rowid,facility_name,facility_id,address,city,state,zip,inspection_date,deficiency_tag,scope_severity,complaint,standard,eventid,inspection_text,filedate
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 interview on 01/21/19 at approximately 8:38 AM, the Administrator revealed s/he was not aware of the requirement that all abuse and injuries of unknown source had to be reported to the state agency no later than two hours. The Administrator stated s/he can see how R4's injury could be an injury of unknown source. During an interview on 01/21/19 at approximately 9:50 AM, the Director of Nursing (DON) revealed s/he was previously the staff training coordinator and that s/he last received abuse training in (MONTH) of (YEAR). The DON revealed s/he was not aware of the requirement to report abuse and injuries of unknown source to the state no later than two hours. 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, indicating the incident was not reported to the state agency until three days later. During an interview on 01/20/19 at approximately 6:10 PM with the RM revealed s/he was responsible for reporting all reportable incidents to the state agency. The RM revealed the allegation of verbal abuse that occurred on 10/29/18 was not reported to her/him until 11/01/18. The RM revealed after the incident was reported to her/him late, s/he sent out mass emails to nursing supervisors reeducating them about reporting requirements. Review of R11's Physician order [REDACTED]. Review of a copy of the actually script dated 09/11/18 indicated, [MEDICATION NAME] 5 mcg patch weekly on Tuesday. On the copy of the script was the notation faxes - received. Review of an email dated 09/20/18 at 7:18 AM from Registered Nurse (RN) 4 indicated, (name of Nurse Practitioner) left a prescription (dated 09/11/18) on the keypad for the [MEDICATION NAME]. I promptly faxed it and fax confirmation was received. I did not call (name of contract pharmacy) with a follow-up phone call to confirm receipt of the prescription. Review of a typed document that was part of the facility's investigation file by the facility's Risk Manager indicated 9/10/18 [MEDICATION NAME] not given by (RN4). 9/17/18 [MEDICATION NAME] not given by LPN6. On 9/17/18, LPN7 called (name of contract pharmacy) to request patches. Review of a hand-written document that was part of the facility's investigation file dated 09/19/18 indicated, on 9/11/17 (sic - the year should have been (YEAR)) I did not receive the [MEDICATION NAME] for resident (R11) in narcotic bag. The document was signed by RN5. Review of the email from the Assistant Director of Nursing (ADON) to the RM, dated Monday 09/17/18 indicated, I received a call from (LPN7) . (s/he) was unable to find the narcotic medication, '[MEDICATION NAME]es.' The medication was signed as received by RN5 on (MONTH) 11th at 11:07 pm. After searching all subacute cottages for the med (medication) to no avail, I called the pharmacy and asked for a copy of the signature page. The signature page was sent and does appear to have been signed by the said nurse at the said time. I called (RN5) . (s/he) has no recollection of receiving any narcotic patches. I informed (RN 5) I have a copy of the signature page showing (s/he) signed for the med (medication). (RN5) again stated, 'If I did sign the paper, I do not remember receiving any narcotic patches.' Review of an email from LPN 7, dated Tuesday 09/18/18 which indicated, On (MONTH) 17th, a medication on the EMAR (Electronic Medication Administration Record) was ordered for [MEDICATION NAME] Patch once a week . I was told in report that the medication was not here so I thought pharmacy had not sent it yet . I called (name of contract pharmacy) and was told that the medication was delivered and that a staff member at (name of facility) had signed for it. I believe (s/he) said it was delivered 9/10 or 9/11 . I reported this information to the nurse supervisor and (s/he) came over to look for the medication. I held the dose due to unavailabity. Review of a hand-written note that was part of the facility's investigation file dated 09/18/18 written by LPN6 indicated On 9/17/18 there was an order for [REDACTED]. I reported this to oncoming nurse to call pharmacy. Review of the Initial 24-hour Report dated 09/19/18 indicated the date and time of the incident was 09/18/18 at 2:00 PM. The description of the incident revealed, Missing Medication. Review of the Fax Call Report indicated the Initial 24-hour Report was faxed to the State Agency on 09/19/18 at 12:36 PM. Review of an email from the State Agency dated 09/19/18 at 2:53 PM indicated, It has been received and will be reviewed. During an interview with the RM on 01/20/18 at 2:50 PM, the RM confirmed that s/he was notified by the ADON on 09/17/18; however, the RM confirmed that R11's [MEDICATION NAME]es were not available at the facility on 09/11/18. The RM confirmed the State Agency should have been notified on 09/11/18 when the pharmacy indicated that the patches had been delivered and the patches were not in the facility. Review of the undated policy titled, Narcotics, Controlled Substances, and Preventing Drug Diversion indicated d. any discrepancies are immediately reported to the Administrator. Review of R1's clinical record revealed R1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of R11's quarterly MDS dated [DATE] indicated that R1 was severely cognitively impaired an unable to answer the questions on the Brief Interview for Memory Status. Review of the facility's document titled Initial 24-hour Report dated 01/10/19 indicated, the type of injury of unknown source was documented, non-displaced right [MEDICATION NAME] patella fracture. The date and time of the reportable incident indicated 1/10/19 at 9:30 AM. Review of the facility's document titled, Five-Day Follow-up Report, dated 01/11/19, indicated the same injury as the initial report; however, the date and time of the Reportable Incident indicated 1/8/19 at 20:35 (8:35 PM) reported to Risk Manager 1/10/19 at 8:30 AM. The document indicated the category of Details of Reportable Incident the following, 1/8/19 Resident presented with right knee swelling and redness. Review of R1's Physician order [REDACTED]. During an interview with the RM on 01/20/18 at 2:50 PM, the RM confirmed that s/he was notified on 01/10/19 by a supervisor who no longer worked for the facility. The RM confirmed that R1's injury of unknown origin should have been reported to the State Agency on 01/08/19. Review of the facility's undated policy, Abuse Investigation and Reporting revealed all alleged violations of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but no later than two hours to the state licensing/certification agency responsible for surveying/licensing the facility.",2020-09-01
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 were interviewed. During an interview on 01/20/19 at 6:10 PM, the facility's Risk Manager (RM) revealed s/he was responsible for reporting all reportable incidents to the state agency and investigating the reportable incidents. Continued interview with the RM revealed s/he did not interview any interviewable residents in the facility that had received services from RN2. During an interview on 01/21/19 at 9:50 AM, the Director of Nursing (DON) revealed s/he assisted the RM in completing the investigation of alleged abuse against R9. The DON revealed that s/he believed, based on RN2's typed witness statement, RN2's verbal explanation, and the two staff members' witness statements, that was all that was needed to unsubstantiated the allegation. 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 15, indicating the resident was severely cognitively impaired. Review of the facility's reportable incidents revealed no documented evidence the sewing needle being discovered in R4's wounds was identified as an injury of unknown source to be investigated. A subsequent interview on 01/20/19 at 2:35 PM with the facility's Risk Manager (RM), the RM revealed, even though the resident's cognitive status prevented the resident from explaining how the needle got into the wound and it was not witnessed, the facility did not identify the incident as an injury of unknown source. During an interview on 01/21/19 at 8:38 AM, the Administrator revealed s/he did not participate in the investigation related to the allegation of verbal abuse to R9. The Administrator revealed when the survey team showed her/him the witness statements, it was the first-time s/he had seen the statements. The Administrator revealed s/he did not remember the allegation being reported to her/him by the RM and s/he did not have any documented evidence it was reported to her/him. The Administrator stated s/he can see how R4's injury could have been identified and investigated as an injury of unknown source. During an interview on 01/21/19 at 3:10 PM, Licensed Practical Nurse (LPN) 2 revealed s/he was the one who discovered a sewing needle in R4's wound on top of her/his right foot. Continued interview revealed after pulling the sewing needle out, s/he notified her/his supervisor per policy. LPN2 revealed, to her/his knowledge, there was no investigation completed. Review of LPN2's nursing notes, dated 12/02/18, revealed while doing wound care on the top of R4's right foot where the resident had an ulcerated lesion, the gauze got caught on what was thought to be a scab; the gauze got caught on a sewing needle that was sticking out of the wound. The nursing notes revealed the nurse pulled the sewing needled out of the wound and then notified her/his supervisor and the resident's daughter. Review of the undated policy Abuse Investigation and Reporting revealed all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management . the role of the investigator at a minimum would interview any witnesses to the incident, interview the resident's roommate, family members and visitors, and consult daily with the administrator. Review of R1's Face Sheet in the clinical record revealed R1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of R1's quarterly MDS, dated [DATE] indicated that R1 was severely cognitively impaired an unable to answer the questions on the Brief Interview for Memory Status. Review of the Initial 24-hour Report, dated 1/14/19, indicated swelling to R (right) hand with skin tears. The date and time of the reportable incident indicated 1/14/19 at 8:00 PM. Review of the Five-Day Follow-up Report, dated 01/18/19, indicated the same injury as the initial report and the same date and time. The document indicated the category of Details of Reportable Incident the following, Resident noted to have swelling to R hand on 1/14(/19) at approx. 8:00 pm, son notified nursing staff . Staff report resident was restless during the day. Review of the facility's documentation provided by the Administrator indicated that the facility obtained written statements from the nurses and nurse aides on 01/13/19 and 01/14/19. The Assistant Director of Nursing (ADON) confirmed that the night nurse (LPN1) on the night shift, starting at 7 PM on 01/13/19 and ending at 7 AM on 01/14/19, did not write a statement. Review of the statement written by Certified Nurse Aide (CNA) 2 dated 01/18/19 indicated, I worked with (R1) on Monday, (MONTH) 14th in Rose Cottage . I removed her/his hand brace, like usual and gently cleaned just under her/his fingers. S/he had the skin tears and band aids, so I left those on. Review of the statement written by CNA3 dated 01/14/19 indicated, I worked on Sunday evening/night shift . there was no problem with (R1) the night or when I left work on Monday morning at 7 am. When I returned to work on Monday evening around 7:35 pm, her/his son (son's name) was here and asked me if I knew about the scratch and bruise to her/his right hand. Her/his hand was swollen and appeared to be bruised . The CNA did not mention anything about her/him having any problem with her/his hand during the day. Review of R1's Progress Notes, dated 01/10/19 through 01/16/19, revealed that there was no documentation regarding how R1's skin tears occurred or that band aids were placed over the right-hand skin tears. During an interview on 01/21/19 at 1 PM with the Administrator and ADON, the Administrator confirmed that LPN1 did not write a statement and that the facility did not have any further documentation that an investigation had been conducted to determine how the skin tears occurred that were documented in NA2's written statement. The Administrator confirmed that the CNA3 documented on Sunday, 01/13/19, there was no problem with R1's right hand; however, CNA2 documented on the day shift of 01/14/19, R1 had band aids and skin tears to the right hand. Review of R11's medical record revealed Physician Orders, dated 09/10/18, which indicated (narcotic medication) (buprenorphine) Patch Weekly 5 MCG (microgram)/HR apply 5 MCG/hr [MEDICATION NAME] (sic) weekly every Mon (Monday) for pain. Review of an email dated 09/20/18 at 7:18 AM from RN4 indicated, (name of Nurse Practitioner) left a prescription (dated 09/11/18) on the keypad for the (name of brand of narcotic) (buprenorphine) patch. I promptly faxed it and fax confirmation was received. I did not call (Name of Pharmacy) with a follow-up phone call to confirm receipt of the prescription. Review of a hand-written document that was part of the facility's investigation file, dated 09/19/18, indicated on 9/11/17 (sic - the year should have been (YEAR)) I did not receive the (name of brand of narcotic) (buprenorphine) patch for resident (R11) in narcotic bag. The document was signed by RN5. Review of the email from the ADON to the facility's Risk Manager dated Monday, 09/17/18 indicated, I received a call from (LPN 7) . s/he was unable to find the narcotic medication, '(name of brand of narcotic) (buprenorphine) [MEDICATION NAME]es.' The medication was signed as received by RN5 on (MONTH) 11th at 11:07 pm. After searching all subacute cottages for the med (medication) to no avail, I called the pharmacy and asked for a copy of the signature page. The signature page was sent and does appear to have been signed by the said nurse at the said time. I called (RN5) . s/he has no recollection of receiving any narcotic patches. I informed (RN 5) I have a copy of the signature page showing s/he signed for the med (medication). (RN5) again stated, 'If I did sign the paper, I do not remember receiving any narcotic patches.' During an interview on 01/20/18 at 9 AM with the ADON and Administrator, the ADON stated that the pharmacy sent the residents' medication by courier. The courier delivered the medications to each cottage. The narcotics arrived in a pink bag with a pink slip that the nurse had to sign. The ADON stated that the facility did not have the pink slip that someone signed on 09/11/18. The ADON stated that when the nurse received the narcotic there was a narcotic sheet in the bag that the nurse then signed, added the number of pills, and placed the sheet in the cottage's narcotic book. The ADON stated that since the facility did not receive the buprenorphine patches for R11, there would not have been a narcotic sheet in the narcotic book. Therefore, that was why the nurses did not notice after 09/11/18 that the resident did not have the buprenorphine patches in the locked narcotic drawer. During an interview with the RM on 01/20/18 at 2:50 PM, the RM confirmed that s/he was notified by the ADON on 09/17/18 that R11's buprenorphine patches were not available at the facility. The RM stated that there was no documentation in the documents provided by the facility that a search of all 12 cottages' locked narcotic boxes in the medication carts was performed to see if the patches were delivered to another cottage. The RM confirmed that the email from the ADON on 09/17/18 indicated that a search of the subacute cottages was performed, but not of all of the cottages. The RM stated there was no documentation that interviews were conducted with the residents who may have been seated near the medication cart or with the nurse aides who were working during the time on 09/11/18 when the courier brought the medications to the cottage. The RM also confirmed that the facility did not interview the courier. The RM stated that the facility turned the investigation over to the pharmacy and have not heard anything further regarding the missing buprenorphine patches. Review of the undated policy Abuse Investigation and Reporting revealed all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management . the role of the investigator at a minimum would interview any witnesses to the incident, interview the resident's roommate, family members and visitors, and consult daily with the Administrator.",2020-09-01
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 Sheet revealed the facility readmitted the resident on 01/10/19, with [DIAGNOSES REDACTED]. Review of the (MONTH) 2019 Physician order [REDACTED]. Review of the Controlled Medication Utilization Record and the count of R15's [MEDICATION NAME] tablets on 01/18/19 at 4:44 PM revealed, the Utilization Record indicated the resident should have six [MEDICATION NAME] tablets remaining of his/her narcotic pain medication with the last dose being signed out on 01/17/19 at 9:00 PM; however, count of the residents [MEDICATION NAME] tablets revealed only five [MEDICATION NAME] tablets remaining, indicating inaccurate reconciliation. Review of R17's Face Sheet revealed the facility admitted the resident on 12/27/18, with [DIAGNOSES REDACTED]. Review of R17's (MONTH) 2019 Physician order [REDACTED]. Review of the Controlled Medication Utilization Record and observation of R17's [MEDICATION NAME] tablets on 01/18/19 at 4:44 PM revealed the Utilization Record indicated the resident should have had 20 [MEDICATION NAME] tablets remaining of her/his narcotic pain medication with the last dose being signed out on 01/18/19 at 5:20 AM; however, count of the residents [MEDICATION NAME] tablets revealed only 19 tablets remaining, indicating inaccurate reconciliation. During an interview, on 01/18/19 at 4:44 PM with Register Nurse (RN) 3 revealed both R15's and R17's medication cards showed one less narcotic medication than indicated on the narcotic count sheets because s/he got caught up with everything else going on around her/him and forgot to sign it out on the narcotic count sheet. The RN revealed s/he would have seen the discrepancy at the end of her/his shift and would have fixed it then. RN3 revealed s/he should have signed the narcotic medication on the narcotic count sheet before s/he pulled the medication. The RN stated it was important to record the narcotic medication on the narcotic count sheet to keep an accurate record. Review of the undated policy, Narcotics, Controlled Substances and Preventing Drug Diversion indicated Policy interpretation and Implementation . 2. Administration of medication must be documented immediately after (never before) it is given.",2020-09-01
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 document the physical assessment of R2 when s/he was observed on the floor after the fall from the mechanical lift. The document did not identify who was the writer of the document. Review of the document titled PACS: Nursing-Body assessment, dated 12/27/18 at 7 PM, indicated Body assessment - Skin condition hematoma back of head and complaint of pain to L (left) leg. There was no further documentation on this document nor whom was the writer of the document. Review of a document titled Witnessed Fall, completed by Licensed Practical Nurse (LPN) 5 dated 12/27/18 at 6:50 PM indicated Incident Description - While CNA was transferring the resident to bed via hoyer lift, upon placing the hoyer lift in the upright positions, the left side of the sling (black plastic piece) popped. Patient fell on the floor out of the lift. The Patient stated the sling broke and I fell out onto the floor. Immediate Action Taken - Resident was assessed . Injury type - Hematoma/Bruise back of head, alert, oriented to place time, person and situation. Review of a document titled Health Status Note, dated 12/27/18 at 10:49 PM. indicated While CNA 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 . sent to ER . PCP notified at 2034 (8:34 PM) . EMS arrived and transported resident at 1906 (7:06 PM). Review of the undated facility's policy titled, Falls-Clinical Protocol indicated, 5. The staff will evaluate, and document falls that occur while the individual is in the facility, for example, when and where they happen, any observation of the events, etc. During an interview on 01/21/18 at 1 PM with the Administrator and Assistant Director of Nursing (ADON), the Administrator stated that s/he was unable to locate any further documentation regarding the physical assessment of R2 after s/he fell to the floor from the mechanical lift on 12/27/18 at 7 PM. The Administrator and ADON stated that it was their expectation that nurses document their assessment of the resident after a fall. The Administrator confirmed that s/he had no explanation, nor could s/he find any documentation why the PCP was not notified until 8:34 PM (almost one and one-half hours after R2 was transported to the ER).",2020-09-01
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,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 operate the bed controls and will raise the bed up when it is in low position. LPN #5 stated sometimes we turn the bed controls over so the resident can't raise the bed, but the resident had since figured out how to turn the controls back over and raise the bed. At 3:10 PM on 2/28/2018, Resident #18 was observed in bed with the bed in normal position with the bed controls within the resident's reach. LPN #5 lowered the bed and left the bed controls within reach of the resident upon leaving the room. At 3:16, Resident #18 was observed with the bed back in normal position (with LPN #5 present). Resident #18 had used the bed controls to raise the bed back to normal position. During an interview with Registered Nurse (RN) #1 on 2/28/2018 at 3:55 PM, RN #1 confirmed the Resident was care planned to have the bed in lowest position and to remove the bed controls when in lowest position. RN #1 stated the resident's bed had been lowered and the bed controls were unplugged. Review of Nurse's Notes, Incident Reports, and the Care Plan revealed that the Interdisciplinary Team had reviewed each fall and reviewed and/or revised the Care Plan.",2020-09-01
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,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,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 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 operate the bed controls and will raise the bed up when it is in low position. LPN #5 stated sometimes we turn the bed controls over so the resident can't raise the bed, but the resident had since figured out how to turn the controls back over and raise the bed. At 3:10 PM on 2/28/2018, Resident #18 was observed in bed with the bed in normal position with the bed controls within the resident's reach. LPN #5 lowered the bed and left the bed controls within reach of the resident upon leaving the room. At 3:16, Resident #18 was observed with the bed back in normal position (with LPN #5 present). Resident #18 had used the bed controls to raise the bed back to normal position. During an interview with Registered Nurse (RN) #1 on 2/28/2018 at 3:55 PM, RN #1 confirmed the Resident was care planned to have the bed in lowest position and to remove the bed controls when in lowest position. RN #1 stated the resident's bed had been lowered and the bed controls were unplugged. In addition, RN #1 stated the resident's bed would be switched out for a crank bed (a bed without automatic controls).",2020-09-01
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 computerized staff coverage did not identify whether the nursing staff was a registered or licensed nurse. The computerized documentation was inconsistent as to staff coverage. The handwritten staffing for 2/26/18 indicated a census of 10 residents in the Forsythia Cottage on first and second shift and the computerized copy indicated a census of 12 residents in the Forsythia Cottage. The Administrator confirmed the computerized staffing information was on the unit and not accessible to residents/visitors/families.",2020-09-01
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 set up for the resident's appointment. LPN #3 was told transportation was set up for an appointment on 3/7/2018. The DON confirmed that the facility did not follow up with the resident regarding the appointment scheduled for 2/28/2018. During an interview with Resident #121 and family member on 2/28/2018 at 2:33 PM, the family member stated she/he had informed multiple staff members over the past week regarding the resident's appointment on 2/28/2018. Resident #121 stated he/she had also told staff about the upcoming appointment. The family member stated she/he asked staff if transportation was set up for the appointment or if she/he needed to arrange transportation. Neither the resident or family member could remember names of who they asked about the appointment, but did remember being told the facility would arrange transportation. Review of the transportation schedule on 3/1/2018 at 10:51 AM revealed transportation was not set up for the 2/28/2018 appointment.",2020-09-01
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,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,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,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 that it had been an ongoing issue due to how the facility was set up. The Administrator further stated he/she does try to address each identified residents' concerns.",2020-09-01
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 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 and that there was no statements provided from resident/family member or witness named in the perpetrator's statement. During an interview on 5/15/19 at approximately 12:05 PM with RN #2 he/she confirmed the allegation of abuse was not reported to the state agency within the 2 hours requirement per facility policy.",2020-09-01
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,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,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 expressed these concerns to administration. Review of schedules for the previous month on 5/16/19 at approximately 9:40 AM confirmed that during night shifts one nurse may have two cottages.",2020-09-01
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 of Rose cottage with the RD on [DATE] at approximately 11:00 AM, Jelly was observed with an expiration date of [DATE]. During the observation of the refrigerator, 2 mustards bottles, 3 ketchup bottles, and 1 mayonnaise bottle did not have dates opened for use. Resident's personal food was also observed in the facility kitchen refrigerator. During observation of the counter area near the toaster, bread observed did not have the date opened. The expiration date of the jelly was verified by the RD at the time of observation. The lack of opened-on dates for the mustard, ketchup, mayonnaise and bread was verified by the RD at the time of observation. Resident's food in the facility kitchen refrigerator was verified by the RD at the time of observation. Review of facility policy Refrigerators and Freezers under Policy Interpretation and Implementation on [DATE]. Number 7 stated, All food shall be appropriately dated to ensure proper rotation by expiration dates. Expiration dates on unopened food will be observed and use by dates indicated once food is opened. Review of facility policy Food receiving and Storage under Policy Interpretation and Implementation on [DATE] Number 14e stated, Other opened containers must be dated and sealed or covered during storage. Review of the facility policy Resident Refrigerators on [DATE] states, No Elder/Guest food to be stored in Cook's fridge. A random observation of the Dogwood Cottage on [DATE] at approximately 11:10 AM revealed a staff member preparing meals with a thick mustache uncovered. An interview with Cook #1 confirmed the observation and further stated he/she was not aware the mustache had to be covered. He/She further stated he/she was aware the beard had to be covered. A random observation of the Azalea Cottage on [DATE] at approximately 8:51 AM revealed a large trash can in the kitchen area without a lid. The trash can was positioned between the hand washing sink and dishwasher. A random observation of the Azalea Cottage on [DATE] at approximately 12:26 PM revealed Cook #2 preparing residents meals with the large trash can located between the hand washing sink and dishwasher without a lid. During an interview on [DATE] at approximately 1 PM with Cook #2 confirmed the large trash can in the kitchen during meal preparation did not have a lid. Cook #2 stated he/she was new at the facility and did not recall the trash can ever having a lid. On [DATE] at approximately 2:48 PM the facility's Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices policy was provided. The policy indicated under #12 Hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils and linens.",2020-09-01
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 requested to receive both the morning and evening doses of [MEDICATION NAME] on 4/23/19. The ADON stated s/he told the resident that would be ok, but the 2 doses would have to be spaced apart due to the every 12 hour order. The ADON stated s/he should have documented this conversation with the resident in the nurse's notes but did not. During an interview with the ADON on 5/16/19 at 9:12 AM, the ADON confirmed Resident #366 received 2 tablets of [MEDICATION NAME] 50mg on 4/23/19 at 5:06 PM and 10:13 PM. The ADON confirmed the orders were to give the [MEDICATION NAME] every 12 hours. The ADON stated the Nurse Practitioner (NP) was called on 4/23/19 and a onetime verbal order was received to allow the resident to have the 2 doses of [MEDICATION NAME] at the times they were administered on 4/23/19. The ADON stated a note and order should have been entered reflecting the NP's orders, but this was not done. During an interview with the NP on 5/16/19 at 9:38 AM the NP stated s/he was on call on 4/23/19 and remembered the nurse calling around 4:50 PM for a verbal order. The NP gave an order for [REDACTED]. Review of the facility's Controlled Substances policy revealed the controlled substance record must contain the time of administration. Additional record review of Resident #366 nurse's notes, the MAR and pain assessments revealed the resident did not experience a decline in functioning or uncontrolled pain as a result of the missing [MEDICATION NAME]. The resident had [MEDICATION NAME] ordered as needed for pain and received 1 dose of this while the [MEDICATION NAME] was missing. 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 further indicated the family member demanded that the resident see a physician and the nurse notified the resident. The nurse practitioner was notified, and pain medication was ordered. 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 electronic medical record on 5/15/19 at approximately 9:34 AM revealed no documentation to indicate the resident and/or family member expressed concerns about a Certified Nursing Aide's alleged mistreatment/verbal abuse of a resident. Nurses notes dated 3/23/19 (admission) to 4/01/19 (discharge) did not indicate any allegations of abuse. During an interview on 5/15/19 at 10:27 AM with Registered Nurse (RN) #1 revealed he/she did not document anything in the electronic medical record about the allegation of abuse related to Resident #365. RN#1 further stated he/she could not recall when the incident occurred after reading his/her undated written statement. RN #1 stated the incident could have occurred on 3/28/19 then stated it happened when the CNA was fired. RN #1 further stated that it had been a long time ago and honestly, he/she does not remember.",2020-09-01
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/repositioning. Mid, right back possible a sheet or sling shear. Denies anyone harmed (him/her). In an interview with the Risk manager on 6//26/18 at 9:36 AM s/he stated that she did not report both incidents for Resident #2 to the State Agency because the resident had a high BI[CONDITION] (Brief Interview for Mental Status) and the resident did not report bruises to her/him the resident did not know they (the bruises) were there and it did not hurt. S/he stated that s/he did not report the incident for Resident #3 to the State Agency because the resident had a high BI[CONDITION] and can tell you what happened. The Risk Manager confirmed that Resident #3 did not know how s/he received the bruises but thought it may have happened during repositioning/transfer. Review of the facility's policy titled Reporting of Alleged Abuse to Facility Management revealed definitions of abuse to include Injury of unknown source is defined as an injury that meets both of the following conditions: (1) The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and (2) The injury is suspicious because of: (a) the extent of the injury; or (b) the location of the injury (e.g. the injury is located in an area not generally vulnerable to trauma); or (c) the number of injuries observed at one particular point in time; or (d) the incidence of injuries over time. Pursuant to the Elder Justice Act, any employee that suspects a crime has occurred against a resident of the facility must report the incident to the State Survey Agency and local law enforcement agency.",2020-09-01
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 Administration Record [REDACTED]. The MAR indicated [REDACTED]. The resident had no pain on 3/27 and 3/28. The resident had mild pain (2/10) on the day shift on 3/29 and 3/30. Record review of the Nurses Notes on 8/23/2017 at 10:16 AM revealed a note, dated 3/27/2017 at 3:45 PM, that indicated at 3:30 PM the resident was in her/his wheelchair pale, limp, drooling and lethargic. At 3:40 PM, the resident was combative, alert and talking. The Nurse Practitioner (NP) was notified and gave new orders, including the in and out catheter. There were no further Nurse's Notes on 3/27/2017 indicating the resident had any additional behaviors. There were no Nurse's Notes indicating the resident became combative during the in and out catheter attempt. A Nurse's Note, dated 3/28/2017, indicated the resident spent the day in bed due to loose stools. The note did not indicate the resident was having pain. A Nurse's Note, dated 3/29/2017, indicated the resident was screaming when staff touched or moved her/his left leg and left foot. There were no open areas, redness, swelling or bruising to the left leg/foot. The NP was notified and an X-ray was obtained at 6:30 PM. A Nurse's Note, dated 3/30/2017 at 12:01 AM, indicated the facility had received the X-ray results and the on call physician was notified. Record review of the practitioner Progress Notes on 8/23/2017 at 10:59 AM revealed a note, dated 3/27/2017. The note indicated the NP was seeing the resident due to a witnessed [MEDICAL CONDITION] a minute that occurred at 3:00 PM. At the time of the NPs exam the resident was alert and combative. The NP ordered a urinalysis and labwork (re 3/27/2017 Telephone Order at 4:00 PM). A 3/29/2017 Progress note indicated that the NP was seeing the resident for pain in the left leg. The note indicated the resident had a [MEDICAL CONDITION] 3/27, was in bed on 3/28 and today (3/29) yells/screams whenever you attempt to raise her/his leg, touch her/his feet. The NPs exam indicated the resident had no obvious fracture and no bruising. In addition, the note indicated the resident's legs were contracted at the knees and the pain could be muscle spasms. The NP ordered scheduled Tylenol and X-rays. A Progress Note from 3/30/2017 indicated the resident was seen for follow up of the acute non-displaced left fibula and tibial shaft fracture. New orders were written, interventions were implemented and the care plan and family were updated on treatment/comfort options. Staff statements related to the incident were reviewed on 8/23/2017 at 11:02 AM. A statement by LPN (Licensed practical Nurse) #1, dated 3/31/2017, indicated that on the night shift on 3/28/2017 nothing abnormal was reported or observed. On 3/29/2017 it was reported to LPN #1 that the resident was having left leg pain during the day shift. LPN #1 Received the X-ray results on her/his shift and called those results to the provider. LPN #1 indicated that the resident was not observed to be in pain and was sleeping during observations that night. A Statement by CNA (Certified Nursing Assistant) #1 indicated that CNA #1 provided care during and after the resident's [MEDICAL CONDITION] on 3/27/2017. The statement did not indicate the resident was having any pain or behaviors. A statement by CNA #2 indicated he/she worked the night shift on 3/27, 3/28, 3/29 and 3/30/2017. CNA #2's statement indicated the resident rested throughout the night each night he/she worked. A statement by LPN #2, dated 4/3/2017, indicated LPN #2 was on duty when the resident had the [MEDICAL CONDITION] on 3/27. LPN #2 notified the NP and the NP saw the resident about 30 minutes later. The resident was agitated during the NP's exam. The NP ordered a in and out catheter, but LPN #2 did not attempt the in and out catheter. A statement by CNA #3 indicated that she/he cared for the resident on 3/27 and 3/28/2017 on the day shift. CNA #3 assisted during the [MEDICAL CONDITION]. On 3/28/2017 the resident was weak, sleepy and having loose stools. CNA #3 provided personal care and dressed the resident. The resident remained in bed for the day per the daughter's request. After supper, CNA #3 required assistance providing evening personal care because the resident was screaming and resisting care. There was no statement from LPN #3, the nurse who performed the in and out catheter procedure on 3/27/2017. There was no documentation in the record of any combative behaviors the resident may have had during the in and out catheter procedure. Review of the Care Plan on 8/23/2017 at 1:17 PM revealed the resident had a problem area for Dementia and Sometimes I resist care and refuse to take my medications. An intervention listed for this problem was to Gently redirect me when I become angry or combative. If I don't respond to redirection, leave me alone for a little while. The problem onset date was 12/9/2016. The care plan was reviewed and revised each quarter and as needed. Record review of the daily Behavior and Mood monitoring flowsheets on 8/23/2017 at 12:22 PM revealed that no problem behavior was noted on 3/27, 3/28, 3/29 and 3/30/2017. During an interview with the NHA (Nursing Home Administrator) on 8/23/2017 at 10:06 AM, the NHA stated that only one staff person attempted the in and out catheter procedure for resident #1 on 3/27/2017. The NHA stated that LPN #3, attempted the procedure and was not assisted by any staff. The NHA stated that LPN #3 was an agency nurse (contracted nurse). During an interview with LPN #3 on 8/23/2017 at 11:42 AM, LPN #3 stated she remembered very little about Resident #1. LPN #3 stated she/he vaguely remembered doing the in and out catheter, but did not remember if it was successful or not. In addition, LPN #3 stated she/he did not recall if Resident #1 was combative or not during the procedure. During an interview with LPN #1 on 8/23/2017 at 12:33 PM, LPN #1 confirmed her/his written statement. LPN #1 stated she/he cared for Resident #1 on the 7:00 PM-7:00 AM shift (night shift). LPN #1 stated she/he did not recall the resident being combative or having any behaviors on 3/28/2017 or 3/29/2017. In addition, LPN #1 stated, she/he did not recall the resident having any behaviors during her/his shifts. During an interview with LPN #4 on 8/23/2017 at 12:55 PM, LPN #4 stated she/he worked with the resident on the 7:00 AM-7:00 PM (day shift). LPN #4 did not recall any specific details about the resident from 3/27-3/30/2017. LPN #4 stated the resident could be a little belligerent at times, but found if you left her/him alone for a bit, she/ he would calm down. LPN #4 stated the resident usually didn't display any behaviors when she/he worked with her/him. In addition, LPN #4 stated that the resident was much more cooperative with staff that she/he recognized and had worked with before. LPN #4 stated that if the resident refused any care, medicine or treatments, she/he would usually cooperate once you left her/him alone and went back to her/him. During an interview with CNA #3 on 8/23/2017 at 1:00 PM, CNA #3 confirmed her/his written statement. CNA #3 stated she/he cared for the resident on the day shift. CNA #3 stated the resident went limp during the [MEDICAL CONDITION] on 3/27 and did not fall from her/his chair or appear to suffer any injury as a result of the [MEDICAL CONDITION]. CNA #3 stated that it was normal for the resident to resist care, become agitated and scream during care. CNA #3 did not think the resident was in any pain during dressing or personal care during her/his shift on 3/28/2017. During an interview with the NP on 8/23/2017 at 1:10 PM, the NP stated she/he ordered the in and out catheter on 3/27/2017 after examining the resident. The NP recalled that the staff were unable to get a urine sample with the in and out catheter and that is why an order to discontinue the in and out catheter was given on 3/28/2017. In addition, the NP recalled she/he looked at the documentation to find out why the in and out catheter was not successful, but found that there was no documentation related to the procedure. During an interview with the Risk Manager with, the DON (Director of Nursing) present, on 8/23/2017 at 10:44 AM, the Risk Manager stated that no statement or interview was obtained from LPN #3 related to the in and out catheter procedure on 3/27/2017. The Risk Manager stated she/he was unable to reach LPN #3 by phone. The Risk Manager confirmed that the facility's investigation concluded that the resident's fracture appeared to be a result of combative behavior during the in and out catheter procedure. During an interview with the Risk Manager on 8/23/2017 at 11:32 AM, the Risk Manager confirmed there was no documentation or staff statements to indicate that Resident #1 was combative during the in and out catheter procedure on 3/27/2017. The Risk Manager also stated that she/he had just spoken to LPN #3 and LPN #3 did not remember anything related to the in and out catheter procedure, including whether the resident had combative behaviors or not. The Risk Manager also stated that CNA #4 may have been present in the room for the in and out catheter procedure. The Risk Manager stated she/he did not have a statement from CNA #4. In addition, the Risk Manager stated CNA #4 did not recall if she/he was in the room or not on 3/27/2017. The Risk Manager stated it was concluded the resident was combative during the procedure based on statements from day shift staff who reported that the resident had been frequently combative or resistant to care on the day shift. During an interview with the DON on 8/23/2017 at 12:22 PM, the DON confirmed there was no documentation or Nurse's Notes to indicate that the resident was combative during the in and out catheter procedure. The DON also confirmed that the daily Behavior and Mood monitoring flowsheets indicated the resident was not having any behaviors on 3/27/2017. During an interview with CNA #4 on 8/23/2017 at 1:27 PM, CNA #4 stated she/he did not recall who Resident #1 was or any details related to the resident's care. Review of the facility's Abuse Prevention Program policy revealed: [NAME] The Administrator/designee will make all reasonable efforts to investigate and address alleged reports, concerns and grievances. B. The person (s) observing the incident will immediately report and provide a written statement that includes the name of the resident, date and time incident occurred, where it occurred, staff involved and a description of what occurred.",2020-09-01
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,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,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 care plan meeting at the facility for Resident #265. There was no evidence that a Hospice representative reviewed the facility care plan.",2020-09-01
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 Regional Nurse Consultant verified that Resident #265's bed/chair alarm had a turn off switch and that a fall mat was not present in Resident #265's room. During an interview on 11/30/16 at 9:25 AM with Certified Nursing Assistant (CNA) #1 the CNA Care Plan was reviewed and did not have updated fall care plan information. CNA #1 provided the Master Copy of the CNA Care Plan.",2020-09-01
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 and were unable to find any evidence of deficiency. She/He reviewed the record and was unable to provide additional information.",2020-09-01
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,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 about the thermometer not working properly but she/he did not know how to contact the CDM. LPN #1 contacted the CDM to assist with temping foods. The CDM was unable to turn on the thermometer. Cook #1 retrieved a working thermometer and began to calibrate it. At 12:22 PM the CDM stated that the thermometer should be calibrated to 0 degrees Fahrenheit. The temperature at which to calibrate the thermometer was clarified (32 F) and food temperatures were found to be within acceptable range. During an observation on 11/28/2016 at 12:40 PM, CNA #1 started to feed a resident a pureed diet from the warmer before it was temped. Food was taken back to the kitchen and temped. Temperature for the pureed green beans was 133.8 degrees Fahrenheit. An interview at this time revealed that Cook #1 did not know did not know the proper reheat temperatures. When asked where food temperatures were documented prior to beginning food service, Cook #1 called attention to a notebook where the last documented food temperatures were recorded on 11/21/2016.",2020-09-01
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,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,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]-[MEDICATION NAME]-[MEDICATION NAME]) Ophthalmic Ointment to which Resident 62 was listed as allergic to [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME]-[MEDICATION NAME]). He/she stated that the nursing staff should have detected the allergy issue each month before signing off on the physician orders and medication administration record.",2020-09-01
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 2-4,5-16 asked IS [MEDICATION NAME] OPHTH. OINT. still needed? The handwritten response on the report state Eyes are still red and the DON (Director of Nursing) stated on 7/24/17 at approximately 4:38 PM that he/she had written this response. -MAR review [REDACTED]. -MAR review [REDACTED]. 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]-[MEDICATION NAME]-[MEDICATION NAME]) Ophthalmic Ointment to which Resident 62 was listed as allergic to [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME]-[MEDICATION NAME]).",2020-09-01
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 the can rack. When the Assistant Dietary Manager was questioned regarding storage of dented cans, h/she said they are put on shelf outside storeroom and when asked, What do you do with the dented cans after you put them on the shelf? The Assistant Dietary Manager said, We use them. An interview on 07/23/2017 at 12:43 PM, with Certified Dietary Manager (CDM) h/she said dented cans are stored in his/her office and are used if the dent on the can is not on the seam of the can. The CDM's office contained multiple dented cans which h/she planned to obtain credit from the vendor. The CDM stated: The vendor does not pick up the dented cans, the vendor is now requiring that h/she make a picture of the dented cans to receive credit for the dented cans. The Policy and Procedures, Dented Cans states, If a can is dented, it is placed in the designated place for dented cans. During an observation on 07/25/2017 at 8:40 AM, the Buffalo Chopper's cutting blade had multiple cuts and missing pieces of metal on the cutting surface and this was verified by the CDM. Additionally, the Robot coupe blade had one nick in the blade and this was verified by the CDM. The CDM provided an invoice showing that replacement blades were ordered for both pieces of equipment on 7/25/2017. Observed both sides of grill top (the grill top was located in between the stove top and the deep fat fryer) had a substantial grease build on both sides and this was verified by the CDM. The CDM said the grill top it is on the cleaning schedule and the cook stated that h/she cleans the grill top every other week. The Cleaning schedule from July 16th to July 29th 2017 shows that the stoves/ovens/fryers all carts cleaned on 6/16, 6/17, 6/18 had employee initial indicating cleaned. The CDM said the grill top will be cleaned today. The grill was cleaned on 7/26/2017. Observations made on 07/26/2017 at 9:35 AM of the Nutrition Center located on the South Hall and were verified by the DON of the following items: 1) An open, expired container of CoffeeMate; expiration date of [DATE] located in the cabinet above the sink. 2) A second cabinet above the sink, had dried spilled brown substance and multiple soiled plastic containers, knives and forks, all stored behind the closed doors of the cabinet. 3) A sealed plastic box, located above the refrigerator labeled South contained 2 containers of chocolate chip cookies, one package was opened. 4) The interior of the Ice machine had brown spotting on the surface of the gray plastic gasket. On 07/26/2017 at 11:29 AM, an interview with the Director of Maintenance confirmed the brown spotting around the gasket which resulted in brown spotting imprinted on the stainless steel area where the brown spotted gasket had come in contact with the surface of the ice machine. The Director of Maintenance said and provided in writing, the dates which the Ice Machine was cleaned and sanitized: 6/26/17 North Ice Machine, 7/5/17 South Ice Machine, and 7/7/17 Dietary Ice Machine. H/She said the ice machines are emptied and sanitized quarterly throughout the building. Observations made on 07/26/2017 at 9:45 AM of the Nutrition Center located on the North Hall were verified by the DON of the following items: 1) a plastic trash can with food debris on the exterior, and labeled, Laundry. The DON and the CNA in the Nutrition Center both said that laundry is not stored in the Nutrition Center. 2) A plastic sealed container contained an open package of chocolate chip cookies which were not labeled. 3) A plastic container of peach cobbler which had not been labeled. The CNA #2 stated the resident's family had brought the peach cobbler for resident last night and we put in the refrigerator. H/She stated: We are supposed to label and date food when the family brings in and store in the refrigerator and we are supposed to throw away the next day. 4) Inside the refrigerator was a container of Mighty Shake manufacturer label stated: Use by date August 9. On 07/26/2017 at 11:07 AM the CDM said the Mighty Shake once pulled from the freezer for thawing are good for 14 days from the removal from the freezer. 5)The interior top of the Microwave oven had a buildup of a black substance and the white rim interior had spots of brown substance, and was verified by the DON. The Ice Chests and Machines Policy Statement, Ice Machines: .4.b. Thoroughly clean the machine and the parts. If build up of a sediment is noted, follow routine maintenance procedures for removing lime, rust or other elements. The Policy and Procedure titled, Food Brought into Resident's Room From Outside Sources states, Procedure: .2. Foods or Beverages brought in from the outside will be labeled with the Resident's name and room number and dated by nursing with the current date before putting in the refrigerator .3B. All cooked or prepared food brought in for a resident and stored in the unit's pantry refrigerator or personal room refrigerator will be dated when accepted and discarded after 72 hours .4. Nursing staff will monitor resident's room, unit pantry and refrigeration units for food and beverage disposal. An observation on 7/23/2017 at approximately 12:23 PM during the lunch meal service on the South Hall revealed Certified Nursing Assistant (CNA) #1 taking lunch trays in resident rooms without first cleansing/sanitizing his/her hands and setting up the trays without cleansing his/her hands and leaving resident rooms without first cleansing his/her hands on 1 of 2 halls. Review on 7/23/2017 at approximately 1:00 PM of the facility policy titled, Handwashing, states, All personnel working in the long-term care facility are required to wash their hands before and after resident contact, before and after performing any procedure, after sneezing or blowing noses, after using toilet, before handling food, and when hands are obviously soiled.",2020-09-01
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 12:05 PM that he/she had failed to detect and report the allergy to Neosporin when Maxitrol had been prescribed and in the succeeding months.",2020-09-01
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,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, Weekly Cleaning/Vacuuming Of Lint In/Around Dryers, was started on 11/1/2015 and was signed by the Maintenance Supervisor as completed. Further review on 7/25/2017 at approximately 1015 AM of the form revealed the next date logged was 6/20/2017 and was also signed by the Maintenance Supervisor. There was no consistency documented on the form to ensure the lint was cleaned and vacuumed weekly per the schedule. An interview on 7/25/2017 at approximately 10:40 AM with the Maintenance Supervisor confirmed the dryers were not vacuumed and cleaned out weekly. He/she went on to say the maintenance department does try to vacuum the clothes dryers out weekly but the log was pushed to the bottom of a stack of papers on his/her desk. He/she could not ensure that the dryers were cleaned/vacuumed out weekly and the build-up of lint removed.",2020-09-01
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,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,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 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 resident, nurses, CNAs on the unit, visitors, and other people on duty at the time. The facility's abuse policies and procedures regarding reporting state: 7. E. Abuse, alleged or otherwise, will be reported within 2 hours or 24 hours. Appropriate agencies will be called . The facility's abuse policies and procedures regarding investigation state: D. 7. Develop a list of known and possible witnesses to the reportable incident. Interview staff, residents and/or visitors, or anyone who has or might have knowledge of the incident under investigation . 9. Obtain written signed, double witnessed or notarized statements from the reporter and all other identified witnesses . Statements taken from actual eyewitnesses should .contain the witness's name, address, and phone number.",2020-09-01
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 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. The facility's abuse policies and procedures regarding reporting state: 7. E. Abuse, alleged or otherwise, will be reported within 2 hours or 24 hours. Appropriate agencies will be called . Reporting Requirements noted The facility must ensure that all allegations of abuse, neglect, injuries of unknown source, and misappropriation of resident property are reported immediately to the administrator of the facility, the State Survey Agency, to other officials in accordance with state law . The facility admitted Resdient #37 on 11/04/13 with [DIAGNOSES REDACTED]. On 10/09/18 at 11:27 AM, review of the Reportable for a 09/01/18 incident revealed an Accident/Incident Report indicating the incident occurred at 06:25 AM on 09/01/18. Further review revealed the Initial 2/24-Hour Report dated 09/01/18 indicated it was a 2 hr (hour) initial report. Another Initial 2/24-Hour Report was dated 09/02/18. Review of the radiology report revealed it was faxed to the facility at 9:31 PM on 09/01/18 stating the resident had an incompletely characterized recent right proximal fracture with mild angular deformity and noted that the physician was notified at 11:01 PM. Additional review revealed it was reported to the Bureau of Certification on 09/02/18 at 9:40 AM. On 10/09/18 at 02:01 PM, review of the General Progress Notes revealed a note dated 09/01/18 and timed at 10:42 AM stating the resident had swelling to the right upper arm with bruising noted and the area was warm to touch. The resident was whimpering in pain when the arm was elevated. The physician was notified and orders received for an x-ray and a CBC (complete blood count). The Resident Representative was notified at 10:25 AM. The x-ray was done at 05:00 PM and the resident was started on [MEDICATION NAME] 500 mg (milligrams) for [MEDICAL CONDITION]. During an interview on 10/11/18, the Director of Nursing (DON) confirmed the dates on the Initial 2/24-Hour Report but stated that the x-ray results were received in the nursing office and that s/he was unsure when the nurse obtained the result from the office. The DON also confirmed the notation on the x-ray result indicating the physician was notified of the result at 11:01 PM pn 09/01/18 and that the incident was not reported timely.",2020-09-01
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 resident, nurses, CNAs on the unit, visitors, and other people on duty at the time. The facility's abuse policies and procedures regarding investigation state: D. 7. Develop a list of known and possible witnesses to the reportable incident. Interview staff, residents and/or visitors, or anyone who has or might have knowledge of the incident under investigation . 9. Obtain written signed, double witnessed or notarized statements from the reporter and all other identified witnesses . Statements taken from actual eyewitnesses should .contain the witness's name, address, and phone number. Based on record review and interview, the facility failed to thoroughly investigate an injury of unknown origin for Resident #37 and an allegation of abuse for Resident #42, 2 of 4 residents reviewed for reportable incidents. The findings included: The facility admitted Resdient #37 on 11/04/13 with [DIAGNOSES REDACTED]. On 10/09/18 at 11:27 AM, review of the reportable for a 07/14/18 incident revealed Resident #37 experienced a fall and sustained a Left Femoral Neck Fracture on 07/14/18. Further review revealed the resident was receiving a bath by the CNA (Certified Nursing Assistant) and when the CNA turned the resident on her/his side to wash the back, the resident slid out of bed to the floor on her/his knees. The Accident/Incident Report stated the CNA reported that s/he lost control of the resident and the resident slid to the floor. A statement was obtained from the CNA that was giving Resident #37 a bath but no other statements were obtained from any other staff on duty at the time. In addition, Resident #37 also sustained an incompletely characterized recent right proximal fracture with mild angular deformity on 09/01/18. Review of the reportable file revealed employee statements from the nurse on all 3 shifts on 08/31/18 and day shift on 09/01/18. Statements were also obtained from the CNA assigned to Mrs.[NAME]on the 3:00-11:00 PM and 11:00 PM-7:00 AM shift on 08/31/18 and the day and evening shift on 09/01/18. No statements were obtained from any other staff assigned to the unit during the 2 days. During an interview on 10/11/18 at 02:33 PM, the Director of Nursing (DON) stated Resident #37 did have side rails ordered at the time of the fall on 07/14/18. The DON confirmed there was no mention in the CNA's statement if the side rail was up and that s/he could not say for sure. The DON confirmed there was no documentation of an investigation and asked the Assistant Director of Nursing (ADON) if the side rail had been up when the resident fell . The ADON stated s/he did not recall asking and also confirmed the statement did not say if the side rails were in use. Both the DON and the ADON confirmed no statements had been obtained from any staff that had not been assigned to Resident #37 related to the 09/01/18 fracture and that a thorough investigation had not been done to rule out possible abuse.",2020-09-01
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 Bilateral Lower Extremity [MEDICAL CONDITION], and [MEDICATION NAME]. (3) From 8/28/18 to 8/29/18 for Acute Hypoxic [MEDICAL CONDITIONS], Hypertensive Emergency, [MEDICAL CONDITIONS], Mitral Stenosis, and [MEDICAL CONDITION] Fibrillation. (4) From 9/11/18 to 9/12/18 for Acute Hypoxic [MEDICAL CONDITIONS], Hypertensive Emergency, [MEDICAL CONDITIONS], Mitral Stenosis, and [MEDICAL CONDITION] Fibrillation. (5) From 10/2/18 to 10/4/18 for Acute Hypoxic [MEDICAL CONDITIONS], Malignant Hypertension, Fluid Overload, and [MEDICAL CONDITION]. There was no evidence in the medical record of written notices to the resident's representative of the facility-initiated hospital transfers, including the reasons for the moves. The facility admitted Resident #100 with [DIAGNOSES REDACTED]. Review of Progress Notes on 10/10/18 at 8:40 AM revealed that the resident complained of hip pain after sustaining a fall on 6/14/18. Radiology reports showed no acute fractures at that time. The resident continued to complain of hip pain, and after an orthopedic consult, the facility was notified on 7/18/18 to send Resident #100 to the hospital for direct admission for treatment for [REDACTED]. There was no evidence in the medical record of written notices to the resident's representative of the facility-initiated hospital transfers, including the reasons for the moves. The facility admitted Resident #19 on 06/02/17 with [DIAGNOSES REDACTED]. On 10/08/18 at 03:01 PM, record review revealed the resident was hospitalized from [DATE] to 06/01/18 and from 06/22/18 to 6/29/18. Review of the general progress notes revealed no documentation that the facility provided a written notice of transfer to the resident or the resident representative. The facility admitted Resident #47 on 02/09/15 with [DIAGNOSES REDACTED]. On 10/08/18 at 01:13 PM, record review revealed the resident was hospitalized from [DATE] to 09/21/18. Review of the General Progress Notes on 10/10/18 revealed no documentation that the facility provided a written notice of transfer to the resident or the resident representative. During an interview on 10/10/18 04:09 PM, the Social Services Director confirmed the facility had not been providing written notices of transfer to the resident or resident representative when a resident was transferred to the hospital.",2020-09-01
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,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,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 the survey revealed inconsistent and limited communication between the facility and the [MEDICAL TREATMENT] center. Pre- and post-[MEDICAL TREATMENT] weights were not provided by the [MEDICAL TREATMENT] facility to ensure accuracy in determination of weight loss. Two-way communication between the facility and [MEDICAL TREATMENT] did not include medication administration, new and discontinued medication, labs, resident compliance with food/fluid restrictions, [MEDICAL TREATMENT] treatment provided and the resident's response. During an interview on 10/09/18 at 3:28 PM, the Director of Nursing stated s/he expected communication from the [MEDICAL TREATMENT] center to include at least post-[MEDICAL TREATMENT] weights, what was done at [MEDICAL TREATMENT] (changes, labs drawn), and vital signs.",2020-09-01
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,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,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,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 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 provided and what physical harm, mental anguish, mental illness, or deterioration in the resident's mental or physical condition resulted. Neglect is also evaluated as a result of indifference, carelessness, or deliberate negligence. Resident #17 was admitted into the facility on [DATE] with admitting [DIAGNOSES REDACTED]. Review of Resident #17's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 was severely cognitively impaired and exhibited no behavioral symptoms. Resident #17 required the total assistance of one (1) staff person for bed mobility, locomotion on and off the unit, dressing, eating, toileting, personal hygiene and bathing. The resident required the extensive assistance of one (1) staff person for transfers and had impairment to one (1) side of her upper extremities. Resident #17 utilized a wheelchair for mobility. According to the MDS, Resident #17 had no falls and received no therapy services, during the assessment period. Review of Resident #17's Comprehensive Care Plan revealed the following care areas were addressed: 9/5/19 - Problem: Potential for falls resulting in injury related to limited mobility, poor endurance and poor judgement due to Alzheimer's Dementia, [MEDICAL CONDITION], Hypertension, [MEDICAL CONDITION], right humeral neck fracture, [MEDICAL CONDITION], Constipation, Depression, Loss of Appetite and [MEDICAL CONDITION]. Goal: Resident #17 will not suffer injury related to falls (through review date 12/5/19). Interventions for this care area were initiated prior to the resident's fall from bed on 7/13/19 and included: 1. Monitor for safety and maintain safe environment; 2. Assist as needed in all ADLs (activities of daily living) areas; 3. Offer reminders not to arise unassisted as needed and transport to high visibility areas as needed; 4. Encourage to wear shoes with non-slip soles; 5. Maintain bed in low position while not rendering care. 6. Keep call light within reach at all times. Instruct/remind on use of system and answer promptly; 7. Assess all falls and circumstances surrounding falls in an effort to determine cause or contributing factors and eliminate if possible; 8. Notify Responsible Party and MD of all fall instances; 9. Monitor for s/sx (signs/symptoms) of [DIAGNOSES REDACTED] such as tingling of extremities, muscle cramps, twitching, stooped posture, and brittle bones; 10. Provide diet per order, encourage consumption of calcium rich foods such as eggs, milk, cheese and other dairy products served within diet; 11. Strive to keep room free from clutter and pathway to bathroom clear, mop all spills; and 12. Administer med and monitor labs per MD orders. 9/5/19 - Problem: Resident #17 requires total assist of staff for ADLs related to limited mobility and poor endurance related to Alzheimer's Dementia, [MEDICAL CONDITION], Hypertension, [MEDICAL CONDITION], right humeral neck fracture, [MEDICAL CONDITION], Constipation, Depression, Loss of Appetite and [MEDICAL CONDITION]. Goal: Resident #17 will be clean and well-groomed by staff (through review date 12/5/19). Interventions for this care area were initiated prior to the resident's fall from bed on 7/13/19 and included: 1. Provide routine oral hygiene; 2. Clean and trim fingernails/toenails; Dress/undress appropriately and groom hair daily and as needed; 3. Offer toileting assistance every two hours and as needed in an effort to maintain some continence; 4. Provide incontinence skin care daily and as needed; 5. Turn and reposition every two (2) hours and as needed while in bed; 6. Transport to specific destinations once up; 7. Provide ROM (range of motion) exercises to all extremities throughout nursing care as tolerates; 8. Provide showers three (3) times weekly and sponge baths daily shampoo hair with shower unless other arrangements are made; 9. Spoon feed all meals by staff in an effort to ensure adequate nutritional intake; 10. Transfer from bed to geri-chair as tolerated; and 11. Perform treatments per MD orders. Review of Resident #17's Progress Notes revealed the following: 7/7/19 - Resident #17 Quietly resting in bed with eyes closed. (No added distress) NAD noted. Resp(irations) even and nonlabored. Total dependent care by staff. Kept clean, dry and comfortable in bed. 7/13/19 - CNA was in room providing care resident rolled off right side of bed and hit left side of face and shoulder on chair beside bed. Res(ident) noted to obtain laceration to left eyebrow and left upper cheek. Bruises noted to left elbow and upper elbow. [MEDICAL CONDITION] noted to left elbow. ROM (range of motion) within normal limits for lower extremities and right arm. C/O (complains of) pain to left shoulder and elbow . Review of Resident #17's Radiology report dated 7/13/19 revealed the resident's left shoulder was x-rayed and compared to an x-ray completed 12/12/17. According to the comparison there was no change in resident's status since prior x-ray. Results: Impacted fracture involving the humeral neck. The acromioclavicular and coracoclavicular joints are intact. Conclusion: Impacted humeral neck fracture (present prior to the fall from bed). The report also noted no fracture to the resident's left elbow. Review of the facility's Investigation Report dated 7/16/19 revealed on 7/13/19, Resident #17 rolled off bed during care. Laceration to left eyebrow and left upper cheek. (Resident) complained of left shoulder pain and elbow pain. X-ray ordered. According to the report, CNA #6 had Resident #17 facing her while the staff performed incontinent care, but when the aide moved to reach for the diaper located at the foot of the resident's bed, Resident #17 suddenly flipped over causing her to hit the left side of her face on the chair which was beside her bed then fell to the floor. Bed was in low position. Interventions by facility to prevent future injury/Alleged Abuse: Floor pads placed on floor resident is facing when she is in bed and make sure chair is not right beside bed. The facility summarized the incident, as follows: After investigation, facility concludes there was no abuse involved. Staff still unsure how resident rolled over that way but agrees that she should have all materials within easy reach. Continued review of the Investigation Report revealed CNA #6's witness statement dated 7/13/19 noted the following: I was changing (Resident #17) when she rolled off the side of the bed. She bumped her head on the corner of the chair as she went down. She was facing me and when I reached for the diaper, she all of a sudden rolled out of the bed and I could not catch her. The bed was in a low position the whole time. I called for the nurse right away as soon as this happened. All the nurses and CNAs came to help. Further review revealed RN (Registered Nurse) #2's witness statement dated 7/13/19 was documented, as follows: Called to res(ident's) room by CN[NAME] Res was lying on back on right side of bed. Resident noted to have laceration to left eyebrow and left upper cheek. Bleeding noted. ROM (range of motion) performed WNL (within normal limits) to lower extremities and right arm. C/O (complained of) pain to left arm. (Two) bruises noted to left elbow. Bleeding stopped and steri-strips applied to lacerations. Ice applied to lacerations and left arm. When asking CNA what happened she stated she was turning resident towards her (standing on right side of bed) and res slid between her and the bed and hit face and arm on chair as she fell . The witness statements detailed contradictory information. Review of CNA #6's Employee file revealed the Aide was hired on 7/18/08. On 7/15/19, CNA #6 received a Second Written Warning or Work Suspension Notice for negligence. The document noted the following: Negligence in assigned duties or overall resident care. CNA failed to follow proper turn and reposition. Not making sure resident is in the center of the bed before turning and repositioning. CNA was in-serviced 1:1 on turning and repositioning with charge aide. If it happens again - will terminate. The form was executed by both the Director of Nursing (DON) and the Assistant DON (ADON). The form noted that CNA #6 Refused to sign the document. Observation in the common TV area of North unit on 10/15/19 at 10:47 a.m. revealed Resident #17 was reclined in a Geri-chair with her bilateral (b/l) feet elevated. The resident's mouth was open throughout the observation and a blanket covered the resident's lower extremities from waist down and covered all of resident's b/l lower extremities. Continued observation revealed Resident #17 had a protruding tongue. The resident was able to nod yes or no to direct questions. Observation in Resident #17's room on 10/16/19 at 2:14 p.m. revealed that CNA #2 escorted Resident #17 to her room in order to transfer the resident from her Geri-chair to her bed. CNA #2 completed a one-person pivot transfer and placed the resident in the center of her bed, elevated the head of Resident #17's bed and then placed the bed in a low position. The transfer was completed safely without incident or injury. Interview on 10/15/19 at 10:47 a.m. with Resident #17 revealed the resident was able to answer Yes and No questions by nodding or shaking her head. When asked if the resident recalled having fallen from her bed in (MONTH) 2019, Resident #17 indicated No. When asked if the resident was experiencing any pain, Resident #17 stated, No. When the resident was asked if she had ever been neglected by staff, Resident #17 indicated, No. Interview on 10/16/19 at 1:57 p.m. with CNA #1 revealed CNA #6 was currently out of the country and on vacation. CNA #1 reported being on duty the day Resident #17 fell from bed. CNA #1 said she heard CNA #6 yelling out for help and she hurried to Resident #17's room and saw Resident #17 lying face down on the floor and positioned between the two (2) beds in the room. CNA #1 said that when she entered the room, she saw that Resident #17's bed was not in a low position and neither side rail was raised. CNA #1 explained that when providing resident care and moving residents from side to side, aides were to raise the side rail so that residents could hold onto the rails during care. CNA #1 said Resident #17 was not able to independently roll from side to side while in the bed. She said the resident was total assist and required assistance from staff to move in the bed. She said she did not understand how the resident could have rolled from bed. According to CNA #1, CNA #6 told her that while she (CNA #6) was providing care for Resident #17, she (CNA #6) had the resident on her side and facing her when CNA #6 reached for something and the resident fell . CNA #1 said she was not interviewed regarding the incident; however, she did complete and submit a witness statement. During an interview on 10/17/19 at 11:00 a.m. with the facility's Director of Nursing (DON) and the MDS Coordinator, the DON confirmed that CNA #6 was currently out on vacation. The DON stated that the Assistant DON (ADON) conducted the investigation regarding Resident #17's fall from bed during peri-care. Interview on 10/17/19 at 11:50 a.m. with the facility's ADON, the nurse confirmed she completed the investigation regarding Resident #17's fall during peri-care. When asked about the position of residents' beds during peri-care, the ADON said the aides were to adjust residents' beds to a comfortable height in order to provide care. Upon completion of care, aides were to place the beds back in a lower position. The ADON said CNA #6 reported to her that Resident #17 was on her back and that when CNA #6 went to grab a diaper on the wheelchair, Resident #17 fell from the bed. The ADON said CNA #6 was written up because she performed peri-care incorrectly. The ADON said the resident's fall was not identified as a possible incident of neglect. Further interview revealed that CNA #1 told the ADON that she believed Resident #17 was too close to the edge of the bed, and that was the reason the resident fell . Telephone interview on 101/17/19 at 4:38 p.m. with RN #2 revealed the nurse did not recall well Resident #17's fall from bed during peri-care. RN #2 said the incident was so long ago. RN #2 said she did remember that CNA #6 told her that she (CNA #6) pulled Resident #17 towards her (CNA #6) and when she did this, Resident #17 slipped between her and the bed. RN #2 said she did not recall CNA #6 saying that she was reaching for a diaper (incontinent brief). RN #2 continued and said that she did not think CNA #6 could have done anything differently to prevent the incident from occurring. RN #2 said possible neglect was not considered because if CNA #6 had required more assistance to complete peri-care, then the aide would have asked her co-workers for help. The RN said it was possible for that type of thing to happen.",2020-09-01
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 provided and what physical harm, mental anguish, mental illness, or deterioration in the resident's mental or physical condition resulted. Neglect is also evaluated as a result of indifference, carelessness, or deliberate negligence .Completion of the following interviews: i. Person(s) reporting the incident; ii. Any witnesses to the incident (a) The resident (if appropriate); (b) The resident's roommate, family members and visitors (if applicable); (c) Staff members who have had contact with the resident during the period of the alleged incident. Resident #17 was admitted into the facility on [DATE] with admitting [DIAGNOSES REDACTED]. Review of Resident #17's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 was severely cognitively impaired and exhibited no behavioral symptoms. Resident #17 required the total assistance of one staff person for bed mobility, locomotion on and off the unit, dressing, eating, toileting, personal hygiene and bathing. The resident required the extensive assistance of one staff person for transfers and had impairment to one side of her upper extremities. Resident #17 utilized a wheelchair for mobility. According to the MDS, Resident #17 had no falls and received no therapy services, during the assessment period. Review of Resident #17's Comprehensive Care Plan revealed the following care areas were addressed: 9/5/19 - Problem: Potential for falls resulting in injury related to limited mobility, poor endurance and poor judgement due to Alzheimer's Dementia, [MEDICAL CONDITION], Hypertension, [MEDICAL CONDITION], right humeral neck fracture, [MEDICAL CONDITION], Constipation, Depression, Loss of Appetite and [MEDICAL CONDITION]. 9/5/19 - Problem: Resident #17 requires total assist of staff for ADLs related to limited mobility and poor endurance related to Alzheimer's Dementia, [MEDICAL CONDITION], Hypertension, [MEDICAL CONDITION], right humeral neck fracture, [MEDICAL CONDITION], Constipation, Depression, Loss of Appetite and [MEDICAL CONDITION]. Review of Resident #17's Progress Notes revealed the following: 7/13/19 - CNA was in room providing care resident rolled off right side of bed and hit left side of face and shoulder on chair beside bed. Res(ident) noted to obtain laceration to left eyebrow and left upper cheek. Bruises noted to left elbow and upper elbow. [MEDICAL CONDITION] noted to left elbow. ROM (range of motion) within normal limits for lower extremities and right arm. C/O (complains of) pain to left shoulder and elbow . Review of the facility's Investigation Report dated 7/16/19 revealed on 7/13/19, Resident #17 rolled off bed during care. Laceration to left eyebrow and left upper cheek. (Resident) complained of left shoulder pain and elbow pain. X-ray ordered. The facility summarized the incident, as follows: After investigation, facility concludes there was no abuse involved. Staff still unsure how resident rolled over that way but agrees that she should have all materials within easy reach. Continued review of the Investigation Report revealed CNA #6's witness statement dated 7/13/19 noted the following: I was changing (Resident #17) when she rolled off the side of the bed. She bumped her head on the corner of the chair as she went down. She was facing me and when I reached for the diaper she all of a sudden rolled out of the bed and I could not catch her. The bed was in a low position the whole time. I called for the nurse right away as soon as this happened. All the nurses and CNAs came to help. Further review revealed RN #2's witness statement dated 7/13/19 was documented, as follows: Called to res(ident's) room by CN[NAME] Res was lying on back on right side of bed. Resident noted to have laceration to left eyebrow and left upper cheek. Bleeding noted. ROM (range of motion) performed WNL (within normal limits) to lower extremities and right arm. C/O (complained of) pain to left arm. (Two) bruises noted to left elbow. Bleeding stopped and steri-strips applied to lacerations. Ice applied to lacerations and left arm. When asking CNA what happened she stated she was turning resident towards her (standing on right side of bed) and res slid between her and the bed and hit face and arm on chair as she fell . The witness statements detailed contradictory information. In addition, there were no other witness statements documented in the Investigation Report. Review of CNA #6's Employee file revealed the aide was hired on 7/18/08. On 7/15/19, CNA #6 received a Second Written Warning or Work Suspension Notice for negligence in reference to failing to follow proper turn and reposition technique. Observation in the common TV area of North unit on 10/15/19 at 10:47 a.m. revealed Resident #17 was reclined in a geri-chair with her bilateral (b/l) feet elevated. The resident's mouth was open throughout the observation and a blanket covered the resident's lower extremities from waist down and covered all of resident's b/l lower extremities. Continued observation revealed Resident #17 had a protruding tongue. Interview at this time with Resident #17 revealed the resident was able to answer Yes and No questions by nodding or shaking her head. When asked if the resident recalled having fallen from her bed in (MONTH) 2019, Resident #17 indicated No. When asked if the resident was experiencing any pain, Resident #17 stated, No. When the resident was asked if she had ever been neglected by staff, Resident #17 indicated, No. Interview on 10/16/19 at 1:57 p.m. with CNA #1 revealed CNA #6 was currently out of the country and on vacation. CNA #1 reported being on duty the day Resident #17 fell from bed. CNA #1 said she heard CNA #6 yelling out for help and she hurried to Resident #17's room and saw Resident #17 lying face down on the floor. CNA #6 told CNA #1 that she (CNA #6) had the resident on her side and facing her when CNA #6 reached for something and the resident fell . CNA #1 said she was not interviewed regarding the incident; however, she did complete and submit a witness statement. CNA #1 was not sure if CNA #6 was suspended during the investigation of the incident. During an interview on 10/17/19 at 11:00 a.m. with the facility's Director of Nursing (DON) and the MDS Coordinator, the DON confirmed that CNA #6 was currently out on vacation. The DON stated that the Assistant DON (ADON) conducted the investigation regarding Resident #17's fall from bed during peri-care. According to the DON, a thorough investigation included interviewing the resident involved in the allegation (if possible), other residents, all pertinent staff/family/visitors (as applicable). When reviewing the witness statements from CNA #6 and RN #2, the DON confirmed that components of their statements were contradictory. The DON said when contradictory statements were obtained during an investigation, it was expected for the assigned Investigator to conduct follow-up interviews to obtain clarification. Interview on 10/17/19 at 11:50 a.m. with the facility's ADON, the nurse confirmed she completed the investigation regarding Resident #17's fall during peri-care. The ADON said that all witness statements (2) were included in the Investigation Report. In addition, the ADON said the resident's fall was not identified as a possible incident of neglect and CNA #6 was written up because she performed peri-care incorrectly. Continued interview with the ADON confirmed that the aide's failure to properly perform peri-care could be possible neglect that required investigation. Further interview revealed that CNA #6 was not suspended pending the outcome of the facility's investigation.",2020-09-01
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 nurse using bilateral arms to push herself up out of w/c without difficulties or distress noted. MD made aware, no new orders noted at this time. RR (Resident Representative) made aware and stated, She had bruises on her arm when I was down there on Monday, but I didn't recognize them as bruises, I just thought they were smudges. Review of the facility's Investigation Report dated 11/13/18 confirmed Resident #15 sustained unexplained bruising. Review of Resident #15's Comprehensive Care Plan revealed the following care areas were addressed: 8/1/19 - Problem: Resident at times may resist care or make physical contact with staff or other residents due to Dementia and [MEDICAL CONDITION]. Goal: Talk to resident in a calm, reassuring tone of voice (through review date 11/1/19). Interventions (all initiated before 11/22/18) : Talk to resident in a calm, reassuring tone of voice; explain all procedures to resident prior to assisting; If resident is resistant or combative with care, give her time to calm down and re-approach at a later time; Administer [MEDICATION NAME] per MD's (doctor's) orders; and family contacted/informed about drug use and possible side effects. 8/1/19 - Problem: Resident displays socially inappropriate/disruptive behaviors due to [MEDICAL CONDITION] Dementia. Goal: Decline in disruptive behaviors (through review date 11/1/19). Interventions (all initiated before 11/22/18): Place resident in area where constant observation when possible; Approach resident warmly and positively; Talk to resident in a calm voice when behaviors are recent; Remove resident from area when behaviors are unacceptable/disruptive; Offer food/drink when behaviors are present; Check to see if resident is soiled or cold; Administer [MEDICATION NAME] per MD orders. Monitor for effectiveness, for possible side effects or adverse reaction and report to MD as needed; and family informed/contacted about drug use and possible side effects. 8/1/19 - Problem: Potential for falls resulting in injury related to limited mobility, poor endurance and poor judgement due to left [MEDICAL CONDITION], Dementia, Urinary tract infection, Constipation,[MEDICAL CONDITIONS]. Goal: Resident will not suffer injury related to falls (through review date 11/1/19). Interventions (all initiated before 11/22/18) : Monitor for safety and maintain a safe environment; Assist as needed in all ADL (activities of daily living) areas; Offer reminders not to arise unassisted as needed and transport to high visibility area as needed; Encourage to wear shoes with non-slip soles; Keep room free from clutter and pathway to be clear. Mop up all spills promptly; Maintain bed in low position while not rendering care. Keep call light within reach at all times. Instruct/remind on use of system and answer promptly; Assess all falls and circumstances surrounding falls in an effort to determine cause or contributing factors and eliminate if possible; Notify responsible party (RP) and MD of all fall instances; Monitor for signs and symptoms of [DIAGNOSES REDACTED], such as tingling of extremities, muscle cramps, twitching, stooped posture and brittle bones; Provide diet per order, encourage consumption of calcium rich foods, such as eggs, milk, cheese and other dairy products served within diet; and monitor labs per order. Report to MD as needed. 8/1/19 - Problem: Potential for skin tears and bruising related to fragile condition of skin. Goal: Skin tears will heal without complication (through review date 11/1/19). Interventions (all initiated before 11/22/18): Monitor for safety and maintain a safe environment. Handle gently and protect from injury; Provide treatment to skin tears per order. Monitor effectiveness of treatment and progression of healing; Monitor for s/sx (signs/symptoms) of infection, such as redness, warmth, pain, tenderness, [MEDICAL CONDITION] and purulent drainage; Have resident wear long sleeves/pants/geri-sleeves as needed to protect extremities (2/24/19); Provide adequate lighting to reduce the risk of bumping into furniture or equipment; offer fluids with medication pass, at meals and as needed between meals in an effort to ensure hydration; Apply lotions and moisturizers to skin as needed; Use a lift sheet to move and turn resident when in bed as needed; Pad wheelchair arms and leg supports as needed; Support dangling arms and legs with pillows and blankets as needed; and perform skin tear risk assessment initially upon admission and quarterly thereafter, as needed. 8/1/19 - Problem: Resident requires extensive to total assistance from staff for ADLs related to limited mobility and poor endurance related to history left [MEDICAL CONDITION], Dementia, UTI, Constipation,[MEDICAL CONDITIONS]. Goal: Resident will continue to participate in ADLs after set-up by staff (through review date 11/1/19). Interventions (all initiated before 11/22/18): Provide showers three times per week and sponge baths daily. Shampoo hair weekly with a shower unless other arrangements are made; Provide routine oral hygiene; Clean and trim fingernails/toenails as needed; Offer toileting assistance every two hours and as needed in an effort to maintain some continence; Provide preventative skin care daily and as needed; Provide tray set up for meal consumption and assist with meals as needed in an effort to ensure adequate nutritional intake; Assist the resident to turn and reposition ever two hours and as needed while in bed; Assist to transfer from bed to wheelchair as tolerated; Transport to specific destinations once up; Provide Range of Motion (ROM) exercises to all extremities throughout nursing care as tolerated; and assist to dress/undress appropriately and groom hair daily and as needed. The comprehensive care plan was not updated after Resident #15 sustained unexplained bruising to her left arm on 11/11/18. 2. Review of Resident #16's clinical record revealed Resident #16 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #16's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored four (4) out of 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was severely cognitively impaired and exhibited no behavioral symptoms. Continued review of the assessment noted the resident required the total assistance of one staff person for bed mobility, transfers, locomotion on and off the unit, dressing, toileting and bathing. Resident #16 had no impairment to upper and lower bilateral extremities and did not utilize a mobility device. During the assessment period, Resident #16 had no falls and received no therapy services. Review of Resident #16's Annual MDS assessment dated [DATE] revealed the resident was moderately cognitively impaired and exhibited no behavioral symptoms during the assessment period. The Annual MDS noted Resident #16 required the total assistance of one staff person for bed mobility, transfers, locomotion off and on the unit, dressing, toileting, personal hygiene and bathing. Resident #16 had impairment of one side of lower extremity, and according to the MDS, the resident did not utilize a mobility device. During the assessment period, Resident #16 had no falls, was administered opioid medication for seven (7) days and received no therapy services. Review of Resident #16's Progress Notes revealed the following: 12/31/18 at 10:40 a.m. - Upon getting up this morning, resident complained (of) left leg pain. No swelling or bruise noted .when staff tries to push her to go to the activity she hollers and says that her leg is still hurt. When this nurse checked her leg once again, her leg just below the knee is swollen, tender to touch but not warm. No redness or bruise on the area. (MD) notified and made aware with no new order noted at this time. Continue monitoring resident condition. Review of Resident #16's Radiology report dated 12/31/18 revealed Resident #16 sustained an Acute proximal left lower leg fracture. Review of Resident #16's Care Plan revealed the following care areas were addressed: 9/12/19 - Problem: Requires extensive to total assistance from staff for ADLs (activities of daily living) related to limited mobility, poor endurance and intermittent episodes of confusion related to [MEDICAL CONDITIONS], Abnormality of Gait, Debility, [MEDICAL CONDITIONS], History of Pneumonia, [MEDICAL CONDITION] Fibrillation, [MEDICAL CONDITIONS], Dysphasia, Hypertension, Obesity, Anxiety and Dementia. Goal: Resident will be cleaned and well-groomed by staff (through review date 12/12/19). Interventions (all interventions initiated as of 10/18/18): Clean and trim fingernails/toenails as needed; Offer toileting assistance every two hours and as needed in an effort to maintain some continence; Provide incontinent skin care after each incontinent episode; Provide preventative skin care daily and as needed; Provide tray set up for meals. Monitor self- feeding performance and meal consumption and assist with meals as needed in an effort to ensure adequate nutritional intake; Transport to specific destinations once up; Provide range of motion (ROM) exercises to all extremities throughout nursing care as tolerated; Provide showers three times weekly and sponge baths daily as tolerated. Shampoo hair weekly with a shower unless other arrangements are made. Encourage to wash face, hands and upper body after set-up and cueing from staff. Monitor performance and assist as needed; Dress/undress appropriately and groom hair daily and as needed; Turn and reposition every two hours and as needed while in bed; Side rails up x 2 when in bed to assist with turning and repositioning. Check every 30 minutes and release every two hours. Allow free time during meals, care and family/social visits; Perform positioning assessment quarterly; and transfer from bed to chair with Hoyer lift or sit-to-stand. 9/12/19 - Problem: Potential for falls resulting in injury related to limited mobility, poor endurance and poor judgement due to Cardiovascular Accident ([MEDICAL CONDITION]), Debility, Abnormal Gait, [MEDICAL CONDITIONS], Anxiety, Age-related [MEDICAL CONDITION] without current pathological fracture and intermittent episodes of confusion related to Dementia. Goal: Resident #16 will not suffer injury related to fall (through review date 12/12/19). Interventions (all interventions initiated as of 10/18/18): Monitor for safety and maintain a safe environment; Assist as needed in all ADL areas; Offer reminders not to arise unassisted as needed and transport to high visibility area as needed; Encourage to wear shoes with non-slip soles; Keep room free from clutter and pathway to bathroom clear. Mop up all spills promptly; Maintain bed in low position while not rendering care. Keep call light within reach at all times. Instruct/remind on use of system and answer promptly; Assess all falls and circumstances surrounding factors and eliminate if possible; Notify responsible party (RP) and MD of all fall instances; Monitor for s/sx of [DIAGNOSES REDACTED] such as tingling of extremities, muscle cramps, twitching, stooped posture, and brittle bones; Provide diet per order. Encourage consumption of calcium rich foods such as eggs, milk, cheese and other dairy products served within diet; and administer medications and monitor labs per MD orders. Report to MD as needed. 9/12/19 - Problem: Potential for pain or discomfort related to limited mobility and [MEDICAL CONDITION] and history of proximal left lower leg fracture. Goal: Resident #16 will obtain relief from pain/discomfort 30-60 minutes after medications/measures taken (through review date 12/12/19). Interventions (all interventions initiated as of 10/18/18): Monitor for s/sx of pain/discomfort such as verbal complaints, moaning, crying, facial grimace, loss of appetite, withdrawal and resistance to care; Maintain calm and reassuring environment. Avoid stressors; Position for comfort with pillow supports as needed; Provide diversionary activities so resident does not focus only on pain; Encourage and assist with exercise to tolerance within physical limitations within. Allow resident to guide pacing of movements and provide frequent rest periods; and administer medications per MD orders. The comprehensive care plan was not updated to address Resident #16's potential to sustain pathological fractures related to the [DIAGNOSES REDACTED]. 3. Record review revealed Resident #17 was admitted into the facility on [DATE] with admitting [DIAGNOSES REDACTED]. Review of Resident #17's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 was severely cognitively impaired and exhibited no behavioral symptoms. Resident #17 required the total assistance of one staff person for bed mobility, locomotion on and off of the unit, dressing, eating, toileting, personal hygiene and bathing. The resident required the extensive assistance of one staff person for transfers and had impairment to one side of her upper extremities. Resident #17 utilized a wheelchair for mobility. According to the MDS, Resident #17 had no falls and received no therapy services, during the assessment period. Review of Resident #17's Progress Notes revealed the following: 7/13/19 - CNA (Certified Nursing Assistant) was in room providing care resident rolled off right side of bed and hit left side of face and shoulder on chair beside bed. Res(ident) noted to obtain laceration to left eyebrow and left upper cheek. Bruises noted to left elbow and upper elbow. [MEDICAL CONDITION] noted to left elbow. ROM (range of motion) within normal limits for lower extremities and right arm. C/O (complains of) pain to left shoulder and elbow . Review of the facility's Investigation Report dated 7/16/19 revealed the following interventions were to be added to Resident #17's fall care plan: Floor pads placed on floor resident is facing when she is in bed and make sure chair is not right beside bed. Review of Resident #17's Comprehensive Care Plan revealed the following care areas were addressed: 9/5/19 - Problem: Potential for falls resulting in injury related to limited mobility, poor endurance and poor judgement due to Alzheimer's Dementia, [MEDICAL CONDITION], Hypertension, [MEDICAL CONDITION], right humeral neck fractures, [MEDICAL CONDITION], Constipation, Depression, Loss of Appetite and [MEDICAL CONDITION]. Goal: Resident #17 will not suffer injury related to falls (through review date 12/5/19). Interventions: Monitor for safety and maintain safe environment; Assist as needed in all ADLs (activities of daily living) areas; Offer reminders not to arise unassisted as needed and transport to high visibility areas as needed; Encourage to wear shoes with non-slip soles; Maintain bed in low position while not rendering care. Keep call light within reach at all times. Instruct/remind on use of system and answer promptly; Assess all falls and circumstances surrounding falls in an effort to determine cause or contributing factors and eliminate if possible; Notify Responsible Party and MD of all fall instances; Monitor for s/sx of [DIAGNOSES REDACTED] such as tingling of extremities, muscle cramps, twitching, stooped posture, and brittle bones; Provide diet per order, encourage consumption of calcium rich foods such as eggs, milk, cheese and other dairy products served within diet; Strive to keep room free from clutter and pathway to bathroom clear, mop all spills; and administer med and monitor labs per MD orders. 9/5/19 - Problem: Resident #17 requires total assist of staff for ADLs related to limited mobility and poor endurance related to Alzheimer's Dementia, [MEDICAL CONDITION], Hypertension, [MEDICAL CONDITION], right humeral neck fracture, [MEDICAL CONDITION], Constipation, Depression, Loss of Appetite and [MEDICAL CONDITION]. Goal: Resident #17 will be clean and well-groomed by staff (through review date 12/5/19). Interventions: Provide routine oral hygiene; Clean and trim fingernails/toenails; Dress/undress appropriately and groom hair daily and as needed; Offer toileting assistance every two hours and as needed in an effort to maintain some continence; Provide incontinence skin care daily and as needed; Turn and reposition every two hours and as needed while in bed; Transport to specific destinations once up; Provide ROM (range of motion) exercises to all extremities throughout nursing care as tolerates; Provide showers three times weekly and sponge baths daily shampoo hair with shower unless other arrangements are made; Spoon feed all meals by staff in an effort to ensure adequate nutritional intake; Transfer from bed to geri-chair as tolerated; and perform treatments per MD orders. Resident #17's care plan was not updated to include the interventions to place floor pads on the floor and to make sure a chair was not right beside Resident #17's bed. Observation in Resident #17's room on 10/16/19 at 2:14 p.m. revealed a chair was placed next to the head of Resident #17's bed. Interview on 10/17/19 at 11:00 a.m. with the facility's Director of Nursing (DON) and the MDS Coordinator revealed residents' care plans were maintained in the electronic health record, and a hard copy was also maintained in the resident's paper chart. The MDS Coordinator said that nursing staff can update residents' hard copy care plans when needed by writing in newly developed interventions. The MDS Coordinator said that updated information documented on the hard copy care plans was formally added to residents' electronic care plans on a quarterly basis when care plan meetings were held. The DON and MDS Coordinator acknowledged that care plans for Residents #15, #16, and #17 were not updated; however, they should have been.",2020-09-01
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 02/21/17 at 12:42 p.m. A Hospice Certification and Plan of Treatment indicated hospice was initiated 10/27/16 for [MEDICAL CONDITION]. The Minimum Data Set assessments, dated 11/05/16 and 02/05/17, were reviewed on 02/21/17 at 12:55 p.m. They identified the resident received hospice (Section O0100k) but did not have a terminal prognosis (Section J1400). The Resident Assessment Coordinator, Registered Nurse #9, in an interview on 02/21/17 at 3:47 p.m. verified the assessments did not accurately reflect the resident's terminal prognosis. RESIDENT #127 The medical record for Resident #127 was reviewed on 02/21/17 at 1:45 p.m. A Hospice Certification and Plan of Treatment indicated hospice was initiated on 06/05/14 for a [DIAGNOSES REDACTED]. In an interview on 02/21/17 at 3:50 p.m. the Resident Assessment Coordinator, Registered Nurse #9, verified the assessments did not accurately reflect the resident's terminal status. In an interview on 02/21/17 at 4:15 p.m., Director of Nursing Services, Registered Nurse #5, stated hospice was good about getting the Certification of Terminal Illnesses to the facility, and if needed, the nurse could call and get them faxed over to verify the prognosis. She stated if a resident was on hospice, the facility should have certification of the terminal prognosis.",2020-09-01
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-in refrigerator as partially opened, not fully sealed. The main kitchen was observed on 2/23/17 at 1:03 p.m. A five-pound container of pimento cheese was observed in the walk-in refrigerator as partially opened, not fully sealed. D. Staff Interviews The registered dietitian (RD), DM and the nursing home administrator (NHA) were interviewed on 2/23/17 at 1:56 p.m. The DM said her staff was in charge of throwing out expired foods. She had completed monthly in-services with the staff. The DM also said this food item was thrown out that same day. She would ensure the above issues were addressed.",2020-09-01
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 Resident #65 to the hospital due to decreased blood pressure and oxygen level with increased heart rate and temperature. The facility readmitted Resident #65 on 6/6/19. Further review of the medical record indicated Resident #65 was admitted to the hospital on [DATE] due to abnormal vital signs 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 facility provided a copy of a form entitled, Facility Initiated Discharge Letter which indicated Resident #65 would be discharged from the facility 4/9/19 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.",2020-09-01
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,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,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,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 resident, s/he was making a strange noise and needed to be suctioned. That was the first time. Don't remember the exact time. Somewhere between 7:30 and 8:00 AM. 2nd time the original aide heard her/him and went and told the nurse, s/he needed to check on the resident. I was standing there. We were getting the residents ready to eat. S/he (nurse) was standing outside the room, passing medicine. S/he heard us talking about telling her/him to come and check the resident. S/he came in the room and looked at him/her (resident). S/he said, 'yeah s/he do need to be suctioned. Around 10:30 the CNA (assigned to the resident) called me to come and look. S/he said s/he thought the resident was dead. I went into the room. His eyes was open and he had foam out is mouth. I called her/his name, I rubbed her/his chest, nothing. I ran up to the desk where the nurse was at. I yelled are you calling a code blue? S/he said she was about to. We tried to tell her that he was having a hard time breathing. We take care of these people every day. We know when something ain't right. On [DATE] at 8:30 AM, Registered Nurse (RN) #138 was interviewed via phone by 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. At 2:50 PM: CNA # 47 was interviewed by the surveyor. When I came in (,[DATE]), when I went to his room CNA # 44 was already in there. S/He (the resident) was making a noise like something was in her/his throat. CNA # 44 said s/he had already talked to the nurse. The nurse was outside the door with her/his med cart and said ok. Then the trays came out about 8:30 AM. The CNA and I were feeding two other residents (4 residents were in that room) and resident #48 was making noise again. I go and talked to the nurse and told her/him the resident needed to be suctioned. The nurse was a RN, I don't remember her/his name. I am prn (as needed). That time s/he came in and said, 'OK, I will suction her/him. When s/he (the nurse) came in s/he just looked at her/him (the resident). It was 10:00 something when I went and looked at her/him and s/he wasn't breathing. The other CNA was walking by and I called her/him in. The other CNA was in the room. I went to the desk and told the nurse to come and look, I didn't think s/he was breathing. S/he walked down to the room and looked at him. Again, didn't do anything. S/he left the room and got her/his chart. We asked her/him if s/he was going to call a code. S/he called the code and everyone came rushing into the room. They sent me to escort the ambulance. So I went outside and brought them in. The other CNA usually worked with the resident. Review of the facility investigation revealed the facility had obtained statements from the two Certified Nursing Assistants. There was no statement from the Registered Nurse. Review of the facility's summary of the investigation revealed, RN #138 stated when s/he entered the room the resident was unresponsive and s/he immediately reported to the nurse's station to call a code. She did not check vitals or pulse. S/he also stated s/he previously went into the room at 0900 and the resident sounded gargly but respirations were even and unlabored, there was no suction machine in the room at this time. The nurse was asked why s/he didn't suction in a timely manner and s/he stated that s/he could not find a suction machine on the crash carts. Other staff members were interviewed and it was determined that there were suction machines on each crash cart. The crash carts were located at each nurses station. During the survey, the crash carts were observed on ,[DATE], ,[DATE] and on [DATE]. Each observation the crash carts contained a suction machine as well as suction cannisters, suction tubing and suction catheters. On each crash cart was a check list which had been checked daily for required equipment. 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 . On [DATE] at 12:57 PM Resident #6 was observed sitting very low in her bed, with the head of the bed raised causing her to to have her chin to her chest. Her tray of food was on the table and she was feeding herself. When asked if she is comfortable like that, she confirmed that she was not. On [DATE] at 12:37 PM during an observation, she is slouched in her bed, not at a 90 degree angle and tilted on her right side, and is feeding herself. A Certified Nurses Assistant (CNA) Staff #34 is currently in the room feeding another resident. The same CNA brought her food. Her call light is out of reach hanging on the other side of her bed. On [DATE] at 12:37 PM During an interview with the Resident #6, when asked if she still works with therapy, she stated that she does, when asked if she remembers what they tell her when she eats, she stated, yes, they tell me I am supposed to be sitting straight up so the food goes down into my stomach, not like this. On [DATE] 12:45 PM R#6 began yelling at Certified Nurse's Assistant (CNA) Staff #34, asking several times to put her head up, and CNA Staff #34 continued saying that the bed was all the way up. R#6 asks two more times, and CNA Staff #34 stated that her head is fine. CNA Staff #34 came to the edge of the bed and adjusted her tray, but did not put her head up or help her adjust in the bed. The resident remained in the same position, slouched and turned to the right side of the bed. On [DATE] at 12:47 PM during an interview with Resident #6, when asked if she is having trouble swallowing that way, she states,yes, everything is hard sitting like this. Resident #6 begins coughing, and coughed up coleslaw that she was eating. LPN (Licensed Practical Nurse) Staff #12 and LPN Staff #38 were in hall and were asked to come straighten up the resident and check on her. They came in and pulled her up in bed and repositioned her, but not in a 90 degree angle. She remained low in the bed and tilted to the right side. On [DATE] at 12:57 PM, during an interview with R#6, when asked if they always put her head up to eat, she stated no. She stated, this is better than when I am laying down, I cant eat like that. All residents were observed for proper positioning while in the bed feeding them self. During the extended survey observation was made of resident #22 on [DATE] at 5:15 PM and revealed she was observed to be served her meal and the nursing assistant elevated the head of her bed but she did not pull the resident up in the bed. Resident #22 remained slouched down in the bed and was in poor position to feed herself when her meal was served. The staff prepared her meal and left her to feed herself while she was still not positioned straight up in the bed as she was still noted to be slouched down in the bed. Resident #22 was observed to feed herself but was noted to struggle getting the food on her spoon and feeding herself without spilling the food on herself. During this observation the Social Service staff #108 walked by the room and observed Resident #22 in her bed positioned poorly and she entered the room and ask the resident why are you laying so far back in the bed trying to feed yourself. She began to reposition the resident and when doing so the resident began to cough/choke on the food that she had in her mouth. The Social Service staff #108 attempted to assist the resident by offering her a drink of water but the resident continued to cough and her eyes began to water and she was not able to speak. The Social Service staff #108 called for the nurse to come the the room and the nurse assessed Resident #22 and she was then able to drink water and she ceased coughing. Nurse #51 and Social Service Staff #108 pulled the resident up in bed and repositioned her in an adequate position so she could feed herself in an upright position and the resident was then able to feed herself her meal with no further concerns. Record review revealed Resident # 22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent Minimum (MDS) data set [DATE] revealed she had no swallowing disorder and receives a therapeutic mechanically altered diet. She was noted to require the extensive assistance of two staff members to position her in bed, required eating supervision with oversight and encouragement/cueing and was a set up only with her meals. Review of Resident #22's current care plan dated [DATE] revealed interventions to include that staff are to assist her with eating, monitor for mastication difficulties, monitor her intake for safe swallowing and report any problems to the nurse. Review of Nurse Aide flow records for (MONTH) and (MONTH) (YEAR) revealed she requires the extensive assistance from staff to turn in bed. Her record was silent to any speech therapy orders or evaluations. During this same meal observation on [DATE] at 5:15 PM Resident #49 was also observed during the supper meal service. He was observed to be served his meal and nursing assistant #93 elevated the head of his bed but she did not pull the resident up in the bed to position him properly so he could feed himself safely. Resident #49 remained slouched down in the bed and he was leaning the to left against the bed rail. The Nurse Aide Staff #93 prepared his meal and left him to feed himself while he was not positioned straight up in the bed so he could eat without risk of choking and potential aspiration. The Social Service staff #108 walked by Resident 49's room and observed him slouched down in the bed, leaning to the left and attempting to feed himself. She repositioned the resident by pulling him up and over in the bed and placing pillows beside him for positioning so he could feed him self without risk of choking. When the Social Service Staff #108 repositioned him so he could feed himself safely he was not able to self assist with positioning. Interview with Nurse Aide #93 on [DATE] at 5:30 PM revealed she had been educated by the Speech Therapist when she arrived on shift on this date prior to the evening meal about how to properly position resident while they are eating in bed. She said she was in-serviced to elevate the head of the bed and to use pillows as needed to position the resident so they were in a safe position to feed them self. She stated she had never observed Resident #22 or #49 to have any issues feeding themselves in bed and had never observed them to choke. Review of the sign in sheet for the education/in-service provided by the Speech Therapist on [DATE] revealed Nurse Assistant #93 was present for the mandatory in-service on safe positioning of resident while eating. Review of the education that was provided to the staff during this mandatory in-service revealed they were educated on assisting residents with feeding and positioning, swallowing precautions and a review was done of swallowing guidelines for the patient and the caregiver. This in-service was to be provided to all staff on shift on [DATE] and to all staff who worked on the days following prior to them providing care until all the staff who assisted residents with meals had been in-serviced. The Corporate Nurse #134 was advised of the observation of Resident #22 being poorly positioned by Nurse Aide Staff #93 on [DATE] at 6 PM. At 6:10 PM she advised this surveyor that she had spoken with Nurse Aide #93 and the Nurse Aide had been suspended due to the poor positioning of Resident #22 during her meal after she had just been inserviced on how to properly position resident for safe eating while in bed. The corporate Nurse #134 verified Resident #22 had not had any previous speech evaluations and had not had any incidence of previous choking or coughing incidents while feeding herself. The staff failed to monitor Resident #22 for safe swallowing per her nutrition care plan and failed to position her in a safe manner in bed so she could eat her meal on [DATE] at 5:30 PM. The staff also failed to position Resident #49 in a position while in bed to promote safety while he was feeding himself in bed. Both residents were found by the Social Service Staff #108 to be poorly positioned and Resident #22 was observed to experience a coughing/choking episode while feeding herself in bed while being poorly positioned. Two additional residents were observed during the meal service on [DATE] as they were identified by the facility as being on swallowing precautions. At 5:05 PM Resident #1 who was identified by the facility as being on swallowing precautions was observed sitting in a wheelchair in the dining room feeding himself. He was observed eating a pureed diet and thick liquids and was observed to have no concerns while feeding himself. Resident #20 was also observed in the dining room in her wheelchair feeding herself and no concerns were noted as she fed herself a mechanical soft diet with chopped meats. On [DATE] at 2:10 PM, Corporate Nurse Staff #134, Regulation Specialist Staff #135, and Director of Nursing Staff #136 were notified that Immediate Jeopardy (IJ) began on [DATE] at 12:47 PM when Resident #6 was observed lying slouched down in her bed on her right side and began choking while feeding herself lunch after repeated requests from the resident to be placed in a position so she could feed herself safely. 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's Allegation of Compliance (A[NAME]) to address the concerns with positioning of residents to prevent episodes of choking was received on [DATE] at 6:22 PM. The A[NAME] included: 1. Affected resident has been assessed by Speech Therapy and staff educated on proper positioning during meals. 2. Education provided to floor staff regarding proper positioning of residents who eat in bed by speech therapy and nursing management prior to dinner meal on [DATE]. 3. DON (Director of Nursing) or designee to visually check on residents during meal times to ensure proper positioning in bed at each meal x 7 days. 4. Speech Therapy will screen residents noted to have any difficulties with swallowing as reported by nursing on therapy referral form. 5. Residents noted for speech therapy screen will be reviewed in Q[NAME] (Quality of Care) meeting weekly beginning immediately. 6. Speech therapy to provide DON with copy of recommendations for processing to current orders or Kardex. 7. Staff that did not attend initial education on [DATE] will be educated on proper positioning and aspiration precautions before working the floor. The facility's Allegation of Compliance (A[NAME]) to address failure to assess and treat respiratory issues was submitted [DATE] to the surveyor and included the following: 1) Affected resident was transported to the hospital via 911 for evaluation and expired at the hospital. 2) Allegation of neglect was reported to the State Agency as required. 3) RN involved was suspended, terminated and reported to the SC Board of Nursing. 4) DON and Unit Managers to provide education on [DATE] to all nurses and Certified Nursing Assistants on neglect, oral suctioning procedure, location of suctioning equipment, recognizing change in condition and performing respiratory assessment. Inservice is mandatory and no one will be allowed to work until education is completed. 5) All resident's orders were audited by Nurse Management staff for identification of orders for advanced respiratory care/oxygen/suction. Findings were 2 residents in house with orders for continuous oxygen, 2 residents in house with orders for PRN (as necessary) oxygen and no residents in house with suction orders. 6) All respiratory care plans for affected residents have been reviewed and revised if needed on [DATE]. 7) Residents that have the potential for advanced respiratory care have been re-assessed for the need for suction on [DATE]. 8) Maintenance Director and Nursing verified that all 8 suction machines in the facility were functioning properly and central supply clerk verified that suction supplies are readily available on [DATE]. 9) A root cause analysis determined the nurse failed to respond to a change in condition of a resident and failed to respond appropriately to assess and treat. Equipment was available and functioning at the time of the incident. All staff including any new hires have been re-educated on neglect, respiratory assessment, equipment to use and location of equipment and recognizing change in condition. 10) The designated staff and DON will verify location of suction machines daily and nurses will check weekly their functionality. 11) This A[NAME] has been reviewed in an ad hoc QAPI meeting with the Medical Director's involvement and will be reviewed monthly at the QAPI meetings. The survey team completed record review, observation and interview to ensure the facility had implemented their A[NAME]. The Immediate Jeopardy at F279, F323 and F520 was removed on [DATE], but the citations remained at a lowered scope and severity of D. The Immediate Jeopardy citations at F223, F281 and F328 were removed on [DATE] after observations and interviews were completed to ensure the A[NAME] was in place and in practice. These citations remained cited at a lower scope and severity of D.",2020-09-01
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,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,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 Customary Routine and Activities .The following boxes are checked: Family or significant other involvement for care decisions, Listening to music, Doing things with groups of people, spending time outdoors .Section G Functional Status indicates that the resident is dependent in all areas of care. Record review of CAA Summary Report for Resident #110 dated 03/31/15 revealed under communication the resident is non-verbal due to illness. Factors to include in care plan sensory deprivation, social isolation, mood/behavior disorder and has problems making self understood. Develop an individual care plan to help stimulate his/her cognitive, creative, social/converse/communication, independent, empowerment, sensory stimulation, spiritual and physical well being. On 04/11/17 at the following times, during observations, Resident # 110 was found in her bed, alone, facing the wall away from her roommates and the door with no music or television: 04/11/17 at 8:40 AM, 10:17 AM, 11:03 AM, 12:27 PM, 1:32 PM, 2:29 PM, and 3:06 PM, 4:54 PM, and 5:17 PM. On 04/12/17 at 7:42 AM and 8:44 AM during observations, she was in her bed, facing the wall away from her roommates and the door with no music or television. On 04/12/17 during the following times, she was up in her chair in her room, alone: 10:39 AM, 1:19 PM, and 2:40 PM. On 04/12/17 at 3:37 PM during an interview Licensed Practical Nurse Staff #66, when asked if there is any reason that Resident #110 doesn't come out of her room, she stated, She comes out during meals. When asked if she comes out for all meals, she confirmed that she did. When asked why she had not been out for the past two meals observed by this surveyor, she confirmed that she should have been out and that she had not been. She stated, She isn't supposed to be around them other residents when they are eating because its a dignity issue. On 04/12/17 at 4:39 PM during an interview with the Assistant Director of Nursing Staff #3, when asked how many people worked in activities, she confirmed there are three, but before they got the third person, there were only two. When asked if three people doing the activities for that building was enough, she confirmed that it is not. When asked if they work seven days per week, she stated that she did not think so. When asked if there were any residents that could not get up for activities on the A/B Hall, she confirmed that there isn't. She stated, They (A/B hall) don't really have activities back there, so they have to come up to the front. When asked if there is any reason why staff cannot take Resident #110 out of the room, she stated, They would have to make sure it is ok with the nurse, as well as activities. On 04/12/17 at 3:24 PM during an interview with the Activities Director Staff #9, when asked if an individual can't get to activities by themselves, what is offered to them, she stated, We go in their rooms, ask them what they want to do and they may want to listen to music or watch TV. We have other residents that are bed ridden, and we have 1:1 (one on one individual activities) two times a week. We do some type of stimulation like hand massage, head massage, or some type of stimulation. When asked how activities knows what the resident preferences are if they are unable to voice them, she stated, When asked if they had a meeting with Resident #110's family about preferences, she confirmed that they had and stated, When we spoke to her father, he told me that she liked to listen to music, and she never attended church services. We sometimes come in with our phone or a radio and play some music for a short period of time. Sometimes she will open her eyes and move her body so we know she knows someone is with her. When asked if there is anywhere to take people if they want to go outside, or if they want to watch TV outside of their room, she stated, With the structure of out facility, we have most of our activities in the dining room. When asked if Resident #110 comes out of her room, she confirmed that she does not. When asked if the staff was able to take her to watch TV somewhere else besides her room, she confirmed that they could. When asked if the CNA's (Certified Nurse's Assistant) could get her up to have activities somewhere else besides her room, she confirmed that they could. When asked why she stays in her room if she has the opportunity to leave it, she stated, I don't know, that would be up to the nurse, and they would tell the CN[NAME] On 04/13/17 at 7:44 AM during an interview with the Interim Administrator Staff # 23 When asked if there is any reason someone wouldn't be taken out of their room sometime during the day to work with activities, or to be provided stimulation, she confirmed that there is no reason that should happen. When asked if one day of 1:1 activities per week was enough for someone that is totally dependent, and cannot express their concerns, she stated, It needs to be more often. When asked who brings the residents to activities, she confirmed that activities does that. When asked if activities is unable to get someone up, who gets the residents to activities, she confirmed that the CNAs should help get them up. On 04/13/17 at 8:17 AM, during an interview with Unit Manager Staff #45, she was brought to Resident #110's room and asked if there is a reason she is facing the wall or why she doesn't come out of her room, she stated confirmed that she did not know. She stated, In her 72 hour meeting, her dad stated that she likes to watch TV, so maybe that is why (The residents area is observed to have no TV). When asked if they could turn her around to face her roommates side of the room directly behind her so that she can see the TV that is on in the room, she stated, I am not sure. On 04/13/17 at 8:23 AM, during an interview with Minimum Data Set (MDS) Nurse Staff #99, she was brought to Resident #110's room and was asked why the resident's bed is facing the wall, away from her roommates and the door, she stated, I don't know why she would be like that. On 04/13/17 8:55 AM during an interview with the Administrator Staff #43, she confirmed that the staff is now turning her bed around to face her roommates, and the door. Record review of Activity Policies and Procedures dated 07/01/16 revealed, Policy: The Activity/Recreation Director and staff will provide for ongoing Activity/Recreation programs. Purpose: To provide programs to address the abilities, needs and interests of the patients/residents. This would include large groups, small groups, individual and independent opportunities. Programs take place mornings and afternoons, seven days a week to include holidays and evening and take place in various areas, both inside and outside of the Facility.",2020-09-01
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 on the closet doors. Room Skilled 11 B on 4/10/2017 at 11:04 AM there was a build up dirt at the entry to room and the closet doors were noted with chipped paint. Room Skilled 21 A on 4/10/2017 at 9:39 AM the walls were noted with chipped paint in room and bathroom. The bathroom floor had a buildup around the cove base. Room Skilled 5 A on 4/10/2017 at 10:56 AM there was a build up of dirt around floor at the entry into the room and the bathroom walls behind toilet was noted to have smears of brown substance on the walls. Room Skilled 9 A on 4/10/2017 at 10:54 AM there was chipped paint on closets and a build up of dirt throughout the room around the cove base. Room C 5 A on 4/10/2017 at 9:55 AM the door frame into room was scraped with chipped paint. Room Skilled 4 A on 4/10/2017 at 10:41 AM there was a build up of dirt on floor and around cove base in the room and the walls in room and closet doors were noted with chipped paint. These observations were shared and verified with the Maintenance Director on 4/12/2017 at 1:20 PM. He stated the building was in the process of selling and he was not able to get any supplies for any repairs so he does the best he can with what he has. He verified he did not currently have a schedule in place to begin any repairs. These findings were also shared with the Administrator and corporate staff on 4/12/2017 at 3:05 PM.",2020-09-01
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,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 revealed, Swallowing functional limitation, current status has been documented based on clinical judgment;pt able to follow safe swallow strategies with min cues to increase upper airway protection. Education provided to the resident on the importance of sitting upright in 90 degree position for all oral intake . Record review of ST -Therapist Progress & Discharge Summary dated 04/07/17 revealed, .The patient will perform pharyngeal elevation/excursion (specific phases of swallowing) exercise given 30% visual and verbal instruction/cues to increase pharyngeal squeeze to decrease aspiration risk exhibiting mild impairment (25-50% impairment;risk of aspiration on liquids; mild oral residue and may need meats ground or chopped; cueing and intermittent supervision for carry-over. Record review of OT (Occupational Therapy) daily treatment record dated 03/30/17 revealed, OT supervisory visit completed .OT saw patient in her room initially for using ADL (Activities of Daily Living) training. OT pulled her up in edge then set up her lunch tray. Patient stayed up to complete her meal with 20% spillage .the resident transition from supine (lying face up) to sit EOB (edge of bed) with max (maximum) A (assist). resident was then taken to rehab gym .to work on arm strength to assist with bed/chair mobility/positioning . Record review of Nursing Policies and Procedures for Aspiration Precaution Guidelines dated 07/01/16 revealed, Follow protocols/guidelines developed by speech and/or occupational therapists. Remember mealtime strategies should always be individualized. Every precaution should be communicated to all staff. These may include: Position the resident at a 90 degree angle or as upright as possible while eating or taking oral medications; .Avoid positioning the resident in a flat position . Record review of Aspiration Precautions Sheet for Resident #6, with no date revealed, 1. upright in chair for all meals . Record review of Kardex (CNA communication/task sheet) with no date for Resident #6 revealed, Eating- Independent/Set-up, Activity/Mobility- out of bed/wheelchair/mechanical lift ., no further indication of positioning. On 04/10/17 at 12:57 PM Resident #6 was observed sitting very low in her bed, with the head of the bed raised causing her to to have her chin to her chest. Her tray of food was on the table and she was feeding herself. On 04/11/17 at 12:37 PM during an observation, she is slouched in her bed, not at a 90 degree angle and tilted on her right side, and is feeding herself. A CNA (Certified Nurses Assistant) Staff #34 is currently in the room feeding another resident. The same CNA brought her food. Her call light is out of reach hanging on the other side of her bed. On 04/11/17 at 12:37 PM During an interview with the Resident #6, when asked if she still works with therapy, she stated that she does, when asked if she remembers what they tell her when she eats, she stated, yes, they tell me I am supposed to be sitting straight up so the food goes down into my stomach, not like this. On 04/11/17 12:45 PM Resident #6 began yelling at CNA Staff #34, asking several times to put her head up, and CNA Staff #34 continued saying that the bed was all the way up. Resident #6 asked two more times, and CNA Staff #34 stated that her head is fine. CNA Staff #34 came to the edge of the bed and adjusted her tray, but did not put her head up or help her adjust in the bed. The resident remained in the same position, slouched and turned to the right side of the bed. On 04/11/17 at 12:47 PM during an interview with Resident #6, when asked if she is having trouble swallowing that way, she states,yes, everything is hard sitting like this. Resident #6 begins coughing, and coughed up coleslaw that she was eating. LPN (Licensed Practical Nurse) Staff #12 and LPN Staff #38 were in hall and were asked to come straighten up the resident and check on her. They came in and pulled her up in bed and repositioned her, but not in a 90 degree angle. She remained low in the bed and tilted to the right side. On 04/11/17 at 12:57 PM, during an interview with Resident #6, when asked if they always put her head up to eat, she stated no. She stated, this is better than when I am laying down, I can't eat like that. On 04/11/17 at 1:03 PM, during an interview with the ST (Speech Therapist) Staff #125 that wrote recommendations for Resident #6, she was brought to the room to see the positioning for Resident #6. She was asked if this was the correct positioning for her to eat in, and she verified that it is not. She asked Resident #6 why she was sitting that way, and the resident stated, I asked for help, but they wont help me. ST Staff #125 asked if she knows where she should be, and the resident confirmed that she should be straight up in the bed. ST Staff #125 asked Resident #6 what CNA was working with her, and the resident stated, I don't remember her name but it is someone who works with me a lot. ST Staff #125 stated that she discharged her from her service last week, or the week before and she used to come in before meals to help get her positioned with help from a CN[NAME] She stated that she has done education many times with Resident #6, and she knows where she should be positioned. ST Staff #125 walked down the hall to find the CNA that was working with her and found CNA Staff #34. ST Staff #125 asked CNA #34 if she had helped the resident position herself, and CNA #34 confirmed that she helped her with her tray and raised the head of her bed. CNA #34 then stated that the nurses came in later to reposition her. ST Staff #125 asked CNA #34 if she understands how she should be positioned, and she confirmed that she did. On 04/11/17 1:28 PM during an interview with LPN Staff #38, when asked how Resident #6 is supposed to be positioned when eating, she responded She should be on her back, but she has an area on her bottom, so she has to be on her side. We try to get her straight up on her back, but she turns every two hours. When we do pull her up, she slides back down in the bed. When asked if Resident #6 will let staff know if she needs readjusted, she confirmed that she will. When asked if Resident #6 will get up in a chair, she stated, Yes, she will get up for therapy for a little while, and she wants right back in the bed. If she needs anything, she will let you know. On 04/11/17, in the evening, the most current and complete care plan for Resident #6 was requested from Corporate Nurse Staff # 134. It was received in the morning of 04/11/17 with no indication of a swallowing or positioning care plan. 2. Record review for Resident # 77 revealed she was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. The resident was noted to be receiving Risperidol 2 milligrams two times a day for [MEDICAL CONDITION]. Review of the Most recent Minimum Data Set ((MDS) dated [DATE] documented the resident was receiving an anti-psychotic medication 7 days a week. Review of the current care plan revealed the care plan was silent to the use of the anti-psychotic medication. There were no individual person centered care plan goals or interventions noted regarding the use of the anti-psychotic medication or any behaviors the resident exhibits in regards to the use of this anti-psychotic medication. Interview with the MDS nurse #99 on 4/11/2017 at 1:30 PM verified there was not a current comprehensive care plan in place to address Resident #77s [MEDICAL CONDITION] diagnosis, her use of anti-psychotic medications or current goals and interventions to direct her care in regards to the anti-psychotic medication. On 04/11/17 at 2:10 PM, Corporate Nurse Staff #134, Regulation Specialist Staff #135, and Director of Nursing Staff #136 were notified that Immediate Jeopardy (IJ) began on 04/11/17 at 12:47 PM when Resident #6 was observed lying slouched down in her bed on her right side and began choking while feeding herself lunch after repeated requests from the resident to be placed in a position so she could feed herself safely. The facility's Allegation of Compliance (A[NAME]) was received on 04/11/17 at 6:22 PM. The A[NAME] included: 1. Affected resident has been assessed by Speech Therapy and staff educated on proper positioning during meals. 2. Education provided to floor staff regarding proper positioning of residents who eat in bed by speech therapy and nursing management prior to dinner meal on 04/11/17. 3. DON (Director of Nursing) or designee to visually check on residents during meal times to ensure proper positioning in bed at each meal x 7 days. 4. Speech Therapy will screen residents noted to have any difficulties with swallowing as reported by nursing on therapy referral form. 5. Residents noted for speech therapy screen will be reviewed in Q[NAME] (Quality of Care) meeting weekly beginning immediately. 6. Speech therapy to provide DON with copy of recommendations for processing to current orders or Kardex. 7. Staff that did not attend initial education on 04/11/17 will be educated on proper positioning and aspiration precautions before working the floor. The survey team completed record review and interview to ensure the facility had implemented their A[NAME]. The Immediate Jeopardy at F279 was removed on 4/13/2017, but the citation remained at a lowered scope and severity of D.",2020-09-01
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 headboard or footboard. In an interview on 04/12/17 at 9:15 a.m., MDS Coordinator Staff #99 stated the Falls care plan should have been updated to accurately reflect the current interventions in place.",2020-09-01
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 the nurse did not assess the resident at any time, from the time they first reported the resident's noisy breathing until the code was called and CPR started. 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's Allegation of Compliance (A[NAME]) to address failure to assess and treat respiratory issues was submitted [DATE] to the surveyor and included the following: 1) Affected resident was transported to the hospital via 911 for evaluation and expired at the hospital. 2) Allegation of neglect was reported to the State Agency as required. 3) RN involved was suspended, terminated and reported to the SC Board of Nursing. 4) DON and Unit Managers to provide education on [DATE] to all nurses and Certified Nursing Assistants on neglect, oral suctioning procedure, location of suctioning equipment, recognizing change in condition and performing respiratory assessment. Inservice is mandatory and no one will be allowed to work until education is completed. 5) All resident's orders were audited by Nurse Management staff for identification of orders for advanced respiratory care/oxygen/suction. Findings were 2 residents in house with orders for continuous oxygen, 2 residents in house with orders for PRN (as necessary) oxygen and no residents in house with suction orders. 6) All respiratory care plans for affected residents have been reviewed and revised if needed on [DATE]. 7) Residents that have the potential for advanced respiratory care have been re-assessed for the need for suction on [DATE]. 8) Maintenance Director and Nursing verified that all 8 suction machines in the facility were functioning properly and central supply clerk verified that suction supplies are readily available on [DATE]. 9) A root cause analysis determined the nurse failed to respond to a change in condition of a resident and failed to respond appropriately to assess and treat. Equipment was available and functioning at the time of the incident. All staff including any new hires have been re-educated on neglect, respiratory assessment, equipment to use and location of equipment and recognizing change in condition. 10) The designated staff and DON will verify location of suction machines daily and nurses will check weekly their functionality. 11) This A[NAME] has been reviewed in an ad hoc QAPI meeting with the Medical Director's involvement and will be reviewed monthly at the QAPI meetings. The Immediate Jeopardy citations at F223, F281 and F328 were removed on [DATE] after observations and interviews were completed to ensure the A[NAME] was in place and in practice. These citations remained cited at a lower scope and severity of D.",2020-09-01
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, only a screen is appropriate and therapy will not pick them, up but they should be screened right away. When asked who decides when a resident may need a therapy evaluation, she stated, It is a multi-tier decision. I have had nurses, therapists, or other coworkers ask for screenings. When asked if someone contracted, what interventions are normally recommended, or how would the process begin, she stated, Anyone that comes to this facility should be evaluated based on how they will be, here. You go through the same process with everyone. For contractures, you would do passive range of motion and try to find the most appropriate splint, then decide how long they should wear it, then DC (discontinue) the resident from therapy and they go to restorative (nursing). Then it is a nursing decision. When asked who provides the therapy recommendations if a splint is required or passive range of motion, she confirmed that nursing will provide those interventions after the therapy evaluation. When asked if there would be any situation where a resident with contractures would not receive some type of intervention, she stated, pain may be an issue, its situational . On 04/12/17 at 11:46 AM during an interview with Physical Therapy Assistant Staff # 123, when asked if Resident #110 has been evaluated by therapy, he stated, We don't have a full-time OT (occupational therapist), so she is awaiting an eval (evaluation) on Thursday (04/13/17). When asked where this information is documented, he confirmed it should be in her chart . On 04/12/17 at 2:48 PM during an interview with Licensed Practical Nurse #66, when asked if there was anyone that she is taking care of today that receives range of motion from nursing, she stated, No, restorative does that. They (CNA's) may walk them and things like that. The CNA's aren't told to do it (ROM), they do get them up and do ADL's (activities of daily living). Record review 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) . On 04/12/17 at 3:08 PM, during an interview with Restorative Aide Staff #99, when asked if Resident #110 was on restorative services such as range of motion, she confirmed that therapy have not given recommendations for her for any restorative services. 2. Resident # 22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. [MEDICAL CONDITION]. Review of the most recent Minimum (MDS) data set [DATE] revealed she had no swallowing disorder and receives a therapeutic mechanically altered diet. She was noted to require the extensive assistance of two staff members to position her in bed, required eating supervision with oversight and encouragement/cueing and was a set up only with her meals. Review of her current care plan dated 3/1/2017 revealed interventions to include that staff are to assist her with eating, monitor for mastication difficulties, monitor her intake for safe swallowing and report any problems to the nurse. Review of Nurse Aide flow records for (MONTH) and (MONTH) (YEAR) revealed she requires the extensive assistance from staff to turn in bed. Her record was silent to any speech therapy orders or evaluations. Observation of resident #22 on 4/11/2017 at 5:15 PM revealed she was observed to be served her meal and the nursing assistant elevated the head of her bed but she did not pull the resident up in the bed. Resident #22 remained slouched down in the bed and was in poor position to feed herself when her meal was served. The staff prepared her meal and left her to feed herself while she was still not positioned straight up in the bed as she was still noted to be slouched down in the bed. Resident #22 was observed to feed herself but was noted to struggle getting the food on her spoon and feeding herself without spilling the food on herself. During this observation the Social Service staff #108 walked by the room and observed Resident #22 in her bed positioned poorly and she entered the room and ask the resident why are you laying so far back in the bed trying to feed yourself. She began to reposition the resident and when doing so the resident began to cough/choke on the food that she had in her mouth. The Social Service staff #108 attempted to assist the resident by offering her a drink of water but the resident continued to cough and her eyes began to water and she was not able to speak. The Social Service staff #108 called for the nurse to come the the room and the nurse assessed Resident #22 and she was then able to drink water and she ceased coughing. Nurse #51 and Social Service Staff #108 pulled the resident up in bed and repositioned her in an adequate position so she could feed herself in an upright position and the resident was then able to feed herself her meal with no further concerns. The staff failed to monitor Resident #22 for safe swallowing per her nutrition care plan during her meal on 4/11/2017 at 5:30 PM. She was found by the Social Service Staff #108 to be poorly positioned and experienced a coughing/choking episode while feeding herself in bed. 3. Resident #66 was admitted to the facility on [DATE]. She was noted to have a current [DIAGNOSES REDACTED]. Review of her most recent Minimum (MDS) data set [DATE] revealed she required the extensive assistance of 2 staff for bed mobility and eating. She was noted to have a pressure ulcer to her right heel and had pressure reduction for bed and was receiving pressure ulcer care. Review of her current pressure ulcer care plan dated 10/24/2016 revealed she was at risk for pressure ulcers due to impaired mobility. The current interventions included to avoid shearing, conduct skin assessment per facility protocol, encourage and assist with turning and to report any signs of skin breakdown. On 12/24/2016 new orders were noted for the resident to wear heel protectors at all times and to float her heels. Observations of Resident #66 on 4/11/2017 7:40 AM she was observed to be in bed with heel protectors on but her heels were noted to resting on the bed. On 4/12/2017 at 8:40 AM she was observed to be in bed with heel protectors on but her heels were not being floated per her current orders. Observation again on 4/13/2017 at 8:32 AM revealed Resident #60 was observed in the bed with heel protectors on both her feet but her feet were laying on the bed and not floated per orders. These concern were shared with the Administrative staff on 4/12/17 at 11 AM. The facility failed to implement the care plan interventions for Resident #66 in regards to promoting healing of her current pressure ulcer.",2020-09-01
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 during the following times, the resident was observed positioned on her right side in her bed: 8:25 AM, 8:45 AM, 10:18 AM, 11:02 AM, 12:26 PM, 1:33 PM, 2:30 PM, 3:01 PM, 4:53 PM, and 5:17 PM. On 04/12/17 during the following times, the resident was observed positioned on her right side in her bed: 8:44 AM, 9:18 AM, 10:45 AM, 1:20 PM, and 2:43 PM. On 04/12/17 at 1:22 PM, during an interview with Unit Manager Staff #45, when asked when Resident #60's pressure ulcer was first identified, she stated, It was acquired in-house on 10/4/16. On 04/12/17 at 1:36 PM during an interview with Licensed Practical Nurse #54 while doing wound care for Resident #60 during observation of wound care, when asked if Resident #60 has an air mattress, she confirmed that she does. When asked how often nurses do skin checks, she stated, Once a week, and the CNA's (Certified Nurses Assistant) check their skin once a day. When asked how often the resident goes to the wound clinic, she confirmed that she used to go once a week, but now she goes once every three weeks because the wound is healing. When asked if Resident #60 is ever is disagreeable about getting out of bed, or being moved, she stated, Every once in a while, but not often. On 04/12/17 at 3:53 PM, during an interview with Licensed Practical Nurse Staff # 54, when asked if there is a reason resident #60 is not getting turned, she stated, I was just in the room and helped the CNA (Certified Nurse's Assistant) turn her, and she has an air mattress anyway. When asked if that was the first time that she assisted today with turning R #60, she would not answer the question. When asked why she is not getting out of bed, she stated, I don't know that she isn't getting out of the bed. She has a high-back chair she can get up into. She used to get up everyday, before we (morning shift) came in. She was also going to therapy. She started getting these areas on her butt and started breaking down a lot., When asked if she has pain, she confirmed that she does not appear to be in pain, but she does have Tylenol ordered if she did. 2. Record review of the care plan for Resident #110 dated 3/22/17 revealed, Problem: Pressure Ulcer Resident at risk of pressure ulcer due to friction and shear .Goal: Intact skin without evidence of redness, irritation, maceration, or open areas through next review .Approach: Minimum or 2 people plus draw sheet to lift resident while in bed .Skin assessment and inspection every shift with close attention to heels . On the care plan the following notes were added: 04/08/2017 Open area to right buttock with DWC (wound cleanser). Apply hydrogel and dry dressing BID (twice a day) until healed .4/11/2017 per Nurses note R (right) buttocks measurements are 0.4 cm , width 0.5 cm . Record review of Minimum Data Set (MDS) for Resident #110 dated 03/28/17, revealed, Section G Functional Status indicated that resident is dependent with one person assist with all function, including bed mobility. Section M Skin Conditions revealed that R #110 is at risk for pressure ulcers. On 04/10/17 at 4:00 PM, during a family interview with Resident #110's father, when asked if had any concerns with the care that his daughter receives in the facility, he stated, I do have a concern that she has a gray area on her buttocks now. In the last place that she was, they were turning her often, and she did not have any skin problems, but now she does. I don't feel like they are turning her enough. On 04/11/17 during observations at the following times, the resident was positioned on her back: 8:40 AM, 10:17 AM, 11:03 AM, 12:27 PM, 1:32 PM, 2:29 PM, 3:06 PM, 4:54 PM, and 5:17 PM. On 04/13/17 at 8:10 AM during an interview with Certified Nurse's Assistant (CNA) Staff #116, when asked how she knows if a resident needs specific positioning, she stated, I would look in the Kardex. When asked if there is a place for documenting turning, she confirmed that there is not. When asked how often R #110 was repositioned, she confirmed it was every two hours. When asked if she has any other interventions, she stated, Yes, she has heel protectors. Record review of Resident #110's Kardex with no date, revealed, no indication of positioning. On 04/12/17, in the afternoon during an interview with Corporate Nurse Staff #134, when asked if the facility uses air mattresses, she stated, Only for stage four's (pressure ulcers), we just don't have another option. When asked how turning schedules are relayed to CNA's, she stated, That is a standard of care that we teach . Record review of Performance Improvement Projects (PIPs) dated 2/10/17 revealed, Issues Identified: Facility is over stated average for wounds, wound documentation is not accurate and staging is not correct. Accurate information was not coded correctly on MDS (Minimum Data Set) which lead to QM (Quality Measures) % increasing .Wounds were not being staged correctly and wound sheets were not filled out correctly which lead to inaccurate coding and wound worsening due to improper treatment. Wound measuring not accurate, turn schedule not being performed in timely manner, no assisted devices to heels and other areas of concern .Action #2 Facility wide turn schedule to be implemented. Labs to be obtained and tests to be ordered for other types of wounds, staff education provided on 2/20/17 .Action #4 DON(Director of Nursing)/ADON(Assistant Director of Nursing)/Wound nurse and Unit Managers to monitor for turn schedule, skin sheets, and frequent incontinent care provided to residents . On 04/13/17 at 7:44 AM during an interview with the Administrator Staff #43, when asked if she if familiar with the residents in the facility, she stated, I am not familiar with a lot of them. When asked if the facility has a positioning protocol, she stated, We are working on that. We were going to do a turning and repositioning thing and they got clocks and received the clocks on 3/21 and need to implement the program. When asked if there are alerts for the staff now for positioning, she stated, If the CNA's (Certified Nurse's Assistants) have someone, they turn them. When asked if it is a standard practice that the facility staff turns residents every two hours, she confirmed that it is. When asked if there is a place to document positioning and turning, she stated, am not sure. I know that there are some things that need to get addressed here, I need to get order and time to do it.' 3. Resident #66 was admitted to the facility on [DATE]. Her record revealed she had a current pressure ulcer to her right heel. Review of the residents most recent Minimum (MDS) data set [DATE] revealed she required the extensive assistance of 2 staff for bed mobility. The MDS also reflected documentation of a current pressure ulcer to her right heel and was noted to have a pressure reduction mattress for her bed and was receiving pressure ulcer care. Review of her current pressure ulcer care plan dated 10/24/2016 revealed Resident #66 was at risk for pressure ulcers due to impaired mobility. The current interventions included that staff were to avoid shearing, conduct skin assessment per facility protocol, encourage and assist the resident with turning and to report any signs of skin breakdown. On 12/24/2016 new orders were noted for the resident to wear heel protectors at all times and to float her heels off the bed to promote healing of her pressure ulcer to her right heel. Observations were made of Resident #66 on 4/11/2017 7:40 AM and she was observed to be in bed with heel protectors on but her heels were noted to resting on the bed. On 4/12/2017 at 8:40 AM she was observed to be in bed with heel protectors on but her heels were not being floated per orders. Observation on 4/13/2017 at 8:32 AM revealed Resident #60 was observed in the bed with heel protectors on both her feet but her feet were not floated per current orders. These concerns were shared with the Administrative staff on 4/12/17 at 11 AM. The facility failed to implement the floating of Resident #60's heels to assist in the promotion of healing of her current pressure ulcer to her right heel.",2020-09-01
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 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. On 4/12/17 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 Therapy's 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, only a screen is appropriate and therapy will not pick them, up but they should be screened right away. When asked who decides when a resident may need a therapy evaluation, she stated, It is a multi-tier- decision. I have had nurses, therapists, or other coworkers ask for screenings. When asked if someone contracted, what interventions are normally recommended, or how would the process begin, she stated, Anyone that comes to this facility should be evaluated based on how they will be, here. You go through the same process with everyone. For contractures, you would do passive range of motion and try to find the most appropriate splint, then decide how long they should wear it, then DC (discontinue) the resident from therapy and they go to restorative (nursing). Then it is a nursing decision. When asked who provides the therapy recommendations if a splint is required or passive range of motion, she confirmed that nursing will provide those interventions after the therapy evaluation. When asked if there would be any situation where a resident with contractures would not receive some type of intervention, she stated, pain may be an issue, its situational . On 04/12/17 at 11:46 AM during an interview with Physical Therapy Assistant Staff # 123, when asked if Resident #110 has been evaluated by therapy, the stated, We screened off on her. We don't have a full-time OT (occupational therapist), so she is awaiting an eval (evaluation) on Thursday .When asked where this information is documented, he confirmed it should be in her chart . On 04/12/17 at 2:48 PM during an interview with Licensed Practical Nurse #66, when asked if there was anyone that she is taking care of today that receives range of motion from nursing, she stated, No, restorative does that. They (CNA's) may walk them and things like that. The CNA's aren't told to do it (ROM), they do get them up and do ADL's (activities of daily living). On 04/12/17 at 3:08 PM, during an interview with Restorative Aide Staff #99, when asked if Resident #110 was on restorative services such as range of motion, she confirmed that therapy have not given recommendations for her for any restorative services.",2020-09-01
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 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 revealed, Swallowing functional limitation, current status has been documented based on clinical judgment;pt able to follow safe swallow strategies with min cues to increase upper airway protection. Education provided to pt on importance of sitting upright in 90 degree position for all oral intake . Record review of ST -Therapist Progress & Discharge Summary dated 04/07/17 revealed, .The patient will perform pharyngeal elevation/excursion (specific phases of swallowing) exercise given 30% visual and verbal instruction/cues to increase pharyngeal squeeze to decrease aspiration risk exhibiting mild impairment (25-50% impairment;risk of aspiration on liquids; mild oral residue and may need meats ground or chopped; cueing and intermittent supervision for carry-over . Record review of OT (Occupational Therapy) daily treatment record dated 03/30/17 revealed, OT supervisory visit completed .OT saw pt (patient) in her room initially for using ADL (Activities of Daily Living) training. OT pulled pt up in edge then set up her lunch tray. Pt stayed up to complete her meal with 20% spillage .Pt transition from supine (lying face up) to sit EOB (edge of bed) with max (maximum) A (assist). Pt then taken to rehab gym .to work on arm strength to assist with bed/chair mobility/positioning . Record review of care plan for Nutritional Status for R#6 edited on 11/02/16 with long term goal target date: 4/30/17 revealed, Resident receives CCHA, NAS, Renal Mechanical Soft with ground meats diet .Resident will ave (average) nutritional needs met qd by weight remaining stable within +/- 5% each month through next review period .Monitor for needed assistance with meals and notify nurse and dietary manager .notify nursing staff immediately if resident shows any signs or symptoms of difficulty swallowing . Record review of Nursing Policies and Procedures for Aspiration Precaution Guidelines dated 07/01/16 revealed, Follow protocols/guidelines developed by speech and/or occupational therapists. Remember mealtime strategies should always be individualized. Every precaution should be communicated to all staff. These may include: Position the resident at a 90 degree angle or as upright as possible while eating or taking oral medications; .Avoid positioning the resident in a flat position . Record review of Aspiration Precautions Sheet for Resident #6, with no date revealed, 1. upright in chair for all meals . Record review of Kardex (CNA communication/task sheet) with no date for R #6 revealed, Eating- Independent/Set-up, Activity/Mobility- out of bed/wheelchair/mechanical lift ., no further indication of positioning. On 04/10/17 at 12:57 PM Resident #6 was observed sitting very low in her bed, with the head of the bed raised causing her to to have her chin to her chest. Her tray of food was on the table and she was feeding herself. When asked if she is comfortable like that, she confirmed that she was not. On 04/11/17 at 12:37 PM during an observation, she is slouched in her bed, not at a 90 degree angle and tilted on her right side, and is feeding herself. A Certified Nurses Assistant (CNA) Staff #34 is currently in the room feeding another resident. The same CNA brought her food. Her call light is out of reach hanging on the other side of her bed. On 04/11/17 at 12:37 PM During an interview with the Resident #6, when asked if she still works with therapy, she stated that she does, when asked if she remembers what they tell her when she eats, she stated, yes, they tell me I am supposed to be sitting straight up so the food goes down into my stomach, not like this. On 04/11/17 12:45 PM R#6 began yelling at Certified Nurse's Assistant (CNA) Staff #34, asking several times to put her head up, and CNA Staff #34 continued saying that the bed was all the way up. R#6 asks two more times, and CNA Staff #34 stated that her head is fine. CNA Staff #34 came to the edge of the bed and adjusted her tray, but did not put her head up or help her adjust in the bed. The resident remained in the same position, slouched and turned to the right side of the bed. On 04/11/17 at 12:47 PM during an interview with Resident #6, when asked if she is having trouble swallowing that way, she states,yes, everything is hard sitting like this. Resident #6 begins coughing, and coughed up coleslaw that she was eating. LPN (Licensed Practical Nurse) Staff #12 and LPN Staff #38 were in hall and were asked to come straighten up the resident and check on her. They came in and pulled her up in bed and repositioned her, but not in a 90 degree angle. She remained low in the bed and tilted to the right side. On 04/11/17 at 12:57 PM, during an interview with R#6, when asked if they always put her head up to eat, she stated no. She stated, this is better than when I am laying down, I cant eat like that. On 04/11/17 at 1:03 PM, during an interview with the ST (Speech Therapist) Staff #125 that wrote recommendations for R#6, she was brought to the room to see the positioning for R#6. She was asked if this was the correct positioning for her to eat in, and she verified that it is not. She asked Resident (R)#6 why she was sitting that way, and the resident stated, I asked for help, but they wont help me. ST Staff #125 asked if she knows where she should be, and the resident confirmed that she should be straight up in the bed. ST Staff #125 asked R#6 what Certified Nurse's Assistant (CNA) was working with her, and the resident stated, I don't remember her name but it is someone who works with me a lot. ST Staff #125 stated that she discharged her from her service last week, or the week before and she used to come in before meals to help get her positioned with help from a CN[NAME] She stated that she has done education many times with R#6, and she knows where she should be positioned. ST Staff #125 walked down the hall to find the CNA that was working with her and found CNA Staff #34. ST Staff #125 asked CNA #34 if she had helped the resident position herself, and CNA #34 confirmed that she helped her with her tray and raised the head of her bed. CNA #34 then stated that the nurses came in later to reposition her. ST Staff #125 asked CNA #34 if she understands how she should be positioned, and she confirmed that she did. On 04/11/17 1:28 PM during an interview with Licensed Practical Nurse (LPN) Staff #38, when asked how Resident #6 is supposed to be positioned when eating, she responded She should be on her back, but she has an area on her bottom, so she has to be on her side. We try to get her straight up on her back, but she turns every two hours. When we do pull her up, she slides back down in the bed. When asked if Resident #6 will let staff know if she needs readjusted, she confirmed that she will. When asked if Resident #6 will get up in a chair, she stated, Yes, she will get up for therapy for a little while, and she wants right back in the bed. If she needs anything, she will let you know. On 04/11/17, in the evening, the most current and complete care plan for Resident #6 was requested from Corporate Nurse Staff # 134. It was received in the morning of 04/11/17 with no indication of a swallowing or positioning care plan. 2. During the extended survey process all residents were observed for proper positioning while in the bed feeding them self. During the extended survey observation was made of resident #22 on 4/11/2017 at 5:15 PM and revealed she was observed to be served her meal and the nursing assistant elevated the head of her bed but she did not pull the resident up in the bed. Resident #22 remained slouched down in the bed and was in poor position to feed herself when her meal was served. The staff prepared her meal and left her to feed herself while she was still not positioned straight up in the bed as she was still noted to be slouched down in the bed. Resident #22 was observed to feed herself but was noted to struggle getting the food on her spoon and feeding herself without spilling the food on herself. During this observation the Social Service staff #108 walked by the room and observed Resident #22 in her bed positioned poorly and she entered the room and ask the resident why are you laying so far back in the bed trying to feed yourself. She began to reposition the resident and when doing so the resident began to cough/choke on the food that she had in her mouth. The Social Service staff #108 attempted to assist the resident by offering her a drink of water but the resident continued to cough and her eyes began to water and she was not able to speak. The Social Service staff #108 called for the nurse to come the the room and the nurse assessed Resident #22 and she was then able to drink water and she ceased coughing. Nurse #51 and Social Service Staff #108 pulled the resident up in bed and repositioned her in an adequate position so she could feed herself in an upright position and the resident was then able to feed herself her meal with no further concerns. Record review revealed Resident # 22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent Minimum (MDS) data set [DATE] revealed she had no swallowing disorder and receives a therapeutic mechanically altered diet. She was noted to require the extensive assistance of two staff members to position her in bed, required eating supervision with oversight and encouragement/cueing and was a set up only with her meals. Review of Resident #22's current care plan dated 3/1/2017 revealed interventions to include that staff are to assist her with eating, monitor for mastication difficulties, monitor her intake for safe swallowing and report any problems to the nurse. Review of Nurse Aide flow records for (MONTH) and (MONTH) (YEAR) revealed she requires the extensive assistance from staff to turn in bed. Her record was silent to any speech therapy orders or evaluations. During this same meal observation on 4/11/2017 at 5:15 PM Resident #49 was also observed during the supper meal service. He was observed to be served his meal and nursing assistant #93 elevated the head of his bed but she did not pull the resident up in the bed to position him properly so he could feed himself safely. Resident #49 remained slouched down in the bed and he was leaning the to left against the bed rail. The Nurse Aide Staff #93 prepared his meal and left him to feed himself while he was not positioned straight up in the bed so he could eat without risk of choking and potential aspiration. The Social Service staff #108 walked by Resident 49's room and observed him slouched down in the bed, leaning to the left and attempting to feed himself. She repositioned the resident by pulling him up and over in the bed and placing pillows beside him for positioning so he could feed him self without risk of choking. Record review for Resident #49 revealed he was not on any swallowing precautions and his care plan was silent to any special interventions regarding swallowing. Review of Resident 49's most recent MDS dates 1/17/2017 revealed he required the extensive assistance of staff for bed mobility. When the Social Service Staff #108 repositioned him so he could feed himself safely he was not able to self assist with positioning. Interview with Nurse Aide #93 on 4/11/2017 at 5:30 PM revealed she had been educated by the Speech Therapist when she arrived on shift on this date prior to the evening meal about how to properly position resident while they are eating in bed. She said she was in-serviced to elevate the head of the bed and to use pillows as need to position the resident so they were in a safe position to feed them self. She stated she had never observed Resident #22 or #49 to have any issues feeding themselves in bed and had never observed them to choke. Further interview with Nurse Aide staff #97 and #102 at this time also revealed they had been educated on how to position residents in bed to ensure they are safe to feed themselves in bed to prevent any choking hazards. They both also stated they had never known Resident #22 or #49 to have any issues with feeding themselves while in bed and had not known either of them to choke while feeding themselves in bed. Review of the sign in sheet for the education/in-service provided by the Speech Therapist on 4/11/2017 reveled Nurse Assistant #93. #97,and #102 were all present for the mandatory in-service on safe positioning of resident while eating. Review of the education that was provided to the staff during this mandatory in-service reveled they were educated on assisting residents with feeding and positioning, swallowing precautions and a review was done of swallowing guidelines for the patient and the caregiver. This in-service was to be provided to all staff on shift on 4/11/2017 and to all staff who worked on the days following prior to them providing care until all the staff who assisted residents with meals had been in-serviced. The Corporate Nurse #134 was advised of the observation of Resident #22 being poorly positioned by Nurse Aide Staff #93 on 4/11/2017 at 6 PM. At 6:10 PM she advised this surveyor that she had spoken with Nurse Aide #93 and the Nurse Aide had been suspended due to the poor positioning of Resident #22 during her meal after she had just been inserviced on how to properly position resident for safe eating while in bed. The corporate Nurse #134 verified Resident #22 had not had any previous speech evaluations and had not had any incidence of previous choking or coughing incidents while feeding herself. The staff failed to monitor Resident #22 for safe swallowing per her nutrition care plan and failed to position her in a safe manner in bed so she could eat her meal on 4/11/2017 at 5:30 PM. The staff also failed to position Resident #49 in a position while in bed to promote safety while he was feeding himself in bed. Both residents were found by the Social Service Staff #108 to be poorly positioned and Resident #22 was observed to experience a coughing/choking episode while feeding herself in bed while being poorly positioned. Two additional residents were observed during the meal service on 4/11/2017 as they were identified by the facility as being on swallowing precautions. At 5:05 PM Resident #1 who was identified by the facility as being on swallowing precautions was observed sitting in a wheelchair in the dining room feeding himself. He was observed eating a pureed diet and thick liquids and was observed to have no concerns while feeding himself. Resident #20 was also observed in the dining room in her wheelchair feeding herself and no concerns were noted as she fed herself a mechanical soft diet with chopped meats. 3. During the environmental tour observations were made of the handrails in the hallway on all 4 units that were noted to have rough and splintered areas along the edges and along the lengths of the handrails. The Maintenance Director who was present during this tour verified the splintered areas on the handrails and indicated he had repaired some of them in the past with wood putty but verified there were still many areas that still needed to be repaired. He advised this surveyor that they need to replace all of the handrails but the building is in the process of being sold and he has not been given any funds to do any repairs in the building in a very long time so he does the best he can do. He stated all he can do at this time is to put blue tape on all of the splintered areas until he is given funds to do repairs. On 04/11/17 at 2:10 PM, Corporate Nurse Staff #134, Regulation Specialist Staff #135, and Director of Nursing Staff #136 were notified that Immediate Jeopardy (IJ) began on 04/11/17 at 12:47 PM when Resident #6 was observed lying slouched down in her bed on her right side and began choking while feeding herself lunch after repeated requests from the resident to be placed in a position so she could feed herself safely. The facility's Allegation of Compliance (A[NAME]) was received on 04/11/17 at 6:22 PM. The A[NAME] included: 1. Affected resident has been assessed by Speech Therapy and staff educated on proper positioning during meals. 2. Education provided to floor staff regarding proper positioning of residents who eat in bed by speech therapy and nursing management prior to dinner meal on 04/11/17. 3. DON (Director of Nursing) or designee to visually check on residents during meal times to ensure proper positioning in bed at each meal x 7 days. 4. Speech Therapy will screen residents noted to have any difficulties with swallowing as reported by nursing on therapy referral form. 5. Residents noted for speech therapy screen will be reviewed in Q[NAME] (Quality of Care) meeting weekly beginning immediately. 6. Speech therapy to provide DON with copy of recommendations for processing to current orders or Kardex. 7. Staff that did not attend initial education on 04/11/17 will be educated on proper positioning and aspiration precautions before working the floor. The survey team made observations, record review and interview to ensure the facility had implemented their A[NAME]. The Immediate Jeopardy and Substandard Quality of Care at F-323 was removed on 4/13/2017, but the citation remained at a lowered scope and severity of D.",2020-09-01
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's Allegation of Compliance (A[NAME]) to address failure to assess and treat respiratory issues was submitted [DATE] to the surveyor and included the following: 1) Affected resident was transported to the hospital via 911 for evaluation and expired at the hospital. 2) Allegation of neglect was reported to the State Agency as required. 3) RN involved was suspended, terminated and reported to the SC Board of Nursing. 4) DON and Unit Managers to provide education on [DATE] to all nurses and Certified Nursing Assistants on neglect, oral suctioning procedure, location of suctioning equipment, recognizing change in condition and performing respiratory assessment. Inservice is mandatory and no one will be allowed to work until education is completed. 5) All resident's orders were audited by Nurse Management staff for identification of orders for advanced respiratory care/oxygen/suction. Findings were 2 residents in house with orders for continuous oxygen, 2 residents in house with orders for PRN (as necessary) oxygen and no residents in house with suction orders. 6) All respiratory care plans for affected residents have been reviewed and revised if needed on [DATE]. 7) Residents that have the potential for advanced respiratory care have been re-assessed for the need for suction on [DATE]. 8) Maintenance Director and Nursing verified that all 8 suction machines in the facility were functioning properly and central supply clerk verified that suction supplies are readily available on [DATE]. 9) A root cause analysis determined the nurse failed to respond to a change in condition of a resident and failed to respond appropriately to assess and treat. Equipment was available and functioning at the time of the incident. All staff including any new hires have been re-educated on neglect, respiratory assessment, equipment to use and location of equipment and recognizing change in condition. 10) The designated staff and DON will verify location of suction machines daily and nurses will check weekly their functionality. 11) This A[NAME] has been reviewed in an ad hoc QAPI meeting with the Medical Director's involvement and will be reviewed monthly at the QAPI meetings. The Immediate Jeopardy citations at F223, F281 and F328 were removed on [DATE] after observations and interviews were completed to ensure the A[NAME] was in place and in practice. These citations remained cited at a lower scope and severity of D.",2020-09-01
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 medication. Entries on both 04/10/17 at 11:00 p.m. and 04/11/17 at 11:00 p.m. revealed the resident was administered prn pain medication and prn [MEDICATION NAME] at the same time, without mention of NDIs and without consideration that if the pain was treated perhaps the anxiety would also be managed without medication. In an interview on 04/12/17 at 2:11 p.m., Licensed Nurse #70 reviewed the MAR. She stated she could not determine if the prn [MEDICATION NAME] was administered 12 or 13 times due to the handwriting, Maybe twice on 04/07/17, not sure. She looked at the back of the MAR and commented, Oh, they aren't writing it on the back. She acknowledged there was no behavior monitoring form. 2. Review of physician's orders [REDACTED]. The listed [DIAGNOSES REDACTED]. According to the (YEAR) Nursing Drug Handbook, [MEDICATION NAME] is used to treat [MEDICAL CONDITION] and [MEDICAL CONDITION] disorder. Behaviors is not a recognized [DIAGNOSES REDACTED].",2020-09-01
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,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,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 observations of a lack of handwashing / glove change when preparing / touching food items and potentially contaminated objects during lunch meal preparation on 04/12/17 were discussed with Dietary Manager #114 and Corporate Regulatory Specialist #135 on 04/12/17 at 4:20 p.m. Both expressed an understanding of these issues.",2020-09-01
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 see the residents. In an interview on 04/12/17 at 8:14 a.m., Social Services Staff #27 was asked if Resident #34 had been seen by a dentist, or offered and refused, since admission in 2013. She stated she was not sure if that had occurred and that she would check. As of 04/13/17 at 11:00 a.m., no further information was provided. 2. Observation on 04/10/17 at 11:49 a.m. revealed Resident #23 appeared to have some missing and broken teeth. He had white debris / build-up along his lower gum. The resident was unable to respond to any questions due to cognitive loss. Record Review, conducted on 04/11/17 at 8:30 a.m., revealed the resident admitted to the facility 09/16/15. A Nursing Data Collection Form, dated 03/15/17, identified the resident was missing some teeth. A Dietary Data Collection / Evaluation Nutritional form, dated 09/15/16, revealed the resident had his own teeth, condition / missing. Social Service Progress Reviews, dated 03/15/17, 12/13/16, 09/15/16 and 06/16/16 all indicated Dental care: Provided by facility. Review on 04/12/17 at 5:39 p.m. of the 09/15/16 Annual Minimum Data Set assessment identified the resident had Obvious or likely cavity or broken natural teeth. The associated Care Area Assessment identified the Resident has several missing teeth and very poor dentition. It indicated see care plan. The Care Plan, reviewed on 04/11/17 at 2:53 p.m. identified the resident was At risk for mouth or facial pain related to decaying (cavity) and/or broken natural teeth. One of the identified approaches was for staff to Consult with dentist and follow recommendations. In an interview on 04/12/17 at 8:14 a.m. Social Service Staff #27 was asked if Resident #23 had been seen by a dentist, or offered and refused, since admission. She was unable to provide any evidence the resident was seen or dental services were offered and refused.",2020-09-01
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,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 produce any documentation to address how they were correcting the care plan concerns identified back in (MONTH) (YEAR). She stated they currently have an Interim Director of Nursing and she is not able to produce a lot of the documentation and monitoring being requested because she is not sure where the previous DON has put things. She stated the previous DON left the faciity on in (MONTH) (YEAR). The Administrator later provided this surveyor with a copy of a Performance Improvement Plan (PIP) for Pressure ulcers dated 2/10/2017. This document revealed the facility had identified a concern with wounds not being staged correctly, residents not being turned timely, wound sheets not being filled out correctly and wound measurements not being done correctly. The action plan indicated the facility would hire a new wound nurse, they would establish a facility wide turn schedule, staff education would be provided on wounds and the Director of Nursing/Wound Care Nurse and Unit Managers were to monitor for turn schedules, skin sheets and frequent incontinence care to residents. The facility was not able to produce any education that had been provided to the staff, nor documentation on any monitoring conducted as stated on the action plan and they did not currently have a wound nurse. The Administrator was not able to produce any further meeting minutes from this PIP to address the progress of the corrective action in this area. Refer to F314. In the area of Dental services that Resident Council meeting minutes had identified in January, (MONTH) and (MONTH) (YEAR) the residents complained about the lack of dental services and several residents were requesting to be able to see the dentist. The Administrator was not aware of this concern and the Quality Assurance team had not addressed the ongoing lack of dental services for residents in the facility. Refer to F244 and F312. In the area of Housekeeping and Maintenance she verified there was not plan in place to address any of the observed findings identified during the survey from 4/10/2017 through 4/13/2017. Refer to F253. She also verified the lack of Registered Nurse coverage and stated this had not been addressed through their current Quality Assurance process. Refer to F354. On 04/11/17 at 2:10 PM, Corporate Nurse Staff #134, Regulation Specialist Staff #135, and Director of Nursing Staff #136 were notified that Immediate Jeopardy (IJ) began on 04/11/17 at 12:47 PM when Resident #6 was observed lying slouched down in her bed on her right side and began choking while feeding herself lunch after repeated requests from the resident to be placed in a position so she could feed herself safely. The facility's Allegation of Compliance (A[NAME]) was received on 04/11/17 at 6:22 PM. The A[NAME] included: 1. Affected resident has been assessed by Speech Therapy and staff educated on proper positioning during meals. 2. Education provided to floor staff regarding proper positioning of residents who eat in bed by speech therapy and nursing management prior to dinner meal on 04/11/17. 3. DON (Director of Nursing) or designee to visually check on residents during meal times to ensure proper positioning in bed at each meal x 7 days. 4. Speech Therapy will screen residents noted to have any difficulties with swallowing as reported by nursing on therapy referral form. 5. Residents noted for speech therapy screen will be reviewed in Q[NAME] (Quality of Care) meeting weekly beginning immediately. 6. Speech therapy to provide DON with copy of recommendations for processing to current orders or Kardex. 7. Staff that did not attend initial education on 04/11/17 will be educated on proper positioning and aspiration precautions before working the floor. The survey team made observations, record review and interview to ensure the facility had implemented their A[NAME]. The Immediate Jeopardy at F520 was removed on 4/13/2017, but the citation remained at a lowered scope and severity of F.",2020-09-01
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,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,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,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,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 hung low and eyes closed. The resident was not provided any stimulating activities during this time. On 12/20/19 at 2:00 PM, the resident was observed asleep in her wheelchair in her room. The lights were off, and the room was dark. There were no meaningful activities being provided to the resident. On 12/20/19 at 2:00 PM, an activity of exercise occurred. At 2:30 PM, residents were putting puzzles together, and at 3:30 PM music was provided. All activities were in the main dining room. Resident #15 remained in her room, with the lights off and was not offered to attend and/or taken to the activities in the main dining room. There were no meaningful activities being provided to the resident. On 12/21/19 from 8:51 AM to 12:00 PM, the resident was observed in her room in her wheelchair. She sat at an overbed table at the foot of her roommate's bed. There were no activities in the room being provided and the resident was not taken to the morning activities of Christmas Movies/Arts and Crafts at 10:30 AM in the main dining room. On 12/21/19 at 1:10 PM, the Activity Director (AD) and Assistant Activity Director (AAD) were interviewed regarding Resident #15. They both agreed it was the activity department's responsibility to make sure the residents were provided a meaningful program of activities. They stated the residents were logged in on an attendance record for group activities and a separate sheet for one-on-one activities. They indicated Resident #15 was quiet and liked to listen to Gospel music and attend religious activities to hear about the Bible. They both stated the resident was dependent on staff to tell them when the activities were going on and required assistance to get to and from the activities. The AD and AAD stated they needed to monitor the residents better to make sure they are coming to activities and provide them with one-on-one activities of their likings. On 12/21/19 at 3:01 PM, Certified Nurse Aide #135 stated it was all the staff's responsibility to make sure residents were aware of and taken to activities. She then stated residents that do not go to group activities should have room visits or one-on-one activities provided. She stated Resident #15 enjoyed television and music, but there was nothing in the room to provide them. She then stated the resident did not always like to go to group activities. She then acknowledged the resident did not attend and was not taken to any activities on the previous day or during the morning of 12/21/19. She stated the resident had not been provided much for activities and more should be provided. 2. Resident #21 had [DIAGNOSES REDACTED]. A quarterly (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. The current physician's orders [REDACTED].activities as tolerated . An activity progress note, dated 10/05/19, documented, .She attends group activities also gets activities in AB hall lobby . This was the last documented activity progress note in the clinical record. The resident's care plan, last updated 11/13/19, documented, Problem .is receiving hospice services .she continues to attend our activities 1-2x's a week. She prefers to watch tv/movies/news, attending spiritual socials and food related events. She is able to make her simple needs and wants yes and no question .Interventions encourage to become involved with activities out of their room [ROOM NUMBER]x's a week or offer entertainment in their room . On 12/20/19 at 9:45 AM, the resident was observed up in her geri-chair in the common area of the AB hall. The resident was facing a white wall, away from the television that was on. On 12/20/19 from 9:45 AM to 12:05 PM, the resident was observed in the common area facing away from the television at a white wall. There were no meaningful activities for the resident, and she was observed with her eyes closed while in the room. On 12/20/19 at 12:05 PM, the resident was taken to her room, provided care and then taken back out and placed across from the nurses' station. The resident was not taken to the morning activities. 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 and/or taking her to the activity. On 12/21/19 from 8:51 AM to 12:00 PM, the resident was observed in her room in bed. There were no activities being provided in the room. A roommate's television was on, but it was behind the center privacy curtain at the resident's head of the bed and Resident #21 could not see it from her bed. The resident was not taken to the morning activities of Christmas Movies/Arts and Crafts at 10:30 AM in the main dining room. On 12/21/19 at 1:10 PM, the Activity Director and Assistant Activity Director were interviewed regarding Resident #21. They indicated it was the activity department's responsibility to make sure residents were provided with a meaningful activity program. They stated the residents are logged in on an attendance record for group activities and a separate sheet for one-on-one activities. The AD and AAD indicated Resident #21 liked to listen to music, reading and religious activities. They also indicated the resident enjoyed watching television and listening to music relaxed her. They stated the resident was totally dependent on staff to assist with and provide activities. They both stated they needed to monitor the residents better to make sure they are coming to activities and provide them with one-on-one activities of their likings. On 12/21/19 at 3:01 PM, Certified Nurse Aide (CNA) #135 stated it was all the staff's responsibility to make sure residents were aware of and taken to activities. She then stated residents that do not go to group activities should have room visits or one-on-one activities provided. CNA #135 stated Resident #21 enjoyed television, music and conversations with others. She then acknowledged the resident did not attend and was not taken to any activities on the previous day or during the morning of 12/21/19. She stated the resident had not been provided much for activities and more should be provided.",2020-09-01
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 practitioner and an x-ray of the right leg was ordered. There were no Nurse's Progress Notes between 9/29/17 and 10/18/17 at 9:50 AM. Review of Resident #1's Physician's Progress Note dated 10/19/17 revealed the resident was seen for right leg pain and swelling. The note indicated the other day the resident began to experience swelling and pain in the right lower extremity. They were unable to determine any specific traumatic event or problem which occurred. Unfortunately due to the resident's dementia, s/he could not provide any reliable history. Review of Resident #1's Quarterly Minimum (MDS) data set [DATE] revealed the resident's Brief Interview for Mental Status score was 7, which indicated the resident was non-interviewable. The surveyor requested a copy of the facility's complete investigation into the injury of unknown origin. Review of the facility's investigation revealed there was no statement from the nurse assigned to Resident #1 on the 7:00 PM - 7:00 AM shift on 10/17/17 and 10/18/17. There was also no statement from the nurse assigned to the resident on the 7:00 PM - 7:00 AM shift on 10/15/17 or the nurse assigned to the resident on 7:00 AM-7:00 PM shift on 10/16/17. There were also no statements from the CNAs that were assigned to Resident #1 on 10/15/17 on the 7:00 AM -7:00 PM shift and the 7:00 PM-7:00 AM shift. There was no statement from the CNA that was assigned to Resident #1 on 10/16/17 on the 7:00 AM- 7:00 PM shift. There was no statement from the CNA that was assigned to the resident on 10/17/17 on the 7:00 AM-7:00 PM shift. There was no statement from the CNA that was assigned to Resident #1 on 10/18/17 on the 7:00 AM - 7:00 PM shift. CNA #1's facility-obtained statement dated 10/19/17 revealed on Tuesday night (10/17/17) on the 7:00 PM- 7:00 AM shift s/he put Resident #1 to bed., pivot to stand. Resident #1 was able to stand and was transferred to bed with no complaints of pain. CNA #1 immediately called LPN (Licensed Practical Nurse) #1 to the room to assure the resident that s/he was on the bed and not on the floor. LPN #1 came in and assured Resident #1 that everything was okay and that s/he was on the bed. LPN #1's facility-obtained statement dated 10/19/17 indicated s/he was called to Resident #1's room by CNA #1 on 10/17/17. The CNA stated Resident #1 was really confused and kept asking the CNA to get him/her out of the floor but the resident was in the bed. LPN #1 walked over to the resident and told him/her that s/he was in the bed and not in the floor. Resident #1 stated No I am not, I am in the floor. The resident was redirected that s/he was in bed and not on the floor. In an interview with the surveyor on 1/23/18 at approximately 12:05 PM, the DON (Director of Nursing) stated s/he completed the investigation into Resident #1's injury of unknown origin. The DON stated for an injury of unknown injury, they interview everyone who worked with the resident for 24-48 hours prior to the identification of the injury. That would include nurse aides, nurses, and anyone else who may have been involved with the resident. The DON confirmed the investigation did not include statements from all staff who worked with Resident #1 prior to the identification of the injury. In a telephone interview with the surveyor on 1/23/18 at approximately 12:45 PM, CNA #1 confirmed s/he transferred Resident #1 as a stand and pivot per his/her statement. CNA #1 stated Resident #1 was a one person assist, which means s/he was a stand and pivot transfer. CNA #1 stated that was the information on Resident #1's CNA information sheet. CNA #1 stated the paperwork in Resident #1's room and in the PCR (patient care record) book both said one person assist and not sit to stand lift. In an interview with the surveyor on 1/23/18 at approximately 12:55 PM, the DON stated s/he talked with CNA #1 and s/he said s/he used a lift and pivoted the resident. The DON did not have CNA #1 clarify his/her statement related to how Resident #1 was transferred or make a note that they talked with CNA #1 to clarify the statement related to him/her pivoting the resident.",2020-09-01
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 swollen, discolored area to the right lower leg (shin area). Called the physician and reported with 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 x-ray. The nurse called the nurse practitioner and left a message. The Nurse's Progress Note dated 10/18/17 at 6:00 PM indicated received a call back from the nurse practitioner and an x-ray of the right leg was ordered. CNA #1's facility-obtained statement dated 10/19/17 revealed on Tuesday night (10/17/17) on the 7:00 PM- 7:00 AM shift s/he put Resident #1 to bed., pivot to stand. Resident #1 was able to stand and was transferred to bed with no complaints of pain. CNA #1 immediately called LPN #1 to the room to assure the resident that s/he was on the bed and not on the floor. LPN (Licensed Practical Nurse) #1 came in and assured Resident #1 that everything was okay and that s/he was on the bed. LPN #1's facility-obtained statement dated 10/19/17 indicated s/he was called to Resident #1's room by CNA #1 on 10/17/17. The CNA stated Resident #1 was really confused and keeps asking the CNA to get him/her out of the floor but the resident was in the bed. LPN #1 walked over to the resident and told him/her that s/he was in the bed and not in the floor. Resident #1 stated No I am not I am in the floor. The resident was redirected that s/he was in bed and not the floor. In an interview with the surveyor on 1/23/18 at approximately 11:50 AM, CNA #3 stated s/he had worked at the facility almost 3 years. CNA #3 stated residents' transfer status is on a care plan sheet in the resident's closet and also the PCR (patient care record) book. It's the same information, they have it in two places. CNA #3 reviewed the Nurse Aide information sheet for Resident #1 and stated s/he would not use a lift for the resident because it was not indicated on the form. In an interview with the surveyor on 1/23/18 at approximately 11:55 AM, CNA #4 stated s/he had worked at the facility almost 6 months. CNA #4 stated residents' transfer status is on a care plan sheet in the resident's closet and also the PCR book. CNA #4 reviewed the Nurse Aide information sheet for Resident #1 and stated s/he would not use a lift for the resident because it was not indicated on the form. In an interview with the surveyor on 1/23/18 at approximately 12:05 PM, the DON (Director of Nursing) stated the CNAs look at the Nurse Aide Information sheet which is in the PCR book and the wall locker in the resident's rooms. The DON confirmed Resident #1's Nurse Aide Information sheet indicated two assist, but did not have information that the resident required a lift for transfers. The DON stated Resident #1 had been back and forth between the sit to stand lift and the total lift. Resident #1 required a sit to stand lift at the time the fracture was identified. The DON stated the nurses and the unit coordinator (RN (Registered Nurse) supervisor) are responsible for updating the care plan when there are changes in care. If the care plan says mechanical lift it is a generic term, it could be different types of lifts. They have sit to stand, hoyer, and a steady lifts that will go all the way to the floor to pick residents up. The DON stated it should be on the CNA Information Sheet what type of lift is required.",2020-09-01
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 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 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 practitioner and an x-ray of the right leg was ordered. There were no Nurse's Progress Notes between 9/29/17 and 10/18/17 at 9:50 AM. Review of Resident #1's Physician's Progress Note dated 10/19/17 revealed the resident was seen for right leg pain and swelling. The note indicated the other day the resident began to experience swelling and pain in the right lower extremity. They were unable to determine any specific traumatic event or problem which occurred. Unfortunately due to the resident's dementia, s/he could not provide any reliable history. Review of Resident #1's Quarterly Minimum (MDS) data set [DATE] revealed the resident's Brief Interview for Mental Status score was 7, which indicated the resident was non-interviewable. CNA #1's facility-obtained statement dated 10/19/17 revealed on Tuesday night (10/17/17) on the 7:00 PM- 7:00 AM shift s/he put Resident #1 to bed., pivot to stand. Resident #1 was able to stand and was transferred to bed with no complaints of pain. CNA #1 immediately called LPN (Licensed Practical Nurse) #1 to the room to assure the resident that s/he was on the bed and not on the floor. LPN #1 came in and assured Resident #1 that everything was okay and that s/he was on the bed. LPN #1's facility-obtained statement dated 10/19/17 indicated s/he was called to Resident #1's room by CNA #1 on 10/17/17. The CNA stated Resident #1 was really confused and kept asking the CNA to get him/her out of the floor but the resident was in the bed. LPN #1 walked over to the resident and told him/her that s/he was in the bed and not in the floor. Resident #1 stated No I am not, I am in the floor. The resident was redirected that s/he was in bed and not on the floor. In an interview with the surveyor on 1/23/18 at approximately 11:50 AM, CNA #3 stated s/he had worked at the facility almost 3 years. CNA #3 stated residents' transfer status is on a care plan sheet in the resident's closet and also the PCR (patient care record) book. It's the same information, they have it in two places. CNA #3 reviewed the Nurse Aide information sheet for Resident #1 and stated s/he would not use a lift for the resident because it was not indicated on the form. In an interview with the surveyor on 1/23/18 at approximately 11:55 AM, CNA #4 stated s/he had worked at the facility almost 6 months. CNA #4 stated residents' transfer status is on a care plan sheet in the resident's closet and also the PCR book. CNA #4 reviewed the Nurse Aide information sheet for Resident #1 and stated s/he would not use a lift for the resident because it was not indicated on the form. In an interview with the surveyor on 1/23/18 at approximately 12:05 PM, the DON (Director of Nursing) stated the CNAs look at the Nurse Aide Information sheet which is in the PCR book and the wall locker in the resident's rooms. The DON confirmed Resident #1's Nurse Aide Information sheet indicated two assist, but did not have information that the resident required a lift for transfers. The DON stated Resident #1 had been back and forth between the sit to stand lift and the total lift. Resident #1 required a sit to stand lift at the time the fracture was identified. The DON stated the nurses and the unit coordinator (RN (Registered Nurse) supervisor) are responsible for updating the care plan when there are changes in care. If the care plan says mechanical lift it is a generic term, it could be different types of lifts. They have sit to stand, hoyer, and a steady lifts that will go all the way to the floor to pick residents up. The DON stated it should be on the CNA Information Sheet what type of lift is required. In a telephone interview with the surveyor on 1/23/18 at approximately 12:45 PM, CNA #1 confirmed s/he transferred Resident #1 as a stand and pivot per his/her statement. CNA #1 stated Resident #1 was a one person assist, which means s/he was a stand and pivot transfer. CNA #1 stated that was the information on Resident #1's CNA information sheet. CNA #1 stated the paperwork in Resident #1's room and in the PCR book both said one person assist and not sit to stand lift.",2020-09-01
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,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,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 interview with MDS Nurse #1 on 5/11/17 at approximately 10:18 AM, s/he verified that the Admission Comprehensive MDS with ARD of 4/25/17 did not accurately reflect the skilled ST and PT services that Resident #26 received during the assessment period. MDS Nurse #1 further verified that the coding for section O items 0400A, 0400C and O0420 were all incorrectly coded and additionally reported that s/he only counted therapy if a resident was receiving skilled therapy services for short term rehabilitation (rehab) under Medicare Part A. MDS Nurse #2 was present during interview and supported this statement by further verifying that both MDS Nurses have historically only code skilled therapy services for those residents identified as short term rehab or Medicare A.",2020-09-01
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,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,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, MD #1 initiated an order to decrease the ziprasidone from 20 mg twice daily to 20 mg once daily to begin on 5/11/17. The facility admitted Resident #31 with [DIAGNOSES REDACTED]. Review of Resident #31's record on 5-10-17 at 4:07 p.m. revealed that a repeated pharmacy recommendation from 2-23-17 stated to add an appropriate [DIAGNOSES REDACTED]. The physician indicated to discontinue the medication and signed the pharmacy recommendation on 4-20-17. The order to discontinue the medication was not written until 4-25-17, as evidenced by the 'Physicians Order Form'. The initial pharmacy recommendation was signed by the physician on 3-1-17 but did not indicate a response from the physician regarding the recommendation. Review of the resident's Medication Administration Record [REDACTED]. The records were reviewed by the Director of Nursing DON on 5-11-17 at 12:28 p.m. and confirmed that an order should have been written and the ordered should have been discontinued prior to 4-25-17.",2020-09-01
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,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,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 degrees Fahrenheit with a minimum holding time at the specified temperature for 15 seconds and a maximum time of 2 hours. The policy also states cold food items must maintain a temperature of 41 degrees Fahrenheit and below for safe consuming.",2020-09-01
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,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 been discarded 28 days after opening. The LPN also confirmed the resident received 5 doses of Novolog after day 28. 05/10/2017 3:03:38 PM, review of the Unit 1 medication room revealed 1 open bottle of Vitamin B-1 100 mg that expired 01/17. The finding was confirmed by LPN #2.",2020-09-01
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 ordered stat. The Nurses' Progress Note dated 8/3/17 at 6:40 PM indicated the nurse practitioner was notified of the x-ray results and a new order was received to send the resident to the emergency room for evaluation and treatment related to complaints of pain. There was no documentation that the physician was notified of Resident #3's complaints of pain on 8/1/17 or 8/2/17. Review of Resident #1's (MONTH) Medication Administration Record [REDACTED]. The resident did not receive the as needed medication any other time during the month of August. Resident #1 received scheduled Tylenol 2 tablets (650 mg) three times daily for pain at 8:00 AM, 4:00 PM, and 8:00 PM. Review of the physician progress notes [REDACTED]. Apparently the other day during the transfer his knee with some way twisted. The exact mechanism of action was unknown, and from conversation with the facility staff history does not seem to be consistent with another. The physician ordered an x-ray. The note was signed 8/3/17 at 4:24 PM. Review of the Mobilex Radiology Report dated 8/3/17 revealed the conclusion was noted as possible non-displaced fracture through the medial femoral condyle. Resident #1 was sent out to the hospital and noted to have a fracture. Review of Resident #3's medical record revealed the Nurse's Progress Note dated 6/19/17 at 9:55 AM indicated the nurse practitioner rounded and new orders were written for hospice to evaluate and treat the resident related to [MEDICAL CONDITION]. On 6/19/17 at 2:00 PM the Nurse's Note indicated Resident #3 had two bowel movements that were black, sticky and had blood clots in them. Resident resting in bed. On 6/19/17 at 6:00 PM the Nurses' Note indicated the resident was in bed with black blood and clots pouring out from rectum as quick as it can be wiped up. Still alert and awake at present. Review of the Nurses' Note dated 6/19/17 at 8:00 PM revealed the resident was constantly trying to get out of bed. Staff redirected resident with ease after attempt #4. Notified supervisor of actions. Supervisor reported to nurse practitioner who gave order for [MEDICATION NAME] 0.5 mg every 6 hours as needed related to agitation. Resident is alert with confusion. Black tarry blood still noted coming out of rectum. Review of the resident's Nurses' Notes from 6/1/17-6/19/17 revealed no prior documentation related to the resident having blood and clots coming from rectum. There was no documentation that the physician was notified related to the resident's change in condition. Review of Resident #3's medical record revealed the resident was admitted to hospice on 6/21/17. In an interview with the surveyor on 8/16/17 at approximately 1:10 PM, the Director of Nursing (DON) stated s/he would check on physician notification related to resident with blood clots from the rectum. The DON returned and had no documentation that the physician was notified of Resident #3's change in condition. The DON stated s/he thinks the nurses did not notify the physician because they were waiting on hospice, didn't want to be aggressive.",2020-09-01
101,ELLEN SAGAR NURSING CENTER,425012,1817 JONESVILLE HIGHWAY,UNION,SC,29379,2017-08-16,225,G,1,0,MGP911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, the facility failed to ensure that all alleged violations involving abuse or neglect were reported immediately, but not later than 2 hours after the allegation was made. The facility also failed to have evidence that all alleged violations were thoroughly investigated. Resident #1 was noted to have complaints of pain on 8/1/17 and the allegation of neglect was not reported to the State Agency until 8/3/17. Review of the facility's investigation revealed statements from three staff members, the Registered Nurse (RN) Supervisor on the unit (RN #1), the wound care nurse (RN #3) and Certified Nursing Assistant (CNA) #1. It was noted on the Daily Assignment Sheet for 8/1/17 that CNA #1 was not assigned to Resident #1. There were no statements from the staff assigned to care for the resident on the days surrounding the incident. One of two residents reviewed for reportable incidents. The findings included: The facility reported an allegation of neglect to the State Agency for Resident #1 by CNA #1 on 8/3/17. Review of the facility's Five-Day Follow-Up Report dated 8/8/17 indicated after investigation, Resident #1 was found to have right knee fracture from attempted transfer to wheelchair without lift or two-person assist. The Initial 24-hour Report dated 8/3/17 revealed Resident #1 stated that while being pivoted by CNA #1, the CNA assisted him/her to slide to the floor and at that time his/her right knee popped. Further review of the medical record revealed the Annual Minimum Data Set ((MDS) dated [DATE] coded Resident #1 as having a Brief Interview for Mental Status score of 6. The Quarterly MDS dated [DATE] coded the resident as having a Brief Interview for Mental Status score of 5. The Quarterly MDS coded Resident #1 as totally dependent for transfers. Review of the care plan revealed resident needs moderate to max assistance with ADLs was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included resident transfers with assist of mechanical lift. Review of the Nurses' Progress Notes dated 8/2/17 indicated called to room by CNA to look at resident's leg. Right leg is swollen. States had pain in leg while receiving peri-care. RN supervisor notified who also looked at leg. Resident's socks removed and legs elevated. The previous note was dated 7/21/17 and noted weekly summary and body audit completed. The next note was noted as a late entry for 8/1/17 and indicated resident complained in wheelchair that right knee popped while being transferred to bed. Some slight [MEDICAL CONDITION] noted, daughter present. Daughter stated possible the footrest (missing) may have caused pain and [MEDICAL CONDITION]. Replaced footrest. Reported to nurse to get something for pain and monitor. The note was completed by RN #1. The Nurses' Progress Note dated 8/3/17 at 3:00 AM indicated the resident had complaints of pain and swelling to the right knee and warm to touch. Ice pack applied and elevated. As needed Tylenol given related to pain. On 8/3/17 at 5:00 AM the Nurses' Note indicated Tylenol was effective. Resident states My knee still hurts but feels a lot better since that ice. Ice appears to be effective. Swelling slightly reduced in size and less warm to touch. Resident now resting quietly. At 10:10 AM the note indicated the physician was asked to see the resident related to right knee pain. X-ray and CBC ordered stat. The Nurses' Progress Note dated 8/3/17 at 6:40 PM indicated the nurse practitioner was notified of the x-ray results and a new order was received to send the resident to the emergency room for evaluation and treatment related to complaints of pain. There was no additional documentation related to monitoring the resident for complaints of pain or assessing the resident's knee. Review of Resident #1's (MONTH) Medication Administration Record [REDACTED]. The resident did not receive the as needed medication any other time during the month of August. Resident #1 received scheduled Tylenol 2 tablets (650 mg) three times daily for pain at 8:00 AM, 4:00 PM, and 8:00 PM. Review of the physician progress notes [REDACTED]. Apparently the other day during the transfer his/her knee was some way twisted. The exact mechanism of action was unknown, and from conversation with the facility staff history does not seem to be consistent with another. Resident #1 is a poor historian. The physician ordered an x-ray. The note was signed 8/3/17 at 4:24 PM. Review of the Mobilex Radiology Report dated 8/3/17 revealed the conclusion was noted as possible non-displaced fracture through the medial femoral condyle. Further evaluation with oblique views was recommended. RN #1's facility-obtained statement dated 8/1/17 indicated at approximately 8:40 AM, resident's niece reported that the resident's right leg hurt and that s/he needed his/her foot rest on the wheel chair. RN #1 assessed the resident's right and left legs. Resident stated hurts more with movement, grimaced. Resident also reported it happened while being put to bed. Niece stated she felt like it was because the resident had been up in wheelchair without a foot rest. RN #1 and CNA #1 found the foot rest. CNA #1 replaced them on the wheelchair. RN #1 reported to the primary nurse and asked if resident could get something for pain and to continue to monitor his/her leg. RN #1's facility-obtained statement dated 8/4/17 indicated when s/he arrived to work on 8/3/17 s/he was made aware that Resident #1 was in the hospital with a fracture. It had been reported to another RN that CNA #1 had dropped the resident while transferring without a lift. When CNA #1 was called to the office to investigate the incident, s/he stated s/he never lifted the resident without a lift. CNA #1 did observe the resident in the wheelchair without a foot rest with the resident's leg stuck behind the front wheel and had to lift the chair up and get the resident's leg free. RN #1 explained to CNA #1 that this was considered an incident and should have been reported to the primary nurse. RN #1's facility-obtained statement dated 8/7/17 indicated upon entering Resident #1's room since return from the hospital s/he asked the resident how s/he hurt his/her leg. Resident #1 replied That (boy/girl) holding me up made me slide into the floor. Asked how s/he had picked the resident up and if s/he had used the lift. Resident #1 replied no, s/he had him/her under his/her arms. Resident #1 stated (s/he) picked me up under my arms and put me in the chair. In an interview with the surveyor on 8/15/17 at approximately 2:20 PM, RN #1 stated s/he is the unit manager for Unit 1. RN #1 stated that the resident's niece said his/her leg was hurting out in the lobby. RN #1 went and assessed the resident's leg and it was painful. Resident #1 didn't have petals on his/her wheelchair and his/her niece felt that may be what was causing the resident's leg to hurt. Normally the resident had petals but staff said they couldn't find them that day. RN #1 walked down the hall and found them on another wheelchair. The CNA said they looked like the resident's and the CNA checked and they fit Resident #1's wheelchair. The petals were on an extra wheelchair that was on the hall. Resident #1's knee had slight [MEDICAL CONDITION]. RN #1 stated s/he had the resident's nurse give the resident his/her pain medication. RN #1 stated s/he was not assigned to the resident, s/he was on as unit manager. The niece thought the resident's leg might be bothering him/her because it was not supported by the petal. RN #1 told the resident's nurse to monitor the resident's leg and let him/her know if there were any additional complaints of pain. RN #1 stated s/he did not hear anything else about the resident's leg until s/he heard the resident went out to the hospital with a fracture. RN #1 works days Monday-Friday. RN #1 stated Resident #1 was a total lift prior to the incident. RN #3's facility-obtained statement dated 8/1/17 indicated on 8/1/17 at 8:45 AM, the resident's niece reported to RN supervisors, RN #3 and RN #1, the resident complained of pain to the right knee. Resident states It happened when I was put back to bed. Assessment findings of slight [MEDICAL CONDITION] noted to right knee and pain with movement. Niece states It might be from sitting up in wheelchair without a foot rest. Foot rest placed by CNA, RN to monitor. In an interview with the surveyor on 8/15/17 at approximately 2:35 PM, RN #3 stated s/he is the wound care nurse. RN #1 stated the resident's niece told them about the resident complaining of pain. RN #1 stated s/he does not remember anything about the incident. In an interview with the surveyor on 8/15/17 at approximately 2:45 PM, Licensed Practical Nurse (LPN) #1 stated the resident's family member stated the resident was complaining his/her leg hurt. LPN #1 stated s/he gave him some Tylenol. The resident doesn't usually complain about anything. Resident #1 said s/he was hurting. LPN #1 didn't look at the resident's leg. LPN #1 worked 7 AM-7 PM. CNA #1's facility-obtained statement dated 8/4/17 indicated on the afternoon of 8/1/17 at approximately 11:30 AM, Resident #1 was transferred from the bed to the chair using the lift. Resident #1's wheel chair only had one left pedal attached to it. When the resident was in the hallway his/her right leg twisted under the chair. Resident #1 called out and said that his/her leg was stuck. CNA #1 then began to undo the resident's leg. RN #1 walked up and said that Resident #1 needed two pedals on his/her wheelchair. They began to look throughout the facility for another pedal to add to the resident's wheelchair. After they found a right pedal that would fit, RN #1 and CNA #1 put the pedal on the right side of the wheelchair. The day in question, the resident did not complain of any pain or discomfort and his/her leg was not swollen. After Resident #1's wheelchair was adjusted his/her sister took over and pushed the resident to the lobby. In an interview with the surveyor on 8/16/17 at approximately 10:15 AM, RN #2 (Director of Education) stated the only registry verification for CNA #1 was the one checked on 7/10/17. CNA #1's date of hire was 7/5/17. RN #2 confirmed the registry verification was done after the employee's date of hire. In an interview with the surveyor on 8/16/17 at approximately 1:50 PM, the Director of Nursing (DON) stated s/he was not at the facility when the incident happened with Resident #1. The DON stated s/he usually goes back to interview staff who worked with the resident prior to the incident. The DON stated s/he would have looked back to try to find out when the pain started. The DON stated Resident #1 did not usually complain of pain. The DON stated the resident could tell you what happened. The DON stated s/he would expect the nurses to monitor a resident for a new complaint of pain. Review of the Disciplinary Action Form dated 8/4/17 revealed the facility placed CNA #1 on administrative leave pending results of investigation for resident care. Review of an email dated 8/14/17 from Spartanburg Regional to staffing agency that CNA #1 was employed by revealed due to the current issue involving (CNA #1), managers are terminating his/her contract effective immediately. There was no documentation in any emails provided that the facility notified the staffing agency about the incident that led to the termination of CNA #1's contract.",2020-09-01
102,ELLEN SAGAR NURSING CENTER,425012,1817 JONESVILLE HIGHWAY,UNION,SC,29379,2017-08-16,309,G,1,0,MGP911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Resident #1 was noted to have complaints of pain on 8/1/17 and there was no documentation that the resident was monitored for pain. Resident #1 was found to have a right femur fracture on 8/3/17. One of three residents reviewed for fracture. The findings included: The facility reported an allegation of neglect to the State Agency for Resident #1 by Certified Nursing Assistant (CAN) #1 on 8/3/17. Review of the facility's Five-Day Follow-Up Report dated 8/8/17 indicated after investigation, Resident #1 was found to have right knee fracture from attempted transfer to wheelchair without lift or two-person assist. The Initial 24-hour Report dated 8/3/17 revealed Resident #1 stated that while being pivoted by CNA #1, the CNA assisted him/her to slide to the floor and at that time his/her right knee popped. Further review of the medical record revealed the Annual Minimum Data Set ((MDS) dated [DATE] coded Resident #1 as having a Brief Interview for Mental Status score of 6. The Quarterly MDS dated [DATE] coded the resident as having a Brief Interview for Mental Status score of 5. The Quarterly MDS coded Resident #1 as totally dependent for transfers. Review of the care plan revealed resident needs moderate to max assistance with ADLs was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included resident transfers with assist of mechanical lift. Review of the Nurses' Progress Notes dated 8/2/17 indicated called to room by CNA to look at resident's leg. Right leg is swollen. States had pain in leg while receiving peri-care. RN supervisor notified who also looked at leg. Resident's socks removed and legs elevated. The previous note was dated 7/21/17 and noted weekly summary and body audit completed. The next note was noted as a late entry for 8/1/17 and indicated resident complained in wheelchair that right knee popped while being transferred to bed. Some slight [MEDICAL CONDITION] noted, daughter present. Daughter stated possible the footrest (missing) may have caused pain and [MEDICAL CONDITION]. Replaced footrest. Reported to nurse to get something for pain and monitor. The note was completed by RN #1. The Nurses' Progress Note dated 8/3/17 at 3:00 AM indicated the resident had complaints of pain and swelling to the right knee and warm to touch. Ice pack applied and elevated. As needed Tylenol given related to pain. On 8/3/17 at 5:00 AM the Nurses' Note indicated Tylenol was effective. Resident states My knee still hurts but feels a lot better since that ice. Ice appears to be effective. Swelling slightly reduced in size and less warm to touch. Resident now resting quietly. At 10:10 AM the note indicated the physician was asked to see the resident related to right knee pain. X-ray and CBC ordered stat. The Nurses' Progress Note dated 8/3/17 at 6:40 PM indicated the nurse practitioner was notified of the x-ray results and a new order was received to send the resident to the emergency room for evaluation and treatment related to complaints of pain. There was no additional documentation related to monitoring the resident for complaints of pain or assessing the resident's knee. Review of Resident #1's (MONTH) Medication Administration Record [REDACTED]. The resident did not receive the as needed medication any other time during the month of August. Resident #1 received scheduled Tylenol 2 tablets (650 mg) three times daily for pain at 8:00 AM, 4:00 PM, and 8:00 PM. Review of the physician progress notes [REDACTED]. Apparently the other day during the transfer his/her knee was some way twisted. The exact mechanism of action was unknown, and from conversation with the facility staff history does not seem to be consistent with another. Resident #1 is a poor historian. The physician ordered an x-ray. The note was signed 8/3/17 at 4:24 PM. Review of the Mobilex Radiology Report dated 8/3/17 revealed the conclusion was noted as possible non-displaced fracture through the medial femoral condyle. Further evaluation with oblique views was recommended. Registered Nurse (RN) #1's facility-obtained statement dated 8/1/17 indicated at approximately 8:40 AM, resident's niece reported that the resident's right leg hurt and that s/he needed his/her foot rest on the wheel chair. RN #1 assessed the resident's right and left legs. Resident stated hurts more with movement, grimaced. Resident also reported it happened while being put to bed. Niece stated she felt like it was because resident had been up in wheelchair without foot rest. RN #1 and CNA #1 found the foot rest. CNA #1 replaced them on the wheelchair. RN #1 reported to the primary nurse and asked if resident could get something for pain and to continue to monitor his/her leg. RN #1's facility-obtained statement dated 8/4/17 indicated when s/he arrived to work on 8/3/17 s/he was made aware that Resident #1 was in the hospital with a fracture. It had been reported to another RN that CNA #1 had dropped the resident while transferring without a lift. When CNA #1 was called to the office to investigate the incident, s/he stated s/he never lifted the resident without a lift. CNA #1 did observe the resident in the wheelchair without a foot rest with the resident's leg stuck behind the front wheel and had to lift the chair up and get the resident's leg free. RN #1 explained to CNA #1 that this was considered an incident and should have been reported to the primary nurse. RN #1's facility-obtained statement dated 8/7/17 indicated upon entering Resident #1's room since return from the hospital s/he asked the resident how s/he hurt his/her leg. Resident #1 replied That (boy/girl) holding me up made me slide into the floor. Asked how s/he had picked the resident up and if s/he had used the lift. Resident #1 replied no, s/he had him/her under his/her arms. Resident #1 stated (s/he) picked me up under my arms and put me in the chair. In an interview with the surveyor on 8/15/17 at approximately 2:20 PM, RN #1 stated s/he is the unit manager for Unit 1. RN #1 stated that the resident's niece said his/her leg was hurting out in the lobby. RN #1 went and assessed the resident's leg and it was painful. Resident #1 didn't have petals on his/her wheelchair and his/her niece felt that may be what was causing the resident's leg to hurt. Normally the resident had petals but staff said they couldn't find them that day. RN #1 walked down the hall and found them on another wheelchair. The CNA said they looked like the resident's and the CNA checked and they fit Resident #1's wheelchair. The petals were on an extra wheelchair that was on the hall. Resident #1's knee had slight [MEDICAL CONDITION]. RN #1 stated s/he had the resident's nurse give the resident his/her pain medication. RN #1 stated s/he was not assigned to the resident, s/he was on as unit manager. The niece thought the resident's leg might be bothering him/her because it was not supported by the petal. RN #1 told the resident's nurse to monitor the resident's leg and let him/her know if there were any additional complaints of pain. RN #1 stated s/he did not hear anything else about the resident's leg until s/he heard the resident went out to the hospital with a fracture. RN #1 works days Monday-Friday. RN #1 stated Resident #1 was a total lift prior to the incident. RN #3's facility-obtained statement dated 8/1/17 indicated on 8/1/17 at 8:45 AM, the resident's niece reported to RN supervisors, RN #3 and RN #1, the resident complained of pain to the right knee. Resident states It happened when I was put back to bed. Assessment findings of slight [MEDICAL CONDITION] noted to right knee and pain with movement. Niece states It might be from sitting up in wheelchair without a foot rest. Foot rest placed by CNA, RN to monitor. In an interview with the surveyor on 8/15/17 at approximately 2:35 PM, RN #3 stated s/he is the wound care nurse. RN #1 stated the resident's niece told them about the resident complaining of pain. RN #1 stated s/he does not remember anything about the incident. In an interview with the surveyor on 8/15/17 at approximately 2:45 PM, Licensed Practical Nurse (LPN) #1 stated the resident's family member stated the resident was complaining his/her leg hurt. LPN #1 stated s/he gave him some Tylenol. The resident doesn't usually complain about anything. Resident #1 said s/he was hurting. LPN #1 didn't look at the resident's leg. LPN #1 worked 7 AM-7 PM. CNA #1's facility-obtained statement dated 8/4/17 indicated on the afternoon of 8/1/17 at approximately 11:30 AM, Resident #1 was transferred from the bed to the chair using the lift. Resident #1's wheel chair only had one left pedal attached to it. When the resident was in the hallway his/her right leg twisted under the chair. Resident #1 called out and said that his/her leg was stuck. CNA #1 then began to undo the resident's leg. RN #1 walked up and said that Resident #1 needed two pedals on his/her wheelchair. They began to look throughout the facility for another pedal to add to the resident's wheelchair. After they found a right pedal that would fit, RN #1 and CNA #1 put the pedal on the right side of the wheelchair. The day in question, the resident did not complain of any pain or discomfort and his/her leg was not swollen. After Resident #1's wheelchair was adjusted his/her sister took over and pushed the resident to the lobby. In an interview with the surveyor on 8/16/17 at approximately 10:15 AM, RN #2 (Director of Education) stated the only registry verification for CNA #1 was the one checked on 7/10/17. CNA #1's date of hire was 7/5/17. RN #2 confirmed the registry verification was done after the employee's date of hire. In an interview with the surveyor on 8/16/17 at approximately 1:50 PM, the Director of Nursing (DON) stated s/he was not at the facility when the incident happened with Resident #1. The DON stated s/he usually goes back to interview staff who worked with the resident prior to the incident. The DON stated s/he would have looked back to try to find out when the pain started. The DON stated Resident #1 did not usually complain of pain. The DON stated the resident could tell you what happened. The DON stated s/he would expect the nurses to monitor a resident for a new complaint of pain. Review of the Disciplinary Action Form dated 8/4/17 revealed the facility placed CNA #1 on administrative leave pending results of investigation for resident care. Review of an email dated 8/14/17 from Spartanburg Regional to staffing agency that CNA #1 was employed by revealed due to the current issue involving (CNA #1), managers are terminating his/her contract effective immediately. There was no documentation in any emails provided that the facility notified the staffing agency about the incident that led to the termination of CNA #1's contract.",2020-09-01
103,ELLEN SAGAR NURSING CENTER,425012,1817 JONESVILLE HIGHWAY,UNION,SC,29379,2017-08-16,496,D,1,0,MGP911,"> Based on review of facility files and interview, the facility failed to ensure that information from every State registry was received before allowing an individual to serve as a nurse aide. Certified Nurse Aide (CNA) #1 started working for the facility prior to his/her South [NAME]ina Nurse Aide Registry Verification being checked. One of one nurse aides reviewed. The findings included: The facility reported an allegation of neglect to the State Agency for Resident #1 by CNA #1. Review of the facility's Five-Day Follow-Up Report dated 8/8/17 indicated after investigation, Resident #1 was found to have a right knee fracture from attempted transfer to wheelchair without lift or two-person assist. The Initial 24-hour Report dated 8/3/17 revealed Resident #1 stated that while being pivoted by CNA #1, the CNA assisted him/her to slide to the floor and at that time his/her right knee popped. Review of CNA #1's employee file revealed a South [NAME]ina Nurse Aide Registry Verification dated 7/10/17. CNA #1 was noted with a hire date of 7/5/17. In an interview with the surveyor on 8/16/17 at approximately 10:15 AM, Registered Nurse (RN) #2 (Director of Education) stated the only registry verification was the one checked on 7/10/17. RN #2 confirmed CNA #1's date of hire was 7/5/17. RN #3 confirmed the registry verification was done after the employee's date of hire.",2020-09-01
104,ELLEN SAGAR NURSING CENTER,425012,1817 JONESVILLE HIGHWAY,UNION,SC,29379,2017-08-16,526,D,1,0,MGP911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to obtain the most recent hospice plan of care specific to the resident, the hospice election form, and documentation of the communication between the facility and the hospice provider to ensure that the needs of the resident are addressed and met 24 hours per day. Resident #3 was noted to be receiving hospice services at the facility from [DATE]-[DATE] at which time the resident expired. Review of the resident's closed medical record on ,[DATE]-[DATE] revealed there was no documentation in the resident's medical record from the hospice agency. One of one residents reviewed for hospice. The findings included: Review of Resident #3's medical record revealed the Nurse's Progress Note dated [DATE] at 9:55 AM indicated the nurse practitioner rounded and new orders were written for hospice to evaluate and treat the resident related to [MEDICAL CONDITION]. Review of the Physician order [REDACTED]. Review of Resident #3's closed medical record on [DATE] and [DATE] revealed no documentation from the hospice agency. The medical records staff was asked about the missing documentation. In an interview with the surveyor on [DATE] at approximately 1:55 PM, medical records stated the hospice documentation was faxed over today, there was no information in the resident's medical record from the hospice agency.",2020-09-01
105,ELLEN SAGAR NURSING CENTER,425012,1817 JONESVILLE HIGHWAY,UNION,SC,29379,2018-08-16,578,D,0,1,PLLD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure residents were afforded the opportunity to formulate their own decisions regarding health care for 1 of 2 residents reviewed for Advanced Directives. Resident # 26 was not provided the opportunity to update his/her healthcare decision. The findings included: Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Medical Record on 08/14/2018 at 11:53 AM revealed Resident #26 Advance Directive status was Do Not Resuscitate (DNR). Further review revealed the document was not signed by Resident #26. Continued review revealed the document was signed by the legal representative in (YEAR). Review of the Progress Note Addressing Decisional Capacity dated 9/16/16 revealed This patient DOES possess the decisional capacity to make healthcare decisions for self. Interview with Registered Nurse #1 on 08/15/2018 at approximately 2:30pm revealed when the resident is sent out to the Hospital the facility supplies Emergency Medical Services with the DNR order. Further interview revealed the capacity to make healthcare decisions needs to be updated to reflect resident's current wishes.",2020-09-01
106,ELLEN SAGAR NURSING CENTER,425012,1817 JONESVILLE HIGHWAY,UNION,SC,29379,2018-08-16,582,D,0,1,PLLD11,"Based on record review and interview, the facility failed to issue the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN)/ Centers for Medicare/Medicaid (CMS) and CMS forms for 2 of 3 residents reviewed for Medicare Part A Services. Resident #33 was not issued the CMS timely, Resident #87 did not receive the required SNFABN/CMS . The findings included: Review of the Medicare non coverage notices on 08/16/2018 at approximately 11:00 am revealed Resident #87 had services ended with additional days left for services. Continued review revealed Resident #87 had not been provided the CMS form . Review of the Medicare non coverage notices on 8/16/2018 at approximately 11:00 am revealed the CMS indicated the resident services would end for Resident # 33 on 05/29/2018. Continued review revealed Resident #33 was provided notice on 05/28/2018. Interview with the Business Manager on 08/16/2018 at approximately 11:30 am confirmed CMS notices were not distributed as required.",2020-09-01
107,ELLEN SAGAR NURSING CENTER,425012,1817 JONESVILLE HIGHWAY,UNION,SC,29379,2018-08-16,584,D,0,1,PLLD11,"Based on record review and interview, the facility failed to exercise reasonable care for the protection of resident property from loss or theft for 1 of 2 residents reviewed for Personal Property. Resident #55 was not reimbursed for several missing clothing items. The findings included: Interview with Resident # 55 on 8/14/2018 at approximately 11:40 am revealed he/she has had several clothing items that do not return from laundry. Further interview revealed he/she had not been replaced nor was he/she reimbursed for any of the missing clothing items. Resident #55 stated he/she informed facility staff to include the Social Worker of the missing items. Interview with Resident #55 on 8-16-18 at 11:15 am revealed he/she had a closet full of clothing that went missing which had not been replaced nor had he/she been reimbursed for the items. Resident #55 further stated he/she wore his/her (roommates) clothes. Resident #55 stated see, as he/she proceeded to show the written name of another resident inside the clothing he/she was wearing. Review of purchase receipts supplied by the facility Administrator on 8/15 and 08/16/2018 revealed no receipt of clothing purchase for Resident #55. Review of Policy #200.128 - Resident Valuables or Belongings revealed Procedure IV- If ESNC is notified that a resident's personal effects are missing, we shall attempt to locate the missing item but are not assuming responsibility for replacement of the lost or stolen property. Interview with Social Worker #1 on 08/16/2018 at approximately 11:30 am revealed items were replaced but could not provide documentation to support this. Social Worker #1 further stated he/she gave Resident #55 two pair of pants on 08-13-2018 but did not document this.",2020-09-01
108,ELLEN SAGAR NURSING CENTER,425012,1817 JONESVILLE HIGHWAY,UNION,SC,29379,2018-08-16,623,E,0,1,PLLD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to give a written notice of transfer to the resident or the resident's representative when Resident #17 was transferred out of the facility for evaluation after a fall. The findings included: The facility admitted Resident #17 on 2/1/18 with [DIAGNOSES REDACTED]. Review of the Nurse's Progress Record revealed the notation dated 6/27/18 at 1130 indicated the resident was sent to the hospital for evaluation. The notation stated, R/P (representative) notified. The notation dated 6/27/18 at 2000 indicated the resident returned to the facility. The Nurse's Progress note dated 6/29/18 at 1925 indicated staff sent Resident #17 to the hospital for evaluation following a fall. The notation indicated that staff notified a family member. The notation dated 6/29/18 at 2230 indicated the resident returned to the facility. Review of the Social Services notes revealed no documentation that staff sent a written Notice of Transfer with the resident or to the resident's representative on those dates. During an interview on 8/16/18 at approximately 2:00 PM, Social Services Staff #1 reviewed the Nurse's Progress Notes and Social Services notations and confirmed these findings.",2020-09-01
109,ELLEN SAGAR NURSING CENTER,425012,1817 JONESVILLE HIGHWAY,UNION,SC,29379,2018-08-16,657,D,0,1,PLLD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure all required members of the Interdisciplinary Team participated in the development of care plans and/or reviewed and revised the care plan for 3 of 21 residents reviewed for care plans. (Residents #6, #17, and #35) The findings included: The facility admitted Resident #6 on 11/1/00 with [DIAGNOSES REDACTED]. Review of the medical record revealed the care plan conference attendance sheets contained space for signatures of staff participating in the care plan meeting. Review of the attendance sheet dated 5/11/18 revealed no signature of a Certified Nurse Aide (CNA) to indicate participation in development of the care plan. The facility admitted Resident #17 on 2/1/18 with [DIAGNOSES REDACTED]. Review of the medical record revealed the care plan conference attendance sheets contained space for signatures of staff participating in the care plan meeting. Review of the attendance sheet dated 5/17/18 revealed no signature of a Certified Nurse Aide (CNA) to indicate participation in development of the care plan. The facility admitted Resident #35 on 1/16/66 with [DIAGNOSES REDACTED]. Review of the medical record revealed the care plan conference attendance sheets contained space for signatures of staff participating in the care plan meeting. Review of the attendance sheets dated 3/15/18 and 6/14/18 revealed no signature of a Certified Nurse Aide (CNA) to indicate participation in development of the care plan. During an interview on 8/16/18 at approximately 2:00 PM, Social Services Staff #1 and MDS Staff #1 reviewed the attendance forms and confirmed that there was no CNA signature on the care plan attendance sheets for these residents.",2020-09-01
110,ELLEN SAGAR NURSING CENTER,425012,1817 JONESVILLE HIGHWAY,UNION,SC,29379,2018-08-16,755,E,0,1,PLLD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interviews and review of manufacture's recommendations, the facility's Consulting Pharmacist failed to assure that the Pharmaceutical service oversight for which it was contracted to provide, continued to identify, evaluate and prevent the improper storage of medications for 1 of 3 medication storage rooms reviewed. There was no immediate action documented which indicated the Pharmacy addressed the improperly stored medications at the time of the inspection of the Unit 1 medication storage room, educated the nursing staff as to the proper procedure to follow nor documented follow up to assure a concern was immediately corrected. (cross refer to F761) The findings included: On 8/13/18 at approximately 10:25 AM, an observation of the Unit 1 medication storage room with Licensed Practical Nurse (LPN) #1 revealed the temperature of the medication refrigerator was 32 degrees Fahrenheit (F) which was confirmed by LPN #1. The contents of the refrigerator was: 1.) (4) containers of Lananoprost Opthalmic Solution .0005% 125ug/2.5 ml. 2.) (38) vials of [MEDICATION NAME] 20 mcg. / 2 ml. 3.) (2) 10 ml. vials [MEDICATION NAME] R insulin 100 u/ml. 4.) (1) 10 ml. vial [MEDICATION NAME] R insulin 100 u/ml. 5.) (1) 2 mg. / ml. bottle of Lorazapam oral concentrate 6.) (2) 10 ml. vials Humalog insulin 100 u/ml. 7.) (5) 10 ml. vials of [MEDICATION NAME] 100 u/ml. 8.) (2) 12.5 mg. injections of [MEDICATION NAME] Consta 9.) (2) vials of [MEDICATION NAME]100 u/ml. The (MONTH) (YEAR) Unit Drug Refrigerator Temperature Log on top of the refrigerator revealed 5 dates (August 2, 3, 4, 5, 6) had been recorded On 8/13/18 at approximately 11:30 AM, during a review of the Unit 1's medication storage refrigerator's logs revealed in (MONTH) (18) days, (MONTH) (6) days, (MONTH) (14) days, and (MONTH) (5) days had temperature readings below 36 degrees F. On 8/14/18 at 12:30 PM, a review of the (MONTH) Monthly QA Consultant Pharmacy Report dated 8/9/18 revealed Consultant Pharmacist #1 reviewed the Unit 1 medication storage room and refrigerator log. On the Medication Storage Audit Consultant Pharmacist #1 noted under C. Refrigerator: Medication refrigerator log completed daily, and Medications stored per manufacture's recommendations, were both checked as Met, and did not make any recommendations for the facility or identify any temperature concerns even though 5 dates (August 2, 3, 4, 5, 6) had been recorded On 8/13/18 at 1:25 PM, a review of the facility policy entitled, Safe and Sanitary Handling, Storage, Wastage, and Controlled Substance Management Medication Storage in the Facility stated under procedure (1.b) Medications are stored to ensure stability, This includes: 1.) Storing medications at proper temperatures. Review of the manufacture recommendations for insulin, Lorazapam, Lantanoprost, [MEDICATION NAME], and [MEDICATION NAME] Consta, state refrigerated storage temperatures between 36-46 degrees F.",2020-09-01
111,ELLEN SAGAR NURSING CENTER,425012,1817 JONESVILLE HIGHWAY,UNION,SC,29379,2018-08-16,757,E,0,1,PLLD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a drug regimen free from unnecessary drugs for 1 of 6 sampled residents reviewed for unnecessary medications. An antipsychotic was initiated for Resident #41 without justification and/or non-pharmacological attempts. The findings included: The facility admitted Resident #41 on 03/26/2015 with [DIAGNOSES REDACTED]. Review of the medical record on 08-15-2018 at approximately 5:30 pm revealed he/she was prescribed [MEDICATION NAME] 05-16-2018. Further review revealed no adequate indication for it's use. Continued review of the record revealed no documentation of inappropriate behavior for Resident #41 and there was no indication staff received Dementia management training/techniques. Nurses Note dated 05-16-2018 revealed New order for [MEDICATION NAME] 25 mg (milligrams), po (by mouth), daily at 1700 for agitation and anxiety. Further review of Nurses Notes revealed no documentation of inappropriate behavior. Review of Pharmacy Consultant Report dated 6-14-2018 revealed receives an antipsychotic [MEDICATION NAME] but does not have a supporting indication for use documented. Further review revealed Dementia with behaviors written under Physician's Response dated 06-18-2018. Review of the Medication Administration Record [REDACTED]. Interview with the Director of Nursing (DON) on 08/16/2018 revealed no behaviors had been documented for Resident # 41. Further interview revealed the Nurse Practitioner (NP) was seated at the Nursing Station one day and saw Resident # 41 looking as if he/she was agitated and headed for the door and the order for [MEDICATION NAME] was written.",2020-09-01
112,ELLEN SAGAR NURSING CENTER,425012,1817 JONESVILLE HIGHWAY,UNION,SC,29379,2018-08-16,760,D,0,1,PLLD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and review of manufacture's recommendations, the facility failed to administer the correct amount medication for 1 of 1 resident reviewed for TB [MEDICATION NAME], Purified Protein Derivative (PPD) medication administration. Resident #449 did not receive the correct amount of physician ordered PPD during medication administration. The findings included: On [DATE] at approximately 10:45 AM, an observation of the medication refrigerator in the Director of Nursing's (DON's) office with the DON revealed (1) 1 milliliter (ml), 10 test, vial of [MEDICATION NAME] Purified Protein Derivative (PPD) (Mantoux) (Lot # 0) which was opened (,[DATE] empty) with a puncture date of [DATE] recorded on the vial, and an expiration date of [DATE] on the pharmacy bottle that the vial was stored in. Following the observation of the PPD vial, the DON verified the vial of PPD was opened on [DATE] and expired on [DATE]. On [DATE] at approximately 1:30 PM, during an interview with the Director of Nursing (DON), the DON verified the vial of PPD (Lot # 0) was in use after the manufactures recommended expiration date and revealed that Resident #449 received PPD on [DATE] which was after the expiration date of [DATE]. Review of the manufacture's recommendations for [MEDICATION NAME] Purified Protein Derivative, (Mantoux) (PPD) ([MEDICATION NAME]) states under section Storage, A vial of [MEDICATION NAME] which has been entered and in use for 30 days should be discarded. Do not use after the expiration date.",2020-09-01
113,ELLEN SAGAR NURSING CENTER,425012,1817 JONESVILLE HIGHWAY,UNION,SC,29379,2018-08-16,761,E,0,1,PLLD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, review of the facility policy, Medication Storage in the Facility, and review of manufacture's recommendations, the facility failed to follow a procedure to ensure that recommended temperatures were maintained in 1 of 3 medication storage refrigerators and expired medication was removed in 1 of 3 medication storage rooms reviewed. Medications were stored in the Unit 1 medication storage room below the FDA (Food and Drug Administration) approved package inserts and manufacturer package labeling, and expired medication was in the Director of Nursing's (DON's) medication storage room refrigerator,. The findings included: On [DATE] at approximately 10:25 AM, an observation of the Unit 1 medication storage room with Licensed Practical Nurse (LPN) #1 revealed the temperature of the medication refrigerator was 32 degrees Fahrenheit (F) which was confirmed by LPN #1. The contents of the refrigerator was: 1.) (4) containers of Lananoprost Opthalmic Solution .0005% 125ug/2.5 ml. 2.) (38) vials of [MEDICATION NAME] 20 mcg. / 2 ml. 3.) (2) 10 ml. vials [MEDICATION NAME] R insulin 100 u/ml. 4.) (1) 10 ml. vial [MEDICATION NAME] R insulin 100 u/ml. 5.) (1) 2 mg. / ml. bottle of Lorazapam oral concentrate 6.) (2) 10 ml. vials Humalog insulin 100 u /ml. 7.) (5) 10 ml. vials of [MEDICATION NAME] 100 u /ml. 8.) (2) 12.5 mg. injections of [MEDICATION NAME] Consta 9.) (2) vials of [MEDICATION NAME]100u /ml. The (MONTH) (YEAR) Unit Drug Refrigerator Temperature Log on top of the refrigerator revealed 5 dates ([DATE], 4, 5, 6) had been recorded On [DATE] at approximately 11:00 AM, during an interview with Maintenance Director and LPN #1, the surveyor's thermometer was placed in the Unit 1's medicine refrigerator which read 31 degrees F. Both thermometers (facility's and surveyors) were then tested for accuracy with the Maintenance Directors thermometer which all read the same temperature. The Maintenance Director verified the thermometers had the same reading and were accurate. On [DATE] at approximately 11:30 AM, during a review of the Unit 1's medication storage refrigerator's logs revealed in (MONTH) (18) days, (MONTH) (6) days, (MONTH) (14) days, and (MONTH) (5) days had temperature readings below 36 degrees F. On [DATE] at 1:25 PM, a review of the facility policy entitled, Safe and Sanitary Handling, Storage, Wastage, and Controlled Substance Management Medication Storage in the Facility stated under procedure (1.b) Medications are stored to ensure stability, This includes: 1.) Storing medications at proper temperatures. Review of the manufacture recommendations for insulin, Lorazapam, Lantanoprost, [MEDICATION NAME], and [MEDICATION NAME] Consta, state refrigerated storage temperatures between ,[DATE] degrees F. On [DATE] at approximately 10:45 AM, an observation of the medication refrigerator in the Director of Nursing's (DON's) office with the DON revealed (1) 1 milliliter (ml), 10 test, vial of [MEDICATION NAME], Tuber-culin Purified Protein Derivative (PPD) (Mantoux) (Lot # 0) which was opened (,[DATE] empty) with a puncture date of [DATE] recorded on the vial, and an expiration date of [DATE] on the pharmacy bottle that the vial was stored in. Following the observation of the PPD vial, The DON verified the vial of PPD was opened on [DATE] and expired on [DATE]. Review of the [MEDICATION NAME] Purified Protein Derivative (PPD) (Mantoux) packet insert manu-facture recommendations #262 stated, A vial of [MEDICATION NAME] which has been entered and in use for 30 days should be discarded.",2020-09-01
114,ELLEN SAGAR NURSING CENTER,425012,1817 JONESVILLE HIGHWAY,UNION,SC,29379,2019-10-18,600,E,1,0,CCZ611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to ensure that each resident has the right to be free from mistreatment, abuse or neglect for 5 out of 14 resident-to-resident altercations. The findings included: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of complaint records indicated Resident #2 was involved in five incidents of resident-to-resident altercations between November 2018 and September 2019 in which Resident #2 was the physical aggressor. Review of Resident #2's medical book revealed there were no interventions and no direct care plans to prevent Resident #2 from being physically aggressive towards other residents. During an interview on 10/16/2019 at approximately 2:20 PM, the Director of Nursing (DON) stated that Resident #2 was being picked on by others residents which caused Resident #2 to get upset and act out by having altercations with other residents. The DON stated that Resident #2 was on informal 15 minutes checks, and we have him/her stay around the nursing station because we can keep him/her in our sights. Also, the DON stated that Resident #2 doesn't have a care plan to address his/her altercations with other residents and there was no documentation for the 15 minutes checks because the DON decided that Resident #2 was being picked on, which makes him/her agitated. On 10/16/19 at approximately 3:30 PM, review of the facility policy entitled Adult or Elder Abuse, Mistreatment and Neglect revealed: It is facility policy to protect residents from abuse, neglect, mistreatment or exploitation from anyone, including staff members, students, volunteers, other residents, consultants' staff or other agencies serving the resident, family members, legal guardians, friends, or visitors.",2020-09-01
115,ELLEN SAGAR NURSING CENTER,425012,1817 JONESVILLE HIGHWAY,UNION,SC,29379,2019-10-18,607,E,1,0,CCZ611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, facility failed to implement written policies and procedures that would prohibit or prevent each resident from mistreatment, abuse or neglect. The finding included: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of complaint records indicated Resident #2 was involved in five incidents of resident-to-resident altercations between November 2018 and September 2019 in which Resident #2 was the physical aggressor. On 10/16 at approximately 3:30 PM, reviewed of Resident #2 medical book revealed there was no care plan for Resident #2's behaviors. Also there was no documentation on Resident #2 being picked on by other residents. During an interview on 10/16/2019 at approximately 2:20 PM, the Director of Nursing (DON) stated that Resident #2 was being picked on by others residents which caused Resident #2 to get upset and act out by having altercations with other residents. The DON stated that Resident #2 was on informal 15 minutes checks and we have him/her stay around the nursing station because we can keep him/her in our sights. Also, the DON stated that Resident #2 does not have a care plan to address his/her altercations with other residents and there was no documentation for the 15 minutes checks because the DON decided that Resident #2 was being picked on, which makes him agitated. On 10/16/19 at approximately 3:30 PM, review of the facility policy entitled Adult or Elder Abuse, Mistreatment and Neglect revealed: It is facility policy to protect residents from abuse, neglect, mistreatment or exploitation from anyone, including staff members, students, volunteers, other residents, consultants' staff or other agencies serving the resident, family members, legal guardians, friends, or visitors.",2020-09-01
116,ELLEN SAGAR NURSING CENTER,425012,1817 JONESVILLE HIGHWAY,UNION,SC,29379,2019-10-18,610,E,1,0,CCZ611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to take action in response to an alleged violation of abuse, neglect, exploitation or mistreatment for 5 out 14 resident-to-resident altercations. The findings included: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of complaint records indicated Resident #2 was involved in five incidents of resident-to-resident altercations between November 2018 and September 2019. In each complaint, Resident #2 was the physical aggressor. Review of Resident #2's medical book revealed there were no interventions and no direct care plans to prevent Resident #2 from being physically aggressive towards other residents. During an interview on 10/16/19 at approximately 10:43 AM, Licensed Practical Nurse (LPN) #2 stated there was no formal care plan for Resident #2's behaviors. LPN #2 stated that they keep watch on Resident #2 every 15 minutes and she/he likes to play country music for him/her, offer him/her snacks, and offer to take him/her outside. During an interview on 10/16/19 at 10:50 AM, LPN #1 stated there no formal care plan for Resident #2 and also stated that they keep watch on him/her every 15 minutes and staff is instructed to redirect Resident #2 with snacks and drinks when Resident #2 appears to be agitated. On 10/16/19 at approximately 3:30 PM, review of the facility policy entitled Adult or Elder Abuse, Mistreatment and Neglect revealed: It is facility policy to protect residents from abuse, neglect, mistreatment or exploitation from anyone, including staff members, students, volunteers, other residents, consultants' staff or other agencies serving the resident, family members, legal guardians, friends, or visitors.",2020-09-01
117,ELLEN SAGAR NURSING CENTER,425012,1817 JONESVILLE HIGHWAY,UNION,SC,29379,2019-10-18,657,E,1,0,CCZ611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to ensure that the comprehensive care plan was reviewed and revised by an interdisciplinary team composed of individuals with knowledge of the resident and his/her needs for 1 of 18 resident care plans reviewed (Resident #2). The findings included: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of complaint records indicated Resident #2 was involved in five incidents of resident-to-resident altercations between November 2018 and September 2019 in which Resident #2 was the physical aggressor. Review on 10/16/2019 at approximately 10:00 AM of Resident #2's comprehensive care plan revealed it did not address behavior for Resident #2. During an interview on 10/16/19 at 10:50 AM, Licensed Practical Nurse (LPN) #1 stated there was no formal behavior care plan for Resident #2. LPN #1 stated that they keep watch on him/her every 15 minutes and staff was instructed to redirect Resident #2 with snacks and drinks when Resident #2 appears to be agitated. During an interview on 10/16/2019 at approximately 2:45 PM, the Administrator stated that each discipline writes their own care plans and makes sure their care plans are completed. During an interview on 10/16/ 2019 at approximately 3:10 PM, the Director of Nursing stated that when it comes to making any care plan changes, the nurses will write in their own care plans without having a meeting or letting other disciplines know. On 10/16/2019 at approximately 3:15 PM, LPN #1 stated that he/she wrote in Resident #2's care plan about having 15 minutes checks and also will continue to use the paper system to record each time. LPN #1 stated that it was the Administrator who told her/him to write the care plans. Also, LPN #1 stated that she/he has never been to a care plan meeting or been trained on how to write a care plan.",2020-09-01
118,ELLEN SAGAR NURSING CENTER,425012,1817 JONESVILLE HIGHWAY,UNION,SC,29379,2019-10-18,658,D,1,0,CCZ611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to provide nursing services according to professional standards of quality for 1 of 1 resident reviewed for [MEDEQUIP] tube. Facility staff performed a [MEDEQUIP] tube flush for Resident #11 which was outside their scope of practice. The findings included: The facility admitted Resident #11 on 5/20/19 with [DIAGNOSES REDACTED]. Review of the medical record revealed a facility-reported incident dated [DATE] which indicated that staff performed a skill outside of scope of practice. Review of the facility's investigative file revealed the Five-Day Report indicated that the Director of Nursing (DON) spoke with Certified Nurses Aide (CNA) #1 regarding a report that he/she had proceeded to put water in the residents feeding tube. Documentation indicated that CNA #1 stated that (he/she) had asked the charge nurse if she could disconnect resident's feeding tube so she could put the resident to bed. Charge nurse (sic) stated that he/she could disconnect to put resident to bed. I asked (CNA#1) if (Charge Nurse) authorized her to put water in residents feeding tube. (CNA#1) stated that she did not. Further documentation by the DON indicated, (CNA#1) did admit to putting water in the feeding tube.I told (CNA#1) by disconnecting and putting water in (Resident #11's) feeding tube was out of (his/her) scope of practice. Further documentation indicated the DON spoke with the Charge Nurse. Documentation indicated that the Charge Nurse was unaware that CNA #1 performed a tube flush for Resident #11. Further documentation indicated that the Charge Nurse did give (CNA #1) permission to disconnect the tubing to put resident to bed. I (DON) told (Charge Nurse) that allowing the C.N.A. to disconnect the tubing was out of the C.N.A.'s scope of practice. Further review of the Five-Day Follow-Up report indicated it was confirmed that the C.N.A. did a peg flush of approximately 400 cc's of water after putting the resident in bed. Resident did not suffer any adverse effects from the incident. The C.N.A. was terminated from (his/her) employment. In addition, the report indicated the facility educated the nurse that (he/she) allowed the C.N.A. to do a procedure outside of (his/her) scope. Disciplinary action was done on both the C.N.A. and (Charge Nurse). Review of the facility's Investigative File revealed CNA #1 confirmed in his/her facility-obtained written statement that he/she had disconnected the tube feeding and put water in the bag. The statement further indicated that I done what I have done and was taught to at other facilities and put water in the bag and disconnected it. During an interview on 10/17/19 at approximately 9:00 AM, the DON confirmed that both staff members had been disciplined and that CNA #1 was no longer employed at the facility.",2020-09-01
119,ELLEN SAGAR NURSING CENTER,425012,1817 JONESVILLE HIGHWAY,UNION,SC,29379,2019-11-10,550,D,0,1,NAMT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to protect the dignity of one of 37 residents (Resident #41). Signs were observed posted in the resident's room containing personal information. The findings included: Resident #41 was admitted on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #41's care plan noted a concern for assistance with activities of daily living dated 02/04/19. A concern for end stage [MEDICAL CONDITION] listed a 1500 milliliter per day fluid restriction. A review of the Annual Minimum Data Set (MDS) assessment dated [DATE] noted that Resident #41 was totally dependent on one staff member for eating assistance. Resident #41 was noted to have a Brief Interview for Mental Status score of 3, indicating severe cognitive impairment. On 11/08/19 at 12:09 PM, a sign was noted taped to the wall over the head of the bed documenting 1500 cc (milliliter) a day fluid restriction and a second sign that Resident #41 needed thickened liquids. On 11/09/19 at 3:49 PM, an interview was completed with the Director of Nurses (DON). We try not to have much signage, it looks tacky. We try to keep it to a minimum. We have colored bracelets that would show swallowing difficulty. I don't know who put the sign up there, but we wouldn't normally put that up. We don't usually put up fluid restrictions. That would be on the MAR (medication administration record).",2020-09-01
120,ELLEN SAGAR NURSING CENTER,425012,1817 JONESVILLE HIGHWAY,UNION,SC,29379,2019-11-10,656,D,0,1,NAMT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and staff interviews, the facility failed to implement the care plan for pressure ulcer risk and activities of daily living care for one of 20 sampled residents reviewed (Resident #37). The findings included: 1. Resident #37 had [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment, dated 09/11/19, documented the resident's cognition was severely impaired and was totally dependent on staff for bed mobility, transfer, dressing, toilet use, and hygiene. The resident was always incontinent of bowel and bladder. A care plan last updated 11/07/19 documented the resident was at risk for impaired skin integrity related to immobility and incontinence of bowel and bladder. Interventions included to keep skin clean and dry and assist with turning as needed. A second care plan, last updated 11/07/19, documented the resident was an extensive assist and dependent with activities of daily living. The interventions included to assist with repositioning for comfort and to maintain skin integrity. On 11/08/19 at 9:45 AM, the resident was observed in his room working with therapy. The therapist stated they were about finished with him and would bring him out of his room when they were completed. At 10:30 AM, the resident was observed in the common area of unit two in front of the television. At 10:45 AM, a staff member was observed giving the resident a drink. After giving the drink the staff member left. From 10:45 AM through 12:05 PM, the resident remained in the common area. Staff was observed passing by the resident and taking other residents into the dining room for the noon meal. No staff was observed stopping and checking on the resident, repositioning him and/or taking him to provide care. At 12:05 PM, the therapist approached the resident, removed a towel from behind his head, and stated she would bring back a new one. She did not check the resident, reposition him or take the resident to his room to provide any care. At 12:10 PM, the therapist placed a new rolled towel behind his head and immediately left. From 12:10 PM through 1:35 PM, the resident continued to be observed up in the common area without staff checking on him, repositioning or taking him to provide care. The resident had a strong odor of urine that was permeating from his body during the observation. The resident was observed up in the common area for three hours and five minutes without being repositioned, checked or provided care. At 2:15 PM, Certified Nurse Assistant (CNA) #49 stated the resident was incontinent, required care to be provided every two hours and needed to be checked on frequently for positioning. At 2:57 PM, CNA #80 stated the resident was incontinent and required assistance with repositioning. He stated the resident was not able to communicate his needs and required staff to check on him and provide all care. He stated the resident should have care provided at least every two hours. The aide stated the last time he changed the resident was just prior to therapy working with him in the morning which was sometime around 10:00 AM. He stated after the noon meal he offered to take the resident back to his room but was told by the nurse he was alright being up in the common area. The aide continued by saying not being changed for three hours was too long. When asked if the resident had any skin break down he shook his head side to side and then stated, No. At 3:16 PM, CNA #80 was observed taking the resident from the common area to his room. He stated he was going to get CNA #49 to help transfer him to bed and provide care. On 11/09/19 at 9:28 AM, Licensed Practical Nurse (LPN) #26 stated the resident was incontinent, was dependent on staff for positioning and could only answer yes and no questions. She stated that someone should be checking on him at least every two hours and provide a brief change. She was made aware of the observation from the previous day and the nurse stated the care plan was not being followed when he sat without care for over three hours. When asked if the resident had any skin breakdown she stated he did not. At 9:42 AM, the Director of Nursing (DON) stated the resident was totally dependent on staff for all care. She stated the resident was incontinent of bowel and bladder and required to be changed every two hours and more often if needed. She stated staff should be checking on him about every hour between the changes to make sure he was positioned and to see if he needed any additional care. When told about the observation she stated the resident's care plan was not being followed and implemented.",2020-09-01
121,ELLEN SAGAR NURSING CENTER,425012,1817 JONESVILLE HIGHWAY,UNION,SC,29379,2019-11-10,677,D,0,1,NAMT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and staff interviews, the facility failed to provide activities of daily living (ADL) care for two of 20 residents reviewed for ADL care. (Residents #37 and #41) The findings included: 1. Resident #37 had [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment, dated 09/11/19, documented the resident's cognition was severely impaired and was totally dependent on staff for bed mobility, transfer, dressing, toilet use, and hygiene. The resident was always incontinent of bowel and bladder. There was no documentation on the assessment the resident had any skin breakdown or issues. Weekly skin audit sheets dated 10/28/19 and 11/04/19 documented the resident's skin was intact. A care plan last updated 11/07/19 documented the resident was at risk for impaired skin integrity related to immobility and incontinence of bowel and bladder. Interventions included to keep skin clean and dry and assist with turning as needed. A second care plan, last updated 11/07/19, documented the resident was an extensive assist too dependent with activities of daily living. The interventions included to assist with repositioning for comfort and to maintain skin integrity. A weekly skin audit sheet, dated 11/09/19, documented the resident had shearing to the right buttocks. There was no documentation the resident had any skin issues related to moisture. On 11/08/19 at 9:45 AM, the resident was observed in his room working with therapy. The therapist stated they were about finished with him and would bring him out of his room when they were completed. At 10:30 AM, the resident was observed in the common area of unit two in front of the television. At 10:45 AM, a staff member was observed giving the resident a drink. After giving the drink the staff member left. From 10:45 AM through 12:05 PM, the resident remained in the common area. Staff was observed passing by the resident and taking other residents into the dining room for the noon meal. No staff was observed stopping and checking on the resident, repositioning him and/or taking him to provide care. At 12:05 PM, the therapist approached the resident, removed a towel from behind his head, and stated she would bring back a new one. She did not check the resident, reposition him or take the resident to his room to provide any care. At 12:10 PM, the therapist placed a new rolled towel behind his head and immediately left. From 12:10 PM through 1:35 PM, the resident continued to be observed up in the common area without staff checking on him, repositioning or taking him to provide care. The resident had a strong odor of urine that was permeating from his body during the observation. The resident was observed up in the common area for three hours and five minutes without being repositioned, checked or provided care. At 2:15 PM, Certified Nurse Assistant (CNA) #49 stated she had been working half of the resident's hall and she had not provided any care to him since she arrived at 6:50 AM. She stated CNA #80 was responsible for the care of the resident. She stated the resident was incontinent, required care to be provided every two hours and needed to be checked on frequently for positioning. She stated she did check on the resident about 10:00 AM, and therapy was working with him and no care was provided. She stated the last brief change was when CNA #80 got the resident up for the day. At 2:57 PM, CNA #80 stated the resident was incontinent and required assistance with repositioning. He stated the resident was not able to communicate his needs and required staff to check on him and provide all care. He stated the resident should have care provided at least every two hours. The aide stated the last time he changed the resident was just prior to therapy working with him in the morning which was sometime around 10:00 AM. He stated after the noon meal he offered to take the resident back to his room but was told by the nurse he was alright being up in the common area. The aide continued by saying not being changed for three hours was too long. When asked if the resident had any skin break down he shook his head side to side and then stated, No. At 3:16 PM, CNA #80 was observed taking the resident from the common area to his room. He stated he was going to get CNA #49 to help transfer him to bed and provide care. At 3:34 PM, CNA #80 stated they had changed the resident's brief and he had urinated more than once. He then stated the resident was wet enough the brief was heavy. He then stated the resident had a small open area when he changed the brief. At 3:39 PM, CNA #49 confirmed the resident had urinated two or three times and the brief was heavy with urine. She then stated she did not notice any skin break down, but the other CNA may have had a better view. On 11/09/19 at 9:28 AM, Licensed Practical Nurse (LPN) #26 stated the resident was incontinent, was dependent on staff for positioning and could only answer yes and no questions. She stated the someone should be checking on him at least every two hours and provide a brief change. She was made aware of the observation from the previous day and the nurse stated the care plan was not being followed when he sat without care for over three hours. When asked if the resident had any skin breakdown she stated he did not. At 9:42 AM, the Director of Nursing (DON) stated the resident was totally dependent on staff for all care. She stated the resident was incontinent of bowel and bladder and required to be changed every two hours and more often if needed. She stated staff should be checking on him about every hour between the changes to make sure he was positioned and to see if he needed any additional care. When told about the observation she stated the resident's care plan was not being followed and implemented. She then stated the resident did not have any skin issues. At 9:53 AM, the resident's skin was observed after care was provided. The resident had a bowel movement and his brief had urine that was to the small of his back. The resident's buttocks were red and there was small open area. Present during the observations was the Wound Nurse, Director of Education, and LPN #26. The Wound Nurse confirmed the resident had a small open area. On 11/09/19 at 1:35 PM, LPN #26 stated the resident's brief was saturated with urine that morning when the skin was observed. She stated the resident had a small area of skin break down about the size of a dime due to moisture and sitting in soiled briefs a long time. She stated she found out the last time the aide provided care was at 7:00 AM, almost three hours before the skin observation. 2. Resident #41 was admitted on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #41's care plan noted a concern for assistance with activities of daily living dated 02/04/19. Interventions for facial hair were not included. A review of the Annual MDS assessment dated [DATE] noted that Resident #41 was totally dependent on staff for personal hygiene and dressing, requiring one staff person for assistance. Resident #41 was noted to have a Brief Interview for Mental Status score of 3, indicating severe cognitive impairment. On 11/08/19 at 9:26 AM, an observation of Resident #41 was completed. She was noted to have a mole on the right side of her chin with long hairs growing out. The hairs were approximately 1 inch long. On 11/09/19 at 3:08 PM, an interview was completed with CNA #62. I saw those long hairs. I don't do anything with them. I'm not sure what we would do. I guess I'd have to ask the nurse. They are so long, I'm not sure if you can pluck them out. An interview was completed with the DON on 11/09/19 at 3:56 PM. It would be difficult to trim the hair. She shakes a lot. We try normally to get the chin hair removed (for other residents). We can try with her, but we would have to be very careful. I'm not sure if anyone has tried. On 11/09/19 at 4:10 PM, an interview was completed LPN #24. LPN #24 stated that she was familiar with Resident #41. She's always had that (chin hair) and I've worked with her about 3 years. I don't know that anyone's ever tried to remove the chin hair.",2020-09-01
122,ELLEN SAGAR NURSING CENTER,425012,1817 JONESVILLE HIGHWAY,UNION,SC,29379,2019-11-10,684,D,0,1,NAMT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews, it was determined the facility failed to implement care for a dependent resident which resulted in moisture related skin issues for one of two residents reviewed for skin integrity (Resident #37). The facility identified 36 residents who were frequently incontinent of bladder. The findings included: Resident #37 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 09/11/19, documented the resident's cognition was severely impaired and was totally dependent on staff for bed mobility, transfer, dressing, toilet use, and hygiene. The resident was always incontinent of bowel and bladder. There was no documentation on the assessment the resident had any skin breakdown or issues. Weekly skin audit sheets dated 10/28/19 and 11/04/19 documented the resident's skin was intact. A care plan last updated 11/07/19 documented the resident was at risk for impaired skin integrity related to immobility and incontinence of bowel and bladder. Interventions included to keep skin clean and dry and assist with turning as needed. A second care plan, last updated 11/07/19, documented the resident was an extensive assist and dependent with activities of daily living. The interventions included to assist with repositioning for comfort and to maintain skin integrity. A weekly skin audit sheet, dated 11/09/19, documented the resident had shearing to the right buttocks. There was no documentation the resident had any skin issues related to moisture. On 11/08/19 at 9:45 AM, the resident was observed in his room working with therapy. The therapist stated they were about finished with him and would bring him out of his room when they were completed. At 10:30 AM, the resident was observed in the common area of unit two in front of the television. At 10:45 AM, a staff member was observed giving the resident a drink. After giving the drink the staff member left. From 10:45 AM through 12:05 PM, the resident remained in the common area. Staff was observed passing by the resident and taking other residents into the dining room for the noon meal. No staff was observed stopping and checking on the resident, repositioning him and/or taking him to provide care. At 12:05 PM, the therapist approached the resident removed a towel from behind his head and stated she would bring back a new one. She did not check the resident, reposition him or take the resident to his room to provide any care. At 12:10 PM, the therapist placed a new rolled towel behind his head and immediately left. From 12:10 PM through 1:35 PM, the resident continued to be observed up in the common area without staff checking on him, repositioning or taking him to provide care. The resident had a strong odor of urine that was permeating from his body during the observation. The resident was observed up in the common area for three hours and five minutes without being repositioned, checked or provided care. At 2:15 PM, Certified Nurse Assistant (CNA) #49 stated she had been working half of the resident's hall and she had not provided any care to him since she arrived at 6:50 AM. She stated CNA #80 was responsible for the care of the resident. She stated the resident was incontinent, required care to be provided every two hours and needed to be checked on frequently for positioning. She stated she did check on the resident about 10:00 AM, and therapy was working with him and no care was provided. She stated the last brief change was when CNA #80 got the resident up for the day. At 2:57 PM, CNA #80 stated the resident was incontinent and required assistance with repositioning. He stated the resident was not able to communicate his needs and required staff to check on him and provide all care. He stated the resident should have care provided at least every two hours. The aide stated the last time he changed the resident was just prior to therapy working with him in the morning which was sometime around 10:00 AM. He stated after the noon meal he offered to take the resident back to his room but was told by the nurse he was alright being up in the common area. The aide continued by saying not being changed for three hours was too long. When asked if the resident had any skin break down he shook his head side to side and then stated, No. At 3:16 PM, CNA #80 was observed taking the resident from the common area to his room. He stated he was going to get CNA #49 to help transfer him to bed and provide care. At 3:34 PM, CNA #80 stated they had changed the resident's brief and he had urinated more than once. He then stated the resident was wet enough the brief was heavy. He then stated the resident had a small open area when he changed the brief. At 3:39 PM, CNA #49 confirmed the resident had urinated two or three times and the brief was heavy with urine. She then stated she did not notice any skin break down, but the other CNA may have had a better view. On 11/09/19 at 9:28 AM, LPN #26 stated the resident was incontinent, was dependent on staff for positioning and could only answer yes and no questions. She stated the someone should be checking on him at least every two hours and provide a brief change. She was made aware of the observation from the previous day and the nurse stated the care plan was not being followed when he sat without care for over three hours. When asked if the resident had any skin breakdown she stated he did not. At 9:42 AM, the Director of Nursing (DON) stated the resident was totally dependent on staff for all care. She stated the resident was incontinent of bowel and bladder and required to be changed every two hours and more often if needed. She stated staff should be checking on him about every hour between the changes to make sure he was positioned and to see if he needed any additional care. When told about the observation she stated the resident's care plan was not being followed and implemented. She then stated the resident did not have any skin issues. At 9:53 AM, the resident's skin was observed after care was provided. The resident had a bowel movement and his brief had urine that was to the small of his back. The resident's buttocks was red and there was a small open area. Present during the observations was the wound nurse, director of education, and LPN #26. The wound nurse confirmed the resident had a small open area. On 11/09/19 at 1:35 PM, LPN #26 stated the resident's brief was saturated with urine that morning when the skin was observed. She stated the resident had a small area of skin break down about the size of a dime due to moisture and sitting in soiled briefs a long time. She stated she found out the last time the aide provided care was at 7:00 AM. At 2:15 PM, the Wound Nurse stated during the skin observation the resident had a scaly callused area that opened. She stated when the resident's brief was changed it had enough urine in it to indicate he had urinated two or three times. She stated the open area was probably caused by being wet and soiled and moving up and down in the bed. She then stated she was not aware the resident had an open area on the previous day. When asked about the documentation of the area being shearing, she stated she should have documented the wound was related to moisture and needed to do better documentation.",2020-09-01
123,ELLEN SAGAR NURSING CENTER,425012,1817 JONESVILLE HIGHWAY,UNION,SC,29379,2019-11-10,686,D,0,1,NAMT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to identify and treat a wound on the coccyx as a pressure ulcer for one of two residents reviewed for pressure ulcers (Resident #82). The findings included: On 11/09/19 at 11:30 AM, wound care was observed on Resident #82 with Registered Nurse/Wound Care (RN #21) and Certified Nurse Assistant (CNA #53). The wound was located on the coccyx with an open area on the right buttocks. The skin surrounding the open area showed scarring from a healed pressure ulcer. The open area was approximately 3 centimeters (cm) long x 0.25 cm wide X 0.02 cm deep. The area on the left buttocks was superficial but reddened. RN #21 applied a skin barrier ointment to the area. No drainage or odor were noted. When asked if the resident felt pain at the site, she stated, It's pretty sore. An interview with RN #21 on 11/09/19 at 1:35 PM revealed that she identified the wound as shearing rather than a pressure ulcer. She stated that the resident stayed up in her wheelchair most of the day. She stated that she encouraged the resident to stay off of that area as much as possible by lying down in bed instead of in her wheelchair. She stated that she had tried multiple forms of treatment based on standing orders. She stated that she had discussed it with the physician and the nurse practitioner but neither of them had visualized the wound. The wound was first noted on 09/24/19. RN #21 stated that she became aware of the open area when the resident asked her to look at her buttocks because she was having pain. RN #21 stated that she had not asked the physician or the nurse practitioner to observe the wound. She stated that there was no order or policy for when the physician or nurse practitioner should be asked to visualize the wound when it was not improving. A second interview with RN#21 on 11/10/19 at 10:40 AM revealed that Resident #82 had been put on the list to be seen by the nurse practitioner the following day when making rounds. She also stated that the resident had a cushion in her WC before the breakdown occurred, but a different type was ordered after the breakdown. An interview was done with the Director of Nursing (DON) and the nursing home administrator (NHA) about the wound on 11/09/19 at 2:20 PM. The NHA is also an RN. Both the NHA and the DON stated that they had not observed the wound on Resident #82. A review of the medical records showed the following physician orders [REDACTED].#21 and signed by either the physician or the nurse practitioner: 09/24/19 - Apply Duoderm to right buttocks/sacral area. Change q (every) 5 days and PRN (as needed) soiled. 09/26/19 - 1) Discontinue PRN order for buttock wound care. 2) Start: Apply foam dressing to open wound and secure (with) tape/bandaid, change every 3 days and PRN if soiled. 3) Place Geomat 4 WC (wheelchair) cushion in WC. 10/02/19 - 1) Discontinue prior R (right buttock wound orders. 2) Start: Clean with saline and pat dry. 2) Apply skin prep to periphery. Apply small border foam drsg (dressing). Change on shower days and PRN if soiled or non-occlusive. 3) Continue 4 Geomat WC cushion when in WC. 10/06/19 - Body wedge for positioning and coccyx pressure relief while in bed. 10/09/19 - 1) Discontinue all previous wound care. 2) Start: Wound care to buttocks every 3 days and PRN if soiled. Clean with saline and pat dry. Apply [MEDICATION NAME] (cut to size) to each area. Secure with [MEDICATION NAME] tape. 3) Start wound care to left anterior lower every 7 days and PRN if non-occlusive. Clean with NS (normal saline) and pat dry. Apply skin prep to periphery. Apply [MEDICATION NAME]. 4) Left elbow healed - maintain [MEDICATION NAME] x 1 wk (week) then DC. 10/16/19 - D/C previous tx (treatment) to buttocks. Tx to (upper) buttocks fold: Duoderm q 7 ds (days) and PRN soiled. 11/07/19 - 1) Discontinue all prior wound care to buttocks. 2) Start 2xday (twice a day): Clean areas with soap and water. Pat dry. Apply [MEDICATION NAME] paste. 3) Cont care to RLE (right lower extremity) as ordered. Most recent wound documentation sheet stated: 11/07/19 - location L & R buttocks areas on both sides of natural fold. Will use barrier cream as no success with [MEDICATION NAME]. Resident encouraged to stay off back and to take breaks from WC during the day. Wound type: shearing. Exudate: serous. Wound bed: normal for skin. Surrounding skin color: Normal for skin. Wound Edges/Surrounding tissue: Harness/induration. Weekly Nursing Summary: 10/27/19 Skin Condition: Pressure Ulcers (was checked), Location: BLE (bilateral lower extremities). 10/16/19 Area identified (upper) buttocks fold Description: R (right) 6 cm x 4 cm 'crusted'/open area, L (left) 1) 3 cm x 2 cm blistered area 3) 3 cm x 2 cm blistered area 2) 2.5 cm x 2 cm blister. 10/09/19(left side buttock marked) shearing 0.5 x 0.5 x 0.0; no odor, wound bed gray, surrounding skin dark red/purple blanchable Wound edges/surrounding tissue hardness/induration. 10/09/19 (right buttock marked) wound is macerated. Shearing and pinching (buttock to buttock) keeping area agitated. Encouraged resident to get out of WC q2h (every 2 hours) and to sleep on her side at night. She has a wedge for positioning. Cleaned and [MEDICATION NAME] applied/secured with [MEDICATION NAME] tape. Wound bed - slough yellow Wound Edges/Surrounding tissue - Hardness/induration, maceration. 09/26/19 (right buttock marked) - R of natural fold on buttock. Open area unchanged. Area just below is soft this AM (morning). Underside of right thigh and buttock does have a bruised appearance this AM. Foam bandage every 3 days and PRN. Will use 4 Geomat in WC. The most recent quarterly Minimum Data Set (MDS), dated [DATE], was not coded for a pressure ulcer. It was coded Moisture associated skin damage.",2020-09-01
124,PRUITTHEALTH- COLUMBIA,425013,2451 FOREST DRIVE,COLUMBIA,SC,29204,2019-03-22,610,D,1,0,U4GQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to ensure all allegations were thoroughly investigated for 1 out of 2 complaints reviewed. The findings included: Resident #545 was admitted to the facility with [DIAGNOSES REDACTED]. Resident #545's family alleged that on 10/07/18 that Resident #545 was found by his/her family seated in his/her wheelchair in urine. Review of facility documentation for Resident #545 on 03/21/19 at 2:01 PM revealed the Certified Nursing Assistant (CNA) Care Interventions Record Form revealed the section related to elimination needs was left blank and the CNA-ADL (Activities of Daily Living) Flow Sheet Form was coded as fully incontinent on 10/05/18, 10/06/18, and 10/07/18; however, the number of times the resident urinated during the shift was not documented. Review of the facility internal investigation of the incident on 03/21/19 at 12:47 PM revealed the blank section of the CNA Care Interventions Record Form and CNA-ADL missing documentation were not investigated. In an interview on 03/21/19 at 11:14 AM, the facility Director of Nursing confirmed the missing information on the CNA Care Interventions Record Form and CNA-ADL missing documentation were not investigated.",2020-09-01
125,PRUITTHEALTH- COLUMBIA,425013,2451 FOREST DRIVE,COLUMBIA,SC,29204,2019-03-22,623,D,0,1,U4GQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the contents of the written notice upon transfer to the resident and/or resident representative included all required information for Resident #89 (1 of 2 sampled residents reviewed for hospitalization ). The findings included: The facility admitted Resident #89 with [DIAGNOSES REDACTED]. Record review on 03/20/19 at approximately 1:08 PM revealed a physician's orders [REDACTED].#89 to the hospital due to shortness of breath, [MEDICAL CONDITION] and increased blood pressure. No documentation of the written notice upon transfer was found in the medical record, but the written notice was provided by the Director of Health Services (Nursing) and the Business Manager. Review of the written notice revealed it did not include all of the required information such as the reason for the transfer, place of transfer, and contact information for the state agency and local ombudsman. In an interview on 03/20/19 at approximately 2:40 PM, the Director of Health Services (Nursing), the Administrator, and Business Manager confirmed that the facility notice did not include the reason for the transfer, place of transfer, and contact information for the state agency and local ombudsman.",2020-09-01
126,PRUITTHEALTH- COLUMBIA,425013,2451 FOREST DRIVE,COLUMBIA,SC,29204,2019-03-22,657,E,1,0,U4GQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to ensure Care Plans were revised in a timely manner for 1 out of 5 residents reviewed for Unnecessary Medications (Resident 67). The findings included: Resident #67 was admitted to the facility with [DIAGNOSES REDACTED]. Review of Resident #67's Psychotherapy notes on 03/19/19 at 12:42 PM revealed a note dated 12/19/18 which noted an initial mental health examination by the Nurse Practitioner recommending starting [MEDICATION NAME] 7.5 milligrams twice daily for agitation. Review of Resident #67's physician's orders [REDACTED]. In an interview on 03/21/19 at 10:18 AM, the Director of Nursing confirmed Resident #67's [MEDICATION NAME] 7.5 milligrams twice daily was not started in a timely manner.",2020-09-01
127,PRUITTHEALTH- COLUMBIA,425013,2451 FOREST DRIVE,COLUMBIA,SC,29204,2018-03-23,636,D,0,1,LL0111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and limited record reviews, the facility failed to complete a comprehensive Minimum Data Set (MDS) 3.0 assessment within the timeframe required by the Centers for Medicare and Medicaid (CMS) for 1 of 1 resident reviewed for pressure ulcers. Resident #16 did not have a comprehensive (annual or significant change in status) MDS assessment completed as required within 92 days of the prior Omnibus Budget Reconciliation Act (OBRA) MDS quarterly assessment with Assessment Reference Date (ARD) of 8/22/17. The findings included: Resident #16 was admitted to facility with the following [DIAGNOSES REDACTED]. Record review on 3/23/18 at approximately 9:00 AM revealed that Resident #16 had a Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 8/22/17 completed. Further review of the medical record on 3/23/18 revealed that the next MDS completed was a Significant Change in Status (SCSA) MDS assessment with an ARD of 12/5/17. Additional review revealed that the prior comprehensive MDS assessment was completed with an ARD of 11/24/16 and identified as an annual MDS assessment. The ARD for the SCSA (12/5/17) was ARD + 105 calendar days from the prior quarterly assessment (8/22/17) and was ARD + 377 calendar days from the prior annual MDS assessment (11/24/16). Review on 3/23/18 at of the MDS Resident Assessment Instrument (RAI) Manual version 1.15 effective date 10/1/2017; Chapter 2 page 2-22 revealed the following: The ARD (Item A2300) must be set within 366 days after the ARD of the previous OBRA comprehensive assessment (ARD of previous comprehensive assessment +366 calendar days AND within 92 days since the ARD of the previous OBRA quarter or Significant Correction to Prior Quarterly assessment (ARD of previous Quarterly assessment + 92 calendar days). MDS nurses #1 and #2 verified during interviews on 3/23/18 that a annual MDS had not been completed as originally scheduled with an assessment reference date of 11/24/17 but changed due to Resident #16 being admitted to hospice services 11/22/17. Further discussion revealed that MDS nurse #2 had initiated a significant change in status assessment with an ARD of 12/5/17 to replace the annual assessment. S/he verified during interview that s/he was not aware that the time frame for the required comprehensive MDS had lapsed and that was due with ARD no later than 11/21/17 related to the date of the prior OBRA Quarterly MDS ARD (8/22/17) +92 calendar days.",2020-09-01
128,PRUITTHEALTH- COLUMBIA,425013,2451 FOREST DRIVE,COLUMBIA,SC,29204,2018-03-23,637,D,0,1,LL0111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and limited record reviews, the facility failed to complete a Significant Change in Status (SCSA) Minimum Data Set (MDS) 3.0 assessment within the timeframe required by the Centers for Medicare and Medicaid (CMS) for 1 of 1 resident reviewed for pressure ulcers. Resident #16 did not have a SCSA MDS assessment completed as required within 14 days after admission to hospice services effective 11/22/2017. The findings included: Resident #16 was admitted to facility with the following [DIAGNOSES REDACTED]. Record review on 3/23/18 at approximately 9:00 AM revealed that Resident #16 was admitted to hospice services with start of care date effective 11/22/2017. Additional review revealed that Resident #16 had a Significant Change in Status (SCSA) MDS assessment with an ARD of 12/5/17 completed and signed by RN on 12/19/2017. Review on 3/23/18 at of the MDS Resident Assessment Instrument (RAI) Manual version 1.15 effective date 10/1/2017; Chapter 2 page 2-23 revealed the following: The MDS completion date (Item Z0500B) must be no later than 14 days from the ARD (ARD + 14 calendar days) and no later than 14 days after the determination that the criteria for a SCSA were met. MDS nurses #1 and #2 verified during interviews on 3/23/18 that the significant change in status assessment initiated when Resident #16 was admitted to hospice services on 11/22/17 was not completed within required time frame. They verified that the ARD for SCSA was 12/5/17 and item Z0500B was signed by RN to signify assessment as complete on 12/19/17, which was 27 calendar days after admission to hospice services.",2020-09-01
129,PRUITTHEALTH- COLUMBIA,425013,2451 FOREST DRIVE,COLUMBIA,SC,29204,2018-03-23,638,D,0,1,LL0111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and limited record reviews, the facility failed to complete a quarterly Minimum Data Set (MDS) assessment within the required time frame as outlined in the MDS 3.0 Resident Assessment Instrument (RAI) manual for 1 of 1 resident reviewed for pressure ulcers. Resident #16's quarterly MDS was not completed with an Assessment Reference Date (ARD) within 92 calendar days of the ARD of the most recent Omnibus Budget Reconciliation Act (OBRA) assessment, a Significant Change in Status Assessment (SCSA) with ARD of 12/5/17. The findings included: Resident #16 was admitted to facility with the following [DIAGNOSES REDACTED]. Record review on 3/23/18 at approximately 9:00 AM revealed that Resident #16 had a Significant Change in Status (SCSA) Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 12/5/17 completed related to admission to hospice care services. Further review of the medical record on 3/23/18 revealed that there was not a quarterly MDS assessment completed as required on or before 3/7/18. Additionally, the only MDS with an ARD after 12/5/17 was a SCSA MDS that was currently in the process of being completed with an ARD of 3/15/18. Review on 3/23/18 at of the MDS Resident Assessment Instrument (RAI) Manual version 1.15 effective date 10/1/2017; Chapter 2 page 2-32 revealed the ARD of an assessment drives the due date of the next assessment. The next non-comprehensive assessment is due within 92 days after the ARD of the most recent OBRA assessment (ARD of the previous OBRA assessment- Admission, Annual, Quarterly, Significant Change in Status, or Significant Correction assessment + 92 calendar days). MDS nurses #1 and #2 verified during interviews on 3/23/18 that a quarterly MDS had not been completed as originally scheduled with an assessment reference date of 3/6/18 due to hospice services being discontinued effective 3/8/2018. Further discussion revealed that MDS nurse #2 had initiated a significant change in status assessment with an ARD of 3/15/18 to replace the quarterly assessment. S/he verified during interview that s/he was not aware that the time frame for the required quarterly MDS had lapsed and that was due with ARD no later than 3/7/18. MDS Nurse #2 reported that s/he had initiated an assessment using the previously scheduled ARD of 3/6/18 to be completed and transmitted to the state, but verbalized that it was considered late.",2020-09-01
130,PRUITTHEALTH- COLUMBIA,425013,2451 FOREST DRIVE,COLUMBIA,SC,29204,2018-03-23,640,D,0,1,LL0111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to complete and/or transmit Minimum Data Set (MDS) 3.0 information within required 14 day timeframe as required by CMS (Centers for Medicare and Medicaid Services) and the State for 4 of 6 residents identified on Certification and Survey Provider Enhanced Reporting (CASPER) Minimum Data Set (MDS) 3.0 Missing Omnibus Budget Reconciliation Act (OBRA) Report generated on 3/14/2018. The findings included: Resident #382 had an assessment target date of 01/08/2018 which was the last transmitted Minimum Data Set (MDS) assessment per the CASPER (Certification and Survey Provider Enhanced Reporting) MDS 3.0 Missing OBRA (Omnibus Budget Reconciliation Act) Assessment Report generated on 03/14/2018. Resident #382 was discharged from facility on 1/12/2018 which was signed as complete by the Registered Nurse on 3/19/2018 which was not within the required 14 day time frame from the Assessment Reference Date (ARD) of 1/12/2018 as required by regulatory guidelines. The documentation provided for review by MDS Nurse #1 on 3/21/2018 at 11:30 AM revealed a Final Validation Report (FVR) with the submission Identification (ID) of 823 that was completed on 3/20/2018 at 12:55: 21 PM. Record #11 identified Resident #382's Discharge MDS assessment which was signed as complete on 3/19/2018 and submitted on 3/20/2018 was accepted into the CMS database and subsequently identified as Assessment Completed late: Z0500B (assessment completion date) is more than 14 days after A2300 (assessment reference date) . Resident #1 had an assessment target date of 10/10/2017 which was the last transmitted Minimum Data Set (MDS) assessment per the CASPER (Certification and Survey Provider Enhanced Reporting) MDS 3.0 Missing OBRA (Omnibus Budget Reconciliation Act) Assessment Report generated on 03/14/2018. Resident #1 was not discharged from facility and a quarterly MDS with an Assessment Reference Date (ARD) of 1/9/2018 was signed as complete by the Registered Nurse on 1/16/2018, however, the MDS was not transmitted to the Centers for Medicare and Medicaid (CMS) database and accepted within the 14 day time frame as required by CMS. The documentation provided for review by MDS Nurse #1 on 3/21/2018 at 11:30 AM revealed a Final Validation Report (FVR) with the submission Identification (ID) of 823 that was completed on 3/20/2018 at 12:55: 21 PM. Record #12 identified Resident #1's quarterly MDS assessment which was signed as complete on 1/23/2018 and submitted on 3/20/2018 was accepted into the CMS database and subsequently identified as Record Submitted Late. Resident #2 had an assessment target date of 10/24/2018 which was the last transmitted Minimum Data Set (MDS) assessment per the CASPER (Certification and Survey Provider Enhanced Reporting) MDS 3.0 Missing OBRA (Omnibus Budget Reconciliation Act) Assessment Report generated on 03/14/2018. Resident #2 was not discharged from the facility and a quarterly MDS with an ARD of 1/22/2018 was signed as complete by the Registered Nurse on 02/05/2018; however, the MDS was not transmitted to the Centers for Medicare and Medicaid (CMS) database and accepted within the 14 day time frame as required by CMS. The documentation provided for review by MDS Nurse #1 on 3/21/2018 at 11:30 AM revealed a FVR with the submission Identification (ID) of 823 that was completed on 3/20/2018 at 12:55: 21 PM. Record #31 identified Resident #2's quarterly MDS assessment which was signed as complete on 2/5/2018 and submitted 3/20/2018 was accepted into the CMS database and subsequently identified as Record Submitted Late. Resident #2 had an assessment target date of 10/24/2018 which was the last transmitted Minimum Data Set (MDS) assessment per the CASPER (Certification and Survey Provider Enhanced Reporting) MDS 3.0 Missing OBRA (Omnibus Budget Reconciliation Act) Assessment Report generated on 03/14/2018. Resident #383 admitted to the facility on [DATE] and an admission MDS with an ARD of 1/09/2018 was signed as complete by the Registered Nurse on 01/16/2018; however, the MDS was not transmitted to the Centers for Medicare and Medicaid (CMS) database within the 14 day time frame as required by CMS. The documentation provided for review by MDS Nurse #1 on 3/23/2018 at 11:01 AM revealed a FVR with the submission Identification (ID) of 095 that was completed on 3/21/2018 at 13:13:51. Record # 14 identified Resident #383's admission MDS assessment which was signed as complete on 1/16/2018 and submitted 3/21/2018 was accepted into the CMS database and subsequently identified as Record Submitted Late. During interview with MDS nurse #1 on 3/22/18 at 12: 45 PM , s/he verified that Resident #1's Quarterly MDS with ARD 1/9/2018 was submitted late, Resident #2's Quarterly MDS with ARD of 1/22/18 was submitted late. S/he further verified that Resident #382's discharge MDS assessment with ARD 1/12/18 was completed late as evidenced by date of RN signature reflecting completion of assessment of 3/19/2018 on Z0500B which was ARD + 66 days, which is outside the regulatory time frame of no later than 14 days after the assessment reference date. After receipt of FVR for Resident #383's admission MDS with ARD of 1/09/2018 on 3/23/2018/ at 11:01 AM, MDS Nurse #1 verified that the MDS was submitted late as it was sent greater than 14 days after it was initially completed on 1/16/2018.",2020-09-01
131,PRUITTHEALTH- COLUMBIA,425013,2451 FOREST DRIVE,COLUMBIA,SC,29204,2018-03-23,641,D,0,1,LL0111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to code 1 of 1 resident reviewed on hospice accurately for the Health Conditions Prognosis. Resident #49 was not coded in Section J Health Conditions with the accurate life expectancy. The findings included: The facility admitted Resident #49 with [DIAGNOSES REDACTED]. On 3/21/18 at 5:23PM, review of the Minimum Data Set (MDS) assessment dated [DATE] for significant change and 1/5/18 for Quarterly Assessment revealed Section J Health Conditions: J1400 Prognosis: life expectancy of less than 6 months marked No. On 3/21/18 at 5:59 PM, review of the Hospice Certification and Plan of Care revealed the Start Date of Care was 9/23/17. Further record review from the hospice company revealed, Order date 12/7/17 Order Description: I recertified that patient is terminally ill with a life expectancy of Six (6) months or less if the disease process runs it's normal course. During an interview on 3/23/18 at 10:34 AM with MDS Coordinator #1 is familiar with Resident #49 and confirmed the inaccurate coding for Health Conditions Prognosis. S/he stated was just educated on 3/22/18 by a State Agency Surveyor on coding residents on Hospice.",2020-09-01
132,PRUITTHEALTH- COLUMBIA,425013,2451 FOREST DRIVE,COLUMBIA,SC,29204,2018-03-23,657,D,0,1,LL0111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, records review and staff interview, the facility failed to reassess and revise the comprehensive resident-centered care plan to make sure that resident's current nutrition status reflects the discontinuation of enteral feeding therapy. The facility also failed to update the care plan regarding the percutaneous endoscopic gastrostomy (PEG) status and percentage of by mouth (PO) intake for one of six sampled resident reviewed for nutrition. The findings included: Resident #62 was admitted to the facility with [DIAGNOSES REDACTED]. During the initial tour on 03/19/18 at approximately 2:30 PM Resident #62 was observed laying on his/her bed without signs or symptoms of distress. The resident's room was free of enteral nutrition supplies or equipment and the resident's PEG off sight. Nurse's notes reviewed on 03/22/18 at approximately 2:50 PM revealed that on 02/14/18 the Physician wrote and ordered to discontinue current enteral feeding therapy (tube-feeding) and flush. S/he also wrote an order to have the gastrostomy tube ([DEVICE]) flush with 100 ml of water twice per day for tube patency. Medicine administration regiment reviewed 03/22/18 at approximately 3:00 PM revealed that the nutritional supplement [MEDICATION NAME] 1.5-237 ml bolus five times per day was discontinued on 2/14/18. The care plan review on 03/22/18 at 3:19 AM stated that the resident has the potential for nutrition and hydration deficits and aspiration related to [DEVICE] feeding. The care plan goal includes to nourish and adequately hydrate. The intervention includes administration of H2O flush as ordered per Hierarchical Condition Categories (HCC) protocol, monitor residual volume as ordered, and to care for PEG site daily and as needed. During an interview with Minimum Date Set coordinator (MDS) #1 conducted on 03/23/18 at 10:12 AM s/he confirmed that the care plan is not updated to include improvement in PO intake and discontinuation of PEG tube feeding.",2020-09-01
133,PRUITTHEALTH- COLUMBIA,425013,2451 FOREST DRIVE,COLUMBIA,SC,29204,2018-03-23,761,E,0,1,LL0111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, limited record reviews, interviews, and review of the facility policy, the facility failed to ensure that medications were properly labeled in 2 of 7 medication carts reviewed for medication storage. In addition, the facility failed to ensure controlled substances medication was accounted for in 1 of 1 emergency narcotics box reviewed for medication storage. The findings included: During the medication storage review, conducted in part on 3/22/18 at approximately 09:50 AM with Licensed Practical Nurse (LPN) #1, two packages of [MEDICATION NAME] 10 milligrams (mg) oral tablets (thirty tablets per package) were found with a discard date of 1/12/19 and a manufacturer expiration date of 1/29/18 for Resident #48. One package was in use and the other package was unopened. LPN #1 stated, I use the discard date as the expiration date. I never look on the back of the package. LPN #6, also present on the unit, stated, I just use the discard date as the expiration date. During continuation of the medication storage review on 3/22/18 at approximately 1:35 PM with LPN #4, one unopened package of [MEDICATION NAME] 10 mg oral tablets (thirty tablets) was found with a discard date of 1/1/19 and a manufacturer expiration date of 1/29/18 for Resident #72. LPN #4 stated, I was trained on checking the discard date only. LPN #2, also present on the unit, stated, We use the discard date as the expiration date. In a telephone interview with Pharmacist #2 on 3/22/18 at approximately 10:20 AM, s/he stated, There was an error on the pre-pack label for the [MEDICATION NAME] dispensed with the manufacturer lot # 59[NAME] The expiration date should be 1/29/19 not 1/29/18. S/he also stated, There is no policy for how to check the expiration date of a medication. We train the staff to use whichever date comes first, the discard date or the expiration date. The expectation is they will call us if they find a discrepancy. During an interview on 3/23/18 at approximately 8:50 AM, the Director of Nurses (DON), also known as the Director of Health Services (DHS) stated, The discard date is used as an expiration date. The new staff are trained on medication administration and storage in a video they are shown when they are hired. The pharmacy consultant also does occasional in-services. In addition, during controlled medication storage review on 3/22/18 at approximately 4:00 PM with Unit Manager #1, the Emergency Narcotic Medication Log was found incomplete. The Emergency Narcotic Box has an inventory including the following controlled medications: [REDACTED]. Unit Manager #1 verified that the Controlled Drug Shift Audit Form - 12 Hour Shifts with dates from 3/5/18 - 3/22/18, had 4 of 35 shifts with the required signatures documenting the medications were counted and the lock code numbers were recorded as required by the facility policy. Unit Manager #1 stated, They should be counting this with their narcotic count every shift and recording the code on the security ties. Review of the facility policy entitled Controlled Substances for Healthcare Centers on 3/23/18 at approximately 9:00 AM revealed: Policy Statement: Medications listed as controlled substances (Schedules I-V) under federal or state regulations will be properly stored with maintained accountability. Reconciliation of controlled substances will be performed at the end of each shift by licensed professional nurses. The healthcare center will obtain and keep on file any permits related to ordering and storing controlled substances required by state or federal agencies. Also revealed under South [NAME]ina (SC Code Ann. Reg 61-4 Part 5, Section 508): Accounting: 1. A physical inventory of all controlled substances is conducted at each shift change by the oncoming and outgoing licensed professional nurses. 2. The inventory is documented on the Controlled Drug Shift Audit Sheet. 3. During the Shift Change Inventory, the controlled drug emergency kit is also checked for security of contents and recorded on the audit record. Any apparent tampering or theft of the contents will be recorded on the audit sheet.",2020-09-01
134,PRUITTHEALTH- COLUMBIA,425013,2451 FOREST DRIVE,COLUMBIA,SC,29204,2018-03-23,801,F,0,1,LL0111,"Based on observation, record review and interview the facility failed to employ sufficient qualified staff with the appropriate competencies and skill set forward to carry out food and nutritional services in accordance to the Centers for Medicare and Medicaid Services (CMS) regulations and the state of South[NAME]nutritional professional standards for one of one kitchen sample reviewed for qualified food and nutrition service staff. The findings included: On 03/19/18 at 10:43 AM during the initial tour of the facility's kitchen the dietary manager #1 revealed that s/he has been functioning as one of the dietary managers for three years now. S/he also stated s/he has not yet taken/passed the nationally recognized credentialing exam needed to obtain/maintain certified status. When asked if the facility has a registered dietitian or food and nutrition services director s/he stated that the facility has a consultant registered dietitian that comes to the facility three to four times per month. At approximately 04:21 PM on the same day during the continuation of kitchen tour the dietary manager #2 stated that s/he has a bachelor degree in food management and culinary art. S/he also stated that s/he is eligible for the Certified Dietary Manager (CDM) exam and that s/he was currently enrolled in the class. However, s/he has not yet taken/pass the exam to obtain/maintain certification status. On 03/20/18 the work schedule for the dietary managers and registered dietitian was requested. However, the facility administrator stated that s/he does not have formal/hard copy work scheduled for the dietary staff. S/he provides a handwritten note stating that the dietary manager #1 works from Sunday through Thursday for 8 hours per day. The dietary manager #2 works Mondays through Fridays for 8 hours. The written note also states that the consultant register dietitian worked (MONTH) 6th, 7th, and 8th, (MONTH) 22nd, 23rd, 24th (MONTH) 13th, 14th, 15th and 16th for 8 hours each day. The registered dietitian #2 works approximately 3 hours per week based on the volume of new admission. The registered dietitian #2 worked 5.5 hours in December, 11.15 hours in January, 6.15 hours in February, and 3.45 hours in March. On 03/22/18 at 11:49 PM during an interview with the administrator and consultant registered dietitian #1 they both stated that according to their interpretation of the regulation the dietary manager #2 has the credential to perform as dietary manager without the CDM. The administrator stated that s/he is enrolled in the course and will eventually take the test. However, they both feel that if an individual has an associate degree or higher education s/he can form as a dietary manager without CDM credentials. The surveyor explained to both that according to CMS regulation, professional qualification/standard, and the state law the individual that performs as a dietary manager without a full time registered dietitian or food service director need to be a certified dietary manager (CDM).",2020-09-01
135,PRUITTHEALTH- COLUMBIA,425013,2451 FOREST DRIVE,COLUMBIA,SC,29204,2018-03-23,812,F,0,1,LL0111,"Based on observation, interview, and review of the facility's policy titled Food Storage, the facility failed to ensure that the kitchen's walkin cooler was kept in good working condition to guarantee cold food items were kept at 41F degrees or lower to prevent the growth of pathogenic microorganisms that can cause foodborne illness. The findings included: During the initial kitchen tour on 03/19/18 at 10:49 AM the thermometer in the walkin cooler read 49F degrees. At approximately 11:20 AM a brand new thermometer was observed in the same walkin cooler, and it read 60F degrees at the time. The dietary manager stated the thermometer was just put in and that it needed some time to adjust. At 04:21 PM on the same day the walkin cooler temperature was reading 49F degrees. At 4:51 PM the temperature of 236 ml carton of 2% milk that was placed on dinner tray at the kitchen read 48F degrees. The milk was taken off the tray and discarded. At approximately 5:08 PM on the same day the walkin cooler temperature log was requested. It was provided. However, it was incomplete and some areas white out. At approximately 5:15 PM on the same day dietary manager #2 stated that the maintenance person was on his/her way to the facility to take a look at the walkin cooler. At approximately 5:20 PM the administrator acknowledged that the walkin cooler was not working properly and s/he stated that the food items in it were not maintained at 41F degrees or lower. S/he also stated that all the food items in the walkin cooler that have the potential for bacterial growth and the potential to cause harm was going to be discarded. At approximately 5:30 PM the surveyor observed the administrator, dietary manager, and kitchen staff throw the following items into a large trash can: 600 of individual cartons of milk (236 ml of whole, 2%, 1% milk carton), one gallon of 2% milk, one container of chy salad, three containers of pimento cheese, two containers of cottage cheese, two pounds of sliced turkey, one container of gravy, one bag of parmesan cheese, 32 sandwiches, 12 cup of yogurt, 20lbs of ground beef, 30 sausage patties, 15lbs of bacon, and 20 pack tortillas. On 3/20/18 at approximately 8:45 AM the walkin cooler temperature was 39F degrees. During an interview with the administration on the same day at approximately 10:00 AM s/he stated that the maintenance person did not find any mechanical problem with the cooler but s/he found a plastic wrap from food on the vent blocking air flow. The plastic wrap was removed, and the cooler temp was back to normal.",2020-09-01
136,PRUITTHEALTH- COLUMBIA,425013,2451 FOREST DRIVE,COLUMBIA,SC,29204,2017-06-20,278,D,1,0,5BIF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interviews the facility failed to accurately assess 1 of 3 residents reviewed for assessments. Resident #2's assessment did not have a cognitive assessment. The resident had been assessed as having a [MEDICAL CONDITION], which was actually a fistula. The findings included: The facility admitted resident #2 with [DIAGNOSES REDACTED]. Review of the medical record revealed a Quarterly Minimum Data Set (MDS) of 2/17/17 revealed the resident's cognition was not coded. No mood or behavior problems. Functional status was total care with Activities of Daily Living, non-ambulatory. S/he was incontinent of bowel and bladder. Weight was 84 lbs. A Significant Change Minimum Data Set (MDS) of 5/10/17 had the resident coded to have no memory problems and was able to make decisions. There were no mood or behavior problems. Functional ability- S/he required total care with all aspects of Activities of Daily Living (ADL's), non-ambulatory. Resident had an indwelling foley and an ostomy for waste elimination. She was 67 inches tall and weighed 84 lbs. Mechanically Altered Therapeutic Diet. One stage III pressure sore, present on admission. 04.0 x 03.5 x 00.1, granulation tissue present in wound bed. The resident received pressure ulcer care and was on pressure reducing devices for bed and chair. On 6/20/17 at 9:20 AM: Registered Nurse (RN), (wound nurse) was interviewed by the surveyor. Resident #2 no longer here. S/he had a sacral wound, stage III. We were doing daily treatments. S/he had a groin wound and was going to the wound clinic for it. S/he had a flesh-eating bacteria, before s/he came here. S/he was an established patient when I became wound nurse. We found out that the groin area was actually a fistula. It wasn't infected, stool was coming through it. It had the risk of being infected. I assessed her/him and sent her/him out. They were using a [MEDICAL CONDITION] device, but s/he did not have a [MEDICAL CONDITION]. They used an ostomy device.",2020-09-01
137,PRUITTHEALTH- COLUMBIA,425013,2451 FOREST DRIVE,COLUMBIA,SC,29204,2017-06-20,279,D,1,0,5BIF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interviews the facility failed to provide an accurate care plan for 1 of 3 residents care plans reviewed. Resident #2's plan of care did not address the fistula or possible complications. The findings included: The facility admitted resident #2 with [DIAGNOSES REDACTED]. Review of the care plan dated 3/26/15, updated 5/17/17 revealed a problem of Self-care deficit in activities of daily living (ADL's). Requires total care with all ADL's related to Cerbralvascular Accident ([MEDICAL CONDITION]), has a foley catheter and a [MEDICAL CONDITION]. Intervention included to provide [MEDICAL CONDITION] care. Review of the Nurse's Notes revealed: On 4/20/17 Upon assessment of groin wound, brown loose stool noted oozing from left groin wound. Family and physician notified. New orders to send resident to ER for further evaluation and treatment. 5/3/17 returned from hospital with a [MEDICAL CONDITION] bag over left abd fold with brown liquid in bad. BM in diaper. Resident on [MEDICATION NAME] for [MEDICAL CONDITION] and on a [MEDICATION NAME]. 5/5/17 at 11:45 AM Labia noted with excoriation related to excessive stools. Review of the Hospital Discharge Summary dated 4/28/17 revealed the resident was admitted to the hospital with [REDACTED]. On 6/20/17 at 9:20 AM: Registered Nurse (RN), (wound nurse) was interviewed by the surveyor. Resident #2 no longer here. S/he had a sacral wound, stage III. We were doing daily treatments. S/he had a groin wound and was going to the wound clinic for it. S/he had a flesh-eating bacteria, before s/he came here. S/he was an established patient when I became wound nurse. We found out that the groin area was actually a fistula. It wasn't infected, stool was coming through it. It had the risk of being infected. I assessed her/him and sent her/him out. They were using a [MEDICAL CONDITION] device, but s/he did not have a [MEDICAL CONDITION]. They used an ostomy device.",2020-09-01
138,PRUITTHEALTH- COLUMBIA,425013,2451 FOREST DRIVE,COLUMBIA,SC,29204,2016-12-15,253,E,0,1,UWQ711,"Based on observation and interview, the facility failed to ensure housekeeping and maintenance services provided an orderly and comfortable interior for the residents. The findings included: During a tour of the facility the following issues and concerns were noted: 1. In the 700 hall the handrails and walls below the handrails had chipped and missing paint. 2. In room 705, there was a broken nightstand, the faucet on the sink leaks, there was black build up on the tile seams, one bed did not have a privacy curtain, and the paint was gouged behind 1 bed. 3. In room 711, 1 dresser was missing wood laminate, a dresser handle was missing, and the baseboard was pulling away from the wall. 4. In the bathroom attached to room 711, there was a brown build up on the pipe leading to the sink and paint chipped away from the wall. 5. In room 715, the clothing lockers were damaged and in poor repair, paint was chipped away from the wall, there was no call light for 1 occupied bed, and 1 bed did not have a privacy curtain. 6. In room 102, the nightstand was missing laminate. 7. In the bathroom attached to room 102, the paint was chipped away from the wall and there was a gap around the pipe leading from the wall to the toilet . 8. In room 107, 1 dresser and 1 nightstand were missing laminate. 9. In room 111, 1 nightstand was missing laminate, the call light box was pulled away from the wall, and the paint behind the bed was gouged. 10. In room 112, 1 nightstand was missing a drawer pull and the paint was chipped away from the wall. 11. In room 125, the closet doors were damaged, 1 dresser and 2 nightstands were missing laminate, and the paint was chipped away from the wall. 12. In the bathroom attached to room 125, there was a gap between the wall and the baseboard. 13. In the dining area on the 200 floor, there was missing laminate from the handrails and rust colored staining on the wallpaper. 14. In room 202 1 nightstand had a missing handle and 1 dresser had missing laminate. 15. In the bathroom attached to room 202 there was a gap around the pipe leading from the wall to the toilet and a gap in the wall around the soap dispenser. 16. On the 300 floor, a piece of the mounted Wanderguard system was hanging off of the wall. 17. In the dining area on the 300 floor there was a large seam in the wallpaper that was pulled apart. 18. In the hall bathroom on the 300 floor, there were large rust colored stains on the walls and the paint was chipped away from the wall. 19. In room 300, 1 dresser had missing laminate and the closet doors had been written on with a black marker. 20. In room 301, there was chipped paint along the entire wall beneath the window. 21. In the bathroom attached to room 301, the adaptive toilet seat had rust colored marks on the metal and the bathroom sink had missing laminate. 22. In room 305, there was a gap between the hall flooring and the room flooring at the threshold to the door. 23. In room 313, there was a gouge in the bathroom door, 1 dresser had missing laminate, the paint was chipped away from the wall, the closet doors were damaged, there were rust colored spots on the ceiling, and there was a hole in the wall behind the door that was approximately 12 inches by 8 inches. 24. In room 317 there was a large area gouged from the bathroom door, 1 dresser had missing laminate, paint was chipped away from the walls, 1 nightstand was missing a drawer pull, and the closet doors were marred with missing stain. 25. In the bathroom attached to room 317, there was a large gap around the pipe leading from the wall to the toilet. 26. In the dining area on the 400 floor, a large vent was bent and pulled away from the wall. 27. In room 406, 1 nightstand was missing a drawer pull. 28. In room 406, 1 nightstand was missing a drawer pull. During a tour on 12/15/16 starting at 10:25 AM, the facility maintenance manager confirmed the above noted issues and concerns.",2020-09-01
139,PRUITTHEALTH- COLUMBIA,425013,2451 FOREST DRIVE,COLUMBIA,SC,29204,2016-12-15,371,E,0,1,UWQ711,"Based on initial tour observation, interview and review of the facility policy Labeling, Dating, and Storage, the facility failed to store foods under sanitary conditions in 1 of 1 kitchen. Dietary staff failed to ensure expired foods were removed from the walk in refrigerator. Freezer food items open and unlabeled. The findings included: During initial tour of the kitchen on 12/12/16 at 10:40 AM with Certified Dietary Manager (CDM) revealed the walk-in refrigerator with 2 containers of 5 lbs. (pound) wholesome foods sour cream had expired on 12/3/16. In the walk-in freezer a bag of full cooked sausage, 1 box of Nordica breaded flounder fillets, and 1 box Baker Source waffles were opened and unlabeled. During the review of the facility policy Labeling, Dating, and Storage: Procedure: 1. Food and/or beverage items will be properly labeled with the name of the item, an open date, and a discard date.",2020-09-01
140,PRUITTHEALTH- COLUMBIA,425013,2451 FOREST DRIVE,COLUMBIA,SC,29204,2016-12-15,441,D,0,1,UWQ711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and review of the facility policy titled, Indwelling Urinary Catheter Care and Management, and Transporting and sorting Soiled Linen, the facility failed to ensure proper perineal care during Foley catheter care for Resident #4 for 1 of 3 residents reviewed for Urinary Incontinence. The facility further failed to handle soiled laundry in a manner to prevent the spread of infections for 1 of 1 laundry rooms observed. The findings included: The facility admitted Resident #4 with [DIAGNOSES REDACTED]. Review on 12/14/2016 at approximately 12:24 PM of the physician's orders revealed an order for [REDACTED]. And an additional physician's order to use a #18 French Foley catheter with a 5-10 milliliter bulb and to change it monthly and as needed for leakage and occlusion. Observation on 12/14/2016 at approximately 1:55 PM of Foley Catheter Care revealed Certified Nursing Assistant (CNA) #1 as he/she knocked on Resident #4's door and asked permission to enter. Resident #4 did not answer. CNA #1 explained the procedure to Resident #4, provided privacy and then washed his/her hands. This surveyor asked for permission to observe the CNA performing Foley catheter care and Resident #4 was unable to answer. After CNA #1 washed his/her hands, he/she proceeded to apply 2 pairs of gloves, removed the brief with the same gloves applied a cleanser to a wipe and cleansed the right outside of the labia with 1 swipe. CNA #1 then did the same for the left side outside the labia. He/she then proceeded to cleanse the catheter tubing from the labia to approximately 2 inches down the tubing. CNA #1 never cleansed the inside of the labia nor did he/she cleanse around the Foley catheter insertion site. The room had a strong urine odor noted on all days of the survey and was brought to the attention of the Nurse Manager for the 400 Unit. During an interview on 12/14/2016 at approximately 2:10 PM with CNA #1, he/she confirmed that he/she had not cleansed the inside of the labia nor the Foley catheter insertion site. Review on 12/14/2016 at approximately 2:30 PM of the facility policy titled,Indwelling Urinary Catheter (Foley) Care and Management, states under, Implementation, bullet 12 reads, Provide routine hygiene for meatal care. The clinical alert reads, Clean the periurethral area carefully, . An observation on 12/15/2016 at approximately 9:50 AM a laundry worker applied a gown and gloves and sorted soiled linen and placed it in a clothes washer. After closing the washer the laundry worker proceeded to start the washer without removing the soiled gloves, and then went over to the laundry room exit door, opened the door and exited into the soiled laundry room and continued to wear the soiled gloves. During an interview on 12/15/2016 at approximately 9:55 AM with Laundry Worker #1, he/she confirmed that he/she had not removed the soiled gloves and started the washer and opened the door and exited without removing the soiled gloves. When asked the Laundry Worker stated the outside of the washers are cleansed in the AM and at around 2:00 PM before the next shift arrives. Review on 12/15/2016 at approximately 10:30 AM of the facility policy titled, Transporting & Sorting Soiled Linen, states under, Policy: This process is a crucial part of infection control requirements. Inservices and constant supervision are necessary to stay within guidelines. Under the section titled, Loading Machines: #1 states, Do not over/under fill machines. Number 2 states, Shut the washer door and select correct programming cycles, start machine. Number 4 states, Remove gloves and wash hands.",2020-09-01
141,PRUITTHEALTH- COLUMBIA,425013,2451 FOREST DRIVE,COLUMBIA,SC,29204,2016-12-15,456,D,0,1,UWQ711,"Based on observations, interviews and review of the facility policy titled, Cleaning of Laundry Equipment, the facility failed to ensure an excessive large amount of lint was removed from the lint baskets, inside the upper dryer walls and from behind 4 of 4 clothes dryers. The facility further failed to ensure stagnant water was not standing behind the clothes washers and draining properly for 1 of 1 laundry rooms observed. The findings included: An observation on 12/15/2016 at approximately 8:30 AM of the laundry room revealed the clothes dryers with an excessive large amount of lint in the lint baskets, inside the upper dryer walls, and behind 4 of 4 clothes dryers. During an interview on 12/15/2016 at approximately 8:30 AM with the Laundry Supervisor, he/she confirmed the findings and stated, The lint baskets, the upper inside walls of the clothes dryers and behind the clothes dryers are cleaned every 2 weeks. Review on 12/15/2016 at approximately 9:00 AM of the facility policy titled, Cleaning of the Laundry Equipment, states under, Dryers: It is important that dryer filters be cleaned after every load. The frame should be cleaned daily, or as needed, with a disinfectant. At the end of the day, the door should be left open to allow the gasket to reshape. Items to be cleaned on the machines are, but not limited to: Dryer filter, shelf above the filter and the floor under the filter At least weekly the combustion chambers must be vacuumed to remove lint build-up. At least quarterly the front of dryers are to be removed and the interior vacuumed to remove lint build-up. Inspect and clean as necessary the dryer exhaust ducts. The area around the thermocouple must be lint free. Lint and heat causes fire. An observation on 12/15/2016 at approximately 8:35 AM of the clothes washers revealed stagnant water standing behind the clothes washers. There were towels around the outside of the area to soak up overflow. Water was pouring into the drain and none was moving out via the drain. An interview on 12/15/2016 at approximately 9:00 AM with the Laundry Supervisor revealed and confirmed that there was stagnant water standing in the drain behind the clothes washers and not properly draining. The Laundry Supervisor went on to say that he/she would have the maintenance department look at it.",2020-09-01
142,CARLYLE SENIOR CARE OF AIKEN,425014,123 DUPONT DR NORTHEAST,AIKEN,SC,29801,2020-01-22,689,D,1,0,E8OZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to provide adequate supervision to prevent resident to resident altercations for one of 17 residents (Resident #16) reviewed for altercations. Resident #16 continued to wander about the facility, including into other resident rooms, following four resident to resident altercations. The findings included: Review of Resident #16's Face Sheet, provided by the facility on 01/20/20, revealed s/he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #16's Quarterly Minimum Data Assessment (MDS) with an Assessment Reference Date of 11/08/19 revealed he/she was unable to complete the Brief Interview of Mental Status (BI[CONDITION]) interview but was assessed by staff to have moderately impaired decision-making abilities; had no behavioral symptoms directed at others; did not wander; and ambulated independently. Review of facility investigations of resident to resident altercations revealed Resident #16 was involved in four of these incidents between 11/15/19 and [DATE]: On 11/15/19 at 04:00 PM, Resident #16 entered Resident #15's room and got into Resident #15's bed while Resident #15 was out of the room. When Resident #15 returned to the room and found Resident #16 in the bed, s/he asked Resident #16 to leave, and Resident #16 hit him/her in the face. On 11/20/19 at 06:00 PM, Resident #16 was again in Resident #15's bed. When Resident #15 asked Resident #16 to leave, Resident #16 hit Resident #15 with his/her shoe. The facility sent Resident #16 to the emergency room , where his/her [MEDICATION NAME] dosage was increased from 0.5 milligrams (mg) three times daily to 1 mg three times daily. On 11/25/19 at 02:15 PM, Resident #16 was ambulating in the hallway near the nurse's station, turned a corner, and encountered Resident #17, who was pacing near the nurse's station. Resident #16 struck Resident #17 in the face. On 1[DATE] at 07:30 PM, Resident #16 was sitting on a sofa in the facility's lobby, where Resident #20 was sitting nearby in his/her wheelchair hitting the sofa cushions. Resident #16 struck Resident #20 on the cheek. On 01/20/19 at 3:30 PM, an interview with Registered Nurse (RN) #1 revealed he/she worked with Resident #16 regularly and was caring for the resident at the time of one of the resident to resident altercations. RN #1 stated he/she was not aware of any other resident to resident altercations for Resident #16, and unaware there may be any need to be aware of his/her whereabouts or proximity to other residents. RN #1 stated it was not uncommon for Resident #16 to wander into other resident rooms, and he/she was not easy to redirect once he/she was in another room. On 01/20/19 at 4:00 PM, an interview with Certified Nursing Assistant (CNA) #1 revealed he/she regularly cared for Resident #16 and was aware of at least two of the altercations. CNA #1 stated it was not unusual for Resident #16 to become agitated with other residents and to wander into other resident rooms. CNA #1 stated Resident #16 could be easily redirected with candy or reading materials if s/he was discovered before s/he entered another resident room, but once s/he was in a resident room it was best to wait until s/he had completed whatever it was s/he thought s/he had to do and leave on his/her own. On 01/20/20 at 4:10 PM, Resident #16 was observed in the hallway outside his/her room, ambulating towards the end of the hallway away from the nurse's station. He/she tried to open the doorway at the end of the hall, which was locked. Resident #16 turned around, ambulated to the other end of the hallway, past the nurse's station in the lobby and several offices where staff were present, past the nurse's station on the back hallway, down the hall to the end where he/she entered another resident's room. When the resident in the room made a noise, Resident #16 left the room, slamming the door shut behind him/her and returning on his/her path. At 4:36 PM, Resident #16 returned to the lobby where he/she sat on a sofa. On 01/21/20 at 09:30 AM, an interview with Licensed Practical Nurse (LPN) #1 revealed he/she worked on what the facility called the back hallway, which was on the opposite end of the facility from where Resident #16 resided. The back hallway included the resident room Resident #16 was observed to enter on 1/20/20 at 4:10 PM. LPN #1 stated he/she was aware of Resident #16 because he/she wanders back here every day. LPN #1 stated it was common for Resident #16 to go into other residents' rooms. LPN #1 stated at times when staff attempted to redirect Resident #16 from those rooms, he/she became agitated and it was best to leave him/her until he/she came out on his/her own. LPN #1 stated he/she was unaware that Resident #16 had had any resident to resident altercations and was unaware of the need for any additional supervision when he/she was wandering. On 01/21/20 at 10:15 AM, an interview with the Director of Nursing Services (DNS) and the Administrator revealed the facility considered the room changes and medication changes to be at the root of Resident #16's resident to resident altercation and had not implemented increased supervision. The DNS stated he/she would expect all staff caring for Resident #16 to be aware of his/her history of resident to resident altercations and automatically redirect him/her if he/she was wandering into other resident rooms. Review of the facility's policy titled, Accidents and Supervision - Policy, dated 10/23/19, revealed, .each resident receives adequate supervision.to prevent accidents.This includes.1. Identifying hazard(s) and risk(s).3. Implementing interventions to reduce hazard(s) and risk(s).",2020-09-01
143,CARLYLE SENIOR CARE OF AIKEN,425014,123 DUPONT DR NORTHEAST,AIKEN,SC,29801,2020-01-22,758,D,1,0,E8OZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review, and review of the facility's policy, it was determined the facility failed to identify and monitor specific target behaviors for residents taking [MEDICAL CONDITION] medications. This was true for one of seventeen residents (Resident #16) sampled for [MEDICAL CONDITION] medication use. The findings included: Review of Resident #16's Face Sheet, provided by the facility on 01/20/20, revealed he/she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #16 Admission physician's orders [REDACTED]. [MEDICATION NAME] (an antipsychotic medication), 5 milligrams (mg) twice daily for a [DIAGNOSES REDACTED]. [MEDICATION NAME] (a benzodiazepine), 2 mg three times daily beginning 08/05/19; and [MEDICATION NAME] (an antipsychotic), 1 mg twice daily beginning 08/05/19. Physician's telephone orders located in the Orders tab of Resident #16's paper clinical record revealed: 08/06/19, decrease [MEDICATION NAME] to 2.5 mg twice daily and decrease [MEDICATION NAME] to 0.5 mg three times daily; 11/21/19, increase [MEDICATION NAME] to 1 mg three times daily; [DATE], increase [MEDICATION NAME] to 5 mg twice daily; 12/05/19, decrease [MEDICATION NAME] to 0.5 mg three times daily. Review of Resident #16's Quarterly Minimum Data Assessment (MDS) with an Assessment Reference Date of 11/08/19 revealed he/she was unable to complete the Brief Interview of Mental Status (BI[CONDITION]) interview but was assessed by staff to have moderately impaired decision-making abilities; had no behavioral symptoms directed at others; and ambulated independently. On 01/21/20 at 10:15 AM, an interview with the Director of Nursing Services (DNS) revealed the facility monitored behaviors for [MEDICAL CONDITION] medications on the Medication Administration Record [REDACTED]. Review of Resident #16's MAR for November and December 2019 and January 2020 revealed, Monitor Resident every shift for behaviors and side effects related to [MEDICAL CONDITION] medication use. The MAR indicated [REDACTED]. An interview with the DNS on 01/21/20 at 02:30 PM revealed the facility had not identified a specific behavior for Resident #16, but he/she was known to wander, become agitated with staff and others, and resist care. The DNS stated the facility did not review the behavior monitors and did not use them when coordinating with the physician or Nurse Practitioner (NP) when discussing [MEDICAL CONDITION] medication dosages or changes. The DNS stated Resident #16's medication changes had all been because he/she either appeared to be over medicated or had engaged in altercations with other residents. An interview with Resident #16's NP on 01/21/20 at 02:45 PM revealed he/she had decreased Resident #16's [MEDICAL CONDITION] medications when he/she saw him/her the day after he/she was admitted because he/she appeared to be so overly sedated and he/she was drooling. The NP stated he/she had made the remainder of the [MEDICAL CONDITION] medication changes based on what he/she saw of Resident #16 when he/she was in the facility, based on staff report, or based on resident to resident altercations. Review of the facility's policy titled, Behavior Management Plan and Form - Policy, dated 03/18/19, indicated, .4. Behaviors should be documented clearly and concisely by facility staff. Documentation should include specific behaviors, time and frequency of behaviors, observations of what may be triggering behaviors, what interventions were utilized, and the outcomes of the interventions.8. Behavior monitoring will be completed through the electronic medical record process.",2020-09-01
144,CARLYLE SENIOR CARE OF AIKEN,425014,123 DUPONT DR NORTHEAST,AIKEN,SC,29801,2016-09-09,226,D,0,1,LUPR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, review of an abuse incident investigation, record review, observation, and a review of the facility's policy and procedure for abuse, including protection, the facility failed to ensure that 1 of 35 sampled residents was protected against future abuse incidents, Resident #2. The findings include: Review of the Abuse Prevention, Investigation and reporting policy (Carlyle Senior Care) approval date 8/25/2016: Policy Statement: The resident has the right to be free from verbal, sexual, physical, and mental abuse, neglect, involuntary seclusion and misappropriation of personal property. Policy Interpretation and Implementation: Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. 1. Screening 2. Training 3. Prevention 4. Identification 5. Investigation 6. Protection The facility protects residents from harm during an investigation. A representative or designee from the Social Services department assesses the resident ' s emotions concerning the incident as well as the residents' reactions to his/her involvement in the investigation. Appropriate steps are taken for protection of the resident from additional harm during the investigation. Unless otherwise requested by the resident, the social service representative or designee will provide the administrator and the director of nursing services with a report of his/her findings. Employees of this facility who have been accused of resident abuse will be reassigned or suspended until the results of the investigation have been reviewed by the administrator. 7. Reporting/Response The facility analyzes the occurrences to determine what changes are needed, if any, to policies and procedures to prevent further occurrences. Resident #2 was admitted in 2000 and readmitted on [DATE]. The resident's current Diagnoses: [REDACTED]. On 9/07/2016 at 2:28 PM an incident report concerning substantiated abuse involving Resident #2 was reviewed and revealed the following: On 6/26/16 at 7 PM several staff members and residents witnessed a CNA hand a small spiral bound index card book to a confused resident and instructed the resident to throw it at Resident #2. The intended target whose book it was asked the CNA why you did that and the CNA stated because you're a pervert, pervert, pervert. The confused resident had picked up Resident #2's spiral bound index card book and a card and carried them away at 6:55 PM and Resident #2 activated their call light and began to yell for help. A nursing assistant answered the call light and the resident explained what happened. The nursing assistant stepped out of the room and noted the CNA, with the book and the card and asked, Is that Resident #2's book? The CNA said, No, it is not his/hers and went to the dining area to sit at the table. The charge nurse approached the CNA and asked her to return the items to Resident #2. The CNA stated, Leave it here and let him/her throw a fit. The charge nurse corrected the CNA by stating, No, you take it back, you cannot let him/her get upset more than he/she already is because someone took his/her property. The CNA took the confused resident by the hand and guided him to Resident #2's doorway and instructed the confused resident to throw it at him/her (Resident #2), hit him/her in the face with it. A statement from the CNA revealed that she had instructed the confused resident to throw the spiral notebook at Resident #2. A review of the facility investigation revealed the facility did remove the CNA from the situation immediately per the Director of Nursing's orders on the evening of 6/26/16. After the facility investigated, it was determined the CNA had violated the resident and was terminated from employment on 6/30/2016 after the incident occurred. A review of the resident's care plan #5 noted the problem was potential for alterations in thought process and difficulty with communication - often has difficulty with finding words to complete sentences, at time runs his words together due to talking very fast. Periods of forgetfulness but often recalls after being reminded related to past head injury Updates: 6/29/16 - request a stop sign be placed in his doorway to prevent residents from entering his room 8/31/16 - Roommate passed away 9/1/16 - Cont. with current care plan Observations of the resident's doorway on 9/6/2016 at approximately 1:15 PM did not reveal any stop sign at the entrance to the resident's room. Apparently the Stop Sign, which was in the care plan as requested by the resident, has been removed but at whose request - it is unknown. The resident is OK with the Stop Sign not here - in honor of his new roommate which is wheeled in and out daily by staff. Observation of the resident on 9/6/2016 at approximately 2 PM revealed the resident in bed stating he/she was doing good . Staff take care of his/her needs. There was on the over the bed table a very small spiral notebook which he/she said was very important to him/her - this notebook was involved in the abuse incident. The resident did state he/she had residents coming in and out of their room - that's what occurred when the resident came in his/her room and took their spiral notebook. Then the staff had him throw it at Resident #2. Interview with the resident on 9/6/16 and 9/7/16 at 1:15 PM revealed the resident confirmed the incident occurred however he/she has no feelings of not being safe. The resident feels the facility takes good care of him/her. Since their admission in 2000 due to [MEDICAL CONDITION] related to a MVA (Motor vehicle accident) the resident has not had any issues like what happened in June. The resident further stated he/she doesn't like people messing with their things. The facility was unable to provide documentation in resident's clinical record, nurse's notes, plan of care, and social services, of the substantiated abuse incident, which was reported by the facility to the state agency. There was a 24 hour report filed with the State of South [NAME]ina and a final report completed by the Director of Nursing on 6/30/16 as a part of the investigation. However there was no documented evidence of effort by the facility to ensure the resident was protected, based on #6 Protection of their Abuse, Prevention, Investigation and Reporting Policy and Procedure located in the facility's Operations Manual approved on 8/25/2016. On 9/07/2016 at 3:15 PM an interview with the DON revealed she was not able to locate any further notes about the incident in the clinical record and was not able to reveal why the incident wasn't documented in the resident's clinical record. An interview with the Social Services Director on 9/09/2016 at 10:14 AM revealed she had documented the incident of abuse but put it somewhere else - not in the clinical record. The facility failed to address the resident psychosocial well-being at the time of the incident and to monitor his/her well-being after the abuse incident occurred to ensure the resident had no further issues. This was also a missed opportunity to monitor the resident's private space and to ensure staff understood how important his/her private space was to Resident #2 by development of a plan of care for Quality of Life. The facility failed to follow their policy and procedure, including documentation of the resident's reactions to his/her involvement in the investigation, to ensure the resident was protected from future abusive incidents.",2020-09-01
145,CARLYLE SENIOR CARE OF AIKEN,425014,123 DUPONT DR NORTHEAST,AIKEN,SC,29801,2016-09-09,253,D,0,1,LUPR11,"Based on observations in the main dining room, 1 of 2 dining areas in the facility, an interview with an unsampled resident, and an interview with the administrator, the facility failed to ensure the main dining room was maintained in a sanitary, orderly and comfortable interior to ensure a pleasant dining environment for the many residents that eat breakfast, lunch, and dinner in the main dining room. The findings include: Observations in the main dining room on 09/08/2016 at 12:33 PM it was noted that both of the cathedral type ceiling, closest to the kitchen, had the following concerns: 1. The overhead vent located on the cathedral ceiling closest to the steam table had peeling plaster/paint peeling on one side of the vent. The area with the peeling plaster/paint was approximately 6 inches by 15 inches long. Approximately 4 inches of plaster/paint was also hanging from this area, resembling icicles. There was a table with a tablecloth located directly under this area of the peeling plaster/paint. Two residents were at the table waiting for their meal. At least 5 ceiling tiles located in this same area appeared with a beige looking stain, possibly indicating a wet appearance. At least 3 tiles were bowed in appearance. There were at least 2 plastic 5 gallon size buckets located under the front of the steam table, not coming into direct contact with the foods being served. There was additional buckets located near the entry to the dining room. Two of the 4 borders had peeling paint on the surface that edged the cathedral ceiling. There were 6 other ceiling tiles that are darker in appearances then the white tiles located next to them. They appear wet (beige looking stain) and bowed. Some of this area also had peeling plaster/paint hanging down. 2. On the cathedral ceiling located near the entrance of the dining room there are numerous ceiling tiles with a beige looking stain, possibly indicating long-term water damage. 3. A red painted wall in the dining room, to the right facing the kitchen/serving line, had stains on it that resembled old moisture drippings. 4. An interview on 9/08/2016 12:39 PM with the dietary manager revealed the issues of the ceiling had come up before. She added the facility management has made an effort to fix the roof which was suspected as the cause of the ceiling disrepair however their attempts have not worked. The facility has a flat roof that has been known to leak when it rains. 5. An observation and an interview with the administrator on 9/08/2016 1:01 PM revealed he was aware of the ceiling and they had someone coming out to look at it. There was no evidence that the facility had made additional effort to repair the roof which may or may not solve the environmental issues on the main dining room ceiling. 6. An interview on 9/8/2016 at approximately 5:05 PM with an alert and oriented resident in the main dining room revealed the roof leaks when it rains. The resident further stated the buckets are used to catch the rain water; the roof leaks.",2020-09-01
146,CARLYLE SENIOR CARE OF AIKEN,425014,123 DUPONT DR NORTHEAST,AIKEN,SC,29801,2017-10-11,155,D,1,1,SACF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and review of the facility policy, the facility failed to observe resident's Advanced Directive rights for 1 of 12 residents reviewed for Advanced Directives. The facility did not ensure the correct code status for Resident #67. The findings included: The facility admitted Resident #67 with a [DIAGNOSES REDACTED]. On [DATE] at 11:10 AM, during record review, a signed and notarized Advanced Directive dated (MONTH) 1, (YEAR), prior to the Resident's admission on [DATE], revealed the Resident requested DNR status. The Physician's admission documentation for Resident #67 stated the Resident did not want CPR and was discussed with the Resident's daughter who is also the Responsible Party. On [DATE] 1:36 PM an interview with the Social Services Director revealed s/he agrees with documentation in the chart stating Resident #67 should be a DNR. S/he also discovered a signed DNR order in the file cabinet in Social Services office for the Resident that was not in the chart. On [DATE] 1:48 PM The Social Services Director stated, I will be changing the code status to DNR immediately for this resident. S/he also stated, I should have caught it; I used to work for DHEC. This surveyor witnessed the Social Services Director remove the FULL CODE page and replace it with the DNR page in Resident #67's chart. On [DATE] 2:05 PM Review of Facility Policy, DO NOT RESUSCITATE- POLICY, Policy Interpretation and Implementation #5 states: If the decision has been made for a natural death, the physician shall be notified and a DNR (DO NOT RESUSCITATE) order will be obtained as well as documented in the clinical records.",2020-09-01
147,CARLYLE SENIOR CARE OF AIKEN,425014,123 DUPONT DR NORTHEAST,AIKEN,SC,29801,2017-10-11,323,G,1,1,SACF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interviews, and observations, the facility failed to provide the care and services necessary to prevent accidents for 1 of 3 residents reviewed for accidents. The facility failed to provide Mechanical Lift for all transfers to have assist of two people required for use of lift for Resident #16. The findings included: Record review revealed Resident #16 was admitted [DATE] with [DIAGNOSES REDACTED]. Non ambulatory and very frail with muscle loss. Observation revealed Resident #16 who has contractures to all the extremities, fingers, with foot drop on both feet. Call bell was observed by her right hand, and the call bell is a squeezable, round-shape that can be rung using her fingers. Resident requires total assistance for all ADL skills and requires a two staff transfer Resident#16's bedroom revealed low bed, bed alarm and floor mat in place. Resident #16 declined to be interviewed. A review of the nurse's notes revealed the following entries; 09/20/2017-- At 8:30pm, CNA called the nurse to Resident #16's room. Nurse observed Resident #16 had a right knee swollen and bruise with knee dislocated. Notified Doctor, DON, and family. 09/21/2017 - Resident #16 returned from the hospital at 12:30 am -- ER reported femur fracture -X-ray reported. Pain meds were given and leg splint in place. Continue to monitor. Review of the Physicians Orders revealed dated 09/20/2017 -Order (R) knee immobilizer Apply to (R) leg Check skin and circulation, shift R/T fracture. A review of the resident's Care Plans revealed the following; Resident #16 will have reduced risk of falls with injury thru the 90 days. Attend to lower extremities during daily care. Evaluate falls risk quarterly and prn. Attend to resident's needs promptly. Keep bed in lowest position. When care isn't being provided, ensure call bell is within reach. Mechanical Lift for all transfers. Assist of two people required for use of lift (05/02/2016). Place in supervised area when up as necessary. On 10/11/2017 at approximately 8:37 am, this surveyor interviewed the Director of Nursing (DON), who stated that Certified Nursing Assistant (CNA #1) was involved in the incident with Resident #16. The DON stated that the CNA's first written statement was not true because the CNA claimed that she and another CNA lifted Resident #16 from the geri chair to the bed, but when asked for the other CNA's name, CNA #1 recanted and stated that she was alone and did the pivoting of Resident #1 by herself/himself from the geri chair to the bed. On 10/11/2017 at approximately 10:30am, this surveyor interviewed the CNA #1 by telephone, who stated that she picked-up Resident #16 from her geri-chair to her bed. When changing the resident, the CNA removed the resident's pants and noticed a bump that had a shape of a light bulb. CNA #1 asked a CNA to get a nurse. Two nurses looked at the resident and decided to send Resident #16 to the hospital. CNA #1 stated that she did not know Resident #16 required a two person transfer. She did not see the policy on the two person transfer because it was hidden behind the closet door. CNA #1 further stated that Resident #16 was not CNAs' resident, and CNA #1 was just helping out. When asked about the first statement which said there was another CNA involved, CNA #1 stated that she was confused.",2020-09-01
148,CARLYLE SENIOR CARE OF AIKEN,425014,123 DUPONT DR NORTHEAST,AIKEN,SC,29801,2017-10-11,441,D,1,1,SACF11,"> Based on observation and interview, the facility failed to follow manufacturer's instructions for disinfecting a multi-use glucometer during 1 of 1 observation of a Finger Stick Blood Sugar. The findings included: On 10/10/2017 at 4:18 PM Licensed Practical Nurse (LPN) #1 was observed performing a Finger Stick Blood Glucose on Resident # 1. The LPN washed her/his hands, placed the glucometer inside a glove and pinched an opening into the glove. After obtaining the specimen and completing the procedure the LPN removed the glucometer from glove, removed her/his gloves, sanitized her/his hands and signed the procedure off on the Medication Administration Record. LPN #1 cleaned the glucometer with an Alclavis Bleach-Wipe for approximately 10 seconds. During an interview at that time, the LPN stated s/he cleaned the glucometer for about 5 seconds. The LPN confirmed s/he was not aware manufacturer's instructions were to keep the device visibly wet for 5 minutes to be effective against Clostridium Difficile. In addition, the LPN stated s/he usually used the other (Microdot) bleach wipe and just wipes it down good and allows it to air dry and stated that was the policy. Review of the Microdot instructions at that time revealed the instructions indicated a 3 minute contact time for Clostridium Difficile. The nurse also stated that it was policy to clean the device after use, not before. During an interview at 4:37 PM, the Director of Nursing (DON) stated each cart had 2 glucometers, one to be used will the other is air drying. Three additional nurses were interviewed regarding the policy for cleaning the glucometer and all 3 stated the device needed to have a contact time of 3-5 minutes. Review of the policy revealed 2. Sanitize the glucometer with the appropriate product (i.e. (that is) Sani cloth, Glucometer Wioe, etc (et cetera) .) as long as the product contains bleach. 3. Allow the glucometer to completely air dry before storage or use. During an interview on 10/11/17 at 2:14 PM, the DON confirmed the instructions on both products and stated s/he would expect the nurse to read the directions. The DON also stated that s/he would expect the device to be kept wet for the longest amount of contact time specified in the directions. The DON further stated that 40 new glucometers had been ordered so each resident that needs it will have their own dedicated device and provided a copy of the purchase order dated 10/02/17.",2020-09-01
149,CARLYLE SENIOR CARE OF AIKEN,425014,123 DUPONT DR NORTHEAST,AIKEN,SC,29801,2018-11-30,573,E,0,1,JLSM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy titled Resident Rights and interview, the facility failed to provide copies of medical records to 5 of 5 residents who had requested them. Four of 10 residents in the Group Meeting (Residents #7, #31, #73, and #77) and Resident #43 stated they had requested copies of their medical records and had not received them. The findings included: On 11/28/18 at approximately 10:36 AM, a Resident Council meeting was held with the surveyor, attended by 10 interviewable residents, all with Brief Interview for Mental Status scores ranging from 10-15. During the group interview, 4 of the 10 residents expressed that multiple requests had been made in attempts to obtain their medical records from the facility. Resident #s 7, 31, 73, and 77 all expressed they had made multiple requests to the Administrator and to their direct care staff. Review of the grievance log on 11/28/18 at approximately 3:00 PM revealed there were no references to requests made. During an interview with the Administrator and Social Services Director on 11/29/2018 at 9:45 AM, the Administrator indicated s/he was unaware of any requests and if there had been, they would have been taken care of. However, upon further interview, s/he indicated there was no documentation available proving or disproving the requests were made. Review of the facility's admission packet section labeled Resident Rights states: The resident has the right to access personal and medical records pertaining to him or herself. The facility admitted Resident #43 with [DIAGNOSES REDACTED]. Record review on 11/30/18 at 7:50 AM revealed that the resident was hospitalized from 8-31-18 to 9-6-18 Urinary Tract Infection, Hydro[DIAGNOSES REDACTED], [MEDICAL CONDITION], Dehydration, and Acute Kidney Injury. S/he was also hospitalized from 9-25-18 to 9-26-18 for [MEDICAL CONDITION] Calculus, Hydro[DIAGNOSES REDACTED], and Recurrent [MEDICATION NAME]. During an interview on 11/26/18 at 4:19 PM, Resident #43 stated s/he had requested to see her medical records related to the kidney problems s/he had experienced. S/he stated s/he had requested them from Licensed Practical Nurse (LPN) #2 four times. When asked what the nurse's response was, the resident stated, She (He) says she (he) can't find them. During an interview on 11/29/18 at 4:13 PM, LPN #2 stated s/he did not remember discussing a medical records request with the resident. When asked, the nurse initially stated that if the resident requested medical records, s/he would have told her/him that her/his daughter would need to go to the physician and request them. When the surveyor noted the resident's cognitive status, the nurse stated s/he would have obtained them for the resident. Following the interview, LPN #2 and the surveyor went to the resident's room. The resident confirmed that this nurse was the one from whom s/he had requested the records. The resident stated s/he had handed the records to LPN #2 in an envelope when s/he returned from her/his urology appointment. After visiting with Resident #43, LPN #2 stated, She (He) probably has me mixed up with (LPN #3). Record review on 11/30/18 at 8:25 AM revealed a 10/18/18 Nurses Note at 2:56 PM signed by LPN #2 which stated, Resident returned from Dr.---, urology.",2020-09-01
150,CARLYLE SENIOR CARE OF AIKEN,425014,123 DUPONT DR NORTHEAST,AIKEN,SC,29801,2018-11-30,578,D,0,1,JLSM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility policy titled Resident Right to Formulate Advance Directives, the facility failed to ensure accuracy for 2 of 2 residents reviewed for advance directives. The findings included: Resident #51 was admitted to the facility on [DATE]. Review of his/her medical record on [DATE] showed that on [DATE] the Patient Self-Determination Act was signed by the Responsible Party (RP) indicating desires to have a living will or medical proxy. Additional review showed only an Emergency Medical Services Do Not Resuscitate Order signed on [DATE]. An interview with the Director of Nursing (DON) on [DATE] at 3:49 PM indicated there was no Physician's Order for a DNR nor was there any documentation indicating the Resident's inability to make health care decisions. Review of the facility's policy titled, Resident Right to Formulate Advance Directives, on [DATE] indicated the facility will periodically assess the resident for decision-making abilities and approach the health care proxy or legal representative if the resident is determined not to have decision making capabilities. The facility admitted Resident #135 on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission 5-day Minimum Data Set assessment revealed the resident had both short- and long-term memory problems with severely impaired decision-making ability. Record review on [DATE] at 8:53 AM revealed a full-page bright green form noting FULL CODE in the front of the medical record. Physician's Orders also noted the resident as a full code. Review of the Care Plan on [DATE] at 9:48 AM revealed Problem/Need #1: I desire advanced directives/DNR (Do Not Resuscitate) as of [DATE]. Approaches included to Honor my request for DNR status and Do not perform CPR (Cardiopulmonary Resuscitation) on me. During an interview on [DATE] at 11:38 AM, when asked individually how they would determine a resident's code status in case of an emergency, Licensed Practical Nurse (LPN) #1 and Registered Nurse (RN) #1 opened the medical record to the bright green page indicating the resident was a full code. Both nurses verified there was no documentation under the advance directives tab in the medical record. RN #1 reviewed the Care Plan and confirmed that it noted that a DNR advance directive was effective [DATE]. After further record review, the RN also confirmed there was no Physician's Order for DNR. During an interview on [DATE] at 11:58 AM, the Director of Nurses (DON) reviewed and verified the Care Plan and full code form. On [DATE] at 9:29 AM, the DON stated, They should not have added DNR to the Care Plan until the certification by 2 physicians of inability to make health care decisions had been completed.",2020-09-01
151,CARLYLE SENIOR CARE OF AIKEN,425014,123 DUPONT DR NORTHEAST,AIKEN,SC,29801,2018-11-30,580,D,0,1,JLSM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure written notice of room/roommate change was provided to 2 of 2 residents reviewed for notification of change (Residents #51 and #11). The findings included; Review of the medical record on 11/29/2018 at 4:47 PM revealed that Resident #51 was moved from room [ROOM NUMBER]A to 151A on 11/26/2018. The Social Services Notes dated 11/26/2018 stated that the family was notified by telephone. Additionally, review of Resident #11's medical record on 11/28/2018 indicated s/he had a last documented roommate change on 7/13/2017 by Social Services. However, the resident received a new roommate on 11/26/2018 and indicated to this surveyor during an interview on 11/26/2018 that s/he had not been informed of the change. S/he stated the new roommate just showed up with his/her belongings and no one told me anything. Review of the Social Services Notes revealed no documentation related to the recent roommate change. During an interview on 11/28/18 at 12 PM, the Social Services Director stated that written notices were not sent out and notifications of room/roommate changes were made only by telephone calls. Review of the facility's policy titled, Resident Rights/ Room and/or Roommate Change states, The resident and/or family have the right to be informed in advance and in writing, to include the reason for the change, before the room or roommate in the facility is changed, unless it is an emergent situation for resident safety.",2020-09-01
152,CARLYLE SENIOR CARE OF AIKEN,425014,123 DUPONT DR NORTHEAST,AIKEN,SC,29801,2018-11-30,583,E,0,1,JLSM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to protect the privacy of medical records for 3 of 3 sampled residents reviewed for Baseline Care Plans (Residents #51, #65, and #135). The findings included: The facility admitted Resident #135 on 11-8-18 with [DIAGNOSES REDACTED]. Dementia with Behavioral Disturbance, [MEDICAL CONDITIONS] Fibrillation, [MEDICAL CONDITION], Hypertension, [MEDICAL CONDITION], Reflux, [MEDICAL CONDITION] Left Lower Extremity, and Acute Kidney Injury. Review of the 11/8/18 Baseline Care Plan on 11/28/18 at 9:48 AM revealed documentation that the plan was verbally reviewed with the Resident Representative on 11/9/18. There was no evidence in the record that a summary or copy of the Baseline Care Plan was provided. During an interview on 11/28/18 at 4:31 PM, the Minimum Data Set (MDS) Coordinator stated that if the resident and family were not able to attend the Baseline Care Plan meeting and s/he was unable to reach them by phone, s/he documented and left a copy in the resident's room in an envelope. Resident #65 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #51 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Record review for Residents #65 and #51 revealed no evidence that the facility had provided summaries or copies of the Baseline Care Plans to the residents or their representatives. During an interview on 11/28/18 at 4:31 PM, the Minimum Data Set (MDS) Coordinator stated s/he did not mail out the summaries or copies. S/he stated s/he left them in the resident's room in an envelope and called the family to let them know s/he left it in the room if s/he could get hold of them. The facility's Baseline Care Plan and Form Policy states, The facility must provide the resident and their representative with a summary of the baseline care plan .",2020-09-01
153,CARLYLE SENIOR CARE OF AIKEN,425014,123 DUPONT DR NORTHEAST,AIKEN,SC,29801,2018-11-30,584,E,0,1,JLSM11,"Based on observations and interviews, the facility failed to ensure corridor wall coverings and baseboards were in good repair primarily on 1 of 4 halls. The findings included: On all days of the survey,[NAME]Hall wall coverings were noted to be permanently stained with what appeared to be some type of liquid that had been sprayed, run down the walls, and dried. Baseboards were darkly scarred throughout and chipped in multiple places. Housekeeping contracted management was observed cleaning the walls on 11/27/18 and 11/28/18 in unsuccessful attempts to remove the wall stains. On 11/27/18 at 1:38 PM, the Assistant Director of Nurses verified that wall coverings were discolored and stated, It looks like it has been sprayed with something. On 11/27/18 at 5:30 PM, the Administrator and Housekeeping Contract Manager stated the walls had been cleaned but the stains would not come out. On 11/28/18 at 8:51 AM, the Housekeeping Contract Manager stated the walls must have been cleaned with an inappropriate chemical.",2020-09-01
154,CARLYLE SENIOR CARE OF AIKEN,425014,123 DUPONT DR NORTHEAST,AIKEN,SC,29801,2018-11-30,604,D,0,1,JLSM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to ensure the resident is free from unnecessary physical restraint. The facility did not afford the resident the opportunity to be free from the restraint when in close view of the staff or when participating in activities in the presence of the activity coordinator, other staffs and residents. The facility also failed to appropriately implement attempts to discontinue the restraint for one of six sample residents reviewed for restraints. The findings included: The facility admitted Resident #66 on 6/9/17 with [DIAGNOSES REDACTED]. During the initial survey tour on 11/26/18 at 10:45 AM Resident #66 seat on his/her wheelchair in the dining/activity room, lap belt in place, attempting to take off arm skin protector, at which time a certified nursing assistant (C.N.A) took the resident back to his/her room. On 11/27/18 the resident was seated at the nurse's station again and half an hour later in the activity room, lap belt in place at both observations. Resident's room observation on 11/28/18 at 10:42 AM revealed bed in low position, side rails in place and large floor mats at both side of the bed. Nurse's notes reviewed on 11/27/18 at 1:13 PM revealed that the resident has a lap belt restraint that is released every two hours, during activity and meal times. However, this intervention did not occur during surveying hours. According to the care plan reviewed on 11/28/18 at approximately 11:00 AM on 11/13/18 the facility put a three day restraint reduction attempt in placed, Lap belt removed and resident situated in the common area for easy viewing. But the restraint reduction documentation showed that after releasing the lap belt if the resident tried to get up from his/her wheelchair the staff would place the lap belt back on. During an interview with the care plan coordinator and director of nursing (DON) on 11/28/18 at approximately 11:30 AM confirmed that the three days restraint reduction attempt not done correctly according to documentation.",2020-09-01
155,CARLYLE SENIOR CARE OF AIKEN,425014,123 DUPONT DR NORTHEAST,AIKEN,SC,29801,2018-11-30,607,D,0,1,JLSM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement the policy related to Abuse for one incident of resident to resident abuse reviewed. The findings include; Res #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 11/26/2018 at approximately 2:43 PM during a resident interview with this surveyor, Resident #11 indicated that s/he had been kicked on last week by another resident and nothing was done about it. Further interview, the resident explained a male resident had approached him/her, kicked and walked away. After the incident, s/he told Registered Nurse (RN) #2 who then was believed to have told the Director of Nursing (DoN). Further interview with RN #2, s/he stated s/he had told the DoN but had not personally done anything to alleviate or investigate the incident. During record review on 11/28/18 at 9:15 AM, there was no documentation of the alleged incident noted. During an interview with RN#2 on 11/28/18 at 12:28 PM, s/he indicated that s/he had not visibly witnessed the incident, but the resident had made him/her aware and s/he told his/her direct supervisor, the DoN. On 11/28/2018 at 3:26 PM, during an interview with the DoN, s/he stated this was his/her first time hearing of the incident. Review of the facility's policy titled, Resident Rights- Abuse and Abuse Prevention, Neglect and Exploitation provided by the DoN on 11/28/18 at 3:30 PM states response and reporting of abuse, neglect and exploitation- anyone in the facility can report suspected abuse to the abuse agency hotline, when abuse, neglect or exploitation is suspected, the Licensed Nurse should: respond to the needs of the resident and protect them from further incident (Document), notify the Director of Nursing and Administrator (document), and initiate an investigation immediately .",2020-09-01
156,CARLYLE SENIOR CARE OF AIKEN,425014,123 DUPONT DR NORTHEAST,AIKEN,SC,29801,2018-11-30,609,D,0,1,JLSM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to report an allegation of resident-resident abuse in a timely manner. The findings included; Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 11/26/2018 at approximately 2:43 PM during a resident interview with this surveyor, Resident #11 indicated that s/he had been kicked on last week by another resident and nothing was done about it. Further interview, the resident explained a male resident had approached him/her, kicked and walked away. After the incident, s/he told Registered Nurse (RN) #2 who then was believed to have told the Director of Nursing (DoN). During record review on 11/28/18 at 9:15 AM, there was no documentation of the alleged incident noted. During an interview with RN#2 on 11/28/18 at 12:28 PM, s/he indicated that s/he had not visibly witnessed the incident, but the resident had made him/her aware and s/he told his/her direct supervisor, the DoN. On 11/28/2018 at 3:26 PM, during an interview with the DoN, s/he stated this was his/her first time hearing of the incident. Review of the facility's policy titled, Resident Rights- Abuse and Abuse Prevention, Neglect and Exploitation provided by the DoN on 11/28/18 at 3:30 PM states response and reporting of abuse, neglect and exploitation- anyone in the facility can report suspected abuse to the abuse agency hotline, when abuse, neglect or exploitation is suspected, the Licensed Nurse should: respond to the needs of the resident and protect them from further incident (Document), notify the Director of Nursing and Administrator (document), and initiate an investigation immediately .",2020-09-01
157,CARLYLE SENIOR CARE OF AIKEN,425014,123 DUPONT DR NORTHEAST,AIKEN,SC,29801,2018-11-30,610,D,0,1,JLSM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to report an allegation of resident-resident abuse in a timely manner. The findings included; Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 11/26/2018 at approximately 2:43 PM during a resident interview with this surveyor, Resident #11 indicated that s/he had been kicked on last week by another resident and nothing was done about it. Further interview, the resident explained a male resident had approached him/her, kicked and walked away. After the incident, s/he told Registered Nurse (RN) #2 who then was believed to have told the Director of Nursing (DoN). During record review on 11/28/18 at 9:15 AM, there was no documentation of the alleged incident noted. During an interview with RN#2 on 11/28/18 at 12:28 PM, s/he indicated that s/he had not visibly witnessed the incident, but the resident had made him/her aware and s/he told his/her direct supervisor, the DoN. On 11/28/2018 at 3:26 PM, during an interview with the DoN, s/he stated this was his/her first time hearing of the incident. S/he then verified there was no investigation started at the time or any information documented regarding the incident. Review of the facility's policy titled, Resident Rights- Abuse and Abuse Prevention, Neglect and Exploitation provided by the DoN on 11/28/18 at 3:30 PM states response and reporting of abuse, neglect and exploitation- anyone in the facility can report suspected abuse to the abuse agency hotline, when abuse, neglect or exploitation is suspected, the Licensed Nurse should: respond to the needs of the resident and protect them from further incident (Document), notify the Director of Nursing and Administrator (document), and initiate an investigation immediately .Additionally the policy states when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur, an investigation is immediately warranted. Once the resident is cared for and intial reporting has occurred, an investigation should be conducted.",2020-09-01
158,CARLYLE SENIOR CARE OF AIKEN,425014,123 DUPONT DR NORTHEAST,AIKEN,SC,29801,2018-11-30,623,D,0,1,JLSM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview , the facility failed to provide written notice of facility-initiated transfer to the Residents' Representatives and/or Ombudsman for 2 of 5 sampled residents reviewed for hospitalization (Residents #67 and #70) . The findings included: The facility admitted Resident #67 with [DIAGNOSES REDACTED]. Record review on 11/28/18 at 2:31 PM revealed the resident was transferred to the hospital on 9-25-18 for Aspiration Pneumonia. Further review revealed no evidence of written notification of the transfer to the Resident Representative. During an interview on 11/30/18 at 12:12 PM, when asked about notification of the family, Social Services stated there should be documentation in the record that the family was called. S/he was unaware of the requirement for a written notice to be sent. The facility admitted Resident #70 with [DIAGNOSES REDACTED]. Record review on 11/27/18 at 12:53 PM revealed the resident was hospitalized from [DATE] to 10/26/18 for Agitation, Combativeness, and [DIAGNOSES REDACTED]. Further review revealed no evidence of written notification of the transfer to the Resident Representative or Ombudsman. During an interview on 11/30/18 at 12:18 PM, Social Services reviewed her/his documentation of monthly reports and stated s/he had not sent transfer notifications to the Ombudsman for the month of October. S/he was unaware of the requirement for a written notice of transfer to be sent to the Resident Representative.",2020-09-01
159,CARLYLE SENIOR CARE OF AIKEN,425014,123 DUPONT DR NORTHEAST,AIKEN,SC,29801,2018-11-30,625,D,0,1,JLSM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide written notice of bed-hold to the Residents' Representatives upon facility-initiated transfer for 2 of 5 sampled residents reviewed for hospitalization (Residents #67 and #70). The findings included: The facility admitted Resident #67 with [DIAGNOSES REDACTED]. Record review on 11/28/18 at 2:31 PM revealed the resident was transferred to the hospital on 9-25-18 for Aspiration Pneumonia. Further review revealed no evidence of written notification of the facility's bed-hold policy supplied to the Resident Representative upon transfer. During an interview on 11/30/18 at 9:18 AM, the Director of Nurses (DON) reviewed the record, was unable to locate any information about bed-hold notification, and referred the surveyor to Social Services. During an interview on 11/30/18 at 12:12 PM, Social Services reviewed the record and was unable to locate any information about bed-hold notification. S/he was unsure who was responsible for bed-hold notification upon transfer. The facility admitted Resident #70 with [DIAGNOSES REDACTED]. Record review on 11/27/18 at 12:53 PM revealed the resident was hospitalized from [DATE] to 10/26/18 for Agitation, Combativeness, and [DIAGNOSES REDACTED]. Further review revealed no evidence of written notification of the facility's bed-hold policy supplied to the Resident Representative upon transfer. During an interview on 11/30/18 at 9:18 AM, the Director of Nurses (DON) reviewed the record, was unable to locate any information about bed-hold notification, and referred the surveyor to Social Services. During an interview on 11/30/18 at 12:18 PM, Social Services reviewed the record and was unable to locate any information about bed-hold notification. S/he was unsure who was responsible for bed-hold notification upon transfer.",2020-09-01
160,CARLYLE SENIOR CARE OF AIKEN,425014,123 DUPONT DR NORTHEAST,AIKEN,SC,29801,2018-11-30,641,E,0,1,JLSM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to assure the accuracy of assessments for 7 of 23 sampled residents reviewed for accuracy of Minimum Data Set (MDS) assessments (Residents #23, #52, #57, #66, #67, #70, and #135) and for 2 of 2 residents noted on the MDS 3.0 Missing OBRA Assessment report (Residents #40 and #60). The findings included: The facility admitted Resident #23 with [DIAGNOSES REDACTED]. Review of the 8-29-18 Admission/5-Day and the 9/7/18 14-Day MDS assessments on 11/29/18 at 11:23 PM revealed the following: (1) Section B of both assessments noted that the resident was sometimes understood and sometimes understands. However, the Section C Brief Interview for Mental Status (BIMS) and the Section D Mood interviews were not conducted. The reasons recorded were that the resident was rarely/never understood. (2) The 9/7/18 14-Day assessment only had one fall coded. Review of Incident/Accident Reports on 11/30/18 at 9:34 AM revealed the resident had sustained 2 falls during the 7-day look-back period (on 9/1/18 and 9/5/18). During an interview on 11/30/18 at 10:19 AM, the MDS Coordinator stated that Sections C and D were completed by Social Services. S/he verified that the coding for not conducting the interview because the resident was rarely/never understood was not consistent with the coding in Section B. S/he reviewed the record, verified the falls noted in the Nurses Notes and on the Care Plan, and confirmed that the number of falls coded on the 14-Day MDS was incorrect. The facility admitted Resident #52 with [DIAGNOSES REDACTED]. Hypertension, [MEDICAL CONDITION], Dementia, Aspiration Pneumonia, Dysphagia, Gastro-[MEDICAL CONDITION] Reflux Disease, B-12 Deficiency, and Multiple [MEDICAL CONDITION]. Review of the 2-6-18 Significant Change and the 10-21-18 Quarterly MDS assessments on 11/27/18 at 7:48 PM revealed the following: (1) Section B of both assessments noted that the resident was usually understood and sometimes understands. However, the Section D Mood and Section F Preferences for Customary Routines and Activities interviews were not conducted. The reasons recorded were that the resident was rarely/never understood. (2) On the 2/6/28 MDS, J1400 was coded that the resident did not have a life expectancy of less than 6 months. Record review on 11/29/18 at 12:32 PM revealed physician's orders [REDACTED]. During an interview on 11/29/18 at 3:05 PM, the MDS Coordinator stated that Section D was completed by Social Services. S/he verified that the coding for not conducting the interview because the resident was rarely/never understood was not consistent with the coding in Section B. S/he reviewed the record and verified that J1400 should have been coded that the resident's life expectancy was less than 6 months. S/he stated that Section F, usually completed by the Activity Director, should have been completed with the resident's/family's input as the spouse came 3 times per week. The facility admitted Resident #57 with [DIAGNOSES REDACTED]. Review of the 10-21-18 Annual MDS assessment on 11/29/18 at 11:43 PM revealed the following: The Section F Preferences for Customary Routines and Activities interviews were not conducted. The reason recorded was that the resident was rarely/never understood. Section B noted the resident was usually understood and understands. During an interview on 11/30/18 at 11:46 AM, the MDS Coordinator confirmed that the Section F interviews had not been conducted and that the coding for not conducting the interview because the resident was rarely/never understood was not consistent with the coding in Section B. The facility admitted Resident #67 with [DIAGNOSES REDACTED]. Review of the 6-3-18 Quarterly and the 10-26-18 30-Day Quarterly MDS assessments on 11/26/18 at 1:59 PM revealed the following: (1) The 6-3-18 Quarterly MDS noted that the resident had both a weight loss and a weight gain. (2) The 10-26-18 30-Day Quarterly MDS noted that there was a weight loss but that the resident was on a physician prescribed weight loss program. During an interview on 11/30/18 at 11:51 AM, the MDS Coordinator confirmed that the resident had no significant weight gain during the period in review by the 6-3-18 MDS and that the resident had never been on a physician prescribed weight loss program. The facility admitted Resident #70 with [DIAGNOSES REDACTED]. Review of the 12-3-17 Annual and the 11-2-18 Significant Change MDS assessments on 11/27/18 at 6:22 PM revealed the following: (1) The pain interviews in Section J were not conducted for either assessment. (2) The 12-3-17 Annual MDS noted the resident's weight at 221 pounds and indicated s/he was on a physician prescribed weight gain program. (3) The 11-2-18 Significant Change MDS noted the resident's weight at 198 pounds and indicated s/he was on a physician prescribed weight loss program. During an interview on 11/29/18 at 03:13 PM, the MDS Coordinator verified that the pain interviews had not been conducted. S/he stated that the resident had not been on any physician-prescribed weight loss or gain programs. During an interview on 11/29/18 at 4:20 PM, the Dietary Manager stated s/he had hit the wrong button. The facility admitted Resident #135 on 11-8-18 with [DIAGNOSES REDACTED]. Dementia with Behavioral Disturbance, [MEDICAL CONDITIONS] Fibrillation, [MEDICAL CONDITION], Hypertension, [MEDICAL CONDITION], Reflux, [MEDICAL CONDITION] Left Lower Extremity, and Acute Kidney Injury. Review of the 11-15-18 Admission/5 day MDS on 11/28/18 at 9 AM revealed the following: (1) [DIAGNOSES REDACTED]. (2) Inattention, disorganized thinking, and physical behavior toward others were not coded for this resident. The resident was admitted with information from the hospital stating that s/he was exit-seeking and incapable of reality-based thinking. Review of Nurses Notes on 11/28/18 at 10:07 AM revealed the resident was combative when redirected, aimlessly ambulated in the hall, and remained seated for short times only. S/he struck another resident while s/he was asleep on 11-15-18. During an interview on 11/29/18 at 03:30 PM, the MDS Coordinator verified that the [DIAGNOSES REDACTED]. S/he also noted that the resident-to-resident abuse should have been coded because the incident occurred on the assessment reference date. Review of the MDS 3.0 Missing OBRA Assessment report with the MDS Coordinator on 11-29-18 revealed that (1) the facility had completed/transmitted an assessment for Resident #40 with the wrong gender, and (2) for Resident #60, the facility had entered the wrong birth date. The facility admitted Resident # 66 on 6/9/17 with [DIAGNOSES REDACTED]. Nurse's notes reviewed on 11/27/18 at 1:13 PM revealed that on 8/9/18 the facility placed a self-release lab belt restraint on the resident, related to many falls. On 8/14/18 the facility had the resident evaluated for hospice services. The resident started hospice care on 8/15/18. The Minimum Data Set (MDS) reviewed on 11/27/18 at 2:39 PM indicated that the MDS coordinator conducted a significant change assessment on 8/15/18. However, s/he did not note the restraint or hospice services. During an interview on 11/28/18 at 9:38 AM the DMS coordinator confirmed the above findings.",2020-09-01
161,CARLYLE SENIOR CARE OF AIKEN,425014,123 DUPONT DR NORTHEAST,AIKEN,SC,29801,2018-11-30,644,D,0,1,JLSM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to complete a Preadmission Screening and Resident Review (PASRR) Level II for a resident with a positive PASRR level I and a history of psychiatric hospitalization at the time of admission to the facility for one of one sampled resident reviewed for PASRR. Findings: The facility admitted Resident #15 on 12/1/14 with [DIAGNOSES REDACTED]. During an observation on 11/26/18 at 3:34 PM the resident seems to get agitated very easy when greeted in the hallway s/he responded in a distrustful manner. The next day, during lunch in the dining room s/he did not want the certified nursing assistant (C.N.A) to help him/her with the food protector. Nurse's notes reviewed on 11/29/18 at 2:36 PM indicated that the resident could verbalize some need to staff. However, his speech is unclear and incoherent and often refuses care, gets combative and yells out loud. Record reviewed on 11/29/18 at approximately 3:00 PM revealed a PASRR level I completed on 11/18/14 (prior admission) indicated that the resident had a history of [REDACTED]. During an interview with the DON on 11/29/18 at 4:00 PM she stated that the resident had not had any incidents for the last three months. She also noted that the resident had not had a PASARR Level II because according to his/her interpretation of the regulation the resident did not need one. The DON later acknowledged that the resident should have had a level II PASRR and possibly psychiatric services.",2020-09-01
162,CARLYLE SENIOR CARE OF AIKEN,425014,123 DUPONT DR NORTHEAST,AIKEN,SC,29801,2018-11-30,655,E,0,1,JLSM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation,record review and interview the facility failed to provide evidence of Baseline care plan development and provided summaries for 3 of 3 residents reviewed for baseline care plans. The findings included: Resident #65 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #51 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Record review for Residents #65 and #51 revealed the facility had not provided copies of the summary of the baseline care plans to the residents or their representatives. During an interview on 11/28/18 at 4:31 PM, the Minimum Data Set (MDS) Nurse indicated s/he does not mail out the summaries, s/he leaves it in the room in an envelope and calls the family to let them know s/he left it in the room if s/he can get a hold of them. A review of the facility's MDS Policy- Baseline Care Plan and Form Policy on 11/30/2018 at 12:47 PM states, the facility must provide the resident and their representative with a summary of the baseline care plan . The facility admitted Resident #135 on 11-8-18 with [DIAGNOSES REDACTED]. Dementia with Behavioral Disturbance, [MEDICAL CONDITIONS] Fibrillation, [MEDICAL CONDITION], Hypertension, [MEDICAL CONDITION], Reflux, [MEDICAL CONDITION] Left Lower Extremity, and Acute Kidney Injury. Review of the 11/8/18 Baseline Care Plan on 11/28/18 at 9:48 AM revealed documentation that the plan was verbally reviewed with the Resident Representative on 11/9/18. There was no evidence in the record that a summary or copy of the Baseline Care Plan was provided. During an interview on 11/28/18 at 4:31 PM, the Minimum Data Set (MDS) Coordinator stated that if the resident and family were not able to attend the Baseline Care Plan meeting and s/he was unable to reach them by phone, s/he documented and left a copy in the resident's room in an envelope. The Minimum Data Set (MDS) Coordinator stated s/he never mailed a summary or copy of the Baseline Care Plan to the Resident Representative.",2020-09-01
163,CARLYLE SENIOR CARE OF AIKEN,425014,123 DUPONT DR NORTHEAST,AIKEN,SC,29801,2018-11-30,656,D,0,1,JLSM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to develop/implement the care plan interventions related to proper positioning during enteral feeding therapy for one of two sampled residents reviewed for tube feeding. Findings: The facility admitted Resident #33 on 3/11/18 with [DIAGNOSES REDACTED]. During the initial survey tour on 11/26/18 at 4:22 PM observed Resident #33 in a low bed with the head of it slightly raised and the resident slid down to the lower part of the bed while receiving enteral feeding. On 11/27/18 at 11:03 AM, 11/29/18 at 2:57 PM, and 11/29/18 at 4:05 PM observed the resident in a similar position. At no point during the survey, from 11/26 through 11/30, the surveyor saw any of the facility staff turning or repositioning the resident. The care plan reviewed on 11/29/18 at 3:40 PM indicated that the head of the resident's bed should be up 30-45 degrees during feeding therapy. The care plan also stated that the certified nursing assistant would turn and reposition the resident every 2 hours to prevent skin breakdown related to impaired bed mobility. The care plan did not address the resident actual or inappropriate positioning during feeding therapy. During an interview on 11/29/18 at 4:05 PM the unit manager confirmed that the resident slid down in his/her bed during feeding and stated that as an intervention to prevent complication the resident gets repositioned every 2 hours, however, s/he was not able to provide supporting evidence/documentation to indicate that the resident is being turned and repositioned every 2 hours.",2020-09-01
164,CARLYLE SENIOR CARE OF AIKEN,425014,123 DUPONT DR NORTHEAST,AIKEN,SC,29801,2018-11-30,657,D,0,1,JLSM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to update the Care Plan for one of two sampled residents reviewed for abuse. The Care Plan for Resident #135 was not updated to include an incident of resident-to-resident abuse. The findings included: The facility admitted Resident #135 on 11-8-18 with [DIAGNOSES REDACTED]. Dementia with Behavioral Disturbance, [MEDICAL CONDITIONS] Fibrillation, [MEDICAL CONDITION], Hypertension, [MEDICAL CONDITION], Reflux, [MEDICAL CONDITION] Left Lower Extremity, and Acute Kidney Injury. Record review on 11/28/18 at 10:07 AM revealed an entry in Nurse's Notes at 12:57 PM on 11/15/18: Notified by (Licensed Practical Nurse #1) that resident was found by two CNAs (Certified Nursing Assistants) hitting another resident in his back while he was resting in his bed . Review of the 11/8/18 Baseline Care Plan and the 11/22/18 Interdisciplinary Care Plan on 11/28/18 at 9:48 AM revealed no mention of the behavior/incident. During an interview on 11/28/18 at 4:08 PM, the Director of Nurses verified that neither the Baseline nor Interdisciplinary Care Plan had been updated to include the resident-to-resident abuse incident on 11/15/18.",2020-09-01
165,CARLYLE SENIOR CARE OF AIKEN,425014,123 DUPONT DR NORTHEAST,AIKEN,SC,29801,2018-11-30,686,D,0,1,JLSM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview , the facility failed to provide appropriate care and services to promote healing and prevent infection for one of two sampled residents observed for pressure ulcer treatments. The nurse failed to clean the scissors prior to cutting off the soiled dressing during observation of a pressure ulcer treatment for [REDACTED]. The findings included: During observation of a pressure ulcer treatment to the left heel on 11/27/18 at 2:08 PM, Registered Nurse (RN) #1 removed a scissors from her/his pocket. Without sanitizing it, s/he cut the undated soiled dressing from the unstageable malodorous wound (at least 3 inches in diameter eschar) on the heel. During an interview following the treatment, RN #1 verified s/he had taken the scissors from her/his pocket and used it to cut the dressing off without cleansing it. The RN stated s/he should have cleaned it with bleach wipes.",2020-09-01
166,CARLYLE SENIOR CARE OF AIKEN,425014,123 DUPONT DR NORTHEAST,AIKEN,SC,29801,2018-11-30,692,D,0,1,JLSM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to complete a nutritional assessment and implement recommendations in a timely manner for Resident #67, one of 2 sampled residents reviewed for nutrition. The findings included: The facility admitted Resident #67 with [DIAGNOSES REDACTED]. Review of weights on 11/26/18 at 1:55 PM revealed the resident sustained [REDACTED].#) to 11/6/18 (148#), equivalent to 10.3%. Record review on 11/28/18 at 2:31 PM revealed a 10/11/18 physician's orders [REDACTED]. Review of Dietary Notes on 11/28/18 at 3:33 PM revealed that the Licensed Dietitian did not complete the assessment until 10/24/18, 13 days later. A recommendation to increase the resident's tube feeding of Fibersource HN from 58 milliliters (ml) per hour to 77 ml per hour over a 12 hour period to promote weight maintenance was not ordered or implemented until 10/26/18. During an interview on 11/29/18 at 2:54 PM, the Director of Nurses verified the above information.",2020-09-01
167,CARLYLE SENIOR CARE OF AIKEN,425014,123 DUPONT DR NORTHEAST,AIKEN,SC,29801,2018-11-30,693,D,0,1,JLSM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to ensure that the resident maintained proper position during administration of enteral feeding for one of two sample residents reviewed for tube feeding. Findings: The facility admitted Resident #33 on 3/11/18 with [DIAGNOSES REDACTED]. During the initial survey tour on 11/26/18 at 4:22 PM observed Resident #33 in a low bed with the head of it slightly raised, and the resident slides down to the lower part of the bed while receiving enteral feeding. On 11/27/18 at 11:03 AM, 11/29/18 at 2:57 PM, and 11/29/18 at 4:05 PM observed the resident in a similar position. The care plan reviewed on 11/29/18 at 3:40 PM indicated that the head of the resident's bed should be up 30-45 degrees during feeding therapy. During an interview on 11/29/18 at 4:05 PM the unit manager confirmed that the resident slides down his/her bed during feeding.",2020-09-01
168,CARLYLE SENIOR CARE OF AIKEN,425014,123 DUPONT DR NORTHEAST,AIKEN,SC,29801,2018-11-30,755,E,0,1,JLSM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure that medications were started in a timely manner for 1 of 5 sampled residents reviewed for unnecessary medication. [MEDICATION NAME] and [MEDICATION NAME] were not available for administration so as to be started in a timely manner for Resident #67. The findings included: The facility admitted Resident #67 with [DIAGNOSES REDACTED]. Record review on 11/28/18 at 2:31 PM revealed 11/1/18 physician's orders [REDACTED]. Review of the Medication Administration Records (MARs) on 11/28/18 revealed that the [MEDICATION NAME] was not started until 11/4/18 and was omitted on 11/7/18 due to awaiting med from pharmacy. Review of physician's orders [REDACTED].#67 had an order for [REDACTED]. Nurses Notes indicated that Registered Nurse (RN) #2 contacted the pharmacy representative who instructed her/him to access the Cubex system (emergency drug supply) for the medication. RN #2 documented that the medication was not available for administration. Review of the Medication Administration Records on 11/28/18 revealed that the [MEDICATION NAME] was not started until 9/29/18. During an interview on 11/29/18 at approximately 10 AM, RN #2 verified that the [MEDICATION NAME] was not available to be given as ordered. When asked about the availability of [MEDICATION NAME], the RN stated s/he remembered running low in Cubex. During an interview on 11/29/18 at 10:44 AM, the Director of Nurses stated the [MEDICATION NAME] was increased due to an exascerbation of the Bullous Disorder and verified the documentation in the Nurses Notes and MAR. During an interview on 11/29/18 at 10:09 AM, the RN Consultant provided a copy of the contents of the Cubex system which noted both [MEDICATION NAME] and [MEDICATION NAME] should have been available for administration.",2020-09-01
169,CARLYLE SENIOR CARE OF AIKEN,425014,123 DUPONT DR NORTHEAST,AIKEN,SC,29801,2018-11-30,757,E,0,1,JLSM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to document the necessity for and effectiveness of PRN (as needed) medication administered for pain for 1 of 5 sampled residents reviewed for unnecessary medication. Resident #67 received [MEDICATION NAME] five times in 11/18 with no documented reason or results. The findings included: The facility admitted Resident #67 with [DIAGNOSES REDACTED]. Record review on 11/28/18 at 2:31 PM revealed a physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. There was no documentation found to show pain level or location at the time the medication was administered or monitoring to determine effectiveness after administration. During an interview on 11/29/18 at 10:44 AM, the Director of Nurses (DON) reviewed the record and verified the lack of documentation for [MEDICATION NAME] administration. The DON stated s/he would expect the documentation to be on the MAR.",2020-09-01
170,CARLYLE SENIOR CARE OF AIKEN,425014,123 DUPONT DR NORTHEAST,AIKEN,SC,29801,2018-11-30,880,D,0,1,JLSM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews, the facility failed to ensure that appropriate handwashing procedures were implemented following completion of one of two pressure ulcer treatments observed (Resident #67). The findings included: The facility admitted Resident #67 with [DIAGNOSES REDACTED]. Following a pressure ulcer treatment for [REDACTED].#2 sanitized her/his hands and exited the resident's room. S/he entered the shower room, opened the bin with her/his hand, and disposed of the bag of trash from the treatment. The nurse then left the room without washing/sanitizing her/his hands and headed toward the nursing station. When asked about washing her/his hands after touching the trash bin lid, RN #2 stated s/he would go to the nurse's desk to sanitize her/his hands or to the bathroom located near there. No sanitizer was observed at the nurses station. When washing hands in the bathroom was discussed, the nurse admitted s/he would contaminate the key and doorknob prior to being able to wash hands in that location. The Assistant Director of Nurses (ADON) observed the procedure and stated that RN #2 should have washed her/his hands in shower. The DON stated the nurse should have washed hands in the shower where a sink was readily available.",2020-09-01
171,CARLYLE SENIOR CARE OF AIKEN,425014,123 DUPONT DR NORTHEAST,AIKEN,SC,29801,2018-11-30,924,D,0,1,JLSM11,"Based on observation and interview, the facility failed to ensure that handrails were installed as required on one of 4 halls. The findings included: Observations on all days of the survey revealed 3 sections of handrails missing on[NAME]Hall. Two sections were missing, one on either side of the Conference room, and one section was missing between the patio exit (across from the Conference Room) and the fire doors. During an interview on 11/28/18 at 8:16 AM, the Maintenance Supervisor and Administrator were measuring the walls and verified that (2) 4' and (1) 8' sections of handrails had not been installed.",2020-09-01
172,"LINLEY PARK REHABILITATION AND HEALTHCARE CENTER,",425016,208 JAMES STREET,ANDERSON,SC,29625,2018-06-27,812,F,0,1,Z84K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of facility policy and procedure the facility failed to ensure 1)Foods stored in refrigerator were stored appropriately to prevent cross- contamination in 1 of 1 kitchen and 2)Expired bottled juice which was stored in the Nourishment Refrigerator was discarded on or before the expiration date in 1 of 2 Nourishment Refrigerators. The findings included: During an observation made while in the Walk-In Refrigeration Unit on [DATE] at 4:45 PM, an aluminum sheet pan located on the bottom shelf of a shelving rack contained 2, 10 pound rolls of frozen ground beef and 5 bags of frozen assorted chicken pieces. One of the 10 pound rolls of ground beef was on one side of the pan and the other 10 pound roll was on the other side of the same pan, the 5 bags of assorted chicken pieces were sandwiched between the two rolls of ground beef. This observation was verified by the Kitchen Manager and the Certified Dietary Manager (CDM). When the CDM was asked should the ground beef and chicken be stored on the same tray together, he/she said, No and then told the Kitchen Manager to get a pan and move the bags of chicken pieces to a separate pan. The Kitchen Manager had already begun to move the bags of chicken pieces to a separate pan and relocated the pan which now contained the bags of chicken pieces on the same shelf and beside the ground beef which was now on the same pan which previously had shared space with the bags of thawing chicken. On [DATE] at 9:30 AM, the Kitchen Manager provided a copy of the Inservice titled, Cross Contamination, which was Given By: CDM and the Kitchen Manager, to the dietary staff, 10 team members signed the inservice on [DATE] after the discovery of thawing ground beef and chicken on the same pan in the Walk- In Cooler. The form titled, Cross Contamination, states, .Raw meat, poultry and seafood should be stored in containers or sealed plastic bags to prevent their juices from dipping onto other foods. Liquids from raw meat, poultry, and seafood can contain harmful bacteria. Always store raw meat, poultry and seafood on the bottom shelf of the refrigerator to prevent the liquids from contaminating other items. On [DATE] at 9:30 AM, the Kitchen Manager provided a copy of Policy 019, Food Storage: Cold Foods, which states:, Policy Statement, All Time/Temperature Control for Safety (TCS) foods, frozen and refrigerate, will be appropriately stored in accordance with guidelines of the FDA (Federal Food and Drug Administration) Food Code Procedures .5. All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross-contamination. On [DATE] at approximately 9:30 AM, the Kitchen Manager said the chicken and ground beef were placed on the pan together in the walk-in refrigerator by the cook on [DATE] prior to leaving for the day. The Kitchen Manager said that he/she could not locate in the policies and procedures that raw chicken pieces and raw ground beef could not share the same space/tray for thawing. Review of the Food Code, U. S. Public Health Service, FDA, U. S. Food & Drug Administration (YEAR), US. Department of Health and Human Services, page 421, Section titled, Preventing Food and Ingredient Contamination, ,[DATE].11, Packaged and Unpackaged Food-Separation, Packaging, and Segregation, states: .With regard to the storage of different types of raw animal foods as specified under subparagraph ,[DATE].11 (A) (2), it it the intent of this Code to require separation based on anticipated microbial load and raw animal food type (species). Separating different types of raw animal foods from one another during storage, preparation, holding and display is based on as succession of cooking temperatures as specified under ,[DATE].11. During an observation on [DATE] at 05:58 PM of the Nourishment Refrigerator located on the A Unit, there was a bottle of juice with initials and room number written on the top and side of the bottle for Resident #39. The bottle of juice had an expiration date, stamped on the label, [DATE]. This observation was verified by the Housekeeping Supervisor and the Unit Manager/LPN #1. LPN #1 said that he/she had just checked the refrigerator this morning and this bottle of juice was not in the refrigerator. He/She said that he/she checks the refrigerator daily for expired products. LPN#1 stated that the family member most likely brought in today and wrote the resident's initials and room number on the bottle. The bottle of juice was then discarded. The Administrator immediately began placing signage on the refrigerators to inform the family/residents of the policy/procedure to notify a member of nursing or activities of foods they are bringing in for the residents. The Administrator provided a copy of form titled, Policy 031, Food: Safe Handling for Foods from Visitors, Policy Statement which states: Residents will be assisted in properly storing and safely consuming food brought into the facility for residents and visitors. Procedures, 1. The facility staff will request that visitors bringing in food, and/or residents that receive food, must notify a member of the nursing or activities departments. 2. The responsible facility staff will determine whether the food item is for immediate consumption or to be stored for later use .4. When food items are intended for later consumption, the responsible facility staff member will: Label foods with the resident name and current date 5. Refrigerators/freezers for storage of foods brought in by visitors will be properly maintained and: .Daily monitoring for refrigerated storage duration and discard of any food items that have been stored for greater than or equal to 7 days.",2020-09-01
173,"LINLEY PARK REHABILITATION AND HEALTHCARE CENTER,",425016,208 JAMES STREET,ANDERSON,SC,29625,2019-08-01,578,D,0,1,5ZED11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to give 2 of 2 residents reviewed an opportunity to formulate an advance directive. Residents #11 and #14 were judged as mentally capable by physicians, yet were not involved in their own advance directive. The findings included: Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent brief interview for mental status (BIMS) yielded a score of 13. Review of Resident #11's chart on 7/29/19 at approximately 2:50 PM revealed two physicians had judged Resident #11 to be mentally capable, but Resident #11 did not sign his/her advance directive. During an interview with the Director of Nursing (DON) on 7/30/19 at approximately 2:58 PM s/he confirmed that Resident #11 is capable of formulating an advance directive but did not sign off on it. The DON stated when the physicians declared him/her capable, they should have reapproached the resident regarding his/her advance directive. The facility admitted Resident #14 with [DIAGNOSES REDACTED]. Record review of Resident #14's Resident/Family Consent for Cardiopulmonary Resuscitation form on 7/29/19 at 3:54 PM, revealed do not resuscitate (DNR) status had been selected for the resident on 1/31/19. The form was signed by the resident's representative. Record review of Resident #14's Physicians Determination of Capacity form, dated 2/17/19, on 7/29/19 at 3:55 PM, revealed Resident #14 had decisional capacity to make his/her own healthcare decisions. Record review of Resident #14's Telephone Orders on 7/29/19 at 3:55 PM, revealed a DNR order for the resident, dated 2/17/19. There was no documentation indicating it was Resident #14's choice to be DNR status. During an interview with Registered Nurse (RN) #3 on 7/30/19 at 2:24 PM, RN #3 stated Resident #14 was unable to sign the DNR consent form on admission and the family signed it for him/her. RN #3 confirmed the physician determined the resident had the capacity to make healthcare decisions on 2/17/19 and a DNR order was written. RN #3 stated at that time, Resident #14 should have been given the opportunity to select resuscitation status and sign the Resident/Family Consent for Cardiopulmonary Resuscitation. RN #3 stated this was not done. RN #3 stated s/he had spoken with Resident #14 today and s/he selected DNR status and signed the Resident/Family Consent for Cardiopulmonary Resuscitation.",2020-09-01
174,"LINLEY PARK REHABILITATION AND HEALTHCARE CENTER,",425016,208 JAMES STREET,ANDERSON,SC,29625,2019-08-01,641,D,0,1,5ZED11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to accurately complete the Minimum Data Set (MDS) assessment for 1 of 4 sampled resident reviewed for nutrition (Resident #49). The findings included: The facility admitted Resident #49 on 01/16/15 with [DIAGNOSES REDACTED]. Review of Resident #49's 07-03-19 5-day Minimum Data Set (MDS) assessment revealed under section K under K0300 Weight Loss the code entered is 1. Yes, on a physician-prescribed weight-loss regimen. Review of Resident #49's orders on 07/30/19 at approximately 11:15 AM revealed the resident did not have orders for weight loss. During an interview on 08/01/19 at 09:58 AM, the Certified Dietary Manger stated that the MDS had been coded wrong. S/he would reopen it (MDS) and change the information.",2020-09-01
175,"LINLEY PARK REHABILITATION AND HEALTHCARE CENTER,",425016,208 JAMES STREET,ANDERSON,SC,29625,2019-08-01,755,D,1,1,5ZED11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to obtain and provide routine medications for Resident #174, 1 of 7 sampled residents reviewed for Abuse/Neglect. Routine medications were not provided in a timely manner after admission to the facility. The findings included: The facility admitted Resident #174 on 5/3/19 with [DIAGNOSES REDACTED]. Record review of Resident #174's Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. In addition, the MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Review of Resident #174's Nurse's Notes on 8/1/19 at 9:16 AM, revealed the [MEDICATION NAME] and [MEDICATION NAME] were not given as ordered due to the medications had not been received from the pharmacy. During an interview with the Director of Nursing (DON) on 8/1/19 at 9:16 AM, the DON Confirmed Resident #174 did not receive the [MEDICATION NAME] and [MEDICATION NAME] as ordered. The DON stated the pharmacy delivered all other medications for the resident, but wasn't sure why these medications were not delivered. The DON stated the facility does have a back up pharmacy, but use of the back up pharmacy has to be initiated by the primary pharmacy when there are issues with delivery of medications. The DON was not sure why the back up pharmacy wasn't used and was waiting to hear from the primary pharmacy to find out what happened. The DON provided documentation revealing the facility followed their protocol for medication requisition when Resident #174 was admitted on [DATE]. During an interview with Registered Nurse (RN) #3 on 8/1/19 at 12:12 PM, RN #3 was on the phone with the pharmacy. When s/he got off the phone, RN #3 stated the pharmacy said the [MEDICATION NAME] order was cancelled by the pharmacy for unknown reasons. The [MEDICATION NAME] order was not delivered due to a possible drug interaction. The [MEDICATION NAME] was not delivered because the pharmacy stated they did not receive a prescription for it. RN #3 stated the pharmacy told her/him someone from the pharmacy should have contacted the facility about the discrepancies, but did not. During an interview with the DON on 8/1/19 at 12:41 PM, the DON provided documentation indicating the nurse had called the pharmacy on 5/4/19 to report all of the resident's medications had not been delivered. Review of Resident #174 pain assessments revealed the resident's pain was well controlled. The resident had as needed pain medication available, but did not use any. Review of Nurse's Notes, Nursing assessments and Physical Therapy assessments from 5/3 and 5/4/19 revealed the resident was stable and in no distress. Resident #174 left the facility against medical advice the morning of 5/5/19. The Medical Director was not present on 8/1/19, but provided a written statement regarding the missed doses of [MEDICATION NAME] and [MEDICATION NAME]. In the statement the Medical Director wrote These single missed doses could do no harm to the patient.",2020-09-01
176,"LINLEY PARK REHABILITATION AND HEALTHCARE CENTER,",425016,208 JAMES STREET,ANDERSON,SC,29625,2017-10-11,159,F,1,0,TBH011,"> Based on review of facility files and interview, the facility failed to act as a fiduciary of the resident's funds and hold, safeguard, manage, and account for the personal funds of the resident deposited with the facility. The facility's Business Office Manager removed $600.00 from the resident petty cash fund. An audit completed after the incident revealed the receipt book had signatures with questionable validity totaling $1899.00. One of one staff reviewed for mishandling resident funds. The findings included: The facility reported an allegation of misappropriation of resident property to the State Agency on 8/11/17 and identified three residents affected. Review of the facility's Five-Day Follow-Up Report dated 8/16/17 indicated at the completion of the investigation the $600.00 was removed and replaced by the Business Office Manager. Results of the investigation also revealed 11 additional residents had signatures with questionable validity totaling $1899.00. Review of facility files revealed on 8/11/17 at 4:40 PM, the assistant Business Office Manager (BOM) reported to the administrator that there were questionable receipts in the resident trust petty cash book. The administrator interviewed the Business Office Manager at 5:05 PM and s/he admitted after questioning to taking $600.00. The Business Office Manager left the facility to go to the bank and returned with money to replace what s/he had taken. In an interview with the surveyor on 9/18/17 at approximately 4:00 PM, the facility administrator stated the assistant BOM came to him/her on 8/11/17 and said that were receipts in the resident trust petty cash book that didn't add up. They had the assistant BOM's name and social services staff's name as the two signatures. The assistant BOM stated s/he didn't sign those receipts. The assistant BOM was trying to balance the cash box and it didn't balance. The cash box should be balanced every Friday. The assistant BOM did not balance the cash box the previous Friday because s/he didn't have a chance because of admissions, so she was reviewing 2 weeks on 8/11/17. When the spreadsheet and the cash box did not balance s/he went to the receipt book and started balancing from those. That is when s/he saw the receipts with his/her name that were not his/her signature. The administrator stated there is $250.00 in petty cash, when a resident comes and gets money then the BOM writes a check to the administrator Heritage -petty cash. The administrator goes to the bank, cashes the check and the money is replenished back in to the petty cash box. The administrator went to the social services staff and asked if it was his/her signature on the petty cash receipt and s/he said no. The administrator called the Business Office Manager and asked him/her to come in, s/he had already left for the day. The BOM came in around 5:05 PM and the administrator told him/her there were some questionable receipts. The BOM said I will be honest with you, I took the money. The BOM said s/he would do whatever to make it right, s/he had the money in his/her account. The BOM left and went to the bank and brought $600 cash back to the facility around 5:30 PM. The administrator stated the regional business office coordinator came in that evening around 7:00 PM and started auditing. The regional business office coordinator had found some receipts signed by the assistant BOM while s/he was out on medical leave. S/he audited the resident trust account and found some signatures that did not match. There were also receipts that had the social services staff's name that s/he had not signed for. The administrator called the BOM on 8/15/17 and told him/her that some signatures were in question. The BOM stated s/he had signed the assistant BOM's and social services staff's name and s/he assumed the assistant BOM knew. The BOM stated social services staff didn't know s/he was signing their name. The administrator asked the BOM on 8/11/17 if s/he had taken any other money and s/he stated no, it was the first time. In an interview with the surveyor on 9/18/17 at approximately 4:50 PM, social services staff stated the administrator told him/her s/he needed to look at the receipt book to see if they were his/her signatures. The ones s/he saw were not his/her signatures. The social services staff stated s/he use to work in the business office in 2012 and s/he would have signed the petty cash receipts then. S/he has not signed any receipts for money in a long time. S/he sated s/he does not have anything to do with the facility shopping trips. The Assistant Business Office Manager's facility-obtained statement indicated on 8/11/17, s/he was beginning to count the cash box for the Resident Fund Management System and fill out the weekly form to make sure the box was balanced. As s/he was filling out the form while using the petty cash disbursement log spreadsheet, s/he noticed that the box was not balancing. The Assistant Business Office Manager went to get the withdrawal receipt book to ensure all the withdrawals that had happened for the week were accounted for on the spreadsheet. Upon looking in the receipt book, s/he noticed several withdrawals that s/he was not aware of and that had his/her name signed to them but it was not his/her signature. After finding this, s/he took the receipt book to the administrator and showed him/her the withdrawals that s/he had not witnessed with his/her name signed to them. In an interview with the surveyor on 9/18/17 at approximately 5:15 PM, the assistant BOM, stated s/he was doing the cash box count and realized that the totals were off. The assistant BOM went and got the receipt book and saw that there were several receipts where money had been withdrawn that s/he didn't know about. The assistant BOM saw his/her name and it was not his/her signature. Some of the residents never take out money or not that much at a time. The assistant BOM took the information to the administrator. The assistant BOM states s/he normally is the person who does the cash box count. In an interview with the surveyor on 9/18/17 at approximately 5:35 PM, the regional business office coordinator stated s/he was told there was an issue with the resident trust and they would need to investigate that and do an audit. The regional business office coordinator stated they identified some other signatures that they thought might be questionable. Some were activity trips and the activity staff remembered them receiving money, they still reimbursed the money. The policy requires that if a resident has an illegible signature then they have 3 staff signatures, two who witness the one give the money. If it is a legible signature then they have to have one witness the one person give the money. In an interview with the surveyor on 9/19/17 at approximately 12:15 PM, the regional business office coordinator stated if a resident comes and says they need money, the assistant BOM will complete a withdrawal ticket in the receipt book. S/he will have the resident sign and have witnesses sign. The ticket is taken out of the book and handed to the BOM. There is a copy that stays in the receipt book. The receipt book is a 3 copy so the resident will also have a copy. The BOM enters the ticket into the Resident Funds Management System (RFMS) as a withdrawal. Through that process it is charged to the resident's account. The cash box is the vendor, that generates a check (administrator - petty cash) that is taken to the bank and the money is replenished in the petty cash box. The person who disburses the cash is separate from the person who enters the transaction into the RFMS system and the disbursement log. That is so there will be a checks and balance system. The BOM was the one doing the transaction and the assistant BOM was the one entering in RFMS and doing the disbursement log. It doesn't necessarily have to be a certain person, but two different people must complete the transaction and enter the withdrawal in RFMS. A different person must take the check to the bank to cash. The Business Office Manager's facility-obtained statement dated 8/11/17 indicated s/he took $600.00 of resident money and replaced it with cash. Documentation of a telephone interview of the Business Office Manager by the administrator dated 8/15/17 indicated the Business Office Manager stated s/he had signed other employees' signatures and stated that s/he assumed they knew. The administrator informed the Business Office Manager that the facility's investigation and audit had revealed questionable signatures on petty cash receipts. Review of the facility's policy for Petty Cash Withdrawals revealed a receipt book marked for withdrawals should be used to obtain patient authorization for the disbursement. The form should be completed in its entirety. The resident should authorize the disbursement via signature. If the resident is unable to sign or has an illegible signature, two witnesses must be obtained. The custodian of cash may not be one of the witnessing signatures.",2020-09-01
177,"LINLEY PARK REHABILITATION AND HEALTHCARE CENTER,",425016,208 JAMES STREET,ANDERSON,SC,29625,2017-10-11,224,F,1,0,TBH011,"> Based on review of facility files and interview, the facility failed to ensure each resident remained free from misappropriation of resident property. The facility's Business Office Manager removed $600.00 from the resident petty cash fund. An audit completed after the incident revealed the receipt book had signatures with questionable validity totaling $1899.00. One of one staff reviewed for misappropriating resident funds. The findings included: The facility reported an allegation of misappropriation of resident property to the State Agency on 8/11/17 and identified three residents affected. Review of the facility's Five-Day Follow-Up Report dated 8/16/17 indicated at the completion of the investigation the $600.00 was removed and replaced by the Business Office Manager. Results of the investigation also revealed 11 additional residents had signatures with questionable validity totaling $1899.00. Review of facility files revealed on 8/11/17 at 4:40 PM, the assistant Business Office Manager (BOM) reported to the administrator that there were questionable receipts in the resident trust petty cash book. The administrator interviewed the Business Office Manager at 5:05 PM and s/he admitted after questioning to taking $600.00. The Business Office Manager left the facility to go to the bank and returned with money to replace what s/he had taken. In an interview with the surveyor on 9/18/17 at approximately 4:00 PM, the facility administrator stated the assistant BOM came to him/her on 8/11/17 and said that there were receipts in the resident trust petty cash book that didn't add up. They had the assistant BOM's name and social services staff's name as the two signatures. The assistant BOM stated s/he didn't sign those receipts. The assistant BOM was trying to balance the cash box and it didn't balance. The cash box should be balanced every Friday. The assistant BOM did not balance the cash box the previous Friday because s/he didn't have a chance because of admissions, so she was reviewing 2 weeks on 8/11/17. When the spreadsheet and the cash box did not balance s/he went to the receipt book and started balancing from those. That is when s/he saw the receipts with his/her name that were not his/her signature. The administrator stated there is $250.00 in petty cash, when a resident comes and gets money then the BOM writes a check to the administrator Heritage -petty cash. The administrator goes to the bank, cashes the check and the money is replenished back in to the petty cash box. The administrator went to the social services staff and asked if it was his/her signature on the petty cash receipt and s/he said no. The administrator called the Business Office Manager and asked him/her to come in, s/he had already left for the day. The BOM came in around 5:05 PM and the administrator told him/her there were some questionable receipts. The BOM said I will be honest with you, I took the money. The BOM said s/he would do whatever to make it right, s/he had the money in his/her account. The BOM left and went to the bank and brought $600 cash back to the facility around 5:30 PM. The administrator stated the regional business office coordinator came in that evening around 7:00 PM and started auditing. The regional business office coordinator had found some receipts signed by the assistant BOM while s/he was out on medical leave. S/he audited the resident trust account and found some signatures that did not match. There were also receipts that had the social services staff's name that s/he had not signed for. The administrator called the BOM on 8/15/17 and told him/her that some signatures were in question. The BOM stated s/he had signed the assistant BOM's and social services staff's name and s/he assumed the assistant BOM knew. The BOM stated social services staff didn't know s/he was signing their name. The administrator asked the BOM on 8/11/17 if s/he had taken any other money and s/he sated no, it was the first time. In an interview with the surveyor on 9/18/17 at approximately 4:50 PM, social services staff stated the administrator told him/her s/he needed to look at the receipt book to see if they were his/her signatures. The ones s/he saw were not his/her signatures. The social services staff stated s/he use to work in the business office in 2012 and s/he would have signed the petty cash receipts then. S/he has not signed any receipts for money in a long time. S/he stated s/he does not have anything to do with the facility shopping trips. The Assistant Business Office Manager's facility-obtained statement indicated on 8/11/17, s/he was beginning to count the cash box for the Resident Fund Management System and fill out the weekly form to make sure the box was balanced. As s/he was filling out the form while using the petty cash disbursement log spreadsheet, s/he noticed that the box was not balancing. The Assistant Business Office Manager went to get the withdrawal receipt book to ensure all the withdrawals that had happened for the week were accounted for on the spreadsheet. Upon looking in the receipt book, s/he noticed several withdrawals that s/he was not aware of and that had his/her name signed to them but it was not his/her signature. After finding this, s/he took the receipt book to the administrator and showed him/her the withdrawals that s/he had not witnessed with his/her name signed to them. In an interview with the surveyor on 9/18/17 at approximately 5:15 PM, the assistant BOM, stated s/he was doing the cash box count and realized that the totals were off. The assistant BOM went and got the receipt book and saw that there were several receipts where money had been withdrawn that s/he didn't know about. The assistant BOM saw his/her name and it was not his/her signature. Some of the residents never take out money or not that much at a time. The assistant BOM took the information to the administrator. The assistant BOM states s/he normally is the person who does the cash box count. In an interview with the surveyor on 9/18/17 at approximately 5:35 PM, the regional business office coordinator stated s/he was told there was an issue with the resident trust and they would need to investigate that and do an audit. The regional business office coordinator stated they identified some other signatures that they thought might be questionable. Some were activity trips and the activity staff remembered them receiving money, they still reimbursed the money. The policy requires that if a resident has an illegible signature then they have 3 staff signatures, two who witness the one give the money. If it is a legible signature then they have to have one witness the one person give the money. In an interview with the surveyor on 9/19/17 at approximately 12:15 PM, the regional business office coordinator stated if a resident comes and says they need money, the assistant BOM will complete a withdrawal ticket in the receipt book. S/he will have the resident sign and have witnesses sign. The ticket is taken out of the book and handed to the BOM. There is a copy that stays in the receipt book. The receipt book is a 3 copy so the resident will also have a copy. The BOM enters the ticket into the Resident Funds Management System (RFMS) as a withdrawal. Through that process it is charged to the resident's account. The cash box is the vendor, that generates a check (administrator - petty cash) that is taken to the bank and the money is replenished in the petty cash box. The person who disburses the cash is separate from the person who enters the transaction into the RFMS system and the disbursement log. That is so there will be a checks and balance system. The BOM was the one doing the transaction and the assistant BOM was the one entering in RFMS and doing the disbursement log. It doesn't necessarily have to be a certain person, but two different people must complete the transaction and enter the withdrawal in RFMS. A different person must take the check to the bank to cash. The Business Office Manager's facility-obtained statement dated 8/11/17 indicated s/he took $600.00 of resident money and replaced it with cash. Documentation of a telephone interview of the Business Office Manager by the administrator dated 8/15/17 indicated the Business Office Manager stated s/he had signed other employees' signatures and stated that s/he assumed they knew. The administrator informed the Business Office Manager that the facility's investigation and audit had revealed questionable signatures on petty cash receipts. Review of the facility's policy for Petty Cash Withdrawals revealed a receipt book marked for withdrawals should be used to obtain patient authorization for the disbursement. The form should be completed in its entirety. The resident should authorize the disbursement via signature. If the resident is unable to sign or has an illegible signature, two witnesses must be obtained. The custodian of cash may not be one of the witnessing signatures.",2020-09-01
178,WHITE OAK MANOR - LANCASTER,425017,253 CRAIG MANOR ROAD,LANCASTER,SC,29720,2020-01-16,607,D,1,1,FL9111,"> Based on record review, interview, and review of the facility's policy Protocol for Reporting Abuse the facility failed to follow policy to report an allegation of abuse within the required timeframe for Resident #98, 1 of 7 reviewed for abuse. CNA #3 allegedly witnessed CNA #2 physically abuse Resident #98 on 1/30/19. The allegation was not reported to the State Agency until 2/6/19. The findings included: The facility reported an allegation of physical abuse for Resident #98 by CNA #2 to the State Agency. On 1/14/20 at 12:13 PM, review of the Initial 2/24-Hour revealed it was faxed to the State Agency on 2/6/19 at 09:34 AM. The Initial 2/24-Hour Report indicated Resident #98 was physically abused by CNA #2 and indicated the date/time of incident as 2/6/19 at 07:40. The report indicated there was an allegation that while two CNAs were providing care to resident, resident became combative and hit a CNA. There is an allegation that CNA may have physically retaliated. Further review revealed a Five-Day Report dated 2/8/19 that indicated the incident occurred on 1/30/19 at 08:50 PM at which time an incident report was done. The summary indicated physical abuse not substantiated by facility. CNA #3 reported that CNA #2 struck Resident #98 on the arm after the resident struck him/her and was forceful when turning the resident. At 12:33 PM on 1/14/20, review of the Occurrence Report also indicated the incident occurred on 1/30/19 and indicated the resident had 2 skin tears measuring 2.5x1.0 and 4.0x3.5 cm and was completed by LPN #2. On 1/30/19, CNA #3's statement on the Occurrence Report stated s/he was changing Resident #98 and observed a skin tear abrasion on (his/her) left arm. (S/he) was combative during care and hitting and grabbing at us. There was no statement obtained from CNA #2. Review of the Occurrence Report also indicated a 24 hour follow-up was done by Unit Manager RN #1 on 1/31/19 and was also signed by the Director of Nursing on 2/1/19. LPN #3's facility-obtained statement dated 2/6/19 indicated s/he was informed that Resident #98 had a skin tear. Went to the resident's room and noted the resident did not appear to be in any distress. A few minutes later CNA #4 asked LPN #3 to to talk to CNA #3. At that time CNA #3 said (s/he) got the skin tear because (s/he) roller (him/her) to hard. The LPN asked the CNA if s/he had written a statement and the CNA responded that s/he had. RN #2's facility-obtained statement indicated on 2/5/19 at 10:50 PM, CNA #4 informed the nurse that CNA #3 reported s/he had worked with CNA #2 and that the resident smacked CNA #2 and CNA #2 smacked the resident back and then threw the resident over to his/her side so they could change him/her and caused a skin tear. The statement also indicated when the RN spoke to CNA #3, the CNA stated they reached down to turn the resident and resident smacked (CNA #2) and (CNA #2) smacked (him/her) back and then pushed (him/her) over hard and resident hit (him/her) arm and got a skin tear. CNA #3 wrote another statement dated 2/6/19 stating s/he and CNA #2 used the total lift with the resident and that Resident #98 was getting irritated and combative, grabing at everything. S/he stated the resident hit CNA #2 and CNA #2 hit (him/her) back causing (him/her) to hit (his/her) hand on the rail. CNA #3 stated s/he told CNA #2 to turn the resident back towards him/her, and CNA #2 pushed (him/her) back more like shoved. CNA #3 stated CNA #2 then left the room stating I better leave before I lose my job. CNA #3 found the skin tear after CNA #2 left the room per the statement. CNA #3 then reported the skin tear to the nurse and afterward told CNA #4 what had happened. CNA #4 got LPN #3 at that time and CNA #3 told (him/her) everything that had happened. CNA #4's statement corroborated CNA #3's statement and that s/he witnessed CNA #3 telling LPN #3 about the incident. CNA #2's statement confirmed s/he assisted a co-worker putting Resident #98 to bed with the total lift. The statement also confirmed Resident #98 hit him/her on his/her left arm. CNA #2's statement indicated s/he pushed (his/her) arm down to stop (him/her). CNA #2 stated s/he used pads to turn Resident #98 and pushed his/her bottom. Review of the facility's policy entitled Protocol for Reporting Abuse stated Immediately notify, but not later that 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later that 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. During an interview on 1/16/20 at 9:44 AM, the Nursing Home Administrator confirmed the incident occurred on 1/31/19 and that the Initial 2/24-Hour Report was sent to the State Agency on 2/6/20. The Administrator further confirmed the facility failed to follow its policy related to reporting.",2020-09-01
179,WHITE OAK MANOR - LANCASTER,425017,253 CRAIG MANOR ROAD,LANCASTER,SC,29720,2020-01-16,609,D,1,1,FL9111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to report an allegation of abuse within the required timeframe for Resident #98, 1 of 7 reviewed for abuse. CNA #3 allegedly witnessed CNA #2 physically abuse Resident #98 on 1/30/19. The allegation was not reported to the State Agency until 2/6/19. The findings included: The facility admitted Resident #98 on 11/21/18 with [DIAGNOSES REDACTED]. On 1/14/20 at 12:13 PM, review of the Initial 2/24-Hour revealed it was faxed to the State Agency on 2/6/19 at 09:34 AM. The Initial 2/24-Hour Report indicated Resident #98 was physically abused by CNA #2 and indicated the date/time of incident as 2/6/19 at 07:40. The report indicated there was an allegation that while two CNAs were providing care to resident, resident became combative and hit a CNA. There is an allegation that CNA may have physically retaliated. Further review revealed a Five-Day Report dated 2/8/19 that indicated the incident occurred on 1/30/19 at 08:50 PM at which time an incident report was done. The summary indicated physical abuse not substantiated by facility. CNA #3 reported that CNA #2 struck Resident #98 of the arm after the resident struck him/her and was forceful when turning the resident. At 12:33 PM on 1/14/20, review of the Occurrence Report also indicated the incident occurred on 1/30/19 and indicated the resident had 2 skin tears measuring 2.5x1.0 and 4.0x3.5 cm and was completed by LPN #2. On 1/30/19, CNA #3's statement on the Occurrence Report stated s/he was changing Resident #98 and observed a skin tear abrasion on (his/her) left arm. (S/he) was combative during care and hitting and grabbing at us. There was no statement obtained from CNA #2. Review of the Occurrence Report also indicated a 24 hour follow-up was done by Unit Manager RN #1 on 1/31/19 and was also signed by the Director of Nursing on 2/1/19. LPN #2's facility-obtained statement dated 2/6/19 indicated s/he was notified by CNA #3 that Resident #98 sustained a skin tear. Per statement, CNA stated s/he was putting Resident #98 to bed and that resident was fighting and once I got (him/her) into the bed I noticed a skin tear on (his/her) arm. LPN #3's facility-obtained statement dated 2/6/19 indicated s/he was informed that Resident #98 had a skin tear. Went to the resident's room and noted the resident did not appear to be in any distress. A few minutes later CNA #4 asked LPN #3 to to talk to CNA #3. At that time CNA #3 said (s/he) got the skin tear because (s/he) roller (him/her) to hard. The LPN asked the CNA if s/he had written a statement and the CNA responded that s/he had. RN #2's facility-obtained statement indicated on 2/5/19 at 10:50 PM, CNA #4 informed the nurse that CNA #3 reported s/he had worked with CNA #2 and that the resident smacked CNA #2 and CNA #2 smacked the resident back and then threw the resident over to his/her side so they could change him/her and caused a skin tear. The statement also indicated when the RN spoke to CNA #3, the CNA stated they reached down to turn the resident and resident smacked (CNA #2) and (CNA #2) smacked (him/her) back and then pushed (him/her) over hard and resident hit (him/her) arm and got a skin tear. CNA #3 wrote another statement dated 2/6/19 stating s/he and CNA #2 used the total lift with the resident and that Resident #98 was getting irritated and combative, grabing at everything. S/he stated the resident hit CNA #2 and CNA #2 hit (him/her) back causing (him/her) to hit (his/her) hand on the rail. CNA #3 stated s/he told CNA #2 to turn the resident back towards him/her, and CNA #2 pushed (him/her) back more like shoved. CNA #3 stated CNA #2 then left the room stating I better leave before I lose my job. CNA #3 found the skin tear after CNA #2 left the room per the statement. CNA #3 then reported the skin tear to the nurse and afterward told CNA #4 what had happened. CNA #4 got LPN #3 at that time and CNA #3 told (him/her) everything that had happened. CNA #4's statement corroborated CNA #3's statement and that s/he witnessed CNA #3 telling LPN #3 about the incident. CNA #2's statement confirmed s/he assisted a co-worker putting Resident #98 to bed with the total lift. The statement also confirmed Resident #98 hit him/her on his/her left arm. CNA #2's statement indicated s/he pushed (his/her) arm down to stop (him/her). CNA #2 stated s/he used pads to turn Resident #98 and pushed his/her bottom. During an interview on 1/16/20 at 9:44 AM, the Nursing Home Administrator confirmed the incident occurred on 1/31/19 and that the Initial 2/24-Hour Report was sent to the State Agency on 2/6/20.",2020-09-01
180,WHITE OAK MANOR - LANCASTER,425017,253 CRAIG MANOR ROAD,LANCASTER,SC,29720,2020-01-16,625,D,1,1,FL9111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to provide the resident or the resident's representative with the written bed-hold policy prior to a facility initiated hospital transfer/discharge for one of three sampled residents reviewed for hospitalization . Resident #118 was sent to the hospital on [DATE] and [DATE] and the facility did not provide written information that specified the bed-hold policy. The findings included: The facility admitted Resident #118 on 7/26/19 with [DIAGNOSES REDACTED]. Review of Resident #118's Quarterly Minimum (MDS) data set [DATE] revealed the resident was coded as having short-term and long-term memory problems with severely impaired cognitive skills for daily decision-making. Nurse's notes reviewed on 1/16/20 at 8:16 AM revealed that the facility sent Resident #118 to the hospital emergency roiagnom on [DATE] with difficulty breathing, wheezing, pneumonia and foul smelling urine. Resident #118 was admitted back to the facility on [DATE]. The nurse's notes also revealed that Resident #118 went back to the hospital emergency room again on [DATE] for increased respiratory distress. Resident #118 returned to the facility on [DATE]. In an interview with the social worker on 1/16/20 at 8:32 AM s/he stated that the facility did not provide/discuss the bed-hold policy with the resident or the resident's representative for the two hospital transfers that occurred during December 2019.",2020-09-01
181,WHITE OAK MANOR - LANCASTER,425017,253 CRAIG MANOR ROAD,LANCASTER,SC,29720,2020-01-16,908,F,1,1,FL9111,"> Based on observations and interviews, the facility failed to maintain all mechanical and electrical equipment in safe operating condition. The kitchen ice machine condensation draining pipes were not clean and in place. The facility was unable keep the floor behind and underneath the ice-maker clean and free from debris for one of one kitchen observed. The findings included: During the initial kitchen observation on 1/13/20 at 10:39 AM and in the presence of the registered dietitian/quality improvement support person, the surveyor noticed cups, some of which were Styrofoam on the floor behind the ice-maker. There was also paper trash on the floor and the floor appeared soiled (dark brown and oily). On 1/15/20 at 9:24 AM, during a second observation of the ice-machine, in the presence of the registered dietitian/quality support person, the surveyor observed the same cups (including Styrofoam), and paper-trash on the floor behind the ice-maker. The floor still appeared soiled (dark brown and oily). On 1/15/20, at approximately 9:25 AM, the registered dietitian got on his/her knees and attempted to remove the cups and paper-trash. At this time, the surveyor looked underneath the ice-machine and noticed two condensation draining pipes covered with black matter and the pipes were not aligned with the drainage underneath the ice-machine. The pipes were touching the floor. In a brief interview with the registered dietitian/quality improvement support person on 1/15/20 at approximately 9:27 AM (s/he) acknowledged that the floor and pipes were dirty and that the condensation draining pipes were touching the floor underneath the ice-machine.",2020-09-01
182,WHITE OAK MANOR - LANCASTER,425017,253 CRAIG MANOR ROAD,LANCASTER,SC,29720,2017-06-15,225,D,0,1,HKAH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility files, interview, and review of the facility's policy titled, Neglect, Abuse, Mistreatment, Threatened or Alleged Abuse of Residents, the facility failed to ensure that all alleged violations including resident to resident altercations were reported to the State Health Agency. Resident # 9 involved in an altercation that resulted with an injury for 1 of 3 residents reviewed for accidents. The findings included: The facility admitted Resident #9 with [DIAGNOSES REDACTED]. During record review of the facility's occurrence reports on 06/15/17 at 9:21 AM, revealed Resident # 9 had resident to resident altercations on 4/12/17, 4/29/17, and 5/2/17. Report for 4/12/17 revealed Resident #9 was trying to enter in the TV room and Resident #41 would not move. Resident #9 began hitting the Resident #41 there were no injuries. Report for 4/29/17 Resident #9 entered into Resident #92's room and began hitting the resident. Resident #92 had redness on the right side of the face. Report for 5/2/17 Resident #9 wandered into Resident # 38's room and starting grabbing him. Resident#9 stated she can go anywhere she wants. Resident #9 suffered with bruises on the face and hematoma. Staff separated Resident #9 from the 3 incidents that occurred. There was no documentation of the incidents being reported in the section for Reported to State Agency. During an interview on 06/15/17 at 9:15 AM with the Administrator, Director of Nursing, and the facility's consultants it was confirmed the incidents that occurred were not reported. It was also stated it was not required to report to the health agency if it was a resident to resident altercation. Review of the facility's policy, Neglect, Abuse, Mistreatment, Threatened or Alleged Abuse of Residents, revealed under VII. Reporting/Response Section B: Upon receipt of allegation of abuse or neglect, the Administrator or designee will notify the appropriate State agency as soon as practicable, but not exceed twenty four (24) hours.",2020-09-01
183,WHITE OAK MANOR - LANCASTER,425017,253 CRAIG MANOR ROAD,LANCASTER,SC,29720,2017-06-15,278,D,0,1,HKAH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to assure that 2 out of 3 residents reviewed for nutrition, 1 out of 3 residents reviewed for activities of daily living, dental, vision, and accidents and 1 out of 1 resident reviewed for pressure ulcers received accurate assessments. Residents #18 and #48. The Findings Included: Review of the medical record conducted on 6/14/2017 revealed that the facility admitted Resident #18 with [DIAGNOSES REDACTED]. Record review of Resident #18's Annual Comprehensive Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 5/25/2017 on 6/14/17 revealed Section B (Hearing, Speech Vision) item B1200 (Corrective lenses) was coded 0=no. Further review of medical record revealed documentation on Daylight IQ Assessments (COMS) entered on 5/20/2017 at 6:19 PM and 5/22/17 T 12:58 am which both reflects EENT Vision Corrective: Glasses indicating that resident utilized corrective lenses during the 7 day assessment window prior to the ARD of 5/25/17 of the Comprehensive MDS. During group interview on 6/14/17 at 3:45 PM, when asked if Resident #18 wore glasses when awake, Licensed Practical Nurse) LPN #1, LPN # 2, and Certified Nursing Assistant (C.N.[NAME]) #1 all replied Yes. When LPN #1 was asked if s/he could recall how long Resident #18 has worn glasses, s/he replied as long as I can remember. During an interview on 6/15/17 at 10:00 AM, MDS Nurse #1 agreed that item B1200 (corrective lenses) was incorrectly coded as 0=no and should have been coded as 1=yes. Additional record review on 6/14/2017 of Resident #18's Annual Comprehensive MDS assessment with ARD of 5/25/2017 revealed Section G (Functional Status) items G0110A2 (Bed mobility: support provided), G0110H2 (Eating: support provided), and G0110I2 (Toilet use: support provided) were all coded as 2=one person physical assist and item G0110H1 (Eating: self-performance) was coded as 2=limited assistance-resident highly involved in activity; staff provided guided maneuvering of limbs or other non-weight- bearing assistance. Further review on 6/14/2017 of ADL Assistance and Support report for the Month of (MONTH) (YEAR) for Resident #18 revealed the amount of assistance as well as amount of support provided by staff for ADL's during the 7 day assessment window of 5/19/17-5/25/17 for Comprehensive MDS with ARD of 5/25/17. Review of documentation revealed 7 episodes where Resident #18 received 2+ persons physical assist for bed mobility, and 5 episodes where Resident #18 received 2+ persons physical assist for toileting. Review of the documentation for the amount of assistance and support provided for eating for 5/19/17-5/25/17 revealed 8 episodes where resident was independent with only set-up help provided, 4 episodes of supervision with only set-up help provided, and 1 episode of supervision with no set-up or physical help from staff provided. When asked where s/he looks in the resident's record/ documentation to gather information regarding ADL assistance and support provided during interview on 6/15/17 at 10:22 AM, MDS Nurse #1 stated the ADL flowsheet. When asked if the ADL flowsheet is the ADL Assistance and Support report, s/he indicated that it was the same report. MDS Nurse #1 further verified during interview that using the ADL flowsheet for (MONTH) (YEAR) for Resident #18, items G0110A2 (bed mobility: support provided), G0110H2 (eating: support provided), and G0110I2 (toilet use: support provided) were incorrectly coded as 2=one person physical assist. Using the ADL flowsheet, MDS Nurse #1 verified that G0110A2 (bed mobility: support provided) and G0110I2 (toilet use: support provided) should have been coded as 3=2+ persons physical assist and G0110H2 (eating: support provided) should have been coded as 1=set up help only. Additionally, MDS Nurse #1 verified that G0110H1 (eating: self-performance) was incorrectly coded as 2=limited assistance when the ADL flowsheet reflects 9 episodes with resident identified with self-performance independent (0) with eating and 5 episodes of self-performance level of supervision (1) with no episodes of any other levels of self-performance identified. S/he further agreed that item G0110H1 was incorrectly coded when following the ADL self-performance coding instructions regarding the rule of 3 in Chapter 3 page G-6 in Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.14 updated (MONTH) (YEAR). MDS Nurse #1 further stated that she does not agree with the information documented on the ADL Flowsheet for self-performance and support provided for eating during the assessment period of 5/19/17-5/25/17 and that is why s/he coded G0110H1 as 2=limited assistance and G0110H2 as 2=one person physical assist, however, when asked where the additional supportive documentation to reflect that Resident #18 received limited assistance on at least three occasions during assessment period and one person physical assist at least on one occasion during the assessment period of 5/19/17-5/25/17, s/he verified that there was no documentation in record to support what was coded regarding eating self-performance and support provided. Ongoing record review on 6/14/2017 of Resident #18's Annual Comprehensive MDS assessment with ARD of 5/25/2017 revealed that Section L (Oral/ Dental Status) item L0200B (Dental: no natural teeth or tooth fragment(s)) was not checked and item L0200Z (Dental: none of the above) was checked. Additional review of documentation on 6/14/17 revealed Daylight IQ Assessments (COMS) entered on 5/8/17 at 11:44 AM which identifies Dental Condition: no natural teeth or tooth fragment(s). Further review of Nutritional Screening Review completed by Registered Dietitian (RD) #1 on 5/19/17, revealed under staff comments: .Resident with no natural teeth or dentures . MDS Nurse #1 verified that Section L (Oral / Dental Status) was incorrectly coded and that L0200B (Dental: no natural teeth or tooth fragment(s)) should have been checked instead of L0200Z (Dental: none of the above) during interview on 6/15/17 at 10:00 AM. Review of Resident #48's medical record revealed that s/he was admitted to facility with [DIAGNOSES REDACTED]. Record review on 6/13/107 of Resident #48's Comprehensive MDS assessment with ARD of 10/20/2016 revealed Section G (Functional Status) items G0110A (Bed mobility: self-performance), G0110HA (Eating: self-performance) and G0110IA (Toilet use: self-performance) were all coded as 4=total dependence-full staff performance every time during entire 7-day period. Further review revealed that in Section L (Oral/ Dental Status) Item L0200B (no natural teeth or tooth fragment(s) (edentulous) was not checked, and Item L0200Z (none of the above) was checked. Further review on 6/13/2017 of ADL Assistance and Support report for the Month of (MONTH) (YEAR) for Resident #48 revealed the amount of assistance as well as amount of support provided by staff for ADL's during the 7 day assessment window of 10/14/16-10/20/16 for Comprehensive MDS with ARD of 10/20/2016. Review of this documentation revealed that Resident #48 received limited assistance with bed mobility on three occasions, extensive assistance with bed mobility on three occasions, and was totally dependent with bed mobility on fifteen occasions. Further review of this documentation reveals that Resident #48 received extensive assistance with eating on one occasion and was totally dependent with eating on sixteen occasions, and s/he received extensive assistance with toileting on two occasions with total dependence documented on 13 occasions during assessment period of 10/14/16-10/20/16. Additional review of Resident #48's Care Plan page 1 of 20 revealed that Resident #48 was identified to have no teeth or dentures as a part of the second approach. MDS Nurse #1 was interviewed on 6/15/17 at 10:22 AM. When MDS Nurse #1 was asked where s/he looks in the resident's record/ documentation to gather information regarding ADL assistance and support provided, s/he stated the ADL flowsheet. When asked if the ADL flowsheet is the ADL Assistance and Support report, s/he indicated that it was the same report. MDS Nurse #1 also verified that the documentation on the (MONTH) (YEAR) ADL Flowsheet for Resident #48, during the dates of 10/14/16-10/20/16 reflected that limited assistance was provided with bed mobility on three occasions and extensive assistance was provided with bed mobility on three occasions. Additionally, s/he verified that the documentation on the ADL flowsheet for (MONTH) (YEAR) during the dates of 10/14/16-10/20/16 reflected that extensive assistance was provided with eating on one occasion, and extensive assistance was provided with toileting on to occasions. When asked if there was any additional documentation in the record that would indicate that the information documented on the ADL flowsheet was identified as incorrect and should not be used as a source for calculation of the ADL self-performance/ support provided during the assessment period of 10/14/16-10/20/16, MDS Nurse #1 replied that there was no additional documentation. When asked if the coding was incorrect for items G0110A (Bed mobility: self-performance), G0110HA (Eating: self-performance), and G0110IA (Toileting: self-performance) which all indicated 4=total dependence when using the ADL flowsheet as supportive documentation, MDS Nurse #1 agreed. S/he further stated that s/he did not agree with the information on the ADL flowsheet, but verified that there was no documentation in the record that identified any disputed entries on the ADL flowsheet as incorrect and that with information available, the MDS was incorrectly coded for G0110A, G0110HA, and G0110IA when following the rules in Chapter 3 page G5-6 of the (MONTH) (YEAR) RAI Manual. Additional review of Resident #48's Care Plan page 1 of 20 revealed that Resident #48 was identified to have no teeth or dentures as a part of the second approach. During interview with MDS Nurse #1 on 6/15/17 at 10:22 AM, s/he agreed that Resident #48 did not have any natural teeth and that item L0200B (no natural teeth or tooth fragment(s)/ edentulous) should have been checked instead of L0200Z (none of the above). Further record review on 6/13/107 of Resident #48's Quarterly MDS assessment with ARD of 1/19/17 revealed Section G (Functional Status) items G0110A (Bed mobility: self-performance), G0110GA (Dressing: self-performance) and G0110HA (Eating: self-performance) were all coded as 4=total dependence-full staff performance every time during entire 7-day period. Additionally, items G0400A (ROM limitation: upper extremity) and G0400B (ROM limitation: lower extremity) were both coded as 1=impairment on one side. Additional review on 6/13/2017 of ADL Assistance and Support report for the Month of (MONTH) (YEAR) for Resident #48 revealed the amount of assistance as well as amount of support provided by staff for ADL's during the 7 day assessment window of 1/13/17-1/19/17 for Quarterly MDS with ARD of 1/19/17. Review of this documentation revealed that Resident #48 received limited assistance with bed mobility on one occasion, extensive assistance with bed mobility on three occasions. Further review of this documentation reveals that Resident #48 was independent with eating on one occasion, received extensive assistance with eating on three occasions, and s/he received extensive assistance with toileting on three occasions during assessment period of 1/13/17-1/19/17. Further review of Narrative Notes from Daylight IQ (COMS) completed 1/15/17 at 1:42 PM revealed that Resident #48 was noted to have FROM impairment on both upper and lower extremities. During interview with MDS Nurse #1 on 6/15/17 at 10:22 AM, s/he agreed that G0110A (bed mobility-self performance), G0110GA (Dressing: self-performance) and G0110HA (eating: self-performance) were incorrectly coded and with the supportive documentation available, should have all been coded as 3=extensive assistance using the guidance in the (MONTH) (YEAR) RAI Manual regarding the rule of 3 in chapter 3 on page G-6. S/he also verified that items G0400A & G0400B (functional limitations in range of motion in upper and lower extremities) were incorrectly coded and (1=impairment on one side), and both G0400A and G0400B should have been coded as 2=impairment on both sides. Additional review of medical record on 6/13/107 of Resident #48's Quarterly MDS assessment with ARD of 3/30/17 revealed Section G (Functional Status) items G0110A (Bed mobility: self-performance), G0110HA (Eating: self-performance), and G0110I1 (Toileting-self performance) were all coded as 4=total dependence-full staff performance every time during entire 7-day period. Additionally, items G0400A (ROM limitation: upper extremity) and G0400B (ROM limitation: lower extremity) were both coded as 1=impairment on one side. Further review revealed that in Section M (Skin Conditions) that Item M0300B1 (Stage 2 pressure ulcers: number present) was coded as 1 and Item M0300B3 (Stage 2 pressure ulcers: date of oldest) was coded as 2/13/2017. Item M0300C1 (stage 3 pressure ulcers: number present) was 0 and Items M0610A, M0610B, and M0610C were all Blank Additional review on 6/13/2017 of ADL Assistance and Support report for the Month of (MONTH) (YEAR) for Resident #48 revealed the amount of assistance as well as amount of support provided by staff for ADL's during the 7 day assessment window of 3/24/17-3/30/17 for Quarterly MDS with ARD of 3/30/17. Review of this documentation revealed that Resident #48 received limited assistance with bed mobility on one occasion, and extensive assistance with bed mobility on two occasions. Further review of this documentation reveals that Resident #48 required supervision with eating on one occasion, and s/he received extensive assistance with toileting on one during assessment period of 3/24/17-3/30/17. Ongoing review revealed that on Daylight IQ Assessment (COMS) completed on 3/27/17 at 12:18 AM that Resident #48 had FROM limitations in both upper and lower extremities. Additional record review revealed a Wound Care *Skin Integrity* Evaluation completed on 3/24/17 which identified Wound 1 on sacrum which had an onset date of 2/14/17 was identified as a pressure ulcer-stage III (3). During interview with MDS Nurse #1 on 6/15/17 at 10:22 AM, s/he agreed that G0110A (bed mobility-self performance), G0110HA (Eating: self-performance) and G0110HI (Toileting: self-performance) were incorrectly coded and with the supportive documentation available, should have all been coded as 3=extensive assistance using the guidance in the (MONTH) (YEAR) RAI Manual regarding the rule of 3 in chapter 3 on page G-6. S/he also verified that items G0400A & G0400B (functional limitations in range of motion in upper and lower extremities) were incorrectly coded and (1=impairment on one side), and both G0400A and G0400B should have been coded as 2=impairment on both sides. Additionally, MDS Nurse #1 verified that M0300 (current number of unhealed pressure ulcers at each stage), M0610 (dimensions of unhealed stage 3 or 4 pressure ulcer .), and M0700 (most severe tissue type for any pressure ulcer) were all incorrectly coded on the quarterly MDS assessment with ARD of 3/30/17.",2020-09-01
184,WHITE OAK MANOR - LANCASTER,425017,253 CRAIG MANOR ROAD,LANCASTER,SC,29720,2017-06-15,279,D,0,1,HKAH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to develop and implement a care plan to meet the medical, nursing, and mental/ psychosocial needs for Resident #48. A care plan was not developed to address [DIAGNOSES REDACTED]. A care plan was not developed to address presence of actual contractures in upper and lower extremities in one of three residents reviewed for range of motion. A care plan was not developed or implemented to address presence of sacral pressure ulcer that was identified on 2/13/17 and resolved on 4/12/17 for one of one resident reviewed for pressure ulcer. The Findings Included: The facility admitted Resident #48 with [DIAGNOSES REDACTED]. Review of the Comprehensive Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 10/20/16 revealed that Items G0400A (Functional Limitation in Range of Motion {FROM} of upper extremities) and G0400B (FROM of lower extremities) were coded as 2=impairment on both sides. Further review revealed that Items I3300 ([MEDICAL CONDITION]) and I4800 (non-Alzheimer's dementia) were both checked. Additionally, presence of limitations in range of motion in upper and lower extremities identified in nursing notes on 10/17/16 at 10:09 PM. Review of (MONTH) (YEAR) monthly Physician orders [REDACTED].#48 was prescribed the medications [MEDICATION NAME] for [DIAGNOSES REDACTED]. Additional review of medical record on 6/14/17 revealed pressure ulcer reports for sacral pressure ulcer that was identified on 2/13/17 and reported as resolved on 4/12/2017. Review of Resident #48's care plan (pages 1-20 of 20) on 6/14/17 revealed that the care plan did not address the [DIAGNOSES REDACTED]. Additionally, review of page 4 of 20 on Resident #48's care plan revealed that FROM in bilateral extremities/ contractures were not addressed as a current problem, with impaired physical mobility attributed only to cervical stenosis with [DIAGNOSES REDACTED] and goal for resident to .develop no contractures. Further review of both active and resolved care plan problems for Resident #48 revealed that there were no care plans that addressed the presence of sacral pressure ulcer identified on 2/13/17 and reported as healed on 4/12/17. Review of Care Planning policy on 6/14/17 revealed under the section Comprehensive Team Care Planning on page 35 under the heading of Identification of Problems/ Needs/ Strengths that .the care plan must address a resident concern if clinically warranted (ex.: [MEDICAL CONDITIONS], etc.). Further review of Care Planning policy revealed on page 40 under the section Care Planning Areas for Consideration, a list of 6 general care planning areas that are recommended by CMS (the Centers for Medicare and Medicaid) that are useful in the long-term setting. Under #1 Functional Status the instructions identify that functional status limitations are identified using the MDS and triggers . and the conditions identified by the RAI (Resident Assessment Instrument) should be clearly linked to the problems addressed on the care plan. Additionally, under #3 Health Maintenance includes (care planning) to address monitoring of disease processes that are currently being treated . MDS Nurse #1 was interviewed regarding Resident #48's care plan on 6/15/17 at 10:22 AM. During this interview, s/he verified that the care plan problem initiated on 12/10/10 that addressed impaired physical mobility for Resident #48 did not reflect the presence of contractures and did not reflect his/her current medical and nursing needs in the problem statement, goal or approaches. S/he further verified that neither [MEDICAL CONDITION] nor the use of medications to treat [DIAGNOSES REDACTED].#48's care plan, although according to facility policy, [MEDICAL CONDITION] should have been addressed somewhere in Resident #48's plan of care. Finally, s/he verified that there was no care plan problems or interventions implemented to address the emergence of sacral pressure ulcer that was identified on 2/13/17 and resolved on 4/12/17, although there should have been at least updates to care plan to address the presence of an actual pressure ulcer. During interview with Social Services Staff #1 on 6/15/17 at 11:00 am, s/he verified that there was no care plan problem or interventions in place that addressed the [DIAGNOSES REDACTED]. Social Services Staff #1 further stated that s/he would take care of that immediately.",2020-09-01
185,WHITE OAK MANOR - LANCASTER,425017,253 CRAIG MANOR ROAD,LANCASTER,SC,29720,2018-09-27,550,E,0,1,52MP11,"Based on observations, interview, and review of the facility policy, the facility failed to maintain the dignity of residents with catheter bags for 1 of 1 resident reviewed for catheters. Resident #25's catheter bag was exposed on the 100 hall. The findings included: On 9/24/18 at approximately 1:16 PM, an observation on the 100 hall of Resident #25's catheter bag hanging on the right side of the bed facing the hallway and was approximately 1/2 full of urine. The catheter bag was not covered and in full view from the hallway. On 9/24/18 at approximately 3:32 PM, an observation on the 100 hall of Resident #25's catheter bag hanging on the right side of the bed facing the hallway. The catheter bag was not covered and in full view from the hallway. On 9/25/18 at approximately 8:59 AM, an observation on the 100 hall of Resident #25's catheter bag hanging on the right side of the bed and was approximately 1/4 full of urine. The catheter bag was not covered and in full view from the hallway. On 9/25/18 at approximately 5:20 PM, an observation with Licensed Practical Nurse (LPN) #1 on the 100 hall of Resident #25's catheter bag hanging on the right side of the bed that was approximately 1/4 full of urine. The catheter bag was not covered and in full view from the hallway. On 9/25/18 at approximately 5:20 PM, during an interview LPN #1 verified the catheter bag was in full view from the hallway and indicated the bag should be placed in a privacy bag on the side of the bed away from view from the hallway. Review of the facility policy, Closed Urinary Drainage states under procedure (3.) Attach drainage bag to bed frame, below level of resident's bladder, not touching floor; cover with dignity bag (unless fig leaf bag used).",2020-09-01
186,WHITE OAK MANOR - LANCASTER,425017,253 CRAIG MANOR ROAD,LANCASTER,SC,29720,2018-09-27,580,E,0,1,52MP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of the facility policy titled, Standard Of Care, the facility failed to ensure the physician and the personal representative for Resident #5, #105, #82 and #56 was notified of refusal of multiple medications on multiple days. The facility further failed to ensure the physician was notified of falls/falls with injury for Resident #30 for 5 of 5 residents reviewed for Notification. The findings included: The facility admitted Resident #5 with [DIAGNOSES REDACTED]. Review on 9/26/2018 at approximately 1:24 PM of the medical record for Resident #5 revealed on multiple days multiple medications were refused by Resident #5. Resident #5 had refused medications on 5/2/2018, 5/16/2018, 5/29/2018, 5/30/2018, 5/31/2018, 6/3/2018, 6/4/2018, 6/6/2018, 6/15/2018, 7/24/2018, 7/27/2018, 8/6/2018, 8/9/2018, 8/10/2018, 8/15/2018, 8/16/2018, 8/22/2018, 8/28/2018, 9/5/2018 and 9/21/2018. No documentation could be found in the medical record for Resident #5 to ensure the physician or the personal representative was notified of the refusal of medications. The facility admitted Resident #30 with [DIAGNOSES REDACTED]. Review on 9/27/2018 at approximately 2:00 PM of the medical record for Resident #30 revealed a fall on 7/12/2018 and 7/14/2018. No documentation could be found in the medical record for Resident #30 to ensure the physician was notified. Review on 9/27/2018 at approximately 2:30 PM of the, Occurrence Report, for Resident #30 dated 7/12/2018 revealed a fall with a laceration above right eye and discoloration to the right outer calf. Further review on 9/27/2018 at approximately 2:30 PM of a second Occurrence Report for Resident #30 dated 7/14/2018 revealed a fall from the bed with no injury assessed. No documentation could be found in the medical record nor on the Occurrence report to ensure the physician was notified of either fall. During interview on 9/27/2018 at approximately 2:40 PM with LPN (Licensed Practical Nurse) #4 stated, If a resident receives an injury then we call the physician but if they do not sustain an injury then we log it in the communication book and he/she will be informed when they come in to see the patients on rounds. An interview on 9/27/2018 at approximately 2:50 PM with the physician, he/she verbalized his/her expectation was for the nurses to notify him/her of refusal of medications and falls/falls with injury. The physician also stated that he/she would expect to be notified of refusal of medications in case a change needed to be made in the medications and to update the plan of care. The physician went on to say that the nurses were good about letting him/her know of refusal of medications/care and falls/falls with injury. Review on 9/27/2018 at approximately 3:00 PM of the facility policy titled, Standards of Care, states under Policy: Each resident shall receive quality of care that is designed to meet individual needs and enhance the quality of life. Under Supervision 1. states, The physician and the family (or the resident's representative) shall be informed of any change in the resident's condition. Resident # 56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Nurse's notes reviewed on 9/25/18 at 2:57 PM revealed that Resident #56 refuses to take /his/her medication, or spits them out multiple occasions. However, there is no documentation to indicate that the physician and the resident's representative have been notified. Medication Administration Record [REDACTED]. In (MONTH) Resident #56 did not take medication on 10th and the 11th. For (MONTH) the resident did not receive multiple medications on the 14th, 17th, 24th, and 28th. For (MONTH) the resident did not take medication on 3rd, 7th, and 18th. Resident # 82 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]., [MEDICAL CONDITION], and Dysphagia. Nurse's notes reviewed on 9/27/18 at 9:24 AM revealed that Resident #82 refuses to take /his/her medication, or spits them out multiple occasions. However, there is no documentation to indicate that the physician and the resident's representative have been notified. Medication Administration Record [REDACTED]. In (MONTH) Resident #82 did not take medication on 3rd, 7th, 15th, 23rd, and 30th. In (MONTH) the resident did not receive medication on the 6th. Resident # 105 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Nurse's notes reviewed on 9/27/18 at 2:37 PM revealed that Resident #105 refuses to take his/her medication, or spits them out multiple occasions. However, there is not documentation to indicate that the physician and the resident's representative have been notified. Medication Administration Record [REDACTED]. In (MONTH) Resident #105 did not take medication on 4rd and the 11th7th. In (MONTH) the resident did not receive mediation on the 20th and in (MONTH) s/he did not take medication on the 3rd.",2020-09-01
187,WHITE OAK MANOR - LANCASTER,425017,253 CRAIG MANOR ROAD,LANCASTER,SC,29720,2018-09-27,656,D,0,1,52MP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a Comprehensive Plan of Care was developed for Resident #5 related to refusal of medications. The findings included: The facility admitted Resident #5 with [DIAGNOSES REDACTED]. Review on 9/26/2018 at approximately 1:24 PM of the medical record for Resident #5 revealed on multiple days multiple medications were refused by Resident #5. Resident #5 had refused medications on 5/2/2018, 5/16/2018, 5/29/2018, 5/30/2018, 5/31/2018, 6/3/2018, 6/4/2018, 6/6/2018, 6/15/2018, 7/24/2018, 7/27/2018, 8/6/2018, 8/9/2018, 8/10/2018, 8/15/2018, 8/16/2018, 8/22/2018, 8/28/2018, 9/5/2018 and 9/21/2018. Review on 9/26/2018 at approximately 3:10 PM of the Plan of Care for Resident #5 revealed no problem, goals or interventions for refusal of medications. An interview on 9/26/2018 at approximately 3:15 PM with the Care Plan Coordinator confirmed that there was no care plan developed for refusal of medications.",2020-09-01
188,WHITE OAK MANOR - LANCASTER,425017,253 CRAIG MANOR ROAD,LANCASTER,SC,29720,2018-09-27,686,D,0,1,52MP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and review of the facility policy titled, Dressing - Non-Sterile, the facility failed to follow a procedure during wound care for Resident #8 and #24 consistent with professional standards of practice to promote healing and prevent infection for 2 of 3 residents reviewed for wound care. The findings included: The facility admitted Resident #8 with [MEDICAL CONDITION], Pneumonia, Heart Failure, Pain and Pressure Ulcers. An observation on 9/26/2018 at approximately 10:30 AM during wound care for Resident #8, revealed a pair of scissors on the over the bed table. The scissors were not observed to be cleaned by RN (Registered Nurse) #3 prior to cutting a small amount of calcium alginate for placement on wound beds for Resident #8 during wound care. An additional observation on 9/26/2018 at approximately 10:40 AM, during wound care, revealed RN #3 removing gloves from his/her pocket to use for the dressing changes for Resident #8 after each time cleansing his/her hands. The facility admitted Resident #24 with [DIAGNOSES REDACTED]. An observation on 9/26/2018 at approximately 11:10 AM, during wound care for Resident #24, revealed RN #3 removing a pair of scissors from his/her pocket and cutting a piece of Calcium Alginate with Silver for the wound beds. An additional observation on 9/26/2018 at approximately 11:10 AM , during wound care for Resident 24, revealed RN #3 removing gloves from his/her pocket and applying them each time he/she removed the soiled gloves and after washing his/her hands. During an interview on 9/26/2018 at approximately 11:35 AM with RN #3 confirmed that he/she had not cleaned the scissors prior to wound care and had removed gloves from his/her pocket for use during wound care for Resident #24 and #8. Review on 9/26/2018 at approximately 11:50 AM of the facility policy titled, Dressing - Non Sterile, states under Objective: number 1. states, To protect wound from contamination and/or injury. Under Note: number 1 states, Clean scissors before and after each resident use.",2020-09-01
189,WHITE OAK MANOR - LANCASTER,425017,253 CRAIG MANOR ROAD,LANCASTER,SC,29720,2018-09-27,690,D,1,0,52MP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview the facility failed to provide follow up and appropriate treatment and services to prevent urinary tract infection to a resident with signs and symptoms of urinary tract infection for one of one sample resident reviewed for bowel and bladder incontinent. Findings: Resident # 56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Nurse's notes reviewed on 9/25/18 at 2:57 PM revealed that on 6/7/18 Resident #56 on 6/7/18 complained of dysuria and also had some foul smelling urine. According to the nurse's notes, the nurse notified the physician. However, there is no documentation to support that the physician or the facility staff took any further action or performed a urinalysis to rule out urinary tract infection [MEDICAL CONDITION]. On 6/9/18 the nurse's notes indicated that the resident wanted to get out of the facility. S/he has thrown his/her cover on the floor and was attempting to get out of bed. On 6/13/18 the facility found the resident on the floor with his/her back against the bedside commode. On 6/20/18 the facility sent the resident at the hospital where s/he was treated for [REDACTED]. During an interview with the director of nursing (DON) and registered nurse consultant on 9/26/18 at 9:23 AM the DON confirmed that the facility did not perform a urinalysis to rule out UTI.",2020-09-01
190,WHITE OAK MANOR - LANCASTER,425017,253 CRAIG MANOR ROAD,LANCASTER,SC,29720,2018-09-27,759,D,0,1,52MP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and review of the facility policy, the facility failed to maintain a medication error rate of less than 5%. There were 3 errors out of 31 opportunities for error, resulting in a medication error rate of 9.68%. The findings included: Error #1 and #2 On 9/26/18 at approximately 8:50 AM, during an observation of Resident #5's medication administration on the 100 hall, Registered Nurse (RN) #1 crushed [MEDICATION NAME] 10 meq. and [MEDICATION NAME] HCL 10 mg. and placed the medication in applesauce and attempted to administer the medication to Resident #5. RN #1 was stopped before administering the medication and was asked to review Resident #5's physicians orders which stated, [MEDICATION NAME] 10 MEQ Tablet- Give one tablet by mouth twice daily with or after meals and with at least 4 oz of liquid.***Do not crush***, also [MEDICATION NAME] HCL 10 MG Capsule- Give 1 capsule by mouth daily. **Do not crush**. Following the review of Resident #5's physician's orders RN #1 verified s/he crushed [MEDICATION NAME] and [MEDICATION NAME] and indicated s/he should not have. Error #3 On 9/26/18 at approximately 8:55 AM, during an observation of Resident #5's medication administration on the 100 hall, Registered Nurse (RN) #1 administered (1) drop of Artificial Tears into each of the residents' eyes. RN #1 then returned to the cart and placed the Artificial Tears back into the Resident #5's drawer in the medication cart, and signed the medication off as given. On 9/26/18 at 9:00 AM, during reconciliation of Resident #5's med pass, a review of the Medication Administration Record [REDACTED]. On 9/26/18 at 9:00 AM, during an interview with RN #1, s/he verified giving only 1 drop per eye of Artificial Tears instead of 2 drops per eye. Review of the facility policy, Oral Medication Administration Procedure states under procedure (6.b.) Medications, not otherwise indicated may be crushed. If Do Not Crush is added to a medication order and the resident needs to have the medication crushed, please consult the pharmacy.",2020-09-01
191,WHITE OAK MANOR - LANCASTER,425017,253 CRAIG MANOR ROAD,LANCASTER,SC,29720,2018-09-27,761,D,0,1,52MP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and review of the facility policy titled, Medication Storage In The Facility, the facility failed to ensure medications were secured and out of reach of residents that were capable of obtaining them on Unit 200 for 1 of 3 units observed. The findings included: An observation on 9/25/2018 at approximately 9:10 AM revealed unsecured medications on the top of a treatment cart on the 200 Unit. The medications consisted of [MEDICATION NAME] Powder, [MEDICATION NAME] Cream and Santyl. Residents were observed sitting in wheel chairs approximately 3 feet from the treatment cart and others were observed walking by the cart on the unit. An interview on 9/25/2018 at approximately 9:10 AM with LPN (Licensed Practical Nurse) #2 confirmed the findings and stated, these medications came in during the night and were left on the cart. LPN #2 went on to say that the medications should have been secured in the treatment cart and not stored on the top of it. Review on 9/25/2018 at approximately 10:00 AM of the facility policy titled, Medication Storage In The Facility, states, Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.",2020-09-01
192,WHITE OAK MANOR - LANCASTER,425017,253 CRAIG MANOR ROAD,LANCASTER,SC,29720,2018-09-27,804,D,0,1,52MP11,"Based on observation, and interview the facility failed to provide food prepared at an appetizing temperature for 2 of 2 residents reviewed during lunch meal. Two Residents on the 300 unit were served melted ice cream. The findings included: On 9/25/18 at 1:57 PM, an observation of the meal service on the 300 hall revealed the meal trays were placed on the hall at 12:15 PM. The last 2 trays were removed from the uncovered food cart at 12:57 PM. Certified Nursing Assistant (CNA) #1 and CNA #2 removed the last 2 trays from the cart and verified the ice cream on the tray was melted.",2020-09-01
193,FLEETWOOD REHABILITATION AND HEALTHCARE CENTER,425018,200 ANNE DRIVE,EASLEY,SC,29640,2016-10-05,241,D,0,1,WRBU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to ensure that dignity in dining was enhanced for residents who required assistance with eating during meals. Two random meal observations in 1 of 3 dining rooms. (Section 1) The findings included: During a random lunch observation on 10/03/16 at approximately 12 PM revealed four dining tables with two to five residents seated at each table. The residents seated at three of the four tables were served. There were three residents seated at a table close to room [ROOM NUMBER]. None of the residents seated at the table were served while the other residents in the dining room were served and eating independently or being fed by family members. Staff was observed delivering food to residents in their rooms while the three residents in the dining room were not served or eating. Further meal observation in the dining room on 10/03/16 revealed Certified Nursing Aide (CNA) #3 touching two residents bread with bare hands and putting butter on it. At approximately 12:17 PM staff was observed feeding the residents at the fourth table near room [ROOM NUMBER]. Random observation of meal service down the hallway on 10/03/16 at approximately 12:20 PM near medical records revealed a Certified Nurse Aide (CNA) in a room texting on his/her phone; while a resident that required assistance with eating was in bed with a food tray on a bedside table. A random observation of meal delivery on 10/04/16 at approximately 11:56 AM revealed four tables in the dining room. There was a long table with six residents present. Staff was observed serving residents at two other tables before serving all the residents at the long table. Staff was observed serving some residents in their rooms before serving all the residents in the dining room. During meal observation down the hallway on 10/04/16 at approximately 12:12 PM revealed two residents in Rooms #22, #17 and #15 with one resident with a food tray and eating while the other resident was not served. They were eating without the privacy curtains being closed. An interview on 10/04/16 at approximately 12:15 PM with Licensed Practical Nurse (LPN) #1 and Certified Nurse Aide (CNA) #1 confirmed the findings of delay in meal delivery in rooms. An interview on 10/05/16 at approximately 8:19 AM with CNA #2 confirmed findings on 10/04/16 of delay of meal delivery in dining room. An interview on 10/05/16 at approximately 9:08 AM with CNA #3 confirmed he/she touched resident's bread with bare hands during meal delivery on 10/03/16.",2020-09-01
194,FLEETWOOD REHABILITATION AND HEALTHCARE CENTER,425018,200 ANNE DRIVE,EASLEY,SC,29640,2016-10-05,431,D,0,1,WRBU11,"Based on observation and interview the facility failed to maintain medication (med) storage rooms free of expired medications on 1 of 3 nursing stations. Magic Mouthwash was stored in the refrigerator in the Station 1 med room and had expired. The findings included: During an observation of the Station 1 med room on 10/5/2016 at 9:05 AM, a bottle of Magic Mouthwash with Lidocaine was found in the refrigerator. The medicine was ordered to be used 3 times daily as needed for mouth pain. The medication was dispensed on 9/16/2016 and had a hand written expiration date of 9/30/2016 on the label. During an interview with RN (Registered Nurse) #1 on 10/5/2016 at 9:05 AM, RN #1 confirmed the hand written date of 9/30/2016 appeared to be the expiration date of the Magic Mouthwash. RN #1 called the pharmacist for clarification on the expiration date. Per RN #1, the pharmacist confirmed that the magic mouthwash was a compounded medication with a 14 day shelf life and did expire on 9/30/2016. Review of the Medication Administration Records revealed that the resident did not receive any of the Magic Mouthwash after 9/30/2016.",2020-09-01
195,FLEETWOOD REHABILITATION AND HEALTHCARE CENTER,425018,200 ANNE DRIVE,EASLEY,SC,29640,2017-10-06,157,D,1,1,NTTE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to notify the physician of significant changes in blood glucose levels for 1 of 5 sampled residents reviewed for unnecessary medication. The physician was not notified of multiple blood sugar results greater than 400 as ordered for Resident #2. The findings included: The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Record review on 10/6/17 revealed 6/29/2017 physician's orders [REDACTED].= 3 units; 251-300 = 5 units; 301-350 = 8 units; 351-400 = 10 units; 401-450 = 13 units. Notify provider; 451-500 = 15 units subcutaneously before a meal and at bedtime for diabetes. Notify provider if BG >400 and Review of the 7/17 Medication Administration Record [REDACTED]= 433 at 1630h(ou)rs and 429 at 2100hrs, 7/3 = 454 at 1630hrs, 542 at 2100hrs, 7/7 = 4[AGE] at 2100hrs, 7/13 = 426 at 2100, 7/15 = 406 at 2100, 7/17 = 499 at 2100hrs, 7/20 = 426 at 1630hrs and 458 at 2100hrs, 7/21 = 415 at 0700hr, 7/22 = 414 at 2100hrs, 7/28 = 422 at 2100, and 7/29 = 458 at 2100. Continuing review of the 8/17 MARs revealed that Resident #2's blood glucose was 405 on 8/1, 413 on 8/3 at 1630hrs, 402 on 8/4, 432 on 8/8 at 2100hrs, 448 on 8/9 at 1630hrs, 478 on 8/12 at 2100hrs, 427 on 8/17, 415 on 8/18 at 1630hrs, 414 on 8/24 at 2100hrs, and 416 on 8/29 at 1630hrs. Review of 9/17 MARs revealed that Resident #2's blood glucose was 407 on 9/4 at 2100hrs, 427 on 9/6 at 1630hrs, 402 on 9/8, 401 on 9/9, 525 on 9/12/17, 410 on 9/18, 504 on 9/25 at 2100hrs, and 468 on 9/26 at 0700hrs. Review of Nurse's Notes on 10/05/2017 at 9:45 AM for the months of July, August, and September, 2017 revealed no documentation regarding notifying the physician of blood sugar results greater than 400. During an interview on 10/05/2017 at 9:09 AM, Licensed Practical Nurse (LPN) #4 could not locate any documentation on either the computerized records or the resident's medical record that stated the physician had been notified of any blood sugar results of greater than 400. LPN #4 spoke to the Director of Nursing (DON) on the same day at approximately 9:15 AM regarding locating documentation to show that the physician had been notified at any time. The DON was unable to find any evidence of physician notification. S/he stated that the facility was aware of the problem and it had provided group in-service/counseling on 9/20/17 but the problem had not been resolved. The DON verified the above findings on 10/05/2017 9:47 AM.",2020-09-01
196,FLEETWOOD REHABILITATION AND HEALTHCARE CENTER,425018,200 ANNE DRIVE,EASLEY,SC,29640,2017-10-06,274,D,1,1,NTTE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to complete a Significant Change in Status Assessment (SCSA) in a timely manner for 1 of 5 residents reviewed for Hospice services. The facility did not complete the SCSA within 14 days following revocation of Hospice for Resident #8. The findings included: The facility admitted Resident #8 with [DIAGNOSES REDACTED]. Review of the medical record on 10/5/17 at 1:50 PM revealed that there was an order for [REDACTED]. Further review of the medical record revealed that resident was transferred to the hospital on [DATE] after the revocation of hospice services and returned to facility on 2/3/17. Review of the Minimum Data Set (MDS) assessments indicated the SCSA was not initiated with an assessment reference date until 2/13/17. Further review revealed that items Z0500B, V0200B2 and V0200C2 were all signed, which reflected the completion of the assessment on 2/21/17. The significant change in status assessment was not completed within 14 days of Hospice admission as required. During an interview on 10/6/17 at 3:17 PM, MDS Nurse #1 reviewed the medical record for Resident #8 and confirmed that hospice services were discontinued prior to hospitalization , and that a SCSA was not completed within 14 days of Resident #8 ' s return to facility, identified as the date a SCSA was indicated, as required.",2020-09-01
197,FLEETWOOD REHABILITATION AND HEALTHCARE CENTER,425018,200 ANNE DRIVE,EASLEY,SC,29640,2017-10-06,278,B,1,1,NTTE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, and interview, the facility failed to accurately code the Minimum Data Set (MDS) for 1 of 2 sampled residents reviewed for contractures. Resident #94's MDS was not coded accurately to reflect the functional limitation of range of motion for the upper extremity contractures. The findings included: Resident #94 was admitted with [DIAGNOSES REDACTED]. During an observation on 10/3/17 at 10am, Resident #94 was observed to have contractures of her/his wrists and hands. Record review on 10/5/17 at 10am of hospice Interdisciplinary Team (IDT) Note on 3/8/17 stated, She (he) has bilateral hand contractures, and all extremities have fixed contractures and no purposeful use. Further record review of a Skilled Nursing (SN) Clinical Note dated 6/1/17 stated, All extremities with fixed contractures. Review of the MDS on 10/5/17 at 9am revealed the MDS with review dates of 6/6/17 and 8/31/17 was coded a 0-no impairment under Functional Limitation of Range of Motion, Section G0400, A- Upper Extremity. During an interview on 10/5/2017 at 12:50pm, MDS #1 verified that the 6/6/17 and 8/31/17 MDS was not coded correctly to reflect the upper extremity contractures.",2020-09-01
198,FLEETWOOD REHABILITATION AND HEALTHCARE CENTER,425018,200 ANNE DRIVE,EASLEY,SC,29640,2017-10-06,323,D,1,1,NTTE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record review and staff interview, the facility failed to ensure one of three residents reviewed for accidents received adequate supervision and assistance devices to prevent accidents. Facility staff used an improper lift during care resulting in Resident #8 being lowered to floor. The Findings Include The facility admitted Resident #8 with [DIAGNOSES REDACTED]. Review of the Certified Nursing Assistant (C.N.A.) Care Card for Resident #8 was completed on 10/5/17 at 10:00 AM. The C.N.A. Care Card identified that a sling lift and 2 staff assist were required for transfers. Further review of the Lift Evaluation Form completed on 8/11/17, revealed that Resident #8 was not able to bear weight, did not have upper body strength, and that a total body lift was indicated. Observations on 10/3/17 and 10/5/17 revealed that two staff members used a total lift / sling lift to transfer Resident #8 to and from bed to Geri-chair with no concerns identified related to the transfer procedures. During interview with C.N.A. #1 on 10/5/17 at 2:00 PM, s/he reviewed her/his written statement regarding an incident related to Resident #8 being lowered to the floor that occurred on 9/11/17 and verified that the statement resident had soiled self I took her to shower room placed on stand lift to clean her. Resident raised her arms and began to fall. I got behind her and lowered her to the floor was correct. When asked how s/he was made aware of what each resident ' s specific care needs were, s/he identified the C.N.A. Care Card. When asked if s/he could indicate where on the C.N.A. Care Card it identified the use of a sit-to-stand lift, s/he could not. When asked how Resident #8 currently was transferred, s/he replied with the total lift. When asked how many staff members were required to assist with transfers for Resident #8, s/he replied 2 . During an interview on 10/5/17 at 2:12 PM with C.N.A. #2, s/he stated that s/he was familiar with Resident #8. S/he stated that the C.N.A. Care Card was the information source used to identify how each resident was to be cared for because it outlined what care was to be provided which included safety devices and specialized equipment utilized with each resident. When asked how Resident #8 was transferred, s/he replied with the total lift. When asked how many staff members were required to assist with transfers for Resident #8, s/he replied 2 . During an interview on 10/5/17 at 2:07 PM with LPN #1, s/he stated that s/he was familiar with Resident #8. S/he stated that the C.N.A. Care Card was where the information regarding safety interventions and equipment required was located. When asked how Resident #8 was transferred, s/he replied sling lift with two staff. On 10/6/17 at 11:02 AM, review of record for in-service conducted on 9/14/17 revealed that staff was educated regarding utilization of the C.N.A. Care Card to identify what lifts are to be used and that total/ sling lifts require 2 staff members to operate.",2020-09-01
199,FLEETWOOD REHABILITATION AND HEALTHCARE CENTER,425018,200 ANNE DRIVE,EASLEY,SC,29640,2018-11-09,577,C,0,1,NICZ11,"Based on observations and interview, the facility failed to post notice of the latest survey report in a prominent place in all areas of the facility. In addition, the facility failed to post notice of the availability of the results of the preceding 3 years survey reports in a place readily accessible to residents and the public. The findings included: During the Recertification Survey, a Group Interview was held with 8 residents on 11/7/18 at approximately 4:00 PM. At that time, residents were asked if they knew where the latest State survey inspection report was located. The participants were unable to answer this question and indicated that they were unaware of this information. Observations during the survey indicated the survey report was located in a binder placed in a holder on the wall outside the Administrator's office near the entrance to the facility. Observations of the first and second floor units revealed no signage indicating the location of the survey report. Observation revealed the past year's survey report was located in the binder. Further observation revealed there was no signage to indicate that the preceding 3 years survey reports were available for review upon request. During an interview on 11/9/18, the Administrator reviewed the contents of the survey binder and confirmed these findings at that time.",2020-09-01
200,FLEETWOOD REHABILITATION AND HEALTHCARE CENTER,425018,200 ANNE DRIVE,EASLEY,SC,29640,2018-11-09,584,E,0,1,NICZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to provide housekeeping and maintenance services to maintain a clean, safe and comfortable environment on 11/6/2018 through 11/8/2018 on 3 of 3 units. The findings included: The following concerns were identified during the Initial Pool Process on 11/6/2018 and 11/7/2018 and confirmed during and environmental tour with facility administrator and housekeeping supervisor on 11/08/18 beginning at approximately 2:23 PM. (1)room [ROOM NUMBER] hall 3-A- floors and bathroom with dirt and residue buildup, cluttered with boxes on the floor (2) room [ROOM NUMBER] hall 3-B cluttered items on the floor, dirty/torn baseboards on the wall at the head of the bed (3) room [ROOM NUMBER] hall 12-W dirt and residue buildup on the baseboards in the bathroom and baseboards to the left side of the residents bed (4) room [ROOM NUMBER] hall 2-C cluttered items on the floor, underneath bed dirt and residue buildup, dirty brown substance build up in the toilet, and underneath the sink with moderate dirt and buildup (5) room [ROOM NUMBER] hall 6-D closet door with large scrapes and missing paint, missing paint around the sink with appearance of dried coating (6) room [ROOM NUMBER] hall 13-A dirt and residue buildup on floor and walls, overbed table dirty with build up on the rolling base support, and bedframe with splatter of sticky light brown substance (7) room [ROOM NUMBER] hall 7-W closet doors with large scrapes and scuffs and missing paint, cluttered items on the floor (8) room [ROOM NUMBER] hall 11-W bathroom with black spatter substance appears with grime and build up, clothing closet with large scrapes and missing paint, light bulb apparatus with missing cover (9) room [ROOM NUMBER] hall 13-W privacy curtain dirty with streaks of red substance, dirt build up on walls, baseboards and shelves, cluttered items on the floor (10) room [ROOM NUMBER] hall 15-C floors, baseboards, walls with dirt build up, and window blind broken",2020-09-01
201,FLEETWOOD REHABILITATION AND HEALTHCARE CENTER,425018,200 ANNE DRIVE,EASLEY,SC,29640,2018-11-09,693,D,0,1,NICZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and review of the facility policy, the facility staff failed to ensure appropriate treatment for 1 of 1 resident observed for enteral medication administration. During Resident #6's gastric tube ([DEVICE]) medication administration, the nurse failed to follow established procedures to check for placement verification prior to the instillation of the prescribed medication. The findings included: The facility admitted Resident #6's with [DIAGNOSES REDACTED]. On 11/7/18 at approximately 2:30 PM, an observation of Resident #6's medication administration on the station 2 unit, Licensed Practical Nurse (LPN) #1 prior to administration checked for [DEVICE] placement and residual by attaching a syringe and pushing in 60 milliliters (ml's) of air into Resident #6's [DEVICE] and pulling back on the syringe for stomach contents. On 11/7/18 at approximately 2:38 PM, during an interview LPN #1 verified s/he checked for placement by pushing in 60 ml. of air through Resident #6's [DEVICE], the surveyor asked, if s/he was trained to use 60 ml. of air to check placement? LPN #1 stated, The Unit Manager instructed me to do so. Review of the facility policy revealed there was not a policy relating to enteral tubes, the Director of Nursing (DON) provided the surveyor with the Gastrostomy Feeding Competency form completed by LPN #1 which states under Guideline Step, #8, Check gastric residual volume (GRV) before each feeding (for bolus and intermittent feedings) and every 4 to 6 hours (for continuous feedings) (a.) Draw up to 10 to 30 ml air into syringe and connect the end of the feeding tube. (b.) Inject air into the tube. Pull back slowly and aspirate total amount of gastric contents. LPN #1 last completed the competency on 9/4/17.",2020-09-01
202,FLEETWOOD REHABILITATION AND HEALTHCARE CENTER,425018,200 ANNE DRIVE,EASLEY,SC,29640,2018-11-09,730,F,0,1,NICZ11,"Based on record review and interview, the facility failed to ensure the adequacy of the Certified Nurse Aide (CNA) in-service education program for all employed CNAs. The facility failed to track and ensure the in-service training for nurse aides included the required 12 hours per year based on hire date. The findings included: During a review of CNA inservice training, the Director of Nursing (DON) provided a list of currently employed CNAs. The surveyor chose to review the inservice training documentation for 2 of the CNAs on the list. Record review indicated the reports did not calculate the total number of yearly inservice hours for the CNAs based on the hire date. The surveyor requested documentation of the total number of inservice hours based on hire date. When provided this information, review of the records revealed the inservice hours did not meet the minimum number of 12 hours as required. On 11/9/18 at approximately 11:00 AM, the DON reviewed the records and confirmed the surveyor's findings at that time. No further documentation related to CNA inservice training was provided prior to exit from the facility.",2020-09-01
203,FLEETWOOD REHABILITATION AND HEALTHCARE CENTER,425018,200 ANNE DRIVE,EASLEY,SC,29640,2018-11-09,759,E,0,1,NICZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and review of the facility policies and the Humalog KwikPen manufacture recommendations, the facility failed to maintain a medication rate of less than 5%. There were 3 errors out of 25 opportunities for error, resulting in a medication error rate of 12%. The findings included: Error #1 On 11/6/18 at approximately 4:30 PM, during an observation of Resident #76's medication administration on the station 3 unit, Licensed Practical Nurse (LPN) #1 reviewed the Medication Administration Record [REDACTED]. LPN #1 then prepared the Humalog KwikPen for administration and without wiping the Rubber Seal and without attaching a needle, LPN #1 selected 2 units on the Dose Knob dial and pressed the administration button indicating s/he was checking the KwikPen for patency. LPN #1 then attached a needle and administered 4 units of insulin to Resident #76. Following the administration LPN #1 verified s/he did not clean the Rubber Seal or attach the needle before priming the Humalog KwikPen. Review of the facility policy, How To Use an Insulin Pen, revealed under Taking Your Insulin, (4.) Use alcohol to clean the end of the pen where the needle twists on, and (6.) states, To clear the air out of the pen: Remove the cap from the needle. Turn the dose dial to 2 units. Hold the pen so the needle is up in the air. Push the end of the pen in to clear the air. Watch the tip of the needle for a drop of insulin. You may need to do this more than once to see the drop of insulin on the needle. Review of the Humalog KwikPen manufactures recommendations under Preparing your pen, states, Step 1: Pull the Pen Cap straight off. - Do not remove the Pen Label. Wipe the Rubber Seal with an alcohol swab. Step 2: Check the liquid in the Pen. HUMALOG should look clear and colorless. Do not use if it is cloudy, colored, or has particles or clumps in it. Step 3: Select a new Needle. Pull off the Paper Tab from the Outer Needle Shield. Step 4: Push the capped Needle straight onto the Pen and twist the Needle on until it is tight. Step 5: Pull off the Outer Needle Shield. Do not throw it away. Pull off the Inner Needle Shield and throw it away. Priming your Pen Prime before each injection. Priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. Step 6: To prime your Pen, turn the Dose Knob to select 2 units. Step 7: Hold your Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top. Step 8: Continue holding your Pen with Needle pointing up. Push the Dose Knob in until it stops, and 0 is seen in the Dose Window. Hold the Dose Knob in and count to 5 slowly. You should see insulin at the tip of the Needle. - If you do not see insulin, repeat priming steps 6 to 8, no more than 4 times. - If you still do not see insulin, change the Needle and repeat priming steps 6 to 8. Small air bubbles are normal and will not affect your dose. Error #2 On 11/6/18 at approximately 6:45 PM, during an observation of Resident #195's Peripheral Inserted Central Catheter (PICC) line medication administration on the station 2 unit, Registered Nurse (RN) #1 opened (4) 10 milliliter (ml.) 0.9% Sodium Chloride (normal saline or NS) syringes and placed them on a tray table next to Resident #195's bed. RN #1 proceeded to clean port #1 of the (2) ports and administered (2) of the 10 ml. Sodium Chloride syringes into port #1. RN #1 then cleaned the medication #2 port and administered (2) more of the 10 ml. Sodium Chloride syringes into port #2. RN #1 then connected tubing to the #2 medication port for the [MEDICATION NAME] 1.25 mg HCL to infuse into Resident #195's PICC line. Immediately following Resident #195's PICC line medication administration a reconciliation of Resident #195's medication pass with RN#1 revealed a physician's order stating, Sodium Chloride Flush Solution 0.9% Use 10 ml intravenously every 8 hours for flush for line patency into each lumen of the double lumen PICC line. Also, review of the facility policy Infusion Maintenance Table states under PICC Intermittent Non-Valved, 10 ml NS, infuse medication, then 10 ml NS, follow with 5 ml. 10 units/ml [MEDICATION NAME], and Valved states, 10 ml NS, infuse medication, then 10 ml NS. RN#1 verified s/he administered 20 ml. of NS syringes into each of Resident #195's (2) PICC ports. Error #3 On 11/6/18 at approximately 7:25 PM, during an observation of Resident #63's medication administration on the station 2 unit, LPN #2 prepared Resident #63's (3) ordered 8:00 PM medications Atrovastin Calcium 80 mg., [MEDICATION NAME]-[MEDICATION NAME] HCl 2.5-500 mg., but LPN #2 could not locate Renexa ER (extended release) 12 hour 500 mg. in the cart. LPN #2 stated, The medication is not on the cart I will have to order it from pharmacy. On 11/7/18 at approximately 10:00 AM, a review of Resident #63's Medication Administration Record [REDACTED]. ER 12 hour 500 mg. at 8:00 PM. On 11/7/18 at approximately 12:05 PM, during an interview with the Director of Nursing (DON) s/he stated, Resident #63's Renexa medication card was on the cart misplaced. The DON then verified that Resident #63 did not receive their Renexa ER 12 hour 500 mg. until 6:00 AM on 11/7/18, 10 hours after the Renexa was scheduled.",2020-09-01
204,FLEETWOOD REHABILITATION AND HEALTHCARE CENTER,425018,200 ANNE DRIVE,EASLEY,SC,29640,2018-11-09,760,D,0,1,NICZ11,"Based on observations, interview, and review of the Humalog KwikPen manufacture recommendations, the facility failed to administer the correct amount of insulin for 1 of 1 resident's reviewed for insulin administration. Staff did not follow an established procedure to deliver the correct amount insulin to Resident #76. The findings included: On 11/6/18 at approximately 4:30 PM, during an observation of Resident #76's medication administration on the station 3 unit, Licensed Practical Nurse (LPN) #1 reviewed the Medication Administration Record [REDACTED]. LPN #1 then prepared the Humalog KwikPen for administration and without wiping the Rubber Seal and without attaching a needle, LPN #1 selected 2 units on the Dose Knob dial and pressed the administration button indicating s/he was checking the KwikPen for patency. LPN #1 then attached a needle and administered 4 units of insulin to Resident #76. Following the administration LPN #1 verified s/he did not clean the Rubber Seal or attach the needle before priming the Humalog KwikPen. Review of the facility policy, How To Use an Insulin Pen, revealed under Taking Your Insulin, (4.) Use alcohol to clean the end of the pen where the needle twists on, and (6.) states, To clear the air out of the pen: Remove the cap from the needle. Turn the dose dial to 2 units. Hold the pen so the needle is up in the air. Push the end of the pen in to clear the air. Watch the tip of the needle for a drop of insulin. You may need to do this more than once to see the drop of insulin on the needle. Review of the Humalog KwikPen manufactures recommendations under Preparing your pen, states, Step 1: Pull the Pen Cap straight off. - Do not remove the Pen Label. Wipe the Rubber Seal with an alcohol swab. Step 2: Check the liquid in the Pen. HUMALOG should look clear and colorless. Do not use if it is cloudy, colored, or has particles or clumps in it. Step 3: Select a new Needle. Pull off the Paper Tab from the Outer Needle Shield. Step 4: Push the capped Needle straight onto the Pen and twist the Needle on until it is tight. Step 5: Pull off the Outer Needle Shield. Do not throw it away. Pull off the Inner Needle Shield and throw it away. Priming your Pen Prime before each injection. Priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. Step 6: To prime your Pen, turn the Dose Knob to select 2 units. Step 7: Hold your Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top. Step 8: Continue holding your Pen with Needle pointing up. Push the Dose Knob in until it stops, and 0 is seen in the Dose Window. Hold the Dose Knob in and count to 5 slowly. You should see insulin at the tip of the Needle. - If you do not see insulin, repeat priming steps 6 to 8, no more than 4 times. - If you still do not see insulin, change the Needle and repeat priming steps 6 to 8. Small air bubbles are normal and will not affect your dose.",2020-09-01
205,FLEETWOOD REHABILITATION AND HEALTHCARE CENTER,425018,200 ANNE DRIVE,EASLEY,SC,29640,2018-11-09,812,F,0,1,NICZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of the facility policies, the facility failed to prepare, distribute, and serve food under sanitary conditions for 1 of 1 kitchen and 3 of 3 nourishment rooms reviewed and has the potential to affect 95 of 95 residents with ordered diets as evidenced by failing to do the following: Calibrate a thermometer, plate food sanitarily, remove expired food from storage, air dry pans, clean (floors, walls, equipment, microwave, stove, drying racks, ice machine and scoop holder). The findings included: On [DATE] at approximately 9:20 AM, an initial tour of the main kitchen with the Certified Dietary Manager (CDM) revealed: 1.) The ice machine had a build-up of a black/brown substance on the inside of the door and (2) uncovered scoops were on top of the machine resting on dust and debris. 2.) The hood over the cooking line had a build-up of grease dripping below onto the floor and cooking equipment below. 3.) Fan in the main kitchen to the right of the Reach-In cooler had a large build-up of dust and was blowing into the kitchen. 4.) Leftover food in the Reach In cooler was stored beyond the use by date which was hand written on the container: (Egg Salad use-by date [DATE], Vegetable Beef Soup use by date [DATE], Black eye peas use by date [DATE], Cabbage use by date [DATE], Chicken [NAME]es use by date [DATE], Butter Scotch pudding use by date [DATE] and a package of Salami meat was opened and had a date of [DATE]). 5.) (6) Puree pans were stacked wet on the clean drying rack. 6.) Floors in the main kitchen and dish washing area had a build-up of a dust, grease, and food debris under all equipment and on the base boards. 7.) Steam table had dried food spatter on the counter and base. 8.) The walls, windows, and windowsill in the dishwashing area had a black substance growing. 9.) The dishware drying racks next to the steam table had a large build-up of rust. 10.)The stove had a large build-up of grease and food debris. On [DATE] at approximately 10:40 AM, an observation of the lunch line steam table temping in the main kitchen, Cook #1 was asked by the surveyor to calibrate the temping probe for accuracy. Cook #1 stated, I don't know how to. On [DATE] at approximately 11:15 AM, an observation of the lunch line plating in the main kitchen with the Dietary Manager (DM) revealed Cook #1 donned gloves touched plates, pellets, steam table counter, handles of scoops, and then grabbed bread buns with the same gloved hand placing the bun on the residents plate. During an interview following the observation, the DM verified Cook #1 touch buns with his/her hands and indicated they should have used tongs. On [DATE] at approximately 12:30 PM, and on [DATE] at approximately 11:30 AM, an observation of the station 1 unit nourishment room revealed a cooler filled with ice and the scoop resting outside in a tray without drainage that contained cloudy water. Also, the resident refrigerator had spillage and food debris throughout. Furthermore, the microwave had food spatter throughout the interior. On [DATE] at approximately 12:50 PM and [DATE] at approximately 10:30 AM, an observation of the station 2 unit nourishment room revealed a cooler filled with ice and the scoop resting outside in a tray without drainage that contained cloudy water. Also, the resident refrigerator had spillage and food debris throughout. Furthermore, the microwave had food spatter throughout the interior and the coffee maker was resting in a tray of leaking coffee. On [DATE] at approximately 1:20 PM and on [DATE] at approximately 10:35 AM, an observation of the station 3 unit nourishment room revealed a cooler filled with ice and the scoop resting outside in a tray without drainage that contained cloudy water. Also, the resident refrigerator had spillage and food debris throughout and the crisper on the bottom shelf was cracked and broken. Furthermore, the microwave had food spatter throughout the interior. On [DATE] at approximately 11:00 AM, an observation of the main kitchen with the DM and administrator revealed: 1.) The ice machine had a build-up of a black/brown substance on the inside of the door and (2) uncovered scoops were on top of the machine resting on dust and debris. 2.) The floor around the fryer had a large amount of grease spillage and French fries from [DATE]. 3.) Fan in the main kitchen to the right of the Reach-In cooler had a large build-up of dust and was blowing into the kitchen. 4.) (1) Puree pans were stacked wet on the clean drying rack. 5.) Floors in the main kitchen and dish washing area had a build-up of a dust, grease, and food debris under all equipment and on the base boards. 6.) Steam table had dried food spatter on the counter and base. 7.) The walls, window, and windowsill in the dishwashing area had a black substance growing. 8.) The dishware drying racks next to the steam table had a large build-up of rust. 9.) In the dry storage room the emergency food supply had (10) 60 ounce (oz.) containers of Ocean Spray Orange juice with a Best Before date of [DATE]. (2) 5 pound (lb.) boxes of Chocolate cake mix with a Best By date of [DATE], (6) 6 lb. 10 oz. cans of Tropical Fruit Salad with a Best Used, date of ,[DATE]. (6) 6 lb. 10 oz. cans of Pineapple Tidbits with a Best By date of ,[DATE]. (6) 6lb. 12 oz. cans of Beef Ravioli with a Best By date of [DATE]. (12) 7 Lb. cans of Vanilla Pudding with a Best By date of [DATE]. (2) 5 Lb. containers of Creamy Peanut Butter with a Best By date of [DATE]. 10.) The stove had a build-up of grease and food debris. Following the observations the DM and Administrator verified the (10) observations. Review of the facility policy, Environment, states under action step (1.) The Food Service Director will insure that the physical plant is maintained in a clean and sanitary manner, including floors, walls, ceilings, lighting, and ventilation. Also, ,[DATE].15 Gloves, Use Limitation, revealed under (A) If used, SINGLE-USE gloves shall be used for only one task such as working with READY-TO-EAT FOOD or with raw animal FOOD, used for no other purpose, and discarded, and when damaged or soiled, or when interruptions occur in the operation. Also, policy, Food and Supply Storage Procedures, states under Dry Storage, bullet (4.) Remove from storage any items for which the expiration date has expired, and under Refrigerated Storage, bullet (3.) Discard leftovers not utilized within 48 hours. Furthermore, policy Storage of Pots, Dishes, Flatware, Utensils, states, under bullet (1.) Air dry pots, dishes, flatware, and utensils before storage, or in a self draining position. Observation of Unit 3 on [DATE] at approximately 12:30 PM revealed staff serving lunch to residents in the dining area. At that time, Certified Nurses Aide (CNA) #1 was observed to touch food with his/her bare hands while setting-up resident's plates. CNA #1 was observed to pick-up a roll with bare hands while buttering the bread on the plate of 2 residents.",2020-09-01
206,FLEETWOOD REHABILITATION AND HEALTHCARE CENTER,425018,200 ANNE DRIVE,EASLEY,SC,29640,2018-11-09,883,D,0,1,NICZ11,"Based on record reviews and interview with Director of Nursing, the facility failed to educate, screen, and offer the Prevnar 13 Pneumococcal Vaccine or have a policy or process in place to identify eligible residents. The findings included: Record review of residents #41, #9, #6, #10, and #46 had no evidence documented of education or opportunity to consent or decline if eligible for the Prevnar 13 Pneumococcal Vaccine. Interview on 11/6/2018 at approximately 5:02 PM with DON confirmed that the facility did not offer the Prevnar 13.",2020-09-01
207,FLEETWOOD REHABILITATION AND HEALTHCARE CENTER,425018,200 ANNE DRIVE,EASLEY,SC,29640,2019-11-27,641,D,1,0,4NC511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to perform accurate fall assessments for 2 of 6 residents reviewed for accidents. Residents #7 and #13 had inaccurate fall assessments. The findings included: Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #7's fall assessments on 11/25/19 at approximately 1:26 PM revealed the following: 1. 8/30/19 assessment scored at 13. 2. 9/4/19 assessment - after his/her first fall in facility - scored at 3. Discrepancies were noted regarding medicines placing the resident at risk, alertness, and predisposing illnesses. Review of Resident #7's (MONTH) 2019 Medication Administration Record [REDACTED]. Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #13's fall risk assessments on 11/25/19 at approximately 3:15 PM revealed the following: 1. 3/13/19 assessment scoring at 5. The resident was marked as alert with no predisposing illnesses or fall risk medications. This was inconsistent with other fall assessments. 2. 2/6/19 assessment scoring at 7. The resident was marked as alert with no predisposing illnesses. It should be noted that [MEDICAL CONDITION] is listed as a predisposing illness with regard to falls. Review of Resident #7's progress notes on 11/25/19 at approximately 3:25 PM revealed a 2/5/19 psychosocial note stating the resident was severely cognitively impaired related to a dementia diagnosis. Review of Resident #7's (MONTH) 2019 MAR indicated [REDACTED]. Interview with the Administrator and Director of Nursing on 11/26/19 at approximately 3 PM confirmed the inaccurate assessments.",2020-09-01
208,WHITE OAK MANOR - SPARTANBURG,425024,295 EAST PEARL STREET,SPARTANBURG,SC,29303,2017-06-08,241,D,0,1,FPCM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and review of the facility's Resident Meal Service policy, the facility failed to ensure that residents who ate in their rooms were served/eating at the same time their roommates were served/eating and failed to pull privacy curtains for residents that were not served/eating for 2 of 2 units observed. Residents who ate in their rooms were served milk out of milk cartons due to no extra glasses being available on the opened food cart for residents who eat in their rooms for 2 of 2 units observed. The findings included: During a random meal observation of Unit 3 on 6/05/17 at approximately 5:35 PM the food carts were not delivered to unit per schedule. At 5:45 PM the first opened food cart was delivered to the unit and remained near room [ROOM NUMBER] unit around 5:55 PM. The opened food cart was noted with liquid beverages in glasses while milk was served in milk cartons. There were no extra glasses on the opened food cart for the milk. At approximately 6 PM during random meal observation on Unit 3, a second opened food cart was delivered to the unit. The resident seated near the door in room [ROOM NUMBER] was served a food tray while his/her roommate was not served. The roommate was positioned in his/her bed facing the resident who had been served and eating in room [ROOM NUMBER]. The privacy curtains were not pulled while the resident near the door was seated in his/her wheelchair and eating when the roommate was seated in bed facing him/her and not served or eating. A nurse entered room [ROOM NUMBER] and delivered the resident who was eating an additional request on his/her food tray. Staff did not attempt to provide the resident in bed a food tray/or pull privacy curtains while the resident in the wheelchair continued to eat. Staff which included the Director of Nursing and Administrator were observed delivering meals to other residents in their rooms on the unit near room [ROOM NUMBER] before the resident in bed was served. On 6/05/17 at approximately 6:17 PM, a facility consultant walked pass and looked in room [ROOM NUMBER] where one resident was served and eating while the roommate was seated in bed and not served or eating. The resident not served or eating continued to be positioned facing his/her roommate with the privacy curtains not drawn while the roommate seated at the door had nearly completed his/her meal. During an interview, the facility consultant confirmed the findings and stated he/she would find out why the resident seated in bed had not be served while the resident/roommate near the door had been served. The resident seated in bed did not get served until approximately 6:20 PM and the privacy curtains remained open. Review of the facility's Resident Meal Service policy dated 08-2010 revealed under the procedures section #9 For residents who chose to eat in their room on a routine basis, roommates will be served their meal trays at the same time as possible. If this is not possible, the curtain will be pulled before tray service. An interview on 6/08/17 at approximately 9:49 AM with the Dietary Manager confirmed that the kitchen staff did not provide extra glasses on food carts during the evening meal on 6/05/17 in order for residents on the unit who ate in their rooms to be served milk in glasses instead of the carton. An interview on 6/08/17 at approximately 9:55 AM with the Administrator confirmed one resident in room [ROOM NUMBER] was served/eating while the other resident was not served/eating and the privacy curtain not pulled. During the supper meal observation on 6/5/17 at 5:30 PM, there were 16 residents served milk on their food trays without glasses provided to pour the milk into. Staff did not ask residents if they preferred their milk in a glass or carton. While observing the meal pass to the rooms in the downstairs unit, a resident in room [ROOM NUMBER] was observed finishing her supper meal, which had been brought in by family. The other resident in the room had not been served her supper meal . The staff did not pull the privacy curtain between the two residents.",2020-09-01
209,WHITE OAK MANOR - SPARTANBURG,425024,295 EAST PEARL STREET,SPARTANBURG,SC,29303,2017-06-08,314,D,1,1,FPCM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on closed record review and interview the facility failed to do skin assessment sheets or wound documentation for December 2016 and January 2017 for Resident # 16. ( 1 of 2 residents reviewed for pressure ulcers.) The findings included: The facility admitted Resident # 16 with [DIAGNOSES REDACTED]. In connection with a family concern related to possible skin breakdown, documentation for any previous skin breakdown and skin assessment sheets were looked for in the medical record. No documentation could be found. During an interview with the Nurse Consultant on 6/7/17 at 12 Noon, the consultant stated there were no sheets available for skin audits or wound assessments for December 2016 and January 2017. A Quality Assurance Problem was identified by the facility and corrective action plan put into place on 5/23/17. The family concern was identified in January, 2017. At that time the facility was not doing daily skin sheets or weekly wound documentation. The family member brought to the attention of the nurse on 12/22/16 an area of broken skin on Resident # 16's left heel. The nurse assessed the area, called the physician, and treatment started. The calloused area on the left heel had begun to break down but not completely. There was a circular area of red skin underneath. The physician ordered the skin to be left in tact, skin prep, and a border foam ordered for every other day. The area was documented as healed on 1/20/17.",2020-09-01
210,WHITE OAK MANOR - SPARTANBURG,425024,295 EAST PEARL STREET,SPARTANBURG,SC,29303,2018-06-08,580,D,1,1,FQ8O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and interview the facility failed to notify the family/ resident representative for Resident #2, 1 of 1 sampled resident reviewed for Accidents. The findings included: The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Record review on 03/09/18 at approximately 2:42 PM revealed a Nurse's Note dated 03/09/18 stating, Continue on antibiotic related to fever. No noted signs/symptoms of adverse reactions. A Febrile with no complaint of pain or discomfort. No documentation of new order or notification of Resident Representative related to change in medication noted in the Nurse's Notes. In an interview on 06/06/18 at approximately 2:42 PM the Director of Nursing (DON) provided a copy of a telephone order from the thinned chart records for 1 gram [MEDICATION NAME] by injection x 4 days. The DON also confirmed that there was no documentation of notification to the family/ resident representative of the new medication.",2020-09-01
211,WHITE OAK MANOR - SPARTANBURG,425024,295 EAST PEARL STREET,SPARTANBURG,SC,29303,2018-06-08,641,D,0,1,FQ8O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure assessment accuracy for Resident #21 for 1 of 5 residents reviewed for unnecessary medication. The findings included: Resident #21 was admitted to the facility with [DIAGNOSES REDACTED]. Record review of the resident's care plan, on 06/08/18, revealed the resident to be participating in a Urinary toileting program. During an interview with the Registered Nurse #1, on 06/08/18 at 2:55 pm, s/he indicated s/he is not responsible for the toileting program but pulls that information from 'Smart Charting' - the clinical input from the Certified Nursing Assistants. The date onset of the toileting program is 09/08/17, on page 17 of 27 of the resident's provided care plan. MDS nurse provided smart charting documentation that did indicate Resident #21 was on the toileting program during the dates of the assessment, 03/20/18 and should have been coded as such.",2020-09-01
212,WHITE OAK MANOR - SPARTANBURG,425024,295 EAST PEARL STREET,SPARTANBURG,SC,29303,2018-06-08,655,D,0,1,FQ8O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to provide a written summary of the baseline care plan to Resident #29, 2 of 3 sampled residents reviewed for hospitalization . The findings included: The facility admitted Resident #29 with [DIAGNOSES REDACTED]. Record review on 06/08/18 at approximately 2:49 PM revealed an Interim (Baseline) Care Plan dated 01/05/18. There was no written summary of the Baseline Care Plan in the medical record. In an interview on 06/08/18 at approximately 3:26 PM Registered Nurse #1, the Resident Assessment Coordinator, stated that if there was no copy of the summary in the record, it was not completed.",2020-09-01
213,WHITE OAK MANOR - SPARTANBURG,425024,295 EAST PEARL STREET,SPARTANBURG,SC,29303,2018-06-08,657,E,0,1,FQ8O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to insure the participation of all required disciplines in the Care Plan Conferences for Residents #2, #3, #30 and #45, 4 of 16 sampled residents reviewed for Care Plans. The findings included: The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Record review on 06/06/18 at approximately 2:42 PM revealed signature sheets for Care Plan Review meetings held on 02/24/18 and 09/20/17 did not verify representation from Dietary at the meetings. The facility admitted Resident #45 with [DIAGNOSES REDACTED]. Disease. Record review on 06/07/18 at approximately 10:11 AM revealed Care Plan Conference signature sheets for 02/24/18 with no documentation of attendance by a Certified Nursing Assistance (CNA) or Dietary representative and no documentation of attendance by a CNA on 05/10/18, 11/21/17, 08/25/17. In an interview 06/06/18 Registered Nurse #1, the Resident Assessment Coordinator, stated that all disciplines do not attend the Care Plan Review meeting. Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. Record review on 06/08/18 revealed the required staff participation was not evident x 5 care plan meetings, dated 06/15/17, 09/14/17, 12/15/17, and 02/27/18. Resident #30 was admitted to the facility with [DIAGNOSES REDACTED]. Record review on 06/08/18 revealed the required staff participation was not evident x 3 care plan meetings, dated 01/23/18, 02/15/18 and 04/17/18. The provided RAI (Resident Assessment Instrument) Process Review, Care Plan Review forms with missing signatures for Residents #3 and 30 were reviewed and confirmed by the Administrator on 06/08/18 at 6:02 p.m. Review of the provided RAI and Care Plan Process revised on 05/08/17, policy indicates on page 11, line item 10, states, TEAM CONFERENCE: Everyone present should sign the RAI Process Review Sheet to evidence attendance and/or participation in the care planning process.",2020-09-01
214,WHITE OAK MANOR - SPARTANBURG,425024,295 EAST PEARL STREET,SPARTANBURG,SC,29303,2018-06-08,812,E,1,1,FQ8O11,"> Based on observation, interview, and review of the facility policy, the facility failed to prepare, distribute, and serve food under sanitary conditions for 1 of 2 kitchens reviewed and has the potential to affect 19 of 53 residents with ordered diets as evidenced by failing to avoid cross contamination of food items during temperature taking (temping) on unit 4. The findings included: On 6/5/18 at 11:45 AM, during an observation of the unit 4 lunch line temping with Cook #1, the cook first placed a food temperature probe into rice, then into mixed vegetables, followed by chicken and finally into pureed rice before being stopped by the surveyor. Cook #1 did not sanitize the temperature probe between each food item s/he was temping and was asked, Were you trained to sanitize the temperature probe between food items. S/he stated, Yes, I forgot. Review of the facility policy, Thermometer Calibration/Food Temps stated under (5.) To check food temperatures: bullet (5) rinse, sanitize and air dry the thermometer between foods unless the same food in another consistency is checked and the previous temperature was within desirable range.",2020-09-01
215,WHITE OAK MANOR - SPARTANBURG,425024,295 EAST PEARL STREET,SPARTANBURG,SC,29303,2018-06-08,842,D,0,1,FQ8O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure accuracy of medical records related to completion of Incident Reports for a fall for Resident #2, 1 of 1 sampled resident reviewed for Accidents. The findings included: The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Record review on 06/06/18 at approximately 2:42 PM revealed a Nurse's Note dated 03/08/18 stating, A visitor notified this nurse that this resident was sitting on the floor in his/her room. When this nurse entered the room the Resident was sitting on the cushion from his/her wheelchair in front of his/her wheelchair with his/her legs stretched out and feet going across the rails of his/her side table. When this nurse tried to assess the Resident, s/he became verbally abusive and tried to strike me with the side table but failed. When other staff entered the room to assist, the resident continued to curse and attempt to be combative. The Resident refused to allow staff to use a lift to get him/her from the floor. When asked could s/he get him/herself off the floor, the resident did so on his/her own without any assistance. The resident refused a body audit but stated that s/he was not in pain and had not hit his/her head. This surveyor requested a copy of the incident report documenting this fall and any interventions implemented to prevent reoccurrence. In an interview on 06/06/18 at 10:51 AM the Administrator confirmed s/he was unable to locate an incident report. In a subsequent interview on 06/08/18 at 1:41 PM the Director of Nursing confirmed that staff would be expected to complete an incident report for a fall.",2020-09-01
216,WHITE OAK MANOR - SPARTANBURG,425024,295 EAST PEARL STREET,SPARTANBURG,SC,29303,2019-06-26,550,D,0,1,UQ7G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interview, the facility failed to ensure residents rights were honored when staff failed to knock on doors to residents' rooms before entering their room. Staff was observed entering residents' rooms on the Unit 3 without knocking. 1 of 2 Units observed. The findings included: Random observations on Unit 3 on 6/24/19 at approximately 12:37 PM revealed staff entering rooms [ROOM NUMBERS] without knocking. The doors to both rooms were opened with resident's present. At approximately 12:44 PM on 6/24/19 a different staff member was observed entering rooms [ROOM NUMBERS] without knocking. An interview on 6/24/19 at approximately 12:47 PM with Certified Nursing Aide (CNA) #1 confirmed he/she entered residents' rooms without knocking. CNA #1 further stated he/she generally enter residents' rooms without knocking when the door to the resident's room was opened. An observation on 6/24/19 at approximately 12:50 PM revealed a laundry/housekeeping staff entering residents' rooms without knocking. The doors were opened to the resident's rooms and the resident was present.",2020-09-01
217,WHITE OAK MANOR - SPARTANBURG,425024,295 EAST PEARL STREET,SPARTANBURG,SC,29303,2019-06-26,578,D,0,1,UQ7G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to give 1 of 13 residents the opportunity to formulate their advance directive. Resident #16 was declared incapable of making his/her own decisions by one physician but not a second per South [NAME]ina law (Adult Health Care Consent Act). The findings included: Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #16's Record on 6/24/19 at approximately 2:14 PM revealed the resident was signed Do Not Resuscitate by a resident representative. Review of capacity form revealed only one physician had assessed the resident as incapable of making his/her own decisions. Interview with Social Services Director on 6/25/19 at approximately 2:50 PM confirmed the capacity form of Resident #16 was missing a second physician signature. Review of Advance Directive Policy on 6/26/19 at approximately 10 AM revealed if a physician is to order that life sustaining measures be withheld; the resident must be declared mentally incapacitant by state law. Interview with the Administrator on 6/26/19 at approximately 10:37 AM confirmed the capacity form of Resident #16 second missing a second physician signature. The administrator said the physician was correcting it. Review of the Adult Health Care Consent Act revealed A patient's inability to consent must be certified by two licensed physicians, each of whom has examined the patient.",2020-09-01
218,WHITE OAK MANOR - SPARTANBURG,425024,295 EAST PEARL STREET,SPARTANBURG,SC,29303,2019-06-26,756,D,0,1,UQ7G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to act upon, in a timely manner, pharmacy recommendations for laboratory blood work to monitor related medications for 2 of 5 residents reviewed for unnecessary medications. (Residents #29 and #45) The findings included: Resident #29 was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #29's medical record on 06/25/19 at approximately 3:00 PM revealed The Pharmacist Progress note showed the pharmacy performed a medication record review on 04/26/19. The pharmacist progress note made the following recommendations under nursing, Labs (laboratory) recommended, Complete Blood Count (CBC) and Magnesium level for Magnesium oxide and Eliquis use. The pharmacist progress note was dated by the pharmacist on 04-29-19. Review of doctor's orders on 6/25/19 at approximately 3:10 PM revealed, the order for the CBC and Magnesium level was not written until 06-02-19. The blood work was done on 06/03/19. During an interview with the Director of Nursing (DON) on 06-25-19 at approximately 4:00 PM, s/he confirmed the blood work was done on 06-03-19. Resident #45 was admitted [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #45's medical record on 06/25/19 at approximately 3:30 PM revealed, The Pharmacist Progress Note showed the pharmacy performed a medication record review on 04/26/19. The pharmacist made the following recommendation under Nursing, Labs (laboratory) recommended, Potassium level for Micro-K use (dose changed 03.25.19). The Pharmacist Progress Note was dated by the pharmacist on 04/29/10. Review of doctor's orders on 6/25/19 at approximately 3:35 PM revealed the order for the potassium level was not written until 06/02/19. The laboratory work was done on 06/03/19. During an interview with the Director of Nursing (DON) on 06-25-19 at approximately 4:00 PM, h/she confirmed the blood work was done on 06-03-19. Review on 06/25/19 at approximately 4:15PM of the facility policy Medication Regimen Review #3 revealed, Recommendations should be addressed within 30 days of receipt of the recommendation.",2020-09-01
219,MOUNTAINVIEW NURSING HOME,425027,340 CEDAR SPRINGS ROAD,SPARTANBURG,SC,29302,2018-08-09,550,D,0,1,3Y8D11,"Based on observations and interview, the facility failed to ensure that residents seated in the dining area were served and/or being assisted with eating while others were eating and/or being fed by staff. Two random observations on the 200 Unit dining area revealed residents that required assistance with being fed were not fed while other residents around them were eating or being assisted with eating by staff. 1 of 4 dining rooms observed. The findings included: A random meal observation on the 200 Unit on 8/07/18 at approximately 12:30 PM revealed the meal trays delivered to the unit. There were two (2) long tables in the dining set up with residents present. There were two residents seated near the left side wall with bedside tables in front of them and three (3) residents seated to the right side wall with bedside tables. When all of the residents were provided with food trays the staff delivered meals to residents who eat in their rooms. At approximately 12:45 PM, staff was observed assisting four of the five residents that required assistance with eating/feeding in the dining room. An interview and observation on 8/07/18 with Licensed Practical Nurse (LPN) #3 revealed one resident that required assistance with eating was not being fed by staff while other residents around him/her were eating independently or being fed by staff. LPN #3 stated the resident would be fed once staff was available to feed him/her. A random lunch meal observation on the 200 Unit on 8/08/18 at approximately 12:43 PM revealed four residents in the dining room that required staff assistance during dining with eating. Two of the four residents that required assistance with eating was observed not eating or being assisted by staff while meals/food trays were being delivered down the hallway to residents who eat in their rooms. One of the two residents waiting to be fed/assisted with eating was seated at a long table with staff that was feeding a resident and other residents who were able to feed themselves. The other resident was seated near the wall on right side with tray on bedside table without staff assistance available while other residents in the dining room were eating and being assisted by staff.",2020-09-01
220,MOUNTAINVIEW NURSING HOME,425027,340 CEDAR SPRINGS ROAD,SPARTANBURG,SC,29302,2018-08-09,567,D,0,1,3Y8D11,"Based on interview and record review the facility failed to make 1 of 1 resident reviewed for personal funds aware of how to access funds on weekends. Resident #39 was unaware of how to access funds on weekend. The findings included: During record review, observation, and interview with Resident #39 on 8/7/18 at approximately 10:06 AM, the resident stated s/he was unable to access funds on the weekend. Review of personal funds policy on 8/9/18 at approximately 2:11 PM revealed it was possible to access personal funds on the weekend from the nursing supervisor. Interview with Bookkeeper on 8/9/18 at approximately 2:11 PM revealed the residents are informed at admission and during resident council. When asked about residents who were admitted some time ago or residents who were not part of resident council, the Bookkeeper stated those residents could ask the business office how to access money on weekends, but admitted that they would only be able to ask during business hours. Observations of the facility throughout days of survey revealed no signs / postings that clarified how resident funds could be accessed on weekends.",2020-09-01
221,MOUNTAINVIEW NURSING HOME,425027,340 CEDAR SPRINGS ROAD,SPARTANBURG,SC,29302,2018-08-09,582,B,0,1,3Y8D11,Based on record review and interview the facility failed to submit beneficiary notices in a timely manner for 2 of 3 residents reviewed for beneficiary notices. Residents #87 and 269 were not informed of discharge from Medicare Part A services until after those services were discharged . The findings included: Review of beneficiary notices on 8/9/18 at approximately 12:13 PM revealed Resident #89 was discharged for m Medicare Part A services on 6/15/18. The denial letter (CMS-R-131) was not sent until 6/18/18 and the CMS-Notice of Medicare Non-Coverage (NOMNC) was not signed until 6/21/18. Review of beneficiary notices on 8/9/18 at approximately 12:13 PM revealed Resident #269 was discharged from Medicare Part A services on 4/3/18. The Skilled Nursing Facility Advanced Beneficiary Notice (SNF-ABN) and CMS-NOMNC were not signed until 4/4/18. Interview with Bookkeeper on 8/9/18 at approximately 12:20 PM confirmed these two residents were not informed of discharge from Medicare Part A services until after the services had been discharged .,2020-09-01
222,MOUNTAINVIEW NURSING HOME,425027,340 CEDAR SPRINGS ROAD,SPARTANBURG,SC,29302,2018-08-09,609,G,0,1,3Y8D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of facility policy, the facility failed to report a violation involving neglect that resulted in serious bodily injury for Resident #4, 1 of 2 sampled residents reviewed for Accidents/Hazards. Resident #4 fell from the bed while receiving care and sustained a fractured femur. Cross Refer to F656 and F689 The findings included: The facility admitted Resident #4 with [DIAGNOSES REDACTED]. Record review of an Incident/Accident Report on 8/9/2018 at 1:52 PM, revealed on 5/23/2018 at 5:15 AM, Resident #4 fell from the bed while receiving incontinence care from Certified Nursing Assistant (CNA) #5. The report indicated the bed wheels were not in the locked position and the resident fell to the floor while being turned in the bed. The report also indicated the resident had pain and swelling to the right knee and right leg. Orders for x-rays of the right leg were given by the provider. Review of the Radiology Report, dated 5/23/2018, on 8/9/2018 at 3:00 PM, revealed Resident #4 sustained a [MEDICAL CONDITION] right femur. Review of the Resident Information Sheet (CNA care plan) on 8/9/2018 at 2:38 PM, revealed the resident required the assistance of 2 persons for positioning. Review of the Falling Leaf Program Care Plan on 8/9/2018 at 1:52 PM, revealed staff were to ensure to secure locks on beds. Review of the facility's investigation on 8/9/2018 at 3:00 PM, revealed CNA #5 failed to lock the wheels of the bed prior to performing care and failed to get another staff member to assist with turning and positioning the resident. During an interview with the Director of Nursing (DON) on 5/9/2018 at 2:36 PM, the DON stated s/he reported the incident to Licensure, but did not report it to the State Survey Agency. When asked why s/he did not report to the State Survey Agency, the DON stated s/he did not believe the incident rose to the level of neglect because it was an accident and unintentional. The DON also stated CNA #4 had been an outstanding employee the past 4-5 years. Review of the facility's Abuse and Neglect policy revealed when an alleged or suspected case of mistreatment or neglect is reported, the facility Administrator, or his/her designee, will immediately notify the State licensing/certification agency responsible for surveying/licensing the facility.",2020-09-01
223,MOUNTAINVIEW NURSING HOME,425027,340 CEDAR SPRINGS ROAD,SPARTANBURG,SC,29302,2018-08-09,623,F,0,1,3Y8D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews and review of the facility's Resident Transfer or Discharge policy, the facility failed to ensure that a notice was sent to the Office of the State Long-Term Care Ombudsman for 5 of 5 sampled residents reviewed for discharge/transfer. Residents #23, #51, #89. #119 and #120 were discharged /transferred from the facility with no documentation of a notice being provided to the Office of the State Long-Term Care Ombudsman. The findings included: The facility admitted Resident #23 on 3/08/11 with [DIAGNOSES REDACTED]. A review of the medical record on 8/08/18 at approximately 10:27 AM revealed the resident was transferred to the hospital on [DATE] due to [MEDICAL CONDITION] with a re-admission on 5/24/18. Further review of the medical record revealed there was documentation to indicate the facility notified the Office of the State Long-Term Care Ombudsman. The facility admitted Resident #120 on 11/08/17 with [DIAGNOSES REDACTED]. A review of the medical record on 8/09/18 at approximately 9:10 AM revealed the resident was discharged to home with family from the facility on 5/24/18 with no documentation that the facility notified the Office of the State Long-Term Care Ombudsman. An interview on 8/09/18 at approximately 9:32 AM with the Social Services Director (SSD) confirmed that the ombudsman office was not notified. The SSD provided a copy of a form that was available to notify the ombudsman office of discharges/transfers but stated the form was not being used. A review of the facility's Resident Transfer or Discharge policy dated (YEAR) under #4 Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, Mountianview will implement the following procedures: section h, Notify the local Ombudsman's office via fax of transfer at the time of the transfer. The facility admitted Resident # 89 with [DIAGNOSES REDACTED]. Review of the medical record revealed that the resident went to the hospital on [DATE] and returned to the facility on [DATE]. Further review revealed no documentation in the record of transfer papers or bed hold notification prior to transfer. Licensed Practical Nurse ( LPN ) #1, during interview on 8/9/18, confirmed there were no transfer papers nor bed hold papers in this record. Interview with the Social Service Director on 8/9/18 also confirmed there were no papers available and she did not do any. Was not aware of the bed hold papers in writing and verbal at each transfer. Stated that was done only at admission as part of their policy. The facility admitted Resident # 119 with [DIAGNOSES REDACTED]. The family was notified of the transfer. There was no documentation of bed hold notification. Social Service did not sent notifications to the Ombudsman related to either transfer of discharge. Resident #51 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of nursing notes for Resident #51 on 8/9/18 at approximately 9:14 AM revealed the resident was transported to the emergency roiagnom on [DATE]. Interview with Social Services Director on 8/9/18 at approximately 3:16 PM revealed there was no ombudsman notification for the transfer of Resident #51 on 4/24/18. Review of policy for Resident Transfer/Discharge on 8/9/18 at approximately 3:18 PM revealed it was policy to inform local ombudsman's office via fax of a resident's emergency transfer or discharge to hospital.",2020-09-01
224,MOUNTAINVIEW NURSING HOME,425027,340 CEDAR SPRINGS ROAD,SPARTANBURG,SC,29302,2018-08-09,625,E,0,1,3Y8D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide notification of bed hold policy to residents or resident representatives for 3 of 4 residents reviewed for hospitalization s. Residents #23, #51, and #89 were provided no notification of bed hold policy when they were transferred to the hospital. The findings included: Resident #51 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of nursing notes for Resident #51 on 8/9/18 at approximately 9:14 AM revealed the resident was transported to the emergency roiagnom on [DATE]. Interview with Licensed [MEDICATION NAME] Nurse (LPN) #1 on 8/9/18 at approximately 11:15 AM revealed there were no bed hold policy notices prior to transfer to hospital. The family is informed on admission of the bed hold policy. Interview with Social Services Director on 8/9/18 at approximately 11:53 AM confirmed there was no notification of bed hold policy before transfer to hospital, and the director stated they were unaware it was supposed to be done for every transfer. The facility admitted Resident #31 on 3/08/11 with [DIAGNOSES REDACTED]. A review of the medical record on 8/08/18 at approximately 10:27 AM revealed the resident was transferred to the hospital on [DATE] due to [MEDICAL CONDITION]. Further review of the medical record revealed there was no documentation to indicate the facility provided the resident and/or resident representative with the bed hold notice upon transfer to the hospital to indicate the duration of the bed hold. An interview on 8/08/18 at approximately 10:40 AM with Licensed Practical Nurse (LPN) #1 revealed the facility's nurse provided a Mountainview Transfer Form to residents as well as social services providing a form. There was nothing on the form to indicate the bedhold policy was provided. LPN #1 confirmed the form does not address the bedhold policy being provided as required. An interview on 8/09/18 at approximately 9:32 AM with the Social Services Director (SSD) revealed there was no documentation to indicate a copy of the bed hold policy was provided. The facility admitted Resident # 89 with [DIAGNOSES REDACTED]. Review of the medical record revealed that the resident went to the hospital on [DATE] and returned to the facility on [DATE]. Further review revealed no documentation in the record of transfer papers or bed hold notification prior to transfer. Licensed Practical Nurse ( LPN ) #1, during interview on 8/9/18, confirmed there were no transfer papers nor bed hold papers in this record. Interview with the Social Service Director on 8/9/18 also confirmed there were no papers available and she did not do any. Was not aware of the bed hold papers in writing and verbal at each transfer. Stated that was done only at admission as part of their policy.",2020-09-01
225,MOUNTAINVIEW NURSING HOME,425027,340 CEDAR SPRINGS ROAD,SPARTANBURG,SC,29302,2018-08-09,656,G,0,1,3Y8D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to follow the care plan for Resident #4, 1 of 2 sampled residents reviewed for Accidents/Hazards. While receiving personal care, Resident #4 fell from the bed. The bed wheels were not locked and the resident was not receiving the assistance of 2 persons, per the care plan. Cross Refer to F609 and F689 The findings included: The facility admitted Resident #4 with [DIAGNOSES REDACTED]. Record review of an Incident/Accident Report on 8/9/2018 at 1:52 PM, revealed on 5/23/2018 at 5:15 AM, Resident #4 fell from the bed while receiving incontinence care from Certified Nursing Assistant (CNA) #5. The report indicated the bed wheels were not in the locked position and the resident fell to the floor while being turned in the bed. The report also indicated the resident had pain and swelling to the right knee and right leg. Orders for x-rays of the right leg were given by the provider. Review of the Radiology Report, dated 5/23/2018, on 8/9/2018 at 3:00 PM, revealed Resident #4 sustained a [MEDICAL CONDITION] right femur. Review of the Falling Leaf Program Care Plan on 8/9/2018 at 1:52 PM, revealed staff were to ensure to secure locks on beds. Review of the Resident Information Sheet (CNA care plan) on 8/9/2018 at 2:38 PM, revealed the resident required the assistance of 2 persons for turning and positioning. Review of a written statement, dated 5/23/2018, by CNA #5, revealed while turning the resident during incontinence care, the bed began to roll and the resident fell from the bed. In addition, per the statement, the bed had not been locked. The statement did not indicate CNA #5 had another staff member assisting her/him during the incontinence care. Review of the facility's investigation on on 8/9/2018 at 3:00 PM, revealed CNA #5 failed to lock the wheels of the bed prior to performing care and failed to get another staff member to assist with turning and positioning the resident. During an interview with the Director of Nursing (DON) on 5/9/2018 at 2:36 PM, the DON confirmed the bed wheels were not locked prior to rendering care, per the care plan. The DON also confirmed a 2 person assist was not provided during care per the care plan.",2020-09-01
226,MOUNTAINVIEW NURSING HOME,425027,340 CEDAR SPRINGS ROAD,SPARTANBURG,SC,29302,2018-08-09,657,D,0,1,3Y8D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to involve the CNA responsible for the care of Residents #5, #23, #31, #38, #39, #51, and #112 in the care plan meetings of the residents. The findings included: The facility admitted Resident #23 on 3/08/11 with [DIAGNOSES REDACTED]. Further record review revealed a care plan conference was held (MONTH) (YEAR) and (MONTH) (YEAR) that indicated the CNA was not involve in the care plan meeting per the conference attendance documentation sheet. The facility admitted Resident #31 on 9/22/14 with diagnosed that included [MEDICAL CONDITION] Disorders and [MEDICAL CONDITION]. Further record review revealed a care plan conference was held Feb (YEAR) and (MONTH) (YEAR) that indicated the CNA was not involved in the care plan meeting per the conference attendance documentation sheet. An interview on 8/09/18 at approximately 12:04 PM with Licensed Practical Nurse #1 confirmed the care plan conference attendance sheet did not indicate the CNA was involved in care plan meeting for Resident #23 and #31 who were on Unit 300. The facility admitted Resident #5 on 1/23/18 with [DIAGNOSES REDACTED]. Further review of the medical record revealed a care plan conference held in (MONTH) (YEAR) that indicated the certified nursing aide (CNA) was not involved in the care plan meeting per the conference attendance documentation sheet. The facility admitted Resident #112 on 5/18/82 with [DIAGNOSES REDACTED]. Further review of the medical record revealed a care plan conference was held (MONTH) (YEAR) and (MONTH) (YEAR) that indicated the CNA was not involved in the care plan meeting per the conference attendance documentation sheet. An interview on 8/08/18 at approximately 3 PM with Licensed Practical Nurse #3 confirmed there was no documentation on the care plan conference attendance sheets to indicate the CNA attended care plan meeting for Residents #3 and #112 on the 200 unit. The facility admitted Resident #23 on 3/08/11 with [DIAGNOSES REDACTED]. Further record review revealed a care plan conference was held (MONTH) (YEAR) and (MONTH) (YEAR) that indicated the CNA was not involve in the care plan meeting per the conference attendance documentation sheet. The facility admitted Resident #31 on 9/22/14 with diagnosed that included [MEDICAL CONDITION] Disorders and [MEDICAL CONDITION]. Further record review revealed a care plan conference was held Feb (YEAR) and (MONTH) (YEAR) that indicated the CNA was not involved in the care plan meeting per the conference attendance documentation sheet. An interview on 8/09/18 at approximately 12:04 PM with Licensed Practical Nurse #1 confirmed the care plan conference attendance sheet did not indicate the CNA was involved in care plan meeting for Resident #23 and #31 who were on Unit 300. Review of 5/22/18 Care Plan Conference Summary for Resident #38 on 8/9/18 at approximately 3:36 PM revealed no documentation of Certified Nursing Aide (CNA) involvement in care plan development. This was confirmed by Licensed [MEDICATION NAME] Nurse (LPN) #1. Review of 5/29/18 Care Plan Conference Summary for Residentt #51 on 8/9/18 at approximately 3:38 PM revealed no documentation of CNA involvement in care plan development. This was confirmed by LPN #1. Review of 5/24/18 Care Plan Conference Summary for Resident #39 on 8/9/18 at approximately 3:41 PM revealed no documentation of CNA involvement in care plan development. This was confirmed by LPN #5.",2020-09-01
227,MOUNTAINVIEW NURSING HOME,425027,340 CEDAR SPRINGS ROAD,SPARTANBURG,SC,29302,2018-08-09,689,G,0,1,3Y8D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of facility policy, the facility failed to ensure that Resident #4 received adequate assistance and supervision to prevent accidents, 1 of 2 sampled residents reviewed for Accidents/Hazards. Resident #4 fell from the bed while receiving care and sustained a fractured femur. Cross Refer to F609 and F656 The findings included: The facility admitted Resident #4 with [DIAGNOSES REDACTED]. Record review of an Incident/Accident Report on 8/9/2018 at 1:52 PM, revealed on 5/23/2018 at 5:15 AM, Resident #4 fell from the bed while receiving incontinence care from Certified Nursing Assistant (CNA) #5. The report indicated the bed wheels were not in the locked position and the resident fell to the floor while being turned in the bed. The report also indicated the resident had pain and swelling to the right leg. Record review of the Nurse's Notes on 8/9/2018 at 2:15 PM, revealed on 5/23/2018 the CNA called the nurse and reported the resident fell from bed while providing incontinence care. The resident was complaining of pain to the right knee. Swelling was observed to the right knee. An x-ray was ordered. The resident was transferred to the hospital after receiving the x-ray results. Review of the Radiology Report, dated 5/23/2018, on 8/9/2018 at 3:00 PM, revealed Resident #4 sustained a [MEDICAL CONDITION] right femur. Record review of the provider progress notes on 8/9/2018 at 2:20 PM, revealed a note from 6/1/2018 indicating the resident required surgical intervention to repair the fractured femur. Review of the facility's investigation on 8/9/2018 at 3:00 PM, revealed CNA #5 failed to adhere to resident safe handling. CNA #5 failed to ensure the bed wheels were locked prior to providing care and did not get assistance from another staff member prior to providing incontinence care. In addition, the investigation revealed Resident #4 was considered a total care resident and all total care residents should have 2 staff members assisting during care. Review of the personnel file for CNA #5 on 8/9/2018 at 2:43 PM, revealed no documentation to indicate CNA #5 had received training to carry out her/his duties prior to caring for Resident #4. The file did not reveal any disciplinary action related to resident care. Review of a written statement, dated 5/23/2018, by CNA #5 on 8/9/2018 at 3:00 PM, revealed while s/he was turning the resident during incontinence care, the bed began to roll and the resident fell from the bed. In addition, per the statement, the bed wheels had not been locked. The statement did not indicate CNA #5 had another staff member assisting her/him during the incontinence care. During an interview with the Director of Nursing (DON) on 5/9/2018 at 2:36 PM, the DON confirmed CNA#5 failed to ensure the bed wheels were locked prior to providing incontinence care. The DON also confirmed CNA #5 was providing care without assistance of another staff member. The DON stated it is facility policy to have 2 staff members provide incontinence care for total care residents. The DON stated Resident #4 was considered a total care resident. Regarding the personnel file, the DON stated s/he was certain the facility had provided the appropriate and necessary training and orientation for CNA #5. However, the DON stated the documentation to show this could not be located. The DON stated CNA #5 had been an outstanding employee for many years and had no disciplinary action related to patient care. Review of the facility's Use Of All Lift Devices And Turning of Residents policy revealed: -If your resident is unable to assist you when turning and/or unable to control their body movements, you are required to get the assistance of another person. -If you are unable to get assistance when needed, please inform the nurse. Do not move the resident alone.",2020-09-01
228,MOUNTAINVIEW NURSING HOME,425027,340 CEDAR SPRINGS ROAD,SPARTANBURG,SC,29302,2018-08-09,812,E,0,1,3Y8D11,"Based on initial tour of the main kitchen a glob of whitish gray greasy type substance noted on meat slicer. The cook temped two items of food without cleaning temperature probe between foods. Microwave oven contained rust inside, cabinets stained and soiled, refrigerator had multiple spills inside, ( 1 of 1 main kitchen and 2 of 3 unit kitchens observed) The findings included: Based on initial tour of the main kitchen on 8/07/18 at 9:30 AM with the Dietary and Assistant Dietary Managers a one inch glob of whitish gray greasy type substance noted on flat part of slicer where the sliced meat falls onto. On 8/08/18 at 12:16 PM during the taking of food temperatures, the cook temped two items of food without cleaning temperature probe between the ham and potatoes. Microwave oven in the 300 Unit Kitchen contained four to five areas of rust inside the microwave. There were also spots of brown food material on inside top of microwave and the interior walls. The kitchen cabinets had spills and sticky substance on top of the counter. The refrigerator and freezer had multiple spills and dark substances on shelves. The Dietary manager confirmed areas in the main Kitchen, Licensed Practical Nurse # 2 confirmed the kitchen area on 300 unit. A random observation and interview on 8/08/18 at approximately 11:57 AM with Licensed Practical Nurse (LPN) #3 revealed the microwave oven on the 200 unit had rust/burned appearance on the inside door, the entire inside top and bottom of the microwave oven. LPN #3 looked at the microwave oven and described the brown discoloration as being burnt. LPN #3 stated paper towels were used to cover the residents food before placing the food in the microwave.",2020-09-01
229,MOUNTAINVIEW NURSING HOME,425027,340 CEDAR SPRINGS ROAD,SPARTANBURG,SC,29302,2018-08-09,880,D,0,1,3Y8D11,"Based on observation and interview, the facility failed to adhere to basic infection control principles. Facility staff failed to perform hand hygiene after disposing of potentially infectious waste after 1 of 3 pressure ulcer treatments observed during the survey. The findings included: A pressure ulcer treatment was observed on 8/8/2018 at 9:30 AM. Treatment was provided to Resident #97 for a open Stage II pressure ulcer with a small amount of drainage. After completion of the treatment, Licensed Practical Nurse (LPN) #4 disposed of the soiled treatment supplies in the trash. LPN #4 washed her/his hands, removed the trash from the room and disposed of the trash in the soiled utility room-using her/his bare hand to open and closed the receptacle. LPN #4 then left the soiled utility room without performing hand hygiene. LPN #4 then entered the locked treatment room to return wound care supplies. LPN #4 was observed exiting the treatment room and returned to the treatment cart to complete documentation. During an interview with LPN #4 on 8/8/2018 at 10:01 AM, LPN #4 confirmed s/he did not perform hand hygiene after disposing of the trash, entering the treatment room and returning to the cart. LPN #4 stated that hand hygiene should always be performed after disposing of trash and before beginning any other tasks. During an interview with LPN #4 on 8/8/2018 at 10:42 AM, LPN #4 stated the she did use hand sanitizer on her hands after entering the treatment room. When asked why s/he did not report this in her previous interview, LPN #4 stated s/he was nervous.",2020-09-01
230,MOUNTAINVIEW NURSING HOME,425027,340 CEDAR SPRINGS ROAD,SPARTANBURG,SC,29302,2017-08-16,253,E,1,1,8R3N11,"> Based on observation and interview, the facility failed to maintain a neat and well-kept environment on 2 of 3 units observed on all days of the survey. Resident furniture was observed to be scuffed, chipped or in disrepair. The findings included: During resident room observations on 8/15/2017 from 9:07 AM-9:50 AM multiple rooms were observed to have scuffed, worn dresser drawers. Semi- private rooms 104, 106, 111, 113, 114 and 119 each had 2 chest of drawers for resident use in the rooms. All dresser drawers were observed to be scuffed and worn. Observation of room 315 on 8/14/2017 at 2:47 PM revealed a bulletin board with a broken frame and a scuffed, chipped nightstand used by the resident in the window bed in the room. During a tour of rooms 104, 106, 111, 113, 114, 119 and 315 with the Plant Director on 8/16/2017 at 1:46 PM, the Plant Director confirmed the scuffed, worn dresser drawers, the broken frame and scuffed, chipped nightstand. The Plant Director stated there were no scheduled repairs and replacement furniture had not been ordered. In addition, the Plant Director stated there was no action plan in place addressing the above items.",2020-09-01
231,MOUNTAINVIEW NURSING HOME,425027,340 CEDAR SPRINGS ROAD,SPARTANBURG,SC,29302,2017-08-16,332,D,1,1,8R3N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, interview, and review of the manufacturer recommendations, the facility failed to maintain a medication rate of less than 5%. There were 2 errors out of 26 opportunities for error, resulting in a medication error rate of 7.69%. The findings included: Error #1 On 8-14-17 at approximately 7:39 PM, during an observation of Resident #15's medication administration on the North neighborhood, Licensed Practical Nurse (LPN) administered (1) drop of Refresh eye drops into the residents' eyes. Approximately 25 seconds later, LPN #5 then administered (1) drop of [MEDICATION NAME] 0.05% eye drops into Resident #15's eyes. Following the observation LPN #5 verified, s/he administered the eye drops without waiting a period of time between administrations. Review of Resident #15's physician's orders [REDACTED]. Review of the manufacture recommendations for [MEDICATION NAME] and Refreshstates under Dosage and Administration, Invert the unit dose vial a few times to obtain a uniform, white, opaque [MEDICATION NAME] before using,. Instill one drop of [MEDICATION NAME] ophthalmic [MEDICATION NAME] twice a day in each eye approximately 12 hours apart. [MEDICATION NAME] can be used concomitantly with lubricant eye drops, allowing a 15-minute interval between products. Discard vial immediately after use. Error #2 On 8-14-17 at approximately 8:05 PM, during observation of Resident #67's medication administration on the North neighborhood, LPN #4 crushed (1) tablet of [MEDICATION NAME] Coated (EC) and administered the medication to the resident in pudding. Review of Resident #67's physicians orders dated 8/1/17 through 8/31/17 revealed there was no order to crush Resident 67's [MEDICATION NAME] EC. Review of the [MEDICATION NAME] manufactures Directions on the bottle which states, Do not take more than directed- swallow whole do not crush or chew-take recommended dose in a single daily dose-take with water .",2020-09-01
232,MOUNTAINVIEW NURSING HOME,425027,340 CEDAR SPRINGS ROAD,SPARTANBURG,SC,29302,2017-08-16,371,F,1,1,8R3N11,"> Based on observation, interview, and review of facility policies, the facility failed to prepare, distribute, and serve food under sanitary conditions for 1 of 1 kitchen, 1 of 2 steam tables and 3 of 6 medication carts reviewed, and has the potential to affect 126 of 126 residents with ordered diets and supplements as evidenced by failing to do the following: Remove expired foods, calibrate a Fahrenheit (F) temping probe, reheat food items to specifications, maintain temperature specifications for Med Pass supplement, and clean floor/fan. The findings included: On 8-14-17 at approximately 10:00 AM, an initial tour of the main kitchen with the Dietary Manager (DM) revealed: 1.) Walk- in refrigerator had (25) rotten potatoes with white substances growing and brown soft patches. 2.) Walk-in freezer had a large tray of leftover of turkey and rice casserole with a use by date of 8-3-17. 3.) Main kitchen stove had a large build-up of grease and food debris. 4.) Main kitchen had black food build-up and spillage on floors around stove and steamers/under hood area and along the walls. 5.) Dishwashing area had a fan with a build-up of grease and dust blowing on cleaned dishware. 6.) Right of dishwashing area had pooled cloudy liquid on the floor with a foul odor. Following the observation of the walk-in refrigerator and freezer, the DM verified the potatoes were rotten and the casserole was expired and indicated they should have been removed from storage. On 8/14/17 at 12:45 PM, an observation of the main dining room steam table temping with the DM; Cook #1 placed a temperature probe in a cup of ice water and the gauge read 15 degrees of F. Cook #1 then began to take the temperature of food. Cook #1 was asked, What temperature a F temperature probe should be calibrated to? Cook #1 stated, Anywhere between 0-20 degrees is good. Cook #1 then attempted and was unable to calibrate the temperature probe to 32 degrees of F. Also, after Cook #1 got a calibrated thermometer s/he then took the temperature of a pan of Beef Teriyaki on the steam table which read 120 degrees of F and of (5) hamburgers that were on a side table that read 70 degrees. of F. The Beef Teriyaki and hamburgers were removed from the steam table and put in the main kitchen steamer to reheat. Cook #2 then removed the hamburgers from the steamer and took the temperature which read 130 degrees and asked the DM, Is that good. The DM stated, Reheated food should be heated to 145 degrees. On 8/14/17 at 3:45 PM, during an interview with the DM and Certified Dietary Manager (CDM), the DM and CDM were asked for the temping logs for the dining room steam table. The DM and CDM indicated there were no logs because the dining room steam table food temperatures are not taken, only the main kitchen steam table is temped. On 8/15/17 at 11:16 AM, an observation of the main kitchen with the DM and CDM revealed: 1.) Main kitchen stove had a large build-up of grease and food debris. 2.) Main kitchen had black food build-up and spillage on floors around stove and steamers/under hood area and along the walls. 3.) Dishwashing area had a fan with a build-up of grease and dust blowing on cleaned dishware. 4.) Right of dishwashing area had pooled cloudy liquid on the floor with a foul odor. Following the observation of the main kitchen the DM and CDM verified the above (4) findings. Review of the facility policy entitled, Leftover Policy, states under procedure (3.) All leftovers must be discarded or frozen if not used within [AGE] hours of the preparation date. (Place date frozen on the item before placing it in the freezer). Review of the facility policy, Food Safety, states under procedure (2.) Cut away any damaged or bruised areas on fresh fruits and vegetables before preparing and/or eating. Throw away any produce that looks rotten. Review of the facility policy entitled, Proper Use of Thermometers states under procedure (3.) All thermometers are checked for accuracy prior to each meal. The accuracy is checked by the following procedure: Place the thermometer in the ice water and wait three minutes stirring occasionally. After three minutes the thermometer should read 32 degrees. If the temperature does not read 32 degrees F it should be calibrated prior to use. Review of the facility policy entitled, Safe Food Temperatures states under procedure (1.) Prior to the beginning of the trayline the temperature of all food being served is taken and recorded appropriately on the temperature control form. On 8/15/17 at 12:40 PM, an observation of the West neighborhood cart (1) with Licensed Practical Nurse (LPN) # 1 revealed (1) carton of Med Pass 2.0 liquid supplement opened with approximately 1/2 remaining and had a temperature 70.2 degrees F. LPN #1 verified the Med Pass 2.0 was at room temperature and indicated s/he opened the carton during morning med pass. On 8/15/17 at 12:45 PM, an observation of the East neighborhood cart (2) with LPN # 2 revealed (1) carton of Med Pass 2.0 liquid supplement opened with approximately 1/2 remaining and had a temperature 70.8 degrees F. LPN #2 verified the Med Pass 2.0 was at room temperature and indicated s/he opened the carton during morning med pass. On 8/15/17 at 12:50 PM, an observation of the North neighborhood cart (2) revealed (1) carton of Med Pass 2.0 liquid supplement opened with approximately 1/4 remaining and had a temperature 70.5 degrees F. LPN #3 verified the Med Pass 2.0 was at room temperature and indicated s/he opened the car-ton during morning med pass. On 8/15/17 at 2:50 PM, during an interview with the Director of Nursing (DON), s/he stated med pass starts at approximately 7:45 AM. Review of the manufacture recommendations for Med Pass 2.0 states under procedure (5) MED PASS(R) 2.0/MED PASS(R) NSA needs to be kept at refrigerated temperature (34-40 degrees F) once opened. If kept at this temperature range, product is good for 4 days from the time opened. If product is opened and not refrigerated, product should be discarded after 4 hours.",2020-09-01
233,MOUNTAINVIEW NURSING HOME,425027,340 CEDAR SPRINGS ROAD,SPARTANBURG,SC,29302,2017-08-16,456,E,1,1,8R3N11,"> Based on observation, interview, and record review, the facility failed to keep essential equipment in safe operating condition in 1 of 1 laundry room. The ventilation unit in the laundry room had been broken for at least 4 - 5 weeks, and the air in the laundry room smelled musty and stagnant. The findings included: Observation of the sorting of laundry on 8/16/17 at approximately 9 AM revealed a musty and stagnant odor that pervaded the laundry room. Interview with the Assistant Administrator and the Housekeeping Director on 8/16/17 at approximately 9 AM revealed they both noticed the musty, stagnant odor in the laundry room. The Housekeeping Director stated the ventilation system in the room had been broken for several months. S/he also stated that maintenance was aware of the concern. Interview with the Plant Manager on 8/16/17 at approximately 9:33 AM revealed that s/he knew about the broken ventilation in the laundry room but was having difficulty fixing it. When asked if there was any documentation that corroborated that maintenance knew about the broken ventilation and was actively working to repair it, s/he was unable to provide any. The Plant Manager also stated that it came to his/her attention 4 - 5 weeks ago, but s/he could not find the original work order and believes it may have been a verbal request. Record review of facility policy on 8/16/17 at approximately 12:52 PM revealed the following: Routine requests for repairs or moveable equipment purchase or replacement should be made in writing on the Briggs Carbonized Three Part Form #430/3 (repair requisition).The form must be completed in detail by the requestor, signed only by the department head from which the request originated. The department head will deposit yellow and pink copies of the three part form in the in the mail slot provided for the Plant Services Director in the Administrative offices. The white copy of the form should be retained by the department head. Daily, the Plant Services Director will obtain these requests from the Administrative offices. The work will be scheduled according to priorities approved will be returned to the department head with an explanation for their rejection.",2020-09-01
234,MOUNTAINVIEW NURSING HOME,425027,340 CEDAR SPRINGS ROAD,SPARTANBURG,SC,29302,2019-10-20,561,D,1,1,4IGP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on resident and staff interviews and record reviews, the facility failed to allow one out of three (Resident #11) residents to make choices about their life in the facility. Specifically, Resident #11 was not able to attend an activity as requested. Findings include: According to the Face Sheet, Resident #11 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. According to the quarterly Minimum Data Set (MDS) assessment, dated 07/14/19, Resident #11 was moderately cognitively impaired with a Brief Interview of Mental Status (BIMS) score of nine out of 15. She required total assistance with all activities of daily living (ADL). The resident was interviewed on 10/18/19 at 9:57 AM. She said she loved to go to bingo. She said she only got to go if she was already up in her wheelchair. If she was in bed, then the staff didn't have time to get her out of bed and into her wheelchair. She said she became tearful a couple of months ago because she couldn't go to bingo because the Certified Nurse Aide (CNA) was serving food. She was upset that she couldn't go. A letter sent by the facility regarding a reportable incident was reviewed. The incident occurred on 08/08/19. Staff were passing out meal trays and assisting with resident meals when it was announced that bingo was starting in the main dining room. CNA #31 entered the resident's room and Resident #11 told her that she wanted the CNA to get her up so she could go to bingo. CNA #31 explained that she had to help residents with their meals first and then she could get her up. When the CNA finished assisting with the meal, she went back into Resident #11's room and told Resident #11 that bingo was ending. Resident #11 was observed banging her reacher (assistive device for picking up objects) on the bed because she was angry that bingo was over. CNA #31 was interviewed on 10/18/19 05:39 PM. She was the CNA working with Resident #11 the evening of 08/08/19. She said when dinner trays were being passed, it was announced that bingo was going to be starting. Resident #11 requested to go. CNA #31 told her that she could not get her up right then because she needed to finish passing trays and assist with feeding residents. She said Resident #11 was very upset and took her reacher and hit the end of the bed. She said that they have been instructed by administration to not stop what they're doing during meal times. They want all residents to be fed at the same time. The activity calendar was reviewed. Bingo was scheduled for 6:45 PM on 08/08/19. Meal time at the facility where Resident #11 resided began at 5:40 PM. Charge nurse #9 was interviewed on 10/20/19 at 10:45 AM. She said that all residents had to eat first before staff could get residents up out of bed. The staff need to make sure all trays were passed and everyone was fed before getting other residents up to go somewhere. She said she would have found a way to get the resident up to go to bingo on 08/08/19. CNA #60 was interviewed on 10/20/19 at 9:48 AM. She said that if a resident wants to get up during meal time and they're passing out trays, then they will get that resident up. She said she would communicate with the other staff to let them know what she was doing. If there was an activity while a meal was going on and the resident wanted to go, then they would get them up. Social Worker #108 was interviewed on 10/20/19 at 12:32 PM. She said it was the policy, that if it's meal time then the residents need to be fed and the staff couldn't get residents up during that time. Everyone needed to get their food at the same time. The Director of Nursing (DON) was interviewed on 10/20/19 at 2:52 PM. She said that all staff assist with feeding residents in the evening. If the CNA was in the middle of feeding someone, they were not supposed to stop in the middle of feeding to get another resident up out of bed. She said the night of 08/08/19, the dinner trays were late that night and residents didn't get served until around 6:30 PM.",2020-09-01
235,MOUNTAINVIEW NURSING HOME,425027,340 CEDAR SPRINGS ROAD,SPARTANBURG,SC,29302,2019-10-20,567,E,0,1,4IGP11,"Based on record review and interviews, it was determined the facility failed to ensure residents access to funds were not limited to $30 or less for four of four sampled residents whose trust accounts were reviewed (#63, #34, #77, and #104). The facility identified 120 residents who held money in the trust account out of a census of 123. Findings include: The facility trust account policy documented, When a resident needs money, it can be accessed through the business office. The business office keeps a reasonable amount on hand for small purchases. Resident/Responsible party should request larger amounts in excess of $20.00 one week in advance. The admission packet contained a form titled, Accessing your Personal Funds on Weekends. The form documented the maximum amount for withdrawal on the weekend was $3. A review of the resident trust ledgers for resident #63, #34, #77, and #104 contained documentation of petty cash withdrawals of funds no greater than $30. On 10/19/19 at 4:31 PM Business Office Manager #112, the employee responsible for the resident trust account, stated residents could get money from her Monday through Friday up to $30. She then stated the residents could get money from the charge nurse on the weekend, but it could not exceed $3. She stated any amounts over those amounts the resident would need to notify them a week in advance so a check could be cashed and the money available because they only provide a very little amount in petty cash on the weekends for the residents. At 5:04 PM, the administrator stated that he did not know the amount that should be available was up to $50.",2020-09-01
236,MOUNTAINVIEW NURSING HOME,425027,340 CEDAR SPRINGS ROAD,SPARTANBURG,SC,29302,2019-10-20,570,E,0,1,4IGP11,"Based on record review and interviews, it was determined the facility failed to ensure the surety bond was sufficient to cover the account balances. The facility identified 120 residents who held money in the trust account. Findings include: A review of the surety bond for the resident's trust account documented the facility had coverage of $100,000. A review of the bank statements for July, August, and (MONTH) 2019 was conducted. The facility had the following monthly ending balances: July: $87,162.87; (MONTH) $111,614.83; and (MONTH) $86,692.39. A current ledger report, dated 10/19/19, documented the balance in the trust account was $132,137.83. On 10/19/19 at 4:31 PM, Business Office Manager #112, the employee responsible for the resident trust account, confirmed the surety bond was for $100,000. She then stated the administrator was the one that reviewed that. At 5:04 PM, the administrator stated he could get a higher value on the surety bond. He then stated he was not sure how it crept above the $100,000.",2020-09-01
237,MOUNTAINVIEW NURSING HOME,425027,340 CEDAR SPRINGS ROAD,SPARTANBURG,SC,29302,2019-10-20,578,D,0,1,4IGP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to provide information on Advanced Directives for three of four residents reviewed (Residents #6, #36, and #113). Findings include: 1. Resident #6 was admitted [DATE]. [DIAGNOSES REDACTED]. A review of Resident #6's annual Minimum Data Set (MDS), dated [DATE], noted that she was rarely or never understood. An interview was completed with Social Worker #108 (SW #108) on 10/18/19 at 3:27 PM. SW #108 said, On admission, Social Services talks to residents about advanced directives. There is a form we fill out and give that to nursing to talk with the doctor about what they want. We discuss advanced directives at quarterly care plan meetings. On admission, I talk to the resident about being a full code or a DNR (do not resuscitate). I ask if they have a living will or a guardian. If they don't know about a living will, I get nursing to explain it. The form we have is the advanced directive if they want to fill it out and don't already have one. On 10/18/19 at 3:45 PM, a follow up interview was completed with SW #108. We don't have any documentation that advanced directives have been discussed for (Resident #6). She has a sister who comes in sometimes for the care plan meetings. I didn't get her to sign our form. 2. Resident #36 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. A review of the quarterly MDS, dated [DATE], noted that resident #36 had a Brief Interview for Mental Status (BIMS) score of 8, indicating moderately impaired cognition. An interview was completed with SW #108 on 10/18/19 at 3:27 PM. SW #108 said, On Admission Social Services talks to residents about advanced directives. There is a form we fill out and give that to nursing to talk with the doctor about what they want. We discuss advanced directives at quarterly care plan meetings. On admission, I talk to the resident about being a full code or a DNR, I ask if they have a living will or a guardian. If they don't know about a living will, I get nursing to explain it. The form we have is the advanced directive if they want to fill it out and don't already have one. A follow up interview was completed with SW #108 on 10/18/19 at 3:40 PM. For this resident, his sister is his responsible party. She hasn't been to a care plan meeting in the last 5 years. She does come in every so often, but we haven't talked about advanced directives. There is no documentation that advanced directives have been discussed with him or his family since admission. 3. Resident #113 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #113's quarterly MDS assessment, dated 09/22/19, noted that he was rarely or never understood and that he had short-term and long-term memory problems. An interview was completed with SW #108 on 10/18/19 at 3:27 PM. SW #108 said, On admission Social Services talks to residents about advanced directives. There is a form we fill out and give that to nursing to talk with the doctor about what they want. We discuss advanced directives at quarterly care plan meetings. On admission, I talk to the resident about being a full code or a DNR, I ask if they have a living will or a guardian. If they don't know about a living will, I get nursing to explain it. The form we have is the advanced directive if they want to fill it out and don't already have one. A follow up interview was completed on 10/18/19 at 3:49 PM with SW #108. His father is his power of attorney. He has been in prison until recently and hasn't been able to visit. We talked to him about the code status, but not advanced directives.",2020-09-01
238,MOUNTAINVIEW NURSING HOME,425027,340 CEDAR SPRINGS ROAD,SPARTANBURG,SC,29302,2019-10-20,584,D,0,1,4IGP11,"Based on observations, record review and staff interviews, the facility failed to maintain a system for reporting maintenance needs on two of three units (100 and 200 Halls). Findings include: On 10/20/19 at 11:22 AM, a policy dated 08/21/17 titled, Routine requests for repairs or moveable equipment purchase or replacement, was reviewed. The policy stated that routine requests for repairs must be made in writing using a repair requisition. Requisitions are to be collected each day by the Plant Services Department except on weekends. Requests placed over the weekend will be collected on Monday. On 10/17/19 at 11:57 AM, an observation was made of the bathroom for Resident #3. There was no string on the call light switch so it could not be reached by the resident if the switch itself was out of reach. Resident #3's room was also noted to have about six inches of the ends of three blind slats broken off. On 10/17/19 at 3:17 PM, an observation was completed of Resident #67's room. A ceiling tile over the bathroom commode appeared to be wet and had a large black stain. The tile was yellow and sagging with the blackened area approximately six inches in diameter. On 10/18/19 09:27 AM, an observation was completed of Resident #1's room. Water stained ceiling tiles were noted near the wall. An interview was completed with the Maintenance Supervisor #117 on 10/20/19 at 9:20 AM. Supervisor #117 said, We use a work ticket system. Staff fill them out and each morning, we stop and pick them up. We are out on the floor all day so they can call us anytime if it's something more urgent. We are caught up on our tickets unless something came in over the weekend. After touring rooms #103, #217, and #224, Supervisor #117 said, We weren't aware of the water damaged ceiling tiles. There were no tickets turned in. I used to make rounds. I haven't been able to do it as much in the last year. We don't go into the bathrooms much, so I depend on the staff a lot, so I didn't know about the call light string. The blinds would be something that we would replace, but we were not aware of the broken blind. On 10/20/19 at 9:58 AM, an interview was completed with Nurse #11. Nurse #11 said, If there is something that needs repair, there is a form we fill out. Maintenance comes by each morning and picks them up.",2020-09-01
239,MOUNTAINVIEW NURSING HOME,425027,340 CEDAR SPRINGS ROAD,SPARTANBURG,SC,29302,2019-10-20,609,D,1,1,4IGP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record reviews, the facility failed to report allegations of abuse and bruises of unknown origin to the appropriate agencies within the required time frames for two of five residents reviewed for allegations of abuse (Resident #11 and Resident #94). Findings include: 1. Resident #11 According to the Face Sheet, Resident #11 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. According to the quarterly Minimum Data Set (MDS) assessment, dated 07/14/19, Resident #11 was moderately cognitively impaired with a Brief Interview of Mental Status (BIMS) score of nine out of 15. She required total assistance with all activities of daily living (ADL). The reportable incident investigation and letter were reviewed. The letter was sent to the state agency on 08/16/19. The letter served as the initial and final notification of the reportable incident. The reportable incident was that a Certified Nurse Aide (CNA) had repeatedly bashed Resident #77's head against the nightstand and twisted her arm on 08/09/19. Through the investigation, it was determined the incident occurred on 08/08/19 and not 08/09/19. Three CNA statements were obtained on 08/15/19. CNA #31 was interviewed on 10/18/19 at 5:39 PM. She was the CNA working with Resident #11 the evening of 08/08/19. She said when dinner trays were being passed, it was announced that bingo was going to be starting. Resident #11 requested to go. CNA #31 told her that she could not get her up right then because she needed to finish passing trays and assist with feeding residents. She said Resident #11 was very upset and took her reacher and hit the end of the bed. The following day, on 08/09/19, Resident #11 had a bruise on her arm, so she was questioned about it. She said charge Nurse #9 and Social Worker #108 completed the investigation. Resident #11 informed them that CNA #31 had banged her head against the bedside table and she grabbed her arm. She said she did neither of those and the resident was just upset about bingo. She thought the bruise was from the reacher, when Resident #11 was hitting it against the bed. The reportable incident investigation was reviewed once more. The skin tear/discoloration investigation form was completed on 08/09/19. There was no report informing the state agency of the bruise of unknown origin and alleged abuse on 08/09/19, when the staff were made aware. Charge Nurse #9 was interviewed on 10/20/19 at 10:45 AM. She recalled the incident. She said Resident #11 told her about the incident during first shift and staff found a bruise on her arm at that time. The incident occurred on the 2nd shift the previous day. Resident #11 told her that a CNA attacked her. She looked at the schedule and figured out which CNA it was and spoke with the CN[NAME] Charge Nurse #9 called Social Worker #108 and that was when the investigation started. The investigation was started because they noticed the bruise and Resident #11 said a CNA attacked her. She thought the bruise was from the wheelchair. She said the social workers complete the investigations and the Director of Nursing (DON) does the paperwork and reporting. Social Worker #108 was interviewed on 10/20/19 at 12:32 PM. She said she helped investigate the incident with Resident #11. She knew allegations of abuse had to be reported to the state agency within two hours of the staff being made aware. She said the DON did all of the reporting. She was informed by Charge Nurse #9 that Resident #11 said a CNA had attacked her. When she spoke with the resident on 08/09/19, Resident #11 told her that the CNA caring for her got mad and banged her head against the bedside table. This would be an allegation of abuse. Once she spoke with Resident #11 and the nursing staff, she reported it to the DON. The DON was interviewed on 10/20/19 at 12:42 PM. She said they were required to report incidents to the state agency within two hours if the resident could be in immediate danger, like abuse. If there was no immediate danger, then they had 24 hours to report it to the state agency and then a five day follow up was required. She said the time frames began from when they were notified of the situation. She said she was not notified of the incident until 08/15/18. Social Worker #108 joined the interview. She said she informed the DON on 08/09/19. She said she would not have kept that information to herself and not reported it. A concern form was completed on 08/09/19 by Social Worker #108. The concern from was regarding Resident #11's bruise. Nursing got statements from the nurse and CNAs providing care and the Social Worker spoke with Resident #11. Resident #11 was banging her reacher against the bed when she was upset and possibly hit her arm to cause the bruise. There was no evidence the bruise was caused by the staff. The Information sent to and date sent section was blank. Based on all of the information gathered, the staff were made aware of the bruise and the abuse allegation on 08/09/19, but the DON did not complete her investigation until 08/15/19. The incident was not reported to the state agency until 08/16/19. 2. Resident #94 Review of the clinical record revealed an admission history form dated 03/06/19. The admission history documented Resident #94 was admitted to the facility on [DATE] with a readmitted d of 04/19/19. The quarterly MDS assessment, dated 09/08/19, documented that Resident #94 had severe memory impairment and needed extensive assistance for all ADLs. Resident #94 had a plan of care (P[NAME]), initially dated 04/19/19, for being a high fall risk. Interventions included constant observation and maintain a safe unit environment by removing excess equipment/supplies/furniture from rooms and hallways. Resident #94's P[NAME], dated 03/19/19 and updated on 10/17/19, documented her need for extensive assistance for bed mobility, assist for transfers, and assist for personal hygiene. P[NAME] also documented that Resident #94 got distracted while feeding herself. On 10/17/19 at 12:16 PM, during the first dining observation, Resident #94 was observed with a large bruise to the left side of her eye, between her eyebrow and the side of her eye. The bruise was purple and pink with a greenish/yellowish discoloration around the edges. Resident #94 appeared to be calm and was focused on eating lunch. Investigation: On 10/20/19 at 8:28 AM, facility's investigation for a 'discoloration' of unknown origin was reviewed. The investigation revealed the following: On 10/13/19 at 7:30 AM, Resident #94 was in the day room, sitting up in her wheelchair when Licensed Practical Nurse (LPN) #56 observed a raised discoloration above the Resident's left eyebrow. The physician's office was not notified until 9:20 AM, the resident's responsible party was not notified until 9:22 AM, and the nurse on call was not notified until 9:25 AM. A statement dated 10/13/19 from LPN #38 documented, I was the med nurse on cart 2 and I was not aware of a raised discoloration area on Resident #94 above left eyebrow. A statement dated 10/13/19 from LPN #56 documented, When this nurse arrived this AM, Resident #94 was up sitting in wheelchair in common area. When this nurse administered morning meds a purple discoloration was noted to left outer eyebrow. A statement dated 10/13/19 from CNA #29 documented, I had the resident last night but did not notice a bruise on her at all. I didn't have her the night before, so I am not sure if it was there or not. A statement dated 10/13/19 from CNA #41 documented, To whom it may concern, I don't know anything about no bruise on Resident #94. A statement dated 10/13/19 from CNA #14 documented, During my 7 PM to 7 AM shift I, CNA #14, did not note any discoloration to Resident #94's left side throughout my shift. While administering meds, I was on her right side of bed. A Restorative Nursing Note from Registered Nurse (RN) #24 dated 10/17/19 at 8:30 AM documented in part, .Resident was unable to tell nurse what happened due to her dementia. There were no indicators of abuse noted. Resident does not exhibit any fear of caregivers nor were there any collateral signs of abuse. Incident not referred to DON due to no indicators of abuse noted. The staff were educated on monitoring more closely while helping Resident #94 dress and when she is eating to make sure resident doesn't hurt herself due to poor safety awareness. On 10/20/19 at 8:43 AM, the DON was interviewed. The DON stated that she had asked RN #24 to investigate the discoloration of unknown origin for Resident #94's left eye and 'try to narrow down what happened.' The process was to talk to staff, look at the actual bruise, find out if there was an altercation with any other resident(s), we get statements from everybody we can, but definitely statements from staff who took care of Resident #94. We look for patterns and/or anything suspicious. DON stated that if it feels suspicious, I report it within 24 hours and conduct a more in-depth investigation for the 5 day report. The DON stated that she followed up with staff after this incident but did not document. The DON stated that based on RN #24's findings, she did not report the bruise of unknown origin. Policy: Mountainview Abuse and Neglect Management Policy Statement, dated (YEAR), documented the following (in part) under the section entitled Reporting: It is the responsibility of our employees, facility consultants, attending physicians, family members, visitors, etc., to promptly report any incident or suspected incident of neglect of resident abuse, including of unknown source, and theft or misappropriation of resident property to facility management. #5. When an alleged or suspected case of mistreatment, neglect, injuries of unknown source, or abuse is reported, the facility Administrator, or his/her designee, will immediately (within twenty-four hours of the alleged incident) notify the following persons or agencies of such incident: a. The state licensing/certification agency responsible for survey/licensing the facility. b. The local/state Ombudsman c. The Resident's representative of Record d. Adult Protective Services e. Law enforcement officials f. The Resident's attending physician g. The facility Medical Director",2020-09-01
240,MOUNTAINVIEW NURSING HOME,425027,340 CEDAR SPRINGS ROAD,SPARTANBURG,SC,29302,2019-10-20,610,D,0,1,4IGP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and observation, the facility failed to complete a thorough investigation to determine how a resident sustained [REDACTED]. This affected one out of five sampled residents (#94). Resident #94 was observed to have a bruise on the left side of her face near her left eye. Findings include: Review of the clinical record revealed an admission history form dated 03/06/19. The admission history documented Resident #94 was admitted to the facility on [DATE] with a readmitted d of 04/19/19. The quarterly minimum data set (MDS) assessment dated [DATE] documented that Resident #94 had severe memory impairment and needed extensive assistance for all activities of daily living (ADLs). Resident #94 had a plan of care (P[NAME]) initially dated 04/19/19 for being a high fall risk. Interventions included constant observation and maintain a safe unit environment by removing excess equipment/supplies/furniture from rooms and hallways. Resident #94's P[NAME], dated 03/19/19 and updated on 10/17/19, documented her need for extensive assistance for bed mobility, assist for transfers, and assist for personal hygiene. P[NAME] also documented that Resident #94 got distracted while feeding herself. On 10/17/19 at 12:16 PM, during the first dining observation, Resident #94 was observed with a large bruise to the left side of her eye, between her eyebrow and the side of her eye. The bruise was purple and pink with a greenish/yellowish discoloration around the edges. Resident #94 appeared to be calm and was focused on eating lunch. Investigation: On 10/20/19 at 8:28 AM, facility's investigation for a 'discoloration' of unknown origin was reviewed. The investigation revealed the following: On 10/13/19 at 7:30 AM, Resident #94 was in the day room, sitting up in her wheelchair when Licensed Practical Nurse (LPN) #56 observed a raised discoloration above the Resident's left eyebrow. The physician's office was not notified until 9:20 AM, the resident's responsible party was not notified until 9:22 AM, and the nurse on call was not notified until 9:25 AM. A statement dated 10/13/19 from LPN #38 documented, I was the med nurse on cart 2 and I was not aware of a raised discoloration area on Resident #94 above left eyebrow. A statement dated 10/13/19 from LPN #56 documented, When this nurse arrived this AM, Resident #94 was up sitting in wheelchair in common area. When this nurse administered morning meds a purple discoloration was noted to left outer eyebrow. A statement dated 10/13/19 from Certified Nursing Assistant (CNA) #29 documented, I had the resident last night but did not notice a bruise on her at all. I didn't have her the night before, so I am not sure if it was there or not. A statement dated 10/13/19 from CNA #41 documented, To whom it may concern, I don't know anything about no bruise on Resident #94. A statement dated 10/13/19 from CNA #14 documented, During my 7 PM to 7 AM shift I, CNA #14, did not note any discoloration to Resident #94's left side throughout my shift. While administering meds, I was on her right side of bed. A Restorative Nursing Note from Registered Nurse (RN) #24 dated 10/17/19 at 8:30 AM documented in part, .Resident was unable to tell nurse what happened due to her dementia. There were no indicators of abuse noted. Resident does not exhibit any fear of caregivers nor were there any collateral signs of abuse. Incident not referred to Director of Nursing (DON) due to no indicators of abuse noted. The staff were educated on monitoring more closely while helping Resident #94 dress and when she is eating to make sure resident doesn't hurt herself due to poor safety awareness. Staff interviews: On 10/19/19 at 3:51 PM, RN #24 was interviewed. RN #24 stated that as the Restorative Nurse, she was in charge of investigating the discoloration of unknown origin. RN #24 asked for statements from some staff. She stated that she did not ask for a statement from the resident's roommate or any other residents. RN #24 stated that the resident moves around while getting dressed and providing care. There were no hazards in her room that she could have hit. And, Resident #94 had no safety awareness due to her dementia. RN #24 stated that she did not investigate any further because she did not believe there was abuse but could not tell this surveyor how she came to that conclusion. On 10/20/19 at 8:43 AM, the DON was interviewed. The DON stated that she had asked RN #24 to investigate the discoloration of unknown origin for Resident #94's left eye and 'try to narrow down what happened.' The process was to talk to staff, look at the actual bruise, find out if there was an altercation with any other resident(s), get statements from everybody we can, but definitely statements from staff who took care of Resident #94. We look for patterns and/or anything suspicious. DON stated that if it feels suspicious, I'll report it within 24 hours and conduct my more in-depth investigation for the 5 day report. The DON stated that she followed up with staff after this incident but did not document. The DON was unable to locate the education documented by RN #24. On 10/20/19 at 9:23 AM, LPN #1 was interviewed. LPN #1 was unable to locate a P[NAME] that addressed that Resident #94 flails her arms around. On 10/20/19 at 9:32 AM, RN #8 was interviewed. RN #8 stated Resident #94 had days where she did not have any behaviors such as flailing her arms around. On 10/20/19 at 10:07 AM, CNA #34 was interviewed. CNA #34 stated Resident #94 can be very fidgety while being toileted or getting dressed. It was safer to provide her care with two staff present. CNA #34 stated that she had observed Resident #94 fidgety, but never hitting herself or swinging her utensils. CNA #34 was asked to provide a statement about the bruise by Resident #94's left eye. On 10/20/19 at 10:14 AM, CNA #44 was interviewed. CNA #44 stated Resident #94 is very fidgety and moved her arms and legs a lot, but I've never seen her hit herself. Resident #94 was never seen hitting herself with her utensils. On 10/20/19 at 10:25 AM, LPN #3 was interviewed. LPN #3 stated Resident #94 will move her arms around as if she was conducting music or sewing. LPN #3 continued to reveal that she had never observed Resident #94 swing her utensils when she is eating. Policy: Mountainview Abuse and Neglect Management Policy Statement dated (YEAR) documented the following (in part) under the section entitled Investigation: #3. The individual conducting the investigation will, as a minimum: a. Review completed statements b. Review the resident's medical record to determine events leading up to the c. Incident; d. Interview the person(s) reporting the incident; e. Interview and witnessed of the incident f. Interview the resident (as medically appropriate); g. Interview the resident's attending physician as needed to determine the h. Resident's current level of cognitive function and medical condition; i. Interview staff members (on all shifts) who have contact with the resident during the period of the alleged incident; j. Interview the resident's family members, and visitors as needed; k. Interview other residents to whom the accused employee provides care or services; and l. Review all events leading up to the alleged incident. #14. The Administrator or designee will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency, the local police department, the ombudsman, and others as may be required by state and local laws, within the reporting guidelines for the divisions of the state agencies.",2020-09-01
241,MOUNTAINVIEW NURSING HOME,425027,340 CEDAR SPRINGS ROAD,SPARTANBURG,SC,29302,2019-10-20,677,D,0,1,4IGP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, and record reviews, the facility failed to provide adequate activities of daily living (ADL) care for two out of two residents reviewed for ADLs (Resident #11 and #77). Specifically, Resident #11 did not receive timely incontinence care and Resident #77 did not receive showers as scheduled. Findings include: Resident #11 According to the Face Sheet, Resident #11 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. According to the quarterly Minimum Data Set (MDS) assessment, dated 07/14/19, Resident #11 was moderately cognitively impaired with a Brief Interview of Mental Status (BIMS) score of 9 out of 15. She required total assistance with all activities of daily living (ADL). Resident #11 was always incontinent of urine. A concurrent observation and interview were conducted with Resident #11 on 10/18/19 beginning at 10:32 AM. The resident was complaining that her shirt was very wet and she wanted to take it off. She was not sure if she had been incontinent. She pressed her call light and there was a beeping noise outside of the room in the hallway. Approximately 30-60 seconds later, a staff member spoke with the resident through an intercom and asked her if she could help her. The resident requested that someone come to the room and the staff said they would be right in. The beeping noise outside of the room in the hallway stopped. At 10:50 AM, no staff member had come into the room to assist the resident. Resident #11 ended up taking off her shirt. She did not want to lay on a wet shirt any more. She had felt her brief and confirmed she had been incontinent. The resident was encouraged to press her call light again since it seemed to have been turned off. Resident #11 said the staff do that sometimes. They would turn off the light without coming into the room. Licensed Practical Nurse (LPN) #36 entered the room at 10:53 AM. She helped the resident try and find an item before she went to get another staff member to help with incontinence care. LPN #36 and another staff member re-entered the resident's room at 10:58 AM. It took 26 minutes for Resident #11 to receive the incontinence care that she needed. On 10/20/19 at 9:21 AM, the call light control board on Westside Gardens (where Resident #11 resided) was observed. There was a corded phone and buttons that lit up for all of the call lights. There was a sign that read, Must push buttons twice to reset. Certified Nurse Aide (CNA) was interviewed on 10/20/19 at 9:48 AM. She said Resident #11 was incontinent of urine. She knew when she was wet and would turn on her call light. She confirmed they had the capability to speak with residents and turn call lights off remotely, using the call light control board. She said administrative staff didn't like when they turned call lights off remotely. They wanted them to actually go into the resident's room and turn off the call light. She said she always went into the resident's room before shutting off a call light, so she knew what the resident actually needed. If they do use the control board to speak to the resident, they were supposed to go into the room right away to assist the resident. Charge Nurse #9 was interviewed on 10/20/19 at 10:45 AM. She said they recently did a teachable moment regarding the call lights. They educated the staff on how to answer the call lights using the call light control board and to make sure they actually answer the call light. If they use the control board and speak to the resident via the phone, they're supposed to see if they need a nurse or a CN[NAME] If it is not clear about who they need, the CNA is supposed to go into the room and check on them. When asked about turning the call lights off remotely, she said the staff had the capability to do that. They could turn off the light if the resident wanted something simple. The staff should not turn off the call light until the staff are aware of what the resident needs, which could mean going into the room. The Director of Nursing (DON) was interviewed on 10/20/19 at 2:52 PM. She said staff could turn call lights off remotely from the call light control board. If staff used the call light control board to speak with a resident and turn the light off, the staff were to go straight to the resident's room to assist the resident. They needed to ensure the resident was receiving the assistance that they needed. Resident #77 According to the Face Sheet, Resident #77 was admitted to the facility on [DATE] and readmitted on [DATE]. [DIAGNOSES REDACTED]. According to the annual MDS assessment, dated 08/25/19, Resident #77 was cognitively intact with a BIMS score of 15 out of 15. She required total assistance with bathing. Resident #77 was interviewed on 10/17/19 at 3:45 PM. She said she was supposed to get showers three times per week, but she was lucky if she received one per week. She said she loves to bathe and the feeling of a hot shower, so she would never refuse. She said they don't offer for her to take a shower. She said it had been going on four months. Resident #77 was interviewed for a second time on 10/20/19 at 10:31 AM. She confirmed that she does not receive the showers she is supposed to get. She said the staff tell her she refuses, but she would never refuse showers. She said she loves to take showers. LPN #36 was interviewed on 10/20/19 at 9:25 AM. She looked at the shower schedule and Resident #77 was scheduled for showers on Mondays, Wednesdays, and Fridays during the 3rd shift. As the schedule was reviewed, Charge Nurse #9 said Resident #77 always refused her showers. The CNA ADL Tracking Form was reviewed. Resident #77 had received one shower for the month of October. She received a shower on 10/14/19. She received three showers in the month of September. She received showers on 09/2/19, 09/16/19, and 09/30/19. CNA #60 was interviewed on 10/20/19 at 9:42 AM. She said if residents refuse showers, then they were supposed to tell the nurse. She said they don't document a refusal in their shower documentation. Resident #77's care plans were reviewed. There was nothing in the care plan indicating the resident frequently refused her showers. The nursing notes were reviewed. There were no notes indicating Resident #77 had refused any showers. Charge Nurse #9 was interviewed on 10/20/19 at 10:59 AM. She said Resident #77 was very non-compliant. She said she had been refusing to get out of bed for about six months, and since then she had been refusing her showers as well. She said if a resident refused a shower, the CNA was supposed to tell the nurse and then the nurse would go into the room and speak with the resident. She said the nurses were supposed to document each time a resident refused their showers. Charge Nurse #9 looked through Resident #77's chart. She confirmed there were no nursing notes indicating Resident #77 refused showers. She also confirmed there was nothing written in her care plan regarding the refusals of showers. The DON was interviewed on 10/20/19 at 2:52 PM. She said if a resident refuses a shower, the CNA was to go back at another time and offer. After two or three attempts, then they tell the nurse. The nurse speaks with the resident and then the nurse documents the refusal. She said the CNA should mark the refusal on the ADL Tracking Form. She said all residents should get showers when scheduled and if they refuse, it should be documented.",2020-09-01
242,MAGNOLIA MANOR - INMAN,425032,63 BLACKSTOCK ROAD,INMAN,SC,29349,2018-09-13,563,J,1,0,FNQ411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility [MEDICATION NAME], record review, interviews and review of policies and procedures, the facility failed to provide written policies and procedures regarding the visitation rights of residents. There were no policies and procedures to determine the limitation or safety restrictions that the facility may need to place on such rights as clinically indicated. The facility reported an allegation of sexual abuse of Resident #1 by a visitor at the facility. The facility failed to prevent the abuse. One of 3 residents reviewed for abuse. The findings included. Resident #1 was reviewed for alleged sexual abuse following a facility reported incident received by the State Agency. Resident #1 admitted to the facility with [DIAGNOSES REDACTED]. The Admission Minimum Data Set assessment dated [DATE], indicated the resident's BI[CONDITION] (brief interview of mental status) score as 9. Review of the medical record revealed a facility form Addressing Decisional Capacity signed by one physician on [DATE] that stated, This patient DOES NOT meet all the criteria for decisional capacity, therefore is not able to make healthcare decisions for self. Furthermore, it is my opinion that due to the patient's medical condition(s), this lack of capacity is not likely to change in the immediate future. Review of the facility 5 Day Follow up investigation indicated that on [DATE] two Certified Nurse Aide (CNA) #1 and #2 entered the room of Resident #1. They asked what the visitor was doing. The visitor responded that they were okay. The visitor had shorts on with the front opened.penis was not exposed. The CNAs immediately got the nurse who questioned the visitor who identified himself and stated he had known the resident for a long time. The social worker questioned the visitor who stated the resident asked him to hump her. The resident stated the visitor was her man, but did not know his name. The social worker removed the visitor from the room and sat him at the nurses station to be supervised until authorities arrived. In a telephone interview with the surveyor on [DATE] at 11:40 AM Licensed Practical Nurse (LPN) #1 stated s/he was two doors down from Resident#1's room when two CNAs came to me running and stated, they are having sex. Running back that way (all of us) we burst in the room, pushing door open. The surveyor asked if the door was closed, LPN #1 responded, Yes. S/he stated that the CNAs pulled the door closed and ran toward her/him. The surveyor asked LPN #1 what s/he saw when s/he entered the room, her laying flat on bed, visitor sitting on side of bed with back to door, s/he was saying, 'I told you they don't like this here.' S/he moved from bed to the chair and was facing the staff. I was asking her/him if s/he was ok, s/he was confused. The visitor said we're ok. I asked him/her how s/he knew the resident? The visitor stated, 'We go way back, just friends. I knew her/him before s/he came here.' The resident said, 'That's my man'. S/he started trying to get up, s/he was undressed from waist down. LPN #1 stated that s/he told them s/he was going to call Resident #1's family. The visitor stated, 'ok to call family.' LPN #1 stated s/he stepped out in the hall to call the DON (director of nursing) and Administrator. The visitor was still in the room, left door open, CNAs might have stayed. I don't remember closing the door. The Social Worker came in just a few minutes and took over. S/he brought the visitor out of the room to the desk. LPN #1 stated that s/he had never seen the visitor and Resident #1 together before the incident. In a telephone interview with the surveyor on [DATE] at 10:05 AM Certified Nurse Aide (CNA) #1 was asked by the surveyor about the incident with Resident #1 that occurred on [DATE] while the CNA was working on Unit 3. CNA #1 stated s/he was the first person to find Resident #1 and the visitor between 1:30 and 2:00 PM. I was assigned both residents in the room. Resident #1's roommate was outside in smoking area. S/he stated s/he saw the visitor on top of Resident #1, with pants open. S/he was moving and had hands down in private area. CNA #1 asked the visitor what was going on and the visitor responded, 'we good.' I said no you're not and called the nurse. When asked by the surveyor what s/he did CNA #1 stated that s/he pulled the door up and stepped out and called LPN #1 who was two doors away. When LPN #1 was coming toward me, I opened the door and the visitor was getting back on bed. CNA #2 and LPN #1 were behind me when I opened the door. We went in, CNA #2 didn't. CNA #1 stated s/he stood outside the door with it cracked and watched the visitor, standing on the side of the bed. The social worker came in a few minutes. When asked by the surveyor what the visitor was wearing, CNA #1 stated blue jean shorts. In a telephone interview with the surveyor on [DATE] at 9:15 AM the Social Worker was read a facility obtained statement and s/he confirmed s/he had given the information to the facility. The Social Worker confirmed s/he entered Resident #1's room and the visitor was in the room, with clothes up. The visitor was in bed beside the resident, hand under the blanket holding the resident's hand. The Social Worker stated the staff was at the door when s/he arrived, the door was closed, we knocked'. No one was in the room just the two of them. When asked by the surveyor what was the time, the Social Worker stated about 2:10 PM. The Social Worker stated s/he directed the visitor to the nurses station and two staff stayed with the visitor until the police arrived, at that time the visitor was taken to the facility business office, about 2:30 PM. The Social Worker stated that when s/he first arrived on Unit 3, after asking the visitor to come out of the room, s/he directed the nurse to do a body audit. S/he stated that s/he attempted to call the Director of Nursing and the Administrator, s/he spoke with the corporate clinical nurse. S/he asked one of the nurses to call the Sheriffs Department. S/he stated the resident was unable to tell what occurred and was rambling about stuff that was not related to the questions asked. In a face-to-face interview with the surveyor on [DATE] at 3:00 PM the Social Work Assistant stated that s/he entered the room with the Social Worker and that two CNAs were standing outside the door. The door was closed, knocked and went in. The visitor was lying on the bed with the resident, the Social Worker told the visitor to get up and s/he took him/her out of the room. The Social Work Assistant stated that s/he stayed in the room with Resident #1 several minutes, during the time s/he was in the room the resident just mumbled. I walked out of the room and stayed with the visitor until we took him/her to the business office/reception area. Two CNAs watched the visitor until the police arrived. I walked back to Unit 3 and the resident was on the stretcher to go out. I asked her/him if s/he was alright. S/he said, 'Yes baby'. The Social Work Assistant stated that the visitor's aunt had been in the facility for sometime and the s/he had never received any complaints about him/her. Review of the Daily Skilled Nurse's Note dated [DATE] stated, Around 2 PM a male visitor was reported to be in res. (resident) room. Nurse went in to res. room and observed male on bed side stating, 'I told you they don't like you doing this in here'. Res. asked nurse, 'So ya'll don't let people do this in your restaurant?' Nurse observed res. undressed from waist down, visitor moved to sit in chair beside bed and states, it's ok, we been knowing each other for a long time before she came in here. CNAs at room with nurse res. states she is ok. 2:15 PM Nurse starts attempting to call management. 2:20 PM Soc. Svc. (social service) came to floor removed visitor to sit at nurse station while continuing to call management. 2:30 PM visitor taken to front office to wait for management and police dept. (department) to arrive. 3 PM staff continues to monitor res. call placed to MD (medical doctor), order given to send to ER (emergency room ) for eval. (evaluation). RP (responsible party) number one called multiple times. Party denies knowing res. but agrees number is correct. Between 3:30 and 4 PM statement given to police dept. res. leaving for ER with clothing and bedding in use sent with res. Attempt to call RP #2 spoke with at around 7:50 PM after several attempts. RP states s/he is in route to [STATE] to see mother when attempt to inform RP s/he states hospital had called and informed him/her of what happened. RP was told visitor stated s/he had been her/his friend for a long time before s/he came here. RP states that is not true 'My mother knows no one in the area'. RP then states 'the hospital is calling me and I need to answer it, thank you.' and hangs up the phone. Late entry - body audit completed at 220 PM no areas of concern were noted. Review of the Medical Record revealed a Physician order [REDACTED]. Further review revealed a SBAR (Situation, Background, Assessment, Recommendation) Communication Form dated [DATE] that showed the physician was notified and the Res (resident) sent to ER (emergency room ) for rape test kit to be performed. And to eval (evaluate) for further tx (treatment) as needed. In a face to face interview with the surveyor on [DATE] at approximately 10:50 AM the Director of Nursing (DON) stated they have a sign in/out log that people sign and that the doors are locked from 4:00 PM until 8:00 AM Monday-Friday and at all times on the weekend. Visitors have to ring the door bell to gain access to the facility during times when the doors are locked. The surveyor asked the DON if s/he had seen the visitor at the facility before, s/he stated that s/he had seen him/her generally visiting with Resident C. Sometimes s/he would sit with Resident C for haircut, thought s/he was a son. The surveyor asked if the DON noticed any impairment of the visitor, s/he stated the only thing s/he noticed was a cigarette smoke odor. In a face to face interview with the Administrator on [DATE] s/he stated they did not have a policy and procedure regarding the visitation rights of residents. When asked how they determined who visited resident with cognitive impairments the Administrator said they do not have a policy and procedure. S/he provided an Access and Visitation Rights from the facility Admission Packet that stated, Each resident has the right to receive visitors of his/her choosing and designation (including but not limited to a spouse of the same or opposite sex, domestic partner (of the same or opposite sex), another family member or friend, subject to the resident's right to deny visitation when applicable. The facility must provide access to any resident by (1) any representative of the Secretary, (2) Any representative of the State. (3) Any representative of the Office of the State long term care ombudsman. (4) the resident's individual physician. (5) any representative of the protection and advocacy system (5) any representative of the agency responsible for the protection and advocacy system for individuals with a mental disorder, and (6) the resident representative. The facility must provide immediate access to a resident by immediate family and other relatives, and reasonable access by any entity or individual that provides health, social, legal or other services to the resident, all of which are subject to the resident's right to deny or withdraw consent at any time. In a face to face interview with the surveyor on [DATE] at 12:00 PM Resident #2 stated s/he kind of knew the visitor and had no problems with him/her. In a face to face interview with the surveyor on [DATE] at 12:10 PM Licensed Practical Nurse (LPN) #2 stated the visitor, visited with other residents in the facility, s/he stated s/he worked Monday-Friday on the first shift and the visitor was at the facility. When asked by the surveyor if s/he had seen the visitor with Resident #1, s/he stated s/he would push her/him from the dining room to her/his room or sit in the dining room with her/him. Never saw him/her go in his/her room. In a face to face interview with the surveyor on [DATE] at 1:20 PM Certified Nurse Aide (CNA) #3 stated s/he saw the visitor once or twice sitting in the dining room, s/he noted nothing alarming. S/he stated the visitor visited with everybody. S/he stated Resident #1 did most of her/his ADLs (activities of daily living) by her/himself. In a face to face interview with the surveyor on [DATE] at 9:35 AM the Activities Assistant stated that the visitor first started coming to the facility when his/her aunt was a resident and that after the resident died s/he continued to visit other residents, s/he would bring residents to the dining room. S/he was in here often, outside with the men residents. Resident C and the visitor are outside a lot. When asked by the surveyor if there was anything unusual about his/her visits s/he stated that about a year ago s/he was speaking harshly to his/her aunt and the Administrator explained to him/her s/he couldn't speak that way. About a week ago there was a problem with a resident and chicken wings that the visitor had bought for her/him. When the visitor saw me s/he went the other way. In a face to face interview with the surveyor on [DATE] at 10:40 AM LPN #3 related an incident several months ago with a resident who expired in [DATE]; the visitor came down the hallway and the resident was at the nurses station, s/he said get away from me. LPN #3 stated s/he told the visitor to leave the resident alone. The visitor replied, Mind your own business. LPN #3 responded to the visitor that s/he was going to tell the Administrator and that s/he did. LPN #3 stated s/he never bother the resident again. In a face to face interview with the surveyor on [DATE] at 1:10 PM Resident C stated that s/he met the visitor at the facility and that s/he had an aunt who had passed away (2017) at the facility. Resident C stated the visitor offered to go to the store for him/her and that little by little other residents would ask him/her to go to the store for them. Resident C stated s/he believed in tipping, the visitor would always bring the change back, never had any problems with him/her. Review of the facility visitor's log for [DATE] indicated the visitor did not sign in on the log. In a telephone interview with the surveyor on [DATE] at 11:30 AM Resident #1's physician confirmed that the resident lacked decisional capacity. I doubt very seriously s/he could consent to sex. In a telephone interview with the surveyor on [DATE] at 1:05 PM the Investigator with the Sheriffs Department stated that the alleged perpetrator had been charged with Criminal Sexual Conduct 3rd. Degree and was in jail. It was determined on [DATE] at approximately 11:55 AM that Immediate Jeopardy and/or Substandard Quality of Care existed in the facility as of [DATE] related to complaint SC 949 in the following areas. The Administrator was notified of this determination at 12:15 PM. The deficiencies involved were as follows: 4[AGE].10(f)(4) Right to Receive/deny Visitors, F0563 was identified at Immediate Jeopardy at a scope and severity level of J. The facility failed to have a written policy to address visitors. Resident #1 was allegedly abused sexually by a visitor in the facility. 4[AGE].12 Freedom from Abuse, F0[AGE]0 was identified at Immediate Jeopardy and Substandard Quality of Care at a scope and severity level of J. The facility failed to ensure each resident remained free from abuse. Resident #1 was allegedly abused sexually by a visitor in the facility. 4[AGE].12(b) Develop/Implement Abuse/Neglect Policies, F0[AGE]7 was identified at Immediate Jeopardy and Substandard Quality of Care at a scope and severity level of J. The facility failed to implement written policies and procedures that prohibit and prevent abuse. Resident #1 was allegedly abused sexually by a visitor in the facility. The facility staff failed to protect the resident, by removing the alleged abuser from the resident care area. One of 3 residents reviewed for abuse. 4[AGE].70 Administration, F0[AGE]5 was identified at Immediate Jeopardy at a scope and severity level of J. The facility failed to be administered in a manner that enables it to use resources effectively and efficiently to attain or maintain the highest practicable physical , mental, and psychosocial well-being of each resident. Resident #1 was allegedly abused sexually by a visitor at the facility The facility provided an acceptable Allegation of Compliance (AOC) Resident #1 was assessed by a licensed nurse, the physician was notified and an order was received and resident was transported to the hospital and no longer resides in the facility. Residents who reside in the facility and were in contact with the identified visitor had the potential to be affected. The facility will interview all alert and oriented residents and complete body audits on all non-alert and oriented resident to observe for any signs of abuse. Staff were interviewed by the Administrator, Director of Nursing and nursing managers on [DATE] to determine which residents the identified visitor had interaction with and if it was in or out of the resident's room. Alert and oriented residents were interviewed by the Administrator, Director of Nursing and nursing managers to determine if any unwanted touching occurred or any witness to others. Residents with a BIM score of 12 or less were assessed by a registered nurse and no other concerns were identified. These assessments were completed on [DATE]. Interviews of all Alert and Oriented residents were completed by [DATE]. Those residents were educated to notify staff of any unusual or inappropriate behaviors or if they fell afraid or unsafe. All residents with a BIM score of 12 or less were assessed by a licensed nurse by [DATE]. No other concerns were identified. All residents in the facility will be educated by [DATE] on resident safety and notifying staff of any unusual or inappropriate behavior or if they feel threatened or afraid. On [DATE] a resident council meeting was held to discuss resident safety and to notify staff of any unusual or inappropriate behavior or if they feel threatened or afraid. Facility staff was educated by the Staff Development Coordinator, the Director of Nursing and the Administrator on the following: *Facility staff was re-educated on Abuse, Neglect, Misappropriation and Exploitation including preventing, recognizing, reporting abuse, neglect, exploitation, and mistreatment and protecting the residents. *The identification of residents who should not have visitors without notification of Responsible Party. *Notation will be made in Medication Administration Record [REDACTED]. *Social Service Director will identify and maintain a list of residents with cognitive impairments. Cognitive impairment will be determined by either an incapacitation order by a court of law or a lack of decisional capacity by two physicians. *Visitor sign in log process - any visitor entering facility will sign in on log which includes the visitor name, the date, the resident being visited and relationship and will be given a visitor sticker. Visitors will sign out upon exit from the facility. From 4 PM to 8 AM and on weekends the doors are locked, visitors will ring the doorbell and staff member answering door will have visitor sign log and issue a visitor sticker. The re-education will be completed by [DATE]. Any staff member not receiving this education by this date will receive prior to next scheduled shift. This information will be presented in New Hire Orientation. A visitor sign in log and the process of issuing a visitor sticker will be implemented by [DATE]. Letters regarding the visitor sign in log and notification of anything suspicious to charge nurse will be mailed out on [DATE] by the Administrator. CNA (certified nurse aide) #1 and #2 who were agency CNAs have not been back to the facility to work since the incident. The staffing agency will be notified on [DATE] to no longer send them to the facility. The facility will report the two CNAs to DHEC as a possible abuse incident. LPN (licensed practical nurse) #1 will receive corrective action failing to ensure the resident's safety on [DATE]. This LPN will be reported to SC LLR on [DATE]. An ad hoc Quality Assurance Performance Improvement Committee Meeting was held on [DATE] and Medical Director was informed the immediate jeopardy and the content of this plan. Allegation of Compliance (AOC) [DATE] Observations, interviews, and review of the Allegation of Compliance (AOC) submitted by the facility on [DATE] revealed the implementation of the AOC and that it was in practice removing the immediacy of the deficient practice. Facility nursing staff had been educated and was knowledgeable of the new visitors procedure, abuse policy and the importance of protecting the residents. The Administrator was informed of this on [DATE] at approximately 3:30 PM. The Immediate Jeopardy at F0563, F0[AGE]0 and F0[AGE]7 was removed but the citations remained at a lower scope and severity of D.",2020-09-01
243,MAGNOLIA MANOR - INMAN,425032,63 BLACKSTOCK ROAD,INMAN,SC,29349,2018-09-13,600,J,1,0,FNQ411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of a facility reportable, record review and interviews, the facility failed to ensure each resident remained free from abuse. The facility reported an allegation of sexual abuse of Resident #1 by a visitor at the facility. The facility failed to prevent the abuse. One of 3 residents reviewed for abuse. The findings included. Resident #1 was reviewed for alleged sexual abuse following a facility reported incident received by the State Agency. Resident #1 admitted to the facility with [DIAGNOSES REDACTED]. The Admission Minimum Data Set assessment dated [DATE], indicated the resident's BI[CONDITION] (brief interview of mental status) score as 9. S/he required assistance of one person with activities of daily living, setup help with eating; s/he used a wheelchair for long distance ambulation. S/he could walk short distances. The resident was occasionally incontinent of bladder and frequently incontinent of bowel. Further review of the medical record revealed a facility form Addressing Decisional Capacity signed by one physician on 09/04/2018 that stated, This patient DOES NOT meet all the criteria for decisional capacity, therefore is not able to make healthcare decisions for self. Furthermore, it is my opinion that due to the patient's medical condition(s), this lack of capacity is not likely to change in the immediate future. Review of the facility 5 Day Follow up investigation indicated that on 09/08/2018 two Certified Nurse Aide (CNA) #1 and #2 entered the room of Resident #1. They asked what the perpetrator was doing. The perpetrator responded that they were okay. The perpetrator had shorts on with the front opened.penis was not exposed. The CNAs immediately got the nurse who questioned the visitor who identified himself and stated he had known the resident for a long time. The social worker questioned the visitor who stated the resident asked him to hump her. The resident stated the visitor was her man, but did not know his name. The social worker removed the visitor from the room and sat him at the nurses station to be supervised until authorities arrived. In a telephone interview with the surveyor on 09/12/2018 at 11:40 AM Licensed Practical Nurse (LPN) #1 stated s/he was two doors down from Resident#1's room when two CNAs came to me running and stated, they are having sex. Running back that way (all of us) we burst in the room, pushing door open. The surveyor asked if the door was closed, LPN #1 responded, Yes. S/he stated that the CNAs pulled the door closed and ran toward her/him. The surveyor asked LPN #1 what s/he saw when s/he entered the room, her laying flat on bed, visitor sitting on side of bed with back to door, s/he was saying, 'I told you they don't like this here.' S/he moved from bed to the chair and was facing the staff. I was asking her/him if s/he was ok, s/he was confused. The visitor said we're ok. I asked him/her how s/he knew the resident? The visitor stated, 'We go way back, just friends. I knew her/him before s/he came here.' The resident said, 'That's my man'. S/he started trying to get up, s/he was undressed from waist down. LPN #1 stated that s/he told them s/he was going to call Resident #1's family. The visitor stated, 'ok to call family.' LPN #1 stated s/he stepped out in the hall to call the DON (director of nursing) and Administrator. The visitor was still in the room, left door open, CNAs might have stayed. I don't remember closing the door. The Social Worker came in just a few minutes and took over. S/he brought the visitor out of the room to the desk. LPN #1 stated that s/he had never seen the visitor and Resident #1 together before the incident. In a telephone interview with the surveyor on 09/12/2018 at 10:05 AM Certified Nurse Aide (CNA) #1 was asked by the surveyor about the incident with Resident #1 that occurred on 09/08/2018 while the CNA was working on Unit 3. CNA #1 stated s/he was the first person to find Resident #1 and the visitor between 1:30 and 2:00 PM. I was assigned both residents in the room. Resident #1's roommate was outside in smoking area. S/he stated s/he saw the visitor on top of Resident #1, with pants open. S/he was moving and had hands down in private area. CNA #1 asked the visitor what was going on and the visitor responded, 'we good.' I said no you're not and called the nurse. When asked by the surveyor what s/he did CNA #1 stated that s/he pulled the door up and stepped out and called LPN #1 who was two doors away. When LPN #1 was coming toward me, I opened the door and the visitor was getting back on bed. CNA #2 and LPN #1 were behind me when I opened the door. We went in, CNA #2 didn't. CNA #1 stated s/he stood outside the door with it cracked and watched the visitor, standing on the side of the bed. The social worker came in a few minutes. When asked by the surveyor what the visitor was wearing, CNA #1 stated blue jean shorts. In a telephone interview with the surveyor on 09/12/2018 at 9:15 AM the Social Worker was read a facility obtained statement and s/he confirmed s/he had given the information to the facility. The Social Worker confirmed s/he entered Resident #1's room and the visitor was in the room, with clothes up. The visitor was in bed beside the resident, hand under the blanket holding the resident's hand. The Social Worker stated the staff was at the door when s/he arrived, the door was closed, we knocked'. No one was in the room just the two of them. When asked by the surveyor what was the time, the Social Worker stated about 2:10 PM. The Social Worker stated s/he directed the visitor to the nurses station and two staff stayed with the visitor until the police arrived, at that time the visitor was taken to the facility business office, about 2:30 PM. The Social Worker stated that when s/he first arrived on Unit 3, after asking the visitor to come out of the room, s/he directed the nurse to do a body audit. S/he stated that s/he attempted to call the Director of Nursing and the Administrator, s/he spoke with the corporate clinical nurse. S/he asked one of the nurses to call the Sheriffs Department. S/he stated the resident was unable to tell what occurred and was rambling about stuff that was not related to the questions asked. In a face-to-face interview with the surveyor on 09/13/2018 at 3:00 PM the Social Work Assistant stated that s/he entered the room with the Social Worker and that two CNAs were standing outside the door. The door was closed, knocked and went in. The visitor was lying on the bed with the resident, the Social Worker told the visitor to get up and s/he took him/her out of the room. The Social Work Assistant stated that s/he stayed in the room with Resident #1 several minutes, during the time s/he was in the room the resident just mumbled. I walked out of the room and stayed with the visitor until we took him/her to the business office/reception area. Two CNAs watched the visitor until the police arrived. I walked back to Unit 3 and the resident was on the stretcher to go out. I asked her/him if s/he was alright. S/he said, 'Yes baby'. Review of the Daily Skilled Nurse's Note dated 09/08/18 stated, Around 2 PM a male visitor was reported to be in res. (resident) room. Nurse went in to res. room and observed male on bed side stating, 'I told you they don't like you doing this in here'. Res. asked nurse, 'So ya'll don't let people do this in your restaurant?' Nurse observed res. undressed from waist down, visitor moved to sit in chair beside bed and states, it's ok, we been knowing each other for a long time before she came in here. CNAs at room with nurse res. states she is ok. 2:15 PM Nurse starts attempting to call management. 2:20 PM Soc. Svc. (social service) came to floor removed visitor to sit at nurse station while continuing to call management. 2:30 PM visitor taken to front office to wait for management and police dept. (department) to arrive. 3 PM staff continues to monitor res. call placed to MD (medical doctor), order given to send to ER (emergency room ) for eval. (evaluation). RP (responsible party) number one called multiple times. Party denies knowing res. but agrees number is correct. Between 3:30 and 4 PM statement given to police dept. res. leaving for ER with clothing and bedding in use sent with res. Attempt to call RP #2 spoke with at around 7:50 PM after several attempts. RP states he is in route to [STATE] to see mother when attempt to inform RP he states hospital had called and informed him of what happened. RP was told visitor stated he had been her friend for a long time before she came here. RP states that is not true 'My mother knows no one in the area'. RP then states 'the hospital is calling me and I need to answer it, thank you.' and hangs up the phone. Late entry - body audit completed at 220 PM no areas of concern were noted. Review of the Medical Record revealed a Physician order [REDACTED]. Further review revealed a SBAR (Situation, Background, Assessment, Recommendation) Communication Form dated 09/08/2018 that showed the physician was notified and the Res (resident) sent to ER (emergency room ) for rape test kit to be performed. And to eval (evaluate) for further tx (treatment) as needed. In a face to face interview with the surveyor on 09/11/2018 at approximately 10:45 AM the Administrator stated that Resident #1 was no longer at the facility. S/he stated the resident was admitted to the hospital and s/he was not sure where s/he was right now, s/he stated the resident wasn't coming back. In a telephone interview with the surveyor on 09/12/2018 at 11:30 AM Resident #1's physician confirmed that the resident lacked decisional capacity. I doubt very seriously s/he could consent to sex. In a telephone interview with the surveyor on 09/18/2018 at 1:05 PM the Investigator with the Sheriffs Department stated that the alleged perpetrator had been charged with Criminal Sexual Conduct 3rd. Degree and was in jail. It was determined on September 12, 2018 at approximately 11:55 AM that Immediate Jeopardy and/or Substandard Quality of Care existed in the facility as of September 08, 2018 related to complaint SC 949 in the following areas. The Administrator was notified of this determination at 12:15 PM. The deficiencies involved were as follows: 4[AGE].10(f)(4) Right to Receive/deny Visitors, F0563 was identified at Immediate Jeopardy at a scope and severity level of J. The facility failed to have a written policy to address visitors. Resident #1 was allegedly abused sexually by a visitor in the facility. 4[AGE].12 Freedom from Abuse, F0[AGE]0 was identified at Immediate Jeopardy and Substandard Quality of Care at a scope and severity level of J. The facility failed to ensure each resident remained free from abuse. Resident #1 was allegedly abused sexually by a visitor in the facility. 4[AGE].12(b) Develop/Implement Abuse/Neglect Policies, F0[AGE]7 was identified at Immediate Jeopardy and Substandard Quality of Care at a scope and severity level of J. The facility failed to implement written policies and procedures that prohibit and prevent abuse. Resident #1 was allegedly abused sexually by a visitor in the facility. The facility staff failed to protect the resident, by removing the alleged abuser from the resident care area. 4[AGE].70 Administration, F0[AGE]5 was identified at Immediate Jeopardy at a scope and severity level of J. The facility failed to be administered in a manner that enables it to use resources effectively and efficiently to attain or maintain the highest practicable physical , mental, and psychosocial well-being of each resident. Resident #1 was allegedly abused sexually by a visitor at the facility The facility provided an acceptable Allegation of Compliance (AOC) Resident #1 was assessed by a licensed nurse, the physician was notified and an order was received and resident was transported to the hospital and no longer resides in the facility. Residents who reside in the facility and were in contact with the identified visitor had the potential to be affected. The facility will interview all alert and oriented residents and complete body audits on all non-alert and oriented resident to observe for any signs of abuse. Staff were interviewed by the Administrator, Director of Nursing and nursing managers on 9/10/2018 to determine which residents the identified visitor had interaction with and if it was in or out of the resident's room. Alert and oriented residents were interviewed by the Administrator, Director of Nursing and nursing managers to determine if any unwanted touching occurred or any witness to others. Residents with a BIM score of 12 or less were assessed by a registered nurse and no other concerns were identified. These assessments were completed on 9/10/2018. Interviews of all Alert and Oriented residents were completed by 9/13/18. Those residents were educated to notify staff of any unusual or inappropriate behaviors or if they fell afraid or unsafe. All residents with a BIM score of 12 or less were assessed by a licensed nurse by 9/13/18. No other concerns were identified. All residents in the facility will be educated by 9/13/18 on resident safety and notifying staff of any unusual or inappropriate behavior or if they feel threatened or afraid. On 9/11/2018 a resident council meeting was held to discuss resident safety and to notify staff of any unusual or inappropriate behavior or if they feel threatened or afraid. Facility staff was educated by the Staff Development Coordinator, the Director of Nursing and the Administrator on the following: *Facility staff was re-educated on Abuse, Neglect, Misappropriation and Exploitation including preventing, recognizing, reporting abuse, neglect, exploitation, and mistreatment and protecting the residents. *The identification of residents who should not have visitors without notification of Responsible Party. *Notation will be made in Medication Administration Record [REDACTED]. *Social Service Director will identify and maintain a list of residents with cognitive impairments. Cognitive impairment will be determined by either an incapacitation order by a court of law or a lack of decisional capacity by two physicians. *Visitor sign in log process - any visitor entering facility will sign in on log which includes the visitor name, the date, the resident being visited and relationship and will be given a visitor sticker. Visitors will sign out upon exit from the facility. From 4 PM to 8 AM and on weekends the doors are locked, visitors will ring the doorbell and staff member answering door will have visitor sign log and issue a visitor sticker. The re-education will be completed by 9/13/18. Any staff member not receiving this education by this date will receive prior to next scheduled shift. This information will be presented in New Hire Orientation. A visitor sign in log and the process of issuing a visitor sticker will be implemented by 9/13/18. Letters regarding the visitor sign in log and notification of anything suspicious to charge nurse will be mailed out on 9/13/18 by the Administrator. CNA (certified nurse aide) #1 and #2 who were agency CNAs have not been back to the facility to work since the incident. The staffing agency will be notified on 9/13/19 to no longer send them to the facility. The facility will report the two CNAs to DHEC as a possible abuse incident. LPN (licensed practical nurse) #1 will receive corrective action failing to ensure the resident's safety on 9/13/18. This LPN will be reported to SC LLR on 9/13/18. An ad hoc Quality Assurance Performance Improvement Committee Meeting was held on [DATE] and Medical Director was informed the immediate jeopardy and the content of this plan. Allegation of Compliance (AOC) September 13, 2018 Observations, interviews, and review of the Allegation of Compliance (AOC) submitted by the facility on September 13, 2018 revealed the implementation of the AOC and that it was in practice removing the immediacy of the deficient practice. Facility nursing staff had been educated and was knowledgeable of the new visitors procedure, abuse policy and the importance of protecting the residents. The Administrator was informed of this on September 13, 2018 at approximately 3:30 PM. The Immediate Jeopardy at F0563, F0[AGE]0, F0[AGE]7 and F0[AGE]5 was removed but the citations remained at a lower scope and severity of D.",2020-09-01
244,MAGNOLIA MANOR - INMAN,425032,63 BLACKSTOCK ROAD,INMAN,SC,29349,2018-09-13,607,J,1,0,FNQ411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of a facility reportable, record review, interviews and the Leadership Policies and Procedures (Abuse, Neglect, and Misappropriation of Property), the facility failed to implement written policies and procedures that prohibit and prevent abuse. The facility reported an allegation of sexual abuse of Resident #1 by a visitor at the facility. The facility staff failed to protect the resident, by removing the alleged abuser from the resident care area. One of 3 residents reviewed for abuse. The findings included. Resident #1 was reviewed for alleged sexual abuse following a facility reported incident received by the State Agency. Resident #1 admitted to the facility with [DIAGNOSES REDACTED]. The Admission Minimum Data Set assessment dated [DATE], indicated the resident's BI[CONDITION] (brief interview of mental status) score as 9. Review of the medical record revealed a facility form Addressing Decisional Capacity signed by one physician on 09/04/2018 that stated, This patient DOES NOT meet all the criteria for decisional capacity, therefore is not able to make healthcare decisions for self. Furthermore, it is my opinion that due to the patient's medical condition(s), this lack of capacity is not likely to change in the immediate future. Review of the facility 5 Day Follow up investigation indicated that on 09/08/2018 two Certified Nurse Aide (CNA) #1 and #2 entered the room of Resident #1. They asked what the perpetrator was doing. The perpetrator responded that they were okay. The perpetrator had shorts on with the front opened.penis was not exposed. The CNAs immediately got the nurse who questioned the visitor who identified himself and stated he had known the resident for a long time. The social worker questioned the visitor who stated the resident asked him to hump her. The resident stated the visitor was her man, but did not know his name. The social worker removed the visitor from the room and sat him at the nurses station to be supervised until authorities arrived. In a telephone interview with the surveyor on 09/12/2018 at 11:40 AM Licensed Practical Nurse (LPN) #1 stated s/he was two doors down from Resident#1's room when two CNAs came to me running and stated, they are having sex. Running back that way (all of us) we burst in the room, pushing door open. The surveyor asked if the door was closed, LPN #1 responded, Yes. S/he stated that the CNAs pulled the door closed and ran toward her/him. The surveyor asked LPN #1 what s/he saw when s/he entered the room, her laying flat on bed, visitor sitting on side of bed with back to door, s/he was saying, 'I told you they don't like this here.' S/he moved from bed to the chair and was facing the staff. I was asking her/him if s/he was ok, s/he was confused. The visitor said we're ok. I asked him/her how s/he knew the resident? The visitor stated, 'We go way back, just friends. I knew her/him before s/he came here.' The resident said, 'That's my man'. S/he started trying to get up, s/he was undressed from waist down. LPN #1 stated that s/he told them s/he was going to call Resident #1's family. The visitor stated, 'ok to call family.' LPN #1 stated s/he stepped out in the hall to call the DON (director of nursing) and Administrator. The visitor was still in the room, left door open, CNAs might have stayed. I don't remember closing the door. The Social Worker came in just a few minutes and took over. S/he brought the visitor out of the room to the desk. LPN #1 stated that s/he had never seen the visitor and Resident #1 together before the incident. In a telephone interview with the surveyor on 09/12/2018 at 10:05 AM Certified Nurse Aide (CNA) #1 was asked by the surveyor about the incident with Resident #1 that occurred on 09/08/2018 while the CNA was working on Unit 3. CNA #1 stated s/he was the first person to find Resident #1 and the visitor between 1:30 and 2:00 PM. I was assigned both residents in the room. Resident #1's roommate was outside in smoking area. S/he stated s/he saw the visitor on top of Resident #1, with pants open. S/he was moving and had hands down in private area. CNA #1 asked the visitor what was going on and the visitor responded, 'we good.' I said no you're not and called the nurse. When asked by the surveyor what s/he did CNA #1 stated that s/he pulled the door up and stepped out and called LPN #1 who was two doors away. When LPN #1 was coming toward me, I opened the door and the visitor was getting back on bed. CNA #2 and LPN #1 were behind me when I opened the door. We went in, CNA #2 didn't. CNA #1 stated s/he stood outside the door with it cracked and watched the visitor, standing on the side of the bed. The social worker came in a few minutes. When asked by the surveyor what the visitor was wearing, CNA #1 stated blue jean shorts. In a telephone interview with the surveyor on 09/12/2018 at 9:15 AM the Social Worker was read a facility obtained statement and s/he confirmed s/he had given the information to the facility. The Social Worker confirmed s/he entered Resident #1's room and the visitor was in the room, with clothes up. The visitor was in bed beside the resident, hand under the blanket holding the resident's hand. The Social Worker stated the staff was at the door when s/he arrived, the door was closed, we knocked'. No one was in the room just the two of them. When asked by the surveyor what was the time, the Social Worker stated about 2:10 PM. The Social Worker stated s/he directed the visitor to the nurses station and two staff stayed with the visitor until the police arrived, at that time the visitor was taken to the facility business office, about 2:30 PM. The Social Worker stated that when s/he first arrived on Unit 3, after asking the visitor to come out of the room, s/he directed the nurse to do a body audit. S/he stated that s/he attempted to call the Director of Nursing and the Administrator, s/he spoke with the corporate clinical nurse. S/he asked one of the nurses to call the Sheriffs Department. S/he stated the resident was unable to tell what occurred and was rambling about stuff that was not related to the questions asked. Review of the Medical Record revealed a Physician order [REDACTED]. Further review revealed a SBAR (Situation, Background, Assessment, Recommendation) Communication Form dated 09/08/2018 that showed the physician was notified and the Res (resident) sent to ER (emergency room ) for rape test kit to be performed. And to eval (evaluate) for further tx (treatment) as needed. In a telephone interview with the surveyor on 09/12/2018 at 11:30 AM Resident #1's physician confirmed that the resident lacked decisional capacity. I doubt very seriously s/he could consent to sex. In a telephone interview with the surveyor on 09/18/2018 at 1:05 PM the Investigator with the Sheriffs Department stated that the alleged perpetrator had been charged with Criminal Sexual Conduct 3rd. Degree and was in jail. Review of the facility Leadership Policies and Procedures, Section III: Organizational Ethics, Subject: Abuse, Neglect, Exploitation, or Mistreatment; page 5.Component VII: Protection 1. During the investigation, the facility protects the patient/resident, as appropriate, including but not limited to the following: A. Removal of the alleged abuser from the patient/resident care setting. It was determined on September 12, 2018 at approximately 11:55 AM that Immediate Jeopardy and/or Substandard Quality of Care existed in the facility as of September 08, 2018 related to complaint SC 949 in the following areas. The Administrator was notified of this determination at 12:15 PM. The deficiencies involved were as follows: 4[AGE].10(f)(4) Right to Receive/deny Visitors, F0563 was identified at Immediate Jeopardy at a scope and severity level of J. The facility failed to have a written policy to address visitors. Resident #1 was allegedly abused sexually by a visitor in the facility. 4[AGE].12 Freedom from Abuse, F0[AGE]0 was identified at Immediate Jeopardy and Substandard Quality of Care at a scope and severity level of J. The facility failed to ensure each resident remained free from abuse. Resident #1 was allegedly abused sexually by a visitor in the facility. 4[AGE].12(b) Develop/Implement Abuse/Neglect Policies, F0[AGE]7 was identified at Immediate Jeopardy and Substandard Quality of Care at a scope and severity level of J. The facility failed to implement written policies and procedures that prohibit and prevent abuse. Resident #1 was allegedly abused sexually by a visitor in the facility. The facility staff failed to protect the resident, by removing the alleged abuser from the resident care area. One of 3 residents reviewed for abuse. 4[AGE].70 Administration, F0[AGE]5 was identified at Immediate Jeopardy at a scope and severity level of J. The facility failed to be administered in a manner that enables it to use resources effectively and efficiently to attain or maintain the highest practicable physical , mental, and psychosocial well-being of each resident. Resident #1 was allegedly abused sexually by a visitor at the facility The facility provided an acceptable Allegation of Compliance (AOC) Resident #1 was assessed by a licensed nurse, the physician was notified and an order was received and resident was transported to the hospital and no longer resides in the facility. Residents who reside in the facility and were in contact with the identified visitor had the potential to be affected. The facility will interview all alert and oriented residents and complete body audits on all non-alert and oriented resident to observe for any signs of abuse. Staff were interviewed by the Administrator, Director of Nursing and nursing managers on 9/10/2018 to determine which residents the identified visitor had interaction with and if it was in or out of the resident's room. Alert and oriented residents were interviewed by the Administrator, Director of Nursing and nursing managers to determine if any unwanted touching occurred or any witness to others. Residents with a BIM score of 12 or less were assessed by a registered nurse and no other concerns were identified. These assessments were completed on 9/10/2018. Interviews of all Alert and Oriented residents were completed by 9/13/18. Those residents were educated to notify staff of any unusual or inappropriate behaviors or if they fell afraid or unsafe. All residents with a BIM score of 12 or less were assessed by a licensed nurse by 9/13/18. No other concerns were identified. All residents in the facility will be educated by 9/13/18 on resident safety and notifying staff of any unusual or inappropriate behavior or if they feel threatened or afraid. On 9/11/2018 a resident council meeting was held to discuss resident safety and to notify staff of any unusual or inappropriate behavior or if they feel threatened or afraid. Facility staff was educated by the Staff Development Coordinator, the Director of Nursing and the Administrator on the following: *Facility staff was re-educated on Abuse, Neglect, Misappropriation and Exploitation including preventing, recognizing, reporting abuse, neglect, exploitation, and mistreatment and protecting the residents. *The identification of residents who should not have visitors without notification of Responsible Party. *Notation will be made in Medication Administration Record [REDACTED]. *Social Service Director will identify and maintain a list of residents with cognitive impairments. Cognitive impairment will be determined by either an incapacitation order by a court of law or a lack of decisional capacity by two physicians. *Visitor sign in log process - any visitor entering facility will sign in on log which includes the visitor name, the date, the resident being visited and relationship and will be given a visitor sticker. Visitors will sign out upon exit from the facility. From 4 PM to 8 AM and on weekends the doors are locked, visitors will ring the doorbell and staff member answering door will have visitor sign log and issue a visitor sticker. The re-education will be completed by 9/13/18. Any staff member not receiving this education by this date will receive prior to next scheduled shift. This information will be presented in New Hire Orientation. A visitor sign in log and the process of issuing a visitor sticker will be implemented by 9/13/18. Letters regarding the visitor sign in log and notification of anything suspicious to charge nurse will be mailed out on 9/13/18 by the Administrator. CNA (certified nurse aide) #1 and #2 who were agency CNAs have not been back to the facility to work since the incident. The staffing agency will be notified on 9/13/19 to no longer send them to the facility. The facility will report the two CNAs to DHEC as a possible abuse incident. LPN (licensed practical nurse) #1 will receive corrective action failing to ensure the resident's safety on 9/13/18. This LPN will be reported to SC LLR on 9/13/18. An ad hoc Quality Assurance Performance Improvement Committee Meeting was held on [DATE] and Medical Director was informed the immediate jeopardy and the content of this plan. Allegation of Compliance (AOC) September 13, 2018 Observations, interviews, and review of the Allegation of Compliance (AOC) submitted by the facility on September 13, 2018 revealed the implementation of the AOC and that it was in practice removing the immediacy of the deficient practice. Facility nursing staff had been educated and was knowledgeable of the new visitors procedure, abuse policy and the importance of protecting the residents. The Administrator was informed of this on September 13, 2018 at approximately 3:30 PM. The Immediate Jeopardy at F0563, F0[AGE]0, F0[AGE]7 and F0[AGE]5 was removed but the citations remained at a lower scope and severity of D.",2020-09-01
245,MAGNOLIA MANOR - INMAN,425032,63 BLACKSTOCK ROAD,INMAN,SC,29349,2018-09-13,835,J,1,0,FNQ411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility [MEDICATION NAME], record review, interviews and review of policies and procedures, the facility failed to be administered in a manner that enables it to use resources effectively and efficiently to attain or maintain the highest practicable physical , mental, and psychosocial well-being of each resident. Resident #1 was allegedly abused sexually by a visitor at the facility. The facility failed to prevent the abuse. One of 3 residents reviewed for abuse. The findings included. Resident #1 was reviewed for alleged sexual abuse following a facility reported incident received by the State Agency. Resident #1 admitted to the facility with [DIAGNOSES REDACTED]. The Admission Minimum Data Set assessment dated [DATE], indicated the resident's BI[CONDITION] (brief interview of mental status) score as 9. Review of the medical record revealed a facility form Addressing Decisional Capacity signed by one physician on [DATE] that stated, This patient DOES NOT meet all the criteria for decisional capacity, therefore is not able to make healthcare decisions for self. Furthermore, it is my opinion that due to the patient's medical condition(s), this lack of capacity is not likely to change in the immediate future. Review of the facility 5 Day Follow up investigation indicated that on [DATE] two Certified Nurse Aide (CNA) #1 and #2 entered the room of Resident #1. They asked what the visitor was doing. The visitor responded that they were okay. The visitor had shorts on with the front opened.penis was not exposed. The CNAs immediately got the nurse who questioned the visitor who identified himself and stated he had known the resident for a long time. The social worker questioned the visitor who stated the resident asked him to hump her. The resident stated the visitor was her man, but did not know his name. The social worker removed the visitor from the room and sat him at the nurses station to be supervised until authorities arrived. In a telephone interview with the surveyor on [DATE] at 11:40 AM Licensed Practical Nurse (LPN) #1 stated s/he was two doors down from Resident#1's room when two CNAs came to me running and stated, they are having sex. Running back that way (all of us) we burst in the room, pushing door open. The surveyor asked if the door was closed, LPN #1 responded, Yes. S/he stated that the CNAs pulled the door closed and ran toward her/him. The surveyor asked LPN #1 what s/he saw when s/he entered the room, her laying flat on bed, visitor sitting on side of bed with back to door, s/he was saying, 'I told you they don't like this here.' S/he moved from bed to the chair and was facing the staff. I was asking her/him if s/he was ok, s/he was confused. The visitor said we're ok. I asked him/her how s/he knew the resident? The visitor stated, 'We go way back, just friends. I knew her/him before s/he came here.' The resident said, 'That's my man'. S/he started trying to get up, s/he was undressed from waist down. LPN #1 stated that s/he told them s/he was going to call Resident #1's family. The visitor stated, 'ok to call family.' LPN #1 stated s/he stepped out in the hall to call the DON (director of nursing) and Administrator. The visitor was still in the room, left door open, CNAs might have stayed. I don't remember closing the door. The Social Worker came in just a few minutes and took over. S/he brought the visitor out of the room to the desk. LPN #1 stated that s/he had never seen the visitor and Resident #1 together before the incident. In a telephone interview with the surveyor on [DATE] at 10:05 AM Certified Nurse Aide (CNA) #1 was asked by the surveyor about the incident with Resident #1 that occurred on [DATE] while the CNA was working on Unit 3. CNA #1 stated s/he was the first person to find Resident #1 and the visitor between 1:30 and 2:00 PM. I was assigned both residents in the room. Resident #1's roommate was outside in smoking area. S/he stated s/he saw the visitor on top of Resident #1, with pants open. S/he was moving and had hands down in private area. CNA #1 asked the visitor what was going on and the visitor responded, 'we good.' I said no you're not and called the nurse. When asked by the surveyor what s/he did CNA #1 stated that s/he pulled the door up and stepped out and called LPN #1 who was two doors away. When LPN #1 was coming toward me, I opened the door and the visitor was getting back on bed. CNA #2 and LPN #1 were behind me when I opened the door. We went in, CNA #2 didn't. CNA #1 stated s/he stood outside the door with it cracked and watched the visitor, standing on the side of the bed. The social worker came in a few minutes. When asked by the surveyor what the visitor was wearing, CNA #1 stated blue jean shorts. In a telephone interview with the surveyor on [DATE] at 9:15 AM the Social Worker was read a facility obtained statement and s/he confirmed s/he had given the information to the facility. The Social Worker confirmed s/he entered Resident #1's room and the visitor was in the room, with clothes up. The visitor was in bed beside the resident, hand under the blanket holding the resident's hand. The Social Worker stated the staff was at the door when s/he arrived, the door was closed, we knocked'. No one was in the room just the two of them. When asked by the surveyor what was the time, the Social Worker stated about 2:10 PM. The Social Worker stated s/he directed the visitor to the nurses station and two staff stayed with the visitor until the police arrived, at that time the visitor was taken to the facility business office, about 2:30 PM. The Social Worker stated that when s/he first arrived on Unit 3, after asking the visitor to come out of the room, s/he directed the nurse to do a body audit. S/he stated that s/he attempted to call the Director of Nursing and the Administrator, s/he spoke with the corporate clinical nurse. S/he asked one of the nurses to call the Sheriffs Department. S/he stated the resident was unable to tell what occurred and was rambling about stuff that was not related to the questions asked. In a face-to-face interview with the surveyor on [DATE] at 3:00 PM the Social Work Assistant stated that s/he entered the room with the Social Worker and that two CNAs were standing outside the door. The door was closed, knocked and went in. The visitor was lying on the bed with the resident, the Social Worker told the visitor to get up and s/he took him/her out of the room. The Social Work Assistant stated that s/he stayed in the room with Resident #1 several minutes, during the time s/he was in the room the resident just mumbled. I walked out of the room and stayed with the visitor until we took him/her to the business office/reception area. Two CNAs watched the visitor until the police arrived. I walked back to Unit 3 and the resident was on the stretcher to go out. I asked her/him if s/he was alright. S/he said, 'Yes baby'. The Social Work Assistant stated that the visitor's aunt had been in the facility for sometime and the s/he had never received any complaints about him/her. Review of the Daily Skilled Nurse's Note dated [DATE] stated, Around 2 PM a male visitor was reported to be in res. (resident) room. Nurse went in to res. room and observed male on bed side stating, 'I told you they don't like you doing this in here'. Res. asked nurse, 'So ya'll don't let people do this in your restaurant?' Nurse observed res. undressed from waist down, visitor moved to sit in chair beside bed and states, it's ok, we been knowing each other for a long time before she came in here. CNAs at room with nurse res. states she is ok. 2:15 PM Nurse starts attempting to call management. 2:20 PM Soc. Svc. (social service) came to floor removed visitor to sit at nurse station while continuing to call management. 2:30 PM visitor taken to front office to wait for management and police dept. (department) to arrive. 3 PM staff continues to monitor res. call placed to MD (medical doctor), order given to send to ER (emergency room ) for eval. (evaluation). RP (responsible party) number one called multiple times. Party denies knowing res. but agrees number is correct. Between 3:30 and 4 PM statement given to police dept. res. leaving for ER with clothing and bedding in use sent with res. Attempt to call RP #2 spoke with at around 7:50 PM after several attempts. RP states s/he is in route to [STATE] to see mother when attempt to inform RP s/he states hospital had called and informed him/her of what happened. RP was told visitor stated s/he had been her/his friend for a long time before s/he came here. RP states that is not true 'My mother knows no one in the area'. RP then states 'the hospital is calling me and I need to answer it, thank you.' and hangs up the phone. Review of the Medical Record revealed a Physician order [REDACTED]. Further review revealed a SBAR (Situation, Background, Assessment, Recommendation) Communication Form dated [DATE] that showed the physician was notified and the Res (resident) sent to ER (emergency room ) for rape test kit to be performed. And to eval (evaluate) for further tx (treatment) as needed. In a face to face interview with the surveyor on [DATE] at approximately 10:50 AM the Director of Nursing (DON) stated they have a sign in/out log that people sign and that the doors are locked from 4:00 PM until 8:00 AM Monday-Friday and at all times on the weekend. Visitors have to ring the door bell to gain access to the facility during times when the doors are locked. The surveyor asked the DON if s/he had seen the visitor at the facility before, s/he stated that s/he had seen him/her generally visiting with Resident C. Sometimes s/he would sit with Resident C for haircut, thought s/he was a son. The surveyor asked if the DON noticed any impairment of the visitor, s/he stated the only thing s/he noticed was a cigarette smoke odor. In a face to face interview with the Administrator on [DATE] s/he stated they did not have a policy and procedure regarding the visitation rights of residents. When asked how they determined who visited resident with cognitive impairments the Administrator said they do not have a policy and procedure. S/he provided an Access and Visitation Rights from the facility Admission Packet that stated, Each resident has the right to receive visitors of his/her choosing and designation (including but not limited to a spouse of the same or opposite sex, domestic partner (of the same or opposite sex), another family member or friend, subject to the resident's right to deny visitation when applicable. The facility must provide access to any resident by (1) any representative of the Secretary, (2) Any representative of the State. (3) Any representative of the Office of the State long term care ombudsman. (4) the resident's individual physician. (5) any representative of the protection and advocacy system (5) any representative of the agency responsible for the protection and advocacy system for individuals with a mental disorder, and (6) the resident representative. The facility must provide immediate access to a resident by immediate family and other relatives, and reasonable access by any entity or individual that provides health, social, legal or other services to the resident, all of which are subject to the resident's right to deny or withdraw consent at any time. In a face to face interview with the surveyor on [DATE] at 9:35 AM the Activities Assistant stated that the visitor first started coming to the facility when his/her aunt was a resident and that after the resident died s/he continued to visit other residents, s/he would bring residents to the dining room. S/he was in here often, outside with the men residents. Resident C and the visitor are outside a lot. When asked by the surveyor if there was anything unusual about his/her visits s/he stated that about a year ago s/he was speaking harshly to his/her aunt and the Administrator explained to him/her s/he couldn't speak that way. About a week ago there was a problem with a resident and chicken wings that the visitor had bought for her/him. When the visitor saw me s/he went the other way. In a face to face interview with the surveyor on [DATE] at 10:40 AM LPN #3 related an incident several months ago with a resident who expired in [DATE]; the visitor came down the hallway and the resident was at the nurses station, s/he said get away from me. LPN #3 stated s/he told the visitor to leave the resident alone. The visitor replied, Mind your own business. LPN #3 responded to the visitor that s/he was going to tell the Administrator and that s/he did. LPN #3 stated s/he never bother the resident again. Review of the facility visitor's log for [DATE] indicated the visitor did not sign in on the log. In a telephone interview with the surveyor on [DATE] at 11:30 AM Resident #1's physician confirmed that the resident lacked decisional capacity. I doubt very seriously s/he could consent to sex. In a telephone interview with the surveyor on [DATE] at 1:05 PM the Investigator with the Sheriffs Department stated that the alleged perpetrator had been charged with Criminal Sexual Conduct 3rd. Degree and was in jail. It was determined on [DATE] at approximately 11:55 AM that Immediate Jeopardy and/or Substandard Quality of Care existed in the facility as of [DATE] related to complaint SC 949 in the following areas. The Administrator was notified of this determination at 12:15 PM. The deficiencies involved were as follows: 4[AGE].10(f)(4) Right to Receive/deny Visitors, F0563 was identified at Immediate Jeopardy at a scope and severity level of J. The facility failed to have a written policy to address visitors. Resident #1 was allegedly abused sexually by a visitor in the facility. 4[AGE].12 Freedom from Abuse, F0[AGE]0 was identified at Immediate Jeopardy and Substandard Quality of Care at a scope and severity level of J. The facility failed to ensure each resident remained free from abuse. Resident #1 was allegedly abused sexually by a visitor in the facility. 4[AGE].12(b) Develop/Implement Abuse/Neglect Policies, F0[AGE]7 was identified at Immediate Jeopardy and Substandard Quality of Care at a scope and severity level of J. The facility failed to implement written policies and procedures that prohibit and prevent abuse. Resident #1 was allegedly abused sexually by a visitor in the facility. The facility staff failed to protect the resident, by removing the alleged abuser from the resident care area. One of 3 residents reviewed for abuse. 4[AGE].70 Administration, F0[AGE]5 was identified at Immediate Jeopardy at a scope and severity level of J. The facility failed to be administered in a manner that enables it to use resources effectively and efficiently to attain or maintain the highest practicable physical , mental, and psychosocial well-being of each resident. Resident #1 was allegedly abused sexually by a visitor at the facility The facility provided an acceptable Allegation of Compliance (AOC) Resident #1 was assessed by a licensed nurse, the physician was notified and an order was received and resident was transported to the hospital and no longer resides in the facility. Residents who reside in the facility and were in contact with the identified visitor had the potential to be affected. The facility will interview all alert and oriented residents and complete body audits on all non-alert and oriented resident to observe for any signs of abuse. Staff were interviewed by the Administrator, Director of Nursing and nursing managers on [DATE] to determine which residents the identified visitor had interaction with and if it was in or out of the resident's room. Alert and oriented residents were interviewed by the Administrator, Director of Nursing and nursing managers to determine if any unwanted touching occurred or any witness to others. Residents with a BIM score of 12 or less were assessed by a registered nurse and no other concerns were identified. These assessments were completed on [DATE]. Interviews of all Alert and Oriented residents were completed by [DATE]. Those residents were educated to notify staff of any unusual or inappropriate behaviors or if they fell afraid or unsafe. All residents with a BIM score of 12 or less were assessed by a licensed nurse by [DATE]. No other concerns were identified. All residents in the facility will be educated by [DATE] on resident safety and notifying staff of any unusual or inappropriate behavior or if they feel threatened or afraid. On [DATE] a resident council meeting was held to discuss resident safety and to notify staff of any unusual or inappropriate behavior or if they feel threatened or afraid. Facility staff was educated by the Staff Development Coordinator, the Director of Nursing and the Administrator on the following: *Facility staff was re-educated on Abuse, Neglect, Misappropriation and Exploitation including preventing, recognizing, reporting abuse, neglect, exploitation, and mistreatment and protecting the residents. *The identification of residents who should not have visitors without notification of Responsible Party. *Notation will be made in Medication Administration Record [REDACTED]. *Social Service Director will identify and maintain a list of residents with cognitive impairments. Cognitive impairment will be determined by either an incapacitation order by a court of law or a lack of decisional capacity by two physicians. *Visitor sign in log process - any visitor entering facility will sign in on log which includes the visitor name, the date, the resident being visited and relationship and will be given a visitor sticker. Visitors will sign out upon exit from the facility. From 4 PM to 8 AM and on weekends the doors are locked, visitors will ring the doorbell and staff member answering door will have visitor sign log and issue a visitor sticker. The re-education will be completed by [DATE]. Any staff member not receiving this education by this date will receive prior to next scheduled shift. This information will be presented in New Hire Orientation. A visitor sign in log and the process of issuing a visitor sticker will be implemented by [DATE]. Letters regarding the visitor sign in log and notification of anything suspicious to charge nurse will be mailed out on [DATE] by the Administrator. CNA (certified nurse aide) #1 and #2 who were agency CNAs have not been back to the facility to work since the incident. The staffing agency will be notified on [DATE] to no longer send them to the facility. The facility will report the two CNAs to DHEC as a possible abuse incident. LPN (licensed practical nurse) #1 will receive corrective action failing to ensure the resident's safety on [DATE]. This LPN will be reported to SC LLR on [DATE]. An ad hoc Quality Assurance Performance Improvement Committee Meeting was held on [DATE] and Medical Director was informed the immediate jeopardy and the content of this plan. Allegation of Compliance (AOC) [DATE] Observations, interviews, and review of the Allegation of Compliance (AOC) submitted by the facility on [DATE] revealed the implementation of the AOC and that it was in practice removing the immediacy of the deficient practice. Facility nursing staff had been educated and was knowledgeable of the new visitors procedure, abuse policy and the importance of protecting the residents. The Administrator was informed of this on [DATE] at approximately 3:30 PM. The Immediate Jeopardy at F0563, F0[AGE]0, F0[AGE]7 and F0[AGE]5 was removed but the citations remained at a lower scope and severity of D.",2020-09-01
246,MAGNOLIA MANOR - INMAN,425032,63 BLACKSTOCK ROAD,INMAN,SC,29349,2016-09-22,155,D,0,1,HKBR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews Resident # 219 had a Do Not Resuscitate order written with only one physician's documentation of diminished capacity and unable to make advance directive decisions. ( 1 of 20 reviewed for Advance Directives.) The findings included: Chart review on 9/21/16 revealed a red DNR (No Not Resuscitate) sheet in the front of Resident # 219's chart. There was also copy of physician's orders [REDACTED]. Only one physician had signed and documented that the resident was not competent to make own decisions. Interview with Social Service Worker on 9/21/16 at 3:10 PM revealed that the facility only had declaration of incompetency from one physician, two Physician's documentation required. When asked where nurses would look first for resuscitation orders in case of an emergency, she/he stated They would go to the sheet in the front of the chart. Three nurses were interviewed on 9/21/16 at 3:23 PM related to where they would look first for code status in an emergency. Registered Nurse #4 and Licensed Practical Nurses #3 and # 4 each stated they would look in the front of the chart for the red sheet. The resident was admitted [DATE] and had been designated as a NO Code until 9/21/16. The resident's care plan also documented the resident as no code status.",2020-09-01
247,MAGNOLIA MANOR - INMAN,425032,63 BLACKSTOCK ROAD,INMAN,SC,29349,2016-09-22,157,J,0,1,HKBR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility files and interviews, the facility failed to notify the resident's family and physician of a change in status. Resident #88 was found in a locked janitor's closet after being missing for approximately 4.5 hours. Facility staff failed to follow the facility's policy for missing residents. The Administrator, Director of Nursing, responsible party, sheriff's office and physician were not notified timely that the resident was missing. Housekeeping staff failed to notify their supervisor or maintenance that the locking mechanism on the janitor's closet on the unit was not working properly. In addition, multiple physician orders [REDACTED]. (Two of 2 residents reviewed for change of condition) The findings included: The facility reported an unusual occurrence to the State Agency for Resident #88 on 6/12/16. The facility was unable to locate Resident #88 in the facility for 4.5 hours. The resident was located in the janitor's closet on the unit s/he resided on. The facility's synopsis of the elopement indicated the Administration was notified of the missing resident on 6/12/16. The Administrator, Director of Nursing (DON) and Assistant Director of Nursing (ADON) arrived at the facility to assist with the search for the resident. Local law enforcement was made aware of the situation along with the resident's responsible party. The search for Resident #88 continued until 3:30 AM when the resident was located in the janitor's closet. The synopsis indicated the identified door mechanism was immediately repaired and subsequently replaced. A list of chemicals present in the closet was completed at the time the resident was discovered. The items included Emerald floor cleaner, Wiwax cleaning and maintenance [MEDICATION NAME] and Airx disinfectant cleaner. Review of the Resident Incident/Accident Investigation Worksheet dated 6/11/16 revealed the time of incident was 11:00 PM. The resident was noted not in his/her room around 11:00 PM and a Code [NAME]/Star Search was initiated. The nurse practitioner was notified at 1:30 AM and the resident's responsible party was notified at 1:30 AM. The resident was located in the facility. A body audit was completed with no apparent injuries. Review of the Weekly Skin Integrity Review revealed on 6/8/16 the resident was noted to have some old scattered discoloration. On 6/12/16 the resident was noted to have bruising, a red area to the right hip and an abrasion to the lower leg. Review of Resident #88's Risk of Elopement/Wandering Review revealed the form was last completed on 12/30/15. The instructions on the form indicated to complete the form upon admission, quarterly and at significant change. Review of Resident #88's Psychotherapy Visit note dated 6/22/16 revealed the resident was seen after being found in the closet at the facility after several hours. Resident #88 had a history of [REDACTED]. In an interview with the surveyor on 9/20/16 at approximately 1:35 PM Housekeeper #1 stated they changed the lock after the incident, it wasn't latching. Sometimes it would and sometimes it wouldn't. You would have to push on it and it would catch. The closet is supposed to lock automatically. Housekeeper #1 stated the janitor's closet is where they get their mop water, Unit 1, Unit 2 and the floor techs get their water from there. In an interview with the surveyor on 9/20/16 at approximately 1:52 PM, the Housekeeping manager stated the facility did an investigation, the conclusion was that two of the floor techs told them the door opens by itself sometimes. The staff did not tell anybody prior to the incident. The floor techs no longer work at the facility. The facility maintenance changed the lock after the incident. In an interview with the surveyor on 9/20/16 at approximately 2:30 PM, the Maintenance Director stated s/he was called at 2:00 AM that evening to help look for Resident #88. There were some doors they could not access while searching for the resident. The Maintenance Director stated s/he looked in the janitor's closet on Station 2 and found Resident #88. The resident was laying on the floor between the mop bucket and wall. The resident was on his/her back with his/her knees up, it is a small closet. Resident #88 had on a sweater and a brief. The Maintenance Director notified the nurse around the corner at the Nurses' station. Resident #88 was awake when s/he found him/her and the light was on in the closet. The Maintenance Director stated the janitor's closet door was locked and s/he had to unlock it. Once the closet was cleaned, s/he checked the locking mechanism and the door locked. Upon talking to housekeeping after the incident, they told him/her the lock wouldn't work sometimes. The Maintenance Director stated there is a maintenance book at the nurses' stations but nobody logged the lock on the janitor's closet. At the time of the incident only housekeeping and maintenance had keys to the closet. In an interview with the surveyor on 9/20/16 at approximately 3:13 PM, the Director of Nursing (DON) stated Resident #88 had Alzheimer's and liked to walk around the building constantly. The DON stated s/he received a call around 1:30 AM from the Assistant Director of Nursing(ADON). The ADON said they could not find Resident #88. The DON arrived at the facility before 2, approximately 1:50 AM. When s/he got to the facility s/he got his/her set of keys and went and checked all the offices and rooms. The DON started on the Administration hall and then went room to room to check all the residents rooms. The DON pulled on the janitor's closet door on Station 2 but did not have a key and it was locked. The police arrived a few minutes after s/he arrived at the facility. Staff called the police while s/he was on the way to the facility. Staff found the resident around 3:00 in the janitor's closet. The resident had a bowel movement and it was all over him/her. Staff called the weekend supervisor around 12:50 AM. The weekend supervisor came to the facility, and had forgotten his/her work keys. S/he went home, got the keys, came back and started opening doors s/he had keys for. The policy states the Administrator is called for a star search. They did not call the administrator or DON. The DON stated the nurse on duty stated s/he didn't know what to do. In an interview with the surveyor on 9/21/16 at approximately 10:25 AM, the DON stated elopement assessments should be done every 3 months. The last elopement assessment for Resident #88 was (MONTH) (YEAR). In an interview with the surveyor on 9/21/16 at approximately 11:40 AM, the DON confirmed the responsible party, MD and sheriff's department were not notified timely. In an interview with the surveyor on 9/21/16 at approximately 11:48 AM, the ADON stated she completed the weekly skin integrity review right before EMS took Resident #88 out to the hospital after being located. Resident #88 had a couple of blanchable red areas to his/her right hip, s/he also had an abrasion to the left lower leg(like a strawberry, no bleeding). Staff called him/her around 1:35 AM, the resident's CNA was who called him/her. The CNA told him/her they could not locate the resident, they had already done a star search. Review of the facility's Elopement Leadership Policies and Procedures revealed once it had been established that a resident was missing, all employees should be notified immediately by paging overhead Code [NAME]. Further review of the policy revealed an immediate and thorough search of the center and surrounding grounds should be instituted. The search should include the entire unit where the resident resides or was last seen and the remainder of the facility (all rooms, closets-including storage facilities- and bathrooms). The entire search process of the facility and grounds, from the time the resident is missing, will be completed within 30 minutes. If the search fails to locate the missing resident within 30 minutes from the time the resident is found to be missing, the Administrator and/or designee contacts the appropriate community agencies (including police) and Administration, the resident's legal representative and attending physician. When the resident is located, the Charge Nurse completes a head to toe assessment. It was determined on 9/20/16 at 4:10 PM that Immediate Jeopardy and/or Substandard Quality of Care at Past Noncompliance existed in the facility as of 6/11/16 and was corrected as of 6/26/2016. The facility's Plan of Correction/Allegation of Compliance for Immediate Jeopardy included: 1. Identified resident was located inside the facility in a housekeeping closet at 3:30 am on 6/12/16. A full head to toe assessment was performed on the resident with no concerns identified. The resident was sent to Spartanburg Regional Medical Center at 3:55 am, and returned to the facility at 8:30 am in stable condition with no substantial findings. PO fluids were encouraged with intake and output ordered by resident's physician for 48 hrs. 2. Residents with wandering behaviors have the potential to be affected by this alleged deficient practice. At time resident was unable to be located by facility staff, all other facility residents were accounted for. This was completed on 6/12/16 by the Assistant Director of Nursing. All residents with wanderguards were validated to have them in place with function checked and expiration date verified, no concerns were identified. This was completed on 6/12/16 by the facility Central Supply Coordinator. All facility outer doors were validated to be functioning appropriately. All facility staff present at time of incident were interviewed to validate no door alarms sounded in the hour before the resident was unable to be located. This was completed on 6/12/16 by the facility Administrator. Identified housekeeping door mechanism was immediately repaired and subsequently replaced by the facility Maintenance Director on 6/12/16. A list of items present in the identified housekeeping closet was completed at time resident was discovered, no evidence items had been accessed by the resident. All potentially harmful items located in housekeeping closets have been removed and placed in an unaccessible area. This was completed on 6/12/16 by the Housekeeping Supervisor. The identified resident was being reviewed by social services daily for 7 days to validate no psychosocial effects of the incident persist. This was completed on 6/21/16. The identified resident has been placed on 15 minute location checks for 14 days to validate no further attempts to enter other inappropriate areas in the facility. This was completed on 6/26/16. The incident has been reported to the facility's contracted psychiatric services for resident review. Elopement drills were conducted on all 3 shifts on 6/12/16. The facility charge nurse assigned to the resident and the facility weekend supervisor were both immediately suspended pending investigation, and subsequently terminated from the facility. 3. The facility Director of Nursing/department managers has re-educated all facility staff on the facility elopement policy, the securing of all facility doors and the immediate reporting of any facility door that is not functioning properly. This re-education was completed on 6/13/16. Any staff member not receiving this re-education by this date will receive prior to next scheduled shift. This information will be presented in new hire orientation. 4. The facility Maintenance Director will monitor all facility interior doors for proper functioning daily for 14 days then monthly indefinitely. Elopement drills will be conducted on every shift 1 time per week for 4 weeks then monthly indefinitely. 5. Results of the monitoring will be presented to the Quality Assurance Performance Improvement (QAPI) Committee for a period of 3 months or until substantial compliance is achieved and maintained. Any areas of concern identified will be addressed at time of discovery. Chart review on 9/21/16 revealed a nurses note dated 9/12/16 and 9/14/16 for medication changes for resident # 219. There was no documentation that family/ responsible party had been notified. At 9/21/16 at 2 PM the Director of Nursing reviewed the chart and confirmed there was no documentation that family/ responsible party had been notified. She stated there was a line on the physician's orders [REDACTED]. Further review of the resident's record revealed orders written on 9/6, 9/2, 7/8, 7/17, 7/22, 7/27 and 6/3, 6/9, 6/21/16 also had no documentation that family/responsible party had been notified. Facility policy stated The patients's /residents family member / legal represent. will be notified of any changes in medical condition or treatment plan as indicated by HIPPA directives. Res/family/ Responsible Party will be notified of any change in condition requiring an emergent transfer to the hospital. All attempts to notify physician/ family member/legal representative will be documented in resident record.",2020-09-01
248,MAGNOLIA MANOR - INMAN,425032,63 BLACKSTOCK ROAD,INMAN,SC,29349,2016-09-22,241,D,0,1,HKBR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During a random observation on 9/21/16 at 3:55 PM on Unit 200 a Certified Nursing Aide (CNA) was observed pulling a resident seated in a gerri chair backward from one side of the dining room to the other side of the dining. The CNA did not inform the resident that he/she will be pulled backward while in the gerri chair. The CNA moved a resident seated in a wheelchair out of the way and proceeded to pull the resident backward while he/she was seated in a geri chair from the dining room down the hallway toward room [ROOM NUMBER]. There were two nurses standing at the nurse's station when the CNA was observed pulling the resident backward while he/she was seated in the geri chair. An interview and observation on 9/21/16 at approximately 4 PM with Licensed Practical Nurse (LPN) #5 confirmed the findings. LPN #5 stated the resident should not have been pulled backward after observation. The LPN further stated he/she was distracted and did not observe the resident being pulled backward in the geri chair pass the nurse's station and down hallway. The nurse's station was in position near the dining room and in view of the hallway. During an interview on 9/21/16 at approximately 4:05 PM with Certified Nursing Aide (CNA) #1, the CNA confirmed the findings that he/she pulled the resident backward from the dining room down the hallway and further stated the resident should not have pulled backward. Based on random observations and interview, residents were observed in rooms not served while other residents were eating. Random observation of resident being pulled backwards in gerichair down a hallway. ( 1 of 4 units r/t to dining, 1 of 4 units r/t pulling chair backward) The findings included: Random observations on two days of the survey 9/19/16 and 9/20/16 at 12:30 PM revealed residents eating in rooms 417, 421, 422, 414, and 415 with other residents not eating. No curtains were pulled between the beds. Interview with CNA #2 (Certified Nursing Assistant) on 9/29/16 at 12:20 PM revealed the CNA not sure of what the policy was when feeding only one resident in room with other residents.",2020-09-01
249,MAGNOLIA MANOR - INMAN,425032,63 BLACKSTOCK ROAD,INMAN,SC,29349,2016-09-22,250,D,0,1,HKBR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews and review of Dialysis Resident Communication Report sheet, the facility failed to provide medically related social services for 1 of 1 sampled dialysis resident reviewed. Resident #72 had been refusing to participant in dialysis treatment with no documentation of counseling services to address the potential negative outcomes non-compliance of medical care. The findings included: The facility admitted Resident #72 with [DIAGNOSES REDACTED]. A review of the medical record on 9/20/16 revealed Dialysis Resident Communication Report sheet that provided sections for the facility nursing staff to complete before and after the resident attends dialysis as well as a section for the dialysis facility staff to complete when the resident goes to the dialysis center. The Dialysis Resident Communication Report sheets dated 6/20/16, 8/05/16, 8/10/16, 8/12/16, 9/12/16 and 9/19/16 did not indicate whether the resident completed dialysis services or not. The section on the form that addressed whether dialysis was completed at the dialysis center was left blank or the entire section that was to be completed by the dialysis staff was left blank. Dialysis Resident Communication Report sheets dated 8/31/16 and 9/05/16 indicated the resident refused to participate in dialysis services. There was no documentation in the nurses's notes of the resident's refusal to participate in dialysis services. There was no documentation in the social services notes of the resident's refusal to participate in dialysis services. During an interview on 9/20/16 at approximately 3:20 PM with Licensed Practical Nurse (LPN) #1 revealed the Dialysis Resident Communication Report sheet for 8/12/16 and 9/12/16 were not completed by the dialysis center staff. LPN #1 confirmed the findings and stated the resident may have refused to participate in dialysis services on 8/12/16 and 9/12/16. During an interview on 9/22/16 at approximately 9:40 AM with Social Services Worker (SSW) #1 and #2 revealed they were aware of the resident's refusal to participate in dialysis services and further stated that the resident had been refusing to participate in services for some time now. SSW #1 further stated they have not met with the resident/family to address the resident's refusal to participate in dialysis services the negative outcomes that could occur due to non compliance with medical care. SSW #1 stated the resident would refuse at first but then would corporate if his/her family member (sister) would encourage him/her to attend dialysis. There was no documentation in social services or nurses' notes to indicate the facility had met with the resident/family to address the negative outcomes of the resident's refusal to participate in dialysis services although the facility was aware of the resident's refusal. An interview on 9/22/16 at approximately 11:05 AM with Registered Nurse (RN) #1 confirmed the findings that there was no documentation to determine that the facility met with the resident/family to address the resident's refusal to participate in dialysis medical care and the negative outcome of non-compliance. .",2020-09-01
250,MAGNOLIA MANOR - INMAN,425032,63 BLACKSTOCK ROAD,INMAN,SC,29349,2016-09-22,253,D,0,1,HKBR11,"Based on observations and interviews the facility failed to maintain oxygen concentrators on 2 of 4 units observed during the survey. One of 4 concentrators observed did not have a filter and 4 of 4 concentrators had dirt build up. The Findings included: Surveyor resident room observations on 9/19/2016 at 9:20 AM, 9/20/2016 at 1:14 PM, 9/21/2016 at 2:45 PM and 9/22/2016 at 8:50 AM resulted in the following observations of oxygen concentrators in residents rooms Room 320-1 dirt build up Room 324-1 missing the filter and dirt build up Room 326-1 dirt build up Room 405-1 dirt build up On 9/21/2016 at 3:15 PM RN #3 Interviewed and confirmed that 324-1 did not have a concentrator filter. RN #3 stated we only have one and directed surveyor to room 321-1. Surveyor asked RN #3 if she was sure and RN #3 replied, yes. Surveyor requested RN #3 to go with surveyor to room 324-1. RN #3 confirmed with surveyor that 324-1 did not have a filter in place on 09/21/2016, day 3 of survey. RN #3 stated I will get one, the resident recently moved to this unit from another unit. Surveyor asked RN #3 for the process for checking and cleaning filters, and cleaning the concentrators. RN #3 stated that second shift changes and cleans the filters daily and central supply cleans the concentrator units every 2 weeks. On 9/21/2016 at 04:00 PM RN #4 provided surveyor with a document titled Infection Control Prevention and Control Policy and Procedure. The Infection Control Prevention and Control Policy and Procedure document did not specify/include a process for oxygen concentrators for changing and/or cleaning of oxygen filters or cleaning of concentrators.",2020-09-01
251,MAGNOLIA MANOR - INMAN,425032,63 BLACKSTOCK ROAD,INMAN,SC,29349,2016-09-22,280,D,0,1,HKBR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews and [MEDICAL TREATMENT] Resident Communication Report, the facility failed to review and revise a care plan for 1 of 1 sampled [MEDICAL TREATMENT] resident reviewed. Resident #72's care plan was not updated to address the resident's refusal of [MEDICAL TREATMENT] services with interventions in place. The findings included: The facility admitted Resident #72 with [DIAGNOSES REDACTED]. A review of the medical record on 9/20/16 revealed [MEDICAL TREATMENT] Resident Communication Report sheet that provided sections for the facility nursing staff to complete before and after the resident attends [MEDICAL TREATMENT] as well as a section for the [MEDICAL TREATMENT] facility staff to complete when the resident goes to the [MEDICAL TREATMENT] center. The [MEDICAL TREATMENT] Resident Communication Report sheets dated 6/20/16, 8/05/16, 8/10/16, 8/12/16, 9/12/16 and 9/19/16 did not indicate whether the resident completed [MEDICAL TREATMENT] services are not. The section on the form that addressed whether [MEDICAL TREATMENT] was completed at the [MEDICAL TREATMENT] center was left blank or the entire section that was to be completed by the [MEDICAL TREATMENT] staff was left blank. [MEDICAL TREATMENT] Resident Communication Report sheets dated 8/31/16 and 9/05/16 indicated the resident refused to participate in [MEDICAL TREATMENT] services. During an interview on 9/20/16 at approximately 3:20 PM with Licensed Practical Nurse (LPN) #1 revealed the [MEDICAL TREATMENT] Resident Communication Report sheet for 8/12/16 and 9/12/16 were not completed by the [MEDICAL TREATMENT] center staff. LPN #1 confirmed the findings and stated the resident may have refused to participate in [MEDICAL TREATMENT] services on 8/12/16 and 9/12/16. During an interview on 9/22/16 at approximately 9:24 AM with Registered Nurse (RN) #1 confirmed the findings that the care plan was not updated to address the resident's refusal to participate in [MEDICAL TREATMENT] services. RN #1 further stated the care plan should have been updated to address the resident's refusal to participate [MEDICAL TREATMENT] services. RN #1 stated he/she was not aware the resident had refused to participate in [MEDICAL TREATMENT] services. During an interview on 9/22/16 at approximately 9:40 AM with Social Services Worker (SSW) #1 and #2 revealed they were aware of the resident's refusal to participate in [MEDICAL TREATMENT] services and further stated that the resident had been refusing to participate in services for some time now. SSW #1 further stated they have not met with the resident/family to address the resident's refusal to participate [MEDICAL TREATMENT] services the negative outcomes that could occur due to non compliance with medical care. SSW #1 stated the resident would refuse at first but then would corporate if his/her family member (sister) would encourage him/she to attend [MEDICAL TREATMENT].",2020-09-01
252,MAGNOLIA MANOR - INMAN,425032,63 BLACKSTOCK ROAD,INMAN,SC,29349,2016-09-22,281,J,0,1,HKBR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility files and interviews, the facility failed to ensure that the services provided by the facility met professional standards of care. Resident #88 was found in a locked janitor's closet after being missing for approximately 4.5 hours. Facility staff failed to follow the facility's policy for missing residents. The Administrator, Director of Nursing, responsible party, sheriff's office and physician were not notified timely that the resident was missing. Housekeeping staff failed to notify their supervisor or maintenance that the locking mechanism on the janitor's closet on the unit was not working properly. One of one wanderers reviewed The findings included: The facility reported an unusual occurrence to the State Agency for Resident #88 on 6/12/16. The facility was unable to locate Resident #88 in the facility for 4.5 hours. The resident was located in the janitor's closet on the unit s/he resided on. The facility's synopsis of the elopement indicated the Administration was notified of the missing resident on 6/12/16. The Administrator, Director of Nursing (DON) and Assistant Director of Nursing (ADON) arrived at the facility to assist with the search for the resident. Local law enforcement was made aware of the situation along with the resident's responsible party. The search for Resident #88 continued until 3:30 AM when the resident was located in the janitor's closet. The synopsis indicated the identified door mechanism was immediately repaired and subsequently replaced. A list of chemicals present in the closet was completed at the time the resident was discovered. The items included Emerald floor cleaner, Wiwax cleaning and maintenance [MEDICATION NAME] and Airx disinfectant cleaner. Review of the Resident Incident/Accident Investigation Worksheet dated 6/11/16 revealed the time of incident was 11:00 PM. The resident was noted not in his/her room around 11:00 PM and a Code [NAME]/Star Search was initiated. The nurse practitioner was notified at 1:30 AM and the resident's responsible party was notified at 1:30 AM. The resident was located in the facility. A body audit was completed with no apparent injuries. Review of the Weekly Skin Integrity Review revealed on 6/8/16 the resident was noted to have some old scattered discoloration. On 6/12/16 the resident was noted to have bruising, a red area to the right hip and an abrasion to the lower leg. Review of Resident #88's Risk of Elopement/Wandering Review revealed the form was last completed on 12/30/15. The instructions on the form indicated to complete the form upon admission, quarterly and at significant change. Review of Resident #88's Psychotherapy Visit note dated 6/22/16 revealed the resident was seen after being found in the closet at the facility after several hours. Resident #88 had a history of [REDACTED]. In an interview with the surveyor on 9/20/16 at approximately 1:35 PM Housekeeper #1 stated they changed the lock after the incident, it wasn't latching. Sometimes it would and sometimes it wouldn't. You would have to push on it and it would catch. The closet is supposed to lock automatically. Housekeeper #1 stated the janitor's closet is where they get their mop water, Unit 1, Unit 2 and the floor techs get their water from there. In an interview with the surveyor on 9/20/16 at approximately 1:52 PM, the Housekeeping manager stated the facility did an investigation, the conclusion was that two of the floor techs told them the door opens by itself sometimes. The staff did not tell anybody prior to the incident. The floor techs no longer work at the facility. The facility maintenance changed the lock after the incident. In an interview with the surveyor on 9/20/16 at approximately 2:30 PM, the Maintenance Director stated s/he was called at 2:00 AM that evening to help look for Resident #88. There were some doors they could not access while searching for the resident. The Maintenance Director stated s/he looked in the janitor's closet on Station 2 and found Resident #88. The resident was laying on the floor between the mop bucket and wall. The resident was on his/her back with his/her knees up, it is a small closet. Resident #88 had on a sweater and a brief. The Maintenance Director notified the nurse around the corner at the Nurses' station. Resident #88 was awake when s/he found him/her and the light was on in the closet. The Maintenance Director stated the janitor's closet door was locked and s/he had to unlock it. Once the closet was cleaned, s/he checked the locking mechanism and the door locked. Upon talking to housekeeping after the incident, they told him/her the lock wouldn't work sometimes. The Maintenance Director stated there is a maintenance book at the nurses' stations but nobody logged the lock on the janitor's closet. At the time of the incident only housekeeping and maintenance had keys to the closet. In an interview with the surveyor on 9/20/16 at approximately 3:13 PM, the Director of Nursing (DON) stated Resident #88 had Alzheimer's and liked to walk around the building constantly. The DON stated s/he received a call around 1:30 AM from the Assistant Director of Nursing(ADON). The ADON said they could not find Resident #88. The DON arrived at the facility before 2, approximately 1:50 AM. When s/he got to the facility s/he got his/her set of keys and went and checked all the offices and rooms. The DON started on the Administration hall and then went room to room to check all the residents rooms. The DON pulled on the janitor's closet door on Station 2 but did not have a key and it was locked. The police arrived a few minutes after s/he arrived at the facility. Staff called the police while s/he was on the way to the facility. Staff found the resident around 3:00 in the janitor's closet. The resident had a bowel movement and it was all over him/her. Staff called the weekend supervisor around 12:50 AM. The weekend supervisor came to the facility, and had forgotten his/her work keys. S/he went home, got the keys, came back and started opening doors s/he had keys for. The policy states the Administrator is called for a star search. They did not call the administrator or DON. The DON stated the nurse on duty stated s/he didn't know what to do. In an interview with the surveyor on 9/21/16 at approximately 10:25 AM, the DON stated elopement assessments should be done every 3 months. The last elopement assessment for Resident #88 was (MONTH) (YEAR). In an interview with the surveyor on 9/21/16 at approximately 11:40 AM, the DON confirmed the responsible party, MD and sheriff's department were not notified timely. In an interview with the surveyor on 9/21/16 at approximately 11:48 AM, the ADON stated she completed the weekly skin integrity review right before EMS took Resident #88 out to the hospital after being located. Resident #88 had a couple of blanchable red areas to his/her right hip, s/he also had an abrasion to the left lower leg(like a strawberry, no bleeding). Staff called him/her around 1:35 AM, the resident's CNA was who called him/her. The CNA told him/her they could not locate the resident, they had already done a star search. Review of the facility's Elopement Leadership Policies and Procedures revealed once it had been established that a resident was missing, all employees should be notified immediately by paging overhead Code [NAME]. Further review of the policy revealed an immediate and thorough search of the center and surrounding grounds should be instituted. The search should include the entire unit where the resident resides or was last seen and the remainder of the facility (all rooms, closets-including storage facilities- and bathrooms). The entire search process of the facility and grounds, from the time the resident is missing, will be completed within 30 minutes. If the search fails to locate the missing resident within 30 minutes from the time the resident is found to be missing, the Administrator and/or designee contacts the appropriate community agencies (including police) and Administration, the resident's legal representative and attending physician. When the resident is located, the Charge Nurse completes a head to toe assessment. It was determined on 9/20/16 at 4:10 PM that Immediate Jeopardy and/or Substandard Quality of Care at Past Noncompliance existed in the facility as of 6/11/16 and was corrected as of 6/26/2016. The facility's Allegation of Compliance/Plan of Correction for Immediate Jeopardy included: 1. Identified resident was located inside the facility in a housekeeping closet at 3:30 am on 6/12/16. A full head to toe assessment was performed on the resident with no concerns identified. The resident was sent to Spartanburg Regional Medical Center at 3:55 am, and returned to the facility at 8:30 am in stable condition with no substantial findings. PO fluids were encouraged with intake and output ordered by resident's physician for 48 hrs. 2. Residents with wandering behaviors have the potential to be affected by this alleged deficient practice. At time resident was unable to be located by facility staff, all other facility residents were accounted for. This was completed on 6/12/16 by the Assistant Director of Nursing. All residents with wanderguards were validated to have them in place with function checked and expiration date verified, no concerns were identified. This was completed on 6/12/16 by the facility Central Supply Coordinator. All facility outer doors were validated to be functioning appropriately. All facility staff present at time of incident were interviewed to validate no door alarms sounded in the hour before the resident was unable to be located. This was completed on 6/12/16 by the facility Administrator. Identified housekeeping door mechanism was immediately repaired and subsequently replaced by the facility Maintenance Director on 6/12/16. A list of items present in the identified housekeeping closet was completed at time resident was discovered, no evidence items had been accessed by the resident. All potentially harmful items located in housekeeping closets have been removed and placed in an unaccessible area. This was completed on 6/12/16 by the Housekeeping Supervisor. The identified resident was being reviewed by social services daily for 7 days to validate no psychosocial effects of the incident persist. This was completed on 6/21/16. The identified resident has been placed on 15 minute location checks for 14 days to validate no further attempts to enter other inappropriate areas in the facility. This was completed on 6/26/16. The incident has been reported to the facility's contracted psychiatric services for resident review. Elopement drills were conducted on all 3 shifts on 6/12/16. The facility charge nurse assigned to the resident and the facility weekend supervisor were both immediately suspended pending investigation, and subsequently terminated from the facility. 3. The facility Director of Nursing/department managers has re-educated all facility staff on the facility elopement policy, the securing of all facility doors and the immediate reporting of any facility door that is not functioning properly. This re-education was completed on 6/13/16. Any staff member not receiving this re-education by this date will receive prior to next scheduled shift. This information will be presented in new hire orientation. 4. The facility Maintenance Director will monitor all facility interior doors for proper functioning daily for 14 days then monthly indefinitely. Elopement drills will be conducted on every shift 1 time per week for 4 weeks then monthly indefinitely. 5. Results of the monitoring will be presented to the Quality Assurance Performance Improvement (QAPI) Committee for a period of 3 months or until substantial compliance is achieved and maintained. Any areas of concern identified will be addressed at time of discovery.",2020-09-01
253,MAGNOLIA MANOR - INMAN,425032,63 BLACKSTOCK ROAD,INMAN,SC,29349,2016-09-22,282,D,0,1,HKBR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations and interviews, the facility failed to follow the care plan for 1 of 6 sampled residents reviewed for medications and 1 of 3 sampled residents reviewed for range of motion/restorative services. Resident #205's care plan was not followed for medications given as ordered. Resident #140's care plan was not followed for compression sleeves being applied everyday in the morning hours to Right Upper Extremity (RUE) The findings included: The facility admitted resident #205 with [DIAGNOSES REDACTED]. Review of the medical record on 9/20/16 revealed Resident #205 had a care plan that indicated administer medications as ordered. Further review of the medical record revealed a pharmacy consult report dated 7/04/16 that indicated when existing supply of [MEDICATION NAME] medications are exhausted, [MEDICATION NAME] therapy can be initiated at 5 milligrams daily at bedtime for four (4) weeks and then the dose can be increased to 10 milligrams daily at bedtime. During an interview on 9/20/16 at approximately 3:53 PM with Registered Nurse (RN) #2 after reviewing the medical record revealed the resident should have received [MEDICATION NAME] at 10 milligrams four weeks after the physician's orders [REDACTED]. RN#2 further confirmed the resident continued to receive 5 milligrams of [MEDICATION NAME] on 8/16/16 to present and that the medication was not given as ordered. The facility admitted Resident #140 with [DIAGNOSES REDACTED]. A review of the medical record revealed a physician's orders [REDACTED]. Review of the updated care plan dated 9/01/16 indicated compression sleeves to RUE (Right Upper Extremity) except when bathing, every morning on and off in the afternoon. During random observation on 9/19/16 at 9:18 AM revealed resident not wearing compression sleeves as care planned and as ordered to RUE (Right Upper Extremity). During random observation on 9/20/16 at 9 AM the resident was not wearing compression sleeves as care planned and as ordered. During random resident observation on 9/21/16 at 9 AM and 10:53 AM the resident was not wearing compression sleeves to right upper extremity. During an interview on 9/21/16 at approximately 9: 03 AM with Licensed Practical Nurse (LPN) #2 confirmed documentation that compression sleeves for Resident #140 was not available. LPN #2 further stated the compression sleeves might be something that therapy does but it was not done on the unit. An interview on 9/21/16 at approximately 10:47 AM with the Director of Nursing (DON) confirmed there was no documentation that the compression sleeves were in place as care planned.",2020-09-01
254,MAGNOLIA MANOR - INMAN,425032,63 BLACKSTOCK ROAD,INMAN,SC,29349,2016-09-22,318,D,0,1,HKBR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interviews, the facility failed to ensure that residents with physician's orders for therapeutic assertive devices had those devices in place for 1 of 3 sampled residents reviewed for range of motion. Resident #140 did not have compression sleeves in place as ordered to Right Upper Extremity (RUE) The findings included: The facility admitted Resident #140 with [DIAGNOSES REDACTED]. A review of the medical record revealed a physician's order dated 8/31/16 that indicated compression sleeves to RUE (Right Upper Extremity) except when bathing on every morning. During random observation on 9/19/16 at 9:18 AM revealed resident not wearing compression sleeves as care planned and as ordered to RUE (Right Upper Extremity). During random observation on 9/20/16 at 9 AM the resident was not wearing compression sleeves as as care planned and as ordered. During random resident observation on 9/21/16 at 9 AM and 10:53 AM the resident was not wearing compression sleeves to right upper extremity. During an interview on 9/21/16 at approximately 9: 03 AM with Licensed Practical Nurse (LPN) #2 confirmed documentation that compression sleeves for Resident #140 was not available. LPN #2 further stated the compression sleeves might be something that therapy does but it was not done on the unit. An interview on 9/21/16 at approximately 10:47 AM with the Director of Nursing (DON) confirmed there was no documentation that the compression sleeves were in place.",2020-09-01
255,MAGNOLIA MANOR - INMAN,425032,63 BLACKSTOCK ROAD,INMAN,SC,29349,2016-09-22,333,E,0,1,HKBR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to that residents received medication as ordered for 1 of 6 sampled residents reviewed for medications. Resident #205 did not receive [MEDICATION NAME] medications as ordered for over a month. The findings included: The facility admitted resident #205 with [DIAGNOSES REDACTED]. Review of the medical record on 9/20/16 revealed Resident #205 had a pharmacist consult dated 7/04/16 that indicated when existing supply of [MEDICATION NAME] medications are exhausted, [MEDICATION NAME] therapy can be initiated at 5 milligrams daily at bedtime for four (4) weeks and then the dose can be increased to 10 milligrams daily at bedtime. During an interview on 9/20/16 at approximately 3:53 PM with Registered Nurse (RN) #2 after reviewing the medical record revealed the resident should have received [MEDICATION NAME] at 10 milligrams four weeks after the physician's orders [REDACTED]. RN#2 further confirmed the resident continued to receive 5 milligrams of [MEDICATION NAME] on 8/16/16 to present. During an interview on 9/21/16 at approximately 10:24 AM with the Director of Nursing (DON) confirmed that Resident #205 did not get medications as ordered and it was a med error. The DON further stated the pharmacist had been notified.",2020-09-01
256,MAGNOLIA MANOR - INMAN,425032,63 BLACKSTOCK ROAD,INMAN,SC,29349,2016-09-22,428,D,0,1,HKBR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility's pharmacist failed to identify that Aricept was not given as ordered for 1 of 6 sampled residents reviewed for medications. Resident #205 Aricept medication was not reviewed by the facility's pharmacist during last review on 9/01/16, The findings included: The facility admitted resident #205 with [DIAGNOSES REDACTED]. A review of the medical record on 9/20/16 revealed Resident #205 had a pharmacist consult dated 7/04/16 that indicated when existing supply of Exelon medications are exhausted, Aricept therapy can be initiated at 5 milligrams daily at bedtime for four (4) weeks and then the dose can be increased to 10 milligrams daily at bedtime. Further review of the medical revealed the facility's pharmacy did a medication regimen review on 9/01/16. There was no documentation to indicate the pharmacist was aware that Resident #205 was not receiving the Aricept as ordered on [DATE]. During an interview on 9/20/16 at approximately 3:53 PM with Registered Nurse (RN) #2 after reviewing the medical record revealed the resident should have received Aricept at 10 milligrams four weeks after the physician's orders [REDACTED]. RN#2 further confirmed the resident continued to receive 5 milligrams of Aricept on 8/16/16 to present. During an interview on 9/21/16 at approximately 10:24 AM with the Director of Nursing (DON) confirmed that Resident #205 did not get medications as ordered and it was a med error. The DON further stated the pharmacist had been notified.",2020-09-01
257,MAGNOLIA MANOR - INMAN,425032,63 BLACKSTOCK ROAD,INMAN,SC,29349,2017-10-05,241,D,0,1,V3MK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to promote resident dignity during 2 of 2 meals observed. Staff were observed entering rooms to deliver food trays without knocking. The findings included: Observation of dining on Units 3 and 4 on 10/3/17 at approximately 12:14 PM revealed Certified Nursing Assistant (CNA) #1 entered room [ROOM NUMBER] without knocking. Observation of dining on Units 3 and 4 on 10/4/17 at approximately 12:25 PM revealed CNA #1 entered room [ROOM NUMBER] without knocking. Interview with CNA #1 on 10/4/17 at approximately 12:25 PM confirmed s/he did not knock prior to entering room [ROOM NUMBER] that day or 405 the day prior. Review of facility policies and procedures on 10/5/17 at approximately 9:15 AM revealed it was procedure for staff to knock on a resident's door, identify self, and request permission to enter before doing so.",2020-09-01
258,MAGNOLIA MANOR - INMAN,425032,63 BLACKSTOCK ROAD,INMAN,SC,29349,2017-10-05,250,D,0,1,V3MK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide social services interventions for a resident on psychotropic medications for 1 of 5 sampled residents reviewed for unnecessary medications. Resident #79 had no documented social services notes in the medical record since 5/04/17. The findings included: The facility admitted Resident #79 was admitted with [DIAGNOSES REDACTED]. Review of the medical record on 10/04/17 at approximately 11:14 AM revealed a social services progress review note dated 2/2/17 that indicated Resident #79 got along well with roommate and other residents. A social services progress review note dated 5/04/17 indicated the resident got along well with roommate and others. Further record reviewed revealed no further social services notes after 5/04/17. A review of nurse's notes dated 5/19/17 revealed the Resident #79 was in another resident's room on a different unit when the resident in that room got up and hit Resident #79 and caused Resident #79 to fall to floor and hit his/her head. No other behavioral documentation was noted in the nurse's notes. A review of a quarterly activity note dated 7/06/17 revealed Resident #79 continued to go about facility wandering and seeking exit from the facility. An interview on 10/04/17 at approximately 1:04 PM with the Social Services Assistant confirmed the findings that there were no social services notes since 5/04/17.",2020-09-01
259,MAGNOLIA MANOR - INMAN,425032,63 BLACKSTOCK ROAD,INMAN,SC,29349,2017-10-05,282,D,0,1,V3MK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that a care plan was followed for social services interventions for a resident on [MEDICAL CONDITION] medications for 1 of 5 sampled residents reviewed for unnecessary medications. Resident #79 care was not followed related to social services monitoring resident for signs of depression. The findings included: The facility admitted Resident #79 was admitted with diagnosed that included Unspecified Dementia with Behavioral Disturbances, Pseudobulbar Affect and Anxiety Disorder. Review of the medical record on 10/04/17 at approximately 11:14 AM revealed a social services progress review dated 2/2/17 that indicated Resident #79 got along well with roommate and other residents. A social services progress review dated 5/04/17 indicated the resident got along well with roommate and others. Further record reviewed revealed no further social services notes after 5/04/17. An interview on 10/04/17 at approximately 1:04 PM with the Social Services Assistant confirmed the findings that there were no social services notes since 5/04/17. Review of a care plan on 10/04/17 at approximately 2:05 PM revealed an the care plan was edited (MONTH) (YEAR) that indicated the resident was on [MEDICAL CONDITION] medications and that social services should monitor resident for signs of depression.",2020-09-01
260,MAGNOLIA MANOR - INMAN,425032,63 BLACKSTOCK ROAD,INMAN,SC,29349,2017-10-05,309,G,0,1,V3MK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and observation, the facility failed to provide pain management to Resident #209, 1 of 1 sampled resident reviewed for Pain. Resident #209 did not have pain medication available in a timely manner after admission to the facility. The findings included: The facility admitted Resident #209 with [DIAGNOSES REDACTED]. Record review of hospital progress notes on 10/4/2017 at 3:50 PM revealed that Resident #209 underwent surgical procedures to the Abdominal Wall Abscess on 9/21/2017, 9/17/2017 and 9/16/2017. The notes indicated the abscessed area was 30 centimeters (cm) x 12cm, with a surgical incision 17cm in length. Record review of the nursing admission assessment on 10/4/2017 at 2:06 PM revealed the resident was admitted to the facility on [DATE] at 3:40 PM. A pain evaluation was completed as part of the assessment and indicated the resident had pain frequently over the past 5 days. A section of the pain evaluation asking the resident to rate her/his pain was not completed. The pain evaluation indicated the resident had vocal complaints of pain, specifically, incisional pain. Record review of the physician's orders [REDACTED]. The MAR indicated [REDACTED]. The resident's pain score was 8 of 10 on the 0-10 pain scale. Review of copies of faxed orders on 10/4/2017 at 12:22 PM indicated the facility faxed the pharmacy Resident #209's prescriptions at 5:53 PM on 10/2/2017. During an interview and observation of Resident #209 on 10/3/2017 at 2:36 PM, Resident #209 was laying in bed and appeared tense and rigid (uncomfortable). When asked to rate her/his pain on the 0-10 pain scale, Resident #209 rated her/his pain at a 10 of 10. Resident #209 stated she/he was admitted to the facility yesterday afternoon around 4:00 PM. She/he stated that she/he had pain medicine in the hospital at 12:30 PM on 10/2/2017 and did not receive pain medication in the facility until 2:00 AM today (10/3). Resident #209 stated the facility did not have her/his pain medication in the facility until then. The resident stated she/he was upset that the facility took so long to get her/his pain medication because she/he had been taking pain medications every 3 and 4 hours in the hospital. The resident felt like her/his pain level was so high at this time because she/he had to go 13 hours without any pain medication and it was taking longer to get under control because of that. During an interview with Licensed Practical Nurse (LPN) #2 on 10/4/2017 at 11:32 AM, LPN #2 stated Resident #209's pain medication was delivered to the facility at 12:45 AM on 10/3/2017. LPN #2 stated the resident should not have had to wait that long for her/his pain medication. LPN #2 stated that facility protocol for medication acquisition after 5:00 PM is to fax the pharmacy and call the pharmacy for any medications needed as soon as possible. If the pharmacy is not called after 5:00 PM, medications may not arrive at the facility until 1:00 AM. LPN #2 stated that the admitting nurse did not call the pharmacy and request the pain medication as soon as possible. During an interview with Resident #209 on 10/4/2017 at 12:12 PM, Resident #209 stated she/he was feeling a little better, but was still having more pain than she/he was having while in the hospital. Resident #209 stated she was receiving the pain medications [MEDICATION NAME] every 3 hours and [MEDICATION NAME] every 4 hours while in the hospital. The resident stated she/he was now getting pain medication every 4 hours and rated her/his pain 8 of 10. During an interview with the Director of Nursing (DON) on 10/4/2017 at 1:28 PM, the DON stated that all nurses, including the admitting nurse, had been inserviced this past (MONTH) on medication acquisition. The DON stated nurses were educated to call the pharmacy for medication needed after 5:00 PM. The DON stated the facility did not have a back up pharmacy for medications needed after hours because the pharmacy they contract with is supposed to provide medications 24 hours per day, 7 days per week. During an interview with LPN #3 on 10/4/2017 at 2:02 PM, LPN #3 confirmed she/he faxed Resident #209's prescriptions to the pharmacy, but did not call the pharmacy. LPN #3 stated she/he knew the pharmacy needed to be called for prescriptions needed after 5:00 PM, but forgot to do so. During an interview with resident #209 on 10/5/2017 at 11:02 AM, Resident #209 stated she/he was feeling much better. She/he stated she was getting her pain medication every 4 hours, as needed, and felt like her pain was under control. Resident #209 stated she/he first asked the nurse for pain medication around 5:30 PM on 10/2/1017. Resident #209 stated she/he was told she/he would have to wait until the medication was delivered by the pharmacy. Resident #209 stated she/he was told that the medication should be delivered by 9:00 PM. Resident #209 stated her/his pain level was tolerable at the time and was ok with waiting until 9:00 PM. Resident #209 stated she/he was due for pain medication at 4:30 PM based on her/his last dose from the hospital. Resident #209 stated she/he asked for her/his pain medication at 9:30 PM and was told it had not been delivered yet. Resident #209 stated she/he was told another pharmacy delivery was scheduled at 12:00 AM. Resident #209 stated she/he asked for her/his pain medication at 12:00 AM and was told it would be delivered at 1:00 AM. Resident #209 stated her pain level was outrageous by this time. During an interview with the Medical Director on 10/5/2017 at 11:21 AM, the Medical Director stated it was inexcusable for a patient to have to wait that long for pain medication. The Medical Director stated if the facility can't get medication from the pharmacy in a timely manner then maybe they need to look at getting a new pharmacy. The Medical Director stated the facility's medication acquisition process is not working if a patient has to wait that long for medication. During an interview with the DON, Nurse Consultant and Nursing Home Administrator on 10/5/2017 at 1:00 PM, the DON stated the facility was implementing a stat box for controlled medications to ensure there would be no future delays for residents needing narcotic pain medication. The Nurse Consultant confirmed the admission pain evaluation was incomplete.",2020-09-01
261,MAGNOLIA MANOR - INMAN,425032,63 BLACKSTOCK ROAD,INMAN,SC,29349,2017-10-05,314,D,0,1,V3MK11,"Based on observation of pressure ulcer treatment, Wound Care Policy and Procedure, and Environment That Preserves Dignity, the staff failed to provide privacy/dignity by not closing doors or pulling curtains prior to treatment, hand washing not done from soiled utility room before entering resident's room and donning gloves to complete procedure for Resident #92. (1 of 2 wound observations ). The findings included: On 10/5/17 at 8:55 AM the ADON ( Assistant Director of Nursing ) serving as the current wound nurse entered the Room of Resident # 92 The nurse knocked on the door, entered the room and explained the procedure. The nurse did not close the door nor pull the curtains around the resident's bed. The resident in the next bed watched the entire procedure. The nurse then cleaned off the table, placed a barrier, and set up supplies. The area was cleaned with normal saline and gauze properly. The wound was the size of a dime with pink tissue around the wound and no exudates. Meta honey was placed on the wound with a Q-tip and a dry dressing placed over the wound, (dated initialed and timed). Trash was placed into a plastic bag and taken to the soiled utility room. After placing the bag into the barrel, the nurse left the soiled utility room without washing or sanitizing her hands, went back to the resident's room and donned gloves to remove soiled linen into a plastic bag, removed gloves washed hands and took the plastic bag to the soiled utility room for disposal into the barrel. The nurse went to another room to wash hands. The nurse confirmed he/she had failed to close the door and pull curtains before procedure. The ADON also confirmed he/she did not wash hands after placing the plastic bag into the trash barrel and before donning gloves back in the resident's room. He/she stated, Nerves. RESIDENT's RIGHTS POLICY documented the environment should be one that is respectful of patient's dignity. The environment that preserves dignity and contributes to a positive self image. WOUND CARE POLICY documented Wash hands before and after donning gloves",2020-09-01
262,MAGNOLIA MANOR - INMAN,425032,63 BLACKSTOCK ROAD,INMAN,SC,29349,2017-10-05,425,G,0,1,V3MK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of facility policy and contract, the facility failed to provide pain medication to meet the needs of Resident #209, 1 of 1 sampled resident reviewed for Pain. Resident #209 did not have pain medication available in a timely manner after admission to the facility. Cross refer to F309 The findings included: The facility admitted Resident #209 with [DIAGNOSES REDACTED]. Record review of hospital progress notes on 10/4/2017 at 3:50 PM revealed that Resident #209 underwent surgical procedures to the Abdominal Wall Abscess on 9/21/2017, 9/17/2017 and 9/16/2017. The notes indicated the abscessed area was 30 centimeters (cm) x 12cm, with a surgical incision 17cm in length. Record review of the nursing admission assessment on 10/4/2017 at 2:06 PM revealed the resident was admitted to the facility on [DATE] at 3:40 PM. A pain evaluation was completed as part of the assessment and indicated the resident had pain frequently over the past 5 days. A section of the pain evaluation asking the resident to rate her/his pain was not completed. The pain evaluation indicated the resident had vocal complaints of pain, specifically, incisional pain. Review of copies of faxed orders on 10/4/2017 at 12:22 PM indicated the facility faxed the pharmacy Resident #209's prescriptions at 5:53 PM on 10/2/2017. Record review of the Physician's Orders and Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. The resident's pain score was 8 of 10 on the 0-10 pain scale. During an interview and observation of Resident #209 on 10/3/2017 at 2:36 PM, Resident #209 was laying in bed and appeared tense and rigid (uncomfortable). When asked to rate her/his pain on the 0-10 pain scale, Resident #209 rated her/his pain at a 10 of 10. Resident #209 stated she/he was admitted to the facility yesterday afternoon around 4:00 PM. She/he stated that she/he had pain medicine in the hospital at 12:30 PM on 10/2/2017 and did not receive pain medication in the facility until 2:00 AM today (10/3). Resident #209 stated the facility did not have her/his pain medication in the facility until then. During an interview with Licensed Practical Nurse (LPN) #2 on 10/4/2017 at 11:32 AM, LPN #2 stated Resident #209's pain medication was delivered to the facility at 12:45 AM on 10/3/2017. LPN #2 stated that facility protocol for medication acquisition after 5:00 PM is to fax the pharmacy and call the pharmacy for any medications needed as soon as possible. During an interview with the Director of Nursing (DON) on 10/4/2017 at 1:28 PM, the DON stated the facility did not have a back up pharmacy for medications needed after hours because the pharmacy they contract with is supposed to provide medications 24 hours per day, 7 days per week. During an interview with the Medical Director on 10/5/2017 at 11:21 AM, the Medical Director stated it was inexcusable for a patient to have to wait that long for pain medication. The Medical Director stated if the facility can't get medication from the pharmacy in a timely manner then maybe they need to look at getting a new pharmacy. The Medical Director stated the facility's medication acquisition process is not working if a patient has to wait that long for medication. During an interview with the DON, (with the Nurse Consultant and Nursing Home Administrator present) on 10/5/2017 at 1:00 PM, the DON stated the facility was implementing a stat box for controlled medications to ensure there would be no future delays for residents needing narcotic pain medication. Review of the facility policy entitled Physician/Prescriber Authorization and Communication of Orders to Pharmacy on 10/4/2017 at 12:22 PM revealed the policy did not identify a procedure for medication acquisition after hours. The policy did not indicate that staff needed to call the pharmacy for medications needed after hours. Review of the Pharmacy Services Agreement on 10/4/2017 at 12:22 PM revealed in the event PHARMACY cannot furnish an ordered medication on a prompt and timely basis, PHARMACY will make arrangements with another pharmacy supplier in a community local to FACILITY to promptly and timely provide such pharmaceutical products to FACILITY. In addition, the contract revealed that the facility will order medications for all residents exclusively from the contacted pharmacy. Per the Pharmacy Services Agreement, PHARMACY shall provide STAT Deliveries and pharmaceutical products on a 24-hour basis, seven days a week (including holidays)., and PHARMACY shall provide adequate backup pharmacies and suppliers to support the emergency needs of FACILITY residents.",2020-09-01
263,MAGNOLIA MANOR - INMAN,425032,63 BLACKSTOCK ROAD,INMAN,SC,29349,2017-10-05,431,D,0,1,V3MK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to store medications properly in 1 of 2 treatment carts observed. The treatment cart on Unit 2 had multiple expired items. The findings included: Observation of the Unit 2 treatment cart on [DATE] at approximately 4:08 PM revealed five expired items. A tube of triad hydrophilic wound dressing had an expiration date of ,[DATE]. Three packets of betadine swabsticks had expiration dates of ,[DATE], and another packet had an expiration date of ,[DATE]. Interview with Licensed Practicing Nurse #1 on [DATE] at approximately 4:10 PM confirmed these five expired items. Interview with the Director of Nursing on [DATE] at approximately 9:18 PM revealed that treatment carts are to be checked every month and expired items are to be discarded.",2020-09-01
264,MAGNOLIA MANOR - INMAN,425032,63 BLACKSTOCK ROAD,INMAN,SC,29349,2019-10-23,602,D,1,0,M1W411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, [MEDICATION NAME] Tablets (60) were missing from the narcotic lock box on the 400 unit assigned to Resident #1 (1 of 11 reviewed for abuse). The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. On 9/7/19 Licensed Practical Nurses (LPNs) # 4 and #5 notified the Director of Nursing (DON) of missing [MEDICATION NAME] Tabs (60) from the 400 unit med cart assigned to Resident # 1. It was discovered the sign out sheets and the copy of the pharmacy delivery sheet had all been removed plus the medication. Pharmacy sent a copy of the delivery sheet to the facility which documented the medication was delivered on 8/29/19 and signed for. The nurse then placed the sign out sheets in the book and the medications in the locked narcotic box. Not only were the sign out sheets for this resident for the [MEDICATION NAME] missing but also the shift to shift sign in sheets were missing. Further investigation documented the 400 Unit manager LPN #6 worked on the Medication cart on 9/1/19 and 9/2/19. On 9/3/19 she/ he suddenly turned in his/her keys and resigned. Licensure and Certification were notified as well as the police and DE[NAME] Omnicare Pharmacy did an audit on 9/16/19. Interview with the current DON and the Administrator on 10/23/19 confirmed that the 60 [MEDICATION NAME] tablets were discovered missing from the 400 unit med cart after LPN #6 had resigned.",2020-09-01
265,MAGNOLIA MANOR - INMAN,425032,63 BLACKSTOCK ROAD,INMAN,SC,29349,2019-10-23,607,E,1,0,M1W411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to follow facility policy related to multiple delayed reports to state agencies, not following policies related to protecting residents from sexual abuse, misappropriation, and not following policies related to abuse investigations for Residents #1, #4, #5, and #6 (4 of 11 residents reviewed for abuse). The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. The facility did not protect Resident #1 from the misappropriation of pain medication stored in the locked narcotic box of the medication cart on unit 400. Sixty [MEDICATION NAME] tablets were taken by a staff member who had a key to the med cart and the narcotic box. This act is considered misappropriation of the Resident's medication which was prescribed for the resident by the attending physician. The misappropriation of 60 [MEDICATION NAME] tablets was not reported immediately to Certification. The missing medication was reported to the Director of Nursing (DON) on 9/7/19 but not reported to Certification until 9/9/19 at 12:45 PM. The facility admitted Resident #5 with [DIAGNOSES REDACTED]. While in the shower on 9/24/19 the resident told the Certified Nursing Assistant (CNA) that he/she had been sexually assaulted in her room the night before. As soon as the CNA could safely get the resident out of the shower, the CNA notified the supervisor of the alleged sexual abuse. The supervisor waited to interview the resident and other staff before notifying Certification of the alleged abuse. The report was a 24 hour report. Resident #4 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of 24-hour report and 5-day report on 10/21/19 at approximately 10:30 AM revealed the 5-day was reported 7 days later. Per the investigation summary, CNA #4 was caring for Resident #4 when s/he passed gas. Per Resident #4, CNA #4 stated s/he better be glad it was just gas. Interview with DON on 10/21/19 at approximately 11:51 AM revealed confirmed the 5-day report was late. The DON said several other 5-days of Facility Reported Incidents being investigated in the survey were late as well. Interview with DON on 10/21/19 at approximately 2:10 PM revealed there was no signed statement from alleged perpetrator. DON confirmed there was no third-party witness who could corroborate what CNA #4 told him/her following the incident. S/he stated CNA #4 was fuming and upset following the incident and complained about the resident, saying s/he got off on getting feces on staff. The DON immediately escorted CNA #4 out of the building. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of investigation summary on 10/22/19 at approximately 9:21 AM revealed the Resident #6 accused CNA#1 of physical and mental abuse. The facility did not substantiated based on lack of evidence and inability to prove willful intent. Review of 5-day report on 10/22/19 at approximately 10:50 AM revealed the 5-day was submitted on 5/13/19, which was 7 days after the facility discovered the incident (5/16/19). Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Facility Summary of Investigation on 10/22/19 at approximately 11:44 AM revealed Resident #1 accused Activities Assistant (AA) #1 of taking his/her money to buy him/her cigarettes. AA #1 shouted at resident that this did not occur and swore at the resident. Review of the 2/24 hour and 5-day report on 10/22/19 at approximately 12:21 PM revealed a delay in the 5-day report. The incident occurred on 5/18/19 and the 5-day was submitted 5/24/19. Review of Abuse Policy on 10/23/19 at approximately 11 AM revealed the following: 1. Interviews are conducted with individuals having first-hand knowledge of incident. 2. Employees / witnesses do not write out statements. A designated staff member conducts the interview and types it. The interviewer signs the finished statement. 3. There was no policy that outlined how the authenticity of witness statements would be guaranteed. 4. Investigation summaries were to be submitted to the appropriate authorities within 5-days.",2020-09-01
266,MAGNOLIA MANOR - INMAN,425032,63 BLACKSTOCK ROAD,INMAN,SC,29349,2019-10-23,609,E,1,0,M1W411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to report abuse timely for Residents #1, #4, #5, and #6 (4 of 11 residents reviewed for abuse). Resident #1's misappropriation of property was not reported timely. Resident #5's sexual abuse allegation was not reported timely. Residents #6, #4, and #1 did not have 5-day reports submitted timely. The findings included: Resident #4 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of 24-hour report and 5-day report on 10/21/19 at approximately 10:30 AM revealed the 5-day was reported 7 days later. Per the investigation summary, Certified Nursing Assistant (CNA) #4 was caring for Resident #4 when s/he passed gas. Per Resident #4, CNA #4 stated s/he better be glad it was just gas. Interview with Director of Nursing (DON) on 10/21/19 at approximately 11:51 AM revealed confirmed the 5-day report was late. The DON said several other 5-days of Facility Reported Incidents being investigated in the survey were late as well. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of investigation summary on 10/22/19 at approximately 9:21 AM revealed the Resident #6 accused CNA#1 of physical and mental abuse. The facility did not substantiated based on lack of evidence and inability to prove willful intent. Review of 5-day report on 10/22/19 at approximately 10:50 AM revealed the 5-day was submitted on 5/13/19, which was 7 days after the facility discovered the incident (5/16/19). Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Facility Summary of Investigation on 10/22/19 at approximately 11:44 AM revealed Resident #1 accused Activities Assistant (AA) #1 of taking his/her money to buy him/her cigarettes. AA #1 shouted at resident that this did not occur and swore at the resident. Review of the 2/24 hour and 5-day report on 10/22/19 at approximately 12:21 PM revealed a delay in the 5-day report. The incident occurred on 5/18/19 and the 5-day was submitted 5/24/19. The facility admitted Resident #1 with [DIAGNOSES REDACTED]. The misappropriation of 60 [MEDICATION NAME] tablets was not reported immediately to Certification. The missing medication was reported to the DON on 9/7/19 but not reported to Certification until 9/9/19 at 12:45 PM. As of 10/21/19, the missing medications had not been reported to Board of Pharmacy or the Board of Nursing. The facility admitted Resident #5 with [DIAGNOSES REDACTED]. While in the shower on 9/24/19 the resident told the CNA that he/she had been sexually assaulted in her room the night before. As soon as the CNA could safely get the resident out of the shower, the CNA notified the supervisor of the alleged sexual abuse. The supervisor waited to interview the resident and other staff before notifying Certification of the alleged abuse. The report was a 24 hour report.",2020-09-01
267,MAGNOLIA MANOR - INMAN,425032,63 BLACKSTOCK ROAD,INMAN,SC,29349,2019-10-23,610,D,1,0,M1W411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to sufficiently investigate abuse for Resident #4 (1 of 11 residents reviewed for abuse). The facility failed to obtain a proper statement from an Certified Nursing Assistant (CNA) #4. Because the statement taken by the Director of Nursing (DON) was neither signed by the CNA nor witnessed by a third party, and because the CNA later denied making that statement, the abuse could not be substantiated. The findings included: Resident #4 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of DON's recollection of CNA #4's statement on 10/21/19 at approximately 10:45 AM revealed the following: 1. CNA #4 confirmed s/he stated the resident better be glad it was just gas. 2. CNA #4 stated s/he thinks the resident sprays them with poop on purpose. S/he thinks s/he gets off on getting his/her poop on employees. 4. CNA #4 did not sign this statement. It was written and signed by the DON. There were no witness signatures. Interview with CNA #4 on 10/21/19 at approximately 1:55 PM revealed the following: 1. CNA stated s/he only asked the resident to inform him/her if s/he felt the urge to pass gas. 2. Resident #4 passed gas. CNA #4 denied saying anything to making threats. 3. When asked about his/her statement, CNA #4 denied writing a statement. S/he spoke with staff regarding what happened, but s/he did not see what they wrote. S/he was concerned they misunderstood what s/he said, as s/he did express that s/he was glad (Resident #4) only passed gas to other staff members. Interview with DON on 10/21/19 at approximately 2:10 PM revealed there was no signed statement from alleged perpetrator. DON confirmed there was no third-party witness who could corroborate what CNA #4 told him/her following the incident. S/he stated CNA #4 was fuming and upset following the incident and complained about the resident, saying s/he got off on getting feces on staff. The DON immediately escorted CNA #4 out of the building.",2020-09-01
268,MAGNOLIA MANOR - INMAN,425032,63 BLACKSTOCK ROAD,INMAN,SC,29349,2019-10-23,684,D,1,0,M1W411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to provide adequate quality of care for Resident #6 (1 of 11 residents reviewed for abuse). Resident #6's head was injured during transfer, and neither Certified Nursing Assistant (CNA) reported it to nursing. The Director of Nursing (DON) agreed that they should have reported the incident as even a minor head injury could be serious in an elderly patient. The findings included: Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of investigation summary on 10/22/19 at approximately 9:21 AM revealed the following: 1. On (MONTH) 6, 2019 Resident #6 spoke with Registered Nurse (RN) #1 regarding an incident of alleged abuse that occurred on 5/2/10 at approximately 10 PM. 2. Resident #6 had a BIMS of 13. 3. Resident #6 stated on Thursday around 10 PM, two CNAs entered the room to help him/her get into bed. 4. CNAs helped move the resident's legs on the bed so the s/he could lay down, and one CNA threw them on the bed, causing the resident to hit her head on the wall. 5. Resident #6 stated the CNA hurt him/her. S/he said s/he would report him/her. CNA said, I don't give a (expletive). They won't believe you anyway. 6. Resident #6 did not report to the nurse that night -- either that s/he had hit his/her head or that CNA #1 had cursed at him/her. 7. The resident stated, I didn't want to tell anyone because I have to stay here and was afraid they would hurt me worse or lose their job, and I don't want anyone to lose their job. 8. CNA #1 was the suspect and was an agency CN[NAME] 9. Staff interviewed CNAs #1 and #3. 10. Facility concluded that Resident #6 hitting his/her head against the wall was accidental. Abuse unsubstantiated. Review of CNA #3's statement on 10/22/19 at approximately 9:35 AM revealed the following: 1. CNA #3 was with CNA #1 during resident transfer from wheelchair to bed. 2. Resident #6 hit his/her head when staff placed his/her feet in the bed. 3. Resident did not complain, and nothing was reported to nurse. Review of CNA #1's statement via contractor on 10/22/19 at approximately 9:46 AM revealed the following: 1. CNAs #1 and #3 helped Resident #6 into bed. 2. CNA #1 placed the resident's legs on the bed, and the resident's head bumped lightly against the wall located at the head of the bed. 3. CNA #1 asked if the resident was okay, and resident stated yes. 4. Resident #6 stated s/he would report it. 5. CNA #1 asked if resident was hurting and resident said no. 6. CNA #1 assessed resident and did not observe any signs of bruising or breaks in skin. Resident #6 did not complain of pain or injury. Review of 5/6/19 physician progress notes [REDACTED].#6 denied pain and there was no obvious bruising. Review of Resident #6's closed record on 10/22/19 at approximately 10:27 AM revealed there was no documentation of assessment of resident's head injury prior to physician's note on 5/6/19. Interview with CNA #1 on 10/22/19 at approximately 12:39 PM revealed the following: 1. CNA #1 transferred resident but did not recall specifics. 2. Resident #6 mentioned hitting his/her head. The CNA did not say anything back to her. 4. The nurse was informed and assessed resident. 5. The CNA never worked with that resident again. Interview with CNA #3 on 10/22/19 at approximately 3:17 PM revealed the following: 1. During transfer of Resident #6, the resident tapped his/her head on the wall. 2. The resident did not say anything. 3. The incident was not reported to the nurse. Interview with Licensed [MEDICATION NAME] Nurse (LPN) #4, the nurse on duty during the incident, on 10/23/19 at approximately 9:09 AM revealed s/he could not recall the resident and had not worked in the facility in months. Interview with DON on 10/23/19 at 9:26 AM revealed the CNAs should have notified the nurse if a resident's head was accidentally bumped during transfer. The DON stated minor head injuries may be serious in the elderly and merited nursing assessment.",2020-09-01
269,MAGNOLIA MANOR - INMAN,425032,63 BLACKSTOCK ROAD,INMAN,SC,29349,2019-10-23,745,D,1,0,M1W411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to provide adequate social services for Resident #6 (1 of 11 residents reviewed for abuse). Resident #6 alleged staff of abuse, and when recounting abuse to the physician was tearful, but there was no follow-up social services or counseling for the resident. The findings included: Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of investigation summary on 10/22/19 at approximately 9:21 AM revealed the following: 1. On (MONTH) 6, 2019 Resident #6 spoke with Registered Nurse (RN) #1 regarding an incident of alleged abuse that occurred on 5/2/10 at approximately 10 PM. 2. Resident #6 had a BIMS of 13. 3. Resident #6 stated on Thursday around 10 PM, two Certified Nursing Assistants (CNAs) entered the room to help him/her get into bed. 4. CNAs helped move the resident's legs on the bed so the s/he could lay down, and one CNA threw them on the bed, causing the resident to hit her head on the wall. 5. Resident #6 stated the CNA hurt him/her. S/he said s/he would report him/her. CNA said, I don't give a (expletive). They won't believe you anyway. 6. Resident #6 did not alert report to the nurse that night -- either that s/he had hit his/her head or that the CNA #1 had cursed at her. 7. The resident stated, I didn't want to tell anyone because I have to stay here and was afraid they would hurt me worse or lose their job, and I don't want anyone to lose their job. 8. CNA #1 was the suspect and was an agency CN[NAME] 9. RN #1 contacted agency regarding the incident and agency did not schedule CNA #1 pending completion of investigation. 10. Staff interviewed CNAs #1 and #3. 11. Social Service was to follow up and offer psychosocial support. 12. Resident was under APS custody due to living situation prior to admission to facility. 13. Facility concluded that Resident #6 hitting her head against the wall was accidental. Abuse unsubstantiated. Review of 5/6/19 physician progress notes [REDACTED]. 1. When abuse allegation was brought up, Resident #6 became teary eyed and stated, I really do not want to talk about this again. I'm afraid, and I was told if I said anything no one would believe me and nothing would be done. I'm not trying to cause any trouble because I have to stay here. I didn't even tell my family what happened to me. I did tell the head nurse about what happened to me. I was getting back in bed. My legs were swung over and my head hit the wall. I asked why s/he was doing this, and when I said I would tell someone, s/he said 'Go ahead. No one is going to believe you.' 2. Resident #6 denied pain and there was no obvious bruising. 3. Physician noted in Assessment and Plan that resident appeared fearful and teary when recounting the abuse allegation. Resident kept insisting s/he did not want to cause any trouble during his/her stay. Review of Resident #6's closed record on 10/22/19 at approximately 10:27 AM revealed the following: 1. Review of orders revealed resident was not taking [MEDICAL CONDITION]. 2. Review of physician progress notes [REDACTED]. 3. Review of nursing notes revealed no other concerns related to mood / behaviors. 4. Review of social service notes did not bring up incident. It was not documented that social services met with the resident following the abuse allegation. Social Worker (SW) #1 was working as director at that time, but he/she was no longer with the facility. Interview with SW #1 on 10/22/19 at approximately 11:03 revealed s/he did not recall the incident or resident and was uncertain if Resident #6 received social services support following the allegation.",2020-09-01
270,MAGNOLIA MANOR - INMAN,425032,63 BLACKSTOCK ROAD,INMAN,SC,29349,2019-10-23,755,D,1,0,M1W411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, staff had inaccurate documentation on narcotic signout sheets and medication administration sheets for Resident #1 (1 of 11 residents observed for abuse). The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. During record review on 10/21/19, multiple narcotic sign out sheets documented more medication given than ordered by the physician. The physicians order read [MEDICATION NAME] 10/325 give 1/2 tab q 4h PRN (1/2 tablet every 4 hours as needed) for pain. Review of the sign out sheets revealed the following: 8/22/19 - 2 tabs signed out (only ordered 1 tab); 8/28/19 2 tabs signed out, 1 tab ordered; 9/5/19 2 tabs signed out, MAR (Medication Administration Record) shows 3 given; 9/6/19 3 signed out, MAR indicated [REDACTED] On 10/22/19 at 9/10/AM, the Director of Nursing (DON) confirmed that all the physicians orders for [MEDICATION NAME] were for 1/2 tablet. The DON reviewed each of the entries and confirmed the inaccuracies. A narcotic check was done on 10/23/19 at 3:15 PM with 2 staff nurses and totals were correct and accounted for on both 400 unit med carts.",2020-09-01
271,MAGNOLIA MANOR - INMAN,425032,63 BLACKSTOCK ROAD,INMAN,SC,29349,2019-10-23,761,D,1,0,M1W411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, narcotic medications were left stored all day in an unsecured area and went missing (1 of 1 storage cabinets for pharmacy reviewed). The findings included: Investigation into an allegation of 60 missing [MEDICATION NAME] tablets revealed that on 3/19/19 at 2:40 PM the 60 [MEDICATION NAME] tablets were missing from a cabinet where the Employee Health Records were housed. The records were needed for a state inspection. Neither the Director of Nursing (DON) nor the Assistant Director of Nursing were in the facility at the time. The Maintenance Director was asked to cut off the lock to the cabinet. The narcotic medications had been stored in the cabinet for destruction since the medications had been discontinued for a resident. Records showed the cabinet remained unlocked with the meds inside through out the day with various staff going in and out of the office. Time lapsed before the DON checked the office to find the 60 [MEDICATION NAME] tablets missing. The sheets were still in the cabinet. Pharmacy Guidelines stipulate Pharmaceutical controlled substances transferred from ultimate users to authorized collectors shall be securely stored until rendered non-retrievable.",2020-09-01
272,MAGNOLIA MANOR - INMAN,425032,63 BLACKSTOCK ROAD,INMAN,SC,29349,2019-10-23,812,D,1,0,M1W411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to ensure meal delivery policies were followed for Resident # 7 (1 of 11 reviewed for abuse). The findings included: Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of facility's five day report indicated on 7/29/19 Resident #7 reported at 8:45 AM to the Director of Nursing (DON) and Social Services Assistant that Certified Nursing Assistant (CNA) #2 and CNA #4 put hot sauce in his/her tea and on his/her dinner last night (7/28/19). During an interview with CNA #2 on 10/22/19 at 10:30 am, s/he stated, s/he was not allowed in the room due to a previous incident and did not come into contact with the dinner tray on the night in question. During an interview with CNA #1 on 10/22/19 at 12:44 PM, s/he stated they were assisting in passing trays the night in question and when the tray was delivered, the meal had already been prepared and the straw had been placed in the cup of tea. CNA #1 stated s/he had no knowledge of who prepared the meal prior to delivery. During an interview with the DON on 10/23/19 at 9:25 AM, s/he confirmed the meal delivery policy had not been followed and that for safety and sanitary reasons, the meals should be prepared in front of the resident. Review of the facility's Meal Delivery policy states, When serving the meal, tell the patient what is being served, open and unwrap food items, butter bread, cut meat and add seasoning if the patient desires or is unable to perform these tasks. Perform these tasks avoiding bare hand contact with the food.",2020-09-01
273,MAGNOLIA MANOR - INMAN,425032,63 BLACKSTOCK ROAD,INMAN,SC,29349,2018-12-20,574,E,0,1,0G2K11,"Based on interview and record review, the facility failed to ensure The Resident Council was aware of how to file a complaint with the South [NAME]ina State Survey Agency for 1 of 1 Resident Council meetings. The findings included: During the Resident Council Group Meeting held 12/17/2018 at 2:20 pm the residents stated they did not receive information and did not know how to file a complaint with the state survey agency. Record review revealed the majority of residents in attendance were long term residents who had resided in the facility for several months/years. Review of Resident Council meetings revealed no information to suggest information related to how to file a complaint/grievance had been discussed with residents. Interview with the Administrator on 12/17/2018 at approximately 4:30 pm revealed residents are provided this information upon admission. Further interview revealed residents are not provided this information after admission.",2020-09-01
274,MAGNOLIA MANOR - INMAN,425032,63 BLACKSTOCK ROAD,INMAN,SC,29349,2018-12-20,577,E,1,1,0G2K11,"> Based on observation and interview, the facility failed to ensure the results of the most recent survey were accessible and readily available to residents without having to ask for assistance to examine the report for 5 of 5 residents in Resident Council. The findings included: During the Resident Council Group Meeting held on 12/17/2018 at 2:20 pm the residents stated they did not know where the latest state survey inspection report results were located. All residents in attendance stated they had never reviewed the survey inspection results and did not know where they were located. Observations during the days of the survey revealed a binder hanging on the entry wall with survey results written on the front. Further review revealed the writing was facing the wall and not facing the direction in which residents would be able to read it. Continued observation revealed there was no signage on any of the three Nursing Units to indicate the location of the survey inspection results. Interview with the Administrator on 12/17/2018 at approximately 4:30 pm verified that survey inspection reports were located in a binder hanging on the entry wall only.",2020-09-01
275,MAGNOLIA MANOR - INMAN,425032,63 BLACKSTOCK ROAD,INMAN,SC,29349,2018-12-20,600,G,1,0,0G2K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, an incorrect method of providing mobility for Resident #7 resulted in injury for 1 of 3 reportable's reviewed for falls. The findings included: The facility admitted Resident #7 with [DIAGNOSES REDACTED]. The resident had a BIMS (Brief Interview for Mental Status) of 15 denoting ability to make own decisions. The Minimum Data Set (MDS) documented that this resident was a total care resident needing total lift with 2 person assist for mobility and transfers. The Physicians Order read: 2 Certified Nursing Assistant (CNA) Hoyer Lift. On 10/14/18 resident was seated in a gerichair. The CNA proceeded to try to transfer the resident from the gerichair to the bed by herself. While lifting resident in gerichair to place lift pad under the resident, the resident slipped and fell to the floor. The CNA later stated the resident slipped and resident was eased down to the floor. The resident stated in an interview on 12/20/18 at 8 AM that the (staff) dropped her. Licensed Practical Nurse (LPN) # 5 assessed the resident after the fall and in his/her opinion did not see any injury. The Physician was notified and stated, Let the Nurse Practitioner (NP) check the resident in the morning. The resident asked to go to the hospital. The resident continued to complain and asked for his/her leg to be X-rayed. The Nurse told the resident s/he could not call for an X-Ray. In a late entry on 10/16/18 at 1 AM clarification note, the Nurse told the resident s/he could not order an X-Ray without calling the doctor, but the resident could send himself/herself out. The Nurse told the resident to let his/her meds take effect and see the NP in the morning. The family called Emergency Medical Services (EMS) to do a welfare check. EMS came to facility and assessed the resident. EMS wanted to take him/her to the emergency room (ER), but the resident refused. They called a doctor at the ER to see what to do. Since the resident refused, the ER doctor advised them to leave him/her at the facility. There was no documentation of the NP checking the resident. The resident went to [MEDICAL TREATMENT] on 10/15/18 and was transferred to the hospital from there. A scan was done and the resident was found to have a fractured right ankle. The resident was treated and returned to the facility on [DATE] with a splint to the right foot and leg. Five CNA's were interviewed about care of residents with a fall risk and transfers. All of the CNA's knew to look in the resident profile in the kiosk for instructions on how to lift residents and the number of staff needed. The Physician was interviewed via telephone twice on 12/20/18. At 7:45 AM, the Physician could not remember anything about the incident, except the nurse did call him. About 8:15 AM, the Physician called back and made a statement corresponding to the information given by the facility related to the incident.",2020-09-01
276,MAGNOLIA MANOR - INMAN,425032,63 BLACKSTOCK ROAD,INMAN,SC,29349,2018-12-20,607,D,1,0,0G2K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and review of facility Leadership Policies and Procedures for Abuse Neglect, Exploitation, or Mistreatment, the facility failed to implement its policy related to investigations for abuse for 2 of 3 reviewed for abuse related to injury. The findings included: The facility admitted Resident #7 with [DIAGNOSES REDACTED]. Review of the facility's investigation of a fall for Resident #7 on 10/14/18 at 11:30 AM revealed an account of the incident written by the Administrator. Only 2 witnesses were listed . During an interview with the Administrator on 12/20/18 at 8:30 AM, he/she confirmed that he/she did not get a written witness statement from either of the two witnesses involved. He/she also confirmed that no statements were obtained from the other staff working on the unit at the time of the incident. There was also no interview statement from the resident who was interviewable. Review of the facility Leadership Policies and Procedures for Abuse, Neglect, Exploitation, or Mistreatment under Component VI: Investigation: #5 Written summaries of individuals having first hand knowledge of the incident. Designated facility staff will interview the staff and the interviewer will record all witness accounts in a document, written, dated, and signed by the interviewer. No document was submitted by the Administrator or facility staff. The Administrator thought he/she had done interviews but could not find the documentation. Resident #102 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. On 10/20/2018 at 3:00 PM, Resident #102 was noted during wound care to have bruising to her left foot, 5th toe. On X-ray the resident was noted with an acute [MEDICAL CONDITION] metatarsal neck. The resident was not ambulatory and transferred by Hoyer Lift. Resident #102 was unable to recall any injury to his/her foot. After interviewing the staff and resident, the facility was unable to determine how the fracture occurred. During the re-certification/complaint survey process, five Certified Nursing Assistants (CNAs) were interviewed related to transfer procedures. All five CNAs stated procedures for resident transfer were located in the Kiosk used by them for daily assignments. Interview with Licensed Practical Nurse (LPN) #5 and LPN #6 on 12/19/2018 at approximately 1:00 pm revealed CNAs were interviewed during the investigation and all stated that they did not bump Resident # 105's toe during care/treatment. Further interview revealed this information was not recorded. During an interview with the Abuse Coordinator, Director of Nursing, and the Administrator on 12/19/2018 at approximately 3:30 pm, it was revealed no direct care staff had been interviewed regarding how Resident #102 sustained the injury to his/her left 5th toe. Further interview verified the facility had no evidence to support that the alleged violation had been thoroughly investigated.",2020-09-01
277,MAGNOLIA MANOR - INMAN,425032,63 BLACKSTOCK ROAD,INMAN,SC,29349,2018-12-20,610,D,1,0,0G2K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to investigate, prevent and/or correct allegations of alleged abuse for 2 of 3 residents reviewed for abuse related to injury. The findings included: Resident #102 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. On 10/20/2018 at 3:00 PM, Resident #102 was noted during wound care to have bruising to her left foot, 5th toe. On X-ray the resident was noted with an acute [MEDICAL CONDITION] metatarsal neck. The resident was not ambulatory and transferred by Hoyer Lift. Resident #102 was unable to recall any injury to his/her foot. After interviewing the staff and resident, the facility was unable to determine how the fracture occurred. During the re-certification/complaint survey process, five Certified Nursing Assistants (CNAs) were interviewed related to transfer procedures. All five CNAs stated procedures for resident transfer were located in the Kiosk used by them for daily assignments. Interview with Licensed Practical Nurse (LPN) #5 and LPN #6 on 12/19/2018 at approximately 1:00 pm revealed CNAs were interviewed during the investigation and all stated that they did not bump Resident # 105's toe during care/treatment. Further interview revealed this information was not recorded. During an interview with the Abuse Coordinator, Director of Nursing, and the Administrator on 12/19/2018 at approximately 3:30 pm, it was revealed no direct care staff had been interviewed regarding how Resident #102 sustained the injury to his/her left 5th toe. Further interview verified the facility had no evidence to support that the alleged violation had been thoroughly investigated. The facility admitted Resident #7 with [DIAGNOSES REDACTED]. Flaccid [MEDICAL CONDITION] affecting unspecified side, Major [MEDICAL CONDITION], Legally Blind, Weakness, and a Brief Interview for Mental Status (BIMS) Score of 15 noting the resident is able to make own decisions and interviewable. Review of the facility's investigation of a fall for Resident #7 on 10/14/18 at 11:30 AM revealed an account of the incident written by the Administrator. Only 2 witnesses were listed . During an interview with the Administrator on 12/20/18 at 8:30 AM, he/she confirmed that he/she did not get a written witness statement from either of the two witnesses involved. He/she also confirmed that no statements were obtained from the other staff working on the unit at the time of the incident. There was also no interview statement from the resident who was interviewable. Review of the facility Leadership Policies and Procedures for Abuse, Neglect, Exploitation, or Mistreatment under Component VI: Investigation: #5 Written summaries of individuals having first hand knowledge of the incident. Designated facility staff will interview the staff and the interviewer will record all witness accounts in a document, written, dated, and signed by the interviewer. No document was submitted by the Administrator or facility staff. The Administrator thought he/she had done interviews but could not find the documentation.",2020-09-01
278,MAGNOLIA MANOR - INMAN,425032,63 BLACKSTOCK ROAD,INMAN,SC,29349,2018-12-20,655,E,0,1,0G2K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the baseline care plan did not include required information, was not updated as required, and/or provided to the resident or resident representative for Residents #148 and #267 (2 of 5 residents reviewed for baseline care plans). The findings included: The facility admitted Resident #148 on 11/21/18 with [DIAGNOSES REDACTED]. On 12/17/18 at 02:05 PM, review of the baseline care plan dated 11/21/18 revealed no documentation that a copy of the care plan or a reconciled list of medications was provided to the resident or resident representative. Further review revealed the resident received both Physical and Occupational Therapy which was not included on the baseline care plan. Review of the Social Service Notes indicated the resident was admitted for short term but was not indicated on the baseline care plan which also did not include a discharge plan and/or goals. Continued review revealed an order dated 11/23/18 for [MEDICATION NAME] and the baseline care plan was not updated to include the medication or risks. The facility admitted Resident #267 on 12/14/18 with [DIAGNOSES REDACTED]. Record review on 12/16/18 at approximately 03:35 PM revealed Resident #267 was admitted with an order for [REDACTED]. During an interview on 12/19/18, the Director of Nursing (DON) confirmed the findings as documented and stated the facility had implemented a Performance Improvement Plan related to baseline care plans. The DON also stated that Resident #267 had pulled out the PICC line. The DON further confirmed that occurred after the baseline care plan was due and that the PICC line was not listed on the base line care plan. When informed that the care plan was to be updated with changes from admission to the time the comprehensive care plan was completed, the DON stated we've got a lot of work to do. We need to revamp it.",2020-09-01
279,MAGNOLIA MANOR - INMAN,425032,63 BLACKSTOCK ROAD,INMAN,SC,29349,2018-12-20,657,D,0,1,0G2K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the comprehensive care plan was reviewed and revised by an interdisciplinary team that included a nurse aide with responsibility for Residents # 47 and 94 (2 of 29 reviewed for care plans). The findings included: The facility admitted Resident #94 on 07/29/2014 with [DIAGNOSES REDACTED]. Review of the record on 12/16/2018 at approximately 4:00 PM revealed the care plan attendance sheet was not signed by a Certified Nursing Assistant (CNA). The Unit Manager for Unit 200 confirmed that the CNA's did not attend the care plan meetings. The facility admitted Resident #47 on 10/11/16 with [DIAGNOSES REDACTED]., Acute [MEDICAL CONDITIONS], Dysphagia, and Hypertension. On 12/20/18 at 12:02 PM, review of the care plan attendance record revealed no CNA attended the care plan conference for Resident #47. During an interview on 12/20/18 at approximately 02:30 PM, the Nurse Consultant confirmed there was no documentation the CNA participated in the care plan process or attended the care plan conference.",2020-09-01
280,MAGNOLIA MANOR - INMAN,425032,63 BLACKSTOCK ROAD,INMAN,SC,29349,2018-12-20,658,D,0,1,0G2K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to ensure that the care plan was followed for resident #94 related to safety interventions (1 of 4 residents reviewed for falls). The findings included: The facility admitted Resident #94 on 07/29/2014 with [DIAGNOSES REDACTED]. During the initial tour on Unit 200, Resident #94 was out of the room. A bed alarm box without batteries was noted on the roommates over table. The bed alarm sensor pad was noted on resident # 94's bed and the cord for the box was under the bed. Further observations 12/16/18 at 12:30 PM revealed the alarm box remained on the roommates over table with no batteries. New batteries were applied and alarm was functioning at 4:00 PM when tested Record Review revealed that resident # 94 had a Physicians order for bed alarm to bed at all times with function and placement checked every shift. During an interview on 12/16/2018 at approximately 10:43 AM Certified Nursing Assistant #1 confirmed that the box had no batteries and was not connected to the sensor pad cord. On 12/16/2018 at 3:50 PM, Registered Nurse #1 stated, I saw the last 2 days that the bed alarm was not in place and that is why I circled it on the treatment flowsheet.",2020-09-01
281,MAGNOLIA MANOR - INMAN,425032,63 BLACKSTOCK ROAD,INMAN,SC,29349,2018-12-20,660,E,0,1,0G2K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to follow-up on a request to discharge for Resident #31 (1 of 1 residents reviewed for discharge planning). The findings included: The facility admitted Resident #31 on 03/19/18 with [DIAGNOSES REDACTED]. During an interview on 12/16/18 at 02:51 PM, Resident #31 voiced that s/he wanted to return to the community and go to her/his son's house to live. Resident #31 also reported that no one had discussed discharge planning with her/him. On 12/19/18 at 01:23 PM, review of the Care Plan Conference Summary dated 07/03/18 revealed the resident was requesting to go to her/his son's home to live and also indicated that Social Services will address resident's concerns with (her/his) son. The Social Services Director (SSD) was present at the care plan conference as evidenced by her/his signature. At 01:31 PM, review of the Social Services Progress Review dated 07/03/18 also indicated the resident wanted to discharge home with her/his son and that the resident felt like s/he was capable of taking care of her/himself while her/his son was at work. Further review of the Social Service Progress Notes revealed no documentation that the SSD followed up with the resident's son related to discharge. During an interview on 12/19/18 at 02:02 PM, Social Services designee #1 stated the SSD that was present at that time was no longer at the facility. At that time, each Social Services designee was responsible for a unit, but stated that now all Social Services designees work with all residents. S/he also confirmed there was no documentation that social services followed up with the resident's son. The current Social Services Director stated s/he was not aware of Resident #31's desire to be discharged to the son's house.",2020-09-01
282,MAGNOLIA MANOR - INMAN,425032,63 BLACKSTOCK ROAD,INMAN,SC,29349,2018-12-20,679,E,0,1,0G2K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to assess for and provide meaningful activities in accordance with the activities assessment for Resident #156 (1 of 1 resident reviewed for activities). The findings included: The facility admitted Resident #156 on 11/06/18 with [DIAGNOSES REDACTED]. During random observations on 12/16/18 from approximately 10:30 AM until 4:30 PM and 12/17/18 from 9:00 AM until 1:45 PM, Resident #156 was observed in the bed. On 12/17/18 at approximately 01:45 PM, the charge nurse stated the resident became agitated when the staff attempted to get him/her out of bed. Review of the activity assessment revealed the resident would receive one-on-one activities three times per week. Further review revealed an activity note dated 11/19/18 that indicated that a series of activities would be attempted to see how the resident responded to different activities. The participation record indicated only reading and music were offered and the documented follow-up of the resident's response to the one-on-one activities provided indicated sometimes the resident responded but mostly had no response. There was no change in the types of activities offered. Review of the care plan also indicated the resident was to receive one-on-one activities three times per week. Review of the participation record with the Activities Director (AD) indicated the resident did not receive one-on-one as the assessment indicated. On 12/18/18 at 04:10 PM, the AD confirmed the activity participation record for Resident #156 indicated the resident was offered music or reading to the resident 1-2 times a week most weeks. One week, the resident received one-on-one three times. The AD confirmed the resident did not receive one-on-one activities per the care plan and that only two forms of one-on-one activity had been offered with no changes to assess the resident's response to different types of activities.",2020-09-01
283,MAGNOLIA MANOR - INMAN,425032,63 BLACKSTOCK ROAD,INMAN,SC,29349,2018-12-20,684,E,0,1,0G2K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide care and services to meet the residents' needs for Residents #148 and #116 (2 of 2 residents reviewed for care and services). The facility failed to obtain orthostatic blood pressures as ordered for Resident #148. In addition, hospice communication was not accessible, the hospice and facility care plans were not integrated, and hospice did not attend the care plan conference for Resident #116. The findings included: The facility admitted Resident #148 on 11/21/18 with [DIAGNOSES REDACTED]. On 12/17/18 at 02:19 PM, review of the Vital Signs and Weight Record indicated orthostatic blood pressure (BP) was to be obtained BID (twice a day) for seven days. There were no documented blood pressures on the form. Review of the Physicians telephone orders revealed an order dated 11/28/18 for orthostatic BP lying and sitting BID for 5 days related to dizziness. Review of the nurses' notes revealed a blood pressure documented daily without indication whether it was sitting or lying down. During an interview on 12/17/18 at 02:30 PM, Licensed Practical Nurse (LPN) #1 confirmed the orthostatic blood pressures were not obtained as ordered. The facility admitted Resident #116 with [DIAGNOSES REDACTED]. Review of the resident record on 12/18/18 revealed this resident was admitted to hospice on 10/24/18. The Unit Nurse was asked where hospice information was kept for each resident. S/he responded, in a separate notebook. LPN #6 was asked to help locate the notebook which was not on the unit. It took one hour for the nurse to locate the book which was in Medical Records. Review of the hospice care plan and the facility care plan revealed they were not integrated. The facility provided a copy of the care plan on 12/18/18. During interview with the Care Plan Coordinators, they stated the care plan had just been updated, although the resident had been admitted to hospice on 10/24/18. One care plan meeting had been held for this resident, but the hospice nurse did not attend. The Certified Nursing Assistant, Chaplain, and Social Service notes were in the notebook, but staff had no access to them since they were in Medical Records.",2020-09-01
284,MAGNOLIA MANOR - INMAN,425032,63 BLACKSTOCK ROAD,INMAN,SC,29349,2018-12-20,688,E,0,1,0G2K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to accurately assess and provide treatment and services to maintain or improve passive range of motion for Resident #42 (1 of 1 resident reviewed for limited range of motion). The findings included: The facility admitted Resident #42 on 04/21/15 with [DIAGNOSES REDACTED]. On 12/17/18 at 01:34 PM, record review revealed a joint mobility screen dated 06/27/18 that stated Resident is quadraplegic. There was no documentation of the resident's passive range of motion (PROM) on admission. Further review revealed a second assessment dated [DATE] that also stated Resident is quadraplegic. The assessment did not include measurement of the resident's current mobility status and did not identify if there was any opportunity for improvement. There was no documentation if the resident had previously received treatment and services for mobility or why the treatment/services were stopped. Review of the 04/20/18 annual Minimal Data Set (MDS), Admission MDS dated [DATE], and Quarterly MDS dated [DATE] revealed the resident was coded as having impaired range of motion bilaterally of the upper and lower extremities. During an individual interview on 12/17/18 at approximately 01:15 PM, the resident confirmed that s/he was not able to move his/her upper or lower extremities. A Quarterly Therapy Screening Form dated 10/04/18 was reviewed and indicated no therapy evaluation was recommended. Review of the physician's orders [REDACTED]. Review of the care plan on 12/18/18 at 03:11 PM revealed contractures/[DIAGNOSES REDACTED] of the bilateral upper extremities was identified as a problem area and included the intervention to assess for increased pain and/or stiffness with daily care but did not include any intervention to maintain range of motion. During an interview at that time, Licensed Practical Nurse (LPN) #1 confirmed that s/he did not assess the resident's passive range of motion. The LPN stated s/he assumed it was an assessment of active range of motion but confirmed the instructions stated, Draw a line through the arc showing how far the limb can be moved (PROM). When asked how s/he would know if the resident had a decline in ROM from his/her baseline or was starting to develop a contracture, the LPN stated, Right.",2020-09-01
285,MAGNOLIA MANOR - INMAN,425032,63 BLACKSTOCK ROAD,INMAN,SC,29349,2018-12-20,689,G,1,1,0G2K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and interview, the facility failed to identify a risk of falling when turning in a geri-chair with 1 staff member for Resident #7 and failed to use a bed alarm as ordered for Resident #94 (2 of 4 reviewed for accidents/falls). The findings included: The facility admitted Resident #7 with [DIAGNOSES REDACTED]. The resident had a BIMS (Brief Interview for Mental Status) of 15 denoting ability to make own decisions. The Minimum Data Set (MDS) documented that this resident was a total care resident needing total lift with 2 person assist for mobility and transfers. The Physicians Order read: 2 Certified Nursing Assistant (CNA) Hoyer Lift. On 10/14/18 resident was seated in a gerichair. The CNA proceeded to try to transfer the resident from the gerichair to the bed by herself. While lifting resident in gerichair to place lift pad under the resident, the resident slipped and fell to the floor. The CNA later stated the resident slipped and resident was eased down to the floor. The resident stated in an interview on 12/20/18 at 8 AM that the (staff) dropped her. Licensed Practical Nurse (LPN) # 5 assessed the resident after the fall and in his/her opinion did not see any injury. The Physician was notified and stated, Let the Nurse Practitioner (NP) check the resident in the morning. The resident asked to go to the hospital. The resident continued to complain and asked for his/her leg to be X-rayed. The Nurse told the resident s/he could not call for an X-Ray. In a late entry on 10/16/18 at 1 AM clarification note, the Nurse told the resident s/he could not order an X-Ray without calling the doctor, but the resident could send himself/herself out. The Nurse told the resident to let his/her meds take effect and see the NP in the morning. The family called Emergency Medical Services (EMS) to do a welfare check. EMS came to facility and assessed the resident. EMS wanted to take him/her to the emergency room (ER), but the resident refused. They called a doctor at the ER to see what to do. Since the resident refused, the ER doctor advised them to leave him/her at the facility. There was no documentation of the NP checking the resident. The resident went to [MEDICAL TREATMENT] on 10/15/18 and was transferred to the hospital from there. A scan was done and the resident was found to have a fractured right ankle. The resident was treated and returned to the facility on [DATE] with a splint to the right foot and leg. Five CNA's were interviewed about care of residents with a fall risk and transfers. All of the CNA's knew to look in the resident profile in the kiosk for instructions on how to lift residents and the number of staff needed. The Physician was interviewed via telephone twice on 12/20/18. At 7:45 AM, the Physician could not remember anything about the incident, except the nurse did call him. About 8:15 AM, the Physician called back and made a statement corresponding to the information given by the facility related to the incident. The facility admitted Resident #94 on 07/29/2014 with [DIAGNOSES REDACTED]. During the initial tour on Unit 200, Resident #94 was out of the room. A bed alarm box without batteries was noted on the roommates over table. The bed alarm sensor pad was noted on resident #94's bed and the cord for the box was under the bed. Further observations 12/16/18 at 12:30 PM revealed the alarm box remained on the roommates over table with no batteries. New batteries were applied and alarm was functioning at 4:00 PM when tested Record Review revealed that resident #94 had a Physicians Order for bed alarm to bed at all times with function and placement checked every shift. During an interview on 12/16/2018 at approximately 10:43 AM, CNA #1 confirmed that the box had no batteries and was not connected to the sensor pad cord. On 12/16/2018 at 3:50 PM, Registered Nurse #1 stated, I saw the last 2 days that the bed alarm was not in place and that is why I circled it on the treatment flowsheet.",2020-09-01
286,MAGNOLIA MANOR - INMAN,425032,63 BLACKSTOCK ROAD,INMAN,SC,29349,2018-12-20,759,D,0,1,0G2K11,"Based on observation and interview, the facility failed to ensure a medication error rate of 5% or less. The medication error rate was 7.41% with 2 errors out of 27 opportunities. The findings included: During the medication administration observation on 12/19/18 at 08:47 AM, Licensed Practical Nurse (LPN) #3 administered Humalog Kwikpen 8 units. Observation revealed the nurse did not prime the Kwikpen prior to administration. During an interview on 12/19/18 at 10:19 AM, LPN #3 confirmed s/he did not prime the device per manufacturer's instructions. The LPN stated she knew the pen had to be primed prior to the first use but not prior to each use. At 9:08 AM on 12/19/18, LPN #2 was observed for medication administration. After allowing the surveyor to document the medication, the nurse placed the blister pack of medications on the top of the pills already placed in the cup and omitted placing the Carvedilol 3.125 milligrams 1 tablet into the cup. The medication pass was stopped and the nurse was asked to count the number of pills in the medication cup. The nurse and surveyor counted and found the number of pills in the cup to be 11 which should have been 12, including the Carvedilol, which was confirmed by the nurse.",2020-09-01
287,MAGNOLIA MANOR - INMAN,425032,63 BLACKSTOCK ROAD,INMAN,SC,29349,2018-12-20,812,F,0,1,0G2K11,"Based on record review and interview, the facility failed to calibrate the food thermometer prior to use, improperly cleaned the food thermometer with a paper towel, and did not maintain refrigerator temperatures above acceptable parameters in 1 of 1 kitchen and 2 of 3 nutrition refrigerators. The findings included: Observation on 12/17/18 at approximately 1:10 PM revealed Refrigeration & Freezer Monthly Temperature Logs for (MONTH) and (MONTH) (YEAR), which were both blank. Also, written on the Refrigeration & Freezer Monthly Temperature Logs for (MONTH) and (MONTH) (YEAR) was a statement that 47 degrees Fahrenheit (F) or higher is Too warm: Record Exact Temperature and Take Immediate action. The form also stated that at 35 degrees F or lower is Too Cold: Record Exact Temperature and Take Immediate Action. Interview with the dietary manager on 12/17/2018 at approximately 2:30 PM revealed s/he thought that 47 degrees F and 35 degrees F were the correct temperatures for spoilage. S/he did not realize that any thing above 41 degrees F was considered unacceptable to use and did not realize that 32 degrees F was the temperature for freezing. Observation on 12/18/2018 at approximately 11: 25 AM revealed the Line Cook using a food thermometer to test the temperature of cooked ground pork. After getting the correct temperature, s/he then used a paper towel to clean the food thermometer. When asked, s/he stated that s/he ran-out of sanitary wipes. This was also observed by the Head Dietitian, who then provided more sanitary wipes. Observation also revealed the Line Cook placed the food thermometer on the steam table, which caused the food thermometer to roll off and fall to the floor. The Head Dietitian picked it up and got a new food thermometer, but did not calibrate it. S/he then gave the food thermometer to the Line Cook to use on the next two items, which were pureed, cooked sweet potatoes and pureed, cooked pork.",2020-09-01
288,MAGNOLIA MANOR - INMAN,425032,63 BLACKSTOCK ROAD,INMAN,SC,29349,2018-12-20,867,D,0,1,0G2K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to review and/or revise an ineffective Quality Assurance(QA) plan related to baseline care plans for 1 of 3 QA plans reviewed. The findings included: On 12/17/18 at 02:05 PM, the survey team was informed that a PIP (Performance Improvement Plan) had been initiated in October, (YEAR) related to baseline care plans. Review of the provided PIP revealed the PIP had a completion date of 11/27/18. On 12/17/18 at 02:05 PM, review of the baseline care plan dated 11/21/18 for Resident #148 revealed no documentation that a copy of the care plan or a reconciled list of medications was provided to the resident or resident representative. Further review revealed the resident received both Physical and Occupational Therapy which was not included on the baseline care plan. Review of the Social Service Notes indicated the resident was admitted for short term but was not indicated on the baseline care plan which also did not include any discharge plan and/or goals. Continued review revealed an order dated 11/23/18 for [MEDICATION NAME] and the baseline care plan was not updated to include the medication or risks. Record review on 12/16/18 at approximately 03:35 PM revealed Resident #267 was admitted [DATE] with an order for [REDACTED]. Review of the policy entitled Leadership Policies and Procedures, Quality Assurance and Performance Improvement Program Committee Guidelines revealed The QAA (Quality Assessment and Assurance) Committee plan is a living document that will be reviewed and/or revised by the Facility to assure that quality care, safety and quality life practices are provided. During an interview on 12/20/18 at 02:14 PM, the Director of Nursing (DON) and Nursing Home Administrator confirmed the findings as documented above and confirmed the Performance Improvement Plan related to baseline care plans had not been revised. When informed that the care plan was to be updated with changes from admission to the time the comprehensive care plan was completed, the DON stated we've got a lot of work to do. We need to revamp it.",2020-09-01
289,J F HAWKINS NURSING HOME,425035,1330 KINARD STREET,NEWBERRY,SC,29108,2017-05-11,155,D,1,1,X7DC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to allow resident #14 to formulate their own Advance Directive, 1 of 21 sampled residents reviewed for Advance Directives. Resident #14 was DNR (Do Not Resuscitate) on admission to the facility with no documentation to indicate that was his/her choice. The findings included: The facility admitted Resident #14 with [DIAGNOSES REDACTED]. Record review of a telephone order, dated 4/18/2017, on 5/9/2017 at 2:01 PM, revealed an order that indicated Resident #14 is DNR status. Record review of a Advance Directive form, dated 4/18/2017, on 5/9/2017 at 2:01 PM, revealed that DNR status was chosen and signed for by the resident's family member. Record review of the Minimum Data Set 3.0 on 5/9/2017 at 3:03 PM, revealed that the resident had a BIMS (Brief Interview for Mental status) score of 14, indicating the resident was cognitively intact. Record review of a competency form on 5/9/2017 at 2:01 PM, revealed the physician documented that Resident #14 was unable to make health care decisions for himself/herself secondary to Dementia. This form was signed by the physician on 4/20/2017. There was no documentation from a second physician addressing the resident's ability to make his/her own healthcare decisions. Record review of the Social Worker notes on 5/9/2017 at 2:38 PM, revealed no documentation that Advance Directives or code status had been discussed with the resident. Record review of the Initial Social Service History, dated 4/18/2017, on 5/10/2017 at 3:45 PM, revealed that the resident had given family permission to sign all admission paper work for him/her. A section of the Initial Social Service History that addressed Advance Directives and code status was left blank. During an interview with the Admissions Coordinator and Director of Social Services on 5/10/2017 at 3:27 PM, the Director of Social Services confirmed that the facility did not have 2 physicians address the resident's decisional capacity. The Director of Social Services stated the facility had been waiting for the 2nd physician to evaluate the resident. The Director of Social Services confirmed that on 4/20/2017 one of the facility's physicians determined that the resident was unable to make his/her own health care decisions due to Dementia and the resident remained DNR status. The Admissions Coordinator stated that the resident had given family permission to sign all paperwork, including the Advance Directive. The Admissions Coordinator stated she was aware the resident had been evaluated by the physician on 4/20/2017 and that the physician determined that the resident was unable to make his/her own health care decisions. The Admissions Coordinator and Director of Social Services confirmed there was no documentation indicating a discussion had been had with the resident on 4/18/2017 regarding Advance Directives.",2020-09-01
290,J F HAWKINS NURSING HOME,425035,1330 KINARD STREET,NEWBERRY,SC,29108,2017-05-11,156,D,1,1,X7DC11,"> Based on observations and record review, the facility failed to provide written notices of Medicare non-coverage for two of three sampled residents reviewed and liability notices for three of three sampled residents reviewed. In addition, based on record review and interview, the facility failed to provide residents with required written contact information for governmental and advocacy agencies which affects all newly admitted residents. The findings included: A review of Generic and Liability Notices was conducted on 5/11/2017 at 3:59 PM for 3 sampled residents and revealed the following: (1) The facility provided a telephone notification of Medicare non-coverage (Form NOMNC) to Resident #22's representative on 4/20/17. There was no evidence that a written notice was sent as required. No liability notice (SNFABN/CMS or 1 of 5 approved letters) was provided for review. (2) The facility provided verbal notification of Medicare non-coverage (Form NOMNC) to Resident #17 and her/his representative on 4/10/17. There was no evidence that a written notice was provided as required. No liability notice (SNFABN/CMS or 1 of 5 approved letters) was provided for review. (3) No liability notice (SNFABN/CMS or 1 of 5 approved letters) was provided for review for Resident #39. During an interview on 5/10/17 at 9 AM, the Admissions Coordinator verified the two sampled residents did not receive written notification of Medicare non-coverage. S/he did not know about the liability notices and stated s/he would have to check up front to see if the liability notices had been sent. At 10:57 AM on 5/10/17, the Admissions Coordinator and the Administrator verified that they did not send the generic notices in writing and that the liability notices had not been completed. During an interview on 05/11/2017 at 01:35 PM, the Resident Council President stated that residents had not been informed of how to formally complain to the state about the care received at the facility. Review of the Council President's admission packet at 3:14 PM on 5/9/17 revealed no evidence that the information had been supplied in writing. Review of the packet of information supplied to newly admitted residents on 5/10/2017 at 10:57 AM revealed that it did not contain contact information for pertinent State agencies, resident advocacy groups, the protection and advocacy agency, and the Medicaid Fraud Control Unit. During an interview at 9:35 AM on 5/9/17, after reviewing the new admissions packet, the Admissions Coordinator verified that it did not contain the required information.",2020-09-01
291,J F HAWKINS NURSING HOME,425035,1330 KINARD STREET,NEWBERRY,SC,29108,2017-05-11,157,D,1,1,X7DC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to notify the physician and/or family of a significant change in condition requiring potential physician intervention for 1 of 5 sampled residents reviewed for unnecessary medication. The physician and family of Resident #10 were not notified of a blood sugar of 51. The findings included: The facility admitted Resident #70 with [DIAGNOSES REDACTED]. Record review on 5/9/17 at 10 AM revealed a physician's orders [REDACTED]. Recheck in 15 minutes and notify MD (doctor). Review of the 3/17 Medication Administration Record [REDACTED]. No physician/family notification was noted on the MAR. Review of Nurse's Notes on 5/9/2017 at 10:17 AM revealed none recorded between 2-27-17 and 3-11-17. During an interview on 5/11/17 at 11:32 AM, Registered Nurse (RN) #4 reviewed the record and verified the blood sugar of 51 with no documentation of family or physician notification. RN #4 was unable to explain the facility's process for reporting abnormal blood sugars.",2020-09-01
292,J F HAWKINS NURSING HOME,425035,1330 KINARD STREET,NEWBERRY,SC,29108,2017-05-11,159,D,1,1,X7DC11,"> Based on observations and interviews, the facility failed to ensure that 1 of 3 census sampled residents had access to resident funds account on weekends. Resident #59 did not know how to access his/her funds account on the weekends. The findings included: During individual interview on 5/08/17 at approximately 12:45 PM, Resident #59 stated the business office was closed on weekends when asked if he/she had access to resident funds on the weekend. Random observation on 5/10/17 at approximately 2:45 PM of the entrance way to the facility on Unit 1, Unit 2, review of posting in dining rooms on Unit 1 and Unit 2. There was no posting that informed residents how to get access to resident funds on the weekends. Random observation on 5/10/17 at approximately 12:50 PM revealed an 8 inch by 10 inch (sheet of paper) high up on a bulletin board near Unit 1 nurses station that indicated resident funds are available on the weekends. There was a sign at the business office that indicated the office was open Monday through Friday 8:30 AM to 5 PM. There was no posting that informed the residents who to contact regarding funds being available on the weekend. The posting was not at eye level for residents in wheel chairs. An interview on 5/10/17 at approximately 4 PM with the Accountable Payable Staff (APS) confirmed the posting regarding residents access was placed high on bulletin for wheelchair residents. The APS also confirmed the posting did not inform residents where to go or who to contact in order to access funds on the weekends. On 5/11/17 at approximately 1:45 PM, the facility Administration provided a Resident Council Minutes Meeting statement dated 7/18/2016 that indicated residents could access funds on Unit 1. There were no specifics related to who to contact. There were no Resident Council Minutes within the past 6 months that reminded the residents how to access funds on the weekends and who to contact.",2020-09-01
293,J F HAWKINS NURSING HOME,425035,1330 KINARD STREET,NEWBERRY,SC,29108,2017-05-11,160,C,1,1,X7DC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record reviews and interviews, the facility failed to ensure that the final accounting (closed out) of residents funds was completed within 30 days of discharge/death of 3 of 3 sampled residents reviewed. Residents #24, #83 and #110 funds were not conveyed timely. The findings included: During record review and interview on [DATE] at approximately 2:59 PM with the Accounts Payable Office Assistant during conveyance of funds; it was revealed that Resident #24 expired in (MONTH) (YEAR), Resident #83 expired (MONTH) (YEAR) and Resident #110 expired (MONTH) (YEAR) with the final accounting of the resident's account not being closed. The Accounts Payable Staff confirmed the findings,",2020-09-01
294,J F HAWKINS NURSING HOME,425035,1330 KINARD STREET,NEWBERRY,SC,29108,2017-05-11,167,C,1,1,X7DC11,"> Based on observation and interview, the facility failed to have 3 years of survey and complaint investigation results readily available for review on 2 of 4 units and failed to post notices of availability in prominent locations. The findings included: Observations on 5-8-17 and 5-9-17 revealed that the DHEC Survey notebooks on Units 1 and 2 contained only the most recent annual survey, complaints since that date, and plans of correction. There were no notices posted regarding availability of the preceding 3 years surveys upon request. During an interview on 5-9-17 at 11:17 AM, the Administrator verified that the preceding 3 years of surveys were not available for review.",2020-09-01
295,J F HAWKINS NURSING HOME,425035,1330 KINARD STREET,NEWBERRY,SC,29108,2017-05-11,250,D,1,1,X7DC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interviews, the facility failed to ensure that medically related social services were provided for 1 of 2 sampled residents reviewed. Resident #98 did not receive assistance with missing dentures and no documented participation/attendance of court hearing related to skilled nursing home placement. The findings included: The facility admitted Resident #98 with [DIAGNOSES REDACTED]. An interview on 5/08/17 at approximately 4:19 PM with Resident #98 revealed the facility was aware he/she had missing dentures and nothing had been done to locate the missing dentures. A review of the medical record on 5/09/17 at approximately 2:24 PM revealed Resident #98 had a Brief Interview of Mental Status (BIMS) score of 14 which indicated the resident was alert and interview-able. Further review of the medical record revealed an Evaluation of Oral/Dental Status form dated 3/22/17 that indicated the resident wears dentures while awake. There was a Data Collection/Evaluation Nutritional form dated 3/22/17 that indicated the resident wore upper and lower dentures with good fit. A nutritional progress note dated 3/27/17 indicated the resident wore upper and lower dentures with no difficulty in chewing and swallowing. There was no documentation in the social services notes related to missing dentures. An interview on 5/09/17 at approximately 3:24 PM with Licensed Practical Nurse (LPN) #1 revealed the resident did not have dentures when he/she came to the facility. LPN #1 confirmed there was no documentation in the medical record related to the missing dentures. An interview on 5/10/17 at approximately 9:24 AM with the Admission's Coordinator revealed the resident's upper dentures were provided a week ago after the resident reported they were misplaced. The Admissions Coordinator stated a family member was contacted after discussing concerns with surveyor. Staff reportedly spoke to resident about missing dentures on 5/10/17 and the resident wanted the bottom dentures found. Review of the medical record on 5/11/17 revealed a social services noted dated 4/12/17 that indicated Resident #98 had a court date on 4/12/17 at 1:30 PM to address his/her continued placement in the skilled nursing facility. The note further indicated the resident wanted to attend the court hearing. There was no documentation in the medical record to indicate the facility provided assistance in getting the resident to the court hearing. An interview on 5/11/17 at approximately 10:53 AM with the Admission's Coordinator confirmed there was no documentation to indicate the resident had participated in the court hearing on 4/12/17 to address his/her skilled nursing placement.",2020-09-01
296,J F HAWKINS NURSING HOME,425035,1330 KINARD STREET,NEWBERRY,SC,29108,2017-05-11,252,E,1,1,X7DC11,"> Based on observations and interview, the facility failed to provide a homelike dining environment for 19-21 residents on Unit 3 (locked unit). There were 18 worn, stained dining chairs noted with heavy build up of black stains or streaks. There was regular cushioned chair noted with large wet stain in seat in the living area. One of 4 dining areas observed. The findings included: Random observations on 5/08/17 at 12 :08 PM and 5/09/17 at 9:04 AM revealed multiple worn and stained dining room chairs on the locked unit ( Unit 3). The dining chairs were observed with heavy black stains to back of chair where the resident had to be seated. There was a cushion chair noted with a large wet spot in the seat of the cushion. An observation and interview on 5/10/17 at approximately 9:13 AM with the Housekeeping Manager confirmed the 18 worn dining chairs with black stains/streaks noted to back of chair and stain in padded chair in living area. The Housekeeping Manager stated these were the old chairs that came from another building. Around 2 PM on 5/10/17, the facility Administrator provided a plan of action that addressed the stained and worn chairs on Unit. The issues regarding the stained and worn chairs on Unit 3 (locked unit) was identified on 8/20/16.",2020-09-01
297,J F HAWKINS NURSING HOME,425035,1330 KINARD STREET,NEWBERRY,SC,29108,2017-05-11,253,D,1,1,X7DC11,"> Based on observation, record review and interview the facility failed to maintain a clean and sanitary environment on 2 of 4 units observed on all days of the survey. Reusable personal care equipment was observed un-bagged and unlabeled. Resident rooms and bathrooms were observed in disrepair or unclean. The findings included: A bed pan was observed, un-bagged and unlabeled, on the shower chair in the 212L bathroom on all days of the survey. The above observations were made in the 212L bathroom on 5/8/2017 at 3:48 PM, 5/9/2017 at 10:04 AM, 5/10/2017 at 3:30 PM and 5/11/2017 at 11:42 AM. During an interview with RN (Registered Nurse) #2 on 5/11/2017 at 11:42 AM, RN #2 confirmed the bedpan was un-bagged and unlabeled on the shower chair. RN #2 stated bed pans are to be cleaned, bagged and labeled after each use. Observation of Room 25 on 5/8/17 at approximately 11:20 AM revealed insect remains in bathroom light and stained grout around the toilet. The urinal was not contained and the bed pan was bagged but not labeled. Observation of Room 24 on 5/8/17 at approximately 11:50 AM revealed a loose baseboard beneath the sink. Observation of [RM #] on 5/8/17 at approximately 1 PM revealed a loose baseboard beneath the sink. Observation of Room 22 on 5/8/17 at approximately 1:10 PM revealed a loose baseboard beneath the sink. Tour with the Maintenance Director and Housekeeping Director on 5/10/17 at approximately 12:10 PM confirmed environmental concerns.",2020-09-01
298,J F HAWKINS NURSING HOME,425035,1330 KINARD STREET,NEWBERRY,SC,29108,2017-05-11,256,D,1,1,X7DC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and interview with the Housekeeping and Maintenance Directors, the facility failed to provide adequate lighting for multiple rooms on 1 of 4 units. The findings included: Observation of room [ROOM NUMBER] on 5/8/17 at approximately 11:50 AM revealed the left overbed light bulb was burnt. The lower light would not turn on. Observation of room [ROOM NUMBER] on 5/8/17 at approximately 12:22 PM revealed the left overbed light bulb was burnt. The lower light would not turn on. Observation of room [ROOM NUMBER] on 5/9/17 at approximately 12:20 PM revealed the left overbed light bulb was burnt. The lower light would not turn on. Interview with Resident #98 on 5/8/17 at approximately 11:53 AM revealed the light over the sink flickered on and off. Tour with the Maintenance and Housekeeping Directors on 5/10/17 at approximately 12:10 PM confirmed these environmental concerns.",2020-09-01
299,J F HAWKINS NURSING HOME,425035,1330 KINARD STREET,NEWBERRY,SC,29108,2017-05-11,274,D,1,1,X7DC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to complete a significant change in status assessment for Resident #22, 1 of 4 sampled residents reviewed for Activities of Daily Living (ADLs) and 1 of 3 sampled residents reviewed for Urinary Incontinence. Resident #22 experienced a decline in functional status and bowel and bladder continence. The findings included: The facility admitted Resident #22 with [DIAGNOSES REDACTED]. Record review of a nurse practitioner progress note, dated 3/8/2017, on 5/10/2017 at 9:47 AM, revealed that Resident #22 had a difficult couple of weeks. The resident had GI (gastrointestinal) bleeding and her/his white blood cell count was elevated. Resident #22 was treated for [REDACTED]. Resident #22 used to be able to participate in therapy and participate in ADL care and now she/he is completely dependent for ADL care. In addition, it was noted they even have to use a sit to stand lift to get the resident from bed to the wheelchair. The resident is just not able to participate or cooperate due to mental status. Record review of the physician's progress note dated, 4/6/2017, on 5/10/2017 at approximately 9:52 AM, revealed Resident #22 was treated for [REDACTED]. Record review of the admission Minimum Data Set (MDS) assessment, dated 12/26/2016 and the quarterly MDS assessment, dated 3/27/2017, on 5/10/2017 at 9:54 AM, revealed that Resident #22 had decline in bladder and bowel function. The admission assessment indicated the resident was occasionally incontinent of bladder and frequently incontinent of bowel. The quarterly assessment indicated the resident was always incontinent of bowel and bladder. In addition, the resident had a decline in functional status. Per the admission MDS, Resident #22 required extensive assistance with transfers, walking in the room, walking in the corridor, locomotion on the unit, locomotion off the unit, toilet use and personal hygiene. Per the quarterly MDS, the resident had declined in all of the above areas. The resident was totally dependent for toilet use and personal hygiene. Transfers occurred only once or twice. Walking and locomotion did not occur over the entire 7 day review period. During an interview with CNA (Certified Nursing Assistant) #1 on 5/9/2017 at 1:51 PM, CNA #1 stated Resident #22 had declined a lot over the past 1-2 months. During an interview with LPN (Licensed Practical Nurse) #4 on 5/9/2017 at 3:20 PM, LPN #4 stated the resident's Dementia has greatly progressed over the past couple of months with increased behaviors of refusals of care and being resistive to care from staff and hired sitters. During an interview with RN (Registered Nurse) #1 on 5/10/2017 at 2:17 PM, RN #1 stated that a significant change in status assessment should have been done for resident #22.",2020-09-01
300,J F HAWKINS NURSING HOME,425035,1330 KINARD STREET,NEWBERRY,SC,29108,2017-05-11,278,D,1,1,X7DC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to accurately code the Minimum Data Set for 1 of 1 sampled resident reviewed for hospice. Resident #113 was not coded as having a terminal illness under J1400. The findings included: The facility admitted Resident #113 with [DIAGNOSES REDACTED]. On 5-10-17 at 12:36 PM, review of hospice certifications for 10-26-16 and 1-2-17 noted that the resident's life expectancy was less than 6 months. Review of the 11/14/16 Annual and 2/13/17 Quarterly Minimum Data Sets on 5/10/17 at 10:30 AM revealed that item J1400 was coded as 0 indicating that the resident did not have a life expectancy of less than six months. During an interview on 05/11/2017 at 9:27 AM, Licensed Practical Nurse #3 and Registered Nurse #1 verified the life expectancy was not coded correctly. MDS staff were not aware that the information was located in the hospice book.",2020-09-01
301,J F HAWKINS NURSING HOME,425035,1330 KINARD STREET,NEWBERRY,SC,29108,2017-05-11,282,E,1,1,X7DC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, observation, and record review the facility failed to follow the care plan for 1 of 5 residents reviewed for unnecessary medications, 2 of 4 reviewed for pressure ulcers, and 2 of 6 residents randomly reviewed for transfers. Resident #70's care plan was not followed with regards to blood sugar, blood pressure, and constipation. Resident #70 and Resident #113 were not positioned as care planned. Residents #101 and #118 were not transferred per care plan. The findings included: Review of transfer assessment for Resident #101 on 5/11/17 at approximately 10:10 AM revealed that the resident required a full body lift with a medium-sized sling assisted by 2 caregivers. Review of the transfer assessment for Resident #118 on 5/11/17 at approximately 10:10 AM revealed that the resident required a full body lift with a small-sized sling assisted by 2 caregivers. Interview with Certified Nursing Assistant (CNA) #3 on 5/11/17 at approximately 10:22 AM revealed that s/he used a large-sized sling when transferring resident #101. When asked if s/he needed to consult the CNA Care Sheet, s/he said no because s/he knew. The CNA stated Resident #101 had gained weight, and the CNA had been using a large-sized sling during transfer to compensate. S/he continued that s/he had not alerted a nurse that the resident may require reassessment. The CNA left during the interview, and s/he returned to state that s/he was mistaken and had only used a large-sized sling once. Interview with CNA #3 on 5/11/17 at approximately 10:22 AM revealed that the CNA did not use a sling or lift to transfer Resident #118 because the resident can pivot weight. When asked about the assessment stating the resident required a lift with a small sling and 2 caregivers for transfer, the CNA stated that the resident was incorrectly assessed and that it depended on her days. Review of Care Plan for Resident #118 on 5/11/17 at approximately 10:30 AM revealed that the resident requires a total lift with 2 caregivers assisting as needed. Interview with Registered Nurse (RN) #4 on 5/11/17 at approximately 10:50 AM confirmed that Resident #101 requires a full body lift with a medium-sized sling and Resident #118 requires a full body lift with a small-sized sling. S/he continued that it is expected of CNAs to follow the transfer assessment to keep residents safe, and that CNAs need to alert the nurse if a resident needs to be reassessed for transfers rather than intervening directly. Interview with the Director of Nursing (DON) on 5/11/17 at approximately 11:13 AM revealed that CNAs are required to follow assessments with respect to transfers. S/he continued that if a CNA recognizes changes in a resident transfer ability, they should inform the nurse so the resident can be reassessed. The facility admitted Resident #113 with [DIAGNOSES REDACTED]. Review of the Skin Pressure Ulcer Assessment tool on 5-11-17 revealed the resident was at risk for pressure ulcers. The 2-13-17 Quarterly Minimum Data Set (MDS) assessment noted that the resident required extensive assistance of 2 persons for bed mobility and was at risk for developing pressure ulcers. No behaviors were coded for rejection of care. Record review on 5/10/2017 at 8:48 AM revealed a current physician's orders [REDACTED]. Review of the Care Plan on 5-11-17 at 9:27 AM revealed Focus areas of Pressure ulcer. Alteration in skin integrity R/T (related to) pressure wound to (R)ight heel and Risk for alteration in skin integrity R/T cognition, medication . Interventions included to encourage/assist to offload heels as much as resident will comply and encourage/assist to turn and reposition every 2 hours and PRN (as needed) as much as resident will comply. Multiple observations revealed Resident #113 laying on his/her back (on 05/08/2017 at 11:18 AM, 2:46 PM, 3:25 PM; on 05/09/2017 at 8:34 AM, 9:53 AM, 10:25 AM; on 05/10/2017 at 10:08 AM, 11:37 AM, 12 PM, 1:00 PM, 2:20 PM, and 4:20 PM) without heels floated. Review of Nurses Notes on 5-11-17 at 11:02 AM revealed no evidence of care refusal. During an interview and observation on 05/11/2017 8:36 AM, Certified Nursing Assistant (CNA) #5 confirmed that Resident #113's heels were not floated and there was no pillow in the bed. During an interview on 5-11-17 at 11:14 AM, CNA #5 reviewed and confirmed the computerized Kardex/care plan with instructions to encourage to float heels as much as resident will comply and encourage/assist to turn and reposition every 2 hours and PRN (as needed) as much as resident will comply. When asked about procedure to follow if the resident refused care, the CNA stated s/he would report to the nurse. The facility admitted Resident #70 with the [DIAGNOSES REDACTED]. Review of the 3-13-17 Quarterly Minimum Data Set (MDS) assessment revealed that the resident required extensive assistance of 1 person for bed mobility and was at risk for developing pressure ulcers. No behaviors were coded for rejection of care. Record review on 5-9-17 at 3:04 PM revealed a current physician's orders [REDACTED]. Review of the current Care Plan on 5-11-17 at 10:02 AM revealed a Focus of Risk for alteration in skin integrity R/T (related to) diagnoses, incontinence, mobility status, . skin desensitized to pain /pressure, [MEDICAL CONDITION], hx (history) impaired skin integrity, [MEDICAL CONDITION]. Interventions included to encourage/assist to turn and reposition every 2 hours and PRN as much as resident will comply and encourage to float heels as much as resident will comply. Multiple observations revealed Resident #70 laying on his/her back (on 05/10/2017 at 10:07 AM, 11:33 AM, 11:55 AM, 12:05 PM, 1:00 PM and 2:20 PM) without heels floated. Review of Nurses Notes on 5-11-17 at 11:32 AM revealed no evidence of care refusal. During an interview on 05/11/2017 at 11:32 AM, Registered Nurse #6 stated that turning and positioning is standard every 2 hours and should be documented per the CN[NAME] Continued review of the Care Plan on 5-11-17 at 10:27 AM revealed Focus areas of [MEDICAL CONDITION]-risk for complications R/T HTN, hypomagnesium, [MEDICAL CONDITION] and Risk for constipation R/T immobility, medication . Interventions included to check vital signs as ordered and PRN (as needed), observe for bowel movements, and administer medications as ordered-see MAR (Medication Administration Record) for specific instructions. Record review on 5/11/2017 at 10:36 AM revealed a physician's orders [REDACTED]. Review of the Medication Administration Records and BM (Bowel Movement) Report on 05/11/2017 at 10:50 AM revealed no documented bowel movements between 2/24/2017 and 3/3/2017 with no evidence of intervention. During an interview on 5/11/2017 at 11:32 AM, Registered Nurse (RN) #4 reviewed and confirmed the physician's orders [REDACTED]. RN #4 confirmed that the resident had an order for [REDACTED]. Additional review revealed physician's orders [REDACTED]. physician's orders [REDACTED]. The BP (Blood Pressure) was not monitored at least weekly for long term use of anti-hypertensives. Review of nursing notes and vital signs on 5/11/2017 at 11:05 AM revealed that the BP had not been done as ordered. There were no documented blood pressures for (MONTH) or May, (YEAR). During an interview on 05/11/2017 at 11:32 AM, Registered Nurse (RN) #4 was unable to locate the weekly blood pressure results.",2020-09-01
302,J F HAWKINS NURSING HOME,425035,1330 KINARD STREET,NEWBERRY,SC,29108,2017-05-11,309,D,1,1,X7DC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to maintain hospice documentation at the facility to ensure continuity of care for one of one sampled resident reviewed for hospice. Resident #113 did not have completed nursing and social services notes at the facility. The findings included: The facility admitted Resident #113 with [DIAGNOSES REDACTED]. Review of the hospice plan of care on 05/11/2017 at 1:55 PM revealed that the nurse was to visit weekly and the Social Worker was to visit twice monthly. Review of the Hospice Book on 05/11/2017 at 1:35 PM revealed no evidence of nursing visits after 3/22/2017. The last documented Social Service note was 4/13/2017. During an interview on 5/11/2017 at 2:38 PM, the Director of Nursing verified the missing hospice documentation.",2020-09-01
303,J F HAWKINS NURSING HOME,425035,1330 KINARD STREET,NEWBERRY,SC,29108,2017-05-11,311,D,1,1,X7DC11,"> Based on interview and record review the facility failed to ensure safe transfer of 2 of 6 residents randomly reviewed for transfers. Residents #101 and #118 were not transferred appropriately according to their assessments. The findings included: Review of transfer assessment for Resident #101 on 5/11/17 at approximately 10:10 AM revealed that the resident required a full body lift with a medium-sized sling assisted by 2 caregivers. Review of the transfer assessment for Resident #118 on 5/11/17 at approximately 10:10 AM revealed that the resident required a full body lift with a small-sized sling assisted by 2 caregivers. Interview with Certified Nursing Assistant (CNA) #3 on 5/11/17 at approximately 10:22 AM revealed that s/he used a large-sized sling when transferring resident #101. When asked if s/he needed to consult the CNA Care Sheet, she said no because she knew. S/he stated Resident #101 had gained weight, and the CNA had been using a large-sized sling to compensate. S/he continued that s/he had not alerted a nurse that the resident may require reassessment. The CNA left during the interview, and s/he returned to state that s/he was mistaken and had only used a large-sized sling once. Interview with CNA #3 on 5/11/17 at approximately 10:22 AM revealed that the CNA did not use a sling or lift to transfer Resident #118 because the resident can pivot weight. When asked about the assessment stating the resident required a lift with a small sling and 2 caregivers for transfer, the CNA stated that the resident was incorrectly assessed and that it depended on her days. Interview with Registered Nurse (RN) #4 on 5/11/17 at approximately 10:50 AM confirmed that Resident #101 requires a full body lift with a medium-sized sling and Resident #118 requires a full body lift with a small-sized sling. S/he continued that it is expected of CNAs to follow the transfer assessment to keep residents safe, and that CNAs need to alert the nurse if a resident needs to be reassessed for transfers rather than intervening directly. Interview with the Director of Nursing (DON) on 5/11/17 at approximately 11:13 AM revealed that CNAs are required to follow assessments with respect to transfers. S/he continued that if a CNA recognizes changes in a resident transfer ability, they should inform the nurse so the resident can be reassessed.",2020-09-01
304,J F HAWKINS NURSING HOME,425035,1330 KINARD STREET,NEWBERRY,SC,29108,2017-05-11,312,D,1,1,X7DC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview the facility failed to provide Activities of Daily Living (ADL) care for 1 of 4 residents reviewed for ADLs. Resident #149 was observed with facial hair and long nails over the days of the survey. The findings included: Resident #149 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation of Resident #149 on 5/8/17 at approximately 12:30 PM revealed the corners of his mouth were unshaven with several long strands of hair. Observation of Resident #149 on 5/8/17 at approximately 9 AM revealed the corners of his mouth were still unshaven with long and uneven whiskers. Interview with Certified Nursing Assistant (CNA) #6 on 5/10/17 at approximately 9:40 AM revealed that she has not shaved the resident since she has cared for him. She stated that she normally shaves residents every day or every other day, but Resident #149 does not grow much facial hair. Interview with CNA #6 on 5/10/17 at approximately 9:40 AM confirmed that Resident #149 has facial hair coming from the corners of his mouth. Observation of Resident #149 on 5/10/17 at approximately 9:40 AM revealed the resident had long fingernails. Interview with CNA #6 on 5/10/17 at approximately 9:40 AM revealed she was aware and planned to clip and trim the fingernails. Review of Resident #149's Minimum Data Set (MDS) assessment dated [DATE] on 5/10/17 revealed that the resident was coded as requiring extensive, one-person assistance for personal hygiene. Observation of Resident #149 at approximately 5/10/17 at 2:30 PM revealed the resident still had long fingernails.",2020-09-01
305,J F HAWKINS NURSING HOME,425035,1330 KINARD STREET,NEWBERRY,SC,29108,2017-05-11,314,D,1,1,X7DC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record review, interview and review of the facility's policy entitled Prevention of Pressure Ulcers, the facility failed to ensure that two of four sampled residents reviewed for pressure ulcers received care to prevent new pressure ulcer development. Resident #70 and Resident #113 were not turned and positioned at least every two hours. Resident #113 did not have heels floated per physician's orders [REDACTED].>The findings included: The facility admitted Resident #113 with [DIAGNOSES REDACTED]. Review of the Skin Pressure Ulcer Assessment tool on 5-11-17 revealed the resident was at risk for pressure ulcers. The 2-13-17 Quarterly Minimum Data Set (MDS) assessment noted that the resident required extensive assistance of 2 persons for bed mobility and was at risk for developing pressure ulcers. No behaviors were coded for rejection of care. Record review on 5/10/2017 at 8:48 AM revealed a current physician's orders [REDACTED]. Review of the Care Plan on 5/11/2017 9:27 AM revealed Focus areas of Pressure ulcer. Alteration in skin integrity R/T (related to) pressure wound to (R)ight heel and Risk for alteration in skin integrity R/T cognition, medication . Interventions included to encourage/assist to offload heels as much as resident will comply and encourage/assist to turn and reposition every 2 hours and PRN (as needed) as much as resident will comply. Multiple observations revealed Resident #113 laying on his/her back (on 05/08/2017 at 11:18 AM, 2:46 PM, 3:25 PM; on 05/09/2017 at 8:34 AM, 9:53 AM, 10:25 AM; on 05/10/2017 at 10:08 AM, 11:37 AM, 12 PM, 1:00 PM, 2:20 PM, and 4:20 PM) without heels floated. During an interview and observation on 05/11/2017 8:36 AM, Certified Nursing Assistant (CNA) #5 confirmed that Resident #113's heels were not floated and there was no pillow in the bed. During an interview on 5-11-17 at 11:14 AM, CNA #5 reviewed the computerized Kardex/care plan with instructions to encourage to float heels as much as resident will comply and encourage/assist to turn and reposition every 2 hours and PRN (as needed) as much as resident will comply. When asked about procedure to follow if the resident refused care, the CNA stated s/he would report to the nurse. Review of Nurses Notes on 05/11/2017 11:02 AM revealed no evidence of care refusal. The facility admitted Resident #70 with the [DIAGNOSES REDACTED]. Review of the 3-13-17 Quarterly Minimum Data Set (MDS) assessment revealed that the resident required extensive assistance of 1 person for bed mobility and was at risk for developing pressure ulcers. No behaviors were coded for rejection of care. Record review on 05/11/2017 at 11:02 AM revealed a current physician's orders [REDACTED]. Review of the current Care Plan on 5/11/2017 9:27 AM revealed a Focus of Risk for alteration in skin integrity R/T (related to) diagnoses, incontinence, mobility status, skin desensitized to pain /pressure, [MEDICAL CONDITION], hx (history) impaired skin integrity, [MEDICAL CONDITION]. Interventions included to encourage/assist to turn and reposition every 2 hours and PRN as much as resident will comply and encourage to float heels as much as resident will comply. Multiple observations revealed Resident #70 laying on his/her back (on 05/10/2017 at 10:07 AM, 11:33 AM, 11:55 AM, 12:05 PM, 1:00 PM and 2:20 PM) without heels floated. Review of Nurses Notes on 05/11/2017 11:02 AM revealed no evidence of care refusal. During an interview on 05/11/2017 at 11:02 AM, Registered Nurse #6 stated that turning and positioning is standard every 2 hours and should be documented per the CN[NAME] On 05/11/2017 at 8:36 AM, review of the facility's policy, Prevention of Pressure Ulcers revealed the following: 1. Pressure ulcers are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decrease of circulation (blood flow) to that area and subsequent destruction of tissue. Interventions and Preventive Measures: General included: 2. For a person in bed: a. Change position at least every two hours or more frequently if needed .",2020-09-01
306,J F HAWKINS NURSING HOME,425035,1330 KINARD STREET,NEWBERRY,SC,29108,2017-05-11,328,D,1,1,X7DC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and interview, the facility failed to clean the filter for Resident #167's oxygen concentrator as ordered, 1 of 1 sampled resident reviewed with Oxygen Therapy. The filter was observed with dust build up. The findings included: The facility admitted Resident #167 with [DIAGNOSES REDACTED]. Observation of Resident #167's oxygen filter on 5/8/2017 at 11:47 AM and 4:02 PM, revealed dust build up to the oxygen filter. Observation of the oxygen filter on 5/11/2017 at 10:45 AM, revealed dust build up to the oxygen filter. Record review of the physician's orders [REDACTED]. Record review of the TAR (Treatment Administration Record) on 5/11/2017 at 10:49 AM, revealed that nursing had signed off that the oxygen filter had been cleaned on 5/10/2017 on the night shift. During an observation and interview with RN (Registered Nurse) #2 on 5/11/2017 at approximately 10:49 AM, RN #2 confirmed the dust build up to the oxygen filter. RN #2 stated that the filter is supposed to be cleaned every Wednesday on the night shift. RN #2 stated that the filter had not been cleaned by the night shift last night (Wednesday). In addition, RN #2 confirmed that nursing had signed off that the filter had been cleaned last night shift.",2020-09-01
307,J F HAWKINS NURSING HOME,425035,1330 KINARD STREET,NEWBERRY,SC,29108,2017-05-11,329,D,1,1,X7DC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview and review of the facility's policy entitled, Urinary and Bowel Incontinence and Care-Clinical Protocol, the facility failed to ensure that medications were monitored for continued need and effectiveness for 1 of 5 sampled residents reviewed for unnecessary medication. For Resident #70, who had a [DIAGNOSES REDACTED]. The findings included: The facility admitted Resident #70 with [DIAGNOSES REDACTED]. Record review on 5/11/2017 at 10:36 AM revealed a physician's orders [REDACTED]. Review of the Medication Administration Records and BM (Bowel Movement) Report on 05/11/2017 10:50 AM revealed no documented bowel movements between 2/24/2017 and 3/3/2017 with no evidence of intervention. During an interview on 5/11/2017 at 11:32 AM Registered Nurse (RN) #4 reviewed and confirmed the physician's orders [REDACTED]. On 05/11/2017 at 10:50 AM, s/he provided a copy of the Urinary and Bowel Incontinence and Care-Clinical Protocol which stated under Monitoring: b. Documentation of bowel movements and intervention per doctor order if no bowel movement in three days or as described by the physician. RN #4 confirmed that the resident had an order for [REDACTED]. Additional review revealed physician's orders [REDACTED]. physician's orders [REDACTED]. The BP (Blood Pressure) was not monitored at least weekly for long term use of anti-hypertensives. Review of nursing notes and vital signs on 5/11/2017 at 11:05 AM revealed that the BP had not been done as ordered. There were no documented blood pressures for (MONTH) or May, (YEAR). During an interview on 05/11/2017 at 11:32 AM, Registered Nurse (RN) #4 was unable to locate the weekly blood pressure results.",2020-09-01
308,J F HAWKINS NURSING HOME,425035,1330 KINARD STREET,NEWBERRY,SC,29108,2017-05-11,411,D,1,1,X7DC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review or interviews, the facility failed to ensure that 1 of 3 sampled residents reviewed for dental services had a dental consult. Resident #54 with broken/cracked and darken teeth did not have a dental consult. The findings included: The facility admitted Resident #54 with [DIAGNOSES REDACTED]. A random observation on 5/09/17 at approximately 12:15 PM revealed Resident #54 in his/her room in bed. The resident was noted with broken/cracked and darken teeth on front bottom of mouth. A review of the medical record on 5/09/17 at approximately 1:45 PM revealed an oral assessment completed by the facility on 3/28/17 the resident had three (3) broken bottom teeth and no top teeth. The dental consult section on the back of the oral assessment form was left blank. There was no documentation in the medical record to indicate when the resident's last dental examination was completed. Review of a dietary assessment indicated the resident had missing and broken teeth with a pureed diet being recommended. Review of the social services noted revealed no documentation related to the resident's missing and broken teeth with a dental consult being recommended. An interview on 5/09/17 at approximately 2:16 PM with Licensed Practical Nurse (LPN) #2 revealed the Unit Manager would be responsible for requesting dental services for the residents. An interview on 5/09/17 at approximately 2:19 PM with LPN #1 confirmed the facility would be responsible for making a referral for a dental consult and that he/she could find where a referral was made for Resident #54. A nurse practitioner seated at the nurse station commented, would the resident be referred for dental consult if on hospice. A review of the Admission's Minimum Data Set ((MDS) dated [DATE] indicated the resident had broken/cavity teeth. There was no documentation in the medical record that addressed the resident's dental concerns with resident and/or family members. An interview on 5/09/17 at 2:30 PM with the Admission's Coordinator confirmed the findings that there was no documentation in the chart to address the resident being referred for a dental consult.",2020-09-01
309,J F HAWKINS NURSING HOME,425035,1330 KINARD STREET,NEWBERRY,SC,29108,2017-05-11,469,E,1,1,X7DC11,"> Based on observation and interview, the facility failed to provide adequate pest control services on 2 of 4 units. There were multiple observations of pests noted in the facility and multiple staff interviews confirming concerns regarding pests. The findings included: Initial tour of the facility on 5/8/17 at approximately 9:52 AM revealed a roach crawling along the wall of the communal lavatory on Unit 1. Observation of Room 24 on 5/8/17 at approximately 11:50 AM revealed an insect crawling along the floor beneath the sink. Interview with Certified Nursing Assistant (CNA) #6 on 5/10/17 at approximately 2:38 PM revealed that s/he has seen roaches once a week and saw one that day. S/he stated, We've let them (maintenance) know in the past. They definitely know about them. Observation of Room 24 on 5/11/17 at approximately 8:46 AM revealed a roach on the floor. Interview with CNA #7 on 5/11/17 at approximately 11:05 AM revealed that s/he sees a roach daily. S/he continued that maintenance knows it's a concern. Interview with CNA #8 on 5/11/17 at approximately 11:05 AM revealed that s/he saw a roach run across a facility shower earlier that day. S/he continued that maintenance is aware of pest concerns. Interview with the Maintenance Director on 5/11/17 at approximately 11:16 AM revealed that the facility had only sprayed monthly. The facility had not increased or made extra efforts to limit presence of pests. Review of Pest Control policy on 5/11/17 at approximately 11:34 AM revealed that maintenance should assist, when appropriate and necessary, in providing pest control services.",2020-09-01
310,J F HAWKINS NURSING HOME,425035,1330 KINARD STREET,NEWBERRY,SC,29108,2018-09-06,690,D,0,1,A2DZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide timely treatment for [REDACTED].#100, 1 of 3 sampled residents reviewed for Urinary Tract Infections [MEDICAL CONDITION] and 1 of 5 sampled residents reviewed for Unnecessary Medications. Residents #69 and #100 had a delay in treatment for [REDACTED]. The findings included: The facility admitted Resident #69 with [DIAGNOSES REDACTED]. Record review of the Medication Administration Record [REDACTED]. The medication was discontinued on 6/22/2018. The MAR indicated [REDACTED]. Record review of the Nurse's Notes on 9/5/2018 at 3:05 PM, revealed notes from 6/22/2018 (Friday)indicating the resident had broken out in a rash all over her/his body. The on call provider was notified and discontinued the Bactrim DS due to a possible allergic reaction. Per the notes, the nurse asked the on call provider if s/he would like to order another antibiotic to continue treating the UTI. The on call provider stated No, the provider can decide that on Monday when you contact them. A Nurse's Note from 6/26/2018 (Tuesday) revealed new orders were obtained from the provider to start the [MEDICATION NAME] to continue treating the UTI. During an interview with the Director of Nursing (DON) on 9/6/2018 at 11:14 AM, the DON confirmed the resident had a 3 day delay in treatment. The DON also stated s/he did not feel like it was reasonable on the on call provider's part to defer the treatment decision until the following Monday. The DON stated s/he had spoken to the Medical Director (MD) about this to develop a back up plan should similar situations arise. The MD had agreed to be called after hours and on weekends if the on call providers fail to initiate appropriate treatment. The facility admitted Resident #100 with [DIAGNOSES REDACTED]. Records review of Nurse's Notes on 9/4/2018 at 1:03 PM, revealed a note from 8/30/2018 indicating the resident had blood drawn for lab tests. A note from 8/31/2018, revealed the Nurse Practitioner (NP) evaluated the resident and reviewed the labs from the day before. The NP gave new orders for a urinalysis with a culture and sensitivity based on an elevated white blood cell count and the resident was having dysuria (pain with urination and/or difficulty urinating). Record review of the Nurse's Notes on 9/5/2018 at 12:59 PM, revealed a note from 9/4/2018 at 6:02 PM, indicating the NP reviewed the resident's urine culture results that day. The NP ordered [MEDICATION NAME] 100 milligrams twice daily to treat a UTI. Record review of the Lab Reports on 9/5/2018 at 3:45 PM, revealed the urinalysis was collected on 8/31/2018 at 4:30 PM and reported to the facility at 5:46 PM. Review of the final culture report revealed culture results were available on 9/2/2018 at 9:10 AM. There was no documentation to show the provider had been contacted with the culture results before 9/4/2018. During an interview the Assistant Director of Nursing (ADON) on 9/5/2018 at 3:45 PM, the ADON stated the Lab did not send the culture results to the facility until 9/4/2018. In addition, the ADON stated antibiotic therapy was not indicated based on the urinalysis results alone. The culture results were needed to determine treatment. The ADON also confirmed the culture results were available on 9/2/2018, per the Lab Report. When asked what facility policy was related to tracking cultures results, the ADON stated nursing should contact the Lab within 48-72 hours to request culture results if they are not received by the facility. The ADON confirmed nursing did contact the lab within 48-72 hours to request the culture results. Additional record review revealed no ill effects from the delay in treatment for [REDACTED].",2020-09-01
311,J F HAWKINS NURSING HOME,425035,1330 KINARD STREET,NEWBERRY,SC,29108,2018-09-06,770,D,0,1,A2DZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of facility policy, the facility failed to obtain lab results in a timely manner for Resident #100, 1 of 3 sampled residents reviewed for Urinary Tract Infection [MEDICAL CONDITION]. Urine culture results were not obtained in a timely manner or per facility policy and protocol. Cross refer to F690 The findings included: The facility admitted Resident #100 with [DIAGNOSES REDACTED]. Record review of Nurse's Notes on 9/4/2018 at 1:03 PM, revealed a note from 8/30/2018 indicating the resident had blood drawn for lab tests. A note from 8/31/2018, revealed the Nurse Practitioner (NP) evaluated the resident and reviewed the labs from the day before. The NP gave new orders for a urinalysis with a culture and sensitivity based on an elevated white blood cell count and the resident was having dysuria (pain with urination and/or difficulty urinating). Another note from 8/31/2018 revealed the urinalysis results were received on 8/31/2018. Record review of the Nurse's Notes on 9/5/2018 at 12:59 PM, revealed a note from 9/4/2018, indicating the NP reviewed the resident's urine culture results that day. The NP ordered [MEDICATION NAME] 100 milligrams twice daily to treat a UTI. Record review of the Lab Reports on 9/5/2018 at 3:45 PM, revealed preliminary culture results were received on 9/1/2018 at 10:06 AM. Final culture results were still pending. The final culture results were available on 9/2/2018 at 9:10 AM, per the final culture report. There was no documentation to show the provider had been contacted with the culture results before 9/4/2018. During an interview the Assistant Director of Nursing (ADON) on 9/5/2018 at 3:45 PM, the ADON stated the Lab did not send the culture results to the facility until 9/4/2018. The ADON also confirmed the culture results were available on 9/2/2018, per the Lab Report. When asked what facility policy was related to tracking culture results, the ADON stated nursing should contact the Lab within 48-72 hours to request final culture results if they are not received by the facility. The ADON confirmed nursing did contact the lab within 48-72 hours to request the culture results. Review of the facility's Laboratory and Diagnostic Tracking Guideline Policy revealed The facility should have a system to monitor lab/diagnostic test daily. For example, the lab binder(s) are reviewed during daily clinical meeting to determine if tests were completed, results received as expected, reporting and follow up was completed.",2020-09-01
312,J F HAWKINS NURSING HOME,425035,1330 KINARD STREET,NEWBERRY,SC,29108,2018-09-06,865,E,0,1,A2DZ11,"Based on interviews, record reviews and observations, the facility's quality assurance and performance improvement committee failed to implement an effective pest control program ensure the facility was free from pests in 4 of 4 units. Cross Reference to F-925 The findings included: An interview on 9/06/18 with the Administrator and the Director of Nursing revealed the Quality Assurance Committee met on 7/05/18 to address the pest control issue in the facility around the time the cease and desist letter from Clemson University was received. A review of a Facility Past Non-Compliance Checklist dated 7/05/18 revealed Ecolab was to provide weekly services instead of monthly visits. There was no documentation to indicate Ecolab had been providing weekly services and there was documentation to indicate whatever services that were being provided was effective. A review of the Clemson University cease and desist notice dated indicated Pest Control Activities performed by Ecolab/Wicker's Greenhouse & Nursery/In house staff was in violation due to pest control activities required licensure. The facility was in violation Code 27-1085 L 1. On 9/06/18 at approximately 12:02 PM with the Administration who stated the Quality Assurance (QA) started on 7/05/18. No documented QA was provided with an effective date, problem indication, plan of action/monitoring or completion date. The Administration provided a statement that a bid was requested from a pest control company on 8/28/18. The Administrator did not provide documentation weekly pest control services as outlined in the Facility Past Non-Compliance Checklist. Prior to exiting the facility documentation of pest control services was not provided.",2020-09-01
313,J F HAWKINS NURSING HOME,425035,1330 KINARD STREET,NEWBERRY,SC,29108,2018-09-06,925,E,0,1,A2DZ11,"Based on interviews, record reviews and observations, the facility failed to maintain an effective pest control program to ensure the facility was free from pests in 4 of 4 units. The findings included: During individual interviews on 9/04/18, 2 of 4 residents interviewed expressed that they have seen roaches in their rooms. The resident stated they were the large roaches/[NAME]ina bugs. A family interview on 9/04/18 revealed that roaches have been seen crawling in and out of dresser drawers in resident rooms. During group interview on 9/04/18 at approximately 3:30 PM 3 of 5 group members reported they have seen pests in the facility. The resident reported seeing roaches, spiders and a few caterpillars. Review of a pest control monitoring logs with a start date of 6/30/18 to 9/04/18 on Unit 1 revealed multiple sightings of roaches through out the months in the dining area, on baseboards, residents dresser drawers, residents closets, residents bed side tables, under and round sinks, residents mirrors, on ceiling area near fan, on walls, by trash cans and television stand, Unit 1 nursing station, air conditioner unit, roaches in lights in residents rooms and spiders in rooms on two occasions. Review of the pest control monitoring logs with a start date 6/29/18 to 8/08/18 on Unit 2 revealed multiple sightings of roaches through out the months in residents rooms in bathroom, in residents bed, walls and floors in resident rooms, ice machines, nurse's stations, resident geri chairs, nurse's station bathroom, medication cart and reports of ants in bed with a resident. Review of the pest control monitoring logs with a start date of 6/29/18 to 7/30/18 on Unit 3 revealed multiple sightings of roaches and spiders in the dining area, residents rooms, nursing station, on counter in medication room, residents closets and residents beds. During an interview on 9/05/18 at approximately 2:48 PM with Maintenance Staff, the surveyor requested documentation of the last time the pest control company provided services to the facility. The Maintenance Staff stated the pest control company Eco lab was at the facility two weeks ago. The pest control contract/agreement was also requested. An interview on 9/05/18 at approximately 3:11 PM with the Administrator who provided a copy of the pest control contract with Ecolab which was in effect since 2014. The Administrator stated the facility was in process of locating a different pest control company and stated he/she would provide documentation. On 9/05/18 at approximately 3:45 PM the Administrator introduced the surveyor to an Ecolab staff member who asked the surveyor what the residents had to say about their pest control concerns. The Ecolab staff was informed that the resident expressed the same concerns that was documented on the pest control logs about roaches and spiders in the facility. The Administrator stated the facility was spraying the bugs with regular household chemical until they received a cease and desist letter from Clemson University. Documentation of Ecolab providing services was not provided. Observation of Resident #107's room on 9/5/2018 at 2:21 PM, revealed several ants on the floor. 4 ants were observed near the base board and 3 ants were observed near the trash can. Licensed Practical Nurse #1 (LPN) was present in the room and confirmed ants were on the floor in the room. Resident #107 asked if we were seeing more ants. Observation of Resident #107's room on 9/6/2018 at 11:01 AM, revealed an ant near the trash can and an ant near the heating and air unit in the room. During an interview with Resident #107 on 9/5/2018 at 2:21 PM, Resident #107 stated he had a bag of hard candy, Jolly Ranchers, on his night stand this past Friday and the bag was covered with ants. The resident stated he reported this to maintenance, who said they were going to spray for ants, but didn't know if that had happened or not. LPN # 1 was present in the room and stated she was aware of the ants in the room last Friday. S/he stated the resident told her/him it had been reported to maintenance. LPN #1 stated housekeeping had gone into the room to clean up the ants and s/he had also seen maintenance go into the room. LPN #1 wasn't sure what action maintenance had taken for the ants. During an interview with Resident #107 on 9/6/2018 at 11:01 AM, the resident stated he found an ant crawling on his arm while he was laying in bed last night. In addition, the resident stated s/he wouldn't be keeping anymore candy in his room while he was staying in the facility due to the ants. Review of the Pest Control Request Log on 9/6/2018 at 12:10 PM, revealed multiple reports by staff of ants and roaches present throughout the unit (Unit 4) from July, (YEAR)-present.",2020-09-01
314,J F HAWKINS NURSING HOME,425035,1330 KINARD STREET,NEWBERRY,SC,29108,2019-11-20,607,D,1,0,8NDB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, the facility failed to implement written policies and procedures that prohibit and prevent abuse and establish policies and procedures to investigate any such allegations. The facility did not follow policies related to reporting and/or investigating allegations of abuse for four of twenty-one facility reported incidents reviewed (Residents #5, #2, #8, and #13). The findings included: The facility reported an allegation of resident to resident abuse involving Resident #4 and Resident #5 to the State Agency on 10/23/18. A Certified Nurse Aide (CNA) observed Resident #5 inappropriately touching Resident #4. Review of the facility's Brief Summary revealed on 10/23/18 a CNA reported to nursing staff that as s/he was walking by room s/he witnessed Resident #5 with his/her hand up Resident #4's shorts making a rubbing motion. Resident #5 was removed from the room and nursing staff was alerted of the incident. Resident #4 was interviewed and denied any inappropriate behavior/touching from Resident #5. Resident #5 was reassigned to another room post incident. Resident #5 was unable to state what had occurred but did state I won't do it again, I just want to go back to my room, I am sorry. The facility notified the residents responsible parties, physician and police of the the incident. Review of the facility's files revealed there were no other statements included in the investigative file for the incident. The surveyor asked facility staff if there were any additional statements obtained. The facility provided an additional statement by Licensed Practical Nurse (LPN) #1 that indicated s/he did not witness the incident. Review of the Unit 1 Assignment Sheet for 10/23/18 revealed there were 2 nurses and 3 CNAs assigned to the unit at the time of the incident. In an interview with the administrator and Social Services #1 on 11/20/19 at approximately 3:15 PM they stated the only statement was from the CNA who witnessed the incident and LPN #1. They stated the incident occurred on Unit 1. At 3:45 PM the surveyor talked with the administrator about the facility's policy which indicates to interview all staff who worked with resident at time of alleged incident. The administrator stated they only interviewed witnesses to the incident. Informed administrator that policy states to interview witnesses but also to interview staff who have worked with resident during period of the alleged incident. The facility reported an allegation of physical abuse of Resident #2 by physical therapist #1 to the State Agency on 8/20/19. Review of the Five Day Follow-Up Report dated 8/26/19 revealed at approximately 2:05 PM on 8/20/19 Resident #2 reported to LPN #2 that an older physical therapist lady had entered his/her room and provided care to him/her and then drug him/her out of bed. Resident #2 stated the therapist was hateful, mean and rough with him/her. Resident #2 further stated (s/he) hurt me and jerked me up. Physical therapist was immediately identified and suspended pending further investigation. Two witnesses were listed: physical therapist #1 and Resident #2's roommate. The facility interviewed Resident #2 on 8/20/19 and s/he stated the incident occurred the morning before. Resident #2 stated s/he did not report the incident to any staff. Resident #2 indicated the therapist came into his/her room and started tossing and turning him/her back and forth in the bed. The therapist was putting on his/her clothes. Resident #2 stated s/he told therapist s/he didn't want to get up but s/he put him/her in the chair anyway and took him/her to the hallway. The facility interviewed Resident #2's roommate on 8/21/19. The roommate stated s/he had no concerns with staff in the facility and they are nice. Resident stated s/he was not aware of any type of incident with Resident #2. The surveyor noted that there was no documentation that the roommate was in the room at the time of the alleged incident. The facility interviewed physical therapist #1 on 8/20/19. Physical therapist #1 indicated s/he provided care to Resident #2. S/he dressed the resident and assisted him/her into his/her wheelchair. Physical therapist #1 stated Resident #2 did state s/he did not want to get out of bed. After physical therapist #1 began encouraging Resident #2 s/he agreed to get up in the wheelchair and go to the nurses' station, but did not want to go to the therapy department. Physical therapist #1 stated Resident #2 did not ask him/her to stop changing or dressing him/her. In an interview with the surveyor on 11/18/19 at approximately 1:15 PM, the Director of Nursing (DON) stated s/he may have some other interviews in his/her file. The DON reviewed the investigative file provided to the surveyor. There were three witness statements in the investigative file: physical therapist #1, Resident #2, and Resident #2's roommate. Review of Resident #2's Physical Therapy Treatment Encounter Notes for (MONTH) 2019 revealed physical therapist #1 worked with the resident only 1 time during the month on 8/19/19. Resident #2 was noted with 10 encounters during the month of August. In an interview with the surveyor on 11/18/19 at approximately 1:35 PM the DON stated s/he did not interview any other staff related to the allegation of abuse. When asked why s/he did not interview staff on duty at the time of the alleged incident the DON did not respond to the surveyor. The DON stated s/he interviewed Resident #2, the resident's roommate and the physical therapist. The DON stated s/he interviewed three other residents related to the abuse allegation. The DON stated s/he picked the three residents because they go to therapy. The DON stated s/he was not sure if they had therapy with physical therapist #1 or another therapist. The DON stated they assign residents to therapists randomly and s/he did not pick residents to interview based on if they were assigned to and received therapy from physical therapist #1. The DON stated s/he did not interview any other staff related to the allegation. The surveyor reviewed witness statements for the residents interviewed and all were asked how staff treats them and if they had any concerns with the therapy staff. Review of the Staff Assignment sheet for 8/19/19 revealed there were two nurses and four CNAs on duty on Unit 2, where the resident resided, at the time of the alleged incident. LPN #2 was not one of the two nurse working on the unit at the time of the alleged incident. Review of the facility's Abuse Prevention Program Policy Interpretation and Implementation revealed a section for Abuse Investigations. The policy indicated under 16. The individual conducting the investigation will, at a minimum: .Interview the person(s) reporting the incident; Interview any witnesses to the incident; Interview the resident (as medically appropriate); Interview the resident's Attending Physician as needed to determine the resident's current level of cognitive function and medical condition; Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; Interview the resident's roommate, family members, and visitors On 11/19/19 at approximately 2:10 PM, review of the medical record revealed Resident #8 was admitted to the facility with [DIAGNOSES REDACTED]. On 11/19/19 at 3:55 PM, review of the Nursing Progress Notes revealed a note dated and timed 5/18/2019 14:20 stating Nurse from Unit 2 called and reported to Nurse that resident was inappropriately touching two residents on that unit. Nurse went to get resident from Unit, when nurse noted that resident was on the way back to Unit 1. Resident is currently sitting at the nurses desk (1430) with Nurses on Unit 1. At 17:18 PM, the nurse notified the Physician Assistant and an order received for [MEDICATION NAME] 150 mg (milligrams) twice a day. Review of all of the reportable incident files provided by the facility upon entrance revealed no file related to the incident involving Resident #8 and two other residents on unit 2 on 5/18/19. The reportable file was requested from the Administrator and the Director of Nursing at approximately 5:00 PM on 11/19/19. During an interview on 11/20/19 at 8:50 AM, the DON confirmed they did not have a file and that the 5/18/19 incident was not reported to the State Agency. The DON further confirmed there was no investigation and stated the facility took all allegations of abuse seriously but they had not been informed of the incident occurring on 5/18/19 until the surveyor informed them on 11/19/19. S/he confirmed the policy had not been followed. Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Five-Day Follow-Up Report dated 10/04/19 revealed no documentation that the Five-Day Follow-Up Report was submitted to the State Bureau of Certification. During an interview on 11/20/19, the DON confirmed the documentation indicated the report was faxed to the Bureau of Health Licensing in error and was not to the Bureau of Certification. The Director of Nursing also confirmed the facility did not follow its policy related to reporting. Review of the facility's policy entitled Abuse Prevention Program, page 3, revealed 5. When alleged or suspected case of mistreatment, neglect, injuries of unknown source, or abuse is reported, the facility Administrator, DON (Director of Nursing), or individuals designated will immediately (not to exceed 24 hours if the event does not result in serious bodily injury. NO LATER THAN 2 HOURS IF THE EVENT IS AN ALLEGATION OF ABUSE OR WHERE THERE IS SIGNIFICANT INJURY, OR NEGLECT WHERE THERE IS SERIOUS BODILY INJURY) notify the following persons or agencies of such 1. The State licensing/certification agency responsible for surveying/licensing the facility; .",2020-09-01
315,J F HAWKINS NURSING HOME,425035,1330 KINARD STREET,NEWBERRY,SC,29108,2019-11-20,609,D,1,0,8NDB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, the facility failed to ensure that all alleged violations involving abuse were reported to the administrator of the facility and to the State Agency. An allegation of abuse involving Resident #8 and an injury of unknown origin for Resident #13 were not reported to the State Agency. Two of twenty-one facility reported incidents reviewed. The findings included: On 11/19/19 at approximately 2:10 PM, review of the medical record revealed Resident #8 was admitted to the facility with [DIAGNOSES REDACTED]. On 11/19/19 at 3:55 PM, review of the Nursing Progress Notes revealed a note dated and timed 5/18/2019 14:20 stating Nurse from Unit 2 called and reported to Nurse that resident was inappropriately touching two residents on that unit. Nurse went to get resident from Unit, when nurse noted that resident was on the way back to Unit 1. Resident is currently sitting at the nurses desk (1430) with Nurses on Unit 1. At 17:18 PM, the nurse notified the Physician Assistant and an order received for [MEDICATION NAME] 150 mg (milligrams) twice a day. Review of all of the reportable incident files provided by the facility upon entrance revealed no file related to the incident involving Resident #8 and two other residents on unit 2 on 05/18/19. The reportable file was requested from the Administrator and the Director of Nursing (DON) at approximately 05:00 PM on 11/19/19. During an interview on 11/20/19 at 8:50 AM, the DON confirmed they did not have a file and that the 05/18/19 incident was not reported to the State Agency. The DON further confirmed there was no investigation and stated the facility took all allegations of abuse seriously but they had not been informed of the incident occurring on 05/18/19 until the surveyor informed them on 11/19/19. Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Five-Day Follow-Up Report dated 10/04/19 revealed no documentation that the Five-Day Follow-Up Report was submitted to the State Bureau of Certification. During an interview on 11/20/19, the DON confirmed the documentation indicated the report was faxed to the Bureau of Health Licensing in error and was not to the Bureau of Certification. The DON also confirmed the facility did not follow its policy related to reporting. Review of the facility's policy entitled Abuse Prevention Program, page 3, revealed 5. When alleged or suspected case of mistreatment, neglect, injuries of unknown source, or abuse is reported, the facility Administrator, DON, or individuals designated will immediately (not to exceed 24 hours if the event does not result in serious bodily injury. NO LATER THAN 2 HOURS IF THE EVENT IS AN ALLEGATION OF ABUSE OR WHERE THERE IS SIGNIFICANT INJURY, OR NEGLECT WHERE THERE IS SERIOUS BODILY INJURY) notify the following persons or agencies of such 1. The State licensing/certification agency responsible for surveying/licensing the facility; .",2020-09-01
316,J F HAWKINS NURSING HOME,425035,1330 KINARD STREET,NEWBERRY,SC,29108,2019-11-20,610,D,1,0,8NDB11,"**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 involving abuse, neglect, exploitation or mistreatment were thoroughly investigated. The facility did not thoroughly investigate allegations of abuse for Residents #2, #4, and #8. Three of twenty-one facility reported incidents reviewed The findings included: The facility reported an allegation of resident to resident abuse involving Resident #4 and Resident #5 to the State Agency on 10/23/18. A Certified Nurse Aide (CNA) observed Resident #5 inappropriately touching Resident #4. Review of the facility's Brief Summary revealed on 10/23/18 a CNA reported to nursing staff that as s/he was walking by room s/he witnessed Resident #5 with his/her hand up Resident #4's shorts making a rubbing motion. Resident #5 was removed from the room and nursing staff was alerted of the incident. Resident #4 was interviewed and denied any inappropriate behavior/touching from Resident #5. Resident #5 was reassigned to another room post incident. Resident #5 was unable to state what had occurred but did state I won't do it again, I just want to go back to my room, I am sorry. The facility notified the residents responsible parties (RP), physician and police of the the incident. CNA #1's facility-obtained statement dated 10/23/18 indicated s/he walked by the room and saw Resident #5 with his/her hand up the leg of Resident #4's pants making a rubbing motion. CNA #1 removed Resident #5 from the room and reported the incident to the nursing staff. Review of the facility's files revealed there were no other statements included in the investigative file for the incident. The surveyor asked facility staff if there were any additional statements obtained. The facility provided an additional statement by Licensed Practical Nurse #1 that indicated s/he did not witness the incident. Review of the Unit 1 Assignment Sheet for 10/23/18 revealed there were 2 nurses and 3 CNAs assigned to the unit at the time of the incident. In an interview with the administrator and Social Services #1 on 11/20/19 at approximately 3:15 PM they stated the only statement was from the CNA who witnessed the incident and LPN #1. They stated the incident occurred on Unit 1. At 3:45 PM the surveyor talked with the administrator about the facility's policy which indicates to interview all staff who worked with resident at time of alleged incident. The administrator stated they only interviewed witnesses to the incident. Informed administrator that policy states to interview witnesses but also to interview staff who have worked with resident during period of the alleged incident. The facility reported an allegation of physical abuse of Resident #2 by physical therapist #1 to the State Agency on 8/20/19. Review of the medical record revealed Resident #2's date of birth as 1/29/35 with admission to the facility on [DATE]. [DIAGNOSES REDACTED]. Further review of the medical record revealed the Quarterly Minimum Data Set ((MDS) dated [DATE] coded Resident #2 as having a Brief Interview for Mental Status score of 12. The Quarterly MDS coded Resident #2 as requiring extensive assistance with 1 person physical assist for transfers, dressing, and bed mobility with no behaviors coded as occurring during the assessment period. Review of the care plan revealed resident exhibiting behaviors of confabulating stories regarding care here and home prior to admission. RP states resident has had these behaviors for years. The care plan was initiated on 8/20/19. Further review of the care plan revealed the resident has a mood problem related to hallucinations, GAD, depression was initiated on 8/22/19. Interventions included to provide care in an unhurried manner and psych evaluation as needed. Review of the Five Day Follow-Up Report dated 8/26/19 revealed at approximately 2:05 PM on 8/20/19 Resident #2 reported to LPN #2 that an older physical therapist lady had entered his/her room and provided care to him/her and then drug him/her out of bed. Resident #2 stated the therapist was hateful, mean and rough with him/her. Resident #2 further stated (s/he) hurt me and jerked me up. Physical therapist was immediately identified and suspended pending further investigation. Two witnesses were listed: physical therapist #1 and Resident #2's roommate. The facility interviewed Resident #2 on 8/20/19 and s/he stated the incident occurred the morning before. Resident #2 stated s/he did not report the incident to any staff. Resident #2 indicated the therapist came into his/her room and started tossing and turning him/her back and forth in the bed. The therapist was putting on his/her clothes. Resident #2 stated s/he told therapist s/he didn't want to get up but s/he put him/her in the chair anyway and took him/her to the hallway. The facility interviewed Resident #2's roommate on 8/21/19. The roommate stated s/he had no concerns with staff in the facility and they are nice. Resident stated s/he was not aware of any type of incident with Resident #2. The surveyor noted that there was no documentation that the roommate was in the room at the time of the alleged incident. The facility interviewed physical therapist #1 on 8/20/19. Physical therapist #1 indicated s/he provided care to Resident #2. S/he dressed the resident and assisted him/her into his/her wheelchair. Physical therapist #1 stated Resident #2 did state s/he did not want to get out of bed. After physical therapist #1 began encouraging Resident #2 s/he agreed to get up in the wheelchair and go to the nurses' station, but did not want to go to the therapy department. Physical therapist #1 stated Resident #2 did not ask him/her to stop changing or dressing him/her. Review of the Quality Assurance Form completed by LPN #2 indicated on 8/20/19 at 2:05 PM Resident #2 approached nurse at desk and reported that yesterday morning physical therapy (the older, gray-haired one) entered his/her room, drug him/her out of bed, dressed him/her and put his/her shoes on, put him/her in the wheelchair, and pushed him/her out into the hallway. Resident #2 stated that the therapist was hateful, mean, and rough. Resident #2 stated (s/he) hurt me and jerked me up when I was sick. I told (him/her) I was sick and that I didn't feel like getting up, (s/he) didn't listen. Social worker #1 indicated Resident #2 stated the older physical therapist lady came in to get him/her up and s/he tossed and turned him/her several times trying to get his/her clothes on causing him/her to become nauseated. Resident #2 stated s/he told the physical therapist several times I'm sick and (s/he) didn't listen to me. The physical therapist was getting him/her up in w/c and put him/her in the hall by him/herself. Social Worker indicates therapy director will talk with physical therapist about not getting resident up if s/he states s/he doesn't feel well. In an interview with the surveyor on 11/18/19 at approximately 1:15 PM, the Director of Nursing (DON) stated s/he may have some other interviews in her file. She reviewed investigative file provided to surveyor. There were three witness statements in the investigative file: physical therapist #1, Resident #2, and Resident #2's roommate. Review of Resident #2's Physical Therapy Treatment Encounter Notes for (MONTH) 2019 revealed physical therapist #1 worked with the resident only 1 time during the month on 8/19/19. Resident #2 was noted with 10 encounters during the month of August. In an interview with the surveyor on 11/18/19 at approximately 1:35 PM the DON stated s/he did not interview any other staff related to the allegation of abuse. When asked why s/he did not interview staff on duty at the time of the alleged incident the DON did not respond to the surveyor. The DON stated s/he interviewed Resident #2, the resident's roommate and the physical therapist. The DON stated s/he interviewed three other residents related to the abuse allegation. The DON stated s/he picked the three residents because they go to therapy. The DON stated s/he was not sure if they had therapy with physical therapist #1 or another therapist. The DON stated they assign residents to therapists randomly and s/he did not pick residents to interview based on if they were assigned to and received therapy from physical therapist #1. The DON stated s/he did not interview any other staff related to the allegation. The surveyor reviewed witness statements for the residents interviewed and all were asked how staff treats them and if they had any concerns with the therapy staff. Review of the Staff Assignment sheet for 8/19/19 revealed there were two nurses and four CNAs on duty on Unit 2, where the resident resided, at the time of the alleged incident. LPN #2 was not one of the two nurse working on the unit at the time of the alleged incident. On 11/19/19 at approximately 2:10 PM, review of the medical record revealed Resident #8 was admitted to the facility with [DIAGNOSES REDACTED]. On 11/19/19 at 3:55 PM, review of the Nursing Progress Notes revealed a note dated and timed 5/18/2019 14:20 stating Nurse from Unit 2 called and reported to Nurse that resident was inappropriately touching two residents on that unit. Nurse went to get resident from Unit, when nurse noted that resident was on the way back to Unit 1. Resident is currently sitting at the nurses desk (1430) with Nurses on Unit 1. At 17:18 PM, the nurse notified the Physician Assistant and an order received for [MEDICATION NAME] 150 mg (milligrams) twice a day. Review of all of the reportable incident files provided by the facility upon entrance revealed no file related to the incident involving Resident #8 and two other residents on unit 2 on 5/18/19. The reportable file was requested from the Administrator and the Director of Nursing at approximately 05:00 PM on 11/19/19. During an interview on 11/20/19 at 8:50 AM, the DON confirmed they did not have a file and that the 5/18/19 incident was not reported to the State Agency. The DON further confirmed there was no investigation and stated the facility took all allegations of abuse seriously but they had not been informed of the incident occurring on 5/18/19 until the surveyor informed them on 11/19/19. Review of the facility's policy entitled Abuse Prevention Program, page 3, revealed 5. When alleged or suspected case of mistreatment, neglect, injuries of unknown source, or abuse is reported, the facility Administrator, DON (Director of Nursing), or individuals designated will immediately (not to exceed 24 hours if the event does not result in serious bodily injury. NO LATER THAN 2 HOURS IF THE EVENT IS AN ALLEGATION OF ABUSE OR WHERE THERE IS SIGNIFICANT INJURY, OR NEGLECT WHERE THERE IS SERIOUS BODILY INJURY) notify the following persons or agencies of such 1. The State licensing/certification agency responsible for surveying/licensing the facility; .",2020-09-01
317,J F HAWKINS NURSING HOME,425035,1330 KINARD STREET,NEWBERRY,SC,29108,2019-11-20,757,E,1,0,8NDB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to ensure unnecessary medications were not administered to 1 of 1 reviewed for medication administration (Resident #8). The findings included: Resident #8 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the Medication Administration Record [REDACTED]. (milligrams) at bedtime. The [MEDICATION NAME] was increased to 150 mg twice daily on 5/19/19. Review of the MAR indicated [REDACTED]. During an interview on 11/20/19 at 1:17 PM, the Director of Nursing (DON) confirmed the resident received the [MEDICATION NAME] 150 mg. at 9:00 PM and again at 10:00 PM according to the MAR. The DON also confirmed that was an unnecessary medication.",2020-09-01
318,J F HAWKINS NURSING HOME,425035,1330 KINARD STREET,NEWBERRY,SC,29108,2019-11-25,679,E,0,1,F0I411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, it was determined the facility failed to provide meaningful activities to 3 of 3 residents reviewed for activities in the secured unit (Residents #52, #39, and #70). The facility identified 19 residents who resided in the secured unit. The findings included: 1a. Resident #52 had [DIAGNOSES REDACTED]. The resident's current care plan, last updated 06/05/19, documented the resident had little group and one on one activities related to decreased social interactions. It had documented interventions that included explain to the resident the importance of social interaction, leisure activity time, and encourage participation in activities. It further documented the facility would explore past interest and encourage participation in those activities. An activities evaluation, dated 03/13/19, documented the resident enjoyed religious activities, painting, tinkering with old cars, exercise, and sports. The evaluation documented the resident enjoyed small group activities, 1:1 activity, and would self-recreate in the afternoon. A quarterly Minimum Data Set (MDS) assessment, dated 09/09/19, documented the resident's cognition was severely impaired, usually made self-understood and was able to understand others. The resident required one-person extensive assistance with bed mobility, walking, locomotion, and dressing. The resident required two-person extensive assistance with transfers. 1b. Resident #39 had [DIAGNOSES REDACTED]. The Admission MDS assessment, dated 01/04/19, documented it was very important for the resident to choose bed time, have family and friends involved in care, use the phone in private, read, and do favorite activities. An activities evaluation, dated 08/01/19, documented the resident enjoyed games, movies, TV, music, and talking. It further documented the resident would self-recreate in the morning. A quarterly MDS assessment, dated 09/16/19, documented the resident was severely impaired with cognition, and required extensive assistance with bed mobility, transfers, and dressing. The resident's current care plan, last updated 09/18/19, documented the resident had little group activity involvement and enjoyed self-initiated activities such as reading all kinds of books and listening to classical music. It had documented interventions that included explain to the resident the importance of social interaction, leisure activity time, and encourage participation in activities. It further documented the facility would explore past interest and encourage participation in those activities. 1c. Resident #70 had [DIAGNOSES REDACTED]. An activities evaluation, dated 01/08/19, documented the resident enjoyed community outings, cooking/baking, cultural events/news, exercise/sports, family/friends, reading/writing, and religious activities. A quarterly MDS assessment, dated 10/07/19, documented the resident's cognition was severely impaired. The resident required two-person extensive assistance with bed mobility, transfers, dressing, and toilet use. The current care plan, last updated 10/10/19, documented the resident was at risk for activity deficit. It further documented the resident required visits to build rapport and develop opportunities to increase activity involvement. The resident enjoyed religious functions and cleaning up around the unit and moving things from place to place. The interventions included to offer mentally stimulating activities to help maintain cognitive strengths such as religious functions, singings, and socials. On 11/23/19 at 9:40 AM, Residents #52, #39, and #70 were observed in the common area of the secured unit while a movie was playing. The residents were observed sleeping while the movie was playing. No staff was observed engaging the residents in attempts to awaken them and/or provide any meaningful activities. On 11/23/19 at 10:03 AM, the activities aide attempted to play some music and bounce a ball with the residents. No residents attempted to participate in the activity. Residents #52, #39, and #70 were not engaged in the activity and remained asleep. No staff was observed arousing the residents and attempting to engage them in the activity. After approximately five minutes, the aides shut the music off and then left the area. The residents remained asleep with no meaningful activities being provided. On 11/23/19 from 2:00 PM through 4:15 PM, the residents were observed in the secured unit. No meaningful activities were being provided. The residents sat in the common area with no music, television or any activities being provided. On 11/24/19 at 8:50 AM, Resident #52 was at the dining room table finishing his breakfast. At 8:53 AM, an aide moved the resident to the center of the common area and left him. There was no music or meaningful activities being provided to the resident. He sat in the common area in silence. Residents #39 and #70 were also in the common area in silence with no activities being provided. Residents #52 and #70 were observed closing their eyes while up in their wheelchairs. On 11/24/19 at 9:06 AM, Activities Assistant #40 was observed reading scriptures. Residents #52 and #70 remained asleep. Resident #39 was across the room and not engaged in the activities. Staff did not attempt to awaken the residents and/or encourage participation in the scripture reading. On 11/24/19 from 9:06 AM through 9:50 AM, the residents remained in the common area, asleep and not participating in the activities. No staff was observed providing meaningful activities to the residents. On 11/24/19 at 9:50 AM, Activities Assistant #40 asked the residents if they wanted to attend the Sunday school starting at 10:00 AM. When Residents #52 and #32 did not awaken and respond, they were not awakened and/or taken to the activity of Sunday school. The residents remained in the common area while Sunday school was provided in the chapel. On 11/24/19 at 10:59 AM, Certified Nurse Aide (CNA) #15 stated Residents #52, #39, and #70 were watched to see if they will participate. She stated they were not forced or really encouraged to participate if they do not. She stated the residents usually sleep during the activities. She then identified all the residents as enjoying religious or spiritual activities and they should be taken to them when they were offered. On 11/24/19 at 11:24 AM, CNA #22 stated the residents did not get anything out of the activities and most of them sleep. She then stated the residents were not encouraged to attend the church activity in the chapel and were not taken when they did not respond. She then stated it was the responsibility of the activities department to make sure the residents were provided activities they enjoyed. She then stated the current activities provided no meaning to the residents because they slept through them. On 11/24/19 at 11:49 AM, Activities Assistant #40 stated she did not force the residents to participate. She then stated the residents were kept busy during the week, but not on the weekends. She then stated the residents do sleep a lot during the activities when they were provided. On 11/24/19 at 3:28 PM, the Activities Director stated the activities that were provided in groups were not necessarily what the residents liked. She stated she noticed a problem the previous day and did not realize it was a problem.",2020-09-01
319,J F HAWKINS NURSING HOME,425035,1330 KINARD STREET,NEWBERRY,SC,29108,2019-11-25,812,E,0,1,F0I411,"Based on observation, record review, and interview, the facility failed to store food in accordance with professional standards for food service safety for 1 of 2 kitchens. Specifically, the facility failed to store cold food items at less than 41 degrees Fahrenheit (F). The findings included: The satellite kitchen was observed on 11/23/19 at 8:30 AM. The tall refrigerator, near the steamtable, had a temperature of 48 degrees F. The satellite kitchen was observed on 11/24/19 at 12:35 PM. The refrigerator temperature was 48 degrees F. The satellite kitchen was observed again on 11/25/19 at 7:03 AM. The refrigerator temperature was 48-50 degrees F. The refrigerator contained two large trays of milk cartons; sandwiches; sliced cheese; glasses of juice; and glasses of thickened milk products. Tray line for breakfast meal started at 7:10-7:15 AM. Tray line ended at 8:10 AM. At 8:10 AM., the food service director (FSD) tested the temperature of two items in the refrigerator. A glass of thickened milk had a temperature of 55 degrees F. A pimento cheese sandwich had a temperature of 47 degrees F. The FSD said the temperature was as low as 45 degrees F for the sandwich. The FSD said they placed items into the refrigerator prior to meal service. The registered dietitian (RD) was interviewed on 11/25/19 at 8:40 AM. She said she completed a sanitation inspection monthly. She said she was not aware of the refrigerator temperatures running high. She said she was not aware the food items needed to be served at proper temperature throughout meal service. At 8:50 AM, the refrigerator temperature was 50 degrees F. There were three thermometers in the refrigerator. The one on the left side measured 50 degrees F. The one in the back measured 48 degrees F. The outside thermometer measured 44 degrees F. The executive chef (EC) was interviewed and he said he was not aware food items needed to be served at the proper temperature. Review of (MONTH) 2019 temperature log revealed the following refrigerator temperatures: -10/21/19: 44 degrees F for the AM temperature -10/29/19: 42 degrees F for the AM temperature Review of the (MONTH) 2019 temperature log revealed the following refrigerator temperatures: -11/1/19: 45 degrees F for the AM temperature -11/8/19: 45 degrees F for the AM temperature -11/23/19: 46 degrees F for the AM temperature",2020-09-01
320,J F HAWKINS NURSING HOME,425035,1330 KINARD STREET,NEWBERRY,SC,29108,2019-11-25,880,D,0,1,F0I411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain infection control practices while providing care to one of two residents observed for incontinence care (Resident #56). The findings included: Resident #56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident was currently on Hospice and was receiving IM (intramuscular) injections of [MEDICATION NAME] for his UTI. The most recent Minimum Data Set (MDS), dated [DATE], coded this resident as always being incontinent and requiring total assistance from staff for all ADLs (activities for daily living). The resident had both short- and long-term memory loss. On 11/24/19 at 11:08 AM, personal care was observed that was performed by two Certified Nursing Assistants (CNAs). CNA #112 and CNA #9 washed their hands prior to beginning care and applied gloves. The perineal area was cleansed by CNA #112 while CNA #9 assisted by holding and moving the resident. When the cleansing was completed, both CNAs adjusted the resident's clothing and bed covers wearing the same gloves that they had put on prior to the care. CNA #9 gathered the dirty supplies and placed them in a trash bag. CNA #112 emptied the wash basin that was used during the care and placed it on the shelf of the resident's closet. As CNA #9 was preparing to leave the room with the trash, she removed her gloves and put them into the trash bag. CNA #112 adjusted her own clothing while still wearing the same gloves. While still in Resident #56's room at 11:20 AM, both CNA #112 and CNA #9 were asked when they removed or changed their gloves while providing care. Both CNAs replied, When we get finished. The CNAs were asked if they did not feel the dirty gloves should be changed before touching other items in the resident's room including their own clothing. CNA #112 and CNA #9 stated that they probably should have. An interview was conducted with the Director of Nurses (DON) on 11/25/19 at 4:16 PM regarding the observation of the CNAs not changing their gloves at any time while doing the incontinence care. She stated that based on professional standards of care, they should have changed their gloves when going from dirty to clean. She further stated that she would have expected them to change their gloves when they finished cleaning the resident and before touching the resident's clothes and bed covers. A copy of the facility's policies on Handwashing/Hand Hygiene (undated) and Urinary Continence and Incontinence (undated). Neither of these policies specifically addressed the changing of gloves during incontinence care. The DON stated on 11/25/19 at 4:14 PM that she did not have a policy that specifically addressed this.",2020-09-01
321,GREENVILLE POST ACUTE,425042,661 RUTHERFORD RD,GREENVILLE,SC,29609,2020-02-06,725,D,1,1,NI3N11,"> Based on staff and resident interview the facility failed to provide sufficient nursing staff to care for resident's needs for 2 out of eight Residents investigated. Residents #272 and #53 expressed concerns regarding sufficiency of staff. The findings included: Interview with Resident #272 on 2/4/20 at 12:18 PM The Resident stated it takes 20 to 60 minutes for staff to respond to a call light/request for assistance. The resident also mentioned that s/he sat in waste for over an hour after requresting staff assistance. Interview with Resident #53 on 2/4/20 at 2:58 PM, The Resident stated there is a shortage of weekend staff especially second shift. The Resident stated that s/he asked and had to wait over an hour for staff to put him/her to bed. An interview on 2/6/20 at 12:58 PM, Certified Nursing Assistant (CNA) #1 stated that once or twice a week she does not have time to complete all assignmenst and did not put Resident #53 to bed prior to shift change as she was assigned. CNA #1 also stated once or twice a week she doesn't have time to complete rehabilitation therapy on Resiendents as ordered due to short staffing.",2020-09-01
322,GREENVILLE POST ACUTE,425042,661 RUTHERFORD RD,GREENVILLE,SC,29609,2020-02-06,732,D,1,1,NI3N11,"> Based on interview and observation, the facility failed to post cumulative staffing hours worked at the beginning of each shift. The findings included: Observation of all bulletin boards for staff postings on 2/4/20 at 10:40 AM revealed cumulative hours were not listed. Observation of all bulletin boards for staff postings on 2/5/20 at 1:48 PM revealed cumulative hours were not listed. Observation of all bullentin boards staff postings on 2/6/20 at 1:10 PM revealed cumulative hours were not listed. A Record review of (MONTH) 2019, (MONTH) 2019, and (MONTH) 2020 on 2/6/20 at 1:15 PM revealed cumulative hours had been listed with these postings. Durring an interview with the Staffing Coordinator on 2/6/20 at 1:20 PM, The Staffing Coordinator stated s/he does not post cumulative hours until the end of the shift, rather than the beginning of each shift as required. S/he confirmed that visitors will not see the postings until end of shift.",2020-09-01
323,GREENVILLE POST ACUTE,425042,661 RUTHERFORD RD,GREENVILLE,SC,29609,2017-07-19,167,C,1,1,VOF211,"> Based on record review and interview, the facility failed to provide the recertification surveys and plan of correction in a place readily accessible to residents. There was no sign as to where the information could be located to obtain the 2014 and (YEAR) recertification surveys. The findings included: Review of the survey results book located in the lobby on 7/19/17 at 4:15pm revealed no information posted as to where the previous years' surveys could be located or how to access them. During an interview on 7/19/2017 at 4:37pm, the Administrator verified the missing recertification surveys information or location.",2020-09-01
324,GREENVILLE POST ACUTE,425042,661 RUTHERFORD RD,GREENVILLE,SC,29609,2017-07-19,223,D,1,1,VOF211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to provide an environment free of abuse for Resident #117. Resident #117 with a reported incident of verbal abuse by a Certified Nursing Assistant. (1 of 1 reviewed for abuse) The findings included: The facility admitted Resident #117 with the [DIAGNOSES REDACTED]. Record review on 7/18/17 revealed on 1/15/17 an alleged incident of verbal abuse was reported to the State Survey Agency on 1/17/17 with a conclusion that abuse was substantiated after an investigation on 1/20/2017. Witness statements were obtained with dates of 1/17/17. The incident was reported to the facility on [DATE] at which time an investigation was begun. During an interview with the Administrator on 7/19/17, s/he stated that Certified Nursing Assistant (C.N.[NAME]) #1 was suspended for an event that occurred immediately prior to the incident that occurred on 1/15/17. S/he further reported that C.N.[NAME] #1 resigned when s/he was contacted on 1/19/17 to come in to facility to discuss the alleged incident regarding Resident #117. Further discussion with the Administrator revealed that the process to terminate C.N.[NAME] #1 had been initiated; however, s/he resigned before the process could be completed. On 7/19/17, a review of the Five Day Follow-Up Report completed on 1/20/17 revealed a summary report of facility investigation which stated After investigation, including review of staff statements and medical record. Incident did occur.",2020-09-01
325,GREENVILLE POST ACUTE,425042,661 RUTHERFORD RD,GREENVILLE,SC,29609,2017-07-19,241,E,1,1,VOF211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and interview, the facility failed to provide an environment to promote the dignity of residents. Residents were not offered glasses with canned or cartoned drinks for 28 residents on five of five units during meal tray delivery. Also, 6 Certified Nursing Assistants (CNAs) entered resident rooms without knocking on doors on four of five units. The findings included: Observations during meal tray delivery on 7/16/17 at 5:57pm revealed that no glasses were offered to 6 residents that received canned and/or in carton beverages on the 500-unit. A random observation on 7/17/17 at 8:40am revealed a CNA entering a 100-unit resident room to remove a tray without knocking on their door. Observations on 7/17/17 at 11:48am on the 200-unit revealed 3 different CNAs entering multiple rooms (202, 201, 204, and 203) without knocking on the resident doors during meal tray delivery. Observations during meal tray delivery on 7/18/17 at 12:45pm on the 500-unit revealed a CNA did not knock on the door when delivering the meal tray to room [ROOM NUMBER]. A random observation on 7/18/17 at 5:35pm revealed a CNA entered resident room [ROOM NUMBER] without knocking. During an interview on 7/19/17 at 5:35pm, the Administrator verified that it is the expectation to knock on the door whether open or not before entering a resident's room. On 07/18/2017 at 12:38 PM, observation of the dining area for Halls 400 and 500 revealed 6 residents served milk in cartons or sodas in cans. One additional resident was served a soda in a can but resident had brought a styrofoam cup to the dining room which s/he poured the soda into. None of the residents were asked if they preferred to have their drinks in a cup and no cup was offered. Observation of the dining room for the 200 and 300 Units on 7/16/17 at approximately 5:20 PM revealed 1 resident sitting at a table with 2 cartons of milk. The milk was served in the cartons, and staff did not ask if the resident would like the milk served in a glass. Observation of the tray cart sitting in the dining room revealed milk cartons were located on 3 trays with no glasses observed on the trays and no glasses observed on the cart. Observation of the dining room for the 200 and 300 Units on 7/18/17 at approximately 12:30 PM revealed 1 resident sitting at a table with 3 cartons of milk and another resident sitting at table with 1 carton of milk. The milk was served in the cartons, and staff did not ask if the residents would like the milk served in a glass. Observation of the tray cart revealed milk cartons on 4 trays with no glasses observed on the trays and no glasses observed on the cart. During the second dining observation on 7/18/17 at approximately 12:25 pm, on hall 400, there were 3 trays observed with canned sodas being served directly out of the can. It was also observed that 2 trays contained milk cartons that residents were directly drinking out of. Further investigation showed staff did not offer residents cups or glasses to drink their beverages out of, neither were they readily available if a resident had requested one.",2020-09-01
326,GREENVILLE POST ACUTE,425042,661 RUTHERFORD RD,GREENVILLE,SC,29609,2017-07-19,253,E,1,1,VOF211,"> Based on observation and interview, the facility failed to ensure effective housekeeping and maintenance services were provided to ensure an orderly and comfortable interior. Numerous environmental concerns were observed in resident rooms and common areas on 5 of 5 units throughout the facility. The findings included: During the Initial Tour of the facility on 7/16/17 at approximately 4:00 PM, observation of common areas of the facility revealed the following environmental concerns: 100 Unit: Observation of the 100 Unit shower room revealed the privacy curtains were soiled. 200 Unit: Observation of the 200 Unit shower room revealed the wall tile was soiled with a grayish-colored substance, and the shower room door was observed with multiple scrapes and scratches. 300 Unit: Observation of the 300 Unit shower room revealed a dark-colored build-up along the baseboards in the shower. 500 Unit: Observation of the 500 Unit back shower room revealed chipped tile with sharp edges along the corner of the shower stall. Observation of the 500 Unit hallway revealed a large area of water stain on the ceiling tiles near the maintenance area and 7 ceiling tiles with water stains in the hallway. Observation of resident rooms on 7/16/17 and 7/17/17 revealed the following environmental concerns: Room 100 - The wall behind the bed was observed with missing decorative molding. The baseboards in the bathroom with observed with a dark-colored substance, and the floor on the right side of the bed was observed with dark-colored areas between the floor tiles. Room 102 - The wall behind the headboard was observed with numerous dark marks. Decorative railing above the headboard was missing with the bare wood exposed. There were missing sections of decorative molding on the lower wall. Metal was observed to be exposed on the bathroom door, and the baseboards in the bathroom were observed with a dark-colored substance. Room 200D - The bottom drawer of the dresser was observed to have scrapes, scratches and brown spots. The door to the room was observed with numerous scratches, and the overbed tray table was observed with scratches and visible particle board. Room 201 - The privacy curtain was observed with white and brown-colored spots and stains near the bottom of the curtain. The closet doors were observed with areas of chipped paint and scratches. An area of rust-like material was observed around the waste container underneath the sink. Room 204D - The closet doors were observed with numerous scratches. Room 208C - The sink in the room was observed with a crack between the sink and wall, and the baseboard under the sink was discolored. The closets in the room had numerous marks and scratches. Room 216 - A piece of molding was missing on the wall between the bathroom and the room. The wall behind the head of the bed was observed with numerous scratches, and a piece of decorative molding was missing on the wall behind the bed. The baseboards in the room were observed with scratches and a dark-colored substance. The bathroom sink was observed with rust stains at the faucet and sink drain, and the vent in the bathroom fan had a heavy build-up of dust. Room 402D - The front of the closet doors were observed with numerous marks and scratches. The wall behind the head of the bed was observed with white marks, and the wall underneath the sink was discolored. Room 403D - The wall at the foot of the bed was observed with numerous marks and scratches. The closet doors and front of the dresser drawers had numerous marks and scratches. Room 406D - The wall behind the head of the bed had numerous scratches and marks, and the closet doors were scratched and marked. Room 500 - The wall behind the bed had numerous scratches. Room 503 - The overbed table had exposed particle board on the edges. Room 515 - The wall behind the head of the bed was observed to be damaged, and dark scrapes were observed on the wall behind the door. The bathroom door was observed with scrapes on the door frame and bottom of the door. Room 516 - The wall at the head of the bed was observed with scrapes. The bottom section of the legs on the beside table were observed to be soiled with debris and stains. A dark smudge was observed on the bathroom wall, and paint was observed missing below the soap dispenser. Multiple nail holes were observed on the wall above the television, and the 2 chairs in the room had stains on the seats. Room 517 - The wall behind the head of the bed was observed with numerous scratches and dark marks A dark substance was observed in the corner under the sink in the room . Room 519 - Wall damage was observed near the floor beside the bathroom door, and the wall under the call light had dark scrapes. Room 521 - The wall behind the head of the bed was observed with numerous scrapes and scratches, and the wall near the television and the doorway was observed with scrapes. Room 522 - The wall behind the left side of the bed was observed with a white material, and the wall between the sink and bathroom door was observed with dark marks. The interior and exterior of the bathroom door was observed with scratches. Room 523 - The wall behind the head of the bed was observed with scrapes and scratches, and the wall between the bed and the heating/cooling unit was observed with scrapes. During a tour of the facility with the Administrator and Maintenance Director on 7/19/17 at approximately 1:45 PM, the above environmental concerns were confirmed by the facility staff.",2020-09-01
327,GREENVILLE POST ACUTE,425042,661 RUTHERFORD RD,GREENVILLE,SC,29609,2017-07-19,278,D,1,1,VOF211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interviews, the facility failed to code the MDS (Minimal Data Set) to accurately reflect the status of Residents #85, 165, and 117, 3 of 12 residents reviewed for accuracy of assessments. The MDS was coded incorrectly related to prognosis for Residents #85 and #165 and inaccurately coded related to behaviors, mobility and [DIAGNOSES REDACTED]. The findings included: The facility admitted Resident #85 with [DIAGNOSES REDACTED]. On 07/18/2017 at 8:51 AM, review of the Significant Change in Status MDS (Minimal Data Set) Assessment revealed Question J1400, Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months? was coded as no. On 07/18/2017 at 11:09:34 AM, review of the physicians orders revealed an order dated 7/10/17 to Admit to Southern Care Hospice Dx. (diagnosis) Alzheimer's. The facility admitted Resident #165 with [DIAGNOSES REDACTED]. At 4:15 PM on 07/18/2017, review of the physicians orders revealed an order dated 2/22/17 to Admit to Southern Care Hospice. Dx Anorexia, Malaise, Dementia with behaviors, Hypertension, and Multiple Wounds. Further record review of the Significant Change in Status MDS (Minimal Data Set) assessment dated [DATE] revealed Question J1400, Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months? was coded as no. During an interview at 3:35 PM on 07/19/17, MDS Coordinator #2 confirmed Resident #85 and #165 were receiving hospice services and were coded on the MDS as no at question J1400. The MDS Coordinator stated that there was no documentation from the physician that the resident had a life expectancy of less than 6 months. Review of CMS ' s (Centers for Medicare and Medicaid) RAI Version 3.0 Manual, October, (YEAR), page J-24 revealed Coding Instructions: Code 0, no: if the medical record does not contain physician documentation that the resident is terminally ill and the resident is not receiving hospice services. Code 1, yes: if the medical record includes physician documentation: 1) that the resident is terminally ill; or 2) the resident is receiving hospice services. Upon reviewing the manual with this surveyor, the MDS Coordinator stated s/he did not know that it should be coded as yes if the resident was receiving hospice services. The facility admitted Resident #117 with the [DIAGNOSES REDACTED]. Record review on 7/19/17 revealed a psychiatric follow-up evaluation indicating a [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessments for Resident #117 dated 2/27/17 and 5/25/17 revealed that depression was not listed as an active [DIAGNOSES REDACTED]. During an interview with MDS Nurse #1 on 7/19/17 at 11:36 AM, s/he reviewed the MDS assessments and agreed that item I5800 should have been, bit was not checked to identify an active [DIAGNOSES REDACTED]. Review of medical record on 7/19/17 revealed a psychosocial note dated 2/27/17 that identified Resident #117 .ambulates in merry-walker through the facility . Additional review of Medication Administration Record [REDACTED]. Review of the Quarterly MDS Assessments for Resident #117 dated 2/27/17 and 5/25/17 revealed that item G0600B (mobility device normally used: walker) was not checked, despite the documented use of merry-walker during the assessment periods for both MDS assessments. During an interview with MDS Nurse #1 on 7/19/17 at 11:36 AM, s/he reviewed the MDS Assessments and the documentation related to the Merry-walker and verified that item G0600B should have been checked on the Quarterly MDS assessments dated 2/27/17 and 5/25/17. Review of medical record on 7/19/17 revealed nursing notes on 2/25/17 at 2:18 PM that reported that Resident #117 was entering other patient's room, redirected as necessary. Further review reveals nursing note dated 2/27/17 at 1:59 PM that reported unable to obtain resident blood sugar at 11:30, resident combative, pushing nurse's hands away and grabbing and twisting fingers. Review on 7/19/17 of Quarterly MDS assessment dated [DATE] revealed that resident had no behaviors coded in section E. During an interview with Social Services Director on 7/19/17 at 2:15 PM, s/he agreed that the behavior section of the MDS was incorrectly coded with no identified behaviors during assessment period, despite documentation in nursing notes reflecting various behaviors on 2/21/17, 2/22/17, 2/25/17 and 2/27/17.",2020-09-01
328,GREENVILLE POST ACUTE,425042,661 RUTHERFORD RD,GREENVILLE,SC,29609,2017-07-19,280,E,1,1,VOF211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to review and revise the care plan for 1 of 12 residents reviewed for care plans, failed to develop a care plan to address all care areas for 1 of 12 residents reviewed, and failed to document participation of all required members of the Interdisciplinary Team for 8 of 8 residents reviewed for care plans. The care plan for Resident #100 was not updated related to a call light; the care plan for Resident #82 was not developed for [MEDICAL CONDITION]; the care plan Interdisciplinary Team did not include a Certified Nurse Aide (CNA) for Residents #165, #49, #78, #64, #172, #82, #100, #47, the Interdisciplinary Team did not include Social Services for Resident #117 and Resident #100; and the Interdisciplinary Team did not include Therapy participation for Resident #82. The findings included: The facility admitted Resident #64 with [DIAGNOSES REDACTED]. Record review revealed the Care Plan Attendance Record dated 6/27/17 and 4/4/17 included spaces for signatures of staff attending the care plan meeting. Further review of the form revealed no signature of a Certified Nurse Aide (CNA) to indicate they were part of the Interdisciplinary Team that developed the care plans. During an interview on 7/19/17, the MDS/Care Plan Coordinator reviewed the signature sheets, confirmed the findings, and stated that he/she was unaware of that requirement. The facility admitted Resident #165 with [DIAGNOSES REDACTED]. At 4:33 PM on 07/18/2017, review of the Care Plan Attendance Record revealed the Certified Nursing Assistant was not included in the care plan conference on 6/6/17 or on 2/7/17. During an interview on 07/19/17 at approximately 3:00 PM, the Director of Nursing confirmed there was no documentation on the Care Plan Attendance Record to indicate the Certified Nursing Assistant was involved in the care plan process. During review of the medical records, it was discovered Resident #'s 100, 49, and 78 did not have a Certified Nursing Assistant (CNA) in attendance at the Care Plan meetings. An interview conducted on 7/18/17 at approximately 3:56 PM with Minimum Data Set (MDS) Nurse #1 confirmed that CNAs were not actually attending the care plan meetings. Review of the Care Plan attendance sign in sheets showed there was no place on the form for CNAs to sign. Additionally, an interview with CNA #4 on 7/18/17 at 4:15 PM confirmed that CNAs were not invited to the care plan meetings. The facility admitted Resident #100 with [DIAGNOSES REDACTED]. Review of the Care Plan (6-01-17) and Nurse's Notes (6-30-17) on 7-19-17 at 11:35 AM, Resident #100 showed a history of suicidal behavior (Ideations) related to depression disorder. On 7-18-17 at 11:25 AM, Resident #100 was observed without a call light and with a bell on top of his/her over-bed table. Record review showed no physician's orders or documentation in the care plan supporting or explaining the reasons why his/her call light was replaced with a bell. During an interview on 7-19-17 at 2:26 PM, Licensed Practical Nurse (LPN) #3 stated that the care plan had not been updated to reflect the removal of the call light and placement of a bell as a self-harm precaution measure. On 7-19-17 at 3:15 PM, review of the Care Plan Attendance Record revealed no evidence of certified nursing assistant or Social Services participation in the care plan. The facility admitted Resident # 82 with [DIAGNOSES REDACTED]. Record review on 7/18/17 at 10am revealed the Comprehensive Care Plan did not include a Focus/Problem for the [DIAGNOSES REDACTED]. Review of the Physician's Telephone Orders on 7/18/17 at 11am revealed an order dated 6/12/17 for Trazadone 25mg by mouth at bedtime for [MEDICAL CONDITION]/Dementia. During an interview on 7/19/17 at 10:52am, the Minimum Data Set (MDS) Nurse #2 verified there was no Care Plan for [MEDICAL CONDITION] and no non-pharmacological interventions in place for [MEDICAL CONDITION]. Record review on 7/18/17 at 11am revealed Physician's Telephone Orders dated 6/8/17 for Speech Therapy 5 x wk x 4 wk (five times a week for four weeks) for Dysphagia, and Skilled Physical Therapy 6x wk x 4 wks (six times a week for four weeks) for therapy. Review of the Care Plan Attendance Record dated 6/27/17 on 7/19/17 at 10:30am, revealed no attendance by Therapy, or the Certified Nursing Assistant (CNA). During an interview on 7/19/17 at 5pm, the MDS Nurse #1 verified that the CNA did not participate in or attend the Care Plan Meetings. S/he also stated that if the resident was receiving therapy, then the therapist was expected to attend the Care Plan Meeting. S/he verified no attendance by Physical or Speech Therapy at the Care Plan Meeting on 6/27/17 for Resident #82. The facility admitted Resident #172 with [DIAGNOSES REDACTED]. The records reviewed on 7/19/17 at 11:40am revealed there was no CNA present at the care plan meeting for resident #172 on 2/14/17 or 5/9/17. Additionally, no Social Services staff participated in the care plan meeting for resident #172 on 5/9/17. During an interview on 7/19/17 at 4:28pm, Social Services Director (SSD) verified Social Services staff did not participate in the care plan meeting for resident #172 on 5/9/17. An interview with the Assistant Director of Nursing (ADON) on 7/19/17 at 1:35pm verified that there was no CNA participation in care planning for resident #172 on 2/14/17 or 5/9/17.",2020-09-01
329,GREENVILLE POST ACUTE,425042,661 RUTHERFORD RD,GREENVILLE,SC,29609,2017-07-19,314,D,1,1,VOF211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, interview, and review of the facility's policy, Wound Care Treatment, the facility failed to provide treatments in accordance with standard infection control practices for Resident #165, 1 of 1 resident reviewed for pressure ulcers. The nurse failed to wash or sanitize her/his hands between cleaning the wound and applying the clean dressing. The findings included: The facility admitted Resident #165 with [DIAGNOSES REDACTED]. At 11:04 AM on 07/19/2017, observation of the wound care of the sacrum and left ischial tuberosity revealed the Wound Nurse washed her/his hands and donned gloves. The nurse proceeded to clean the wound bed, dry the wound bed, apply the [MEDICATION NAME] and cover it with a foam border dressing. The nurse removed the gloves and washed her/his hands upon completion. The nurse did not wash or sanitize her/his hands after cleaning the wound before applying the clean dressing. Review of the facility's policy entitled Wound Care Treatment revealed the following instructions: 10. Wash hands 11. Gloves are put on and wound is cleansed with ordered solution. 12. Gloves are removed and discarded along with wound cleansing material appropriately. 13. Wash hands. 14. Gloves are reapplied and treatment is performed as ordered by the physicians. 15. Wound is dressed appropriately. 16. Gloves are removed and disposed of properly. During an interview at 11:26 AM on 07/19/2017, LPN (Licensed Practical Nurse) #6, confirmed s/he did not clean or sanitize her/his hands after cleaning the wound and before applying the treatment and clean dressing on the sacrum.",2020-09-01
330,GREENVILLE POST ACUTE,425042,661 RUTHERFORD RD,GREENVILLE,SC,29609,2017-07-19,325,D,1,1,VOF211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to adequately assess and initiate interventions for significant weight loss for one of two residents reviewed for nutrition. Resident #82 experienced a significant weight loss of 7.4% within 30 days of admission with no further assessment or interventions regarding the weight loss. The findings included: The facility admitted Resident #82 with [DIAGNOSES REDACTED]. Record review of the Comprehensive Care Plan on 7/18/17 at 9am revealed a Resident goal stating, No significant weight change. Record review on 7/18/17 at 11am revealed the following weights for Resident #82: 6/07/17 188 pounds 6/14/17 186 pounds 6/21/17 183 pounds 6/28/17 180 pounds 7/05/17 174 pounds 7/07/17 174 pounds Review of the Provider Worksheet on 7/18/17 at 3:52pm revealed the Nurse Practitioner was notified on 7/10/17 of decrease weight loss .on list for Registered Dietician (RD). No identification or review of weight loss was found in the physician progress notes [REDACTED]. Record review on 7/18/17 at 11am revealed a Weight Change Note dated 7/11/17 stating, 7.45% loss x 30 days PO (by mouth) intakes do not support weight loss. Recommend monitor weekly weights and establish a baseline. No interventions were implemented. Record review on 7/19/17 at 2pm revealed continued weight loss. On 7/18/17 Resident #82's weight was 166 pounds; A 22-pound weight loss in 6 weeks (11.7%). Review of the policy for Weight Management Program on 7/19/17 at 1:25pm stated the following: A weight change notification form to be completed during the PAR (Patient at Risk) meeting, and the PAR committee will review weight loss, place residents on weight program, develop interventions for weight loss, document current weight and any interventions in place or newly implemented, and update care plan with new interventions. Review of the PAR (Patient At Risk) Note's dated 6/22/17, 6/30/17, 7/6/17 and 7/14/17 on 7/19/17 at 1:35pm revealed no documentation regarding Resident #82's weight loss. During an interview on 7/19/2017 at 1:37 PM, the Director of Nursing stated, We do not do weight change notification form for weekly weights, only for monthly, or if they trigger for 30-day significant weight loss. Resident #82 didn't trigger until later in (MONTH) because of the initial (MONTH) weight. In the PAR meeting, we document and talk about the residents on weekly weights, and documentation is in the progress notes. During an interview on 7/19/17 at 11:05pm, the Certified Dietary Manager (CDM) stated, Initially the decision was to just do weekly weights. The CDM also stated, There is a monthly weight change sheet they fill out regarding interventions. Notifications to the physician and the responsible party are on that form. During an interview with the Assistant Director of Nursing on 7/19/17 at 2:20pm, s/he stated,Dietary does the weight change notification form if they have a 30-day loss, but dietary did not initiate a significant weight loss form for this resident.",2020-09-01
331,GREENVILLE POST ACUTE,425042,661 RUTHERFORD RD,GREENVILLE,SC,29609,2017-07-19,329,E,1,1,VOF211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to attempt non-pharmacological interventions prior to administration of anti-psychotic medication and failed to document reasons and effectiveness of medication administered on an as needed (PRN) basis for 1 of 5 sampled residents reviewed for unnecessary medication. Resident #100 received multiple doses of [MEDICATION NAME] ([MEDICATION NAME]) without evidence of non-pharmacological interventions prior to administration and/or documentation of reason for or effectiveness of the medication. In addition, based on record review and interview, the facility also failed to monitor the blood pressure (BP) as ordered for one of five sampled residents reviewed for unnecessary medications. Resident # 100 did not have his/her BP monitored twice daily as ordered. The findings included: The facility admitted Resident #100 with [DIAGNOSES REDACTED]. Record review on 7-18-17 revealed a physician's orders [REDACTED]. Review of the 5-17 Medication Administration Record [REDACTED]. On 5-20-17, there was no documentation found regarding reason for administration or effectiveness of the medication after it was given. Review of the 6-17-17 MAR indicated [REDACTED]. On 6-3-17 and 6-8-17, there was no documentation found regarding reasons for administration or effectiveness of the medication after it was given. On 6-12-17 and 6-17-17, the intervention of redirect was given without specifications on what redirect meant for each intervention to develop/implement an individualized care plan. Four out of six times (6-3-17 x2 and 6-8-17 x2), there was no evidence in the record of attempts at non-pharmacological interventions prior to administration. During the interview on 7-19-17 at 2:25 PM, Licensed Practical Nurse (LPN) #3 reviewed the medical record and verified the above information. When asked if the documentation could be found elsewhere, LPN #3 stated documentation could be found in Nurses Notes or in the Electronic Documentation Record. At 2:37 PM, LPN #3 stated s/he was unable to locate specific information in either place other than redirect in the Nurses Notes. Continued review of the record on 7-18-17 revealed 5-15-17 physician's orders [REDACTED]. Review of the Blood Pressure Summary record on 7-18-17 revealed that blood pressures were not completed as ordered. On 5-11-17, 5-12-17, 5-19-17, and 5-26-17, the BP was taken only one time per day. On 6-23-17, 6-25-17, 6-26-17, 6-27-17, 6-28-17, 6-29-17, 6-30-17, 7-01-17 and 7-02-17, the BP was not monitored at all. During the interview on 7-19-17 at 2:25 PM, Licensed Practical Nurse (LPN) #3 reviewed the medical record and verified the above information.",2020-09-01
332,GREENVILLE POST ACUTE,425042,661 RUTHERFORD RD,GREENVILLE,SC,29609,2017-07-19,332,E,1,1,VOF211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, interview, and review of the facility's policy, Procedure for Medication Administration, the facility failed to ensure a medication error rate of less than 5 percent. The medication error rate was 11.1 percent with 3 errors out of 27 opportunities. The finding included: Error #1: On 07/17/17 at 8:00 PM, Licensed Practical Nurse (LPN) #4 was observed administering medications to Resident #78. [MEDICATION NAME] 3 milligrams (mg) was administered to the resident. Review of the physicians orders revealed an order dated 08/08/16 for [MEDICATION NAME] Tablet 3 mg Give 6 mg by mouth at bedtime for [MEDICAL CONDITION]. During an interview on 07/18/17 at 7:23 PM, LPN #4 stated s/he always give 2 pills then stated s/he was not sure when this surveyor informed the LPN that only 1 pill was observed administered. Error #2: 07/18/2017 at 9:14 AM, Licensed Practical Nurse (LPN) #5 was observed administering medications to Resident #126. Sodium Chloride 1 gram (gm) was administered to the resident. Review of the physician's orders [REDACTED]. During an interview on 07/18/2017 at 3:02 PM, LPN #5 confirmed s/he administered 1 gm of Sodium Chloride and that the current order was for 500 mg. every other day. Error #3: During the medication administration for Resident #126, the LPN crushed Aspirin, Natural Vegetable Laxative, Sodium Chloride, Vitamin C, and Carvedilol together, dissolved them together and pushed the medications via the Percutaneous Gastrostomy (PEG) tube. The PEG was not flushed with water prior to administering medications. During an interview on 07/18/2017 at 3:02 PM, LPN #5 confirmed s/he crushed and dissolved all the medications together and pushed the mixture via the PE[NAME] During an interview on 7/18/17, the Staffing Development Coordinator confirmed the standard of practice was to administer the medications separately and to flush between each medication. Review of the facility's policy entitled Procedure for Medication Administration revealed 12. Pours medications into barrel of syringe with 5 cc (cubic centimeters) to 10 cc of water in between each type of medication.",2020-09-01
333,GREENVILLE POST ACUTE,425042,661 RUTHERFORD RD,GREENVILLE,SC,29609,2017-07-19,371,F,1,1,VOF211,"> Based on observation, interview, and review of the facility's policy entitled Food: Quality and Palatability, the facility failed to store and serve food in accordance with professional standards for 1 of 1 kitchen observed. Multiple food items stored in the cooler were observed to be unlabeled and undated, food items stored in the freezer were improperly closed, expired milk was observed in the Walk-in Cooler, a step-on trash can was not available at the handwashing sink, and cleaning items were observed in the kitchen when not in use. The findings included: During the Initial Tour of the kitchen on 7/16/17 at approximately 4:30 PM, three kitchen staff were observed to be plating food for the evening meal. Observation of the handwashing sink revealed the basin of the sink appeared heavily stained with multiple dark areas. No step-on trash can was observed at the sink, and a cleaning bucket with mop and water was observed near the sink. The outside of the bucket was observed with a dark-colored substance. During the Initial Tour of the kitchen, the following concerns were identified related to food items: Observation of the Reach-in Cooler revealed the following unlabeled and undated items: A plastic container with a yellow-colored, thick substance had no label and no date on the plastic covering on the top. A metal container with an unidentified item had no label and no date on the plastic covering. Several slices of ham were wrapped in plastic wrap with no label and no date. Several slices of cheese were wrapped in plastic wrap with no label and no date. A metal container with an unidentified food item had no label and no date on the plastic covering. An open carton of liquid eggs was undated. One-half of a cantaloupe was covered with plastic wrap with no date. An open package of mozzarella cheese was undated. Observation of the Walk-in Cooler revealed six cartons of milk with an expiration date of 7/14/17. Observation of the Walk-in Freezer revealed a package of[NAME]House Rolls and a package of french fries which were only partially closed. On 7/16/17 at approximately 5:40 PM, the Dietary Manager was informed of the above concerns and stated that he/she would discard the items. During an observation of the kitchen with the Administrator and Dietary Manager on 7/18/17 at approximately 9:30 AM, there was no step-on trash can near the handwashing sink. A large covered trash can was observed near the handwashing sink, and staff had to touch the top of the trash can to discard paper towels after handwashing. A cleaning bucket with mop and water was observed near the door beside the sink. The outside of the bucket was observed to be heavily discolored. A broom and dust pan was observed along the wall to the left of the handwashing sink. The outside door near the sink was observed to be heavily discolored. The Administrator and Dietary Manager were informed of the above concerns at that time. Review of the facility's policy entitled Food: Quality and Palatability revealed under Preparation, 13. All Time/Temperature Control for Safety (TCS) foods that are to be held for more than 24 hours at a temperature of 41 (degrees) F or less, will be labeled and dated with a 'preparation date' (Day 1) and a 'use by date' (Day 7).",2020-09-01
334,GREENVILLE POST ACUTE,425042,661 RUTHERFORD RD,GREENVILLE,SC,29609,2017-07-19,469,E,1,1,VOF211,"> Based on observation and record review, the facility failed to maintain an effective pest control program as evidenced by observation of flies in the kitchen and resident areas throughout 3 of 5 units. The findings included: During a tour of the kitchen on 7/16/17 at approximately 5:40 PM, an elongated insect was observed in the basin of the handwashing sink. A fly was observed on the top of the trash can near the handwashing sink. During an observation of the kitchen on 7/18/17 at approximately 9:30 AM, a fly was observed in the kitchen area near the Reach-in Cooler. During observation of the sanitizing buckets at this time, a fly was observed on the edge of the stainless steel counter top near the food processor. During observation of the 3-compartment sink, a fly was observed to be on the window sill above the sink. At that time, a fly swatter was observed laying on the top of a work table with the paper label still attached to the head of the fly swatter. When opening the door from the kitchen to the outside, the outside area around the door was observed with several flies in the area and several small pieces of debris near the door. The facility provided documentation related to pest control service for the past 12 months. Record review revealed the reports indicated monthly pest control service but did not include any recommendations from the pest control company. On 7-19-17 at 10:25 AM, Resident #158 was observed swatting house flies with a wash cloth in the activity/dining room located between unit 400 and unit 500. Multiple flies were observed hovering around in the area. When asked what s/he was doing, the resident stated, Trying to kill flies. Resident #158 also said, Look, I have killed 3 so far. There were 3 dead flies observed on the table in front of the resident. When asked how often s/he tried to kill the flies, the resident said, Every day. Observations on 7/18/17 1:45pm revealed a fly in the hallway between the 300 and 400 unit. Observations on 7/18/17 at 8:45am revealed a fly in hallway of 300 unit.",2020-09-01
335,GREENVILLE POST ACUTE,425042,661 RUTHERFORD RD,GREENVILLE,SC,29609,2019-10-17,607,D,1,0,F9YN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files, facility policy, and interview, the facility failed to implement their Abuse policy related to injuries of unknown source for Residents #2 and #3 (2 of 10 sampled residents reviewed for Abuse). Injuries of unknown source with serious bodily injuries were reported later than two hours. The findings included: The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Review of a facility investigation, on 10/15/19 at 11:07 AM, revealed on 7/22/19 Resident #2 was transported to a non-emergent appointment by ambulance transport. Upon return to the facility, transport staff reported the resident complained of pain to the knees during the entire appointment. Nursing assessed the resident and noted swelling and pain to the knees. The nurse practitioner was notified and completed an exam. X-rays were ordered due to the knee pain and swelling. X-rays were obtained at the facility on 7/22/19 at 7:45 PM and results were received [DATE] at 2:34 AM. The x-ray results revealed a fracture deformity of proximal fibular shaft of unknown age. No gross acute fracture is seen. The resident was unable to report what may have caused the injury. Review of staff statements revealed no witnesses to any recent accidents or injuries. Further review of the facility investigation revealed the State Agency was not notified of the injury of unknown source with serious bodily injury until 7/24/19 at 3:23 PM. During an interview with the Director of Nursing (DON) and Nurse Consultant on 10/15/19 at 12:56 PM, the DON confirmed the resident's injury was not reported to the State Agency until 7/24/19 at 3:23 PM. The DON stated the injury was reported by the administrator within two hours of becoming aware of the injury. The DON stated staff failed to notify the administrator of the injury timely. The Nurse Consultant stated the facility was aware they had a problem with 2 hour reporting in the past, but they have re-educated and in-serviced the staff on timely reporting since. Review of facility education and in-services, on 10/16/19 at 12:29 PM, revealed on 6/17/19 all nurses were in-serviced on reporting any abuse and injuries of unknown origin to the administrator or DON immediately. The facility admitted Resident #3 with [DIAGNOSES REDACTED]. Review of the facility investigation, on 10/15/19 at 9:30 AM, revealed on 4/3/19, at approximately 5:25 PM, Resident #3 complained of pain to the left wrist and thumb. The nurse observed swelling around the wrist and pain with movement and palpation. The resident could not recall what may have caused the injury. The nurse practitioner (NP) was notified and evaluated the resident. Upon completion of her/his exam, x-rays were ordered. X-rays were obtained and results were received on 4/4/19 at 12:04 PM. Radiology results indicated no fracture was present. The results did reveal a 4 millimeter scapholunate dissociation (ligament injury). The NP completed another exam of the resident after reviewing the x-ray results and referred the resident to the hand center for further follow up. Staff and the resident reported no recent falls or other injuries to the NP. Further review of the facility investigation revealed the State Agency was not notified of the injury of unknown source with serious bodily injury until 4/5/19 at 11:56 AM. During an interview with the DON on, 10/16/19 at 12:24 PM, the DON confirmed the injury of unknown source was not reported timely to her/him or the administrator and therefore was not reported timely to the State Agency. The DON stated nursing had been educated on reporting injuries of unknown source immediately prior to this incident. Review of the facility's Abuse Investigating and Reporting policy revealed injuries of unknown source will be reported immediately, but not later than two hours if the injury has resulted in serious bodily injury.",2020-09-01
336,GREENVILLE POST ACUTE,425042,661 RUTHERFORD RD,GREENVILLE,SC,29609,2019-10-17,609,D,1,0,F9YN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files, facility policy, and interview, the facility failed to report injuries of unknown source with serious bodily injury within the required reporting time frames for Residents #2 and #3 (2 of 10 sampled residents reviewed for Abuse). Injuries of unknown source with serious bodily injuries were reported later than two hours. The findings included: The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Review of a facility investigation, on 10/15/19 at 11:07 AM, revealed on 7/22/19 Resident #2 was transported to a non-emergent appointment by ambulance transport. Upon return to the facility, transport staff reported the resident complained of pain to the knees during the entire appointment. X-rays were obtained at the facility on 7/22/19 at 7:45 PM and results were received [DATE] at 2:34 AM. The x-ray results revealed a fracture deformity of proximal fibular shaft of unknown age. No gross acute fracture is seen. The resident was unable to report what may have caused the injury. Review of staff statements revealed no witnesses to any recent accidents or injuries. Further review of the facility investigation revealed the State Agency was not notified of the injury of unknown source with serious bodily injury until 7/24/19 at 3:23 PM. During an interview with the Director of Nursing (DON) and Nurse Consultant on 10/15/19 at 12:56 PM, the DON confirmed the resident's injury was not reported to the State Agency until 7/24/19 at 3:23 PM. The DON stated the injury was reported by the administrator within two hours of becoming aware of the injury. The DON stated staff failed to notify the administrator of the injury timely. The Nurse Consultant stated the facility was aware they had a problem with 2 hour reporting in the past, but they have re-educated and in-serviced the staff on timely reporting since. Review of facility education and in-services, on 10/16/19 at 12:29 PM, revealed on 6/17/19 all nurses were in-serviced on reporting any abuse and injuries of unknown source to the administrator or DON immediately. The facility admitted Resident #3 with [DIAGNOSES REDACTED]. Review of the facility investigation, on 10/15/19 at 9:30 AM, revealed on 4/3/19, at approximately 5:25 PM, Resident #3 complained of pain to the left wrist and thumb. The nurse observed swelling around the wrist and pain with movement and palpation. The resident could not recall what may have caused the injury. X-rays were obtained and results were received on 4/4/19 at 12:04 PM. Radiology results indicated no fracture was present. The results did reveal a 4 millimeter scapholunate dissociation (ligament injury). Further review of the facility investigation revealed the State Agency was not notified of the injury of unknown source with serious bodily injury until 4/5/19 at 11:56 AM. During an interview with the DON on, 10/16/19 at 12:24 PM, the DON confirmed the injury of unknown source was not reported timely to her/him or the administrator and therefore was not reported timely to the State Agency. The DON stated nursing had been educated on reporting injuries of unknown source immediately prior to this incident and since then. Review of the facility's Abuse Investigating and Reporting policy revealed injuries of unknown source will be reported immediately, but not later than two hours if the injury has resulted in serious bodily injury.",2020-09-01
337,GREENVILLE POST ACUTE,425042,661 RUTHERFORD RD,GREENVILLE,SC,29609,2019-10-17,689,D,1,0,F9YN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to take reasonable steps to prevent accidents for 2 of 10 residents reviewed for abuse. On 12/10/18 Certified Nursing Assistant (CNA) #1 was pushing Resident #1 in a wheelchair. When the resident lowered his/her feet onto the floor, the CNA continued pushing the resident, directly contributing to the resident's fall. The findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of 12/10/18 incident report on 10/16/19 at approximately 9:25 AM revealed the following. 1. Nurse was near nursing station med cart when she witnessed staff member pushing patient in wheelchair. Resident #1 tried to stop the chair with his feet which caused patient to fall out of chair. 2. Resident was transferred off the floor to the wheelchair with help of another staff member. 3. Vitals were obtained and skin assessment performed. There were no visible injuries observed. Review of CNA #1's statement on 10/16/19 at approximately 9:33 AM revealed the following: 1. CNA #1 was pushing Resident #1 in wheelchair. Resident put both his feet on the floor while she was pushing, slowing the wheelchair down. 2. CNA #1 continued to push the wheelchair. 3. The resident thought s/he had stopped and tried to stand while wheelchair was still in motion, falling to the floor. Review of Registered Nurse (RN) #2's statement on 10/16/19 at approximately 9:37 AM revealed the following: 1. RN #2 was near the medcart. S/he observed CNA #1 pushing Resident #1 in the wheelchair. 2. While approaching room [ROOM NUMBER], the resident tried to get out of the chair. CNA #1 told the resident to pick up his/her feet but continued pushing the chair. 3. Resident #1 fell to the floor next to the 100 room. 4. RN #2 reprimanded CNA #1, explaining the fall could have been prevented and would be reported. 5. Vitals were taken and Resident #1 was assessed. S/he was found to be without injury. Interview with RN #1, Regional Director, and Director of Nursing on 10/16/19 at approximately 12:34 PM revealed CNA #1 should have stopped pushing the wheelchair and reminded the resident to pick up his/her feet. All parties agreed CNA #1 should not have continued pushing the wheelchair when s/he discovered Resident #1 was putting his/her feet down on the floor during transport and that this fall could have been prevented.",2020-09-01
338,GREENVILLE POST ACUTE,425042,661 RUTHERFORD RD,GREENVILLE,SC,29609,2018-10-18,577,C,0,1,E2SV11,"Based on interview the facility failed to ensure members of the Resident Council were informed of the location of the state survey results, for 8 of 8 residents attending the group meeting. The findings included: An impromptu meeting was held with members of the facility's Resident Council group on 10/16/18 at approximately 11:00 a.m. During this meeting the residents were asked if the results of the state survey were available to them without having to ask. The residents were not aware of where they could find this information. During an interview with the Activities Director on 10/18/18 at approximately 12:00 p.m., s/he indicated that the residents are informed of this information generally after the completion of the survey and noted that it was done the last survey, over one year ago.",2020-09-01
339,GREENVILLE POST ACUTE,425042,661 RUTHERFORD RD,GREENVILLE,SC,29609,2018-10-18,677,D,0,1,E2SV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, Resident # 19 noted to have no nail care or facial hair removal provided. ( 1 of 3 residents reviewed for ADLs) The findings included: The facility admitted Resident # 19 with [DIAGNOSES REDACTED]. Observation of Resident # 19 on 10/15/18 revealed the resident to have facial hair on her chin and fingernails with dark substance under his / her fingernails and cuticles. Resident # 19 was able to indicate he/she would like for the facial hair to be removed . Licensed Practical Nurse #1 observes the resident and confirmed the facial hair should have been removed on bath day and also the fingernails should have been cleaned. The Nurse confirmed the staff do not sign off when the care is provided. The only way she knows the care has been provided is by checking the residents daily or just by spot checking residents. An inservice was done on 10/10/18 at 2 PM related to Making sure residents are clean and neatly groomed. Hair, nails, and shaving should be part of their shower. Even after the inservice the problem was still noted on 10/15/18.",2020-09-01
340,GREENVILLE POST ACUTE,425042,661 RUTHERFORD RD,GREENVILLE,SC,29609,2018-10-18,812,E,0,1,E2SV11,"Based on observation and interview ovens were not cleaned per cleaning schedule. ( 1 of 1 kitchen) The findings included: On initial tour of the main kitchen on 10/15/18 at 11:30 AM with the Dietary Consultant and Dietary Manager 2 ovens were noted with large amounts of dark brown splatters built up on inside of the ovens. The Dietary Consultant confirmed the ovens had a large amount of splatters and should have been cleaned. Interview with Dietary Manager at 9:25 AM 10/18/18, the Manager explained she assigns staff duties, cleaning, and checks them off at end of day. The stacked ovens were supposed to have been cleaned on Sunday. They were not cleaned until Monday and Wednesday afternoons.",2020-09-01
341,GREENVILLE POST ACUTE,425042,661 RUTHERFORD RD,GREENVILLE,SC,29609,2018-10-18,883,E,0,1,E2SV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to screen for and offer both the 23-valent pneumococcal [MEDICATION NAME] vaccine (PPSV23) and the 13-valent pneumococcal conjugate vaccine (PCV13) vaccine to 4 of 5 residents reviewed for immunizations. (Residents #105, #90, #50, #362) The findings included: The facility admitted Resident #105 on 12/29/17 with [DIAGNOSES REDACTED]. Review of the medical record revealed the Pneumococcal Immunization Informed Consent form indicated Resident #105 received the PPSV23 vaccine on 12/22/17. There was no documentation on the form to indicate that Resident #105 was screened for receiving nor offered the PCV13 vaccine. The facility admitted Resident #90 on 5/14/16 with [DIAGNOSES REDACTED]. Review of the medical record revealed the Pneumococcal Immunization Informed Consent form indicated Resident #90 received the PPSV23 vaccine on 4/16/16. There was no documentation on the form to indicate that Resident #105 was screened for receiving nor offered the PCV13 vaccine. The facility admitted Resident #50 on 3/2/16 with [DIAGNOSES REDACTED]. Review of the medical record revealed the Pneumococcal Immunization Informed Consent form indicated Resident #50 received the PPSV23 vaccine on 10/6/16. There was no documentation on the form to indicate that Resident #50 was screened for receiving nor offered the PCV13 vaccine. The facility admitted Resident #362 on 10/13/18 with [DIAGNOSES REDACTED]. Review of the medical record revealed the Pneumococcal Immunization Informed Consent form indicated Resident #362's representative declined the PPSV23 pneumococcal vaccine. There was no documentation on the form to indicate that Resident #362 was screened for nor offered both the PPSV23 and PCV13 vaccine. During an interview on 10/18/18 at approximately 11:30 AM, the Director of Nursing reviewed the documentation and confirmed that the residents were not offered and screened for receipt of the PCV13 vaccine.",2020-09-01
342,CONDOR HEALTH ANDERSON,425047,611 EAST HAMPTON STREET,ANDERSON,SC,29624,2019-03-28,550,D,0,1,HSS711,"Based on observation and interview, the facility failed to ensure that staff knocked on residents' doors and got permission prior to entering residents' rooms. Staff was observed entering multiple resident rooms on the 100 Unit without permission (1 of 4 units observed). The findings included: A random observation on 3/27/19 at 9:55 AM of the 100 Unit, revealed the facility physician entering a resident's room (109) without knocking. Further observations revealed Certified Nursing Aide (CNA) #2 entering rooms 107, 109, 110, and 112 without knocking and getting residents permission to enter these rooms. An interview on 3/27/19 at approximately 10:12 AM with CNA #2 confirmed the observation that he/she entered multiple residents rooms without knocking. CNA #2 further stated he/she was in a hurry and did not think to knock.",2020-09-01
343,CONDOR HEALTH ANDERSON,425047,611 EAST HAMPTON STREET,ANDERSON,SC,29624,2019-03-28,584,D,0,1,HSS711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain a safe environment for Resident #128 (1 of 3 sampled residents reviewed for falls). A safety rail in the resident's bathroom was loose and pulling away from the wall. The findings included: The facility admitted Resident #128 with [DIAGNOSES REDACTED]. During an observation on 3/25/18 at 3:36 PM, Resident #128 was observed ambulating in his/her room while pushing his/her wheelchair. It appeared the resident was using the wheelchair like a walker to maintain balance. Observation of the resident's bathroom revealed a grab bar on the wall next to the sink that was loose and pulling away from the wall. On 3/28/19 at 12:15 PM, the grab bar was observed with the Housekeeping Supervisor present. The Housekeeping Supervisor confirmed the grab bar was not secure. The Housekeeping Supervisor stated maintenance conducted monthly and as needed room checks to all rooms to determine if repairs were needed. The Housekeeping Supervisor provided a maintenance room audit from 3/26/19 that included a list of repairs needed. The grab bar in Resident #128's bathroom was not identified in the audit.",2020-09-01
344,CONDOR HEALTH ANDERSON,425047,611 EAST HAMPTON STREET,ANDERSON,SC,29624,2019-03-28,607,E,1,1,HSS711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview and review of the facility's policy on Abuse and Neglect, the facility failed to implement its policy related to reporting and/or investigating allegations of abuse related to resident-to-resident altercations between Resident #45 and Resident #120 and #122 (3 of 13 residents reviewed for abuse and/or neglect). The findings included: Resident #45 was admitted on [DATE] with [DIAGNOSES REDACTED]. The facility admitted Resident #120 11/25/17 with [DIAGNOSES REDACTED]. At 10:09 AM on 03/28/2019, review of the Interdisciplinary Progress Notes revealed a note dated and timed 01/19/19 at 08:40 AM that stated the nurse heard a verbal altercation in the hall and heard someone get smacked. The note stated the nurse ran out to the hall and Resident #120 reported Resident #45 hit her/him in the face. During an interview on 03/28/19 at 03:12 PM, Social Services Director (SSD) #1 confirmed s/he did not report this incident. SSD #1 also confirmed there was no documentation of an investigation of this incident. SSD #1 stated that s/he seemed to recall that when s/he spoke to the staff, s/he determined that the incident did not occur but confirmed there was no documentation of the conversation or the nurse's response. The SSD further stated that she did not investigate why the resident had redness to her face and stated that she felt like the note s/he wrote covered it. The facility admitted Resident #122 on 12/14/17 with [DIAGNOSES REDACTED]. On 03/26/19 at 10:07 AM, review of the IPN (Interdisciplinary Progress Notes) revealed a note dated and timed 10/09/18 17:25 PM. Resident (#122) stated that (Resident #45) approached him/her in the hall and hit him/her on the arm. The incident was reported to the State Agency at 09:18 PM and was not within the required 2 hour time frame for an allegation of abuse. Further review revealed the Five-Day Follow-Up Report was faxed to the State Agency on 10/26/18 at 15:20 (03:20) PM and was not within the required five days from the date of the incident. During an interview on 03/27/19 at 09:46 AM, SSD #1 confirmed the incident report documented the incident occurred at 05:25 PM and that the 2/24-Hour Report was faxed to the State Agency at 09:18 PM. The SSD also confirmed the Five-Day Follow-Up was faxed to the State Agency on 10/26/18 and stated no, that's not timely. On 03/27/19 at 10:24 AM, review of the 2/24-Hour Report and Five-Day Follow-Up Report revealed the facility substantiated the allegation of abuse by Resident #45. During an interview on 03/27/19 at 11:41 AM, Resident #122 reported to the surveyor that Resident #45 did not make contact with him/her and stated s/he caught Resident #45's hand before s/he was able to hit him/her. Review of the 24 hour report revealed no documentation of an interview with Resident #122 at the time of the incident. During an interview on 03/27/19 at 02:20 PM, Social Services Director (SSD) #2 confirmed the that s/he did not interview Resident #122 and stated that s/he didn't think to get one and s/he believed what Resident #122 reported because Resident #122 was so alert. She further stated that s/he spoke to Resident #122 later and s/he reported then that Resident #45 did not make contact with him/her. SSD #2 confirmed that there was no statement to that effect, the investigation was not thorough, and the facility's policy had not been followed. Review of the facility's policy entitled Freedom form Abuse, Neglect and Exploitation revealed All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately to the Administrator/his designee, the Director of Nursing/her designee, and to the Social Services Director/designee. The facility or its covered individuals shall report immediately, but not later that 2 hours after the allegation is made, if he events that cause the allegation involve abuse or serious bodily injury.",2020-09-01
345,CONDOR HEALTH ANDERSON,425047,611 EAST HAMPTON STREET,ANDERSON,SC,29624,2019-03-28,608,D,1,1,HSS711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to report reasonable suspicion of a crime. Resident #75 accused Resident #68 of sexual abuse, and the facility failed to report the allegation to the police for investigation. The findings included: Resident #75 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent score for Brief Interview of Mental Status (BIMS) was 13. Resident #68 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent BIMS score was 6. Review of the 24 Hour and 5 Day report on 3/27/19 at 1:51 PM revealed Resident #75 alleged Resident #68 had been messing with his/her genitals a few days before 11/1/18. There were no witnesses. Interview with Social Services Director #1 on 3/27/19 at 4:18 PM revealed that the allegation was not reported to the police. Interview with Resident #75 on 3/27/19 at 3:25 PM revealed s/he maintained the allegation that Resident #68 was messing with (him/her) in her room at night and it had been unwitnessed. S/he was unable to offer further details such as what resident #68 had done or when it occurred. Review of abuse policy on 3/28/19 at 11:59 AM revealed that in response to allegations of sexual abuse the facility is to immediately report the allegation to the administrator, the physician, the appropriate state and local authorities.",2020-09-01
346,CONDOR HEALTH ANDERSON,425047,611 EAST HAMPTON STREET,ANDERSON,SC,29624,2019-03-28,609,E,1,1,HSS711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interviews, and review of the facility's Abuse and Neglect Policy, the facility failed to report, or report timely, allegations of abuse and/or neglect for Residents #45, #120, #122, and #61 (4 of 13 residents reviewed for abuse/neglect). The findings included: Resident #45 was admitted on [DATE] with [DIAGNOSES REDACTED]. The facility admitted Resident #120 11/25/17 with [DIAGNOSES REDACTED]. At 10:09 AM on 03/28/2019, review of the Interdisciplinary Progress Notes revealed a note dated and timed 01/19/19 at 08:40 AM that stated the nurse heard a verbal altercation in the hall and heard someone get smacked. The note stated the nurse ran out to the hall and Resident #120 reported Resident #45 hit her/him in the face. There was a slight redness noted to the left side of resident #120's face. No documentation for resident to resident altercation being reported to the State Agency was provided by facility. During an interview on 03/28/19 at 03:12 PM, Social Services Director (SSD) #1 confirmed s/he did not report this incident. SSD #1 stated that s/he seemed to recall that when s/he spoke to the staff, s/he determined that the incident did not occur but confirmed there was no documentation of the conversation or the nurse's response. The facility admitted Resident #122 on 12/14/17 with [DIAGNOSES REDACTED]. On 03/26/19 at 10:07 AM, review of the IPN (Interdisciplinary Progress Notes) revealed a note dated and timed 10/09/18 17:25 PM Resident (#122) stated that (Resident #45) approached him/her in the hall and hit him/her on the arm. On 03/27/19 at 10:24 AM, review of the 2/24-Hour Report and Five-Day Follow-Up Report for timeliness indicated the incident occurred at 7:32 PM but the notes indicated the incident was reported by Resident #122 at 17:25 (5:25 PM). The incident was reported to the State Agency at 09:18 PM and was not within the required 2 hour time frame for an allegation of abuse. Further review revealed the Five-Day Follow-Up Report was faxed to the State Agency on 10/26/18 at 15:20 (03:20) PM and was not within the required five days from the date of the incident. During an interview on 03/27/19 at 09:46 AM, SSD #1 confirmed the incident report documented the incident occurred at 05:25 PM and that the 2/24-Hour Report was faxed to the State Agency at 09:18 PM. The SSD also confirmed the Five-Day Follow-Up was faxed to the State Agency on 10/26/18 and stated no, that's not timely. Review of the facility's policy entitled Freedom form Abuse, Neglect and Exploitation revealed All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately to the Administrator/his designee, the Director of Nursing/her designee, and to the Social Services Director/designee. The facility or its covered individuals shall report immediately, but not later that 2 hours after the allegation is made, if he events that cause the allegation involve abuse or serious bodily injury. The facility admitted Resident #61 with [DIAGNOSES REDACTED]. An allegation of physical abuse of a resident by a Certified Nursing Aide was reported by the facility to the State Certification Agency on 12/24/18. Further review of the reportable incident on 3/27/19 at approximately 9:02 AM revealed the facility failed to report the allegations of physical abuse to the State Agency within the 2 hours of the reportable incident. Documentation of the reportable incident revealed the allegation of physical abuse to Resident #61 occurred on 12/24/18 at approximately 3 PM and the facility did not report the incident to the State Certification Agency until after 6 PM on 12/24/18 which was beyond the two hour reporting guidelines. An interview on 3/28/19 at approximately 9:36 AM with SSD #1 confirmed the findings that the allegation of physical abuse was not reported within the 2 hours per the reporting guidelines.",2020-09-01
347,CONDOR HEALTH ANDERSON,425047,611 EAST HAMPTON STREET,ANDERSON,SC,29624,2019-03-28,610,E,1,1,HSS711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview and review of the facility's Abuse and Neglect policy, the facility failed to investigate allegations of abuse for Resident #120 and #122 with Resident #45 (2 of 13 residents reviewed for abuse). The findings included: Resident #45 was admitted on [DATE] with [DIAGNOSES REDACTED]. The facility admitted Resident #120 11/25/17 with [DIAGNOSES REDACTED]. At 10:09 AM on 03/28/2019, review of the Interdisciplinary Progress Notes revealed a note dated and timed 01/19/19 at 08:40 AM that stated the nurse heard a verbal altercation in the hall and heard someone get smacked. The note stated the nurse ran out to the hall and Resident #120 reported Resident #45 hit her/him in the face. There was a slight redness noted to the left side of resident #120's face. No documentation for resident to resident altercation being reported to the State Agency was provided by facility. Review of a Social Progress Note dated 01/19/19 at 12:20 PM revealed Resident #120 had a history of [REDACTED].#45 and that when Resident #120 tried to talk to her/him, Resident #45 would yell or strike out at Resident #120 who then responded by striking out at Resident #45. The note further documented behaviors and interventions used for Resident #120 and stated that Resident #45 was to have a trial move to another unit. There was no documentation of redness to Resident #120's face, interview with the nurse or investigation of the incident. During an interview on 03/28/19 at 03:12 PM, Social Services Director (SSD) #1 confirmed there was no documentation of an investigation of this incident. SSD #1 stated that s/he seemed to recall that when s/he spoke to the staff, s/he determined that the incident did not occur but confirmed there was no documentation of the conversation or the nurse's response. The SSD further stated that she did not investigate why the resident had redness to her face and stated that she felt like the note s/he wrote covered it. The facility admitted Resident #122 on 12/14/17 with [DIAGNOSES REDACTED]. On 03/26/19 at 10:07 AM, review of the IPN (Interdisciplinary Progress Notes) revealed a note dated and timed 10/09/18 17:25 PM Resident (#122) stated that (Resident #45) approached him/her in the hall and hit him/her on the arm. The note further indicated both residents were in the hallway the previous day and Resident #122 held onto Resident #45's wheelchair to prevent her/him from running into another resident. Resident #122 indicated s/he thought Resident #45 was still angry about the day before and that was why s/he hit him/her. On 03/27/19 at 10:24 AM, review of the 2/24-Hour Report and Five-Day Follow-Up Report revealed the facility substantiated the allegation of abuse by Resident #45. During an interview with Resident #122, s/he reported to the surveyor that Resident #45 did not make contact with him/her and stated s/he caught Resident #45's hand before s/he was able to hit him/her. Review of the 24 hour report revealed no documentation of an interview with Resident #122 at the time of the incident. During an interview on 03/27/19 at 09:46 AM, SSD #1 confirmed that there were no witnesses to the incident and that the perpetrator did not recall the incident when interviewed. S/he stated that the allegation was substantiated based on the fact that Resident #122 said it happened and s/he was very alert and oriented and had no history of making up stories. During an interview on 03/27/19 at 02:20 PM, SSD #2 confirmed the that s/he did not interview Resident #122 and stated that s/he didn't think to get one and s/he believed what Resident #122 reported because Resident #122 was so alert. She further stated that s/he spoke to Resident #122 later and s/he reported then that Resident #45 did not make contact with him/her. SSD #2 confirmed that there was no statement to that effect and that the investigation was not thorough. Review of the facility's policy entitled Freedom form Abuse, Neglect and Exploitation revealed All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately to the Administrator/his designee, the Director of Nursing/her designee, and to the Social Services Director/designee. The facility or its covered individuals shall report immediately, but not later that 2 hours after the allegation is made, if he events that cause the allegation involve abuse or serious bodily injury.",2020-09-01
348,CONDOR HEALTH ANDERSON,425047,611 EAST HAMPTON STREET,ANDERSON,SC,29624,2019-03-28,637,D,0,1,HSS711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to conduct a MDS (Minimal Data Set) Significant Change in Status Assessment (SCSA) for 2 areas of decline and 2 areas of improvement for Resident #45 (1 of 2 residents reviewed with a significant change in status). The findings included: The facility admitted Resident #45 on 07/26/18 with [DIAGNOSES REDACTED]. Review of the MDS on 03/26/18 at approximately 3:30 PM revealed the resident had 2 areas of improvement and 2 areas of decline from the 10/18/18 Quarterly MDS as compared to the 01/10/19 Quarterly MDS assessment. The resident exhibited an improvement in behaviors and transfers and a decline in cognition and a significant weight loss. During an interview on 03/27/19 at approximately 3:00 PM, the MDS Registered Nurse confirmed the findings as above. When asked if a SCSA should have been completed, the MDS nurse stated It appears so.",2020-09-01
349,CONDOR HEALTH ANDERSON,425047,611 EAST HAMPTON STREET,ANDERSON,SC,29624,2019-03-28,641,D,0,1,HSS711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to accurately complete the Minimum Data Set (MDS) assessment for 1 of 1 sampled resident reviewed for Range of Motion (ROM) (Resident #49). The findings included: The facility admitted Resident #49 with [DIAGNOSES REDACTED]. Review of the 10-05-18 Admission MDS assessment and the 01-17-19 Quarterly MDS assessment at on 03-27-19 at 2:37 PM revealed under section G Functional Status, Functional Limitation ROM was coded 0 no impairment for A-upper extremity and 0 no impairment for B-lower extremity. Review of the Range of Motion Tracking dated 11-02-18 on 03-28-19 at 3:15 PM revealed the left and right shoulder were marked slightly limited ROM. The left and right elbow were marked slightly limited ROM. The left and right wrist were marked slightly limited ROM. The left and right hip were marked slightly limited ROM. The left and right knee were marked slightly limited ROM. The left and right ankle were marked moderate ROM. During an interview on 03-28-19 at approximately 3:25 PM, Licensed Practical Nurse #1 verified the MDS had been coded wrong.",2020-09-01
350,CONDOR HEALTH ANDERSON,425047,611 EAST HAMPTON STREET,ANDERSON,SC,29624,2019-03-28,657,D,0,1,HSS711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to update the Care Plan to reflect the residents status for 2 of 3 sampled residents reviewed for Nutrition (Residents #49 and #45). The findings included: The facility admitted Resident #49 with [DIAGNOSES REDACTED]. Record review on 03-27-19 at 10:32 AM revealed the resident had significant weight loss. Review of the resident's weights revealed they were as follows: 10-11-18 =156.4 pounds; 11-14-18 =151.2 pounds; 11-28-18 = 134.6 pounds; 12-11-18 =132.2 pounds; 01-14-19 = 124.6 pounds; 02-11-19 = 137 pounds; 03-12-19 =124 pounds. Review of physician progress notes [REDACTED].#49 had numerous changes in tube feeding amounts related to increased residuals and intolerance. Record review on 03-28-19 at approximately 9:46 AM of the Registered Dietitian Nutrition Goals/Recommendations dated 10-22-18 revealed, Problem #1 Inadequate intake from enteral nutrition. Etiology #1 (related to) intake less than calculated needs. Signs & Symptoms #1 residuals of 120 ml and tube feeding at 30 ml/hour. Comments: tube feeding has high residuals per nursing and has been ordered to 30 ml/hour, tube feeding not providing adequate calories Record review on 03-28-19 at approximately 9:48 AM of the Quarterly Dietary Review V. 2.1 dated 01-16-19 revealed, Nutritional Concerns, trending weight the statement did not indicate increase or decrease. Record review on 03-28-19 at approximately 10:20 AM of the policy Weight Management and Intervention states, Care Planning 1. Care planning for weight loss or impaired nutrition will be a multidisciplinary effort. 2. Individualized care plans shall address, to the extent possible: a. The identified causes of weight loss; b. Goals and benchmarks for improvement and c. Time frames and parameters for monitoring and reassessment. Record review of the Care Plan updated 01-21-19 on 03-27-19 at 3:15 PM revealed under Problems/Strengths, Requires nutritional needs to be met by tube feeding 100% of the time due to [DIAGNOSES REDACTED]. Further review of the Care Plan revealed that it had not been updated to reflect high residuals, tube feeding not providing adequate calories, weight loss or interventions to provide adequate caloric intake. During an interview on 03-28-19 at 9:50 AM, the Certified Dietary Manager confirmed that the Care Plan had not been updated to reflect the above. The facility admitted Resident #45 on 07/26/18 with [DIAGNOSES REDACTED]. On 03/25/19 at 10:57 AM, record review revealed a weight of 187 pounds on approximately 10/22/18 and a current weight on 3/13/18 of 163.20 pounds, a 12.73% weight loss. On 03/27/19 at 01:49 PM, review of the care plan revealed risk of choking was identified as a problem area. Interventions included, but were not limited to, monitoring weights monthly and notifying the physician. The care plan was not updated to reflect actual weight loss. During an interview on 03/27/19 at approximately 3:00 PM, the MDS Registered Nurse confirmed the care plan had not been updated with actual weight loss and provision of supplements ordered on [DATE].",2020-09-01
351,CONDOR HEALTH ANDERSON,425047,611 EAST HAMPTON STREET,ANDERSON,SC,29624,2019-03-28,693,E,0,1,HSS711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and review of the facility policy titled, Weight Assessment and Intervention the facility failed to address significant weight loss for Resident #49. The facility failed to follow their weight loss policy, follow up with referrals, and evaluate. The findings included: The facility admitted Resident #49 with [DIAGNOSES REDACTED]. Review of physician progress notes [REDACTED]. Record review on 03-27-19 at 10:32 AM revealed the resident had significant weight loss. Review of resident's weights revealed they were as follows: 10-11-18 =156.4 pounds; 11-14-18 =151.2 pounds; 11-28-18 = 134.6 pounds; 12-11-18 =132.2 pounds; 01-14-19 = 124.6 pounds; 02-11-19 = 137 pounds; 03-12-19 =124 pounds. Review of the policy Weight Assessment and Intervention states, 3. Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, the Dietary Manager or designee will immediately notify the Dietitian in writing. Verbal notification must be confirmed in writing. 4. The Dietitian will review the resident weight record during the routine facility visits to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether the criteria for significant weight change has been met. Record review on 03-28-19 at approximately 9:46 AM revealed a Registered Dietitian (RD) had seen the resident on 10-22-18 but not since. There was no evidence that the RD had been consulted following the noted weight losses on 11-14-18, 11-28-19, 12-11-18, 01-14-19, and 03-12-19. Review of the Quarterly Dietary Review V. 2.1 dated 01-16-19 on 03-28-19 at approximately 9:48 AM revealed, Nutritional Concerns, trending weight. Further review revealed no weight verification when losses were noted. There was no evidence the RD had been notified and evaluated the weight loss. Further review on 03-27-19 at 3:15 PM revealed that the Care Plan had not been updated with interventions to address the continued loss. During an interview on 03-28-19 at approximately 9:47 AM, the RD confirmed s/he had not seen the resident since (MONTH) and stated that the resident had not been on the facility list to be seen by the RD. During an interview on 03-28-19 at 9:50 AM, the Certified Dietary Manager confirmed that the resident weights had not been reassessed, the resident had not been seen by the RD, and that there were no ongoing dietary notes reflecting the resident's status.",2020-09-01
352,CONDOR HEALTH ANDERSON,425047,611 EAST HAMPTON STREET,ANDERSON,SC,29624,2019-03-28,760,D,0,1,HSS711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to follow physician's orders to increase [MEDICATION NAME] for 3 days for Resident #45 (1 of 5 residents reviewed for unnecessary medications). The findings included: The facility admitted Resident #45 on 07/26/18 with [DIAGNOSES REDACTED]. On 03/26/19 at 10:07 AM, review of the Interdisciplinary Progress Notes revealed a note dated 10/19/18 stating the resident was having episodes of paranoia and was crying. A new order was received to increase [MEDICATION NAME] 5 mg (milligrams) from 1 tablet every PM to BID (twice a day). Further review revealed a note dated 10/20/18 stating the resident backed her/his wheelchair into the nurse several times and hit the nurse. Further review revealed a note dated 10/22/18 at 12:48 PM that stated the resident did not receive [MEDICATION NAME] BID as ordered. The physician was notified and stated to start the [MEDICATION NAME] BID and schedule a consult with the Psychiatrist. Another note dated 10/22/18 at 13:15 PM stated Resident #45 struck another resident in the face and scratched a CNA (Certified Nursing Assistant). The resident was sent to the emergency room for evaluation and was admitted to the hospital shortly after the incident. During an interview on 03/26/18 at approximately 5:00 PM, the Director of Nursing (DON) confirmed the resident did not receive the medication as ordered on [DATE] through 10/21/18. The DON stated the nurse wrote the telephone order and transcribed it onto the monthly cumulative orders but did not put the order into the computer so it did not show up on the Medication Administration Record. The DON stated it was a med (medication) error. The DON also indicated the resident had a urinary tract infection and that the the med wouldn't have stopped the incident that occurred on 10/22/18.",2020-09-01
353,CONDOR HEALTH ANDERSON,425047,611 EAST HAMPTON STREET,ANDERSON,SC,29624,2019-03-28,812,D,0,1,HSS711,"Based on observation and interview, the facility failed to ensure that 1 of 4 unit kitchen refrigerator was clean and sanitary. The Unit 200 kitchen refrigerator was noted with thick dried stains/spills on inside doors and shelves of the freezer and refrigerator. The findings included: A random observation on 3/27/19 at approximately 10:18 AM of the Unit 200 kitchen area revealed the residents' refrigerator had thick dried stains/spills on the shelves and inside doors in the freezer compartment and the refrigerator compartment. An interview and observation on 3/27/19 at approximately 10:30 AM with Certified Nursing Aide (CNA) #1 confirmed the observation of the thick dried stains/spills on the shelves and inside doors of the freezer and refrigerator compartments. CNA #1 further stated it was the third shift responsibility to ensure that the unit refrigerators are cleaned. The CNA and surveyor observed that the dried stains/spills appeared to have been in the refrigerator for some time.",2020-09-01
354,CONDOR HEALTH ANDERSON,425047,611 EAST HAMPTON STREET,ANDERSON,SC,29624,2018-03-29,684,E,0,1,VOC611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to implement standing orders related to bowel elimination for Residents #131, #134, and #45, 3 of 17 residents reviewed for bowel elimination. The findings included: The facility admitted Resident #131 with [DIAGNOSES REDACTED]. Asthma, Depression Hypertension, [MEDICAL CONDITION] Cardiovascular [MEDICAL CONDITION], Heart Failure, and History of [MEDICAL CONDITION] Infarction. During an interview on 03/26/18 at 03:29 PM, Resident #131 reported that s/he sometimes went 4 days without a bowel movement. The resident also stated that s/he prefers to take prune juice to medication. On 03/28/18 at 10:25 AM, review of the CNA flowsheets for January, February, and (MONTH) of (YEAR) revealed Resident #131 had multiple occurrences of going more than 3 days without a bowel movement. In January, (YEAR), the flowsheet indicated the resident did not have a bowel movement (MONTH) 1st through the 7th (7 days), (MONTH) 14th through the 17th (4 days), and (MONTH) 28th through the 31st (4 days). Review of the MAR (Medication Administration Record) with LPN (Licensed Practical Nurse) #1 revealed the resident received Milk of Magnesia on 01/31/18, the 4th day, and was documented as effective on (MONTH) (documented on the night shift for 01/31/18). There was no other documentation in the nursing progress notes or on the MAR indicated [REDACTED]. Review of the flowsheet for February, (YEAR) revealed the resident had no documented bowel movement (MONTH) 1st through the 8th (8 days), (MONTH) 10th until the night shift on (MONTH) 13th, (MONTH) 14th through 17th until the second shift on the 18th. Review of the MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The resident also received the medication on 02/28/18 which was effective on (MONTH) 1st which was documented on the night shift on 02/28/18 which was all confirmed by the LPN. There was no documentation in the progress notes that the resident was checked for fecal impaction prior to administration of the milk of magnesia on the 6th, 15th or 28th. Review of the (MONTH) flowsheet revealed no documented bowel movement (MONTH) 15th through the 25th (11 days). There was no documentation that the resident was checked for fecal impaction or given the milk of magnesia. There was no documentation that the resident was offered prune juice, which was the resident's preference, at any time in January, (MONTH) or March. During an interview at approximately 10:40 AM, LPN #1 stated that the CNAs (Certified Nursing Assistants) had been reminded to question continent residents regarding bowel movements each shift and to document on the flowsheet if the resident reported they had a bowel movement. The LPN also stated the nurses ask the CNAs at the end of the shift if a resident was noted on the flow sheet to have no bowel movements documented for 3 days and document that in either the nurses progress notes or on the MAR (Medication Administration Record). The LPN confirmed there was no documentation to reflect that the resident reported having a bowel movement that was not documented on the flowsheet. Review of the Standing Orders at approximately 11:05 AM revealed a standing order for constipation that stated If no BM (bowel movement) for 3 days: Check for fecal impaction. If no fecal impaction: Give laxative ordered (if no laxative ordered: Give Milk of Magnesia 30 ml (milliliters) PO/PEG (by mouth or by percutaneous endoscopic gastrostomy) q (every) day (as needed). During an interview on 03/28/18 at 11:10 AM, the unit RN (Registered Nurse) Supervisor stated that Resident #131 had a BIMS (Brief Interview for Mental Status) score of 15, was alert and oriented and able to verbalize when s/he was constipated. The RN Supervisor agreed that the nurse had the responsibility to ask the resident if it was noted the resident had no bowel movement in 3 days and to follow the standing orders. The facility admitted Resident #134 with [DIAGNOSES REDACTED]. On 03/28/18 at 02:09 PM, review of the physician's orders [REDACTED]. At 2:27 PM on 03/28/2018, review of the CNA flowsheets revealed in January, (YEAR), there was no documented bowel movements on the 3rd through the 7th and the 19th through the 29th. In February, (YEAR), there was no documented bowel movement on the 1st through the 5th. Further review revealed no documented bowel movement on the 16th through the 19th (4 days) and the documentation on day shift on the 20th was indiscernible whether it was marked as N or Y. At 2:34 PM, review of the Medication Administration Record [REDACTED]. Review of the (MONTH) MAR indicated [REDACTED]. The (MONTH) MAR indicated [REDACTED]. Review of the radiology reports at 2:52 PM revealed the KUB dated 01/08/18 was negative. During an interview at 4:01 PM on 03/28/2018, LPN #2 confirmed the documentation on the CNA flowsheets. The LPN also confirmed there was no documentation of a bowel movement after the administration of the Milk of Magnesia on (MONTH) 12th or 24th or (MONTH) 19th and that there had been no follow up. In addition, the LPN confirmed the standing orders to check for impaction, then administer the milk of magnesia if no bowel movement in 3 days and that the progress notes had no documentation that the resident had been checked for impaction prior to administering the medication. The facility admitted Resident #45 with [DIAGNOSES REDACTED]. At 10:01 AM on 03/29/2018, review of the CNA flowsheets revealed in January, (YEAR), Resident #45 had no documented bowel movement from the night shift on 1/17/18 until 2nd shift on 1/21/18, the 4th day. Further review revealed no documented bowel movement on 1/22/18 until the second shift on 1/29/18 with 2 shifts having no documentation. Review of the (MONTH) CNA flowsheets revealed no documented bowel movement from the second shift on 3/12/18 through second shift on 3/19/18. Review of the (MONTH) Medication Administration Record [REDACTED]. Review of the (MONTH) Medication Administration Record [REDACTED]. Review of the nursing progress notes revealed a note dated 03/18/18 for Milk of Magnesia 400 mg (milligrams) per 5 ml (milliliters) 30 ml once daily as needed for 3 days for constipation. During an interview on 03/29/18, Licensed Practical Nurse (LPN) #3 confirmed the documentation indicated the resident had no bowel movement for greater than 3 days twice in (MONTH) and for a period of 6 days in March.",2020-09-01
355,CONDOR HEALTH ANDERSON,425047,611 EAST HAMPTON STREET,ANDERSON,SC,29624,2018-03-29,755,D,0,1,VOC611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, limited record review, and interview, the facility failed to reconcile and account for controlled substances in 1 of 4 medication storage rooms and 1 of 4 medication carts. The findings include: During tour of the Unit #1 medication storage room on 03/28/18 at 11:37 AM, [MEDICATION NAME] 2 milligrams (mgs) per milliliter (ml), 30 ml vial belonging to Resident #12, was found locked in the refrigerator with the tracking label wrapped around the vial. The date of arrival shows 3/12/18 per the pharmacy tracking sheet. During an interview on 3/28/18 at approximately 11:40 AM, regarding counting controlled substances, RN #1 stated, We did not count it. We did didn't know it was there. RN #2 also present, stated, I forgot to put the pharmacy slip into the narcotic log book. Both RN's confirmed that the [MEDICATION NAME] was not counted at all from 3/12/18 -3/28/18. During tour of the Unit #1 medication cart on 3/29/18 at 12:15 PM, [MEDICATION NAME] 50 mg, fifteen tablets, were found for Resident #49 after being discontinued on 3/5/18. The [MEDICATION NAME] was received from pharmacy on 3/1/18, however, it was not removed from the medication cart for 24 days after being discontinued. In an interview on 3/29/18 at 12:26 PM, RN #1 stated, It should have been pulled from the cart and delivered to the Director of Nursing (DON) on the discontinue date of 3/5/18. I will do that now. During an interview on 3/29/18 at 12:43 PM, the DON stated, We do not have a policy addressing the timeliness for removal of discontinued narcotics, but I would think within about 3 days would be timely.",2020-09-01
356,CONDOR HEALTH ANDERSON,425047,611 EAST HAMPTON STREET,ANDERSON,SC,29624,2018-03-29,812,D,0,1,VOC611,"Based on observation, interview, and review of the refrigerator temperature control log, the facility failed to ensure that the snacks/nourishments refrigerator on the 400 unit was maintained in proper working condition. The facility failed to maintain the refrigerator temperature at 41F degrees or lower to prevent the growth of pathogenic microorganisms that may cause foodborne illness. The facility also failed to use the appropriate temperature control log on one of four units at the facility. The findings included: On 03/29/18 at 8:43 AM while checking the snacks/nourishments refrigerators temperature on the 400 unit it was noticed that the thermostat inside the refrigerator read 46F degrees. After pointing the refrigerator temperature out to the unit manager, s/he stated that staff had the door opened for some time while restocking snacks/drinks. At 9:57 AM on the same say, the refrigerator temperature was re-checked. At this time the temperature was reading 44F degrees. At 10:00 AM the Unit Manager stated that according to the facility temperature control log and policy the refrigerator temperature was within normal range. S/he proceeds to show the temperature log for the medication refrigerator, which was the same but the temperature on it was not above 41F degrees. At approximately 10:05 AM on the same day it was noticed that the temperature control log on the refrigerator on the 400 unit stated that temperature to be maintained at 35 to 46 degrees. Review of the temperature control log for the month of (MONTH) on this unit revealed the following: 3/10-42 F; 3/17-44; 3/18-42; 3/19-44; 3/20-44; 3/21-42; 3/22-44;3/23-42; 3/24-44; 3/25-44; 3/26-42; 3/27-42; 3/28-42; and 2/29-42. After reviewing the (MONTH) log, the surveyor requested the facility's policy for review. However, at approximately 10:20 AM the Administrator, and the Certified Dietary Manager presented the facility's policy and the temperature control log that stated the safe temperature range 36 -41F degrees. The Administrator stated that the staff was using the wrong form and that the refrigerator was going to be replaced and the food items are thrown away. The surveyor did not witness the food being discarded but observed the refrigerator being replaced.",2020-09-01
357,CONDOR HEALTH ANDERSON,425047,611 EAST HAMPTON STREET,ANDERSON,SC,29624,2019-07-26,602,D,1,0,8E5W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to protect Residents #38 and #93 from misappropriation of narcotics, 2 of 2 residents reviewed for misappropriation. The findings included: During investigation of a Facility Reported Incident, review of the reportable file revealed a statement from RN (Registered Nurse) #1 dated 04/02/19 which stated that the LPN (Licensed Practical Nurse) counting the cart on Unit 1 noticed the liquid [MEDICATION NAME] to be a lighter shade in color and reported the difference to her/him. RN #1 then notified the Director of Nursing. S/he further stated that a short time later the ADON and another nurse retrieved another bottle of liquid [MEDICATION NAME] from the second medication cart and it too looked lighter in color. Further review revealed a facility-obtained statement from RN ADON (Assistant Director of Nursing) dated 04/02/19 reiterated that it had been reported that a bottle of liquid [MEDICATION NAME] was lighter in color than usual and also stated that the dropper was missing. S/he and the unit supervisor retrieved the medication and after comparison to a new bottle went back to the unit and retrieved a bottle of liquid [MEDICATION NAME] from another medication cart. Additional review revealed a statement from the Director of Nursing stating s/he had been notified during the morning report at approximately 09:00 AM that morning that there seemed to be a problem with a bottle of [MEDICATION NAME] Oral Solution on Unit 1. The Unit Manager had reported that the color appeared lighter than usual. Upon comparison to another bottle of [MEDICATION NAME], the vial from Unit 1 appeared several shades lighter (blue) than the medication that was in storage. Upon further inspection, another bottle of [MEDICATION NAME] from Unit 1 was also noted to be several shades lighter in color. The Consultant Pharmacist and State Agencies were notified. The facility decided to question all nurses that would have had access to the medication. At approximately 11:55 PM (?AM), the DON spoke to RN #2 at the facility. RN #2 stated that (s/he) took the [MEDICATION NAME] in question. (S/he) stated that on 6 different occasions (s/he) removed 5 mls (milliliters) of [MEDICATION NAME] from the medication bottle and replaced it with the same amount of water over the last 2 weeks. The medication was secured in a safe at the request of the DEA Agent and the South [NAME]ina Department of Labor, Licensing and Regulation was notified. Further review revealed the [MEDICATION NAME] belonged to Resident #93 and #38. Resident #93 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #93's (MONTH) Medication Administration Record [REDACTED]. S/he had received [MEDICATION NAME] 325/7.5 mg (milligrams) twice during the month, on 03/13 and 03/20/19. Review of the Narcotic reconciliation form revealed 30 ml (milliliters) of [MEDICATION NAME] sulfate 20 mg/ml was delivered to the facility on [DATE]. The prescription label on the reconciliation form was 0.25 ml (5 mg) PO (by mouth) every hour as needed. Further review revealed Resident #93 had received a total of 16 doses, the last dose being 02/24/19. Review of the Nursing Progress Notes from 03/01-03/22/19 revealed the resident voiced no complaints of pain documented in the notes. Resident #38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #38's (MONTH) Medication Administration Record [REDACTED]. Review of the Narcotic reconciliation form revealed 30 ml (milliliters) of [MEDICATION NAME] sulfate 20 mg/ml was delivered to the facility on [DATE]. The prescription label on the reconciliation form was 0.50 ml (10 mg) SL (sublingual) every 2 hours as needed for resp(iratory) distress or pain. Further review revealed the resident had received a total of 2 doses, the last dose being 02/13/19 (documented as 02/13/18 but resident was not in the facility at that time and is likely a documentation error of the year). Review of Resident #38's Nursing Progress Notes from 03/01-03/22/19 revealed the resident voiced no complaints of pain or respiratory distress documented in the notes. Further review revealed RN #2 was suspended pending the final outcome of the investigation and an audit was conducted of all medication carts by inspection and cross reference of the received date, medication on hand and delivery sheets. All narcotics were appropriately recorded and secured per policy and all received narcotics were accounted for per the audit. The facility had previously been conducting monthly Controlled Substance Reconciliations. During an interview on 07/25/19 conducted with the Director of Nursing the Consultant Pharmacist and RN #3, it was revealed that the Controlled Substance Reconciliation had been initiated in August, (YEAR). After the diversion was discovered on 03/22/19, the facility initiated weekly audits. RN #3 was responsible for conducting the audits and the Director of Nursing conducted the audit if RN #3 was not available. The Director of Nursing confirmed there was no documentation that the audits were being done but that s/he had verified the audits weekly. RN #3 and another RN, both involved in the Quality Assurance (QA) process, were both involved in the reconciliation process. One QA RN received a copy of all orders and informed of discontinuation of medications. That QA RN notified RN #3 that a controlled medication had been discontinued, RN #3 then removed the medication from the cart along with the narcotic reconciliation report sheet and verifies the number of doses left with the reconciliation sheet. The medication was then given to the Director of Nursing for secured storage until the Pharmacist conducted a monthly visit and discontinued controlled substances were then destroyed and witnessed by the Director of Nursing with the Pharmacist. During the days of survey the surveyor was unable to verify that the weekly audits were being completed. The facility initiated a signature sheet for the Weekly Narcotic Control Reconciliation on 07/24/19. An in-service related to Abuse, including misappropriation, was conducted on 04/25/19 as part of a plan of correction for the facility's Recertification Survey. In addition, the facility replaced the [MEDICATION NAME] for both residents on the same day the diversion was discovered.",2020-09-01
358,CONDOR HEALTH ANDERSON,425047,611 EAST HAMPTON STREET,ANDERSON,SC,29624,2017-09-30,224,G,1,0,L16E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, the facility failed to ensure each resident remained free from neglect. Resident #1 was found to have a fractured tibia and fibula. The facility's investigation revealed two certified nurse aides (CNA) transferred the resident without using the resident's plan of care. Both CNAs stood the resident up and pivoted her instead of using a lift sheet. One of three residents reviewed for incidents. The findings included: The facility reported an injury of unknown origin for Resident #1 to the State Agency. Review of the facility's Five-Day Follow-Up Report dated 9/12/17 indicated Resident #1 experienced a fracture of his/her tibia and fibula. During investigation two certified nurse aides admitted to transferring the resident without a partner or lift sheet. No unusual events were reported by the staff who transferred the resident. Review of the care plan revealed resident needs to be lifted using lift sheet with assist x 2 and is at risk for falls was identified as a problem area on 4/11/17. Interventions and approaches to this problem area were documented on the care plan and included resident transfers with lift sheet with assist x 2 for all transfers. Review of Resident #1's physician orders [REDACTED]. Review of the CNA Resident Care Card for Resident #1 revealed the resident transferred via lift sheet. Review of the resident's Medication Administration Record [REDACTED]. The order indicated [MEDICATION NAME] sulfate 20 milligram/1 milliliter solution 0.25 milliliter oral every 2 hours as needed for pain. The nurse indicated the resident displayed signs of pain by yelling out when care was being given and holding head as if having a headache. The 9/7/17 dose at 5:49 AM was the first time the resident was administered the medication during the month of (MONTH) (YEAR). Review of the Nurses' Notes dated 9/7/17 at 22:50 indicated CNA reported to both this nurse and oncoming nurse that the resident's leg appeared to be swollen. CNA stated s/he was responding to the resident yelling out. Upon assessment, resident's left leg lower leg swollen, warm to touch, some redness noted, and resident yells obscenities when leg is palpated. Resident's left lower leg also moves on palpitation. No other findings other than yelling has been reported to staff. Resident #1 was sent out to the hospital for evaluation. Review of the hospital Discharge Summary for hospital stay 9/8-9/11/17 revealed the resident had a closed [MEDICAL CONDITION] tibia and fibula left leg. CNA #1's facility-obtained statement dated 9/8/17 indicated that after lunch s/he took Resident #1 to his/her room and pivoted him/her into the bed. In a telephone interview with the surveyor on 9/30/17 at approximately 12:48 PM, CNA #2 stated s/he worked 11 PM-7 AM the night prior to when the resident's fracture was noted. CNA #2 stated there were no problems when s/he transferred Resident #1. Resident #1 is very small so CNA #2 lifted him/her and pivoted him/her. The resident did not complain of pain during the transfer. CNA #2 stated s/he transferred the resident that morning around 5:30 AM. CNA #2 stated s/he knew the resident was a lift sheet transfer because it is on the resident's care card. CNA #2 stated she knows she should not have transferred the resident alone. CNA #2 stated the facility does not have enough staff and there is too much work. CNA #2 also stated the facility expects you to do the work alone. CNA #2 stated that Resident #1 seemed to be in pain during the night when s/he gave the resident care prior to the transfer. CNA #2 notified the nurse on duty and the resident was medicated with [MEDICATION NAME]. In an interview with the surveyor on 9/20/17 at approximately 2:45 PM, the social worker stated the nurse called and told him/her Resident #1's leg appeared to be broken. They found out the next morning that the resident did have a fracture. The two CNAs admitted transferring the resident without help. The physician said it could have happened at any time because of her severe [MEDICAL CONDITION]. The social worker asked the two CNAs if they knew they were supposed to have a second person and they said yes. The CNAs said they knew to look on the cards or the care plan and knew the system. The social worker stated they review with the staff that not following the care plan for a resident is neglect.",2020-09-01
359,CONDOR HEALTH ANDERSON,425047,611 EAST HAMPTON STREET,ANDERSON,SC,29624,2017-09-30,226,G,1,0,L16E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, the facility failed to ensure each resident remained free from neglect. Resident #1 was found to have a fractured tibia and fibula. The facility's investigation revealed two certified nurse aides (CNA) transferred the resident without using the resident's plan of care. Both CNAs stood the resident up and pivoted her instead of using a lift sheet. One of three residents reviewed for incidents. The findings included: The facility reported an injury of unknown origin for Resident #1 to the State Agency. Review of the facility's Five-Day Follow-Up Report dated 9/12/17 indicated Resident #1 experienced a fracture of his/her tibia and fibula. During investigation two certified nurse aides admitted to transferring the resident without a partner or lift sheet. No unusual events were reported by the staff who transferred the resident. Review of the care plan revealed resident needs to be lifted using lift sheet with assist x 2 and is at risk for falls was identified as a problem area on 4/11/17. Interventions and approaches to this problem area were documented on the care plan and included resident transfers with lift sheet with assist x 2 for all transfers. Review of Resident #1's physician orders [REDACTED]. Review of the CNA Resident Care Card for Resident #1 revealed the resident transferred via lift sheet. Review of the resident's Medication Administration Record [REDACTED]. The order indicated [MEDICATION NAME] sulfate 20 milligram/1 milliliter solution 0.25 milliliter oral every 2 hours as needed for pain. The nurse indicated the resident displayed signs of pain by yelling out when care was being given and holding head as if having a headache. The 9/7/17 dose at 5:49 AM was the first time the resident was administered the medication during the month of (MONTH) (YEAR). Review of the Nurses' Notes dated 9/7/17 at 22:50 indicated CNA reported to both this nurse and oncoming nurse that the resident's leg appeared to be swollen. CNA stated s/he was responding to the resident yelling out. Upon assessment, resident's left leg lower leg swollen, warm to touch, some redness noted, and resident yells obscenities when leg is palpated. Resident's left lower leg also moves on palpitation. No other findings other than yelling has been reported to staff. Resident #1 was sent out to the hospital for evaluation. Review of the hospital Discharge Summary for hospital stay 9/8-9/11/17 revealed the resident had a closed [MEDICAL CONDITION] tibia and fibula left leg. CNA #1's facility-obtained statement dated 9/8/17 indicated that after lunch s/he took Resident #1 to his/her room and pivoted him/her into the bed. In a telephone interview with the surveyor on 9/30/17 at approximately 12:48 PM, CNA #2 stated s/he worked 11 PM-7 AM the night prior to when the resident's fracture was noted. CNA #2 stated there were no problems when s/he transferred Resident #1. Resident #1 is very small so CNA #2 lifted him/her and pivoted him/her. The resident did not complain of pain during the transfer. CNA #2 stated s/he transferred the resident that morning around 5:30 AM. CNA #2 stated s/he knew the resident was a lift sheet transfer because it is on the resident's care card. CNA #2 stated she knows she should not have transferred the resident alone. CNA #2 stated the facility does not have enough staff and there is too much work. CNA #2 also stated the facility expects you to do the work alone. CNA #2 stated that Resident #1 seemed to be in pain during the night when s/he gave the resident care prior to the transfer. CNA #2 notified the nurse on duty and the resident was medicated with [MEDICATION NAME]. In an interview with the surveyor on 9/20/17 at approximately 2:45 PM, the social worker stated the nurse called and told him/her Resident #1's leg appeared to be broken. They found out the next morning that the resident did have a fracture. The two CNAs admitted transferring the resident without help. The physician said it could have happened at any time because of her severe [MEDICAL CONDITION]. The social worker asked the two CNAs if they knew they were supposed to have a second person and they said yes. The CNAs said they knew to look on the cards or the care plan and knew the system. The social worker stated they review with the staff that not following the care plan for a resident is neglect. Review of the facility's Freedom from Abuse, Neglect, and Exploitation Policy revealed the resident has the right to be free from neglect. The policy defined neglect as the failure or omission of the facility or its employees or service providers to provide the care, goods, or services necessary to avoid physical harm, mental anguish, or mental illness or emotional distress.",2020-09-01
360,CONDOR HEALTH ANDERSON,425047,611 EAST HAMPTON STREET,ANDERSON,SC,29624,2017-09-30,282,G,1,0,L16E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, the facility failed to ensure services were provided in accordance with each resident's written plan of care. Resident #1 was found to have a fractured tibia and fibula. The facility's investigation revealed two certified nurse aides (CNA) transferred the resident without using the resident's plan of care. Both CNAs stood the resident up and pivoted her instead of using a lift sheet. One of three residents reviewed for incidents. The findings included: The facility reported an injury of unknown origin for Resident #1 to the State Agency. Review of the facility's Five-Day Follow-Up Report dated 9/12/17 indicated Resident #1 experienced a fracture of his/her tibia and fibula. During investigation two certified nurse aides admitted to transferring the resident without a partner or lift sheet. No unusual events were reported by the staff who transferred the resident. Review of the care plan revealed resident needs to be lifted using lift sheet with assist x 2 and is at risk for falls was identified as a problem area on 4/11/17. Interventions and approaches to this problem area were documented on the care plan and included resident transfers with lift sheet with assist x 2 for all transfers. Review of the CNA Resident Care Card for Resident #1 revealed the resident transferred via lift sheet. Review of the Nurses' Notes dated 9/7/17 at 22:50 indicated CNA reported to both this nurse and oncoming nurse that the resident's leg appeared to be swollen. CNA stated s/he was responding to the resident yelling out. Upon assessment, resident's left leg lower leg swollen, warm to touch, some redness noted, and resident yells obscenities when leg is palpated. Resident's left lower leg also moves on palpitation. No other findings other than yelling has been reported to staff. Resident #1 was sent out to the hospital for evaluation. Review of the hospital Discharge Summary for hospital stay 9/8-9/11/17 revealed the resident had a closed [MEDICAL CONDITION] tibia and fibula left leg. CNA #1's facility-obtained statement dated 9/8/17 indicated that after lunch s/he took Resident #1 to his/her room and pivoted him/her into the bed. In a telephone interview with the surveyor on 9/30/17 at approximately 12:48 PM, CNA #2 stated s/he worked 11 PM-7 AM the night prior to when the resident's fracture was noted. CNA #2 stated there were no problems when s/he transferred Resident #1. Resident #1 is very small so CNA #2 lifted him/her and pivoted him/her. The resident did not complain of pain during the transfer. CNA #2 stated s/he transferred the resident that morning around 5:30 AM. CNA #2 stated s/he knew the resident was a lift sheet transfer because it is on the resident's care card. CNA #2 stated she knows she should not have transferred the resident alone. CNA #2 stated the facility does not have enough staff and there is too much work. CNA #2 also stated the facility expects you to do the work alone. CNA #2 stated that Resident #1 seemed to be in pain during the night when s/he gave the resident care prior to the transfer. CNA #2 notified the nurse on duty and the resident was medicated with [MEDICATION NAME]. In an interview with the surveyor on 9/20/17 at approximately 2:45 PM, the social worker stated the nurse called and told him/her Resident #1's leg appeared to be broken. They found out the next morning that the resident did have a fracture. The two CNAs admitted transferring the resident without help. The physician said it could have happened at any time because of her severe [MEDICAL CONDITION]. The social worker asked the two CNAs if they knew they were supposed to have a second person and they said yes. The CNAs said they knew to look on the cards or the care plan and knew the system. The social worker stated they review with the staff that not following the care plan for a resident is neglect.",2020-09-01
361,CONDOR HEALTH ANDERSON,425047,611 EAST HAMPTON STREET,ANDERSON,SC,29624,2017-09-30,323,G,1,0,L16E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents. Resident #1 was found to have a fractured tibia and fibula. The facility's investigation revealed two certified nurse aides (CNA) transferred the resident without using the resident's plan of care. Both CNAs stood the resident up and pivoted her instead of using a lift sheet. One of three residents reviewed for incidents. The findings included: The facility reported an injury of unknown origin for Resident #1 to the State Agency. Review of the facility's Five-Day Follow-Up Report dated 9/12/17 indicated Resident #1 experienced a fracture of his/her tibia and fibula. During investigation two certified nurse aides admitted to transferring the resident without a partner or lift sheet. No unusual events were reported by the staff who transferred the resident. Review of the care plan revealed resident needs to be lifted using lift sheet with assist x 2 and is at risk for falls was identified as a problem area on 4/11/17. Interventions and approaches to this problem area were documented on the care plan and included resident transfers with lift sheet with assist x 2 for all transfers. Review of Resident #1's physician orders [REDACTED]. Review of the CNA Resident Care Card for Resident #1 revealed the resident transferred via lift sheet. Review of the resident's Medication Administration Record for (MONTH) (YEAR) revealed the resident received 0.25 milliliters of morphine sulfate on 9/7/17 at 5:49 AM. The order indicated morphine sulfate 20 milligram/1 milliliter solution 0.25 milliliter oral every 2 hours as needed for pain. The nurse indicated the resident displayed signs of pain by yelling out when care was being given and holding head as if having a headache. The 9/7/17 dose at 5:49 AM was the first time the resident was administered the medication during the month of (MONTH) (YEAR). Review of the Nurses' Notes dated 9/7/17 at 22:50 indicated CNA reported to both this nurse and oncoming nurse that the resident's leg appeared to be swollen. CNA stated s/he was responding to the resident yelling out. Upon assessment, resident's left leg lower leg swollen, warm to touch, some redness noted, and resident yells obscenities when leg is palpated. Resident's left lower leg also moves on palpitation. No other findings other than yelling has been reported to staff. Resident #1 was sent out to the hospital for evaluation. Review of the hospital Discharge Summary for hospital stay 9/8-9/11/17 revealed the resident had a closed fracture of the distal tibia and fibula left leg. CNA #1's facility-obtained statement dated 9/8/17 indicated that after lunch s/he took Resident #1 to his/her room and pivoted him/her into the bed. In a telephone interview with the surveyor on 9/30/17 at approximately 12:48 PM, CNA #2 stated s/he worked 11 PM-7 AM the night prior to when the resident's fracture was noted. CNA #2 stated there were no problems when s/he transferred Resident #1. Resident #1 is very small so CNA #2 lifted him/her and pivoted him/her. The resident did not complain of pain during the transfer. CNA #2 stated s/he transferred the resident that morning around 5:30 AM. CNA #2 stated s/he knew the resident was a lift sheet transfer because it is on the resident's care card. CNA #2 stated she knows she should not have transferred the resident alone. CNA #2 stated the facility does not have enough staff and there is too much work. CNA #2 also stated the facility expects you to do the work alone. CNA #2 stated that Resident #1 seemed to be in pain during the night when s/he gave the resident care prior to the transfer. CNA #2 notified the nurse on duty and the resident was medicated with morphine. In an interview with the surveyor on 9/20/17 at approximately 2:45 PM, the social worker stated the nurse called and told him/her Resident #1's leg appeared to be broken. They found out the next morning that the resident did have a fracture. The two CNAs admitted transferring the resident without anybody. The physician said it could have happened at any time because of her severe osteoporosis. The social worker asked the two CNAs if they knew they were supposed to have a second person and they said yes. The CNAs said they knew to look on the cards or the care plan and knew the system. The social worker stated they review with the staff that not following the care plan for a resident is neglect.",2020-09-01
362,BLUE RIDGE IN GEORGETOWN,425048,2715 SOUTH ISLAND ROAD,GEORGETOWN,SC,29440,2017-03-30,167,B,0,1,XEGY11,"Based on observations and interviews the facility failed to ensure the results of the most recent survey of the facility conducted by the State surveyors and any plan of correction was readily available for resident /family and visitor review for 1 of 1 posting of survey results. The findings included: An observation on 3/27/2017 at approximately 9:00 AM of the recent Survey Results notebook revealed the survey results for (YEAR) and not the current (YEAR) results. A second observation on 3/30/2017 at approximately 2:00 PM revealed the (YEAR) State Survey results and the plan of correction and not the (YEAR) State Survey results. During an interview 3/29/2017 at approximately 5:21 PM with the facility Administrator concerning the Survey Results posting he/she stated, Someone must have removed it because a couple of weeks ago it was in the note book. The administrator then provided a copy of the (YEAR) State Survey results and included the results for 2013 and (YEAR).",2020-09-01
363,BLUE RIDGE IN GEORGETOWN,425048,2715 SOUTH ISLAND ROAD,GEORGETOWN,SC,29440,2017-03-30,248,D,0,1,XEGY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of the facility policy titled Activity Programs, the facility failed to offer in room activities for Resident #79 for 1 of 3 residents reviewed for activities. The findings included: The facility admitted Resident #79 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set((MDS) dated [DATE] listed the Brief Interview for Mental Status(BIMS) as 15 of 15. Review of the Admission MDS for activity preferences listed the following activities as somewhat important: listen to music you like, be around animals such as pets, do things with groups of people, go outside get fresh air when the weather is good and participate in religious services or practices. Review of the (MONTH) activity calendar for 3/27-3/30/17 revealed activities such as Bingo, Snack Shack, Choir Practice, Beauty Shop, Women's Devo/Communion, Resident Council, Resident Birthday Party, Thursday Morning Blessings and Nail Care were listed. Observations of the resident during the survey process revealed Resident #79 was in his/her room or at [MEDICAL TREATMENT]. Documentation of Resident #79's participation in activities during the survey process listed a family visit and sitting out in the hallway/lobby. There was no in room activities documented as offered. Review of the resident's care plan revealed no care plan had been developed for activities. During an interview with the Activity Director on 3/30/17 at 4:34 PM, he/she stated the resident's main focus is therapy and he/she would continue to encourage attendance and participation in activities of choice. He/she continued by stating books, magazines, puzzles, and cards are offered but Resident #79 refused the items. He/she stated there was no documentation to reflect in room activities had been offered. Review of the facility policy titled Activity Programs lists under the Policy Interpretation and Implementation 3g the following: Creative and expressive activities, such as arts and crafts, ceramics, painting, drama, creative writing, poetry and music, are available on a regular basis to meet the needs of residents. and 7a Reflect the schedules, choices and rights if the residents; b. Are offered at hours convenient to the residents, including evenings holidays and weekends .",2020-09-01
364,BLUE RIDGE IN GEORGETOWN,425048,2715 SOUTH ISLAND ROAD,GEORGETOWN,SC,29440,2017-03-30,279,D,0,1,XEGY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop a comprehensive care plan related to activities for Resident #79.(1 of 3 reviewed for activities) The findings included: The facility admitted Resident #79 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set((MDS) dated [DATE] listed the Brief Interview for Mental Status(BIMS) as 15 of 15. Review of the Admission MDS for activity preferences listed the following activities as somewhat important: listen to music you like, be around animals such as pets, do things with groups of people, go outside get fresh air when the weather is good and participate in religious services or practices. Review of the (MONTH) activity calendar for 3/27-3/30/17 revealed activities such as Bingo, Snack Shack, Choir Practice, Beauty Shop, Women's Devo/Communion, Resident Council, Resident Birthday Party, Thursday Morning Blessings and Nail Care were listed. Observations of the resident during the survey process revealed Resident #79 was in his/her room or at [MEDICAL TREATMENT]. Documentation of Resident #79's participation in activities during the survey process listed a family visit and sitting out in the hallway/lobby. There was no in room activities documented as offered. Review of the resident's care plan revealed no care plan had been developed for activities. During an interview on 3/30/17 at 5:42 PM with the Care Plan Coordinator, he/she stated the Activity Director could develop Resident #79's activity care plan. On 3/30/17 at 6:15 PM, during an interview with the Activity Director, he/she stated had not had a chance to meet with resident due to [MEDICAL TREATMENT] and therapy and when a chance arose, the resident stated he/she was tired and asked him/her to come back later.",2020-09-01
365,BLUE RIDGE IN GEORGETOWN,425048,2715 SOUTH ISLAND ROAD,GEORGETOWN,SC,29440,2017-03-30,280,D,0,1,XEGY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews the facility failed to review and revise the plan of care for Resident #31 with interventions to reflect use of a pressure mattress and prevalon boots for 1 of 1 resident reviewed with pressure ulcers. The findings included: The facility admitted Resident #31 with [DIAGNOSES REDACTED]. Record review on 3/29/17 revealed Resident #31 had interventions of black prevalon boots and and air mattress due to pressure ulcers and to prevent worsening of pressure sores. Review of the residents care plan revealed the care plan for risk for further skin breakdown and pressure ulcers had not been updated to reflect the prevalon boots or the air mattress. During an interview with Registered Nurse(RN)#1 on 3/30/17 at 6:19 PM, he/she confirmed the care plan had not been updated to reflect the prevalon boots and air mattress.",2020-09-01
366,BLUE RIDGE IN GEORGETOWN,425048,2715 SOUTH ISLAND ROAD,GEORGETOWN,SC,29440,2017-03-30,282,D,0,1,XEGY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility did not follow Resident #79's care plan related to assessing the bruit and thrill for 1 of 1 reviewed for [MEDICAL TREATMENT]. The findings included: The facility admitted Resident #79 with [DIAGNOSES REDACTED]. Record review on 3/30/17 revealed a care plan for End Stage [MEDICAL CONDITION] which included an approach to assess for thrill and bruit upon return and per shift. Review of the nurse's notes and Medication Administration Record(MAR) and Treatment Administration Record(TAR) revealed the care plan was not followed to reflect assessing the bruit and thrill on return from [MEDICAL TREATMENT] and every shift. On 3/30/17 at 6:19 PM, during an interview, Registered Nurse #1 confirmed the care plan had not been followed. No policy was provided during the survey process related to following the resident's care plan,",2020-09-01
367,BLUE RIDGE IN GEORGETOWN,425048,2715 SOUTH ISLAND ROAD,GEORGETOWN,SC,29440,2017-03-30,309,D,0,1,XEGY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to assess Resident #79's bruit and thrill as ordered for 1 of 1 resident reviewed for [MEDICAL TREATMENT]. The findings included: The facility admitted Resident #79 with [DIAGNOSES REDACTED]. Review of the current physician orders [REDACTED]. Record review on 3/30/17 revealed a care plan for End Stage [MEDICAL CONDITION] which included an approach to assess for thrill and bruit upon return and per shift. Review of the (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR) MAR's and TAR's revealed there was no documentation related to the bruit and thrill. Review of the nurse's notes revealed there was no documentation and/or only one shift documented on Resident #79's bruit and thrill on the following dates: 1/18/17, 1/19/17, 1/21/17, 1/25/17, 1/27/17 1/26/17, 1/28/17, 1/29/17,1/30/17, 1/31/17, 2/8/17, 2/11/17, 2/12/17, 2/14/17, 2/17/17, 2/18/17, 2/20/17, 2/22/17, 2/25/17, 2/26/17, 2/28/17, 3/3/17, 3/4/17, 3/6/17, 3/8/17, 3/11/17, 3/12/17, 3/13/17, 3/19/17, 3/20/17, 3/21/17, 3/22/17, 3/25/17, 3/26/17 and 3/27/17. During an interview with Registered Nurse #1 on 3/30/17 at 5:45 PM, he/she confirmed there were omissions where the bruit and thrill was not checked as ordered. No policy and procedure related to the care of [MEDICAL TREATMENT] residents was provided during the survey process.",2020-09-01
368,BLUE RIDGE IN GEORGETOWN,425048,2715 SOUTH ISLAND ROAD,GEORGETOWN,SC,29440,2017-03-30,314,D,0,1,XEGY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to accurately implement an intervention related to pressure ulcer treatment for 1 of 1 resident reviewed for pressure ulcer. Resident #31's air mattress was not set on the proper weight setting. The findings included: The facility admitted Resident #31 with [DIAGNOSES REDACTED]. Record review on 3/29/17 revealed Resident #31 had a stage IV pressure ulcer to the coccyx and a stage II pressure ulcer to the right heel. Review of the interventions revealed the resident was to be on an air mattress. Observation of the air mattress on 3/28/17 at 4:23 PM, 3/29/17 at 5:45 PM and 3/30/17 at 4:01 PM revealed the weight setting on the bed was on a patient weight of 100 pounds. This was confirmed by Registered Nurse(RN)#1 during the observation on 3/30/17. Review of the weights revealed Resident #31 currently weighed 171.6 pounds on 3/15/17. Further record review revealed there was no documentation the settings of the air mattress was being monitored. During an interview with RN #1 on 3/30/17 at 4:01 PM, he/she stated once a mattress is ordered, maintenance sets the mattress up and the person taking care of the resident should check the bed settings to ensure the settings were correct.",2020-09-01
369,BLUE RIDGE IN GEORGETOWN,425048,2715 SOUTH ISLAND ROAD,GEORGETOWN,SC,29440,2017-03-30,325,D,0,1,XEGY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure one of one resident reviewed for nutritional problems received a therapeutic diet when one was recommended by the registered dietitian. Resident #31 identified with a pressure ulcer and weight loss was recommended to receive an additional supplement that was never followed through. The findings included: The facility admitted Resident #31 with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].#31's diet was mechanical soft with ground meats-thin liquids. Further review revealed the resident was receiving Magic Cup three times a day. Resident #31's weights were as follows: 1/31/17-177.4 pounds 2/14/17-177.6 pounds 2/28/17-174.6 pounds 3/15/17-171.6 pounds. Review of the laboratory tests revealed on 1/30/17 [MEDICATION NAME] was 2.0 and Total Protein was 6.6. On 3/9/17 the resident's Hemoglobin was 11.2. Review of the dietary assessments revealed on 2/1/17 Resident #31 had a 13% weight loss over 180 days and was consuming 50-75% of most meals and at that time was receiving magic cup three times a day. The Registered Dietician(RD) recommended No Sugar Added Med Pass 2.0 120 cc(cubic centimeters) three times a day and provide large protein portions with meals to assist with wound healing, weight maintenance and improve protein stores. Further review of the medical record revealed the recommendation by the RD on 2/1/17 had not been carried through. During an interview with Registered Nurse(RN)#1 on 3/30/17 at 2:54 PM, he/she stated when a RD has a recommendation, it is sent to dietary and in the morning meetings it is given to the Unit Manager. The Unit Manager then speaks with the physician to see if the recommendation should be implemented and if the physician accepts the recommendation then the order is put into the system. He/she confirmed the recommendation made by the RD on 2/1/17 did not get reviewed.",2020-09-01
370,BLUE RIDGE IN GEORGETOWN,425048,2715 SOUTH ISLAND ROAD,GEORGETOWN,SC,29440,2017-03-30,371,F,0,1,XEGY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, interviews and review of facility policies titled Handwashing, Emergency Menu & Supplies Disaster List, Dietary Considerations for Residents, Food Receiving and StorageRefrigerators and Freezers, Food Preparation and Service, review of emergency menus and freezer logs, the facility failed to follow proper sanitization and food handling practices for 1 of 1 kitchen reviewed and 2 of 2 nutrition kitchens which has the potential to affect all residents with physician ordered therapeutic diets. Opened items were not dated/labeled in the walk in cooler and box freezer. Bread was observed with no use by date. The meat freezer was above the recommended temperature. Staff was utilizing a chart above the 3 compartment sink to measure sanitization instead of having the actual container test strips come in. The dish machine did not register the required temperature during sanitization of dishes. [MEDICAL TREATMENT] lunches were not sent in coolers with ice packs. Dusty chargers were observed on the counter. Both nurse's stations were observed with soft ice cream in the freezers. In addition, during the serving of the meals, staff was observed distributing meal trays and assisting residents with no handwashing or sanitizing of hands between residents on 1 of 2 nursing wings. The findings included: On 3/27/17 at approximately 9:42 AM, initial tour of the kitchen revealed the following: -The walk-in cooler contained (1) opened bag of parmesan cheese with no decipherable date. -The box freezer contained (1) item wrapped with no date/label and (1) package of cookie dough with no date/label. -The dry storage revealed (4) buns and (1) loaf of bread with no use by date. -The meat freezer had a temperature of 14 degrees Fahrenheit(F)-all items were frozen solid and staff was going in and out of the freezer. -Emergency Food was noted in a storage area in a shower room. Contents were (2) cases of cereal, (1) case of chicken and dumplings, (1) case of chicken noodle soup and (1) case of applesauce. -the facility low dish machine was observed with a temperature of 100 degrees F during the running of items through the machine -the container holding the strips to test the 3 compartment sink was not available which has the readings on the side of the container for staff to utilize. On 3/27/17, during an interview with the Administrator, he/she stated maintenance had been called to check the dishwasher machine and the lever which controls the hot water had not been turned all the way to emit the correct temperature of water for the machine. He/she stated the issue had been remedied and the facility also had obtained a container for the testing strips for the 3 compartment sink. On 3/30/17 at 11:31 AM, the meat freezer again was noted at an elevated temperature of 20 degrees and staff again was observed utilizing the freezer. The Certified Dietary Manager(CDM) stated a second thermometer had been placed which read 10 degrees Fahrenheit. (2) stacks of chargers were noted on the counter with dust build-up and when pointing them out to the CDM, he/she stated did not know what they were used for and removed the top two chargers. On 3/30/17 at 5:40 PM, the meat freezer again was at 12 degrees. During an interview with the Maintenance Director, he/she stated a serviceman had come in and evaluated the freezer. He/she stated the person who observed the freezer had stated during the day to day activities and when the freezer was in the defrost mode, the temperature would not be at zero degrees. He/she stated the service person would be coming back the next day. During the interview the Maintenance Director was asked why the serviceman could not come back this day since every observation revealed an elevated temperature. He/she stated would call the service repairman. Observation of the freezer log revealed it had not been completely filled out since the morning of 3/22/17. This was confirmed by the DM. During an interview with the DM on 3/30/17 regarding the emergency food, he/she stated the facility had a 11/2 day of emergency food. He/she continued by stating the facility would use what was in the freezers first. He/she continued by stating when [MEDICAL TREATMENT] resident leave to go to [MEDICAL TREATMENT], sometimes a meat sandwich is sent. The snack items sent were in a bag. No cooler or ice pack was included. Observation of the[NAME]Wing nutritional room on 3/30/17 at 10:00 AM revealed (1) soft ice cream in the freezer compartment. Observation of the[NAME]Wing Nutritional room on 3/30/17 at 9:55 AM revealed several containers of ice cream that were soft. The thermometer in the freezer read 12 degrees. At that time the Unit Manager removed the ice cream. Review of the facility policies revealed the following: Food Preparation and Service-10. Foods served at special events and/or transported from the facility shall be subject to the same food safety standards as food served in the facility. Refrigerators and Freezers-1. Acceptable temperature ranges are 35 degrees F to 40 degrees F for refrigerators and less than 0 degrees F for freezers. Food Receiving and Storage-7. All foods stored in the refrigerator or freezer will be covered, labeled and dated(use bydate). Dietary Considerations for Residents-4. A minimum of food and water to last for 3 days shall be maintained at the facility in a specific location. An observation made on 3/27/2017 at approximately 12:40 PM revealed Certified Nursing Assistants (CNAs) serving lunch trays on the[NAME]Hall. CNA #1 entered room 24 B and started setting up the tray for the resident. CNA #1 then called out for assistance to help position the resident. CNA #1 applied gloves and assisted with positioning the resident. CNA #1 then proceeded with same gloved hands to finish setting up the lunch tray for the resident in 24 B. An observation on 3/29/2017 at approximately 12:45 PM revealed CNA #1 delivering and setting up lunch trays on the[NAME]Hall into rooms 25 and 26. CNA #1 pulled up a straight chair in the resident room and proceeded to set up the lunch tray and feed the resident in 26 B. During an interview on 3/30/2017 at approximately 12:30 PM with CNA #1 confirmed that he/she had not cleansed his/her hands after pulling up the resident in Room 25 and did not remove his/her gloves before continuing to set up the meal tray. CNA #1 also confirmed that he/she had pulled up a straight chair in Room 26 and then proceeded to feed the resident in 26 B. Review on 3/30/3017 at approximately 2:15 PM titled, Assistance with Meals, states under #7. All employees who provide resident assistance with meals will be trained and shall demonstrate competency in the prevention of foodborne illness, personal hygiene practices and safe food handling.",2020-09-01
371,BLUE RIDGE IN GEORGETOWN,425048,2715 SOUTH ISLAND ROAD,GEORGETOWN,SC,29440,2017-03-30,441,E,0,1,XEGY11,"Based on observations, interviews and review of the facility policy titled, Laundry and Bedding, Soiled, and, Infection Control - Linen Handling Policy, and, Surveillance for Infections, and, Policies and Practices - Infection Control, the facility failed to maintain an infection control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of disease and infection. During transport of soiled linen the staff did not utilize proper personal protective equipment for 1 of 1 laundry room reviewed. In addition the facility could not provide complete tracking and trending for the past year nor the policy related to tracking and trending of infections. The findings included: During an observation on 3/29/2017 at approximately 3:00 PM a laundry worker was transporting soiled linen to the laundry room without wearing gloves. During an interview on 3/29/2017 at approximately 3:00 PM the laundry worker verified that he/she had removed the bagged and unbagged soiled linen from the soiled linen room with his/her bare hands. Review on 3/29/2017 at approximately 3:20 PM of the facility policy titled, Laundry and Bedding, Soiled, under Policy Statement reads, Soiled laundry/bedding shall be handled in a manner that prevents gross microbial contamination of the air and persons handling the linen. Number 4. under Policy Interpretation and Implementation reads, Anyone who handles soiled laundry must wear protective gloves and other appropriate protective equipment. Further review on 3/29/2017 at approximately 3:20 PM of the facility policy titled, Infection Control - Linen Handling Policy, under Procedure: Soiled Linen, #2. reads, Personal Protective Equipment (PPE) may be used when handling soiled linen, as necessary if linen is heavily soiled with blood or body fluids. All employees MUST wear gloves when handling soiled linen. During review on 3/30/2017 at approximately 12:10 PM of the tracking and trending of infections in the facility revealed tracking and trending for (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR). The tracking and trending for (YEAR) since the last state survey could not be found in the facility. Further review on 3/30/3017 at approximately 12:15 PM of the Infection Control Policy and Procedure manual for the facility could not be found in the facility. During an interview on 3/30/2017 at approximately 12:30 PM with the Director of Nursing (DON) he/she confirmed that the Infection Control Policy and Procedure Manual was no where to be found in the facility. The DON went on to say that he/she realized it was missing last month. Review on 3/30/2017 at approximately 1:10 PM of the facility policy titled, Surveillance for Infections, states under Policy Statement, The infection Preventionist will conduct ongoing surveillance for Healthcare-Associated Infections and other epidemiologically significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventative interventions, Review on 3/30/2017 at approximately 1:15 PM of the facility policy titled, Policies and Practices - Infection Control, reads under the Policy Statement, This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections.",2020-09-01
372,BLUE RIDGE IN GEORGETOWN,425048,2715 SOUTH ISLAND ROAD,GEORGETOWN,SC,29440,2017-03-30,456,D,0,1,XEGY11,"Based on observation, interview and review of the facility policy titled, Lint Trap Cleaning Policy and Procedure, the facility failed to ensure an excessive amount of lint was removed form 1 of 2 clothes dryers. The findings included: An observation on 3/29/2017 at approximately 3:15 PM revealed an excessive amount of lint built up over the lint basket and was draped over the basket and piling on the floor of the dryer. During an interview on 3/29/2017 at approximately 3:15 PM the laundry worker verified the findings and provided a copy of the cleaning schedule to remove the lint from the clothes dryers. Review on 3/29/2017 at approximately 3:30 PM of the facility policy titled, Lint Trap Cleaning Policy and Procedure, reads, Dryer lint traps are to be checked and cleaned every 2 hours, when in use. Employees must acknowledge and verify cleaning of the dryer lint traps by initialing the lint trap cleaning log.",2020-09-01
373,BLUE RIDGE IN GEORGETOWN,425048,2715 SOUTH ISLAND ROAD,GEORGETOWN,SC,29440,2019-07-19,550,D,0,1,8NBB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to protect the resident's dignity by not providing appropriate clothing and privacy for 1 of 1 sampled resident reviewed for dignity (Resident #62). The findings included: The facility admitted Resident #62 on 6/5/18 with [DIAGNOSES REDACTED]. On 7/15/19 at 4 PM, Resident #62 was observed in (his/her) bed. S/he had appropriate clothing on the upper body but only an adult brief and no cover on the lower body. The door of the resident's room was wide open and the privacy curtain pulled back. On 7/16/19 at 10: 23 AM and 7/17/19 at 3:45 PM, Resident #62 was noticed in bed with the door open and the privacy curtain pulled back. The resident's lower body part was exposed the same way it was the day before. On 7/18/19 at 10:30 AM, the resident was laying on (his/her) bed with the door opened and the curtain pulled back with no clothes or cover on the lower body part. The resident had (his/her) hand inside the front of (his/her) adult brief. The Minimum Data Set (MS) assessment dated [DATE] and reviewed on 7/18/19 at approximately 9:00 AM revealed that Resident #62 scored a 2 (Severely impaired cognition) in the Brief Interview for Mental Status (BIMS). In the area of functional status related to activities of daily living (ADLs), the resident was coded as requiring extensive assistance with dressing. The 7/3/19 Care Plan reviewed on 7/18/19 at approximately 9:15 AM stated that Resident #62 required assistance with ADLs. The care plan also noted that the resident could become restless, tearful, and agitated, especially in the afternoon hours. In an interview with the unit manager on 7/18/19 at 3:20 PM, (s/he) acknowledged that the facility failed to protect the resident's dignity. The unit manager also said that Resident #62 took (his/her) clothes and cover off and would touch (him/herself) inappropriately at times. The unit manager also reported that the resident's roommate liked the room door open and the curtain of both beds pulled back.",2020-09-01
374,BLUE RIDGE IN GEORGETOWN,425048,2715 SOUTH ISLAND ROAD,GEORGETOWN,SC,29440,2019-07-19,657,D,0,1,8NBB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to revise the resident's care plan to include the resident's inappropriate behaviors, including taking clothes and covers off and touching (him/herself) inappropriately with the bedroom door open for 1 of 1 sampled resident reviewed for dignity (Resident #62). The findings included: The facility admitted Resident #62 on 6/5/18 with [DIAGNOSES REDACTED]. On 7/15/19 at 4 PM, Resident #62 was observed in (his/her) bed. S/he had appropriate clothing on the upper body but only an adult brief and no cover on the lower body. The door of the resident's room was wide open and the privacy curtain pulled back. On 7/16/19 at 10: 23 AM and 7/17/19 at 3:45 PM, Resident #62 was noticed in bed with the door open and the privacy curtain pulled back. The resident's lower body part was exposed the same way it was the day before. On 7/18/19 at 10:30 AM, the resident was laying on (his/her) bed with the door open and the curtain pulled back with no clothes or cover on the lower body part. The resident had (his/her) hand inside the front of (his/her) adult brief. The Minimum Data Set (MS) assessment dated [DATE] and reviewed on 7/18/19 at approximately 9:00 AM revealed that Resident #62 scored a 2 (Severely impaired cognition) in the Brief Interview for Mental Status (BIMS). In the area of functional status related to activities of daily living (ADLs), the resident was coded as requiring extensive assistance with dressing. The 7/3/19 Care Plan reviewed on 7/18/19 at approximately 9:15 AM stated that Resident #62 required assistance with the ADLs. The care plan also noted that the resident could become restless, tearful, and agitated, especially in the afternoon hours. In an interview with the unit manager on 7/18/19 at 3:20 PM, (s/he) stated that Resident #62 takes (his/her) clothes and covers off and touches (him/herself) inappropriately at times. The unit manager also confirmed that the care plan had not been updated to include the resident's behaviors.",2020-09-01
375,BLUE RIDGE IN GEORGETOWN,425048,2715 SOUTH ISLAND ROAD,GEORGETOWN,SC,29440,2019-07-19,692,D,0,1,8NBB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to provide and monitor adequate nutrition services for a resident with a compromised nutrition and hydration status. The facility also failed to implement and monitor nutrition interventions to stabilize or improve the resident's weight and diet for 1 of 7 sampled residents reviewed for nutrition. The findings included: The facility admitted Resident #27 on 3/2/17 with [DIAGNOSES REDACTED]. On 7/14/19 at 12:49 AM, Resident #27 was observed in a low bed in (his/her) room. The resident appeared thin and frail. Resident #27s weight record reviewed on 7/19/19 at 9:06 AM revealed the following: 143.8 pounds (lbs) on 5/6/19, 132.6 lbs on 6/5/19, and 129 lbs on 7/2/19. Also, (his/her) diet consisted of puree with thin liquids, ice cream, magic cup, and milkshakes. Progress notes dated 6/17/19 and reviewed on 7/19/19 at approximately 10:12 AM stated that Resident #27 had inadequate appetite/intake and was fed by staff. On 6/18/19, progress notes indicated that Resident #27 was not (his/her) usual self and was not interested in eating. The unit manager was notified of the resident's status. Nurse's notes dated 6/20/19 and reviewed on 7/19/19 at approximately 11:00 AM indicated that the facility sent Resident #27 to the hospital to be evaluated regarding symptoms of lethargy. At the hospital, the resident was treated for [REDACTED]. The hospital discharged the resident to the facility in stable condition. In an interview with the Registered Dietitian on 7/19/19 at 10:49 AM regarding the resident's nutritional status, physical appearance and weight record, (s/he) said that the resident's weekly weights and meal intake percentile were discontinued because (s/he) was under the impression that the resident returned to the facility on comfort care. In an interview with the administrator on 7/19/19 at 11:19 AM, (s/he) stated that Resident #27 was not on comfort care and that (s/he) was not aware nutritional services were not provided for the resident related to comfort care.",2020-09-01
376,BLUE RIDGE IN GEORGETOWN,425048,2715 SOUTH ISLAND ROAD,GEORGETOWN,SC,29440,2019-07-19,812,E,0,1,8NBB11,"Based on observation and staff interview, the facility failed to ensure all food items in the kitchen were dated, labeled, and stored in good condition, and failed to maintain a clean kitchen floor for 1 of 1 kitchen observed. The findings included: During the initial observation of the kitchen on 7/15/2019 at 3:15 PM the following items were noticed in two of the three reach-in freezers checked: one clear bag containing four pieces of chicken, three large blue bags containing breaded vegetables, and six 8 pancake bags without labels or dates. In the walk-in cooler, two large wet boxes containing fresh produce, and two 1 gallon of mayonnaise/salad dressing without use by day or expiration date. The entire kitchen floor was dirty and sticky. In an interview with the dietary manager on 7/15/19 at approximately 4:00 PM, (s/he) confirmed the unlabeled/undated food items and the dirty floor.",2020-09-01
377,BLUE RIDGE IN GEORGETOWN,425048,2715 SOUTH ISLAND ROAD,GEORGETOWN,SC,29440,2018-10-16,550,E,0,1,96XN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and observation, the facility failed to maintain the dignity of Resident #64 as evidenced by yelling without intervention the days of the survey. The findings included: Resident #64 was admitted to the facility with [DIAGNOSES REDACTED]. During the days of the survey the resident was heard yelling out during varying times during varying shifts. Staff were not noted to be present on the hallway at times and had to be alerted to resident's behavior. Resident does not use the call light. On 07/20/18 at 9:48 a.m. the Director of Nursing (DON) indicated the resident exhibits this behavior often and that it is on the care plan. The DON indicated the resident is in a private room and the aides check on the resident as often as they can but they cannot stop what they are doing when they are with other residents to check on her/him. Further interview with the DON revealed the staff offer to get the resident up out of bed, reposition, offer snacks & drinks. Review of the resident's care plan indicates the resident is encouraged to use call bell.",2020-09-01
378,BLUE RIDGE IN GEORGETOWN,425048,2715 SOUTH ISLAND ROAD,GEORGETOWN,SC,29440,2018-10-16,578,D,0,1,96XN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, the facility failed to afford Resident #9 the opportunity to formulate his/her advance directive for 1 of 2 residents reviewed for advance directives. The findings included: The facility admitted Resident #9 with [DIAGNOSES REDACTED]. Record review on 7/20/18 at 4:17 PM revealed a physician's orders [REDACTED]. Further review of the medical record revealed a Social Service Note dated 11/6/17 stating the resident was now a DNR. There were no other social service notes which reflected when and to whom the DNR status was discussed. A General Power of Attorney was presented which indicated the resident lacked the capacity to manage property, including the capacity to take actions necessary to administer real and personal property, intangible property, business property, benefits and income. There was no documentation on the medical record stating the resident had been deemed incapable for making healthcare decisions by two physicians. No further information was presented during the survey process related to the resident's advance directive.",2020-09-01
379,BLUE RIDGE IN GEORGETOWN,425048,2715 SOUTH ISLAND ROAD,GEORGETOWN,SC,29440,2018-10-16,580,D,0,1,96XN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of the facility policy titled Charting and Docmentation, the facility failed to notify the physician and/or the resident representative of a change in condition for 1 of 2 residents reviewed for notification. Resident #9 with a change in condition in respiratory status which treatment was rendered. The findings included: The facility admitted Resident #9 with [DIAGNOSES REDACTED]. Record review on 7/20/18 of the nurse's notes dated 7/3/18 at 11:31 AM revealed Resident #9 was observed in respiratory distress. Oxygen saturation was observed at 78% on room air. Shortness of breath was observed with a respiratory rate of 32 breaths per minute with accessory muscles utilized. The resident's chin was repositioned and oxygen was initiated at two liters per minute via nasal cannula. Further record review revealed there was no documentation the physician or the resident representative was notified. During an interview with the Director of Nursing on 7/20/18, s/he confirmed there was no documentation the physician or resident representative was notified. Review of the facility policy titled Charting and Documentation revealed the following: 7. Documentation of procedures and treatments will include care-specific details, including: .f. Notification of family, physician or other staff, if indicated;",2020-09-01
380,BLUE RIDGE IN GEORGETOWN,425048,2715 SOUTH ISLAND ROAD,GEORGETOWN,SC,29440,2018-10-16,607,D,0,1,96XN11,"Based on record review and interview the facility failed to develop written policies and procedures to prohibit and prevent abuse, neglect, exploitation of resident, and misappropriation of resident property, that includes the minimum required components by the Centers for Medicare and Medicaid Services (CMS) regulation. The findings included: The regulation states that written policies must include, but are not limited to, the following components Screening, Training, Prevention, Identification, Investigation, Protection, and Reporting/response. However, the facility policy reviewed on 7/21/18 at approximately 11:55 AM did not include the screening and training components. During an interview with the facility administrator and the registered nurse (RN) consultant 0n 7/21/18 at approximately 5:15 PM they both acknowledged that the facility abuse policy did not meet the requirement. They also stated that facility screening before hiring and that training is done for all new employees, annually and on an as-needed basis. The administrator and RN said that these components would be developed and included in the facility abuse policy.",2020-09-01
381,BLUE RIDGE IN GEORGETOWN,425048,2715 SOUTH ISLAND ROAD,GEORGETOWN,SC,29440,2018-10-16,622,D,0,1,96XN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews the facility failed to assure that the discharge process for 1 of 1 resident reviewed for discharge to the community was documented in the medical record. Resident # 76 had been admitted to the facility on [DATE], readmitted on [DATE] and discharged on [DATE]. (Cross refer to F660 and F661) The findings included: On 7/21/18 at approximately 2:19 PM a review of the medical record for Resident # 76 failed to show information related to the discharge from the facility, except for an incomplete Post-Discharge Plan of Care by Social Services which stated that Resident # 76 had been discharged to[NAME]Manor. On 7/21/18 at approximately 3:16 PM a review of the Facility's Policy on Transfer or Discharge Documentation (Revised December, (YEAR)) showed the following: When a resident is transferred or discharged , details of the transfer or discharge will be documented in the medical record and appropriate information will be communicated to the receiving health care facility or provider. On 7/21/18 at approximately 3:30 PM a review of the Facility's Policy Statement on Transfer or Discharge Notice (Revised December, (YEAR)) showed the following: Our facility shall provide a resident and/or resident's representative (sponsor) with a thirty (30)-day advance notice of an impending transfer or discharge from our facility. This same policy on Transfer or Discharge Notice states under Policy Interpretation and Implementation: 1. A resident, and/or his or her representative (sponsor), will be given a thirty (30)-day advance notice of an impending transfer or discharge from our facility. and 2. Under the following circumstances, the notice will be given as soon as it is practicable but before the transfer or discharge: a. through h. is then detailed and 3. The resident and /or representative (sponsor) will be notified in writing of the following information: a through i. is then detailed 4. A copy of the notice will be sent to the Office of the State Long-Term Care Ombudsman. 5. The reasons for the transfer will be documented in the resident's medical record. These findings were verified on 7/21/18 at approximately 5:19 PM by the Nurse Consultant who stated there was no further information in the medical record.",2020-09-01
382,BLUE RIDGE IN GEORGETOWN,425048,2715 SOUTH ISLAND ROAD,GEORGETOWN,SC,29440,2018-10-16,623,E,0,1,96XN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide the resident and the resident's representative in writing in a language understood, the reason why the resident was discharged to the community or to the hospital for one of one reviewed for discharge to the community and 4 of 6 reviewed for discharge to the hospital. Resident's #6, #9, #49, and #34. The findings included: The facility admitted Resident #6 with [DIAGNOSES REDACTED]. Record review on 7/19/18 revealed Resident #6 had a hospitalization on [DATE] through 3/22/18. Further record review revealed there was no documentation the resident or the resident's representative had been notified in writing in a language understood of the reasons of the hospitalization . The facility admitted Resident #9 with [DIAGNOSES REDACTED]. Record review on 7/20/18 revealed Resident #9 was discharged to the hospital on [DATE], 4/24/18 through 4/26/18, 5/22/18, and 6/6/18. Further record review revealed there was no documentation the resident or the resident's representative had been notified in writing in a language understood of the reasons of the hospitalization . The facility admitted Resident #49 with [DIAGNOSES REDACTED]. Record review on 7/17/18 revealed Resident #49 was discharged to the hospital 5/28/18 through 5/30/18 and 7/3/18 through 7/5/18. Further record review revealed there was no documentation the resident or the resident's representative had been notified in writing in a language understood of the reasons of the hospitalization . During the survey process, no further documentation was provided related to the transfer notification. Resident #34 was admitted to the facility with [DIAGNOSES REDACTED]. Secretion, and Depression. Resident medical record reviewed on 7/19/18 at 3:27 PM indicates that the facility discharge Resident # 34 to the hospital emergency room (ER) on 6/16/18 related to chest pain. The resident was admitted to the hospital, treated and discharged back to the facility on [DATE] to the same room. On 6/27/18 the facility sent the resident to the ER again with the same complaint (chest pain). The hospital admitted and treated the resident, and discharge him/her back to the facility on [DATE]. During the resident's medical record reviewed on 7/19/18 from approximately 3:27 PM to 4:15 PM showed no proof that the facility notified the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing, and in a language and manner they understand. Continuing record review revealed no evidence that the facility sent a copy of the notice of transfer to a representative of the Office of the State Ombudsman. During an Interview with the Director of Nursing (DON) on 7/20/18 at 2:30 PM s/he stated that hospital transfer/discharge notification is done via phone call, not in writing.",2020-09-01
383,BLUE RIDGE IN GEORGETOWN,425048,2715 SOUTH ISLAND ROAD,GEORGETOWN,SC,29440,2018-10-16,625,E,0,1,96XN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to notify Resident #6, #9, #49 and #34 and/or the resident's representative of the facility policy for bed hold, including reserve bed payment for 4 of 6 residents reviewed for hospitalization . The findings included: The facility admitted Resident #6 with [DIAGNOSES REDACTED]. Record review on 7/19/18 revealed Resident #6 had a hospitalization on ,[DATE]-[DATE]. Further record review revealed there was no documentation the facility bed hold policy was discussed with the resident or the resident's representative. The facility admitted Resident #9 with [DIAGNOSES REDACTED]. Record review on 7/20/18 revealed Resident #9 was discharged to the hospital on [DATE], 4/24/18 through 4/26/18, 5/22/18, and 6/6/18. Further record review revealed there was no documentation the facility bed hold policy was discussed with the resident or the resident's representative. The facility admitted Resident #49 with [DIAGNOSES REDACTED]. Record review on 7/17/18 revealed Resident #49 was discharged to the hospital 5/28/18 through 5/30/18 and 7/3/18 through 7/5/18. Further record review revealed there was no documentation the facility bed hold policy was discussed with the resident or the resident's representative. During the survey process, no evidence was provided by the facility the resident's received information related to bedhold upon discharge to the hospital. Resident #34 was admitted to the facility with [DIAGNOSES REDACTED]. Secretion, and Depression. Resident medical record reviewed on 7/19/18 at 3:27 PM indicates that the facility discharged Resident # 34 to the hospital emergency room (ER) on 6/16/18 related to chest pain. The resident was admitted to the hospital, treated and discharged back to the facility on [DATE] to the same room. On 6/27/18 the facility sent the resident to the ER again with the same complaint (chest pain). The hospital admitted and treated the resident, and discharge him/her back to the facility on [DATE]. The resident's medical record reviewed on the same day from approximately 3:27 PM to 4:15 PM showed no proof that the facility provided written information or that the facility discussed/explained with/to the resident or resident representative the facility's bed-hold policy. During an Interview with the Director of Nursing (DON) on 7/20/18 at 2:30 PM s/he stated that the bed-hold policy is sent with the resident upon hospital transfer (hospital transfer package). However, the DON could not testify that the facility provides and explains, to the resident and resident representative, the facility's bed-hold policy prior to discharge/hospital transfer.",2020-09-01
384,BLUE RIDGE IN GEORGETOWN,425048,2715 SOUTH ISLAND ROAD,GEORGETOWN,SC,29440,2018-10-16,657,F,0,1,96XN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure interdisciplinary collaboration was established on the care plans for Residents #6, #9, #49, #75, #27, #21, #66, #47, #70, and #67. 10 of 23 residents reviewed for care plans. The findings include: Resident #27 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the most recently completed Care Conference information sheet indicated involvement of the Licensed Practical Nurse (LPN), Unit Manager, and Social Worker that Resident and Family declined to attend on 5/23/18, yet there was no indication of involvement or participation of physician, registered nurse (RN) or activities personnel. Resident #21 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the most recently completed Care Conference Information sheet dated 05/09/18, indicated that amongst the interdisciplinary team (IDT), including Certified Nursing Assistant, the resident was present - there is however, no indication of physician involvement or participation in the care plan process. Resident #66 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the most recently completed Care Conference Information sheet dated 07/03/18, indicated that amongst the IDT participation there was no involvement or collaboration evident of the attending physician. Resident #47 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the most recently completed Care Conference Information sheet dated 06/13/18, revealed there was no participation or involvement evident of the attending physician or social services. Resident #70 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the most recently completed Care Conference information dated 07/03/18 indicated the Certified Dietary Manager, LPN, Director of Nursing, Certified Nursing Assistant, Social Worker and Activity personnel were present, however there was no indication of physician participation or involvement. Resident #67 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the most recently completed Care Conference Information sheet dated 07/03/18 revealed varying disciplines were in attendance to include the Activities director, the social worker, CNA, LPN and CDM. There is no indication that the physician was involved in the care planning process. Review of the facility's policy, entitled Care Plans and Care Plan Meetings revised on 06/14/18, there was no explicit definition of the Interdisciplinary Team, to include the physician. The facility admitted Resident #6 with [DIAGNOSES REDACTED]. Review of the care plan participation revealed the following: -care plan dated 1/31/18-no documented evidence dietary and physician participated in the care plan process; -care plans dated 4/18/18 and 7/18/18-no documented evidence the physician participated in the care plan process. The facility admitted Resident #9 with [DIAGNOSES REDACTED]. Review of the care plan participation revealed the following: -care plan dated 2/7/18-no documented evidence the Certified Nursing Assistant(CNA), dietary and physician participated in the care plan process; -care plan dated 4/25/18-no documented evidence the physician participated in the care plan process. The facility admitted Resident #49 with [DIAGNOSES REDACTED]. Review of the care plan participation revealed the following: -care plan dated 2/21/18-no documented evidence dietary and the physician participated in the care plan process; -care plan dated 5/16/18-no documented evidence the CNA and physician participated in the care plan process; -care plan dated 6/13/18-no documented evidence the physician participated in the care plan process. The facility admitted Resident #75 with [DIAGNOSES REDACTED]. Review of the care plan participation revealed there was no documented evidence the physician participated in the 7/3/18 care plan process.",2020-09-01
385,BLUE RIDGE IN GEORGETOWN,425048,2715 SOUTH ISLAND ROAD,GEORGETOWN,SC,29440,2018-10-16,660,D,0,1,96XN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews the facility failed to show documentation of discharge planning for 1 of 1 resident reviewed for discharge to the community. Resident # 76 had been admitted to the facility on [DATE], readmitted on [DATE] and discharged on [DATE]. (Cross refer to F622 and F661) The findings included: On 7/21/18 at approximately 2:19 PM a review of the medical record for Resident # 76 failed to show evidence related to the discharge planning process. Review of the Facilities Policy on Transfer or Discharge Documentation, Revised December, (YEAR) on 7/21/18 at approximately 3:18 PM showed the following: When a resident is transferred or discharged , details of the transfer or discharge will be documented in the medical record and appropriate information will be communicated to the receiving health care facility or provider. This finding was verified on 7/21/18 at approximately 5:19 PM by the Nurse Consultant who stated there was no further information in the medical record.",2020-09-01
386,BLUE RIDGE IN GEORGETOWN,425048,2715 SOUTH ISLAND ROAD,GEORGETOWN,SC,29440,2018-10-16,661,D,0,1,96XN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews the facility failed to show evidence of a discharge summary for 1 of 1 resident reviewed for discharge to the community. Resident # 76 had been admitted to the facility on [DATE], readmitted on [DATE] and discharged on [DATE]. (Cross refer to F622 and F660) The findings included: On 7/21/18 at approximately 2:19 PM a review of the medical record for Resident # 76 failed to show evidence of a discharge summary, except for an incompleted Post-Discharge Plan of Care by Social Services which stated that Resident # 76 had been discharged to[NAME]Manor. This finding was verified on 7/21/18 at approximately 5:19 PM by the Nurse Consultant who stated there was no further information in the medical record.",2020-09-01
387,BLUE RIDGE IN GEORGETOWN,425048,2715 SOUTH ISLAND ROAD,GEORGETOWN,SC,29440,2018-10-16,676,E,0,1,96XN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to show evidence of ordered Restorative services for Resident #17 and Resident #27, for 2 of 3 reviewed for Rehab and Restorative services. The findings included: Resident #27 was admitted to the facility with [DIAGNOSES REDACTED]. Record review on 07/20/18 at 9:03am revealed an 'Interdisciplinary Resident Screen' completed on 03/09/18 that indicated the resident has had no change in physical function/ROM or Mobility. Pt (patient) continues to wear contracture boots per order at night fitting well. Pt coninues to wear R (right) hand splint per order splint fitting well at this time. Hand splint worn during the day. No changes in nutrition/swallowing, Communication/cognition from the last screen. Skilled therapy services not warranted at this time. Further review of the resident's care plan on 07/21/18 at 12:00pm revealed problem areas including but not limited to, ' falls (transfers per hoyer lift with assist of 2), hx (history) [MEDICAL CONDITION]-[MEDICAL CONDITION], risk for pain r/t (related to) [MEDICAL CONDITION], risk for skin breakdown r/t splint use-incontinence and decreased mobility, and requires assistance for ADLs r/t [MEDICAL CONDITION]. Review of Annual Minimum Data Set assessment dated [DATE] revealed in Section O, the last treatment for [REDACTED]. During an interview with the Rehab Director, on 07/21/18 at 4:09pm, it was revealed the resident received Restorative nursing services for range of motion (ROM) to right lower extremity. S/he described the program to entail 5-10 second holds a the end of each ROM for the ankle, knee, and hip. Rehab director confirmed there was no evidence of restorative services being provided to prevent further ROM impairment. Resident #17 was admitted to the facility with [DIAGNOSES REDACTED]. During a brief resident interview at the initial survey process on 7/16/18 at approximately 11:30 AM Resident #17 stated that s/he asks the facility staff to straighten him/her up when in bed because s/he is not able to move his/her body on his/her own. S/he said that Certified Nursing Assistant (C.N.A) not always assist him/her when needed. During this interview, the resident was observed wearing a nightgown (the resident wore nightgown during the day every day of the survey). The resident appeared unkempt; long hair/facial hair, dried up/scaly facial skin, and long fingernails. Care plan reviewed on 7/18/18 at 9:02 AM states that Resident #17 is at risk of falls/injury related to impaired mobility. The care plan also states that the resident requires assistance with activities of daily living (ADL) and that the resident refuses (facial and hair) care at times. However, the care plan does not address the reasons why the resident wears nightgown during day and night. Additional review of the resident's clinical record reviewed on 7/18/18 at approximately 11:15 AM indicate the resident's chart lacked documentation to support that the facility provided the resident with social service. There was no entry of any type, in the resident's chart, from social services related to any aspect of the resident's life. During an interview with social service on 7/18/18 at 12:41 PM s/he stated Resident #17 has been in the facility for a while and that the resident's family is not involved with his/her care. S/he also stated that s/he started working at the facility in (MONTH) (YEAR), has a lot to catch up with and did not know s/he had to document in the resident medical record. During an interview with the unit manager on 7/19/18 at 5:30 PM s/he reported that s/he is aware of the resident's refusal to care at times but did not know the why the resident wears a nightgown during the day.",2020-09-01
388,BLUE RIDGE IN GEORGETOWN,425048,2715 SOUTH ISLAND ROAD,GEORGETOWN,SC,29440,2018-10-16,684,E,0,1,96XN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure Resident #27 received intervention for multiple bouts of constipation. The facility failed to coordinate care with Hospice for Resident #6. The facility failed to address concerns with [MEDICAL CONDITION] for Resident #9. 3 of 9 residents reviewed for quality of care. The findings include: Resident #27 was admitted to the facility with [DIAGNOSES REDACTED]. Record review on 07/22/18 11:17 AM revealed physician's orders [REDACTED]. days give laxative of choice - if no BM by next day give fleets enema or soap sud enema - still no BM by the following day notify the physician for further orders; Document BMs every shift. Review of medications received on 07/22/18 at 3:57pm revealed, Enema last given on 10/15/15, MOM last given on 07/09/17, [MEDICATION NAME] last given on 07/22/18, Senna last given on 07/22/18. During an interview with Registered Nurse on 07/22/18 at 4:44pm, s/he verified bowel movements did not occur on (MONTH) 23-28, nor (MONTH) 5-15. Review of the nurse's notes nor the administration record revealed intervention or notification to the physician as ordered. The facility admitted Resident #6 with [DIAGNOSES REDACTED]. Record review on 7/19/18 revealed Resident #6 was to have Hospice Aide visits five times per week, skilled nursing visits one time per week and social service visits two times a month. Further review of the medical record revealed the Hospice Aide visited thirteen times in the month of April, twenty visits in the month of May, nineteen visits in the month of (MONTH) and eight visits the month of (MONTH) with no documentation for the week of 7/16/18. Review of the skilled nursing notes revealed there was no documentation for the week of 7/16/18. Review of the Hospice social service notes revealed there was no documentation for the months of (MONTH) and July. The current certification for Hospice was not in the resident's Hospice book. During an interview with the Director of Nursing on 7/20/18, s/he confirmed all required documentation was not in the resident's record and the Hospice Aide was not visiting five times per week. Review of the Hospice Care of SC contract on 7/23/18 revealed the following: Section 3e Responsibilities of Hospice-Provision of Information. Hospice shall promote open and frequent communication with Facility and shall provide Facility with sufficient information to ensure that the provision of Facility Services under this Agreement is in accordance with the Hospice Patient's Plan of care, assessments, treatment planning and care coordination. The facility admitted Resident #9 with [DIAGNOSES REDACTED]. Record review on 7/20/18 of the nurse's notes revealed the following: -4/16/18 5:57 PM-went in to give medications and do trach([MEDICAL CONDITION]) care and [MEDICAL CONDITION] half out of throat . -4/24/18 2:34 PM-noted to have [MEDICAL CONDITION] approximately 12:30 this afternoon during care. -5/22/18 2:55 PM-called to room by CNA(Certified Nursing Assistant) [MEDICAL CONDITION] noted to be out of place . -6/6/18 7:08 AM-called into resident room by CNA during care,[MEDICAL CONDITION] to be out of place . Further review of the record revealed no new interventions were put into place after each incident of [MEDICAL CONDITION]. During an interview with the Director of Nursing on 7/22/18 at 3:39 PM, s/he confirmed there was no documentation of interventions to prevent further [MEDICAL CONDITION].",2020-09-01
389,BLUE RIDGE IN GEORGETOWN,425048,2715 SOUTH ISLAND ROAD,GEORGETOWN,SC,29440,2018-10-16,686,D,0,1,96XN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interview, and review of the facility policy titled Wound Care, the facility failed to provide necessary treatment and services to promote healing and prevent infection for Resident #6. In addition, pressure ulcer evaluation with staging was signed by a Licensed Practical Nurse(LPN) for Resident #49.(2 of 3 residents reviewed for pressure ulcer) The findings included: The facility admitted Resident #6 with [DIAGNOSES REDACTED]. Record review on 7/19/18 revealed Resident #6 had an unstageable wound to the back of the right and left thigh and a Stage IV wound to the sacrum. During pressure ulcer treatment on 7/19/18 at 2:18 PM, Resident #6 was observed with no dressings to the wound areas prior to the start of the treatments. During the treatment, Registered Nurse(RN) #2 was observed to remove 4 x 4 gauze soaked with wound cleanser out of a cup and cleanse Wound #1. This was repeated two more times with the same soiled gloved hand. RN #2 continued to repeat the process for Wound #2 and Wound #3 obtaining gauze out of the same cup using a soiled, gloved hand. After applying ointments to Wound #3, RN #2 was observed to remove gloves, donn gloves, tie the trash bag, remove his/her gloves and exit the room. RN #2 did not wash his/her hands prior to exiting the room. During an interview with RN #2 on 7/19/18 at 3:08 PM, RN #2 stated all the dressings were removed by the Certified Nursing Assistant due to being soiled. S/he continued by stating s/he understood obtaining 4 x 4 gauze from the cup with the soiled gloved hand could contaminate the 4 x 4's. Review of the facility policy titled Wound Care states the following: 8. Pour liquid solutions directly on gauze sponges on their papers. 23. Wash and dry your hands thoroughly. The facility admitted Resident #49 with [DIAGNOSES REDACTED]. Record review on 7/22/18 revealed Weekly Pressure Ulcer Documentation which included the staging of wounds was signed by a Licensed Practical Nurse. During an interview with the Director of Nursing on 7/22/18 at 4:37 PM, s/he stated the Hospice Nurse staged the wounds on his/her visit. S/he confirmed the Weekly Pressure Ulcer Documentation did not indicate a Registered Nurse(RN) measured the wound nor did it have a RN co-sign the document.",2020-09-01
390,BLUE RIDGE IN GEORGETOWN,425048,2715 SOUTH ISLAND ROAD,GEORGETOWN,SC,29440,2018-10-16,688,D,0,1,96XN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure Resident #47 was provided services to prevent further contractures. The findings included: Resident #47 was admitted to the facility with [DIAGNOSES REDACTED]. Record review on 07/20/18 at 9:22 am revealed a 'Therapist Progress & Discharge Summary' dated 04/17/18 signed by the physical therapist that included: Goals for the resident's orthotic use The patient improve right plantar flexion contracture to 50 degrees and tolerate dorsal night splints for 6 hours. Discharge plans and instructions indicate: Recommendations discussed with patient and/or caregivers include PROM and daily wear of AFO up to 8 hours. -dated 04/17/18 'Physical Therapy Screening Form' completed on 06/22/18 by the physical therapist. The comments indicated the resident 'exhibits joint limitations/contractures'. Comments reviewed stated,Pt (patient) received power WC (wheelchair) in 2008 or 2009. Now . is requesting a reclining WC with elevating leg rests, detachable armrests, Has had protector boots from (provider) that pt would like to use here. Further record review indicated an 'Occupational Therapy Screening Form' completed on 06/22/18 by the therapist. The comments indicate, Dependent for completion of ADL (Activities of daily living). Nursing states patient is able to feed self and use computer. Occupational Therapy is not recommended. Patient remains at baseline. During an interview with the Director of Nursing (DON) on 07/21/18 1:22pm, it was noted the resident to be unable to sit in a wheelchair. The DON stated the resident chooses not to get out of bed and only gets up for showers or appointments, in which a stretcher is utilised.",2020-09-01
391,BLUE RIDGE IN GEORGETOWN,425048,2715 SOUTH ISLAND ROAD,GEORGETOWN,SC,29440,2018-10-16,695,D,0,1,96XN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to implement additional safety measures for one of one resident reviewed for [MEDICAL CONDITION].(Resident #75) The findings included: The facility admitted Resident #75 with [DIAGNOSES REDACTED]. Record review on 7/20/18 revealed on 7/1/18 and 7/9/18 Resident #75 had dislodgement of the [MEDICAL CONDITION] apparatus. Further review of the record revealed the care plan had been updated on 7/9/18 to monitor the resident for manipulating of [MEDICAL CONDITION], and redirect as needed. No other safety interventions were initiated Observation of the resident during the survey process revealed the resident was in a private room furthest away from the nursing station and appeared anxious and tearful on several observations. During an interview with Physician #1 on 7/23/18 at 11:07 AM, s/he stated if a resident was going to pull [MEDICAL CONDITION] they would. S/he continued by stating the facility could not chemically or physically restrain a resident to prevent them from dislodging [MEDICAL CONDITION] Resident #75 had been seen by psychiatric services related to depression and anxiety. When asked if maybe moving the resident closer to the nurse's desk, s/he stated did not know if that would make any difference. During an interview with the Medical Director on 7/22/18 at 5:38 PM, when asked was s/he aware of resident's dislodging their [MEDICAL CONDITION] apparatus, s/he stated resident's do pull them out and it is a difficult problem because resident's cannot be restrained and some residents may have mental conditions. S/he stated the expectation for the facility would be to document the event, educate the family, and engage social services and activity involvement. The Medical Director stated a resident whose room was at the end of the hall was not a safety issue, but perhaps if the resident was closer the staff would be more engaged with the resident and respond to the resident in a more timely manner.",2020-09-01
392,BLUE RIDGE IN GEORGETOWN,425048,2715 SOUTH ISLAND ROAD,GEORGETOWN,SC,29440,2018-10-16,732,E,0,1,96XN11,"Based on review of postings and interview, the facility failed to ensure nurse staffing postings explicitly differentiated between Registered Nursing versus Licensed Nursing. The findings included: Review of staff postings dated (MONTH) 18, (YEAR) through (MONTH) 18, (YEAR) revealed the facility's postings for staff directly responsible for resident care did not explicitly differentiate the Registered Nurse/Licensed Practical Nurses. These concerns were reviewed and confirmed with the Director of Nursing on 07/22/18 at 2:40pm.",2020-09-01
393,BLUE RIDGE IN GEORGETOWN,425048,2715 SOUTH ISLAND ROAD,GEORGETOWN,SC,29440,2018-10-16,745,F,0,1,96XN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide medically related social services to attain or maintain the highest practicable physical, mental and psychosocial well being for 9 of 23 residents reviewed. (Resident #15, #69, #6, #61, #17, #75, #9, #49, and #34). The findings included: The facility admitted Resident #6 with [DIAGNOSES REDACTED]. Record review on 7/19/18 revealed Resident #6 was receiving Hospice services. Further review of the medical record revealed there was no documentation of social services involvement from 6/20/17-7/22/18. The facility admitted Resident #9 with [DIAGNOSES REDACTED]. Record review on 7/20/18 revealed there was no documentation of social services involvement from 11/6/17-7/22/18. The facility admitted Resident #49 with [DIAGNOSES REDACTED]. Record review on 7/18/18 revealed there was no documentation of social services involvement from 10/25/17-7/9/18. The facility admitted Resident #75 with [DIAGNOSES REDACTED]. Record review on 7/20/18 revealed Resident #75 revealed the resident had two incidences of dislodgement of the [MEDICAL CONDITION] apparatus and appeared anxious and tearful at times. In addition, on 7/23/18, Resident #75 wrote on a piece of paper s/he wanted to go home and presented it to the surveyor. At the time, Registered Nurse #2 stated the facility was working on trying to get him/her closer to home. Further review of the medical record revealed two entries on 7/22/18 and one entry on 7/23/18 related to social service notes. No other social service notes were presented during the survey process. During an interview with the Medical Director on 7/22/18 at 5:38 PM, s/he stated not aware of any documentation issues with social services. S/he stated his/her interaction with social services dealt with Do Not Resuscitate orders and transfer orders. S/he continued the expectation of social services would be to follow the regulations regarding documentation and that there should be documentation related to transfer, discharge, hospice, and so on. When asked did s/he know the facility did not have a social service consultant, s/he stated was unaware and s/he would expect the Administrator and Director of Nursing to familiarize social service and if more training was needed that the facility would provide. Resident #34 was admitted to the facility with [DIAGNOSES REDACTED]. Resident #34 reviewed for the following areas: abuse, choices, vision/hearing, dental and food. During the survey, 7/16 -7/23, the resident's clinical record was reviewed in multiple occasions, including but limited to 7/16 at 5:45 PM, 7/19 at 1:45 PM, 7/20 at 9:38 AM and 7/21at 9:09 AM. The resident's medical chart lacked documentation to support that the facility provided the resident with social services. There was no entry of any type, in the resident's chart, from social services related to any aspect of the resident's life for seven consecutive months. During an interview with social service on 7/18/18 at 12:41 PM the social worker stated s/he had visited Resident #34 and that the resident has not shared any concern with him/her. The social worker was unable to provide evidence to support such visits. S/he also stated that s/he started working at the facility in (MONTH) (YEAR), had a lot to catch up with and did not know s/he had to document in the resident medical record. Resident #17 was admitted to the facility with [DIAGNOSES REDACTED]. Resident #17 reviewed for the following areas: abuse, choices, vision/hearing, dental and food. During the survey, 7/16 -7/23, the resident's clinical record was reviewed in multiple occasions, including but limited to 7/17 at 11:35 AM, 7/18 at 8:29 AM, and 7/19 at 2:13 PM. The resident's medical chart lacked documentation to support that the facility provided the resident with social services. There was no entry of any type, in the resident's chart, from social services related to any aspect of the resident's life for seven consecutive months. During an interview with social service on 7/18/18 at 12:41 PM s/he stated Resident #17 has been in the facility for a while and that the resident's family is not involved with his/her care. S/he also stated that s/he started working at the facility in (MONTH) (YEAR), has a lot to catch up with and did not know s/he had to document in the resident medical record. Resident #15 was admitted to the facility with [DIAGNOSES REDACTED]. Resident #15 reviewed for the following areas: Care plan, pressure ulcer, and food. During the survey, 7/16 -7/23, the resident's clinical record was reviewed in multiple occasions, including but limited to 7/21 at 4:10 PM, 7/22 at 11:41 AM, and 7/23 at 11:13 AM. The resident's medical chart lacked documentation to support that the facility provided the resident with social services. There was no entry of any type, in the resident's chart, from social services related to any aspect of the resident's life for seven consecutive months. During an interview with social service on 7/18/18 at 12:41 PM the social worker stated s/he had visited Resident #15 and that the resident has not shared any concern with him/her. The social worker was unable to provide evidence to support such visits. S/he also stated that s/he started working at the facility in (MONTH) (YEAR), had a lot to catch up with and did not know s/he had to document in the resident medical record. Resident #69 was admitted to the facility with [DIAGNOSES REDACTED]. Resident #69 reviewed for the following areas: Unnecessary medication, accident, position and mobility, and food. During the survey, 7/16 -7/23, the resident's clinical record was reviewed in multiple occasions, including but limited to 7/16 at 4:58 PM, 7/22 at 6:44 AM, and 7/23 at 12:13 PM. The resident's medical chart lacked documentation to support that the facility provided the resident with social service. There was no entry of any type, in the resident's chart, from social services related to any aspect of the resident's life for seven consecutive months. During an interview with social service on 7/18/18 at 12:41 PM the social worker stated s/he had visited Resident #69 and that the resident has not shared any concern with him/her. The social worker was unable to provide evidence to support such visits. S/he also stated that s/he started working at the facility in (MONTH) (YEAR), had a lot to catch up with and did not know s/he had to document in the resident medical record. Resident #61 was admitted to the facility with [DIAGNOSES REDACTED]. Resident #61 reviewed for the following areas: abuse, accident, dementia care, general (sin condition), personal property rehab and restorative, respiratory care and unnecessary medication. During the survey, 7/16 -7/23, the resident's clinical record was reviewed in multiple occasions, including but limited to 7/16 at 12:00 PM, 7/18 at 4:45 PM, and 7/21 at 11:00 AM. The resident's medical chart lacked documentation to support that the facility provided the resident with social service. There was no entry of any type, in the resident's chart, from social services related to any aspect of the resident's life for seven consecutive months. During an interview with social service on 7/18/18 at 12:41 PM the social worker stated s/he had visited Resident #34 and that the resident has not shared any concern with him/her. The social worker was unable to provide evidence to support such visits. S/he also stated that s/he started working at the facility in (MONTH) (YEAR), had a lot to catch up with and did not know s/he had to document in the resident medical record.",2020-09-01
394,BLUE RIDGE IN GEORGETOWN,425048,2715 SOUTH ISLAND ROAD,GEORGETOWN,SC,29440,2018-10-16,756,D,0,1,96XN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews the facility and the pharmacy failed to assure that medications were correctly ordered for 1 of 6 residents reviewed for unnecessary medications. Resident # 76 had been admitted to the facility on [DATE], readmitted on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. The findings included: On 7/21/18 at approximately 2:19 PM a review of the physicians orders for Resident # 76 revealed an opened order dated 5/19/18 for Tylenol ([MEDICATION NAME]) (OTC) (over-the-counter) tablet; 325 mg Amount to Administer: 2 tabs (tablets); oral As Needed Give 2 tabs po(by mouth) for pain. Subsequent reviews of pharmacy consultation report for May, June, and (MONTH) (YEAR) failed to show any negative finding relevant to Tylenol. This finding was verified on 7/21/18 at approximately 2:26 PM by the Nurse Consultant. Standards of Practice for physician prescribing state that medications order as needed are incomplete unless a frequency specified by time (for example, every 6 hours or 4 times daily) is indicated.",2020-09-01
395,BLUE RIDGE IN GEORGETOWN,425048,2715 SOUTH ISLAND ROAD,GEORGETOWN,SC,29440,2018-10-16,758,E,0,1,96XN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to implement non-pharmacological interventions prior to administration of an anti-anxiety medication for 1 of 6 residents reviewed for unnecessary medications.(Resident #75) The findings included: The facility admitted Resident #75 with [DIAGNOSES REDACTED]. Record review revealed a physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. Review of the nurse's notes from 7/3/18-7/21/18 revealed several times redirection was attempted. The nurse's notes were not specific as to what was attempted and if different interventions were attempted. During an interview with the Director of Nursing on 7/20/18, he/she confirmed documentation of non-pharmacological interventions were not documented with each administration of [MEDICATION NAME].",2020-09-01
396,BLUE RIDGE IN GEORGETOWN,425048,2715 SOUTH ISLAND ROAD,GEORGETOWN,SC,29440,2018-10-16,761,D,0,1,96XN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, interviews and manufacturer package inserts information the facility failed to assure that medications for Resident # 19 were properly stored in 1 of 2 medication rooms. Resident # 19 had been admitted to the facility on [DATE] and readmitted on [DATE] and had [DIAGNOSES REDACTED]. The findings included: On 7/16/18 at approximately 10:41 AM inspection of the MillerWing Medication Room refrigerator revealed one opened (not in use) [MEDICATION NAME] 100 U (unit) /ml (milliliter) 3 ml prefilled pen dated as opened on 7/14/18. The package insert of Sanofi, the manufacturer of [MEDICATION NAME], states once opened should not be returned to refrigerator. This finding was verified as being in the refrigerator and opened by Registered Nurse # 1 on 7/16/18 at approximately 10:47 AM.",2020-09-01
397,BLUE RIDGE IN GEORGETOWN,425048,2715 SOUTH ISLAND ROAD,GEORGETOWN,SC,29440,2018-10-16,804,E,0,1,96XN11,"Based on observation, record review, and interviews the facility failed to provide food that is palatable, attractive, and at a safe and appetizing temperature. The findings included: During a resident interview at the initial survey process on 7/16/18 at 10:42 AM Resident # 34 stated that s/he does not like the food. S/he said the food does not taste good and that sometimes it is late and cold. On the same day at 4:47 PM Resident #69 looked away when asked about the food and stated that the food is not good. S/he said that the facility always covers the food with gravy and that s/he is not able to taste/savore the food itself. On 7/17/18 at 10:38 AM Resident # 15 also expressed discontent with the food. S/he stated that s/he does not like the food. On 7/17/18 a food test tray, for temperature and teste, was conducted. The meal for the day included pasta with meat sauce, tossed salad with dressing, garlic bread, and fruit cup, beverage of choice and grated cheese. The food tray was brought up to the conference room by the certified dietary manager (CDM) and the consultant CDM. The temperature of the foods was within standards, and the taste appeared acceptable (two surveyors tried the pasta and salad). However, the facility served the dessert in a Styrofoam food bowl. On 7/21/18 at 12:54 a second surveyor conducted a food test tray for appearance, palatability, and temperature. The certified dietary manager (CDM) brought up the food tray to the conference room this time. The CDM also temped the foods in the present of surveyors and with the facility's thermometer. Results were the following: Turkey Pot Pie- Temp 121.4F Side salad-9.3F Corn on the cob-125F Fruit Cobbler (strawberry)-82F Observation of the food plated on the tray revealed that the facility served the Turkey Pot Pie (hot) on the same plate with the side salad (cold). The side salad appeared soggy and limp and did not taste good to the surveyor that sampled it. At the end of the test, the dietary manager acknowledged that the temperature of the foods was out of range and that the meal was unattractive and unappealing.",2020-09-01
398,BLUE RIDGE IN GEORGETOWN,425048,2715 SOUTH ISLAND ROAD,GEORGETOWN,SC,29440,2018-10-16,812,F,0,1,96XN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview that facility failed to ensure that the kitchen staff used appropriate dishware to serve residents their meals. It also was unable to maintain the kitchen floor clean and in good condition, and the ice-maker drainage installation in compliance with manufacturer requirements. The facility failed to implement/keep an emergency food supply and store the emergency water supply in an appropriately sanitary location for one of one kitchen reviewed during the survey. The findings included: During a brief tour of the kitchen on [DATE] at 9:00 AM the surveyor saw six large areas throughout the kitchen floor without tiles. Unlike the rest of the flooring, it seems that these areas were covered with concrete not tiles. In five of the six areas, the concrete appeared black/brown and porous. One of the surveyors removed matter/dirt from the floor area, with a paper towel, between the dishwasher and a reach-in cooler. There was also a pool of dirty water accumulated in front of the dishwashing work area, which creates a potential for bacterial growth. On [DATE] at approximately 9:00 AM, the maintenance person, was working on the Ice-maker machine due to clotting. S/he stated that it happens often, it takes no time to get it fixed and that otherwise the ice-maker works fine. Observation of the ice-maker revealed that the condensation exhaust connected to a long pipe line that leads to the drainage on the floor of another room had no air gap and it touched the waste trap. During a lunch observation on [DATE] at approximately 12: 09 PM surveyors noticed a Styrofoam bowl on the residents' lunch tray. On day two of the survey, [DATE], during another lunch observation, the dessert was served to the residents in a Styrofoam bowl as well. On [DATE] the surveyor asked to see the emergency food and water supply. The facility located the emergency water supply in the residents' common bathroom between 100 and 200 nursing satiations. There were also 75 gallons of expired water stored along with ,[DATE].9oz-unexpired bottlers of water, and the facility did not have an emergency food supply. During an interview on [DATE] at approximately 12: 46 PM the dietary manager stated that s/he could not explain why dessert, a fruit cocktail, was served in Styrofoam and gave the impression that s/he did not know that Styrofoam dishware was not to be used on a regular basis without a justification. S/he also said that the expired water is to be used to flush the toilets during an emergency and that the facility does not have any other room where to place the emergency water supply. The dietary manager also shared that the facility does not have an emergency food supply but is his/her belief that the facility has enough foods to cover all residents for three days. However, upon a review of the emergency meal menu and food on hand, the facility did not have any dry/powder milk, which is included in the emergency menu.",2020-09-01
399,BLUE RIDGE IN GEORGETOWN,425048,2715 SOUTH ISLAND ROAD,GEORGETOWN,SC,29440,2018-10-16,835,F,0,1,96XN11,"Based on record review and interview, the facility failed to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Social Service documentation and intervention was not consistent. The findings included: During an interview with the Administrator on 7/22/18 at 7:40 PM, s/he stated was not aware social services was not documenting and until the survey, social service issues had not come to light. S/he continued by stating Social was providing services, but was not documenting the services provided. S/he stated Social Service staff was provided training by the previous social worker and s/he had also visited another facility and worked with a social worker there. The Administrator was asked what was his/her expectation in which s/he stated to use all resources available. During the interview, s/he confirmed there was no social service consultant and there was no audit tool for evaluating social service documentation and services. Cross refer to F-745 as it relates to Social Service lack of documentation and/or services related to 9 of 23 residents reviewed.",2020-09-01
400,BLUE RIDGE IN GEORGETOWN,425048,2715 SOUTH ISLAND ROAD,GEORGETOWN,SC,29440,2018-10-16,842,F,0,1,96XN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to document the resident's medical treatment information following accepted professional standard and practice for nine of twenty-three residents sample reviewed for accuracy of the medical record. (Resident #15, #69, #6, #61, #17, #75, #9, #49, and #34). The findings included: The facility admitted Resident #6 with [DIAGNOSES REDACTED]. Record review on 7/19/18 revealed Resident #6 was receiving Hospice services. Further review of the medical record revealed there was no documentation of social services involvement from 6/20/17-7/22/18. The facility admitted Resident #9 with [DIAGNOSES REDACTED]. Record review on 7/20/18 revealed there was no documentation of social services involvement from 11/6/17-7/22/18. The facility admitted Resident #49 with [DIAGNOSES REDACTED]. Record review on 7/18/18 revealed there was no documentation of social services involvement from 10/25/17-7/9/18. The facility admitted Resident #75 with [DIAGNOSES REDACTED]. Record review on 7/20/18 revealed Resident #75 revealed the resident had two incidences of dislodgement of the [MEDICAL CONDITION] apparatus and appeared anxious and tearful at times. In addition, on 7/23/18, Resident #75 wrote on a piece of paper s/he wanted to go home and presented it to the surveyor. At the time, Registered Nurse #2 stated the facility was working on trying to get him/her closer to home. Further review of the medical record revealed two entries on 7/22/18 and one entry on 7/23/18 related to social service notes. No other social service notes were presented during the survey process. During an interview with the Medical Director on 7/22/18 at 5:38 PM, s/he stated not aware of any documentation issues with social services. S/he stated his/her interaction with social services dealt with Do Not Resuscitate orders and transfer orders. S/he continued the expectation of social services would be to follow the regulations regarding documentation and that there should be documentation related to transfer, discharge, hospice, and so on. When asked did s/he know the facility did not have a social service consultant, s/he stated was unaware and s/he would expect the Administrator and Director of Nursing to familiarize social service and if more training was needed that the facility would provide. Medicine administration regimen (MAR) reviewed on 7/22/18 at 2:01 PM revealed that Resident #69 received antibiotic therapy ([MEDICATION NAME] 500mg-once a day for 10days) from (MONTH) 13th through (MONTH) 22nd as per the physician's orders [REDACTED]. Resident #34 was admitted to the facility with [DIAGNOSES REDACTED]. Resident #34 reviewed for the following areas: abuse, choices, vision/hearing, dental and food. During the survey, 7/16 -7/23, the resident's clinical record was reviewed in multiple occasions, including but limited to 7/16 at 5:45 PM, 7/19 at 1:45 PM, 7/20 at 9:38 AM and 7/21at 9:09 AM. The resident's medical chart lacked documentation to support that the facility provided the resident with social services. There was no entry of any type, in the resident's chart, from social services related to any aspect of the resident's life for seven consecutive months. During an interview with social service on 7/18/18 at 12:41 PM the social worker stated s/he had visited Resident #34 and that the resident has not shared any concern with him/her. The social worker was unable to provide evidence to support such visits. S/he also stated that s/he started working at the facility in (MONTH) (YEAR), had a lot to catch up with and did not know s/he had to document in the resident medical record. Resident #17 was admitted to the facility with [DIAGNOSES REDACTED]. Resident #17 reviewed for the following areas: abuse, choices, vision/hearing, dental and food. During the survey, 7/16 -7/23, the resident's clinical record was reviewed in multiple occasions, including but limited to 7/17 at 11:35 AM, 7/18 at 8:29 AM, and 7/19 at 2:13 PM. The resident's medical chart lacked documentation to support that the facility provided the resident with social services. There was no entry of any type, in the resident's chart, from social services related to any aspect of the resident's life for seven consecutive months. During an interview with social service on 7/18/18 at 12:41 PM s/he stated Resident #17 has been in the facility for a while and that the resident's family is not involved with his/her care. S/he also stated that s/he started working at the facility in (MONTH) (YEAR), has a lot to catch up with and did not know s/he had to document in the resident medical record. Resident #15 was admitted to the facility with [DIAGNOSES REDACTED]. Resident #15 reviewed for the following areas: Care plan, pressure ulcer, and food. During the survey, 7/16 -7/23, the resident's clinical record was reviewed in multiple occasions, including but limited to 7/21 at 4:10 PM, 7/22 at 11:41 AM, and 7/23 at 11:13 AM. The resident's medical chart lacked documentation to support that the facility provided the resident with social services. There was no entry of any type, in the resident's chart, from social services related to any aspect of the resident's life for seven consecutive months. During an interview with social service on 7/18/18 at 12:41 PM the social worker stated s/he had visited Resident #15 and that the resident has not shared any concern with him/her. The social worker was unable to provide evidence to support such visits. S/he also stated that s/he started working at the facility in (MONTH) (YEAR), had a lot to catch up with and did not know s/he had to document in the resident medical record. Resident #69 was admitted to the facility with [DIAGNOSES REDACTED]. Resident #69 reviewed for the following areas: Unnecessary medication, accident, position and mobility, and food. During the survey, 7/16 -7/23, the resident's clinical record was reviewed in multiple occasions, including but limited to 7/16 at 4:58 PM, 7/22 at 6:44 AM, and 7/23 at 12:13 PM. The resident's medical chart lacked documentation to support that the facility provided the resident with social service. There was no entry of any type, in the resident's chart, from social services related to any aspect of the resident's life for seven consecutive months. During an interview with social service on 7/18/18 at 12:41 PM the social worker stated s/he had visited Resident #69 and that the resident has not shared any concern with him/her. The social worker was unable to provide evidence to support such visits. S/he also stated that s/he started working at the facility in (MONTH) (YEAR), had a lot to catch up with and did not know s/he had to document in the resident medical record. On (MONTH) 25 the physician [MEDICATION NAME] twice per day for seven days related to a urinary tract infection [MEDICAL CONDITION]. The MAR indicated [REDACTED]. However, the progress note states that the resident continues antibiotic therapy through (MONTH) 6th. During an interview on 7/22/18 at 3:10 PM the registered nurse (RN) consultant confirmed the above findings. Resident #61 was admitted to the facility with [DIAGNOSES REDACTED]. Resident #61 reviewed for the following areas: abuse, accident, dementia care, general (sin condition), personal property rehab and restorative, respiratory care and unnecessary medication. During the survey, 7/16 -7/23, the resident's clinical record was reviewed in multiple occasions, including but limited to 7/16 at 12:00 PM, 7/18 at 4:45 PM, and 7/21 at 11:00 AM. The resident's medical chart lacked documentation to support that the facility provided the resident with social service. There was no entry of any type, in the resident's chart, from social services related to any aspect of the resident's life for seven consecutive months. During an interview with social service on 7/18/18 at 12:41 PM the social worker stated s/he had visited Resident #34 and that the resident has not shared any concern with him/her. The social worker was unable to provide evidence to support such visits. S/he also stated that s/he started working at the facility in (MONTH) (YEAR), had a lot to catch up with and did not know s/he had to document in the resident medical record.",2020-09-01
401,BLUE RIDGE IN GEORGETOWN,425048,2715 SOUTH ISLAND ROAD,GEORGETOWN,SC,29440,2018-10-16,880,E,0,1,96XN11,"Based on observation, interview and review of facility policy titled Departmental(Environmental Services)-Laundry and Linen the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to prevent development and transmission of disease and infection. Observation of the laundry revealed laundry worker wearing soiled apron on hallway for collection of soiled linen, no handwashing after soiled linen placed in barrel, clean linens stored on soiled side during sorting and loading washer. The findings included: During laundry observation on 7/18/18 at 1:45 PM, Laundry Staff #1 was observed to wear a soiled apron throughout the facility collecting soiled linen. After collection of the soiled linen and removal of gloves, Laundry Staff #1 did not wash his/her hands. During the sorting and loading of the washers, two uncovered clean laundry baskets containing clean linen was observed in the soiled side of the laundry. During an interview with Laundry Staff #1 after the observation, s/he stated was unaware that clean items could not be in the soiled side while sorting and loading the washer. Review of the facility policy titled Departmental(Environmental Services)-Laundry and Linen revealed the following: Under General Guidelines Standard Precautions- 1. Separate soiled and clean linen at all times. 2. Wash hands after handling soiled linen and before handling clean linen. Under Washing Linen and other Soiled Items -6. Keep soiled and clean linen, and their respective hampers and laundry carts, separate at all times.",2020-09-01
402,BLUE RIDGE IN GEORGETOWN,425048,2715 SOUTH ISLAND ROAD,GEORGETOWN,SC,29440,2018-11-17,550,D,1,0,H6ZB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review, the facility failed to ensure Resident #4 was treated with respect and dignity during activities of daily living. 1 of 3 sampled residents for dignity. Resident #4 stated that Certified Nursing Aide (CNA) #1 left her/him uncovered for thirty minutes during incontinent care. The findings included: The facility admitted Resident #4 on 2/17/16 with [DIAGNOSES REDACTED]. Review of Resident #4's electronic medical record on 11/04/18 at approximately 12:44 PM revealed a quarterly Minimum Data Set ((MDS) dated [DATE] that indicated Resident #4 had a Brief Interview of Mental Status (BIMS) score of 14. The resident was listed on the interviewable list provided by the facility during the survey. During an interview with Resident #4 on 10/03/18 at approximately 10:45 AM. Resident #4 stated that when he/she was evacuated to another facility, CNA #1 provided incontinent care and left the bed covers pulled up from his/her feet to his/her waist for about thirty minutes until the CNA returned and provided care. During an interview with CNA #1 on 11/04/18 at approximately 8:45 AM. CNA #1 confirmed he/she did leave Resident #4 uncovered for approximately 15 to 20 minutes.",2020-09-01
403,BLUE RIDGE IN GEORGETOWN,425048,2715 SOUTH ISLAND ROAD,GEORGETOWN,SC,29440,2018-11-17,600,J,1,0,H6ZB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review the facility failed to keep residents free from abuse and neglect. Two certified nursing assistants (CNAs), CNA #2 and #3, left their assigned residents unsupervised for approximately 30 minutes during an evacuation. 2 of 2 CNA's reviewed for assignments. The facility failed to protect residents from sexual abuse. Staff members observed sexually inappropriate behavior in a common area between residents #8 and #14. The facility failed to protect residents from verbal abuse. Resident #1 alleged that CNA #4 told him/her if s/he didn't stop hollering s/he was going to put a bag over his/her head and strangle him/her. 3 of 10 residents sampled for abuse. The findings included: Two certified nursing assistants (CNAs), CNA #2 and #3, left their assigned residents unsupervised for an hour during an evacuation. Review of the facility assignment sheet for 9/11/18 revealed CNA #2 was assigned 12 residents and CNA #3 was assigned 10 residents. Review of the facility investigation on 11/3/18 at approximately 9:50 AM revealed that CNA #2 and #3 left their assigned residents without permission on 9/11/18 at approximately 10 AM. During an interview with the Director of Nursing (DON) and Chief Operations Officer (COO) on 11/3/18 at approximately 11 AM. The DON and COO stated that CNA #2 and #3 left the facility without reporting to supervisors. Review of 9/11/18 time card reports on 11/3/18 at approximately 11:38 AM revealed CNA #2 clocked out at 10:05 AM and CNA #3 clocked out at 9:50 AM. During an interview with the DON on 11/16/18 at approximately 1:20 pm. The DON stated that the resident assignments were redone within 30 minutes of CNA #2 and #3 leaving. During an interview with the Human Resources Director on 11/3/18 at approximately 11:51 AM. The Human Resources Director confirmed interviews with the DON and COO and stated that resident care was affected because the facility was short-staffed during the evacuation. During an interview with CNA #2 on 11/3/18 at approximately 3:15 PM revealed both CNAs left the facility without arranging for care for residents. CNA #2 stated that s/he did not know who would look after the residents after s/he left. On 7/11/18 staff members observed sexually inappropriate behavior in a common area between residents #8 and #14. Resident #8 was observed to be holding resident #14's penis. Resident #14 had a history of [REDACTED]. The facility admitted resident #8 on 7/20/17 with [DIAGNOSES REDACTED]. Review of Resident #8's medical record revealed Nurse's Notes dated 7/11/18. The Nursed Note revealed Resident noted to be standing in front of resident (#14) holding resident's penis in her/his hand. Resident #14 was sitting in rollator walker. Floor nurse separated the two immediately. Resident's family and physician notified. Review of Resident #8's medical record revealed a Significant Change assessment dated [DATE]. The Significant Change Assessment revealed Long and short term memory impairment. Seldom understood or understands. Never rarely makes decisions. Wanders daily throughout facility. No sexual behaviors were listed for the Significant Change. During an interview with the Unit Manager on 11/16/18 at 12:05PM. The Unit Manager stated that Resident #8 initiated the incident on 7/11/18. The Unit Manager stated that Resident #8 likes to touch and rub on people. The facility admitted Resident #14 on 9/11/17 with [DIAGNOSES REDACTED]. Review of the Resident #14's medical record revealed in (MONTH) of (YEAR), the resident displayed inappropriate sexual behavior of touching a resident's breast. Resident #14's medical record revealed that throughout Resident #14's stay the resident demonstrated inappropriate sexual behaviors of exposing him/herself in public areas. Review of Resident #14's Nurses Notes from (MONTH) 1, (YEAR) through 11/16/18 revealed that Resident #14 noted to be alert and able to make needs known with some confusion noted. The Nurses Notes also revealed that Resident #14 continually takes pull ups off and refuses to wear pull ups or any underwear at times. Review of the Resident #14's Plan of Care dated 9/26/17 revealed, Inappropriate sexual behaviors, such as exposing self in common areas of facility, attempting inappropriate behaviors with female residents, inappropriate comments also noted and can be difficult to redirect. Review of Resident #14's medical record revealed a Psychiatric evaluation dated 9/26/17. BIMS (Brief Interview for Mental Status) - 6 (6 of 15). Due to Dementia, s/he is unable to provide reliable review of systems. S/he has behavioral episodes of resistance to care and unwillingness to participate in PT (Physical Therapy) program. Patient also has been observed with sexually inappropriate behaviors and poor boundaries. Has exposed self inappropriately and touched resident's breast. S/He has poor insight and memory regarding behaviors. During an interview with Licensed Practical Nurse (LPN) #2 on 11/16/18 at approximately 11:45 AM. LPN #2 stated that when Resident #14 first came to the facility the resident would make sexual remarks. LPN #2 also stated that Resident #14 liked for the CNAs to wash him/her. During an interview with the Unit Manager on 11/16/18 at 12:05PM. The Unit Manager stated that when Resident #14 first came to the facility s/he did not wear underwear, and his/her penis would fall out of his/her pants. Resident #1 alleged that CNA #4 told him/her if s/he didn't stop hollering s/he was going to put a bag over his/her head and strangle him/her. Review of the facility investigation on 11/3/18 at approximately 3:10 PM revealed that on 4/4/18 Resident #1 alleged that CNA #4 told him/her if s/he didn't stop hollering s/he was going to put a bag over his/her head and strangle him/her. Resident #1's roommate confirmed the CNA stating this. The facility investigation revealed that the facility substantiated the allegation and CNA #4 was terminated. During an interview with Resident #1's roommate on 11/3/18 at approximately 4:11 PM. Resident #1's roommate confirmed his/her statement that CNA #4 said s/he would put a bag over Resident #1's head who then started cursing him/her out. During an interview with CNA #4 on 11/4/18 at approximately 11:20 AM. CNA #4 stated that after s/he changed Resident #1 the Resident began cursing at him/her so s/he left and had another CNA care for the resident. CNA #4 denied stating s/he would put a bag over the resident's head.",2020-09-01
404,BLUE RIDGE IN GEORGETOWN,425048,2715 SOUTH ISLAND ROAD,GEORGETOWN,SC,29440,2018-11-17,607,E,1,0,H6ZB11,"> Based on interview and record review the facility failed to implement abuse policies. Two certified nursing assistants (CNAs) CNA# 2 and CNA #3 left their assigned residents unsupervised for approximately 30 minutes during an evacuation. 2 of 2 CNA's reviewed for assignments. Resident #1 alleged that CNA #4 told him/her if s/he didn't stop hollering s/he was going to put a bag over his/her head and strangle him/her. 1 of 10 residents sampled for abuse. The facility failed to complete pre-employment screening prior to date of hire for 1 of 5 new hires reviewed. The findings included: Review of the facility investigation on 11/3/18 at approximately 9:50 AM revealed that CNA #2 and #3 left their assigned residents without permission on 9/11/18 at approximately 10 AM. Review of the facility assignment sheet for 9/11/18 revealed CNA #2 was assigned 12 residents and CNA #3 was assigned 10 residents. Review of policy Abuse & Neglect on 11/3/18 at approximately 12:50 PM revealed the following. Similar to neglect is abandonment - which is the desertion of a vulnerable resident by a caregiver or other responsible party. This may include a caregiver leaving a vulnerable resident alone for a long period without arranging for substitute care. Review of the facility investigation on 11/3/18 at approximately 3:10 PM revealed that on 4/4/18 Resident #1 alleged that CNA #4 told him/her if s/he didn't stop hollering s/he was going to put a bag over his/her head and strangle him/her. Resident #1's roommate confirmed the CNA stating this. The facility investigation revealed that the facility substantiated the allegation and CNA #4 was terminated. Review of the facility Abuse Prevention Program revealed Our Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but not limited to freedom from corporal punishment, involuntary seclusions, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. A background check was not completed prior to date of hire for 1 of 5 new hires. Review of the personnel file for Registered Nurse (RN) #2 on 11/4/2018 at 12:24 PM revealed RN #2's date of hire was 8/30/2018. Review of the criminal background check in the personnel file revealed the background check was completed on 8/31/2018. During an interview with the Director of Nursing (DON) and Regional Human Resources Director (HR) on 11/4/2018 at 12:40 PM. The Director of Nursing and Regional Human Resources Director (HR) confirmed the criminal background check was not done prior to date of hire. The Regional HR Director stated, we know the process and know background checks have to be completed prior to hire. The DON stated, the facility's HR was terminated a couple weeks ago. The DON stated the Regional HR Director had been brought in to clean up the mess. Review of the facility Abuse and Neglect policy provided by the DON did not address pre-employment screening. Review of the facility Abuse Prevention Program revealed As part of the resident abuse prevention, the administration will: 2. Conduct employee background checks and will not knowingly employ or otherwise engage any individual who has: a. Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law",2020-09-01
405,BLUE RIDGE IN GEORGETOWN,425048,2715 SOUTH ISLAND ROAD,GEORGETOWN,SC,29440,2018-11-17,610,J,1,0,H6ZB11,"> Based on record review and interview, the facility failed to investigate, prevent and/or correct allegations of alleged abuse for 2 of 10 residents sampled for abuse. Resident #8 and #14. The findings included: On 7/11/18 residents #8 and #14 were observed with inappropriate sexual behavior conducted in a resident common area. The residents were separated, and the incident was reported to the Director of Nursing (DON). There was no evidence the facility conducted an investigation or put interventions in place to prevent any further abuse from occurring. During an interview with the DON on 11/16/18 at approximately 1:20 pm. The surveyor requested the facility investigation for the incident dated 7/11/18 involving Resident #8 and #14. The surveyor was informed by the DON that an investigation was not completed. Review of Resident #14's care plan dated 9/26/17 revealed that the resident had inappropriate sexual behaviors, such as exposing him/herself in common areas of the facility, attempting inappropriate behaviors with female residents, inappropriate comments also noted and can be difficult to redirect. Review of Resident #14's medical record revealed a Psychiatric evaluation dated 9/26/17. BIMS (Brief Interview for Mental Status) - 6 (6 of 15). Due to Dementia, s/he is unable to provide reliable review of systems. S/he has behavioral episodes of resistance to care and unwillingness to participate in PT (Physical Therapy) program. Patient also has been observed with sexually inappropriate behaviors and poor boundaries. Has exposed self inappropriately and touched resident's breast. S/He has poor insight and memory regarding behaviors. Review of the facility's policy labeled Abuse Investigation and Reporting reveled All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported.",2020-09-01
406,BLUE RIDGE IN GEORGETOWN,425048,2715 SOUTH ISLAND ROAD,GEORGETOWN,SC,29440,2018-11-17,657,J,1,0,H6ZB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to revise care plans for 2 of 10 residents sampled for abuse. Resident #8 and #14 with sexual behaviors, care plans were not revised following an incident on 7/11/18 of sexual behaviors. The findings included: On 7/11/18 staff members observed sexually inappropriate behavior in a common area between residents #8 and #14. Resident #8 was observed to be holding resident #14's penis. Resident #14 had a history of [REDACTED]. During an interview with the Unit Manager on 11/16/18 at 12:05PM. The Unit Manager stated that Resident #8 initiated the incident on 7/11/18. The Unit Manager stated that Resident #8 likes to touch and rub on people. Review of Resident #8's Care Plan revealed that the Care Plan did not address the resident's need to touch/feel others or the sexual encounter between the Resident #8 and #14. The facility admitted resident #8 on 7/20/17 with [DIAGNOSES REDACTED]. Review of Resident #8's medical record revealed a Significant Change assessment dated [DATE]. The Significant Change Assessment revealed Long and short-term memory impairment. Seldom understood or understands. Never rarely makes decisions. Wanders daily throughout facility. No sexual behaviors were listed for the Significant Change. Review of the Resident #8's Plan of Care revealed care was planned for [MEDICAL CONDITION] drug use: [MEDICATION NAME] for depression, [MEDICATION NAME] for mood disorder and depression, [MEDICATION NAME] for depression and prn [MEDICATION NAME] for anxiety. There was no plan of care for the sexually inappropriate behaviors. The facility admitted resident #14 on 9/11/17 with [DIAGNOSES REDACTED]. Review of Resident #14's Care Plan revealed that the Care Plan addressed sexually inappropriate behaviors; however, the care plan was not revised to speak to reoccurrences of the behaviors. Resident #14 had repeated behaviors of sexually inappropriate behaviors. Review of Resident #14's Plan of Care dated 9/26/17 revealed, Inappropriate sexual behaviors, such as exposing self in common areas of facility, attempting inappropriate behaviors with female residents, inappropriate comments also noted and can be difficult to redirect. The care plan was not revised until 11/3/18.",2020-09-01
407,BLUE RIDGE IN GEORGETOWN,425048,2715 SOUTH ISLAND ROAD,GEORGETOWN,SC,29440,2018-11-17,835,J,1,0,H6ZB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to be administer in a way to prevent abuse, follow abuse policies, investigate, and report allegations of abuse. The findings included: Cross refer to F600 Abuse/Neglect, F610-Investigate/Prevent/Correct alleged violation, F657 Care Plan Timing and Revision, and F865 QAPI. Review of the facility's Abuse Prevention Program revealed As part of the resident abuse prevention, the administration will: 3. Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of [REDACTED]. Identify and assess all possible incidents of abuse; 7. Investigate and report any allegations of abuse within timeframes as required by federal requirements; 9. Establish and implement a QAPI review and analysis of abuse incidents; and implement changes to prevent future occurrences of abuse . Review of the facility's policy labeled Abuse Neglect - Clinical Protocol revealed The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect.",2020-09-01
408,BLUE RIDGE IN GEORGETOWN,425048,2715 SOUTH ISLAND ROAD,GEORGETOWN,SC,29440,2018-11-17,839,E,1,0,H6ZB11,"> Based on review of personnel files and interview, the facility failed to complete licensure checks prior to hire. 4 of 5 new hires reviewed did not have a licensure check done prior to hire. The findings included: Review of personnel files, on 11/4/2018 at 12:24 PM, for 5 new hires since the last Recertification Survey revealed 4 of 5 new hires did not have a licensure check done prior to date of hire. Licensed Practical Nurse (LPN) #2's date of hire was 10/17/18. Review of the personnel file revealed a licensure check was done on 11/4/2018. LPN #3's date of hire was 9/11/2018. Review of the personnel file revealed a licensure check was done on 10/25/2018. Registered Nurse (RN) #1's date of hire was 10/2/2018. Review of the personnel file revealed a licensure check was done on 11/4/2018. RN #2's date of hire was 8/30/2018. Review of the personnel file revealed a licensure check was done on 11/4/2018. During an interview with the Director of Nursing and Regional Human Resources Director on 11/4/2018 at 12:40 PM, the Director of Nursing and Regional Human Resources Director confirmed the licensure checks were not done prior to date of hire. The Regional Human Resources Director stated, we know the process and know licenses have to be checked prior to hire. The Regional Human Resources Director (HR) stated the facility's HR was terminated a couple weeks ago, and the personnel files were very unorganized. Licensure checks were printed today because they could not be located in the files.",2020-09-01
409,BLUE RIDGE IN GEORGETOWN,425048,2715 SOUTH ISLAND ROAD,GEORGETOWN,SC,29440,2018-11-17,865,J,1,0,H6ZB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interviews, the facility failed to maintain a Quality Assurance Program that identified and addressed the facility's problems. The findings included: Cross refer to F600 for incident involving resident #8 and #14. On 7/11/18 Resident #8 and #14 had inappropriate sexual behaviors in a common area. Resident #14 had a history of [REDACTED]. The facility did not investigate the incident nor report the incident to the state agency. Resident #8 and #14's care plans were not revised to address the behaviors of the incident. The facility failed to put a plan into place to prevent incident reoccurrences.",2020-09-01
410,NHC HEALTHCARE -  ANDERSON,425052,1501 EAST GREENVILLE STREET,ANDERSON,SC,29621,2019-03-28,567,C,0,1,KUSC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews and record review, the facility failed to allow residents access to money in personal fund accounts timely for 11 of 11 sampled residents with accounts. Interviews and policy review revealed that residents only had access to $5 cash per day. Findings include: Resident #74 was admitted to the facility on [DATE]. On 3/27/19 at 4:45 PM, a review of Resident #74's Minimum Data Set (MDS) assessment revealed a Brief Mental Status score of 10 indicating moderately impaired cognition. On 03/25/19 at 12:03 PM, an interview was completed with Resident #74. Resident #74 said, They will only give you $5 a day when you go down there (to the front desk). On 03/27/19 at 10:06 AM, an interview was completed with Nurse #120. S/he stated, If they (residents) want money, they go up the front desk. They can get $5 at the time. An interview was completed with Bookkeeper #146 on 03/27/19 at 10:12 AM. Bookkeeper #146 said, They (residents) can get $5 at a time. More than that has to go through the head bookkeeper. If s/he isn't here, the DON (Director of Nurses) has been instructed on how to approve a request for more than $5. An interview was completed with the DON on 03/27/19 at 10:24 AM. The DON said, I'm not aware of any restrictions on what they can get out (of personal fund accounts) as long as they have that much in their accounts. On 03/27/19 at 10:42 AM, an interview was completed with Bookkeeper #2. S/he stated, We give them (residents) up to $5 so they don't have a lot of money in their room. If they want more, we give them a check and usually their family member cashes it for them. We've not had an issue getting in touch with the family, but if they want more cash, then they would come up each day and get $5 each day. When asked how a resident would get $20 in cash, Bookkeeper #2 said that the resident would request $5 each day for 4 days. On 03/27/19 at 2:50 PM, an interview was completed with the Administrator. The Administrator said, Our policy says that we will give a check for anything more than $5. That is more secure than the regulation. The guidance says they have to have access to cash, but the regulation doesn't; and we don't get surveyed on the guidance. The families usually want more money to reimburse them for purchases and they take a check. On 03/27/19, a review of the facility policy titled NHC Bookkeeping Manual, dated 08/07, was reviewed. The policy noted Disbursements by Check. All disbursements from the Patient Trust Fund which exceed $5.00 are made by check. A follow up interview was completed with Resident #74 on 03/27/19 at 4:04 PM. Resident #74 said, They gave me a check once and I gave it back. If they gave me a check, I would have to have my daughter or son-in-law take it to get it cashed. I don't see her/him very much, maybe once a month.",2020-09-01
411,NHC HEALTHCARE -  ANDERSON,425052,1501 EAST GREENVILLE STREET,ANDERSON,SC,29621,2019-03-28,607,D,0,1,KUSC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and observation, the facility failed to investigate and report an allegation of resident to resident abuse. This affected two of 28 sampled residents. Resident #84 poured soda on Resident #130's head on 3/24/19. According to staff interviews multiple staff were aware of the incident on the day that it occurred, the facility failed to thoroughly investigate and report to the State Agency. The findings include: During the initial resident interview on 03/26/19 at 11:33 AM, Resident #84 stated that s/he needed to confess to something s/he did during the previous weekend (3/24/19). Resident #84 stated that while sitting in the day room, the Certified Nursing Assistants (CNAs) were busy helping other residents and Resident #84 was mad that they weren't helping her/his roommate (Resident #130). Resident #130 was trying to pour soda into her/his coffee, and Resident #84 didn't want to see her/his roommate ruin her/his coffee. Resident #84 poured the can of soda over her/his roommate's head. Resident #130 is severely cognitively impaired and unable to be interviewed. Review of Resident #84's clinical record revealed an admission history form dated 11/14/14. The admission history documented Resident #84 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #84's quarterly Minimum Data Set (MDS) assessment, dated 01/28/19, documented that the resident had no memory impairment, brief interview for mental status (BIMs) of 15, and s/he was supervised at a wheelchair level for mobility around the facility. Review of Resident #84's Plan of Care (P[NAME]) for mood, dated 02/08/19 documented an approach that stated, Resident very upset when other residents do not do what (s/he) requests. Redirected and very upset. Continued under the P[NAME] for mood was documented, Patient is moderately impaired with daily decision making. The approach was to encourage interactions with others, assisting others with tasks had always brought (her/him) pleasure. Review of Resident #130's quarterly minimum data set (MDS) assessment, dated 02/18/19, revealed Resident #130 had a BIMS of 04; severe cognitive impairment. Resident #130 was unable to be interviewed. Resident #130 required extensive assistance of two people for all of her/his ADLs. Review of Residents #130's medical record revealed no documentation of the incident on 3/24/19 with Resident #84. On 03/26/18 at 4:08 PM, Registered Nurse (RN) #195 was interviewed. RN #195 was the Unit Supervisor. RN #195 stated that s/he was not there when the incident occurred on 3/24/19. RN #195 stated that last weekend (3/24/19) Resident #84 was helping her/his roommate with a soda and then reported spilling it over her/his head. RN #195 stated that s/he had not done any type of investigation into the incident. On 03/26/18 at 4:45PM, RN #169 was interviewed. RN #169 stated that s/he was the House Supervisor that day (3/24/19). RN #169 stated that at approximately 2:00 PM, RN #169 received a call from the Station 200 nurse (Licensed Practical Nurse #163) requesting her/him to bring over a shower cap because one resident had just poured a can of soda over Resident #130's head. RN #169 stated that s/he only interviewed Resident #84 because Resident #84 stated it was an accident. RN #169 stated that staff had reported to her/him that Resident #84 poured a can over her/his roommate's head. RN #169 stated that s/he did not interview any of the staff to see if anyone was witness to the incident. On 03/26/18 at 5:00 PM, Resident #84 was interviewed by RN #169 and the surveyor. Resident #84 stated that s/he was upset that the staff were not helping her/his roommate, so s/he poured the can of soda over her/his roommate's head. Resident #84 was not able to say why s/he did it. On 03/26/18 at 5:32PM, Resident #84 was interviewed by the Nursing Home Administrator (NHA) and the surveyor. Resident #84 stated that s/he was upset that the staff were not helping her/his roommate, so s/he poured the can of soda over her/his roommate's head. Resident #84 was not able to say why s/he did it. Resident #84 stated that s/he did not want to harm her/his roommate and that s/he felt bad that s/he did it. On 03/27/19 at 9:01 AM, Resident #84's daughter and son-in-law were interviewed. The daughter stated when they arrived at the facility the day of the incident on 3/24/19, s/he was informed by two unnamed CNAs that he/his (mother/father) (Resident #84) had just poured a can of soda over her/his roommate's head. The daughter asked Resident #84 day it happened (3/24/19) why s/he poured the soda over her/his roommate's head. The resident replied s/he wanted one of the CNAs to come help her/his roommate eat. While the family was visiting Resident #84 on 3/24/19, RN #169 came down to find out why s/he had poured a can of soda over her/his roommate's head. The daughter stated her/his (mother/father) changed her/his story while talking to RN #169, saying it was an accident. The family member stated RN #169 indicated this incident was very concerning and that (s/he) was going to have to file a report. On 03/27/19 at 10:13 AM, LPN #163 was interviewed. LPN #163 was the charge nurse on Station 200 at the time of the incident on 3/24/19. LPN #163 stated about 2:00 PM s/he heard Resident #84 yell for someone to bring her paper towels. Resident #84 told LPN #163 that s/he did not want her/his roommate to ruin her/his coffee by pouring soda into it. When Resident #84 tried to assist her/his roommate, the roommate jerked her/his hand back causing the drink to spill. LPN #163 stated that s/he called for the House Supervisor (RN #169) to bring her a dry shower cap and talk to Resident #84. LPN #163 stated that s/he did not document anything in Resident #84's medical record. On 03/27/19 at 11:39 AM, CNA #240 was interviewed. CNA #240 stated that s/he was walking through the station 200-day room on 3/24/19 when Resident #84 was saying something about her/his roommate trying to mix her/his coffee with another drink. S/he stated that Resident #84 seemed confused. CNA #240 sated that s/he continued to walk on once Resident #84 told her/him to go back home. On 03/27/19 at 11:57 AM, CNA #214 was interviewed. CNA #214 stated that s/he was in the station 200-day room, but her/his back was to Resident #84 and her/his roommate. CNA #214 heard the roommate make a startled sound and turned around to see what happened. The roommate's hair was wet and dripping a bit. Resident #84 stated that s/he was trying to stop her/his roommate from pouring the soda into her/his coffee. CNA #214 stated that s/he only attended to the roommate to get her/him cleaned up. On 03/27/19 at 4:59PM, LPN #249 was interviewed. LPN #249 stated that in the shift change report on 3/24/19, LPN #163 stated that there had been an incident where Resident #84 poured a can of soda over her/his roommate's head. LPN #249 stated that when s/he went to give Resident #84 her/his medications on 3/24/19, Resident #84 stated to LPN #249 I guess you heard what I did earlier today. LPN #249 stated that Resident #84 was apologetic. The facility had a policy entitled Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation dated 08/01/01 and revised on 11/28/16. The policy, in part, documented under #3. Training Policy - Policy: The center will train all partners, through orientation, and ongoing in-services, on the prevention, identification, investigation and reporting of abuse, neglect, misappropriation of patient property and exploitation. Documented under #5. Identification Policy - Policy: Any patient event that is reported to any partner by patient, family, other partner or any other person will be considered an allegation of either abuse, neglect, misappropriation of patient property or exploitation if it meets any of the following criteria: 7. Any instances of hitting, slapping, pinching, or kicking or other potentially harmful action. #6. Reporting Policy - Policy: Any partner having either direct or indirect knowledge of any event that might constitute abuse, neglect misappropriation of patient property or exploitation must report the event immediately, no later than two hours if the allegation involves abuse or serious bodily injury, but not to exceed 24 hours. All allegations of possible abuse, neglect, misappropriation of patient property or exploitation will be immediately assessed to determine the appropriate direction of the investigation.",2020-09-01
412,NHC HEALTHCARE -  ANDERSON,425052,1501 EAST GREENVILLE STREET,ANDERSON,SC,29621,2019-03-28,609,D,0,1,KUSC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and observation, the facility failed to report an allegation of resident to resident abuse. This affected two of 28 sampled residents. Resident #84 poured soda on Resident #130's head on 3/24/19. According to staff interviews multiple staff were aware of the incident on the day that it occurred, the facility failed to report this incident to the State Agency. The findings include: During the initial resident interview on 03/26/19 at 11:33 AM, Resident #84 stated that s/he needed to confess to something s/he did during the previous weekend (3/24/19). Resident #84 stated that while sitting in the day room, the Certified Nursing Assistants (CNAs) were busy helping other residents and Resident #84 was mad that they weren't helping her/his roommate (Resident #130). Resident #130 was trying to pour soda into her coffee, and Resident #84 didn't want to see her/his roommate ruin her/his coffee. Resident #84 poured the can of soda over her/his roommate's head. Resident #130 is severely cognitively impaired and unable to be interviewed. Review of Resident #84's clinical record revealed an admission history form dated 11/14/14. The admission history documented Resident #84 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #84's quarterly Minimum Data Set (MDS) assessment, dated 01/28/19, documented that the resident had no memory impairment, brief interview for mental status (BIMs) of 15, and s/he was supervised at a wheelchair level for mobility around the facility. Review of Resident #84's Plan of Care (P[NAME]) for mood, dated 02/08/19 documented an approach that stated, Resident very upset when other residents do not do what (s/he) requests. Redirected and very upset. Continued under the P[NAME] for mood was documented, Patient is moderately impaired with daily decision making. The approach was to encourage interactions with others, assisting others with tasks had always brought (her/him) pleasure. Review of Resident #130's quarterly minimum data set (MDS) assessment, dated 02/18/19, revealed Resident #130 had a BIMS of 04; severe cognitive impairment. Resident #130 was unable to be interviewed. Resident #130 required extensive assistance of two people for all of her/his ADLs. Review of Residents #130's medical record revealed no documentation of the incident on 3/24/19 with Resident #84. On 03/26/18 at 4:08 PM, Registered Nurse (RN) #195 was interviewed. RN #195 was the Unit Supervisor. RN #195 stated that s/he was not there when the incident occurred on 3/24/19. RN #195 stated that last weekend (3/24/19) Resident #84 was helping her/his roommate with a soda and then reported spilling it over her/his head. RN #195 stated that s/he had not done any type of investigation into the incident. On 03/26/18 at 4:45PM, RN #169 was interviewed. RN #169 stated that s/he was the House Supervisor that day (3/24/19). RN #169 stated that at approximately 2:00 PM, RN #169 received a call from the Station 200 nurse (Licensed Practical Nurse #163) requesting her/him to bring over a shower cap because one resident had just poured a can of soda over Resident #130's head. RN #169 stated that s/he only interviewed Resident #84 because Resident #84 stated it was an accident. RN #169 stated that staff had reported to her/him that Resident #84 poured a can over her/his roommate's head. RN #169 stated that s/he did not interview any of the staff to see if anyone was witness to the incident. Review of the facility Abuse Complaint Reporting Guidelines revealed 4. Obtain written statements from the employee and any witnesses. On 03/26/18 at 5:00 PM, Resident #84 was interviewed by RN #169 and the surveyor. Resident #84 stated that s/he was upset that the staff were not helping her/his roommate, so s/he poured the can of soda over her/his roommate's head. Resident #84 was not able to say why s/he did it. On 03/26/18 at 5:32PM, Resident #84 was interviewed by the Nursing Home Administrator (NHA) and the surveyor. Resident #84 stated that s/he was upset that the staff were not helping her/his roommate, so s/he poured the can of soda over her/his roommate's head. Resident #84 was not able to say why s/he did it. Resident #84 stated that s/he did not want to harm her/his roommate and that s/he felt bad that s/he did it. On 03/27/19 at 9:01 AM, Resident #84's daughter and son-in-law were interviewed. The daughter stated when they arrived at the facility the day of the incident on 3/24/19, s/he was informed by two unnamed CNAs that he/his (mother/father) (Resident #84) had just poured a can of soda over her/his roommate's head. The daughter asked Resident #84 day it happened (3/24/19) why s/he poured the soda over her/his roommate's head. The resident replied s/he wanted one of the CNAs to come help her/his roommate eat. While the family was visiting Resident #84 on 3/24/19, RN #169 came down to find out why s/he had poured a can of soda over her/his roommate's head. The daughter stated her/his (mother/father) changed her/his story while talking to RN #169, saying it was an accident. The family member stated RN #169 indicated this incident was very concerning and that (s/he) was going to have to file a report. On 03/27/19 at 10:13 AM, LPN #163 was interviewed. LPN #163 was the charge nurse on Station 200 at the time of the incident on 3/24/19. LPN #163 stated about 2:00 PM s/he heard Resident #84 yell for someone to bring her paper towels. Resident #84 told LPN #163 that s/he did not want her/his roommate to ruin her/his coffee by pouring soda into it. When Resident #84 tried to assist her/his roommate, the roommate jerked her/his hand back causing the drink to spill. LPN #163 stated that s/he called for the House Supervisor (RN #169) to bring her a dry shower cap and talk to Resident #84. LPN #163 stated that s/he did not document anything in Resident #84's medical record. On 03/27/19 at 11:39 AM, CNA #240 was interviewed. CNA #240 stated that s/he was walking through the station 200-day room on 3/24/19 when Resident #84 was saying something about her/his roommate trying to mix her/his coffee with another drink. S/he stated that Resident #84 seemed confused. CNA #240 sated that s/he continued to walk on once Resident #84 told her/him to go back home. On 03/27/19 at 11:57 AM, CNA #214 was interviewed. CNA #214 stated that s/he was in the station 200-day room, but her/his back was to Resident #84 and her/his roommate. CNA #214 heard the roommate make a startled sound and turned around to see what happened. The roommate's hair was wet and dripping a bit. Resident #84 stated that s/he was trying to stop her/his roommate from pouring the soda into her/his coffee. CNA #214 stated that s/he only attended to the roommate to get her/him cleaned up. On 03/27/19 at 4:59PM, LPN #249 was interviewed. LPN #249 stated that in the shift change report on 3/24/19, LPN #163 stated that there had been an incident where Resident #84 poured a can of soda over her/his roommate's head. LPN #249 stated that when s/he went to give Resident #84 her/his medications on 3/24/19, Resident #84 stated to LPN #249 I guess you heard what I did earlier today. LPN #249 stated that Resident #84 was apologetic. Review of the facility policy Reporting Policy revealed Any partner having either direct or indirect knowledge of any event that might constitute abuse, neglect, misappropriation of patient property or exploitation must report the event immediately, no later than two our if the allegation involves abuse or serious bodily injury, but no to exceed 24 hours. All allegations of possible abuse, neglect, misappropriation of patient property or exploitation will e immediately assessed to determine the appropriate direction of the investigation . under the Procedure section it revealed All alleged violations and all substantiated incidents will be reported immediately to the Administrator or her/his designated representative and to other officials in accordance with State and Federal law (including to the State survey and certification agency).",2020-09-01
413,NHC HEALTHCARE -  ANDERSON,425052,1501 EAST GREENVILLE STREET,ANDERSON,SC,29621,2019-03-28,610,D,0,1,KUSC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and observation, the facility failed to investigate an allegation of resident to resident abuse. This affected two of 28 sampled residents. Resident #84 poured soda on Resident #130's head on 3/24/19. According to staff interviews multiple staff were aware of the incident on the day that it occurred, the facility failed to thoroughly investigate this incident. The findings include: During the initial resident interview on 03/26/19 at 11:33 AM, Resident #84 stated that s/he needed to confess to something s/he did during the previous weekend (3/24/19). Resident #84 stated that while sitting in the day room, the Certified Nursing Assistants (CNAs) were busy helping other residents and Resident #84 was mad that they weren't helping her/his roommate (Resident #130). Resident #130 was trying to pour soda into her coffee, and Resident #84 didn't want to see her/his roommate ruin her/his coffee. Resident #84 poured the can of soda over her/his roommate's head. Resident #130 is severely cognitively impaired and unable to be interviewed. Review of Resident #84's clinical record revealed an admission history form dated 11/14/14. The admission history documented Resident #84 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #84's quarterly Minimum Data Set (MDS) assessment, dated 01/28/19, documented that the resident had no memory impairment, brief interview for mental status (BIMs) of 15, and s/he was supervised at a wheelchair level for mobility around the facility. Review of Resident #84's Plan of Care (P[NAME]) for mood, dated 02/08/19 documented an approach that stated, Resident very upset when other residents do not do what (s/he) requests. Redirected and very upset. Continued under the P[NAME] for mood was documented, Patient is moderately impaired with daily decision making. The approach was to encourage interactions with others, assisting others with tasks had always brought (her/him) pleasure. Review of Resident #84's Social Services note dated 1/28/19 revealed Pt. (patient) also cont. (continues) with intrusive behaviors towards other residents care Redirection works at times, some times pt. becomes angry. Review of Resident #130's quarterly minimum data set (MDS) assessment, dated 02/18/19, revealed Resident #130 had a BIMS of 04; severe cognitive impairment. Resident #130 was unable to be interviewed. Resident #130 required extensive assistance of two people for all of her/his ADLs. Review of Residents #130's medical record revealed no documentation of the incident on 3/24/19 with Resident #84. On 03/26/18 at 4:08 PM, Registered Nurse (RN) #195 was interviewed. RN #195 was the Unit Supervisor. RN #195 stated that s/he was not there when the incident occurred on 3/24/19. RN #195 stated that last weekend (3/24/19) Resident #84 was helping her/his roommate with a soda and then reported spilling it over her/his head. RN #195 stated that s/he had not done any type of investigation into the incident. On 03/26/18 at 4:45PM, RN #169 was interviewed. RN #169 stated that s/he was the House Supervisor that day (3/24/19). RN #169 stated that at approximately 2:00 PM, RN #169 received a call from the Station 200 nurse (Licensed Practical Nurse #163) requesting her/him to bring over a shower cap because one resident had just poured a can of soda over Resident #130's head. RN #169 stated that s/he only interviewed Resident #84 because Resident #84 stated it was an accident. RN #169 stated that staff had reported to her/him that Resident #84 poured a can over her/his roommate's head. RN #169 stated that s/he did not interview any of the staff to see if anyone was witness to the incident. On 03/26/18 at 5:00 PM, Resident #84 was interviewed by RN #169 and the surveyor. Resident #84 stated that s/he was upset that the staff were not helping her/his roommate, so s/he poured the can of soda over her/his roommate's head. Resident #84 was not able to say why s/he did it. On 03/26/18 at 5:32PM, Resident #84 was interviewed by the Nursing Home Administrator (NHA) and the surveyor. Resident #84 stated that s/he was upset that the staff were not helping her/his roommate, so s/he poured the can of soda over her/his roommate's head. Resident #84 was not able to say why s/he did it. Resident #84 stated that s/he did not want to harm her/his roommate and that s/he felt bad that s/he did it. On 03/27/19 at 9:01 AM, Resident #84's daughter and son-in-law were interviewed. The daughter stated when they arrived at the facility the day of the incident on 3/24/19, s/he was informed by two unnamed CNAs that he/his (mother/father) (Resident #84) had just poured a can of soda over her/his roommate's head. The daughter asked Resident #84 day it happened (3/24/19) why s/he poured the soda over her/his roommate's head. The resident replied s/he wanted one of the CNAs to come help her/his roommate eat. While the family was visiting Resident #84 on 3/24/19, RN #169 came down to find out why s/he had poured a can of soda over her/his roommate's head. The daughter stated her/his (mother/father) changed her/his story while talking to RN #169, saying it was an accident. The family member stated RN #169 indicated this incident was very concerning and that (s/he) was going to have to file a report. On 03/27/19 at 10:13 AM, LPN #163 was interviewed. LPN #163 was the charge nurse on Station 200 at the time of the incident on 3/24/19. LPN #163 stated about 2:00 PM s/he heard Resident #84 yell for someone to bring her paper towels. Resident #84 told LPN #163 that s/he did not want her/his roommate to ruin her/his coffee by pouring soda into it. When Resident #84 tried to assist her/his roommate, the roommate jerked her/his hand back causing the drink to spill. LPN #163 stated that s/he called for the House Supervisor (RN #169) to bring her a dry shower cap and talk to Resident #84. LPN #163 stated that s/he did not document anything in Resident #84's medical record. On 03/27/19 at 11:39 AM, CNA #240 was interviewed. CNA #240 stated that s/he was walking through the station 200-day room on 3/24/19 when Resident #84 was saying something about her/his roommate trying to mix her/his coffee with another drink. S/he stated that Resident #84 seemed confused. CNA #240 sated that s/he continued to walk on once Resident #84 told her/him to go back home. On 03/27/19 at 11:57 AM, CNA #214 was interviewed. CNA #214 stated that s/he was in the station 200-day room, but her/his back was to Resident #84 and her/his roommate. CNA #214 heard the roommate make a startled sound and turned around to see what happened. The roommate's hair was wet and dripping a bit. Resident #84 stated that s/he was trying to stop her/his roommate from pouring the soda into her/his coffee. CNA #214 stated that s/he only attended to the roommate to get her/him cleaned up. On 03/27/19 at 4:59PM, LPN #249 was interviewed. LPN #249 stated that in the shift change report on 3/24/19, LPN #163 stated that there had been an incident where Resident #84 poured a can of soda over her/his roommate's head. LPN #249 stated that when s/he went to give Resident #84 her/his medications on 3/24/19, Resident #84 stated to LPN #249 I guess you heard what I did earlier today. LPN #249 stated that Resident #84 was apologetic. Review of the facility policy Internal Investigation Policy revealed All events reported as possible abuse, neglect, or misappropriation of patient property will be investigated to determine whether the alleged abuse, neglect, misappropriation of patient property or exploitation did or did not take place. The Administrator or Director of Nurses will determine the direction of the investigation once notified of alleged incident. Under the Procedure section it revealed a. The investigation is conducted immediately under the following circumstances: i. When it is identified that an alleged incident may have occurred. ii. As soon as any partner has knowledge and reports an alleged event. **When there is a question as to whether to conduct an investigation, it is best to do so.",2020-09-01
414,NHC HEALTHCARE -  ANDERSON,425052,1501 EAST GREENVILLE STREET,ANDERSON,SC,29621,2019-03-28,880,D,0,1,KUSC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to ensure nebulizer mask and tubing was changed timely. This affected one out of four sampled residents. Resident #207 had been using the same nebulizer mask and tubing for approximately 16 days, two times per day. The findings include: Review of Resident #207's clinical record revealed an admission history form dated 03/01/19. The admission history documented Resident #207 was admitted to the facility with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment, dated 03/08/19, documented that Resident #207 was on oxygen therapy for [MEDICAL CONDITION] and [MEDICAL CONDITION]. The baseline Plan of Care (P[NAME]) and the physician's orders [REDACTED].#207 was on [MEDICATION NAME] 0.83mg/ml, give contents of one nebule via hand held nebulizer two times per day. The facility's policy on oxygen stated, Per NHC Policy: All oxygen equipment (this includes nasal cannulas, masks, tubing) and suction equipment must be changed weekly, dated and a set up bag provided for each item Nebulizer tubing to be changed every 3 days. During the initial interview on 03/26/19 at 11:27 AM, Resident #207 was observed having her/his morning nebulizer treatment. The mask and the tubing were dated 03/10/19. On 03/26/19 at 4:15 PM, Registered Nurse (RN) #198 was interviewed. RN #198 stated that oxygen tubing should be changed weekly, and nebulizer masks and tubing should be changed every three days. RN #198 verified that the nebulizer mask and tubing for Resident #207 was dated 03/10/19 and should have been changed 13 days prior and every three days after that date. RN #198 stated that the orders for Resident #207's nebulizer treatments were for twice a day. RN #195 was interviewed on 03/26/19 at 4:27 PM. RN #195 stated that this was the responsibility of the overnight shift to change out the nebulizer mask and tubing and that s/he would have to find out how it got missed.",2020-09-01
415,NHC HEALTHCARE -  ANDERSON,425052,1501 EAST GREENVILLE STREET,ANDERSON,SC,29621,2017-11-09,281,D,1,0,8NXL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to adequately assess Resident #3 for signs and symptoms of infection and other possible complications resulting from the continuing use of an indwelling catheter, 1 of 3 residents reviewed with a catheter. The findings included: The facility admitted Resident #3 with [DIAGNOSES REDACTED]. On 11/08/17 at 2:55 PM, review of the Daily Skilled Nurse's Note dated 02/13/17 through 03/09/17 revealed on 02/12/17 the resident was noted to have hematuria in the urine. On 02/14/17, the urologist visited the resident at the nursing home at 1:41 PM and a new order was received to change the Foley catheter on Monday (February 20, 2017). On 02/16/17, the resident was again noted to have hematuria. At 12:00 PM on 02/20/17, the nurse documented that the daughter reported no urine in the Foley catheter collection bag. The nurse also documented that the resident reported no urinary output since the catheter was changed at 5:00 AM and that the abdomen was slightly distended. There was no nurse's notes regarding the change of the catheter at 5:00 AM. Further review revealed a note timed at 1:30 PM on 02/20/17 that the nurse checked the catheter placement, deflated the bulb, repositioned the catheter and re-inflated the bulb and obtained [AGE]0 plus cc (cubic centimeters) of urine drained to the collection bag. There was no documentation of abnormal characteristics of the urine at that time. A late entry on 02/21/17 for 3:00 PM on 02/20/17 stated [AGE]0 ml (milliliters) of yellow urine (with) small amount of blood noted; Res(ident) stated My stomach feels relieved will monitor. At 10:00 PM on 02/20/17, the resident c/o (complained of) dysuria (and) thick yellow pus noted inside brief (and) on tip of penis. Will monitor. At 4:00 AM on 02/21/17, Resident #3 again c/o dysuria, hematuria noted. in the collection bag and stated will monitor. There was no documentation the physician was notified of the dysuria or pus noted at 10:00 PM or the hematuria at 4:00 AM. At 7:20 AM on 02/21/17, the resident's daughter reported that the resident was having increased abdominal pain. The nurse documented the abdomen was tender and distended, sluggish bowel sounds present in all 4 quadrants, increased pain to the left lower quadrant when palpated and that the catheter was intact and draining and noted a small amount of yellow urine in the collection bag with a small blood clot present. The resident stated It hurts all over down to my private area. Vital signs were taken at that time and the daughter requested the resident be sent to the emergency room . The physician was notified at that time and an order received to send the resident to the emergency room for evaluation per the daughter s request. Review of the hospital history and physical dated 2/21/17 revealed the patient had Foley catheter adjusted, after which s/he drained 1500 cc of urine in the ER. According to professional standards set by (Potter, Perry, Stockert, & Hall, 2013) Report any extreme increase or decrease in urine volume. An hourly output of less than 30ml for more than 2 consecutive hours is cause for concern. Document and report any abnormal color or sediment, especially if the cause is unknown. (p.1052). Review of the Medication, Treatment and Task Administration Record revealed a Pain Assessment that indicated the resident had no pain on the 11:00 PM - 7:00 AM shift on 02/20-02/21/17. Further review revealed the resident was medicated with [MED] for c/o gen(eralized) pain at 1:30 AM on 02/21/17. In addition, review of the record indicated a pulse and respiratory rate were documented before and after a nebulizer treatment at 2:00 AM but no temperature or blood pressure were documented. Review of the Hospital History and Physical indicated the resident had Acute [MEDICATION NAME] with Hematuria, Urinary Tract Infection due to Chronic Foley Catheter, [MEDICAL CONDITION] with Benign [MED]e Hypertrophy, and Abdominal Pain with Constipation. During an interview on 11/08/17 at 6:20 PM the Director of Nursing (DON) confirmed the physician should have been notified of pus in urine and hematuria. The DON stated that the resident had a TURP (Transurethral Resection of the [MED]e) but when told the TURP was done when the resident went to the hospital following the episodes, the DON stated that's not good and that I wish I had known about that. During an interview on 11/09/17 at 11:40 AM, the attending physician stated that he/she did not recall when he/she was notified by the Nurse Practitioner of the lack of urine output on 2/20/17. The physician also stated that the nurses were familiar with catheter care and know to monitor for signs and/or symptoms systemic infection. When asked if the nurse would be expected to notify the physician of hematuria from a resident with a Foley, the doctor stated it could wait until the next morning and that was within the standard of care. The physician further stated that he/she would have seen the resident the next day ordered a urinalysis and culture and sensitivity at that time if the resident had still been at the facility. During an interview on 11/09/17 at approximately 12:45 PM, RN (Registered Nurse) #1 stated systemic signs and symptoms of infection would be identified by looking at the resident for changes, listlessness, pallor, changes in mental status, pain, vital signs, or if they've voided. For a resident with an indwelling catheter, the resident would be monitored for output, monitor the insertion site for drainage/ redness, characteristics of the urine for clarity/ blood/ sediment, amount. The nurse confirmed blood in the urine and pus would be a symptom of infection and stated that blood could also be related to trauma and that would be a symptom unless it was already in the urethra. The RN also confirmed the presence of pus usually means infection. RN #1 also stated s/he would have notified the physician in the morning because the on-call doctors typically would not treat for 1 symptom and would have instructed the nurse to monitor the resident. The nurse also stated because the resident was being followed by a urologist, the on-call physician usually would wait until the specialist could be notified. The RN confirmed that the documentation indicated the resident had dysuria, pain, hematuria, and pus and that s/he did not take full vital signs during the episodes.",2020-09-01
416,NHC HEALTHCARE -  ANDERSON,425052,1501 EAST GREENVILLE STREET,ANDERSON,SC,29621,2017-11-09,315,D,1,0,8NXL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to adequately assess Resident #3 for signs and symptoms of infection and other possible complications resulting from the continuing use of an indwelling catheter, 1 of 3 residents reviewed with a catheter. The findings included: The facility admitted Resident #3 with [DIAGNOSES REDACTED]. On 11/08/17 at 2:55 PM, review of the Daily Skilled Nurse's Note dated 02/13/17 through 03/09/17 revealed on 02/12/17 the resident was noted to have hematuria in the urine. On 02/14/17, the urologist visited the resident at the nursing home at 1:41 PM and a new order was received to change the Foley catheter on Monday (February 20, 2017). On 02/16/17, the resident was again noted to have hematuria. At 12:00 PM on 02/20/17, the nurse documented that the daughter reported no urine in the Foley catheter collection bag. The nurse also documented that the resident reported no urinary output since the catheter was changed at 5:00 AM and that the abdomen was slightly distended. There was no nurse's notes regarding the change of the catheter at 5:00 AM. Further review revealed a note timed at 1:30 PM on 02/20/17 that the nurse checked the catheter placement, deflated the bulb, repositioned the catheter and re-inflated the bulb and obtained [AGE]0 plus cc (cubic centimeters) of urine drained to the collection bag. There was no documentation of abnormal characteristics of the urine at that time. A late entry on 02/21/17 for 3:00 PM on 02/20/17 stated [AGE]0 ml (milliliters) of yellow urine (with) small amount of blood noted; Res(ident) stated My stomach feels relieved will monitor. At 10:00 PM on 02/20/17, the resident c/o (complained of) dysuria (and) thick yellow pus noted inside brief (and) on tip of penis. Will monitor. At 4:00 AM on 02/21/17, Resident #3 again c/o dysuria, hematuria noted. in the collection bag and stated will monitor. There was no documentation the physician was notified of the dysuria or pus noted at 10:00 PM or the hematuria at 4:00 AM. At 7:20 AM on 02/21/17, the resident's daughter reported that the resident was having increased abdominal pain. The nurse documented the abdomen was tender and distended, sluggish bowel sounds present in all 4 quadrants, increased pain to the left lower quadrant when palpated and that the catheter was intact and draining and noted a small amount of yellow urine in the collection bag with a small blood clot present. The resident stated It hurts all over down to my private area. Vital signs were taken at that time and the daughter requested the resident be sent to the emergency room . The physician was notified at that time and an order received to send the resident to the emergency room for evaluation per the daughter s request. Review of the hospital history and physical dated 2/21/17 revealed the patient had Foley catheter adjusted, after which s/he drained 1500 cc of urine in the ER. Review of the Medication, Treatment and Task Administration Record revealed a Pain Assessment that indicated the resident had no pain on the 11:00 PM - 7:00 AM shift on 02/20-02/21/17. Further review revealed the resident was medicated with [MED] for c/o gen(eralized) pain at 1:30 AM on 02/21/17. In addition, review of the record indicated a pulse and respiratory rate were documented before and after a nebulizer treatment at 2:00 AM but no temperature or blood pressure were documented. Review of the Hospital History and Physical indicated the resident had Acute [MEDICATION NAME] with Hematuria, Urinary Tract Infection due to Chronic Foley Catheter, [MEDICAL CONDITION] with Benign [MED]e Hypertrophy, and Abdominal Pain with Constipation. During an interview on 11/08/17 at 6:20 PM the Director of Nursing (DON) confirmed the physician should have been notified of pus in urine and hematuria. The DON stated that the resident had a TURP (Transurethral Resection of the [MED]e) but when told the TURP was done when the resident went to the hospital following the episodes, the DON stated that's not good and that I wish I had known about that. During an interview on 11/09/17 at 11:40 AM, the attending physician stated that he/she did not recall when he/she was notified by the Nurse Practitioner of the lack of urine output on 2/20/17. The physician also stated that the nurses were familiar with catheter care and know to monitor for signs and/or symptoms systemic infection. When asked if the nurse would be expected to notify the physician of hematuria from a resident with a Foley, the doctor stated it could wait until the next morning and that was within the standard of care. The physician further stated that he/she would have seen the resident the next day ordered a urinalysis and culture and sensitivity at that time if the resident had still been at the facility. During an interview on 11/09/17 at approximately 12:45 PM, RN (Registered Nurse) #1 stated systemic signs and symptoms of infection would be identified by looking at the resident for changes, listlessness, pallor, changes in mental status, pain, vital signs, or if they've voided. For a resident with an indwelling catheter, the resident would be monitored for output, monitor the insertion site for drainage/ redness, characteristics of the urine for clarity/ blood/ sediment, amount. The nurse confirmed blood in the urine and pus would be a symptom of infection and stated that blood could also be related to trauma and that would be a symptom unless it was already in the urethra. The RN also confirmed the presence of pus usually means infection. RN #1 also stated s/he would have notified the physician in the morning because the on-call doctors typically would not treat for 1 symptom and would have instructed the nurse to monitor the resident. The nurse also stated because the resident was being followed by a urologist, the on-call physician usually would wait until the specialist could be notified. The RN confirmed that the documentation indicated the resident had dysuria, pain, hematuria, and pus and that s/he did not take full vital signs during the episodes.",2020-09-01
417,PRUITTHEALTH-WALTERBORO,425053,401 WITSELL STREET,WALTERBORO,SC,29488,2019-01-11,550,D,1,1,BXNI11,"> Based on observation, interview, and review of the, Resident's Bill of Right's, the facility failed to ensure each resident's dignity and respect related to knocking on room doors prior to entering the room and or knocking on resident room doors and not waiting for permission to enter on Hall 2 for 1 of 4 halls observed during dining observations. The findings included: An observation on 1/8/2019 at approximately 12:22 PM during the lunch meal service on Hall 2 revealed staff entering rooms with meal trays without first knocking and/or knocking on resident room doors and not waiting for permission to enter. A second observation on 1/10/2019 at approximately 12:20 PM, during the lunch meal service on Hall 2, revealed staff continuously entering rooms without first knocking or knocking on resident room doors and entering without waiting for permission to enter. An interview on 1/10/2019 at approximately 12:45 PM with Certified Nursing Assistant #1 confirmed staff was entering residents' rooms with meal trays and not first knocking or knocking and not waiting for permission to enter. Review on 1/10/2018 at approximately 1:40 PM of the facility's, Resident's Bill of Rights, under Personal Treatment, states residents have a right to Be treated with respect and dignity.",2020-09-01
418,PRUITTHEALTH-WALTERBORO,425053,401 WITSELL STREET,WALTERBORO,SC,29488,2019-01-11,561,D,1,1,BXNI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview, and review of the facility form titled, Influenza (Flu) Vaccine Consent/Refusal Form, the facility failed to ensure Resident #110 was afforded the right to make a choice related to receiving or refusing the influenza vaccine for 1 of 5 residents reviewed for the flu or pneumonia vaccine. The findings included: The facility admitted Resident #110 with [DIAGNOSES REDACTED]. Review on 1/10/2019 at approximately 8:10 AM of the medical record for Resident #110 revealed a form titled, Influenza (Flu) Vaccine Consent/Refusal Form, which indicated Resident #110 did not sign to give consent to receive or refuse the flu vaccine. Resident #110 was given the flu vaccine. Further review on 1/10/2019 at approximately 8:15 PM of the medical record for Resident #110 revealed a second form titled, Authorization of Do Not Resuscitate Order With Decision-Making Capacity, signed by the resident that indicated Resident #110 was able to make his/her own health care decisions. An interview on 1/10/2019 at approximately 8:25 AM with the Administrator confirmed Resident #110 was not afforded the right to make his/her own decision to receive or refuse the influenza vaccine based on the documentation in the medical record. The Administrator then went to Resident #110's room and obtained consent to receive the flu vaccine that was administered in (MONTH) (YEAR). Review on 1/10/2019 at approximately 8:30 AM of the facility's form titled, Influenza (Flu) Vaccine Consent/Refusal Form, dated 10/5/2018 for Resident #110 which states under Policy: It is the policy to this facility that an annual Influenza (Flu) vaccine be given to each patient/resident who resides in this healthcare center unless contraindicated by the physician or refused by the patient/resident or family, and depending on the availability of the vaccine. Permission to receive the vaccine will be obtained on admission, annually, with any significant changes, or as ordered by the physician, patient/resident or family.",2020-09-01
419,PRUITTHEALTH-WALTERBORO,425053,401 WITSELL STREET,WALTERBORO,SC,29488,2019-01-11,600,D,1,1,BXNI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview, and review of the facility's policy entitled, Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, the facility failed to ensure residents were free from abuse for 1 of 1 resident reviewed for verbal abuse. The facility failed to ensure that Resident #19 was free from verbal abuse. The findings included: The facility admitted Resident #19 on 4/21/16 with [DIAGNOSES REDACTED]. Review of the medical record revealed Resident #19 had a Brief Interview for Mental Status (BIMS) score of 3 which indicated severely impaired cognitive skills for daily decision-making. Further record review revealed resident #19's care plan indicated the resident had episodes of refusing assistance and yelling at staff. Interventions were in place to address this care area. An Initial 2/24-Hour Report dated 1/1/18 and subsequent Five-Day Follow-Up Report concerning Resident #19 were reviewed during the recertification survey. Both reports were submitted to the State Agency with an allegation of verbal abuse concerning Certified Nurses Aide (CNA) #2 dated 1/1/19. Review of the Nurses Notes dated 1/1/19 indicated, CNA assisting resident to hall in w/c (wheelchair). Resident cursing, yelling turning around in w/c to look @ CNA, when CNA stopped w/c, resident slid to floor on buttocks. Body Audit completed (with) (no) injuries noted. Resident assisted back to chair. Further documentation indicated Resident #19 had x-rays with no injury noted. Review of the Five-Day Follow-Up Report indicated that on 1/1/19 at approximately 12:00 AM, CNA #2 spoke to Resident #19 in a derogatory manner (i.e., told the resident to shut up). The report further indicated that CNA #2 was terminated as a result of the facility's investigation and abuse/neglect inservice education was provided to staff. Review of the facility-obtained staff statements revealed CNA #2 indicted he/she told Resident #19 to shut up while pushing the resident in his/her wheelchair. The statement indicated that Resident #19 was cursing at the staff member at the time. During a telephone interview on 1/11/19 at approximately 4:30 PM, CNA #2 confirmed that he/she told Resident #19 to shut up. The facility policy entitled, Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, indicates, It is the policy of PruittHealth and its affiliated entities .to actively preserve each patient's right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, exploitation, mistreatment, and misappropriation of patient property . Under the section entitled Definitions, Verbal Abuse is defined as, Any use of oral, written or gestured language that includes disparaging and derogatory terms to residents or their families, or within their hearing distance, to describe residents regardless of age, ability to comprehend, or disability.",2020-09-01
420,PRUITTHEALTH-WALTERBORO,425053,401 WITSELL STREET,WALTERBORO,SC,29488,2019-01-11,602,D,1,1,BXNI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, and interview, the facility failed to protect Resident #266 from misappropriation of funds for 1 of 2 sampled residents reviewed for abuse. The findings included: The facility admitted Resident #266 with [DIAGNOSES REDACTED]. Record review on 01/11/19 at approximately 2:19 PM revealed a Skilled Daily Nurses Noted dated 11/21/18 stating, Resident went out of facility and came back with $460 worth twenties. Resident gave me the envelope and watched me count it and place into the narcotic box. Resident was told that it will be locked into cart. Business office was closed and no further issues at this time. The nursing note was signed by Licensed Practical Nurse (LPN) #4. Review of the facility investigative file on 01/11/19 at approximately 2:19 PM related to Resident #266's money revealed that the money could not be located when the resident asked for it on 11/29/18. In a subsequent written statement, LPN #4 stated that the money was received at 3:30 PM 11/21/18. Further review of the investigative file revealed staffing sheets showing LPN #4 as the assigned nurse for the medication cart on Resident #266's unit from 7 AM to 7 PM on 11/21/18, followed by LPN #3 from 7 PM to 11 PM, then LPN #2 from 11 PM to 7 AM with LPN #4 returning at 7 AM on 11/22/18. In written statements, both LPN #2 and LPN #3, stated they did not see nor were told about any money belonging to Resident #266 being in the narcotic box of the medication cart. In an interview on 01/11/19 at approximately 4:30 PM, the facility Administrator confirmed there was no policy or procedure that calls for storing money belonging to residents in the narcotics box. In a subsequent interview, the Business Manager confirmed that Resident #266 did not have a Personal Funds Account. The Business Manager also confirmed that the Business Office was open on 11/21/18 at 3:30 PM and could have taken the money from LPN #4. Further review of the facility investigative file revealed evidence from the bank that the funds were reimbursed to Resident #266 prior to discharge. In addition, staff was inserviced on proper procedures for securing residents' money with the business office, including after hours procedures.",2020-09-01
421,PRUITTHEALTH-WALTERBORO,425053,401 WITSELL STREET,WALTERBORO,SC,29488,2019-01-11,607,D,1,1,BXNI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, and interview, the facility failed to implement its abuse policy to protect Residents #19 and #266 for 2 of 2 sampled residents reviewed for Abuse. The findings included: The facility admitted Resident #266 with [DIAGNOSES REDACTED]. Record review on 01/11/19 at approximately 2:19 PM revealed a Skilled Daily Nurses Noted dated 11/21/18 stating, Resident went out of facility and came back with $460 worth twenties. Resident gave me the envelope and watched me count it and place into the narcotic box. Resident was told that it will be locked into cart. Business office was closed and no further issues at this time. The nursing note was signed by Licensed Practical Nurse (LPN) #4. Review of the facility investigative file on 01/11/19 at approximately 2:19 PM related to Resident #266's money revealed that the money could not be located when the resident asked for it on 11/29/18. In a subsequent written statement, LPN #4 stated that the money was received at 3:30 PM 11/21/18. Further review of the investigative file revealed staffing sheets showing LPN #4 as the assigned nurse for the medication cart on Resident #266's unit from 7 AM to 7 PM on 11/21/18, followed by LPN #3 from 7 PM to 11 PM, then LPN #2 from 11 PM to 7 AM with LPN #4 returning at 7 AM on 11/22/18. In written statements, both LPN #2 and LPN #3, stated they did not see nor were told about any money belonging to Resident #266 being in the narcotic box of the medication cart. In an interview on 01/11/19 at approximately 4:30 PM, the facility Administrator confirmed there was no policy or procedure that calls for storing money belonging to residents in the narcotics box. In a subsequent interview, the Business Manager confirmed that Resident #266 did not have a Personal Funds Account. The Business Manager also confirmed that the Business Office was open on 11/21/18 at 3:30 PM and could have taken the money from LPN #4. Further review of the facility investigative file revealed evidence from the bank that the funds were reimbursed to Resident #266 prior to discharge. In addition, staff was inserviced on proper procedures for securing residents' money with the business office, including after hours procedures. The facility admitted Resident #19 on 4/21/16 with [DIAGNOSES REDACTED]. Review of the medical record revealed Resident #19 had a Brief Interview for Mental Status (BIMS) score of 3 which indicated severely impaired cognitive skills for daily decision-making. An Initial 2/24-Hour Report dated 1/1/19 and subsequent Five-Day Follow-Up Report concerning Resident #19 were reviewed during the recertification survey. Both reports were submitted to the State Agency with an allegation of verbal abuse concerning Certified Nurses Aide (CNA) #2 dated 1/1/19. Review of the Five-Day Follow-Up Report indicated that on 1/1/19 at approximately 12:00 AM, CNA #2 spoke to Resident #19 in a derogatory manner (i.e., told the resident to shut up). The report further indicated that CNA #2 was terminated as a result of the facility's investigation and abuse/neglect inservice education was provided to staff. Review of the facility-obtained staff statements revealed CNA #2 indicted he/she told Resident #19 to shut up while pushing the resident in his/her wheelchair. The statement indicated that Resident #19 was cursing at the staff member at the time. During a telephone interview on 1/11/19 at approximately 4:30 PM, CNA #2 confirmed that he/she told Resident #19 to shut up. The facility policy entitled, Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, indicates, It is the policy of PruittHealth and its affiliated entities .to actively preserve each patient's right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, exploitation, mistreatment, and misappropriation of patient property . Under the section entitled Definitions, verbal abuse is defined as, Any use of oral, written or gestured language that includes disparaging and derogatory terms to residents or their families, or within their hearing distance, to describe residents regardless of age, ability to comprehend, or disability.",2020-09-01
422,PRUITTHEALTH-WALTERBORO,425053,401 WITSELL STREET,WALTERBORO,SC,29488,2019-01-11,623,D,1,1,BXNI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to ensure Resident #117 and his/her representative received in writing and in a language they could understand the reason for transfer to the hospital for 1 of 4 residents reviewed for hospitalization . The facility further failed to ensure the Ombudsman received the same notification for Resident #117 and Resident #95 for 2 of 4 residents reviewed for hospitalization . The findings included: The facility admitted Resident #117 with [DIAGNOSES REDACTED]. Review on 1/11/2019 at approximately 2:36 PM of the medical record for Resident #117 revealed no documentation to ensure the resident and the representative received in writing and in a language they could understand the reason for transfer to the hospital, Further review on 1/11/2019 at approximately 2:36 PM of the medical record for Resident #117 revealed no documentation to ensure the Ombudsman received the same notice of transfer in a timely manner. During an interview on 1/11/2019 at approximately 3:30 PM with the Business Office Manager, he/she confirmed the resident and the resident representative had not received in writing and in a language they could understand the reason for transfer to the hospital and the Ombudsman was not notified in a timely manner. The facility admitted Resident #95 with [DIAGNOSES REDACTED]. In an interview on 01/10/19 at approximately 2:13 PM, the Business Manage stated there was no record of Notice of Transfer for Resident #95 being provided to the local Ombudsman because the facility had not been providing notice to the Ombudsman. In an interview on 01/10/19 at approximately 3:55 PM, the Director of Nursing confirmed Notice of Transfer for facility residents was not being reported the Ombudsman and stated the facility was not aware that Notice of Transfer needed to be given to the Ombudsman.",2020-09-01
423,PRUITTHEALTH-WALTERBORO,425053,401 WITSELL STREET,WALTERBORO,SC,29488,2019-01-11,625,D,1,1,BXNI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to ensure Resident #117 nor his/her representative received a copy of the bed hold policy with the amount upon transfer to the hospital for 1 of 4 residents reviewed for hospitalization . The findings included: The facility admitted Resident #117 with [DIAGNOSES REDACTED]. Review on 1/11/2019 at approximately 2:36 PM of the medical record for Resident #117 revealed no documentation to ensure the resident nor the resident representative received a copy of the bed hold policy with the amount upon transfer to the hospital During an interview on 1/11/2019 at approximately 3:30 PM with the Business Office Manager, he/she confirmed Resident #117 nor the representative for Resident #117 had received a copy of the bed hold policy with the amount to hold the bed upon transfer to the hospital.",2020-09-01
424,PRUITTHEALTH-WALTERBORO,425053,401 WITSELL STREET,WALTERBORO,SC,29488,2019-01-11,640,C,1,1,BXNI11,"> Based on record review and interview, the facility failed to ensure an OBRA Assessment for Resident #1 was coded correctly and transmitted to the state agency in a timely manner for 1 of 1 residents listed on the Missing OBRA Assessment Report. The findings included: Review on 1/10/2019 at approximately 1:38 PM of a missing OBRA assessment for Resident #1 revealed 2 different birthdates. According to the Minimum Data Set (MDS) assessment coordinator, the birthdate for Resident #1 was corrected on 1/8/2019. Interview on 1/10/2019 at approximately 1:38 PM with the MDS Coordinator confirmed the MDS assessment was not coded correctly and transmitted to the state agency in a timely manner and that it would be transmitted on 1/10/2019.",2020-09-01
425,PRUITTHEALTH-WALTERBORO,425053,401 WITSELL STREET,WALTERBORO,SC,29488,2019-01-11,690,D,1,1,BXNI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and review of the facility policy titled, Lippincott Procedures - Suprapubic Catheter Care, the facility failed to follow a procedure to ensure Resident #15 received proper catheter care and would remain free from an infection for 1 of 1 residents reviewed for catheter care. The findings included: The facility admitted Resident #15 with [DIAGNOSES REDACTED]. An observation on 1/9/2019 a approximately 3:03 PM of suprapubic catheter care revealed the following: Licensed Practical Nurse (LPN) #4 knocked on Resident # 15's door and waited for permission to enter. Resident #15 was nonverbal so we entered the room. The LPN explained the procedure to the resident and this surveyor asked permission to observe suprapubic catheter care. Privacy was provided and the LPN and the Certified Nursing Assistant (CNA) assisting with with procedure washed their hands and donned gloves. LPN #4 assisted the CNA in positioning Resident #15 and pulled up his/her gown to expose the gastric tube site and then removed the soiled bandage from the site. The LPN then removed his/her gloves and washed his/her hands and applied gloves and cleaned around the feeding tube with normal saline soaked gauze x 2 and then down the tubing, LPN #4 did not change his/her gloves after cleaning around the feeding tube site and then placed a drain sponge around the site and taped it down. At this time, LPN #4 realized he/she had cleaned and applied a clean dressing around the feeding tube site and had not performed suprapubic catheter care. With the same gloved hands, LPN #4 put 4 x 4's into small cups of saline (2). He/she then used the same gloved hands to remove the soiled dressing from around the catheter site. The LPN then removed his/her gloves and did not wash his/her hands and applied gloves and cleaned around the suprapubic cath site and down the tubing and using the same gloved hands applied Zgard cream around the insertion site of the suprapubic catheter tubing (the Zgard cream was ordered by the physician to be applied around the feeding tube site and not the suprapubic insertion site) and placed a drain sponge and taped it down. LPN #4 then removed his/her gloves and assisted the CNA in making Resident #15 comfortable then removed his/her gloves and washed his/her hands and carried the soiled linen in a plastic bag along with the bagged trash to the soiled utility room and then took the soiled linen out of a plastic bag and placed it in the soiled linen bin and then washed his/her hands and charted the treatment. Interview on 1/9/2019 at approximately 3:40 PM with LPN #4 confirmed that he/she had not removed his/her gloves and washed his/her hands after cleaning the feeding tube site and tubing and then starting the suprapubic catheter care. LPN #4 also confirmed at this time that the Zgard cream was ordered for the feeding tube site and not the suprapubic catheter site. LPN #4 went on to say that he/she was in the process of doing other things and the Director of Nursing instructed him/her to stop and do the suprapubic catheter care. Review on 1/9/2018 at approximately 4:35 PM of the facility policy titled, Lippincott Procedures - Suprapubic Catheter Care, revealed a procedure to use mild soap and water and washcloth to clean an established suprapubic catheter. The facility policy did mention performing hand hygiene, which was not done during the observation of LPN #4 completing the catheter care and between feeding tube care and suprapubic catheter care.",2020-09-01
426,PRUITTHEALTH-WALTERBORO,425053,401 WITSELL STREET,WALTERBORO,SC,29488,2019-01-11,692,E,1,1,BXNI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to ensure Resident #50 received the correct amount of fluid based on a physician ordered fluid restriction. The facility further failed to document the correct fluid intake for Resident #50 for the fluid restriction for 1 of 1 residents reviewed for [MEDICAL TREATMENT]. The findings included: The facility admitted Resident #50 with [DIAGNOSES REDACTED]. Review on 1/9/2019 at approximately 4:30 PM of the physician's orders [REDACTED]. The documentation on the Medication Administration Record [REDACTED]. The documented amount of fluid provided by nursing on 11/17/2018 was 480 mls and not the ordered 280 mls by nursing. Further review on 1/9/2019 at approximately 4:30 PM of the physician's orders [REDACTED].#50 was to receive a 1500 mls daily fluid restriction and dietary was to provide 840 mls and nursing was to provide 640 mls daily. Review of the documentation of the daily amount of fluid provided by nursing indicated on 12/21/2018 nursing provided 200 mls, on 12/22/2018 nursing provided 200 mls, and nursing provided 590 mls on 12/23/2018. On 12/24/2018 nursing provided 100 mls, 12/25/2018 nursing provided 200 mls, on 12/27/2018 nursing provided 200 mls, on 12/28/2018 nursing provided 120 mls, none on 12/29/18 and 12/30/2018, and on 12/31/ nursing provided 200 mls. Review on 1/9/2019 at approximately 4:40 PM of the (MONTH) 2019 orders revealed the same order for a 1500 ml daily fluid restriction and the documentation by nursing indicated on 1/1/2019 Resident #50 received 300 mls of fluid. On 1/2/2019 he/she received 320 mls by nursing, and on 1/3/2019 220 mls was provided by nursing. On 1/4/2019 he/she received 400 mls of fluid by nursing. The total amount of fluid Resident #50 received by nursing on 1/5/2019 was 300 mls, on 1/6/2019 and 1/7/2019 the amount of fluid provided by nursing was 400 mls, and on 1/8/2019 the total amount of fluid provided by nursing was 120 mls. No other documentation could be found in the medical record for Resident #50 to ensure nursing was providing the ordered amount of fluid for him/her. Interview on 1/11/2019 at approximately 8:45 AM with the Director of Nursing confirmed that nursing was not providing the amount of fluid ordered by the physician to adhere to the fluid restriction for Resident #50.",2020-09-01
427,PRUITTHEALTH-WALTERBORO,425053,401 WITSELL STREET,WALTERBORO,SC,29488,2019-01-11,730,D,1,1,BXNI11,"> Based on record review and interview, the facility failed to ensure each Certified Nursing Assistant (CNA) completed the required 12 hours of annual in service/training based on their performance and their hire date for 12 of 63 CNAs reviewed for the required annual 12 hours of in service/training. The findings included: Review on 1/10/2019 at approximately 1:03 PM of the staffing revealed 12 of 63 CNAs did not complete the required 12 hours of annual in service/training based on performance and hire date. Interview on 1/10/2019 at approximately 3:40 PM with the Director of Human Resources confirmed that all of the CNAs had not completed the 12 hours of required in service/training based on the CNAs performance and their hire date.",2020-09-01
428,PRUITTHEALTH-WALTERBORO,425053,401 WITSELL STREET,WALTERBORO,SC,29488,2019-01-11,761,D,0,1,BXNI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, records review, and interview, the facility failed to assure that medications were properly stored and monitored, that a medication room door was locked, and that expired medications were removed from active storage in 2 of 4 medication rooms. The findings included: On 1/08/19 at approximately 9:08 AM inspection of the Hall 3 Medication Room Vaccine refrigerator revealed a thermometer which read 20 degrees F (Fahrenheit). This same refrigerator thermometer was rechecked on 1/08/19 at approximately 2:24 PM and the thermometer reading was 30 degrees F. On 01/08/19 at approximately 2:35 PM, the Surveyor's calibrated thermometer was left in refrigerator for approximately 15 minutes and the reading was 37 degrees F. The facility's Vaccine Storage Temperature Log stated (Vaccine MUST be stored between 35 degrees F and 46 degrees F (2 degrees C (centigrade) and 8 degrees C) to maintain potency). The Vaccine Storage Log for (MONTH) 2019 contained 14 of 15 entries at 35 degrees (including the morning entry for 1/8/19) and one evening entry on 1/4/18 for 36 degrees. On 01/08/19 03:49 PM, the Maintenance Director tested this refrigerator with the facility's thermometer and obtained a reading of 37 degrees F. He/she stated that no one had reported that there was a problem with the refrigerator's thermometer and that the thermometer found in the refrigerator was not approved by Maintenance for checking refrigerator temperatures. The Director of Nursing stated on 01/08/19 at approximately 4:40 PM that the nurse on each of the two 12 hour shifts was responsible for checking refrigerator temperatures. On 1/08/19 at approximately 2:48 PM, the Hall 2 Medication Room door was found ajar and unlocked. This finding was verified by LPN (Licensed Practical Nurse) # 1 who stated, Oh that door didn't shut all the way. On 1/08/19 at approximately 3:42 PM, the Hall 2 Medication Room refrigerator was inspected and contained one opened 1 ml (milliliter) (10 tests) vial of [MEDICATION NAME], Purified Protein Derivative Diluted, [MEDICATION NAME] by PAR which had been dated by the facility as having been opened on 11/29/18. The manufacturer's label stated: Once entered, vial should be discarded after 30 days. This finding was verified by LPN #1 on 1/08/19 at approximately 3:54 PM.",2020-09-01
429,PRUITTHEALTH-WALTERBORO,425053,401 WITSELL STREET,WALTERBORO,SC,29488,2019-01-11,770,D,1,1,BXNI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, and interview, the facility failed to obtain laboratory services as ordered by the physician for Resident #77 for 1 of 3 sampled residents reviewed for falls. The findings included: The facility admitted Resident #77 with [DIAGNOSES REDACTED]. Record review on 01/10/19 at approximately 8:52 AM revealed a Physicians Order dated 12/03/18 to complete Urine dip and send for culture if positive and a Physicians Order dated 12/05/18 stating staff may do an in/out catheter if unable to collect sample by clean catch. In an interview on 01/10/19 at approximately 10:56 AM, the Director of Nursing (DON) stated the lab results were not available because the urine sample was never obtained. The DON provided a copy of a new order dated 01/10/19 discontinuing the (MONTH) orders for the laboratory test.",2020-09-01
430,PRUITTHEALTH-WALTERBORO,425053,401 WITSELL STREET,WALTERBORO,SC,29488,2019-01-11,880,E,1,1,BXNI11,"> Based on observation, interview, and review of the facility policy titled, Infection Control - Linen and Laundry Services, the facility failed to ensure soiled linen was bagged at point of use and not placed in the bins unbagged on 2 of 2 halls observed during laundry pick up. The findings included: An observation on 1/10/2019 at approximately 9:30 AM during soiled linen pick up on the halls by the laundry department revealed soiled linen was unbagged and placed in bins in the soiled utility rooms on hall 2 and hall 3. Interviews on 1/10/2019 at approximately 9:40 AM with Laundry Worker #1 and the Housekeeping/Laundry Supervisor confirmed the unbagged linen and stated that it should have been bagged before it was put in the bins at the point of use. Review on 1/10/2019 at approximately 10:30 AM of the facility policy titled, Infection Control - Linen and Laundry Services, states under Procedure: Routine Handling of Soiled Linen: Number 1 states, All soiled linen will be treated as potentially infectious. 3. All soiled linen should be bagged or put into carts where used: it should NOT be sorted or pre rinsed in patient/resident care areas. Linen that is saturated with blood or body fluids should be deposited in impervious bags.",2020-09-01
431,PRUITTHEALTH-WALTERBORO,425053,401 WITSELL STREET,WALTERBORO,SC,29488,2017-08-14,225,D,1,0,07IQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to report an allegation of neglect timely and accurately for 1 of 3 sampled residents reviewed. Resident #1 with allegations that a certified nursing aide would not take him/her to the bathroom and rolled a wheelchair over the resident's foot was not reported timely. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the facility's reportable incidents on 8/14/17 at approximately 2:30 PM revealed Resident #1's family member made an allegation that a certified nursing aide did not take the resident to the bathroom upon request. The incident allegedly occurred on 4/28/17 and was documented as a grievance until the facility reported the incident as an allegation of neglect on 5/25/17. Reviewing the facility's investigation of the 4/28/17 incident revealed another grievance written on 5/05/17 which indicated that Resident #1 reported the same certified nursing aide for rolling a wheelchair over his/her foot that was not reported timely. Further review of the facility's reportable's revealed the facility failed to ensure that the fax machine used to report the incidents had the correct time stamp to verify when the fax was sent. The facility was noted to have documented allegations of resident neglect as a grievance rather than an allegation of abuse/neglect. An interview on 8/14/17 at approximately 2:45 PM with the Administrator confirmed the finding that the incident was not reported timely and the resident accused the same certified nursing aide who would not take him/her to the toilet of rolling a wheelchair over his/her foot. The Administrator reported that he/she thought the accused certified nursing aide was reassigned from working with Resident #1 since the 4/28/17 incident. The Administrator stated that he/she later discovered that the certified nursing aide continued to work with the resident after the 4/28/17 incident which was overlooked by the facility. The Administrator further confirmed that the facility did not look at the time stamp of the facility's fax machine to ensure accuracy of the date and time a fax was sent.",2020-09-01
432,PRUITTHEALTH-WALTERBORO,425053,401 WITSELL STREET,WALTERBORO,SC,29488,2017-08-14,226,D,1,0,07IQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview and review of the facility's Abuse Reporting and Investigation policy, the facility failed to follow implemented written policies and procedures that included reporting an allegation abuse and neglect timely. The facility further failed to protect the resident from further neglect when the accused certified nursing aide continued to interact with the resident with no follow up by the facility staff. Resident #1 was not protected from further neglect for 1 of 3 sampled reportable's reviewed. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the facility's reportable incidents on 8/14/17 at approximately 2:30 PM revealed Resident #1 family member made an allegation that a certified nursing aide did not take resident to the bathroom upon request. The incident allegedly occurred on 4/28/17 and was documented as a grievance until the facility reported the incident as an allegation of neglect on 5/25/17. Reviewing the facility's investigation of the 4/28/17 incident revealed another grievance written on 5/01/17 which indicated that the Resident #1 reported the same certified nursing aide for rolling a wheelchair over his/her foot that was not reported timely. An interview on 8/14/17 at approximately 2:45 PM with the Administrator confirmed the finding that the incident was not reported timely and the resident accused the same certified nursing aide who would not take him/her to the toilet of rolling a wheelchair over his/her foot. The Administrator reported that he/she thought the accused certified nursing aide was reassigned from working with Resident #1 since the 4/28/17 incident. The Administrator stated that he/she later discovered that the certified nursing aide continued to work with the resident after the 4/28/17 incident which was overlooked by the facility.",2020-09-01
433,PRUITTHEALTH-WALTERBORO,425053,401 WITSELL STREET,WALTERBORO,SC,29488,2018-08-23,600,D,1,0,BWJK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interviews and review of facility files, the facility failed to evaluate/assess a resident without signs of life for 1 of 3 residents reviewed for loss of life. Resident #1 was not assessed for signs of life when reported to nurse the resident had expired. The findings included: The facility admitted resident #1 with [DIAGNOSES REDACTED]. Review of the medical record revealed the resident's plan of care. Review of the Care Plan (CP) revealed CP for Advance Directive DNR- Honor and carry out advanced directive. [DATE]: Admit to hospice services, severe protein calorie malnutrition. Review of physician's orders [REDACTED]. [DATE]: Admit to hospice [DATE]: D/C (discontinue) all by mouth (Po) meds with exception of [MEDICATION NAME] and [MEDICATION NAME]. Start [MEDICATION NAME] 25 mg suppository rectally. Review of Nurses Notes revealed [DATE] (should be [DATE]) at 9:40 PM Hospice of(NAME)notified of resident demise. Hospice nurse notified. [DATE] 10:40 PM Resident in bed eyes closed, daughter at bedside. Unable to obtain vital signs. No respirations noted. No heart rate. No spontaneous movements noted. Resident expired, noted at 10:40 PM. Review of the facility investigation of the incident revealed resident's #1 family complained they went and asked the nurse to come check their mother, they thought s/he had passed. The nurse never went into the resident's room. The family waited for over an hour and the nurse did not check the resident. After approximately one hour after the resident had quit breathing the hospice nurse entered and pronounced the resident. Licensed Practical Nurse (LPN) #1 was not available for interview. The surveyor interviewed the Director of Hospice. The complaint from the family was that the resident had passed and the nursing home nurse did not go into resident's room. It was a complaint here. Our nurse came out and pronounced the resident. The family did not make any complaints to our nurse. LPN #2 and #3 were interviewed by the surveyor. Both nurses stated they would check the resident for signs of life. They would notify the Registered Nurse, or the Director of Healthcare Services (DHS), notify the doctor and hospice if the resident was a hospice patient. 4:00 PM the Director of Health Services (DHS) was interviewed by the surveyor. The DHS stated LPN #1 did not examine the resident or enter the resident's room. A RN supervisor was on duty and was not aware the resident had passed. The LPN was negligent in her/his duties.",2020-09-01
434,PRUITTHEALTH-WALTERBORO,425053,401 WITSELL STREET,WALTERBORO,SC,29488,2018-08-23,684,D,1,0,BWJK12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to provide care in a timely manner for 1 of 4 residents reviewed for abuse. Resident #6 complained of pain. Evaluation, assessment, and intervention were not provided for an extensive period of time. The findings included: The facility readmitted resident #6 with [DIAGNOSES REDACTED]. Review of the medical record revealed the resident showed signs of pain when her/his right arm was moved on 10/12/18. Nurses Notes of 10/12/18 stated: 6 AM- Called to room by CNA (Certified Nursing Assistant) due to Res (resident) showing s/sx (signs/symptoms) of pain to rt (right) arm/shoulder during care. When rt arm is move (sic) Res will yell out in pain. Will report to MD (Medical Doctor) & NP (Nurse Practitioner). 7 PM Pt (patient) had x-ray done. 7:15 PM Called family to notify them this pt had some pain in the rt arm so we had an x-ray done. Spoke to R/P (Responsible Party) .Spoke to N.P. regarding this pts x-ray report. N.P. gave orders to send to ER (emergency room ) for evaluation. 10:30 PM Called (Ambulance Service) to transport pt to ER called ER to give report. RP called by RN (Registered Nurse) Evening Supervisor regarding this pt x-ray that s/he was going to the ER for evaluation. 10/13/18: 1:00 AM Returned from hospital, resident with fractured right shoulder. No new orders. RP and NP notified of resident's return to facility. 3:42 AM Pt resting with Rt arm in a sling. S/he yells out that arm was painful when moved around on the bed. Review of the mobile x-ray report dated 10/12/18 at 8:49 PM revealed the conclusion of the x-ray was Subacute proximal femoral fracture. Review of the hospital x-ray report dated 10/12/18 at 2338: Conclusion: Medially displaced [MEDICAL CONDITION] humeral metaphysis. Review of Physician's Telephone Orders (TO) revealed an order on 10/12/18 for 2 view x-ray right shoulder and right humerus. There was no time as to when the order was obtained. A second order for 10/12/18 to send patient to ER for evaluation. The resident complained of pain in right shoulder at 6 AM. An x-ray was done 13 hours later and found the resident had a fracture and orders obtained to send to ER. Three hours following the order to send the resident to the ER, the resident was sent out and the responsible party was notified. On 10/30/18 at approximately 4:30 PM, the Administrator was interviewed by the surveyor regarding the timeliness of the resident being x-rayed and sent to the hospital. The Administrator stated the ambulances were busy. The staff were monitoring her/his pain. S/he received Tylenol on a routine basis. S/he wasn ' t complaining of pain.",2020-09-01
435,PRUITTHEALTH-WALTERBORO,425053,401 WITSELL STREET,WALTERBORO,SC,29488,2018-08-23,698,D,1,0,BWJK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to provide Physician's Orders for [MEDICAL TREATMENT] for 2 of 3 residents reviewed for [MEDICAL TREATMENT]. Residents #3 and #4 did not have a physician's order for [MEDICAL TREATMENT]. The findings included: The facility admitted resident #3 with [DIAGNOSES REDACTED]. Review of the medical record revealed an Admission Minimum Data Set (MDS). The resident was coded s/he required extensive assistance needed with all Activities of Daily Living (ADL's) except limited assist with eating. The resident was occasionally incontinent of bowel and bladder. The resident was coded s/he received [MEDICAL TREATMENT]. Review of Nurses Notes revealed resident was blind and required extensive assist of 2 with mobility. Resident out to [MEDICAL TREATMENT]. Review of Physician's Orders revealed no physician's orders for [MEDICAL TREATMENT]. Physician's progress notes spoke to resident's need of [MEDICAL TREATMENT]. The facility admitted resident #4 on 8/6/18 with [DIAGNOSES REDACTED]. Review of the medical record revealed an Admission MDS of 8/13/18. The resident was noted to be alert and oriented. S/he required limited assistance with ADL's and supervision with eating; non ambulatory. Special treatment of [REDACTED]. 12:30 PM: Resident observed in room, up in wheel chair, wearing a brace on right leg. Alert and oriented, verbal and pleasant. Resident confirmed s/he went to [MEDICAL TREATMENT]. Review of Physician's orders revealed the resident received [MEDICATION NAME]. Medication was monitored and followed up on. Orders for discharge on 8/26/18-home with home health. No orders were noted for [MEDICAL TREATMENT] although physician discussed in progress notes. Licensed Practical Nurse (LPN) #3 reviewed Physician's orders and did not find an order for [REDACTED].>Director of Health Services (DHS) reviewed Physician's Orders and confirmed there was no orders for [MEDICAL TREATMENT].",2020-09-01
436,PRUITTHEALTH-WALTERBORO,425053,401 WITSELL STREET,WALTERBORO,SC,29488,2018-08-23,732,C,1,0,BWJK11,"> Based on review of facility records and interview, the facility failed to complete the Daily Staff Posting daily. Staff Posting did not include the census for each shift. The findings included: Review of the Daily Staff Posting. of 8/21/18, 8/22/18 and 8/23/18, for staffing numbers and facility census, revealed there was no census recorded for the 3-11 and the 11-7 shift. On 8/23/18 at 2:10 PM the Director of Health Care Services (DHS) was interviewed by the surveyor regarding the postings. The DHS stated, I didn't know the census had to be for each shift. I will tell them to add it.",2020-09-01
437,PRUITTHEALTH-WALTERBORO,425053,401 WITSELL STREET,WALTERBORO,SC,29488,2018-08-23,776,D,1,0,BWJK12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to obtain an x-ray in a timely manner for 1 of 5 residents reviewed for abuse. Resident #6 complained of pain at 6 AM did not receive x-ray until 7 PM. The findings included: Cross refer to F 684 Quality of Care The facility readmitted resident #6 with [DIAGNOSES REDACTED]. Review of the medical record revealed the resident showed signs of pain when her/his right arm was moved on 10/12/18. Nurses Notes of 10/12/18 stated: 6 AM- Called to room by CNA (Certified Nursing Assistant) due to Res (resident) showing s/sx (signs/symptoms) of pain to rt (right) arm/shoulder during care. When rt arm is move (sic) Res will yell out in pain. Will report to MD (Medical Doctor) & NP (Nurse Practitioner). 7 PM Pt (patient) had x-ray done. 1:00 AM Returned from hospital, resident with fractured right shoulder. Review of the mobile x-ray report dated 10/12/18 at 8:49 PM revealed the conclusion of the x-ray was Subacute proximal femoral fracture. Review of the hospital x-ray report dated 10/12/18 at 2338: Conclusion: Medially displaced [MEDICAL CONDITION] humeral metaphysis. Review of Physician's Telephone Orders (TO) revealed an order on 10/12/18 for 2 view x-ray right shoulder and right humerus. There was no time as to when the order was obtained. The resident complained of pain in right shoulder at 6 AM. An x-ray was done 13 hours later and found the resident had a fracture and orders obtained to send to ER. There was no evidence of what time the x-ray was ordered. The report from the mobile x-ray stated the resident had a fractured femur, the x-ray was done of the right shoulder. On 10/30/18 at approximately 4:30 PM, the Administrator was interviewed by the surveyor regarding the timeliness of the resident being x-rayed and sent to the hospital. The Administrator stated the ambulances were busy. There was no explanation as to the timeliness of the x-ray.",2020-09-01
438,PRUITTHEALTH-WALTERBORO,425053,401 WITSELL STREET,WALTERBORO,SC,29488,2016-10-13,155,D,0,1,6NBC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of the facility policy titled Do Not Resuscitate Policy: South [NAME]ina, the facility failed to ensure that 2 of 17 residents reviewed for advance directives were afforded the opportunity to formulate their own advance directive.(Resident #97 & #116) The findings included: The facility admitted Resident #97 with [DIAGNOSES REDACTED]. Record review on [DATE] revealed a facility form titled Authorization of Do Not Resuscitate Order Without Decision-Making Capacity. The form did not have any category marked, but was signed by two physicians and the Responsible Party. Further review of the record revealed there was no documentation two physician's signed a statement to indicate the resident lacked the capacity to sign his/her own advance directive. During the review of Resident #97''s medical record, a red DNR sticker was observed on the facesheet. Review of the physician's order dated [DATE] revealed the resident's code status was a DNR. Review of the 14-day Minimum Data Set, the Brief Interview for Mental Status was coded as an 11. The facility admitted Resident #116 with [DIAGNOSES REDACTED]. Record review on [DATE] revealed a facility form titled Authorization of Do Not Resuscitate Order Without Decision-Making Capacity. The area marked stated The patient/resident is a person for whom Cardiopulmonary Resuscitation would be medically futile in that such resuscitation will likely be unsuccessful in restoring cardiac and respiratory function; or will only restore cardiac and respiratory function for a brief period of time so that the patient/resident will likely experience repeated need for (CPR) over a short period of time. The form was signed by two physicians and the Responsible Party. The form did not state why the resident was incapable of making healthcare decisions and no documentation was found that the resident had been deemed unable to make healthcare decisions by two physicians . A DNR order was implemented on [DATE]. Further review of Resident #116's medical record revealed a red DNR sticker on the face sheet. Review of the Quarterly Minimum (MDS) data set [DATE] revealed the Brief Interview for Mental Status score was scored as a 3. On [DATE] at 9:13 AM, during an interview with the Director of Nursing, he/she confirmed the forms did not reflect the resident was incapable of making healthcare decisions and did not list the [DIAGNOSES REDACTED]. Review of the facility policy titled Do Not Resuscitate Policy: South [NAME]ina under the Definitions Section #4 the following: Decision Making Capacity means the ability to understand and appreciate the nature and consequences of an order not to resuscitate, including the benefits and disadvantages of such an order, and to reach an informed decision regarding the order. Every adult is presumed to have Decision Making Capacity unless determined otherwise by a physician in writing in the patent/resident's medical record or pursuant to a court order.",2020-09-01
439,PRUITTHEALTH-WALTERBORO,425053,401 WITSELL STREET,WALTERBORO,SC,29488,2016-10-13,431,D,0,1,6NBC11,"Based on observations, record reviews, interviews and manufacturer package insert and product labeling, the facility failed to assure that medications were properly stored in 1 of 6 medication carts and that expired medications had been removed from active storage in 1 of 4 medication rooms. The findings include: Inspection of the Hall 3 Medication Cart top left drawer on 10/10/2016 at approximately 12:33 PM revealed one opened bottle of Sterile 0.9% (percent) Normal Saline, USP (United States Pharmacopoeia) 100 ml (milliliter) dated as opened 10/6/16 and labeled by Medline (the manufacturer) as follows: No antimicrobial or other substance added. and Contents sterile unless container is opened or damaged. The finding was verified on 10/10/2016 at 12:36 PM by LPN (Licensed Practical Nurse) #1 Inspection of the Hall 4 Medication Room Refrigerator on 10/10/2016 at approximately 1:10 PM revealed one opened (approximately 2/5 full) 1 ml vial of Tuberculin, Purified Protein Derivative, Diluted Aplisol by PAR dated by facility as opened 9/7/16. The finding was verified on 10/10/2016 at approximately 1:13 PM by LPN # 2",2020-09-01
440,PRUITTHEALTH-WALTERBORO,425053,401 WITSELL STREET,WALTERBORO,SC,29488,2019-10-25,600,D,1,0,TFZI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on limited record review and interview, the facility failed to protect Resident #3 from physical abuse by 1 of 4 residents reviewed for physical abuse (Resident #4). The findings included: Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 10/24/19 at 02:06, review of the facility's Initial 2/24-Hour Report revealed an incident occurred on 07/26/19 at 07:30 PM. At 02:11 PM, review of the facility's Five-Day Follow-Up Report revealed Resident #4 entered Resident #3's room. Resident #3 reported Resident #4 had a fork raised and was going to stab her/him and that s/he knocked the fork out of (his/her) hand, and yelled for help. Upon entering the room, staff observed Resident #4 with his/her hands around Resident #3's wrists. Review of the Nursing Progress Notes revealed on 07/14/19 Resident #4 attempted to go outside stating s/he saw his/her mother's car. Resident #4 became angry with staff attempts at re-direction, jumped out of (his/her) wheelchair and walked quickly to the front doors and walked out the building. When s/he realized it was not his/her mother's car, the staff were able to bring Resident #4 back in the building. On 07/16, Resident #4 went into a resident's room on another unit. When the resident told Resident #4 to get out of her/his room, Resident #4 kept moving towards (her/him) with his/her w/c (wheelchair) and the other resident swung at Resident #4 to leave and he rammed into (her/him) with his w/c. On 07/17, the nurse observed Resident #4 grab the tire on (a) hall 3 resident's w/c and would not let her/him move. The note indicated Resident #4 was easily directed to release the resident's wheelchair. At 07:10 PM on 07/18, Resident #4 entered room [ROOM NUMBER]B and the resident started waving (her/his) arms and yelling at resident to get out and (Resident #4) hit the other resident's wheelchair when he/she turned to leave. On 07/21/19, Resident #4 tried multiple times to get outside this evening and documented that attempts to re-direct were not successful. A Wanderguard was placed on the resident's right arm by the nurse. At 03:31 PM, Social Services documented it has been noted that resident is wandering, getting out of his wheelchair and at times hard to be redirected back to chair. Review of Licensed Practical Nurse (LPN) #1's facility-obtained statement indicated s/he heard Resident #3 screaming, saying stop it, get off of me. Upon entering the room, the LPN found Resident #3 sitting in the wheelchair with Resident #4 holding her/his wrists tightly in his/her hands and Resident #3 still yelling. The LPN told Resident #4 to stop and yelled for help. Other staff arrived and removed Resident #4 from the room. When the LPN asked Resident 3 what happened, s/he reported that s/he was watching television when Resident #4 came in the room holding the fork up like (he/she) was going to stab me. I knocked the fork out (the resident's) hand and (he/she) grabbed both my wrist (sic) and held them tight, so I started screaming to get some help. Review of Registered Nurse (RN) #1's facility-obtained statement dated 07/26/19 indicated that at 07:20 PM, s/he was receiving report when s/he heard screams. The RN ran down the hall with LPN #1 to Resident #3's room and observed Resident #4 with a tight grip on Resident #3's right wrist. During an interview on 10/25/19 at approximately 11:30 AM, the Nursing Home Administrator (NHA) confirmed the documentation of Resident #4 exhibiting aggressive behaviors towards other residents prior to the incident with Resident #3. The NHA further confirmed Resident #4 abused Resident #3 and that person-centered interventions were not provided when Resident #4 was wandering and that the facility failed to provide adequate supervision to prevent wandering and prevent abuse of other residents.",2020-09-01
441,PRUITTHEALTH-WALTERBORO,425053,401 WITSELL STREET,WALTERBORO,SC,29488,2019-10-25,607,D,1,0,TFZI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, and review of the facility's policy, Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, the facility failed to follow it's policy to report allegations of abuse timely for 2 of 6 residents reviewed for allegations of abuse (Resident #2 and #3). The findings included: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 10/22/19 at approximately 12:00 PM, review of the facility's Initial 2/24-Hour Report dated 04/08/19 indicated Resident #1 entered Resident #2's room at approximately 12:00 AM on 04/08/19 and allegedly exposed him/herself. The report further indicated that information was not shared with the Director of Health Services (DHS) initially. The Initial 2/24-Hour Report was submitted to the State Agency on 04/08/19 at 01:25 PM. During an interview on 10/25/19 at approximately 11:35 AM, the Nursing Home Administrator confirmed the report was not submitted timely to the State Agency. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 10/24/19 at 02:06, review of the facility's Initial 2/24-Hour Report dated 07/26/19 indicated the incident occurred on 07/26/19 at 07:30 PM. Further review revealed the incident was reported to the State Agency at 22:50 PM (10:50 PM) and was not within the required 2 hours. During an interview on 10/25/19 at approximately 11:30 AM, the Nursing Home Administrator confirmed the report was not submitted timely to the State Agency. Review of t he facility's policy entitled Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, revised 07/29/19, revealed 2. In accordance with applicable laws and regulations, the Administrator or his or her designee should notify the appropriate state agency (or agencies), the patient's attending physician, and the patient's designated representative of any allegation or incident described above and of the pending investigation. The state survey agency and the state agency for protective adult services should be notified in accordance with state law through established procedures of any allegations of abuse, neglect, exploitation or mistreatment, including injuries of an unknown source and misappropriation of patient property, within 2 hours after the allegation is made if the events upon which the allegation is based involve abuse or result in serious injury, and not later than 24 hours if the events upon which the allegation is based do not involve abuse or do not result in serious bodily injury. During the interview on 10/25/19 at 11:35 AM, the Nursing Home Administrator confirmed the facility's policy related to reporting had not been followed.",2020-09-01
442,PRUITTHEALTH-WALTERBORO,425053,401 WITSELL STREET,WALTERBORO,SC,29488,2019-10-25,609,D,1,0,TFZI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to report allegations of abuse timely for 2 of 6 residents reviewed for allegations of abuse (Resident #2 and #3). The findings included: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 10/22/19 at approximately 12:00 PM, review of the facility's Initial 2/24-Hour Report dated 04/08/19 indicated Resident #1 entered Resident #2's room at approximately 12:00 AM on 04/08/19 and allegedly exposed him/herself. The report further indicated that information was not shared with the Director of Health Services (DHS) initially. The Initial 2/24-Hour Report was submitted to the State Agency on 04/08/19 at 01:25 PM. During an interview on 10/25/19 at approximately 11:35 AM, the Nursing Home Administrator confirmed the report was not submitted timely to the State Agency. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 10/24/19 at 02:06, review of the facility's Initial 2/24-Hour Report dated 07/26/19 indicated the incident occurred on 07/26/19 at 07:30 PM. Further review revealed the incident was reported to the State Agency at 22:50 PM (10:50 PM) and was not within the required 2 hours. During an interview on 10/25/19 at approximately 11:30 AM, the Nursing Home Administrator confirmed the report was not submitted timely to the State Agency.",2020-09-01
443,PRUITTHEALTH-WALTERBORO,425053,401 WITSELL STREET,WALTERBORO,SC,29488,2019-10-25,657,D,1,0,TFZI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to update the care plan for wandering and aggressive behaviors for 1 of 2 residents reviewed for wandering (Resident #1). The findings included: Review of the medical record revealed resident Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 10/22/19 at 02:23 PM, review of the care plan revealed risk for adverse drug reactions related to [MEDICAL CONDITION] medication use was identified as a problem area on 03/05/19 with an addendum for potential for behaviors. Interventions and approaches included, but not limited to, medications as ordered, psychiatric evaluation as needed, and assess for and implement non-pharmacological interventions. The care plan was updated on 04/08/19 for an episode of inappropriate behaviors including interventions of one-on-one observation and observe for and report episodes of behaviors. The care plan had not been updated to include wandering into residents' rooms or for physical/aggressive behaviors. There were no resident specific non-pharmacological interventions listed and no interventions related to wandering. During an interview on 10/25/19 at 11:35 AM, the Nursing Home Administrator confirmed the care plan had not been updated to include wandering or aggression and/or physical behaviors. The Administrator also confirmed there were no person-centered interventions to prevent the resident from wandering into other residents' rooms.",2020-09-01
444,PRUITTHEALTH-WALTERBORO,425053,401 WITSELL STREET,WALTERBORO,SC,29488,2019-10-25,658,D,1,0,TFZI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to ensure that services provided were within the scope of practice in accordance with accepted standards for a Certified Nursing Assistant (CNA) for 1 of 3 residents reviewed for staff abuse (Resident #8). The findings included: The facility admitted Resident #8 10/23/18 with [DIAGNOSES REDACTED]. On 10/23/19 at 02:45 PM, review of the facility's Five-Day Follow-Up Report dated 01/26/19 indicated Resident #8 reported to the nurse practitioner on 01/22/19 that he had some intermittent constipation and that a CNA stuck his finger up his butt and told him to push. The summary of the report indicated Resident #8 relayed the same information to the Social Services Director and indicated the CNA was terminated for [MEDICATION NAME] outside the scope of his certification. During an interview on 10/25/19 at 11:42 AM, the Nursing Home Administrator confirmed the the CNA acted outside the scope of certification and that the fecal matter should have been done by a nurse.",2020-09-01
445,PRUITTHEALTH-WALTERBORO,425053,401 WITSELL STREET,WALTERBORO,SC,29488,2019-10-25,744,D,1,0,TFZI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to implement individualized interventions to prevent wandering for Resident #1 and failed to initiate care plan interventions for #4 related to wandering (2 of 2 residents reviewed for Dementia with wandering behaviors). The findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Nurse's Notes at 02:16 PM on 10/22/19 revealed a noted timed and dated 12 AM on 04/08/19 that the resident was wandering into female's rooms without clothing. The notes from 03/15-04/08/19 were reviewed and indicated the resident was wandering in and out of other resident's rooms on 03/29, 03/27, 03/25, and 03/24/19. On 10/22/19 at 02:23 PM, review of the care plan revealed risk for adverse drug reactions related to [MEDICAL CONDITION] medication use was identified as a problem area on 03/05/19 with an addendum for potential for behaviors. Interventions and approaches included, but not limited to, medications as ordered, psychiatric evaluation as needed, and assess for and implement non-pharmacological interventions The care plan had not been updated to include wandering into residents' rooms or for actual physical/aggressive behaviors. There were no resident specific non-pharmacological interventions listed and no interventions related to wandering. During an interview on 10/25/19 at 11:35 AM, the Nursing Home Administrator confirmed the care plan had not been updated to include wandering or aggression and/or physical behaviors. The Administrator also confirmed there were no person-centered interventions to prevent the resident from wandering into other residents' rooms. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Nursing Progress Notes on 10/24/19 at approximately 10:00 AM revealed on 07/14/19 the resident attempted to go outside stating s/he saw his mother's car. S/he became angry with staff attempts at re-direction, jumped out of his/her wheelchair and walked quickly to the front doors and walked out the building. When s/he realized it was not his/her mother's car, the staff were able to bring him back in the building. On 07/16, Resident #4 went into a resident's room on another unit. When the resident told him to get out of her/his room, s/he kept moving towards her/him with his/her s/c (wheelchair) and the other resident swung at him/her to leave and s/he rammed into her/him with his w/c. On 07/17, the nurse observed Resident #4 grab the tire on (a) hall 3 residents (sic) w/c and would not let her/him move. The note indicated s/he was easily directed to release the resident's wheelchair. At 07:10 PM on 07/18, Resident #4 entered room [ROOM NUMBER]B and the resident started waving her/his arms and yelling at resident to get out and Resident #4 hit the other resident's wheelchair when s/he turned to leave. On 07/21/19, Resident #4 tried multiple times to get outside this evening and documented attempts to re-direct were not successful. A Wanderguard was placed on the resident's right arm by the nurse. At 03:31 PM, Social Services documented it has been noted that resident is wandering, getting out of his wheelchair and at times hard to be redirected back to chair. On 10/25/19 at 10:48 AM, review of the care plan revealed Dementia with behaviors, Post-concussional Syndrome, [MEDICAL CONDITION], Past career as Professional Boxer, At risk for decline in his behavior/mood state, history of verbal/physical aggression and need for Wanderguard bracelet r/t sun-downing in the evening with increased confusion and exit seeking was identified as a problem area on 07/12/19. Interventions and approaches included: If resident noted agitated, postpone care, leave him alone and re-approach him/her later. Administer meds (medications) as ordered. Psych Consult as ordered; Administer and monitor the effectiveness and side effects of medications as ordered; Assess for pain involvement with patient/resident behaviors; Intervene as needed to protect the rights and safety of others; approach in a calm manner, divert attention, remove from situation, and take to another location as needed. The care plan was updated on 07/24/19 to include a goal that Resident will be easily redirected when noted exit seeking and s/he will be kept safe within his environment at facility over the next 90 days. Interventions and approaches included: Approach resident warmly and provide diversional activity when resident noted wandering. Encourage resident's family to visit and/or call often; encourage resident to attend and participate with activities. S/he enjoys music, all types but he really enjoys that southern soul, oldies but goodies kind of music; Psych (Psychiatric) consult as warranted/ordered; and Wanderguard bracelet on at all times, check for placement and proper functioning of Wanderguard q (every) shift and PRN (as needed). Replace Wanderguard immediately if noted malfunctioned. There was no documentation of resident-specific diversion activities to be attempted when wandering other than music added on 07/24/19 and there was no documentation in the nursing progress notes that music was attempted as an intervention when the resident was wandering into the room of Resident #3 resulting in a resident-to-resident altercation on 07/26/19. During an interview on 10/25/19 at approximately 11:30 AM, the Nursing Home Administrator confirmed there was no documentation that the interventions listed in the care plan, such as providing music, was provided to the resident to prevent wandering.",2020-09-01
446,PRUITTHEALTH-WALTERBORO,425053,401 WITSELL STREET,WALTERBORO,SC,29488,2017-11-02,157,E,0,1,UBTQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews and review of the facility policy titled, SBAR Communication, the facility failed to ensure the physician and the responsible party for Resident #117 were notified of refusal to take medications on multiple days and refusal of treatment for 1 of 1 resident reviewed for Notification. The findings included: The facility admitted Resident #117 with [DIAGNOSES REDACTED]. Review on 11/1/2017 at approximately 4:11 PM of the nurse's notes dated 8/27/2017 states, Resident refuses treatment to open area on neck. No documentation could be found to ensure the physician nor the responsible party were notified of the refusal of care. Further review on 11/1/2017 at approximately 4:11 PM of the nurse's notes dated 9/5/2017 at 9:00 PM states, Refused all 9:00 PM medications x 3 attempts. Resident stated, No, I have already taken medications for today. Resident redirected with 3 attempts what the medication was for and the time for the medication. A nurses note dated 9/8/2017 at 9:45 PM states, Resident refused 9:00 PM medications x 2. Information placed in the Nurse Practitioner log and on the 24 hour report. Again on 9/19/2017, 9/28/2017 and 10/18/2017 Resident #117 refused all medications. No documentation could be found to ensure the physician nor the responsible party were notified that Resident #117 refused all of his/her medications on the above mentioned dates. An interview on 11/2/2017 at approximately 3:30 PM with Licensed Practical Nurse (LPN) #3 confirmed that the physician and the responsible party had not been notified of Resident #117's refusal to take medications on multiple days and the refusal of care. LPN #3 went on to confirm that the physician and the responsible party should have been notified of Resident #117's refusal of medications and treatments. Review on 11/2/2017 at approximately 4:14 PM of the facility policy titled, SBAR Communication, states under, Putting SBAR Communication Into Practice, Key Elements, states, The nurse provides pertinent information from the patient's history, along with current vital signs, relevant assessment findings and his ambulation ability. The nurse has assessed the patient personally before calling the practitioner.",2020-09-01
447,PRUITTHEALTH-WALTERBORO,425053,401 WITSELL STREET,WALTERBORO,SC,29488,2017-11-02,167,C,0,1,UBTQ11,"Based on observations and interviews, the facility failed to ensure that the most recent and past three years of survey results were readily accessible to residents, family and visitors on 4 of 4 units. The findings included: On 10/30/17, upon initial tour and on all days of the survey, the most recent survey results were unable to be located. Observation of the facility's 4 units on all days of the survey revealed a printed sign stating that results could be found in the front lobby. In an interview on 11/2/17 at approximately 11:30 AM, when asked to assist in locating the most recent survey results, the Administrator stated They are located in the brown box, right beside the nursing station on unit one. The Administrator pointed out a small sign measuring approximately 1.5 inches x 2 inches on the front of the box which stated, DHEC Survey results. The Administrator confirmed the signs on all 4 units stated that the most recent results could be found in the front lobby. When the Administrator was asked to differentiate between the front lobby and where the results were located, he/she stated Well, I guess the front entrance is considered the lobby and unit one is considered the commons area. In an interview with the Resident Council President on 11/2/17 at 12:05 PM, the Resident Council President was asked to identify the location of the most recent survey results and he/she stated In the glass case on hallway one.",2020-09-01
448,PRUITTHEALTH-WALTERBORO,425053,401 WITSELL STREET,WALTERBORO,SC,29488,2017-11-02,223,D,0,1,UBTQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to ensure that Resident #205's physical abuse incident involving family members which was documented in the medical record and observed by staff was investigated and reported per facility policy and procedure in 1 of 1 resident reviewed for abuse. The findings include: Resident #205 was admitted with [DIAGNOSES REDACTED]. During record review on 11/01/2017 at 10:00 AM, the Skilled Daily Nurses Note entry on 9/10/17 at 2:00 PM stated: Pt (Patient) sisters in room cussing and yelling at pt slapping her on the bottom witnessed by therapy. Laundry Aide #3 from housekeeping asked them to leave, DHS (Director of Nursing) notified c/o (complaint) from other residents lead us to this incidence will monitor. The Skilled Daily Nurses Note entry on 10/15/17 at 8:00 PM stated: Resident is in room watching TV (television). Resident son came in and tried to walk her to the bathroom-yelling that she needs to do things more for herself. Son continued to scream at resident. Resident refuse CNA to help assist her to the bathroom once the son had left. No further issues at this time. On 11/01/2017 at 10:42:13 AM, The Skilled Daily Nurses Notes were reviewed with the DON, h/she said was not aware of the incidents on 9/10/17 and 10/15/17. During an interview on 11/01/2017 at 10:45 AM with the Administrator and he/she said was not aware of incidents on 9/10/17 and 10/15/17. On 11/01/2017 at 11:02:15 AM during an interview with the Therapy Outcomes Coordinator h/she said h/she was contacted by phone on Sunday 9/10/17 by the Physical Therapist. The Therapy Outcomes Coordinator said h/she was made aware of the incident which occurred on 9/10/17. The Therapy Outcomes Coordinator asked the Physical Therapist if the DON was aware of the incident and the Physical Therapist replied to the Therapy Outcome Coordinator that the DON was aware of the incident. During an interview on 11/01/2017 at approximately 12:15 PM with the Physical Therapist h/she said that on Sunday, 9/10/17, he/she walked in room to treat Resident #205. Resident #205's two sisters were in the room with the resident, so the Physical Therapist left the room. The Physical Therapist went back to room at the end of work day, Resident #205 was the last patient that h/she saw on that day. The Physical Therapist said the two sisters were giving Resident #205 a bed bath. On sister was rolling Resident #205 back and forth in the bed and hitting Resident #205 on the but in a playful way. The sister was saying to Resident #205: Who loves you the more than us? Resident #205 was saying to this sister; Please stop. The Physical Therapist then stated to the sisters in the room and the resident: I am going to get a nurse. The Physical Therapist then reported to LPN #6 and said h/she said to LPN #6, I think there is something wrong. The Physical Therapist said h/she called her supervisor, The Therapy Outcomes Coordinator. LPN #6 told The Physical Therapist that h/she had called the DON and reported the incident to the DON. During an interview on 11/01/2017 at 11:44 AM with Laundry Aide #3, h/she said that he/she was made aware of the situation on 9/10/17. Laundry Aide #3 stated: I was putting the clothes up on the hall and the nurse on the unit mentioned to me what was going on in Resident #205's room. I did not hear or see anything. Laundry Aide #3 said that h/she knew one of the sisters who used to work at the facility. Laundry Aide #3 further stated: I went to the room and asked the family to leave and the family (sisters) left). Laundry Aide #3 said, We did a training on abuse, and I am supposed to report abuse to my supervisors. I did not report to supervisor since the nurse was aware. I was looking for someone to talk to me Monday about the incident and no one did. A review of the facility 24 Hour Report Sheet for 9/10/17 shows for Resident #205 a statement, Family escorted off property for disturbance (Loud). The facility policy and procedure titled, Reporting Patent Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Property, Effective: 12/01/2001, Reviewed: 04/26/2017, Revised: 4/26/2017, states, Procedures: 1. Any allegation, suspicion or identified occurrence is identified involving patient abuse .should be immediately reported to the Administrator of the provider entity. The facility policy and procedure titled, Abuse Identification states: The provider will identify events such as suspicious: Occurrences . and the policy further states, .Once an injury or event is identified as suspicious and may constitute abuse or neglect, the provider should follow the investigative procedures. Additionally the policy states: .3. Identification of coverage and responsibility Any person observing, hearing a complaint of and/or identifying any signs and symptoms of abuse . mistreatment should report it to the Administrator as soon as possible It is the responsibility of any department head receiving the complaint of alleged abuse .mistreatment to inform the Administrator as soon as possible. During an interview with the DON and the Administrator, on 11/01/17 at approximately 2:00 PM said they were transmitting the report of the incident and reporting to Dhec per requirements and have also contacted the Ombudsman DON stated that the Administrator emailed the report to the DHEC triage nurse yesterday.",2020-09-01
449,PRUITTHEALTH-WALTERBORO,425053,401 WITSELL STREET,WALTERBORO,SC,29488,2017-11-02,226,D,0,1,UBTQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to ensure that facility policies and procedures were implemented for staff reporting abuse incidents for Resident #205 in 1 of 1 resident reviewed for abuse. The findings included: Resident #205 was admitted with [DIAGNOSES REDACTED]. During record review on 11/01/1/2017 at 10:00 AM, the Skilled Daily Nurses Note entry on 9/10/17 at 2:00 PM stated: Pt (Patient) sisters in room cussing and yelling at pt slapping her on the bottom witnessed by therapy. Laundry Aide #3 from housekeeping asked them to leave, DHS (Director of Nursing) notified c/o (complaint) from other residents lead us to this incidence will monitor. The Skilled Daily Nurses Note entry on 10/15/17 at 8:00 PM stated: Resident is in room watching TV (television). Resident son came in and tried to walk her to the bathroom-yelling that she needs to do things more for herself. Son continued to scream at resident. Resident refused CNA to help assist her to the bathroom once the son had left. No further issues at this time. On 11/01/2017 at 10:42:13 AM, The Skilled Daily Nurses Notes were reviewed with the DON, h/she said was not aware of the incidents on 9/10/17 and 10/15/17. During an interview on 11/01/2017 at 10:45 AM with the Administrator and he/she said was not aware of incidents on 9/10/17 and 10/15/17 On 11/01/2017 at 11:02:15 AM during a interview with the Therapy Outcomes Coordinator h/she said h/she was contacted by phone on Sunday 9/10/17 by the Physical Therapist. The Therapy Outcomes Coordinator said h/she was made aware of the incident which occurred on 9/10/17. The Therapy Outcomes Coordinate said he/she asked the Physical Therapist if the DON was aware of the incident and the Physical Therapist replied to the Therapy Outcome Coordinator that the DON was aware of the incident. *During an interview on 11/01/2017 at approximately 12:15 PM with the Physical Therapist h/she said that on Sunday, 9/10/17, he/she walked in room to treat Resident #205. Resident #205's two sisters were in the room with the resident, so the Physical Therapist left the room. The Physical Therapist went back to room at the end of work day, Resident #205 was the last patient that h/she saw on that day. The Physical Therapist said the two sisters were giving Resident #205 a bed bath. On sister was rolling Resident #205 back and forth in the bed and hitting Resident #205 on the but in a playful way. The sister was saying to Resident #205: Who loves you the more than us? Resident #205 was saying to this sister; Please stop. The Physical Therapist then stated to the sisters in the room and the resident: I am going to get a nurse. The Physical Therapist then reported to LPN #6 and said h/she said to LPN #6, I think there is something wrong. The Physical Therapist said h/she called her supervisor, The Therapy Outcomes Coordinator. LPN #6 told The Physical Therapist that h/she had called the DON and reported the incident to the DON.* During an interview on 11/01/2017 at 11:44 AM with Laundry Aide #3, h/she said that he/she was made aware of the situation on 9/10/17. Laundry Aide #3 stated: I was putting the clothes up on the hall and the nurse on the unit mentioned to me what was going on in Resident #205's room. I did not hear or see anything. Laundry Aide #3 said that h/she knew one of the sisters who used to work at the facility. Laundry Aide #3 further stated: I went to the room and asked the family to leave and the family (sisters) left the room. Laundry Aide #3 said, We did a training on abuse, and I am supposed to report abuse to my supervisors. I did not report to supervisor since the nurse was aware. I was looking for someone to talk to me Monday about the incident and no one did. A review of the facility 24 Hour Report Sheet for 9/10/17 shows for Resident #205 a statement, Family escorted off property for disturbance (Loud). During an interview with the DON and the Administrator, on 11/01/17 at approximately 2:00 PM said they were transmitting the report of the incident and reporting to DHEC per requirements and have also contacted the Ombudsman. The facility policy and procedure titled: Training on Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, Effective: 12/01/2001, Reviewed: 11/21/2016, Revised: 11/21/2016, Policy Statement: It is the policy of PruittHealth and its affiliated healthcare providers to offer recurring training on the prevention of patient abuse, neglect, exploitation, mistreatment, and misappropriation of property 2. PruittHealth providers should have mandatory ongoing inservice training for all staff related to the prevention of patient abuse mistreatment at least annually, among the Ute topics that might be covered are the following: Appropriate interventions to deal with .inappropriate treatment of [REDACTED]. A review of The Inservice Education Program Attendance Record Form, Program Title: Abuse & Reporting held on 3/3/17, 5/26/17, and 10/26/16,shows that Laundry Aide #3 attended. The Inservice Education Program Attendance Record Form, Program Title: Abuse & Reporting held on 5/9/17 and 5/26/17, shows that LPN#6 attended. The Inservice Program Attendance Record form for Program Title: Abuse, Date: 10/24/17, shows the Physical Therapist and the Therapy Outcomes Coordinator attended the inservice.",2020-09-01
450,PRUITTHEALTH-WALTERBORO,425053,401 WITSELL STREET,WALTERBORO,SC,29488,2017-11-02,241,D,0,1,UBTQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and review of the facility policy and procedure, the facility failed to provide an environment to promote dignity of residents during dining. The privacy curtain was not pulled between residents while residents were dining and the resident's roommates were not dining in 2 of 2 residents reviewed for dignity. The findings included: During dining observation on 10/30/2017 at 12:31 PM, there were 2 residents in room [ROOM NUMBER]. Resident #8 was sitting up in his/her bed with no tray on his/her bedside table. Nursing staff entered room and offered a beverage to resident #8. Resident #205 was eating her lunch from her bedside table which was positioned close to Resident #8's bed. The privacy curtain was not pulled between the 2 residents. During an interview on 10/30/17 at approximately 12:40 PM, LPN #3 said that Resident #8 was not eating because she was not feeling well and nauseous was most likely going to be admitted to the hospital. LPN#3 said that Resident #8 had been offered liquids and ice and Resident #8 had refused. During dining observation on 10/30/2017 at approximately 12:35 PM, there were 2 residents in room [ROOM NUMBER]. Resident #153 was eating her lunch was being fed by the CNA (Certified Nurse Assistant). Resident #77 who was receiving a tube feeding and h/she had no tray. The privacy curtain was not pulled between the two residents. On 10/30/17 at 12:40PM LPN #3 was asked, Is there anything you do so the resident who is receiving a tube feeding or is nauseous does not have to watch the other resident eat? LPN #3 said: There is nothing we do. LPN #3 further said; In regards to a tube feeder in room while other residents are eating, don't know what we do so one patient that can't eat will not have to watch the other resident eat. On 10/31/2017 at approximately 9:00 AM, LPN #3 said she knows that the privacy curtain should be pulled when one resident eating and the other is not. The facility provided the form Resident's Bill of Rights when a Policy and Procedure was requested for providing dignity during dining. The Resident's Bill of Rights states, As a resident of this facility, YOU have or your legal guardian has, the right to: Personal Treatment, Be treated with respect and dignity .",2020-09-01
451,PRUITTHEALTH-WALTERBORO,425053,401 WITSELL STREET,WALTERBORO,SC,29488,2017-11-02,247,D,0,1,UBTQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interview and review of the facility policy titled, Room or Roommate Changes, the facility failed to notify Resident #117 and the responsible party for Resident #117 of a room change for 1 of 1 resident reviewed with a room change. The findings included: The facility admitted Resident #117 with [DIAGNOSES REDACTED]. Review on 11/1/2017 at approximately 3:30 PM of the nurse's notes dated 7/18/2017, 7/19/2017, 7/20/2017 indicated Resident #117 was in room [ROOM NUMBER]. The nurse's note dated 7/22/2017 revealed Resident #117 was in room [ROOM NUMBER]. No documentation could be found in the medical record for Resident #117 to ensure the resident or the family/responsible party was notified of the room change prior to the room change. On 11/1/2017 at approximately 4:00 PM during an interview with the Social Services Director, he/she stated a form should be in the chart. No documentation could be found in Resident #117's chart to ensure he/she or the responsible party for Resident #117 was notified of a room change prior to the room change. Review on 11/1/2017 at approximately 4:30 PM of the facility policy titled, Room or Roommate Changes, revealed under Policy Statement: It is our policy to inform patients/residents in advance of any change in room or roommate and allow patients/residents the opportunity to have input in the decision. The Procedure states under number 1, The patient/resident and responsible family member will be informed in advance of room or roommate changes and given the opportunity to have input in the decision.",2020-09-01
452,PRUITTHEALTH-WALTERBORO,425053,401 WITSELL STREET,WALTERBORO,SC,29488,2017-11-02,279,D,0,1,UBTQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During observation, record review, and interview the facility failed to develop a comprehensive care plan for Resident #119, Resident #15, and Resident #14 for 1 of 2 sampled residents reviewed for accidents, 1 of 1 sampled residents reviewed for parental fluids, and 1 of 2 reviewed for change of condition. Resident #119 did not have a care plan developed related to behaviors. Resident #14 did not have a care plan developed related to chest pain. Resident #15 did not have a Care plan developed related to IV (intravenous) fluid therapy. The findings included: The facility admitted Resident #14 with [DIAGNOSES REDACTED]. Review of the Physician's Interim Orders at 11/1/17 at 5:30pm revealed an order written [REDACTED]. Review of the Skilled Daily Nurse's Notes on 11/1/17 at 6pm revealed the following entries: 9/29/17 4:35pm Patient in wheelchair complain of chest pain, [MEDICATION NAME] PRN (as needed) given as ordered by NP (Nurse Practitioner), EGC (electrocardiogram) ordered waiting on results to relay to NP. 9/30/17 4:15am Patient c/o (complain of) chest pain and lower abdominal pain. VS 136/56, 79, 18. Given PRN Nitro x 1 dose with effective results. 10/4/17 5:53pm C/o chest pain PRN Nitro given with good effect after her return from [MEDICAL TREATMENT]. 10/8/17 Resident complained of chest pain times one. PRN nitro given at 12:30pm. Vital signs stable. HR regular. She states in 5 minutes after receiving med that it eased up and that she did not want any more again because it burns. Review of the Comprehensive Care Plan on 11/1/17 at 6pm revealed no active problem/need for chest pain or [MEDICAL CONDITION]. During an interview on 11/2/17 at 12:25pm, MDS Nurse #2 stated that if the problem occurred after the Care Plan meeting then the Unit Manager would be responsible for updating the Care Plan regarding the chest pain. During an interview on 11/2/17 at 1:18pm, RN #3 verified there was no care plan for the chest pain and stated that if the resident is here short term they don't care plan everything. The facility admitted Resident #15 with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Change tubing every 24hrs. Use sterile cap between infusions to maintain sterility. Change PICC line dressing and caps once weekly on Wednesdays. Review of the Comprehensive Care Plan on 11/1/17 at 12pm revealed no evidence of a Care Plan that addressed the PICC line or IV antibiotic therapy for [DIAGNOSES REDACTED]. During an interview on 11/02/2017 at 12:25pm, MDS (Minimum Data Set) Nurse #1 verified that there was no care plan for the PICC line inserted on 8/28/17 or for the IV antibiotic therapy and stated the resident should have had an IV Infusion Care Plan initiated. Review of the Nurses Notes for August, (MONTH) and October, (YEAR) on 11/1/17 at approximately 9:19 AM revealed twelve instances where Resident 119 had been chewing on self, clothing and/or bed sheets with shredded pieces of fabric found in his/her mouth. Eight of these twelve instances did not did indicate that interventions had been taken. During interviews in the Care Plan Coordinator office on 11/1/17 at approximately 12:04 PM, Registered Nurse # 1 reviewed the medical record for Resident 119 on 11/1/17 at approximately 12:15 PM and acknowledged that chewing/shredding/biting behaviors were charted in nurses notes and that [MEDICATION NAME] had been prescribed on 9/12/17, but had not been reflected in the resident's current care plan or in the Multidisciplinary Care Conference Meeting dated 9/25 & 27/17. On 11/1/17 at approximately 12:19 PM, LPN (Licensed Practical Nurse) # 1 stated that the last quarterly was completed on 8/29/17, the last care plan meeting occurred on 9/5/17 and that it is the Unit Manager's job to keep the care plan updated. During an interview on 11/01/2017 at approximately 12:23 PM the Social Services Director acknowledged that he/she had made a social services entry was made on 10/5/17, but was unable to clearly describe any specific input he/she had made for helping Resident 119 other than to states that he/she meets weekly with Department Heads. On 11/1/17 at approximately 12:42 PM the LPN # 2, 11/01/2017 stated that he/she had discussed the behaviors of Resident 119 related to shredding clothing and bed linen at the care plan meeting on 9/27/17. He/she stated that the family was aware of the behaviors and that he/she had exhibited this kind of behavior before and that a pacifier helped. LPN # 2 stated that the facility could not let him/her use a pacifier because of the swallowing risk, but did focus on snacks and activities such as television that would redirect him/her. LPN # 2 stated that the physician had ordered [MEDICATION NAME] which had been started on 9/12/17 and that it seemed to help decrease these type of behaviors.",2020-09-01
453,PRUITTHEALTH-WALTERBORO,425053,401 WITSELL STREET,WALTERBORO,SC,29488,2017-11-02,280,E,0,1,UBTQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to include all required disciplines in the care plan process for 10 of 30 resident care plans reviewed.(Resident #14, 134, 187, 47, 205, 58, 153, 139, 201 and 173) Resident #183's care plan was not revised for weight loss.(1 of 3 reviewed for nutrition) Resident #112's care plan was not updated related to refusal of care.(1 of 1 reviewed for refusal of care) Resident #14's care plan was not updated related to heel protectors and chest pain(1 of 3 reviewed for pressure ulcer and 1 of 1 reviewed for chest pain) Resident #15's care plan was not updated related to mattress and turning.(1 of 3 reviewed for pressure ulcer) Resident #139's care plan was not updated related to noncompliance(1 of 1 reviewed for noncompliance) In addition, Resident #104 and #14 were not afforded the opportunity to participate in the care plan process. The findings included: The facility admitted Resident #104 with [DIAGNOSES REDACTED]. During an interview with Resident #104 on 10/31/17, he/she stated staff did not include him/her in decisions related to care nor was he/she invited to the care plan meeting. Record review on 11/1/17 revealed there was no documentation Resident #104 was invited to the care plan meeting. During an interview on 11/2/17 at 3:00 PM, Minimum Data Set(MDS) Nurse #1 stated residents should be invited to the care plan. During an interview on 11/2/17 at approximately 3:05 PM, MDS Nurse #2 confirmed Resident #104 had not been invited to participate in the care plan process and there was no documentation the resident was invited The facility admitted Resident #173 with [DIAGNOSES REDACTED]. Review of the Multidisciplinary Care Conference Meeting dated 8/17/17 revealed the nurse and certified nursing assistant most familiar with the resident did not attend the care plan conference. The facility admitted Resident #117 with [DIAGNOSES REDACTED]. Review on 11/1/2017 at approximately 4:11 PM of the nurse's notes dated 8/27/2017 states, Resident refuses treatment to open area on neck. No documentation could be found to ensure the physician nor the responsible party were notified of the refusal of care. Further review on 11/1/2017 at approximately 4:11 PM of the nurse's notes dated 9/5/2017 at 9:00 PM states, Refused all 9:00 PM medications x 3 attempts. Resident stated, No, I have already taken medications for today. Resident redirected with 3 attempts what the medication was for and the time for the medication. A nurses note dated 9/8/2017 at 9:45 PM states, Resident refused 9:00 PM medications x 2. Information placed in the Nurse Practitioner log and on the 24 hour report. Again on 9/19/2017, 9/28/2017 and 10/18/2017 Resident #117 refused all medications. No documentation could be found to ensure the physician nor the responsible party were notified that Resident #117 refused all of his/her medications on the above mentioned dates. Review on 11/2/2017 at approximately 10:11 AM of the Plan of Care for Resident #117 made no mention of refusal of care and medications for Resident #117. The plan of care for Resident #117 was not reviewed or revised to include goals and interventions for the refusal of care and medications. During an interview on 11/2/2017 at approximately 1:30 PM with Minimum Data Set (MDS) assessment nurse #2 confirmed that the plan of care for Resident #117 was not revised with goals and interventions for refusal of care and medications. The facility admitted Resident #183 with [DIAGNOSES REDACTED]. Review on 11/2/2017 at approximately 2:00 PM of the Plan of Care for Resident #183 revealed a 9.1 % weight loss in 1 month. The weight loss on 7/5/2017 was 10.2 % weight loss in 3 months. The weight loss on 8/10/2017 was 8.9 % in 1 month and 12.6 % weight loss in 3 months. The weight loss on 9/29/2017 was 17.3 % in one month. On 10/13/2017 indicated a 19.3 % weight loss for 1 month. The interventions included, supplement as ordered, colored napkin on tray and milk and pudding on tray. After the weight loss was recorded on 10/13/2017. No other interventions were put in place to ensure an improvement in weight loss for Resident #183 until the weight loss was brought to the Certified Dietary Managers attention on 11/2/2017. On 11/2/2017 Resident #183 weighed 133.6 pounds which indicated a further weight loss without revision of the care plan with interventions to prevent further weight loss for Resident #183. During an interview on 11/2/2017 at approximately 5:00 PM with the Certified Dietary Manager, he/she stated he/she was aware of the weight loss but did not do anything prior to today because Resident #183 was on the medication [MEDICATION NAME] daily. On 11/2/2017 at approximately 5:30 PM during an interview with the Registered Dietician (RD) revealed that the RD was not aware of the weight loss. The RD stated she finds out about a weight loss when the unit manager puts the resident on a list to be seen. Resident #183 has not been assessed by the RD to make recommendations to prevent further weight loss. Review on 11/2/2017 at approximately 5:40 PM of the facility policy titled, Care Plans, states under Care Plan Review and Update, 1. Comprehensive care plans should be reviewed not less than quarterly according to the OBRA MDS schedule, following the completion of the assessment. Care plan updates/reviews will be performed within 7 days of each quarterly assessment, each acute change in condition, and as needed following each hospital stay. Resident #205 was admitted with [DIAGNOSES REDACTED]. There was no documentation and of Dietary or Certified Nurse Assistant participation in the Multidisciplinary Care Conference Meeting held on 9/7/2017 for Resident #205. The form titled: The Multidisciplinary Care Conference Meeting, Attendance at Meeting, shows no signatures of the participants: Social Services Director, Therapy, Resident, CMD, Senior Care Partner, Family/Friends. Resident #47 was admitted with [DIAGNOSES REDACTED]. There was no documentation of Dietary or Certified Nurse Assistant participation in the Multidisciplinary Care Conference Meeting held on 6/30/17, 11:00, 48 hour meeting. The form titled: The Multidisciplinary Care Conference Meeting, Attendance at Meeting, Attendance at Meeting shows no signatures of Dietary or Certified Nursing Assistant. Resident #201 was admitted with [DIAGNOSES REDACTED]. There was no documentation of Dietary or Certified Nurse Assistant participation in the Multidisciplinary Care Conference Meeting held on 8/9/17, 11:30, 48 hour meeting. The form titled: The Multidisciplinary Care Conference Meeting, Attendance at Meeting, Attendance at Meeting shows no signatures of Dietary or Certified Nursing Assistant. The facility admitted Resident #14 with [DIAGNOSES REDACTED]. During a resident interview on 10/31/17 at 11:48am, the resident stated s/he is not always invited to meetings regarding her care. Review of the Comprehensive Care Plan Attendance sheet on 11/1/17 at 5pm revealed no signature involvement of the CNA, dietary, or the resident for the 9/21/17 meeting. During an interview on 11/2/17 at 12:20pm the MDS Nurse #2 stated It is the expectation for the CNA and dietary to be present. S/he was unsure why the resident was not present at the meeting and referred to the Senior Care Partner. During an interview on 11/2/17 at 12:23pm, the Senior Care Partner stated s/he was unsure why the resident was not invited to the care plan meeting and has no documentation to support why s/he was or was not invited. Review of the Physician's Order Sheet on 11/2/17 at 9am revealed an order that stated, Boot to left foot while in bed as patient tolerates. Review of the CNA (Certified Nursing Assistant) Care Record and review of the Comprehensive Care Plan had no evidence of the intervention. During an interview on 11/2/17 at 11:45am, MDS Nurse #1 verified the intervention for the deep tissue injury to the left heel was not on either Care Plans and stated it could fall under treatment as ordered. The facility admitted Resident #15 with [DIAGNOSES REDACTED]. Review of the Treatment Record on 11/1/17 at 5pm revealed a treatment for [REDACTED]. Further review of the (MONTH) Physician Orders did not reveal an order for [REDACTED]. During an interview on 11/2/17 at 12:40pm, LPN #3 verified the resident was using a low air loss mattress and that the 10/5/17 physician's order was not transcribed onto the (MONTH) Physician Orders. S/he verified that there was no evidence of the ordered interventions on the Comprehensive Care Plan or the CNA care plan.",2020-09-01
454,PRUITTHEALTH-WALTERBORO,425053,401 WITSELL STREET,WALTERBORO,SC,29488,2017-11-02,282,D,0,1,UBTQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to follow resident care plans for 1 of 2 residents reviewed for falls. Resident #173's care plan was not followed related to fall prevention measures. Tab alarms were not placed on the resident and Resident #173 sustained a fall. The findings included: The facility admitted Resident #173 with [DIAGNOSES REDACTED]. Review of the care plan on 11/1/17 revealed a care plan dated 8/14/17 with a problem of at risk for pain related to a fall. Interventions were chair alarm for safety, monitor patient frequently and a bed alarm. Further review of the medical record revealed the resident sustained [REDACTED]. Further review revealed the tab alarms were not properly applied to the wheelchair. During an interview with Licensed Practical Nurse #3 on 11/2/17 at 4:45 PM, he/she confirmed the chair alarm was not on the resident at the time of the fall.",2020-09-01
455,PRUITTHEALTH-WALTERBORO,425053,401 WITSELL STREET,WALTERBORO,SC,29488,2017-11-02,309,D,0,1,UBTQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, the facility failed to monitor the administration of [MEDICATION NAME] for 1 of 2 sampled residents reviewed for change of condition. Resident #14 did not have monitoring of blood pressure and heart rate during administration of [MEDICATION NAME] for chest pain for 3 different episodes. The blood pressure and pulse was either not performed, or not documented before and after administration. The findings included: The facility admitted Resident #14 with [DIAGNOSES REDACTED]. Review of the Physician's Interim Orders at 11/1/17 at 5:30pm revealed an order written [REDACTED]. Review of the Skilled Daily Nurse's Notes on 11/1/17 at 6pm revealed the following entries: 9/29/17 4:35pm Patient in wheelchair complain of chest pain, [MEDICATION NAME] PRN (as needed) given as ordered by NP (Nurse Practitioner), EGC (electrocardiogram) ordered waiting on results to relay to NP. 9/30/17 4:15am Patient c/o (complain of) chest pain and lower abdominal pain. VS 136/56, 79, 18. Given PRN Nitro x 1 dose with effective results. 10/4/17 5:53pm C/o chest pain PRN Nitro given with good effect after her return from [MEDICAL TREATMENT]. 10/8/17 (no time) Resident complained of chest pain times one. PRN nitro given at 12:30am. Vital signs stable. HR regular. She states in 5 minutes after receiving med that it eased up and that she did not want any more again because it burns. Review of the Medication Administration Record [REDACTED] 9/29/17 2pm 9/29/17 9pm 10/4/17 12:15pm During an interview on 11/2/17 at 1:18pm RN #3 stated, The resident came back from [MEDICAL TREATMENT] (on 9/29/17) and complained of chest pain. The NP was here and assessed the resident. The vital signs were checked, and she (he) was not in any distress. The NP gave orders for SL [MEDICATION NAME], an ECG, and a Consult to Cardiology. When questioned about the medication administration times and the Nurse's Note documentation, s/he stated I gave the SL NTG at 2pm. S/he verified that s/he did not document any vital signs or write an entry into the medical record. RN #3 stated, I had the nurse document it since it was her resident, and the NP had just done a set of vital signs and documented in her (his) assessment, and then the next set of VS were completed on 3-11 shift. RN #3 verified there were no documented vital signs for the 9/29/17 administration in the NP notes, and no evidence of blood pressure or pulse taken before or after administration of [MEDICATION NAME] on 10/4/17. S/he also verified that there was no documented pain score for the chest pain and no evidence of the 10/8/17 [MEDICATION NAME] administration on the MAR. S/he also verified no PRN documentation on the back of the MAR for any of the PRN [MEDICATION NAME]. RN #3 stated the documentation was in the Nurse's Notes and verified the time of the notes did not correspond to the times of the PRN administration. During an interview on 11/2/17 at 10:45am, when asked about the expectation regarding administration of [MEDICATION NAME], the Director of Nursing (DON) stated, Assessment before to see if warranted, check MD order, and expect that nurse takes full set of VS including heart rate and blood pressure before and after administration of [MEDICATION NAME]. Review of the administration and monitoring of [MEDICATION NAME] on Drugs.com, stated Monitoring Parameters: Blood pressure, heart rate; consult individual institutional policies and procedures. The facility stated they had no policy regarding administration and monitoring of [MEDICATION NAME]. Review of the Medication Administration: General Guidelines facility policy 11/3/17 at 11pm stated, When PRN medications are administered, the following documentation is provided: Date and time of administration, dose, route of administration; complaints or symptoms for which the medication was given; results achieved from giving the dose and the time results were noted; signature or initials of person recording the administration. The policy also stated, Only the licensed or legally authorized personnel that prepare a medication may administer it. This individual records the administration on the patient/residents MAR indicated [REDACTED]. After medication administration, the patient/resident's MAR indicated [REDACTED]. Initials on each MAR indicated [REDACTED]. Review of the care plan on 11/1/17 at 6pm revealed no active problem/need for chest pain or [MEDICAL CONDITION]. During an interview on 11/2/17 at 1:18pm, RN #3 stated that if the resident is here short term they don't care plan everything.",2020-09-01
456,PRUITTHEALTH-WALTERBORO,425053,401 WITSELL STREET,WALTERBORO,SC,29488,2017-11-02,314,D,0,1,UBTQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to assess and document wound measurements for Resident #104. In addition, Resident #38's pressure ulcer when assessed was down staged.(2 of 3 pressure ulcers reviewed) The findings included: The facility admitted Resident #104 with [DIAGNOSES REDACTED]. Record review on 11/1/17 revealed Resident #104 had eschar on the right and left heel and the right lateral foot and a dressing to the left great toe. Further review of the medical record revealed there were no measurements of the areas until 8/30/17. At the time of the assessment on 8/30/17, the areas were documented as an unstageable to the left shin 1 centimeter(cm) x 1.4 cm, unstageable to the right heel 2.2 cm x 3.7 cm, unstageable to the left great toe 3 cm x 4.9 cm and an unstageable to the left outer ankle 5 cm x 6.6 cm. Measurements for the wounds were not done again until 9/19/17 at the Wound Center. At the time of the 9/19/17 observation, the Wound Center classified the areas as arterial wounds measuring - left heel 6 cm x 6 cm x .2 cm; left lateral foot 5.5 cm x 3 cm x .2 cm; and right foot 6 cm x 5 cm x .2 cm. The wounds were dry with no sign of infection. Resident #104 had two hospitalization s on 7/29/17-8/7/17 and 8/21/17-8/30/17. During an interview with the Wound Care Nurse at the facility on 11/2/17 at 6:42 AM, he/she stated there were no measurements of the areas until 9/19/17. He/she further stated the wounds should have been assessed and measurements should have been taken and documented. No facility policy was provided during the survey process addressing how often wounds were to be assessed and measured. The facility admitted Resident #38 with [DIAGNOSES REDACTED]. Review on 11/1/2017 at approximately 5:21 PM of the Wound Observation and Assessment Form dated 9/21/2017 revealed a Stage III pressure ulcer of the left thigh, lateral side. On 10/3/2017 the wound care nurse measured the left thigh, lateral pressure ulcer and down staged the ulcer to a Stage II. Further review on 11/1/2017 at approximately 5:21 PM of the Wound Observation and Assessment Form dated 10/14/2017 revealed a Stage III pressure ulcer of the right 5th toe, lateral aspect. A second measurement was completed on 10/18/2017 and was downstaged to a Stage II During an interview on 11/1/2017 at approximately 5:30 PM with Registered Nurse (RN) #2 stated, I knew that I should not down stage wounds but was told when I first came here that I could down stage them. The RN stated, I knew better.",2020-09-01
457,PRUITTHEALTH-WALTERBORO,425053,401 WITSELL STREET,WALTERBORO,SC,29488,2017-11-02,323,D,0,1,UBTQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and observation, the facility failed to ensure an environment remains as free from accident hazards as possible for 2 of 2 residents reviewed for accidents. Resident #119 with behavior of placing cloth items in his/her mouth. Resident #173 with risk of falls and intervention not applied. The findings included: The facility admitted Resident #173 with [DIAGNOSES REDACTED]. Review of the medical record on 11/1/17 revealed a Fall Risk Observation Form dated 7/11/17 listed the resident with a score of 8 and a Fall Risk Observation Form dated 9/18/17 listed the resident with a score of 18 Guidelines for the form stated for residents who score (10) or more, or any resident at risk for falls, interventions should promptly be put in place. Interventions listed from the 7/11/17 assessment were a chair alarm, prompt patient to call when he/she needed to get up for assistance, callbell in reach, bed in low position and wheelchair locked. Further record review revealed Resident #173 was found on the bathroom floor on his/her right side. Resident stated he/she was trying to use the bathroom and did not ask for help. At the time Resident #173 complained of right arm pain which an x-ray revealed negative for a fracture. On 8/14/17 at 6:00 PM, sustained another fall. At that time, Resident #173 stated he/she was trying to shut the blinds and did not want to bother anyone by asking for help. No injury was noted. On 9/18/17 at 12:15 PM, Resident #173 was noted on the floor in front of his/her wheelchair in his/her room. A small hematoma was noted to right forehead. Review of the resident's care plan revealed interventions to prevent falls were: Remind resident/patient to call for assist with transfers and/or ambulation as needed; Maintain proper shoe size with non-skid soles/or gripper socks; keep call light within reach while in room; keep pathway clear and free of obstacles; therapy as ordered and maintain safety with transfers. On 8/14/17, chair and bed alarm for safety and monitor patient frequently was added. Review of the incident report dated 9/18/17 revealed tab alarms were not attached properly and staff were instructed on properly applying body alarms. During an interview with Licensed Practical Nurse(LPN) #3 on 11/2/17 at 4:45 PM, he/she stated the Certified Nursing Assistant had not attached the tab alarm properly on the resident. During an observation of the resident sitting in a wheelchair in his/her room with LPN #3 on 11/2/17 at 4:45 PM, he/she demonstrated the chair alarm was functional. Observation of the bed alarm revealed it had been placed in the off position. After turning the alarm on, the alarm was noted to be functional. The Facility readmitted Resident 119 on 4/25/16 with [DIAGNOSES REDACTED]. Review of the Nurses Notes for August, (MONTH) and October, (YEAR) on 11/1/17 at approximately 9:19 AM revealed multiple instances where Resident 119 had been chewing on self, clothing and/or bed sheets with shredded pieces of fabric found in his/her mouth: -8/10/17 2AM Chewing on sheets (bed sheets) -no interventions noted- -8/12/17 1:30 AM Observed resident with shredded pieces of his shirt on bed and floor. Resident was repositioned -8/12/17 5PM Resident biting pieces of shirt up. Resident redressed but continues to rip up with teeth, also did this to sheets. - no interventions noted- -8/13/17 4AMResident in bed quiet and chewing on collar of yellow shirt, corner piece chewed off and fragments in bed. - no interventions noted- -8/13/17 8:50PM Resident has torn white t-shirt and had fragments in mouth, Resident removed t-shirt fragment from mouth. -8/14/17 6AM Resident has shredded t-shirt and sheet. ADL provided intermittent yelling noted. Denies pain - no interventions noted- -8/21/17 12:30 AM Resident in bedroom yelling for help, nose bleed, observed resident picking pieces in nose until it bleeds. Advise resident not to pick in nose and it will stop bleeding. Continues shredding sheets, gowns with teeth and chewing the pieces then spitting on floor. Resident has been told numerous occasions to stop chewing on sheets and gowns because it will make him sick but he continues.' - no interventions noted- -9/5/17 4:30 AM Resident chewing and ripping linens with teeth - no interventions noted- -9/9/17 4 AM continuing to rip clothing with teeth. Yelling out during the night. Resident repositioned, ADL care provided and continues to yell out. Denies pain at this time. -9/12/17 3:02 AM continues eating gown and linens. - no interventions noted- -10/19/17 resident biting him/herself on right upper arm - no interventions noted- -10/23/27 shreds clothing and linen, removed from mouth -Review of the Nursing Monthly Assessment Form dated 8/23/17 on 11/1/17 at approximately 9: 31 AM revealed a statement related to chewing and tearing bed linen and clothes with teeth. -On 11/1/17 at approximately 10:52 AM a review of the Social Services Progress Notes Form for Resident 119 revealed one entry dated 10/5/17 which states Need to be a t-shirt, he/she chews on everything. He/she chews on sheets. -On 11/1/17 at approximately 11:00 AM a review of the current care plan did not show interventions for chewing/swallowing or the addition of Nuedexta 20 mg-10 mg to the medication regimen. There were entries dated 8/29/17, 9/4/17 and 9/5/17 for other Problem/Need areas . -On 11/1/17 at approximately 11:18 AM a review of the August, (MONTH) and October, (YEAR) Medication Administration Record for Behavior Monitoring did not show that chewing/swallowing,biting had being charted CNA (Certified Nursing Assistant) # 1 stated in an interview on 11/1/17 at approximately 11:39 AM that he/she is not involved with care planning for Resident 119, but acknowledged that he/she shreds and chews clothing and sheets. In order to control chewing/shredding behaviors and minimize harm, CNA # 1 stated that he/she uses diversions of snacks, television and clothing such as t-shirts that don't have buttons, but isn't sure of what others do. CNA # 1 stated We ask him why he does it, and he has no answer. On 11/1/17 at approximately 12:42 PM the LPN (Licensed Practical Nurse) # 2, 11/01/2017 stated that he/she had discussed the behaviors of Resident 119 related to shredding clothing and bed linen at the care plan meeting on 9/27/17. He/she stated that the family was aware of the behaviors and that he/she had exhibited this kind of behavior before and that a pacifier helped. LPN # 2 stated that they could not let him/her use a pacifier because of the swallowing risk, but did focus on snacks and activities such as television that would redirect him/her. LPN # 2 stated that the physician had ordered Nuedexta which had been started on 9/12/17 and that it seemed to help decrease these type of behaviors.",2020-09-01
458,PRUITTHEALTH-WALTERBORO,425053,401 WITSELL STREET,WALTERBORO,SC,29488,2017-11-02,325,D,0,1,UBTQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews, and review of the facility policy titled, Weight Monitoring Program, the facility failed to ensure Resident #183 maintained acceptable parameters of nutritional status with weight monitoring and interventions in place to improve and or prevent weight loss. The facility further failed to ensure a nutritional supplement was implemented for Resident #205 with weight loss for 2 of 4 sampled residents reviewed for Nutrition. The findings included: The facility admitted Resident #183 with [DIAGNOSES REDACTED]. Review on 11/2/2017 at approximately 2:00 PM of the Plan of Care for Resident #183 revealed a 9.1 % weight loss in 1 month. The weight loss on 7/5/2017 was 10.2 % weight loss in 3 months. The weight loss on 8/10/2017 was 8.9 % in 1 month and 12.6 % weight loss in 3 months. The weight loss on 9/29/2017 was 17.3 % in one month. On 10/13/2017 indicated a 19.3 % weight loss for 1 month. The interventions included, supplement as ordered, colored napkin on tray and milk and pudding on tray. After the weight loss was recorded on 10/13/2017. No other interventions were put in place to ensure an improvement in weight loss for Resident #183 until the weight loss was brought to the Certified Dietary Managers attention on 11/2/2017. On 11/2/2017 Resident #183 weighed 133.6 pounds which indicated a further weight loss without revision of the care plan with interventions to prevent further weight loss for Resident #183. Review on 11/2/2017 at approximately 3:33 PM of the Yearly Weight Record Form, revealed on (MONTH) 1, (YEAR) Resident #183 weighed 196 pounds. On (MONTH) 8, (YEAR) he/she weighed 198 pounds. Resident #183 weighed 180 on (MONTH) 1, (YEAR). The weight on (MONTH) 5, (YEAR) was 176 pounds. On 8/9/2017 Resident #183 weighed 173 pounds and on 8/28/2017 he/she weighed 164 pounds. On 9/6/2017 Resident #183 weighed 176 pounds and on 9/29/2017 he/she weighed 143 pounds. On 11/2/2017 Resident #183 weighed 133.6 lbs. No interventions were in place to improve weight loss or to prevent further weight loss. During an interview on 11/2/2017 at approximately 5:00 PM with the Certified Dietary Manager, he/she stated he/she was aware of the weight loss but did not do anything prior to today because Resident #183 was on the medication [MEDICATION NAME] daily. A physician's order was obtained on 11/2/2017 to administer a dietary supplement of Standard 2.0, 90 milliliters by mouth 3 times daily with medications. Review on 11/2/2017 at approximately 5:45 PM of the facility policy titled, Weight Monitoring Program, states under, Weight Frequency, number 6 states, Re-Weighs. Reweighs must be obtained on all weights (Daily, weekly or monthly) that shows a weight loss/gain of 3 pounds or more for weekly weights and 5 pounds or more for monthly weights. Reweighs must be obtained and documented within 24 hours of prior weight. Number 3 under, Weight Team, states, The Weight Team's responsibilities include evaluating weights or significant changes; recommending appropriate interventions; reviewing patient/resident meal, supplement, and snack intakes; revision interventions, if necessary; attending weekly meetings; completing the Weight Loss/Gain Checklist and completing weekly documentation in the patient's/resident's chart. For healthcare centers that utilize electronic charting, it will be located within the electronic chart. The facility failed to ensure the supplement intervention as recommended by the RD (Registered Dietitian) and per facility policy and procedure was implemented for Resident #205's whose significant weight loss was documented as greater than 5% in 1 month. The findings include: Resident #205 was admitted with [DIAGNOSES REDACTED]. Review of the medical record on 10/31/2017 at approximately 4:30 PM reveals that the Diet order for Resident #205 is Regular, No Added Salt. The Yearly Weight Record form has the following weights recorded for Year : (YEAR): 8/31: 173 9/8: 173 9/15: 174 9/28: 163.7 10/4: 164 10/11: 159 The Nutrition Screening and Assessment Form completed by the Registered Dietitian on 10/3/17 states: Resident receives a NAS (No Added Salt) Regular diet, consuming 25-75% @(at) most meals. Wt(Weight) trend-9/28: 163.7#(pounds)-decrease 5.6% x(times) 1 month Rcmd(Recommend) 1) Start 2.0 Supplement 60 ml (milliner) TID (three times daily) (360 kcals(kilocalorie)/15 g(grams) pro(protein.) Review of the Physician Orders dated 10/01/17 to 10/31/17 and 11/01/17 through 11/30/17 reveals no evidence of order for the 2.0 Supplement as recommended by the Registered Dietitian. The form titled, Significant Weight loss Gain Checklist form dated 09/29/17 shows weight of 163.7, 5.4% weight loss 1 month, .4. Weight Team Recommendations: Start pudding L/S , milk all meals ,colored napkin on tray The form titled, Significant Weight loss Gain Checklist form dated 10/6/17 shows weight of 164, 5.2% weight loss 1 month, .4. Weight Team Recommendations: continue pudding l/s , milk all meals. The Care Plan for problem Onset has written: .9/29/17: 5.4% wt loss 1 month., 10/6/17: 5.2% weight loss 1 month. Approaches: 9/8/17: . Diet upgraded, 9/29/17: Pudding l/s on Tray, Milk with each meal, Colored Napkin on Tray. The from titled, Weight Progress Notes for Resident #205 has an entry on 10/4/17: Weight 164, no changes in diet orders, eats 50-75% continue approaches On 11/01/2017 at 12:50 PM Interview with RN#1 he/she said if a supplement is ordered for resident it is placed on the MAR (Medication Administration Record) and verified by the Nurse. RN#1 verified the (MONTH) MAR for Resident #205 had no orders for the 2.0 Supplement. On 11/01/2017 at 2:43 PM, LPN #3 said that RD recommendations are entered on the Physician's Interim Orders by the CDM and then the Nurse processes the order and enters on the MAR. On 11/01/2017 at approximately 3:00 PM, The CDM said that at the end of each RD visit, the RD gives a list of RD recommendations to the CDM. The CDM said the RD recommendations are then entered on the Physician's Interim Orders in each residents medical record by the CDM and then the Nurse processes the orders and enters on the MAR. The CDM verified an entry on the form titled, RD Consultant Recommendations, Date: (MONTH) (YEAR), there is an entry for Resident #205 which states: Resident #205, Rcmd(Recommendation): 1) Start 2.0 Supplement 60 ml TID. Document % intake on the MAR. The CDM said, I did not enter the order on the Physician's Interim Orders. After the discovery that no supplement had been ordered, the CDM then wrote a Physician's Interim Order on 11/1/2017 for Resident #205 for: 60 ml standard 2.0 TID with meals. On 11/02/2017 at 2:26 PM, the RD verified the recommendation that h/she made for Resident#205 and h/she verified that the CDM is responsible for writing the orders on the Physician's Interim Orders and then the Nurses processes the order. The RD verified that the last weight entered in the medical record was 10/11 of 159 pounds which shows further weight loss of 5 pounds from 10/4/17 to 10/11/17. The RD was able to locate a reweigh which had been completed on 10/11/17 which was not readily available in the resident's medical record and this reweigh was 164 pounds. The RD asked the staff to obtain a weight on the resident today and the weight obtained on 11/2/17 was 170.8 pounds. The RD provided a new copy of the Yearly Weight record form with the reweigh completed on 10/11 and the (MONTH) weight obtained today on 11/02/17 of 170.8. The facility policy and procedure titled: Weight Monitoring Program, Effective: 09/01/2017, Reviewed: 10/16/17 and Revised: 10/16/17, states,Significant Weight Changes: 1. A significant weight change is defined as: 5% weight loss or gain in one month.;;;2. The Weight Team will evaluate these changes and determine if the change is either: Significant Weight Gain: .or Significant Weight Loss .Unplanned/unanticipated: Complete Weight Loss/Weight Gain Checklist, Add to Weekly Weights, Add to Colored Napkin Program, Weekly Weight Team documentation,Update Food Preferences, Update Care Plan, Interventions will be added as needed Weight Discrepancies: .If a variance of five percent (5%) or greater is obtained when establishing new baseline weights, the patient/resident will be re- weighed consecutively for the next two days to verify baseline weight. All weights will be documented on the Yearly Weight Record Form. During an interview on 11/01/2017 at 3:15 PM with the DON, he/she said that he/she is aware of how recommendations are put into place from the RD. He/She said that he/she has been here for 2 years and the process has worked well. Reviewed the Registered Dietitian Recommendations with the DON and he/she verified that the recommendation made by the RD on 10/3/17 and that no order was written until today 11/1/17. The facility Policy and Procedure titled, Registered Dietitian Recommendations, Effective 09/01/2001, Reviewed: 08/03/2017, and Revised 04/11/2016, states: Policy Statement: It is the policy of PruittHealth for the Registered Dietitian's recommendations regarding the patient/resident's nutritional therapy be implemented Procedure: 1. The Consultant or In-house Registered Dietitian will communicate any recommendations for patient/resident assessed on the Medcal Nutrition Therapy Recommendations form. 2. The Consultant/Registered Dietitian's recommendations will be emailed to the Administrator, Dietary Manager, Director of Nursing and/or appropriate nursing partners for follow-up with the physician. The in-house Registered Dietitian will communicate any recommendations to the physician and/or the designated nursing partners. 3. Recommendations require implementation within 5 days.",2020-09-01
459,PRUITTHEALTH-WALTERBORO,425053,401 WITSELL STREET,WALTERBORO,SC,29488,2017-11-02,328,E,0,1,UBTQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and review of the South [NAME]ina Board of Nursing Advisory Option #9, the facility failed to provide care and services that met professional standards of practice for 1 of 1 sampled resident who had a Peripheral Inserted Central Catheter (PICC) Line. Residents #15 was administered PICC Line flushes and antibiotics by Licensed Practical Nurses (LPN) with no documentation of advanced training and there were twenty days when a Registered Nurse (RN) was not on site when the LPN's administered the medications and flushes via the PICC Line. The findings included: The facility admitted Resident #15 with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. New order on 8/28/17 stated, Flush PICC line with 10 ml normal saline every shift to maintain patency 7a-7p & 7p-7a. Physician order [REDACTED]. After 10/4/17, IV [MEDICATION NAME] was ordered every 24 hours. Review of the (MONTH) and (MONTH) Medication Administration Record [REDACTED]. No evidence of PICC line flushes with [MEDICATION NAME] for August, dressing change on 8/30/17 or 9/6/17, or injection cap changed on 8/30/17 as the MAR indicated [REDACTED]. Review of the Medication Administration Record(MAR) for (MONTH) (YEAR) revealed Licensed Practical Nurses administered medication and flushed the resident's PICC Line without proper training of the use of a PICC Line on day shift 7a-7p on 10/1/17,10/4/17- 10/6/17, 10/9/17-10/12/17, 10/14-10/15/17, 10/19-10/20/17, and 10/23-10/25/17; and on night shift 7p-7a on 10/1/17-10/13/17, 10/15/17, 10/16/17, 10/19/17, 10/21/17-10/24/17, and 10/26/17-10/31/17. Review of the facility staffing sheets for the time of (MONTH) through (MONTH) (YEAR) revealed that there were 20 days when a RN was not in the building as required while the medication and flushes were being administered via a PICC Line per documentation on the medication administration record. During an interview with LPN #1 and LPN #3 on 11/02/2017 at 12:50pm they verified they both had initialed the MAR but stated they did not administer the medication. They were unable to identify who administered the medications if they initialed as given but didn't administer. They also verified they had not received any training regarding PICC line flushes or medication administration. During an interview on 11/2/17 at 7:22pm, the Director of Nursing verified there was no documentation to support the LPN's received proper training regarding PICC lines. Per the South [NAME]ina Department of Labor, Licensing and Regulation, (Advisory Opinion # 9B) states: The selected LPN shall document completion of special education and training to include: cardiopulmonary resuscitation and intravenous therapy course relative to the administration of fluids via peripheral and central venous access devices/lines that includes didactic and supervised clinical competency training with return demonstration The LPN may not give medications directly into the vein (intravenous push) or insert medication via an external catheter site (PICC). The Agency must have specific standing orders to deal with potential complications or emergency situations and provision for supervision by the RN. Section 40-33-20 defines supervision as meaning the process of critically observing, directing, and evaluating another's performance.",2020-09-01
460,PRUITTHEALTH-WALTERBORO,425053,401 WITSELL STREET,WALTERBORO,SC,29488,2017-11-02,332,D,0,1,UBTQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a observation, record review, and interview the Facility failed to ensure a medication error rate of less than 5%. The facility medication error rate was 7.4%. Resident #15 received a saline flush before and after the administration of [MEDICATION NAME] through a Peripherally Inserted Central Catheter (PICC). The findings included: The facility admitted Resident #15 with [DIAGNOSES REDACTED]. During a medication observation on 10/31/17 at 12:36pm, Registered Nurse #1 cleaned the PICC line red lumen port with alcohol, administered 5ml of Normal Saline, set the Normal Saline on the bedside table, administered 5ml of [MEDICATION NAME], and then administered the remaining 5ml left in the first syringe of normal saline. Review of the physician's orders [REDACTED]. During an interview on 10/31/17, RN #1 verified that s/he administered 1/2 the normal saline (5ml), then the 5ml of [MEDICATION NAME], and then administered the remaining 5ml of normal saline from the first syringe to flush the red port of the PICC line. Verified with RN #1 that the physician's orders [REDACTED]. Verified the physician's orders [REDACTED]. During an interview on 11/1/17 at 11:10pm, the Director of Nursing verified per physician's orders [REDACTED]. Review of the Central Infusion Access Device Maintenance policy on 10/31/17 at 6:20pm stated, A physician's orders [REDACTED]. The Procedure section of the policy stated, Flush protocol for PICC is 5ml [MEDICATION NAME] 10 units per ml final flush, and 5ml [MEDICATION NAME] 10units per ml all unused lumens every 24 hours. Further review of the Flush Protocol for Vascular Access Devices policy stated, All flush solutions must be stated in the physician's orders [REDACTED].",2020-09-01
461,PRUITTHEALTH-WALTERBORO,425053,401 WITSELL STREET,WALTERBORO,SC,29488,2017-11-02,333,D,0,1,UBTQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a observation, record review, and interview the Facility failed to ensure that Resident #15 was free of significant medication errors related to administration of a [MEDICATION NAME] flush for a Peripherally Inserted Central Catheter (PICC). The findings included: The facility admitted Resident #15 with [DIAGNOSES REDACTED]. During a medication observation on 10/31/17 at 12:36pm, Registered Nurse #1 cleaned the PICC line red lumen port with alcohol, administered 5ml of Normal Saline, set the Normal Saline on the bedside table, administered 5ml of [MEDICATION NAME], and then administered the remaining 5ml left in the first syringe of normal saline. S/he did not disinfect the port between flushes. Review of the physician's orders [REDACTED]. During an interview on 10/31/17, RN #1 verified that s/he administered 1/2 the normal saline (5ml), then the 5ml of [MEDICATION NAME], and then administered the remaining 5ml of normal saline from the first syringe to flush the red port of the PICC line. Verified with RN #1 that the physician's orders [REDACTED]. Verified the physician's orders [REDACTED]. RN #1 also verified that s/he only disinfected the red lumen once prior to the first flush and did not disinfect prior to the next 2 flushes administered. During an interview on 11/1/17 at 11:10pm, the Director of Nursing verified per physician's orders [REDACTED]. Review of the Central Infusion Access Device Maintenance policy on 10/31/17 at 6:20pm stated, A physician's orders [REDACTED]. The Procedure section of the policy stated, Flush protocol for PICC is 5ml [MEDICATION NAME] 10 units per ml final flush, and 5ml [MEDICATION NAME] 10units per ml all unused lumens every 24 hours. Further review of the Flush Protocol for Vascular Access Devices policy stated, All flush solutions must be stated in the physician's orders [REDACTED]. Review of the Flush Protocol for Vascular Access Devices Policy on 10/31/17 at 6:20pm stated, Scrub the injection cap/valve with an alcohol prep pad, attach the normal saline syringe, flush, scrub injection cap/valve with an alcohol prep pad and attach the tubing and administer the infusion medication/solution. Review of Lippincott Procedures Peripherally Inserted Central Catheter (PICC) drug administration on 10/31/17 at 4:30pm stated, Perform a vigorous mechanical scrub of the needleless connector for at least 5 seconds using an antiseptic pad, attach a prefilled syringe containing preservative free normal saline, remove and discard the syringe, perform a vigorous scrub of the needless connector for at least 5 seconds using an antiseptic pad, then connect the IV (intravenous) administration set tubing to the PICC.",2020-09-01
462,PRUITTHEALTH-WALTERBORO,425053,401 WITSELL STREET,WALTERBORO,SC,29488,2017-11-02,334,D,0,1,UBTQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews and review of the facility policy titled, Influenza Vaccinations for Partners, the facility failed to ensure the Personal Representative for Resident #38 was provided the information and education regarding the benefits and potential side effects of the Influenza Vaccine prior to receiving it for 1 of 6 residents reviewed for receipt of the Influenza Vaccine. The findings included: The facility admitted Resident #38 with [DIAGNOSES REDACTED]. Review on 10/31/2017 at approximately 4:41 PM of the medical record for Resident #38 revealed an Influenza (Flu) Vaccine Consent/Refusal Form for Resident #38 signed by Licensed Practical Nurse (LPN) #3 the unit manager. LPN #3 had obtained a telephone consent from the responsible party of Resident #38 for him/her to receive the Influenza vaccine this flu season. Further review of the medical record for Resident #38 revealed a form titled, Immunization Summary Record, in which Resident #38 received the Influenza Vaccine on 10/27/2017. No documentation could be found in the medical record to ensure the responsible party was provided the information and education regarding the benefits and potential side effects of receiving the Influenza Vaccine. Review on 10/31/2017 at approximately 4:42 PM of the facility policy titled, Influenza (Flu) Vaccinations for Partners, states under Procedure: Number 5, Prior to the vaccination the partner will be provided the information and education regarding the benefits and potential side effects of the influenza vaccine. Provisions of such education shall be documented in the partner's record, as indicated below. Number 6 states, The partner will sign a consent indicating he or she wishes to receive the vaccination on the Influenza (Flu) Vaccination for Partners Informed Consent and Administration Form. During an interview on 10/31/2017 at approximately 4:55 PM with Licensed Practical Nurse (LPN) #3, Unit Manager, confirmed that the documentation to ensure the responsible party for Resident #38 had received the education regarding the benefits and the potential side effects of the influenza vaccine had not been completed and in the medical record for Resident #38.",2020-09-01
463,PRUITTHEALTH-WALTERBORO,425053,401 WITSELL STREET,WALTERBORO,SC,29488,2017-11-02,371,F,0,1,UBTQ11,"Based on observation, interview and review of the facility policies and procedures the facility failed to ensure the following in 1 of 1 kitchen, 1 of 4 medication room refrigerators, 4 of 4 medication carts and 2 of 4 nourishment room refrigerators: 1) Expired lettuce was removed from the refrigeration unit in the kitchen. 2) The manual can opener blade and housing was free of build up of debris. 3) Meat slicer when stored as clean was free from meat debris. 4)The sneeze guard housing which is located directly above the food serving line was free from build up grease and food debris. 5) Plate covers were stored clean and free from debris. 6) Apple juice temperature was maintained at 41 degrees or below for 24 hours each day which was stored on top of the medication carts. 7) Expired Ensure and apple juice removed in the medication room refrigerator 8) Expired resident's personal food was removed from the nourishment room refrigerators. The findings included: An observation was verified by the CDM (Certified Dietary Manager) during initial tour,on 10/30/2017 at 10:55 AM of 3 bags, each containing multiple heads of Romaine lettuce with brown substance on the lettuce leaves and the base of each head. The label on the bags of lettuce stated: 10/20/2017. When the CDM was asked, When does the label on the lettuce indicate it has expired? H/she said; I do not know, the date on the label is the day it (the lettuce) came in from the vendor. H/She then removed the lettuce from the cooler and discarded. During initial tour of the dry storeroom on 10/30/17 at approximately 11:00 AM, the CDM verified a partially open bag of House of Autry Mills Breading. H/She said it should have been wrapped up before placing back on the shelf. The facility policy and procedure titled, Labeling Dating and Storage, Effective: 06/01/2016, states, Policy Statement: It is the policy of PruittHealth for all partners who assist in handling, preparing,serving and and storing food and beverage items to follow the proper procedures for labeling, dating and storage to ensure proper food safety. Procedure: 1. Food and/or beverage items will be properly labeled with the name of the item, and a use by date., 2. Foods will be stored in their original containers or in an approved container or wrapped tightly with film, foil,etc. and clearly labeled with the name of the item and the use by date. An observation was verified by the CDM (Certified Dietary Manager) during initial tour,on 10/30/2017 at 11:00 AM of the manual can opener attached to the table top, the blade and the can opener housing both had a build up of brown colored debris The CDM said that the can opener is cleaned after each meal. An observation on 11/01/2017 at approximately 3:00 PM, the can opener is free from debris, the can opener blade has a rough surface with some chipped away silver paint the CDM stated that he/she plans to order a new blade. The facility policy and procedure titled, Cleaning Procedures: Small Equipment, Effective: 06/01/2016, Reviewed: 08/03/2017, Revised: 04/15/2016,which states:Procedure: Can Opener and Base, Daily: 1. Wash the handle portion of the can opener in the dish machine or pot/pan sink. 2. Wash the base with a detergent solution, using a brush and cloth. Make sure the shaft cavity is clean. 3. Rinse the base with fresh water and allow to air dry. 4. Sanitize with appropriate strength solution. During initial tour, an observation on 10/30/2017 at approximately 11:00 AM of the Meat Slicer covered with plastic cover, when the plastic cover was removed there were crumbs of meat behind the blade and on the surface of the meat slicer. The CDM said I will clean this. On 11/1/2017 at approximately 4 PM an observation of the meat slicer stored under plastic cover,there were crumbs of meat underneath the blade and on surface of the meat slicer. The CDM stated: I thought I got all of this. H/she then said that he/she would clean it again. The facility policy and procedure titled, Cleaning Procedures: Small Equipment, Effective: 06/01/2016, Reviewed: 08/03/2017, Revised: 04/15/2016, and states: Procedure: Food Slicers, After each use: 1. Unplug, Remove blade cover and guars. Wash in hot soapy water, sanitize, and allow to air dry 2. Wash the knife blade carefully with hot, soapy water and sanitize. Allow to air dry .3. Wash, rinse, sanitize and air dry other parts of the slicer. 4. Reassemble blade cover an all guards and reset blade at zero as soon as possible (for safety purposes) 6. Cover and remain unplugged in proper location. During initial tour on 10/30/2017 at approximately 11:05 AM, an observation of the green, plastic plate covers which were stored as clean on the plate cover drying rack were noted to have small white flecks stuck to the interior of the plate covers. Multiple plate covers had the white flecks which could be scraped off. During and interview with the CDM, h/she verified this observation and said that h/she would watch this, but h/she was unsure of what the substance was or how it got on the green plate domes. An observation on 10/30/2017 at approximately 11:05 AM and again on 11/02/2017 at approximately 3:15 PM of the plastic sneeze guard which was located directly over the food serving line, had a build up of brown greasy substance in the crevices and the surface was soiled. The CDM verified the observation and during an interview h/she said that a new replacement steamtable and sneeze guard had been ordered by the facility and had not arrived yet. An observation on 11/02/2017 at 10:26 AM of the Unit 2 refrigerator which contained a tupperwear container of food/small round brown substance for Resident# 174 and was dated 10/30. The observation was verified by LPN #4, h/she said: We will throw this away today. H/she then removed the container from the refrigerator. An observation was verified by RN #3 on 11/02/2017 at 10:35:32 AM of the Unit 1 refrigerator which contained 4 pimento cheese sandwiches with the date 10/31 written on label. RN #3 stated: Will discard this at end of today. The refrigerator also contained a bag with resident name/date written on label; Resident #157, the date on label stated 10/30. RN #3 said she asked the resident yesterday about the food and the resident said h/she still wanted the salad. RN# 3 said she would ask the resident again today if h/she still wanted the salad before h/she discarded. RN#3 said that food for residents should be discarded after 48 hours. The facility policy and procedure titled, Patients/Residents' Personal Food, Effective 09/01/2001, Reviewed: 11/21/2016, Revised: 11/21/2016, states, Policy statement: It is the policy of PruittHealth to allow the patient/resident's family to provide personal food items for patient/resident consumption. The patient/resident's personal food items will be maintained in a clean, healthy environment to help prevent foodborne illnesses. Procedure: .4. Foods requiring refrigeration must be stored in the nursing unit refrigerator those items stored in the nursing unit refrigerator must be kept to a minimum due to limited space. Food requiring refrigeration must be labeled and dated will be discarded after 48 hours .7. Nursing personnel will be responsible for the disposal of outdated foods maintained in the patient/resident's room and those stored in the nursing unit refrigerators. An observation on 11/02/2017 at approximately 10:30 AM of pitchers of apple juice stored at room temperature located on the medication carts of each nursing unit. The pitchers of juice all have a white label with the date written on the label: 11/02. An interview with LPN #3 on 11/02/2017 at 11/02/2017 11:04 AM, he/she said the apple juice comes out each morning from the dietary and is not refrigerated. On 11/02/2017 at 11:07 AM an interview with LPN #2 and LPN #7 said the apple juice comes out in morning and we give per protocol for diabetics and for resident that request the juice, the apple juice is on the cart all day. An interview with the CDM on 11/02/17 at approximately 10:45 AM h/she said they send out fresh apple juice every day, first thing in the morning and h/she said was unsure if juice needs to be refrigerated, The facility policy and procedure titled, Labeling Dating and Storage, Effective: 06/01/2016, states, Policy Statement: It is the policy of PruittHealth for all partners who assist in handling, preparing,serving and and storing food and beverage items to follow the proper procedures for labeling, dating and storage to ensure proper food safety. Procedure: 1. Food and/or beverage items will be properly labeled with the name of the item, and a use by date .4. Those items that require refrigeration and/or require refrigeration once they have been opened will be labeled with a use by date based on the USDA Quick Reference Shelf Life List. On 10/31/17 at 9:22am during a medication room inspection on Unit 4, the following expired items were found, and verified with LPN #3. 1. 5 bottles of Topcare Nutrisure Original Nutrition Shake, Vanilla, 8 ounces each, with an expiration date of 10/25/17. 2. A 4.2 ounce Minute Maid Kids Mini apple juice with expiration date of 5/8/17.",2020-09-01
464,PRUITTHEALTH-WALTERBORO,425053,401 WITSELL STREET,WALTERBORO,SC,29488,2017-11-02,441,E,0,1,UBTQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and review of the facility policy titled, Infection Control-Linen and Laundry Services, the facility failed to ensure soiled linen was handled and transported in a manner to decrease and or prevent the spread of infections in 3 of 3 soiled utility rooms and 1 of 1 Laundry room. The facility further failed to ensure bed pans and urine collection hats were covered during random room observations. The facility additionally failed to ensure Resident #67 and #165 did not share a cup of a beverage during a random observation of residents in the dining room. The findings included: An observation on 11/2/2017 at approximately 9:15 AM revealed Laundry Staff #1 entered the soiled utility rooms on unit 1 and 2, he/she applied gloves and removed the soiled linen from one bin to another. Laundry worker #1 removed his/her gloves and did not wash his/her hands prior to leaving one soiled utility room and going into the next soiled utility room. Laundry Staff #1 returned to the Laundry Room with bins of soiled linen and moved to the washers and applied gloves and proceeded to remove clean linen from the washer. Laundry Staff #1 failed to wash his/her hands after removing his/her gloves and moving to another soiled utility room and did fail to wash his/her hands after returning to the laundry room prior to removing clean clothes from the washers. An observation on 11/2/2017 at approximately 9:20 AM during the transporting of soiled linen from the soiled utility room to the laundry room revealed soiled linen dropped in the bins in the soiled utility rooms and not first bagged in the resident's rooms in 3 of 3 soiled utility rooms. An interview on 11/2/2017 at approximately 9:20 AM with the Housekeeping Supervisor and Laundry Staff #1 confirmed the above findings and stated the soiled linen should have been bagged in the resident's room prior to taking it into the soiled utility rooms and placing it in the bins. An observation on 11/2/2017 at approximately 9:30 PM revealed Laundry Staff #1 unfolding the soiled linen and shaking it out in front of his/her face and then throwing it into a bin of other sorted soiled linen. During an interview on 11/2/2017 at approximately 9:35 AM Laundry Staff #1 confirmed that he/she had not washed his her hands after removing his/her gloves and proceeding to the next laundry room and after returning to the laundry room and prior to removing clean clothes from the washers. Laundry Staff #1 also confirmed at this time that he/she did shake out the soiled sheets and other linen prior to putting it in bins of like clothes during the sorting process. An observation on 11/2/2017 at approximately 9:45 PM revealed Laundry Staff #2 transporting a soiled bed sheet into the soiled utility room not bagged and holding the soiled sheet against his/her clothes and not wearing gloves. During an interview on 11/2/2017 at approximately 9:45 AM Laundry Staff #2 confirmed the bed sheet was not bagged and he/she stated, I just removed my gloves. I keep them in my pocket. Review on 11/2/2017 at approximately 10:20 PM of the facility policy titled, Infection Control - Linen and Laundry Services, revealed under Policy Statement, It is the policy of this facility to provide a clean supply of linens and protect partners who handle and process the laundry. Stated under Procedure, revealed, 1. All soiled linen will be treated as potentially infectious. 2. Soiled linen should be handled as little as possible and with a minimum of agitation to prevent gross microbial contamination of the air and of persons handling the linen. Standard precautions will be used by laundry staff handling the linen. 3. All soiled linen should be bagged or put into carts at the location where used: it should not be sorted or pre-rinsed in patient/resident care area. Linen that is saturated with blood or body fluids should be deposited in impervious bags. The section titled, Protection of Personnel Who Sort Laundry: states, under number 2, Laundry personnel should wash their hands and remove protective barriers before going into the clean linen area. Resident # 67 was admitted with [DIAGNOSES REDACTED]. Resident #67's Diet order was: No Added Salt, Liberalized Diabetic, Regular Consistency and no known allergies [REDACTED]. Resident #165 was admitted with [DIAGNOSES REDACTED]. Resident #165's Diet order was: No Added Salt, Low Potassium, Liberalized Diabetic, Regular Consistency and no listed food allergies [REDACTED].>A random observation on 10/30/2017 4:19 PM when a resident's family member appeared in the common area of Unit 4. Multiple residents were sitting at the dining tables and nurses were sitting at the nurse's station directly across from the dining room tables. A family member had brought some food from Burger[NAME]which he/she setup for his/her mother at the table and his/her mother was eating the food and drinking a beverage with a straw in it. Resident #165 and Resident #67 were sitting at the same table together and were drinking beverages from small plastic cups. Resident #165 and Resident #67 swapped the small plastic cups they had each been drinking from. The family member who had brought the food for his/her mother, opened the lid of his/her personal coffee mug and began to pour a brown, chalky liquid into Resident #165's cup which had formerly belonged to Resident #67. The resident's family member then poured more brown, chalky substance in Resident #165's cup and then the family member stuck a straw in the cup. The resident's family member then asked resident #67 if he/she was diabetic and gave Resident #67 a sprite. During an interview LPN#3 on 10/30/17 at approximately 4:30 PM said that a visitor can only to give food or drink to his/her immediate family member after they must first consult with the nurse. The Facility Policy and Procedure titled: Patients/Resident's Personal Food, Effective 09/01/2001, Reviewed: 11/21/2016, and Revised 11/21/2016, states: Policy Statement: It is the policy of Prithee to allow the patient/resident's family to provide personal food items for patient/resident consumption. The patient/resident's personal food items will be maintained in a clean, healthy environment to help prevent foodborne illness. During room rounds on 10/30/17 at 2:52 PM, Resident #63's restroom was observed with an uncovered bedpan. During room rounds on 10/30/17 at 2:58 PM and on 10/31/17 at 12:23 PM, Resident #15's restroom was observed with uncovered urine collection hats. During the environmental tour on 11/2/17 at 5:00 PM with the Maintenance Director and the Housekeeping Director, the above findings were observed and confirmed by the Housekeeping Director.",2020-09-01
465,PRUITTHEALTH-WALTERBORO,425053,401 WITSELL STREET,WALTERBORO,SC,29488,2017-11-02,456,E,0,1,UBTQ11,"Based on observations, interviews and review of the facility policy titled, Policy And Procedure For Laundry, the facility failed to ensure a large build-up of lint was removed from 4 of 4 clothes dryers in 1 of 1 laundry room. The findings included: An observation on 11/2/2017 at approximately 9:15 AM revealed a large build up of lint on the floor behind the lint baskets and on the upper 3 walls above the lint baskets. During interviews on 11/2/2017 at approximately 9:15 AM with Laundry Staff 1 and 2 and the Director of Housekeeping confirmed the findings. A maintenance worker got a vacuum cleaner and proceeded to vacuum out the clothes dryers. Review on 11/2/2017 at approximately 9:25 AM of the facility policy titled, Policy And Procedure For Laundry, states, Clean the lint filter after each dryer load. In order to operate in an efficient and safe manner, al equipment must be kept clean and in good working order. The entire lint compartment will be cleaned with the shop vac. Daily inspect the area surrounding tumblers, remove all combustible materials, including lint, before operating the machines. 3. Clean lint from lint compartment and screen to maintain proper airflow and avoid overheating. Under Daily, e. reads, Carefully wipe any accumulated lint off of the cabinet high limit thermostat and thermistor. Failure to do so will allow a build up of lint in this area to act as an insulator, causing the insulated to overheat.",2020-09-01
466,PRUITTHEALTH-WALTERBORO,425053,401 WITSELL STREET,WALTERBORO,SC,29488,2017-11-02,502,D,0,1,UBTQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, interview and review of the facility policy titled, Diagnostic and Laboratory Services: Procedure for Processing, the facility failed to ensure an Ammonia level for Resident #183, ordered by the physician, was obtained and resulted in a timely manner for 1 of 1 resident reviewed for a Change in Condition. The findings included: The facility admitted Resident #183 with [DIAGNOSES REDACTED]. An observation on 11/1/2017 at approximately 11:44 AM revealed Resident #183 asleep. Further observation on 11/1/2017 at approximately 12:32 PM revealed Resident #183 still asleep with a lunch tray set up in front of him/her. An observation on 11/1/2017 at approximately 12:50 PM revealed Resident #183 still asleep. During an interview on 11/1/2017 approximately 12:50 PM with Licensed Practical Nurse (LPN) #3, the unit manager, stated he/she was not aware of any change in the condition of Resident #183. LPN #3 went on to say that Resident #183 did not take his/her morning medications nor did he/she eat breakfast and has missed lunch. The nurse manager could not verify that Resident #183 had been administered any medications to cause the long period of sleep. LPN #3 then assessed Resident #183 and called the physician. Review of the medical record on 11/1/2017 at approximately 3:45 PM for Resident #183 revealed a physician's order dated 11/1/2017 for a Urinalysis and a Culture and Sensitivity today. Further review of the physician's orders on 11/1/2017 at approximately 3:45 PM revealed a Complete Metabolic Panel (CMP), a Complete Blood Count (CBC) with differential and an Ammonia Level to be drawn today. Also ordered by the physician was a chest x-ray with 2 views to be done today. Review on 11/1/2017 at approximately 6:00 PM of the results revealed the CMP and CBC with diff completed. The urinalysis revealed a urinary tract infection and the results of the Chest X-ray was called to the physician for Resident #183. The results for the Ammonia Level had not resulted at that time. Further review of the physician's orders for Resident #183 on 11/1/2017 at approximately 6:00 PM revealed a physician order for [REDACTED].>An observation on 11/1/2017 at approximately 6:19 PM revealed Resident #183 still asleep. No medications had been administered by mouth and Resident #183 had not eaten all day. An observation on 11/2/2017 at approximately 10:00 AM revealed Resident #183 alert to name call but very drowsy. The intravenous fluids are infusing as ordered by the physician for Resident #183. During an interview on 11/2/2017 at approximately 4:18 PM with LPN #3 Unit Manager concerning the Ammonia Level results for Resident #183 he/she stated, the Ammonia Level was drawn in the wrong tube. We would have found it when we realized it was not resulted. This surveyor asked about the Ammonia Level results and the Unit Manager then started trying to locate the results. Review on 11/2/2017 at approximately 4:30 PM of the facility policy titled, Diagnostic and Laboratory Services: Procedure for Processing, states under Policy Statement, Each healthcare center will maintain a system for processing, monitoring and reporting patient/resident diagnostic and laboratory test results. Under, Communicating Radiology or Diagnostic Test Results with the Provider and Responsible Party, number 1 states, The Unit Manager or charge nurse obtains the patient/resident radiology or diagnostic test results from the contracted provider. The nurse utilizes the computer for obtaining results, if available. Number 2, reads, The licensed nurse obtains a hard copy of the patient's radiology or diagnostic test results by either printing the results from the computer or receiving the results via fax from the contracted provider. Number 3, reads, The licensed nurse is responsible for communicating patient/resident diagnostic results to the provider upon receipt. Number 4 reads, The licensed nurse will communicate radiology or other diagnostic test results to the patient/resident and/or responsible party at the time a new provider order is received related to the tests results. The licensed nurse will document the notification in the clinical record. .",2020-09-01
467,NHC HEALTHCARE - LAURENS,425054,379 PINEHAVEN STREET EXTENSION,LAURENS,SC,29360,2018-11-30,759,D,0,1,H1G611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation and interview, the facility failed to maintain a medication error rate of less than 5 percent. There were 2 errors out of 25 opportunities for error resulting in a medication error rate of 8%. The findings included: Error #1 and Error #2 On 11/28/18 at approximately 8:45 AM, during an observation of Resident #137's medication pass on the 400 front hall, Registered Nurse (RN) #1 separately crushed (1) [MEDICATION NAME] 50 milligram (mg.) tablet and (4) Aspirin 81 mg. tablets and placed the medications in (2) in separate 30 milliliter (ml.) medication cups. RN #2 then combined the medications with water. Also, two other liquid medications ([MEDICATION NAME] and Levetiracetam) were placed in separate 30 ml. medication cups. Juven, a supplement was placed in a 9 oz. plastic drinking cup. RN #1 then poured the cups into Resident #137's gastric tube leaving a significant amount of medication in the Metroprolol and Aspirin cups. RN #1 and RN #2 then exited Resident #137's room with the medication cups. On 11/28/18 at approximately 9:00 AM, during an interview with RN #1 and RN #2 immediately following the observation of Resident #137's medication pass, the surveyor, RN #1 and RN #2 observed the 30 ml. medication cups which revealed a significant amount of medication remaining in both the Metroprolol and Aspirin medication cups. RN #1 and RN #2 verified the contents remaining inside of the (2) medication cups as Metroprolol and Aspirin. RN #2 then stated, Medication residue is always left behind in the cups. On 11/28/18 at approximately 9:05 AM, during an interview with the Director of Nursing (DON) and survey team, the DON verified that a significant amount medication residue was in the (2) 30 oz. medication cups.",2020-09-01
468,NHC HEALTHCARE - LAURENS,425054,379 PINEHAVEN STREET EXTENSION,LAURENS,SC,29360,2018-11-30,761,E,0,1,H1G611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and review of the manufactures recommendations, the facility failed to follow a procedure to ensure that expired medications were removed from medication storage in 1 of 8 medication carts reviewed. Expired medications (insulin) were on the 400 back hall cart after the manufactures recommended expiration date. The findings included: On 11/26/18 at 10:20 AM, an observation of the 400 back hall medication cart with LPN #1 revealed Resident #124 had (1) open vial of [MEDICATION NAME] (Lot #8F025B) with approximately 55 units of insulin remaining. An open puncture date of 10/19 and an expiration date of 11/16 was hand written on the vial. Also, (1) [MEDICATION NAME] (Lot #HZF6856) with approximately 250 units of insulin remaining had an open puncture date of 10/23 and an expiration date of 11/20 hand written on the [MEDICATION NAME]. On 11/26/18 at approximately 10:25 AM, during an interview with LPN #1, s/he verified the [MEDICATION NAME] vial and the [MEDICATION NAME] was in-use after the expiration date and indicated the insulin should have been removed from storage. Review of the [MEDICATION NAME] 100 Units/ML vial manufactures recommendations states under the section Storage: Discard all containers in use after 28 days, even if there is insulin left. Review of the [MEDICATION NAME] manufactures recommendations revealed under section How should I store [MEDICATION NAME], Bullet (2) states, Store the [MEDICATION NAME] you are currently using out of the refrigerator below 86 degrees F or 30 degrees C for up to 28 days. Furthermore, bullet (6) states, The [MEDICATION NAME] should be thrown away after 28 days, even if it still has insulin left in it.",2020-09-01
469,NHC HEALTHCARE - LAURENS,425054,379 PINEHAVEN STREET EXTENSION,LAURENS,SC,29360,2018-11-30,812,F,0,1,H1G611,"Based on observation, interview, and review of the facility policy Manual Warewashing, the facility failed to prepare, distribute, and serve food under sanitary conditions for 1 of 1 kitchen reviewed and has the potential to affect 154 of 154 residents with ordered diets as evidenced by failing to do the following: Air dry pans, clean (stove top and equipment). The findings included: On 11/26/18 at 9:45 AM, an initial tour of the main kitchen with the Dietary Manager (DM) revealed: 1.) The stove top had a large build-up of a black charred substance, grease, and food debris around all burners. 2.) On the stove and equipment next to the stove, the was yellow/orange food spatter. 3.) On the shelf above the stove a build-up of grease and dust. 4.) On a rack facing the stove 3 hotel pans were stacked wet. On 11/28/18 at approximately 11:05 AM, an observation with the DM revealed: 1.) The stove top had a large build-up of a black charred substance, grease, and food debris around all burners. 2.) On the stove and equipment next to the stove, yellow/orange food spatter. 3.) On the shelf above the stove a build-up of grease and dust. 4.) On a rack facing the stove 4 hotel pans were stacked wet. On 11/28/18 at approximately 11:10 AM, an interview with the DM, s/he verified the build-up and food spatter on the stove/equipment and the hotel pans were stacked wet. Review of the facility policy, Manual Warewashing, states under guideline (5.) Air-dry all items. Make sure all items are completely dry before stacking to prevent wet nesting.",2020-09-01
470,NHC HEALTHCARE - LAURENS,425054,379 PINEHAVEN STREET EXTENSION,LAURENS,SC,29360,2018-11-30,880,D,0,1,H1G611,"Based on observations, interview, review of the facility policy and the Center for Disease Control Prevention safety recommendations, the facility failed to follow a procedure to ensure precautions were observed for the disposal of contaminated equipment for 1 of 1 resident observed for finger stick blood sugar (FSBS) and injection. A finger stick device and needle were not disposed of in an approved sharps container on the 400 front hall. The findings included: On 11/27/18 at 4:25 PM, during an observation of Resident #124's med pass on the 400 front hall, Licensed Practical Nurse (LPN) #1 used a finger stick device to penetrate the residents' finger producing blood to monitor the residents' blood sugar. LPN #1 then placed the finger stick device into a trash can in Resident 124's bathroom. LPN #1 then administered insulin to Resident #124 by subcutaneous needle injection, s/he then placed the needle into general trash on the medication cart. There was a puncture proof sharps container on the medication cart. On 11/27/18 at approximately 4:45 PM, during an interview LPN #1 verified the finger stick device was in the Resident #124's bathroom trash can and the injection needle was placed in the general trash on the medication cart. LPN #1 then retrieved the needle from the medication cart trash and exposed another finger stick device in the trash and indicated the device was from the resident before Resident #124. LPN #1 then indicated that the finger stick devices and needle should have been placed into the sharps container on the cart. Review of the Center for Disease Control Prevention recommendations revealed under Infection Prevention during Blood Glucose Monitoring and Insulin Administration, section Blood Glucose Monitoring, Fingerstick Devices bullet #2 states, Dispose of used lancets at the point of use in an approved sharps container. Never reuse lancets. Also, under Insulin Administration bullet (5) states, Dispose of used injection equipment at point of use in an approved sharps container. Never reuse needles or syringes. Review of the facility policy entitled, Medication, Injections-Subcutaneous revealed under procedure (15.) Dispose of needle and syringe into a puncture proof container (sharps container).",2020-09-01
471,JOLLEY ACRES HEALTHCARE CENTER,425055,1180 WOLFE TRAIL,ORANGEBURG,SC,29115,2017-05-04,225,D,1,1,6ILV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to report an allegation of neglect timely for Resident #28, 1 of 1 reportable reviewed. The findings included: The facility admitted Resident #28 with [DIAGNOSES REDACTED]. Review of the Initial 24-Hour Report dated 11/30/16 revealed the incident occurred at approximately 8:00 PM on 11/28/16 and reported to the facility on [DATE]. Review of the Five Day Follow-Up Report dated 12/2/16 revealed Mr. (NAME REDACTED) reported the incident to Registered Nurse (RN) #2 at 8:00 PM. Review of the record revealed a verbal statement was obtained from RN #2 that stated about 8PM (sic) (Resident #28) was furious because that girl told me to pee in my diaper. During an interview on 05/04/2017 at 11:06 AM, the Social Services Director (SSD) confirmed the RN's statement indicated the RN was aware on 11/28/16 at 8:00 PM. The SSD stated /she was not informed until 11/29/16 and that it was reported within 24 hours of her/him becoming aware. The SSD further confirmed the facility's nurses were trained on abuse and neglect and the RN should have identified the incident as neglect. S/he stated the RN should have called someone to determine if the allegation was neglect if s/he wasn't sure. The SSD also confirmed the incident was not reported within 24 hours of the RN becoming aware of the incident.",2020-09-01
472,JOLLEY ACRES HEALTHCARE CENTER,425055,1180 WOLFE TRAIL,ORANGEBURG,SC,29115,2017-05-04,226,D,1,1,6ILV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to implement a policy for identification of neglect and reporting of an incident for Resident #28, 1 of 1 reportable reviewed. In addition, the facility failed to implement a policy for screening of employees for Licensed Practical Nurse #3, 1 of 5 employees reviewed for background checks. The findings included: The facility admitted Resident #28 with [DIAGNOSES REDACTED]. Review of the investigation file for an allegation of neglect revealed an Initial 24-Hour Report dated 11/30/16 that indicated the incident occurred at approximately 8:00 PM on 11/28/16. The report indicated the incident was reported to the facility on [DATE]. Review of the Five Day Follow-Up Report dated 12/2/16 revealed the resident reported the incident to Registered Nurse (RN) #2 at 8:00 PM on 11/28/16. Review of the facility-obtained verbal statement from RN #2 revealed on 11/28/16 about 8PM (sic) (Resident #28) was furious because that girl told me to pee in my diaper. During an interview on 05/04/2017 at 11:06 AM, the Social Services Director (SSD) confirmed the RN's statement indicated the RN was aware on 11/28/16 at 8:00 PM. The SSD stated /she was not informed until 11/29/16 and that it was reported within 24 hours of her/him becoming aware. The SSD further confirmed the facility's nurses were trained on abuse and neglect and the RN should have identified the incident as neglect. S/he stated the RN should have called someone to determine if the allegation was neglect if s/he wasn't sure. The SSD also confirmed the incident was not reported within 24 hours of the RN becoming aware of the incident. In addition, on 05/03/2017 at 2:06 PM, review of personnel files revealed Licensed Practical Nurse #3's hire date was 4/10/17. The facility obtained a background check from a third party entity which conducted a background check for Orangeburg, [STATE] and a Sanction Check was conducted through the National Healthcare Data Bank (NHDB). The report did not indicate a statewide background check through SLED (State Law Enforcement Division) was conducted as required by state law. During an interview on 05/03/2017 5:01 PM, the Human Resources Director confirmed the background check did not include a SLED check and was conducted for Orangeburg only.",2020-09-01
473,JOLLEY ACRES HEALTHCARE CENTER,425055,1180 WOLFE TRAIL,ORANGEBURG,SC,29115,2017-05-04,280,E,1,1,6ILV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to review and/or revise the care plan related to falls for Resident #[AGE], 1 of 1 resident reviewed for accidents. Resident #[AGE] was identified as a fall risk and had 3 falls in the past 30 days. Review of the care plan did not reveal any new or change in interventions since January 2017. The findings included: The facility admitted Resident #[AGE] with [DIAGNOSES REDACTED]. Durine the staff interview on 05/01/2017 at 06:01 PM, the staff member reported Resident #[AGE] had 3 falls in the last 30 days; 4/15/17 with a right forehead hematoma, 4/23/17 with no injury, and 4/27/17 which resulted in a laceration to the forehead. At 8:36 AM on 05/04/2017, review of the physician's orders [REDACTED]. lowest position, and 11/09/17 Restorative Nursing for sit to stand 6 times a week for 6 weeks. Review of the Nursing Progress Notes on 05/04/2017 revealed the following notes: 10/20/16 calling out for help, found sitting on edge of bed. Tab alarm placed 11/15/16 Resident found on floor in room at 6:30pm laying on right side. Stated (s/he) was trying to leave room to look for (spouse). 11/19/16 CNA (Certified Nursing Assistant) assisting resident from WC (wheelchair) to bed. Stated resident's knees buckled and (s/he) lowered (her/him) to a sitting position on the floor. 11/20/17 1112am Res (resident) hollering out help! this nurse entered room and found res lying on the floor on top of (her/his) bed linens beside (her/his) bed. Res pulled alarm string when this nurse walked into room. Res had taken clip alarm off and it was still attached to the cane rail on bed. 2/23/17 This nurse called to room [ROOM NUMBER] in response to resident being on the floor. ST (skin tear) (0.1x0.1x0.4) noted to back of resident's R (right) lower leg. Contusion noted to L (left) arm. 3/14/17 11:30pm Resident yelling out 'help' when staff entered room resident on floor laying on right side and some blood noted to floor res did c/o (complain of) some pain to right elbow, hip, and leg. skin tear 1.2x1.5x0.1cm (centimeter) noted to resident right elbow.resident also with a hematoma to right post head 4.2x2.2cm .resident stated I was trying to get up 3/15/17 Called to residents room by staff. resident was noted to be lying on the floor .Activities director had heard resident's w/c alarm sounding & found resident sliding out of (her/his) chair & onto the floor & assisted resident onto the floor & called for assistance. 3/30/17 Current fall interventions effective, no further falls since 3/14/2017. Pressure pad in place and showers remain in place on 3-11 shift. 4/15/17 This nurse responded to resident's alarm sounding down the far end of South hall. Resident was in a prone position on the floor .Resident noted with 2 ST above R eye measuring 3.0x2.5x0.1 and 2.5x1.3x0.1. 4/23/17 6:15p Called to resident's room per CNA. W/c alarm sounding & resident noted to be lying on (her/his) right side on the floor in the doorway of (her/his) room. Sandaled shoes noted to be on feet. C/o bilateral hip pain & when touched, resident flinches. Unable to grasp or move right hand at all when asked. States (s/he) hit (her/his) head on the right side as well. Roommate states resident fell out of (her/his) w/c. 4/27/17 1415-called to resident's room .Resident was in a prone position on the floor with alarms in place and sounding. Resident noted to have lacerations to (her/his) forehead and bridge of (her/his) nose. MD notified at 1423. Send to ED (Emergency Department)for eval(uation) and tx. (treatment).Steri-strips reapplied to lacerations and transport contacted to return resident to facility. At 8:43 AM on 05/04/2017, review of the Care Plan revealed a care plan dated 1/7/17 for Potential for falls. Interventions included: 1/07/17 Order comprehensive medication review by pharmacist, assess for polypharmacology and medications that increase the fall risk 1/07/17 Increased staff supervision with intensity based on resident need 1/31/17 Implement exercise program that targets strength, gait, and balance 1/07/17 Evaluate need for bed/chair alarms 5/3/17 Wedge cusion added to wheel chair. At 9:03 AM on 05/04/2017, review of the Evaluation Notes attached to the care plan revealed a note dated 1/20/17 for the QOC (Quality of Care) Meeting Resident fell from wheelchair in front lobby on 1/7/17. Alarm on and in working order. Bruising to face resolving. Review of the nursing progress notes contained no documentation related to a fall on 1/7/17. Another notation stated 3/14/17 Pressure pad to bed while in bed. During an interview at 1:06 PM on 05/04/2017, The Unit Manager confirmed the care plan was not reviewed and revised. The Unit Manager confirmed the following interventions listed on the physician's orders [REDACTED]. In addition, the Unit Manager confirmed that the arm protectors would help prevent injury but would not prevent a fall. Thh Unit Manager also confirmed that the intervention after the 11/15/16 fall for Physical Therapy for Upper Extremity strengthening and exercise would not prevent falls and that there was no new intervention following the 4/23/16 fall.",2020-09-01
474,JOLLEY ACRES HEALTHCARE CENTER,425055,1180 WOLFE TRAIL,ORANGEBURG,SC,29115,2017-05-04,323,D,1,1,6ILV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to provide supervision/assistive devices related to falls for Resident #[AGE], 1 of 1 resident reviewed for accidents. Resident #[AGE] identified at risk for falls and a history of numerous falls, was observed on the days of the survey to have an alarm on the wheelchair that was not functioning. The findings included: The facility admitted Resident #[AGE] with [DIAGNOSES REDACTED]. Durine the staff interview on 05/01/2017 at 06:01:32 PM, the staff member reported Resident #[AGE] had 3 falls in the last 30 days; 4/15/17 with a right forehead hematoma, 4/23/17 with no injury, and 4/27/17 which resulted in a laceration to the forehead. At 8:36 AM on 05/04/2017, review of the physician's orders [REDACTED]. lowest position, and 11/09/17 Restorative Nursing for sit to stand 6 times a week for 6 weeks. Review of the Nursing Progress Notes on 05/04/2017 revealed the following notes: 10/20/16 calling out for help, found sitting on edge of bed. Tab alarm placed 11/15/16 Resident found on floor in room at 6:30pm laying on right side. Stated (s/he) was trying to leave room to look for (spouse). 11/19/16 CNA (Certified Nursing Assistant) assisting resident from WC (wheelchair) to bed. Stated resident's knees buckled and (s/he) lowered (her/him) to a sitting position on the floor. 11/20/17 1112am Res (resident) hollering out help! this nurse entered room and found res lying on the floor on top of (her/his) bed linens beside (her/his) bed. Res pulled alarm string when this nurse walked into room. Res had taken clip alarm off and it was still attached to the cane rail on bed. 2/23/17 This nurse called to room 108 in response to resident being on the floor. ST (skin tear) (0.1x0.1x0.4) noted to back of resident's R (right) lower leg. Contusion noted to L (left) arm. 3/14/17 11:30pm Resident yelling out 'help' when staff entered room resident on floor laying on right side and some blood noted to floor res did c/o (complain of) some pain to right elbow, hip, and leg. skin tear 1.2x1.5x0.1cm (centimeter) noted to resident right elbow.resident also with a hematoma to right post head 4.2x2.2cm .resident stated I was trying to get up 3/15/17 Called to residents room by staff. resident was noted to be lying on the floor .Activities director had heard resident's w/c alarm sounding & found resident sliding out of (her/his) chair & onto the floor & assisted resident onto the floor & called for assistance. 3/30/17 Current fall interventions effective, no further falls since 3/14/2017. Pressure pad in place and showers remain in place on 3-11 shift. 4/15/17 This nurse responded to resident's alarm sounding down the far end of South hall. Resident was in a prone position on the floor .Resident noted with 2 ST above R eye measuring 3.0x2.5x0.1 and 2.5x1.3x0.1. 4/23/17 6:15p Called to resident's room per CNA. W/c alarm sounding & resident noted to be lying on (her/his) right side on the floor in the doorway of (her/his) room. Sandaled shoes noted to be on feet. C/o bilateral hip pain & when touched, resident flinches. Unable to grasp or move right hand at all when asked. States (s/he) hit (her/his) head on the right side as well. Roommate states resident fell out of (her/his) w/c. 4/27/17 1415-called to resident's room .Resident was in a prone position on the floor with alarms in place and sounding. Resident noted to have lacerations to (her/his) forehead and bridge of (her/his) nose. MD notified at 1423. Send to ED (Emergency Department)for eval(uation) and tx. (treatment).Steri-strips reapplied to lacerations and transport contacted to return resident to facility. At 8:43 AM on 05/04/2017, review of the Care Plan revealed a care plan dated 1/7/17 for Potential for falls. Interventions included: 1/07/17 Order comprehensive medication review by pharmacist, assess for polypharmacology and medications that increase the fall risk 1/07/17 Increased staff supervision with intensity based on resident need 1/31/17 Implement exercise program that targets strength, gait, and balance 1/07/17 Evaluate need for bed/chair alarms 5/3/17 Wedge cusion added to wheel chair. At 9:03 AM on 05/04/2017, review of the Evaluation Notes attached to the care plan revealed a note dated 1/20/17 for the QOC (Quality of Care) Meeting Resident fell from wheelchair in front lobby on 1/7/17. Alarm on and in working order. Bruising to face resolving. Review of the nursing progress notes contained no documentation related to a fall on 1/7/17. Another notation stated 3/14/17 Pressure pad to bed while in bed. During an interview at 1:06 PM on 05/04/2017, The Unit Manager confirmed that the arm protectors would help prevent injury but would not prevent a fall. The Unit Manager also confirmed that the intervention after the 11/15/16 fall for Physical Therapy for Upper Extremity strengthening and exercise would not prevent falls and that there was no new intervention following the 4/23/16 fall. In addition, the facility was unable to provide a copy of a comprehensive medication review by the pharmacist to assess for polypharmacology and medications that increase the fall risk that was listed on the care plan dated 1/07/17. During the days of the survey, observations of the resident revealed the TAB alarm attached to the resident. During an observation at 1:35 PM on 05/04/2017, The Unit Manager confirmed the alarm box for the pressure pad alarm was not present on the resident's wheelchair. The Unit Manager also confirmed the pressure pad was not functional without the alarm box. The Unit Manager was unable to locate the alarm in the resident's room. During an interview 1:39 PM 05/04/2017, the Certified Nursing Assistant assigned to the resident stated s/he did not know where the alarm for the pressure pad was and stated the last time s/he saw it was about 2 days ago.",2020-09-01
475,JOLLEY ACRES HEALTHCARE CENTER,425055,1180 WOLFE TRAIL,ORANGEBURG,SC,29115,2017-05-04,333,D,1,1,6ILV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, interview, and review of the facility policy and manufactures recommendations, the facility failed to administer the correct amount of medication resulting in significant medication errors for 1 of 3 residents reviewed for [MED] medication administration. Resident #55 did receive [MED] three times after the medication had expired. The finding included: The facility admitted Resident #55 with [DIAGNOSES REDACTED]. Error #1, #2, #3 On [DATE] at 2:00 PM, an observation with Registered Nurse (RN) #1 and the Director of Nursing (DON) of the 200 unit (North hall) medication cart revealed a [MEDICATION NAME] (Lot #FZF0530) with approximately 200 units of fluid [MED] remaining. The [MEDICATION NAME] had an open date of [DATE] and expiration date [DATE]. Further review of Resident #55's Medication Administration Record [REDACTED]. Following the review of the MAR, the DON verified Resident #55 received [MED] from the [MEDICATION NAME] after expiration date. On [DATE] at 2:30 PM, a review of the facility policy entitled, Drugs & Biological Storage, revealed under procedure (4a.)No discontinued, outdated, or deteriorated drugs or biologicals may be retained for use. All such drugs must be returned to the issuing pharmacy or destroyed in accordance with the procedure governing the destruction of medication. On [DATE] at 3:00 PM, review of the manufacture recommendations for [MEDICATION NAME] Flex Pen states under section How should I store [MEDICATION NAME], Bullet (2) states, Store the [MEDICATION NAME] you are currently using out of the refrigerator below [AGE] degrees F or 30 degrees C for up to 28 days. Furthermore, bullet (6) states, The [MEDICATION NAME] should be thrown away after 28 days, even if it still has [MED] left in it.",2020-09-01
476,JOLLEY ACRES HEALTHCARE CENTER,425055,1180 WOLFE TRAIL,ORANGEBURG,SC,29115,2017-05-04,371,F,1,1,6ILV11,"> Based on observation, interview, and review of facility policies, the facility failed to distribute and serve food under sanitary conditions for 1 of 1 kitchen reviewed and has the potential to affect 56 of 56 residents with ordered diets as evidenced by failing to do the following: Temp foods without cross contamination. The findings included: On 5/1/17 at 4:36 PM, during an observation of the dinner line temping with the Dietary Manager (DM) revealed, the DM used the same temperature probe between food items, mash potatoes, pork sausage, carrots, and green beans, sanitizing the probe with the same alcohol pad between food items. Following the observation of the dinner line temping, the DM verified the same sanitizing pad was used between food items and indicated a new pad should have been used between food items to avoid cross food contamination. Review of the facility policy Safe Food Temperatures, states under, Guidelines For Checking Food Temperatures (1.) Make certain the thermometer is clean and has been sanitized with an appropriate sanitizer (100 ppm (parts per million) bleach solution or 25 ppm iodine solution). The use of individual, foil wrapper alcohol pads also is acceptable for sanitizing probes; however, allow time for the alcohol to evaporate before inserting the probe into the food. Another method is to utilize the coffee urn making sure water temperature is 1[AGE]F. Note: The thermometer must be cleaned and sanitized between each product that is tested .",2020-09-01
477,JOLLEY ACRES HEALTHCARE CENTER,425055,1180 WOLFE TRAIL,ORANGEBURG,SC,29115,2017-05-04,431,D,1,1,6ILV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, interview, review of the manufactures recommendations and facility policy, the facility failed to follow a procedure to ensure that expired medication were removed from medication storage in 1 of 3 medication carts and 1 of 3 units reviewed. Expired [MED] medication was on the 200 unit (North hall) medication cart after the expiration date. The findings included: On [DATE] at 2:00 PM, an observation with Registered Nurse (RN) #1 and the Director of Nursing (DON) of the 200 unit (North hall) medication cart revealed a Novolog FlexPen (Lot #FZF0530) with approximately 200 units of fluid [MED] remaining. The Novolog FlexPen had an open date of [DATE] and expiration date [DATE]. Following the observation RN #1 and the DON verified the Novolog FlexPen was expired and indicated the [MED] pen should have been removed from the cart. On [DATE] at 2:30 PM, a review of the facility policy entitled, Drugs & Biological Storage, revealed under procedure (4a.)No discontinued, outdated, or deteriorated drugs or biologicals may be retained for use. All such drugs must be returned to the issuing pharmacy or destroyed in accordance with the procedure governing the destruction of medication. On [DATE] at 3:00 PM, review of the manufacture recommendations for Novolog Flex Pen states under section How should I store Novolog FlexPen, Bullet (2) states, Store the FlexPen you are currently using out of the refrigerator below [AGE] degrees F or 30 degrees C for up to 28 days. Furthermore, bullet (6) states, The Novolog FlexPen should be thrown away after 28 days, even if it still has [MED] left in it.",2020-09-01
478,JOLLEY ACRES HEALTHCARE CENTER,425055,1180 WOLFE TRAIL,ORANGEBURG,SC,29115,2018-09-07,550,E,0,1,FDCO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure resident rights. Resident #52 was exposed during bathing/bed change (1 of 1 reviewed for dignity). Residents on the 300 hall were referred to as feeders, and residents received dessert service off paper plates (1 of 2 meals observed). The findings included: Observation on 09/06/18 at 12:30 PM revealed the residents in the main dining room were eating dessert (sweet potato pie) on small paper plates. Interview with the Dietary Manager on 09/06/18 at 01:40 PM revealed pie was not served often but s/he likes to serve something special occasionally. S/he stated that the facility did not have any regular dessert plates. During observation of the noon meal on 9-4-18 on the 300 Hall, Certified Nursing Assistants (CNAs) #2 and #3 referred to residents as feeders multiple times. Trays were left on the cart for distribution at a later time because these residents required assistance with eating. The facility admitted Resident #52 with [DIAGNOSES REDACTED]. During the Initial Pool process on 9-4-18, the surveyor knocked on the resident's door and CNA #1 answered, Come in. Resident #52 was observed on a work-height bed with only the fitted sheet on the mattress. The resident had no covers and had on only a disposable brief. The window blinds were open. The CNA quickly grabbed a towel to cover the resident's mid-section and stated s/he had been bathing him/her. During an interview on 9/07/18 at 1:51 PM, the Director of Nurses (DON) stated, They should keep body parts covered except for what is being bathed. When informed that CNAs referred to residents as feeders, the DON stated,We no longer use that term. The facility policy titled Bathing - Tepid Sponge Bath (7/1/2016) states: .Keep bath blankets over body parts not being sponged .",2020-09-01
479,JOLLEY ACRES HEALTHCARE CENTER,425055,1180 WOLFE TRAIL,ORANGEBURG,SC,29115,2018-09-07,577,E,0,1,FDCO11,"Based on interview and observation the facility failed to notify residents of the State Agency (SA) survey results and post the required information in an accessible location for facility residents and community persons to review. Nine of nine residents attending group interview were not aware of the SA annual survey, the report that comes to the facility and the location of the results of that report for them to review. The findings included: On 9/6/2018 a group interview with 9 facility residents was held. These 9 residents were members that regularly attended the monthly resident council meetings. When asked about their knowledge of the SA survey that is conducted annually, they were not aware. When asked about their knowledge of the survey results to be posted in the facility for them to review, they were not aware of the posting or the location in the building of the posting. A review of the resident council minutes did not reveal that these findings were ever discussed with resident council members during the meetings.",2020-09-01
480,JOLLEY ACRES HEALTHCARE CENTER,425055,1180 WOLFE TRAIL,ORANGEBURG,SC,29115,2018-09-07,604,E,0,1,FDCO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to complete restraint assessments for alarm use for Residents #20, 51, 52, 4, 256, 42, 35 (7 of 7 reviewed with alarms). The findings included: Resident #20 was observed on 09/04/18 at 11:00 AM, 09/06/18 at 05:55 PM, and 09/07/18 at 09:15 AM with a bed alarm. Record review of the (MONTH) (YEAR) physician's orders [REDACTED]. Record review of the 7/5/18 Care Plan revealed: Requires total assistance with transfers, locomotion, toilet use, and bathing. Extensive assistance with bed mobility, dressing, and personal hygiene. Supervision with eating. APPROACH: Clip alarm for bed/chair, check every shift for placement and functioning. Record review of the 7/2/18 Quarterly Minimum Data Set (MDS) revealed Section P was coded for bed alarm and chair alarm as used daily. Record review of the 4/3/18 Annual MDS and the 1/8/18 Quarterly MDS revealed Section P was coded for bed alarm as used daily and chair alarm as used less than daily. Resident #51 admitted with [DIAGNOSES REDACTED].#4 admitted with Depression were both observed on 9/5/18 up in the chair with a tab alarm and in bed with a bed alarm attached. Review of the resident's MDS revealed they were coded to use the alarms daily. There was no evidence an assessment had been done for use of the alarms and if they were the least restrictive. The facility admitted Resident #35 with [DIAGNOSES REDACTED]. Observations during the survey and review of Physician's 0rders on 9-5-18 at 2:13 PM and Medications Administration History on 9/07/18 at 10:10 AM revealed that a clip alarm to bed and wheelchair was applied as ordered. Review of the 8-2-18 Quarterly Minimum Data Set (MDS) Assessment on 9-5-18 at 2:43 PM revealed that the alarm use was coded under Section P but no restraint assessment could be located in the medical record. There was no evidence of alternative interventions attempted prior to use of alarms. The facility admitted Resident #42 with [DIAGNOSES REDACTED]. Observations during the survey and review of 7-25-18 Physician's 0rders on 9/06/18 at 11:50 PM and Medications Administration History on 09/07/18 12:02 AM revealed that a clip alarm was applied to bed and wheelchair as ordered. No restraint assessment could be located in the medical record. There was no evidence of alternative interventions attempted prior to use of alarms. The facility admitted Resident #52 with [DIAGNOSES REDACTED]. Observations during the survey and review of Physician's 0rders on 9/06/18 at 12:02 PM and Medications Administration History on 9/06/18 at 8:43 PM revealed that a clip alarm to bed and chair was applied as ordered. Review of the 8-24-18 30 Day Minimum Data Set Assessment on 9/06/18 at 2:17 PM revealed that the alarm use was coded under Section P but no restraint assessment could be located in the medical record. There was no evidence of alternative interventions attempted prior to use of alarms. The facility admitted Resident #256 with [DIAGNOSES REDACTED]. Observations during the survey and review of Physician's 0rders on 9/06/18 at 6:10 PM 9/06/18 and Medications Administration History on 9/06/18 at 10:57 PM revealed that a clip alarm to bed and wheelchair was applied as ordered. No restraint assessment could be located in the medical record. There was no evidence of alternative interventions attempted prior to use of alarms. During an interview on 9/06/18 at 3:31 PM, the MDS Coordinator and Registered Nurse #1 reviewed the record and found no assessment for use of alarms as possible restraints. They contacted the Assistant Director of Nursing who stated no assessments had been completed prior to use to determine if the use of the alarms was because of an underlying medical symptom, resulted in possible restraint, or was being used for convenience of the staff. There was no evidence of alternative interventions attempted prior to use of alarms. During an interview on 9-7-18 at 3 PM, the Administrator stated the facility had no written policies regarding alarm use.",2020-09-01
481,JOLLEY ACRES HEALTHCARE CENTER,425055,1180 WOLFE TRAIL,ORANGEBURG,SC,29115,2018-09-07,637,D,0,1,FDCO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to identify and complete a comprehensive assessment for 1 of 1 sampled resident with a significant decline in status. The facility did not complete a Significant Change in Status Assessment (SCSA) when required for Resident #35. The findings included: The facility admitted Resident #35 with [DIAGNOSES REDACTED]. Review of the 8-2-18 Quarterly and 2-9-18 Admission/5-Day Minimum Data Set (MDS) Assessments on 9-5-18 at 2:43 PM revealed that the resident had sustained a significant decline and no Significant Change in Status Assessment (SCSA) had been completed. The resident's cognitive status had declined from cognitively intact to moderately impaired. S/he was noted as feeling depressed. His/her locomotion on the unit declined from minimal to extensive assistance required while locomotion off the unit required total assistance. The ability to feed him/herself declined from supervision to extensive assistance required. Functional range of motion (ROM) was impaired in one upper extremity while the resident had no impairment on admission. Bowel incontinence declined. S/he exhibited moderate pain requiring PRN (as needed) pain medication when previously the resident required none. Weight loss was noted and the resident developed a pressure ulcer. During an interview on 9/06/18 at 3:11 PM, the MDS Coordinator reviewed the assessments and verified the changes. S/he stated the resident had been treated in (MONTH) and (MONTH) for urinary tract infections. On 9/07/18 at 12:08 PM, the MDS Coordinator stated s/he had spoken to her/his consultant and that a SCSA should have been done. We missed him.",2020-09-01
482,JOLLEY ACRES HEALTHCARE CENTER,425055,1180 WOLFE TRAIL,ORANGEBURG,SC,29115,2018-09-07,688,E,0,1,FDCO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, there was no evidence of provision of Range of Motion (ROM) to prevent further decline for Resident #20 (1 of 3 reviewed for ROM). The findings included: Record review of the (MONTH) (YEAR) physician's orders [REDACTED]. The physician's orders [REDACTED]. Record review of the Medication Administration Record [REDACTED]. As a result, there was no evidence that ROM was provided to Resident #20. RN #1 provided a 4/1/18 Nursing Weekly Summary Progress Note regarding the ROM, but no other documentation was located. The current Care Plan dated 7/5/18 listed ROM as an approach for the following goal: Will have no decline in activities of daily living through next review date.",2020-09-01
483,JOLLEY ACRES HEALTHCARE CENTER,425055,1180 WOLFE TRAIL,ORANGEBURG,SC,29115,2018-09-07,693,D,0,1,FDCO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of the facility policy titled Gastrostomy Tube Flush/Irrigation (Revised 6/16/17), the facility failed to ensure that professional standards of practice were followed for care of 1 of 1 sampled resident reviewed for tube feeding. The nurse failed to wash hands appropriately prior to the tube feeding and failed to check for residual prior to initiating a water flush for Resident #42. The findings included: The facility admitted Resident #42 with [DIAGNOSES REDACTED]. During observation of tube feeding on 9/06/18 at 1:00 PM, Licensed Practical Nurse (LPN) #1 initially washed her/his hands. She proceeded to measure 100 milliliters of water into each of 2 cups. S/he elevated the bed to work height, closed the privacy curtain, changed gloves without washing her/his hands, and continued with the feeding procedure. After adjusting the resident's clothing and draping her/him, the nurse connected the 60 milliliter (ml) syringe barrel to the open gastrostomy tube and began pouring water into the syringe without checking for placement. The surveyor stopped the procedure and questioned LPN #1 who confirmed s/he had not checked for residual. After the feeding and flushes were completed, the nurse rinsed and dried the 60 ml syringe, then stored it in a plastic bag with the plunger in the barrel and moisture in the tip. During an interview immediately following the procedure, LPN #1 verified all of the above information. The facility policy titled Gastrostomy Tube Flush/Irrigation (Revised 6/16/17) states: Verify correct tube placement at least every eight (8) hours: [NAME] Prior to beginning a feeding/flushing . by: 1) Checking for gastric residual . The policy/procedure did not address post-use care of the 60 ml. syringe.",2020-09-01
484,JOLLEY ACRES HEALTHCARE CENTER,425055,1180 WOLFE TRAIL,ORANGEBURG,SC,29115,2019-12-19,623,D,0,1,FV0011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to notify the resident and the resident's representative in writing. In a language and manner, they understand the discharge/transfer to the hospital emergency room (ER) for 2 of 3 sample residents reviewed for hospitalization . The findings included: The facility admitted Resident #1 on 01/11/19 with [DIAGNOSES REDACTED]. Nurse's notes reviewed on 12/17/19 at approximately 2:00 PM revealed that on 10/15/19, Resident #1's nurse found the pe[DEVICE] on the floor. The physician was notified, and the resident was sent to the hospital for pe[DEVICE] replacement. According to the residents' hospital discharge summary, the resident was admitted to the hospital with [REDACTED]. The resident returned to the facility on [DATE] with the peg tube in place. Resident #1 was sent to the hospital for pe[DEVICE] replacement again on 12/2/19. S/he returned to the facility on [DATE]. In an interview with the administrator, director of nursing and social worker on 12/19/19 at approximately 11: 15 AM, they stated that they were unable to locate any documentation to support that the resident and the resident's representative were notified in writing, the reasons for Resident #1 hospitalization . The facility admitted Resident #14 with [DIAGNOSES REDACTED]. Record review on 12/18/19 at approximately 11:53 AM revealed Nursing progress noted dated 12/11/19 stating Resident #14 was transferred to the hospital on [DATE] after experiencing a [MEDICAL CONDITION]. No written Notice of transfer could be located in the electronic health record. In an interview on 12/18/19 at approximately 12:31 PM the Business Manager stated the facility did not issue a written Notice of Transfer to Resident and/or Resident Representative for Resident #14 due to his/her private pay status.",2020-09-01
485,JOLLEY ACRES HEALTHCARE CENTER,425055,1180 WOLFE TRAIL,ORANGEBURG,SC,29115,2019-12-19,625,D,0,1,FV0011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to provide written Notice of Bed Hold to the Residents #1 and #14 and/or their Resident Representatives, 2 of 3 sampled residents reviewed for hospitalization . The findings included: The facility admitted Resident #14 with [DIAGNOSES REDACTED]. Record review on 12/18/19 at approximately 11:53 AM revealed a Nursing progress noted dated 12/11/19 stating Resident #14 was transferred to the hospital on [DATE] after experiencing a [MEDICAL CONDITION]. In an interview on 12/18/19 at approximately 12:31 PM the Business Manager stated the facility did not issue a written Notice of Bed Hold to Resident #14 and/or the Resident Representative for Resident #14 due to his/her private pay status. The facility admitted Resident #1 on 01/11/19 with [DIAGNOSES REDACTED]. Nurse's notes reviewed on 12/17/19 at approximately 2:00 PM revealed that on 10/15/19, Resident #1's nurse found the pe[DEVICE] on the floor. The facility notified the physician and sent the resident to the hospital for pe[DEVICE] replacement. According to the residents' hospital discharge summary, the hospital admitted the resident was with IV fluid and planned for replacement of peg-tub, after numerous attempt to reinsert the tube failed. The resident returned to the facility on [DATE] with the peg tube in place. Resident #1 was sent to the hospital for pe[DEVICE] replacement again on 12/2/19. S/he returned to the facility on [DATE]. In an interview with the administrator, director of nursing and social worker on 12/19/19 at approximately 11:15 AM, they stated that they were unable to locate any documentation to support that the resident or the resident's representative was provided with the bed-hold policy.",2020-09-01
486,JOLLEY ACRES HEALTHCARE CENTER,425055,1180 WOLFE TRAIL,ORANGEBURG,SC,29115,2019-12-19,812,F,0,1,FV0011,"Based on observation and staff interview, the facility failed to ensure the kitchen dishware was dried and stored according to standard practice to prevent bacterial growth and cross-contamination. The findings included: During the initial kitchen observation on 12/16/19 at 10:19 AM, the following was noticed: Six wet nesting pots on a solid concrete surface, the cleaned/dried dishware storage area, and two stainless steel wet bowls on top of them. The certified dietary manager (CDM) was present during the kitchen observation and confirmed the wet nesting pots and bowls.",2020-09-01
487,JOLLEY ACRES HEALTHCARE CENTER,425055,1180 WOLFE TRAIL,ORANGEBURG,SC,29115,2019-12-19,880,D,0,1,FV0011,"Based on observation, interview and facility policy, the facility laundry staff failed to observe standard practice related to hand washing and glove use while sorting soiled linen. The findings included: In a laundry observation on 12/17/19 at approximately 10:55 AM the laundry aide washed his/her hands, donned personal protective equipment including plastic gloves and disposable apron, sorted the soiled linen into the washing machine. Then, while still wearing the contaminated gloves, the aide started the washing machine, changed the plastic liner for the container and handled other items in the room before removing the gloves and washing his/her hands. In an interview on 12/17/19 at approximately 3:30 PM the Head of Housekeeping and the Administrator confirmed the laundry aide should have removed the soiled gloves after sorting the laundry. Review of facility policy entitled Maintenance/ Housekeeping Policies and Procedures: Laundry, states, Handwashing: 2. Hands are washed after handling soiled linens even if gloves have been worn. At all times laundry service personnel are in compliance with Facility Handwashing Policy in the Facility Surveillance, Prevention and Control of Infections Manual #4.",2020-09-01
488,"ABBEVILLE NURSING HOME, INC.",425057,83 THOMSON CIRCLE,ABBEVILLE,SC,29620,2019-01-16,550,E,1,1,8N1U11,"> Based on observations and interviews, the facility failed to ensure that residents were treated with respect and dignity during the dining experience. Three to four residents were served or being assisted with eating by staff at one table while 18 plus residents were seated at tables in the dining room on the 100 Unit with clothing protectors in place for over 45 minutes and not served or eating.1 of 2 Unit dining rooms observed. The findings included: During a random lunch observation on 1/14/19 at approximately 11:50 AM of the dining room on the 100 Unit revealed residents seated in the dining room on the 100 Unit and residents being transported to the 100 Unit dining room. Staff was observed offering and placing clothing protectors on all residents in the dining room. At approximately 12:15 PM, one table with four (4) residents were served with two of the four residents requiring staff assistance with eating. There were two long tables with multiple residents and two smaller tables with three to four residents with clothing protectors on waiting to be served. Some residents were looking at the table were the residents were eating independently or being assisted by staff. At approximately 12:26 PM two food carts were delivered pass the residents seated in the dining room down the hallways while the resident remained in the dining room on the 100 Unit not served or eating. One resident was observed self-ambulating from the dining table in his/her wheelchair. The resident asked staff when the food was coming. Staff informed the resident not to leave the table because lunch was coming. During an interview on 1/14/19 at approximately 12:46 PM with Registered Nurse (RN) #2 and Licensed Practical Nurse (LPN) #1 revealed the residents at the table being served is restorative dining residents. Both confirmed the observations of 4 residents seated at a dining table and eating or being feed while other residents were waiting to be served. RN #2 and LPN#1 stated the facility has been delivering food to the dining room this way for a long time. At approximately 12:53 PM on 1/14/19, a food cart was delivered to the 100 Unit dining room to serve the other residents seated at the four other tables in the dining room. During the agency group interview on 1/15/19 at approximately 10:59 AM, one of five group members expressed concerns about having to wait close to an hour on the 100 Unit dining for lunch while one group of residents were served and eating. The group member that expressed concerns eat meals in the dining room on the 100 Unit. The group member stated he/she has expressed concerns, but he/she does not want to cause any trouble. The group member further stated food delivery for lunch has been going on like that for a long time. A lunch observation on 1/15/19 at approximately 12 PM revealed staff offering multiple residents clothing protectors on the 100 Unit dining room. There were residents seated at 2 long tables and three smaller tables. At approximately 12:11 PM one cart was delivered to the dining room. At 12:14 PM, staff was observed serving three residents at a small table that required assistance with eating while multiple residents were seated at two (2) long table and two (2) other smaller tables. At 12:25 PM, two food carts had passed the residents seated in the dining room not served or eating while wearing clothing protectors waiting to eat. The two food carts were delivered to the hallways on the 100 Unit. At approximately 12:47 PM on 1/15/19 an observation and interview with the facility consultant confirmed the observation of one table with residents being served and eating while multiple residents in the dining room had not been served or eating. The facility consultant stated he/she did not know why the dining experience was set up that way, but he/she would check and find out. At approximately 12:48 PM on 1/15/19, a staff member ambulated a resident who was in a wheelchair to the dining room to be served. The resident was place at a long table where other residents were waiting to be served. The resident was heard stating you got me out here while they are eating. Staff informed the resident that lunch was on the way, but the resident expressed disagreement verbally and with hand moments. The resident continued to express disagreement about the one table with residents being feed and he/she had to wait. LPN #1 and the facility's Pharmacy Consultant was present and heard the resident's disappointment in having to be in the dining room waiting while others are eating. LPN #1 attempted to console the resident and informed him/her that the food was on the way as he/she still expressed concerns. At approximately 12:55 PM another resident seated at the long table near the glass door in back of the dining room stated he/she was ready to eat. During an interview on 1/15/19 at approximately 1 PM with LPN #2 revealed there was no policy as to why one table with residents are served while the others are waiting. LPN #2 further stated the facility has been serving the residents this way for a long time. During the interview, food carts were observed being delivered to the dining room to serve the other residents waiting to be served.",2020-09-01
489,"ABBEVILLE NURSING HOME, INC.",425057,83 THOMSON CIRCLE,ABBEVILLE,SC,29620,2019-01-16,580,D,1,1,8N1U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record reviews and interviews, the facility failed to ensure that residents responsible parties were notified of changes that affected the resident's care while in the facility for 1 of 4 sampled residents reviewed for change in condition. Resident #134's responsible party was not notified of a skin tear that required a bandage/dressing. The findings included: The facility admitted Resident #134 on 4/12/18 with [DIAGNOSES REDACTED]. A review of Resident #134's medical record revealed a nurse's note dated 5/07/18 at 4:26 AM revealed the resident removed a brown bandage from his/her LFA (Left Fore Arm) while receiving a bath causing a category 2 skin tear. Further review of the medical record revealed there was no documentation to address the resident receiving an injury to his/her LFA that required him/her needing a bandage/dressing to the LF[NAME] Further review of Resident #134's record revealed the resident's responsible party was notified on 5/07/18 at 6:58 AM and by 9 AM the resident was transported to the emergency room . During an interview on 1/15/19 at approximately 3:05 PM with Registered Nurse #1 revealed he/she did not know when or why a bandage was first placed on Resident #134 LFA before 5/07/18. RN #1 stated after the resident removed the first bandage; a second bandage was placed on the resident by RN #2 and when that bandage was removed by the resident, further injuries occurred, and the resident was sent to the hospital for treatment. During an interview on 1/15/19 at approximately 3:21 PM with RN #1 revealed through the facility's investigation, no staff member admitted to knowing why a bandage/dressing was on the resident's LFA before 5/07/18 though the resident had a history of [REDACTED]. RN #1 stated whoever put the bandage/dressing on the LFA before 5/07/18 did not report it to the nursing heads and did not document the incident. RN #1 stated the facility did not notify the family prior to the first bandage/dressing to the resident's LFA because no one was aware as to why it was on the resident. During an interview on 1/16/19 at 9:18 AM with RN #2 revealed he/she did not know who applied the first bandage/dressing to Resident #134 LFA but he/she placed the second dressing to the resident's LFA at approximately 4:26 AM and he/she went off duty. It was reported to him/her later that the resident pulled off the second bandage/dressing that required a hospital visit and 17 sutures. RN #2 acknowledged there was no documentation of when the second injury occurred that required the hospital visit and he/she thought it was best to call the responsible party at a decent hour so the responsible party was notified by 7 AM.",2020-09-01
490,"ABBEVILLE NURSING HOME, INC.",425057,83 THOMSON CIRCLE,ABBEVILLE,SC,29620,2019-01-16,842,D,1,1,8N1U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record reviews and interviews, the facility failed to ensure that a resident's medical record accurately document the care and services that was received while placed in the facility for 1 of 4 sampled residents reviewed for change in condition. Resident #134 with treatment being given without documentation as to what occurred that required treatment. The findings included: The facility admitted Resident #134 on 4/12/18 with [DIAGNOSES REDACTED]. A review of Resident #134's medical record revealed a nurse's note dated 5/07/18 at 4:26 AM revealed the resident removed a brown bandage from his/her LFA (Left Fore Arm) while receiving a bath causing a category 2 skin tear. Further review of the medical record revealed there was no documentation to address the resident receiving an injury to his/her LFA that required him/her needing a bandage/dressing to the LFA prior to 5/07/18. During an interview on 1/15/19 at approximately 3:05 PM with Registered Nurse #1 revealed he/she did not know when or why a bandage was first placed on Resident #134 LFA before 5/07/18. RN #1 stated after the resident removed the first bandage; a second bandage was placed on the resident by RN #2 and when that bandage was removed by the resident, further injuries occurred and the resident was sent to the hospital for treatment. During an interview on 1/15/19 at approximately 3:21 PM with RN #1 revealed through the facility's investigation, no staff member admitted to knowing why a bandage/dressing was on the resident's LFA before 5/07/18 though the resident had a history of [REDACTED]. RN #1 stated whoever put the bandage/dressing on the LFA before 5/07/18 did not report it to the nursing heads and wrote no documentation. RN #1 stated the facility did not notify the family prior to the first bandage/dressing to the resident's LFA because no one was aware as to why it was on the resident. During an interview on 1/16/19 at 9:18 AM with RN #2 revealed he/she did not know who applied the first bandage/dressing to Resident #134 LFA but he/she placed the second dressing to the resident's LFA at approximately 4:26 AM and he/she went off duty. It was reported to him/her later that the resident pulled off the second bandage/dressing that required a hospital visit and 17 sutures. RN #2 acknowledged there was no documentation of when the second injury occurred that required the hospital visit and he/she thought it was best to call the responsible party at a decent hour so the responsible party was notified by 7 AM. Further record review revealed the resident's responsible party was notified on 5/07/18 at 6:58 AM and by 9 AM the resident was transported to the emergency room . The interview on RN #2 on 1/16/19 revealed he/she applied the second dressing at 4:26 AM and there was no documentation as to when the second bandage was removed by the resident.",2020-09-01
491,"ABBEVILLE NURSING HOME, INC.",425057,83 THOMSON CIRCLE,ABBEVILLE,SC,29620,2017-03-16,241,E,0,1,3CJJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews, facility failed to maintain the dignity of residents during meal service on 2 of 2 units. Resident room trays were not distributed in a sequential manner on Unit 1. The privacy curtain was not pulled for a resident who was fed by Gastrostomy tube, when other residents were served in the room. Residents were not offered glasses for canned drinks and supplements served in cartons on Units 1 and 2. Resident #85 was served with plastic utensils without documented current need. The findings included: During observation of the noon meal on 03-13-17 at 12:38 PM, Certified Nursing Assistant (CNA) #1 was the only staff member distributing room trays on Unit 1. S/he served the resident nearest the door in room [ROOM NUMBER], but did not provide a tray for the second occupant in the room or pull the privacy curtain before moving on to the next room (room [ROOM NUMBER]). It was approximately 20 minutes before the second resident in room [ROOM NUMBER] was served. room [ROOM NUMBER] was occupied by 3 residents. CNA #1 served 2 of the 3 residents sequentially. The third resident was nourished by use of a gastrostomy (G-) tube. The CNA did not pull the privacy curtain between residents. Therefore, the resident with the [DEVICE] was fully able to see other residents eating their meals. During meal observation on 03-14-17 at 12:35PM, all residents in the dining rooms on Units 1 and 2 who were served Ready Shakes and/or canned sodas were not offered or provided with glasses for these beverages. During an interview on 03-14-17 at 12:50PM, Registered Nurse (RN) #2 indicated that some residents preferred to have their beverages directly from the container. S/he stated that the kitchen usually sent extra cups on the set up cart. No extra cups/glasses were noted during observed meal times. On 03-14-17, Resident #85 was observed eating with plastic utensils in the Wing 2 dining room at 8:40 AM and at 12:40 PM. Review of the resident's diet card revealed that s/he was to have plastic ware sent with each meal. Review of the incomplete 3/7/17 dietary assessment noted plastic utensils only. Quarterly nutrition notes dated 7-12-16, 10-4-16, and 12-20-16 did not mention the use of plastic utensils. After observing the second meal, an interview with the Assistant Director of Nurses at 12:45 PM revealed that Resident #85 had become aggressive a couple of years ago and attempted to stab a nurse with a fork and it was care planned that s/he would use plastic ware from then on. No disruptive behaviors were observed during the survey. On 03-16-17 at 1:07PM, record review revealed no Physician's Order for plastic utensils. Review of Nurses Notes revealed no recent documented behaviors. Review of the 2-6-17 Minimum Data Set assessment revealed no documented behaviors. The care plan did not include a reference to associated/ongoing behavioral concerns for which the use of plastic ware was indicated. Use of plastic ware was not included in planned interventions.",2020-09-01
492,"ABBEVILLE NURSING HOME, INC.",425057,83 THOMSON CIRCLE,ABBEVILLE,SC,29620,2017-03-16,329,D,0,1,3CJJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide evidence of non-pharmacological intervention prior to administration of an antipsychotic for 1 of 5 sampled residents reviewed for unnecessary medications. Staff administered [MEDICATION NAME] multiple times to Resident #36 without documented evidence of behaviors and/or evidence of non-pharmacological interventions prior to administration. The findings included: Resident #36 was admitted to the facility with [DIAGNOSES REDACTED]. Record review on 3-15-17 at 12:08PM revealed physician's orders [REDACTED]. Review of behavior monitoring for (MONTH) through March, (YEAR) on 3/16/17 revealed no documented behaviors. Review of the Medication Administration Records revealed that [MEDICATION NAME] was administered twice in 1-17 (on 1-1-17 and 1-20-17), six times in 2-17 (on 2-8-17, 2-9-17, 2-19-17, 2-23-17 x 2, and 2-24-17), and five times in 3-17 (on 3-3-17, 3-4-17, 3-5-17, 3-9-17, and 3-10-17) for yelling out, hollering out, agitation, and anxiety. Review of Nurse's Notes revealed there was no evidence of evaluation of the underlying cause of the behavior and no attempts at non-pharmacological interventions prior to administering the medication. There were no behaviors documented when agitation or anxiety was noted as the reason for administration of the medication. Review of the care plan revealed When res(ident) noted to be yelling out, paranoid, agitated after misinterpretation of others actions or conversation, staff to approach calmly, attempt to get res to talk, give time to express self, take res to a more comfortable area, offer snacks and liquids, and if this does not work offer to take back to room. Reassure res r/t (related to) whatever is causing her (him) agitation. Make nurse aware of behaviors and meds as ordered. Call her (his) daughter or other family member when requested. During an interview on 3-16-17 at 9:44AM, Licensed Practical Nurse (LPN) #1 stated that prior to administering a PRN medication, especially antipsychotics, staff should typically try to always check for pain first and check the patient care record for behaviors. Per LPN #1, staff should do less aggressive measures before administering drug and be sure to check the environment for irritants, check their activities of daily living, and check for pain. A preliminary drug policy was provided by the Director of Nurses on 3-16-17 which did not define parameters for interventions prior to administration of PRN psychoactive medication.",2020-09-01
493,"ABBEVILLE NURSING HOME, INC.",425057,83 THOMSON CIRCLE,ABBEVILLE,SC,29620,2017-03-16,428,D,0,1,3CJJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure that irregularities identified by licensed pharmacist during drug regimen review were addressed in a timely manner by the attending physician for one of five residents reviewed for unnecessary medications. The findings included: Resident #23 was admitted to the facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. Review of the medical record on 3/15/17 at 4:30 PM revealed that the Consulting Pharmacist initiated three Note to Attending Physician/ Prescriber communication forms on 11/22/2016 regarding recommendations related to irregularities identified during monthly medication regimen review for resident #23. Review of one of the three recommendations submitted by the Licensed Pharmacist on 11/22/2016 revealed request submitted for consideration of Gradual Dose Reduction (GDR) for hypnotic medication from scheduled to as needed (PRN) dosing, this request was not addressed by the Family Nurse Practitioner (FNP) until 2/2/2017, when it was approved. Review of a second communication form submitted by the Licensed Pharmacist on 11/22/2016 addressed irregularity regarding fasting blood glucose levels and request for consideration to change dose of Lantus insulin from 10 units every 12 hours to 20 units every morning to address this issue, which was not addressed by the FNP until 2/2/17, where the request was denied with the following reason provided resident has had multiple hyperglycemic episodes- Lantus increased-HgbA1c 7.8 on 11/21/16. Review of the third communication form submitted by the Licensed Pharmacist on 11/22/2016 revealed that resident #23 was identified with weight loss, difficulty swallowing, and abnormal Thyroid Stimulating Hormone (TSH) laboratory test results with request for consideration to change medication dose for Levothyroxine followed by labs in 8 weeks, where the request was not addressed until 2/2/17 when it was approved and medication was changed and laboratory test was ordered to be done in 8 weeks. During an interview with the Director of Nursing (DON) on 3/16/17 at 10:58 am, s/he stated that after review of the medical record and discussion with the nursing staff, s/he was not able to determine a reason for the delay between when the Licensed Pharmacist submitted recommendations on 11/22/2016 and when the FNP acknowledged and initiated orders related to those recommendations 73 days later on 2/2/2017.",2020-09-01
494,"ABBEVILLE NURSING HOME, INC.",425057,83 THOMSON CIRCLE,ABBEVILLE,SC,29620,2017-03-16,431,D,0,1,3CJJ11,"Based on observations, interview, review of the manufactures recommendations and facility policy, the facility failed to follow a procedure to ensure that expired medication were removed from medication storage in 3 of 8 medication carts and 2 of 2 units reviewed. Expired medications were on the medication carts after the expiration date. The findings included: On 3/13/17 at 12:24 PM, an observation with RN#1 of the Hall 1/Unit 1 medication cart revealed a Novolog FlexPen (Lot #FP ) with approximately 225 units of fluid insulin remaining. The Novolog FlexPen had an open date of 2/10 and expiration date 3/10. Following the observation, RN #1 verified the Novolog FlexPen was expired and stated, The insulin pen should have been removed from the cart. On 3/14/17 at 1:20 PM, an observation with RN #2 of the Hall 2/Unit 1 treatment cart revealed 1-2-3-Paste with a pharmacy stamped expiration date of 1/24/17. Following the observation, RN #2 verified the 1-2-3 Paste was expired and indicated the paste should have been removed from the cart. On 3/14/17 at 1:45 PM, an observation with RN #1 of the Hall 1/Unit 2 treatment cart revealed Premarin vaginal cream .625 mg/g with a manufactures stamped expiration date of 9/16. Following the observation, RN #1 verified the Premarin vaginal cream was expired and indicated the cream should have been removed from the cart. On 3/14/17 at 10:45 AM, a review of the facility policy entitled, Medication Storage in the Facility, revealed under Expiration Dating (Beyond-use dating), procedure ([NAME]) All expired medications will be removed from the active supply and destroyed in the facility, regardless of amount remaining. The medication will be destroyed in the usual manner. On 3/14 at 2:55 PM, review of the manufacture recommendations for Novolog Flex Pen states under section How should I store Novolog FlexPen, Bullet (2) states, Store the FlexPen you are currently using out of the refrigerator below 86 degrees F or 30 degrees C for up to 28 days. Furthermore, bullet (6) states, The Novolog FlexPen should be thrown away after 28 days, even if it still has insulin left in it.",2020-09-01
495,"ABBEVILLE NURSING HOME, INC.",425057,83 THOMSON CIRCLE,ABBEVILLE,SC,29620,2017-03-16,441,D,0,1,3CJJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and review, the facility's laundry contractor failed to follow agreed upon policy and procedure for transfer of soiled linen from the facility on 1 of 2 units reviewed for Infection Control. The findings included; Observation of the facility's contracted Laundry Service delivering and retrieving laundry on 03/16/17 at 10:14 am revealed that the handler used an unlined and unmarked container which was used to bring clean linen to the facility to retrieve soiled linen. The handler also placed unbagged soiled linen in the container. In an interview on 03/16/17 at 10:14 am while loading the container into the vehicle for transport, the handler stated that the carts are cleaned once or twice a week. Subsequent review of the contractor's policy revealed that Soiled linen containers should be lined with an impervious liner. Do not allow soiled linens to simply be dropped into a container. At designated times, laundry workers using a large bin For Soiled Linen Use Only will go to each Soiled Linen Room to pick up the soiled linens. During observations from 3-13-16 through 3-16-17, resident care equipment was stored in an improper/unsanitary manner: (1) An uncovered, unlabeled bedpan was initially noted on the floor behind the toilet in room [ROOM NUMBER] (semi-private) bathroom on 03/13/2017 at 3:04 PM. (2) On 03/14/2017 at 9:35 AM, an uncovered, unlabeled bedpan was found on the grab bar in the bathroom for room [ROOM NUMBER] (semi-private). An environmental tour was conducted with the Housekeeping/Environmental Manager, Plant Maintenance Manager, Area Manager and Assistant Maintenance Manager on 3/16/17 at 2:35 PM. The bedpans had not been moved or properly stored for the duration of the survey. All staff present verified the storage of the items. The Housekeeping Manager stated that this concern was the responsibility of the nursing department. During an interview on 3/16/27 at 2:54 PM, Registered Nurse (RN) #3 verified that the items were present in both residents' bathrooms. When asked about the protocol for storage, RN #3 stated that bedpans should be bagged and labeled.",2020-09-01
496,"ABBEVILLE NURSING HOME, INC.",425057,83 THOMSON CIRCLE,ABBEVILLE,SC,29620,2017-12-07,582,C,0,1,PQLY11,"Based on record review and interviews, the facility failed to issue the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN)/Centers for Medicare/Medicaid (CMS) form to 3 of 3 sampled residents reviewed for Medicare Part A Services. Residents #38, #44 and #80 received the Notice of Medicare Non-Coverage (NOMNC), but did not receive the required SNFABN/CMS form. The findings included: Review of the medicare non coverage notices on 12/04/17 at approximately 3 PM revealed Residents #38, #44 and #80 had services ended with additional days left for services. There was no CMS forms provided by the facility. During an interview on 12/04/17 at approximately 3:10 PM with the Administrator, the Administrator confirmed the facility did not provide the Skilled Nursing Facility Advanced Beneficiary Notice (CMS ) form for Residents #38, #44 and #80. The Administrator stated the CMS would only be given if it was requested by the resident/responsible party. An interview with the facility consultant on 12/05/17 at approximately 3:48 PM revealed the facility does not provide the SNFABN/CMS form until the resident/responsible party request they want to appeal the Medicare non coverage decision.",2020-09-01
497,"ABBEVILLE NURSING HOME, INC.",425057,83 THOMSON CIRCLE,ABBEVILLE,SC,29620,2017-12-07,641,D,0,1,PQLY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure accuracy of assessments. Resident #23's Minimum Data Set (MDS) was coded inaccurately for insulin administration, diuretics, and Urinary Tract Infection (1 of 1 sampled resident reviewed for hospitalization ). The findings included: The facility admitted Resident #23 with [DIAGNOSES REDACTED]. During record review of the MDS on 12/5/17 at 2 pm revealed the MDS with assessment review date (ARD) of 9/25/17 had Insulin coded as 0 under medications, and did not have the [DIAGNOSES REDACTED]. Further review of the MDS ARD of 10/24/17 revealed Urinary Tract Infection was not coded under active diagnoses, and had diuretics inaccurately coded as 7 under medications. Review of the Medication Administration Record [REDACTED]. Review of the (MONTH) MAR indicated [REDACTED]. Review of the hospital records on 12/6/17 at 2:30 pm revealed the resident was treated and sent back to the facility on [DATE] and 10/26/17 on antibiotic therapy for a UTI. During an interview on 12/6/17 at 10:20 am, MDS Registered Nurse #1 verified inaccurate coding on the 9/25/17 MDS regarding Insulin, and did not code the presence of a UTI. S/he also verified the inaccurate coding on the 10/24/17 MDS regarding diuretics under medications.",2020-09-01
498,"ABBEVILLE NURSING HOME, INC.",425057,83 THOMSON CIRCLE,ABBEVILLE,SC,29620,2017-12-07,657,D,0,1,PQLY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to revise the comprehensive care plan. Resident #23 was hospitalized and treated for [REDACTED].# 13 did not include a problem and interventions regarding Blepharitis of the left eye (1 of 1 sampled resident for infections, and 1 of 2 sampled residents reviewed for UTI). The findings included: The facility admitted Resident #23 with [DIAGNOSES REDACTED]. Review of the hospital records on 12/6/17 at 2:30 pm revealed the resident was treated and sent back to the facility on [DATE] and 10/26/17 on antibiotic therapy for treatment of [REDACTED]. During an interview on 12/6/17 at 10:20 am, MDS Registered Nurse (RN) #1 verified the comprehensive care plan was not updated to reflect the UTI or antibiotic therapy on 9/7/17 or 10/26/17 after readmission to the facility from the hospital. The facility admitted Resident #13 with [DIAGNOSES REDACTED]. During an observation on 12/4/17 at 1:45 pm, Resident #13 was noted to have a large amount of dried beige drainage to the left eye and eyelash with swelling and redness of the lower lid. Review of the care plan on 12/5/17 at 4 pm revealed no evidence in the care plan to address the chronic Blepharitis condition of left eye drainage, redness and swelling or the ordered interventions including antibiotic eye ointment and cleansing of the eye with baby soap twice a day. During an interview on 12/6/17 at 10:25 am, MDS RN #1 verified there was no comprehensive care plan to address the Blepharitis [DIAGNOSES REDACTED].",2020-09-01
499,MUSC HEALTH CHESTER NURSING CENTER,425061,1 MEDICAL PARK DRIVE,CHESTER,SC,29706,2017-02-23,248,D,0,1,4GPQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to provide an on-going activity program for 3 of 31 sampled residents (Residents #75, #56, & #26), that supported their choices of activities, met their interests, and supported their physical, mental and psychological well-being. Findings include: 1. Resident (R) 75 was admitted on [DATE] with a [DIAGNOSES REDACTED]. Observations of R75 on 2/20/17 at 11:30 a.m., 2:40 p.m. and 2:50 p.m., revealed she was not engaged in activities. Record review of Activity Progress notes on the Point Click Care electronic medical record revealed R75 was provided group or one to one activities on only one occasion since admission. On 2/21/17, a gospel tape was played in her room, to which R75 responded I like that. During an interview with the Activities Therapist (AT) on 2/22/17 at 4:57 p.m., she reviewed the daily activity resident records contained in her activity book and stated R75 came to 3 activities during the past 6 months: 2/14/17 Valentine's Party for 10 to 15 minutes; 1/30/17 horse shoes and 1/13/17 church. Additionally, during the interview on 2/22/2017 at 4:57 p.m., the AT stated she considered placing R75 on one to one activities in her room because she was disruptive during group activities, but did not. 2. Resident (R) 56 was admitted on [DATE] with the primary [DIAGNOSES REDACTED]. During an interview with R56 on 2/21/17 at 11:02 a.m., the resident was noted to be bedridden responded to survey questions about activities, that staff did not encourage her to attend activities or provide assistance to attend them. During an interview with the AT on 2/22/17 at 5:40 p.m., she stated there are no evening activities and that the last activity of the day ends at 3:30 p.m. She stated activities are provided Monday through Saturday. Additionally, the AT stated R56 does not come to activities because she stays in her room and is on one to one activities in her room. During the interview with the AD reviewed the daily activity resident records contained in her activity book and stated R56 had been provided one to one activity on only 3 occasions during the past 6 months: 11/22/16, 2/6/17 and 2/16/17. 3. According to the Admission record dated 2/22/17 Resident (R) R26 had the following pertinent diagnosis; dementia without behavioral disturbances, anxiety and major [MEDICAL CONDITION]. Review of the 5/20/16 annual Minimum Data Set (MDS) section C Cognition identified that R26 has short and long-term memory problems and is severely impaired for decision regarding tasks of daily life. Section J1400 Prognosis identified that R26 had a condition or chronic disease that may result in a life expectancy of less than 6 months. Section F Preferences for Routine & Activities revealed that R26's was not assessed for daily preferences, activity preferences, interview with primary respondent (resident, family/significant or interview could not be completed), and staff assessment of daily activity and preferences was not completed. Review of the focus title Activities care plan last revised on 7/28/16 identified that R26 was dependent on staff for meeting emotional, intellectual, physical, and social needs related to physical limitations and cognitive deficits. The goal was that the resident would respond to 1:1 visits or activity verbally or with facial expressions. Observations 2/20/17 at 1:00 p.m. R26 was observed lying in bed in the fetal position. He had nothing in his room that would provide any stimulation. He was not observed to attend any activities. On 2/21/17 at 10:20 a.m. R26 was observed lying in bed in the fetal position, he had no radio or TV in his room. On 2/22/17 at 8:20 a.m. R26 was observed lying in bed on his left side, he was awake and alert. He had no TV or radio in the room. On 2/22/17 at 10:30 a.m. R26 remained in bed on his left side, he was alert but had a difficult time communicating as he is very hard of hearing and unable to see. He stated help me, and I love you, he was unable to elaborate any more than that. On 2/23/17 at 8:15 a.m. the resident was observed lying in bed, sleeping. On 2/23/17 at 9:00 a.m. the resident was observed sleeping. A certified nursing assistant (CNA) was setting up to give resident a bed bath. On 2/23/17 at 1:44 p.m. resident on his left side in the fetal position. His eyes were open, he responded to verbal stimuli. He had no TV or radio the room was dark. Record Review Review of the activity sheets for on 2/22/17 for 11/16 through 2/23/17 revealed that R26 was only seen by the activity staff three times in November, once in December, six times in (MONTH) and three times in February. There was no documentation regarding what the 1:1 consisted of, duration of visit or the resident participation/response to the activity. Review of the quarterly activity progress notes for R26 dated 10/17/16, 6/17/16, 4/25/16, and 2/4/16. The quarterly notes only addressed the visit being conducted during the quarterly note visit. There was no summary of the resident's participation, response, or frequency of the visits conducted during the quarter. There were no notes regarding how the activity staff incorporated the resident's activity preferences and needs. Review of the task documents in Point Click Care (PCC) for R26 on 2/20/17 at 3:10 p.m. revealed that there was no activity documentation found under the following tasks, 1:1 program, arts/crafts, barber, cards, cooking baking, games/exercise, kids visit, nail care, newspaper, self-directed activity, outings, puzzles, religious, social activity, special needs activity or TV/Movies. Staff Interviews: On 2/21/2017 at 3:00 p.m. spoke with the Activity Coordinator (AC) and the Activity Therapist (AT) they stated that they had documented in PCC and they may have some paper activity records. Neither record indicated that they had provided 1:1 visits with R26. On 2/21/2017 at 3:50 p.m. the AT stated that she had been the only one in the department and she had been struggling to get the documentation done as she has an AC whom staff pull to work the floor. She discussed that she does a quarterly activity note only and has not been documenting what activity she did for R26's 1:1 visits. She was unable to verbalize what activities she has done other than referencing her last quarterly note where she visited with him in his room. She stated she was not aware of the activities listed under tasks in PCC and was not aware that she needed to document time, activity, and R26's response to the activity. She was unable to remember what 1:1 activity was done with R26 yesterday. 2/21/17 at 4:13 p.m. the Administrator stated that it was his expectation that the activity staff find out and be aware of what the resident's activity preferences were and build a program around those interest. He would expect that they were trying to encourage them to come out for socialization. If the resident were bed bound by physician's orders [REDACTED]. He discussed that he would prefer to have activities staff see bed bound residents daily if possible but at minimum a few times a week. He discussed that activity staff could encourage other departments to visit with the resident and report to activity so they could capture those visits. He stated that he expected that any activity that was being provided or the resident participated in would be documented on the activity sheet and if receiving 1:1 visits there be detailed documentation of the activity.",2020-09-01
500,MUSC HEALTH CHESTER NURSING CENTER,425061,1 MEDICAL PARK DRIVE,CHESTER,SC,29706,2017-02-23,278,D,0,1,4GPQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure each Resident (R) had an accurate comprehensive assessment for dental status for 1 of 31 sampled residents (R37) and an accurate comprehensive assessment for nutritional status for 1 of 31 sampled residents (R32). Findings include: 1. During an observation of R37 on 2/21/17 at 9:15 a.m., R37 was observed to be edentulous except for one broken tooth in the lower front of her mouth. A review of her annual Minimum Data Set (MDS) assessment, dated 8/1/16, in the Dental section of the assessment, it indicated unable to examine. A review of her quarterly MDS assessment dated [DATE] indicated there were no dental concerns and did not identify her dental status as being edentulous or having one broken tooth in her mouth. A review of R37's quarterly assessment dated [DATE] also indicated there were no dental concerns. During an interview with the MDS Coordinator, on 2/22/17 at 9:16 a.m., she confirmed the MDS assessments for dental status were incorrect for R37and she would modify the current MDS dated [DATE]. Cross reference to F325. A review of the quarterly MDS assessment, dated 1/28/17, indicated R32 had no weight loss. A review of facility weights for R32 revealed she weighed 169 pounds (lbs.) 11/28/16, 130 lbs. 12/19/16, and 125 lbs. on 1/20/17. During an interview with the MDS Coordinator reference to F32 on 2/22/17 at 9:16 a.m., she confirmed the MDS assessment for weight loss was inaccurate.",2020-09-01
501,MUSC HEALTH CHESTER NURSING CENTER,425061,1 MEDICAL PARK DRIVE,CHESTER,SC,29706,2017-02-23,279,D,0,1,4GPQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to develop a comprehensive care plan for one resident (R26) out of 31 sample residents. Specifically, the facility failed to ensure R26 had a person-center and measurable care plan for activities. Findings include: According to the Admission record dated 2/22/17 Resident (R) R26 had the following pertinent diagnosis; dementia without behavioral disturbances, anxiety and major [MEDICAL CONDITION]. Review of the 5/20/16 annual Minimum Data Set (MDS) section C Cognition identified that R26 has short and long-term memory problems and is severely impaired for decision regarding tasks of daily life. Section J1400 Prognosis identified that R26 had a condition or chronic disease that may result in a life expectancy of less than 6 months. Section F Preferences for Routine & Activities revealed that R26's was not assessed for daily preferences, activity preferences, interview with primary respondent (resident, family/significant or interview could not be completed), and staff assessment of daily activity and preferences was not completed. Record Review Review of the focus title Activities care plan last revised on 7/28/16 identified that R26 was dependent on staff for meeting emotional, intellectual, physical, and social needs related to physical limitations and cognitive deficits. The goal was that resident would respond to 1:1 visits or activity verbally or with facial expressions. There was no documentation on the activity sheets regarding what the 1:1 visits consisted of, the duration of visit or what the resident's participation and response was to the activity. Review of the activity sheets provided on 2/22/17 for 11/16 through 2/23/17 revealed that R26 was only seen by the activity staff thirteen times. There was no documentation on the activity sheets regarding what the 1:1 visits consisted of, the duration of visit or what the resident's participation and response was to the activity. Review of the quarterly activity progress notes for R26 revealed one note for (YEAR) dated 2/4/16. There was no documentation regarding how many 1:1 visits R26 received in the quarter. Staff Interviews: On 2/21/2017 at 3:50 p.m. the Activity Therapist stated that she was not aware that she needed to document time, activity performed, resident's participation or response to the activity for R26. On 2/23/17 at 3:00 p.m. the MDS Coordinator stated that Activity Therapist does her own care plan for R26. She stated that if during a care conference the family or resident bring up things they would like to do or did in the past she will update the care plan to reflect those interests. She was unaware that the care plan needed to have measurable goals.",2020-09-01
502,MUSC HEALTH CHESTER NURSING CENTER,425061,1 MEDICAL PARK DRIVE,CHESTER,SC,29706,2017-02-23,280,D,0,1,4GPQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to revise the Care Plan for the nutritional status for 1 of 31 sampled Residents (R37) and for activities for 1 of 31 sampled Residents (R75). Findings include: 1. A review of facility weights for R37 revealed the Resident weighed 177 pounds (lbs.) on 2/15/17, and on 11/10/16 weighed 200 lbs. The weights indicated a 13% weigh loss. A review of the care plan for R37 revealed a concern indicating R37 has potential nutritional problem r/t (due to) [MEDICAL CONDITION], poor dentition diabetes. The care plan was last revised on 8/16/16 for weight gain. Further review of the care plan revealed no evidence the care plan was revised after R37 experienced unexpected weight loss from 11/6/16 through 2/23/17. During an interview with the facility Registered Dietician, on 2/21/17 at 4:25 p.m., she stated R37 should have been put on Nutritional Alert in (MONTH) (YEAR), and her care plan revised for the unexpected weight loss. She further stated neither was done. 2. Record review of R75 behavior care plan indicated The resident has behavior problem shouting out, combative, grabbing, slapping, cursing, pulling clothes off, hitting staff with fists related to dementia. The interventions included: Administer medications as ordered. Monitor / document for side effects and effectiveness. Anticipate and meet the resident needs. Explain all procedures to the resident before starting and allow the resident a few minutes to adjust to the changes. Intervene as necessary to protect the rights and safety of others. Approach and speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Praise any indication of the resident's progress/improvement in behavior. Observations on 2/20/17 revealed no activities for R75. During an interview with the Activity Therapist on 2/22/17 at 4:57 p.m., she stated, I know (R75) didn't come to many activities. (R75) is up cussing by the nursing station, because she can't stay down here with us. What does she do? Tell you off as you walk by . The Activity Therapist confirmed that no revisions were made to the behavior care plan to include diversional activities that were individualized and person centered.",2020-09-01
503,MUSC HEALTH CHESTER NURSING CENTER,425061,1 MEDICAL PARK DRIVE,CHESTER,SC,29706,2017-02-23,282,E,0,1,4GPQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy review and staff interviews the facility failed to demonstrate implementation of side effect monitoring as written in the [MEDICAL CONDITION] medication care plan for 4 out of 31 Residents (R) (R4, R17, R37 and R75) as evidenced by lack of abnormal involuntary movement scale (AIMS) assessments scheduled to be performed every 6 months per facility policy. Cross Refer to F329 Findings include: 1. Review of the record for Resident (R4) revealed [DIAGNOSES REDACTED]. R4's current list of medications included [MEDICATION NAME] 12.5 milligrams (mg) 1 tablet daily, and [MEDICATION NAME] 25 mg 1 tablet daily. Per record review for R4 the care plan for [MEDICAL CONDITION] medications initiated on 6/12/14 indicated: Administer medications as ordered. Monitor/document for side effects and effectiveness. The care plan was last revised on 11/16/16 with no changes to the above intervention. 2. Resident (R17) was admitted from the hospital due to patient exhibiting bizarre behaviors at the assisted living facility. Record review revealed R17's list of [DIAGNOSES REDACTED]. R17's current list of medications included [MEDICATION NAME] 12.5 mg 1 tablet daily, and [MEDICATION NAME] 10 mg 1 tablet daily Per record review the care plan for [MEDICAL CONDITION] medications initiated on 9/02/14 indicated: Administer medications as ordered. Monitor/document for side effects and effectiveness, [MEDICATION NAME] and [MEDICATION NAME]. The care plan was last revised on 02/17/17 with no changes to the above intervention. A query of R4 and R17's AIMS assessments documented in Point Click Care (PCC) revealed no AIMS assessments were completed and entered for either resident since the PCC electronic software was initiated in on 11/13/15. Review of the nurse's notes of both residents (R4, R17) in PCC and hard chart from 2/19/16 to 2/23/17 revealed no documentation reported [MEDICAL CONDITION] side effects identified and or assessments of side effects performed. An interview conducted with Licensed Practical Nurse (LPN3) on 2/22/17 at 3:06 p.m. acknowledged based on her review of R4 and R17 hard charts and PCC no AIMs assessments were found for the past year on either resident. She further stated review of the nurses notes over the past year did not reflect reports of or absence of [MEDICAL CONDITION] side effects and or nursing assessments of [MEDICAL CONDITION] assessments completed. An interview conducted with the Director of Nursing (DON) on 2/22/17 at 3:12 p.m. stated it is her expectation that the nurses comply with our policies and general standards for nursing practice. We expect our nurses to perform AIMS assessment on all resident receiving [MEDICAL CONDITION] medications. Review of the facility policy titled, Nursing Staff Reports - Medication Monitoring and Management dated (MONTH) 2009 states: For Antipsychotics: The continued monitoring of AIMS. 3. The facility failed to implement the Abnormal Involuntary Movement Scale (AIMS) for Resident (R) 75 as care planned. Record review of the Point Click Care electronic medical record revealed the AIMS report was not completed. During an interview with LPN1 on 2/23/17 at 1:54 p.m., she checked R75's Point Click Care electronic record and stated the AIMS report was 173 days overdue. During an interview with the Case Manager Assistant on 2/23/17 at 2:05 p.m., she reviewed the AIMS report on the Point Click Care electronic medical record and stated the Social Worker does the AIMS monitoring and some were done on paper. During an interview with the Social Worker on 2/23/17 at 2:20 p.m., he stated he had no AIMS monitoring for R75. 4. A review of the Physician's orders for R37 for (MONTH) (YEAR) revealed R37 had orders for [MEDICATION NAME] (anti-anxiety medication) 0.25 milligrams (mg) to be given twice a day and [MEDICATION NAME] 0.25 mg to be given as needed, for anxiety. A review of the care plan for R37 indicated resident uses anti-anxiety medications [MEDICATION NAME], R/T (due to) Anxiety disorder last revised 3/10/16, revealed an intervention stating Administer anti-anxiety medications as ordered by physician. Monitor for side effects and effectiveness Q-shift. A review of R37's clinical record including electronic and paper documents revealed no evidence [MEDICATION NAME] was being monitored for effectiveness. During an interview with the Unit Manager, Licensed Practical Nurse (LPN1) on 2/22/17 at 2:00 p.m., she stated she could find no evidence of [MEDICATION NAME] being monitored for effectiveness in R37's clinical record.",2020-09-01
504,MUSC HEALTH CHESTER NURSING CENTER,425061,1 MEDICAL PARK DRIVE,CHESTER,SC,29706,2017-02-23,325,E,0,1,4GPQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to provide nutritional care and services to prevent or treat avoidable weight loss for 2 of 31 sampled Residents (R) (R37, R51). Findings include: 1. A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R37 was assessed as having a weight loss of 5% or more in last month or loss of 10% or more in the last 6 months. It further indicated R37 was not on a prescribed weight loss regimen and received a mechanically altered diet. A review of facility weights for R37 revealed the Resident weighed 177 pounds (lbs.) on 2/15/17, and on 11/10/16 weighed 200 lbs. The weights indicated a 13% weigh loss. A review of the care plan for R37 revealed a concern indicating R37 has potential nutritional problem r/t (due to) [MEDICAL CONDITION], poor dentition diabetes. The care plan was last revised on 8/16/16 for weight gain. Further review of the care plan revealed no evidence the care plan was revised after R37 experienced unexpected weight loss from 11/6/16 through 2/23/17. A review of R37's document for Total Fluid Meal Intake Reports for 2/8/17 through 2/22/17 revealed R37 ate 25%-50% of her breakfast meal 7of 15 documented opportunities and none of her breakfast on one day. R37 ate 25%-50% of her lunch meal 4 of 9 documented opportunities. R37 ate none of her supper meals on 2 of 8 documented opportunities and 25%-50% for 2 of 8 documented opportunities. A review of all physicians' notes from 11/2017 through 2/21/17 revealed no mention of R37's weight loss. A review of Physicians' order for R37 for (MONTH) (YEAR), included Mech(sic) (mechanical) soft w/pureed meats and vegs thin liquids. During an observation and interview with R37 on 2/22/17 at 8:13 a.m., it was observed that she was served pureed pork sausage, cheese grits, and scrambled eggs. The resident was observed to eat 1/2 of her eggs, 1/2 of her cheese grits and none of her pureed sausage. R37 stated she does not like pureed food and will not eat it. She further stated she had told the facility multiple times she will not eat pureed food. During an interview with the facility Registered Dietician, on 2/21/17 at 4:25 p.m., she stated R37 should have been put on Nutritional Alert in (MONTH) (YEAR), and her care plan revised for the unexpected weight loss. She further stated neither was done. She continued she was unaware of why R37 had such a dramatic weight loss. During a second interview with the Registered Dietician on 2/22/17 at 9:30 a.m. she stated she was unaware R37 was refusing her pureed foods. 2. Review of the record for R51 indicated the resident had a past medical history of [REDACTED]. On 11/29/16 an x-ray was completed of R51's left hand due to persistent complaints of pain and swelling. Findings revealed severe [MEDICAL CONDITION] arthritis noted at the first carpometacarpal and second carpometacarpal joint. Severe [MEDICAL CONDITION] arthritis at the first metacarpophalangeal joint, second through fifth proximal interphalangeal joints, and first through fifth distal interphalangeal joints. She was screened and treated by occupational therapy from 1/18/17 - 2/17/17 with underlying impairments assessed as follows: Strength in left upper extremity (UE) 2+/5, strength in right UE 3/5, strength of left hand grip was 5, and strength of right hand grip was 22. Resident requires set up for meals with assist as needed. Record review for R51 from 10/17/16 to 2/07/17, the resident demonstrated a 44 pound (lb.) weight loss at 20%. Further review of the RD records of weekly IDT meeting minutes' summary reports for residents on nutritional alert from 12/15/16 - 2/23/17 reflected R51 had not been included in the list of residents for review each week. Record review of R51's activities of daily living (ADL) care plan initiated on 9/30/15 indicated: For eating the resident requires assistance by (1) staff to set up. Last updated on 2/20/17 with no changes to the aforementioned intervention. Record review of R51's daily percentage of meal intake from 2/07/17 to 2/21/17 revealed 14 out of the 22 entries revealed R51 ate at a consumption rate of 0 - 25% for 63.6% of his/her meals documented during this time frame. On 2/20/17 records revealed R51 ate 0 - 25% of her breakfast with 250cc of fluid. On 2/20/17 records revealed R51 ate 0 - 25% of her lunch with 250cc of fluid. On 2/20/17 records revealed CNA did not record meal intake percentage, not applicable was entered. Multiple observations were made from 2/20/17 - 2/23/17 revealing R51 failed to receive assistance from staff for meal set up. Observation on 2/20/17 at 12:15 p.m. R51's lunch tray was brought to her room by a Certified Nursing Assistant (CNA) who pleasantly greeted resident and placed the lunch tray on the residents over bed table and left the room. No set up or repositioning was provided. The resident was positioned poorly in bed, head of bed elevated 45 - 60 degrees with R51 leaning to left side. R51's lunch tray remained covered with green plate lid, all liquids remained covered with plastic lids, milk carton not opened, and dessert remained covered with cellophane. An observation on 2/20/17 at 12:25 p.m. spoke with R51 who stated she usually gets help from her family with meals they are on their way. The food tray and drinks remained covered. R51 stated due to her severe arthritis she cannot feed herself. The resident indicated her hands hurt really bad and she can barely move them. The head of bed (HOB) was elevated 45 - 60 degrees, and the resident was slumped toward her left side. Observation on 2/20/17 at 12:40 p.m. R51 still lying in bed with tray untouched. Remains in same position. R51 was observed attempting to remove a plastic lid from her drink, but was unable to do so. An observation on 2/20/17 at 12:58 p.m. R51 remains in bed and awake. The food tray remains untouched. CNA6 enters the room and prepares to sit and feed R51's roommate R4. Observation on 2/20/17 at 1:17 p.m. spoke with R51 at her bedside. The food tray remained untouched. The resident position was unchanged, remained slumped to the left side in bed. CNA6 is still in room feeding roommate. Upon completing feeding R4 CNA6, asked R51 if she was finished eating and removed her tray with 0% consumed by resident. Observation on 2/22/17 at 8:06 a.m. R51 lying in bed. HOB elevated 45 - 60%, R51 sitting in bed with eyes closed. The breakfast tray was on the bedside table and the plate was uncovered. Liquids with lids remaining, milk carton unopened, the Danish covered with cellophane. The food was untouched. Observation at 8:22 a.m. R51 resting in bed with eyes closed. Food tray remains untouched Interview conducted with CNA7 on 2/22/17 at 8:37 a.m. who stated R51 is confused. She usually will say her family is coming to feed her. We will bring her tray and set her up. She can eat well by herself without assistance. Lately she only eats about 25 - 50% of her meals. We try to encourage her to eat more. Observation on 2/22/2017 8:40 a.m. CNA1 enters R51 room and takes her tray. Ask CNA1 in hallway prior to placing tray back on cart if I can see how much R51 consumed. 0% eaten. Asked CNA1 to take tray back to the room and ask R51 if she wanted something on her tray. R51 stated she wanted to eat the cheese grits however, due to her hands hurting she was unable to do so. CNA1 reheated the cheese grits and fed them to R51 who at 100% of the cheese grits and drank 60cc of juice. Interview conducted with Licensed Practical Nurse (LPN1) on 2/22/17 at 8:57 a.m. who stated R51 sometimes can do for herself in feeding and sometimes she can't and the staff will assist her. Our CNAs know to inform us if the resident is not eating. She was in our nutritional alert meetings due to weight loss some time ago. She was placed on weekly weights. We spoke with the family (daughter and son in-law) they were aware of her not eating and tried to bring in foods but she still would not eat. Therapy has reassessed her several times. An interview conducted with the Registered Dietician (RD) on 2/22/17 at 9:18 a.m. who acknowledged she had seen R51 for the first time on 2/14/17 to talk to her about her food preferences and to complete her next nutritional quarterly review. She acknowledged she was not aware of R51 severe arthritic left hand. The RD indicated when residents are noted to have weight loss they are placed on our weight monitor program and weekly weights. She further stated R51 was placed on the Nutritional Alert program due to weight loss by her predecessor on 12/15/16 with recommendations for weekly weight assessments and interdisciplinary team (IDT) monitoring. R51 was added to weekly weight list however she failed to add her to the weekly list of residents for IDT to review. She stated she would discuss further with Interdisciplinary Team (IDT) and the physician as resident is now on nutritional alert list as of 2/22/17. An interview conducted with the Occupational Therapist, (OT) on 2/22/17 at 1:59 p.m. who stated based on his last review which ended on 1/18/17, R51 could lift a cup, and feed herself. She required assistance with set up only. He stated R51 has had problems with her left hand primarily due to [MEDICAL CONDITION] arthritis. She doesn't do anything with her left hand and doesn't want anyone touch it. We've had her on skilled care multiple times however she has declined in the past few months demonstrating increasing confusion. There were additional recommendations in the past such as restorative care but now she had reached her max potential. She used to get up back in September, October, and maybe in (MONTH) by the PT staff. When out of bed her posture is better and facilitates her ability to eat. But now she refuses to get out of bed. When she does eat she is often in poor positioning as the staff do not pull her up in bed. The CNA's are supposed to assist her with set up by removing lids, removing tray cover, placing the straw if drink. The OT therapist was accompanied to R51's room and resident was found well positioned in bed. She was asked to pick up her cup of water with her right hand, R51 was unable to do so, she was asked to hold a butter knife with her right hand, again R51 was unable to do so. 02/22/2017 4:49:32 PM Interview conducted with the RD who stated R51 was placed on Nutritional Alert List back in (MONTH) (YEAR). Per record review she was added to weekly weights on 12/15/16 and at this time she would have been placed on the Nutritional Alert. Based on our process this resident should have had weekly interdisciplinary team (IDT) meetings to address interventions implemented to address identified weight loss concerns. The IDT team consist of the nurses, administrator, MDS Coordinator, social worker, rehab, and activities. I always tell the CNAs to inform me if a resident is eating at 25% or less of meal intake. No one reported any meal intake concerns regarding R51. She will be placed on the weekly weights as today 2/22/17. The physician is notified of all residents who are placed on weekly weights for nutrition alerts, as our Nutritional Alert summary reports are forwarded to the physician for review each week. She did not get placed on the report like she should have. She further acknowledged by not placing her on the nutritional alert list the facility failed to include her in their weekly IDT meetings held on Friday mornings Interview conducted with LPN3 on 2/23/17/ at 8:23 a.m. who stated she participated in the weekly Friday morning interdisciplinary meetings for residents placed on nutritional alert, restraints, falls, and wounds. The team members included the Administrator, DON, registered dietician, MDS, Social Worker, Infection Control and the Rehab Manager. She acknowledged she did not recall R51 being discussed in the weekly IDT meetings. She further stated R51 was not on the list to assist with feeding she was on the list to assist with set up meaning bring tray, remove lids, positioning for meals, open straws, ensure items are within reach, make sure food is seasoned as desired, and for CNA staff to ask if they can assist the resident further prior to leaving the room. Interview conducted with DON on 2/23/27 at 9:54 a.m. who stated it was her expectation that all residents who require set up with meals receive the assistance needed. I expect our staff to monitor the percentage of food intake, and report poor intake and weight loss. A review of the facility's undated Weight Management Protocol revealed a section entitled For residents identified with weight loss trend. This section indicated the following was to be done: dietician will add residents to Nutrition Alert list and have interdisciplinary team discussion/approach at Nutrition Alert Meeting to identify the etiology/cause of weight loss and begin monitoring resident's nutritional status in a frequently and intensive (weekly) manner.",2020-09-01
505,MUSC HEALTH CHESTER NURSING CENTER,425061,1 MEDICAL PARK DRIVE,CHESTER,SC,29706,2017-02-23,329,E,0,1,4GPQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure each Resident (R) was free from unnecessary drugs such as an anti-anxiety medication for R37 and anti-psychotic medications for R4 and R17. This affected 3 of 6 sampled Residents for unnecessary medications. Findings include: 1. A review of the clinical record for R37 revealed she was admitted to the facility on [DATE] with the following Diagnosis: [REDACTED]. A review of R37's quarterly Minimum Data Set (MDS) assessment dated [DATE] coded the resident as having received an anti-anxiety medication. A review of her care plan for R37 revealed a concern Uses anti-anxiety medications [MEDICATION NAME], R/t (due to) anxiety disorder. The interventions included: Administer anti-anxiety medications as ordered by physician. Monitor for side effects and effectiveness Q (every)-shift initiated 8/7/15 and last revised 8/10/16. A review of physician's orders [REDACTED]. A review of the clinical for record for R37 including nurses notes, progress notes, assessments and Medication Administration Record [REDACTED]. During an interview with the Director of Nursing (DON), on 2/23/1 at 12:26 p.m. she stated she could find no evidence in R37's clinical record of the effectiveness of the anti-anxiety medication for R37. She further stated there should be documentation of the medications effectiveness on each shift, each day. Further review of R37's MAR indicated [REDACTED]. During a review of the Consultant Pharmacist's medication review for R37, a document entitled Note to Attending Physician/Prescriber indicated a pharmacist recommendation to reduce the anti-anxiety medication from .25 mg twice a day to .25 mg once a day. The physician had signed the note but did not date when he signed it, wrote no change to the medication, but did not give a rationale for not following the pharmacist's recommendation. During an interview with the facility Medical Director on 2/22/17 at 2:20 p.m., he stated he was not aware of the necessity of documenting a rationale for not following a pharmacist recommendation to reduce medication for R37. 2. The record review for R4 revealed a list of [DIAGNOSES REDACTED]. R4's current list of medications included [MEDICATION NAME] 12.5 milligrams (mg) 1 tablet daily, and [MEDICATION NAME] 25 mg 1 tablet daily. Per record review of R4 the care plan for [MEDICAL CONDITION] medications initiated on 6/12/14 states: Administer medications as ordered. Monitor/document for side effects and effectiveness. Care plan last revised on 11/16/16 with no changes to the above intervention. 3. Resident (R17) was admitted to the facility from the hospital due to patient exhibiting bizarre behaviors at the assisted living facility. Record review revealed R17's list of [DIAGNOSES REDACTED]. Per R17's review of her care plan for [MEDICAL CONDITION] medications initiated on 9/02/14 indicated: Administer medications as ordered. Monitor/document for side effects and effectiveness, [MEDICATION NAME] and [MEDICATION NAME]. The care plan was last revised on 02/17/17 with no changes to the above intervention. A query of R4 and R17's AIMS assessments documented in Point Click Care (PCC) revealed no AIMS assessments were completed and entered for either resident since the PCC electronic software was initiated in on 11/13/15. Review of the nurse's notes of both residents (R4, R17) in PCC and hard chart from 2/19/16 to 2/23/17 revealed no documentation reported [MEDICAL CONDITION] side effects identified and or assessments of side effects performed. Interview conducted with Licensed Practical Nurse (LPN3) on 2/22/17 at 3:06 p.m. acknowledged based her review of R4 and R17 hard charts and PCC no AIMs assessments were found for the past year on either resident. She further stated review of the nurses notes over the past year did not reflect reports of or absence of [MEDICAL CONDITION] side effects and or nursing assessments of [MEDICAL CONDITION] assessments completed. Interview conducted with Director of Nursing (DON) on 2/22/17 at 3:12 p.m. who stated it is her expectation that the nurses comply with our policies and general standards for nursing practice. We expect our nurses to perform AIMS assessment on all resident receiving [MEDICAL CONDITION] medications. This is an area we can reeducate the nursing staff on. Facility policy titled, Nursing Staff Reports - Medication Monitoring and Management dated (MONTH) 2009 states: For Antipsychotics: The continued monitoring of AIMS is also evaluated with antipsychotic medications, as well as [MEDICATION NAME]. AIMs testing is performed every 6 months by the facility and stored on the resident's chart.",2020-09-01
506,MUSC HEALTH CHESTER NURSING CENTER,425061,1 MEDICAL PARK DRIVE,CHESTER,SC,29706,2017-02-23,371,F,0,1,4GPQ11,"Based on observation and interview, the facility failed to ensure a sanitary kitchen, sanitary food preparation, and sanitary food service for 31 of 31 sampled Residents (R) (R51, R64, R90, R2, R11, R60, R4, R34, R26, R59, R58, R17, R37, R38, R53, R8, R29, R69, R86, R84, R12, R23, R19, R16, R40, R71, R75, R32, R56, R33, and R30.) Findings include: 1. During an observation in the kitchen, on 2/20/17 at 9:30 a.m., the walk-in freezer was observed to have paper trash and French fries littering the freezer floor. An observation of the walk-in refrigerator, on 2/20/17 at 9:33 a.m., revealed a tray of chicken sitting in a liquid that was not covered. An interview with the Dietary Manager, on 2/20/17 at 9:33 a.m. confirmed the observation in the walk-in freezer and the tray of uncovered chicken in the refrigerator. The dietary Manager stated neither was acceptable. Further observation in the kitchen on 2/20/17 at 9:36 a.m., revealed an oven with baked on food debris on the front face of the oven, a food preparation table that had built up grease and food debris on it, and metal shelves that held clean dishes had built up greasy debris on them. An interview with the Dietary Manager on 2/20/17 at 9:40 a.m. confirmed the observations. During an observation in the kitchen on 2/22/17 at 11:20 a.m., a Dietary Aide (DA1) was observed to open and enter the walk-in refrigerator with gloved hands and exit the refrigerator holding an unopened package of sliced ham. With the same gloved hands, she was observed to open the package of ham and hold slices of ham in her same gloved hands to slice the ham. An interview with DA1, on 2/22/17 at 11:25 a.m., confirmed she had contaminated her gloves in touching the walk-in refrigerator's door handle and handling the unopened package of ham prior to handling the ham with the same gloves. During an observation on 2/22/17 at 12:07 p.m., the Cook was observed to bring a box of disposable plates to a counter with gloved hands. He was then observed to open the card board box with his gloved hands and reach in and handle the food holding sections of the disposable plates with the same gloved hands. During an interview with the Cook on 2/22/17 at 12:07 p.m., he stated he should have removed the gloves after handling the card board box, wash his hands then don new gloves before handling the food surface of the disposable plates. During an observation in the 3 Hall, on 2/20/17 at 12:43 p.m., a Certified Nursing Assistant (CNA4) was observed to enter room 56 with a meal tray for the Resident. She was observed to set the meal tray down on the Resident's bed table, and then pick the Resident's cell phone off the floor. After picking the phone up off the floor, she proceeded to serve the Resident his meal handling his silver ware with her hand that handled the cell phone. During an interview with CNA4, on 2/20/17 at 12:44 p.m. she states she should have washed her hands after picking up the cell phone from the floor and before she served the resident his meal. 2. On 2/20/17 at 12:38 p.m. during the tray delivery Certified Nursing Assistant (CNA) CNA1 and the Activity Coordinator (AC) were observed touching the tips of the straws while opening them and putting them in the resident's drinks. On 2/20/17 at 12:43 p.m. CNA1 was observed opening a pack of crackers, she removed the crackers from the wrapper and put them on the resident plates using her hands. She was not observed sanitizing her hands before or after the tray delivery. On 2/20/17 at 12:43 p.m. the AC was observed removing items from the meal tray, removing the lids that covered the drinks and soup bowl. She then picked the glasses and the bowl up by the rim and placed them in front of the resident. She also touched the tip of the straw while placing it into the milk carton. On 2/22/17 at 1:00 p.m. the AC was observed pulling the paper off the resident's straw, she then touched the top of the straw bending it over after inserting it into the resident's drink. She was observed delivering and setting up others trays and did not sanitize her hands prior to touching the straw. On 2/22/17 at 1:00 p.m. and again at 1:05 p.m. CNA2 was observed removing corn bread from the bag with her bare hands and putting it on the resident's plate, she also pulled the paper off the straw and handled the tip as she put it in the residents' drink. She was not observed sanitizing her hands during the tray pass and meal set-up. Observations on Hall #1 rooms 18-31: On 2/22/17 at 12:35 p.m. CNA4 was observed picking up R75's fried chicken and shredding piece of chicken off with her bare hands. Prior to handling the chicken she had moved the tray, moved and set-up a chair and set up the resident's meal she was not observed sanitizing her hands. On 2/22/17 at 12:43 p.m. CNA5 was observed dropping Resident 26's tray off, she raised the head of the bed, got a folding chair, and set it next to the bed. She returned to the hall and retrieved a towel and touched the tip of the resident's straw while putting it in his drink. She was not observed sanitizing her hands. Staff Interview: On 2/22/17 at 1:05 p.m. the Director of Nursing (DON) stated that staff are to keep the top part of the straw encapsulated so the resident if able can remove the paper without touching the tip of the straw and if the resident could not remove the tip on their own she would expect staff to place the straw in the glass and then pull the paper off without touching the straw. She discussed that staff should not be handling any food bare handed, the should use a napkin or utensils to cut food up. Staff were also to be sanitizing/washing their hands frequently. On 2/22/17 at 1:10 p.m. Register Nurse (RN) RN1 who was the nurse assigned to the dining room stated that staff should not touch the straws with their bare hands, they should be sanitizing their hands in between tray delivery/setup, and they are never to touch any food with their bare hands. On 2/23/17 at 8:58 a.m. CNA4 stated that you are not to handle food with your bare hands ever. When asked if she was aware that she had picked up R75's chicken and started to pull the chicken apart. CNA4 stated that she did not realize she had done that. On 2/23/17 at 11:00 a.m. the Dietary Manger (DM) stated that he was not aware that he needed to do or coordinate training with nursing staff regarding how to handle foods and he was not sure when they last received training. He stated that staff were not to handle bowls or glasses by the rims, they were to tear the straw and leave the top part covered and either they could remove the paper by the tip or the resident could remove. The staff should never touch the top of the straw with their hands. He further discussed that staff were never to handle food with their bare hands and they should be sanitizing their hands in between meal deliver/set up and prior to assisting the resident.",2020-09-01
507,MUSC HEALTH CHESTER NURSING CENTER,425061,1 MEDICAL PARK DRIVE,CHESTER,SC,29706,2017-02-23,428,D,0,1,4GPQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy review and staff interviews the facility failed to demonstrate an adequate physician written response to pharmacist' medication regimen review (MRR) recommendations as evidenced by lack of documented clinical rationale for 3 out of 31 sampled Residents (R4, R17, and R37.) Findings include: 1. Review of the record for Resident (R4) revealed [DIAGNOSES REDACTED]. The MRR for R4 dated 6/27/16 revealed the Pharmacist wrote a recommendation for a gradual dose reduction (GDR) to decrease/discontinue both Seroquel 25 mg 1 tablet daily for psychosis since (MONTH) 2014 and Zoloft 25 mg daily for depression since (MONTH) 2014. The Physician responded, Disagree - No Changes. The date of physician entry was not recorded. Documentation of the physician clinical rationale was not found in the record. Review of the MRR for R4 dated 12/20/16 the Pharmacist wrote a recommendation for a GDR for both Sertraline 25 mg daily and Seroquel 25 mg daily documented: There are no reported behaviors documented at this time. Please consider if appropriate decreasing both medications to 1/2 tab daily or to lowest effective dose. The Physician responded: Agree to decreasing Seroquel to 12.5 mg daily however, failed to provide documented clinical rational for not agreeing to decrease Sertraline. The date of physician entry not recorded. 2. Resident (R17 was admitted from the hospital due to patient exhibiting bizarre behaviors at the assisted living facility. Record review revealed R17's list of [DIAGNOSES REDACTED]. R17's current list of medications included Seroquel 12.5 mg 1 tablet daily, and Celexa 10 mg 1 tablet daily. The MRR for R17 dated 6/12/16 revealed the Pharmacist wrote a recommendation to decrease both Seroquel 12.5 mg 1 tablet daily for psychosis since (MONTH) 2010 and Celexa 10 mg daily for depression since (MONTH) 2010. Physician responded, No Changes. The date of physician entry was not recorded. Documentation of the physician rationale could not be found in the record. An interview conducted with the Consulting Pharmacist on 2/21/17 at 3:12 p.m. who stated, the prescribing physician has been reminded more than once on the importance of documenting a clinical rationale when he/she disagrees with a pharmacy GDR recommendation. An interview conducted with the Medical Director on 2/22/17 at 2:19 p.m., who upon review of the GDR request forms signed by the prescribing physician who disagreed with the GDR recommendation with no clinical rationale documented, stated he would reeducate the physician to comply with the regulatory standard as written. 3. A review of physician's orders [REDACTED]. During a review of the Consultant Pharmacist's medication review for R37, a document entitled Note to Attending Physician/Prescriber indicated a pharmacist recommendation to reduce the anti-anxiety medication from .25 mg twice a day to .25 mg once a day. The physician had signed the note related to R37 but did not date when he signed it, wrote no change to the medication, but did not give a rationale for not following the pharmacist's recommendation. During an interview with the Registered Pharmacy Consultant, on 2/22/17 at 1:38 p.m., she stated she had spoken with the physician multiple times about R37 informing him he must document a rationale for not following her recommendations, but he continued to disregard her instructions. During an interview with the facility Medical Director on 2/22/17 at 2:20 p.m. a review of his response to pharmacy recommendations about R37's medications was discussed. He stated he was not aware of the necessity of documenting a rationale for not following a pharmacist recommendation to reduce a resident medication. The facility undated policy titled, Consultant Pharmacy Reports - Medication Monitoring and Management indicated: For Antipsychotics: If a resident is admitted on an antipsychotic medication or the facility initiates antipsychotic therapy, the facility must attempt a gradual dose reduction (GDR) in two separate quarters (with at least one month between the attempts) within the first year, unless clinically contraindicated. After the first year, a GDR must be attempted annually, unless clinically contraindicated. B. If a medication seems unnecessary or harmful to the resident, the (Director of Nursing, consultant pharmacist) requests the prescriber to evaluate the resident for the continued need for the medication and/or to consider tapering the medication. If the prescriber deems the medication necessary, a documented clinical rationale for the benefit of, or necessity for, the medication is documented in the resident's (active record).",2020-09-01
508,MUSC HEALTH CHESTER NURSING CENTER,425061,1 MEDICAL PARK DRIVE,CHESTER,SC,29706,2017-02-23,456,F,0,1,4GPQ11,"Based on observation, reviewing dishwasher manufacturer's instruction sheet, and interview, the facility failed to ensure the kitchen dishwashing machine was operating at the appropriate temperatures to ensure all items washed in the machine were properly cleaned and sanitized. This had the potential to affect 31 of 31 sampled residents, Residents (R) (R51, R64, R90, R2, R11, R60, R4, R34, R26, R59, R58, R17, R37, R38, R53, R8, R29, R69, R86, R84, R12, R23, R19, R16, R40, R71, R75, R32, R56, R33, and R30.) Findings include: During an observation in the kitchen on 2/22/17 at 10:10 a.m., the dishwashing machine was observed to run multiple cycles with the maximum wash water temperature of 145 degrees Fahrenheit (F) and a maximum water rinse temperature at 159 degrees F. A review of posted manufacturer's instructions revealed the wash temperature should be 150 degrees F and the rinse should be 180 degrees F to ensure clean, sanitized dining and cooking utensils and plates. An interview with the Dietary Manager on 2/22/17 at 10:13 a.m. confirmed the temperatures of the wash and rinse cycle and confirmed the dish washing machine was not performing at the necessary temperatures.",2020-09-01
509,MUSC HEALTH CHESTER NURSING CENTER,425061,1 MEDICAL PARK DRIVE,CHESTER,SC,29706,2019-06-12,550,E,0,1,C9E011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to provided dignity during the dining experience on 1 of 3 halls observed and 1 of 1 main dining room observed. Residents that depended on staff to feed them were not served and eating while their roommate was served and eating in full view of the resident not served or eating on the hall with room numbers 33 through 46. Staff was observed placing clothing protectors on residents in the main dining without asking. The finding included: During a random meal observation on 6/10/19 at approximately 12:45 PM revealed a resident served and eating independently in rooms [ROOM NUMBERS] while their roommate was in the room not served or eating in full view of the resident that was eating. During an interview and observation with the Director of Nursing (DON) on 6/10/19 at approximately 12:55 PM s/he confirmed that residents that can feed themselves independently are served first and the residents that require staff assistance are served and fed last when staff are available. The DON further acknowledged the privacy curtains were not pulled and the resident that was eating was in full view of the resident waiting to be served. During a dining room observation on 06/10/19 at approximately 12:00 PM, CNA #1 was in the main dining room assisting residents. CNA #1 applied clothing protectors to residents #57, #40 and #7 without asking permission. During an interview with CNA #1 on 06/10/19 at approximately 12:40 PM CNA #1 stated I just know they want one and they do (want one) when I ask.",2020-09-01
510,MUSC HEALTH CHESTER NURSING CENTER,425061,1 MEDICAL PARK DRIVE,CHESTER,SC,29706,2019-06-12,584,D,0,1,C9E011,"Based on observations and interview, the facility failed to ensure that privacy curtains in rooms near the window provided full privacy. The privacy curtains in rooms 34-B, 35-B, 36-B, 45-B and 46-B did not extend from wall to wall to ensure full privacy, had stains or tears. 1 or 3 halls reviewed. The findings included: Random room observations on 6/10/19 at approximately 10:41 AM revealed the privacy curtain near the window in rooms 34-B, 35-B, 36-B, 45-B and 46-B did not extend from wall to wall to provide full privacy, had stains or in poor repair (tears). During an interview and observation with the Housekeeping Manager on 6/10/19 at approximately 11:05 AM s/he confirmed there were privacy curtains that did not extend from wall to wall near the window. The Housekeeping Manager stated the facility was in the process of replacing worn and stained privacy curtains. When asked if there was documentation to indicate the facility had identified the concerns with the privacy curtains; the Housekeeping Manager stated no. At approximately 11:20 AM on 6/10/19, the housekeeping department provided a list of rooms #26, #27, #34, #35, #36, #37, #38, #41, #45, #46, #48, #51 and #54 with a note that indicated need to order. No further information was noted.",2020-09-01
511,MUSC HEALTH CHESTER NURSING CENTER,425061,1 MEDICAL PARK DRIVE,CHESTER,SC,29706,2019-06-12,636,D,0,1,C9E011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview Resident #29 had no resident assessment done after readmission to the facility related to pressure ulcer developed in the hospital. 1 of 4 residents reviewed for pressure area. The findings included: The facility admitted Resident #29 on 4/26/19 with [DIAGNOSES REDACTED]. Review of Resident #29's Physicians orders revealed an order to clean wound to right hip with wound cleanser and prep area with skin prep, apply therahoney gel and cover with dry dressing daily and PRN(as necessary). Review of Resident #29's Nurses note dated 5/23/19 documented skin condition fair with redness on buttocks, open pressure area on right hip, standing orders applied (therahoney to right hip.) Record review of Resident #29's record revealed that a MDS (Minimum Data Set) had not been completed since re-admission. Review of Resident #29's Care Plan on 6/12/19 revealed no care plan addressing the pressure ulcer. During an interview with the Director of Nursing (DON) on 6/12/19 the DON stated that s/he had not assessed Resident #29 for pressure ulcers when the resident returned from the hospital. Therefore, the pressure area had not been staged or measured, and no documentation had been done on the wound since 5/23/19.",2020-09-01
512,MUSC HEALTH CHESTER NURSING CENTER,425061,1 MEDICAL PARK DRIVE,CHESTER,SC,29706,2019-06-12,655,D,0,1,C9E011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview an initial care plan problem for pressure area was never added to the care plan when Resident #29 returned from the hospital. 1 of 4 care plans reviewed for pressure areas. The findings included: The facility admitted Resident #29 on 4/26/19 with [DIAGNOSES REDACTED]. Review of Resident #29's Physicians orders revealed an order to clean wound to right hip with wound cleanser and prep area with skin prep, apply therahoney gel and cover with dry dressing daily and PRN(as necessary). Review of Resident #29's Nurses note dated 5/23/19 documented skin condition fair with redness on buttocks, open pressure area on right hip, standing orders applied (therahoney to right hip.) Record review of Resident #29's record revealed that a MDS (Minimum Data Set) had not been completed since re-admission. Review of Resident #29's Care Plan on 6/12/19 revealed no care plan addressing the pressure ulcer. During an interview with the Director of Nursing (DON) on 6/12/19 the DON stated that s/he had not assessed Resident #29 for pressure ulcers when the resident returned from the hospital. Therefore, the pressure area had not been staged or measured, and no documentation had been done on the wound since 5/23/19. During an interview with the Care Plan Co-coordinator on 6/12/19 s/he stated that the care plan was not updated to reflect the pressure area because it had not been assessed as a wound. The Care Plan Co-coordinator stated that s/he usually picks up in daily meetings or wound assessments. S/he also stated the physicians order for treatment was missed. Review of Resident #29's Medication Administration and Treatment Administration Sheets were reviewed, and treatments were documented as done daily to the pressure area on the right hip. Observation of wound care on 6/12/19 at 3:30 PM showed the wound to be clean, no drainage, and healing.",2020-09-01
513,MUSC HEALTH CHESTER NURSING CENTER,425061,1 MEDICAL PARK DRIVE,CHESTER,SC,29706,2019-06-12,761,D,0,1,C9E011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to ensure medications were not expired. 2 of 2 medication storage rooms reviewed. The findings included: On 06/11/19 at approximately 09:28 AM surveyor was performing medication storage and discovered expired [MEDICATION NAME] (5 mls/300 mg). The expired [MEDICATION NAME] sulfate was packaged in individual doses of 5 milliliters. 50 individual dosages of the expired medication was dated as expiration date (MONTH) 2019. In addition, 20 individual dosages of the expired medication was dated as expiration date (MONTH) (YEAR). On 06/11/19 at approximately 09:28 AM the Unit Manager and Pharmacist were present during the medication storage checking for expired medications and confirmed the expired medications and removed the expired medications.",2020-09-01
514,MUSC HEALTH CHESTER NURSING CENTER,425061,1 MEDICAL PARK DRIVE,CHESTER,SC,29706,2019-06-12,812,F,0,1,C9E011,"Based on observation and interview the oven and back splash of range were not cleaned per schedule and a kitchen staff member was observed not wearing a beard protector while in the kitchen preparing food. 1 of 1 main kitchen reviewed. The findings included: During initial observation of the main kitchen on 6/10/10 at 9:30 AM with the Dietary Manager, the ovens had dark brown splatters built up on the inside of the ovens. When the Dietary Manager was asked for the cleaning schedule it was revealed that the ovens were supposed to have been cleaned on 6/5/19; however, that employee had been on leave of absence and no one had taken that assignment. The back splash behind the range top also had build-up of dark brown splatters. On 6/12/19 at 11:45 AM the Chef was observed working over food with no beard protector in place. This was confirmed by the Dietary Manager.",2020-09-01
515,MUSC HEALTH CHESTER NURSING CENTER,425061,1 MEDICAL PARK DRIVE,CHESTER,SC,29706,2019-06-12,880,E,0,1,C9E011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to ensure that residents' personal laundry was processed to an appropriate manner. The laundry room large overhead vent near the front of the washer was noted with a heavy build of gray matter. There was large section of plastic peeling from the ceiling near the rear of the washer with a hole in the area. Staff did not use a sanitation process of wiping the washer when doing individual residents' laundry. There was no policy in place regarding the handling on resident's personal laundry while at the facility. 1 of 1 laundry rooms reviewed. The findings included: A random observation of the laundry process on 6/11/19 at approximately 7:48 AM with the Linen Service worker revealed a single stainless-steel washer with multiple streaks on the outside of the washer. A large overhead vent near the front of the washer was noted with a heavy buildup of gray matter. There was a large section plastic peeling from the ceiling behind the washer with a hole in the area. The laundry staff did not wipe the washer with a sanitation process after washing individual residents clothing. All the residents clothing was transported in a clear thin plastic bag. Residents identified as being on contact precaution laundry was transported in a clear thin plastic bag. During an interview on 6/11/19 at approximately 8:08 AM with the Linen Service Worker s/he confirmed the observation related to the multiple streaks on the outside of the washer, the hole in ceiling with peeling plastic and heavy lint build up. The Linen Service Worker further stated s/he would wipe down the inside and outside of the washer after every two loads of laundry but did not have an training on how often to clean the washer. During an interview on 6/11/19 at approximately 9:27 AM with the Director of Nursing revealed the facility did not have a policy in place regarding washing resident's personal laundry. The facility reportedly uses the universal precaution doctrine but there was no formal guidance in place for laundry staff to follow. During an interview on 6/12/19 at approximately 12:26 PM with the Housekeeping Manager revealed there was no documentation of training provided to laundry staff on how to maintain the laundry area when handling resident's personal laundry. And no documentation of training when handling resident's laundry who were identified as being on contact precautions such as C.diff ([MEDICAL CONDITION]) or MSRA (Methionine Sulfoxide Reductase A). The Housekeeping Manager further stated that all residents' clothes are transported to the laundry in clear plastic bag. There was no distinction between a resident on contact precautions or the other residents clothing process.",2020-09-01
516,MUSC HEALTH CHESTER NURSING CENTER,425061,1 MEDICAL PARK DRIVE,CHESTER,SC,29706,2018-06-27,550,D,0,1,11DB11,"Based on observation and interview the facility failed to maintain the environment in a way that promoted Resident's #6's rights and dignity, 1 of 2 sampled residents reviewed for Dignity. The facility posted confidential clinical information above Resident #6's bed. The findings included: The facility admitted Resident #6 with diagnoses, including, but not limited to, Dementia. Resident #6 was observed in bed on 6/25/2018 at 3:47 PM. A sign, dated 8/29/2017, with swallowing guidelines instructions was posted above his/her bed. The sign was in view of anyone who entered the room. Clinical information posted on the sign included the resident's diet type (puree) and the resident required a low stimulation environment. In addition, the sign indicated the resident required one to one assistance for meals, to sit up for an hour after meals, to crush medications, small bites/sips, one bite at a time, alternate liquids/solids and to remain upright at 90 degrees for all intake. The resident was also observed on 6/26/2018 at 10:39 AM and 12:38 PM with the sign posted above his/her bed. Resident #6 was observed on 6/26/2018 at 12:42 PM with the Director of Nursing (DON) present. The DON confirmed the sign displayed confidential clinical information and removed the sign. The DON also stated the sign should not have been posted for public viewing.",2020-09-01
517,MUSC HEALTH CHESTER NURSING CENTER,425061,1 MEDICAL PARK DRIVE,CHESTER,SC,29706,2018-06-27,565,E,0,1,11DB11,Based on interview and record review the facility failed to act on grievances of the resident council for 3 to 5 months of concerns. The resident council filed concerns of call lights and response times that the facility failed to address in a timely manner. The findings included: Review of resident council minutes on 6/25/18 at approximately 1:22 PM revealed concerns of call light response times and staff taking call lights from residents for (MONTH) and (MONTH) of (YEAR). Interview with resident council on 6/25/18 at approximately 2 PM revealed staffing issues are ongoing and that it can still take time for staff to respond to call lights. Some of the residents expressed having wet themselves because staff were taking too long to respond to call lights. They expressed this issue had been going on for approximately 5 months. Review of grievance logs on 6/27/18 at approximately 10:50 AM revealed concerns with call bell response times going back since (MONTH) (YEAR).,2020-09-01
518,MUSC HEALTH CHESTER NURSING CENTER,425061,1 MEDICAL PARK DRIVE,CHESTER,SC,29706,2018-06-27,580,D,0,1,11DB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure that the physician was notified as ordered when Resident #36's finger stick blood sugars went above 400 for 1 of 3 sampled residents reviewed for hospitalization s. Resident #36 had finger stick blood sugars above 400 on 5/28/18 and 6/02/18 with no physician notification as ordered. The findings included: The facility admitted Resident #36 on 5/02/18 with [DIAGNOSES REDACTED]. A review of the medical record on 6/26/18 at approximately 12:20 PM revealed a physician's orders [REDACTED].=2 units, 201-250=4 units, 251-300=6 units, 301-350=8 units, 351-400=10 units, above 400=12 units and call medical doctor. Further review of the medical record revealed a nurse's note dated 5/28/18 that indicated resident had a FSBS of 438 at 16:30 (4:30 PM) with insulin given and rechecked in 30 minutes. There was no documentation to indicate the physician had been called/notified as ordered. A nurses noted dated 6/02/18 indicated the resident had a FSBS of 452 at 11:30 (11:30 AM) with 12 units of insulin given per physician orders. There was no documentation to indicate the physician had been called/notified as ordered. An interview on 6/26/18 at approximately 2:50 PM with Licensed Practical Nurse (LPN) #1 revealed the electronic medical record and 24 hour reporting and confirmed the findings that the physician was not notified of the FSBS over 400 as ordered. An interview on 6/27/18 at approximately 10:17 AM with the Director of Nursing (DON) reviewed the electronic record and confirmed there was no documentation to indicate the physician was notified of the FSBS over 400 on 5/28/18 and 6/02/18.",2020-09-01
519,MUSC HEALTH CHESTER NURSING CENTER,425061,1 MEDICAL PARK DRIVE,CHESTER,SC,29706,2018-06-27,585,C,0,1,11DB11,Based on interview and record review the facility failed to inform residents of their right to file a grievance in 4 of 4 units reviewed. Grievance procedure was not posted in public view as specified by the facility's grievance policy. The findings included: Resident council interview on 6/25/18 at approximately 2 PM revealed several residents did not know how to file a grievance. Review of grievance policy on 6/26/18 at approximately 3:29 PM revealed a copy of grievance / complaint procedure was to be posted on the resident bulletin board. Observation of resident bulletin boards on 6/26/18 at approximately 3:40 PM revealed it was not posted on either resident bulletin board. Interview with social services director on 6/26/18 at approximately 3:50 PM confirmed it was not posted.,2020-09-01
520,MUSC HEALTH CHESTER NURSING CENTER,425061,1 MEDICAL PARK DRIVE,CHESTER,SC,29706,2018-06-27,655,D,0,1,11DB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to develop a baseline care plan within 48 hours of admission for Resident #33, 1 of 1 sampled resident reviewed for [MEDICAL TREATMENT]. In addition, the facility had no documentation to show the Resident Representative (RR) was provided a written summary of the baseline care plan by completion of the comprehensive care plan. The findings included: The facility admitted Resident #33 with [DIAGNOSES REDACTED]. Record review of the baseline care plan on 6/27/2018 at 10:01 AM, revealed instructions to date top of each problem section upon initiation. 5 problem sections of the baseline care plan were initiated and were not dated. The section to show who initially completed the baseline care plan was blank. The date for when the baseline care plan was initially completed was blank. The baseline care plan was signed by the RR, but there was no date to indicate when it was signed. Further review of the medical record revealed no documentation of when the baseline care plan was initiated or when the RR was given the written summary. During an interview with the Director of Nursing (DON) on 6/27/2018 at 10:54 AM, the DON confirmed the baseline care plan was not dated on initiation nor dated when the RR signed the baseline care plan. The DON stated there was no documentation to show when the baseline care plan was created or when the RR was given a written summary.",2020-09-01
521,MUSC HEALTH CHESTER NURSING CENTER,425061,1 MEDICAL PARK DRIVE,CHESTER,SC,29706,2018-06-27,656,D,0,1,11DB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to follow the care plan related to contractures for 1 of 2 residents reviewed for positioning/mobility. The findings included: Resident #12 was admitted to the facility with [DIAGNOSES REDACTED]. Initial observation of Resident #12 on 6/25/2018 at approximately 10AM revealed that the Resident had severe contractures of the left (L) and Right (R) hand, however, there were no splints or interventions applied. Random observations throughout the day on 6/26/2018 and 6/27/2018 revealed that there were no interventions in place for Resident #12's contractures. On 6/26/2018 at approximately 10AM, Resident #12's medical record was reviewed and provided that on 5/17/2018, a physician (MD) order was written for a L hand splint; 4-6 hours a day; 5 times a week. On 6/1/2018, a telephone order was given for bilateral hand splints; 4 hours; 7 days a week for 12 weeks. Resident #12's care plan was reviewed on 6/26/2018 at 1018AM revealed that the Resident was care planned to have splints applied. Review of the Restorative Care Flow Record on 6/26/2018 at 1050AM revealed that the splints had not been applied since the original order was written on 5/17/2018. In an interview with the Director of Nursing (DON) on 6/26/2018 at 11AM, the DON stated For 6/25/2018 and 6/26/2018, the restorative aide was pulled to a floor assignment at the hospital and couldn't place the splint on the Resident and we didn't have anyone else to do it. The DON also stated the splints haven't been applied because we probably had staffing issues on those days and didn't have anyone to place them.",2020-09-01
522,MUSC HEALTH CHESTER NURSING CENTER,425061,1 MEDICAL PARK DRIVE,CHESTER,SC,29706,2018-06-27,657,D,0,1,11DB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to revise the care plan for Resident #35, 1 of 2 sampled residents reviewed for Range of Motion. In addition, the facility failed to implement interventions on the care plan to maintain or prevent a decline in Range of Motion. The findings included: The facility admitted Resident #35 with [DIAGNOSES REDACTED]. Resident #35 was observed at lunch on 6/26/2018 at 11:52 AM. The resident was in a wheel chair with her/his right arm resting on a pillow to her/his right side. The right arm appeared flaccid, but not contracted. The resident did not move her/his right arm. Record review of the care plan on 6/26/2018 at 2:23 PM, revealed a focus area for Activities of Daily Living (ADLs) indicating the resident had limited physical mobility related to Stroke with right sided [MEDICAL CONDITION]. The were no interventions to promote Range of Motion. In addition, a focus area for Musculoskeletal indicated the resident had a alteration in musculoskeletal status [MEDICAL CONDITION], contractures. A goal listed for the focus area was to remain free of contractures. There were no interventions listed for this focus area to promote Range of Motion or prevent contractures. During an interview with the Director of Nursing (DON) on 6/27/2018 at 11:01 AM, the DON confirmed the care plan addressed the resident's impaired Range of Motion and risk for contractures. The DON stated there were no interventions on the care plan to prevent contractures or to prevent a decline in Range of Motion.",2020-09-01
523,MUSC HEALTH CHESTER NURSING CENTER,425061,1 MEDICAL PARK DRIVE,CHESTER,SC,29706,2018-06-27,698,D,0,1,11DB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of facility policy the facility failed to provide appropriate services to Resident #33, 1 of 1 sampled resident reviewed for [MEDICAL TREATMENT]. The resident's [MEDICAL TREATMENT], weight and vital signs were not monitored. In addition, there were no orders to receive [MEDICAL TREATMENT] or how often. The findings included: The facility admitted Resident #33 with [DIAGNOSES REDACTED]. Record review of the physician's orders [REDACTED]. In addition, there were no orders related to monitoring the residents [MEDICAL TREATMENT] for bleeding or infection. There were no orders to check the thrill and bruitt of the access site. Record review of the Medication Administration Record [REDACTED]. Record review of the [MEDICAL TREATMENT] Communication Record (DCR) on 6/27/2018 at 9:45 AM, revealed the resident attended [MEDICAL TREATMENT] 3 days a week and the DCR was sent to [MEDICAL TREATMENT] with the resident. The DCR revealed that vital signs and weights were to be checked before and after [MEDICAL TREATMENT]. In addition the thrill and bruitt was to be checked prior to [MEDICAL TREATMENT]. From 4/17/18-6/26/18 the thrill and bruitt was not checked 13 times. Pre-[MEDICAL TREATMENT] vital signs were not checked 6 times. Pre-[MEDICAL TREATMENT] weights were not checked 18 times. Post-[MEDICAL TREATMENT] weights were not checked 7 times. Review of the facility's [MEDICAL TREATMENT] policy on 6/27/2018 at 10:15 AM revealed The facility staff will provide immediate monitoring and documentation of the status of the resident's access site (s) upon return from the [MEDICAL TREATMENT] treatment to observe for bleeding or other complications. During an interview with the Director of Nursing (DON) on 6/27/2018 at 10:20 AM, the DON confirmed the thrill and bruitt checks, weights and vital signs were not documented as done. During an interview with the DON on 6/27/2018 at 10:54 AM, the DON confirmed the facility policy for monitoring the access site was not done. The DON also confirmed there was no order for [MEDICAL TREATMENT]. The DON stated there was no additional documentation to show thrill and bruitt, vital signs and weights were done pre and post [MEDICAL TREATMENT]. The DON stated the [MEDICAL TREATMENT] center should have been checking the pre and post weights. In addition, the DON stated there should have been orders for checking the thrill and bruitt and monitoring of the access site every shift. The DON stated this should have been on the TAR to ensure it was done.",2020-09-01
524,MUSC HEALTH CHESTER NURSING CENTER,425061,1 MEDICAL PARK DRIVE,CHESTER,SC,29706,2018-06-27,725,E,0,1,11DB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to maintain sufficient staffing to provide care and services to the residents for 4 of 4 units reviewed during the survey. The findings included: Resident #19 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the facility's grievance log from January-June (YEAR) on 6/26/2018 at approximately 930AM revealed that there was an ongoing issue with call-light response time since (MONTH) (YEAR). The Resident Council minutes for the same period were also reviewed and proved that call light response was an ongoing issue since (MONTH) (YEAR). In a telephone interview with Resident 19's Responsible Party (RP), RP stated that it could take up 30 minutes for the facility staff to answer the call light. The RP also stated that when staff did respond after waiting, staff would verbalize to him/her that it took so long to respond because the facility was short staffed. In an interview with the Director of Nursing (DON) regarding a different resident on 6/26/2018 at 11AM, the DON stated, the splints haven't been applied because we probably had staffing issues on those days and didn't have anyone to place them. Review of resident council minutes on 6/25/18 at approximately 1:22 PM revealed concerns of call light response times and staff taking call lights from residents for (MONTH) and (MONTH) of (YEAR). Interview with resident council on 6/25/18 at approximately 2 PM revealed staffing issues are ongoing and that it can still take time for staff to respond to call lights. Some of the residents expressed having wet themselves because staff were taking too long to respond to call lights. They expressed this issue had been going on for approximately 5 months. Review of grievance logs on 6/27/18 at approximately 10:50 AM revealed concerns with call bell response times going back since (MONTH) (YEAR). Interview with Licensed [MEDICATION NAME] Nurse (LPN) #2 on 6/27/18 at approximately 9:20 AM revealed s/he watches over 30 residents and does not have enough time in a shift to finish tasks without sacrificing breaks or staying late. S/he also stated that the facility is aware with staffing problems and short staffing, and they try to get people to work overtime and are trying to hire new staff. Interview with Certified Nursing Assistant (CNA) #1 on 9:30 AM confirmed concerns with staffing. S/he stated that nurses, restorative, and activities staff are often pulled onto units to help out. Interview with Director of Nursing (DON) on 6/27/18 at approximately 9:55 AM confirmed that staff from activities and restorative staff are pulled a couple times a week to work as a CN[NAME] Interview with Staffing Coordinator on 6/27/18 at approximately 10 AM revealed turnover rate was high. Review of Turnover Report on 6/27/18 at approximately 10:30 AM revealed a 20% turnover rate for skilled nursing care over the period of a year.",2020-09-01
525,MUSC HEALTH CHESTER NURSING CENTER,425061,1 MEDICAL PARK DRIVE,CHESTER,SC,29706,2018-06-27,756,D,0,1,11DB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to identify medication irregularities in 1 of 5 residents reviewed for unnecessary medications. Resident #17 was ordered PRN [MEDICATION NAME] for over 14 days and the pharmacist did not identify this irregularity in the medication regimen review. The findings included: Resident #17 was admitted to to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of orders on 6/26/18 at approximately 9:50 AM revealed an order for [REDACTED]. Review of medication reviews on 6/26/18 at approximately 10:20 AM revealed the pharmacist did not identify the extended use of PRN [MEDICATION NAME] as an irregularity. Interview with the pharmacist on 6/26/18 at approximately 12:17 PM confirmed that the extended use of PRN [MEDICATION NAME] was not identified as an irregularity.",2020-09-01
526,MUSC HEALTH CHESTER NURSING CENTER,425061,1 MEDICAL PARK DRIVE,CHESTER,SC,29706,2018-06-27,758,E,0,1,11DB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to provide a documented rationale for continued use of as needed (PRN) [MEDICAL CONDITION] medication ([MEDICATION NAME]) beyond 14 days for Resident #9 and continued to use PRN [MEDICATION NAME] for Resident #17 beyond 14 days for 2 of 5 sampled residents reviewed for unnecessary medications. The findings included: The facility admitted Resident #9 on 12/25/12 with [DIAGNOSES REDACTED]. A review of the medical record on 6/26/18 at approximately 11:18 AM revealed a pharmacy consultant with a printed date of 3/01/18 that indicated this was the third request from 11/2017 to indicate why the PRN (as needed) [MEDICATION NAME] 0.25 milligrams was given. The pharmacy consultant document further indicated Residents do not receive PRN [MEDICAL CONDITION] drugs unless med is necessary to treat a diagnosed specific condition that is documented in the clinical record. PRN orders for [MEDICAL CONDITION] drugs are limited to 14 days. If order needs to be extended, physician should document their rationale in the medical record and indicate the duration PRN orders for antipsychotic drugs are limited to 14 days. Orders cannot be renewed unless physician evaluates the resident for continued appropriateness of the med and document in the resident's chart. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. Further review of the medical record revealed a new physician's orders [REDACTED]. There was no documentation in the medical record to indicate the reason for the continued use of the as needed [MEDICAL CONDITION] medication [MEDICATION NAME]. An interview on 6/26/18 at approximately 11:35 AM with the facility's pharmacy consultant who reviewed the medical record confirmed there was no documentation to address the reason for the continued use of the PRN medication [MEDICATION NAME] beyond 14 days. An interview on 6/27/18 at approximately 10:17 AM with the Director of Nursing (DON) revealed he/she spoke with the facility's pharmacy consultant and was informed that there was no documentation in the medical record to justify the continued use of the PRN [MEDICATION NAME] beyond 14 days. Resident #17 was admitted to to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of orders on 6/26/18 at approximately 9:50 AM revealed an order for [REDACTED]. Interview with the pharmacist on 6/26/18 at approximately 12:17 PM confirmed extended order for PRN [MEDICATION NAME] as well as the lack of documentation regarding justification for extended use of PRN [MEDICATION NAME] or intended duration.",2020-09-01
527,MUSC HEALTH CHESTER NURSING CENTER,425061,1 MEDICAL PARK DRIVE,CHESTER,SC,29706,2018-06-27,812,D,0,1,11DB11,"Based on observation, interview and record review, the facility failed to ensure that all staff members working in the kitchen had proper hair restraints in place for 1 of 1 main kitchen. The findings included: A random observation of the kitchen on 6/26/2018 at about 11:45AM revealed that a food service staff member was in the food preparation area without a hair restraint. An interview with the Food Services Director revealed that he/she would expect food services members to wear the proper hair restraints when in the kitchen area. A review of the food services policy on hair restraints on 6/27/18 at approximately 930AM stated Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food. The policy also states, Facial hair must be effectively restrained as per local and state regulations.",2020-09-01
528,"BLUE RIDGE IN BROOKVIEW HOUSE, LLC",425062,510 THOMPSON STREET,GAFFNEY,SC,29340,2018-01-23,684,G,1,0,EMI411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and limited record reviews, the facility failed to provide the care as identified on the physician orders [REDACTED]. The findings included: Review of the medical record on 1/23/18 revealed that resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. On 1/23/18 at 12:00 PM, review of Resident #1's care plan with problem start date 9/26/17 revealed impaired skin integrity identified as a problem area. Interventions and approaches included treatments to left and right lower shins initiated on 10/21/17. The care plan was updated on 10/30/17 to include changes in treatment regimens. On 1/23/18 at 12:10 PM, review of the Daily Skilled Nurse's Note for Resident #1 dated 10/30/17 at 11:29 AM revealed the following: During wound rounds Res noted to have dressings dated 10-27-17 with the initials for LPN (Licensed Practical Nurse) #3 on them. Upon removing the old dressings the wounds to bilateral shins were noted to have deteriorated significantly. The wounds went from 100% granular to 100% slough with moderate purulent drainage noted. MD was notified and the treatment was changed to clean with NS, apply santyl to the wound beds, and cover with a border gauze and as needed until healed. RP also notified of new orders and change in wound status. Review of the Physicians Orders on 1/23/18 at 12:15 PM revealed an order with start date of 10/23/17 which read cleanse left lower shin with NS (normal saline)/WC (wound cleanser)-apply [MEDICATION NAME] and cover with border gauze change daily. Further review of the Physician order [REDACTED]. Review of the Treatment Administration Record on 1/23/18 at 12:20 PM revealed that the treatment initiated on 10/23/17 to the left lower shin was electronically signed by LPN#1 as being administered on 10/28/17 and 10/29/17 during 7:00 am-3:00 pm shift. On 1/23/18 at 12:45 PM, review of the facility's Five-Day Follow-Up Report dated 11/3/17 indicated that on 10/30/17 during wound rounds, dressings to Resident #1's bilateral shins were noted to have nurse initials (LPN#3) and date from 10/27/17 despite being a once daily treatment to both shins. Review of written statement provided by RN (Registered Nurse) #1 on 10/30/17 revealed that upon completing wound rounds on 10/30/17, it was identified that Resident #1 was noted to have bandages with the initials of LPN#3 and the date of 10/27/17. It was further noted that the wounds were to have deteriorated to bilateral shins. Review of written statement provided by LPN #2 revealed that while s/he was assisting with wound rounds, it was noted that Resident #1 had wounds on bilateral shins with the date of 10/27/17 and the initial for LPN#3. LPN#2 further stated that the old dressings were removed and the wounds had deteriorated. Interviews were conducted with RN #1 and LPN #2, when asked if they had any information to add to prior statements provided, both RN #1 and LPN #2 replied no. During an interview with the DON (Director of Nursing) and administrator on 1/23/18 at approximately 2:00 PM, both verified that LPN #1 failed to follow physician orders [REDACTED].",2020-09-01
529,"BLUE RIDGE IN BROOKVIEW HOUSE, LLC",425062,510 THOMPSON STREET,GAFFNEY,SC,29340,2017-03-23,314,D,0,1,8N9311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of the facility's policy entitled Clean Dressing Change, the facility failed to provide treatment to prevent infection during wound care for Resident #101, 1 of 3 residents reviewed for pressure ulcers. The findings included: The facility admitted Resident #101 with [DIAGNOSES REDACTED]. At 9:26 AM on 03/22/2017, Licensed Practical Nurse (LPN) #3 was observed providing Wound Care to Resident #101. The LPN was assisted by Certified Nursing Assistant #1, and observed by the Director of Nursing (DON). The overbed table was already set up with a towel as a barrier, 4x4 gauze moistened with wound cleanser, dry 4x4 gauze, cut [MEDICATION NAME], and a border dressing. The LPN washed her/his hands and donned gloves. The CNA uncovered the resident, opened the resident's brief, and turned the resident onto the right side. The LPN removed the soiled dressing and gloves, discarded them, washed her/his hands and donned gloves. The CNA replaced the sheet and blanket over the resident while the LPN washed her/his hands and donned gloves. The LPN used the 4x4 gauze with wound cleanser and wiped the left periwound twice with the same gauze and without turning the gauze to a clean area between wipes and discarding the gauze. The LPN repeated the procedure for the wound bed and then the right periwound, wiping twice with the same gauze and without turning the gauze to a clean area between wipes and discarding the gauze. LPN #3 removed the gloves and discarded them, washed her/his hands and donned clean gloves. The CNA replaced the covers over the resident, including the cleaned wound bed with the contaminated covers while the LPN washed her/his hands and then removed the covers and the LPN applied the clean dressing to the contaminated wound. The LPN then removed the gloves, washed her/his hands, donned gloves, tied the trash shut, bagged the used linen, and disposed of them in the appropriate barrels and washed her/his hands to complete the procedure. During an interview at 9:41 AM on 03/22/2017, the LPN stated s/he did not recall any of the procedure because s/he was just too nervous. The DON stated s/he thought the nurse had turned the gauze but that s/he couldn't really see. Review of the facility's policy, Clean Dressing Change, revealed 15. Clean wound as ordered. Carefully dry skin around wound. 16. Assess the wound and evaluate if dressing continues to be appropriate for the wound. 17. Remove gloves. 18. Wash hands. 19. Put on clean gloves. 20. Apply dressing and secure as ordered . The policy does not state how to clean the wound bed.",2020-09-01
530,"BLUE RIDGE IN BROOKVIEW HOUSE, LLC",425062,510 THOMPSON STREET,GAFFNEY,SC,29340,2017-03-23,441,D,0,1,8N9311,"Based on observations, interview, review of the facility policy and the Center for Disease Control Prevention safety recommendations, the facility failed to follow a procedure to ensure precautions were observed for the disposal of contaminated equipment for 2 of 3 residents observed for finger stick blood sugars. Finger stick devices were not disposed of in an approved sharps container. The findings included: On 3/21/17 at 3:35 PM, during an observation of Resident # 160's med pass on the Magnolia unit short hall, Licensed Practical Nurse #1 used a finger stick device to penetrate the residents' finger to produce blood to monitor the residents' blood sugar. LPN #1 then placed the finger stick device into the trash can in Resident #160's room. Following the observation LPN #1 verified the finger stick device was in the trash and indicated that the device should be disposed into a sharps container. On 3/21/17 at 4:02 PM, during an observation of Resident # 101's med pass on the Dogwood unit long hall, Licensed Practical Nurse #2 used a finger stick device to penetrate the residents' finger to produce blood to monitor the residents' blood sugar. LPN #2 then placed the finger stick device into the trash can on the side of the medication cart. Following the observation LPN #2 verified the finger stick device was in the trash and indicated that the device should be disposed into a sharps container. Review of the facility policy, Wastes & Cleaning Practices revealed under Fundamental Information, Disposable sharps (contaminated needles and other contaminated sharps) are not bent, recapped, or removed. The shearing or breaking of contaminated needles is prohibited. Self-sheathing needles are disposed of in a sharps container because there is no guarantee of correct usage or proper functioning of the device. Review of the Center for Disease Control Prevention recommendations revealed under Infection Prevention during Blood Glucose Monitoring and Insulin Administration, section Blood Glucose Monitoring, Fingerstick Devices bullet #2 states, Dispose of used lancets at the point of use in an approved sharps container. Never reuse lancets.",2020-09-01
531,"BLUE RIDGE IN BROOKVIEW HOUSE, LLC",425062,510 THOMPSON STREET,GAFFNEY,SC,29340,2018-06-28,582,C,0,1,IK4G11,"Based on record review and interview, the facility failed to provide the required Medicare Non Coverage notice for 2 of 3 residents reviewed for Beneficiary Protection Notification who remained in the facility with Medicare benefit days remaining. The facility failed to provide the CMS NOMNC (Notice of Medicare Non Coverage) notification to Residents #25 and #49. The findings included: Review of Beneficiary Protection Notices for Resident #25 revealed Medicare Part A Skilled Services ended 4/5/18, and the resident remained in the facility with Medicare benefit days remaining. Further review revealed the facility did not issue the CMS NOMNC notification informing the resident of his/her right to an expedited review of the services termination. Review of Beneficiary Protection Notices for Resident #49 revealed Medicare Part A Skilled Services ended 4/13/18, and the resident remained in the facility with Medicare benefit days remaining. The facility did not issue the CMS NOMNC notification informing the resident of his/her right to an expedited review of the services termination. These findings were confirmed by the facility Social Worker on 6/27/18 during a review of Beneficiary Protection notices.",2020-09-01
532,"BLUE RIDGE IN BROOKVIEW HOUSE, LLC",425062,510 THOMPSON STREET,GAFFNEY,SC,29340,2018-06-28,623,C,0,1,IK4G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide a copy of a written notice of transfer to the Resident and/or Resident Representative for Residents #113 and 165 when transferred to the hospital. 2 of 5 residents reviewed for hospitalization . The findings included: The facility admitted Resident #113 with [DIAGNOSES REDACTED]. On 06/26/18 at 01:19 PM, review of the Nursing Progress Notes revealed Resident #113 was hospitalized from 02/12-2/14/18 and from 5/18-5/20/18. On 06/27/18 01:20 PM, record review revealed no documentation of a written notice of transfer in either the paper or electronic health record. During an interview on 06/27/18 at 02:08 PM, the Social Worker confirmed that facility did not send a a written notice when a resident was transferred to the hospital. The facility admitted Resident #165 with [DIAGNOSES REDACTED]. Review of the Progress Notes revealed the facility transferred Resident #165 to the hospital on [DATE] for treatment and evaluation. Documentation in the record indicated, MD and family were aware. The Progress Note dated 2/9/18 indicated, Family updated at this time. Further record review revealed no documentation the facility sent a written notice for the reason of transfer to Resident #165's representative.",2020-09-01
533,"BLUE RIDGE IN BROOKVIEW HOUSE, LLC",425062,510 THOMPSON STREET,GAFFNEY,SC,29340,2018-06-28,625,C,0,1,IK4G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide a copy of the bed hold policy to the Resident and/or Resident Representative for Residents #113 and 165 when transferred to the hospital, 2 of 5 residents reviewed for hospitalization . The findings included: The facility admitted Resident #113 with [DIAGNOSES REDACTED]. On 06/26/18 at 01:19 PM, review of the Nursing Progress Notes revealed Resident #113 was hospitalized from 02/12-2/14/18 and from 5/18-5/20/18. On 06/27/18 01:20 PM, record review revealed no documentation of the bed hold policy in either the paper or electronic health record. During an interview on 06/27/18 at 02:08 PM, the Social Worker confirmed that the facility did not send a copy of the bedhold policy when a resident was transferred to the hospital. During an interview at 02:14 PM, the Admissions Coordinator stated that the bed hold policy is reviewed upon admission but that a copy is not provided when the resident is transferred to the hospital. The facility admitted Resident #165 with [DIAGNOSES REDACTED]. Review of the Progress Notes revealed the facility transferred Resident #165 to the hospital on [DATE] for treatment and evaluation. Documentation in the record indicated, MD and family were aware. The Progress Note dated 2/13/18 indicated Resident #165 was discharged to the hospital for treatment and evaluation. Further record review revealed no documentation that the facility provided a written notice of the Bed Hold Policy to Resident #165 and/or the resident's representative.",2020-09-01
534,"BLUE RIDGE IN BROOKVIEW HOUSE, LLC",425062,510 THOMPSON STREET,GAFFNEY,SC,29340,2018-06-28,657,C,0,1,IK4G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure all required members of the Interdisciplinary Team participated in the development of care plans for 12 of 26 residents reviewed for care plans. (Residents #49, 32, 89, 28, 165, 33, 166, 96, 113, 101, 43, and 104) The findings included: The facility admitted Resident #89 on 8/29/03 with [DIAGNOSES REDACTED]. Review of the medical record revealed the care plan conference attendance sheets contained space for signature of staff participating in the care plan meeting. Review of the attendance sheet dated 6/5/18 revealed no signature of a Certified Nurse Aide (CNA) to indicate participation in development of the care plan. The facility admitted Resident #49 on 7/9/16 with [DIAGNOSES REDACTED]. Review of the medical record revealed the care plan conference attendance sheets contained space for signatures of staff participating in the care plan meeting. Review of the attendance sheets dated 11/28/17 and 2/6/18 revealed no signature of a CNA to indicate participation in development of the care plan. The facility admitted Resident #33 on 7/20/15 with [DIAGNOSES REDACTED]. Review of the medical record revealed the care plan conference attendance sheets contained space for signatures of staff participating in the care plan meeting. Review of the attendance sheets dated 11/25/18 and 4/26/18 revealed no signature of a CNA to indicate participation in development of the care plan. The facility admitted Resident #28 on 10/17/17 with [DIAGNOSES REDACTED]. Review of the medical record revealed the care plan conference attendance sheets contained space for signatures of staff participating in the care plan meeting. Review of the attendance sheet dated 4/19/18 revealed no signature of a CNA to indicate participation in development of the care plan. The facility admitted Resident #32 on 4/26/17 with [DIAGNOSES REDACTED]. Review of the medical record revealed the care plan conference attendance sheets contained space for signatures of staff participating in the care plan meeting. Review of the attendance sheets dated 1/25/18 and 4/26/18 revealed no signature of a CNA to indicate participation in development of the care plan. The facility admitted Resident #165 on 3/14/18 with [DIAGNOSES REDACTED]. Review of the medical record revealed the care plan conference attendance sheets contained space for signatures of staff participating in the care plan meeting. Review of the attendance sheets dated 12/8/17 and 2/15/18 revealed no signature of a CNA to indicated participation in development of the care plan. The facility admitted Resident #166 on 3/1/18 with [DIAGNOSES REDACTED]. Review of the medical record revealed the care plan conference attendance sheets contained space for signatures of staff participating in the care plan meeting. Review of the attendance sheet dated 5/31/18 revealed no signatures of a CNA to indicate participation in development of the care plan. The Director of Nursing confirmed the above findings. Resident # 43 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 06/27/18, review of the Interdisciplinary Care Plan Review Sheet revealed the IDT (Interdisciplinary Team) did not include the participation of a Certified Nursing Assistant on 02/01/18 and did not include a Registered Nurse on 05/03/18. The facility admitted Resident #104 on 09/13/17 with [DIAGNOSES REDACTED]. On 06/27/18, review of the Interdisciplinary Care Plan Review Sheet revealed the IDT (Interdisciplinary Team) did not include the participation of a Registered Nurse on 03/22/18 and on 06/14/18 did not include a Certified Nursing Assistant or Registered Nurse. Resident # 113 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 06/26/18, review of the Interdisciplinary Care Plan Review Sheet revealed the IDT (Interdisciplinary Team) did not include the participation of a Certified Nursing Assistant or Registered Nurse on 01/21/18 or 03/22/18. Resident #101 was admitted on [DATE] with [DIAGNOSES REDACTED]. of Abnormal weight loss, Cerebral Infarction, Allergy, Disorder of the Skin and Subcutaneous tissue, Allergic Rhinitis, [MEDICAL CONDITION], Constipation, [MEDICAL CONDITION], and [MEDICAL CONDITION]. On 06/27/18, review of the Interdisciplinary Care Plan Review Sheet revealed the IDT (Interdisciplinary Team) did not include the participation of a Registered Nurse on 03/15/18 and on 06/14/18 did not include a Certified Nursing Assistant or Registered Nurse. The facility admitted Resident #96 on 02/18/11 with [DIAGNOSES REDACTED]. On 06/27/18, review of the Interdisciplinary Care Plan Review Sheet revealed the IDT (Interdisciplinary Team) did not include the participation of a Registered Nurse on 03/15/18 and on 06/07/18 did not include a Certified Nursing Assistant.",2020-09-01
535,"BLUE RIDGE IN BROOKVIEW HOUSE, LLC",425062,510 THOMPSON STREET,GAFFNEY,SC,29340,2018-06-28,757,E,0,1,IK4G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that the physician's order for a duration of 5 days for a medication was followed resulting in unnecessary medication being administered to Resident #96, 1 of 5 residents reviewed for unnecessary medication. The findings included: The facility admitted Resident #96 on 02/18/11 with [DIAGNOSES REDACTED]. On 06/28/18 at 11:36 AM, review of the monthly cumulative orders revealed an order for [REDACTED]. Review of the physical medical record revealed an order dated 04/20/18 for [MEDICATION NAME] 600 mg every 12 hours for 5 days. During an interview at 02:19 PM, the SDC (Staff Development Coordinator) confirmed the order dated 04/20/18 for [MEDICATION NAME] for 5 days and stated that a renewal order may have been written. At 03:43 PM, the SDC confirmed there had not been an order to renew the medication stating that it was an entry error and confirmed the resident received the medication unnecessarily.",2020-09-01
536,"BLUE RIDGE IN BROOKVIEW HOUSE, LLC",425062,510 THOMPSON STREET,GAFFNEY,SC,29340,2019-08-22,607,D,0,1,Z2R711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to follow their Abuse and Neglect Policy and Procedure related to reporting and investigating an observed resident to resident altercation for Resident #12 and Resident #11 and a timely 5-Day report for Resident #90. 3 of 3 residents reviewed for not reporting timely. The findings included: The facility admitted Resident #12 on (MONTH) 19, (YEAR) with [DIAGNOSES REDACTED]. The facility admitted Resident # 11 on (MONTH) 29, (YEAR) with [DIAGNOSES REDACTED]. During review of the medical record it was noted that on 05/11/2019 at 2:59 PM-Resident # 11 was in the dining room eating and Resident #12 was sitting beside Resident #11 cursing and carrying on about various subjects. Resident #11 asked Resident #12 to please stop twice then became loud with Resident #12. Residents were separated at that time. Resident #12 came back to the dining room table where Resident #11 was sitting and started pulling his/her hair and moving his/her plate around. Resident #11 smacked Resident #12 and s/he grabbed Resident #11's face pinching his/her cheeks causing multiple scratches. Residents were separated and the residents were observed for injury. During an interview with the Director of Nursing (DON) on 08/21/19 at 3:07 PM, it was confirmed that the facility had not reported the resident to resident altercation that occurred on 5/11/19. The DON stated We thought if both residents were confused, we did not have to report it but, we did do an incident report. Review of the facility's Abuse and Neglect Policy and Procedure revealed All alleged violations involving mistreatment, neglect or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to: the Director of Nursing, the administrator or the designated representative, Regional Director of Operations and Regional Clinical Nurse, the resident's attending physician- obtain order for treatment if needed,the resident's family/responsible party. Follow State guidelines for reporting. The facility admitted Resident #90 on 01/08/2013 with [DIAGNOSES REDACTED]. joint, initial encounter,Recurrent dislocation, right shoulder, Factitial [MEDICAL CONDITION] Unspecified dementia with behavioral disturbance and [MEDICAL CONDITION]. During review of facility files on 8/22/2019 at 1:00 PM, it was noted that the resident had an Injury of Unknown Origin, a dislocated right shoulder, on 5/29/2019. A 2- Hour Report was sent to the State Agency and the Ombudsman and the 24- Hour Report was sent to the Sate Agency timely. The 5- Day Report was not submitted timely to the State Agency. During an interview on 8/22/19 at 1:31 PM -The Director of Nursing stated that s/he could not get any faxes to go through and kept trying until it finally did. The only fax confirmation provided was the fax where it was accepted, none provided for rejected attempts. Review of the facility Abuse Policy and Procedure revealed under Investigation and 7. Reporting Procedure. The results of all investigations where appropriate will be reported within 5 working days of the incident.",2020-09-01
537,"BLUE RIDGE IN BROOKVIEW HOUSE, LLC",425062,510 THOMPSON STREET,GAFFNEY,SC,29340,2019-08-22,609,D,0,1,Z2R711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to follow their Abuse and Neglect Policy and Procedure related to reporting an observed resident to resident altercation for Resident #12 and Resident #11 and a timely 5-Day report for Resident #90. 3 of 3 residents reviewed for not reporting timely. The findings included: The facility admitted Resident #12 on (MONTH) 19, (YEAR) with [DIAGNOSES REDACTED]. The facility admitted Resident # 11 on (MONTH) 29, (YEAR) with [DIAGNOSES REDACTED]. During review of the medical record it was noted that on 5/11/2019 at 2:59 PM-Resident #11 was in dining room eating and Resident #12 was sitting beside Resident #11 cursing and carrying on about various subjects. Resident #11 asked Resident #12 to please stop twice then became loud with Resident #12. Residents were separated at that time. Resident #12 came back to the dining room table where Resident #11 was sitting and started pulling his/her hair and moving his/her plate around. Resident #11 smacked Resident #12 and Resident #12 grabbed Resident #11's face pinching his/her cheeks causing multiple scratches. Residents were separated and the residents were observed for injury. During an interview with the Director of Nursing on 8/21/19 3:07 PM , it was confirmed that the facility had not reported the resident to resident altercation that occurred on 5/11/19. The Director of Nursing stated We thought if both residents were confused, we did not have to report it but we did do an incident report. The facility admitted Resident #90 on 01/08/2013 with [DIAGNOSES REDACTED]. joint, initial encounter,Recurrent dislocation, right shoulder, Factitial [MEDICAL CONDITION] Unspecified dementia with behavioral disturbance and [MEDICAL CONDITION]. During review of facility files on 8/22/2019 at 1:00 PM, it was noted that the resident had an Injury of Unknown Origin, a dislocated right shoulder, on 5/29/2019. A 2- Hour Report was sent to the State Agency and the Ombudsman and the 24- Hour Report was sent to the Sate Agency timely. The 5- Day Report was not submitted timely to the State Agency. During an interview on 8/22/19 at 1:31 PM the Director of Nursing stated that s/he could not get any faxes to go through and kept trying until it finally did. The only fax confirmation provided was the fax where it was accepted, none provided for rejected attempts. During an interview on 8/22/19 at 12:31 PM the Administrator was asked why the resident to resident altercation that occurred on 5/11/2019 was not reported as required. The administrator replied that is a Memory Unit and they did not know what they were doing, I have a Psychiatrist that comes and I was off. The staff did a wonderful job separating and protecting the residents but, when the incident report was completed, they did not call the DON and when (s/he) saw it , (s/he) was going by there was no serious body injury. If I had been here and seen the incident report, a red flag would have went off.",2020-09-01
538,"BLUE RIDGE IN BROOKVIEW HOUSE, LLC",425062,510 THOMPSON STREET,GAFFNEY,SC,29340,2019-08-22,610,D,0,1,Z2R711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to follow their Abuse and Neglect Policy and Procedure related to investigating an observed resident to resident altercation for Resident #12 and Resident #11. 2 of 2 residents reviewed for abuse. The findings included: The facility admitted Resident #12 on (MONTH) 19, (YEAR) with [DIAGNOSES REDACTED]. The facility admitted Resident # 11 on (MONTH) 29, (YEAR) with [DIAGNOSES REDACTED]. Review of Resident #11's medical record revealed a Quarterly Review dated 5/28/19 that indicated resident had a Brief Interview for Mental Status score of 7 indicating severely cognitively impaired. Resident is alert and oriented x 2 to person and place with confusion and forgetfulness. Resident is verbal and can make his/her needs known to staff. During review of Resident #11's medical record it was noted that on 05/11/2019 at 02:59 PM-Resident # 11 was in dining room eating and resident #12 was sitting beside resident #11 cursing and carrying on about various subjects. Resident #11 asked Resident #12 to please stop twice then became loud with Resident #12. Residents were separated at that time. Resident #12 came back to the dining room table where resident #11 was sitting and started pulling his/her hair and moving his/her plate around. Resident#11 smacked resident #12 grabbed resident #11's face pinching her cheeks causing multiple scratches. Residents were separated and the residents were observed for injury. No treatments needed at this time. Body audit on 5/17/19 revealed scratches to the resident's face. Review of Resident #12's medical record revealed on 5/11/2019 at 1:53 PM- Resident was arguing and fussing with others in dining room around 12:30 PM. Resident removed 2 times from dining room. Resident went back into dining room around 12:40 PM and was arguing with another resident. CNA went into dining room and saw both residents have each other by the hair and hitting each other. This resident was also trying to scratch other resident in the eyes. CNA stated that resident did scratch other resident on the face. This nurse went to check on other resident and scratch was noted to right cheek. This nurse give resident [MEDICATION NAME] at 12:45 PM and medication was effective. This nurse also tried to contact responsible party but unable to contact. During an interview with the Director of Nursing on 8/21/19 3:07 PM, it was confirmed that the facility had not reported the resident to resident altercation that occurred on 5/11/19. We thought if both residents were confused, we did not have to report it but, we did do an incident report. Review of the facility Abuse Policy and Procedure revealed under 6. Investigation and Reporting Procedure. The facility will thoroughly investigate and document each alleged violation and will prevent further potential abuse while the incident is under investigation. The 5/11/19 resident to resident altercation was not reported to the police or State Agency at all. The Incident Report only had staff statements and was not investigated thoroughly. The facility did not follow their Policy/ Procedure for Reporting.",2020-09-01
539,"BLUE RIDGE IN BROOKVIEW HOUSE, LLC",425062,510 THOMPSON STREET,GAFFNEY,SC,29340,2019-08-22,800,E,0,1,Z2R711,"Based on interviews in Resident Council Meeting facility did not take into consideration resident choices of food. ( 6 of 6 Residents interviewed in Resident Council) The findings included: Six residents interviewed during the Resident Council Meeting voiced concerns that dietary staff did not always follow their likes and dislikes on the the menu foods served. Most of the time the residents were served foods on their do not like list. Interview with the Assistant Dietary Manager on 8/21/19 at 10:30 AM revealed no one discussed the residents likes and dislikes with them except when they were admitted to the facility. If a staff member came and told them the resident did not like a specific food the dietary department would change that on the ticket. However, the residents in Council said the foods were never removed and they were still receiving foods they did not like or want.",2020-09-01
540,"BLUE RIDGE IN BROOKVIEW HOUSE, LLC",425062,510 THOMPSON STREET,GAFFNEY,SC,29340,2019-08-22,804,D,0,1,Z2R711,"Based on observations and interviews the facility failed to provide foods prepared by methods that conserve nutritive value, flavor, and appearance and at a safe and appetizing temperature. (Main Kitchen observed and Test Tray to Magnolia Unit) The findings included: A tour was made of the Main Kitchen on 8/21/19 at 11;30 AM with the Assistant Dietary Manager. At this time food temperatures were also taken and the tray line serving observed. All foods were at the appropriate temperatures to be served. Six residents in Resident Council Meeting conducted during the survey voiced concerns that the meat was usually dry and tough. The vegetables were mushy and had extra sugar on them. They also stated the food was not very warm when they received it. A test tray was done to the last unit and the last tray served. The cube steak (noted fried in the deep fryer) was very dry and tough and difficult to chew. No gravy was served with the meat. The zucchini was very mushy in the center and the rind around the outside was hard and tough. The zucchini was also served in a lot of juice on the plates. The rice was soft and cooked okay. No sugar was noted on the food this day, however a lot of pepper was added to it in the kitchen before serving. When asked about adding sugar, the Corporate Dietary Consultant and the Assistant Dietary Manager stated the staff had been adding extra sugar to the green beans and cornbread but denied placing sugar in other foods. The Consultant and Assistant Manager stated that practice had been stopped now. From the test tray, the foods were not cold nor hot. The foods were warm. When the trays came to the unit, the dining room trays were served first and then the trays to the floor. These findings were all discussed with the Corporate Dietary Consultant and the Assistant Dietary Manager.",2020-09-01
541,"BLUE RIDGE IN BROOKVIEW HOUSE, LLC",425062,510 THOMPSON STREET,GAFFNEY,SC,29340,2019-08-22,812,E,0,1,Z2R711,"Based on observation and interview the facility failed to prepare, store, and serve foods in a sanitary manner. (Main kitchen and Dogwood unit pantry.) The findings included: During the initial tour on 8/19/19 at 9:52 AM with dietary staff, the following items were noted: the outside of the stove had grease and splatters on all sides. The stand alone ovens had dark brown splatters on all inside walls and bottom, grease and splatters on all areas of outside walls, deep fryer had large amount of crumbs built up on top of oil. Outsides of walk-in freezer, refrigerator and reach-in refrigerator had grease and food splatters, steam table had a grease build up on all surfaces, the floor had a build up of grease and dirt ( floor sticky and shoes slid) tea container, juice container, paper towel holder, ice maker, microwave and outside of deep fryer all had grease build up. The microwave in the Dogwood unit pantry had dark brown splatters on top and inside walls of microwave. This observation was confirmed by Nurse #1 The Assistant Dietary Manager was asked to present a cleaning schedule which took him/her 2 days to find. The Assistant Dietary Manager's initial statement was We clean as things need cleaning. The floor was last deep cleaned by Maintenance on 7/21/19. The dietary staff mop and clean daily. On 8/21/19 a cleaning schedule was finally presented with initials marked on areas. There was no documentation noting the Supervisor had checked areas. These areas were reviewed with the Corporate Dietary Consultant and the Assistant Dietary Manager on 8/22/19 and areas confirmed. The Dietary Consultant stated new areas of equipment cleaning had already been added to their cleaning schedule.",2020-09-01
542,"BLUE RIDGE IN BROOKVIEW HOUSE, LLC",425062,510 THOMPSON STREET,GAFFNEY,SC,29340,2018-10-02,602,D,1,0,TO0011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, the facility failed to ensure residents remained free from misappropriation of resident property. Laundry aide #1 brought a bracelet and a wedding band to a jewelry shop to be pawned. The bracelet and wedding band belonged to Resident #1. One of two residents reviewed for abuse. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the MDS revealed the resident had a BIMS score of 2 and was extensive to total assist for all ADLs (activities of daily living). Review of the Police Report from 7/9/2018 revealed a medical ID bracelet and wedding band ring were taken from a drawer in Resident #1's room. The property was taken to a pawn shop and sold by laundry aide #1 and another suspect. The ring and bracelet were recovered by the police at the pawn shop. Review of the facility's investigation revealed on 7/10/2018 the Police came to the facility and reported to the Director of Nursing (DON) the owner of the pawn shop turned over a medical alert bracelet that had Resident #1's name on it. The police reported the owner stated laundry aide #1 and father brought the bracelet in to the shop to be pawned. The police arrested laundry aide #1 on 7/10/2018. The facility five day report revealed laundry aide #1 was terminated. Further review of the facility's investigation revealed the facility was unaware that laundry aide #1 had also taken a wedding band from the resident, in addition to the bracelet. In addition, the investigation did not indicate the facility attempted to determine if there were any additional victims involved. There were no staff statements taken as part of the investigation. The facility had knowledge of the misappropriation of the resident's property on 7/10/2018 and failed to report the incident to the State Agency until the afternoon of 7/11/2018. During an interview with the Nursing Home Administrator (NHA) on 10/2/18 at 9:38 AM the NHA stated the facility had no knowledge of the misappropriation until 7/10/2018 when laundry aide #1 was arrested in the facility by the police. In addition, the NHA stated the facility's investigation consisted of the Five-Day Follow Up Report and the Incident Report. The NHA also stated the facility did not have a copy of the Police Report, but would obtain it from the Police Department. During an exit conference with the NHA, DON and Abuse Coordinator on 10/2/2018 at 3:56 PM, the NHA confirmed the facility's investigation did not reveal Resident #1 also had a wedding band taken from her/him and had not requested a copy of the police report prior to today. In addition, the facility did not investigate to determine if there were any other victims and no staff were interviewed related to the incident. When asked about reporting requirements the DON was aware and stated all allegations related to abuse are to be reported in 2 hours. The NHA confirmed the requirement for reporting was not met related to the misappropriation of Resident #1's property.",2020-09-01
543,"BLUE RIDGE IN BROOKVIEW HOUSE, LLC",425062,510 THOMPSON STREET,GAFFNEY,SC,29340,2018-10-02,609,D,1,0,TO0011,"> Based on review of facility files and interview, the facility failed to ensure that all alleged violations involving misappropriation of resident property were reported to the State Agency within 2 hours after the allegation is made. Alleged violations involving misappropriation of Resident #1's property was not reported to the State Agency within 2 hours after the allegation was made. The facility had knowledge of the misappropriation of the resident's property on 7/10/2018 and failed to report the incident to the State Agency until the afternoon of 7/11/2018. One of two residents reviewed for abuse. The findings included: Cross refer to F602 The facility reported to the State Agency on 7/11/18 an alleged violation involving misappropriation of Resident #1's property. During an interview with the Nursing Home Administrator (NHA) on 10/2/18 at 9:38 AM the NHA stated the facility had no knowledge of the misappropriation until 7/10/2018 when laundry aide #1 was arrested in the facility by the police . Review of the facility's Abuse and Neglect policy revealed the policy addressed 24 hour and 5 day reporting, but did not address 2 hour reporting for violations involving abuse/neglect/misappropriation of resident property. During an interview with the Abuse Coordinator on 10/2/2018 at 1:29 PM, s/he verbalized how the screening, training, prevention, identification, protection and supervision components of the facility's abuse policies are met. However, the Abuse Coordinator was unware that all violations involving abuse are required to be reported within 2 hours. The Abuse Coordinator stated 2 hour reporting was required if a resident required hospitalization and 24 hour reporting if not. During an exit conference with the NHA, Director of Nursing (DON) and Abuse Coordinator on 10/2/2018 at 3:56 PM, When asked about reporting requirements the DON was aware and stated all allegations related to abuse are to be reported in 2 hours. The NHA confirmed the requirement for reporting was not met related to the misappropriation of Resident #1's property.",2020-09-01
544,"BLUE RIDGE IN BROOKVIEW HOUSE, LLC",425062,510 THOMPSON STREET,GAFFNEY,SC,29340,2018-10-02,610,D,1,0,TO0011,"> Based on review of facility files and interview, the facility failed to have evidence that all alleged violations are thoroughly investigated and prevent further potential abuse. Alleged violations involving misappropriation of Resident #1's property, one of two residents reviewed for abuse. The findings included: Cross refer to F602 Review of the facility's investigation revealed the facility was unaware that laundry aide #1 had also taken a wedding band from the resident, in addition to the bracelet. In addition, the investigation did not indicate the facility attempted to determine if there were any additional victims involved. There were no staff statements taken as part of the investigation. During an interview with the Nursing Home Administrator (NHA) on 10/2/18 at 9:38 AM the NHA stated the facility had no knowledge of the misappropriation until 7/10/2018 when laundry aide #1 was arrested in the facility by the police. In addition, the NHA stated the facility's investigation consisted of the Five-Day Follow Up Report and the Incident Report. The NHA also stated the facility did not have a copy of the Police Report, but would obtain it from the Police Department. During an exit conference with the NHA, DON and Abuse Coordinator on 10/2/2018 at 3:56 PM, the NHA confirmed the facility's investigation did not reveal Resident #1 also had a wedding band taken from her/him and had not requested a copy of the police report prior to today. In addition, the facility did not investigate to determine if there were any other victims and no staff were interviewed related to the incident .",2020-09-01
545,NHC HEALTHCARE - GREENWOOD,425063,437 EAST CAMBRIDGE STREET,GREENWOOD,SC,29646,2019-01-25,658,D,0,1,CYEV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of the facility policy titled Feeding/ Enteral Tube Medication Administration (Revised 5/2018), the facility failed to follow acceptable standards of practice for one of one sampled resident observed for medication administration via gastrostomy (G-) tube. Three (3) medications were administered via [DEVICE] to Resident #16 without flushing between each medication. The findings included: During observation of medication administration on 1/24/19 at 4:16 PM, Licensed Practical Nurse (LPN) #1 crushed [MEDICATION NAME] and memantine separately and placed a small amount of applesauce in one of the cups. When asked about this, the nurse stated, That's a little trick I learned. S/he dissolved each medication with 10-15 milliliters (ml) of water. The nurse then inserted 10 ml of air into the [DEVICE] but did not auscultate the abdomen. After s/he checked for residual and obtained no stomach contents, the nurse proceeded to flush the [DEVICE] with 30 ml water. LPN #1 poured the dissolved [MEDICATION NAME] into the [DEVICE], followed immediately by the dissolved memantine and then 15 ml of Potassium Chloride. S/he followed the 3 medications with 30 ml water. Following the procedure on 1/24/19 at 4:43 PM, LPN #1 verified s/he had not flushed with water between the medications. S/he stated, I did put 15 cc (cubic centimeters) into the crushed meds. Record review on 1/24/19 at 10:46 AM revealed no Physician's Orders or dietitian's note related to limitation of fluid intake or orders to administer the medications together. The facility policy titled Feeding/Enteral Tube Medication Administration (Revised 5/2018) provided by the Director of Nurses on 1/24/19 at 5:20 PM states: Procedure: 13. Separately dissolve each medication in water (do not mix medications). Pour one medication mixture into tube; allow to flow by gravity. After each medication has gone through tube, flush tube with 15 ml water prior to putting the next medication down the tube. Continue to administer each ordered medication. followed by 15 ml water between medications to flush tube .",2020-09-01
546,NHC HEALTHCARE - GREENWOOD,425063,437 EAST CAMBRIDGE STREET,GREENWOOD,SC,29646,2019-01-25,759,D,0,1,CYEV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of the facility policy titled Feeding/ Enteral Tube Medication Administration (Revised 5/2018), the facility failed to ensure that the medication error rate was less than 5%. There were 3 errors in 25 opportunities, resulting in a 12% medication error rate. 3 medications were administered via gastrostomy (G-) tube without flushing between each medication. The findings included: During observation of medication administration on 1/24/19 at 4:16 PM, Licensed Practical Nurse (LPN) #1 crushed [MEDICATION NAME] and memantine separately and placed a small amount of applesauce in one of the cups. When asked about this, the nurse stated, That's a little trick I learned. S/he dissolved each with 10-15 milliliters (ml) of water. The LPN took the 60 ml piston syringe from a plastic bag and confirmed the surveyor's observation that it had been stored wet with the plunger in the barrel. S/he inserted 10 ml of air into the [DEVICE] but did not auscultate the abdomen. After s/he checked for residual and obtained no stomach contents, the nurse proceeded to flush the [DEVICE] with 30 ml water. LPN #1 poured the dissolved [MEDICATION NAME] into the [DEVICE], followed immediately by the dissolved memantine and then 15 ml of Potassium Chloride. S/he followed the 3 medications with 30 ml water. Following the procedure on 1/24/19 at 4:43 PM, LPN #1 verified s/he had not flushed with water between the medications. S/he stated, I did put 15 cc (cubic centimeters) into the crushed meds. The facility policy titled Feeding/Enteral Tube Medication Administration (Revised 5/2018) provided by the Director of Nurses on 1/24/19 at 5:20 PM states: Procedure: 13. Separately dissolve each medication in water (do not mix medications). Pour one medication mixture into tube; allow to flow by gravity. After each medication has gone through tube, flush tube with 15 ml water prior to putting the next medication down the tube. Continue to administer each ordered medication. followed by 15 ml water between medications to flush tube . 18. Clean syringe with soap and water. 19. Wrap barrel and plunger separately in paper towels to dry.",2020-09-01
547,NHC HEALTHCARE - GREENWOOD,425063,437 EAST CAMBRIDGE STREET,GREENWOOD,SC,29646,2019-01-25,880,D,0,1,CYEV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to follow procedures to ensure prevention and control of infections for 1 of 1 sampled resident reviewed for wound care (Resident #53) and 1 of 1 sampled resident reviewed for medication administration via gastrostomy (G-) tube (Resident #16). The findings included: During observation of a gangrenous wound treatment on 1/24/19 at 2:14 PM for Resident #53, Registered Nurse (RN) #1 had preset the clean surface on the over-bed table with supplies needed. As RN #2 assisted by holding the resident's leg, RN #1 lifted the gauze wrap away from the leg and started to cut off the soiled dressing. Before s/he actually cut the soiled dressing, the surveyor stopped her/him and asked to describe what had been done in preparation for the treatment prior to the surveyor's arrival. RN #1 stated s/he had established a clean surface and opened the supplies (saline, betadyne swabs, crushed [MEDICATION NAME], 4x4s, and gauze wrap). There was one sodium hypochlorite wipe on the table that s/he indicated s/he would use to clean her/his scissors after the procedure was completed. When asked if s/he had cleaned the scissors prior to starting the wound care, RN #1 stated, I will now. Following the treatment, the surveyor stated the only identified concern was that the scissors had not been cleaned prior to starting to cut the soiled dressing. RNs #1 and #2 made no comment. A Pressure Ulcer Policy and Procedure was provided by the Director of Nurses on 1/24/19 at 5:20 PM in lieu of a requested procedure for wound dressing change, stating it was the same as an aseptic dressing change. The procedure did not address the cleaning and use of scissors. During observation of medication administration via [DEVICE] on 1/24/19 at 4:16 PM, Licensed Practical Nurse (LPN) #1 removed the 60 milliliter piston syringe from a plastic bag and confirmed the surveyor's observation that it had been stored wet with the plunger in the barrel. S/he stated they normally washed the syringes with soap and water, dried and wrapped the barrel and plunger separately in paper towels, and placed them in the emesis basin to air dry. The facility policy titled Feeding/Enteral Tube Medication Administration (Revised 5/2018) provided by the Director of Nurses on 1/24/19 at 5:20 PM states: Procedure: .18. Clean syringe with soap and water. 19. Wrap barrel and plunger separately in paper towels to dry.",2020-09-01
548,OAKHAVEN NURSING CENTER,425064,123 OAK STREET,DARLINGTON,SC,29532,2017-04-26,176,D,0,1,NK2H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined the facility failed to ensure a resident who self-administered medication was assessed as safe to do so. Failure to assess Resident #92's ability to self-administer, obtain physician's orders [REDACTED]. Findings include: RESIDENT #92 Observation of the resident's bedside table on 04/24/17 at 8:16 a.m. revealed three bottles of eye drops, an unlabeled orange prescription bottle with a lotion like substance, and two bottles of nasal spray with the labels marked out in black ink. In an interview at that time, Resident #92 stated the lotion was his magic cream, the nasal spray bottles contain Listerine that he sprays in his face (to kill germs), and the eye drops are different over the counter treatments. He explained he asked family members to bring these items to him as he previously used them at home and wanted to continue to do so. He stated he used each of the substances whenever, on no schedule and did not notify staff or record the administration. He stated staff had not asked him about the items on the over the bed table, that were visible. Review of the resident's record on 04/26/17 at 8:12 a.m. revealed Resident #92 admitted in 01/2017. Review of physician's orders [REDACTED]. In an interview on 04/26/17 at 8:43 a.m., Registered Nurse 87 stated if a resident wanted to self administer medication, the nurse would contact the physician to determine if it was safe. Nursing staff would then educate the resident about the administration of the medication and have the resident demonstrate their ability to do so safely. Registered Nurse 87 stated she had not had any resident request self-administration since she started as Unit Manager ten months earlier. When the multiple medications at Resident #92's bedside were described, along with his admission of self-administration, Registered Nurse 87 stated she was not aware of the medications at the resident's bedside. She stated staff should have identified the medications / treatments, assessed the resident's ability to self-administer and gotten physician's orders [REDACTED].",2020-09-01
549,OAKHAVEN NURSING CENTER,425064,123 OAK STREET,DARLINGTON,SC,29532,2018-09-12,584,D,0,1,3QMS11,"Based on observations, interviews, and facility policy review, it was determined the facility failed to ensure a clean and comfortable environment free of the growth of a black substance in one of four shower rooms. Findings include: Observation of shower room D on 09/10/18 at 10:34 AM with the Environmental Director (ED), revealed a black substance along the base of the wall where the wall met the floor that measured approximately 18 inches in length and 0.25 inches in width. This wall contained the shower head and shower controls. The black substance was also observed at the base of the left (as facing the controls) sidewall where it met the floor and measured approximately 12 inches in length and 0.25 inches in width. The ED was able to scrape off the substance with his pocketknife. The black substance was also observed in the corner of the walls along the caulk/grout line. This area measured approximately 8 inches in length and 0.25 inches in width. Observation of the soap dispenser that was attached to the wall revealed more of the black substance behind the soap dispenser. During an interview at this same time, the ED confirmed the presence of the black substance at the base of the two walls and behind the soap dispenser on the wall. Continued observation revealed when the soap dispenser was opened, additional amounts of the black substance were found inside the dispenser. The ED scraped off the substance with his pocketknife. The ED closed the shower room for use until it could be cleaned. During an interview on 09/10/18 at 10:42 AM, Housekeeper (HSKP) 12 confirmed the black substance located at the base of the walls and behind the soap dispenser attached to the wall. At 11:20 AM, HSKP12 stated the old soap dispenser had been removed, the area cleaned with bleach, and a new dispenser mounted was on the wall. HSPK12 also stated, I never thought to look behind the soap dispenser. During an interview on 09/10/18 at 4:42 PM, with the Administrator and the ED, the Administrator and the ED both stated the shower rooms were to be cleaned daily. They both confirmed there was no documentation to show the cleaning has been completed, and that confirmation is provided by general oversight by staff. Review of the facility's policy titled, Environmental Services Guidelines dated 07/2017, indicated for the routine cleaning of horizontal surfaces, the policy directed the staff as follows: Horizontal surfaces such as tabletops, window ledges, beside stands, counters, sinks, tubs, shower floors, toilet seats, floors etc. will be cleaned daily with an acceptable disinfectant/germicide. This procedure will vary with the item being cleaned. For cleaning of other surfaces, the policy directed the staff as follows: Doorknobs, handrails, bath rails, sink handles, etc. will all be cleaned at least once daily and as needed.",2020-09-01
550,OAKHAVEN NURSING CENTER,425064,123 OAK STREET,DARLINGTON,SC,29532,2018-09-12,688,D,0,1,3QMS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assure that one (Resident (R) 1) of three residents reviewed for range of motion (ROM) out of a sample of 20 residents, received services in accordance with her plan of care to prevent further decline in ROM. Findings include: Observations on 09/10/18 at 9:30 AM, 11:27 AM, 12:02 PM, 1:01 PM, 4:56 PM, and 09/11/18 at 11:45 AM revealed R1 had limitations in range of motion on both sides of the body and sat in a motorized wheelchair which she operated by using her thumb to push a switch. The resident's hands were contracted, with the fingers of both hands in bent positions, affecting her ability to use them in a normal fashion. Interview with R1 on 09/10/18 at 1:01 PM revealed she was waiting for staff to feed her lunch, saying, I need help because she could not feed herself. Review of R1's Face Sheet revealed she was a long-term resident with [DIAGNOSES REDACTED]. Review of OT (Occupational Therapy) - Therapy Progress and Discharge Summary records revealed the resident last received skilled therapy services in (YEAR). At that time, the resident received therapy services for range of motion issues in the upper extremities (shoulder and elbow). Review of Restorative Nursing forms revealed the resident was placed on a restorative nursing program on 12/01/16 for passive range of motion (PROM) to both lower extremities three times per week to maintain flexibility and ROM. A Restorative Nursing communication form, dated 04/18/17, also revealed the resident was to receive ROM to both upper extremities five times per week. Review of the resident's Care Plan revealed that it included a problem for, ADLs (Activities of Daily Living), with a target (completion) date of 11/01/18. Per the care plan, the resident is unable to perform ADLs r/t (related to) (the) effects of [MEDICAL CONDITION]. She is at risk for decreased flexibility and ROM in BLE (bilateral lower extremities) d/t (due to) (the) effects of [MEDICAL CONDITION]. Approaches to meet the goal of maintaining flexibility and ROM included, RNP (Restorative Nursing Program) 3x/week for PROM to BLE to maintain flexibility and ROM. The care plan also listed an intervention for the RNP to provide range of motion for the bilateral upper extremities; however, this intervention had a line drawn through it, indicating that it was no longer current. Review of Departmental Notes by Registered Nursing (RN) staff on 08/14/18 and 09/03/18 revealed notes stating, RNP continues 3x wk (week) for PROM to bilateral lower extremities to maintain flexibility and ROM. However, review of the Restorative CNA (certified nursing assistant) Roster revealed R1 did not receive ROM three times per week on a consistent basis as directed in her care plan. For example: Week of 08/12/18 - did not receive one of three ROM sessions. Week of 08/19/18 - did not receive one of three ROM sessions. Week of 08/26/18 - did not receive two of three ROM sessions. Week of 09/02/18 - did not receive one of three ROM sessions. During an interview on 09/11/18 at 12:50 PM, CNA51 stated she was the restorative aide routinely assigned to R1. She stated she provided PROM to R1's lower extremities and used a little weight when providing ROM for her arms. CNA51 stated she worked Monday - Friday; however, she could get pulled for other stuff and was not able to provide restorative services when that occurred. CNA51 stated on any day that ROM was provided, it was documented, and If she's (R1) not getting (PROM) three times a week, it's because I'm pulled to the floor (to perform routine nurse aide duties). During an interview on 09/11/18 at 12:53 PM, the Director of Nursing (DON) stated if the resident's care plan called for ROM three times per week, she (R1) should be receiving those services. The DON stated there were two restorative CNAs. However, if one of the two restorative aides were off work or pulled away from restorative services due to other staffing needs, the remaining restorative aide would have up to 40 residents and can't get them all done. Further interview with the DON revealed the restorative staff, normally doesn't get pulled more than once per week and confirmed this could explain why R1 was consistently not receiving all three days of ROM as care planned.",2020-09-01
551,OAKHAVEN NURSING CENTER,425064,123 OAK STREET,DARLINGTON,SC,29532,2018-09-12,689,E,0,1,3QMS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** AMENDED 11/7/18 Based on observation, interview, record review, and review of the facility's Falls Management policy, the facility failed to provide supervision and/or assistance devices needed to prevent accidents for one of four residents reviewed for falls, (Resident (R) 78), out of 20 sampled residents. Accidents were not thoroughly investigated, resulting in a failure to identify potential contributing factors. Care plan interventions to prevent falls were not implemented for R78, who sustained multiple falls. Findings include: Review of R78's Face Sheet revealed she was admitted to the facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. Review of the resident's admission Minimum Data Set (MDS), an assessment tool completed by the facility staff used to identify resident care problems and assist with care planning, with an Assessment Reference Date (ARD), the end-point of the evaluation period of 01/26/18, indicated under Section C: Cognitive Patterns, the R78's Brief Interview for Mental Status (BIMS) score was 15 of 15, which indicated the resident had intact cognition. Section E: Behavior, indicated the resident did not reject care. Section G: Functional Status, indicated the resident required limited assistance with bed mobility, transfers, ambulation, and dressing, and extensive assistance with toilet use. Section H: Bladder and Bowel, indicated R78 exhibited occasional incontinence of urine. Review of the resident's comprehensive care plan revealed the staff developed a problem related to falls as of 01/19/18. Per the care plan, the resident is at risk for falls related to weakness of core and legs, pain in knees, decreased activity tolerance. Interventions to prevent the goal of no major injury from falls included: Transfer with 1 person assist. Ensure that she is wearing appropriate footwear when walking. Uses rollator. Be sure call light is within reach and encourage her to use it for assistance. Review of R78's fall history, as documented in Resident Incident Report forms, included: a. 04/10/18 at 9:44 PM: Called to Room Per CNA (Certified Nursing Assistant). Resident observed sitting on floor with pants halfway down and blanket on floor with her foot on top of it. Resident stated, I was going to the bathroom and fell on my butt. Review of facility records revealed no evidence that a thorough investigation was conducted in response to this fall. In addition to the Resident Incident Report, the only other evidence of investigation provided by the facility was a three-sentence Incident Investigation form which stated, Root/cause analysis: Noted sitting on floor. Stated she was going to (the) bathroom and fell on her butt. A 3-day bowel and bladder (B & B) patterning assessment to be completed. Review of this information revealed that it failed to thoroughly describe and evaluate all possible contributing factors. For example, the investigation records failed to address the resident's footwear at the time of the fall and identify if the care plan intervention of appropriate footwear had been in place. There was no mention of the resident's call light as to whether it had been in place per the care plan, was used by the resident, and if so, if staff had responded in a timely manner to the resident's need for assistance with toileting. Review of R78's comprehensive care plan revealed that in response to this fall on 04/10/18, the resident's care plan was updated with the new approach of, 3-day B&B patterning assessment. Review of R78's electronic health record (EHR) and the hard copy record, revealed that the B&B patterning assessment was completed. b. 06/07/18 at 4:40 AM: Per the Resident Incident Report, staff were, called to room per resident. Resident observed sitting on buttocks on (the) floor on the right side of the bed. Bed was in (the) lowest position. Resident stated, I was going to the bathroom and slid down on my butt. Review of facility records revealed no evidence that a thorough investigation was conducted in response to this fall. In addition to the Resident Incident Report, the only other evidence of investigation provided by the facility was a two-sentence Incident Investigation form, which stated, Root/cause analysis: Noted sitting on buttocks on right side of bed. To have low bed with mat at bedside. Review of this information revealed that it failed to thoroughly describe and evaluate all possible contributing factors. For example, the investigation records again failed to address the resident's footwear at the time of the fall and determine if the care plan intervention of appropriate footwear had been in place. There was no mention of the resident's call light as to whether it had been in place per the care plan, was used by the resident, and if so, if staff had responded in a timely manner. c. 06/26/18 at 9:00 PM: Per the Resident Incident Report staff was standing at medication cart preparing meds for resident when I heard resident yell out, 'Oh.' When I went into resident's room, resident noted lying on left side on floor in front of the closets.Resident stated, 'I was going to the bathroom and the walker slipped away from me.' Resident then asked to go to the bathroom, as resident stood up with assist, she complaint (sic) of left hip pain when trying to walk. Review of an Accident/Incident Reporting Form - Bureau of Health Facilities Licensing form revealed the facility made a report of this accident to the State Survey Agency (SSA). Per this form, after the fall, the resident was transferred to the hospital, where x-rays showed that the resident had non-displaced fractures of the inferior and superior pubic rami (pelvic) on the L (left) side. Further review of the report to the SSA revealed, Intervention was placed for her to wear non-skid socks or shoes when she starts to ambulate. Review of the investigation records provided by the facility revealed no evidence that a thorough investigation was conducted in response to the fall. Review of the Incident Investigation form revealed, Root cause analysis: Noted lying on left side on floor. Stated going to bathroom and walker slipped away from her. Non-skid socks to be worn when not wearing shoes. Review of the investigation revealed the facility failed to thoroughly assess and address all possible contributing factors. For example, the new intervention was for the resident to have non-skid sock when not wearing shoes. There was no evidence to indicate the facility investigated why this intervention, which had been in place since admission on 01/19/18, was now considered a new intervention. The investigation failed to document what type (if any) footwear the resident was wearing at the time of the fall or assess why (if none was present) the care plan had not been followed. After the resident's fall with fracture on 06/26/18, a significant change assessment MDS, dated [DATE], revealed the resident had experienced declines in cognition and bladder continence, required extensive assistance with bed mobility, transfers, ambulation, and locomotion in a wheelchair, and had developed a Stage II pressure ulcer to the sacrum. A new comprehensive care plan, dated 07/30/18, was developed which showed the resident continued to be at risk for falls and fracture. Review of this care plan revealed the previously identified intervention of 6/7/18 - low bed with mat at bedside was not carried forward to the new care plan, although there was no information to justify why this intervention was no longer necessary. The care plan did continue the interventions of, To wear non-skid socks when not wearing shoes as tolerated and for call light availability. d. 07/28/18 at 1:16 PM: The resident sustained [REDACTED]. Resident stated that she was tryin (sic) to get to the bathroom and slid and (sic) to the ground. Review of the Incident Investigation form revealed Root/Cause Analysis: Noted sitting on floor with back to bed. Stated attempting to go to bathroom. Staff to offer toileting every hour while awake. Review of the investigation records revealed no evidence that the facility thoroughly described the incident and assessed possible contributing factors such as use of footwear or call light availability in accordance with the care plan. e. 08/12/18 at 7:30 AM: The resident was noted on floor in room beside bed per the Resident Incident Report. Per the Incident Investigation the Root/Cause Analysis: Noted on floor in room beside bed. To be placed on frequent checks. There was no evidence of a thorough investigation to determine the possible root causes of the resident's fall. Review of these two investigation records, as well as a Post -Fall Investigation form provided by the facility, revealed no evidence as to whether previously identified care plan interventions, such as appropriate footwear and call light availability, were in use at the time of the fall. f. 08/31/18 at 4:21 PM: The resident was found sitting in floor at foot of bed per the Resident Incident Report. Per the Incident Investigation the Root/Cause Analysis: Noted sitting on floor at foot of bed. A room change provided moving resident closer to nurse's (sic) station. There was no evidence of a thorough investigation to determine the possible root causes of the resident's fall. Review of the investigation records provided no evidence as to whether previously identified care plan interventions, such as appropriate footwear, call light availability, and fall mats were in place at the time of the fall. Observations throughout the survey revealed that previously identified care plan interventions to prevent falls were not consistently implemented. Observation on 09/10/18 at 9:00 AM during the initial tour of the facility, revealed the resident was in bed on her back, complaining of pain due to a spot on my rectum. During this observation, the resident was noted to have a fall mat on the floor next to the left side of her bed. However, there was no fall mat on the right side of the bed. Additional observations of the resident in bed on 09/10/18 at 11:45 AM and 3:50 PM, and on 09/11/18 at 7:35 AM and 5:00 PM, revealed that although there was a fall mat on the floor next to the left side of bed, there was none on the right side of the bed. In addition, observation on 09/11/18 at 5:13 PM revealed that while the resident was in bed, she was noted to be barefoot and not wearing non-skid socks or shoes. During an interview on 09/11/18 at 5:13 PM, Licensed Practical Nurse (LPN) 78 verified that the resident was not wearing anything on her feet. He stated the resident should have been wearing socks while in bed. During this interview, LPN78 stated that the resident (who requires extensive assistance with dressing) will sometimes take off her socks. However, observation at this time revealed there were no socks present in the bed or on the floor nearby to indicate they had been provided by staff and then removed by the resident. Interview on 09/11/18 at 4:45 PM with the Director of Nursing (DON) revealed that she had provided all the facility's investigative information for each fall since the resident's admission. She confirmed the information provided did not constitute a thorough investigation of each fall, as she was unable to answer specific questions about the circumstances of each fall, based on the facility's investigation reports. Further interview with the DON revealed that the facility had identified a problem with staff not completing a thorough investigation after each fall. She provided an Immediate Post - Fall Investigation form and stated that staff should be completing this form after every fall; however, the facility was having problems getting staff to complete these forms so that they could accurately determine root causes. Review of the form revealed it required staff to document multiple factors, including resident and staff interviews, observations of the environment, and a review of medication changes and then determine the Why of the problem. Further interview with the DON revealed that although this process had been in place since at least (MONTH) (YEAR), there were no Immediate Post-Fall Investigation forms for either of the two falls the resident sustained [REDACTED]. Further interview with the DON revealed that prior to the 06/26/18 fall with fracture, the resident was ambulatory. The DON stated that the 06/26/18 fracture occurred when the resident got up out of bed to go to the bathroom and fell . The DON stated at the time of that fall, the resident was not wearing footwear, and as a result, the need for non-skid socks was added to the care plan. When informed that the intervention of appropriate footwear had already been in place since 01/19/18, the DON stated, I don't know why she did not have footwear on. The DON responded, Oh definitely when asked if the resident should have had footwear on at the time of the fall. Further interview with the DON on 09/11/18 at 4:45 PM revealed the DON did not know, based on the investigation records, if R78 had a low bed and a fall mat in place (as per the resident's care plan) at the time of her fall with fracture on 06/26/18. Review of the Medication and Treatment Administration Records revealed that the low bed and mat were in place. After a review of the record, the DON confirmed that the previous intervention of a low bed with fall mat was not carried forward to the new comprehensive care plan when it was revised after the 07/17/18 significant change assessment. She stated it should be on the current care plan, as it was an intervention that was still needed. The DON stated it would make sense to have mats on both sides of the bed, as the resident could fall from either side. The DON stated that prior to the last fall (08/31/18), the resident was in a different room, and only needed one mat due to the placement of her bed against a wall. She stated that R78 was moved closer to the nursing station after her last fall and it appeared staff failed to identify that she now needed a mat for both sides of the bed, due to the placement of her bed in the new room. Interview on 09/11/18 at 5:21 PM with the MDS Coordinator revealed that the care plan intervention for the low bed with fall mat just got missed when the care plan was revised on 07/30/18. She stated that the low bed with fall mat was still a current intervention and should have been included on the new care plan initiated after the significant change assessment. Review of the facility policy titled, Falls Management, revised 02/2017, revealed that it included the following steps: . 4. Staff will implement care approaches per the resident's individual care plan . 8. The following measures will be implemented as indicated post a Fall: Assess and provide care to the resident. Evaluate the fall for new contributing or underlying causes and the resident for any change in condition. Visual inspection of resident and environment and communication with resident and staff. 9. The resident's care plan will be modified and updated as indicated. 10. Nursing staff will identify and implement interventions to try to reduce the risk and minimize consequences of falls.",2020-09-01
552,OAKHAVEN NURSING CENTER,425064,123 OAK STREET,DARLINGTON,SC,29532,2018-09-12,693,D,0,1,3QMS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility's Gastrostomy/PEG Tube Medication Administration policy, the facility failed to ensure the staff flushed the resident's [DEVICE] after medication administration for one of one resident, (Resident (R) 5), reviewed for administration of medication via a [DEVICE]. Findings include: Observation on 09/11/18 at 8:20 AM revealed Licensed Practical Nurse (LPN)78 retrieved, crushed, and mixed several medications in a 5-ounce (oz) plastic disposable cup with 30 cubic centimeters (cc) of water for administration to R5 via the resident's [DEVICE] (gastrostomy tube- a flexible tube placed in the stomach through surgically-created opening in the abdominal wall and stomach). LPN78 first checked for residual gastric volume, and then flushed the [DEVICE] with 30 cc of water. LPN78 then poured the medication mixture from the 5-oz cup into a 60-cc syringe and gravity-fed the medications through the [DEVICE]. After the medication-water mixture had infused, a significant amount of residual medication was left in the bottom of the 5-oz cup. LPN78 used 30 ccs of water, which had been set aside for the final flush of the [DEVICE], to remix the medications in the 5-oz cup. LPN78 then infused the remainder of the medications from the 5-oz cup into the [DEVICE]. Upon the delivery of the medication-water mixture, LPN78 did not conduct a final flush of R5's [DEVICE]. During an interview on 09/11/18 at 8:45 AM, LPN78 stated, I was told you could use the last flush water to clean out the med (medication) cup. Normally, I would re-hook the feeding tube and the water (for automatic flushes), but I'm going to change them out. A review of R5's eMAR (electronic medication administration record) indicated an order, dated 11/28/17, that read, [MEDICATION NAME] 1.5 (a liquid nutritional solution) at 42ml/hr (hour) with 27 ml/hr water flushes continuously via gastrostomy tube. The order failed to include instructions for flushes before and after medication administration. During an interview on 09/11/18 at 10:17 AM, the DON stated the resident's monthly Physician Recap for (MONTH) (YEAR), showed 27 milliliters (ml) per hour of continuous flush with water, but did not address flushing the [DEVICE] before or after the administration of medications. Review of the facility's policy titled, Gastrostomy/PEG tube Medication Administration, last updated on 01/2013, indicated the policy instructed the staff as follows: . Procedure: 16. After medication administration is completed, provide a 30-cc flush as ordered.",2020-09-01
553,OAKHAVEN NURSING CENTER,425064,123 OAK STREET,DARLINGTON,SC,29532,2018-09-12,697,D,0,1,3QMS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assure effective ongoing pain management for one of two residents (Resident (R) 185) reviewed for pain, out of a sample selection of 20 residents. The facility failed to take action when the resident continued to experience ongoing pain after the discontinuation of a PRN (as needed) pain medication. Findings include: During an interview on [DATE] at 4:05 PM, R185 stated she was a new admission to the facility and was currently receiving therapy services. R185 stated she had been having issues with pain in her back and left leg since she was admitted to the facility. The resident stated she had different orders for pain medication but was still having pain. During the interview as she discussed her pain, the resident was observed to continuously rub her lower back, hip and along the outside of her upper left leg. Review of the resident's Face Sheet revealed she was admitted to the facility on [DATE] with a primary [DIAGNOSES REDACTED]. Per the resident's admission Minimum Data Set (MDS), an assessment tool completed by the facility staff used to identify resident care problems and assist with care planning, with an Assessment Reference Date (ARD), the end-point of the evaluation period, of [DATE], the resident's [DIAGNOSES REDACTED]. The MDS specified under Section C: Cognitive Patterns, R185 had a Brief Interview for Mental Status (BIMS) score of 15 of 15, which indicated the resident had no cognitive impairment. Section H: Health Conditions, indicated in the five days prior to being interviewed for the assessment, the resident experienced pain, which limited her day-to-day activities. Review of the resident's Baseline Care Plan revealed the problem of Pain was marked. The care plan noted interventions that included observing for signs and symptoms of pain, as well as Medication as ordered, Monitor for effectiveness, and Report to MD if resident has no reduction or relief of pain PRN. The Baseline Care Plan noted the resident received three medications for pain: [MEDICATION NAME] (opioid pain reliever), [MEDICATION NAME] (muscle relaxer), and [MEDICATION NAME] (nerve pain medication). Review of the resident's [DATE] admission Physician Orders revealed they included: [MEDICATION NAME] HCL ([MEDICATION NAME]) 10 milligrams (mg) Take 1 tablet by mouth every 6 hours as needed for pain x (times) 7 days. The Physician's Orders sheet showed a stop date of this medication of [DATE]. [MEDICATION NAME] ([MEDICATION NAME]) 5 mg, one tablet three times daily (no stop date). [MEDICATION NAME] 800 mg, one tablet three times daily (no stop date). In addition, admission orders [REDACTED]. Use pain scale 0 = no pain to 10 = worst pain .Medicate if in pain. There was no stop date to this order. Review of the resident's (MONTH) (YEAR) Medication Administration Record [REDACTED]. Per this MAR, the resident received [MEDICATION NAME] on: [DATE] at 4:15 PM for a pain level of 5; [DATE] at 1:14 PM for a pain level of 6; [DATE] at 10:54 AM for a pain level of 8; [DATE] at 9:06 AM for a pain level of 8; and [DATE] at 7:55 PM for a pain level of 8. Review of the physician's orders revealed no further orders for any PRN pain medications after the admission order for PRN [MEDICATION NAME] expired on [DATE]. Review of the resident's Notes tab in the electronic health record revealed the resident continued to experience pain after the order for PRN [MEDICATION NAME] was discontinued on [DATE]. These notes included: [DATE] 2:46 PM - Therapy note - Resident reports LB (lower back) discomfort. [DATE] 1:37 PM - Therapy note - Patient requires rest break due to c/o (complaint of) LBP (lower back pain). Patient requests pain medication, consulted with nsg (nursing) who followed up with patient. [DATE] 2:41 PM - LPN (Licensed Practical Nurse) note - Resident c/o pain ,[DATE] to mid-abdomen. PRN pain pill given as ordered and noted to be effective. [DATE] 5:17 PM - LPN note - Resident c/o pain ,[DATE] to lower back. PRN pain pill given as ordered and noted to be effective. [DATE] 12:27 PM - Therapy note - Increased tenderness left lumbar paraspinals noted today. C/O LBP during ambulation, requiring rest breaks between bouts for pain relief. Although the nursing notes on both [DATE] and [DATE] stated the resident received a PRN pain pill due to complaints of pain at a level of ,[DATE] (severe pain), a review of the physician's orders revealed no evidence that the physician was contacted to obtain a new order for PRN pain medication. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Interview on [DATE] at 9:36 AM with LPN40 revealed that she was aware the resident had ongoing issues with pain. She stated, I know she had surgery on her back, and has pain. I've given her a pain pill before. Interview on [DATE] at 9:41 AM with the Director of Nursing (DON) revealed the resident was monitored each shift for pain. She reviewed the resident's record and stated, I'm not seeing that she has had pain meds ordered since [DATE], although she had required a daily PRN every day prior to the stop date of the [MEDICATION NAME]. After a review of the record, the DON confirmed that the resident was still experiencing pain after the PRN [MEDICATION NAME] was discontinued. The DON stated that after the admission order for the PRN pain medication ended, the physician should have been notified that the resident was still complaining of pain. She stated the facility should have contacted the physician for new orders and did not know why this did not occur. Further interview with the DON confirmed that although nursing staff documented they gave PRN pain medication on [DATE] and [DATE], there was no order for any PRN pain medications. After reviewing the record, the DON stated that although she could see where the resident received her routine [MEDICATION NAME] and [MEDICATION NAME], a review of the MAR indicated [REDACTED]. Interview with Corporate Nurse 2 on [DATE] at 9:50 AM revealed that after surveyor intervention, she went and interviewed the nurse who documented that he gave PRN pain medication on [DATE] and [DATE]. Corporate Nurse 2 stated the LPN told her that he was so used to writing PRN, that's what he put in the nursing note; however, what he actually administered was the resident's regularly scheduled [MEDICATION NAME] and [MEDICATION NAME]. Interview with LPN78 on [DATE] at 10:00 AM confirmed the resident did not have orders for PRN pain medications on the days he had documented that he had given them ([DATE], [DATE]) and what he had actually administered was the resident's routine medications. Review of the facility policy titled, Pain Management, dated ,[DATE], revealed: Resident pain will be identified and addressed with pharmacological and/or non-pharmacological interventions with the goal of pain control to promote comfort and quality of life .Nursing will monitor the effectiveness of the interventions and notify the MD as needed.",2020-09-01
554,OAKHAVEN NURSING CENTER,425064,123 OAK STREET,DARLINGTON,SC,29532,2018-09-12,880,D,0,1,3QMS11,"Based on observation, interview, record review, and review of the facility's policies, the facility failed to use appropriate infection control precautions during the performance of ostomy care for one of two residents observed for dressing changes, (Resident (R) 31), and during the performance of blood sugar testing for one of one resident observed for blood sugar monitoring, (R2). Findings include: 1. Observation on 09/10/18 at 10:35 AM, revealed Licensed Practical Nurse (LPN)59 prepared to change the dressing to R31's stoma site. LPN59 put a pair of uncovered scissors into the right pocket of her scrub-top. After removing the old dressing and cleaning the stoma, LPN59 removed her gloves, but did not sanitize her hands before donning new gloves. LPN59 then dried the area around the stoma with a dry towel and removed her gloves. The LPN did not sanitize her hands before donning new gloves. LPN59 then pulled the scissors from her scrub-top pocket and used the potentially contaminated scissors to cut a new dressing, which she placed around the stoma site. The LPN put the scissors back into the pocket of her scrub-top and removed her gloves. The LPN failed to sanitize her hands. LPN59 then picked up a new pair of gloves from the supply box; however, LPN59 decided not to don the new pair of gloves and then put the potentially contaminated gloves back into the supply box. LPN59 then washed her hands and left the room. During an interview on 09/10/18 at 11:02 AM, LPN59 stated that another nurse (the wound nurse) had cleaned the scissors before giving them to LPN59 to use for the dressing change. LPN59 stated she did put the scissors into the pocket of her scrub-top pocket, and probably should not have done so. LPN59 stated she should have washed her hands after cleaning of the resident's stoma area and before going on to apply the new stoma dressing and bag, and in between the dirty to clean tasks. During an interview on 09/10/18 at 11:49 AM, the wound nurse stated the staff use Sani-cloth Germicidal Disposable wipes to clean their scissors before putting the scissors back into the treatment cart. The scissors were stored in a plastic bag. During an interview on 09/11/18 at 9:20 AM, Corporate Nurse 2 stated, We don't have a policy specific to putting gloves in pockets. We have an infection control policy. A review of the facility's undated policy titled, (Facility name) Infection Prevention and Control, indicated the policy instructed the staff as flows: Procedure: 1. Disposable gloves will be worn by all employees when caring for all patients if there is actual or anticipated contact with blood, bloody body fluid, secretions, mucous membranes or non-intact skin . 3. Hands will be washed with soap and water or cleaned with the instant antiseptic gel after removing gloves. A review of the facility's policy titled, Dressing change (Clean Technique), last updated 08/2016, instructed the staff as follows: . Procedure: 5. Prepare equipment and supplies. Clean scissors with (a) Super Sani-Wipe . 2. Clean the scissors with (a) Super Sani-Wipe and place on a clean corner of your setup, if you need to use scissors again during the procedure. 2. Observation on 09/11/18 at 7:25 AM, revealed LPN78 prepared to perform a blood glucose monitoring test on R2. LPN78 placed a clean pair of gloves into his pants pockets prior to entering the resident's room. After sanitizing his hands, LPN78 reached into his pocket and pulled out the pair of gloves and donned them. LPN78 then performed the resident's blood glucose test while wearing the potentially contaminated gloves. During an interview on 09/11/18 at 7:34 AM, LPN78 stated, (I) probably should get them (gloves) straight out of the box and put them on. (I) probably shouldn't have put them in my pocket. Review of the facility's policy titled, Glucometer (Finger-stick Procedure), last updated 06/2007, instructed staff to wash their hands and apply gloves, and how to prepare the equipment and supplies, but it did not address the transportation of supplies.",2020-09-01
555,OAKHAVEN NURSING CENTER,425064,123 OAK STREET,DARLINGTON,SC,29532,2019-12-08,677,D,0,1,JQ7W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and staff interviews, the facility failed to provide activities of daily living (ADL) care for 2 of 2 sampled residents reviewed for ADL care (Residents #28 and #49). The findings included: 1. Resident #28 had [DIAGNOSES REDACTED]. Resident #28's current care plan, last updated 10/15/19, documented the resident had a problem with ADLs. The goals documented the resident would be clean, dry, and odor free. Interventions included assist with turning and repositioning approximately every hour and as needed. A quarterly Minimum Data Set (MDS), dated [DATE], documented the resident's cognition was severely impaired. The resident was totally dependent on staff for locomotion, and toilet use. The resident was always incontinent of bowel and bladder. On 12/06/19 at 9:29 AM, Resident #28 was observed up in his geri-chair at the nurses' station near the activity room. On 12/06/19 from 9:29 AM to 11:01 AM the resident was observed continuously up in his geri-chair at the nurses' station. The resident's eyes were closed on and off. Twice he yelled out he needed to go to the bathroom before closing his eyes again. There were staff at the nurses' station and nearby in the hall but they did not check on the resident or provide any care when he yelled out. At 11:01 AM, a nurse passed by and stated, He's asleep. She did not stop to check on or reposition the resident. On 12/06/19 at 11:04 AM, the resident again began to yell out and say he needed to go to the bathroom. Registered Nurse (RN) #56, heard the resident, stopped, looked down then left. No one checked on the resident and did not provide any care. On 12/06/19 at 11:04 AM to 11:47 AM the resident remained up in the geri-chair at the nurses' station without any care being provided. He again called out twice he needed to go the bathroom, and no one stopped to take him or provide care. The unit manager and two certified nurse aides (CNAs) were at the nurses' station while he yelled that he needed to go the bathroom. From 11:47 AM to 12:12 PM the resident remained up with no care being provided. At 12:12 PM, a CNA took the resident to his room and then left the room. She did not provide any care to the resident when she took him to the room. From 12:12 PM to 1:14 PM the resident remained in his room without any care being provided. At 1:14 PM, CNA #39 was observed providing the resident his meal tray. She sat down and assisted him with his meal. CNA #39 stated she only provided meal assistance and was not responsible for providing any care to the resident. She stated she probably would help change him after the meal if she was asked by CNA #50. At 1:21 PM, CNA #39 brought the resident out of his room and placed him at the nurses' station. No care was provided prior to bringing him out of his room after the meal. From 1:21 PM to 1:48 PM the resident remained out in the hall with no care being provided. At 1:48 PM RN #56 and licensed practical nurse (LPN) #77 took the resident to his room and placed a splint on his hand. They then returned him to the hallway without providing any care to the resident. At 1:56 PM, LPN #77 stated the resident was incontinent and when he says he had to go to the bathroom he needs to be changed. She stated the resident should be changed, repositioned, and checked at least every two hours or more often if needed. On 12/06/19 at 2:02 PM, CNA #50 and CNA #39 were observed taking the resident to his room to provide care. The resident was observed up without care being provided for four hours and thirty-two minutes. On 12/06/19 at 2:05 PM, CNA #50 stated she was the one working with the resident and she had not provided care since early in the morning when she first started her shift. She stated the resident will yell if he had to have a bowel movement. She stated he was last changed when she got him up for breakfast around 8:00 AM. She then stated he should have been checked and changed at least every two hours. She stated the resident had a bowel movement and was wet when she changed him. 2. Resident #49 had [DIAGNOSES REDACTED]. An annual MDS, dated [DATE], documented the resident's cognition was severely impaired. The resident was totally dependent on one staff for bed mobility, transfers, dressing, eating, and toilet use. Resident #49's current care plan, last updated 11/11/19, documented the resident required total assistance with all ADL's related to severe cognitive impairment. Interventions included the resident required total assistance with dressing, personal hygiene, oral care and bathing. The care plan also documented the resident was incontinent of bowel and bladder and was unaware of toileting needs. The interventions included to check for incontinent episodes and provide care as needed at least every two hours. On 12/06/19 at 9:29 AM, Resident #49 was observed up in her Broda chair (a wheelchair that can be tilted back in a reclining position) at the nurses' station near the activity room. On 12/06/19 from 9:29 AM to 10:39 AM the resident remained at the nurses' station in her chair. Staff was observed passing by her and not checking her, repositioning her or taking her to the room to provide care. On 12/06/19 at 10:39 AM a CNA took the resident into the activity room where a Bible study was going on. The CNA did not take the resident to her room to provide any care or reposition her in the chair. On 12/06/19 from 10:39 AM to 11:34 AM, the resident remained in the activity room for the Bible study. No staff came in and checked on the resident or provided any care or repositioning. On 12/06/19 at 11:34 AM, the Life Enrichment Director took the resident from the activity room and placed her outside in the hall on hall D. The resident remained there until 11:39 AM when she was transported down to the main dining room for the noon meal. No care was provided to the resident prior to her going to the dining room. On 12/06/19 from 11:39 AM to 1:52 PM the resident remained in the dining room. No staff was observed providing any care to the resident during this time. At 1:52 PM, the resident was observed being taken from the dining room to her room to be laid down for care. The resident was observed up in her chair for four hours and twenty-three minutes without any care or being repositioned. On 12/06/19 at 1:42 PM CNA #30 stated the resident was incontinent and required total assistance with all care. She stated she was the aide working on the hall responsible for her care and she last provided care early in the morning when she first arrived at 7:00 AM. She stated the resident was to have care every two hours. She then stated she was going to change the resident, but she was in an activity then taken to the dining room for her meal. She then stated she did not want to interrupt the activity and her meal to provide the care. At 1:56 PM, LPN #77 stated the resident was incontinent and was not able to make her needs known. She stated the resident should be checked and changed at least every two hours. She then stated the resident was totally dependent on staff for all care.",2020-09-01
556,BAYVIEW MANOR,425067,11 TODD DRIVE,BEAUFORT,SC,29901,2018-02-16,600,G,1,1,HGEW11,"> Based on review of facility files and interview, the facility failed to ensure Resident #120 was free from neglect, that resulted in harm for 1 of 3 residents reviewed for neglect. The findings included: The facility reported an improper transfer to the State Agency for Resident #120 by CNA #2. Review of the facility's Five-Day Report dated 11/08/17 indicated after the review of presented evidence and documentation, the staff member admitted to not following the facility's established policy and procedures for properly transferring residents and was terminated for her/his actions that resulted in the harm of Resident #120. During an interview with the Medical Director and the Assistant Director of Nursing (ADON) on 02/15/18 at approximately 5:25 p.m., it was discussed what the role of each party was concerning the incident that occurred resulting in Resident #120's right hip being fractured. Per the ADON, her/his role was to investigate how the fall occurred. S/he completed the incident report, obtained witness statements, spoke with the nurse on duty and to the Certified Nursing Assistant (CNA) working with the Resident at that time, CNA #2. The CNA was able to provide the ADON with a step -by-step reenactment, by phone which was similar to the statement s/he provided at the time of the incident. The ADON stated that the CNA had the proper training and understood the transfer was incorrect. Per the ADON, the resident was able to assist with her/his arms with transfers, with 2 CNAs to help her/him; without that assistance the resident would lose balance. Once the ADON determined the facility's policies had been breached, the CNA was terminated for improper transfer of the resident that resulted in serious bodily injury. The Medical Director indicated that the on-call doctor was notified of the incident at approximately 7:55 p.m. The Medical Director stated the resident's transfer status changed after the hospital stay following the fracture. S/he indicated that the resident had been in the facility for many years and had never had usage of her/his lower extremities, with atrophic legs and no muscle tone. Attempted to reach CNA #2 on two occasions, on 02/15/18 at 4:46 p.m. and on 02/16/18 at 3:17 p.m. with no answer. Review of the facility's policy, entitled, Abuse Prohibition/Investigative Policy, Revised (MONTH) (YEAR), on 02/14/18 at 4:34 p.m. revealed the statement, The facility will prohibit abuse, neglect, misappropriation of resident property, and exploitation. The policy continues and explains that Neglect; is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Furthermore, the policy describes actions to prevent such occurrences, as evidenced by the following statement, .Developing a care plan identifying appropriate intervention to prevent occurrences.",2020-09-01
557,BAYVIEW MANOR,425067,11 TODD DRIVE,BEAUFORT,SC,29901,2018-02-16,623,E,0,1,HGEW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on limited record review and interviews, the facility failed to ensure that a representative of the Office of the State Long-Term Care Ombudsman was notified of the emergent transfer of resident for 3 of 5 residents reviewed for hospitalization . Residents #130, #138, & #153, and was emergently transferred to the emergency room at local hospital and subsequently admitted related to an acute change in health status requiring a higher level of care without notification provided as required to the State Long-Term Care Ombudsman. The Findings Included: The facility admitted resident #130 with the [DIAGNOSES REDACTED]. Record review on [DATE] at 1:17 PM revealed in nursing notes portion of the record that a change in Resident #130's condition was identified as evidenced by increased temperature of 100.8, fluctuating pulse with rate range of ,[DATE] beats per minute, and elevated blood pressure of ,[DATE] millimeters of mercury (mmHg). Additionally, it was documented that Resident #130 displayed labored breathing and had a congested cough with abnormal lung sounds and an oxygen saturation level of 79% on room air. Resident #130's Physician was notified of change in condition on [DATE] at 9:15 AM. New orders were received to initiate supplemental oxygen at a rate of 5 liters/minute via nasal cannula, administer a hand held nebulizer treatment and to emergently transfer Resident #130 to the emergency room for evaluation and treatment. Documentation in record reveals that after the supplemental oxygen was applied, there was an improvement in Resident #130's oxygen saturation (O2 sat) levels which increased to 92%. Documentation reveals that Resident #130's Responsible Party (RP) was notified of change of condition for Resident #130 and the need for higher level of care and emergent transfer to emergency room . Review of the admission packet provided to residents and their responsible parties on [DATE] revealed that RP's and/or residents are notified of the bed hold policy upon admission to the facility. This paperwork was completed, and bed hold policy acknowledged by Resident #130/ RP upon admission to facility on [DATE]. The facility admitted resident #138 with the [DIAGNOSES REDACTED]. Record review of the nursing notes portion of the record on [DATE] at 9:52 AM revealed that at on [DATE] at 9:20 AM, Resident #138 had pulled his/her PEG (Percutaneous Endoscopic Gastrostomy) tube out and it was not able to be reinserted by nursing staff. The Director of Nursing (DON) was notified at 9:40 AM on [DATE]. Hospice provider, Physician and Responsible party were notified at approximately 9:45 AM on [DATE] of the change in condition for Resident #138 and the need for higher level of care/ evaluation and emergent transfer to emergency room . Further review of the physician order [REDACTED]. During interview with Social Services Director (SSD) and Social Services Assistant (SSA) on [DATE] at 12:00 PM, they were asked how the representative of the Office of the State Long-Term Care Ombudsman (ombudsman) was notified when residents were emergently transferred to the hospital and admitted due to need for a higher level of care. The SSD responded that the ombudsman would not have been notified of hospitalization s. S/he further reported that the ombudsman is notified when there is a difficult discharge which include, but are not limited to, those which involve coordination with Adult Protective Services. When asked if there was any evidence that could be provided to reflect that the ombudsman was notified of any unplanned discharges of facility residents to the hospital related to changes in condition that required a higher level of care, both SSD and SSA replied that had been no communication with ombudsman for any residents for the time frame of (MONTH) 1, (YEAR) to current date of [DATE]. When asked if they were aware of the regulatory changes that occurred on [DATE] regarding this requirement, both SSD and SSA replied that they were not aware of the changes that occurred on [DATE]. Additional interview/ discussion on [DATE] at 12:30 PM with both SSD and Administrator included review of regulation 483.15(c) (3) Notice before transfer, in appendix PP - Guidance to Surveyors for Long Term Care Facilities (Rev. 173, [DATE]). After review of information and discussion, the administrator and SSD both verbalized understanding that requirement regarding notification of transfer/ discharge stated as The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman was implemented on [DATE]. Both Administrator and SSD further stated that they were under the impression that the implementation for this requirement was not until Phase 3 or [DATE] due to their incorrect interpretation of Survey and Certification (S&C) letter with reference number of ,[DATE]-NH which was released on (MONTH) 12, (YEAR). Finally, the administrator reported that the facility would immediately initiate a process to ensure the ombudsman is aware of emergent transfers to an acute care facility related to need for higher level of care as required. Resident #153 was admitted to the facility with [DIAGNOSES REDACTED]. Record review of the Interdisciplinary Discharge Summary on [DATE] at 2:29 p.m. revealed the resident was unresponsive and was transferred to the local hospital for treatment where s/he later expired. During an interview with the Social Services Assistant on [DATE] at 3:00 p.m., s/he indicated the Ombudsman was not notified of the emergent discharge concerning Resident #153 in (MONTH) of (YEAR).",2020-09-01
558,BAYVIEW MANOR,425067,11 TODD DRIVE,BEAUFORT,SC,29901,2018-02-16,656,G,1,1,HGEW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, the facility failed to ensure the developed care plan for Resident #120 was followed, resulting in the resident's right hip being fractured for 1 of 3 residents reviewed for abuse/neglect. The findings included: The facility reported an improper transfer to the State Agency for Resident #120 by CNA #2. Review of the facility's Five-Day Report dated 11/08/17 indicated after the review of presented evidence and documentation, the staff member admitted to not following the facility's established policy and procedures for properly transferring residents and was terminated for her/his actions that resulted in the harm of Resident #120. Resident # 120 was admitted to the facility with [DIAGNOSES REDACTED]. Nurse's notes were reviewed on 02/14/18 at approximately 4:35 p.m., for the date of the incident, and revealed at approximately 7:50 p.m. a Certified Nursing Assistant (CNA) notified the nurse on duty that s/he was putting the resident in bed from the wheelchair when a snap was heard and the resident cried out. The on-call physician was notified and ordered the resident be sent to the hospital for evaluation, where she was admitted for a right [MEDICAL CONDITION]. Review of the resident's care plan revealed a handwritten approach dated 10/01/17 that stated, Assist x2. In the comments section, on the 'Nurse Aide's Information Sheet' it read, 2 apple bites. Per the Assistant Director of Nursing, the 'Apple Bite System' is the facility transfer protocol for staff to determine what type of assistance is required for transfers and it is utilized for every resident in the facility. Two bites in the apple indicates a 2 person transfer. During an interview with the Medical Director and the Assistant Director of Nursing (ADON) on 02/15/18 at approximately 5:25 p.m., it was discussed what the role of each party was concerning the incident that occurred resulting in Resident #120's right hip being fractured. Per the ADON, her/his role was to investigate how the fall occurred. S/he completed the incident report, obtained witness statements, spoke with the nurse on duty and to the Certified Nursing Assistant (CNA) working with the Resident at that time, CNA #2. The CNA was able to provide the ADON with a step -by-step reenactment, by phone which was similar to the statement s/he provided at the time of the incident. The ADON stated that the CNA had the proper training and understood the transfer was incorrect. Per the ADON, the resident was able to assist with her/his arms with transfers, with 2 CNAs to help her/him; without that assistance the resident would lose balance. Once the ADON determined the facility's policies had been breached, the CNA was terminated for improper transfer of the resident that resulted in serious bodily injury. The Medical Director indicated that the on-call doctor was notified of the incident at approximately 7:55 p.m. The Medical Director stated the resident's transfer status changed after the hospital stay following the fracture. S/he indicated that the resident had been in the facility for many years and has never had usage of her/his lower extremities, with atrophic legs and no muscle tone. Attempted to reach CNA #2 on two occasions, on 02/15/18 at 4:46 p.m. and on 02/16/18 at 3:17 p.m. with no answer. Review of the facility's policy, entitled, Safe Lifting and Movement of Residents, Revised (MONTH) (YEAR), on 2/13/18 at 12:41 p.m. revealed the statement, In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Furthermore the policy stated in item 3,Nursing staff in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan.",2020-09-01
559,BAYVIEW MANOR,425067,11 TODD DRIVE,BEAUFORT,SC,29901,2018-02-16,657,D,0,1,HGEW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, records review and staff interview the facility failed to update the comprehensive person-centered care plan to include the improvement in behavior and pending transfer status from a locked unit to an unlocked unit for one of five sampled residents reviewed for unnecessary medication. Findings: Resident # 68 was admitted to the facility with [DIAGNOSES REDACTED]., Non-Pressure Chronic Ulcer, [MEDICAL CONDITION], Anxiety, Somnolence, [MEDICAL CONDITION], Difficulty understanding Others, and Depression. During observation on 02/14/18 03:11 PM resident #68 was seen at the dining room having breakfast. On 02/15/18 10:05 PM the resident was observed in the dining/television room. When asked if s/he is doing okay s/he responded yes ma'am, yes ma'am. Care plan reviewed on 02/14/2018 at 7:22 PM states the following; Potential for social isolation and needs to be involved in activities on the secure unit for socialization related to impaired mobility. Resident resides on the secure unit. Resident has a [DIAGNOSES REDACTED]. Resident does not comprehend the use of the call light bell. Resident has a history of being combative with staff, cursing, threatening, staff and residents with kitchen utensils and fighting with other residents. 1/8/18 care plan reviewed with resident. Continuing care plan review revealed no other entry regarding resident #68's behavior and/or transfer to an unlocked unit status. Review of the Social Services note on 02/15/18 at 12:19 PM stated that the resident #68 no longer exhibits behaviors that require secure placement and that the resident is on a waiting list for an alternative, standard long-term setting at the same facility s/he is at. The resident awaits for an appropriate available room. During an interview with the unit manager on 02/15/18 at approximately 12:30 PM s/he stated that resident #68 in on a waiting list to be transferred to an unlocked unit along with other residents what have been evaluated for possible transfer out of the locked unit.",2020-09-01
560,BAYVIEW MANOR,425067,11 TODD DRIVE,BEAUFORT,SC,29901,2018-02-16,677,D,0,1,HGEW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to provide the necessary services to maintain grooming and personal hygiene to a resident who is unable to carry out activities of daily living without staff assistance. The facility also failed to keep the resident's environment clean and free from faulty odor for one of two sampled residents reviewed for dignity. Findings: Resident #71 was admitted to the facility with [DIAGNOSES REDACTED]. During the initial tour on 02/11/2018 at approximately 6:00 PM resident #71 was observed in his/her wheelchair in his/her room. A prosthetic leg on the floor, facial hair and long fingernails, clothing appeared soiled, bed unmade, bathroom door propped open and strong urine odor in the room and bathroom. The resident stated being itching, having stomach ache and feeling nauseous. When asked it s/he have told the nurse s/he stated that s/he had. The resident stated that s/he was waiting on medication if the doctor approves it. On 02/13/18 at 08:43 AM resident #71 was observed laying on her/his left side on his/her bed. S/he stated that s/he feels better today. Breakfast tray still in the room, resident still on his/her nightgown and the faulty urine odor still present. During breakfast, observation noticed two large pieces of ham untouched and small amount of scrambled eggs on his/her breakfast's tray. The resident was asked if s/he did not like the breakfast s/he said that ham is not good for him/her and s/he doesn't want to eat it. S/he also stated that a cough was bothering him/her today. During an interview on 02/13/18 at approximately 02:50 PM resident #71 stated that s/he needs help getting dressed, going to the bathroom, and making his/her bed. S/he stated that s/he couldn't do it on his/her own because s/he is a double [MEDICAL CONDITION]. S/he also stated that the room is unclean, small very bad and that his bed is wet. The resident stated that the certified nursing assistants (CNAs), during the day shift, don't respond to his/her call light and when they do they make fun of him/her and call him/her names. The resident was unable to provide a waiting time frame or the names of the CNAs that made fun of and called him/her names. During an interview with the unit manager s/he stated the resident #71 is confused at times and that other times he refuses care offered. During an interview with the DON s/he stated that s/he was not aware of resident #71 concerns and that s/he was going to get housekeeping to deep clean his/her room.",2020-09-01
561,BAYVIEW MANOR,425067,11 TODD DRIVE,BEAUFORT,SC,29901,2018-02-16,692,D,0,1,HGEW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and limited record review, the facility failed to provide care and services to maintain acceptable nutritional status for 1 of 5 residents reviewed for nutritional status and 1 of 5 residents reviewed for unnecessary medications. The facility failed to implement recommended nutritional interventions resulting from Registered Dietitian ' s initial and follow up nutritional assessments. The findings included The facility admitted Resident #84 with the [DIAGNOSES REDACTED]. Observation of lunch meal in D-wing dining area on 2/12/18 revealed that Resident #84 required extensive to total assistance for eating which was provided by staff. Review of the tray card revealed that resident received mechanical soft diet dislikes identified as Pork and meal preference identified as Ice tea-one serving. There were no supplements observed on the meal tray at the lunch meal observation on 2/12/18. Medical record review on 2/14/18 at 6:54 PM revealed that initial nutritional assessment was completed by Registered Dietitian (RD) on 12/12/17 with nutritional [DIAGNOSES REDACTED]. #1: Increased nutritional needs for wound healing related to infected stage IV - sacrum with osteo[DIAGNOSES REDACTED], right heel stage IV. #2: Altered nutrition related labs, low albumen, low pre-albumen, increased blood urea nitrogen. Recommendations were made by the RD which included the weekly weights and the addition of a magic cup at lunch and dinner meals. With notation that RD will follow until skin issues resolve or as needed concluding the assessment. Further review of record revealed the Nutritional Risk Assessment completed by the Certified Dietary Manager (CDM) on 1/6/18 which did not include the recommended interventions of weekly weights and addition of magic cup with lunch and dinner meals as supplements provided or results of weekly weights. Finally, the Nutritional Evaluation follow-up completed by the RD on 1/16/18 resulted in the addition of nutritional [DIAGNOSES REDACTED]. New additional nutritional [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. During interview with the RD on 2/15/18 at 9:05 AM, s/he verified that a nutritional recommendation was made on 12/11/17 to provide a magic cup supplement with each lunch and dinner meal. S/he further verified that the CDM Nutritional Risk Assessment completed on 1/6/18 did not include magic cup at lunch and dinner meals under supplements . When asked how nutritional recommendations are processed to be initiated, s/he reported that when the nutritional evaluations are completed on a unit, a flow sheet is generated to reflect the residents who were evaluated, the recommendations for each resident and what discipline is responsible for the initiation of the recommendation. This Flow sheet is given to multiple facility staff members including, but not limited to the Director of Nursing, the Medical Director, the Unit Manager, and the Administrator. Further dissemination of the information to interdisciplinary team members is initiated by the facility as deemed necessary. When asked to provide the documentation reflecting this process for (MONTH) 16, (YEAR) nutritional evaluations and recommendations, RD discovered that one page of the report was not signed and initialed to indicate that it was forwarded to the facility team members. RD stated that it was an oversight and that the residents on that page, including Resident #84, would be evaluated again today before s/he exited the building. Further discussion revealed that as a contract interim RD, s/he has been working to 4 days a month; however the facility has hired a Registered Dietitian that with a start date of 2/16/18. RD further explained that the facility has been working toward initiating procedures to ensure the continuity of information is achieved between all of the interdisciplinary team members. The facility admitted Resident #115 with the [DIAGNOSES REDACTED]. Medical record review on 2/16/18 at 3:00 PM revealed that initial nutritional assessment for Resident #115 was completed by Registered Dietitian (RD) on 1/17/18 with nutritional [DIAGNOSES REDACTED]. #1: Inadequate calorie and protein intake related to (r/t) dementia as exhibited by (AEB) intake info from staff; #2: Increased calorie & protein needs r/t healing & nutritional status AEB recent [MEDICAL CONDITION] & surgery; and #3: Intake of types of carbohydrate inconsistent with needs r/t non-diabetic diet AEB diet order but on insulin. Recommendations were made by the RD which included to change diet to Consistent Carbohydrate (CCHO), No added salt (NAS) and mechanical soft, addition of 30 milliliters of prostat supplement given twice daily for 30 days, sugar free med pass supplement 90 milliliters given three times a day, multivitamin with minerals given once daily for 30 days, and addition of a CCHO mechanical soft high protein finger food at bedtime snack. Review of the Physician orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. Finally, review of provider visit documentation reflected no evidence of receipt of the recommendations for visits between 1/17/18 and 2/16/18. During interview with the RD on 2/16/18 at 3:41 PM, s/he verified that nutritional recommendations made on 1/17/18 outlined on the nutritional assessment for resident #115 were not reflected on the Medication Administration Record [REDACTED]. RD was not initially able to determine whether or not the recommendations made on 1/17/18 were forwarded to the facility staff. At 4:04 PM, the RD submitted a photocopy of a portion of the documentation s/he stated was submitted to the facility at the conclusion of her/his visit on 1/17/18. Review of this information revealed that there was no date, time or information that would indicate that this information was forwarded to the facility. During interview with Director of Nursing (DON) on 2/16/18 at 4:20 PM, s/he reported that no recommendations were received for Resident #115 between the dates of 1/17/18 and 2/16/18. DON further verified that there was no evidence in the medical record that the recommended interventions were implemented",2020-09-01
562,BAYVIEW MANOR,425067,11 TODD DRIVE,BEAUFORT,SC,29901,2018-02-16,801,F,0,1,HGEW11,"Based on observation, record review and interview the facility failed to employ sufficient qualified staff with the appropriate competencies and skill set forward to carry out food and nutritional services in accordance to the Centers for Medicare and Medicaid Services (CMS) regulations and the state of South[NAME]nutritional professional standards for one of one kitchen sample reviewed for qualified food and nutrition service staff. Findings: On 02/11/2018 at 5:50 PM during the initial tour of the facility's kitchen the dietary manager revealed that although s/he is functioning as the dietary manager s/he has not yet taken/passed the nationally recognized credentialing exam needed to obtain/maintain certified status. When asked if the facility has a registered dietitian or food and nutrition services director s/he stated that a consultant registered dietitian comes to the facility for two days per month. The review of the last 3 months of work schedule (Dec (YEAR) and January-February (YEAR)) reviewed on 02/14/2018 at approximately 11:00 AM revealed that the consultant registered dietitian worked a total of 12 hours for the week of (MONTH) 4, (YEAR), (6 hours on (MONTH) 4th and 6 hours on (MONTH) 6th) and a total of 18 hours for the week of (MONTH) 17, (YEAR)( 8 hours on (MONTH) 15th, 6.5 hours on (MONTH) 16th, and 3.5 hours on (MONTH) 17th ). On the other hand the dietary manager worked 18.15 hours for the week of (MONTH) 29th, (YEAR), 40 hours for per week from (MONTH) 5th through (MONTH) 2nd, (YEAR), and 36.45 hours the week of (MONTH) 9th, (YEAR) During an interview on 2/15/2018 at approximately 3:36 PM the DON stated that the dietary manager was supposed to take the exam this week but due to the survey it has to be postponed but, that the consultant dietitian was going to be at the facility the next day (2/15/18). Nevertheless, the DON acknowledged that s/he did not have a full-time dietitian or a nutrition services director on staff that the individual in the dietary manager position did not possess the nationally recognized credential.",2020-09-01
563,BAYVIEW MANOR,425067,11 TODD DRIVE,BEAUFORT,SC,29901,2018-02-16,805,D,0,1,HGEW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and limited record review, the facility failed ensure Resident #39 received identified food preferences for 1 of 5 reviewed for nutrition. The findimgs included: The facility admitted Resident # 39 with [DIAGNOSES REDACTED]. During an interview with Resident #39 on 2/12/18 at 3:49 PM, the surveyor asked Does the food taste good and look good? S/he stated the food is terrible and don't like white meat. During observation on 2/15/18 at 12:40PM, revealed chicken was on the menu and the resident was eating the alternative meal that consist of fish and rice. S/he consumed her rice and vegetables only. The surveyor requested the Administrator, Director of Nursing, and Dietary Manager come and observe the resident plate that had fish on it. Resident stated do not like white meat. S/he don't like fish and writes it on the paper that is on the tray. Dietary Manger is aware the resident don't like white meat. During review of the diet card for Resident #39 on 2/15/18 at 12:49PM revealed the listed dislikes of ground Beef, hamburger, Pineapples, and Tea. Further limited record review revealed on Nutritional Risk Assessment no documentation of the residents dislikes.",2020-09-01
564,BAYVIEW MANOR,425067,11 TODD DRIVE,BEAUFORT,SC,29901,2018-02-16,808,D,0,1,HGEW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to provide the therapeutic diet as ordered. The facility also failed to provide a diet that supports the resident's nutritional need, health status and preference for one of two sample resident review for dining. Findings: Resident #71 was admitted to the facility with [DIAGNOSES REDACTED]. On 02/13/18 at 08:43 AM resident #71 was observed laying on her/his left side on his/her bed. S/he stated that s/he feels better today. Breakfast tray still in the room. Noticed two large pieces of ham untouched and small amount of scrambled eggs on his/her breakfast's tray. When asked if s/he did not like the breakfast s/he stated that ham is not good for you and don't want to eat it. S/he also stated that a cough was bothering him/her today. According to the physician's orders [REDACTED].#71 a renal diet with double portions of meat for protein. Review of the menu on 2/13/2018 at approximately 3:20PM revealed that the renal diet breakfast indicates 4 fluid ounces of apple, grape or cranberry juice, 1/4 of a cup of scrambled eggs, 1/2 cup of hot grits, one white toast, 1each jelly and margarine, 4 fluid ounces of whole milk, 8 fluid ounces of beverage of choice, 1 each sugar and nondairy creamer, and one each Mrs. dash pepper sugar. During an interview with the dietary manager on 02/14/2018 at approximately 3:45 PM s/he stated that the staff might have gotten confused about the diet order since it says double portions of meat, they may have thought that the resident needs to have a double portion of meat at all meals.",2020-09-01
565,BAYVIEW MANOR,425067,11 TODD DRIVE,BEAUFORT,SC,29901,2018-02-16,880,F,0,1,HGEW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on limited record review, interview, and the facility's policy titled Water Management Program, the facility failed to implement water system infection control risk assessment that could affect 152 residents residing in the facility. Water heaters are not flushed monthly and no documentation for nightly cleaning off the continuous positive airway pressure machines ([MEDICAL CONDITION]). The findings included: During limited record review on 2/14/18 at 2:57 PM, revealed Water System Infection Control Risk Assessment was not dated. In addition the ([MEDICAL CONDITION]) machines are to be cleaned nightly and water heaters are to be flushed monthly. During an interview with Maintenance Director on 2/14/18 at 4:03PM, s/he confirmed the flushing of water heaters began in (MONTH) (YEAR) and unable to provide documents for the cleaning of the water system infection control risk. Review of the facility's policy Water Management Program on 2/14/18 revealed under Policy Explanation and Compliance Guidance 12. Routine infection control surveillance data will be used to validate the effectiveness of the water management program.",2020-09-01
566,BAYVIEW MANOR,425067,11 TODD DRIVE,BEAUFORT,SC,29901,2019-03-27,580,D,1,0,L46011,"**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 mental status. The Assistant Director of Nursing (ADON) noted a change in mental status for Resident #143 on 11/15/18 and requested the unit manager obtain an order for [REDACTED]. The findings included: The facility reported an allegation of verbal abuse to the State Agency on 11/15/18. Resident #143 alleged Certified Nursing Assistant #2 verbally abused him/her. Review of the statement of events completed by the ADON revealed Resident #143 was observed with increased confusion and will ask for U/A C&S. Review of Resident #143's Quarterly Minimum Data Sets dated 9/13/18 and 11/30/18 revealed the resident had a Brief Interview for Mental Status score of 15 with no behaviors noted. Review of Resident #143's Departmental Notes revealed a Nursing Note dated 11/20/18 at 7:00 PM the following orders were written: [MEDICATION NAME] 100 milligrams three times daily for two days related to [DIAGNOSES REDACTED]. Review of the Provider Communication Log revealed Resident #143 was entered on the log on 11/19/18 for increased confusion, can a U/A C&S be done per ADON request. Review of Resident #143's Medication Administration Record [REDACTED]. The order was signed as completed on 11/21/18. Resident #143's Medication Administration Record [REDACTED]. In an interview with the surveyor on 3/27/19 at approximately 6:27 PM, the ADON stated on 11/15/18 s/he noted increased confusion for Resident #143 and asked the unit manager about getting a U/A related to the increased confusion. The ADON stated the nurse practitioner will assess and approve then write the order. The ADON confirmed the order for a U/A was written on 11/20/18. The ADON stated the unit manager forgot to put the resident on the Nurse Practitioner's schedule prior to 11/19/18. The ADON stated the Nurse Practitioner was at the facility daily Monday-Friday, and the physician was on call during other hours. The ADON stated the unit manager should have put the request for Resident #143 to have a U/A on the schedule prior to 11/19/18.",2020-09-01
567,BAYVIEW MANOR,425067,11 TODD DRIVE,BEAUFORT,SC,29901,2019-03-27,584,D,0,1,L46011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to properly label and store personal care equipment for 2 of 35 rooms observed. Three urinals were observed uncovered and unlabeled in the bathroom between Unit B rooms [ROOM NUMBERS] during the survey. The findings included: During initial observation on 03-11-19 at approximately 1:00 PM the bathroom between Unit B rooms [ROOM NUMBERS] had three uncovered and unlabeled urinals. Additional observations of the same bathroom on 03-13-19 at approximately 03:50 PM (2 days later) revealed the urinals continued to be unlabeled and uncovered. During an observation and interview on 03-13-19 at 03:56 PM Certified Nursing Assistant #1 confirmed there were 3 unlabeled and uncovered urinals in the bathroom between Unit B rooms [ROOM NUMBERS].",2020-09-01
568,BAYVIEW MANOR,425067,11 TODD DRIVE,BEAUFORT,SC,29901,2019-03-27,607,D,1,0,L46011,"> Based on review of facility files and interview, the facility failed to implement written policies and procedures related to investigating allegations of abuse. Resident #143 alleged that Certified Nursing Assistant (CNA) #2 verbally abused him/her in (MONTH) (YEAR). Review of the facility's investigative file revealed several staff members who were working at the time of the alleged incident did not have written statements in the file. Resident #143 was alert and oriented and there was no documentation that the resident was interviewed related to the incident. The allegation was initially reported to staff by a relative of Resident #143 (1 of 4 sampled residents reviewed for abuse). The findings included: The facility reported an allegation of verbal abuse to the State Agency on 11/15/18. Resident #143 stated CNA #2 verbally abused him/her. The allegation was reported to staff by Resident #143's relative, who completed a statement related to the allegation. A typed summary statement indicated on 11/15/18 it was reported that there could possibly be a verbal abuse allegation from C Wing. CNA #2 stated that every time s/he went into Resident #143's room s/he had another staff member with him/her. The first time s/he went in to change resident s/he had CNA #4 with him/her. CNA #4 stated that no words were exchanged between the two at all and that they changed the resident together. The second time CNA #2 went in was with CNA #3 who stated that no words as alleged were ever stated. Increased confusion was observed with Resident #143 who received restorative care. An hour later, Resident #143 forgot that s/he already received services but restorative aide was willing to give more restorative care if s/he wanted and Resident #143 said, Oh no, I forgot. Will ask for U/A C&S. Findings were unsubstantiated and the CNA will not work with the resident again. Review of Resident #143's Social Service Notes revealed there were no entries in (MONTH) (YEAR). In an interview with the surveyor on 3/27/19 at approximately 7:00 PM, the ADON confirmed there were no social service notes in (MONTH) (YEAR). Review of the resident interviews completed by social services during the investigation revealed there was no documentation of an interview with Resident #143. Review of Resident #143's Quarterly Minimum Data Sets dated 9/13/18 and 11/30/18 revealed the resident had a Brief Interview for Mental Status score of 15 with no behaviors noted. There was no documentation Resident #143 was interviewed related to the incident. Review of the facility's investigation of the alleged verbal abuse revealed there were no written statements from CNA #2, CNA #3 or CNA #4. In an interview with the surveyor on 3/27/19 at approximately 4:15 PM, the Assistant Director of Nursing (ADON) stated s/he spoke with CNA #2 and took a verbal statement over the phone while s/he was talking with him/her about the suspension. The ADON stated s/he spoke with CNA #3, who wrote a statement. The ADON stated s/he also talked with Resident #143 but s/he did not write up the interview with the resident. The ADON stated s/he also talked with CNA #4 who completed a written statement. In an interview with the surveyor on 3/27/19 at approximately 6:50 PM, the Administrator stated s/he had no concerns with the investigation. The Administrator stated s/he was at home at the time of the allegation. S/he walked staff through how to start the investigation and staff was to report back to him/her what they learned during the investigation. The Administrator stated s/he would expect staff to include information that the resident was interviewed or attempted to be interviewed. Review of the facility's Abuse Investigation and Reporting policy revealed the individual conducting the investigation will, at a minimum: review the completed documentation forms, interview the person(s) reporting the incident, interview any witnesses to the incident, interview the resident (medically appropriate), interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident. The following guidelines will be used when conducting interviews: witness reports will be obtained in writing. Either the witness will write his/her statement and sign and date it, or the investigator may obtain a statement, read it back to the member and have him/her sign and date it.",2020-09-01
569,BAYVIEW MANOR,425067,11 TODD DRIVE,BEAUFORT,SC,29901,2019-03-27,609,D,1,0,L46011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to report suspected abuse to the State Agency within the mandated 2 hour timeframe for Resident #517 (1 of 4 sampled residents reviewed for abuse). The findings included: The facility admitted Resident #517 with [DIAGNOSES REDACTED]. Record review on 03/13/19 at approximately 9:30 AM revealed an investigative file related to an incident involving Resident #517 which the resident reported to the Nurse Liaison the morning of 12/10 /18. The facility verification of transmission cover sheet stated the reporting time to be 3:50 PM. In an interview on 03/13/19 at approximately 3:53 PM the Administrator reviewed the fax transmission cover sheet and confirmed the report was submitted to the State Agency after the mandated 2-hour reporting time for suspected abuse. Review of the facility policy entitled Abuse Prevention Program under #6 stated staff will, investigate and report any allegation of abuse within timeframes as required by federal requirements.",2020-09-01
570,BAYVIEW MANOR,425067,11 TODD DRIVE,BEAUFORT,SC,29901,2019-03-27,610,D,1,0,L46011,"> Based on review of facility files and interview, the facility failed to have evidence that all allegations of abuse were thoroughly investigated. Resident #143 alleged that Certified Nursing Assistant (CNA) #2 verbally abused him/her in (MONTH) (YEAR). Review of the facility's investigative file revealed several staff members who were working at the time of the alleged incident did not have written statements in the file. Resident #143 was alert and oriented and there was no documentation that the resident was interviewed related to the incident. The allegation was initially reported to staff by a relative of Resident #143 (1 of 4 sampled residents reviewed for abuse). The findings included: The facility reported an allegation of verbal abuse to the State Agency on 11/15/18. Resident #143 stated CNA #2 verbally abused him/her. The allegation was reported to staff by Resident #143's relative, who completed a statement related to the allegation. Review of the facility's Five-Day Follow-Up Report dated 11/19/18 revealed after staff and resident interviews, it was determined that the CNA #2 was never alone with the resident. They had also completed a gradual dose reduction of Resident #143's anxiety and depression medication several weeks prior to the alleged incident. After investigation, it was determined that the verbal abuse was unsubstantiated. A typed summary statement indicated on 11/15/18 it was reported that there could possibly be a verbal abuse allegation from C Wing. CNA #2 stated that every time s/he went into Resident #143's room s/he had another staff member with him/her. The first time s/he went in to change the resident s/he had CNA #4 with him/her. CNA #4 stated that no words were exchanged between the two at all and that they changed the resident together. The second time CNA #2 went in was with CNA #3 who stated that no words as alleged were ever stated. Increased confusion was observed with Resident #143 who received restorative care. An hour later, Resident #143 forgot that s/he already received services but restorative aide was willing to give more restorative care if s/he wanted and Resident #143 said, Oh no, I forgot. Will ask for U/A C&S. Findings were unsubstantiated and the CNA will not work with the resident again. Review of Resident #143's Social Service Notes revealed there were no entries in (MONTH) (YEAR). In an interview with the surveyor on 3/27/19 at approximately 7:00 PM, the ADON confirmed there were no social service notes in (MONTH) (YEAR). Review of the resident interviews completed by social services during the investigation revealed there was no documentation of an interview with Resident #143. Review of Resident #143's Quarterly Minimum Data Sets dated 9/13/18 and 11/30/18 revealed the resident had a Brief Interview for Mental Status score of 15 with no behaviors noted. There was no documentation Resident #143 was interviewed related to the incident. Review of the facility's investigation of the alleged verbal abuse revealed there were no written statements from CNA #2, CNA #3, or CNA #4. In an interview with the surveyor on 3/27/19 at approximately 4:15 PM, the Assistant Director of Nursing (ADON) stated s/he spoke with CNA #2 and took a verbal statement over the phone while s/he was talking with him/her about the suspension. The ADON stated s/he spoke with CNA #3, who wrote a statement. The ADON stated s/he also talked with Resident #143 but s/he did not write up the interview with the resident. The ADON stated s/he also talked with CNA #4 who completed a written statement. In an interview with the surveyor on 3/27/19 at approximately 6:50 PM, the Administrator stated s/he had no concerns with the investigation. The Administrator stated s/he was at home at the time of the allegation. S/he walked staff through how to start the investigation and staff was to report back to him/her what they learned during the investigation. The Administrator stated s/he would expect staff to include information that the resident was interviewed or attempted to be interviewed.",2020-09-01
571,BAYVIEW MANOR,425067,11 TODD DRIVE,BEAUFORT,SC,29901,2019-03-27,657,D,1,0,L46011,"> Based on record review and interview, the facility failed to develop a comprehensive care plan. Resident #143 was reported to have behaviors related to making allegations against staff. Intervention of two staff to assist at all times was put in place in (MONTH) (YEAR). The care plan did not reflect the resident's behavior or interventions (1 of 4 sampled residents reviewed for abuse). The findings included: The facility reported an allegation of verbal abuse to the State Agency on 11/15/18. Resident #143 stated Certified Nursing Assistant (CNA) #2 verbally abused him/her. Review of Resident #143's care plan revealed there was no care plan for resident behaviors and intervention of two staff to assist the resident at all times. Review of the Nurse Aide's Information Sheet revealed the resident was to be a two person assist at all times beginning (MONTH) (YEAR). There was no documentation on why the resident required a two person assist at all times. In an interview with the surveyor on 3/27/19 at approximately 3:00 PM, CNA #3 stated s/he responded to Resident #143's call light with CNA #2 because Resident #143 will sometimes say things that are not true. In an interview with the surveyor on 3/27/19 at approximately 4:40 PM, CNA #2 stated Resident #143 had made allegations against other staff so staff was instructed to work two at all times with the resident prior to the 11/15/18 alleged incident. In an interview with the surveyor on 3/27/19 at approximately 5:35 PM, the Assistant Director of Nursing (ADON) stated Resident #143 was usually alert and oriented, but had a little confusion at times. Resident #143 usually wants staff to drop what they are doing and take care of him/her. If they don't, the resident will start complaining and get mad at staff. Resident #143 will cry and tell the nurse that s/he was not changed. The ADON stated they have in place that two staff go in to provide care. In an interview with the surveyor on 3/27/19 at approximately 5:55 PM, the ADON stated two assist at all times started in (MONTH) (YEAR) and provided the Nurse Aide's Information Sheet to the surveyor. The ADON reviewed Resident #143's care plan to show where two staff need to work with the resident and confirmed the care plan did not contain the information. The ADON stated s/he would expect the care plan to reflect that two staff assist with Resident #143 at all times.",2020-09-01
572,BAYVIEW MANOR,425067,11 TODD DRIVE,BEAUFORT,SC,29901,2019-03-27,689,D,0,1,L46011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to implement interventions per the resident's care plan for 1 of 2 residents reviewed for accidents. Resident #103 was not transferred per the care plan. The findings included: The facility admitted Resident #103 with [DIAGNOSES REDACTED]. Observation of Resident #103 on 03/12/19 at 2:50 PM revealed bruising under the resident's right eye and cheek. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] on 03/13/2019 at approximately 12:42 PM revealed under Section G - Functional Status, B (transfer) that Resident #103 required extensive assistance and two person physical assist for support. Review of the care plan for Resident #103, on 3/13/2019 at approximately 1:00 PM revealed an intervention for transfers included two person physical assist. Review of Situation, Background, Assessment, Recommendation (SBAR) on 3/7/2019 at approximately 1:45 PM revealed that Resident #103 was transferred by one person physical assist. Interview with the Director of Nursing on 03/13/2019 at approximately 1:15 PM verified staff used one person physical assist instead of two as per the resident's plan of care.",2020-09-01
573,BAYVIEW MANOR,425067,11 TODD DRIVE,BEAUFORT,SC,29901,2019-03-27,693,D,0,1,L46011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to change peg tube site dressings as ordered for 1 of 1 resident observed for peg tube dressing change (Resident #157). The findings included: The facility admitted Resident #157 with [DIAGNOSES REDACTED]. On 03-13-19 at 11:56 AM during an observation of a peg tube site dressing change for Resident #157, the soiled dressing was dated 03-11-19. During an interview on 03-13-19 at approximately 12:05 PM Registered Nurse #1 confirmed that the soiled dressing was dated 03-11-19. Record Review of the Treatment Administration Record on 03-13-19 at approximately 12:30 PM revealed an order to, Change dressing to Peg Tube once daily. Further review revealed that the 03-12-19 dressing change was signed off/initialed as having been completed. During an interview on 03-13-19 at approximately 02:28 PM, the Director of Nursing confirmed that the peg site dressing change had been signed off on 03-12-19 as having been completed.",2020-09-01
574,BAYVIEW MANOR,425067,11 TODD DRIVE,BEAUFORT,SC,29901,2019-03-27,812,D,0,1,L46011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure the Nutrition Kitchen (D Hall/Wing) that was used for residents had a microwave that was free from rusted areas on the inside top of the microwave, the small refrigerator had a heavy ice build up in the freezer part of refrigerator, the temperature gauge was stored in freezer part with heavy ice build up and an expired nutrition drink dated ,[DATE] was noted in the refrigerator (1 of 4 Nutrition Kitchens observed). The findings included: A random observation on [DATE] at approximately 9 AM of the Nutrition Kitchen on the D Hall/Wing revealed a microwave noted with two rusted areas on the inside top of the microwave. The white coating on the microwave was gone and the metal was noted to be rusted. There was a heavy build up of ice in the freezer part of the small refrigerator used for residents with no observed temperature gauge. There was a nutrition drink noted with an expiration drink of ,[DATE]. An observation and interviews on [DATE] at approximately 9:11 AM with Maintenance Staff #1 and Licensed Practical Nurse (LPN) #1 confirmed these findings. Maintenance Staff #1 stated there was a temperature gauge in the refrigerator and then located the temperature gauge in the freezer part of small refrigerator with the heavy ice build up. LPN #1 stated, I looked in the refrigerator on yesterday and that nutrition drink was not in there. LPN #1 further stated that no one informed him/her of the rusted area on the inside of the microwave.",2020-09-01
575,BAYVIEW MANOR,425067,11 TODD DRIVE,BEAUFORT,SC,29901,2019-09-26,609,D,1,0,O9M911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview the facility failed to report an allegation of Abuse or Neglect to the state agency within the required timeframe. The findings included: The facility admitted Resident #84 with [DIAGNOSES REDACTED]. The facility admitted Resident #80 with [DIAGNOSES REDACTED]. Record review on 09/25/19 at approximately 11:30 AM revealed an altercation between Resident #84 to Resident #80 occurred on 06/01/19. The fax cover sheet revealed the report was received on 06/02/19 from a business line. In an interview on 09/25/19 at approximately 1:04 PM, the Administrator confirmed the incident occurred on Saturday, 06/01/19 and the report was submitted to the State Agency on Sunday, 06/02/19 from a business line belonging to him/her.",2020-09-01
576,BAYVIEW MANOR,425067,11 TODD DRIVE,BEAUFORT,SC,29901,2016-11-11,253,E,0,1,695M11,"Based on interview, random observations of resident rooms,observation with the Maintenance Supervisor, review of the facility audit for Unit A and the facility's Daily Room Cleaning Procedures, services were not provided as necessary to maintain a sanitary, orderly and comfortable interior for 4 of 4 units observed. The findings included: During random observations of rooms on 11/7/16 and 11/8/16 and during environmental rounds with the Maintenance Supervisor on 11/11/16, the following was observed. Unit A Room 1P-resident restroom flooring appeared dirty and a brown buildup was noted around the edges of the restroom door facing; Room 2W-restroom doors with damage and wall damage observed around air conditioner unit; Room 10L-damage to wall at head of bed, restroom wall damage behind toilet, floor appeared dirty and brown buildup was observed around the edges of the restroom door facing; Room 12D-restroom door with damage; Room 19D-wall damage observed behind headboard, room door and restroom doors with damage observed; Room 20D-drywall peeling behind toilet in restroom; Room 21D-brown buildup around edges of the restroom door facing. Unit B Room 4D/W-buildup noted in corners of restroom and around toilet. Unit C Room 8W-bedside table observed with scuffs and rust noted on the handles of the commode chair; Room 14W-wardrobe edges observed worn; Room 28W-molding coming away from wall near television, restroom door facing scuffed, buildup of brown substance observed around restroom door facing. Unit D Room 8P-missing panel on blind and table with rough edges; Room 13P-portion of closet door missing and sink vanity faded and worn. On 11/11/16 at approximately 4:00 PM, environmental rounds were made with the Maintenance Supervisor. The above items were observed. At that time, he/she stated monthly rounds were made. He/she continued by stating Unit A had been audited and a list had been made of repairs. On 11/11/16 at 4:26 PM, the Maintenance Supervisor presented the surveyor with the A Wing audit with a date of 8/2/16. Review of the audit revealed damaged restroom doors to Room 2 and Room 12 bath wall needed repair which had been identified by the survey team. There was no time frame presented as to when the repairs for these two rooms would be conducted. A daily room cleaning procedures form was presented which states under #7 the following: Dust mop floors with dust mop. Check corners for built up dust or dirt.",2020-09-01
577,BAYVIEW MANOR,425067,11 TODD DRIVE,BEAUFORT,SC,29901,2016-11-11,280,D,0,1,695M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to update the care plan to reflect adjustments in interventions related to both the changes in the status of an inherited sacral pressure ulcer and the identification of an acquired pressure ulcer behind the right ear for 1 of 4 sampled residents reviewed for pressure ulcers. Resident #166 ' s care plan was not reviewed/ revised to include changes in interventions when stage 2 pressure ulcer on sacrum was first determined to be healed on 8/30/16 and then later identified to be re-opened on sacrum and classified as an unstageable pressure ulcer due to slough on 10/15/16. Resident #166 ' s care plan was also not reviewed/ revised with interventions to address newly acquired stage 3 pressure ulcer behind right ear identified on 9/10/16. The Findings Included The facility admitted Resident #166 with [DIAGNOSES REDACTED]. Review of Wound Assessment Reports provided by MDS (Minimum Data Set) Coordinator on 11/10/2016 at 4:45 PM, revealed that Resident #166 was admitted on [DATE] with multiple pressure ulcers including, but not limited to a stage 2 sacral pressure ulcer. Weekly update of Wound Assessment Report for sacral pressure ulcer completed on 8/30/2016 revealed on page 3 of 4 that Sacral wound has completely closed, edges are not distinct. Area has resolved. Discontinue treatment. Further review of Wound Assessment Report dated 10/15/16, revealed a New Wound Assessment for unstageable due to slough type pressure ulcer on sacrum, further identified as area when (where) previous wound had healed on 8/31/16 (8/30/16). Further review of New Wound Assessment Report completed on 9/13/2016 provided by MDS Coordinator on 11/10/2016 at 4:46 PM revealed that Resident #166 acquired a new area of skin breakdown originally identified on 9/10/16 as an abrasion behind the base of her/his right ear. Review of Weekly Wound Report completed on 9/20/16 reclassifies the area of skin breakdown behind the base of her/his right ear as a stage 3 pressure ulcer which was a former abrasion. Subsequent Weekly Wound Reports completed on 9/27/16, 10/4/16, 10/11/16, 10/18/16, 10/25/16, and 11/4/16 reflect that Resident #166 has had a stage 3 pressure ulcer present behind her/his right ear with ongoing treatment regimen in progress. Review of Resident #166 ' s care plan revealed a problem statement of Altered skin integrity related to Stage 2 to sacrum initiated on 9/6/2016, though the wound had been documented as being completely closed, .Area has resolved . on the Weekly Wound Report completed on 8/30/2016. Further review of this care plan revealed that it had not been updated to address any changes in problem statement or interventions since the onset date of 9/6/16, although the resolved sacral pressure ulcer had re-opened and was identified as an unstageable pressure ulcer due to slough on the New Wound Assessment completed on 10/15/2016. Further review of Resident #166 ' s comprehensive care plan initiated on 9/6/2016 revealed that it had not been reviewed or revised with interventions since onset date despite identification of newly acquired pressure ulcer behind right ear on 9/10/16 with treatments ordered and risk for complications. During an interview on 11/11/16 at 9:35 AM, the MDS Coordinator verified that the care plan to address the stage 2 sacral pressure ulcer for Resident #166 was initiated on 9/6/16, although the Weekly Update of the Wound Assessment Report identified the wound as being completely closed .area has resolved on 8/30/2016. The MDS Coordinator also verified that although Resident #166 had a re-opened sacral pressure ulcer which was identified on 10/15/16 and staged as an unstageable pressure ulcer due to slough, the care plan initiated on 9/6/16 had not been updated since onset date to reflect any changes in sacral pressure wound status or update interventions to prevent further deterioration and minimize risk for complications. The MDS Coordinator also verified that the care plan for Resident #166 had not been updated with interventions to address the acquired pressure ulcer behind right ear which was identified originally on 9/10/16 as an abrasion and then reclassified as a stage 3 pressure ulcer on 9/20/2016.",2020-09-01
578,BAYVIEW MANOR,425067,11 TODD DRIVE,BEAUFORT,SC,29901,2016-11-11,282,D,0,1,695M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observations, the facility failed to provide care in accordance with the care plan for 1 of 3 residents reviewed for accidents. Staff failed to provide a fall mat as care planned for Resident #182. The findings included: The facility admitted Resident #182 with [DIAGNOSES REDACTED]. Review of the medical record indicated Resident #182 was hospitalized prior to admission to the facility related to a series of falls with fractures. Review of the (MONTH) (YEAR) physician's orders [REDACTED]. Review of the care plan with review date of 10/28/16 revealed risk for falls was identified as a problem area. Interventions to address this area included fall mat to floor. Review of the Nurse Aide's Information Sheet indicated fall mat to floor when in bed was documented in the comments section of the form. Review of the Daily Skilled Nurses Notes dated 11/09/16 indicated Resident #182 received therapy related to unsteady gait. The notation further indicated the resident had a history of [REDACTED]. The notation dated 11/10/16 indicated the same. Observation on 11/10/16 at approximately 2:15 PM revealed Resident #182 was not in the bed; however, no fall mat was observed in the room. Observation on 11/11/16 at approximately 1:45 PM also revealed no fall mat was observed in the room. Observation on 11/11/16 at approximately 1:50 PM with Certified Nurses Aide (CNA) #2 revealed the same finding. When asked about a fall mat for the floor, CNA #2 stated that Resident #182 did not have a fall mat, and stated that the resident had never had a fall mat.",2020-09-01
579,BAYVIEW MANOR,425067,11 TODD DRIVE,BEAUFORT,SC,29901,2016-11-11,314,D,0,1,695M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interview and review of the facility policy titled Dressings, Dry/Clean, the facility did not provide the necessary care and treatment to promote healing and to prevent infections for two of four residents observed with pressure ulcers. During pressure ulcer treatment on Resident #41 and #153, the licensed staff member was observed to swipe down and through the residents' wound bed. The findings included: The facility admitted Resident #41 with [DIAGNOSES REDACTED]. During pressure ulcer treatment on 11/9/16 at 11:20 AM, Licensed Practical Nurse(LPN) #3, was observed during the cleaning of the wound to use gauze saturated with wound cleanser and swipe down the entire wound bed. He/she continued by using more gauze saturated with wound cleanser and wiped in a circular motion around the outside of the wound. The facility admitted Resident #153 with [DIAGNOSES REDACTED]. During pressure ulcer observation on 11/9/16 at 9:45 AM, LPN #3 was observed during the cleaning of the wound to cleanse across the wound bed using gauze saturated with wound cleanser. He/she continued to cleanse around the the outside of the wound using more gauze saturated with wound cleanser. Review of the facility policy titled Dressings, Dry/Clean revealed under the Steps in the Procedure the following: 16. Cleanse the wound. Use a syringe to irrigate the wound, if ordered. If using gauze, use a clean gauze for each cleansing stroke. Clean from the least contaminated area to the most contaminated area(usually, from the center outward). During an interview with LPN #3 on 11/11/16, he/she stated prior to performing the wound care, he/she inquired about the cleaning of the wound and it was his/her understanding he/she could cleanse the residents' wound as observed.",2020-09-01
580,BAYVIEW MANOR,425067,11 TODD DRIVE,BEAUFORT,SC,29901,2016-11-11,323,D,0,1,695M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and observations, the facility failed to provide the care and services necessary to prevent accidents for 1 of 3 residents reviewed for accidents. The facility failed to provide a fall mat as ordered for Resident #182. The findings included: The facility admitted Resident #182 with [DIAGNOSES REDACTED]. Review of the medical record indicated Resident #182 was hospitalized prior to admission to the facility related to a series of falls with fractures. Review of the (MONTH) (YEAR) physician's orders [REDACTED]. Review of the care plan with review date of 10/28/16 revealed risk for falls was identified as a problem area. Interventions to address this area included a fall mat to the floor. Review of the Nurse Aide's Information Sheet indicated the resident was to have a fall mat to floor when in bed. Review of the Daily Skilled Nurses Notes dated 11/09/16 indicated Resident #182 received therapy related to unsteady gait. The notation further indicated the resident had a history of [REDACTED]. The notation dated 11/10/16 indicated the same. Observation on 11/10/16 at approximately 2:15 PM revealed Resident #182 was not in the bed; however, no fall mat was observed in the room. Observation on 11/11/16 at approximately 1:45 PM also revealed no fall mat was observed in the room. Observation on 11/11/16 at approximately 1:50 PM with Certified Nurses Aide (CNA) #2 revealed the same finding. When asked about a fall mat for the floor, CNA #2 stated that Resident #182 did not have a fall mat, and stated that the resident had never had a fall mat. On the final day of the survey, after completing the observations and interview with CNA #2, the unit nurse manager informed the surveyor that staff called the resident's physician and received an order to discontinue the fall mat. The nurse manager stated that the resident had improved with his/her mobility. Review of the Daily Skilled Nurses Notes dated 11/11/16 revealed, A clarification order received to d/c fall mat next to bed wib (when in bed) r/t resident shows improvement with (his/her) mobility. He/she continues (with) safety unawareness and unsteady gait .",2020-09-01
581,BAYVIEW MANOR,425067,11 TODD DRIVE,BEAUFORT,SC,29901,2016-11-11,371,F,0,1,695M11,"Based on observations, interviews and review of the facility policies titled Dry Storage, Label and Dating and Cold Food Storage, the facility failed to follow proper sanitation and food handling practices in 1 of 1 kitchen reviewed. This has a potential for affecting all residents with prescribed therapeutic diets. The findings included: During the initial tour of the kitchen on 11/7/16 at 11:23 AM, two plate covers, stored on a rack were noted with food particles. In addition the plate covers were noted damaged. The Dietary Manager stated if plate covers were too damaged the covers would be discarded. At the time of the observation, the Dietary Manager removed the rack so the plate covers could be sanitized The Assistant Dietary Manager was observed without a hair restraint. On 11/9/16 at approximately 4:11 PM, Dietary Aide #1 was observed with a hair restraint which did not capture all of Dietary Aide's #1 hair. Observation of the dry storage area along with the Assistant Dietary Manager on 11/9/16 at 4:19 PM revealed the following: (1) Nonfat Dry Milk Crystals opened with no date; (1) package of macaroni Noodles opened with no date and not sealed completely; (1) 6 pound 10 ounce dented can of spaghetti sauce; (2) 8 pack hotdog bun packages opened no date; (1) loaf of bread opened with no date; (1) 1 pound jar of chicken base paste open not dated; (1) 5 pound container of black pepper open not dated with an area that was matted as if moisture had entered the container. At the time of the observation, the Assistant Dietary Manager removed the items identified. Plate covers stored on a rack were observed with food particles. Dust was observed on the vent of the ice machine. Observation of the walk-in cooler revealed the following: (5) salad packages with a best buy date of 11/7/16; (1) salad package dated 11/6/16 ; (1) cole slaw package with use thru date of 10/26/16. Items were removed by the Dietary Manager. During the temping of the line on 11/9/16 at approximately 5:00 PM, Dietary Aide #2 was observed to drop the thermometer into the mashed potatoes and after wiping the thermometer continued to take the food temperatures. Dietary Aide #1 came to the line and removed the mashed potatoes. Dietary Aide #2 was asked why the mashed potatoes were removed and he/she stated they did not know. On 11/11/16 at 9:53 AM, the ice machine again was observed with dust on the vent. A sign on the machine stated to clean every two months. During an interview with the Dietary Manager at that time, he/she stated there was no documentation when the staff cleaned the vent. Review of the facility policy titled Dry Storage revealed under the Procedure section the following: 4. Leaking or severely dented cans and spoiled foods should be disposed of promptly to prevent contamination of other foods. Review of the facility policy titled Label and Dating revealed under the Procedure section the following: 1. All items will be labeled with item name and date of preparation, and USE BY date. The USE BY date for perishable items is today's date plus three days or less. Review of the facility policy titled Cold Food Storage revealed under the Procedure section the following: 3. All other items in coolers and freezers will be used or discarded before any manufacturer's listed expiration, use by, or freeze by dates .",2020-09-01
582,BAYVIEW MANOR,425067,11 TODD DRIVE,BEAUFORT,SC,29901,2016-11-11,425,D,0,1,695M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the pharmacy failed to provide timely delivery of a medication to resident #189 who was readmitted to facility on 10/25/2016 with [DIAGNOSES REDACTED]. The findings include: During Medication Pass Observation on 11/7/2016 at approximately 2:00 pm LPN (Licensed Practical Nurse) #1 attempted to administer Depakote Sprinkles 125 mg (milligram) capsules (6 capsules) to Resident #189 and discovered that there was none available. LPN #1 stated that s/he has been trying to get this medication delivered since this morning. The ADON (Assistant Director of Nursing) checked the emergency medication stock at approximately 2:00 pm and reported that the medication is not included in the emergency stock. On 11/7/2016 at approximately 2:05 pm, LPN #1 called the physician and asked the physician if the medication could be held because it was not available at that time from the pharmacy. The physician declined to hold medication stating that s/he was concerned about the resident having a grand mal seizure if s/he did not receive his seizure medication. The LPN #1 at approximately 2:10 pm on 11/7/2016 called the pharmacy asking when the Depakote Sprinkles would be arriving for Resident #189. LPN #1 then stated that the pharmacy staff s/he had spoken to on the telephone had instructed her/him to check cart again and LPN #1 checked both medication carts on B wing and was unable to locate the medication. On 11/7/2015 at 2:20 pm, Medication reconciliation was completed and all scheduled medications administered correctly with exception of Depakote Sprinkles 125 mg capsules (6 capsules to equal 750 mg). During interview on 11/8/2016 at approximately 9:00 am, LPN #1 stated that the medication Depakote Sprinkles 125 mg capsules (#6) had been found and administered at approximately 4:30 pm on 11/7/2016. During interview with Director of Nursing (DON) 11/8/16 at 1:15 pm, s/he stated that LPN #1 reported s/he borrowed the medication (Depakote sprinkles) from another resident for the late dose of Depakote Sprinkles given at 4:30 pm; however, did not document the event correctly. Staff education completed (Teachable moment) by DON on 11/8/16 at 1:00 pm with LPN #1. During interview with Corporate Clinical Consultant on 11/8/16 at approximately 2:30 pm, s/he verified that the pharmacy contract states that the facility will receive deliveries twice daily Monday through Friday, and when asked what the two times that pharmacy delivered medications on 11/7/16. S/he reported that pharmacy made one delivery on Monday 11/7/16 which was the delivery at approximately 9:00 pm; s/he further stated that s/he discussed the matter with the pharmacy management. Corporate Clinical Consultant reported during interview on 11/9/2016 at approximately 11:30 am, that a miscommunication occurred between the main pharmacy and the back-up pharmacy regarding need for medication on 11/7/2016 between approximately 10:00 am and 9:01 pm.",2020-09-01
583,BAYVIEW MANOR,425067,11 TODD DRIVE,BEAUFORT,SC,29901,2016-11-11,441,F,0,1,695M11,"Based on interview, observation, review of Safety Data Sheets, and facility polices titled Soiled Laundry and Using Gloves, the facility failed to maintain an Infection Control Program designed to provide a safe and sanitary environment and to help prevent the development and transmission of disease and infection. During observation of the Laundry, soiled items were not contained in bags upon delivery to the laundry, two clean laundry carts were stored in the soiled side with the washers During the loading of the washer, soiled items were observed touching the outside of the machine. Housekeeping staff was observed not utilizing infection control procedures. In addition, after pressure ulcer treatment, staff was observed to gather trash and exit room without washing hands. Two observations of the biohazard barrels filled and unable to close completely. The findings included: During observation of the laundry on 11/9/16 at 2:00 PM, Housekeeping staff member #3 was observed sorting the laundry. Multiple items were noted delivered to the laundry but not contained in bags. During the sorting, Housekeeping staff member #3 stated when items were sent to laundry they should be bagged. Upon entering the wash room, two clean containers were observed in the entryway. During the transfer of soiled items to the washer, the clean containers were in close proximity. During an interview with Housekeeping staff member #3 at that time, he/she stated the clean carts were to be stored in the room with the dryers and he/she did not know who had put them on the soiled side. After donning personal protective equipment(PPE), he/she wiped down the carts with Air Lift and placed the carts on the clean side of the laundry. During the loading of the washer machines, several soiled items were observed brushing against the machine. After removing the PPE and washing his/her hands, Housekeeping staff member #3 closed the washer door and started the machine using his/her bare hands. At that time, Housekeeping Member #3 was asked if he/she was through and he/she stated yes. Housekeeping staff member #3 was asked when the washers were sanitized and he/she stated the washer would be wiped down now and after the wash was finished the inside of the machine would be cleaned. No sanitizer was available in the laundry and Housekeeping Member #3 left the laundry to obtain a sanitizing agent. After obtaining Citrus Shine, the outside of the machine was sanitized. Upon leaving out of the washer room, Housekeeping Member #2 , with his/her bare hand, removed the soiled cloth out of Housekeeping Member #3's gloved hand . At the time of the observation, Housekeeping Staff Member #3 informed the staff member he/she could not do that and he she needed to wash his/her hands. Housekeeping Member #1 pushed his/her housekeeping cart into the hallway near the sorting area and upon entering spilled contents of his/her mop bucket. After obtaining a cloth, Housekeeping Member #1 wiped the spill. No gloves were donned and no handwashing was observed immediately after the spill was wiped up. After performing pressure ulcer care and applying an Allevyn dressing to Resident #153's site on 11/9/16 at 9:45 AM, Licensed Practical Nurse(LPN)#3, removed his/her gloves, washed hands, donned gloves, collected trash in a red bag, removed gloves and gown and exited the room without washing hands after removal of PPE. At the time of the observation, Resident #153 was on contact precautions related to Clostridium Difficile. After performing pressure ulcer care and applying an Allevyn dressing to Resident 41's site on 11/9/16 at 11:20 AM, Licensed Practical Nurse(LPN)#3 removed his/her gloves, gathered the trash and exited the room without washing his/her hands. On arrival to the soiled utility room on the J Wing, LPN #3 obtained the key to the room, unlocked the door and placed the contents into the biohazard barrel. At the time of the observation, the biohazard barrel was full and would not close completely. On 11/11/16, observations of not washing his/her hands after gathering trash was shared with LPN #3. Observation of the C Hall soiled utility room on 11/11/16 at approximately 11:00 AM revealed the biohazard container was filled and would not completely close. Review of the Safety Data Sheet on 11/11/16 for Airlift revealed the recommended use was as an air freshener. Review of the Safety Data Sheet for Citra-Shine revealed the recommended use was for a General purpose cleaner. Review of the facility policy titled Soiled Laundry revealed the following: 1. Routine handling of Soiled Linen- b. All soiled linen should be bagged or put into carts at the location where it was used; it should not be sorted or prerinsed in resident-care areas. Review of the facility policy titled Using Gloves revealed the following: Gloves should be used:4. When cleaning potentially contaminated items; and 5. Whenever in doubt.",2020-09-01
584,BAYVIEW MANOR,425067,11 TODD DRIVE,BEAUFORT,SC,29901,2016-11-11,463,D,0,1,695M11,"Based on observation and interview, the facility failed to ensure each resident's restroom was equipped with a functioning callbell system for 2 of 40 rooms reviewed. The findings included: During room observation on 11/8/16, the callbell was tested in Resident #27's restroom and was discovered nonfunctional. At the time of the observation, Licensed Practical Nurse(LPN)#3 was asked to test the callbell and confirmed the callbell did not work and would contact maintenance to repair the callbell. During room observation on 11/8/16, the callbell was tested in Resident #105's restroom and was discovered nonfunctional. During rounds with the Maintenance Director on 11/11/16, he/she tested the callbell and confirmed the callbell was not working.",2020-09-01
585,WHITE OAK MANOR - COLUMBIA,425068,3001 BEECHAVEN ROAD,COLUMBIA,SC,29204,2017-04-13,241,E,0,1,TZYH11,"Based on observation, interview and review of the facility policy titled Points to Remember in Respecting Dignity, the facility failed to promote dignity of the residents when entering resident rooms for 1 of 4 sampled residents reviewed for dignity. For Resident #137, staff failed to await permission to enter the rooms after knocking. In addition, the facility failed to promote dignity during the dining experience in 3 of 3 dining rooms. Residents were served on trays in the social dining room. The findings included: While the surveyor was conducting a resident interview on 4/12/17 at 1:40 PM, Laundry Aide #1 knocked on the resident's door and entered without awaiting permission. Resident #137 stated, Please do not enter the room. Laundry Aide #1 continued to enter the room and placed two pieces of laundry on the bed and then described the two pieces of laundry to Resident #137. After Laundry Aide #1 left the room, Resident #137 said to the surveyor, I did not want the staff member in the room during the interview. During an interview on 4/13/17 at 3:41 PM, the Director of Laundry stated that the expectation for correct room entry procedure was to Knock on the resident's door three times, state who you are and why you are in the room and then enter the room. An interview was conducted on 4/13/2017 at 3:50 PM with the Director of Nursing (DON) regarding expectations for employees entering resident rooms. The DON said the employee should knock and announce who they are. Further, the DON stated if the employee needed to provide care to another resident in the room, s/he believed that the employee did the right thing. The facility policy titled Points to Remember in Respecting Dignity #2 states, Before entering a room, knock on the resident's door, give your name, ask permission to enter, pause briefly, and then go into room. During initial tour on 4/10/17 at 11:45 AM and 12:00 PM, trays were served to residents in the social and 200 hall dining rooms. However, the plates, flatware, and glassware were not removed from the trays. The staff did not offer to remove the items. During an interview on 04/13/2017 at 4:49 PM the Director of Dietary said, s/he said the CNA should take the plates and flatware off the tray, but some residents may state preference for the dishes and flatware to remain on the tray during meal service. During a dining observation of the Social Dining Room at 11:37 a.m. on 4-10-17, all residents' plates were noted to remain on the serving trays throughout the dining experience. No efforts were made to remove them. During an interview on 4-12-17 at 12:08 p.m., the Health Information Manager explained the process for the dining experience, to include staff removing the residents' meals from the serving tray.",2020-09-01
586,WHITE OAK MANOR - COLUMBIA,425068,3001 BEECHAVEN ROAD,COLUMBIA,SC,29204,2017-04-13,253,E,0,1,TZYH11,"Based on observations, interviews, and review of the facility's policies entitled Housekeeping/Laundry and Maintenance, the facility did not ensure housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior to Unit 100 and Unit 200. Resident rooms are in need of repairs and identified resident bathrooms in need of additional cleaning were identified in various areas of the units where residents reside. The findings included: Observations of the facility on 4/10-4/13/17 throughout various times revealed the following: Unit 100 Room 103: Bedroom floor corners and edges with buildup. Bathroom brown substance around and behind the toilet. Bed A footboard is missing Room 110: Bedroom (bed b) the light is not working. Bathroom tiles are heavy soiled Room 114: Bathroom vent with heavy dust build up Unit 200 Room 202 Bathroom vent with heavy dust build up. Room 203: Bedroom chipped paint on the edge of the window. Bathroom vent had dust build up. Room 204: Bedroom closet drawer for Bed C off the hinge. Light Bed D is dim. Bathroom railing is loose. Room 206: Bathroom baseboards in the bathroom are brown and exhaust fan not working. Room 210: Bed pan uncovered on the bathroom floor Room 211: Bedroom electrical plate for the phone connection coming out of the wall. Chair arms in the room are damaged. Bathroom trash on the floor and stained tiles Room 216: Bedroom chair in the room seat is torn Room 220: Bedroom rust on the vent near the window During Stage 2 of the survey on 04/13/2017 at 1:15PM, the Housekeeping Director and Maintenance Director toured with the surveyor to observe and confirm the concerns that were identified throughout the facility. An interview with the Maintenance Director revealed he/she was aware of some of the rooms that had concerns. Maintenance Director also stated the exhaust ventilation is located on the outside of the building. In addition the Housekeeping confirmed the concerns as well and stated the linen carts are the nursing staff responsibilities and will be taken care of. In addition the resident's chairs that are in disrepair will be replaced. An observation with Director of Nursing (DON) and Administrator on 4/13/17 at 1:54 PM revealed the unlabeled and uncovered basin on the floor in Room 210. Room 202 with linen cart filled with laundry DON discarded the basin and removed the linen cart. Review of the 3/22/17 resident council minutes on 04/13/2017 3:01:29 PM revealed some residents had concerns about the mop water not being changed enough in their rooms. A review of the policy provided by the facility on 4/12/17 entitled Housekeeping/Laundry revealed under Resident Rooms: resident rooms shall be clean, orderly and well ventilated. All floors shall be cleaned regularly . Under Repair and Replacement: Worn and torn articles are removed for repair or replacement. In addition the Maintenance policy revealed under Maintenance and Repair: lighting level are adequate . The facility is well-ventilated through the use of windows, mechanical ventilation, or a combination of both.",2020-09-01
587,WHITE OAK MANOR - COLUMBIA,425068,3001 BEECHAVEN ROAD,COLUMBIA,SC,29204,2017-04-13,314,D,0,1,TZYH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and review of the facility's policy, Dressing - Non-Sterile, the facility failed to provide treatment as ordered for Resident #121, 1 of 1 resident reviewed for pressure ulcers. The findings included: The facility admitted Resident #121 with [DIAGNOSES REDACTED]. At 11:54 AM on 04/12/2017, review of the Physician's Telephone Orders revealed orders dated 03/27/17 to cleanse the left inner ankle and the right outer ankle with normal saline, apply an Allevyn 3x3 dressing 3 times a week on Monday, Wednesday, and Friday. Another order dated 3/29/17 was noted to cleanse the sacrum with normal saline and apply a [MEDICATION NAME] dressing 3 times a week on Monday, Wednesday, and Friday. At 3:10 PM on 04/12/2017, Licensed Practical Nurse (LPN) #3 was observed providing wound care to Resident #121. During the dressing change to the sacrum, the LPN wiped the right periwound top to bottom 2 times with a skin prep and discarded, then wiped from the top periwound of the wound through the wound bed and down the bottom of the periwound with a second skin prep and finished by wiping the left periwound from the top to the bottom with a third skin prep. The wound was not cleaned as ordered. The LPN proceeded to the wound on the right ankle. Sterile water was applied to 4x4 gauze and the periwound was wiped from the top edge of the wound bed upward, from the bottom edge of the wound bed downward and the posterior periwound top to bottom using a clean gauze with each wipe. The LPN then removed her/his gloves, sanitized her/his hands, and donned clean gloves and repeated with skin prep wipes. The LPN then applied the Allevyn dressing as ordered. The wound bed and the anterior periwound was not cleaned. At 3:46 PM on 04/12/2017, LPN # 3 confirmed s/he did not clean the sacral wound bed. The nurse further confirmed s/he did not clean the wound bed of the wound on the right ankle and only the top, bottom, and posterior periwound but not the anterior periwound. At 3:54 PM on 04/12/2017, review of the policy entitled Dressing - Non-Sterile revealed 9. Open sterile dressings. Pour prescribed cleaning solutions over needed number of clean (for wound cleaning) and sterile (for wound dressing) gauze pads.11. Clean wound gently but thoroughly with prepared gauze pads. Clean from top to bottom and from center outward. Use a separate gauze pad for each stroke.",2020-09-01
588,WHITE OAK MANOR - COLUMBIA,425068,3001 BEECHAVEN ROAD,COLUMBIA,SC,29204,2017-04-13,514,D,0,1,TZYH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to maintain resident medical records that are complete and accurately documented for 1 of 2 sampled residents reviewed for notification. Resident #95 had a change in treatment orders on the bottom of the right foot, acquired a stage III pressure area on the left elbow, ran a fever overnight and was given a rapid flu test related to cough and fever. There was no documentation in the clinical record that the responsible party was notified at the time of any of these issues. The findings included: The facility admitted Resident #95 with [DIAGNOSES REDACTED]. Review of the Pressure Ulcer Report on 04/12/2017 at 3:32 PM revealed an entry on 3/8/17 that Resident #95 acquired a stage III pressure ulcer on the left elbow. A Physician's Order was noted on 3/8/17 to Cleanse area left (L) (Left) elbow with N/S (Normal Saline) -Apply Allevyn 3 x 3 3 x (times) weekly (RT) related to Pressure. There was no evidence of family notification of the new pressure area and treatment in the medical record. Record review revealed a 2/6/17 Physician's Order to Clean area on Right bottom foot with NS (Normal Saline). Pat dry. Applied (sic) Xeroform & wrap with Kerlix daily. Another Physician's Order dated 2/7/17 read to: 1) D/C (Discontinue) cleanse area right bottom foot (with) N/S. Pat dry. Apply Xeroform, wrap with Kerlix QD (every day) r/t tx (treatment) change. 2) Skin Prep Apply to area bottom of (R) (Right) foot Q (every) shift RT pressure. There was no evidence of family notification in the medical record of the new treatments. Review of Nurse's Notes at approximately 3:45 PM on 4/12/2017 revealed an entry on 1/13/17 at 6:41 am: Resident has run fever throughout the night. According to pm (7 PM to 7 AM) nurse, he (she) ran fever on that shift also. Temp-101.1 at the beginning of the shift. Resident was medicated with Tylenol 325 mg (milligrams) (2) po (by mouth). Resident's temp came down to 100.5 . A Nurses's Note dated 1/13/2017 at 2:42 PM read: Resident running temp of 101.6. Given Tylenol at 12:22 PM. Recheck temp after 1 hour 101.6 . A Nurse's Note dated 1/4/2017 at 11:30 AM: Medication Follow-up-(Rapid Flu test x 1 r/t Fever.) Negative results. There was no evidence of family notification in the medical record of the change in the resident's condition. Review of Physician's Orders and Nurses Notes revealed that on 1/14/17 Resident #95 received a Rapid Flu test x 1 related to cough and fever. A Nurse's Note dated 1/14/2017 at 11:30 AM stated: Medication Follow-up-(Rapid Flu test x1 r/t Fever.) Negative results 1/14/2017. There was no evidence of family notification in the medical record. During an interview on 04/13/2017 at 8:39 AM regarding notification Licensed Practical Nurse (LPN) #1 stated; I notify everything about the resident in the Nurses Notes; if I call family members, if I do treatments or a resident has a new drug, I notify my supervisor. I also put it on the 24 hour report at the desk. I put everything in Nurse's Notes. During an interview on 04/13/2017 at 8:59 AM LPN #4 stated, I notify the RP (Responsible Party) and then I document in the COMS system (electronic record) in Nurse's Notes. I will also tell the supervisor who places it on the 24 hour report and usually the supervisor is the one who does the order and they also place it on the shift report. During an interview on 04/13/2017 at 9:30 AM the Director of Nurses (DON) stated, Regarding the 24 hour report, RP (Responsible Party) notifications are not placed on 24 hour report. The DON reviewed the Nurse's Notes and confirmed there was no evidence of family notification for changes in resident conditions and new Physician's Orders for treatments and diagnostic tests. During an interview on 4/13/17 at approximately 3:30 PM, LPN #6 stated, in the presence of the DON, that the resident's wife was visiting frequently at that time and was aware of the fever. The nurse further stated that s/he did not document this in Nurse's Notes. The DON reported that the treatment nurse at the time of the Pressure ulcer development stated that the wife was present in the room while s/he was doing the treatment but s/he did not make a Nurse's Note about the notification. Review of the facility policy on 4/13/17 at approximately 11:00 AM titled, Acute Episode Documentation stated: Acute episode documentation is to be instituted immediately upon any change noted in the resident's physical, mental or emotional status. Detailed documentation is to be entered in nurses notes each shift until the acute episode is resolved or stabilized. Physician and resident's family/responsible party are to be notified of any acute episode and/or change in the resident's status.",2020-09-01
589,WHITE OAK MANOR - COLUMBIA,425068,3001 BEECHAVEN ROAD,COLUMBIA,SC,29204,2017-10-30,280,D,1,0,N14311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to update care plans for 2 of 3 residents with recurrent Urinary Tract Infections [MEDICAL CONDITION]. Resident #1 and #2 with histories of UTIs care plans did not reflect the episodes of infections. The findings included: The facility admitted resident #1 with [DIAGNOSES REDACTED]. Review of the current Care Plan revealed a plan originally dated for 10/24/16- Always incontinent of urine due to urge incontinence. A goal of: Will not experience infections from incontinence. (No care plan for recurrent UTIs.) Review of the medical record revealed physician's orders [REDACTED]. 5/17/17 -Cipro 250 milligrams one bid x 7 days UTI 5/21/17-[MEDICATION NAME] milligrams one bid x 7 days UTI 6/16/17- [MEDICATION NAME] 500 mg twice a day (BID) x 7 days, pending Culture and Sensitivity (C&S) 6/19/17- Bactrim DS, one po BID x 7 days-UTI 7/31/17- Urinalysis (u/a), Culture and Sensitivity (c&s), Dysuria The resident had repeated urinary tract infections. The resident's plan of care was not updated to provide a plan for treatment or prevention of UTI's. The facility admitted resident #2 with [DIAGNOSES REDACTED]. Review of the resident's care plan revealed a care plan for frequently incontinent of urine due to history of incontinence. Observe for acute behavioral changes that may indicate UTI, Assess for symptoms of UTI. Although the resident had been admitted with a UTI, the resident's care plan did not address the resident's history of UTI. On 10/30/17 at approximately 4:00 PM The Director of Nursing (DON) was interviewed by the surveyor. The DON reviewed the care plans of resident #1 and #2. Anyone on the Interdisciplinary Team (IDT) can update the care plan. The DON confirmed there was no care plan for the resident's history of UTI. There was no updates of the care plan regarding the residents recurrent UTI's.",2020-09-01
590,MYRTLE BEACH MANOR,425070,"9547 HIGHWAY 17, NORTH",MYRTLE BEACH,SC,29572,2020-02-07,583,D,1,1,NWK011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and interview, the facility failed to provide privacy while administering medications. Eye drops and [MED] were administered without the privacy curtain pulled and/or the door closed for one of one resident receiving eye drops and one of 2 residents receiving an injection.(Resident #4 and Resident #81) The findings included: The facility admitted Resident #4 with [DIAGNOSES REDACTED]. Observation of medication administration on 2/6/20 at 1:30 PM revealed Registered Nurse(RN)#1 did not pull the privacy curtain or close the door during the administration of eye drops. During the administration of the eye drops, Resident #4's roommate and a visitor were observed in the room. The facility admitted Resident #81 with [DIAGNOSES REDACTED]. Observation of medication administration on 2/6/20 at 12:00 PM revealed during the administration of [MED], Licensed Practical Nurse(LPN)#1 did not pull the privacy curtain or close the door. During an interview with LPN #1 on 2/6/20 at 5:00 PM, s/he confirmed privacy was not provided during the administration of [MED]. During an interview with RN #1 on [DATE] at approximately 1:56 PM, s/he confirmed privacy was not provided during the administration of eye drops. No facility policy was provided addressing privacy during administration of medications.",2020-09-01
591,MYRTLE BEACH MANOR,425070,"9547 HIGHWAY 17, NORTH",MYRTLE BEACH,SC,29572,2020-02-07,812,E,1,1,NWK011,"> Based on observation, interview and review of facility policy titled Food Safety, the facility staff failed to handle and store foods in accordance with professional standards in 1 of 1 kitchens and failed to provide a hands free trash can near the hand washing sink in 1 of 2 unit food service areas. The findings included: On [DATE] at approximately 10:10 AM, during initial kitchen tour, accompanied by Food and Beverage Manager the following was observed: a gallon size plastic container of tartar sauce dated [DATE], boxes of produce placed on floor of walk-in cooler, 1/2 full gallon size container of Greek salad dressing with no open date and no expiration date; gallon size container of BBQ sauce open with no date, spillage on container and on two shelves; 32 ounces chopped garlic in oil open with no date; clear plastic storage container with off white flaky substance with no label to indicate contents and no date opened. Also, in the freezer, 2 boxes of food stored on floor, 2 open bags of french fries, 1 package of hush puppies and 1 bag of pepperoni all with no label indicating date opened. The Food and Beverage Manager observed and acknowledged the improperly labeled and stored food items. On [DATE] at approximately 12:00 PM while on the Rehabilitation Unit, the hand washing sink had no hands-free trash can available to dispose of used paper towels. On [DATE]20 at approximately 12:03 PM the Certified Dietary Manager stated the trash can was inside the cabinet of the hand washing sink and confirmed the hands-free trash can was not properly placed next to the hand washing sink. On [DATE]20 at approximately 1:45 PM, review of facility policy titled Food Safety Section IV W. stated that all stored food items require a product identifier/ label and use by date. The facility policy entitled Food Safety in the Receiving and Storage Section B. stated that food must be stored in a manner to allow air circulation around food and that repackaged food will be placed in a leak-proof, pest proof, non-absorbent, sanitary container with a tight fitting lid. The Policy also states that containers will be labeled with the name of the contents and dated when it was transferred to the new container.",2020-09-01
592,MYRTLE BEACH MANOR,425070,"9547 HIGHWAY 17, NORTH",MYRTLE BEACH,SC,29572,2020-02-07,880,D,1,1,NWK011,"> Based on observation, interview, and review of the facility policy titled Hand washing, facility staff during the laundry process failed to wash hands after removal of gloves for one of one laundry observation. In addition, staff failed to wash hands after removal of gloves, during medication administration, for 2 of 4 observations during medication pass when gloves were worn. The findings included: During observation of the laundry process on [DATE]20 at 10:20 AM, Laundry Staff #1 was observed donning gloves to obtain soiled laundry bags and placed them in the laundry cart. After loading the cart, Laundry Staff #1 removed his/her gloves and did not wash his/her hands and continued to the next unit. During observation of medication administration on 2/6/2020 at 1:15 PM, Registered Nurse (RN) #1 was observed discontinuing an intravenous antibiotic from a Resident. RN #1 removed his/her gloves and exited the room without washing his/her hands. During observation of medication administration on 2/6/2020 at 1:30 PM, RN #1 was observed administering eye medication to a Resident, removed his/her gloves, and exited the room without washing his/her hands. During an interview with Laundry Staff #1 on [DATE]20, after the observation, s/he agreed that s/he did not wash his/her hands after removal of gloves. During an interview with RN #1 on [DATE]20 at approximately 1:30 PM, RN#1 stated s/he did not remember if hand washing had been done after the removal of gloves. S/he stated it was his/her practice to perform hand washing after removal of gloves. On [DATE]20 at approximately 3:15 PM, a review of the facility policy titled Hand washing revealed the following under Procedures: Hand washing will be performed before and after applying or administering eye drops or ointment, after gloves are removed, between resident contact, and when otherwise indicated to avoid transfer of microorganisms to other residents.",2020-09-01
593,MYRTLE BEACH MANOR,425070,"9547 HIGHWAY 17, NORTH",MYRTLE BEACH,SC,29572,2017-08-11,157,D,0,1,PD4911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews, and review of the facility policy titled, Resident Condition Changes That Require Physician Notification Guidelines, the facility failed to ensure the responsible party and/or an interested family member was notified of the development of a pressure ulcer for Resident #180 and #203 for 2 of 3 residents reviewed with pressure ulcers. The findings included: The facility admitted Resident #180 with [DIAGNOSES REDACTED]. Review on 8/11/2017 at approximately 2:50 PM of the medical record for Resident #180 revealed Resident #180 was admitted 7 days prior to the development of a stage II pressure area to his/her sacral area. Review on 8/11/2017 at approximately 2:50 PM of the nurses notes for Resident #180 did not include documentation to ensure that the responsible party nor the spouse was notified of the development of a stage II pressure ulcer located on the sacrum of Resident #180. An interview on 8/11/2017 at approximately 3:00 PM with Licensed Practical Nurse (LPN) #2 confirmed that the responsible party/interested family member had not been notified of the development of a stage II pressure area on the sacrum of Resident #180. Review on 8/11/2017 at approximately 3:30 PM of the facility policy titled, Resident Condition Changes That Require Physician Notification Guidelines, states on page 3 under, Expectations, Number 1, Licensed nurses (staff and management) are expected to recognize resident situations/conditions that require physician notification. The nurse shall complete an assessment of the condition, including levels of urgency. The nurse shall implement appropriate interventions and have accurate information available when contacting the physician. Number 4 states, The licensed nurse shall also notify, the Unit Nurse Manager/Nursing Supervisor and the Resident and/or family. Also, Provide appropriate follow-up with staff who do not comply with facility guidelines. The facility admitted Resident #203 with [DIAGNOSES REDACTED]. Record review on 8/10/17 of the Nursing Weekly Wound Progress Review revealed Resident #203 developed a Stage II pressure area on the right heel on 7/17/17. On 7/28/17 documentation on the Nursing Weekly Wound Progress Review stated the resident had developed a deep tissue injury to the left heel. Review of the Nursing Weekly Wound Progress Review and the Nurse's Notes during that time revealed the responsible party was not notified of the development of the wounds.",2020-09-01
594,MYRTLE BEACH MANOR,425070,"9547 HIGHWAY 17, NORTH",MYRTLE BEACH,SC,29572,2017-08-11,272,D,0,1,PD4911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to ensure the Minimum Data Set (MDS) assessment was coded correctly for a sacral Stage II pressure ulcer acquired after admission to the facility for Resident #180 for 1 of 3 residents reviewed for pressure ulcers. The findings included: The facility admitted Resident #180 with [DIAGNOSES REDACTED]. Review on 8/10/2017 at approximately 2:50 PM of the medical record for Resident #180 revealed he/she was admitted 7 days prior to the development of a Stage II pressure ulcer of the sacrum. Review on 8/10/2017 at approximately 4:50 PM of the MDS assessment coded on admission revealed under Section M0210 - Unhealed Pressure Ulcer(s) which asked the question, Does this resident have one or more unhealed pressure ulcer(s) at Stage I or higher? was coded with a (0) to indicate, no. Further review on 8/11/2017 at approximately 3:00 PM of the MDS assessment coded as the 14 day assessment revealed under Section M0210 coded with a (1) which indicated that Resident #180 had an unhealed pressure ulcer(s) at a Stage I or higher. Section M0300 - B. Stage 2 - number 2 was coded with a (1) and asks, Number of these Stage II pressure ulcers that were present on admission/entry or reentry, to indicate that the pressure ulcer was not acquired in the facility but the resident was admitted with the pressure ulcer of the sacrum. During an interview on 8/11/2017 at approximately 3:15 PM with the MDS/Care Plan Coordinator confirmed that the 14 day MDS assessment had been coded incorrectly and provided a corrected MDS assessment to indicate Resident #180 was not admitted with a Stage II pressure ulcer on his/her sacrum.",2020-09-01
595,MYRTLE BEACH MANOR,425070,"9547 HIGHWAY 17, NORTH",MYRTLE BEACH,SC,29572,2017-08-11,280,C,0,1,PD4911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to document participation of all required disciplines in the Care Plan Conferences for Residents #15, #42, #45, #46, #48, #56, #88, #180 and #203. There was no signature to verify attendance by a Dietary Representative and/or Certified Nursing Assistant (CNA) on the Plan of Care Conference Summaries for 9 of 9 sampled residents whose Care Plans were reviewed. The findings included: The facility admitted Resident #45 with [DIAGNOSES REDACTED]. Review of the Care Plan on 08/10/17 at 12:47 PM revealed that the signature section of the Plan of Care Conference Summary sheet did not document participation by a CNA, Dietary representative or Physician in the formulation of the plan. The facility admitted Resident #56 with [DIAGNOSES REDACTED]. Review of the Care Plan 0n 08/10/17 at 10:43 AM revealed that the signature section of the Plan of Care Conference Summary sheet did not document participation by a CNA, Dietary representative or Physician in the formulation of the plan. The facility admitted Resident #42 with [DIAGNOSES REDACTED]. Review of the Care Plan on 08/10/17 at 4:27 PM revealed that the signature section of the Plan of Care Conference Summary sheet did not document participation by a CNA, Dietary representative or Physician in the formulation of the plan. In an interview on 08/11/17 at 11:31 AM the Minimum Data Set (MDS) Coordinator #2, stated, if there is no signature, there is no way to verify participation. In an interview on 08/11/17 at 12:34 PM, the Director of Nursing stated the facility does not have a Care Plan policy. The facility admitted Resident #203 with [DIAGNOSES REDACTED]. Record review on 8/10/17 of the resident's care plan dated 7/13/17 revealed Dietary and the Certified Nursing Assistant did not participate in the care plan process. The facility admitted Resident #48 with [DIAGNOSES REDACTED]. Review on 8/10/2017 at approximately 11:02 AM of the medical record for Resident #48 revealed a form titled, Plan of Care Conference Summary, dated 5/17/2017 and indicated that Social Services and the rehab/therapy staff were the only disciplines involved with planning the care for Resident #48. Further review on 8/10/2017 at approximately 11:05 AM of the form indicated that Dietary, the Registered Nurse (RN) and the Certified Nursing Assistant (CNA) involved with the resident's care did not have input into developing the plan of care for Resident #48. Review on 8/10/2017 at approximately 11:15 AM of a second form titled, Plan of Care Conference Summary, dated 7/18/2017 for Resident #48 and indicated that Dietary and the CNA involved with the care for Resident #48 did not participate and have input into the care planning process for Resident #48. The facility admitted Resident #180 with [DIAGNOSES REDACTED]. Review on 8/10/2017 at approximately 4:53 PM of the medical record for Resident #180 revealed a form titled, Plan of care Conference Summary, dated 6/1/2017 revealed that Dietary and the CNA involved with the caring for Resident #180 did not have input nor were they involved in developing the plan of care for Resident #180. Resident #15 was admitted with [DIAGNOSES REDACTED]. There was no documentation of CNA (Certified Nurse Assistant), Nurse, or Dietary participation in care plan, per the Plan of Care Conference Summary dated 6/23/17. Resident #46 was admitted with [DIAGNOSES REDACTED]. There was no documentation of CNA participation in care plan, per the Plan of Care Conference Summary dated 6/1/17. Resident #88 was admitted with [DIAGNOSES REDACTED]. There was no documentation of CNA participation in care plan, per the Plan of Care Conference Summary dated 6/13/17.",2020-09-01
596,MYRTLE BEACH MANOR,425070,"9547 HIGHWAY 17, NORTH",MYRTLE BEACH,SC,29572,2017-08-11,314,E,0,1,PD4911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, review of the facility policy titled Categories/Staging of Pressure Ulcers and review of LLR Advisory Opinion #46, the facility failed to have a Registered Nurse stage pressure ulcer wounds for 3 of 3 pressure ulcers reviewed.(Resident #203, #48 & #180) The findings included: The facility admitted Resident #203 with [DIAGNOSES REDACTED]. Record review on 8/10/17 of the Nursing Weekly Wound Progress Reviews revealed Licensed Practical Nurse(LPN)#2 documented the stage of the wound. Further review of the wound notes revealed there was no documentation a Registered Nurse was with LPN #2 during the staging of the wound. During an interview with the Director of Nursing(DON) on 8/11/17 at approximately 12:45 PM, he/she stated the wound nurse was Wound Care Certified(WCC) and the facility policy states if a LPN is WCC they can stage a resident's wound. He/she continued by stating wounds are discussed at risk meetings and the risk meetings are signed by Registered Nurses. The DON during the interview stated he/she made rounds with the wound nurse and sometimes performs wound care when the WCN is not available. No documentation could be provided by the DON regarding making rounds with the WCN and staging resident's wounds. Review of the facility policy titled Categories/Staging of Pressure Ulcers revealed the following: .It is the position of Five Star Senior Living that staging pressure ulcers be performed by a Registered Nurse OR a Licensed Practical/Vocational Nurse who holds a current certification as a wound care nurse, unless otherwise indicated in your state specific scope and standards of nursing practice. Review of the LLR(Labor, Licensing and Regulation) Advisory Opinion #46 states the following: It is not within the role and scope of the Licensed Practical Nurse to evaluate and/or stage vascular, diabetic/neuropathic or pressure ulcers. The facility admitted Resident #48 with [DIAGNOSES REDACTED]. Review on 8/9/2017 at approximately 2:46 PM of the medical record for Resident #48 revealed a form titled, Nursing Initial Wound Evaluation, and indicated a Stage III pressure wound to the Coccyx. No documentation could be found to ensure a Registered Nurse had staged the pressure wound. Further review on 8/9/2017 at approximately 2:50 PM of a form titled, Weekly Wound Progress Review Form, indicated that the pressure wound assessed on the coccyx of Resident #48 had been staged by a Licensed Practical Nurse (LPN). The facility admitted Resident #180 with [DIAGNOSES REDACTED]. Review on 8/10/2017 at approximately 2:53 PM of the medical record for Resident #180 revealed a form titled, Initial Wound Review, and was signed and staged as a stage II by a Licensed Practical Nurse at time of discovering the sacral pressure ulcer. No documentation could be found in the medical record for Resident #180 to ensure a RN had staged the new found pressure ulcer. Further review on 8/10/2017 at approximately 3:00 PM of a form titled, Weekly Wound Progress Review Form, indicated weekly the LPN continued to assess and stage the sacral wound. No documentation was found to ensure a RN was present at the time of the staging and assessment process for Resident #180's sacral pressure wound.",2020-09-01
597,MYRTLE BEACH MANOR,425070,"9547 HIGHWAY 17, NORTH",MYRTLE BEACH,SC,29572,2017-08-11,329,D,0,1,PD4911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure behavior monitoring for resident with Physician order [REDACTED].#15 identified as receiving [MEDICATION NAME] for behavior disturbances did not have any monitoring of the efficacy of the medication and/or adverse consequences. The findings include: The facility admitted Resident #15 with [DIAGNOSES REDACTED]. Record review on 8/09/2017 at approximately 3:30 PM revealed a Physician order [REDACTED].) Has hallucinations & delusions. -Order Date- 6/28/2017 1045. Record review on 8/09/2017 reveals no evidence of behavior monitoring in the Physician Orders. An interview on 08/10/2017 at 12:55 PM with LPN #1, who verified no order for monitoring behavior for medication, [MEDICATION NAME]. A review of the policy titled: Psychopharmacological Medication states 3.2 Psychopharmacological and Sedative/Hypnotic, Residents who use psychopharmacological and sedative/hypnotic medications must be reviewed on a regular basis and there must be monitoring for efficacy of the medications and Adverse Consequences. On 8/10/2017 at approximately 1:15 PM, the facility provided a copy of Physician order [REDACTED].=s/s of Dementia with behavioral disturbance, 3=Target mood/behavior: combative/resistive to care, screaming out, fidgeting behaviors, yelling, no easily redirectable every shift Document Behavior, # of Episodes, Interventions, Outcome and side effects.",2020-09-01
598,MYRTLE BEACH MANOR,425070,"9547 HIGHWAY 17, NORTH",MYRTLE BEACH,SC,29572,2017-08-11,371,E,0,1,PD4911,"Based on interview, observation and record review, the facility failed to ensure: 1)Labeling and dating of refrigerated food 2)Cold foods on serving line were held at or below 41 degrees, and, 3) Safe storage of foods in refrigerator; cooked gravy was stored in refrigerator beneath raw eggs in 1 of 1 kitchen and 2 of 2 dining rooms. The findings include: During initial tour of the kitchen, on 08/08/2017 at 9:05 AM, observed 5 partially open packages of sliced cheese which had been rewrapped in clear plastic were not labeled or dated. The General Manger verified the cheese was not labeled and said the cheese should have be labeled when the package was opened and rewrapped. The Facility Policy and Procedure titled, Food Safety in Receiving and Storage, . 2.0 Procedure, The following guidelines will be followed for Receiving and Storage:, General Food Storage Guidelines, 3. Food that is repackaged will be placed in a leak-proof, pest-proof, non-absorbent, sanitary container with a tight fitting lid. The container will be labeled with name of the contents and dated with the date it was transferred to the new container. On 8/10 at 4:40 PM in the Health Care Dining Room, the temperatures were taken for dinner meal service by the Dietary Employee and were as follows: Puree Ham 55.4 degrees, Sliced [NAME]toes and Lettuce 47.3 degrees. The dietary employee stated that the correct cold food temperature 35 to 40 degrees for serving line, and food must be removed from the line if not at the correct cold food temperature. The foods were removed from the line before meal service and taken back to the kitchen and put in the freezer to be chilled down, returned to the dining room at 5:15 PM, the Puree chicken salad was 39.3, Sliced [NAME]toes and Lettuce 40.1 degrees. On 8/10 at 4:55 PM in the Rehab Center Dining Room the General Manager delivered meals and took the temperatures of food prior to meal service. The Chicken Salad Sandwich was 46.5 degrees, the Potato Salad was 42.8 degrees. The General Manager said the temperatures were incorrect and the food was removed and returned to the kitchen for chilling. On 8/10 at 5:40 PM, the General Manager brought the re-chilled plates for the Rehab Center Dining Room and the temperatures were 37.5 degrees, and the chicken salad and potato salad were 34.0 degrees. A review of the facility Policy and Procedure titled, Safe Food Temperatures, 3.11 Procedure, Adhere to the following practice guidelines: .4.Cold foods will be held at 41 degrees or lower during meal service (on the trayline). On 08/11/2017 at 9:01 AM, observed a pan of brown gravy stored on lower shelf of cooler beneath raw eggs, verified with the kitchen manager who stated it should not be there and removed from cooler. A review of the facility Policy and Procedure titled: Food Safety in Receiving and Storage, states Cold Food Storage Guidelines, 6. Cooked and ready-to-eat foods will be stored above raw foods (including shell pasteurized eggs) in the refrigerator to prevent cross-contamination",2020-09-01
599,MYRTLE BEACH MANOR,425070,"9547 HIGHWAY 17, NORTH",MYRTLE BEACH,SC,29572,2017-08-11,372,D,0,1,PD4911,"Based on observation, interview and record review,the facility failed to ensure the area surrounding the outside grease storage receptacle was maintained and free from spillage and leaking grease in one of one grease storage receptacle. The findings include: An observation on 08/11/2017 at 10:08 of the grease storage receptacle had spillage of black greasy substance on the concrete surface which the container was stored and the gravel in front of the grease receptacle. An interview on 8/11/2017 at approximately 10:30 AM with the General Manager of Dining and he/she said that they don't know when they are going to pick up the grease from the grease container. On 08/11/2017 at 10:48 AM, the Director of Maintenance verified the spillage of grease on gravel area and concrete surface. He/She said that the company which picks up the grease comes about every 8 weeks and, further he/she stated that there was a problem recently where they did not come timely and that is how the spillage of the black grease in the gravel area occurred. He/She said that he/she tried to clean with degreaser and this did not clean this area up. He/She provided a letter dated 8/11/2017 from Valley Proteins, Inc. which stated: .Re: Customer Number 1 (Used Waste Oil), the following is a confirmation for service for raw material services at your facility: Confirmation of Service, Service: Valley Proteins provides raw material service for the removal of waste kitchen grease. Valley Proteins furnishes these services on an 8 week frequency. We last serviced on 6/29/17. The next service expected on or around 8/14/2017. We have servicing your location since (MONTH) 1994.",2020-09-01
600,MYRTLE BEACH MANOR,425070,"9547 HIGHWAY 17, NORTH",MYRTLE BEACH,SC,29572,2017-08-11,441,D,0,1,PD4911,"Based on observations, interviews and review of the facility policy titled, Laundry Handling Practices, and, Standard Precautions, the facility failed to handle soiled linen in a manner to prevent the spread of infections in 1 of 1 laundry room. The facility further failed to ensure soiled linen was bagged before leaving the resident's room and placing it in a soiled bin in the hallway on 1 of 2 halls. The findings included: An observation on 8/11/2017 at approximately 10:30 AM revealed the Laundry Worker vigorously shaking soiled linen before placing it in the soiled bins in the laundry room. Further observation on 8//11/2017 at approximately 10:35 AM revealed the Laundry Worker removing soiled linen from the soiled linen bins located in the hallway that was not bagged before placing it in the bin. During an interview on 8/11/2017 at approximately 10:45 AM the Laundry Worker stated, we shake out the linen to ensure nothing is wrapped up in it and so nothing like forks and knives are put in the washers. During the interview the Laundry Worker also confirmed that the soiled linen was not bagged prior to putting it in the soiled linen bins in the hallway. He/she went on to say that sometimes it is bagged and sometimes it is not. Review on 8/11/2017 at approximately 11:30 AM of the facility policy titled, Laundry handling Practices, under Procedure, number 3 states, Handle contaminated laundry as little as possible, with minimal agitation. Number 4 states, Bag or contain contaminated laundry bagged/contained where it is used. Do not sort or rinse in the location of use, move to identified area in laundry. Review on 8/11/2017 at approximately 11:50 AM of the facility policy titled, Standard Precautions, number 7 states, Linen: Transport linen that is soiled with blood, body fluid, secretions, or excretions in a manner that prevents skin and mucous membrane exposure, contamination of clothing, and transfer of microorganisms to other residents and environments.",2020-09-01
601,MYRTLE BEACH MANOR,425070,"9547 HIGHWAY 17, NORTH",MYRTLE BEACH,SC,29572,2017-08-11,456,E,0,1,PD4911,"Based on observations, interviews and review of the manufacturers recommendations for the facility's clothes dryers, the facility failed to ensure an excessive build up of lint was removed from inside and behind 4 of 4 clothes dryers. The findings included: An observation on 8/11/2017 at approximately 9:00 AM of the facility laundry room revealed 4 of 4 clothes dryers with an excessive build up of lint inside the clothes dryers, on the sides of the lint baskets, the upper sides of the dryers and on the wiring system. Further observation on 8/11/2017 at approximately 9:00 AM revealed a build up of lint behind the clothes dryers on the belts and ducts and on the back panels of the dryers. An interview on 8/11/2017 at approximately 9:15 AM with the Laundry Worker and the Maintenance Director confirmed the findings. Review on 8/11/2017 at approximately 9:40 AM of the Manufacturers Recommendations for the clothes dryers states under, Daily, Keep tumbler area clear and free of combustible materials, gasoline, and other flammable vapors and liquids. Number 2, reads, Remove all accumulated lint in the lint compartment area. Lightly brush any lint that may be left on the lint screen. Lint left in the lint compartment is drawn back onto the lint screen and will restrict proper air circulation. Number 5 states, Wipe any accumulated lint off of the thermostat sensing probe, cabinet hi-limit thermostat or thermistor. Failure to do so will allow a a buildup of lint in this area to act as an insulator, causing the tumbler to overheat.",2020-09-01
602,MYRTLE BEACH MANOR,425070,"9547 HIGHWAY 17, NORTH",MYRTLE BEACH,SC,29572,2017-08-11,463,D,0,1,PD4911,"Based on record review, interview and observation, the facility failed to provide a functioning call bell for all residents. Two call bells were observed difficult to operate and two call bells did not function.(4 of 30 residents reviewed) The findings included: During room rounds on 8/8-9/17, the following was observed: Room 102P-call bell did not activate x 3 attempts; Room 105B-call bell did not activate after resident attempted to ring call bell; Room 207A-call bell did not activate; Room 207B-call bell did not activate. On 8/8/17 at 11:45 AM, Certified Nursing Assistant #1 and Licensed Practical Nurse(LPN)#3 confirmed the call bells for 207A and 207B would not activate. On 8/8/17 at approximately 4:00 PM, the Maintenance Director stated a wire had to be replaced and could not tell the surveyor how long the call bell had not been working or how often the call bells were checked to make sure they were in good working condition. On 8/11/17 at approximately 11:30 AM, the environmental tour was done with the Director of Nursing and call bells in Rooms 102P, 105B, 207A and 207B were checked and were functioning. During an interview with the Maintenance Director on 8/11/17, he/she stated call bells in a couple of rooms are checked randomly on a monthly basis. He/she could not tell the surveyor when the above rooms were checked last.",2020-09-01
603,MYRTLE BEACH MANOR,425070,"9547 HIGHWAY 17, NORTH",MYRTLE BEACH,SC,29572,2018-10-11,623,D,0,1,BXWS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to provide written notification upon transfer for Resident #128, 1 of 2 sampled residents reviewed for hospitalization . The findings included: The facility admitted Resident #128 with [DIAGNOSES REDACTED]. Record review on 10/10/18 at approximately 10:22 AM revealed Nursing Notes dated 09/28/18 and 09/05/18 documenting orders to send Resident #128 to the emergency room for evaluation. No documentation of written Notice of Transfer being provided to the resident or resident representative was located in the medical record. In an interview on 10/10/18 at approximately 2:30 PM, the Director of Nursing confirmed the facility did not send written notices at transfer to the resident or the resident representative.",2020-09-01
604,MYRTLE BEACH MANOR,425070,"9547 HIGHWAY 17, NORTH",MYRTLE BEACH,SC,29572,2018-10-11,625,D,0,1,BXWS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to provide written notification upon transfer for Resident #128, 1 of 2 sampled residents reviewed for hospitalization . The findings included: The facility admitted Resident #128 with [DIAGNOSES REDACTED]. Record review on 10/10/18 at approximately 10:22 AM revealed Nursing Notes dated 09/28/18 and 09/05/18 documenting orders to send Resident #128 to the emergency room for evaluation. No documentation of written Notice of Bed Hold being provided to the resident or resident representative was located in the medical record. In an interview on 10/10/18 at approximately 2:30 PM the Director of Nursing confirmed the facility did not send written notices of Bed Hold Policy to the resident or the resident representative.",2020-09-01
605,MYRTLE BEACH MANOR,425070,"9547 HIGHWAY 17, NORTH",MYRTLE BEACH,SC,29572,2018-10-11,812,E,0,1,BXWS11,"Based on observation and interview, the facility failed to follow standard practices for ensuring safe food handling. The findings included: During initial tour of the facility kitchen on 10/09/18 at approximately 1:08 PM with the Executive Chef the following was observed: Reach-in cooler held open food bags and/or containers of chicken salad, potato salad, sausage links, chopped garlic and lettuce with no markings to indicate date opened. Also, there were green peppers and cucumbers with black and white mold spots. Observation in the freezers revealed fish fillets (2 bags), potato skins, and hashbrowns inside the kitchen freezer and in the freezer across the hallway bread, cooked pasta, fish, meatballs, unbaked dinner rolls, hot dogs and cookies were observed with no dating as to when opened. In the dry storage area, an open bag of pancake/waffle mix less than half full, not in a plastic bag, was observed sitting on a shelf but not dated. During the observation, the Executive Chef stated these items should have been dated at the time they were opened and prior to placing for storage as per facility policy.",2020-09-01
606,NHC HEALTHCARE - CLINTON,425071,304 JACOBS HIGHWAY,CLINTON,SC,29325,2017-07-25,371,D,0,1,ZJG111,"Based on observations and interviews, the facility failed to ensure that residents who eat in their rooms had meals delivered to the rooms in a sanitary manner. Staff observed removing food trays from covered food cart and delivering meals to residents rooms with rolls, cornbread, cakes and/or bread pudding uncovered on 1 of 3 units observed. ( Unit 100) The findings included: During random lunch observation ON 7/23/17 at approximately 12:01 PM, staff was observed removing food trays from a covered food cart and delivered food trays to resident rooms with rolls and bread pudding uncovered. Staff was observed walking from room 130 to room 125 with roll and bread pudding uncovered. Residents in rooms 128 and 135 received roll and bread pudding that was not covered. Little clear plastic lids were noted on top of food cart but staff did not use the tops to cover the foods that were not covered prior to removing them from the food cart. There were three hallways on Unit 100. During random lunch observation on 7/24/17 at approximately 11:57 AM staff was observed removing food trays from a covered food cart and delivered food trays to residents rooms with cornbread and cake uncovered Staff was observed passing more than 2 resident rooms while delivering food trays. There were three hallways on Unit 100. An interview on 7/24/17 at approximately 12:09 PM with the facility's Certified Dietary Manager (CDM)confirmed the rolls, cornbread, cake and bread pudding were not covered for room delivery. The CDM stated when staff deliver food trays directly from the food cart all food did not have to covered. The CDM further stated he/she will review the facility policy to address how many rooms staff should pass when delivering food trays uncovered. An interview on 7/24/17 at approximately 12:13 PM with Certified Nursing Aide (CNA) #1 confirmed he/she had delivered food trays to resident rooms with foods uncovered. The CNA further stated they usually deliver food trays to resident rooms with breads, cakes/desserts uncovered. An interview on 7/24/17 at approximately 1:25 PM with the Director of Nursing (DON) with the CDM present revealed the facility did not have a policy related to food tray delivery to rooms with foods uncovered. The DON stated staff should not deliver foods trays to rooms with food uncovered no more than two doors away from the residents rooms. An interview on 7/24/17 at approximately 3:30 PM with the DON with the CDM present revealed the facility had an in-service within the past three months related to meal delivery. The in-service provided was not dated and did not address foods being covered during meal delivery. The DON stated the in-service was from a customer service standpoint for freshness and appropriate temps.",2020-09-01
607,NHC HEALTHCARE - CLINTON,425071,304 JACOBS HIGHWAY,CLINTON,SC,29325,2018-10-17,758,D,0,1,XD6O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that a resident with documentation of an allergy to a [MEDICAL CONDITION] medication did not receive the [MEDICAL CONDITION] medication until clarification was made regarding the allergy. Resident #38 was given [MEDICATION NAME] on 10/11/18 through 10/16/18 with documentation throughout the medical record that the resident had an allergy to [MEDICATION NAME]. One of five sampled residents reviewed for unnecessary medications. The findings included: The facility admitted Resident #38 on 10/17/15 with [DIAGNOSES REDACTED]. A review of the medical record on 10/16/18 at approximately 9:14 AM revealed a large allergy sticker on the inside tab of the medical record that identified [MEDICATION NAME] as an allergy for Resident #38. Further record review revealed a physician's orders [REDACTED]. There was no documentation to address the resident's documented [MEDICATION NAME] allergy. A review of the nurse practitioner's progress reports dated 10/02/18 and 10/11/18 did not address the resident's allergy to [MEDICATION NAME]. A nurse's note dated 10/11/18 at 4:50 PM revealed the nurse practitioner made rounds and a new order was received and processed for [MEDICATION NAME] 25 milligrams every day at 2 PM and 9 PM. There was nothing in the nurse's note to indicate the resident's documented allergy to [MEDICATION NAME] was addressed. A review the resident's history and physical on admission in (YEAR) identified [MEDICATION NAME] as an allergy for the resident. The monthly cumulative physician's orders [REDACTED]. The monthly Medication Administration Record [REDACTED]. A review of the comprehensive care plan updated 8/21/18 indicated under risk of [MEDICAL CONDITION] medications as an approach Ensure that no meds containing [MEDICATION NAME] are administered. Allergy noted on record and IMAR. A review of the MAR for (MONTH) (YEAR) indicated Resident #38 received [MEDICATION NAME] 25 milligrams as ordered on [DATE] through 10/16/18. There was on documentation to address the allergy to [MEDICATION NAME]. An interview on 10/16/18 at approximately 2:40 PM revealed Licensed Practical Nurse (LPN) #1 reviewed the medical record and confirmed there was no documentation to address the resident's documented allergy to [MEDICATION NAME] although the medication was given. LPN #1 stated he/she would find out why the [MEDICATION NAME] was given with the documented allergy to [MEDICATION NAME] and let the surveyor know. In an interview on 10/16/18 at approximately 2:53 PM, LPN #1 informed the surveyor the he/she had spoken with the nurse practitioner who would provide an addendum to his/her 10/11/18 progress note. An interview on 10/16/18 at approximately 3:49 PM with Registered Nurse (RN) #1 confirmed there was nothing in the medical record to address the [MEDICATION NAME] given to Resident #38 with documented allergy to [MEDICATION NAME]. RN #1 stated he/she spoke to the family today and the family stated they did not feel resident had a true allergy to [MEDICATION NAME]. RN #1 stated the nurse practitioner would discontinue the allergy to [MEDICATION NAME] today. A review of the medical record on 10/17/18 at approximately 9:04 AM revealed a nurse's note dated 10/16/18 that the family was notified to get clarification of allergy to [MEDICATION NAME] and the nurse practitioner was informed of the family's response that [MEDICATION NAME] was not a true allergy.",2020-09-01
608,NHC HEALTHCARE - CLINTON,425071,304 JACOBS HIGHWAY,CLINTON,SC,29325,2018-11-29,600,G,1,0,5UH311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, the facility failed to ensure each resident remained free from neglect. Certified Nurse Aide (CNA) #1 transferred Resident #1 without the assistance of another staff member or lift as required. Resident #1 fell and sustained a femur fracture. One of three residents reviewed for neglect. The findings included: Review of Resident #1's medical record revealed a Nurses' Note dated 9/18/18 at 2:00 PM indicated resident resting in bed quietly. Range of motion within normal limits. Facial grimacing is observed when performed on right lower leg. Awaiting company to do x-rays in facility. Review of Resident #1's Post Falls Nursing assessment dated [DATE] revealed at 11:00 AM resident found on floor. CNA reports while assisting resident in shower resident's knees buckled and resident slid on floor. Assessed for injury and finished shower. Then assisted resident back to bed. Resident complained of pain to right leg, as needed Tylenol administered for pain. At time of fall resident was transferring to/from shower chair. X-ray ordered for right hip down to right foot. Review of the care plan revealed Resident #1 requires extensive assist per staff to complete transfers was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included assistance per 2 staff and use of mechanical lift to complete all transfers. Review of the Radiology Report results for Resident #1 dated 9/18/18 revealed oblique [MEDICAL CONDITION] femur. In an interview with the Surveyor on 11/29/18 at approximately 11:45 AM, Licensed Practical Nurse (LPN) #1 stated s/he went to the bathroom and realized CNA #1 had dropped Resident #1 in the floor. There was a shower chair and the resident's wheelchair in the shower room with no additional equipment. The CNA was trying to transfer the resident from his/her wheelchair to the shower chair. CNA #1 was transferring the resident by him/herself, that was against the care plan. The resident required two person assist for transfers. CNA #1 should have had a second person but did not. LPN #1 asked CNA #1 why s/he did not wait for him/her, because s/he would have come and helped. CNA #1 said s/he was doing it by him/herself. CNA #1 was terminated because of this incident. LPN #1 stated the residents have care plans in their closets that have the information on transfer status. LPN #1 went and looked at the care plan in Resident #1's closet and it had two person assist for transfers. CNA #1 was assigned to that group and worked with Resident #1 regularly. CNA #1 said s/he didn't know the resident was going to buckle, CNA #1 did know s/he was supposed to have a second person. In an interview with the Surveyor on 11/29/18 at approximately 12:25 PM, the Director of Nursing and Administrator were asked about the incident. They stated the Unit Manager came and talked with the administrator at the time of the incident. The Unit Manager explained the situation, that the resident had fallen, and they were sending Resident #1 out. The Unit Manager talked to the administrator about the CNA #1 not following Resident #1's plan of care and that CNA #1 would be terminated. The Administrator stated they did not complete an investigation, because they knew what happened. In an interview with the Surveyor on 11/29/18 at approximately 12:27 PM, the 100-Unit Manager stated CNA #1 used the emergency call light in the shower room for assistance. When they got there the resident was in the floor with CNA #1 in the shower with him/her. CNA #1 said s/he was preparing the resident for a shower, when s/he went to transfer the resident the resident had a bowel movement while transferring and that caused him/her to slide down. CNA #1 was in the shower room by him/herself, s/he should have another staff. The Unit Manager talked with CNA #1 and s/he said s/he was trying to get the resident's shower done. The Unit Manager looked at the resident's care plan on the closet door and it indicated s/he required two person assist for transfers. In an interview with the Surveyor on 11/29/18 at approximately 12:30 PM, the Administrator stated s/he did not report the incident to the State Survey Agency because there was nothing to report. There did not need to be an investigation. The CNA knew what the protocol was and s/he chose not to do it.",2020-09-01
609,NHC HEALTHCARE - CLINTON,425071,304 JACOBS HIGHWAY,CLINTON,SC,29325,2018-11-29,607,G,1,0,5UH311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview the facility failed to implement written policies and procedures that prohibit and prevent neglect. Certified Nurse Aide (CNA) #1 transferred Resident #1 without the assistance of a staff member and mechanical lift per the resident's plan of care. Resident #1 fell during the transfer and sustained a femur fracture. One of three residents reviewed for neglect. The findings included: Review of the POS [REDACTED]. CNA reports while assisting resident in shower resident's knees buckled and resident slid on floor. Assessed for injury and finished shower. Then assisted resident back to bed. Resident complained of pain to right leg, as needed Tylenol administered for pain. At time of fall resident was transferring to/from shower chair. X-ray ordered for right hip down to right foot. Review of Resident #1's care plan revealed resident requires extensive assist per staff to complete transfers was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included assistance per 2 staff and use of mechanical lift to complete all transfers. Review of the Radiology Report results for Resident #1 dated 9/18/18 revealed oblique [MEDICAL CONDITION] femur. In an interview with the Surveyor on 11/29/18 at approximately 11:45 AM, Licensed Practical Nurse (LPN) #1 stated s/he went to the bathroom and realized CNA #1 had dropped Resident #1 in the floor. CNA #1 was transferring the resident by him/herself, that was against the care plan. The resident required two person assist for transfers. In an interview with the Surveyor on 11/29/18 at approximately 12:25 PM, The Administrator stated they did not complete an investigation, because they knew what happened. In an interview with the Surveyor on 11/29/18 at approximately 12:27 PM, the 100-Unit Manager stated CNA #1 was in the shower room by him/herself, s/he should have another staff. In an interview with the Surveyor on 11/29/18 at approximately 12:30 PM, the Administrator stated there did not need to be an investigation. The CNA knew what the protocol was, and s/he chose not to do it. Review of the facility's Patient Protection and Response Policy revealed the center administrator is responsible for assuring that patient safety, including from risk of abuse or neglect, holds the highest priority. The policy defined neglect as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. The policy indicated the center will provide supervision and support services designed to reduce the likelihood of abusive behaviors. In order for all care needs to be met, the nursing supervisors will provide the needed assistance when notified by fell ow partners of the inability to complete their assignments. Review of the facility's Patient Protection and Response Policy revealed any patient event that is reported to any partner by patient, family, other partner or any other person will be considered an allegation or either abuse, neglect, misappropriation of patient property or exploitation if it meets any of the following criteria: any patient or family complaint of physical harm, pain or mental anguish resulting from the actions of others; any complaint of deprivation by an individual caregiver of goods and services necessary to attain or maintain physical, mental, and psychological well-being to include toileting issues. Review of the facility's Patient Protection and Response Policy revealed procedures that the investigation is conduced immediately under the following circumstances: when it is identified that an alleged incident may have occurred, as soon as any partner has knowledge and reports an alleged event. When there is a question as to whether to conduct an investigation, it is best to do so. External reporting to the state survey and certification agency and all other state required agencies will follow federal, individual state laws, and licensure regulations.",2020-09-01
610,NHC HEALTHCARE - CLINTON,425071,304 JACOBS HIGHWAY,CLINTON,SC,29325,2018-11-29,609,G,1,0,5UH311,"> Based on review of facility files and interview, the facility failed to ensure that all alleged violations involving neglect are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, to the State Survey Agency. Certified Nurse Aide (CNA) #1 was noted to neglect Resident #1 by transferring the resident without assistance per the resident's plan of care. Resident #1 fell during the transfer and sustained a femur fracture. One of three residents reviewed for neglect. The findings included: The Surveyor requested to see all reportable incidents upon entering the facility on 11/29/18. Review of the information provided revealed no report was made to the State Agency for Resident #1. On 9/18/18 CNA #1 transferred Resident #1 without the assistance of another staff member or mechanical lift. Resident #1 fell during the transfer and sustained a femur fracture. The facility did not report the incident to the State Survey Agency. In an interview with the Surveyor on 11/29/18 at approximately 12:25 PM, the Director of Nursing and Administrator were asked about the incident. They stated the Unit Manager came and talked with the Administrator at the time of the incident. The Unit Manager explained the situation, that Resident #1 had fallen and they were sending him/her out. The Unit Manager talked to the Administrator about the CNA #1 not following Resident #1's plan of care and that CNA #1 would be terminated. The Administrator stated they did not complete an investigation, because they knew what happened. In an interview with the Surveyor on 11/29/18 at approximately 12:30 PM, the Administrator stated s/he did not report the incident to the State Survey Agency because there was nothing to report. There did not need to be an investigation. The CNA knew what the protocol was and s/he chose not to do it. Review of the facility's Patient Protection and Response Policy revealed all allegations of possible neglect will be immediately assessed to determine the appropriate direction of the investigation. All alleged violations and all substantiated incidents will be reported immediately to the administrator and to other officials in accordance with state and federal law (including to the state survey and certification agency). All events reported as possible neglect will be investigated to determine whether the alleged neglect did or did not take place. The administrator or director of nurses will determine the direction of the investigation once notified of alleged incident.",2020-09-01
611,NHC HEALTHCARE - CLINTON,425071,304 JACOBS HIGHWAY,CLINTON,SC,29325,2018-11-29,610,G,1,0,5UH311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview the facility failed to investigate and prevent neglect. Certified Nurse Aide (CNA) #1 transferred Resident #1 without the assistance of a staff member and mechanical lift per the resident's plan of care. Resident #1 fell during the transfer and sustained a femur fracture. The facility did not complete an investigation and document the findings. One of three residents reviewed for neglect. The findings included: Review of the POS [REDACTED]. CNA reports while assisting resident in shower resident's knees buckled and resident slid on floor. Assessed for injury and finished shower. Then assisted resident back to bed. Resident complained of pain to right leg, as needed Tylenol administered for pain. At time of fall resident was transferring to/from shower chair. X-ray ordered for right hip down to right foot. Review of Resident #1's care plan revealed resident requires extensive assist per staff to complete transfers was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included assistance per 2 staff and use of mechanical lift to complete all transfers. Review of the Radiology Report results for Resident #1 dated 9/18/18 revealed oblique [MEDICAL CONDITION] femur. In an interview with the Surveyor on 11/29/18 at approximately 11:45 AM, Licensed Practical Nurse (LPN) #1 stated CNA #1 was transferring the resident by him/herself, that was against the care plan. The resident required two person assist for transfers. In an interview with the Surveyor on 11/29/18 at approximately 12:25 PM, The Administrator stated they did not complete an investigation, because they knew what happened. In an interview with the Surveyor on 11/29/18 at approximately 12:30 PM, the Administrator stated there did not need to be an investigation. The CNA knew what the protocol was, and s/he chose not to do it. Review of the facility's Patient Protection and Response Policy revealed procedures that the investigation is conduced immediately under the following circumstances: when it is identified that an alleged incident may have occurred, as soon as any partner has knowledge and reports an alleged event. When there is a question as to whether to conduct an investigation, it is best to do so. External reporting to the state survey and certification agency and all other state required agencies will follow federal, individual state laws, and licensure regulations.",2020-09-01
612,NHC HEALTHCARE - CLINTON,425071,304 JACOBS HIGHWAY,CLINTON,SC,29325,2018-11-29,656,G,1,0,5UH311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interviews, the facility failed to implement a comprehensive person-centered care plan for each resident. Certified Nurse Aide (CNA) #1 transferred Resident #1 without following the resident's plan of care. Resident #1 fell during the transfer and sustained a femur fracture. One of three residents reviewed for care plans. The findings included: Review of Resident #1's Post Falls Nursing assessment dated [DATE] revealed at 11:00 AM resident found on floor. CNA reports while assisting resident in shower resident's knees buckled and resident slid on floor. Assessed for injury and finished shower. Then assisted resident back to bed. Resident complained of pain to right leg, as needed Tylenol administered for pain. At time of fall resident was transferring to/from shower chair. X-ray ordered for right hip down to right foot. Review of Resident #1's care plan revealed resident #1 requires extensive assist per staff to complete transfers was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included assistance per 2 staff and use of mechanical lift to complete all transfers. Review of the Radiology Report results for Resident #1 dated 9/18/18 revealed oblique [MEDICAL CONDITION] femur. In an interview with the Surveyor on 11/29/18 at approximately 11:45 AM, Licensed Practical Nurse (LPN) #1 stated s/he went to the bathroom and realized CNA #1 had dropped Resident #1 in the floor. There was a shower chair and the resident's wheelchair in the shower room with no additional equipment. The CNA was trying to transfer the resident from his/her wheelchair to the shower chair. CNA #1 was transferring the resident by him/herself that was against the care plan. The resident required two person assist for transfers. CNA #1 should have had a second person but did not. LPN #1 asked CNA #1 why s/he did not wait for him/her, because s/he would have come and helped. CNA #1 said s/he was doing it by him/herself. CNA #1 was terminated because of this incident. LPN #1 stated the residents have care plans in their closets that have the information on transfer status. LPN #1 went and looked at the care plan in Resident #1's closet and it had two person assist for transfers. CNA #1 was assigned to that group and worked with Resident #1 regularly. CNA #1 said s/he didn't know the resident was going to buckle, CNA #1 did know s/he was supposed to have a second person. In an interview with the Surveyor on 11/29/18 at approximately 12:27 PM, the 100-Unit Manager stated CNA #1 used the emergency call light in the shower room for assistance. When they got there the resident was in the floor with CNA #1 in the shower with him/her. CNA #1 said s/he was preparing the resident for a shower, when s/he went to transfer the resident the resident had a bowel movement while transferring and that caused him/her to slide down. CNA #1 was in the shower room by him/herself, s/he should have another staff. The Unit Manager talked with CNA #1 and s/he said s/he was trying to get the resident's shower done. The Unit Manager looked at the resident's care plan on the closet door and it indicated s/he required two person assist for transfers.",2020-09-01
613,C M TUCKER JR NURSING CARE,425074,2200 HARDEN STREET,COLUMBIA,SC,29203,2020-01-09,686,D,0,1,VNMK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure residents at risk for pressure ulcers did not develop pressure areas for one (1) of two (2) residents identified with pressure ulcers from a sampled 27 residents. (Resident #37) The facility failed to perform a thorough assessment to identify the root cause of Resident #37's pressure ulcer/injury to the left heel. Resident #37 developed a Stage II Pressure Ulcer on the left heel due to ill-fitting shoes on 7/31/19. The findings include: Review of the clinical record revealed Resident #37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 11/5/19, revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of three (3) and determined he/she was cognitively impaired and not interviewable. The facility assessed the resident was at risk for developing pressure ulcers, needed extensive assistance of two (2) persons for bed mobility and was not interviewable. In addition, the facility assessed Resident #37 was always incontinent of bowel, required extensive assistance of two (2) persons with bed mobility, transfers, dressing, personal hygiene and bathing and supervision with meals. Review of Resident #37's comprehensive plan of care, developed on 11/12/19, revealed the resident was at risk for developing skin breakdown related to impaired mobility, presence of dry fragile aging skin conditions and bowel incontinence. The goal stated the resident would be free of avoidable skin breakdown through the next review period. The interventions included staff to assess for risk factors of skin breakdown, assessment of bowel and bladder continence and Braden Scale quarterly, assist to turn and reposition the resident every two (2) hours and as necessary while in bed, observe skin weekly and document, Prevalon boots to bilateral heels at all times, provide incontinence care, and wound 300 mattress without bolsters Review of the Nursing Services Admission Assessment, dated 8/6/18, revealed discoloration, no open area, and blanchable to Resident #37's left heel. Review of the Resident #37's Personal Property Inventory, dated 8/6/18, revealed the facility received one (1) brown pair of shoes and one (1) black pair of shoes from the family on admission. Review of Resident #37's Physical Therapy Prescription Report M-396, dated 8/7/18, revealed the facility assessed the resident as requiring deluxe bed and wheelchair alarms, wheelchair for mobility, direct supervision for gait, restorative nursing mobility program, assistance of two (2) staff for wheelchair follow and hamstring stretching. Review of the Nurse's Weekly Body Audits, dated (MONTH) 2019, revealed Resident #37 had no new skin issues on 7/4/19, 7/11/19, 7/18/19 and 7/25/19. Review of the (MONTH) 2019 Weekly Body Audits revealed scabbed over area on the left heel on 8/2/19. Review of the Nurses' Progress Notes, dated 7/31/19, revealed Resident #37 had a ruptured blister noted to the left heel with after hour treatment guideline applied. Continued review of the Nurses' Progress Notes, dated 8/1/19, revealed Resident #37 had a left heel wound with treatment to cleanse with normal saline and pat dry, apply [MEDICATION NAME] cream to sterile gauze then apply directly to wound and secure with tape and change every day for 14 days. Do not allow resident to wear left shoe, instead wear blue bootie. Review of the Nurses' Progress Notes, dated 8/2/19, revealed the Wound Care Nurse was requested to observe a blister to the left heel measured 6.5 centimeters (cm) times (x) 4.5 cm, no depth or drainage. Resident #37's shoes noted to be worn out and have a raised ridge to all areas of shoes. Interview on 1/08/20 at 4:33 PM, with the Unit Manager (UM) #2, revealed Resident #37 was transferred to Unit 124 from Unit 122 on 8/1/19 with two (2) pairs of shoes. He/she stated a body audit was performed on Resident #37 on 8/2/19 which revealed a scabbed over area to the left heel. The UM stated the resident's shoes didn't fit appropriately so pressure relieving boots were applied to reduce the pressure to the left heel. Additionally, the UM stated he/she did not know who was responsible for assessing the resident's shoes; however, the nursing staff would report to the Physician or Wound Care Nurse if the shoes didn't properly fit the resident. Interview with the Wound Care Nurse (WCN), on 1/8/20 at 4:46 PM, revealed the Physician requested him/her to observe a blister on Resident #37's left heel. The WCN stated that examination of Resident #37's shoes on 8/2/19 revealed they were worn out and ill-fitting. Further interview revealed the resident's shoes and equipment are evaluated by the Physical Therapy Department upon admission. He/she stated it's important to determine the root cause of pressure injuries to prevent skin breakdown for it's easier to maintain good skin than injured skin. Interview with Physical Therapist III on 1/9/20 at 10:04 AM, revealed a physical therapy assessment was conducted on Resident #37 on 8/6/18; however, he/she couldn't remember if the resident's shoes were examined for proper fitting and damage. Further interview revealed he/she did not document the shoe assessment on the physical therapy evaluation for he/she documents by exception, meaning he/she only noted issues with shoes and devices. Interview on 1/9/20 at 3:22 PM with the Director of Nursing (DON), revealed that the admission nursing assessment did not include an examination of the resident's shoes and there wasn't a formal process in place to document this information. He/she stated that it's important to assess the resident's shoes to determine if the shoes were causing skin alterations. Interview on 1/9/20 at 3:34 PM with the Administrator, revealed he/she expected the physical therapy staff to complete intake of the resident's equipment and perform the functional assessment. Additionally, the Administrator stated it's important to conduct the shoe screenings upon admission to prevent skin breakdown to the residents. Review of the facility's policy titled, Skin Care for Resident at High Risk for Skin Breakdown, dated (MONTH) 2019, revealed the facility would reduce the chance of pressure injury in residents at high risk for skin breakdown by staff reporting changes in skin condition to the physician and wound care nurse. Review of the facility's policy titled, Physical Therapy Services, dated (MONTH) 2019, revealed the facility would assess and train residents in locomotion, including as appropriate, the use and issue of orthotic, prosthetics, assistive devices, or seating systems. The form M-396, Physical Therapy Prescription Record, would be completed on the resident's first visit and maintained in the resident's record under rehabilitation.",2020-09-01
614,C M TUCKER JR NURSING CARE,425074,2200 HARDEN STREET,COLUMBIA,SC,29203,2020-01-09,689,D,0,1,VNMK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, review of the facility's policy and fall incident report, it was determined the facility failed to have an effective system to ensure falls were thoroughly investigated to identify the root cause and failed to ensure corrective actions were in place after the fall for one (1) of eight (8) residents that had a fall out of a total sample of 27 residents, (Resident #37). Record review revealed Resident #37 fell on [DATE] with no injuries. Record review revealed that Resident #37 was found in his/her room sitting on the floor (unwitnessed fall); however, the root cause of the fall was not listed on either the incident report or the falls committee meeting report. Interview with the Unit Nurse Manager and Quality Improvement Director revealed there was no documented evidence that corrective actions were monitored after the fall to prevent reoccurrence of falls. The findings include: Review of the clinical record revealed Resident #37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Resident #37's Quarterly Minimum Data Set (MDS) Assessment, dated 11/5/19, revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of three (3) and determined he/she was cognitively impaired and not interviewable. Review of the Significant Change MDS Assessment, dated 8/13/19, revealed Resident #37 had no falls since admission or the prior assessment. Additionally, the facility assessed Resident #37 to require extensive assistance of two (2) persons with bed mobility and transfers and total dependence of one (1) person with dressing, toilet use and personal hygiene. Review of Resident #37's comprehensive plan of care, developed on 8/20/19, revealed the resident was at risk for falls related to [DIAGNOSES REDACTED]. The goal was for resident to have no unrecognized injuries following falls through the next review period on 11/19/19. The approaches stated staff was to provide deluxe chair and bed alarms, falling star program, falls risk assessment reviewed when necessary for fall, identify and correct any situation that may lead to a fall, restorative nursing mobility program, self-release belt while up in wheelchair, and to wear hipsters at all times. Review of the comprehensive care plan, dated 11/12/19, revealed new interventions of deluxe bed alarms per physician order [REDACTED]. Review of Resident #37's admission Falls Risk Assessment, dated 8/6/18, revealed the resident was assessed to be at low risk for falls with a score of six (6) out of 24 total points. Review of the quarterly fall assessment, dated 5/2/19 revealed the resident was assessed to be at high risk for falls with a score of nine (9). Review of the Nurses Progress Notes, dated 9/6/19, revealed Resident #37 sitting on the floor clinging to his mattress with upper body, assessed for injuries with none noted. Review of the Incident Report, dated 9/6/19, revealed a Certified Nursing Assistant (CNA) found the Resident #37 hanging off the right side of the bed and the following protective measures were in place: bed alarm, bedside mats, Posey bed mat, and hipsters. Continued review of the report revealed a Post Fall Episodic Care Plan that was developed with interventions to assess for injury, notify physician and responsible party of the fall, evaluate the cause and circumstances surrounding the fall, assist with ambulation and transfers, and assess for Posey falls red identification items (i.e., red star over bed, red star sticker clinical record, red star magnet on door, red gripper socks, red blanket, red star fall risk bracelet). However, the report did not identify the root cause of the fall. Interview with CNA #5, on 1/8/19 at 7:40 PM, revealed he/she went to Resident #37's room at approximately 4:00 AM to get the resident up since the resident is on the night's get up list but the resident was asleep in bed. CNA #5 stated he/she left Resident #37's room to get another resident up then heard Resident #37's bed alarm sounding, one (1) hour after he/she left his/her room. He/she stated he/she went to Resident #37's room and found him/her on the floor hanging on to the bed. He/she stated he/she reported it to Registered Nurse (RN) #1. RN #1 took the resident's vital signs and RN #1 and CNA #5 assisted Resident #37 back to bed. CNA #5 stated the cause of Resident #37's fall was he/she wanted to get out of the bed when he/she woke up that morning. Interview on 1/8/20 at 8:55 PM, with Certified Nursing Assistant (CNA) #6, revealed he/she did not witness Resident #37 fall but was working on 9/6/19 and heard about the fall from CNA #5. Continued interview revealed that he/she had provided care to Resident #37 and that the resident is on the get up list because he normally wakes up around 4:30 or 5:00 AM. CNA #6 stated he/she gets him out of bed before the other residents, puts him in the wheelchair and takes him/her down the hall to watch television. Interview with Registered Nurse (RN) #1, on 1/9/20 at 4:12 PM, revealed CNA #5 reported Resident #37 was found on the floor holding onto the bed on 9/6/19. RN #1 stated he/she took the resident's vital signs which were normal and assessed the resident for injuries, none were found. He/she completed the incident report and determined the resident had fallen out of bed due to poor safety awareness; however, this information was not documented as the root cause of the fall. Continued interview revealed that it's the responsibility of nursing staff to ensure that the care planned interventions are in place after a fall. RN #1 stated that the nurses documented the falls care planned interventions for Resident #37 on the Treatment Administration Record (TAR) and CNA's documented the falls interventions on the Activities of Daily Living (ADL) sheets. Interview on 1/9/20 at 2:05 PM with Unit Nurse Manager (UM) #2, revealed that falls are reviewed every morning and discussed with the nursing staff. He/she stated that post fall assessments and the root cause analysis of the fall is completed by the nurse on the unit which completed the incident report, which was RN #1. He/she reviewed the incident report and confirmed the root cause of the fall was not identified. He/she stated that he/she made rounds on the residents to ensure the post fall interventions were in place and reviewed the completed TAR and ADL sheets; however, he/she did not document the audits that showed corrective actions were in place after a fall. Interview with the Performance Improvement Nurse (PIN) Director, on 1/9/20 at 2:36 PM, revealed he/she received and reviewed the fall incident reports and a falls committee meeting were held every two (2) weeks with all department heads. Continued interview revealed the root cause of falls are determined by the description of the incident on the incident report. The PIN stated that the description of the incident is the root cause of the fall and no other information is needed on the form. The PIN Director stated the location of the fall and measures put in place are discussed at the meeting then further actions to be taken are determined. He/she stated that the fall interventions were in place for Resident #37, so the falls committee determined that no further action was to be taken for Resident #37 at that time. He/she further stated that a PI nurse performed random weekly Quality Assurance chart audits and risk safety rounds on residents to ensure the resident's fall care planned interventions are in place; however, these audits are not documented. Interview, on 1/9/20 at 1:38 PM, with the Director of Nursing, revealed he/she is responsible for the care of the residents in the facility. He/she stated that after Resident #37's fall, it was not identified that a formal auditing process or an action plan was needed to address his/her fall for he/she didn't have a history of falls and it was an isolated incident. He/she stated that the root cause of Resident #37's fall wasn't determined, and the incident report needed to be revised to include this information. Continued interview revealed he/she was supposed to monitor if the unit managers are ensuring the corrective actions are in place; however, he/she hadn't documented this information. Per interview, the facility process did not identify the need for a corrective action plan related to Resident #37's fall, but should have. Interview with the Administrator on 1/9/19 at 3:52 PM, revealed he/she served on the falls committee and attended the meetings. Further interview revealed the Administrator was responsible for reviewing the incident reports on falls with no injuries then sending it to PI. The Administrator stated that he/she is responsible for completing the incident report, conducting the investigation, and reporting the final report for falls with injuries. He/she stated it was the responsibility of his management staff to monitor for the implementation of fall prevention measures. Per interview, neither the Administrator nor his staff could provide evidence of an action plan or audits related to Resident #37's fall. Review of the facility's policy titled, Fall Prevention and Management Program, dated (MONTH) 2019, revealed the purpose of the program is to establish the facility policy, assign responsibility and provide a procedure for residents at risk for falls, assess fall risk factors, provide guidelines for falls and repeat fall preventive interventions, and outline procedures for documentation and communication process. Registered Nurses are responsible for implementation of and oversight of individualized residents fall prevention by collaborating with the interdisciplinary team in the prevention of falls and appropriately managing residents who experience a fall by implementing post-fall management. The Registered Nurse will complete the resident post fall assessment and notify the physician/nurse practitioner, section B, of the unusual occurrence form M-300 Attachment F. Residents experiencing a fall will be managed according to protocol post-fall management Attachment D. The Risk/Safety/Quality Improvement Rounds Form, Attachment E, is completed by the Quality Improvement Nurse for each unit in the building and corrective actions are to be completed and returned to the Quality Improvement Department within 15 working days.",2020-09-01
615,C M TUCKER JR NURSING CARE,425074,2200 HARDEN STREET,COLUMBIA,SC,29203,2020-01-09,800,E,0,1,VNMK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observations, interviews, and record reviews the facility failed to demonstrate an established process to ensure that there was ongoing communication and coordination between all staff to ensure that residents were offered meaningful choices in menus/diets. Menus were not provided to residents in their rooms allowing the bedbound residents to make choices of their meals, and staff did not have a process to ensure communication of meal choices to bedbound residents. This system failure potentially placed seven (7) residents identified on the facility's CMS form 672 as being bedbound at risk for decline in health status and psychosocial harm due to inadequate or inappropriate nutritional intakes and lack of choice of foods to support meal preferences due to the lack of a facility process to ensure resident meal choices were communicated to all residents. Findings include: Review of Resident #28's medical chart reflected a male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #28's Significant Change Minimum Data Set ((MDS) dated [DATE] reflected a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. The MDS noted that Resident #28 was triggered on his care plan for nutritional needs due to his dental status. The MDS also noted that Resident #28 was being actively treated for [REDACTED].#28 required extensive assistance with mobility. Observations of the facility on 1/6/20, 1/7/20, and 1/8/20 revealed that menus were posted on bulletin boards near the nursing stations of two (2) units and that no menus were posted in the locked unit. There were no menus posted in any resident rooms or in other locations. Review of the facility's menu for 1/6/20 revealed scrambled eggs, raisin bran cereal, bologna, wheat toast, diet jelly, margarine, coffee creamer, low fat milk, and coffee for breakfast; baked ham, pinto beans, turnip greens, cornbread, applesauce, and iced tea for the noon meal; and cubed steak, brown gravy, rice, squash, mandarin oranges, dinner roll, margarine, low fat milk, and iced tea for the evening meal. Review of Resident #28's medical record reflected that Resident #28 was receiving wound care for pressure ulcers on both heels as well as a skin tear on his leg. Registered Dietician's notes dated 11/15/19 reflected that the resident required a mechanical soft diet due to his dental status, and that his meal preferences had been updated. Dietician notes did not address Resident #28's wounds. During an interview on 1/6/20 at 9:22 AM Resident #28 said meals suck, there was no diversity, the same every day. He further stated that he had difficulty changing the meals because the staff would say, when asked, that it was too late to get something different. Resident #28 said that no menu was delivered to the room and no dietician comes around to see what I want to eat. He said that when he was in the hospital someone would come around to ask him what he wanted but that this didn't happen here. He said that he was not aware that he had choices of meals in the facility. He said that he has suffered weight loss. He said that he does get snacks at night if he requests them. He stated that he can't leave his room because he was told he must stay off his feet until the wounds are better. While interviewing Resident #28 Recreational Director came into the room and was asked where menus were posted. He said menus were posted in each hallway near the nurse's station. When asked how the non-ambulatory residents find out their menu choices, he said he didn't know. During an interview on 1/6/20 at 11:34 AM Nutritionist IV said that she and the Dietician create the menus and the menus have a three (3) week schedule that rotates. She stated that an alternative tray is available for lunch and dinner (chicken for lunch and hamburger for dinner roll and rice, meat and gravy); that the staff has extra trays to give residents. Also, there are peanut butter, pimento cheese, ham, and turkey sandwiches, salads, and tomato soup available. She said that if something else is requested they (the staff) call Building 29 (the location of central dietary services). She said that menus from the Dietician are given to the Nurse Managers of the units. She said that the menu is posted in the hall and changed daily but she did not know who was responsible for posting the menus. During an interview on 1/7/20 at 9:29 AM Nutritionist IV (who is the Dietician and Nutritionist) stated that she performs Quarterly MDS assessments. She said the residents that eat in the dining room tell her their preferences and that they don't see menus and other options that are available. She said that alternate trays with options of hamburger or chicken are delivered every day. She said that the pantry at Building 29 sends standard items but must know in advance of requested changes. She said that it is an outdated technology but it's in the works of being changed. She stated that the menu is placed on units and that she is not communicating menus to residents. She said that it is nursing's responsibility on the units to educate the residents. She said that if the resident wants something else to eat the nurses let you know. She said they can contact Building 29 and put in request but that they will not get the food that day. She said that if residents want extra food the staff can take food from another tray. She said that during care planning conferences menus are not discussed. She said that she does not review resident council meeting minutes and that during the meetings menus are not discussed and she doesn't attend. She said that residents in the dining room talk to her daily at lunch but she did not mention the residents who ate in their rooms. She said she performs meal rounds and monitors consumption of those items served and sends the information to her supervisor. Nutritionist IV stated it's important for the residents to be informed of the daily menu for resident satisfaction. During an interview on 1/8/20 at 9:35 AM Chief Clinical Dietician stated that they deliver sets of menus to the nursing units and the nurses have access to answer any questions regarding menus. She said they have a three (3) week plan menu and that quarterly and annual assessments meet and get updated food preferences and allergies [REDACTED]. She said the employee at the resident council meetings will complete a form detailing food concerns and draft a plan to address different issues. She did not know of any issues with the menus. She stated that the Dietician on site performs meal rounds daily but she did not know the specifics of the rounding. She said that menus are posted on the unit hallways and outside the kitchen door. She stated that she will work with the Dietician to disseminate menus to the residents and discuss food preferences. During an interview on 1/8/20 at 9:40 AM Recreation Director said that he does daily visits with the residents. He said that he doesn't know how bedbound residents find out about meal choices/alternatives and said that there is no policy that he knows of to ensure residents have menu information. During an interview on 1/8/20 at 3:40 PM Social Worker #1 stated that there was no process to ensure that the non-ambulatory (bedbound) residents were asked their menu choices. She stated that if she knows they don't like something she would refer them to the Dietician. During an interview on 1/9/20 at 9:20 AM Unit Manager #1 stated that the menus were posted at the nursing station. She said that she did not know of a process to let the bedbound residents know their menu choices. She stated that the Dietician asked residents their meal preferences. She said that if the Certified Nursing Assistants (CNAs) noted that the resident was not eating, the CNA should offer an alternative to the resident. She stated that it was her expectation that the CNAs would tell the nursing staff if the residents did not eat their meals. She stated that the CNAs should ask the kitchen for alternative meals for the residents. During an interview on 1/9/20 at 11:05 AM Social Worker #2 she said she talks to Resident #28 all the time and didn't know he didn't like the food/lack of choice. She said Resident #28's brother had signed the admissions paperwork that advised the residents of the procedures to request alternative meals, but that Resident #28 was very alert, so she was surprised that he didn't say anything to her. She stated that she had held a care conference with Resident #28 present and that he didn't mention his concern. During an interview on 1/9/20 at 4:34 PM Chief Clinical Dietician stated that the Dietary Department was now aware of the lack of process/process breakdown and that the Dietary Department would own the process. During an interview on 1/9/20 at 5:00 PM Director of Nutrition Services stated that during the admissions process information about food preferences and allergies [REDACTED]. She said that the Dietary Department will monitor food consumption trends as part of their Quality Assurance (QA) process. She stated that the Dietary Department will arrange for monotony breaker meals (e.g., special meals during holiday periods). She stated that the Nutritionist IV does frequent rounds with the residents but she did not specify the rounding protocol. She stated that the dietary department has no policy for QA or assurance of meal choices to the residents. Review of the facility grievance log for the past six months reflected no grievances recorded about lack of choices for food. Record review on 1/9/20 of the facility Resident Rights Policy dated 3/2019 had no reference to the resident rights for meal choices or preferences.",2020-09-01
616,C M TUCKER JR NURSING CARE,425074,2200 HARDEN STREET,COLUMBIA,SC,29203,2020-01-09,812,E,0,1,VNMK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of facility policy, it was determined that the facility failed to maintain proper sanitary measures during meal services for residents on one (1) of four (4) units and in one (1) of two (2) dining rooms. During the lunch meal service on 1/6/19 and 1/7/19, staff members failed to perform hand hygiene before serving meal trays and were observed to touching the rim of residents' cups and glasses with their bare hands. The findings include: [NAME] Observations and Interviews 1. During lunch observations on Unit 120 on 1/6/20 at 12:37 PM, CNA #1 was observed passing trays to residents on the hallway. CNA #1 passed lunch trays in Rooms #409, #410, and #411 without performing any form of hand hygiene between residents' or before setting up the meal trays for residents. 2. During an interview with CNA #1 on 1/6/20 at 3:09 PM, the CNA stated that she should use hand sanitizer between residents contact and before feeding them. She pulled a container of hand sanitizer from her pocket to show it to the surveyor. 3. During the lunch meal service on the 400 Hall on 1/6/20 at 12:57 PM, Certified Nursing Assistant (CNA) #11 was observed setting up the meal tray in resident room [ROOM NUMBER]. The CNA touch inside of the glass with bare hand and set it on the tray and left the room. CNA #11 went to another room got stool and brought it back to room [ROOM NUMBER]. The CNA proceeded feed the resident without hand hygiene. 4. During an interview on 1/6/20 at 2:34 PM with CNA #11, the CNA stated she had been trained to use hand sanitizer before handling the resident's trays and in between resident contact. CNA #11 also stated that she did not realize that she had touched the drinking rim of the resident's glass. 5. During meal observation on 1/7/20 at 12:03 PM, CNA #12 was observed to touch the drinking rims of the glass and cup when placing on the meal tray for Resident #20. CNA touched the rim of the glass while holding the glass for the resident to drink. The CNA then reached in her uniform pocket to give a co-worker a pen and then continued feeding resident without hand hygiene. Several times while feeding Resident #20, the CNA was observed to handle the resident's drinking glass by the rim. 6. Additional meal observation on 1/7/20 at 12:10 PM revealed CNA #13 sanitized his hands and delivered tray to resident then walked back and forth between meal carts and touched a female CNA on the arm and proceeded to pull a lunch tray for a resident. The CNA placed a drinking glass on the tray by holding the glass by the rim. The CNA then used hand sanitizer and started feeding the resident.holding drinking glass around the lip of the glass. CNA #13 was observed several times while the feeding the resident to handle the resident's drinking glass by the rim with his bare hands. 7. During an interview on 1/7/20 at 12:53 PM with CNA #12, the CNA stated staff is supposed to use hygiene before serving each resident tray. CNA #12 also stated that she should have used hand sanitizer after reaching in her uniform pocket. also acknowledged that she did not realize she that touched the rim of the glasses and stated that's how she was trained. 8 In an interview on 1/7/20 at 12:58 PM with CNA #13, the CNA acknowledged that he was trained to do hand hygiene prior to serving meal trays and did not realize that he had touched another employee before removing a meal tray from the cart. CNA #13 also stated that he was never trained how to handle cup and glasses. 9. In an interview on 1/9/20 at 9:09 AM, the Infection Control Nurse revealed that facility wide training on hand hygiene was conducted in (MONTH) 2019 after the hand hygiene was identified as a problem in the (MONTH) 2019 Quality Assurance Performance Improvement (QAPI) meeting. The Infection Control Nurse stated also stated the monitoring was being followed in the monthly QAPI meetings. The situation of how the staff members were handling the residents' drinking glasses and cups was described to the Infection Control Nurse who responded this was an incorrect manner. 10. During an interview with the Director of Nursing (DON) on 1/9/20 at 10:47 AM, the DON stated the staff received hand hygiene training during orientation, annually and as needed. The DON stated the staff recently received hand hygiene training but was unable to provide training. The situation was explained to the DON of how the staff was handling the residents drinking glasses and cups when setting up meal trays and feeding the residents. The DON stated this was incorrect but was unable to say if the meal training entailed how to handle the residents drinking glasses and cups. 11. An Interview on 1/9/20 at 11:15 AM, the Performance Improvement Nurse revealed hand hygiene was identified as a problem during the (MONTH) 2019 meeting and a monitoring tool was developed. The monitoring tool was to be posted on each nursing unit and the staff were to document random observations of staff members performing resident cares and whether or not hygiene was observed. The Nurse also stated the committee discussed in the (MONTH) 2019 meeting the hand hygiene monitoring tool was going well but not 100% compliance. Facility wide training on hand hygiene was conducted in (MONTH) 2019 along with training on the hand hygiene monitoring tool. The DON and her staff were responsible for the training the staff and ensuring the monitoring tool was completed and submitted to the Performance Improvement Nurse. The Nurse further stated the monitoring tool was not consistently completed especially on Units 120 and 122. 12. Observations on 1/9/20 at 12:01PM revealed the monitoring tool was not posted on Units 120 and 122. 13. An additional interview with the DON on 1/9/20 at 12:30 PM, she revealed that the hygiene monitoring tool is posted on each unit and collected at the end of the month. The DON was asked to review the submitted monitoring tools. The DON stated the staff are to document when they see someone providing care and if they perform hand hygiene. The DON was asked to explain the blank spaces. The DON stated, I guess there weren't any other observations and admitted the monitoring tools were incomplete. The DON also stated that it was probably time for another training session. The DON was unable to explain who was responsible for monitoring the units for compliance in completing tool and how the information is communicated to the QAPI committee. The DON was also unaware that the monitoring tool was not posted on every unit. B. Monitoring Tools Review Copies of the hand hygiene monitoring tool for the last six (6) months for Units 120 and 122 was requested. A review of the facility's hand hygiene monitoring tool revealed facility instituted monitoring tool in (MONTH) 2019; the facility provided the following documentation: Unit 120 surveillance sheets for (MONTH) 2019 and (MONTH) 2019 incomplete Unit 122 surveillance sheets (MONTH) 2019 only completed Unit 124 surveillance sheets (MONTH) September, and (MONTH) incomplete C. Policy Review 1. A review of the facility's Infection Control Policy and Procedure manual revealed a policy titled Hand Hygiene with a revision date (MONTH) (YEAR). The policy was developed to reduce the transmission of nosocomial transmission of possible contaminants and infectious diseases; all employees will perform hand hygiene. 2. Review of the facility policy titled Feeding Residents with a revision date of (MONTH) 2019 revealed item #3 under Procedure .perform hand hygiene, the rationale for performing hand hygiene was to reduce the transmission of harmful micro-organisms. The policy did not instruct the employees on how to handle the residents' drinking glasses and cups during meal service.",2020-09-01
617,C M TUCKER JR NURSING CARE,425074,2200 HARDEN STREET,COLUMBIA,SC,29203,2020-01-09,813,F,0,1,VNMK11,"Based on interview and facility policy review, it was determined the facility failed to develop and maintain a policy regarding food brought to residents by family and other visitors to ensure safe and sanitary storage, handling and consumption. The findings include: Interview with the Dining Manager, on 1/8/20 at 9:18 AM, revealed food brought in from outside sources policy is a draft and has not been disseminated to residents, families, or visitors at this time. Continued interview revealed staff have been trained to contact nutritional services regarding any foods brought in by families. Additionally, family members are educated upon admission to check with the nurse before bringing in and giving food to residents. Interview on 1/8/20 at 9:35 AM, with the Chief Clinical Dietician, revealed that the purpose of the policy is ensure safe food is brought in by families and visitors. He/she further stated the Nutritionist educated the family at care team conferences about bringing in food and the family members are educated resident food policy upon admission. Further interview revealed the Dietician has educated staff on how to store food brought in by families; however, the facility was unable to provide documented evidence of the staff education. Interview with the Director of Nutrition Services, on 1/8/20 at 7:21 PM, revealed the purpose of the policy for food brought in from outside sources is to protect residents from food borne illness. He/she stated he/she was not aware that the policy for food from outside sources was a requirement; however, he/she knew it was something they needed to look at but needed to work with the nursing department to develop it. The Director of Nutrition Services stated there is a draft policy about food brought in from outside sources; however, it was not used at this time. Continued interview revealed the facility's admission packet contains a paragraph about food brought in from visitors. He/she stated that his/her plan is to revise the policy in the admission packet, have the nutritionist educate the families on it during the resident's initial assessment and quarterly care conferences, then educate staff on it. Review of the facility's policy titled Foods Brought in from Outside Sources, not dated, revealed was in draft form and nursing would make every effort to ensure foods brought in from outside sources are safe and follow food safety sanitary code standards from infection control and the resident's diet restrictions. Continued review revealed the resident's family members, or the resident's friend would be encouraged to check with the facility's staff (dietary and nursing) before bringing in foods to determine if there are any recommended dietary restrictions or texture modifications that should be allowed. Review of the facility's policy titled Resident Food Policy, not dated, revealed the family would check with the nurse on duty to ensure that the resident is not on a special diet before giving the resident any food, make the nurses aware of any food left for the resident, store the food in containers, and not give any food or drink to any residents without approval from nursing staff. However, the policy does not address staff assisting the resident in accessing and consuming the food if needed and the storage of food brought in by family or visitors.",2020-09-01
618,C M TUCKER JR NURSING CARE,425074,2200 HARDEN STREET,COLUMBIA,SC,29203,2017-06-01,155,D,0,1,YBVO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to have 2 physicians evaluate the decisional capacity of Resident #99, 1 of 11 residents reviewed for Advance Directives. Resident #99 was made DNR (Do Not Resuscitate) Status after being evaluated by 1 physician who determined that the resident was not capable of making their own healthcare decisions. The findings included: The facility admitted Resident #99 with [DIAGNOSES REDACTED]. Record review of the Election of Code Status and Medical Intervention form on 5/31/2017 at 11:25 AM, revealed that DNR status was selected for the resident. The form was signed by a family member and Physician #1 on 5/17/2017. Review of a Certification Of Inability To Consent form on 5/31/2017 at 11:25 AM, revealed that Resident #99 was examined by Physician #1 on 5/18/2017. Physician #1 certified that resident #99 was unable to make healthcare decisions due to his/her cognitive status. There was an area on the form to be completed by a 2nd physician to indicate whether they concurred or did not concur with the previous physician's findings. This was not completed by a 2nd physician. During an interview with the Social Worker on 6/1/2017 at 10:22 AM, the Social Worker confirmed that Resident #99 had been made DNR status and was not evaluated by 2 physicians for decisional capacity. In addition, the Social Worker stated he/she was not aware that 2 physicians were required to determine decisional capacity for a resident when family members select Code status for a resident.",2020-09-01
619,C M TUCKER JR NURSING CARE,425074,2200 HARDEN STREET,COLUMBIA,SC,29203,2017-06-01,157,D,0,1,YBVO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide notification for 1 of 3 residents reviewed for falls and 1 of 5 reviewed for unnecessary medications. Hospice staff for Resident #43 were not notified of falls and the family of Resident #43 was not notified of medication changes. The family of Resident #68 was not notified of a hospital admission. The findings included: Resident #43 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Nursing Notes for Resident #43 on 6/1/17 at approximately 9 AM revealed the resident was placed on [MEDICATION NAME] 10 mL by mouth every six hours as needed for coughing episodes. The note revealed no indication that family was notified of medication changes. Interview with Registered Nurse (RN) #1 on 6/1/17 at approximately 10:10 AM confirmed there was no documentation that family was notified regarding medication changes in the nursing notes or original telephone order. Resident #43 was admitted to Tri-County Hospice on 4/25/16. Review of Nursing Notes for Resident #43 on 6/1/17 at approximately 9 AM revealed the resident fell [DATE] and 5/5/17. Nursing notes lacked documentation that hospice was notified. Review of Incident Reports for Resident #43 on 6/1/17 at approximately 9:10 AM revealed the resident fell on [DATE], 5/8/17, 5/5/17, and 5/3/17. The incident reports lacked documentation that hospice was notified. Review of the Resident Coordination Form for Hospice Care of Tri-County on 6/1/17 at 12:14 PM revealed that hospice is to be called at a provided 24-hour phone number in the event the Resident # 43 suffers the following: temperature, falls, signs and symptoms of infection. Interview with Licensed [MEDICATION NAME] Nurse (LPN) #3 on 6/1/17 at approximately 12:40 PM confirmed the lack of documentation that hospice was notified of resident falls. Interview with Social Worker #1 and LPN #1 on 6/1/17 at approximately 12:50 PM confirmed that communication to hospice is done via phone and such communications are documented in nursing notes. Review of nursing notes for Resident #68 on 5/31/17 at approximately 1:41 PM revealed the resident was sent out to be admitted to the hospital on [DATE]. Nursing notes did not indicate that the resident's family was notified of the hospital admission. Interview with LPN #3 on 5/31/17 at approximately 3:30 PM revealed that s/he was unable to find documentation that indicated the resident family was informed of the resident's admission on 1/31/17. Review of policy for family notification on 6/1/17 at approximately 11 AM revealed that it is the physician's responsibility to notify the responsible party of any changes during normal business hours. After normal business hours it is the responsibility of the nursing supervisor or charge nurse to notify family.",2020-09-01
620,C M TUCKER JR NURSING CARE,425074,2200 HARDEN STREET,COLUMBIA,SC,29203,2017-06-01,253,E,0,1,YBVO11,"Based on observations of multiple resident bathrooms during survey; urinals, wash basins, and bedpans were improperly stored. Findings included: Resident # 44 on all 3 days of survey had a wash basin and dirty clothes in a plastic bag observed on the floor of the resident's bathroom. Resident # 5 on all 3 days of the survey had 3 urinals on the floor of the resident's shared bathroom, and a bedpan unlabeled and stored improperly on the bathroom rails. Confirmed by LPN #2 on 06/01/2017 at approximately 09:00 AM. Observation of the bathroom for room 401 on 5/31/2017 at 9:21 AM revealed 3 urinals hanging from a grab bar in the bathroom. Two of the urinals were not labeled with resident names. Observation of the bathroom shared by rooms 402 and 403 on 5/31/2017 at 9:33 AM, revealed 3 urinals hanging from the grab bar in the bathroom. None of the urinals were labeled with resident names. Observation of the bathroom shared by rooms 430 and 431 on 5/31/2017 at 9:39 AM, revealed 3 urinals hanging from a grab bar in the bathroom. Two of the urinals were not labeled with resident names. All 3 urinals did not appear clean due to small amounts of yellow colored fluid and small amounts of what appeared to be dried, yellowish fluid in the bottom of the urinals. During an observation and interview with LPN (Licensed Practical Nurse) #4 on 6/1/2017 at 11:35 AM, LPN #4 confirmed that all 3 urinals in the bathroom shared by rooms 430 and 431 did not appear to be clean. In addition, LPN #4 confirmed that 2 of the urinals were not labeled with resident names. LPN #4 stated that urinals should be labeled with resident names, cleaned after each use and stored with lids closed. During an observation and interview with LPN #3 on 6/1/2017 at 11:40 AM, LPN #3 confirmed that 2 of the 3 urinals in the bathroom for room 401 were not labeled. LPN #1 stated that only 1 resident used a urinal in this room and that resident's urinal was labeled. LPN #3 also confirmed that the labeled urinal was stored with a small amount of dark yellow fluid in the bottom of the urinal. During an observation and interview with LPN #3 on 6/1/2017 at 11:42 AM, LPN #3 confirmed that the 3 urinals in the shared bathroom for rooms 403 and 402 were not labeled. In addition, LPN #3 confirmed that one of the urinals was stored with a small amount of light yellow fluid in the bottom of the urinal. Review of the facility's Bedpan/Urinal/ Bedside Commode: Cleaning policy on 6/1/2017 at 11:50 AM, revealed that new urinals/bedpans are to be labeled with the resident's name in permanent marker. In addition, urinals/bedpans are to be sprayed with disinfectant and rinsed with water after use.",2020-09-01
621,C M TUCKER JR NURSING CARE,425074,2200 HARDEN STREET,COLUMBIA,SC,29203,2017-06-01,282,D,0,1,YBVO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to implement fall interventions ordered for 1 of 1 resident reviewed for accidents. Resident #43 did not have interventions in place that were care planned and ordered for fall prevention. The findings included: Resident #43 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the care plan for Resident #43 on 6/1/17 at approximately 8:53 AM revealed the care plan for fall risk included a deluxe bed and chair alarm and falling star program red bracelet indicating fall risk status. Review of physician orders [REDACTED]. Observation of Resident #43 on 6/1/17 at approximately 6/1/17 revealed the resident lacked the red bracelet indicating the fall risk status and the chair alarm. Interview with Registered Nurse #1 on 6/1/17 at approximately 10:23 AM confirmed the resident lacked the red bracelet and the chair alarm. Review of policy for falls on 6/1/17 at approximately 11:50 AM revealed the falling star logo, including red armband, are to alert all staff to resident's fall risk status.",2020-09-01
622,C M TUCKER JR NURSING CARE,425074,2200 HARDEN STREET,COLUMBIA,SC,29203,2017-06-01,323,D,0,1,YBVO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to implement fall interventions ordered for 1 of 1 resident reviewed for accidents. Resident #43 did not have interventions in place that were care planned and ordered for fall prevention. The findings included: Resident #43 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the care plan for Resident #43 on 6/1/17 at approximately 8:53 AM revealed the care plan for fall risk included a deluxe bed and chair alarm and falling star program red bracelet indicating fall risk status. Review of physician orders [REDACTED]. Observation of Resident #43 on 6/1/17 revealed the resident lacked the red bracelet indicating the fall risk status and the chair alarm. Interview with Registered Nurse #1 on 6/1/17 at approximately 10:23 AM confirmed the resident lacked the red bracelet and the chair alarm. Review of policy for falls on 6/1/17 at approximately 11:50 AM revealed the falling star logo, including red armband, are to alert all staff to resident's fall risk status.",2020-09-01
623,C M TUCKER JR NURSING CARE,425074,2200 HARDEN STREET,COLUMBIA,SC,29203,2017-06-01,356,C,0,1,YBVO11,"Based on observation and interview with the administrator, the facility failed to post completed staff posting information in 1 of 1 main entrance. Staff postings were incomplete and unfilled for the current shifts. The findings included: Observation of staff postings on 5/30/17 at approximately 4:04 PM revealed only the first shift information was filled out. The second shift (3 PM - 11 PM) and third shift (11 PM - 7 AM) information was not filled out. Observation of staff postings on 5/31/17 at approximately 4:06 PM revealed only the first shift information was filled out. The second and third shifts were unfilled. Interview with the administrator on 5/31/17 at approximately 4:06 PM confirmed the second and third shifts were unfilled.",2020-09-01
624,C M TUCKER JR NURSING CARE,425074,2200 HARDEN STREET,COLUMBIA,SC,29203,2017-06-01,371,E,0,1,YBVO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to assure sanitary storage of foods on 2 of 3 units.[NAME] 124's refrigeration unit contained expired glucerna and[NAME] 122's refrigeration unit did not meet safe temperatures. The findings included: Observation of the refrigeration unit on[NAME] 124 on 6/1/17 at approximately 11:15 AM revealed a glucerna container that expired (MONTH) (YEAR) was still in the refrigerator. Interview with Licensed [MEDICATION NAME] Nurse #5 on 6/1/17 at approximately 11:15 AM confirmed the expired glucerna. Observation of the refrigeration unit on[NAME] 122 on 6/1/17 at approximately 11:28 AM revealed the refrigerator temperature was 50 degrees Fahrenheit. Interview with Registered Nurse #2 on 6/1/17 at approximately 11:28 AM confirmed the refrigerator temperature. Review of temperature logs for the refrigerator on[NAME] 122 at approximately 11:30 AM revealed the refrigerator routinely reached temperatures above 41 degrees Fahrenheit. From the previous month alone, 25 of the temperature checks read to 42 degrees Fahrenheit or above. Interview with the Director of Nursing on 6/1/17 at approximately 11:58 AM revealed the procedure was for nursing staff to inform maintenance if refrigerator temperatures were inadequate. Maintenance had not been alerted prior to survey.",2020-09-01
625,C M TUCKER JR NURSING CARE,425074,2200 HARDEN STREET,COLUMBIA,SC,29203,2017-06-01,502,D,0,1,YBVO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure that 1 of 5 sampled residents reviewed for unnecessary medications and 1 of 3 sampled residents reviewed for nutrition/weight loss received laboratory services as ordered. Resident #22 did not have lipid panel, [MEDICAL CONDITION]-stimulating hormone (TSH) or hemoglobin (hgbA1c ) labs done as ordered. Resident #14 hemoglobin lab not done as ordered. The findings included: The facility admitted Resident #22 with diagnosed that included Depression, [MEDICAL CONDITION], Pacemaker, and Behavioral Disturbances. A record review on 5/31/17 at approximately 12:59 PM revealed a monthly cumulative physician's orders [REDACTED]. The monthly order was signed by a nurse on 3/25/17 as being checked. The physician signed the orders on 3/31/17. Further review of the physician's orders [REDACTED]. The request for labs was also noted on the Medication Administration Record [REDACTED]. An interview on 6/01/17 at approximately 9:53 AM with Licensed Practical Nurse (LPN) #1 who reviewed the chart and stated he/she could not locate the physician's orders [REDACTED]. LPN #1 stated he/she would notify the unit clerk to see if the labs are on the facility's computer. An interview on 6/01/17 at approximately 10:16 AM with the Director of Nursing (DON) and LPN #1 confirmed the Lipid Panel, TSH and HgbA1c lab was not done as ordered. The facility admitted Resident #14 with [DIAGNOSES REDACTED]. Record review of the physician's orders [REDACTED]. Another physician's orders [REDACTED]. Review of the lab reports on 6/1/2017 at 11:16 AM, revealed no lab results for the hemoglobin and hematocrit. During an interview with Physician #1 on 6/1/2017 at 11:16 AM, Physician #1 stated that she/he thought she/he remembered seeing the hemoglobin and hematocrit results and talking with the family about the results. After reviewing her/his notes, she/he could not find any documentation of this. During an interview with LPN (Licensed practical Nurse) #3 on 6/1/2017 at 11:20 AM, LPN #3 confirmed the facility did not have the lab results for the hemoglobin and hematocrit. LPN #3 stated the lab would be called to request the results. LPN #3 provided a lab requisition slip left by the lab company that indicated the resident's blood was collected on 5/11/2017. The lab slip indicated a hematocrit and a hemoglobin A1c was collected on 5/11/2017. The lab slip indicated that a hemoglobin was not collected. On 6/1/2017 at 11:37 AM, the lab company faxed a copy of the results of the hematocrit level to the facility. The lab report indicated the hematocrit had been drawn on 5/11/2017 and the results had been reported to the facility on [DATE]. The hematocrit level was within normal limits. During an interview with the Quality Improvement Director on 6/1/2017 at 11:56 AM, the Quality Improvement Director stated that the hemoglobin level was not drawn as ordered.",2020-09-01
626,C M TUCKER JR NURSING CARE,425074,2200 HARDEN STREET,COLUMBIA,SC,29203,2019-12-05,657,D,1,0,XYQD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record reviews and staff interviews, the facility's Interdisciplinary team (IDT) continued to update Resident#1's care plan without specifying exactly what re-direction entailed for 1 of 8 sampled residents who displayed resident to resident aggressive behaviors. Findings included: Resident#1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident#1's care plan dated 3/14/19 documented Interdisciplinary meetings after each episode of resident to resident physical altercations as follows: 2/12/19-Resident#1's care plan was up-dated. Review of the psychologist report and the episodic care plan dated 2/13/19 revealed no change of the original behavioral goal and intervention to reduce Resident#1's aggressive behaviors. 4/15/19-The psychiatrist ordered [MEDICATION NAME] (antipsychotic) and [MEDICATION NAME] (antianxiety) for anxiety symptoms and irritability after resident to resident physical altercation involving Resident#1 and Resident#2. The physician will continue to follow and re-evaluate the resident's medications and dosages so that they are appropriate to assist the resident in managing his behaviors. This intervention was the same intervention originally documented on Resident#1's original care plan dated 3/14/19. 4/19/19-Resident#1 was evaluated by the facility's physician and psychologist. Both reported no injuries to either resident and continued follow-up was recommended. The Interdisciplinary Team created an episodic care plan but did not change the original care plan interventions to reduce aggressive behaviors.",2020-09-01
627,C M TUCKER JR NURSING CARE,425074,2200 HARDEN STREET,COLUMBIA,SC,29203,2019-12-05,742,D,1,0,XYQD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, resident and staff interviews, medical record review and review of facility policy, the facility failed to assess a resident's expressions of physical aggressions toward other residents and failed to identify indicators of distress to determine the psychological services and treatment needed to reduce the aggressive behavior(s) for 1 of 8 residents identified as displaying resident to resident physical aggression. On multiple dates (1/31/19, 2/12/19, 4/15/19, 4/19/19, and 10/8/19), Resident#1 (R#1) displayed physical behavioral symptom, of punching other sampled residents (R#2, R#3, and R#4) in the abdomen, shoulder and chest without any identified provocation. Psychological service staff failed to ensure the resident received appropriate treatment and services to anticipate the trigger and decrease the frequency of this physically aggressive behavior. Findings included: On 12/4/19 observations revealed eleven residents were seated in either wheelchairs or regular chairs at the Nurses' Station. Facility staff were observed going in and out of residents' rooms performing daily duties such as housekeeping, and personal care of residents. There was no interaction of resident and staff during this observation period. The television was on and tuned to a game show. There were no residents observed viewing the television program. Resident#2 was observed to be neatly dressed and seated in a regular chair between two residents. Resident#2 stood up and walked over to another resident and pushed the resident's wheelchair approximately five (5) feet down the hallway, before staff intervened and re-directed Resident#2 back to a chair. At 10:45 a.m. Resident#1 propelled his wheelchair down to the North end of the hallway and remained there for approximately five (5) minutes before returning to the Nurses' station. Resident#1 again wheeled himself at 11:10 a.m. to the opposite end of the hallway (South end) and remained there for ten (10) minutes before returning to the Nurses' station, and later entering his room. During an interview with CNA #2 on 12/4/19 at 2:00 p.m., Resident#1 was described as a resident who hit other residents, and no one understood why. She recalled an incident involving Resident#1 and Resident#2. According to the CNA, Resident#1 punched Resident#2 in the stomach and walked away. The CNA continued stating, Resident#1 is known for this type of aggressive behavior towards Resident#2 and other residents. He, (Resident#1) never explains any reason for his behavior nor does he display any remorse. He simply does not respond when his behavior is questioned. Review of Resident#1's medical record revealed documentation of eight (8) incidents of aggressive behavior towards other residents, including the incident described by CNA #2 on 4/19/19. Facility Incident Reports documented the following: 1/31/19-Staff witnessed Resident#1 punch Resident#2 in right side of abdomen, no injury reported. 2/12/19-Resident #1 was holding onto Resident#3's wheelchair. Resident#1 was sitting in his wheelchair. Resident #1 turned around facing Resident#2 and hit Resident#2 the left (L) shoulder. No apparent injury noted to either resident. 4/15/19-Resident #1 punched his peer, Resident#2 in the chest, no injuries noted at this time. 4/19/19- Resident to resident altercation. Resident#1 hit and punched Resident#3, with no apparent injury. 9/20/19-Both residents were ambulating per wheelchair. Resident #4 put his foot into Resident#1's wheelchair. Resident#1 hit Resident#4 in the chest twice and attempted to choke Resident#4. Staff immediately intervened and separated the residents. Both residents were examined by the facility's Medical Doctor (MD). No apparent injuries were noted. 10/8/19-Resident#1 pushed and hit Resident#3. The MD examined both residents, no apparent injuries noted. The facility investigated all reported incidents and completed the 24-Hour Reports and the required 5-Day Follow- Up Reports dated 1/31/19, 2/12/19, 4/19/19, 9/20/19 and 10/8/19, which documented the following resolutions: 1/31/19-The facility's investigation documented two (2) revised episodic care plans for Resident#1 consisting of referral to the facility's psychologist. The psychologist report dated 1/12/19, revealed continued observation of R#1 and staff to anticipate any aggressive behaviors. Psychological Progress Notes contained in Resident#1's medical recorded documented the following: 1/9/19-Resident#1's depression continues, major neurocognitive disorder with behavioral disturbance (wandering) likely mixed etiology (vascular and alcohol); secure unit; continue current medications. Continue [MEDICATION NAME] (antidepressant); follow up Psychological care plan interventions. 2/12/19-Resident care plan up-dated and referral to the facility's psychologist. Review of the psychologist report dated 2/13/19 revealed continued redirection and observation of Resident#1. 2/1/19-Psychological Progress Note documented occasional episodes of angry outbursts and striking out at others. Continue with current medications. 5/24/19-Psychological Progress Note revealed resident continues to display episodes of angry outbursts and striking out at others. Continue to observe behaviors and implement care interventions. 9/30/19-Psychological Progress Report revealed recommendations to continue to implement psychological interventions to reduce occasional angry outburst of and striking out at others. No change in medications. The most recent Minimum Data Set (MDS) assessment dated [DATE] was a Quarterly Review. Resident#1 was assessed to be cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 02 which indicated cognitively impaired with both short- and long-term memory problems. Review of the mood and behaviors, documented physical aggression towards other. The medical record also contained Resident#1's Care Plan dated 3/14/19. The following identified problems were documented with both goals and approaches for resolution: Problem (Start Date 3/14/19) Resident #1 has cognitive loss r/t (related to) dx (diagnosis) of Dementia with behavioral disturbances AEB (as evidenced by) short- and long-term memory problems, impaired decision-making ability, SLUMS (Saint Louis University Status) score of 1 (12/21/17) and BIMS score of 1 (12/21/17) with the annual assessment. Has had several episodes of peer on peer aggression towards staff. Goal: Target Date: 06/13/19 Resident #1 will remain safe and have his needs met through the next review period. Approaches (Start Date 3/14/19) Allow adequate time to absorb and respond to information. Approach Start Date: 3/14/19 Assess BIMS quarterly Approaches Start Date 3/14/19 Explain all procedures, tasks, activities and treatment to veteran prior to starting them such as pain guarding, moaning, grimacing, restlessness, diaphoresis or withdrawal. Approach Start Date: 3/14/19 Observe and document any changes or decline in cognitive status Approach Start Date: 3/14/19 Reorientation and redirection PRN (as needed) Approach Start Date: 3/14/19 Medication Change 4/15/19: [MEDICATION NAME] (antipsychotic) per MD order, [MEDICATION NAME] (antianxiety) per MD order, all medications are prescribed for paranoia and aggressive behaviors. Problem Start Date: 3/14/19 Target Date: 6/13/19 Problem Resident #1 will not harm self or others and he will utilize his potential to improve his quality of life as well as, express satisfaction with unit activities. Approaches: Activity staff will check regularly to assess satisfaction with activities offered Approach Start Date: 3/14/19 Problem: Resident will be welcomed to facility and introduced to residents with similar interest. Problem Start Date 9/20/19 Goal: Resident hit his peer in the chest. Problem Start Date: 3/14/19 Approach Resident redirection The care plan did not direct staff on how to anticipate Resident#1's aggressive behavior and did not reference the resident requiring referral to psychological services as indicated in the resolution of the facility's Investigation Report. In addition, the care plan was updated to address decreasing and or managing the resident's physical behavioral incidents occurring after 3/14/19. Resident#1 was again observed on the Secured Unit neatly dressed, eyes closed with head slumped close to chest, seated in wheelchair at the Nurse's Station on 12/5/19 at 11:02 p.m. There were twelve other residents seated in wheelchair in a circle. When asked if residents always sat at the Nurse's Station, Certified Nurse Assistant (CNA#1) stated Yes, it allows the housekeeping staff an opportunity to change the bed linen, give morning baths, and provide incontinent care. Observations conducted on the Secured Unit on 12/4/19 at 10:22 a.m. through 12/5/19 at 10:35 a.m. revealed there were no observed activities being provided. Interview with the Human Service Counselor, who was assigned to assess and identify residents' behaviors, both aggressive and non-aggressive, and develop care plan interventions to reduce and or eliminate aggressive behaviors, was conducted on 12/4/19 at 4:05 p.m. in a vacant office on the Secured Unit. According to the Counselor, the only non-pharmacological interventions developed to address the resident's aggression were to remove the resident from the room and re-direct the resident's behavior. He did not recall Resident#1 having any assessment to identify indicators of distress in order to determine the psychological services and treatment Resident #1 needed to reduce incidents of aggressive behaviors. He acknowledged understanding of the importance to identify distresses to behavior, and said the facility, to his knowledge, did not assess for resident's behavioral distress. On 12/5/19, interview with the facility's Administrator at 9:07 a.m. revealed the assigned Director of Psychology had been on leave since (MONTH) 2019. The Medical Director was aiding the Psychological Services Department, during the absence of the Director. During a conference call with the Administrator and Medical Director, the Medical Director explained the use of the MDS as the only assessment tool to identify distresses. She further stated the written psychological notes contained information pertaining to identified behavioral distresses and interventions. The Director also stated that Resident#1's care plan documented other interventions such as removal from the room. She requested the Administrator to ask the psychological staff to review Resident#1's medical record for evidence of behavioral assessment distress and interventions. After review by the psychological staff, there was no written documentation of behavioral distresses or interventions in the record. The Human Service Counselor responsible for providing psychological assessment and developing behavioral interventions for residents of the Secured Unit and for Resident#1, was interviewed on 12/5/19 in the Secured Unit's Day room at 9:00 a.m. The Counselor stated he was aware of Resident#1's aggressive behaviors. When asked if there were specific behavioral interventions to decrease the resident's aggression, he replied re-direction and removal from the environment. The Surveyor asked the effectiveness of the intervention considering R#1 continued escalation in the number of behavioral incidents. The Counselor responded by saying to his knowledge these were the only interventions implemented. He was unaware of any assessment, other than the MDS, used to identify aggressive behaviors. When asked if the facility implemented non-pharmacological interventions, other than removal from the environment and re-direction. The response was No. Interview on 12/4/19 at 3:45 p.m. in the Unit Nurse office revealed Licensed Practical Nurse (LPN) #2 acknowledged Resident#1 displayed aggressive behavior, such hitting/striking out at residents and staff. She stated she had been the victim of Resident#1's aggression. According to the staff, when attempting to administer routine medications to Resident#1, he refused. When she later attempted again, Resident#1 became physically assaultive. When asked if she understood or knew the reason for Resident#1's aggressive behavior, she replied, I think he doesn't like white women, because he only responds this way toward white women. During the same interview LPN#3 validated LPN#2's impression of R#1 and stated R#1 was not only physically aggressive towards females, but also toward other residents and referred to aggression toward R#2, R#3 and R#4. The facility Social Worker was interviewed on 12/6/19 in the Social Worker's office at 9:30 a.m. According to the Social Worker she was aware of Resident#1's physically aggressive behavior. She has interviewed Resident#1 on several occasions after he aggressed toward other residents. She described Resident#1 as a person who had a [DIAGNOSES REDACTED]. She was of the opinion these [DIAGNOSES REDACTED].#1's aggression, stating he was angry and had no desire to be a resident. The Social Worker stated he would like to be home with his sister, who cannot care for him, due to her own personal responsibilities. The Social Worker continued by stating R#1 refused to provide verbal response for the reason/rational for his aggressive behaviors. The Director of Activities was interviewed on 12/5/19 at 10:45 a.m. in the Secured Unit Day Room. The Director stated he was aware of the frequency of R#1's aggressive behaviors towards others. Interventions such as diversional activities were used occasionally to distract inappropriate behaviors. These activities, however, did not always result in reduction of negative behaviors. Currently, the Secured Unit was without an assigned Activity staff, since (MONTH) 2019. The responsibility of providing scheduled activities had been shared between the Director of Activities and the assigned activity staff from the Non-secured Unit. During the interview the Surveyor described observations of residents in the Secured Unit sitting in wheelchairs and regular chairs near the Nurses' Station with no observed activities being provided on 12/4/19-12/5/19. The Surveyor explained how the Second Shift Nursing staff on 12/5/19, began to interact with residents, at 4:05 p.m., tossing a beach ball to residents seated in the circle, after the Surveyor began to question nursing staff about activities. The following morning Christmas music was played, and nursing staff was observed to engage in a Sing-Along activity. At 11:10 a.m. on 12/6/19, the Director of Activities was observed throwing the same ball from the previous day and music was changed from Christmas songs to R&B songs. During the interview with the Activity Director on 12/5/19, he stated the nursing staff was responsible for following the Activity Schedule posted in the Unit. An activity scheduled was observed on the wall of the Unit near the exit door. The schedule documented a large group activity in the Main Dining Room. Singers from the community will provide entertainment for all residents of the facility. Observation of the residents, at the time of the scheduled activity revealed no resident being escorted to the activity until the Activity Director requested staff to assist residents to the activity. Interview with the facility Administrator on 12/5/19 at 11:00 a.m. confirmed the vacancy of the Activity Staff for the Secured Unit. A review of the facility's policy entitled South [NAME]ina Department of Mental Health Psychological Services dated 8/2019 documented the policy of the Psychology Services is to provide behavioral and psychological consultation, assessments, and interventions, with respect to improving the quality of the life for residents. The facility's current psychological assessment does not assess for distress triggers contributing to resident's aggressive behaviors. Behavioral interventions such as redirection and removal of resident from the toxic environment are the most utilized interventions to reduce aggression. Diversional activities to reduce, distract and redirect resident's attention from engaging in inappropriate behaviors are not being implemented due to a lack of activity staff, the facility cannot implement non-pharmacological interventions to decrease resident to resident altercations and keep residents safe from abuse.",2020-09-01
628,PRISMA HEALTH-LILA DOYLE,425075,101 LILA DOYLE DRIVE,SENECA,SC,29672,2019-01-11,552,G,1,1,P8ZJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, and interview the facility failed to ensure resident rights related to choices in treatment. Staff ignored Resident #61's refusal for use of [MEDICATION NAME]. 1 of 1 resident reviewed for Foley catheter. The findings included: The facility admitted Resident #61 on 08/14/2018 with [DIAGNOSES REDACTED]. Review of Resident #61's nurse's notes revealed on 11/04/2018 the nurse explained the procedure for inserting a Foley catheter to the resident. The resident stated (s/he) was allergic to [MEDICATION NAME]. At that point the nurse stated the Physicians progress note dated 10/5/2018 stated the resident was not allergic to [MEDICATION NAME]. [MEDICATION NAME] was used, and the Foley catheter inserted using sterile technique. During an interview on 01/08/19 at approximately 04:37 PM Resident #61 stated The Nurse said (s/he) had to put the Foley in, (s/he) had an order. I didn't object to the Foley, just the [MEDICATION NAME] (s/he) was going to use. I had an allergy to it, so I told (her/him) it is against my will. (S/he) kept saying I have a doctor's order and I have to do this. The order came from my doctor stating that I did not have an allergy to [MEDICATION NAME]. My daughter even told them I did not. After the [MEDICATION NAME] was used and the Foley put in, I burned for days and felt like I was swollen in my vagina, (s/he) cried when (s/he) got in trouble for not listening to me.",2020-09-01
629,PRISMA HEALTH-LILA DOYLE,425075,101 LILA DOYLE DRIVE,SENECA,SC,29672,2019-01-11,580,G,1,1,P8ZJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview, and review of the facility's policy Notification of Change the facility failed to notify the physician and/or family timely of a change in condition for Resident #100, 1 of 2 residents reviewed for change in condition. The findings included: The facility admitted Resident #100 on 05/18/18 with [DIAGNOSES REDACTED]. On 01/10/19 at 01:44 PM, review of the Daily Skilled Nurse's Note for Resident #100 dated 06/08/18 through 06/10/18 revealed on 06/08/18 the resident was alert and able to voice needs. There was no documentation on 06/09/18. On 06/10/18 at 05:00 AM, the nurse documented the resident was lethargic. At 07:30 AM, the day shift nurse also documented the resident was lethargic but responds to staff. At 11:00 AM, the resident continued to be lethargic and responding to staff but was incontinent and refused breakfast and morning medications. At 11:22 AM, the family was in the resident's room and were concerned about the resident's condition and the nurse paged the physician to notify (him/her) of the resident's condition. Further review of Resident #100's record revealed a SBAR (Situation/ Background/ Assessment/ Request) Communication Form dated 06/10/18 that indicated the resident had decreased consciousness as indicated by the signs/ symptoms described as lethargic, won't eat, wake up, incontinent. The report also indicated the family was notified of the resident's condition at the facility at 11:00 AM and the physician was notified at 11:22 AM. Review of the facility's policy entitled Notification of Change revealed the facility must immediately inform the resident, consult with the resident's physician and if known, notify the resident's legal representative of (sic) interested family member when there is . a significant change in the resident's physical, mental, or psychosocial status . During an interview on 01/10/19 at 04:28 PM, the Director of Nursing (DON) confirmed the documentation indicated the family was aware of the change in the resident's condition at 11:00 AM when they came to visit, and the MD was notified at 11:22 AM. The DON further stated s/he would have expected the nurse to notify someone earlier and stated the Nurse Practitioner would have been the best person to notify.",2020-09-01
630,PRISMA HEALTH-LILA DOYLE,425075,101 LILA DOYLE DRIVE,SENECA,SC,29672,2019-01-11,602,D,1,1,P8ZJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, the facility failed to ensure residents remained free from misappropriation of resident property. Resident #97's wallet went missing during care by Certified Nursing Assistant (CNA #3). 1 of 1 resident reviewed for misappropriation. The findings included: The facility admitted Resident # 97 on 11/1/2017 with the [DIAGNOSES REDACTED]. Review of Resident #97's medical record revealed a Brief Interview for Mental Status (BIMS) Score of 9. Review of the facility investigation revealed that Resident #97 reported to facility staff on 08/06/2018 at approximately 10:30 AM that (his/her) wallet went missing during care by CNA #3. The investigation revealed that the alleged perpetrator was identified by Resident #97 as the Certified Nursing Assistant (CNA) #3 that provided care on the previous evening shift on 08/05/2018. Resident #97 reported his/her missing wallet the next morning at approximately 10:30 AM. CNA #3 had already completed his/her shift and had left prior to the resident reporting his/her wallet missing. Review of Registered Nurse (RN) #4's statement revealed that Resident # 97 told staff member that (CNA #3) was helping (him/her) to the bathroom and asked (him/her) to hold onto (his/her) wallet. Resident # 97 stated that (s/he) asked (CNA #3) about (his/her) wallet and (CNA #3) told (him/her) that (s/he) put the wallet in the bedside table. When Resident #97 woke up on 8/6/2018, (s/he) reported that (s/he) checked the bedside table and the wallet was not there. During an interview on 01/10/19 at 10:20 AM RN #4 Confirmed her/his statements with additional information that RN #4 remembered that Resident #97's daughter/son was not concerned about replacement of the resident's wallet, but that s/he was mostly upset about the loss of sentimental pictures that were in the resident's wallet. Review of CNA #2 statements revealed that CNA #2 reported to the Licensed Practical Nurse (LPN) that Resident # 97 told (her/him) that (his/her) wallet was missing and (Resident #97) stated that the male CNA young man who put (him/her) to bed last night put it in (his/her) pocket, and then (s/he) asked (CNA #3) what (s/he) did with the wallet. CNA #2 stated that Resident #97 stated (S/he) (CNA #3) put the wallet in (his/her) top drawer, and states the wallet is not in the drawer. Resident #97 then reported to the LPN the same timeline of events reported to the CN[NAME] During an interview on 01/08/19 at 2:43 PM Resident #97 stated s/he had almost $60 in his/her wallet. During an interview on 01/10/19 at 2:12 PM Resident #97's daughter/son stated that Resident #97 told him/her that a male CNA took his/her wallet. The daughter/son stated that Resident #97 did have some money in his/her wallet but was not sure on how much, s/he stated, maybe fifty to seventy dollars. Resident #97's daughter/son stated that the facility notified her/him of the incident, but the facility did not replace the missing wallet.",2020-09-01
631,PRISMA HEALTH-LILA DOYLE,425075,101 LILA DOYLE DRIVE,SENECA,SC,29672,2019-01-11,607,D,1,1,P8ZJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, the facility failed to implement written policies and procedures that prohibit and prevent abuse. Resident #97's wallet went missing during care by Certified Nursing Assistant (CNA #3). 1 of 1 resident reviewed for misappropriation. The facility failed to obtain a criminal background check from the state of residency prior to employment for 1 of 1 Certified Nursing Assistant (CNA) reviewed for misappropriation. The findings included: Review of the facility investigation revealed that Resident #97 reported to facility staff on 08/06/2018 at approximately 10:30 AM that (his/her) wallet went missing during care by CNA #3. Review of Registered Nurse (RN) #4's statement revealed that Resident # 97 told staff member that (CNA #3) was helping (him/her) to the bathroom and asked (him/her) to hold onto (his/her) wallet. Resident # 97 stated that (s/he) asked (CNA #3) about (his/her) wallet and (CNA #3) told (him/her) that (s/he) put the wallet in the bedside table. When Resident #97 woke up on 8/6/2018, (s/he) reported that (s/he) checked the bedside table and the wallet was not there. During an interview on 01/10/19 at 10:20 AM RN #4 Confirmed her/his statements with additional information that RN #4 remembered that Resident #97's daughter/son was not concerned about replacement of the resident's wallet, but that s/he was mostly upset about the loss of sentimental pictures that were in the resident's wallet. Review of CNA #2 statements revealed that CNA #2 reported to the Licensed Practical Nurse (LPN) that Resident # 97 told (her/him) that (his/her) wallet was missing and (Resident #97) stated that the male CNA young man who put (him/her) to bed last night put it in (his/her) pocket, and then (s/he) asked (CNA #3) what (s/he) did with the wallet. CNA #2 stated that Resident #97 stated (S/he) (CNA #3) put the wallet in (his/her) top drawer, and states the wallet is not in the drawer. Resident #97 then reported to the LPN the same timeline of events reported to the CN[NAME] During an interview on 01/08/19 at 2:43 PM Resident #97 stated s/he had almost $60 in his/her wallet. During an interview on 01/10/19 at 2:12 PM Resident #97's daughter/son stated that Resident #97 told him/her that a male CNA took his/her wallet. The daughter/son stated that Resident #97 did have some money in his/her wallet but was not sure on how much, s/he stated, maybe fifty to seventy dollars. Resident #97's daughter/son stated that the facility notified her/him of the incident, but the facility did not replace the missing wallet. Review of the facility policy titled Abuse, Neglect, Exploitation and Reasonable Suspicion of a Crime in a Subacute Facility stated At Greenville Health System (GHS) residents (patients) residing in a Subacute Unit have the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion, and exploitation/misappropriation of financial and personal property. Review of CNA #3's employee file revealed that CNA #3 was a travel CNA that worked for a staffing agency. Review of CNA #3's personnel record provided to the facility by the staffing agency revealed that the CNA's background screening report included searches of counties that the perpetrator resided in West Virginia and documents his/her residency. A West Virginia county criminal records search was included for the counties that the perpetrator resided in West Virginia. Noted in the documentation that West Virginia does not provide a Statewide search. Review of the facility policy titled Abuse, Neglect, Exploitation and Reasonable Suspicion of a Crime in a Subacute Facility stated All potential employees will be screened for history of abuse, neglect or exploitation/mistreatment of [REDACTED]. [NAME] The following screening interventions should be conducted prior to employment 1. Inquiry of state, local and federal jurisdictions for criminal convictions by the Greenville Hospital System (GHS) Human Recourse Department or its contracted affiliate .",2020-09-01
632,PRISMA HEALTH-LILA DOYLE,425075,101 LILA DOYLE DRIVE,SENECA,SC,29672,2019-01-11,609,D,1,1,P8ZJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, the facility failed to ensure that all alleged violations related to mistreatment, exploitation, neglect, or abuse were reported immediately, but not later than 2 hours after the allegation is made to the State Survey Agency. The facility did not report the 2 hour and the 5-day reports for Resident #61 within the required time frames. One of three incidents reviewed for reporting. The findings included: The facility admitted Resident #61 on 08/14/2018 with [DIAGNOSES REDACTED]. Review of the Incident Report and Investigation for an incident that occurred on 11/04/2018 revealed that the incident was not reported to the State Agency within the required time frame. There was no documentation of a 2-hour report being sent to the State Agency. The 24- Hour report was submitted to the State Agency on 11/08/2018 and the Five-Day Follow-Up Report was submitted on 11/12/2018. During an interview with the Director of Nursing on 01/11/2019 at approximately 10:30 AM, confirmation was obtained that the facility was late in reporting to the State Agency within the required time frames.",2020-09-01
633,PRISMA HEALTH-LILA DOYLE,425075,101 LILA DOYLE DRIVE,SENECA,SC,29672,2019-01-11,655,D,0,1,P8ZJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and chart review, the facility failed to update the baseline care plan for Resident #98, 1 of 6 residents reviewed for Baseline Care Plan. The findings included: The facility admitted Resident #98 with [DIAGNOSES REDACTED]. Review of Resident #98's Baseline Care Plan on 01/09/19 at 3:40 PM revealed the Baseline Care Plan had not been updated with the following physician's orders [REDACTED]. 12-19-18 [MEDICATION NAME] 10mg by mouth daily. 12-20-18 [MEDICATION NAME] 4 milligrams dissolving tabs every 8 hours as needed nausea/vomiting. 12-27-18 Type, cross, and transfuse 1 unit Packed Red Blood Cells (PRBS) [DIAGNOSES REDACTED]. Review of Resident #98's Nurses Notes on 12/27/18 at 0950 AM revealed Resident #98 was sent at 10am receive a transfusion. During an interview on 01/10/19 at 10:30am, Register Nurse #2 confirmed that the Baseline Care Plan had not been updated.",2020-09-01
634,PRISMA HEALTH-LILA DOYLE,425075,101 LILA DOYLE DRIVE,SENECA,SC,29672,2019-01-11,657,E,1,1,P8ZJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to ensure that all required disciplines participated in, and attended the care plan meeting for Residents #79, #93, #100 and #95. 4 of 18 residents reviewed for care plans. The findings included: The facility admitted Resident #79 on 11/21/18 with [DIAGNOSES REDACTED]. On 01/09/18 at approximately 04:00 PM, review of Resident #79's care plan revealed the only person present for the care plan was the Registered Nurse (RN). There was no indication that a Certified Nursing Assistant (CNA) or a dietary representative participated in the care plan or attended the care plan meeting. During an interview on 01/09/19, Minimal Data Set (MDS) Coordinator, confirmed there was documentation of RN participation only in the care plan for Resident #79. The MDS Coordinator stated that with the short-term rehab residents, the MDS Coordinator usually goes to the room and reviews the care plan with the resident or resident representative but the other disciplines do not attend. The facility admitted Resident #93 on 03/22/18 with [DIAGNOSES REDACTED]. On 01/09/19 at 04:23 PM, review of Resident #93's care plan revealed no documentation that a Certified Nursing Assistant participated in the care plan or attended the care plan meeting. During an interview on 01/09/18, the MDS Registered Nurse #1 confirmed there was no indication the CNA attended the care plan meeting or participated in the care plan for Resident #93. The facility admitted Resident #100 on 05/18/18 with [DIAGNOSES REDACTED]. On 01/09/18 at approximately 01:37 PM, review of Resident #100's care plan revealed no documentation that the RN was the only person present at the care plan meeting. There was no documentation that a CNA or any other discipline attended. During an interview on 01/09/19, Minimal Data Set (MDS) Coordinator, confirmed there was documentation of RN participation only in the care plan for Resident #100. The MDS Coordinator stated that with the short-term rehab residents, the MDS Coordinator usually goes to the room and reviews the care plan with the resident or resident representative but the other disciplines do not attend. The facility admitted Resident #95 with [DIAGNOSES REDACTED]. Review of Resident #95's record on 01/11/19 at 09:57 revealed the Baseline Care Plan was signed by the Registered Nurse and the resident. During an interview on 01/11/19, Registered Nurse #1 confirmed that the Baseline Care Plan for Resident #95 had no signatures to show it was developed by a representative from Dietary and a Certified Nursing Assistant.",2020-09-01
635,PRISMA HEALTH-LILA DOYLE,425075,101 LILA DOYLE DRIVE,SENECA,SC,29672,2019-01-11,658,G,1,0,P8ZJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview, and review of the US National Library of Medicine National Institutes of Health Pharmacy and Therapeutics Journal, the facility failed to ensure that staff followed the 5 Rights of Medication Administration for Resident #100. 1 of 7 residents reviewed for medication administration. The findings included: Resident #100 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review on 1/10/19 at 10:25 AM of Resident #100's Progress Notes revealed a re-admission note dated 06/11/18 that indicated on 06/10/18 the resident was lethargic with poor PO (by mouth) intake and was sent to the emergency department. A drug screen was positive for opiates. A [DIAGNOSES REDACTED]. A 06/13/18 progress note indicated suspicion here that (s/he) may have mistakenly been given roommate's quetiapine on 6/9 evening (and) level was drawn here (and) is (positive). Review of Resident #100's laboratory studies revealed the resident also had a positive [MEDICATION NAME] level. Review of the US National Library of Medicine National Institutes of Health Pharmacy and Therapeutics Journal, volume 35 dated October, 2010 revealed Most health care professionals, especially nurses, know the five rights of medication use: the right patient, the right drug, the right time, the right dose, and the right route-all of which are generally regarded as a standard for safe medication practices. During an interview on 01/10/19, the Director of Nursing confirmed the documentation indicated the resident received the wrong medication based on laboratory tests and that the nurse didn't follow the 5 rights of medication administration.",2020-09-01
636,PRISMA HEALTH-LILA DOYLE,425075,101 LILA DOYLE DRIVE,SENECA,SC,29672,2019-01-11,760,G,1,0,P8ZJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to ensure that Resident #100, 1 of 1 resident reviewed, was free of significant medication errors as evidenced by laboratory results positive for Opiates and quetiapine. The findings included: Resident #100 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review on 01/10/19 at 10:25 AM of Resident #100's Progress Notes revealed a re-admission note dated 06/11/18 that indicated on 06/10/18 the resident was lethargic with poor PO (by mouth) intake and was sent to the emergency department. Labs drawn on 06/10/18 at the hospital included a drug screen that was positive for opiates. A [DIAGNOSES REDACTED]. A progress note dated 06/13/18 indicated suspicion here that (s/he) may have mistakenly been given roommate's quetiapine ([MEDICATION NAME]) on 6/9 evening (and) level was drawn here (and) is (positive). Review of an incident and investigation file revealed a copy of Resident 100's roommate's nursing note dated 06/09/18 indicating the roommate received medication for a complaint of back pain and [MEDICATION NAME] on that date. The file contained a Narcotic Inventory Record for the roommate that indicated 1 tablet of [MEDICATION NAME]/ APAP ([MEDICATION NAME]) 5/325 milligrams was signed out on 06/09/18 at 09:30 PM. Further review revealed Resident #100's roommate who had an order for [REDACTED]. Res (resident) states people have been in room who have not. Res refused meds 5 x (times) this AM stated they're not going to do me any good or how do I know they are the right ones. Additional review revealed an Opiates Expanded, Quantitative, Urine test done on Resident #100 that was positive for [MEDICATION NAME]. During an interview on 01/10/19 at 04:28 PM, the Director of Nursing confirmed the documentation indicated the resident received the wrong medication based on laboratory tests.",2020-09-01
637,PRISMA HEALTH-LILA DOYLE,425075,101 LILA DOYLE DRIVE,SENECA,SC,29672,2019-01-11,865,G,1,0,P8ZJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to identify and implement an action plan timely related to medication errors for 12 of 12 months reviewed. The findings included: Resident #100 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review on 01/10/19 at 10:25 AM of Resident #100's Progress Notes revealed a re-admission note dated 06/11/18 that indicated on 06/10/18 the resident was lethargic with poor PO (by mouth) intake and was sent to the emergency department. A drug screen performed at the hospital was positive for opiates for which the resident did not have an order. A progress note dated 06/13/18 indicated suspicion here that (s/he) may have mistakenly been given roommate's quetiapine on 6/9 evening (and) level was drawn here (and) is (positive). Review of the Nurse's education transcript dated 11/01/17 to 01/11/19 revealed the nurse completed education entitled Medication Written Competency Examination-Combo (combination) Adult and Peds (Pediatrics) on 09/19/18 through the hospital, after her/his last day of employment at the facility. Review of the medication errors log provided by the facility revealed the facility had 3-9 medication errors per month from (MONTH) (YEAR) through (MONTH) (YEAR). In (YEAR) the medication errors log revealed 7 medication errors in (MONTH) and December. In (YEAR) the medication errors log revealed 9 medication errors in January, 5 in February, 6 in March, 3 in (MONTH) and May, 6 in June, 8 in July, 6 in August, 3 in (MONTH) and October, 5 in (MONTH) and 4 in December. During an interview on 01/10/19, the Director of Nursing (DON) provided documentation of an Ad Hoc QAPI (Quality Assurance Performance Improvement) meeting on (MONTH) 3, 2019. Review of the committee minutes revealed a new documentation system to start in (MONTH) of 2019, the font on the MAR (medication administration record) was to be adjusted, and the nurse educator and pharmacist will randomly check nurses for medication pass competency. The DON confirmed the facility had not implemented a plan earlier.",2020-09-01
638,PRISMA HEALTH-LILA DOYLE,425075,101 LILA DOYLE DRIVE,SENECA,SC,29672,2016-10-20,282,D,0,1,ZF5L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews a Certified Nursing Assistant failed to follow care plan on transferring for Resident # 129. ( 1 of 1 resident reviewed for following care plan.) The findings included: Closed record review and facility investigation records for Resident # 129's fall on 6/10/16 revealed that the resident did experience a fall during the transfer of the resident to the bathroom. The resident told CNA #1 she/he needed to go to the bathroom. The CNA (Certified Nursing Assistant) tried to encourage the resident to use the bedpan. The resident refused and said he/she wanted to go to the bathroom. Resident # 129 had a BIMS (Brief Interview of Mental State) score of 15, which signified the resident was alert, oriented, and able to make own decisions. The resident also stated he/she had been walking with a walker. The resident would not wait for the CNA to check for transfer status [REDACTED]. As the CNA walked with the resident, the resident's leg started to give way. The CNA turned to get a wheelchair, but the resident fell sustaining a 4 cm (centimeter) x .5 cm skin tear to his/her right forearm. The resident's transfer status should have been 2 person assist with use of gait belt. Interview with Director of Therapy on 10/20/16 at 9:30 AM confirmed that on the date of the incident the resident was indeed able (in the therapy department) to ambulate on level surfaces for 42 feet maximum distances with rolling walker supervised minimum assist ( helper provides verbal cues or touching /steadying assistance as patient completes activity.) The Resident had not been cleared to ambulate by herself with a walker. Care plan on the unit still listed transfer resident with gait belt and 2 person assist.",2020-09-01
639,PRISMA HEALTH-LILA DOYLE,425075,101 LILA DOYLE DRIVE,SENECA,SC,29672,2016-10-20,323,D,0,1,ZF5L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews a Certified Nursing Assistant failed to follow the assistant care plan on transferring. Resident # 129 fell resulting in a skin tear to their right forearm. ( 1 of 1 resident reviewed for accident.) The findings included: Closed record review and facility investigation records for Resident # 129's fall on 6/10/16 revealed that the resident did experience a fall during the transfer of the resident to the bathroom. The resident told CNA #1 she/he needed to go to the bathroom. The CNA (Certified Nursing Assistant) tried to encourage the resident to use the bedpan. The resident refused and said he/she wanted to go to the bathroom. Resident # 129 had a BIMS (Brief Interview of Mental State) score of 15, which signified the resident was alert, oriented, and able to make own decisions. The resident also stated he/she had been walking with a walker. The resident would not wait for the CNA to check for transfer status [REDACTED]. As the CNA walked with the resident, the resident's leg started to give way. The CNA turned to get a wheelchair, but the resident fell sustaining a 4 cm (centimeter) x .5 cm skin tear to his/her right forearm. The resident's transfer status should have been 2 person assist with use of gait belt. Interview with Director of Therapy on 10/20/16 at 9:30 AM confirmed that on the date of the incident the resident was indeed able (in the therapy department) to ambulate on level surfaces for 42 feet maximum distances with rolling walker supervised minimum assist ( helper provides verbal cues or touching /steadying assistance as patient completes activity.) Resident had not been cleared to ambulate by herself with a walker.",2020-09-01
640,PRISMA HEALTH-LILA DOYLE,425075,101 LILA DOYLE DRIVE,SENECA,SC,29672,2016-10-20,371,D,0,1,ZF5L11,"Based on observation, interview and review of the facility's Food Storage Policy, the failed to ensure that opened food items were dated in one of one main kitchens reviewed. The findings included: Random observation during initial tour of the main kitchen at approximately 7:35 AM on 10/18/16 revealed that a bag of grated cheddar cheese had been opened but not dated. A bottle of chocolate syrup was also opened and undated. The Food Service Coordinator confirmed the opened and undated food items and discarded them. A review of the facility's policy at approximately 2:45 PM on 10/19/16 revealed that the food storage policy indicated that opened foods must be covered, labeled, and dated in a clean container.",2020-09-01
641,PRISMA HEALTH-LILA DOYLE,425075,101 LILA DOYLE DRIVE,SENECA,SC,29672,2017-11-16,278,D,0,1,IMXM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to accurately code the comprehensive MDS (Minimal Data Set) assessment relevant to Hospice and prognosis for Resident #62, 1 of 1 resident reviewed for Hospice. The findings included: Resident #62 was admitted to the facility with [DIAGNOSES REDACTED]. On 11/13/17, at approximately 2:30 PM, record review revealed an order dated 07/11/17 to admit Resident #62 to Hospice. Further review at 2:41 PM revealed a Significant Change in Status MDS (Minimal Data Set) assessment dated [DATE]. Section J, Health Conditions, Question J1400, Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months? was coded as No. In addition, Section O, Special Treatments and Programs, Question O0100 K Hospice Care, was coded as No. On 11/14/17, review of CMS ' s (Center for Medicare and Medicaid Services) RAI (Resident Assessment Instrument) Version 3.0 Manual, October, (YEAR), page J-23, Prognosis, Question J1400 revealed the following coding instructions: Code 1, yes: if the medical record includes physician documentation: 1) that the resident is terminally ill; or 2) the resident is receiving hospice services. During an interview on 11/15/17 at 4:54 PM, MDS RN (Registered Nurse) #1 confirmed the Significant Change in Status Assessment was coded inaccurately. In addition, the RN confirmed the subsequent Quarterly Assessment was also coded inaccurately.",2020-09-01
642,WHITE OAK MANOR - NEWBERRY,425077,2555 KINARD STREET,NEWBERRY,SC,29108,2018-01-16,568,F,1,0,8YR911,"> Based on review of facility files and interview, the facility failed to establish and maintain a system that assures a full and complete and separate accounting, according to generally accepted accounting principles, of each resident's personal funds entrusted to the facility on the resident's behalf. The Business Office Manager was noted to misappropriate money from resident accounts. No receipt books could be located after the Business Office Manager resigned. There were 121 residents' accounts that were affected by the Business Office Manager's misappropriation between (MONTH) (YEAR) and (MONTH) (YEAR). One of one Business Office Manager reviewed for accounting principles. The findings included: The facility reported an allegation of misappropriation of funds by the former Business Office Manager to the State Agency on 9/7/17. Review of the South [NAME]ina Victim Impact Statement revealed the financial loss was noted as $161,622.53. The administrator and the corporate accounts receivable manager gave conflicting statements to the surveyor on how the misappropriation was identified. In an interview with the surveyor on 12/5/17 at approximately 10:25 AM, the facility administrator stated they had someone from corporate office at the facility training the new Business Office Manager and they noted there was a discrepancy between the system when they pulled a financial file for a resident. The corporate staff decided to do an audit and started to note suspicious zero deposits. They confirmed the Business Office Manager was responsible when they pulled the former Business Office Manager's direct deposit account number from Human Resources and it matched an account number on one of the checks that was created. The former Business Office Manager had resigned and was no longer working at the facility when the discrepancy was found. In an interview with the surveyor on 12/5/17 at approximately 11:05 AM, the corporate accounts receivable manager stated a resident's family had called and stated the check they received was not the right amount. The check was a refund for the amount they had private paid, the resident had passed away. The consultant looked up the information and the information was correct in the computer, but when s/he looked in the billing file it was not right. S/he noted the discrepancy and called the corporate accounts receivable manager. They started looking to find out what was wrong and saw some cash that was receipted but never posted for a different resident. The former Business Office Manager posted the cash received from another resident to the resident whose check was incorrect, that was to try to make the account look right. The corporate accounts receivable manager stated there were no set time frame for audits, generally an audit would be done if there was a change in Business Office Manager or if something flagged at the corporate office. The Business Office Manager was responsible for everything - taking money, disbursing money, and the resident trust fund. At the end of the month, the Business Office Manager does an accounting for resident fund accounts. The problem was everything was balancing because the Business Office Manager was using funds from one resident's account to make another resident's account look correct. This way it balanced when the corporate office looked at the funds information. The former Business Office Manager was writing checks out of resident fund accounts to him/herself and putting it into his/her personal account and 4 other accounts. The former Business Office Manager was using the checks to make payments to those accounts. The former Business Office Manager was using his/her credit cards to buy things for their children and family, then s/he would come back and reimburse him/herself from a resident fund account. Some of those receipts were signed, some were not. The Business Office Manager would have a resident sign a petty cash receipt for example $15 from their account, then the social worker would sign and then the Business Office Manager would go back and put a 3 in front of the 15 to make it $315.00. If a resident can't sign a receipt for cash, they will put an X, the Business Office Manager would sign that s/he gave the money. No one had to witness the transaction. All the receipt books could not be found after the Business Office Manager left. There were some receipts attached in the files, but they were not consecutive receipt numbers. There is a copy of the bogus checks included with the investigation. They pulled up all resident accounts and audited from the time the former Business Office Manager started, as well as receivable accounts. They have no idea how much cash s/he actually took, there is no way to know how much may have been affected by cash that came in that should have been credited to resident accounts. The facility hired a forensic account to audit the resident accounts. Residents were made whole with interest. The facility notified residents and families, whoever is in the system to get financial information is who was notified. They notified them by letter, some were also notified over the phone if there were any questions. They sent the letters out with the reimbursement checks with interest. Review of the Resident's Funds policy revealed the facility will hold, safeguard, manage and account for the resident's funds deposited with the facility. The resident fund account should always be up-to-date; all transactions should be accounted for and entered daily. Review of the Resident's Funds procedures revealed every cash disbursement must be recorded on the Resident Fund Monthly Cash Ledger. A receipt should be signed by the resident requesting the disbursement. If the resident can only make a mark (X), two witnesses must sign the receipt. The receipts should be entered into the resident trust fund software (RFMS) daily and be attached to the Transaction Report printed after the transactions have been transmitted. A resident fund numbered receipt book should be used for all cash transactions. Review of the section for Resident Fund Monthly Reconciliation revealed auditors recommend separation of duties when it comes to managing the resident fund account. One person should disburse cash and complete the resident fund transactions. Another person should complete the bank account reconciliation's.",2020-09-01
643,WHITE OAK MANOR - NEWBERRY,425077,2555 KINARD STREET,NEWBERRY,SC,29108,2018-01-16,602,F,1,0,8YR911,"> Based on review of facility files and interview, the facility failed to ensure residents remained free from misappropriation of resident property. The Business Office Manager was noted to misappropriate money from resident accounts. There were 121 residents' accounts that were affected by the Business Office Manager's misappropriation between (MONTH) (YEAR) and (MONTH) (YEAR). One of one reportable allegation of misappropriation. The findings included: The facility reported an allegation of misappropriation of funds by the former Business Office Manager to the State Agency on 9/7/17. Review of the facility's Five-Day Follow-Up Report dated 9/14/17 revealed suspicious deposits were noted on a resident's account. The investigation had not been concluded. Review of the South [NAME]ina Victim Impact Statement revealed the financial loss was noted as $161,622.53. In an interview with the surveyor on 12/5/17 at approximately 11:05 AM, the corporate accounts receivable manager stated a resident's family had called and stated the check they received was not the right amount. The check was a refund for the amount they had private paid, the resident had passed away. The consultant looked up the information and the information was correct in the computer, but when s/he looked in the billing file it was not right. S/he noted the discrepancy and called the corporate accounts receivable manager. They started looking to find out what was wrong and saw some cash that was receipted but never posted for a different resident. The former Business Office Manager posted the cash received from another resident to the resident whose check was incorrect, that was to try to make the account look right. The Business Office Manager was using funds from one resident to make another resident's account look correct. The former Business Office Manager was writing checks out of resident fund accounts to him/herself and putting it into his/her personal account and 4 other accounts. The former Business Office Manager was using the checks to make payments to those accounts. The former Business Office Manager was using his/her credit cards to buy things for their children and family, then s/he would come back and reimburse him/herself from a resident fund account. Some of those receipts were signed, some were not. The Business Office Manager would have resident sign petty cash receipt for example $15 from their account, then the social worker would sign and then the Business Office Manager would go back and put a 3 in front of the 15 to make it $315.00. They pulled up all resident accounts and audited from the time the former Business Office Manager started. They have no idea how much cash s/he actually took, there is no way to know how much may have been affected by cash that came in that should have been credited to resident accounts. The facility hired a forensic account to audit the resident accounts. Residents were made whole with interest. The facility notified residents and families, whoever is in the system to get financial information is who was notified. They notified them by letter, some were also notified over the phone if there were any questions. They sent the letters out with the reimbursement checks with interest. Review of the facility's Abuse Policy revealed misappropriation of resident property was defined as the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. Review of the Resident's Funds policy revealed the facility will hold, safeguard, manage and account for the resident's funds deposited with the facility. The resident fund account should always be up-to-date; all transactions should be accounted for and entered daily.",2020-09-01
644,WHITE OAK MANOR - NEWBERRY,425077,2555 KINARD STREET,NEWBERRY,SC,29108,2018-01-16,607,F,1,0,8YR911,"> Based on review of facility files and interview, the facility failed to ensure residents remained free from misappropriation of resident property. The Business Office Manager was noted to misappropriate money from resident accounts. No receipt books could be located after the Business Office Manager resigned. There were 121 residents' accounts that were affected by the Business Office Manager's misappropriation between (MONTH) (YEAR) and (MONTH) (YEAR). One of one reportable allegation of misappropriation. The findings included: The facility reported an allegation of misappropriation of funds by the former Business Office Manager to the State Agency on 9/7/17. Review of the facility's Five-Day Follow-Up Report dated 9/14/17 revealed suspicious deposits were noted on a resident's account. The investigation had not been concluded. Review of the South [NAME]ina Victim Impact Statement revealed the financial loss was noted as $161,622.53. The administrator and the corporate accounts receivable manager gave conflicting statments to the surveyor on how the missapropriation was identified. In an interview with the surveyor on 12/5/17 at approximately 10:25 AM, the facility administrator stated they had corporate office here training the new Business Office Manager and they noted there was a discrepancy between the system and when they pulled a financial file for a resident. The corporate staff decided to do an audit and started to note suspicious zero deposits. It was confirmed when they pulled the former Business Office Manager's direct deposit account number from Human Resources and it matched an account number on one of the checks that was created. The former Business Office Manager had resigned and was no longer working at the facility when the discrepancy was found. In an interview with the surveyor on 12/5/17 at approximately 11:05 AM, the corporate accounts receivable manager stated they had a resident's family that called and said the check they received was not the right amount. The check was a refund for the amount they had private paid, the resident had passed away. The consultant looked up the information and the information was correct in the computer, but when s/he looked in the billing file it was not right. S/he noted the discrepancy and called the corporate accounts receivable manager. They started looking to find out what was wrong and saw some cash that was receipted but never posted for a different resident. The former Business Office Manager posted the cash received from another resident to the resident whose check was incorrect, that was to try to make the account look right. The corporate accounts receivable manager stated there were no set time frame for audits, generally if there was a change in Business Office Manager or if something flagged at the corporate office. The Business Office Manager was responsible for everything - taking money, disbursing money, and the resident trust fund. At the end of the month, the Business Office Manager does an accounting for resident fund accounts. The problem was everything was balancing because the Business Office Manager was using funds from one resident to make another resident's account look correct. This way it balanced when the corporate office looked at the funds information. The former Business Office Manager was writing checks out of resident fund accounts to him/herself and putting it into his/her personal account and 4 other accounts. The former Business Office Manager was using the checks to make payments to those accounts. The former Business Office Manager was using his/her credit cards to buy things for their children and family, then s/he would come back and reimburse him/herself from a resident fund account. Some of those receipts were signed, some were not. The Business Office Manager would have resident sign petty cash receipt for example $15 from their account, then the social worker would sign and then the Business Office Manager would go back and put a 3 in front of the 15 to make it $315.00. Receipts for cash, if the resident can't sign they will put an X, the Business Office Manager would sign that s/he gave the money. No one had to witness the transaction. All the receipt books could not be found after the Business Office Manager left. There were some receipts attached in the files, but they were not consecutive receipt numbers. There is a copy of the bogus checks included with the investigation. They pulled up all resident accounts and audited from the time the former Business Office Manager started, as well as receivable accounts. They have no idea how much cash s/he actually took, the amount from the resident funds was $109,000. That was actual resident money that they know was tampered with. There is no way to know how much may have been affected by cash that came in that should have been credited to resident accounts. The facility hired a forensic account to audit the resident accounts. Residents were made whole with interest. The facility notified residents and families, whoever is in the system to get financial information is who was notified. They notified them by letter, some were also notified over the phone if there were any questions. They sent the letters out with the reimbursement checks with interest. Review of the facility's Abuse Policy revealed misappropriation of resident property was defined as the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent.",2020-09-01
645,WHITE OAK MANOR - NEWBERRY,425077,2555 KINARD STREET,NEWBERRY,SC,29108,2017-07-19,318,D,1,1,DYWP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure restorative services were provided for 1 of 3 sampled residents reviewed for range of motion. Resident #147 with physician's orders [REDACTED]. The findings included: The facility admitted Resident #147 with [DIAGNOSES REDACTED]. A review of the medical record on 7/18/17 at approximately 10:48 AM revealed a physician's orders [REDACTED]. Further record review revealed a care plan that indicated resident was to receive PROM five (5) days a week to bilateral upper extremities every shift with a problem onset date of 9/2/16 with the next review target date of 10/03/17. The care plan also addressed Resident #147 receiving PROM to lower extremities times 10 reps three (3) days a week every shift. Further review of the medical record revealed PROM documentation for the months of 4/17/17 to 7/18/17 that indicated documented PROM services was provided to Resident #147 on 4/17/17 one shift, 4/18/17 one shift, 4/25/17 one shift and 4/27/17 one shift. The PROM for the month of May 2017 revealed documented services for 5/01/17 one shift, 5/02/17 one shift, and 5/03/17 one shift. The PROM for the month of June 2017 revealed services were provided on 6/15/17 one shift, 6/21/17 and 6/22/17 one shift. The PROM for the month of July 2107 revealed services were provided on 7/04/17 one shift, 7/11/17 and 7/12/17 one shift. An interview on 7/19/17 at approximately 11:40 AM with the Director of Nursing confirmed the restorative documentation as noted and further stated the blanks noted on the PROM documentation indicated the Certified Nursing Aide may not have been able to provide the services due to being called away.",2020-09-01
646,WHITE OAK MANOR - NEWBERRY,425077,2555 KINARD STREET,NEWBERRY,SC,29108,2017-07-19,371,F,0,1,DYWP11,"Based on observation, interview, and review of the facility policy, the facility failed to prepare, distribute, and serve food under sanitary conditions for 1 of 1 kitchen reviewed and has the potential to affect 129 of 129 residents with ordered diets as evidenced by failing to do the following: Dispose of expired food items. The findings included: On 7/17/17 at 9:20 AM, an initial tour of the kitchen with the Food Service Director /Certified Dietary Manager (CDM) revealed: Walk-in refrigerator: 1.) (4) gallons of reduced fat milk (2) dated 7/4/17 and (2) dated 7/9/17. 2.) (1) gallon of skim milk dated 7/16/17. 3.) Leftover vegetable soup in a clear container dated 7/13/17. 4.) Bowl of peaches undated. 5.) Clear container of grape jelly undated. Walk-in freezer: 6.) (4) bags of chicken legs frozen in liquid open and undated. 7.) (1) bag of chopped beef that had freezer burn and was undated. 8.) (4) 32 ounce cartons of V8 Smoothie Mix Fusion with a Best by date of 11/18/16. 9.) (4) 32 ounce cartons of V8 Smoothie Watermelon Raspberry with a Best by date of 9/29/16. Following the initial tour observations, the CDM verified the above (9) listed expired/undated items in the walk-in refrigerator/freezer and indicated the expired and unlabeled items should have been re-moved from storage. Review of the facility policy entitled, Storage of Food and Supplies, revealed under procedure (7.) All opened items are securely wrapped or stored in a secure storage container and labeled to identify the product (if not readily identifiable) as well as a use-by date of no greater than 72 hours after opening (unless documentation available for a longer shelf life is available). Staple products such as flour, sugar, cornmeal, dried pasta, etc. may be stored in designated, secure bins. Staple bin scoops may be stored in the product if the handle is out of the product in a manner to prevent touching of the food product. Also, the facility policy, Leftover Foods states under procedure (5.) Refrigerated leftovers are discarded after 72 hours and frozen leftovers discarded after 30 days.",2020-09-01
647,WHITE OAK MANOR - NEWBERRY,425077,2555 KINARD STREET,NEWBERRY,SC,29108,2017-07-19,431,D,0,1,DYWP11,"Based on observations, interview, and review of the facility policy, the facility failed to ensure that controlled substance medications were secured in 1 of 3 medication storage rooms reviewed. Controlled substances were unsecured in the Unit 3 medication storage room. The findings included: On 7/18/17 at 10:23 AM, an observation of the Unit 3 medication storage room with Licensed Practical Nurse (LPN) #1 revealed the medication refrigerator was unlocked and contained (20) 1 mg./ml. syringes of Lorazapam gels. Following the observation LPN #1 verified the (20) Lorazapam gels were not double locked in medication storage and indicated all controlled substance needed to be kept behind double locked doors. Review of the facility policy entitled Controlled Medications - Ordering and Receipt revealed under procedure (8.) Medications listed in Schedule II, III, IV, and V are stored under double lock in a locked cabinet or safe designated for that purpose. The access key to controlled medications is not the same key giving access to other medications. The medication nurse on duty maintains possession of a key to controlled medications. Back-up keys to all medication storage areas, including those for con-trolled medications, are kept by the Director of Nursing.",2020-09-01
648,WHITE OAK MANOR - NEWBERRY,425077,2555 KINARD STREET,NEWBERRY,SC,29108,2018-08-30,688,D,0,1,PJTX11,"Based on observation, interview and record review, the facility failed to provide the restorative range of motion (ROM) program for one of two residents, (Resident (R) 35), selected for review. Findings include: Review of R35's admission Minimum Data Set (MDS), an assessment tool completed by the facility staff used to identify resident care problems and assist with care planning, with an Assessment Reference Date (ARD), the end-point of the evaluation period, of 06/20/18, specified under Section G: Functional Status, R35 had functional limitation in ROM to bilateral upper and lower extremities. Review of a Functional Range of Motion form, dated 06/14/18 and found in R35's medical record under the Therapy tab identified limitations of varying degrees to bilateral upper and lower extremities. All of the limitations were noted to interfere with R35's daily function and/or put him at risk for injury. Review of R35's care plan, found in R35's electronic medical record (EMR) under the Care Plan section, dated 07/11/18, identified the potential for decline in upper extremity strength and ROM. The identified goal was for the resident to participate in the exercise activities without complication. Approaches included direction for restorative active ROM upper extremity exercises three days a week to maintain strength. A second care plan identified R35 with the potential for decline in lower extremity strength and ROM, with a goal for the resident to complete seated exercises. Approaches included directions for restorative active ROM, seated exercises as well as right knee hamstring stretches, three days a week. These care plans were noted as resolved/achieved 08/29/18. In addition, care plans dated 06/14/18, identified R35 with the potential for falls and with a self-care deficit. Both of these care plans included the approach Restorative therapy as ordered. Review of the Restorative - CNA (Certified Nurse Aide) Data Collection form, provided by the Assistant Director of Nursing (ADON), on 08/29/18 at 2:15PM revealed between 7/11/18, when the restorative program was initiated and 08/28/18, R35 participated in the program one time on 07/11/18. It was also noted on 07/11/18 the resident refused the restorative program. On every other date, staff documented Activity Did Not Occur. In an interview on 08/29/18 at 2:50 PM, the ADON explained the facility was without a program coordinator for the restorative program and she was covering until someone was hired. She stated she reviewed the attendance records for R35 and discussed the lack of attendance with the restorative aide. She explained R35 apparently had refused the restorative program each time it was offered, and the restorative aide inaccurately documented the activity did not occur, instead of refused. The ADON stated she had not been notified R35 had refused the program for the past six weeks. In an interview on 08/30/18 at 9:29 AM, R35 stated he had been asked to attend an exercise program one time. He explained he had participated in therapy prior to that but did not find value in the exercises they had him do, so he had refused to attend when asked by the restorative aide. He stated he had not understood the program was different than skilled therapy and that the exercises could be customized to his desires. The resident denied having been invited to the restorative program recently. In an interview on 08/30/18 at 12:40 PM, Restorative Aides 78 and 13 explained what they would do if a resident refused the restorative program. Both agreed they would offer the program several times in a day, and if the resident still refused, they would notify the resident's nurse and the ADON. They stated they would then enter refused in the record. Restorative Aide 78 then explained R35 was on her caseload. She recalled that when she first offered the program to the resident, he got very upset so she told him to just come down to the therapy room when he wanted to do something. She stated she notified his nurse but did not recall notifying the ADON. She stated she had not gone back and offered the program to R35 because he had been so upset. She said the resident participated in some exercises one time but never returned, and she had not offered him the program again. In an interview on 08/30/18 at 1:48 PM, the ADON stated she thought R35 was being offered the program three times a week and consistently refusing. She explained based on that belief, she discontinued the restorative program 08/29/18.",2020-09-01
649,WHITE OAK MANOR - NEWBERRY,425077,2555 KINARD STREET,NEWBERRY,SC,29108,2018-08-30,842,D,0,1,PJTX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to accurately document an identified allergy for one resident, (Resident (R) 61), and failed to document the implementation and resident response to the weaning of oxygen as ordered by the physician for one resident, R54, of the 25 residents selected for review. As a result of this deficient practice, staff were unable to identify and/or determine R61's allergy status and were unable to determine if the weaning of oxygen was successful for R54. Findings include: 1. Review of a Prescriber Recommendation Form, dated 07/12/18 and found in R61's medical record under the Consultation tab revealed the consulting pharmacist identified a doctor's note from an outside provider that indicated the resident had an allergy to nonsteroidal anti-[MEDICAL CONDITION] drugs (NSAIDs). The pharmacist documented, . Should NSAIDS be added to her allergy list? On 7/30/18, the physician signed the form and indicated he agreed with the recommendation. Review of the resident's hard chart revealed the allergy sticker on the front cover noted the resident had no known allergies. The Face Sheet, at the front of the hard chart identified No Known Drug Allergies. According to the electronic medical record (EMR), under the Diagnosis & Allergy tab, No Known Drug Allergies were noted. In no other place in the EMR or hard chart was this allergy identified. In an interview on 08/29/18 at 1:16 PM, Registered Nurse (RN) 36 reviewed the resident's record and stated when the physician signed the Recommendation form, the nurse on duty should have entered the allergy into the computer and added the information to the cover of the record. In an interview on 08/30/18 at 3:15 PM the Director of Nursing (DON) stated when a physician accepted a pharmacy recommendation, nursing staff were expected to document or implement the change. The DON acknowledged that the process had not been followed as staff should have either documented the allergy or contacted the physician to discuss the accuracy of the data. Review of the facility's policy titled, Provider Pharmacy Requirements dated (MONTH) 1, (YEAR), revealed The consultant shall ensure that all known allergies and adverse effects are documented in plain view in the resident's medical record . 2. Observation on 08/27/18 at 11:00 AM revealed R54 lying in bed with oxygen on via nasal cannula. She stated she had used the oxygen for many months. Review of the (MONTH) (YEAR) Treatment Administration Record (TAR), found in the EMR under the eMAR/eTAR tab, revealed a physician's orders [REDACTED]. A physician's orders [REDACTED]. Staff placed a check mark on each of the three shifts between 06/01/18 and 06/24/18, except for 6/10/18 at 6:30 AM and 06/17/18 at 2:30 PM, when they recorded an N. There was no indication of what rate the oxygen had been reduced to or what the resident's oxygen saturations were as a result of the ordered reduced rate. In an interview on 08/29/18 at 10:53 AM, RN 36 stated she would document the oxygen rate and resulting saturation rate in the TAR. In an interview on 08/29/18 at 1:29 PM, Administrative Nurse 142 stated typically there would be a nurse's note that identified staff either decreased or discontinued the oxygen and what was the resident's response and the saturation rate. She stated if it was successful, staff would discontinue the oxygen, however R54 had previously failed at having the oxygen weaned. She acknowledged staff had not documented in a manner sufficient to allow the facility to determine if the weaning had been successful. A policy regarding the documentation of oxygen therapy was requested, however at the time of exit the facility did not provide a policy.",2020-09-01
650,WHITE OAK MANOR - NEWBERRY,425077,2555 KINARD STREET,NEWBERRY,SC,29108,2019-12-12,550,D,1,1,5CPY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, interviews, and record reviews, the facility failed to treat residents with dignity for 1 of 3 residents reviewed for abuse and on 1 of 3 units (Hall 300 Rooms 316-323) observed during the dining experience. Certified Nursing Assistant (CNA) #2 lost composure and argued with Resident #136 while providing care for his/her roommate. Staff was observed entering rooms during meal delivery without knocking. All residents in room [ROOM NUMBER] were not served sequentially and privacy curtain was not pulled closed while a resident was eating and another resident was not served or eating. The findings included: Resident #136 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review facility investigation of abuse allegation for Facility Reported Incident (FRI) #SC 482 on 12/11/19 at approximately 3:46 PM revealed the following: 1. Resident #136 was upset about a dirty linen bag that had been left in the room. 2. CNA #2 was arguing back with the resident, stating they would get the bag out and Resident #136 did not have to yell at them. 3. CNA #2 stated that s/he was tired of all this laughing up and cutting up with us one minute, then yelling and fussing at us the next. S/he must be [MEDICAL CONDITION] or something. 4. CNA #3, Resident #136, and the resident's roommate (at that time) confirmed what CNA #2 said during the facility's investigation. 5. Facility did not substantiate abuse but found CNA #2 to be inconsiderate to the resident. Interview with Director of Nursing (DON) and Administrator on 12/12/19 at approximately 9:39 PM revealed that both concluded CNA #2 was commenting to CNA #3 about a separate, non-work, topic and was misunderstood by all parties. During a previous interview, CNA #2 made a similar claim. Interview with CNA #2 on 12/12/19 at approximately 9:52 AM confirmed that both Resident #136 and CNA #3 were arguing back and forth, but s/he could not recall the content of the argument. Review of Dignity Policy on 12/12/19 at approximately 12:39 PM revealed that staff are to Maintain composure during care . (Don't lose it). During random meal observation on 12/10/19 at approximately 12:36 PM a food cart was delivered to the 300 hall rooms 316-323. At approximately 12:27 and 12:39 PM CNA #1 was observed entering rooms [ROOM NUMBERS] without knocking when delivering lunch trays. The CNA further did not voice knock knock to seek permission to enter the residents room due to having food tray in hands. An interview on 12/10/19 at approximately 12:40 PM with CNA #1 acknowledged he/she entered resident rooms without knocking. On 12/10:19 at 12:40 PM, a resident was in room [ROOM NUMBER] in the first bed with food tray and eating while another in the room in bed near the window was not served or eating. The privacy curtain was not pulled while the resident in bed near the window was not eating or served. An observation and interview on 12/10/19 at 12:42 PM with Licensed Practical Nurse (LPN) #1 confirmed the observation and pulled/closed the privacy curtains since the resident in the bed by the window was not served or eating. At approximately 12:48 PM, LPN #1 was observed reminding staff to pull/close privacy curtains when all residents in the room were not served.",2020-09-01
651,WHITE OAK MANOR - NEWBERRY,425077,2555 KINARD STREET,NEWBERRY,SC,29108,2019-12-12,842,D,1,1,5CPY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews, observation, and record review, the facility failed to ensure that clinical paper and electronic records were complete and accurate for 1 of 25 sampled resident reviewed. Resident #87 had no dietary/nutritional notes in his/her medical record. The findings included: The facility admitted Resident #87 on 7/30/19 with [DIAGNOSES REDACTED]. During individual interview on 12/10/19 at approximately 9:55 AM Resident #87 stated he/she would like a variety of foods in his/her diet. When asked if anyone has specifically addressed his/her diet the resident stated he/she would like to talk to someone about his/her diet. A review of the electronic medical record on 12/11/19 at approximately 1:07 PM revealed the resident was on a regular renal diet with no fluid restrictions noted. A meal delivery observation on 12/11/19 at 1:18 PM revealed Resident #87 received diet as ordered. Staff had to encourage the resident to wake up to eat. Staff placed the food tray on the bedside table and raised the resident's bed. A review of the medical record on 12/11/19 at 2:40 PM revealed no dietary/nutritional notes in paper or electronic medical records. The paper chart had multiple yellow sheets indicating diet changes with no accompanying notes or dietary consults/assessments. The facility staff could not locate any dietary/nutritional notes in the paper chart or electronic records and referred the surveyor to the registered dietitian. An interview on 12/11/19 at 8:25 AM with the Registered Dietitian (RD) revealed he/she had a system in place to ensure documentation was completed and stated he/she had meet with Resident #87 on 10/30/19 to address his likes and dislikes but could not find the documentation. The RD further stated he/she looked through the electronic medical records under multiple tabs and could not find any dietary/nutritional notes to indicate a dietary consult/assessment had been done for Resident #87.",2020-09-01
652,HEALTHCARE CENTER OF WESLEY COMMONS,425078,1110 MARSHALL ROAD,GREENWOOD,SC,29646,2017-04-20,253,D,0,1,WBVK11,"Based on observations and staff interview the facility failed to maintain a clean and safe environment for six of forty rooms observed for environment. The facility census was 82. The findings included: Observations were made on 4/18/17 of room #'s 230, 242, 131, 234, 224 and 126. Room #230 was observed to have scraped walls. Room #242 was observed to have a dirty floor. Room #131 was observed to have a bathroom door made of wood that was splintered. Room #234 was observed to have paint that was scraped. Room #224 was observed to have a dirty floor. Room #126 was observed to have a bathroom door that was made of wood that was splintered and cove base molding that was missing. On 04/20/2017 at 2:27 PM observations were made on an environmental tour with Maintenance Director #152 and Maintenance Technician #57 to rooms 230, 242, 131, 234, 224, 126. Maintenance Director #152 verified rooms #230 and #234 had scraped walls, room #242 and #224 had dirty floors, rooms 126 and #131 had splintered wood on the bathroom doors and room #126 had cove base molding that was missing. On 04/20/2017 at 3:31 PM Maintenance Director #152 verified there had been no work orders for the identified concerns in the observed mentioned rooms from any staff members. Maintenance Director #152 verified there was no specific procedure of the inspection of rooms and they are done on a random basis. Maintenance Director #152 verified he put in work orders for the identified areas because no staff, including maintenance had identified the problems.",2020-09-01
653,HEALTHCARE CENTER OF WESLEY COMMONS,425078,1110 MARSHALL ROAD,GREENWOOD,SC,29646,2017-04-20,315,D,0,1,WBVK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and review of the policy on bowel and bladder assessment the facility failed to prevent a decline in urinary incontinence for one #63 of three residents reviewed for urinary incontinence. Findings include: On 04/20/2017 at 9:07 AM the medical record for Resident #63 was reviewed. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had an admission Minimum Data Set (MDS) assessment completed on 11/21/16. Section H0300 Urinary Continence was assessed to be always continent. A quarterly MDS assessment was completed on 2/15/17. Section H0300 Urinary Continence was assessed to be frequently incontinent. On 04/20/2017 at 10:22 AM Licensed Practical Nurse (LPN) #99 was interviewed. The LPN stated she put the resident on a specific toileting program today. LPN #99 stated she reviewed the resident's Patient Care Records for urinary incontinence and changed her toileting program due to that over time the resident's incontinence at night had increased. The Patient Care Records of resident #63 was reviewed with LPN #99 and verified the resident did have a decline in incontinence of bladder at night and an increased frequency in incontinence since her admission to the facility. LPN #99 verified the MDS assessment dated [DATE] when the resident was assessed as always continent was accurate. LPN #99 verified the MDS assessment dated [DATE] the resident was assessed as frequently incontinent and had more than seven episodes of incontinence was also correct, but no toileting program was put in place at that time. The most recent plan of care was reviewed on 04/20/2017 at 2:55 PM. The care plan indicated the resident required limited assistance with Activities of Daily Living related to [MEDICAL CONDITION]. The interventions were to provide assistance when necessary. The Patient Care Record for resident #63 was reviewed and indicated: the resident was an assist of one for toileting. On 04/20/2017 at 2:59 PM the policy on bowel and bladder assessment dated [DATE] was reviewed. The document indicated a Scope, Policy and Procedure. The POLICY indicated: to assess resident's bowel and bladder functioning for continence. To determine the plan of care if resident is incontinent and could benefit from a toileting program. On 04/20/2017 at 4:06 PM MDS Coordinator #81 was interviewed. The resident's urinary incontinence and MDS assessments dated 11/21/16 and 2/15/16 were reviewed. MDS Coordinator #81 verified a decline in urinary incontinence in (MONTH) (YEAR) and stated the resident should have been re-assessed at that time for the decline in urinary incontinence. On 04/20/2017 at 4:21 PM Licensed Practical Nurse (LPN) #116 was interviewed. LPN #116 stated she cared for resident #63 and upon admission the resident was continent of urine and now she was incontinent of urine.",2020-09-01
654,HEALTHCARE CENTER OF WESLEY COMMONS,425078,1110 MARSHALL ROAD,GREENWOOD,SC,29646,2017-04-20,365,E,0,1,WBVK11,"Based on observations and staff interviews, the facility failed to provide food prepared in a form designed to meet individual needs for the five residents on a pureed diet and two residents with pureed meat. Specifically, the facility failed to: -Provide proper pureed texture for the residents ordered to receive a pureed diet. The findings included: Professional Standards According to Dysphagia Diet (2015). Retrieved from https://www.saintlukeshealthsystem.org/health-library/dysphagia-diet-0; These are foods that are pureed or smooth, like pudding. They need no chewing. This includes foods such as yogurt, mashed potatoes with gravy . Accessed on 4/23/17. I. Observations The main kitchen was observed on 4/20/17 at 8:32 a.m. Cook #69 was observed throughout pureed food preparation. She placed some beef brisket into the robot coupe. She then added some soup (appearance of mushroom soup). She also added some vitamin D milk to the mixture. The pureed brisket had the appearance of some small pieces throughout. -She was also observed to have pureed the carrots. She added some vitamin D milk to the carrots in the robot coupe. The taste test of the pureed beef brisket was completed on 4/20/17 at approximately 8:40 a.m. The pureed beef brisket contained small pieces of meat throughout the mixture. The texture was similar to pieces of tuna fish. The product was not smooth. The main kitchen was observed on 4/20/17 at 3:30 p.m. Cook #140 was observed throughout pureed food preparation. She placed a vegetable blend consisting of squash, green beans and carrots into the robot coupe. She pureed the mixture in its own juices. The final texture appeared to have small pieces throughout the mixture. II. Staff Interviews Cook #69 was interviewed on 4/20/17 at 8:40 a.m. When asked if she followed a recipe for the pureed foods, she said not really. Not for pureed texture. She said they tasted the pureed food to make sure it was smooth. She said the pureed brisket was a good texture based on the appearance. (She did not taste the food item.) Cook #140 was interviewed on 4/20/17 at 3:30 p.m. When asked what the texture of the pureed food items should be, she said pudding, thick. She said she used thickener if the product needed to be thicker or she would add broth if it was too thick. She confirmed there were no recipes. The certified dietary manager (CDM) was interviewed on 4/20/17 at 3:40 p.m. When asked for the pureed food recipes, she confirmed that they did not have any recipes. They had some pre-formed pureed foods, but they mostly pureed the food on the menu. When asked about previous training on pureed texture, she said the cook would train the new cook. She had provided no training to the staff regarding pureed texture. She confirmed the pureed food should not have any chunks in it. She said the registered dietitian (RD) had also not completed any training with the staff.",2020-09-01
655,HEALTHCARE CENTER OF WESLEY COMMONS,425078,1110 MARSHALL ROAD,GREENWOOD,SC,29646,2017-04-20,371,E,0,1,WBVK11,"Based on observations, record review and staff interviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service in one of one kitchen. Specifically, the facility failed to: -Maintain proper temperatures in refrigeration; and -Date health shakes and food items I. Temperatures [NAME] Professional Standards According to the 2013 Food Code from the U.S Department of Health and Human Services, page 91, Except during preparation, cooking, or cooling, or when time is used as the public health control .time/temperature control for safety food shall be maintained at 41 degrees Fahrenheit or less. B. Observations The refrigerator for resident #4 was observed on 4/18/17 at 12:50 p.m. The temperature of the refrigerator was 45 degrees Fahrenheit. The refrigerator for resident #4 was observed again on 4/20/17 at 9:30 a.m. The temperature of the refrigerator was 45 degrees Fahrenheit. C. Record Review According to the (MONTH) refrigerator temperature log for room #245: -4/1/17: 50 degrees -4/2/17: 45 degrees -4/3/17: blank -4/6/17: 42 degrees -4/7/17: 44 degrees -4/8/17: 51 degrees -4/9/17: 45 degrees -4/10/17: 51 degrees -4/12/17: blank -4/13/17: 49 degrees -4/14/17: 43 degrees -4/15/17: 47 degrees -4/16/17: 43 degrees -4/18/17: 50 degrees -4/19/17: 42 degrees -4/20/17: 48 degrees According to the (MONTH) refrigerator temperature log for room #247: -4/1/17: 51 degrees -4/2/17: 48 degrees -4/3/17: blank -4/4/17: 48 degrees -4/6/17: 50 degrees -4/7/17: 51 degrees -4/8/17: 49 degrees -4/9/17: 48 degrees -4/10/17: 49 degrees -4/11/17: blank -4/12/17: 49 degrees -4/13/17: blank -4/14/17: 50 degrees -4/15/17: 49 degrees -4/16/17: 49 degrees -4/17/17: 48 degrees -4/18/17: 49 degrees -4/19/17: 48 degrees -4/20/17: 48 degrees According to the (MONTH) refrigerator temperature log for room #251: -4/2/17: 42 degrees -4/3/17: blank -4/4/17: 42 degrees -4/5/17: 42 degrees -4/6/17: 42 degrees -4/7/17: 44 degrees -4/10/17: 45 degrees -4/13/17: 48 degrees -4/14/17: 45 degrees -4/15/17: 44 degrees -4/16/17: 45 degrees -4/17/17: 46 degrees -4/18/17: 51 degrees -4/19/17: 45 degrees -4/20/17: 44 degrees According to the (MONTH) refrigerator temperature log for room #240: -4/1/17: 49 degrees -4/3/17: blank -4/4/17: 42 degrees -4/5/17: 44 degrees -4/7/17: 43 degrees -4/8/17: 44 degrees -4/9/17: 45 degrees -4/10/17: 50 degrees -4/12/17: blank -4/13/17: 49 degrees -4/14/17: 50 degrees -4/15/17: 52 degrees -4/16/17: 48 degrees -4/17/17: 50 degrees -4/18/17: 49 degrees -4/19/17: 50 degrees -4/20/17: 48 degrees D. Staff Interviews The certified dietary manager (CDM) was interviewed on 4/20/17 at 2:25 p.m. She said the dietary staff was in charge of monitoring the resident's refrigerators. They were supposed to document daily. They would check the temperatures in the late afternoon. -At 3:40 p.m., she said that they checked the resident's refrigerators again and confirmed that some were too warm. They adjusted the refrigerators. She said the dietary staff was supposed to let her know when the temperatures were out of range. Then they would have also let maintenance/ housekeeping know so that the refrigerators could be adjusted. II. Dating [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. B. Observations The refrigerator for resident #4 was observed on 4/18/17 at 12:50 p.m. Four vanilla health shakes were observed in the refrigerator, undated. Sliced turkey was found in a clear plastic bag, undated. A piece of breaded meat was observed in a clear plastic bag, undated. One of the walk-in refrigerators was observed on 4/20/17 at 8:17 a.m. There were seven health shakes, undated, in a large metal pan. Another walk-in refrigerator was observed with eight health shakes, undated. The refrigerator for resident #4 was observed again on 4/20/17 at 9:30 a.m. One no sugar added health shake was observed in the refrigerator, undated. C. Staff Interviews The certified dietary manager (CDM) was interviewed on 4/20/17 at 2:25 p.m. She said she was not aware the health shakes had a shelf life and needed to be dated. She said they did not track how long the health shakes were in the walk-in refrigerator.",2020-09-01
656,HEALTHCARE CENTER OF WESLEY COMMONS,425078,1110 MARSHALL ROAD,GREENWOOD,SC,29646,2018-07-26,623,D,0,1,B7PC11,"**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 #17 and # 55 at the time of a facility initiated transfer. 2 of 2 reviewed for transfer to the hospital. The findings included: The facility admitted Resident # 17 on 01/25/2018 with [DIAGNOSES REDACTED]., left hand contracture and Irritab(e Bowel Syndrom. During review of the Nurses Notes there was no documentation that a written notice was given to the resident / Resident Representative (RR) at the time of the transfer to the hospital on [DATE] through 03/21/2018. Further review revealed Resident #17 was also hospitalized [DATE] through 04/16/2018 with no written notification to the resident/RR. The facility admitted Resident # 55 on 03/23/2016 with diagnoses, including but not limited to, Type II Diabetes Mellitus with Diabetic [MEDICAL CONDITIONS], Hypertension, cerebral infarct due to unspecified occlusion or stenosis of unspecified cerebral artery, paralyti[DIAGNOSES REDACTED] following Cerebro Vascular Accident affecting left non dominate side, elevated Sedimentation Rate, long term use of anticoagulant, Stage 3 [MEDICAL CONDITION],, [MEDICAL CONDITION], constipation, [MEDICAL CONDITION], Cognitive impairment, [MEDICAL CONDITION] with behavioral disturbance and a history of Urinary Tract Infections. During review of the Nurses Notes there was no documentation that a written notice was given to the resident / Resident Representative (RR) at the time of the transfer to the hospital on 05/06-08/2018. Further review revealed that Resident # 55 was also hospitalized ,[DATE]-[DATE] and no written notification was provided to the resident/RR. 07/25/18 08:50 AM- Interview with the Administrator confirmed that the facility was unaware that they were to be giving written notification of transfer to the hospital to the resident/ RR and had not been doing so but would implement that as of today. Notification to the Ombudsman was done monthly and the Bed Hold Policy reviewed- does accompany residents in the transfer packet when he/she is transferred to the hospital Documentation of bed hold policy is in the Social Services Notes.",2020-09-01
657,HEALTHCARE CENTER OF WESLEY COMMONS,425078,1110 MARSHALL ROAD,GREENWOOD,SC,29646,2018-07-26,637,D,0,1,B7PC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to conduct a Significant Change in Status Assessment (SCSA) after election of Hospice Services for Resident #4, 1 of 1 resident reviewed for Hospice. The findings included: The facility admitted Resident #4 on 04//03/18 with [DIAGNOSES REDACTED]. On 07/26/18 at 02:03 PM, review of the MDS assessments revealed an Admission Assessment with an ARD (Assessment Reference Date) of 04/07/18. Section J, Health Conditions, question J1400, Does the resident have a condition or chronic disease that may result in a life expectancy of of less than 6 month?, was coded as no. Section O Special Treatments, Procedures, and Programs, question O100K2, Hospice while a resident was coded no. Further review revealed a Quarterly MDS assessment with an ARD of 07/02/18 with both questions coded as yes. Review of the physician's telephone orders revealed an order to admit to hospice with an original order dated 04/08/18. There was no evidence in the record that a Significant Change in Status Assessment was conducted. Review of the CMS's (Centers for Medicare and Medicaid Service) RAI (Resident Assessment Instrument) Version 3.0- Manual, (MONTH) (YEAR), page 2-23 revealed A SCSA is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. The ARD must be within 14 days from the effective date of the hospice election (which can be the same or later than the date of the hospice election statement, but not earlier than). A SCSA must be performed regardless of whether an assessment was recently conducted on the resident. During an interview on 07/26/18 03:25 PM, MDS Coordinator #1 confirmed the resident was admitted to Hospice on 4/8/18. The nurse further confirmed an admission assessment was completed with an ARD 04/07/18. MDS nurse #1 also confirmed a SCSA was not completed stating the facility's consultant had told her/him it was not necessary as the resident was at his baseline.",2020-09-01
658,HEALTHCARE CENTER OF WESLEY COMMONS,425078,1110 MARSHALL ROAD,GREENWOOD,SC,29646,2018-07-26,732,C,0,1,B7PC11,"Based on record review and interview, the facility failed to post the staffing information on a daily basis by category of licensed staff. The total number of hours worked by Registered Nurses and Licensed Practical Nurses or Licensed Vocational Nurses was combined on the posting. The findings included: On 07/26/18 at approximately 10:15 AM, review of the staff postings for the last 30 days revealed the total hours worked was listed for all licensed staff and for all unlicensed staff. The total number of hours worked by Registered Nurses (RNs) and by Licensed Practical Nurses (LPNs) or Licensed Vocational Nurses (LVNs) was not listed separately on the posting. During an interview at 10:27 AM, the Nursing Home Administrator confirmed the postings combined all licensed staff hours and did not list RNs and LPNs/ LVNs separately.",2020-09-01
659,HEALTHCARE CENTER OF WESLEY COMMONS,425078,1110 MARSHALL ROAD,GREENWOOD,SC,29646,2019-09-26,550,E,0,1,G0YO11,"Based on observation, interview, and review of the facility information Relias-Protecting Resident Rights in Nursing Facilities, the facility failed to treat each resident with respect and dignity and care for each resident in a manner that promotes enhancement of his or her quality of life. During dining observations, staff was observed to knock and/or state knock, knock and enter resident rooms without the resident's permission (2 of 2 dining observations). The findings included: During meal observation on 9/23/19 at approximately 12:47 PM, Certified Nursing Assistant (CNA) #3 and CNA #4 were observed knocking on resident room doors and/or saying knock, knock and entering resident rooms without the resident's permission. On 9/26/19 at 1:00 PM, during the meal observation, CNA #5 and CNA #6 were observed to knock on the resident's door or say knock, knock and enter the resident's rooms without the resident's permission. On 9/26/19 after the observation was made, CNA #5 and CNA #6 confirmed s/he entered the room without the resident's permission. CNA #5 stated after knocking on the resident's door you should wait for the invitation to enter. During an interview with CNA #6, s/he stated after knocking on the resident's door you were supposed to wait on a response. Review of information provided by the facility titled Relias-Protecting Resident Rights in Nursing Facilities, revealed the following: Before entering a resident's room you should knock on the door, ask for permission to enter, and allow the resident the time to respond before entering the room.",2020-09-01
660,HEALTHCARE CENTER OF WESLEY COMMONS,425078,1110 MARSHALL ROAD,GREENWOOD,SC,29646,2019-09-26,684,D,0,1,G0YO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and review of the Hospice agreement, the facility failed to ensure all documentation related to Hospice services were available for 1 of 1 resident reviewed for Hospice services. Resident #18's Hospice chart did not include all documentation for Certified Nursing Assistant (CNA), Registered Nurse (RN), and Volunteer visits. The findings included: The facility admitted Resident #18 with [DIAGNOSES REDACTED]. Record review on 9/24/19 at 11:48 AM revealed hospice services for Resident #18 started on 3/21/19. Review of the Hospice care plan stated CNA's were to visit 1-3 times per week, RN visits were 1-3 times per week, and Volunteers were to visit 2-4 times per month. Further review of the hospice notes revealed there was no documentation CNA's had visited from 9/6/19 to present. No volunteer visits were documented in the hospice record. The last nursing visit record was dated 8/2/19. During an interview with the Hospice Nurse on 9/26/19 at 2:25 PM, s/he stated it was her responsibility to ensure the nursing notes were in the facility. S/he further stated s/he understood all discipline notes should be in the Hospice record. Review of the Hospice Agreement on 9/26/19 revealed the following under the medical records section: The nursing home shall prepare and maintain medical records for each Hospice patient receiving services pursuant to this agreement the medical records shall consist of progress notes and clinical notes.",2020-09-01
661,HEALTHCARE CENTER OF WESLEY COMMONS,425078,1110 MARSHALL ROAD,GREENWOOD,SC,29646,2019-09-26,686,G,0,1,G0YO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record, and facility policy review, the facility failed to provide preventative measures to prevent the development of an avoidable pressure ulcer for 1 of 3 residents (Resident (R) 26) and failed to prevent infection of the pressure ulcer. Specifically, R26 developed a stage four pressure ulcer on her right heel within a week of admission and developed a bacterial infection of the pressure ulcer within 48 days of wound treatment by the facility. This deficient practice impacted R26's ability to walk and caused her pain during care of the pressure ulcer. The findings included: Observation on 09/23/19 at 08:46 AM, revealed R26 was observed lying on her back in bed. R26 stated, I usually stay in bed and watch television or read because of my foot. I have a sore on my foot and I can't put my shoe on. I've had it for a long time. R26 did not have an air mattress for pressure reduction and there were no pillows for positioning. Review of R26's Record of Admission, located in the resident's paper chart, indicated the facility admitted the resident on 04/22/19 with [DIAGNOSES REDACTED]. Review of R26's 48 Hour Care Plan, not dated, indicated, Resident is here for short-term rehabilitation.nursing and therapy will assist you with off-loading while in bed or chair to prevent pressure areas on your skin. The care plan was signed by R26. Review of the comprehensive care plan, dated 05/05/19, indicated a concern at risk for skin breakdown had revisions dated 05/05/19 which included routine body audits, provide supplements, consult wound MD, assist resident with turning and repositioning, float heels, provide treatment, monitor signs and symptoms of wound infections, encourage po intake, assess for pain, administer antibiotics, bunny boots as ordered. The revised care plan 06/18/19 arterial dopplers, culture right heel, follow new treatment orders. The care plan was revised. R26's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/29/19, indicated the resident had a Brief Interview for Mental Status (BIMS) score of seven out of 15, which indicated cognitive impairment. R26 had no behaviors of rejection of care and required two persons assistance for bed mobility, extensive assistance for transfer and limited assistance for walking. R26 had no pressure ulcers on admission and was at risk for developing pressure ulcers according to the MDS. Review of R26's Nutritional Evaluation, dated 04/29/19, indicated Current diet order-regular.[MEDICAL CONDITION] slight lower extremity.skin condition intact.no pressure ulcers. R26's quarterly MDS, with an ARD of 07/24/19, indicated R26 continued to require two persons assistance for bed mobility, extensive assistance for transfer but no longer walked in her room, or corridor on the unit. R26 had no nutritional concerns and had not experienced weight loss. The MDS indicated the resident had an unhealed stage four pressure ulcer. (Stage 4 pressure ulcer-full thickness loss with exposed bone, tendon or muscle. Slough or eschar (dead tissue) may be present on some parts of the wound bed. If slough or eschar obscures the wound bed, the wound is considered unstageable). Review of R26's Nurse's Notes, dated 04/30/19 at 07:00 PM, indicated, Resident alert.resident has blister to right heel.feet floated off pillows. Nurse's notes, dated 05/05/19 at 07:00 PM, indicated, Right heel dressing changed. Blister open now but skin is in place Review of R26 Physician Orders, dated 05/08/19, indicated, .right heel, skin prep daily then cover with calcium alginate and cover with bordered gauze. These orders were discontinued and changed as the wound went from unstageable, was debrided and then was identified as a stage 4. Review of R26's Active physician's orders [REDACTED].cleanse with wound cleanser, pat dry with gauze, apply Santyl ointment, apply gauze island dressing.change daily.[DIAGNOSES REDACTED].bunny boots bilateral heels.ensure placement at all time except when ambulating or transferring. Review of a Wound Specimen, laboratory report, dated 06/20/19, revealed the wound on R26's right heel had a bacterial infection. The laboratory report indicated, Wound specimen from right heel collected on 06/18/19 was verified on 06/20/19 with final results-[MEDICAL CONDITION] Resistant Staph Aureus. (MRSA-[MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA) is a cause of staph infection that is difficult to treat because of resistance to some antibiotics). Reference: Centers for Disease Control, (CDC). Review of the Treatment Administration Record, (TAR), dated 06/21/19, indicated R26 required an antibiotic due to the infection in the pressure ulcer on her right heel. The TAR indicated, [MEDICATION NAME] 50 mg by mouth twice daily for 10 days for [MEDICAL CONDITION] Staphylococcus aureus infection, give two tablets (100 mg) twice daily. Review of the Nurse's Notes, dated 06/21/19 at 11:00 PM, revealed there was no documentation regarding signs or symptoms of infection of the wound on R26's right heel. The notes indicated, Resident started antibiotic therapy [MEDICAL CONDITION] to the right heel wound. R26's Specialty Wound Physician Notes, dated 07/10/19, indicated, Surgical excision of pressure wound right heel, stage 4 pressure wound with moderate serous exudate. After excision of the dead tissue by the wound physician, the wound was a stage 4. Observation on 09/23/19 at 12:59 PM, revealed R26 lying on her back in bed with both heels against the mattress. The bunny boot (pressure reducing device) was not on her right heel and was lying at the foot of the bed. R26 stated, I can't put it on myself but when someone comes in, I'll get some help. The facility failed to ensure the preventative device was in use and pillows were used to keep the heel from the surface of the mattress. During an interview with the Director of Nursing (DON) on 09/24/19 at 12:54 PM, the DON stated, She (referring to R26) was deconditioned when she was admitted . She's a lot more mobile now. She was found to have [MEDICAL CONDITION] (impaired circulation) and that's what caused the pressure ulcer. The pressure ulcer was unavoidable because of the vascular disease. The DON verified the wound was identified by the facility as a pressure ulcer. On 09/24/29 at 03:00 PM, R26 was observed in bed lying on her back in bed. The right foot was out of the bed covers and did not have a bunny boot (pressure relieving device) on her foot. The bunny boot was at the top of the bed near R26's head. The facility failed to ensure the preventative device was in use and pillows were used to keep the heels off the surface of the mattress. During a follow-up interview on 09/25/19 at 08:18 AM, the DON stated, I agree not all residents with impaired circulation will develop a pressure ulcer. The DON was unable to find documented evidence that the facility provided pressure relieving interventions to prevent the development of the pressure ulcer. The DON stated, We typically don't use bunny boots for prevention. We started aggressively using them for her (referring to R26) when we discovered the pressure ulcer. She does take the boot off and we have to put it back on. On 09/25/19 at 8:21 AM, R26 was observed in bed on her back with both legs out of the covers. R26 was wearing socks and did not have a bunny boot on her right foot. The bunny boot was observed next to the resident's head. The facility failed to ensure the preventative device was in use. There were no pillows or device in use to keep the heels free from the surface of the mattress. On 09/25/19 at 10:13 AM, the DON verified that the facility could find no documentation that the resident had taken the bunny boots off. The DON stated, I couldn't find any documentation that the right heel was pressure off-loaded by direct care staff. There is no documentation in the nurses notes or the care plan that she takes the boot off herself. Review of an email, dated 09/25/19, from the Registered Dietitian indicated, Based on information from nutritional data collection, resident was not at nutritional risk for skin breakdown. Med pass (nutritional supplement) was added based on meal percentage consumed not consistently meeting nutritional needs. During an interview on 09/25/19 at 01:27 PM, the Certified Dietary Manager (CDM) stated, She (referring to R26) was not high risk for pressure ulcer development. Her pre-[MEDICATION NAME] level (laboratory test of the body's protein status for wound healing) was good and she had no pre-existing pressure wounds on admission. Her weight has been stable. On 09/25/19 at 3:15 PM, the wound care physician was observed providing wound care to R26. The wound care physician cleansed the wound on the residents' right heel, measured the wound and began to use a sharp instrument to debride the wound (Debride-remove dead tissue). When the wound doctor started cutting tissue from R26's heel, she pulled her foot back and said, Ow, that hurts. The wound care physician then sprayed [MEDICATION NAME] on the residents' right heel ([MEDICATION NAME] is used to temporarily numb and relieve pain). During an interview on 09/25/19 at 3:24 PM, the wound care physician stated, I have been providing services to the resident since (MONTH) of this year. She has dementia and [MEDICAL CONDITION] and was at risk for development of a pressure ulcer. Not all residents with [MEDICAL CONDITION] will end up with a pressure ulcer. On 09/25/19 at 03:33 PM, following the wound care treatment by the wound care physician, R26 stated, It didn't hurt very much in the beginning, but when they start cutting it hurts. I'm glad it's getting better. The resident was not wearing a bunny boot and did not have a positioning device to prevent the heel from lying on the surface of the mattress. During an interview on 09/26/19 at 02:03 PM, the Infection Preventionist (IP) who was also the facility MDS Coordinator (MDSC) stated while reviewing the MDS on line, Yes, she (referring to R26) was admitted with no pressure ulcers but she was at risk. I see where she had a decline in ambulation from her admission MDS. It was possibly because she had the wound on her right heel. She had an order for [REDACTED]. All the nurses provided daily wound care dressings and once a week the wound care doctor treats the wound and takes measurements. I'm not sure how the wound got infected. I didn't do any education to staff at that time regarding wound care. Review of the policy titled Skin Care Guidelines, dated (MONTH) 9, 2019, indicated, Stage Four.Cleanse and change dressings daily and as needed, air mattress, bunny boots.heels floated.ensure pressure reduction.turn and reposition every 2 hours and as needed.avoid pressure.avoid positioning.on existing pressure ulcers.low air loss mattress utilization.may use pillows to assist with positioning.off load every 2 hours.elevate heels from surface of bed using pillows so heel is completely off mattress.",2020-09-01
662,HEALTHCARE CENTER OF WESLEY COMMONS,425078,1110 MARSHALL ROAD,GREENWOOD,SC,29646,2019-09-26,698,D,0,1,G0YO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to administer medications in a timely manner for 1 of 1 resident reviewed for [MEDICAL TREATMENT] (Resident #121). On [MEDICAL TREATMENT] days, Resident #121 did not receive all of his/her medications. The findings included: The facility admitted Resident #121 with [DIAGNOSES REDACTED]. Record review on 9/24/19 at 3:34 PM revealed Resident #121 had physician's orders [REDACTED]. Further record review revealed Resident #121 received the medications prior to going to [MEDICAL TREATMENT] from 9/11/19-9/23/19. On 9/14/2019, 9/17/19, and 9/21/19, medications were held due to [MEDICAL TREATMENT]. On 9/22/19, a note was written by pharmacy stating the resident was not receiving medications related to [MEDICAL TREATMENT] and suggested the prescriber re-evaluate when medications were to be held. On 9/24/19, the administration time for the medications was changed to 12:00 PM. During this time on [MEDICAL TREATMENT] days, Resident #121 was not in the facility to receive the medications. All of Resident #121's medications were missed on 9/24/19 due to being out of the facility to [MEDICAL TREATMENT]. During an interview on 9/26/19 at approximately 1:45 PM with Registered Nurse #1, s/he confirmed Resident #121 would not be in the building at the prescribed time for the medications and s/he would have to notify the physician. During an interview on 9/26/19 at 2:30 PM with the Administrator, s/he stated the time of the administration of the medications should have been caught sooner.",2020-09-01
663,HEALTHCARE CENTER OF WESLEY COMMONS,425078,1110 MARSHALL ROAD,GREENWOOD,SC,29646,2019-09-26,880,E,0,1,G0YO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to follow infection control practices in the laundry (1 of 1 observations of the laundry). In addition, Resident #72 developed an infection in a pressure ulcer wound (1 of 2 residents with infections in the pressure ulcer). The findings included: Observation of the laundry on 9/25/19 at 10:23 AM revealed Laundry Staff #1 gathered clothes in a resident's room and placed the items in a clear bag. During the observation, the bag was placed on the floor while clothes were inserted into the bag. The laundry bag was brought out of the resident's room and placed on the floor near the resident's door. Laundry Staff #1 removed his/her gloves, obtained a sharpie pen from the top of the cart, initialed the bag, and sanitized his/her hands. Upon arrival to the laundry, Laundry Staff #1 placed hangers, which were hanging off of the soiled linen cart, in a box on the clean side of the laundry. S/he entered the soiled side of the laundry room where covered clean carts were located. The dirty linen carts were in close proximity to the clean linen carts. Laundry Staff #1 washed hands, donned a gown, removed clean items from the washers, placed them in the clean cart and pushed the cart to the clean side of the laundry. Laundry Staff #2 was observed to load the washer, close and lock the washer door, and start the washer with his/her soiled gloved hand. Laundry Staff #1 was observed to sort soiled items and load the washer. S/he was observed to obtain a sharpie located on the dirty cart, enter room numbers in unlabeled clothing, and place the sharpie pen back onto the soiled cart. S/he loaded the small washer, removed gloves, closed washer doors, started washers, and removed his/her gown. After waiting a few moments, this surveyor asked was there anything else that needed to be done and Laundry Staff #1 stated, Oh, I need to wash my hands. While in the laundry, Laundry Staff #2 was observed to leave out of the clean side of the laundry with gloves on and re-enter the clean side wearing gloves. During an interview with Laundry Staff #1 after the observation, s/he stated machines were sanitized after removing clean linen a couple of times a day. This was not demonstrated during the observation of removal of clean linen. S/he continued by confirming the soiled sharpie pen was placed back onto the dirty cart. Review of the facility policy titled Laundry Care and Cleaning revealed the following: 2. Washing Machine a. washing machines will be cleaned and sanitized daily. The facility admitted Resident #72 with [DIAGNOSES REDACTED]. Review of the medical record on 9/25/19 revealed Resident #72 developed a decubitus ulcer on the left calf on 8/16/18 due to an immobilizer which was in place with physician orders to have the immobilizer at all times. Resident #72 was seen and treated weekly by the Wound Care physician. On 10/4/18, the wound cultures were positive for [MEDICAL CONDITION]-resistant Staphylococcus Aureus, [MEDICATION NAME] (non [MEDICATION NAME]-resistant [MEDICATION NAME]), and Proteus Mirabilis. Further review of the medical record revealed oral antibiotics were prescribed and eventually intravenous antibiotics were needed for the wound. During an interview with the Director of Nursing on 9/26/19 at 4:45 PM, s/he stated the splint was not to be removed per physician orders and was to be on the resident at all times. S/he continued by stating s/he was unaware of how the area became infected and the Wound Care Physician and staff treated and dressed the area. During an interview with the Infection Control Preventionist on 9/26/19 at 4:55 PM, s/he stated s/he did not know how the infection started in Resident #72's wound and would have to speculate it was due to cross contamination at some point.",2020-09-01
664,KERSHAWHEALTH KARESH LONG TERM CARE,425080,1315 ROBERTS STREET,CAMDEN,SC,29020,2017-01-25,278,D,0,1,BVYX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to accurately assess the pain status of Resident #71 reviewed for unnecessary medication. The findings included: The facility admitted Resident #71 with [DIAGNOSES REDACTED]. On 01/25/17 at 9:38 AM, review of the Minimum Data Set (MDS) assessments dated 08/24/16 Annual and 11/23/16 Quarterly revealed under section J200 Should Pain Assessment Interview be Conducted was answer No resident is rarely/never understood. Further review revealed the question Should Brief Interview for Mental Status be Conducted was answered Yes . The Summary Score for the resident was a 14. Review of the resident ' s pain assessments dated 06/01/16, 08/31/16, and 11/29/16 on 01/25/17 at 10:45 AM, revealed Able to verbalize pain.",2020-09-01
665,KERSHAWHEALTH KARESH LONG TERM CARE,425080,1315 ROBERTS STREET,CAMDEN,SC,29020,2017-01-25,282,D,0,1,BVYX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to follow the comprehensive plan of care related to interventions prior to administration of pain and anxiety medication for 1 of 5 residents reviewed for unnecessary medications and 1 of 2 residents reviewed for Behavioral and Emotional Status. Resident #71's intervention was not used prior to giving [MEDICATION NAME] for pain and [MEDICATION NAME] (HCL) for behaviors. Resident #147 interventions were not used prior to giving [MEDICATION NAME] HCL and [MEDICATION NAME] medication for behaviors. The findings included: The facility admitted Resident #71 with [DIAGNOSES REDACTED]. On 01/25/17 review of the physician's order [REDACTED]. [MEDICATION NAME] 1 tablet by mouth twice daily as needed for headache. Review of the resident ' s current care plan dated 11/29/16 on 01/25/17 at 10:21 AM revealed, Resident has [DIAGNOSES REDACTED]. S/he is taking medications for pain control, depression, anxiety, and paranoia. Review of (MONTH) (YEAR) through (MONTH) (YEAR) medication record on 01/25/17 at 10:33 AM revealed on multiple days in the months of (MONTH) (YEAR) through (MONTH) (YEAR) the resident was given [MEDICATION NAME] for pain and [MEDICATION NAME] (HCL) for behaviors as needed. Further record review of the medication records revealed no interventions were used prior to giving the pain and behavioral medication. Review of the Nurses ' Notes on 1/25/17 at 10:46 AM revealed no documentation of interventions being used prior to giving pain and behavior medications. During an interview with Registered Nurse #1 (RN) and Registered Nurse #2 on 01/25/17 at 12:29 PM confirmed there was no documentation of interventions being used prior to giving pain and behavior medications. RN #1 stated The Resident is adament about what she wants. The facility admitted Resident #147 with [DIAGNOSES REDACTED]. Review of the resident ' s current care plan dated 12/19/16 on 01/24/17 at 4:25 PM revealed Resident is at risk for drug related side effects due to use of [MEDICAL CONDITION] medications. [DIAGNOSES REDACTED]. Approaches nursing to try non-medication interventions also. Review of (MONTH) (YEAR) through (MONTH) (YEAR) Medication Administration on 01/24/17 at 4:18 PM revealed on 11/1/16, 11/19/16, 12/14/16, 12/16/16, 12/17/16, 12/25/16, 12/29/16, 01/02-01/04/17, 01/11/17, 01/18/17, and 01/21/17 [MEDICATION NAME] was administered as needed. Further record review of the medication records revealed no interventions were used prior to giving the behavioral medication. Further record review on 01/25/17 at 11:45 AM of the Nurse Notes revealed, resident having agitation and confusion medication given. There was no information on prior interventions for the use of [MEDICATION NAME]. During an interview with Registered Nurse (RN) #2 on 01/25/17, he/she stated Resident having chronic pain will place the resident back in the bed when he/she is hurting. RN #2 confirmed there is no documentation of interventions being used prior to using medications.",2020-09-01
666,KERSHAWHEALTH KARESH LONG TERM CARE,425080,1315 ROBERTS STREET,CAMDEN,SC,29020,2017-01-25,329,D,0,1,BVYX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to provide interventions for 2 of 5 residents reviewed for Unnecessary Medications. Resident # 71 did not receive interventions prior to given pain and behavior medications and Resident #147 did not receive interventions prior to given behavioral medications The findings included: The facility admitted Resident #71 with [DIAGNOSES REDACTED]. On 01/25/17 review of the physician's order [REDACTED]. [MEDICATION NAME] 1 tablet by mouth twice daily as needed for headache. Review of the resident ' s current care plan dated 11/29/16 on 01/25/17 at 10:21 AM revealed, Resident has [DIAGNOSES REDACTED]. S/he is taking medications for pain control, depression, anxiety, and paranoia. Review of (MONTH) (YEAR) through (MONTH) (YEAR) medication record on 01/25/17 at 10:33 AM revealed on multiple days in the months of (MONTH) (YEAR) through (MONTH) (YEAR) the resident was given [MEDICATION NAME] for pain and [MEDICATION NAME] (HCL) for behaviors as needed. Further record review of the medication records revealed no interventions were used prior to giving the pain and behavioral medication. Review of the Nurses ' Notes on 1/25/17 at 10:46 AM revealed no documentation of interventions being used prior to giving pain and behavior medications. During an interview with Registered Nurse #1 (RN) and Registered Nurse #2 on 01/25/17 at 12:29 PM confirmed there was no documentation of interventions being used prior to giving pain and behavior medications. RN #1 stated The Resident is adamant about what she wants. The facility admitted Resident #147 with [DIAGNOSES REDACTED]. Review of the resident ' s current care plan dated 12/19/16 on 01/24/17 at 4:25 PM revealed Resident is at risk for drug related side effects due to use of [MEDICAL CONDITION] medications. [DIAGNOSES REDACTED]. Approaches nursing to try non-medication interventions also. Review of (MONTH) (YEAR) through (MONTH) (YEAR) Medication Administration on 01/24/17 at 4:18 PM revealed on 11/1/16, 11/19/16, 12/14/16, 12/16/16, 12/17/16, 12/25/16, 12/29/16, 01/02-01/04/17, 01/11/17, 01/18/17, and 01/21/17 [MEDICATION NAME] was administered as needed. Further record review of the medication records revealed no interventions were used prior to giving the behavioral medication. Further record review on 01/25/17 at 11:45 AM of the Nurse Notes revealed, resident having agitation and confusion medication given. There was no information on prior interventions for the use of [MEDICATION NAME]. During an interview with Registered Nurse (RN) #2 on 01/25/17, he/she stated Resident having chronic pain will place the resident back in the bed when he/she is hurting. RN #2 confirmed there is no documentation of interventions being used prior to using medications.",2020-09-01
667,KERSHAWHEALTH KARESH LONG TERM CARE,425080,1315 ROBERTS STREET,CAMDEN,SC,29020,2017-01-25,371,F,0,1,BVYX11,"Based on observations and interviews, the facility failed to follow proper food handling practices to store, distribute, and serve food under sanitary conditions as evidenced by expired food stored in the walk in cooler and dry storage. The findings included: On 1/23/17 at 11:15 AM, during initial tour of the main kitchen with the Certified Dietary Manager (CDM) and the Kitchen Manager, observation revealed expired foods in the walk-in cooler. Observation revealed a container of butterscotch pudding dated 1/19/17, a boxed lunch containing a turkey sandwich and Jell-O pudding dated 1/21/17, an angel food cake dated 1/12/17, a 1/2 gallon of cultured buttermilk with a use by date of 1/20/17, 16- 4 oz. containers of Activia yogurt with an expiration date of 1/11/17, 3-5 lb. containers of Sour Cream with a use by date of 1/21/17, a 5 lb. container of Sour Cream with an expiration date of 1/11/17, 8 bags of shredded [NAME] Slaw with a use by date of 1/21/17, one bag of [NAME] Slaw with a use by date of 1/13/17. Further investigation of the 2nd walk-in cooler revealed 9 lunch meat combo packs with a use by date of 1/9/17, a 5 lb. roll of ground beef with a use or freeze by date of 1/6/17 and 2- 5 lb. rolls of ground beef with a use or freeze by date of 1/13/17. On 1/23/17 at 11:52 AM, initial tour of the dry storage revealed 11 boxes of Quaker instant Original grits with an expiration date of 11/10/16, 2 boxes of 100 tea bags each labeled 7/29/16, 8- 20 oz. orange Gatorades with an expiration date of 1/17/17, 3- 3 lb. Grey Poupon Dijon Mustard bottles, Lite French Dressing 1.5 oz with an expiration date of 12/26/2016, a Creamy Caesar 1.5 oz. bottle of dressing with a use by date of 1/13/17 and a box of House Decaf Coffee pods containing 24 cups with an expiration date of 7/21/2016. During an interview on 1/23/17 at 12:35 PM with the CDM and Kitchen Manager, it was revealed that there was not a set policy in place for the proper handling and labeling of food items.",2020-09-01
668,KERSHAWHEALTH KARESH LONG TERM CARE,425080,1315 ROBERTS STREET,CAMDEN,SC,29020,2018-04-06,604,D,0,1,3F6I11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to conduct an assessment to determine the underlying cause of falls and attempt alternate interventions prior to the implementation of alarms for one of two sampled residents reviewed for restraints (Resident #82). Resident #82 had no restraint assessment completed prior to implementation of alarms. The findings included: The facility admitted Resident #82 on 2-25-18 with [DIAGNOSES REDACTED]. Review of Progress Notes at 3:26 PM on 4-5-18 and Incident Reports on 4-5-18 at 4:09 PM revealed that Resident #82 sustained two falls in the facility, one self-reported on 3-23-18 at approximately 3 AM (witnessed by roommate) and one on 3-26-18 at 6:45 AM. Record review at 12:24 PM on 4-5-18 revealed that no changes in interventions were implemented to prevent further falls until a 3-31-18 physician's orders [REDACTED]. (patient) safety. Further review revealed no investigations to determine the underlying causes of the accidents. No restraint assessment could be located in the medical record. During an interview on 4-6-18 at 11:16 AM, the Minimum Data Set (MDS) Coordinator stated the facility did have a form they used for restraint assessment. S/he reviewed the medical record and verified it was not in the chart. There was no evidence of assessments following the 3-23-18 or 3-26-18 falls to determine the underlying cause(s) so individualized interventions could be attempted prior to alarm use. During an interview at 10:52 AM on 4-6-18, the MDS Coordinator verified that there were no changes in interventions following the 3-23-18 fall.",2020-09-01
669,KERSHAWHEALTH KARESH LONG TERM CARE,425080,1315 ROBERTS STREET,CAMDEN,SC,29020,2018-04-06,641,B,0,1,3F6I11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to ensure the Minimal Data Set (MDS) was accurately coded related to Nutritional Status. The MDS was coded incorrectly for Resident #38 to have a gastrostomy tube and Resident #82 to be on an incorrect diet. The findings included: Resident # 38 was admitted to the facility 11/20/2017 with [DIAGNOSES REDACTED]. During review of the Quarterly MDS with an Assessment Reference Date of 02/13/2018 Section K0510B2 was coded as checked (indicating the resident had a feeding tube.) Observation on 04/04/18 at 12:23 pm - Resident was in the unit dining room. Glasses on in w/c. lunch meal observation- 2% milk, Ensure pudding, and coffee, pureed diet, banana pudding desert, and prune juice. On 04/04/2018 during an interview the MDS Coordinator confirmed that the resident had never had a feeding tube and that Section K0510B2 was coded inaccurately. The facility admitted Resident #82 on 2-25-18 with [DIAGNOSES REDACTED]. Record review on 4-5-18 at 12:24 PM revealed that upon admission, Resident #82 was on a full liquid diet and a physician's orders [REDACTED]. Review of the 3-24-18 30 day Minimum Data Set (MDS) assessment on 4-5-18 at 8:54 PM revealed that the mechanically altered diet was not coded under Section K. During an interview at 10:52 AM on 4-6-18, the MDS Coordinator verified that the MDS was not accurate related to the diet coding.",2020-09-01
670,KERSHAWHEALTH KARESH LONG TERM CARE,425080,1315 ROBERTS STREET,CAMDEN,SC,29020,2018-04-06,657,E,0,1,3F6I11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs for Resident's #38, # 58, # 65, #25, #34, #69, #63, #82, #47, #48, #51, #54, #81 and #72. The findings included: Resident # 38 was admitted to the facility 11/20/2017 with [DIAGNOSES REDACTED]. Record review on 04/05/2018, the Care Plan Conference sheet was reviewed with no Certified Nursing Assistant attendance or signature. During an interview on 04/05/2018 at 11:48 am the facility Consultant confirmed that the care plan meeting was not attended by the Certified Nursing Assistant. Resident # 58 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review on 04/05/2018, the Care Plan Conference sheet was reviewed with no Certified Nursing Assistant attendance or signature. During an interview on 04/05/2018 at 11:00 am the facility Consultant confirmed that the care plan meeting was not attended by the Certified Nursing Assistant that cared for the resident. Resident # 72 was admitted : 10/27/13 with diagnoses, including but not limited to, [MEDICAL CONDITION] Arthritis, [MEDICAL CONDITION], pleurisy, unspecified Hydro[DIAGNOSES REDACTED], Heart Failure, [MEDICAL CONDITION], neuromuscular dysfunction of bladder, long term use of anticoagulant, muscle weakness, [MEDICAL CONDITION], history of chronic Urinary Tract Infections, other discord of bone density, unspecified [MEDICAL CONDITION] Fibrillation, [MEDICAL CONDITION], Lumbar Disc disease and history of [MEDICAL CONDITION]. Record review on 04/03/2018, the Care Plan Conference sheet was reviewed with no Certified Nursing Assistant attendance or signature. During an interview on 04/03/2018 at 04:15 pm the facility Consultant confirmed that the care plan meeting was not attended by the Certified Nursing Assistant. Resident #65 was admitted [DATE] with [DIAGNOSES REDACTED]. Vein [MEDICAL CONDITIONS] bladder secondary to [MEDICAL CONDITION] requiring in and out catheter, status [REDACTED]. Record review on 04/03/2018, the Care Plan Conference sheet was reviewed with no Certified Nursing Assistant attendance or signature. During an interview on 04/03/2018 at 04:15 pm the facility Consultant confirmed that the care plan meeting was not attended by the Certified Nursing Assistant. Resident #25 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Record review on 04/06/18 at approximately 9:00 a.m. revealed multiple care plan conference forms that did not include the required participation of the interdisciplinary team. On 02/22/18, a meeting was held and the staff present included the Minimum Data Set (MDS) nurse, the hospice nurse, the facility social worker, the hospice social worker and the hospice chaplain. On 12/20/17, a meeting was held and the staff present included the MDS nurse, the dietician and the facility social worker. On 09/20/17, a meeting was held and the staff present included the nurse, the social worker, the dietician and the activities coordinator. Resident # 34 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Record review on 04/06/18 at approximately 9:00 a.m. revealed multiple care conference forms that did not include the required participation of the interdisciplinary team. On 02/14/18, a meeting was held and the documented staff present included the MDS nurse and the social worker. On 11/17/17, a meeting was held and documented staff included the MDS nurse, the dietician, the activities coordinator and the social worker. On 08/23/17, a meeting was held and staff present included the MDS nurse, the dietician, the social worker and the activities coordinator. Resident #69 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A care plan meeting was held on 03/02/18. Staff present included the social worker, the activities coordinator, physical and occupational therapist and the MDS nurse. At approximately 10:09 a.m. on 04/06/18, the forms for Residents #65, 25, and 34 were reviewed with the Director of Nursing who reviewed and confirmed the staff titles, as indicated on the conference form. The provided policy entitled Comprehensive Team Care Planning was reviewed on 04/05/18 at 12:53 p.m. and indicated on line item 1 B. of the Procedure, The planning for each resident must be interdisciplinary and involve at least one staff member from Social Services, Activities, Nursing, Dietary and other disciplines as indicated. The facility admitted Resident #63 on 2-10-18 with [DIAGNOSES REDACTED]. Review of Resident 63's weight record on 4-5-18 at 8:32 AM revealed a 14.6 pound (#) weight loss (8.8%) from 2-10-18 (165.9#) to 3-5-18 (151.3#) and an additional 5 pounds by 3-26-18 (146.3#). By 4-2-18 (144.4#), in less than 2 months, Resident #63 had lost a total of 21.5# or 12.95% of his/her body weight. Review of Nurses Notes at 9:44 AM on 4-5-18 revealed an entry on 2-21-18 that a Care Plan meeting had been held with the resident and family member, There was no evidence of participation by nutrition services or a Certified Nursing Assistant (CNA). Review of the 2-21-18 and 4-3-18 LTC Care Plan Conference forms also revealed no evidence of participation by the physician, nutrition services, or a CN[NAME] During an interview at 1:48 PM on 4-5-18, the Director of Nurses (DON) reviewed the medical record and stated, I don't see where they participated. Record review on 4-5-18 at 9:47 AM revealed that the Care Plan included a potential for weight loss as a problem, but it had not been updated with the actual weight loss on 3-8-18 and any subsequent interventions. During an interview at 1:49 PM on 4-5-18, the DON and Corporate Representative verified that the Care Plan had not been updated with the weight loss. The facility admitted Resident #82 on 2-25-18 with [DIAGNOSES REDACTED]. Review of Progress Notes at 3:26 PM on 4-5-18 and Incident Reports on 4-5-18 at 4:09 PM revealed that Resident #82 sustained two falls in the facility, one self-reported on 3-23-18 at approximately 3 AM and one on 3-26-18 at 6:45 AM. Record review at 12:24 PM on 4-5-18 a 3-31-18 physician's orders [REDACTED]. (patient) safety. Multiple observations over 2 shifts on 4-5-18 (11:35 AM, 2:45 PM, 4:55 PM) revealed that Resident #82 was seated in a bedside chair with no alarm in place. During an interview on 4-5-18 at 4:55 PM, when asked how s/he knew about special care items that were required to be in place, Certified Nursing Assistant (CNA) #1 (assigned to the resident's care) stated they did not have a CNA care plan to go by. S/he stated they got a verbal report of changes and went by an assignment sheet. CNA #1 produced the assignment sheet and confirmed that it did not include alarms. Review of the Interdisciplinary Care Plan at 5:08 PM on 4-5-18 revealed that it had been updated with the 3-23-18 self-reported fall but there there were no noted changes in interventions to prevent recurrence. The Interdisciplinary Care Plan had not been updated with the 3-26-18 fall or the 3-31-18 physician-ordered alarms. During an interview at 10:52 AM on 4-6-18, the MDS (Minimum Data Set) Coordinator verified that there were no changes in interventions following the 3-23-18 fall and that the care plan had not been updated following the 3-26-18 fall. Review of the 3-12-18 LTC (long term care) Care Plan Conference form revealed no nutrition services or CNA participation. This was verified during an interview on 4-6-18 at 11:16 AM by the MDS Coordinator. Review of the facility's undated Comprehensive Team Care Planning Policy and Procedure revealed it had not been updated with the 11-28-16 requirements for required care plan participation. It states: The services are implemented and updated on the care plan . The planning for each resident must be interdisciplinary and involve at least one staff member from Social Services, Activities, Nursing, Dietary, and other disciplines as indicated . The facility admitted Resident #47 on 3/6/16 with [DIAGNOSES REDACTED]. Review of the medical record revealed the care plan conference attendance sheets contained space for signatures of staff participating in the meeting. Review of the attendance sheet dated 3/22/18 revealed no signature of a Certified Nurses Aide (CNA) or Dietary staff member. The attendance sheets dated 12/20/17 and 9/20/17 contained no CNA signature. During a review of the attendance forms on 4/6/18 at approximately 9:15 AM, the MDS Coordinator confirmed these findings. The facility admitted Resident #48 on 1/29/18 with [DIAGNOSES REDACTED]. Review of the medical record revealed the care plan attendance sheet dated 2/14/18 contained no signature of a CNA or Dietary staff member. This finding was confirmed by the MDS Coordinator on 4/6/18 at approximately 9:15 AM. The facility admitted Resident #51 on 11/15/95 with [DIAGNOSES REDACTED]. Review of the care plan attendance sheets dated 3/7/18, 12/13/17, and 9/13/17 revealed no signature of a CNA to indicate participation in the meeting. The MDS Coordinator confirmed this finding on 4/6/18 at approximately 9:15 AM. The facility admitted Resident #54 on 5/26/17 with [DIAGNOSES REDACTED]. Review of the medical record revealed the care plan attendance sheets dated 2/28/18, 12/6/17, and 9/13/17 contained no CNA signature to indicate participation in the meeting. The MDS Coordinator confirmed this finding on 4/6/18 at approximately 9:15 AM. The facility admitted Resident #81 on 1/16/14 with [DIAGNOSES REDACTED]. Review of the medical record revealed the care plan attendance forms dated 3/29/18, 1/11/18, and 10/17/17 contained no CNA signature to indicate participation in the meeting. The MDS Coordinator confirmed this finding on 4/6/18 at approximately 9:15 AM.",2020-09-01
671,KERSHAWHEALTH KARESH LONG TERM CARE,425080,1315 ROBERTS STREET,CAMDEN,SC,29020,2018-04-06,689,D,0,1,3F6I11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure that 1 of 3 sampled residents reviewed for accidents were assessed following falls to determine the underlying cause, that fall prevention measures were implemented in a timely manner to prevent recurrence, and that physician's orders [REDACTED]. Resident #82 had a history of [REDACTED]. Resident #82 was also observed multiple times without an alarm in place as ordered. The findings included: The facility admitted Resident #82 on 2-25-18 with [DIAGNOSES REDACTED]. Review of Progress Notes at 3:26 PM on 4-5-18 and Incident Reports on 4-5-18 at 4:09 PM revealed that Resident #82 sustained two falls in the facility, one self-reported on 3-23-18 at approximately 3 AM and one on 3-26-18 at 6:45 AM. No Incident Report could be located for the 3-23-18 fall and there were no Progress Notes documented for the 3-26-18 fall as verified by the Director of Nurses on 4-4-18 at 3 PM. Record review at 12:24 PM on 4-5-18 revealed that no changes in interventions were implemented to prevent further falls until a 3-31-18 physician's orders [REDACTED]. (patient) safety. Further review revealed no investigations to determine the underlying causes of the accidents. No restraint assessment could be located in the medical record. During an interview on 4-6-18 at 11:16 AM, the Minimum Data Set (MDS) Coordinator stated the facility did have a form they used for restraint assessment. S/he reviewed the medical record and verified it was not in the chart. Multiple observations over 2 shifts on 4-5-18 (11:35 AM, 2:45 PM, 4:55 PM) revealed that Resident #82 was seated in a bedside chair with no alarm in place. During an interview and observation on 4-5-18 at 4:55 PM, Certified Nursing Assistant (CNA) #1, who was assigned to the resident's care, verified that the alarm was not connected. When asked how s/he knew about special care items that were required to be in place, the CNA stated they did not have a CNA care plan to go by. S/he stated they got a verbal report of changes and went by an assignment sheet. CNA #1 produced the assignment sheet and confirmed that it did not include alarms. The CNA stated, Day shift probably took her (him) to the bathroom and didn't put it (the alarm) back on. I should have checked but I didn't notice. Review of the Interdisciplinary Care Plan at 5:08 PM on 4-5-18 revealed that it had been updated with the 3-23-18 self-reported fall but there was no investigation as to the underlying cause and there were no noted changes in interventions to prevent recurrence. The Interdisciplinary Care Plan had not been updated with the 3-26-18 fall or the 3-31-18 physician-ordered alarms. During an interview at 10:52 AM on 4-6-18, the MDS Coordinator verified that there were no changes in interventions following the 3-23-18 fall and that the care plan had not been updated following the 3-26-18 fall.",2020-09-01
672,KERSHAWHEALTH KARESH LONG TERM CARE,425080,1315 ROBERTS STREET,CAMDEN,SC,29020,2018-04-06,761,E,0,1,3F6I11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interviews, and review of the facility policy, the facility failed to ensure that medications were stored in 1 of 2 medication room refrigerators at temperatures specified by FDA (Food and Drug Administration) approved package inserts, manufacturer package labeling and the Facility's policy. Medication was stored in the unit 2 medication storage room refrigerator below manufacture specifications. The findings included: On 4/3/18 at 11:19 AM, an observation of the unit 2 medication storage room refrigerator with Licensed Practical Nurse (LPN) #1 revealed the temperature of the refrigerator was 30 degrees of Fahrenheit (F). The medication in the refrigerator was: 1.) (1) 10 ml. vial of [MEDICATION NAME] R insulin 2.) (1) 10 ml. vial of [MEDICATION NAME] mix 70/30 insulin 3.) (1) 10 ml. vial of [MEDICATION NAME] 70/30 insulin 4.) (1) 3 ml. vial of Humalog insulin 5.) (1) 10 ml. vial [MEDICATION NAME] 6.) (1) 10 ml. vial of Levamir insulin 7.) (1) 10 ml. vial of [MEDICATION NAME] N insulin 8.) (8) 2gm./ml. vials of Lorazapam 9.) (2) .5 ml. vial of Pnuemovax 23 10.) (1) 5TU/0.1 ml. vial of [MEDICATION NAME] Purified Protein Derivative (PPD) On 4/3/18 at 11:20 AM, LPN #1 verified the temperature in the refrigerator was 30 degrees of (F.), and the above (10) medications in the refrigerator, and further indicated s/he did not know the correct temperature for insulin storage. On 4/4/18 at 7:45 AM, a review of the (MONTH) (YEAR) unit 2 Refrigerator Temperature Chart revealed that on (14) days the temperature was recorded at 33 degrees (F.), (4) days at 34 degrees (F.), and (9) days had no temperature recorded. On 4/4/18 at 9:30 AM, a review of the pharmacy technicians Med Room/Station Inspection, dated 3/20/18 revealed under Refrigerator/Freezer, the mark X and 32 degrees was identified next to #44 which stated, Temperature (Refrigerator: 35 degrees to 46 degrees F or 2 to 8 Celsius), indicating the temperature was 32 degrees. On 4/4/18 at 1:56 PM, a review of the facility policy entitled, Medication Storage In The Facility, states under procedure (7) Medications requiring refrigeration or temperatures between 36 degrees F and 46 degrees F are kept in a refrigerator with a thermometer to allow temperature monitoring. Medications requiring storage in a cool place are refrigerated unless otherwise directed on the label. Review of the manufacture specifications for [MEDICATION NAME] Purified Protein Derivative, (Mantoux) (PPD) ([MEDICATION NAME]) states under section Storage, Store at 2 degrees to 8 degrees of Celsius (35 to 46 degrees of Fahrenheit). Do not freeze. Discard product if exposed to freezing. Review of the FDA approved manufacturer package inserts and manufacturer package labeling revealed that the Insulin, Pnuemovax 23, and Lorazapam should be stored 36-46 degrees F.",2020-09-01
673,KERSHAWHEALTH KARESH LONG TERM CARE,425080,1315 ROBERTS STREET,CAMDEN,SC,29020,2018-04-06,812,F,0,1,3F6I11,"Based on observation, interview, and review of the facility policies, the facility failed to prepare, distribute, and serve food under sanitary conditions for 1 of 1 kitchen reviewed and has the potential to affect 84 of 85 residents with ordered diets as evidenced by failing to do the following: Air dry pans, maintain adequate sanitizing solution in cleaning buckets, wear facial hair restraint, clean (floor, fans, vents, coolers, ovens), and temp foods to avoid cross contamination. The findings included: On 04/03/18 at 9:30 AM, during the initial tour of the main kitchen with the Kitchen Manager revealed: 1.) Vents and ceiling above the cooking area had a large build-up of grease and dust. 2.) Double deck convection ovens exhaust vents, motors, and pipes behind ovens had a large build-up of grease and dust. 3.) (2) Red Buckets did not have a chemical solution to sanitize. 4.) Produce cooler and Caterer cooler fan had a large build-up of a white substance that was blowing onto prepared uncovered food, also a white substance was growing on all the racks inside both coolers, furthermore a package of strawberries had a white substance growing on the berries. 5.) Food, grease, and debris build-up were on the floor along the walls near the dry clean utensil racks and behind stove, fryer and ovens. 6.) (12) 1/3 pans were stacked wet below the food preparation area. 7.) Exhaust vent in dishwashing area had a large build-up of dust. Following the above (7) observations the Kitchen Manager verified the large build-up of grease/dust, lack of sanitizer in buckets, and the pans were stacked wet. On 04/04/18 at 11:30 AM, during an observation of the main kitchen lunch line temping, the Dietary Supervisor used the same sanitizing wipe to clean the food temperature probe between food items pork, broccoli, and sweet potato. Following the observation the Dietary Supervisor verified s/he used the same sanitary wipe between food items. On 04/04/18 at 11:45 AM, during an observation of the main kitchen with the Nutrition Food Service Director revealed: 1.) Vents and ceiling above the cooking area had a large build-up of grease and dust. 2.) Double deck convection ovens exhaust vents, motors, and pipes behind ovens had a large build-up of grease and dust. 3.) Produce cooler and Caterer cooler fan had a large build-up of a white substance that was blowing onto prepared uncovered food, also a white substance was growing on all the racks inside both coolers, furthermore a package of strawberries had a white substance growing on the berries. 4.) Food and debris build-up were on the floor along the walls near the dry clean utensil racks and be-hind stove, fryer and ovens. 5.) (8) 1/3 pans were stacked wet below the food preparation area. 6.) (1) man with mustache and beard not restrained at the food serving line. 7.) Exhaust vent in dishwashing area had a large build-up of dust. Following the above (7) observations the Director of Nutrition Food Service verified the large build-up of grease/dust, pans were stacked wet, white substance growing in the coolers, and the man not wearing a facial hair restraint. On 4-4-18 at 4:00 PM, a review of the Licensing report notice dated 12-29-17 revealed, Excessive accumulation of grease build up observed on the vent hood filters above the main line and on pipes behind the cook line equipment. Review of the facility policy, Cross Contamination Precautions, states under procedure, (5.) Use red buckets sanitizing solution for clean rags. Also, policy Uniform Dress Code states,[NAME]guards are to be worn by all employees with facial hair, the guard is to be pulled up over the nose to cover all beard and mustache hair. Furthermore, policy Kitchen Sanitization states under procedures, (4.) All surfaces of the dish room are cleaned and sanitized after each meal. Walls and ceiling are checked weekly, the exhaust fan is cleaned per need. (5.) Ceiling tiles are checked and replaced as needed. (12.) The ovens are cleaned weekly after daily use is completed. (13.) Walk in refrigerators and freezers are cleaned by staff on a weekly schedule.",2020-09-01
674,KERSHAWHEALTH KARESH LONG TERM CARE,425080,1315 ROBERTS STREET,CAMDEN,SC,29020,2018-04-06,814,D,0,1,3F6I11,"Based on observations, and interview, the facility failed to dispose of garbage and refuse properly for 1 of 2 refuse containers reviewed for garbage disposal. Trash was not contained in the dumpster leaving food and debris visible. The findings included: On 4/3/18 at approximately 1:55 PM, during an observation of the small blue dumpster outside behind the dietary department revealed the top covering doors were open. The dumpster contained bags of food and debris. On 4/3/18 at approximately 3:45 PM, another observation of the small blue dumpster outside behind the dietary department revealed the top covering doors were open. The dumpster contained bags of food and debris. On 4/4/18 at approximately 12:00 PM, an observation with the Director of Nutrition Food Service revealed 1 bag of trash containing food and debris hanging outside of the top of the small blue dumpster. The Director of Nutrition Food Services verified that the bag of trash was not contained inside the dumpster. On 4/4/18 at 3:50 PM, an interview with the administrator revealed that the small blue dumpster was the dumpster used by Karesh Long Term Care (his/her facility) and that there was not a policy regarding garbage disposal.",2020-09-01
675,KERSHAWHEALTH KARESH LONG TERM CARE,425080,1315 ROBERTS STREET,CAMDEN,SC,29020,2018-04-06,908,F,0,1,3F6I11,"Based on observation and interview, the facility failed to maintain equipment in a safe operating condition for 2 of 2 double deck convection ovens reviewed. Double deck convection ovens had a large build-up of grease and dust in the main kitchen. The findings included: On 4-3-18 at 9:30 AM, an observation of the main kitchen with the Kitchen Supervisor revealed (2) double deck convection ovens back to back with a large multi-outlet electrical outlet and pipes in between. The backs of the ovens had vents and motors that were covered with a heavy build-up of grease and dust, along with the pipes, wiring and electrical outlet box. Following the observation, in an interview with the Kitchen Supervisor, s/he verified the heavy build-up of grease and dust and was asked if the ovens were on a cleaning schedule, and s/he stated No. On 4-4-18 at 11:45 AM, another observation of the main kitchen with the Nutrition Food Service Director revealed the same (2) double deck convection ovens mentioned above, back to back with a large multi-outlet electrical outlet and pipes in between. The backs of the ovens vents and motors continues to have a heavy build-up of grease and dust, along with the pipes, wiring and electrical outlet box. Following the observation, in an interview with the Nutrition Food Service Director, s/he verified the heavy build-up of grease and dust on the ovens and indicated the kitchen had a licensure inspection recently that referenced the same build-up of grease and dust. On 4-4-18 at 4:00 PM, a review of the DHEC Bureau of Health Facilities Licensing report notice dated 12-29-17 revealed, Excessive accumulation of grease build up observed on the vent hood filters above the main line and on pipes behind the cook line equipment.",2020-09-01
676,KERSHAWHEALTH KARESH LONG TERM CARE,425080,1315 ROBERTS STREET,CAMDEN,SC,29020,2019-05-24,550,D,0,1,J8K211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to protect and ensure dignity for 1 of 1 sampled residents reviewed for dignity (Resident #26). The findings include: The facility admitted Resident #26 with [DIAGNOSES REDACTED]. During random observations by several surveyors during the days of the survey, the catheter discharge bag for Resident #26 was uncovered with contents visible from the doorway and when entering the room to visit both Resident #26 and his/her roommate. An observation on 05/23/19 at approximately 3:27 PM revealed Resident #26 visiting with family members with the catheter bag attached to the foot of the bed at the door side with a large amount of urine observed in the bag. On 05/24/19 at approximately 12:00 PM, Resident #26 was observed in the room with the catheter bag with urine hanging on the rail near the foot of the bed, which was visible from the doorway. In an interview on 05/24/19 at approximately 12:00 PM Licensed Practical Nurse (LPN) #1 confirmed the bag was uncovered with the contents visible from the doorway. LPN #1 stated the cover was only used when the resident left the room. In a subsequent interview on 05/24/19 at approximately 12:13 PM, the Director of Nursing stated it was his/her expectation that the bag should be covered.",2020-09-01
677,KERSHAWHEALTH KARESH LONG TERM CARE,425080,1315 ROBERTS STREET,CAMDEN,SC,29020,2019-05-24,623,D,0,1,J8K211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide written notice of transfer to the Resident and/or Resident Representative for 1 of 3 sampled residents reviewed for hospitalization (Resident #88). The findings included: The facility admitted Resident #88 with [DIAGNOSES REDACTED]. Record review on 05/24/19 at approximately 10:42 AM revealed a physician's orders [REDACTED].#88 to the hospital for evaluation and treatment. No documentation of the facility providing written notice of transfer to the resident and/or resident representative was located in the medical record. In an interview on 05/23/19 at approximately 5:43 PM, the Social Worker confirmed no written Notice of Transfer was provided to the family and/or Resident Representative.",2020-09-01
678,KERSHAWHEALTH KARESH LONG TERM CARE,425080,1315 ROBERTS STREET,CAMDEN,SC,29020,2019-05-24,625,D,0,1,J8K211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of the facility policy titled, Bed Hold, the facility failed to ensure residents and/or their personal representative received a copy of the Bed Hold policy upon transfer/discharge to the hospital for 1 of 3 residents reviewed for hospitalization (Resident #46). The findings included: The facility admitted Resident #46 on 2/26/2009 with [DIAGNOSES REDACTED]. Review on 5/21/2019 at approximately 1:56 PM of the medical record for Resident #46 revealed a hospital stay from 3/24/2019 through 4/1/2019. No documentation could be found in the medical record for Resident #46 to ensure the resident and/or his/her personal representative had received a copy of the bed hold policy upon transfer/discharge to the hospital An interview on 5/24/2019 at approximately 3:59 PM with the Social Worker confirmed that Resident #46 and/or his/her personal representative had not received a copy of the Bed Hold policy upon transfer/discharge to the hospital. Review on 5/24/2019 at approximately 4:30 PM of the facility policy titled, Bed Hold, states, At the time you are admitted , transferred to an acute care facility (hospital), or on a leave of absence, you or your personal representative will be provided written information that specifies Bed Hold Policies and readmission procedures.",2020-09-01
679,KERSHAWHEALTH KARESH LONG TERM CARE,425080,1315 ROBERTS STREET,CAMDEN,SC,29020,2019-05-24,812,E,0,1,J8K211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of facility policies titled Sanitation and Infection Control, Production, Purchasing, and Storage Area and Equipment Cleaning Frequency/Schedules, Ice Machine Maintenance and Cleaning and Hair Restraints, the facility failed to prepare, distribute, and serve food under sanitary conditions for 1 of 1 kitchen reviewed and had the potential to affect residents receiving a physician ordered diet as evidenced by failing to do the following: date and label opened items, remove food which had spoiled or expired, wear facial hair restraint, maintain adequate sanitizing solution in cleaning buckets, clean equipment (can opener) after use, and remove mop from standing water in bucket. In addition, the ice machine located on the second floor had several small gray areas on the inside of the lid. The findings included: On [DATE] at approximately 11:10 AM, during an observation of the main kitchen with the Registered Dietician (RD)/Certified Dietary Manager (CDM) revealed: 1) The can opener with residue on the blade; 2) (1) box of cream of wheat not opened, not wrapped/dated and (1) box of potato pearls opened and not dated; 3) (1) partial ,[DATE] gallon of buttermilk with expiration date of ,[DATE]; 4) (1) container of blueberries with a blueberry with a whitish, gray substance; 5) (1) male employee with beard with no beard restraint. During the initial tour the RD/CDM stated the can opener had been used to prepare the upcoming meal. Upon observing the unwrapped and/or undated boxes of cream of wheat and potato pearls, expired buttermilk and blueberries, the RD/CDM discarded the items. On [DATE] at approximately 11:30 AM, (1) red bucket did not have sufficient sanitization (50 parts per million) and a mop was observed to be stored in standing water. The RD/CDM confirmed the above observations of the red bucket and mop at the time of discovery. During the temping of the lunch meal on [DATE] at approximately 11:30 AM, two male staff members were observed with beard restraints which were not pulled up over the mustache. One male staff member was serving on the line. At the time of the observation, the RD/CDM confirmed these findings. During observation of the second floor kitchenette on [DATE], several small gray areas were observed on the inside panel of the icemaker lid. During the observation, a staff member from environmental services confirmed the areas. Review of the cleaning schedule for the icemaker revealed the last time the icemaker had been cleaned was [DATE]. During an interview with the Nurse Consultant on [DATE] at 5:58 PM, s/he stated the areas had been noticed and could not be removed from the lid of the icemaker. Observation of the icemaker on [DATE] at 5:45 PM revealed the gray areas were no longer present. Review of the facility policy titled Sanitizing Food Contact Surfaces revealed under the Red Bucket section to replace sanitizer solution in buckets every 2 hours or more frequently and under the policy section the sanitizer solution must be at 200 ppm - 400 ppm for Oasis 146 Multi-Quat sanitizer. Review of the facility policy titled Food Production, Service, Storage, and Distribution Standards revealed the following: Food stored refrigerated should be kept no longer than expiration date. Any opened or prepared products should be labeled and dated using the HHS Culinary approved label. Review of the facility policy titled Area and Equipment Cleaning Frequency/Schedules revealed the following: Can opener should be cleaned after each use. Review of the facility policy titled Hair Restraints revealed the following: Team members will wear hair restraints regardless of length of hair or beard at all times in the kitchen. Review of the facility policy titled Ice Machine Maintenance and Cleaning revealed the following: Each department is responsible for cleaning ice machines in their area on a daily basis and nutrition/food service and Environmental Service will perform on weekly basis.",2020-09-01
680,KERSHAWHEALTH KARESH LONG TERM CARE,425080,1315 ROBERTS STREET,CAMDEN,SC,29020,2017-06-28,221,G,1,0,73N811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record reviews and interviews, the facility failed to ensure each resident remained free from physical restraints imposed for purposes of convenience, and not required to treat the resident's medical symptoms. Resident #1 was noted to be physically restrained by a Certified Nursing Assistant when s/he wrapped a gait belt around Resident #1s lower legs to restrict his/her movement. 1 of 4 residents reviewed for abuse/neglect. A review of the facility's abuse reporting and investigation documentation on 6/28/17 revealed there was an allegation that a Licensed Practical Nurse (LPN) observed a gait belt tied around Resident #1s legs just below the knees on while the resident was in bed on 4/11/17 at approximately 4:30 PM. The documentation further indicated a Certified Nursing Assistant (CNA) stated s/he tied the gait belt around the resident's legs. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. Resident #1 could not be interviewed due to severe cognitive impairments. Further review of the medical record on 6/28/17 at 5:40 AM revealed a History and Physical dated 3/07/17 that indicated Resident #1 was unable to provide information due to Dementia. Nurses note dated 3/21/17 at 10 PM indicated Resident #1 was up and wandering all shifts in wheelchair. Nurses note dated 3/22/17 indicated the resident was up the entire night. Nurses note dated 4/06/17 indicated Resident #1 was up all evening wheeling self in wheelchair. Further review of nurses' notes dated 3/09/17 to present did not indicate Resident #1 being physically aggressive towards facility staff. A review of the facility's care plan dated 3/14/17 and updated on 6/12/17 revealed Resident #1 required extensive total assist for all activities of daily living and the gait belt to be used with resident for transfer. The care plan did not indicate that Resident #1 was physically aggressive/combative with staff. During a face to face interview on 6/28/17 at approximately 6:15 AM with LPN #1 revealed s/he observed the gait belt wrapped around Resident #1s legs below the knees when s/he checked him/her for incontinent care. Reportedly CNA #1 was in the room seated by the resident in bed near the window. LPN #1 stated CNA #1 admitted to putting the gait belt around Resident #1s legs to keep him/her from squirming and trying to get up. LPN #1 stated s/he removed the gait belt from Resident #1s legs right away. LPN #1 further reviewed her/his written statement and confirmed s/he wrote the statement that CNA #1 acknowledged s/he placed the gait belt around Resident #1s legs to keep him/her from moving. During a face to face interview on 6/28/17 at approximately 7:30 AM with the Director of Nursing (DON) revealed CNA #1 refused to write a statement related to placing the gait belt around Resident #1s legs. The DON stated that CNA #1 admitted to placing the gait belt around Resident #1s legs to keep him/her from moving and hitting his/her legs. The DON further reviewed and confirmed her/his written statement related to the allegations of abuse. During a telephone interview on 7/05/17 at approximately 9:58 AM with the Administrator revealed CNA #1 admitted to placing the gait belt around Resident #1s legs because s/he would not keep still. The Administrator further acknowledged her/his written statement and confirmed the incident occurred in April 2017 related to the allegations of abuse.",2020-09-01
681,KERSHAWHEALTH KARESH LONG TERM CARE,425080,1315 ROBERTS STREET,CAMDEN,SC,29020,2017-06-28,225,D,1,0,73N811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interviews, the facility failed to report an allegation of physical abuse within two hours after the allegation was made for 1 of 3 sampled residents reviewed. Resident #1 was allegedly observed to be physically restrained (gait belt tied around legs below knees) by a certified nursing assistant as witnessed by a staff member and the allegation was not reported timely. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. A review of the facility's abuse reporting and investigation documentation on 6/28/17 revealed there was an allegation that a licensed practical nurse observed a gait belt tied around Resident #1 legs just below the knees on while the resident was in bed on 4/11/17 at approximately 4:30 PM. The documentation further indicated a certified nursing assistant stated he/tied the gait belt around the resident's legs. Further review of the facility's reporting documentation revealed the facility did not report the incident to the State Survey Agency until 4/12/17 at approximately 3:54 PM. An interview on 6/28/17 at approximately 7:30 AM with the Director of Nursing (DON) confirmed he/she did not report the allegation of abuse within two hours per the new guidelines. The Director of Nursing further stated he/she was informed of the incident on 4/11/17 at approximately 9 PM.",2020-09-01
682,KERSHAWHEALTH KARESH LONG TERM CARE,425080,1315 ROBERTS STREET,CAMDEN,SC,29020,2017-06-28,226,D,1,0,73N811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review,interviews and review of the facility's Abuse Reporting and Investigation policy, the facility failed to develop and implement written policies and procedures that included reporting an allegation of physical abuse within two hours after the allegation was made for 1 of 3 sampled residents reviewed. Resident #1 was allegedly observed to be physically restrained (gait belt tied around legs below knees) by a certified nursing assistant as witnessed by a staff member and the allegation was not reported timely. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. A review of the facility's abuse reporting and investigation documentation on 6/28/17 revealed there was an allegation that a licensed practical nurse observed a gait belt tied around Resident #1 legs just below the knees on while the resident was in bed on 4/11/17 at approximately 4:30 PM. The documentation further indicated a certified nursing assistant stated he/tied the gait belt around the resident's legs. Further review of the facility's reporting documentation revealed the facility did not report the incident to the State Survey Agency until 4/12/17 at approximately 3:54 PM. An interview on 6/28/17 at approximately 7:30 AM with the Director of Nursing (DON) confirmed he/she did not report the allegation of abuse within two hours per the new guidelines. The Director of Nursing further stated the facility's abuse policies and procedures does not address reporting allegations of abuse within two hours of the incident and that staff had not been in-serviced.",2020-09-01
683,SALUDA NURSING CENTER,425081,581 NEWBERRY HIGHWAY,SALUDA,SC,29138,2018-03-01,559,D,0,1,6MGR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide written notice to one of two sampled residents reviewed for room change (Resident #511/513). The findings included: The facility admitted Resident #511/513 with [DIAGNOSES REDACTED]. [MEDICAL CONDITION] Reflux, Schatzski's Rings, and [MEDICAL CONDITION]. Record review at 9:55 AM on 2-28 revealed a 2-25-18 physician's orders [REDACTED]. During an interview on 2-28-18 at 2:35 PM Registered Nurse (RN) #6 reviewed the medical record and was unable to locate the written notice of room change. S/he checked with Social Services and stated none had been sent. The RN stated s/he did not know the facility was required to send a written notice of room change.",2020-09-01
684,SALUDA NURSING CENTER,425081,581 NEWBERRY HIGHWAY,SALUDA,SC,29138,2018-03-01,578,E,0,1,6MGR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to obtain 2 physicians' signatures certifying the resident's inability to consent in accordance with State law before allowing the resident's representative to sign a Do Not Resuscitate order for Residents #17, 29, 52, and 123, 4 of 32 residents reviewed for code status. The findings included: The facility admitted Resident #17 with [DIAGNOSES REDACTED]. On [DATE] at 01:57 PM, review of the medical record revealed a Do Not Resuscitate (DNR) order signed by the resident's spouse. Further review revealed no physician certification of inability to consent in the record. At 04:30 PM on [DATE], review of the Annual Minimal Data Set ((MDS) dated [DATE] revealed Resident #17 had a BIMS (Brief Interview for Mental Status) score of 8, indicating the resident had moderately impaired decision making skills. On [DATE] at 04:40 PM, review of the monthly physicians' orders revealed a DNR order. During an interview on [DATE] at 12:30 PM, Registered Nurse (RN) # 1 confirmed the DNR election form signed by the resident's spouse and that the second physician signature on the Inability to Consent Certification was obtained on [DATE]. The RN also stated Thank goodness nothing happened and when asked if s/he would have performed CPR (CardioPulmonary Resuscitation) if something had happened, the RN responded No. The facility admitted Resident #29 with [DIAGNOSES REDACTED]. On [DATE] at 10:57 AM, review of the DNR (Do Not Resuscitate) status for Resident #29 revealed a DNR Form signed by the resident's daughter. Further review revealed an Inability to Consent Certification form signed by the attending physician and dated [DATE]. There was no second physician signature. At 9:38 AM on [DATE], review of the monthly cumulative orders revealed a DNR order which indicated the order was written [DATE]. Further review of the monthly cumulative orders revealed a DNR order was also written [DATE]. Review of the physicians' progress notes revealed no documentation from a second physician related to the resident's ability to consent. During an interview on [DATE] at 9:49 AM, Registered Nurse (RN) #2 confirmed the DNR Form was signed by the daughter and that the Inability to Consent Certification form was signed by only 1 physician. The RN further confirmed the orders for DNR and, when asked, stated the resident's code status was DNR. The facility admitted Resident #52 with [DIAGNOSES REDACTED]. On [DATE] at 11:59 AM, record review revealed a Do Not Resuscitate (DNR) Form witnessed [DATE], and noted as per phone conversation today with dtr (daughter). Further review revealed an Inability to Consent Certification form signed by the primary physician on [DATE] and by a second physician on [DATE]. During an interview on [DATE] at 04:15 PM, Registered Nurse (RN) #2 confirmed the resident's DNR election form was signed [DATE] and the DNR orders. The RN further confirmed the Inability to Consent was signed by only the primary physician until [DATE] when it was signed by a second physician after it was brought to the facility's attention related to another resident. The RN further stated that once the form is signed by the responsible party, the primary physician signs it. It is then placed in the secondary physician's folder for review and signature but that hasn't been happening. It's been being filed in the chart instead of going to the second physician. The facility admitted Resident #123 with [DIAGNOSES REDACTED]. On [DATE] at 12:59 PM, review of the code status for Resident #123 revealed a DNR (Do Not Resuscitate) Form signed by the Power of Attorney (POA) with witness signatures dated [DATE] and [DATE]. There was no Inability to Consent Certification in the medical record. On [DATE] at 4:05 PM, record review revealed an Inability to Consent Certification signed by the attending physician on [DATE] with a second physician signature dated [DATE]. On [DATE] at 04:42 PM, review of the monthly cumulative orders revealed a DNR order each month from (MONTH) (YEAR) through (MONTH) (YEAR). During an interview on [DATE] at 5:01 PM, Registered Nurse (RN) #2 confirmed the resident had a DNR form signed by the PO[NAME] The RN also confirmed the DNR Form had not been on the chart on [DATE]. In addition, the RN confirmed there was a DNR order monthly and that the second physician signature on the Inability to Consent Certification was not obtained until [DATE].",2020-09-01
685,SALUDA NURSING CENTER,425081,581 NEWBERRY HIGHWAY,SALUDA,SC,29138,2018-03-01,623,E,0,1,6MGR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to notify the Ombudsman of facility-initiated transfers for 3 of 5 sampled residents reviewed who were transferred to hospitals (Residents #26, #40, #107 and #161). The findings included: The facility admitted Resident #161 with [DIAGNOSES REDACTED]., [MEDICAL CONDITIONS], and Anxiety Disorder. Review of Nurses' Notes on 3-1-18 at 4:15 PM revealed that on 12-8-17 at 4:13 AM, Resident #161 was noted with coffee ground emesis, diarrhea, hypertension, and low oxygen saturation. The physician and family were notified and the resident was transported to the hospital. There was no evidence in the medical record that the Ombudsman was notified of the transfer. During an interview on 3-1-18 at 1:55 PM, when asked about Ombudsman notification, the Director of Nurses stated s/he was unaware that the Ombudsman had to be notified of all facility-initiated transfers. The facility admitted Resident #40 with [DIAGNOSES REDACTED]. Record review at 12:17 PM on 2-28-18 revealed an entry in Nurses' Notes that on 11-18-17 at 6:25 PM, a Certified Nursing Assistant found that the resident had fallen from his/her low bed. The left arm was [MEDICAL CONDITION] and tender to touch. S/he was sent to the emergency room for evaluation and returned with a [DIAGNOSES REDACTED]. During an interview on 2-28-18 at 2:04 PM, the Director of Nurses and Administrator stated they were not aware of the requirement for Ombudsman notification of all facility-initiated transfers. The findings included; Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the medical record on 3/3/2018 revealed Resident #26 was admitted to Self Regional in Greenwood, SC on 1/3/2018. Resident #26 was admitted back to the facility on [DATE] with a discharge [DIAGNOSES REDACTED]. Additional review of the medical record revealed there was no communication to the Ombudsman regarding this hospitalization .",2020-09-01
686,SALUDA NURSING CENTER,425081,581 NEWBERRY HIGHWAY,SALUDA,SC,29138,2018-03-01,641,D,0,1,6MGR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for 1 of 2 sampled residents reviewed for pressure ulcers. Resident #511/513's assessment was not accurate related to diagnoses, presence of pressure ulcers, and medication. The findings included: The facility admitted Resident #511/513 with [DIAGNOSES REDACTED]. [MEDICAL CONDITION] Reflux, and [MEDICAL CONDITION]. Review of the 2-14-18 Admission MDS at 8 PM on 2-28-18 revealed that there were no active [DIAGNOSES REDACTED]. Review of Section M Skin Conditions revealed only one stage two pressure ulcer had been coded. Record review revealed an entry in Nurse's Notes on 2-10-18 at 2:40 PM: Noted open area on L(eft) buttock. (No) drainage. Granulation tissue. Measures 0.5 cm X 0.5 cm. R(ight) buttock open area measured 1.5 cm X 1.5 cm. (No) drainage. Granulation tissue. Exuderm applied to both areas . Review of the physician's orders [REDACTED].#511/513 was on [MEDICATION NAME] HCTZ (Hydrochorothiazide) daily, but Section N Medications N0410G was not coded to indicate that s/he received a daily diuretic. During an interview on 3-1-18 at 11 AM, the above information was verified by Registered Nurses #5 and #6.",2020-09-01
687,SALUDA NURSING CENTER,425081,581 NEWBERRY HIGHWAY,SALUDA,SC,29138,2018-03-01,655,D,0,1,6MGR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide a summary or copy of the Baseline Care Plan to the resident/family of 1 of 2 newly admitted residents reviewed (Resident #511/513). In addition, the Baseline Care Plan did not include adequate healthcare information necessary to properly care for 1 of 2 newly admitted residents to identify needs for supervision and behavioral interventions. Resident #511/513's Baseline Care Plan did not address exhibited behaviors with goals and non-pharmacological interventions to be attempted prior to administration of as needed (PRN) antipsychotic medication. The findings included: The facility admitted Resident #511/513 with [DIAGNOSES REDACTED]. [MEDICAL CONDITION] Reflux, and [MEDICAL CONDITION]. Record review on 2-27-18 at 4:40 PM revealed no evidence in the medical record that Resident #511/513's family received a summary or copy of the Baseline Care Plan. During an interview at 3:17 PM on 2-28-18, Registered Nurse #5 stated,(Resident #511/513) came in on Wednesday (2-12-18). I called the Responsible Party on the twelfth (Monday) and reviewed the 48 Hour Care Plan on the phone. S/he confirmed that no copy or summary of the plan had been given to the family. Further record review at 9:55 AM on 2-28-18 revealed an admission physician's orders [REDACTED]. Review of the Baseline Care Plan at 8:30 PM on 2-28-18 revealed that it did not include specific behaviors requiring PRN antipsychotic medication therapy or interventions that should be attempted prior to administration. Review of the Medication Administration Record [REDACTED]. Review of Nurses' Notes revealed no documented attempts at non-pharmacological interventions prior to administration of the PRN antipsychotic medication. Review of the (MONTH) Behavior Monthly Flow Sheet provided on 3-1-18 revealed that 18 shifts reported non-specific agitated behavior. Fifteen of these noted no other interventions prior to medication administration. During an interview at 3 PM on 2-28-18, Registered Nurse #6 stated s/he was unaware that specific interventions should be care planned and documented as attempted prior to administration of PRN psychoactive medications.",2020-09-01
688,SALUDA NURSING CENTER,425081,581 NEWBERRY HIGHWAY,SALUDA,SC,29138,2018-03-01,684,D,0,1,6MGR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview. and review of the facility policy entitled Blood Pressure, Measuring, the facility failed to identify a hypertensive episode and provide required care and services for 1 of 9 sampled residents reviewed for accidents. There was no evidence of assessment or physician notification when Resident #40 had a significantly elevated blood pressure (BP). The findings included: The facility admitted Resident #40 with [DIAGNOSES REDACTED]. Review of Physician's Orders at 12:59 PM on 2-28-18 revealed that the resident was on daily antihypertensive medication ([MEDICATION NAME]). Review of the 11-17 to 2-18 Vital Sign Records at 12:57 PM on 2-28-18 revealed weekly BP readings of 90-114/50-74. On 1-15-18 at 8:39 AM and on 2-5-18 at 9:02 AM, significantly higher BPs of 164/88 and 164/110 respectively were recorded. Review of Nurses' Notes at 12:17 PM on 2-28-18 revealed a summary entry in the Nurses' Notes for the 7 AM-3 PM shift on 2-5-18. The BP of 164/110 was recorded in the note, but there was no assessment of the resident's condition or documentation of notification of the physician. There was no evidence in the Progress Notes that the physician had been made aware of either BP result. During an interview on 2-28-18 at 5 PM, when asked what s/he would do if s/he had obtained the same BP, Registered Nurse (RN) #7 stated, I would have rechecked and verified it, checked to see if the resident was in pain, and let the doctor know. The nurse confirmed that the BP was recorded only weekly. The facility's policy entitled Blood Pressure, Measuring states: 4. Hypertension is usually defined as blood pressure over 140/90 mm/Hg (although the elderly often have persistent systolic readings from 140-160 mm/Hg). 5. Hypertension should be reported to a physician. If a resident has a hypertensive reading, staff should record several readings taken at different times of the day . During an interview on 3-1-18 at 10 AM, Registered Nurse #7 stated that the facility policy had not been followed. The physician had not been notified and there were no BP rechecks.",2020-09-01
689,SALUDA NURSING CENTER,425081,581 NEWBERRY HIGHWAY,SALUDA,SC,29138,2018-03-01,692,D,0,1,6MGR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide the diet as ordered to maintain adequate nutritional status for Resident #109, 1 of 6 residents reviewed for nutrition. The findings included: The facility admitted Resident #109 with [DIAGNOSES REDACTED]. On 02/27/18 at 02:00 PM, review of the weight record revealed resident had a 10% weight loss. On 03/01/18 at 11:51 AM, review of the physicians' orders revealed an order for [REDACTED]. 03/01/18 12:25 PM, observation of the resident's meal revealed the meal consisted of ground pork chop, cabbage, pinto beans, and a brownie. The tray card indicated Resident #109 was to receive double meat portions. CNA (Certified Nursing Assistant) #1 confirmed the resident did not receive a double portion of meat and also confirmed the food items served to the resident. During an interview on 03/01/18 at 02:23 PM, the Certified Dietary Manager (CDM) stated the tray card was wrong and that the resident was not supposed to receive double meat portions. The CDM provided a Diet Type Report that did not indicate the resident was to receive double portions and stated that was what the dietary aide used to plate the resident's food. The dietary aid confirmed s/he used the report, not the tray card to plate and stated that was why s/he didn't give Resident #109 double portion of meat. The CDM did confirm the tray card did not indicate the resident was to receive fortified foods. The aide stated the fortified food at lunch was milk and pudding and confirmed the resident received a brownie, not the fortified pudding.",2020-09-01
690,SALUDA NURSING CENTER,425081,581 NEWBERRY HIGHWAY,SALUDA,SC,29138,2018-03-01,727,C,0,1,6MGR11,"Based on record review and interview, the facility failed to have a designated charge nurse on each tour of duty, on 4 of 4 units. The findings included: On 03/01/18 05:05 PM, Review of the POS [REDACTED]. Registered Nurse (RN) #4 confirmed there was no documentation of the number of hours worked by each type of licensed or certified staff. The RN stated You mean we have to have that to? We've never done that before. During an interview on 03/01/18 at 5:35 PM, the Director of Nursing and the Nursing Home Administrator also confirmed they were not aware of the requirement to post the number of hours worked. The Director of Nursing also stated there was no nurse designated as the charge nurse on each unit each shift to assign the task of calculating the hours on the posting.",2020-09-01
691,SALUDA NURSING CENTER,425081,581 NEWBERRY HIGHWAY,SALUDA,SC,29138,2018-03-01,732,C,0,1,6MGR11,"Based on record review and interview, the facility failed to include the number of actual hours worked on the Staff posting on 4 of 4 units. The findings included: On 03/01/18 at 05:05 PM, Review of the POS [REDACTED]. Registered Nurse (RN) #4 confirmed there was no documentation of the number of hours worked by each type of licensed or certified staff. The RN stated You mean we have to do that too? We've never done that before. During an interview on 03/01/18 at 5:35 PM, the Director of Nursing and the Nursing Home Administrator also confirmed they were not aware of the requirement to post the number of hours worked. The Director of Nursing also stated there was no nurse designated as the charge nurse on each unit each shift to assign the task of calculating the hours on the posting.",2020-09-01
692,SALUDA NURSING CENTER,425081,581 NEWBERRY HIGHWAY,SALUDA,SC,29138,2018-03-01,758,E,0,1,6MGR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to identify and implement non-pharmacological interventions prior to administration of as needed (PRN) antipsychotic medication for one of six sampled residents reviewed for unnecessary medication. In addition, the PRN antipsychotic was administered for greater than 14 days without evidence of a physician's on-site assessment/evaluation for continued need for one of six sampled residents reviewed for unnecessary medication. Resident #511/513 was given [MEDICATION NAME] 20 times over a period of 22 days without evidence of assessment to determine the underlying cause of exhibited behaviors, attempts at non-pharmacological interventions prior to administration, or physician evaluation of continued need. The findings included: The facility admitted Resident #511/513 with [DIAGNOSES REDACTED]. [MEDICAL CONDITION] Reflux, and [MEDICAL CONDITION]. Record review at 9:55 AM on 2-28-18 revealed an admission physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. Review of Nurses' Notes revealed no documented attempts at non-pharmacological interventions prior to administration of the PRN antipsychotic medication. Review of the (MONTH) Behavior Monthly Flow Sheet provided on 3-2-18 revealed that 18 shifts reported non-specific agitated behavior. Of the 18 shifts, 15 documented no other interventions prior to medication administration. Three shifts noted 1 on 1 intervention, but there was no evidence as to what was attempted with the resident during these times. There was no evidence of assessment/evaluation of the underlying cause of the agitation. Review of the Baseline Care Plan at 8:30 PM on 2-28-18 revealed that it did not include specific behaviors requiring PRN antipsychotic medication therapy or interventions that should be attempted prior to administration. During an interview at 3 PM on 2-28-18, Registered Nurse (RN) #6 reviewed the care plan and stated s/he was unaware that specific interventions should be care planned and documented as attempted prior to administration of PRN psychoactive medications. Further review of physician's orders [REDACTED].#5 and #6 revealed that the attending physician had not rewritten the PRN antipsychotic order after 14 days. There was no evidence in the medical record that the physician directly examined the resident and assessed the resident's condition and progress to determine if the PRN antipsychotic medication was still needed after day 14. RN #5 stated, The resident came in on PRN [MEDICATION NAME]. S/he provided a copy of a form dated 2-7-18 (date of admission) when the physician reviewed the [MEDICAL CONDITION] medication. The surveyor requested any evidence of an on-site visit and 14 day review for continued need of the medication, but none was provided. On 3-1-18 at 2:55 PM, the Assistant Director of Nursing and Registered Nurse (RN) #5 submitted a copy of a 2-28-18 Physician Recommendation From Pharmacist which stated Per CMS regulations, PRN antipsychotic drug orders MUST BE RE-WRITTEN EVERY 14 days by the physician who is evaluating the patient at this interval . During an interview at that time, RN #5 confirmed that there had not been a physician evaluation of continued need or a new order written for the PRN [MEDICATION NAME] after the first 14 day interval as required.",2020-09-01
693,SALUDA NURSING CENTER,425081,581 NEWBERRY HIGHWAY,SALUDA,SC,29138,2018-03-01,812,F,0,1,6MGR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness. The food trays and steam table pans were not placed to drain properly. Food was not labeled and/or dated. Expired foods were not discarded. Dented cans were not removed from current stock. The walk-in freezer and dry storage room floors were not clean. The findings included: During the initial tour of the kitchen beginning on [DATE] at 10:06 AM, with the Certified Dietary Manager (CDM), the following observations were made: 1) Food trays and steam table pans were stacked wet. 2) The walk-in refrigerator and walk-in freezer contained items outdated and/or unlabeled. The walk-in refrigerator contained a bag of shredded cheese dated use by [DATE]. The walk-in freezer contained a bag of flat bread without a date or label. 3) The reach in refrigerator contained a sheet pan of strawberry cakes uncovered and without a label or date. 4) The dry storage room had dented cans of banana pudding and stewed tomatoes, along with a 64 ounce jar of expired ([DATE]) cherries in the current stock. 5) The floor of the dry storage room revealed 2 old potatoes on the floor under the shelving as well as individual cans of soda. The floor was dusty and dirty. The CDM stated, The cans probably fell down behind the shelf. They must not have cleaned under there. The walk-in freezer floor had food particles and trash under the shelving. The CDM provided a sign off log listing staff duties for cleaning the kitchen. Review of the facility document entitled, Shift Cleaning Duties dated (MONTH) (YEAR), revealed the log did not list the dry storage room.",2020-09-01
694,SALUDA NURSING CENTER,425081,581 NEWBERRY HIGHWAY,SALUDA,SC,29138,2018-03-01,880,D,0,1,6MGR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to follow hand hygiene following urinary catheter care for 1 of 1 sampled resident reviewed for catheter care. The findings included: The facility admitted Resident #59 with [DIAGNOSES REDACTED]. Certified Nursing Assistant (CNA) #2 was observed completing catheter care on 02/28/18 at approximately 09:07 AM. Upon completion of care, CNA #2 left the room with a bag of soiled linen and a bag of trash. CNA #2 entered the dirty utility room and placed the trash bag into a bin. The bin for soiled linens was not in the dirty utility room so s/he left the dirty utility room without washing or sanitizing his/her hands to locate it. CNA #2 walked down two halls before locating the linen bin in the hall and placing the bag of soiled linen in it. CNA #2 entered room [ROOM NUMBER] to wash his/her hands at the sink. During an interview on 02/28/18 at approximately 09:25 AM, when asked about hand washing, CNA #2 stated, I didn't wash my hands in the dirty utility room. I normally do.",2020-09-01
695,SALUDA NURSING CENTER,425081,581 NEWBERRY HIGHWAY,SALUDA,SC,29138,2019-03-30,600,G,1,1,KGWG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to ensure one of 16 sampled residents reviewed was free from abuse by staff. Certified Nursing Assistant (CNA) #1 hit Resident #37 on (his/her) left cheek while assisting the resident to bed and in the presence of CNA #2. The findings included: Review of the facility 5-day investigation report dated 9/5/18 revealed that on 8/31/18 CNA #1 and CNA #2 worked together while providing care to Resident #37. After putting the resident to bed, CNA #1 rolled the resident toward (him/her) to change (him/her)-The resident was agitated hit CNA #1 in the arm and called (her/him) the N word and CNA #1 slap/hit the resident on left cheek. The facility investigation also uncovered that Resident #37 shared concerns of mistreatment by the same nursing assistant (CNA #1) with (her/his) friend/visitor on 8/30/18. Review of Resident #37's medical record on 3/27/19 revealed that (s/he) was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #37's care plan on 3/27/19 at approximately 9:37 AM revealed a 3/12/18 care plan titled Alteration in thought process-problems including mood, obsessive and pervasive disorders, severe agitation associated with [NAME]D, disorganized thinking, verbal and physical behavioral symptoms daily- The resident is very impulsive, very demanding and impatient at times. -Resident apologize at time when acting out. The interventions include attempting to redirect the resident when (s/he) becomes agitated.-If the resident is agitated (all staff) leave the resident alone and try to approach the resident at a later time.-Approach the resident (all staff) in a calm and gentle manner.-Remind resident in a gentle but firm manner that (his/her) behavior is unacceptable when acting out. On 5/1/18 resident's care plan was updated with x2 staff member (all staff) to render care to at all times. Review of Resident #37's nurse's notes on 3/27/19 revealed a nurses note dated 8/31/18 stated 7:50 pm Resident was yelling out went in room to check on (her/him) and resident stated (s/he) was struck on the left cheek by CN[NAME] Resident stated I was hit on (left) cheek and she said this two times. Another CNA was in the room (at) the time. Review of the facility incident report revealed Resident #37's level of consciousness at the time of the incident was alert and oriented to self. Another certified Nursing Assistant (CNA) #2 was in the room at the time of the incident and confirmed the resident's claim. DHEC licensing notified at 8:10 PM and the Saluda County Sheriff's Department notified at 8:17 PM. Notification to the administrator, DON and unit manager on 8/31/18 at 8:10 AM. Resident up to broad chair-left cheek clear and no residual effects. CNA #1 (alleged perpetrator) facility-obtained statement dated 8/31/19 and timed 7:45 PM- indicated that CNA #1 admitted hitting Resident #37 on (his/her) face but did not mean to do it. CNA #2 (alleged witness) facility-obtained statement dated 9/1/18 indicated that CNA #2 witnessed CNA #1 slap Resident #37 after the resident hit CNA #1 on the arm and called (him/her) N word. During a phone interview with CNA #2 on 3/28/19 at 3:55 PM (s/he) stated that when CNA #1 and (him/her) took Resident #37 to bed, the resident was combative and hit CNA #1 in the arm and called (him/her) the N word and then CNA #1 hit the resident on (his/her) left cheek (left side of her face). CNA #2 added that (s/he) could not remember what hand the CNA used to hit the resident but (s/he) remembers that the resident's face got red for about 5 seconds. Registered Nurse (RN) #3 facility-obtained statement dated 8/31/18 and timed 7:50 PM indicated that Resident #37 told RN #3, two times, that CNA #1 hit (her/him) on the left check and CNA #2, who was in the room at the time, told RN #3 that it was true, CNA #1 hit the resident on the left cheek of face. During an interview with RN #1 on 03/28/19 at 03:29 PM RN #1 stated that Resident #37 kept repeating (CNA #1) slap me in my face. So, I asked the other CNA #2, who was present at the time of the incident and (s/he) confirmed that CNA #1 slap the resident like (s/he) said. CNA #1's employee file review on 3/29/19 revealed that the CNA was suspended on 8/31/18 pending investigation. The CNA was terminated on 9/1/18. His/her last day worked was 8/31/18. During an interview with the Director of Nursing (DON) on 3/29/19 at approximately 4:00 PM (s/he) stated that the CNA #1 was terminated due to facility's investigation concluded substantiated abuse. During a phone interview with the resident's friend/visitor on 3/29/19 at 1:07 PM (s/he) stated that resident #37 told (him/her) that CNA #1 was very rough with (him/her) on 8/30/18. The resident's friend stated that (s/he) shared resident #37's concerns with the nurse in charge. During an interview with the DON on 3/29/19 at approximately 2:00 PM (s/he) stated The facility was not aware that Resident #37 had complained to friend/visitor regarding CNA #1 being rough (him/her) the day before. This issue was brought up during the facility investigation the nurse allegedly was told about concerns no longer works for the facility.",2020-09-01
696,SALUDA NURSING CENTER,425081,581 NEWBERRY HIGHWAY,SALUDA,SC,29138,2019-03-30,607,G,1,0,KGWG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview, and review of the facility policy titled Abuse Investigation and Reporting, the facility failed to implement the facility's abuse policy for 1 of 16 residents reviewed for abuse. The facility failed to implement the components of its abuse policy that prohibit and prevent abuse for Resident #37. Certified Nursing Assistant (CNA) #1 hit Resident #37 on his/her left cheek while assisting the resident to bed and in the presence of CNA #2. The findings included: Review of the facility 5-day investigation report dated 9/5/18-States that on 8/31/18 CNA #1 and CNA #2 worked together while providing care to Resident #37. After putting the resident to bed, CNA #1 rolled the resident toward (him/her) to change (him/her)-The resident was agitated hit CNA #1 in the arm and called (her/him) the N word and CNA #1 slap/hit the resident on left cheek. The facility investigation also uncovered that Resident #37 shared concerns of mistreatment by the same nursing assistant (CNA #1) with (her/him) friend/visitor on 8/30/18. Review of Resident #37's nurse's notes on 3/27/19 revealed a nurses note dated 8/31/18 stated 7:50 pm Resident was yelling out went in room to check on (her/him) and resident stated (s/he) was struck on the left cheek by CN[NAME] Resident stated I was hit on (left) cheek and she said this two times. Another CNA was in the room (at) the time. CNA #1 (alleged perpetrator) facility-obtained statement dated 8/31/19 and timed 7:45 PM- indicated that CNA #1 admitted hitting Resident #37 on (his/her) face but did not mean to do it. CNA #2 (alleged witness) facility-obtained statement dated 9/1/18 indicated that CNA #2 witnessed CNA #1 slap Resident #37 after the resident hit CNA #1 on the arm and called (him/her) N word. During a phone interview with CNA #2 0n 3/28/19 at 3:55 PM (s/he) stated that when CNA #1 and (him/her) took Resident #37 to bed, the resident was combative and hit CNA #1 in the arm and called (him/her) the N word and then CNA #1 hit the resident on (his/her) left cheek (left side of her face). CNA #2 added that (s/he) could not remember what hand the CNA used to hit the resident but (s/he) remembers that the resident's face got red for about 5 seconds. Registered Nurse (RN) #3 facility-obtained statement dated 8/31/18 and timed 7:50 PM indicated that Resident #37 told RN #3, two times, that CNA #1 hit (her/him) on the left check and CNA #2, who was in the room at the time, told RN #3 that it was true, CNA #1 hit the resident on the left cheek of face. Interview with RN #1 on 03/28/19 at 03:29 PM-Stated that Resident #37 kept repeating (CNA #1) slap me in my face. So I asked the other CNA #2, who was present at the time of the incident and (s/he) confirmed that CNA #1 slap the resident like (s/he) said. CNA #1's employee file review on 3/29/19 revealed that the CNA was suspended on 8/31/18 pending investigation. The CNA was terminated on 9/1/18. His/her last day worked was 8/31/18. During an interview with the Director of Nursing (DON) on 3/29/19 at approximately 4:00 PM (s/he) stated that the CNA #1 was terminated due to facility's investigation concluded substantiated abuse. During a phone interview with the resident's friend/visitor on 3/29/19 at 1:07 PM (s/he) stated that resident #37 told (him/her) that CNA #1 was very rough with (him/her) on 8/30/18. The resident's friend stated that (s/he) shared resident $37's concerns with the nurse in charge. During an interview with the DON on 3/29/19 at approximately 2:00 PM (s/he) stated the facility was not aware the Resident #37 had complained to (his/her) regarding CNA #1 being rough (him/her) the day before. This issue was brought up during the facility investigation the nurse that was allegedly told about concerns no longer works for the facility. Review of the facility policy titled Abuse and Neglect-Clinical Protocol revealed under Treatment/Management The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect. Review of the facility policy titled Abuse Prevention Program states Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Under the Policy Interpretation and Implementation section 3. Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of [REDACTED]. Implement measures to address factors that may lead to abusive situations, for example: b. Instruct staff regarding appropriate ways to address interpersonal conflicts; and c. Help staff understand how cultural, religious and ethnic differences can lead to misunderstanding and conflicts.",2020-09-01
697,SALUDA NURSING CENTER,425081,581 NEWBERRY HIGHWAY,SALUDA,SC,29138,2019-03-30,656,D,1,1,KGWG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interviews, the facility failed to implement Resident #108's comprehensive care plan regarding no smoking per the Skilled Nursing Center (SNC) policy, for one of eleven sampled residents reviewed for accidents. The findings included: Review of the five-day investigation report dated 2/28/19 revealed that at approximately 10:45 PM on 2/24/19 Resident #108 approach the nurse station requesting a cigarette. Registered nurse (RN) # 1 provided the resident a cigarette-lighter, and RN #2 provided (him/her) with one of (his/her) cigarettes and opened the door leading to the patio to let (him/her) out to smoke. Resident #108 [DIAGNOSES REDACTED]. During an interview with the Director of Nursing (DON) on 3/25/19 at approximately 11:30 AM (s/he) stated that the facility had been Smoke-Free since (MONTH) 2013. Resident #108 was admitted to the facility on (MONTH) 1, (YEAR). At the time of admission, the resident was and continues to be a smoker. The resident initial OBRA annual assessment scored (him/her) with a Brief Interview for Mental Status (BIMS) of 15 and (s/he) was able to ambulate in and out, and throughout the facility independently. Resident #108's independent smoking (out/in) signing sheet for (MONTH) and (MONTH) reviewed 3/30/19 at approximately 11:00 AM indicated the last signed out/in date was 1/7/19. Resident #108's hospital discharge summary reviewed on 3/26/19 at 2:28 PM revealed that Resident #108 was sent to the hospital on [DATE] with symptoms of high blood pressure and acute hypoxemic respiratory secondary to flash [MEDICAL CONDITIONS] with [MEDICAL CONDITION] progressing to [MEDICAL CONDITION]. After treatment, the resident was discharged to the facility on [DATE] with an Arteriovenous (AV) graft in placed and requiring [MEDICAL TREATMENT] three times per week. Following (his/her) readmission, the resident was encouraged by the physician, including the facility's Medical Director to cease smoking. Review of Resident #108's care plan on 3/26/19 at approximately 3:00 PM revealed that the facility care planned Resident #108, after readmission, for alteration in thought processes. The resident exhibits short term memory loss, impaired decision making, and lack of orientation to time and situation. The interventions included cueing and redirecting as needed. Self-care deficit- resident requires extensive assistance with the activity of daily living (setup assist for meal and locomotion). The interventions included assistance with activities of daily living. No smoking per skill nursing center policy-interventions included monitor resident as closely as possible for safety, discourage resident from on LOAs and from sneaking to smoke-Resident and resident's son are aware of smoking concern with the [MEDICAL TREATMENT] care team and are aware of SNC No smoking Policy. On 2/5/19, a Nicotine patch was tried and appears on care plan as resolved on 2/13/19. During an interview on 03/26/19 09:22 AM with the administrator and the DON the administrator said that the facility had been smoke-free for years. The facility made a contract with Resident #108 that (s/he) would not smoke in the facility since the facility is smoke-free. Resident #108 would sign self out and in and smoke outside the facility's premises. When the resident came back from the hospital, (s/he) agreed to stop smoking, but on 2/24/19 two nurses allowed (him/her) to do just that for their convenience. The nurses were disciplined (suspended for 2 days). During an interview with Resident #108 on 3/26/19 at 11:48 AM (s/he) The resident reported that on 2/24/19, (s/he) could not remember the time but remembered that one nurse gave (him/her) the cigarette-lighter, and another gave (him/her) a cigarette and opened the patio door for (him/her) to go out to smoke alone. The resident said that (s/he) knows s/he is not supposed to smoke but would be crying for a cigarette in about a month. Interview with RN #1 on 3/26/19 at 3:56 PM (s/he) stated that after Resident #108 came back from the hospital, (s/he) has been out-there to smoke twice. On 2/21/19 RN #1 took Resident #108 out to smoke in the patio and smoked with (him/her), and that's why the RN #1 was in possession of the resident's cigarette lighter. RN #1 stated that on 2/24/19 Resident #108 come-up to the desk and asked for a cigarette and (s/he) said I am not going out with you to smoke; I am getting ready to give the report and go home. Then the resident said well, you have my lighter, so I gave it to (him/her) and left. Interview with RN #2 on 3/27/19 at 3:23 PM (s/he) stated that the resident came out of his/her room up to the desk and asked for a cigarette. I reminded the resident that (s/he) is trying to quit smoking. But the resident insisted, and I gave him one of (his/her) cigarettes and let (him/her) go on to the patio to smoke. I don't know what I was thinking. I made a bad judgment. I know that Resident #108 is not supposed to go outside to smoke in the facility property.",2020-09-01
698,SALUDA NURSING CENTER,425081,581 NEWBERRY HIGHWAY,SALUDA,SC,29138,2019-03-30,657,G,0,1,KGWG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and facility policy, the facility failed to update the care plan related to interventions to prevent further weight loss for Residents #89, 1 of 7 sampled residents reviewed for Nutrition. The findings include: The facility admitted Resident #89 with [DIAGNOSES REDACTED]. Record review on 03/29/19 at approximately 2:08 PM revealed recorded weights for Resident #89 as follows: 03/06: 163, 03/05: 160, No (MONTH) weights recorded 01/04: 170.5 01/02: 176.2 12/31: 161.2 12/31: 161 12/30: 158.7 12/29: 155.5 12/27: 168.5 12/26: 165.2 12/20: 169.5 12/19: 172 12/12: 188.4 Admission. Subsequent review revealed a Physicians Order for weekly weights dated 01/11/19 but none were found in the electronic health record. Review of the Care Plan revealed the intervention for weekly weights was not included in the plan. During an interview on 03/29/19 at approximately 6:47 PM the Unit Manager stated that the order for weekly weights was entered incorrectly as no action required which caused it to not be added to the Medical Administration Record for tracking nor to the Care Plan for implementation as an intervention. During a meal observation on 3/29/19 at 9:00 AM Resident #89 was observed in room, sitting in wheel chair, LPN #1 entered with tray and fed the resident pureed bacon, eggs, toast, cranberry juice. During a meal observation on 3/29/19 at 12:35 PM Resident #89 was observed in room his/her roommate was eating the curtain was pulled. Resident #89's lunch tray was sitting in the residents room on an over bed table uncovered. Resident #89 was in a high back wheel chair beside bed. At 12:50 PM this surveyor asked the medical records clerk, in the hall at the time, who had put the tray in Resident #89's room. The medical records clerk came back with the CNA responsible for Resident #89 who stated s/he had not put the tray in the room but that s/he was told earlier that Resident #89 was no longer a feeder but a slow eater also stated s/he was willing to feed him/her and set up the tray and began to assist Resident #89. Since the plate had been left uncovered while sitting on the table, the pureed foods had cooled and become stiff. LPN #1 confirmed assisting the resident with breakfast earlier in the day. Review of facility policy titled Weight Assessment and Intervention revealed: 2. Individualized care plans shall address, to the extent possible .c. Time frames and parameters for monitoring and reassessment.",2020-09-01
699,SALUDA NURSING CENTER,425081,581 NEWBERRY HIGHWAY,SALUDA,SC,29138,2019-03-30,692,G,0,1,KGWG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to implement new interventions to prevent further weight loss for 2 of 7 residents reviewed for nutrition. Resident #89 and #141 did not have further/additional nutritional interventions implemented related to continued weight loss. The findings included: The facility admitted Resident #141 with [DIAGNOSES REDACTED]. Record review of Resident #141's medical record on 3/29/19 at 4:57 PM revealed physician orders [REDACTED]. Further review of the physician orders [REDACTED]. Review of Resident #141's nutritional assessment dated [DATE] revealed Resident #141's weight was 193.6 pounds and his/her meal intake were 50-75%. Further review of the nutritional assessment revealed Resident #141 had a greater than 7.5% weight loss in past 90 days and at the time recommended Magic Cup twice a day and would follow as needed. Further review of Resident #141's weight revealed his/her weight was noted as: 9/11/18: 204 10/4/18: 209 11/1/18: 204 12/5/18: 205 1/3/19: 193.6 1/17/19: 191.2 1/24/19: 186.8 2/7/19: 185.4 3/6/19: 177.8 3/15/19: 171 3/22/19: 172.2 3/29/19: 172.2 No further recommendations were noted from the Registered Dietician. Further record review revealed Resident #141 was on the Occupational Therapy (OT) case load for pocketing food and difficulty feeding, from 9/2/18 and was discharged on [DATE]. A referral was made to OT on 1/31/19 for adaptive cup due to spillage, 3/27/19 referral for difficulty eating, not drinking or eating as before hospitalization . During an interview with the Unit Manager on 3/30/19 at 12:10 PM, s/he stated Resident #141's weight loss possibly could be attributed to broken dentures. The resident's dentures have been broken since 11/23/18. The Unit Manager stated that it takes approximately three months to get dentures. S/he stated when the resident did not feed himself/herself, another intervention was to feed Resident #141. S/he also stated the resident's replacement dentures had arrived on 3/27/19. During an interview with the Registered Dietician (RD) on 3/30/19 9:45 AM, s/he stated I can only recommend and evaluate when it is communicated to me of a weight loss. He/she continued by stating if Resident #141 had missing dentures and trouble chewing the resident would be followed by speech therapy. Review of Resident #141's medical record revealed no current orders for speech therapy and no notes were provided to the surveyor related to speech therapy. During an interview with the Dietary Manager on 3/30/19 at 10:06 AM, s/he stated the Registered Dietician receives information from me and he/she goes around to the units and gets information from the nurses related to any concerns for weights and makes his/her recommendations. S/he stated the loss of Resident #141's bottom dentures could have contributed to weight loss, but s/he was put on a mechanical, soft, ground meat diet. The Dietary Manager confirmed the resident had not been seen or had any recommendations from the RD since 1/9/19 and could not find any other information. S/he confirmed it was a concern Resident #141 continued to trend down with no further RD intervention. During meal observations on 3/28/19 at 12:41 PM Resident #141 was observed sitting up in bed with family at bedside feeding the resident. During meal observations on 3/29/19 at 12:30 PM Resident #141 was observed up in the dining room assisted by a CN[NAME] The resident had a two handled cup with lid. Resident #141 was being assisted and was eating without resistance or difficulty with prompting. The facility admitted Resident #89 with [DIAGNOSES REDACTED]. Record review on 03/29/19 at approximately 2:08 PM revealed recorded weights for Resident #89 as follows: 03/06/19: 163, 03/05/19: 160, No (MONTH) weights recorded, 01/04/18: 170.5 01/02/18: 176.2 12/31/18: 161.2 12/31/18: 161 12/30/18: 158.7 12/29/18: 155.5 12/27/18: 168.5 12/26/18: 165.2 12/20/18: 169.5 12/19/18: 172 12/12/18: 188.4 Admission. Subsequent review revealed a Physicians Order for weekly weights dated 01/11/19 but none were found in the electronic health record. Review of the Care Plan revealed the intervention for weekly weights was not included in the plan. During an interview on 03/29/19 at approximately 6:47 PM the Unit Manager stated that the order for weekly weights was entered incorrectly as no action required which caused it to not be added to the Medical Administration Record for tracking nor to the Care Plan for implementation as an intervention. During a telephone interview on 03/30/19 at approximately 9:40 AM the Registered Dietician (RD) stated the facility is to place residents needing review on a weight loss list to be given priority beyond scheduled reviews but that this was not done for Resident #89. During an interview with the Director of Nursing (DON) on 3/29/19 at 4:41 PM The DON stated that the scales were being recalibrated as part of a facility QA plan but that is did not affect the failure of the staff to implement the order for weekly weights to accurately track the resident's progress. During an interview on 03/30/19 at approximately 9:53 AM the Dietary Manager reviewed the Quarterly Dietary Review form s/he completed on 03/13/19 documenting significant weight change but was unable to provide a reason why the section marked Refer to RD was not completed and a referral was not made for Resident #89. During a meal observation on 3/29/19 at 9:00 AM Resident #89 was observed in room, sitting in wheel chair, LPN #1 entered with tray and fed the resident pureed bacon, eggs, toast, cranberry juice. During a meal observation on 3/29/19 at 12:35 PM Resident #89 was observed in room his/her roommate was eating the curtain was pulled. Resident #89's lunch tray was sitting in the residents room on an over bed table uncovered. Resident #89 was in a high back wheel chair beside bed. At 12:50 PM this surveyor asked the medical records clerk, in the hall at the time, who had put the tray in Resident #89's room. The medical records clerk came back with the CNA responsible for Resident #89 who stated s/he had not put the tray in the room but that s/he was told earlier that Resident #89 was no longer a feeder but a slow eater also stated s/he was willing to feed him/her and set up the tray and began to assist Resident #89. Since the plate had been left uncovered while sitting on the table, the pureed foods had cooled and become stiff. LPN #1 confirmed assisting the resident with breakfast earlier in the day.",2020-09-01
700,SALUDA NURSING CENTER,425081,581 NEWBERRY HIGHWAY,SALUDA,SC,29138,2019-03-30,812,E,0,1,KGWG11,"Based on observation, interview, and review of the facility policy, the facility failed to serve food under sanitary conditions for 1 of 4 steam tables reviewed and has the potential to affect 22 of 169 residents with ordered diets as evidenced by failing to plate food sanitarily. The findings included: On 3/26/19 at approximately 12:45 PM, an observation of the dining room steam table revealed: Cook #1 with gloved hands touched the steam table, plates, handles on the table, clothes multiple times then pulled buns out of a bag and put the buns on the resident's plates without sanitizing or changing gloves. On 3/27/19 at approximately 8:35 AM, an observation with the Certified Dietary Manager (CDM) of the dining room steam table revealed: Cook #2, with gloved hands touched the table, shirt pocket, plates and utensils then pulled bread out of a bag and put bread on residents' plates without changing gloves or sanitizing hands. On 3/27/19 at approximately 8:40 AM, the CDM verified Cook #2 was touching bread with his/her hands and putting the bread on the resident's plates. The CDM then stated, They should be using tongs. Review of the facility policy, Food Service / Distribution, states under (6.) Bare hand contact with food is prohibited. Gloves must be worn when handling food directly. However, gloves can also become contaminated and/or soiled and must be changed between tasks. Disposable gloves are single-use items and shall be discarded after each use.",2020-09-01
701,SALUDA NURSING CENTER,425081,581 NEWBERRY HIGHWAY,SALUDA,SC,29138,2019-07-18,603,G,1,0,RMKK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview the facility failed to ensure residents were free from involuntary seclusion. Certified Nursing Aide (CNA) #1 barricaded the doorway of Resident #75 and Resident #128 with two mechanical lifts and one recliner. 2 of 2 residents reviewed for involuntary seclusion. The findings included: Record review of Resident #75's medical record revealed that Resident #75 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #75's Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 9. Record review of Resident #128's medical record revealed that Resident #128 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #128's MDS dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 8. Review of Resident #128's MDS dated [DATE] revealed a BIMS of 9. Review of the facility's five-day report dated 5/29/19 revealed that on 5/24/19 (Resident #75) was noted to up and out of (his/her) room at 4:30 AM (and) was returned to near (his/her) room by nurse, within a few minutes (s/he) was headed off unit again (and) nurse returned (him/her) to unit and nurse told (CNA #1) (s/he) had returned res (resident #75), then around 5:20 AM nurse paged for (CNA #1) (and) told (her/him) resident was in (his/her) w/c (wheelchair) going off the unit and (CNA #1) needed to redirect (him/her) back to (his/her) room because at this time the unit nurse was working with another resident who required medial assistance. At approximately 6:00 AM, (Licensed Practical Nurse (LPN) #2) asked (CNA #1) if (s/he) knew where the resident (Resident #75) was and (CNA #1) replied that (s/he) had given (him/her) a bath and returned (him/her) to bed. At approximately 6:50 AM (LPN #2) went to check on residents on North Side of unit and noticed that the door to resident's room was open and both residents (Resident #75 and Resident #128) in room were asleep. (LPN #2) also noticed that there were lifts and a recliner chair in the doorway of the residents' (Resident #75 and Resident #128) room. (LPN #2) requested that another nurse, (LPN #1) witness the lifts and recliner chair. (LPN #2) then proceeded to remove the lifts and the chair obstructing the doorway, and (s/he) informed (CNA #1) that the action was unacceptable. (CNA #1) statement indicated that (s/he) placed the objects in the doorway so that the resident (Resident #75) would not wander out of the room again while (s/he) was providing care to other residents . Further review of the facility's five-day report dated 5/29/19 revealed that when (Director of Nursing (DON)) met with (CNA #1), (CNA #1) confirmed that (s/he) placed the chair and the lifts in the doorway. (DON) explained to (CNA #1), that the facility, from (MONTH) 22, 2019-April 30, 2019, had just completed abuse in-service training and that all forms of abuse were discussed, including involuntary seclusion . Review of CNA #1's facility obtained statement dated 5/24/19 revealed I (CNA #1) attended care for (Resident #75), around 4:20 AM. Called from care of (another resident) to (Resident #75) going up the wall undressed. Nurse went and got (him/her) came back, I asked (her/him) to tell (her/him) please wait and I will get (her/him) dressed. Got (her/him) back got away again and then I asked (her/him) to wait (s/he) began cursing I asked (her/him) please do not curse me, began to start back out again I asked (her/him) to come back that (s/he) could not go alone in this hallway without assistance (s/he) again tried to get out so I placed a lift in from of door plus recliner to finish work with other patients. Nurse came down the hall said I had to move that recliner and lift I said I would (s/he) stated this was a fire hazard I said ok and did so at 5:20 AM. During an interview with LPN #1 on 07/18/2019 at approximately 3:25 PM, LPN #1 stated that at 6:50 AM I went down to room [ROOM NUMBER] where there were two lifts placed in front of the patient's room to barricade them in. The part that is used to clip the lift to the patient sling was clipped together. A chair was placed in between the two lifts. Resident #75 got up at 4:30 AM trying to come out of (his/her) room before the lift was ever placed. CNA #1 was told to remove the lifts and remove the chair. During an interview with the Administrator on 07/18/2019 at approximately 4:45 PM, the Administrator stated that Resident #75 could get out of bed and yell for staff even though the door was being blocked. The Administrator stated that he/she did not understand why CNA #1 did it, since they were both asleep. Review of the Sheriff's Office Report dated 5/24/19 revealed .Upon arrival R/O (reporting officer) went to (name of unit) and spoke with the floor nurse (name of nurse) who states at approximately 04:30 hours the patient in room (room number) left (his/her) room. The CNA (name of CNA) was able to get (him/her) back to (his/her) room and place the patient back in (his/her) bed (CNA#1) then placed a Geri chair in front of the open door of room (room number) and placed 2 mechanical lifts around it and locked the wheels. The floor nurse made (her/his) rounds at 07:00 hours and noticed room (room number) door open but barricaded. The nurse removed the aforementioned barricade from the patients door allowing ingress and egress from the room. (CNA #1) was subsequently terminated from Saluda Nursing Center .",2020-09-01
702,RIVERSIDE HEALTH AND REHAB,425082,2375 BAKER HOSP BLVD,CHARLESTON,SC,29405,2019-02-14,636,D,1,1,ZBC111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to have an accurate resident assessment related to [DIAGNOSES REDACTED]. Resident #101's complete [DIAGNOSES REDACTED]. The findings included: The facility admitted Resident #101 with [DIAGNOSES REDACTED]. Record review on 2/14/19 of the physician progress notes [REDACTED]. Further review of the Admission MDS dated [DATE] revealed Resident #101 had not been coded for Mild Mental [MEDICAL CONDITION] or Intellectual Disability. During an interview with the MDS Coordinator on 2/14/19 at 10:40 AM, s/he confirmed Resident #101 had not been coded for Mild Mental [MEDICAL CONDITION] or Intellectual Disability and continued by stating the [DIAGNOSES REDACTED].",2020-09-01
703,RIVERSIDE HEALTH AND REHAB,425082,2375 BAKER HOSP BLVD,CHARLESTON,SC,29405,2019-02-14,645,D,1,1,ZBC111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to ensure a Level 2 screening was done as required on admission for 1 of 2 sampled residents reviewed for PASARR (Pre-Admission Screening and Resident Review). Resident #101 was admitted with an Intellectual Disability [DIAGNOSES REDACTED]. The findings included: The facility admitted Resident #101 with [DIAGNOSES REDACTED]. Record review on 2/14/19 at 9:15 AM revealed Resident #101 was admitted on [DATE]. Further record review revealed the admission Level I PASARR screening did not recommend for further evaluation for a Level II screening related to the [DIAGNOSES REDACTED]. During an interview with Social Service staff #1 on 2/14/19 at approximately 10:30 AM, s/he stated Resident #101 did not have any behaviors, was self sufficient and receiving therapy. S/he continued by stating Resident #101 had good socialization skills and did not see a need to intervene. During an interview with the Minimum Data Set staff #1 on 2/14/19 at 10:40 AM, s/he stated due to the [DIAGNOSES REDACTED].#101 for Level II PASARR screening. During an interview with the Administrator on 2/14/19 at 11:00 AM, s/he stated Resident #101 should have had a Level II PASARR and the facility would initiate one.",2020-09-01
704,RIVERSIDE HEALTH AND REHAB,425082,2375 BAKER HOSP BLVD,CHARLESTON,SC,29405,2019-02-14,694,E,1,1,ZBC111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview, and review of the South [NAME]ina Board of Nursing Advisory Opinion #9B, the facility failed to provide care and services that met professional standards of practice for 1 of 2 sampled resident with a Peripheral Inserted Central Catheter (PICC) Line. Resident #16 was administered PICC Line flushes and antibiotics by Licensed Practical Nurses (LPNs) with no documentation of advanced training and there were multiple days when a Registered Nurse (RN) was not on site when the LPNs administered the medications and flushes via the PICC Line. The findings included: The facility admitted Resident #16 with [DIAGNOSES REDACTED]. Record review on 2/13/19 at 4:40 PM revealed a physician order [REDACTED]. Further review of the Medication Administration Record [REDACTED]. Review of the MAR indicated [REDACTED]. Review of the education for PICC line medication administration revealed two of the LPNs did not have documentation for training on PICC line medication administration. Review of the working schedule revealed on 1/19/19, 1/20/19, 1/26/19 at 4 AM, 1/27/19 at 4 AM, 1/28/19 at 4 AM and 1/29/19 at 4 AM, an RN was not on site during the administration of the PICC line medication. Review of the South [NAME]ina Board of Nursing Advisory Opinion #9B revealed the selected LPN shall document completion of special education and training in the area of intravenous therapy relative to the administration of fluids via peripheral and central venous access devices/lines that includes both didactic and supervised clinical competency training with return demonstration. In addition, central line therapies/procedures require that an RN must be immediately available on site for supervision.",2020-09-01
705,RIVERSIDE HEALTH AND REHAB,425082,2375 BAKER HOSP BLVD,CHARLESTON,SC,29405,2018-03-16,583,D,0,1,706R11,"Based on observation, and interview, the facility failed observe resident's privacy and rights for 1 of 7 residents reviewed for privacy during medication administration. Staff did not provide privacy on the 200 unit during medication administration. The findings included: On 3/14/18 at 12:05 PM, during an observation of medication administration on the 200 unit, Registered Nurse (RN) #1 prepared Resident #47's blood sugar check materials on the medication cart outside Resident #47's room. RN #1 then entered the residents room without closing the Medication Administration Record [REDACTED]. RN #1 then checked the residents blood sugar and returned to the medication cart to prepare the residents medication. After preparing Resident 47's medication RN #1 returned to the resident again leaving the MAR indicated [REDACTED]. During an interview following the observation the Assistant Director of Nursing who passed by the cart during med pass verified RN #1 did not provide privacy for Resident #47's medical records by leaving the MAR indicated [REDACTED]. Review of the facility policy for medication administration revealed the facility did not have policy for medical records privacy during medication administration.",2020-09-01
706,RIVERSIDE HEALTH AND REHAB,425082,2375 BAKER HOSP BLVD,CHARLESTON,SC,29405,2018-03-16,759,E,0,1,706R11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and review of manufacture recommendations, the facility failed to maintain a medication rate of less than 5%. There were 3 errors out of 26 opportunities for error, resulting in a medication error rate of 11.54%. The findings included: Error #1 On 3/14/18 at approximately 9:33 AM, during an observation of Resident #55's medication administration on the 400 unit, Registered Nurse (RN) #2 administered Breo Ellipta 100-25 mcg. powder inhalation medication and did not instruct the resident to rinse their mouth out after administration. Following the observation RN #2 verified s/he did not instruct the resident to rinse and spit after inhalation of the Breo Ellipta powder. On 3/14/18 at 2:19 PM, a review of the physician's orders [REDACTED]. DO NOT SWALLOW. Also, the Breo Ellipta pharmacy stamped box instruction's stated, Rinse mouth after each use. Review of the Breo Ellipta manufacture recommendations revealed under prescribing instructions Step 6 Rinse your mouth states, Rinse your mouth with water after you have used the inhaler and spit the water out. Do not swallow the water. Also, under Important Safety Information for Breo Ellipta bullet one states, Breo can cause serious side effects, including: fungal infection in your mouth or throat (thrush). Rinse your mouth with water without swallowing after using BREO to help reduce your chance of getting thrush. Error #2 On 3/14/18 at approximately 12:05 PM, during an observation of Resident #47's medication administration on the 200 unit, Registered Nurse (RN) #1 administered (2) eye drops of Liqui-tears into the residents right eye. During reconciliation of Resident #47 of the med pass a review of the Medication Administration Record [REDACTED]. Following the observation and review of the MAR indicated [REDACTED]. Error #3 On 3/14/18 at approximately 4:12 PM, during an observation of Resident #142's medication admin-istration on the 100 unit, Licensed Practical Nurse (LPN) #1 placed (2) 325 mg. tablets of Tylenol into a medicine cup and attempted to give the resident the medication. Prior to the administration LPN #1 was asked to review the Medication Administration Record [REDACTED]. Following the observation and review of Resident #142's MAR, LPN #1 verified s/he was going to administer 650 mg. of Tylenol instead of 500 mg. ordered.",2020-09-01
707,RIVERSIDE HEALTH AND REHAB,425082,2375 BAKER HOSP BLVD,CHARLESTON,SC,29405,2018-03-16,761,D,0,1,706R12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** ADDITIONAL DEFICIENCY Based on observations, interview, and review of physician's orders, the facility failed to follow a procedure to ensure accurate labeling to meet the needs of the residents for 1 of 4 residents reviewed for medication labeling during med pass. Resident #52's medication was not labeled in accordance to the Medication Administration Record [REDACTED] The findings included: On 4/23/18 at approximately 9:15 AM, during Med Pass on the 200 unit with Licensed Practical Nurse (LPN) #1 revealed Resident #52's MAR indicated [REDACTED]. 1 tablet 3 times a day. Resident #52's pharmacy stamped medication card on the cart stated, [MEDICATION NAME] 50 mg. 1 tablet, 3 times a day. On 4/23/18 at 9:20 AM, a review of Resident #52's physician's orders revealed an order stating, [MEDICATION NAME] 50 mg; amt: 1 tablet; oral Three Times A DAY; 09:00 AM, 01:00 PM, 05:00 PM. On 4/23/18 at approximately 9:25 AM, during an interview with LPN #1, s/he verified Resident #52's pharmacy stamped medication card for [MEDICATION NAME] did not reflect the MAR indicated [REDACTED]",2020-09-01
708,RIVERSIDE HEALTH AND REHAB,425082,2375 BAKER HOSP BLVD,CHARLESTON,SC,29405,2018-03-16,812,E,0,1,706R11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure: 1) the wall directly behind the dish machine was clean and free from multiple areas of built up black substance and food debris; 2) bins used to store dry foods had clean lids and the exterior of gallon containers of soy sauce were maintained clean and free from spillage on the exterior in 1 of 1 kitchens, and; 3) foods stored in the diet kitchens on the nursing units and inside the refrigerators, which were labeled as Resident Food, were labeled/dated and expired food was discarded for 3 of 3 nursing units. During initial tour of the kitchen on [DATE] at 6:10 PM, an observation was verified by Dietary Cook #1 of plastic food storage containers of bread crumbs and graham cracker crumbs with built up soil and dust on the lids. An observation of 2, 1-gallon containers of soy sauce, which had built up spills of soy sauce on the exterior, were also verified by Dietary Cook #1. Dietary Cook #1 said that s/he would get the lids and the exterior of the soy sauce containers cleaned immediately. The form, titled, Nutrition Orientation Policies and Procedures, Food Storage, Complete Revision: [DATE], stated: .Keep all storage areas clean and dry. An observation was verified by Dietary Cook #1 during initial tour of the kitchen on [DATE] at 6:30 PM of the wall behind the dish machine, which had areas of black substance and food debris. During an observation of the resident refrigerator in the diet kitchen on the 100 nursing unit, Registered Nurse (RN) #1 verified the following on [DATE] at 6:40 PM: 1) a box of pizza with no name or date on the label with an expiration date of (MONTH) (YEAR), which was discarded by RN #1; 2) clear plastic to go container of vegetable salad with boiled eggs and salad dressing with no date/label, which was discarded by RN #1; 3) a sandwich in a zip lock bag with no date/label, which was discarded by RN #1; and 4) a container of salad with no date/label, which was discarded by RN #1. During an observation of the resident refrigerator in the diet kitchen on the 200 nursing unit, the Administrator verified the following on [DATE] at 6:45 PM: 1) a partially used container of a nutritional supplement drink had no label indicating the open date, which the Administrator discarded; 2) 2 packages of hickory smoked bacon with a name written on the label with no dates, which the Administrator discarded; and 3) the interior bottom shelf of the refrigerator was soiled. During an observation of the resident refrigerator in the diet kitchen on the 400 nursing unit, the Administrator verified on [DATE] at 6:50 PM there was a container of honey consistency apple juice dated ,[DATE] and with no expiration date recorded, which the Administrator discarded. The form titled, Nutrition Policies and Procedures, Subject: Safe Handling of Food Brought in by Family/Friends for Patient Consumption Complete Revision [DATE], stated: Procedures: .5. Foods are labeled to identify the patient/resident's name, container contents, and the date it was prepared. Food items are stored in disposable, tightly covered containers, or sealable plastic bags. Items will be stored for (3) days. Expired and unlabeled items will be discarded.",2020-09-01
709,RIVERSIDE HEALTH AND REHAB,425082,2375 BAKER HOSP BLVD,CHARLESTON,SC,29405,2018-09-21,623,C,0,1,B0N711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview the facility failed to provide written Notice of Transfer upon occurrence to 2 of 3 sampled residents reviewed for hospitalization . The notification process was not followed for Residents #122 and 65 and/or their Resident Representatives. The findings include: The facility admitted Resident #65 with [DIAGNOSES REDACTED]., [MEDICAL CONDITION], Presence of Cardiac Defibrillator, [MEDICAL CONDITION], Major [MEDICAL CONDITION] and [MEDICAL CONDITION] after Gastric Bypass. Record review on 09/29/18 at approximately 4:29 PM revealed that Resident #65 was transferred to the hospital on [DATE], 06/22/18 and 06/01/18. No documentation of facility staff providing written Notice of Transfer to the resident and/ or Resident Representative was found in the medical record. In an interview on 09/21/18 at approximately 3:48 PM, the facility's Administrator confirmed staff was sending Notice of Transfer documents to the hospital only and not to the Residents or Resident Representatives. The facility admitted Resident #122 with [DIAGNOSES REDACTED]. Record review on 9/19/18 at 4:42 PM revealed Resident #122 was discharged to the hospital on [DATE] and 4/9/18. Further record review revealed there was no documentation in the nurse's notes or social service notes the resident and the resident representative were notified in writing and in a language understood for the reason of the transfer to the hospital.",2020-09-01
710,RIVERSIDE HEALTH AND REHAB,425082,2375 BAKER HOSP BLVD,CHARLESTON,SC,29405,2018-09-21,625,C,0,1,B0N711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview the facility failed to provide written Notice of Bedhold Policy upon occurrence to 2 of 3 sampled residents reviewed for hospitalization . The notification process was not followed for Residents #122 and 65 and/or their Resident Representatives. The findings include: The facility admitted Resident #65 with [DIAGNOSES REDACTED]., [MEDICAL CONDITION], Presence of Cardiac Defibrillator, [MEDICAL CONDITION], Major [MEDICAL CONDITION] and [MEDICAL CONDITION] after Gastric Bypass. Record review on 09/29/18 at approximately 4:29 PM revealed that Resident #65 was transferred to the hospital on [DATE], 06/22/18 and 06/01/18. No documentation of facility staff providing written Notice of Bedhold Policy to the resident and/ or Resident Representative was found in the medical record. In an interview on 09/21/18 at approximately 3:48 PM, the facility's Administrator confirmed staff was sending Notice of Bedhold Policy documents to the hospital only and not to the Residents or Resident Representatives. The facility admitted Resident #122 with [DIAGNOSES REDACTED]. Record review on 9/19/18 at 4:42 PM revealed Resident #122 was discharged to the hospital on [DATE] and 4/9/18. Further record review revealed there was no documentation in the nurse's notes or social service notes the resident and the resident representative were notified in writing information related to bed hold.",2020-09-01
711,RIVERSIDE HEALTH AND REHAB,425082,2375 BAKER HOSP BLVD,CHARLESTON,SC,29405,2018-09-21,684,E,0,1,B0N711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview and review of facility policy, the facility failed to implement appropriate standards of care for 1 of 3 Residents reviewed for hospitalization . Facility staff failed to follow physician's orders [REDACTED].#65. The findings include: The facility admitted Resident #65 with [DIAGNOSES REDACTED]., [MEDICAL CONDITION], Presence of Cardiac Defibrillator, [MEDICAL CONDITION], Major [MEDICAL CONDITION] and [MEDICAL CONDITION] after Gastric Bypass. Record review on 09/20/18 at approximately 4:29 PM revealed a Physicians Order dated 07/20/18 provided for administration of the drug [MEDICATION NAME] 2.5mg tablet by mouth. Special instructions for administration included: Prn (as needed) for fluid overload and if weight is >220 pounds, no more than 3 days in a row. Subsequent review of the Medical Administration Record (MAR) revealed staff failed to administer [MEDICATION NAME] as ordered when Resident #65's weight exceeded 220 pounds on dates including, but not limited to, (MONTH) 13, 28, 30 and 31, (MONTH) 3, 5, 6, 8, 9, 14, 16 and 17, (YEAR). In an interview on 09/21/18 at approximately 2:54 PM the Director of Nursing (DON) reviewed the (MONTH) MAR and confirmed that Resident #65 had weights greater than 220 pounds and staff did not administer Metalozone as ordered. The DON stated that facility staff would be expected to chart the medication if it had been given. The DON provided a copy of facility policy entitled Medication Administration Policy which stated, The facility will provide medication administration in accordance with accepted professional standards and principles .",2020-09-01
712,RIVERSIDE HEALTH AND REHAB,425082,2375 BAKER HOSP BLVD,CHARLESTON,SC,29405,2018-09-21,686,D,0,1,B0N711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interview and review of the facility policy titled Dressing-Absorption Dressing, Application OF, the facility failed to provide necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing for one of one resident reviewed for pressure ulcers. During pressure ulcer care, staff did not clean wounds appropriately and did not wash hands after cleaning wounds for Resident #3. The findings included: The facility admitted Resident #3 with [DIAGNOSES REDACTED]. During observation of pressure ulcer care on 9/21/18, Registered Nurse(RN)#1 was observed to clean the wounds on the left lower extremity, left ankle, and right lower extremity by wiping down several times through the wound bed. Further observation revealed after cleaning each of the six wounds, RN #1 did not remove gloves and wash hands between the cleaning and application of the ordered treatment and clean dressing. During an interview with RN #1 on 9/21/18 at 3:50 PM, s/he confirmed during the cleaning of the wounds s/he did not clean from inner wound to outside of wound. S/he stated had read the facility policy and followed the policy. Review of the facility policy titled Dressing-Absorption Dressing, Application OF did not address how to clean the wound or to change soiled gloves after cleaning the wound.",2020-09-01
713,RIVERSIDE HEALTH AND REHAB,425082,2375 BAKER HOSP BLVD,CHARLESTON,SC,29405,2018-09-21,758,E,0,1,B0N711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, interviews and the FDA (Food and Drug Administration) approved prescribing information (package insert), the facility failed to assure that it was free of unnecessary medications based on 4 of 4 residents reviewed for [MEDICATION NAME]. [MEDICATION NAME] had been prescribed for Residents # 42, #55, #7 and # 36 without adequate indications for use or monitoring. According to the FDA, [MEDICATION NAME] is indicated for the treatment of [REDACTED]. PBA occurs secondary to a variety of otherwise unrelated neurological conditions, and is characterized by involuntary, sudden and frequent episodes of laughing and/or crying. PBA is a specific condition, distinct from other types of emotional lability that may occur in patients with neurological disease or injury. The findings include: Resident # 42 had been admitted to the facility on [DATE] with diagnosed including: [DIAGNOSES REDACTED]. During record review on 9/19/18 at approximately 2:38 PM it noted that Resident # 42 was prescribed [MEDICATION NAME] 20-10 mg (milligram) on 8/29/18 for 7 days, then [MEDICATION NAME] 20-10 mg twice daily on 9/7/18 for worsening behaviors since starting [MEDICATION NAME] XL (extended release) 150 mg tab po (by mouth) qd (daily) and that the resident had PBA due to dementia with worsening agitation/behaviors. Further review of nurses notes, progress notes, behavioral monitoring sheets, social services notes, the care plan and MDS (Minimum Data Set) prior to and after 8/29/18 failed to show any recorded sign of spontaneous laughing and/or crying or a diagnoses of PBA or attempt to assess the continued need for the drug. The FDA package insert states: The need for continued treatment should be reassessed periodically, as spontaneous improvement of PBA occurs in some patients. On 9/20/18 at approximately 12:11 PM LPN (Licensed Practical Nurse) # 2: stated that the Resident # 42 had some behaviors for a couple of days in (MONTH) due to a family situation, but that those behaviors did not last long and that she is fine now. LPN # 2 also stated that the resident had not had behaviors of spontaneous crying or laughing and rarely ever had behaviors. This finding was reviewed with the DON (Director of Nursing on 9/20/18 at approximately 2:30 PM. Resident # 36 had been admitted to the facility on [DATE] with diagnoses included, but not limited to [MEDICAL CONDITIONS] disorder, depression and dementia with behavioral disturbance. -During record review on 9/19/18 at approximately 3:03 PM it was noted that Resident # 36 was prescribed [MEDICATION NAME] 20-10 mg daily on 8/14/18 given as one capsule with no [DIAGNOSES REDACTED]. The FDA package insert states: Then recommended starting dose for [MEDICATION NAME] is one capsule by mouth for the initial seven days of therapy. On the eight day of therapy and thereafter, the daily dose should be a total of two capsules a day, given as one capsule every 12 hours. Further review showed that on 8/15/18 the Consultant Pharmacist made the following recommendation there appears to be no [DIAGNOSES REDACTED]. This recommendation had been reviewed by the RNP (Registered Nurse Practitioner) on 8/16/18 and PBA had been written as a diagnosis. Review of the Consent for Psychoactive Medication Therapy sheet dated 8/14/18 showed The specific condition to be treated: as Agitation and Dementia w (with)/ psychotic features. Further review of nurses notes, progress notes, behavioral monitoring sheets, social services notes, care plan and MDS (Minimum Data Set) prior to and after 8/14/18 failed to show any recorded sign of spontaneous laughing and/or crying or a diagnoses of PB[NAME] Review of the Progress Notes dated (MONTH) 1, (YEAR), (MONTH) 3, 3018, (MONTH) 4, (YEAR), (MONTH) 9, (YEAR), (MONTH) 13, (YEAR) failed to show a [DIAGNOSES REDACTED]. The progress notes dated 8/15/18, (MONTH) 23, (YEAR), (MONTH) 27, (YEAR) and (MONTH) 30, (YEAR) did show a [DIAGNOSES REDACTED]. The FDA package insert states: The need for continued treatment should be reassessed periodically, as spontaneous improvement of PBA occurs in some patients. This finding was reviewed with the DON (Director of Nursing on 9/20/18 at approximately 2:30 PM. During record review on 6/27/18 at approximately 4:35 PM it was noted that Resident 55 was prescribed [MEDICATION NAME] 20 mg-10 mg on 8/30/17 with a diagnoses of Pseudobulbar Affect (PBA) entered on the same date. The facility had admitted Resident 55 on 10/12/15 diagnosed including: [DIAGNOSES REDACTED]. : 9/4/17 11:34 pm Nursing: This nurse spoke to MD (physician) this AM (morning) regarding RDs (residents) behavioral issues. MD made aware RD continues to behave inappropriately towards staff by way of inappropriate sexual behaviors (having erections in front of female staff and laughing, pointing at or touching penis and pointing at staff, making gestures toward staff that indicate Rd wants staff to touch penis or get into bed with him) and inappropriate social behaviors (staring at roommate sleep and laughing, staring at sleeping Rd in room next to his and laughing, entering other Rd's rooms after being told that he cannot enter others' rooms and becoming very agitated with attempts at redirection). 9/1/17 3:09 pm Nursing: tried to contact (Responsible Party) to update on new medication that was ordered due to inappropriate behavior such as trying to go into womens rooms, staring at women, resident trying to get staff to touch him on private areas. She did not an answer and mail box was full and unable to leave a message. 9/4/17 11:44 pm Nursing: Scheduled [MEDICATION NAME] 0.5 mg (milligram) held this HS (bedtime); PRN (as needed) dose of 1 mg administered d/t (due to) agitation toward staff when attempts to redirect inappropriate social and sexual behaviors are made. Rd has thus far this shift (7:50 pm) made gestures to penis and then to staff that suggest he wants staff to touch him and has several times been redirected away from roommate as he has been sitting beside roommates bed and has been laughing at roommate while roommate sleeps. With redirection attempts Rd does become agitated; can be seen in facial expressions and body language,. Rd appears to become angry, withdrawn and at times hostile pushing at staff when attempts to move w/c (wheelchair) away from roommates bed are made. Did accept HS meds without difficulty; PRN dose of [MEDICATION NAME] effective at follow-up. [MEDICATION NAME] is marketed by Avanir Pharmaceuticals and the package insert Indications and Usage section, revised (MONTH) (YEAR), states [MEDICATION NAME] is indicated for the treatment of [REDACTED]. Merriam Webster Medical definition: A condition that is marked by episodes of uncontrolled crying or laughing which is inappropriate or of disproportionate intensity and that is associated with various neurological disorders (such as [MEDICAL CONDITIONS] and stroke). None of the behaviors listed in the Progress Notes are indicators for this drug. Further review of the residents record on 6/27/18 failed to show any charted behaviors or monitoring related to PBA subsequent to the drug being prescribed. On 6/28/18 at approximately 3:00 PM, RN (Registered Nurse) # 1, during a telephone interview, stated that Resident 55 did have occasional episodes of crying for no reason, but that these were not always entered in Progress Notes or elsewhere in the medical record. RN # 1 stated that there is no specific behavioral monitoring for PB[NAME] During record review on 6/27/18 at approximately 6:36 PM it was noted that Resident 7 had been prescribed [MEDICATION NAME] 20 mg-10 mg on 11/8/17 with a [DIAGNOSES REDACTED]. The facility had admitted Resident 7 on 10/11/17 with diagnosed including: [DIAGNOSES REDACTED]. Review of the Progress Notes for Resident 7 provided by Social Services on 7/27/18 at approximately 6:51 PM revealed the following: -10/11/17 4:34 pm Nursing: she is verbal but it is word salad -10/12/17 9:30 am Nursing: did speak clear when giving insulin although resident confused with words -10/13/17 3:45 am Nursing: Alert, garbled speech noted -10/15/17 1:44 pm Nursing resident speaking this shift confusion noted -10/16/17 2:09 am Nursing Note:*****10-14-17***** CNAs (certified nursing assistant) do report resistance with care fro Rd; state Rd does occasionally attempt to hit staff while Rd is receiving care. -10/16/17 2:09 am Nursing: Did repeat no no no and did raise fist to nurse while attempting to obtain FSBS (finger stick blood sugar). CNAs report Rd does display said behaviors often while resident is receiving care. -10/17/17 3:09 am Nursing: garbled speech noted -10/18/17 7:59 am Medical: Cognitive testing: Patient is phasic, with dense left [MEDICAL CONDITION]. Cognitive testing: while patient has some vocalizations, these were mostly nonsensical and not understandable. No further cognitive testing couldn't be performed. -10/19/17 2:50 am Nursing: Alert, garbled speech noted -10/19/17 10:39 am Social Services: She has been able to answer very simple questions at times but for the most part her speech is garbled. Nursing staff note she is resistive to care almost daily. -10/20/17 2:04 am Nursing: Speech is garbled. -10/23/17 3:15 pm Nursing: Resident is alert and seemingly aware of surroundings but is unable to carry on a conversation with staff and speech is somewhat garbled -10/26/17 7:30 am Social Services: She is able to answer simple questions at times but her speech usually garbled.: -10/28/17 11:08 am Nursing: cursing at tech, fighting tech w/ADL's ( with activities of daily living) scratching tech. Resident did curse at tech during mouth care states: Lady, you fu**in up! -10/29/17 11:43 am Nursing: :fighting with mouth care, refusing to turn. -10/30/17 3:08 am Nursing: hitting and cursing at staff with ADL's -11/1/17 2:28 am Nursing: Resident continues to curse tech, resist care and hit during ADL's -11/2/17 1:54 am Nursing: resisting care, fighting with mouth care, and yelling out with ADL's. Yelling out during day. -11/3/17 8:58 am Nursing: yelling out this am, heard in the hall. -11/3/17 5:23 pm Nursing: yelling out hello repeatedly. -11/4/17 7:28 pm Nursing: Resident continues to yell out, Hello!, even after someone enters the room. -11/7/17 3:31 am Nursing: resident continues to yell out hello during the day. This resident did resist and did attempt to hit tech during mouth care this shift. -11/8/17 7:35 am Medical: Nursing staff states that she yells out at inappropriate times, with no response to environmental stimuli. She seems to have little in the way of impulse control. unfortunately continues to have significant verbal dyspraxia, with unintelligble speech and responses inappropriate to question contact. [MEDICAL CONDITION]: Patient is having increased outbursts, with mostly unintelligible speech. There is no real connection with environmental stimuli, raising the possibility of pseudobulbar affective disorder. Trial of [MEDICATION NAME] 10/20, one by tube daily for 1 week, then one by tube twice day. Further review of the resident's record from 11/18/17 to 6/27/18 failed to show any behaviors or monitoring related to PBA subsequent to the drug being prescribed. On 6/28/18 at approximately 3:12 PM, RN (Registered Nurse) # 1, during a telephone interview, stated that Resident 7 did occasionally state hello, hello, but that these were not always entered in Progress Notes or elsewhere in the medical record. RN # 1 stated that there is no specific behavioral monitoring for PB[NAME]",2020-09-01
714,RIVERSIDE HEALTH AND REHAB,425082,2375 BAKER HOSP BLVD,CHARLESTON,SC,29405,2018-09-21,759,D,0,1,B0N711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews the facility failed to assure that it it was free of a medication error rate of 5% (percent or greater. The medication error rate was 8% based on 2 of 25 observations. The findings include: On 09/19/18 at approximately 9:24 AM LPN (Licensed Practical Nurse) # 1 prepared eight medications for Resident 76 and crushed two of the medication which were ER (Extended Release). The medications crushed were [MEDICATION NAME] 25 mg ER and KCl (potassium chloride) 10 mEq (milliequivalents) ER. On 9/19/18 at approximately 9:33 AM, LPN # 1 was stopped prior to administering these medications and acknowledged that the medications were labeled ER, that the Medication Flowsheet (medication administration record) stated either extended release or ER for the medications and that each medication punch card had been labeled by Pharmacy as Do Not Crush.",2020-09-01
715,RIVERSIDE HEALTH AND REHAB,425082,2375 BAKER HOSP BLVD,CHARLESTON,SC,29405,2018-09-21,812,E,0,1,B0N711,"Based on observation, interview, and review of the facility's policies titled Temperature of Food and Handwashing the facility failed to maintain proper food temperature and hand hygiene technique during food service/distribution for one of one kitchen sample reviewed for food temperature and distribution. The findings included: On 9/18/18 at approximately 4:45 PM the facility's cook and certified dietary manager (CDM) were ready to temp and served the residents their dinner from the steam table in the kitchen. The meal for the day includes turkey sandwich, tomatoes soup and chips, baked chicken, mashed potatoes and gravy and wax beans. During observation, the cook, who was wearing disposable gloves, touched her cheeks several times and rubbed his/her eyes and placed sandwiches and handful of chips in the plate without, at any point during serving, changing gloves, washed or sanitized his/her hands. The CDM temped the mashed potatoes at 130F. S/he then took the mashed potatoes off the steam table to re-heat it. S/he placed the pan containing the mashed potatoes on the stove and added hot water. A few minutes later s/he brought the mashed potatoes back to the steam table. The temperature of the mashed potatoes read 140F, but it appeared very loose/soupy. The CDM proceeded to temp baked chicken which read at 120F. S/he also removed the pan and reheated the chicken the same way s/he did the mashed potatoes. During the temping and reheating process this surveyor noticed that the CDM has long fake fingernails, which became in contact with the mashed potatoes during temping/reheating (observed some mashed potatoes under nails). S/he was also very inconsistent when cleaning/sanitizing the thermometer used to temp the foods, at times s/he use alcohol swaps and other time s/he dipped the thermometer in a glass of cold water and back into the food to be temp. The CDM did not wash or sanitize his/her hand during the entire observation. At approximately 5:30 PM on the same day the CDM and cook confirmed the above findings.",2020-09-01
716,RIVERSIDE HEALTH AND REHAB,425082,2375 BAKER HOSP BLVD,CHARLESTON,SC,29405,2017-09-22,155,D,1,0,MJSH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of the medical record, interview and review of the facility policy and procedure, the facility failed to ensure that Resident #217's family involvement related to Advance Directives was completed and available in the medical record upon admission for 1 of 21 residents reviewed for Advance Directives. The findings included: Resident #217 was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review on 9/20/17 at approximately 9:30 AM reveals, a DNR (Do Not Resuscitate) sticker on the front sheet of the medical record. The sheet in the chart labeled, Progress Notes, with the Resident Name, Room # and Physician labeled on the bottom of the sheet, and there was no documentation/entries on the front or the back of the sheet. The page in the Medical Record titled Social Services Progress Notes has an entry which stated: LMSW (Licensed Medical Social Worker) introduced self to Resident #217. He was none responsive. LMSW and Unit Nurse (LPN #3) called RP (Responsible Party) to inquire about her wishes for Advanced Directives. RP stated that h/she wanted a DNR (when it's God's time let him go). LMSW and LPN #3 noted on the DNR form his/her wishes and both signed as witnesses The form titled, Emergency Medical Services Do Not Resuscitate Order, has the following information documented on the form.This 217 notice is to inform all emergency medical personnel who may be called to render assistance to Resident #217 that he/she has a terminal condition which has been diagnosed by me and has specifically requested that no resuscitative efforts including artificial stimulation of the cardiopulmonary system in the event of cardiopulmonary arrest. Date signed: 9/19/17 and written above the line labeled, Patient's signature (or prorogate or Agent), is written: RP (Responsible Party), Lillie Taste, wants a DNR. Two signatures: Medical social worker and LPN#3., dated 9/19/17. Two physician signatures on the form. The form titled: Physician Certification Regarding the Ability to Consent has the resident's name hand printed on the form, no other information is completed on the form and no signatures on the form for the Consulting Physician and the Consulting Physician. An interview with the Social Worker On 9/20/2017 at 11:26 PM, he/she stated: We are working on getting the physician signature. An interview with the Unit Manger, LPN #3 on 9/20/2017 at approximately 11:15 AM, he/she said she talked with the family so he/she would honor their wishes of DNR. LPN #3 verified that there was no RP signature in the medical record. An interview on 09/20/2017 at 11:26 AM, with the DON( Director of Nursing), he/she said to verify a DNR status that he/she would verify in the medical record for the DNR sticker and the second check would be to verify for the Physician order for [REDACTED]. The DON was able to locate an electronic note from the initial visit from the Nurse Practitioner dated 9/19/2017, electronically signed on 9/1917 at 9:51 PM. The DON said that electronic notes completed by the providers are placed in the medical record when the notes are received. Review of the electronic progress note titled, Progress Note, Sep 19.2017, Elite Patient Care (EPC) states, .Admit/discharge date : 9/18/2017, Supervising Provider: Medical Director #1, .Chief Complaint Reason for this Visit, New Admission to EPC services, HPI (History Physical Information) relating to this Visit, .He/She (Resident #217), does not follow commands today. He/She did not speak to me. He/She does have spastic movements with his R (Right) hand. Information was obtained by EMR (electronic medical record) notes from Vibra. He is DNR Assessment and Plan .Additional text,Mother (Resident#17 mother is named and phone number listed). Patient is DNR. The Progress note was Electronically signed by: ( Physician Assistant #1) on Sep 19, 2017 at 9:51 PM, CDT. A review of the facility policy and procedure titled, Social Services Policies and Procedures, Subject: Advance Directives, states the following: .2. Upon admission to the facility, the Admissions Coordinator will: A. Provide each patient/resident AND/OR their legal representative with a copy of the facility's policy and stare requirements for advanced directives AND each patient/representative AND/OR their legal representative will then sign an acknowledgement confirming receipt of this information . .3 1)Ensure the legal representative has the authority to make decisions regarding life sustaining treatments. 2) Notify the legal representative of their rights and responsibilities. 3) If the legal representative requests or consents to the withholding/withdrawal of life-sustaining treatments, steeps outlined in 3(A) 1-4 are followed AND written consent must be obtained from the legal representative. .4. B. 3) The attending physician must talk with the patient/resident regarding consequences and implications of their decision and the discussion must be documented in the progress note.",2020-09-01
717,RIVERSIDE HEALTH AND REHAB,425082,2375 BAKER HOSP BLVD,CHARLESTON,SC,29405,2017-09-22,156,B,1,0,MJSH11,"> Based on record review and interviews, two of three residents (Resident #72 and Resident #7 ) reviewed for Medicare notices of non-coverage was not done timely. The findings included: On 9/22/2017 at approximately 9:00 PM, the review was verified by the Social Worker of Resident #72's CMS - NOMNC, Notice of Medicare Non-Coverage, The Effective Date of Your Current MEDICARE Services Will End: 7/25/17. The form was signed by the RP (Responsible Party) of Resident #72 on 7/24/2017. Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) Form CMS-1055, states; Date of Notice: 7/24/17, and was signed by RP on 7/24/2017. With reference to S&C-09-20: Generic/expedited notice must be issued no later that 2 days before the proposed end of services. On 9/22/2017: at approximately 9:15 PM, the review was verified by the Social Worker of Resident #7. The CMS -NOMNC Form states, The Effective Date of Your Current MEDICARE Services Will End: 7/25/17. The form was not signed by the RP (Responsible Party) of Resident #7. A handwritten notation on the bottom of the form states; LMSW (Licensed Medical Social Worker) spoke with RP, to advise him/her that therapy will end on 7/25/17. He/She does plan on appealing the decision. With reference to S&C-09-20: Residents or their legal representative must sign notices to verify receipt; however, if the resident is unable to receive the notice and the resident's legal representative is unavailable, the SNF (Skilled Nursing Facility) provider may contact the legal representative and inform him/her by phone .must immediately follow up .with a written notice. The date of telephone contact is considered to be the date the telephone notice was given as long as it is not disputed by the beneficiary.",2020-09-01
718,RIVERSIDE HEALTH AND REHAB,425082,2375 BAKER HOSP BLVD,CHARLESTON,SC,29405,2017-09-22,157,D,1,0,MJSH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview and review of the facility policy titled, Physician Communication/Change In Condition, the facility failed to ensure the Physician for Resident #106 was notified of refusal of medications for 1 of 1 resident review for Notification. The findings included: The facility admitted Resident #106 with [DIAGNOSES REDACTED]. Review on 9/21/2017 at approximately 3:36 PM of the nurses notes dated 9/15/2017 at 2:00 PM states, V/S (vital signs) 98, 74, 18, 124/70. Resident alert and oriented. Resident still refusing meds and insulin this shift. No documentation could be found in Resident #106's medical record to ensure the physician was notified of refusal to take medications. During an interview on 9/21/2017 at 5:32 PM with the DON (Director of Nursing) confirmed the findings and stated that sometimes the nurses chart the refusal of medications on the backs of the MARs (Medication Administration Record). Review on 9/21/2017 at approximately 5:40 PM of the MARs for September 2017 revealed documentation of refusal of medications on 9/5/2017, 9/8/2017, 9/10/2017, 9/15/2017 and 9/19/2017. No documentation could be found to ensure the physician was notified of the refusal of medications. Review on 9/21/2017 at approximately 6:00 PM of the facility policy titled, Physician Communication/Change in Condition, under Policy states, 1. To improve communication between physicians and nursing staff in order to promote optimal patient/resident care. 2. To improve nursing staff with guidelines for making decisions regarding appropriate and timely notification of medical staff regarding changes in a patient's/resident's condition. The guidelines, Procedures, under number 3 states, Notify the physician of the change in medical condition. The nurse will document all assessments and changes in the patient's/resident's condition in the medical record.",2020-09-01
719,RIVERSIDE HEALTH AND REHAB,425082,2375 BAKER HOSP BLVD,CHARLESTON,SC,29405,2017-09-22,159,C,1,0,MJSH11,"> Based on record review, interview and the facility's policy, the facility failed to maintain records and document that quarterly statements were sent to residents and/or their Responsible Parties (RP). No quarterly statements were available for 3 of 3 reviewed for Personal Funds. The findings included: In a family interview during Stage 1 of the survey, it was stated that the facility did not provide quarterly statements of residents' accounts. Record review on 09/22/17 at approximately 9:30 AM revealed the quarterly statements in the sampled Resident Account files were dated April 2016. In an interview on 09/22/17 at approximately 9:30 AM the Business Office Manager reported that the Accounting company sends the quarterly statements to the facility for distribution to the Resident and/or RP. S/he stated a copy of those statements is to be placed in the individual files. A review of the facility policy entitled Business Office Policies and Procedures on 09/22/17 at approximately 12:02 PM revealed a quarterly statement of all funds managed by the facility is provided to each resident and or his/her legal representative per OBRA mandate, The facility mails the statement no later than the 25th of the month following the end of the quarter. A copy of the quarterly statement is filed in the Resident Trust Fund monthly folder.",2020-09-01
720,RIVERSIDE HEALTH AND REHAB,425082,2375 BAKER HOSP BLVD,CHARLESTON,SC,29405,2017-09-22,241,D,1,0,MJSH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and review of the facility policy and procedure, the facility failed to ensure that the privacy curtain was closed between 2 residents, resident #72 who had not not yet received her lunch tray and the roommate was being fed his/her lunch in 1 of 1 resident reviewed for dignity. The findings included: Resident #72 had [DIAGNOSES REDACTED]. On 09/22/2017 at 1:05 PM, Resident# 72's roommate received her/his lunch tray, and CNA (Certified Nurse Assistant) # 2 began to feed the roommate and Resident #72 was lying in bed and the privacy curtain was not pulled between the 2 residents. On 09/22/2017 at 1:15 PM when LPN (Licensed Practical Nurse) #2 was asked about Resident #72 who did not have a meal tray and the roommate had a lunch tray, h/she went in the room and pulled the privacy curtain between the 2 residents. An observation on On 09/22/2017 at 1:20 PM, an interview with CNA #2 said that h/she should have pulled the curtain between the two residents while one resident had a tray and the other resident did not. A review of the facility policy and procedure titled;, Leadership Policies and Procedures, Section XI: Resident Rights, Subject: Privacy and Security-Resident Right For. The Policy states: Policy: The Facility staff will provide the patient/resident with his/her right to privacy and security. The Procedures section states: .2. Staff: D. Closes privacy curtains or doors as appropriate during treatment or daily care.",2020-09-01
721,RIVERSIDE HEALTH AND REHAB,425082,2375 BAKER HOSP BLVD,CHARLESTON,SC,29405,2017-09-22,246,D,1,0,MJSH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record review, interviews and review of the facility policy titled, Call Lights - Answering Of, the facility failed to ensure Resident #106 call bell was within reach for 1 of 21 residents reviewed with call bells. The facility further failed to ensure food preferences were honored for Resident #72 for 1 of 5 residents reviewed for Nutrition. The findings included: The facility admitted Resident #106 with [DIAGNOSES REDACTED]. An observation on 9/19/2017 at approximately 3:59 PM revealed Resident #106's call bell is out of reach and is down by the side of the bed that is pushed against the wall. Resident is soiled and in need of care. A second observation on 9/19/2017 at approximately 5:10 PM revealed Resident #106's call bell out of reach and is stuck down beside the bed that is up against the wall. An observation on 9/22/2017 at approximately 5:15 PM during rounds with the Director of Maintenance Resident #106's call call bell was out of reach. An observation on 9/22/2017 at approximately 5:36 PM during rounds with the Unit Manager revealed the call bell for Resident #106 stuck behind the bed that was up against the wall. The Unit Manager had to maneuver around the bed, and move the bed to get the call bell from the floor behind the bed. During an interview on 9/22/2017 at approximately 6:06 PM with the (DON) Director of Nursing concerning the call bells and he/she stated she would expect the call bells to always be in reach of the resident. Review on 9/22/2016 at approximately 6:52 PM of the facility titled, Call Lights - Answering Of, reads, The staff will provide an environment that helps meet the patient's/resident's needs. Number 1 states, Respond to patient's/resident's call lights in a timely manner. Number 7 states, When leaving room, be sure the call light is placed within the patient's/resident's reach. Resident #72 was admitted with [DIAGNOSES REDACTED]. During a meal observation on 9/22/207 at 1:20 PM Resident #72 received puree fish on the lunch tray and the preferences listed on the tray ticket stated no fish. The CDM was interviewed and stated that the tray ticket system was supposed to default to the Puree alternate which was Puree Chicken on 9/22/2017.",2020-09-01
722,RIVERSIDE HEALTH AND REHAB,425082,2375 BAKER HOSP BLVD,CHARLESTON,SC,29405,2017-09-22,247,D,1,0,MJSH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record reviews, interviews and review of the facility policy titled, Room Changes/Transfers Within the Facility, the facility failed to ensure Resident #95 and Resident #175 and the Responsible Party and/or an interested family member was notified of a room change prior to the room change for 2 of 3 residents reviewed for Notification of Room/Roommate Change. The findings included: The facility admitted Resident #95 with [DIAGNOSES REDACTED]. Review on 9/22/2017 at approximately 4:46 PM of the Nurses Notes dated 7/5/2017 at 11:30 PM states, Resident had room reassignment to room [ROOM NUMBER] A. Tolerated transfer and assisted to bed. No complaints voiced, reoriented to current room. Side rails x 2 for bed mobility, call bell in reach. No documentation could be found in Resident #95's medical record to ensure the resident and the responsible party was notified of the room change prior to the room change. An interview on 9/22/2017 at approximately 4:50 PM with the Social Services Director confirmed that Resident #95 nor the responsible party was notified of a room change. The Social Service Director stated, A form is filled out and put in the resident's medical record to ensure it is documented. No forms or documentation could be found in Resident #95's medical record to ensure the resident and the responsible party had been notified of a room change. The facility admitted Resident #175 with [DIAGNOSES REDACTED]. Review on 9/22//2017 at approximately 9:15 PM of the Nurses Notes dated 9/14/2017 on the evening shift, states, Resident transferred to this unit RM #218 B from Unit 300 RM #316 B. Resident oriented to room surroundings and roommate. Resident previously resided on this unit, he/she is familiar with all other details involving care. No complaints this PM. Resting in bed since arrival to unit. Foley cath in tact and draining clear yellow urine. Side rails 1/2 x 2 for bed mobility. Call bell in reach. No mention was made in the nurses notes to ensure Resident #175 or the responsible party had been notified of a room change. During an interview on 9/22/2017 at approximately 10:14 PM with the Social Service Director confirmed there were no Social Service notes and confirmed that Resident #175 nor his/her responsible party or interested family member had been informed of a room change. Review on 9/22/2017 at approximately 10:25 PM of the facility policy titled, Room Changes/Transfers Within The Facility, under Procedures, number 2 states, Social Services staff will assess how room relocation will impact patient's/resident's psychosocial status by evaluating the following: A. The patient's/resident's ability to cope with and to adapt to change, B. The patient's/resident's willingness to move to a new location, and C. How the change will affect the patient's/resident's current relationships and social support systems. Number 3 states, Social Services staff works with the Interdisciplinary Team to consider roommate compatibility and physical/care needs to arrive at the most appropriate location for a patient/resident. Number 4 states, Written notice of all room transfers, utilizing current forms. Room Change Notification form will be provided to the patient/resident or his/her qualified legal representative before the anticipated transfer. If applicable, the notice of room transfer will include or be accompanied/replaced by written notice that includes all appeal rights and processes.",2020-09-01
723,RIVERSIDE HEALTH AND REHAB,425082,2375 BAKER HOSP BLVD,CHARLESTON,SC,29405,2017-09-22,280,F,1,0,MJSH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to ensure required interdisciplinary participation of the care plan process for 17 of 27 residents reviewed.(Residents #106, 95, 130, 72, 165, 79, 26, 27, 217, 71, 136, 159, 62, 129, 212, 117 and 156). The findings included: The facility admitted Resident #129 with [DIAGNOSES REDACTED]. Record review on 9/21/17 of the 72- hour care plan dated 8/7/17 revealed there was no documentation the Registered Nurse(RN) or Certified Nursing Assistant(CNA) most familiar with the resident, the Physician or Dietary Manager(DM) participated in the care plan process. The facility admitted Resident #117 with [DIAGNOSES REDACTED]. Record review on 9/21/17 of the care plans dated 4/25/17 and 8/1/17 revealed there was no documentation the RN or CNA most familiar with the resident or Physician participated in the care plan process. The facility admitted Resident #156 with [DIAGNOSES REDACTED]. Record review on 9/20/17 of the care plan dated 5/9/17 revealed there was no documentation the RN and CNA most familiar with the resident, and the DM and Physician participated in the care plan process. Review of the care plan dated 6/6/17 revealed there was no documentation the CNA most familiar with the resident and the Physician participated in the care plan process. The facility admitted Resident #212 with [DIAGNOSES REDACTED]. Record review on 9/20/17 of the care plan dated 8/11/17 revealed there was no documentation the RN and CNA most familiar with the resident, DM or Physician participated in the care plan process. During an interview with the Minimum Data Set(MDS) Coordinator on 9/22/17 at 10:08 AM revealed during the last week of each month the schedule for assessments is viewed to see which assessments are due. A letter is sent the residents, responsible party, conservator, guardian, Hospice and whoever else may be interested in attending. Social Services sends the letter and the Unit Ward Clerk assists in this process. In the letter the person is informed of the meeting and if they are unable to attend the care plan, a request can be made to reschedule. We also offer a telephone conference if necessary. The facility keeps a copy of this letter. During an interview with the MDS Coordinator on 9/22/17 at 1:54 PM, all disciplines are to be a part of the care plan conferences if they are available. The facility admitted Resident #106 with [DIAGNOSES REDACTED]. Review on 9/21/2017 at approximately 11:00 AM of the Care Plan Conference Summary dated 8/29/2017 revealed the (RN) Registered Nurse and the CNA (Certified Nursing Assistant) involved with Resident #106's was not included in the care planning process for this resident. The facility admitted Resident #95 with [DIAGNOSES REDACTED]. Review on 9/22/2017 at approximately 2:20 PM of the Care Plan Conference Sheet Summary dated 6/28/2017 revealed the RN and the CNA involved in Resident #95's care was not included in the care planning process for the resident. The facility admitted Resident #130 with [DIAGNOSES REDACTED]. Review on 9/21/2017 at approximately 8:07 AM of the Care Plan Conference Summary dated 6/27/2017 revealed the RN and the CNA involved in Resident #130's care was not included in the car planning process for the resident. Resident #72 was admitted with [DIAGNOSES REDACTED]. There was no evidence of participation by the CNA (Certified Nurse Assistant), or the Physician in the Interdisciplinary Care Plan Conference held on 8/15/2017. Resident #79 was admitted with [DIAGNOSES REDACTED]. There was no evidence of participation by the CNA or the Physician in the Interdisciplinary Care Plan Conference held on 8/22/2017. Resident #27 was admitted with [DIAGNOSES REDACTED]. There was no evidence of participation by the CNA or the Physician in the Interdisciplinary Care Plan Conference held on 8/15/2017. Resident # 26 was admitted with [DIAGNOSES REDACTED]. There is no evidence of participation by the CNA or the Physician in the Interdisciplinary Care Plan Conference held on 7/18//2017. Resident #165 was admitted with [DIAGNOSES REDACTED]. There is no evidence of participation by the CNA or the Physician in the Interdisciplinary Care Plan Conference held on 7/13/17. The facility admitted Resident #62 with [DIAGNOSES REDACTED]. Review of the Care Plan on 09/22/17 at 7:49 PM revealed a Care Plan Conference Summary sheet dated 08/29/17 did not include a signature to verify participation by a Certified Nursing Assistant (CNA). The facility admitted Resident #71 with [DIAGNOSES REDACTED]. Review of the Care Plan on 09/21/17 at 1:13 PM revealed a Care Plan Conference Summary sheet dated 06/27/17 did not include a signature to verify participation by a CNA. The facility admitted Resident #159 with [DIAGNOSES REDACTED]. Review of the Care Plan on 09/21/17 at 2:21 PM revealed a Care Plan Conference Summary sheet dated 05/16/17 did not include a signature to verify participation by a CNA. The facility admitted Resident #136 with [DIAGNOSES REDACTED]. Review of the Care Plan on 09/20/17 at 9:41 AM revealed a Care Plan Conference Summary sheet dated 08/22/17 did not include a signature to verify participation by a CNA.",2020-09-01
724,RIVERSIDE HEALTH AND REHAB,425082,2375 BAKER HOSP BLVD,CHARLESTON,SC,29405,2017-09-22,282,D,1,0,MJSH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and review of the facility policies and procedures, the facility failed to ensure: 1)The care plan was followed for Resident #217 related to transfer using the Hoyer Lift for 1 of 2 residents reviewed for accidents, 2)The care plan was followed for Resident #62 related to dental consults for 1 of 3 residents reviewed for dental, and 3) The care plan was followed for Resident #34 related to Urinary Tract Infection risk and Catheter Care for 1 of 3 residents with catheters. The findings included: Resident #217 was admitted on [DATE] with [DIAGNOSES REDACTED]. An observation on 09/19/2017 at 3:19 PM, Resident #217 was sitting in a Geri Chair in hallway directly in front of the Nurses Station on the 300 Unit. CNA #4 began setting up Resident #217 in the Hoyer lift and then began using the Hoyer Lift to lift Resident #217 from the Geri Chair. The Respiratory Therapist #1 was sitting at nurses's desk and got up from the desk and walked over to where Resident #217 was now sitting in the Hoyer Lift and was now hanging from the lift and was being pushed down the hallway. He/She was then transported down the hallway while he was sitting up in the Hoyer lift, his body was swaying back and forth as he was transported down the hallway to his room which was located at the end of the hallway. An interview with Respiratory Therapist #1 On 9/19/2017 at 3:51 PM and he/she said, I thought the CNA was just getting a weight on the resident and then was going to reposition him/her in the chair. As he/she got him out of the chair he had a bowel movement and then I went with her/him and continued down hall. He/She further said: The least little movement startles the resident. The CNA is supposed to have a spotter during transfers using the Hoyer Lift. Not saying this was the best course to take. An interview with the DON on 9/19/2017 at approximately 5:00 PM said she was aware of the incident and both employees had been educated and suspended. The DON said the use of the Hoyer Lift requires 2 people to transfer the resident and that the lift is not to be used to transfer resident down the hallway. Review of the Interim Plan of Care completed on 9/18/17 there is no evidence of care plan for use of Hoyer Lift for resident transfers. The Resident Profile Order states: 1) Order Category, A.D. L. (Activities of Daily Living), Start Date, 09/19/2017, Profile Description, Adaptive devices/special needs: low bed, wheel chair, Hoyer lift, 2) Order Category A.D.L. , Start Date, 09/19/2017, Profile Description, Transfer with assist of_2__. The facility admitted Resident #62 with [DIAGNOSES REDACTED]. Record review on 09/22/17 at approximately 7:49 PM revealed the care plan for Resident #62 identified the problem of some natural teeth loss. The Care Plan identified a goal of no further tooth loss for Resident #62. Further review revealed, Obtain dental consult as an approach for resolving the problem. No documentation of a Dental Consult was located in the record. In an interview on 09/23/17 at approximately 8:03 PM the Social Worker stated that s/he could not locate any documentation of Resident #62 being seen by the facility's dental provider and that the resident is not enrolled in the dental program despite being eligible. The facility admitted Resident #34 with [DIAGNOSES REDACTED]. Record review on 09/22/17 at approximately 5:39 PM revealed a Nurse's Note dated 07/07/17 stating, Resident urine has strong smell and dark in color. The physician was notified and an order for [REDACTED]. No copy of the lab results could be found in the chart. Further review revealed the next Nurse's Note was dated 07/14/17 and stated Resident #34 was complaining of burning at the catheter site and was started on the antibiotic, [MEDICATION NAME] BS two times per day. Review of the Care Plan on 09/22/17 at approximately 5:30 PM revealed a concern that Resident #34 was at risk for complications related to a history of Urinary Tract Infections [MEDICAL CONDITION] and an indwelling catheter. The goal for Resident #34 stated s/he would not have complications related to UTI or catheter use. Approaches included but were not limited to, labs as ordered and report signs of uti (acute confusion, burning, pain, foul odor, concentrated urine, blood in urine .) In an interview on 09/22/17 the Director of Nursing reported the lab ordered on [DATE] was not drawn and there was no documentation of why not.",2020-09-01
725,RIVERSIDE HEALTH AND REHAB,425082,2375 BAKER HOSP BLVD,CHARLESTON,SC,29405,2017-09-22,287,B,1,0,MJSH11,"> Based on record review and interview, the facility failed to transmit accurate and/or Minimum Data Set(MDS) information in the required time frame for 2 of 2 residents.(Resident #218 and #7) The findings included: The facility admitted Resident #218 who had an assessment target date of 3/15/17 which indicated a missing report per the Casper Report (SC) MDS 3.0 Missing OBRA Assessment. The facility admitted Resident #7 who had an assessment target date of 5/19/17 which indicated a missing report per the Casper Report (SC) MDS 3.0 Missing OBRA Assessment. During an interview with the Minimum Data Set Coordinator on 9/18/17, he/she stated Resident #218's discharge assessment had not been submitted and Resident #7's assessment listed an incorrect birth date. No policy was provided during he survey related to timely and accurate transmission of assessments.",2020-09-01
726,RIVERSIDE HEALTH AND REHAB,425082,2375 BAKER HOSP BLVD,CHARLESTON,SC,29405,2017-09-22,309,D,1,0,MJSH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview and review of the facility policy titled Medication Shortages/Unavailable Drugs, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well being. Resident #212 did not receive ordered medications in a timely manner.(1 of 1 new admission reviewed) and Resident #158 did not have coordination of care with Hospice.(1 of 1 reviewed for Hospice) The findings included: The facility admitted Resident #212 with [DIAGNOSES REDACTED]. Record review on 9/21/17 of the admission physician orders dated 8/7/17 revealed an order for [REDACTED]. During an interview with the Director of Nursing(DON) on 9/22/17 at 3:07 PM, he/she stated the cut off time for the pharmacy for receiving medication orders and then sending medications to the facility was 5:00 PM. He/she stated some medications could be pulled from the emergency kit. After reviewing the emergency kit list of available drugs, the DON confirmed the medication was not in the emergency kit and he/she also confirmed the medication was not administered to the resident until 8/8/17 at 6:00 PM. Review of the facility policy titled Medication Shortages/Unavailable Drugs states the following: 3. If a medication shortage is discovered after normal Pharmacy hours: 3.1 A licensed Facility nurse should obtain the ordered medication from the emergency stock supply. 3.2 If the ordered medication is not available in the emergency stock supply, the Facility nurse should call the Pharmacy's emergency answering service and request to speak with the registered pharmacist on duty to manage the plan of action. Action may include: 3.2.1 Emergency delivery. 3.2.2 Use of an emergency (back-up) Third Party Pharmacy. The facility admitted Resident #158 with [DIAGNOSES REDACTED]. Record review on 09/20/17 at approximately 4:45 PM revealed no documentation of visits by the Hospice Nurse since 07/31/17 and no visitation records for the Hospice Aide since 09/05/17. In an interview on 09/21/17 at approximately 2:21 PM the Hospice Nurse stated documentation for August and September visits should have been in the chart and did not know why they were missing.",2020-09-01
727,RIVERSIDE HEALTH AND REHAB,425082,2375 BAKER HOSP BLVD,CHARLESTON,SC,29405,2017-09-22,312,D,1,0,MJSH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview and review of the Point of Care ADL (Activities of Daily Living) Report and the CNA (Certified Nursing Assistant) Assignment Report, the facility failed to ensure Resident #175, who is unable to carry out ADLs and necessary services to maintain good grooming, personal and oral hygiene, received showers per the shower schedule for 1 of 3 residents reviewed for Activities of Daily Living. The findings included: The facility admitted Resident #175 with [DIAGNOSES REDACTED]. During an interview on 9/21/2017 at approximately 5:45 PM with Resident #175 stated that he/she had only received one shower since 9/9/2017. Review on 9/22/2017 at approximately 6:00 PM of a form titled, Point of Care ADL Report, dated from 9/9/2017 through 9/22/2017 revealed only one documented shower on 9/13/2017. Further review on 9/22/2017 at approximately 6:00 PM of a form titled, CNA Assignment Report, indicated that Resident #175 was to receive showers on Mondays, Wednesdays and Fridays. An interview on 9/22/2017 at approximately 6:00 PM with the CNA Scheduler verified that Resident #175 had only received one shower from 9/9/2017 through 9/22/2017 and the one shower was documented on 9/13/2017.",2020-09-01
728,RIVERSIDE HEALTH AND REHAB,425082,2375 BAKER HOSP BLVD,CHARLESTON,SC,29405,2017-09-22,323,E,1,0,MJSH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on Observation, record reviews, interviews and review of the facility policy titled, Behavior Management, the facility failed to ensure a wander guard was in place at time of admission for Resident #174 with a history of wandering and exit seeking for 1 of 1 resident reviewed for Behaviors. The facility further failed to ensure safe use of a Hoya lift on the 200 Unit for 1 of 2 residents reviewed for Accidents. The facility additionally failed to ensure a door to electrical equipment was secure on the 200 Unit for 1 of 4 Units observed. The findings included: The facility admitted Resident #174 with [DIAGNOSES REDACTED]. Review on 9/20/2017 at approximately 11:37 AM of the Nurses Notes dated 3/28/2017 through 5/18/2017 states, Roams aimlessly, stands near exit doors and pushes. Goes to unit door and stands in doorway but does not leave. Resident is redirected out of other resident rooms, balls fist up at this nurse . Agitation and constantly trying to get out of the facility. Will wander into resident's rooms and stand by the exit doors. Will resist care at times and is hard to redirect. No interventions during that time were put in place to ensure exit seeking behaviors were reduced, prevented and monitored. Review on 9/20/2017 at approximately 11:45 AM of the physician's phone orders dated 4/9/2017 revealed an order to check wander guard function each shift and to check wander guard placement each shift. Further review on 9/20/2017 at approximately 11:55 AM revealed no other orders for a wander guard to be placed prior to 4/9/2017. During an interview on 9/20/2017 at approximately 1:35 PM with the Consultant MDS (Minimum Data Set) assessment coordinator he/she stated, I came in to help update the care plans on 5/18/2017. Resident #174 was in the hospital due to uncontrollable behaviors, and he/she was on bed hold. The Consultant MDS Coordinator went on to say that the physician had written an order for [REDACTED].#174 was exit seeking. The wander alarm was placed at the time of the order on 4/9/2017. The plan of care did not include the use of a wander guard. Review on 9/20/2017 at approximately 2:40 PM of the facility policy titled, Behavior Management, states, The staff will incorporate Behavior Management techniques to assist patients/residents in reaching and maintaining their highest practical physical and psychosocial well being. Behaviors are a form of communication: behavior management is an attempt to understand that communication and meet the needs of the patients/residents. Resident #217 was admitted on [DATE] with [DIAGNOSES REDACTED]. An observation on 09/19/2017 at 3:19 PM,Resident #217 was sitting in a Geri Chair in hallway directly in front of the Nurses Station on the 300 Unit. CNA #4 began setting up Resident #217 in the Hoyer lift and then began using the Hoyer Lift to lift Resident #217 from the Geri Chair. The Respiratory Therapist #1 was sitting at nurses's desk and got up from the desk and walked over to where Resident #217 was now sitting in the Hoyer Lift and was now hanging from the lift and was being pushed down the hallway. He/She was then transported down the hallway while he was sitting up in the Hoyer lift, his body was swaying back and forth as he was transported down the hallway to his room which was located at the end of the hallway. An interview with Respiratory Therapist #1 On 9/19/2017 at 3:51 PM and he/she said, I thought the CNA was just getting a weight on the resident and then was going to reposition him/her in the chair. As he/she got him out of the chair he had a bowel movement and then I went with her/him and continued down hall. He/She further said: The least little movement startles the resident. The CNA is supposed to have a spotter during transfers using the Hoyer Lift. Not saying this was the best course to take. An interview with the DON on 9/19/2017 at approximately 5:00 PM said she was aware of the incident and both employees had been educated and suspended. The DON said the use of the Hoyer Lift requires 2 people to transfer the resident and that the lift is not to be used to transfer a resident down the hallway. Review of The Resident Profile Orders states: 1) Order Category, A.D. L. (Activities of Daily Living), Start Date, 09/19/2017, Profile Description, Adaptive devices/special needs: low bed, wheel chair, Hoyer lift, 2) Order Category A.D.L. , Start Date, 09/19/2017, Profile Description, Transfer with assist of_2__. Review of the Record of In-service, Date: 9/1717, Time PM, Objectives of the In-Service: Hoyer Lift-2 person process-No using Hoyer lift without assistance. Review of the facility policy and procedure titled, Nursing Policies and Procedures, Subject: Mechanical Lifts General Guidelines, Procedure: .2. Mechanical lifts may be used for enhanced safety of patients, residents, and staff in situations including but not limited to: A. Lifting from floor. B. Bed to Chair transfer. C. Lateral Transfer. D. Toileting and bathing, E. Repositioning .3. Prior to initiating use of mechanical lift for a patient or resident: C. Determine how many caregivers are necessary to safely lift the patient or resident. In most cases and for safety a minimum of 2 caregivers is recommended. During initial tour on 09/18/2017 at 10:17 AM on the 200 unit, the door to the electrical room with a sign on it which states: Warning Electrical Hazards door is unlocked and opens upon pressing the handle down. On 09/18/2017 at 10:19 AM, Maintenance Employee #1 verified that the door opened when the handle was pressed down and was unlocked. He/She verified that the door comes open even after locking the door, the door handle when pressed down opens on multiple repeated attempts. He/She said that the door should be locked he is going to work on it.",2020-09-01
729,RIVERSIDE HEALTH AND REHAB,425082,2375 BAKER HOSP BLVD,CHARLESTON,SC,29405,2017-09-22,325,D,1,0,MJSH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and review of the facility policy and procedure the facility failed to ensure that Resident #79's significant weight loss of 5.7% in one month was verified and identified per facility policy and procedure. The findings included: Resident # 79 was admitted on [DATE] with [DIAGNOSES REDACTED]. The report titled MatrixCare 2017 Release, Search Vital Results, Vital Signs, Weight, Vitals Taken From 3/21/2017 to 9/21/2017 showed that Resident #79 weight recorded in pounds are as follows: 9/3: 147.6, 8/1: 156.5,7/5: 153.9,7/4: 153.9,6/5: 160.8,5/22: 164.5,5/15: 161.3,5/8: 161,5/3: 163.7,4/6: 161.7. During an interview on 09/21/2017 at 1:24 PM with the Facility RD (Registered Dietitian), he/she said that on 9/7/17 he/she discontinued the supplement Ensure bid(twice daily) and added house shakes tid (three times daily) on the resident's meal tray. The RD stated the resident has a [DIAGNOSES REDACTED]. During an interview with the CDM (Certified Dietary Manager) and the RD regarding reweighs in residents who show a significant weight change both verified this is the facility policy and procedure, but both were aware of this resident's weight loss and addressed the weight loss on 9/7. During an interview on 09/22/2017 at 11:58 AM with the RD regarding reweigh policy and procedure, he/she said that since the resident is on [MEDICATION NAME] the weight loss may be expected related to diuretic therapy. He/She verified the Nutrition Policies and Procedures, Subject: Weighing the Resident, Procedures: .2. If the month to month weight shows more than a five percent gain or loss, the patients/resident is reweigh within 24 hours. A review of the form titled Nutritional Progress Notes, Date: 9/7/17: RD note for weight loss. CBW(Current Body Weight) 147.6 (9/3), 156.5 (8/1), 160.8(6/5), 161.7 (4/6), decreased 5.7% d(days), (significant), decreased 8.2% in 90 d, , decreased 8.7% 150 d. NP (Nurse Practitioner) ordered Ensure BID. Does have [DIAGNOSES REDACTED]. [MEDICATION NAME] noted as well. Will change Ensure to House shakes Tid During an interview on 09/22/2017 at 10:58 AM with the DON regarding why a reweigh was not completed when significant weight loss was noted, he/she stated that the resident had already been seen by the RD and the weight loss was evaluated and interventions in place. He/she further said that the facility had just stopped weekly weights and interventions in place and RD had seen. The DON said that Resident #79 has a new order since yesterday for weights to be obtained for 3 days and he/she thinks the resident's weight yesterday was 141 pounds. The report titled MatrixCare 2017 Release, Search Vital Results, Vital Signs, Weight, Vitals Taken From 9/21/2017 to 9/22/2017 showed that Resident #79 weight recorded in pounds are as follows: 9/21/2017 141.2 pounds and 9/22: 141.2 pounds. A review of the facility policy and procedure titled, Nutrition Polices and Procedures, Subject: Weighing The Resident, states, Procedures: .2. If the month-to-month weight shows more than a five-percent gain or loss the patient/resident is reweigh within 24 hours",2020-09-01
730,RIVERSIDE HEALTH AND REHAB,425082,2375 BAKER HOSP BLVD,CHARLESTON,SC,29405,2017-09-22,328,D,1,0,MJSH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, observation, interview and review of the facility policy titled [MEDICAL CONDITION], the facility failed to provide appropriate respiratory care to 1 of 1 resident reviewed for [MEDICAL CONDITION].(Resident # 156) The findings included: The facility admitted Resident #156 with [DIAGNOSES REDACTED]. Record review on 9/20/17 of the current physician orders stated to cap the [MEDICAL CONDITION] site up to 12 hours daily as tolerated on room air. There were no orders instructing on how often [MEDICAL CONDITION] care and suctioning should be done. Further record review revealed Resident #156 had an order dated 9/18/17 for [MEDICATION NAME] 875 milligrams to be given twice a day for ten days due to a respiratory infection. On 9/20/17 at 12:30 PM, during observation of [MEDICAL CONDITION] care, Respiratory Therapist(RT)#1 after sanitizing hands and donning gloves, obtained supplies out of Resident's #156 bedside drawer and placed the containers directly on the over the bed table. No barrier was on the table at the time of the observations. After assessing the resident, RT #1 removed the [MEDICAL CONDITION] cap and placed it in a container with other caps and/or valves. Gloves were removed and new gloves were donned, the suction machine was turned to the on position, the old dressing to the [MEDICAL CONDITION] site was removed and the area around the site was cleaned with sterile water and a sponge tip applicator. A set of covered sterile gloves was placed across the resident's legs and the sterile gloves were donned over the previous set of gloves. Resident #156 was suctioned and the sterile gloves were then removed. With the previous set of gloves remaining, the area around the [MEDICAL CONDITION] site was cleaned again due to the resident coughing during the suctioning. The old [MEDICAL CONDITION] ties were removed and the [MEDICAL CONDITION] apparatus was held in place as the resident started coughing. New [MEDICAL CONDITION] ties and a new dressing was placed. The cap was reapplied. The resident was assessed again by obtaining the oxygen saturation and heart rate. The suction machine was turned off using the same gloves the resident was observed to cough on when the apparatus was being held into place. During an interview with RT #1 on 9/22/17 at 1:15 PM, he/she confirmed the over the bed table had not been wiped down and double gloves had been used. He/she did not recall the resident coughing and touching items in the room with soiled gloves. Review of the facility policy titled [MEDICAL CONDITION] Care states the following under the Procedure section: 1. Orders for [MEDICAL CONDITION] care should contain the frequency of care and physician's signature. 4.Follow relevant infection control procedures as appropriate.",2020-09-01
731,RIVERSIDE HEALTH AND REHAB,425082,2375 BAKER HOSP BLVD,CHARLESTON,SC,29405,2017-09-22,329,D,1,0,MJSH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview and information provided by the facility titled What You Need To KnowUnderstanding & Managing Difficult Behavior, the facility failed to implement non-pharmacological interventions prior to administration of an anti-anxiety medication for 1 of 6 residents reviewed for unnecessary medications.(Resident #212) The findings included: The facility admitted Resident #212 with [DIAGNOSES REDACTED]. Record review on 9/21/17 of the physician's orders [REDACTED]. Review of the Medication Administration Record(MAR's) for the month of August 2017 revealed Resident #212 received [MEDICATION NAME] without documentation of attempting a non-pharmacological intervention on the dates as follows: 8/9/17, 8/11-14/17, and 8/20/17. Review of nurse's notes during the administration times of [MEDICATION NAME] on 8/9/17 and 8/11-14/17 revealed there was no documentation of non-pharmacological interventions prior to the administration. During an interview with the Director of Nursing on 9/22/17 at 6:13 PM, he/she stated interventions were not placed on the MAR until 8/14/17 for nurse's to document which approach was taken. He/she also confirmed non-pharmacological interventions were not attempted prior to each dose of medication administered. Review of the information provided by the facility titled What You Need To KnowUnderstanding & Managing Difficult Behavior, states the following under the section Documentation with PRN(as needed) medications: [REDACTED].",2020-09-01
732,RIVERSIDE HEALTH AND REHAB,425082,2375 BAKER HOSP BLVD,CHARLESTON,SC,29405,2017-09-22,371,E,1,0,MJSH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and review of the facility policies and procedures the facility failed to ensure: 1)Sanitary storage and handling of clean dishes, 2)Labeling and dating of foods, 3)Food not stored on the floor in the dry storeroom, 4)Microwave oven interiors are clean, 4)Expired foods were discarded, 5)Scoops not stored in containers of coffee, 6) Cutting boards free of black substance 7)Sanitizer solution in the sanitizer buckets are at the appropriate strength for sanitizing, 8) The staff was wearing hair restraints while serving food 9)Soiled meal trays were not stored with clean meal trays in the dietary meal carts. 10) Staff were not washing hands during meal service in 1 of 1 kitchen, 2 of 3 dining rooms, and 1 of 4 dietary kitchens, and 1 of 1 activity room. The findings included: During initial tour on 09/18/2017 at 9:55:AM observation was verified by the CDM (Certified Dietary Manager) of 3 soiled, white notebooks stored on top of the sliding metal doors of the milk cooler. The CDM said these are our temperature logs and removed them. On 09/18/2017 at approximately 10:00 AM , observation was verified by the CDM of a build up of dust on a fan located on the back of oven, and this fan blows directly on to clean dishware stored on open racks. On 09/18/2017 at 10:13 AM, observation was verified by the CDM: 1 )The interior of the top of microwave oven was soiled with food splatters and debris. 2) A metal measuring cup was stored inside of plastic container which contained coffee grounds. 3) A white cutting board which was bolted to the trayline was spotted with a black substance. The CDM unbolted the cutting board and asked an employee to clean, 4) A spatula with broken and melted edges was on a stainless steel preparation table during meal preparation; a dietary employee discarded. During initial tour on 9/18/17 at approximately 10:15 AM, an observation in the Dry Storage Room was verified by the CDM of multiple cases of food stored directly on the floor. The CDM said that the food deliveries from the food vendor arrive on Mondays and Thursdays, and he had received an order today (Monday) at approximately 8:30 AM and the order had not been removed from the cases and stored on the shelves. Observed and was verified by the CDM 2 dented cans of wax beans stored on the can rack, the CDM removed and placed the dented cans on the Dented Can area located outside of the storeroom. A second observation was verified by the CDM on 9/21/17 (Thursday) at approximately 9:45 AM, multiple cases of food were stored directly on the floor in the Dry Food Storage Room. The CDM said he/she had received an order from the food vendor at approximately 8:30 AM and the order had not been removed from the cases and stored on the shelf. An observation on 9/18/17 at approximately 10:12 AM in the walk-in cooler of cooked diced turkey in a plastic bag stored directly over raw lettuce. The CDM moved the turkey to the bottom shelf underneath the lettuce. The heads of lettuce had brown edges and the vendor . labels were on the unopened bags of lettuce stated 9/7/17 on one bag and 9/11/17 on another bag. The CDM said that they had not opened the bags and said food is good for three days after it is opened, and then said he would discard the lettuce. A second observation on 9/21/2017 at approximately 10:00 AM, in the kitchen on a preparation table was a bag of lettuce, which contained 6 heads of lettuce. The vendor . label on it with the date from the vendor of 9/7/17. This bag of lettuce contained one head which was completely brown and slimy and was touching the heads of lettuce inside of the bag. The remaining heads of lettuce, the leaves were brown around the edges. The dietary employee removed and discarded the entire bag. Review of the facility Policy and Procedure titled, Nutrition Orientation, Policies and Procedures, states, Food Storage, If food is not stored properly, chance are that it will spoil quickly., .* Keep food 6(inches) off the floor., .*Always cover, label and date leftovers that are to be stored. They should be date marked with the use by date Throw TCS (Time, Temperature Control for Safety) leftovers out if not used within 3 days. The Policy further states, When food is delivered to the facility, check it for signs of spoilage. When inspecting canned foods, look for the following signs: .*Badly dented cans. An observation of the dishwashing procedure was made and was verified by the CDM on 09/21/2017 at 10:06 AM. The dietary employee who was placing the soiled dishes into the dishmachine was also removing the clean dishes from the dishmachine and putting up clean dishes. H/She stated that when she goes between dirty and clean dishes she rinses her hands in the sanitizer bucket. The red sanitizer solution bucket which he/she had indicated that he/she uses was tested for the strength of the sanitizer in the solution in the bucket. The test strip remained unchanged in color when placed in the solution which was in the sanitizer bucket which indicated no sanitizer present at that time in the bucket. When the dietary employee was questioned if she washes her hands after handling soiled dishes and before touching clean dishes h/she stated, I put my hands in the bucket before I touch dirty dishes. A review of the Facility Policy and Procedure, titled, Nutrition Orientation, Policies and Procedures, Storage and Cleaning of Dishes and Utensils, states .Do not load dirty dishes and then unload clean dishes at the dishmachine without washing your hands first. The policy and procedure further states, .Clean dishes are stored in a clean, dry area. A review of the Facility Policy and Procedure titled, Nutrition Policies and Procedure. Subject: Manual Cleaning & Sanitizing Stationary Equipment & Work Surfaces. The section titled: Sanitizing Bucket Guidelines.states, A. Follow manufacturer's recommendations for mixing and concentration E. Veracity concentration of the solution with the appropriate test kit. The facility provided the information from the Manufacturer; , of the Oasis 146 Multi-Quat Sanitizer and the information states, The solution's broad efficacy range of 150-400 ppm stays within proper range longer. An observation on 09/22/2017 at 1:20 PM of CNA #3 placed a soiled tray inside of the tray delivery cart which still had unserved lunch trays inside of it. He/She then stated: Resident #72 has not gotten her tray and then pulled out the lunch tray for for Resident #72. The facility policy and procedure titled, Nutrition Policies and Procedures, Subject: Meal Delivery, Procedures .20. Do not return trays to the tray delivery car until all unserved trays have been passed. During a Dining observation, in the main dining room, on 9/18/17 at 12:11 PM, observed CNAs (Certified Nurse Assistants) standing over an open container of soup placing soup in soup bowls utilizing a ladle, and other CNAs standing over an open container of ice, using a scoop to place ice in cups. The CNAs serving the soup and scooping the ice were not wearing hair restraints. The facility policy and procedure titled, Nutrition Orientation, Policies and Procedures, Safe Food Handling and Preparation,: states, .6. Keep hair restrained with a hair net or cap when in the kitchen. An observation of the 300 Unit, Diet Kitchen, on 09/18/2017 at 1:07 PM and was verified by RN (Registered Nurse) #1, the interior of the microwave was soiled with food and debris. H/She said; The food is good for 3 days. He/She verified and discarded the following items: 1) The white refrigerator in the freezer unit has cup of pink frozen substance has Name written on it no label or date. 2)Four peanut butter and jelly sandwiches wrapped in plastic wrap, no label or date. 3) 3 Styrofoam cups no label or date 4) Styrofoam container no label or date 5) 2 Tupperware containers with food, no label or date 6) 1 partially open bottled water and and and partially open bottle of mountain dew, no label or date Inside of a small white refrigerator which was identified as the Resident Refrigerator were the following items which were verified by and discarded by RN #1: 1) A carton of milk, expiration date on the label: [DATE] 2) carafe orange juice no date or label 3) A cup of prune juice no label or date An observation on 09/20/2017 at 10:19 AM was verified by Activities Assistant #1 of the Refrigerator in the Activities Room 1) 5 pizzas boxes which contained pizza no label or date, Activities Assistant #1 stated for staff, they came in yesterday for resident staff came in yesterday. 2) A plastic bag of expired Brill Glaze for Strawberries 16 oz with use by date stamped on the label; thru May 2017. Discarded by Activities Assistant #1. 3)1 carton of chocolate milk, expiration date on the label [DATE] and was discarded by Activities Assistant 31. 4) A plastic bag with black substance, no label or date, the Activities Assistant said they are Oreo cookie crumbs and discarded. The facility policy and procedure titled: Nutrition Orientation Polices and Procedures states: Food storage, .Always cover, label and date leftovers that are to be stored. They should be date marked with the use by date .Label and date new food items removed from their original containers. The facility policy and procedure titled: : Nutrition Policies and Procedures, Subject: Safe Handling of Food Brought in by family/friends for patient/resident consumption, states, .5. Foods are labeled to identify the patient/resident's name, container contents, and the date it was prepared. Food items are stored in disposable, tightly covered containers, or sealable plastic bags. Items will be stored for three days. Expired and unlabeled items will be discarded. During a random observation of the delivering of meal trays on 9/18/17 at 12:50 PM on the 100 Unit, observations were made of a Certified Nursing Assistant entering/exiting resident rooms with no hand sanitization after delivery of meal trays. An observation on 9/18/2017 at approximately 1:00 PM during the lunch service on the 200 Units revealed Certified Nursing Assistant (CNA) #1 went into a resident room, turned on the light and scratched his/her ear and then proceeded to set up the lunch tray for the resident. After setting up the tray the CNA came out of the room and retrieved the next tray from the dietary cart and proceeded into the next room without first cleansing his/her hands. An observation on 9/21/2017 at approximately 1:00 PM during the lunch service, CNA #1 went into a resident room on the 200 Unit without first cleansing his/her hands. The CNA #1 set up the tray and left the resident room. The CNA reached into her blouse and adjusting her clothing and proceeded to the tray cart to retrieve another meal tray without cleansing his/her hands. During an interview on 9/21/2017 at approximately 1:10 PM with CNA #1, he/she stated, I do not remember exactly what I did. But I think I cleansed my hands. Review on 9/21/2107 at approximately 2:00 PM of the facility policy titled, Hand Hygiene/Handwashing, states, Hand Hygiene/Hand washing is the most important component for preventing the spread of infection. Maintaining clean hands is important for patients/residents/visitors as well as staff. Section 1 under Procedures: states, Hand hygiene/hand washing is done before, patient/resident contact and after contact with soiled or contaminated articles, after patient/resident contact and after contact with a contaminated object source where there is a concentration of microorganisms, such as,mucous membranes, non-intact skin, body fluids or wounds.",2020-09-01
733,RIVERSIDE HEALTH AND REHAB,425082,2375 BAKER HOSP BLVD,CHARLESTON,SC,29405,2017-09-22,412,D,1,0,MJSH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review, the facility failed to ensure Resident #62 had a consult with the facility dentist, 1 of 1 resident sampled with dental concerns. The following included: The facility admitted Resident #62 with [DIAGNOSES REDACTED]. In an interview on 09/22/2017 at approximately 7:50:48 PM Resident #62 stated that she saw a dentist a while back but had not heard anything since. S/he stated that some foods are painful to eat. Record review on 09/22/17 at approximately 7:49 PM revealed a care plan for Resident #62 identified the problem of some natural teeth loss. The Care Plan identified a goal of no further tooth loss for Resident #62. Further review revealed, Obtain dental consult as an approach for resolving the problem. No documentation of a Dental Consult was located in the record. In an interview on 09/23/17 at approximately 8:03 PM the Social Worker stated that s/he could not locate any documentation of Resident #62 being seen by the facility's dental provider and that the resident is not enrolled in the dental program despite being eligible.",2020-09-01
734,RIVERSIDE HEALTH AND REHAB,425082,2375 BAKER HOSP BLVD,CHARLESTON,SC,29405,2017-09-22,441,E,1,0,MJSH11,"> Based on observation, interview and review of the facility policy titled, The Laundry Process, the facility failed to handle and transport linen in a manner that would prevent the spread of infections during the collecting of soiled linen from the soiled utility rooms in 2 of 4 units observed for collection of soiled linens. The findings included: An observation on 9/20/2017 at approximately 9:30 AM during the collecting and transporting of soiled linen from the soiled utility rooms to the laundry room revealed soiled linen not bagged in resident rooms prior to putting the soiled linen in bins in the soiled utility room. An interview on 9/20/2017 at approximately 9:40 AM with Laundry Worker #1 confirmed that the soiled linen should be bagged prior to bringing it to the soiled utility rooms and putting it in the bins. Review on 9/20/2017 at approximately 3:45 PM of the facility policy titled, The Laundry Process, states under, Transferring Soiled Linen, Soiled Linen containers should be lined with an impervious liner. Do not allow soiled linens to simply be dropped into a container.",2020-09-01
735,RIVERSIDE HEALTH AND REHAB,425082,2375 BAKER HOSP BLVD,CHARLESTON,SC,29405,2017-09-22,456,E,1,0,MJSH11,"> Based on observation, interview and review of the facility policy titled, Description of Dryers, the facility failed to ensure an excessive amount of lint build up was removed from 4 of 4 clothes dryers. The facility further failed to ensure 3 of 3 clothes washers were in good working order in 1 of 1 laundry rooms. The findings included: An observation on 9/20/2017 at approximately 9:30 AM of the clothes dryers in 1 of 1 laundry room revealed 4 of 4 clothes dryers with an excessive build up of lint on the upper sides and on the wiring above the lint baskets. An additional observation of the clothes washers revealed 2 of 3 washers were leaking water from the front and the 3 washer needed a chemical fill hose. A large build up of matter was noted where the chemical container and the hose were joined together. An interview on 9/20/2017 at approximately 9:45 AM with the Regional Housekeeping Director confirmed the findings and stated the parts for the washers had been ordered and he/she would provide a copy. Review on 9/20/2017 at approximately 9:55 AM of the purchase order to repair 3 of 3 clothes washers dated 9/20/2017 revealed faulty door seals, door glass seals and spray nozzle kits. The third washer is in need of a chemical fill hose. The technician was called on 9/20/2017 and the parts were ordered at this time. Review on 9/20/2017 at approximately 10:20 AM of the facility policy titled, Description of Dryers, states, Lint screens must be brushed and cleaned every 2 or 3 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 causing a potentially dangerous situation -- one spark on lint can cause a fire. Lint also may build up on the top compartment of the dryer. This is dangerous because the heat source is here. The top panel must be opened and the area cleaned daily. Lint may also build up between the drum and the sides of the dryer. This may cause a problem because in many dryers there is a heat sensor there. This sensor reads the heat of the basket and is programmed to shut the dryer down if the temperature gets too hot. If the sensor is covered with lint, the lint acts as insulation and fools the sensor into thinking the basket is not as hot as it really may be. So, instead of shutting the dryer down, it allows heat to continue to pour in.",2020-09-01
736,RIVERSIDE HEALTH AND REHAB,425082,2375 BAKER HOSP BLVD,CHARLESTON,SC,29405,2017-09-22,514,D,1,0,MJSH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation interview and review of facility and policy and procedure, the facility failed to ensure Resident #72's diet order and tray tickets were updated to reflect a change in the physician orders [REDACTED]. The facility failed to ensure Resident #158's data base was updated related to discontinued medications for 1 of 1 resident reviewed for Hospice. The findings included: Resident # 72 was admitted with [DIAGNOSES REDACTED]. On 09/22/207 at 1:05 PM, Resident# 72 received her/his lunch tray and the tray ticket states: Frozen Nutritional Treat-1 Ea. The Frozen Nutritional Treat was missing from the tray. An interview with the CDM revealed that the Dining Services staff places all items on meal trays before the trays are delivered to the units. H/She said that the final check for the tray accuracy is for Certified Nurse Assistant to check tat ray and ensure all items on tray that are listed on the tray card. The CDM verified that the Frozen Nutritional Treat is printed on tray card despite being discontinued. A review of the medical record and the physician orders [REDACTED]. A review of the Physician order [REDACTED]. The facility admitted Resident #158 with [DIAGNOSES REDACTED]. Record review on 09/21/17 at 10:20 AM revealed a physician's orders [REDACTED]. Further review revealed a Physician's Note dated 09/19/17 that stated .continue [MEDICATION NAME], In an interview on 09/21/17 at 10:20 AM the Director of Nursing (DON) reviewed the paper chart and electronic charts for Resident #158. The DON stated that the order to discontinue the [MEDICATION NAME] was not entered into the electronic record by the nursing staff.",2020-09-01
737,MANNA REHABILITATION AND HEALTHCARE CENTER,425084,716 E CEDAR ROCK ST,PICKENS,SC,29671,2020-02-27,550,E,1,1,848R11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record reviews, interviews and review of the facility's Feeding the Impaired Residents policy, the facility failed to ensure that residents were treated with dignity and respect for 3 of 3 residents triggered for dignity and 1 of 3 triggered for pressure ulcer treatment. Resident #14 not served or eating while roommate was served and eating. Residents #63 and #107 with staff standing while feeding the residents. Resident #109 with nurse observed putting dressing on resident wound then writing on the dressing after it was placed on the resident's ankle. The findings included: The facility admitted Resident #107 on 7/21/17 with [DIAGNOSES REDACTED]. During random meal observation on 2/24/20 at approximately 1:53 PM, Certified Nursing Aide (CNA)#1 was observed standing in room [ROOM NUMBER] while feeding Resident #107 who was in bed. The resident's bed was observed in a high position. A folding chair was observed in corner of room while CNA was standing while feeding the resident. The facility admitted Resident #14 on 3/18/19 with [DIAGNOSES REDACTED]. A random observation on 2/25/20 at approximately 8:18 AM revealed Resident #14 in room [ROOM NUMBER] with his/her roommate served and eating breaking while Resident #14 was not served or eating breakfast and the privacy curtain was not pulled. Resident #14 tube feeding was also not in progress at the time of the observation. The facility admitted Resident #63 on 9/26/18 with [DIAGNOSES REDACTED]. A random observation on 2/25/20 at approximately 8:23 AM revealed Certified Nursing Aide (CNA) #2 standing in room [ROOM NUMBER] while feeding Resident #63 who was in bed. Resident #63's bed was not in a high position (at level of CNA) who was standing while feeding the resident. An interview and observation on 2/25/20 at approximately 8:37 AM with Licensed Practical Nurse (LPN) #5 revealed Resident #14 roommate seated at bedside table eating his/her breakfast while Resident #14 was not served or eating breakfast with privacy curtains not pulled/closed. LPN #5 stated the privacy curtains should have been pulled since both residents in room were not served and eating. LPN #5 preceded to close the privacy curtains. An interview on 2/25/20 at approximately 8:41 AM with CNA #2 confirmed he/she was standing while feeding Resident #63 who was in bed. CNA #2 stated he/she should not have been standing and that he/she was standing because she could not find a chair. An interview on 2/25/20 at approximately 9 AM with the Director of Nursing (DON) revealed it was acceptable for staff to stand while feeding resident if the resident and staff was at the same level. A copy of the facility's policy on standing while feeding residents was requested. A review on the facility's policy Feeding the Impaired Residents on 2/26/20 at approximately 7:33 AM, under Steps in the Procedure #10 indicated staff were to Sit at bedside in chair while feeding the resident. There was no documentation to indicate the staff should stand while feeding residents. Reviewed Resident #107 care plan. There was no documentation in the resident's care plan to indicate staff should be standing when feeding the resident. An interview on 2/27/20 at approximately 9:16 AM with CNA #1 revealed he/she confirmed observation of standing while feeding Resident #107 who was in bed. CNA #1 further stated he/she was under the impression it was acceptable to stand while feeding a resident if were at the same eye level. The facility admitted Resident #109 with [DIAGNOSES REDACTED]. Wound care for Resident #109 was observed on 2/25/20 at 2:32 PM. At the completion of the wound care, Registered Nurse (RN) #3 Placed a dressing over the resident's right ankle. RN #3 then proceeded to write the date on the dressing. During an interview with RN #3, on 2/27/20 at 9:46 AM, RN #3 confirmed s/he dated the dressing after it was applied to the resident's ankle. RN #3 stated this is a dignity issue and s/he should not have written on the dressing after it was placed on the resident. During an interview with the Director of Nursing (DON), on 2/27/20 at 9:57 AM, the DON stated RN #3 had come to her/him after the wound care and reported on the treatment s/he provided. The DON stated RN #3 told her/him s/he had written on the residents dressing after placing the dressing on the residents ankle. The DON stated s/he educated RN #3 that this is a dignity issue and nursing can not write on residents after dressings are placed. The DON stated RN #3 was re-educated.",2020-09-01
738,MANNA REHABILITATION AND HEALTHCARE CENTER,425084,716 E CEDAR ROCK ST,PICKENS,SC,29671,2020-02-27,580,D,1,1,848R11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to notify health professionals involved in a resident's care of the resident's change in nutrition/weight status. The Certified Dietary Manager (CDM) #2 failed to notify timely the doctor/nurse practitioner or dietitian of the resident's weight loss. The CMD #2 also failed to consult/notify the physician/nurse practitioner or dietitian prior to restricting some carbohydrates from the resident's diet for one of three sampled residents reviewed for nutrition. Findings: Resident #23 was admitted to the facility with diagnoses, including but not limited to, Type 1 Diabetes, Acute Kidney Failure, Dementia, Muscle Weakness, and Cognitive Communication Deficit. The physician's orders [REDACTED].#23's diet as CCD (carbohydrate-controlled diet) mechanical soft texture related to diabetes and advance dysphagia. Weekly weights, if resident gain/losses three or more pounds, reweigh, record both weights and notify MD/NP. Resident's weight record reviewed on 2/25/20 at 2:15 PM, revealed a 7.4% weight loss from December 24 through January 27 (12/24/19-113.2lbs, 1/1/20-109lbs, 1/7/20-108.1lbs, 1/14/20-104.8lbs, 1/14/20-105lbs, 1/21/20-106.2lbs, and [DATE]-104.8lb). Dietary notes reviewed on 2/25/20 at 2:15 PM revealed the following: On 12/31/19, the dietary manager (CDM) #2 adjusted Resident #23's diet per the resident's daughters' request. On 1/1/20, the resident's weight was down 3.7%, resident consuming 92% of the meal. The CDM #2 notes also said that (s/he) will recommend 90ml of sugar-free med pass twice a day. The resident's record indicated a weight loss of 4.2lbs (113.2lbs on 12/24/19 to 109lbs on 1/1/20). The resident was not reweighed, nor MD/NP notified. On 1/14/20, the resident's weight was down 2.[AGE]% (weight loss of 3.1lbs). CDM recommendation to increase med pass to 120ml twice per day. MD/NP not notified In an interview with the CDM #2 on 2/25/20 at 4:08 PM, (s/he) stated that on 12/31/19, during a care plan meeting, the resident's daughters were concern about (his/her) blood glucose level and wanted (him/her) to take some carbohydrates off resident's diet. In the interview, CDM #2 stated that (s/he) made the changes but listed them as dislike trying to please the resident's family. S/he did not consult the registered dietitian or the nurse practitioner. An interview with the consultant registered dietitian on 2/26/20 at approximately 11:00 AM, (s/he) stated that the CDM #2 did not talk with (him/her) before making changes to the resident's diet. In an interview with the NP on 2/26/20 at 10:13 AM, (s/he) stated that (s/he) does not agree or disagree with what the CDM did, but wished that (s/he) would have talked with (him/her) before making changes to resident's diet. In an interview with the director of nursing (DON) and the administrator on 2/27/20 at 12:55 PM, concerns regarding Resident #23's weight loss and diet changes were shared. The surveyor explained to the administrator and the DON that CDM #2 said that (s/he) took carbohydrates off the resident's diet without consulting the RD or NP, that (s/he) was trying to please the resident's family. The administrator and the DON acknowledge the concerns, and both stated they understood.",2020-09-01
739,MANNA REHABILITATION AND HEALTHCARE CENTER,425084,716 E CEDAR ROCK ST,PICKENS,SC,29671,2020-02-27,609,D,1,1,848R11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interviews, the facility failed to report an allegation involving abuse to the State Survey Agency within the required 2 hours after the allegation of abuse was made for 1 of 2 sampled residents reviewed for abuse. Resident #214 with an allegation of abuse being made known to the facility on [DATE] and the facility reported the allegation of abuse to the State Survey Agency on 7/29/19. The findings included: The facility admitted Resident #214 on [DATE] with [DIAGNOSES REDACTED]. A review of the facility's abuse investigation on 2/25/20 at approximately 9:36 AM and 2:47 PM revealed a written statement from Licensed Practical Nurse (LPN) #4 signed and dated on 7/29/19 that indicated he/she was informed on 7/27/19 at 6:55 AM by LPN#3 that Resident #214 family member was very upset because Resident #214 called him/her and reported that three (3) Certified Nursing Aides (CNAs) came in the resident's room and said nothing was wrong with him/her, go to the rest room and the CNAs just pulled his/her brief off. An interview on 2/25/20 at approximately 9:43 AM with the facility Administrator revealed he/she would be the person responsible for reporting and investigating allegations of abuse at the facility. Further review of the facility's investigation revealed the Director of Nursing (DON) interviewed the resident's daughter on 7/29/19 regarding the allegation of abuse per a signed signed and dated statement on 7/29/19. According to the Initial 24-Hour Report reviewed the incident was reported the administration on 7/29/19. An interview on 2/26/20 at approximately 8:37 AM with LPN #4 who confirmed his/her written statement revealed he/she was made aware of the allegation of abuse on 7/27/19. LPN #4 further stated the nursing staff was suspended for not reporting the allegation of abuse timely. An interview on 2/26/20 at 9:02 AM with LPN #3 revealed he/she could not recall the incident. There was no documentation in LPN #3 written statement to indicate when the alleged incident occurred. An interview on 2/27/20 at approximately 11:56 AM with the Assistant Administrator and Facility Consultants acknowledged the allegation of abuse was not reported to the State Survey Agency within the 2 hours requirement.",2020-09-01
740,MANNA REHABILITATION AND HEALTHCARE CENTER,425084,716 E CEDAR ROCK ST,PICKENS,SC,29671,2020-02-27,641,D,1,1,848R11,"> Based on interview and record review the facility failed to accurately assess 1 of 4 residents for fall risk. Resident #[AGE]'s 12/13/19 fall risk assessment was marked incorrectly for medications, resulting in the resident being marked as NOT a high risk for falls. The findings included: Review of Resident #[AGE] fall risk assessments on 2/25/20 at approximately 1:52 PM revealed the following: 1. On 8/13/19 and [DATE], the resident scored 12 (high risk for falls). 2. On 12/13/19, conducted immediately after a fall, the resident scored a 6 (NOT high risk for falls). 3. The 12/13/19 assessment was inconsistent with previous and following assessments. The resident was marked as only being on 1-2 fall risk medications, which was not the case with other assessments. Review of Resident #[AGE] December 2019 Medication Administration Record [REDACTED]. Interview with Registered Nurse #5 on 2/25/20 at approximately 2:35 PM confirmed the 1[DATE] assessment was inaccurate. S/he clarified that, based on his/her assessment, the score should have been 18 and not a 6, indicating a much higher risk for falls.",2020-09-01
741,MANNA REHABILITATION AND HEALTHCARE CENTER,425084,716 E CEDAR ROCK ST,PICKENS,SC,29671,2020-02-27,655,D,1,1,848R11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview the facility failed to develop a baseline care plan that included the minimum healthcare information necessary to properly care for Resident #212, 1 of 1 sampled residents reviewed with tracheostomies. Resident #212 was admitted with a [MEDICAL CONDITION] and this information was not included in the baseline care plan. In addition, the baseline care plan was not dated to indicate completion within 48 hours. The findings included: The facility admitted Resident #212 with [DIAGNOSES REDACTED]. Review of the baseline care plan, on 02/26/20 at 09:53 AM, revealed the resident's [MEDICAL CONDITION] status was not addressed and there were no interventions related to the care of the [MEDICAL CONDITION]. A section of the baseline care plan dedicated to [MEDICAL CONDITION] status was left blank. In addition, the section of the baseline care plan indicating date of completion was left blank. During an interview with Registered Nurse (RN) #1, on 2/26/20 at 10:44 AM, RN #1 confirmed the baseline care plan did not address the resident's [MEDICAL CONDITION] status. RN #1 also confirmed the base line care plan did not have a completion date or any other documentation to indicate completion within 48 hours. RN #1 stated the nurse that does the admission is supposed to complete the base- line care plan and include all necessary information to care for the resident. RN #1 stated the admission nurse should have included the resident's [MEDICAL CONDITION] status on the baseline care plan. RN #1 also stated the admission assessment has several care areas that, when checked, will flow over to the baseline care plan. The admission assessment was reviewed with RN #1 and there was no section dedicated to [MEDICAL CONDITION] status. The admitting nurse did write a note indicating the resident had a [MEDICAL CONDITION], however, RN #1 stated the notes do not flow over to the baseline care plan.",2020-09-01
742,MANNA REHABILITATION AND HEALTHCARE CENTER,425084,716 E CEDAR ROCK ST,PICKENS,SC,29671,2020-02-27,656,D,1,1,848R11,"> Based on observation and interview, the facility failed to implement accident precautions from the care plan for 1 of 4 residents reviewed for accidents. Resident #[AGE] was care planned for a pad alarm to bed which was observed missing during the survey. The findings included: Review of Resident #[AGE] Care Plan on 2/26/20 at approximately 11:47 AM revealed the resident was care planned for a pad alarm to bed on 1/20/20, following a fall with major injury and subsequent hospitalization . Observation of Resident #[AGE] on 2/26/20 at approximately 12 PM revealed the pad alarm was missing from the resident's bed. Interview with Licensed Practice Nurse #2 on 2/25/20 at approximately 12 PM confirmed the pad alarm had been ordered by the physician, and that it was missing from the bed of Resident #[AGE]. The nurse immediately corrected this, and the pad alarm was observed in place for the remainder of the survey.",2020-09-01
743,MANNA REHABILITATION AND HEALTHCARE CENTER,425084,716 E CEDAR ROCK ST,PICKENS,SC,29671,2020-02-27,686,D,1,1,848R11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and review of facility policy, the facility failed to provide care for 1 of 3 sampled residents reviewed with pressure ulcers. Staff failed to perform appropriate hand hygiene during wound care, in order to promote healing of Resident #63's pressure ulcer. The findings included: The facility admitted Resident #63 with [DIAGNOSES REDACTED]. Resident #63's wound was observed during wound care on 2/25/20 at 3:05 PM. Licensed Practical Nurse (LPN) #1 completed the wound care with Registered Nurse (RN) #2 present. LPN #1 was observed performing hand hygiene and donning clean gloves. LPN #1 then removed the soiled dressing from Resident #63's sacrum. LPN #1 disposed of the soiled dressing in the trash and removed her/his gloves. Without performing hand hygiene, LPN #1 donned clean gloves and cleaned the residents sacral wound with wound cleanser and gauze. LPN #1 then opened a [MEDICATION NAME] dressing and placed it on the resident's sacrum. During an interview with RN #2, on 2/27/20 at 9:45 AM, RN #2 confirmed LPN #1 removed the soiled dressing, removed her/his then dirty gloves and donned clean gloves without performing hand hygiene. RN #2 confirmed LPN #1 could have potentially contaminated the clean supplies used to clean the wound. In addition, RN #2 confirmed LPN #1 potentially contaminated the sacral wound by placing the [MEDICATION NAME] dressing without completing hand hygiene. RN #2 stated that after the wound care was completed, LPN #1 stated I think I missed something. RN #2 stated s/he told LPN #1 s/he did not wash her/his hands after handling the soiled dressing and removing her/his dirty gloves. RN #2 stated she re-educated LPN #2 on appropriate hand hygiene and wound care technique. During an interview with the Director of Nursing (DON), on 2/27/20 at 9:57 AM, the DON stated she was made aware of the lack of hand hygiene after the resident's wound care was completed. The DON confirmed a lack of hand hygiene during wound care has the potential to contaminate the wound and supplies used to clean the wound. The DON stated LPN #1 was re-educated on proper wound care technique and infection control practice during wound care. Review of the facility's Pressure Ulcer policy revealed after removing the soiled dressing from the wound, staff are to remove gloves and perform hand hygiene before donning clean gloves to clean the wound.",2020-09-01
744,MANNA REHABILITATION AND HEALTHCARE CENTER,425084,716 E CEDAR ROCK ST,PICKENS,SC,29671,2020-02-27,692,D,1,1,848R11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, and staff interview, the facility failed to provide adequate nutrition interventions to prevent significant weight loss in a resident at risk for altered nutrition/weight. Resident #23 had a weight decline since admission (9/10/19) and a considerable weight loss (7.4%) from December 24, 2019 (113.2lbs) to January 27, 2020 (104.8lbs) for one of three sampled residents reviewed for nutrition. Findings: Resident #23 was admitted to the facility with diagnoses, including but not limited to, Type 1 Diabetes, Acute Kidney Failure, Dementia, Muscle Weakness, and Cognitive Communication Deficit. During a lunch observation on 02/25/20 12:26 PM, the resident appeared to be enjoying (his/her) lunch. Reviewed (his/her) meal ticket, on 2/25/20 at 1:00 PM, revealed that (s/he) consumed 95% of the meal. The physician's orders [REDACTED].#23's diet as CCD (carbohydrate-controlled diet) mechanical soft texture related to diabetes and advance dysphagia. Weekly weights, if resident gain/losses three or more pounds, reweigh, record both weigh and notify MD/NP. Resident's weight record reviewed on 2/25/20 at 2:15 PM, revealed a 7.4% weight loss from December 24 through January 27 (12/24/19-113.2lbs, 1/1/20-109lbs, 1/7/20-108.1lbs, 1/14/20-104.8lbs, 1/14/20-105lbs, 1/21/20-106.2lbs, and [DATE]-104.8lb). Dietary notes reviewed on 2/25/20 at 2:15 PM revealed the following: On 12/31/19, the dietary manager (CDM) #2 adjusted Resident #23's diet per the resident's daughters' request. On 1/1/20, the resident's weight down 3.7%, resident consuming 92% of the meal. The CDM #2 notes also said that (s/he) will recommend 90ml of sugar-free med pass twice a day. The resident's record indicated a weight loss of 4.2lbs (113.2lbs on 12/24/19 to 109lbs on 1/1/20). The resident was not reweighed, nor MD/NP notified. On 1/14/20, the resident's weight went down 2.[AGE]% (weight loss of 3.1lbs). CDM #2 recommended increasing med pass to 120ml twice per day. MD/NP not notified. In an interview with the CDM #2 on 2/25/20 at 4:08 PM, (s/he) stated that on 12/31/19, during a care plan meeting, the resident's daughters were concern about (his/her) blood glucose level and wanted (him/her) to take some carbohydrates off resident's diet. In the interview, CDM #2 stated that (s/he) made the changes but listed them as dislikes trying to please the resident's family. S/he did not consult the registered dietitian or the nurse practitioner. An interview with the consultant registered dietitian on 2/26/20 at approximately 11:00 AM, (s/he) stated that the CDM #2 did not talk with (him/her) before making changes to the resident's diet. In an interview with the NP on 2/26/20 at 10:13 AM, (s/he) stated that (s/he) does not agree or disagree with what the CDM did, but wished that (s/he) would have talked with (him/her) before making changes to resident's diet. In an interview with the director of nursing (DON) and the administrator on 2/27/20 at 12:55 PM, concerns regarding Resident #23's weight loss and diet changes were shared. The surveyor explained to the administrator and the DON that CDM #2 said, in an interview, that (s/he) took carbohydrates off the resident's diet without consulting the RD or NP, that (s/he) was trying to please the resident's family. The administrator and the DON acknowledge the concerns, and both stated they understood.",2020-09-01
745,MANNA REHABILITATION AND HEALTHCARE CENTER,425084,716 E CEDAR ROCK ST,PICKENS,SC,29671,2020-02-27,812,F,1,1,848R11,"> Based on observation and staff interview, the facility failed to ensure kitchen staff handled cooked food appropriately during food temping and meal serving. Also, the facility did not ensure that the kitchen dishware were dried and stored according to standard practice and that the solution to sanitize surfaces contained the appropriate amount of sanitation concentration for one of one kitchen and one of one dining-room observed. Findings: During the initial dinning observation on 2/24/20 at 12:17 PM, the meal-server touched utensils, dishware, meal tickets, and refrigerator door and cornbread with the same gloved hands. On 2/25/20 at 12:16 PM, the same meal-server did the same. S/he, wearing the same gloves, grabbed meal tickets, dishware, fruit cup, and dinner roll. Certified Dietary Manager (CDM) #2 confirmed that the server did not handle cooked food properly. The server used the same gloved hands to touch several items, including meal tickets, and grabbed the dinner rolls and place them on the residents' plate. In a follow-up visit to the kitchen on 2/26/20 at 8:55 AM, one of one red bucket observed for sanitation did not contain the recommended sanitation concentration (did not see it being used). The food and nutrition services director did the testing. There were also three wet nesting containers (wet containers stocked-up on top of each other) During food temping, on 2/26/20 at 11:45 AM, the cook touched the last cooked food item, Salisbury- steak, with the same gloved hands she used during the entire temping process. S/he touched surfaces, utensils, thermometer and wipes, and the steak with the same gloved hands. The CDM #1 confirmed that (s/he) also observed the cook touching the meat with the same gloved hands.",2020-09-01
746,MANNA REHABILITATION AND HEALTHCARE CENTER,425084,716 E CEDAR ROCK ST,PICKENS,SC,29671,2020-02-27,842,D,1,1,848R11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record reviews and interviews, the facility failed to ensure that residents' medical records were accurately documented in the paper chart/electronic chart for 2 of 24 sampled residents reviewed. Resident #96 had another residents physician's orders [REDACTED]. Resident #214 had no documentation of a body audit being completed when an allegation of abuse/mistreatment was reported to the facility. The findings included: The facility admitted Resident #214 on [DATE] with [DIAGNOSES REDACTED]. A review of the facility's abuse investigation on 2/25/20 at approximately 9:36 AM and 2:47 PM revealed a written statement from Licensed Practical Nurse (LPN) #4 signed and dated on 7/29/19 that indicated he/she was informed on 7/27/19 at 6:55 AM by LPN#3 that Resident #214 family member was very upset because Resident #214 called him/her last night and reported that three (3) Certified Nursing Aides (CNAs) came in the resident's room said nothing was wrong with him/her, go to the rest room and the CNAs just pulled his/her brief off. Further review of LPN #4 witness statement revealed the resident's skin was checked and no areas were noted to brief area. A review of the medical record (paper/electronic) on 2/25/20 at approximately 3:15 PM revealed no documentation/body audits to indicate when a skin assessment was completed related to the allegations of abuse. An interview on 2/26/20 at approximately 8:37 AM with LPN #4 who confirmed his/her written statement. LPN #4 further stated he/she did not document a skin assessment/body audit being completed the date he/she was aware of the alleged abuse. A telephone interview on 2/26/20 at approximately 9:02 AM with LPN #3 revealed he/she could not recall the alleged incident of abuse and further stated he/she would have to check his/her progress notes to determine if he/she documented anything. LPN #3 stated sometimes he/she would have documented in his/her nurses' notes. LPN #3 stated he/she did not do a body audit when he/she was informed of the alleged incident regarding Resident #214. An interview on 2/27/20 at approximately 10:31 AM with Director of Nursing (DON) and Assistant Administrator revealed there was no documentation of a body audit being done at the time the facility staff was aware of the allegation of abuse. There was no documentation in nurses' notes from LPN #3 and #4. The DON did provide an incident report that indicated a body audit was done 7/29/19. The was no documentation of a body audit being done 7/27/19. The facility admitted Resident #96 on 8/27/15 with [DIAGNOSES REDACTED]. A review of the paper chart on 2/26/20 at approximately 11:15 AM revealed a physician's orders [REDACTED]. There was another physician's orders [REDACTED]. Further record review revealed the physician's orders [REDACTED].#96 paper chart were for another resident that was in the facility. An interview on 2/26/20 at approximately 11:48 AM with Registered Nurse (RN) #2 confirmed the documentation related to physician's orders [REDACTED].#96 and that the physician's orders [REDACTED]. RN #2 preceded to place the physician's orders [REDACTED].",2020-09-01
747,MANNA REHABILITATION AND HEALTHCARE CENTER,425084,716 E CEDAR ROCK ST,PICKENS,SC,29671,2020-02-27,880,D,1,1,848R11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and interview, facility staff failed to perform appropriate hand hygiene to provide a safe and sanitary environment for the residents. After completing wound care for Resident #63 (1 of 3 sampled residents reviewed for pressure ulcers), a staff member potentially contaminated multiple items in the room prior to completing hand hygiene. The findings included: The facility admitted Resident #63 with [DIAGNOSES REDACTED]. Resident #63's wound was observed during wound care on 2/25/20 at 3:05 PM. Licensed Practical Nurse (LPN) #1 completed the wound care with Registered Nurse (RN) #2 present. After completing the wound care, LPN #1 removed her/his gloves. LPN #1 touched a bottle of wound cleanser, then turned towards the sink. Before LPN #1 could wash her/his hands, RN#2 asked LPN #1 to get a clean brief so RN #2 could change the resident's brief. LPN #1 opened the resident's closet door, reached inside and removed a clean brief from the closet. LPN #1 then closed the closet door and handed the brief to RN #2. LPN #1 then washed her/his hands. During an interview with RN #2, on 02/27/20 at 10:55 AM, RN #2 confirmed LPN #2 did not perform hand hygiene after wound care prior to touching the above mentioned items. RN #2 stated those items had the potential to be contaminated based on the lack of hand hygiene.",2020-09-01
748,MANNA REHABILITATION AND HEALTHCARE CENTER,425084,716 E CEDAR ROCK ST,PICKENS,SC,29671,2017-09-28,157,D,1,1,DBE611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and interviews, the facility failed to immediately inform the resident's physician and the resident representative(s) when there was an accident involving the resident which resulted in possible injury and had the potential for requiring physician intervention. Resident #270, one of one resident sampled with an injury, had a fall resulting in a [MEDICAL CONDITION]. The physician nor the responsible party was contacted timely. Findings Include: On 09/27/2017 at approximately 1:30 PM, interview with Unit 100 Manager, RN. She/he stated that Certified Nursing Assistant (CNA #2) and Licensed Practical Nurse (LPN #1) saw Resident #270 at 2:30 on July 4, 2017 AM fall out of her/his wheelchair. CNA#1 came to help them get resident #270 off the floor and back to her/his bed. The RN stated Resident #270 is a sundowner (stay up all night and sleeps most of the day), and can independently scoot in her/his wheelchair and will wheel around unit 100 during the night. At the time of the fall, the family nor doctor were notified by LPN #1. Review of Nurse's notes on 9/27/2017 revealed that about 5 PM on 7/4/2017 Resident #270 was found in bed with purple discoloration noted to left hip. Physician order [REDACTED]. When the Manager interviewed the nurse during the investigation, the nurse denied that the incident happened. When the manager interviewed the CNAs, she discovered that the resident had fallen and that the nurse was aware and failed to notify anyone. The facility terminated the Nurse involved and notified the State Nursing bureau.",2020-09-01
749,MANNA REHABILITATION AND HEALTHCARE CENTER,425084,716 E CEDAR ROCK ST,PICKENS,SC,29671,2018-11-16,692,D,0,1,RVU611,"Based on interview and observation the facility failed to ensure the resident was offered and ordered a therapeutic diet for 1 of 3 residents reviewed for nutrition. Resident #68 was ordered a renal diet but his/her meal did not reflect information on the meal card. The findings included: Review of care plan for resident #68 on 11/15/18 at approximately 10:14 AM revealed altered nutrition/hydration status with diets/liquids as ordered. Review of orders for resident #68 on 11/15/18 at approximately 10:29 AM revealed a controlled carbohydrate, renal diet with regular texture and fluids. Observation of dining for resident #68 on 11/15/18 at approximately 1:23 PM revealed the meal ticket did not match the resident's meal. The meal ticket was for hamburger steak and gravy with noodles and a sugar cookie, but the resident received an egg salad sandwich with potato chips. This was confirmed in interviews with a Registered Nurse and a Licensed Practical Nurse. Interview with the Certified Dietary Manager on 11/15/18 at approximately 1:40 PM revealed the kitchen manager had made an error with the meal tray for resident #68.",2020-09-01
750,MANNA REHABILITATION AND HEALTHCARE CENTER,425084,716 E CEDAR ROCK ST,PICKENS,SC,29671,2018-11-16,760,D,0,1,RVU611,"Based on observations, interview, and review of the Humulog KwikPen manufactures 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 #2 on the Transitional Care Unit (TCU). The findings included: On 11/13/18 at approximately 4:00 PM, during an observation of Resident #2's medication administration on the TCU hall, Licensed Practical Nurse (LPN) #1 checked Resident #2's Blood Sugar (BS) which was 309. LPN #1 reviewed the Medication Administration Record [REDACTED]. LPN #1 prepared the Humalog KwikPen for administration by attaching the needle, and without priming the Humalog KwikPen, selected 12 units on the Humalog KwikPen Dose Knob dial and administered the insulin to Resident #2. During an interview immediately following Resident #2's Humolog KwikPen injection, LPN #1 verified s/he did not prime the KwikPen and was asked, if s/he was trained to prime the insulin pen? LPN #1 stated, Yes, but I forgot. Review of the Humolog KwikPen manufactures recommendations reveals under, Priming your Humalog KwikPen: 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. Also, under Preparing your pen, states, Step 1: Pull the Pen Cap straight off. - Do not remove the Pen Label. Wipe the Rubber Seal with an alcohol swab. Step 2: Check the liquid in the Pen. HUMALOG should look clear and colorless. Do not use if it is cloudy, colored, or has particles or clumps in it. Step 3: Select a new Needle. Pull off the Paper Tab from the Outer Needle Shield. Step 4: Push the capped Needle straight onto the Pen and twist the Needle on until it is tight. Step 5: Pull off the Outer Needle Shield. Do not throw it away. Pull off the Inner Needle Shield and throw it away. Priming your Pen Prime before each injection. Priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. Step 6: To prime your Pen, turn the Dose Knob to select 2 units. Step 7: Hold your Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top. Step 8: Continue holding your Pen with Needle pointing up. Push the Dose Knob in until it stops, and 0 is seen in the Dose Window. Hold the Dose Knob in and count to 5 slowly. You should see insulin at the tip of the Needle. - If you do not see insulin, repeat priming steps 6 to 8, no more than 4 times. - If you still do not see insulin, change the Needle and repeat priming steps 6 to 8. Small air bubbles are normal and will not affect your dose.",2020-09-01
751,MANNA REHABILITATION AND HEALTHCARE CENTER,425084,716 E CEDAR ROCK ST,PICKENS,SC,29671,2018-11-16,761,D,0,1,RVU611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and review of the manufactures recommendations, the facility failed to follow a procedure to ensure that expired medication was removed in 1 of 3 medication storage rooms. Expired [MEDICATION NAME] Purified Protein Derivative (PPD) (Mantoux) medication was in the Station 2 unit medication storage room refrigerator. The findings included: On [DATE] at approximately 9:30 AM, an observation of the medication refrigerator on the Station 2 unit with Licensed Practical Nurse (LPN) #2 revealed (1) 1 milliliter (ml), 10 test, vial of PPD (Lot # 9) which was opened (,[DATE] remaining) with a hand written puncture date of [DATE]. On [DATE] at approximately 9:35 AM, during an interview with LPN #2, s/he verified the PPD was considered expired and indicated the PPD should have been removed from storage. Review of the [MEDICATION NAME] Purified Protein Derivative (PPD) (Mantoux) packet insert manufactures recommendations states under Storage, Vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency.",2020-09-01
752,PRUITTHEALTH-ORANGEBURG,425085,755 WHITMAN STREET SE,ORANGEBURG,SC,29115,2017-05-25,280,D,0,1,SDDF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews, and review of the facility's policy entitled, Care Plan, the facility failed to include the Certified Nursing Assistant in the care plan meeting process for 5 out of 21 reviewed for care plan participation. Resident # 26, #36, #69, #70, and #104. The findings included: The facility admitted Resident # 26 with [DIAGNOSES REDACTED]. During record review of Resident #26's care plan on 05/23/17 at 04:23 PM revealed, Multidisciplinary Care Conference Meeting sheet for 4/14/17 no documentation of the Certified Nursing Assistant attending the care plan meetings. The facility admitted Resident # 69 with [DIAGNOSES REDACTED]. During record review of Resident #69's care plan on 05/24/17 at 10:16 AM revealed, Multidisciplinary Care Conference Meeting sheet for 1/12/17 and 4/7/17 no documentation of the Certified Nursing Assistant attending the care plan meetings. The facility admitted Resident # 36 with [DIAGNOSES REDACTED]. During record review of Resident #36's care plan on 05/24/17 at 10:23 AM revealed, Multidisciplinary Care Conference Meeting sheet for 3/24/17 with no documentation of the Certified Nursing Assistant attending the care plan meetings. The facility admitted Resident # 104 with [DIAGNOSES REDACTED]. During record review of Resident #104's care plan on 05/24/17 at 11:32 AM revealed, Multidisciplinary Care Conference Meeting sheet for 12/14/17 and 3/10/17 with no documentation of the Certified Nursing Assistant attending the care plan meetings. The facility admitted Resident # 70 with [DIAGNOSES REDACTED]. During record review of Resident #70's care plan on 05/24/17 at 2:58PM revealed, Multidisciplinary Care Conference Meeting sheet for 3/16/17 with no documentation of the Certified Nursing Assistant attending the care plan meetings. During an interview with Case Mix Coordinator on 05/25/17 at 8:57 AM, he/she confirmed the Certified Nursing Assistant did not attend the care plan meeting. During an interview with Case Mix Director on 05/25/17 at 9:10 AM, he/she confirmed the Certified Nursing Assistant did not attend the care plan meetings. He/she is aware the Certified Nursing Assistant are to attend the care plan meeting. Review of the facility's policy revised on 11/21/16 entitled, Care Plan on 05/25/17 at 10:03 AM, Procedure #5 The Interdisciplinary Team members includes a Registered Nurse, Licensed Practical Nurse (LPN) Charge Nurse, Certified Nursing Assistant (CNA) . and other appropriate partner as determined by the patient/resident's needs.",2020-09-01
753,PRUITTHEALTH-ORANGEBURG,425085,755 WHITMAN STREET SE,ORANGEBURG,SC,29115,2017-05-25,282,D,0,1,SDDF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and review of the facility policy entitled [MEDICAL TREATMENT] Care Pre and Post [MEDICAL TREATMENT], the facility failed to follow the comprehensive care plan related to monitor access site for [MEDICAL TREATMENT] Resident #70. The findings included: The facility admitted Resident #70 with [DIAGNOSES REDACTED]. Review of the Care Plan dated 3/1/17 on 5/24/17 at 2:58 PM for Resident #70 revealed Monitor shunt daily, report any abnormalities to Medical Doctor (MD). Further review on 5/24/17 at 3:07 PM of the nurse's notes and treatment records revealed no documentation for the month of (MONTH) (YEAR) through (MONTH) (YEAR) to ensure monitoring shunt daily per the care plan. During an interview on 5/24/17 at 3:51 PM with Licensed Practical Nurse (LPN) # 1 surveyor asked, Where would the staff document the access site for the [MEDICAL TREATMENT] resident? He/she stated It would be documented on the Medication Administration Record (MAR). He/she confirmed that the shunt is not being monitored on a daily. During an interview on 5/25/17 at 12:30 PM with the Director of Nursing (DON) surveyor asked, What the procedure is for when a resident returns from [MEDICAL TREATMENT]. He/she stated, Do vital signs and check the access site. He/she also stated vitals and access site check are documented in MARS or nurses notes. He/she confirmed there is no documentation of monitoring the access site. During review of the facility's Policy entitled [MEDICAL TREATMENT] Care-Pre- and Post-[MEDICAL TREATMENT] under Special Condition Monitor vascular integrity distal to the shunt sites.",2020-09-01
754,PRUITTHEALTH-ORANGEBURG,425085,755 WHITMAN STREET SE,ORANGEBURG,SC,29115,2017-05-25,309,D,0,1,SDDF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and staff interviews the facility failed to provide care and services for assessing the AV shunt site for [MEDICAL TREATMENT] resident #70, 1 of 1 resident sampled for [MEDICAL TREATMENT]. The findings included: The facility admitted Resident #70 with [DIAGNOSES REDACTED]. Review of the Care Plan dated 3/1/17 on 5/24/17 at 2:58 PM for Resident #70 revealed Monitor shunt daily, report any abnormalities to Medical Doctor (MD). Further review on 5/24/17 at 3:07 PM of the nurse's notes and treatment records revealed no documentation for the month of (MONTH) (YEAR) through (MONTH) (YEAR) to ensure the monitor shunt daily per the care plan. During an interview on 5/24/17 at 3:51 PM with Licensed Practical Nurse (LPN) # 1 surveyor asked, Where would the staff document the access site for the [MEDICAL TREATMENT] resident? He/she stated Would it would be documented on the Medication Administration Record (MAR). He/she confirmed that the shunt is not being monitor on a daily. During an interview on 5/25/17 at 12:30 PM with the Director of Nursing (DON) surveyor asked, What the procedure is for when a resident returns from [MEDICAL TREATMENT]. He/she stated, Do vital signs and check the access site. He/she also stated vitals and access site check are documented in MARS or nurses notes. He/she confirmed there is no documentation of monitoring the access site. During review of the facility's Policy entitled [MEDICAL TREATMENT] Care-Pre- and Post-[MEDICAL TREATMENT] under Special Condition Monitor vascular integrity distal to the shunt sites.",2020-09-01
755,PRUITTHEALTH-ORANGEBURG,425085,755 WHITMAN STREET SE,ORANGEBURG,SC,29115,2018-08-22,623,B,0,1,MIO811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to provide written notice of transfer to 5 of 5 residents reviewed for hospitalization . The findings included; During record review on 8/21/2018 at approximately 1:35 PM, it was noted by this surveyor that Resident # 43 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the medical record revealed s/he was ordered by the Physician to be sent out to The Regional Medical Center on 5/6/2018 due to [MEDICAL CONDITION] activity. The resident was then admitted and discharged back to the facility on [DATE]. Additional review indicated Resident #43 was ordered to be sent out to The Regional Medical Center on 5/30/2018 for [MEDICAL CONDITION] activity and decreased right side movement. S/he was then admitted and returned to the facility on [DATE]. Upon review of the Nursing Notes and Social Services Notes, it was indicated there had not been any documentation of the written notice of transfer being provided to the resident and/or their representative at the time of discharge. Other findings included; during record review on 8/21/18 at approximately 3:15 PM, it was noted that Resident #53 was ordered to be sent to the hospital on [DATE] for an evaluation. S/he was then admitted and returned back to the facility on [DATE]. There was no documentation of the written notice of transfer being provided to the resident or their Representative upon transfer. Additionally, Residents # 56 and 73 were also sent out with no written documentation of being provided with the written notice of transfer. An interview with the Administrator on 8/22/2018 verified the Resident's representatives are notified at the time of transfer, however, a written notice was not being provided at the time of transfer. The facility admitted Resident #73 on 05/07/10 with [DIAGNOSES REDACTED]. On 08/20/18 review of the nurses' notes revealed the resident was hospitalized from [DATE] until 07/23/18. There was no documentation that the facility provided a written notice of transfer to the resident or resident's representative at the time of the transfer. During an interview at 3:00 PM on 08/21/2018, the Nursing Home Administrator (NHA) confirmed no written notices of transfer were being provided and stated that the facility had been unaware of the requirement until 08/21/18 when the corporate Nurse Consultant informed the NH[NAME]",2020-09-01
756,PRUITTHEALTH-ORANGEBURG,425085,755 WHITMAN STREET SE,ORANGEBURG,SC,29115,2018-08-22,625,B,0,1,MIO811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to provide the bedhold policy with payment information to 5 of 5 residents reviewed for hospitalization . The findings included; During record review on 8/21/2018 at approximately 1:35 PM, it was noted by this surveyor that Resident # 43 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the medical record revealed s/he was ordered by the Physician to be sent out to The Regional Medical Center on 5/6/2018 due to [MEDICAL CONDITION] activity. The resident was then admitted and discharged back to the facility on [DATE]. Additional review indicated Resident #43 was ordered to be sent out to The Regional Medical Center on 5/30/2018 for [MEDICAL CONDITION] activity and decreased right side movement. S/he was then admitted and returned to the facility on [DATE]. Upon review of the Nursing Notes and Social Services Notes, it was indicated there had not been any documentation of the bedhold policy being provided to the resident and/or their representative at the time of discharge. Other findings included; during record review on 8/21/18 at approximately 3:15 PM, it was noted that Resident #53 was ordered to be sent to the hospital on [DATE] for an evaluation. S/he was then admitted and returned back to the facility on [DATE]. There was no documentation of the bedhold policy being provided to the resident or their Representative upon transfer. Additionally, Residents # 56 and 73 were also sent out with no written documentation of being provided with the bedhold policy. An interview with the Administrator on 8/22/2018 verified the bedhold policy is signed upon admission, however, the facility was unaware that it was to be given at the time of transfer. The facility admitted Resident #73 on 05/07/10 with [DIAGNOSES REDACTED]. On 08/20/18 review of the nurses' notes revealed the resident was hospitalized from [DATE] until 07/23/18. There was no documentation that the facility provided a copy of the bed hold policy to the resident or resident's representative at the time of the transfer. During an interview at 3:00 PM on 08/21/2018, the Nursing Home Administrator (NHA) stated the facility provided the bed hold policy at the time of admission. The NHA confirmed the facility had not been providing the bed hold policy at the time of a resident's transfer but had started providing it last week. The NHA also confirmed there was no documentation that the bed hold policy was being provided to the resident or resident's representative.",2020-09-01
757,PRUITTHEALTH-ORANGEBURG,425085,755 WHITMAN STREET SE,ORANGEBURG,SC,29115,2018-08-22,761,D,0,1,MIO811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that expired medications were removed from the treatment cart and disposed of on 1 of 1 treatment cart reviewed. The findings included: On 08/22/18 at 09:07 AM, review of the treatment cart revealed a tube of [MEDICATION NAME] 2% with an expiration date of February, (YEAR). Review of the pharmacy label revealed the medication was filled 07/09/18. Further review revealed a notation to Discard after 05/08/19. During an interview at the time of the review, Licensed Practical Nurse (LPN) #1 confirmed the expiration date was February, (YEAR) and that the medication was expired. The LPN also confirmed the medication label indicated the medication was filled on 07/09/18 and that the medication should be discarded after 06/08/19. The LPN stated the Pharmacist was just here and that the pharmacist comes to the facility monthly and that the nurses check the carts weekly.",2020-09-01
758,"LORIS REHAB AND NURSING CENTER, LLC",425086,3620 STEVENS STREET,LORIS,SC,29569,2018-11-16,759,E,0,1,EI3H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interview, and review of the facility policy titled Gastrostomy/PEG Tube Medication Administration, the facility failed to maintain a medication rate of less than 5%. There were 6 errors out of 35 opportunities for error, resulting in a medication error rate of 17.14%. The findings included: ERROR #1-5: Observation of Licensed Practical Nurse(LPN)#1 on 11/15/18 at 11:40 AM revealed s/he crushed [MEDICATION NAME] NA 100 milligrams(mgs), [MEDICATION NAME] 5 mgs, ASA chew 81 mgs, [MEDICATION NAME] 20 mgs, and Vitamin C 500 mgs. After crushing the medications, the crushed medications were mixed with water and administered through a gastrostomy tube. After administering the medications to Resident #79, LPN #1 was asked to show the cup to the surveyor. Residual medication was observed in the bottom of the cup. At the time of the observation, LPN #1 confirmed there was residual in the bottom of the cup. LPN #1 added more water to the the cup several times to ensure all the medication was administered. ERROR #6: During reconciliation, Resident #79 had a current physician's order for [MEDICATION NAME] 220 mgs/5 mls administer 7 mls in which LPN #1 did not administer during the medication pass observed. Review of the facility policy titled Gastrostomy/PEG Tube Medication Administration did not address ensuring all crushed residual medication to be given.",2020-09-01
759,WHITE OAK MANOR - ROCK HILL,425088,1915 EBENEZER RD,ROCK HILL,SC,29732,2017-06-22,275,B,0,1,RY7411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to complete the yearly Minimal Data Set Assessment (MDS) (366 days) as required with Resident #57 for 1 of 17 reviewed for comprehensive assessment. The findings included: The facility admitted Resident # 57 with [DIAGNOSES REDACTED]. During the review of the MDS Assessment on 6/21/17 at 3:53 PM revealed the MDS assessment with Assessment Reference Date (ARD) 5/10/16 Assessment type yearly. The most recent assessment was completed with ARD 4/26/17 with Assessment Type Quarterly. No yearly assessment was found in the data base. During an interview on 6/22/17 at 10:19 AM, MDS Coordinator # 2 confirmed that the yearly assessment was not completed and that instead of the quarterly statement that was completed on 4/26/17 it should have been the yearly.",2020-09-01
760,WHITE OAK MANOR - ROCK HILL,425088,1915 EBENEZER RD,ROCK HILL,SC,29732,2017-06-22,278,D,0,1,RY7411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to assure that 2 of 2 residents reviewed for dental status received accurate assessments. The Findings included: Review of Medical record conducted on 6/20/2017 revealed that Resident #28 was admitted to the facility with [DIAGNOSES REDACTED]. Observation of Resident #28 during all days of the survey (6/19/17-6/22/17) revealed that s/he was edentulous and did not have any upper or lower dentures that were worn during these dates. Record Review of Resident #28's Annual Comprehensive Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 10/27/16 on 6/20/17 revealed Section L (Oral/Dental Status) item L0200B (Dental: no natural teeth or tooth fragment(s)) was not checked and item L0200Z (Dental: none of the above) was checked. Review of PROHEALTH Dental personal consent letter dated 5/31/16 revealed a hand written notation that Resident #28 had no teeth or dentures. During interview with RN#1 and LPN#3 on 6/20/17 at 4:00 PM, when asked if Resident #28 had any natural teeth or if s/he was edentulous, both replied that Resident #28 was edentulous and did not have upper or lower dentures. When LPN#3 was asked how long s/he had been caring for Resident #28, s/he replied for at least a year. Additionally, when asked if s/he could recall how long Resident #28 had been edentulous, s/he replied I don't recall her/him ever having teeth or wearing dentures. During interview with MDS Nurse #1 on 6/20/17 at 4:50 PM, s/he verified that item L0200Z (none of the above) was checked on comprehensive MDS with ARD of 10/27/16. Upon further discussion regarding observed oral dental status and direct care staff interviews that identified Resident #28 as being edentulous for at least a year, MDS Nurse #1 agreed that Oral/ Dental status was incorrectly coded, and L0200B (no natural teeth or tooth fragment(s)-edentulous) should have been checked instead of L0200Z (none of the above) on the Comprehensive MDS with ARD of 10/27/16. Review of the medical record conducted on 6/20/17 revealed that Resident #101 was admitted to the facility with the [DIAGNOSES REDACTED]. Record Review of Resident #101's Annual Comprehensive Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 3/23/17 on 6/20/17 revealed Section L (Oral/Dental Status) item L0200D (Dental: Obvious or likely cavity or broken natural teeth) was not checked and item L0200Z (Dental: none of the above) was checked. Observation of oral cavity/ dental status check of Resident #101 by LPN #4 on 6/21/17 at 1:34 PM revealed that there were some broken/ chipped natural teeth present. Nursing note on 6/21/17 at 1:47 has this oral cavity inspection documented where resident is noted to have greater than 4 teeth with some chipping on teeth. During interview with MDS Nurse #1 on 6/20/17 at 4:50 PM, s/he verified that item L0200Z (none of the above) was checked on Resident #101's comprehensive MDS with ARD of 3/23/17. Additional discussion with MDS Nurse on 6/21/17 at 1:45 PM related to the results of oral cavity/ dental status check conducted by LPN #4 on 6/21/17 at 1:34 PM. MDS #1 agreed that Oral/ Dental status was incorrectly coded as none of the above on the comprehensive MDS with ARD of 3/23/17, and L0200D (Dental: Obvious or likely cavity or broken natural teeth) should have been checked instead of L0200Z (none of the above).",2020-09-01
761,WHITE OAK MANOR - ROCK HILL,425088,1915 EBENEZER RD,ROCK HILL,SC,29732,2017-06-22,312,D,0,1,RY7411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interview the facility failed to assess dental status/ oral status and provide oral care for one of two resident's reviewed for dental status. Resident #101 has dysphagia and is allowed nothing by mouth with dependence Percutaneous Endoscopic Gastrostomy (PEG) tube for all nutrition and hydration with recurrent episodes of thrush that required antibiotic interventions in past 60 days. There is no evidence in medical record to reflect routine oral assessment or oral care provided on a consistent basis for Resident #101. The Findings Included: The facility admitted Resident #101 with [DIAGNOSES REDACTED]. Review of medical record on 6/21/17 revealed that there was no evidence to show that oral assessments were routinely conducted or that regular oral care was provided for Resident #101 on routine basis. Review of telephone order dated 4/11/17 revealed orders for [MEDICATION NAME] oral swabs and [MEDICATION NAME] to be administered via PEG tube for [DIAGNOSES REDACTED]. Further review reveals telephone order written on 5/31/17 to initiate a 7 day course of [MEDICATION NAME] to be swabbed in oral cavity to treat [DIAGNOSES REDACTED]. Further review of medical record on 6/20/17 revealed nursing notes for (MONTH) (YEAR) to current with intermittent episodes where resident needs assistance with oral care; however there is no evidence that oral status is assessed or that oral care is provided on a regular basis. Record reflects that resident is dependent on staff for all aspects of care and is NPO with all nutrition and hydration provided via PEG tube. Additional review medical record on 6/20/17 revealed a comprehensive care plan that did not address routine oral assessment or oral care as a part of any problem statements, goals, or interventions. Further review of care plan revealed that recurrent episodes of oral candidiasis or thrush in (MONTH) and (MONTH) (YEAR) were not included with any updates that were made to care plan. During interview on 6/21/17 at 1:34 PM, LPN #4 reviewed care plan for Resident #101 and verified that neither oral assessment nor oral care were addressed anywhere on pages 1-17 of 17 as a part of problem statements, goals, or interventions. When asked if s/he ever personally performed oral care or assessed oral status of Resident #101, LPN #4 replied yes, when I am a floor nurse, when we do her [DEVICE] (meaning provide water flushes as ordered), we do her mouth care. When asked where oral assessment or care is documented in the medical record, LPN #4 stated that it is just a standard of care, we do oral care on everybody. We don't document the oral care. Additional interview with LPN # 1 on 6/21/17 at 2:25 PM revealed that s/he was not aware of anywhere where oral care is documented in the record. When MDS Nurse #1 was asked during interview on 6/21/17 at 1:47 PM to identify where oral care is located on Resident #101's care plan, s/he replied I don't see it on here, but I did a lot of updates on her this morning. When asked to show where the care plan was updated to reflect the recurrent episodes of oral candidiasis that occurred on 4/11/17 and 5/31/17, s/he replied I am working on her now. When asked if the care plan should have been updated after the orders for treatment for [REDACTED]. When MDS Nurse #1 was asked with two episodes of thrush/ oral candidiasis in two months, would s/he be at risk for recurrence of this? s/he replied, This is an area that would be considered for care planning. S/he is under review now, and this will be reviewed and addressed.",2020-09-01
762,WHITE OAK MANOR - ROCK HILL,425088,1915 EBENEZER RD,ROCK HILL,SC,29732,2018-09-20,692,D,0,1,X7WY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review the facility failed to follow orders related to nutrition for 1 of 4 residents reviewed for nutrition. Resident #91 was ordered for nutritional supplements which were not given, and the resident was also ordered for no straws with drinks which was not followed. The findings included: Resident #91 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of care plan for resident #91 on 9/19/18 at approximately 9:22 AM revealed the resident was care planned to have no straws with meals and to have supplements as ordered. Review of orders for resident #91 on 9/19/18 at approximately 9:33 AM revealed the following: 1. an order for [REDACTED].>2. and an order for [REDACTED].>3. an 8/16/18 order to hold meds while in [MEDICAL TREATMENT] 4. an 8/27/18 order clarifying that only metaclopromide and calcium acetate are to be held in [MEDICAL TREATMENT] Review of medication administration records (MARs) for resident #91 at approximately 10:37 AM revealed the following: 1. 8/28/18 high protein liquid 30 milliliters was not administered because the resident was unavailable 2. 9/5/18 high protein liquid 30 milliliters was not administered because the resident was unavailable Observation of resident #91 on 9/19/18 at approximately 12:45 PM revealed the resident was using a straw contrary to meal card. Interview with director of nursing (DON) on 9/19/18 at approximately 1:10 PM confirmed that only calcium acetate and metoclopromide were to be held when the resident was at [MEDICAL TREATMENT]. Review of nutrition notes for resident #91 on 9/19/18 at approximately 1:17 PM confirmed no straws. Review of speech therapy plan of care dated 8/13/18 on 9/19/18 at approximately 1:31 PM confirmed no straws. Interview with speech therapist #1 on 9/20/18 at approximately 10:05 AM confirmed that speech recommended against use of straws for resident #91 due to risk of aspiration. S/he stated the resident requests straws and staff honors her choices but educates her on aspiration risks. The speech therapist stated s/he never reassessed the resident with regards to preferences for straws despite aspiration risk and stated, S/he's not safe with straws and s/he knows it. Interview with registered dietitian on 9/20/18 at approximately 10:27 AM revealed the dietitian was unaware of resident preference for straws. S/he spoke with the resident on 8/8/18 about diet and straws did not come up. If the resident had expressed a preference for straws, the dietitian would have contacted speech therapy to reassess the resident.",2020-09-01
763,WHITE OAK MANOR - ROCK HILL,425088,1915 EBENEZER RD,ROCK HILL,SC,29732,2018-09-20,908,E,0,1,X7WY11,"Based on observation and interview the facility failed to keep essential equipment in safe operating condition in 1 of 1 main laundry areas. Dryer vents in the laundry room were not cleaned of lint presenting a potential fire hazard. The findings included: Observation of laundry room on 9/19/18 at approximately 12:20 PM revealed a film of lent on dryer vents for all three dryers. This was confirmed by the environmental director, and it was cleaned. Interview with environmental director on 9/19/18 at approximately 12:20 PM revealed there was no policy or logs with regards to cleaning dryers but it was policy to clean dryer vents after loads were finished. Observation of laundry room on 9/20/18 at approximately 8:48 AM revealed a film of lint on dryer vents for two dryers. The third dryer against the wall on the right had been pieces of lint as if it had been cleaned recently but not completely. This was confirmed by the environmental director, and it was cleaned.",2020-09-01
764,WHITE OAK MANOR - YORK,425089,111 SOUTH CONGRESS STREET,YORK,SC,29745,2017-05-05,309,D,0,1,V3W111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, standing physician orders [REDACTED]. Resident #53 had physician orders [REDACTED]. This was obtained after a second successful attempt from an in and out catheterization of the resident. Upon investigation it was found the facility did not have standing orders for in and out catheterization and no order was available from the physician. The Findings included: The facility admitted Resident #53 0n 8/18/2016 with the [DIAGNOSES REDACTED]. Review of the medical record for Resident #53 on 5/3/17 at 11:00 AM revealed a Physician's Telephone Order dated 8/19/16 for Urinalysis, Culture and Sensitivity (UA/ C&S) with corresponding urine culture final report with draw date listed as 8/29/16 at 8:14 AM which identified the source of the urine sample as I/O CATH indicating in-and-out catheterization was performed. Further review revealed nursing notes on 8/23/16 and 8/24/16 that reveal nurses attempted x2 (with success on 2nd attempt done on 8/24/16) in and out catheterization to obtain urine sample. Review of routine standing Physician orders [REDACTED]. During interview on 5/4/17 at 3:25 PM the Director of Nursing (DON) verified that there was not an order specifically written to obtain the urine sample via in and out catheter for the tests ordered on [DATE]. Further review of the medical record revealed that there was no active order in place for resident #53 when the invasive method of obtaining a urine sample via in-and-out catheterization was attempted on 8/23/16 and successfully performed on 8/24/2016. DON further verified that there is no mention of in-and-out urinary catheterization on the routine physician standing orders signed for Resident #53 on 8/19/16.",2020-09-01
765,WHITE OAK MANOR - YORK,425089,111 SOUTH CONGRESS STREET,YORK,SC,29745,2017-05-05,315,D,0,1,V3W111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on perineal care observation, facility policy, and interview the staff provided improper perineal care to Resident # 39. The Certified Nursing Assistant observed did not separate the labia to clean and did not change the towelette when cleaning the rectal area. ( 1 of 5 residents reviewed for unnecessary drugs.) The findings included: The facility admitted Resident # 39 with [DIAGNOSES REDACTED]. On 5/4/17 at 2:53 PM CNA # 3 ( Certified Nursing Assistant ) was observed to do perineal care on this resident. The CNA knocked, entered room, explained procedure, closed blinds, closed door, and pulled privacy curtain around resident. The assistant prepared the resident for the procedure while CNA #3 obtained towelette, washed hands, and donned gloves. The CNA correctly wiped down right side and left side of perineum. The CNA then with new towelette wiped down the middle without separating the labia. The resident was then turned to left side to clean the rectal area. The CNA cleaned from front to back down right side and disposed of wipe. CNA took new wipe and cleaned front to back down left side, getting some stool on wipe. Without changing wipe the CNA cleaned down the middle over the rectal area. Removed gloves, disposed of wipe, washed hands, and put residents clothes back on. Prepare to get resident up to take to bathroom. CNA left the building immediately. Interview done with LPN #2 (Licensed Practical Nurse) at 3:10 PM 5/4/17. The LPN reviewed the facility policy which documented should: Separate labia and hold open while cleaning down center. # 10 on facility policy & procedure states Using a clean towelette for each stroke, cleanse rectal area without re-contaminating perineal area. The RN stated he/she would have expected the CNA to follow the policy for perineal care. This resident has had numerous Urinary Tract Infections in the last six months.",2020-09-01
766,WHITE OAK MANOR - YORK,425089,111 SOUTH CONGRESS STREET,YORK,SC,29745,2017-05-05,329,E,0,1,V3W111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews, and review of the facility's policy entitled Guidelines for Antipsychotic/Anxiolytic Documentation, the facility failed to provide interventions for 1 of 5 residents reviewed for Unnecessary Medications. Resident #130 did not receive interventions prior to given [MEDICATION NAME] and [MEDICATION NAME]. The findings included: The facility admitted Resident # 130 with [DIAGNOSES REDACTED]. On 05/04/17 at 10:09 AM review of the physician's orders [REDACTED]. [MEDICATION NAME] 2 milligram/milliliters (mg/ml) (Oral Concentration administer .25ml (equal .5mg) by mouth every 8 hours as needed. [MEDICATION NAME] 2 mg/ml give .25ml (.5mg) by mouth every 8 hours prn when cooperative. Review of (MONTH) (YEAR) through (MONTH) (YEAR) Medication Administration Record [REDACTED] During the month of (MONTH) (YEAR) on 2/15/17, 02/17/17, 02/18/17, and 02/23/17 [MEDICATION NAME] .5 mg was administered with no interventions. During the month of (MONTH) (YEAR) on 03/01/17, 03/07/17, 03/09/17, 03/10/17, 03/11/17, 03/15/17, 03/17/17, 03/21/17 [MEDICATION NAME] .5 mg was administered; 03/23/17 [MEDICATION NAME] 2mg/ml was administered, and 03/31/17 [MEDICATION NAME] 2mg/ml oral concentration was administered with no interventions. During the month of (MONTH) (YEAR) on 04/03/17, 04/05/17, 04/06/17, 04/08/07, 04/11/17, 04/13/17, 04/26/17, 04/28/17, and 04/29/17 [MEDICATION NAME] 2 mg/ml oral concentration was administered with no interventions. During the month of (MONTH) (YEAR) on 05/03/17 [MEDICATION NAME] 2 mg/ml oral concentration was administered with no interventions. Further record review on 05/04/17 at 11:48 AM revealed no documentation in the nurse's notes no interventions were used prior to administering the [MEDICATION NAME] and [MEDICATION NAME] during (MONTH) (YEAR) through (MONTH) (YEAR). During an interview with the Licensed Practical Nurse#2 on 05/05/17 at 10:26 AM, the surveyor asked the procedure for handling a resident that is combative prior to given as needed medication. LPN #2 stated would try to decrease stimuli, offer snacks, or do one on one with residents that are showing behaviors prior to administering [MEDICAL CONDITION] medications. LPN# 2 reviewed the medical administration records for the month of (MONTH) (YEAR) through (MONTH) (YEAR) and confirmed [MEDICATION NAME] and [MEDICATION NAME] was given prior to using interventions. During an interview with the Director of Nursing on 05/05/17 at 10:29 AM, the surveyor asked the procedure for handling a resident that is combative prior to given as needed medication. DON stated would try to calm the resident down, make sure they are safe, and use multiple interventions. Review of the facility's policy provided by the Administrator on 05/05/17 at 11:26 AM entitled Guidelines for Antipsychotic/Anxiolytic Documentation, under Procedure 3. For as needed (PRN) medications, the behavior exhibited, non-medication interventions and their effectiveness and the effectiveness of the given dose are documented in the medical record for each dose that is administered.",2020-09-01
767,WHITE OAK MANOR - YORK,425089,111 SOUTH CONGRESS STREET,YORK,SC,29745,2018-08-03,637,D,0,1,1MXI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to identify and/or complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) in a timely manner for 1 of 1 resident reviewed for hospice services and 1 of 5 residents reviewed for unnecessary medications. The facility did not complete the SCSA for Resident #46 within 14 days following admission to hospice services, and further failed to identify and complete a SCSA MDS for Resident #5 when there was evidence of declines from comprehensive assessment in at least two areas on at least three different occasions. The findings included: The facility admitted Resident #46 with [DIAGNOSES REDACTED]. Record review on 7/31/18 at 10:15 AM revealed that Resident #46 was admitted to hospice services with a start date effective 5/29/18. Additional review revealed that Resident #45 had a SCSA MDS with an Assessment Reference Date (ARD) of 6/6/18 completed and signed by RN on 6/16/18. Review on 7/31/18 of the MDS Resident Assessment Instrument (RAI) Manual version 1.15 effective date 10/1/2017; Chapter 2 page 2-23 revealed the following: The MDS completion date (Item Z0500B) must be no later than 14 days from the ARD (ARD + 14 calendar days) and no later than 14 days after the determination that the criteria for a SCSA were met. MDS/RAC Nurse #2 verified during interview on 8/3/18 at 11:39 AM that the SCSA initiated when Resident #46 was admitted to hospice services on 5/29/18 was not completed within the required time frame. S/he verified that the ARD for the SCSA MDS was 6/6/18 and item Z0500B was signed by RN to signify that assessment was complete on 6/16/18, which was 18 calendar days after admission to hospice services. The facility admitted Resident #5 with the [DIAGNOSES REDACTED]. Review of the medical record on 8/3/18 at 11:58 AM revealed that an Admission Comprehensive Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 10/20/17 was signed as complete on 10/25/17. Further review revealed that Section C on the MDS with ARD of 10/20/17 was coded to reflect that Resident #5 scored 14 out of 15 on the Brief Interview for Mental Status (BIMS), and that Section D was coded to reflect that Resident #5's Mood Interview score was 1 out of 30. Additional review revealed that there were no identified behaviors coded in Section [NAME] and that Section H was coded to reflect that Resident #5 was occasionally continent of bladder. Finally, review revealed that Section N was coded to reflect that Resident # 5 did not receive any antipsychotic medications during the assessment period of 10/14/17-10/20/17. Ongoing review of the medical record on 8/3/18 revealed that the Quarterly MDS assessment with ARD of 1/26/18 was signed as complete on 2/1/18. Further review revealed that Section C of the MDS with ARD of 1/26/18 was coded to reflect that Resident #5 scored a 4 out of 15 on the BIMS, and that Section D was coded to reflect that Resident #5's Mood Interview score was 21 out of 30, indicating declines in both cognitive and status compared to the comprehensive assessment with ARD of 10/20/17. Additional review revealed that Section [NAME] was coded to reflect rejection of care occurred 4-6 days during assessment period of 1/20/18-1/26/18, and Section H was coded to reflect that Resident #5 was frequently incontinent of bladder, indicating declines in both behaviors and urinary continence compared to the comprehensive assessment with ARD of 10/20/17. Finally review of section K revealed that Resident #5 sustained a significant weight loss not related to a Physician prescribed program and Section N was coded to reflect that Resident #5 received 7 days of antipsychotic medications during the assessment period of 1/20/18-1/26/18, indicating declines in status related to unplanned weight loss and onset of use of antipsychotic medication in relation to the comprehensive assessment with ARD of 10/20/17. Overall, there were 6 areas of decline identified on the Quarterly MDS assessment with ARD of 1/26/18 when compared to the comprehensive MDS assessment with ARD of 10/20/17, indicating the need for Significant Change in Status Assessment MDS with no evidence that the declines were identified or discussed by the interdisciplinary team at the time of the completion Quarterly MDS assessment on/ before 2/1/18. Additional review of the medical record on 8/3/18 revealed that the Quarterly MDS assessment with ARD of 4/25/18 was signed as complete on 5/4/18. Further review revealed that Section C of the MDS with ARD of 4/25/18 was coded to reflect that Resident #5 scored a 0 (zero) out of 15 on the BIMS, and that Section D was coded to reflect that Resident #5's Mood Interview score was 9 out of 30, indicating declines in both cognitive and status compared to the comprehensive assessment with ARD of 10/20/17. Additional review revealed that Section [NAME] was coded to reflect rejection of care occurred daily during assessment period of 4/19/18-4/25/18, indicating decline behaviors compared to the comprehensive assessment with ARD of 10/20/17. Finally review of Section N was coded to reflect that Resident #5 received 7 days of antipsychotic medications during the assessment period of 4/19/18-4/25/18, indicating declines in status related to unplanned weight loss and onset of use of antipsychotic medication in relation to the comprehensive assessment with ARD of 10/20/17. Overall, there were 4 areas of decline identified on the Quarterly MDS assessment with ARD of 4/25/18 when compared to the comprehensive MDS assessment with ARD of 10/20/17, indicating the need for Significant Change in Status Assessment MDS with no evidence that the declines were identified or discussed by the interdisciplinary team at the time of the completion Quarterly MDS assessment on/ before 5/4/18. Further review of the medical record on 8/3/18 revealed that the Quarterly MDS assessment with ARD of 7/24/18 was signed as complete on 8/1/18. Further review revealed that Section C of the MDS with ARD of 7/24/18 was coded to reflect that Resident #5 scored a 0 (zero) out of 15 on the BIMS, and that Section D was coded to reflect that Resident #5's Mood Interview score was 20 out of 30, indicating declines in both cognitive and status compared to the comprehensive assessment with ARD of 10/20/17. Finally review of section K revealed that Resident #5 sustained a significant weight loss not related to a Physician prescribed program and Section N was coded to reflect that Resident #5 received 7 days of antipsychotic medications during the assessment period of 7/19-/18-7/24/18, indicating declines in status related to unplanned weight loss and onset of use of antipsychotic medication in relation to the comprehensive assessment with ARD of 10/20/17. Overall, there were 4 areas of decline identified on the Quarterly MDS assessment with ARD of 7/24/18 when compared to the comprehensive MDS assessment with ARD of 10/20/17, indicating the need for Significant Change in Status Assessment MDS with no evidence that the declines were identified or discussed by the interdisciplinary team at the time of the completion Quarterly MDS assessment on/ before 8/1/18. Review of the MDS assessments on 8/3/18 revealed that a SCSA MDS was not initiated within 14 days of the identification of the declines in multiple sections of each Quarterly MDS assessments that were completed on or before 2/1/18, 5/4/18, and 8/1/18 as required. During an interview on 8/3/18 at 3:15 PM MDS/RAC Nurse #1 reviewed the MDS assessments with ARD's of 10/20/17, 1/26/18, 4/25/18 and 7/24/18 and confirmed that Resident #5 had a decline in at least two areas when each quarterly MDS assessment were completed and a SCSA was not completed at the time of the review for each of the quarterly MDS assessments. S/he further verified that there was no discussion between the members of the interdisciplinary team related to the need for SCSA related to at least 2 areas of change between comprehensive MDS assessment with ARD of 10/20/17, and the quarterly MDS assessments with ARD's of 1/26/18, 4/25/18, and 7/24/18.",2020-09-01
768,WHITE OAK MANOR - YORK,425089,111 SOUTH CONGRESS STREET,YORK,SC,29745,2018-08-03,657,D,0,1,1MXI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to ensure that Residents #5, #19, #46, and #61 had comprehensive care plans that were updated to reflect changes in physician orders [REDACTED]. The facility failed to update the comprehensive care plan for Resident #5 related to use and risk of adverse effects of antipsychotic medication. The facility failed to update the comprehensive care plan for Resident #19 related to use of assistive device and episodes of coughing and choking during meals. The facility failed to update the comprehensive care plan for Resident #46 related to discontinuation of anticoagulant medication. And finally, the facility failed to update the comprehensive care plan for Resident #61 related to recurrent refusals of respiratory interventions and routine respiratory intervention equipment checks. The findings included: The limited medical record review conducted on 8/3/18 at 11:58 AM revealed that the facility admitted Resident #5 with the [DIAGNOSES REDACTED]. Review of the Monthly Physician orders [REDACTED].#5 was ordered to receive [MEDICATION NAME] 50 mg every night at bedtime with an order date of 4/27/18 and start date of 6/25/18 as well as [MEDICATION NAME] 5 mg daily with an order date of 7/31/18 and start date of 8/4/18. Review of the comprehensive care plan on 8/3/18 at 2:31 PM revealed that there were no problems or interventions on any of the 23 pages that addressed the use of and/or risk for adverse effects of antipsychotic medications. During interview with MDS(Minimum Data Set)/RAC (Resident Assessment Coordinator) Nurse #1 on 8/3/18 at approximately 3:15 PM, s/he verified that there were no specific problems or interventions outlined on care plan problem that addressed use of or risk for adverse effects of antipsychotic medications. The limited record review conducted on 8/3/18 at 11:10 AM revealed that the facility admitted Resident #46 with [DIAGNOSES REDACTED]. Further review of Resident #46's medical record on 8/3/18 revealed that page 17 of 47 of the comprehensive care plan addressed risk for abnormal bleeding related to use of anticoagulant therapy with onset date of 2/5/2010 and goal for no complications related to anticoagulant therapy through next assessment with goal target date of 9/13/18. Additional review of the record reveals a handwritten physician order [REDACTED]. During interview with MDS/RAC Nurse #2 on 8/3/18 at 11:39 AM, s/he verified that the anticoagulant xarelto was discontinued on 7/7/18 ant that the care plan had not been updated to reflect this change as of the date of the interview on 8/3/18. The limited record review conducted on 8/2/18 at 10:00 AM revealed that Resident #61 was admitted to the facility with the [DIAGNOSES REDACTED]. Review of the Treatment Administration Records (TAR) for (MONTH) 1, (YEAR) through (MONTH) 1, (YEAR), revealed that Resident #61 refused the application and/or use of Bilevel Positive Airway Pressure ([MEDICAL CONDITION]) treatments 23 out of 30 days in (MONTH) (YEAR), 28 out of 31 days in (MONTH) (YEAR), and 1 out of 1 day in (MONTH) (YEAR). Review of the Comprehensive care Plan on 8/2/18 at 12:30 PM revealed that on page 17 of 22 identified problem .is at risk for SOB (Shortness of Breath), poor endurance, and other complications related to [DIAGNOSES REDACTED]. Goal for this care plan problem was listed as .will have no extended episodes of SOB through next assessment period with goal target date of 9/30/18. Additional review of the care plan reveals that there is no mention of recurrent refusal of application and/or use of [MEDICAL CONDITION] treatments and education of risks for this decision as an approach of the plan of care. Further review of the care plan reveals that there is no intervention to correspond with the physician order [REDACTED]. During interview with MDSRAC Nurse #2 on 8/2/18, s/he verified that there were no specific interventions outlined on care plan problem that addressed Resident #61's recurrent refusal of application and/or use of [MEDICAL CONDITION] treatments and education of risk for this decision nor any interventions to reflect annual [MEDICAL CONDITION] visits to manage the settings of the [MEDICAL CONDITION] machine initiated on 1/9/18. Resident #19 was admitted with [DIAGNOSES REDACTED]. During an observation on 7/30/18 at 11:26 AM, Resident #19 was eating lunch in the dining room, feeding himself with weighted utensils and drinking from cup, he/she was coughing throughout the meal service head positioned to the left. During an interview with the Registered Dietitian on 07/31/18 at 04:57 PM he/she said that he/she was aware of resident's coughing pattern at meals and the resident has worked with speech therapy to help correct the situation. He/She said resident was non-compliant with thickened liquids and was aware that a special straw was attempted as an intervention to help with coughing at meals. Review of the Physician Telephone order on 3/3/18: which states: Speech Therapy (ST) discontinued (d/c) clarification. The Therapy note on 3/3/18 states: Patient has achieved maximum potential with dsypahgia management. Physical Therapy Assistant (PTA) and Caregiver (CG) demonstrate compliance and use of care of adaptive Bionix Safe Swallow Straw. Coughing after swallow initiation still occurs, but patient is coughing on less. Review of the Physician order [REDACTED]. Review of Resident #19's CNA Care and Data Collection Guide for the month of (MONTH) (YEAR) states, For Your Information (FYI)-Thickened Liquids/Location of Meal, Mechanical Soft Diet; built up spoon,fork,knife. Review of the Care Plan for Resident #19 states: Problem Onset: 12/16/16: Resident #19 requires a mechanically altered diet related to (r/t) difficulty chewing/swallowing. He also receives built up silverware to encourage independent eating. During an interview on 07/31/18 at 05:05 PM, The DON verified that the care plan had not been updated to reflect the resident's frequent coughing and choking at meals and the interventions attempted and the the special straw.",2020-09-01
769,WHITE OAK MANOR - YORK,425089,111 SOUTH CONGRESS STREET,YORK,SC,29745,2018-08-03,688,D,0,1,1MXI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide service to prevent further Range of Motion (ROM) decline for resident #19 with a restorative ROM program in place and not consistently implemented by qualified staff related to staffing issues for 1 of 2 residents reviewed for position mobility. The findings included: Resident #19 was admitted with [DIAGNOSES REDACTED]. Resident #19's Care Plan states: Problem/Need, Problem Onset: 05/23/2014, Resident #19 has decreased joint mobility of Bilateral Upper Extremities (BUE)/ Bilateral Lower Extremities (BLE). Goal and Target Date, *Will have no further decrease in joint mobility of BUE/BLE as evidenced by (AEB) completing flexion/extension 10 reps 3 times 5 days week through next review 8/15/2018. Approaches, *Active ROM: Restorative Active Range of Motion (AROM) to all joints BUE/BLE flexion/extension 10 reps 3 times 5 days week to continue to promote joint mobility. *Explain procedure to promote understanding and cooperation. *Praise for effort and encourage participation. *Provide rest periods as needed. *Report any changes or decline to the restorative nurse. The Restorative Roster dated 7/1/2018 to 7/31/2018 for Resident #19 shows that Active Range of Motion occurred 5 days out of 31 days for (MONTH) (YEAR). During an interview on 08/01/18 at 12:14 PM with DON, he/she said that there is a Restorative Certified Nurse Assistant (CNA) and that he/she verified the inconsistency of the completion of range of motion exercises and stated this is due to staffing issues. The DON verified for the month of (MONTH) (YEAR), that Resident # 19 received ROM therapy 5 days out of 31 days. He/She stated that the facility is training other CNA and Nurses to perform ROM but they have yet completed the training. The DON said that unless the CNAs and the Nurses have completed training they are not educated and unable to document resident participation in restorative therapy.",2020-09-01
770,WHITE OAK MANOR - YORK,425089,111 SOUTH CONGRESS STREET,YORK,SC,29745,2018-08-03,695,E,0,1,1MXI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, limited record reviews, interviews, and policy reviews, the facility failed to ensure Resident #55 received the required respiratory care including monitoring of Oxygen saturation levels required to titrate Oxygen supplementation liter flow rate as ordered and use of oxygen on treatment record or electronic medical record to include oxygen rate of flow per facility policy for 1 of 1 reviewed for respiratory care. The findings included: Limited record review on 8/1/18 at 1:06 PM revealed that Resident #55 was admitted to the facility with the [DIAGNOSES REDACTED]. Medical record review on 8/1/18 at 4:36 PM revealed that Resident #55's physician orders [REDACTED]. Further review of the Physician orders [REDACTED].#55 on a routine basis or as needed. Additional medical record review on 8/1/18 at 4:45 PM of the Treatment Administration Records (TARS) for (MONTH) 1, (YEAR) through (MONTH) 1, (YEAR) revealed the following regarding Oxygen administration: (MONTH) (YEAR): dates/ times used with no specified liter flow or documented oxygen saturation level 6/2/18 10:59 AM 6/3/18 7:16 AM 6/7/18 11:29 PM 6/9/18 11:01 AM 6/10/18 11:31 AM 6/15/18 8:02 AM 6/16/18 7:52 AM 6/17/18 11:34 AM 6/22/18 9:38 PM 6/23/18 10:51 AM 6/24/18 11:13 AM 6/27/18 8:52 PM (MONTH) (YEAR): dates/ times used with no specified liter flow or documented oxygen saturation level 7/1/18 5:56 PM 7/4/18 3:10 PM 7/6/18 3:03 PM 7/24/18 8:51 PM 7/27/18 7:14 AM (MONTH) 1, (YEAR) date/ times used with no specified flow or documented oxygen saturation level NO entries for (MONTH) 1st at time of review. Review of facility policies received on 8/2/18 revealed on Oxygen Therapy policy with revision date 5/31/17, item #7 under Procedure read as follows: Record oxygen therapy on treatment record or in EMR (Electronic Medical Record) to include rate of flow. During interview with Director of Nursing on 8/2/18 at 11:25 AM, s/he reported that there was no evidence in medical record that Oxygen saturation level readings were obtained between (MONTH) 1, (YEAR)-August 2, (YEAR). S/he further reported that the last time Oxygen Saturation levels were monitored for Resident #55 was (MONTH) (YEAR) and that the Oxygen saturation levels were not consistently monitored. Additionally, s/he verified that there is no supportive documentation to reflect monitoring of Oxygen saturation levels to determine how to titrate the oxygen liter flow rate as outlined in the physician order [REDACTED].#55 had received oxygen continuously during multiple observations by surveyor from 7/30/18 through time of interview on 8/2/18. DON further agreed that the facility was not following the Oxygen Therapy policy with revision date 5/31/17 regarding documentation of oxygen therapy on treatment record or in electronic medical record to include rate of flow.",2020-09-01
771,WHITE OAK MANOR - YORK,425089,111 SOUTH CONGRESS STREET,YORK,SC,29745,2018-08-03,732,B,0,1,1MXI11,"Based on observation and interview, the facility failed to provide accurate information as required daily nurse postings for multiple days in (MONTH) (YEAR). The findings included: Review of the Report of Nursing Staff Directly Responsible for Resident Care posted daily by the facility revealed postings were not corrected to include staff changes on a daily basis for (MONTH) (YEAR). Additional review of postings for the months of (MONTH) and (MONTH) (YEAR) revealed the same. On (MONTH) 1, at approximately 10 AM, an interview with the Administrator confirmed the postings had not been updated to reflect schedule changes.",2020-09-01
772,WHITE OAK MANOR - YORK,425089,111 SOUTH CONGRESS STREET,YORK,SC,29745,2018-08-03,842,D,0,1,1MXI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and limited record reviews, the facility failed to ensure that 2 of 3 residents reviewed for accidents and 1 of 2 residents reviewed for respiratory care had accurate and complete medical records. Residents #49 and #55 had incomplete records related to falls and Resident #49 had inaccurate and/or incomplete records related to the use of supplemental oxygen. The findings included: Limited record review on 8/1/18 at 1:06 PM revealed that Resident #55 was admitted to the facility with the [DIAGNOSES REDACTED]. Review of the copy of the incident report log provided by the Director of Nursing (DON) on 8/1/18 at 1:30 PM revealed that on (MONTH) 20, (YEAR) at 2:09 PM, Resident #55 sustained a fall. Further review of departmental notes revealed on page 3 of 11 that the only reference to Resident #55 sustaining a fall is on 7/21/18 at 3:01 PM, which stated Resident had an unwitnessed fall in room about this time yesterday. No apparent injury. Continues on head trauma protocol per policy. Voices no concerns. During interview with DON on 8/2/18 at approximately 11:15 AM, s/he verified that there were no departmental notes in the medical record regarding the fall that occurred on 7/20/18 at 2:09 pm until the following day 7/21/18 at 3:01 PM. Further stated that expectation is that documentation in the record should reflect any incidents that occur and be entered by nursing prior to the end of their shift on that date. The limited record review conducted on 8/2/18 at 10:00 AM revealed that Resident #61 was admitted to the facility with the [DIAGNOSES REDACTED]. Random serial observations on 7/30/18, 7/31/18, 8/1/18 and 8/2/18 were conducted and during each observation supplemental oxygen was in use. During interview with Resident #61 on 8/1/18 at 11:20 AM, s/he stated that s/he wears oxygen continuously and only takes it off during baths when needed. S/he further stated that the flow rate for the oxygen on the oxygen concentrator should be set at 2 liters/ minute. During interview with LPN #1 on 8/1/18 at 11:23 AM, s/he verified that the oxygen concentrator was in use and resident was set for Resident #61 to receive oxygen at 1.5 liters/ minute via nasal cannula. During interview with LPN #2 on 8/2/18 at 11:05 AM, s/he verified that the oxygen concentrator was set for Resident #61 to receive 4 liters/ minute via nasal cannula. Review of the Treatment Administration Records (TAR) for (MONTH) (YEAR), revealed that Resident #61 did not have supplemental oxygen in use on (MONTH) 30, (YEAR) despite being observed in use on that date.",2020-09-01
773,WHITE OAK MANOR - YORK,425089,111 SOUTH CONGRESS STREET,YORK,SC,29745,2019-09-26,656,D,0,1,TDLZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to implement care plan interventions for 1 of 5 residents reviewed for unnecessary medications. Resident #70 was care planned to be given 'AIMS per protocol' but when pharmacy recommended an AIMS assessment, it was not done. The findings included: Resident #70 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #70 orders on 9/24/19 at approximately 2:20 PM revealed the resident took 1 mg [MEDICATION NAME] twice a day. Review of Resident #70 care plan on 9/24/19 at approximately 2:26 PM revealed the resident was care planned for [MEDICAL CONDITION] drug use and possible side effects. Interventions care planned included assessing for adverse side effects and conducting AIMS assessment per protocol. Review of Resident #70 medication regimen reviews 9/24/19 at approximately 3:29 PM revealed an admission review dated (MONTH) 31, 2019 that recommended an AIMS assessment be conducted at admission and every three months. No AIMS assessment could be found in the record at that time. Interview with Director of Nursing (DON) on 9/25/19 at approximately 11:20 AM revealed an AIMS assessment had been conducted that morning. It was the first AIMS assessment for Resident #70 since admission. The DON confirmed an AIMS assessment should have been performed when the pharmacist first recommended it in July.",2020-09-01
774,WHITE OAK MANOR - YORK,425089,111 SOUTH CONGRESS STREET,YORK,SC,29745,2019-09-26,756,D,0,1,TDLZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow pharmacy recommendations for 2 of 5 residents reviewed for unnecessary medications. The pharmacist recommended that Residents #10 and #70 be given an Abnormal Involuntary Movement Scale (AIMS) on admission to establish baseline. The recommendation went unfollowed. The findings included: Resident #70 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #70 orders on 9/24/19 at approximately 2:20 PM revealed the resident took 1 mg [MEDICATION NAME] twice a day. Review of Resident #70 medication regimen reviews 9/24/19 at approximately 3:29 PM revealed an admission review dated (MONTH) 31, 2019 that recommended an AIMS assessment be conducted at admission and every three months. No AIMS assessment could be found in the record at that time. Interview with Director of Nursing (DON) on 9/25/19 at approximately 11:20 AM revealed an AIMS assessment had been conducted that morning. It was the first AIMS assessment for Resident #70 since admission. The DON confirmed an AIMS assessment should have been performed when the pharmacist first recommended it in July. Resident #10's Medical Record reviewed on 9/26/19 at 10:06 AM revealed on 4/10/19 AIMS assessment was recommended by Pharmacist to be done now and every 3 months. AIMS test was completed on 6/14/19 only and none were noted in the medical record. During an interview with Registered Nurse (RN) #1 on 9/26/2019 at 10:36 AM, RN #1 stated that AIMS assessments were not being done as ordered. When asked about procedures to follow up on pharmacist recommendations, RN #1 stated that she and second shift nurse were to review all pharmacy recommendations and send all documents to the DON. An interview with the DON on 9/26/2019 at 10:44 AM revealed that the DON sends all recommendations to the night shift nurse after s/he reviews them to be followed up on and completed. The DON revealed that software had been updated and it will begin alerting staff when AIMs testing will need to be completed. The DON also confirmed pharmacist recommendations for AIMS was not completed per recommendations.",2020-09-01
775,WHITE OAK MANOR - YORK,425089,111 SOUTH CONGRESS STREET,YORK,SC,29745,2019-09-26,812,F,0,1,TDLZ11,"Based on observation and interview, the facility failed to remove out of date boiled eggs in the refrigerator, had rusty/baked on food on wire storage rack, and an open large trash barrel during meal serving time (1 of 1 main kitchen). The findings included: During the initial tour of the kitchen on 9/23/19 at 9 AM with both the Cook and the Dietician, a container of 10-12 boiled eggs was in the refrigerator over 72 hours. These were removed by the Dietician. There was a large gray 30 gallon trash can uncovered in the area while breakfast trays were being served. On 9/25/19 at 11:15 AM, the trash barrel was again observed uncovered while lunch trays were being served. On both days, a wire storage rack beside the stove was observed with rust and a dark brown caked on substance on the wires. Equipment and food containers were sitting on the rack. The Dietician and the Corporate Dietary Consultant both confirmed these findings.",2020-09-01
776,MAGNOLIA MANOR - GREENVILLE,425090,411 ANSEL ST,GREENVILLE,SC,29601,2019-03-09,550,E,0,1,ZX5911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide an environment that promotes and/or enhances the resident's quality of life and recognizing each resident's individuality for 2 of 2 residents reviewed for catheters, one of 2 reviewed for pressure ulcer treatment, and 3 of 3 dining observations. Catheter bags for Resident #62 and #340 were observed uncovered, Resident #62 was observed exposed over a long period of time during pressure ulcer treatment, three Certified Nursing Assistants (CNA's) were observed standing and feeding Resident #61 and Resident #66 during meals and milk in cartons were served with no glasses. The findings included: The facility admitted Resident #61 with [DIAGNOSES REDACTED]. Further review of the medical record revealed Resident #61 had impairment on both sides of the upper and lower extremities. On 3/5/19 at 12:00 PM, observation of the lunch meal on the East Wing revealed CNA #2 was standing while feeding Resident #61. The facility admitted Resident #66 with [DIAGNOSES REDACTED]. Further review of the medical record revealed Resident #66 had impairment on both sides of the upper extremities. Further observation of the lunch meal on the East Wing revealed CNA #3 standing while feeding Resident #66. During an interview with the Director of Nursing (DON) on 3/8/19 at 4:51 PM, s/he stated staff should be at eye level when feeding a resident. During an interview with CNA #3, s/he stated s/he should have gotten a chair. S/he continued by stating when standing, I have been told it makes the residents feel rushed. During the Initial Pool process on 3/5/19, a breakfast tray was noted in room [ROOM NUMBER] with no glass for milk served in a carton. On 3/07/19 at 8:35 AM, the surveyor observed 9 breakfast trays on a rack ready for delivery on East Hall with unopened milk cartons and no glasses available on the trays or on the unit to offer residents. The surveyor observed delivery of 3 trays with no glasses offered by facility staff. During an interview at that time, the Unit Manager verified that glasses had not been provided for the cartons of milk. During an interview and kitchen observation on 3/07/19 at 8:56 AM, the Certified Dietary Manager stated that s/he did not have enough glasses to offer them with breakfast for milk. The facility admitted Resident #62 with [DIAGNOSES REDACTED]. During treatment observations on 3/7/19 Resident #62 was left exposed for an excessive period of time. At 9:37 AM on 3/7/19, Certified Nursing Assistant (CNA) #1 and Registered Nurse (RN) #1 prepared Resident #62 for pressure ulcer treatments and catheter care. After washing hands and donning gloves, the CNA uncovered the resident and opened his/her disposable brief before pulling the privacy curtain around the bed and between the residents. The resident's roommate was in the room at this time. The CNA positioned the resident onto his/her right side and proceeded with the Stage 4 sacral pressure ulcer treatment. After the sacral care, the resident was repositioned onto his/her back and the CNA started to reattach the brief. The RN instructed the CNA to leave the brief open since s/he was going to do catheter care but was going to do the heel first. The RN proceeded to complete the treatment/dressing change to the unstageable (eschar) pressure ulcer on the left heel. S/he then removed treatment supplies from the room, leaving the resident exposed throughout this time. The catheter care procedure was not initiated until 9:57 AM. During an interview on 3/8/19 at 5 PM, RN #1 verified that Resident #62 had been left uncovered/exposed as noted. During an observation on 03/05/19 at 09:20 AM revealed that Resident #62's catheter bag was on the floor, uncovered and visible from the hallway. Throughout the course of the survey on (03/05/19 at 09:20 AM, 11:08 AM, and 04:16 PM; on 03/08/19 at 8:46 AM and 10:52 AM), Resident #62's catheter bag was observed uncovered and on the floor. During an interview and observation on 3/08/19 at 10:52 AM, Licensed Practical Nurse (LPN) #1 confirmed that Resident #62's catheter tubing was on the floor and that the catheter bag was uncovered and visible from the corridor. The facility admitted Resident #340 with [DIAGNOSES REDACTED]. During multiple observations on (03/05/19 at 09:20 AM, 11:30 AM, and 04:16 PM; on 03/06/19 at 8:56 AM) revealed that Resident #340's catheter bag was uncovered. During an interview on 03/07/19 at 5:30 PM, the Director of Nurses (DON) confirmed that catheter bags were to be covered. During dining observation on 3/05/19 at 12:25 PM, Certified Nursing Assistant (CNA) #1 was observed standing and feeding Resident #340.",2020-09-01
777,MAGNOLIA MANOR - GREENVILLE,425090,411 ANSEL ST,GREENVILLE,SC,29601,2019-03-09,555,D,0,1,ZX5911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review, the facility failed to develop a baseline care plan to address the needs of 1 of 2 sampled residents reviewed for a urinary catheter. The care plan for Resident #340 did not address pressure ulcer risk or presence of a urinary catheter. The findings included: The facility admitted Resident #340 on 2/21/19 with [DIAGNOSES REDACTED]. Multiple observation of Resident #340 on (03/05/19 at 9:20 AM, 11:30 AM, and 04:16 PM; on 03/06/19 at 08:56 AM) revealed the resident with contractures in the same position, on his/her back, slightly tilted to the right, with a urinary catheter in place. Review of Resident #340's 2/22/19 Braden Scale for Predicting Pressure Sore Risk revealed a total score of 14 (moderate risk). Review of Resident #340's Baseline Care Plan on 03/06/19 at 04:21 PM revealed it did not address the presence and care of the Foley catheter or the pressure ulcer risk with preventive interventions. During an interview on 03/08/19 at 03:15 PM, Minimum Data Set Coordinator #1 reviewed the medical record for Resident #340 and confirmed that the baseline care plan did not address the presence of the urinary catheter or pressure ulcer risk interventions.",2020-09-01
778,MAGNOLIA MANOR - GREENVILLE,425090,411 ANSEL ST,GREENVILLE,SC,29601,2019-03-09,565,E,0,1,ZX5911,"Based on record review and interview, the facility failed to respond in a timely manner to resident complaints or provide written responses to grievances voiced in Resident Council. 10 of 17 residents complained of continuing concerns related to call light response time and/or provision of food items ordered. 7 of 17 residents expressed concern that their food choices were not being honored. The findings included: Review of Resident Council minutes dated from (MONTH) (YEAR) through (MONTH) 2019 on 03/05/2019 at 9:00 PM revealed: 8/27/18: Call lights aren't getting answered fast enough on wknd (weekend) 9/24/18: CNA's are telling Resident's not to push call lights. 10/15/18: Call lights are taking to long to be answered 12/12/18: Call lights take to long to be answered 2/18/19: 2nd shift CNA's take too long to answer call lights During the Resident Council meeting on 03/07/19 at 02:15 PM, 10 of 17 residents stated CNAs were turning off the call lights and not returning to help residents, residents were being instructed to not use call lights, and there were long wait times for calls to be answered. During an interview on 03/06/2019 at 4:45PM, the Assistant Director of Nursing (ADON) provided information that staff training had been conducted on 12/11/18, 1/16/19, and 2/05/19 relating to call light response time. Most recently, on 02/05/2019, the training included teaching the staff that, Call lights are the responsibility of every employee in the building. There have been lots of complaints from residents as well as family members. Take the time to at least answer the call and see what the resident needs and if you cannot help them at that time, let them know you will find someone but only if there is no way you can help them. As of the 02/18/19 Resident Council meeting, the minutes reflected that call light response time continued to be an issue. Continued review of Resident Council minutes revealed a complaint report was written on 10/17/18 which stated per the residents, We are not getting what we order on our tickets. Minutes from the 10/15/18 meeting noted the Certified Dietary Manager (CDM) as having been present at the meeting, however there was no evidence of follow-up and the CDM stated s/he was unaware of the concern. During the Resident Council meeting on 03/07/19 at 02:07PM, 7 of 17 residents expressed concern that their food choices were still not being honored. While interviewing the CDM on 03/07/19 at 04:34 PM, s/he stated, No formal complaint was brought to my attention about food being on trays that residents had not ordered. During an interview on 3/07/19 at 4:45 PM, the Activities Director (AD) stated that s/he wrote up grievances and turned them over to the Administrator. S/he could not respond as to why the complaint has not been answered. The AD stated the CDM was always at the Resident Council meeting and that s/he should have been aware of tray line issues. During an Interview on 03/07/19 at 05:00 PM, the Administrator stated that after Resident Council, the AD met with the her/him and the DON. Complaints were then turned over to the appropriate department heads for correction.",2020-09-01
779,MAGNOLIA MANOR - GREENVILLE,425090,411 ANSEL ST,GREENVILLE,SC,29601,2019-03-09,584,E,0,1,ZX5911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to provide housekeeping and maintenance services as required to provide a safe, sanitary, and comfortable environment on 2 of 2 units. The findings included: During the Initial Pool Process beginning at approximately 9 AM on 3/5/19, the following concerns were identified and confirmed as still present on 3/09/19 at 11:03 AM during the environmental tour with the Administrator: room [ROOM NUMBER]: (1) There was wall damage beside the bed. (2) The continuous positive airway pressure ([MEDICAL CONDITION]) mask was uncovered. (3) The bathroom door was deeply scarred. (4) There was a pipe cover/insulator on the floor in the bathroom. room [ROOM NUMBER]: (1) There was dried brown substance on the wall in the bathroom. (2) The resident room and bathroom doors were deeply scarred. room [ROOM NUMBER]: (1) The bathroom door was deeply scarred. (2) Corners and edges of the bathroom floor had dark build-up around the baseboard and around the base of the toilet. (3) The cover of the toilet paper holder was off and under the sink. room [ROOM NUMBER]: (1) Pipe cover, vent full of dust, bathroom with strong void odor (2) The filter was missing on one side of the oxygen concentrator. (3) The [MEDICAL CONDITION] mask was uncovered. (4) The bathroom door was deeply scarred. (5) There was a pipe cover/insulator on the floor in the bathroom. (6) There was a strong smell of urine in the bathroom with no visible cause and inability to determine if the exhaust vent was operational. (7) The exhaust vent in the bathroom had a heavy build-up of dust. (8) The bathroom walls had several areas of dried brown substance on them. (9) Corners and edges of the bathroom floor had dark build-up around the baseboard. (10) There was an open, unlabeled urinal in the bathroom. (11) Mattress torn. room [ROOM NUMBER]: (1) The wall beside the heating/air conditioning unit had numerous deep gouges. room [ROOM NUMBER]: (1) The bathroom door was deeply scarred. Corridor near room [ROOM NUMBER]: (1) Ceiling tiles appeared wet with fuzzy black substance room [ROOM NUMBER]: (1) Nebulizer mask was not covered. room [ROOM NUMBER]: (1) Ceiling tiles were stained room [ROOM NUMBER]: (1) There were 3 soiled uncovered, unlabeled urinals in the bathroom. room [ROOM NUMBER]: (1) Tube feeding poles (x 2) with dried spills all over the bases and floor. (2) Dried spills on the front of the bedside stand. (3) Walls had dried spills at the head of bed A and on the wall where the TV was located. (4) Baseboards were deeply scuffed, damaged, and had dark build-up. (5) The privacy curtain was soiled near where the feeding pump was located. (6) Toilet had urine left in it. (7) The bathroom door was deeply scarred. (8) There were 2 soiled, uncovered, unlabeled urinals in the bathroom. On 3/6/19 at approximately 1:00 PM, Registered Nurse #2, after observing concerns in room [ROOM NUMBER], confirmed the mattress was torn and one oxygen filter was missing from the oxygen concentrator.",2020-09-01
780,MAGNOLIA MANOR - GREENVILLE,425090,411 ANSEL ST,GREENVILLE,SC,29601,2019-03-09,641,E,0,1,ZX5911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure that Residents received accurate assessments that were reflective of the residents' status. One of 2 sampled residents reviewed for pressure ulcers (Resident #62), one of 5 sampled residents reviewed for unnecessary medication (Resident #28), and 1 of 1 sampled resident reviewed for [MEDICAL TREATMENT] (Resident #33). The findings included: The facility admitted Resident #28 with [DIAGNOSES REDACTED]. Review of Resident #28's 10/9/18 Quarterly and the 1/9/19 Annual MDS Assessments at 11:35 AM on 3/9/19 revealed the following: -Under Section J on the 10/9/18 MDS, the pain assessment was dashed, not completed, though under Section B, the resident was noted with clear speech, able to understand, and able to make her/himself understood. -Under Section N on the 1/9/19 MDS, N 0450 Antipsychotic Medication Review, the resident was coded as not having received antipsychotic medication since admission/entry or reentry or the prior OBRA assessment, though N0410 was coded correctly that the resident had received an antipsychotic medication daily in the 7-day look-back period. Therefore, the information under items B, C and D regarding gradual dose reduction were not completed. During an interview at 12:30 PM on 3/9/19, MDS Coordinator #1 reviewed Resident #28's medical record and confirmed that the MDS Assessments were not accurately coded to reflect the resident's status at the time of the assessments. The facility admitted Resident #33 with [DIAGNOSES REDACTED]. Record review of Resident #33's Quarterly Minimum Data Set ((MDS) dated [DATE] on 3/7/19 at 5:48 PM revealed [MEDICAL TREATMENT] had not been coded on the Quarterly MDS. During an interview with the MDS Coordinator on 3/8/19, s/he confirmed [MEDICAL TREATMENT] should have been coded when the assessment was completed for Resident #33. The facility admitted Resident #62 with [DIAGNOSES REDACTED]. Review of Resident #62's 1/29/19 Quarterly Minimum Data Set (MDS) on 03/06/19 at 3:01 PM revealed that it was incorrectly coded as follows: -Under Section I, [MEDICAL CONDITION] was noted as a [DIAGNOSES REDACTED]. -Under Section J, the resident was coded as receiving no PRN (as needed) pain medication. Review of the 1/19 physician's orders [REDACTED]. -Under Section J, the resident interview for pain assessment was not completed though all other required interviews were. -Under Section K, the resident was coded as having received [MEDICATION NAME]/IV feeding instead of tube feeding noted during review of the medical record on 03/05/19 at 11:48 AM. -Under Section M, the resident was coded as having one Stage 4 pressure ulcer. Review of the (MONTH) 2019 Wound Treatment and Progress Records on 03/05/19 at 11:48 AM revealed that Resident #62 had a Stage 4 pressure ulcer on the sacrum and a deep tissue injury (DTI) to the left heel. The DTI was not coded. -Further review of the physician's orders [REDACTED].#62 had an order dated 1/3/19 and received a treatment for [REDACTED]. The applications of dressings to feet was not coded under M1200. -Section N was not coded for the daily use of antipsychotic or opioid medications. Review of Resident #62's medical record on 03/05/19 at 11:48 AM revealed a physician's orders [REDACTED]. Further review revealed a physician's orders [REDACTED]. Review of the MAR indicated [REDACTED]. During an interview on 03/06/19 at 3:34 PM, the MDS Coordinator #1 reviewed the medical records and MDS and verified the coding did not accurately reflect the status of Resident #62 at the time it was completed.",2020-09-01
781,MAGNOLIA MANOR - GREENVILLE,425090,411 ANSEL ST,GREENVILLE,SC,29601,2019-03-09,655,D,0,1,ZX5911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review, the facility failed to develop a baseline care plan to address the needs of 1 of 2 sampled residents reviewed for a urinary catheter. The care plan for Resident #340 did not address pressure ulcer risk or presence of a urinary catheter. The findings included: The facility admitted Resident #340 on 2/21/19 with [DIAGNOSES REDACTED]. Multiple observation of Resident #340 on (03/05/19 at 9:20 AM, 11:30 AM, and 04:16 PM; on 03/06/19 at 08:56 AM) revealed the resident with contractures in the same position, on his/her back, slightly tilted to the right, with a urinary catheter in place. Review of Resident #340's 2/22/19 Braden Scale for Predicting Pressure Sore Risk revealed a total score of 14 (moderate risk). Review of Resident #340's Baseline Care Plan on 03/06/19 at 04:21 PM revealed it did not address the presence and care of the Foley catheter or the pressure ulcer risk with preventive interventions. During an interview on 03/08/19 at 03:15 PM, Minimum Data Set Coordinator #1 reviewed the medical record for Resident #340 and confirmed that the baseline care plan did not address the presence of the urinary catheter or pressure ulcer risk interventions.",2020-09-01
782,MAGNOLIA MANOR - GREENVILLE,425090,411 ANSEL ST,GREENVILLE,SC,29601,2019-03-09,657,D,0,1,ZX5911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure all required disciplines attended and/or had input into resident's care plan process for 7 of 20 residents reviewed (Resident #12, 28, 33, 55, 62, and 81) In addition, Resident #62's care plan was not updated to reflect a pressure ulcer of the heel and the resident's nothing by mouth (NPO) status. The findings included: The facility admitted Resident #12 with [DIAGNOSES REDACTED]. Record review of Resident #12's medical record on 3/9/19 at 10:18 AM revealed a Care Plan Conference Summary dated 2/19/19. The Registered Nurse (RN) most familiar with the resident and the resident's Physician did not participate in the care plan process. Record review of Resident #12's medical record on 3/9/19 at 10:18 AM revealed that Hospice did not participate in the facility's care plan. During an interview with the Minimum Data Set Coordinator on 3/9/19 at 12:58 PM, s/he stated Hospice was not invited to participate in the care plan process and Social Services was unaware to invite Hospice and coordinate with Hospice related to the care plan. The facility admitted Resident #33 with [DIAGNOSES REDACTED]. Record review of Resident #33's medical record on 3/7/19 at 5:48 PM revealed a Care Plan Conference Summary dated 9/25/18. The Certified Nursing Assistant (CNA) most familiar with the resident and the resident's physician did not participate in the care plan process. Review of the 7/31/18 Care Plan Conference Summary revealed the RN and CNA most familiar with the resident, Dietary, and the resident's Physician did not participate in the care plan process. The facility admitted Resident #55 with [DIAGNOSES REDACTED]. Record review of Resident #55's medical record on 3/8/19 at 6:34 PM revealed a Care Plan Conference Summary. The RN most familiar with the resident and the resident's physician did not participate in the care plan process. The facility admitted Resident #81 with [DIAGNOSES REDACTED]. Record review of Resident #81's medical record revealed a Care Plan Conference Summary dated 9/25/18 and 2/14/19. The RN and CNA most familiar with the resident and the resident's physician did not participate in the care plan process. During an interview with the MDS Coordinator on 3/9/19 at 3:29 PM, s/he, after reviewing the Care Plan Conference Summary sheets, confirmed all required disciplines were not participative in the care plan process. The facility admitted Resident #28 with [DIAGNOSES REDACTED]. Review of Resident #28's Care Plan at 12:01 PM on 3/9/19 revealed that there was no evidence of recent care plan participation. There were no signature sheets in the record to indicate which staff members had participated in development of the care plan. The last Care Plan Conference Summary available for review in active and inactive files was dated 8/7/18 and did not include participation by a Registered Nurse (RN) or Certified Nursing Assistant responsible for the care of the resident. At l2:30 PM on 3/9/19, MDS Coordinator #1 provided a Care Plan Conference Summary dated 2/27/19 for Resident #28 and confirmed it did not include signatures to indicate participation in care plan development by a Registered Nurse (RN) or a representative of Nutrition Services. The facility admitted Resident #62 with [DIAGNOSES REDACTED]. Review of Resident #62's 1/29/19 Quarterly Minimum Data Set (MDS) on 03/06/19 at 3:01 PM revealed that under Section M, the resident was coded as having only one Stage 4 pressure ulcer. Review of Resident #62's (MONTH) 2019 Wound Treatment and Progress Records on 03/05/19 at 11:48 AM revealed that Resident #62 had a Stage 4 pressure ulcer on the sacrum and a deep tissue injury (DTI) to the left heel. Review of Resident #62's care plan revealed it had not been updated to reflect the DTI to the left heel. Further review revealed that, although there were physician's orders [REDACTED].loss of appetite . Review of Resident #62's medical record revealed that there was no evidence of recent care plan participation. There were no signature sheets to indicate which staff members had participated in development of the care plan. The last Care Plan Conference Summary available for review in active and inactive files was dated 9/18/18. During an interview on 3/08/19 at 03:03 PM, MDS Coordinator #1 reviewed Resident #62's medical record and verified that the care plan had not been updated to include the left heel pressure ulcer. S/he confirmed that interventions on the care plan had not been individualized for the resident with a tube feeding. MDS Coordinator #1 also stated no other care plan participation records could be located.",2020-09-01
783,MAGNOLIA MANOR - GREENVILLE,425090,411 ANSEL ST,GREENVILLE,SC,29601,2019-03-09,686,E,0,1,ZX5911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interview, the facility failed to provide care and services to promote healing and prevent infection and new ulcers from developing for 2 of 2 sampled residents reviewed for pressure ulcers. Residents #62 and #340 were not turned and positioned at least every two hours per professional standards of care. Additionally, the nurse failed to clean the scissors appropriately prior to changing the dressing on a Stage 4 sacral pressure ulcer for Resident #62. The findings included: The facility admitted Resident #340 with [DIAGNOSES REDACTED]. During multiple observation of Resident #340 on (03/05/19 at 9:20 AM, 9:33 AM, 11:30 AM, 12;25 PM and 04:16 PM; on 03/06/19 at 08:56 AM) revealed the resident with contractures in the same position, on his/her back, slightly tilted to the right. Review of Resident #340's 2/22/19 Braden Scale for Predicting Pressure Sore Risk revealed a total score of 14 (moderate risk). Review of Resident #340's Baseline Care Plan on 03/06/19 at 04:21 PM revealed it did not address the pressure ulcer risk with preventive interventions. During an interview on 03/08/19 at 03:15 PM, Minimum Data Set Coordinator #1 reviewed Resident #340's medical record and confirmed that the baseline care plan did not include interventions to address the pressure ulcer risk. The facility admitted Resident #62 with [DIAGNOSES REDACTED]. Record review of Resident #62 on 03/05/19 at 04:09 PM revealed 2/26/19 Wound Healing Center instructions for treatment of [REDACTED]. During multiple observations of Resident #62 on (03/05/19 at 09:30 AM, 11:08 AM, 12:25 PM and 04:16 PM; on 03/08/19 at 8:46 AM and 10:52 AM) revealed Resident #62 positioned on his/her back. During an observation and interview on 03/08/19 at 10:52 AM, Licensed Practical Nurse #1 confirmed that Resident #62 was positioned on his/her back with the head of the bed elevated 90 degrees putting direct pressure on the sacral ulcer. Record review of Resident #62's medical record on 03/05/19 at 04:09 PM revealed the wound care instructions had not been updated on the care plan. During an interview on 03/07/19 at 5:30 PM, the Director of Nurses (DON) reviewed Resident #62's medical record and confirmed the Wound Center's instructions. S/he reviewed the Task List for Certified Nursing Assistants in the computer and confirmed it included this information and should have been followed. Review of Resident #62's interdisciplinary care plan revealed that it did not include interventions for turning and positioning every 2 hours though the resident had pressure ulcers on the sacrum and left heel. During an interview on 03/08/19 at 03:03 PM, the MDS (Minimum Data Set) Coordinator stated that the standard of care for residents with pressure ulcers would include turning every two hours and not to lay on the pressure ulcer. The MDS (Minimum Data Set) Coordinator also verified that the care plan for Resident #62 did not address this standard. During an observation of Resident #62's Stage 4 sacral pressure ulcer treatment at 9:27 AM on 3/7/19, Registered Nurse (RN) #1 removed the soiled dressing and cleansed the wound with wound cleanser. As s/he prepared to cut the Kerlix roll to be used for packing the wound, the RN stated s/he had cleansed the scissors prior to setting up to do the treatment. S/he asked if the surveyor needed to see this part of the procedure. When asked what s/he had used to sanitize the item, the nurse replied s/he had cleaned it with alcohol. When asked if this was effective to sanitize the scissors, the nurse stated, I guess I should use this and proceeded to cleanse the scissors with MicroKill. S/he cut the Kerlix, moistened it with Dakin's solution and packed the wound. Review of the facility's Wound Care Policies and Procedures provided by and reviewed with the Assistant Director of Nurses on 3/8/19 at 9:52 AM revealed that it did not address sanitizing the scissors prior to use.",2020-09-01
784,MAGNOLIA MANOR - GREENVILLE,425090,411 ANSEL ST,GREENVILLE,SC,29601,2019-03-09,688,E,0,1,ZX5911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to provide splints and positioning devices as ordered for 2 of 3 residents reviewed for range of motion. Resident #81 observed without splints and/or positioning devices. Resident #62 no splints/washcloth in place to prevent decline in range of motion. The findings included: The facility admitted Resident #81 with [DIAGNOSES REDACTED]. Record review of Resident #81's medical record on 3/7/19 at 7:32 PM revealed current physician orders [REDACTED]. Observation of Resident #81 on 3/5/19 at 11:08 AM, 3/5/19 at 2:18 PM, and on 3/7/19 at 10 AM, 12:15 PM, and 3:30 PM revealed Resident #81 was not wearing the elbow splints. In addition, on 3/7/19 at 8:10 PM, Resident #81 did not have an abductor wedge between his/her legs. During an interview with Certified Nursing Assistant (CNA) #4 on 3/8/19 at 3:07 PM, s/he stated there was no one over the restorative program. S/he continued by stating the CNA would be responsible and would get the information to care for the resident in the CNA tracker. S/he stated Minimum Data Set (MDS) Coordinator puts information into the care tracker so staff would know what to do for residents. During an interview with CNA #5 on 3/8/19 at 3:19 PM, s/he stated did not think there were any orders for restorative. S/he continued by stating range of motion was done with the resident during care and stated a pillow is put between the legs of Resident #81. During an observation of Resident #81 along with the Assistant Director of Nursing on 3/8/19 at 12:46 PM, s/he confirmed Resident #81 was not wearing the elbow splints and there were none located in his/her room. In addition, Resident #81 did not have an abductor wedge between his/her legs. During an interview with the Director of Nursing on 3/9/19 at 1:24 PM, s/he stated there was no restorative program at the time and therapy and the nurses were responsible for care related to splints, positioning devices ordered. The facility admitted Resident #62 with [DIAGNOSES REDACTED]. During multiple observations on (03/05/19 at 9:30 AM, 11:08 AM, 12:25 PM, and 04:16 PM; 03/08/19 at 8:46 AM) Resident #62 was observed with bi-lateral hand contractures. Only the left hand held a rolled wash cloth. Record review of Resident #62's medical record on 03/07/19 at 11:41 AM revealed that there was no care plan problem directly relating to contractures with planned interventions to prevent further decline. During an interview on 03/08/19 at 11:01 AM, the Occupational Therapist stated that Resident #62 would benefit from hand rolls, one in each hand, to protect his/her palms and prevent further contracture. Record review of Resident #62's medical record revealed no evidence of provision of an ongoing program of ROM to prevent further decline. During an interview on 03/05/19 at 09:30 AM, the Restorative Aide (Certified Nursing Assistant #1) stated s/he was unable to provide restorative services as s/he has been pulled to the floor to work assignments due to staffing issues. During an interview on 03/07/19 at 5:30 PM, the Director of Nurses (DON) reviewed the Task List (Certified Nursing Assistant care plan) and confirmed it did not include interventions to be implemented to prevent further decline for Resident #62. There were no instructions to provide ROM exercises or to apply splints/handrolls. During an interview on 03/08/19 at 03:03 PM, MDS (Minimum Data Set) Coordinator #1 reviewed and confirmed that Resident #62's Care Plan did not address contractures to include interventions to prevent further decline.",2020-09-01
785,MAGNOLIA MANOR - GREENVILLE,425090,411 ANSEL ST,GREENVILLE,SC,29601,2019-03-09,689,E,0,1,ZX5911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and observation the facility failed to provide fall risk interventions as ordered for Resident #28. One of five residents reviewed for unnecessary meds. The facility failed to secure treatment solutions for Resident #62 during 3 observations. The findings included: The facility admitted Resident #28 with [DIAGNOSES REDACTED]. Record review of Resident #28's medical record at 6:38 PM on 3/8/19 revealed a physician's orders [REDACTED]. No floor mats were observed in place by the resident's bed at any time during the survey. Further review revealed that floor mats were not included on the Medication/Treatment Administration Records to be monitored by staff for placement. Review of Resident #28's 10/9/18 Quarterly and the 1/9/19 Annual Minimum Data Set Assessments at 11:35 AM on 3/9/19 revealed the resident had a Brief Interview for Mental Status score of 12, indicating moderate cognitive impairment. Resident #28 required extensive assistance with bed mobility, transfers, and toileting. Resident #28 was on daily antipsychotic, anti-anxiety, and antidepressant medication. Review of Resident #28's Fall Risk Assessments scores revealed: 1/21/18: 22, 2/8/19: 24, 4/23/18: 24, 10/9/18: 24, with 10 or higher indicating the resident is at risk for falls. During an interview on 3/9/19 at 9 AM, the Certified Nursing Assistant assigned on Resident #28's hall stated, I've been here about a mouth and have never seen mats next to the bed. Review of Resident #28's Care Plan at 12:01 PM on 3/9/19 revealed no reference to the use of fall mats to minimize injury in the event of falls. During an interview on 3/9/19 at 12:18 PM, MDS (Minimum Data Set) Coordinator #2 reviewed Resident #28's record and verified the physician's orders [REDACTED]. The MDS Coordinator stated s/he did not see a DC (discontinue) order. During an interview at 1:18 PM on 3/9/19, MDS Coordinator #1 reported s/he took it off the care plan because they were not in the room. The facility admitted Resident #62 with [DIAGNOSES REDACTED]. During random observations of Resident #62's room throughout the survey there were treatment solutions noted in Resident #62's room, posing a risk for cognitively impaired self-mobile residents. During the Initial Tour of the facility on 03/05/18 at 09:20 AM, there was a 25-ounce bottle of Hy[DATE] NaHypoCl (a sodium hypochloride solution) on the bedside table. Later in the day, at 02:16 PM, the sodium hypochloride solution had been removed, but a 4-ounce bottle of Betadyne was noted on the same table. Both Residents in the room were bed bond, the solutions were out of reach form the residents. There were no other residents observed in the immediate area. During an interview with the Director of Nurses on 03/05/19 at 05:00 PM, when informed of the observations, the DON stated, Neither one should be left at the bedside. During an observation on 03/07/19 at 09:10 AM, the surveyor observed Hy[DATE] and Betadyne at Resident #62's bedside on an overbed table. Registered Nurse #1 confirmed the treatment solutions had been left at the bedside and were accessible to cognitively impaired self-mobile residents.",2020-09-01
786,MAGNOLIA MANOR - GREENVILLE,425090,411 ANSEL ST,GREENVILLE,SC,29601,2019-03-09,690,G,0,1,ZX5911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, and review of the facility policies titled Intake and Output and Catheter Urinary Cleaning & Maintenance, the facility failed to provide appropriate care and services to 2 of 2 sampled residents reviewed for urinary catheters. Resident #62's catheter drainage bag/tubing was observed on the floor. While providing catheter care to Residents #62 and #340, the nurse failed to anchor the tubing prior to cleansing it, causing discomfort to Resident #62. Output was not monitored for Residents #62 and #340. The findings included: The facility admitted Resident #62 with [DIAGNOSES REDACTED]. During an observation on 03/05/19 at 09:20 AM Resident #62's catheter bag was on the floor, uncovered and visible from the hallway. Throughout the course of the survey (on 03/05/19 at 09:20 AM, 11:08 AM, and 04:16 PM; on 03/08/19 at 8:46 AM and 10:52 AM), Resident #62's catheter bag was observed uncovered and on the floor. During an interview and observation on 3/08/19 at 10:52 AM, Licensed Practical Nurse (LPN) #1 confirmed that Resident #62's catheter tubing was on the floor and that the catheter bag was uncovered and visible from the corridor. Record review of Resident #62's medical record on 03/05/19 at 04:09 PM revealed no evidence that the facility was routinely monitoring the resident's urinary output. Review of Resident #62's care plan for the indwelling catheter revealed that interventions included to Assess the drainage every shift. Record the amount, type, color, odor. The facility's policy titled Intake and Output provided by the Assistant Director of Nurses on 03/07/19 at 5:30 PM stated: Note: Conditions which can require monitoring as indicated: 1. Foley or intermittent catheter. During an interview on 03/08/19 at 03:03 PM, MDS (Minimum Data Set) Coordinator #1 reviewed Resident #62's medical record and verified that the urinary output was not being monitored. The facility admitted Resident #62 with [DIAGNOSES REDACTED]. During observation of catheter care for Resident #62 at 9:57 AM on 3/7/19, no leg band was noted to secure the catheter from pulling at the insertion site during activities of daily living. After preparing the work area, Registered Nurse (RN) #1 proceeded to cleanse Resident #62's perineal area. After cleansing around the head of the penis, the nurse proceeded to cleanse and rinse the Foley tubing without anchoring it to prevent pulling at the insertion site. The resident started moaning continuously at this point, but the nurse did not address it with the resident. The surveyor asked the resident, Does that hurt? He replied, Very much. During an interview at that time, RN #1 stated, For immobile people, we don't use something to secure the catheter from pulling. The facility admitted Resident #340 with [DIAGNOSES REDACTED]. During observation of catheter care for Resident #340 on 3/8/19 at 1:33 PM, RN #1 cleansed around the urethral meatus and held the penis while cleansing the catheter tubing. S/he did not anchor the tubing to prevent pulling on the insertion site. The facility policy titled Catheter Urinary Cleaning & Maintenance states: 13. Cleanse area at catheter insertion site, taking care not to pull . It did not address anchoring of the catheter while cleaning the tubing.",2020-09-01
787,MAGNOLIA MANOR - GREENVILLE,425090,411 ANSEL ST,GREENVILLE,SC,29601,2019-03-09,693,D,0,1,ZX5911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to follow physician orders [REDACTED]. Resident #81 observed not positioned at 90 degrees as ordered by the physician during tube feeding. The findings included: The facility admitted Resident #81 with [DIAGNOSES REDACTED]. Record review of Resident #81's medical record on 3/7/19 at 7:32 PM revealed a physician's orders [REDACTED]. Head of the bed at > (greater than) 45-degree angle secondary to secretions while at rest. Further review of the physician's orders [REDACTED]. During multiple observations during the survey while the tube feeding was in progress and on 3/7/19 at 8:10 PM, the head of the bed was not at a 90-degree angle. On 3/7/19 at 9:14 PM, review of the physician orders [REDACTED].#2, s/he confirmed the order the head of the bed should be in a 90-degree angle during the tube feeding. On 3/7/19 at approximately 9:15 PM, LPN #2 confirmed Resident #81's head of bed was not at the 90-degree angle as ordered.",2020-09-01
788,MAGNOLIA MANOR - GREENVILLE,425090,411 ANSEL ST,GREENVILLE,SC,29601,2019-03-09,698,E,0,1,ZX5911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, observation, review of the Nursing Facility [MEDICAL TREATMENT] Agreement and the facility policy titled Meal Service for Residents Out of Facility at Meal Time the facility failed to coordinate services with [MEDICAL TREATMENT]. In addition, observation of the food sent to [MEDICAL TREATMENT] revealed there was no cold pack in Resident #33's meal storage bag. One of one resident reviewed for [MEDICAL TREATMENT]. The findings included: The facility admitted Resident #33 with [DIAGNOSES REDACTED]. Record review of Resident #33's medical record on 3/7/19 at 5:48 PM revealed communication sheets with the [MEDICAL TREATMENT] center was missing and/or incomplete for the following dates: 1/5/19, 1/8/19, 1/10/19, 1/12/19, 1/17/19, 1/22/19, 1/24/19, 1/26/19, 1/29/19, 1/31/19/19, 2/2/19, 2/5/19, 2/12/19, 2/28/19. Missing and/or incomplete [MEDICAL TREATMENT] sheets was confirmed by the Assistant Director of Nursing on 3/9/19. In addition, on 3/7/19 at 10:20 AM as Resident #33 was leaving the building for [MEDICAL TREATMENT], an observation was made of Resident #33 taking sandwiches and drinks in a clear, plastic bag which did not contain a cooling agent. Review of the Nursing Facility [MEDICAL TREATMENT] Agreement revealed the [MEDICAL TREATMENT] center will communicate with the Nursing Facility via the [MEDICAL TREATMENT] Communication Form, including when a resident refuse scheduled medical management or non-compliance with medical management relating to [MEDICAL TREATMENT] treatment. Review of the facility policy titled Meal Service for Residents Out of Facility at Meal Time did not include a cooling agent should be included with the meal that is sent with the resident.",2020-09-01
789,MAGNOLIA MANOR - GREENVILLE,425090,411 ANSEL ST,GREENVILLE,SC,29601,2019-03-09,758,D,0,1,ZX5911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to implement non-pharmacological interventions prior to initiating antipsychotic drug therapy and document evidence of continued need for 1 of 5 sampled residents reviewed for unnecessary medication. Resident #28 started on [MEDICATION NAME] in (MONTH) (YEAR) with no evidence of behaviors or non-pharmacological interventions attempted prior to initiating drug therapy. The findings included: The facility admitted Resident #28 with [DIAGNOSES REDACTED]. Review of Resident #28's 9/12/18 Psychotherapy Progress Notes at approximately 10 AM on 3/9/19 revealed that [MEDICATION NAME] 25 milligrams (mg) daily was added to the resident's drug regimen when the resident requested an increase in [MEDICATION NAME] due to issues with sleep and periods of increased anxiety. On 1/14/19, the [MEDICATION NAME] was increased to 50 mg Q (every) HS (hour of sleep). There was no order for behavioral monitoring and/or non-pharmacological interventions attempted prior to adding or increasing the medication. Review of Resident #28's Nurse's Notes, Medication Administration Records, and Behavior Monitoring Flowsheets revealed no evidence of documented behaviors or non-pharmacological interventions attempted prior to initiating or increasing the [MEDICATION NAME]. Review of a 1/9/19 Pharmacy Consultation Report for Resident #28 on 3/9/19 at 10:15 AM revealed a physician recommendation to add specific targeted behavior monitoring on an ongoing basis for the resident's routine psychoactive medications ([MEDICATION NAME], and [MEDICATION NAME]). The Nurse Practitioner responded on 2/28/19 to monitor for symptoms of depression and anxiety. Antipsychotics were not addressed. During an interview on 3/9/19 at 2:15 PM, the Assistant Director of Nurses (ADON) verified the pharmacy reports. The ADON reviewed Resident #28's medical record and verified there was no evidence of non-pharmacological interventions attempted prior to initiating or increasing the [MEDICATION NAME]. Review of Resident #28's 10/9/18 Quarterly Minimum Data Set (MDS) Assessment at 11:35 AM on 3/9/19 revealed Under Section N, N0450 was coded that a GDR (gradual dose reduction) had not been attempted and that the physician had not documented the GDR as clinically contraindicated. During an interview at 12:30 PM on 3/9/19, MDS Coordinator #1 reviewed Resident #28's medical record and confirmed the coding of the MDS Assessments.",2020-09-01
790,MAGNOLIA MANOR - GREENVILLE,425090,411 ANSEL ST,GREENVILLE,SC,29601,2019-03-09,812,D,0,1,ZX5911,"Based on observation, record review and interview, the facility failed to calibrate the food thermometer prior to use, improperly hand washing and improperly handled food scoop in 1 of 1 kitchen. Findings include: During an interview on 03/06/19 at approximately 11:20 am, the Kitchen Aid stated that s/he put the digital food thermometer in ice-water until it reaches 32 degrees to calibrate. On 03/06/19 at approximately 11:22 am, observation of digital food thermometer in ice water revealed temperature reaching only 35 degrees. The Kitchen Aid stated that the digital food thermometer is calibrated on a weekly basis. S/he stated that the calibration was not done this week and could not show any recording of digital temperatures for the past three months. On 03/06/19 at 12:20 PM, during an observation of the lunch line plating with the Kitchen Supervisor, the Kitchen Aid was using a food scoop to transfer food. Without wearing gloves and with his/her left fingers touching the inside of the food scoop, the Kitchen Aid then proceeded to put the food scoop into the steamed vegetable tray. Once the Surveyor notified him/her that he/she touched the food with his/her hands, he/she wiped his/her hands with a kitchen towel and proceeded to put gloves on his/her hands. The Kitchen Supervisor verified that Kitchen Aid touched the food scoop without wearing gloves and his/her left fingers touched the steamed vegetable tray. The Kitchen Supervisor also stated that the Kitchen Aid should have properly washed his/her hands prior to donning gloves. On 03/06/19 at approximately 4:15 pm, review of the facility policy on Hand hygiene/hand washing, which includes procedures for kitchen and food preparation. This includes hand washing by using the hand washing sink only. Use this method to clean hands by rinsing and exposed portions of arms, using warm running water. Apply an amount cleaning compound. Lather all area. Rinse hands under warm running water. Dry hands with a disposable paper towel. Turn water off using a dry paper towel. Discard paper towel properly.",2020-09-01
791,MAGNOLIA MANOR - GREENVILLE,425090,411 ANSEL ST,GREENVILLE,SC,29601,2019-03-09,880,E,0,1,ZX5911,"Based on interview, record review and observation the facility failed to provide a safe and sanitary environment to prevent the transmission of disease and infection. Certified Nursing Assistants (CNAs) were observed touching multiple items before washing hands after incontinent and catheter care. Observations of the Laundry room revealed clean laundry in close proximity to washers with no separation between clean and soiled items. 2 of 2 units observed. The findings included: Following an observation of catheter care for Resident #62 at 9:57 AM on 3/7/19, Certified Nursing Assistant (CNA) #1 took bags of trash and linen down the hall for disposal. The CNA used the keypad to open the soiled utility on the West Wing, opened the lid and placed the trash in the container. S/he crossed the hall, opened the bath room door, lifted the lid, and disposed of the bag of soiled linen in the container. The CNA then proceeded to the nursing station to wash her/his hands. When asked why s/he had washed her/his hands there, the CNA stated, I can't wash them in the soiled utility room. During an interview at 10:15 AM, Licensed Practical Nurse #1 entered the soiled utility room with the surveyor and verified that there was a large plastic container of lift belts and cords stored in the sink, making it inaccessible for use. The bottom of the sink was full of dust, dirt and debris. There was no soap available to wash hands. There were 15 batteries and 2 feeding pumps on the counter. Observation on 3/7/19 at 8:10 PM, revealed Certified Nursing Assistant (CNA) #6 after performing incontinent care on Resident #81 the CNA placed a brief, opened door where clothes were kept, made a second attempt to find appropriate clothing for resident, placed gown on resident, raised the head of the bed, straightened the covers, touched the bedside table, placed trash liners in trash cans, pulled back the privacy curtain and then removed his/her soiled gloves. CNA #6 after gathering trash and soiled clothing, exited the resident's room, placed the trash in the soiled utility, dropped off the bagged clothing across the hall and washed his/her hands at the nursing station. During an interview with CNA #6 on 3/7/19 after the observation, s/he did not dispute the breach in infection control practice. During observation of the laundry on 3/7/19 at 10:21 AM, Laundry Staff #1 was observed to pick up resident laundry from rooms and observed with soiled gloves to reach into his/her pocket and remove or place laundry basket tags. Observation of the laundry revealed two carts of uncovered clean laundry within close proximity to washers (approximately four feet). In addition, there was no separation between clean and soiled items and a cart containing soiled bagged clothes was observed butted up to the clean folding table. On 3/7/19 after the observation, the concerns were shared with Laundry Staff #1 and s/he did not dispute the findings.",2020-09-01
792,MAGNOLIA MANOR - GREENVILLE,425090,411 ANSEL ST,GREENVILLE,SC,29601,2018-03-15,580,D,1,1,VLIR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to notify the Responsible Party (RP) for Resident #90 of a change in treatment, 1 of 6 sampled residents reviewed for unnecessary medications. The facility discontinued the resident's [MEDICATION NAME] without notifying the RP. Cross refer to F[AGE]7 The findings included: The facility admitted Resident #90 with [DIAGNOSES REDACTED]. Record review of a Neurology progress note, dated 8/8/2017, on 3/13/2018 at 1:37 PM revealed instructions for dosing and administering Resident #90's [MEDICATION NAME] (a medication to treat [MEDICAL CONDITION]). The instructions were as follows: Increase first dose of [MEDICATION NAME] ([MEDICATION NAME]/[MEDICATION NAME]) to 1.5 tablets. After 1 month increase 2nd dose to 1.5 tablets. After another month increase 3rd dose to 1.5 tablets. After another month, increase 4th dose to 1.5 tablets. Patients GOAL dose wilt be 1.5 tablets 4 times a day. Titration chart provided. In addition, the progress note indicated the facility was to call the Neurology office if there needs to be any medication changes. Record review of the Telephone Orders on 3/13/2018 at 1:37 PM , revealed an order, dated 9/12/2017, to give [MEDICATION NAME] 10-100, one and a half tablets at 9:00 AM and 1:00 PM and one tablet at 5:00 PM and 9:00 PM. Record review of a Neurology progress note, dated 9/12/2017, on 3/13/2018 at 1:37 PM revealed orders to increase the 2nd dose of [MEDICATION NAME] to 1.5 tablets. The note indicated that the resident's [MEDICATION NAME] dose was not to be decreased. Record review of the December, 2017 Physician order [REDACTED]. Record review of the Medication Administration Records (MARs) on 3/14/2018 at 2:45 PM revealed that Resident #90 stopped receiving [MEDICATION NAME] on 1[DATE]17. The resident's [MEDICATION NAME] was restarted on 1/13/2018 per a 1/12/2018 Telephone Order. There were no orders to discontinue the [MEDICATION NAME] and no progress notes indicating it should be discontinued. In addition, there was no documentation indicating the RP had been notified of the [MEDICATION NAME] being discontinued. During an interview with the resident's Responsible Party (RP) on 3/13/2018 at 1:25 PM, the RP expressed concerns related to Resident #90's [MEDICATION NAME]. The RP stated that in January she/he began to notice that the resident was becoming more rigid, or stiff, in his/her arms and legs. The RP also stated that around this time, staff had asked that different clothing be brought in to make it easier to change the resident's clothes. On 1/12/2018, the RP asked Licensed Practical Nurse (LPN) #3 if the resident's [MEDICATION NAME] should be increased to help loosen him up. The RP stated that LPN #3 told her/him the resident's [MEDICATION NAME] was discontinued on 1[DATE]17. The RP stated she/he was not notified of the [MEDICATION NAME] being discontinued. The RP stated she/he asked staff who discontinued the [MEDICATION NAME], but no one knew who did or why. During an interview with LPN #3 on 3/15/2018 at 9:20 AM, LPN #3 recalled that the RP approached her/him on 1/12/2018 asking what dosage of [MEDICATION NAME] Resident #90 was receiving. LPN #3 informed the RP the [MEDICATION NAME] was discontinued on 1[DATE]18. LPN #3 stated the RP said the [MEDICATION NAME] should have never been discontinued and asked why she/he wasn't notified of this. LPN #3 stated she/he called the Neurologist's office and was told that the resident should still be receiving the [MEDICATION NAME] and it should not have been discontinued. LPN #3 stated she/he received new orders to restart the [MEDICATION NAME]. During an interview with the Director of Nursing (DON) on 3/15/2018 at 8:33 AM, the DON confirmed there were no orders or notes to discontinue the [MEDICATION NAME]. The DON stated it appears to have been a transcription error. She/he stated when the order was put in the computer in September, a stop date of 1[DATE]18 was entered.",2020-09-01
793,MAGNOLIA MANOR - GREENVILLE,425090,411 ANSEL ST,GREENVILLE,SC,29601,2018-03-15,655,D,0,1,VLIR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, records review and staff interview the facility failed to develop a baseline care plan that includes the needed instructions and resident health information to provide effective and person-center care for one of one resident sampled reviewed for [MEDICAL TREATMENT]. The findings included: Resident #144 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Care plan reviewed on 03/14/18 at approximately 9:30 AM revealed that baseline care plan developed on 03/09/18 includes the following statement under the subtitle Problem: Objective: Resident is a new admission. admitted from hospital status [REDACTED]. Continuing review baseline care plan revealed the following goals: Resident's stated goals and objective (goal target date 3/2018), resident's immediate health and safety needs will be identified (goal target date 3/2018), services and treatment to be administered by facility will be identified (goal target date 3/2018), current resident functional status will be identified (goal target date 3/2018), dietary instructions will be identified and communicated to staff/resident (goal target date 3/2018), resident activity goals and preferences will be identified by completion of comprehensive assessment (goal target date 3/2018), discharge plans will be identified (goal target date 3/2018), resident /and or legal representative will be provided a list of current medications by completion of comprehensive assessment (goal target date 3/2018), and plan of distribution (goal target date 3/2018). Review of the baseline care plan approach the same day and time states the following: resident stated goal and desired outcomes: wound healed and return home (approach start date: 03/09/18), hydration risk: provide adequate fluids; determine likes/dislike; offer fluids between meals (approach start date: 03/09/18), fall risk: minimized fall-encourage the use of call light; orient to room (approach start date: 03/09/18), pain management: monitor pain; verbal/descriptor; location-arm; treatment-see physician orders [REDACTED]./18), diet/consistency: regular, renal; liquid/consistency-thin; restriction -renal diet; likes/dislikes-see food and beverage preference list (approach start date: 03/09/18), activity preferences-shopping, cooking and yard work(approach start date: 03/09/18), complete discharge evaluation and plan. Provide to resident and legal representative (approach start date: 03/09/18), and review and confirm admitting orders with attending. Obtain [DIAGNOSES REDACTED]. However, the baseline care plan does not address the [DIAGNOSES REDACTED]. During an interview with the care plan coordinator on 03/14/18 at 10:15 AM, s/he stated that s/he was not aware that the baseline care plan needed to include [DIAGNOSES REDACTED].",2020-09-01
794,MAGNOLIA MANOR - GREENVILLE,425090,411 ANSEL ST,GREENVILLE,SC,29601,2018-03-15,657,E,0,1,VLIR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure that residents #58 and #80 care plan was reviewed and revised to address activities for cognitively impaired residents that could benefit from one to one ongoing activity program. The care plan does not address activities of interest identified on the facility's Activities Evaluation form. Two (2) of 2 residents reviewed for activities. The findings included: The facility admitted Resident #58 with [DIAGNOSES REDACTED]. Random observations on 3/12/18 at approximately 11:01 AM, 11:51 AM and 2:40 PM revealed Resident #58 in his/her room with no activities in progress. Random observations on 3/13/18 at 11:58 AM resident was in room with no structured activities in progress. A random observation on 3/13/18 at approximately 1:31 PM revealed resident seated in day area with several residents with no structured activity in progress. The television program Matlock was noted on a large screen television. Throughout the survey, the resident observed in his/her room in bed with no structured activities in progress. Review of the medical record on 3/13/18 at approximately 2:13 PM revealed an Activity Evaluation dated 7/26/17 that indicated Resident #58 activities of interest included Dogs, Current Events/News, Movies, Music (50's, R&B (rhythm and blues), Country, Sing-Alongs, Social/Parties and resident love to dance and sing. A review of the care plan with a problem start date of 8/09/16 and updated on 2/06/18 that indicated the resident preferred to stay in bed under the problem area of activities. Under the approach area of the care indicated to assist the resident to activities such as bingo, manicures, children related, crafts and musicals which was not addressed in the Activities Evaluation dated 7/26/17. The care plan did not address providing in room one to one activities for the resident. An interview on 3/15/18 at approximately 10:51 AM with the Activity Director confirmed Resident #58 preferred to stay in his/her room. The Activity Director acknowledged the care plan did not address specific activities of interest based on the Activity Evaluation. The facility admitted Resident #80 with [DIAGNOSES REDACTED]. Random observations on 3/12/18 at 11:29 AM and 2:39 PM revealed resident in room on low bed with no structured activities in progress. Random observations on 3/13/18 at 11:52 AM and 2 PM revealed resident in room in bed with no structured activities being offered. The resident remained in his/her room on all days of the survey with no structured activities being offered. A review of the medical record on 3/13/18 at approximately 2:09 PM revealed an Activity Evaluation dated 5/15/17 that indicated Resident #80 activities of interest included Dogs, Loves Gospel Music, Social/Parties, Sports likes volley ball, kickball and ball toss. A review of the care plan with a start date of 5/31/16 indicated resident had a cognitive impairment and he/she disliked group activities. Under the approach area of the care plan indicate one to one activities provide as needed and that resident to be escorted to and from activities. On 3/14/18 at 9:40 AM the Activity Director provided one to documentation for (MONTH) (YEAR). The Activity Director then stated he/she updated Resident #80 care plan last night after realizing it needed to be changed. The changes noted on the care plan was that Resident #58 refused activities. The Activity Director further acknowledged the resident interested in Dogs as listed on the Activity Evaluation had not been provided. An interview on 3/15/18 at approximately 10:51 AM with the Activity Director confirmed Resident #80 stays in his/her room in bed. The Activity Director acknowledged the care plan did not address specific activities of interest based on the Activity Evaluation.",2020-09-01
795,MAGNOLIA MANOR - GREENVILLE,425090,411 ANSEL ST,GREENVILLE,SC,29601,2018-03-15,679,E,0,1,VLIR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure that residents with cognitive impairments received an on-going structured program of activities for 2 of 2 sampled residents reviewed. Resident #58 and #80 were observed in their room with no program of activities being provided. The findings included: The facility admitted Resident #58 with [DIAGNOSES REDACTED]. Random observations on 3/12/18 at approximately 11:01 AM, 11:51 AM and 2:40 PM revealed Resident #58 in his/her room with no activities in progress. Random observations on 3/13/18 at 11:58 AM resident was in room with no structured activities in progress. A random observation on 3/13/18 at approximately 1:31 PM revealed resident seated in day area with several residents with no structured activity in progress. The television program Matlock was noted on a large screen television. Throughout the survey, the resident observed in his/her room in bed with no structured activities in progress. Review of the medical record on 3/13/18 at approximately 2:13 PM revealed an Activity Evaluation dated 7/26/17 that indicated Resident #58 activities of interest included Dogs, Current Events/News, Movies, Music (50's, R&B (rhythm and blues), Country, Sing-Alongs, Social/Parties and resident love to dance and sing. An Annual Minimum Data Set ((MDS) dated [DATE] and a quarterly MDS dated [DATE] indicated revealed the resident had a Brief Interview of Mental Status (BIMS) of 6 which indicate the resident was not interview-able. Documentation in the medical record further indicated the resident did not have decisional capacity. A review of an individual activity documentation sheet for Resident #58 for (MONTH) (YEAR) revealed the resident participated in an educational program on 1/17/18 and participated in music and social party on 1/26/18. A (MONTH) participation record revealed resident participated in arts/crafts on 2/05/18 and 2/12/18. Current events was provided 2/07/18, 2/12/18, 2/20/18 and 2/26/18. Group discussion was provided on 2/07/18, 2/20/18, 2/26/18 and 2/28/18. Sport activity was provided 2/07/18 and dance provided 2/16/18. The (MONTH) (YEAR) one to one indicate conversation was provided with the resident on 3/07/18, 3/13/18 and 3/14/18 for 15 minutes. On 3/14/18 at 9:40 AM the Activity Director provided one to documentation for (MONTH) (YEAR). The Activity Director then stated he/she updated Resident #80 care plan last night after realizing it needed to be changed. The changes noted on the care plan was that Resident #58 refused activities. The Activity Director further acknowledged the resident interested in Dogs as listed on the Activity Evaluation had not been provided. An interview on 3/15/18 at approximately 10:51 AM with the Activity Director confirmed Resident #58 preferred to stay in his/her room. The Activity Director stated the resident would participate in group activities at times but preferred to stay in his/her room. The AD further acknowledged some of the activities provided were not the activities as noted on the Activity Evaluation. The facility admitted Resident #80 with [DIAGNOSES REDACTED]. Random observations on 3/12/18 at 11:29 AM and 2:39 PM revealed resident in room on low bed with no structured activities in progress. Random observations on 3/13/18 at 11:52 AM and 2 PM revealed resident in room in bed with no structured activities being offered. The resident remained in his/her room on all days of the survey with no structured activities being offered. A review of the medical record on 3/13/18 at approximately 2:09 PM revealed an Activity Evaluation dated 5/15/17 that indicated Resident #80 activities of interest included Dogs, Loves Gospel Music, Social/Parties, Sports likes volley ball, kickball and ball toss. A review of the care plan with a start date of 5/31/16 indicated resident had a cognitive impairment and he/she disliked group activities. Under the approach area of the care plan indicate one to one activities provide as needed and that resident to be escorted to and from activities. An Annual Minimum Data Set ((MDS) dated [DATE] and a quarterly MDS dated [DATE] revealed the resident was severely cognitive impaired. Documentation in the medical record further indicated the resident did not have decisional capacity. A review of the individual participation record for (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR) revealed activities offered and refused by Resident #80 did not include activities listed on the 5/15/17 Activity Evaluation and there was no updated evaluation completed to determine a change in the resident's activity interest. Activity offered were educational programs, reading, music (non specific) and happy heart. An interview on 3/15/18 at approximately 10:51 AM with the Activity Director confirmed Resident #80 stays in his/her room in bed. The Activity Director acknowledged activities noted on Activity Evaluation were not activities provided to resident.",2020-09-01
796,MAGNOLIA MANOR - GREENVILLE,425090,411 ANSEL ST,GREENVILLE,SC,29601,2018-03-15,684,D,1,1,VLIR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview the facility failed to provide necessary care and services for 1 of 6 residents reviewed for unnecessary medications. Resident #147 had abnormal laboratory results that were not reported to the provider in a timely manner leading to possible delay in care. The findings included: Resident #147 was admitted to the facility with [DIAGNOSES REDACTED]. Review of complaint on 3/13/18 at approximately 1:21 PM revealed that Resident #147 had blood work that was completed on 9/22/17. The lab results were faxed to the facility the same day at 11:59 AM. The results were not called to the provider leading to a delay in treatment. On 9/25/18 the resident had confusion, weakness, incontinence of bladder, and dysphagia. The nurse practitioner had the resident sent to the emergency room for evaluation. Review of the Facility's 5-day report on 3/13/18 at approximately 1:22 PM revealed the 9/22/17 basic metabolic panel (BMP) for Resident #147 showed abnormal [MED], potassium, and blood urea nitrogen. These results were not reported to the provider promptly and the resident continued to receive [MEDICATION NAME] [AGE] milligrams (mg) twice daily and [MED] 30 milliequivalents (mEq) twice daily. Additional changes on 9/25/17 led to the resident's transfer to emergency room for further evaluation. Review of telephone orders for Resident #147 on 3/13/18 at approximately 1:47 PM revealed a 9/25/17 order to send the resident to St. Francis related to weakness and confusion, new onset. Review of telephone orders for Resident #147 on 3/13/18 at approximately 1:47 PM revealed the following orders dated 9/15/17. 1. [MEDICATION NAME] was increased to [AGE] mg twice daily for two weeks, then lowered to [AGE] mg twice daily 2. [MED] was increased to 30 mEq twice daily for two weeks, then lowered to 20 mEq twice daily 3. BMP was to be done one week from that time (9/22/17) Review of discharge summary for Resident #147 on 3/13/18 at approximately 1:50 PM revealed the resident was sent to the hospital secondary to weakness, altered mental status, and lethargy. Review of progress notes on 3/13/18 at approximately 1:52 PM confirmed the provider increased [MEDICATION NAME] and [MED] for two weeks and ordered a basic metabolic panel to be done on 9/22/17. Progress notes also documented normal lab values for Resident #147. 1. Na = 141 2. K = 4.1 3. BUN = 44. Review of Medication Administration Record [REDACTED]. Review of 9/22/17 Lab Report for Resident #147 on 3/13/18 at approximately 2:15 PM revealed the following lab values: Na = 127, K = 5.4, and BUN = 45. The lab report had been signed by the provider on 9/25/17. Review of Nursing Notes for Resident #47 on 3/13/18 at approximately 2:24 PM revealed no documentation that the provider was informed of abnormal electrolyte values. The Nursing Note dated 9/25/17 revealed the resident was confused, lethargic, and [MEDICAL CONDITION]. S/he was sent to the emergency room at 9:30 AM and from the hospital was transferred to hospice house. Interview with medical director at 9:25 AM on 3/14/18 at approximately 9:25 AM confirmed the medical director did not believe any harm was done to the resident by the delay in lab reporting. Per the physician, the resident would have gone to the hospital regardless because any attempt to treat the electrolyte imbalance likely would have caused other issues. Specifically, the medical director stated that decreasing [MEDICATION NAME] to rectify electrolyte abnormalities may have led to congestion and [MEDICAL CONDITION]. Review of critical lab values for the lab service on 3/14/18 at approximately 9:33 AM revealed the abnormal electrolyte values were not considered critical. Interview with DON on 3/14/17 at approximately 11:23 AM revealed Resident #147's BMP results were sent to the facility on [DATE] at 10:02 AM. Interview with DON on 3/14/17 at approximately 11:55 AM revealed that nurses signing on to a shift have a log book that tells what lab values are expected to be received for their patients on that shift. If the nurse does not receive those lab reports, he or she is to call the lab service before signing off for the shift to inquire about lab results. Review of Notification policy on 3/14/18 at approximately 12:06 PM revealed the physician is to be notified of recent labs. Interview with Licensed [MEDICATION NAME] Nurse (LPN) #1 on 3/14/18 at approximately 12:24 PM revealed that s/he left the facility at 3 PM. S/he stated that the fax machine was broken and no lab results were received. S/he also stated that the 24-hour report did not state that Resident #147 had pending labs expected that shift. Review of Specimen log and Lab collection report on 3/14/18 at approximately 12:41 PM revealed that Resident #147 in room [ROOM NUMBER]A was expecting lab results on 9/22/17. Interview with DON on 3/14/18 at approximately 2:16 PM confirmed the Resident #147 had the incorrect room number on the specimen lab report. The DON confirmed it was possible that the nurse on duty or the reporting nurse missed that Cart B was expecting lab results because of this error. Review of Room Change Notification 3/14/18 at approximately 2:19 PM revealed Resident #147 changed rooms on 9/18/17. The resident changed from room [ROOM NUMBER]A to room [ROOM NUMBER]A which would have resulted in moving from Cart A to Cart B.",2020-09-01
797,MAGNOLIA MANOR - GREENVILLE,425090,411 ANSEL ST,GREENVILLE,SC,29601,2018-03-15,757,D,1,1,VLIR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record and interview, the facility failed to provide medication as ordered for Resident #90, 1 of 6 sampled residents reviewed for unnecessary medications. The facility discontinued Resident #90's [MEDICATION NAME], in error, without an order to discontinue the medication. The findings included: The facility admitted Resident #90 with [DIAGNOSES REDACTED]. Record review of a Neurology progress note, dated 8/8/2017, on 3/13/2018 at 1:37 PM revealed instructions for dosing and administering Resident #90's [MEDICATION NAME] (a medication to treat [MEDICAL CONDITION]). The instructions were as follows: Increase first dose of [MEDICATION NAME] ([MEDICATION NAME]/[MEDICATION NAME]) to 1.5 tablets. After 1 month increase 2nd dose to 1.5 tablets. After another month increase 3rd dose to 1.5 tablets. After another month, increase 4th dose to 1.5 tablets. Patients GOAL dose will be 1.5 tablets 4 times a day. Titration chart provided. In addition, the progress note indicated the facility was to call the Neurology office if there needs to be any medication changes. Record review of a Neurology progress note, dated 9/12/2017, on 3/13/2018 at 1:37 PM revealed orders to increase the 2nd dose of [MEDICATION NAME] to 1.5 tablets. The note indicated that the resident's [MEDICATION NAME] dose was not to be decreased. Record review of the Telephone Orders on 3/13/2018 at 1:37 PM , revealed an order, dated 9/12/2017, to give [MEDICATION NAME] 10-100, one and a half tablets at 9:00 AM and 1:00 PM and one tablet at 5:00 PM and 9:00 PM. Record review of the December, 2017 Physician order [REDACTED]. Record review of the Telephone Orders on 3/14/2018 at 2:10 PM, revealed an order from the Neurologist's office, dated 1/12/2018, for [MEDICATION NAME] 25/100 a half tablet twice daily for 2 weeks. Then increase to one tablet twice daily for 2 weeks. Then increase to one and a half tablets twice daily and remain at one and a half tablets twice daily. Record review of the Medication Administration Records (MARs) on 3/14/2018 at 2:45 PM revealed that Resident #90 stopped receiving [MEDICATION NAME] on 1[DATE]17. The resident's [MEDICATION NAME] was restarted on 1/13/2018 per the 1/12/18 Telephone Order. There were no orders to discontinue the [MEDICATION NAME] and no progress notes indicating it should be discontinued. During an interview with the resident's Responsible Party (RP) on 3/13/2018 at 1:25 PM, the RP expressed concerns related to Resident #90's [MEDICATION NAME]. The RP stated that in January she/he began to notice that the resident was becoming more rigid, or stiff, in his/her arms and legs. The RP also stated that around this time staff had asked that different clothing be brought in to make it easier to change the resident's clothes. On 1/12/2018, the RP asked Licensed Practical Nurse (LPN) #3 if the resident's [MEDICATION NAME] should be increased to help loosen him up. The RP stated that LPN #3 told her/him the resident's [MEDICATION NAME] was discontinued on 1[DATE]17. The RP stated she/he was not notified of the [MEDICATION NAME] being discontinued. The RP stated she/he asked staff who discontinued the [MEDICATION NAME], but no one knew who did or why. During an interview with LPN #2 on 3/15/2018 at 9:19 AM, LPN #2 stated that she/he recalled the [MEDICATION NAME] being discontinued, but could not remember which provider did so. LPN #2 confirmed there were no orders or notes on the record to discontinue the Sinmet. In addition, LPN #2 confirmed the Neurology note from 8/8/2017 indicated the resident's goal was to receive [MEDICATION NAME] one and a half tablets four times per day and to call if any medication changes were needed. During an interview with LPN #3 on 3/15/2018 at 9:20 AM, LPN #3 recalled that the RP approached her/him on 1/12/2018 asking what dosage of [MEDICATION NAME] Resident #90 was receiving. LPN #3 informed the RP the [MEDICATION NAME] was discontinued on 1[DATE]18. LPN #3 stated the RP said the [MEDICATION NAME] should have never been discontinued. LPN #3 stated she/he called the Neurologist's office and was told that the resident should still be receiving the [MEDICATION NAME] and it should not have been discontinued. LPN #3 stated she/he received new orders to restart the [MEDICATION NAME]. When asked why the RP had asked her/him about the [MEDICATION NAME] dosing, LPN #3 stated the wife thought the resident was becoming more rigid in his/her arms and legs. During an interview with the Director of Nursing (DON) on 3/15/2018 at 8:33 AM, the DON confirmed there were no orders or notes to discontinue the [MEDICATION NAME]. The DON stated it appears to have been a transcription error. She/he stated when the order was put in the computer in September, a stop date of 1[DATE]18 was entered. The DON stated discontinuing the [MEDICATION NAME] was an error.",2020-09-01
798,MAGNOLIA MANOR - GREENVILLE,425090,411 ANSEL ST,GREENVILLE,SC,29601,2018-03-15,758,D,0,1,VLIR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that as needed [MEDICAL CONDITION] medications were ordered every fourteen days unless the practitioner provided a sound explanation for 1 of 6 residents reviewed for unnecessary medications. The findings included: Resident #17 was admitted to the facility with [DIAGNOSES REDACTED]. Review of Resident 17's medical record on 3/14/18 at approximately 10AM revealed that after Resident 17 was seen by the Psychiatric Nurse Practitioner (NP) on 3/7/18, a new order was written for as needed (PRN) [MEDICATION NAME] 0.5mg for 90 days, with no sound rationale. An interview with the Director of Nursing (DON) confirmed that there was no rationale behind the new order and stated that s/he would contact NP for further clarification. An additional interview was held with DON on 3/15/18 at 12:27PM and DON stated that NP also confirmed that there was no rationale behind the extended PRN medication and agreed to write an addendum with explanations as to why the extended order was valid. On 3/15/2018 at 11AM an amended progress note from 3/7/2018 was received from the DON and proved that NP wrote an addendum stating Resident was prescribed [MEDICATION NAME] as need with good efficacy in the past. [MEDICATION NAME] 0.5mg PO BID prn anxiety order x90 days to address symptoms not addressed by standing regimen and/or staff interventions. No increase in standing regimen recommended at this time.",2020-09-01
799,MAGNOLIA MANOR - GREENVILLE,425090,411 ANSEL ST,GREENVILLE,SC,29601,2018-03-15,773,D,1,1,VLIR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview the facility failed to notify providers of laboratory results for 1 of 6 residents reviewed for unnecessary medications. Resident 147 had abnormal lab results that were not reported to the provider in a timely manner leading to possible delay in care. The findings included: Resident #147 was admitted to the facility with [DIAGNOSES REDACTED]. Review of complaint on 3/13/18 at approximately 1:21 PM revealed that Resident #147 had blood work that was completed on 9/22/17. The lab results were faxed to the facility the same day at 11:59 AM. The results were not called to the provider leading to a delay in treatment. On 9/25/18 the resident had confusion, weakness, incontinence of bladder, and dysphagia. The nurse practitioner had the resident sent to the emergency room for evaluation. Review of the Facility's 5-day report on 3/13/18 at approximately 1:22 PM revealed the 9/22/17 basic metabolic panel (BMP) for Resident #147 showed abnormal [MED], potassium, and blood urea nitrogen. These results were not reported to the provider promptly and the resident continued to receive [MEDICATION NAME] [AGE] milligrams (mg) twice daily and [MED] 30 milliequivalents (mEq) twice daily. Additional changes on 9/25/17 led to the resident's transfer to emergency room for further evaluation. Review of telephone orders for Resident #147 on 3/13/18 at approximately 1:47 PM revealed a 9/25/17 order to send the resident to St. Francis related to weakness and confusion, new onset. Review of telephone orders for Resident #147 on 3/13/18 at approximately 1:47 PM revealed the following orders dated 9/15/17. 1. [MEDICATION NAME] was increased to [AGE] mg twice daily for two weeks, then lowered to [AGE] mg twice daily 2. [MED] was increased to 30 mEq twice daily for two weeks, then lowered to 20 mEq twice daily 3. BMP was to be done one week from that time (9/22/17) Review of discharge summary for Resident #147 on 3/13/18 at approximately 1:50 PM revealed the resident was sent to the hospital secondary to weakness, altered mental status, and lethargy. Review of progress notes on 3/13/18 at approximately 1:52 PM confirmed the provider increased [MEDICATION NAME] and [MED] for two weeks and ordered a basic metabolic panel to be done on 9/22/17. Progress notes also documented normal lab values for Resident #147. 1. Na = 141 2. K = 4.1 3. BUN = 44. Review of Medication Administration Record [REDACTED]. Review of 9/22/17 Lab Report for Resident #147 on 3/13/18 at approximately 2:15 PM revealed the following lab values: Na = 127, K = 5.4, and BUN = 45. The lab report had been signed by the provider on 9/25/17. Review of Nursing Notes for Resident #47 on 3/13/18 at approximately 2:24 PM revealed no documentation that the provider was informed of abnormal electrolyte values. The Nursing Note dated 9/25/17 revealed the resident was confused, lethargic, and [MEDICAL CONDITION]. S/he was sent to the emergency room at 9:30 AM and from the hospital was transferred to hospice house. Review of telephone orders on 3/13/18 at approximately 3:06 PM revealed the following orders dated 8/15/17. 1. [MEDICATION NAME] [AGE] mg PO BID x 2 weeks then decrease to 40 mg PO BID r/t [MEDICAL CONDITION] 2. KCl to 30 mEq PO BID then decrease to 20 mEq PO BID r/t [DIAGNOSES REDACTED] 3. Repeat BMP and BNP in 2 weeks (8/28/17). Review of lab reports for Resident #147 on 3/13/18 at approximately 3:09 PM confirmed the 8/28/17 BMP and BNP had no documentation that they had been reported to the provider timely. Review of nursing notes for Resident #147 on 3/13/18 at approximately 3:12 PM confirmed no documentation for timely reporting of BMP and BNP on 8/28/17. Interview with medical director at 9:25 AM on 3/14/18 at approximately 9:25 AM confirmed the medical director did not believe any harm was done to the resident by the delay in lab reporting. Per the physician, the resident would have gone to the hospital regardless because any attempt to treat the electrolyte imbalance likely would have caused other issues. Specifically, the medical director stated that decreasing [MEDICATION NAME] to rectify electrolyte abnormalities may have led to congestion and [MEDICAL CONDITION]. Review of critical lab values for the lab service on 3/14/18 at approximately 9:33 AM revealed the abnormal electrolyte values were not considered critical. Interview with DON on 3/14/17 at approximately 11:23 AM revealed Resident #147's BMP results were sent to the facility on [DATE] at 10:02 AM. Interview with DON on 3/14/17 at approximately 11:55 AM revealed that nurses signing on to a shift have a log book that tells what lab values are expected to be received for their patients on that shift. If the nurse does not receive those lab reports, he or she is to call the lab service before signing off for the shift to inquire about lab results. Review of Notification policy on 3/14/18 at approximately 12:06 PM revealed the physician is to be notified of recent labs. Interview with Licensed [MEDICATION NAME] Nurse (LPN) #1 on 3/14/18 at approximately 12:24 PM revealed that s/he left the facility at 3 PM. S/he stated that the fax machine was broken and no lab results were received. S/he also stated that the 24-hour report did not state that Resident #147 had pending labs expected that shift. Review of Specimen log and Lab collection report on 3/14/18 at approximately 12:41 PM revealed that Resident #147 in room [ROOM NUMBER]A was expecting lab results on 9/22/17. Interview with DON on 3/14/18 at approximately 2:16 PM confirmed the Resident #147 had the incorrect room number on the specimen lab report. The DON confirmed it was possible that the nurse on duty or the reporting nurse missed that Cart B was expecting lab results because of this error. Review of Room Change Notification 3/14/18 at approximately 2:19 PM revealed Resident #147 changed rooms on 9/18/17. The resident changed from room [ROOM NUMBER]A to room [ROOM NUMBER]A which would have resulted in moving from Cart A to Cart B.",2020-09-01
800,MAGNOLIA MANOR - GREENVILLE,425090,411 ANSEL ST,GREENVILLE,SC,29601,2017-08-23,225,E,1,0,FYRU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to implement abuse prohibition policy in 2 of 3 abuse investigations reviewed. Suspected abuse of Residents #15 and #53 were not promptly reported by staff, and the direct consequence was delayed investigation. The findings included: An initial 24-Hour Report was sent to the Department of Health and Environmental Control on 8/1/17 regarding an allegation that Resident #15 was inappropriately touching another resident. Interview with Certified Nursing Assistant (CNA) #1 on 8/22/17 at approximately 6:15 AM revealed that s/he had observed Resident #15 touching other residents and staff inappropriately on 7/23/17 and 7/28/17. S/he stated that both times s/he reported the suspected abuse to a nurse but was unable to name which nurse. Review of facility policy regarding Abuse Prohibition on 8/22/17 at approximately 7:40 AM revealed the following: All alleged isolations concerning abuse, neglect, or misappropriation of property are reported verbally immediately to the Facility Abuse Coordinator, the Administrator, and to other officials in accordance with state law including the State Certification Agency (nurse aide registry or licensing authorities). The facility policy also clarified that reporting must be within 24 hours. Review of the 8/1/17 with CNA #1 on 8/22/17 at approximately 9:15 AM revealed that CNA #1 stated that s/he called the Director of Nursing (DON) when s/he witnessed Resident #15 inappropriately touching residents but waited until the DON returned to the facility to discuss it. Interview with DON on 8/22/17 at approximately 10:40 AM revealed that CNA #1 called while s/he was out of town but said her concern could wait until the DON returned. The DON also stated that CNA #1 did not discuss the suspected abuse until a week after the DON had returned. The DON clarified that both the administrator and unit manager were available for CNA #1 to report to. An initial 24-Hour Report was sent to DHEC on 4/29/17 regarding an injury of unknown origin noted on Resident #53. Review of 4/29/17 interview of Licensed [MEDICATION NAME] Nurse (LPN) #1 on 8/22/17 at approximately 11 AM revealed that LPN #1 noted the injury of unknown origin on Resident #53 on 4/24/17. LPN #1 continued that she was aware of the requirement to immediately report injuries of unknown origin but failed to do so. Review of 4/24/17 nursing note on 8/22/17 at approximately 11 AM confirms that abnormal bruising on the abdomen of Resident #53 was identified five days before investigation.",2020-09-01
801,MAGNOLIA MANOR - GREENVILLE,425090,411 ANSEL ST,GREENVILLE,SC,29601,2016-12-14,155,D,0,1,1MGH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure that residents who were deemed unable to make health care decisions had two physician signatures to determine the resident's inability to make health care decisions. Resident #101 was coded for Do Not Resuscitate (DNR) with only one physician's signature for mental incapacity. (1 of 16 sampled residents reviewed for Advance Directives). The findings included: The facility admitted Resident #101 with [DIAGNOSES REDACTED]. A review of the medical record on 12/13/16 at approximately 11:17 AM revealed Resident #101 was coded as a Do Not Resuscitate (DNR) on a tabbed sheet in medical record, a written physician's orders [REDACTED]. There was only one physician's statement in the medical record to indicate the resident did not have the mental capacity to make health care decisions. An interview on 12/13/16 at approximately 11:20 AM with Licensed Practical Nurse (LPN) #1 who reviewed the medical record and confirmed the resident was coded for DNR with only one physician's signature to indicate the resident did not have mental capacity to make health care decisions. An interview on 12/13/16 at approximately 1:39 PM with the Social Services Director (SSD) who reviewed the medical record and stated Resident #101 was coded for DNR. The SSD further confirmed there was no second physician statement to indicate the resident had no decisional capacity to make health care decisions.",2020-09-01
802,MAGNOLIA MANOR - GREENVILLE,425090,411 ANSEL ST,GREENVILLE,SC,29601,2016-12-14,282,J,0,1,1MGH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to transfer Resident #67 per the Care Plan, 1 of 6 sampled residents reviewed for accidents. Resident #67 was not transferred with a hoyer lift per the Care Plan but by a stand and pivot method used by one Certified Nursing Assistant. The resident was found the next morning to have a femur fracture. This action resulted in an Immediate Jeopardy at Past non-compliance. The facility put a corrective plan of action in place to address this incident and it was accepted by the survey agency. However non-compliance was identified at F282 when the facility failed to provide splints for Resident #76 and #101 per the care plan, 2 of 4 sampled residents reviewed for range of motion. The finding included: The facility admitted Resident #67 with [DIAGNOSES REDACTED]. Record review of Resident #67's Resident Profile on 12/13/2016 at 3:09 PM, revealed that Resident #67 was to transfer with the assist of 2 persons with a hoyer lift. Record review of Resident #67's Care Plan on 12/13/2016 at 4:37 PM, revealed that staff were to use a hoyer lift to transfer the resident. Review of documentation of an interview conducted by the facility with CNA (Certified Nursing assistant) #1 on 12/12/2016 at 10:30 AM, revealed that on 6/10/2016 CNA #1 transferred Resident #67 inappropriately. Per the statement (dated 6/12/2016), CNA #1 stated that he/she transferred Resident #67 from the bed to the wheelchair without using a hoyer lift and assistance from other staff. In addition, CNA #1 later transferred the resident back to bed without using a hoyer lift and assistance from other staff. Per the statement, CNA #1 stated he/she did not know the resident was to be transferred with a hoyer lift. In addition, CNA #1 did not know where to look in the resident's record to know how the resident should be transferred. During an interview with CNA #3 on 12/13/2016 at 2:19 PM, CNA #3 was asked how CNAs know how to transfer residents. CNA #3 stated that CNAs look at the Resident Profile in the computer to find this information. In addition, CNA #3 stated that there are symbols above each residents bed that indicate certain types of care the resident should receive, including transfers. CNA #3 stated that she/he received training during orientation on using the Resident Profile in the computer, on the symbols above the bed and on the use of hoyer and other mechanical lifts for transferring residents. During an interview with CNA #1 on 12/13/2016 at 3:28 PM, CNA #1 confirmed his/her statement from 6/12/2016. CNA #1 stated he/she did not transfer the resident with a hoyer lift and assistance from other staff. CNA #1 stated he did not remember receiving any training on how to access the Resident Profile or training on what the symbols above the resident's bed meant. CNA #1 stated he/she asked other staff how to transfer the resident prior to caring for her/him. CNA #1 stated that he/she was told that Resident #67 was a one person transfer. CNA #1 could not remember who told him/her that the resident was a one person transfer. Immediate Jeopardy at Past Noncompliance existed in the facility on 6/10/16 related to Resident #67 found to have a fractured femur after an incorrect transfer by a Certified Nursing Assistant. The facility submitted a Plan of Correction ( P[NAME] ) which was reviewed by the survey team and approved on 12/14/16. The identified Immediate Jeopardy citation was corrected as of 7/16/2016. The P[NAME] included the following: All residents at the facility were reviewed to ensure they were not affected by the deficient practice. On (MONTH) 13, (YEAR) education was initiated by Director of Nursing (DON) and Director of Education (DOE) for Nursing staff that included: Staff re-education by Director of Education on Resident Abuse/Neglect was initiated and completed on (MONTH) 14, (YEAR); Inservice included icons to determine care plan of residents Following that date, education was completed as staff members arrived for their next scheduled shift. Administrator and Director completed an ad hoc Quality Assurance and Performance improvement meeting with the Medical Director on (MONTH) 13, (YEAR). In addition inservice to all staff on resident transfer technique, resident profile and the icons posted in each resident's room to inform staff which type of transfer to use for the resident. Results of monitoring will be presented by the Quality Assurance Performance Improvement (QAPI) committee by the Director of Nursing and Administrator for period of 3 months to ensure compliance is maintained. Any areas of concern identified will be addressed at time of discovery. During the survey based on observation and interview of staff members and residents related to the items noted in the facility plan of correction the Immediate Jeopardy at Past non-Compliance was determined to be in place and corrected as of 7/16/2016. The facility admitted Resident #101 with [DIAGNOSES REDACTED]. Random observations on 12/12/16 and 12/13/16 between the hours of 8:30 AM and 4: 30 PM revealed Resident #101 had contractures in both hands with no splint devices in place. Review of the medical record on 12/13/16 at approximately 1:44 PM revealed a physician's orders [REDACTED]. Further review of the medical record revealed a care plan updated on 11/17/16 that indicated hand carrots as ordered. An interview on 12/13/16 at approximately 2 PM with Registered Nurse (RN) #1 stated Resident #101 needed hand splints and confirmed they were not in place as care planned. The facility admitted Resident #76 with [DIAGNOSES REDACTED]. Random observations on 12/12/16 and 12/13/16 between the hours of 8:30 AM to 4:30 PM revealed the resident was not wearing hand splints for contracture. Review of the medical record on 12/13/16 at approximately 2:52 PM reviewed a physician's orders [REDACTED]. Further review of the medical record revealed a care plan updated on 11/09/16 that indicated PROM and apply splints as ordered. An interview on 12/13/16 at approximately 3:11 PM with Registered Nurse (RN) #1 confirmed Resident #76 was care planned for wrist splint. RN #1 stated there was no documentation to indicate the wrist splint was being provided as care planned.",2020-09-01
803,MAGNOLIA MANOR - GREENVILLE,425090,411 ANSEL ST,GREENVILLE,SC,29601,2016-12-14,312,D,0,1,1MGH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to provide facial hair grooming and fingernail care to 1 of 3 sampled residents reviewed for Activities of Daily Living. Resident #76 was observed with a dark substance under long fingernails (both hands) and noted with long hairs coming out both ear canals. The finding included: The facility admitted Resident #76 with [DIAGNOSES REDACTED]. An observation on 12/12/16 at approximately 2:05 PM revealed Resident #76 in bed and noted with long fingernails both hands with long hairs coming out of both ear canals. An observation and interview on 12/13/16 at approximately 9:01 AM with Licensed Practical Nurse #6 and Director of Nursing revealed the resident in day area and noted with long fingernails with long hair coming out of both ear canals. The DON confirmed the resident's long fingernails and hair extended to outside of the ear. The DON stated he/she would have the resident fingernails and facial hairs addressed. There was no documentation to indicate the resident had refused fingernail or facial hair care.",2020-09-01
804,MAGNOLIA MANOR - GREENVILLE,425090,411 ANSEL ST,GREENVILLE,SC,29601,2016-12-14,318,E,0,1,1MGH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews, the facility failed to provided physician's ordered hand and/or wrist splints for 2 or 4 sampled residents reviewed for range of motion services. Resident #101 and #76 did not have hand splints as ordered by a physician. The findings included: The facility admitted Resident #101 with [DIAGNOSES REDACTED]. Random observations on 12/12/16 at approximately 10:45 AM and 12:38 PM revealed resident in room with contracture to both hands no splint devices in place. Random observations on 12/13/16 at approximately 11:26 AM and 2:04 PM revealed resident in room with no splint devices in place. Review of the medical record on 12/13/16 at approximately 1:44 PM revealed a physician order dated 10/16/16 to discontinue bilateral hand carrots due to misplacement and will re-issue upon receipt of new splints. There was no documentation to indicate the resident refused to use splints and the splints were discontinued. An interview on 12/13/16 at approximately 2 PM with Registered Nurse (RN) #1 stated Resident #101 needed hand splints and confirmed they were not in place as care planned. RN #1 further stated there was no documentation to indicate the splints were put in place after they were ordered and received. The new splints were received on 10/26/16 per RN #1 with copy of purchase order provided. During an interview and observation with Licensed Practical Nurse (LPN) #5 revealed the resident was suppose to have a wash cloth rolled in his/her hands. There was no documentation to indicate a wash cloth to hands was recommended through therapy. LPN #5 confirmed there were no wash cloths placed in resident's hands to address contractures. An interview on 12/13/16 at approximately 2:36 PM with Occupational Therapist (OT) revealed there was no assessment for splint devices. OT stated an assessment for hand splints will be done on Resident #101 so that splints will be put in place. The facility admitted Resident #76 with [DIAGNOSES REDACTED]. Random observation on 12/12/16 at approximately 2:05 PM revealed resident in bed with no hand splints in place. Random observation on 12/13/16 at 9:05 AM and 11:13 AM revealed resident in day area not wearing hand splints as ordered to prevent further contractures. Review of the medical record on 12/13/16 at approximately 2:52 PM reviewed a physician's order dated 10/22/15 that indicated Restorative nursing for Passive Range Of Motion/Active Range of Motion (PROM/AROM) and apply splint of elbow and hand wrist Right Upper Extremities (RUE) 4 hours daily. There was no documentation to indicate the resident refused to use splints and the splints were discontinued. An interview on 12/13/16 at approximately 3:11 PM with Registered Nurse (RN) #1 confirmed Resident #76 was care planned for wrist splint. RN #1 stated there was no documentation to indicate the wrist splint was being provided as care planned. RN #1 further stated the wrist splint was suppose to be discontinued and an elbow splint was suppose to be provided but the physician's orders were not written to discontinue the wrist splint. RN #1 stated the wrist splint should have been in place until the order was written to discontinue. RN #1 stated Resident #76 was another resident that needed new splint devices that were supposed to be ordered by the Occupational Therapy Department. An interview on 12/13/16 at approximately 4:25 PM with RN #1 and Restorative Aide (RA) confirmed Resident #76 did not have hands splints as ordered. The RA further stated the facility staff have reviewed issues related to splints not being available in (MONTH) (YEAR). RN #1 stated the elbow splint was needed for Resident #76 but it was not ordered so the device was not in place.",2020-09-01
805,MAGNOLIA MANOR - GREENVILLE,425090,411 ANSEL ST,GREENVILLE,SC,29601,2016-12-14,323,J,0,1,1MGH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview Resident #67 was transferred incorrectly by a staff Certified Nursing Assistant (CNA). The CNA transferred the resident alone using a stand and pivot method instead of the hoyer lift with the assistance of two staff members. The resident was found to have a fracture of the left femur the next morning. Resident # 78 was left unsupervised in an enclosed courtyard for an extended period of time with staff not checking on him/her. This failure on the part of staff resulted in Resident #78 receiving burns to both shoulders. After review of corrective action put in place related to both incidents it was determined that Immediate Jeopardy at past non-compliance existed in the facility as of 6/10/2017 (with Resident 67's incorrect transfer) and continued with Resident #78's burns. The facility was in compliance with both as of 7/16/2017. ( 2 of 6 residents reviewed for accidents/hazards.) The findings included: The facility admitted Resident #67 with [DIAGNOSES REDACTED]. Review of the facility's Initial 24 - Hour Report regarding an injury of unknown source for Resident #67 on 12/12/16 at 10:30 AM, revealed that on 6/11/2016 at 7:00 AM the resident had a large discoloration to the left inner thigh. The resident was sent to the emergency room where x-rays revealed that the resident had suffered a fracture of the Left Femur. Record review of Resident #67's Resident Profile on 12/13/2016 at 3:09 PM, revealed that Resident #67 was to transfer with the assist of 2 persons with a hoyer lift. Record review of Resident #67's Care Plan on 12/13/2016 at 4:37 PM, revealed that staff were to use a hoyer lift to transfer the resident. In addition, the Care Plan revealed that the resident will kick, bite, cry, pull hair and scratch during care. Review of an Incident Report on 12/13/2016 at 1:45 PM, revealed that the injury was identified by the facility on 6/11/2016 at 7:00 AM. Record review of the Radiology Reports on 12/12/2016 at 10:30 AM revealed that Resident #67 had significant Osteopenia (reduced bone mass). The report indicated that the age of the fracture (when it occurred) could not be determined by x-ray due to the Osteopenia. Review of documentation of an interview conducted by the facility with CNA (Certified Nursing assistant) #1 on 12/12/2016 at 10:30 AM, revealed that on 6/10/2016 between 9:30 AM - 10:00 AM, CNA #1 transferred Resident #67 inappropriately. Per the statement (dated 6/12/2016), CNA #1 stated that he/she transferred Resident #67 from the bed to the wheelchair without using a hoyer lift and assistance from other staff. Per the statement CNA #1 used a stand and pivot transfer. In addition, at approximately 1:30 PM CNA #1 used a stand and pivot transfer to return the resident back to bed. Per the statement, CNA #1 stated he/she did not know the resident was to be transferred with a hoyer lift. In addition, CNA #1 did not know where to look in the resident's record to know how the resident should be transferred. CNA #1 denied that the resident had any pain or bruising at any time on his/her shift. CNA #1 cared for Resident #67 on the 1st shift. Review of documentation of an interview conducted by the facility with CNA #4 on 12/12/2016 at 10:30 AM, revealed that CNA #4 cared for Resident #67 on the 2nd shift. Per the statement (dated 6/13/2016), CNA #4 did not transfer the resident, but did reposition the resident in bed. CNA #4 denied seeing any bruising or discoloration to the resident's skin on his/her shift. Per the statement, while turning the resident to change her/his brief, Resident #67 did fight a little and was grabbing at me, but she always does this. Review of documentation of an interview conducted by the facility with CNA #2 on 12/12/2016 at 10:30 AM, revealed that CNA #2 cared for Resident #67 on the 3rs shift. Per the statement (dated 6/11/16), CNA #4 stated that while changing the resident's brief she/he noticed a large, dark discoloration to the resident's upper, left thigh. This was observed on CNA #4's final rounds. Review of documentation of an interview conducted by the facility with LPN (Licensed Practical Nurse) #2 on 12/12/2016 at 10:30 AM, revealed that LPN #2 cared for Resident #67 on the 1st shift on 6/10/2016. Per the statement (dated 6/13/2016), LPN #1 stated that she/he did not observe nor was it reported to her/him that Resident #67 had any complaints of pain or discoloration to the left thigh. Review of documentation of an interview conducted by the facility with LPN (Licensed Practical Nurse) #1 on 12/12/2016 at 10:30 AM, revealed that LPN #1 cared for Resident #67 on the 2nd shift on 6/10/2016. Per the statement (dated 6/13/2016), LPN #1 stated that she/he did not observe any discoloration to Resident #67's thigh. In addition, LPN #1 stated that CNA #4 did not report any skin changes or complaints of pain to her/him. The statement indicated that CNA #4 did report the combative behavior during care to LPN #1. Review of documentation of an interview conducted by the facility with the Orthopedic physician who treated Resident #67's fractured Femur on 12/12/2016 at 10:30 AM, revealed that the resident had brittle bones. Per the statement (dated 6/16/2016), the physician stated Resident #67 suffered an impact fracture to the Left Femur. The physician could not identify the cause of the fracture. He/she stated that it may have occurred during a transfer in which the resident's foot landed on the floor. The physician statement indicated that it would not have taken much to cause the fracture due to the resident's brittle bones and age. During an interview with CNA #3 on 12/13/2016 at 2:19 PM, CNA #3 was asked how CNAs know how to transfer residents. CNA #3 stated that CNAs look at the Resident Profile in the computer to find this information. In addition, CNA #3 stated that there are symbols above each residents bed that indicate certain types of care the resident should receive, including transfers. CNA #3 stated that she/he received training during orientation on using the Resident Profile in the computer, on the symbols above the bed and on the use of hoyer and other mechanical lifts for transferring residents. CNA #3 is Resident #67's current CN[NAME] During an interview with CNA # 2 (3rd shift) on 12/13/2016 at 2:15 PM, CNA #2 confirmed her/his statement from 6/11/2016. CNA #2 denied transferring the resident, but did reposition the resident during rounds. CNA #2 stated the resident had no signs of pain during her/his shift. CNA #2 verbalized what type of care the resident required and where to look in the record for the type of care the resident required. During an interview with CNA # 1 on 12/13/2016 at 2:15 PM, CNA #1 confirmed her/his statement from 6/12/2016. CNA #1 stated he/she did not transfer the resident with a hoyer lift and assistance from other staff per the Care Plan and Resident Profile. CNA #1 stated he did not remember receiving any training on how to access the Resident Profile or training on what the symbols above the resident's bed meant. CNA #1 stated he/she asked other staff how to transfer the resident prior to caring for her/him. CNA #1 stated that he/she was told that Resident #67 was a one person transfer. CNA #1 could not remember who told him/her that the resident was a one person transfer. During an interview with the facility's Medical Director (MD) on 12/13/2016 at 2:26 PM, the MD stated he/she had read the Orthopedic physicians statement and office notes. The MD stated she concurred with the findings of the Orthopedic physician. The MD stated we can't be sure of how the fracture occurred. The MD stated it was a logical, educated guess that the fracture occurred during the one person transfer. The MD stated the resident had a history of [REDACTED]. In addition, the MD stated he/she had witnessed these behaviors and it was possible the fracture occurred as a result of kicking. LPNs #2 and #1 confirmed there statements during interviews on 12/13/2016 at 2:45 PM and 3:06 PM. Both LPNs stated that the resident seemed like her normal self on their shifts. LPN #1 and #2 stated they checked on Resident #67 at least every 2 hours. Both LPNs denied that the resident had any signs or symptoms of pain or that any injury had occurred. During an interview with the Nurse Practitioner (NP) on 12/14/2016 at 9:39 AM, the NP stated that it was unknown when exactly Resident #67's fracture occurred. The NP reviewed the Radiology Reports during the interview and stated that the x-rays could not determine if this was an acute fracture. When asked what this meant the NP stated that this meant the fracture could have occurred on the day of the incident or days before the incident. The NP stated that the resident had brittle bones from Osteopenia The facility admitted Resident # 78 with [DIAGNOSES REDACTED]. Hyperthermia, Blisters to both shoulders, and Dehydration were a result of the failure of the facility to bring the resident back in timely from the courtyard after being left outside by the Speech Therapist. On 7/12/16 at 4:30 PM Resident #78 was observed alone in the enclosed courtyard unattended. Staff described the resident as lethargic and unresponsive with blisters noted to both shoulders. The resident was brought into the Activity room and the Director of Nursing and nursing staff called to the room. The resident's temperature axillary was 106.6 degrees. Ice packs were applied and EMS called to transport resident to the hospital. The resident was given IV fluids( intravenous) and admitted for observation. Resident #78 also treated for [REDACTED]. Resident #78 was readmitted to facility on 7/14/6 with thermal burns to both shoulders and was treated with silvadene cream and xerofoam dressing twice a day. An interview with Resident #78 on 12/12/16 revealed that the resident remembered being taken to the courtyard by the speech therapist and being left out side for a long time. He had no way to call for help and he could not self propel his wheelchair. Also he could not open the door to exit the courtyard. The facility DON ( Director of Nursing) went with this surveyor to observe the resident's shoulders. Both shoulders near back of shoulders had scar tissue. The Resident did state that was where he got burned sitting out in sun. He said he did not have any T Shirts, CNA's (Certified Nursing Assistants) assigned stated they had never seen him have any T Shirts. DON checked residents closet and drawers. There were no T Shirts. Director of Social services stated also that resident did not own any T Shirts. He/she only wore button up shirts or short sleeved pull over shirts. Resident said it was really hot outside that day. DON checked weather app on her phone and stated on 7/12/16 It was between 68-95 degrees. The average temperature being 82 degrees. The staff interviews done by the Director of Nursing stated the Speech Therapist said she was taking the resident outside for a while and would bring him back to his room. Interview With LPN #1 ( Licensed Practical Nurse.) on 12/14/16 at 11:30 AM stated he/she was on duty the day of the incident and heard the therapist tell the floor nurse she/he was going to take the resident outside and would bring him back in side in a few minutes. Whenever Therapy takes a resident off the unit, they always return the resident to their unit. Staff thought the resident had been brought back into the facility. On 12/14/16 at 10:25 AM the Administrator, Director of Nursing , and Corporate Consultant were notified that Immediate Jeopardy and Substandard Quality of Care was identified at F 323 at a scope and severity of [NAME] Immediate Jeopardy and Substandard Quality of Care at Past Noncompliance existed in the facility on 6/10/16 related to Resident #67 found to have a fractured femur after an incorrect transfer by a Certified Nursing Assistant and Resident # 78 being found unresponsive and lethargic in the courtyard after 3.0 hours unattended. The facility submitted a Plan of Correction ( P[NAME] ) which was reviewed by the survey team and approved on 12/14/16. The identified Immediate Jeopardy citations were corrected as of 7/16/2016. The P[NAME] included the following: All residents at the facility were reviewed to ensure they were not affected by the deficient practice. On (MONTH) 13, (YEAR) education was initiated by Director of Nursing (DON) and Director of Education (DOE) for Nursing staff that included: the expectation that residents are hydrated especially during summer months water pitchers are full and within reach Residents are to be signed out in log book by a staff member when leaving the unit The log book is located at all nurse's stations Residents are not to be left in any area without a way or ability to communicate need for help; residents are not to be left in any area without supervision nurses and aides are to do hourly rounds on unit and record on log Nursing staff are to complete walking rounds at shift change and record on log. Education for Maintenance staff was done by Director of Nursing and Director of Education on completing outside walking rounds during daylight hours and recording on log. This was initiated and completed on (MONTH) 13, (YEAR) Education by Director of Nursing for Department Heads on completing walking rounds to account for residents was initiated and completed on (MONTH) 14, (YEAR). Staff re-education by Director of Education on Resident Abuse/Neglect was initiated and completed on (MONTH) 14, (YEAR); Inservice included icons to determine care plan of residents Following that date, education was completed as staff members arrived for their next scheduled shift. Outside rounding conducted by Maintenance personnel was recorded on log sheets beginning (MONTH) 14, (YEAR). Rounding on units was conducted by Nurses beginning (MONTH) 14, (YEAR). Resident sign out books are located at all nursing stations. Administrator and Director completed an ad hoc Quality Assurance and Performance improvement meeting with the Medical Director on (MONTH) 13, (YEAR). In addition inservice to all staff on resident transfer technique, resident profile and the icons posted in each resident's room to inform staff which type of transfer to use for the resident. Results of monitoring will be presented by the Quality Assurance Performance Improvement (QAPI) committee by the Director of Nursing and Administrator for period of 3 months to ensure compliance is maintained. Any areas of concern identified will be addressed at time of discovery. During the survey based on review of log books for both nursing and maintenance staff, interview of staff members and residents related to the items noted in the facility plan of correction and observation of residents leaving the unit supervised by staff per their plan of correction the Immediate Jeopardy at Past non-Compliance was determined to be in place and corrected as of 7/16/2016.",2020-09-01
806,MAGNOLIA MANOR - GREENVILLE,425090,411 ANSEL ST,GREENVILLE,SC,29601,2016-12-14,371,E,0,1,1MGH11,"Based on observation and interview the facility had dark brown debris on back splash of stove and build up of dark brown substances on inside walls and door of free standing ovens. ( 1 of 1 kitchen reviewed.) The findings included: On 12/12/16 at 9:45 AM on initial tour, the stove back splash had three areas of dark brown substance caked on with lighter shades of brown substances around areas. The free standing ovens had build up inside ovens on walls and door. These observations were confirmed again on tour 12/13/16 at 11 AM. The CDM ( Certified Dietary Manager) confirmed the areas noted.",2020-09-01
807,MAGNOLIA MANOR - GREENVILLE,425090,411 ANSEL ST,GREENVILLE,SC,29601,2016-12-14,520,E,0,1,1MGH11,"Based on interviews and review of the facility's Quality Assessment and Assurance Committee plan, the facility failed ensure that a plan of action implemented in (MONTH) 29, (YEAR) addressed the identified issues of residents' need for restorative or other therapy services. Resident #101 and #76 did not have physician ordered splints in place during survey and no documentation of receiving restorative or other therapy based on physician ordered splint devices for past 2 1/2 months. Cross Refer to F282 and F318. The findings included: During interview on 12/14/16 at approximately 12:31 PM with the facility's Administrator and Nurse Consultant it was revealed the facility implemented a Plan of Action related to restorative orders to ensure care plans are updated accurately and that outdated orders are discontinued. The Plan of Action indicated that identified residents would be referred to therapy rather than only restorative services. There was nothing in the facility's Plan of Action that addressed splint devices being provided for resident's as ordered. The Plan of Action did not address monitoring and documenting to ensure that residents with contractures had splint devices in place and ordered as care planned. There was no documentation provided that the facility's Quality Assessment and Assurance Committee revisited concerns related to restorative services since a concern was identified in August/September (YEAR). The Administrator stated the Restorative Program was revamped and that the Director of Therapy and Registered Nurse #1/Care Plan Coordinator were put in place to review services to ensure therapy/restorative services would be provided. There was nothing in place to ensure that the Director of Therapy and Registered Nurse #1 was monitoring the revamped program. An interview on 12/14/16 at 12:55 PM with Registered Nurse #1 who confirmed services not provided for Resident #101 and #76 was due to a lack of communication with rehabilitation and Quality Assurance Committee.",2020-09-01
808,MAGNOLIA MANOR - SPARTANBURG,425091,375 SERPENTINE DRIVE,SPARTANBURG,SC,29305,2017-03-08,253,E,0,1,123611,"Based on observation and staff interview the facility failed to maintain housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. This involved rooms on all three units in the facility. Findings include: During observations in Stage 1 and during a tour of the facility on 3/8/2017 at 11:00 AM with the Maintenance Director the following environmental concerns were noted and confirmed by the Maintenance Director: Room 102 Chipped paint around the bathroom door trim, a build up of dirt and debris on the bathroom floor and in the corners and the overbed tables in the room were noted to have chipped wood tops and rust on frame the frames. Room 104 there was chipped paint on the wall beside bed. The metal locker doors that were used for closets were noted with chipped paint. The tile floor in then bathroom was chipped and there was chipped paint around the bathroom door frame, a build up dirt and debris on bathroom floors and in the corners and black marks on bathroom door. The overbed tables were noted to have rust on frame and chipped wood tops. Room 106 the overbed table was chipped wood and the metal lockers used as closets were noted to have chipped paint on the doors. There was chipped paint on the wall door trim and chipped tiles in the bathroom. The dresser was missing a drawer and was noted with multiple mismatched pulls on drawers. There was a build up of dirt and debris on floor and in the corners of the room. The paint was marred on the bathroom door,and stained ceiling tile by the window. There was also chipped floor tile at entrance of room. Room 107 the lockers used as a closet in the room was noted to be scratched. and there were broken floor tiles at the entry into the room. The overbed table had a build up of rust on the metal frame and a chipped wood top. There was a build up of dirt and debris on floor in the room and in the in corners. There were mismatched pulls on the small dresser and the bathroom door was noted to marred . Room 111 was noted to have chipped floor tiles in bathroom and chipped paint on the bathroom door trim and hvac wall unit. Room 112 was noted to have an overbed table with rust on frame and chipped wood top. There was dirt and debris on the floors and in the corners with chipped paint on the bathroom door frame. The bathroom sink faucet was very loose and water was continuously dripping from it and was not able to be turned off. Room 114 was noted have marred wood closet and bathroom doors and missing tiles on the bathroom floor. There was cracked grout floor transition from room to bathroom and rust stains in the bathroom sink. There was a worn finish on the dresser and a build up of dirt and debris on floors and in corners of the room. There was a hole in wall behind head of bed. Room 115 there was a build up of dirt and debris along wall and floor trim with build up in the corners of the room. There was chipped wood on the bathroom door frame, hole in bathroom door, and black mold growing around shower head faucet and down shower tile, Room 116 the bathroom floor was noted to have cracks in tiles and build up of dirt on the floors. The sink was noted to be rusty. Room 118 was noted to have a build up of dirt around floor and wall trim especially in the corners. There was chipped wood on the bathroom door and closet doors and a loose trim piece on the front of night stand and the drawer was off track. There were cracked floor tile and a brown substance smeared on bathroom door frame, During this observation the resident stated I am a clean person and my bathroom here is just nasty.The transition from room floor leading into the bathroom floor was an unfinished piece of wood. There were missing floor tile and rusted hinges on bathroom door Room 119 was noted cracked bathroom tiles and a brownish substance on the tile floor. The bathroom facet was noted to be very loose and water leaking from the facet. Room 121 was noted with the edges of floor to have build up of dirt. The wood molding was marred and the handrail in bathroom was cracked and there was a brownish substance on the tile on the bathroom floor. The bathroom facet very loose and water leaking from the facet and could not be turned off. Room 123 was noted with large gouges out of the door frame into that led into the bathroom, The caulking around toilet was observed to have a dark colored stain all around the toilet. The nightstand in the bedroom was in need of repair. Room 124 the bathroom floor was observed to be dirty and the bathroom sink had an extreme amt of corrosion build up on it. The cove molding in the bathroom was dirty and broken and the paint was peeling off walls. Room 126 the walls and floors were noted to be dirty and the bathroom door was marred. The doorway into room had chipped paint. Room 127 the paint on the wall was marred and the bathroom floor and cove base had a large build up of dirt with missing floor tile. Room 128 was noted to have a large build up of dirt around the edges of the bathroom floor. Room 212 the soap dispenser was broken and not usable and there was no trash bag in trash can although there were dirty paper towels in the can. The Maintenance Director verified these finding and stated he just started working in the facility in (MONTH) (YEAR) and he did not currently have a plan in place to address the identified concerns.",2020-09-01
809,MAGNOLIA MANOR - SPARTANBURG,425091,375 SERPENTINE DRIVE,SPARTANBURG,SC,29305,2017-03-08,282,D,0,1,123611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to ensure services were provided by the facility, as outlined by the comprehensive care plan to promote the healing of a pressure ulcer for one, Resident #111, of 3 residents reviewed in Stage 2 for pressure ulcers. Findings include: Resident #111 was documented to have a [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] documented Resident #111 required the extensive assistance of 2 staff for bed mobility and his balance wasn't steady and only able to stabilize with human assistance. This MDS also documented Resident #111 had a Stage 4 and a unstageable pressure ulcer, was noted to have a pressure reducing device for his bed and was being provided pressure ulcer care. The current pressure ulcer care plan documented Resident #111 was at risk for skin breakdown related to his decreased mobility, muscle weakness, lack of coordination, unsteady gait and his [DIAGNOSES REDACTED]. Review of a skin risk analysis and interventions dated 10/15/16 documented a goal to prevent skin integrity concerns indicating the staff should reposition Resident #111 every 2 hours and use pillows to boney prominence, use pillows to reduce pressure on his heels, use pressure reducing support to his bed and use lifting devices turn sheets to move him rather than drag him during positioning. Review of the clinical record revealed Resident #111 currently had a unstagable pressure ulcer to his right heel and a Stage 4 pressure ulcer to his left hip. Observation on 3/07/2017 at 10:00 AM revealed Resident #111 was seated in his wheelchair in the dining room. He was noted to have socks on but no shoes and both of his heels were observed the be resting on the floor. Observation 3/07/2017 at 1:19 PM Resident #111 was noted to be in in bed on his right side. This surveyor ask Nurse #16 to determine if Resident #111's heels were being floated and she showed this surveyor that his heels were resting on the surface of the mattress and were not being floated. Interview with Nurse Aide Staff #27 on 3/07/2017 at 1:33 PM revealed she tries to put pillows under his legs to keep his heels up off the bed and was not sure why his heels were not floated during this observation. Also during this observation the pressure settings on the residents air mattress was noted to be set at 7. Nurse #16 was not aware of what the settings should be on the air mattress. She stated the company that sets the bed up puts the setting where it needs to be and she is not responsible for changing it or monitoring it. There was a setting chart on top of the air mattress device at the foot of the resident's bed that indicated it was a Stat 3 low air loss mattress and a setting of 7 would be indicated for a resident who weighed 175 to 200 pounds. Resident #111's current weight was noted to be 134 pounds and his bed setting should be on 6 for this weight range. This was verified during this observation with the Unit Manager Staff #65. Interview with the physical therapy #102 revealed they are currently working with Resident #111 in for bed mobility. core strengthening, and transfers. He stated the wheelchair the resident was currently in should allow him to place his feet flat on the floor but stated he is very tall and he does not sit straight up in the wheelchair. He stated when he slouches down in the chair and straightens his legs out that would cause his heels to rest on the floor instead of his feet flat on the ground. He verified when he was in the chair there was no foot support nor are his heels floated of the floor per his current care plan. During an interview with Corporate Nurse Staff #86 and Unit Manager Staff #65 on 3/9/2017 at 10:05 AM revealed they verified Resident #111's heels should always be floated per his care plan and physician orders [REDACTED]. They also confirmed the setting on the residents air mattress was not set accurately to promote healing of his current pressure ulcer and they had no system in place to ensure staff were educated on what air mattress settings on the beds should be and ensure that they remained on the proper setting to ensure adequate pressure relief per Resident #111's current pressure ulcer care plan.",2020-09-01
810,MAGNOLIA MANOR - SPARTANBURG,425091,375 SERPENTINE DRIVE,SPARTANBURG,SC,29305,2017-03-08,314,D,0,1,123611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to prevent a resident (#111) with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing and and prevent new ulcers from developing. This involved one of three residents reveled in Stage 2 for the care are of pressure ulcers. Findings include: Resident #111 was documented to have a [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] documented Resident #111 required the extensive assistance of 2 staff for bed mobility and his balance wasn't steady, only able to stabilize with human assistance. This MDS also documented Resident #111 had a Stage 4 and unstageable pressure ulcer with a pressure reducing device for his bed and was being provided pressure ulcer care. The current pressure ulcer care plan documented Resident #111 was at risk for skin breakdown related to his decreased mobility, muscle weakness, lack of coordination, unsteady gait and his [DIAGNOSES REDACTED]. The nurse aide profile guide for Resident #111 included that Resident #111 was at risk for pressure ulcer development and staff were to float his heels to reduce pressure. Review of a skin risk analysis and interventions dated 10/15/16 documented a goal to prevent skin integrity concerns and staff should reposition Resident #111 every 2 hours and use pillows to boney prominence, use pillows to reduce pressure on his heels, use pressure reducing support to his bed and use lifting devices turn sheets to move rather than drag him during positioning. Review of the clinical record revealed Resident #111 currently had a unstagable pressure ulcer to his right heel and a Stage 4 pressure ulcer to his left hip. Observation on 3/07/2017 at 10:00 AM revealed Resident #111 was seated in his wheelchair in the dining room. He was noted to have socks on but no shoes and both of his heels were observed the be resting on the floor. Observation 3/07/2017 at 1:19 PM Resident #111 was noted to be in in bed on his right side. This surveyor ask Nurse #16 to determine if Resident #111's heels were being floated and she showed this surveyor that his heels were resting on the surface of the mattress and were not being floated. Interview with Nurse Aide Staff #27 on 3/07/2017 at 1:33 PM revealed she tries to put pillows under his legs to keep his heels up off the bed and was not sure why his heels were not floated during this observation. Also during this observation the pressure settings on the residents air mattress was noted to be set at 7. Nurse #16 was not aware of what the settings should be on the air mattress. She stated the company that sets the bed up puts the setting where it needs to be and she is not responsible for changing it or monitoring it. There was a setting chart on top of the air mattress device at the foot of the resident's bed that indicated it was a Stat 3 low air loss mattress and a setting of 7 would be indicated for a resident who weighed 175 to 200 pounds. Resident #111's current weight was noted to be 134 pounds and his bed setting should be on 6 for this weight range. This was verified during this observation with the Unit Manager Staff #65. She was not able to provide any manufacture recommendation for the bed and was also not able to provide a policy, procedure or a system that they had in place that spoke to who should monitor the settings on the air mattress. Interview with the physical therapy #102 revealed they are currently working with Resident #111 in for bed mobility. core strengthening, and transfers. He stated the wheelchair the resident was currently in should allow him to place his feet flat on the floor but stated he is very tall and he does not sit straight up in the wheelchair. He stated when he slouches down in the chair and straightens his legs out that would cause his heels to rest on the floor instead of his feet flat on the ground. He verified when he was in the chair there was no foot support nor are his heels floated of the floor per his current care plan. During an interview with Corporate Nurse Staff #86 and Unit Manager Staff #65 on 3/9/2017 at 10:05 AM revealed they verified Resident #111's heels should always be floated per his care plan and physician orders [REDACTED]. They also confirmed the setting on the residents air mattress was not set accurately to promote heeling of his current pressure ulcer and they had no system in place to ensure staff were educated on what air mattress settings on the beds should be and ensure that they remained on the proper setting to ensure adequate pressure relief.",2020-09-01
811,MAGNOLIA MANOR - SPARTANBURG,425091,375 SERPENTINE DRIVE,SPARTANBURG,SC,29305,2017-03-08,323,D,0,1,123611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to ensure 2 of four residents reviewed for accidents was provided an environment that was as free from accident hazards as is possible. Findings include: 1) Resident #111 was documented to have a [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] documented Resident #111 required the extensive assistance of 2 staff for bed mobility and his balance wasn't steady and he was only able to stabilize with human assistance. The current fall care plan documented Resident #111 was at risk for falls related to his decreased mobility, muscle weakness, lack of coordination, unsteady gait and his [DIAGNOSES REDACTED].#111 was at risk for falls, was documented to have balance concerns and was not able to attempt standing, sitting or transfers without physical help from the staff. Review of the physician orders [REDACTED].#111's bed due to recent skin breakdown on noted on 12/8/2016. Review of the progress notes dated 2/18/2017 revealed the staff found the resident on the floor beside his bed with no injuries noted. The physician progress notes [REDACTED].#111 fell out of his bed but reported that he most likely fell asleep and slid out of his bed onto the floor. He was not injured with this incident. An order was noted after this incident for the staff to apply bolsters to both sides of his bed to prevent further falls from the bed. Interview with physical therapy Staff #102 on 3/8/2017 at 3:30 PM revealed they are currently working with Resident #111 for bed mobility, core strengthen and transfers. He stated Resident #111 has very poor core strength and poor torso support. Interview with Corporate Nurse Staff #86 and Unit Manager Staff #65 on 3/9/2017 at 10:05 AM revealed that Resident #111 was placed on a pressure reducing air mattress on 12/8/2016. They both verified there was no assessment conducted for the use of the air mattress which had a slick surface and Resident #111 was noted to have poor balance, poor core strength and poor upper torso support which put him at risk of falls from the bed with the use of this air mattress. They both stated they do not currently have a process in place to assess residents for any safety concerns before utilizing any type of air mattresses and they were unable to provide the manufactures recommendations for the air mattress . 2. In an interview on 03/06/17 at 9:28 a.m., Licensed Nurse Staff # 50 stated Resident #128 experienced two falls in the previous 30 days. She stated she thought the resident was ambulating to the bathroom on both occasions when he fell . According to the 02/10/17 Minimum Data Set assessment, Resident #128 was able to make himself understood and was able to understand others. The resident was assessed to be cognitively intact. The Incident Reports, reviewed on 03/07/17 at 10:42 a.m., verified the resident experienced falls on 02/10/17 and 03/03/17. The 02/10/17 Incident Report revealed the resident was found at 2:00 p.m. on the floor in the resident's room. Staff identified the resident sustained [REDACTED]. Staff identified the resident's wheelchair was not locked and that they removed the walker from his room as a preventative action. The investigation did not include a statement from the resident indicating what he was attempting to do at the time of the fall, nor did it include statements from his cognitively intact roommate or other staff who might be able to identify the length of time the was on the floor, when he was last toileted or seen, etc. Without a thorough investigation, staff were unable to determine if removal of the walker was an effective and reasonable preventative action. Similarly, review of the 03/03/17 Incident Report revealed the resident was found on the floor in his room at 4:30 a.m. While the report revealed the resident stated that he was trying to get OOB (out of bed), it did not reveal any statement from the resident regarding why he was getting out of bed. As a result of the fall, staff initiated non-skid socks and a bed alarm to the bed. This Incident Report inaccurately identified the number of falls in the last 30 days as 0, despite the 02/10/17 fall. It also identified a change in sleep patterns due to frequent urination at night, but did not include any staff statement regarding when they last checked on / toileted / provided care for the resident. The At Risk for Falls Care Plan, reviewed on 03/07/17 at 10:52 a.m., with a problem start date of 02/17/17, identified approaches implemented on 03/03/17 of a bed alarm and non skid socks when OOB (out of bed). This intervention did not match the intervention of non-skid socks while in bed, as identified on the Incident Report. In addition, an intervention dated 01/09/17 directed staff to keep the call light in reach at all times. In an interview on 03/07/17 at 11:08 a.m., Corporate Nurse Staff #86 explained every fall was discussed in an interdisciplinary team meeting once a week. She explained staff reviewed and dissected triggers and causes of falls. She stated a resident should absolutely be asked what was happening at the time of the fall and that information should be on the Incident Report. She explained the floor nurse fills out the report and gives it to the Unit Manager. If there are questions or missing information, the Unit Manager should go back and talk to anyone else who has information on what happened. Observation on 03/07/17 at 12:32 p.m. revealed Resident #128 in his wheelchair beside his bed. The call light was between the bed and the wall, out of the resident's reach. When asked if he could locate his call light, he turned his body and reached behind him. When unable to locate it, he started to stand and said, Let me look. He was encouraged to sit down. In an interview on 03/07/17 at 12:48 p.m. Licensed Nurse Staff #50 stated the call light should be within the resident's reach at all times. She reviewed the Incident Report and stated it was not clear what the resident was attempting to do when he fell . She stated the floor nurse or herself usually talk to the staff and the resident. I don't know why we didn't with either of them (the falls). She stated it was difficult to know how to prevent a fall if we don't know the details of the fall. She reviewed the care plan and said, No, that should say non-slip socks while in bed. In an interview on 03/08/17 at 10:58 a.m., Corporate Nurse Staff #86 reviewed both Incident Reports and stated staff needed to complete them with the information relevant to the falls in order for staff to ensure interventions were appropriate to prevent future falls.",2020-09-01
812,MAGNOLIA MANOR - SPARTANBURG,425091,375 SERPENTINE DRIVE,SPARTANBURG,SC,29305,2017-03-08,364,E,0,1,123611,"Based on observation and staff interview the facility failed to prepare food by methods that conserve nutritive value, flavor, and appearance. Findings include: On 03/07/2017 at 3:42 PM Department Aide Staff #5 was observed pureeing chicken for the chicken rice casserole being served for the evening meal. When queried she stated she was preparing 12 servings of pureed chicken however was unable to verbalize the quantity of chicken she was pureeing and was unable to verbalize how many ounces of chicken was required for each serving. Department Aide Staff #5 placed an undetermined amount of cooked chicken into the [NAME]o Coupe along with 6 slices of bread and an undetermined amount of chicken broth. In order to thin the chicken and bread further Department Aide Staff #5 added an undetermined amount of water. When queried was unable to verbalize how much water had been added. During interview conducted on 03/07/2017 at 3:50 PM with Dietary Department Director Staff # 70 stated we follow a recipe book when preparing pureed food items. Review of the Chicken Rice Casserole Meal Tracker Recipe each resident was to receive 6 ounces of chicken. In addition, the following was documented For Pureed: Measure # of servings into food processor. Blend until smooth. Add broth or gravy if product needs thinning. Add commercial thickener if product needs thickening. During interview conducted on 03/08/2017 at 8:53 AM Registered Dietitian Staff #87 verified the aforementioned observation was not in accordance with their facility practice. Stated Department Aide Staff #5 should have followed the menu guidelines to ensure the resident's receiving a pureed diet were served the appropriate amount of chicken. Registered Dietitian Staff #87 verified there were 13 resident's receiving a pureed diet. Registered Dietitian Staff #87 stated the 13 residents receiving a pureed diet had stable weights at this time.",2020-09-01
813,MAGNOLIA MANOR - SPARTANBURG,425091,375 SERPENTINE DRIVE,SPARTANBURG,SC,29305,2017-03-08,371,E,0,1,123611,Based on observation and staff interview the facility failed to prepare and distribute food in accordance with professional standards for food service safety. Findings include: During initial tour conducted on 03/06/2017 at 8:45 AM the kitchen floor had a heavy buildup of dirt and debris along the edges of the floor with a heavier build up observed in the corners. The floors had a sticky build up throughout. The door to the dry storage area had dried food stains and was sticky to touch. The window air conditioner located above the spice rack had a heavy buildup of clinging dust on the front vent. The window air conditioner located in the dishwashing area had a heavy buildup of clinging dust on the front vent. This was also observed again on 03/07/2017 at 11:35 AM. During interview at that time the aforementioned observations were verified by Dietary Department Director Staff # 70. Dietary Department Director Staff # 70 further stated they routinely clean the floors but stated there was no routine schedule for a deep cleaning of the kitchen floors and there was no routine schedule for cleaning the front vents of the air conditioners. On 03/07/17 at 3:46 PM Department Aide Staff #5 was observed washing the top portion of the [NAME]o Coupe food processor in the three compartment sink. With gloved hands Department Aide Staff #5 picked up the top portion of the [NAME]o Coupe food processor and a white cloth that was lying next to the three compartment sink and walked back to the counter. Department Aide Staff #5 proceeded to puree lima beans in the [NAME]o Coupe food processor. While the [NAME]o Coupe food processor was running the staff member wiped the outside of the [NAME]o Coupe food processor with the white cloth and touched a serving spoon lying on the counter. Department Aide Staff #5 took their gloved hand and scooped the lima beans out of the [NAME]o Coupe food processor into a serving container. Dietary Department Director Staff # 70 was present and was notified of Department Aide Staff #5 ' s mishandling of the lima beans.,2020-09-01
814,MAGNOLIA MANOR - SPARTANBURG,425091,375 SERPENTINE DRIVE,SPARTANBURG,SC,29305,2018-06-20,550,E,0,1,5ML011,"Based on interviews and review of the Resident Council Minutes, the facility failed to keep residents informed and provided them with an opportunity to vote in the local and/or state primary elections. Five of five residents identified as interview-able by the facility stated they were not informed they could vote in local and state primary elections during the group interview. The findings included: During group interview on 6/19/18 at appropriately 10:32 AM with residents identified as being interview-able by the facility. All five group members stated they were not given the opportunity to vote on the most recent local/state primary elections held on 6/12/18. A review of the Resident Council Minutes for the months of March, (MONTH) and (MONTH) (YEAR) had no documentation to indicate the residents were informed of theirs rights to vote in locate and/or state primary elections or if they wanted to do so. An interview on 6/19/18 at approximately 11:48 AM with the Activity Director (AD) confirmed the residents were not informed they could vote in the local and/or state primary elections. The AD stated he/she did not make arrangements for the residents to vote in last week's primary elections because he/she was not aware.",2020-09-01
815,MAGNOLIA MANOR - SPARTANBURG,425091,375 SERPENTINE DRIVE,SPARTANBURG,SC,29305,2018-06-20,577,C,0,1,5ML011,"Based on observations and interviews, the facility failed to ensure that the State Agency survey book was accessible on three days of the survey for 3 of 3 units observed. Access to the State Agency survey book was blocked by a tall metal stand that held a large container of handi wipes, gloves and other sanitizing material in foyer area to entrance door. There were no signs on the units to indicate where the survey book was located. The findings included: A random observation on 6/18/18 at approximately 2:30 PM revealed the State Agency survey book was located in the foyer area behind a tall metal stand that held sanitizing materials. During the group interview on 6/19/18 at 10:32 AM, five of five residents determined to be interview-able by the facility stated they did not know where the State Agency survey book was located. A random observation on 6/19/18 at approximately 3:58 PM revealed the State Agency survey book in the foyer area located behind a tall metal stand that held sanitizing material. Further review of the units revealed there were no postings to inform the residents the location of the survey book. An interview and observation with the facility Administration confirmed the residents did not have access to the survey book due to the tall stand with gloves and cleaning wipes blocking access to the survey book. The Administrator removed the stand and stated the stand was not usually placed in front of the survey book. The Administrator further stated there were no postings on the units to inform the residents where the survey book was located.",2020-09-01
816,MAGNOLIA MANOR - SPARTANBURG,425091,375 SERPENTINE DRIVE,SPARTANBURG,SC,29305,2018-06-20,584,D,0,1,5ML011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe and homelike environment for 1 of 3 units. room [ROOM NUMBER] had chipped painting on its wall, and room [ROOM NUMBER] had scuff marks and exposed piping. The findings included: Observation of room [ROOM NUMBER] on 6/18/18 at approximately 3:30 PM revealed chipped paint on the wall to the far right of the doorway. Observation of room [ROOM NUMBER] on 6/18/18 at approximately 3:30 PM revealed exposed piping and scuff marks along the wall of the entryway to the room. The exposed piping jutted approximately a foot from the wall and could pose an obstacle or hazard. Observation of room [ROOM NUMBER] on 6/20/18 at approximately 12:40 PM revealed chipped paint on right wall to the far right of the doorway. Observation of room [ROOM NUMBER] on 6/20/18 at approximately 12:40 PM revealed exposed piping and scuff marks along the wall of the room. Interview with maintenance director on 6/20/18 at approximately 1 PM revealed no documentation for the monthly resident room rounds. Interview with maintenance director on 6/20/18 at approximately 1:30 PM revealed the sink was removed from room [ROOM NUMBER] approximately a year prior and the piping was not removed as it required shutting down water for the whole unit. Review of maintenance policy on 6/20/18 at approximately 2 PM revealed the work order log was to be maintained by the maintenance department.",2020-09-01
817,MAGNOLIA MANOR - SPARTANBURG,425091,375 SERPENTINE DRIVE,SPARTANBURG,SC,29305,2018-06-20,656,D,0,1,5ML011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to follow the Care Plan for Resident #52, 1 of 3 sampled residents reviewed with oxygen therapy. Resident #52's oxygen concentrator was observed in use with out a filter in place. The findings included: The facility admitted Resident #52 with [DIAGNOSES REDACTED]. Observation of Resident #52 on 6/18/2018 at 5:10 PM, revealed the resident was receiving oxygen from a oxygen concentrator. The oxygen concentrator did not have a filter in place. On 6/19/2018 at 9:09 AM, the oxygen concentrator was again observed in use with no filter in place. Resident #52 was observed on 6/19/2018 at 2:32 PM with Licensed Practical Nurse (LPN) #1 present and an interview took place. LPN #1 confirmed the resident was receiving oxygen from the concentrator and no filter was in place to the concentrator. LPN #1 stated that nursing didn't check filters on the concentrators. LPN #1 stated she/he thought someone from the medical equipment supply company came out to the facility to check the concentrators. Record review of the Care Plan on 6/20/2018 at 10:39 AM, revealed nursing staff were to clean oxygen concentrator filters every night, if the concentrator was equipped with a filter. During an interview with LPN #1 on 6/20/2018 at 10:51 AM, LPN #1 confirmed nursing was responsible for checking and cleaning filters to oxygen concentrators.",2020-09-01
818,MAGNOLIA MANOR - SPARTANBURG,425091,375 SERPENTINE DRIVE,SPARTANBURG,SC,29305,2018-06-20,679,D,0,1,5ML011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interview, the facility failed to ensure that 2 of 2 sampled residents reviewed for activities were provided a structured program of activities. Resident #74 and # 77 were not observed being provided structured program of activities during the survey on 1 of 3 units observed. The residents remained in their rooms with no structured activities in progress. The findings included: The facility admitted Resident #74 on 7/13/16 with [DIAGNOSES REDACTED]. Random observations on 6/18/18 at approximately 3:10 PM to 6 PM revealed the Resident #74 in his/her room seated on side of bed, standing in room or seated in chair talking to him/herself. The resident's roommate television was playing. Staff was observed providing activities of daily living (ADL) care and medications. Random observations on 6/19/18 at approximately 11:38 AM revealed Resident #74 in room self ambulating and standing in doorway of room talking to self. The resident's roommate television was playing. Staff was not observed encouraging out of room activities. A random observation on 6/19/18 at approximately 2:20 PM revealed loud rap music being played in the day area on the upstairs 200 Halls. The Activity Director was asked by staff what activity was in progress and the Activity Director (AD) stated we are dancing. There were mostly cognitively impaired residents in the day area. Resident #74 was not encouraged to participate in the activity. At approximately 2:22 PM on 6/19/18 the resident was standing in his/her room talking to him/herself. Between the hours of 9 AM to 10:30 AM and 2 PM to 4 PM, the resident was not observed in any structured program of activities outside of his/her room and the resident did not receive any structured in room/1:1 activities. Random observation on 6/19/18 at approximately 2:45 PM and 3:28 PM revealed the resident standing in his/her room talking out loud to him/herself. A review of the care plan revealed a care plan conference was held on 3/01/18 and 6/01/18. The care plan under goals indicated the resident will participate in activity and verbalize satisfaction with activities of choice. Under the problem area in the care plan, it was indicated the resident will need assistance and encouragement with activity of choice. The care plan further indicated the resident was dependent on staff to meet his/her needs. A review of an Activity Evaluation dated 9/17/17 indicated the resident's current activity pursuits included Animals/Pets, Bingo, Cards, Current Events, Music, Religious Services and Sports. The activity evaluation further indicated the resident will do the above activities independently. An interview on 6/20/18 at approximately 11:38 AM with the Activity Director (AD) revealed pet therapy was provided once a month and acknowledged that pet therapy was identified as a activity of importance for Resident #74 per the activity assessment. The Activity Director further stated the resident prefers to stay in his/her room but had no documentation of resident's participation in activities identified on the activity evaluation completed by the facility. The AD did not determine if the resident would benefit from a one to one program of activities since it was documented that he/she prefers to be in his/her room and resident talks to him/herself The facility admitted Resident #77 on 7/03/13 with [DIAGNOSES REDACTED]. A random observation on 6/18/18 at approximately 3:15 PM revealed Resident #77 in room on low bed in the fetal position facing wall. A random observation at 6/19/18 at 11:35 AM revealed resident in room in bed facing wall. No program of activities in progress. A random observation on 6/19/18 at 2:21 PM revealed the resident on bed with no structured program of activities in progress. A random observation on 6/19/18 at approximately 3:28 PM revealed the resident in room on low bed with no activities in progress. Review of the medical record revealed a care plan that indicated a care plan conference was held on 3/01/18 and 6/01/18. The care plan further indicated provide in-room activities as needed. Activities offered should not be hard to follow and easily cued to help resident participation. A social services noted dated 5/20/18 indicated the Resident #77 was cognitively impaired severely. Review of the last Activities Evaluation dated 8/07/16 indicated the resident's current activity pursuits included Animals/Pets, Music, Religious Services and Current Events/News. An interview and review of one to one activities documentation for Resident #77 on 6/20/18 at approximately 11:45 AM with the Activity Director (AD) revealed staff does not attempt to engage resident in activities if the resident was sleepy. The AD reviewed the one to one documentation and stated pet therapy was provided once a month. The AD confirmed there was no activity evaluation since 8/07/16 and further stated the resident's activity interest has not changed. The was a RECORD OF ONE-TO-ONE ACTIVITIES form that indicated reason/frequency for one to one activities that was not completed. The form also indicated the time spent/duration that was not documented and resident's reaction/response to activity that was not documented. The one to one documentation dated 5/05/18 indicated there was a room visit with the resident's response section indicating ball toss in dayroom. The 5/10/18 one to one activity indicated a sensory movie watched and discussed with the resident. On 5/16/18 a book was read and discussed with resident. On 5/19/18 the resident received a snack. On 5/23/18 staff had the resident to do light exercise. On 5/26/18 staff prayed with resident and the resident listened. On 5/29/18 staff held up pictures for resident. On 6/01/18 resident was provided seashells to hold. On 6/03/18 staff worked a puzzle with resident. On 6/06/18 had resident to do some exercise. On 6/09/18 resident given stuff therapy dog to hold. On 6/12/18 music was played for resident. On 6/15/18 ball toss and on 6/20/18 read and discussed ?? listed as an activity provided. There was no documentation to indicate what time of day the activities were offered, duration or if the resident benefited from the activity offered. The AD confirmed the documentation on the one to one activities form.",2020-09-01
819,MAGNOLIA MANOR - SPARTANBURG,425091,375 SERPENTINE DRIVE,SPARTANBURG,SC,29305,2018-06-20,695,E,0,1,5ML011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview and review of facility policy the facility failed to maintain oxygen concentrators in good working condition for Residents #52 and #14, 2 of 3 sampled residents reviewed with oxygen therapy. Resident #52 did not have a filter in place to her/his oxygen concentrator. Resident #14 had heavy dust build up to 1 of 2 filters to his/her oxygen concentrator. The findings included: The facility admitted Resident #52 with [DIAGNOSES REDACTED]. Observation of Resident #52 on 6/18/2018 at 5:10 PM, revealed the resident was receiving oxygen from a oxygen concentrator. The oxygen concentrator did not have a filter in place. On 6/19/2018 at 9:09 AM, the oxygen concentrator was again observed in use with no filter in place. Resident #52 was observed on 6/19/2018 at 2:32 PM with Licensed Practical Nurse (LPN) #1 present and an interview took place. LPN #1 confirmed the resident was receiving oxygen from the concentrator and no filter was in place to the concentrator. LPN #1 stated that nursing didn't check filters on the concentrators. LPN #1 stated she/he thought someone from the medical equipment supply company came out to the facility to check the concentrators. During an interview with the Director of Nursing (DON) on 6/19/2018 at 2:43 PM, the DON stated the medical supply company was supposed to be providing filter-less oxygen concentrators to the facility. The DON stated she/he had not been aware there were concentrators in the facility that required filters. The DON also stated she/he had all oxygen concentrators in the facility checked to see if filters were required and found one other concentrator that required a filter. The DON stated orders were being obtained for all residents with oxygen concentrators to have the filter checked and cleaned nightly, if a filter was present. Review of the facility's Respiratory Policies and Procedures on 6/20/2018 at 1:45 PM, revealed Inlet filters on oxygen concentrators shall be visually inspected and cleaned/replaced as necessary. The facility admitted Resident #14 with [DIAGNOSES REDACTED]. Observation of Resident #14 on 6/20/2018 at 9:30 AM revealed the resident was receiving oxygen via a [MEDICAL CONDITION] from an oxygen concentrator. The concentrator had 2 filters. 1 filter, on the left side of the unit, was free of any dust or debris. The other filter, on the right side, had a dust/debris build up so thick the color of the filter nearly matched the color of the oxygen concentrator. Resident #14 was observed on 6/20/2018 at 1:07 PM with Licensed Practical Nurse #2 present and an interview took place. The resident's oxygen concentrator had the same heavy dust/debris build up to the filter on the right side. LPN #2 stated she/he didn't know the concentrator had 2 filters and could not locate the filter on the right side until it was pointed out to her/him. LPN #2 confirmed the heavy dust/debris build up to the filter on the right side and replaced the filter. Review of the facility's Respiratory Policies and Procedures on 6/20/2018 at 1:45 PM, revealed Inlet filters on oxygen concentrators shall be visually inspected and cleaned/replaced as necessary.",2020-09-01
820,MAGNOLIA MANOR - SPARTANBURG,425091,375 SERPENTINE DRIVE,SPARTANBURG,SC,29305,2019-07-24,550,D,0,1,VPO011,"Based on observations and interview, the facility failed to respect residents' rights by failing to knock on resident's door and request permission to enter their room during random observations. Staff entered resident's rooms without permission on Unit 1. (1 of 3 units observed). The findings included: A random meal observation on 7/21/19 at approximately 6:15 PM revealed a Certified Nursing Aide entering multiple resident's rooms without knocking on Unit 1. A random observation on 7/23/19 at approximately 10:23 AM revealed laundry staff entering multiple resident's rooms without knocking. During an interview with Laundry Staff #1 on 7/23/19 at approximately 10:25 AM Laundry Staff #1 confirmed the observations that he/she entered resident rooms without knocking. Laundry Staff #1 further stated sometimes he/she knocks and sometimes he/she does not knock.",2020-09-01
821,MAGNOLIA MANOR - SPARTANBURG,425091,375 SERPENTINE DRIVE,SPARTANBURG,SC,29305,2019-07-24,584,E,0,1,VPO011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, and interview the facility failed to maintain flooring, equipment, fixtures and drainage on 2 of 3 units observed during the survey. Multiple rooms with loose, cracked and rusted flooring, water below the level of a drain, and loose fixtures observed during survey. The facility failed to maintain clean equipment for 1 of 4 oxygen concentrators observed during the survey. The findings included: Observations during the facility initial tour on 07/21/19 between approximately 2:30 PM and 4:30 PM and during a second observation on 07/22/19 between approximately 2:15 PM and 2:30 PM the following rooms revealed, the bathroom connected to room [ROOM NUMBER] revealed, the shower was cracked, and the raised toilet seat had rust. Observation of the bathroom connected to room [ROOM NUMBER] revealed, the sink faucet was loose and dripping, and the front bar under the toilet lid of the raised toilet seat was wrapped and taped with something plastic in appearance. Observation of room [ROOM NUMBER] revealed, the floor ramp between the room and the connected bathroom was cracked/loose and the bathroom handrails had rust. Observation of the bathroom connected to room [ROOM NUMBER] revealed loose towel holders and the bathroom handrails had rust. Observation of the bathroom connected to room [ROOM NUMBER] revealed, loose towel holders and rusted tile. Observation of the bathroom connected to room [ROOM NUMBER] on 07/22/19 at approximately 2:20 PM revealed a puddle of water on the bathroom floor below the level of the drain. During an observation and interview on 07/23/19 at approximately 2:10 PM the Maintenance Assistant confirmed, the bathroom connected to room [ROOM NUMBER] had a cracked shower floor and rust on the bathroom handrails. The Maintenance Assistant confirmed that the bathroom connected to room [ROOM NUMBER] had a loose/dripping sink faucet and the raised toilet seat front bar had something plastic in appearance tapped around it. The Maintenance Assistant confirmed that in room [ROOM NUMBER] the floor ramp between the room and bathroom was cracked/loose and the bathroom handrails had rust. The Maintenance Assistant confirmed that room [ROOM NUMBER] had a puddle of water in the bathroom floor below the level of the drain. The Maintenance Assistant confirmed that the bathroom connected to room [ROOM NUMBER] had loose towel holders and the bathroom handrails had rust. The Maintenance Assistant confirmed that the bathroom connected to room [ROOM NUMBER] had loose towel holders and rusted tiles. The facility admitted Resident #10 with [DIAGNOSES REDACTED]. During the Initial Tour of the facility on 7/21/19 at 1:22 PM, Resident #10's oxygen concentrator was observed with, what appeared to be, food and/or beverage splatters and stains. Observation of the resident's oxygen concentrator, on 7/22/19 at 9:11 AM, revealed the same stains and splatters to the concentrator. The Resident #10's oxygen concentrator was observed again on 7/23/19 at 3:19 PM, with Registered Nurse (RN) #1 present. RN #1 confirmed there were multiple stains and splatters to the concentrator. During an interview, during the observation, RN #1 stated every Sunday on 3rd shift the oxygen concentrator is supposed to be cleaned. RN #1 agreed that the concentrator was not clean.",2020-09-01
822,MAGNOLIA MANOR - SPARTANBURG,425091,375 SERPENTINE DRIVE,SPARTANBURG,SC,29305,2019-07-24,585,E,0,1,VPO011,"Based on interviews and review of the facility's grievance log, the facility failed to ensure that residents with grievances regarding missing/lost clothing received a resolution to their grievance. Five (5) of six (6) group members expressed concerns about not getting a response when a grievance/concern was reported. The findings included: During a group meeting on 7/22/19 at approximately 11:17 AM 5 of 6 group members expressed concerns that they have reported missing/lost clothing and have not received a response. One resident stated his/her missing items were specially designed and they were irreplaceable. Some group members expressed multiple reports of missing clothing at various times and no response. During an interview on 7/23/19 at approximately 8:47 AM with the Activity Director (AD) revealed the residents expressed concerns during the monthly Resident Council Meeting about missing clothing. The AD further stated s/he basically complete a grievance form and does not make notes in the meeting minute's related missing clothing. On 7/23/19 at approximately 2:56 PM during an interview with the Administrator a request for the grievance log was made to determine what process was in place to resolve residents' concerns for missing clothing. Review of the grievance log on 7/23/19 regarding missing items of clothing from 1/01/2019 to present revealed multiple reports of missing clothing on the grievance log with no resolution provided. Further review of the grievance log indicated on 1/28/19 and 4/22/19 that missing clothing was resolved satisfactory. Review of the actual grievance reports dated 1/28/19 and 4/22/19 revealed the missing clothing issues were not resolved satisfactory and indicated on the grievance log. Review of the facility's policy on missing items policy revealed the facility staff and patient/resident and/or legal representative will create a personal inventory list. The policy indicated the facility will make efforts to locate the missing items. The policy further indicated the administrator or the facility designee will provide follow up to the patient/resident/family on the status in 3 working days. During an interview on 7/23/19 at approximately on 3:08 PM with the Administrator s/he acknowledged the concerns with missing clothing.",2020-09-01
823,MAGNOLIA MANOR - SPARTANBURG,425091,375 SERPENTINE DRIVE,SPARTANBURG,SC,29305,2019-07-24,656,D,0,1,VPO011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop a comprehensive person-centered care plan for Resident #11, 1 of 3 sampled residents reviewed for Accidents. Resident #11 fell during a transfer with a sit to stand mechanical lift on 4/23/19. The use of the sit to stand lift for the resident was not on the care plan at the time of the accident. The findings included: The facility admitted Resident #11 with [DIAGNOSES REDACTED]. Record review of a SBAR (Situation, Background, Assessment and Recommendation) Communication Form for Resident #11 on 7/21/19 at 5:18 PM, revealed the resident was being transferred with a mechanical lift from the chair to bed on 4/23/19. Resident #11 was unable to hold on to the bars on the lift and fell . Record review of the facility investigation into the accident on 7/22/19 at 3:14 PM, revealed the mechanical lift was not being used per the manufacturer's specifications due to only 1 staff member was transferring Resident #11 with the sit to stand lift. Record review of a Corrective Action Form on 7/22/19 at 3:14 PM, revealed disciplinary action was taken against the staff member as a result of the accident for not having another staff person assisting with the use of the sit to stand lift for the transfer of Resident #11. The Corrective Action Form indicated it was company protocol for 2 persons to assist a resident when transferring with a mechanical lift. Review of Resident #11 care plan on 7/23/19 at 10:42 AM, revealed the sit to stand lift was not care planned for Resident #11 at the time of the accident. In addition, the care plan revealed Resident #11 required a 2 person assist with ambulation and with transfers from the wheelchair to the toilet. During an interview with Licensed Practical Nurse (LPN) #2 on 7/23/19 at 10:40 AM, LPN #2 confirmed the sit to stand lift was not care planned for Resident #11 at the time of the accident. LPN #2 stated the care plan did indicate the resident required the assistance of 2 persons for other transfers at the time of the accident. Record review of a nurse practitioner progress note from 4/24/19 for Resident #11, on 7/23/19 at 9:55 AM, revealed the nurse practitioner performed a complete physical examination of Resident #11 and found no injuries or abnormalities as a result of the fall during the transfer with the sit to stand lift.",2020-09-01
824,MAGNOLIA MANOR - SPARTANBURG,425091,375 SERPENTINE DRIVE,SPARTANBURG,SC,29305,2019-07-24,661,D,0,1,VPO011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to complete a discharge summary that summarized the resident's stay at the facility. Resident #84 was discharged to the community on 6/11/19 and there was no discharge summary completed. The findings included: The facility admitted Resident #84 on 3/29/19 with [DIAGNOSES REDACTED]. A review of Resident #84's medical record on 7/24/19 at approximately 7:55 AM revealed a discharge planning meeting was held on 4/01/19 and a physician's orders [REDACTED]. Further review of the medical record revealed there was no discharge summary to summarize the resident's stay, discharge plan of care, medication and additional services provided. There was no social or nurse's note to indicate when Resident #84 was discharged from the facility and who transported the resident from the facility. During an interview on 7/24/19 at approximately 8:41 AM with the Medical Records Officer (MRO) who looked in Resident #84's medical record and confirmed he/she could not locate a nurse's note, social note or discharge summary in the medical record. The MRO stated he/she would ask other staff if they knew where the information could be located. During an interview on 7/24/10 at approximately 9:51 AM with the MRO revealed he/she could not locate the discharge summary that addressed Resident #84's final stay while at the facility.",2020-09-01
825,MAGNOLIA MANOR - SPARTANBURG,425091,375 SERPENTINE DRIVE,SPARTANBURG,SC,29305,2019-07-24,684,D,0,1,VPO011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that required hospice documentation was available in the medical record for 1 of 1 residents reviewed for hospice. Resident #44 who had physician's orders [REDACTED]. The findings included: The facility admitted Resident #44 on 2/20/18 with [DIAGNOSES REDACTED]. A review of Resident #44's medical record on 7/23/19 at approximately 10:03 AM revealed a physician's orders [REDACTED]. Further record review revealed there was no consent for hospice, hospice certification with terminal illness documentation and no hospice care plan in the medical record or the resident's hospice book. During an interview on 7/23/19 at approximately 10:10 AM with Licensed Practical Nurse (LPN) #1 s/he confirmed there was no hospice documentation in the medical record or the hospice book for Resident #44. LPN #1 further stated the required documentation might be down stairs in the business office and that s/he would check. On 7/23/19 at approximately 10:44 AM, LPN #1 provided a copy of the hospice certification and the hospice care plan for Resident #44. LPN #1 stated it was located in the business office. Further review of the hospice certification and hospice care plan provided by LPN #1 revealed the information was faxed to the facility on [DATE]. LPN #1 confirmed the findings after reviewing the faxed date on the documentation.",2020-09-01
826,MAGNOLIA MANOR - SPARTANBURG,425091,375 SERPENTINE DRIVE,SPARTANBURG,SC,29305,2019-07-24,689,D,0,1,VPO011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility policy and interview, the facility failed to provide adequate supervision to prevent accidents for Resident #11, 1 of 3 sampled residents reviewed for Accidents. Resident #11 fell during a transfer with a sit to stand mechanical lift on 4/23/19. The findings included: The facility admitted Resident #11 with [DIAGNOSES REDACTED]. Record review of a SBAR (Situation, Background, Assessment and Recommendation) Communication Form on 7/21/19 at 5:18 PM, revealed Resident #11 was being transferred with a sit to stand mechanical lift, from the chair to bed on 4/23/19. The resident was unable to hold on to the bars on the lift and fell . Record review of the Incident Report and facility investigation into the accident on 7/22/19 at 3:14 PM, revealed on 4/23/19 Resident #11 was being transferred with the sit to stand lift from the chair to the bed, let go of the handles and fell to her/his knees. The resident was assessed and found to have no injuries. The investigation revealed the mechanical lift was not being used per the manufacturer's specifications due to only 1 staff member was transferring the resident with the sit to stand lift. Record review of a Corrective Action Form on 7/22/19 at 3:14 PM, revealed disciplinary action was taken against the staff member as a result of the accident for not having another staff person assisting with the use of the sit to stand lift for the transfer. The Corrective Action Form indicated it was company protocol for 2 persons to assist a resident when transferring with a mechanical lift. During an interview with Licensed Practical Nurse (LPN) #2 on 7/23/19 at 10:40 AM, LPN #2 confirmed the sit to stand lift was not care planned for at the time of the accident. LPN #2 stated the care plan did indicate the resident required the assistance of 2 persons for other transfers at the time of the accident. During an interview with the Administrator on 07/23/19 at 11:40 AM, the Administrator confirmed it is company protocol for 2 staff members to assist with transfers involving mechanical lifts. Record review of Resident #11's nurse practitioner progress note from 4/24/19, on 7/23/19 at 9:55 AM, revealed the nurse practitioner performed a complete physical examination of Resident #11 and found no injuries or abnormalities as a result of the fall during the transfer with the sit to stand lift. Review of the facility's Mechanical Lifts: General Guidelines policy revealed: Determine how many caregivers are necessary to safely lift the patient or resident. In most cases and for safety, a minimum of 2 caregivers is recommended.",2020-09-01
827,MAGNOLIA MANOR - SPARTANBURG,425091,375 SERPENTINE DRIVE,SPARTANBURG,SC,29305,2019-07-24,692,D,0,1,VPO011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure acceptable parameters of nutritional status and failed to provide a therapeutic diet based on resident preferences for Resident #69, 1 of 3 sampled residents reviewed for Nutrition. Recommendations by the Registered Dietician (RD) were not acted upon timely and the facility was not providing meals and beverages based on the resident's preferences. The findings included: The facility admitted Resident #69 on 7/13/12 with [DIAGNOSES REDACTED]. Record review of Resident #69's Telephone Orders on 7/22/19 at 12:08 PM, revealed an order, from 7/15/19, for [MEDICATION NAME] 30 milliliters daily at bedtime for weight and appetite. Record review of Resident #69's Medication Administration Record (MAR) on 7/22/19 at 1:59 PM, revealed the resident was not receiving the [MEDICATION NAME]. Record review of Resident #69's Dietary notes on 7/22/19 at 2:10 PM, revealed the resident was assessed by the RD on 7/15/19. The RD noted the resident had an 8.5 % weight loss over the past 90 days and a significant weight loss of 10.6% over the last 180 days. The RD note indicated [MEDICATION NAME] would be started to improve appetite. Further review of the dietary notes revealed no documentation of the resident's food and beverage preferences. Resident #69 was observed feeding him/herself lunch on 7/22/19 at 12:15 PM. The resident's meal consisted of baked chicken, mashed potatoes and gravy, carrots, a dinner roll, milk and dessert. The resident was observed again at 12:49 PM and had eaten everything except the carrots and dinner roll. It did not appear any of the carrots or roll had been eaten. During an interview with Registered Nurse (RN) #2 on 07/22/19 at 3:23 PM, RN #2 stated the order for the [MEDICATION NAME] had been entered into the computer, but was not added to the MAR. RN #2 confirmed the resident was not receiving the [MEDICATION NAME] because it was not added to the MAR. RN #2 stated the order should have been added to the MAR when it was entered into the computer. RN #2 stated the [MEDICATION NAME] had been added to the MAR and the resident would start receiving it today. During an interview with Resident #69's family member on 7/21/19 at 2:19 PM, the family member expressed concerns related to the resident's diet. S/he stated the facility gives the resident enough to eat, but they don't always give him what he likes to eat. The family member stated s/he wished the facility would provide more foods and drinks based on the resident's preferences. During an interview with the Certified Dietary Manager (CDM) on 7/22/19 at 3:35 PM, the CDM stated resident food and beverage preferences should be updated and documented on admission and with each annual assessment. The CDM stated s/he was not employed at the facility for Resident #69's last annual assessment, but was working on the current annual assessment. The CDM stated s/he had called the resident's wife today to update the resident's food and beverage preferences. The CDM provided the resident's updated food and beverage preference list, dated 7/22/19. Carrots were listed as a dislike and the bread section was blank. When asked to see previous food and beverage preference lists the CDM stated s/he could not find any, but would look through the entire record for past lists. During an interview with the CDM on 7/23/19 at 3:02 PM, the CDM stated there was no record of the resident's food and beverage preferences prior to 7/22/19.",2020-09-01
828,MAGNOLIA MANOR - SPARTANBURG,425091,375 SERPENTINE DRIVE,SPARTANBURG,SC,29305,2019-07-24,693,D,0,1,VPO011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to provide tube feeding services for 1 of 2 residents with tube feeding reviewed. Resident #233 was not given tube feedings as ordered on day of discharge. The findings included: Resident #233 was admitted [DATE] with [DIAGNOSES REDACTED]. During an interview with the family of Resident #233 on 7/23/19 at approximately 3:35 PM revealed the resident had not eaten all day during the day of discharge. Review of Resident #233's treatment administration records on 7/24/19 at approximately 9 AM revealed the resident was last fed at 4 AM on day of discharge, missing feedings at 8 AM and 12 PM. Records show the resident was discharged at approximately 1:15 PM. During an interview with Registered Nurse (RN) #1 s/he confirmed Resident#233 missed two feedings prior to discharge, per the records.",2020-09-01
829,MAGNOLIA MANOR - SPARTANBURG,425091,375 SERPENTINE DRIVE,SPARTANBURG,SC,29305,2019-07-24,745,E,0,1,VPO011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure that medically related social services were provided to 3 of 5 sampled residents reviewed on unnecessary medications/[MEDICAL CONDITION] medications. Resident #14, #19 and #39 did not have quarterly statements documented to indicate that services were provided for psychosocial concerns. The findings included: The facility admitted Resident #14 on 11/30/17 with [DIAGNOSES REDACTED]. A review of Resident #14's medical record on 7/23/19 at approximately 8:56 AM revealed a social services progress note dated 3/29/19 that Resident #14 was readmitted back to the hospital for psych evaluation related to Anxiety and Paranoia. The social services note further indicated that social services with follow up with treatment and the resident's readjustment to the facility. There were no other social services notes to indicate any follow up was made. During an interview on 7/23/19 at approximately 9:44 AM with Registered Nurse #1 s/he confirmed there was no documentation of any follow up in the medical record to address Resident #14's readjustment back to the facility after the (MONTH) 2019 hospital stay. The facility admitted Resident #19 on 9/17/17 with [DIAGNOSES REDACTED]. A nurse's note dated 7/09/19 revealed Resident #19 refused to go to [MEDICAL TREATMENT]. A nurses' note dated 7/20/19 indicated Resident #19 has verbal behaviors at times and refuses care. A communication form dated 7/12/19 indicated Resident #19 was non complaint and fell out of bed. The communication form further indicated the resident was transported to the hospital due to receiving an abrasion on back of head. A review of social services notes for Resident #19 revealed there were no documented social services notes since 8/12/18. During an interview on 7/23/19 at approximately 11:58 AM with Licensed Practical Nurse (LPN) #1 revealed Resident #19 remained in the hospital after the 7/12/19 fall due to noncompliance with [MEDICAL TREATMENT] and low lab levels. LPN #1 further confirmed s/he could not locate any additional social services notes in the medical record for Resident #19 but s/he will check with medical records. During an interview on 7/23/19 at approximately 3:26 PM with LPN #1 revealed s/he still cannot locate any additional social services notes for Resident #19. The facility admitted Resident #39 on 2/15/19 with [DIAGNOSES REDACTED]. A review of Resident #39's medical record on 7/23/19 at approximately 12:36 PM revealed the resident was on multiple [MEDICAL CONDITION] medications. Further record review revealed the resident was documented with behaviors and medications given to address the behaviors. A social services note dated 2/22/19 for Resident #39 revealed a psych referral was completed for agitated state. The resident wanders throughout the building and social services to follow up. There were no additional social services notes to determine if further follow up was provided. During an interview on 7/23/19 at approximately 3:35 PM with LPN #1 s/he confirmed there were no additional social services notes in the medical record for Resident #39.",2020-09-01
830,MAGNOLIA MANOR - SPARTANBURG,425091,375 SERPENTINE DRIVE,SPARTANBURG,SC,29305,2019-07-24,812,E,0,1,VPO011,"Based on observation, interviews, and policy review, the facility failed to store and prepare food in accordance with professional standards for 1 of 1 kitchens reviewed for food and kitchen services. Storage areas observed with items used for cooking not dated with the date received, use by dates and/or expiration dates. The findings included: During the initial tour of the kitchen with Cook #1 on 07/21/19 at approximately 1:24 PM, the following items were observed opened without an opened-on date, use by date or received on date: In the dry storage area 3 boxes of Buttermilk Pancake and Waffle Mix, 6 boxes of Angel Food Cake mix, Gravy Mix, 1 box and 1 pack of Chicken Gravy mix, 2 packs of Brown Gravy, 1 box of ready crust, opened Pretzels, 2 gallons of Barbeque sauce, 1 gallon of Teriyaki Sauce, 2 opened cereal boxes, and opened bread did not have a received on, use by or expiration date. This was confirmed by Cook #1 at the time of the observation. In the walk-in refrigerator, Hard boiled eggs, opened eggs, bacon, lettuce, cucumbers, tomatoes, potatoes and cabbage did not have a received on, use by or expiration date. This was confirmed by Cook #1 at the time of the observation. The walk-in freezer area was cluttered with boxes on the floor making it difficult to get into the freezer to see items on the shelving. The following items were observed without a received by, use by or expiration date, ham base, chocolate ice cream, corn dogs, Bacon, waffles, and hushpuppies. The boxes and items were confirmed at the time of observation with the Administrator. Record Review of the Nutrition Policies and Procedures #12. On 07/23/19 at approximately 8:30 AM revealed, Refrigerated, ready to eat Time/Temperature Control for Safety Foods (TCS) are properly covered, labeled, dated with use by date and refrigerated immediately. Mark them clearly to indicate the date by which the food shall be consumed or discarded.",2020-09-01
831,MAGNOLIA MANOR - SPARTANBURG,425091,375 SERPENTINE DRIVE,SPARTANBURG,SC,29305,2019-07-24,842,D,0,1,VPO011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure that a resident's medical record was accurately documented related to code status. Resident #10 medical record indicated a code status of Do Not Resuscitate and Full Code (cardiopulmonary resuscitation). 1 of 1 resident reviewed for Advance Directive. The findings included: The facility admitted Resident #10 on 9/25/18 with [DIAGNOSES REDACTED]. A review of Resident #10's medical record on 7/22/19 at approximately 3:10 PM revealed Resident #10's medical record indicate a physician's orders [REDACTED]. A nurse's note dated 6/12/19 indicated Resident #10 was sent to the emergency room due to abnormal labs. The nurse's note further indicated the resident had returned back from the hospital on [DATE]. During an interview on 7/22/19 at approximately 3:24 PM with Registered Nurse RN) #1 revealed Resident #10 was discharged to the hospital and readmitted as a Full Code then changed back to DNR. RN#1 confirmed the (MONTH) 2019 cumulative order had resident coded as Full Code and the physician order [REDACTED]. During an interview on 7/22/19 at approximately 3:37 PM with the facility Administrator s/he confirmed the inconsistency in Resident #10's medical record and stated s/he will get the cumulative order updated with the corrected information.",2020-09-01
832,MAGNOLIA MANOR - SPARTANBURG,425091,375 SERPENTINE DRIVE,SPARTANBURG,SC,29305,2019-07-24,865,E,0,1,VPO011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations and record reviews, the facility failed to identify and correct quality deficiencies timely and effectively to prevent reported concerns of roaches throughout the facility. 3 of 3 floors reviewed. The findings included: During an individual interview on 7/21/19 at approximately 4:44 PM a roach was observed crawling on the wall of room [ROOM NUMBER] [NAME] The residents in the room both expressed concerns about roaches in their room. The resident in 207 B stated roaches can been seen all over the place and stated they are in the bathrooms and come out at night. An observation 7/22/19 at approximately 11:15 AM revealed a large cockroach crawling in the basement near the food carts located outside the kitchen. The Activity Director confirmed the observation of the large roach crawling in the basement on the floor. During the group interview on 7/22/19 at approximately 11:17 AM, the group members expressed concerns about roaches crawling around in the facility. Four of six group members reported seeing roaches in their rooms and 1 resident stated he/she has seen roaches in his/her food. The Administrator provided a quality assurance (QA) and performance improvement report that was reportedly started in (MONTH) 2019. The report further indicated that a pest control company will spot spray on 5/14/19 and come weekly. There was no date on the report to indicate the date the QA started, what will be put in place to address the issue and a completion date to the identified concerns. On 7/23/19 at approximately 8:01 AM a review of the pest control documentation revealed no documentation of weekly monitoring or spraying. On 7/23/19 at approximately 8:36 AM a review of the grievance log indicated concerns about roaches in resident rooms was expressed by residents since 9/2018 to present. Multiple visits by pest control company have not addressed the pest issues effectively. A review of the facility's insect monitoring documentation revealed inconsistencies as to when the monitoring started. Unit 1 had documented sighting of bugs/roaches on 5/23/19. Unit 2 had documented pest sightings on 5/31/19 and Unit 3 had documented pest sighting since 5/15/19. A family interview on 7/23/19 at approximately 7:11 AM revealed s/he has seen roaches crawling around the facility since his/her spouse was admitted in the facility over a year now. During an interview on 10:17 AM with the facility Administrator revealed s/he did not have documentation to indicate the pest control company had been spraying the facility weekly as noted on the Q[NAME]",2020-09-01
833,MAGNOLIA MANOR - SPARTANBURG,425091,375 SERPENTINE DRIVE,SPARTANBURG,SC,29305,2019-07-24,925,E,0,1,VPO011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations and record reviews, the facility failed to maintain and effective pest control program to keep the facility from pests on 3 of 3 floors reviewed. The findings included: During an individual interview on 7/21/19 at approximately 4:44 PM a roach was observed crawling on the wall of room [ROOM NUMBER] [NAME] The residents in the room both expressed concerns about roaches in their room. The resident in 207 B stated roaches can been seen all over the place and stated they are in the bathrooms and come out at night. An observation 7/22/19 at approximately 11:15 AM revealed a large cockroach crawling in the basement near the food carts located outside the kitchen. The Activity Director confirmed the observation of the large roach crawling in the basement on the floor. During the group interview on 7/22/19 at approximately 11:17 AM, the group members expressed concerns about roaches crawling around in the facility. Four of six group members reported seeing roaches in their rooms and 1 resident stated he/she has seen roaches in his/her food. On 7/23/19 at approximately 8:01 AM a review of the pest control documentation revealed no documentation of weekly monitoring or spraying. On 7/23/19 at approximately 8:36 AM a review of the grievance log indicated concerns about roaches in resident rooms was expressed by residents since 9/2018 to present. Multiple visits by pest control company have not addressed the pest issues effectively. A review of the facility's insect monitoring documentation revealed inconsistencies as to when the monitoring started. Unit 1 had documented sighting of bugs/roaches on 5/23/19. Unit 2 had documented pest sightings on 5/31/19 and Unit 3 had documented pest sighting since 5/15/19. A family interview on 7/23/19 at approximately 7:11 AM revealed s/he has seen roaches crawling around the facility since his/her spouse was admitted in the facility over a year now. During an interview on 10:17 AM with the facility Administrator revealed s/he did not have documentation to indicate the pest control company had been spraying the facility weekly as noted on the quality assurance report.",2020-09-01
834,SUNNY ACRES NURSING HOME,425093,1727 BUCK SWAMP ROAD,FORK,SC,29543,2017-04-20,241,D,0,1,2ZIO11,"Based on observation, interview and facility review of facility policy titled, Dignity During Meal Time, the facility staff failed to ask residents prior to putting on clothing protectors. The findings included: During observation prior to the dinner meal service on 04/19/17 at 4:35 pm a Certified Nursing Assistant (CNA) was observed placing clothing protectors on residents without asking if the resident wished to have one, in the dining room on the 300/200 unit. CNA #1 was observed telling the CNA putting on the protectors to ask the residents first if they wanted a protector. The CNA was then observed asking a resident if s/he wanted a protector. The resident stated s/he did No. The CNA told the resident s/he had to put the protector on. The resident agreed to take the protector in her hand. In an interview on 04/19/17 at 4:35 pm CNA #1 confirmed that the CNA had gone into the cabinet, took out the protectors and started putting them on the residents. CNA #1 stated the proper procedure was to offer a clothing protector and allow residents to choose whether to accept. Review of facility policy titled, Dignity During Meal Times on 04/21/17 at 1:54 pm revealed that It is the practice of this facility to treat each resident with respect and dignity and care for each resident in a manner and in an environment that maintains or enhances his or her quality of life. Recognizing each resident's individuality and protecting the rights of each resident.",2020-09-01
835,SUNNY ACRES NURSING HOME,425093,1727 BUCK SWAMP ROAD,FORK,SC,29543,2017-04-20,247,D,0,1,2ZIO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews and review of the facility policy titled, Room And/Or Roommate Change, the facility failed to ensure Resident #144 was notified of a room change on 2 different occasions while out of the facility for 1 of 1 resident reviewed for Admission,Transfer and Discharge. The findings included: The facility admitted Resident #144 with [DIAGNOSES REDACTED]. During an interview on 4/18/2017 at approximately 10:39 AM with Resident #144 he/she stated, I went to [MEDICAL TREATMENT] and came back and they had moved me to another room. Resident #144 had been asked if he/she had had a room or roommate change in the last nine months and if he/she was given notice prior to the change. Review on 4/21/2017 at approximately 10:37 AM of the nurses notes dated 3/13 (YEAR) until 3/18/2017 Resident #144 was out of the facility and in the hospital. When he/she returned he/she was moved to another room which was the facility's decision to do so. No documentation could be found in the nurses notes nor the social service notes to indicate that Resident #144 was informed of the room change prior to the change. During an interview on 4/21/2017 at approximately 10:45 AM with the Social Service worker he/she stated, Resident #144 was moved again due to the resident being unable to see outside of the facility. No documentation could be found in the nurses notes nor the social service notes to indicate that Resident #144 was notified of the room change. Per Resident #144 when he/she returned from [MEDICAL TREATMENT] he/she had been moved to another room without prior notification. Review on 4/21/2017 at approximately 11:40 AM of the facility policy titled, Room And/Or Roommate Change, states under Policy: A resident and/or family have the right to refuse a transfer to another room within the facility. In addition, the resident and/or family have the the right to be informed in advance and in writing, to include the reason for the change, before the room or roommate in the facility is changed.",2020-09-01
836,SUNNY ACRES NURSING HOME,425093,1727 BUCK SWAMP ROAD,FORK,SC,29543,2017-04-20,280,D,0,1,2ZIO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of the facility policy titled MDS/Care Plans, the facility failed to afford the opportunity to Resident #144 to participate in the care plan process for 1 of 1 resident reviewed for care plan participation. The findings included: The facility admitted Resident #144 with [DIAGNOSES REDACTED]. Record review on 4/19/17 revealed the Admission Minimum Data Set((MDS) dated [DATE] listed Resident #144's Brief Interview for Mental Status(BIMS) as12 with a current BIMS dated 4/1/17 of 14. During an interview with Resident #144 on 4/18/17 at 10:34 AM, he/she stated the facility did not talk to him/her about medications, therapy or other treatments. Review of the Care Plan Review Form on 4/19/17 revealed the care plan dated 4/3/17 did not indicate the resident had been invited to the care plan nor did it indicate the care plan had been discussed with the resident at a later date. A second copy of the Care Plan Review Form was provided on 4/20/17 which stated the resident had been invited but declined. During an interview with Social Service Director on 4/20/17 at 1:34 PM, he/she stated the resident had been in the hospital and the family member wanted to have the care plan meeting on 4/3/17. He/she continued by stating an invitation was probably not sent to him/her due to the request. The Social Service Director reviewed both copies of the sign in sheet and stated he/she did not check the box on the second copy indicating the resident had been invited but declined the invitation to the care plan meeting. After reviewing a book which contained information related to when a resident is sent a care plan invitation, the Social Service Director stated there was no documentation an invitation had been sent. Review of the facility policy titled MDS/Care Plans states under the Policy Interpretation and Implementation #7 the following: The resident and responsible party are encouraged to actively participate in the development and review of the care plan. Each resident and responsible party will be notified of the date and time for each interdisciplinary care plan team meeting,",2020-09-01
837,SUNNY ACRES NURSING HOME,425093,1727 BUCK SWAMP ROAD,FORK,SC,29543,2017-04-20,287,B,0,1,2ZIO11,"Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) assessments for Resident #126 was transmitted to the State Agency in a timely manner without error for 1 of 1 resident with missing MDS 3.0 OBRA Assessments. The findings included: Review on 4/20/2017 at approximately 2:00 PM of the missing assessment report from the facility revealed Resident #126 had missing MDS 3.0 OBRA Assessments and or errors during transmission to the state agency. An interview on 4/20/2017 at approximately 2:30 PM with the MDS (Minimum Data Set) assessment nurse confirmed the findings. The MDS assessment nurse went on to say, the message we got stated the assessments were accepted so therefore I did not follow up on it. This surveyor then presented the list of missing assessments to be corrected.",2020-09-01
838,SUNNY ACRES NURSING HOME,425093,1727 BUCK SWAMP ROAD,FORK,SC,29543,2017-04-20,309,D,0,1,2ZIO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of the facility policy titled Assessment of Unconscious Resident, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well-being. Resident #144 with an episode of unresponsiveness with no documented monitoring or reassessments. (1 of 1 reviewed for change in condition) The findings included: The facility admitted Resident #144 with [DIAGNOSES REDACTED]. Record review on 4/20/17 of the nurse's notes revealed on 3/13/17 at 8:05 AM, Resident #144 was non responsive to verbal stimuli and not responsive to touch. Only slight facial grimacing was observed during firm sternal rub. The resident's oxygen saturation level was 98% on 2 liters of oxygen and the pulse rate was 99, blood pressure of 100/60 and respirations were documented at 24. No shortness of breath, congestion, or diaphoresis were observed. The right upper chest tunnel catheter was dry and intact. At that time the physician was notified. At 8:20 AM, the physician called back and gave an order to transfer to the hospital. At 8:50 AM, Resident #144 was transported to the hospital and continued to be non responsive to verbal stimuli and sternal rub. The nurse's notes documented at the time of transfer the vital signs were stable. No documentation was presented to indicate what the vital signs were at the time of transfer. Further record review revealed no documentation of reassessing the resident from 8:05 AM to 8:50 AM at the time of transfer. During an interview with the Licensed Practical Nurse(LPN) #2 on 4/20/17 at 1:00 PM, after reviewing the documentation, he/she confirmed there was no documentation related to reassessing the resident. He/she continued by stating if a resident had an episode of unresponsiveness, he/she would assess the resident which included vital signs and a blood sugar check. The resident would be sent out immediately and he/she would not wait on the phone call from the physician. During an interview on 4/20/17 at 1:15 PM with LPN #3, he/she stated if a resident's vital signs were normal but the resident is not responsive, he/she would use nursing judgement and call the physician. If vital signs were not stable and the resident was unresponsive, he/she would transport to the hospital immediately. He/she continued by stating someone was in the room with the resident and confirmed he/she should have documented the incident better. Review of the facility policy titled Assessment of Unconscious Resident states under Policy Interpretation and Implementation states the following: 2. If the resident is unconscious but breathing on his/her own, check vital signs and monitor blood pressure, pulse and respirations as needed, depending on resident assessment. 3. During resident assessment, inspect the tongue for signs of biting, which may indicate a [MEDICAL CONDITION]. The policy also states a nurse or assistant should remain with the resident until emergency services arise for transport.",2020-09-01
839,SUNNY ACRES NURSING HOME,425093,1727 BUCK SWAMP ROAD,FORK,SC,29543,2017-04-20,323,D,0,1,2ZIO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interview and review of facility policy titled Resident Environment Quality, the facility failed to provide an environment as free from accident hazards as possible. During observation of resident rooms, a regular extension cord was used to operate resident equipment for 2 of 2 residents observed utilizing oxygen concentrators. The findings included: The facility admitted Resident #144 with [DIAGNOSES REDACTED]. The facility admitted Resident #41 with [DIAGNOSES REDACTED]. During room observations on 4/18/17 at 3:21 PM, a regular extension cord was noted in Resident #144 and 41's room with items plugged into the cord. During environmental rounds on 4/20/17 at 9:45 AM, with the Director of Operations, the Administrator and the Maintenance Director, the extension cord was observed. The Maintenance Director confirmed two oxygen concentrators had been plugged into the extension cord. Review of the facility policy titled Resident Environment Quality under Policy Explanation and Compliance Guidelines revealed the following: 2. Maintain all essential mechanical, electrical, and patient care equipment in safe operating condition.",2020-09-01
840,SUNNY ACRES NURSING HOME,425093,1727 BUCK SWAMP ROAD,FORK,SC,29543,2017-04-20,371,E,0,1,2ZIO11,"Based on record review, observation, interview and review of facility policies titled Food Storage and Proper Use of Thermometers, the facility failed to follow proper food storage and food handling practices for 1 of 1 kitchen. During observation of the kitchen undated/unlabeled items and opened foods not sealed properly were observed. During the temping of the foods, staff could not accurately state how to calibrate a thermometer nor could correctly read the thermometer. The findings included: During the initial kitchen observation on 4/17/17 at 11:20 AM the following was observed: (1) partial pack of hamburger buns; (1) partial pack of rolls; (1) partial pack of hot dog buns; all items opened with no open date. Observation of the reach in freezer revealed (1) partial bag of peas and (1) partial bag of greens opened with no open date. Observation of the dry storage area revealed an opened bag of black eye peas not sealed completely. Observation of the box freezer revealed a thermometer with a reading of 30 degrees. The seal of the freezer was not tight. All items in the freezer were frozen solid. The above observations were confirmed by the Dietary Manager during the initial tour of the kitchen. Observation of the box freezer on 4/19/17 at 5:15 PM revealed the freezer thermometer again had a reading of 30 degrees. All items in the freezer were frozen solid. A second thermometer was placed and when observed within ten minutes the new thermometer read 10 degrees. Review of the temperature log for the freezer revealed the temperatures were taken every day in (MONTH) (YEAR) with a reading of minus 10 degrees Fahrenheit. Prior to temping of the food items on 4/19/17 at 4:45 PM, the evening cook was asked what was the accepted temperature for calibration of the thermometer He/she stated the thermometer should be calibrated to 30 degrees and then changed his/her answer to 40 degrees. During the temping of the food temperatures for the evening meal the evening cook incorrectly read the thermometer at times with a difference of 10 degrees. Dietary staff #2 was asked to calibrate a thermometer prior to obtaining the temperature of the milk. He/she stated the thermometer should be calibrated to 20 degrees and then stated 30 degrees. At that time the Dietary Supervisor cued the staff member that the proper calibration temperature was 32 degrees. Review of the facility policy titled Food Storage revealed under the procedure section the following: 15b.-Frozen foods must be maintained at a temperature to keep the food frozen solid. Freezer temperatures should be checked at least two times each day. 15c.- All foods should be covered, labeled and dated. Review of the facility policy titled Proper Use of Thermometers revealed under the procedure section the following: 3- .Place the thermometer in ice water and wait three minutes stirring occasionally. After three minutes the thermometer should read 32 degrees Fahrenheit.",2020-09-01
841,SUNNY ACRES NURSING HOME,425093,1727 BUCK SWAMP ROAD,FORK,SC,29543,2017-04-20,372,D,0,1,2ZIO11,"Based on observation, interview and review of the facility policy titled Dumpsters-Garbage Refuse Policy, the facility failed to dispose of garbage and refuse properly for 2 of 2 dumpters observed. One dumpster was observed without a plug to prevent leakage and another dumpster was observed with the side door open. The findings included: Observation of the dumpsters on 4/20/17 at approximately 12:45 PM revealed one dumpster without a plug to prevent leakage and a second dumpster with the side door open. During an interview with the Dietary Manager at the time of the observation, he/she confirmed a plug was missing and the door of the dumpster was not completely shut. Review of the facility policy titled Dumpsters-Garbage Refuse Policy states the following: 1. Garbage and refuse containers should be free from cracks or leaks and covered when not in use. 6. Refuse containers and dumpsters kept outside the facility should have tightly fitting lids and should be kept covered when not being loaded.",2020-09-01
842,SUNNY ACRES NURSING HOME,425093,1727 BUCK SWAMP ROAD,FORK,SC,29543,2017-04-20,460,D,0,1,2ZIO11,"Based on observations, interview and review of the facility policy titled Resident Environment Quality, the facility failed to equip each resident's room to assure full visual privacy for each resident. Resident rooms were observed with privacy curtains which did not meet to provide full visual privacy. The findings included: During room rounds on 4/18/17, the following rooms were not equipped with a privacy curtain which ensured full visual privacy: Room 211B Room 213A Room 213B. During environmental rounds on 4/20/17 at 9:45 AM with the Director of Operations, the Administrator and the Maintenance Director, the privacy curtains were observed and the Director of Operations and Maintenance Director confirmed the curtains did not provide full visual privacy. Review of the facility policy titled Resident Environment Quality lists under the Policy Explanation and Compliance Guidelines the following: 4d. Resident rooms must be designed and equipped for adequate nursing care, comfort, and privacy of residents-Be designed or equipped to assure full visual privacy for each resident.",2020-09-01
843,SUNNY ACRES NURSING HOME,425093,1727 BUCK SWAMP ROAD,FORK,SC,29543,2018-08-17,584,E,0,1,X2DT11,"Based on observation, interview, and record review, the facility failed to ensure the shower room was maintained in safe and sanitary condition. This deficient practice affected 21 of 24 residents residing on the 200 Hall who were showered in the room. Findings include: Observation on 08/14/18 at 12:10 PM of the Shower Room in Hall 200 revealed the following: The hallway tiles adjoining the threshold to the shower floor included three broken tiles with missing portions, exposing the underlying subfloor. The outside of the shower room door revealed there were three tiles located across the doorway opening. The first tile from the right had a missing piece of tile measuring 4 inches by 1 1/2 in size, the second tile had a missing piece of tile measuring 1 inch by 1 inch, and the third tile had a missing piece of tile measuring 5 inches by 3 inches in size. The floor of the shower room had two missing tiles where the two floor drains were located exposing the underlying grout over concrete subfloor. Three broken floor tiles were located on lower right shower room wall with four of five tiles broken where the right wall met the back wall. These breaks resulted in large gaps where black, soft matter was visible. Grout was missing from between floor tiles with standing water and black debris visible in the vacant spaces. The back wall was covered with sheets of pressed wood that had been painted. There were cracks in the wood running from the floor to near the top of the wood. A soft, black matter was visible in the cracks. Calk was missing from around the wood covering and moisture was evident in all cracks in the partially tiled and wooden surfaces. During an interview on 08/17/18 at 2:00 PM, Housekeeper 1, stated she was responsible for keeping the Shower Room in Hall 200 clean. She described this procedure as clearing any debris that might be in the shower area, mopping the floor, and disinfecting the walls, shower controls, spray heads and shower chairs with a substance used at the facility called Good Spray. She stated, she tried to disinfect the shower room but couldn't get into all the cracks in the tiles, gaps in the grout, and cracks/holes in the wood paneling. She stated there was black mold growing in the cracks and holes and she tried everything she and her supervisor could think of to stop the mold from growing but nothing really worked. She stated, she tried cleaning the cracks and holes with a long stick to scrape up the mold but it didn't work well. She stated, she tried her best, but she just couldn't get the broken surfaces clean. On 08/17/18 at 2:15 PM, Certified Nursing Assistant (CNA) 2 stated she preferred not to use the Shower Room in the 200 Hall because of the poor condition of the room. She stated the maintenance man had recently installed a metal threshold piece along the doorway floor to cover most of the broken tiles in the doorway but the missing tile which was still present in front of the new threshold still posed problems with moving residents who used wheelchairs into the shower room. The added threshold was supposed to make is safer to wheel residents into the shower room. She stated she used the shower room to give baths and to clean people up who needed some extra cleaning during the shift. She stated she preferred taking residents to the 300 Hall, but that wasn't always possible. On 08/17/18 at 2:30 PM, CNA3 stated the shower room was in poor repair and she hated to use it. She stated the surfaces were in such bad shape that they were uncleanable. On 08/16/18 at 9:25 AM, the Maintenance Supervisor stated he was unaware of how long the 200 Hallway Shower Room had been in that condition because he had only worked at the facility for two months. He confirmed the Shower Room has been in the same condition for the two months he had been on duty. He added he was aware the shower room had been identified for repair/remodeling by the facility administration. The Maintenance Supervisor confirmed the cracks in the tiles, the missing grout between tiles and the gaps in the walls created unsealed surfaces that could not be effectively sanitized. On 08/16/18 at 10:00 AM, the Administrator explained environmental rounds were conducted weekly by key personnel including the himself (Administrator), the Director of Nursing, and the Social Worker, among others. The purpose of these rounds, is to identify any issues in need of maintenance attention. He stated he had documented something on the 200 Shower Room and would provide that. On 08/16/18 at 11:00 AM, the Administrator provided a document labeled, 07/30/18 Hall 2 Group Rounds. The document included 15 items requiring maintenance attention. Among those items was listed, Shower - Fix broken tile in shower ASAP (as soon as possible)! Esp (especially) at drain. On 08/18/18 at 2:00 PM, during a follow up interview with the Administrator. He reported a belief that the facility does a really good job of identification of issues but stated, we need to do better at getting the system to assure the things identified get fixed. He added, We may need a better filing system or computer system which identifies when identified concerns actually are resolved. Review of the facility's policy titled, Resident Environmental Quality, effective 11/23/16, indicated, The facility should be designed, constructed, equipped, and maintained to protect the health and safety of residents, personnel and the public. The policy was not specific to shower rooms beyond that and instead focused on equipment bedrooms, water pest control, etc. Additional documentation provided by the Administrator described as the instructions to staff for the cleaning the bathroom, indicated, scrubbing ceramic tile, mopping and rinsing the entire shower room.",2020-09-01
844,SUNNY ACRES NURSING HOME,425093,1727 BUCK SWAMP ROAD,FORK,SC,29543,2018-08-17,915,B,0,1,X2DT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interview the facility failed to ensure each resident's bedroom had a window to the outside. Two of 56 facility rooms did not meet that requirement. No actual harm resulted from the limited square footage. Findings include: Observation during a resident interview on 08/13/18 at 4:23 PM, revealed the only window in room [ROOM NUMBER]'s looked into the therapy room. During an interview on 08/14/18 at 9:45 AM, the Administrator stated he was not aware that room [ROOM NUMBER] did not have a window to the outside. Additional observation on 08/14/18 at 10:58 AM, revealed the only window in room [ROOM NUMBER] looked into an office. In an interview on 08/14/18 at 2:15 PM, the Maintenance Supervisor stated he was not aware that there were two resident rooms that did not have a window to the outside.",2020-09-01
845,SUNNY ACRES NURSING HOME,425093,1727 BUCK SWAMP ROAD,FORK,SC,29543,2019-11-15,644,D,0,1,0DHL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to coordinate an assessment for Resident #20 for the level II PASARR after a change in [DIAGNOSES REDACTED]. The findings included: Per record review on 11/12/19, the resident was seen by LifeSource on 10/23/19, due to a referral by staff for behavior outbursts. Seen by psychotherapy via telemedicine. The psychotherapy consult listed the [DIAGNOSES REDACTED]. Care plan in record to monitor for behaviors with guidance for redirection and medication monitoring. [MEDICAL CONDITION] was not included on admission list of diagnoses. Level 1 PASARR noted no further intervention needed on admission. A level II PASARR was not in the record for the change in behavior and the new [DIAGNOSES REDACTED]. On 11/12/19 at 11:20 AM, interview with the Director of Nursing revealed that the facility just started the telemedicine psychotherapy in 2019. She stated they decided which residents to sign up for the therapy and they (facility staff) chose Resident #20 for the psychotherapy program. She stated, the doctor did not complete a level 2 PASARR on any of the patients in therapy that were referred for therapy by the facility staff. When Social Services (SS) was asked on 11/13/19 at 10:20 AM if there was any PASARR level II referral completed for Resident #20, SS stated, not to her knowledge and that she does not know anything about it.",2020-09-01
846,SUNNY ACRES NURSING HOME,425093,1727 BUCK SWAMP ROAD,FORK,SC,29543,2019-11-15,646,D,0,1,0DHL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to notify the state mental health authority after a significant change in mental condition for 1 of 2 residents reviewed for Preadmission Screening and Resident Review (PASARR) referrals (Resident #20). The findings included: Per record review on 11/12/19, the resident was seen by LifeSource on 10/23/19, due to a referral by staff for behavior outbursts. Seen by psychotherapy via telemedicine. The psychotherapy consult listed the [DIAGNOSES REDACTED]. A level II PASARR was not in the record for the change in behavior and the new [DIAGNOSES REDACTED]. In an interview on 11/12/19 at 11:20 interview with Director of Nursing (DON), she stated, the doctor did not complete a level 2 PASARR on the resident. When Social Services (SS) was asked on 11/13/19 at 10:20 AM if there was any PASARR level II referral completed for resident, SS stated, not to her knowledge and that she does not know anything about it. Social Services stated she was not informed that there was a need for a PASARR. On 11/15/19 at 11:45 AM, interview with DON revealed that resident's doctor who was treating her prior to being in the facility stated she has had [MEDICAL CONDITION] the whole time he has seen her. The DON stated, the [DIAGNOSES REDACTED].",2020-09-01
847,SUNNY ACRES NURSING HOME,425093,1727 BUCK SWAMP ROAD,FORK,SC,29543,2019-11-15,693,D,0,1,0DHL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews, the facility failed to provide hydration via the enteral tube as ordered for 1 of 1 resident reviewed for enteral feedings (Resident #95). The findings included: The facility admitted Resident #95 on 02/08/19 with [DIAGNOSES REDACTED]. Observation of Resident #95 on 11/12/19 at 09:54 AM revealed Novosource Renal infusing at 60 ml/hr (milliliters per hour) and Water flush infusing at 30 ml/hr. At 12:53 PM, review of the monthly cumulative orders revealed an order for [REDACTED].>Observation at 08:55 AM on 11/13/19 revealed the flush infusing at 30 ml/hr. At 08:55, review of the Medication Administration Record [REDACTED]. Review of the Nutrition assessment dated [DATE] revealed the flush at 35 ml/hr from 05:00 PM to 11:00 AM provided 630 ml. On 11/13/19 at 09:26 AM, observation of Resident #95 revealed the Outsource Renal infusing at 60 ml/hr and Water flush at 30 ml/hr. During an interview on 11/13/19 09:26 AM, Licensed Practical Nurse (LPN) #1 confirmed the water flush was infusing at 30 ml/hr. The LPN #1 further confirmed the order for the flush was 35 ml/hr.",2020-09-01
848,PEACHTREE CENTRE,425095,1434 N LIMESTONE ST,GAFFNEY,SC,29340,2020-01-23,604,D,0,1,17BO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, it was determined the facility failed to ensure one of one (#[AGE]) sampled resident remained free from the use of a restraint imposed for the purposes of discipline or convenience, and not required to treat the resident's medical symptoms. The facility identified no additional residents with a restraint. The findings included: Resident #[AGE] had [DIAGNOSES REDACTED]. The resident's clinical record contained no documentation the resident exhibited symptoms of a medical condition/[DIAGNOSES REDACTED]. Resident #[AGE]'s quarterly assessment, dated 12/26/19, documented the resident was severely impaired in cognition and a trunk restraint was used daily while the resident was in a wheelchair (wc). A care plan, dated 06/25/19, documented the resident used a lap lock (buddy) while seated in a wheelchair (a lap buddy is a cushioned restraint that sits across the resident's lap and prevents the resident from rising). The care plan contained no additional information related to the resident's use of a restraint. A physician's orders [REDACTED]. An initial evaluation form for use of a physical restraint, dated 06/28/19, documented the reasons for the use of the restraint were the resident had falls and s/he had an unsteady gait. The evaluation also documented the family had requested the device be used when the resident was in the wheelchair due to frequent falls. The evaluation contained no documentation the resident exhibited symptoms of a medical condition/diagnosis, which would warrant the use of a restraint. On 01/22/20 at 8:25 a.m., the resident was observed in the dining room seated in a wheelchair, the lap buddy was in place. The resident was asked if s/he was able to remove the lap buddy, s/he did not respond. On 1/22/20 at 10:02 a.m., Activity Aide #1 propelled Resident #[AGE]'s wheelchair to the activities room/dining room. The lap buddy was still in place. The activity aide was asked why the resident needed the lap buddy. Activity Aide #1 stated it was to prevent the resident from standing and walking; s/he added the resident needed it for safety. The aide was asked what interventions were in place related to the use of the lap buddy. Activity Aide #1 stated s/he did not know. Activity Aide #1 added s/he had not been given instructions on what to do with the lap buddy while the resident was in activities. Activity Aide #1 further added s/he had not seen the resident try to walk in months and s/he had not seen the resident remove the lap buddy. On 1/22/20 at 1:27 p.m., the resident was seated in the lobby of the dining room. Resident #[AGE] was attempting to remove the lap buddy; s/he was observed pulling and tugging at the lap buddy. The resident was repeatedly saying, Come on I have to get out! I can't get out! Come on! Come on! The resident was unable to remove the lap buddy. A staff member was in the immediate vicinity and provided no interventions and/or assistance to the resident. The resident was also observed attempting to stand up. On 1/22/20 at 1:57 p.m., the Assistant Director of Nurses (ADON) was asked if the resident had a restraint. The ADON said, Yes. The ADON stated the resident had a fall with a major injury about a year or two ago. S/he added the family had requested the restraint for safety reasons. The ADON stated the resident had worn the lap buddy for a couple of years. S/he stated prior to June of 2019, the resident was able to remove the lap buddy. After June, they started coding the lap buddy as a restraint. The ADON was asked if the facility had attempted a reduction to a lesser restraint. The ADON stated they had not. The ADON stated the resident liked the lap buddy and wanted to use it. The facility did not provide documentation of a signed informed consent form from the resident and no documentation the resident had requested the use of a restraint.",2020-09-01
849,PEACHTREE CENTRE,425095,1434 N LIMESTONE ST,GAFFNEY,SC,29340,2017-07-12,224,D,1,1,82L711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, and interviews, the facility failed to prevent neglect for Resident #91, 1 of 2 residents reviewed for abuse and/or neglect. The findings included: The facility admitted Resident #91 with [DIAGNOSES REDACTED]. On 7/12/17, review of the facility's Five-Day Follow-Up Report dated 5/30/17 indicated Resident #91 was noted with soaked brief and pants. The report indicated the facility substantiated neglect based on the investigation including the CNA's statement. Review of the facility-obtained statement from Certified Nursing Assistant (CNA) #1 dated 5/26/17 indicated the CNA got the resident out of bed, dressed her/him and took the resident out into the hallway at approximately 8:00 AM. At approximately 10:30 AM, CNA #1 took Resident #91 back to the room and rolled the resident side to side? in the gerichair and checked her/him and that there was no BM (bowel Movement) and (the resident) was not wet then took Resident #91 back down the hallway for lunch. The resident's personal sitter took the resident back to the room and fed her/him. The statement indicated that after lunch the sitter told me don't lay (the resident) down because s/he has to get her/his hair done. At approximately 2:00 PM CNA #1 took the resident to the beauty shop and, with the assistance of CNA #2, put the resident in a wheelchair and left her/him at the beauty shop. There was no mention in the statement if the resident was wet or soiled at the time s/he was transferred into the wheelchair. In an interview on 7/12/17 at approximately 12:12 PM, CNA #2 stated that Resident #91 had no visible signs of incontinence at that time but confirmed that neither s/he nor CNA #1 checked the resident when transferring the resident from the gerichair to the wheelchair at approximately 2:00 PM on 5/25/17.",2020-09-01
850,PEACHTREE CENTRE,425095,1434 N LIMESTONE ST,GAFFNEY,SC,29340,2017-07-12,313,D,1,1,82L711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interviews the facility did not provide services to Resident # 108 related to vision care. Resident #108, 1 of 3 residents sampled for vision services, was identified as having vision impairment, but did not have corrective lens or evidence of an eye exam. The findings included: The facility admitted Resident #108 with [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set ) revealed the resident to have a vision impairment with no corrective lens. The latest Quarterly assessment done 6/15/17 showed none of the above. However, during an interview with LPN # 2 and # 3 (Licensed Practical Nurse) serving as MDS (Minimum Data Set) Nurses confirmed the MDS did trigger a Vision Deficit which they did not address with a care plan problem. Continued interview with the Social Service Director confirmed the resident had not had a vision appointment to check his/her vision for a need for corrective lens. The Social Service Director proceeded to make an appointment to have an eye exam performed for Resident # 108.",2020-09-01
851,PEACHTREE CENTRE,425095,1434 N LIMESTONE ST,GAFFNEY,SC,29340,2017-07-12,371,E,1,1,82L711,"> Based on random observations, interviews and facility policy, 3 of 3 unit refrigerators observed contained unlabeled and undated foods. In addition, Unit I refrigerator contained dark brown spills in the bottom of the refrigerator and soiled shelves. The findings included: On 7/11/17 at 11:45 AM a random observation was made of the unit kitchen on Unit 1. This was also checked and confirmed with LPN # 1 (Licensed Practical Nurse) that the refrigerator contained an uncovered, unlabeled, and undated can of coca cola, cookie, and container of vegetables. The nurse also confirmed the dark brown substance spill over bottom of refrigerator and soiled shelves. The Unit 2 unit kitchen was checked with LPN # 4 on 7/11/17 at approximately 12:4:45 PM. The nurse confirmed the refrigerator contained 1 container of soup, some meat slices in plastic bag, and 3/4 sleeve of saltine crackers all undated and unlabeled with name. The unit 3 kitchen was checked with LPN # 5 on 7/11/17 at 1 PM. The nurse confirmed there was a Styrofoam container dated 7/6/17 still in the refrigerator. Also some cantaloupe slices in a zip lock bag unlabeled and undated . Per facility policy on leftovers, all leftover foods must be properly covered, dated ( the date of preparation), labeled and stored under refrigeration. All leftovers must be discarded if not used within [AGE] hours of the preparation date.",2020-09-01
852,PEACHTREE CENTRE,425095,1434 N LIMESTONE ST,GAFFNEY,SC,29340,2018-09-27,637,D,0,1,RG6511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to identify a significant change in condition and conduct a Significant Change in Status MDS (Minimal Data Set) assessment Residents #15 and #81, 1 of 3 residents reviewed for for ADLs and 1 of 1 resident reviewed for Hospice. The findings included: The facility admitted Resident # 15 on 11/24/14 with [DIAGNOSES REDACTED]. On 09/25/18 at 11:40 AM, review of the MDS revealed the resident had a decline in bed mobility and dressing from limited assistance to extensive assistance and a decline in continence from frequently incontinent to always incontinent from the 04/12/18 Annual MDS to the 07/05/18 Quarterly MDS assessment. Further review revealed no Significant Change in Status Assessment had been conducted. During an interview on 09/26/18 02:27 PM, MDS Licensed Practical Nurse (LPN) #1 confirmed the decline in bed mobility, dressing and continence. The nurse also confirmed the 07/12/18 progress note indicating the resident had an overall decline. The LPN also confirmed that, based on the documentation, a SCSA should have been completed. During an interview on 09/27/18 10:24 AM, the Nursing Home Administrator provided documentation that the facility had reviewed Resident #15 in the monthly At Risk Meeting which indicated the resident had been reviewed for weight loss. The NHA stated that the resident did not trigger for decline in ADLs but the documentation indicated that independent moving had worsened. In addition, a copy of the care plan was provided that indicated the care plan had been updated on 07/12/18 indicating the resident was extensive to total assistance for transfers, requiring a Hoyer lift at times and that the resident was usually weaker later in the day. There was no indication that the resident's decline in dressing or continence had been addressed. A progress note was written on 09/27/18, after discussion with the surveyor, stating the resident required varying levels of assistance with ADL's (activities of daily living) and B&B (bowel and bladder) continence/ incontinence episodes. Resident has been discussed and reviewed by IDT with prior assessments, 6/26/18 and 7/12/18 (review dates) showing variance in ADL abilities and continence status. Team decided a Significant Change was not warranted related to resident's baseline is variable. The facility admitted Resident #81 on 10/02/17 with [DIAGNOSES REDACTED]. On 09/27/18 at 11:12 AM, review of the record revealed Resident #81 was admitted to Hospice on 08/22/18. On 09/27/18 11:35 AM, review of MDS (Minimal Data Set) RAI (Resident Assessment Instrument) assessment revealed an Assessment Reference Date (ARD) of 09/04/18 and a completion date of 09/18/18. Further review revealed Section J, question 1400, Does the resident have a condition of chronic disease that may result in a life expectancy of less than 6 months? was answered 0 indicating no. Review of CMS ' s (Centers for Medicare and Medicaid) RAI Version 3.0 Manual, October, (YEAR), Chapter 2, page 2-23revealed A SCSA is required to be performed when a terminally ill resident enrolls in a hospiceprogram (Medicare-certified or State-licensed hospice provider) or changes hospiceproviders and remains a resident at the nursing home. The ARD must be within 14 daysfrom the effective date of the hospice election . Further review revealed the RAI OBRA-required Assessment Summary stated the completion date was 14th calendar day after determination that significant change in resident ' s status occurred (determination date + 14 calendar days). Page J-24 revealed Coding Instructions Code 0, no: if the medical record does not contain physician documentation that the resident is terminally ill and the resident is not receiving hospice services. Code 1, yes: if the medical record includes physician documentation: 1) that the resident is terminally ill; or 2) the resident is receiving hospice services. During an interview on 09/27/18 11:28 AM, LPN #1 confirmed the ARD and the date of completion. In addition, the nurse confirmed that the assessment should have been completed within 14 days of the date of admission to Hospice. The nurse further confirmed J1400 was coded as no, stating that s/he did not have the physician documentation and indicated s/he was not aware that the question should have been coded yes if the resident was receiving Hospice services.",2020-09-01
853,PEACHTREE CENTRE,425095,1434 N LIMESTONE ST,GAFFNEY,SC,29340,2018-09-27,656,D,0,1,RG6511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan related to nutrition and tube feeding for 1 of 1 resident reviewed for the use of feeding tube. The findings include: Resident #95 was admitted to the facility on (MONTH) 9, (YEAR), with [DIAGNOSES REDACTED]. On 9/27/2018, review of the medical record indicated there were multiple admitted s for the resident due to hospitalization s. Further review indicated Resident #95's baseline care plan dated 9/9/2018 did not indicate the resident had a feeding tube. Review of the comprehensive care plan on 9/25/2018 at 9:30 AM indicated a care plan had not been initiated related to nutrition nor the Resident's tube feeding status. Review of the Resident's Nutrition assessment dated [DATE] and the (MONTH) Physician order [REDACTED]. An interview with the Director of Nursing on 9/25/2018 at 3:45 PM confirmed the nonexistent care plan.",2020-09-01
854,PEACHTREE CENTRE,425095,1434 N LIMESTONE ST,GAFFNEY,SC,29340,2018-09-27,657,E,0,1,RG6511,"Based on record review and interview, the facility failed to have a Registered Nurse with responsibility to participate in residents' Care Plans and help determine the resident needs or represent their requests, for Residents # 19, #51 , #68, and #71. Four out of 21 sampled residents record reviews of care plans indicated that there was no documentation of any Registered Nurse with responsibility to participate in residents' care plans and help determine the resident needs or represent their requests. The findings included: On 09/25/2018 at approximately 1:45pm, interviewed the Admissions Director (Kara[NAME]LPN), who stated that she finds it hard to get a Registered Nurse to the Care Plan Meeting because they are so busy.",2020-09-01
855,PEACHTREE CENTRE,425095,1434 N LIMESTONE ST,GAFFNEY,SC,29340,2018-09-27,659,D,0,1,RG6511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the Nutrition care plan was followed for 1 of 2 residents reviewed for nutrition. The findings included: Resident #53 was admitted to the facility with [DIAGNOSES REDACTED]. On 9/24/2018 during the lunch observation in the 100 Unit Dining Room, Resident #53 was placed at the table with 2 other residents that required assistance with meals. During the process of handing out beverages, a Guardian Angel ( Facility Department Head) offered Resident #53 the option of milk to drink. A 2nd Guardian Angel proceeded afterwards to place the milk in Resident 53's kennedy cup that s/he is ordered to use with meals. This Surveyor in response to verifying the Resident's name, asked both Guardian Angels the name of the resident. They were both unable to identify him/her. Review of the medical record on 9/25/2018 indicated a comprehensive care plan dated 8/16/2018 with nutrition as the care area. The interventions were to provide resident with fluids daily for meals and resident is only to have clear liquids to drink (apple juice, water, and ginger ale). An interview with the Administrator on 9/27/2018 at 4:30 PM indicated the Guardian Angels are assigned to various meals and are responsible for being able to identify each resident and ensure awareness of his/her dietary restrictions prior to administering food or beverages. Review of the facility's Dietary Policy states; Residents who are unable to feed themselves shall be assisted with the dining process with attention to safety, comfort, and dignity.",2020-09-01
856,PEACHTREE CENTRE,425095,1434 N LIMESTONE ST,GAFFNEY,SC,29340,2018-09-27,800,E,0,1,RG6511,"Based on observation and interview, the facility failed to ensure that foods were held at appropriate holding temperatures at 1 of 3 steam tables. The findings included: On 09/24/18 at 12:11 PM, observation of Dietary Aide #1 checking the temperatures of the Unit 2 steam table revealed the egg noodles had a temperature of 112 degrees, the pork steak had a temperature of 120 degrees and the brussel sprouts were 134 degrees. The dietary aide confirmed the temperatures as they were checked. At 12:23 PM, the Aide began plating and placed the egg noodles on a plate. Service was stopped by the surveyor and the dietary aide again confirmed the temperature of the egg noodles as 112 degrees and that the pork steak and brussel sprouts also did not meet temperature requirements. The Aide was aware that the foods should be 135 degrees and confirmed that they needed to be reheated. At 12:42 PM, the egg noodles, pork steaks and brussel sprouts were returned from the kitchen and the pork steaks still did not reach 135 degrees which was confirmed by the Dietary Manager who removed the pork steaks from the steam table and stated that all 3 foods were reheated to 165 degrees before bringing them back to the unit.",2020-09-01
857,PEACHTREE CENTRE,425095,1434 N LIMESTONE ST,GAFFNEY,SC,29340,2018-09-27,812,E,0,1,RG6511,"Based on record review and interviews, the facility failed to ensure Food safety requirements for 1 of 3 refrigerator units by not maintaining the temperature within acceptable parameters. The findings included: On 09/26/2018 at approximately 3:45 pm, observed refrigerator unit at Station 2. The refrigerator temperature gauge was at 52 degrees. On 09/26/2018 at approximately 04:00pm, observed refrigerator unit at Station 2. The refrigerator temperature gauge was still at 52 degrees. Observed the contents of the refrigerator, which included ham and cheese sandwiches, pudding, and milk. Reviewed Temperature Daily Freeze/Refrigerator Log for Station 2 dated (MONTH) (YEAR). The entry for (MONTH) 26th was blank for both AM and PM and no entry was initialed by any staff member. On 09/26/2018 at approximately 05:15pm, interviewed Administrator, who stated that she agreed that the refrigerator was above the normal temperature. She did not have any explanation for the non recorded entry on the Temperature Log.",2020-09-01
858,PEACHTREE CENTRE,425095,1434 N LIMESTONE ST,GAFFNEY,SC,29340,2019-12-05,550,D,1,0,B63R11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, it was determined the facility failed to protect resident rights by impeding freedom of movement for one (1) resident (Resident #11) of five (5) sampled residents investigated for staff to resident abuse allegations. The findings included: Record review revealed Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #11's Admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed as being cognitively intact with a Brief Interview for Mental Status (BI[CONDITION]) score of 15. The resident was assessed as displaying no signs of depression and no behaviors. The resident was assessed as requiring extensive assistance of one (1) person with activities of daily living (ADLs). The resident had limitations of his lower extremities and was incontinent of bladder and bowel and wore a condom catheter for his [MEDICAL CONDITION] bladder. The resident had community acquired pressure ulcers; utilized a wheelchair for mobility; and received anti-depressants during the assessment period. Resident #11 was also identified as a smoker. Review of the resident's comprehensive care plan dated 9/25/19 revealed the resident had no cognitive deficits at the time. The resident was identified as a smoker and interventions included education on facility's smoking policy; maintaining the resident smoking materials at the nurses' station; charge nurse to notify immediately if the resident violates the smoking policy; and staff supervision while smoking. Review of the facility's self-report initial incident dated 9/30/19 revealed that Resident #11 reported that he felt he had been abused by the staff on the evening of 9/29/19. The form indicated the staff member placed his/her hands on the resident's wheelchair and forced him to leave the smoking area and return to the facility. Review of the facility's Five (5)-Day Investigation Report documented the resident felt that he was abused since the Certified Nursing Assistant (CNA) placed her hands on his wheelchair to return him to the facility when he was not ready to go inside. The resident expressed concern that the wheelchair was a part of him and since the CNA touched the wheelchair, she essentially touched him. The alleged perpetrator was suspended pending investigation and witness statements obtained. A body audit was completed which revealed the resident did not sustain any injuries. The employee in question was returned to duty for the night shift [DATE]. To prevent re-occurrence of this type of incident the employee was scheduled for Customer Service and Abuse training upon return to work. Review of the Facility's Investigation revealed that on the evening of 9/29/19 at approximately 8:30 PM to 9:00 PM two (2) CNAs assisted Resident #11 and another resident to the smoking area, the facility's gazebo area. When it was time to return to the facility Resident #11 stated he was not ready to go inside. CNA #9 was present and informed the resident that it was a safety issue for him to stay outside alone that late at night. The alleged perpetrator told the resident he would push him onto the porch. The alleged perpetrator pushed the resident's wheelchair (w/c) up the ramp. As the alleged perpetrator pushed the w/c up the ramp, the resident applied the w/c brakes to stop the wheelchair. The alleged perpetrator released the brakes and continued to push the resident's w/c up the ramp until they reached the porch area. Review of the witness statements from the alleged perpetrator and CNA #9 both document that at no point did the resident say stop. There was a loud discussion reported on the facility porch about the resident returning to his unit; the resident still wanted to remain outside. During the discussion a female security guard approached the trio and offered to sit with the resident while the two (2) CNAs returned the other resident to his/her unit and got guidance from the supervisor regarding how to approach Resident #11. The security guard remained with the resident until he was ready to return to his unit. Additional review of the facility's investigation failed to identify the other residents present during the incident. The facility failed to obtain a witness statement from the female security guard and other witnesses present during the exchange. The facility Administrator determined the allegation of abuse was unsubstantiated because the CNA only touched the resident's wheelchair and not the resident's person. Interview with Resident #11 on [DATE] at 2:03 PM revealed the resident remembered the incident that occurred on the evening of 9/29/19. Resident #11 stated that as soon as he finished smoking his cigarette one (1) of the CNAs said it was time to return to the facility. Resident #11 stated he was not ready to go inside and wanted to sit outside for a while. Resident #11 also stated the two (2) CNAs were discussing which unit he resided. One (1) of the CNAs said the resident resided on Unit I and Resident #11 was trying to tell the CNAs that he no longer lived on Unit I and he now lived on Unit III. Resident #11 stated that before he knew it the alleged perpetrator grabbed his wheelchair and started up the ramp towards Unit I. Resident #11 stated he applied the brakes of the wheelchair and continued to tell the CNAs that he was not ready to go inside and that he no longer resided on Unit I. The resident stated the CNA removed the brakes and continued pushing him up the ramp. The resident stated that he was getting angry and started cursing, but the CNA cursed him back. The resident stated he felt he was being abused since the CNA touched his wheelchair which was an extension of him, and the CNA tried to force him to go inside against his wishes. The resident also stated that his feet came off the leg rests during the incident and had to be replaced; but he did not sustain any injuries. Resident #11 stated it was getting late but still wanted to sit outside for a while. Resident #11 further stated that once the female guard arrived the CNAs left him outside and the security guard stayed with him. After the CNAs left, he felt much better. Interview with the facility Administrator on 12/5/19 at 1:30 PM revealed after she had investigated the incident, she stated that since the CNA did not touch the resident, but only his wheelchair there was no abuse involved. The Administrator further stated there it was the intention of the CNAs to bring the resident to a more secured area. They did not want to leave him outside alone since it was getting dark. The Administrator acknowledged that the resident did put on his brakes. The CNA removed the brakes and continued to push the resident up the ramp. The Administrator felt the resident was angry about having to go inside and was not listening to the directions from the CNA. The Administrator also stated there were two (2) residents from the assistant living floor in the gazebo at the time of the incident; however, she did not get witness statements. The Administrator stated that she had not obtained a statement from the security guard. She stated that a witness statement from the security guard would have been crucial to her final determination of the investigation. The Administrator was asked if there was another way that the CNAs could have handled the situation. The Administrator stated the staff members handled the situation the best way they could in order to ensure the resident's safety. The Administrator was asked if it would have been better once the resident refused to go inside to for one of the CNAs to sit with the resident until he was ready to go inside. The Administrator responded that could have been a possible solution. It was explained to the Administrator that the resident has been assessed as being alert and oriented and able to make his own decisions. The staff could have offered him the option of staying with him until he was ready to return to his unit. The Administrator stated after hearing the explanation that it could have been an option for the staff to offer to stay with the resident. The Administrator stated the alleged perpetrator and CNA #9 and the security guard have resigned. The facility was reluctant to give the alleged perpetrator's contact information since she is involved in a Worker's Compensation lawsuit against the facility. Attempts were made to contact CNA #9 on 12/5/19 at 2:59 PM and 4:30 PM with no response.",2020-09-01
859,PEACHTREE CENTRE,425095,1434 N LIMESTONE ST,GAFFNEY,SC,29340,2019-12-05,610,E,1,0,B63R11,"**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 conduct thorough investigations for five (5) of 15 facility investigations reviewed involving five (5) of 17 sampled residents (Resident #10, Resident #11, Resident #12, Resident #13, and Resident #14). The findings included: Review of the facility's policy titled Abuse Reporting and Terminology revised 8/1/17 directed All alleged violations involving mistreatment, abuse or neglect will be thoroughly investigated by the facility under the direction of the Administrator and in accordance with state and federal law. Additionally, the facility will thoroughly investigate, under the direction of the Administrator, all injuries of unknown origin to determine if abuse or neglect was involved . Interview the resident or other resident witnesses. The interview is to be dated, documented and signed by the nursing supervisor . Interview staff on that unit as well as other staff or other available witnesses. Witnesses are to document their knowledge of the incident in a written narrative, signed and dated on the 'Employee/Witness Investigation Statement' form. Review of the facility's policy titled Abuse Investigation Process revised 6/19 noted Immediately secure the residents to a safe disposition i.e. separate residents or remove alleged abuser from direct access and document in nurses notes and incident report. 1. Record review revealed that Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's Admission Minimum Data Set ((MDS) dated [DATE] documented the resident with moderately impaired cognition with a Brief Interview for Mental Status (BI[CONDITION]) score of 12. The resident was totally dependent on staff requiring extensive assistance of one (1) to two (2) staff for activities of daily living (ADLs). The resident was assessed to require one (1) person assist for personal hygiene. The resident was also assessed to be frequently incontinent of bladder and bowel. Review of Resident #10's comprehensive care plan revised 10/2/19 identified the resident had cognition deficit related to Dementia. The resident was at risk for decline in mood and behaviors related to apparent depressive mood at times. Interventions included allowing the resident opportunities to voice feelings and thoughts as needed. The resident was also identified as being incontinent of bladder and bowel. The interventions included checking resident frequently for incontinence and give peri-care after each episode (one (1) person assist with personal hygiene); observe resident's skin for redness or breakdown during peri-care and report immediately if noted. Review of the facility's Five (5)-Day Follow-up Report dated 10/30/19 revealed an alleged complaint of staff to resident abuse that occurred on 10/27/19. The complaint alleged that Resident #10 stated the Certified Nursing Assistant (CNA) #14 gouging her while providing incontinent care. Review of CNA #14's statement dated 10/27/19 revealed the staff felt she did not do anything to hurt the resident while providing incontinent care. The CNA acknowledged the resident's skin was raw and that it would hurt but she had to clean the resident. The facility's investigation documented there were no witness to the incident but a Licensed Practice Nurse (LPN) was on duty the day of the incident. A review of the witness statements revealed a statement from Resident #10 and CNA #14; however, the investigation file lacked witness statements from the LPN on duty the night of the incident and LPN #2 who reported the incident. Interview conducted on 12/5/19 at 10:45 AM with LPN #2 revealed that when she came on duty the morning of 10/27/19 she heard the resident (#10) crying. At that time the resident told LPN #2 that CNA #14 was gouging her while providing incontinent care causing her pain and she had asked the CNA to stop but the CNA continued. The resident stated she did not want the CNA #14 to take care of her anymore. LPN #2 stated that she reported the incident to the Supervisor. LPN #2 also stated after she reported the incident no one asked her to supply a witness statement. Interview with the facility Administrator on 12/5/19 at 1:30 PM revealed that she thought there were witness statements from LPN #2 and the night shift LPN, but she would double check the investigation file. At 3:47 PM the Administrator returned and stated the she was unable to locate the witness statements. The Administrator further stated that she was away from the facility when she was notified of the incident and had instructed the Supervisor to attain witness statements and she thought this had been done. The facility failed to obtained witness statements from the night shift LPN on duty and LPN #2 who reported the incident. 2. Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's Admission MDS dated [DATE] revealed the resident was assessed as being cognitively intact on BI[CONDITION] with a score of 15. The resident was documented as not exhibiting signs of depression or behaviors. Review of Resident #11's comprehensive care plan dated 9/25/19 revealed the resident had no cognitive deficits at the time. The resident was identified as a smoker and interventions included education on facility's smoking policy; maintaining the resident smoking materials at the nurses' station; charge nurse to notify immediately if the resident violates the smoking policy; and staff supervision while smoking. The resident was also identified to resist cares such as turning, re-positioning and medications. Interventions included to allow the resident to make decisions about treatment regime, to provide sense of control; give clear concise explanations of all care activities prior to and as they occur; if possible negotiate a time for Activities of Daily Living (ADLs) so that resident can participate in the decision making process; if resists with ADLs reassure resident, leave and return five (5)-10 minutes later and try again. Review of the facility's Five (5)-Day Follow-up Report dated [DATE] documents the resident felt he was abused since the CNA placed her hands on his wheelchair to return him to the facility when he was not ready to go inside. The resident expressed concern that the wheelchair was a part of him and since the CNA touched the wheelchair, she essentially touched him. The alleged perpetrator was suspended pending investigation and witness statements obtained. A body audit was completed which revealed the resident did not sustain any injuries. The employee in question was returned to duty for the night shift [DATE]. To prevent re-occurrence of this type of incident the employee was scheduled for customer service and abuse upon return to work. Investigation identified two (2) witnesses to the incident (CNA #10 and a female Security Guard). The investigation report contained statements from the alleged perpetrator and CNA#10 but the file did not contain a report from the female Security Guard. Interview with the facility Administrator on 12/5/19 at 1:30 PM revealed after she had investigated the incident, she felt that since the alleged perpetrator did not touch the resident only his wheelchair there was no abuse involved. The Administrator stated there were two (2) residents from the Assisted Living floor present in the gazebo at the time of the incident; however, she did obtain a witness statement from them either. In reviewing the facility's investigation, the Administrator admitted that she had not obtained a statement from the security guard and that a witness statement from the security guard would have been crucial to her final determination of the investigation. The Administrator also confirmed that she did not attempt to locate the two (2) residents from the assisted living floor that were present during the incident. The facility investigation did not contain witness statements from the Security Guard and the two (2) residents from the assisted living floor. 3. a) Resident #12 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to the resident's Quarterly MDS assessment dated [DATE], the resident was cognitively intact, had no symptoms of depression, and exhibited no behavioral symptoms, during the assessment period. Resident #12 required the extensive assistance of one staff person for bed mobility, transfers, dressing, toileting, and personal hygiene. Review of Resident #12's comprehensive care plan initiated 11/9/16 noted Resident #12 has no mood/behavior problems currently noted, resident is diagnosed with [REDACTED]. b) Resident #13 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's annual MDS assessment dated [DATE] revealed the resident was severely cognitively impaired having scored six (6) out of 15 on the BI[CONDITION] assessment. According to the assessment, Resident #13 had symptoms of mild depression and exhibited no behavioral symptoms, during the assessment period. Resident #13 required the extensive assistance of one staff person for bed mobility, transfers, dressing, toileting, and personal hygiene. Review of Resident #13's comprehensive care plan initiated 4/25/17 noted Resident #13 has some current mood/behavior problems noted, resident is at risk for decline in mood/behavior related to depression [DIAGNOSES REDACTED]. Resident with recent incident of hitting at another resident (initiated 2/9/18 and revised 3/8/19). c) Resident #14 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #14's Quarterly MDS dated [DATE] revealed the resident was severely cognitively impaired and exhibited symptoms of inattentive behavior. The resident exhibited no signs of depression, no hallucinations, no delusions, and no behavioral symptoms. Resident #14 required the extensive assistance of two (2) staff persons for bed mobility, transfers, dressing, and toileting. The resident had no impairment of bilateral lower extremities and utilized a wheelchair for mobility. Review of Resident #14's comprehensive care plan initiated 8/23/18 revealed the resident has some mood/behavior problems noted, resident will occasionally refuse medications, and has episodes of yelling out that appear to be non-goal directed and without purpose, as well as has pulled out catheter on occasion. Resident is at risk for decline in mood/behavior related to [DIAGNOSES REDACTED]. 4. a) Review of the facility's Five-Day Follow-Up Report dated 3/11/19 revealed an alleged incident of resident-to-resident abuse occurred on 3/7/19. According to the report, Resident #13 was propelling (self in) wheelchair down the hall and Resident #12 was also in the hall. It was reported that Resident #13 struck Resident #12 to get (him/her) to move out of the way. The nurse immediately separated the two residents. No injuries noted to Resident #12 . Resident #13 tested positive for a urinary tract infection . abuse is unsubstantiated. Continued review of the report revealed facility residents were interviewed and reported having no knowledge of incidents of abuse occurring in the facility. There were no witness statements from employees included in the investigation report. The facility unsubstantiated the allegation. On 12/5/19 at 4:30 p.m., the facility presented an Incident Witness statement completed by Licensed Practical Nurse (LPN) #10 which noted: resident was in hallway in (his/her) wheelchair when a (resident) rolled up to another resident and punched him/her in the arm for not moving out of the way for (resident) to get by. This nurse and a CNA reached the residents and separated them from each other and looked them over for any injuries and noted no injuries at time of incident. There were no other witness statements from staff to determine 1) if residents' care plans (behavioral, supervision, etc.) were being followed; and/or 2) the cause of Resident #13's behavior. b) Review of the facility's Five (5)-Day Follow-up Report dated 3/14/19 revealed on 3/10/19 Resident #14 kicked Resident #12 in the shin area. Residents were separated immediately and Resident #14 was put on increased rounds (increased supervision). The facility determined that the allegation of resident-to-resident abuse was unsubstantiated. Continued review of the report revealed facility residents were interviewed and reported having no knowledge of incidents of abuse occurring in the facility. There were no witness statements from employees included in the investigation report. On 12/5/19 at 4:30 p.m., the facility presented two (2) Incident Witness statements completed by 1) LPN #11 which noted: witnessed incident and filled out incident report; aggression from another resident given to Resident #12 for no apparent reason; Resident #12 crying out; no injury noted; nurse able to console resident afterwards; and 2) completed by LPN #11 on behalf of a visitor which noted: visitor left shortly after incident; she visits another resident frequently. This was the statement in its entirety and did not provide details of what the visitor observed during the incident. The Investigation Report and the Incident Witness statement did not include information regarding where the incident occurred. Interview with CNA #8 on [DATE] at 10:15 a.m. revealed in the past, the aide witnessed Resident #13 strike out or kick at other residents during the evening time when Resident #13 self-propelled around the unit. The aide said Resident #13 tells other resident to move out of the way and staff could not stop Resident #13 from self-propelling because Resident #13 did not understand what he/she was doing. Staff try to clear Resident #13's path when he/she begins to self-propel in the wheelchair. CNA said that Resident #13 had never hurt another resident when striking or kicking. Continued interview with CNA #8 revealed Resident #14 sometimes exhibited physical aggression towards staff when staff attempted to complete some of the resident's ADLs (activities of daily living). The aide said she had not witnessed Resident #14 striking out at staff; however, the aide had heard about Resident #14 hitting staff when they would attempt to comb her hair, etc. CNA #8 said Resident #14 would on occasion roll her eyes, and the resident was also easily redirected. Resident-to-resident abuse was discussed during an interview with the facility's Administrator on 12/5/19 at 2:10 p.m. When asked about the facility's policy in addressing an allegation of resident-to-resident abuse, the Administrator said that once residents were to safety an investigation into the incident would begin immediately. The investigation would consider how medical interventions, medication changes, and environmental factors impacted the incident and interviews with various staff would be conducted. The Administrator further stated that for resident-to-resident altercations, high traffic areas and loud commotion could also be considered. The Administrator said that supervision was also considered when an incident of resident-to-resident altercation occurred. When asked about the facility unsubstantiating the incidents of resident-to-resident abuse, the Administrator said the allegations were unsubstantiated because both Resident #13 and Resident #14 had related urinary tract infections.",2020-09-01
860,PEACHTREE CENTRE,425095,1434 N LIMESTONE ST,GAFFNEY,SC,29340,2019-12-05,684,D,1,0,B63R11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and clinical record review, the facility failed to ensure one (1) of 17 sampled residents (Resident #17) received care and treatment in accordance with the resident's care plan. 1) During peri-care, facility staff failed to provide Resident #17 with the necessary assistance as directed in the resident's care plan, and as a result, the resident experienced arm pain. 2) During two (2) observations, Resident #17 was poorly positioned in a Broda chair without off-loading of bilateral heels, as directed in the resident's care plan. The findings included: Resident #17 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #17's Annual Minimum Data Set ((MDS) dated [DATE] revealed the resident was cognitively intact having scored 15 out of 15 on the Brief Interview for Mental Status (BI[CONDITION]) assessment. Resident #17 required the extensive assistance of two (2) staff persons for bed mobility, transfers, locomotion on/off the unit, dressing, toileting, and personal hygiene. The resident had no impairment of upper and lower bilateral extremities and utilized a wheelchair for mobility. Review of Resident #17's comprehensive care plan initiated 4/26/18 revealed the resident had care areas, as follows: - Resident #17 needs assistance with ADLs (activities of daily living) (8/15/19). Interventions included: Resident needs extensive assistance of two (2) staff persons for toileting, bed mobility and transfers; and required the total assistance of two (2) staff persons for bathing (8/15/19). - Resident #17 is at risk for impaired skin integrity related to decreased mobility, incontinence of bowel and bladder and use of equipment that may cause pressure (8/16/19). Interventions included: Off load heels as indicated (8/16/19). - Resident #18 is at risk for pain related to [MEDICAL CONDITION], [DIAGNOSES REDACTED]. Interventions included: Assist resident with repositioning or other non-pharmacological aspect of pain relief (8/15/19). 1. Review of the facility's Five (5)-Day Follow-up Report dated 6/25/19 revealed that on 6/21/19, Resident #17 reported to aide that a Certified Nursing Assistant (CNA) #2 from the previous night had hurt her. CNA reported it to nurse who immediately came to tell the Administrator. There were no injuries assessed on Resident #17 and the aide in question was immediately suspended. The facility's investigation unsubstantiated the allegation of physical abuse. Review of CNA #2's Witness Statements (dated 7/24/19 in error as the correct date was 6/24/19) noted I worked Thursday night on Unit 1 on second shift. I bathed my people between 3:00 PM til 4:15 PM I made rounds before supper. I took break five (5) minutes. [ENTITY]ted on 7:00 PM rounds, 8:00 PM charted, 9:30 PM started last round, and 10:15 PM Resident #17 had bowel movement (I) tried (to) clean it out (from the) front (and I) asked (resident) to roll over. She didn't really try so (I) proceeded to turn her so I could clean the back. I finished and said goodnight. My group was (Rooms) 170 through 1[AGE]A. Review of the facility's Interview Summary Worksheet dated 6/24/19 and signed by CNA #2 noted CNA #2 had problems rolling her that evening and she was needing to be cleaned. Had to hold her and try to clean her at the same time. 'I get behind her arm, behind the fatty part of her arm and push her . Review of a signed witness statement dated 6/21/19 and completed by Licensed Practical Nurse (LPN) #9 noted that a CNA reported to her that Resident #17 reported that the second shift CNA #2 was mean to her last night, pulled on her and hurt her left arm. LPN #9 immediately called the Assistant Director of Nursing (ADON) and personally spoke with the Administrator. Interview on 12/3/19 at 10:32 AM with Resident #17 revealed the resident recalled an incident occurring with CNA #2 (who the resident called by name). Resident #17 reported CNA #2 entered the resident's bedroom and was talking smart and being mean to him/her. Resident #17 said CNA #2 also twisted the resident's arm. The resident did not recall exactly what the aide said or what event(s) occurred that caused the aide to be mean and twist his/her arm. The resident further stated that the aide hurt his/her arm. Follow-up interview on [DATE] at 9:40 AM with Resident #17 confirmed CNA #2 was providing peri-care when the aide hurt the resident's arm. When asked the number of aides required to assist her with bed mobility and peri-care, the resident stated, sometimes one person changes me and sometimes two people change me; and the amount of assistance the resident received was dependent upon the shift in question. Resident #17 stated she did not want CNA #2 back in her room because she was scared of her - she hurt me. The resident confirmed the aide had not worked with her since the incident and no longer worked at the facility. Interview on [DATE] at 9:52 AM with CNA #7 revealed Resident #17 always required two (2) staff persons to assist with transfers in the mechanical lift. When asked about the assistance the resident required for peri-care (changing the resident's incontinent brief), CNA #7 said it was the CNAs preference. CNA #7 said I've worked with (the resident) for so long, it doesn't have to be two people. I can turn her by myself. The aide was not familiar with the resident's activity of daily living (ADL) care plan regarding bed mobility. A telephone interview with CNA #2 was attempted on 12/5/19 at 9:44 AM. The telephone number was not in service and the facility had no other contact number for the aide. Interview on 12/5/19 at 2:35 PM with the facility's Director of Nursing (DON) revealed the nurse did consider that the resident's care plan was not followed when the resident reported that CNA #2 hurt her during care. The DON said, the interdisciplinary team talked about reassessing Resident #17 to see if (the resident) was a one (1) person assist; however, in order to keep the resident safe and prevent injury, the team decided to keep the resident as a two (2) person assist with bed mobility. The DON said CNA #2 was going to be written up for the incident; however, the aide did not return to work at the facility. 2. Review of Resident #17's physician's orders [REDACTED]. Observation on 12/3/19 at 10:25 AM revealed Resident #17 was in the unit's common area dining room, sitting in a broad chair. The back of the chair was at an approximate 90-degree angle, and the resident was sitting with chin-to-chest in the chair. The resident was not positioned properly in the chair and appeared as if he/she would slide forward out of the chair. The resident's legs were hanging down without support from the leg rests and the resident's bilateral heels were not off loaded. Resident #17 was obese. During an interview on 12/3/19 at 10:32 AM Resident #17 said he/she was not comfortable in the Broda chair. The resident said that his/her back, stomach and back of legs were hurting from sitting in the chair. Resident #17 said yes, it feels like I might fall from the chair. After Surveyor intervention, at 10:47 AM on this date, the facility's Corporate Nurse and another staff provided Resident #17 with assistance to be repositioned in the chair. Once repositioned, Resident #17 was reclined with feet elevated in the chair. Interview with the Corporate Nurse at this time revealed the nurse was not sure about the details of the resident's plan of care. The Corporate Nurse stated he/she would follow-up to determine the plan for Resident #17 sitting in the Broda chair. Observation on [DATE] at 9:26 AM in the 300 Unit's dining room revealed Resident #17 was again sitting in a Broda chair with the head/back of the chair at an approximate [AGE]-degree angle. Resident #17's sat in the chair with chin-to-chest and the resident's heels were not off loaded while the resident talked on the facility's cordless phone. During interview on [DATE] at 9:40 AM, Resident #17 said he/she was uncomfortable in the chair and the resident's legs and back hurt. Resident #17 further stated, If they'd reposition me like they did yesterday, I'd be more comfortable. At 9:45 AM, LPN #8 approached the dining table where Resident #17 was sitting. The nurse informed Resident #17 that another resident needed to use the facility's cordless phone which was on the table next to Resident #17. The nurse retrieved the phone and left the area. LPN #8 did not return to assist Resident #17 with repositioning between 9:45 AM and 10:00 AM. Interview on [DATE] at 9:52 AM with CNA #7 revealed Resident #17 had to be repositioned often. The aide was not sure about whether the resident's heels had to be off loaded when the resident was sitting up in the Broda chair.",2020-09-01
861,PEACHTREE CENTRE,425095,1434 N LIMESTONE ST,GAFFNEY,SC,29340,2019-12-05,686,G,1,0,B63R11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, record review, and review of facility policy, facility clinical staff failed to ensure one (1) of 17 residents received treatment and services to promote the healing and prevent the development of pressure ulcers (Resident #3). Facility staff failed to complete required assessments; failed to follow physician's orders [REDACTED]. As a result, Resident #3's Stage IV pressure ulcer to the right posterior lateral heel was slow to heal, and on 12/5/19, through Surveyor intervention, a deep tissue injury was discovered to the resident's posterior left heel. The findings included: Review of the facility's policy titled Wound Care Management dated 12/2017 noted each resident receives the care and services necessary to retain or regain in optimal skin integrity to the extent possible. Each resident is evaluated by the interdisciplinary team to determine his or her risk for skin compromise or the presence of wounds and/or pressure ulcers. A plan of care is developed and implemented based on this evaluation with ongoing review. If skin compromise occurs, evaluation is conducted by the interdisciplinary team to ensure appropriate measures are in lace to minimize the further compromise and aid in healing to extent possible . A. General Guidelines (1) The Director of Nursing and the Interdisciplinary Team are responsible for coordination of an interdisciplinary approach to managing the process for prediction, assessment, treatment, management and tracking of pressure ulcers . (3) Risk factors for Pressure Ulcers: impaired/decreased mobility and decreased functional ability .co-morbid conditions, such as end stage [MEDICAL CONDITIONS] disease or diabetes . a previous ulcer that has healed .B. Reporting (2) Report other information in accordance with facility policy and professional standards of practice; and (3) care plan accordingly. C. Procedure (2) Residents identified as at risk for development of pressure ulcers will have a plan and interventions included in the care plan to address each resident specific risk factor; (3) All residents will be checked from head to toe skin assessment t least weekly by a licensed nurse to identify any new pressure ulcers or other types of skin concerns. The licensed nurse will document the results of weekly skin checks in resident's medical record. (4) When a pressure ulcer is identified, the licensed nurse will document the wound in the Weekly Wound Assessment (WWA). Documentation to include size, stage, location, drainage, odor and pain. Notify MD and obtain treatment orders, initiate the care plan and notification of the interdisciplinary team utilizing the 24-hour report process . (6) Residents with newly identified or known pressure ulcers will be assessed by the interdisciplinary team upon notification and weekly thereafter, and a care plan will be developed, implemented, evaluated, and re-evaluated to treat actual pressure ulcers and reduce further pressure ulcers. This will include but not limited to review of lab results, risk factors, positions, etc. Review of the facility's policy titled Charting and Documentation: Nurse's Notes dated 10/17 noted the policy was to maintain a complete account of the resident's care, treatment, response to care, signs, symptoms, etc., as well as the progress of the resident's care. To provide caregivers with clear, concise guidelines for documentation of an assessment and care given. An assessment will be done on each resident upon admission and at regular intervals, as appropriate, thereafter. Purpose - To ensure that all services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record. General Guidelines - (1) All observations, medications administered, services performed, etc., must be documented in the resident's clinical records . Resident #3 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #3's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired having scored six (6) out of 15 on the Brief Interview for Mental Status (BI[CONDITION]) assessment. According to the assessment, the resident exhibited physical behavioral symptoms one (1) to three (3) days during the assessment period. In addition, Resident #3 was administered antianxiety medication for one (1) day during the assessment period. Resident #3 required the extensive assistance of two staff persons for bed mobility, transfers, dressing, and personal hygiene. The resident required the extensive assistance of one staff for toileting and was always incontinent of bowel and bladder. The MDS indicated the resident was at risk for the development of pressure ulcers and was assessed to have a Stage IV pressure ulcer at the time of the assessment. Review of Resident #3's comprehensive care plan initiated 10/23/18 revealed the following care plan areas: 1. Resident #3 is at risk for impaired skin integrity related to incontinent episodes, history of impaired skin, use of equipment that may cause pressure and decreased mobility. See wound report. Community acquired. One (1) Stage four (4) Pressure Ulcer - Right posterior lateral heel (initiated 2/7/19). Interventions included: Assess resident for verbal and nonverbal pain and if noted report to nurse (8/1/19); Easy boots bilateral feet at all times. May remove for hygiene/transfers (initiated 2/4/19); Encourage/provide fluids with meals and in between as tolerated (2/7/19); Ensure proper body alignment when in bed or a chair (initiated 2/7/19); Float heels while in bed (initiated 10/3/19); Head-to-toe skin assessment weekly and PRN (as needed) (8/1/19); Keep bed linen clean, dry and free of wrinkles (initiated 2/7/19); Observe skin with daily care and while in the shower/bath (initiated 2/7/19); Provide incontinence care for episodes of incontinence (2/7/19); RD (Registered Dietician) to assess as needed (2/7/19); Staff will report changes to MD as needed and obtain treatments as ordered as indicated (initiated 2/7/19); Supplements will be administered as ordered (2/7/19); and therapy to screen an evaluate for modalities for wound healing (initiated [DATE]). 2. Resident #3 has impaired circulation related to HLD (Hypersensitivity Lung Disease), [MEDICAL CONDITION] Embolism, and [MEDICAL CONDITION] (initiated 8/1/19). Interventions included: Assess fingers and toes for warmth and color. Report if noted (initiated 8/1/19); Elevate legs when resting (initiated 8/1/19); Inspect foot/ankle/calf skin for changes: maceration (white, wrinkly, moist), redness, purple tinge, blue, rust coloring, weeping, [MEDICAL CONDITION], puffiness, tenderness, areas with no sensation (initiated 8/1/19); Observe vital signs as ordered (initiated 8/1/19); and report abnormalities in pedal pulses. If abnormality noted report to MD PRN (initiated 8/1/19). Review of Resident #3's Skin Weekly Review dated 2/4/19 completed when Resident #3 returned from the hospital with a 4 x 1 cm pressure ulcer to the right heel. The assessment did not include staging of the ulcer. Review of Resident #3's physician's orders [REDACTED]. 2/4/19 (discontinued) - [MEDICATION NAME] to posterior right heel on Tuesday, Thursday and Saturday and cover with [MEDEQUIP] 2/4/19 - Easy boot bilateral feet at all times may remove for hygiene and transfers every day and every night shift for pressure relief. 2/5/19 - Skin prep to left heel every shift. 2/9/19 - Weekly body audits. 5/22/19 - Patient to tolerate 20-30 mmHg compression thigh high stocking on left lower extremity when OOB (out of bed) for [MEDICAL CONDITION] management. 8/1/19 - Up OOB as tolerated with feet elevated every shift. [DATE] - Limit sitting to [AGE] minutes every shift. 10/3/19 - Float heels while in bed every shift for wound. 11/17/19 - Wound: right posterior lateral heel; clean with wound cleanser/NS (normal saline) apply iodsorb gauze packing strips 1/2 inch and superabsorbent pad with border gauze, apply skin prep to periwound one time a day for wound. [DATE] - (duplicate order) Wound: right posterior lateral heel; clean with wound cleanser/NS (normal saline) apply iodsorb gauze packing strips 1/2 inch and superabsorbent pad with border gauze, apply skin prep to periwound one time a day for wound. Review of Resident #3's Wound Evaluation and Management Summary dated 11/14/19 noted the resident had a Stage IV pressure wound of the right posterior, lateral heel which had been present for more than 314 days. Exam on this date revealed the resident had mild [MEDICAL CONDITION] to bilateral lower extremities (feet) and the pedal pulse was positive in both lower extremities. On this date the wound measured 2.8 x 1.5 x 0.2 cm with maceration, moderate serous and 100% slough. Dressing plan treatment was as follows: Primary Dressing - Gauze packing strips ([MEDICATION NAME]) 1/2 inch apply once daily for 30 days; superabsorbent w/o bdr (without border) apply once daily for 30 days. Secondary Dressing - Gauze island (with border) apply once daily for 15 days. Peri Wound Treatment - Skin prep apply once daily for 15 days. The physician performed a surgical excisional debridement procedure of the wound and documented the following recommendations: Reposition per facility policy; Dietician consult; protein supplementation; Off-load wound; Limit sitting to [AGE] minutes; [MEDICATION NAME]; Float heels in bed. The summary further noted: Coordination of Care - Data and history pertinent to this patient's care were obtained via nursing staff. This patient's care was discussed with another health care provider Nursing Staff member during this visit. The clinical documentation for this consultation was made available to the referring physician. This documentation is also made available to the skilled nursing facility at any time and for placement in the skilled nursing facility record. Follow-up in seven (7) days. Review of Resident #3's Wound Evaluation and Management Summary dated 11/21/19 reviewed the resident's pressure ulcer to the left heel. The resident had mild [MEDICAL CONDITION] and positive pedal pulses to bilateral lower extremities. On this date, the wound measured 2.5 x 1.7 x 0.4 cm with heavy serous and 100% slough. The summary noted This wound is in [MEDICAL CONDITION] stage and is unable to progress to a healing phase because of the presence of a biofilm. The wound was again debrided. The wound care treatment orders and recommendations from the physician were unchanged from the orders and recommendation noted in the 11/14/19 Wound Evaluation and Management Summary. Follow-up by wound care specialist in eight (8) to 14 days with further intervention as indicated. Review of Resident #3's Podiatry Services Progress Notes revealed the following: 4/19/19 - resident seen for mycotic nail care. The Podiatrist assessed the resident's bilateral feet with +3 capillary filling time (time taken for color to return to an external capillary bed after pressure is applied to cause blanching). The skin texture to both feet was noted to be thin, shiny, dry, friable and atrophic. According to the assessment, the resident's dorsalis pedis pulse and posterior tibial pulse were non-palpable and the resident had non-[MEDICAL CONDITION] to bilateral lower extremities and a right heel ulcer. Follow-up in two (2) - three (3) months. 7/26/19 - resident seen for DM foot care. The doctor noted history of right heel ulcer current concern and feet are in prevalon boots. The resident had a +3 capillary fill time to both extremities and skin texture was noted to be thin, shiny, dry, friable and atrophic. Non-palpable dorsalis pedis and posterior tibial pulses. The Podiatrist noted to defer to primary team for right heel wound care. Review of Resident #3's Podiatry Exam dated [DATE] revealed Patient present for diabetic foot care . has covered right heel ulcer . Non-palpable dorsalis pedal pulse and non-palpable posterior tibial pulse to bilateral feet and ankles. Capillary refill time +3. Skin texture thin, shiny, dry and friable with non-[MEDICAL CONDITION] to both feet. The Assessment/Plan noted the resident have to daily foot checks; defer to primary team for right heel ulcer, dressing was not removed today; and follow-up with the Podiatrist in two (2) to three (3) months. The consult further documented should the Primary Care Physician not agree with the medical necessity of both care delivered and the proposed plan of care (podiatrist) is to be notified immediately. Review of Resident #3's Monthly ICF Summary dated 11/12/19 noted under the section titled Cardiovascular System it was noted the resident had a regular heart rate. The area to address the resident's peripheral pulses was blank. Review of Resident #3's Weekly Wound Observation/Measurement revealed assessments were completed on these dates: -8/1/19, 8/15/19 and 8/29/19 (no weekly assessment between 8/15/19 and 8/29/19 - two (2) weeks between assessments) -[DATE], 9/12/19, [DATE] and 9/26/19 -10/17/19 and 10/24/19 (no weekly assessment between 9/26/19 and 10/17/19 - three (3) weeks between assessments) -[DATE], 11/21/19 and 11/28/19 (no weekly assessment between 10/24/19 and [DATE] - two (2) weeks in between assessments; and no weekly assessment between [DATE] and 11/21/19 - 13 days in between assessments). The Weekly Wound Observation/Measurement noted the following: [DATE] - right posterior heel Stage III pressure ulcer acquired on 12/2/18 measuring at 2.3 x 1.8 x 0.2 cm with granulation present and moderate serosanguinous fluid and odor present. Current treatment plan Dakins. 11/28/19 - right posterior lateral heel (not staged) and admitted with ulcer acquired on 12/20/18. The wound measured 2.5 x 1.5 x 0.4 cm with granulation and slough tissue present and a small amount of serosanguinous fluid present. Current treatment plan idoform packing daily. [DATE] - left lateral foot - unopened area - pressure. The document noted the resident was admitted with the wound acquired on [DATE]. The wound measured 1.4 x 0.8 cm with necrotic and dry tissue present. First observation - current treatment plan - skin prep. There were no Weekly Wound Observation/Measurement assessments completed between 2/4/19 and 7/31/19. Review of the resident's Skin Weekly Review reports between 2/4/19 and 7/18/19 revealed the form allowed for documentation of pressure ulcers (site, type, length, width, depth and stage). There were 24 assessments completed between 2/4/19 and 7/18/19, and of the 24 weekly skin reviews, 18 of them documented no new areas noted, as the only information on the assessment. The report on 6/6/19 documented Stage IV pressure ulcer to right lateral heel measuring 3.2 x 3.6 x 0.6; and the report on [DATE] documented Stage IV pressure ulcer to right posterior heel measuring 3.2 x 4 x 0.3 cm. Of the 24 assessments, the two (2) assessments dated 6/6/19 and [DATE] were the only reviews that measured the resident's right heel wound. Review of the Resident #3's Weekly Skin Assessments revealed the resident was assessed by licensed nursing staff on: -8/2/19, 8/9/19, 8/15/19 and 8/30/19 (no assessment for two (2) weeks between 8/15/19 and 8/30/19) -9/13/19 and 9/23/19 (no assessment for two (2) weeks between 8/30/19 and 9/13/19 and 10 days between 9/13/19 and 9/23/19). -[DATE] and 10/25/19 (no assessment for 24 days between [DATE] and 10/25/19). -[DATE], 11/15/19 and [DATE] (no assessment for two (2) weeks between 10/25/19 and [DATE]) Observation on 12/3/19 at 11:13 AM revealed Resident #3 was in the common area dining room on the unit. The resident was wearing a red long sleeve sweatshirt and was sitting in a broda chair with a blanket laying over the resident's bilateral lower extremities. The resident's feet were not covered by the blanket and the resident's right leg was observed to have significant [MEDICAL CONDITION]. The right foot had no sock and on Resident #3's left foot was what appeared to be a regular sock. Resident #3's legs were not elevated while the resident sat in the broda chair and the resident was not wearing boots to bilateral feet. When Surveyor attempted interview, the resident did not respond. Observation on [DATE] at 10:25 AM revealed Resident #3 was again sitting in the common area dining room on the unit. Resident #3 was wearing the same red long sleeve sweatshirt he/she was observed wearing on 12/3/19. The resident sat in the broda chair without his/her feet being elevated and without wearing bilateral boots. On Resident #3's left foot was a sock (no shoe) and the right foot did not have on a sock or shoe. [MEDICAL CONDITION] to the resident's right foot appeared to be approximately 2+. Resident #3 sat in the dining room area along with five (5) other facility residents. There were no staff present during this observation. Observation on 12/4/10 at 12:00 PM revealed Resident #3 was in his/her room and lying in bed in a supine position. The resident's legs were not elevated, and the resident was not wearing boots while in bed. Review of resident MD orders for treatment dated [DATE] revealed Wound; right posterior lateral heel; Clean with wound cleanser/Normal saline (NS), apply iodsorb gauze packing strips one-half (1/2) inch and a superabsorbent pad with border gauze, apply skin prep to peri wound (tissue surrounding the wound). Nurse reviewed the orders to verify that she had recently changed order from one quarter ( 1/4) inch iodsorb gauze to one-half ( 1/2) inch gauze. Wound Care observation on [DATE] at 1:25 PM for Resident #3 revealed the following: The WCN used hand sanitizer prior to setting up wound supplies (wound cleanser with normal saline (NS), 4 by (x) 4 gauze, alcohol wipes, superabsorbent pad and 1/2 inch iodsorb packing strip). The WCN pulled over two (2) inches of iodsorb packing strip out of the bottle and left it hanging over the side of the bottle. The excess packing strip touched the bare top of the dressing cart thereby contaminating the iodsorb packing strip. The nurse then cut the desired length of iodsorb gauze and placed it in a medication cup (this included the piece of gauze that was touching the outside of the bottle and top of dressing cart. After gathering her wound care supplies, the WCN created a clean field at the resident's bedside to perform the resident's wound care. Both the WCN and CNA #15 performed hand hygiene and donned a clean pair of gloves. While CNA #15 elevated Resident #3's right foot the WCN removed the dressing dated [DATE] which contained a small amount of greenish drainage. The heel ulcer had a small amount beige colored slough at the 12 o'clock position on the wound; the rest of the wound had red granulating tissue. The resident's foot was swollen, dark in color with black splotches on top of his foot. The WCN removed her gloves, performed hand hygiene and donned a clean pair of gloves. The nurse cleaned the heel ulcer with a moistened 4x4 gauze going from cleanest part of the ulcer to the dirtiest part (from clean to dirty). The WCN repeated the motion with another clean moistened 4x4 gauze. The WCN removed her gloves, performed hand hygiene and donned a clean pair of gloves and proceeded to pack the heel ulcer with 1/4 inch iodsorb packing strip. After the wound was packed the WCN reached her uniform pocket with her gloved hand and pulled a out a pair of scissors to cut the dressing. The WCN failed to apply the skin prep around the wound area before applying the dressing. The WCN finished dressing the heel ulcer and dated the dressing. During the wound care the WCN stated the resident transferred from Unit I approximately two (2) months ago with the heel ulcer. The WCN stated it was a Stage III ulcer that was healing. The resident is seen weekly by the Wound Care Physician. The WCN confirmed the resident's foot was swollen and that it was possibly two (2) plus [MEDICAL CONDITION]. The WCN was unable to palpate the resident's pedal pulse, however she was able to palpate the post tibial pulse in the resident's right foot. The WCN stated even though the resident had [MEDICAL CONDITION] in his lower extremities especially his feet she had never checked for the pedal or post tibial pulse before. The WCN was asked about the resident's left foot and she responded to her knowledge the resident did not have any problems with his left foot. The resident was wearing a normal white sock instead of the compression stocking as ordered. The WCN was asked to examine the resident's left foot. Removal of the white sock revealed the resident's left leg and foot were [MEDICAL CONDITION] and the sock had left an indentation in the resident's leg due to the swelling. The resident's foot was [MEDICAL CONDITION] with white dry flaky skin peeling. On the outer side of the resident's left foot was a discolored area that measured approximately one (1) inch in length. Both the WCN and the CNA confirmed they had never seen the area before. The WCN confirmed that it was a deep tissue injury (DTI). The WCN was able to palpate both the pedal and post tibial pulses on the resident's left foot. An interview with the WCN immediately after the wound care observation revealed the that when the staff identify a skin concern, they should notify the WCN, Physician and the resident's responsible party. The WCN would immediately start treatment for [REDACTED]. During the interview the WCN was made aware of the observation of her contaminating the iodsorb packing strip on the medication cart and the failure to apply the skin prep around the ulcer on the resident's right heel. The WCN stated that she was not aware that she had committed those errors and agreed that it was not an acceptable practice. Interview on [DATE] at 1:53 PM with LPN #4 revealed licensed nursing staff were responsible for completing residents' body audits and the aides were to observe residents' skin for skin tears or injuries when providing daily hygiene and showers. When asked how licensed staff ensured that residents' personal hygiene and showers were being completed, LPN #4 said if staff tells us it's done (we) believe them. The nurse continued and stated aides were to notify licensed nursing staff of any observed injuries to residents' skin and the nurse, in turn, completes an assessment and documentation (i.e. incident report). Interview on [DATE] at 3:05 PM with the facility's Wound Nurse (WN) revealed the nurse had been employed with the facility since October 2019 and became responsible for completing the Weekly Wound Observations/Measurements around 10/21/19. The nurse confirmed an assessment was not completed for the week of 11/15/19. During a telephone interview on [DATE] at 3:30 PM with Resident #3's Wound Doctor (WD) revealed that not using the compression stockings and not elevating legs while out of bed could be a contributing factor to the delay in healing to Resident #3's right heel pressure ulcer. The doctor stated there could be other co-morbidities contributing to the slow rate of healing to the ulcer. The doctor confirmed that normal socks were not a substitute for using compression stockings. When asked further about the use of the compression stocking, the WD stated that the resident could not tolerate compression stockings and instead should be using [MEDICATION NAME] because they were not as intolerable for the resident. Interview on [DATE] at 4:09 PM, the facility's WN said a pair of compression socks had been placed in the resident's second drawer. The nurse confirmed that before Surveyor intervention on [DATE], the resident did not have the stockings. Follow-up interview on 12/5/19 at 2:35 PM with the WD revealed the doctor was not aware of an order for [REDACTED].#3 had a [DIAGNOSES REDACTED]. During continued interview, the WD again confirmed the resident's legs should be elevated while wearing bilateral boots to promote healing of the resident's pressure ulcer to right heel. When the WD was asked about Resident #3's pedal pulse and whether nursing staff should be assessing the presence of it on a routine basis, the WD said there was no need to do pedal pulse of all residents and that the absence of a pedal pulse would indicate that the resident should be sent to the emergency room . When asked about an individualized plan of care for Resident #3 in reference to his/her pedal pulse being routinely assessed, the WD again stated there was no need for nursing staff to assess the resident's pedal pulse. The WD said he/she assessed Resident #3 on this date and the pedal pulse was present. The WD stated he/she was not aware of the resident's Podiatrist assessing the resident's pedal pulse being non-palpable in April 2019, July 2019, and November 2019. The WD confirmed there should be communication between medical disciplines (like podiatry) to ensure the coordination of the resident's care. It was the expectation of the WD that the facility would mediate that communication. During a congruent interview on 12/5/19 at 2:35 PM with the facility's DON, the nurse said that the order for the resident's compression stockings were ordered by therapy services, but nursing did not access the order in the new electronic system. Continued interview revealed assessment information and recommendations from Resident #3's podiatry visits should be moved forward and communicated to the resident's wound doctor and primary care physician. When asked about nursing staff completing the Cardiovascular Assessment section of the Monthly ICF Nursing Summary, the DON this section should be completed with documentation of the assessment of the resident's pedal pulse.",2020-09-01
862,PEACHTREE CENTRE,425095,1434 N LIMESTONE ST,GAFFNEY,SC,29340,2019-12-05,812,E,1,0,B63R11,"> Based on observation, interview, and review of facility policy, it was determined that facility failed to maintain proper sanitary measures during meal services for 23 residents on one (1) of three (3) units. During the lunch meal service on [DATE], two (2) staff members were observed to touch the drinking rim of cups and glasses with their bare hands. The findings included: Review of the facility policy titled Dining Service with a revision date of [DATE] documented under Procedure Line #5 that during the delivery of the dining service the staff will: - Prevent the eating surfaces of the plates from meeting the staff clothing; - Handle the cups/glasses on the outside of the container - Keep their hands away from their hair and face when handling food. Observation of [DATE] at 12:15 PM revealed the Certified Nursing Assistant (CNA) #13 standing at the beginning of the serving line with cups and glasses and a cart that contained liquids (such as water and tea). CNA #13 used hand sanitizer and then poured either tea or water in the glasses or cups. CNA #13 picked up the glasses and cups by touching the lip rim of the container with her bare hand (wearing green sparkling nail polish) and placed the containers on the residents' trays. CNA #13 followed this same procedure during the entire meal service for 23 residents' trays. An additional observation of the meal service on this date at 12:25 PM revealed CNA #4 set the meal tray down in front of the resident and wiped the side of her face with her hand. CNA #4 then picked up the resident's drinking glass by the drinking rim with her bare hand and placed the glass in front of the resident. Interview with CNA #13 on [DATE] at 12:54 PM revealed the CNA was not aware that she had touched the rim of every glass during the meal. CNA #13 stated this was not the way she was trained and that we are supposed to hold the cup or glass around the middle and not the rim where the resident drinks from. During the interview on [DATE] at 1:03 PM with the CNA #4 she admitted that she touched the side of her face but was not aware that she touched the rim of the resident's drinking glass. Observation of the breakfast meal service on 12/5/19 at 8:45 AM revealed CNA #14 exiting Unit II's dining room wearing a hair net, apron, and gloves. During an interview at that time, the CNA stated that she had received training about meal service in the dining room this morning. An interview with the Staff Development Nurse on 12/5/19 at 3:30 PM revealed the staff serving meals in the dining room should wear hair nets and gloves. When handling drinking glasses and cups the staff should handle or pick up the container around the middle and not around the rim of the glass and cup.",2020-09-01
863,PEACHTREE CENTRE,425095,1434 N LIMESTONE ST,GAFFNEY,SC,29340,2019-12-05,880,D,1,0,B63R11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and facility policy review, it was determined the facility failed to adhere to contact isolation precautions for one (1) resident of one (1) residents in contact isolation for [MEDICAL CONDITIONS] for one (1) of three (3) floors. (Resident #8) While performing wound care on Resident #10 on [DATE] the Wound Care Nurse (WCN) and Licensed Practical Nurse (LPN) #12 failed to perform hand hygiene prior to exiting the isolation room. On 12/15/19 three (3) maintenance staff members were observed in the isolation room without wearing personal protections equipment (PPE) gowns and gloves. The findings included: Review of facility policy titled Isolation Initiation dated 12/17/18 documents it is the policy of the facility to initiate isolation precautions for a resident that may have a communicable disease in order to reduce the risk of nosocomial infections. Procedure guidelines include . place personal protection equipment receptacle at doorway entrance for visiting patrons. Encourage good hand hygiene upon entrance and exiting isolated resident. [MEDICAL CONDITION] must soap and water for hand hygiene. Place red bag receptacle in resident's room for biohazard waste and a yellow bag receptacle in resident's room for biohazard linen. 1. Observation on [DATE] at 7:30 AM revealed Resident #8 in a private room with an isolation cart with gowns and gloves outside the room. Inside the room was a yellow barrel for dirty linen and a red barrel for discarded gloves and gowns. Signage on the doorway directed visitors to report the nurses' station before entering the resident's room. Wound care observation on [DATE] at 9:45 AM revealed LPN Wound Care Nurse setting up equipment on cart and LPN #12 assisted with dressing. Both nurses donned gowns and gloves to go into the resident's isolation room but failed to their perform hand hygiene before gowning and gloving. Both nurses stated the resident returned from the hospital yesterday evening with [DIAGNOSES REDACTED]. Resident #8 had a sacral dressing dated 12/2/19 with moderate amount of yellowish green drainage. Resident #8 also had two (2) quarter sized openings in the sacral area: first open area had small amount of beige colored slough at the 12 o'clock position, otherwise had pink granulating tissue. The second open area was beefy red. Resident #8 also had a healed area on the coccyx. WCN washed hands and donned new gloves, cleansed both areas with gauze and normal saline going from inner to outer. After performing the wound care, the WCN nurse discarded the gloves and gown inside the resident's room and walked down hallway to the bathroom at the Nurse's Station to wash her hands. LPN #12 discarded her gown and gloves in the resident's room but did not wash her hands in the resident's room either. Interview with WCN on [DATE] at 2:15 PM revealed the nurse was not aware that she had not washed her hands prior to donning gloves when entering the resident's room. The WCN also confirmed that she went to the nurses' station to wash her hands after exiting the isolation room instead of washing her hands in the resident's room. LPN #12 was unavailable for an interview regarding her deficient practice in the isolation room. 2. Observation on 12/5/19 at 9:32 AM revealed Certified Nursing Assistant (CNA #3) dressing gown and gloves to take clean linen supplies and fresh water into Resident #8's room. CNA #3 removed the gown and gloves and discarded in appropriate receptacles on exit. CNA #3 washed hands before exiting the resident's room. An interview with the CNA at that time revealed the employee had recently received training regarding residents in isolation for [MEDICAL CONDITION]. The CNA stated anyone entering the room should wear gown and gloves and when leaving the room, they should discard the gloves and gowns inside the room and wash hands before leaving the room. The employee also stated there was a sign posted outside the resident's room informing the visitors to stop at nurses' station before entering the resident's room. Observation on 12/5/19 at 10:30 AM revealed CNA #3 in Resident #8's isolation room wearing a gown and gloves assisting three (3) Maintenance staff as they removed an empty bed from the resident's room. The three (3) Maintenance staff were not wearing gowns and gloves. The empty bed was removed from the resident's room and transported down the hallway which was occupied by several residents in wheelchairs and staff members. As two (2) of the Maintenance staff transported the bed down the hallway an interview was conducted with the Maintenance Director who was the third person. The Maintenance Director stated the bed was being removed to place in another resident's room. The Maintenance Director admitted he saw the signage but did not realize it was for [MEDICAL CONDITION] isolation and that gown and gloves were required. The Maintenance Director stated the bed would be wiped down and placed in another resident's room. It was explained to the Maintenance Director that a special cleaning solution was required for equipment and furniture that was in [MEDICAL CONDITION] isolation. The Maintenance Director stated that he would have housekeeping clean the bedframe so that it could be used and have the mattress placed in storage. Again, it was re-iterated to the Maintenance Director the mattress also needed to be cleaned before placing into storage and his staff must to wash their hands with soap and water immediately after contact with this bed. Observation on 12/5/19 at 10:50 AM revealed CNA #3 exiting Resident #8's room after removing gown and gloves and washing her hands. An interview with CNA #3 at the time revealed the CNA thought the maintenance staff knew they needed to wear gowns and gloves and she did not think to remind them about the isolation precautions. Interview with the Director of Nursing (DON) on 12/5/19 at 11:15 AM revealed she was recently promoted to the position in April 2019. The DON was also the Infection Control Nurse. The DON stated currently there was only one (1) resident (Resident #8) on isolation precautions in the facility. The DON stated the staff have been trained on isolation precautions for [MEDICAL CONDITION]. Anyone entering the room must don gloves and gown and when leaving the room, the gown and gloves should be discarded in the red biohazard bag. Staff must wash their hands (with soap and water) before exiting the resident's room; the use of hand sanitizer is not an acceptable form of hand hygiene when caring for residents with [MEDICAL CONDITION]. The situation with Maintenance staff removing the empty bed from the resident's isolation room was explained to the DON. The DON stated the nursing staff should have stopped the Maintenance staff from entering the isolation room until they were properly attired. The nursing staff should have instructed the Maintenance staff on hand hygiene and how to properly sanitize the bed. On 12/5/19 at 12:30 PM the surveyor was approached by the Corporate Nurse (CN) requesting additional information about the isolation situation. The deficient isolation practices observed were explained to the CN. The CN stated the nursing staff should have explained to the Maintenance staff about the isolation practice for this resident and ensure the maintenance staff adhered to the isolation precautions. The CN also stated the staff have been trained to wash their hands before exiting an isolation room. The nurses should not walk all the way down the hall to wash their hands at the nursing station. The CN further stated the empty bed coming from the isolation room should not have been moved down the hall with residents present. That created a potential problem of cross contamination. The CN also stated steps had been taken to ensure the entire bed and mattress were properly sanitized according CDC guidelines.",2020-09-01
864,PEACHTREE CENTRE,425095,1434 N LIMESTONE ST,GAFFNEY,SC,29340,2019-12-05,920,F,1,0,B63R11,"> Based on observation and interview, the facility failed to ensure the dining tables in three (3) of three (3) dining rooms were adequately furnished with steady tables that did not shake or move. The findings included: 1. Interview on [DATE] at 10:30 AM with Unsampled Resident #1's daughter revealed the only concern the family member had with the facility was regarding their failure to repair the dining room tables in 300 Unit dining room. During the interview, the daughter walked to a table in the dining room on the 300 unit and using her right hand grasped the side of the table and made an up and down movement with her hand. As a result, the table moved up and down with the family member's hand movement. The daughter stated, it feels like it will break soon. The daughter said, some time ago, she nearly had an accident because she didn't realize how unsteady the table was. The daughter said, this information was reported to the facility; however, there had been nothing done about the tables. At this time, this Surveyor grasped the table and confirmed it was very wobbly. Continued observation revealed there were six (6) tables in the dining room; one (1) table was very unsteady; two (2) tables were unsteady; and three (3) tables were secure. Observation on [DATE] at 10:45 AM in the dining room on 100 Unit revealed 10 out of 10 dining tables were not secure and were shaky. Observation on [DATE] between 12:04 PM and 12:35 PM in the 300 Unit dining room revealed three (3) residents sat at the dining table that was earlier identified as unsteady by an unsampled resident's daughter. At 12:13 PM, one (1) of the residents at this table placed their elbows on the table and the table leaned forward towards the resident. At 12:30 PM Licensed Practical Nurse (LPN) #4 assisted Unsampled Resident #2 with eating their lunch meal. As LPN #4 began to use utensils to manipulate the food on the resident's plate, the table moved up and down with each movement of the utensils. At 12:35 PM., in this dining room, Unsampled Resident #3 stood up from the first table in front of the dining room's left entrance. The resident placed one (1) hand on the table and one (1) hand on their walker. When the resident used the table and walker to stand, the table leaned toward the resident which caused the other side of the table to rise up while a resident sitting across from Unsampled Resident #3 was eating their lunch meal. The table was not secure. Interview on [DATE] at 1:53 PM with LPN #4 revealed the very shaky table in 300 Unit dining room had been unsteady for several months; and the nurse said he/she could see where that could be an accident hazard. When asked about the protocol for ensuring items were repaired, the nurse said that nursing usually give maintenance information and they come around and fix it. LPN #4 said he/she would look to see if a work-order had been completed for the unsteady table(s) in the 300 Unit dining room. During a follow-up interview on 12/5/19 at 9:55 AM with LPN #4 revealed there was not a work order submitted for the broken table in the 300 Unit dining room. 2. Observation of the resident's main dining room on Unit 200 on [DATE] at 11:55 AM revealed the dining room contained 10 tables for resident meals. Six of the 10 table tops were found to wobble. Observation on [DATE] at 12:05 PM revealed Unsampled Resident #4 in a wheelchair was seated at one (1) of the tables identified with a wobbly table top. The resident stood up from the wheelchair holding onto the table in an attempt to move closer to the table. As the resident attempted to gain her balance the table moved slightly causing the resident to become even more unbalanced. At this point CNA #4 intervened and assisted the resident to sit down and position her wheelchair at the table. Interview with CNA #4 after she assisted the resident revealed she was worried the resident might fall since she had an unsteady balance. CNA #4 stated that she was not aware that any of the tables in the dining room were unsteady. Interview with the Maintenance Supervisor on 12/5/19 at 11:45 AM revealed the staff recently made him aware of the wobbly tables in the main dining room on Unit 300 and he had addressed the problem. The Maintenance Supervisor also stated yesterday was the first time the staff had made him aware of problem with the dining room furniture. The Maintenance Supervisor further stated any requests for maintenance worker/repair are generated through a computerized system that came directly to his cell phone. The Maintenance Supervisor showed the surveyor the maintenance report application on his cell phone.",2020-09-01
865,VALLEY FALLS TERRACE,425096,400 LOCUST GROVE ROAD,SPARTANBURG,SC,29303,2017-01-12,250,E,0,1,SQQC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure Resident #44 received medically related social services due to increased behaviors with no interventions in place for 1 of 2 sampled residents reviewed for social services. The findings included: The facility admitted Resident #44 with [DIAGNOSES REDACTED]. Review of the medical record on 1/11/17 at approximately 11:24 AM revealed a nurse's note dated 9/11/16 that indicated Resident #44 continues to throw Kleenex on floor and blocks roommate in hallway to keep them from coming into room. A nurse's note dated 9/14/16 indicated the resident stated there are no people here and all the lights are off. The resident further stated he/she was going to stay here until he/she dies and began talking about heaven and meeting Jesus. The resident reportedly scratched and hit the nurse. There was no documentation of any social services interventions to address behaviors. A nurse's note dated 9/25/16 indicated the resident was very agitated and rude to roommate, yelling get out of my room. The nurse's note further indicated when staff told resident she had one bed, the resident became combative and hitting staff with remote control. A nurse's note dated 10/04/16 indicated the resident was pouring water in bed and on the floor. The resident was also reportedly throwing rubber gloves from box of gloves on the floor. A nurse's note dated 10/18/16 indicated the resident was combative with a certified nurse aide and roommate. Resident #44 reportedly got the roommate's cup and threw the cup at the roommate. A nurses note dated 10/26/16 indicated the resident threw water in room was redirected and offered apology. A nurse's note dated 10/27/16 indicated the resident was observed throwing a cup of fluids on the floor. A nurse's note dated 11/07/16 indicated the resident was noted with increased behaviors such as throwing water on the floor, ripping paper and throwing it on the floor with redirection being unsuccessful. Further record review revealed there was no documentation in social services notes to address behaviors and no interventions provided. There was no documentation to indicate services was provided to address resident expression of heaven and meeting with Jesus. Review of the resident care plan revealed under behavioral symptoms that Resident #44 was a risk of mood/behaviors due to [DIAGNOSES REDACTED]. There were social services notes in (MONTH) (YEAR) to address room/roommate change but no documentation to address combative behaviors. An interview on 1/11/17 at approximately 12:26 PM with the Social Services Director (SSD) confirmed the findings. The SSD provided documentation the resident was receiving psychiatric follow up services with Life Source of North [NAME]ina, Inc. The medical record indicated the resident was seen by staff at Life Source on 6/28/16 and 8/23/16 with no further documentation of services. The SSD stated there was no documentation the Life Source was contacted to address noted behaviors during the months of September, (MONTH) and (MONTH) (YEAR). An interview with the Director of Nursing (DON) on 1/12/17 at approximately 9:02 AM revealed the 8/23/16 Life Source evaluation indicated the resident was in stable condition. The DON stated there was no documentation to indicate Life Source was contacted to address the combative behaviors and provided physician progress reports. The DON confirmed there was no documentation in the physician progress reports to indicate that interventions were provided to address the resident's combative behaviors and discussion of heaven and meeting Jesus.",2020-09-01
866,VALLEY FALLS TERRACE,425096,400 LOCUST GROVE ROAD,SPARTANBURG,SC,29303,2017-01-12,279,D,0,1,SQQC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with Licensed [MEDICATION NAME] Nurse (LPN) #2 and the Director of Nursing (DON), the facility failed to develop a care plan addressing range of motion for 1 of 3 residents reviewed for range of motion. Resident #32 had no care plan developed to address maintaining or improving range of motion. The findings included: Resident #32 was admitted to the facility with [DIAGNOSES REDACTED]. Review of Minimum Data Set (MDS) on 1/11/17 at approximately 2:40 PM revealed that the resident had been coded as having no upper extremity range of motion limitations during the quarterly assessment dated [DATE]. During the significant change assessment dated [DATE] the resident was coded as having range of motion limitations bilaterally for upper extremities. Review of Cumulative physician's orders [REDACTED]. Review of Care Plan on 1/11/17 at approximately 2:55 PM revealed that range of motion was not being addressed. Review of Joint Mobility Screens on 1/11/17 at approximately 3 PM revealed that Resident #32 experienced a decline in range of motion. Between 8/11/16 and 11/4/17 bilateral shoulder flexion and abduction had declined. The Joint Mobility Screen dated 12/9/16 indicated the resident's range of motion remained limited. Interview with LPN #2 and the DON revealed on 1/12/17 at approximately 11:45 AM verified that the resident's care plan did not address range of motion.",2020-09-01
867,VALLEY FALLS TERRACE,425096,400 LOCUST GROVE ROAD,SPARTANBURG,SC,29303,2017-01-12,318,D,0,1,SQQC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with the Minimum Data Set (MDS) Coordinator, the Regional Director of Operations, the Director of Nursing (DON), and Licensed [MEDICATION NAME] Nurse (LPN) #2, the facility failed to offer range of motion treatment or services to 1 of 3 residents reviewed for range of motion. Resident #32 had no services offered to maintain range of motion or to improve range of motion after a decline. The findings included: Resident #32 was admitted to the facility with [DIAGNOSES REDACTED]. Review of Minimum Data Set (MDS) on 1/11/17 at approximately 2:40 PM revealed that the resident had been coded as having no upper extremity range of motion limitations during the quarterly assessment dated [DATE]. During the significant change assessment dated [DATE] the resident was coded as having range of motion limitations bilaterally for upper extremities. Review of Cumulative physician's orders [REDACTED]. Review of Care Plan on 1/11/17 at approximately 2:55 PM revealed that range of motion was not being addressed. Review of Joint Mobility Screens on 1/11/17 at approximately 3 PM revealed that Resident #32 experienced a decline in range of motion. Between 8/11/16 and 11/4/17 bilateral shoulder flexion and abduction had declined. The Joint Mobility Screen dated 12/9/16 indicated the resident's range of motion remained limited. Interview with MDS Coordinator on 1/11/17 at approximately 3 PM revealed that Resident #32 went to the hospital and when s/he returned, s/he was offered physical therapy and occupational therapy but declined both. S/he was unable to produce documentation proving this occurred. Interview with Regional Director of Operations on 1/12/17 at approximately 10 AM revealed that physical therapy had done a quarterly assessment of Resident #32 on 11/3/16 and found no deficits or changes. S/he continued that physical therapy is not aware of Joint Mobility Screens in making their assessment. S/he continued that when nursing discovers a decline in range of motion, they place a referral for the resident to Physical Therapy. S/he stated that there were no physical therapy referrals for Resident #32 for the month of 11/16. During an interview with the DON on 1/12/17 at approximately 10 AM, policy regarding range of motion services was requested. Interview with LPN #2 and the DON revealed on 1/12/17 at approximately 11:45 AM verified that the resident's care plan did not address range of motion. At the time of exit on 1/12/17 at approximately 1 PM, no range of motion services policy was offered by the facility.",2020-09-01
868,VALLEY FALLS TERRACE,425096,400 LOCUST GROVE ROAD,SPARTANBURG,SC,29303,2017-01-12,369,D,0,1,SQQC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure that physician's orders were followed for 1 of 3 sampled residents reviewed for Activities of Daily Living. Resident #58 had physician's orders to have lids on cups at all meals that was not followed. The findings included: The facility admitted Resident #58 with [DIAGNOSES REDACTED]. A random observation on 1/11/17 at approximately 11:13 AM revealed resident in bed with partially eaten sandwich on bedside table and a cup of milk. There was no lid on the cup of milk. A random observation on 1/11/17 at approximately 12:56 PM during lunch revealed the resident in the dining with liquids in cups and no lids were on the cups. A review of the medical record on 1/11/17 at approximately 1:08 PM revealed a physician' order dated 10/07/16 that indicated Scoop plate at all meals and lids on all cups. Further record review revealed a diet order and communication list dated 9/21/16 that indicated under adaptive equipment Scoop plate, also please put lids on all cups. A random observation of breakfast meal on 1/12/17 at approximately 7:51 AM revealed the resident had liquids in cups with no lids on the cups. An interview on 1/12/17 at approximately 8:30 AM the Dietary Manager (DM) confirmed Resident #58 did not have lids on cups during meal and stated he/she was not aware there was on order for lids being on all cups. An interview on 1/12/17 at approximately 9:10 AM with the Therapy Director confirmed the resident should have lids of all drinks due to spillage and poor dexterity issues with hands. Review of the dietary sheet on 1/12/17 at approximately 9:20 AM with Licensed Practical Nurse (LPN) #1 confirmed the dietary department was provided information to include lids of all cups for Resident #58.",2020-09-01
869,VALLEY FALLS TERRACE,425096,400 LOCUST GROVE ROAD,SPARTANBURG,SC,29303,2017-01-12,371,E,0,1,SQQC11,"Based on observation and interview, the facility failed to ensure food was stored, labeled and/or discarded by the use by date. The findings included: On 1/10/2017 7:47:49 AM observed in the walk In refrigerator- ham in container - no use by date, large gallon of pickles-unlabeled for use by date or opened date, gallon mustard container opened and dated for 12/28/2016 use by date, mozzarella opened and dated 12//27/16 use by date, In the dry storage area-poultry gravy open/wrapped in tin foil- not dated, Pure cane confectioners sugar- large brown bag 25 lb opened/undated, opened 25 lb bag of pure cane sugar crystals- opened with no date, The Nutritionist Director observed, verified and confirmed the findings",2020-09-01
870,VALLEY FALLS TERRACE,425096,400 LOCUST GROVE ROAD,SPARTANBURG,SC,29303,2017-01-12,431,D,0,1,SQQC11,"Based on observation, interview and review of the facility's Medication Management Program policy, the facility failed to ensure that medication carts were free from expired medications. Expired Ferrous Gluconate tablets were observed in 1 of 4 medication carts in the facility. The findings included: On 1/12/2017 at 10:54 AM, fifty-two Ferrous Gluconate 324 mg (milligram) Unit Dose (each medication is individually packed) tablets were observed stored in Medication Cart One on the B Hall. Each of the tablets had an expiration date of October, (YEAR). During an interview with LPN (Licensed Practical Nurse) #2 on 1/12/2017 at 11:04 AM, LPN #2 confirmed that fifty-two Ferrous Gluconate 324 mg tablets, with an expiration date of October, (YEAR), were stored in medication Cart One. LPN #2 stated the tablets should have been discarded. LPN #2 also stated that it is the responsibility of the nurses and Pharmacy to ensure that medication carts are free from expired medications. LPN #2 stated that the pharmacist checked the carts once per month for expired medications and nurses are to ensure their medication carts do not contain expired medications. During an interview with the DON (Director of Nursing) on 1/12/2017 at 11:11 AM, the DON confirmed the procedure for ensuring medication carts are free from expired medications. In addition, the DON confirmed that two residents were currently receiving Ferrous Gluconate 324 mg tablets from Medication Cart One on the B Hall. Review of the Medication Management Program policy on 1/12/2017 at 11:36 AM, revealed that expired medication should be destroyed or returned to the pharmacy.",2020-09-01
871,VALLEY FALLS TERRACE,425096,400 LOCUST GROVE ROAD,SPARTANBURG,SC,29303,2019-03-22,550,E,0,1,07YM11,"Based on observation, interview, and record review, the facility failed to promote an environment that enhanced the dignity of the residents for 3 of 3 meal observations. The findings include: During An observation on 3/18/19 at 5:38 PM on the A Hall in the Dining Room, it was observed that milk and juice was being served to 6 residents while still in the carton. At 5:43 PM on 3/18/19, meal delivery service on the A Hall revealed 10 residents receiving milk, juice, and thickened liquids concentrate on their meal carts with no cups or glasses being made available to them, only a straw. During an interview with Certified Nursing Assistant (CNA) #1 on 3/18/19 at 6:15 PM s/he verified that the residents did not have cups or glasses provided to them with meals. S/he stated, I do not believe I have ever seen them given cups. During an interview on 3/21/19 at 9:05 AM, the Kitchen Supervisor stated that they were unaware that drinks should be served out of glasses/cups and not the cartons. S/he also confirmed that the kitchen was not providing additional cups/glasses for the residents during meal times when milk, juice, and other liquids were being served in their prepackaged cartons. On 3/18/19 at approximately 6:00 PM, during an observation of the A Hall dining room (5) residents were served milk in cartons with a straw in them. During observation of the dining service on the B Hall on 03/18/19 at approximately 05:45 PM, 5 of 7 residents observed received milk in a carton with a straw. No glass was offered, and the residents were not asked if they preferred their milk in a glass.",2020-09-01
872,VALLEY FALLS TERRACE,425096,400 LOCUST GROVE ROAD,SPARTANBURG,SC,29303,2019-03-22,607,D,1,1,07YM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview and review of the facility's Abuse and Neglect Policy, the facility failed to implement their policy for identifying and reporting an allegation of neglect to the facility timely for Resident #17, 1 of 6 residents reviewed for abuse. The findings included: The facility admitted Resident #17 on 07/01/18 with [DIAGNOSES REDACTED]. Review on 03/19/19 at 03:21 PM of the Five-Day Follow-Up Report dated 10/05/18 indicated the Resident #17's niece called the Director of Nursing (DON) on 10/03/18 and alleged neglect related to incontinent care. Review of the staff statements indicated Resident #17 reported the incident to the second shift CNAs (Certified Nursing Assistants) at 03:05 PM on 10/02/18 and it was reported to a Licensed Practical Nurse (LPN) and a Registered Nurse (RN) at that time. Review of the facility's Leadership Policies and Procedures Section III: Organizational Ethics; Subject: Abuse, Neglect, Exploitation, or mistreatment, revised 11/1/2017 page LP-III-5 revealed Component V: Reporting/Response 1. All alleged violations concerning abuse, neglect, or misappropriation of property are reported verbally immediately to the Facility Abuse Coordinator, the Administrator and other officials in accordance with state law including the State Survey and Certification Agency (nurse aide registry or licensing authorities). During an interview on 03/20/19 at 10:24 AM, the Director of Nursing (DON) confirmed the facility was aware of the incident on 10/02/18 after two CNAs reported the allegation of neglect to an LPN and an RN and that the report was not made timely to the State Agency per the regulation and the facility's policy. The DON further stated that s/he became aware of the incident after the resident's family member made the allegation on 10/03/18. The DON stated s/he became aware that the staff were aware of the allegation on 10/02/18 when s/he obtained the staff statements on 10/03/18. During an interview on 03/22/19 at 12:14 PM, the DON and Nursing Home administrator confirmed that the facility staff did not identify the allegation of neglect and that the policy was not followed related to reporting.",2020-09-01
873,VALLEY FALLS TERRACE,425096,400 LOCUST GROVE ROAD,SPARTANBURG,SC,29303,2019-03-22,609,D,1,1,07YM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to report an allegation on neglect timely for Resident #17, 1 of 6 residents reviewed for abuse and/or neglect. The findings included: The facility admitted Resident #17 on 07/01/18 with [DIAGNOSES REDACTED]. Review on 03/19/19 at 03:21 PM of the facility's 2/24-Hour Report documented that the incident occurred on 10/03/18 at 04:00 PM. Further review revealed the incident was reported on 10/03/18 at 03:46 PM. Review of the staff statements indicated Resident #17 reported the incident to the second shift CNA (Certified Nursing Assistant) at 03:05 PM on 10/02/18 and it was reported to a Licensed Practical Nurse (LPN) and a Registered Nurse (RN) at that time. Review of the Five-Day Follow-Up Report dated 10/05/18 indicated the resident's niece called the Director of Nursing (DON) on 10/03/18 and alleged neglect related to incontinent care on 10/02/18. During an interview on 03/20/19 at 10:24 AM, the DON confirmed the facility was aware of the incident on 10/02/18 after two CNAs reported the allegation of neglect to an LPN and an RN and that the report was not made timely to the State Agency. The DON further stated that s/he became aware of the incident after the resident's family member made the allegation on 10/03/18 and that s/he became aware that the staff were aware of the allegation on 10/02/18 when s/he obtained the staff statements on 10/03/18.",2020-09-01
874,VALLEY FALLS TERRACE,425096,400 LOCUST GROVE ROAD,SPARTANBURG,SC,29303,2019-03-22,812,F,0,1,07YM11,"Based on observation, interview, and review of the facility policies, the facility failed to prepare, distribute, and serve food under sanitary conditions for 1 of 1 kitchen reviewed and has the potential to affect 84 of 85 residents with ordered diets as evidenced by failing to do the following: wear facial hair restraints, store food sanitarily, clean can opener and ice scoop tray. The findings included: On 3/18/19 at approximately 3:35 PM, an initial tour of the main kitchen with the Dietary Manager (DM) revealed: 1.) Dietary Aide #1 and the DM had a mustache without facial hair restraint to cover. Walk-in refrigerator: 2.) (1) Box of thawed chicken dripping a red substance onto the floor leaving a puddle below. 3.) The ice scoop tray on the ice machine did not allow for drainage and had a build-up of a black substance on the bottom with the ice scoop resting in it. 4.) The can opener had a black build-up of food debris on the blade. On 3/19/19 at approximately 5:30 PM an observation of the dinner line plating in the main kitchen with the DM revealed: 1.) Dietary Aide #1 and the DM had a mustache without facial hair restraint to cover. 2.) The can opener had a black build-up of food debris on the blade. On 3/19/19 at approximately 5:50 PM, during an interview with the DM, s/he verified facial hair restraints were not covering mustaches, chicken was not in a drip pan and was dripping onto the floor, the ice scoop tray did not have drainage and had a build-up of a black substance, and there was debris build-up on the can opener. Review of the facility policy entitled, Ice, procedure (5) states, Ice scoops will be cleaned and stored in a separate container that limits exposure to dust and moisture. Review of the facility policy entitled, Staff Attire, states under procedure (1) states, All staff members will have their hair off the shoulders, confined in a hair net or cap, and facial hair properly re-strained. Review of the facility policy entitled, Food Preparation, states under procedure (5) states, The Cook thaws frozen items that requires defrosting prior to preparation using one of the following methods: Thawing in the refrigerator, in a drip-proof container, and in a manner that prevents cross-contamination.",2020-09-01
875,VALLEY FALLS TERRACE,425096,400 LOCUST GROVE ROAD,SPARTANBURG,SC,29303,2018-03-28,584,E,0,1,IDLL11,"Based on observation and interview, the facility failed to maintain a homelike environment on 3 of 3 halls observed during the survey. All resident room doors were observed with multiple scuff marks and/or gouges. The findings included: During Initial Tour of the facility on 3/26/2018 at 9:45 AM, all resident room doors observed appeared damaged due to multiple scuff marks, gouges or chipped areas to the door surfaces. During a tour of all resident halls with the Maintenance Director on 3/28/2018 at 12:20 PM, the Maintenance Director confirmed the damage to the surface of all resident doors. In addition, the Maintenance Director stated the facility had no plan in place to repair or replace the doors.",2020-09-01
876,VALLEY FALLS TERRACE,425096,400 LOCUST GROVE ROAD,SPARTANBURG,SC,29303,2018-03-28,655,E,0,1,IDLL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to develop person-centered baseline care plans for 4 of 5 sampled residents reviewed for baseline careplans. In addition, baseline care plans did not indicate when they were developed or when the resident/family were given a summary of the baseline care plan. Residents #62, #70, #130 and #65. The findings included: The facility admitted resident #62 with [DIAGNOSES REDACTED]. Record review of the physician's History and Physical on 3/27/2018 at 10:30 AM, revealed Resident #62 was now weight bearing as tolerated status, incontinent of bowel and bladder and receiving narcotic pain medication. Record review of the physician's orders [REDACTED]. Dietary orders revealed the resident required assistance with meals. Review of the baseline care plan on 3/27/2018 at 10:27 AM, revealed the baseline care plan did not indicate when it was created or when the Resident Representative was given a summary of the baseline care plan. There was no documentation in the medical record to indicate the baseline care plan was created within 48 hours of admission or when the resident representative (RR) was given a summary. The baseline care plan did not reflect the resident's bowel and bladder status. The baseline careplan did not include any initial goals based on the admission orders [REDACTED]. The baseline care plan did not indicate the resident was receiving Occupational and Speech Therapy. The baseline care plan did not indicate the resident's weight bearing status. In addition, the baseline care plan did not indicate if the resident required assistance with eating, bed mobility, toileting, transfers and walking. During an interview with Registered Nurse (RN) #1 on 3/27/2018 at 10:51 AM, RN #1 confirmed there was no documentation to indicate when the RR was given a summary of the baseline care plan. During an interview with Licensed Practical Nurse (LPN) #2 on 3/28/2018 at 12:40 PM, LPN #2 confirmed the baseline care plan was not person-centered to reflect the resident's immediate care needs. LPN #2 confirmed there were no initial goals and the baseline care plan had not been reviewed and/or revised. The facility admitted Resident #70 with [DIAGNOSES REDACTED]. A review of the medical record on 3/27/18 at approximately 9:48 AM revealed a form identified as a baseline care plan. The baseline care plan did not address specific resident centered services. The form was more a a check off list. There were no resident centered goals identified for resident care. The baseline care plan did not address services based on physician's orders [REDACTED]. Further review of the baseline care plan revealed there was no documentation to indicate that the baseline care plan was completed with 48 hours of admission. The baseline care included the representative's signature with no signature date. The section on the care plan for Facility Representative Signature was not signed or dated. There was no documentation in the medical record to indicate when the care plan was developed and addressed with the resident and/or representative. An interview on 3/27/18 at approximately 10:56 AM with Registered Nurse (RN) #2 confirmed the findings that the baseline care plan did not include dates to indicate when the baseline care plan was completed. The RN #2 further acknowledged that the baseline care plan was not resident centered to include specific goals and there was no documentation in the medical record to verify the baseline care plan was addressed with the resident and/or representative. The facility admitted Resident #130 with [DIAGNOSES REDACTED]. During an individual resident interview on 3/26/18 at approximately 11:18 AM, the resident stated he/she did not recall the facility discussing a care plan that addressed services that will be provided and further stated there was no discussing of discharge planning. A review of the medical record on 3/27/18 at approximately 3:15 PM revealed a form identified as a baseline care plan that did not address goals based on physician's orders [REDACTED]. Further review of the baseline care plan revealed that the form was signed by the Facility Representative. The form did not included the resident's signature or dates when the form was signed. There was no other documentation in the medical record to indicate when the baseline care plan was developed or discussed with the resident and/or resident representative. An interview on 3/27/18 at approximately 3:30 PM with the facility's consultant confirmed the findings that the date of completion was not on the baseline care plan and there was documentation to indicate when baseline care plan was completed and addressed with the resident and/or representative. The facility admitted Resident #65 with a [DIAGNOSES REDACTED]. A review of the medical record on 3/28/18 at approximately 12:36 PM revealed an a form identified as the baseline care plan that was not person-centered for resident care. The care plan did not include specific services for physical and occupational therapy with initial goals for resident care. Further review of the baseline care plan revealed there was no documentation to indicate that the baseline care plan was completed within 48 hours of admission. The signature page of the baseline care plan included the signatures with no dates to indicate the baseline care plan was completed timely. There was no documentation in the medical record to indicate when the care plan was developed and addressed with the resident and/or representative.",2020-09-01
877,VALLEY FALLS TERRACE,425096,400 LOCUST GROVE ROAD,SPARTANBURG,SC,29303,2018-03-28,657,D,0,1,IDLL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to review and revise a care plan with interventions to address a resident whose front tooth was noted on a tray table. Resident #16's front tooth was noted on a tray table on 2/18/18 with no follow up. (1 of 1 sampled resident care plans reviewed for care and services). The findings included: The facility admitted Resident #16 with [DIAGNOSES REDACTED]. Review of the medical record on 3/26/18 at approximately 11:46 AM revealed a nurse's note dated 2/16/18 that indicated at 2 PM the resident's front tooth was noted by a Certified Nursing Aide on tray table. The note further indicated the resident's family representative was called and a message was left. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] indicated the resident had a Brief Interview Mental Status (BIMS) score of 6 which indicated the resident was not interview-able. There was no documentation on the comprehensive care plan to address interventions in place to address what occurred with the resident's tooth. An interview on 3/28/18 at approximately 12:20 PM with Registered Nurse (RN) #2 confirmed the care plan was not updated to address the resident's front tooth being found on a tray table. The RN stated he/she was not aware of the incident that was noted in the medical record.",2020-09-01
878,VALLEY FALLS TERRACE,425096,400 LOCUST GROVE ROAD,SPARTANBURG,SC,29303,2018-03-28,684,D,0,1,IDLL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to address care and services for a resident whose front tooth was noted on a tray table. Resident #16's front tooth was noted on a tray table on 2/18/18 with no interventions or documented follow up. (1 of 1 sampled resident reviewed for care and services). The findings included: The facility admitted Resident #16 with [DIAGNOSES REDACTED]. Review of the medical record on 3/26/18 at approximately 11:46 AM revealed a nurse's note dated 2/16/18 that indicated at 2 PM the resident's front tooth was noted by a Certified Nursing Aide on tray table. The note further indicated the resident's family representative was called and a message was left. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] indicated the resident had a Brief Interview Mental Status (BIMS) score of 6 which indicated the resident was not interview-able. There was no further documentation in the medical record to determine what occurred to cause the resident's front tooth to come out and no documentation of interventions put in to address the incident. An interview on 3/27/18 at approximately 1:15 PM with Certified Nursing Aide (CNA) #2 revealed he/she observed the resident's tooth on the a tray. The CNA further stated he/she went in the resident's room and just saw the tooth on the tray and reported it to a nurse. The Director of Nursing (DON) was present and stated he/she would look for an incident report. Registered Nurse (RN) #1 confirmed there was no documentation of follow up related to Resident #16's tooth being found on a tray. RN #1 further stated he/she was not aware of the incident. An interview on 3/28/18 at approximately 8:50 AM the DON stated there was no incident report regarding the resident's front tooth being found on a tray and there was no documentation that follow up was done.",2020-09-01
879,VALLEY FALLS TERRACE,425096,400 LOCUST GROVE ROAD,SPARTANBURG,SC,29303,2018-03-28,725,D,0,1,IDLL11,"Based on interviews with resident families and staff, the facility failed to provide sufficient 24-hour staffing to care for resident needs. Facility and staff expressed concerns that weekend staffing was insufficient to provide adequate care to residents. The findings included: Family interview of Resident #39 on 3/26/18 at approximately 2:35 PM revealed s/he believed care was lacking on weekends citing delayed meal times and incontinence care. Staff interview with certified nursing aide (CNA) #4 on 3/28/18 at approximately 10:35 AM revealed on night shift there were only 2 CNAs to provide care, with each handling 22 residents. The CNA stated that in order to get up all residents in the morning they would start at 4:30 AM which s/he believed was too early. Family interview of Resident #282 on 3/28/18 at approximately 11:05 AM revealed the family did not believe there was enough staff on weekends. The family stated that s/he has waited up to 30 minutes for the resident to receive care. S/he also cited an instance when both aides were on break and s/he had to wait for break to end. Interview with administrator and DON on 3/28/18 at approximately 11:50 AM revealed the facility was above minimum state requirements and the facility population was low acuity. The administrator discussed that staff sometimes shared concerns of insufficient staffing. The administrator also discussed a recent family complaint regarding insufficient staffing that had been resolved.",2020-09-01
880,VALLEY FALLS TERRACE,425096,400 LOCUST GROVE ROAD,SPARTANBURG,SC,29303,2018-03-28,745,D,0,1,IDLL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to provide social services to 2 of 2 sampled residents reviewed for medically related social services. Resident #60 with documentation in the medical record related to being discharged to another facility with no documentation of efforts being made to assist with placement to another facility. Resident #65 with admission to facility with little clothing and documentation of efforts to obtain additional clothing for the resident. The findings included: The facility admitted Resident #60 with [DIAGNOSES REDACTED]. A review of the medical record on 3/27/18 at approximately 3:31 PM revealed a social services progress review form dated 9/13/17 that indicated plans for resident was to return home after therapy. A 11/27/17 social services progress review form indicated continue with current plans. There was no documentation to indicate the facility had been addressing discharge plans for the resident. The last documented social services progress note dated 9/20/17 indicated no changes noted in mood/behaviors with the resident remaining pleasant and cooperative with others. The 9/20/17 note further indicated resident was participating in therapy and will continue to be monitored. Further record review revealed a care plan updated on 3/08/18 that indicated under Long Term Goal Target Date: 5/25/18 resident will actively participate in rehabilitation therapies and discharge planning process through target goal date. The care plan goal further indicated long term bed is being sought. An interview on 3/28/18 at approximately 12:08 PM with Registered Nurse #2 revealed the resident was care planned to be discharged with long term care stay at another facility. RN #2 confirmed there were no long term placements at the facility and the resident would be discharged to another facility RN #2 further stated efforts to locate other placement would be documented in the social notes. The facility admitted Resident #65 with [DIAGNOSES REDACTED]. During initial pool process on 3/26/18 the resident was observed wearing same clothes (jeans, black top and gray black sports [NAME]et) although resident clothing had food spills and stains on them. On 3/27/18 at approximately 9:19 AM the resident was observed wearing jeans with black top. A review of the medical record on 3/27/18 at approximately 2:53 PM revealed there was no documentation of a clothing inventory review done for the resident. An interview on 3/27/18 at approximately 3:10 PM with Social Services Director (SSD) revealed there was no clothing inventory sheet in the medical record. The SSD stated he/she gave the family the form on admission and that if the family does not give the form back he/she would not have one. The SSD stated s/he does not have documentation when s/he gave the form or no documentation of efforts to get clothing for the resident. An interview and observation on 3/27/18 at 4:24 PM with Certified Nursing Aide (CNA) #3 revealed the resident had one pair of jeans and he/she was wearing them. A review of the resident clothes revealed one plaid blue/green long sleeve shirt, 2 white short sleeve T-shirts and gray/black sports [NAME]et. The CNA further stated the dress clothes the resident was wearing are basically the same clothes he/she had been wearing since being in the facility. Random observation on 3/28/18 at approximately 9:22 AM revealed resident #65 in front of nurses' station wearing plaid pajama bottom with red pajama top and gray/black sports [NAME]et.",2020-09-01
881,VALLEY FALLS TERRACE,425096,400 LOCUST GROVE ROAD,SPARTANBURG,SC,29303,2018-03-28,760,D,0,1,IDLL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of the [MEDICATION NAME] 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 #70. The findings included: On 3/27/18 at 5:00 PM, during an observation of Resident #70's medication administration with Licensed Practical Nurse (LPN) #1 revealed Resident #70 had a Blood Sugar (BS) of 254. The physician order [REDACTED]. LPN #1 attached the needle to the [MEDICATION NAME], and without priming [MEDICATION NAME], selected 10 units on the [MEDICATION NAME] dose knob dial. LPN #1 then placed the [MEDICATION NAME] onto Resident 70's right upper arm and pressed the administration dose knob button; holding for 1-2 seconds against the residents' skin. Following the administration LPN #1 verified s/he did not prime the [MEDICATION NAME] prior to administration, and indicated that s/he did not hold the [MEDICATION NAME] for 6 seconds against Resident #70's skin after pressing the Dose Knob administration button. Review of the [MEDICATION NAME] manufactures recommendations reveals under, Prepare your pen; Prime your pen, states, Turn the dose selector to select 2 units. Press and hold the dose button. Make sure a drop appears. Also, under, Give your injection, states, Insert the needle. Press and hold the dose button. After the dose counter reaches 0, slowly count to 6.",2020-09-01
882,VALLEY FALLS TERRACE,425096,400 LOCUST GROVE ROAD,SPARTANBURG,SC,29303,2018-03-28,812,E,0,1,IDLL11,"Based on observations, interviews and review of the facility's Receiving and Staff Attire policies, the facility failed to ensure that food was stored, served and distributed properly. Refrigerated foods were left on carts or counters, foods were noted unlabeled and undated, dietary staff were observed with hairnet not covering front or side of hair on head, non dietary staff entered kitchen without hairnet, dirty dishes were noted on clean dishes rack, baking pans noted with crude and white powdery substance, large fry pan noted with black stains/debris on inside and black heavy substance noted on bottom of pan, there was trash/debris on papers on food particles noted on floor and under dish washer and multiple packets of creamers and spices with no expiration or purchase dates and 1 of 3 sanitation buckets was not sanitized at the proper level. One of 1 main kitchen observed. In addition, based on observation, interview, and review of the facility policy, the facility failed to prepare, distribute, and serve food under sanitary conditions for 1 of 4 halls and 1 of 2 dining rooms reviewed. Staff touched food during dining on the 300 hall and in the main dining room. The findings included: Random observation of the main kitchen during initial tour on 3/26/18 at approximately 9:05 AM with the Certified Dietary Manager (CDM) and Dietary Manager (DM). A dietary worker was observed in the food preparation area with side of hair on head not covered by hairnet. There were 6 eggs in shells in a large egg carton on a counter in the kitchen. When asked why the eggs were not in the refrigerator the DM stated I was just on my way to put them back in the refrigerator. Small white bowls were observed to stand on the clean shelf near the dish washer. There were 25 plus white bowls under the sink near the dish washer. The bowls were noted with black specks. The DM stated the facility was not using the bowls because the facility purchased new clear bowls. The DM stated the white bowls should have been removed. There were several trays with large red soup size bowls in the clean area. There were food particles on the trays where the clean red soup bowls were stored. There were two (2) large baking pans that the CDM indicated were used for baking bread. Both large baking pans were noted discolored with a white powdery substance on the inside of the pans. The substance was movable when touched by surveyor. The CDM stated the white substance looked like burned plastic. The DM touched the substance and stated it looked like a cleaning product. There was a large frying pan noted with the thick black substance under the bottom of the pan and small area of black substance on the inside of the frying pan. There were two (2) large containers in the refrigerator that were unlabeled and undated. The DM stated the containers were tartar sauce. There were several containers of spices the DM stated were used to prepare broth for soup that was undated with no date of purchase. The dry storage area also had multiple packets of creamer with no expiration or purchase dates. The three compartment sink was overflowing with water above the water level line on the three compartment sink. The trash can under the hand washing sink as you enter the kitchen was rusted on inside. There was no plastic liner used. Random observation of the main kitchen on 3/28/18 at approximately 8:16 AM revealed eight (8) large clear bags of dark green frozen vegetables that were left out in the main kitchen in hall to unthaw. The CDM confirmed the observation and stated the vegetables were to be used for lunch. The CDM stated the frozen vegetables should have been put under cold running water to thaw. A container of Pimento Cheese indicated to keep refrigerated was left out of counter while three staff members were in the kitchen. The trash under the hand washing sink did not have a plastic lining. At approximately 8:28 AM on 3/28/18 a dietary staff member was observed in the main kitchen wearing disposable gloves while on his/her personal cell phone. The dietary staff then opened the door to the main kitchen while wearing the disposable gloves to finish his/her telephone call. The CDM requested the dietary staff assistance in putting back a cart that had fruit juices on it in the walk in refrigerator. After assisting the CDM, the dietary opened the door to the main kitchen without removing the gloves and washing his/her hands. The dietary staff proceeded to get clean glasses from the shelf and was observed putting ice in the glasses while wearing the same gloves used to take a phone call, assist CDM and enter and exit the kitchen door. The CDM was present during the observation. The dietary staff continued to not have the side of his/her head of hair under the hairnet. The CDM had the side of his/her hair uncovered by hairnet. A review of the sanitation level of three buckets in the kitchen revealed one (1) sanitation bucket less that 200 part per million. The three compartment sink water level remained above water level lines noted on the three compartment sink. The CDM confirmed the observation. A copy of the facilities labeling, dating and hair coverage policy was requested. During the food temperature observation on 3/28/18 at approximately 11:30 AM revealed the activity assistant entering the main kitchen food prep area without wearing a hairnet. The surveyor asked the activity assistant if he/she was aware he/she should not be in the kitchen without a hair net. The DM who observed the activity assist in the kitchen stated loudly that it was okay. The DM then assisted the activity assist with the cart delivered to the main kitchen. Around 11:35 AM a dietary staff entered the kitchen with the front and sides of his/her hair not covered with hairnet. Observation observed by DM who informed dietary staff to cover the front of his/her hair. The DM did not say anything until questioned by surveyor. During all kitchen observations small bits of trash/debris was noted on kitchen floor throughout. A review of the facility's Receiving policy revised 5/2014 indicated under #6 All food items will be appropriately labeled and dated either through manufacturing packaging or staff notation. A review of the facility's Staff Attire policy revised 5/2014 indicated under #1 The Food Services Directors insures that all staff members have their hair off the shoulders, confined in a hair net or cap, and facial hair properly restrained. On 3/26/18 at approximately 12:47 PM, an observation of Certified Nursing Assistant (CNA) #1 on the 300 hall, revealed the CNA entered the residents room; placed the tray down and opened a package of crackers with his/her fingers, s/he then pulled the crackers out with his/her fingers and placed the crackers into the residents soup. On 3/26/18 at approximately 1:01 PM, another observation of CNA #1 in the main dining room, revealed the CNA placed a tray down and opened a package of crackers with his/her fingers, s/he then pulled the crackers out with his/her fingers and placed the crackers into the residents soup. CNA #1 then opened a carton of milk and placed his/her thumb into the inside of the spout of the carton and index finger on the outside of the spout moving the carton on the tray. On 3/26/18 at 1:05 PM, CNA #1 verified s/he had touched the resident's food. Review of the facility policy entitled, Safe Food Handling states under, Food/Beverages Prepared and Served by Facility Staff for Patients/Residents: (6.) Food is served with clean, sanitized utensils. There is no bare hand contact.",2020-09-01
883,VALLEY FALLS TERRACE,425096,400 LOCUST GROVE ROAD,SPARTANBURG,SC,29303,2018-03-28,842,D,0,1,IDLL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure that the medical record was accurately documented for 1 of 24 sampled residents reviewed for advance directives. Resident #70's medical record had inconsistent documentation related to the correct status of the resident's advance directive. The findings included: The facility admitted Resident #70 with [DIAGNOSES REDACTED]. A review of the medical record on 3/27/18 at approximately 9:48 AM revealed a HISTORY AND PHYSICAL dated 2/02/18 that indicated the resident was a Do Not Attempt Resuscitation per discussion with physician by resident representative on 2/02/18. There was documentation with two physician's signature to indicate the resident was not competent to make health care decisions. A social services progress review form dated 2/06/18 indicated the resident was a Full Code which indicated resuscitation should be attempted. A physician's progress note dated 3/07/18 indicated the resident code status was DNR. Further record review revealed there was a written physician's orders [REDACTED]. An interview on 3/27/18 at approximately 10:10 AM with the Social Services Director (SSD) confirmed the inconsistency in the medical record and stated he/she had spoken to the family representative who would not come in and sign forms but there was no documentation his/her attempts to contact family representative. An interview on 3/27/18 at approximately 10:28 AM with the Assistant Director of Nursing (ADON) confirmed the findings. The ADON further called the SSD regarding the inconsistent information regarding the advance directive and informed the surveyor that SSD did not document contact with the family because the physician's orders [REDACTED]. An interview on 3/27/18 at approximately 3 PM with the ADON revealed the History and Physical dated 2/02/18 and Physician's Progress report dated 3/07/18 were correct and the resident should be a DNR.",2020-09-01
884,PRUITTHEALTH-BARNWELL,425097,31 WREN STREET,BARNWELL,SC,29812,2018-02-08,656,D,0,1,WM4111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, records review and interviews the facility failed to implement the care plan related to continent care for one of five sampled residents reviewed for unnecessary medication. The findings include: The facility admitted Resident # 19 with [DIAGNOSES REDACTED]. Review of Resident #19's comprehensive care plan on 02/07/2018 at 2:13 PM revealed that the resident is at risk for falls related to the [DIAGNOSES REDACTED]. According to care plan on 1/30/18, the resident had a fall and as a prevention intervention, incontinent care every two hours was added to the care plan. Based on observation during the second phase of the survey process, continent care was not observed being performed. On 02/07/18 at approximately 03:15 PM, the resident, was observed in his/her room laying on his/her bed. On 02/08/18 at 10:05 AM the resident was observed in his/her room applying lotion to face. The resident seems in good spirit. On 02/08/18 at 10:05 AM during an interview, Resident #19 stated that s/he had not gotten continent care every 2 hours at all. S/he stated that when s/he needs to go to the bathroom s/he pushes the call light button but if staff takes too long to respond s/he tries on his/her own. During an interview with the director of nursing (DON) on 02/08/2018 at 10:25 AM s/he stated that the resident got and gets continent care every 2 hours but was not able to provide documentation to support claims.",2020-09-01
885,PRUITTHEALTH-BARNWELL,425097,31 WREN STREET,BARNWELL,SC,29812,2018-02-08,689,D,0,1,WM4111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to provide scheduled supervised continent care to prevent avoidable accidents for one of five residents reviewed for unnecessary medication. The findings include: The facility admitted Resident # 19 with [DIAGNOSES REDACTED]. According to Medical doctor (MD)/Nurse Practical (NP) Note reviewed on 02/07/2018 at approximately 2:30 PM on 1/30/18 resident # 19 fell in the bathroom. According to note abrasion to midline and lower back occurred and the care plan intervention included toileting scheduled every 2 hours during the day. On 12/24/17 the resident fell in the bathroom during self-transferring. Left abdominal abrasion. Denies hitting the head and experiencing pain. On 9/13/17 the Resident closed toilet seat down onto left hand. Swelling discolored area. X-Ray obtained and icepack as ordered. No fracture or discomfort. On 8/6/17 the resident fell in the bathroom during self-transfer-no injury observed-denied pain-neuro check as ordered. Intervention- sensor pad to the wheelchair. On 5/9/17 resident placed a hand between toilet seat and lid and sat down resulting in hematoma and skin tear top left hand. On 5/8/17 x-rays to view hand obtained. On 3/28/17 the resident was observed sitting on the floor in the room between the bed and wheelchair .a urinalysis (UA) cast obtained urination .no growth in 48 hours. On 2/17/17 and 2/18/17 resident slid from wheelchair to floor.No injury noted, and the resident denied pain. UA cast was obtained-cast pending. On 2/18 alarm placed in wheelchair seat-intervention-injury screen sent. On 1/4/17 resident fell from the toilet to floor. Pain in the right side. X-ray obtained with no fracture and no breaks noted. Nurse's note reviewed on 02/07/2018 at approximately 3:30 PM stated that staff when in Resident #19's bathroom to answer the call light. According to note, the resident was found sitting upright on the bathroom floor beside the toilet. The resident denied hitting the head, but abrasion to mid and lower midline back was observed. The note also states that the resident-oriented to the toilet by two staffs for activity of daily living (ADL) care, the MD notified, and orders received. The resident's representative was also notified. The note does not reveal the indications or instructions of the order received. Based on observation during the second phase of the survey process, continent care was not observed being performed. On 02/07/18 at approximately 03:15 PM, the resident, was observed in his/her room laying on her bed. On 02/08/18 at 10:05 AM the resident was observed in his/her room applying lotion to face. The resident seems in good spirit. On 02/08/18 at 10:05 AM during an interview, Resident #19 stated that s/he had not gotten continent care every 2 hours at all. S/he stated that when s/he needs to go to the bathroom s/he pushes the call light button but if staff takes too long to respond s/he tries on his/her own. During an interview with the director of nursing (DON) on 02/08/2018 at 10:25 AM s/he stated that the resident got and gets continent care every 2 hours but was not able to provide evidence to support claims.",2020-09-01
886,PRUITTHEALTH-BARNWELL,425097,31 WREN STREET,BARNWELL,SC,29812,2018-02-08,804,D,0,1,WM4111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure resident's meals are served at a preferred temperature. Resident# 11 and #16 had concerns of meals being served cold for 2 of 2 residents reviewed for food. The findings included: The facility admitted Resident #11 with [DIAGNOSES REDACTED]. During an interview with Resident#11 on 2/06/18 at 10:20 AM, the surveyor asked Does the food taste good and look good. The resident stated the food is cold once received. During meal observation on 2/6/18 at 12:27PM, meal trays were on a cart being served by the Certified Nurse Aide that would knock on the door before entering the room. On the wall near the nurse station with the Meal Time it documented 11:45 AM. During record review of Patient/Resident Council Minutes on 2/7/18 at 8:40 AM revealed concerns with food being cold was discussed during the (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR), where Resident #11 attended. The facility admitted Resident #16 with [DIAGNOSES REDACTED]. During an interview with Resident#16 on 2/06/18 at 01:22PM, the surveyor asked Does the food taste good and look good. Resident #16 stated the food is cold. During another observation and interview with Director of Nursing and Certified Dietary Manager on 2/7/18 at 11:59AM, confirmed residents' tray sitting on the cart not being served on the hall. Resident #11 and #16 tray was on the cart near the dining room.",2020-09-01
887,PRUITTHEALTH-BARNWELL,425097,31 WREN STREET,BARNWELL,SC,29812,2018-02-08,812,F,0,1,WM4111,"Based on observation, interview, and review of the facility policies titled Food Storage, Food Temperature, and Cleaning Procedures: Major Equipment, the facility failed to appropriately store, label and date opened food items stored in the kitchen freezer and dry storage areas. The facility also failed to maintain kitchen equipment in good working conditions and good appearance. The findings included: During the initial tour of the kitchen observation on 02/05/2018 at 6:24 PM a clear bag of what looks like breaded chicken of approximately 10lbs without a date or label. Two brown paper without a label or date on it, the dietary manager stated that the bags contain French Fries. A clear bag of chicken of approximately 10-15lbs and a bag of beef patties half full without label and date on it. A half-full bag of uncooked macaroni without label and date. A box containing a blue bag with approximately 20lbs of rice fully opened. Continuing kitchen observation on the same date at 6:41 PM a mop-bucket containing mop and dirty water placed next to clean drinking cups in the kitchen. The hand washing sink did not work properly and appeared soiled. Stand still dirty water was observed in the sink, which could create a potential for bacterial growth. The ice maker had extensive lime buildup all around it, and a tear in the left top corner of the door/front was observed. Throughout the kitchen floor, large brown to black stain was observed, and the floor appeared uncleaned. On 02/07/2018 at 3:49 PM during an interview with the dietary manager s/he confirmed findings. S/he also stated that s/he has been asking for a bigger freezer so items can be stored appropriately since s/he has to take items off their original package to store them in the freezer due to limited space. During an interview with the maintenance and the environmental managers, the maintenance manager stated the lime buildup had been there for a long time, and staff has not been able to take it off despite numeral attempts. S/he also state that the facility has scheduled deep cleaning for the kitchen floor but the stains don't come off. The environmental manager stated that s/he have been trying to have the kitchen floor changed for five years now with no success.",2020-09-01
888,PRUITTHEALTH-BARNWELL,425097,31 WREN STREET,BARNWELL,SC,29812,2019-02-22,550,D,0,1,742V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to care for each resident in an environment or manner that promotes maintenance or enhancement of his or her quality of life for one of one resident reviewed for dignity. Resident #5 was observed with facial hair. The findings included: The facility admitted Resident #5 with [DIAGNOSES REDACTED]. Record review on 2/21/19 at 5:57 PM of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #5 was coded as having a Brief Interview for Mental Status (BIMS) score of 6. Observation of Resident #5 on 2/20/19 at 10:36 AM revealed multiple white chin hairs. During an observation on 2/22/19 at 10:36 AM of Resident #5 with Licensed Practical Nurse (LPN)#1, s/he confirmed the facial hair on the resident's chin. S/he agreed using a reasonable person concept, a resident would want the facial hair removed. On 2/22/19 at 1:00 PM, LPN #1 stated s/he had asked the resident's Certified Nursing Assistant (CNA) to ask the resident if s/he would like the facial hair removed. Per LPN #1, Resident #5 stated s/he would like the facial hair removed. On 2/22/19 at 2:17 PM, CNA #1 stated s/he had asked Resident #5 if s/he would like the facial hair removed and the resident had stated yes. S/he continued by stating usually facial hair is removed during the bath and s/he had not noticed the hair on the resident's chin that morning. During the survey, no policy was provided related to removal of facial hair and/or dignity.",2020-09-01
889,PRUITTHEALTH-BARNWELL,425097,31 WREN STREET,BARNWELL,SC,29812,2019-02-22,558,D,0,1,742V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide reasonable accommodation related to call bell usage for one of 2 residents reviewed. Resident #27 when asked to demonstrate his/her call bell, could not operate his/her call bell provided by the facility. The findings included: The facility admitted Resident #27 with [DIAGNOSES REDACTED]. During observation of Resident #27 on 2/21/19 at approximately 10:35 AM, s/he was asked to demonstrate the use of the call bell system provided by the facility. During the demonstration, Resident #27 exhibited difficulty in the manipulation of the call bell. At the time of the attempted demonstration, Licensed Practical Nurse (LPN) #2 confirmed Resident #27 had difficulty and instructed staff to obtain a different call bell device for easier manipulation. No assessment for call bell usage for Resident #27 was provided during the survey process.",2020-09-01
890,PRUITTHEALTH-BARNWELL,425097,31 WREN STREET,BARNWELL,SC,29812,2019-02-22,623,D,0,1,742V11,"**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 2 residents reviewed for hospitalization . The facility failed to provide a written Notice of Transfer for Resident #41 and Resident #27. The findings included: The facility admitted Resident #41 on 11/15/18 with [DIAGNOSES REDACTED]. Review of the Nurse's Notes dated 11/27/18 indicated the facility transferred Resident #41 to the hospital for evaluation related to critical lab results. The facility received the order to send Resident #41 to the hospital at 2:45 PM after the physician evaluated Resident #41 at 12:00 PM and ordered repeat labs. Documentation indicated the facility notified the resident's Responsible Party (RP) and readmitted Resident #41 on 12/4/18. 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 of the reason for the transfer to the resident's representative. The surveyor requested documentation related to the written Notice of Transfer. During an interview on 2/20/19 at approximately 3:00 PM, the Social Services Director stated that he/she does not send a written Notice of Transfer when a resident is transferred to the hospital. The facility admitted Resident #27 with [DIAGNOSES REDACTED]. Record review on 2/20/19 at 1:20 PM revealed Resident #27 was transferred to the hospital on [DATE] due to increased congestion and decreased oxygen saturation levels. In addition, Resident #27 was transferred to the hospital on [DATE] due to respiratory distress and elevated body temperature. Further record review revealed there was no documentation to reflect the resident and the resident's representative received in writing the reason for the transfer. During an interview with the Social Service Director on 2/22/19 at 2:28 PM, s/he confirmed there was no evidence to show written written notification of the transfer was given to the resident and the resident's representative.",2020-09-01
891,PRUITTHEALTH-BARNWELL,425097,31 WREN STREET,BARNWELL,SC,29812,2019-02-22,625,D,0,1,742V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and review of the facility's policy entitled Bed Holds, the facility failed to ensure residents and/or their representatives received a copy of the facility's Bed Hold Policy upon transfer/discharge to the hospital for 2 of 2 residents reviewed for hospitalization . (Residents #41 and #27) The findings included: The facility admitted Resident #41 on 11/15/18 with [DIAGNOSES REDACTED]. Review of the Nurse's Notes dated 11/27/18 indicated the facility transferred Resident #41 to the hospital for evaluation related to critical lab results. The facility received the order to send Resident #41 to the hospital at 2:45 PM after the physician evaluated Resident #41 at 12:00 PM and ordered repeat labs. Documentation indicated the facility notified the resident's Responsible Party (RP) and readmitted Resident #41 on 12/4/18. Further record review revealed no documentation that the facility sent a written notice of the Bed Hold Policy that included the amount of the Bed Hold to Resident 41's representative. During an interview on 2/20/19 at approximately 3:00 PM, the Social Worker stated that he/she goes over the bed hold policy at the time of admission but does not send a written Bed Hold Policy to the residents' representatives upon transfer/admission to the hospital. Review of the facility's policy entitled Bed Holds revealed, Two notices related to the healthcare center's bed hold policy will be issued. The first notice of bed hold policies is given during this admission, which is well in advance of any transfer. The second notice, which specifies the duration of the bed hold policy, will be issued at the time of any transfer. In cases of emergency transfer, notice 'at the time of transfer' means that the family and/or undersigned parties, not to include the healthcare center, is provided with written notification within 24 hours of the transfer. The requirement is met if the patient/resident's copy of the notice is sent with other papers accompanying the patient/resident to the hospital. The facility admitted Resident #27 with [DIAGNOSES REDACTED]. Record review on 2/20/19 at 1:20 PM revealed Resident #27 was transferred to the hospital on [DATE] due to increased congestion and decreased oxygen saturation levels. In addition, Resident #27 was transferred to the hospital on [DATE] due to respiratory distress and elevated body temperature. Further record review revealed there was no documentation to reflect the resident and/or the resident's representative received in writing the bed hold policy. During an interview with the Social Service Director on 2/22/19 at 2:28 PM, s/he confirmed there was no evidence to show written the bed hold policy was distributed to the resident and/or the resident's representative.",2020-09-01
892,PRUITTHEALTH-BARNWELL,425097,31 WREN STREET,BARNWELL,SC,29812,2019-02-22,638,E,0,1,742V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on limited record review and interview, the facility failed to ensure 3 of 3 residents identified on the Minimum Data Set (MDS) 3.0 Missing Omnibus Budget Reconciliation Assessment (OBRA) Report and 2 of 3 residents triggered for review in the Facility Assessment Task had assessments electronically transmitted and accepted into the Centers for Medicare and Medicaid (CMS) system database as mandated (Resident #1, 2, 3, 91 & 92). The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Record review on 2/20/19 revealed the last MDS assessment received was on 9/6/18. The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Record review on 2/20/19 revealed the MDS assessment was over 120 days old. The facility admitted Resident #3 with [DIAGNOSES REDACTED]. Record review on 2/20/19 revealed the last MDS assessment was over 120 days old. The facility admitted Resident #91 with [DIAGNOSES REDACTED]. Record review on 2/20/19 revealed the last MDS assessment received was on 5/8/18. The facility admitted Resident #92 with [DIAGNOSES REDACTED]. Record review on 2/20/19 revealed the last MDS assessment received was on 3/7/18. Interview with the MDS Coordinator on 2/20/19 at 2:20 PM revealed the facility computer system had indicated assessments were accepted but the validation report indicated some assessments had been rejected. S/he continued by stating there was some type of glitch in the system and some assessments were never accepted and was unsure why those assessments did not show up on the report.",2020-09-01
893,PRUITTHEALTH-BARNWELL,425097,31 WREN STREET,BARNWELL,SC,29812,2019-02-22,644,D,0,1,742V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that a Level 2 screening was done as required for 1 of 2 residents reviewed for PASARR (Pre-Admission Screening and Resident Review). The facility failed to complete a PASARR Level 2 screening following a new [DIAGNOSES REDACTED].#30. The findings included: The facility admitted Resident #30 on 9/14/13 with [DIAGNOSES REDACTED]. Review of the medical record revealed the PASARR Level 1 screening dated 7/16/98. Review of the medical record revealed the Physician's Progress Notes dated 9/11/18 indicated the physician prescribed [MEDICATION NAME] 0.25 mg related to the resident's yelling, cursing, paranoia, and visual auditory hallucinations. The Nurses Notes dated 9/14/18 indicated, on 9/11/18 resident seen by MD (Medical Doctor) with a new order for [MEDICATION NAME], dx (diagnosis): [MEDICAL CONDITION] disorder with auditory and visual hallucinations. Review of the Antipsychotic Prior Authorization Form confirmed the [DIAGNOSES REDACTED]. Further record review revealed there was no Level 2 PASARR in the medical record. During an interview on 2/22/19, the Unit Manager reviewed the medical record and confirmed that a Level 2 PASARR was not completed following the new [DIAGNOSES REDACTED].",2020-09-01
894,PRUITTHEALTH-BARNWELL,425097,31 WREN STREET,BARNWELL,SC,29812,2019-02-22,684,E,0,1,742V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure all physician ordered medications were transcribed onto the Medication Administration Record [REDACTED]. The findings included: During reconciliation of the medication pass on 2/22/19, record review of Resident #140's physician orders [REDACTED]. Further record review revealed the medication had not been transcribed to the MAR indicated [REDACTED] During an interview with Licensed Practical Nurse (LPN)#1 on 2/22/19 at approximately 12:30 PM, s/he confirmed the order for the medication. Further interview with LPN #1 on 2/22/19 revealed the resident's husband had brought the medication from home for the resident and the order had been written. S/he continued by stating since there was no [DIAGNOSES REDACTED]. The physician was notified and discontinued the medication on 2/22/19 due to no [DIAGNOSES REDACTED].",2020-09-01
895,PRUITTHEALTH-BARNWELL,425097,31 WREN STREET,BARNWELL,SC,29812,2019-02-22,880,D,0,1,742V11,"Based on observation, interview, and review of the facility policy titled Infection Control-Linen and Laundry Services, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to prevent development and transmission of disease and infection. Observation of the laundry revealed laundry staff touched the door between the sorting area and the washer area with a soiled gloved hand and after loading the washer, closed the washer door and started the washer with a soiled gloved hand. The findings included: During observation of the laundry on 2/21/19 at 9:55 AM, Laundry Staff #1 was observed after sorting soiled laundry to touch the door between the sorting room and washer room with his/her soiled gloved hand. After loading the washer, Laundry Staff #1 was observed to close the washer door and start the washer with his/her soiled gloved hand. After removal of Personal Protective Equipment and washing hands, Laundry Staff #1 was asked if there was anything else to be done and s/he stated no. Further interview revealed the washer was sanitized during the day but not after every load washed. Review of the facility policy on 2/21/19 titled Infection Control-Linen and Laundry Services revealed it did not address sanitizing the machine after touching the machine with soiled gloves or after loading the washer, but did indicate all areas should be cleaned on a regular schedule.",2020-09-01
896,PRUITTHEALTH-BARNWELL,425097,31 WREN STREET,BARNWELL,SC,29812,2016-11-10,166,D,0,1,UMM011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interviews,and review of the facility policy entitled Grievances-Healthcare Center, the facility failed to follow the grievance policy and satisfactorily resolve a complaint related to resident behavior for one of one sampled resident reviewed for grievances. Resident #17's grievance about another resident's verbal abuse was not recorded, followed up on, or resolved. The findings included: The facility admitted Resident #17 with [DIAGNOSES REDACTED]. Review of the 9-7-16 Admission-5 Day Minimum Data Set (MDS) Assessment at 3:24 PM on 11-8-16 revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating s/he was cognitively intact. No [MEDICAL CONDITION] or behaviors were noted. During an interview on 11/07/2016 at 4:12 PM, when asked if staff, a resident or anyone else at the facility had abused her/him, Resident #17 responded, Yes. S/he stated, (Resident #1) blocked the door to my room so I couldn't get to the bathroom. I asked her (him) to move. She (He) said she (he) was busy talking to someone right then. She (He) called me a [***] . When asked if s/he had told staff, Resident #17 stated, I told the nurses and (Social Services). When asked if anyone had gotten back with her/him regarding resolution to the concern, the resident stated that no one had spoken with her/him further about the issue and that it was not resolved. The resident became tearful when relating what had occurred. S/he also reported that the other resident would not leave her/him alone-that s/he had followed her/him into the dining room and outside. S/he felt stalked. Review of the Grievance Log at 2:33 PM on 11-8-16 revealed that the resident's complaint/concern had not been entered into the log. Review of Nurses Notes on 11-8-16 at 2:51 PM revealed no documentation regarding an incident of verbal abuse by Resident #1. Review of Social Service Notes at 3:10 PM on 11-8-16 revealed no mention of the altercation with Resident #1. During an interview on 11-8-16 at 3 PM, Licensed Practical Nurse (LPN) #2 stated s/he had been told to monitor the situation & be sure everyone stays safe. S/he did not recall who had given that instruction. The nurse stated that Resident #1 had behavioral issues due to a prior head injury. LPN #3 stated s/he had been on duty but did not witness the incident. During an interview at 3:15 PM on 11-8-16, LPN #1 stated s/he had not been at the facility at the time of the incident. S/he heard that Resident #17 was trying to get to the bathroom and (Resident #1) was in the way-wouldn't move. I don't think there were any witnesses. LPN #1 reviewed the medical record and confirmed that there was no documentation of the incident in the Nurses Notes or Social Service Notes. During an interview at 4 PM on 11-8-16 with LPN #1 in attendance, Social Services stated the incident was reported to me. It happened on (MONTH) 25th or 26th. (Resident #17) was trying to get to the bathroom, but (Resident #1) was in the way. (Resident #1) called her (him) a [***] . When asked if the report had been entered in the Grievance Log, LPN #1 and Social Services reviewed and verified that the incident had not been entered in the log. Social Service admitted s/he had not recorded the incident on the grievance form or the log when it was reported. At approximately 5 PM, Social Services provided a completed copy of the Grievance/Complaint Form which documented the date of occurrence/report and date of completion as 10-27-16. The form noted Actions taken: Spoke with both residents. (Resident #1) apologized to resident. They were both on friendly terms the next day. Discuss with (Resident #17) & she (he) agreed to above outcome. During an interview at 1:40 PM on 11-9-16, Resident #17 stated the complaint had not been resolved. S/he stated that Social Services had not followed up with her/him after the incident was initially reported. The as s/he repeated that Resident #1 had followed me and my sister outside and another time into the dining room. I don't want her (him) near me. She (he) did not apologize to me. I don't need an apology. I need her (him) to stay away from me. S/he adamantly denied being on friendly terms with Resident #1. The facility's policy entitled Grievances: Healthcare Centers provided by Social Services states: ''Policy Statement: It is the policy .for healthcare centers to follow an established process whereby patients .may have their grievances and complaints resolved in a prompt, reasonable, and consistent manner . Procedure: 1 . the staff person receiving the information will assist with completing the . Grievance/Complaint Form . 2 .The Social Services or Senior Care Partner will track the grievance on the Grievance/ Complaint Log Form . refer the grievance to the appropriate department for investigation .3.the responsible discipline will make prompt efforts to resolve the grievance. The action taken should be recorded . 4. The Social Services Partner/Senior Care Partner will be responsible for follow-up with the patient/resident. to determine the grievance has been resolved . 5. The Grievance/ complaint is to be resolved within 3 business days .",2020-09-01
897,PRUITTHEALTH-BARNWELL,425097,31 WREN STREET,BARNWELL,SC,29812,2016-11-10,253,D,0,1,UMM011,"Based on observations and interviews, the facility failed to promote an environment that maintains or enhances each resident's living space. Findings include: Observed a black biological substance in grout around the base of the toilet area for resident rooms (104, 110 and 123) during a tour on 11/09/2016 at approximately 10:07 AM. A subsequent observation on 11/09/16 at approximately 11:10 AM revealed the same issues with Director of Maintenance, who indicated that the grout was missing in resident's rooms (104, 110, and 123) around the base of the toilet area. The Director of Maintenance was asked if a work order had been submitted to correct the problem, and he indicated that he did not receive any orders for repairs. In an interview with Administrator on 11/09/2016 1:20 PM, the Administrator indicated that she was not aware of the missing grout and the Director of Maintenance has only been at this position for about three weeks. The Administrator confirmed that a work order has not been submitted to correct the problem.",2020-09-01
898,PRUITTHEALTH-BARNWELL,425097,31 WREN STREET,BARNWELL,SC,29812,2016-11-10,317,D,0,1,UMM011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to provide timely preventive care to one of three sampled residents reviewed for range of motion (ROM). An Occupational therapy (OT) recommendation for ROM was not implemented for 5 weeks for Resident #47. The findings included: The facility admitted Resident #47 with [DIAGNOSES REDACTED]. Review of the 8-5-16 Occupational Therapy Plan of Care (Evaluation Only) at 12:01 PM on 11-9-16 revealed that Skilled OT recommends Restorative Rehab to maintain CLOF (current level of function) and ROM in BUE (bilateral upper extremities) .would benefit from Restorative rehab to maintain ROM for ADL's (activities of daily living) and transfers to prevent contractures and promote skin integrity. Continued review revealed that restorative services were not implemented until 9-14-16, five weeks later, after a Physician's Interim Order was obtained on 9-13-16. During an interview on 11-9-16 at 12:49 PM, Licensed Practical Nurse #1 reviewed the OT recommendations and restorative documentation. S/he stated, We follow recommendations. I don't know why they were not followed for over a month. Sometimes I don't receive the recommendation right away when they come off (therapy).",2020-09-01
899,THE HERITAGE AT LOWMAN REHAB AND HEALTHCARE,425100,201 FORTRESS DRIVE,WHITE ROCK,SC,29177,2017-01-20,226,D,0,1,1LD111,"Based on record review and interview the facility failed to follow policies related to screening employees and reporting/investigation of allegations of abuse. Policies not followed related to screening employees for 1 of 5 employee background checks and policies not followed related to reporting/investigation of allegations of abuse for 1 of 4 allegations of abuse. The findings included: Interview with Resident #68 on 1/17/17 at 4:00 PM revealed that the resident alleged that she/he had been verbally abused. Resident #68 stated that a Certified Nursing Assistant (CNA) brought the residents breakfast tray into their room on 1/16/17 around 7:00 AM and there was no coffee on the tray. Resident #68 asked the CNA for coffee. Resident #68 states that the CNA then expressed that there was no coffee and cursed at the resident. Review of the facility policy Accidents and Incidents - Investigating and Reporting dated (MONTH) 2013 revealed that the facility must ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injures of unknown source are reported immediately to the Administrator, Social Services Director, Director of Nursing, or other department head. Further review of the policy revealed, The Administrator or department head should immediately write the allegation on a grievance form and begin investigating. The Department of Health and Environmental Control and the ombudsman are notified as appropriate. The initial report must be phoned or faxed in within 24 hours. Interview with Director of Social Services on 1/19/17 at 11:14 AM revealed that no allegations of verbal abuse toward Resident # 68 were reported to him/her. Interview with Unit Manager, Registered Nurse (RN) #1 on 1/19/17 at 11:25 AM revealed that the allegation of verbal abuse from Resident #68 was reported to him/her. RN # 1 stated he/she then reported the incident to the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) on 1/16/17. RN #1 stated that the 3 CNA ' s that were on duty that day that worked with Resident # 68 were questioned and then continued on their shift and continued working with Resident # 68. Interview with the DON on 1/19/17 at 11:39 AM revealed that the incident of verbal abuse against Resident #68 had not been reported to him/her. The DON verified that no incident report had been completed or reported and that the CNA involved in the incident continued to work with Resident # 68. Interview with the DON on 1/19/17 at 11:53 AM revealed that 3 CNA ' s and RN #1 were sent home and suspended pending the outcome of an investigation, and an Initial 24-Hour Report was completed and sent to Department of Health and Environmental Control on 1/19/17. Record review on 01/19/2017 at 4:00 PM revealed that the facility used Employment Screening Inc. to conduct a background check on Registered Nurse (RN) #2. On the facilities Background/Criminal History Check form under places lived during the past 24 months RN #2 listed[NAME] North [NAME]ina. During an interview on 01/19/2017 at 5:00 PM the Administrator stated that the third party entity did use a state agency for background checks but was unable to provide documentation. By the end of the survey the Administrator did not provide additional information.",2020-09-01
900,THE HERITAGE AT LOWMAN REHAB AND HEALTHCARE,425100,201 FORTRESS DRIVE,WHITE ROCK,SC,29177,2017-01-20,272,D,0,1,1LD111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to accurately and completely assess Resident #231 for risk for falls, 1 of 1 reviewed for accidents. The findings included: The facility admitted Resident #231 with [DIAGNOSES REDACTED]. At 11:45 AM on 01/20/2017, review of the nurses' notes revealed a note dated 12/27/16 that stated the resident was found on floor with an abrasion on the left elbow. Further review revealed a note dated 12/23/16 that stated the resident was found on floor with a laceration to forehead. The resident was sent to the emergency room . Review of the Fall Risk assessment dated [DATE] revealed the assessment was incomplete related to the resident's history of falls prior to admission, ambulation and vision status, medications and diseases/ conditions that predispose a resident for falls. Review of the Minimal Data Set revealed the facility was in possession of information that the resident had a history of [REDACTED]. During an interview on 1/20/17 at 1:18 PM, the Director of Nursing (DON) confirmed the 12/19/16 Fall Risk Evaluation was not completed and had inaccuracies documented related to the resident's fall history.",2020-09-01
901,THE HERITAGE AT LOWMAN REHAB AND HEALTHCARE,425100,201 FORTRESS DRIVE,WHITE ROCK,SC,29177,2017-01-20,323,D,0,1,1LD111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to implement ordered interventions to prevent falls for Resident #231, 1 of 1 resident reviewed for accidents. The facility failed to implement alarms as ordered. The findings included: The facility admitted Resident #231 with [DIAGNOSES REDACTED]. At 11:45 AM on 01/20/2017, review of the nurses' notes revealed a note dated 12/27/16 that stated the resident was found on the floor with an abrasion on the left elbow. Further review revealed a note dated 12/2316 that stated the resident was found on floor with a laceration to forehead. The resident was sent to the emergency room . At 11:54 AM on 01/20/2017, review of the Incident Report dated 12/27/16 revealed the resident was on a low bed prior to fall and also indicated chair alarm none, call light on. No recommendations were listed to prevent further falls. Further review revealed an Incident Report dated 12/31/16 that stated the alarm was not sounding at the time of the fall and also indicated Immediate Actions Taken: alarm applied. At 12:21 PM on 01/20/2017, review of the monthly cumulative orders revealed orders dated 12/20/16 for a bed alarm, chair alarm, and the bed in low position. Review of the Fall Risk assessment dated [DATE] revealed the assessment was incomplete related to the resident's history of falls prior to admission, ambulation and vision status, medications and diseases/ conditions that predispose a resident for falls. Review of the Minimal Data Set revealed the facility was in possession of information that the resident had a history of [REDACTED]. During an interview on 1/20/17 at 1:18 PM, the Director of Nursing (DON) confirmed the 12/19/16 Fall Risk Evaluation was not completed and had inaccuracies documented related to the resident's fall history. The DON also confirmed the orders for the bed and chair alarm and the low bed were written on 12/20/16, prior to the first fall and that no new interventions had been implemented to prevent further falls. In addition, the DON confirmed the incident reports indicated the alarms were not in use at the time of both falls.",2020-09-01
902,THE HERITAGE AT LOWMAN REHAB AND HEALTHCARE,425100,201 FORTRESS DRIVE,WHITE ROCK,SC,29177,2017-01-20,329,E,0,1,1LD111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that ordered medications were administered as ordered for Resident #124, 1 of 5 residents reviewed for medication administration. Insulin was not administered, or not administered timely, for blood sugar results greater than 300 as ordered. The findings included: The facility admitted Resident #124 with [DIAGNOSES REDACTED]. At 12:18 PM on 01/19/2017, review of the monthly Physician order [REDACTED]. Further review revealed an order for [REDACTED]. At 2:22 PM on 01/19/2017, review of the Treatment Administration Record (TAR) and Medication Administration Record [REDACTED]. Further review of the TAR revealed the Blood Sugar was greater than 300 7 times in January, (YEAR); 339 on 1/1 at 4 PM, 323 on 1/3 at 11 AM, 348 on 1/7 at 11 AM and 426 at 4 PM, 358 on 1/9 at 6 AM and 346 at 11 AM and 322 on 1/16 at 11 AM. Review of the MAR indicated [REDACTED]. In December, the Blood Sugar was greater than 300 on 12/1 (326), 12/2 (315), 12/3 (307), 12/7 (389), 12/8 (377), 12/9 (337), 12/10 357), 12/11 (301 at 11:00 AM and 407 at 4:00 PM), 12/12 (324), 12/14 (419), 12/15 (346), 12/16 (343 at 11:00 AM and 451 at 4:00 PM), 12/17 (306), 12/19 354), 12/20 (318), 12/21 (334), 12/22 (327), 12/25 (355), 12/29 (302 at 11:00 AM and 307 at 4:00 PM), 12/30 (306) and 12/30 (315) for a total of 24 times. Review of the MAR indicated [REDACTED]. During an interview at 4:12 PM on 1/19/17, Licensed Practical Nurse (LPN) #1 confirmed the blood sugar results. S/he also confirmed the doses given on 12/7 and 12/8/16 were not administered timely. In addition, the LPN confirmed only 7 doses were administered in (MONTH) and stated I'll take your word for it. when asked to confirm that only 2 doses were administered in January, (YEAR).",2020-09-01
903,THE HERITAGE AT LOWMAN REHAB AND HEALTHCARE,425100,201 FORTRESS DRIVE,WHITE ROCK,SC,29177,2017-01-20,428,D,0,1,1LD111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the pharmacist failed to identify and report medication irregularities to the Director of Nursing and/or Medical Director related to insulin not being administered as ordered for Resident #124, 1 of 5 residents reviewed for medications. The findings included: The facility admitted Resident #124 with [DIAGNOSES REDACTED]. At 12:18 PM on 01/19/2017, review of the monthly Physician order [REDACTED]. Further review revealed an order for [REDACTED]. At 2:22 PM on 01/19/2017, review of the Treatment Administration Record (TAR) and Medication Administration Record [REDACTED]. Further review of the (MONTH) TAR revealed the Blood Sugar was greater than 300 on 12/1 (326), 12/2 (315), 12/3 (307), 12/7 (389), 12/8 (377), 12/9 (337), 12/10 357), 12/11 (301 at 11:00 AM and 407 at 4:00 PM), 12/12 (324), 12/14 (419), 12/15 (346), 12/16 (343 at 11:00 AM and 451 at 4:00 PM), 12/17 (306), 12/19 354), 12/20 (318), 12/21 (334), 12/22 (327), 12/25 (355), 12/29 (302 at 11:00 AM and 307 at 4:00 PM), 12/30 (306) and 12/30 (315) for a total of 24 times. Review of the MAR indicated [REDACTED] At 11:13 AM on 01/19/2017, review of the Medication Regimen Review by the Pharmacist dated 12/17/17 revealed no report or recommendation related to insulin not being administered as ordered. During an interview on 1/20/17 at approximately 11:30 AM, the Director of Nursing confirmed that s/he would have expected the pharmacist to identify the errors and report them. .",2020-09-01
904,THE HERITAGE AT LOWMAN REHAB AND HEALTHCARE,425100,201 FORTRESS DRIVE,WHITE ROCK,SC,29177,2018-05-03,578,D,0,1,CPUY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to obtain physicians' certifications of inability to consent before the resident representatives authorized a Do Not Resuscitate (DNR) code status for Residents #126, 236, and 238, 3 of 32 residents reviewed for Advance Directives. The findings included: The facility admitted Resident #126 on 03/08/18 with [DIAGNOSES REDACTED]. On 05/01/18 at 09:57 AM, review of the unit Resident Census Book and the Electronic Health Record revealed an Authorization of Do Not Resuscitate signed by the Power of Attorney. No physician documentation was found that certified the resident lacked decisional capacity to consent in the Resident Census Book or in the Electronic Health Record. The facility admitted Resident #236 with [DIAGNOSES REDACTED]. On 04/30/18 at 04:33 PM, record review revealed an Ability to Consent form stating the resident did not have the capacity to make decisions and signed 04/18/18. There was no second physician exam or statement regarding the resident's inability to consent. Further review of the record revealed a DNR (Do Not Resuscitate) order dated 04/13/18 and noted as signed by the physician 04/16/18. Review of the Resident Census Book which contained the residents' DNR consents revealed no second physician certification of the resident inability to consent. The facility admitted Resident #238 on 04/13/18 with [DIAGNOSES REDACTED]. On 05/01/18 at 12:15 PM review of the Electronic Health record revealed an Ability to Consent form signed by 1 physician that certified the resident did not have decisional capacity. There was no second certification of the resident's inability to consent and no second physician signature. Review of the unit Resident Census Book revealed an Authorization for Do Not Resuscitate but no inability to consent form from a second physician. During an interview on 05/01/18 at 4:54 PM, The Director of Nursing (DON) confirmed there was only one physician's certification for inability to consent for Residents 236 and 238 and no certification for Resident #126 in the Electronic Health Record or the Resident Census Book but stated it may be in another doctors book. At approximately 5:30 PM, the DON provided copies of the the hospital discharge summary that stated the resident was a DNR in the hospital. At that time, the DON stated the admission coordinator thought that the fact that the resident had a DNR order in the hospital sufficed as the second physician certification but confirmed that there was no documentation of the resident's ability to make informed decisions.",2020-09-01
905,THE HERITAGE AT LOWMAN REHAB AND HEALTHCARE,425100,201 FORTRESS DRIVE,WHITE ROCK,SC,29177,2018-05-03,600,D,0,1,CPUY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure residents were free from abuse for 1 of 1 resident reviewed. The facility failed to ensure that Resident #131 was free from verbal abuse. The findings included: The facility admitted Resident #131 on 4/1/16 with [DIAGNOSES REDACTED]. Review of the medical record revealed Resident #131 was cognitively alert and oriented. Review of the 4/17/18 Nurses Notes written by Licensed Practical Nurse (LPN) #1 revealed, Resident has refused a shower this pm from CNA (Certified Nurses Aide) so this writer approached resident to inquire why (he/she) didn't want (his/her) shower. I asked was it the time and would (he/she) prefer taking it after the meal this pm and (he/she) replied no. Then I asked (him/her) what. Did (he/she) just didn't want to take a shower today and (he/she) said, 'My goodness, My goodness I don't want a shower and it didn't matter before so why you making it a problem now.' 'MY goodness, My goodness,' and (he/she) was very angry and slapped this writer on my shoulder. Writer exited (his/her) room .Later in the shift (he/she) wanted to go outside .and I explained to the resident that I am not allowed to slap or hit no resident or staff member and that if (he/she) ever slapped me again that I would not take (him/her) outside anymore and asked (him/her) if (he/she) understood. (He/she) stated, My 111 .I explained to (him/her) that it was not an appropriate response when we become angry to lash out at someone out of frustration. The surveyor asked the Director of Nursing (DON) to read the notation during an interview on 5/2/18 at approximately 3:00 PM. The DON stated that he/she was unaware of the notation. Upon reading the documentation, the DON stated that he/she needed to investigate the incident. On 5/2/18 at approximately 4:00 PM, the DON provided a copy of a Corrective Action Form dated 5/2/18 which indicated that the facility terminated LPN #1. The section entitled Description of Infraction indicated, Nurse documented that (he/she) told a resident 'If (he/she) ever slapped me again that I would not take (him/her) outside anymore and asked (him/her) if (he/she) understood.' During interview with this nurse, (he/she) verbalized that this incident did occur as written in (his/her) nurses statement. (See Nurses Note). The section entitled Required Improvement Needed indicated, Abuse policy was reviewed with this employee in (MONTH) (YEAR). This is verbal abuse. Staff in (sic) prohibited from making threats of any kind. Employee will be terminated for verbal abuse. The DON provided documentation to indicate that the incident was reported to the State Agency in a timely manner. The Summary Report of Facility Investigation indicated, After investigating nurse (LPN #1) was terminated. (His/her) clinical note indicated mental/verbal abuse.",2020-09-01
906,THE HERITAGE AT LOWMAN REHAB AND HEALTHCARE,425100,201 FORTRESS DRIVE,WHITE ROCK,SC,29177,2018-05-03,607,D,0,1,CPUY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and review of the facility's policy entitled Abuse Policy and Procedure, the facility failed to implement its written policies and procedures to prevent abuse for 1 of 1 resident reviewed. Facility staff failed to follow abuse policies related to abuse for Resident #131. The findings included: The facility admitted Resident #131 on 4/1/16 with [DIAGNOSES REDACTED]. Review of the medical record revealed Resident #131 was cognitively alert and oriented. Review of the 4/17/18 Nurses Notes written by Licensed Practical Nurse (LPN) #1 revealed, Resident has refused a shower this pm from CNA (Certified Nurses Aide) so this writer approached resident to inquire why (he/she) didn't want (his/her) shower. I asked was it the time and would (he/she) prefer taking it after the meal this pm and (he/she) replied no. Then I asked (him/her) what. Did (he/she) just didn't want to take a shower today and (he/she) said, 'My goodness, My goodness I don't want a shower and it didn't matter before so why you making it a problem now.' 'MY goodness, My goodness,' and (he/she) was very angry and slapped this writer on my shoulder. Writer exited (his/her) room .Later in the shift (he/she) wanted to go outside .and I explained to the resident that I am not allowed to slap or hit no resident or staff member and that if (he/she) ever slapped me again that I would not take (him/her) outside anymore and asked (him/her) if (he/she) understood. (He/she) stated, My 111 .I explained to (him/her) that it was not an appropriate response when we become angry to lash out at someone out of frustration. The surveyor asked the Director of Nursing (DON) to read the notation during an interview on 5/2/18 at approximately 3:00 PM. The DON stated that he/she was unaware of the notation. Upon reading the documentation, the DON stated that he/she needed to investigate the incident. On 5/2/18 at approximately 4:00 PM, the DON provided a copy of a Corrective Action Form dated 5/2/18 which indicated that the facility terminated LPN #1. The section entitled Description of Infraction indicated, Nurse documented that (he/she) told a resident 'If (he/she) ever slapped me again that I would not take (him/her) outside anymore and asked (him/her) if (he/she) understood.' During interview with this nurse, (he/she) verbalized that this incident did occur as written in (his/her) nurses statement. (See Nurses Note). The section entitled Required Improvement Needed indicated, Abuse policy was reviewed with this employee in (MONTH) (YEAR). This is verbal abuse. Staff in (sic) prohibited from making threats of any kind. Employee will be terminated for verbal abuse. Review of the facility's policy entitled Abuse Policy and Procedure revealed the policy stated, This facility does not tolerate any form of mistreatment, neglect, abuse or misappropriation of resident property. Each resident has the right to be free from verbal, sexual, physical and/or mental abuse, corporal punishment and involuntary seclusion. The section entitled Definitions, indicated, Verbal abuse means use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents. Mental abuse includes, but is not limited to: threats of punishment, humiliation, harassment and involuntary seclusion.",2020-09-01
907,THE HERITAGE AT LOWMAN REHAB AND HEALTHCARE,425100,201 FORTRESS DRIVE,WHITE ROCK,SC,29177,2018-05-03,623,D,0,1,CPUY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to provide a written notice of transfer to the resident/resident's representative at the time of a facility initiated transfer to the hospital for resident#8, #24 and resident #134. 3 of 3 residents reviewed for transfers. The findings included: The facility admitted resident # 8 on 01/12/2016 with [DIAGNOSES REDACTED]. Review of the medical record revealed in the Nurses Notes that Resident #8 was transferred to the hospital on [DATE] and 03/02/2018. Basis for the transfers were documented but there was no documentation/ evidence that the required written notification of the transfer had been given to the resident/ residents representative. During an interview on 05/02/18 at approximately 01:12 PM the Director of Nursing (DON) revealed/confirmed that written notification of transfer to the hospital had not provided to the Resident's Representative (RR) since the RR is the one who gave permission for the resident to go to the hospital. Bed hold policy is always sent to the hospital with the resident and the Ombudsman was notified. The facility admitted Resident# 24 on 04/09/2016 with [DIAGNOSES REDACTED]. Review of the medical record revealed in the Nurses Notes that Resident #24 was transferred to the hospital on [DATE]. Basis for the transfer was documented but there was no documentation/ evidence that the required written notification of the transfer had been given to the resident/ residents representative. During an interview on 05/02/18 at approximately 01:12 PM the Director of Nursing (DON) revealed/confirmed that written notification of transfer to the hospital had not been provided to the resident/Resident's Representative (RR). Bed hold policy is always sent to the hospital with the resident and the Ombudsman was notified. The facility admitted Resident #134 on 02/22/18 with [DIAGNOSES REDACTED]. At 5:04 PM at 05/02/2018, review of the Nursing Progress Notes revealed a note dated 03/01/18 that stated Noted with change at 12:26 PM - did not eat breakfast, not talking, leaning to right during shower, refused meds and fluids. RP notified, stated s/he noticed decreased talking and eating the day before. MD notified and N.O. received to send to hospital. Further review revealed a note dated 04/02/18 that stated (Spouse) called by MD (Medical Doctor) talking to (spouse) about (resident's) labs, and (spouse) was more concerned about blood in stool and wanted her/him sent to (hospital). Resident noted to have slurred speech and continues to have slow reactions. Received urine culture, stool culture was sent today and also sent with resident to hospital. Nurse called 911 and nurses called report to (hospital) RN (Registered Nurse). No pain or distress noted. There was no documentation that written notice was provided to the resident or resident representative regarding the reason for transfer. During an interview on 05/03/18 the Director of Nursing confirmed the facility did not provide written notice for a transfer to the hospital to residents or resident representatives.",2020-09-01
908,THE HERITAGE AT LOWMAN REHAB AND HEALTHCARE,425100,201 FORTRESS DRIVE,WHITE ROCK,SC,29177,2018-05-03,637,D,0,1,CPUY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to conduct a Significant Change in Status MDS (Minimal Data Set) Assessment (SCSA) for Resident #51, 1 of 1 resident reviewed with a significant change in condition. The findings included: The facility admitted Resident #51 on 11/17/17 with [DIAGNOSES REDACTED]. On 05/01/18, comparison of the Quarterly MDS dated [DATE] to the Admission MDS revealed a decline in ambulation in room from 2 (limited assistance) to 8 (activity did not occur), decline in eating from 1 (supervision) to 3 (extensive assistance), and decline in bladder and bowel incontinence (bladder from 1 (usually continent) to 3 (always incontinent). During an interview 05/03/18 05:47 PM, MDS Nurse #1, confirmed the decline documented on the (MONTH) assessment. The MDS Nurse stated that a SCSA assessment was in process related to Resident #51 electing to receive Hospice services but also confirmed a SCSA should have been done in February. The Director of Nursing (DON) stated that the resident was started on speech therapy to address her/his eating and that it was her/his understanding that if an intervention was put into place that a SCSA did not need to be conducted.",2020-09-01
909,THE HERITAGE AT LOWMAN REHAB AND HEALTHCARE,425100,201 FORTRESS DRIVE,WHITE ROCK,SC,29177,2019-06-28,607,F,1,1,R52411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview, and review of the facility's policy on abuse and neglect, the facility failed to implement its policies related to conducting a thorough investigation and/or following required reporting time frames for allegations of abuse for 7 of 13 residents reviewed (Residents #9, #46, #140, #297, #302, #88, and #63). The findings included: The facility admitted Resident #88 on 7/30/18 with [DIAGNOSES REDACTED]. Record review revealed the facility submitted an initial 2/24 hour report of an allegation of physical abuse to the State Agency on 6/19/19 concerning Resident #88. The report indicated, Resident states (he/she) was 'abused' by 2 staff members when turned roughly in bed. Resident states they grabbed (his/her) arm and (his/her) head was on the side of the bed facing down toward the floor. Resident is unable to give a specific time of the incident. The 5 day follow-up report for Resident #88 indicated there were no witnesses. Review of the facility's Investigative File revealed written statements were obtained from four staff members. Review of the written statement from Licensed Practical Nurse (LPN) #1 indicated Resident #88 reported on 6/19/19 that the alleged incident occurred early in the am when it was still dark outside. Review of the staffing schedule for 6/18/19 revealed one nurse and two Certified Nurse Aides (CNA) were working on Resident #88's unit on the 11 PM - 7 AM shift. Further review of the facility's Investigative File revealed the facility did not obtain statements from the CNAs working on the unit on that date and during that time period. Review of the facility's policy entitled Abuse Policy and Procedures revealed the Investigation Process under Abuse Investigations indicated 3. The individual conducting the investigation will, as a minimum: .g. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident . The facility admitted Resident #140 with [DIAGNOSES REDACTED]. The facility self-reported an unwitnessed allegation of bruise of unknown origin to the State Agency on 5/13/19 at 11:30 AM. During an interview with the Director of Nursing (DON) on 6/25/19 at 1:30 PM the incident actually occurred on 5/11/19 at 12:34 PM. No 5 day report of the incident was filed with the State Agency. While reviewing the fax sheets from the facility the DON was made aware that a report was sent to the State Agency; however, the fax showed the fax line was busy and report not received by the Agency. The facility did not resend the notification. The DON stated the facility did not check the fax carefully and did not realize the fax did not go through. The facility failed to resend the report. The facility failed to follow their policy and procedures related to investigating and reporting incidents. Section IV of facility Abuse Policy and Procedure documents The initial report must be phoned or faxed in within two hours. Section VIII of policy documents that A written report must be submitted to the Administrator, DHEC (Department of Health and Environmental Control) and Ombudsman's Office within five working days of the incident. The facility admitted Resident #297 with [DIAGNOSES REDACTED]. The facility reported an allegation of verbal abuse as a 24 hour report on 1/28/19 and 5 day sent 1/29/19. Per the facility Abuse Policy and Procedure, Alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of property are reported accordingly: 'The initial report must be phoned or faxed in within two hours'. The DON confirmed in an interview 6/25/19 at 1:30 PM that a 2 hour report was not sent to the State Agency per facility policy and regulation. Only a 24 hour report was sent. The facility admitted Resident #9 with [DIAGNOSES REDACTED]. Record review on 6/27/19 at 8:32 AM of the Quarterly Minimum Data Set (MDS) revealed Resident #9 had a brief interview of mental status (BIMS) of 3. Further review of the MDS revealed Resident #9 had fluctuating disorganized thinking and no other behaviors. Review of Resident #9's nurse's notes revealed on 10/6/18 a late entry was documented at 1:27 PM which stated Bruise to Rt (right) wrist observed by CNA and reported to nurse. Resident denies any pain and ROM (Range of Motion) WNL (Within Normal Limits). Nursing Supervisor made aware. Review of the Occurrence Report dated 10/6/18 at 10:30 AM revealed the following: Called to room by CNA to assess a bruise to resident's right wrist. Nursing Supervisor made aware. Resident denies any pain to the area. Active ROM WNL for resident. Further review of the Occurrence Report revealed Resident #9 was unable to state what happened and the incident was unwitnessed. Review of the investigative file revealed only two staff members had been interviewed related to the incident. The facility admitted Resident #46 with [DIAGNOSES REDACTED]. Record review on 6/27/19 at 10:34 AM of the Quarterly MDS dated [DATE] revealed Resident #46 was coded as having a BIMS of 4. In the areas of bed mobility and toileting Resident #46 was coded as needing extensive assistance with two plus person assist. In the area of transfer and locomotion on and off the unit, Resident #46 was coded as needing extensive assistance with one person assist. Walking in the room had not occurred during the past seven look back days and walking in the corridor had only occurred once or twice in the look back period. Review of the current physician orders for Resident #46 revealed s/he was receiving [MEDICATION NAME], Memantine, Donepezil, [MEDICATION NAME] Sprinkles, and [MEDICATION NAME]. Review of Resident #46's nurse's notes revealed on 3/17/19 Resident #46 was found lying on the bathroom floor. At the time the resident denied any pain. Having put the resident in a lift and transferred him/her to the wheelchair, s/he complained of pain in the right hip. An x-ray was obtained on 3/17/19. Report of the x-ray results were negative. On 3/21/19, due to increasing and persisting pain, Resident #46 was transferred to hospital where it was discovered s/he had a pelvic fracture. Review of the Occurrence Report dated 3/17/19 at 9:00 AM revealed the following: the CNA entered the resident's room to remove the breakfast tray and discovered the resident lying on the bathroom floor, barefoot, and covered in stool. The resident stated to the nurse that s/he was going to the bathroom when she fell . Review of the investigative file revealed only two staff members had been interviewed related to the incident. No further interviews were conducted after discovery of the fracture to rule out if any other incident had occurred. The facility admitted Resident #63 with [DIAGNOSES REDACTED]. Record review on 6/28/19 at 9:43 AM of the investigative report by the facility revealed on 10/23/18 Resident #63 had presented with skin break-down and necrosis. Further review revealed the alleged neglect had not been reported to the State Agency until 10/24/18. During an interview with the Nurse Consultant on 6/27/18, s/he confirmed a thorough investigation had not been completed for Residents #9 and #46. Review of the facility policy titled Abuse Policy and Procedure revealed the following under VII. Investigations: Investigations of injuries of unknown origin 1. Interview will be conducted with resident who has an injury from an unknown source(as appropriate) 2. Signed statements are gathered from all staff who cared for the resident on each shift in the previous 72 hours prior to the observance of the injury 3. Reliable residents near the injured resident will be interviewed as appropriate 4. Nurse Manager will review the chart as well as observation of resident behavior to ascertain possible cause Review of the facility policy titled Abuse Policy and Procedure revealed the following under section VI. Reporting: Alleged violations involving mistreatment, neglect or abuse, including injuries of unknown source and misappropriation of property are reported accordingly: .The Administrator of(sic) designee immediately begins investigating the allegation(s). DHEC and the Ombudsman's Office are also notified as required. The initial report must be phoned or faxed in within two hours . The facility admitted Resident #302 with [DIAGNOSES REDACTED]. Record review on 06/26/19 at approximately 2:10 PM revealed the investigation by the facility staff failed to implement abuse and neglect Policy and Procedures related to reporting of suspected abuse. LPN #1 provided by email a statement on 01/24/19 reporting to have witnessed a verbal altercation between Resident #302 and a CN[NAME] The statement did not include a date for the alleged incident. During the 5 day investigation, the Social Worker estimated the date as 01/15/19, or 9 days prior to the date it was reported. In an interview on 06/28/19 at approximately 4:08 PM, the Administrator confirmed the abuse was not reported timely.",2020-09-01
910,THE HERITAGE AT LOWMAN REHAB AND HEALTHCARE,425100,201 FORTRESS DRIVE,WHITE ROCK,SC,29177,2019-06-28,609,F,1,1,R52411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview, and review of the facility's policy on abuse and neglect, the facility failed to report allegations of abuse in a timely manner as required for 5 of 13 residents reviewed (Residents #140, #297, #302, #11, #63). The findings included: The facility admitted Resident #140 with [DIAGNOSES REDACTED]. The facility self-reported an unwitnessed allegation of bruise of unknown origin to the State Agency on 5/13/19 at 11:30 AM. During an interview with the Director of Nursing (DON) on 6/25/19 at 1:30 PM the incident actually occurred on 5/11/19 at 12:34 PM. The agency showed that no 5 day report of the incident was filed with the State Agency. While reviewing the fax sheets from the facility the DON was made aware that a report was sent to the State Agency; however, the fax showed the fax line was busy and report not received by the State Agency. The facility did not resend the notification. The DON stated the facility did not check the fax carefully and did not realize the fax did not go through. The facility failed to resend the report. The facility failed to follow their policy and procedures related to investigating and reporting incidents. Section IV of facility Abuse Policy and Procedure states, The initial report must be phoned or faxed in within two hours. Section VIII of policy states that A written report must be submitted to the Administrator, DHEC (Department of Health and Environmental Control) and Ombudsman's Office within five working days of the incident. The facility admitted Resident #297 with [DIAGNOSES REDACTED]. The facility reported an allegation of verbal abuse as a 24 hour report on 1/28/19 and 5-Day sent 1/29/19. Per the facility Abuse Policy and Procedure, Alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of property are reported accordingly: 'The initial report must be phoned or faxed in within two hours'. The DON confirmed in an interview 6/25/19 at 1:30 PM that a 2 hour report was not sent to the agency per facility policy and regulation. Only a 24 hour report was sent. The facility admitted Resident #63 with [DIAGNOSES REDACTED]. Record review on 6/28/19 at 9:43 AM of the investigative report by the facility revealed on 10/23/18 Resident #63 had presented with skin break-down, and necrosis. Further review revealed the alleged neglect had not been reported to the State Agency until 10/24/18. Review of the facility policy titled, Abuse Policy and Procedure, revealed the following under section VI. Reporting: Alleged violations involving mistreatment, neglect or abuse, including injuries of unknown source and misappropriation of property are reported accordingly: .The Administrator of(sic) designee immediately begins investigating the allegation(s). DHEC and the Ombudsman's Office are also notified as required. The initial report must be phoned or faxed in within two hours . The facility admitted Resident #302 with [DIAGNOSES REDACTED]. Record review on 06/26/19 at approximately 2:10 PM revealed the investigation by the facility staff failed to report allegations of abuse or neglect in a timely manner. Licensed Practical Nurse #1 provided by email a statement on 01/24/19 reporting to have witnessed a verbal altercation between Resident #302 and a Certified Nursing Assistant (CNA). The statement did not include a date for the alleged incident. During the 5 day investigation, the Social Worker estimated the date as 01/15/19, or 9 days prior to the date it was reported. Time clock records for the alleged CNA established s/he did not work on that date. In an interview on 06/28/19 at approximately 4:08 PM, the Administrator confirmed the abuse was not reported timely. The facility admitted Resident #11 with [DIAGNOSES REDACTED]. Record review on 06/25/19 at approximately 2:00 PM revealed a Nurses Note dated 03/01/19 which stated family members of Resident #11 reported several bruises on his/her right forearm which looked like someone had grabbed the arm. The note stated the information was reported to the Director of Nursing. In an interview on 06/25/19 at approximately 10:00 AM, the Social Worker confirmed that the 2 hour report was sent to the State Agency on 03/02/19 at 4:02 PM, but the allegation of possible abuse or neglect had been reported to staff on 03/01/19 at 7:00 PM.",2020-09-01
911,THE HERITAGE AT LOWMAN REHAB AND HEALTHCARE,425100,201 FORTRESS DRIVE,WHITE ROCK,SC,29177,2019-06-28,610,F,1,1,R52411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview, and review of the facility's policy on abuse and neglect, the facility failed to conduct a thorough investigation of allegations of Abuse for 7 of 13 residents reviewed (Residents #9, #46, #140, #297, #302, #88, and #63). The findings included: The facility admitted Resident #88 on 7/30/18 with [DIAGNOSES REDACTED]. Record review revealed the facility submitted an initial 2/24 hour report of an allegation of physical abuse to the State Agency on 6/19/19 concerning Resident #88. The report indicated, Resident states (he/she) was 'abused' by 2 staff members when turned roughly in bed. Resident states they grabbed (his/her) arm and (his/her) head was on the side of the bed facing down toward the floor. Resident is unable to give a specific time of the incident. The 5 day follow-up report for Resident #88 indicated there were no witnesses. Review of the facility's Investigative File revealed hand-written, facility-obtained statements from four staff members. Review of the written statement from Licensed Practical Nurse (LPN) #1 indicated Resident #88 reported on 6/19/19 that the alleged incident occurred early in the am when it was still dark outside. Review of the staffing schedule for 6/18/19 revealed one nurse and two Certified Nurse Aides (CNAs) were working on Resident #88's unit on the 11 PM - 7 AM shift on that date. Further review of the facility's Investigative File revealed the facility did not obtain statements from the two CNAs working on the unit on that date and during that time period. In addition, the facility-obtained staff statements did not indicate that they were asked if they had any knowledge of the allegation of abuse expressed by Resident #88. The staff statements all referred to the resident's call light and did not address the allegation of abuse or address if they had any problems while providing care to Resident #88. Review of the facility's policy entitled Abuse Policy and Procedures revealed the Investigation Process under Abuse Investigations indicated 3. The individual conducting the investigation will, as a minimum: .g. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident . The facility admitted Resident #140 with [DIAGNOSES REDACTED]. The facility self reported an unwitnessed allegation of bruise of unknown origin to the State Agency on 5/13/19 at 11:30 AM. During an interview with the Director of Nursing (DON) on 6/25/19 at 1:30 PM the incident actually occurred on 5/11/19 at 12:34 PM. No 5 day report of the incident was filed with the State Agency. Review of the facility's investigation folder and discussion with the DON on 6/25/19 at 1:30 PM revealed the facility only interviewed two nurses on the unit and two CNAs. Other nurses, CNAs, and alert residents on the unit were not interviewed . The DON stated he/she may have interviewed other people, but he/she did not get any written statements or document any other interviews. Per the facility Abuse Policy and Procedure Section VII Investigations, interviews must be signed, dated, and double witnessed, Resident's able to report, write out statements in presences of a witness. Signed statements are gathered from all staff who cared for the resident on each shift in the previous 72 hours prior to the injury. Reliable residents near the injured resident will be interviewed as appropriate. The facility policy was not followed by the staff or DON. The facility admitted Resident #297 with [DIAGNOSES REDACTED]. The facility reported an allegation of verbal abuse as a 24 hour report on 1/28/19 and 5 day sent 1/29/19. During review of the facility investigation folder of the incident, the DON on 6/25/19 at 1:30 PM stated he/she only got one statement from the alleged perpetrator. No other statements were taken from staff on the unit nor any residents who may have witnessed the incident. The DON stated the nurse who made the allegation was asked on three different occasions to write a statement regarding his/her allegation, and the nurse refused to write any statement. The CNA stated he/she never made a statement against the resident. Per facility Policy and Procedure related to investigations, staff nor resident statements were gathered from all staff on each shift 72 hours prior to incident. Reliable residents in the area will be interviewed as appropriate. No residents were interviewed. The facility admitted Resident #9 with [DIAGNOSES REDACTED]. Record review on 6/27/19 at 8:32 AM of the Quarterly Minimum Data Set (MDS) revealed Resident #9 had a brief interview of mental status (BIMS) of 3. Further review of the MDS revealed Resident #9 had fluctuating disorganized thinking and no other behaviors. Review of Resident #9's nurse's notes revealed on 10/6/18 a late entry was documented at 1:27 PM which stated Bruise to Rt (right) wrist observed by CNA and reported to nurse. Resident denies any pain and ROM (Range of Motion) WNL (Within Normal Limits). Nursing Supervisor made aware. Review of the Occurrence Report dated 10/6/18 at 10:30 AM revealed the following: Called to room by CNA to assess a bruise to resident's right wrist. Nursing Supervisor made aware. Resident denies any pain to the area. Active ROM WNL for resident. Further review of the Occurrence Report revealed Resident #9 was unable to state what happened and the incident was unwitnessed. Review of the investigative file revealed only two staff members had been interviewed related to the incident. The facility admitted Resident #46 with [DIAGNOSES REDACTED]. Record review on 6/27/19 at 10:34 AM of the Quarterly MDS dated [DATE] revealed Resident #46 was coded as having a BIMS of 4. In the areas of bed mobility and toileting Resident #46 was coded as needing extensive assistance with two plus person assist. In the area of transfer and locomotion on and off the unit, Resident #46 was coded as needing extensive assistance with one person assist. Walking in the room had not occurred during the past seven look back days and walking in the corridor had only occurred once or twice in the look back period. Review of the current physician orders for Resident #46 revealed s/he was receiving [MEDICATION NAME], Memantine, Donepezil, [MEDICATION NAME] Sprinkles, and [MEDICATION NAME]. Review of Resident #46's nurse's notes revealed on 3/17/19 Resident #46 was found lying on the bathroom floor. At the time the resident denied any pain. Having put the resident in a lift and transferred him/her to the wheelchair, s/he complained of pain in the right hip. An x-ray was obtained on 3/17/19. Report of the x-ray results were negative. On 3/21/19, due to increasing and persisting pain, Resident #46 was transferred to hospital where it was discovered s/he had a pelvic fracture. Review of the Occurrence Report dated 3/17/19 at 9:00 AM revealed the following: the CNA entered the resident's room to remove the breakfast tray and discovered the resident lying on the bathroom floor, barefoot, and covered in stool. The resident stated to the nurse that s/he was going to the bathroom when she fell . Review of the investigative file revealed only two staff members had been interviewed related to the incident. No further interviews were conducted after discovery of the fracture to rule out if any other incident had occurred. The facility admitted Resident #63 with [DIAGNOSES REDACTED]. Record review on 6/28/19 at 9:43 AM of the investigative report by the facility revealed on 10/23/18 Resident #63 had presented with skin break-down and necrosis. Further review revealed the alleged neglect had not been reported to the State Agency until 10/24/18. During an interview with the Nurse Consultant on 6/27/18, s/he confirmed a thorough investigation had not been completed for Residents #9 and #46. Review of the facility policy titled Abuse Policy and Procedure revealed the following under VII. Investigations: Investigations of injuries of unknown origin 1. Interview will be conducted with resident who has an injury from an unknown source(as appropriate) 2. Signed statements are gathered from all staff who cared for the resident on each shift in the previous 72 hours prior to the observance of the injury 3. Reliable residents near the injured resident will be interviewed as appropriate 4. Nurse Manager will review the chart as well as observation of resident behavior to ascertain possible cause Review of the facility policy titled Abuse Policy and Procedure revealed the following under section VI. Reporting: Alleged violations involving mistreatment, neglect or abuse, including injuries of unknown source and misappropriation of property are reported accordingly: .The Administrator of(sic) designee immediately begins investigating the allegation(s). DHEC and the Ombudsman's Office are also notified as required. The initial report must be phoned or faxed in within two hours . The facility admitted Resident #302 with [DIAGNOSES REDACTED]. Record review on 06/26/19 at approximately 2:10 PM revealed the facility staff failed to thoroughly investigate allegations Abuse or Neglect. LPN #1 provided by email a statement on 01/24/19 reporting to have witnessed a verbal altercation between Resident #302 and a CN[NAME] There was no follow up interview to obtain details pertinent to substantiating or unsubstantiating the allegations. The statement did not include a date for the alleged incident. During the 5 day investigation, the Social Worker estimated the date as 01/15/19, or 9 days prior to the date it was reported. Time clock records for the alleged CNA established s/he did not work on that date. No other interviews were conducted to identify any other perpetrators or witnesses. In an interview on 06/28/19 at approximately 4:08 PM, the Administrator confirmed there was insufficient information gathered during the investigation.",2020-09-01
912,THE HERITAGE AT LOWMAN REHAB AND HEALTHCARE,425100,201 FORTRESS DRIVE,WHITE ROCK,SC,29177,2019-06-28,657,D,1,1,R52411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, and interview, the facility failed to ensure timeliness of resident's person-centered care plan including the review/revision and update of it by an interdisciplinary team (IDT) and the resident or resident's representative for 2 of 2 residents reviewed for care plans. The findings included: The facility admitted Resident #85 on 5/2/19 with [DIAGNOSES REDACTED]. In an interview with Resident #85 on 6/25/19 at 10:17 AM, the resident stated that no one in the facility had met with him/her regarding their care plan and that s/he had not been invited to their care plan meeting. Resident #85's care plan was reviewed on 6/25/19 at 11:15 AM and revealed no supporting documents to indicate that the facility had met with the the resident or resident's representative to review the resident's care plan. The facility admitted Resident #33 on 3/18/1995 with [DIAGNOSES REDACTED]. On 6/25/19 at 12:15 PM, Resident #33 was observed sitting in his/her wheelchair being assisted with lunch by a speech therapy intern. A left hand contraction without splint in placed was observed. On 6/26/19 at 4:02 PM, Resident #33 was seen in his/her room with no left hand splint in place. The Occupational Therapy (OT) progress and discharge summary dated 1/9/19 and reviewed on 6/26/19 at approximately 4:15 PM recommended a splint to the left hand during waking on 1/9/19. Review of Resident #33's care plan on 6/27/19 at approximately 9:30 AM revealed that the resident had a history of [REDACTED]. In an interview with the Minimum Data Set/Care Plan coordinator on 6/27/19 at 2:56 PM, s/he confirmed that the facility had not met with the resident or resident's representative to review Resident #85's care plan. S/he also confirmed that Resident #33's care plan had not been updated to reflect the recommendation of the use of a splint during waking.",2020-09-01
913,THE HERITAGE AT LOWMAN REHAB AND HEALTHCARE,425100,201 FORTRESS DRIVE,WHITE ROCK,SC,29177,2019-06-28,688,D,1,1,R52411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, and interview, the facility failed to ensure that a resident with contraction and impaired mobility was given the opportunity to wear a left-hand splint as recommended for 1 of 2 residents reviewed for mobility (Resident #33). The findings included: The facility admitted Resident #33 on 3/18/1995 with [DIAGNOSES REDACTED]. On 6/25/19 at 12:15 PM, Resident #33 was observed sitting in his/her wheelchair being assisted with lunch by a speech therapy intern. A left hand contraction without splint in place was observed. On 6/26/19 at 4:02 PM, Resident #33 was seen in his/her room with no left hand splint in place. The Occupational Therapy (OT) progress and discharge summary dated 1/9/19 and reviewed on 6/26/19 at approximately 4:15 PM recommended a splint to the left-hand during waking on 1/9/19. Review of Resident #33's care plan on 6/27/19 at approximately 9:30 AM revealed that the resident had a history of [REDACTED]. In an interview on 6/27/19 at 3:39 PM with Licensed Practical Nurse (LPN) #2, s/he stated that Resident #33 had a left hand splint. LPN #2 said s/he had seen the resident wearing it before but not that day.",2020-09-01
914,THE HERITAGE AT LOWMAN REHAB AND HEALTHCARE,425100,201 FORTRESS DRIVE,WHITE ROCK,SC,29177,2019-06-28,842,D,0,1,R52411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to assure that computerized medical records were accurate relative to allergy information for 1 of 5 residents reviewed for unnecessary medications (Resident #115). The findings included: Resident #115 was readmitted to the facility on [DATE] with allergies [REDACTED]. On 6/25/19 at approximately 8:37 AM a review of the computerized medical record revealed that Resident #115 was listed as allergic to [MEDICATION NAME] ([MEDICATION NAME]). Further review on 6/26/19 at approximately 11:32 AM revealed that Resident #115 was shown as being allergic to [MEDICATION NAME] upon admission and this allergy was shown on the physician's orders [REDACTED]. Further review on 6/26/19 revealed that the physician had documented the allergy to [MEDICATION NAME] as being due to ear ringing. These findings were acknowledged and verified by the Director of Nursing on 6/26/19 at approximately 12:03 PM.",2020-09-01
915,THE HERITAGE AT LOWMAN REHAB AND HEALTHCARE,425100,201 FORTRESS DRIVE,WHITE ROCK,SC,29177,2019-06-28,880,D,1,1,R52411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, observation, interview, and review of the facility policy Dressings, Dry/Clean, the facility failed to follow infection control procedures related to wound care for 1 of 2 reviewed (Resident #63). During wound care, staff was observed to reach into the pocket of their uniform and use scissors to remove gauze on both legs. In addition, staff was observed to clean different areas of the resident's foot/leg without changing gloves and place ordered ointment to areas on foot/leg using the same gloved hand. The findings included: The facility admitted Resident #63 with [DIAGNOSES REDACTED]. Record review on 6/28/19 at 9:43 AM of current physician orders for Resident #63 revealed an order for [REDACTED]. Observation of wound care on 6/27/19 at 9:40 AM revealed Licensed Practical Nurse (LPN) #2, after donning gloves, removed scissors out of his/her uniform pocket and cut gauze off of Resident #63's left and right leg. During the cleaning of the two areas on the resident's right foot/leg, LPN #2 did not remove his/her gloves after cleansing of the first wound. S/he continued to clean the second wound while continuing to wear the same soiled gloves. After removing his/her gloves, washing hands, and donning gloves, LPN #2 applied Santyl to both areas of the foot/leg using the same gloved hand. During an interview with LPN #2 on 6/28/19 at 11:00 AM, LPN #2 confirmed s/he had removed scissors from his/her uniform pocket and removed (cut) gauze from both legs and did not change gloves between the cleansing of the two wounds on the right foot/leg. Review of the facility policy titled, Dressings, Dry/Clean, revealed it did not address cleaning of scissors prior to use, cleaning scissors between use, changing gloves between cleaning of different wounds, and how to apply ointments to wounds.",2020-09-01
916,THE HERITAGE AT LOWMAN REHAB AND HEALTHCARE,425100,201 FORTRESS DRIVE,WHITE ROCK,SC,29177,2019-12-11,580,D,1,0,PRO011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview and review of facility policy, the facility failed to notify the Resident Representative (RR) of a significant change in condition for 1 of 4 sampled residents reviewed for Pressure Ulcers (Resident #5). Resident #5 developed Pressure Ulcers and the RR was not notified immediately. The findings included: The facility admitted Resident #5 with [DIAGNOSES REDACTED]. Record review of nurse's notes on 12/10/19 at 12:13 PM, revealed a note from 10/7/19 indicating the resident had skin breakdown to the buttocks and groin area. Per the note, the nurse notified the Wound Nurse and Nurse Practitioner (NP) of the new findings. A nurse's note from 10/10/19 indicated the resident had developed a new Stage III Pressure Ulcer to the right and left buttocks. In addition, the resident had developed a new shear wound to the scrotum. There were no notes indicating the RR had been notified of the new wounds. A nurse's note from 10/17/19 indicated the resident had developed new, unstageable deep tissue injuries to the left and right heels. There were no notes indicating the RR had been notified of the new wounds. During an interview with the Director of Nursing (DON) on 12/11/19 at 1:30 PM, the DON confirmed the RR was not notified immediately of the new wounds that developed on 12/7/19 and 12/17/19. The DON stated it is facility policy to immediately notify the NP and RR of a significant change in condition. The DON stated the nurse should have notified the RR and documented the notification. During an interview with Licensed Practical Nurse (LPN) #1 on 12/11/19 at 1:50 PM, LPN #1 was asked if a resident develops a Pressure Ulcer in the facility, who should be notified? LPN #1 stated the NP, Wound Nurse, and her/his supervisor should be notified. When asked if anyone else should be notified, LPN #1 stated the DON should also be notified if the supervisor is unavailable. During an interview with Licensed Practical Nurse (LPN) #2 on 12/11/19 at 1:56 PM, LPN #2 was asked if a resident develops a Pressure Ulcer in the facility, who should be notified? LPN #2 stated she/he would notify the DON, NP, and unit manager of the change in condition. When asked if anyone else should be notified, LPN #2 stated no, that is our chain of command. Review of the facility's Change in a Resident's Condition or Status policy revealed unless otherwise instructed by the resident, the nurse will notify the resident's representative when there is a significant change in the resident's physical, mental, or psychosocial status.",2020-09-01
917,POINSETT REHABILITATION AND HEALTHCARE CENTER,425102,8 NORTH TEXAS AVENUE,GREENVILLE,SC,29611,2018-02-01,568,D,0,1,80ZB11,"Based on interview and record review, the facility failed to share quarterly statements with 82 residents and/or responsible parties. The facility had no system in place to confirm that residents or appropriate family members received their quarterly statements. The findings included: Interview with Resident #7 on 1/29/18 at approximately 11:12 AM revealed that the resident did not get a quarterly statement of his/her personal funds account from the facility. Interview with the family of Resident #28 on 1/30/18 at approximately 9:51 AM revealed s/he did not get the quarterly statement of the resident's personal funds account from the facility. Interview with the Business Office Manager (BOM) on 1/30/18 at approximately 2:18 PM revealed the resident and the family member received quarterly statements, but there was no way for the facility to confirm the quarterly statements were received by either.",2020-09-01
918,POINSETT REHABILITATION AND HEALTHCARE CENTER,425102,8 NORTH TEXAS AVENUE,GREENVILLE,SC,29611,2018-02-01,577,B,0,1,80ZB11,Based on interview and observation the facility failed to post DHEC survey results accessible to all residents. The DHEC survey results were posted out of reach to wheel-chair bound residents. The findings included: Interview with Resident Council on 1/29/18 at approximately 3:20 PM revealed that the survey results were not accessible to those in the wheelchair. Observation on 1/29/18 at approximately 4:08 PM revealed the survey results were approximately 1 foot above the handrails and might not be accessible to all wheelchair bound residents.,2020-09-01
919,POINSETT REHABILITATION AND HEALTHCARE CENTER,425102,8 NORTH TEXAS AVENUE,GREENVILLE,SC,29611,2018-02-01,583,D,0,1,80ZB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interview, the facility failed to ensure that a resident received personal care in privacy when a medication was given. Resident #101 was given an insulin treatment at the nurse's station on the Unit 3. Random observation on 1 of 3 units and 1 of 5 residents reviewed for unnecessary medication. The findings included: The facility admitted Resident #101 with [DIAGNOSES REDACTED]. A random observation on 1/31/18 at approximately 3:30 PM revealed a nurse talking to Resident #101 who was seated in a wheelchair in front of the nursing station on Unit 3. The nurse informed the resident it time to take your insulin treatment. The nurse did not offer to take the resident to his/her room or did not ask the resident's consent to take the insulin treatment while seated at the nurse's station. There were nursing staff and other residents present when the insulin was given. After the nurse gave the resident the insulin while seated at the nursing station, Registered Nurse (RN) #1 was observed going over to the nurse, leaning to talk quietly into his/her ears. An interview on 1/31/18 at approximately 3:34 PM with RN #1 confirmed the observation of the nurse giving Resident #101 his/her insulin while he/she was seated in a wheelchair at the nurse's station. RN#1 stated he/she addressed the observation with the nurse on the unit after the incident.",2020-09-01
920,POINSETT REHABILITATION AND HEALTHCARE CENTER,425102,8 NORTH TEXAS AVENUE,GREENVILLE,SC,29611,2018-02-01,645,D,0,1,80ZB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure that a resident's Preadmission Screening and Resident Review (PASARR) form was completed prior to admission. Resident #115 was admitted to the facility prior to the PASARR being completed. One of three discharged resident's charts reviewed. The findings included. The facility admitted Resident #115 with [DIAGNOSES REDACTED]. A record review on 1/31/18 at approximately 12:20 PM revealed the resident was admitted on [DATE] and the Preadmission Screening and Resident Review (PASARR) form was not completed until 9/08/17. An interview on 1/31/18 at approximately 12:30 PM with Registered Nurse (RN) #1 confirmed the findings. RN #1 further stated he/she will inform the Director of Nursing (DON). An interview on 1/31/18 at approximately 3:30 PM with the DON revealed the facility was looking to determine if there was another PASARR because Resident #115 was at the facility previously for respite care. An interview on 2/01/18 at approximately 9:34 AM with the DON revealed the facility did not have documentation to indicate a PASARR was done prior to admission for Resident #115.",2020-09-01
921,POINSETT REHABILITATION AND HEALTHCARE CENTER,425102,8 NORTH TEXAS AVENUE,GREENVILLE,SC,29611,2018-02-01,679,D,0,1,80ZB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure that an ongoing program of activities were provided for 1 of 3 sampled residents reviewed. Resident #62 was observed in his/her room on Unit 1 with no structured activities in progress. The findings included: The facility admitted Resident #62 with [DIAGNOSES REDACTED]. Resident #62 was not observed being provided a structured program of activities on the days of the survey. The resident was observed in his/her room in bed. An observation on 1/30/18 at approximately 11:51 AM revealed resident in room in bed on specialty mattress. The resident was observed to be severely contractured. Random observations throughout the survey reviewed the resident was in his/her room in bed. A review of the medical chart 1/30/18 on the unit at approximately 12:01 PM revealed the last activity assessment completed on the resident 5/10/15. At approximately 3 PM the activity department was interviewed and the surveyor requested documentation of one to one being provided for the resident. On 1/31/18 the documentation of one to one was provided. The facility also provided an updated activity assessment dated [DATE]. The activity assessment form indicated staff determined the resident's activities of choice. The form also indicated in one section the resident prefers activity setting in his/her own room and activities in the day/activities rooms. Review of the care plan indicated provide one 1:1 activities as needed or requested, staff to transport to activities provide manicures. No 1:1 activities were observed on the days of the survey. A review of a Quarterly Minimum Data Set (MDS) data 10/01/17 and an Annual MDS dated [DATE] that indicated the resident was severely cognitively impaired and rarely/never made decision. A review of 1:1 activity sheets from 11/06/17 to 1/30/18 revealed resident participated in one out of room activity on 1/06/18. The activity sheets did not indicate the time of day or duration of the activity. The activity sheets also indicated that hospice services were provided for the months of 11/06/17 to 1/30/18. An interview on 2/01/18 at approximately 10:15 AM with the Activity Director revealed the standard time of thirty minutes was the length of time the activity assistants were supposed to interact with residents on 1:1 activities. The Activity Director further stated the standard time of thirty minutes was by word of month and that he/she does not monitor to ensure the 1:1 activity of 30 minutes takes place. The AD confirmed the hospice information on the 1:1 activity sheet was incorrect and that resident was not receiving hospice services.",2020-09-01
922,POINSETT REHABILITATION AND HEALTHCARE CENTER,425102,8 NORTH TEXAS AVENUE,GREENVILLE,SC,29611,2018-02-01,684,D,0,1,80ZB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure that a resident with a physician's order for gerri sleeves to be worn to prevent injuries for 1 of 5 sampled resident reviewed for unnecessary medications. Resident #61 had physician's orders for gerri sleeves to be worn to prevent injuries. The findings included: The facility admitted Resident #61 with [DIAGNOSES REDACTED]. An observation on 1/29/18 at approximately 9:16 AM revealed Resident #61 self ambulating in wheelchair with a sitter present. The resident was not wearing gerri sleeves. A review of the medical record on 1/30/18 at approximately 2:58 PM revealed a physician's order dated 1/24/18 that indicated gerri sleeves . to prevent injuries. An observation on 1/30/18 at approximately 3:11 PM revealed resident seated in wheelchair with sitter present and no gerri sleeves were observed to arms. An interview and observation on 1/31/18 at approximately 12:05 PM with the Director of Nursing (DON) confirmed the resident was not wearing gerri sleeves as ordered. The DON stated the resident was not in compliance with wearing the gerri sleeves although an order was written as recently as 1/24/18 for gerri sleeves to be worn to prevent injuries. At approximately 12:14 PM on 1/31/18 a care plan coordinator provided a care plan that indicated the resident was non compliance with wearing gerri sleeves (MONTH) (YEAR). An interview on 1/31/18 at approximately 3:37 PM with the facility Administrator confirmed the observation that Resident #61 did not have physician ordered gerri sleeves in place. 01/31/18 03:27 PM Res observed at NS without PO gerri sleeves in place. The Administrator stated the nurse practitioner was not aware of the resident's non compliance when the physician order was written.",2020-09-01
923,POINSETT REHABILITATION AND HEALTHCARE CENTER,425102,8 NORTH TEXAS AVENUE,GREENVILLE,SC,29611,2018-02-01,812,E,0,1,80ZB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interview the facility failed to ensure cleanliness of the kitchen and failed to ensure residents leaving the facility for [MEDICAL TREATMENT] had a lunch with them (the resident) that was kept at the right temperature to allow for quality and safety of the food. Resident #163 was observed transported out for his [MEDICAL TREATMENT] treatment without his/her lunch bag that was a clear plastic bag (no insulation) containing an egg salad sandwich and juice. Another lunch was also observed in a plastic, re-sealable zipper storage bag that consisted of a ham and cheese sandwich and juice. The findings included: An initial tour of main kitchen on 1/29/18 at approximately 8:55 AM with the Food Director/Dietary Manager revealed a white basin hand washing sink noted with dark stains and discolorations throughout. The trash can near the sink was filled to the top. The walk in freezer had magic cups noted on the floor under the shelves. The Food Director/Dietary Manager confirmed the findings and stated the magic cups will be thrown in the trash can. The facility admitted Resident #163 with a [DIAGNOSES REDACTED]. An observation on 1/29/18 at approximately 9:30 AM revealed Resident #163 being transported on a gurney to [MEDICAL TREATMENT] by medical transportation. One of the transportation staff asked Licensed Practical Nurse (LPN) #1 where was the resident's lunch. LPN #1 instructed the transportation staff that the kitchen would provide the lunch. An observation on 1/29/18 at approximately 9:43 AM revealed the medical transport staff taking Resident #163 to the ambulance without going to the kitchen. An interview on 1/29/18 at approximately 9:50 AM with LPN #1, the surveyor asked LPN #1 who was supposed to get the lunch for Resident #163. LPN #1 stated the medical transport staff was supposed to go by the kitchen. When LPN #1 was informed that the medical transport staff took the resident directly to the ambulance without lunch. LPN #1 went to the kitchen and dietary staff provided the nurse a clear plastic, re-sealable zipper storage bag with a sandwich, juice, crackers. The resident's lunch was not put in a insulated container. An interview on 1/29/18 at approximately 9:55 AM with the Food Director/Dietary Manager revealed the meal provided to the resident in the clear plastic, re-sealable zipper storage bag was probably an egg salad sandwich, crackers and juice. When asked about meals being provided in insulated containers, the manager confirmed the meal was given a clear plastic bag and asked the surveyor if the surveyor wanted the meal to be placed in an insulated container. An interview on 1/29/18 at approximately 11:17 AM with the facility Administrator who informed the surveyor that a lunch meal was not provided to Resident #163 during transport to [MEDICAL TREATMENT], but staff did take lunch to [MEDICAL TREATMENT] clinic for resident. An observation and interview on 1/31/18 at approximately 9:47 AM with LPN #1 revealed medical transportation staff being given meal in clear plastic bag from from unit kitchen that consisted of a ham and cheese sandwich, crackers and juice for Resident #163 [MEDICAL TREATMENT] appointment. The clear plastic, re-sealable zipper storage bag was placed on the medical gurney by transport staff. LPN confirmed the clear plastic, re-sealable zipper storage bag was the bag used to transport [MEDICAL TREATMENT] residents meals. An interview on 1/31/18 at approximately 11:12 AM with the facility consultant revealed the facility had no policy in place to address the [MEDICAL TREATMENT] residents meals be provided in insulated containers.",2020-09-01
924,POINSETT REHABILITATION AND HEALTHCARE CENTER,425102,8 NORTH TEXAS AVENUE,GREENVILLE,SC,29611,2018-02-01,842,D,0,1,80ZB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based record review and interviews, the facility failed to ensure that clinical records were accurate for 1 of 1 sampled resident reviewed for range of motion. Resident #62 had a therapy referral and screening form that indicated a communication from dietary and therapy to refer resident to hospice with no follow up that was dated 6/12/17. The findings included: The facility admitted Resident #62 with [DIAGNOSES REDACTED]. A review of the medical record on 1/30/18 at approximately 12:01 PM reveal a Therapy Referral and Screening Form dated 6/12/17 that indicated in a therapist observation section refer to hospice. There was a section on the form that indicated the resident had a recent weight loss. There was no documentation in the medical record to indicate the resident was referred to hospice. An interview on 1/31/18 at approximately 3:10 PM with the Speech Therapist (ST) confirmed the refer to hospice note on the referral form. The ST refer to hospice note was in error and that dietary informed therapy about the resident's weight loss and speech would not be able to address weight loss. The form was used as a communication sheet to dietary and not meant as a referral to hospice. Per the ST the form was not sent back to dietary. The Director of Nursing (DON) and the facility consultant was also present during the interview. The DON and facility consultant stated the therapist thought the resident was already on hospice when the note was written. The DON further stated the resident was not on hospice. Review of activity note dated during the months of (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR) that indicated the resident was receiving hospice services. An interview on 2/01/18 at approximately 9:34 AM with the DON and facility consultant confirmed the findings and stated the activity notes were in error and that Resident #62 was not receiving hospice services. The DON provided a note that indicated the resident had not received hospice services since (YEAR).",2020-09-01
925,POINSETT REHABILITATION AND HEALTHCARE CENTER,425102,8 NORTH TEXAS AVENUE,GREENVILLE,SC,29611,2018-02-01,880,E,0,1,80ZB11,"Based on observations and interviews the facility failed to clear the laundry room of dust and debris as well as a closet used to store clean linens. The findings included: Random observation on 2/01/18 at approximately 9:43 AM with the Laundry Manager and Laundry Account Manager revealed a large dark gray clump hanging from the light fixture over the dryer. There was large area of dust/spider web on the ceiling to the right side of the dryer and multiple clumps of spider webs on the window in the laundry room near the dryer and clean clothes side. The Laundry Manager and Laundry Account Manager confirmed the findings. Random observation of the clean linen closet on 2/01/18 at approximately 9:56 AM revealed a heavy build up of dust and debris on the floor under the linen shelves. The observation was confirmed by the Laundry Account Manager. The Laundry Account Manager confirmed the build up of dust, spider webs and debris had been there for awhile.",2020-09-01
926,POINSETT REHABILITATION AND HEALTHCARE CENTER,425102,8 NORTH TEXAS AVENUE,GREENVILLE,SC,29611,2019-02-14,600,G,0,1,KJ6U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to ensure residents remained free from abuse. Resident #73, who required 1:1 supervision due to aggressive/agitated behaviors, grabbed Resident #2 by the wrists causing a skin tear and bruises to both of his/her wrists. Resident #3 who was on 1:1 supervision due to wondering/elopement grabbed Resident #38's cane and struck Resident #38 on the head. Two of 6 residents reviewed for abuse. The findings included: Review of the facility 5-day investigation report dated 12/17/18 revealed that on 12/12/18 Resident #2 was having an aggressive outburst towards staff when Resident #73 stood up to intervene. Resident #73 made contact with Resident #2 arms. Care plan followed. Observed with skin tear to right write and Skin tear to left wrist. The facility admitted Resident #73 on 4/3/18 with [DIAGNOSES REDACTED]. During an observation on 2/11/19 at approximately 11:32 AM Resident #73 was observed in his/her wheelchair in his/her room accompanied by a sitter and wearing a wonder guard on his/her right foot. During an interview on 2/11/19 at approximately 11:32 AM Resident #73 was asked by the surveyor if s/he has had an issue with another resident s/he stated no. Resident #73 was asked by the surveyor if s/he has had any issue with Resident #2 s/he stated no. During an observation on 2/11/19 at approximately 10:55 AM Resident #2 was observed walking throughout the facility's hallways by him/herself. Resident #2 had a small skin tear (healing) on his/her left wrist and small bruises to his/her forearms. Review of Resident #73's nurse's notes on 2/12/19 at 2:29 PM revealed a nurse's note dated 10/1/18 (Resident #73) was belligerent in the hallway; screaming, yelling, and cursing up and down the hall. Aggressive to other residents and staff. Nurse's note dated 12/6/18, during the second shift, (Resident #73) has been aggressive towards others, when awake, called the sheriff department and had to be redirected from other female residents. Nurse's note dated 12/12/18 at 6:12 AM (Resident #73) continued on 1:1 supervision and was up in (his/her) wheelchair rolling around the unit. Nurse's note dated 12/12/18 at 2:07 PM (Resident #73) was noted yelling at another resident, jumped up out of his/her wheelchair shouting aloud. Review of Resident #73's Social Service notes revealed a Social Service note dated 12/12/18 at 1:07 PM (Resident #73) was seen by psychosocial support following concerns related to a resident to a resident altercation and that the resident was unable to recall the event and showed no signs of distress or injury. Review of Resident #73's care plan revealed that Resident #73 was care planned for 1:1 supervision r/t (related to) risk for adverse/unprovoked behavior towards other residents date initiated 6/7/18. During an interview with the LPN #1 (witness) on 2/12/19 at 2:54 PM LPN #1 that the incident happened on12/12/18 at around lunchtime (11:30 AM to 12:00 PM). LPN #1 stated that s/he was sitting at the first table facing the door and window in the dining room. S/he heard noises and saw the commotion as Resident #73 approached Resident #2, who was walking down the hall, cursing at him/her and making motions as if s/he was going to fight Resident #2. LPN #1 stated that Resident #73 tried to get up from his/her wheelchair but was not able to sustain his/her body and leaned to the side of the wall and held on to the handrail. The nursing assistant put Resident # 73 back to his/her wheelchair. LPN #1 stated that Resident #2 also made motions as if s/he was going to fight back Resident #73. LPN #1 stated that s/he believed that there was no physical contact between the residents and cannot remember if anyone (staff) grabbed Resident #2. During an interview with Certified Nursing Assistant (CNA) #1(not interviewed by the facility) on 2/13/19 at approximately 9:00 AM CNA #1 stated that s/he was in Resident #3's room (resident not involved) when s/he heard/saw Resident #2 eliminating (urinating) on the floor of Resident #3's room. CNA #1 stated that s/he told Resident #2 not to do that, then the resident fixed him/herself up and started walking down the hallway. CNA #1 stated that s/he looked down the hall to see if the resident was going to enter another resident's room, but saw was Resident #2 coming back charging at him/her. CNA #1 stated that s/he screamed for help and walked backward, trying to get out of Resident #2's way, and walked into the back door making a loud sound. At that time, Resident #2 turned around and started walking down the hall as if nothing has happened. CNA #1 stated that Resident #2 walked back and for the hallway a couple of times, and at one point, when Resident #73 was coming out of the dining room, they met. Resident #73 stood up from his/her wheelchair and grabbed Resident #2 by both wrists. Resident #2 pulled his/her arm back and continued walking his/her usual way. Resident #73 than, lost his/her balance but held on to the handrail, the staff assisted him/her back to his/her wheelchair. Resident #2 ended up with skin tear and bruises on his wrists. During an interview with CNA # 2 on 2/13/19 at 9:14 AM CNA #2 stated s/he did not see the whole incident, however, s/he saw Resident #73 trying to stand up and acting as if s/he was going to fight Resident #2. S/he said that Resident #73 was mad. S/he added that Resident #73 gets upset from time to time and can be physically and verbally aggressive. During an interview with CNA #3 on 2/13/19 at 9:26 AM CNA #3 stated that s/he saw Resident #73 propelling his/her wheelchair, with his/her feet, out of the dining room very fast. S/he did not expect Resident #73 to confront Resident #2 but as Resident #2 walked down the hallway and as Resident #73 was coming out to the dining room s/he stood up but could not tell if Resident #73 grabbed Resident #2, but saw Resident #2 pulled his/her arms back and Resident #73 lost his/her balance. During an interview with the Administrator and the Director of Nursing (DON) on 2/13/19 at 4:56 PM it was confirmed that CNA #1 who witness the resident to resident altercation was not interviewed. Review of the facility 5-day investigation report dated 11/2/18 revealed that on 10/28/18 Resident #38 was eating dinner in the dining hall when staff saw Resident #3 grab Resident #38's cane and make contact with Resident #38. The facility admitted Resident #3 on 4/3/18 with [DIAGNOSES REDACTED]. Review of Resident #3's care plan revealed that Resident #3 was care planned to be on 1:1 related to wandering/elopement, intervention dated 7/4/18. Review of Resident #38's Progress notes review on 2/12/19 at approximately 4:00 PM revealed that on 10/28/18 the certified nursing assistant report to a registered nurse that another resident (Resident #3) hit (Resident #38) in the top of (his/her) forehead and back of (his/her) head with resident's cane causing (him/her) a hematoma to the front of (his/her) forehead. During an interview on 2/14/19 at 2:49 PM CNA #5 stated that Resident #38 has always threatened Resident #3 with his/her cane but s/he never acted on and that Resident #3 has never before responded to Resident #38's threats. CNA #5 stated that s/he was the 1:1 sitter for Resident #3 on the date of the incident but since no one was bringing out Resident #3's meal tray CNA #5 asked CNA #6 to keep an eye on Resident #3 while s/he went to go get Resident #3's meal tray. CNA #5 sated that when s/he turned around s/he saw Resident #3 holding Resident #38's cane and when Resident #38 tried to get his/her cane back s/he saw Resident #3 strike Resident #38 on his/her forehead. During an interview with Registered Nurse #3 on 2/14/19 at 3:58 PM, RN #3 stated that s/he only knows what the nursing assistant told her/him. Resident #3 hit Resident #38 on the forehead with a cane. RN #3 stated that during his/her assessment of Resident #38 s/he saw some swelling on his/her forehead but no severe trauma.",2020-09-01
927,POINSETT REHABILITATION AND HEALTHCARE CENTER,425102,8 NORTH TEXAS AVENUE,GREENVILLE,SC,29611,2019-02-14,607,G,0,1,KJ6U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, including the facility's abuse policy, and interview the facility failed to implement the components of its abuse policy that prohibit and prevent abuse for two of 6 residents reviewed for abuse and for conducting a thorough investigation for one of 6 residents reviewed for abuse. Resident #73, who required 1:1 supervision due to aggressive/agitated behaviors, grabbed Resident #2 by the wrists causing a skin tear and bruises to both of his/her wrists. CNA #1 was not interviewed as a witness for the incident involving Resident #73 and Resident #2. Resident #3 who was on 1:1 supervision due to wondering/elopement grabbed Resident #38's cane and struck Resident #38 on the head. The findings included: Review of the facility 5-day investigation report dated 12/17/18 revealed that on 12/12/18 Resident #2 was having an aggressive outburst towards staff when Resident #73 stood up to intervene. Resident #73 made contact with Resident #2 arms. Care plan followed. Observed with skin tear to right write and Skin tear to left wrist. The facility admitted Resident #73 on 4/3/18 with [DIAGNOSES REDACTED]. Review of Resident #73's nurse's notes on 2/12/19 at 2:29 PM revealed a nurse's note dated 10/1/18 (Resident #73) was belligerent in the hallway; screaming, yelling, and cursing up and down the hall. Aggressive to other residents and staff. Nurse's note dated 12/6/18, during the second shift, (Resident #73) has been aggressive towards others, when awake, called the sheriff department and had to be redirected from other female residents. Nurse's note dated 12/12/18 at 6:12 AM (Resident #73) continued on 1:1 supervision and was up in (his/her) wheelchair rolling around the unit. Nurse's note dated 12/12/18 at 2:07 PM (Resident #73) was noted yelling at another resident, jumped up out of his/her wheelchair shouting aloud. Review of Resident #73's care plan revealed that Resident #73 was care planned for 1:1 supervision r/t (related to) risk for adverse/unprovoked behavior towards other residents date initiated 6/7/18. During an interview with the LPN #1 (witness) on 2/12/19 at 2:54 PM LPN #1 that the incident happened on12/12/18 at around lunchtime (11:30 AM to 12:00 PM). LPN #1 stated that s/he was sitting at the first table facing the door and window in the dining room. S/he heard noises and saw the commotion as Resident #73 approached Resident #2, who was walking down the hall, cursing at him/her and making motions as if s/he was going to fight Resident #2. LPN #1 stated that Resident #73 tried to get up from his/her wheelchair but was not able to sustain his/her body and leaned to the side of the wall and held on to the handrail. The nursing assistant put Resident # 73 back to his/her wheelchair. LPN #1 stated that Resident #2 also made motions as if s/he was going to fight back Resident #73. LPN #1 stated that s/he believed that there was no physical contact between the residents and cannot remember if anyone (staff) grabbed Resident #2. During an interview with Certified Nursing Assistant (CNA) #1(not interviewed by the facility) on 2/13/19 at approximately 9:00 AM CNA #1 stated that s/he was in Resident #3's room (resident not involved) when s/he heard/saw Resident #2 eliminating (urinating) on the floor of Resident #3's room. CNA #1 stated that s/he told Resident #2 not to do that, then the resident fixed him/herself up and started walking down the hallway. CNA #1 stated that s/he looked down the hall to see if the resident was going to enter another resident's room, but saw was Resident #2 coming back charging at him/her. CNA #1 stated that s/he screamed for help and walked backward, trying to get out of Resident #2's way, and walked into the back door making a loud sound. At that time, Resident #2 turned around and started walking down the hall as if nothing has happened. CNA #1 stated that Resident #2 walked back and for the hallway a couple of times, and at one point, when Resident #73 was coming out of the dining room, they met. Resident #73 stood up from his/her wheelchair and grabbed Resident #2 by both wrists. Resident #2 pulled his/her arm back and continued walking his/her usual way. Resident #73 than, lost his/her balance but held on to the handrail, the staff assisted him/her back to his/her wheelchair. Resident #2 ended up with skin tear and bruises on his wrists. During an interview with CNA # 2 on 2/13/19 at 9:14 AM CNA #2 stated s/he did not see the whole incident, however, s/he saw Resident #73 trying to stand up and acting as if s/he was going to fight Resident #2. S/he said that Resident #73 was mad. S/he added that Resident #73 gets upset from time to time and can be physically and verbally aggressive. During an interview with CNA #3 on 2/13/19 at 9:26 AM CNA #3 stated that s/he saw Resident #73 propelling his/her wheelchair, with his/her feet, out of the dining room very fast. S/he did not expect Resident #73 to confront Resident #2 but as Resident #2 walked down the hallway and as Resident #73 was coming out to the dining room s/he stood up but could not tell if Resident #73 grabbed Resident #2, but saw Resident #2 pulled his/her arms back and Resident #73 lost his/her balance. During an interview with the Administrator and the Director of Nursing (DON) on 2/13/19 at 4:56 PM it was confirmed that CNA #1 who witness the resident to resident altercation was not interviewed. Review of the facility policy titled Abuse Investigation and Reporting Revealed all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management . Under Role of the Investigator revealed Interview any witnesses to the incident Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident Review of the facility 5-day investigation report dated 11/2/18 revealed that on 10/28/18 Resident #38 was eating dinner in the dining hall when staff saw Resident #3 grab Resident #38's cane and make contact with Resident #38. The facility admitted Resident #3 on 4/3/18 with [DIAGNOSES REDACTED]. Review of Resident #3's care plan revealed that Resident #3 was care planned to be on 1:1 related to wandering/elopement, intervention dated 7/4/18. Review of Resident #38's Progress notes review on 2/12/19 at approximately 4:00 PM revealed that on 10/28/18 the certified nursing assistant report to a registered nurse that another resident (Resident #3) hit (Resident #38) in the top of (his/her) forehead and back of (his/her) head with resident's cane causing (him/her) a hematoma to the front of (his/her) forehead. During an interview on 2/14/19 at 2:49 PM CNA #5 stated that Resident #38 has always threatened Resident #3 with his/her cane but s/he never acted on and that Resident #3 has never before responded to Resident #38's threats. CNA #5 stated that s/he was the 1:1 sitter for Resident #3 on the date of the incident but since no one was bringing out Resident #3's meal tray CNA #5 asked CNA #6 to keep an eye on Resident #3 while s/he went to go get Resident #3's meal tray. CNA #5 sated that when s/he turned around s/he saw Resident #3 holding Resident #38's cane and when Resident #38 tried to get his/her cane back s/he saw Resident #3 strike Resident #38 on his/her forehead. During an interview with Registered Nurse #3 on 2/14/19 at 3:58 PM, RN #3 stated that s/he only knows what the nursing assistant told her/him. Resident #3 hit Resident #38 on the forehead with a cane. RN #3 stated that during his/her assessment of Resident #38 s/he saw some swelling on his/her forehead but no severe trauma. Review of the facility policy titled Abuse and Neglect - Clinical Protocol revealed under Treatment/Management The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect.",2020-09-01
928,POINSETT REHABILITATION AND HEALTHCARE CENTER,425102,8 NORTH TEXAS AVENUE,GREENVILLE,SC,29611,2019-02-14,610,G,0,1,KJ6U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to thoroughly investigate an allegation of resident to resident abuse for one of six resident review for abuse. Resident #73 who required supervision due to aggressive/agitated behaviors, grabbed Resident #2 by the wrists causing a skin tear and bruises to both of his/her wrists. The facility did not interview the certified nursing assistant that witnessed the altercation. The findings included: The facility admitted Resident #73 on 4/3/18 with [DIAGNOSES REDACTED]. Review of the facility 5-day investigation report dated 12/17/18 revealed that on 12/12/18 Resident #2 was having an aggressive outburst towards staff when Resident #73 stood up to intervene. Resident #73 made contact with Resident #2 arms. Care plan followed. Observed with skin tear to right write and Skin tear to left wrist. During an observation on 2/11/19 at 11:32 AM Resident #73 was observed in his/her wheelchair in his/her room accompanied by a sitter and wearing a wonder guard on his/her right foot. Review of the facility 5-day investigation revealed that the social worker and Licensed Practical Nurse (LPN) #1 witness the altercation. However, during an interview with the Social Worker (witness) on 2/12/19 at 2:34 PM s/he stated that s/he was at the nurse's station faxing some documents and did not see what had happened between the residents. The Social Worker stated that s/he heard the commotion and heard the staff (CNA) screaming. During an interview with the LPN #1 (witness) on 2/12/19 at 2:54 PM LPN #1 that the incident happened on12/12/18 at around lunchtime (11:30 AM to 12:00 PM). LPN #1 stated that s/he was sitting at the first table facing the door and window in the dining room. S/he heard noises and saw the commotion as Resident #73 approached Resident #2, who was walking down the hall, cursing at him/her and making motions as if s/he was going to fight Resident #2. LPN #1 stated that Resident #73 tried to get up from his/her wheelchair but was not able to sustain his/her body and leaned to the side of the wall and held on to the handrail. The nursing assistant put Resident # 73 back to his/her wheelchair. LPN #1 stated that Resident #2 also made motions as if s/he was going to fight back Resident #73. LPN #1 stated that s/he believed that there was no physical contact between the residents and cannot remember if anyone (staff) grabbed Resident #2. During an interview with Certified Nursing Assistant (CNA) #1(not interviewed by the facility) on 2/13/19 at approximately 9:00 AM CNA #1 stated that s/he was in Resident #3's room (resident not involved) when s/he heard/saw Resident #2 eliminating (urinating) on the floor of Resident #3's room. CNA #1 stated that s/he told Resident #2 not to do that, then the resident fixed him/herself up and started walking down the hallway. CNA #1 stated that s/he looked down the hall to see if the resident was going to enter another resident's room, but saw was Resident #2 coming back charging at him/her. CNA #1 stated that s/he screamed for help and walked backward, trying to get out of Resident #2's way, and walked into the back door making a loud sound. At that time, Resident #2 turned around and started walking down the hall as if nothing has happened. CNA #1 stated that Resident #2 walked back and for the hallway a couple of times, and at one point, when Resident #73 was coming out of the dining room, they met. Resident #73 stood up from his/her wheelchair and grabbed Resident #2 by both wrists. Resident #2 pulled his/her arm back and continued walking his/her usual way. Resident #73 than, lost his/her balance but held on to the handrail, the staff assisted him/her back to his/her wheelchair. Resident #2 ended up with skin tear and bruises on his wrists. During an interview with CNA # 2 on 2/13/19 at 9:14 AM CNA #2 stated s/he did not see the whole incident, however, s/he saw Resident #73 trying to stand up and acting as if s/he was going to fight Resident #2. S/he said that Resident #73 was mad. S/he added that Resident #73 gets upset from time to time and can be physically and verbally aggressive. During an interview with CNA #3 on 2/13/19 at 9:26 AM CNA #3 stated that s/he saw Resident #73 propelling his/her wheelchair, with his/her feet, out of the dining room very fast. S/he did not expect Resident #73 to confront Resident #2 but as Resident #2 walked down the hallway and as Resident #73 was coming out to the dining room s/he stood up but could not tell if Resident #73 grabbed Resident #2, but saw Resident #2 pulled his/her arms back and Resident #73 lost his/her balance. During an interview with the Administrator and the Director of Nursing (DON) on 2/13/19 at 4:56 PM it was confirmed that CNA #1 who witness the resident to resident altercation was not interviewed.",2020-09-01
929,POINSETT REHABILITATION AND HEALTHCARE CENTER,425102,8 NORTH TEXAS AVENUE,GREENVILLE,SC,29611,2019-02-14,625,D,0,1,KJ6U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to include the amounts to be paid for reserve bed payment or the private pay daily rate on the bed hold policy sent to residents/resident representatives upon transfer for 2 of 3 sampled residents reviewed for hospitalization s. (Residents #47 and #98) The findings included: The facility admitted Resident #98 with [DIAGNOSES REDACTED]. Record Review of Resident #98's medical record on 02/13/19 at approximately 9:30 AM revealed Resident #98 was sent to the hospital on [DATE]. The Nurses Note stated, Resident states (s/he) does not feel well, that (s/he) is dizzy, and would like be sent to the hospital. Record Review of Resident #98's medical record on 02/13/19 at approximately 9:30 revealed that on 01/02/19, the Communication with Family Note stated that the resident was sent to the emergency room for altered mental status and elevated blood pressure. Record Review of Resident #98's medical record on 02/13/19 at approximately 9:30 AM revealed that on 01/17/19, the Hospital Summary Note stated, Nurses Assistant notified this nurse that resident had large stool burgundy in color, odd and appeared to look like blood. The resident stated s/he had had a colonoscopy in the hospital. The physician was called, notified of change in status, and orders were obtained to transfer to the emergency room for evaluation. Review of the Bed Hold Policy on 02/13/19 at 1:00 PM revealed that the policy sent to the resident/representative did not include the amounts to be paid for reserve bed payment or the private pay daily rate. The facility admitted Resident #47 with [DIAGNOSES REDACTED]. Record Review of Resident #47's medical record on 02/14/19 at 08:50 AM revealed that Resident #47 was sent to the hospital on [DATE]. The General Note from the eRecord stated, Resident complained of headache at 15:15. Tylenol was given. Staff told this nurse at 17:45 that resident did not eat much supper, this nurse went to check on resident at 18:10. Resident lethargic, sternum rub was performed. This nurse was still unable to arouse resident. Vitals checked blood pressure 100/62. Temperature 98.0 Respiration 17, Oxygen saturation 92%. Nurse Practitioner and Responsible Party notified. Emergency Medical Service (EMS) called at 18:25. Resident left facility via EMS at 18:45. Review of the Bed Hold Policy on 02/13/19 at 1:00 PM revealed that the policy sent to the resident/representative did not include the amounts to be paid for reserve bed payment or the private pay daily rate. During an interview on 02/13/19 at 1:00 PM, Medical Records confirmed the Bed Hold Policy did not include the payment amounts.",2020-09-01
930,POINSETT REHABILITATION AND HEALTHCARE CENTER,425102,8 NORTH TEXAS AVENUE,GREENVILLE,SC,29611,2019-02-14,656,D,0,1,KJ6U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan to address Resident #2's behavior of urinating and defecating in resident rooms and throughout the facility hallways. One of 4 residents review for behavior. The findings included: The facility admitted Resident #2 on 8/01/2018 with [DIAGNOSES REDACTED]. During an interview with the certified nursing assistant (CNA) #1 on 2/13/19 at approximately 9:00 AM. CNA #1 stated that Resident #2 defecates and urinates in other residents' room (on the floor), throughout the facility's hallways, or in any other place where s/he feels s/he would not be seen. During an interview with CNA #2 on 2/13/19 at 9:14 AM. CNA #2 stated Resident #2 refuses care including shower and has a bowel movements and urinates anywhere in the facility. During an interview with CNA #3 on 2/13/19 at 9:26 AM. CNA #3 stated that Resident #2 walks around the hallways non-stop. Resident #2 goes into the resident rooms and defecates/urinates on the floor but usually does not bother any person/resident. On 2/13/19 at 11:03 AM during the residents' council meeting more than one resident voiced concerns about the resident (Resident #2) who walks all around the building, goes into their rooms and uses the floor as a bathroom. Review of Resident #2's Care Plan on 2/14/19 at approximately 9:30 AM revealed that the facility did not develop/implement a plan of care to address and prevent the resident's behavior of defecating and urinating in inappropriate places. During an interview with the Director of Nursing and the Administrator, the Administrator stated that s/he did not know that Resident #2 was urinating and defecating on the floor of hallways and in resident rooms.",2020-09-01
931,POINSETT REHABILITATION AND HEALTHCARE CENTER,425102,8 NORTH TEXAS AVENUE,GREENVILLE,SC,29611,2019-02-14,698,E,0,1,KJ6U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide appropriate care and services for one of one resident reviewed for [MEDICAL TREATMENT]. Staff failed to consistently monitor Resident #98's [MEDICAL TREATMENT] for bleeding, thrill and bruit. The findings included: The facility admitted Resident #98 with [DIAGNOSES REDACTED]. Review of Resident #98's treatment sheets on 02/12/19 at approximately 4:00 PM revealed that on 12/11/18 night shift, 12/25/18 day and evening shift, 01/22/19 night shift, 02/02/19 day shift, 02/03/19 day shift, and 02/11/19 night shift were missing initials, indicating that physician's orders [REDACTED]. If bleeding noted apply pressure and call 911. Review of Resident #98's treatment sheets on 02/12/19 at approximately 4:00 PM revealed that 12/11/18 night shift, 12/25/18 day and evening shift, 01/22/19 night shift, 02/02/19 day shift, 02/03/19 day shift, and 02/11/19 day and night shift were missing initials, indicating physician's orders [REDACTED]. During an interview on 02-13-19 at 11:50 AM, the Director of Nursing verified that the treatments had not been initialed to indicate the order had been followed.",2020-09-01
932,POINSETT REHABILITATION AND HEALTHCARE CENTER,425102,8 NORTH TEXAS AVENUE,GREENVILLE,SC,29611,2019-02-14,758,E,0,1,KJ6U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to administer [MEDICATION NAME], [MEDICAL CONDITION] medication, as prescribed and did not document medication administration consistently. Resident #73's [MEDICATION NAME] prescribed for [MEDICAL CONDITION] was given for behaviors. The findings included: The facility admitted Resident #73 on 4/3/18 with [DIAGNOSES REDACTED]. Review of Resident #73's physician's orders [REDACTED]. Review of Resident #73's Progress Note dated 10/13/18 at 8:00 AM revealed resident became violently agitated with staff this am, refusing to be redirected, kicking at staff, putting hands back as to punch staff. This nurse administered 1 mg IM [MEDICATION NAME] in left arm . Review of Resident #73's Progress Note dated 10/13/18 at 9:04 AM revealed [MEDICATION NAME] tablet 1 MG Inject 1 mg intramuscularly every 6 hours as needed for [MEDICAL CONDITION] activity for 60 days threating and swinging at staff Review of Resident #73's Progress Note dated 1/1/19 at 1:57 AM revealed at 1230 am resident started yelling out at staff and being aggressive with sitter. Staff approached resident and resident stated (s/he) was going to leave here. Staff tried to redirect resident without any success. Resident then started cursing out loud. Nurse administered PRN [MEDICATION NAME] IM in resident right arm . According to the nurse's notes, the resident received [MEDICATION NAME] PRN on 1/1/19 for behavior; however, the facility did not provide a physician's orders [REDACTED]. Review of Resident #73's Medication Administration Record [REDACTED]. Review of Resident #73's Progress Note dated 2/12/18 at 3:38 AM revealed [MEDICATION NAME] Solution 2 MG/ML Inject 0.5 ml intramuscularly every 6 hours as needed for [MEDICAL CONDITION] patient agitated woke up cursing and attempting to awaken other patients. During an interview with the Physician and the Director of Nursing (DON) on 2/14/19 at approximately 11:00 AM the physician stated that the resident's [MEDICAL CONDITION] are successfully controlled with the scheduled [MEDICATION NAME] and that the PRN [MEDICATION NAME] is for his/her aggressive behaviors. The Physician and the DON believed that the [MEDICATION NAME] PRN for [MEDICAL CONDITION] might have carried over from an old order, but they were not able to provide documentation to support their claim.",2020-09-01
933,POINSETT REHABILITATION AND HEALTHCARE CENTER,425102,8 NORTH TEXAS AVENUE,GREENVILLE,SC,29611,2019-02-14,812,F,0,1,KJ6U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to ensure that the dietary staff-maintained walk-in-cooler and walk-in-freezer free from expired, spoiled and freezer burned foods. The facility also failed to ensure that the ice-maker and walk-in-cooler were kept clean for one of one kitchen review/observed. The findings included: During an observation of the kitchen with the Food and Nutrition Director on [DATE] at 9:52 AM the walk-in-cooler contained a 3lbs bag of deli ham expired, two large spoiled onions, and two large spoiled cucumbers. The walk-in cooler's floor had trash/food debris and dark, unclean spots on it. The walk-in-freezer contained an opened box with several pieces of fish filet that appeared freezer burned. The door of the ice-machine, located in the dining room, was soiled. The filter and mat in front of the ice-machine located in the dining room was dirty. The Food and Nutrition Director acknowledged the above findings and removed the food items immediately.",2020-09-01
934,POINSETT REHABILITATION AND HEALTHCARE CENTER,425102,8 NORTH TEXAS AVENUE,GREENVILLE,SC,29611,2019-05-09,607,G,1,0,WLPR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, including the facility's abuse policy titled Abuse Investigation and Reporting, and interview the facility failed to implement the components of its abuse policy that prohibit and prevent abuse for one of three residents reviewed for abuse. Resident #87's family member informed the facility of an allegation of abuse on 4/20/18. The facility failed to interview the resident and the resident's roommate, both were noted to be interviewable. The facility failed to follow their policy related to protection of residents after an allegation of abuse. The findings included: The facility reported an allegation of mental abuse for Resident #87 to the State Agency on 4/20/19 and noted the incident was reported to the administrator on 4/20/19 at 6:00 PM. The report was faxed on 4/20/19 at 6:54 PM. Review of the assignment sheet dated 4/18/19 revealed CNA #6 worked 3:00 PM- 11:00 PM and was assigned to Resident #87. Review of the facility's 5-day report summary revealed Resident #87 alleged CNA #6 came into his/her room and threw his/her doll onto the ground and said you pee every five minutes and would not give the doll back when asked to. Review of Resident #87's Quarterly Minimum (MDS) data set [DATE] revealed the resident had a Brief Interview for Mental Status score 15. Review of the facility's investigation revealed a statement from the administrator dated 4/20/19 that indicated she received a phone call from staff stating that Resident #87's family member was at the facility with concerns. The administrator called the facility and spoke with the family member. The family member explained that Resident #87 called him/her and told him/her that a CNA refused to pick up his/her family member's baby doll from the floor. Review of the facility's investigation revealed a statement by Resident #87 dated 4/22/19 taken by the administrator and the Risk Manager. The statement indicated last Thursday on 2nd shift CNA #6 came in and threw my doll down and said you pee every 5 minutes. Resident #87 asked CNA #6 to give it back and s/he walked out. Resident #87 asked another CNA to give it to him/her and s/he said give him/her a minute and left. CNA #7 gave it back to the resident. There was no statement that indicated Resident #87 was interviewed at the time of the allegation on 4/20/19. In an interview with the surveyor on 5/9/19 at approximately 2:45 PM, the administrator stated the incident was reported to him/her on 4/20/19. The weekend nurse called and stated Resident #87's family was at the facility and very irate, they were upset about an incident that happened. The administrator talked with the resident's responsible party on the phone and s/he stated Resident #87 called him/her and told him/her someone threw his/her doll down and would not pick it up. It was a doll baby that the resident has on his/her bed. The administrator told the responsible party s/he would find out what was going on. The responsible party said the incident happened last Thursday during 1st shift. The responsible party said it was somebody named (CNA #6). When the administrator looked at the schedule CNA #6 did not work that day on 1st shift. The administrator talked to the resident on 4/22/19 and s/he said it was CNA #6, s/he stated it was not on 1st shift but on 2nd shift. The resident said it happened between 8:00 and 9:00 PM on Thursday. They identified it was CNA #6 and they suspended him/her. The administrator called CNA #6 on Monday 4/22/19 and told him/her s/he was suspended. CNA #6 was not on the schedule to work on Sunday. The administrator stated the Risk Manager came to the facility on Saturday and sent the reportable in. The administrator stated the Risk Manager did not talk with Resident #87. The administrator stated s/he talked with Resident #87 on Monday 4/22/19. The administrator stated s/he would expect the staff member who came up to the facility to interview the resident and try to identify the alleged staff member. When the administrator talked with Resident #87 on Monday 4/22/19 s/he identified the staff as CNA #6. Resident #87 said CNA #6 came in and threw his/her doll down, said you pee every 5 minutes, and left. The administrator and the Risk Manager interviewed CNA #6 together and s/he stated s/he told the resident not to be on the call light too much in a joking manner. At times, the resident will clip his/her call light to the doll. They talked with Resident #53, the roommate, and s/he stated that a CNA was changing another resident (there are 4 in the room). Resident #53 is blind and cannot see. They asked Resident #53 if s/he heard anything about CNA #6. Resident #53 said s/he didn't hear anything about peeing. S/he did hear Resident #87 ask CNA #6 to pick up the doll. Resident #53 did not hear anything else after that. The administrator could not locate a statement for Resident #53, the administrator stated s/he thought they typed the statement up. The administrator stated CNA #6 should have been suspended at the time the resident identified him/her on Saturday 4/20/19. The administrator stated they did not have any documentation of the interview with Resident #53. In an interview with the surveyor, the Risk Manager stated s/he talked with Resident #87 on Saturday 4/20/19. The Risk Manager asked Resident #87 how his/her weekend was. Resident #87 said not so good. Stated a CNA had put his/her doll on the floor. The Risk Manager asked who the CNA was, and the resident stated CNA #6 on 2nd shift. The Risk Manager stated s/he did not document the interview with Resident #87 on Saturday. The Risk Manager stated they suspended CNA #6 on Monday. The Risk Manager confirmed CNA #6 worked until 11:04 PM on Saturday. The Risk Manager stated s/he was not sure why CNA #6 was not suspended on Saturday. Review of the facility's Abuse Prevention Program revealed a section for protection of the resident. Guidance included .the charge nurse will immediately remove the suspected perpetrator from resident care areas, obtain the staff members witness statement and immediately suspend the employee pending the outcome of the investigation. Review of the facility policy titled Abuse Investigation and Reporting Revealed all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management . Under Role of the Investigator revealed Interview any witnesses to the incident Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident",2020-09-01
935,POINSETT REHABILITATION AND HEALTHCARE CENTER,425102,8 NORTH TEXAS AVENUE,GREENVILLE,SC,29611,2019-05-09,610,G,1,0,WLPR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview the facility failed to thoroughly investigate and protect residents related to an allegation of abuse for one of three residents reviewed for abuse. Resident #87's family member informed the facility of an allegation of abuse on 4/20/18. The facility failed to interview the resident and the resident's roommate at the time of the allegation, both were noted to be interviewable. The facility failed to immediately suspend the alleged employee. The findings included: The facility reported an allegation of mental abuse for Resident #87 to the State Agency on 4/20/19 and noted the incident was reported to the administrator on 4/20/19 at 6:00 PM. The report was faxed on 4/20/19 at 6:54 PM. Review of the assignment sheet dated 4/18/19 revealed CNA #6 worked 3:00 PM- 11:00 PM and was assigned to Resident #87. Review of the facility's 5-day report summary revealed Resident #87 alleged CNA #6 came into his/her room and threw his/her doll onto the ground and said you pee every five minutes and would not give the doll back when asked to. Investigation was initiated. Staff member suspended pending investigation. After completing investigation of incident concluded the allegation of abuse did not occur. Educated staff member on call bell placement and all staff on abuse. Staff member will not care for this resident per resident request. Review of Resident #87 's Quarterly Minimum (MDS) data set [DATE] revealed the resident had a Brief Interview for Mental Status score 15. Review of the Social Services Progress Note dated 4/22/19 indicated the social services staff received a verbal report from the Risk Manager related to the concern expressed by Resident #87. Social services staff visited with Resident #87 for the purpose of offering/providing psychosocial support. Social services asked the resident if s/he wanted to discuss his/her concerns. Resident #87 described the event to social services staff confirming what s/he had related to the Risk Manager. Resident #87 stated s/he was still very upset and did not want that person back in his/her room. Review of CNA #6's time card revealed s/he worked on Saturday 4/20/19 from 7:20 AM- 11:04 PM. CNA #6 was not immediately suspended after the allegation was reported on 4/20/19 at 6:00 PM per the facility's abuse policy. Review of the facility's investigation revealed a statement from the administrator dated 4/20/19 that indicated she received a phone call from staff stating that Resident #87's family member was at the facility with concerns. The administrator called the facility and spoke with the family member. The family member explained that Resident #87 called him/her and told him/her that a CNA refused to pick up his/her family member's baby doll from the floor. Review of the facility's investigation revealed a statement by Resident #87 dated 4/22/19 taken by the administrator and the Risk Manager. The statement indicated last Thursday on 2nd shift CNA #6 came in and threw my doll down and said you pee every 5 minutes. Resident #87 asked CNA #6 to give it back and s/he walked out. Resident #87 asked another CNA to give it to him/her and s/he said give him/her a minute and left. CNA #7 gave it back to the resident. CNA #6 was interviewed by phone by the administrator and the Risk Manager. CNA #6 indicated on Thursday s/he went into Resident #87's room to change him/her and told him/her don't be on the call light to much in a joking manner. When CNA #6 finished changing the resident s/he put the call light, pillow and doll back beside the resident. Nothing else happened, s/he did not throw the resident's call light on the floor. CNA #6 stated s/he knew better than to do that. CNA #7's facility-obtained statement dated 4/25/19 indicated s/he came to work at 11:00 PM on Thursday 4/18/19 and went into Resident #87's room and s/he picked his/her call light off the floor. Resident #87 had his/her roommate ring the light for him/her because it was on the floor. CNA #7 was noted to work 11:00 PM - 7:00 PM. LPN #3's facility-obtained statement dated 4/23/19 indicated Resident #87 stated the bed wasn't working correctly, the bed was fixed. No other knowledge of any issues. LPN #3 was noted as the 3:00 PM-11:30 PM nurse. In an interview with the surveyor on 5/9/19 at approximately 2:45 PM, the administrator stated the incident was reported to him/her on 4/20/19. The weekend nurse called and stated Resident #87's family was at the facility and very irate, they were upset about an incident that happened. The administrator talked with the resident's responsible party on the phone and s/he stated Resident #87 called him/her and told him/her someone threw his/her doll down and would not pick it up. It was a doll baby that the resident has on his/her bed. The administrator told the responsible party s/he would find out what was going on. The responsible party said the incident happened last Thursday during 1st shift. The responsible party said it was somebody named (CNA #6). When the administrator looked at the schedule CNA #6 did not work that day on 1st shift. The administrator talked to the resident on 4/22/19 and s/he said it was CNA #6, s/he stated it was not on 1st shift but on 2nd shift. The resident said it happened between 8:00 and 9:00 PM on Thursday. They identified it was CNA #6 and they suspended him/her. The administrator called CNA #6 on Monday 4/22/19 and told him/her s/he was suspended. CNA #6 was not on the schedule to work on Sunday. The administrator stated the Risk Manager came to the facility on Saturday and sent the reportable in. The administrator stated the Risk Manager did not talk with Resident #87. The administrator stated s/he talked with Resident #87 on Monday 4/22/19. The administrator stated s/he would expect the staff member who came up to the facility to interview the resident and try to identify the alleged staff member. When the administrator talked with Resident #87 on Monday 4/22/19 s/he identified the staff as CNA #6. Resident #87 said CNA #6 came in and threw his/her doll down, said you pee every 5 minutes, and left. The administrator and the Risk Manager interviewed CNA #6 together and s/he stated s/he told the resident not to be on the call light too much in a joking manner. At times, the resident will clip his/her call light to the doll. They talked with Resident #53, the roommate, and s/he stated that a CNA was changing another resident (there are 4 in the room). Resident #53 is blind and cannot see. They asked Resident #53 if s/he heard anything about CNA #6. Resident #53 said s/he didn't hear anything about peeing. S/he did hear Resident #87 ask CNA #6 to pick up the doll. Resident #53 did not hear anything else after that. The administrator could not locate a statement for Resident #53, the administrator stated s/he thought they typed the statement up. The administrator stated CNA #6 should have been suspended at the time the resident identified him/her on Saturday 4/20/19. The administrator stated they did not have any documentation of the interview with Resident #53. In an interview with the surveyor, the Risk Manager stated s/he talked with Resident #87 on Saturday 4/20/19. The Risk Manager asked Resident #87 how his/her weekend was. Resident #87 said not so good. Stated a CNA had put his/her doll on the floor. The Risk Manager asked who the CNA was, and the resident stated CNA #6 on 2nd shift. The Risk Manager stated s/he did not document the interview with Resident #87 on Saturday. The Risk Manager stated they suspended CNA #6 on Monday. The Risk Manager confirmed CNA #6 worked until 11:04 PM on Saturday. The Risk Manager stated s/he was not sure why CNA #6 was not suspended on Saturday. The surveyor talked with Resident #87 and s/he stated s/he had a problem with a staff member throwing his/her call light on the floor. The facility took care of it and suspended the CN[NAME] The CNA no longer works with him/her.",2020-09-01
936,POINSETT REHABILITATION AND HEALTHCARE CENTER,425102,8 NORTH TEXAS AVENUE,GREENVILLE,SC,29611,2018-05-16,584,D,1,0,7M0511,"> Based on observation and interview, the facility failed to provide clean bed linens to the residents on 3 of 3 units observed. The facility contracted with an outside linen provider who was not supplying enough linens to last between shipments. The findings included: During Initial Tour of the facility on 5/15/2018 at 10:47 AM, two linen carts were observed on Unit 1. Both carts appeared nearly depleted of linens. Each cart contained two, wrapped packages of bed linens. Observation of the Unit 2 linen room on 5/15/2018 at 10:57 AM, also revealed very few linens. Approximately 90 percent of the shelf space for linens was empty. Observation of the Unit 3 Linen room revealed approximately 70 percent of the shelf space for linens was empty. On 5/16/2018 at 10:15 AM all linen carts and linen rooms were observed to be restocked at approximately 50 percent of capacity. During an interview with Resident #1 on 5/15/2018 at 2:37 PM, Resident #1 stated the facility has been short on linens the past few weeks. Resident #1 stated about 2 weeks ago there were not enough linens for his/her bed. The Certified Nursing Assistant (CNA) had to use a blanket in place of a fitted bed sheet for his/her bed. Resident #1 stated sleeping on the blanket was not comfortable. During an interview with Resident #2 on 5/15/2018 at 4:15 PM, Resident #2 had concerns related to bed linens. Resident #2 stated the facility was short on linens today and did not have clean linens for my bed this morning. Resident #2, who was up in her/his wheelchair, stated she/he hoped more linens would come in today before it was time to go back to bed. During an interview with CNA #1 on 5/15/2018 at 10:47 AM, CNA #1 confirmed the 2 packs of bed linens on each cart on Unit 1 were all the bed linens on the unit. CNA #1 was interviewed again at 12:00 PM and stated the facility had been running low on bed linens prior to each shipment. CNA #1 didn't think they had ever completely run out of linens before the next shipment. During an interview with CNA #2 on 5/15/2018 at 11:10 AM, CNA #2 confirmed the Unit 2 Linen room was nearly empty. CNA #2 stated the facility was always running short of linens prior to the next delivery. When asked if they had ever run out of linens on the unit, CNA #2 stated they had not. CNA #2 stated, while pointing at the shelves, you can see we are almost there, though. During an interview with CNA #3 on 5/15/2018 at 12:10 PM, CNA #3 stated she/he had no concerns with the linens on Unit 3 (Rehab Unit) and they had never run out of linens prior to delivery. During an interview with the Housekeeping Director on 5/15/2018 at 11:18 AM, the Housekeeping Director confirmed the facility was low on linens right now. She/he stated the facility gets linens in every Monday, Wednesday and Friday around 1:00 AM. The Housekeeping Director stated the facility had switched to a new linen provider about 3 -4 months ago and she/he was not happy with them because they were not meeting the facility's linen needs. The Housekeeping Director stated that linen deliveries were frequently short of what she/he orders. For example she/he explained, If I order 500 sheets I may get 400. The Housekeeping Director stated they frequently run low between deliveries. During an interview with the Housekeeping Director on 5/16/2018 at 11:25 AM, the Housekeeping Director stated we did get our linens in last night, but as you probably saw we are still under stocked. The Housekeeping Director stated the linen company representative (Rep) was here at the facility and had been meeting with Housekeeping leadership. The Housekeeping Director stated we made it clear to the Rep they were not meeting our needs. The Housekeeping Director stated the Rep had explained the linen company was supplying the facility based on our Par Level and not on what was being ordered. The Housekeeping Director explained the Par level is a predetermined amount of linens for the facility based on the facility's size. The Housekeeping Director further explained that regardless of what she/he was ordering, the linen company would only provide linens based on the Par level. The Housekeeping Director stated we made it clear to the Rep that our Par level was not meeting our needs. She/he stated the Rep will be increasing our Par level and will be sending us another shipment tonight to get us fully stocked. A larger shipment will also come on Friday, the Housekeeping Director stated. The Housekeeping Director stated, hopefully this adjustment to our Par level will keep me from running out of linens all the time.",2020-09-01
937,POINSETT REHABILITATION AND HEALTHCARE CENTER,425102,8 NORTH TEXAS AVENUE,GREENVILLE,SC,29611,2016-10-13,174,D,0,1,HOWI11,"Based on interviews and observations, the facility failed to ensure that residents had reasonable access to the use of a telephone where calls could be made without being overhead by staff or other residents. Residents were observed using the telephone at the nurses's station on 2 of 3 units to make telephone calls. (Units 1 and 2). The findings included: During individual interview on 10/10/16 at approximately 10:48 AM, Resident #121 stated he/she did not like having the telephone at the nurses' station to make a telephone call. Resident #121 who resides on Unit 1, further stated when the portable telephone was not available or working, he/she would have to use the telephone at the nurses' station where staff and other residents are present to make a telephone call. Random observation on 10/11/16 at approximately 12:52 PM revealed a random resident at the nurses' station using the telephone to talk to a family member, while staff, other residents and surveyor were present. The staff did not ask the if he/she wanted to use a cordless phone to talk in private. Further observation revealed a cordless phone cradle/docking station without the cordless phone. The resident talking to a family member was using the facility's telephone at the nurses' station. During an interview on 10/11/16 at approximately 12:54 PM with Licensed Practical Nurse (LPN) #1 and #2 confirmed the cordless telephone was not in the cradle/docking station. LPN #2 stated he/she gave the resident the telephone at the nurses' station because he/she did not know the location of the cordless telephone. LPN #1 stated he/she gave the cordless telephone to a resident but he/she did not know which resident had the cordless telephone. LPN #1 was observed asking staff in the dining area the location of the cordless telephone. LPN #1 was later observed going down the unit hallway asking staff about the location of the cordless telephone. The LPNs began looking for the telephone after the surveyor informed staff that a resident expressed concerns about the cordless telephone not being available to have a private telephone call. At approximately 1 PM, LPN #1 stated a Certified Nursing Aide located the cordless telephone in a resident's room (#17). During a random observation on 10/13/16 at approximately 8:32 AM, a staff member used a cordless telephone, dialed a family member for a resident and gave the resident the telephone at the nurses' station while other staff members and other residents were present. The staff member did not ask the resident if he/she wanted to take the telephone to his/her room to have a private telephone call. While the resident was on the telephone at the nurses' station a Certified Nursing Aide (CNA) began talking to the resident and adjusting the lap buddy on the resident's wheelchair. An interview on 10/13/16 at approximately 8:42 AM with CNA #1 confirmed he/she adjusted the resident's lap buddy while he/she was on the telephone at the nurses' station.",2020-09-01
938,POINSETT REHABILITATION AND HEALTHCARE CENTER,425102,8 NORTH TEXAS AVENUE,GREENVILLE,SC,29611,2016-10-13,247,D,0,1,HOWI11,"Based on interviews and record review, the facility failed to ensure that 1 of 1 sampled resident reviewed with a roommate change was informed in advance of the roommate change. Resident #43 had a roommate change in (MONTH) (YEAR) with no notification to resident or the resident's family/responsible party. The findings included: An interview on 10/11/16 at approximately 10 AM, with a family member revealed Resident #43 had a new roommate with no notification of the roommate change. During a review of the medical record on 10/11/16 revealed there was no documentation to indicate Resident #43 had a roommate change in the past several months or that notice was given of a roommate change. During an interview on 10/11/16 at approximately 12:24 PM, the Social Services Director (SSD) stated he/she was not aware of a roommate change for Resident #43. The SSD reviewed the social services progress notes and stated there was no documentation of a roommate change. The Social Services Assistant/Discharge Planner (SSA/DP) who was also present checked the computer and confirmed Resident #43 did have a roommate change in (MONTH) (YEAR). The SSA/DP further stated the resident had a new roommate assigned 7/29/16. The SSD stated he/she was not aware of the roommate change because it must have been a late admission into the facility. The SSD confirmed there was no documentation that the resident/family was informed of the roommate change. An interview on 10/11/16 at approximately 1:15 PM with the facility Administrator after reviewing the medical record, confirmed the resident/family member was not informed of the roommate change prior to the change.",2020-09-01
939,POINSETT REHABILITATION AND HEALTHCARE CENTER,425102,8 NORTH TEXAS AVENUE,GREENVILLE,SC,29611,2016-10-13,279,D,0,1,HOWI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to care plan the need to assess the thrill and bruit for Resident #51, 1 of 1 resident reviewed for [MEDICAL TREATMENT]. In addition, the facility failed to develop a care plan for contracture management for Resident #65, 1 of 3 residents reviewed for Range of Motion. The findings included: The facility admitted Resident #51 with [DIAGNOSES REDACTED]. On 10/13/2016 at 11:26 AM, review of care plan revealed no intervention for checking the thrill and bruit for Resident #51. Record review revealed no documentation that the thrill and bruit was being checked every shift. During an interview on 10/13/16 at 11:34 AM, the Director of Nursing (DON) confirmed the intervention was not listed on the care plan. The DON also confirmed s/he would expect it to be checked every shift and that there was no documentation in the record that the thrill and bruit had been checked every shift. The Regional Nurse Consultant, also present during the interview, stated the facility had no policy related to [MEDICAL TREATMENT]. The facility admitted Resident #65 with [DIAGNOSES REDACTED]. A review of the medical record on 10/11/16 at approximately 3:33 PM revealed a care plan initiated in (MONTH) (YEAR) that did not address the resident's contracture to Right Arm/Hand or any services being provided for the contractures. Further review of the medical record revealed an incomplete Therapy Referral and Screening Form dated 10/07/16 that indicated the resident had right hand/wrist/elbow contracture and was advised of a splint to prevent further contractures and joint protection but the resident refused. There was no documentation in the medical record to indicate the facility had evaluated/assessed the resident for a splint device. There was no documentation on the care plan to indicate services were provided and resident's refusal was addressed. During an interview on 10/12/16 approximately 3:29 PM with Licensed Practical Nurse (LPN) #3 and Registered Nurse (RN) #3 confirmed the care plan had not been developed to address the resident's contracture to right hand/wrist/elbow with a splint device being identified as an intervention. LPN #3 and RN #3 were aware the resident had a contracture on admission (6/14/16).",2020-09-01
940,POINSETT REHABILITATION AND HEALTHCARE CENTER,425102,8 NORTH TEXAS AVENUE,GREENVILLE,SC,29611,2016-10-13,282,D,0,1,HOWI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to follow a care plan for 1 of 1 sampled resident reviewed with a pacemaker. Resident #54's care plan was not followed for getting pacemaker checks as ordered by the physician. The findings included: The facility admitted with Resident #54 with [DIAGNOSES REDACTED]. A review of the medical record on 10/11/16 at approximately 2:21 PM revealed a care plan initiated on 12/24/14 and updated on 9/20/16 that indicated Resident #54 had a pacemaker with interventions that included pacemaker checks as ordered and document in the medical record. Further review of the medical record revealed a PACEMAKER CHECKS sheet that indicated the last documented pacemaker check for Resident #54 was done on 11/24/15. An interview on 10/12/16 at approximately 3:15 PM with Registered Nurse (RN) #1 confirmed Resident #54 last pacemaker check was done on 11/24/15. RN #1 further stated he/she had contacted the cardiologist's office today and the resident's pacemaker should have been checked every 3 months (quarterly).",2020-09-01
941,POINSETT REHABILITATION AND HEALTHCARE CENTER,425102,8 NORTH TEXAS AVENUE,GREENVILLE,SC,29611,2016-10-13,309,E,0,1,HOWI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to receive orders for [MEDICAL TREATMENT], assess the access site for thrill and bruit, or receive communication from the [MEDICAL TREATMENT] provider for Resident #51, 1 of 1 resident reviewed for [MEDICAL TREATMENT]. In addition, the facility failed to provide medications and/or treatments as ordered for Residents #40 and #169, 2 of 6 residents reviewed for medication and treatment administration. The facility also failed to obtain pacemaker checks as ordered for Resident #54, 1 of 1 resident reviewed with a pacemaker. The findings included: The facility admitted Resident #51 on 9/6/16 with [DIAGNOSES REDACTED]. On 10/13/2016 at 10:09 AM, review of the physician orders revealed no order for the Resident #51 to receive [MEDICAL TREATMENT] until 10/10/16. Further review revealed no communication or labs from the [MEDICAL TREATMENT] provider. In addition, review of the Medication and Treatment Administration Records revealed no documentation that the thrill and bruit was checked in (MONTH) or (MONTH) except on 10/8 and 10/13/16 in the nurse's notes. During an interview on 10/13/16, the Director of Nursing (DON) confirmed s/he would expect the thrill and bruit be checked every shift and that there was no documentation in the record that the thrill and bruit had been checked every shift. The facility admitted Resident #40 with [DIAGNOSES REDACTED]. Review of the Discharge summary dated 5/11/16 on 10/11/16 revealed an order for [REDACTED]. Review of the Medication Administration Record revealed that the [MEDICATION NAME] ordered on admission was not carried over from the initial admission medication record to the computer generated medication administration record (MAR) and the resident received the medication for only 2 days. Review of the Physicians Orders on 10/11/16 at 2:23 PM revealed an order dated 6/6/16 for skin prep to the right heel daily. Review of the Treatment Administration Record revealed the treatment was not implemented until 5/17/16. During an interview on 10/13/16 at 8:35 AM, the Director of Nursing (DON) confirmed the [MEDICATION NAME] had not been carried over to the computer generated MAR and that it had not been administered for 14 days as ordered. The DON also confirmed the treatment to the heel was no started until 6/17/16. The facility admitted Resident #169 with [DIAGNOSES REDACTED]. At 9:16 AM, review of the Physician ' s Telephone Orders revealed orders dated 2/21/16 to clean the right hip with wound cleanser, pat dry and apply a border gauze daily and an order dated 2/25/16 to change the dressing every shift. An order dated 2/21/16 was noted for Sureprep to the left heel every shift and an order to clean the right knee with wound cleanser, pat dry and apply a border gauze daily. Further review revealed an order dated 2/25/16 for [MEDICATION NAME] 500 mg (milligrams) daily for 7 days. Review of the Treatment Administration Record (TAR) on 10/12/16 at 10:19 AM revealed the daily treatments were not signed off as completed on 2/20, 2/23, and 2/24/16. The treatment change to dressing changes every shift was transcribed to the TAR and were not signed as completed on 2/29/16 day and evening shift. In March, (YEAR), the treatments were not documented as completed on 3/3 and 3/7/16 day shift. The treatment to the right knee was signed as completed on 2/23/16. No other treatments were documented in February. In March, (YEAR), the treatments to the right knee were not documented as completed on 3/1, 3/2, 3/3, 3/5 or 3/7/16. In addition, treatments to the left heel diabetic ulcer ordered every shift were not done as ordered in (MONTH) or March, (YEAR). Review of the Medication Administration Record (MAR) revealed the order for [MEDICATION NAME] had been transcribed to the MAR and initiated on 2/24/16 instead of 2/25/16. The MAR indicated that the resident received 5 doses of the medication, not the ordered 7 doses. During an interview on 10/12/16, the Director of Nursing (DON) confirmed the treatment orders for the right hip and right knee. The DON further confirmed the order for [MEDICATION NAME] to be administered for 7 days, a total of 7 doses and confirmed the MAR indicated the resident received only 5 doses of antibiotic, not 7 as ordered. Additionally, the DON confirmed the multiple days the treatments were not done according to the TAR. The facility admitted with Resident #54 with [DIAGNOSES REDACTED]. A review of the medical record on 10/11/16 at approximately 2:21 PM revealed a PACEMAKER CHECKS sheet that indicated the resident had quarterly pacemaker checks during (YEAR). The Pacemaker Checks sheet further indicated the resident's last pacemaker check was performed on 11/24/15. Further review of the medical record revealed there was no documentation to indicate Resident #54 had his/her pacemaker check since 11/24/15. There were no physician's orders for pacemaker checks in the medical record. An interview on 10/12/16 at approximately 2:34 PM with Registered Nurse (RN) #1 confirmed the last documented pacemaker check in the medical record was 11/24/15 and stated he/she would contact the cardiologist's office and find out when the last pacemaker check was actually done. RN #1 stated he/she would also find out how often the pacemaker should be performed. RN #1 stated there were no physician's orders for pacemaker checks in the medical record. An interview on 10/12/16 at approximately 3:15 PM with RN #1 confirmed the resident last pacemaker check was done on 11/24/15 and that the resident's pacemaker should have been checked every three months. RN #1 further stated that an audit was done 3 weeks ago and the facility contacted the cardiologist and got an appointment scheduled for 12/07/16. RN #1 stated he/she did not think about all the missed appointments when he/she contacted the cardiologist office three weeks ago because he/she would have tried to gotten an earlier appointment other than 12/07/16. An interview on 10/13/16 at approximately 8:25 AM with the Director of Nursing (DON) after reviewing the medical record confirmed the last pacemaker check was performed on (MONTH) (YEAR).",2020-09-01
942,POINSETT REHABILITATION AND HEALTHCARE CENTER,425102,8 NORTH TEXAS AVENUE,GREENVILLE,SC,29611,2016-10-13,318,E,0,1,HOWI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews and review of a Quality Assurance Plan Initiative, the facility failed to ensure that 1 of 3 sampled residents reviewed for range of motion received appropriate treatment/services to prevent further contractures. Resident #65 admitted with a right hand and arm contracture did not receive services/devices to prevent further contractures. The finding included: The facility admitted Resident #65 with diagnose that included Right Arm/Hand Contracture, Right Sided Paralysis and [MEDICAL CONDITION] Disease. A review of the medical record on 10/11/16 at approximately 3:33 PM revealed an incomplete Therapy Referral and Screening Form dated 10/07/16 that indicated the resident had right hand/wrist/elbow contracture and was advised of a splint to prevent further contractures and joint protection but the resident refused. There was no documentation in the medical record to indicate the resident had refused the use of a splint device to prevent further contracture to right hand/wrist/elbow. There were no physician's orders that addressed the use of a splint device for contractures. A review of the medical record revealed a hospital discharge report date (MONTH) (YEAR) that indicated the resident had right sided paralysis with right arm/hand contracture on admission into the facility in (MONTH) (YEAR). Further record review revealed there was no documentation in the medical record to indicate the facility had evaluated/assessed the resident for a splint device due to right hand/wrist/elbow contractures. An interview on 10/12/16 at approximately 10:39 AM with the Occupational Therapist (OT) revealed the splint device for contracture of right hand/wrist/elbow did not occur because the resident refused. When documentation of the resident's refusal of the splint device was requested, the OT reviewed the occupational therapy notes and stated there was no documentation of the resident's refusal to use a splints device. An interview on 10/12/16 at approximately 11 AM with OT revealed he/she had contacted medical records and he/she was waiting for medical records to find the initial referral for occupational therapy with splint device recommendation. An interview on 10/12/16 at approximately 11:58 AM with the medical records staff revealed he/she could not locate any documentation that addressed Resident #65 being assessed/recommended to use a splint device. The medical records staff further stated there was no documentation of the resident's refusal for a splint device or a physician's order that addressed the use of a splint device. There was no documentation of the resident being providing services for a splint device. An interview on 10/12/16 at approximately 12:27 PM with OT confirmed there was no documentation in the medical record to indicate occupational services were provided related to a splint device offered on admission. The medical record indicated Resident #65 was admitted on [DATE] with services being provided for contracture to right hand/wrist/elbow. An interview on 10/13/16 at approximately 11:11 AM with the Director of Nursing (DON) confirmed there was no documentation to indicate Resident #65 refused the use of splints after reviewing the medical record. The DON further stated he/she was not aware of the 10/07/16 Therapy Referral and Screening Form that indicated the resident had refused therapy for use of splint device to prevent further contractures. The DON confirmed the QA did not address residents without physician's orders but required range of motion services. The DON further confirmed the QA did not address newly admitted residents being evaluated/assessed to range of motion services to prevent further contractures and ensure that splint devices were in place as needed. The facility provided a Quality Assurance Plan Initiative (QAPI) with a start date of 9/09/16 and a complete date of 10/07/16 that indicated there was an issue with current restorative physician's orders not being followed. The QAPI further indicated that restorative documentation was not done and not care planned. Further review of the QAPI revealed that the Quality Assurance (QA) process did not address newly admitted residents with contractures being assessed to prevent further contractures. The QA did not address making sure there were physician's orders for residents required range of motion therapy. The QA did not address of the use on splint devices and ensuring they were applied as needed.",2020-09-01
943,POINSETT REHABILITATION AND HEALTHCARE CENTER,425102,8 NORTH TEXAS AVENUE,GREENVILLE,SC,29611,2016-10-13,372,E,0,1,HOWI11,"Based on observation, interview, and record review the facility failed to properly dispose of refuse. Two of three garbage dumpsters were open, and the refuse inside both dumpsters was visible and accessible. The findings included: Observation of garbage receptacles at approximately 11:20 AM on 10/12/16 revealed that the two dumpsters farthest from the building were open. The refuse inside was both visible and accessible. The Certified Dietary Manager confirmed that both dumpsters were open. S/he then closed both dumpsters. Observation of garbage receptacles at approximately 3:15 PM on 10/12/16 revealed that the dumpster closest to the building was partially open and the middle dumpster was completely open. The refuse inside was both visible and accessible. The Certified Dietary Manager confirmed that both dumpsters were open. S/he then closed both dumpsters. Record review of the facility's policy regarding environment at approximately 11:50 on 10/13/2016 revealed that the facility had no clear instruction that garbage receptacles are to remain closed. The relevant policy reads, The Food Services Director will insure that all trash is properly disposed in external receptacles (dumpsters) and that the area is free of debris.",2020-09-01
944,POINSETT REHABILITATION AND HEALTHCARE CENTER,425102,8 NORTH TEXAS AVENUE,GREENVILLE,SC,29611,2016-10-13,502,D,0,1,HOWI11,"**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 with behaviors had laboratory services done as ordered by a physician. Resident #47 with a physician order [REDACTED]. The findings included: The facility admitted Resident #47 with diagnosed that included Dementia, Anxiety and [MEDICAL CONDITION] Disorder. A review of the medical record on 10/11/16 at approximately 2:43 PM revealed a physician's orders [REDACTED]. Further record review revealed there was no documentation in the chart to determine the lab was done as ordered. Additional record review revealed a nurse's note dated 9/04/16 indicated the resident was cursing at staff. A nurse's note dated 9/15/16 indicated the resident was very agitated, yelling, screaming and very uncooperative with staff. A nurse's note dated 10/04/16 indicated the resident was combative and trying to strike other residents. During an interview on 10/12/16 at approximately 11:30 AM Registered Nurse (RN) #2 stated after checking the computer he/she would have to contact medical records to see if the UA lab results were available. An interview on 10/12/16 at approximately 11:41 AM with RN #2 revealed he/she could not find lab results or anything to indicate the resident went out to have the laboratory services done as ordered. RN# confirmed the 9/22/16 lab was not done as ordered.",2020-09-01
945,POINSETT REHABILITATION AND HEALTHCARE CENTER,425102,8 NORTH TEXAS AVENUE,GREENVILLE,SC,29611,2017-11-20,223,D,1,0,ZQI511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure resident freedom from involuntary seclusion for 1 of 3 residents reviewed for seclusion. Resident #2 was involuntarily secluded in his/her room by Certified Nursing Assistant (CNA) #2 on 6/24/17. The findings included: The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Review of facility investigation of involuntary seclusion on 11/19/17 at approximately 4:40 PM revealed the Risk Manager messaged the Greenville County Sheriff explaining that Resident #2 was involuntarily secluded by CNA #2 who was suspended. Review of facility investigation of involuntary seclusion on 11/19/17 at approximately 4:50 PM revealed that CNA #4 went to Resident #2's room several times because the call light was on and found each time that CNA #2 had blocked the door with the chair. S/he walked by the door once more and heard the doorknob turning. Believing that Resident #2 was trying to leave his/her room, CNA #4 informed the nurse. Review of facility investigation of involuntary seclusion on 11/19/17 at approximately 4:55 PM revealed that CNA #3 did not see anything, but heard knocking on the door of Resident #2's room. S/he believed it sounded like someone trying to leave the room. Review of facility investigation of involuntary seclusion on 11/19/17 at approximately 5 PM revealed that CNA #4 reported to Licensed [MEDICATION NAME] Nurse (LPN) #2 that Resident #2 was being confined to his/her room by CNA #2. LPN #2 forced open the door to find CNA #2 sitting in chair in front of door. LPN #2 explained that the door cannot be blocked. Resident #2 was found to be agitated and immediately left the room. Review of facility investigation of involuntary seclusion on 11/20/17 at approximately 8:40 PM revealed CNA #2 was with Resident #2 in his/her room and was encouraging him/her to finish his/her supper but the resident kept getting up and down. The tray was taken from the resident's room by another CNA. A nurse told CNA #2 that we cannot keep him/her in the room and CNA #2 explained s/he wanted him/her to finish his/her supper. CNA #2 took the resident out and Resident #2 looked tired and confused and almost fell three times. They made it to Station 1 and went in room [ROOM NUMBER] and the nurse from the agency told CNA #2 to walk him/her out. CNA #2 said s/he would let out the resident slowly because s/he is one on one. Soon after a nurse told CNA #2 to leave and stated that CNA #2 was keeping Resident #2 from leaving the room. Interview with CNA #2 on 11/20/17 at approximately 10 AM revealed that CNA #2 left the door cracked. The door, CNA #2 stated, was not closed or blocked. CNA #2 stated s/he was encouraging Resident #2 to finish his/her supper. Interview with CNA #3 on 11/20/17 at approximately 10:10 AM revealed that CNA #3 was passing trays. S/he heard Resident #2 knocking on the door and trying to get out. CNA #3 tried to locate the resident's CNA. CNA #4, the resident's CNA, tried to open the door but found it blocked by the sitter. CNA #3 admitted s/he did not witness CNA #4 trying to force open the blocked door, and only heard about it after. Interview with CNA #4 on 11/20/17 at approximately 11:05 AM revealed that around lunch CNA #4 knocked on the door and tried to open it. S/he found the sitter's chair was in the way but assumed it was an accident at that time. A few hours later CNA #4 heard the doorknob turning and realized Resident #2 was trying to leave. S/he did not hear CNA #2's explanation but went to find the nurse. Interview with the Director of Nursing (DON) on 11/20/17 at approximately 3 PM revealed that LPN #2 called the DON at home to explain that Resident #2's door had been blocked. LPN #2 stated that CNA #4 informed her of this, and when LPN #2 went to open the door, it had to be forced open because the sitter--CNA #2-- had been blocking it with his/her chair. The DON told CNA #2 to leave the building. Interview with the DON on 11/20/17 at approximately 3:35 PM revealed that CNA #2 told the DON that the reason Resident #2's door was blocked was because s/he kept getting up and down and the CNA wanted to keep him/her in his/her bed so the resident would take a nap.",2020-09-01
946,POINSETT REHABILITATION AND HEALTHCARE CENTER,425102,8 NORTH TEXAS AVENUE,GREENVILLE,SC,29611,2017-11-20,224,G,1,0,ZQI511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and interviews, the facility failed to ensure that each resident remained free from neglect for 1 of 4 sampled residents reviewed. Resident #3 was found to have an Anterior Shoulder dislocation on 9/23/17. The facility's investigation revealed that one Certified Nursing Aide (CNA) transferred the resident using a stand lift. The findings included: The facility admitted Resident #3 with [DIAGNOSES REDACTED]. An observation and interview on 11/19/17 at approximately 4:40 PM revealed Resident #3 seated in wheel chair in room. Resident #3 could not recall the date, time or CNA involved in the incident that occurred on 9/23/17. Record review on 11/20/17 revealed a Quarterly Minimum Data Set ((MDS) dated [DATE] and a Significant change MDS dated [DATE] that indicated the resident had a Brief Interview of Mental Status (BI[CONDITION]) score of 6 (6 indicated resident not interview-able). Further record review revealed a nurse's note dated 9/20/17 that indicated a CNA lowered the resident to the floor because the resident was needing repositioned in w/c (wheel chair) and the CNA attempted to pull up resident with sling pad and the resident tried to sit on the floor. There was no documentation to indicate that two (2) CNA tried to position the resident in wheel chair while using a sling pad. The nurse's note also indicated an agency CNA was involved in the care of the resident. A nurse's note dated 9/23/17 indicated Resident #3 fell from a stand lift reportedly because an agency CNA did not realized the resident was unable to stand until the resident was off the bed. The nurse's note further indicated the facility nurse explained to the agency CNA after the incident that two (2) staff members are required for transfer with stand or sling lift. Per the nurse's note the resident was sent out to the hospital and returned with Rt (right) arm in sling, for support, support to be kept in place, in order to prevent dislocation of shoulder until assessment. A review of a radiology report dated 9/23/17 indicated Resident #3 had an Anterior Shoulder Dislocation. A review of an undated Nurse Aide's Information Sheet revealed the Resident #3 required two (2) staff assist with activities of daily living. A review of the care plan initiated on 9/14/16 revealed assist with transfers time 2 staff members using hoyer lift and assist with mobility. A review of the facility's witness statement written by the agency Certified Nursing Aide (CNA) involved in the incident that cause the dislocation of Resident #3 shoulder, revealed he/she was aware that the resident required another staff member when using a mechanical lift. The written statement by the CNA further indicated he/she used the wrong lift and did not get another staff member to assist. An interview on 11/20/17 at approximately 10:05 AM with the Director of Nursing (DON) confirmed that Resident #3 required two staff assist with transfer. The DON stated the agency CNA was dismissed and will no longer be allowed back to the facility. The incident report for 9/20/17 was requested by the surveyor but not received at time of exit from the facility. An interview on 11/20/17 at approximately 10:25 AM with the Medical Director revealed he/she examined Resident #3 on 9/25/17 and that the resident had a dislocation of the right shoulder which was not broken or fractured. The Medical Director further stated he/she was told the resident had a fall but not the circumstances of the fall. The Medical Director stated staff should have followed instructions of the care plan and personal care record. The Medical Director stated there was protocol in place and there should be policy to avoid incidents like this in the future. A telephone call was made of 11/20/17 at approximately 2:10 PM with the agency CNA involved in incident. There was no answer.",2020-09-01
947,POINSETT REHABILITATION AND HEALTHCARE CENTER,425102,8 NORTH TEXAS AVENUE,GREENVILLE,SC,29611,2017-11-20,226,G,1,0,ZQI511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interviews and review of the facility's abuse policy and procedures, the facility failed to ensure that policy and procedures were being implemented for 2 of 5 sampled residents reviewed. Resident #3 was found to have an Anterior Shoulder dislocation on 9/23/17 in which the facility's investigation revealed that one Certified Nursing Aide (CNA) transferred the resident using a stand lift. Resident #2 was involuntarily secluded in his/her room by Certified Nursing Assistant (CNA) #2 on 6/24/17. There was nothing in the abuse policy and procedures that addressed agency staff. The findings included: The facility admitted Resident #3 with [DIAGNOSES REDACTED]. Record review on 11/20/17 revealed a nurse's note dated 9/20/17 that indicated a CNA lowered the resident to the floor because the resident was needing repositioned in w/c (wheel chair) and the CNA attempted to pull up resident with sling pad and the resident tried to sit on the floor. There was no documentation to indicate that two (2) CNA tried to position the resident in wheel chair while using a sling pad. The nurse's note also indicated an agency CNA was involved in the care of the resident. A nurse's note dated 9/23/17 indicated Resident #3 fell from a stand lift reportedly because an agency CNA did not realized the resident was unable to stand until the resident was off the bed. The nurse's note further indicated the facility nurse explained to the agency CNA after the incident that two (2) staff members are required for transfer with stand or sling lift. Per the nurse's note the resident was sent out to the hospital and returned with Rt (right) arm in sling, for support, support to be kept in place, in order to prevent dislocation of shoulder until assessment. A review of a radiology report dated 9/23/17 indicated Resident #3 had an Anterior Shoulder Dislocation. A review of an undated Nurse Aide's Information Sheet revealed the Resident #3 required two (2) staff assist with activities of daily living. A review of the facility's witness statement written by the agency Certified Nursing Aide (CNA) involved in the incident that cause the dislocation of Resident #3 shoulder, revealed he/she was aware that the resident required another staff member when using a mechanical lift. The written statement by the CNA further indicated he/she used the wrong lift and did not get another staff member to assist. An interview on 11/20/17 at approximately 10:05 AM with the Director of Nursing (DON) confirmed that Resident #3 required two staff assist with transfer. The DON stated the agency CNA was dismissed and will no longer be allowed back to the facility. An interview on 11/20/17 at approximately 10:25 AM with the Medical Director revealed he/she saw Resident #3 on 9/25/17 and that the resident had a dislocation of the right shoulder which was not broken or fractured. The Medical Director further stated he/she was told the resident had a fall but not the circumstances of the fall. The Medical Director stated staff should have followed instructions of the care plan and personal care record. The Medical Director stated there was protocol in place and there should be policy to avoid incidents like this in the future. A review of the facility's abuse policy and procedures under ABUSE PREVENTION PROGRAM revealed Verbal, sexual, physical, and mental abuse, corporal punishment, neglect and involuntary seclusion of the resident, resident exploitation as well as misappropriation of resident property, are prohibited. In order to provide a safe environment for the residents. The policy further indicated that staff will receive training at orientation and on-going on how to recognize signs of burnout, frustration and stress that may lead to abuse. The policy had a revised date of September 2016. There was no in the facility's abuse policy and procedures that addressed the use of agency CNA and the training agency staff would receive to ensure the facility policy/guidelines would be followed while working in the facility. An interview on 11/20/17 at 12:20 PM with Staff Development Coordinator revealed the facility did not have a training record for agency staff to show documentation of training. The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Review of facility investigation of involuntary seclusion on 11/19/17 at approximately 4:40 PM revealed the Risk Manager messaged the Greenville County Sheriff explaining that Resident #2 was involuntarily secluded by CNA #2 who was suspended. Review of facility investigation of involuntary seclusion on 11/19/17 at approximately 4:50 PM revealed that CNA #4 went to Resident #2's room several times because the call light was on and found each time that CNA #2 had blocked the door with the chair. S/he walked by the door once more and heard the doorknob turning. Believing that Resident #2 was trying to leave his/her room, CNA #4 informed the nurse. Review of facility investigation of involuntary seclusion on 11/19/17 at approximately 4:55 PM revealed that CNA #3 did not see anything, but heard knocking on the door of Resident #2's room. S/he believed it sounded like someone trying to leave the room. Review of facility investigation of involuntary seclusion on 11/19/17 at approximately 5 PM revealed that CNA #4 reported to Licensed [MEDICATION NAME] Nurse (LPN) #2 that Resident #2 was being confined to his/her room by CNA #2. LPN #2 forced open the door to find CNA #2 sitting in chair in front of door. LPN #2 explained that the door cannot be blocked. Resident #2 was found to be agitated and immediately left the room. Review of facility investigation of involuntary seclusion on 11/20/17 at approximately 8:40 PM revealed CNA #2 was with Resident #2 in his/her room was encouraging him/her to finish his/her supper but the resident kept getting up and down. The tray was taken from the resident's room by another CNA. A nurse told CNA #2 that we cannot keep him/her in the room and CNA #2 explained she wanted him/her to finish his/her supper. CNA #2 took the resident out and Resident #2 looked tired and confused and almost fell three times. They made it to Station 1 and went in room [ROOM NUMBER] and the nurse from the agency told CNA #2 to walk him/her out. CNA #2 said s/he would let out the resident slowly because s/he is one on one. Soon after a nurse told CNA #2 to leave and stated that CNA #2 was keeping Resident #2 from leaving the room. Interview with CNA #2 on 11/20/17 at approximately 10 AM revealed that CNA #2 left the door cracked. The door, CNA #2 stated, was not closed or blocked. CNA #2 stated s/he was encouraging Resident #2 to finish his supper. Interview with CNA #3 on 11/20/17 at approximately 10:10 AM revealed that CNA #3 was passing trays. S/he heard Resident #2 knocking on the door and trying to get out. CNA #3 tried to locate the resident's CNA. CNA #4, the resident's CNA, tried to open the door but found it blocked by the sitter. CNA #3 admitted s/he did not witness CNA #4 trying to force open the blocked door, and only heard about it after. Interview with CNA #4 on 11/20/17 at approximately 11:05 AM revealed that around lunch CNA #4 knocked on the door and tried to open it. S/he found the sitter's chair was in the way but assumed it was an accident at that time. A few hours later CNA #4 heard the doorknob turning and realized Resident #2 was trying to leave. S/he did not hear CNA #2's explanation but went to find the nurse. Interview with the Director of Nursing (DON) on 11/20/17 at approximately 3 PM revealed that LPN #2 called the DON at home to explain that Resident #2's door had been blocked. LPN #2 stated that CNA #4 informed her of this, and when LPN #2 went to open the door, it had to be forced open because the sitter--CNA #2-- had been blocking it with his/her chair. The DON told CNA #2 to leave the building. Interview with the DON on 11/20/17 at approximately 3:35 PM revealed that CNA #2 told the DON that the reason Resident #2's door was blocked was because s/he kept getting up and down and the CNA wanted to keep him/her in his/her bed so the resident would take a nap.",2020-09-01
948,POINSETT REHABILITATION AND HEALTHCARE CENTER,425102,8 NORTH TEXAS AVENUE,GREENVILLE,SC,29611,2017-11-20,282,G,1,0,ZQI511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interviews, the facility failed to ensure that each resident's care plan was followed 1 of 8 sampled residents reviewed for falls. Resident #3 care plan was not followed which resulted in an Anterior Shoulder dislocation on 9/23/17. The facility's investigation revealed that one Certified Nursing Aide (CNA) transferred the resident using a stand lift while the care plan indicated the resident was to be transfer with 2 staff members when a lift was used. The findings included: The facility admitted Resident #3 with [DIAGNOSES REDACTED]. Record review on 11/20/17 revealed a Quarterly Minimum Data Set ((MDS) dated [DATE] and a Significant change MDS dated [DATE] that indicated the resident had a Brief Interview of Mental Status (BI[CONDITION]) score of 6 (6 indicated resident not interview-able). Further record review revealed a nurse's note dated 9/20/17 that indicated a CNA lowered the resident to the floor because the resident was needing repositioned in w/c (wheel chair) and the CNA attempted to pull up resident with sling pad and the resident tried to sit on the floor. There was no documentation to indicate that two (2) CNA tried to position the resident in wheel chair while using a sling pad. The nurse's note also indicated an agency CNA was involved in the care of the resident. A nurse's note dated 9/23/17 indicated Resident #3 fell from a stand lift reportedly because an agency CNA did not realized the resident was unable to stand until the resident was off the bed. The nurse's note further indicated the facility nurse explained to the agency CNA after the incident that two (2) staff members are required for transfer with stand or sling lift. Per the nurse's note the resident was sent out to the hospital and returned with Rt (right) arm in sling, for support, support to be kept in place, in order to prevent dislocation of shoulder until assessment. A review of a radiology report dated 9/23/17 indicated Resident #3 had an Anterior Shoulder Dislocation. A review of an undated Nurse Aide's Information Sheet revealed the Resident #3 required two (2) staff assist with activities of daily living. A review of the care plan initiated on 9/14/16 revealed assist with transfers time 2 staff members using hoyer lift and assist with mobility. A review of the facility's witness statement written by the agency Certified Nursing Aide (CNA) involved in the incident that cause the dislocation of Resident #3 shoulder, revealed he/she was aware that the resident required another staff member when using a mechanical lift. The written statement by the CNA further indicated he/she used the wrong lift and did not get another staff member to assist. An interview on 11/20/17 at approximately 9:55 AM with Licensed Practical Nurse (LPN) #1 who coordinates the care plan confirmed Resident #3 required two (2) staff members assist with transfer when using a lift. LPN #1 further stated the care plan for two (2) staff members assist with transfer was developed on 9/14/16. LPN further stated that the facility had contacted the contract agency on 9/20/17 abuse an agency CNA due to the incident that occurred on 9/20/17 with Resident #3. An interview on 11/20/17 at approximately 10:05 AM with the Director of Nursing (DON) confirmed that Resident #3 required two staff assist with transfer. The DON stated the agency CNA was dismissed and will no longer be allowed back to the facility. An interview on 11/20/17 at approximately 10:25 AM with the Medical Director revealed he/she saw Resident #3 on 9/25/17 and that the resident had a dislocation of the right shoulder which was not broken or fractured. The Medical Director further stated he/she was told the resident had a fall but not the circumstances of the fall. The Medical Director stated staff should have followed instructions of the care plan and personal care record. The Medical Director stated there was protocol in place and there should be policy to avoid incidents like this in the future.",2020-09-01
949,POINSETT REHABILITATION AND HEALTHCARE CENTER,425102,8 NORTH TEXAS AVENUE,GREENVILLE,SC,29611,2017-11-20,323,G,1,0,ZQI511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and interviews, the facility failed to ensure that each resident received supervision and/or have interventions in place to prevent accidents for 2 of 8 sampled residents reviewed for falls. Resident #4 was found to have an Acute Right Hip Intertrochanteric Fracture due to fall on 9/14/17 while receiving care. Resident #1 was assessed as a falls risk with no timely interventions put in place to prevent further falls. The findings included: The facility admitted Resident #4 with [DIAGNOSES REDACTED]. An observation and interview on 11/19/17 at approximately 3:50 PM revealed Resident #4 in fetal position while in bed. The resident was observed to be petite and frail. Resident did not respond to greeting, he/she just looked at surveyor. Record review on 11/19/17 at approximately 4:53 PM revealed a Quarterly Minimum Data Set ((MDS) dated [DATE] that indicated the resident had a Brief Interview of Mental Status (BI[CONDITION]) score of 7 and a Significant change MDS dated [DATE] that indicated the resident had a Brief Interview of Mental Status (BI[CONDITION]) score of 6 (6-7 indicated resident not interview-able). Further record review revealed there was no nurse's note dated at the time of the 9/14/17 fall. There was an incident report that indicated the resident fell from bed to the floor. The facility's Five-Day Follow-Up Report dated 9/18/17 and staff turned to get supplies and resident was observed sitting on floor. The Five Day Report further indicated the resident's radiology report showed the resident had an Acute Right intertrochanteric Fracture. A review of the radiology report dated 9/14/17 revealed no dislocation or destructive bony process and there was no soft tissue abnormality. The radiology report indicated there was an Acute right hip intertrochanteric fracture. Osseous structures are osteopenic. An interview on 11/20/17 at approximately 8:30 AM with Licensed Practical Nurse (LPN) #3 revealed that he/she was the nurse on duty at time of the fall. LPN #3 stated he/she did not witness the fall but stated CNA #1 had the resident sitting on the side of the bed like he/she usually does when the resident fell to the floor. A review of the facility's witness statement written by Certified Nursing Aide (CNA) #1 revealed he/she had Resident #4 sitting on the side of the bed like he/she always does; he/she turned to get some things and the resident was on the floor. An interview on 11/20/17 at approximately 10:40 AM with the Medical Director revealed he/she was informed that Resident #4 fell out of bed. The Medical Director stated he/she was no aware staff had resident sitting on side of bed at the time of the fall. The Medical Director stated he/she did not think the resident was capable of sitting on side of bed due to postural condition. An interview on 11/20/17 at approximately 10:47 AM with CNA #1 confirmed his/her written statement and stated he/she usually sit up the resident on side of bed like he/she always do. CNA #1 stated he/she turned his/her back to the resident to get the resident shirt from bedside table and the resident fell to floor. The CNA stated the bed side table was no more than 4 feet away and the resident fell so fast. The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Record review of a Fall Risk assessment, dated 6/9/2017, on 11/20/2017 at 10:41 AM revealed that Resident #1 had a Fall Risk score of 10 indicating the resident was a high fall risk. Record review of the Nurse's Notes on 11/20/2017 at 11:03 AM revealed a note from 6/21/2017 indicating the resident had fallen out of bed. Staff heard a thump and observed resident on floor laying on right side with no apparent injuries noted. Review of the Incident Report (dated 6/21/2017 at 2:45 AM) for the fall on 11/20/2017 at 10:41 AM revealed the facility implemented a fall mat to the floor and pillows to the bed to prevent the resident from sliding off the air mattress and falling out of bed. The Incident Report indicated the resident did not suffer any injuries. Review of additional Nurse's Notes also revealed the resident did not suffer any injuries from the fall. Review of the Interim Care Plan on 11/20/2017 at 9:17 AM revealed a problem area for falls with interventions. However, Falls was not selected as a risk area on the Interim Care Plan and none of the interventions were checked to indicate they had been implemented. Record review of the resident's Comprehensive Care Plan on 11/20/2017 at 10:51 AM revealed that the resident's Risk for Falls had been care planned for on 6/21/2017. All interventions to prevent falls were also initiated on 6/21/2017, including but not limited to, use of a bed alarm and keep bed in lowest position. Review of the Nurse Aide's Information Sheet revealed interventions including bed alarm, bed in lowest position and floor mats on both sides of bed. There was not a date to indicate when these interventions were implemented. There was no other documentation to indicate fall prevention interventions had been implemented prior to 6/21/2017. During an interview with the Director of Nursing (DON) on 11/20/2017 at 11:35 AM the DON confirmed that the resident was assessed as a high fall risk on admission. The DON also confirmed that Fall Risk and associated interventions were not initiated on the Interim Care Plan on admission. During an interview with the DON on 11/20/2017 at 12:12 PM the DON stated she/he completed the Interim Care Plan on admission. The DON stated the Fall Risk area of the Interim Care Plan was left blank because the resident's electronic (computer) Fall Risk assessment indicated the resident was a high fall risk. The DON stated the Fall Risk assessment should have triggered Fall Risk and interventions on the electronic (computer) Comprehensive Plan of Care. The DON explained the facility was transitioning to an electronic medical record at the time and away from the paper Interim Care Plans. The DON stated that whenever a resident is assessed as a high fall risk the computer Fall Risk assessment triggers Fall Risk on the computer Care Plan. The DON did not know why Fall Risk and interventions did not trigger to the computer care plan. The DON stated that side rails were implemented on admission for safety and did have documentation of this. The DON confirmed that the resident's Fall Risk and interventions were not initiated until 6/21/2017, after the resident fell from bed to the floor. During an interview with the resident's family member on 11/20/2017 at 8:50 AM, the family member stated the facility did not implement appropriate fall prevention interventions until after the resident fell from bed.",2020-09-01
950,JOHN EDWARD HARTER NURSING CENTER,425103,185 REVOLUTIONARY TRAIL,FAIRFAX,SC,29827,2017-01-05,372,E,0,1,9V7Y11,"Based on observation and interviews, the facility failed to maintain the grease disposal system according to regulations. The findings included: During an observation on 01/05/17 at 12:42 pm along with the Dietary Manager (DM) the grease disposal container was observed to be sitting partially off of its concrete platform. It was also observed to have dark, caked grease spillage along the back end and covering a plastic trash can lid that was lying beside the container. In an interview on 01/05/17 at 12:51 pm, the DM stated that the fryers are cleaned weekly and the grease is placed in the container. The DM did not have any information on the vendor who maintains the container. In an interview on 01/05/17 at 1:04 pm the Administrator stated a maintenance company comes in and pumps out the grease quarterly but was not sure how the container was emptied.",2020-09-01
951,JOHN EDWARD HARTER NURSING CENTER,425103,185 REVOLUTIONARY TRAIL,FAIRFAX,SC,29827,2018-03-15,851,B,0,1,UZQ111,"Based on observation and limited record reviews, the facility failed to electronically submit to the Centers for Medicare and Medicaid Services (CMS) complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS for the 1st, 2nd, and 4th quarters of Fiscal Year (FY) (YEAR), and the 1st quarter of FY (YEAR). Reports for 4 out of 5 quarters reviewed for FY (YEAR) and FY (YEAR). The findings included: Review of the Certification And Survey Provider Enhanced Report (CASPER) report 1702S Staffing Summary Reports for FY (YEAR) and the first quarter of FY (YEAR) generated 3/8/2018, on 3/13/18 at 5:30 PM revealed that report results for the following dates had no data returned for selected criteria for[NAME]Edward Harter Nursing Center: 10/01/2016 thru 12/31/2016-first quarter FY (YEAR) 01/01/2017 thru 03/31/2017-second quarter of FY (YEAR) 07/01/2017 thru 09/30/2017-third quarter of FY (YEAR) 10/01/2017 thru 12/31/2017-first quarter of FY (YEAR) Further review of the results of CASPER report 1702S Staffing Summary Report for the third quarter of FY (YEAR) (04/01/2017 thru 06/30/2017) revealed required information regarding staffing for this time frame that was submitted 07/18/2017, within the regulatory time frame of 45 days after the last day in the fiscal quarter. During interview with Director of Nursing (DON) and Minimum Data Set (MDS) nurse on 3/13/18 at 6:00 PM, they verified that there was no staffing data submitted for the first, second and third quarter of FY (YEAR) and the first quarter of FY (YEAR). DON reported that the Human Resources Manager (HRM) is responsible for submission of the information to the CMS database. Both DON and MDS nurse reported that they had verbalized concerns regarding submission of the staffing information when they had reviewed Quality Measures/5 Star Reporting information, but were assured that the information was being submitted as required by the HRM. During interview with HRM on 3/14/18 at 9:55 AM, when asked for a copy of the policy regarding submission of the Payroll Based Journal (PBJ) files regarding staffing to the CMS database, s/he replied that there was no policy. When asked to describe the process that s/he followed when submitting the PBJ files regarding staffing to the CMS database, s/he replied that the information was submitted via the CMS transmission website quarterly. S/he further reported that there had been a data entry error regarding the facility identification (ID) information provided during submission, stating that the SC was not entered as a part of the facility ID, and this was why the files were rejected. S/he reported that all of the information had been re-submitted the morning of 3/14/18 prior to the interview. HRM later returned at 10:39 AM and provided a policy,[NAME]Edward Harter Nursing Center Payroll Based Journal-Electronic Staffing Data Submission. When asked to clarify when asked if there was a policy earlier, surveyor was told that there was no policy, HRM did not reply. Review of documentation provided by HRM on 3/14/18 at 10:18 revealed a photocopy of the original submission report for submission ID 89, which was submitted to the CMS PBJ database on 7/17/17 at 12:22 PM. The information in this file reflected the staffing information for 01/01/17-03/31/17. The report was rejected due to a fatal error related to invalid facility ID. Additional information provided to reflect resubmission of information on 3/14/18 at 09:42 AM with submission ID 26 with pending final validation that file was accepted. Review of photocopy of PBJ Submitter Final Validation Report provided by HRM on 3/14/18 at 11:56 AM revealed that the information was accepted with a processing completion date/time of 03/14/2018 at 9:42 AM with a message 4009/WARNING: The record was submitted more than 45 days after the end of the Federal Fiscal Quarter. Review of documentation provided by HRM on 3/14/18 at 10:18 revealed a photocopy of the original submission report for submission ID 95, which was submitted to the CMS PBJ database on 7/18/17 at 09:38 AM. Review of photocopy of PBJ Submitter Final Validation Report provided by revealed that the information was accepted with a processing completion date/time of 7/18/17 at 9:39 AM. The information in this file reflected the staffing information for 04/01/17-06/30/17. This information was originally sent and accepted within the regulatory guideline timeframe of 45 days. Review of documentation provided by HRM on 3/14/18 at 10:18 revealed a photocopy of the original submission report for submission ID 921 which was submitted to the CMS PBJ database on 10/03/2017 at 3:02 PM. The information in this file reflected the staffing information for 07/01/17-09/30/17. The report was rejected due to a fatal error related to invalid facility ID. Additional information provided to reflect resubmission of information on 3/14/18 at 09:46 AM with submission ID 28 with pending final validation that file was accepted. Review of photocopy of PBJ Submitter Final Validation Report provided by HRM on 3/14/18 at 11:56 AM revealed that the information was accepted with a processing completion date/time of 03/14/2018 at 9:46 AM with a message 4009/WARNING: The record was submitted more than 45 days after the end of the Federal Fiscal Quarter. Review of documentation provided by HRM on 3/14/18 at 10:18 revealed a photocopy of the original submission report for submission ID 27, which was submitted to the CMS PBJ database on 02/15/2018 at 09:55 AM. The information in this file reflected the staffing information for 10/01/17-12/31/17. The report was rejected due to a fatal error related to invalid facility ID. Additional information provided to reflect resubmission of information on 3/14/18 at 09:46 AM with submission ID 28 with pending final validation that file was accepted. Review of photocopy of PBJ Submitter Final Validation Report provided by HRM on 3/14/18 at 1:27 PM revealed that the information was accepted with a processing completion date/time of 03/14/2018 at 1:16 PM with a message 4009/WARNING: The record was submitted more than 45 days after the end of the Federal Fiscal Quarter. Despite requests, no information was provided regarding the transmission information regarding the first quarter of FY (YEAR), which included the dates 10/1/2016-12/31/2016. Review of the[NAME]Edward Harter Nursing Center Payroll Based Journal-Electronic Staffing Data Submission policy and procedure information provided by the HRM on 3/14/18 at 10:39 AM revealed that the submission will be done on a quarterly basis and that when the report has been successfully submitted to CMS, the facility should receive a confirmation sheet with ID#, including a date and time stamp.",2020-09-01
952,PRUITTHEALTH- BAMBERG,425104,439 NORTH STREET,BAMBERG,SC,29003,2020-01-10,623,E,1,1,S0WQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Amended February 11, 2020 Based on record review and interview, the facility failed to give the resident and the resident representative in writing a notice of transfer in a language understood for 1 of 3 residents reviewed for hospitalization . Resident #78 admitted to hospital with no evidence of notice of transfer given to resident and resident representative. The findings included: The facility admitted Resident #78 with [DIAGNOSES REDACTED]. Record review on 1/8/20 at 5:43 PM revealed the resident was transferred to the hospital on [DATE], 10/14/19, 10/23/19, [DATE], and 1/7/20. Further review of the medical record revealed there was no documentation the resident or the resident representative received a written notice of transfer. During an interview with the Director of Nursing on [DATE] at approximately 11:00 AM, s/he confirmed the transfer forms were not issued to the resident or the resident representative.",2020-09-01
953,PRUITTHEALTH- BAMBERG,425104,439 NORTH STREET,BAMBERG,SC,29003,2020-01-10,625,E,1,1,S0WQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Amended February 11, 2020 Based on record review and interview, the facility failed to issue a bed hold notice to the resident representative upon discharge for 1 of 3 residents reviewed for hospitalization . Resident #78 admitted to hospital with no evidence a bed hold notice was issued. The findings included: The facility admitted Resident #78 with [DIAGNOSES REDACTED]. Record review on 1/8/20 at 5:43 PM revealed the resident was transferred to the hospital on [DATE], 10/14/19, 10/23/19, [DATE], and 1/7/20. Further review of the medical record revealed there was no documentation the resident representative received a bed hold notice. During an interview with the Director of Nursing on [DATE] at approximately 11:00 AM, s/he stated a bed hold notice was not issued due to the resident being private pay. Review of the facility bed detail revealed all [AGE] beds were certified.",2020-09-01
954,PRUITTHEALTH- BAMBERG,425104,439 NORTH STREET,BAMBERG,SC,29003,2020-01-10,658,E,1,1,S0WQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Amended February 11, 2020 Based on observations, record reviews and interviews the facility failed to assure that care and services were provided according to accepted standards of clinical practice for 1 of 5 residents reviewed for unnecessary medications. Resident #12 had two different physician orders [REDACTED]. An interview with the Director of Nursing (DON) revealed that the nursing staff providing care to Resident #12 failed to realize there were two different orders in place for finger stick blood sugar testing resulting in additional finger sticks. An interview with Licenses Practical Nurse (LPN) #3 revealed that s/he was aware that the orders were confusing but failed to report this to the DON. The findings included: Resident #12 had been admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/08/20, at approximately 3:47 PM, a random medical record observation revealed that Resident #12 had two different physician orders [REDACTED]. On 1/8/20 at approximately 4:04 PM, LPN #3 stated that the orders were confusing and that he/she had been intending to report this to the DON (Director of Nursing) but had not done so. On 1/8/20 at approximately 4:37 PM, the Surveyor made the DON aware of the finger stick blood sugar testing concerns related to Resident #12. On 1/8/10 at approximately 5:20 PM, a review of physician's orders [REDACTED]. The first was an opened ended physician order [REDACTED]. Blood Sugar is less than [AGE], Call MD. If Blood Sugar is 151 to 200, give 2 Units. If Blood Sugar is 201 to 250, give 4 Units. If Blood Sugar is 251 to 300, Give 6 Units. If Blood Sugar is 301 to 350, Give 8 Units. If blood Sugar is 351 to 400, give 10 Units. If Blood Sugar is greater than 400, call MD. Three times a Day; 07:30 AM, 11:30 PM, 05:30 PM. After reviewing Resident #12's medical record it revealed that Resident #12 was being tested ,[DATE] times daily for blood sugar levels. On 1/8/20 at approximately 5:40 PM, the DON stated that Resident #12 was being tested too frequently, and that the resident had been in and out of the hospital due to [MEDICAL CONDITION] and agreed to generate all physician orders [REDACTED]. On 1/8/20 at approximately 5:55 PM the DON stated that somewhere along the way three different nurses had failed to realize that there were two different orders in place for finger stick blood sugar testing and that the resident was definitely getting stuck to many times per day. On 1/8/20 at approximately 5:45 PM the DON (Director of Nursing) provided a report quantifying the number of unnecessary finger stick per day since October 2019 that had been performed on Resident # 12. There was a total of 121 extras finger sticks performed 10/20/19 through 1/8/20 and they occurred as follows: October 2019 = 11, November 2019 = 28, December 2019 = 61, January 2020 = 21. On 1/9/20 at approximately 10:15 AM, these numbers were confirmed by the DON.",2020-09-01
955,PRUITTHEALTH- BAMBERG,425104,439 NORTH STREET,BAMBERG,SC,29003,2020-01-10,732,E,1,1,S0WQ11,"> Amended February 11, 2020 Based on record review and interview, the facility failed to post accurate daily staffing postings for 31 of 31 days reviewed. Postings observed with incomplete census and/or staff and inaccurate total number of hours worked. The findings included: Review of the facility postings on [DATE] at 11:00 revealed the following: 12/1-31/ 2019-all with inaccurate total of number of hours worked; 12/1, 3, 6, 7, 9, 15, 17, 19, 20, 22, 25, 27, 28, 29, 30, 31/2019- census not documented each shift; 12/1, 3, 6, 19, 20, 22/ 2019 licensed and non- licensed staff incomplete ; 12/1, 9, 22/ 2019-shift supervisor not documented. During an interview with the Director of Nursing on [DATE] at 8:15 AM, s/he confirmed the postings were incomplete and the total number of hours worked had not been calculated. S/he stated during the week the Unit Managers were responsible for ensuring correct information was documented on the postings and the week-end supervisors were responsible to place the correct information on the posting form on the week-ends.",2020-09-01
956,PRUITTHEALTH- BAMBERG,425104,439 NORTH STREET,BAMBERG,SC,29003,2020-01-10,761,D,1,1,S0WQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations and interviews the facility failed to assure that opened, single use only sterile medications, used for treatments, were removed from 2 of 6 medication carts. The findings included: On 1/07/20 at approximately 12:16 PM, inspection of the Hall 200 Treatment Cart revealed one opened, folded shut foil package of Curad (Xeroform Petroleum Dressing) Sterile 5 (inch) x 9 labeled by the manufacturer Single Use Only. Do Not Reuse stored in the bottom drawer. On 01/07/20 at approximately 12:20 PM LPN (Licensed Practical Nurse) #1 verified the manufacturer's labeling and that the package had been opened and stored for reuse. On 1/07/20 at approximately 12:32 PM inspection of the Hall 100 Treatment Cart revealed one opened tube of [MEDICATION NAME] Wound and Burn Dressing 1.5 oz. (ounce) labeled Sterile and Tube Sterility guaranteed in unopened, undamaged package was stored in the top drawer. On 01/07/20 at approximately 12:44 PM, LPN #2 verified the manufacturer's labeling related to single use only for sterility and that the package had been opened and stored for reuse. On 01/07/20 at approximately 2:18 PM LPN #1 stated that he/she did not realize that the manufacturer had labeled the [MEDICATION NAME] as sterile and for single use only and verified that it had been stored for reuse.",2020-09-01
957,PRUITTHEALTH- BAMBERG,425104,439 NORTH STREET,BAMBERG,SC,29003,2020-01-10,806,D,1,1,S0WQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review, the facility failed to ensure Resident #52, 1 of 1 with Food Allergy, did not receive food items to which s/he was allergic. The findings included: The facility admitted Resident #52 with [DIAGNOSES REDACTED]. During meal observation on 01/07/19 at approximately 12:50 PM, Resident #52 was served a salmon croquette. The Resident Representative for Resident #52 was present and sent the plate back to the kitchen for a substitute. The tray card stated No seafood but listed the pureed salmon croquette as a meal item. During Record review on [DATE] at approximately 4:03 PM, a dietary order dated 11/26/19 stated Regular Diet, Pureed consistency, allergic to seafood, was noted. In an interview on 01/07/20, the Dietary Manager confirmed that the resident received fish today. S/he also reviewed the tray card and confirmed that when it states no seafood it means no fish also. Stated the tray should be checked to make sure the resident does not receive any food to which s/he is allergic. Also confirmed that the resident had received seafood/ fish previously and the family had returned it to the kitchen. In an interview on 0[DATE] at approximately 12:38 PM the Director of Nursing confirmed that the staff needs to come up with a plan to make sure it does not happen again.",2020-09-01
958,PRUITTHEALTH- BAMBERG,425104,439 NORTH STREET,BAMBERG,SC,29003,2020-01-10,880,D,1,1,S0WQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Amended February 11, 2020 Based on record review, observation, interview, and review of facility policies titled Infection Control-Linen and Laundry, Infection Control Prevention and Control Activities, Infection Control-Linen and Laundry and information from ECOLAB, the facility failed to ensure infection control procedures were adhered to for one of one laundry observation and 2 of 2 handwashing observations. During observation of the laundry, staff was observed to carry a soiled gown close to his/her uniform, no separation between clean and soiled items in the personal laundry room. In addition, two observations were made of staff entering a soiled utility room and exiting without washing or sanitizing his/her hands. The findings included: During observation of the laundry on [DATE] at 8:30 AM, Laundry Staff #1 was observed after removing a soiled gown to hold it close to his/her uniform. Observation of the laundry for personal care items revealed one door entering into a small laundry room. To the right of the door soiled items and washers were observed. To the left of the door clean items and dryers were observed. Staff was observed entering the laundry with the soiled bin and clean, uncovered items were stored within 6 inches of the doorway. Measurements from the dirty laundry bin to the clean items was approximately 7 feet 2 inches. Due to the proximity and crowded area in the laundry, Laundry Staff were asked how did s/he manage to get clean items into the dryer. S/he stated the laundry racks were moved back. This placed the clean racks midway and very close to the soiled side of the room. In addition, Laundry Staff was observed to obtain the water temperature of the washer which was 125 degrees. S/he tested the pH of the linen and stated some days it is yellow and some days it is green. When Laundry Staff #1 was asked what the parameters for the water temperature and pH should be, s/he was unable to tell the surveyor. On [DATE] at 11:04 AM, after observing pressure ulcer treatment, Licensed Practical Nurse #1 washed his/her hands, entered the soiled utility room and placed items in receptacles. S/he exited the soiled utility room without evidence of washing or sanitizing his/her hands. During an interview with the Director of Nursing on [DATE] at 4:24 PM, s/he stated staff should wash or sanitize hands after placing items in the soiled utility. Review of the facility policy titled Infection Control-Linen and Laundry revealed the following under Section 2300- Water Supply, Hygiene, and Temperature Control-D. Hot water provided for washing linen and clothing shall not be less than one hundred sixty (1[AGE]) degrees Fahrenheit. Should chlorine additives or other chemicals that contribute to the margin of safety in disinfecting linen and clothing be a part of the washing cycle, the minimum hot water temperature shall not be less than one hundred ten(110) degrees Fahrenheit, provided hot air drying is used. Review of the Fabric pH indicator by ECOLAB revealed instructions for determining the pH from a range of 4-12+ with the number 7 and 8 circled. Written instructions states if color is green or yellow that indicates a good pH. Review of the facility policy titled Infection Control Prevention and Control Activities revealed the following under the Hand Washing section: 2. Wash hands after touching blood, body fluids, secretions, excretions, and contaminated items, whether or not gloves are worn. Hands will be washed immediately after gloves are removed, between patient contact, equipment handling and when otherwise indicated to wash hands between tasks:. Review of the facility policy titled Infection Control-Linen and Laundry revealed the following: 5. Laundry Process a. Soiled laundry i. The soiled laundry area is to be clearly separate from the clean laundry area. Resident #62 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Observation of the pressure ulcer dressing change on 0[DATE]20 at 10:53 AM, Registered Nurse (RN) #1 and Licensed Practical Nurse (LPN) # 1 entered the resident's room and both washed hands and donned gloves. The RN #1 removed the soiled dressing, washed her hands with soap/water, and donned new gloves. The RN #1 measured the pressure ulcer 1.13 cm x 0.1 cm x 0.7 cm, then washed hands with soap/water. The LPN #1 washed hands and donned new gloves, cleaned wound with wound cleanser, washed hands with soap/water, and donned new gloves. The LPN #1 applied calcium alginate dressing to sacrum. The RN #1 and LPN # 1 pulled up Resident #62 in the bed, collected the trash and both washed their hands. The LPN #1 then took the trash down the hall to the soiled utility room, entered the soiled utility room and placed the trash in the bin. After leaving the soiled utility room, LPN # 1 did not wash hands with soap or water or appear to sanitize with an alcohol based rub. During an interview with the Director of Nursing on 0[DATE]20 AT 4:16 PM, the concerns about handwashing were mentioned and she confirmed that the LPN should have washed hands after placing trash in the soiled utility. A review of the facility policy titled Infection Control Prevention and Control Activities revealed that 1.) Hands should be washed often. 2.) Wash hands after touching blood, body fluids, secretions, excretions, and contaminated items, whether or not gloves are worn. Hands will be washed immediately after gloves are removed, between patient contact, equipment handling and when otherwise indicated to wash hands between tasks.",2020-09-01
959,PRUITTHEALTH- BAMBERG,425104,439 NORTH STREET,BAMBERG,SC,29003,2017-05-05,157,D,0,1,P4RY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and review of the facility's Change in Condition Policy, the facility failed to notify the family of significant changes in the resident's condition requiring potential physician intervention for one of one sampled resident reviewed for notification. The family of Resident #22 was not notified of falls that occurred on 3/22/17 and 4/30/17. The findings included: The facility admitted Resident #22 with [DIAGNOSES REDACTED]. Review of Nurse's Notes and Incident Reports on 05/04/2017 at 2:34 PM revealed that Resident #22 fell in the hallway on 3/22/17. On 4/30/17, s/he was found sitting on the floor after attempting to go to the bathroom unassisted. There was no evidence located that the family was notified of the falls. During an interview on 05/05/2017 2:36 PM, the Director of Nursing (DON) reviewed the medical record and incident reports and verified there was no evidence that the family had been notified. On 5/5/17 at 3:44 PM, the DON stated, All I have is what's on the incident report. Review of the facility's Change in Condition Policy revealed no reference to family notification.",2020-09-01
960,PRUITTHEALTH- BAMBERG,425104,439 NORTH STREET,BAMBERG,SC,29003,2017-05-05,241,D,0,1,P4RY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and review of the facility policy titled, Educating & Promoting Patient/Resident Rights, the facility failed to promote care for Resident #87, #85 and resident #72 in a manner and in an environment that maintains or enhances the resident's dignity and respect for 3 of 3 residents reviewed for Dignity. The findings included: The facility admitted Resident #87 with [DIAGNOSES REDACTED]. An observation on 5/3/2017 at approximately 11:48 AM revealed Resident #87 lying in bed and wearing a hospital gown. Review on 5/4/2017 at approximately 10:27 AM of the plan of care for Resident #87 made no mention of Resident #87's preference to wear a hospital gown daily. Review on 5/4/2017 at approximately 10:29 AM of a form titled, Nursing Monthly Observation Form, dated 1/3/2017 states, Daily Decision Making Skills, are consistent and reasonable. No mention was made on the form that Resident #87 prefers to wear a hospital gown daily. Review on 5/4/2017 at approximately 10:32 AM of the nurses notes from 1/11/2017 through 4/28/2017 made no mention that Resident #87 prefers to wear a hospital gown daily. An observation on 5/4/2017 at approximately 11:30 AM revealed Resident #87 sitting up in bed wearing a hospital gown. During an interview on 5/4/2017 at approximately 3:11 PM with Certified Nursing Assistant (CNA) #4 stated, It is definitely this resident's preference to wear a hospital gown daily. Review on 5/5/2017 at approximately 8:50 AM of a form titled, Social Services Progress Notes Form. dated 5/4/2017 at 7:15 PM included an interview with the Social Services Director and reads, In speaking with Resident #87, he/she stated, .I prefer to wear gowns, it is more comfortable. If I am going out of the building, I want to wear clothes. No documentation could be found in Resident #87's medical record to ensure wearing a hospital gown daily was his/her preference. Review on 5/5/2017 at approximately 9:10 AM of the facility policy titled, Educating and Promoting Patient/Resident Rights, states, It is the Pruitt Corporation companies' policy that the individual rights of patients/residents will be protected and safeguarded by all partners. The right to be treated with dignity. The facility admitted Resident #72 with [DIAGNOSES REDACTED]. An observation on 5/2/2017 at approximately 2:43 PM of Resident #72 revealed his/her name written with a permanent marker on the outside aspect of the collar of his/her shirt. A second observation on 5/2/2017 at approximately 3:20 PM revealed Resident #72 sitting at the nurses desk in a wheel chair and a Certified Nursing Assistant referred to him/her as grandpa on two different occasions. Review on 5/5/2017 at approximately 9:15 AM of the plan of care made no mention of a preference by Resident #72 to be called grandpa. During an interview on 5/5/2017 at approximately 10:45 AM with Licensed Practical Nurse (LPN) #2, he/she confirmed that the name was written on the outside aspect of Resident #72's shirt collar. LPN #2 also was not aware of a nickname or a preferred name that Resident #72 wished to be called other than his/her given name. During an interview on 5/5/2017 at approximately 10:50 AM with Certified Nursing Assistant (CNA) #2 he/she stated. I am not aware of any other name other than the given name for this resident. An interview on 5/5/2017 at approximately 10:55 AM confirmed that CNA #5 was not aware of a nickname or any other name other than Resident #72's given name that he/she wished to be called. During an interview on 5/5/2017 at approximately 10:55 AM with the Social Service Director, he/she was not aware of any other name than Resident #72's given name as a preference to be called when addressing him/her. The Social Service Director went on to say that he/she did not know who had written the resident's name on the outside of his/her shirt across the collar. The facility admitted Resident #85 with [DIAGNOSES REDACTED]. A random observation on 5/2/2017 at approximately 4:48 PM revealed Resident #85 asleep in bed, lying on his/her right side, with door open, the privacy curtain was not pulled and his/her torso and brief were exposed to the hallway with visitors and staff walking by the room. Review on 5/5/2017 at approximately 9:10 AM of the facility policy titled, Educating and Promoting Patient/Resident Rights, states, It is the Pruitt Corporation companies' policy that the individual rights of patients/residents will be protected and safeguarded by all partners. The right to be treated with dignity and the right to Privacy",2020-09-01
961,PRUITTHEALTH- BAMBERG,425104,439 NORTH STREET,BAMBERG,SC,29003,2017-05-05,253,E,0,1,P4RY11,"Based on observations and interviews, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly and comfortable interior on 1 of 2 Units. The findings included: Observations made on 5/2/2017 and 5/3/2017 during visits to resident rooms on the 100 Hall revealed the following. Room #102 B - 1. Geri chair with spills along the side. 2, Bottom mattress visible at the head of bed of 102 B. 3. Dried tube feeding at the head of the bed on the floor and on the pole holding tube feeding pump. 4. Dried brown/yellow substance on the wall at the bed, 5. Privacy curtain with reddish/pink stains. 6. Privacy curtain of 102 A stained. 7. Base of toilet in the bathroom has a brown substance. 8. A urinal in the bathroom was uncovered and unlabeled. Room #103 A 1. Ceiling patched but not painted. 2. Scuffed walls in need of paint. Room #104 B 1. Paint peeling on door. 2. Walls scuffed and in need of paint. 3. Three drawer handles loose and one missing on the dresser. 4. Dried spills on the drawers of the dresser. 5. Spider web above the window curtain. 6. Soiled chair seat with large brown stain visible. 7. Trash noted under the bed. 8. Wall damaged behind the bed in need of repair. 9. Ceiling with stains. 10. Two fall mats on the floor one is ripped and the second has visible stains. Room #107 B 1. Wall behind the bed is scuffed and in need of repair. Room #118 P 1. The air conditioner not working and has not worked for a period of time. Room #128 1. Large bug crawling about in the bathroom. Further observations made on the 200 Hall included: Room #208 B 1. Bathroom floor has dark stains. 2. Baseboards in the bathroom are soiled and stained. 3. Base of the commode has rusty/dirty substance. Room #218 A 1, Bathroom floor is dirty. 2. Bucket and grey pan sitting on the bathroom floor. 3. Privacy curtain with stains. 4. The elevated toilet seat has rust stains. During rounds on 5/5/2017 at approximately 8:00 PM the Administrator and the Housekeeping Supervisor verified the above findings.",2020-09-01
962,PRUITTHEALTH- BAMBERG,425104,439 NORTH STREET,BAMBERG,SC,29003,2017-05-05,256,D,0,1,P4RY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to ensure adequate and comfortable lighting in 3 resident rooms on the 100 Hall of 1 of 2 units. The findings included: During observations on 5/2/2017 and 5/3/2017 revealed the following: 1. Two lights out in room [ROOM NUMBER] on the 100 Hall. 2. room [ROOM NUMBER] on the 100 Hall the light is out over the sink in the room and the light is out in the bathroom and has a cracked cover. 3. room [ROOM NUMBER] on the 100 Hall has the light out in the bathroom. During rounds on 5/5/2017 at approximately 8:00 PM the Administrator and the Housekeeping Supervisor verified the findings on the 100 Hall.",2020-09-01
963,PRUITTHEALTH- BAMBERG,425104,439 NORTH STREET,BAMBERG,SC,29003,2017-05-05,278,D,0,1,P4RY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to accurately ensure the Minimum Data Set (MDS) was accurate for 1 of 3 for pressure ulcers, 1 of 3 for nutritional status, and 1 of 5 for medications. Resident #22's (MDS) was inaccurate related to medications, Resident #27's MDS was inaccurately coded for nutritional status, Resident #95's MDS inaccurately reflected pressure ulcer staging. The findings included, Resident #27 was admitted with [DIAGNOSES REDACTED]. Record review on [DATE] at 2:30 PM Resident #27's Quarterly MDS dated [DATE] revealed that Section K was incorrectly documented a therapeutic diet and should have been documented as a Mechanically Altered diet. Record review on [DATE] at approximately 2:00 PM revealed current physician's orders [REDACTED]. Further review of the Annual MDS dated [DATE] revealed weight loss had been incorrectly coded. On [DATE] at 3:30 PM, an interview with the MDS coordinator verified that Section K on MDS dated [DATE] was incorrectly coded for therapeutic diet and that the Section K on the MDS dated [DATE] was coded incorrectly for physician prescribed weight loss regimen. The facility admitted Resident #95 with [DIAGNOSES REDACTED]. Record review at 12:54 PM on [DATE] revealed that the [DATE] Admission Assessment noted open areas present on the sacrum, buttocks, and toe. The [DATE] Body Audit Form noted Pressure ulcer to sacrum + L(eft) buttock and R(ight) great toe amputation (with) scab @ surgical site. No measurements or staging of the wounds were recorded until [DATE], 3 days later. Further review revealed weekly wound assessments were not completed. On [DATE] at 5:06 PM, review of Wound Observation and Assessment forms revealed that on [DATE], the pressure ulcer on the left buttock was noted as a Stage 2 measuring 4 centimeters (cm) length x 2.5 cm width x 0.1 cm depth with 100% granulation tissue and light serosanguinous-sanguinous drainage. Surrounding skin showed maceration, [DIAGNOSES REDACTED], and unexplained other. The pressure ulcer on the sacrum was noted as a Stage 4 measuring 6 cm length x 5.8 cm width x 2.6 cm depth with tunneling from ,[DATE] at 4 cm and a moderate amount of serosanguinous drainage. Surrounding skin showed maceration, [DIAGNOSES REDACTED], and unexplained other. These were the only recorded wound assessments in the record until the resident expired on [DATE]. On [DATE] at 1:45 PM, Licensed Practical Nurse (LPN) #2 provided additional information from a [DATE] wound care center appointment which noted that the sacral pressure ulcer measurements were 9 cm length x 11 cm width x 3.3 cm depth, with an area of 99 sq (square) cm and a volume of 326.7 cubic cm. Muscle and bone are exposed. Undermining has been noted at 9:00 and ends at 3:00 with a maximum distance of 4.7 cm .large amount of serosanguinous drainage .yellow slough, ,[DATE]% bright red granulation .Right Great Toe is an Unstageable Pressure Injury. Obscure full thickness skin and tissue loss Pressure Ulcer .Wound bed is ,[DATE]% dry, black eschar .Left Medial Buttock is a Stage 3 Pressure Injury Pressure Ulcer .measurements are 3.5 cm length x 2.5 cm width x 0.1 cm depth .scant amount of yellow drainage .Wound bed is ,[DATE]% granulation . Review of the [DATE] Admission MDS on [DATE] at 1:05 PM revealed that the resident was coded as having one Stage 2 and one Stage 4 pressure ulcer. Measurements reflected those taken in the facility on [DATE] as opposed to those provided by the wound center on [DATE]. During an interview on [DATE] at 2:08 PM, the MDS Coordinator reviewed the [DATE] wound center report and verified s/he should have coded a Stage 3 and a Stage 4 instead of a Stage 2 and a Stage 4 as per the report confirmed as received on [DATE]. The facility admitted Resident #22 with [DIAGNOSES REDACTED]. Review of the [DATE] Quarterly Minimum Data Set (MDS) Assessment Section N-Medication revealed that an anticoagulant was coded as having been received 5 days and an antibiotic was coded as not having been received during the 7 day look back period. Record review on [DATE] at 4:14 PM revealed [DATE] physician's orders [REDACTED]. No orders were found for anticoagulant use. Review of the ,[DATE] Medication Administration Record [REDACTED]. During an interview on [DATE] at 2:01 PM, Registered Nurse #1 reviewed the record and verified that the information was entered incorrectly.",2020-09-01
964,PRUITTHEALTH- BAMBERG,425104,439 NORTH STREET,BAMBERG,SC,29003,2017-05-05,280,D,0,1,P4RY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews the facility failed to ensure the plan of care was reviewed and revised to include Resident #87's refusal to turn and reposition to prevent decline in skin integrity and to include Resident #87's choice to wear hospital gowns daily for 1 of 3 residents reviewed for pressure Ulcers. The facility further failed to ensure that all disciplines participated in the care planning process for Resident #95 for 1 of 31 care plans reviewed. The findings included: The facility admitted Resident #87 with [DIAGNOSES REDACTED]. Observations made on 5/2/2017, 5/3/2017 and 5/4/2017 revealed Resident #87 wearing a hospital gown daily. Review on 5/4/2017 at approximately 10:27 AM of the plan of care for Resident #87 made no mention of Resident #87's preference to wear hospital gowns daily. Review on 5/4/2017 at approximately 12:40 PM of the nurses notes revealed notes dated 3/15/2017 through 3/27/2017 in which Resident #87 refused to turn and reposition. A second review on 5/4/2017 at approximately 1:00 PM of the plan of care for Resident #87 revealed no revision of the plan of care to include Resident #87's refusal to turn and reposition. During an interview on 5/4/2017 at approximately 1:28 PM with Registered Nurse (RN) #1, the Care Plan Coordinator confirmed that the care plan did not include Resident #87 choosing to wear a hospital gown daily and the his/her refusal to turn and reposition. The facility admitted Resident #95 with [DIAGNOSES REDACTED]. Care Plan review at 1:09 PM on 05/04/17 revealed that only the Activities Director and MDS Coordinator participated in the 12-2-16 Care Plan Conference Meeting. There was no evidence of participation by Social Services, Dietary, or the Certified Nursing Assistant. According to facility documentation, problems included a Stage 2 pressure ulcer on the left buttock and a Stage 4 on the sacrum. During an interview at 1:11 PM on 5-5-17, the Director of Nursing stated that an X on the form initially indicated that the staff member attended the meeting. Then, the policy changed to indicate that the x completion of the assigned sections of the MDS and staff had to physically sign the form to indicate care plan meeting participation. The DON reviewed the Care Plan form and confirmed that only the MDS Coordinator and Activities participated.",2020-09-01
965,PRUITTHEALTH- BAMBERG,425104,439 NORTH STREET,BAMBERG,SC,29003,2017-05-05,282,D,0,1,P4RY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure that residents received appropriate care according to the current care plan for 1 of 3 residents reviewed for range of motion services. Resident #77 did not receive consistent range of motion services. The findings included: The facility admitted Resident #77 with a [DIAGNOSES REDACTED]. A review of the care plan for Resident #77 on 5/5/2017 at approximately 5:30 PM, revealed a Problem/Need for activities of daily living which included impaired mobility with an intervention for AROM/PROM (Active Range of Motion/Passive Range of Motion) with daily care as tolerated which was initiated on 9/24/2014. On 5/5/2017 at approximately 6:30 PM a review of the resident's Care Task Documentation revealed no documentation on these dates for AROM/PROM: 2/5/17, 2/6/17, 2/9/17,3/5/17, 3/23/17,4/2/17, 4/3/17, 4/417, 4/5/17 4/8/17, 4/12/17 4/1617, 4/17/17, 4/19/17,4/22/17 ,4/26/17,4/27/17, 4/29/17 and 4/30/17. Interview with the MDS Coordinator on 5/5/2017 at approximately 7:00 PM verified inconsistent documentation of AROM/PROM for resident #77.",2020-09-01
966,PRUITTHEALTH- BAMBERG,425104,439 NORTH STREET,BAMBERG,SC,29003,2017-05-05,309,D,0,1,P4RY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews and review of the facility's agreement with Hospice titled, Hospice Nursing Home Agreement, the facility failed to ensure coordination of care for Resident #68 between the facility and United Hospice of the Midlands for 1 of 1 resident reviewed for Hospice Care and Services. The findings included: The facility admitted Resident #68 with [DIAGNOSES REDACTED]. Review on [DATE] at approximately 7:00 PM of the Hospice notebook for Resident #68 revealed, the hospice care plan has not been updated since [DATE]. The Certification period for Hospice was expired [DATE]. The Certified Nursing Assistant (CNA) visit documentation was not in the Hospice notebook nor the facility for Resident #68 to ensure coordination of care. During an interview on [DATE] at approximately 7:00 PM with the Licensed Practical Nurse (LPN) #3, Unit Manager verified the findings and stated, the CNA visits Resident #68 for care as ordered and we sign their form and they take it with them. They do not leave a copy with us. Review on [DATE] at approximately 7:15 PM of the facility policy titled, Hospice Nursing Home Agreement, states under, Section VI. Records, a. Compilation of Records: i. Preparation: . Each Residents clinical record shall completely, promptly and accurately document all services provided to, and events concerning each Residential Hospice Patient and that all services are provided pursuant to this Agreement including, evaluations, treatments, progress notes, authorizations to admission to Hospice and/or facility and physician orders [REDACTED]. Facility and Hospice shall cause each entry made for services provided hereunder to be signed by the person providing the services. Each clinical record shall document all services provided and the events occurring to Hospice patients, periodic reassessments of the Hospice Patient/Family unit, coordination of care between the Hospice and the Facility . :",2020-09-01
967,PRUITTHEALTH- BAMBERG,425104,439 NORTH STREET,BAMBERG,SC,29003,2017-05-05,314,D,0,1,P4RY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure Resident #87's and Resident #95's pressure ulcers were measured and staged in a timely manner for 2 of 3 residents reviewed for Pressure Ulcers. The findings included: The facility admitted Resident #87 with [DIAGNOSES REDACTED]. Review on [DATE] at approximately 3:37 PM of a form titled, Wound observation and Assessment Form, revealed Resident #87 was in the hospital from [DATE] through [DATE] and was admitted back into the facility on [DATE]. Licensed Practical Nurse (LPN) #2 assessed the pressure ulcers on admission on [DATE]. The Wound Nurse was not available until 4 days later to actually measure and stage the pressure ulcers. An interview on [DATE] at approximately 3:40 PM with Registered Nurse (RN) #2, Wound Care Nurse, confirmed Resident #87 returned from the hospital on [DATE], but he/she was not working until [DATE] and pressure ulcers were not measured and staged until his/her return to work on [DATE]. RN #2 went on to say that all wounds/pressure ulcers are measured on Thursdays. This surveyor then asked, If a resident is admitted any other day of the week other than Thursday did the wounds/pressure ulcers not get assessed, measured and staged by an RN, until the wound nurse returns to work and he/she stated, yes. During an interview on [DATE] at approximately 4:45 PM the Director of Nursing, (DON) verified Resident #87 returned for the hospital on [DATE] and the pressure ulcers were not measured and staged by the wound nurse until [DATE]. This surveyor asked if the DON would expect a newly admitted resident with wounds/pressure ulcers to be assessed, measured and staged in a timely manner and he/she stated, I think it is best if only one nurse measures and stages the wounds/pressure ulcers. The wound nurse will measure the wounds/pressure ulcers when he/she returns to work. The facility admitted Resident #95 with [DIAGNOSES REDACTED]. Record review at 12:54 PM on [DATE] revealed that the [DATE] Admission Assessment noted open areas present on the sacrum, buttocks, and toe. The [DATE] Body Audit Form noted Pressure ulcer to sacrum + L(eft) buttock and R(ight) great toe amputation (with) scab @ surgical site. No measurements or staging of the wounds were recorded until [DATE], 3 days later. Further review revealed weekly wound assessments were not completed. On [DATE] at 5:06 PM, review of Wound Observation and Assessment forms revealed that on [DATE], the pressure ulcer on the left buttock was noted as a Stage 2 measuring 4 centimeters (cm) length x 2.5 cm width x 0.1 cm depth with 100% granulation tissue and light serosanguinous-sanguinous drainage. Surrounding skin showed maceration, [DIAGNOSES REDACTED], and unexplained other. The pressure ulcer on the sacrum was noted as a Stage 4 measuring 6 cm length x 5.8 cm width x 2.6 cm depth with tunneling from ,[DATE] at 4 cm and a moderate amount of serosanguinous drainage. Surrounding skin showed maceration, [DIAGNOSES REDACTED], and unexplained other. These were the only recorded wound assessments in the record until the resident expired on [DATE]. On [DATE] at 1:45 PM, Licensed Practical Nurse (LPN) #2 provided additional information from a [DATE] wound care center appointment which noted that the sacral pressure ulcer measurements were 9 cm length x 11 cm width x 3.3 cm depth, with an area of 99 sq (square) cm and a volume of 326.7 cubic cm. Muscle and bone are exposed. Undermining has been noted at 9:00 and ends at 3:00 with a maximum distance of 4.7 cm .large amount of serosanguinous drainage .yellow slough, ,[DATE]% bright red granulation .Right Great Toe is an Unstageable Pressure Injury. Obscure full thickness skin and tissue loss Pressure Ulcer .Wound bed is ,[DATE]% dry, black eschar .Left Medial Buttock is a Stage 3 Pressure Injury Pressure Ulcer .measurements are 3.5 cm length x 2.5 cm width x 0.1 cm depth .scant amount of yellow drainage .Wound bed is ,[DATE]% granulation . Based on this information, compared to the [DATE] assessment/measurements, the sacral wound increased in size, depth, tunneling, and amount of drainage. There was little change in the buttock ulcer size, but it worsened to a Stage 3. The [DATE] wound center noted an unstageable area to the great toe (in addition to the surgical/amputation site) that the facility failed to identify and measure. During an interview on [DATE] at 1:24 PM, the Minimum Data Set (MDS) Coordinator stated that the resident's admitted was on a Friday. The Director of Nurses stated it was the practice of the facility to measure pressure ulcers on Mondays when the admission was on Friday. LPN #2 confirmed that the only weekly measurements/staging were those noted on [DATE]. Record review on [DATE] at 2:09 PM revealed Physician order [REDACTED]. Pat dry. Apply Chlorpactin 4 gm (grams). Cover (with) dry dsg (dressing) tid (three times daily) + PRN (as needed). (2) Clean L(eft) buttock (with) NS. Pat dry. Apply Chlorpactin 4 gm. Cover (with) dry dsg tid + PRN. (3) Skin Prep to R(ight) great toe amputation daily. Review of the ,[DATE] Treatment Administration Record on [DATE] at 5:00 PM revealed treatments were not done as ordered. The sacral and left buttock wound treatments were not initialed as completed 15 times from ,[DATE] through [DATE]. During an interview on [DATE] at 1:28 PM, when advised of the omissions, the Director of Nurses (DON) stated s/he expected physician's orders [REDACTED]. Review of Nurse's Notes on [DATE] at 4:14 PM revealed that the resident developed a new Stage 2 pressure ulcer on the left upper buttock on [DATE]. Review of the [DATE] Admission MDS on [DATE] at 1:05 PM revealed that the resident was coded as having one Stage 2 and one Stage 4 pressure ulcer. Measurements reflected those taken in the facility on [DATE] as opposed to those provided by the wound center on [DATE]. During an interview on [DATE] at 2:08 PM, the MDS Coordinator reviewed the [DATE] wound center report and verified s/he should have coded a Stage 3 and a Stage 4 instead of a Stage 2 and a Stage 4 as per the report confirmed as received on [DATE]. Care Plan review at 1:09 PM on [DATE] revealed that only the Activities Director and MDS Coordinator participated in the [DATE] Care Plan Conference Meeting. There was no evidence of participation by Social Services, Dietary, or the Certified Nursing Assistant. Problems included a Stage 2 pressure ulcer on the left buttock and a Stage 4 on the sacrum. During an interview at 1:11 PM on [DATE], the DON stated that an X on the form initially indicated that the staff member attended the meeting. Then, the policy changed to indicate completion of the assigned sections of the MDS and staff had to physically sign the form to indicate care plan meeting participation. The DON reviewed the Care Plan form and confirmed that only the MDS Coordinator and Activities participated.",2020-09-01
968,PRUITTHEALTH- BAMBERG,425104,439 NORTH STREET,BAMBERG,SC,29003,2017-05-05,315,E,0,1,P4RY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and review of the facility policy titled, Handwashing, and Indwelling Urinary Catheter (Foley) Care and Management, the facility failed to ensure Resident #113 received proper foley catheter care for 1 of 2 residents reviewed with a foley catheter. The facility further failed to provide care with interventions for Resident #78 to improve or prevent further decline in urinary incontinence. And the facility additionally failed to ensure Resident #72 received the proper incontinent care for 2 of 2 residents reviewed for urinary incontinence. The findings included: The facility admitted Resident #113 with [DIAGNOSES REDACTED]. An observation on 5/4/2017 at approximately 9:07 AM of Foley catheter care for Resident #113 went as follows: Resident #113 was on contact isolation for an infection. The Certified Nursing Assistant (CNA) #3 applied Personal Protective Equipment (PPE) outside the room before entering and this surveyor did also. CNA #3 knocked on the door with gloved hands. The procedure was explained to Resident #113 and this surveyor asked for permission to observe the CNA performing the catheter care and he/she stated it was ok. Using the same gloved hands raised the bed, pulled the privacy curtains, moved the bedside table away from the bed and pulled down the bed linens and removed his/her brief. The CNA was not observed removing his/her gloves and washing his/her hands prior to starting the catheter care. The CNA used the same gloved hands to retrieve a pre moistened wipe from a pack of wipes and swiped down one time on either side of the groin area and then threw the wipe in the trash. The CNA then retrieved another wipe and secured the tubing and held the wipe over the tubing and cleansed down the tubing. He/she did not cleanse the insertion site of the foley catheter. He/she then refastened the brief, using the same gloved hands, checked to make sure the tubing was not kinked , lowered the bed, took a clean brief from the bedside table and placed it in a closet, arranged the overbed table for the resident's convenience, pushed a straight chair closer to the bed. The resident asked the CNA to lower the bed further and to raise the head of the bed and the CNA used the same gloved hands to perform all these task and never removed the gloves nor did he/she remove the gloves and wash his/her hands. The CNA then pulled the privacy curtains back from around the bed and went over to the biohazard bins and raised the bin lid with his/her same gloved hands and removed the gloves and the gown and placed them in the bin and used her ungloved hand to close the bin and not the foot pedal to open and close the bin. Then he/she went into the resident restroom to wash his/her hands. During an interview on 5/4/2017 at approximately 9:20 AM with CNA #33 confirmed that he/she had not washed his/his hands and had used the same gloved hands used to perform the cath care that he/she used to pull the privacy curtains, raise the bed, move the furniture, and unfasten and fasten the brief. He/she also confirmed that he/she had not cleaned the insertion site of the foley catheter. Review on 5/4/2017 at approximately 9:45 AM of the facility policy titled, Handwashing, states under the Policy Statement: It is the policy of PruittHealth to prevent the spread of bacteria which may lead to foodborne illness by using proper hand washing techniques. Review on 5/4/2017 at approximately 10:00 AM of the facility policy titled, Indwelling Urinary Catheter (Foley) Care and Management, states under implementation, Gather the equipment and supplies at the patient's bedside. Perform hand hygiene. Provide Privacy and explained the procedure to the patient. Perform hand hygiene. Put on gloves and other personal protective equipment (PPE). Provide routine hygiene for meatal care. :Remove and discard your gloves and any other PPE if worn and perform hand hygiene. The facility admitted Resident #78 with [DIAGNOSES REDACTED]. Review on 5/5/2017 at approximately 8:16 AM of the Admission Nursing Observation Form for Resident #78 states, resident on admission (12/29/2016) was continent of bowel and bladder. Review on 5/5/2017 at approximately 8:18 AM of the Plan of Care for Resident #78 included a problem onset dated 12/29/2016 and reads, Resident has physical limitations and cognitive deficits that render the resident with impaired mobility to perform ADLs (Activities of Daily Living) and requires 1 to 2 persons to assist to meet ADL needs with a [DIAGNOSES REDACTED]. Resident #78 does have daily use of a diuretic. No other documentation could found in the medical record for Resident #78 to indicate that he/she was incontinent when admitted to the facility. Review on 5/5/2017 at approximately 8:38 AM of the Nursing Monthly Observation Form states Resident #78 is continent of bowel and bladder. Review on 5/5/2017 at approximately 8:40 AM of a form titled, Bowel/Bladder Elimination Program Assessment Form. reads resident has no history of incontinence and uses the bedside toilet without difficulty. No documentation could be found in the medical record to ensure Resident #78 would not benefit and would not be able to participate in a bowel and bladder training program. Review on 5/5/2017 at approximately 8:42 AM of the Minimum Data Set (MDS) assessment dated [DATE], Section H - Bowel and Bladder under H0300 - Urinary continence is coded with a 1, as occasionally incontinent of bladder and Section H0400 is coded with a 2, frequently incontinent of bowel. Section H also includes a section which asks if a bowel and bladder toileting program has been attempted and the questions was answered with a, No. During an interview on 5/5/2017 at approximately 8:45 AM with the Director of Nursing (DON) confirmed that Resident #78 was continent on admission but since then has had incontinent episodes and also confirmed that a bowel and bladder toileting program had not been attempted for Resident #78. During observation of incontinent care at 2:40 PM on 5-3-17, Certified Nursing Assistant (CNA) #1 gowned and gloved in the hall. When asked why the resident was on isolation precautions, s/he stated,[MEDICAL CONDITIONS]. Resident #72 was transported from the hall to the bathroom in his room. After removing the seatbelt and locking the wheelchair, the CNA assisted the resident to stand using the grab bar. The CNA pulled his pants and brief down and assisted him to sit on the toilet. S/he removed the wet brief. The CNA used the soap from the hand dispenser at the sink to add soap to a periwipe from a container on the back of toilet. S/he proceeded to cleanse the right groin and penis twice, wiping toward the urethra, then wiped around the urethra with the same side of cloth. S/he did not rinse the soap off. CNA #1 said,I know I did that wrong. The CNA assisted the resident to stand and cleansed the perianal area with another disposable cloth, front to back, changing sides of cloth. S/he did not cleanse the left groin or scrotum. CNA #1 stated,Oh, I didn't bring in any gloves as s/he pushed the resident's wheelchair up to the sink. The CNA removed the soiled gloves, put them in the trash in the bathroom, and washed her/his hands. After assisting the resident to wash his hands, s/he removed her/his isolation gown and disposed of it by opening the isolation bin with her/his hands instead of using the foot pedal. The CNA then pushed the resident out of the bathroom and exited the room after opening the door to the hallway without using any type of barrier. S/he did not wash her/his hands before leaving the room and pushing the resident into and down the hall. During an interview immediately following the procedure, CNA #1 verified s/he touched the top of the disposal bin and opened the door without a barrier. On 5-5-17 at 1:02 PM, the corporate consultant provided a copy of the table used for training and return demonstration, Perineal Care. Review of the table listing the procedure to follow for perineal care included: Apply soap to wet washcloth. Wash the perineal area. Wipe in only one direction, from front to back and from center to thighs Male: .Wash and rinse the tip of the penis using a circular motion beginning at the urethra. Continue washing down the penis to the scrotum and inner thighs. With fresh water and a clean washcloth, rinse the area thoroughly with the same [MEDICAL CONDITION].",2020-09-01
969,PRUITTHEALTH- BAMBERG,425104,439 NORTH STREET,BAMBERG,SC,29003,2017-05-05,318,D,0,1,P4RY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure that residents received appropriate care according to the current care plan for 2 of 3 residents reviewed for restorative services. Resident #77 did not receive consistent range of motion services and resident #22 did not receive restorative services to assist with ambulation daily per physician orders. The findings included: The facility admitted Resident #77 with a [DIAGNOSES REDACTED]. A review of the care plan for Resident #77 on 5/5/2017 at approximately 5:30 PM, revealed a Problem/Need for activities of daily living which included impaired mobility with an intervention for AROM/PROM (Active Range of Motion/Passive Range of Motion) with daily care as tolerated which was initiated on 9/24/2014. On 5/5/2017 at approximately 6:30 PM a review of the resident's Care Task Documentation revealed no documentation on these dates for AROM/PROM: 2/5/17, 2/6/17, 2/9/17,3/5/17, 3/23/17,4/2/17, 4/3/17, 4/417, 4/5/17 4/8/17, 4/12/17 4/1617, 4/17/17, 4/19/17,4/22/17 ,4/26/17,4/27/17, 4/29/17 and 4/30/17. Interview with the MDS Coordinator on 5/5/2017 at approximately 7:00 PM verified inconsistent documentation of AROM/PROM for Resident #77. The facility admitted Resident #22 with [DIAGNOSES REDACTED]. Record review on 5/3/17 at 4:14 PM revealed a physician's orders [REDACTED]. Restorative Nursing Flow Record Forms provided on 5/5/2017 at 2:34 PM revealed that restorative was to,Increase mobility AEB (as evidenced by) the ability to ambulate at least 100 feet with RW (rolling walker) daily through next review. Services were not provided as ordered between (MONTH) and (MONTH) (YEAR) on the following dates: 2/4/17, 2/5/17, 2/7/17, 2/11/17, 2/12/17, 2/16, 2/17/17, 2/18/17, 2/20/17, 2/21/17, 2/24/17, 2/26/17, 2/27/17, 3/4/17, 3/8/17, 3/9/17, 3/10/17, 3/21/17, 3/23/17, 3/26/17, 4/8/17, 4/10/ 17, 4/12/17, 4/13/17, 4/16/17, 4/18/17, 4/22/17, 4/23/17, 4/27/17 and 5/1/17. During an interview on 05/05/2017 at 2:45 PM, Certified Nursing Assistant (CNA) #2 stated the blanks in the documentation meant that s/he had been pulled off restorative to handle patient assignments. S/he stated, If Restorative is pulled to the floor, there is no coverage. The CNA assigned to the resident on restorative services does not provide it.",2020-09-01
970,PRUITTHEALTH- BAMBERG,425104,439 NORTH STREET,BAMBERG,SC,29003,2017-05-05,431,D,0,1,P4RY11,"Based on observations, record reviews, interviews the facility failed to assure that medications were stored properly and that expired medications were not in use in 1 of 2 medication rooms and 1 of 2 treatment carts. The findings included: On 5/2/2017 at approximately 10:00 AM inspection of the 100 Hall Medication Room Refrigerator revealed 1 unlabeled, 1 cc (cubic centimeter) syringe containing .1 ml (milliliter). LPN #3, when questioned stated h/she did not know what it was and removed the syringe. On 5/2/17 at approximately 10:10 AM inspection of the 100 Unit treatment cart revealed in the 2nd drawer of the right front storage compartment, one opened 4 ounce tube of Remedy Antifungal Cream (Active ingredient is miconazole nitrate 2%) 1/5th full, expiration 2/2015, and one unopened tube of Remedy Antifungal Cream (Active ingredient is miconazole nitrate 2%), Expiration 2/2015. On 5/2/17 at 10:15 am , the finding was verified by by LPN #4 and h/she stated that no residents were receiving. On 5/2/17 at approximately at 10:20 AM an inspection of the 100 Unit treatment cart revealed a container of Cavilon Durable Barrier Cream 1 oz, Active Ingredient Dimethicone 1.3% Half full expiration, (YEAR)-03 On 5/2/17 at 10:20 AM, the finding was verified by LPN #4.",2020-09-01
971,PRUITTHEALTH- BAMBERG,425104,439 NORTH STREET,BAMBERG,SC,29003,2017-05-05,441,F,0,1,P4RY11,"Based on observation and interview, the facility inappropriately handled soiled laundry in 1 of 1 laundry room. The laundry aide was noted to use protective clothing that did not prevent contact with soiled linen when sorting soiled laundry. The findings included: On 05/05/2017 at 9:31 AM, Laundry Aide #1 was observed sorting soiled laundry with the following protection over her uniform; an apron and wrist length disposable gloves. Laundry Aide #1 reached into the soiled laundry container and her/his bare arms and the sleeve and side of her/his uniform touched the soiled laundry and the inside of the soiled laundry container multiple times throughout the sorting process. On 5/05/2017 at approximately 10:00 AM, Laundry Aide #1 was observed during the process of placing the soiled laundry into the front loading washing machines. Again, Laundry Aide #1 was observed reaching into the soiled laundry containers with bare arm, sleeve and side of uniform touched the soiled linen and interior of soiled linen container. On 05/05/2017 at approximately 10:30 AM, during an interview with the Director of Maintenance and Housekeeping he/she said that the facility had long gloves for protection of the arms, but they are not used because the gloves irritated the arms of staff wearing the gloves. On 5/05/2017 at approximately 11:30 AM a review of the facility policy and procedure titled Infection Control-Linen and Laundry Services states: Policy Statement: It is the policy of this facility to provide a clean supply of linens and protect partners who handle and process the linen. The Policy and Procedure further states, Procedure: Routine Handling of Soiled Linen: 2. Soiled linen should be handled as little as possible and with a minimum of agitation to prevent gross microbial contamination of the air and of persons handling the linen. Standard precaution will be used by staff handling the linen.",2020-09-01
972,PRUITTHEALTH- BAMBERG,425104,439 NORTH STREET,BAMBERG,SC,29003,2018-09-20,568,D,0,1,F5OV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of quarterly statements and interviews, the facility failed to provide quarterly statements to the Resident Representative for 1 of 1 sampled resident reviewed for funds (Resident #68). The findings included: The facility admitted Resident #68 with [DIAGNOSES REDACTED]. During an interview on 9/09/18 at 2:43 PM, the resident representative stated s/he had not received the last quarterly statement. During an interview on 9/20/18 at 2:28 PM, the Business Office Manager reviewed her/his records and stated that the facility was representative payee and that the quarterly statement had been sent to the resident at the facility even though s/he was incapable of receipt.",2020-09-01
973,PRUITTHEALTH- BAMBERG,425104,439 NORTH STREET,BAMBERG,SC,29003,2018-09-20,569,D,0,1,F5OV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Resident Trust Fund and interviews, the facility failed to provide evidence of Resident Representative notification of account balances greater than that allowable for Medicaid for 1 of 1 sampled resident reviewed for funds (Resident #68). The findings included: The facility admitted Resident #68 with [DIAGNOSES REDACTED]. Review of Resident #68's account revealed that the balance had been greater than $2000 since 12/17. During an interview on 9/20/18 at 2:28 PM, the Business Office Manager (BOM) stated s/he had contacted the Resident Representative to spend down the monies. The BOM stated s/he had not sent the notification in writing to the Representative and was unable to state when s/he had contacted her/him because s/he kept no records of the conversation.",2020-09-01
974,PRUITTHEALTH- BAMBERG,425104,439 NORTH STREET,BAMBERG,SC,29003,2018-09-20,575,C,0,1,F5OV11,"Based on observation and interviews, required postings were not available and/or readily accessible to residents and visitors on 2 of 2 units. The findings included: Observations throughout the survey revealed that the contact information for the Ombudsman and protection and advocacy agency was not readily accessible to wheelchair-bound residents. There was also no information posted about contacting the State licensure or State Survey agencies or the Medicaid Fraud Control Unit to file complaints. During a tour of the facility to observe postings on 9/20/18 at 9:29 AM, the Director of Nursing verified the above.",2020-09-01
975,PRUITTHEALTH- BAMBERG,425104,439 NORTH STREET,BAMBERG,SC,29003,2018-09-20,577,C,0,1,F5OV11,"Based on observation and interview, the results of the survey were not readily available to residents and visitors of the facility. There were no available postings to indicate the location of survey results on 2 of 2 units. The findings included: Observations throughout the survey revealed that the survey was located in a wooden box in the hallway near the 100 Hall nursing station on the back of the entry wall. Only residents and visitors passing this area would notice the wooden box with a small (less than 3 inches by 1 inch) attached sign indicating its contents. There were no signs at any of the 4 visitor entrances to indicate the location of previous survey results. The only residents and visitors passing the wooden box would be those accessing from one of the entrances and proceeding down one of the 4 resident halls or those standing at the 100 Hall nursing station. During a tour of the facility to observe postings on 9/20/18 at 9:29 AM, the Director of Nursing and Administrator verified the above.",2020-09-01
976,PRUITTHEALTH- BAMBERG,425104,439 NORTH STREET,BAMBERG,SC,29003,2018-09-20,584,D,0,1,F5OV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, and interview, the facility failed to maintain a clean environment in 2 of 4 rooms reviewed with feeding machines. Rooms 104A and 105A had tube feeding spatter on walls, floor equipment, also walls, handles and furniture were in disrepair. The findings included: 09/19/18 11:30 AM an observation with the House Keeping Supervisor revealed: room [ROOM NUMBER]A had tube feeding spatter on the wall, floor, machine, pole, and base of the pole. room [ROOM NUMBER]A had tube feeding spatter on the wall, floor, machine, pole, and base of the pole. Also, the walls were scuffed, 2 handles (closet and drawer) were broken, and the bed stand furniture was damaged and in disrepair. Furthermore, the suction machine was uncovered, and the tubing was between the drawers. Following the observations of room [ROOM NUMBER]A and 105A, the House Keeping Supervisor verified the tube feeding spatter, and disrepair of the walls, handles, band stand, and suction machine.",2020-09-01
977,PRUITTHEALTH- BAMBERG,425104,439 NORTH STREET,BAMBERG,SC,29003,2018-09-20,585,C,0,1,F5OV11,"Based on observations and interview, the facility failed to support the residents' right to voice grievances by failure to post the grievance policy/procedure including how to contact the grievance official for residents and/or their representatives on 2 of 2 units. The findings included: Observations throughout the survey revealed that the grievance policy/procedure was not readily accessible to residents and/or resident representatives. It was not posted anywhere in the facility. During an interview on 9/18/18 at 4:40 PM, the Director of Nurses stated that the grievance policy was only reviewed with the family on admission. S/he was unaware if posted in the facility so as to be accessible following the admissions process. During an interview on 9/18/18 at 5 PM, the Administrator verified that the grievance policy/procedure was not posted and readily accessible to residents and their representatives.",2020-09-01
978,PRUITTHEALTH- BAMBERG,425104,439 NORTH STREET,BAMBERG,SC,29003,2018-09-20,637,D,0,1,F5OV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review the facility failed to complete a significant change in status assessment after Resident #47 was admitted to hospice. Resident #47 was 1 of 1 resident sampled for Hospice. The findings included: Resident #47 was admitted with Partial traumatic amputation between shoulder and elbow, muscle weakness, [MEDICAL CONDITION] and pressure ulcer. The resident was admitted to hospice effective 9/5/18. Review of the Minimum Data Set (MDS) on 9/19/18 revealed no Significant Change in Status assessment had been completed. Review of the RAI manual related to hospice election states, A SCSA must be performed regardless of whether an assessment was recently conducted on the resident. This is to ensure a coordinated plan of care between the hospice and nursing home is in place. It must be within 14 days from the effective date of the hospice election.",2020-09-01
979,PRUITTHEALTH- BAMBERG,425104,439 NORTH STREET,BAMBERG,SC,29003,2018-09-20,644,D,0,1,F5OV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that a Level 2 screening was done as required for one of 3 sampled residents reviewed for PASARR (Pre-Admission Screening and Resident Review). The facility readmitted Resident #68 following hospitalization with a new mental health [DIAGNOSES REDACTED]. The findings included: The facility admitted Resident #68 with [DIAGNOSES REDACTED]. Further review revealed a [DIAGNOSES REDACTED]. No recent hospitalization records were noted in the record. During an interview on 9/20/18 at 10:28 AM, the Minimum Data Set (MDS) Coordinator reviewed the record with the surveyor and verified that the resident did not have the [DIAGNOSES REDACTED]. On 9/20/18 at 12:25 PM, after additional review, the MDS Coordinator affirmed that the resident did not have the stated [DIAGNOSES REDACTED]. S/he stated s/he was not aware of the [DIAGNOSES REDACTED].",2020-09-01
980,PRUITTHEALTH- BAMBERG,425104,439 NORTH STREET,BAMBERG,SC,29003,2018-09-20,645,D,0,1,F5OV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, a Level II Preadmission Screening and Resident Review (PASARR) was not completed on admission for 1 of 3 residents reviewed for PASARR. Resident #24 was admitted with a mental illness [DIAGNOSES REDACTED]. The findings included: Resident #24 was admitted on [DATE] with [DIAGNOSES REDACTED].#24 had a psychiatric hospitalization within the previous two years. Further review revealed no further evaluation was recommended. Interview with the facility Administrator on 09/18/18 at 12:15 PM revealed Resident #24 was not having any problems adjusting so a Level II PASARR was not completed; however, record review revealed the PASARR Level I Screening Form was completed on 6/20/18 but the resident was not admitted until 6/25/18.",2020-09-01
981,PRUITTHEALTH- BAMBERG,425104,439 NORTH STREET,BAMBERG,SC,29003,2018-09-20,655,D,0,1,F5OV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and family interview the facility failed to complete and share with the resident/resident's responsible party a baseline care plan. Resident #44 had a care plan completed but there was no evidence it was shared with the resident and resident #47 had a baseline care plan completed but the responsible party stated during interview that she/he had not received the care plan or had a discussion with anyone about a care plan. Two of 4 residents sampled for baseline care plans. The findings included: Resident #47 was admitted with Partial traumatic amputation between shoulder and elbow, muscle weakness, [MEDICAL CONDITION] and pressure ulcer. During an interview with the resident's responsible party she/he revealed that the facility had not discussed a care plan with her/him since admission. She/he had not seen a copy of her/his mother's plan of care at any time. During a review of the resident's record there was a care plan completed but no documentation that it was reviewed with the resident's responsible party. Resident #44 was admitted with a pressure ulcer and indwelling catheter. A review of the resident's record revealed a baseline care plan completed timely but no documentation it was reviewed with the resident or his/her spouse. There was an area specifically set aside for the date and signature of when the baseline care plan was shared with the resident or responsible party, but it was blank and not signed off.",2020-09-01
982,PRUITTHEALTH- BAMBERG,425104,439 NORTH STREET,BAMBERG,SC,29003,2018-09-20,656,E,0,1,F5OV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to develop and/or implement care plan interventions for turning and positioning for 3 of 8 sampled residents reviewed for pressure ulcers (Residents #26, #29, #68) and 1 of 6 sampled residents reviewed for activities (Residents #68). Additionally, measures were not implemented to minimize fall injuries per the care plan for 1 of 5 sampled residents reviewed for accidents (Resident #29) and the Care Plan was not followed related to use of devices/splints for 1 of 6 sampled residents reviewed for range of motion (Residents #68). The findings included: The facility admitted Resident #26 with [DIAGNOSES REDACTED]. Review of the 7-10-18 Quarterly Minimum Data Set (MDS) Assessment on 9/10/18 at 10:15 PM revealed that the resident was totally dependent on staff for bed mobility. Record review on 9/19/18 at 1:26 PM revealed physician's orders [REDACTED]. Review of the Care Plan on 9/19/18 at 3:01 PM revealed interventions for decreased mobility included turning and positioning every 2 hours. Multiple observations revealed Resident #26 positioned on his/her back with the head of the bed elevated at least 30 degrees (on 9/09/18 at 10:28 AM, 12:15 PM, and 2:12 PM; on 9/10/18 at 8:43 AM, 9:30 AM, 11:03 AM, 12:37 AM, 2:16 PM, and 4:02 PM; on 9/18/18 at 9:31 AM, 11 AM, 12:31 PM, 2:15 PM, and 4:18 PM), indicating s/he had not been turned and positioned every 2 hours. During all observations, a positioning wedge was noted on the bedside table. No pillows or positioning devices were noted in the bed with the resident. During an observation and interview on 9/19/18 at 8:36 AM, the Director of Nurses (DON) verified that the resident was positioned on his/her back. S/he stated, He (she) should be turned every 2 hours and the wedge used for positioning. The facility admitted Resident #29 with [DIAGNOSES REDACTED]. Review of the 7-13-18 Quarterly MDS Assessment on 9/10/18 at 9:25 PM revealed that the resident had a BIMS (Brief Interview for Mental Status) score of 9, indicating a moderately impaired cognitive status. S/he experienced inattention, disorganized thinking, and trouble concentrating. The resident required extensive assistance for bed mobility and was totally dependent for transfers. The MDS noted a fall with minor injury had occurred since the previous assessment. A 11-5-17 significant change in status assessment noted the resident with a stage 3 pressure ulcer. Record review on 9/18/18 at 10:12 AM revealed physician's orders [REDACTED]. Review of the Care Plan on 9/18/18 at 12:47 PM revealed interventions for decreased mobility and skin breakdown included turning and positioning every 2 hours. Interventions for fall risk included a 5-25-18 entry for a Floor mat to right side (of) bed. Multiple observations revealed Resident #29 positioned on his/her back with the head of the bed elevated at least 30 degrees (on 9/09/18 at 11:48 AM, 1:55 PM, and 3:59 PM; on 9/10/18 at 8:24 AM, 9:45 AM, 11:13 AM, and 12:47 PM; on 9/18/18 at 9:25 AM, 11:04 AM, 12:05 PM, 2:10 PM, 2:25 PM and 4:13 PM), indicating s/he had not been turned and positioned every 2 hours. No pillows or positioning devices were noted in the bed with the resident except to prop up [MEDICAL CONDITION] right arm. Multiple observations on 9/18/18 also revealed Resident #29 in bed without the floor mat in place as ordered and care planned (at 9:25 AM, 11:04 AM, 12:05 PM, 2:10 PM, and 2:25 PM). During an interview and observation on 09/18/18 at 2:25 PM, Licensed Practical Nurse (LPN) #3 verified that the mat was folded and leaning against the bedside table. S/he stated, That mat should be down. During an interview and observation on 9/19/18 at 8:43 AM, the DON verified the resident's positioning. S/he stated that the resident should be turned and positioned every 2 hours. Regarding the mat, the DON stated that it should be in place at all times. The facility admitted Resident #68 with [DIAGNOSES REDACTED]. Review of the 8-16-18 Quarterly MDS Assessment on 9/10/18 at 7:21 PM revealed that the resident required extensive assistance of staff for bed mobility, had impaired ROM in both upper and lower extremities, and had a stage 4 pressure ulcer. Record review on 9/18/18 at 3:21 PM revealed physician's orders [REDACTED]. resting hand splints 6-8 hours daily as tolerated. Review of the Care Plan on 09/19/18 at 8:50 PM revealed interventions for decreased mobility and skin breakdown included a turning and positioning program. Interventions for multiple contractures included Bilateral elbow & wrist braces as tolerated. During an interview on 9/09/18 at 2:36 PM, Resident #68's family asked, When does that (positioning) wedge go on? We never see it used. (Resident #68) is always on her (his) back when we're here. They also stated that facility staff used to put splints on but couldn't get it uncontracted. They never put splints on or rolls in her (his) hands. Multiple observations revealed Resident #68, with bilateral upper extremity contractures, positioned on his/her back with the head of the bed elevated at least 30 degrees (on 9/09/18 at 10:36 AM, 12:24, 2:19 PM, and 4:17 PM; on 9/18/18 at 9:32 AM, 11:30 AM, 2:17 PM, and 5:47 PM), indicating s/he had not been turned and positioned every 2 hours. During all observations, a positioning wedge was noted in the chair. No pillows or positioning devices were noted in the bed with the resident. No devices/splints were in place to prevent further decline in ROM and no splints were visible in the room until 9/18/18 at 11:30 AM, when one resting hand splint was noted on the left upper extremity. During an interview on 9/19/18 at 9:23 AM, the DON stated, They should turn her (him) every 2 hours and use the wedge. During an interview on 9/18/18 at 4:24 PM, LPN #4 verified that only the left resting hand splint was in place. S/he searched the room and was unable to locate any other splints. LPN #4 stated that the Certified Nursing Assistant was responsible for splint application. During an interview and observation on 9/19/18 at 9:23 AM, while Resident #68 was at [MEDICAL TREATMENT], the DON confirmed 2 resting hand splints on the cabinet next to the television. S/he did not know how long the splints had been missing. During an interview on 9/19/18 at 12:21 PM, after review of the therapy notes, the Rehab Coordinator stated that Resident #68 had been discontinued from skilled therapy on 3-9-17 with splints after caregiver education. S/he further stated, We will need to do a new evaluation since the elbow splints are missing to determine if contractures are worse. On 9/19/18 at 2:49 PM, the Occupational Therapist verified the physician's orders [REDACTED]. Additionally, observations on all days of the survey revealed that the resident was either in bed or out to [MEDICAL TREATMENT]. No activities were observed other than the television being on in the room. During an interview on 9/09/18 at 2:34 PM, Resident #68's family members expressed concern that they never saw her/him out of bed and would like to see her/him attend activities and get out of the room on days s/he didn't have [MEDICAL TREATMENT]. When asked, they stated they had expressed this to facility staff. They stated that Resident #68 had previously been very active individually (always on the go), in community groups, and had attended church every Sunday. Review of the 12-29-17 Annual MDS Assessment on 9/10/18 at 7:21 PM revealed that books, magazines, newspapers, music, news, groups, and religious services were very important to the resident. Section G noted that the resident transferred from bed only 1-2 times during the 7-day look-back period. Review of the Care Plan on 09/19/18 at 8:50 PM revealed that Resident needs one on one activities in room when not up and out of bed. (MONTH) also attend activities of interest out of room as tolerated. The goal was limited to one on one in room activities and did not address group activities. Although the resident was unable to communicate and only made eye contact, interventions included to Ask Resident about activity preferences and help plan. The plan did not include resident representatives' concerns. On 9/20/18 at 9:59 AM, review of One-to-One/Small Group Attendance Record Forms for 6/18 through 9/18 with the Activity Director (AD) revealed no attendance at group activities of any kind. During an interview on 9/19/18 at 11:38 AM, the Activity Director stated, The resident is not up and out to come to group. Basically, s/he's always in bed. That's why we do 1:1. The Activity Director reviewed the (MONTH) calendar and noted multiple events the resident would have enjoyed based on her/his noted interests, but that s/he had not been out of bed. S/he stated, We (Activities) can't get her (him) up but we would be glad to bring her (him) to programs.",2020-09-01
983,PRUITTHEALTH- BAMBERG,425104,439 NORTH STREET,BAMBERG,SC,29003,2018-09-20,657,D,0,1,F5OV11,"Based on observation, record review, and interview, the facility failed to update Care Plans for 1 of 5 residents reviewed for accidents. The Care Plan for Resident #50 was not updated related to wanderguard placement. The findings included: Observation of Resident #50 on 09/18/18 at 06:18 PM revealed the resident sitting in the TV room by the nurse's station. A wanderguard was observed on the right ankle. Observation on 09/19/18 at 08:37 AM revealed Resident #50 in bed eating breakfast. Staff entered the room and used a device to check for placement and function of the wanderguard, which was on the resident's right ankle. Record review of a 8/21/18 Nurse's Note revealed, Resident noted to be outside on premises. Wanderguard not in place. Resident assisted back inside by staff. Another 8/21/18 Nurse's Note stated Wanderguard placed to residents R (right) leg. Review of the Care Plan for Resident #50 revealed Resident is an elopement risk and requires the use of a wanderguard. Further review revealed this Care Plan was not updated following the incident on 8/21/18. Interview with the Director of Nurses on 09/19/18 at 09:45 AM confirmed the 8/21/18 Nurse's Note that Resident #50 was found outside. Interview with Licensed Practical Nurse #3 on 09/19/18 at 10:45 AM revealed Resident #50 was able to get the wanderguard off his/her wrist, so they started applying it to his/her ankle though this was not indicated on the Care Plan. Interview with MDS (Minimum Data Set) Care Plan Coordinator #1 on 09/19/18 at 10:47 AM confirmed the Care Plan was not updated with the change in wanderguard placement following this incident.",2020-09-01
984,PRUITTHEALTH- BAMBERG,425104,439 NORTH STREET,BAMBERG,SC,29003,2018-09-20,679,D,0,1,F5OV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interview, the facility failed to provide opportunities to attend group activities and/or provide individualized activities based on the resident's previous lifestyle and preferences for 1 of 6 sampled residents reviewed for activity participation (Residents #68). The findings included: The facility admitted Resident #68 with [DIAGNOSES REDACTED]. Observations on all days of the survey revealed that the resident was either in bed or out to [MEDICAL TREATMENT]. No activities were observed other than the television being on in the room. During an interview on 9/09/18 at 2:34 PM, Resident #68's family members expressed concern that they never saw her/him out of bed and would like to see her/him attend activities and get out of the room on days s/he didn't have [MEDICAL TREATMENT]. When asked, they stated they had expressed this to facility staff. They stated that Resident #68 had previously been very active individually (always on the go), in community groups, and had attended church every Sunday. Review of the 12-29-17 Annual Minimum Data Set (MDS) Assessment on 9/10/18 at 7:21 PM revealed that books, magazines, newspapers, music, news, groups, and religious services were very important to the resident. Section G noted that the resident transferred from bed only 1-2 times during the 7-day lookback period. Review of the Care Plan on 09/19/18 at 8:50 PM revealed that Resident needs one on one activities in room when not up and out of bed. (MONTH) also attend activities of interest out of room as tolerated. The goal was limited to one on one in room activities and did not address group activities. On 9/20/18 at 9:59 AM, review of One-to-One/Small Group Attendance Record Forms for 6/18 through 9/18 with the Activity Director (AD) revealed no attendance at group activities of any kind. During an interview on 9/19/18 at 11:38 AM, the Activity Director stated, The resident is not up and out to come to group. Basically, s/he's always in bed. That's why we do 1:1. The Activity Director reviewed the (MONTH) calendar and noted multiple events the resident would have enjoyed based on her/his noted interests, but that s/he had not been out of bed. S/he stated, We (Activities) can't get her (him) up but we would be glad to bring her (him) to programs.",2020-09-01
985,PRUITTHEALTH- BAMBERG,425104,439 NORTH STREET,BAMBERG,SC,29003,2018-09-20,686,E,0,1,F5OV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to provide care and services to prevent development of pressure ulcers in high risk residents and promote healing of existing pressure ulcers for 3 of 8 residents reviewed with pressure ulcers. Residents #68, #29, and #26 were not turned and positioned every 2 hours per physician's orders [REDACTED]. In addition, the nurse failed to cleanse the scissors prior to cutting a dressing to be used as wound packing on a stage 4 pressure ulcer for Resident #68. The findings included: The facility admitted Resident #26 with [DIAGNOSES REDACTED]. Review of the 7-10-18 Quarterly Minimum Data Set (MDS) Assessment MDS on 9/10/18 at 10:15 PM revealed that the resident was totally dependent on staff for bed mobility. Record review on 9/19/18 at 1:26 PM revealed physician's orders [REDACTED]. Review of the Care Plan on 9/19/18 at 3:01 PM revealed interventions for decreased mobility included turning and positioning every 2 hours. Multiple observations revealed Resident #26 positioned on his/her back with the head of the bed elevated at least 30 degrees (on 9/09/18 at 10:28 AM, 12:15 PM, and 2:12 PM; on 9/10/18 at 8:43 AM, 9:30 AM, 11:03 AM, 12:37 AM, 2:16 PM, and 4:02 PM; on 9/18/18 at 9:31 AM, 11 AM, 12:31 PM, 2:15 PM, and 4:18 PM), indicating s/he had not been turned and positioned every 2 hours. During all observations, a positioning wedge was noted on the bedside table. No pillows or positioning devices were noted in the bed with the resident. During an observation and interview on 9/19/18 at 8:36 AM, the Director of Nurses (DON) verified that the resident was positioned on his/her back. S/he stated, He (she) should be turned every 2 hours and the wedge used for positioning. The facility admitted Resident #29 with [DIAGNOSES REDACTED]. Review of the 7-13-18 Quarterly Minimum Data Set (MDS) Assessment MDS on 9/10/18 at 9:25 PM revealed that the resident required extensive assistance of 2 staff members for bed mobility. A 11-5-17 significant change in status assessment noted the resident with a stage 3 pressure ulcer. Record review on 9/18/18 at 10:12 AM revealed physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. Review of the Care Plan on 9/18/18 at 12:47 PM revealed interventions for decreased mobility and skin breakdown included turning and positioning every 2 hours. Multiple observations revealed Resident #29 positioned on his/her back with the head of the bed elevated at least 30 degrees (on 9/09/18 at 11:48 AM, 1:55 PM, and 3:59 PM; on 9/10/18 at 8:24 AM, 9:45 AM, 11:13 AM, and 12:47 PM; on 9/18/18 at 9:25 AM, 11:04 AM, 12:05 PM, 2:10 PM, 2:25 PM and 4:13 PM), indicating s/he had not been turned and positioned every 2 hours. No pillows or positioning devices were noted in the bed with the resident except to prop up [MEDICAL CONDITION] right arm. During an interview and observation on 9/19/18 at 8:43 AM, the DON verified the resident's positioning. S/he stated that the resident should be turned and positioned every 2 hours. The facility admitted Resident #68 with [DIAGNOSES REDACTED]. Review of the 8-16-18 Quarterly Minimum Data Set (MDS) Assessment MDS on 9/10/18 at 7:21 PM revealed that the resident required extensive assistance of staff for bed mobility and had a stage 4 pressure ulcer. Record review on 9/18/18 at 3:21 PM revealed physician's orders [REDACTED]. Review of the Care Plan on 09/19/18 at 8:50 PM revealed interventions for decreased mobility and skin breakdown included a turning and positioning program. During an interview on 9/09/18 at 2:36 PM, Resident #68's family asked, When does that (positioning) wedge go on? We never see it used. (Resident #68) is always on her (his) back when we're here. Multiple observations revealed Resident #68 positioned on his/her back with the head of the bed elevated at least 30 degrees (on 9/09/18 at 10:36 AM, 12:24, 2:19 PM, and 4:17 PM; on 9/18/18 at 9:32 AM, 11:30 AM, 2:17 PM, and 5:47 PM), indicating s/he had not been turned and positioned every 2 hours. During all observations, a positioning wedge was noted in the chair. No pillows or positioning devices were noted in the bed with the resident. During an interview on 9/19/18 at 9:23 AM, the DON stated, They should turn her (him) every 2 hours and use the wedge. During observation of the stage 4 sacral pressure ulcer treatment on 9/18/18 at 11:30 AM, Licensed Practical Nurse #5 removed a pair of scissors from her/his pocket and cut the silver alginate dressing with which the wound was to be packed. Before application, the surveyor stopped the nurse and asked about cleansing the implement. The nurse stated s/he had cleaned it earlier with a Clorox Wipe. The Lippincott Procedures for alginate dressing application provided by the facility at 10:23 AM on 9-20-18 stated to Cut the dressing to the size of the wound using sterile scissors .",2020-09-01
986,PRUITTHEALTH- BAMBERG,425104,439 NORTH STREET,BAMBERG,SC,29003,2018-09-20,688,E,0,1,F5OV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to provide services as ordered to prevent further decline in mobility for 1 of 6 sampled residents reviewed for range of motion (R0M). Resident #68 did not have splints applied as ordered. The findings included: The facility admitted Resident #68 with [DIAGNOSES REDACTED]. Review of the 8-16-18 Quarterly Minimum Data Set (MDS) Assessment on 9/10/18 at 7:21 PM revealed that the resident had impaired ROM in both upper and lower extremities. Record review on 9/18/18 at 3:21 PM revealed physician's orders [REDACTED]. resting hand splints 6-8 hours daily as tolerated. Review of the Care Plan on 09/19/18 at 8:50 PM revealed interventions for multiple contractures included Bilateral elbow & wrist braces as tolerated. During an interview on 9/09/18 at 3:05 PM, Resident #68's family members stated that facility staff used to put splints on but couldn't get it uncontracted. They never put splints on or rolls in her (his) hands. Multiple observations revealed Resident #68 with bilateral upper extremity contractures without any devices/splinting in place to prevent further decline in ROM (on 9/09/18 at 10:36 AM, 12:24, 2:19 PM, and 4:17 PM; on 9/18/18 at 9:32 AM). No splints were visible in the room. On 9/18/18 at 11:30 AM, one resting hand splint was noted for the first time on the left upper extremity. During an interview on 9/18/18 at 4:24 PM, Licensed Practical Nurse (LPN) #4 verified that only the left resting hand splint was in place. S/he searched the room and was unable to locate any other splints. LPN #4 stated that the Certified Nursing Assistant was responsible for splint application. On 9/19/18 at 9:23 AM, while Resident #68 was at [MEDICAL TREATMENT], 2 resting hand splints were noted on the cabinet next to the television. During an interview at this time, the Director of Nurses (DON) checked the Medication Administration Record [REDACTED]. The DON stated, The nurse should circle their initials and document why the splints were not on. S/he did not know how long the splints had been missing. During an interview on 9/19/18 at 12:21 PM, after review of the therapy notes, the Rehab Coordinator stated that Resident #68 had been discontinued from skilled therapy on 3-9-17 with splints after caregiver education. S/he further stated, We will need to do a new evaluation since the elbow splints are missing to determine if contractures are worse. On 9/19/18 at 2:49 PM, the Occupational Therapist verified the physician's orders [REDACTED].",2020-09-01
987,PRUITTHEALTH- BAMBERG,425104,439 NORTH STREET,BAMBERG,SC,29003,2018-09-20,689,E,0,1,F5OV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview, the facility failed to provide a fall mat as ordered to minimize injury in the event of falls for one of five sampled residents reviewed for accidents (Resident #29). The findings included: The facility admitted Resident #29 with [DIAGNOSES REDACTED]. Review of the 7-13-18 Quarterly Minimum Data Set (MDS) Assessment on 9/10/18 at 9:25 PM revealed that the resident had a BIMS (Brief Interview for Mental Status) score of 9, indicating a moderately impaired cognitive status. S/he experienced inattention, disorganized thinking, and trouble concentrating. The resident required extensive assistance for bed mobility and was totally dependent for transfers. The MDS noted a fall with minor injury had occurred since the previous assessment. Record review on 9/18/18 at 10:12 AM revealed physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. Review of the Care Plan on 9/18/18 at 12:47 PM revealed interventions for fall risk included a 5-25-18 entry for a Floor mat to right side (of) bed. Multiple observations on 9/18/18 revealed Resident #29 in bed without the floor mat in place as ordered and care planned (at 9:25 AM, 11:04 AM, 12:05 PM, 2:10 PM, and 2:25 PM). During an interview and observation on 09/18/18 at 2:25 PM, Licensed Practical Nurse (LPN) #3 verified that the mat was folded and leaning against the bedside table. S/he stated, That mat should be down. During an interview regarding the mat on 9/19/18 at 8:43 AM, the Director of Nurses stated that it should be in place at all times.",2020-09-01
988,PRUITTHEALTH- BAMBERG,425104,439 NORTH STREET,BAMBERG,SC,29003,2018-09-20,730,E,0,1,F5OV11,"Based on review of inservice records and interviews, the facility failed to ensure that 8 of 20 Certified Nursing Assistants (CNAs) received 12 hours of continuing education on an annual basis as required. This has the potential to affect patient care rendered to all residents to whom they are assigned. The findings included: Review of the facility's inservice records on 9-20-18 revealed that 8 of the 20 CNAs employed greater than one year had not completed their 12 hours of continuing education as required to maintain their certification. During an interview on 9-20-18 at 4:30 PM, this requirement was explained to the Director of Nurses. No further documentation was provided.",2020-09-01
989,PRUITTHEALTH- BAMBERG,425104,439 NORTH STREET,BAMBERG,SC,29003,2018-09-20,770,E,0,1,F5OV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure labs were done timely and/or done as ordered for 4 of 8 residents reviewed for unnecessary medications. Labs for Residents #24, #7, #60, #74 were not done timely and/or done as ordered with two resulting in delay of treatment. The findings included: Record review of the 7/4/18 Physician's Interim Order for Resident #24 revealed an X-ray to bilateral ribs (3 views) STAT (immediately) was ordered related to a fall. Review of another 7/4/18 Physician's Interim Order revealed: U/A (urinalysis) with C&S (culture and sensitivity) per family request to rule out UTI (Urinary Tract Infection). Review of the 7/14/18 Physician's Interim Order revealed: D/C'd (discontinued) U/A with C&S dated 7/5/18, U/A with C&S 7/15/18. Further review revealed a 7/16/18 Physician's Interim Order [MEDICATION NAME] mg (1) tab PO (by mouth) BID (twice daily) x 7 days for UTI and a 7/18/18 Physician's Interim Order to D/[MEDICATION NAME] start [MEDICATION NAME] 100 mg 1 tab PO BID x 10 days for UTI. Interview with the Director of Nurses (DON) on 09/18/18 at 04:24 PM revealed the U/A with C&S was ordered on [DATE] but no requisition was sent so it was reordered on [DATE]. S/he provided the (MONTH) (YEAR) Daily Laboratory Draw Form, which listed the U/A with C&S for Resident #24. The form indicated no requisition. Further interview with the DON on 09/18/18 at 05:57 PM revealed the requisition was located but the lab never received it. A copy of this was provided with a collection date of 7/5/18. The DON stated at some point it was discovered that the lab was not completed so the previous order was discontinued and the lab was reordered. The facility admitted Resident #7 with [DIAGNOSES REDACTED]. Record review on 9/19/18 at 9:55 AM revealed physician's orders [REDACTED]. Continued review revealed that the last lipid panel in the medical record was dated 1/8/18. During an interview on 9/19/18 at 2:29 PM, the Minimum Data Set (MDS) Coordinator #1 verified that the lipid panel had not been done as ordered with the other labs scheduled for every 6 months. S/he reviewed the record and confirmed that the lab order had been signed by the physician monthly from 6/18 through the dates of the survey (4 months). During an interview on 9/19/18 at 4:10 PM, MDS Coordinator #2 and Licensed Practical Nurse (LPN) #6 stated that the facility policy had changed in 10/17 to do the lipid profile annually. Review of the Lab Book revealed that the lipid profile had been crossed out on the lab form. Both nurses verified the physician's orders [REDACTED]. No order could be found changing the timeframes for the lab draws. The facility admitted Resident #60 with [DIAGNOSES REDACTED]. Record review on 9/19/18 at 3:31 PM revealed 7-26-18 physician's orders [REDACTED]. Lab results were reviewed on 9/19/18 at 4:37 PM and no results could be located for the Lipid Profile. During an interview on 9/19/18 at 5:35 PM, the Director of Nurses (DON) stated that the labs had been done at the consultant physician's office, but these were not available on the record for review. The lab results were faxed to the facility on [DATE], but did not include the Lipid Profile. During an interview at 9:15 AM on 9-20-18, the DON verified that the Lipid Profile results were not included in this information. At 9:31 AM, the DON stated that the lipid profile had not been done because the resident was not fasting. The facility admitted Resident #74 with [DIAGNOSES REDACTED]. Record review on 9/20/18 at 10:30 AM revealed physician's orders [REDACTED]. Review on 9/20/18 at 11:12 AM revealed the only lab results in the record consistent with this order were completed in 3/18. No results were located for 9/17. Further review revealed physician's orders [REDACTED]. Review of labs revealed that the physician reviewed the 9-6-18 monthly results and ordered that the test be repeated in one week. No results were noted in the medical record. During an interview on 9/20/18 at 1:06 PM, the MDS Coordinator verified the physician's orders [REDACTED]. The lab results, faxed to the facility on [DATE], noted that the PT/INR had been drawn and reported on 9-13-18. The Nurse Practitioner did not review the lab until 9-20-18 which resulted in a delay in treatment. After review, s/he increased the resident's [MEDICATION NAME] dose to 9 mg daily. During an interview on 9/20/18 at 3:53 PM, the DON confirmed that the lab results had been faxed to the facility that morning and medication orders were changed, resulting in delay of treatment. No lab results were provided for 9/17.",2020-09-01
990,PRUITTHEALTH- BAMBERG,425104,439 NORTH STREET,BAMBERG,SC,29003,2018-09-20,779,D,0,1,F5OV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to have signed and dated diagnostic reports available for review in the clinical record as required to maintain continuity of care for one of 8 sampled residents reviewed for unnecessary medications (Resident #60). The findings included: The facility admitted Resident #60 with [DIAGNOSES REDACTED]. Record review on 9/19/18 at 3:31 PM revealed 7-26-18 physician's orders [REDACTED]. Lab and Diagnostic results were reviewed on 9/19/18 at 4:37 PM and no results could be located for these diagnostic tests. During an interview on 9/19/18 at 5:35 PM, the Director of Nurses (DON) stated that the diagnostic tests had been done at the consultant physician's office, but these were not available on the record for review.",2020-09-01
991,PRUITTHEALTH- BAMBERG,425104,439 NORTH STREET,BAMBERG,SC,29003,2018-09-20,812,F,0,1,F5OV11,"Based on observation, interview, and review of the facility policies, the facility failed to prepare, distribute, and serve food under sanitary conditions for 1 of 1 kitchens reviewed and has the potential to affect 73 of 73 residents with ordered diets as evidenced by failing to do the following: Clean vents, pans, cooler, and air-dry pans. The findings included: On 9/18/18 at 4:45 PM, during an observation in the main kitchen of the dinner line plating revealed (3) vents above the steam table, (1) vent above the food preparation area across from the stove, and (1) vent in the dishwashing area had a large build-up of dust. Also, below the steam table and on the dry pan rack, a stack of (4) full pans, (7) 1/6 pans, and (4) 1/3rd pans were stacked wet and had food debris on them. On 9/19/18 at 9:10 AM, an observation of the main kitchen with The Certified Dietary Manager (CDM) revealed (3) vents above the steam table, (1) vent above the food preparation area across from the stove, and (1) vent in the dishwashing area had a large build-up of dust. Also, the door and base board of the cooler were rusted showing holes through the outer layer of steel. On 9/19/18 at 9:15 AM, during an interview with the CDM, s/he verified pans were stacked wet and had food debris on them, also the vents above the steam table, food preparation area and in the dishwashing area had a large build-up of dust, furthermore the door and base of the cooler were rusted. Review of the facility policy entitled, Dishwashing, revealed under procedure (8.) Allow all items to thoroughly air dry before unloading racks or storing items.",2020-09-01
992,MILLENNIUM POST ACUTE REHABILITATION,425105,2416 SUNSET BOULEVARD,WEST COLUMBIA,SC,29169,2018-01-23,550,D,1,0,EINS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and interview, the facility failed to provide a meal tray in a timely manner and provide privacy for one of four sampled residents observed for in room dining. The findings included: The facility admitted Resident #7 with [DIAGNOSES REDACTED]. Meal tray delivery was observed on 1/22/18 beginning at approximately 05:30 PM on the Jasmine Hall on the second floor. Resident #7 did not receive a meal tray at 5:45 PM when the roommate received his/her tray. Resident #7 witnessed the tray being delivered to the other resident in the room and then watched the roommate eat since there was no curtain drawn in between them. Resident #7 received a tray at 06:21 PM, 36 minutes after the roommate received his/her tray.",2020-09-01
993,MILLENNIUM POST ACUTE REHABILITATION,425105,2416 SUNSET BOULEVARD,WEST COLUMBIA,SC,29169,2018-01-23,580,E,1,0,EINS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to notify the physician of changes requiring potential physician intervention for one of seven sampled residents reviewed for notification. Resident #5 had multiple abnormal blood pressure (BP) readings without evidence of physician notification. The findings included: The facility admitted Resident #5 with [DIAGNOSES REDACTED]. Record review on 1-23-18 at 10 AM revealed physician's orders [REDACTED]. Review of the Blood Pressure Summary at 10:08 AM on 1-23-18 revealed abnormal BPs recorded as follows: 1-21-18 at 9:51 AM = 158/112 12-22-17 at 10:01 AM = 87/38 11-28-17 at 11:45 AM = 187/82 11-17-17 at 2:34 PM = 188/76 11-16-17 at 9:55 AM = 94/57 Nursing and Physician's Progress Notes were reviewed at 6:09 PM on 1-22-18. There was no evidence of physician notification of BP results as noted. On 1-21-18 at 9:51 AM, when the BP was recorded at 158/112, there was no documented resident assessment. The BP was retaken at 11:30 AM at 150/88. On 12-22-17 at 10:01 AM, when the BP was recorded as 87/38, there was no documented assessment and the next recorded BP was at 7:05 PM (9 hours later) at 110/70. On 11-28-17 at 11:45 AM, when the BP was recorded as 187/82, the next recorded BP was at 8:44 PM (9 hours later) at 156/78. On 11-17-17 at 2:34 PM, when the BP was recorded at 188/76, there was no documented assessment and the next recorded BP was at 9:32 PM at 104/40. On 11-16-17 at 9:55 AM, when the BP was recorded at 94/57, the next recorded BP was at 9:07 PM (11 hours later) at 122/64. During an interview on 1-23-18 at 2:56 PM, the nurse consultant verified the above and noted that s/he would have assessed the resident and notified the physician. During an interview on 1-23-18 at 4 PM, after reviewing the medical record, the Director of Nursing and the Nurse Consultant verified that the physician had not been notified of the noted BP results.",2020-09-01
994,MILLENNIUM POST ACUTE REHABILITATION,425105,2416 SUNSET BOULEVARD,WEST COLUMBIA,SC,29169,2018-01-23,656,D,1,0,EINS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to develop a person-centered care plan for incontinence for one of one sampled resident reviewed for a toileting program. Although Resident #5 was assessed as a possible candidate for bowel and bladder retraining, there was no care plan developed to address this need. The findings included: The facility admitted Resident #5 with [DIAGNOSES REDACTED]. Review of the 11-22-17 Admission Minimum Date Set (MDS) assessment on 1-23-18 at 10:33 AM revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 9, required limited assistance of one person for toileting, and was frequently incontinent of bowel and bladder. The MDS noted that no toileting programs had been attempted. Review of the 11-15-17 Bowel and Bladder Evaluation on 1-23-17 at 2:35 PM revealed Resident #5 scored a ''9, indicating s/he was a possible candidate for bowel and bladder retraining. Further record review revealed no evidence that a training program had been attempted/implemented. Review of the 11-15-17 Care Plan on 1-23-18 at 11 AM revealed a focus of Has bowel/bladder incontinence r/t (related to) dementia. The Focus did not include potential candidacy for any type of training program. Goals did not address a decrease of incontinence episodes, only avoidance of potential skin breakdown. Interventions did not include an individualized training and/or toileting program, only a check and change program. During an interview on 1-23-18 at 4 PM, the Director of Nursing and Nurse Consultant verified that no training program had been implemented.",2020-09-01
995,MILLENNIUM POST ACUTE REHABILITATION,425105,2416 SUNSET BOULEVARD,WEST COLUMBIA,SC,29169,2018-01-23,657,D,1,0,EINS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview, and review of the facility's fall prevention policy, the facility failed to update the care plan interventions to prevent recurrent falls in 1 of 3 sampled residents reviewed for falls. Resident #6 had been assessed and considered a high risk for falls and had also sustained several falls since admission and although care planned for falls, there were no preventative measures incorporated following each fall. The findings included: The facility admitted Resident #6 with [DIAGNOSES REDACTED]. Review of Resident #6's care plan on 1/23/18 at approximately 3 PM revealed that the resident had a care plan for the problem area of falls. However, the care plan was not updated following each fall that occurred on 1/11/18, 11/27/17, 11/24/17, and 11/9/17. 3 of 4 of the falls were related to the resident falling out of the bed. The care plan created on 12/22/17 specifically stated that Resident #6 was at risk for falls due to the amputation of the left lower extremity. No interventions were added/changed to prevent recurrence. During an interview with Licensed Practical Nurse (LPN) #2, it was revealed that the plan of care and associated forms were to be updated each time a resident had a significant event, such as a fall or abnormal vital signs. Per the facility's fall prevention policy, The Licensed Nurse will complete the form as follows: .5. Identify an action plan or approaches to be taken in an attempt to prevent further falls based on newly identified factors or risk factors. 6. If there is an existing plan of care in the resident's medical pertaining to falls, it should be updated to reflect newly identified risk factors and approaches. Neither of these actions were performed.",2020-09-01
996,MILLENNIUM POST ACUTE REHABILITATION,425105,2416 SUNSET BOULEVARD,WEST COLUMBIA,SC,29169,2018-01-23,659,E,1,0,EINS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to implement care plan interventions for restorative nursing services for one of three sampled residents reviewed for falls. The facility did not provide restorative ambulation as per the care plan for Resident #5. The findings included: The facility admitted Resident #5 with [DIAGNOSES REDACTED]. Record review at 5:07 PM on 1-22-18 revealed a 12-6-17 Physician's Telephone Order for Restorative for amb(ulation) 3 times per w(ee)k. Review of the 11-15-17 Care Plan on 1-23-18 at 11 AM revealed a focus of ADL (activities of daily living) self care performance deficit r/t (related to) dementia. Interventions included Nursing Rehab: Restorative Nursing Program: Ambulate with staff hand held assistance three times a week. Review of computerized Restorative Nursing revealed an entry for Restorative Nursing Program: Ambulate with staff hand held assistance three times a week to be completed. However, there were no initials to indicate that the service had ever been provided. During an interview on 1-23-18 at 4 PM, the Director of Nursing and Nurse Consultant stated that if services were provided, restorative would be documented on this record. There were no other places where restorative services were documented. They verified that restorative ambulation had not been done as ordered and care planned",2020-09-01
997,MILLENNIUM POST ACUTE REHABILITATION,425105,2416 SUNSET BOULEVARD,WEST COLUMBIA,SC,29169,2018-01-23,661,D,1,0,EINS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to provide documentation at the time of discharge for Resident #4, 1 of 3 sampled residents reviewed for infections. Resident #4 was discharged Against Medical Advice (AMA) and there was no evidence to address resident disposition, interventions and post-discharge instructions. The findings included: The facility admitted Resident #4 with [DIAGNOSES REDACTED]. Record review on 1/23/18 at approximately 2:50 PM revealed that Resident #4 left the facility Against Medical Advice (AMA) on 1/22/18. When reviewing the resident's medical record, there was no documentation stating that the resident was discharged or why s/he was discharged . There were no discharge instructions, medication reconciliation, future appointments for resident nor a home health referral. In an interview with the Director of Nursing (DON) on 1/23/18 at 4:45 PM, when asked why Resident #4 left AMA, the DON stated She (he) said that she (he) didn't want to be here now and never wanted to. The DON confirmed that there was no discharge summary in the electronic health record (EHR), nor in the resident's closed record. During an interview on 1/23/18 at 4:27 PM, Licensed Practical Nurse (LPN) #1, who discharged the resident, said The resident stated that she (he) wasn't happy here. She (He) had a bad weekend and complained of not receiving her (his) medications on time. LPN #1 then stated that the resident voiced concerns to the Assistant Director of Nursing but never voiced concerns to him/her. LPN #1 said that Resident #4 stated that s/he was ready to go home and was looking into other long term care options. The Clinical Research Nurse confirmed that LPN #1 did not document the discharge or that the resident was leaving AMA.",2020-09-01
998,MILLENNIUM POST ACUTE REHABILITATION,425105,2416 SUNSET BOULEVARD,WEST COLUMBIA,SC,29169,2018-01-23,679,D,1,0,EINS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, interview, and review of the facility policy entitled Infection Prevention and Control Program, the facility failed to allow participation in group activities for one of one sampled resident observed on Transmission Based Precautions. Resident #3 was not allowed to participate in group activities because of contact precautions. The findings included: The facility admitted Resident #3 with [DIAGNOSES REDACTED]. The Physician's Orders reviewed on 1/22/18 at 11:41 AM revealed that Contact Precautions were no longer required on 1/17/18 for [MEDICAL CONDITION], but were needed to continue for [MEDICAL CONDITION] Resistant [DIAGNOSES REDACTED] Aureus (MRSA) in the surgical site. A Physician Encounter record from 1/18/18 revealed the resident is not having any drainage from the incision in his (her) knee is now closed. No problems with the Peripherally Inserted Central Catheter (PICC) in the right arm. No diarrhea or other side effects from antibiotics. Record review of Activities documentation and the Resident's Plan of Care on 1/23/18 at 3:25 PM revealed the resident would have liked to participate in group activities, such as bingo, as soon as s/he was off contact precautions. In an interview on 01/22/18 at approximately 03:00 PM, Certified Nursing Assistant (CNA) #1 stated,The contact precautions were for [MEDICAL CONDITION] at first, pretty sure. Now I am not sure, but we get all bundled up to go in the room. At approximately 03:05 PM, CNA #1 stated, The precautions are for [MEDICAL CONDITION] Resistant [DIAGNOSES REDACTED] Aureus (MRSA) now. In an interview on 01/23/18 at 4:52 PM, Licensed Practical Nurse (LPN) #1 stated, The incision is closed. There is no drainage and no dressing. In an interview on 01/23/18 at approximately 4:55 PM, the Director of Nurses (DON) stated, The resident came in with [MEDICAL CONDITION] and was on precautions until 1/17/18 when he (she) had no symptoms of [MEDICAL CONDITION], but then he (she) [MEDICAL CONDITION] in his knee. So, he (she) is still on precautions. In an interview on 01/23/18 at 5:00 PM, the Infection Control Nurse stated, I normally round with the doctors but I didn't this week. I don't make the decisions for residents to come off precautions. After reviewing the policy Infection Prevention and Control Program, the Infection Control Nurse stated, The resident should be free to attend group activities as he (she) desires based on this policy. The facility policy entitled, Infection Prevention and Control Program was reviewed on 1/23/18 at approximately 5:10 PM with the Infection Control Nurse. In the section PREVENTION AND CONTROL OF MDRO (Multi-drug Resistant Organisms) TRANSMISSION under letter I. Activities, it states, Residents should be allowed to ambulate, interact with other residents socially and participate in group activities. It is the philosophy of the facility to isolate the infection (the germ), not necessarily, the resident. In the section TERMINATION OF CONTACT PRECAUTIONS #1 states, Contact precautions may be discontinued when MDRO resident becomes asymptomatic. It is not necessary to wait until the completion of the antibiotic. Assess the resident for clinical improvement which is evident by resolution of the symptoms. Good assessment and documentation of each resident's clinical condition is necessary before discontinuing the isolation precautions. Isolation may be discontinued when there is documentation that the resident is free of symptoms for 24 hours or more. At the end of isolation, the resident will then be managed with Standard Precautions.",2020-09-01
999,MILLENNIUM POST ACUTE REHABILITATION,425105,2416 SUNSET BOULEVARD,WEST COLUMBIA,SC,29169,2018-01-23,684,D,1,0,EINS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to follow discharge orders for one of two sampled residents reviewed for hospice services/palliative care. There was no evidence of oncology or hospice consults for Resident #2. In addition, based on record review and interview, facility staff failed to assess one of seven sampled residents reviewed for notification for signs and symptoms related to documented hyper- and [MEDICAL CONDITION] (Resident #5). The findings included: The facility admitted Resident #2 following hospitalization for [DIAGNOSES REDACTED]. Review of the 8-30-17 hospital Discharge Summary revealed that the physician had ordered a consult with oncology and palliative care [MEDICAL CONDITION], poor overall progress, GOC (goals of care) and code statuswhile in the hospital. Discharge instructions included a follow-up with oncology in one week. Review of Consultation Reports, Physician's Progress Notes, and Nursing and Social Services Progress Notes revealed no evidence of follow-up on the oncology appointment. There were no references to discussion of hospice services/palliative care in the record. During interviews on 1-23-18, the Nurse Consultant and Administrator were unable to locate this information. Based on record review and interview, the facility failed to notify the physician of changes requiring potential physician intervention for one of seven sampled residents reviewed for notification. Resident #5 had multiple abnormal blood pressure (BP) readings without evidence of physician notification. The findings included: The facility admitted Resident #5 with [DIAGNOSES REDACTED]. Record review on 1-23-18 at 10 AM revealed physician's orders [REDACTED]. Review of the Blood Pressure Summary at 10:08 AM on 1-23-18 revealed abnormal BPs recorded as follows: 1-21-18 at 9:51 AM = 158/112 12-22-17 at 10:01 AM = 87/38 11-28-17 at 11:45 AM = 187/82 11-17-17 at 2:34 PM = 188/76 11-16-17 at 9:55 AM = 94/57 Nursing and Physician's Progress Notes were reviewed at 6:09 PM on 1-22-18. There was no evidence of physician notification of BP results as noted. On 1-21-18 at 9:51 AM, when the BP was recorded at 158/112, there was no documented resident assessment. The BP was retaken at 11:30 AM at 150/88. On 12-22-17 at 10:01 AM, when the BP was recorded as 87/38, there was no documented assessment and the next recorded BP was at 7:05 PM (9 hours later) at 110/70. On 11-28-17 at 11:45 AM, when the BP was recorded as 187/82, the next recorded BP was at 8:44 PM (9 hours later) at 156/78. On 11-17-17 at 2:34 PM, when the BP was recorded at 188/76, there was no documented assessment and the next recorded BP was at 9:32 PM at 104/40. On 11-16-17 at 9:55 AM, when the BP was recorded at 94/57, the next recorded BP was at 9:07 PM (11 hours later) at 122/64. During an interview on 1-23-18 at 2:56 PM, the nurse consultant verified the above and noted that s/he would have assessed the resident and notified the physician. During an interview on 1-23-18 at 4 PM, after reviewing the medical record, the Director of Nursing and the Nurse Consultant verified that the physician had not been notified of the noted BP results.",2020-09-01
1000,MILLENNIUM POST ACUTE REHABILITATION,425105,2416 SUNSET BOULEVARD,WEST COLUMBIA,SC,29169,2018-01-23,688,E,1,0,EINS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to provide restorative services as ordered by the physician for one of three sampled residents reviewed for falls. The facility did not provide restorative ambulation three times per week as ordered for Resident #5 who had a history of [REDACTED]. The findings included: The facility admitted Resident #5 with [DIAGNOSES REDACTED]. Review of Incident Reports at 11:03 AM on 1-23-18 revealed that Resident #5 had sustained at least 3, possibly 4 falls since admission. On 12-4-17, the resident was found sitting on the bed with a quarter-sized red area on his/her forehead and stated, I hit my head on the wall this morning. On 12-13-17, s/he fell in the hallway. On 12-22-17, s/he rolled out of bed. On 1-21-18, Resident #5 tripped over another resident in the dining room. Record review at 5:07 PM on 1-22-18 revealed a 12-6-17 Physician's Telephone Order for Restorative for amb(ulation) 3 times per w(ee)k. Review of the 11-15-17 Care Plan on 1-23-18 at 11 AM revealed a focus of ADL (activities of daily living) self care performance deficit r/t (related to) dementia. Interventions included Nursing Rehab: Restorative Nursing Program: Ambulate with staff hand held assistance three times a week. Review of computerized Restorative Nursing revealed an entry for Restorative Nursing Program: Ambulate with staff hand held assistance three times a week to be completed. However, there were no initials to indicate that the service had ever been provided. During an interview on 1-23-18 at 4 PM, the Director of Nursing and Nurse Consultant stated that if services were provided, restorative would be documented on this record. There were no other places where restorative services were documented. They verified that restorative ambulation had not been done as ordered.",2020-09-01