business office coordinator stated they identified some other signatures that they thought might be questionable. Some were activity trips and the activity staff remembered them receiving money, they still reimbursed the money. The policy requires that if a resident has an illegible signature then they have 3 staff signatures, two who witness the one give the money. If it is a legible signature then they have to have one witness the one person give the money. In an interview with the surveyor on 9/19/17 at approximately 12:15 PM, the regional business office coordinator stated if a resident comes and says they need money, the assistant BOM will complete a withdrawal ticket in the receipt book. S/he will have the resident sign and have witnesses sign. The ticket is taken out of the book and handed to the BOM. There is a copy that stays in the receipt book. The receipt book is a 3 copy so the resident will also have a copy. The BOM enters the ticket into the Resident Funds Management System (RFMS) as a withdrawal. Through that process it is charged to the resident's account. The cash box is the vendor, that generates a check (administrator - petty cash) that is taken to the bank and the money is replenished in the petty cash box. The person who disburses the cash is separate from the person who enters the transaction into the RFMS system and the disbursement log. That is so there will be a checks and balance system. The BOM was the one doing the transaction and the assistant BOM was the one entering in RFMS and doing the disbursement log. It doesn't necessarily have to be a certain person, but two different people must complete the transaction and enter the withdrawal in RFMS. A different person must take the check to the bank to cash. The Business Office Manager's facility-obtained statement dated 8/11/17 indicated s/he took $600.00 of resident money and replaced it with cash. Documentation of a telephone interview of the Business Office Manager by the administrator dated 8/15/17 indicated the Business Office Manager stated s/he had signed other employees' signatures and stated that s/he assumed they knew. The administrator informed the Business Office Manager that the facility's investigation and audit had revealed questionable signatures on petty cash receipts. Review of the facility's policy for Petty Cash Withdrawals revealed a receipt book marked for withdrawals should be used to obtain patient authorization for the disbursement. The form should be completed in its entirety. The resident should authorize the disbursement via signature. If the resident is unable to sign or has an illegible signature, two witnesses must be obtained. The custodian of cash may not be one of the witnessing signatures. | 2020-09-01 |
| 177 | LINLEY PARK REHABILITATION AND HEALTHCARE CENTER, | 425016 | 208 JAMES STREET | ANDERSON | SC | 29625 | 2017-10-11 | 224 | F | 1 | 0 | TBH011 | > Based on review of facility files and interview, the facility failed to ensure each resident remained free from misappropriation of resident property. The facility's Business Office Manager removed $600.00 from the resident petty cash fund. An audit completed after the incident revealed the receipt book had signatures with questionable validity totaling $1899.00. One of one staff reviewed for misappropriating resident funds. The findings included: The facility reported an allegation of misappropriation of resident property to the State Agency on 8/11/17 and identified three residents affected. Review of the facility's Five-Day Follow-Up Report dated 8/16/17 indicated at the completion of the investigation the $600.00 was removed and replaced by the Business Office Manager. Results of the investigation also revealed 11 additional residents had signatures with questionable validity totaling $1899.00. Review of facility files revealed on 8/11/17 at 4:40 PM, the assistant Business Office Manager (BOM) reported to the administrator that there were questionable receipts in the resident trust petty cash book. The administrator interviewed the Business Office Manager at 5:05 PM and s/he admitted after questioning to taking $600.00. The Business Office Manager left the facility to go to the bank and returned with money to replace what s/he had taken. In an interview with the surveyor on 9/18/17 at approximately 4:00 PM, the facility administrator stated the assistant BOM came to him/her on 8/11/17 and said that there were receipts in the resident trust petty cash book that didn't add up. They had the assistant BOM's name and social services staff's name as the two signatures. The assistant BOM stated s/he didn't sign those receipts. The assistant BOM was trying to balance the cash box and it didn't balance. The cash box should be balanced every Friday. The assistant BOM did not balance the cash box the previous Friday because s/he didn't have a chance because of admissions, so she was reviewing 2 weeks on 8/11/17. When the spreadsheet and the cash box did not balance s/he went to the receipt book and started balancing from those. That is when s/he saw the receipts with his/her name that were not his/her signature. The administrator stated there is $250.00 in petty cash, when a resident comes and gets money then the BOM writes a check to the administrator Heritage -petty cash. The administrator goes to the bank, cashes the check and the money is replenished back in to the petty cash box. The administrator went to the social services staff and asked if it was his/her signature on the petty cash receipt and s/he said no. The administrator called the Business Office Manager and asked him/her to come in, s/he had already left for the day. The BOM came in around 5:05 PM and the administrator told him/her there were some questionable receipts. The BOM said I will be honest with you, I took the money. The BOM said s/he would do whatever to make it right, s/he had the money in his/her account. The BOM left and went to the bank and brought $600 cash back to the facility around 5:30 PM. The administrator stated the regional business office coordinator came in that evening around 7:00 PM and started auditing. The regional business office coordinator had found some receipts signed by the assistant BOM while s/he was out on medical leave. S/he audited the resident trust account and found some signatures that did not match. There were also receipts that had the social services staff's name that s/he had not signed for. The administrator called the BOM on 8/15/17 and told him/her that some signatures were in question. The BOM stated s/he had signed the assistant BOM's and social services staff's name and s/he assumed the assistant BOM knew. The BOM stated social services staff didn't know s/he was signing their name. The administrator asked the BOM on 8/11/17 if s/he had taken any other money and s/he sated no, it was the first time. In an interview with the surveyor on 9/18/17 at approximately 4:50 PM, social services staff stated the administrator told him/her s/he needed to look at the receipt book to see if they were his/her signatures. The ones s/he saw were not his/her signatures. The social services staff stated s/he use to work in the business office in 2012 and s/he would have signed the petty cash receipts then. S/he has not signed any receipts for money in a long time. S/he stated s/he does not have anything to do with the facility shopping trips. The Assistant Business Office Manager's facility-obtained statement indicated on 8/11/17, s/he was beginning to count the cash box for the Resident Fund Management System and fill out the weekly form to make sure the box was balanced. As s/he was filling out the form while using the petty cash disbursement log spreadsheet, s/he noticed that the box was not balancing. The Assistant Business Office Manager went to get the withdrawal receipt book to ensure all the withdrawals that had happened for the week were accounted for on the spreadsheet. Upon looking in the receipt book, s/he noticed several withdrawals that s/he was not aware of and that had his/her name signed to them but it was not his/her signature. After finding this, s/he took the receipt book to the administrator and showed him/her the withdrawals that s/he had not witnessed with his/her name signed to them. In an interview with the surveyor on 9/18/17 at approximately 5:15 PM, the assistant BOM, stated s/he was doing the cash box count and realized that the totals were off. The assistant BOM went and got the receipt book and saw that there were several receipts where money had been withdrawn that s/he didn't know about. The assistant BOM saw his/her name and it was not his/her signature. Some of the residents never take out money or not that much at a time. The assistant BOM took the information to the administrator. The assistant BOM states s/he normally is the person who does the cash box count. In an interview with the surveyor on 9/18/17 at approximately 5:35 PM, the regional business office coordinator stated s/he was told there was an issue with the resident trust and they would need to investigate that and do an audit. The regional business office coordinator stated they identified some other signatures that they thought might be questionable. Some were activity trips and the activity staff remembered them receiving money, they still reimbursed the money. The policy requires that if a resident has an illegible signature then they have 3 staff signatures, two who witness the one give the money. If it is a legible signature then they have to have one witness the one person give the money. In an interview with the surveyor on 9/19/17 at approximately 12:15 PM, the regional business office coordinator stated if a resident comes and says they need money, the assistant BOM will complete a withdrawal ticket in the receipt book. S/he will have the resident sign and have witnesses sign. The ticket is taken out of the book and handed to the BOM. There is a copy that stays in the receipt book. The receipt book is a 3 copy so the resident will also have a copy. The BOM enters the ticket into the Resident Funds Management System (RFMS) as a withdrawal. Through that process it is charged to the resident's account. The cash box is the vendor, that generates a check (administrator - petty cash) that is taken to the bank and the money is replenished in the petty cash box. The person who disburses the cash is separate from the person who enters the transaction into the RFMS system and the disbursement log. That is so there will be a checks and balance system. The BOM was the one doing the transaction and the assistant BOM was the one entering in RFMS and doing the disbursement log. It doesn't necessarily have to be a certain person, but two different people must complete the transaction and enter the withdrawal in RFMS. A different person must take the check to the bank to cash. The Business Office Manager's facility-obtained statement dated 8/11/17 indicated s/he took $600.00 of resident money and replaced it with cash. Documentation of a telephone interview of the Business Office Manager by the administrator dated 8/15/17 indicated the Business Office Manager stated s/he had signed other employees' signatures and stated that s/he assumed they knew. The administrator informed the Business Office Manager that the facility's investigation and audit had revealed questionable signatures on petty cash receipts. Review of the facility's policy for Petty Cash Withdrawals revealed a receipt book marked for withdrawals should be used to obtain patient authorization for the disbursement. The form should be completed in its entirety. The resident should authorize the disbursement via signature. If the resident is unable to sign or has an illegible signature, two witnesses must be obtained. The custodian of cash may not be one of the witnessing signatures. | 2020-09-01 |
| 178 | WHITE OAK MANOR - LANCASTER | 425017 | 253 CRAIG MANOR ROAD | LANCASTER | SC | 29720 | 2020-01-16 | 607 | D | 1 | 1 | FL9111 | > Based on record review, interview, and review of the facility's policy Protocol for Reporting Abuse the facility failed to follow policy to report an allegation of abuse within the required timeframe for Resident #98, 1 of 7 reviewed for abuse. CNA #3 allegedly witnessed CNA #2 physically abuse Resident #98 on 1/30/19. The allegation was not reported to the State Agency until 2/6/19. The findings included: The facility reported an allegation of physical abuse for Resident #98 by CNA #2 to the State Agency. On 1/14/20 at 12:13 PM, review of the Initial 2/24-Hour revealed it was faxed to the State Agency on 2/6/19 at 09:34 AM. The Initial 2/24-Hour Report indicated Resident #98 was physically abused by CNA #2 and indicated the date/time of incident as 2/6/19 at 07:40. The report indicated there was an allegation that while two CNAs were providing care to resident, resident became combative and hit a CNA. There is an allegation that CNA may have physically retaliated. Further review revealed a Five-Day Report dated 2/8/19 that indicated the incident occurred on 1/30/19 at 08:50 PM at which time an incident report was done. The summary indicated physical abuse not substantiated by facility. CNA #3 reported that CNA #2 struck Resident #98 on the arm after the resident struck him/her and was forceful when turning the resident. At 12:33 PM on 1/14/20, review of the Occurrence Report also indicated the incident occurred on 1/30/19 and indicated the resident had 2 skin tears measuring 2.5x1.0 and 4.0x3.5 cm and was completed by LPN #2. On 1/30/19, CNA #3's statement on the Occurrence Report stated s/he was changing Resident #98 and observed a skin tear abrasion on (his/her) left arm. (S/he) was combative during care and hitting and grabbing at us. There was no statement obtained from CNA #2. Review of the Occurrence Report also indicated a 24 hour follow-up was done by Unit Manager RN #1 on 1/31/19 and was also signed by the Director of Nursing on 2/1/19. LPN #3's facility-obtained statement dated 2/6/19 indicated s/he was informed that Resident #98 had a skin tear. Went to the resident's room and noted the resident did not appear to be in any distress. A few minutes later CNA #4 asked LPN #3 to to talk to CNA #3. At that time CNA #3 said (s/he) got the skin tear because (s/he) roller (him/her) to hard. The LPN asked the CNA if s/he had written a statement and the CNA responded that s/he had. RN #2's facility-obtained statement indicated on 2/5/19 at 10:50 PM, CNA #4 informed the nurse that CNA #3 reported s/he had worked with CNA #2 and that the resident smacked CNA #2 and CNA #2 smacked the resident back and then threw the resident over to his/her side so they could change him/her and caused a skin tear. The statement also indicated when the RN spoke to CNA #3, the CNA stated they reached down to turn the resident and resident smacked (CNA #2) and (CNA #2) smacked (him/her) back and then pushed (him/her) over hard and resident hit (him/her) arm and got a skin tear. CNA #3 wrote another statement dated 2/6/19 stating s/he and CNA #2 used the total lift with the resident and that Resident #98 was getting irritated and combative, grabing at everything. S/he stated the resident hit CNA #2 and CNA #2 hit (him/her) back causing (him/her) to hit (his/her) hand on the rail. CNA #3 stated s/he told CNA #2 to turn the resident back towards him/her, and CNA #2 pushed (him/her) back more like shoved. CNA #3 stated CNA #2 then left the room stating I better leave before I lose my job. CNA #3 found the skin tear after CNA #2 left the room per the statement. CNA #3 then reported the skin tear to the nurse and afterward told CNA #4 what had happened. CNA #4 got LPN #3 at that time and CNA #3 told (him/her) everything that had happened. CNA #4's statement corroborated CNA #3's statement and that s/he witnessed CNA #3 telling LPN #3 about the incident. CNA #2's statement confirmed s/he assisted a co-worker putting Resident #98 to bed with the total lift. The statement also confirmed Resident #98 hit him/her on his/her left arm. CNA #2's statement indicated s/he pushed (his/her) arm down to stop (him/her). CNA #2 stated s/he used pads to turn Resident #98 and pushed his/her bottom. Review of the facility's policy entitled Protocol for Reporting Abuse stated Immediately notify, but not later that 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later that 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. During an interview on 1/16/20 at 9:44 AM, the Nursing Home Administrator confirmed the incident occurred on 1/31/19 and that the Initial 2/24-Hour Report was sent to the State Agency on 2/6/20. The Administrator further confirmed the facility failed to follow its policy related to reporting. | 2020-09-01 |
| 179 | WHITE OAK MANOR - LANCASTER | 425017 | 253 CRAIG MANOR ROAD | LANCASTER | SC | 29720 | 2020-01-16 | 609 | D | 1 | 1 | FL9111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to report an allegation of abuse within the required timeframe for Resident #98, 1 of 7 reviewed for abuse. CNA #3 allegedly witnessed CNA #2 physically abuse Resident #98 on 1/30/19. The allegation was not reported to the State Agency until 2/6/19. The findings included: The facility admitted Resident #98 on 11/21/18 with [DIAGNOSES REDACTED]. On 1/14/20 at 12:13 PM, review of the Initial 2/24-Hour revealed it was faxed to the State Agency on 2/6/19 at 09:34 AM. The Initial 2/24-Hour Report indicated Resident #98 was physically abused by CNA #2 and indicated the date/time of incident as 2/6/19 at 07:40. The report indicated there was an allegation that while two CNAs were providing care to resident, resident became combative and hit a CNA. There is an allegation that CNA may have physically retaliated. Further review revealed a Five-Day Report dated 2/8/19 that indicated the incident occurred on 1/30/19 at 08:50 PM at which time an incident report was done. The summary indicated physical abuse not substantiated by facility. CNA #3 reported that CNA #2 struck Resident #98 of the arm after the resident struck him/her and was forceful when turning the resident. At 12:33 PM on 1/14/20, review of the Occurrence Report also indicated the incident occurred on 1/30/19 and indicated the resident had 2 skin tears measuring 2.5x1.0 and 4.0x3.5 cm and was completed by LPN #2. On 1/30/19, CNA #3's statement on the Occurrence Report stated s/he was changing Resident #98 and observed a skin tear abrasion on (his/her) left arm. (S/he) was combative during care and hitting and grabbing at us. There was no statement obtained from CNA #2. Review of the Occurrence Report also indicated a 24 hour follow-up was done by Unit Manager RN #1 on 1/31/19 and was also signed by the Director of Nursing on 2/1/19. LPN #2's facility-obtained statement dated 2/6/19 indicated s/he was notified by CNA #3 that Resident #98 sustained a skin tear. Per statement, CNA stated s/he was putting Resident #98 to bed and that resident was fighting and once I got (him/her) into the bed I noticed a skin tear on (his/her) arm. LPN #3's facility-obtained statement dated 2/6/19 indicated s/he was informed that Resident #98 had a skin tear. Went to the resident's room and noted the resident did not appear to be in any distress. A few minutes later CNA #4 asked LPN #3 to to talk to CNA #3. At that time CNA #3 said (s/he) got the skin tear because (s/he) roller (him/her) to hard. The LPN asked the CNA if s/he had written a statement and the CNA responded that s/he had. RN #2's facility-obtained statement indicated on 2/5/19 at 10:50 PM, CNA #4 informed the nurse that CNA #3 reported s/he had worked with CNA #2 and that the resident smacked CNA #2 and CNA #2 smacked the resident back and then threw the resident over to his/her side so they could change him/her and caused a skin tear. The statement also indicated when the RN spoke to CNA #3, the CNA stated they reached down to turn the resident and resident smacked (CNA #2) and (CNA #2) smacked (him/her) back and then pushed (him/her) over hard and resident hit (him/her) arm and got a skin tear. CNA #3 wrote another statement dated 2/6/19 stating s/he and CNA #2 used the total lift with the resident and that Resident #98 was getting irritated and combative, grabing at everything. S/he stated the resident hit CNA #2 and CNA #2 hit (him/her) back causing (him/her) to hit (his/her) hand on the rail. CNA #3 stated s/he told CNA #2 to turn the resident back towards him/her, and CNA #2 pushed (him/her) back more like shoved. CNA #3 stated CNA #2 then left the room stating I better leave before I lose my job. CNA #3 found the skin tear after CNA #2 left the room per the statement. CNA #3 then reported the skin tear to the nurse and afterward told CNA #4 what had happened. CNA #4 got LPN #3 at that time and CNA #3 told (him/her) everything that had happened. CNA #4's statement corroborated CNA #3's statement and that s/he witnessed CNA #3 telling LPN #3 about the incident. CNA #2's statement confirmed s/he assisted a co-worker putting Resident #98 to bed with the total lift. The statement also confirmed Resident #98 hit him/her on his/her left arm. CNA #2's statement indicated s/he pushed (his/her) arm down to stop (him/her). CNA #2 stated s/he used pads to turn Resident #98 and pushed his/her bottom. During an interview on 1/16/20 at 9:44 AM, the Nursing Home Administrator confirmed the incident occurred on 1/31/19 and that the Initial 2/24-Hour Report was sent to the State Agency on 2/6/20. | 2020-09-01 |
| 180 | WHITE OAK MANOR - LANCASTER | 425017 | 253 CRAIG MANOR ROAD | LANCASTER | SC | 29720 | 2020-01-16 | 625 | D | 1 | 1 | FL9111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to provide the resident or the resident's representative with the written bed-hold policy prior to a facility initiated hospital transfer/discharge for one of three sampled residents reviewed for hospitalization . Resident #118 was sent to the hospital on [DATE] and [DATE] and the facility did not provide written information that specified the bed-hold policy. The findings included: The facility admitted Resident #118 on 7/26/19 with [DIAGNOSES REDACTED]. Review of Resident #118's Quarterly Minimum (MDS) data set [DATE] revealed the resident was coded as having short-term and long-term memory problems with severely impaired cognitive skills for daily decision-making. Nurse's notes reviewed on 1/16/20 at 8:16 AM revealed that the facility sent Resident #118 to the hospital emergency roiagnom on [DATE] with difficulty breathing, wheezing, pneumonia and foul smelling urine. Resident #118 was admitted back to the facility on [DATE]. The nurse's notes also revealed that Resident #118 went back to the hospital emergency room again on [DATE] for increased respiratory distress. Resident #118 returned to the facility on [DATE]. In an interview with the social worker on 1/16/20 at 8:32 AM s/he stated that the facility did not provide/discuss the bed-hold policy with the resident or the resident's representative for the two hospital transfers that occurred during December 2019. | 2020-09-01 |
| 181 | WHITE OAK MANOR - LANCASTER | 425017 | 253 CRAIG MANOR ROAD | LANCASTER | SC | 29720 | 2020-01-16 | 908 | F | 1 | 1 | FL9111 | > Based on observations and interviews, the facility failed to maintain all mechanical and electrical equipment in safe operating condition. The kitchen ice machine condensation draining pipes were not clean and in place. The facility was unable keep the floor behind and underneath the ice-maker clean and free from debris for one of one kitchen observed. The findings included: During the initial kitchen observation on 1/13/20 at 10:39 AM and in the presence of the registered dietitian/quality improvement support person, the surveyor noticed cups, some of which were Styrofoam on the floor behind the ice-maker. There was also paper trash on the floor and the floor appeared soiled (dark brown and oily). On 1/15/20 at 9:24 AM, during a second observation of the ice-machine, in the presence of the registered dietitian/quality support person, the surveyor observed the same cups (including Styrofoam), and paper-trash on the floor behind the ice-maker. The floor still appeared soiled (dark brown and oily). On 1/15/20, at approximately 9:25 AM, the registered dietitian got on his/her knees and attempted to remove the cups and paper-trash. At this time, the surveyor looked underneath the ice-machine and noticed two condensation draining pipes covered with black matter and the pipes were not aligned with the drainage underneath the ice-machine. The pipes were touching the floor. In a brief interview with the registered dietitian/quality improvement support person on 1/15/20 at approximately 9:27 AM (s/he) acknowledged that the floor and pipes were dirty and that the condensation draining pipes were touching the floor underneath the ice-machine. | 2020-09-01 |
| 182 | WHITE OAK MANOR - LANCASTER | 425017 | 253 CRAIG MANOR ROAD | LANCASTER | SC | 29720 | 2017-06-15 | 225 | D | 0 | 1 | HKAH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility files, interview, and review of the facility's policy titled, Neglect, Abuse, Mistreatment, Threatened or Alleged Abuse of Residents, the facility failed to ensure that all alleged violations including resident to resident altercations were reported to the State Health Agency. Resident # 9 involved in an altercation that resulted with an injury for 1 of 3 residents reviewed for accidents. The findings included: The facility admitted Resident #9 with [DIAGNOSES REDACTED]. During record review of the facility's occurrence reports on 06/15/17 at 9:21 AM, revealed Resident # 9 had resident to resident altercations on 4/12/17, 4/29/17, and 5/2/17. Report for 4/12/17 revealed Resident #9 was trying to enter in the TV room and Resident #41 would not move. Resident #9 began hitting the Resident #41 there were no injuries. Report for 4/29/17 Resident #9 entered into Resident #92's room and began hitting the resident. Resident #92 had redness on the right side of the face. Report for 5/2/17 Resident #9 wandered into Resident # 38's room and starting grabbing him. Resident#9 stated she can go anywhere she wants. Resident #9 suffered with bruises on the face and hematoma. Staff separated Resident #9 from the 3 incidents that occurred. There was no documentation of the incidents being reported in the section for Reported to State Agency. During an interview on 06/15/17 at 9:15 AM with the Administrator, Director of Nursing, and the facility's consultants it was confirmed the incidents that occurred were not reported. It was also stated it was not required to report to the health agency if it was a resident to resident altercation. Review of the facility's policy, Neglect, Abuse, Mistreatment, Threatened or Alleged Abuse of Residents, revealed under VII. Reporting/Response Section B: Upon receipt of allegation of abuse or neglect, the Administrator or designee will notify the appropriate State agency as soon as practicable, but not exceed twenty four (24) hours. | 2020-09-01 |
| 183 | WHITE OAK MANOR - LANCASTER | 425017 | 253 CRAIG MANOR ROAD | LANCASTER | SC | 29720 | 2017-06-15 | 278 | D | 0 | 1 | HKAH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to assure that 2 out of 3 residents reviewed for nutrition, 1 out of 3 residents reviewed for activities of daily living, dental, vision, and accidents and 1 out of 1 resident reviewed for pressure ulcers received accurate assessments. Residents #18 and #48. The Findings Included: Review of the medical record conducted on 6/14/2017 revealed that the facility admitted Resident #18 with [DIAGNOSES REDACTED]. Record review of Resident #18's Annual Comprehensive Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 5/25/2017 on 6/14/17 revealed Section B (Hearing, Speech Vision) item B1200 (Corrective lenses) was coded 0=no. Further review of medical record revealed documentation on Daylight IQ Assessments (COMS) entered on 5/20/2017 at 6:19 PM and 5/22/17 T 12:58 am which both reflects EENT Vision Corrective: Glasses indicating that resident utilized corrective lenses during the 7 day assessment window prior to the ARD of 5/25/17 of the Comprehensive MDS. During group interview on 6/14/17 at 3:45 PM, when asked if Resident #18 wore glasses when awake, Licensed Practical Nurse) LPN #1, LPN # 2, and Certified Nursing Assistant (C.N.[NAME]) #1 all replied Yes. When LPN #1 was asked if s/he could recall how long Resident #18 has worn glasses, s/he replied as long as I can remember. During an interview on 6/15/17 at 10:00 AM, MDS Nurse #1 agreed that item B1200 (corrective lenses) was incorrectly coded as 0=no and should have been coded as 1=yes. Additional record review on 6/14/2017 of Resident #18's Annual Comprehensive MDS assessment with ARD of 5/25/2017 revealed Section G (Functional Status) items G0110A2 (Bed mobility: support provided), G0110H2 (Eating: support provided), and G0110I2 (Toilet use: support provided) were all coded as 2=one person physical assist and item G0110H1 (Eating: self-performance) was coded as 2=limited assistance-resident highly involved in activity; staff provided guided maneuvering of limbs or other non-weight- bearing assistance. Further review on 6/14/2017 of ADL Assistance and Support report for the Month of (MONTH) (YEAR) for Resident #18 revealed the amount of assistance as well as amount of support provided by staff for ADL's during the 7 day assessment window of 5/19/17-5/25/17 for Comprehensive MDS with ARD of 5/25/17. Review of documentation revealed 7 episodes where Resident #18 received 2+ persons physical assist for bed mobility, and 5 episodes where Resident #18 received 2+ persons physical assist for toileting. Review of the documentation for the amount of assistance and support provided for eating for 5/19/17-5/25/17 revealed 8 episodes where resident was independent with only set-up help provided, 4 episodes of supervision with only set-up help provided, and 1 episode of supervision with no set-up or physical help from staff provided. When asked where s/he looks in the resident's record/ documentation to gather information regarding ADL assistance and support provided during interview on 6/15/17 at 10:22 AM, MDS Nurse #1 stated the ADL flowsheet. When asked if the ADL flowsheet is the ADL Assistance and Support report, s/he indicated that it was the same report. MDS Nurse #1 further verified during interview that using the ADL flowsheet for (MONTH) (YEAR) for Resident #18, items G0110A2 (bed mobility: support provided), G0110H2 (eating: support provided), and G0110I2 (toilet use: support provided) were incorrectly coded as 2=one person physical assist. Using the ADL flowsheet, MDS Nurse #1 verified that G0110A2 (bed mobility: support provided) and G0110I2 (toilet use: support provided) should have been coded as 3=2+ persons physical assist and G0110H2 (eating: support provided) should have been coded as 1=set up help only. Additionally, MDS Nurse #1 verified that G0110H1 (eating: self-performance) was incorrectly coded as 2=limited assistance when the ADL flowsheet reflects 9 episodes with resident identified with self-performance independent (0) with eating and 5 episodes of self-performance level of supervision (1) with no episodes of any other levels of self-performance identified. S/he further agreed that item G0110H1 was incorrectly coded when following the ADL self-performance coding instructions regarding the rule of 3 in Chapter 3 page G-6 in Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.14 updated (MONTH) (YEAR). MDS Nurse #1 further stated that she does not agree with the information documented on the ADL Flowsheet for self-performance and support provided for eating during the assessment period of 5/19/17-5/25/17 and that is why s/he coded G0110H1 as 2=limited assistance and G0110H2 as 2=one person physical assist, however, when asked where the additional supportive documentation to reflect that Resident #18 received limited assistance on at least three occasions during assessment period and one person physical assist at least on one occasion during the assessment period of 5/19/17-5/25/17, s/he verified that there was no documentation in record to support what was coded regarding eating self-performance and support provided. Ongoing record review on 6/14/2017 of Resident #18's Annual Comprehensive MDS assessment with ARD of 5/25/2017 revealed that Section L (Oral/ Dental Status) item L0200B (Dental: no natural teeth or tooth fragment(s)) was not checked and item L0200Z (Dental: none of the above) was checked. Additional review of documentation on 6/14/17 revealed Daylight IQ Assessments (COMS) entered on 5/8/17 at 11:44 AM which identifies Dental Condition: no natural teeth or tooth fragment(s). Further review of Nutritional Screening Review completed by Registered Dietitian (RD) #1 on 5/19/17, revealed under staff comments: .Resident with no natural teeth or dentures . MDS Nurse #1 verified that Section L (Oral / Dental Status) was incorrectly coded and that L0200B (Dental: no natural teeth or tooth fragment(s)) should have been checked instead of L0200Z (Dental: none of the above) during interview on 6/15/17 at 10:00 AM. Review of Resident #48's medical record revealed that s/he was admitted to facility with [DIAGNOSES REDACTED]. Record review on 6/13/107 of Resident #48's Comprehensive MDS assessment with ARD of 10/20/2016 revealed Section G (Functional Status) items G0110A (Bed mobility: self-performance), G0110HA (Eating: self-performance) and G0110IA (Toilet use: self-performance) were all coded as 4=total dependence-full staff performance every time during entire 7-day period. Further review revealed that in Section L (Oral/ Dental Status) Item L0200B (no natural teeth or tooth fragment(s) (edentulous) was not checked, and Item L0200Z (none of the above) was checked. Further review on 6/13/2017 of ADL Assistance and Support report for the Month of (MONTH) (YEAR) for Resident #48 revealed the amount of assistance as well as amount of support provided by staff for ADL's during the 7 day assessment window of 10/14/16-10/20/16 for Comprehensive MDS with ARD of 10/20/2016. Review of this documentation revealed that Resident #48 received limited assistance with bed mobility on three occasions, extensive assistance with bed mobility on three occasions, and was totally dependent with bed mobility on fifteen occasions. Further review of this documentation reveals that Resident #48 received extensive assistance with eating on one occasion and was totally dependent with eating on sixteen occasions, and s/he received extensive assistance with toileting on two occasions with total dependence documented on 13 occasions during assessment period of 10/14/16-10/20/16. Additional review of Resident #48's Care Plan page 1 of 20 revealed that Resident #48 was identified to have no teeth or dentures as a part of the second approach. MDS Nurse #1 was interviewed on 6/15/17 at 10:22 AM. When MDS Nurse #1 was asked where s/he looks in the resident's record/ documentation to gather information regarding ADL assistance and support provided, s/he stated the ADL flowsheet. When asked if the ADL flowsheet is the ADL Assistance and Support report, s/he indicated that it was the same report. MDS Nurse #1 also verified that the documentation on the (MONTH) (YEAR) ADL Flowsheet for Resident #48, during the dates of 10/14/16-10/20/16 reflected that limited assistance was provided with bed mobility on three occasions and extensive assistance was provided with bed mobility on three occasions. Additionally, s/he verified that the documentation on the ADL flowsheet for (MONTH) (YEAR) during the dates of 10/14/16-10/20/16 reflected that extensive assistance was provided with eating on one occasion, and extensive assistance was provided with toileting on to occasions. When asked if there was any additional documentation in the record that would indicate that the information documented on the ADL flowsheet was identified as incorrect and should not be used as a source for calculation of the ADL self-performance/ support provided during the assessment period of 10/14/16-10/20/16, MDS Nurse #1 replied that there was no additional documentation. When asked if the coding was incorrect for items G0110A (Bed mobility: self-performance), G0110HA (Eating: self-performance), and G0110IA (Toileting: self-performance) which all indicated 4=total dependence when using the ADL flowsheet as supportive documentation, MDS Nurse #1 agreed. S/he further stated that s/he did not agree with the information on the ADL flowsheet, but verified that there was no documentation in the record that identified any disputed entries on the ADL flowsheet as incorrect and that with information available, the MDS was incorrectly coded for G0110A, G0110HA, and G0110IA when following the rules in Chapter 3 page G5-6 of the (MONTH) (YEAR) RAI Manual. Additional review of Resident #48's Care Plan page 1 of 20 revealed that Resident #48 was identified to have no teeth or dentures as a part of the second approach. During interview with MDS Nurse #1 on 6/15/17 at 10:22 AM, s/he agreed that Resident #48 did not have any natural teeth and that item L0200B (no natural teeth or tooth fragment(s)/ edentulous) should have been checked instead of L0200Z (none of the above). Further record review on 6/13/107 of Resident #48's Quarterly MDS assessment with ARD of 1/19/17 revealed Section G (Functional Status) items G0110A (Bed mobility: self-performance), G0110GA (Dressing: self-performance) and G0110HA (Eating: self-performance) were all coded as 4=total dependence-full staff performance every time during entire 7-day period. Additionally, items G0400A (ROM limitation: upper extremity) and G0400B (ROM limitation: lower extremity) were both coded as 1=impairment on one side. Additional review on 6/13/2017 of ADL Assistance and Support report for the Month of (MONTH) (YEAR) for Resident #48 revealed the amount of assistance as well as amount of support provided by staff for ADL's during the 7 day assessment window of 1/13/17-1/19/17 for Quarterly MDS with ARD of 1/19/17. Review of this documentation revealed that Resident #48 received limited assistance with bed mobility on one occasion, extensive assistance with bed mobility on three occasions. Further review of this documentation reveals that Resident #48 was independent with eating on one occasion, received extensive assistance with eating on three occasions, and s/he received extensive assistance with toileting on three occasions during assessment period of 1/13/17-1/19/17. Further review of Narrative Notes from Daylight IQ (COMS) completed 1/15/17 at 1:42 PM revealed that Resident #48 was noted to have FROM impairment on both upper and lower extremities. During interview with MDS Nurse #1 on 6/15/17 at 10:22 AM, s/he agreed that G0110A (bed mobility-self performance), G0110GA (Dressing: self-performance) and G0110HA (eating: self-performance) were incorrectly coded and with the supportive documentation available, should have all been coded as 3=extensive assistance using the guidance in the (MONTH) (YEAR) RAI Manual regarding the rule of 3 in chapter 3 on page G-6. S/he also verified that items G0400A & G0400B (functional limitations in range of motion in upper and lower extremities) were incorrectly coded and (1=impairment on one side), and both G0400A and G0400B should have been coded as 2=impairment on both sides. Additional review of medical record on 6/13/107 of Resident #48's Quarterly MDS assessment with ARD of 3/30/17 revealed Section G (Functional Status) items G0110A (Bed mobility: self-performance), G0110HA (Eating: self-performance), and G0110I1 (Toileting-self performance) were all coded as 4=total dependence-full staff performance every time during entire 7-day period. Additionally, items G0400A (ROM limitation: upper extremity) and G0400B (ROM limitation: lower extremity) were both coded as 1=impairment on one side. Further review revealed that in Section M (Skin Conditions) that Item M0300B1 (Stage 2 pressure ulcers: number present) was coded as 1 and Item M0300B3 (Stage 2 pressure ulcers: date of oldest) was coded as 2/13/2017. Item M0300C1 (stage 3 pressure ulcers: number present) was 0 and Items M0610A, M0610B, and M0610C were all Blank Additional review on 6/13/2017 of ADL Assistance and Support report for the Month of (MONTH) (YEAR) for Resident #48 revealed the amount of assistance as well as amount of support provided by staff for ADL's during the 7 day assessment window of 3/24/17-3/30/17 for Quarterly MDS with ARD of 3/30/17. Review of this documentation revealed that Resident #48 received limited assistance with bed mobility on one occasion, and extensive assistance with bed mobility on two occasions. Further review of this documentation reveals that Resident #48 required supervision with eating on one occasion, and s/he received extensive assistance with toileting on one during assessment period of 3/24/17-3/30/17. Ongoing review revealed that on Daylight IQ Assessment (COMS) completed on 3/27/17 at 12:18 AM that Resident #48 had FROM limitations in both upper and lower extremities. Additional record review revealed a Wound Care *Skin Integrity* Evaluation completed on 3/24/17 which identified Wound 1 on sacrum which had an onset date of 2/14/17 was identified as a pressure ulcer-stage III (3). During interview with MDS Nurse #1 on 6/15/17 at 10:22 AM, s/he agreed that G0110A (bed mobility-self performance), G0110HA (Eating: self-performance) and G0110HI (Toileting: self-performance) were incorrectly coded and with the supportive documentation available, should have all been coded as 3=extensive assistance using the guidance in the (MONTH) (YEAR) RAI Manual regarding the rule of 3 in chapter 3 on page G-6. S/he also verified that items G0400A & G0400B (functional limitations in range of motion in upper and lower extremities) were incorrectly coded and (1=impairment on one side), and both G0400A and G0400B should have been coded as 2=impairment on both sides. Additionally, MDS Nurse #1 verified that M0300 (current number of unhealed pressure ulcers at each stage), M0610 (dimensions of unhealed stage 3 or 4 pressure ulcer .), and M0700 (most severe tissue type for any pressure ulcer) were all incorrectly coded on the quarterly MDS assessment with ARD of 3/30/17. | 2020-09-01 |
| 184 | WHITE OAK MANOR - LANCASTER | 425017 | 253 CRAIG MANOR ROAD | LANCASTER | SC | 29720 | 2017-06-15 | 279 | D | 0 | 1 | HKAH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to develop and implement a care plan to meet the medical, nursing, and mental/ psychosocial needs for Resident #48. A care plan was not developed to address [DIAGNOSES REDACTED]. A care plan was not developed to address presence of actual contractures in upper and lower extremities in one of three residents reviewed for range of motion. A care plan was not developed or implemented to address presence of sacral pressure ulcer that was identified on 2/13/17 and resolved on 4/12/17 for one of one resident reviewed for pressure ulcer. The Findings Included: The facility admitted Resident #48 with [DIAGNOSES REDACTED]. Review of the Comprehensive Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 10/20/16 revealed that Items G0400A (Functional Limitation in Range of Motion {FROM} of upper extremities) and G0400B (FROM of lower extremities) were coded as 2=impairment on both sides. Further review revealed that Items I3300 ([MEDICAL CONDITION]) and I4800 (non-Alzheimer's dementia) were both checked. Additionally, presence of limitations in range of motion in upper and lower extremities identified in nursing notes on 10/17/16 at 10:09 PM. Review of (MONTH) (YEAR) monthly Physician orders [REDACTED].#48 was prescribed the medications [MEDICATION NAME] for [DIAGNOSES REDACTED]. Additional review of medical record on 6/14/17 revealed pressure ulcer reports for sacral pressure ulcer that was identified on 2/13/17 and reported as resolved on 4/12/2017. Review of Resident #48's care plan (pages 1-20 of 20) on 6/14/17 revealed that the care plan did not address the [DIAGNOSES REDACTED]. Additionally, review of page 4 of 20 on Resident #48's care plan revealed that FROM in bilateral extremities/ contractures were not addressed as a current problem, with impaired physical mobility attributed only to cervical stenosis with [DIAGNOSES REDACTED] and goal for resident to .develop no contractures. Further review of both active and resolved care plan problems for Resident #48 revealed that there were no care plans that addressed the presence of sacral pressure ulcer identified on 2/13/17 and reported as healed on 4/12/17. Review of Care Planning policy on 6/14/17 revealed under the section Comprehensive Team Care Planning on page 35 under the heading of Identification of Problems/ Needs/ Strengths that .the care plan must address a resident concern if clinically warranted (ex.: [MEDICAL CONDITIONS], etc.). Further review of Care Planning policy revealed on page 40 under the section Care Planning Areas for Consideration, a list of 6 general care planning areas that are recommended by CMS (the Centers for Medicare and Medicaid) that are useful in the long-term setting. Under #1 Functional Status the instructions identify that functional status limitations are identified using the MDS and triggers . and the conditions identified by the RAI (Resident Assessment Instrument) should be clearly linked to the problems addressed on the care plan. Additionally, under #3 Health Maintenance includes (care planning) to address monitoring of disease processes that are currently being treated . MDS Nurse #1 was interviewed regarding Resident #48's care plan on 6/15/17 at 10:22 AM. During this interview, s/he verified that the care plan problem initiated on 12/10/10 that addressed impaired physical mobility for Resident #48 did not reflect the presence of contractures and did not reflect his/her current medical and nursing needs in the problem statement, goal or approaches. S/he further verified that neither [MEDICAL CONDITION] nor the use of medications to treat [DIAGNOSES REDACTED].#48's care plan, although according to facility policy, [MEDICAL CONDITION] should have been addressed somewhere in Resident #48's plan of care. Finally, s/he verified that there was no care plan problems or interventions implemented to address the emergence of sacral pressure ulcer that was identified on 2/13/17 and resolved on 4/12/17, although there should have been at least updates to care plan to address the presence of an actual pressure ulcer. During interview with Social Services Staff #1 on 6/15/17 at 11:00 am, s/he verified that there was no care plan problem or interventions in place that addressed the [DIAGNOSES REDACTED]. Social Services Staff #1 further stated that s/he would take care of that immediately. | 2020-09-01 |
| 185 | WHITE OAK MANOR - LANCASTER | 425017 | 253 CRAIG MANOR ROAD | LANCASTER | SC | 29720 | 2018-09-27 | 550 | E | 0 | 1 | 52MP11 | Based on observations, interview, and review of the facility policy, the facility failed to maintain the dignity of residents with catheter bags for 1 of 1 resident reviewed for catheters. Resident #25's catheter bag was exposed on the 100 hall. The findings included: On 9/24/18 at approximately 1:16 PM, an observation on the 100 hall of Resident #25's catheter bag hanging on the right side of the bed facing the hallway and was approximately 1/2 full of urine. The catheter bag was not covered and in full view from the hallway. On 9/24/18 at approximately 3:32 PM, an observation on the 100 hall of Resident #25's catheter bag hanging on the right side of the bed facing the hallway. The catheter bag was not covered and in full view from the hallway. On 9/25/18 at approximately 8:59 AM, an observation on the 100 hall of Resident #25's catheter bag hanging on the right side of the bed and was approximately 1/4 full of urine. The catheter bag was not covered and in full view from the hallway. On 9/25/18 at approximately 5:20 PM, an observation with Licensed Practical Nurse (LPN) #1 on the 100 hall of Resident #25's catheter bag hanging on the right side of the bed that was approximately 1/4 full of urine. The catheter bag was not covered and in full view from the hallway. On 9/25/18 at approximately 5:20 PM, during an interview LPN #1 verified the catheter bag was in full view from the hallway and indicated the bag should be placed in a privacy bag on the side of the bed away from view from the hallway. Review of the facility policy, Closed Urinary Drainage states under procedure (3.) Attach drainage bag to bed frame, below level of resident's bladder, not touching floor; cover with dignity bag (unless fig leaf bag used). | 2020-09-01 |
| 186 | WHITE OAK MANOR - LANCASTER | 425017 | 253 CRAIG MANOR ROAD | LANCASTER | SC | 29720 | 2018-09-27 | 580 | E | 0 | 1 | 52MP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of the facility policy titled, Standard Of Care, the facility failed to ensure the physician and the personal representative for Resident #5, #105, #82 and #56 was notified of refusal of multiple medications on multiple days. The facility further failed to ensure the physician was notified of falls/falls with injury for Resident #30 for 5 of 5 residents reviewed for Notification. The findings included: The facility admitted Resident #5 with [DIAGNOSES REDACTED]. Review on 9/26/2018 at approximately 1:24 PM of the medical record for Resident #5 revealed on multiple days multiple medications were refused by Resident #5. Resident #5 had refused medications on 5/2/2018, 5/16/2018, 5/29/2018, 5/30/2018, 5/31/2018, 6/3/2018, 6/4/2018, 6/6/2018, 6/15/2018, 7/24/2018, 7/27/2018, 8/6/2018, 8/9/2018, 8/10/2018, 8/15/2018, 8/16/2018, 8/22/2018, 8/28/2018, 9/5/2018 and 9/21/2018. No documentation could be found in the medical record for Resident #5 to ensure the physician or the personal representative was notified of the refusal of medications. The facility admitted Resident #30 with [DIAGNOSES REDACTED]. Review on 9/27/2018 at approximately 2:00 PM of the medical record for Resident #30 revealed a fall on 7/12/2018 and 7/14/2018. No documentation could be found in the medical record for Resident #30 to ensure the physician was notified. Review on 9/27/2018 at approximately 2:30 PM of the, Occurrence Report, for Resident #30 dated 7/12/2018 revealed a fall with a laceration above right eye and discoloration to the right outer calf. Further review on 9/27/2018 at approximately 2:30 PM of a second Occurrence Report for Resident #30 dated 7/14/2018 revealed a fall from the bed with no injury assessed. No documentation could be found in the medical record nor on the Occurrence report to ensure the physician was notified of either fall. During interview on 9/27/2018 at approximately 2:40 PM with LPN (Licensed Practical Nurse) #4 stated, If a resident receives an injury then we call the physician but if they do not sustain an injury then we log it in the communication book and he/she will be informed when they come in to see the patients on rounds. An interview on 9/27/2018 at approximately 2:50 PM with the physician, he/she verbalized his/her expectation was for the nurses to notify him/her of refusal of medications and falls/falls with injury. The physician also stated that he/she would expect to be notified of refusal of medications in case a change needed to be made in the medications and to update the plan of care. The physician went on to say that the nurses were good about letting him/her know of refusal of medications/care and falls/falls with injury. Review on 9/27/2018 at approximately 3:00 PM of the facility policy titled, Standards of Care, states under Policy: Each resident shall receive quality of care that is designed to meet individual needs and enhance the quality of life. Under Supervision 1. states, The physician and the family (or the resident's representative) shall be informed of any change in the resident's condition. Resident # 56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Nurse's notes reviewed on 9/25/18 at 2:57 PM revealed that Resident #56 refuses to take /his/her medication, or spits them out multiple occasions. However, there is no documentation to indicate that the physician and the resident's representative have been notified. Medication Administration Record [REDACTED]. In (MONTH) Resident #56 did not take medication on 10th and the 11th. For (MONTH) the resident did not receive multiple medications on the 14th, 17th, 24th, and 28th. For (MONTH) the resident did not take medication on 3rd, 7th, and 18th. Resident # 82 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]., [MEDICAL CONDITION], and Dysphagia. Nurse's notes reviewed on 9/27/18 at 9:24 AM revealed that Resident #82 refuses to take /his/her medication, or spits them out multiple occasions. However, there is no documentation to indicate that the physician and the resident's representative have been notified. Medication Administration Record [REDACTED]. In (MONTH) Resident #82 did not take medication on 3rd, 7th, 15th, 23rd, and 30th. In (MONTH) the resident did not receive medication on the 6th. Resident # 105 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Nurse's notes reviewed on 9/27/18 at 2:37 PM revealed that Resident #105 refuses to take his/her medication, or spits them out multiple occasions. However, there is not documentation to indicate that the physician and the resident's representative have been notified. Medication Administration Record [REDACTED]. In (MONTH) Resident #105 did not take medication on 4rd and the 11th7th. In (MONTH) the resident did not receive mediation on the 20th and in (MONTH) s/he did not take medication on the 3rd. | 2020-09-01 |
| 187 | WHITE OAK MANOR - LANCASTER | 425017 | 253 CRAIG MANOR ROAD | LANCASTER | SC | 29720 | 2018-09-27 | 656 | D | 0 | 1 | 52MP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a Comprehensive Plan of Care was developed for Resident #5 related to refusal of medications. The findings included: The facility admitted Resident #5 with [DIAGNOSES REDACTED]. Review on 9/26/2018 at approximately 1:24 PM of the medical record for Resident #5 revealed on multiple days multiple medications were refused by Resident #5. Resident #5 had refused medications on 5/2/2018, 5/16/2018, 5/29/2018, 5/30/2018, 5/31/2018, 6/3/2018, 6/4/2018, 6/6/2018, 6/15/2018, 7/24/2018, 7/27/2018, 8/6/2018, 8/9/2018, 8/10/2018, 8/15/2018, 8/16/2018, 8/22/2018, 8/28/2018, 9/5/2018 and 9/21/2018. Review on 9/26/2018 at approximately 3:10 PM of the Plan of Care for Resident #5 revealed no problem, goals or interventions for refusal of medications. An interview on 9/26/2018 at approximately 3:15 PM with the Care Plan Coordinator confirmed that there was no care plan developed for refusal of medications. | 2020-09-01 |
| 188 | WHITE OAK MANOR - LANCASTER | 425017 | 253 CRAIG MANOR ROAD | LANCASTER | SC | 29720 | 2018-09-27 | 686 | D | 0 | 1 | 52MP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and review of the facility policy titled, Dressing - Non-Sterile, the facility failed to follow a procedure during wound care for Resident #8 and #24 consistent with professional standards of practice to promote healing and prevent infection for 2 of 3 residents reviewed for wound care. The findings included: The facility admitted Resident #8 with [MEDICAL CONDITION], Pneumonia, Heart Failure, Pain and Pressure Ulcers. An observation on 9/26/2018 at approximately 10:30 AM during wound care for Resident #8, revealed a pair of scissors on the over the bed table. The scissors were not observed to be cleaned by RN (Registered Nurse) #3 prior to cutting a small amount of calcium alginate for placement on wound beds for Resident #8 during wound care. An additional observation on 9/26/2018 at approximately 10:40 AM, during wound care, revealed RN #3 removing gloves from his/her pocket to use for the dressing changes for Resident #8 after each time cleansing his/her hands. The facility admitted Resident #24 with [DIAGNOSES REDACTED]. An observation on 9/26/2018 at approximately 11:10 AM, during wound care for Resident #24, revealed RN #3 removing a pair of scissors from his/her pocket and cutting a piece of Calcium Alginate with Silver for the wound beds. An additional observation on 9/26/2018 at approximately 11:10 AM , during wound care for Resident 24, revealed RN #3 removing gloves from his/her pocket and applying them each time he/she removed the soiled gloves and after washing his/her hands. During an interview on 9/26/2018 at approximately 11:35 AM with RN #3 confirmed that he/she had not cleaned the scissors prior to wound care and had removed gloves from his/her pocket for use during wound care for Resident #24 and #8. Review on 9/26/2018 at approximately 11:50 AM of the facility policy titled, Dressing - Non Sterile, states under Objective: number 1. states, To protect wound from contamination and/or injury. Under Note: number 1 states, Clean scissors before and after each resident use. | 2020-09-01 |
| 189 | WHITE OAK MANOR - LANCASTER | 425017 | 253 CRAIG MANOR ROAD | LANCASTER | SC | 29720 | 2018-09-27 | 690 | D | 1 | 0 | 52MP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview the facility failed to provide follow up and appropriate treatment and services to prevent urinary tract infection to a resident with signs and symptoms of urinary tract infection for one of one sample resident reviewed for bowel and bladder incontinent. Findings: Resident # 56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Nurse's notes reviewed on 9/25/18 at 2:57 PM revealed that on 6/7/18 Resident #56 on 6/7/18 complained of dysuria and also had some foul smelling urine. According to the nurse's notes, the nurse notified the physician. However, there is no documentation to support that the physician or the facility staff took any further action or performed a urinalysis to rule out urinary tract infection [MEDICAL CONDITION]. On 6/9/18 the nurse's notes indicated that the resident wanted to get out of the facility. S/he has thrown his/her cover on the floor and was attempting to get out of bed. On 6/13/18 the facility found the resident on the floor with his/her back against the bedside commode. On 6/20/18 the facility sent the resident at the hospital where s/he was treated for [REDACTED]. During an interview with the director of nursing (DON) and registered nurse consultant on 9/26/18 at 9:23 AM the DON confirmed that the facility did not perform a urinalysis to rule out UTI. | 2020-09-01 |
| 190 | WHITE OAK MANOR - LANCASTER | 425017 | 253 CRAIG MANOR ROAD | LANCASTER | SC | 29720 | 2018-09-27 | 759 | D | 0 | 1 | 52MP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and review of the facility policy, the facility failed to maintain a medication error rate of less than 5%. There were 3 errors out of 31 opportunities for error, resulting in a medication error rate of 9.68%. The findings included: Error #1 and #2 On 9/26/18 at approximately 8:50 AM, during an observation of Resident #5's medication administration on the 100 hall, Registered Nurse (RN) #1 crushed [MEDICATION NAME] 10 meq. and [MEDICATION NAME] HCL 10 mg. and placed the medication in applesauce and attempted to administer the medication to Resident #5. RN #1 was stopped before administering the medication and was asked to review Resident #5's physicians orders which stated, [MEDICATION NAME] 10 MEQ Tablet- Give one tablet by mouth twice daily with or after meals and with at least 4 oz of liquid.***Do not crush***, also [MEDICATION NAME] HCL 10 MG Capsule- Give 1 capsule by mouth daily. **Do not crush**. Following the review of Resident #5's physician's orders RN #1 verified s/he crushed [MEDICATION NAME] and [MEDICATION NAME] and indicated s/he should not have. Error #3 On 9/26/18 at approximately 8:55 AM, during an observation of Resident #5's medication administration on the 100 hall, Registered Nurse (RN) #1 administered (1) drop of Artificial Tears into each of the residents' eyes. RN #1 then returned to the cart and placed the Artificial Tears back into the Resident #5's drawer in the medication cart, and signed the medication off as given. On 9/26/18 at 9:00 AM, during reconciliation of Resident #5's med pass, a review of the Medication Administration Record [REDACTED]. On 9/26/18 at 9:00 AM, during an interview with RN #1, s/he verified giving only 1 drop per eye of Artificial Tears instead of 2 drops per eye. Review of the facility policy, Oral Medication Administration Procedure states under procedure (6.b.) Medications, not otherwise indicated may be crushed. If Do Not Crush is added to a medication order and the resident needs to have the medication crushed, please consult the pharmacy. | 2020-09-01 |
| 191 | WHITE OAK MANOR - LANCASTER | 425017 | 253 CRAIG MANOR ROAD | LANCASTER | SC | 29720 | 2018-09-27 | 761 | D | 0 | 1 | 52MP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and review of the facility policy titled, Medication Storage In The Facility, the facility failed to ensure medications were secured and out of reach of residents that were capable of obtaining them on Unit 200 for 1 of 3 units observed. The findings included: An observation on 9/25/2018 at approximately 9:10 AM revealed unsecured medications on the top of a treatment cart on the 200 Unit. The medications consisted of [MEDICATION NAME] Powder, [MEDICATION NAME] Cream and Santyl. Residents were observed sitting in wheel chairs approximately 3 feet from the treatment cart and others were observed walking by the cart on the unit. An interview on 9/25/2018 at approximately 9:10 AM with LPN (Licensed Practical Nurse) #2 confirmed the findings and stated, these medications came in during the night and were left on the cart. LPN #2 went on to say that the medications should have been secured in the treatment cart and not stored on the top of it. Review on 9/25/2018 at approximately 10:00 AM of the facility policy titled, Medication Storage In The Facility, states, Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. | 2020-09-01 |
| 192 | WHITE OAK MANOR - LANCASTER | 425017 | 253 CRAIG MANOR ROAD | LANCASTER | SC | 29720 | 2018-09-27 | 804 | D | 0 | 1 | 52MP11 | Based on observation, and interview the facility failed to provide food prepared at an appetizing temperature for 2 of 2 residents reviewed during lunch meal. Two Residents on the 300 unit were served melted ice cream. The findings included: On 9/25/18 at 1:57 PM, an observation of the meal service on the 300 hall revealed the meal trays were placed on the hall at 12:15 PM. The last 2 trays were removed from the uncovered food cart at 12:57 PM. Certified Nursing Assistant (CNA) #1 and CNA #2 removed the last 2 trays from the cart and verified the ice cream on the tray was melted. | 2020-09-01 |
| 193 | FLEETWOOD REHABILITATION AND HEALTHCARE CENTER | 425018 | 200 ANNE DRIVE | EASLEY | SC | 29640 | 2016-10-05 | 241 | D | 0 | 1 | WRBU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to ensure that dignity in dining was enhanced for residents who required assistance with eating during meals. Two random meal observations in 1 of 3 dining rooms. (Section 1) The findings included: During a random lunch observation on 10/03/16 at approximately 12 PM revealed four dining tables with two to five residents seated at each table. The residents seated at three of the four tables were served. There were three residents seated at a table close to room [ROOM NUMBER]. None of the residents seated at the table were served while the other residents in the dining room were served and eating independently or being fed by family members. Staff was observed delivering food to residents in their rooms while the three residents in the dining room were not served or eating. Further meal observation in the dining room on 10/03/16 revealed Certified Nursing Aide (CNA) #3 touching two residents bread with bare hands and putting butter on it. At approximately 12:17 PM staff was observed feeding the residents at the fourth table near room [ROOM NUMBER]. Random observation of meal service down the hallway on 10/03/16 at approximately 12:20 PM near medical records revealed a Certified Nurse Aide (CNA) in a room texting on his/her phone; while a resident that required assistance with eating was in bed with a food tray on a bedside table. A random observation of meal delivery on 10/04/16 at approximately 11:56 AM revealed four tables in the dining room. There was a long table with six residents present. Staff was observed serving residents at two other tables before serving all the residents at the long table. Staff was observed serving some residents in their rooms before serving all the residents in the dining room. During meal observation down the hallway on 10/04/16 at approximately 12:12 PM revealed two residents in Rooms #22, #17 and #15 with one resident with a food tray and eating while the other resident was not served. They were eating without the privacy curtains being closed. An interview on 10/04/16 at approximately 12:15 PM with Licensed Practical Nurse (LPN) #1 and Certified Nurse Aide (CNA) #1 confirmed the findings of delay in meal delivery in rooms. An interview on 10/05/16 at approximately 8:19 AM with CNA #2 confirmed findings on 10/04/16 of delay of meal delivery in dining room. An interview on 10/05/16 at approximately 9:08 AM with CNA #3 confirmed he/she touched resident's bread with bare hands during meal delivery on 10/03/16. | 2020-09-01 |
| 194 | FLEETWOOD REHABILITATION AND HEALTHCARE CENTER | 425018 | 200 ANNE DRIVE | EASLEY | SC | 29640 | 2016-10-05 | 431 | D | 0 | 1 | WRBU11 | Based on observation and interview the facility failed to maintain medication (med) storage rooms free of expired medications on 1 of 3 nursing stations. Magic Mouthwash was stored in the refrigerator in the Station 1 med room and had expired. The findings included: During an observation of the Station 1 med room on 10/5/2016 at 9:05 AM, a bottle of Magic Mouthwash with Lidocaine was found in the refrigerator. The medicine was ordered to be used 3 times daily as needed for mouth pain. The medication was dispensed on 9/16/2016 and had a hand written expiration date of 9/30/2016 on the label. During an interview with RN (Registered Nurse) #1 on 10/5/2016 at 9:05 AM, RN #1 confirmed the hand written date of 9/30/2016 appeared to be the expiration date of the Magic Mouthwash. RN #1 called the pharmacist for clarification on the expiration date. Per RN #1, the pharmacist confirmed that the magic mouthwash was a compounded medication with a 14 day shelf life and did expire on 9/30/2016. Review of the Medication Administration Records revealed that the resident did not receive any of the Magic Mouthwash after 9/30/2016. | 2020-09-01 |
| 195 | FLEETWOOD REHABILITATION AND HEALTHCARE CENTER | 425018 | 200 ANNE DRIVE | EASLEY | SC | 29640 | 2017-10-06 | 157 | D | 1 | 1 | NTTE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to notify the physician of significant changes in blood glucose levels for 1 of 5 sampled residents reviewed for unnecessary medication. The physician was not notified of multiple blood sugar results greater than 400 as ordered for Resident #2. The findings included: The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Record review on 10/6/17 revealed 6/29/2017 physician's orders [REDACTED].= 3 units; 251-300 = 5 units; 301-350 = 8 units; 351-400 = 10 units; 401-450 = 13 units. Notify provider; 451-500 = 15 units subcutaneously before a meal and at bedtime for diabetes. Notify provider if BG >400 and Review of the 7/17 Medication Administration Record [REDACTED]= 433 at 1630h(ou)rs and 429 at 2100hrs, 7/3 = 454 at 1630hrs, 542 at 2100hrs, 7/7 = 4[AGE] at 2100hrs, 7/13 = 426 at 2100, 7/15 = 406 at 2100, 7/17 = 499 at 2100hrs, 7/20 = 426 at 1630hrs and 458 at 2100hrs, 7/21 = 415 at 0700hr, 7/22 = 414 at 2100hrs, 7/28 = 422 at 2100, and 7/29 = 458 at 2100. Continuing review of the 8/17 MARs revealed that Resident #2's blood glucose was 405 on 8/1, 413 on 8/3 at 1630hrs, 402 on 8/4, 432 on 8/8 at 2100hrs, 448 on 8/9 at 1630hrs, 478 on 8/12 at 2100hrs, 427 on 8/17, 415 on 8/18 at 1630hrs, 414 on 8/24 at 2100hrs, and 416 on 8/29 at 1630hrs. Review of 9/17 MARs revealed that Resident #2's blood glucose was 407 on 9/4 at 2100hrs, 427 on 9/6 at 1630hrs, 402 on 9/8, 401 on 9/9, 525 on 9/12/17, 410 on 9/18, 504 on 9/25 at 2100hrs, and 468 on 9/26 at 0700hrs. Review of Nurse's Notes on 10/05/2017 at 9:45 AM for the months of July, August, and September, 2017 revealed no documentation regarding notifying the physician of blood sugar results greater than 400. During an interview on 10/05/2017 at 9:09 AM, Licensed Practical Nurse (LPN) #4 could not locate any documentation on either the computerized records or the resident's medical record that stated the physician had been notified of any blood sugar results of greater than 400. LPN #4 spoke to the Director of Nursing (DON) on the same day at approximately 9:15 AM regarding locating documentation to show that the physician had been notified at any time. The DON was unable to find any evidence of physician notification. S/he stated that the facility was aware of the problem and it had provided group in-service/counseling on 9/20/17 but the problem had not been resolved. The DON verified the above findings on 10/05/2017 9:47 AM. | 2020-09-01 |
| 196 | FLEETWOOD REHABILITATION AND HEALTHCARE CENTER | 425018 | 200 ANNE DRIVE | EASLEY | SC | 29640 | 2017-10-06 | 274 | D | 1 | 1 | NTTE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to complete a Significant Change in Status Assessment (SCSA) in a timely manner for 1 of 5 residents reviewed for Hospice services. The facility did not complete the SCSA within 14 days following revocation of Hospice for Resident #8. The findings included: The facility admitted Resident #8 with [DIAGNOSES REDACTED]. Review of the medical record on 10/5/17 at 1:50 PM revealed that there was an order for [REDACTED]. Further review of the medical record revealed that resident was transferred to the hospital on [DATE] after the revocation of hospice services and returned to facility on 2/3/17. Review of the Minimum Data Set (MDS) assessments indicated the SCSA was not initiated with an assessment reference date until 2/13/17. Further review revealed that items Z0500B, V0200B2 and V0200C2 were all signed, which reflected the completion of the assessment on 2/21/17. The significant change in status assessment was not completed within 14 days of Hospice admission as required. During an interview on 10/6/17 at 3:17 PM, MDS Nurse #1 reviewed the medical record for Resident #8 and confirmed that hospice services were discontinued prior to hospitalization , and that a SCSA was not completed within 14 days of Resident #8 ' s return to facility, identified as the date a SCSA was indicated, as required. | 2020-09-01 |
| 197 | FLEETWOOD REHABILITATION AND HEALTHCARE CENTER | 425018 | 200 ANNE DRIVE | EASLEY | SC | 29640 | 2017-10-06 | 278 | B | 1 | 1 | NTTE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, and interview, the facility failed to accurately code the Minimum Data Set (MDS) for 1 of 2 sampled residents reviewed for contractures. Resident #94's MDS was not coded accurately to reflect the functional limitation of range of motion for the upper extremity contractures. The findings included: Resident #94 was admitted with [DIAGNOSES REDACTED]. During an observation on 10/3/17 at 10am, Resident #94 was observed to have contractures of her/his wrists and hands. Record review on 10/5/17 at 10am of hospice Interdisciplinary Team (IDT) Note on 3/8/17 stated, She (he) has bilateral hand contractures, and all extremities have fixed contractures and no purposeful use. Further record review of a Skilled Nursing (SN) Clinical Note dated 6/1/17 stated, All extremities with fixed contractures. Review of the MDS on 10/5/17 at 9am revealed the MDS with review dates of 6/6/17 and 8/31/17 was coded a 0-no impairment under Functional Limitation of Range of Motion, Section G0400, A- Upper Extremity. During an interview on 10/5/2017 at 12:50pm, MDS #1 verified that the 6/6/17 and 8/31/17 MDS was not coded correctly to reflect the upper extremity contractures. | 2020-09-01 |
| 198 | FLEETWOOD REHABILITATION AND HEALTHCARE CENTER | 425018 | 200 ANNE DRIVE | EASLEY | SC | 29640 | 2017-10-06 | 323 | D | 1 | 1 | NTTE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record review and staff interview, the facility failed to ensure one of three residents reviewed for accidents received adequate supervision and assistance devices to prevent accidents. Facility staff used an improper lift during care resulting in Resident #8 being lowered to floor. The Findings Include The facility admitted Resident #8 with [DIAGNOSES REDACTED]. Review of the Certified Nursing Assistant (C.N.A.) Care Card for Resident #8 was completed on 10/5/17 at 10:00 AM. The C.N.A. Care Card identified that a sling lift and 2 staff assist were required for transfers. Further review of the Lift Evaluation Form completed on 8/11/17, revealed that Resident #8 was not able to bear weight, did not have upper body strength, and that a total body lift was indicated. Observations on 10/3/17 and 10/5/17 revealed that two staff members used a total lift / sling lift to transfer Resident #8 to and from bed to Geri-chair with no concerns identified related to the transfer procedures. During interview with C.N.A. #1 on 10/5/17 at 2:00 PM, s/he reviewed her/his written statement regarding an incident related to Resident #8 being lowered to the floor that occurred on 9/11/17 and verified that the statement resident had soiled self I took her to shower room placed on stand lift to clean her. Resident raised her arms and began to fall. I got behind her and lowered her to the floor was correct. When asked how s/he was made aware of what each resident ' s specific care needs were, s/he identified the C.N.A. Care Card. When asked if s/he could indicate where on the C.N.A. Care Card it identified the use of a sit-to-stand lift, s/he could not. When asked how Resident #8 currently was transferred, s/he replied with the total lift. When asked how many staff members were required to assist with transfers for Resident #8, s/he replied 2 . During an interview on 10/5/17 at 2:12 PM with C.N.A. #2, s/he stated that s/he was familiar with Resident #8. S/he stated that the C.N.A. Care Card was the information source used to identify how each resident was to be cared for because it outlined what care was to be provided which included safety devices and specialized equipment utilized with each resident. When asked how Resident #8 was transferred, s/he replied with the total lift. When asked how many staff members were required to assist with transfers for Resident #8, s/he replied 2 . During an interview on 10/5/17 at 2:07 PM with LPN #1, s/he stated that s/he was familiar with Resident #8. S/he stated that the C.N.A. Care Card was where the information regarding safety interventions and equipment required was located. When asked how Resident #8 was transferred, s/he replied sling lift with two staff. On 10/6/17 at 11:02 AM, review of record for in-service conducted on 9/14/17 revealed that staff was educated regarding utilization of the C.N.A. Care Card to identify what lifts are to be used and that total/ sling lifts require 2 staff members to operate. | 2020-09-01 |
| 199 | FLEETWOOD REHABILITATION AND HEALTHCARE CENTER | 425018 | 200 ANNE DRIVE | EASLEY | SC | 29640 | 2018-11-09 | 577 | C | 0 | 1 | NICZ11 | Based on observations and interview, the facility failed to post notice of the latest survey report in a prominent place in all areas of the facility. In addition, the facility failed to post notice of the availability of the results of the preceding 3 years survey reports in a place readily accessible to residents and the public. The findings included: During the Recertification Survey, a Group Interview was held with 8 residents on 11/7/18 at approximately 4:00 PM. At that time, residents were asked if they knew where the latest State survey inspection report was located. The participants were unable to answer this question and indicated that they were unaware of this information. Observations during the survey indicated the survey report was located in a binder placed in a holder on the wall outside the Administrator's office near the entrance to the facility. Observations of the first and second floor units revealed no signage indicating the location of the survey report. Observation revealed the past year's survey report was located in the binder. Further observation revealed there was no signage to indicate that the preceding 3 years survey reports were available for review upon request. During an interview on 11/9/18, the Administrator reviewed the contents of the survey binder and confirmed these findings at that time. | 2020-09-01 |
| 200 | FLEETWOOD REHABILITATION AND HEALTHCARE CENTER | 425018 | 200 ANNE DRIVE | EASLEY | SC | 29640 | 2018-11-09 | 584 | E | 0 | 1 | NICZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to provide housekeeping and maintenance services to maintain a clean, safe and comfortable environment on 11/6/2018 through 11/8/2018 on 3 of 3 units. The findings included: The following concerns were identified during the Initial Pool Process on 11/6/2018 and 11/7/2018 and confirmed during and environmental tour with facility administrator and housekeeping supervisor on 11/08/18 beginning at approximately 2:23 PM. (1)room [ROOM NUMBER] hall 3-A- floors and bathroom with dirt and residue buildup, cluttered with boxes on the floor (2) room [ROOM NUMBER] hall 3-B cluttered items on the floor, dirty/torn baseboards on the wall at the head of the bed (3) room [ROOM NUMBER] hall 12-W dirt and residue buildup on the baseboards in the bathroom and baseboards to the left side of the residents bed (4) room [ROOM NUMBER] hall 2-C cluttered items on the floor, underneath bed dirt and residue buildup, dirty brown substance build up in the toilet, and underneath the sink with moderate dirt and buildup (5) room [ROOM NUMBER] hall 6-D closet door with large scrapes and missing paint, missing paint around the sink with appearance of dried coating (6) room [ROOM NUMBER] hall 13-A dirt and residue buildup on floor and walls, overbed table dirty with build up on the rolling base support, and bedframe with splatter of sticky light brown substance (7) room [ROOM NUMBER] hall 7-W closet doors with large scrapes and scuffs and missing paint, cluttered items on the floor (8) room [ROOM NUMBER] hall 11-W bathroom with black spatter substance appears with grime and build up, clothing closet with large scrapes and missing paint, light bulb apparatus with missing cover (9) room [ROOM NUMBER] hall 13-W privacy curtain dirty with streaks of red substance, dirt build up on walls, baseboards and shelves, cluttered items on the floor (10) room [ROOM NUMBER] hall 15-C floors, baseboards, walls with dirt build up, and window blind broken | 2020-09-01 |
| 201 | FLEETWOOD REHABILITATION AND HEALTHCARE CENTER | 425018 | 200 ANNE DRIVE | EASLEY | SC | 29640 | 2018-11-09 | 693 | D | 0 | 1 | NICZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and review of the facility policy, the facility staff failed to ensure appropriate treatment for 1 of 1 resident observed for enteral medication administration. During Resident #6's gastric tube ([DEVICE]) medication administration, the nurse failed to follow established procedures to check for placement verification prior to the instillation of the prescribed medication. The findings included: The facility admitted Resident #6's with [DIAGNOSES REDACTED]. On 11/7/18 at approximately 2:30 PM, an observation of Resident #6's medication administration on the station 2 unit, Licensed Practical Nurse (LPN) #1 prior to administration checked for [DEVICE] placement and residual by attaching a syringe and pushing in 60 milliliters (ml's) of air into Resident #6's [DEVICE] and pulling back on the syringe for stomach contents. On 11/7/18 at approximately 2:38 PM, during an interview LPN #1 verified s/he checked for placement by pushing in 60 ml. of air through Resident #6's [DEVICE], the surveyor asked, if s/he was trained to use 60 ml. of air to check placement? LPN #1 stated, The Unit Manager instructed me to do so. Review of the facility policy revealed there was not a policy relating to enteral tubes, the Director of Nursing (DON) provided the surveyor with the Gastrostomy Feeding Competency form completed by LPN #1 which states under Guideline Step, #8, Check gastric residual volume (GRV) before each feeding (for bolus and intermittent feedings) and every 4 to 6 hours (for continuous feedings) (a.) Draw up to 10 to 30 ml air into syringe and connect the end of the feeding tube. (b.) Inject air into the tube. Pull back slowly and aspirate total amount of gastric contents. LPN #1 last completed the competency on 9/4/17. | 2020-09-01 |