cms_SC
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10,300 rows
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| Link | rowid ▼ | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 1 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2019-01-21 | 609 | E | 1 | 0 | ZBYG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review, review of the facility's policy, and review of the facility's investigations, the facility failed to report an allegation of abuse and injury of unknown source within the required time frame to the appropriate state agency as required for four of 14 sampled residents (Resident (R) 1, R4, R9, and R11). On 10/29/18 an allegation of verbal abuse toward R9 was made; however, the facility failed to report the allegation of verbal abuse to the state agency within the required two-hour time frame. On 12/02/18 a sewing needle was discovered in R4's wound on top of his/her right foot; however, even though the resident was not cognitively intact, and the event was unwitnessed, the facility failed to identify the occurrence as an injury of unknown source and failed to report it to the state agency. On 01/08/19 R1 who was not cognitively intact experienced what the facility identified as an injury of unknown source; however, it was not reported to the state agency until 01/10/19 two days after the fact. On 09/11/18 the facility became aware that R11's narcotic pain medication was missing; however, the facility failed to report the misappropriation of the resident's medication within the required two-hour time frame to the state agency. Findings include: Review of R4's Face Sheet revealed s/he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of R4's quarterly MDS, completed on 10/24/18, revealed the facility assessed the resident to have a BIMS score of four out of fifteen, indicating the resident was severely cognitively impaired. During an interview on 01/20/19 at approximately 2:35 PM, the facility's Risk Manager (RM) revealed the incident of the sewing needle being discovered in R4's wound on her/his foot was not reported to the state agency as an injury of unknown source. The RM stated the resident could not tell how the needle got into the wound and it was not witnessed either. During an i… | 2020-09-01 |
| 2 | 2 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2019-01-21 | 610 | E | 1 | 0 | ZBYG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review, review of the facility's policy, and review of the facility's investigations, the facility failed to ensure all allegations of abuse and injury of unknown sources were thoroughly investigated for four of 14 sampled residents reviewed for facility reported incidents (FRI's) (Resident (R) 1, R4, R9, and R11). On 10/29/18 an allegation of verbal abuse toward R9 was made; however, the facility failed to interview other residents of the facility. On 12/02/18 a sewing needle was discovered in R4's wound on top of her right foot; however, even though the resident was not cognitively intact, and the event was unwitnessed, the facility failed to identify the occurrence as an injury of unknown source and failed to initiate an investigation. On 01/08/19 R1, who was not cognitively intact, experienced what the facility identified as an injury of unknown source; however, it was not thoroughly investigated. On 09/11/18 the facility became aware that R11's narcotic pain medication was missing; however, the facility failed to conduct a thorough investigation. Findings include: Review of R9's, Face Sheet revealed s/he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of R9's admission Minimum Data Set (MDS) completed on 11/05/18 revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of three out of fifteen, indicating the resident was severely cognitively impaired. Review of the facility's Initial 24-Hour Report, dated 11/01/18, revealed the type of reportable incident was alleged abuse. Continued review revealed the date and time of the reportable incident was 10/29/18 at 7:17 PM. Review of the facility's Five-Day Follow-Up Report, dated 11/5/18, revealed Registered Nurse (RN) 2 and Certified Nursing Assistant (CNA) 1 were the only staff interviewed about the incident. Additionally, there was no documented evidence interviewable residents in the facility… | 2020-09-01 |
| 3 | 3 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2019-01-21 | 755 | D | 1 | 0 | ZBYG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview, and review of the facility's policy, the facility failed to assure that each cottages' narcotic medications that were locked in the cottages' medication cart corresponded with the cottages' narcotic count recorded in the narcotic book for two of 12 cottages. Findings include: On 01/18/19 at 4:30 PM, review of the narcotic medications that were locked in the locked compartment of the medication cart and in the presence of the Assistance Director of Nursing (ADON), Licensed Practical Nurse (LPN) 4 stated that Resident (R) 1 had nine tablets of [MEDICATION NAME]-ACET 5 mg (milligrams)-325 mg. However, R1's narcotic sheet for [MEDICATION NAME]-ACET 5 mg-325 mg tablet indicated 10 tablets. LPN4 stated that R1 had two tablets of [MEDICATION NAME] HCL 50 mg; however, review of R1's narcotic sheet for [MEDICATION NAME] HCL 50 mg tablet indicated three tablets. During an interview on 01/18/19 at 4:30 PM, LPN 4 stated that s/he gave R1 one [MEDICATION NAME] tablet when s/he returned from her/his doctor's appointment around 2 PM. LPN4 stated that s/he administered the [MEDICATION NAME] at 12 PM at the scheduled time. LPN4 stated that s/he forgot to document on each of the narcotic sheets that s/he had administered the medications. LPN 4 stated it was the facility's policy to document the administration of the medication after the medication was administered. Review of the Electronic Medication Administration Record (EMAR) with LPN4 and the ADON, revealed that there was no documentation that R1 had received one tablet of [MEDICATION NAME] at 2 PM; however, the [MEDICATION NAME] was documented as administered during the scheduled time at 12 PM. During an interview on 01/19/19 at 8:50 AM with the Administrator, ADON, and Unit Manger, the Unit Manager stated that s/he expected the nurses to document on the EMAR and, if applicable, the narcotic sheet immediately after administering any medication. Review of R15's Face She… | 2020-09-01 |
| 4 | 4 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2019-01-21 | 842 | D | 1 | 0 | ZBYG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview, and review of the facility's policy, the facility failed to document in the resident's clinical record the nursing assessment of the physical condition for one of five residents reviewed for falls. (Resident (R) 2) after R2 fell from the mechanical lift to the floor. In addition, the facility failed to document the reason R2's physician was not notified for approximately one and one-half hours after the fall. Findings include: R2 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the 24-hour Report dated 12/28/18 indicated the details of the incident that occurred on 12/27/18 at 7 PM, Resident was in Hoyer lift being placed back to bed. Hoyer lift clip cracked, and resident fell to the floor from an up position to her/his left side . Resident was sent to the ER. Review of R2's Progress Notes dated 12/27/18 at 2240 (11:40 PM) indicated, While CNA (certified nurse aide) was transferring resident to bed via hoyer lift, upon placing the hoyer lift in the upright position, the left side of the sling (black plastic piece) popped. Patient fell on the floor out of the lift. Fall was noted at 1900 (7 PM). Resident was assessed . Resident requested to be sent to ER( emergency room ) . PCP (primary care physician) notified at 2034 (8:34 PM) and informed of incident and request to send to ER. EMS (Emergency Medical Services) arrived at 1906 (7:06 PM). Substitute POA (Power of Attorney) notified at 2234 (10:34 PM). Review of the document titled PACS Nursing - Post Fall Review, dated 12/27/18 at 6:50 PM, addressed that there was no history of falls; the medication the resident received were narcotics, diuretics, and laxatives; memory cognitively intact; adequate vision; total incontinence of urine and bowel movement; no behaviors in last seven days; confined to chair; no problems with blood pressure; and gait indicated unable to independently come to a standing position. The document did not d… | 2020-09-01 |
| 5 | 5 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2018-03-01 | 550 | D | 0 | 1 | JK8711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews the facility failed to provide dignity and privacy for Resident # 41 by not covering the resident's catheter bag when it was in sight of other people. ( 1 of 2 residents observed with catheters) The findings included: The facility admitted Resident # 41 with [DIAGNOSES REDACTED]. On three days of the survey the resident was observed in bed in his/her room with the catheter tubing hanging uncovered on the side of the bed facing the door. The bag could be seen by anyone walking by the door or out in the dining area. Interview with the resident's spouse revealed the staff usually covered the bag but he/she had not seen the bag covered at all this week. Interview with Certified Nursing Assistant # 1 ( CNA) on 2/28/18 @ 10:15 AM revealed that the catheter bags were covered any time a resident was up or catheter bag was in view of other people to protect the privacy and dignity of the resident. When asked what he/she saw when he/she looked into this resident's room. He/she stated the catheter bag uncovered. The CNA confirmed the resident's privacy and dignity was not being protected. The CNA further stated, The cover was removed the other day and not replaced. There have not been any covers in the closet or in the cottage at all this week. The Licensed Practical Nurse #1 also responded that there were no covers in the cottage and that he/she would order some. | 2020-09-01 |
| 6 | 6 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2018-03-01 | 659 | D | 0 | 1 | JK8711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to provide care per the Care Plan for Resident #18, 1 of 7 sampled residents reviewed for Falls. Resident #18 was care planned for the bed to be in low position and to remove bed controls due to the resident being a high fall risk. Cross refer to F689 The findings included: The facility admitted Resident #21 with [DIAGNOSES REDACTED]. Resident #21 was observed in bed with the bed in normal position (not low) on 2/26/2018 at 10:59 AM, 2/27/2018 at 3:56 PM and 2/28/2018 at 3:06 PM. Record review of the Care Plan on 2/28/2018 at 3:23 PM, revealed a focus area indicating Resident #21 was at risk for fall related injuries. Interventions listed for the focus area were to keep the bed in lowest position and to remove the bed controls when the bed is in lowest position so the resident can't raise bed to a high position. In addition, the Care Plan indicated the resident was a high fall risk. During an observation and interview with Certified Nursing Assistant (CNA) #2 on 2/27/2018 at 3:58 PM, Resident #18 was observed in bed with the bed in normal position. In addition, the bed controls were observed on the bed, within reach of the resident. CNA #2 stated that the resident was care planned to have the bed low, but she/he did not like the bed in low position. CNA #2 stated that the resident can become very agitated when the bed is in low position and will crawl out of the bed and then be found on the floor in the room. CNA #2 stated that when the bed is in normal position the resident is calm and content. Upon leaving the room, CNA #2 left the bed in normal position with the bed controls within reach of the resident. During an interview with Licensed Practical Nurse (LPN) #5 on 2/28/2017 at 3:06 PM, LPN #5 verbalized fall prevention interventions for Resident #18, including keeping the bed in lowest position. In addition, LPN #5 stated the resident is cognitively intact enough to op… | 2020-09-01 |
| 7 | 7 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2018-03-01 | 679 | D | 0 | 1 | JK8711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview, the facility failed to provide a structured program of activities for 1 of 1 sampled resident reviewed/triggered for activities. Resident #82 was observed in bed in his/her room with no structured activities in progress. The findings included: The facility admitted Resident #82 with [DIAGNOSES REDACTED]. Observations on 2/26/18 from 10 AM to 1 PM revealed Resident in room in bed with no structured program of activities provided. A record review on 2/26/18 at approximately 11:28 PM revealed documentation on a physician's capacity statement that Resident #82 was admitted on [DATE] and physician's cumulative orders that the resident was admitted on [DATE]. A social note dated 2/06/18 indicated the resident scored 15 cognition indicating cognition was intact and resident able to voice needs. Further record review revealed no activity evaluation was completed and there was no documentation on the paper charting or electronic record to indicate a structured program of activities were provided. An observation on 2/27/18 at approximately 11:33 PM to 1 PM revealed the resident in his/her room with no structured program of activities in place. A nurse's noted dated 2/06/18 indicated Resident #82 refused medication and verbally expressed he/she wanted to die. An interview on 2/28/18 at approximately 8:30 AM with Social Services Assistant #1 revealed the resident received psych services on 2/13/18. A review of the psych results revealed the resident depressed with a recommendation for staff to encourage residents to participate in activities. An interview on 2/28/18 at approximately 10:15 AM with the Activity Director (AD) confirmed the activity assessment/evaluation was not complete and there was no documentation in the medical record (paper/electronic) of activities being provided. | 2020-09-01 |
| 8 | 8 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2018-03-01 | 684 | D | 0 | 1 | JK8711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide the necessary care and services for 1 of 6 residents reviewed for unnecessary medications. Resident #115's elevated blood sugars were not reported to the physician as ordered. The findings included: Resident #115 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. Review of Medication Administration Records for Resident #115 on 2/28/18 at approximately 11:12 AM revealed the resident had an elevated blood sugar of 410 on 2/23/18. Review of Resident #115's Progress Notes on 2/28/18 at approximately 11:50 AM revealed no documentation that the physician was notified of elevated blood sugar on 2/23/18. Interview with Director of Nursing (DON) on 2/28/18 at approximately 1:26 PM confirmed that there was no documentation that the elevated blood sugar on 2/23/18 was relayed to the physician. | 2020-09-01 |
| 9 | 9 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2018-03-01 | 689 | D | 0 | 1 | JK8711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to implement fall prevention interventions for Resident #18, 1 of 7 sampled residents reviewed for falls. The facility failed to maintain the resident's bed in the lowest position and remove the bed controls per the Care Plan. Resident #18 has a history of multiple falls. Cross refer to F659 The findings included: The facility admitted Resident #21 with [DIAGNOSES REDACTED]. Resident #21 was observed in bed with the bed in normal position (not low) on 2/26/2018 at 10:59 AM, 2/27/2018 at 3:56 PM and 2/28/2018 at 3:06 PM. Record review of the Nurse's Notes on 2/28/2018 at 2:23 PM revealed that the resident had unwitnessed falls in her/his room on 10/30/2017, 11/25/2017, 12/27/2017 and 2/9/2018. In each case the resident was found on the floor near her/his bed. Record review of the Care Plan on 2/28/2018 at 3:23 PM, revealed a focus area indicating Resident #21 was at risk for fall related injuries. Interventions listed for the focus area were to keep the bed in lowest position and to remove the bed controls when the bed is in lowest position so the resident can't raise bed to a high position. In addition, the Care Plan indicated the resident was a high fall risk. Review of the Certified Nursing Assistant task sheet for Resident #18 on 3/1/2018 at 10:25 AM, revealed a task to keep the resident's bed in low position. Removing the resident's bed controls was not listed on the task sheet. During an observation and interview with Certified Nursing Assistant (CNA) #2 on 2/27/2018 at 3:58 PM, Resident #18 was observed in bed with the bed in normal position. In addition, the bed controls were observed on the bed, within reach of the resident. CNA #2 stated that the resident was care planned to have the bed low, but she/he did not like the bed in low position. CNA #2 stated that the resident can become very agitated when the bed is in low position and will crawl out of the bed and th… | 2020-09-01 |
| 10 | 10 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2018-03-01 | 732 | C | 0 | 1 | JK8711 | Based on observations, interviews and review of the facility's posting information, the facility failed to complete daily posting information that addressed nursing staff per shift. The posting did not identify whether nurse was registered or licensed and certified nursing to resident coverage was not included. 12 of 12 cottages. The findings included: During initial tour on 2/26/18 of the Forsythia Cottage at approximately 9:30 AM and the Rose Cottage at approximately 9:38 AM review of the hand written staff posting had no documentation of staff coverage related to the second shift (7 PM - 7:30 AM). Random observation on 2/27/18 at approximately 9 AM of the Rose Cottage and 9:30 AM of the Forsythia Cottage revealed the hand written staff posting noted on the wall with no second shift (7 PM - 7:30 AM) staff posted. An interview on 2/27/18 at approximately 12:15 PM with the Director of Nursing (DON) and Facility Administrator confirmed the second shift staff documentation was not posted for any of the cottages until the second shift staff arrived to the facility. Further review of hand written staff postings on the cottage revealed staff posting for 2/24/18 (Saturday) Rose Cottage first shift (7 AM - 7:30 PM) had no documentation of nursing staff coverage and the hand written on 2/25/18 (Sunday) Rose Cottage had no first shift staff coverage. The hand written staff posting for 2/25/18 (Sunday) Forsythia Cottage had no documentation of staff coverage. Review of the hand written posting indicated staff worked 12 and half hours shifts. During the survey, two family members expressed concerns about lack of evening and weekend staff coverage. During group interview on 2/27/18 at approximately 11 AM three of 5 residents who attend resident council regularly expressed concerns about staff coverage at nights and on weekends. A review of a computerized accounting of staff coverage for the past three months on 3/01/18 at 8:40 AM revealed a listing of staff coverage that was not accessible to residents/visitors/families. The… | 2020-09-01 |
| 11 | 11 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2018-03-01 | 745 | D | 0 | 1 | JK8711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the communication sheet and interview, the facility failed to arrange and provide transportation to a medical appointment for Resident #121, 1 of 1 sampled resident reviewed for medically-related social services. Resident #121 missed a doctor's appointment due to the facility not arranging transportation. The findings included: The facility admitted Resident #121 with [DIAGNOSES REDACTED]. During an interview with Resident #121 and family member on 2/26/2018 at 10:00 AM, Resident #121 stated she/he had an upcoming appointment with his/her Oncologist on 2/28/2018. The family member stated she/he was concerned because the facility had provided no confirmation of transportation to the appointment. Resident #121 produced a form from his doctor with a list of upcoming appointments, including appointments on 2/28/2018 and 3/7/2018. During an interview with Licensed Practical Nurse (LPN) #3 on 2/26/2018 at 10:13 AM, LPN #3 was made aware of Resident #121 's and the family member's concerns related to the upcoming appointment on 2/28/2018. LPN #3 stated she/he would take care of the arrangements. On 2/28/2018 at 12:12 PM, LPN #4 was observed talking to another staff member about Resident #121's Oncology appointment. The staff member told LPN #4 that the Oncologist's office was calling asking why Resident #121 had not shown up for his/her appointment. LPN #4 then called the transporter (person in charge of setting up transportation). After the call, LPN #4 was interviewed and stated that transportation had not been arranged for the resident's appointment. LPN #4 stated transportation had been set up for an appointment on 3/7/2018, but not for today. During an interview with the Director of Nursing on 2/28/2018 at 2:00 PM, the DON confirmed that transportation had not been set up for the resident's appointment today. The DON stated LPN #3 reported to her/him that she/he called the transporter on 2/26 to see if transportation had been… | 2020-09-01 |
| 12 | 12 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2018-03-01 | 758 | D | 0 | 1 | JK8711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to monitor antipsychotic usage for 1 of 6 residents reviewed for unnecessary medications. Resident #115 was on antipsychotics and the facility failed to monitor him/her for side effects, behaviors, and nonpharmaceutical interventions. The findings included: Resident #115 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #115's Medication Administration Record [REDACTED]. Interview with the Director of Nursing (DON) on 2/28/18 at approximately 12:54 PM revealed the order for antipsychotic monitoring was discontinued by the physician. The DON was unable to clarify why the order had been discontinued. Interview with the DON on 2/28/18 at approximately 1:26 PM revealed the facility had resumed monitoring for antipsychotic medications. | 2020-09-01 |
| 13 | 13 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2018-03-01 | 842 | D | 0 | 1 | JK8711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to accurately document a medical record (paper/electronic) for 1 of 42 sampled residents reviewed for advanced directives and clinical accuracy. Resident #82 paper charting was noted with full size red sheet of paper that indicated Do Not Resuscitate (DNR) and the electronic documentation indicated Cardiopulmonary Resuscitation (CPR). There was an inconsistency in the resident's admitted . The findings included: The facility admitted Resident #82 with [DIAGNOSES REDACTED]. A review of the paper charting and electronic charting on [DATE] at approximately 11:28 AM revealed the resident's chart for advanced directive was coded as DNR and CPR. The paper charting was noted with a red sheet of paper that indicated DNR. The electronic record indicated the resident's advance directive was CPR (full code). Further review of the medical record review that one physician's signed resident's inability to consent on [DATE] and the second physician signed the inability to consent on [DATE]. The decisional capacity forms indicated Resident #82 was admitted on [DATE] and the Cumulative physician's orders [REDACTED]. An interview on [DATE] at approximately 12:09 PM with Licensed Practical Nurse (LPN) #2 confirmed the findings that the paper chart indicated DNR and the computer documentation was CPR. | 2020-09-01 |
| 14 | 14 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2019-05-16 | 550 | D | 0 | 1 | Y5WG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interview, the facility failed to ensure that residents were treated with respect and dignity in three of 12 Cottages observed. Staff and/or contractor were observed entering residents' rooms without knocking. (Forsythia, Dogwood and Azalea) The findings included: An observation in the Forsythia Cottage on 5/13/19 at approximately 11:30 AM revealed Licensed Practical Nurse (LPN) #1 entering Resident #367 room without knocking. The resident was observed sitting in a wheelchair in his/her room. During an interview on 5/13/19 at approximately 11:33 AM with LPN #1 confirmed the observation. LPN #1 then smiled and knocked on the resident bedside table and playfully stated I have knocked now. A random observation in the Dogwood Cottage on 5/13/19 at approximately 3:13 PM revealed Activity staff entering room [ROOM NUMBER] without knocking. The resident was in the room in bed when the staff member entered the room. During an interview on 5/13/19 at approximately 3:18 PM with the Activity staff confirmed the observation. The Activity staff stated he/she does not generally knock on the resident's door if the door is opened and the resident is looking out toward the door. A random observation in the Azalea Cottage on 5/14/19 at approximately 12:05 PM revealed a nurse entering room [ROOM NUMBER] without knocking. The resident was in the room in bed. A random observation in the Azalea Cottage on 5/14/19 at approximately 12:21 PM revealed someone testing the alarms entering multiple residents' rooms without knocking. During an interview on 5/14/19 at approximately 12:25 PM revealed the alarm tester to be an Outside Fire Contractor who was entering the resident's rooms without knocking. | 2020-09-01 |
| 15 | 15 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2019-05-16 | 565 | E | 0 | 1 | Y5WG11 | Based on interviews and review of the Resident Council Minutes, the facility failed to ensure residents grievance were addressed related to staff being accessible in the cottages. Eight of eight group members and four months of resident council minutes. The findings included: During the agency group interview on 5/14/19 at approximately 10:32 AM eight of eight residents deemed alert, oriented and interview-able by the facility expressed concerns about staff being accessible in the cottages when needed. One resident stated that it takes several hours to see a nurse when needed because there may be one nurse at times who was responsible for rotating between three cottages. Another resident agreed that it takes staff a long time to address needs because staff rotate to other cottages. The resident who expressed concerns about one nurse covering three cottages stated he/she was not sure if one certified nursing aide had to cover three cottages as well. The residents stated they have addressed their concerns in resident council meetings. A review of the resident council minutes on 5/14/19 revealed at the 4/25/19 meeting there were concerns of getting medicine late due to nurse being in another cottage, certified nursing aides (CNA) on cells phone and certified nursing aides cutting off call lights saying they will return, and they do not return. The 3/27/19 resident meetings indicated medication was still being provided late, there are still issues with the certified nursing aides and staff not available to answer phones at night when family members are trying to contact the resident. The 2/28/19 resident meeting indicated concerns with late medications, CNA on cell phones. The (MONTH) 2019 minutes indicated concerns with late medications, cottages being un-staffed at night and CNAs telling residents they are alone in the cottages and unable to answer call lights. During an interview on 5/16/19 at approximately 8:16 AM with the Administrator revealed he/she was aware of the residents' concerns regarding staffing and t… | 2020-09-01 |
| 16 | 16 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2019-05-16 | 607 | D | 1 | 0 | Y5WG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview and review of the facility's abuse policy, the facility failed to ensure that allegations of abuse were reported to the state agency within 2 hrs per policy for 1 of 6 abuse reports reviewed. Resident #365 allegation of abuse known by the facility to have occurred on 3/24/19 was not reported timely per the facility's abuse policy. The findings included: The facility admitted Resident #365 on 3/23/19 with [DIAGNOSES REDACTED]. A review of the facility's complaint investigation on 5/15/19 at approximately 8:35 AM revealed a nurse's statement with no date that indicated Resident #365 and his/her family member reported to the nurse that a Certified Nursing Aide (CNA) that night shift told the resident to hold onto the side rail to be changed because the CNA did not want to hurt his/her back trying to change the resident. The statement allegedly written by the CNA/alleged perpetrator was unsigned and further identified another CNA was present during the time of the alleged incident. The other CNA named in the statement did not provide a written statement. The statement written by the CNA indicated he/she provided care to the resident on 3/23/19 which was earlier than the date provided on the facility's investigation reports. Further review of the facility's complaint investigation revealed the facility reported the incident of alleged abuse on 3/25/19. A review of the facility's abuse policy under Reporting Timeframe, Abuse of any kind is to be reported within 2 hours by the facility as well as serious injury (which could fall under neglect or injury of unknown origin). Further review of the facility's policy under Role of the Investigator under 1(d) Interview any witnesses to the incident, 1(e) Interview the resident if medically possible and 1 (h) Interview family members. During an interview on 5/15/19 at approximately 10:36 AM with Registered Nurse (RN) #2 revealed the incident reportedly occurred on 3/24/19… | 2020-09-01 |
| 17 | 17 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2019-05-16 | 609 | D | 1 | 0 | Y5WG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to ensure that allegations of abuse were reported to the state agency within 2 hours for 1 of 6 abuse reports reviewed. Resident #365 allegation of abuse known by the facility to have occurred on 3/24/19 was not reported until 3/25/19. The findings included: The facility admitted Resident #365 on 3/23/19 with [DIAGNOSES REDACTED]. A review of the facility's complaint investigation on 5/15/19 at approximately 8:35 AM revealed a nurse's statement with no date that indicated Resident #365 and his/her family member reported to the nurse that a Certified Nursing Aide (CNA) that night shift told the resident to hold onto the side rail to be changed because the CNA did not want to hurt his/her back trying to change the resident. The statement allegedly written by the CNA/alleged perpetrator was unsigned and further identified another CNA was present during the time of the alleged incident. The other CNA named in the statement did not provide a written statement. The statement written by the CNA indicated he/she provided care to the resident on 3/23/19 which was earlier than the date provided on the facility's investigation reports. Further review of the facility's complaint investigation revealed the facility reported the incident of alleged abuse on 3/25/19. During an interview on 5/15/19 at approximately 10:36 AM with Registered Nurse (RN) #2 revealed the incident reportedly occurred on 3/24/19 but he/she does not know what time the incident occurred. RN #2 further stated the nurse who had been informed of the allegation of abuse did not include a date in his/her statement. During an interview on 5/15/19 at approximately 12:05 PM with RN #2 confirmed the allegation of abuse was not reported to the state agency within the 2 hours requirement per facility policy. | 2020-09-01 |
| 18 | 18 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2019-05-16 | 610 | D | 1 | 0 | Y5WG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to ensure that allegations of abuse were thoroughly investigation for 1 of 6 abuse reports reviewed. Resident #365 allegation of abuse had unsigned and undated witness statement and other staff members identified as being present at the time of the incident were not interviewed. The findings included: The facility admitted Resident #365 on 3/23/19 with [DIAGNOSES REDACTED]. A review of the facility's complaint investigation on 5/15/19 at approximately 8:35 AM revealed a nurse's statement with no date that indicated Resident #365 and his/her family member reported to the nurse that a Certified Nursing Aide (CNA) that night shift told the resident to hold onto the side rail to be changed because the CNA did not want to hurt his/her back trying to change the resident. The statement allegedly written by the CNA/alleged perpetrator was unsigned and further identified another CNA was present during the time of the alleged incident. The other CNA named in the statement did not provide a written statement. The statement written by the CNA indicated he/she provided care to the resident on 3/23/19 which was earlier than the date provided on the facility's investigation reports. Further review of the facility's complaint investigation revealed the facility reported the incident of alleged abuse on 3/25/19. During an interview on 5/15/19 at approximately 10:35 AM with Registered Nurse (RN) #2 revealed the incident/allegation of abuse occurred on 3/24/19 but he/she does not know the time. RN#2 further confirmed the CNA/alleged perpetrator statement was unsigned and the nurse's statement was not dated. RN #2 confirmed there were no nurses notes to indicate when the resident/family reported the allegations of abuse. RN#2 further stated the new corporation had expressed that more accurate information was needed regarding allegations of abuse. | 2020-09-01 |
| 19 | 19 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2019-05-16 | 725 | D | 0 | 1 | Y5WG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide sufficient staffing for 2 of 12 cottages. Staff and residents expressed that the structure and layout of the cottages along with the insufficient staffing led to long wait times and inadequate care of residents. The findings included: Brushy Creek Rehabilitation and Healthcare Center consists of 12 cottages each with 12 beds. The only way to move between cottages is to traverse outside. Review of Grievance Log for Resident #67 on 5/15/19 at approximately 12 PM revealed that on 4/4/19 at approximately 2 PM the resident had rung his/her call light for assistance and walked away. The resident changed his/her own brief and filed a grievance. Review of Resident Council Minutes on 5/15/19 at approximately 12 PM revealed the following: 1. (MONTH) concerns expressed regarding CNA staffing 2. (MONTH) concerns regarding lack of CNAs in nurses and cottages; CNAs continue to tell the residents they are alone in the cottage and thus unable to answer the call button 3. (MONTH) concerns regarding nurses doing a good job but needed more help; CNAs are being split between cottages and care is limited at times and not enough CNAs for residents During an interview with Certified Nursing Aide (CNA) #1 on 5/15/19 at approximately 3 PM revealed during night shifts there often may be just one staff member (CNA) in a building because the nurse is attending to another cottage. During an interview with Licensed [MEDICATION NAME] Nurse (LPN) #2 on 5/16/19 at approximately 9 AM revealed the following: 1. Sometimes during the night shift residents may fall because the CNA is busy with another resident in the cottage while the nurse is in another cottage and unable to assist. 2. During night shift, when two staff members are required for care s/he stated, If the nurse has two cottages they're called over. If they have three cottages they're called over, but it may take longer. 3. LPN #2 stated she has exp… | 2020-09-01 |
| 20 | 20 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2019-05-16 | 812 | E | 0 | 1 | Y5WG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and policy review, the facility failed to ensure that food was stored, prepared and distributed in an appropriate manner for 5 of 12 Cottages observed for kitchen services. Holly, Magnolia, and Rose Cottages had expired food and foods that were opened with no open date. Magnolia and Rose Cottages were observed with resident's personal food in the refrigerator used by the cook which was against facility policy. The Dogwood Cottage Kitchen had staff preparing meals with facial hair uncovered (thick mustache). The Azalea Cottage Kitchen had staff preparing meals with large trash can with no lid available. The findings included: During the initial tour of Holly Cottage with the Registered Dietitian (RD) on [DATE] at approximately 10:10 AM, butter was observed in the freezer with an expiration date of [DATE]. The expiration date was verified by the RD at the time of the observation. During the initial tour of Magnolia Cottage with the RD on [DATE] at approximately 10:40 AM, Lemon juice was observed in the kitchen area with an expiration date of [DATE]. Also, during the tour, cooking spray, granulated garlic, and ground cinnamon were observed in the kitchen area without dates opened for use. As the tour continued, Paprika had an opened-on date of [DATE], steak seasoning had an opened-on date of [DATE], basil had an opened-on date of [DATE] and vanilla extract had an opened-on date of [DATE]. The expiration date of the lemon juice was verified by the RD at the time of observation. The lack of opened-on dates for the cooking spray, granulated garlic, and ground cinnamon was verified by the RD at the time of observation. When asked about the older opened-on dates, the RD stated that the items should have been thrown out after a year or at expiration. A resident's personal food was observed in the kitchen refrigerator of Magnolia Cottage. This was verified by the RD at the time of observation. During the initial tour … | 2020-09-01 |
| 21 | 21 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2019-05-16 | 842 | D | 1 | 0 | Y5WG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview and review of facility policy the facility failed to maintain a complete and accurate medical record for Residents #366 and 365, 2 of 27 sampled residents reviewed for complete and accurate records. Resident #365's record did not have complete and accurate documentation related to an incident of alleged abuse. Resident #366's record lacked documentation related to controlled substance medication administration. The findings included: The facility admitted Resident #366 with [DIAGNOSES REDACTED]. Review of a Facility Reported Incident on 5/15/19 at 1:49 PM revealed Resident #366's pain medication [MEDICATION NAME] 50 milligrams (mg) was accidentally placed in a bin for discontinued medications on 4/21/19. After a complete investigation by the facility, the medication was found on 4/23/19. Record review of Medication Administration Records (MAR) and narcotic count sheets on 5/15/19 at 1:51 PM revealed an order for [REDACTED]. The narcotic count sheets revealed the resident's 4/21/19 morning dose of [MEDICATION NAME] was signed out at 8:50 AM and administered to the resident per the MAR. The narcotic count sheets revealed the 2 tablets of [MEDICATION NAME] 50mg were signed out on 2 separate occasions on 4/23/19. The time the [MEDICATION NAME] was signed out was not documented by either nurse signing out the [MEDICATION NAME] on 4/23/19. Record review of notes from the MAR on 5/16/19 at 9:12 AM revealed 2 tablets of [MEDICATION NAME] were administered to Resident #366 on 4/23/19 at 5:06 PM and 10:13 PM, about 5 hours apart. The orders were to receive the [MEDICATION NAME] every 12 hours. During an interview with the Assistant Director of Nursing (ADON) on 5/15/19 at 2:26 PM, the ADON confirmed the narcotic count sheets did not indicate what time Resident #366 [MEDICATION NAME] was signed out on 4/23/19. The ADON stated the resident's [MEDICATION NAME] was found around 4:00 PM on 4/23/19 and the resident request… | 2020-09-01 |
| 22 | 22 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2018-06-26 | 609 | E | 1 | 0 | Y9Q111 | > Based on record review, interview, and review of the facility policy titled Reporting of Alleged Abuse to Facility Management, the facility failed to report injuries of unknown source to the State Agency for 2 of 3 sampled residents reviewed for abuse. The facility failed to report injuries of unknown source for Resident #2 and Resident #3 to the state agency. The findings included: Review of Resident #2's health status note dated 5/30/18 revealed a note from the Risk Manager which stated Resident has a 1.5mm purple discoloration to his/her right bottom inner eye. Residents reports s/he is not really sure how it could have happened nor did s/he know it was there but s/he stated 'Oh it could have happened by rubbing my eye, it doesn't hurt, so don't worry about it' Will continue to monitor. Review of the facility incident report for resident #2 dated 6/19/18 reveled the incident description section which stated I was called to Resident room today regarding bruising to bilateral hands with bruising extending from left hand to left forearm. Resident is alert and orientated and stated I don't know how it happened but I pull my table over, eat all my meals in my bed with the tray on my lap, I have arthritis but no, my hands don't hurt. Review of Resident #2's progress notes dated 6/19/18 revealed a note from a Licensed Practical Nurse (LPN) which stated Unidentified bruising on patients top right and left hand. The CNA (Certified Nursing Assistant) noticed as s/he came on for the 7a-7p shift today and brought it to my attention. Patient appears to be in no pain at this time. __ __ in risk management was notified, visited the patient and said s/he would document on the incident. Will continue to monitor. Review of the facility incident report for Resident #3 dated 4/28/2018 revealed the incident description section which stated Yellow/brownish bruise to Left FA new AC Reddish 7cm bruise to med, right back Resident stated s/he thought is may have occurred when s/he wrapped arm around bed rail to assist with turning/re… | 2020-09-01 |
| 23 | 23 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2017-08-23 | 224 | D | 1 | 0 | O8U111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, review of the facility's Abuse policy and interview, the facility failed to conduct a thorough investigation for Resident #1, 1 of 3 sampled residents reviewed for Injury of Unknown Source. Resident #1 suffered a fracture of unknown origin. The facility failed to interview and obtain statements from direct care staff who provided care for Resident #1, on or around the time the resident suffered the fracture. The cause or exact date of the fracture could not be determined. Cross refer to F225 The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Record review of the Initial 24-Hour Report, dated 3/30/2017, on 8/23/2017 at 9:40 AM revealed Resident #1 suffered an injury of unknown source on 3/30/2017 at 12:00 AM. Record review of the Five-Day Follow-Up Report, dated 4/4/ on 8/23/2017 at 9:40 AM revealed the resident suffered an acute non-displaced left fibula and tibial shaft fracture. The injury was discovered on 3/30/2017 at 12:00 AM. Per the Five-Day Follow-Up Report, Resident #1 complained of pain to the left leg with repositioning on 3/29/2017. The resident was able to move her/his left leg. The resident also had a witnessed [MEDICAL CONDITION] on 3/27/2017. In addition, staff attempted to obtain a urine sample on 3/27/2017 via a in and out catheter. Per the report, the resident became very combative with thrashing around in bed while his/her legs were trying to be abducted. The resident spent all day in bed with intermittent diarrhea 3/28/2017. The facility's investigation concluded that the fracture appeared to be the result of the combative behavior during the in and out catheter procedure. Record review of the Telephone Orders on 8/23/2017 at 10:08 AM revealed an order, dated 3/27/2017 at 4:00 PM, for a in and out catheter to obtain a urine sample for urinalysis. A Telephone Order dated 3/28/2017 discontinued the in and out catheter order. Record review of the Medication Administr… | 2020-09-01 |
| 24 | 24 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2017-08-23 | 225 | D | 1 | 0 | O8U111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview and review of the facility's Abuse policy, the facility failed to report an Injury of Unknown Source that resulted in serious bodily injury for 2 of 3 sampled residents reviewed for Injury of Unknown Source. Resident's #1 and #2 suffered fractures and the injuries were reported later than 2 hours. Cross refer to F 224 The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Record review of the Initial 24-Hour Report, dated 3/30/2017, on 8/23/2017 at 9:40 AM revealed Resident #1 suffered an injury of unknown source on 3/30/2017 at 12:00 AM. The resident suffered a fracture. A time stamp on the faxed report indicated it had been sent to the State Agency on 3/30/2017 at 11:45 AM. The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Record review of the Initial 24-Hour Report, dated 4/28//2017, on 8/23/2017 at 9:40 AM revealed Resident #2 suffered an injury of unknown source on 4/28/2017 at 9:00 AM. Resident #2 suffered a left arm fracture. A time stamp on the faxed report indicated it had been sent to the State Agency on 4/28/2017 at 1:59 PM. During an interview with the risk manager on 8/23/2017 at 12:31 PM, the risk manager confirmed that the injuries of unknown origin were reported later than 2 hours. The Risk Manager stated she/he is aware of the 2-hour reporting requirement. Review of the facility's Reporting Abuse to State Agencies and Other Entities policy revealed Should a suspected crime resulting in serious bodily injury, the employee shall report the suspicion immediately, but no later than 2 hours after forming the suspicion. | 2020-09-01 |
| 25 | 25 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2016-12-01 | 282 | D | 0 | 1 | OHU211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to follow the nutrition care plan for 1 of 1 sampled resident for hospice. Dietary approaches for a low fiber diet with ground meat and nectar-thickened liquids was not followed for Resident #265. The findings included: The facility admitted Resident #265 with [DIAGNOSES REDACTED]. Review of nutrition care plan on 11/29/2016 revealed approaches for a low fiber diet with ground meat and nectar-thickened liquids. Record review on 11/29/2016 revealed Physicians Orders for low fiber diet with ground meat and nectar liquids with no straws. Review on 11/29/2016 of nutrition care plan revealed approaches for a low fiber diet with ground meat and nectar-thickened liquids. Observation on 11/29/2016 at 12:40 PM revealed that Resident #265 was served a wheat roll, chopped ham with gravy, mashed potatoes, mixed vegetables (peas, carrots, and lima beans), peaches, and nectar-thickened liquids. Certified Nursing Assistant (CNA) #2 was assisting with feeding the Resident and confirmed what was on the Residents tray. Observation on 11/30/2016 at 1:03 PM revealed Resident #265 was served rice, squash, coconut cake, nectar-thickened tea, and a white roll. CNA #1 was assisting with feeding the Resident and confirmed what was on the Residents tray. During an interview on 11/30/2016 at 1:15 PM CNA #1 pointed out dietary instructions for a low fiber diet for Resident #265 located in a notebook in the dining area. Dietary instructions included that the Resident was not to receive all beans, peas, whole wheat products, and coconut. | 2020-09-01 |
| 26 | 26 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2016-12-01 | 309 | D | 0 | 1 | OHU211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure integration of Hospice and facility services to provide continuity of care for 1 of 1 sampled resident reviewed for Hospice. Complete documentation could not be found in Resident #265's medical record for Hospice services provided and there was no evidence of communication between Hospice and the facility to establish an agreed upon/coordinated plan of care. The findings include: The facility admitted Resident #265 with [DIAGNOSES REDACTED]. Review on 11/29/2016 of Hospice documentation, kept in a separate notebook from the medical chart, revealed the Hospice Care Plan for Nurse visits weekly, Aide visits three times a week, Chaplin visits once a month, and Social Worker visits once a month. Record review on 11/29/2016 revealed incomplete documentation for Hospice Aide visits between 08/23/2016 and 11/17/2016, incomplete documentation for Chaplin visits for (MONTH) (YEAR), and incomplete documentation for Social Worker visits for (MONTH) (YEAR). During an interview on 11/29/2016 at 4:04 PM the Director of Social Services verified missing Hospice documentation. The Director of Social Services verified that at the time of services, Hospice notes were to be documented in Resident #265 ' s Hospice record. Review on 11/29/2016 of the Skilled Nursing Facility Service Agreement with the Hospice provider verified each party is responsible for documenting such communication in its respective clinical records to ensure that the need of hospice patients are met twenty-four hours per day. During an interview on 11/30/2016 at 12:15 PM revealed no evidence of care plan integration. Registered Nurse (RN) #1 verified that the facility staff did not review the Hospice care plan and that Hospice was only included in the facility care plan interventions under nutrition. RN #1 verified that Hospice services were not included in the interdisciplinary care plan and that Hospice did not attend the … | 2020-09-01 |
| 27 | 27 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2016-12-01 | 323 | D | 0 | 1 | OHU211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to ensure that the planned fall prevention measures were in place and/or changed/added to prevent reoccurrence and minimize potential injury for 1 of 2 sampled Residents for accidents. The findings included: The facility admitted Resident #265 with [DIAGNOSES REDACTED]. Review of fall risk assessment on 11/28/2016 revealed that Resident #265 was a high fall risk. Fall assessment dates and scores; 08/05/2016 score 10, 08/25/2016 score 10, 11/16/16 score 16. Review of Nurses notes, incident reports, and care plan revealed that Resident #265 had falls on the following dates: 9/28/16- Fall in bedroom. My knees are red but my ROM is WNL. Please place laser alarm on floor for poor safety awareness. 10/13/16- I lost balance in bathroom going into room CNA lowered me to floor. 10/23/16- Continue bed/chair alarms non skid socks. 10/28/16- Fall in bedroom Laser alarm by bed, re-educate on not turning off alarms and calling for assistance with any transfers. Nurses notes dated 10/28/2016 stated alarm not sounding r/t elder shuts it off. 11/8/16- I slid down to floor when trying to transfer self from WC to chair; no injury noted. 11/16/16- Slid out of bed onto floor with no injury noted. Implement fall mat, ensure alarms are functioning Q shift. 11/21/16- New alarms to bed and chair with no turn off switch. Observation on 11/28/2016 at 12:00 PM revealed no fall mat in Resident #265 ' s room, bed alarm with turn off switch, and laser alarm was turned off. The resident was lying in bed. Observation on 11/29/2016 at 12:35 PM revealed no fall mat in Resident #265 ' s room, and bed alarm with turn off switch. The resident was lying in bed. Observation on 11/30/2016 at 12:00 PM revealed no fall mat in resident #265 ' s room, bed alarm with turn off switch, and wheel chair alarm with turn off switch. Resident #265 was sitting in wheelchair in common area. The Director of Nursing (DON) and Re… | 2020-09-01 |
| 28 | 28 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2016-12-01 | 329 | D | 0 | 1 | OHU211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that 1 of 1 sampled resident reviewed for Hospice had documented clinical reason for medication administration and/or were monitored for effectiveness of medication for Resident #265. Resident #265 was prescribed medication for which there was no documented evidence of clinical need. The findings included: The facility admitted Resident #265 with [DIAGNOSES REDACTED]. Record review on 11/30/2016 at 9:30 AM revealed physician's orders [REDACTED]. 4 hours , [MEDICATION NAME] 0.5 mg tablet one tablet every 6 hours as needed , and Vitamin D3 1,000 units tablet 2 tablets daily . Continued review revealed no clinical indication for Vitamin D3 to treat the Resident's assessed condition. There were no laboratory reports to substantiate Vitamin D3 deficiencies or reason for continued use. No documented evaluation of the underlying cause of behaviors prior to the start of psychiatric medications. No pain measurement tool documented prior to [MEDICATION NAME] administration and after administration to measure effectiveness. No documentation of behaviors prior to administrating [MEDICATION NAME] and [MEDICATION NAME]. Review of the Medication Administration Records (MARs) revealed that from 09/01/2016 through 11/27/2016 Resident #265 received 18 doses of as needed [MEDICATION NAME] 0.5mg tab, 7 doses of as needed [MEDICATION NAME] 5mg/ml 0.5 ml, and 100 doses of as needed [MEDICATION NAME] 50 mg tab. Review of Progress Notes and MARs revealed that no reason for administration and/or effectiveness of PRN (as needed) medication were documented. Continued review revealed no evidence of evaluation of underlying cause of behaviors prior to starting routine psychiatric medications. During an interview on 11/30/2016 at 9:40 AM with the Director of Nursing (DON) information was requested to provide clinical reasons for the use of Vitamin D3. The DON stated they had reviewed the medical records a… | 2020-09-01 |
| 29 | 29 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2016-12-01 | 367 | D | 0 | 1 | OHU211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to assure that 1 of 1 sampled Residents reviewed for Hospice received the diet that was prescribed by the Physician. Resident #265 ' s physician's order [REDACTED]. The findings included: The facility admitted Resident #265 with [DIAGNOSES REDACTED]. Record review on 11/29/2016 revealed Physicians Orders for low fiber diet with ground meat and nectar liquids with no straws. Review on 11/29/2016 of nutrition care plan revealed approaches for a low fiber diet with ground meat and nectar-thickened liquids. Observation on 11/29/2016 at 12:40 PM revealed that Resident #265 was served a wheat roll, chopped ham with gravy, mashed potatoes, mixed vegetables (peas, carrots, and lima beans), peaches, and nectar-thickened liquids. Certified Nursing Assistant (CNA) #2 was assisting with feeding the Resident and confirmed what was on the Residents tray. Observation on 11/30/2016 at 1:03 PM revealed Resident #265 was served rice, squash, coconut cake, nectar-thickened tea, and a white roll. CNA #1 was assisting with feeding the Resident and confirmed what was on the Residents tray. During an interview on 11/30/2016 at 1:15 PM CNA #1 pointed out dietary instructions for a low fiber diet for Resident #265 located in a notebook in the dining area. Dietary instructions included that the Resident was not to receive all beans, peas, whole wheat products, and coconut. | 2020-09-01 |
| 30 | 30 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2016-12-01 | 371 | E | 0 | 1 | OHU211 | Based on observation and interview, the facility failed to assure foods were held at appropriate temperatures prior to serving in 2 of 2 cottages. In the Dogwood cottage, staff failed to calibrate the thermometer. In the Azalea cottage staff served foods that had been held at improper temperatures. Observation of the Azalea cottage at approximately 12:10 to 12:20 PM on 11/29/16 revealed Cook #1 measured the temperature of peaches, a cold food item, to be 49 degrees Fahrenheit. The cook did not alert the Certified Nursing Assistant (CNA) #3, who was serving, that the cold food item did not reach appropriate temperatures. Observation of the Azalea cottage at approximately 12:50 on 11/29/16 revealed that during the meal, the cold food item was held on the table without refrigeration or insulation. When CNA #3 plated four helpings of peaches and began serving, she was stopped and informed that they were not held at appropriate temperatures. Observation on 11/28/16 at 12:03 PM revealed Certified Nursing Assistant (CAN) #2 and Licensed Practical Nurse (LPN) #1 starting to plate lunch without taking food temperatures. When asked if food temperatures had been taken the staff were unaware that this had to be done. Observation on 11/28/2016 at 12:10 PM Dietary Aide #1 checked the temperature of the fish, without calibrating the thermometer. When asked Dietary Aide #1 stated that she/he calibrated the thermometer by placing it in ice water. When asked what temperature, the thermometer should be calibrated to she/he stated till it reads 0 degrees Fahrenheit. Cook #1 stated that after the thermometer was placed in ice water, it should read 32 degrees Fahrenheit. Observation on 11/28/2016 at 12:17 PM, Dietary Aide #1 filled a cup with ice and water and inserted the thermometer. When checked by Cook #1 the thermometer read 42 degrees Fahrenheit. She/He stated that the thermometer was calibrated earlier in the day and read 41.5 degrees Fahrenheit. Cook #1 stated that the Certified Dietary Manager (CDM) would need to be contacted… | 2020-09-01 |
| 31 | 31 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2020-01-29 | 759 | D | 1 | 1 | J64I11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, observation, interview, and review of the facility policy titled Enteral Tube Medication Administration, the facility failed to maintain a medication rate of less than 5%. There were 2 errors out of 32 opportunities for error, resulting in a medication error rate of 6.25%. The findings included: ERROR #1-2: Observation of Licensed Practical Nurse(LPN) #1 on 1/28/20 at 12:10 PM revealed s/he crushed [MEDICATION NAME]/[MEDICATION NAME] 25/100 milligrams(mgs) and [MEDICATION NAME] [AGE] mg and placed each in the same cup. After entering Resident #118B's room, LPN #1 placed 30 cubic centimeters(cc) of water into each of two 30cc medication cups. LPN #1 placed approximately 10 cc of water from one of the medication cups containing water into the medicine cup containing the crushed medications. After checking and confirming placement of the [MEDEQUIP] tube([DEVICE]), LPN #1 placed approximately 20 cc of water into the [DEVICE]. Medications were placed in the [DEVICE], residual medication was observed and LPN #1 placed water from the second medication cup twice trying to administer all of the medication. During this time, a small amount of spillage was noted dripping off of LPN #1's glove. S/he placed the remaining water into the tube. Observation of the medication cup which contained the medications revealed medication was still in the bottom of the cup. LPN #1 confirmed the medication in the cup. LPN #1 stated s/he should have probably let the medicine sit a little longer to help the medications dissolve. Review of the facility policy titled Enteral Tube Medication Administration revealed the policy did not address residual medication. | 2020-09-01 |
| 32 | 32 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2017-07-26 | 159 | B | 1 | 1 | LLSR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to to inform residents of balances in their personal funds for 2 of 12 residents interviewed.(Resident #48 & #46) The findings included: Record review of the Minimum Data Set(MDS) on 7/24/17 revealed Resident #48 had a Quarterly MDS dated [DATE] which listed the resident as having a 12 on the Brief Interview for Mental Status(BIMS). During an interview on 7/24/17 with Resident #48, he/she stated the facility did not inform him/her of the amount of money in his//her personal account. Record review of the MDS on 7/24/17 revealed Resident #46 had a Quarterly MDS dated [DATE] which listed the resident as having a 15 on the BIMS. During an interview on 7/24/17 with Resident #46, he/she stated the facility did not inform him/her of the amount of money in his/her personal account. During an interview with the Business Office Manager on 7/26/17 at 2:30 PM, he/she confirmed only a statement goes to the responsible party and not the resident. Information provided by the facility related to personal funds on 7/26/17 at 3:05 PM states the following: .A summary of activity is made available upon request and at least quarterly to each resident or resident representative . No additional information was presented as how the resident's knew they could request the balance of their personal account. | 2020-09-01 |
| 33 | 33 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2017-07-26 | 281 | E | 0 | 1 | LLSR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a random observation, record reviews and interviews the Facility failed to follow procedures to assure that Resident 62 was free of significant medication errors related to medicine to which allergic. The Facility admitted Resident 62 on 1/27/11 with [DIAGNOSES REDACTED]. (cross reference F333 and F425) The findings include: On 7/23/17 at approximately 1:57 PM during chart review it was noted that Resident 62 had a physician's order for [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME]-[MEDICATION NAME]) Ophthalmic Ointment to be instilled inside lower lids of both eyes at bedtime and that Resident 62 was listed as allergic to [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME]-[MEDICATION NAME]). [MEDICATION NAME] and [MEDICATION NAME] are common ingredients in both [MEDICATION NAME] and [MEDICATION NAME]. On 7/23/17 at approximately 2:05 PM LPN (Licensed Practical Nurse) # 2 stated that the Resident was receiving [MEDICATION NAME] for red eyes with itching. (cross reference F333 and F425) On 7/24/17 at approximately 3:10 PM to 5:00 PM record reviews revealed the following: -Resident 62 was admitted with a listed allergy to [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME]-[MEDICATION NAME]) and multiple doses of [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME]-[MEDICATION NAME]) Ophthalmic Ointment were administered to Resident 62 between 1/27/11 and 7/24/17. (refer to F333) -A review of the Facility Policy and Procedures IB1: PRESCRIBER MEDICATION ORDERS states Any dose or order that appears inappropriate considering the resident's age, condition, allergies [REDACTED]. and The prescriber is contacted to verify or clarify an order (e.g. (for example) when the resident has allergies [REDACTED]. The DON acknowledged in an interview on 7/24/17 at approximately 5:15 PM that the facility, pharmacy and nursing staff had failed to prevent Resident 62 from receiving multiple doses of [MEDICATION NAME] ([MEDICATION NAME]-… | 2020-09-01 |
| 34 | 34 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2017-07-26 | 333 | E | 0 | 1 | LLSR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a random observation, record reviews and interviews the Facility failed to assure that Resident 62 was free of significant medication errors related to medicine to which allergic. The Facility admitted Resident 62 on 1/27/11 with [DIAGNOSES REDACTED]. (cross reference F281 and F425) The findings include: On 7/23/17 at approximately 1:57 PM during chart review it was noted that Resident 62 had a physicians order for [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME]-[MEDICATION NAME]) Ophthalmic Ointment to be instilled inside lower lids of both eyes at bedtime and that Resident 62 was listed as allergic to [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME]-[MEDICATION NAME]). [MEDICATION NAME] and [MEDICATION NAME] are common ingredients in both [MEDICATION NAME] and [MEDICATION NAME]. On 7/23/17 at approximately 2:05 PM LPN (Licensed Practical Nurse) # 2 stated that the Resident was receiving [MEDICATION NAME] for red eyes with itching. On 7/24/17 at approximately 3:10 PM to 5:00 PM record reviews revealed the following: -Physician order dated 1/27/12 (date of admission) listed [MEDICATION NAME] as an allergy. -Physician order dated 6/11/12 stated D/C (discontinue) [MEDICATION NAME] -Physicians order dated 8/23/12 stated [MEDICATION NAME] ung (ointment) sig (give) instill inside lower eye lids ou (both eyes) q PM (every evening) x 7 days and then use PRN (as needed) for itching. - MAR (medication administration record) review January- December, 2012 showed approximately 61 scheduled plus PRN doses of [MEDICATION NAME] Ophthalmic Ointment had been administered -Physician order dated 6/3/13 stated Add allergy to [MEDICATION NAME] and tenoretic. -MAR review [REDACTED]. -January - September, 2013 MAR indicated [REDACTED]. -Physician order dated 9/17/13 stated change [MEDICATION NAME] Oint (ointment) to q hs (every bedtime) -MAR review [REDACTED]. -MAR review [REDACTED]. -MAR review [REDACTED]. -Consultant Pharmacist Report dated… | 2020-09-01 |
| 35 | 35 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2017-07-26 | 371 | E | 1 | 1 | LLSR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > The facility failed to ensure the cooktop was clean and free of grease build up, no dented cans in storage, the blades on the Buffalo Chopper and the Robo-coupe were free of dents and hazards, labeling and dating of raw chicken in the coolers and open packages of cookies, resident's food, use of pasteurized shell eggs, safe and clean storage ice in ice machines, removal of expired food in nutrition center refrigerator, clean and sanitary storage areas in nourishment center in 1 of 1 kitchen and 2 of 2 nourishment areas. The findings included: During initial tour on 7/23/17 at 10:45 AM, inside the walk-in refrigerator, a pan of cake covered with parchment paper and was not labeled or dated. The Assistant Dietary Manager said The cake is for lunch today. A can of pudding was also observed in the refrigerator with the lid partially cut open and still attached to the can and was not labeled or dated. Observed and verified by the Assistant Dietary Manager and the CDM was a larger plastic container which contained 3 whole chickens, and a bag of assorted chicken parts, which were not labeled or dated. Additionally, observed 1 Case of eggs in the shell from Glenview Farms, there was no indication on the box label and, the eggs did not have the stamp indicating that the eggs were pasteurized. The Assistant Dietary Manager and the CDM said the eggs are used for entrees and boiled eggs for the residents and h/she will check and see if the eggs are pasteurized. On 7/25/2017, the CDM provided a copy of the new product h/she will be ordering from foodservice vendor, to ensure that pasteurized eggs are used for the residents, Davidson's Pasteurized Eggs. The Policy and Procedures, Labeling and Dating, states, It is the Policy in the Dietary Department that all items upon delivery to storage area and freezer are labeled and dated. During initial tour on 7/23/2017 at approximately 11:00 AM of the dry storage room, observed 1 dented can of beets stored on th… | 2020-09-01 |
| 36 | 36 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2017-07-26 | 425 | E | 0 | 1 | LLSR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a random observation, record reviews and interviews the Pharmacy failed to follow procedures to assure that Resident 62 was free of significant medication errors related to medicine to which allergic. The Facility admitted Resident 62 on 1/27/11 with [DIAGNOSES REDACTED]. (cross reference F281 and F333) The findings include: On 7/23/17 at approximately 1:57 PM during chart review it was noted that Resident 62 had a physicians order for Maxitrol (Neomycin-Polymyxin-Dexamethasone) Ophthalmic Ointment to be instilled inside lower lids of both eyes at bedtime and that Resident 62 was listed as allergic to Neosporin (Neomycin-Bacitracin-Polymyxin). Neomycin and Polymyxin are common ingredients in both Maxitrol and Neosporin. On 7/23/17 at approximately 2:05 PM LPN (Licensed Practical Nurse) # 2 stated that the Resident was receiving Maxitrol for red eyes with itching. On 7/24/17 at approximately 3:10 PM to 5:00 PM record reviews revealed the following: -Resident 62 was admitted with a listed allergy to Neosporin (Neomycin-Bacitracin-Polymyxin) and multiple doses of Maxitrol (Neomycin-Polymyxin-Dexamethasone) Ophthalmic Ointment were administered to Resident 62 between 1/27/11 and 7/24/17. (refer to F333) -A review of the Facility Policy and Procedures IB1: PRESCRIBER MEDICATION ORDERS states Any dose or order that appears inappropriate considering the resident's age, condition, allergies [REDACTED]. and The prescriber is contacted to verify or clarify an order (e.g. (for example) when the resident has allergies [REDACTED]. The DON acknowledged in an interview on 7/24/17 at approximately 5:15 PM that the facility, pharmacy and nursing staff had failed to prevent Resident 62 from receiving multiple doses of Maxitrol (Neomycin-Polymyxin-Dexamethasone) Ophthalmic Ointment to which Resident 62 was listed as allergic to Neosporin (Neomycin-Bacitracin-Polymyxin). The Consultant Pharmacist verified in an interview on 7/25/17 at approximately 12:0… | 2020-09-01 |
| 37 | 37 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2017-07-26 | 431 | D | 0 | 1 | LLSR11 | Based on observations, record reviews and interviews the facility failed to assure that sterile medications were properly stored in 1 of 4 medication carts and 1 of 2 treatment carts and that medications were securely stored on 1 of 4 medication carts. The findings include: On 7/23/17 at approximately 11:39 AM the medication cart # 2 on the North Unit was observed to be unattended and unlocked for approximately 6 minutes and one wandering resident in a wheelchair was touching and pulling on the cart. LPN (Licensed Practical Nurse) # 1 was informed of the observations on 7/23/17 at approximately 11:46 AM and he/she verified that the cart was had been left unlocked, unattended and that a wandering resident was in the area. On 7/23/17 at approximately 11:49 AM inspection of the top right hand drawer of medication cart # 2 on the North Unit revealed one opened bottle of Normal Saline USP (United States Pharmacopoeia) 100 ml (milliliter) by McKesson Lot # 20 which had been dated by the facility as opened on 7/21/17. The manufacturers label stated Single Patient Use, Sterile, 0.9% (percent) Sodium Chloride and contained about 80 ml. This finding was verified by LPN # 1 on 7/23/17 at approximately 11:53 AM. An observation on 7/25/2017 at approximately 10:50 AM, during wound care, revealed a 100 mg (milligram) bottle of Sterile Normal Saline-Single Use manufactured by McKesson with Lot # 10 with expiration date 5/11/2019 was opened and left on 1 of 2 treatment carts with other medications for resident use. After opened, the Sterile Normal Saline is no longer sterile. During an interview on 7/25/2017 at approximately 10:55 AM the Assistant Director of Nursing verified the findings and removed the bottle of Normal Saline from the treatment cart. | 2020-09-01 |
| 38 | 38 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2017-07-26 | 456 | D | 1 | 1 | LLSR11 | > Based on observations, interviews, and review of the facility policy titled, Description of Dryers, and Equipment Care, the facility failed to ensure a large build-up of lint was removed from the backs and upper sides of the lint traps in 2 of 6 clothes dryers. The four other clothes dryers were in use and the lint traps were not observed at this time. The findings included: An observation on 7/25/2017 at approximately 8:30 AM revealed 2 of 6 clothes dryers with a large build-up of lint in the backs and upper side in 2 of 6 clothes dryers. Four other clothes dryers were in use at this time and the lint traps were not observed. An interview on 7/25/2017 at approximately 8:30 AM with the Housekeeping Supervisor confirmed the findings and provided a copy of the facility policy titled, Description of Dryers, and Equipment Care. The policy titled, Description of Dryers, states, These lint screens MUST be brushed and cleaned every 2 loads. If not, the screen will become packed with lint. When this occurs, the warm air moving through the system is blocked, raising the temperature in the basket and causing a potentially dangerous situation -- one spark on lint can cause a fire. Review on 7/25/2017 at approximately 8:38 AM of the facility policy titled, Equipment Care, states, The equipment in the laundry consists of washing machines and dryers. These items need daily maintenance from laundry personnel and should have preventive maintenance performed by the maintenance department. It is your responsibility to see that the equipment is loaded and operated properly, and to be sure that the staff sets up an effective schedule to clean the lint filters on the dryers every two hours to save energy and to prevent fires. Review on 7/25/2017 at approximately 8:45 AM of a form titled, Lint Trap Schedule, for July 2017 was initialed by a laundry worker that the lint was removed at 8:00 AM on 7/25/2017, but 2 of 6 clothes dryers contained a large build-up of lint. Review on 7/25/2017 at approximately 10:15 AM of a form titled, Wee… | 2020-09-01 |
| 39 | 39 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2018-10-11 | 567 | E | 0 | 1 | KNGB11 | Based on review of personal funds and interview, the facility failed to ensure that written authorization was obtained prior to disbursing monies from the account of one of one sampled resident reviewed for personal funds (Resident #23). The findings included: During an interview on 10/08/18 at 2:06 PM, Resident #23 stated s/he was not aware of the balance and did not receive statements from the facility regarding the status of her/his personal funds account. During an interview and review of the personal funds account with the Resident Financial Coordinator on 10/11/18 at 2:27 PM, multiple deductions (7/12/18, 7/31/18, 8/9/18, 8/24/18, and 9/7/18) were noted for the Beauty Shop for Resident #23. The invoices for the services provided were reviewed but no written authorizations were obtained from the resident/resident representative to deduct monies from the personal funds account. | 2020-09-01 |
| 40 | 40 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2018-10-11 | 568 | D | 0 | 1 | KNGB11 | Based on review of personal funds and interview, the facility failed to ensure that quarterly statements were provided to Resident #23, one of one sampled resident reviewed for personal funds. The findings included: During an interview on 10/08/18 at 2:06 PM, Resident #23 stated s/he was not aware of the balance and did not receive statements from the facility regarding the status of her/his personal funds account. The resident stated,My daughter might. Review of the 7/15/18 Significant Change in Status Assessment revealed the resident had a had a Brief Interview for Mental Status (BIMS) score of 15 indicating s/he was cognitively intact. During an interview on 10/11/18 at 2:27 PM, the Resident Financial Coordinator provided the last quarterly statement for Resident #23 for review. The Resident Financial Coordinator confirmed that the statement had been sent to the resident's daughter instead of to the resident. | 2020-09-01 |
| 41 | 41 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2018-10-11 | 607 | D | 1 | 1 | KNGB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to develop and/or implement abuse reporting and investigation policies for 2 of 4 sampled residents reviewed for abuse/injuries of unknown origin. An allegation of abuse was not reported timely or thoroughly investigated for Resident #42. The finding included: The facility admitted Resident #42 with [DIAGNOSES REDACTED]. Review of the investigation file on 10/10/18 at 4:04 PM revealed that on 8-14-18, a student in the Certified Nursing Assistant (CNA) training program reported that CNA #1 spoke about Resident #42's roommate and her/his personal information, made comments about the prior shift's lack of care of the resident, and handled Resident #42 roughly when assisting her/him out of bed to the bathroom. Another student's statement dated 8/16/18 indicated that (CNA #1) was forcefully pulling on (Resident #42's) right arm saying you have to go to the bathroom. During a telephone interview on 10/11/18 at 1:55 PM, Registered Nurse (RN) #1 stated a student reported the incident to her/him on the date of occurrence (8/14/18) before s/he left that evening. The RN obtained a written statement from the student. (CNA #2) was with me when we talked to the student and got her (his) statement. The nurse thought s/he put the statement in the Director of Nursing's box outside her/his office because s/he was not going to be at work the following day. S/he thought s/he might have given a copy to the Charge CNA (CNA #2) as well. Further review revealed that the facility did not report the allegation of abuse until the following day (8/15/18). During an interview on 10/11/18 at 12:45 PM, the DON stated s/he was aware of the 2 hour reporting requirements for allegations of abuse. S/he stated that s/he was not made aware of the allegation until 8/15/18. Review of the assignment sheet for 8/14/18, obtained from the Director of Nursing (DON), revealed that there were written statements obtained from the… | 2020-09-01 |
| 42 | 42 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2018-10-11 | 609 | D | 1 | 1 | KNGB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview the facility failed to report allegations timely to the State Agency for 2 of 2 allegations/incidents reviewed. Resident #42 had an allegation of physical and verbal abuse that was not reported to the state agency within the required timeframes. The facility failed to report an injury of unknown origin with major injury timely for Resident #37. The findings included: The facility admitted Resident #42 with [DIAGNOSES REDACTED]. Observations during the survey revealed that the resident had a sad affect, was confused, answered questions inappropriately or not at all, had perseverating speech, and wandered aimlessly in the hallways. Review of the investigation file on 10/10/18 at 4:04 PM revealed that on 8-14-18, a student in the Certified Nursing Assistant (CNA) training program reported that CNA #1 spoke about Resident #42's roommate and her/his personal information, made comments about the prior shift's lack of care of the resident, and handled Resident #42 roughly when assisting her/him out of bed to the bathroom. Another student's statement dated 8/16/18 indicated that (CNA #1) was forcefully pulling on (Resident #42's) right arm saying you have to go to the bathroom. During a telephone interview on 10/11/18 at 1:55 PM, Registered Nurse (RN) #1 stated a student reported the incident to her/him on the date of occurrence (8/14/18) before s/he left that evening. The RN obtained a written statement from the student. (CNA #2) was with me when we talked to the student and got her (his) statement. The nurse thought s/he put the statement in the Director of Nursing's box outside her/his office because s/he was not going to be at work the following day. S/he thought s/he might have given a copy to the Charge CNA (CNA #2) as well. Further review revealed that the facility did not report the allegation of abuse until the following day (8/15/18). During an interview on 10/11/18 at 12:45 PM, the DON stated s/he was… | 2020-09-01 |
| 43 | 43 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2018-10-11 | 610 | E | 1 | 1 | KNGB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > The facility admitted Resident #42 with [DIAGNOSES REDACTED]. Observations during the survey revealed that the resident had a sad affect, was confused, answered questions inappropriately or not at all, had perseverating speech, and wandered aimlessly in the hallways. Review of the investigation file on 10/10/18 at 4:04 PM revealed that on 8-14-18, a student in the Certified Nursing Assistant (CNA) training program reported that CNA #1 spoke about Resident #42's roommate and her/his personal information, made comments about the prior shift's lack of care of the resident, and handled Resident #42 roughly when assisting her/him out of bed to the bathroom. Another student's statement dated 8/16/18 indicated that (CNA #1) was forcefully pulling on (Resident #42's) right arm saying you have to go to the bathroom. During a telephone interview on 10/11/18 at 1:55 PM, Registered Nurse (RN) #1 stated a student reported the incident to her/him on the date of occurrence (8/14/18) before s/he left that evening. The RN obtained a statement from the student. (CNA #2) was with me when we talked to the student and got her (his) statement. The nurse thought s/he put the statement in the Director of Nursing's box outside her/his office because s/he was not going to be at work the following day. S/he thought s/he might have given a copy to the Charge CNA (CNA #2) as well. Further review revealed that CNA #1 was suspended during the investigation. Review of the assignment sheet for 8/14/18, obtained from the Director of Nursing (DON), revealed that there were written statements obtained from the RN Supervisor, and 4 of the 5 CNAs on duty on the 100 Hall, including the alleged perpetrator. There were no statements from the two nurses on duty on the 100 Hall. All statements were either unwitnessed or witnessed by one individual. During an interview on 10/11/18 at 12:45 PM, when asked to describe a thorough investigation, the DON stated, You should talk to the res… | 2020-09-01 |
| 44 | 44 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2018-10-11 | 623 | E | 0 | 1 | KNGB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to provide the required written notice of transfer to the resident/ resident representative for Resident #22, #19, # 57, #47 and #100 as soon as practicable of a facility initiated transfer. 5 of 5 reviewed for transfer to the hospital. The findings included: The facility admitted Resident #22 on 7/12/2018 with dignoses including, but not limited to, Muscle weakness, Acute and Chronic [MEDICAL CONDITION], unspecified with [MEDICAL CONDITION] or hypercapnia, Athscl [MEDICAL CONDITION] of native coronary artery without [MEDICAL CONDITION] pectoris, Heart Failure, [MEDICAL CONDITION] (chronic) (peripheral), Essential Hypertension, [MEDICAL CONDITION], Type II Diabetes Mellitus, Spinal Stenosis-lumbar region without [MEDICAL CONDITION] claudication, allergic rhinitis, [MEDICAL CONDITION] Stage 3, [MEDICAL CONDITION] disease, [MEDICAL CONDITION], Major [MEDICAL CONDITION], unspecified [MEDICAL CONDITION], unspecified hearing loss, nausea with vomiting, unspecified Dementia without behavioral disturbance, pressure ulcer right and left heel unstageable. Review of the medical record revealed that Resident #22 was transferred to the hospital on [DATE], 07/27/2018 and 08/22/2018, all were facility initiated with no documentation that written notice was provided to the resident and Resident Represenative (RR) of the transfer. During an interview on 10/09/2018 at approximately 12:30 PM, the Social Worker confirmed that the facility had not been providing written notification to the resident/ RR for hospital transfers. The facility admitted Resident #57 with [DIAGNOSES REDACTED]. Record review on 10/09/18 at 11:59 AM revealed that the resident had multiple recent hospitalization s: (1) From 7/26/18 to 7/30/18 for Acute Hypoxic [MEDICAL CONDITION] and Exacerbation of [MEDICAL CONDITION], (2) From 8/14/18 to 8/17/18 for Shortness of Breath, Oxygen Saturation of 64% [MEDICAL CONDITION] Facial and Bilat… | 2020-09-01 |
| 45 | 45 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2018-10-11 | 640 | B | 0 | 1 | KNGB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that required assessments were completed and/or transmitted as required for 4 of 4 residents reviewed for missing assessments. Four residents were noted with last transmission dates of greater than 120 days. Discharge assessments were not completed for three of these residents (Residents #315, #316, and #317). Resident #1 did not have a Quarterly Minimum Data Set (MDS) assessment transmitted. The findings included: Review of the MDS (Minimum Data Set) 3.0 Missing OBRA Assessment CASPER Report on 10/8/18 revealed the following: -The last assessment transmitted for Resident #317 was 4/1/18. -The last assessment transmitted for Resident #316 was 10/29/17. -The last assessment transmitted for Resident #315 was 10/15/17. -The last assessment transmitted for Resident #1 was 4/29/18. During an interview on 10/09/18 at 2:10 PM, the MDS Coordinator stated that Resident #317 was discharged on [DATE], #316 was discharged on [DATE], and #315 was discharged on [DATE]. No discharge assessments had been completed and transmitted for these residents. Additionally, s/he confirmed that the quarterly assessment for Resident #1 had an assessment reference date of 7/22/18 but had not been transmitted. | 2020-09-01 |
| 46 | 46 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2018-10-11 | 684 | E | 0 | 1 | KNGB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to follow physician's orders for use of siderails and failed to follow standards of practice to address [MEDICAL CONDITION] for one of one sampled resident reviewed for range of motion (Resident #8). The findings included: The facility admitted Resident #8 with [DIAGNOSES REDACTED]. Multiple observations (on 10/08/18 at 7:59 AM, 10:07 AM, 10:51 AM, 1:11 PM, 3:39 PM, and 4:51 PM; on 10/08/18 01:03 PM; on 10/10/18 at 2:01 PM) revealed that the resident's right hand was [MEDICAL CONDITION], had a handroll in place, and was not kept elevated, both in and out of bed, to assist in decreasing the swelling. During an interview on 10/09/18 at 2:56 PM, Certified Nursing Assistant #2 verified the [MEDICAL CONDITION] of the right wrist and hand and that it had not been kept elevated. Record review on 10/09/18 at 3:02 PM revealed Physician's Orders for one siderail to be up. Multiple observations (on 10/08/18 at 7:59 AM, 10:07 AM, 3:39 PM, and 4:51 PM; on 10/10/18 at 2:01 PM) revealed the resident in bed with both half siderails elevated. During an interview on 10/09/18 at 3:49 PM, Licensed Practical Nurse #2 verified the Physician's Order and observed/confirmed that half rails were elevated on both sides of the bed. | 2020-09-01 |
| 47 | 47 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2018-10-11 | 698 | E | 0 | 1 | KNGB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to maintain consistent on-going communications with the [MEDICAL TREATMENT] center to ensure continuity of care for one of one sampled resident reviewed for [MEDICAL TREATMENT] (Resident #57). The findings included: The facility admitted Resident #57 with [DIAGNOSES REDACTED]. Review of Progress Notes on 10/09/18 at 2:31 PM revealed that on 8/14/18 at 4:14 AM, the resident was sent to the emergency room (ER) with shortness of breath and an oxygen saturation of 64% on 2 liters per minute. S/he was admitted to the hospital with [REDACTED]. There was no evidence in the record that the [MEDICAL TREATMENT] center was notified of the change in condition and hospitalization . On 8/28/18, the resident was again sent to the ER with shortness of breath and an oxygen saturation of 77%. S/he was admitted to the hospital with [REDACTED]. There was no evidence in the record that the [MEDICAL TREATMENT] center was notified of the change in condition and hospitalization . On 9/11/18, the resident was sent to the ER with shortness of breath and congestion. Oxygen saturation of 76%. S/he was admitted to the hospital with [REDACTED]. There was no evidence in the record that the [MEDICAL TREATMENT] center was notified of the change in condition and hospitalization . On 10/2/18, Resident #57 was sent to the ER with shortness of breath, a feeling of heaviness in the chest, and an oxygen saturation of 74%. S/he was admitted to the hospital with [REDACTED]. There was no evidence in the record that the [MEDICAL TREATMENT] center was notified of the change in condition and hospitalization . Further review revealed no laboratory reports on file from [MEDICAL TREATMENT] since 4/18. Following a call from the facility, the [MEDICAL TREATMENT] center faxed 4/18 through 9/18 lab results which were provided by the Assistant Director of Nurses. Review of [MEDICAL TREATMENT] Flow Sheets from 7/3/18 through the dates of … | 2020-09-01 |
| 48 | 48 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2018-10-11 | 756 | E | 0 | 1 | KNGB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the pharmacist failed to identify irregularities for 1 of 5 sampled residents reviewed for unnecessary medication. Resident #35 was on long-term [MEDICATION NAME] antibiotic therapy without documentation of physician recommendation regarding evaluation of risks versus benefits of continued use. The findings included: The facility admitted Resident #35 on 7-15-15 with [DIAGNOSES REDACTED]. Record review on 10/10/18 at 11:53 AM revealed physician's orders [REDACTED]. Review of laboratory reports and Progress Notes on 10/10/18 at 12:43 PM revealed no evidence of active infection. Review of Physician's Progress Notes revealed no documentation of continued need or evaluation of risks versus benefits of long-term [MEDICATION NAME] antibiotic use. Review of the Medication Regimen Review reports on 10/11/18 at 1:31 PM revealed no references to long term use of [MEDICATION NAME] antibiotic therapy and inherent risk of antibiotic resistant bacterial infections. During an interview on 10/11/18 at 1:47 PM, the Pharmacist verified the physician's orders [REDACTED]. | 2020-09-01 |
| 49 | 49 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2018-10-11 | 757 | E | 0 | 1 | KNGB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to follow a procedure for 1 of 5 sampled residents reviewed for unnecessary medication to ensure that medication administered for excessive duration is reviewed for continued use. Resident #35 was on long-term [MEDICATION NAME] antibiotic therapy without documented evidence of evaluation of risks versus benefits. The findings included: The facility admitted Resident #35 on 7-15-15 with [DIAGNOSES REDACTED]. Record review on 10/10/18 at 11:53 AM revealed physician's orders [REDACTED]. Review of laboratory reports and Progress Notes on 10/10/18 at 12:43 PM revealed no evidence of active infection. Review of Physician's Progress Notes revealed no documentation of continued need or evaluation of risks versus benefits of long-term [MEDICATION NAME] antibiotic use. During an interview on 10/11/18 at 1:47 PM, the Pharmacist verified the physician's orders [REDACTED]. During an interview on 10/10/18 at 2:49 PM, when asked about the continued use of the antibiotic, the Assistant Director of Nurses stated that the resident had been admitted on an antibiotic for UTIs. S/he stated,We usually try cranberry and UTI Stat. I think we tried to take (the resident) off of it but the family wanted her (him) back on it. | 2020-09-01 |
| 50 | 50 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2018-10-11 | 761 | D | 0 | 1 | KNGB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and record review, the facility failed to dispose of expired medications in the North Unit medication room and the North 2 (N2) medication cart, 1 of 1 Unit reviewed. The findings included: Observation of the N2 unit medication cart on 10/10/18 at 08:43 AM revealed 1 vial of [MEDICATION NAME] 0.083% 2.5 mg (milligrams) per 3 ml (milliliters) with an expiration of September, (YEAR) and 1 473 ml bottle of [MEDICATION NAME] 160 mg per 5 ml Elixer with an expiration date of 08/18 which was close to full. Licensed Practical Nurse #3 confirmed the expiration dates at 08:50 AM on 10/10/18. | 2020-09-01 |
| 51 | 51 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2019-10-17 | 600 | D | 1 | 0 | NNBR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, clinical record review and review of facility policy, facility staff failed to ensure 1 of 24 sampled residents (Resident #17) was free from possible neglect. On 7/13/19, while performing peri-care on Resident #17, Certified Nursing Assistant (CNA) #6 turned the resident onto her side but failed to ensure the resident was safe from falling. As a result, Resident #17 fell from the bed and struck her head on the corner of a chair that was sitting next to the bed. The resident sustained [REDACTED]. The findings included: Review of the facility's policy entitled Perineal Care (Peri-care) (undated) revealed the following: Purpose: 1. To cleanse the perineum; 2. To prevent infection and odors. Equipment: 1. Soap and water; 2. Bath basin; 3. Washcloths and towel. Procedure: 1. Explain procedure to the resident and bring equipment to the bedside; 2. Provide privacy for the resident; 3. Assist the resident to void first if they need to; 4. Do perineal care at least one time a day with bath and PRN (as needed); 5. Cleanse the area with warm water and soap. When washing the area, always wash from the front to back (sic). Be careful not to pull the washcloth from the anal area to the vaginal area; 6. Rinse the area; 7. Towel blot dry the area; 8. Assist the resident to a comfortable position; 9. Return equipment to its proper area; 10. Wash hands; 11. Chart care rendered. Notify the appropriate person of any abnormal findings. The policy did not address adjustment of residents' bed heights, or the use of side rails during peri-care. Review of the facility's policy titled Abuse Prevention, Intervention, Investigation, and Reporting Policy and Procedure effective date of 9/23/19 revealed Residents are to be free from verbal, sexual, physical and emotional/mental abuse; neglect; self-neglect; exploitation; deprivation; involuntary seclusion; and misappropriation of property at all times. Continued review noted neglect was … | 2020-09-01 |
| 52 | 52 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2019-10-17 | 610 | D | 1 | 0 | NNBR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, clinical record review and review of facility policy, the facility failed to thoroughly investigate and prevent the possibility of further neglect from occurring for 1 of 24 sampled residents (Resident #17). On 7/13/19, while performing peri-care on Resident #17, Certified Nursing Assistant (CNA) #6 failed to ensure the resident was safe from falling and as a result, Resident #17 fell and sustained lacerations to the left eyebrow and left upper cheek. According to the facility's Investigation Report, only CNA #6 and the assessing Registered Nurse (RN) #2 were interviewed regarding the incident. In addition, CNA #6 was not suspended pending the outcome of the investigation. The findings included: Review of the facility's policy titled Abuse Prevention, Intervention, Investigation, and Reporting Policy and Procedure effective date of 9/23/19 revealed Residents are to be free from verbal, sexual, physical and emotional/mental abuse; neglect; self-neglect; exploitation; deprivation; involuntary seclusion; and misappropriation of property at all times. All reports of possible abuse are promptly and thoroughly investigated by facility management. Residents and staff are protected during incident investigation by ensuring reports are made without fear of retaliation and that anonymous reports are investigated. Continued review noted neglect was defined as failure to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish, or emotional distress. Neglect may be intentional, such as withholding or omitting care, or unintentional, where the caregiver should have known that care was needed, but it was not provided. This encompasses providing food, clothing, medicine, shelter, supervision, medical care and other services that a prudent person would deem essential for the well-being of the resident .If neglect is suspected, a determination is made as to what services were not provid… | 2020-09-01 |
| 53 | 53 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2019-10-17 | 657 | D | 1 | 0 | NNBR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, clinical record review and review of facility policy, facility nursing staff failed to update 3 of 24 sampled residents' care plans (Residents #15, #16, and #17). The findings included: Review of the facility's Policy and Procedure for RAI (Resident Assessment Instrument)/Care Plans (not dated) revealed 3. Care plan team meets every Thursday to review care plan with family and residents who choose to attend unless arrangements are made for different time or date. Resident #15 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #15's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired. Resident #15 exhibited no behaviors (i.e. no physical behaviors and no self-injurious behaviors) and no signs/symptoms of depression, during the assessment periods. According to the MDS, Resident #15 required the extensive assistance of one staff person for bed mobility, transfers, toileting, dressing, walking in the room, and locomotion on and off the unit. The Annual MDS assessment, noted Resident #15 had impairment to one side of lower extremities and utilized a wheelchair for mobility. Resident #15 had no falls during either MDS assessment period. Continued review of the MDS revealed Resident #15 was administered no anti-coagulant medications; however, the resident did receive antipsychotic medication for seven (7) days during the assessment period. Review of Resident #15's Progress Notes revealed the following: 11/11/8 - While the CNA had the resident in the bathroom, she noticed bruises on resident's left arm, reddish purple in color. The resident was not able to state what might have happened. No complaint of pain or sign or symptom of pain noted to left arm when touched. Resident was able to move bilateral upper extremities on her own without difficulties or distress noted. No swelling noted to left arm. Resident observed by nur… | 2020-09-01 |
| 54 | 54 | HEARTLAND OF COLUMBIA REHAB AND NURSING CENTER | 425008 | 2601 FOREST DRIVE | COLUMBIA | SC | 29204 | 2017-02-23 | 272 | C | 0 | 1 | 999W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review it was determined the facility failed to accurately assess a terminal prognosis for three (#s 45, 1 & 127) of three residents reviewed for hospice of the eight residents in the facility identified as receiving hospice services. Findings include: RESIDENT #45 The medical record for Resident #45 was reviewed on 02/21/17 at 1:29 p.m. The resident's care plan identified the resident received hospice care due to a terminal illness. A Hospice Certification and Plan of Treatment revealed the resident admitted to hospice on 11/01/16 due to a [DIAGNOSES REDACTED]. It was signed by a physician. The Minimum Data Set assessments, dated 01/05/17 and 11/04/16, were reviewed on 02/21/17 at 2:43 p.m. The assessments identified Resident #45 received hospice services while a resident at the facility (Section O0100k). These MDS assessments also indicated, in Section J1400, that the resident did not have a condition or chronic disease that may result in a life expectancy of less than six months. In an interview on 02/21/17 at 3:42 p.m., the Resident Assessment Coordinator, Registered Nurse #9, explained, according to the RAI (Resident Assessment Instrument) Manual, I have to have physician's documentation to support a terminal illness and I must not have (had it). When the Certification and Plan of Treatments were reviewed with the Resident Assessment Coordinator, Registered Nurse #9, she stated she did not know when those were put in the chart. The RAI manual's instructions, that read Under the hospice program benefit regulations, a physician is required to document in the medical record a life expectancy of less than 6 months, so if a resident is on hospice the expectation is that the documentation is in the medical record, were reviewed and the Resident Assessment Coordinator, Registered Nurse #9, verified the assessments were not completed accurately. RESIDENT #1 The medical record for Resident #1 was reviewed on 02… | 2020-09-01 |
| 55 | 55 | HEARTLAND OF COLUMBIA REHAB AND NURSING CENTER | 425008 | 2601 FOREST DRIVE | COLUMBIA | SC | 29204 | 2017-02-23 | 371 | E | 0 | 1 | 999W11 | Based on observations and staff interviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service in one of two kitchens. Specifically, the facility failed to: -Ensure expired foods were disposed of; and -Ensure all foods were covered/ sealed. The findings included: [NAME] Expectations According to the 2013 Food Code from the U.S Department of Health and Human Services, page 92, Ready-to -eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment .and the day or date marked by the food establishment may not exceed a manufacturer's use-by date based on food safety. According to the 2013 Food Code from the U.S Department of Health and Human Services, pages 60 and 76, Food packages shall be in good condition and protect the integrity of the contents so that the food is not exposed to adulteration or potential contaminants .Food shall be protected from contamination by storing the food: where it is not exposed to splash, dust or other contamination. B. Facility Standards According to the storage of food policy provided by the dietary manager (DM) on 2/23/17 at 1:47 p.m., dated 9/2014, Store potentially hazardous foods under refrigeration at or below 41 degrees Fahrenheit for a maximum of 7 days, unless there is a different manufacturer's use by date specified .Discard food that has exceeded the expiration date . C. Observations The main kitchen was observed on 2/20/17 at 8:15 a.m. There were two containers of deluxe tuna salad observed in the walk-in refrigerator with a use-by date of 2/3/17. These containers were approximate five pound containers. (17 days) -One tray with 20 containers of fruit cocktail were observed in the walk-in refrigerator, uncovered. These containers were stored on the second shelf to the right with a box stored on the shelf above. -A five-pound container of pimento cheese was observed in the walk-… | 2020-09-01 |
| 56 | 56 | HEARTLAND OF COLUMBIA REHAB AND NURSING CENTER | 425008 | 2601 FOREST DRIVE | COLUMBIA | SC | 29204 | 2019-08-15 | 623 | D | 0 | 1 | RSRB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure residents and/or their representatives received in writing and in a language they could understand the reason for transfer to the hospital for 2 of 3 residents reviewed for hospitalization . The facility failed to provide a written Notice of Transfer that included the reason for transfer for Residents #7 and #65. The findings included: The facility admitted Resident #7 on 11/2/18 with [DIAGNOSES REDACTED]. Review of the Nurse's Notes dated 3/31/19 indicated the facility transferred Resident #7 to the emergency room due to pneumonia. The resident was hospitalized and re-admitted to the facility on [DATE]. Further review of the medical record revealed Resident #7 was admitted to the hospital on [DATE] due to [MEDICAL CONDITION] activity with re-admission to the facility on [DATE]. There was no documentation in the medical record to indicate the facility sent a written Notice of Transfer with the resident or sent a written notification for the reason for the transfer to the resident's representative at the time of the transfers and admissions to the hospital. The surveyor requested documentation related to the written Transfer Notices for the hospitalization s. The facility provided a copy of a form entitled, Facility Initiated Discharge Letter indicating Resident #7 would be discharged [DATE] and 7/28/19 respectively. The form indicated this was a Notice of Discharge. Review of the form indicated the reason for the resident's transfer to the hospital was not included on the form. During an interview on 8/14/19 at approximately 12:30 PM, the Director of Nursing and Business Office Manager reviewed the forms and confirmed that this was the form the facility sent upon transfer, and no other written Notice of Transfer was provided. The facility admitted Resident #65 on 4/12/19 with [DIAGNOSES REDACTED]. Review of the Nurse's Notes dated 5/28/19 revealed the facility transferred Res… | 2020-09-01 |
| 57 | 57 | HEARTLAND OF COLUMBIA REHAB AND NURSING CENTER | 425008 | 2601 FOREST DRIVE | COLUMBIA | SC | 29204 | 2017-12-11 | 585 | D | 1 | 0 | CJTI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to resolve and/or notify the complainant timely for 1 of 1 grievances by a sampled resident. A grievance was initiated regarding care for resident #3, which was not resolved for eight (8) days. The findings included: In response to a complaint received in this office, review of the facility's grievance log was reviewed. During the review a grievance was noted for 1 of 4 sampled residents. The facility admitted resident #3 with [DIAGNOSES REDACTED]. On 10/1/17 a Concern Form was completed for a grievance regarding the resident's care. The grievance included a request for nursing to call a family member. Under the section Documentation of Facility Follow-up, the results of action taken stated: Staff inservice on call light response. Nurse returned call after admission director informed. There was no date as to when the family was called. Under the section, Resolution of Concern, Identify the method used to notify complainant of resolution, one to one discussion was checked and dated for 10/9/17. Per the Concern Form the complaint was not resolved for eight (8) days. Review of the Policy/Procedure for Concern Process stated, The assigned department head contacts the appropriate party once resolution has been completed. Once resolved, the concern form is updated with the resolution of the concern and returned to the Administrator of designee. There was no time schedule as to how long it should take to resolve an issue or notify the complainant of the resolution. On 12/11/17 at 11:35 AM the Administrator was interviewed by the surveyor. The Administrator stated the family was out of state and it was difficult to get in touch with them. | 2020-09-01 |
| 58 | 58 | FAITH HEALTHCARE CENTER | 425009 | 617 WEST MARION STREET | FLORENCE | SC | 29501 | 2018-02-07 | 770 | D | 1 | 0 | SCLZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interviews, the facility failed to obtain laboratory results timely for 1 of 3 residents reviewed for Diabetic Monitoring. Resident #1 did not have lab results available for eight days for an abnormal lab value. The findings included: The facility admitted resident #1 with [DIAGNOSES REDACTED]. Review of the medical record revealed a physician's orders [REDACTED]. Review of the Nurse's Notes revealed a note written on 12/18/17 at 3:00 PM. Bloodwork collected collected (sic) for numerous labs ordered on [DATE] . Review of the facility investigation regarding the lab reports revealed the facility did not receive the lab reports until 12/28/17, after the resident was sent to the hospital for acute change in condition. The facility called the lab for the results when they reviewed the chart and noted there was no lab report from the ordered labs. The lab report stated the resident's Hemoglobin A1C was 12.5, noted to be high. The blood sample for the lab reports was noted to be drawn five days after the physician ordered the labs. The lab report was not available until eight days after the blood had been drawn. 2/7/18 at 1:30 PM the surveyor interviewed the Director of Nursing. When the resident was sent to the hospital we reviewed his/her chart and noted there was no report for the ordered labs. We called the lab and they faxed over the report. We did not get a call from the lab about the high A1C. | 2020-09-01 |
| 59 | 59 | FAITH HEALTHCARE CENTER | 425009 | 617 WEST MARION STREET | FLORENCE | SC | 29501 | 2018-02-07 | 775 | D | 1 | 0 | SCLZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to maintain laboratory (lab) reports in the medical record for 1 of 3 residents reviewed for lab results. Resident #1 did not have lab reports in her/his medical record that were obtained on 12/18/17. The findings included: The facility admitted resident #1 with [DIAGNOSES REDACTED]. Review of the medical record revealed a physician's orders [REDACTED]. Review of the Nurse's Notes revealed a note written on 12/18/17 at 3:00 PM. Bloodwork collected collected (sic) for numerous labs ordered on [DATE] Review of the medical record revealed there were no lab reports for 12/18/17 available. The lab reports were requested from the Director of Nursing (DON). The DON supplied the lab report at the end of the day. Review of the lab report revealed the report had been faxed to the facility on [DATE] On 2/7/18 at 1:30 PM the surveyor interviewed the Director of Nursing. I am looking for the lab report. I know it is here or we wouldn't have known about the abnormal lab. | 2020-09-01 |
| 60 | 60 | FAITH HEALTHCARE CENTER | 425009 | 617 WEST MARION STREET | FLORENCE | SC | 29501 | 2017-06-14 | 223 | J | 1 | 1 | J20Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interviews, the facility failed to provide needed services to 1 of 3 residents reviewed for change in condition. Resident #48 had a change in condition that required respiratory assessment and treatment which the resident did not receive. In addition, based on observation, record review and interview the facility failed to ensure all residents with concerns with positioning for safe meal intake to avoid choking were given adequate assistance in set up at meal time. Three of 18 residents (Residents #6, #22 and #49) noted to have positioning concerns were found to be improperly positioned in bed to feed themselves effectively and safely. The Certified Nursing Assistant caring for Residents #22 and #49 residents had just been inserviced on how to provide assistance to residents with positioning for meal intake to ensure safety. The findings included: The facility admitted resident # 48 with [DIAGNOSES REDACTED]. Review of Nurses' Notes from [DATE] through [DATE] revealed resident was total care for all Activities of Daily Living (ADL's). S/He was in a persistent vegetative state. On [DATE] at 9:30 AM: resident lying in bed with eyes open, when breathes makes a gargling sound. resp even/unlabored. will continue monitoring. 10:20 AM called to room per Certified Nursing Assistant (CNA). Resident lying in bed with Head of bed (HOB) elevated ( ^) noted to have beige secretions coming out of mouth. No respirations noted. Code blue called &Cardiopulmonary Resuscitation (CPR) was initiated, no pulse, 911 called 10:30 AM Emergency Medical Services (EMS) here. took over CPR. To hospital via stretcher. Per Physician's Cumulative Orders for ,[DATE]-[DATE] an order for [REDACTED]. On [DATE] at 3:30 PM CNA # 44 was interviewed by the surveyor. The CNA had reported to the nurse the change in condition of the resident. In the morning s/he was coughing funny, making a strange noise. I told the nurse s/he needed to check on the reside… | 2020-09-01 |
| 61 | 61 | FAITH HEALTHCARE CENTER | 425009 | 617 WEST MARION STREET | FLORENCE | SC | 29501 | 2017-06-14 | 225 | D | 1 | 1 | J20Y11 | > Based on record review, interviews and review of facility files, the facility failed to obtain a statement from the alleged perpetrator for 1 of 3 residents reviewed for neglect. Resident #48 did not receive required care for respiratory difficulty. The findings included: Cross refer to F223 related to neglect of Resident # 48 and the incomplete investigation of the incident. Review of the facility investigation of the reported incident of Neglect revealed the facility did not have a written statement from the nurse who allegedly neglected resident #48. The facility had written statements of the Certified Nursing Assistants (CNA) who had witnessed the incident. There was no statement from the Nurse. The investigation was summarized with statements the nurse allegedly made, however there was no actual statement from the Nurse. The summary of the investigation revealed the nurse had stated s/he was unable to locate a suction machine and there was no suction machine on the crash cart. On 6/13/17 at 8:30 AM, Registered Nurse (RN) #138 was interviewed via phone by the surveyor. The RN stated the resident was gurgling during med pass. I went and found a suction machine, but it did not work. I never got a suction machine to work. The RN stated s/he had removed the suction machine from the crash cart. I think there are 3 crash carts. It was about 9:00 AM I can't remember exactly. I never had to suction her/him before. Review of the facility Policy and Procedure on Abuse/Neglect, under the section titled Investigation stated, Written summaries of interviews with individuals having first hand knowledge of the incident. NOTE: Employees/witnesses are not to write out statements. Employees/witnesses will be interviewed by designated facility staff and the interviewer will record all witness accounts in a document written, dated and signed by the interviewer. | 2020-09-01 |
| 62 | 62 | FAITH HEALTHCARE CENTER | 425009 | 617 WEST MARION STREET | FLORENCE | SC | 29501 | 2017-06-14 | 244 | D | 0 | 1 | J20Y11 | Based on record review, staff and resident interview the facility failed to act promptly upon grievances from resident council meetings concerning issues of resident care and life in the facility regarding the lack of dental services. The facility was not able to demonstrate their response to resident requests for dental services. This involved 4 residents, #55, #10, # 52 and #29, who voiced requests to see the dentist during the resident council meetings. Findings include: During an interview with Resident #52 on 4/12/2017 at 2:10 PM the resident stated during the monthly resident council meeting residents have been voicing complaints about the lack of routine dental service. He stated in the last several meetings the residents have been asking when will they be provided a response to their request to see the demist. He stated a few residents have indicated they have broken dentures or do not have any dentures but would like to have dentures. Review of the resident council minutes on 4/11/2017 at 1:45 PM revealed in (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR) the meeting minutes revealed documentation that several residents stated they would like to see the demist. The Activity Director informed the residents that she would obtain a list of names of which residents would like to see the dentists and she would attempt to get appointments set up for them. Interview with the Activity Director on 4/12/2017 at 10:05 AM reveled she did obtain a list of resident who would like to see the dentist in the (MONTH) (YEAR) resident counsel meeting and provided this survey the list. During this interview she verified as of this date the residents on the list have still not been scheduled for any dental care as they requested. She stated she had given the list of names to the Social Service staff but there has been no appointments made for these residents at this time. This was confirmed during an interview with the Social Service Director on 2/13/2017 at 11:08 AM. | 2020-09-01 |
| 63 | 63 | FAITH HEALTHCARE CENTER | 425009 | 617 WEST MARION STREET | FLORENCE | SC | 29501 | 2017-06-14 | 248 | D | 0 | 1 | J20Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to provide an individualized program for activities for 1 Resident, #110, of 1 resident reviewed for activities, by not providing activities of interest, or stimulation throughout the day. Findings include: Record review of History and Physical for Resident #110 dated 09/14/16 (from previous facility/hospital), revealed, Past Medical History: 1. [MEDICAL CONDITION] of the liver secondary to [MEDICAL CONDITION], 2. [MEDICAL CONDITION] 3. [MEDICAL CONDITION] infection, 4. Chronic pancreatitis, 5. [MEDICAL CONDITION] brain history with persistent [MEDICAL CONDITION], 6. Hepatic [MEDICAL CONDITION], 7. Recurrent [MEDICAL CONDITION], 8. Dysphagia, status [REDACTED].Review of Systems: Unable to obtain accurate review of systems as patient currently is alert and oriented X 0 with persistent [MEDICAL CONDITION] . Record review of Activities Progress Notes for Resident #110 dated 3/28/17 revealed the resident was new to the facility .Her family stated, she likes to listen to music, go outside, and being around people but she didn't attend church . Record review of the Care Plan for Resident #110 dated 03/28/17 revealed, Resident #110 is new to the facility and will be oriented and introduce to all the department managers and their departments. Her family states she likes to go outside and being around people, but she didn't attend church .Goal: Resident will express(verbally or showing signs of satisfaction with daily routine and leisure activities, in room and out of room activities. The staff were to involve the resident with those who have shared interest e.g. men/women's group, social parties, spiritual related, movies, and music, reminiscing and special events and to offer individualized care based on customary routine to keep them safe, stimulated and involved. Record review of Minimal Data Set (MDS) for Resident #110 dated 03/28/17 revealed, Section F Preferences for Custom… | 2020-09-01 |
| 64 | 64 | FAITH HEALTHCARE CENTER | 425009 | 617 WEST MARION STREET | FLORENCE | SC | 29501 | 2017-06-14 | 253 | E | 0 | 1 | J20Y11 | Based on observation and staff interview the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for residents in the facility. This involved resident rooms and common areas in the facility. Findings include: During Stage 1 the following observations were made: Room 8 B Skilled on 4/10/2017 10:31 AM the closet doors were noted to be marred with chipped paint the bathroom floor had a build up of dirt around the edges of room. There was a urinal hanging on handrail by the commode, the walls were noted with chipping paint on them build up of dirt around cove molding in bedroom. Room AB 6 A on 4/10/2017 at 11:29 AM was noted to have a privacy curtain falling off the ceiling and the hooks were broken. The walls were noted to be dirty with the paint chipping off the walls. Room Skilled 2 B on 4/10/2017 at 10:41 AM was noted to have walls and closet doors with chipped paint. There was a build up dirt around the entrance into the room and the cove base through out the room. Room Skilled 13 B on 4/10/2017 at 10:09 AM the closet doors were noted with marred and chipped paint and the bathroom floor was very dirty with buildup of dirt around the edges all walls. The overbed table was observed to have a very rusty metal base. Room Skilled 12 B on 4/10/2017 at 1:01:20 AM was observed to have a build up dirt at the entry to room and on the bathroom floor around cove base. Room Skilled 18 B on 4/10/2017 at 10:02 AM the closet doors were noted to be marred with chipped paint. The bathroom floor was very dirty with buildup of dirt around the edges all walls. There were three urinals hanging on handrail by the commode. The overbed table base was rusty and the handle on bathroom sink was broken off and laying on the sink. Room AB 1 A on 4/10/2017 at 9:58 AM brown substance was observed to be smeared on wall. Room Skilled 6 A on 4/10/2017 at 10:36 AM the door to the room was noted with chipped paint on the wall behind the bed and there was chipping paint… | 2020-09-01 |
| 65 | 65 | FAITH HEALTHCARE CENTER | 425009 | 617 WEST MARION STREET | FLORENCE | SC | 29501 | 2017-06-14 | 278 | D | 0 | 1 | J20Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure the Minimum Data Set (MDS) accurately reflected the the current status for 3 residents, #77 for anti-psychotic medications, # 94 for Hospice care and Resident #16 for pressure ulcers. MDS data was reviewed for 18 residents in Stage 2. Findings include: 1. Record review for Resident #77 revealed the quarterly MDS dated [DATE] was silent to coding identifying the resident had a current [DIAGNOSES REDACTED]. This was verified by the MDS Nurse ##99 on 4/10/2017 at 1:30 PM. 2. Record review for Resident #94 revealed a physicians verbal order dated 3/8/2017 documenting the physician certified that Resident #94's prognosis was that he had less than six months to live if his disease runs it's normal course. The record review also revealed the resident was currently receiving Hospice services. Review of Resident #94's most recent MDS dated [DATE] revealed it was silent to the fact the resident was receiving Hospice services and was also silent to his [DIAGNOSES REDACTED]. The inaccurate MDS was verified by the MDS nurse #99 on 4/11/2017 at 2:20 PM. 3. The quarterly 02/22/17 Minimum Data Set (MDS) assessment for Resident #16 was reviewed on 04/11/17 at 9:39 a.m. and identified the resident with two unstageable pressure ulcers. One pressure ulcer was noted to be unstageable due to a non-removable dressing and one was noted to be unstageable due to slough/eschar. According to Wound Clinic documentation, reviewed on 04/11/17 at 9:06 a.m., by 02/22/17 the resident had only one unstageable pressure ulcer (to the left lateral heel.) In an interview on 04/12/17 at 9:28 a.m., MDS Coordinator Staff #99 reviewed the MDS and stated only one unstageable pressure ulcer should have been coded. She acknowledged it was an error to code two. | 2020-09-01 |
| 66 | 66 | FAITH HEALTHCARE CENTER | 425009 | 617 WEST MARION STREET | FLORENCE | SC | 29501 | 2017-06-14 | 279 | J | 0 | 1 | J20Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to develop a comprehensive person-centered care plan for each 2 of 18 residents whose care plans were reviewed in Stage 2. This involved Resident #6 for nutrition/swallowing precautions which resulted in an Immediate Jeopardy when the resident became choked during a meal after asking for and not receiving assistance from staff with positioning. In addition, Resident #77 had no care plan to address the use of anti-psychotic medications. Findings include: 1. Record review for Resident #6 of physician progress notes [REDACTED].diabetes with peripheral circulatory disorders, type 1 .coronary [MEDICAL CONDITION] (hardening/narrowing of arteries) of unspecified type of vessel .[MEDICAL CONDITION] (lacking control) bladder, CKD ([MEDICAL CONDITION]) stage IV (4), [MEDICAL CONDITION] . Record review of the Therapy Screening Form dated 01/19/17 revealed, Indicate all areas reflecting a change in condition or an area with a deficit that may warrant therapy: Difficulty with mobility, bed mobility .difficulty turning to assist with ADL's (Activities of Daily Living). Record review of the Functional limitations Assessment by OT (Occupational Therapy) dated 01/25/17 revealed, Pt evaluation this date and is presently at 90% impairment to do self feeding, ADLS and bed/chair positioning requiring increased assist from care givers. Record review of Speech Therapy (ST) Plan of Care dated 01/30/17 revealed, .During routine screen, ST noted increased coughing during PO (by mouth) consumption .Therapy necessary for increased upper airway protection. Without therapy patient at risk for aspiration . Record review of Minimum Data Set ((MDS) dated [DATE] revealed, Section G-Functional Status-Bed mobility: total dependence, one person physical assist .Section K Swallowing/Nutritional Status- Swallowing disorder-Z. None of the above. Record review of ST daily treatment note dated 03/13/17 reveal… | 2020-09-01 |
| 67 | 67 | FAITH HEALTHCARE CENTER | 425009 | 617 WEST MARION STREET | FLORENCE | SC | 29501 | 2017-06-14 | 280 | D | 0 | 1 | J20Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure care plans were reviewed and revised by the interdisciplinary team for 2 of 18 residents whose care plans were reviewed in Stage 2. Findings include: The Activity Care Plan for Resident #23, updated 03/15/17, and reviewed on 04/11/17 at 2:55 p.m., listed a Problem Start Date of 09/23/15. The identified problem indicated the resident is new to the facility, she/he will be orient, introduce, greet and meet staff members, the different department managers and the different department. In an interview on 04/12/17 at 9:30 a.m., MDS Coordinator Staff #99 stated the problem should have been updated to reflect the resident's current status. She acknowledged the resident had been in the facility over a year and a half and was no longer considered new. 2. Resident' #73's comprehensive care plan was reviewed on 04/11/17 at 2:34 p.m. The Potential [MEDICAL CONDITION] related to hx (history) of stroke care plan included the goal, Resident will participate in self care activities to the highest possible level as evidenced by: ___ (specify). One of the approaches was Allow sufficient time to complete self care. According to the 01/31/17 Minimum Data Set, reviewed on 04/11/17 at 10:27 a.m., Resident #73 was totally dependent on staff for all care needs. In an interview on 04/12/17 at 9:15 a.m., MDS Coordinator #99 stated the care plan should have had a specific goal included. She stated it was an oversight. She also stated the resident could not complete self care and that approach should have been updated to accurately reflect this resident's specific care needs. In addition, the Falls care plan, reviewed on 04/11/17 at 2:36 p.m. identified approaches that included mat on both sides of bed and padded headboard and footboard. Observation on 04/11/17 at 3:32 p.m. revealed Resident #73 in bed. The bed was against the wall, with only one mat on the floor. The bed did not have a padded head… | 2020-09-01 |
| 68 | 68 | FAITH HEALTHCARE CENTER | 425009 | 617 WEST MARION STREET | FLORENCE | SC | 29501 | 2017-06-14 | 281 | J | 1 | 1 | J20Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interviews and review of facility files, the facility failed to provide respiratory assessment and care to meet the residents needs for 1 of 3 residents reviewed for neglect. Resident #48, in a persistent vegetative state was gurgling. The resident's condition was reported to the nurse, but she/he did not assess or provide intervention of suctioning. The findings included: Cross refer to F223 Neglect of resident by failure not to assess or intervene with an identified change in respiratory condition. The facility admitted resident #48 with [DIAGNOSES REDACTED]. Review of Nurses' Notes from [DATE] through [DATE] revealed resident was total care for all Activities of Daily Living (ADL's). S/He was in a persistent vegetative state. On [DATE] at 9:30 AM: resident lying in bed with eyes open, when breathes makes a gurgling sound. resp even/unlabored. will continue monitoring. 10:20 AM called to room per Certified Nursing Assistant (CNA). Resident lying in bed with Head of bed (HOB) elevated ( ^) noted to have beige secretions coming out of mouth. No respirations noted. Code blue called &Cardiopulmonary Resuscitation (CPR) was initiated, no pulse, 911 called 10:30 AM Emergency Medical Services (EMS) here. took over CPR. To hospital via stretcher. Per Physician's Cumulative Orders for ,[DATE]-[DATE] an order for [REDACTED]. Review of the medical record revealed the resident was noted at 9:30 AM to have a gurgling sound when breathing. There was no indication the resident was assessed. No vital signs were available. There was no notation of the resident's breath sounds, no auscultation of the lungs. No evidence of any assessment of the resident's respiratory condition. At approximately 10:30 AM the resident was noted to be without respirations. Again, there was no evidence the resident had been assessed for vital signs before CPR was began. Interviews with the two Certified Nursing Assistants (Cross Refer to F223) revealed t… | 2020-09-01 |
| 69 | 69 | FAITH HEALTHCARE CENTER | 425009 | 617 WEST MARION STREET | FLORENCE | SC | 29501 | 2017-06-14 | 282 | D | 0 | 1 | J20Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to implement the care plan for 3 (Resident #110, # 22 and #66) of 18 residents whose care plans were reviewed in Stage 2. This involved lack of a therapy evaluation, for Resident #110, pressure ulcer care for Resident #66 and positioning while eating for Resident #22. Findings include: 1. Record review of the admission nurses note for Resident #110 dated 3/22/17 at 6:00 PM, revealed, .Body assessment completed . Bilat (bilateral) lower extremities contracted .resident requires total assistance and care with all needs . Record review of Care Plan for Resident #110 dated 03/22/17 revealed, Resident is limited in range of motion R/T (related to) contractures of the upper and lower extremities .Goal Resident's joint contractures will be free from injury and skin breakdown Perform a contracture assessment .Staff to perform PROM (passive range of motion) during ADLs (activities of daily living)/care as tolerated . Record review of Minimal Data Set (MDS) for Resident #110 dated 03/28/17 revealed, Section G Functional Status indicates that the resident is dependent in all areas of care. On the following dates and times during observations, the Resident # 110 was found in her bed, with bilateral contractions to her legs, positioned on her back, no splints, and towel rolls in her hand: 04/11/17 at 8:40 AM, 10:17 AM, 11:03 AM, 12:27 AM, 1:32 AM, 2:29 AM, and 3:06 AM, 4:54 AM, and 5:17 AM. 04/12/17 at 7:42 AM and 8:44 AM. On 04/12/17 she was up in her chair at 10:39 AM, 1:19 AM, and 2:40 PM, tilted to her left side with no support, splints, or other interventions for contractures. On 04/12/17 at 11:39 am during an interview with Occupational Therapists Staff #127, when asked if residents get screened when they are admitted , to decide whether they need therapy, she confirmed that they are. When asked if there is a reason why someone would not be screened, she confirmed that sometimes,… | 2020-09-01 |
| 70 | 70 | FAITH HEALTHCARE CENTER | 425009 | 617 WEST MARION STREET | FLORENCE | SC | 29501 | 2017-06-14 | 314 | E | 0 | 1 | J20Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to ensure that interventions to support healing and prevention of pressure ulcers were being implemented for 3 (Resident #60, #66 and #110) of 4 resident reviewed for pressure ulcers in Stage 2. Findings are: 1. Record review for Resident #60 of physicians progress note dated 12/14/17 revealed,72 yo (year old) F (female), who was admitted to secondary to gradual functional decline over several weeks. Prior to admission, pt (patient)resided at an Intermediate Care Facility (ICF)) for 15yrs (years) and steadily became incapable of caring for herself and was incontinent of bowel and bladder per prior documentation at . She had also begun to pocket her food. The pt (patient) is wheelchair-bound at baseline. Record review of Minimum Data Set ((MDS) dated [DATE] revealed, Section G Functional Status- resident is dependent with one person assist for all areas including bed mobility, transfer, personal hygiene .Skin Conditions: Number for untraceable pressure ulcers: 1, Dimensions of Unhealed Stage 3 or 4 Pressure Ulcers or Eschar: Pressure ulcer length: 4.5 cm, width: 2.1, depth: 3.1. Record review of Care Plan date 01/01/17 revealed, Problem: Pressure Ulcer .Goal: Residents skin will remain intact .Approach: Assess resident for presence of risk factors. Treat, reduce, eliminate risk factors to extent possible .turn and reposition every ___(frequency) (section left blank) . On the back of the care plan were wound measurements, on 03/30/17 the documentation revealed, .Left buttock stage 3 CCTX (Continue current treatment) 0.2cmx 0.2cm x 0.2 cm. Record review of Care Plan dated 01/05/17 revealed, Problem: Pressure Ulcer Resident is at risk for skin breakdown R/T incontinence and impaired mobility .Goal: Residents skin will remain intact .Approach: Assess resident for presence of risk factors. Treat, reduce, eliminate risk factors to extent possible . Observations on 04/11/17 durin… | 2020-09-01 |
| 71 | 71 | FAITH HEALTHCARE CENTER | 425009 | 617 WEST MARION STREET | FLORENCE | SC | 29501 | 2017-06-14 | 318 | D | 0 | 1 | J20Y11 | Based on observation, record review and interview, the facility failed to ensure that range or motion services were provided for 1 (Resident #110) of 3 residents reviewed in Stage 2 for range of motion. The findings included: Record review for Resident #110 of Restorative Nursing Policies and Procedures dated 12/01/14 revealed, Subject: Joint Mobility/Range of Motion (ROM) Program and Splinting - Initiating the Program Policy: Patients/residents will be assessed for joint mobility limitation upon admission, re-admission, quarterly, annually, and with significant changes .A restorative program will be implemented through the care plan to increase, maintain, or prevent deterioration of joint mobility and to maximize physical function when referral to therapy is not indicated .Orthotic, assistive, or prosthetic devices will be provided if indicated .Procedures: 2. The problems, goals, target dates and approaches are documented on the patients/residents care plan .Candidates: Appropriate candidates for the Nursing Restorative ROM (Range of motion) Program may include, but are not limited to, patients/residents with the following conditions: contractures, decreased AROM (active range of motion), Decreased PROM (passive range of motion) . Record review of the admission nurses note for Resident #110 dated 3/22/17 at 6:00 PM, revealed, .Body assessment completed . Bilat (bilateral) lower extremities contracted .resident requires total assistance and care with all needs . Record review of Care Plan for Resident #110 dated 03/22/17 revealed, Resident is limited in range of motion to R/T (related to) contractures of the upper and lower extremities .Goal Resident's joint contractures will be free from injury and skin breakdown Perform a contracture assessment .Staff to perform PROM (passive range of motion) during ADLs (activities of daily living)/care as tolerated . Record review of Minimal Data Set (MDS) for Resident #110 dated 03/28/17 revealed, Section G Functional Status indicates that the resident is dependent in all a… | 2020-09-01 |
| 72 | 72 | FAITH HEALTHCARE CENTER | 425009 | 617 WEST MARION STREET | FLORENCE | SC | 29501 | 2017-06-14 | 323 | J | 0 | 1 | J20Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to keep two resident's, #6 and #22, out of 18 residents identified for dependant eating, free from choking due to improper positioning while eating. This resulted in Immediate Jeopardy (IJ) for 2 residents (Resident #6, and #22). The sample was expanded to include Resident #1 and #20 who were identifed to be on swallowing precautions by the facility during the extended survey. The facility identified that the total number of residents that required assistance with meal service was 18. In addition, the facility failed to ensure handrails in the hallways did not have rough and splintered areas making them a hazard to residents when used. Findings include: Record review for Resident #6 of physician progress notes [REDACTED].diabetes with peripheral circulatory disorders, type 1 .coronary arteriosclerosis (hardening/narrowing of arteries) of unspecified type of vessel .Neurogenic (lacking control) bladder, CKD (Chronic Kidney Disease) stage IV (4), [DIAGNOSES REDACTED] . Record review of Therapy Screening Form dated 01/19/17 revealed, Indicate all areas reflecting a change in condition or an area with a deficit that may warrant therapy: Difficulty with mobility, bed mobility .difficulty turning to assist with ADL's (Activities of Daily Living) . Record review of Functional limitations Assessment by OT (Occupational Therapy) dated 01/25/17 revealed, Pt evaluation this date and is presently at 90% impairment to do self feeding, UB ADLS and bed/chair positioning requiring increased assist from care givers . Record review of Speech Therapy (ST) Plan of Care dated 01/30/17 revealed, .During routine screen, ST noted increased coughing during PO (by mouth) consumption .Therapy necessary for increased upper airway protection. Without therapy patient at risk for aspiration . Record review of Minimum Data Set ((MDS) dated [DATE] revealed, Section G-Functional Status-Bed mobility: total… | 2020-09-01 |
| 73 | 73 | FAITH HEALTHCARE CENTER | 425009 | 617 WEST MARION STREET | FLORENCE | SC | 29501 | 2017-06-14 | 328 | J | 1 | 1 | J20Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interviews, the facility failed to provide respiratory care/suctioning to 1 of 3 residents reviewed for neglect. Resident #48 did not receive suctioning for an extended period of time, became unresponsive and was transported out of the facility to the hospital. The findings included: Cross refer to F223- Neglect, Resident #48 was identified with respiratory difficulty which was reported to the nursing staff with no interventions taken. The facility admitted resident #48 with [DIAGNOSES REDACTED]. Review of Nurses' Notes from [DATE] through [DATE] revealed resident was total care for all Activities of Daily Living (ADL's). S/He was in a persistent vegetative state. On [DATE] at 9:30 AM: resident lying in bed with eyes open, when breathes makes a gurgling sound. resp even/unlabored. will continue monitoring. 10:20 AM called to room per Certified Nursing Assistant (CNA). Resident lying in bed with Head of bed (HOB) elevated ( ^) noted to have beige secretions coming out of mouth. No respirations noted. Code blue called & Cardiopulmonary Resuscitation (CPR) was initiated, no pulse, 911 called 10:30 AM Emergency Medical Services (EMS) here. took over CPR. To hospital via stretcher. Per Physician's Cumulative Orders for ,[DATE]-[DATE] an order for [REDACTED]. On [DATE] Registered Nurse, (RN) #138 was interviewed via phone by surveyor at 8:30 AM. The RN stated the resident was gurgling during med pass. S/he stated s/he went and found a suction machine on the crash cart but it was not working. S/he did state suction machines were located on each crash cart. The RN stated s/he never suctioned the resident before. On [DATE] the Administrator was advised of a second Immediate Jeopardy that began on [DATE] when a resident had a change in condition related to respiratory issues that was not addressed by the nurse. The resident became unresponsive and was transported out of the facility to the hospital and expired. The facility… | 2020-09-01 |
| 74 | 74 | FAITH HEALTHCARE CENTER | 425009 | 617 WEST MARION STREET | FLORENCE | SC | 29501 | 2017-06-14 | 329 | D | 0 | 1 | J20Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review it was determined the facility failed to ensure two (#s 113 & 94) of five residents reviewed for unnecessary medications were free from unnecessary medications. Failure to adequately monitor behaviors, attempt non-drug interventions prior to the use of as needed anti-anxiety medication, and administration of pain medication and anti-anxiety medication at the same time for Resident #113, and failure to ensure a proper [DIAGNOSES REDACTED].#94 placed these residents at risk to receive an unnecessary medication. Findings include: 1. Review of the most current physician's orders [REDACTED]. In an interview on 04/12/17 at 1:47 p.m., Licensed Nurse #51 explained when a nurse administered a prn medication, they would complete the behavior monitoring form and/or document in the nurse's notes what staff attempted prior to administering the medication (non-drug interventions), what behaviors the resident exhibited that required the interventions and if the medication was effective. Review of the Medication Administration Record (MAR) on 04/12/17 at 1:54 p.m. revealed no behavior monitoring forms for this resident. The front of the MAR indicated the resident received prn [MEDICATION NAME] on 12 or 13 occasions (unable to decipher handwriting) from 04/04/17 through 04/12/17. Only five of the administrations were listed on the back of the MAR with the reason for giving yelling & screaming each time and that the dose was effective. There were no non-drug interventions (NDIs) identified for any of those doses. Review of the nurse's notes, at 04/12/17 at 2:07 p.m., revealed no mention of the resident's behaviors or the administration of the medication on ten of the occasions the resident received the medication (04/04, 06, 07, 08, or 09/17 at 5:00 a.m.) The nurse's note on 04/09/17 at 11:00 p.m. and 04/11/17 at 12:30 p.m. identified the resident's behaviors and attempted NDIs prior to administration of the medicatio… | 2020-09-01 |
| 75 | 75 | FAITH HEALTHCARE CENTER | 425009 | 617 WEST MARION STREET | FLORENCE | SC | 29501 | 2017-06-14 | 353 | E | 0 | 1 | J20Y11 | Based on observation, interview and record review it was determined the facility failed to ensure nursing staff provided services each resident was assessed to require. This failed practice was evidenced by residents reporting extended wait times for assistance to be provided and observations revealed staff failing to respond to residents requests for assistance. Findings include: During Stage 1 interviews, four (#s 80, 6, 55 & 57) of 13 residents answered No when asked Do you feel there is enough staff available to make sure you get the care and assistance you need without having to wait a long time? For example, in an interview on 04/10/17 at 11:03 a.m., Resident #6 stated, I have to wait a long time. In an interview on 04/10/17 at 11:19 a.m., Resident #55 stated, for all care including bathroom and just overall care needs. All shifts had a lot of people (staff) quit. In an interview on 04/12/17 at 1:20 p.m. Registered Nurse #3 stated a lot of the residents were high acuity, either due to physical or cognitive/mental needs, and that staffing was based on census not acuity. In an interview on 04/13/17 at 7:59 a.m., Staff Scheduler #107 stated staffing was based on the census and not acuity of resident's care needs. She also stated the facility only had one Registered Nurse to work the floor and that it was sometimes difficult to schedule enough nurse aides. Failed practice was determined during the survey related to a lack of nurse aide in-services; failure to utilize a Registered Nurse seven days per week; failure to ensure proper positioning of dependent residents during meals to prevent aspiration; lack of appropriate interventions to prevent / treat pressure ulcers; failure to provide range of motion services a resident was assessed to require and a failure to ensure residents received dental services. The facility's failure to ensure staff provided the care residents were assessed to require in a timely manner placed all residents at risk for unmet care needs. | 2020-09-01 |
| 76 | 76 | FAITH HEALTHCARE CENTER | 425009 | 617 WEST MARION STREET | FLORENCE | SC | 29501 | 2017-06-14 | 354 | D | 0 | 1 | J20Y11 | Based on staff interview and record review it was determined the facility failed to ensure the services of a Registered Nurse (RN) were used at least eight consecutive hours a day, seven days a week. This failure placed residents at risk to not have their care needs met due to a lack of qualified nursing staff. Findings include: In an interview on 04/12/17 at 4:25 p.m., Assistant Director of Nursing (Registered Nurse) #3 explained she worked Monday through Friday, supervising staff and ensuring care needs were met. She also explained the facility employed three RNs who worked the floor. At 4:30 p.m., review of staffing schedules for 03/25/17 through 04/02/17 revealed on Saturday (03/25/17 and 04/08/17) and Sunday (03/26/17 and 04/09/17) the facility had no RN coverage. At 4:35 p.m., Assistant Director of Nursing 3 stated If that is what it says, then that is what it is. In an interview on 04/13/17 at 7:57 a.m., Scheduler #107 explained the facility previously had three RNs, however two recently quit and so there was only one currently on the schedule. She explained she was not aware of the requirement to have an RN scheduled every day. I just schedule what I have. | 2020-09-01 |
| 77 | 77 | FAITH HEALTHCARE CENTER | 425009 | 617 WEST MARION STREET | FLORENCE | SC | 29501 | 2017-06-14 | 371 | E | 0 | 1 | J20Y11 | Based on observation and staff interview it was determined the facility failed to ensure staff completed proper glove changes and handwashing as required while preparing food. This placed residents at risk for foodborne illness. Findings include: Observation of lunch meal preparation on 04/12/17 from 10:00 a.m. to 11:15 a.m. revealed improper hand hygiene. Cook #86 was observed making sandwiches. Wearing gloves, she placed ham on slices of bread that had been laid out on a cooking sheet. She then picked up a plastic bag of eggs, removed a marker from her pocket, wrote the date on the bag, opened the fridge, put the bag of eggs in the fridge, put the marker back in her pocket, and returned to the sandwiches, placing a slice of bread on each sandwich, wearing the same gloves. She was observed to touch a cart, obtain two loaves of bread, open a cabinet, retrieve a pan of food from the stove, retrieve a strainer and food processor from the sink area, turned on the sink faucet and then returned to place pickles on the sandwiches, using the same gloved hands. Using a knife, she opened a cheese wrapper and sliced some cheese. She then put turkey and cheese slices on the sandwiches. She obtained a cutting board and placed it on a counter, then placed the top slice of bread on more of the sandwiches. She proceeded to slice some ham and then chopped it, ripped open a bread wrapper and continued to put the top slice of bread on the sandwiches, without handwashing or glove change. These observations were shared with Dietary Manager #114 at 10:25 a.m. who spoke to the staff member about the need for handwashing and glove changing when moving between tasks. At 10:40 a.m. Dietary Aide #61 was observed making pureed apples. Wearing gloves, she put the food processor together, turned on and off the food processor several times, used a spatula to check the consistency of the apples, obtained a bowl and then, using the same gloved hands, reached into the food processor and scooped apples out of the food processor. These observation… | 2020-09-01 |
| 78 | 78 | FAITH HEALTHCARE CENTER | 425009 | 617 WEST MARION STREET | FLORENCE | SC | 29501 | 2017-06-14 | 412 | D | 0 | 1 | J20Y11 | Based on observation, interview and record review it was determined the facility failed to ensure two (#s 34, 23) of three residents reviewed for dental services received routine dental services. Failure to offer dental services and assist residents with locating a dentist, obtaining appointments and arranging for transportation placed residents at risk for unmet dental needs. Findings include: In an interview on 04/10/17 at 12:05 p.m., Resident #34 stated he had no teeth and would like to see a dentist to obtain dentures. He stated he did not like an altered texture diet and so received a regular diet, at his request, which could sometimes be difficult to chew. He stated the facility had not offered to assist him in locating a dentist or arranging an appointment for dental services. Observation of the resident at this time revealed the resident had no teeth, nor dentures. The Nutrition Risk Assessment, dated 11/23/13, and reviewed on 04/11/17 at 12:58 p.m., identified the resident as edentulous (without teeth). The Annual Minimum Data Set (MDS) assessment, dated 10/06/16, reviewed on 04/13/17 at 8:58 a.m. identified the resident was edentulous. The Care Area Assessment identified the Resident is edentulous. He is impaired physically on his right side due to a stroke. He will need to be assisted with oral care by staff to prevent ulcers of his mouth. Care plan will be developed to prevent ulcers for the resident to receive oral care. There was no indication the offer of a dental visit for dentures was considered or made. In an interview on 04/11/17 at 6:10 p.m., Social Services Staff #27 explained the wheelchair lift in the facility's van had been broken for an extended period of time. She stated the facility arranged with a local transportation company to take residents who required the use of a wheelchair to the dentist, however they did not return at the end of appointments promptly and so the dentist wanted them to remain with the resident. The transportation company refused and so the dentist would no longer… | 2020-09-01 |
| 79 | 79 | FAITH HEALTHCARE CENTER | 425009 | 617 WEST MARION STREET | FLORENCE | SC | 29501 | 2017-06-14 | 498 | D | 0 | 1 | J20Y11 | Based on interview and record review it was determined the facility failed to ensure all nurse aides received at least 12 hours of in-service training per year. This placed residents at risk to not have their care needs met due to insufficiently trained staff. Findings include: Upon request, the facility provided a list of all currently employed, active staff members. On 04/12/17 at 10:30 a.m. a random review of five on-call nurse aides (Nurse Aides 4, 22, 32, 44 & 46) revealed none received 12 hours of in-service education from 01/01/16 through 04/12/17. The facility's documentation of the in-service hours received revealed Nurse Aide #4 had 10.25 hours; Nurse Aide #22 had 7 hours 10 minutes; Nurse Aide #32 had no hours; Nurse Aide #44 had 9.25 hours; and Nurse Aide #46 had 2 hours 50 minutes. In an interview on 04/12/17 at 3:14 p.m., Assistant Director of Nursing #3 explained the facility used computer based in-service training as well as person led in-services. She reviewed the computer system for these five staff and verified the above hours. She stated on-call staff were invited to the live in-services and it was their responsibility to get the 12 hours of in-service education. She was unable to explain why these staff did not receive the required education. | 2020-09-01 |
| 80 | 80 | FAITH HEALTHCARE CENTER | 425009 | 617 WEST MARION STREET | FLORENCE | SC | 29501 | 2017-06-14 | 520 | J | 0 | 1 | J20Y11 | The facility failed to identify quality deficiencies and develop and implement plans of action to correct the quality deficiencies. This includes monitoring the effect of implemented changes and making needed revisions to action plans. This involved accident hazards regarding positioning of residents during meals which resulted in Immediate Jeopardy and Substandard Quality of Care. In addition, lack of dental service, pressure ulcer wound tracking, housekeeping and maintenance and lack of the required 8 hours coverage of an Registered Nurse in the building 7 days a week. Findings include: During the survey from 4/10/2017 through 4/13/2017 care area concerns were noted in the provision of care for the residents by the facility in the areas of accident hazards regarding positioning of residents during meals, lack of dental services, pressure ulcer wound tracking, housekeeping and maintenance, and lack of the required coverage of a Registered Nurse in the building for 8 hours every day. An interview was conducted with the Administrator Staff #23 on 4/13/2017 at 9:05 AM. This surveyor shared with the Administrator the noted concerns in the areas of accident hazards regarding positioning of residents during meals, dental services, pressure ulcer wound tracking, housekeeping and maintenance, and lack of the required coverage of a Registered Nurse in the building for 8 hours every day. She stated their Quality Assurance team meets monthly and none of these care area concerns had been identified in any of their meetings. In the area of accidents hazards the Administrator verified the Quality Assurance team had not identified any concerns with residents not being positioned in bed while feeding themselves in a manner to prevent potential choking and aspiration. Refer to F323. She stated during a meeting a few months ago they had discussed concerns with personalized care plans and updating care plans in the facility but this was after it was brought to their attention in a recent complaint survey. She was not able to produ… | 2020-09-01 |
| 81 | 81 | FAITH HEALTHCARE CENTER | 425009 | 617 WEST MARION STREET | FLORENCE | SC | 29501 | 2018-09-07 | 550 | D | 0 | 1 | NUHA11 | Based on observations, and interview, the facility failed to maintain the dignity of residents during med pass on 1 of 3 units. The Nurse did not knock before entering Resident #30's room on the Skilled West Unit. The findings included: On 9/5/18 at approximately 5:15 PM, an observation during Resident #30's medication administration, Licensed Practical Nurse (LPN) #1 entered the residents' room without knocking to obtain a finger stick blood sugar sample. Following the sample LPN #1 left the room for approximately 3 minutes and returned to Resident #30's room and entered the room again without knocking or asking permission to enter. On 9/5/18 at approximately 5:25 PM, in an interview with LPN #1, s/he verified the s/he entered Resident #30's room without knocking or asking permission to enter. | 2020-09-01 |
| 82 | 82 | FAITH HEALTHCARE CENTER | 425009 | 617 WEST MARION STREET | FLORENCE | SC | 29501 | 2018-09-07 | 638 | B | 0 | 1 | NUHA11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to complete an MDS (Minimal Data Set) Assessment within 92 days of the prior MDS assessment for Resident #10, 1 of 4 residents reviewed for hospitalization . The findings included: The facility admitted Resident #10 on 08/14/17 with [DIAGNOSES REDACTED]. On 09/05/18 at approximately 2:35 PM, review of the State Agency MDS data base revealed an Annual MDS assessment dated [DATE]. Further review revealed a discharge MDS assessment dated [DATE] and a Re-entry MDS dated [DATE]. No Quarterly MDS Assessment, with an Assessment Reference Date no later than 08/11/18 was noted. During an interview on 09/05/18 at approximately 4:30 PM, MDS Coordinator #1 stated a Quarterly MDS had been started but confirmed it was not completed and that s/he would investigate why the assessment wasn't completed. During an interview on 09/07/18 at 08:55 AM, MDS Coordinator #1 again confirmed the MDS was not done and stated another MDS Coordinator had reported that s/he thought it had been completed. | 2020-09-01 |
| 83 | 83 | FAITH HEALTHCARE CENTER | 425009 | 617 WEST MARION STREET | FLORENCE | SC | 29501 | 2018-09-07 | 732 | C | 0 | 1 | NUHA11 | Based on record review and interview, the facility failed to clearly identify on the daily Staff posting how many Registered Nurses and how many Licensed Practical or Licensed Vocational Nurses were working each shift on 25 of 30 days reviewed. The findings included: On 09/06/18 at 01:11 PM, observation of the Staff Posting in the front lobby revealed 1 number posted for the category of Licensed staff. The total number and the actual hours worked by the categories of Registered Nurses and Licensed practical nurses or licensed vocational nurses was not differentiated. Further review of the Staff Posting for the last 30 days revealed no differentiation of licensed staff on 25 days. During an interview on 09/06/18 at 02:19 PM, the Nursing Home Administrator (NHA) confirmed the staff was not differentiated on the Staff Posting. The NHA confirmed that a single number listed in the box for licensed staff did not clearly identify how many of the number of nurses listed were Registered Nurses and how many were Licensed Practical or Licensed Vocational Nurses. | 2020-09-01 |
| 84 | 84 | FAITH HEALTHCARE CENTER | 425009 | 617 WEST MARION STREET | FLORENCE | SC | 29501 | 2018-09-07 | 760 | D | 0 | 1 | NUHA11 | Based on observations, interview, and review of the facility policies and the Humalog KwikPen manufacture recommendations, the facility failed to administer the correct amount of insulin for 1 of 1 resident reviewed for insulin administration. Staff did not follow an established procedure to deliver the correct amount insulin to Resident #30. The findings included: On 9/5/18 at 5:15 PM, during an observation of Resident #30's medication administration on the Skilled West Unit, Licensed Practical Nurse (LPN) #1 checked Resident #30's blood sugar (BS) which was 224. The physician's orders stated, Resident #30 is to receive 4 units of Humalog insulin via the KwikPen for a BS between 200-249. LPN #1 attached a needle to the KwikPen and without priming the KwikPen, selected 4 units on the dose knob dial. LPN #1 proceeded to administer the insulin by putting the KwikPen needle onto Resident #30's left upper arm and pressed the dose knob administration button. Following the administration LPN #1 verified s/he did not prime the Humalog KwikPen prior to administration. LPN #1 was asked, Were you trained in using insulin pens? LPN #1 stated, No, I never heard of priming before. Review of the facility policy Medication Management Program, states under procedure (11. N.) Follow manufactures guidelines for medication pen-style delivery devices for priming and air shots. Review of the Humolog KwikPen manufactures recommendations reveals under, Priming your HUMALOG KwikPen. Step (4) states, Prime before each injection. Priming ensures the Pen is ready to dose and removes air that may collect in the cartridge during normal use. If you do not prime before each injection, you may get too much or too little insulin. | 2020-09-01 |
| 85 | 85 | FAITH HEALTHCARE CENTER | 425009 | 617 WEST MARION STREET | FLORENCE | SC | 29501 | 2019-12-22 | 679 | D | 0 | 1 | WNXB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews, it was determined the facility failed to provide meaningful activities to two (#15 and #21) of two sampled residents reviewed for activities on the AB hall. The facility identified 34 residents who resided on AB Hall. The findings include: The facility's activity calendar for (MONTH) 2019 documented the following activities were to be provided: 12/20/19: 10:30 AM Reverend (name redacted); 2:00 PM Exercise; 2:30 Puzzles; 3:30 PM Music and Table Top Games. 12/21/19: 10:30 AM Christmas Movies/Arts and Crafts; 3:00 PM Church. 1. Resident #15 had [DIAGNOSES REDACTED]. An admission Minimum Data Set (MDS), dated [DATE], documented the resident's cognition was severely impaired and required total assistance from staff for activities of daily living skills such as transfers and locomotion. A care plan, last updated 10/14/19, documented the resident enjoyed family visits, reading the bible, watching TV, listening to music, church, flower/plants and having snacks between meals. The documented interventions included to provide the resident with verbal reminders of the activities. The resident's current physician's orders [REDACTED]. On 12/20/19 at 9:45 AM, the resident was observed up in her wheelchair in her room. The room was dark, and the resident had no television in her room or radio to play music. On 12/20/19 from 9:45 AM to 10:35 AM, the resident remained in her room with the lights off. There were no stimulating activities provided to the resident while she was in the room. The resident was observed with her eyes closed on and off during this time. On 12/20/19 at 10:30 AM, there was a church service provided in the main dining room. No staff was observed letting the resident know of the activity or took her to the activity. On 12/20/19 from 10:30 AM to 12:45 PM, the resident again remained in her room with the lights off. She was observed on multiple occasion in the dark room, with her head hu… | 2020-09-01 |
| 86 | 86 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2018-01-23 | 610 | D | 1 | 0 | S6DX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, the facility failed to have evidence that all alleged violations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated. Resident #1 was noted with a fracture of unknown origin. The facility failed to interview all staff involved with the resident's care around the time the fracture was identified. The facility failed to clarify staff statements related to care provided to Resident #1 around the time the fracture was identified. One of three residents reviewed for abuse/neglect. The findings included: The facility reported an injury of unknown source to the State Agency for Resident #1 on 10/19/17. The CNA (certified nurse aide) observed the resident's right lower leg to be swollen and warm to the touch. Resident #1 had a history of [REDACTED]. The physician was notified and a venous Doppler was ordered. The Doppler results were negative and the physician was notified. An x-ray was ordered and revealed a tiny cortical fracture in proximal tibia. Resident #1 was a stand assist transfer with stand up lift. Review of Resident #1's Nurse's Progress Note dated 10/18/17 at 9:50 AM revealed the CNA and nurse reported the resident having a swollen, discolored area to the right lower leg (shin area). The physician was called and notified with a new order for ultrasound of the right lower leg related to [MEDICAL CONDITION] and discoloration. On 10/18/17 at 4:47 PM the Doppler results were received and were negative for blood clot. The Nurse's Progress Note dated 10/18/17 at 5:37 PM indicated Resident #1's daughters requested the resident receive an x-ray of the leg. The nurse informed them that the physician would be in the facility and would look at the resident then. The resident's daughters insisted on an x-ray. The nurse called the nurse practitioner and left a message. Review of the Nurse's Progress Note dated 10/18/17 at 6:00 PM revealed received a call back from the nurse … | 2020-09-01 |
| 87 | 87 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2018-01-23 | 656 | G | 1 | 0 | S6DX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, the facility failed to develop and implement a comprehensive person-centered care plan that included the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Review of Resident #1's care plan and Nurse Aide Information Sheet revealed the resident's transfer status was not identified. One of three residents reviewed for care plans. The findings included: The facility reported an injury of unknown source to the State Agency for Resident #1 on 10/19/17. The CNA (Certified Nurse Aide) observed the resident's right lower leg to be swollen and warm to the touch. Resident #1 had a history of [REDACTED]. The physician was notified and a venous Doppler was ordered. The Doppler results were negative and the physician was notified. An x-ray was ordered and revealed a tiny cortical fracture in proximal tibia. Resident #1 was a stand assist transfer with stand up lift. Review of Resident #1's (MONTH) (YEAR) physician's orders [REDACTED]. Review of Resident #1's care plan revealed resident needs assist with ADL's due to decreased cognition and decreased mobility was identified as a problem area. Interventions and approaches were listed on the care plan and included transfers with mechanical lift and sling lift pad in wheelchair for positioning. There was no indication what type of lift the resident required. A copy of the Nurse Aide's Information Sheet for Resident #1 was included in the facility's investigation file. Review of the form revealed the resident's status was noted as lift to chair with two assist. Review of Resident #1's Nurse Aide's Information Sheet revealed nothing that indicated the resident required a lift for transfers. There was no additional information related to transfers on the form. Review of Resident #1's Nurse's Progress Note dated 10/18/17 at 9:50 AM revealed the CNA and nurse reported resident having sw… | 2020-09-01 |
| 88 | 88 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2018-01-23 | 689 | G | 1 | 0 | S6DX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents. Resident #1 was noted with a fracture of unknown origin. Resident #1 was transferred as a stand and pivot, the CNA (certified nurse aide) did not use the sit to stand lift the resident required. The resident's Nurse Aide Information sheet did not contain accurate information related to the resident requiring a lift for transfers. One of three residents reviewed for accidents. The findings included: The facility reported an injury of unknown source to the State Agency for Resident #1 on 10/19/17. The CNA observed the resident's right lower leg to be swollen and warm to the touch. Resident #1 had a history of [REDACTED]. The physician was notified and a venous Doppler was ordered. The Doppler results were negative and the physician was notified. An x-ray was ordered and revealed a tiny cortical fracture in proximal tibia. Resident #1 was a stand assist transfer with stand up lift. Review of Resident #1's (MONTH) (YEAR) physician's orders [REDACTED]. Review of the physician's orders [REDACTED]. Review of the Radiology Report dated 10/19/17 revealed the resident had a tiny proximal tibial metaphyseal cortical fracture. Review of Resident #1's care plan revealed resident needs assist with ADL's (activities of daily living) due to decreased cognition and decreased mobility was identified as a problem area. Interventions and approaches were listed on the care plan and included transfers with mechanical lift and sling lift pad in wheelchair for positioning. There was no indication what type of lift the resident required. A copy of the Nurse Aide's Information Sheet for Resident #1 was included in the facility's investigation file. Review of the form revealed the resident's status was noted as lift to chair with two assist. Review of Resident #1's Nurse Aide's Information Sheet r… | 2020-09-01 |
| 89 | 89 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2017-05-11 | 253 | D | 1 | 1 | SD8911 | > Based on observation and interview the facility failed to maintain a clean and functional environment for 2 of 2 units. The findings included: The Environmental Tour was conducted with the Environmental Services Room 1 Areas of paint were noted to be rubbed away from the dry wall; the baseboard was pulled away from the wall near the bathroom. Room 53Odors were noted in the restroom; urine was noted in and around the toilet; the restroom floor was wet and discolored. Room 54 The countertop near the hot water faucet was chipped; baseboard under the sink was pulled away from the wall; discolored floor tiles were noted beneath the sink counter and in the restroom. Room 58 The sink fixture was loose; the fixture was noted to vibrate when turned on; a wheelchair was stored in the restroom; brown build up was noted at the base of the toilet. Room 59 The headboard was bruised on Bed A - nearest to the door; paint was scratched away from the drywall; soap film build up was noted around the sink faucets; 1 unlabeled bed pan noted in the restroom; a wired rack; over the commode seat had some rust on the legs; wood on door leading into Room 59 was splintered above the metal plate. Room 62 There was noted odor in the restroom; two uncovered bed pans (gray and pink) in the restroom; black build up on the bathroom floor. These concerns were noted during the first two days of the survey and reviewed and confirmed with the maintenance manager and environmental services manager on 5-10-17 at 2:11 p.m. | 2020-09-01 |
| 90 | 90 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2017-05-11 | 274 | D | 1 | 1 | SD8911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to identify a change in status and conduct a Significant Change in Status Assessment (SCSA) as required for Resident #96, 1 of 3 residents reviewed with a significant change in status. The findings included: The facility admitted Resident #96 with [DIAGNOSES REDACTED]. On 05/09/2017 at 2:34 PM, comparison of the Admission MDS (Minimal Data Set) assessment dated [DATE] to the Quarterly MDS assessment dated [DATE] revealed the resident declined in cognition from a BI[CONDITION] (Brief Interview for Mental Status) score of 15 to a BI[CONDITION] score of 7, indicating the resident declined from cognitively intact to severely impaired. Further review revealed the resident's eating declined from supervision to total dependence. In addition, Resident #96 was receiving intermittent catheterizations on the Admission MDS but had an indwelling catheter on the Quarterly MDS Assessment. Continued review also revealed the resident had a significant weight loss from 249 pounds to 217 pounds, a weight loss of 12.[AGE]% resulting in a decline in a total of 4 areas: cognition, eating, placement of indwelling catheter, and weight loss. During an interview on 05/10/2017 at 4:20 PM, the RN (Registered Nurse) MDS Coordinator #1, confirmed declines in cognition, eating, continence and weight and that a SCSA should have been completed. | 2020-09-01 |
| 91 | 91 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2017-05-11 | 278 | D | 1 | 1 | SD8911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to assure that 1 of 5 sampled residents reviewed for unnecessary medications and one of 1 sampled resident reviewed for hospice services received accurate assessments. Resident #26 had a Minimum Data Set (MDS) assessment completed with inaccurate data related to skilled speech and physical therapy services. Resident #122 had a MDS assessment completed with inaccurate data for item J1400 addressing resident prognosis. The findings included: The facility admitted Resident #26 with [DIAGNOSES REDACTED]. Record review on 5/10/17 at 8:43 AM revealed that Resident #26 had a Physician Telephone Order dated 4/17/17 for Physical Therapy (PT), Occupational Therapy (OT), and Speech Therapy (ST) to evaluate and treat. Further review revealed a clarification telephone order written on 4/18/17 for .skilled PT services 5 times a week for four weeks . and an additional telephone order written for Patient to participate in skilled ST services 5 times a week .for 30 days . Additional review of section O-Special Treatments, Procedures and Programs, Items 0400A1-3A (ST treatment minutes) and O400C1-3A (PT treatment minutes) and O0420 (distinct calendar days of therapy) revealed that all were all answered with a 0 with 0400A4-6 (ST treatment days/ dates) and O400C4-6 (PT treatment days/ dates) were all blank with no information entered on the Admission Comprehensive MDS with Assessment Reference Date (ARD) of 4/25/2017. Further Record review of ST and PT treatment records for the dates of 4/19/17 through 4/25/17 provided on 5/10/17 at 1:30 PM by COTA #1 revealed that Resident #26 received skilled PT individual treatments on 4/19/17, 4/20/17, 4/21/17, 4/24/17, and 4/25/17 as well as skilled ST individual treatments on 4/19/17, 4/21/17, 4/24/17, and 4/25/17. COTA #1 verified during interview that Resident #26 received skilled ST and PT services during the assessment period of 4/19/17-4/25/17. During interv… | 2020-09-01 |
| 92 | 92 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2017-05-11 | 309 | D | 1 | 1 | SD8911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record reviews and interviews, the facility failed to obtain weekly weights as ordered for one of one resident reviewed for dental status. The findings included: Resident #92 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review on 5/11/2017 at 2:00 PM revealed that a clarification order was written on 3/1/17 to continue weekly weights. Further review of Resident #92's weight sheet revealed that weights were recorded as follows: 3/2/17: 138.0 pounds 3/13/17: 141 pounds 3/29/17: no information entered 4/5/17: line struck through, no information entered 4/24/17: 143 pounds Further review of weekly nursing summaries from 2/2017 to 5/2017 revealed that there were no weights recorded anywhere on the forms. During interview on 5/11/17 at 3:06 PM with DON, s/he verified that there was a clarification order written on 3/1/17 for weekly weights and that the weekly weight sheet did not have weekly weights recorded as ordered on a consistent basis since 3/1/17. Additionally, the DON verified that there were no weights documented on any of the weekly summaries completed by nurses from 2/2017 through 5/2017. When asked, the DON stated that the only two places the weights would have been recorded would have been the weight sheet or the weekly nurse summary form. The DON verified that the order for weekly weights was not followed as ordered. | 2020-09-01 |
| 93 | 93 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2017-05-11 | 315 | D | 1 | 1 | SD8911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to ensure there was medical justification for a foley catheter for Resident #24, 1 of 3 residents reviewed with a catheter. The findings included: The facility admitted Resident #24 with [DIAGNOSES REDACTED]. On 05/11/2017 at 12:29 PM, review of the Facility History and Physical dated 4/13/17 revealed a statement from the physician stating I believe this patient has the Foley catheter in place to help promote proper wound healing regarding his sacral pressure ulcer which is being addressed and surveilled by the wound care nurse. On 05/11/2017 at 12:38 PM, RN (Registered Nurse) #3 confirmed the Stage II on the sacrum was healed at the time of admission. S/he further confirmed the History and Physical indicated the Foley was in place to promote healing of the pressure ulcer and that the resident had a Foley for a month without a justification. | 2020-09-01 |
| 94 | 94 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2017-05-11 | 329 | E | 1 | 1 | SD8911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interviews, the Registered Pharmacist (RPH) failed to identify irregularity for two consecutive months related to the approved gradual dose reduction (GDR) of antipsychotic medication for 2 of 5 residents reviewed for unnecessary medications. The findings included: The facility admitted Resident #120 2/3/17 with [DIAGNOSES REDACTED]. Record review on 5/10/17 at approximately 1:49 PM revealed a Pharmacist recommendation dated 2/23/17 for Physician to please re-evaluate the need for continued use of ziprasidone, perhaps considering a gradual dosage reduction to 20 milligrams (mg) by mouth daily for delusions associated with [MEDICAL CONDITION], with the end goal of discontinuation of therapy if possible. Physician approved this request by checking the response I accept the recommendation(s) above, please implement as written with a signature date of 3/2/17. Further review of physicians orders initiated on 3/2/17 reveal the order change [MEDICATION NAME] to 0.25 mg tabs-take 1 tab by mouth four times daily (QID) which was signed by the Nurse Practitioner on 3/6/17. Additional review of the monthly physician orders [REDACTED]. During interview with MD#1 and DON on 5/11/17 at 10:00 AM, MD#1 verified that s/he did approve the GDR for ziprasidone on 3/2/17 that was recommended by the RPH during February 2017 MMR. MD#1 and DON then reviewed Resident #120's medical record during interview after which both verified that the pharmacy recommendation for GDR of ziprasidone that was approved on 3/2/17 had not been initiated as ordered with 2 subsequent RPH monthly MMR's on 3/9/17 and 4/13/17 that did not identify the irregularity. DON and MD both verified that Resident #120 should have been receiving ziprasidone 20 mg capsule by mouth once daily since 3/2/2017. DON and MD #1 both verified that for 71 days, Resident #120 received a daily unnecessary dose of ziprasidone for a total of 71 doses. At the conclusion of the interview,… | 2020-09-01 |
| 95 | 95 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2017-05-11 | 332 | E | 1 | 1 | SD8911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and interview the facility failed to ensure the medication error rate was less than 5%. The facility had 3 errors of 27 opportunities resulting in a medication error rate of 11.11%. The findings included: On 05/10/2017 at 9:01 AM, LPN #1 was observed during the medication pass. LPN #1 administered 24 units of [MEDICATION NAME] [MED] to Resident #5. Observation revealed the vial of [MED] was opened on 04/11/2017. During an interview on 05/10/2017 at 2:04 PM, LPN #1 confirmed the medication should have been discarded 28 days after opening, on 5/8/17. The LPN also confirmed the resident received 5 doses of [MEDICATION NAME] after day 28. During the medication pass observation of LPN #4 on 05/11/2017 at 9:28 AM, the LPN administered [MEDICATION NAME] that was not completely dissolved via the PEG (Percutaneous Endoscopic Gastrostomy) tube which clogged the tube. While attempting to de-clog the tube, the LPN poured the medication back into the medicine cup but several large pieces of the medication remained in the tube. Using a clean washcloth, LPN #4 removed pieces of the tablet from the connector and discarded them. In addition, while administering the [MED], the connection between the syringe and the tube came loose and a portion of the medication flowed out of the syringe onto the towel. The LPN confirmed the resident did not receive the full dose of the 2 medications. | 2020-09-01 |
| 96 | 96 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2017-05-11 | 333 | E | 1 | 1 | SD8911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and interview, the facility failed to ensure that expired medication was not administered to Resident #5, 1 of 1 resident observed for [MED] administration. The findings included: On [DATE] at 9:01 AM, LPN #1 was observed during the medication pass. LPN #1 administered 24 units of [MEDICATION NAME] [MED] to Resident #5. Observation revealed the vial of [MED] was opened on [DATE] and would have expired on 5//,[DATE]. On [DATE] at 2:04 PM, LPN #1 confirmed the medication should have been discarded 28 days after opening. The LPN also confirmed the resident received 5 doses of [MEDICATION NAME] after day 28. | 2020-09-01 |
| 97 | 97 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2017-05-11 | 371 | F | 1 | 1 | SD8911 | > Based on observation and interview, the facility failed to properly store and label food items in both the reach-in and walk-in coolers. In addition, the cook failed to have foods at the appropriate temperature before serving. The findings included: During initial tour of the kitchen on 5/8/2017 at approximately 3:30 pm, observation of the walk-in cooler revealed 3 large bags of expired salad, stored in a box dated use by 4/30/2017. There was also an additional label on the box dated use by 5/3/2017. The tour also revealed 2 bags of unlabeled and undated shredded cheese in the walk- in cooler. At approximately 4:00 pm on 5/8/17, tour of the reach-in cooler revealed 2 peanut butter and jelly sandwiches with a use by date of 5/3/17 and 1 pimento cheese sandwich with a use by date of 5/6/17. Additional tour of the kitchen showed the ice scoop to have been left inside of the ice machine. Review of the facility's policy on Food Storage stated, Scoops are not to be stored in food or ice containers, but are kept covered in a protected area near the containers. An interview with the Certified Dietary Manager on 5/8/17 at approximately 4:15 pm revealed there were expired and unlabeled items in both the walk-in and reach-in coolers. The facility also failed to properly prepare food items to be served at proper temperatures. During an observation of the temping of the lunch tray line on 5/10/17 at approximately 10:56 am, it was revealed the potato salad to be served was not a proper temperature. The cook who took the temperatures found the first bowl of potato salad to be at 50 degrees Fahrenheit. A second bowl was then obtained and found to be at [AGE] degrees Fahrenheit. The temperatures of the fried chicken wings were shown to be at 120 degrees Fahrenheit. During an interview on 5/10/17 at 11:15 am, the cook stated that s/he allows reheated items to reach a temperature of 1[AGE] degrees Fahrenheit. Review of the facility's policy on Reheated Foods, states All parts of the food must reach an internal temperature of 165 … | 2020-09-01 |
| 98 | 98 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2017-05-11 | 428 | D | 1 | 1 | SD8911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interviews, the Registered Pharmacist (RPH) failed to identify irregularity for two consecutive months related to the approved gradual dose reduction (GDR) of antipsychotic medication for 1 of 5 residents reviewed for unnecessary medications. The findings included: The facility admitted Resident #120 2/3/17 with [DIAGNOSES REDACTED]. Record review on 5/10/17 at approximately 1:49 PM revealed a Pharmacist recommendation dated 2/23/17 for Physician to please re-evaluate the need for continued use of ziprasidone, perhaps considering a gradual dosage reduction to 20 milligrams (mg) by mouth daily for delusions associated with alcohol abuse, with the end goal of discontinuation of therapy if possible. Physician approved this request by checking the response I accept the recommendation(s) above, please implement as written with a signature date of 3/2/17. Further review of physicians orders initiated on 3/2/17 reveal the order change clonazepam to 0.25 mg tabs-take 1 tab by mouth four times daily (QID) which was signed by the Nurse Practitioner on 3/6/17. Additional review of the monthly physician orders [REDACTED]. During interview with MD#1 and DON on 5/11/17 at 10:00 AM, MD#1 verified that s/he did approve the GDR for ziprasidone on 3/2/17 that was recommended by the RPH during February 2017 MMR. MD#1 and DON then reviewed Resident #120's medical record during interview after which both verified that the pharmacy recommendation for GDR of ziprasidone that was approved on 3/2/17 had not been initiated as ordered with 2 subsequent RPH monthly MMR's on 3/9/17 and 4/13/17 that did not identify the irregularity. | 2020-09-01 |
| 99 | 99 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2017-05-11 | 431 | E | 1 | 1 | SD8911 | > Based on observation and interview, the facility failed to label medications with the date opened and/or failed to discard expired medications on 2 of 4 medication carts and in 1 of 2 medication rooms observed. The findings included: During review of the unit 2 medication carts on 5/9/17, 2 bottles of ophthalmic drops were observed on cart 1 with no open date: Artificial Tears 15 ml (milliliters) and Brimonidine Tarrate 0.2 % 5 ml. Review of the American Academy of Ophthalmology recommendations revealed A good rule of thumb is to throw away any opened bottle of eye drops after 3 months. Further review revealed a bottle of [MED] 0.005% 2.5 ml with an open date of 3/19/17. The pharmacy label stated to discard 6 weeks after opening. During an interview on 05/09/2017 at 12:04 PM, RN (Registered Nurse) #2 confirmed the findings and stated the policy is to discard 30 days after opening. On 05/10/2017 at 2:44 PM, review of the Unit 1 medication carts revealed Brimonidine Tarrate 0.2 % 5 ml 2 bottles with no open date, Timolol Maleate 0.5% 5 ml bottle with no open date, Olopatadine Hydrochloride 0.2% 2.5 ml bottle with no open date, and [MED] 0.005% 2.5 ml bottle with no open date. In addition, review of the cart revealed 2 Nicotine Transdermal Patches 7 mg (milligrams) that expired February, 2017. During an interview on 05/10/2017 3:00 PM, LPN (Licensed Practical Nurse) #1 confirmed the findings. Review of the facility's policy for Recommended Minimum Medication Storage Parameters for Ophthalmic, Otic, and Topical Medications on 5/11/17 revealed the recommendation for Ophthalmic preparations was to Refer to manufacturer's recommendations. Review of the online manufacturer's recommendations revealed Artificial Tears are stable for 90 days after opening, On 05/10/2017 at 9:01 AM, LPN #1 was observed during the medication pass. LPN #1 administered 24 units of Novolog [MED] to Resident #5. Observation revealed the vial of [MED] was opened on 04/11/2017. On 05/10/2017 at 2:04 PM, LPN #1 confirmed the medication should have… | 2020-09-01 |
| 100 | 100 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2017-08-16 | 157 | D | 1 | 0 | MGP911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to inform the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status. Resident #1 and Resident #3 were both noted to have a change in condition. Review of the resident's medical records revealed no documentation that the physician was notified of the residents' change in condition. Two of three residents reviewed for change in condition. The findings included: Review of Resident #1's medical record revealed Nurses' Progress Notes dated 8/2/17 indicated called to room by Certified Nursing Assistant (CNA) to look at resident's leg. Right leg is swollen. States had pain in leg while receiving peri-care. Registered Nurse (RN) supervisor (RN #1) 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 after the 8/2/17 entry was noted as a late entry for 8/1/17 and indicated the resident complained in wheelchair that right knee popped while being transferred to bed. Some slight [MEDICAL CONDITION] was 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… | 2020-09-01 |
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CREATE TABLE [cms_SC] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );