rowid,facility_name,facility_id,address,city,state,zip,inspection_date,deficiency_tag,scope_severity,complaint,standard,eventid,inspection_text,filedate
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
1168,PRUITTHEALTH- DILLON,425113,413 LAKESIDE COURT,DILLON,SC,29536,2018-04-12,568,B,0,1,D5V511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to issue quarterly statements for 2 of 2 residents reviewed. (Resident #53 & #9) The findings included: The facility admitted Resident #53 with [DIAGNOSES REDACTED]. Review of the current Minimum Data Set listed the resident's Brief Interview for Mental Status(BIMS) as 10. During an interview with Resident #53 on 4/9/18 at 3:02 PM, s/he stated was unaware if s/he had a personal funds account when asked if they received a quarterly statement. The facility admitted Resident #9 with [DIAGNOSES REDACTED]. Review of the current Minimum Data Set listed the resident's BIMS as 10. During an interview with Resident #9 on 4/10/18 at 11:12 AM, s/he stated was unaware if s/he had a personal funds account when asked if they received a quarterly statement. During an interview with the Business Office Manager on 4/12/18 at 3:03 PM, s/he stated both residents had a personal funds account but had not requested a quarterly statements and the quarterly statements were sent to the responsible party. S/he continued by stating facility procedure was if a resident had a BIMS of 13 or above a quarterly statement is issued to the resident and the resident signs they received the statement. During an interview with the Business Office Manager on 4/12/18 at 4:12 PM, s/he stated there was no policy related to which residents received a quarterly statement, but s/he was instructed by corporate to issue one to those with a BIMS of 13 or above.",2020-09-01
1208,HONORAGE NURSING CENTER,425115,1207 NORTH CASHUA ROAD,FLORENCE,SC,29501,2017-01-13,156,B,0,1,CQPA11,"Based on record review and interview, the facility failed to utilize the required form for Notice of Medicare Non-coverage(NOMNC) for Resident #65(1 of 3 reviewed) and failed to issue the NOMNC in the required time frame for Resident #71.(1 of 3 reviewed). The findings included: Record review on 1/12/17 for Liability Notices revealed the facility issued Form No. CMS- for Resident #65 instead of the required Form No. CMS- -NOMNC. Further review revealed Form No. CMS- was not issued in the 48 hour required time frame for Resident #71. During an interview with the Business Office Manager on 1/12/17 at 11:12 AM, he/she confirmed Resident #65's notice was not on the required form and Resident #71's Liability Notice was not issued in the required 48 hour time frame.",2020-09-01
1214,HONORAGE NURSING CENTER,425115,1207 NORTH CASHUA ROAD,FLORENCE,SC,29501,2017-01-13,354,B,0,1,CQPA11,"Based on interview and record review the facility failed to insure that a Registered Nurse was assigned on duty for eight consecutive hours. The findings included: Review of the facility's licensed nursing staffing schedules for October, November, and (MONTH) up to (MONTH) 12, (YEAR) revealed that on Friday, (MONTH) 25, (YEAR), the Director of Nursing was scheduled to work on the unit as the Registered Nurse (RN) from 7 a- 3p. All other RN's were scheduled off for regular days off, vacations days , or holidays. On 1/12/17 at 1:45 PM in an interview with the DON ( Director of Nursing) she/he stated, I worked on that day in the facility as the RN and not as the DON. He/she further stated that he/she was unaware that the DON could not work in the facility as the RN coverage if the facility was over 60 beds. This facility is an 88 bed facility.",2020-09-01
1424,INMAN HEALTHCARE,425122,51 N MAIN ST,INMAN,SC,29349,2017-02-09,514,B,0,1,6GNK11,**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the Physician 's Certification documentation to receive hospice care was not located in the chart for Resident # 23. ( 1 of 1 Hospice resident reviewed.) The findings included: The facility admitted Resident # 23 with [DIAGNOSES REDACTED]. An interview with RN ( Registered Nurse ) #1 @ 10:50 AM on 2/8/17 confirmed the recertification signatures were not in the Hospice notebook for dates 10/7/16- 12/16 and 12/17- 2/17. The DON ( Director of Nursing) stated she would call and have those sent to the facility from Hospice. They were later faxed from Hospice and placed in the Hospice Book for Resident # 23.,2020-09-01
1452,PRUITTHEALTH- ROCK HILL,425127,261 S HERLONG AVE,ROCK HILL,SC,29732,2020-01-14,582,B,1,1,ZGSA11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to issue Advance Beneficiary Notice of Noncoverage (ABN) for two of two residents (Residents #94 and #255) discharged from Medicare Part A with benefit days remaining. The findings include: 1. Resident #94 was originally admitted on [DATE]. A Notice of Medicare Non-coverage (NOMNC) was issued for services ending on 09/27/19. Although the resident was to be discharged from Medicare Part A with benefits days remaining, he would continue to be a resident in the facility. The facility did not issue an ABN. A second NOMNC was issued for services ending on 01/17/20. The resident was to be discharged from Medicare Part A with benefits days remaining, but he would continue to be a resident in the facility. The facility did not issue an ABN. During an interview on 01/11/20 at 5:39 PM, the Senior Vice President of Clinical Services stated the facility had not been issuing ABNs for any resident. She stated the newly hired Finance Counselor, who issues the notices, began working at the facility in September 2019 and since then, no ABNs had been issued. During an interview on 01/13/20 at 2:20 PM, the Finance Counselor stated she had not been issuing any ABNs. She stated she thought those were only issued if a resident didn't agree and wanted to appeal the decision. No ABN notices had been given to the residents who were discharged from Medicare Part A with benefit days left that remained in the facility. 2. Resident #255 was originally admitted on [DATE]. A Notice of Medicare Non-coverage (NOMNC) was issued for services ending on [DATE]. Although the resident was to be discharged from Medicare Part A with benefits days remaining, she would continue to be a resident in the facility. The facility did not issue an ABN. During an interview on 01/11/20 at 5:39 PM, the Senior Vice President of Clinical Services stated the facility had not been issuing ABNs for any resident. She stated the newly hired Finance Counselor, who issues the notices, began working at the facility in September 2019 and since then, no ABNs had been issued. During an interview on 01/13/20 at 2:20 PM, the Finance Counselor stated she had not been issuing any ABNs. She stated she thought those were only issued if a resident didn't agree and wanted to appeal the decision. No ABN notices had been given to the residents who were discharged from Medicare Part A with benefit days left that remained in the facility.",2020-09-01
1573,BRIAN CENTER NURSING CARE - ST ANDREWS,425129,3514 SIDNEY ROAD,COLUMBIA,SC,29210,2018-10-05,842,B,0,1,5DS011,"Based on observations and interview, the facility failed to provide access to 1 of 24 sampled residents' records as required (Resident #88). The findings included: Upon entrance to the facility, it was noted that staff used both electronic and paper systems (chart) to comprise the complete medical records. Although the facility had a procedure for checking out charts at the nursing station, it was not being consistently utilized. The surveyor reviewed Resident #88's record on 10-2-18, but it was not in the chart rack at 9 AM on 10-3-18 and subsequently remained missing for 3 days of the survey. During an interview on 10/03/18 at 12 PM, the surveyor asked the Registered Nurse (RN) Consultant if s/he had been advised that Resident #88's hard chart had been missing since 9 AM. The RN verified they could not locate the chart and that it was not signed out per the facility policy. The Administrator and RN Consultant thought the Medical Director might have picked it up. On 10/04/18 at 8:32 AM, the Administrator stated they still had not located the chart. The chart was not found prior to exit on 10-5-18.",2020-09-01
1584,THE METHODIST OAKS,425131,151 LOVELY DRIVE,ORANGEBURG,SC,29115,2017-02-10,278,B,0,1,7B3F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview and observation, the facility failed to assure that 1 of 3 sampled residents reviewed for pressure ulcers and 1 of 5 sampled residents reviewed for unnecessary medications received accurate assessments. Resident #86 had 1 Annual Comprehensive Minimum Data Set (MDS) Assessment and 2 Quarterly MDS Assessments with inaccurate data related to Urinary Continence, active diagnoses, and Skin Conditions. Resident #34 had an Annual Comprehensive Minimum Data Set Assessment with inaccurate data related to active diagnoses. The findings included: The facility admitted Resident #86 with [DIAGNOSES REDACTED]. Record review of Resident #86's Quarterly MDS with ARD of 8/15/2016, and Quarterly MDS with ARD of 11/15/2016 on 2/9/2017 at 8:45 AM revealed Section G Items G0400A (Functional limitation in Range of Motion (ROM) in upper extremities and G0400B (Functional limitation in ROM in lower extremities) are both coded as 0, which indicated no impairment in functional ROM. Record review of Resident #86's PACE (Program of All-Inclusive Care for the Elderly) Care Plan Review dated 8/12/16 on 2/9/2017 at approximately 10:20 AM, reveals that an Occupational Therapy (OT) Assessment was completed on 8/2/16 which identified limitations in range of motion in both arms and a Physical Therapy (PT) Assessment was completed on 8/10/2016 which identified .significant decrease range of motion of bilateral knees. Further review revealed that an OT periodic review completed on 1/5/2017 identified ROM deficits and multiple contractures in all extremities with potential for pain, further contracture formation, and skin breakdown . During interview on 2/9/2017 at approximately 8:19 am, C.N.[NAME] #10 verified that Resident # 86 had had contractures in bilateral arms and legs .as long as I can remember. During an interview on 2/9/17 at approximately 8:40 AM, LPN #3 verified that Resident #86 had contractures in arms and legs on both sides. Direct observation on 2/9/2017 at approximately 8:40 AM revealed that Resident #86 displayed contractures at bilateral knees and bilateral arms. Record review of Resident #86's Quarterly MDS with ARD of 8/15/2016, and Quarterly MDS with ARD of 11/15/2016 on 2/9/2017 at 8:45 AM revealed Section H Item H0100B is checked which indicated presence of External Catheter and 0300 is coded as 9 (continence is not rated, resident has had a catheter (indwelling/ condom), urinary ostomy, or no urine output for entire 7 days). Record review of Resident #86's revealed a physician order [REDACTED]. During interview with DON and MDS Coordinator on 2/9/2017 at approximately 3:40 PM, both verified that the condom catheter was discontinued during the assessment period for the Quarterly MDS Assessment with ARD of 8/15/16 and that Resident #86 was incontinent of urine after the removal of the condom catheter through the remainder of the assessment window which ended after 11:59 PM on 8/15/2016. Interview with C.N.[NAME] # 10 on 2/9/17 at 8:39 am revealed that the condom catheter had been discontinued since .before (MONTH) (YEAR) and that Resident #86 had been incontinent of urine since the condom catheter was gone. Record review of Resident #86's Quarterly MDS with ARD of 8/15/2016, and Quarterly MDS with ARD of 11/15/2016 on 2/9/2017 at 8:45 AM revealed Section I Items I0400 [MEDICAL CONDITION] (CAD) was not checked, I3300 [MEDICAL CONDITION] was not checked, I4300 [MEDICAL CONDITION] was not checked, Item I4500 [MEDICAL CONDITIONS] was not checked, Item I4800 Non-Alzheimer's dementia was not checked, and I4900 [MEDICAL CONDITION]/[MEDICAL CONDITION] was not checked. Review of physician progress notes [REDACTED]. During interview with DON and MDS Coordinator on 2/9/2017 at approximately 3:40 PM, both verified that Resident #86 had had active [DIAGNOSES REDACTED].#86's Quarterly MDS with ARD of 8/15/2016, and Quarterly MDS with ARD of 11/15/2016. Record review of Resident #86's Annual Comprehensive MDS with Assessment Reference Date (ARD) of 5/15/2016, and Quarterly MDS with ARD of 8/15/2016 on 2/9/2017 at 8:45 AM revealed that section M item M0100A (Resident has a stage 1 or greater, a scar over bony prominence, or a non-removable dressing/device) was not checked. Further review revealed that item M0210 (Does the resident have one or more unhealed pressure ulcer(s) at stage 1 or higher?) was coded as 1 (yes). DON verified during interview on 2/9/2017 at 11:00 AM that M0100A was not checked and M0210 was coded as 1 on Resident #86's Comprehensive MDS with ARD of 5/15/2016 and Quarterly MDS with ARD of 8/15/2016. The facility admitted resident #34 with [DIAGNOSES REDACTED]. Record review of Resident #34's Annual Comprehensive MDS (Minimum Data Set) with Assessment Reference Date (ARD) of 01/04/2017 on 2/8/2017 at 1:00 P.M. revealed Section I (Active Diagnoses) item I0300 ([MEDICAL CONDITION] Fibrillation or Other [MEDICAL CONDITION] (e.g., [MEDICAL CONDITION] and [MEDICAL CONDITION]) was not checked. Further review revealed that item I8000A was coded as Presence of Cardiac Pacemaker with an ICD-10 code of Z95.0. Record review on 2/8/2017 at 1:30 P.M. revealed that Resident #34 had a Cardiology Clinic Office note dated 12/29/2016 that identified an active [DIAGNOSES REDACTED]. During an interview on 2/9/2017 at approximately 3:36 P.M., MDS Coordinator and DON (Director of Nursing) both verified that item I0300 ([MEDICAL CONDITION] Fibrillation or Other [MEDICAL CONDITION] (e.g., [MEDICAL CONDITION] and [MEDICAL CONDITION]) was unchecked, and that I8000A was coded as Presence of Cardiac Pacemaker with an ICD-10 code of Z95.0. MDS Coordinator and DON both also verified that both Symptomatic [MEDICAL CONDITION] and Complete Heart Block were active [DIAGNOSES REDACTED].",2020-09-01
1586,THE METHODIST OAKS,425131,151 LOVELY DRIVE,ORANGEBURG,SC,29115,2017-02-10,287,B,0,1,7B3F11,"Based on interview and electronic record review the facility failed to complete and transmit required Minimum Data System (MDS) 3.0 assessments as required by CMS and the State for discharged residents. The findings included: On 02/09/2017 at 1:45 PM an interview with MDS RN #1 and electronic record review of residents #147, #148, #149, #150, #151, #152, #153, #154, #155 had missing and/or incomplete discharge assessments encoded and transmitted.",2020-09-01
1598,THE METHODIST OAKS,425131,151 LOVELY DRIVE,ORANGEBURG,SC,29115,2018-06-01,640,B,0,1,VRCK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on limited record review and staff interview, the facility failed to ensure that one of three residents identified on the Minimum Data Set (MDS) 3.0 Missing Omnibus Budget Reconciliation (OBRA) Assessment Report had assessments electronically transmitted to the Centers for Medicare and Medicaid (CMS) system database as mandated. Resident #282's Prospective Payment System (PPS) 5 day start of therapy discharge return not anticipated Minimum Data Set (MDS) assessment was electronically transmitted to the Centers for Medicare and Medicaid (CMS) database System 98 days after discharge date and was considered to be late. The findings included: Review of the resident record on 5/31/18 at 8:45 AM revealed that Resident #282 was admitted to the facility with the [DIAGNOSES REDACTED]. Review of the Missing OBRA MDS assessment Report on 5/29/18 at 10:30 AM revealed that Resident #282 ' s last received assessment was an entry tracking form with a target date of 2/20/2018. Review of the Final Validation Report (FVR) on 5/31/18 at 12:40 PM revealed that a discharge assessment was submitted and accepted to the CMS system database on 5/31/18 at 12:27 PM. Further review of the FVR revealed a submission ID of 269 and Resident #282 ' s Discharge MDS assessment is identified as Record 1. Additional review of the FVR revealed that the discharge MDS assessment for Resident #282 was accepted, with message -3810d WARNING Record Submitted Late: The submission date is more than 14 days after Z0500B2 on this new (A0050 equals 1) assessment. During interview with MDS Nurse #1 on 5/31/18 at 1:51 PM, s/he verified that the MDS assessment for Resident #282 was completed on 2/26/18 but not submitted and accepted by the CMS system database until 5/31/18 and was considered late according to regulatory guidelines outlined in the RAI manual.",2020-09-01
1738,PRUITTHEALTH-MONCKS CORNER,425140,505 SOUTH LIVE OAK DRIVE,MONCKS CORNER,SC,29461,2018-05-25,640,B,0,1,ZKXB11,"Based on record review and interview, the facility failed to complete and/or transmit required assessments in a timely manner for 9 of 9 sampled residents reviewed for Missing Assessments. The findings included: Record review and interview on 05/25/18 at approximately 6:06 PM with the Minimum Data Set (MDS) Coordinator, Licensed Practical Nurse #2 , revealed that corrections were made and reports resubmitted based upon Missing OBRA assessments listed on the CASPER 3 report.",2020-09-01
1764,PRUITTHEALTH-MONCKS CORNER,425140,505 SOUTH LIVE OAK DRIVE,MONCKS CORNER,SC,29461,2019-07-19,640,B,0,1,IPGW11,"Based on record review and interview, the facility failed to complete and transmit Discharge Tracking MDS (Minimum Data Set) Assessments for 3 of 4 residents reviewed for missing assessments (Residents #425, #426, and #427). The findings included: Review of the state database revealed Admission MDS Assessments for Residents #425 dated 12/22/18, #426 dated 10/19/18, and #427 dated 09/28/18. Further review revealed no Discharge Tracking MDS Assessments for Residents #425, #426, or #427. Review of the facility's current electronic health records revealed Residents #425, #426, and #427 did not have any entries in the current system. During an interview with the MDS Coordinator on 07/19/19 09:35 AM, s/he confirmed the Discharge Tracking MDS for Resident #425 was not completed in the software system. S/he further confirmed the Discharge Tracking MDS for Residents #426 and #427 was completed but not closed or transmitted. The MDS Coordinator further stated that s/he runs an open assessment report each month but the residents assessments did not appear on the report.",2020-09-01
1786,HEARTLAND HEALTH CARE CENTER - UNION,425142,709 RICE AVENUE,UNION,SC,29379,2018-07-12,657,B,0,1,EY8011,"**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 5 of 21 residents reviewed for care plans. (Residents #32, 4, 69, 33, and 77) The findings included: The facility admitted Resident #32 on 6/13/18 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 6/25/18 revealed no signature of a Certified Nurse Aide (CNA) to indicate participation in development of the care plan. The facility admitted Resident #4 on 4/11/18 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 4/17/18 revealed no signature of a CNA to indicate participation in development of the care plan. The facility admitted Resident #69 on 8/25/17 with [DIAGNOSES REDACTED]. Review of the medical record revealed the care plan attendance sheets contained space for signatures of staff participating in the care plan meeting. Review of the attendance sheets dated 12/7/17, 3/13/18, and 6/2/18 revealed no signature of a CNA to indicate participation in development of the care plan. The facility admitted Resident #33 on 4/22/16 with [DIAGNOSES REDACTED]. Review of the medical record revealed the care plan attendance sheets contained space for signatures of staff participating in the care plan meeting. Review of the attendance sheets dated 1/18/18 and 4/11/18 revealed no signature of a CNA to indicate participation in development of the care plan. The facility admitted Resident #77 on 6/14/18 with [DIAGNOSES REDACTED]. Review of the medical record revealed the care plan attendance sheets contained space for signatures of staff participating in the care plan meeting. Review of the attendance sheet dated 6/26/18 revealed no signature of a CNA to indicate participation in development of the care plan. During an interview on 7/11/18 at approximately 3:10 PM, the Social Services Director reviewed the attendance forms and confirmed that a CNA did not participate in the development of the care plans for these residents.",2020-09-01
1798,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2017-07-14,156,B,1,1,EIV311,"> Based on record review and interviews, the facility failed to follow guidelines for issuance of the Center for Medicare and Medicaid Services (CMS) Notice of Medicare Non-Coverage (CMS -NOMNC) to Resident #4. Timely notice was not given to 1 of 3 residents reviewed for Liability Notices. The findings include: Record review on 07/13/17 at 3:46 pm revealed that the facility provided less than the required two day notice to Resident #4 for the Notice of Medicare Non-coverage. Further review of the file revealed that Resident #4's benefit period was due to end on 01/25/17. The notice provided by the facility was dated 01/24/17. In an interview on 07/13/17 at 4:11 pm the Social Worker stated that the notice should have been done on 01/23/17 to meet the two day requirement.",2020-09-01
1799,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2017-07-14,167,B,1,1,EIV311,"> Based on observation and interview the facility failed to post signage indicating the location of past survey results and making them readily accessible to both residents and visitors. The findings included: On 07/14/2017 11:42 AM this surveyor along with the Administrator observed placement of the facility's mandatory posting of contact information for state regulatory agencies, the Ombudsman and other advocacy groups. In an interview on 07/14/17 at 11:42 AM the Administrator confirmed that the board contained out-of-date and repetitive information. The Administrator stated that a resident would need to ask for assistance to select the proper contact information. Further observation revealed the facility's past survey results to be placed in a notebook in a mail bin on the left wall of the entrance hall to the dining room. In an interview on 07/14/17 at 11:42 AM, the Administrator was asked, how would a person entering the front door of the facility know where to find the survey results without asking for assistance. The Administrator stated there should be a sign to tell them.",2020-09-01
1802,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2017-07-14,276,B,1,1,EIV311,"> Based on record review and interview, the facility failed to submit a Minimum Data Set (MDS) OBRA quarterly assessment in a timely manner for 4 of 4 residents reviewed for MDS transmission of records. (Residents #96, #80, #69, and #12) The findings included: Review of the facility's MDS 3.0 Missing OBRA Assessment report revealed Resident's #96, #80, #69, and #12 were listed on the report. During an interview on 7/14/17 at approximately 9:45 AM, the facility's Regional MDS Coordinator reviewed the report. The MDS Coordinator later provided a report indicating the missing quarterly assessments had been submitted. The MDS Coordinator confirmed that the quarterly assessments were not submitted within the required timeframe.",2020-09-01
1959,LAKE CITY SCRANTON HEALTHCARE CENTER,425149,1940 BOYD ROAD,SCRANTON,SC,29591,2018-01-26,574,B,0,1,OHH911,"Based on observation, 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 on 01/ 18/18 at 02:04 PM the residents stated they did not receive information on how to file a complaint with the state. The only person who knew about the Ombudsman was a resident who was in rehab and stated she was told at her Assisted Living placement facility. During an interview on 01/26/18 at 05:30 PM, the Activities Director verified that she had not discussed in the resident council meetings about how to file a grievance with the state, but she does tell them where the phone numbers are posted. He/she stated and showed evidence where the Ombudsman information is posted for the residents to contact.",2020-09-01
1963,LAKE CITY SCRANTON HEALTHCARE CENTER,425149,1940 BOYD ROAD,SCRANTON,SC,29591,2018-01-26,640,B,0,1,OHH911,"Based on record review, interview, and review of the facility policy titled MDS-Automation/Electronic Submission, the facility failed to transmit accurate Minimum Data Set(MDS) information in the required time frame for 1 of 1 resident. (Resident #2) The findings included: The facility admitted Resident #2 who had an assessment target date of 7/29/17 which was the last assessment per the Casper Report. During an interview with the MDS Coordinator on 1/19/18 at 4:56 PM, , s/he stated the assessment was probably rejected due to an inaccurate ID number. Review of the facility policy MDS-Automation/Electronic Submission revealed the following: The facility will electronically submit via matrix its state-specific version of the Minimum Data Set(MDS) within the required timeframes according to applicable law and regulations.",2020-09-01
2001,FRASER HEALTH CENTER,425150,300 WOOD HAVEN DRIVE,HILTON HEAD ISLAND,SC,29928,2018-02-22,582,B,0,1,GHY311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, the facility failed to ensure that each resident received proper notice of expiration of Medicare benefits for 1 of 3 residents reviewed for beneficiary protection notification. The findings included: Record review on [DATE] at 4:07PM proved that Resident #80 was not given a 48 hour notice of when his/her Medicare benefits will expire. The Notice of Medicare Non-Coverage form stated that services will end on [DATE], however the Resident signed the form on [DATE]. The Director of Nursing (DON) confirmed that the Resident was not notified 48 hours before Medicare benefits expired.",2020-09-01
2124,RIDGEWAY MANOR HEALTHCARE CENTER,425158,117 BELLFIELD ROAD,RIDGEWAY,SC,29130,2018-05-24,640,B,0,1,CL5J11,"Based on limited record review and interview, the facility failed to electronically transmit encoded, accurate, and completed Minimum Data Sheet (MDS) to the Centers of Medicare and Medicaid Services (CMS) for 1 of 1 reviewed for missing MDS assessment. The findings included: Review of the missing MDS Assessments on 5/21/18 at 10:31 AM revealed the facility failed to transmit MDS assessment for Resident #44 target date 12/8/17. During an interview on 5/23/18 at 3:01 PM with Regional MDS Assessment confirmed Resident # 44 MDS assessment was not submitted within the target date. S/he completed the submission on 5/21/18.",2020-09-01
2129,RIDGEWAY MANOR HEALTHCARE CENTER,425158,117 BELLFIELD ROAD,RIDGEWAY,SC,29130,2018-05-24,727,B,0,1,CL5J11,"Based on limited record reviews and interviews the facility failed to have a RN coverage for 4 out of 30 days reviewed. The findings included: Review of the facility postings and subsequent schedules and time punches revealed the facility did not have required coverage for Registered Nursing on 04/28/18, 04/29/18, 05/12/18, and 05/13/18, for 30 days reviewed. The Director of Nursing and Administrator indicated they were aware of this matter.",2020-09-01
2202,CARLYLE SENIOR CARE OF FLORENCE,425163,133 WEST CLARKE ROAD,FLORENCE,SC,29501,2017-11-16,287,B,0,1,DKQL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to submit a corrected Resident Initial Identification number on 12/15/2016 and therefore had resident information mismatch for Resident #84 for 1 of 1 resident reviewed with missing OBRA Assessments. The findings included: Review on 11/14/2017 at approximately 11:20 AM of a CMS (Centers for Medicare and Medicaid) Submission Report dated 12/15/2016 revealed an assessment for Resident #84 with a Resident Information Mismatch due to the Resident Initial Identification number did not match the values in the QIES ASAP database. The new information was not corrected by the facility. During an interview on 11/14/2017 at approximately 11:25 AM with the MDS (Minimum Data Set) assessment Coordinator, he/she confirmed the findings. The quarterly assessment dated [DATE] contained the corrected Resident Initial Identification number for Resident #84.",2020-09-01
2250,MAGNOLIA MANOR - ROCK HILL,425165,127 MURRAH DR,ROCK HILL,SC,29732,2017-04-21,156,B,0,1,9IUY11,"Based on record review and interviews, one of three residents (Resident #11) reviewed for Medicare notices of non-coverage was not notified in writing following a telephone notification. The findings included: On 4/21/17 at 08:30 AM, review of Resident #11's Medicare Determination on Continued Stay-Skilled Nursing/Facility form revealed D. This is to confirm that you were advised of the noncoverage of the services under Medicare by telephone on 11/8/16. The Beneficiary's name was written on the bottom of form with the signature of the Administrative Officer. The CMS -NOMNC Form was also not signed by the beneficiary. At the bottom of Form CMS -NOMNC, a signed and witnessed handwritten notation stated, 11/18/16 at 3:06 PM Spoke with (family member) concerning (Resident #11). I let her(him) know that she(he) will be moved off of Medicare because she(he) met her(his) goals and prior level of function. She(He) has the right to appeal and gave her(him) the number. On 4/21/17 at 8:49 AM, the Business Office Manager verified that a letter had not been sent to Resident #11 following the telephone notification of Medicare non-coverage. The Business Office Manager said,; Normally we talk to resident or family. 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
2383,PRUITTHEALTH-CONWAY AT CONWAY MEDICAL CENTER,425173,2379 CYPRESS CIRCLE,CONWAY,SC,29526,2018-08-10,640,B,0,1,6SJF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the MDS (Minimum Data Set) assessment dated [DATE] for Resident #229 was coded correctly before transmission to the State Agency for 1 of 1 resident on the Missing OBRA Assessments report. The findings included: Review on 8/10/2018 at approximately 4:42 PM of the Missing OBRA Assessment report revealed an assessment missing for Resident #229. Further review on 8/10/2018 at approximately 4:42 PM of the transmission report to the State Agency revealed the date of birth for Resident #229 was coded incorrectly on the MDS assessment transmitted on 1/8/2018. During an interview on 8/10/2018 at approximately 4:50 PM with the MDS/Care Plan Coordinator, he/she confirmed that the date of birth for Resident #229 was coded incorrectly before transmitting to the State Agency.",2020-09-01
2529,PRUITTHEALTH- RIDGEWAY,425288,213 TANGLEWOOD COURT,RIDGEWAY,SC,29130,2018-06-15,842,B,1,0,RRBC11,"> Based on limited record review and interview the facility failed to accurately document the Active Daily Livings (ADLs) Assistant and Support form for document the Active Daily Living for 1 of 2 reviewed for ADLS. Resident #176's ADLs were documented the day after leaving the facility. The findings included: During record review on 06/13/18 at 10:50AM revealed Discharge Recapitulation Form dated 11/04/17 Resident #176 left the facility against medical advice. Further record review on 06/15/18 at 12:05 PM revealed on November 05, 2017 Resident # 176 ADLS information were completed. During an interview with DON on 06/15/18 at 3:39 PM confirmed Resident #176's ADL information was not complete until 06/05/17.",2020-09-01
2588,WHITE OAK ESTATES,425290,400 WEBBER ROAD,SPARTANBURG,SC,29302,2017-06-21,156,B,0,1,K48X11,"Based on record review and interview, the facility failed to provide a required Advance Beneficiary Notice (ABN) of Non-coverage of medicare CMS (Centers for Medicare/Medicaid Services) form for 2 of 3 sampled residents reviewed. Residents #32 and #57 did not receive ABN forms. The findings included: An interview on 6/20/17 at approximately 10:48 AM with the Business Office Manager confirmed Residents #32 and #57 who had additional medicare days left and remained in the facility did not receive the required ABN form or other medicare notice that addressed the request for a demand bill.",2020-09-01
2625,"THE RIDGE REHABILITATION AND HEALTHCARE CENTER, LL",425293,226 WA REEL DRIVE,EDGEFIELD,SC,29824,2017-05-10,356,B,0,1,T7X811,"Based on record review and interview, the facility failed to retain the nurse staffing postings for 18 months as required. The findings included: A review of the nurse staffing postings during the Extended Survey on 4/28/17 revealed the facility kept past postings in a notebook. A review of the documents revealed the following postings were missing: 12/31/16; 1/1/17; 1/2/17; 1/7/17; 1/8/17; 1/14/17; 1/15/17; 1/21/17; 1/22/17; and 1/24/17-1/31/17. Missing postings for (MONTH) (YEAR) included 2/1/17-2/6/17; 2/8/17; and 2/10/17-2/27/17. Missing postings for (MONTH) (YEAR) included 3/1/17-3/7/17; 3/9/17-3/23/17; and 3/25/17-3/31/17. Missing postings for (MONTH) (YEAR) included 4/1/17; 4/2/17; 4/6/17-4/11/17; 4/14/17-4/17/17; 4/19/17; and 4/20/2017. During an interview on 4/28/17 at approximately 12:57, the Administrator confirmed that staff was unable to locate the missing postings and confirmed that the above postings were not retained. The Administrator stated that it was the responsibility of the Assistant Director of Nursing to retain the daily staffing postings.",2020-09-01
2688,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2019-09-19,640,B,0,1,TX1R11,"Based on record review and interview, the facility failed to ensure the timely transmission of Comprehensive Assessments for 2 of 2 Resident Assessments listed on facility reports. The findings included: Record review of the Missing OBRA Assessment report revealed Resident #1's comprehensive Minimum Data Set (MDS) assessment with a target date of 4/13/19 and Resident #2's comprehensive MDS assessment with a target date of 4/11/19 were not submitted. In an interview on 09/16/19 at approximately 12:30 PM, the MDS Coordinator reviewed the Missing OBRA Assessment report and stated s/he researched the submissions but could not provide a reason as to why the reports were not transmitted timely but would re-attempt.",2020-09-01
2755,LAKE MARION NURSING FACILITY,425300,1527 URBANA ROAD,SUMMERTON,SC,29148,2017-05-11,156,B,0,1,2GZW11,"Based on record review and interview, the facility failed to issue a liability notice of non coverage for Resident #1375 in a timely manner for 1 of 3 residents reviewed for Liability Notices. The findings included: Review on 5/11/2017 at approximately 2:30 PM of a form titled, Notice of Medicare Non-Coverage - CMS -NOMNC, revealed an effective date of ending skilled nursing services as 12/2/2016 and was signed by Resident #1375's personal representative on 12/1/2016 not allowing the required 48 hours for appeal if desired. Review on 5/11/2017 at approximately 2:30 PM of a form titled, Skilled Nursing Facility Advance Beneficiary Notice (SNFABN), Form CMS- revealed a signature by Resident #1375's responsible party on 12/1/2016. During an interview on 5/11/2017 at approximately 2:40 PM the Administrator and the Social Service Director confirmed the findings and stated that Resident #1375's responsible party should have been notified at least 2 days (48 hours) prior to the Medicare Non-Coverage ending date.",2020-09-01
2780,RICHARD M CAMPBELL VETERANS NURSING HOME,425301,4605 BELTON HIGHWAY,ANDERSON,SC,29621,2018-04-19,640,B,0,1,2DMF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to complete/ encode Minimum Data Set (MDS) 3.0 information within required 7 day timeframe as required by CMS (Centers for Medicare and Medicaid Services) and the State for 3 of 3 residents identified as not having assessments completed within 120 days. The findings included: Resident #5 expired in the facility on [DATE]. A death in facility tracking form with ARD (Assessment Reference Date) of [DATE] was signed as being complete by MDS Nurse #1 on [DATE], which was not within the 7 day time frame mandated by regulatory guidelines. During interview on [DATE] at 11:22 AM, MDS Nurse #1 verified that the assessment completed was completed late. Resident #1 expired in the facility on [DATE]. A death in facility tracking form with ARD (Assessment Reference Date) of [DATE] was signed as being complete by MDS Nurse #1 on [DATE], which was not within the 7 day time frame mandated by regulatory guidelines. During interview on [DATE] at 11:22 AM, MDS Nurse #1 verified that the assessment completed was completed late. Resident #2 expired in the facility on [DATE]. A death in facility tracking form with ARD (Assessment Reference Date) of [DATE] was signed as being complete by MDS Nurse #1 on [DATE], which was not within the 7 day time frame mandated by regulatory guidelines. During interview on [DATE] at 11:22 AM, MDS Nurse #1 verified that the assessment completed was completed late.",2020-09-01
2787,CHESTERFIELD CONVALESCENT CENTER,425302,1150 STATE ROAD,CHERAW,SC,29520,2017-06-16,167,B,0,1,BF3E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to inform residents where the current State Survey Results were located and how to access previous surveys, certifications and complaint investigations. The findings included: The facility admitted Resident #45 with [DIAGNOSES REDACTED]. Record review on 6/16/17 revealed a Quarterly Minimum (MDS) data set [DATE] which listed the resident's Brief Interview for Mental Status as 11. During an interview with Resident #45 on 6/16/17, he/she stated the facility had not informed residents of where the State Survey Results were located. Review of the (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR) Resident Council Minutes revealed Resident #45 attended each meeting. Further review of the minutes revealed the location of the State Survey Results had not been discussed with the residents. Observation of the facility revealed a notice had been placed on the bulletin board of the location of the latest survey results. The State Survey Results were observed at the beginning of the hallway near the Administrator's office. Further observation revealed there was no notice posted in the facility related to the past three years of surveys, certifications and complaint investigations were available upon request.",2020-09-01
2814,LAKE EMORY POST ACUTE CARE,425303,59 BLACKSTOCK ROAD,INMAN,SC,29349,2019-04-25,582,B,0,1,IJ5G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide Notice of Medicare Non-coverage (NOMAC) and Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) for 2 of 3 residents reviewed for NOMAC and SNF ABN. (Residents #71 and #77) The findings included: Record review revealed Resident #71 was admitted to the facility on [DATE]. Record review revealed Resident #71 remains in the facility but was discharged from Medicate Part A services on 04-16-19 with Part A days remaining. Review of the Skilled Nursing Facility Protection Notification Review on 04-24-19 at approximately 10:30 AM revealed, the facility did not provide the SNF ABN or NOMAC to Resident #71 or to his/her representative. Record review revealed Resident #77 was admitted to the facility on [DATE]. Record review revealed Resident #77 remains in the facility but was discharged from Medicate Part A services on 04-04-19 with Part A days remaining. Review of the Skilled Nursing Facility Protection Notification Review on 04-24-19 at approximately 10:30 AM revealed, the facility did not provide the SNF ABN or NOMAC to (Resident #77 and Resident #71) or to their representatives. Resident #71 and #77 remained in the facility after discharge from Medicare Part A services with Part A days remaining. During an interview on 04-24-19 at approximately 11:04 AM, the Social Service Assistant confirmed the facility did not complete and give the SNF ABN or the NOMAC to the resident (Resident #71 and Resident #77) or their representative.",2020-09-01
2963,BLUE RIDGE OF SUMTER,425310,1761 PINEWOOD ROAD,SUMTER,SC,29154,2017-12-15,574,B,0,1,DK0Z11,"Based on interviews, record reviews, and the facility's policy titled Resident's Rights, the facility failed to ensure that residents are informed of the Ombudsman's contact information and how to formally file a complaint with the State Agency for residents #3, #42, and #62. 3 of 4 residents who attended Resident Council Group Discussion Meeting. The findings included: Review on 12/12/17 at 11:02 AM of Resident Council Minutes for the months of (MONTH) through (MONTH) revealed no discussion about posting of the Ombudsman's contact information, results of the State Inspection, and information on filing a complaint with the State. During an interview with the residents' on 12/13/17 at 11:30 AM, the question was asked Do residents know where the ombudsman's contact information is posted? Have residents been informed of their right to formally complain to the State about the care they are receiving? Residents' # 3, #42, and #62 stated No. During an interview with the Social Services Director on 12/15/17 at 9:28 AM, s/he confirmed there was no discussion on Ombudsman's contact information, results of State Inspections, and filing a complaint with the state. Review of the Admission Packet on 12/15/17 at 11:24 AM revealed no information on contact information on Advocate Agency Contact and filing a complaint with the State Agency Information. In addition with the facility's policy Resident Rights no information on State Agency Advocacy.",2020-09-01
2964,BLUE RIDGE OF SUMTER,425310,1761 PINEWOOD ROAD,SUMTER,SC,29154,2017-12-15,577,B,0,1,DK0Z11,"Based on interviews and record reviews the facility failed to ensure that residents are aware of the Survey Inspections for residents #3, #42 and #62. Three of 4 residents who attended Resident Council Group Discussion Meeting. The findings included: Review on 12/12/17 at 11:02 AM of Resident Council Minutes for the months of (MONTH) through (MONTH) revealed no discussion about posting of the Ombudsman's contact information, results of the State Inspection, and information on filing a complaint with the State. During an interview with the residents' on 12/13/17 at 11:30 AM, the question was asked Without having to ask, are the results of the State Inspection available to read? Residents' # 3, #42, and #62 stated no. During an interview with the Social Services Director on 12/15/17 at 9:28 AM, s/he confirmed there was no discussion on Ombudsman's contact information, results of State Inspections, and filing a complaint with the state. Review of the Admission Packet on 12/15/17 at 11:24 AM revealed no information on contact information on Advocate Agency Contact and Reporting Information. In addition with the facility's policy Resident Rights no information on State Agency Advocacy.",2020-09-01
3015,MUSC HEALTH MULLINS NURSING HOME,425312,518 S MAIN STREET,MULLINS,SC,29574,2018-03-02,851,B,1,1,X83O11,"> Based on record review and interview, the facility failed to submit staffing information based on payroll data in a timely manner as required by the Centers for Medicare and Medicaid services. The findings included: Review of the CASPER Report 1702S revealed the following: Staffing Summary Report 10/1/16-12/31/16 submitted 2/27/17; Staffing Summary Report 1/1/17-3/31/17 submitted 5/16/17. During an interview with staff responsible for the Payroll Based Journal on 3/2/18, s/he stated the submissions were done in a timely manner and did not understand why the CASPER Reports appeared untimely.",2020-09-01
3116,GOLDEN AGE INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2017-04-12,356,B,0,1,V7AN11,"Based on observation, interview, and record review the facility failed to correctly fill out staff posting information. Daily postings of licensed and unlicensed care staff were incomplete for 2 of 4 days of survey and 3 days of a 30-day look back. The findings included: Observation of the posting for nursing staff on 4/11/17 at approximately 12:06 PM revealed that cumulative hours of nursing staff were not posted for each shift. Observation of posting for nursing staff on 4/12/17 at approximately 8:48 AM revealed that the posting was incomplete. The number of licensed and registered nurses for each shift as well as the cumulative hours worked were not listed for each shift. Interview with the DON on 4/12/17 at approximately 9 AM confirmed that the nurse staffing information sheet was incomplete. S/he then corrected the posting by filling out the blank sheet. Review of the previous 30 days of nurse staffing information on 4/12/17 at approximately 10:42 AM revealed that days 3/15/17, 3/25/17, and 3/26/17 were incomplete. These days were missing either the number of nurses worked or the cumulative hours worked.",2020-09-01
3153,LAUREL BAYE HEALTHCARE BLACKVILLE,425319,1612 JONES BRIDGE ROAD,BLACKVILLE,SC,29817,2017-02-02,287,B,0,1,UFWZ11,"Based on review of missing Minimum Data Set (MDS) Assessments and interview with the MDS Coordinator, the facility failed to transmit MDS Assessments for the following residents: Resident #106, Resident #107, and Resident #108. The findings included: Review of missing MDS Assessments on 2/2/17 at approximately 1:00 PM revealed that the facility failed to transmit MDS Assessments for Residents #106, #107 and #108. Interview with MDS Coordinator on 2/2/17 at approximately 1:50 PM revealed that Resident #106 had been discharged , but the discharge assessment was not yet completed nor transmitted. Resident #106's Assessment Reference Date (ARD) was 6/1/16. Resident #107 was also discharged , but the discharge assessment was not closed or transmitted. The resident's ARD was 8/22/16. Resident #108 had also been discharged , but the discharge assessment had not been closed or transmitted. The resident's ARD was 7/2/16. The MDS Coordinator confirmed s/he was aware that MDS Assessments need to be closed and transmitted within 14 days.",2020-09-01
3233,THE PRESTON HEALTH CENTER,425325,87 BIRD SONG WAY,HILTON HEAD ISLAND,SC,29926,2018-10-18,640,B,0,1,2VYN11,"Based on record review and interview, the facility failed to ensure MDS (Minimum Data Set) assessments were transmitted to the state agency in a timely manner for Resident #1, # 2 and #3. The findings included: Review on 10/17/2018 at approximately 8:40 AM of the Resident Assessment Task of the Long Term Care Survey Process revealed Resident #1 and Resident #2 with MDS assessments over 120 days old not transmitted to the state agency. Further review on 10/17/2018 at approximately 8:50 AM of the Missing OBRA Assessment report dated 10/10/2018 revealed an MDS assessment for Resident #3 not transmitted timely to the state agency. During an interview on 10/17/2018 at approximately 2:10 PM with the MDS/Care Plan Coordinator, he/she stated I have been late in transmitting assessments.",2020-09-01
3377,LAKE MOULTRIE NURSING HOME,425341,1038 MCGILL LANE,SAINT STEPHEN,SC,29479,2018-08-31,640,B,0,1,RRPE11,The facility failed to transmit an assessment timely for Resident #238. No harm resulted to the resident.,2020-09-01
3428,C M TUCKER NURSING CARE CENTER / RODDEY,425360,2200 HARDEN STREET,COLUMBIA,SC,29203,2018-10-04,582,B,1,1,2F3711,"> Based on interview with administrator and record review the facility failed to provide advance beneficiary notices for 1 of 1 resident reviewed for Medicare discharges. Resident #3 was discharged from Medicare Part A on 4/22/18 but the resident representative was not notified in advance. The findings included: Review of Denial Letter and CMS - Notice of Medicare Non-Coverage for Resident #3 on 10/2/18 at approximately 1:30 PM revealed neither forms had been signed by the resident representative. Interview with administrator on 10/2/18 at approximately 2:08 PM revealed the resident's representative was mailed the notice forms but never returned them and verbally expressed understanding. The administrator provided the tracking forms of the forms that had been mailed, but review of tracking forms indicated the notice forms were not sent out until 4/21/18 or received until 4/23/18.",2020-09-01
3583,BETHEA BAPTIST HEALTHCARE CENTER,425372,157 HOME AVENUE,DARLINGTON,SC,29532,2019-01-18,640,B,0,1,Q96O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to transmit required assessments in a timely manner for 2 of 8 residents reviewed for transmission. The Minimum Data Set (MDS) was not transmitted as required for Residents #1 and 76. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Record review on 1/18/19 revealed the last MDS received was dated 8/12/18. The facility admitted Resident #76 with [DIAGNOSES REDACTED]. Record review on 1/18/19 revealed the last MDS received was dated 1/24/18. Interview with the MDS Coordinator on 1/18/19 at 10:25 AM revealed the transmission of the two assessments was missed.",2020-09-01
3747,WILDEWOOD DOWNS,425385,1215 WILDEWOOD DOWNS CIRCLE,COLUMBIA,SC,29223,2018-02-23,640,B,0,1,IZ8B11,"Based on record review, interview, and review of the facility's policy titled, Resident Assessment RAI, the facility failed to electronically transmit encoded, accurate, and completed Minimum Data Sheet (MDS) to the Centers of Medicare and Medicaid (CMS) for 12 out of 24 reviewed for MDS assessments. The findings included: Review of the missing MDS Assessments on 2/20/17 revealed that the facility failed to transmit MDS assessments for Residents # 1, 2, 3, 4, 92, 93, 94, 95, 96, 97, 98, and 99. During the interview 02/23/18 09:40AM with the MDS Coordinator, DON, ADON, and Director of Clinical Services. MDS Coordinator stated when the facility started using electronic software we were having problems transmitting. Director of Clinical Services confirmed they were having problems and unable to provide the results from the submission on the Casper Report MDS 3.0 Missing OBRA Assessment. Review of the facility's policy titled, Resident Assessment RAI, states 5. All MDS assessments will be transmitted per CMS guidelines as illustrated in Chapters 2 and 5. Comprehensive assessments must be transmitted electronically within 14 days of the care plan completion date.",2020-09-01
3785,RICE NURSING HOME,425387,100 FINLEY ROAD,COLUMBIA,SC,29203,2017-03-02,278,B,0,1,JR9V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to accurately assess one of one sampled resident reviewed for Hospice. Resident #102 had two Minimum Data Set (MDS) assessments coded incorrectly, related to terminal diagnosis. The findings included: The facility admitted Resident #102 with [DIAGNOSES REDACTED]. Record review on 3/2/17 at 9:00 am revealed a physician's orders [REDACTED]. The Hospice certification was signed by the Physician and Hospice team. This certification stated, This is to certify that the beneficiary, named below, is terminally ill with a life expectancy of six months or less if the terminal illness runs its normal course. Review of the 3/21/16 and 12/9/2016 quarterly and significant change MDS assessments revealed they were coded incorrectly in Section J, Health Conditions, J1400 Prognosis. Although the Hospice Certification of Terminal Illness was present, the MDS was coded to indicate Resident #102 did not have a life expectancy of less than 6 months. During an interview on 3/2/17 at 10:18 am with MDS Nurse #2, s/he confirmed J1400 was coded incorrectly on both assessments.",2020-09-01
4023,PRUITTHEALTH-BLYTHEWOOD,425400,1075 HEATHER GREEN DRIVE,COLUMBIA,SC,29229,2017-09-15,160,B,1,1,4HVH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview the facility failed to release funds within 30 days of death for 2 of 3 sampled residents reviewed for personal funds. Resident #121 and Resident #135 did not have their funds released within 30 days of their death. The findings included: On [DATE] at 2:45pm, review of records with the Business Office Manager revealed Resident #121 expired on [DATE] and did not have a check issued to his/her estate until [DATE]. Further review revealed Resident #135 expired on [DATE] and did not have a check issued to his/her estate until [DATE]. During an interview on [DATE] at 2pm, the facility administrator stated they did not have a policy, but followed Center for Medicaid/Medicare Services (C[CONDITION]) regulations.",2020-09-01
4152,EASLEY PLACE-A CONTINUUM OF CARE COMMUNITY,425409,706 PELZER HIGHWAY,EASLEY,SC,29642,2017-09-14,356,B,0,1,3N1E11,"Based on record review and interview, the facility failed to post the total number of hours worked for Licensed Practical Nurses for 7 days and for Registered Nurses for 2 days. The findings included: During the Initial Survey, on 09/14/17, review of the facility ' s staff posting revealed 7days which did not reflect the total number of hours worked by Licensed Practical Nurses. Further review revealed 2 days which did not reflect the total number or hours worked by Registered Nurses. During an interview on 09/14/17, the Director of Nursing confirmed the postings did not include the total hours worked.",2020-09-01
4165,BISHOP GADSDEN EPISCOPAL HEALTH CARE CENTER,425411,1 BISHOP GADSDEN WAY,CHARLESTON,SC,29412,2019-01-31,640,B,0,1,S24T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to transmit required assessments in a timely manner for 2 of 2 residents reviewed for transmission. The Minimum Data Set (MDS) was not transmitted as required for Resident #1 and #2. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Record review on 1/28/19 revealed the last MDS received was dated 8/8/18. The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Record review on 1/28/19 revealed the last MDS received was dated 9/6/18. During an interview on 1/28/19 at approximately 2:00 PM, the MDS Coordinator confirmed the assessments had been completed but not transmitted as required.",2020-09-01
4227,COMMANDER NURSING CENTER,425119,4438 PAMPLICO HIGHWAY,FLORENCE,SC,29505,2017-03-23,287,B,0,1,UZ0811,"Based on record review, interview and review of the facility policy titled Transmission Policy, the facility failed to transmit accurate Minimum Data Set(MDS) information in the required time frame for 1 of 1 resident. The findings included: The facility admitted Resident #189 who had an assessment target date of 12/19/16 which was the last assessment per the Casper Report. During an interview with Registered Nurse(RN)#2 on 3/23/17, he/she stated the next assessment was never finalized by the previous MDS Coordinator and there was no explanation as to why the assessment had not been completed and submitted. He/she further stated an assessment was completed on 3/3/17 and submitted on 3/8/17. Review of the facility policy titled Transmission Policy revealed the following: A calendar of all assessments will be maintained in the care plan office. Assessments will be transmitted at least every two weeks .",2020-05-01
4236,L.M.C.- EXTENDED CARE,425321,815 OLD CHEROKEE ROAD,LEXINGTON,SC,29072,2016-06-16,156,B,0,1,3I0411,"Based on record review and interviews, the facility failed to provide in writing a list, of services that the resident on Medicaid, may and may not be billed for, for one of one resident sampled, (resident #382). Findings included - Interview with the responsible party for resident #382 by telephone on 6/14/16 at 2:24 PM revealed the facility did not provide a copy of services Medicaid would and would not pay for. Review of resident #382's business office file lacked evidence the facility provided the resident's responsible party a copy of the list of services that Medicaid would and would not pay for. Interview with administrative staff 1 in her office on 6/16/16 at 11:02 am revealed, the facility would discuss verbally with the resident and/or responsible party what the financial liability would be. But if the resident was going to have a service that was not covered by Medicaid, the facility would notify the resident or responsible party prior to the resident receiving the service. The facility failed to provide a written list of services that Medicaid would and would not cover for this resident",2020-05-01
4283,PRUITTHEALTH-AIKEN,425145,830 LAURENS STREET NORTH,AIKEN,SC,29801,2016-07-12,356,B,0,1,443S11,"Based on record review and interviews, the facility failed to post staffing information on a daily basis as required. Postings available for review failed to include resident census and the total number and actual hours worked by Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Certified Nursing Assistants (CNAs) directly responsible for resident care per shift. Lack of posting information had the potential to affect all residents and visitors who desired to obtain this information. The findings included: During the extended survey on 7-7-16, staff postings (1-1-16 through 6-30-16) were requested for review. The Administrator provided a notebook that s/he stated contained the requested information. The Director of Healthcare Services (DHS) provided a copy of the documents for review at 12:12 PM on 7-7-16. Review of the POS [REDACTED]. Restorative personnel were listed at the bottom of the forms with neither scheduled or actual hours noted. January, (YEAR) Postings were not available for the following dates: 1-1, 1-2, 1-3, 1-4,1-6 through 1-17, 1-19 through 1-24, and 1-26 through 1-31-16. The postings did not include the census on the following dates: 1-5, 1-18, and 1-25-16. Duplicate forms were reviewed that included discrepant staffing information and/or were missing census data for 1-18-16. February, (YEAR) Postings were not available for the following dates: 2-2, 2-3, and 2-4-16. The postings did not include the census on the following dates: 2-10, 2-11, 2-13, 2-18, 2-20, and 2-22-16. Multiple duplicate forms were reviewed that included discrepant staffing information and/or were missing census data: 2-1, 2-12, 2-16, 2-18, 2-19, 2-20, 2-22, 2-25, 2-26, 2-27, 2-28, and 2-28-18. March, (YEAR) Multiple duplicate forms were reviewed that included discrepant staffing information and/or were missing census data: 3-1, 3-9, 3-11, 3-12, 3-14, and 3-28-18. April, (YEAR) A posting was not available for 4-11-16. Multiple duplicate forms were reviewed that included discrepant staffing information and were missing census data: 4-4, 4-16, 4-17, 4-18, 4-20, 4-21, 4-22, 4-23, 4-24, 4-25, 4-26, 4-27, 4-28, and 4-29-16. May, (YEAR) The postings did not include the census on the following dates: The posting for 5-2-16 was missing CNA staffing information for 2 units. Multiple duplicate forms were reviewed that included discrepant staffing information and/or were missing census data:5-2, 5-3, 5-4, 5-5, 5-9, 5-11, 5-17, 5-18, 5-19, 5-20, 5-26, and 5-27-16. June, (YEAR) The 6-24-16 posting included 2 handwritten CNAs' names with question marks instead of hours behind their names. During an interview at 5 PM on 7-7-16, the Administrator reviewed the posting documents and verified multiple dates missing, dates duplicated, and those with census missing and discrepant staffing information. S/he stated s/he was sure the facility had them in the notebook. The DHS verified s/he had copied the documents from the notebook. No further documentation was provided.",2020-04-01
4288,FRASER HEALTH CENTER,425150,300 WOOD HAVEN DRIVE,HILTON HEAD ISLAND,SC,29928,2016-12-15,156,B,0,1,N3QC11,"Based on record review and interview, the facility failed to utilize the required form for Notice of Medicare Non-Coverage(NOMNC) for Residents #14 and #54(2 of 3 reviewed) , failed to accurately complete a Skilled Nursing Facility Advance Beneficiary Notice(SNFABN) for Resident #49(1 of 3 reviewed) and failed to issue the NOMNC for Resident #49(1 of 3 reviewed). The findings included: Record review on 12/15/16 for Liability Notices revealed the facility issued Form No. CMS- to Residents #14 and #54 instead of the required Form No. CMS- -NOMNC. Further review revealed the SNFABN notice for Resident #49 did not indicate which option the resident and/or authorized representative desired. In addition, Form No. CMS- -NOMNC was not issued to Resident #49. During an interview with the Administrator on 12/15/16 at 2:26 PM, he/she was not aware of the newest Form No. -NOMNC nor was he/she aware Form No. -NOMNC needed to be issued in conjunction with the SNFABN. No policy was provided for Liability notices during the survey process.",2020-04-01
4313,WHITE OAK ESTATES,425290,400 WEBBER ROAD,SPARTANBURG,SC,29302,2016-09-09,356,B,0,1,JH7U11,"Based on observation, interview, and record review, the facility failed to post cumulative staff hours for licensed and unlicensed staff on 1 of 1 units. The finding included: Observation during Stage 1 of survey on 9/06/2016 at approximately 4:00 PM revealed the nurse staff posting on Unit 1 did not list cumulative hours worked by licensed and unlicensed staff. Observation during Stage 1 of survey on 9/07/2016 at approximately 9:45 AM revealed the nurse staff posting on Unit 1 did not list cumulative hours worked by licensed and unlicensed staff. Interview with Director of Nursing (DON) on 9/07/2016 at approximately 10:25 AM confirmed the cumulative hours for licensed and unlicensed staff were not posted with nurse staffing information. Review of the prior month of nurse staff postings on 9/07/2016 at approximately 2:15 PM revealed that nurse staff postings had not listed the cumulative hours worked by licensed and unlicensed staff.",2020-04-01
4438,J F HAWKINS NURSING HOME,425035,1330 KINARD STREET,NEWBERRY,SC,29108,2016-06-23,356,B,0,1,45NR11,"Based on observations and interviews, the staffing posting was not readily accessible to residents and visitors on 2 of 3 units in the main building. Postings were located behind the nurses' desks. The findings included: Multiple observations (6-20-16 during Initial Tour, 6-21-16 at 10 AM, 6-22-16 at 10 AM and 3:20 PM) revealed that the staffing posting was located behind the Units 1 and 2 nursing stations. They were not posted in a prominent place, readily accessible to residents and visitors. During an interview on 6-23-16 at 10:20 AM, Licensed Practical Nurse #1 verified the posting was on the wall on a paper (8.5 inches x 11.5 inches) behind the nurses desk on Unit 1.",2020-01-01
4532,"DUNDEE MANOR, LLC",425118,"710 15-401 BYPASS, WEST",BENNETTSVILLE,SC,29512,2016-06-09,156,B,0,1,UM6B11,"Based on record review and interview the facility failed to provide adequate Notice of Medicare Non-Coverage for 1 of 3 residents, (#21) sampled for liability and appeal notices. Findings included: Review of the Notice of Medicare Non-Coverage the facility provided for resident (#21's) coverage that ended 12/13/15 revealed the notice lacked documentation of what services would no longer be covered. The facility also failed to provide a explanation for the reason of non-coverage and failed to provide the number and name of the Quality Improvement Organization. During interview on 6/09/16 at 1:13 PM SW #1 acknowledged when staff filled out the Non-Coverage form the facility failed to provide the number to contact for the Quality Improvement Organization (QIO), failed to provide an explanation of what services would no longer be covered and why the facility determined services were not covered.",2019-11-01
4555,OAKBROOK HEALTH AND REHABILITATION CENTER,425156,920 TRAVELERS BOULEVARD,SUMMERVILLE,SC,29485,2016-09-09,156,B,0,1,706J11,"Based on record review and interview, the facility failed to provide the required CMS Form -NOMNC notice to 1 of 3 sampled residents who had been discharged from Medicare Part A services with days of eligibility remaining. (Resident #45.) The findings included: A review of Liability and Appeal Notices with the Social Services Director on 9/9/16 revealed that Resident #45 had been discharged from Medicare Part A services with Medicare eligibility days remaining, and Resident #45 remained in the facility. The surveyor requested to review the required CMS Form for Resident #45. At that time, the Social Services Director informed the surveyor that he/she did not issue CMS Form .",2019-11-01
4559,"SAINT MATTHEWS HEALTH CARE, LLC",425170,601 DANTZLER STREET,SAINT MATTHEWS,SC,29135,2016-04-21,160,B,0,1,UKCX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Resident Trust account and interview, the facility failed to convey the personal funds and a final accounting upon death within 30 days to the named executor or probate jurisdiction administering the individuals' estates for 2 of 3 expired residents. One of the three sampled residents (Resident #149) reviewed had funds which were not released within 30 days. One of the 3 sampled residents reviewed (Resident #24) had a cash balance issued to an unauthorized family member. The findings included: A closed record review of personal funds was conducted on [DATE] at 3:42 PM with the Business Office Manager (BOM). Review of the Admit/Discharge Report for [DATE] through [DATE] revealed that Resident #149 expired on [DATE]. The Resident Trust Fund Statement noted the balance of $394.36 issued via check #1164 to close the trust account on [DATE]. The date of issue was verified by the BOM. Review of the Admit)Discharge Report revealed that Resident #24 expired on [DATE]. The Resident Trust Fund Statement noted the balance of $38.00 issued via cash ticket #245 to CASH TO RESIDENT which closed the trust account on [DATE]. Review of the Resident Trust Petty Cash Withdrawal Sheet with the BOM revealed that an individual signed receipt for the $38 remaining in the account. The BOM was unable to provide evidence that the monies were received by a named executor or a person authorized by the court.",2019-11-01
4803,STILL HOPES EPISCOPAL RETIREMENT COMMUNITY,425401,1 STILL HOPES DRIVE,WEST COLUMBIA,SC,29169,2016-07-07,156,B,0,1,2KGG11,"Based on record review and interview, the facility failed to provide the required CMS Form -NOMNC notice to 1 of 3 sampled residents who had been discharged from Medicare Part A services with days of eligibility remaining. (Resident #13) The findings included: A review of Liability and Appeal Notices with the Social Services Director on 7/06/16 at approximately 3:30 PM revealed that Resident #13 had been discharged from Medicare Part A services with Medicare eligibility days remaining. At the time of the review, the Social Services Director stated that CMS Form -NOMNC had not been issued for Resident #13. The Social Services Director further indicated that he/she had not been in the facility at the time Resident #13 was discharged from Medicare Part A services, and the form was not issued as required prior to discharge.",2019-08-01
4898,PRESBYTERIAN COMMUNITIES OF SOUTH CAROLINA- CLINTO,425393,801 MUSGROVE STREET,CLINTON,SC,29325,2016-05-25,156,B,0,1,B82Q11,"Based on record review and interview, the facility failed to provide a detailed explanation of the reason coverage for services should not continue. Resident #27 was not issued the CMS- -DENC (Detailed Explanation of Non-Coverage) as required upon appeal for Medicare coverage. The findings included: During a review for issuance of liability notices on 5-25-16 at 12 PM, Resident #27 was noted to have been issued a CMS- -NOMNC (Notice of Medicare Non-Coverage) and a UR (Utilization Review) COMMITTEE DETERMINATION ON CONTINUED STAY letter on 4-6-16. At that time, Medicare non-coverage was appealed. There was no evidence that the detailed explanation about why coverage for services should not continue (CMS- -DENC) was issued to the beneficiary. While conducting the review, Social Services stated s/he was unaware that the Form CMS- -DENC should have been provided,",2019-07-01
4957,VIBRA HOSPITAL OF CHARLESTON -TCU,425405,1200 HOSPITAL DR 2ND FL,MOUNT PLEASANT,SC,29464,2018-06-07,851,B,0,1,K3CB11,"Based on record review and interview, the facility failed to submit staffing information based on payroll data in a timely manner as required by the Centers for Medicare and Medicaid Services. The findings included: Review of the CASPER Report 1702S revealed the following: Staffing Summary Report 4/1/2017-6/30/2017 submitted 8/23/17 During an interview with staff responsible for the Payroll Based Journal on 6/7/18, s/he stated the submissions were done in a timely manner and did not understand why the CASPER Reports appeared untimely.",2019-07-01
5576,SANDPIPER REHAB & NURSING,425146,1049 ANNA KNAPP BOULEVARD,MOUNT PLEASANT,SC,29464,2015-04-01,156,B,0,1,RGIM11,"Based on review of residents' funds and interview, the facility failed to complete the required Centers for Medicare and Medicaid Services (CMS) -Notice of Medicare Non-Coverage (NOMNC) Form, the Medicare Liability Notices and Beneficiary Appeal Rights, and/or the CMS -Advanced Beneficiary Notice (ABN), for 2 of 4 sampled residents discharged from Medicare A with days remaining and remaining in the facility with/without a new payer source. (Resident #38 and Resident #134) The findings included: On 03-31-15 at approximately 10:00 AM, review of Resident #38's and Resident #134's funds revealed the facility staff failed to complete the required CMS- (ABN), for Resident #38 who had been discharged from Medicare A with days remaining and remained in the facility under an alternate payer source. The facility further failed to complete the required CMS- NOMNC and the required CMS- for Resident #134. Resident #134 had been taken off of Medicare Part A, had Medicare days remaining, and remained in the facility. Resident #134 had not received therapy. During an interview on 03-31-15 at approximately 10:00 AM with Registered Nurse (RN) #4, h/she confirmed the above findings.",2018-11-01
5727,DR RONALD E MCNAIR NURSING & REHABILITATION CENTER,425309,56 GENESIS DRIVE,LAKE CITY,SC,29560,2015-03-05,167,B,0,1,HFE711,"Based on observation and interview, the facility failed to ensure that the results of the most recent surveys of the facility were readily accessible for 2 of 2 nursing units. The findings included: During a Group interview on 3/4/15, 6 of 6 alert and oriented residents stated they did not know where the survey results were located. Following the conclusion of the interview, observation of the location of the survey results revealed the survey was posted, in a clear plastic sheet protector, on a bulletin board in the common hallway between the 2 nursing units. The survey was posted approximately 6 feet from the floor and the top page in the sheet protector was the DHEC (Department of Health and Environmental Control) cover letter. Observation also revealed the survey was posted with 17 additional pamphlets and notices on the bulletin board. In addition. there was a bulletin board directly to the right with 8 notices/pamphlets and one to the left with 9 notices/pamphlets. During an interview at that time, the Nursing Home Administrator (NHA) confirmed the location of the survey results and stated s/he thought it was a good location, at eye level for anyone walking by. The NHA also confirmed that most of the facility's residents were in wheel chairs. When asked if wheel chair bound residents could see or reach the results without asking a staff member for assistance, the NHA stated I see what you mean.",2018-10-01
5769,COVENANT TOWERS HEALTHCARE CENTER,425382,5001 LITTLE RIVER ROAD,MYRTLE BEACH,SC,29577,2017-03-09,156,B,0,1,NH9U11,"Based on record review and interview the facility failed to issue a required CMS form or 1 of 5 CMS (Centers for Medicare and Medicaid) approved denial letters for Resident #17 with ending coverage of Medicare part A with days remaining and remained in the facility for 1 of 3 residents reviewed for Liability Notices. The findings included: The facility admitted Resident #17 for Rehabilitation/Therapy Services. Review on 3/9/2017 at approximately 3:54 PM of a form titled, Notice of Medicare Non-Coverage, revealed that current services will end on 11/10/2016 and was signed on 11/07/2017 by the resident's responsible party. Per the Social Services Director Resident #17 had days remaining and was going to remain a resident in the facility. Further review on 3/9/2017 at approximately 4:00 PM of the medical record for Resident #17 revealed no CMS form nor 1 of 5 CMS approved denial letters had been issued. During an interview on 3/9/2017 at approximately 4:00 PM with the Billing Manager, he/she stated, I was filling in for the Social Worker and I forgot to issue the CMS or any of the 1 of 5 CMS approved denial letters.",2018-10-01
5816,"LINLEY PARK REHABILITATION AND HEALTHCARE CENTER,",425016,208 JAMES STREET,ANDERSON,SC,29625,2015-02-24,159,B,0,1,R9Q011,"Based on resident funds review and interview the facility failed to notify three of three residents (or legal representatives) when their accounts reached $200 less than the SSI resource limit. The facility failed to provide evidence that Residents C, D, and E had been notified that their accounts were reaching the resource limit as required and the residents might lose eligibility for Medicaid or SSI. The findings included: Funds review was conducted on 2/24/15 with the Business Office Manager. A Trial Balance sheet was produced listing fund amounts held by the facility. The Business Office Manager indicated the three accounts showing balances over $1800 were Medicaid recipients. The Manager stated their computer program would print out the names of those at $1800 limit and would also print out a form letter to be sent to the resident/legal representative. The Manager stated this had been done; however, there was no documentation of who was informed or when. No records or copies of the letters had been kept to verify the notification. The Business Office Consultant verified this at that time.",2018-08-01
6107,WINDSOR MANOR,425114,5583 SUMMERTON HIGHWAY,MANNING,SC,29102,2014-11-13,156,B,0,1,NM5A11,"Based on record review, interview and review of the facility policy entitled Medicare Part A/Advantage Program, the facility failed to provide 2 of 2 sampled residents reviewed with appropriate generic and liability notices prior to ending Medicare Part A coverage. Residents #4 and #61 were not provided the required Centers for Medicare and Medicaid (CMS) -NOMNC (Notice of Medicare Non-Coverage) or liability notices (CMS or one of the five CMS-approved notices) prior to denial of Medicare Part A services. The findings included: On 11-12-14 at 10 AM, the Administrative Assistant provided a list of 3 residents who had changed from Medicare Part A coverage to other pay sources since 1-1-14 as a result of a facility determination of non-coverage. One of the residents was noted as discharged to the hospital and therefor was not reviewed. During an interview at 3:30 PM on 11-12-14, the Administrative Assistant stated that Resident #4's first non-covered day was 11-7-14. S/he provided a form that was marked as a CMS and a CMS-R-131 Advance Beneficiary Notice of Noncoverage (ABN). An attached form noted that the responsible party was notified of the non-coverage on 9-5-14 and did not request an appeal. ****Denial Letter Only was noted next to the appeal denial. This, then, did not address the expedited appeal rights to the Quality Improvement Organization (QIO) referred to in the CMS- . The Administrative Assistant verified that the CMS NOMNC (Approved 12/31/2011) had not been provided as required. The Administrative Assistant stated that Resident #61's first non-covered day was 7-3-14. S/he provided a form that was marked as a CMS and a CMS-R-131 Advance Beneficiary Notice of Noncoverage (ABN). An attached form noted that the responsible party was notified of the non-coverage on 6-30-14 and did not request an appeal. ****Denial Letter Only was noted next to the appeal denial. This, then, did not address the expedited appeal rights to the Quality Improvement Organization (QIO) referred to in the CMS- . The Administrative Assistant verified that the CMS NOMNC (Approved 12/31/2011) had not been provided as required. Review of the facility policy entitled Medicare Part A/Advantage Program on 11-12-14 revealed that it did not reference CMS- NOMNC as a form to be provided upon notification of Medicare non-coverage. http://www.cms.gov/Medicare/Medicare-General-Information/BNI/MAEDNotices.html states: HHAs (Home Health Agencies), SNFs (Skilled Nursing Facilities), . are required to provide a Notice of Medicare Non-Coverage (NOMNC) to beneficiaries to alert them that Medicare covered item(s) and/or service(s) are ending and give beneficiaries the opportunity to request an expedited determination from a QIO. http://www.cms.gov/Medicare/Medicare-General-Information/BNI/ABN.html states: The Advanced Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131, is issued by providers (including independent laboratories, home health agencies, and hospices), physicians, practitioners, and suppliers to Original Medicare (fee for service) beneficiaries in situations where Medicare payment is expected to be denied .Note: Skilled nursing facilities (SNFs) must use the ABN for items/services expected to be denied under Medicare Part B only.",2018-05-01
6245,"BRUSHY CREEK REHABILITATION AND HEALTHCARE CENTER,",425004,101 COTTAGE CREEK CIRCLE,GREER,SC,29650,2014-09-04,160,B,0,1,0BDJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of the facility's policy, Resident Funds, the facility failed to convey funds deposited with the facility to the estate of the resident or to the probate court for Resident #C and #D, 2 of 3 residents reviewed for conveyance of funds. The findings included: On [DATE] at 11:13 AM, review of the conveyance of funds upon the death of Residents C revealed the resident had a trust account balance of $50.00. The resident expired on [DATE] and the account balance was paid, in cash, to the Power of Attorney (POA) on [DATE]. Review of review of the conveyance of funds upon the death of Residents D revealed the resident had a trust account balance of $50.00. The resident expired on [DATE] and the account balance was paid, in cash, to the POA on [DATE]. During an interview at that time, the Business Analyst confirmed the trust fund balances were paid to the Power of Attorney for both Residents. The Account Specialist confirmed They're supposed to go to the Estate of. When asked why the accounts were paid to the POA, the Account Specialist stated that the Power of Attorney for both residents had deposited $50.00 in the residents' account just in case. Upon the residents' death the POA for both residents had requested the money, stating it was their money in the first place and s/he had paid out the accounts, in cash, to the POA in both instances. Review of the facility's policy, Trust Funds, revealed Upon the death of a Resident with a personal fund, the business office will convey within 30 days the Resident's funds, and a final accounting of those funds, to the individual or probate jurisdiction administering the Resident's estate.",2018-04-01
6368,BROOKDALE ANDERSON,425398,311 SIMPSON RD,ANDERSON,SC,29621,2014-10-15,156,B,0,1,E65111,"Based on record review and interview, the facility failed to use the correct liability notices for 1 of 3 residents reviewed. The Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) Form CMS- was not used for 1 resident reviewed who was discontinued from Medicare Part A with days remaining and stayed in the facility. The findings included: Review of liability notices for Resident #5 on 10/14/14 at 9:00 AM revealed the resident's skilled nursing/therapy services ended on 9/8/14 and the resident converted to private pay on 9/9/14. Further review revealed the Power of Attorney (POA) for Resident #5 signed Form -NOMNC (Notice of Medicare Non-Coverage), but the facility did not have the POA sign the SNFABN Form CMS- as required. Interview with the Business Office Director on 10/14/14 at 9:15 AM confirmed these findings and revealed that a company letter was used instead of the SNFABN Form CMS- . The Business Office Director further stated that the SNFABN Form CMS- was being used, but only for residents who did not remain in the facility.",2018-04-01
6438,"MARION NURSING CENTER, INC.",425015,2770 SOUTH HIGHWAY 501,MARION,SC,29571,2011-06-01,156,B,0,1,BPHS11,"On the days of the survey based on record review and interview, the facility failed to notify the residents of charges not covered under Medicare for 2 of 3 Notices of Medicare Non-Coverage reviewed for timely notification. The facility was not using the CMS Form for 2 of 3 sampled residents for notification and was unaware of the CMS Form . The findings included: On 6/1/11 at 11:55 AM a review of 3 random residents for Medicare Non-Coverage Notification revealed that 2 of the 3 did not have the correct forms for notification and were not provided with the required 48 hour prior notice. In at interview with the Administrator at that time, she revealed that she had taken over the responsibility of the Medicare Notices in the past year, was confused about the forms and was not sure that she was using the correct forms. She was not sure when to use the CMS Form and was unaware of the CMS Form .",2018-02-01
6552,WILLOW BROOK COURT AT PARK POINTE VILLAGE,425375,3025 CHESBROUGH BLVD,ROCK HILL,SC,29732,2014-10-08,156,B,0,1,HQ2811,"Based on observation and interviews, the facility failed to prominently display written information regarding how to receive refunds for previous payments on 1 of 1 units. The findings included: On 10/7/14 at 10:10 AM, the facility's postings were observed in a wooden case with glass doors. No information was posted regarding the process for applying for refunds. In addition, the case was located with the top approximately 8-10 inches from the ceiling. During an interview at that time, the Nursing Home Administrator confirmed there was no information posted regarding how to apply for refunds. The Administrator further confirmed that residents in wheelchairs might have difficulty seeing the postings at the top of the cabinet.",2018-01-01
6612,SUMMIT HILLS SKILLED NURSING FACILITY,425390,110 SUMMIT HILLS DRIVE,SPARTANBURG,SC,29307,2014-11-18,156,B,0,1,7DWW11,"Based on record review and interview, the facility failed to provide notice of rights, rules, services, and charges. The facility failed to use the correct and most current form for notification of Medicare non-coverage for 3 of 3 denial notices reviewed, and failed to provide 48 hour notice for 1 of 3 denial notices reviewed. The findings included: Record review of the Medicare denial letters was conducted on 11/18/14. The Social Worker provided a Notice of Medicare Provider Non-Coverage (CMS- ) letter dated 7/28/14 for a resident who was denied continued coverage due to issues related to participation. Further review revealed services ended on 7/28/14 and the Responsible Party signed the form on 8/4/14. Interview with the Social Worker on 11/18/14 at approximately 12:30 PM revealed the Responsible Party had been notified by telephone prior to the date the form was signed, but there was no documentation of this. The Social Worker provided Notice of Medicare Provider Non-Coverage (CMS- ) letters dated 9/29/14 and 11/7/14 for two residents who had met their Physical Therapy and Occupational Therapy goals. An interview with the Corporate Consultant on 11/18/14 at approximately 1:00 PM confirmed the facility was not using the CMS- NOMNC (Notice of Medicare Non Coverage) form as required by the Centers for Medicare and Medicaid Services.",2017-12-01
6901,WHITE OAK ESTATES,425290,400 WEBBER ROAD,SPARTANBURG,SC,29302,2014-03-20,156,B,0,1,85TP11,"On the days of the survey, based on interview, record review and review of the facility postings for the Ombudsman services, the facility failed to ensure residents were knowledgeable of the role and availability of the Ombudsman. Neither Resident # 103 nor Resident # 54 were aware of the services of the Ombudsman when interviewed. (2 of 2 residents interviewed related to resident rights) The deficient practice had the potential to affect multiple residents who could have the need of the Ombudsman services. The findings included: Upon entrance to the facility, it was determined that the current facility Resident Council had no President per the choice of the resident's. Resident # 103 and Resident # 54 were designated by the facility as residents who regularly attended Resident Council Meetings and were appropriate to be interviewed. Based on resident interview conducted on 3/18/14 at approximately 3:30 PM and 3/19 at approximately 10:15 AM, neither resident was aware of the role of the Ombudsman or how to reach them to obtain their services. Both resident's stated information concerning resident rights had not been covered during their Resident Council Meetings or provided by other means to them. Review of the Resident Council Minutes from September 2013 to present revealed no documentation of a discussion concerning the role of the Ombudsman or how to obtain their services. A tour of the facility on 3/19/14 at 2:15 PM revealed one informational Ombudsman poster located across from Administrators office, letter sized, in a frame hung above standing eye level. A further tour revealed no additional posting accessible for resident's seated in a wheelchair as verified by the facility consultant during an interview on 3/19/14 at 3:07 PM.",2017-08-01
6902,WHITE OAK ESTATES,425290,400 WEBBER ROAD,SPARTANBURG,SC,29302,2014-03-20,167,B,0,1,85TP11,"On the days of the survey, based on record review, interview, and observation, the facility failed to assure residents were knowledgeable in the location/availability of the most recent survey results and failed to post a notice of their availability. The deficient practice had the potential to affect multiple residents who desired to review the most recent survey results. The findings included: Upon entrance to the facility, it was determined that the current facility Resident Council had no President per the choice of the resident's. Resident # 103 and Resident # 54 were designated by the facility as residents who regularly attended Resident Council Meetings and were appropriate to be interviewed. Based on resident interviews conducted on 3/18/14 at approximately 3:30 PM and 3/19 at approximately 10:15 AM, neither resident was aware that the Stage Agency issued a written report of survey findings nor the location of the document. On 3/19/14 at 2: 40 PM, a binder containing survey results was located on a table in the front lobby. This area was separated from the resident's living area by a doorway that remained closed at all times making independent wheelchair access difficult. Additionally, the door was alarmed so any resident wearing an exit prevention device could not enter the area without assistance and further supervision. During an interview with the facility Nurse Consultant at that time,s/he confirmed the location of the survey results. S/he also verified the door was maintained in a closed position; any resident who wanted to look at the binder who was unable to open the door would have to ask for assistance; and there was no posting indicating the location of the survey results. Review of the facility Resident Council minutes for the past 6 months, revealed the last time the Council was informed of their right to look at survey results was in September 2013 and Resident # 54 was not a resident at that time.",2017-08-01
6903,WHITE OAK ESTATES,425290,400 WEBBER ROAD,SPARTANBURG,SC,29302,2014-03-20,170,B,0,1,85TP11,"On the days of the survey, based on interviews, the facility failed to assure the resident of the right to receive mail based on the currently available Postal delivery schedule. The facility had requested no mail delivery on Saturdays. The deficient practice had the potential to affect any resident who received mail in the facility. The findings included, Upon entrance to the facility, it was determined that the current facility Resident Council had no President per the choice of the resident's. Resident # 103 and Resident # 54 were designated by the facility as residents who regularly attended Resident Council Meetings and were appropriate to be interviewed. Based on the resident interview conducted on 3/18/14 at approximately 4 PM and 3/19 at approximately 10:15 AM, neither Resident was able to state if mail was delivered on Saturday. Resident # 103 stated his/her mail did not come to the facility at all and Resident # 54 was unsure. During an interview with the Activity Director (AD) immediately following the interview with Resident 103, the AD stated the Activity Department was responsible for the delivery of resident mail. The Activity Director stated no mail delivery occurred at the facility on Saturdays. Further interview with the facility Administrator on 3/19/14 at approximately 9:30 AM, revealed Saturday mail had not occurred at the facility since 2009 under the direction of previous Administration. The Saturday mail delivery had been discontinued by facility choice and not due to postal restrictions. The Administrator stated s/he had contacted the Postal services and would be no problem resuming Saturday mail delivery.",2017-08-01
6907,CHESTERFIELD CONVALESCENT CENTER,425302,1150 STATE ROAD,CHERAW,SC,29520,2013-08-29,160,B,0,1,2M6X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey based on record review and interview, the facility failed to convey resident funds of 2 of 3 sampled residents reviewed within 30 days of death as required. The findings included: During an interview and review of Resident Trust records with the Business Manager on [DATE] at 2:55 PM, s/he confirmed the following: (1) Resident #39 expired on [DATE]. The balance in the Resident Trust was issued to the estate of . on [DATE] (31 days). (2) Resident #66 expired on [DATE]. The balance in the Resident Trust was issued to the estate of . on [DATE] (31 days). During the interview, the Business Manager stated s/he had been routinely releasing the funds the same date in the following month. Thus, if any resident expired in a month with 31 days, the monies were not released in a timely manner.",2017-08-01
7399,LAUREL BAYE HEALTHCARE BLACKVILLE,425319,1612 JONES BRIDGE ROAD,BLACKVILLE,SC,29817,2013-02-07,160,B,0,1,44DM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On days of the survey, based on review of funds and interviews, the facility failed to convey funds to the to the individual or probate jurisdiction administering the resident's estate. (1 of 1 deceased resident funds reviewed.) The findings included: During a review of resident fund accounts on [DATE] at approximately 12:30 PM, resident funds for 1 of 1 residents deceased were not conveyed per regulatory requirement. An interview on [DATE] at approximately 12:30 PM with the Administrator verified the resident fund balance was not issued to the probate jurisdiction administering the resident's estate.",2017-03-01
7863,"LORIS REHAB AND NURSING CENTER, LLC",425086,3620 STEVENS STREET,LORIS,SC,29569,2012-08-29,160,B,0,1,HQQ311,"On the days of the survey, based on record reviews and interview, the facility failed to convey resident's funds and final accounting of those funds within 30 days to the individual or probate jurisdiction administering the resident's estate for 2 of 3 random sampled residents reviewed. Two residents' funds were conveyed to individuals without documentation to indicate they had individual jurisdiction to administer the resident's estate. The findings included: An interview on 8/28/12 at approximately 4:20 PM with the Business Office Manager confirmed the findings that 2 of 3 random sampled residents' funds reviewed were conveyed to individuals without documentation to indicate the individual had jurisdiction to administer the resident's estate.",2016-10-01
8542,BROOKDALE ANDERSON,425398,311 SIMPSON RD,ANDERSON,SC,29621,2012-01-12,159,B,0,1,25JC11,"On the days of the survey, based on interviews occurring during fund review, the facility failed to maintain resident funds in access of fifty dollars in an interest bearing account with written authorization. The findings included: During an interview with the Social Services Director on 1/12/12 , she revealed that she encouraged residents to not bring money to the facility. If the residents insisted, she would sometimes place their money in an envelope with their name on it and place the envelope in a locked box in her office. The residents did not sign/authorize for her to maintain their funds. When asked: Would you take $60.00 from a resident and keep it for them? The Director stated, I would strongly encourage them not to bring the money to the facility; but upon insistence by the resident, I would place it in the lock box. The Social Service Director stated she was unaware that resident funds amounts over $50.00 must be in an interest bearing account and that she did not maintain an accounting of funds held for the residents. In an earlier interview conducted on 1/12/12 with the Business Office Manager, she stated the facility did not keep any personal funds for residents.",2016-03-01
8594,LIFE CARE CENTER OF CHARLESTON,425332,2600 ELMS PLANTATION BLVD,N CHARLESTON,SC,29406,2012-02-23,167,B,0,1,TKRT11,"On the days of the survey, based on observation and interview, the facility failed to have the most recent survey or notification of where those results were located , posted in a readily accessible place, frequented by the residents and other individuals at 1 of 2 separate entrances that is separated from the other part of the building by a dementia unit. The findings included: On 02/21, 02/22, and 02/23/12, the most recent survey or notification where the results could be located was not found on the Garden Terrace Unit . The Unit is separated by a locked dementia care unit from the other part of the building where the survey result was located. The lack of posting or placement of the most recent survey book for the Garden Terrace Unit was confirmed by the Admissions Coordinator on 02/22/12 at approximately 2:00pm.",2016-02-01
8696,LAUREL BAYE HEALTHCARE OF GREENVILLE,425042,661 RUTHERFORD RD,GREENVILLE,SC,29609,2011-10-19,156,B,0,1,PK5911,"On the days of the survey, based on record review and interview, the facility failed to provide 2 of 3 Medicare Provider Non-Coverage notices timely. The findings included: An interview on 10/18/11 at approximately 10:50 AM with the Business Office Manager revealed 2 of 3 Medicare Non-Coverage Notices were not submitted within the required 48 hour requirement. Resident B services ended 7/18/11 and resident was notified on 7/18/11. Resident C had been scheduled to terminate services on 8/2/11. However, the resident had change in condition and remained covered until 8/21/11 when services and coverage ceased.with no notification provided.",2015-12-01
8952,LAKE CITY SCRANTON HEALTHCARE CENTER,425149,1940 BOYD ROAD,SCRANTON,SC,29591,2012-05-30,160,B,0,1,7U6B11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification Survey, based on review of resident funds, interview and review of the facility's policy Resident Trust Accounts, the facility failed to convey funds to the individual or probate jurisdiction administering the resident's estate. The facility conveyed the funds to the facility for Resident A. (1 of 5 resident records reviewed for conveyance of funds.) The findings included: On [DATE], 5 randomly selected residents were reviewed for conveyance of Trust Account Funds. Review of the Resident Trust Fund Account for Resident A revealed that the balance in the resident trust account, $110.00, had been conveyed to the facility. Resident A expired on [DATE] and a check dated [DATE] was issued to the facility. The Business Office Manager confirmed the check had been written to the facility and stated that the resident's representative had authorized the payment to the facility. She verified that the authorization was obtained after the resident's death. She further stated she thought that the resident's representative could authorize the conveyance based on the authorization signed by the daughter at the time of admission which conveyed any refunds, funds and other property held in trust to the daughter, the resident's Power of Attorney. The Business Office Manager also confirmed that she was aware that the Power of Attorney expired with the resident's death. Review of the facility's policy, Resident Trust Accounts, revealed the following statement: Upon a resident's death, the funds along with a financial accounting, must be promptly delivered to the individual administering the resident's estate or as designated by the state regulations. Check must be made out to estate of.",2015-09-01
8995,"OMEGA HEALTH & REHAB OF GREENVILLE, LLC",425060,809 LAURENS ROAD,GREENVILLE,SC,29607,2011-05-24,160,B,0,1,ZFEO11,"On the days of the survey, based on record reviews and interview, the facility failed to convey resident's funds and final accounting of those funds within 30 days to the individual or probate jurisdiction administering the resident's estate for 2 of 5 random sampled residents. Two residents' funds were conveyed to funeral homes. The findings included: An interview on 5/29/11 at approximately 8:20 AM with the Business Office Manager revealed that 2 of 5 random sampled residents' funds reviewed were conveyed to funeral homes. The Business Office Manager confirmed the findings and further stated the facility did not obtained a signed document/authorization from individual or probate jurisdiction administering the resident's estate to send the funds directly to the funeral home.",2015-08-01
9424,LAKE MOULTRIE NURSING HOME,425341,1038 MCGILL LANE,SAINT STEPHEN,SC,29479,2011-03-09,159,B,0,1,81IK11,"On the days of the Recertification Survey, based on record review and interviews, the facility failed to obtain authorization to manage personal funds for 2 of 3 residents reviewed with Trust Fund Accounts. The findings included: On 3/9/11 at approximately 11:10 AM, review of resident Trust Account Funds revealed two of three residents did not have signed authorizations in their record for the facility to manage their Trust Fund Account. Resident #14's file contained no documentation which indicated authorization had been granted to the facility to handle personal funds. Resident #A had a Resident's Informed Consent, Authorization and Release Agreement dated 2/14/11 which also indicated no authorization had been granted to the facility to handle personal funds. Review of the Trust Fund Account Balance report indicated Resident #14 had a balance of $30.05 in the account and Resident #A had an account balance of $90.01. During an interview on 3/9/11, the Nursing Home Administrator (NHA) and the Chief Operations Officer (COO) stated they did not know why the residents would have funds on deposit unless the resident or family requested the facility to manage the residents' funds. The NHA and COO confirmed that both residents had money deposited in a trust account and that neither resident, or their legal representative, had provided written authorization to manage the funds.",2015-05-01
9425,LAKE MOULTRIE NURSING HOME,425341,1038 MCGILL LANE,SAINT STEPHEN,SC,29479,2011-03-09,160,B,0,1,81IK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification Survey, based on record review and interviews, the facility failed to convey funds deposited with the facility to the estate of the resident or to the probate court for 2 of 5 residents reviewed for conveyance of funds. The findings included: On [DATE] at approximately 10:30 AM, review of 5 randomly selected residents for conveyance of Trust Account Funds revealed 2 residents with funds on deposit with the facility that were conveyed to the facility. Resident B expired [DATE] and had a balance of $20.00 in a trust account at the time of death. The facility issued a check dated [DATE] to the facility to offset money owed to the facility. Resident C expired on [DATE] and had a balance of $90.03 in a trust account. No check was issued to close the account. During an interview at approximately 11:00 AM on [DATE], the Administrative Assistant who managed the accounts stated that the funds for Resident C had been transferred from the Trust Account to the facilities bank account. The Chief Operations Officer and the Administrative Assistant stated they thought they could close out a resident's Trust Account and pay any balance in the account to the facility if the resident owed money to the facility.",2015-05-01
9584,KINGSTREE NURSING FACILITY,425117,401 NELSON BOULEVARD,KINGSTREE,SC,29556,2010-10-13,156,B,0,1,M1ZN11,"On the days of the survey, based on record review and interview, the facility failed to provide documentation of the timely notification of Medicare Provider Non-Coverage (CMS Form ) for 1 of 3 residents reviewed (Resident A). In addition, the facility failed to provide the required Liability Notice to 2 of 3 residents reviewed (Resident A and Resident #4). The findings included: Review of Notices of Medicare Non-Coverage for Resident A on 10/12/10 revealed the Centers for Medicare and Medicaid Services (CMS) Form indicated that current Skilled Services would end on 8/26/10. Review of the form revealed no resident or representative (RP) signature and no documentation to indicate when/how the resident or RP was notified of this change. In addition, CMS dated 8/16/10 was issued instead of a Liability Notice (SNFABN-CMS or 1 of 5 CMS approved denial letters) prior to being discharged from Medicare. Review of Resident #4's Notice of Medicare Non-Coverage revealed CMS was issued instead of a Liability Notice (SNFABN-CMS or 1 of 5 CMS approved denial letters) prior to being discharged from Medicare. During an interview on 10/13/10 at approximately 10:30 AM, a member of the facility's business staff reviewed the forms for Resident A and Resident #4 and confirmed the above findings.",2015-03-01
9679,HEARTLAND HEALTH AND REHABILITATION CARE CENTER-HA,425289,1800 EAGLE LANDING BLVD,HANAHAN,SC,29406,2011-02-03,159,B,0,1,5MWX11,"On the days of the survey, based on record reviews and interviews, the facility failed to maintain a petty cash fund that was available to the residents seven days a week. The findings included: On 2/2/11 at 4:30 PM a review of the resident funds was done with the facility Payroll Clerk/ Human Resources Assistant. During the review, when asked how the petty cash for the residents was handled, she stated that the residents would come to her office and get the money that they needed. When asked if the funds were available on the weekends she stated no and that she had been employed at the facility for eleven years and there had never been a petty cash fund. During a review with the Administrator on 2/2/11 at 5:10 PM, he stated that there had never been a request for petty cash on the weekends except for about a year ago. He stated he just happened to be in the building on a weekend and a resident asked for cash from the petty fund and he was in the building to give it to him. He further stated that he was on call 24 hours a day, seven days a week and the staff knew that he would come in to get funds from the safe. When asked if that was posted in writing so all staff would know that process. the Administrator stated no.",2015-01-01
9885,LAUREL BAYE HEALTHCARE  OF WILLISTON LLC,425297,5721 SPRINGFIELD HWY,WILLISTON,SC,29853,2011-07-27,159,B,0,1,8DSB11,"On the days of the Recertification Survey, based on record review and interviews, the facility failed to obtain authorization to manage personal funds for 1 of 3 residents reviewed for Trust Fund Accounts. The finding included: On 7/27/11 at approximately 10:55 AM, an expanded review of resident Trust Account Funds revealed Resident B did not provide written authorization to the facility to manage personal funds. The Resident Trust Fund Authorization form from the resident's financial record was blank and unsigned and was confirmed at that time with the Business Office Manager and the Regional Field Analyst.",2014-10-01
9970,VETERANS VICTORY HOUSE,425386,2461 SIDNEY ROAD,WALTERBORO,SC,29488,2011-02-16,156,B,0,1,QFX311,"On the days of the survey , based on administrative record reviews and interview, the facility failed to provide the mandated 48 hour expedited Notice of Medicare Provider Non- Coverage for 2 of 3 residents who had been determined by the facility to no longer be eligible for Medicare coverage. Resident #6 was notified the day the services ended and Resident B was notified only 24 hours prior to the services ending. The findings included: On 2/16/11 at 10:05 AM, a review of 3 random Notices of Medicare Provider Non-Coverage and an interview with the Director of Admissions, who prepared the notices, was completed. The review revealed that Resident #6's services were to end on 2/1/11 and the documentation revealed the resdient's daughter was notified on 2/1/11. Resident B's services were to end on 4/9/10 and the documentation revealed the resident's daughter was notified by phone on 4/8/10. During the interview with the Director of Admissions, she stated that there had been some communication problems between departments which resulted in the untimely notifications.",2014-09-01
10188,ROSECREST REHABILITATION AND HEALTHCARE CENTER,425376,200 FORTRESS DRIVE,INMAN,SC,29349,2010-09-08,160,B,,,9VMS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on review of resident funds for conveyance upon death, the facility failed to convey one fund within 30 days of death, and failed to have proper authorization to convey 2 other resident funds. The findings included: An interview with the Business Office Manager on [DATE] related to conveyance of funds upon death revealed 3 of 4 accounts reviewed were refunded improperly. Account of Resident A, who expired on [DATE], was refunded by check written on [DATE]. The manager explained that corporate had recently found several accounts that had not been refunded, and she made out the check this day. Resident B had expired on [DATE] and a check had been made out to Colonial Trust on [DATE]. No legal authorization had been obtained to make the check out to this entity. Resident C expired on [DATE], and a check was made out on [DATE] to a son who had not been appointed as an administrator of the estate.",2014-04-01
10253,HERITAGE HEALTHCARE OF PICKENS,425306,163 LOVE & CARE ROAD,SIX MILE,SC,29682,2010-10-26,156,B,,,M5SK11,"On the days of the survey, based on record review and interview, the facility failed to provide timely Notice of Medicare Provider Non-Coverage notification for 4 of 5 residents reviewed for Change in Pay Source. The findings Included: Review of residents files for change in pay source revealed four of five residents had not received timely notification of Medicare Provider Non-Coverage. Resident A's Notice of Medicare Provider Non-Coverage indicated that effective 1/11/2010 his/her coverage of current skilled nursing services would end. Further review revealed the resident had not received notification of the change in pay source until 1/11/2010. Resident B's Notice of Medicare Provider Non-Coverage indicated that effective 6/11/2010 his/her coverage of current skilled nursing services would end. Further review revealed the resident had not received notification of the change in pay source until the 6/11/10. Resident C's Notice of Medicare Provider Non-Coverage indicated that effective 6/11/2010 his/her coverage of current skilled nursing services would end. Further review revealed the resident had not received notification of the change in pay source until the 6/11/2010. Resident D's Notice of Medicare Provider Non-Coverage indicated that effective 1/14/2010 his/her coverage of current skilled nursing services would end. Further review revealed the resident had not received notification of the change in pay source until the 1/14/2010. During an interview with the Business Office Manager (BOM) on 10/25/10 at approximately 3:30 PM he/she stated "" They wanted to go home that day, so we did not have time to give notice"". The medical records for residents B and C showed a form titled Notification of Therapy Change which was dated 6/2/10 for resident C. (7 days in advance). and Resident B's form was dated 6/7/10. (4 days in advance). The BOM stated when asked what this form was for, ""that is how they let us know the time is ending.""",2014-02-01
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
1007,MILLENNIUM POST ACUTE REHABILITATION,425105,2416 SUNSET BOULEVARD,WEST COLUMBIA,SC,29169,2020-02-13,577,C,0,1,QHZF11,"Based on observations and interviews, the facility failed to ensure the results of the most recent survey conducted by the Federal and State surveyors were readily accessible and available to facility residents and visitors. The most recent state agency survey results were not accessible and there was no posting to indicate where the most recent survey results were located on 2 of 2 units observed. The findings included: Upon entering the facility on 2/10/2020 at approximately 10 AM revealed no state agency survey results available in the front lobby of the facility and no posting as to the location of the most recent survey results. During the state agency group interview on 2/10/2020 at approximately 4 PM, 8 of 9 residents in group stated they did not know where the most recent state agency survey results were located. An interview and observation on 2/12/2020 at approximately 2:34 PM with the facility's Receptionist/Human Resource Staff revealed that the most recent state survey book was behind the receptionist desk on desk on the 1st floor. The Receptionist/Human Resource Staff acknowledge the state agency survey information was not accessible by the receptionist desk and further stated there was no posting to inform the residents or visitors as to where the most recent state agency survey book could be located. An observation on 2/12/2020 at approximately 2:43 PM with the facility's pharmacist revealed the state agency survey book was behind the nurses' station on a shelf. The survey results were not current or accessible. An interview and observation on 2/12/2020 at approximately 2:45 PM with LPN#1 confirmed the state agency survey results were not readily accessible, the survey results were not current and there was no posting to inform the residents or visitors as to the location of the survey results on the 2nd floor.",2020-09-01
1014,MILLENNIUM POST ACUTE REHABILITATION,425105,2416 SUNSET BOULEVARD,WEST COLUMBIA,SC,29169,2017-09-21,167,C,1,1,QQ9911,"> Based on observations and interviews, the facility failed to ensure results of the most recent and past three recertification survey results were readily available for resident/family and visitor review on 2 of 2 units. The findings included: Upon entry to the facility at 10:00 AM on 9/18/17, a sign was identified located at the front reception desk which identified that Survey Results available upon request. On 9/18/17 at 11:00 AM, when Receptionist #1 was asked for survey results, s/he provided a binder which contained the survey results for the following dates: 4/13/17, 8/18/16, 7/13/16, and 3/18/15. Further review identified that annual recertification surveys were dated 7/13/16 and 3/18/15, with complaint surveys dated 4/13/17 and 8/18/16. There were no results in the binder to reflect the annual recertification survey conducted in 9/20/13. During interview with Receptionist #1, s/he verified that the earliest date of a survey in the binder was 3/18/15, and there were no survey results in the binder prior to that date. When the administrator was notified at approximately 7:00 PM on 9/21/17 that the required three prior recertification survey results were not available in the survey binder during initial tour, no further information was provided.",2020-09-01
1033,HEARTLAND HEALTH CARE CENTER - GREENVILLE EAST,425106,601 SULPHUR SPRINGS ROAD,GREENVILLE,SC,29611,2020-01-09,732,C,1,1,8G9611,"> Based on record review and interview, the facility failed to ensure there were accurate daily staff postings. The daily staff postings did not include the total number and hours worked per shift. The findings included: Review at 03:46 PM of the schedule posted on 1/08/20 revealed it was for 1/07/20 and it was incomplete as the total number and hours worked were not broken down by shift. Review of the POS [REDACTED]. Interview with Human Resources staff #1 on [DATE] at 3:40 PM confirmed that she was unaware of how to complete the daily posting. Interview on [DATE] at 3:51 PM with the Administrator confirmed there was no policy in place for posting of hours worked.",2020-09-01
1087,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2018-08-10,657,C,0,1,0H3T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to have evidence that a Certified Nursing Assistant participated in the care plan conference for residents sampled for review of the care plan. Residents #2, #87, #93, #95, #107, #131 and #303. The findings included: The facility admitted Resident #2 with [DIAGNOSES REDACTED]. At 02:55 PM on 08/10/18, review of the Interdisciplinary Care Conference Attendance Record dated 05/30/18 revealed no documentation that a Certified Nursing Assistant was included in the Interdisciplinary Team and participated in the development of the care plan. The facility admitted Resident #87 with [DIAGNOSES REDACTED]. Review of the Interdisciplinary Care Conference Attendance Record dated 04/17/18 revealed no documentation that a Certified Nursing Assistant was included in the Interdisciplinary Team and participated in the development of the care plan. There was no documentation of a care plan conference since 04/17/18. The facility admitted Resident #93 with [DIAGNOSES REDACTED]. At 2:57 PM on 08/10/2018, review of the Interdisciplinary Care Conference Attendance Record dated 07/19/18 revealed no documentation that a Certified Nursing Assistant was included in the Interdisciplinary Team and participated in the development of the care plan. The facility admitted Resident #95 with [DIAGNOSES REDACTED]. On 08/10/18 at 02:22 PM, review of the Interdisciplinary Care Conference Attendance Record dated 04/17/18 revealed no documentation that a Certified Nursing Assistant was included in the Interdisciplinary Team and participated in the development of the care plan. There was no documentation of a care plan conference since 04/17/18. The facility admitted Resident #107 with [DIAGNOSES REDACTED]. At 2:17 PM on 08/10/2018, review of the Interdisciplinary Care Conference Attendance Record for Resident #107 dated 08/01/18 revealed no documentation that a Certified Nursing Assistant was included in the Interdisciplinary Team and participated in the development of the care plan. The facility admitted Resident #131 with [DIAGNOSES REDACTED]. On 08/10/18 at 02:20 PM, review of the Interdisciplinary Care Conference Attendance Records dated 5/30/18 and 08/02/18 revealed no documentation that a Certified Nursing Assistant was included in the Interdisciplinary Team and participated in the development of the care plan. The facility admitted Resident #303 with [DIAGNOSES REDACTED]. At 02:52 PM on 08/10/2018, review of the Interdisciplinary Care Conference Attendance Record dated 04/17/18 revealed no documentation that a Certified Nursing Assistant was included in the Interdisciplinary Team and participated in the development of the care plan. There was no documentation of a care plan conference since 04/17/18. During interviews on 08/10/18, the Social Services Director and the Director of Nursing confirmed the lack of Certified Nursing Assistant participation in the care plan meetings and the lack of documentation of care plan meetings as noted above.",2020-09-01
1097,MOUNT PLEASANT MANOR,425110,921 BOWMAN ROAD,MT PLEASANT,SC,29464,2018-02-16,623,C,1,1,KY1411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to notify the ombudsman of all facility-initiated transfers as required for 2 of 2 sampled residents reviewed for hospitalization (Residents #530 and #28). The findings included: The facility admitted Resident #28 with [DIAGNOSES REDACTED]. Review of Nurse's Notes at 12:08 PM on 2-13-18 revealed that the resident's family member reported a [MEDICAL CONDITION] while s/he and a second family member were feeding the resident on 9-25-17. While Certified Nursing Assistants were getting her/him ready to lie down, Resident #28 slumped over and eyes were gazing. The physician was notified and an order received to Transfer to (hospital) for evaluation of A[CONDITION] (altered mental status). The resident was seen in the emergency room for worsening [MEDICAL CONDITION]/dehydration and returned to the facility. The facility admitted Resident #530 with [DIAGNOSES REDACTED]. Record review on 2-15-18 at 2:43 PM revealed 9-18-17 physician's orders [REDACTED]. Further review revealed a hospital History and Physical that stated Resident #530 had been found on the floor next to her (his) bed. A hematoma was noted on her (his) forehead. The patient appeared to be agitated and was groaning. The resident was admitted to the hospital with [REDACTED]. During an interview on 2-15-18 at 9 AM, when asked about notification of the Ombudsman, the Director of Nursing stated that the Ombudsman had not been notified of any facility-initiated transfers to the emergency room or hospital. S/he said,That's not how we understood it (the regulation).",2020-09-01
1111,MOUNT PLEASANT MANOR,425110,921 BOWMAN ROAD,MT PLEASANT,SC,29464,2016-11-03,156,C,0,1,U4CH11,"Based on observation and interview, the facility failed to prominently display mandatory postings in a manner allowing convenient access by residents and visitors. Findings include: During observations on 11/02/16 at 3:30 PM and 11/03/16 at 1:54 PM, a posting of contact information for state licensing and survey agencies, Protection and Advocacy groups, Medicaid fraud reporting information and contact information for the Ombudsman ' s office was not found in the facility. During an interview and observation with the Administrator on 11/03/16 at 2:10 PM a posting could only be located on the locked wing of the facility. Further observation revealed that the posting could not be read and the display case could not be opened. The Administrator stated the case would be opened and the information placed in the other areas of the facility.",2020-09-01
1196,WINDSOR MANOR,425114,5583 SUMMERTON HIGHWAY,MANNING,SC,29102,2018-04-06,641,C,0,1,YXGL11,"**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 ensure the MDS (Minimum Data Set) assessment dated [DATE] for Resident #15 was coded accurately related to weight loss for 1 of 5 residents reviewed for nutrition. The findings included: The facility admitted Resident #15 with [DIAGNOSES REDACTED]. Review on 4/5/2018 at approximately 7:24 PM of a form titled, Weight Chart, revealed a weight on 10/24/2017 of 153 pounds. The weight on 11/19/2017 was 169 pounds. The weight on 12/8/2017 was 152 pounds. No documentation could be found in the medical record to ensure Resident #15 was reweighed to ensure accuracy. Review on 4/5/2018 at approximately 7:54 PM of the MDS assessment dated [DATE] for Resident #15 revealed a transmitted weight of 169 pounds. During an interview on 4/5/2018 at approximately 6:20 PM with the RN (Registered Nurse) Consultant stated, we usually reweigh the residents and then weigh them for three days consecutively. An interview on 4/5/2018 at approximately 7:00 PM with the Administrator confirmed the error and he/she stated, I would have reweighed the resident. A corrected MDS was transmitted on 4/5/2018 and was presented by the Administrator. Review on 4/5/2018 at approximately 7:15 PM of the facility policy titled, Weight Assessment and Intervention, under Policy Statement, The multidisciplinary team will strive to prevent, and intervene for undesirable weight loss for our residents. Under Weight Assessment, number 3 states, Any weight change of 5 percent or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietician in writing. Verbal notification must be confirmed in writing. Number 4 states, The Dietician will respond within 24 hours of receipt of written notification. .",2020-09-01
1224,EDISTO POST ACUTE,425116,575 STONEWALL JACKSON BOULEVARD,ORANGEBURG,SC,29115,2018-02-23,623,C,0,1,8FY611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide written notification of hospital transfers to the Ombudsman for 2 of 2 sampled residents reviewed for hospitalization (Residents #54 and #69). . The findings included: The facility admitted Resident #54 with [DIAGNOSES REDACTED]. Nurse's Notes and the hospital discharge summary reviewed on 02/23/18 at 04:46 PM revealed Resident #54 was sent to the hospital on [DATE] and was admitted for Acute Hypoxemic [MEDICAL CONDITIONS], Bacterial Pneumonia, Urinary Tract Infection, and Severe Dehydration. During an interview on 02/23/18 at 07:46 PM, when asked about notification of the Ombudsman of the transfers, Social Services stated, I was not aware of the need to notify the Ombudsman for transfers to the hospital.",2020-09-01
1408,CONWAY MANOR,425121,3300 4TH AVENUE,CONWAY,SC,29527,2018-11-10,732,C,0,1,KQVD11,"Based on record review and interview, the facility failed to maintain posted daily nurse staffing as required. The findings included: Record review on 11/10/18 of the facility daily nurse staffing revealed there was no daily nurse staffing available from 10/22/18-11/10/18. During an interview with the Director of Nursing on 11/10/18 at 10:15 AM, s/he confirmed postings could not be located for the dates after 10/21/18.",2020-09-01
1421,INMAN HEALTHCARE,425122,51 N MAIN ST,INMAN,SC,29349,2017-02-09,356,C,0,1,6GNK11,"Based on observation and interview the facility failed to post staffing hours for the facility in a public place for viewing on all days of the survey. The findings included: Observations on 2/6/17, 2/7/16, 2/8/17 and 2/9/17 revealed the staffing hours posted on the side of the refrigerator behind the nurse's station and unable to be seen by the public. On 2/6/17 the DON (Director of Nursing) had to show the surveyor where the posting was located. The posting continued to remain in the same place for all days of the survey. Interview with LPN (Licensed Practical Nurse) # 1 on 2/9/17 at 8:45 AM confirmed that the facility always places the staff posting on the side of the refrigerator located behind the nurse's station. Nurse also confirmed that it could not be seen by people walking by. The DON (Director of Nursing ) also confirmed the posting could not be seen by family or visitors in the facility.",2020-09-01
1465,PRUITTHEALTH- ROCK HILL,425127,261 S HERLONG AVE,ROCK HILL,SC,29732,2017-06-09,287,C,1,1,L4Y911,"> Based on record review and interview, the facility failed to 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 7 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 5/31/17. The findings included: Resident #297 had an assessment target date of 10/4//2016 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 5/31/17. Resident #297 was discharged from facility with return not anticipated on 10/14/2017 and a MDS discharge (D/C) assessment was signed as completed on 10/25/2016; 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 6/7/17 at 1:05 PM revealed a Final Validation Report (FVR) with the submission Identification (ID) of 365 that was completed at 11:44:24 AM. Record #2 identified Resident #297's discharge return not anticipated MDS assessment which was signed as complete on 10/25/16 and submitted on 6/7/17 was accepted into the CMS database and subsequently identified as Record Submitted Late. Resident #125 had an assessment target date of 3/22/2017 which was the last transmitted Minimum Data Set (MDS) assessment/ entry tracking form per the CASPER (Certification and Survey Provider Enhanced Reporting) MDS 3.0 Missing OBRA (Omnibus Budget Reconciliation Act) Assessment Report generated on 5/31/17. Resident #125 had an Admission MDS completed on 4/6/2017; 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 on 6/7/17 at 1:05 PM revealed a Final Validation Report (FVR) with the submission Identification (ID) of 363 that was completed at 11:44:17 AM. Record #8 identified Resident #125's Admission MDS assessment with Assessment Reference Date (ARD) of 3/29/17 which was signed as complete on 4/6/17 and submitted on 6/7/17 and accepted into the CMS database, subsequently identified as Record Submitted Late. Resident # 299 had an assessment target date of 1/31/2017 which was the last transmitted Minimum Data Set (MDS) assessment/ entry tracking form per the CASPER (Certification and Survey Provider Enhanced Reporting) MDS 3.0 Missing OBRA (Omnibus Budget Reconciliation Act) Assessment Report generated on 5/31/17. Resident #299 had an Admission MDS completed on 2/14/2017, as well as a MDS D/C assessment completed on 4/25/17. Neither of the the MDS assessments were 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 on 6/7/17 at 1:05 PM revealed a Final Validation Report (FVR) with the submission Identification (ID) of 363 that was completed at 11:44:17 AM. Record #9 identified Resident #299's Admission MDS assessment with Assessment Reference Date (ARD) of 3/29/17 which was signed as complete on 4/6/17 and submitted on 6/7/17 and accepted into the CMS database, subsequently identified as Record Submitted Late. Record #10 identified Resident #299's discharge return not anticipated MDS assessment which was signed as complete on 4/25/17 and submitted on 6/7/17 was accepted into the CMS database and subsequently identified as Record Submitted Late Resident #298 had an assessment target date of 2/24/2017 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 5/31/17. Resident #298 was discharged from facility with return not anticipated on 3/4/2017 and a MDS discharge (D/C) assessment was signed as completed on 3/4/2017, 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 6/7/17 at 1:05 PM revealed a Final Validation Report (FVR) with the submission Identification (ID) of 365 that was completed at 11:44:24 AM. Record #4 identified Resident #298's discharge return not anticipated MDS assessment which was signed as complete on 3/4/17 and submitted on 6/7/17 was accepted into the CMS database and subsequently identified as Record Submitted Late. Resident #175 had an assessment target date of 12/28/2016 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 5/31/17. Resident #175 was discharged from facility with return not anticipated on 1/18/17 and a MDS discharge (D/C) assessment was signed as completed on 2/8/17, 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 6/7/17 at 1:05 PM revealed a Final Validation Report (FVR) with the submission Identification (ID) of 363 that was completed at 11:44:17 AM. Record 11 identified Resident #175's discharge return not anticipated MDS assessment which was signed as complete on 2/8//17 and submitted on 6/7/17 was accepted into the CMS database and subsequently identified as both Assessment Completed Late and Record Submitted Late. Resident #218 had an assessment target date of 1/11/2017 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 5/31/17. Resident #218 was discharged from facility with return not anticipated on 1/26/17 and a MDS discharge (D/C) assessment was signed as completed on 2/8/17, 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 6/7/17 at 1:05 PM revealed a Final Validation Report (FVR) with the submission Identification (ID) of 363 that was completed at 11:44:17 AM. Record #12 identified Resident #218's discharge return not anticipated MDS assessment which was signed as complete on 2/8/17 and submitted on 6/7/17 was accepted into the CMS database and subsequently identified as Record Submitted Late. Resident #212 had an assessment target date of 12/30/2016 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 5/31/17. Resident #212 was discharged from facility with return not anticipated on 1/24/17 and a MDS discharge (D/C) assessment was signed as completed on 2/7/17, 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 6/7/17 at 1:05 PM revealed a Final Validation Report (FVR) with the submission Identification (ID) of 363 that was completed at 11:44:17 AM. Record #13 identified Resident #212's discharge return not anticipated MDS assessment which was signed as complete on 2/7/17 and submitted on 6/7/17 was accepted into the CMS database and subsequently identified as Record Submitted Late. During an interview with MDS Nurse #1 on 6/8/17 at approximately 4:30 p.m., s/he reported that all assessments are transmitted to the CMS database through a third party and that the assessments were sent to the third party, but there was no further communication back to the facility to identify any issues related to the transmissions. S/he further stated that s/he has brought this concern up with the administrator, and they have not been able to identify a solution to this problem thus far. S/he further verified that MDS assessments completed for Resident #297, Resident #125, Resident #299, Resident #298, Resident #175, Resident #218, and Resident #212 were not transmitted to the CMS Database as required until 6/7/17. Additionally, she verified that the data was not sent within the 14 day window after discharge event/ completion of assessment as required by both CMS and the State of South Carolina and were considered record submitted late.",2020-09-01
1473,PRUITTHEALTH- ROCK HILL,425127,261 S HERLONG AVE,ROCK HILL,SC,29732,2018-09-20,625,C,0,1,0INL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure a written copy of the bedhold policy was provided at the time of transfer for 3 of 4 residents reviewed for hospitalization . The findings included; Resident #45 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the medical record on 9/19/18 showed an order obtained to transport the resident to the hospital for evaluation and treatment on 5/30/18. Additional review of the transport documentation showed no documentation of the bedhold policy being given. During additional review of other medical records, Resident #68 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the medical record on 9/19/2018 showed Resident #68 was sent to the Emergency Department then admitted to the hospital on [DATE]. Additional record review showed no documentation of the bedhold policy being given. At approximately 12:21 PM on 9/19/18, an interview with the Director of Nursing verified that the bedhold policy was only being given at the time of admission and not at the time of transfers. The facility admitted Resident #112 07/09/18 with [DIAGNOSES REDACTED]. On 09/18/18 at 02:03, record review revealed Resident #112 was hospitalized ,[DATE]-[DATE] and 07/30-08/10. There was no documentation in EHR or physical medical record that a copy of the bed hold policy was provided to the resident/ resident representative at the time of transfer to the hospital. During an interview on 09/19/18 at 03:44 PM, the Director of Nursing stated that a copy of the bed hold policy was sent to the hospital upon transfer but also confirmed there was no documentation that the resident or resident representative was provided a copy of the bed hold policy.",2020-09-01
1500,WHITE OAK MANOR - CHARLESTON,425128,9285 MEDICAL PLAZA DR,CHARLESTON,SC,29418,2018-05-19,851,C,0,1,LWXD11,"Based on record review and interview, the facility failed to submit staffing information based on payroll data in a timely manner as required by the Centers for Medicare and Medicaid services. The findings included: Review of the CASPER Report 1702S revealed the following: Staffing Summary Report 1/1/17-3/31/17 submitted 5/16/17; Staffing Summary Report 4/1/17-6/30/17 submitted 8/15/17; Staffing Summary Report 7/1/17-9/30/17 submitted 11/15/17. At the time of the finding, staff responsible for submitting the Staffing Summary Report was unavailable to confirm the submission dates.",2020-09-01
1555,BRIAN CENTER NURSING CARE - ST ANDREWS,425129,3514 SIDNEY ROAD,COLUMBIA,SC,29210,2018-10-05,574,C,0,1,5DS011,"Based on observation and interview, the facility failed to ensure that contact information was posted and readily accessible to 3 of 3 units as required for pertinent State regulatory and informational and advocacy groups. The findings included: During an observation and interview with the Administrator on 10/02/18 at 6:59 PM, s/he verified that the posted contact information was incomplete. No web addresses were noted for State Licensure or Certification, the Ombudsman, or the Protection and Advocacy Agency. No contact information was posted for the Medicaid Fraud Control Unit.",2020-09-01
1557,BRIAN CENTER NURSING CARE - ST ANDREWS,425129,3514 SIDNEY ROAD,COLUMBIA,SC,29210,2018-10-05,577,C,0,1,5DS011,"Based on observations and Group and staff interviews, the facility failed to have 3 years survey data readily accessible to residents and visitors of 3 of 3 units upon request. The findings included: During the Group Interview on 10-3-18, residents stated they did not know the location of the previous inspections. One resident stated they used to keep a book in the activity room. Review of postings on 10/02/18 at 6:59 PM revealed a notice that survey results were located in a black binder in the front lobby. Review of the binder contents with the Administrator revealed only the results of the most current (2017) recertification survey present. When asked for the 2 prior year surveys, the Administrator was unaware of their location. During an interview on 10/02/18 at 7:16 PM, Social Services (SS) and the Registered Nurse (RN)Consultant checked the survey book in the front lobby and verified that only the (YEAR) survey was in the book. SS stated s/he had placed the previous survey results in the black binder in the front lobby and did not know why they were not there. The RN Consultant stated there had been copies in the small activity room so they would be accessible, but they were not there when checked at this time.",2020-09-01
1606,THE METHODIST OAKS,425131,151 LOVELY DRIVE,ORANGEBURG,SC,29115,2019-07-26,640,C,0,1,GEM911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to transmit required assessments in a timely manner for 4 of 4 residents reviewed for transmission (Residents # 72, #73, #74, and #323). The findings included: The facility admitted Resident #72 with [DIAGNOSES REDACTED]. Record review on 7/26/19 revealed the last Minimum Data Set (MDS) received was 10/24/18. The facility admitted Resident #73 with [DIAGNOSES REDACTED]. Record review on 7/26/19 revealed the last MDS received was 8/10/18. The facility admitted Resident #74 with [DIAGNOSES REDACTED]. Record review on 7/26/19 revealed the last MDS received was 8/24/18. The facility admitted Resident #323 with [DIAGNOSES REDACTED]. Record review on 7/26/19 revealed the last MDS received was 9/2/18. During an interview with the Director of Nursing on 7/26/19, s/he confirmed four discharge assessments had not been done. S/he also stated there had been several personnel changes in the MDS position.",2020-09-01
1724,PRUITTHEALTH-MONCKS CORNER,425140,505 SOUTH LIVE OAK DRIVE,MONCKS CORNER,SC,29461,2017-02-09,356,C,0,1,Q7VP11,"Based on observation, staff interview and record review, the facility failed to ensure the required nurse staffing information, was updated daily and posted at the beginning of each shift for residents and visitors in the facility. This had the potential to affect all 107 residents in the facility as well as visitors to the facility. Findings include: During the initial tour on 1/22/17 at 5:30 p.m., the nursing staff information was posted in the entrance hallway of the facility near the social service office. The nurse staffing information document was dated 1/20/17. During an interview on 1/22/17 at 6:35 p.m., the Director of Nursing (DON) stated that the Manger on weekend duty was responsible for completing and posting the nurse staff information. The DON confirmed that the document was dated 1/20/17. The DON confirmed that the Medical Records Manager was the manager on duty for 1/21/17 and 1/22/17 and should have completed and posted the document each day. During an interview with the faculty ' s Corporate Nurse on 1/22/17 at 6:55 p.m., she stated she could only locate the nursing staff information documents back to 12/13/16. During an interview with the Administrator on 1/23/17 at approximately 3 p.m., the Administrator confirmed that the facility did not have further documentation of the nurse staffing information prior to 12/13/16.",2020-09-01
1788,HEARTLAND HEALTH CARE CENTER - UNION,425142,709 RICE AVENUE,UNION,SC,29379,2018-07-12,730,C,0,1,EY8011,"Based on record review and interview, the facility failed to ensure that Certified Nursing Assistants (CNAs) met the requirement for 12 hours of continuing education per year based on the CNA's hire date for 41 of 41 Certified Nursing Assistants. The findings included: Review of an Excel spreadsheet provided by the facility documenting the CNA total education hours revealed 0 of 41 CNAs had 12 hours of continuing education documented on the spreadsheet. The facility also provided a printout of the continuing education obtained through the facility's online education courses for each CN[NAME] The printout did not indicate the date of hire for the employees and had a running total since 01/01/17. There was no evidence that the hours had been calculated to ensure that each CNA had 12 hours based on his or her hire date. During an interview on 07/12/18 at 12:25 PM, the Director of Nursing (DON) stated the spreadsheet had not been used since the previous Human Resources (HR) Director left in March. The DON was unable to say if any CNA had met the 12 hrs of education per year from the date of hire as required. The DON stated s/he would have to sit down and go through the hours and add them up to determine if the requirement was met for a specific employee. When asked how often that was done, the DON stated it should be kept current but that it had not been due to a change in personnel in March. On 7/12/18, the Quality Assurance Consultant confirmed the spreadsheet had not been updated in 3 months when the HR person left and that the new HR person was not using that system. S/he confirmed all employees were marked as having the exact same amount of continuing education documented for the First, second, third, and fourth quarter of (YEAR) but stated she wasn't sure how to interpret the spreadsheet.",2020-09-01
1789,HEARTLAND HEALTH CARE CENTER - UNION,425142,709 RICE AVENUE,UNION,SC,29379,2018-07-12,732,C,0,1,EY8011,"Based on observation, record review and interview, the facility failed to post the staff posting daily in a prominent place accessible to residents and visitors for 7 of 7 months reviewed. The findings included: On 07/12/18, observation of the facility revealed no staff posting in a prominent place accessible to residents and visitors. The Staff Posting for the last 30 days was requested from the facility. The posting provided were all printed after requested on 07/12/18. During an interview at 12:05 PM, the Director of Nursing (DON) stated the facility had a picture frame in which the postings were displayed but that s/he came in one day and and the frame was gone with all the postings. The DON stated postings were usually kept for about 2 weeks to a months worth in the frame. The DON further stated s/he thought the frame broke and was discarded and that s/he assumed that the postings were discarded with the broken frame. The DON also stated s/e has not been able to find the postings. When asked, the DON stated it happened about 2 weeks ago. Review of the staff postings that were posted in the facility since January, (YEAR) revealed only 15 days of staff postings were available for January, 7 days for February, 8 days for (MONTH) and 18 days for April, (YEAR). No staff posting were provided for (MONTH) or July, (YEAR). On 07/12/18 at 01:57 PM, the Quality Assurance Consultant confirmed the number of days for each month and stated the facility was not in compliance.",2020-09-01
1830,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2018-09-27,623,C,0,1,HBGF11,"**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 4 of 4 sampled residents reviewed for hospitalization . The notification process was not followed for Residents #66, #45, #9 and #58 and/or their Resident Representatives. The findings include: The facility admitted Resident #9 with [DIAGNOSES REDACTED]. Record review on 09/27/18 at approximately 2:09 PM revealed that Resident #9 was transferred to the hospital on [DATE] and 06/10/18. No documentation that written Notice of Transfer or Notice of Bed Hold being provided to the resident and/ or resident representative was located in the record. The facility admitted Resident #45 with [DIAGNOSES REDACTED]. Record review on 09/26/18 at approximately 2:27 PM revealed Resident #45 was transferred to the hospital on [DATE], 07/10/18, 05/25/18 and 05/18/18. No documentation that written Notice of Transfer or Notice of Bed Hold being provided to the resident and/ or resident representative was located in the record. The facility admitted Resident #58 with [DIAGNOSES REDACTED]. Record review on 09/28/18 at approximately 11:57 AM revealed that Resident #58 was transferred to the hospital on [DATE]. No documentation that written Notice of Transfer or Notice of Bed Hold being provided to the resident and/ or resident representative was located in the record. In an interview on 09/27/18 at approximately 9:45 AM the facility's Administrator stated no written Notice of Transfer or Notice of Bed Hold Policy was being provided to the Resident and/ or his/her Representative. The Administrator also stated there was no documentation of the notice to the Ombudsman retained at the facility and was unable to obtain any verification. The report sent to the Ombudsman regarding transfers was based on the midnight census and did not include reporting for residents who were transferred out and returned the same day. On 09/27/18 at approximately 11:00 the Administrator provided copies of facility policies entitled Bed Hold Policy and Transfer and Discharge. The policy on Transfer and Discharge stated [NAME] Before a facility transfers or discharges a resident, the facility must: 1) Notify the resident and the resident's representative (s) of the transfer or discharge and the reason for the move in writing and in a language and manner they understand. 2) Send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman and documentation to reflect in the resident's medical record. 3) Document reasons for the transfer or discharge in the residents medical record . The Bed Hold Policy stated Facility's staff will provide each patient/resident or their qualified legal representative with Facility's written bed-hold policy at teatime of admission and each time the patient/ resident leaves the facility for hospitalization or therapeutic leave. The facility admitted Resident #66 on 10/11/16 with [DIAGNOSES REDACTED]. Review of the Progress Notes dated 8/25/18 indicated Resident #66 was sent to the emergency room and admitted to the hospital. The facility readmitted Resident #66 on 8/29/18. There was no documentation in the medical record to indicate the facility sent a written Notice of Transfer with the resident or mailed a written notification for the reason for the transfer to the resident's representative.",2020-09-01
1831,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2018-09-27,625,C,0,1,HBGF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Base on record review, observation and interview the facility failed to provide written Notice of Bed Hold upon occurrence to 4 of 4 sampled residents reviewed for hospitalization . The notification process was not followed for Residents #66, #45, #9 and #58 and/or their Resident Representatives. The findings include: The facility admitted Resident #9 with [DIAGNOSES REDACTED]. Record review on 09/27/18 at approximately 2:09 PM revealed that Resident #9 was transferred to the hospital on [DATE] and 06/10/18. No documentation that written Notice of Transfer or Notice of Bed Hold being provided to the resident and/ or resident representative was located in the record. The facility admitted Resident #45 with [DIAGNOSES REDACTED]. Record review on 09/26/18 at approximately 2:27 PM revealed Resident #45 was transferred to the hospital on [DATE], 07/10/18, 05/25/18 and 05/18/18. No documentation that written Notice of Transfer or Notice of Bed Hold being provided to the resident and/ or resident representative was located in the record. The facility admitted Resident #58 with [DIAGNOSES REDACTED]. Record review on 09/28/18 at approximately 11:57 AM revealed that Resident #58 was transferred to the hospital on [DATE]. No documentation that written Notice of Transfer or Notice of Bed Hold being provided to the resident and/ or resident representative was located in the record. In an interview on 09/27/18 at approximately 9:45 AM the facility's Administrator stated no written Notice of Transfer or Notice of Bed Hold Policy was being provided to the Resident and/ or his/her Representative. The Administrator also stated there was no documentation of the notice to the Ombudsman retained at the facility and was unable to obtain any verification. The report sent to the Ombudsman regarding transfers was based on the midnight census and did not include reporting for residents who were transferred out and returned the same day. On 09/27/18 at approximately 11:00 the Administrator provided copies of facility policies entitled Bed Hold Policy and Transfer and Discharge. The policy on Transfer and Discharge stated [NAME] Before a facility transfers or discharges a resident, the facility must: 1) Notify the resident and the resident's representative (s) of the transfer or discharge and the reason for the move in writing and in a language and manner they understand. 2) Send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman and documentation to reflect in the resident's medical record. 3) Document reasons for the transfer or discharge in the residents medical record . The Bed Hold Policy stated Facility's staff will provide each patient/resident or their qualified legal representative with Facility's written bed-hold policy at teatime of admission and each time the patient/ resident leaves the facility for hospitalization or therapeutic leave. The facility admitted Resident #66 on 10/11/16 with [DIAGNOSES REDACTED]. Review of the Progress Notes dated 8/25/18 indicated Resident #66 was sent to the emergency room and admitted to the hospital. The facility readmitted Resident #66 on 8/29/18. Further record review revealed there was no documentation in the medical record to indicate the resident and/or resident's representative was provided with written information related to the facility's bedhold policy upon transfer to the hospital.",2020-09-01
1837,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2018-09-27,732,C,0,1,HBGF11,"Based on record review and interview, the facility failed to post nurse staffing information that included all the required information. The total number of hours worked by various categories of licensed and unlicensed nursing staff was not included on the postings. The findings included: A review of the staff postings for the past 30 days revealed the total number of hours worked by registered nurses, licensed practical nurses, and certified nurse aides per shift was not documented on the forms. On 9/28/18 at approximately 10:45 AM, the Director of Nursing reviewed the forms and confirmed the finding at that time.",2020-09-01
1882,SANDPIPER REHAB & NURSING,425146,1049 ANNA KNAPP BOULEVARD,MOUNT PLEASANT,SC,29464,2017-05-19,287,C,1,1,OU8V11,"> Based on record review, interview and review of the facility policy titled Electronic Transmission of the MDS, the facility failed to transmit accurate Minimum Data Set(MDS) information in the required time frame for 10 of 10 residents . The findings included: Review of the Casper Report revealed the following residents with an assessment target date which was the last assessment per the report: -Resident #226-assessment target date 2/10/17; -Resident #2[AGE]-assessment target date 9/5/16; -Resident #2[AGE]-assessment target date 12/9/16; -Resident #39-assessment target date 11/30/16; -Resident #245-assessment target date 11/3/16; -Resident #222-assessment target date 11/24/16; -Resident #10-assessment target date 4/25/17; -Resident #99-assessment target date [DATE]; -Resident #231-assessment target date 11/3/16; -Resident #217-assessment target date 8/17/16. During an interview with the Minimum Data Set Coordinator on 5/18/17, he/she stated per the report all MDS assessments were accepted. During the interview, it was explained that there was something incorrect and/or information needing clarification. He/she again stated they were all accepted and did not know who to call to ensure all assessments were accepted and correct. Review of the facility policy titled Electronic Transmission of the MDS revealed under the Policy Interpretation and Implementation the following: 5. MDS electronic submissions shall be conducted in accordance with current OBRA regulations governing the transmission of such data. 6. The MDS Coordinator is responsible for ensuring that appropriate edits are made prior to transmitting MDS data and that initial feedback and validation reports from each transmission are maintained for historical purposes and for tracking. -",2020-09-01
1892,SANDPIPER REHAB & NURSING,425146,1049 ANNA KNAPP BOULEVARD,MOUNT PLEASANT,SC,29464,2018-08-24,582,C,0,1,ON8911,"Based on record review and interview, the facility failed to provide documentation indicating the required Medicare Non Coverage Notice was provided in writing to 2 of 3 residents reviewed for Beneficiary Protection Notification. The facility failed to provide a written notice of form CMS - NOMNC (Notice of Medicare Non-Coverage ) to Residents #241 and #243. The findings included: Review of Beneficiary Protection Notices for Resident #241 revealed Medicare Part A Skilled Services ended 3/20/18, and the resident had Medicare benefit days remaining. Further record review revealed facility staff contacted the resident's representative by telephone on 3/14/18 about the termination of Medicare Part A services. However, form CMS -NOMNC was not signed by the resident's representative, and there was no documentation to indicate a written notice was provided to the resident or resident's representative. Review of Beneficiary Protection Notices for Resident #243 revealed Medicare Part A Skilled Services ended 6/26/18, and the resident had Medicare benefit days remaining. Further record review revealed facility staff contacted the resident's representative by telephone on 6/22/18 about the termination of Medicare Part A services. There was no documentation to indicate a written notice was provided to the resident or resident's representative, and the form CMS -NOMNC was not signed until 8/22/18. Theses findings were confirmed by the facility Social Worker on 8/23/18 at approximately 3:00 PM during a review of Beneficiary Protection notices.",2020-09-01
1893,SANDPIPER REHAB & NURSING,425146,1049 ANNA KNAPP BOULEVARD,MOUNT PLEASANT,SC,29464,2018-08-24,623,C,0,1,ON8911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to notify the resident and resident representative in writing in a language and manner understood of transfer to hospital for 3 of 3 residents reviewed.(Resident #49, #120, and #134) The findings included: The facility admitted Resident #120 with [DIAGNOSES REDACTED]. Record review on 8/21/18 revealed Resident #120 was transferred to the hospital on [DATE] due to pain all over. Further review of the medical record of the nurse's notes and social service notes revealed there was no documentation a transfer notice had been given to the resident and resident representative. No further information was provided during the survey process. The facility admitted Resident #49 on 2/13/15 with [DIAGNOSES REDACTED]. Review of the Progress Notes revealed the notation dated 6/15/18 indicated an order was given to transport the resident to the hospital for further evaluation. The facility readmitted Resident #49 on 6/18/18. 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 for the reason for the transfer to the resident's representative. The Administrator confirmed these findings on 8/24/18. The facility admitted Resident #134 with [DIAGNOSES REDACTED]. Record Review on 08/23/18 at approximately 6:20 PM revealed Resident #134 was transferred to the hospital on [DATE]. No documentation of written Notice of Transfer being provided to the Resident or Resident Representative was found in the medical record.",2020-09-01
1910,LIFE CARE CENTER OF HILTON HEAD,425147,120 LAMOTTE DRIVE,HILTON HEAD ISLAND,SC,29926,2018-05-02,574,C,0,1,KRST11,"Based on observation interview, the facility failed to ensure that residents were aware of the location of the ombudsman's contact information for 11 of 11 residents present in the Resident Council Group Meeting. The findings included: On 3/19/18 at 310PM, residents present in the Resident Council Group meeting were asked if they were aware of the location of the ombudsman's contact information and all responded No.",2020-09-01
1911,LIFE CARE CENTER OF HILTON HEAD,425147,120 LAMOTTE DRIVE,HILTON HEAD ISLAND,SC,29926,2018-05-02,577,C,0,1,KRST11,"Based on interview and observation, the facility failed to ensure that residents were aware of the location of the state inspection results and that postings were posted at an appropriate reading level for 11 of 11 patients who attended the resident council meeting. The findings included: On 3/19/18 at 310PM, residents in the Resident Council Group meeting were asked if they were aware of the location of the state inspection results and all residents responded No. Following the meeting, the Executive Director (ED) was informed of how high the required postings were. ED agreed that they were too high and stated that it would be corrected. According to the Assistance on the Americans with Disabilities Act (ADA), Eye level of a man sitting in a wheelchair is 43-51 inches.",2020-09-01
1931,LIFE CARE CENTER OF HILTON HEAD,425147,120 LAMOTTE DRIVE,HILTON HEAD ISLAND,SC,29926,2018-05-02,732,C,0,1,KRST11,"Based on observations and interview, on all days of the survey, the staffing postings were located on an erasable board and did not include all required information for ready access to all visitors and residents on 2 of 2 units. The findings included: Observations on all days of the survey revealed that staffing information was posted on an erasable board and did not include total hours worked. During an interview on 3-22-18, the Administrator verified that the staffing information was not kept in the posted format for the required 18 months. S/he presented e daily Staffing Sheets which were kept by the facility. These forms included names and hours scheduled for individuals in the required categories by shift, but not what hours were actually worked. The form also did not include the daily census.",2020-09-01
2014,FRASER HEALTH CENTER,425150,300 WOOD HAVEN DRIVE,HILTON HEAD ISLAND,SC,29928,2018-11-01,574,C,0,1,PKPJ11,"Based on observation and interview, the facility failed to ensure residents were provided and were aware of contact information for all resident advocacy groups. The facility failed to post contact information that was readily accessible to residents and visitors in the facility. The findings included: During the Recertification Survey, a Group Interview was held with 7 residents on 10/31/18 at approximately 10:30 AM. Four of the 7 residents actively participated in the Group Interview. At that time, residents were asked if they knew where the Ombudsman's contact information is posted. The 4 active participants were unable to answer this question and indicated that they were unaware of this information. Observations during the survey indicated this information was posted on the wall in a hallway located down from the activity room. This hallway lead out of the unit into another section of the residential campus. Further observations indicated this information was posted high on the wall and would not be visible and readily accessible to residents in wheel chairs. During an interview on 11/1/18, the Director of Nursing confirmed this finding and informed the surveyor this posting would be lowered on the wall.",2020-09-01
2015,FRASER HEALTH CENTER,425150,300 WOOD HAVEN DRIVE,HILTON HEAD ISLAND,SC,29928,2018-11-01,577,C,0,1,PKPJ11,"Based on observation and interview, the facility failed to ensure the results of the most recent survey were posted in a place readily accessible to residents and that the notice of the availability of the reports was posted in areas of the facility that are prominent and accessible to the public. The findings included: During the Recertification Survey, a Group Interview was held with 7 residents on 10/31/18 at approximately 10:30 AM. Four of the 7 residents actively participated in the Group Interview. At that time, residents were asked if they knew where the latest State survey inspection report was located. The 4 active participants were unable to answer this question and indicated that they were unaware of this information. Observations during the survey indicated the inspection report was located in a holder on the wall in a hallway located down from the activity room. This hallway lead out of the unit into another section of the residential campus and was not frequented by all residents and visitors. Observation of the main lobby of the facility revealed no posting or signage indicating where this report was located. Further observation revealed a small sign listing the location was taped to a post at the nurse's station. During an interview on 11/1/18, the Director of Nursing confirmed this finding.",2020-09-01
2019,FRASER HEALTH CENTER,425150,300 WOOD HAVEN DRIVE,HILTON HEAD ISLAND,SC,29928,2018-11-01,657,C,0,1,PKPJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure all members of the interdisciplinary team had input into the care planning process for Resident #6, #13 and #3 for 3 of 12 residents reviewed for Care Plan Participation. The findings included: The facility admitted Resident #6 with [DIAGNOSES REDACTED]. Additional [DIAGNOSES REDACTED]. Review on 10/31/2018 at approximately 12:44 PM of the Care Plan Conference Summary dated 12/1/2017 revealed the CNA (Certified Nursing Assistant) most involved with the care for Resident #6 and Dietary did not have input into the care planning process for Resident #6. Further review on 10/31/2018 at approximately 12:44 PM of the Care Plan Conference Summary dated 3/2/2018 revealed the CNA most involved with the care for Resident #6 and Dietary did not have input into the care planning process for Resident #6 and review of the Care Plan Conference Summary dated 9/21/2018 revealed dietary did not have imput into the care planning process for Resident #6. The facility admitted Resident #3 with [DIAGNOSES REDACTED]. Review on 10/31/2018 at approximately 3:48 PM of the Care Plan Conference Summary dated 2/23/2018 revealed that Dietary did not have input into the care planning process for Resident #3. Further review on 10/ 8 at approximately 3:48 PM of the Care Plan Conference Sheet dated 9/27/2018 revealed Dietary did not have input into the care planning process for Resident #3. The facility admitted Resident #13 with [DIAGNOSES REDACTED]. Additional [DIAGNOSES REDACTED]. Review on 11/1/2018 at approximately 3:15 PM of the Care Plan Conference Summary dated 12/18/2017 revealed the CNA most involved with the care for Resident #13 did not have input into the care planning process for Resident #13. Further review on 11/1/2018 at approximately 3:15 PM of the Care Plan Conference Summary dated 4/17/2018 revealed the CNA most involved with the care for Resident #13 did not have input into the care planning process for Resident #13 and dietary did not have input into the care planning process on 7/17/2018. During an interview on 11/2/2018 at approximately 1:40 PM the DON (Director of Nursing) confirmed the findings.",2020-09-01
2020,FRASER HEALTH CENTER,425150,300 WOOD HAVEN DRIVE,HILTON HEAD ISLAND,SC,29928,2018-11-01,732,C,0,1,PKPJ11,"Based on record review and interview, the facility failed to ensure daily staffing posted included the actual hours worked for each category of licensed and unlicensed nursing staff for the 30 days of staffing reviewed. The findings included: Review on 10/31/2018 at approximately 7:23 PM of the daily posted staffing for licensed and unlicensed personal from 9/29/2018 through 10/29/2018 revealed no actual hours worked by the categories for each shift. An interview on 11/1/2018 at approximately 5:08 PM with RN (Registered Nurse) #1, Nurse Supervisor confirmed that the hours for each category of licensed and unlicensed nursing staff was not posted with the number of staff per shift.",2020-09-01
2041,HERITAGE HOME OF FLORENCE INC,425154,515 SOUTH WARLEY STREET,FLORENCE,SC,29501,2018-10-11,730,C,0,1,KGZL11,"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 date of hire. The findings included: During a review of CNA inservice training on 10/11/18 at approximately 9:45 AM, Registered Nurse (RN) #1 provided reports for CNA inservice courses. Record review indicated the reports did not calculate the total number of yearly inservice hours for the CNAs based on the hire date. At that time, RN #1 stated that the Human Resource office received a copy of the inservices completed but did not track the total number of inservice hours for each CN[NAME]",2020-09-01
2042,HERITAGE HOME OF FLORENCE INC,425154,515 SOUTH WARLEY STREET,FLORENCE,SC,29501,2018-10-11,732,C,0,1,KGZL11,"Based on observation and interview, the facility failed to post nurse staffing information on 3 of 3 of the facility's units in a prominent place readily accessible to residents and visitors. The findings included: Observations during the survey revealed the nurse staffing information was not posted on any of the facility's three units. On 10/11/18 at approximately 10:45 AM, the Director of Nursing (DON) provided copies of the staff postings for the past 30 days. The staff postings were observed posted beside the DON's office on the back hall of the facility. This back hall location connects the facility's resident units, but was not in a resident area and was not a location that was readily accessible to residents and visitors. On 10/11/18 at approximately 10:45 AM, the DON confirmed the surveyor's findings.",2020-09-01
2086,OAKBROOK HEALTH AND REHABILITATION CENTER,425156,920 TRAVELERS BOULEVARD,SUMMERVILLE,SC,29485,2018-08-04,623,C,0,1,0Y0911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews the facility failed to assure that the Resident Representative for Resident 15 and Resident #70 and the Ombudsman were notified in writing as to a change in condition that resulted in the resident being hospitalized . One of one resident reviewed for hospitalization . The finding included: On 8/3/18 at approximately 12:50 PM a review of the computerized and paper medical record for Resident 15 failed to show that written notification had been provided to the Resident Representative or Ombudsman for hospitalization due to [MEDICAL CONDITION] on 5/2/18. On 8/3/18 at approximately 1:22 PM a review of the Facility Discharge/Transfer Policy and Procedure failed to show that a written notification to was required. On 8/3/18 at approximately 1:35 PM the Director of Nursing and Medical Records Coordinator confirmed that no written notice had been provided to either the Resident Representative or Ombudsman and stated they were unaware of this requirement. The facility admitted Resident #70 with [DIAGNOSES REDACTED]. Record review on 8/4/18 at 12:19 PM revealed Resident #70 was admitted to the hospital on [DATE]-7/7/18 and 7/10/18-7/12/18. Further review of the nurse's notes and social services notes did not indicate transfer/discharge information was given to the resident nor the resident representative.",2020-09-01
2113,RIDGEWAY MANOR HEALTHCARE CENTER,425158,117 BELLFIELD ROAD,RIDGEWAY,SC,29130,2017-02-09,278,C,0,1,PSX711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to code residents as having a chronic condition or disease that may result in a life expectancy of 6 months or less, for 4 of 4 residents who were reviewed receiving Hospice Services. (#26, #34, # 40 and #60). In addition, Resident #88 was coded as having a decline in vision but there was no evidence this had occurred. The findings included: Review of Care Plan dated revealed Resident # 60 received hospice services and has a [DIAGNOSES REDACTED]. Review of Minimal Data Set ((MDS) dated [DATE] revealed Resident #60 was coded as not having a condition or chronic illness that may result in a life expectancy of less than 6 months. Interview with Regional MDS Coordinator on 2/9/17 at 5:30 PM verified that J1400 on the MDS for prognosis was coded incorrectly. The facility admitted Resident #26 with [DIAGNOSES REDACTED]. On 2/7/16 at 12:27 PM, review of the MDS Significant Change in Status 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 answered No. Further review revealed the resident was coded as receiving Hospice Services. Review of the record revealed the resident was re-admitted to the facility on [DATE] with orders to admit to Hospice 11/25/16. During an interview on 02/09/2017 at 5:30 PM, the Regional MDS Coordinator confirmed the inaccuracy of coding J1400 on the MDS. The facility admitted Resident #40 with [DIAGNOSES REDACTED]. On 02/07/2017 at 09:40 am, review of the MDS ( Minimal Data Set) Quarterly 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 answered no . Further review revealed the resident was receiving Hospice Services. Review of the record revealed the resident was admitted to Hospice Services on 11/04/2016 with a [DIAGNOSES REDACTED]. During an interview on 02/09/2017 at 5:30 PM with the Regional MDS Coordinator verified that J1400 was coded no and was not accurate. The facility admitted Resident #34 with [DIAGNOSES REDACTED]. On 02/07/2017 at 10:00 am, review of the MDS ( Minimal Data Set) Significant Change in Status 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 answered no . Further review revealed the resident was receiving Hospice Services. Review of the record revealed the resident was admitted to Hospice Services on 08/08/2016 with a [DIAGNOSES REDACTED]. During an interview on 02/09/2017 at 5:30 PM with the Regional MDS Coordinator verified that J1400 was coded no and was not accurate. Based on observation, record review and interview, the facility failed to accurately assess Resident #88 for vision decline. The MDS dated on 6/17/16 coded Resident #88 as having adequate vision. During record review on 2/8/17 at 2:15 pm, the MDS coded on 12/15/16 coded Resident #88 as having moderately impaired vision. Review of the record showed there had been no vision assessments completed for the resident. On 2/9/17 at 11:45 am, interview with the Director of Nursing indicated Resident #88 had never complained of vision problems, therefore a vision assessment was not needed. Additional record review on 2/9/17 at 11:55 am, the review of the Nurses Weekly Progress Reports dated 11/7/16,11/14/16,11/21/16,12/5/16,12/19/16.1/16/17, and 1/31/17, all indicated that Resident #88 had adequate ability to see and that there had not been any changes in vision status. On 2/9/17 at 12:00 pm, interview with the Corporate MDS employee verified that there was not a care plan present for vision and that the 12/15/16 MDS was the most accurate, the resident did have vision decline. Observation of Resident #88 on 2/9/17 at 10:45 am, showed resident to be in their room, sitting directly in front of the television. There were no vision assistive devices noted.",2020-09-01
2131,RIDGEWAY MANOR HEALTHCARE CENTER,425158,117 BELLFIELD ROAD,RIDGEWAY,SC,29130,2018-05-24,851,C,1,1,CL5J11,"> Based on limited record review, and interview, the facility failed to submit accurate staff information for Staffing Summary Report to the Centers of Medicare and Medicaid (C[CONDITION]) for 4 of 5 Staffing Summary Reports. The findings included: During the review of the C[CONDITION] Staffing Summary Report on 5/21/18 at 10:31AM revealed the reports dated 1/1/17 through 10/1/17 did not list the working hours for Certified Nurse Aides, Licensed Practical/Vocational Nurse, Administrator, Housekeeping Service Worker, Licensed Practical /Vocational Nurse with Administrative Duties, Registered Nurse, Registered Nurse Director of Nursing. During interview on 5/23/18 at 12:35 PM with Regional Human Resource Consultant confirmed about the discrepancies with the Staffing Summary Report. S/he stated called C[CONDITION] for guidance on the process of payroll journal submission.",2020-09-01
2135,RIDGEWAY MANOR HEALTHCARE CENTER,425158,117 BELLFIELD ROAD,RIDGEWAY,SC,29130,2019-07-10,577,C,0,1,J3O911,"Based on observation and interview, the facility failed to have the most recent state agency survey posted and accessible to residents in 3 of 3 halls observed and 5 of 5 group members interviewed. The findings included: During initial tour of the facility on 7/07/19 at approximately 1:40 PM, the most recent state agency survey was not posted and there was no notice to indicate where the state agency survey could be located. During the state agency group interview on 7/08/19 at approximately 11 AM, five of five group members stated they did not know where the most recent state agency survey was located. An observation on 7/08/19 at approximately 11:42 AM revealed the most recent state agency survey was not posted or accessible to residents. An interview and observation on 7/08/19 at approximately 11:43 AM with the Administrator confirmed the most recent survey was not accessible. The Administrator stated the surveys were posted in a large notebook on the wall near the nurse's station and acknowledged the book was not there. An interview and observation on 7/08/19 at approximately 11:44 AM with Licensed Practical Nurse #3 who provided the survey book stated the book was located in the nurse's station on the counter.",2020-09-01
2142,RIDGEWAY MANOR HEALTHCARE CENTER,425158,117 BELLFIELD ROAD,RIDGEWAY,SC,29130,2019-07-10,732,C,0,1,J3O911,"Based on observation and interview, the facility failed to post nurse staffing information on a daily basis (3 of 3 halls observed). The findings included: During random observation on initial tour on 7/07/19 at approximately 1:58 PM, the most recent posted nurse staffing information that was located on a bulletin board near the nurse's station was dated 7/02/19. An interview and observation on 7/07/19 at approximately 2:02 PM with Licensed Practical Nurse (LPN) #2 confirmed the findings that the most recent nursing staff posting was dated 7/02/19. LPN #2 further stated the bulletin board would be the location to post the most recent staffing information.",2020-09-01
2160,ROCK HILL POST ACUTE CARE CENTER,425159,159 SEDGEWOOD DR,ROCK HILL,SC,29732,2017-05-18,156,C,1,1,MD8L11,"> Based on record review and interview, the facility failed to provide written notices of Medicare non-coverage (Form NOMNC) for two of three sampled residents reviewed and liability notices (SNFABN/CMS or 1 of 5 approved letters) for three of three sampled residents reviewed. The findings included: A review of Generic and Liability Notices was conducted on 5/16/2017 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) on 2/1/17 to Resident #2's family. 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. (2) The facility provided verbal notification of Medicare non-coverage (Form NOMNC) to Resident #10 on 1/26/17. 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) For Resident #18, there was a documented notification of therapy ending on 12/16/17 in Social Service notes, but there were no written notification forms (Generic or liability notices) available for review. During an interview on 5/16/17 at 2:58 PM, the Social Worker stated s/he did not handle liability notices for the facility and that the liability notices were in the admissions packet. A review of the contents of the residents admission packets revealed no liability notices available. The Social Worker was unaware that written notices were required. During an interview on 5/16/2017 at 3:35 PM, the Administrator stated that the business office was responsible for completion of the ABN. During an interview on, the Administrator confirmed that the residents remained in the facility for at least one day under an alternate pay source after coming off Medicare Part A, but had not been issued liability notices as required.",2020-09-01
2222,CARLYLE SENIOR CARE OF FLORENCE,425163,133 WEST CLARKE ROAD,FLORENCE,SC,29501,2018-12-13,732,C,0,1,OLKH11,"Based on observations and interview, the facility failed to ensure staffing was posted on a daily basis with the facility name, census, current date and total number of actual hours worked by licensed and unlicensed nursing staff directly responsible for the resident care per shift on 3 of 3 units. The findings included: Observations made daily from 12/10/2018 through 12/13/2018 revealed the staffing of licensed and unlicensed nursing staff was not posted for each shift as required with the current date, census and the total hours worked by each category, Registered Nurses, Licensed Practical Nurses and the Certified Nursing Assistants. An interview on 12/13/2018 at approximately 11:30 AM with the Director of Nursing confirmed that the daily staffing was not posted and had not been for an extended period of time.",2020-09-01
2252,MAGNOLIA MANOR - ROCK HILL,425165,127 MURRAH DR,ROCK HILL,SC,29732,2017-04-21,167,C,0,1,9IUY11,"Based on observations and interviews, the facility failed to ensure results of the most recent and past three years of survey results were readily available for resident/family and visitor review on 3 of 3 units. The findings included: No survey results or sign where the survey could be located was observed during the initial tour on 4/17/17 at 10:44 AM, on 4/18/17 and 4/19/17 throughout the day, and upon leaving the facility at the end of the day on 4/19/17. On 4/19/17, when asked where the survey results could be located, the receptionist retrieved them from a bookshelf next to her/his desk behind the business office door. During an interview on 4/19/17 at approximately 5:30 PM concerning the survey results, the Administrator stated; The survey results are kept on a bookshelf beside the receptionist's desk. The Administrator verified the survey results from the last 3 years were not accessible and that only the 1 year was available. The Administrator said, They're in my office.",2020-09-01
2270,MAGNOLIA MANOR - ROCK HILL,425165,127 MURRAH DR,ROCK HILL,SC,29732,2017-04-21,356,C,0,1,9IUY11,"Based on record review and interviews, the facility failed to have the daily nurse staffing information posted in a location visible to both residents and visitors for the first 3 days of the survey on three of three nursing units. Inability to access daily nurse staffing information had the potential to affect all residents and visitors who desired to obtain this information. The findings included: During each of the first three days of the survey, observations upon entry to the facility revealed that the daily nurse staffing information was not posted in a location that was visible to both residents and visitors. During an interview with Administrator on 4/19/17 at 12:15 PM, when asked where the daily nurse staffing posting was located, the Administrator stated that it was usually located in a notebook resting on the hand railing on the wall under the bulletin board that displayed current open positions. Administrator then verified during the interview, that there currently was no notebook in that location. At 12:30 PM on 4/19/17, the Staffing Coordinator presented the surveyor with a black notebook that contained the daily nurse staffing information, at which time the surveyor requested that the Staffing Coordinator return the book to where it is typically kept, and the Staffing Coordinator stated that s/he would put it there right now. Approximately 30 minutes later, the surveyor observed that there was no notebook located on or near the hand railing under the bulletin board that displayed current open positions which was verified by the Clinical Nursing Consultant on 4/19/17 at 1:00 PM. During interview with DON and Clinical Nursing Consultant on 4/19/17 at 1:03 PM Director of Nursing (DON) contacted the Staffing Coordinator via telephone and inquired where the notebook containing current daily nurse staffing info (specifically for current date 4/19/17) was located. DON reported to surveyor that the notebook was located on top of the mail box. Observation on 4/19/17 at 1:04 PM revealed that a black note book containing daily nurse staffing information (including current date 4/19/17) was located on top of the inter-facility mailbox which is behind a glass window and wall making it inaccessible to residents and/ or visitors. On 4/19/17 an 1:05 PM the Staffing Coordinator arrived and verified that this is where the book is kept. The DON also verified that the daily nurse staffing information was kept in the black notebook located on top of the inter-facility mailbox on a consistent basis. The Staffing Coordinator and DON were then asked Is today's nurse staffing posted anywhere in the building, or if the black notebook is the only location where this information is kept, both replied no and yes verifying that the daily nurse staffing information is not located anywhere else in the facility and the notebook is only location where the daily nurse staffing is kept. They both further verified that the daily nurse staffing information is not visible to residents or visitors in its current location. On 4/19/17 at 1:10 PM, the DON returned to surveyor and reported that the daily nurse staffing was currently posted and visible. Further stating that the black notebook was indeed kept in the location specified by the administrator until a recent JCAHO visit when the facility was told that they could not keep the notebook resting on the hand railing of the wall at which time it was moved to the area above the inter-facility mailbox. On 4/19/17 at 1:12 PM, observation revealed a plastic sleeve with 4/19/17 daily nurse staffing information posted on wall adjacent to the bulletin board where open positions are posted. The Administrator provided a copy of the policy for the Posting of Licensed and Unlicensed Direct Care Staff on 4/19/17 at 1:45 PM. During an interview on 4/19/17 at 1:58 PM, the Administrator verified that the facility had not been following the policy for Posting of Licensed and Unlicensed Direct Care Staff which states under posting requirements that the data must be posted in a prominent place readily accessible to residents and visitors.",2020-09-01
2281,CARLYLE SENIOR CARE OF FOUNTAIN INN,425168,501 GULLIVER ST,FOUNTAIN INN,SC,29644,2017-01-06,156,C,0,1,YCDH11,"Based on observation and interview, the facility failed to ensure that contact information for state agencies and advocacy groups was posted in a manner that was accessible to residents/resident representatives in 3 of 3 halls in the facility. The findings included: Initial tour of the facility on 1/3/17 at 10:15 AM revealed a posting with names, telephone numbers and other contact information for pertinent state agencies and advocacy groups posted on the 100 hall at the top of the bulletin board in a glass enclosure. The posting was approximately 6 feet above the floor. During an interview on 1/6/17 at 12:05 PM, the Director of Nursing verified that the posting was not accessible to residents or resident representatives in wheel chairs.",2020-09-01
2285,CARLYLE SENIOR CARE OF FOUNTAIN INN,425168,501 GULLIVER ST,FOUNTAIN INN,SC,29644,2017-01-06,278,C,0,1,YCDH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to have an RN (Registered Nurse) coordinate the MDS (Minimal Data Set) assessments or certify their completion as required by Federal Law. The findings included: The facility admitted Resident #77 with [DIAGNOSES REDACTED]. Review of the Admission MDS dated [DATE] at approximately 5:45 PM on 1/5/17 revealed the LPN (Licensed Practical Nurse) MDS Coordinator had electronically signed Section Z that certified the MDS was completed. Review of the RAI manual revealed Federal regulation requires the RN assessment coordinator to sign and thereby certify that the assessment is complete.The RN assessment coordinator is not certifying the accuracy of portions of the assessment that were completed by other health professionals. The MDS Coordinator confirmed that s/he had signed the MDS as the RN Coordinator that coordinated the completion of the MDS assessment but stated that the Director of Nursing co-signed the assessment as the RN Coordinator. During an interview on 1/5/16 at approximately 5:55 PM, the LPN confirmed her/his signature as the RN Coordinator responsible for certifying completion of the assessment. During an interview on 1/6/16, the LPN stated that s/he completed the MDS, submitted it and printed it for the RN to sign. During an interview at 10:55 AM on 01/06/2017, the LPN confirmed s/he was checking Section Z as complete and submitting the assessments. At that time the corporate Director of Clinical Services also confirmed the LPN was signing the MDS as complete when s/he checked the section as complete in the computer and submitting the assessments. The Director also stated that the facility thought the issue was resolved but confirmed that it was still not being done accurately.",2020-09-01
2361,MAGNOLIA MANOR - GREENWOOD,425172,1415 PARKWAY DRIVE,GREENWOOD,SC,29646,2018-12-14,577,C,0,1,MR7I11,"Based on observation and interview, the facility failed to ensure the results of the most recent survey were posted in an area of the facility readily available and accessible to residents and family members without having to ask for assistance to examine the report. In addition, the facility failed to post notice of the availability of the report on 2 of 2 units. The findings included: During the Recertification survey, a group interview was held with 8 residents on 12/12/18 at approximately 3:00 PM. At that time, residents were asked if they knew where the latest State survey inspection report was located. The residents were unable to answer this question and indicated that they were unaware of the location. Observations during the survey indicated the inspection report was located in a holder on the wall beside the receptionist's window in the front lobby. The holder was noted to be above the surveyor's head when standing underneath the holder. Further observation revealed the report was not accessible to residents/visitors in a wheelchair without having to ask for assistance. In addition, observations revealed there was no signage on either of the two nursing units to indicate the location of the survey report. The Administrator confirmed this finding on 12/14/18 at approximately 10:00 AM.",2020-09-01
2371,MAGNOLIA MANOR - GREENWOOD,425172,1415 PARKWAY DRIVE,GREENWOOD,SC,29646,2018-12-14,732,C,0,1,MR7I11,"Based on observations, the facility failed to post nurse staffing information in an area of the facility readily available and accessible to residents and family members on 2 of 2 units. The findings included: Observations during the survey revealed the nurse staffing information was located in a plastic sleeve placed behind a notebook containing the latest survey report. The staffing posting and notebook were located in a holder on the wall beside the receptionist's window in the front lobby. The holder was noted to be above the surveyor's head when standing underneath the holder. Further observations revealed the staffing report was not accessible to residents/visitors in a wheelchair without having to ask for assistance. In addition, observations revealed there was no signage on either of the 2 nursing units to indicate the location of the staffing posting. The Administrator confirmed this finding on 12/14/18 at approximately 10:00 AM.",2020-09-01
2426,MAGNOLIA PLACE - SPARTANBURG,425175,8020 WHITE AVENUE,SPARTANBURG,SC,29303,2018-08-30,732,C,0,1,6D8G11,"Based on record review and interview with staffing coordinator the facility failed to complete staff postings for the several of the past 90 days reviewed. The findings included: Review of 90 days of staff postings on 8/30/18 at approximately 11:27 AM revealed several incomplete postings including blanks in census, number of staff, and number of hours worked. Interview with Staffing Coordinator on 8/30/18 at approximately 11:35 AM confirmed incomplete staff postings, and stated the previous Staffing Coordinator failed to complete postings.",2020-09-01
2439,MEDFORD NURSING CENTER,425176,105 MEDFORD DRIVE,DARLINGTON,SC,29532,2020-02-19,576,C,1,1,7SU311,"> Based on interviews and record reviews, it was determined the facility failed to deliver mail to residents on Saturdays. The Resident Census and Conditions of Residents form, dated 0[DATE], identified [AGE] residents who resided in the facility. The findings included: On 02/18/20 at 1:17 PM, a confidential resident group meeting was attended by eight cognitively alert residents. They were asked if mail was delivered to residents on Saturdays. None of the residents in attendance thought mail delivery was available on Saturdays. On 02/18/20 at 2:03 PM, the Business Office Manager was asked if mail was delivered to residents on Saturdays. She said, No. She stated the mail stayed locked in the mailbox until Monday, and then she would give the mail to the Activities Department staff to deliver to the residents. On 02/18/20 at 3:06 PM, the Administrator stated in October 2019 the delivery of residents' mail on Saturdays was identified as an area which needed improvement. He stated, at that time, charge nurses were provided a key to the mail, so, if a resident was expecting mail on the weekend, the charge nurse could check for it. On 02/18/20 at 3:37 PM, the Activities Director was asked if mail was delivered to residents on Saturdays. She stated, if a resident was expecting mail on Saturday, they could ask the nurse to check the mail. She stated the nurses had the key to the mail. On 02/18/20 at 3:41 PM, the Director of Nursing (DON) was asked if mail was delivered to residents on Saturdays. She stated the charge nurses had a key to access the mail. She stated the key to the mail was provided, so if a resident was expecting mail on the weekend, the charge nurse could check for it. She was asked if residents were aware charge nurses had access to the mail on Saturdays. She reviewed the resident council meetings minutes since October 2019, as well as information provided to residents in the admission packet and concluded residents had not been informed mail was available to them on Saturdays. She stated the charge nurses had the capability to check and deliver mail on Saturdays, but there was no documentation they had done so. She said, I cannot prove they (charge nurses) check and deliver the mail every Saturday as there is no documentation.",2020-09-01
2483,MAGNOLIA MANOR - COLUMBIA,425287,1007 N KING ST,COLUMBIA,SC,29223,2018-02-09,582,C,0,1,HZ3N11,"Based on record review and interview, the facility failed to provide the appropriate notice, form or one (1) of five generic letters to two (2) residents of three (3) reviewed for Liability notices. The findings included: During an interview on 02/06/2018 at approximately 2:44 PM , the Social Services Director confirmed that Resident # 184 and # 4 were not provide with the . The Social Service Director stated, We were unaware that the or one of the approved generic letters were requirements until the Consultant who just told us about this form and we will be doing this from here on out.",2020-09-01
2553,HEARTLAND HEALTH AND REHABILITATION CARE CENTER-HA,425289,1800 EAGLE LANDING BLVD,HANAHAN,SC,29406,2018-04-14,585,C,0,1,N9KR11,"Based on observation, interview and record review the facility failed to ensure that the Grievance Policy and Procedure which is posted shows evidence of when to expect a timely response to grievances in 1 of 1 facility for Grievance Posting. The findings included: During the Resident Council meeting held on 4/10/2018 at 2:00 PM of which 14 residents were in attendance, 4 of the 14 residents present responded, No to the Question #8 which states: Do you know how to file a grievance? On 04/13/18 at 03:17 PM during an interview with the Administrator he/she states s/he had an ad hoc meeting with the resident council and reviewed the grievance process. The facility form titled, Concerns is displayed with a copy of the : HCR Manor Care, Concern Form. The form does not show or state when a response to a grievance can be expected.",2020-09-01
2583,HEARTLAND HEALTH AND REHABILITATION CARE CENTER-HA,425289,1800 EAGLE LANDING BLVD,HANAHAN,SC,29406,2019-06-20,732,C,0,1,Y2LK11,"Based on review of facility files and interview, the facility failed to post nurse staffing information that included all of the required information. The total number of hours worked by various categories of licensed and unlicensed nursing staff was not included on the postings. The findings included: A review of the staff postings for the past 90 days on 6/20/19 revealed the form entitled Nursing Hours included columns entitled Total Number of Staff, Total Scheduled Hours, Actual Hours Worked, and Resident Census in House. The form included this information for the Day Shift, PM Shift, and Night Shift. Further review of the form revealed the column entitled Actual Hours Worked was blank for all of the postings for the past 90 days and the current posting. On 6/20/19 at approximately 3:08 PM, the Director of Nursing reviewed the forms and confirmed this finding at that time.",2020-09-01
2602,WESTMINSTER HEALTH & REHAB CENTER,425291,831 MCDOW DRIVE,ROCK HILL,SC,29732,2017-11-15,167,C,0,1,G4YM11,"Based on observations during the survey, the facility failed to post the results of the most recent and preceding three years' surveys in a place readily available to residents and family members without having to ask on 1 of 1 unit. The findings included: Observations during the survey from 11/13/17 to 11/15/17 revealed a notebook labeled Survey Results was located sitting on the top of a credenza at the side of the receptionist's window in the main lobby. Observation further revealed that the notebook was located at a height above the head of the surveyor and would be inaccessible to any residents in a wheelchair. Observation of the notebook on 11/15/17 at approximately 9:30 AM revealed the (YEAR) survey was the only survey posted in the notebook. There was no signage located near the notebook nor posted on the bulletin board in the hallway on the unit to indicate that the 3 preceding years' surveys were available for review upon request. On 11/15/17 at approximately 2:30 PM, the Administrator confirmed the surveyor's findings.",2020-09-01
2603,WESTMINSTER HEALTH & REHAB CENTER,425291,831 MCDOW DRIVE,ROCK HILL,SC,29732,2017-11-15,280,C,0,1,G4YM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to have a care plan conference for one newly admitted resident ( resident #79) one of one newly admitted resident reviewed and the facility failed to have a care plan conference with all disciplines present for one of one resident reviewed for care plan conferences (Resident #41). The findings included: The facility admitted Resident #41 with [DIAGNOSES REDACTED]. Review of the medical record revealed the Care Plan Conference Attendance form dated 8/9/17 included space for signatures of staff attending the care plan meeting. Further review of the form revealed no signature to indicate that dietary staff or Certified Nurses Aide (CNA) staff participated in the Interdisciplinary Team that developed the care plan. During an interview on 11/15/17 at approximately 10:30 AM, the Social Services Director reviewed the form and confirmed the findings at that time. The facility admitted Resident #79 with [DIAGNOSES REDACTED]. On 11/15/17 at 10:10 AM, a review of Resident #79's medical record revealed that the resident was admitted to the facility on [DATE]. Further review of Resident #79's care plan revealed the facility had not had an interdisciplinary care plan meeting to assess or reassess the resident's needs since admission (27 Days). On 11/15/17 at 10:30 AM, an interview with the Director of Social Services, s/he verified Resident #79 had not had an interdisciplinary care plan meeting to assess or reassess the resident's needs since admission (27 days).",2020-09-01
2604,WESTMINSTER HEALTH & REHAB CENTER,425291,831 MCDOW DRIVE,ROCK HILL,SC,29732,2017-11-15,287,C,0,1,G4YM11,"Based on record review and interview, the facility failed to submit a Minimum Data Set (MDS) OBRA assessment in a timely manner for 10 of 11 discharged residents reviewed for MDS transmission of records. (Residents #89, #54, #50, #7, #90, #91, #92, #55, #93, and #43) In addition, the facility failed to submit a complete and timely MDS assessment for 1 current resident reviewed for MDS transmission of records. (Resident #34). The findings included: Review of the facility's MDS 3.0 Missing OBRA Assessment report revealed 10 discharged residents (Resident's #89, #54, #50, #7, #90, #91, #92, #55, #93, and #43) and 1 current resident (Resident #34) were listed on the report. On 11/14/17 the surveyor asked the Assistant Director of Nursing (ADON) / MDS Coordinator to review the report and to determine why the assessments were reported as missing. During an interview on 11/15/17 at approximately 2:30 PM, the ADON/MDS Coordinator stated that he/she had been the MDS Coordinator for a short period of time. At that time, the ADON/MDS Coordinator stated that he/she was still working on the report. No further information was provided related to the missing MDS assessments prior to exit from the facility.",2020-09-01
2605,WESTMINSTER HEALTH & REHAB CENTER,425291,831 MCDOW DRIVE,ROCK HILL,SC,29732,2017-11-15,356,C,0,1,G4YM11,"Based on observations, the facility failed to post complete nurse staffing information on a daily basis as required on 1 of 1 unit observed. The findings included: Observations during the survey on 11/13/17-11/15/17 revealed a Daily Staffing form was posted on the bulletin board located inside the Nurses' Station. Observations also revealed a Daily Staffing form was posted on the bulletin board in the hallway leading to the unit. Further observations revealed the form did not list the total number and actual hours worked for Registered Nurses, Licensed Practical Nurses, and Certified Nurse Aides. The form also did not include the resident census for each shift. The staffing information and resident census was not posted at the beginning of each shift. On 11/15/17 at approximately 2:30 PM, the Administrator reviewed the information and confirmed the findings at that time.",2020-09-01
2682,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2018-09-07,732,C,1,0,4EIF11,"> Based on review of 18 months of Daily Nursing Staff Postings and interview, the facility failed to completed the posting with census changes on each shift. 18 months of 18 months reviewed for Daily Nursing Staff Postings. The findings included: 18 months of 18 months of Daily Postings had the census recorded only at the beginning of the day. The facility had nursing staffing shifts of 7AM to 7PM, 7PM to 7AM, 3PM to 11PM and 11PM to 7AM shifts. During review with the Director of Nursing on 9/7/18, s/he confirmed census was not included after the morning shift.",2020-09-01
2694,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2019-09-19,732,C,0,1,TX1R11,"Based on observation and interview, the facility failed to follow Nurse Staffing Posting requirements. On all days of the survey, the resident census was not documented on the posting. In addition, all three shifts were completed at the beginning of the day. The findings included: On all days of the survey, the resident census was not documented on the posting. In addition, all staffing was documented at the beginning of the day instead of at the beginning of each shift. During an interview with the Director of Nursing on 9/19/19 at 5:00 PM, s/he confirmed there was no census documented and the form was completed for all shifts with nursing/certified nursing assistant information.",2020-09-01
2761,LAKE MARION NURSING FACILITY,425300,1527 URBANA ROAD,SUMMERTON,SC,29148,2018-08-16,550,C,1,1,ED9211,"> Based on observations review of the facility policy titled, Quality of Life - Dignity, the facility failed to care for residents in a manner that promotes and or enhances each residents quality of life, respect and dignity on the Carolina Hall during the lunch meal delivery for 1 of 2 meal observations. The findings included: Observations on 8/13/2018 at approximately 12:25 PM, during the lunch meal service, on the Carolina Hall revealed multiple staff yelling, knock, knock, and entering rooms without waiting on permission to enter. Review on 8/14/2018 at approximately 2:40 PM of the facility policy titled, Quality of Life - Dignity, states, Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Policy Interpretation and Implementation states, 1. Residents shall be treated with dignity and respect at all times. 2. Treated with dignity, means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. 6. Residents private space and property shall be respected at all times. a. Staff will knock and request permission before entering residents rooms.",2020-09-01
2886,RIVER FALLS REHABILITATION AND HEALTHCARE CENTER,425307,2906 GREER HWY,MARIETTA,SC,29661,2020-01-01,730,C,1,0,25FT11,"> Based on record review and staff interview, the facility failed to ensure that two Certified Nursing Assistants ((CNA) #13, and CNA#25) out of a sample of five, were provided routine annual evaluations. Failure to complete the annual evaluations which addressed measures of performance as a CNA and identified areas of needed improvement could affect provision of training for the staff member and the quality care for residents. Findings include: 1. Review of CNA#13's paper personnel file, revealed the staff member was hired on 10/01/12. Review of a document titled, Performance Evaluation, for CNA#13, revealed the staff member's last annual performance review was on 09/27/16. The staff member went to an as needed (PRN) position on 03/29/17. 2. Review of CNA#25's paper personnel file, revealed the staff member was hired on 04/27/16. Review of a document titled, Performance Evaluation, for CNA#25, revealed the staff member's last annual performance review was on 10/01/17. The staff member went to a PRN position on 09/22/19. During an interview on 12/31/19 at 2:41 PM, the Administrator stated the direct supervisor of the CNAs' would complete the annual performance review. It was during this interview the Administrator was asked for the CNAs' telephone numbers and these telephone numbers were not provided. During an interview on 12/31/19 at 2:50 PM, the Assistant Director of Nursing (ADON) stated he/she did not do the annual reviews for the CNAs and neither did the Director of Nursing (DON). During an interview on 12/31/19 at 2:50 PM, Registered Nurse (RN#4) stated he/she did not perform annual CNA reviews, but did state he/she did supervise the CNAs while on the floor. During an interview on 12/31/19 at 3:00 PM, Licensed Practical Nurse (LPN#9) stated he/she did not conduct the annual CNA reviews. During an interview on 12/31/19 at 3:45 PM, the DON stated he/she did not complete PRN CNA annual reviews. The DON stated she determines competency while she was out on the floor working with staff. At 3:58 PM, the Administrator and the Business Office Manager (BOM) entered the conference room. The BOM stated the two CNAs were considered employees of the facility. The BOM stated he/she was not sure why the PRN CNAs were not passed onto the DON for completion of the annual reviews and went on to state it has always been this way.",2020-09-01
2887,RIVER FALLS REHABILITATION AND HEALTHCARE CENTER,425307,2906 GREER HWY,MARIETTA,SC,29661,2020-01-01,947,C,1,0,25FT11,"> Based on interviews and record review, the facility failed to ensure that two Certified Nursing Assistants ((CNA)s #20 and CNA#13), out of five sampled, were in-serviced annually on dementia care, abuse prohibition, and additional training which would ensure CNA staff were competent to perform their duties within a nursing home. This failure placed 40 residents at risk for improper care and services. Findings include: 1. Review of CNA#20's personnel file, provided by the facility, revealed the staff member was hired on 06/13/06. Review of the staff member's personnel file, CNA#20 went to as needed (PRN) status on 03/01/16. CNA#20 had no evidence of participating in annual in-services since 2016. There was no evidence of dementia care, abuse prohibition, or any additional training for CNA#20 since 2016 provided by the facility or any other entity. 2. Review of CNA#13's personnel file, provided by the facility, revealed the staff member was hired on 10/01/13. Review of the staff member's personnel file, CNA13 went to PRN status on 03/29/17. CNA#13 had no evidence of participating in annual in-services since 2016. There was no evidence of dementia care, abuse prohibition, or any additional training for CNA#13 since 2016 provided by the facility or any other entity. Review of facility training packet titled, Employee Education Hours, with a hand written date of 09/25/19 identified the following training was to be provided by the Director of Nursing (DON) to CNAs on an annual basis: . Abuse, Neglect, Exploitation.Injury of unknown source.Reporting Suspected or confirmed abuse.Fall Prevention.Turning/Repositioning.Catheter Care Male/Female.Behaviors. After these training objectives, was a document titled, Written Competency Behavior Assessment and Intervention. There were 10 multiple choice questions which were to be taken by the CNAs to ensure their understanding of the material in-serviced on. Also included in this training packet, were documents for return demonstration for hand washing, a full body lift, perineal care for both male and female residents, and catheter care for both male and female residents. During an interview on 01/01/2020 at 9:22 AM, the Administrator presented documents to show evidence of CNA training. During this interview, the Administrator confirmed both CNA#20 and CNA#13 had no annual in-services since 2016. The Administrator stated it was her belief the PRN CNAs received training from other facilities, in which they worked full-time. A request was made for policies on CNA training. The facility did not provide these documents prior to the end of the investigation. During a subsequent interview on 01/01/2020 at 10:46 AM, with the Administrator, he/she once again stated the CNAs received training from other facilities. Also present during this interview was the Clinical Services Consultant (CSC). CSC stated the PRN CNAs needed to bring in proof of their training on dementia care, abuse prevention, and any other competencies they have received. CSC stated in-service training was provided at their facility every six months, upon hire, and as needed. During an interview on 01/01/2020 at 11:09 AM, with the DON, the DON stated he/she attempted to reach the PRN CNAs by telephone and was unsuccessful. The DON stated the facility needed to put a plan in place to train the PRN CNAs and make this a higher priority for the facility.",2020-09-01
2912,THE PLACE AT PEPPER HILL,425308,3525 AUGUSTUS ROAD,AIKEN,SC,29801,2018-10-31,577,C,0,1,L2PV11,"Based on interviews and observations, the facility failed to ensure that the State Agency survey book was accessible on two days of the survey for three of three units and the main lobby. The State agency survey book was blocked from view and access by a large sign in the main lobby. The findings included: On 10/29/18 at approximately 10:30 AM a large sign was noted in the main lobby that indicated Attention: if you have a fever, cough, or sore throat or any flu symptoms, please do not visit our facility. There was nothing in view of anything behind the large sign. During the State Agency group interview on 10/30/18 at approximately 3:30 PM 5 of 5 interview-able residents stated they were not aware of the location of the the State Agency survey book without having to ask. An observation on 10/30/18 at approximately 11:06 AM of a glass case near the front office and front lobby revealed a small sign high up in the glass case that indicated the dhec (State Agency) survey book was posted in the front lobby. The survey book was located with some difficulty behind the large sign posted in the main lobby related to not visiting the facility if you have any flu symptoms. Accessible to the State Agency survey was only available by moving the large sign. An interview and observation with the facility Administrator confirmed the findings that the State Agency survey book was not accessible. The Administrator then removed the large sign that was blocking the survey book.",2020-09-01
2981,BLUE RIDGE OF SUMTER,425310,1761 PINEWOOD ROAD,SUMTER,SC,29154,2017-12-15,851,C,0,1,DK0Z11,"Based on record review and interview, the facility failed to electronically submit complete data into the Payroll Based Journal. The findings included: Review of the Payroll Based Journal revealed the facility did not have data for the reporting periods of 10/01/2016 through 12/31/2016 and 01/01/2017 through 03/31/2017. During an interview on 12/11/2017 at approximately 12:00 PM, the Administrator verified that the Payroll Based Journals were not submitted for the 2 missing quarters.",2020-09-01
3018,MUSC HEALTH MULLINS NURSING HOME,425312,518 S MAIN STREET,MULLINS,SC,29574,2019-03-07,732,C,0,1,HTTO11,"Based on record review and interview, the facility failed to ensure the daily staff posting included a Registered Nurse daily for seven days a week with total hours for 30 days of posted staffing reviewed. The findings included: Review on 3/7/2019 at approximately 9:17 AM of 30 days of daily staff posting from 2/1/2019 through 3/3/2019 revealed no Registered Nurse posted for eight hours each day on the daily staffing on Hall 2, Jasmine Lane, for 2/2/2019, 2/3/2019, 2/4/2019, 2/6/2019, 2/7/2019, 2/8/2019, 2/11/2019, 2/14/2019, 2/16/2019, 2/19/2019, 2/22/2019, 2/23/2019, 2/25/2019, 2/26/2019, 2/28/2019, and 3/2/2019. Further review on 3/7/2019 at approximately 9:17 AM of 30 days of daily staff posting from 2/1/2019 through 3/3/2019 revealed no Registered Nurse posted for 8 hours each day on the the daily staffing that was posted on Hall 3, Magnolia Hall, for 2/12/2019 and 2/25/2019. An interview on 3/7/2019 at approximately 9:40 AM with the Director of Nursing (DON) confirmed a Registered Nurse with hours was not included on the daily staffing posted for the above mentioned days. The DON went on to say that he/she did not know why the Registered Nurse was not included on the daily staff postings.",2020-09-01
3044,SOUTHERN OAKS REHABILITATION AND HEALTHCARE CENTER,425314,109 BENTZ ROAD,PIEDMONT,SC,29673,2019-02-08,732,C,1,1,XZ1O11,"> Based on record review and interview, the facility failed to ensure the daily staffing posted was accurate for sufficient and competent staffing reviewed. The facility further failed to ensure staff postings were available prior to (MONTH) 1 (YEAR) for review during an extended survey. The findings included: Review on 2/7/2018 at approximately 9:40 AM of 30 days of daily staffing posted from 1/6/2019 through 2/4/2019 revealed on 1/13/2019, 1/14/2019, 1/15/2019, 2/1/2019, 2/2/2019, 2/3/2019 and 2/4/2019 only 3 Certified Nursing Assistants, (CNA's) were listed on the daily staffing sheets for 77, 80 and 79 residents indicating that each CNA cared for 26 and 27 residents during the 11 PM to 7 AM shift. During an interview on 2/7/2019 at approximately 10:00 PM with the DON, he/she stated that one of the posted Licensed Practical Nurses (LPN) would do patient/resident care and function as a CNA on that particular shift. The posting did not reflect that the LPN would do patient/resident care. On 02/07/19 at 4:06 PM, during an extended survey, the surveyor requested 18 months of staff postings. The facility provided staff postings from 11/01/18 through 02/05/19 instead of the 18 months as requested and required. During an interview on 02/07/19t 04:22 PM, the Corporate Senior Administrator stated that the facility didn't have the postings. He/she further stated that the facility started the staff posting 3 months ago. He/she then clarified that statement saying that s/he won't say they didn't do them but they haven't been able to locate them.",2020-09-01
3148,IVA REHABILITATION AND HEALTHCARE CENTER,425317,406 WEST BROAD STREET,IVA,SC,29655,2017-07-02,356,C,1,0,U47811,> Based on observation and interviews the facility failed to post staffing hours for the facility in a public place for viewing on the day of the survey. The findings included: An observation on 7/02/17 at approximately 2 PM revealed staff posting dated 6/30/17 was located on bulletin board in hallway near the administrator's office. An interview on 7/02/17 at approximately 2:10 PM with Minimum Data Set (MDS) Coordinator confirmed the findings that the staff posting noted on the hallway was dated 6/30/17. The MDS Coordinator further stated as far as he/she knows that's the only place where the posting would be noted. An interview on 7/02/17 at approximately 2:15 PM with Licensed Practical Nurse #1 confirmed the only place staff posting would be located was in the hallway near the administrative offices. An interview on 7/02/17 at approximately 3:52 PM with the Director of Nursing confirmed the staff posting had not been updated and noted on the bulletin board since 6/30/17.,2020-09-01
3199,L.M.C.- EXTENDED CARE,425321,815 OLD CHEROKEE ROAD,LEXINGTON,SC,29072,2019-12-04,732,C,1,1,GRSS11,"> Based on observation, interview, and record review, the facility failed to post staffing hours worked per shift for 3 of 3 months reviewed. The findings included: Observation of postings in Maxie and Cherokee units on [DATE] at approximately 11:18 AM revealed the census and staff numbers were posted, but not the actual hours worked by staff per shift. Review of previous 90 days of staff postings on [DATE] at approximately 12:45 PM confirmed the staff postings did not list the actual hours worked by staff per shift. Interview with the Assistant Director of Nursing (ADON) on [DATE] at approximately 12:55 PM confirmed staff postings were not calculating the cumulative hours correctly. The ADON stated it was a glitch in the program s/he had not been notified of.",2020-09-01
3229,THE PRESTON HEALTH CENTER,425325,87 BIRD SONG WAY,HILTON HEAD ISLAND,SC,29926,2018-10-18,577,C,0,1,2VYN11,"Based on record review and interviews, the facility failed to ensure residents were informed of their right to view the most recent survey results of the facility and any plan of correction by the facility, based on those results, and their whereabouts in the facility as revealed by 7 of 7 residents in 1 of 1 resident council meetings. The findings included: Interviews on 10/16/2018 at approximately 11:15 AM, during a resident council meeting, 7 of 7 residents in attendance confirmed they were not aware of their right to view the most recent survey results and the facility's plan of correction based on those results and the whereabouts of the results in the facility. Review on 10/16/2018 at approximately 2:40 PM of the Resident Council Minutes for (MONTH) (YEAR), June, July, (MONTH) and (MONTH) (YEAR) made no mention of the resident's right to view the current survey results and their whereabouts in the facility. During an interview on 10/17/2018 at approximately 3:45 PM with the Admissions Coordinator, he/she stated, the residents are informed of their rights during the move in process, and during the resident council meetings. No documentation could be found to ensure residents were informed of their right to view the survey results or their whereabouts in the facility.",2020-09-01
3250,HALLMARK HEALTHCARE CENTER,425326,255 MIDLAND PARKWAY,SUMMERVILLE,SC,29485,2017-08-18,156,C,0,1,SBYG11,"Based on record review and interviews the facility failed to provide the required notice of pending expiration of Medicare Part A eligibility and/or to provide one of the five approved follow-up notices to Residents #7, 12, 67 and 145. The Center for Medicare and Medicaid Services (CMS) Notice of Medicare Non-Coverage (CMS -NOMNC) was not provided or not provided timely and the Skilled Nursing Facility Advanced Beneficiary Notice (CMA ), or other approved follow up notice was not sent to 4 of 4 residents reviewed for Liability Notices. The findings include: Record review on 08/17/17 at 5:00 PM revealed that the facility provided less than the required two-day notice to Resident #67 for the Notice of Medicare Non-Coverage. Further review of the file revealed that Resident #67's benefit period was due to end on 05/23/17. The notice provided by the facility was dated 05/23/17. No CMS 1055 or other approved follow-up notices were provided to Residents #67 and 145. Neither CMS nor CMS or other approved follow-up notice could be located for Resident's #7 and #12. In an interview on 08/17/17 at 5:00 PM, the Business Manager stated she recently took over doing the notices and could not locate any other documentation of notices being sent.",2020-09-01
3274,HALLMARK HEALTHCARE CENTER,425326,255 MIDLAND PARKWAY,SUMMERVILLE,SC,29485,2018-11-02,640,C,0,1,2Q7611,"Based on record review and interview, the facility failed to transmit required assessments in a timely manner or failed to transmit 3 of 3 reviewed for Transmission. The findings included: In an interview on 11/02/18 at approximately 2:46 PM the Minimum Data Set (MDS) Coordinator confirmed that the three Resident Assessments listed on the Casper 3 report were not transmitted, incorrect or not transmitted timely.",2020-09-01
3280,HALLMARK HEALTHCARE CENTER,425326,255 MIDLAND PARKWAY,SUMMERVILLE,SC,29485,2018-11-02,732,C,0,1,2Q7611,"Based on record review and observation, the facility failed to post accurate nurse staffing data on a daily basis for 7 of 30 days reviewed. The findings included: Record review of the nurse staffing data for the month of (MONTH) (YEAR) and (MONTH) (YEAR) revealed inaccurate information related to the number of Certified Nursing Assistants for the following dates: 9/29/18-Daily Staff Posting- 6 CNA's 7-3 and 9 CNA's 3-11; Punch cards reflect 8 CNA's for the 7-3 and 3-11 shift; 10/6/18-Daily Staff Posting-8 CNA's 7-3 and 6 CNA's 3-11; Punch cards reflect 7 CNA's for the 7-3 and 3-11 shift; 10/7/18-Daily Staff Posting-10 CNA's 7-3; Punch cards reflect 8 CNA's for the 7-3 shift; 10/13/18-Daily Staff Posting-8 CNA's 7-3; Punch cards reflect 7 CNA's for the 7-3 shift: 10/14/18-Daily Staff Posting-8 CNA's 7-3; Punch cards reflect 8 CNA's with one CNA leaving at 9:20 AM; 10/19/18-Daily Staff Posting-8 CNA's 7-3; Punch cards reflect 9 CNA's with one of the 9 not entering building until 11:44 AM; 10/28/18-Daily Staff Posting-9 CNA's for 7-3 and 5 CNA's for 3-11: Punch cards reflect 7 CNA's for 7-3 and 6 CNA's for 3-11. On 11/2/18 during an interview, the Administrator and Director of Nursing were aware of the discrepancies between the Daily Nursing Posting and the actual hours worked.",2020-09-01
3372,LAKE MOULTRIE NURSING HOME,425341,1038 MCGILL LANE,SAINT STEPHEN,SC,29479,2017-05-25,167,C,0,1,2XR111,"Based on record review, observation and interview the facility failed to post the results of the most recent survey in a manner which allowed the public to review without asking for them. The findings included: Attempts to locate the results of the most recent survey during the four days of the survey by all surveyors were unsuccessful. The survey could not be located in any of the public areas of the facility. Record review on 05/25/17 at 11:03 AM revealed that the admission packet contained no information as to the location of the most recent survey results. Further review of Resident Council minutes from (MONTH) through (MONTH) (YEAR) revealed no discussion of where the survey results could be found. In an interview on 05/25/17 at 10:13 AM when asked to assist in locating the most recent survey results, the Administrator stated they were in the drawer of the table that held the sign in book. The Administrator pointed out a sign on the table which stated, Survey results for the last 3 years are available upon request. The Administrator confirmed the public would have to ask staff to be able to know the results were in the drawer and stated the location would be added to the sign.",2020-09-01
3464,HEARTLAND OF WEST ASHLEY REHAB AND NURSING CENTER,425362,1137 SAM RITTENBURG BLVD,CHARLESTON,SC,29407,2019-01-24,732,C,1,1,MJMF11,"> Based on observation, record review, and interview, the facility failed to ensure the daily staffing posted included the correct staff that worked, the actual hours, and the census each day for 30 of 30 days of nursing staffing reviewed. The findings included: An observation on 1/22/2019 at approximately 9:20 AM of the daily staffing posted at facility entrance and on the units revealed names of nurses, RN's (Registered Nurses), LPN's (Licensed Practical Nurses) and CNA's (Certified Nursing Assistants) with names of staff from these categories that did not work at all, incorrect hours worked for each category, and no census. Review on 1/22/2019 at approximately 11:10 AM of 30 days of the staffing posted which included 12/19/2018 through 1/19/2019 revealed incorrect information on each of the 30 days reviewed. An interview on 1/22/2019 at approximately 11:15 AM with the Director of Nursing confirmed incorrect information posted daily that did not include the categories of staff worked each day, the hours for each category, and the census for each day.",2020-09-01
3488,HEARTLAND OF WEST ASHLEY REHAB AND NURSING CENTER,425362,1137 SAM RITTENBURG BLVD,CHARLESTON,SC,29407,2016-09-29,356,C,0,1,44XA11,"Based on record review and interviews, the facility failed to update posted daily staffing information for each shift as required. Postings available for review failed to include the actual number of hours worked by Registered Nurses (RNs), Licensed Practical Nurses (LPNs) and Certified Nursing Assistants (CNAs) directly responsible for resident care. Lack of updating posted staffing information on a daily basis had the potential to affect all residents and visitors who desired to obtain this information. The findings included: During each of the first three days of the survey, the posted daily nursing hours form was reviewed upon entry to the facility. On 3 of 3 days, the actual work hours for day shift were calculated and posted at the beginning of the shift. On 9/28/16 at 4:47 PM, review of 6 months of daily posted staffing hours revealed that the actual work hours were calculated and printed only for the day shift with no handwritten entries or edits on any of the documentation. The Director of Nursing, Administrator and Staffing Coordinator verified the following information: (1) Daily Nursing Hours Postings for the dates of 4/1/16-9/28/16 had no handwritten edits or entries present. (2) Daily Nursing Hours Postings for the dates of 4/1/16-9/28/16 had actual hours worked column completed for only day shift. (3) Daily Nursing Hours Postings for the dates of 9/26/16-9/28/16 had the day shift actual hours completed at the beginning of the day shift. During the interview, the Administrator and Staffing Coordinator both reported that when a staff member did not work a scheduled shift, that person was always replaced by another staff member of the same level (CNA replaces CNA; RN replaces RN; LPN replaces LPN).",2020-09-01
3495,HEARTLAND OF WEST ASHLEY REHAB AND NURSING CENTER,425362,1137 SAM RITTENBURG BLVD,CHARLESTON,SC,29407,2017-12-15,575,C,0,1,MFFV11,Based on observation and interview the facility failed to display required postings in a manner accessible and understandable by residents and resident representatives for 1 of 2 Postings reviewed. The findings included: On 12/13/17 at 1:55 PM residents stated during the group meeting that they did not know where the information to file a complaint was located. Following the group meeting the Resident Council President was able to point out the posting but stated that the postings on the upstairs board were hard to read due to the height at which they were posted and because the board was smaller than the one downstairs. On 12/13/17 at 2:39 PM during an observation the Administrator measured the height of the complaint information and determined it to be 61 inches from the floor. The Administrator agreed it would be difficult to read while sitting in a wheelchair and stated the height of the placement was due to the number of items that must be posted. On 12/13/17 at approximately 3:00 PM this surveyor located information from the Americans with Disabilities Act stating that eye level height for persons in wheelchairs is 43-51 inches from the floor.,2020-09-01
3497,HEARTLAND OF WEST ASHLEY REHAB AND NURSING CENTER,425362,1137 SAM RITTENBURG BLVD,CHARLESTON,SC,29407,2017-12-15,623,C,0,1,MFFV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure a copy of the transfer notice of a hospital stay for Resident #28 and #227 was sent to a representative of the Office of the State Long - Term Care Ombudsman in a timely manner for 2 of 2 residents reviewed with hospitalization s. The findings included: The facility admitted Resident #227 with [DIAGNOSES REDACTED]. Review on 12/12/2017 at approximately 3:54 PM of the medical record for Resident # 227 revealed a MDS (Minimum Data Set) assessment dated [DATE] in which Resident #227 was discharged to an acute care facility and later returned to the Nursing and Rehab Center on 11/27/2017. No documentation could be found in the medical record for Resident #227 to ensure a copy of the transfer notice of the hospital stay was sent to a representative of the Office of the State Long-Term Care Ombudsman. The facility admitted Resident #28 with [DIAGNOSES REDACTED]. Resident #28 also has a history of a [MEDICAL CONDITION] and Urinary Tract Infections. Review on 12/13/2017 at approximately 8:23 AM of the medical record for Resident #28 revealed a MDS assessment dated [DATE] in which Resident #28 was discharged to an acute care facility and returned to the Nursing and Rehab Center on 9/20/2017. Further review of the MDS assessments revealed a discharge to an acute care facility on 10/12/2017 and a return to the nursing facility on 10/21/2017 and a discharge to an acute care facility on 11/24/2017 and a return to the nursing facility on 11/27/2017. No documentation could be found in the medical record for Resident #28 to ensure a copy of the transfer notices of the hospital stays were sent to a representative of the Office of the State Long-Term Care Ombudsman. During an interview on 12/14/2017 at approximately 4:00 PM with the DON (Director of Nursing) he/she stated, I do not know who is responsible for letting the Ombudsman office be aware of the discharges to acute care facilities. The DON then directed this surveyor to the Administrator's office. During an interview on 12/14/2017 at approximately 4:05 PM with the Administrator, he/she stated, no one lets the Ombudsman office know that residents are discharged to an acute care facility. He/she went on to say that he/she was not aware that the Ombudsman was to be notified of discharges to acute care facilities.",2020-09-01
3558,"COUNTRYWOOD NURSING CENTER, LLC",425370,1645 RIDGE ROAD,HOPKINS,SC,29061,2017-08-02,156,C,0,1,LF7U11,"Based on observations and interviews, the facility failed to to provide Skilled Nursing Facility Advance Beneficiary Notices (SNF ABN) forms for 3 of 3 sampled residents reviewed for liability notices. (Residents #8, #23 and #26). The findings included: A review of the facility's liability notices process revealed the facility did not provide SNF ABN forms CMS to residents that have additional medicare days left when they are discharged for therapy. - An interview on 8/01/17 at approximately 2:45 PM with the Business Office Manager and Social Services Director revealed the facility only provide the Notice of Medicare Non-Coverage for CMS and not the required CMS form.",2020-09-01
3588,BETHEA BAPTIST HEALTHCARE CENTER,425372,157 HOME AVENUE,DARLINGTON,SC,29532,2017-12-09,575,C,0,1,1IQX11,"Based on observation and interview, the facility failed to post contact information for State and local advocacy organizations and information on filing a complaint with the State Agency in a manner accessible to residents on two of two resident units reviewed. The findings included: During the Resident Council group meeting on 12/6/17 at 2:28 PM, 9 of 9 residents stated that they were unaware that they had the right to file a formal complaint with the State Agency. When asked if they were aware of the location of the contact information for the ombudsman, 9 of 9 residents were unaware of what an ombudsman was and stated that this had never been discussed. Following the meeting, observation of the bulletin board just inside the skilled nursing entrance revealed that contact information was on an 8.5 x 11 inch paper in regular type/font size, posted at approximately 6 feet above the floor. During an interview on 12/6/17 at 4:00 PM, the Director of Social Services (DSS) confirmed that contact information for the State Agency and State/Local Advocacy Agency was posted in an area too high for residents, especially those in wheelchairs, to access.",2020-09-01
3591,BETHEA BAPTIST HEALTHCARE CENTER,425372,157 HOME AVENUE,DARLINGTON,SC,29532,2017-12-09,582,C,0,1,1IQX11,"Based on interview and record review, the facility failed to provide timely notification of Medicare non-coverage for three of three sampled residents reviewed for liability notices. The findings included: Record review on 12/5/17 at 11:52 AM revealed that 3 of 3 residents screened for beneficiary protection notification were not notified in a timely manner of Medicare non-coverage. According to Instructions for the Notice of Medicare Non-Coverage, The NOMNC (Notice of Medicare Non-Coverage) must be delivered at least two calendar days before Medicare covered services end or the second to last day of service if care is not being provided daily. Resident #478's last covered day of Part A service was 7/27/17 and s/he received the notice on 7/28/17. Resident #479's last covered day of Part A service was 11/9/17 and s/he received the notice on 11/10/17. Resident #480's last covered day of Part A service was 7/6/17 and s/he signed the notice on 7/7/17. During an interview on 12/05/17 at 12:02 PM, Registered Nurse #3 confirmed that notices were not distributed at least 2 calendar days before the end of coverage.",2020-09-01
3613,BETHEA BAPTIST HEALTHCARE CENTER,425372,157 HOME AVENUE,DARLINGTON,SC,29532,2017-12-09,851,C,0,1,1IQX11,"Based on record review and interview, the facility failed to submit staffing information based on payroll data in the timely manner as required by the Centers for Medicare and Medicaid services. The findings included: Review of the CASPER Report 1702S revealed the following: Staffing Summary Report 10/1/16-12/31/16 submitted 3/31/17; Staffing Summary Report 1/1/17-3/31/17 submitted 5/23/17; Staffing Summary Report 4/1/17-6/30/17 submitted 8/15/17. During an interview with staff responsible for the Payroll Based Journal on 12/8/17, he/she stated the submissions were done in a timely manner and did not know if when adding agency or contract staff later if that was the reason the CASPER Reports appeared untimely.",2020-09-01
3616,BETHEA BAPTIST HEALTHCARE CENTER,425372,157 HOME AVENUE,DARLINGTON,SC,29532,2016-12-14,249,C,0,1,CZNB11,"Based on staff interviews and review of the personnel file of the facility Activities Director, the facility failed to ensure the current facility Activities Director met the required qualifications for the position. This had the potential to affect all residents in the facility. The current census was 76. The findings included: During interview on 12/14/16 at 2:00 P.M. regarding her qualifications, the Activities Director stated she had a background in a healthcare setting. Review of the Activities Director's personnel record on 12/14/16 at 2:06 P.M. revealed the Activity Director was hired at the facility as the Activities Director on 08/31/16. A job description for the position was described as a Health Care Activities Director and was signed by the Activities Director. Further review of the personnel record revealed the Activities Director's resume indicated she had been employed as a nanny from (MONTH) (YEAR) to present and from (MONTH) 2011 to (MONTH) (YEAR), employed at an eye center as a medical records clerk/scheduler. There was no evidence in the Activities Director's personnel record of any recent activity/recreational experience in a health care setting Interview on 12/14/16 at 2:09 P.M. with the Administrator revealed the Activities Director had attended a one day workshop for six hours on 11/15/16 and was not currently registered for a certification course to meet the requirements of Activities Director. The Administrator provided documentation of attendance that indicated the Activities Director attended a fall activity seminar on 11/15/16 for a total of six hours. The Administrator verified this was not a certification course to meet the requirements of Activities Director. The Administrator reviewed the resume and the Activities Director's previous work experience and verified the current Activities Director did not meet required qualifications for the position.",2020-09-01
3650,WILLOW BROOKE COURT AT PARK POINTE VILLAGE,425375,3025 CHESBROUGH BLVD,ROCK HILL,SC,29732,2017-11-16,280,C,0,1,50Z111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on full and limited record reviews, interviews, and review of the facility policy titled Care Conference, Interdisciplinary, Planning and Implementing, the facility failed to prepare, review and revise a comprehensive plan of care which addresses Advanced Directives 11 of 11 residents reviewed for Advanced Directives. The facility failed to include the Certified Nursing Assistant in the care planning process for 10 out of 11 residents reviewed for interdisciplinary care plan participation. Resident # 4, Resident #21, Resident #34, Resident #2, Resident #23, Resident #65, Resident #6, Resident #45, Resident # 48, Resident #61, and Resident #47 not have advanced directives addressed on their comprehensive care plans. There was no evidence that a C.N.[NAME] was involved in the care planning process for Resident # 4, Resident #21, Resident #34, Resident #2, Resident #23, Resident #65, Resident #6, Resident #45, Resident # 48, and Resident #47. The findings included: The facility admitted Resident #4 with [DIAGNOSES REDACTED]. Review of the Comprehensive care plan initiated 6/23/17 with current target date of 12/21/17 revealed that Advanced Directives are not addressed in focus statements, goals, or interventions. Review of the facility's Care Conference, Interdisciplinary, Planning and Implementing policy on 11/15/17 at 9:00 AM revealed that item #4 on page 2 of 3 identifies individuals who are to be included in the care planning process including, but not limited to, representatives from nursing (nurses and nursing assistance with responsibility for the resident), culinary, social services, rehabilitation, and activities. Further review revealed that item #5 on page 2 of 3 outlines that the interdisciplinary comprehensive care plan addresses areas including but not limited to standards of current professional practice and Resident's personal and cultural preferences. Review of the Care Plan Meeting Review meeting form on 11/14/17 at 4:15 PM revealed that interdisciplinary team meetings were held for Resident #4 on 7/6/17, 7/11/17, and 10/4/17 with no evidence of C.N.[NAME] participation during the care planning process. During an interview on 11/15/17 at 10:00 am, Minimum Data Set (MDS) Nurses #1& #2 reviewed the record and verified that Advanced Directives were not addressed on the comprehensive care plan initiated 6/23/17 with current goal date of 12/21/17, stating that they were not aware that this was a requirement. They further reported that there was no evidence of C.N.[NAME] participation in care planning for the meetings held on 7/6/17, 7/11/17, and 10/4/17. MDS Nurse #1 stated that they have been trying to involve C.N.[NAME]'s in the care plan process and have them attend the meetings with intermittent success. She stated that with the variable level of acuity of the resident population, in addition to the high turnover of short term rehabilitation residents who do not remain in facility an entire quarter, with the number of C.N.A's available to cover each other's assignments, it has been very difficult for C.N.A's to leave the floor to actively participate in the actual Interdisciplinary Care plan / Team meetings. MDS Nurse #1 further verified that the facility was not following the Care Conference, Interdisciplinary, Planning and Implementing policy. Resident # 21 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the Comprehensive care plan initiated 5/23/2017 with current target date of 11/21/17 revealed that Advanced Directives are not addressed in focus statements, goals, or interventions. Review of the Care Plan Meeting Review meeting form on 11/15/17 at 1:15 PM revealed that interdisciplinary team meetings were held for Resident #21 on 6/7/17, 9/6/17, and 11/2/17 with no evidence of C.N.[NAME] participation during the care planning process. Resident # 34 was admitted to facility with [DIAGNOSES REDACTED]. Review of the Comprehensive care plan initiated 9/1/15 with current target date of 2/5/18 revealed that Advanced Directives are not addressed in focus statements, goals, or interventions. Review of the Care Plan Meeting Review meeting form on 11/16/17 at 8:20 AM revealed that interdisciplinary team meetings were held for Resident #34 on 5/24/17, 8/9/17, and 11/18/17 with no evidence of C.N.[NAME] participation during the care planning process. MDS #1 verified during interview on 11/15/17 at 10:45 AM that there were no advanced directives on the care plan for Resident #34 and that there was no evidence of C.N.[NAME] care participation during the care planning process for meetings 5/24/17, 8/9/17, and 11/18/17. The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Comprehensive Care plan review on 11/15/2017 at 1:47 PM revealed that advance directives are not included or discussed in the resident #2's care plan dated 10/13/2017. Further investigation of the interdisciplinary care plan signature form revealed no participation of the CNA in the care planning meeting dated 10/25/2017. During an interview on 11/15/2017 at approximately 3:30 PM the Minimum Date Set Coordinators, nurses #1 and #2, confirmed that Advance Directives was not include in the resident's care plan and that the CNA did not participate in the care plan meeting held on 10/25/2017. The facility admitted Resident #23 with [DIAGNOSES REDACTED]. Based on the Comprehensive Care plan reviewed on 11/15/2017 at approximately 1:55 PM advance directives are not included in the care plan dated 05/05/2017 and 10/24/2017 for resident # 23 reviewed for advance directives inclusion in the care plan. Further investigation revealed not the participation of the Nursing Assistant (C.N.A) in the care plan meeting dated 09/13/2017, 10/18/2017, and 11/01/2017 reviewed for CNA participation in the care plan meeting. During an interview on 11/15/2017 at approximately 3:30 PM the Minimum Date Set Coordinators, nurses #1 and #2, confirmed that Advance Directives was not included in the resident's care plan and that the CNA did not participate in the care plan meeting held on 09/13/2017, 10/18/2017, and 11/01/2017. The facility admitted Resident # 65 with [DIAGNOSES REDACTED]. Care Plan review on 11/14/17 revealed no care plan related to Advance Directive choice and no documentation that A CNA (Certified Nursing Assistant) attended the care plan meeting held for this resident on 10/4/17. Interview on 11/15/17 at 10:40 AM with MDS (Minimum Data Set) / Care Plan Coordinator # 1 and #2 confirmed that they were unaware that the Advanced Directives should be covered on the care plan. They also confirmed that CNA's do not always attend the care plan meetings. Review of the Interdisciplinary Care Plan Signature Form for Care Plan Meeting on 10/4/17 was confirmed that CNA did not attend. The facility admitted Resident # 6 with [DIAGNOSES REDACTED]. Care Plan Review on 11/14/17 and 11/15/17 revealed no care plan to address the Advanced Directive choice for this resident. Also review of the Interdisciplinary Care Plan Signature Form showed no documentation of a CNA attended the care plan meeting for 10/25/17, 4/26/17,or 2/3/16. Interview with MDS/Care Plan #1and #2 on 11/15/17 at 10:40 AM confirmed that Advanced Directive information not included in care plans and CNA's do not always attend care plan meetings due to work load.",2020-09-01
3677,OPUS POST ACUTE REHABILITATION,425379,300 AGAPE DRIVE,WEST COLUMBIA,SC,29169,2017-09-07,356,C,0,1,Z64S11,"Based on observation, interview, and record review the facility failed to have complete and accurate nurse staffing information for 2 of 3 days of survey. The facility did not display the cumulative hours worked by nursing staff for each shift. The findings included: Observation of nurse postings on 9/5/17 at approximately 12:50 PM revealed the cumulative hours worked by nursing staff were not displayed. Observation of nurse postings on 9/5/17 at approximately 1:20 PM revealed the cumulative hours worked by nursing staff were not displayed. Observation of nurse postings on 9/6/17 at approximately 12:10 PM revealed the cumulative hours worked by nursing staff were not displayed. Interview with the director of nursing (DON) on 9/6/17 at approximately 12:20 PM confirmed the cumulative hours were not posted",2020-09-01
3692,OPUS POST ACUTE REHABILITATION,425379,300 AGAPE DRIVE,WEST COLUMBIA,SC,29169,2018-10-18,623,C,0,1,XVQI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and in accordance with the 42 CFR 483.15(c)(4)(ii)(D) the facility failed to provide a notice of discharge/transfer to the resident and the resident's representative, in writing and in a manner they understand the reason (s) for the transfer or discharge for three of three sampled residents reviewed for hospitalization . The findings included: The facility admitted Resident #27 on 1/20/17 with [DIAGNOSES REDACTED]. Record reviewed on 10/17/18 at approximately 10:30 AM revealed that the facility sent Resident #27 to the hospital emergency room (ER) on 8/1/18 with symptoms of fatigue, muscle aches, and nausea with vomiting. The hospital admitted and treated the resident for low hemoglobin and possible urinary tract infection [MEDICAL CONDITION]. The resident returned to the facility from his/her last hospital stay on 8/23/18. However, the resident's medical record revealed no evidence to indicate that the facility notified the resident and the resident's representative, in writing, the reasons why the facility sent the resident to the hospital ER. During an interview with the director of nursing (DON) on 10/17/18 at approximately 11:40 AM s/he confirmed that the facility did not notify the resident and the resident's representative, in writing, of the transfer and the reason for it. The facility admitted Resident #58 on 3/1/16 with [DIAGNOSES REDACTED]. Record reviewed on 10/18/18 at approximately 2:25 PM revealed that the facility sent Resident #58 to the hospital emergency room (ER) on 9/9/18 related to pneumonia and [MEDICAL CONDITION], among others health issues. The resident returned to the facility from his/her last hospital stay on 9/12/18. However, the resident's medical record revealed no evidence to indicate that the facility notified the resident and the resident's representative, in writing, the reasons why the facility sent the resident to the hospital ER. During an interview with the director of nursing (DON) on 10/18/18 at approximately 3:00 PM s/he confirmed that the facility did not notify the resident and the resident's representative, in writing, of the transfer and the reason for it. The facility admitted Resident #53 with [DIAGNOSES REDACTED]. Record review on 10/16/18 at 6:30 PM revealed Resident #53 was admitted to the hospital on [DATE] and 8/5/18. Further record review revealed written information explaining the reason for the transfer to the hospital was not provided to the resident and/or the resident representative. During an interview with the Administrator on 10/18/18 at 5:16 PM, s/he confirmed the facility was not following the proper procedure in notifying the resident and/or the resident representative related to transfers.",2020-09-01
3693,OPUS POST ACUTE REHABILITATION,425379,300 AGAPE DRIVE,WEST COLUMBIA,SC,29169,2018-10-18,625,C,0,1,XVQI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and per the 42 CFR 483.15(d) (1) the facility failed to discussed/explained the bed hold policy with/to the resident and the resident's representative for three of three sampled reviewed for hospitalization . Findings: The facility admitted Resident #27 on 1/20/17 with [DIAGNOSES REDACTED]. Record reviewed on 10/17/18 at approximately 10:30 AM revealed that the facility sent Resident #27 to the hospital emergency room (ER) on 8/1/18 with symptoms of fatigue, muscle aches, and nausea with vomiting. The hospital admitted and treated the resident for low hemoglobin and possible urinary tract infection [MEDICAL CONDITION]. The resident returned to the facility from his/her last hospital stay on 8/23/18. However, the resident's medical record reviewed on the same day at approximately 10:40 AM 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 10/17/18 at approximately 11:40 AM s/he confirmed the above findings. The facility admitted Resident #58 on 3/1/16 with [DIAGNOSES REDACTED]. Record reviewed on 10/18/18 at approximately 2:25 PM revealed that the facility sent Resident #58 to the hospital emergency room (ER) on 9/9/18 related to pneumonia and [MEDICAL CONDITION], among others health issues. The resident returned to the facility from his/her last hospital stay on 9/12/18. However, the resident's medical record reviewed on the same day at approximately 3:00 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 10/18/18 at approximately 3:35 PM s/he confirmed the above findings. The facility admitted Resident #53 with [DIAGNOSES REDACTED]. Record review on 10/16/18 at 6:30 PM revealed Resident #53 was admitted to the hospital on [DATE] and 8/5/18. Further record review revealed there was no documentation the resident and the resident's representative received information related to the bed-hold notice upon transfer.",2020-09-01
3705,LAKES AT LITCHFIELD,425380,120 LAKES AT LITCHFIELD DRIVE,PAWLEYS ISLAND,SC,29585,2018-01-11,577,C,0,1,606211,"Based on observations and interview, the facility failed to ensure that the State Agency survey book was accessible on two days of the survey for 1 of 1 unit observed. The State Agency survey book was blocked by a large medication cart. The findings included: A random observation on 1/09/18 at approximately 9:35 AM revealed the State Agency survey book was located behind a large medication cart on the wall near the unit nursing station. A random observation on 1/09/18 at approximately 12:15 PM revealed the medication cart still blocking physical access to the State Agency survey book. The medication cart remained in the general location throughout the day. A random observation on 1/10/18 at approximately 9:37 AM, 11:57 AM and 2:34 PM revealed the large medication cart blocking access to the State Agency survey book. An interview and observation on 1/10/18 at approximately 2:59 PM with the facility Administrator confirmed the findings the medication cart blocked access to the State Agency survey book. The Administrator further stated the medication cart was in that general location at all times due to lack of space.",2020-09-01
3714,LAKES AT LITCHFIELD,425380,120 LAKES AT LITCHFIELD DRIVE,PAWLEYS ISLAND,SC,29585,2018-12-19,640,C,0,1,0LK711,"Based on record review and interview, the facility failed to encode and transmit discharge assessments to the State Agency in a timely manner for 2 of 2 residents reviewed on the Missing OBRA Assessment Report for (YEAR) since the last Recertification Survey. The findings included: Review on 12/18/2018 at approximately of the Missing OBRA Assessment Report revealed Resident #1 with a target date of 5/23/2018 and Resident #10 with a target date of 1/22/2018. Both residents were discharged from the facility. An interview on 12/18/2018 at approximately 12:33 PM with the Minimum Data Set assessment Coordinator confirmed that discharge assessments were not completed and transmitted in a timely manner to the State Agency.",2020-09-01
3755,WILDEWOOD DOWNS,425385,1215 WILDEWOOD DOWNS CIRCLE,COLUMBIA,SC,29223,2018-02-23,851,C,0,1,IZ8B11,"Based on limited record review, interview, and review of the facility policy's titled, Payroll Based Journal, the facility failed to submit accurate and timely staff information for Staffing Summary Report to the Centers of Medicare and Medicaid (CMS). The findings included: Review of the Casper Report 1702S Staffing Summary Report revealed 10/01/2016 through 12/31/16; 01/01/2017 through 3/31/2017, 4/1/2017 through 6/30/2017, no documentation of the appropriate staff that is required per CMS guidelines and 10/01/2017 through 12/31/2017 no dated returned on selected criteria. During an interview on 2/23/18 at 12:19 PM with Human Resource Director, s/he stated would pull the staffing payroll and gave to the prior administrator to process. The Director of Nursing provided an email from facility Information Technology Application and Support stating unable to upload it's too late. Review on 2/23/18 at 12:57 PM of the facility's policy titled, Payroll Based Journal 5. The facility will submit direct care staffing information on the schedule specified by CMS, but no less frequently than quarterly.",2020-09-01
3867,COMPASS POST ACUTE REHABILITATION,425391,2320 HIGHWAY 378,CONWAY,SC,29527,2018-06-14,574,C,0,1,QH5V11,"Based on record review, observation and interview, the facility failed to ensure that residents were aware of the location of the State Agency Survey results for 1 of 1 resident council interviewed in the Resident Council group meeting. The findings included: On 6/14/2018 at approximately 11AM, the Resident Council meeting minutes from (MONTH) (YEAR)-May (YEAR) were reviewed and provided no documentation that the council discussed the location of the State Agency Survey results. During a random observation on 6/14/2018 at approximately 1PM, it was revealed that the survey results were located in the lobby, on a brown, mantle-like surface. The surface appeared to be high in nature, which could present issues for residents who may be wheelchair bound. The Resident Council group meeting was held on 6/14/2018 at 245PM and all residents in attendance stated that they did not know the location of the State Agency Survey results.",2020-09-01
3880,LINVILLE COURT AT THE CASCADES VERDAE,425392,30 SPRINGCREST COURT,GREENVILLE,SC,29607,2017-08-10,280,C,0,1,SSFJ11,"Based on record review and interviews, the facility failed to ensure that certified nursing aides were involved in the development of the residents quarterly care plan. for 10 of 10 sampled residents reviewed. Residents #1, #2, #17, #33, #56, #63, #103, #174, #175 and #182. The findings included: A review of the care plan meeting process revealed there was no documentation to indicate the facility involved the certified nursing aides in the development of the residents care plan for the above sampled residents reviewed in Stage 2. There was no documentation to indicate the certified nursing aides were involved in the residents care plan process for Residents #1, #2, #17, #33, #56, #63, #103, #174, #175 and #182. An interview on 8/10/17 at approximately 1:32 PM with Registered Nurse (RN) #2 and Licensed Practical Nurse (LPN) #4 revealed the facility had the certified nursing aides involved in the care process through verbal meetings at different times. Reportedly the certified nursing aides are not involved in a formal process but there was a discussion with the certified nursing aides. An interview on 8/10/17 at approximately 1:56 PM with Certified Nursing Aide #2 revealed he/she was not involved in the residents care plan meeting process. An interview on 8/10/17 at approximately 2 PM with Certified Nursing Aide #3 revealed he/she was not involved in the residents care meeting process.",2020-09-01
3899,LINVILLE COURT AT THE CASCADES VERDAE,425392,30 SPRINGCREST COURT,GREENVILLE,SC,29607,2018-08-15,883,C,0,1,721Q11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure that flu/pneumonia education was provided and documented for five of five sampled residents reviewed. Residents #3, #7, #9, #73 and #174 had no documentation the flu/pneumonia education was provided. The findings included: An interview on 8/14/18 at approximately 9:03 AM with the facility Consultant and Licensed Practical Nurse (LPN) #1 reviewed newly admitted residents documentation of flu/pneumonia education would be paper form and older residents flu/pneumonia education would be attached to the electronic medical records. Resident #3 admitted on [DATE], Resident #7 admitted on [DATE], Resident #9 admitted on [DATE], Resident #73 admitted on [DATE] and Resident #174 admitted [DATE] did not have electronic or paper documentation flu/pneumonia education being provided. An interview on 8/14/18 at approximately 9:45 AM with the facility's Executive Director confirmed the findings that there no documentation to indicate the flu/pneumonia education was provided.",2020-09-01
3906,PRESBYTERIAN COMMUNITIES OF SOUTH CAROLINA- CLINTO,425393,801 MUSGROVE STREET,CLINTON,SC,29325,2019-04-11,577,C,0,1,6E6D11,"Based on observation and interview, the facility failed to post the survey results in an area readily accessible to residents, family members and legal representatives on 1 of 1 unit observed. The findings included: During Initial Tour of the facility on 4/8/19 at 10:12 AM, no survey results could be located on the unit. During additional observations on 4/9/19 at 9:39 AM and 4/10/19 at 9:49 AM, survey results could not be located on the unit. During an interview with the Assistant Director of Nursing (ADON) on 4/10/19 at 9:49 AM, the ADON confirmed the survey results were not posted on the unit. The ADON stated maintenance must have taken them down when they were getting ready to paint the halls. The ADON stated s/he did not know how long ago the survey results were removed from the unit. The ADON stated s/he did not know where the survey results were but would locate them. During an interview with the ADON on 4/10/19 at 9:52 AM, the ADON stated the survey results were found at the nurse's station. When asked if this was an area readily accessible to residents, family members and legal representatives, the ADON stated it was not.",2020-09-01
3926,THE ARBORETUM AT THE WOODLANDS,425394,50 ARBORTEUM WAY,GREENVILLE,SC,29617,2017-05-04,356,C,0,1,OHWP11,"Based on observation, interview with the Director of Nursing (DON), and record review the facility failed to post cumulative hours worked for licensed and registered staff for three of three months of nursing staff postings reviewed. The findings included: Observation on 5/2/17 at approximately 1 PM revealed that nursing staff postings did not have cumulative hours displayed for licensed and registered staff. Observation on 5/3/17 at approximately 3:50 PM revealed that the nursing staff postings did not have cumulative hours displayed for licensed and registered staff. Interview with the DON on 5/4/17 at approximately 12:02 PM revealed that cumulative hours of licensed and registered staff were not displayed on the nursing staff postings. Review of nursing staff postings for previous three months on 5/4/17 at approximately 12:12 PM revealed that cumulative hours of licensed and registered staff were not displayed on the nursing staff posting.",2020-09-01
3941,THE RETREAT AT BRIGHTWATER,425395,171 BRIGHTWATER DRIVE,MYRTLE BEACH,SC,29579,2018-03-11,640,C,0,1,J8IL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interview, the facility failed to complete and transmit MDS (Minimum Data Set) assessments in a timely manner for Res #209, #210, #211, 212, #213, #214 and Resident #215 for 7 of 7 residents reviewed for Missing OBRA Assessments. The findings included: The facility admitted Resident #209 with a [DIAGNOSES REDACTED]. The facility admitted Resident #210 with a [DIAGNOSES REDACTED]. The facility admitted Resident #211 with a [DIAGNOSES REDACTED]. The facility admitted Resident #212 with [DIAGNOSES REDACTED]. The facility admitted Resident #213 with a [DIAGNOSES REDACTED]. The facility admitted Resident #214 with a [DIAGNOSES REDACTED]. The facility admitted Resident #215 with a [DIAGNOSES REDACTED]. Review on 3/10/2018 at approximately 5:40 PM of the facility MDS transmission report revealed the MDS assessments for Resident #209, #210, #211, #212, #213, #214 and Resident #215 were not completed and transmitted to the State Agency in a timely manner. During an interview on 3/10/2018 at approximately 5:54 PM with RN (Registered Nurse) #2, he/she confirmed that the MDS Missing OBRA Assessments had not been completed and transmitted in a timely manner.",2020-09-01
3980,PRESBYTERIAN HOME OF SOUTH CAROLINA-COLUMBIA,425396,700 DAVEGA DRIVE,LEXINGTON,SC,29073,2018-05-09,732,C,0,1,8KGD11,"Based on review of facility records, the facility failed to show evidence of complete staff postings to include hours worked and number of staff per shift, for 3 of 3 months reviewed. The findings included: Review of the provided postings for the dates of 02/08/18 through 05/08/18 revealed the facility had not documented hours worked for 87 of 90 days of Staffing Level postings reviewed. Further review revealed the number Certified Nursing Assistants and Licensed Practical Nurse and/or Registered Nurse was not documented per shift for 26 of 90 days of Staffing Level postings reviewed. This information was reviewed and confirmed as being incomplete by the facility's Administrator on 05/08/18.",2020-09-01
4022,PRUITTHEALTH-BLYTHEWOOD,425400,1075 HEATHER GREEN DRIVE,COLUMBIA,SC,29229,2017-09-15,159,C,1,1,4HVH11,"> Based on record review and interview the facility failed to provide the residents/responsible parties quarterly statements for personal funds managed by the facility for 2 of 2 sampled residents reviewed for personal funds. Resident #42 and Resident #65 were not receiving quarterly statements for personal funds managed by the facility. The findings included: During an interview on 9/6/17 at 12:07pm, the responsible party for Resident #42 stated s/he hadn't gotten quarterly statements June of 2017. On 9/6/17 at 1pm, Resident #65 stated s/he had not received quarterly statements until this past June of 2017. During an interview on 9/8/17 at 2:30pm, the Business Office Manager (BOM) verified that the residents just started receiving their quarterly statements for March, April, and May 2017 in June. The BOM stated s/he received a lot of questions because the residents were not used to getting their statement notifications. S/he was unable to provide evidence that the residents received quarterly statements prior to June 2017.",2020-09-01
4025,PRUITTHEALTH-BLYTHEWOOD,425400,1075 HEATHER GREEN DRIVE,COLUMBIA,SC,29229,2017-09-15,167,C,1,1,4HVH11,"> Based on observations and interviews, the facility failed to ensure results of the previous three years of survey results were readily available for resident/family and visitor review. The findings included: From 9-5-17 through 09/08/2017 at 6:28 PM, the survey results were observed in the front lobby, inside of a brown box located on the wall, to the left of the Reception Desk. The label on the brown box stated, Annual Survey Results. Inside the box was a notebook and the contents included survey results from the years 2016 and 2015. A sign was posted in a courtyard exit corridor as to the location of the survey results. This area was not readily accessible to residents or visitors unless entering the courtyard. There was no sign to indicate how to access 3 years of survey/complaint results upon request. The Administrator verified the survey results from the previous 3 years were not accessible and stated, They're in my office. S/he confirmed that the notebook contained survey results from the previous 2 years. On 9/8/2017 at approximately 6:45 PM, the Administrator placed the survey results from 2014 in the Annual Survey Result Book.",2020-09-01
4058,PRUITTHEALTH-BLYTHEWOOD,425400,1075 HEATHER GREEN DRIVE,COLUMBIA,SC,29229,2017-09-15,500,C,1,1,4HVH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview during the Extended Survey, the facility failed to have secured agreements without outside resources for all needed areas. The findings included: Record review during the Extended Survey revealed that at the time of the survey, there were Seven different [MEDICAL TREATMENT] Centers providing services to current residents. During an interview with the Administrator on 9/15/17 at 4:53 PM, he/she provided signed contracts for three local [MEDICAL TREATMENT] Centers; however, he/she could not provide signed contract agreements for six of the seven [MEDICAL TREATMENT] Centers which were providing services to current residents.",2020-09-01
4067,PRUITTHEALTH-BLYTHEWOOD,425400,1075 HEATHER GREEN DRIVE,COLUMBIA,SC,29229,2018-10-05,732,C,0,1,C1DT11,"Based on observation and interview with the Administrator the facility failed to post daily staffing where it is readily accessible for all residents and the public. The postings did not reflect complete and accurate information. The findings included: 10/04/18 09:45 AM -requested daily staff postings 10/05/18 01:58 PM- Administrator stated that the facility has not been going back the following day and correcting with the call outs and changes in the #'s of staff that actually worked, received a daily nursing staffing report going back 30 days- but this is only a report, not the actual postings 10/05/18 02:00 PM Observation. Staff Posting are located only on one unit (TCU) and is not available to the general public or residents on the other units.",2020-09-01
4093,SAVANNAH GRACE AT THE PALMS OF MT PLEASANT,425404,1010 LAKE HUNTER CIRCLE,MOUNT PLEASANT,SC,29464,2017-01-20,167,C,0,1,JIR011,"Based on observation and interviews, the facility failed to have reports with respect to any surveys, certifications, and complaint investigations made respecting the facility during the 3 preceding years, and any plans of correction in effect with respect to the facility, available for any individual to review upon request. Findings Include: Observation during the course of the survey, the facility DHEC Survey book results were in view, however, there were no posted signs to inform the public where the survey book is located and the availability of 3 preceding years of surveys upon request. On 01/19/2017 at approximately 4:05pm, the Administrator was interviewed. The Administrator revealed that she did not know that the facility must have three past years available for review and a sign stating where the survey book is located.",2020-09-01
4097,SAVANNAH GRACE AT THE PALMS OF MT PLEASANT,425404,1010 LAKE HUNTER CIRCLE,MOUNT PLEASANT,SC,29464,2017-01-20,356,C,0,1,JIR011,"Based on observation and interview, the facility failed to have the staffing schedule visible and have it posted in a prominent place readily accessible to residents and visitors. Findings Include: Observation during the course of the survey, both posting for staffing (Savannah Hall and Grace Hall) were behind the back far corner wall. It was posted too far away to be seen from the nursing stations. On 01/19/2017 at approximately 4:10pm, the Administrator was interviewed. The Administrator revealed that she did not know that the facility staffing posting was too far away to be seen from the nursing stations.",2020-09-01
4108,SAVANNAH GRACE AT THE PALMS OF MT PLEASANT,425404,1010 LAKE HUNTER CIRCLE,MOUNT PLEASANT,SC,29464,2018-05-18,623,C,0,1,NX5Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on limited record review and interview, the facility failed to ensure that a representative of the Office of the State Long-Term Care Ombudsman was notified of the transfers and discharges of residents for 1 of 1 resident reviewed for hospitalization . Resident #31 was sent to the hospital without notification provided as required to the State Long-Term Care Ombudsman. The findings included: The facility admitted Resident #31 on 1/15/18 with [DIAGNOSES REDACTED]. During record review on 5/16/18 at 1:03 PM revealed Resident #31's representative request the resident be transferred to the Hospital emergency room . Staff stated they would have the Nurse Practitioner come and evaluate the resident. The resident representative preferred the resident to be transferred to Hospital emergency room . During an interview on 5/16/18 with the Director of Nursing (DON) request the list of notifications hospitalization s and discharges sent to the Long Term Care Ombudsman. S/he stated was not aware it's a requirement to send the information. The surveyor stated the regulation for notification to the Ombudsman went into effect as of (MONTH) 28, (YEAR).",2020-09-01
4122,PRESBYTERIAN COMMUNITIES OF SOUTH CAROLINA-FLORENC,425406,2350 W LUCAS STREET,FLORENCE,SC,29501,2017-07-19,167,C,0,1,8DBE11,"Based on observations, interviews and review of the Resident Council Minutes, 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 posted in an area readily accessible to residents, families, and legal representatives of residents during the survey. The findings included: An observation made upon entering the facility on 7/17/2017 at approximately 7:30 AM revealed a sign that stated the survey results were located on the unit, between the 2 halls, across from the nurses desk. The signage did not include that 3 preceding years of survey results and any plan of correction would be available for viewing upon request. The facility's most recent survey results were not found or observed during the survey. An interview on 7/18/2017 at approximately 10:30 AM with Resident #136, a resident that frequents the resident council meetings, stated that the residents did not know where the state survey results were located without having to ask staff. Review on 7/18/2017 at approximately 10:30 AM of the Resident Council Minutes dated 6/26/2017, 5/29/2017 and 4/24/2017 did include where the results were located. This surveyor could not locate the Survey Results and had to ask staff where to find them. The nurses on the unit had to ask each other where to find the survey results and eventually had to ask the Assistant Director of Nursing (ADON). An interview on 7/19/2017 at approximately 4:00 PM with the ADON stated, If anyone wants to see the survey results they ask for them and we get them. The ADON walked into the Living Room/Day Room, a room between the 2 units, and found the survey results in a very thin notebook pushed up against an end of a book case and out of sight behind 2 large binders. No signage was posted on the units to let residents, families or legal representatives of the residents know where the survey results were located.",2020-09-01
4150,EASLEY PLACE-A CONTINUUM OF CARE COMMUNITY,425409,706 PELZER HIGHWAY,EASLEY,SC,29642,2017-09-14,156,C,0,1,3N1E11,"Based on observation and interview, the facility failed to post required information in a form and manner accessible to residents and their representatives on 1 of 1 unit reviewed. The findings included: Observation of the resident unit on 9/13/17 revealed the required postings of the names and contact information for the State agencies and advocacy groups such as the State Survey Agency, the State licensure office, adult protective services, the Office of the State Long-Term Care Ombudsman program, and information about Medicaid and how to apply for Medicare and Medicaid benefits were hung on the wall of the hallway leading to the Nurses' Station. Further observation revealed these postings were hanging on the wall above the height of the surveyor, were written in small print, and were not readable when viewed standing underneath the postings. During a tour of the unit with the Administrator on 9/14/17 at approximately 3:25 PM, the Administrator observed the postings with the surveyor and confirmed the above findings at that time.",2020-09-01
4158,SKYLYN NURSING AND REHABILITATION CENTER,425410,1705 SKYLN DRIVE OFC,SPARTANBURG,SC,29307,2019-02-07,582,C,0,1,FTTO11,"Based on record review and interview, the facility failed to provide the required Beneficiary Notices related to non-coverage of Medicare Part A services for residents with benefit days remaining. The facility failed to provide the Notice to Medicare Provider Non-coverage (NOMNC), form CMS- and/or the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN), form CMS- to any residents eligible to receive these notices. The findings included: During a review of Beneficiary Notices, the facility provided a list of residents with benefit days remaining who were discharged from Medicare Part A services. When asked to provide the Beneficiary Notices sent to these residents, the surveyor was informed that no one on staff had sent out any Beneficiary Notices since October, (YEAR). The Director of Nursing confirmed this information on 2/7/19 at approximately 4:00 PM.",2020-09-01
4174,"WELLMORE OF LEXINGTON, LLC",425412,200 WELLMORE DRIVE,LEXINGTON,SC,29072,2018-03-09,575,C,0,1,I8RU11,"Based on observation and interviews the facility failed to ensure that the required contact information/ postings were available for residents regarding Ombudsman, advocacy information or state agencies. The findings included: During an interview with members of the facility's resident council, it was discussed that residents were unaware of the role of the Ombudsman nor how to contact this person. Furthermore the residents were concerned that the Resident's Bill of Rights were not Upon entry to the building on 03/06/18, an initial tour at approximately 9:00 am, revealed the required postings were not in a readily accessible, conspicuous location for the residents and their representatives. During an interview on 03/08/18 at 03:44 PM with a Wellness Associate, s/he stated that s/he does attend the resident council meetings on a regular basis. S/he indicated that all resident rights are reviewed every meeting and that the Ombudsman information is reviewed but the contact information is not posted. A packet of information pertaining how to contact this person is provided upon request. With regard to the Bill of Rights postings s/he indicated the poster is at the door, across from the activity room, approximately 4 and half feet from the floor and that it is visible to the residents. Review of the facility's policy, 1.42, Grievance/Concern: Member/Resident/Family, effective 02/03/14 and revised 12/05/14, revealed, Upon admission, information will be provided on the purpose of and how to contact an Ombudsman. In addition, Ombudsman posters will be posted in prominent locations on each unit.",2020-09-01
4179,"WELLMORE OF LEXINGTON, LLC",425412,200 WELLMORE DRIVE,LEXINGTON,SC,29072,2019-03-20,577,C,0,1,2TSC11,"Based on interview and observation, the facility failed to post DHEC survey results publicly so that residents and family could access them. The findings included: During an interview with the Resident Council on 03/18/19 at approximately 10:07 AM revealed the residents did not know how to access the results of the state inspection. During an observation of DHEC survey results on 3/18/19 at approximately 11 AM revealed the survey results were only on the Long-Term Care unit on the 1st Floor, and there were no signs posted elsewhere in the facility that identified where they were. The survey results were inside the top drawer of a credenza that may be difficult for some residents to access. During an interview with the Director of Nursing (DON) on 3/19/19 at approximately 2:52 PM confirmed no signs were posted indicating to residents on the Rehabilitation Unit and the 2nd Floor that the survey results were on the 1st Floor.",2020-09-01
4193,RETREAT AT WELLMORE OF DANIEL ISLAND,425414,580 ROBERT DANIEL DRIVE,CHARLESTON,SC,29492,2019-03-08,732,C,0,1,EOM611,"Based on observation, review of staff postings, and interviews, the facility failed to ensure the staff posting/work hours/time of day was included of the daily staff census per shift. The staffing sheet was noted as day shift, evening shift and night shift. The beginning and ending time of each shift for staff was not posted in a clear manner. The findings included: An observation on 3/08/19 at approximately 1:16 PM revealed the staff posting on the first and second floor did not include the beginning and ending time of each shift for staff noted on the posted. The posting was not clear to inform residents/visitors when one shift begins or ends. An interview on 3/08/19 at approximately 2:13 PM with the Staffing Coordinator confirmed the staff postings were listed as day shift, evening shift, and night shift with no scheduled work times noted per shift.",2020-09-01
4298,PRUITTHEALTH-CONWAY AT CONWAY MEDICAL CENTER,425173,2379 CYPRESS CIRCLE,CONWAY,SC,29526,2016-06-23,156,C,0,1,55GR11,"Based on observation and interview the facility failed to ensure the state agency and ombudsman's information was available and accessible to residents. Information placed out of reach also included the facility's survey results. The findings included: An observation on 6/20/2016 at approximately 11:20 AM revealed the survey results and the contact phone numbers for the state agency and the Ombudsman was pinned to the top of a bulletin board and out of reach and inaccessible to the residents, families and visitors. A second observation on 6/21/2016 at approximately 8:45 AM revealed the survey results and the contact numbers remained out of reach for residents and the visitors that entered the facility. During a third observation made on 6/22/2016 at approximately 8:40 AM revealed the survey results and the contact phone numbers were still out of reach and inaccessible to residents and visitors. An interview on 6/22/2016 at approximately 8:45 AM with the Administrator confirmed the survey results and the phone number postings were out of reach for the residents and visitors. He/she went on to say that if the results and numbers are lower on the bulletin board then someone will reach up and pull them from their attachment to the bulletin board and not replace them. On 6/22/2016 at approximately 10:08 AM the Administrator informed this surveyor that the survey results and the contact phone numbers for the state agency and the ombudsman were moved to the bottom of the bulletin board in a common area for both the residents and visitor to view.",2020-04-01
4351,PRUITTHEALTH-BLYTHEWOOD,425400,1075 HEATHER GREEN DRIVE,COLUMBIA,SC,29229,2017-03-29,356,C,1,0,DGMG11,"> Based on observation and interview, the facility failed to post the daily staffing to include the census from (MONTH) (YEAR) through (MONTH) of (YEAR). The findings included: In response to a complaint received by this office, the daily nursing staffing was requested of the facility for a time period in (MONTH) of (YEAR) and the time period since (MONTH) 1, (YEAR). Copies of the Daily Nursing Hours forms were provided by the Director of Health Services (DHS). Review of the Daily Nursing hours from the time period in (MONTH) and the (MONTH) (YEAR) days revealed the Daily Nursing hours did not contain the census for any shift during the time period reviewed. Adequate staffing could not be determined by the staffing sheets without the census. In an interview with the DHS, s/he stated s/he would obtain the census. The second copy of the Daily Nursing Hours provided by the DHS had the census number for the day written in the left top corner. The census was not recorded for the beginning of each shift.",2020-03-01
4363,PRUITTHEALTH- BAMBERG,425104,439 NORTH STREET,BAMBERG,SC,29003,2016-07-15,205,C,0,1,2DDJ11,"Based on record review and interview, the facility failed to provide a notice that specified the duration of the bed-hold policy during which the resident is permitted to return and the nursing facility's policies regarding bed-hold period for Resident #35, 1 of 1 resident reviewed for bed hold. The findings included: During a family interview for Resident #35 on 7/12/16, the Responsible Party (RP) stated that the resident had been hospitalized in the last several months. The RP also stated that a Bed Hold notice was not provided that stipulated the duration of the Bed Hold. On 07/12/2016 at 9:05 PM, review of the admission records for the resident and interview with the Admissions Coordinator revealed Resident #35's Responsible Party was informed of the Bed Hold Policy upon admission. Record review revealed no documentation that the bed hold policy had been provided to the RP or sent to the hospital at the time of transfer. Review of the Acute Care Transfer Document Checklist revealed a copy of the facility's bed hold policy was not included. Review of the bed-hold policy revealed that any resident transferred/ discharged from the healthcare center be allowed to be readmitted unless the healthcare center believes it will be unable to treat the resident. The policy further stated that the bed hold policy will be provided on admission and at the time of any transfer. The policy also stated that in cases of emergency, at the time of transfer means within 24 hours of the transfer. The policy further states that if the resident's copy of the bed hold notice is sent with other papers accompanying the resident to the hospital, the requirement is met. During an interview on 07/13/2016 at 11:18 AM, Licensed Practical Nurse (LPN) #3 confirmed that the policy stated a second notice which specified the duration of the bed hold policy, would be issued at the time of transfer. The LPN confirmed a Bed Hold notice is not included in the packet sent to the hospital when a resident is transferred and that a notice specifying the duration of the bed hold is not provided by the facility. The LPN further stated that the Transition Nurse, a facility Employee, or Case Manager, from the hospital, provided that information and that no one at the facility kept track of the notification. S/he also stated that the Transition Nurse travels and does not have an office at the facility and was not sure if s/he had an office at the hospital.",2020-02-01
4368,HEARTLAND HEALTH CARE CENTER - GREENVILLE EAST,425106,601 SULPHUR SPRINGS ROAD,GREENVILLE,SC,29611,2016-08-18,156,C,0,1,FW5K11,"Based on review of the facility liability and appeal notices and interview, the facility failed to ensure that 3 of 3 sampled residents denial notices were completed accurately. Resident #49, #50 and #126 denial notices did not address if the residents were informed of their rights to request a medicare intermediary review under medicare services. The findings included: Review of the facility's denial notices for Residents #49, #50 and #126 revealed that the denial notices given did not address under section IV the resident's right to make a request for medicare intermediary review which generates the request for a demand bill. Both check off boxes under section IV were left blank. Further review revealed there was no documentation to indicate the facility addressed the resident right to request a demand bill through the request for medicare intermediary review process. On 8/18/16 at approximately 9:45 AM , during an interview with the Administrative Officer and further review of the denial notices, it was confirmed that section IV on the denial notices that addressed request for medicare intermediary review process was left blank the residents.",2020-02-01
4405,WOODRUFF MANOR,425179,1114 EAST GEORGIA ROAD,WOODRUFF,SC,29388,2016-09-16,356,C,0,1,K44M11,"Based on observation, record review, and interview, the facility failed to post daily nurse staffing data at the beginning of each shift as required and failed to retain daily nurse staffing data for 18 months as required. The findings included: Observation on 9/14/16 at approximately 10:00 AM revealed the daily nurse staffing data was posted on the bulletin board near the main dining room. Further review of the form revealed staffing information was posted for all shifts at that time. Observation of the form revealed the same finding on 9/15/16 at approximately 9:00 AM. The surveyor requested past copies of the daily nurse staffing data. On 9/15/16 at approximately 3:00 PM, the Administrator and office staff informed the surveyor that these forms were unavailable, and that they were unaware of the requirement to retain copies of the staff posting.",2020-02-01
4427,ELLEN SAGAR NURSING CENTER,425012,1817 JONESVILLE HIGHWAY,UNION,SC,29379,2016-08-04,356,C,0,1,DWN811,"Based on observation and interview, the facility failed to follow the requirements for staffing postings on 2 of 2 units. The posting that was viewable did not differentiate between RNs and LPNs as required. Neither did it dictate the total number of hours worked. The findings included: Observation during the initial tour on 8/1/2016 at 3:00 pm showed there was no differentiation on the staffing posting between the number of Registered Nurses and Licensed Practical Nurses currently on duty. Additionally, there was no documentation of the shift and hours being worked by each category of staff. Staff posting reviews were conducted from 12/31/15 to 8/2/16. On (MONTH) 4, (YEAR) at approximately 1:40 pm, an interview was conducted with the Administrator and Director of Nursing (DON) to verify that the postings were inaccurate. The Administrator confirmed the observations as noted above. S/he also stated that when staffing changes were made, the posting would be updated the next day, which verified that the initial postings were not always accurate to the workers available on the floor at that given time. The forms that were stored with the DON contained the changes (final form). Both the Administrator and the DON confirmed that their postings were incorrect and not in concordance with federal regulations.",2020-01-01
4453,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2016-06-10,156,C,0,1,W3VQ11,"Based on record review and interview, the facility failed to provide the amount of time required for notification on Liability and Appeals Notice to 1 of 3 sampled residents who had been discharged from Medicare Part A Services with days of eligibility remaining for Resident #51. Additionally, the facility failed to post contacts and phone numbers to contact outside of the facility in 2 of the 2 buildings and Resident #70 was unaware of the Ombudsman position. The findings included: A review of Liability and Appeals Notice with the Business Office Coordinator (B[NAME]) on 6/19/16, revealed Resident #51 was discharged from Medicare Part A Services on 4/15/16 without the forty eight hour notification with Medicare eligibility days remaining. During the review of these notices, the B[NAME] verified that the Notice of Medicare Non-Coverage -CMS form had The Effective Date Coverage of Your Current Services Will End: 4/14/16. The B[NAME] indicated if the resident is in the facility and able to sign he/she would have the resident sign the Notice of Medicare Non-Coverage -CMS . The B[NAME] was unaware of the forty eight hour notification requirement. A review of the minutes from the Resident Council meetings in the past year, revealed no written discussion about Facility rules, available Ombudsman support or DHEC Survey results. When asked about the state surveys, the Resident Council President stated that s/he was not aware of available survey results, because no one had explained it to her/him. When asked if s/he knew what an Ombudsman does, s/he was not familiar with the position of the Ombudsman. On 06/08/16 at approximately 2:30 pm, during an interview with the Activity Director (AD), the AD stated that s/he had been with the facility for over four years. The AD was asked about the last time s/he went over the facility rules and the results from the last DHEC survey. The AD stated that it had been way over a year. Also, s/he could not remember the last time an Ombudsman came to a Resident Council meeting, and s/he did not know who the current Ombudsman was for the facility.",2020-01-01
4455,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2016-06-10,159,C,0,1,W3VQ11,"Based on interview, record review, and review of the facility 's policy Resident Trust Accounts , the facility failed to ensure that 3 of 4 sampled residents received quarterly statements. Resident #57, Resident #70's Responsible Party and Resident #92 stated they were not given quarterly statements. The Findings included: During a family interview on 6/7/16 at approximately 12:44 PM with Resident #70's Responsible party, individual interview with Resident #57 on 6/7/16 at 1:42 PM, and individual interview with Resident #92 on 6/7/16 revealed they had not received quarterly statements. Review of the facility policy on Resident Trust Accounts: Quarterly Procedures: 3. Trust statements for residents who have been properly declared incompetent to make health care/financial decisions are sent to the resident 's legal representative. During an interview with Accounts Receivable Coordinator (ARC) on 6/9/15 at 5:15 PM, he/she stated the statements are usually mailed out by Corporate. He/she stated there is no documentation when the statement is mailed to responsible party. He/she also stated the resident can request their account statement through the nurse or social worker. ARC confirmed he/she did not give out quarterly statements to the residents that stay in the facility.",2020-01-01
4456,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2016-06-10,170,C,0,1,W3VQ11,"Based on interview, the facility failed to ensure mail would be sent out or delivered promptly to residents whenever there was regularly scheduled postal delivery and pick-up service. Findings included: On 06/08/2016 at approximately 5:15 pm, a phone interview was conducted with the weekend office manager. The office manager stated that she had been with the facility for three years and s/he did not check the Saturday mail on a regular basis. However, if a resident did tell that he or she was expecting mail, s/he would get the mail for that resident. The rest of the mail sits on the AR Coordinator 's desk until Monday morning when s/he comes in. The weekend office manager further stated that if there were no requests for mail, s/he would not get the mail. On 06/08/2016 at approximately 5:25pm, interview with the AR Coordinator revealed that there are some Monday mornings when the mail box was full or there would be a stack of mail on the desk. The AR Coordinator also stated that part of the Monday morning routine was to give the mail to the Activity Director. The Activity Director would then deliver the mail to the residents.",2020-01-01
4497,LINVILLE COURT AT THE CASCADES VERDAE,425392,30 SPRINGCREST COURT,GREENVILLE,SC,29607,2016-10-26,356,C,0,1,XJI011,". Based on observation and interview, the facility failed to post nurse staffing information in 2 of 2 units. The findings included: During initial tour on 10/23/16 at approximately 11:35 AM, no nurse staffing information was found posted in Asher or[NAME]or the main entrance. Observation on 10/24/16 at approximately 9:50 AM revealed that no nurse staffing information was posted in Asher or Duncan. Interview with the Administrator and the Director of Nursing revealed that no nurse staff information was posted in the building.",2020-01-01
4542,PRUITTHEALTH-MONCKS CORNER,425140,505 SOUTH LIVE OAK DRIVE,MONCKS CORNER,SC,29461,2016-03-24,167,C,0,1,17C011,"Based on observations and interview, on three days of the survey, the results of the most recent survey of the facility conducted by the State surveyors was not available for viewing by the residents nor the visitors. The findings included. An observation on 3/21/2016 at approximately 11:20 AM revealed a notebook in the lobby without the current survey results, even though a sign was posted stating the survey results were in a specified notebook. An observation on 3/23/2016 at approximately 2:40 PM of the posted notebook for the current survey results revealed the notebook missing the survey results. During an interview on 3/23/2016 at approximately 2:50 PM with the Administrator, he/she stated the notebook was coming apart so he/she had put the survey results in his/her office on the book self. The Administrator then verified the survey results were not readily accessible for viewing for residents and visitors.",2019-11-01
4595,MAGNOLIA PLACE - GREENVILLE,425361,35 SOUTHPOINT DRIVE,GREENVILLE,SC,29607,2016-08-25,156,C,0,1,FXQ111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to complete the required Notice of Medicare Non-Coverage (NOMNC) Form for 1 of 3 residents sampled that were discharged from Medicare Part A services and remained in the facility. Resident #166 was issued the expired form CMS - which expired [DATE]. The facility further failed to immediately mail the correct NOMNC Form to the Personal Representative (PR) after telephonically notifying 3 of 3 RP's of the ending coverage for Medicare Part A services for Resident #61, #113 and #166. The facility also failed to ensure Liability Notices Form CMS or 1 of 5 denial letters were issued for Resident # 61 and #156 for 2 of 3 residents reviewed for the Liability Notices, CMS Form or 1 of 5 Denial Letters. The findings included: Review on [DATE] at approximately 11:06 AM of the facility issued forms for the Liability Notices and Beneficiary Appeal Rights revealed the incorrect form, CMS- had been issued for Resident #166. An updated CMS Form NOMNC - had not been issued. Further review on [DATE] at approximately 11:10 AM of the Notice of Medicare Provider Non-Coverage Forms revealed Resident #61, #113 and Resident #166's Personal Representative had been telephonically notified of ending Medicare Part A Services but the forms had not been immediately mailed to them. Continued review of the Liability Notices on [DATE] at approximately 11:20 AM revealed Resident #61 and #156 were not issued CMS Form or 1 of 5 Denial Letters for 2 of 3 residents reviewed for Liability Notices. During an interview on [DATE] at approximately 11:30 AM with the Financial Services Manager, he/she verified the findings.",2019-11-01
4639,THE METHODIST OAKS,425131,151 LOVELY DRIVE,ORANGEBURG,SC,29115,2016-04-14,156,C,0,1,M9LZ11,"Based on observation, record review, and interview, the facility failed to provide notice of charges, rights, and rules. The facility failed to ensure postings regarding the location of survey results were accessible to residents in wheelchairs on 3 of 3 units, failed to ensure the resident council president knew the location of the ombudsman contact information, and failed to use the correct and most current forms for notification of Medicare non-coverage for 3 of 3 residents reviewed for termination of benefits with days remaining (Residents #32, #136, and #164). The findings included: Record review of the Medicare denial letters was conducted on 4/14/16. The Discharge Planner provided Notice of Medicare Non-Coverage Form No. CMS- (NOMNC) for Residents #32 for services ending 3/21/16, #136 for services ending 9/17/15, and #164 for services ending 2/29/16. All of these residents had days remaining and stayed in the facility. Further review revealed these forms stated the following: Exp. (expiration) Date 08/31/2010. Interview with the Discharge Planner on 4/14/16 at 11:45 AM revealed this was the only form provided for use. Further interview with the Discharge Planner at this time confirmed the facility was not using the CMS- NOMNC (Notice of Medicare Non Coverage) form as required by the Centers for Medicare and Medicaid Services and (s)he was unaware the SNFABN CMS- was also required if residents had days remaining and stayed in the facility. Observations throughout the days of the survey revealed posted information related to how to complain to the State was not readily available to wheel chair bound residents. Observation revealed this information was posted high on a wall. Further observation revealed information related to how to contact the area Ombudsman was not readily available to wheel chair bound residents as well. Interview with the Resident Council President (RCP) on 04/14/2016 at approximately 2:00 pm revealed when asked if he/she was informed of his/her rights and given information on how to formally complain to the State about the care they (resident's) are receiving the RCP responded no. When asked if he/she knew where the Ombudsman information was located the RCP responded I sure do not.",2019-09-01
4640,THE METHODIST OAKS,425131,151 LOVELY DRIVE,ORANGEBURG,SC,29115,2016-04-14,167,C,0,1,M9LZ11,"Based on observation and interview the facility failed to ensure residents the right to review the most current survey results for 3 of 3 units. Survey results were not readily accessible to wheelchair bound residents. The findings included: Observations throughout the days of the survey revealed no posted information related to how to review the results of the most current State inspection. Further observation revealed on one unit the results of the most recent State inspection were noted on top of the Nursing station counter top and was not accessible to wheelchair bound residents. Interview with the Resident Council President (RCP) on 04/14/2016 at approximately 2:00 pm revealed when asked, without having to ask staff, are the results of the State inspection available to read, the RCP responded he/she would have to ask staff but knows that he/she can.",2019-09-01
4651,THE METHODIST OAKS,425131,151 LOVELY DRIVE,ORANGEBURG,SC,29115,2016-04-14,356,C,0,1,M9LZ11,"Based on observation and interview, the facility failed to post staffing hours per regulatory requirement. Nursing staff postings were not done on all days of the survey. The findings included: On 4/11/16 at 4:15 PM and on 4/14/16 at 10:19 AM, a walk through of all 3 nurses stations revealed no nursing staff postings could be located. Interview with the Administrator and the Director of Nurses on 4/14/16 at 11:13 AM revealed they did not know about this requirement and confirmed this information was not posted anywhere in the facility on all days of the survey.",2019-09-01
4691,GOLDEN AGE INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2016-06-15,334,C,0,1,VGC011,"Based on influenza regulation and record reviews, the facility failed to provide documentation of consent and education, and did not follow the facilities policy. Four of 5 resident records reviewed (Residents #34, #41, #51 and #15) did not contain in the medical record the required documentation. The findings included: The facility failed to include documentation that indicates at a minimum that the resident or resident's legal representative was provided education for the most recent Influenza season (2015-2016). The documentation must include the benefits and potential side effects of influenza immunization, and that the resident received or did not receive the influenza immunization due to medical contraindications or refusal. The findings included that 4 of 5 resident records reviewed did not have the education documentation for the influenza (YEAR)-2016 season and obtained consent or refusal. Resident #34, #41, #51 and #15 did not contain in the medical record the required documentation.",2019-09-01
4692,GOLDEN AGE INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2016-06-15,356,C,0,1,VGC011,"Based on initial tour of the facility on 6/16/2016 at 09:30 AM and staff interviews, the facility failed to post the staffing data required and resident census in a prominent place readily accessible to residents and visitors. The findings included: The findings upon staff interviews of RN #4, RN #1 and the DON, did not know where it was posted. Upon further interview at approximately 10:30 AM, RN #4 located posting information on a clipboard behind the nursing station and stated usually kept on the nurses station, but we have a resident that will take it and tear the papers up.",2019-09-01
4724,WHITE OAK MANOR - SPARTANBURG,425024,295 EAST PEARL STREET,SPARTANBURG,SC,29303,2016-05-26,156,C,0,1,PINY11,"Based on record review and interview, the facility failed to ensure that Notice of Medicare Provider Non-Coverage was provided 48 hours prior to discharge for 3 out of 3 sampled residents reviewed for liability notices and beneficiary appeal rights. Residents #35, #65, and #234 were not provided with Notice of Medicare Provider Non-Coverage prior to discharge. The findings included: Review of facility records revealed no Notice of Medicare Provider Non-Coverage was given to Resident #35 prior to his discharge home. In an interview on 05/25/16 at 4:10 PM, the Facility Administrator confirmed no Notice of Medicare Provider Non-Coverage was given to Resident #35 prior to his discharge home because the facility believed since Resident #35 was a short term admission, no Notice of Medicare Provider Non-Coverage was needed. Review of Resident #35's Care Plan revealed he was expected to be a short term admission, but there was no fixed plan for discharge following 20 days or less in the facility. Review of facility records revealed no Notice of Medicare Provider Non-Coverage was given to Resident #65 prior to his discharge home. In an interview on 05/26/16 at 8:54 AM, the Facility Administrator confirmed no Notice of Medicare Provider Non-Coverage was given to Resident #65 prior to his discharge home because the facility believed since Resident #65 was a short term admission, no Notice of Medicare Provider Non-Coverage was needed. Review of Resident #65's Care Plan revealed he was expected to be a short term admission, but there was no fixed plan for discharge following 20 days or less in the facility. Review of facility records revealed no Notice of Medicare Provider Non-Coverage was given to Resident #234 prior to his discharge home. In an interview on 05/25/16 at 4:10 PM, the Facility Administrator confirmed no Notice of Medicare Provider Non-Coverage was given to Resident #234 prior to his discharge home because the facility believed since Resident #234 was a short term admission, no Notice of Medicare Provider Non-Coverage was needed. Review of Resident #234's Care Plan revealed he was expected to be a short term admission, but there was no fixed plan for discharge following 20 days or less in the facility.",2019-08-01
4737,MUSC HEALTH CHESTER NURSING CENTER,425061,1 MEDICAL PARK DRIVE,CHESTER,SC,29706,2016-05-11,156,C,0,1,1UJ011,"Based on record review and interviews, the facility failed to provided the required Centers for Medicare and Medicaid (CMS) Advance Beneficiary Notice (ABN) form for 3 of 3 sampled residents reviewed for notification of medicare liability notices. The findings included: During a review of the medicare liability notices on 5/11/16 at approximately 8:59 AM with the Business Office Manager (BOM) revealed the facility did not provide the Advance Beneficiary Notice (ABN) form for 3 of 3 sampled residents. The BOM stated he/she was not aware that the CMS ABN form was required During an interview with the BOM and Social Services Director at approximately 9:30 AM revealed the facility had been completing the Notice of Medicare Non-Coverage (NOMNC) Centers for Medicare and Medicaid Services (CMS) form but not the Advance Beneficiary Notice (CMS) which does address the resident's right to request a demand bill.",2019-08-01
4793,"GRAND STRAND REHAB AND NURSING CENTER, LLC",425323,4452 SOCASTEE BLVD,MYRTLE BEACH,SC,29588,2016-02-11,356,C,0,1,0L9T11,"Based on observation, record review, and interview, the facility failed to post staffing information on a daily basis and at the beginning of each shift as required. The findings included: During the Initial Tour of the facility on 1/25/16 at approximately 930 AM, the staff posting information was noted to be dated 1/21/16. The surveyor requested a copy of the posting for 1/28/16 at approximately 8:35 AM. Review of the POS [REDACTED]. The Assistant Director of Nursing (ADON) stated that the staffing information was documented by staff on the 11-7 shift. During an interview with the Administrator, Director of Nursing (DON), and ADON on 1/30/16 at approximately 5:00 PM, the ADON provided a copy of the 1/30/16 posting. Review of the POS [REDACTED]. During the interview, the DON and ADON stated that they were unaware of the requirement to post staffing numbers at the beginning of each shift.",2019-08-01
4904,PRESBYTERIAN COMMUNITIES OF SOUTH CAROLINA- CLINTO,425393,801 MUSGROVE STREET,CLINTON,SC,29325,2016-05-25,356,C,0,1,B82Q11,"Based on observation and interview, the facility failed to post the total number and the actual hours worked by the following categories of licensed nursing staff directly responsible for resident care per shift: registered nurse and licensed practical nurses. The posting did not indicate if the nurse on duty was a registered nurse or a licensed practical nurse. There was also no notation to identify the registered nurse coverage for 8 hours per day as required. One of one unit. The findings included: Review of the Daily Staffing post sheets revealed there is no designation for LPN or RN. There is no documentation of who the RN is or that they are working an 8 hour shift. Staff postings were reviewed from 11/23/15-5/24/16. In an interview with the surveyor on 05/25/2016 at approximately 11:18 AM , the DON (Director of Nursing) stated RN coverage is not on the posting sheet but it is on the schedule. The DON confirmed the findings that coverage is not designated as RN or LPN on the Daily Staffing post sheets.",2019-07-01
4922,SAVANNAH GRACE AT THE PALMS OF MT PLEASANT,425404,1010 LAKE HUNTER CIRCLE,MOUNT PLEASANT,SC,29464,2016-02-10,156,C,0,1,2S3A11,"Based on record review and interview, the facility failed to provide the required CMS Form -NOMNC notices to 2 of 3 sampled residents who had been discharged from Medicare Part A services with days of eligibility remaining. (Resident #77 and Resident #90) The findings included: A review of Liability and Appeal Notices with the Social Services Director on 2/10/16 at approximately 2:00 PM revealed that Resident #77 and Resident #90 had been discharged from Medicare Part A services with Medicare eligibility days remaining. When the surveyor requested to review the required CMS Form -NOMNC for both residents, the Social Services Director was unable to locate the forms. After attempting to locate the forms, the Social Services Director informed the surveyor that he/she was unable to find the documents and that copies of the forms had not been saved",2019-07-01
4934,VIBRA HOSPITAL OF CHARLESTON -TCU,425405,1200 HOSPITAL DR 2ND FL,MOUNT PLEASANT,SC,29464,2016-04-28,167,C,0,1,YC7O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interview, the facility failed to ensure that the results of the most recent survey was readily available to residents and visitors for 3 of 4 days of the survey. The findings included. Upon entrance to the facility on [DATE], a sign was noted in the lobby indicating the location of survey results at the nursing station. Observations throughout the first 3 days of the survey revealed no named document or notebook visible at the nursing station. During an interview at 6 PM on 4-27-16 at the nursing station, Licensed Practical Nurse #2 was unaware of the location of the survey results. The[NAME] Secretary stated, There's a sign posted that it's at the nurse's station. It's kept back here. S/he indicated the cabinet countertop against the wall behind the nursing station. The[NAME] Secretary and Director of Nurses confirmed that the notebook was not readily accessible to residents or visitors wishing to examine survey results without having to ask a staff person.",2019-07-01
4962,BAYVIEW MANOR,425067,11 TODD DRIVE,BEAUFORT,SC,29901,2015-08-17,156,C,0,1,YI1S11,"Based on review of residents' funds and interview, the facility failed to complete 3 of 3 Skilled Nursing Facility Advance Beneficiary Notice(SNFABN), accurately and in a timely manner for sampled residents discharged from Medicare A.(Residents #39, #233, and #241). The findings included: On 8/14/15 at approximately 2:20 PM, review of funds for Resident #39, #233, and #241 revealed the facility had not completed the SNFABN accurately and in a timely manner. The authorized representative for each resident had signed the incomplete SNFABN on admission. During an interview on 8/14/15 at 2:26 PM, the Admissions Coordinator stated the SNFABN letters were done on admission due to Corporate placing the form in the admission packet. At the time of review, the Admission Coordinator confirmed the forms were incomplete. On 8/14/15 at 2:43 PM, the Admissions Coordinator stated the facility did not have a policy related to SNFABN letters.",2019-06-01
4964,BAYVIEW MANOR,425067,11 TODD DRIVE,BEAUFORT,SC,29901,2015-08-17,167,C,0,1,YI1S11,"On three days of the survey, based on observations and interview, the results of the most recent survey of the facility conducted by State surveyors was not available for examination. The findings included: Observation of the survey results book on 8/10/15, 8/11/15, and 8/12/15 revealed no survey results were available for examination. During an interview with with Director of Nursing on 8/14/15 at approximately 4:00 PM, he/she stated the results had been removed so that a new copy of the results could be placed in the book.",2019-06-01
5038,LIFE CARE CENTER OF COLUMBIA,425337,2514 FARAWAY DRIVE,COLUMBIA,SC,29223,2015-06-04,156,C,0,1,T7R511,"Based on record review and interview, the facility failed to provide Liability Notices for 3 of 3 residents reviewed for Liability Notices and Beneficiary Appeal Rights.(Residents #81, 80, and 234) The findings included: Review of the Notice of Medicare Provider Non-Coverage (CMS- NOMNC) and Liability Notices(SNFABN-CMS or 1 of 5 Denial Letters) on 6/4/15 at approximately 10:00 AM revealed Resident #81, #89, and #234, after being taken off Medicare Part A, remained in the facility with days remaining under Medicare Part A. Further review revealed a Liability Notice(SNFABN-CMS or 1 of 5 Denial Letters) had not been issued to each resident as required. During an interview on 6/4/15 at 10:15 AM with the Social Worker, s/he stated s/he was not aware a Liability Notice needed to be issued and had not been issuing the SNFABN-CMS or 1 of 5 Denial Letters.",2019-06-01
5052,THE RETREAT AT BRIGHTWATER,425395,171 BRIGHTWATER DRIVE,MYRTLE BEACH,SC,29579,2016-01-15,167,C,0,1,LLRD11,"F-167 Based on observation and interview, the facility failed to post the most recent survey of the facility conducted by the State surveyors in a readily accessible place nor did the facility post a notice to the availability of the survey results. The findings included: During an interview with Resident #115 on 1/15/16, he/she stated he/she did not know where the most recent State survey results were located. Review of the Resident Council Minutes for three months revealed there was no discussion to where the State survey results were located. Observation of the facility on 1/15/16 revealed there was no posting of a notice as to where the State survey results were located. The State survey results were observed on the Willows Unit on a table in front of the dining room. There were no survey results on the Cypress Unit. During an interview with the Administrator on 1/15/16 at 4:30 PM, he/she confirmed there was no notice posted as to where the State survey results were located.",2019-06-01
5090,RIDGELAND NURSING CENTER INC,425132,1516 GRAYS HIGHWAY,RIDGELAND,SC,29936,2015-07-23,156,C,0,1,OJWN11,"Based on review of residents' funds and interview, the facility failed to complete 2 of 3 required Centers for Medicare and Medicaid Services(CMS) -Notice of Medicare Non-Coverage (NOMNC) forms and 3 of 3 Medicaid Liability Notices and Beneficiary Appeal Rights, accurately and in a timely manner for sampled residents discharged from Medicare A.(Resident #28, #34, & #50) The findings included: Review of the Notice of Medicare Provider Non-Coverage (CMS- NOMNC) on 7/22/15 revealed Resident #34 and #50 had incomplete forms. There was incomplete information related to the effective date of coverage, when services would end and what type of services would end. Further review revealed the responsible party signed the incomplete forms but did no date the forms. During the review no Liability Notices(SNFABN-CMS or 1 of 5 Denial Letters) were found for Residents #28, #34, & #50. On 7/23/15 at 10:41 AM, during an interview with the Social Service Director, he/she confirmed the CMS- NOMNC were not complete and no SNFABN-CMS or 1 of 5 Denial Letters had been completed for Residents #28, 34, & 50.",2019-05-01
5197,HEARTLAND OF WEST ASHLEY REHAB AND NURSING CENTER,425362,1137 SAM RITTENBURG BLVD,CHARLESTON,SC,29407,2015-06-11,156,C,0,1,T7PS11,"Based on review of the facility's records and interview, the facility failed to utilize the CMS form or 1 of the 5 approved Liability Notices for Resident #8 and #11, who stayed in the facility after Medicare coverage ended, 2 of 2 residents reviewed for Liability Notices. In addition, the facility failed to offer Residents #8 and #11 the option of receiving services and submitting a Demand Bill to the intermediary for a Medicare decision. The findings included: On 6/10/15 at approximately 4:00 PM, review of the liability notices revealed the facility was not using the CMS or 1 of the other 5 approved generic letters. Further review revealed the request for intermediary review was blank on both forms. At 4:20 PM, the Social Services Director confirmed the request for a demand bill was blank and stated I never get the residents to choose whether or not to submit a demand bill. The SSD further confirmed the denial letters used by the facility was not one of the 5 generic denial letters",2019-03-01
5198,HEARTLAND OF WEST ASHLEY REHAB AND NURSING CENTER,425362,1137 SAM RITTENBURG BLVD,CHARLESTON,SC,29407,2015-06-11,160,C,0,1,T7PS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's records and interview, the facility failed convey within 30 days the resident's funds, and a final accounting of those funds, to the individual or probate jurisdiction administering the resident's estate for 4 of 4 residents reviewed for conveyance of funds. Residents A, B, C, and D's funds were not conveyed within 30 days and Resident A's balance was conveyed to the resident, not to the estate. The findings included: On [DATE] at approximately 4:30 PM, review of conveyance of funds revealed Residents A expired on [DATE]. The balance of the trust fund account, $43.35, was conveyed on [DATE] and the payee on the check was the resident, in care of the responsible party. Resident B expired on [DATE] and the balance of the trust fund account, $103.82, was conveyed on [DATE]. Resident C expired on [DATE] and the balance of the trust fund account, $221.81, was conveyed on [DATE]. Resident D expired on [DATE] and the balance of the trust fund account, $1,496.57, was conveyed on [DATE]. During an interview at the time of the review, the Business Office Manager (BOM) stated that Resident B's conveyance was late due to attempts to contact the resident's son to confirm to whom the check should be written. The BOM also stated that s/he did not know why the check for Resident A was written to the resident and not to the estate. In addition, the BOM stated that the corporate office wrote the checks and that s/he sent the notice to the corporate office within 30 days.",2019-03-01
5240,GHS LILA DOYLE,425075,101 LILA DOYLE DRIVE,SENECA,SC,29672,2015-07-09,156,C,0,1,A2KC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of Liability Notices and Beneficiary Appeal Rights and interview, the facility failed to provide residents with the current Centers for Medicare and Medicaid Services (CMS) Form CMS -Notice of Medicare Non-Coverage (NOMNC) for 3 of 3 residents discharged from Part A Medicare Services (Residents #85, #156, and #126). The findings included: On [DATE] at approximately 2:00 PM, a review of Liability Notices and Beneficiary Appeal Rights revealed that Residents #85, #156, and #126 were issued Form CMS to inform them of their discharge from Medicare Part A Services. During an interview on [DATE] at approximately 11:30 AM, the Business Office Manager reviewed the notices with the Surveyor. The Business Office Manager stated that the facility became aware of the most current Form CMS -NOMNC about one month ago and that the current form was now being used. The Business Office Manager confirmed that the dates that Residents #85, #156, and #126 received notices of Medicare Non-Coverage was after the date that the new CMS Form was issued; and therefore, their forms were expired.",2019-02-01
5305,MILLENNIUM POST ACUTE REHABILITATION,425105,2416 SUNSET BOULEVARD,WEST COLUMBIA,SC,29169,2015-03-18,167,C,0,1,546D11,"Based on record review and interview, the facility failed to post the results of 3 Complaint Inspections conducted since the last Recertification Survey on 2 of 2 nursing units, readily accessible to residents and visitors. The findings included: On 3/18/15 at approximately 9:50 AM, observation of the survey result books, located in the front lobby on the 1st floor and next to the elevator on the 2nd floor, revealed the results of the Recertification Survey dated 9/26/13 were in the books. Continued review revealed the results of Complaint Inspections conducted on 9/16/14, 1/8/15 and 1/21/15 were not posted in either of the 2 books. During an interview at 9:55 AM, the Nursing Home administrator confirmed the results were not in the books and stated Oh, we have to put those in there, too.",2019-01-01
5347,WESTMINSTER HEALTH & REHAB CENTER,425291,831 MCDOW DRIVE,ROCK HILL,SC,29732,2016-01-21,334,C,0,1,ZBI211,"Based on record reviews, interview and the facility's VACCINATION OF RESIDENTS policy, the facility failed to ensure that 5 of 5 sampled residents reviewed for documentation of immunization education was provided for 5 of 5 census sampled residents reviewed. (Residents #29, #57, #114, #117 and #120) The findings included: Review of 5 of 5 census charts on 1/19/16 that included Residents #29, #57, #114, #117 and #120 revealed there was no documentation in the medical record to indicate immunization education was provided. Review of the facility's VACCINATION OF RESIDENTS policy revealed under #1: Prior to receiving vaccinations, the resident or legal representative will be provided information and education regarding the benefits and potential side effects of the vaccinations. #2: Provision of such education shall be documented in the resident's medical record. #5: If vaccinations are refused, the refusal shall be documented in the resident's medical record. An interview on 1/19/16 at approximately 3:50 PM with the Director of Nursing (DON) confirmed the findings that there was no documentation in the medical record to determine that immunization education was provided related vaccines.",2019-01-01
5424,"PEPPER HILL NURSING & REHAB CENTER, LLC",425308,3525 AUGUSTUS ROAD,AIKEN,SC,29802,2015-05-29,167,C,0,1,GYMV11,"Based on review of the facility's survey book and interview, the facility failed to post the results of the most recent Recertification Survey. The results of the facility's last Recertification Survey were not readily accessible for the residents to view and were not in the facility's survey book. The findings included: A review of the facility's survey book (maintained in the main lobby of the facility) on 5/27/2015 at 4:43 PM revealed that the results of the most recent Recertification Survey were not in the book. During an interview on 5/27/2015 at 4:45 PM, the Nursing Home Administrator confirmed the results of the last Recertification Survey were not in the survey book and were not posted elsewhere in the facility.",2018-12-01
5440,C M TUCKER NURSING CARE CENTER / RODDEY,425360,2200 HARDEN STREET,COLUMBIA,SC,29203,2015-12-17,170,C,0,1,R72X11,"Based on interviews with the Resident Council President and the Director of Health Information Services, the facility failed to allow residents to exercise their right to send and promptly receive mail that is unopened on Saturdays. The findings included: During the interview with the Resident Council President, Resident #108, on 12/16/2015 at approximately 3:45 PM, he/she stated that residents do not receive mail on Saturdays. During the interview with the Director of Health Information Services on 12/16/2015 at approximately 4:10 PM, he/she confirmed that mail is not delivered on Saturdays because the facility Administrative Office is closed. Local U.S. Mail Delivery Service is aware that the facility Administrative Office is closed and therefore delivers mail Monday through Friday only. The Director of Health Information Services added that during the week, mail is sorted and staff from the units pick it up for the residents to disseminate to them; or some residents come up to the front window of the Administrative Office themselves to get their mail.",2018-12-01
5463,OPUS POST ACUTE REHABILITATION,425379,300 AGAPE DRIVE,WEST COLUMBIA,SC,29169,2015-05-06,167,C,0,1,10H311,"Based on observation, record review, and interview, the facility failed to ensure complaint survey results were accessible for review by residents or the public for 1 of 3 complaint surveys conducted since the most recent standard survey. A Complaint survey conducted on 10/16/14 was not posted in the facility. The findings included: Observation on 5/6/15 at approximately 9:00 AM revealed there were survey notebooks in two locations in the facility. One survey notebook was located near the 100 hallway between the nurse's station and the therapy room, and another survey notebook was located by the nurse's station near rooms 1-24. Record review at the time of the observation revealed both survey notebooks contained the survey results for the previous standard (Recertification/Complaint) survey on 4/16/14 as well as Complaint surveys on 8/6/14 and 1/26/15, but did not contain the Complaint survey conducted on 10/16/14. Interview with the facility Administrator on 5/6/15 at 10:35 AM confirmed the 10/16/14 Complaint survey was not available for review by residents or the public.",2018-12-01
5489,VIBRA HOSPITAL OF CHARLESTON -TCU,425405,1200 HOSPITAL DR 2ND FL,MOUNT PLEASANT,SC,29464,2015-12-16,519,C,1,0,MUQO11,"> Based on record review and interview, the facility failed to have current transfer contracts with a hospital. 3 of 3 Hospital Contracts reviewed were not for the current facility. The findings included: During the extended survey on 12/15/15 at approximately 5:00 PM, the facility contracts were reviewed. The facility had no current transfer agreements with any hospital. The hospital agreements the facility provided were dated in 2011 and were for a facility that belonged to another company. The Corporate Licensure/Accreditation Officer confirmed the facility needed current transfer agreements.",2018-12-01
5607,WOODRUFF MANOR,425179,1114 EAST GEORGIA ROAD,WOODRUFF,SC,29388,2015-06-04,167,C,0,1,02VR11,Based on observations and interviews the facility failed to make the most recent survey results accessible and failed to post signs for location of results on 2 of 2 units. The findings include: On 6/4/15 at approximately 8:30 AM the most recent survey results were found on a side table in the entrance lobby and the door from the two resident units to the lobby was locked and could only be opened with a key by a member of the facility staff. On 6/4/15 at approximately 8:35 AM no signs were found posted for location of survey results on the two nursing units. On 6/4/15 at approximately 8:40 AM the person responsible for Medical Records and the Administrator stated that the survey results were kept in the lobby and the Administrator stated that survey results were kept near the exit door to the outside smoking area and that there should be a sign on each nursing unit. On 6/4/15 at approximately 8:45 AM the person responsible for Medical Records discovered that there were no survey results near the exit door to the smoking area and was unable to locate a sign on either of the two nursing units.,2018-11-01
5618,WOODRUFF MANOR,425179,1114 EAST GEORGIA ROAD,WOODRUFF,SC,29388,2015-06-04,501,C,0,1,02VR11,"Based on interview and review of the facility's files in conjunction with the Extended Survey, the facility failed to have a valid contract for the Medical Director. The findings included: On 6/3/15 at approximately 10:00 AM, review of the facility's contracts revealed a Medical Director Agreement dated (MONTH) 1, 2014 and renewed automatically for successive annual renewal terms thereafter. Further review revealed the contract was signed by the Nursing Home Administrator. There was no signature as to the Physician and there was no witness signature to the Administrator. At approximately 11:30 AM, the Administrator confirmed the contract was not signed.",2018-11-01
5749,MAGNOLIA PLACE - GREENVILLE,425361,35 SOUTHPOINT DRIVE,GREENVILLE,SC,29607,2015-04-28,167,C,0,1,IEII11,Based on interview and observation the facility did not have a posting of where the survey results were located in the facility. The findings included: On 4/27/15 a tour of the facility was made by two surveyors and no posting for the location of the survey results could be found. An interview with the Director of Nursing then at 4 PM confirmed there were no postings in the building of where the survey could be located.,2018-10-01
5760,COVENANT TOWERS HEALTHCARE CENTER,425382,5001 LITTLE RIVER ROAD,MYRTLE BEACH,SC,29577,2015-01-29,156,C,0,1,EI2O11,"Based on review of residents' funds and interview, the facility failed to complete the required Centers for Medicare and Medicaid Services (CMS) -Notice of Medicare Non-Coverage (NOMNC) Form, the Medicare Liability Notices and Beneficiary Appeal Rights, on the correct form for 3 of 3 sampled residents discharged from Medicare A and discharged from the facility. The facility staff completed the CMS- instead of the required CMS- NOMNC for Resident #11, Resident #44, and Resident #49. The findings included: On 01-27-15 at approximately 12:30 PM, review of Resident #11's, Resident #44's, and Resident #49's funds revealed the residents were discharged from Medicare A with days remaining and discharged from the facility. Further review of Resident #11's, Resident #44's, and Resident #49's funds revealed the facility had completed the Medicare Liability Notices and Beneficiary Appeal Rights on the incorrect form, CMS- , instead of the correct form of CMS- -NOMNC. During an interview on 01-27-15 at approximately 12:30 PM with the Director of Social Services, he/she revealed he/she had been unaware the CMS- form could not be used.",2018-10-01
5807,COVENANT PLACE NURSING CENTER,425402,2825 CARTER ROAD,SUMTER,SC,29150,2015-03-05,156,C,0,1,EZTI11,"Based on review of residents' funds and interview, the facility failed to complete the required Centers for Medicare and Medicaid Services (CMS) -Notice of Medicare Non-Coverage (NOMNC) Form, the Medicare Liability Notices and Beneficiary Appeal Rights, on the correct form for 3 of 3 sampled residents discharged from Medicare A and discharged from the facility. The facility staff completed the CMS- instead of the required CMS- NOMNC for Resident #2, Resident #12 and Resident #42. The findings included: On 03-04-15 at approximately 12:10 PM, review of Resident #2's, Resident #12's and Resident #42's funds revealed the residents were discharged from Medicare A with days remaining and discharged from the facility. Further review of Resident #2's, Resident #12's and Resident #42's funds revealed the facility had completed the Medicare Liability Notices and Beneficiary Appeal Rights on the incorrect form, CMS- , instead of the correct form of CMS- -NOMNC. During an interview on 03-04-15 at approximately 12:10 PM with the Admissions Coordinator, he/she revealed he/she had been unaware of the correct CMS- NOMNC form.",2018-09-01
5840,PRUITTHEALTH-MONCKS CORNER,425140,505 SOUTH LIVE OAK DRIVE,MONCKS CORNER,SC,29461,2014-11-20,159,C,0,1,MMVE11,"Based on record review and interview, the facility failed to provide quarterly statements to 3 of 4 sampled residents reviewed for personal funds. (Residents #96, #4 and #32) The findings included: During resident interviews on 11/19/14, Residents #96, #4 and #32 stated that they did not receive quarterly statements to inform them of how much money they had in their Resident Trust Fund accounts. During an interview with the Financial Manager on 11/20/14 at approximately 9:20 AM, s/he stated that the residents could get their quarterly statements if they came to the office and requested one. Further along in the interview, the Financial Manager also reported that the statements were sent to alert and oriented residents. S/he stated that the residents who were interviewed (Residents #96, #4 and #32) were all alert and oriented and had a Resident Trust account. The Financial Manager stated that s/he sent these statements to the residents' responsible parties due to the fact that they were the ones who deposited money into the residents' accounts.",2018-08-01
5888,PRESBYTERIAN COMMUNITIES OF SOUTH CAROLINA-SUMMERV,425389,201 W 9TH NORTH STREET,SUMMERVILLE,SC,29483,2015-07-01,156,C,0,1,JGEW11,"Based on observation, record review, and interview, the facility failed to provide notice of charges, rights, and rules. The facility failed to ensure Medicare, Medicaid, and advocacy agency postings were accessible to residents in wheelchairs on 1 of 1 unit, and failed to use the correct and most current form for notification of Medicare non-coverage for 1 of 1 resident reviewed for termination of benefits with days remaining (Resident #5). The findings included: Observation on 6/29/15 at 11:40 AM, 6/30/15 at 12:00 PM, and 7/1/15 at 12:40 PM revealed the Medicare, Medicaid, and advocacy agency postings were located on a bulletin board with a copier directly beneath them, which prevented wheelchair residents from having access to this information. Interview with the Administrator in Training on 7/1/15 at 1:20 PM revealed there had not been any complaints, but they could look at moving the copier or postings to make this information more accessible. Record review of the Medicare denial letters was conducted on 7/1/15. The Administrator in Training provided a Notice of Medicare Provider Non-Coverage (CMS- ) letter signed by Resident #5 on 6/23/15. Resident #5 no longer met requirements to remain under Medicare A benefits effective 6/27/15. Further review revealed this form stated the following: Exp. (expiration) Date 07/31/2011. Interview with the Administrator in Training and the Director of Social Services on 7/1/15 at approximately 9:45 AM confirmed the facility was not using the CMS- NOMNC (Notice of Medicare Non Coverage) form as required by the Centers for Medicare and Medicaid Services.",2018-08-01
5927,THE METHODIST OAKS,425131,151 LOVELY DRIVE,ORANGEBURG,SC,29115,2014-12-12,156,C,0,1,96C711,"Based on record review and interview, the facility failed to provide Liability Notices (CMS or one of the approved CMS non-coverage notices) and/or Notices of Medicare Non-Coverage (CMS NOMNC) to 3 of 3 residents reviewed for Liability Notices (Residents #149, #161, and #166). The findings included: Liability and/or Appeal Notices were requested for Residents #149, #161, and #166 during a review of Liability Notices on 12/12/14. During an interview with the surveyor on 12/12/14 at approximately 5:00 PM, the business office staff informed the Director of Nursing by telephone that no Liability Notices had been sent to any of these residents. The Administrator was present during the interview and confirmed to the surveyor that no notices had been sent as required.",2018-07-01
6017,EMERITUS AT GREENVILLE,425373,1306 PELHAM RD,GREENVILLE,SC,29615,2014-12-18,156,C,0,1,MXTQ11,"Based on record review and interview, the facility failed to provide a CMS (Centers for Medicare and Medicaid Services)- or one of the five CMS approved forms as required for 1 of 3 residents reviewed for Liability Notices and Beneficiary Appeal Rights. The facility failed to provide Resident A with an approved liability notice upon exhaustion of Medicare Part A benefits. The findings included: Record review on 12/16/14 at approximately 3:30 PM revealed that Resident A was mailed a Benefits Exhausted letter on 10-24-14 by the Administrative Officer, advising the resident of non-coverage of services under Medicare effective 10-28-14. The notice provided to Resident A was not one of those approved by CMS. During an interview on 12/16/14 at approximately 4:00 PM, the Administrative Officer stated, I have done it this way for years when a resident had exhausted their Medicare days. I call the family and let them know verbally myself that the days will be exhausted for Medicare coverage. I am not aware of a form or a denial letter to be used for this event. I mail out to the resident the facility approved letter when the days are being exhausted.",2018-07-01
6132,ROLLING GREEN VILLAGE,425160,1 HOKE SMITH BOULEVARD,GREENVILLE,SC,29615,2014-12-31,156,C,0,1,D2FB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide the appropriate Medicare non-coverage letters to 3 of 3 residents reviewed for liability notices upon termination of Medicare coverage. In addition, the facility failed to provide a CMS (Centers for Medicare and Medicaid Services) Form or one of 5 other approved denial letters to 1 of 1 resident reviewed for termination of Medicare coverage who remained in the facility. The findings included: On [DATE] at 5:05 PM, review of Liability Notices and Beneficiary Appeal Rights revealed 3 residents were provided CMS Form NOMNC (Notice of Medicare Non-Coverage) when their Medicare Coverage was terminated instead of the required CMS NOMNC. The CMS Form NOMNC stated on the bottom of the form (Exp. (Expired) [DATE]). Further review revealed that 1 of the 3 residents had Medicare days remaining and stayed in the facility. The CMS Form or 1 of 5 approved Denial letters was not provided to that resident as required. During an interview on [DATE] at 5:15 PM, the Social Worker confirmed the facility was not providing the CMS or one of the five approved letters when residents' Medicare coverage was terminated with days remaining. S/he further confirmed the facility was providing the CMS NOMNC which had expired [DATE].",2018-05-01
6184,LAKE EMORY POST ACUTE CARE,425303,59 BLACKSTOCK ROAD,INMAN,SC,29349,2015-08-20,156,C,0,1,JA3E11,"Based on record reviews and interviews, the facility failed ensure that 3 of 3 sampled residents reviewed for notice of medicare coverage received the required Skilled Nursing Facility Advanced Beneficiary Notice (ABN), Center for Medicare Service (CMS) form. Residents #116, #120 and #130 with additional medicare days did not receive notice to request a demand bill. The findings included: During an interview on 8/19/15 at approximately 2:49 PM with the Social Services Director (SSD) revealed the facility provided the CMS Notice of Medicare Non-Coverage but did not provide the CMS Advanced Beneficiary Notice. At approximately 2:57 PM on 8/19/15, the SSD called the Business Office Manager who stated the facility did not use the CMS form or any form developed by the facility to inform residents of their rights to request a demand bill.",2018-05-01
6243,"BRUSHY CREEK REHABILITATION AND HEALTHCARE CENTER,",425004,101 COTTAGE CREEK CIRCLE,GREER,SC,29650,2014-09-04,156,C,0,1,0BDJ11,"Based on record review and interviews, the facility failed to provide either the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) (Form CMS- ) or one of the five uniform Denial Letters to Residents #4, #5, and #15, 3 of 3 residents reviewed for liability notices that had a change in payer source with Medicare days remaining. The findings included: On 9/4/14 at approximately 11:00 AM, review of the liability notices revealed no Advanced Beneficiary Notice (Form CMS- ) or one of the five uniform Denial Letters had been provided to Residents #4, #5, or #15, who had a change in payer with Medicare A days remaining. During an interview at that time, LBSW (Licensed Bachelor's Social Worker) #2 stated s/he would look into the concern. LBSW #2 returned to the business office with LBSW #1 who stated that therapy provided the CMS- forms. When asked for the forms for the 3 residents, LBSW #2 stated They're Medicare A (residents). After confirming the payer source with the LBSW, s/he then questioned if the letters had to be given to Medicare A residents. The LBSW stated s/he would investigate and provide additional information. No further information was provided.",2018-04-01
6244,"BRUSHY CREEK REHABILITATION AND HEALTHCARE CENTER,",425004,101 COTTAGE CREEK CIRCLE,GREER,SC,29650,2014-09-04,159,C,0,1,0BDJ11,"Based on record review, interviews, and review of the facility's policy, Resident Funds, the facility failed to deposit residents' personal funds in excess of $50 in an interest bearing account for Resident #20, #23, #A and #B, 4 of 10 residents reviewed with a resident trust fund. The findings included: On 9/4/14 at approximately 2:15 PM, review of the resident's trust fund accounts revealed Resident #20 had an account balance of $97.79, #23 had a balance of $90.00, Resident A had a balance of $60.00, and #B's account balance was 100.00. During an interview at 3:45 PM, the Account Specialist confirmed the 4 resident had trust fund account balances, being held by the facility, in excess of $50.00 and were not in an interest bearing account. The Account Specialist also stated s/he thought that a resident who was private pay could have up to $100.00 before it had to be deposited in an interest bearing account. Review of the facility's policy, Trust Funds, revealed 1. Our business office will deposit any Resident's personal funds in excess of $50 in an interest bearing account that is separate from any of the facility's operating accounts, and that credits all interest earned on that account to his/her account.",2018-04-01
6256,MAGNOLIA MANOR - GREENVILLE,425090,411 ANSEL ST,GREENVILLE,SC,29601,2014-06-19,156,C,0,1,336311,"On the days of the survey, based on Liability Notices and Beneficiary Appeal Rights form review and interview, the facility failed to use the correct mandated form for Notice of Medicare Provider Non-Coverage (NOMNC) for 3 of 3 residents reviewed. The findings included: On 06/18/14 at approximately 10:00 AM, during the review of liability notices issued by the facility, it was revealed that the facility was using the form instead of the updated NOMNC form. Interview with the Business Office Manager at the time of the findings confirmed that the updated NOMNC forms were not being used and he/she was unaware the form had been updated.",2018-04-01
6528,BLUE RIDGE OF SUMTER,425310,1761 PINEWOOD ROAD,SUMTER,SC,29154,2014-08-13,156,C,0,1,NZ2Z11,"Based on record review and interview, the facility failed to use the required Liability and Beneficiary Appeal Rights notification of Medicare Non-Coverage forms for 2 of 2 residents reviewed. (Resident A and B) The findings included: On 08/12/14 at approximately 2:30 PM during a review of the Liability and Beneficiary Appeal Rights notifications sent to Residents A and B, it was noted the form was being used instead of the required NOMNC (Notice of Medicare Non-Coverage) form. During an interview with the Social Worker at approximately 2:45 PM, s/he confirmed s/he was issuing the notice instead of the required NOMNC forms.",2018-01-01
6536,BETHEA BAPTIST HEALTHCARE CENTER,425372,157 HOME AVENUE,DARLINGTON,SC,29532,2014-08-21,156,C,0,1,MOWB11,"Based on review of residents' funds and interview, the facility failed to complete the required Centers for Medicare and Medicaid Services (CMS) -Notice of Medicare Non-Coverage (NOMNC) Form, the Medicare Liability Notices and Beneficiary Appeal Rights, on the correct form for 3 of 3 sampled residents discharged from Medicare A and discharged from the facility. The facility staff completed the CMS- instead of the required CMS- NOMNC for Resident #48, Resident #68, and Resident #106. The findings included: On 08-21-14 at approximately 10:00 AM, review of Resident #48's, Resident #68's, and Resident #106's funds revealed the residents were discharged from Medicare A and discharged from the facility. Further review of Resident #48's, Resident #68's, and Resident #106's funds revealed the facility had completed the Medicare Liability Notices and Beneficiary Appeal Rights on the incorrect form, CMS- , instead of the correct form of CMS- -NOMNC. During an interview on 08-21-14 at approximately 10:15 AM with the Director of Social Services, he/she revealed he/she had been unaware of the correct CMS- NOMNC form.",2018-01-01
6553,WILLOW BROOK COURT AT PARK POINTE VILLAGE,425375,3025 CHESBROUGH BLVD,ROCK HILL,SC,29732,2014-10-08,167,C,0,1,HQ2811,"Based on observation and interviews, the facility failed to ensure the survey results were readily accessible to residents and failed to post a notice of their availability on 1 of 1 units. The findings included: On 10/7/14 at 10:10 AM, the facility's survey results were observed in a wooden case with glass doors. The case was located with the top approximately 8-10 inches from the ceiling with a lock located approximately in the middle of the cabinet and the key was in the lock. During an interview at that time, the Nursing Home Administrator confirmed the residents would have to open the case to read the survey result. The Administrator stated that the residents could ask anyone to get the information for them but also confirmed that the residents in wheelchairs would not be able to access the information independently. At approximately 4:00 PM on 10/8/14, the Administrator also confirmed there was no signage posted that survey results were available and could be read by any individual.",2018-01-01
6671,MAGNOLIA MANOR - GREENWOOD,425172,1415 PARKWAY DRIVE,GREENWOOD,SC,29646,2014-02-19,156,C,0,1,0RV111,"On the days of the survey, based on review of the Liability Notices and Beneficiary Appeal Rights and interview, the facility did not provide proper notification of medicare provider-non coverage for 3 of 3 residents reviewed. The findings included: On 02/18/14 at approximately 2:45 PM during a review of three residents remaining in the facility, who had Medicare Part A coverage days remaining but were denied coverage, revealed that form for Notice of Medicare Provider Non-Coverage for Beneficiary Appeal Rights (NONMC) was not used. Interview with the Admissions Director verified the facility was not using the required form for residents remaining in the facility who had not used all their Part A days.",2017-11-01
6713,MAGNOLIA PLACE - GREENVILLE,425361,35 SOUTHPOINT DRIVE,GREENVILLE,SC,29607,2013-11-15,167,C,0,1,0V5K11,"On the days of the Recertification Survey, based on record review and interview, the facility failed to have all survey results since the last Recertification Survey available for review. The findings included: On 11/13/13 at approximately 3:00 PM, review of the facility's Survey Book, maintained in the front lobby, revealed survey results for the last Recertification Survey dated 9/5/13 and a Complaint Inspection dated 3/14/13. The facility also had a Complaint Inspections on 10/2/12, and 6/25/13, During an interview at 5:30 PM, the Nursing Home Administrator (NHA) confirmed only the 9/25/12 and 3/14/13 surveys were in the Survey Book. The NHA stated that someone had been looking at the book recently and s/he did not know where the 10/2/12 and 6/25/13 surveys were.",2017-11-01
6880,HERITAGE HOME OF FLORENCE INC,425154,515 SOUTH WARLEY STREET,FLORENCE,SC,29501,2013-09-27,156,C,0,1,WZ6X11,"On the days of the survey, based on record review and interview, the facility failed to provide the appropriate Notices of Medicare Non Coverage Letters for 3 of 3 residents reviewed for Medicare Beneficiary Liability Notices. The findings included: Review of the Medicare Non Coverage Notice on 9/27/13 at 8:37 AM revealed Resident #136, #29 and #34 did not receive the appropriate notification letter, which is the CMS NOMNC (Notice of Medicare Non Coverage- approved 12/31/2011). The notification form that was provided to the sampled residents by the facility was the CMS . During an interview with Social Services on 9/27/13 at 9:36 AM, he/she confirmed the CMS NOMNC was not provided to the residents. He/she stated was not aware of the updated form or any revisions. .",2017-08-01
6881,HERITAGE HOME OF FLORENCE INC,425154,515 SOUTH WARLEY STREET,FLORENCE,SC,29501,2013-09-27,170,C,0,1,WZ6X11,"On the days of the survey, based on interview with the Resident Council President and facility staff interview, the facility failed to provide Saturday mail delivery to its residents. The concern had the potential to affect all residents residing in the facility. The findings included: During an interview with the Resident Council President on 9/27/13 at approximately 12:08 PM, he/she stated that Residents do not receive mail on Saturdays. The Resident Council President was not aware if the mail was delivered to the facility on Saturdays. An interview was held with the Social Services Director on 9/27/13 at approximately 12:15 PM, who confirmed the Postal Service delivers resident's mail Monday through Friday and the Activity program was in charge of passing out mail to the residents. During an interview with the Activity Director on 9/27/13 at 12:20 PM, he/she stated no one was in the business office on Saturday's to receive the resident's mail if it was delivered to the facility. The Activity Director also stated Saturday mail delivery was available in the area but there was not a system in place for the resident's to receive mail delivery on Saturday.",2017-08-01
7031,RIVERSIDE HEALTH AND REHAB,425082,2375 BAKER HOSP BLVD,CHARLESTON,SC,29405,2013-11-01,519,C,0,1,Q0FH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification survey, based on review of the facility contracts, the facility failed to assure that a written transfer agreement/contract with a hospital was in effect. The findings included: The facility had a transfer agreement (contract) with a local hospital originally dated ,[DATE]. The contract stated the agreement shall continue effect for 5 years. The facility had no current, valid transfer agreement with a hospital during the days of the survey. During an interview with the Director of Nurses on [DATE] s/he confirmed the contract was expired but was in the process of getting a new agreement.",2017-06-01
7069,"THE RIDGE REHABILITATION AND HEALTHCARE CENTER, LL",425293,226 WA REEL DRIVE,EDGEFIELD,SC,29824,2013-07-26,356,C,0,1,DC3311,"On the days of the survey, based on observations and interview, the facility failed to have nurse staffing posted in a prominent location, readily accessible to residents and visitors. Two of two nursing stations had the posting located behind the desk on the back wall, inaccessible to any interested parties. The findings included: During the Initial Tour, Unit 100 was noted with the nurse staffing posted on the back wall of the nursing station, behind a secured gate, not easily visible/readable from the hall. The 200 Unit posting could not be readily located. The posting was later noted on the 200 Unit behind a secured/gated nursing station, on the back wall obstructed by a filing cabinet. The posting was unable to be read from any vantage point around the station. During a tour on 7-25-13 at 12:05 PM, the Administrator verified that visitors would have to know about the required postings and ask for the information as they were not readily accessible.",2017-06-01
7171,"SAINT MATTHEWS HEALTH CARE, LLC",425170,601 DANTZLER STREET,SAINT MATTHEWS,SC,29135,2013-03-27,156,C,0,1,OFL111,"On the days of the survey, based on record review and interview, the facility failed to provide the appropriate Liability Notice for 3 of 3 residents reviewed for Liability Notices. The findings included: On March 26, 2013 at 12:10 PM, review of the Liability Notices revealed that the 3 residents reviewed had received the Advance Beneficiary Notice of Noncoverage (ABN) (CMS form R-131)(03/11) instead of the required Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) (CMS form ) or one of the five uniform Denial Letters. During an interview with the Business Manager on March 27, 2013 at 1:00 PM, he/she stated I have always used this form, referring to the (ABN) notice.",2017-05-01
7197,RICE NURSING HOME,425387,100 FINLEY ROAD,COLUMBIA,SC,29203,2013-08-21,167,C,0,1,YSAM11,"On the days of survey, based on observation and interview, the facility failed to make the results of the most recent survey available in a place readily accessible to residents for 2 of 2 nursing units. The findings included: An observation on the skilled unit 8/20/13 at 12:15 was made of a plastic holder on the bulletin board with written notices saying Survey Results, DHEC. The only paperwork in the holder were menus. On 8/21/13 at 10 AM, the Director of Nursing (DON) provided a notebook with the survey results and stated it was on the nursing station with other notebooks. On 8/19 and 8/20, on the Bernadin Unit, there was no sign posted saying where the Survey Results were located. Observation of the unit revealed no Survey results available. The DON provided a notebook with the survey results and stated it was on the nursing station with other notebooks.",2017-05-01
7199,RICE NURSING HOME,425387,100 FINLEY ROAD,COLUMBIA,SC,29203,2013-08-21,356,C,0,1,YSAM11,"On the days of the survey, based on observations and staff interviews, the facility failed to post the nurse staffing as required on two of two units. The nurse staffing had not been posted in a prominent place readily accessible to resident's and visitors on the Rice and Bernadin units. The findings included: Observations on 8/19/13 at 3:30 PM of the Bernadin unit revealed there was no posting of nurse staffing on the unit. Observations on 8/20/13 at 9:15 AM of the main entrance of the main building revealed no posting of nurse staffing. Observations on 8/20/13 in the afternoon of the Bernadin unit revealed no posting of nurse staffing. At the time, Registered Nurse (RN) #1 was asked where the nurse staffing was located. S/he went to a table next to the nurses desk and stated that the nurse staff postings were located there, in a notebook. S/he showed the surveyor the nurse staff postings for 8/19/13 and 8/20/13. Observation on 8/21/13 at 12:35 PM revealed there was no nurse staffing posted on the Bernadin unit. During an interview at the time, the Director of Nursing (DON) was asked about the nurse staffing and where it was posted. The DON stated that the nurse staffing was posted on the back of a plastic frame that contained the activity schedule, and that this was on a table in the dining area of the unit. However, the nurse staff posting was not there. The surveyor told the DON that the nurse staffing had not been posted and that it had been observed in a notebook by the nurses desk the previous day. Observation of the notebook with the DON revealed the nurse staffing for 8/19/13 and 8/20/13, but there was no nurse staffing for 8/21/13. The DON made a call and stated the Staff Development Coordinator would bring the nurse staffing posting for 8/21/13 to the unit. Observations on 8/20/13 at 12:15 PM and again on 8/21/13 at 10:30 AM on the Rice unit revealed the nurse staffing posting was not readily visible. The posting was attached to the back of a plastic frame on the nurses station counter with the front of the frame containing menu information facing toward the outside of the nursing station. On 8/20/13 at 12:15 PM, when unable to find the nurse staffing posting, the surveyor asked where the nurse staffing was posted. A staff member initially took the surveyor to the timeclock, but the nurse staffing was not posted there. LPN (Licensed Practical Nurse)#3 told them it was on the back of the frame containing the menu. However, the way the frame was facing, only the menu information was visible.",2017-05-01
7217,STILL HOPES EPISCOPAL RETIREMENT COMMUNITY,425401,1 STILL HOPES DRIVE,WEST COLUMBIA,SC,29169,2014-05-07,156,C,0,1,92UF11,"On the days of the survey, based on review of Advanced Beneficiary and Liability Notices and staff interview, the facility failed to use Form CMS (Center for Medicare and Medicaid Services)- -NOMNC (Notice of Medicare Non-Coverage) for 3 of 3 sampled residents reviewed for Liability Notices and Beneficiary Appeal Rights. The findings included: An interview and review of Advanced Beneficiary and Liability Notices was conducted on 5/6/2014 at 2:15pm with the Director of Accounting (DOA). Resident A, Resident B, and Resident C had Form No. CMS- signed instead of Form CMS -NOMNC which was effective 7/1/2012. During an interview on 5/6/2014 the DOA verified the updated form had not been used. The DOA stated that s/he did not know about the updated form.",2017-05-01
7229,"BLUE RIDGE IN BROOKVIEW HOUSE, LLC",425062,510 THOMPSON STREET,GAFFNEY,SC,29340,2014-07-17,167,C,0,1,Q81T11,"On the days of the survey, based on observation, interview, and review of the survey notebook, the facility failed to have the results of the last survey readily accessible in 3 of 3 units. The findings included: A random observation during the initial tour on July 14, 2014 at approximately 11:10 am revealed that notebooks containing the most recent survey results, located on all of the units, did not contain the last complaint survey of January 22, 2014. During a tour of the 3 units with the (DON) Director of Nurses, on July 16, 2014 at approximately 10:40 am, she/he verified the last survey results were not present for review by residents and/or visitors. During an interview on July 16, 2014 at approximately 10:48 am, the Administrator reviewed and verified that the results of the last survey were not in the survey notebooks located on each unit.",2017-04-01
7231,THE METHODIST OAKS,425131,151 LOVELY DRIVE,ORANGEBURG,SC,29115,2013-04-12,167,C,0,1,LOYS11,"On the days of the survey, based on observation and interview, the facility failed to make readily available the results of the most recent survey. The findings included: Throughout the days of the survey, random observations of the three skilled units revealed the facility did not have previous survey results available in a place readily accessible to residents. Information was provided for a complaint survey dated 2-25-13 on units 100 and 300. However, the information was not available without asking for staff assistance. On the 400 unit there was no information available. Interview with LPN #1 on 4-12-13 at 9:05 AM on the 400 unit confirmed that there was no information available on previous survey results.",2017-04-01
7247,FAIRFIELD HEALTH CARE CENTER,425158,117 BELLEFIELD ROAD,RIDGEWAY,SC,29130,2014-05-22,156,C,0,1,SUSR11,"On the days of the Recertification Survey and Complaint Investigation, based on observation, record review, and interview, the facility failed to provide notice of rights, rules, services, and charges. The facility failed to use the correct and most current form for notification of Medicare non-coverage for 1 of 1 denial notices reviewed. The facility failed to post Medicare and/or Medicaid application information in 2 of 2 buildings. The findings included: Record review of the Medicare denial letters was conducted on 5/22/14. The Business Office Manager provided a Notice of Medicare Provider Non-Coverage (CMS- ) dated 2/6/14 for a resident who no longer met Medicare guidelines for therapy and services. Record review revealed and interview with the Business Office Manager on 5/22/14 at 11:05 AM confirmed the facility was not using the new CMS- NOMNC (Notice of Medicare Non Coverage) form required for use since 5/2012. Further interview at this time revealed the Business Office Manager was not aware of the required new form. On 5/22/2014 at approximately 9:20 am, observation with the Activity Director revealed that the bulletin board in the Manor building did not have posted how to apply for and use Medicare and Medicaid benefits. Immediately following Review of the POS [REDACTED]. During an interview on 5/22/2014 at approximately 9:20 am, the Activity Director verified that the required posting was not accessible for residents and /or visitors.",2017-04-01
7248,FAIRFIELD HEALTH CARE CENTER,425158,117 BELLEFIELD ROAD,RIDGEWAY,SC,29130,2014-05-22,167,C,0,1,SUSR11,"On the days of the survey, based on observation, interview, and review of the survey notebook, the facility failed to have the results of the last annual survey readily accessible in 2 of 2 buildings. The findings included: An observation on 5/22/2014 at approximately 9:30 am revealed there was no copy of the last annual survey dated 11/08/2012 in the survey notebook in the Home building. At 10:35 am on 5/22/2014, the same was noted at the Manor building. During an interview on 5/22/2014 at approximately 11:50 am, Registered Nurse #1 reviewed and verified that the survey notebook did not contain the last annual survey for review by residents and/or visitors.",2017-04-01
7262,REDEEMER HEALTH & REHAB OF PICKENS,425318,138 ROSEMOND STREET,PICKENS,SC,29671,2012-11-14,156,C,0,1,NI7I11,"On the days of the survey, based on record review and interview, the facility failed to provide complete Notice of Medicare Non Coverage/ Skilled Nursing Facility Advance Beneficiary Notices (SNFABN) for 3 of 3 resident files reviewed. The findings included: Review of the Medicare Non Coverage Notices and the SNFABN with the Business Office Manager on 11/13/12 at approximately 2:10 PM revealed the random sampled residents notices had the date the services ended but there was no date to verify/indicate that the residents/family members/responsible parties were notified in advance. An interview on 11/13/12 at approximately 2: 15 PM with the Business Office Manager confirmed there was no date on the notices to indicate the residents/family member/responsible parties were notified in advance of the termination of services.",2017-04-01
7304,PRESBYTERIAN COMMUNITIES OF SOUTH CAROLINA- CLINTO,425393,801 MUSGROVE STREET,CLINTON,SC,29325,2014-05-07,156,C,0,1,J5KW11,"On the days of the survey, based on observation and interview, the facility failed to prominently display written information about how to apply for and use Medicare benefits and how to receive refunds for previous payments on 1 of 1 units reviewed for Medicare and refund notices. The findings included: Random observations on Unit H on 5/6/2014 at 12:45 PM and 5/7/2014 at 8:00 AM revealed no written materials displayed on the unit informing residents or applicants for admission about how to apply for and use Medicare benefits, and how to receive refunds for previous payments covered by such benefits. On 5/7/2014 at 9:25 AM the Director of Nursing and Licensed Practical Nurse #1 verified that information on how to request a refund and how to apply for Medicare was not posted on the unit. At 9:40 AM on 5/7/2014 the Social Services Director also verified this information was not posted on the unit.",2017-04-01
7318,PRUITTHEALTH- COLUMBIA,425013,2451 FOREST DRIVE,COLUMBIA,SC,29204,2013-07-24,160,C,0,1,2C6Z11,"On the days of the survey, based on record reviews, interview and review of the facility policy Resident Trust Policy, the facility failed to convey the final accounting of 1 of 5 sampled residents' personal funds to the individual, probate jurisdiction administering the resident's estate upon death and/or convey funds within 30 days upon death. The findings included: On 7/24/13 at approximately 11 AM, an interview was conducted with the Financial Counselor and Resident Trust Administrative Assistant related to the conveyance of funds. Review of the residents funds revealed that Resident C funds were conveyed to a funeral home. Review of Resident C's Patient/Resident Trust Fund Authorization Agreementcompleted on admission revealed no indication that there was any authorization to release the resident's funds to the funeral home. During an interview with the Financial Counselor and Resident Trust Administrative Assistant on 7/24/13, they both verified the surveyor findings and stated they were not aware if there was a policy related to the conveyance of funds. Review of the facility Resident Trust Policy provided by the Administrator on 7/24/13 revealed: Upon the discharge or death of a resident with personal funds deposited with the center, the center must convey the resident's funds along with a final accounting to resident or the individual or probate jurisdiction administering the resident's estate within 30 days.",2017-03-01
7333,THE HERITAGE AT LOWMAN REHAB AND HEALTHCARE,425100,201 FORTRESS DRIVE,WHITE ROCK,SC,29177,2013-04-17,156,C,0,1,OM6Y11,"On the days of the survey, based on a review residents' funds and interview, the facility failed to issue the mandated Liability Notice for 3 of 3 residents reviewed for Medicare Non Coverage and Liability Notices. The findings included: Review of the residents' liability notices on 04/17/2013 at 1:10 PM revealed 3 of 3 residents reviewed did not receive Liability Notices as required. When interviewed concerning the missing Liability Notices, the Director of Social Services stated he/she was unaware that the Liability Notice should have been issued along with the notice of Medicare Non Coverage.",2017-03-01
7416,FRANKE HEALTH CARE CENTER,425374,1885 RIFLE RANGE ROAD,MOUNT PLEASANT,SC,29464,2013-05-09,156,C,0,1,S72D11,"On the days of the Recertification survey, based on review of liability notices and interviews, the facility failed to complete the required Centers for Medicare and Medicaid Services(CMS) -NOMNC(Notice of Medicare Non-Coverage) Form, the Medicare Liability Notices and Beneficiary Appeal Rights and further failed to complete three of three mandated nursing Liability Notices: Skilled Facility Advance Beneficiary Notices (SNFABN) in a timely manner for 3 of 3 sampled residents discharged from Medicare and remaining in the facility with Part A days remaining. The findings included: On 5/9/13 at approximately 2:30 PM, review of 3 of 3 residents' funds revealed the facility had not completed the required CMS Form, the Medicare Liability Notices and Beneficiary Appeal Rights or the mandated SNFABNs in a timely manner. During an interview on 5/9/13 at approximately 2:30 PM, the Community Outreach Director and the Accounting Director both revealed they were unaware of the CMS Form NOMNC and further revealed they were not informed of the requirement to use the SNFABN form.",2017-03-01
7428,ROSECREST REHABILITATION AND HEALTHCARE CENTER,425376,200 FORTRESS DRIVE,INMAN,SC,29349,2014-03-25,167,C,1,0,8DQ711,"On the days of the Recertification and Complaint Survey, based on record review and interview, the facility failed to make the results of complaint surveys performed on 12/27/12 and 3/27/13 and the subsequent plans of correction available for examination and accessible to residents in 2 of 2 survey books reviewed. The deficient practice had the potential to affect all residents wishing to review the most recent survey results. The findings included: On 3/24/14 at 10:30 AM, upon entering the facility, the survey book located in the first floor lobby was reviewed and noted to contain the results of the last Recertification Survey dated 11/05/12. On 3/25/14 at approximately 1:00 PM, the survey book in the common area at the second floor elevator was reviewed and also noted to contain only the 11/05/12 Recertification Survey. During and interview on 3/25/14 at 2:30 PM, the Director of Nursing (DON) confirmed the 12/27/12 and 3/27/13 Complaint Inspection results and plans of correction were not in either of the survey books. The DON stated s/he was not at the facility at the time of the surveys and did not know why they were not in the survey books. At the time of the exit on 3/25/14, the Nursing Home Administrator stated he/she was under the impression that only the last Recertification had to be in the book, not the complaint inspections.",2017-03-01
7433,WILDEWOOD DOWNS NURSING AND REHABILITATION CENTER,425385,1215 WILDEWOOD DOWNS CIRCLE,COLUMBIA,SC,29223,2013-06-28,156,C,0,1,K1JZ11,"On the days of the survey, based on observations and interview, the facility failed to prominently display information on how to apply for Medicaid benefits and how to obtain refunds for previous payments. The findings included: Observations on 6-25-13 and 6-26-13 revealed that information on how to apply for medicaid benefits and how to obtain refunds for previous payments was not posted as required. This was verified by the Director of Nurses at 9 am on 6-26-13.",2017-03-01
7470,SAVANNAH GRACE AT THE PALMS OF MT PLEASANT,425404,1010 LAKE HUNTER CIRCLE,MOUNT PLEASANT,SC,29464,2013-03-13,159,C,0,1,7OB011,"On the days of the survey, based on review of residents funds and interview, the facility failed to issue the mandated Notices of Medicare Non-Coverage and Lialibility in a timely manner for 1 of 2 residents' reviewed for Medicare Non Coverage and Liability Notices. The findings included: Review of the resident funds on 03/12/13 at 5:15 PM, revealed Resident #1 was taken off Medicare with days remaining and remained in the facility. Review of the Notice of Medicare Non-Coverage for Resident #1 revealed services ended July 30, 2012. However, s/he received and signed notification on July 31, 2012. During an interview with the Social Service Director, he/she verified that the Notice of Medicare Non Coverage was not issued with the required 2 days notice before the proposed end of services. When questioned about the Liability Notice, the Director of Social Services stated he/she was unaware that the Liability Notice should have been issued along with the Notice of Medicare Non-Coverage. .",2017-03-01
7486,VIBRA HOSPITAL OF CHARLESTON -TCU,425405,1200 HOSPITAL DR 2ND FL,MOUNT PLEASANT,SC,29464,2014-03-21,356,C,0,1,LREU11,"On the days of the survey, based on review of the facility's Daily Nurse Staffing Postings and interview, the facility failed to accurately post the staffing data correctly at the beginning of each shift. (11 of 80 days) The findings included: Review of the POS [REDACTED] 01-20-14: 7A to 7P shift: no documentation of the facility census 01-24-14: 7A to 7P shift: no documentation of the facility census 02-16-14: 7P to 7A shift: no documentation of the facility census 02-18-14: 7A to 7P shift: no documentation of the facility census 03-03-14: 7A to 7P shift: no documentation of the facility census Incorrect Actual Hours Worked: 7A to 7P shift: 02-04-14: Certified Nursing Assistant (CNA) Hours reflected 32 hours instead of actual hours worked of 24 02-05-14: Certified Nursing Assistant (CNA) Hours reflected 32 hours instead of actual hours worked of 24 02-13-14: Certified Nursing Assistant (CNA) Hours reflected 32 hours instead of actual hours worked of 24 02-14-14: Certified Nursing Assistant (CNA) Hours reflected 32 hours instead of actual hours worked of 24 02-18-14: Certified Nursing Assistant (CNA) Hours reflected 32 hours instead of actual hours worked of 24 Omission of Category of Staff: Licensed: Staff Total: 7A to 7P shift: 02-12-14: no documentation provided 02-16-14: no documentation provided During an interview on 03-21-14 at approximately 11:15 AM with the Director of Nursing, he/she, after Review of the POS [REDACTED].",2017-03-01
7507,LAKE EMORY POST ACUTE CARE,425303,59 BLACKSTOCK ROAD,INMAN,SC,29349,2015-03-19,156,C,0,1,E69M11,"Based on observation and interview, the facility failed to ensure that the names and phone numbers of State advocacy groups were posted in a public area for easy access by visitors and residents in 1 of 1 main entrances. This had the potential to affect any interested residents and/or visitors. The findings included: On initial tour of the facility on 03/16/15 at 10:00 AM, it was noted that the posting of the names and phone numbers of State advocacy groups was in a hall near the therapy room, away from the main public areas of the facility. The posting did not include the number for the Medicaid Fraud Unit. During an interview at approximately 10:20 AM on 03/16/15, the Nursing Home Administrator confirmed that the postings were not in the main public area in the facility. Further interview revealed that the posting was near the former main entrance to the facility, but had not been moved following renovations to move the facility entrance to the opposite hall in the building. Observation of the door to the outside near the postings revealed a sign on the door directing visitors to use another door to enter the facility.",2017-02-01
7519,LAKE EMORY POST ACUTE CARE,425303,59 BLACKSTOCK ROAD,INMAN,SC,29349,2015-03-19,356,C,0,1,E69M11,"Based on observation and interview, the facility failed to ensure that nursing staffing data was posted in a prominent place readily accessible to residents and visitors. public area for easy access by visitors and residents in 1 of 1 main entrances. This had the potential to affect any interested residents and/or visitors. The findings included: On initial tour of the facility on 03/16/15 at 10:00 AM, it was noted that the nursing staffing data was in a hall near the therapy room, away from the main public areas of the facility. It was on a clipboard just outside the conference room. Interview with the Nursing Home Administrator at approximately 10:20 AM on 03/16/15 confirmed that the posting was not in a main public area in the facility, easily accessible to visitors and residents. Further interview revealed that the staffing was posted near the former main entrance to the facility, but had not been moved following renovations. Observation of the door to the outside near the postings revealed that a sign was on the door directing people to use another door to enter the facility.",2017-02-01
7560,HEARTLAND OF WEST ASHLEY REHAB AND NURSING CENTER,425362,1137 SAM RITTENBURG BLVD,CHARLESTON,SC,29407,2012-10-17,156,C,0,1,G4MF11,"On the days of the survey, based on record review and interview, the facility failed to provide Medicare Denial Letters for 3 of 3 residents reviewed for Funds. The findings included: Review of Medicare Denial Forms for the facility on 10/16/2012 at 3:10 PM, revealed that Denial Letters were not provided for 3 of 3 residents reviewed for Funds. The findings were verified with the Social Service Manager and the Business Office Manager. They expressed that a Notice of Medicare Non-Coverage was sent but was unaware they needed to send the Denial Letters. The Social Service Manager presented this surveyor with blank Denial Letters and documents. S/he explained /she was instructed to use the document to determine when to send Denial Letter. She referred to a section in the document that stated SNF Denial Letter (previously called :Skilled Nursing Facility Determination) .After admission: On the last covered Medicare day If the resident is remaining in the facility (given in addition to and after the Medicare Notice of Non-Coverage, CMS # , i.e. Generic/48 hour Notice) . On 10/17/2012 at 3:35 PM the Social Service Manager presented this surveyor with required Skilled Nursing Facility Denial Letters dated 10/16/12. S/he stated the forms were sent by certified mail to the 3 residents identified on 10/16/12.",2017-01-01
7561,HEARTLAND OF WEST ASHLEY REHAB AND NURSING CENTER,425362,1137 SAM RITTENBURG BLVD,CHARLESTON,SC,29407,2012-10-17,167,C,0,1,G4MF11,"On the days of the survey, based on observations, the facility failed to ensure survey results were complete and readily accessible to residents. The findings included: Observations of facility postings on 10/17/12 at approximately 12:30 PM revealed a notice in a glass front case to see receptionist for survey results. The posting was in the facility's entrance hallway. At 2 PM on 10/17/12, the Administrator was asked for the survey results and s/he confirmed that anyone wishing to see the facility's survey results would have to ask for them from the receptionist. Review of the facility's survey results binder revealed the latest complaint survey results were not included. The complaint survey was conducted on 8/21/12 and resulted in two citations. When asked about the omission of the complaint survey results, the Administrator stated s/he was waiting for the final CMS 2567B, showing the facility was back in compliance, before adding those survey results to the facility's binder.",2017-01-01
7569,BETHEA BAPTIST HEALTHCARE CENTER,425372,157 HOME AVENUE,DARLINGTON,SC,29532,2013-02-27,159,C,0,1,U05T11,"On the days of the survey, based on record review and interview, the facility failed to obtain the appropriate signature (s) during withdrawal transactions from the residents' petty cash. The finding included: On 02/27/2013 at 12:55 PM, during an interview with Nursing Supervisor #1 regarding the residents' petty cash, s/he explained that if the resident's family brings in money for the resident and gives it to the nurse on the unit, the nurse documents the amount, dates and signs, notating the shift the transaction occured When asked if the resident signs indicating that they received the money or is given a receipt, Nursing Supervisor #1 stated neither the resident and or family do not sign nor are they given a receipt. S/he presented this surveyor with a copy of the transaction document used entitled (NAME)ea Baptist Health Care Center Resident Cash which noted the date, amount, shift and the signature of the nurse performing the transaction. There was no evidence provided that the resident signed documentation when cash was withdrawn from the account.",2017-01-01
7570,BETHEA BAPTIST HEALTHCARE CENTER,425372,157 HOME AVENUE,DARLINGTON,SC,29532,2013-02-27,160,C,0,1,U05T11,"On the days of the survey,based on record review, review of facility policy related to conveyance of funds, and interview, the facility failed convey funds to the Estate of the resident in a timely manner for 2 of 3 residents' reviewed for Conveyance of Funds. The finding included: During an interview with the Director of Financial Services on 02/27/2013 at 12:05 PM,s/he explained that funds from one resident were used to pay the balance on the resident's account. S/he stated that there was no documentation authorizing conveyance of funds to the facility. The Director of Financial Services stated that s/he can not recall the conversation s/he possibly had with the resident's daughter, giving her (him) permission to pay the balance owed. The Director of Financial Services stated that the funds regarding the other resident had not been conveyed because the resident has an outstanding balance to the facility and s/he did not think that the facility would get their money from the family member. Review of the information regarding Personal Funds provided in the resident Admission Packet revealed If a Resident who has personal funds deposited with the Facility expires, the Facility shall refund the Resident's account balance within (30) days and provide a full accounting of these funds to the individual, probate jurisdiction administering the Resident's estate, or other entity as required by State law or regulation.",2017-01-01
7587,MYRTLE BEACH MANOR,425070,"9547 HIGHWAY 17, NORTH",MYRTLE BEACH,SC,29572,2012-09-26,156,C,0,1,CTH411,"On the days of the survey, based on review of residents' funds and interview, the facility failed to complete the required Centers for Medicare and Medicaid Services (CMS) Form, The Medicare Liability Notices and Beneficiary Appeal Rights and further failed to complete 3 of 3 mandated Liability Notices: Skilled Nursing Facility Advanced Beneficiary Notices (SNFABN) in a timely manner for three of three residents. The findings included: On 09-26-12 at approximately 11:45 AM, review of 3 of 3 residents' funds revealed the facility had not completed the required CMS Form, The Medicare Liability Notices and Beneficiary Appeal Rights or the mandated SNFABNs in a timely manner. During an interview on 09-26-12 at approximately 11:45 AM with the Director of Social Services, she revealed she had not been using the required CMS Form and had not been informed to use the SNFABN form.",2016-12-01
7613,RIDGELAND NURSING CENTER INC,425132,1516 GRAYS HIGHWAY,RIDGELAND,SC,29936,2012-11-29,159,C,0,1,T83011,"On the days of the survey, based on record review and interview, the facility failed to obtain the appropriate signature (s) during withdrawal transactions from the residents' fund account. Funds from the residents' petty cash account were issued to residents or responsible party without signature (s). The findings included: On November 28, 2012 at 9:55 AM, during an interview with the Administrator regarding withdrawal from the residents' fund account revealed that there are no signature (s) obtained during withdrawal transaction from the residents' petty cash fund account. The Administrator presented this surveyor with a copy of the Trust Fund Receipt. Review of the Trust Fund Receipt revealed notation of the resident's name, the amount withdrawn, and the date, however, there was no notation of the resident's signature. This surveyor asked the Administrator how does s/he account for the withdrawal transaction from the residents' fund account without signature (s). She stated The residents' have never signed for as long as I have been working here.",2016-12-01
7614,RIDGELAND NURSING CENTER INC,425132,1516 GRAYS HIGHWAY,RIDGELAND,SC,29936,2012-11-29,160,C,0,1,T83011,"On the days of the survey, based on record review and interview, the facility failed to convey the residents' personal funds to The Estate of the residents' name or according to probate authorization for 5 of 5 sampled residents' reviewed for conveyance of funds. The finfings included: On 11/28/2012 at 9:55 PM, record review of the conveyance of funds revealed that the residents' personal funds were not administered to the Estate of the residents' name or according to probate authorization. During an interview with the Administrator, s/he stated that s/he was not aware that the funds needed to be issued to the Estate of the resident. S/he stated that s/he has always written the checks to the responsible party.",2016-12-01
7653,MCCOY MEMORIAL NURSING CENTER,425174,207 CHAPPELL DRIVE,BISHOPVILLE,SC,29010,2012-10-31,156,C,0,1,MVCX11,"On the days of the survey, based on record review and interview, the facility failed to complete 3 of 3 mandated Liability Notices. The findings included: During review of resident funds on 10/31/12, three of three mandated Liability Notices were not completed per regulatory requirement by the Business Manager. During the review, the Business Manager stated that he/she had been informed that the Liability Notices form did not have to completed due to CMS (Center for Medicare Services) updating the forms. The review revealed only the CMS form was completed for the three residents.",2016-12-01
7663,MAGNOLIA MANOR - COLUMBIA,425287,1007 N KING ST,COLUMBIA,SC,29223,2013-02-12,167,C,0,1,XHFF11,"On the days of the survey, based on observation and interview, the results of the most recent certification survey(s) was not available in a place readily accessible for review by residents or the public. The findings included: On all days of the survey, the results of the most recent survey(s) were unable to be located. On the wall to the right of the receptionist desk was a black metal wall 'file' holder and each day of the survey this holder was observed empty. On 02-13-13 at 10 am, having been unable to locate the most recent survey, the Administrator was questioned as to where the survey was posted. He immediately went to the wall file folder in the receptionist area and stated the survey should have been there. The Administrator looked about the room and then left to locate the survey. The survey was located in the Director of Nursing's office. There was no evidence the facility made the results available for examination and posted a notice of their availability.",2016-12-01
7672,MAGNOLIA MANOR - COLUMBIA,425287,1007 N KING ST,COLUMBIA,SC,29223,2013-02-12,356,C,0,1,XHFF11,"On the dates of the survey, based on observation and interview, the Facility failed to post the Nurse Staff Information for review by residents or the public. The findings included: During initial tour of the Facility on 02-10-13 at 4:45 PM facility staff was questioned as to where the facility nursing staff list was posted. The Administrator overheard the conversation and stated s/ he would show this surveyor the Posting of Licensed and Unlicensed Direct Care Staff. The Administrator guided this surveyor to the bulletin board next to the main dining room doors. The nursing staff posting was for two days previous to the beginning of the survey (Friday not Sunday). The Administrator verified the posting was for the proceeding Friday and that it was not current.",2016-12-01
7681,"PEPPER HILL NURSING & REHAB CENTER, LLC",425308,3525 AUGUSTUS ROAD,AIKEN,SC,29802,2012-09-26,174,C,0,1,GIN311,"On the days of the survey through observation and group interview, the facility failed to provide a telephone that was readily accessible to residents that do not have phones to make calls. The findings included: On 09/25/12 at approximately 2 pm during the group meeting, the residents were asked how they made calls and was privacy maintained during the calls. Some residents had cells phones and stated there was no problem. The residents that did not have phones stated they made calls at the nurses station, or social services office and there was a portable phone they could use but it did not work in certain areas and would have a lot of interference or would cut off. Interview on 09/26/12 with Social Services Director (SSD) and the Director of Nurses (DON) confirmed that residents do make their calls at the nurses station or in the social services office. The DON also stated that the portable phone worked well on the 300 unit but did not function properly on the other units and got a cell phone for residents that needed to make calls, but also confirmed it was locked up in the medication room on unit 300 and not all residents were aware of the cell phone.",2016-12-01
7689,"COUNTRYWOOD NURSING CENTER, LLC",425370,1645 RIDGE ROAD,HOPKINS,SC,29061,2013-04-25,156,C,0,1,4NZG11,"On the days of the survey, based on review of residents' funds and interview, the facility failed to complete the required Centers for Medicare and Medicaid Services (CMS) -NOMNC (Notice of Medicare Non-Coverage) Form, the Medicare Liability Notices and Beneficiary Appeal Rights and further failed to complete three of three mandated nursing Liability Notices: Skilled Facility Advance Beneficiary Notices (SNFABN) in a timely manner. The findings included: On 04-23-13 at approximately 4:41 PM, review of three of three residents' funds revealed the facility had not completed the required updated CMS NOMNC Form, the Medicare Liability Notices and Beneficiary Appeal Rights or the mandated SNFABNs in a timely manner. During an interview on 04-23-13 at approximately 4:30 PM with the Business Office Manger, he/she, in response to the completion of the SNFABNs, stated, I don't do them. I told him/her (Director of Social Services) he/she was to do them, not me. During an interview on 04-23-13 at approximately 4:41 PM with the Director of Social Services, he/she revealed he/she had been unaware of the updated CMS NOMNC Form. In response to the completion of the SNFABNs, he/she stated, I told him/her (Business Office Manager) that he/she was to do them, not me.",2016-12-01
7691,"COUNTRYWOOD NURSING CENTER, LLC",425370,1645 RIDGE ROAD,HOPKINS,SC,29061,2013-04-25,167,C,0,1,4NZG11,"On the days of the survey, based on observations and interview, the facility failed to post a notice of the availability of the results of the most recent survey of the facility conducted by State surveyors. The findings included: On all days of the survey, observation of the facility's postings revealed that the facility had not posted a notice as to the whereabouts of the facility's most recent survey results. During an interview on 4/24/13 with the Resident Council President, he stated that he did not know if the survey results were available. On 4/25/13, the Director of Nursing confirmed that there was not a notice posted as to the whereabouts of the survey results.",2016-12-01
7725,MAGNOLIA MANOR - INMAN,425032,63 BLACKSTOCK ROAD,INMAN,SC,29349,2012-10-03,156,C,0,1,RGS411,"On the days of the survey, based on record review and interview, the facility failed to provide Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) Denial letters for 2 of 3 residents reviewed for Medicare beneficiary liability notices. The findings included: While Reviewing the Liability Notices and Beneficiary Appeal Rights on 10/3/12, the surveyor observed one form that was given to the three residents which was the CMS(Centers for Medicare/Medicaid) form which indicated the first day of Medicare non coverage for the residents. The residents reviewed did not exhaust their 100 days of medicare services. Issuing the Notice to Medicare Provider Non-coverage form CMS- to a resident only gives notice of his or her rights to a review of service termination. The facility did not provide the residents the SNFABN or a Denial letter to address liability for payment. During an interview with the Admissions Coordinator on 10/3/12, she verified two of the residents did not receive an approved CMS SNFABN form.",2016-11-01
7743,"ALPHA HEALTH & REHAB OF GREER, LLC",425138,401 CHANDLER RD,GREER,SC,29651,2013-03-22,170,C,0,1,IEVG11,"On the days of the survey, based on multiple interviews, the facility failed to assure residents received mail delivery including on Saturday. The findings included: During the days of the survey, a randomly selected resident was interviewed related to mail delivery The Resident was selected from a list of 6 resident names provided by the facility of residents who regularly attended Resident Council, who could be interviewed. On 3/20/13, the resident stated s/he was not aware of any mail being delivered on Saturdays. The Business Office Manager stated, when interviewed on 3/20/13 following the resident interview, that the facility did not receive mail on Saturdays. However, the Activity Director stated the Activity Assistant delivered mail on Saturdays which was then verified by the Activity Assistant. When the discrepancy was mentioned, the Activity Assistant stated: When there is mail on the desk I deliver it. I haven't been here long, maybe I mixed up the days. The facility Administrator then contacted the Postal Services, who verified there was no current Saturday mail delivery.",2016-11-01
7744,"ALPHA HEALTH & REHAB OF GREER, LLC",425138,401 CHANDLER RD,GREER,SC,29651,2013-03-22,172,C,0,1,IEVG11,"During the days of the survey, a randomly selected resident was interviewed related to the Ombudsman and services available through the Ombudsman's office. The Resident was selected from a list of 6 resident names provided by the facility of residents who regularly attended Resident Council, who could be interviewed. On 3/20/13, the resident stated s/he was not familiar with the term and did not have knowledge concerning the Ombudsman. Following the interview, the Activity Director (AD) was interviewed and asked how residents were informed about the Ombudsman. The AD pulled a copy of the Ombudsman poster from the front of the resident council minutes book and stated s/he regularly reviews the information and even holds up the form for residents to see. However, the interviewed resident was noted to be visually impaired. The Activity Director verified the information was not in braille, therefore a sight impaired resident would not be able to read it. On the days of the survey, based on multiple interviews, the facility failed to provide residents and or family members information concerning access to the Ombudsman office and the services it provides. (5 of 5 resident/families interviewed related to the provision of services provided by the Ombudsman office) The findings included; During interviews conducted during the days of the survey of two resident families and two cognitively intact residents, all parties stated that they were unaware of the Ombudsman office and the services which they provided.",2016-11-01
7798,C M TUCKER NURSING CARE CENTER / RODDEY,425360,2200 HARDEN STREET,COLUMBIA,SC,29203,2013-02-28,156,C,0,1,7HTP11,"On the days of the survey, based on review of liability notices and interview , the facility failed to use the correct and most current forms for notification for Medicare non-coverage. ( 1 of 1 denial notice reviewed.) The findings included: On 2/26/13 at 3:30 PM an interview was held with staff responsible for the completion of Medicare Denial Letters. The Registered Nurse #1, who actually did the denial letter, showed the form used which was the CMS- and another form which was not the required CMS- letter. Social Worker #1 explained the form for had been in use but could not find that their form they were using was one of the possible five letters deemed acceptable for use. Also, the facility was not using the new CMS- -NOMNC (Notice of Medicare Non Coverage) form required for use since 5/2012. None of the staff were aware of the required new form.",2016-11-01
7862,"LORIS REHAB AND NURSING CENTER, LLC",425086,3620 STEVENS STREET,LORIS,SC,29569,2012-08-29,156,C,0,1,HQQ311,"On the days of the survey, based on record reviews and interview, the facility failed to provide 3 of 3 sampled residents reviewed for medical denial notices with a SNFABN (Skilled Nursing Facility Advance Beneficiary Notice) in order for the residents or responsible party to request a demand bill. The findings included: An interview on 8/28/12 at approximately 4:40 PM with the Business Office Manager confirmed the findings that the SNFABN form, CMS (Center for Medicare/Medicaid) form were not submitted because she was unaware that an additional notice was required other than the CMS form.",2016-10-01
7895,HERITAGE HOME OF FLORENCE INC,425154,515 SOUTH WARLEY STREET,FLORENCE,SC,29501,2012-08-28,156,C,0,1,3YB411,"On the days of the survey, based on review of the residents' funds and interview, the facility failed to provide the mandated Liability Notices: Skilled Nursing Facility Advanced Beneficiary Notices (SNFABN) Denial Letters for 3 of 3 sampled residents. The findings included: Review of the residents' funds on 08/28/2012 at 1:00 PM revealed that the mandated Liability Notices: SNFABN Denial Letters were not provided for 3 of 3 sampled residents. After informing the Administrator of the findings, she verified that the mandated Liability Notices: SNFABN Denial Letters were not provided for 3 of 3 sampled residents. She revealed that she did have the Liability Notices: SNFABN Denial Letters, but was unaware that it should have been provided to the residents.",2016-10-01
7896,HERITAGE HOME OF FLORENCE INC,425154,515 SOUTH WARLEY STREET,FLORENCE,SC,29501,2012-08-28,160,C,0,1,3YB411,"On the days of the survey, based on review of the residents' funds and interview, the facility failed to provide documentation from probate to authorize the conveyance of the residents' funds to the individual or to the funeral home for 5 of 5 sampled residents. The findings included: Review of the residents' funds on 08/28/2012 at 2:15 PM revealed that there was no documentation from probate to authorize conveyance of the residents' funds to the individual responsible party or to the funeral home for 5 of 5 sampled residents. When the findings were brought to the Administrator's attention, she stated that she was not aware that she needed authorization from probate to convey the residents' funds to the individual or to the funeral home.",2016-10-01
7996,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2016-06-09,156,C,0,1,W3VQ11,"Based on record review and interview, the facility failed to provide the amount of time required for notification on Liability and Appeals Notice to 1 of 3 sampled residents who had been discharged from Medicare Part A Services with days of eligibility remaining for Resident #51. Additionally, the facility failed to post contacts and phone numbers to contact outside of the facility in 2 of the 2 buildings and Resident #70 was unaware of the Ombudsman position. The findings included: A review of Liability and Appeals Notice with the Business Office Coordinator (BOC) on 6/19/16, revealed Resident #51 was discharged from Medicare Part A Services on 4/15/16 without the forty eight hour notification with Medicare eligibility days remaining. During the review of these notices, the BOC verified that the Notice of Medicare Non-Coverage -CMS form had The Effective Date Coverage of Your Current Services Will End: 4/14/16. The BOC indicated if the resident is in the facility and able to sign he/she would have the resident sign the Notice of Medicare Non-Coverage -CMS . The BOC was unaware of the forty eight hour notification requirement. A review of the minutes from the Resident Council meetings in the past year, revealed no written discussion about Facility rules, available Ombudsman support or DHEC Survey results. When asked about the state surveys, the Resident Council President stated that s/he was not aware of available survey results, because no one had explained it to her/him. When asked if s/he knew what an Ombudsman does, s/he was not familiar with the position of the Ombudsman. On 06/08/16 at approximately 2:30 pm, during an interview with the Activity Director (AD), the AD stated that s/he had been with the facility for over four years. The AD was asked about the last time s/he went over the facility rules and the results from the last DHEC survey. The AD stated that it had been way over a year. Also, s/he could not remember the last time an Ombudsman came to a Resident Council meeting, and s/he did not know who the current Ombudsman was for the facility.",2016-09-01
7998,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2016-06-09,159,C,0,1,W3VQ11,"Based on interview, record review, and review of the facility 's policy Resident Trust Accounts , the facility failed to ensure that 3 of 4 sampled residents received quarterly statements. Resident #57, Resident #70's Responsible Party and Resident #92 stated they were not given quarterly statements. The Findings included: During a family interview on 6/7/16 at approximately 12:44 PM with Resident #70's Responsible party, individual interview with Resident #57 on 6/7/16 at 1:42 PM, and individual interview with Resident #92 on 6/7/16 revealed they had not received quarterly statements. Review of the facility policy on Resident Trust Accounts: Quarterly Procedures: 3. Trust statements for residents who have been properly declared incompetent to make health care/financial decisions are sent to the resident 's legal representative. During an interview with Accounts Receivable Coordinator (ARC) on 6/9/15 at 5:15 PM, he/she stated the statements are usually mailed out by Corporate. He/she stated there is no documentation when the statement is mailed to responsible party. He/she also stated the resident can request their account statement through the nurse or social worker. ARC confirmed he/she did not give out quarterly statements to the residents that stay in the facility.",2016-09-01
7999,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2016-06-09,170,C,0,1,W3VQ11,"Based on interview, the facility failed to ensure mail would be sent out or delivered promptly to residents whenever there was regularly scheduled postal delivery and pick-up service. Findings included: On 06/08/2016 at approximately 5:15 pm, a phone interview was conducted with the weekend office manager. The office manager stated that she had been with the facility for three years and s/he did not check the Saturday mail on a regular basis. However, if a resident did tell that he or she was expecting mail, s/he would get the mail for that resident. The rest of the mail sits on the AR Coordinator 's desk until Monday morning when s/he comes in. The weekend office manager further stated that if there were no requests for mail, s/he would not get the mail. On 06/08/2016 at approximately 5:25pm, interview with the AR Coordinator revealed that there are some Monday mornings when the mail box was full or there would be a stack of mail on the desk. The AR Coordinator also stated that part of the Monday morning routine was to give the mail to the Activity Director. The Activity Director would then deliver the mail to the residents.",2016-09-01
8020,SANDPIPER REHAB & NURSING,425146,1049 ANNA KNAPP BOULEVARD,MOUNT PLEASANT,SC,29464,2012-09-19,156,C,0,1,ZKNU11,"On the days of the survey, based on record review and interview, the facility failed to provide Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) Denial letters for 3 of 3 residents reviewed for Medicare beneficiary liability notices. The findings included: While Reviewing the Liability Notices and Beneficiary Appeal Rights on 9/18/12, the surveyor observed one form that was given to the three residents which was the CMS(Centers for Medicare/Medicaid) form which indicated the first day of Medicare non coverage for the residents. The residents reviewed did not exhaust their 100 days of medicare services. Issuing the Notice to Medicare Provider Non-coverage form CMS- to a resident only gives notice of his or her rights to a review of service termination. The facility did not provide the residents the SNFABN or a Denial letter to address liability for payment. During an interview with the Minimum Data Set Coordinator on 9/18/12, she confirmed the surveyor findings and stated she was not aware of any letter to be issued other than the CMS .",2016-09-01
8039,CHESTERFIELD CONVALESCENT CENTER,425302,1150 STATE ROAD,CHERAW,SC,29520,2012-06-27,156,C,0,1,2KBC11,"On the days of the survey, based on review of Medicare Denial Letter/Liability Notices and interview, the facility failed to provide the resident and/or responsible party with the Skilled Nursing Facility Advance Beneficiary Notices (SNFABN) or one of the five Center for Medicare/Medicaid Services (CMS) approved beneficiary notice forms for 3 of 3 residents reviewed. The findings included: Review of the Medicare Denial Letter/Liability Notices on 6/27/12 at 8:45 am revealed that 3 of 3 records reviewed had not been issued the SNFABN form or one of the five CMS approved beneficiary notice forms. During an interview with the Business Office Manager (BOM) on 6/27/12 at 9:00 am, she stated that she was not familiar with the SNFABN or any of the approved required forms. An interview with the Administrator at 9:45 am also revealed that she was unaware of the additionally required form.",2016-09-01
8053,GOLDEN AGE - INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2016-06-16,334,C,0,1,VGC011,"Based on influenza regulation and record reviews, the facility failed to provide documentation of consent and education, and did not follow the facilities policy. Four of 5 resident records reviewed (Residents #34, #41, #51 and #15) did not contain in the medical record the required documentation. The findings included: The facility failed to include documentation that indicates at a minimum that the resident or resident's legal representative was provided education for the most recent Influenza season (2015-2016). The documentation must include the benefits and potential side effects of influenza immunization, and that the resident received or did not receive the influenza immunization due to medical contraindications or refusal. The findings included that 4 of 5 resident records reviewed did not have the education documentation for the influenza 2015-2016 season and obtained consent or refusal. Resident #34, #41, #51 and #15 did not contain in the medical record the required documentation.",2016-09-01
8054,GOLDEN AGE - INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2016-06-16,356,C,0,1,VGC011,"Based on initial tour of the facility on 6/16/2016 at 09:30 AM and staff interviews, the facility failed to post the staffing data required and resident census in a prominent place readily accessible to residents and visitors. The findings included: The findings upon staff interviews of RN #4, RN #1 and the DON, did not know where it was posted. Upon further interview at approximately 10:30 AM, RN #4 located posting information on a clipboard behind the nursing station and stated usually kept on the nurses station, but we have a resident that will take it and tear the papers up.",2016-09-01
8083,BLUE RIDGE IN GEORGETOWN,425048,2715 SOUTH ISLAND ROAD,GEORGETOWN,SC,29440,2012-07-12,156,C,0,1,K60411,"On the days of the survey, based on record review and interview, the facility failed to inform residents in writing of the items and services which were covered under Medicare and Medicaid. The findings included: On the days of the survey, record review revealed no documentation in the facility admission packet which informed residents in writing of items and services that were covered under the Medicaid plan or items that were not covered and the amount of chargers for those services as confirmed by the facilities Social Service Director on 7/11/12. The form entitled Georgetown Healthcare and Rehab Center Statement of Room Rates and Ancillary Charges did not delineate which services/supplies were covered under Medicare and Medicaid. Further record review revealed residents in the facility were being charged for personal laundry which was a covered service.",2016-07-01
8122,"DUNDEE MANOR, LLC",425118,"710 15-401 BYPASS, WEST",BENNETTSVILLE,SC,29512,2012-05-16,156,C,0,1,31Y011,"On the days of the survey, based on review of residents' funds and interview, the facility failed to complete 3 of 3 mandated Liability Notices: Skilled Nursing Facility Advanced Beneficiary Notices (SNFABN) in a timely manner for three of three residents. The findings included: On 05-16-12 at approximately 9:15 AM, review of 3 of 3 residents' funds revealed mandated Liability Notices had not been completed in a timely manner. During an interview on 05-16-12 at approximately 9:40 AM with the Director of Social Services/ Admissions, she revealed the Liability Notices (SNFABN) had been completed only upon admission for residents if they had Medicaid. She stated, I never knew to do them at any other time.",2016-07-01
8163,L.M.C.- EXTENDED CARE,425321,815 OLD CHEROKEE ROAD,LEXINGTON,SC,29072,2012-10-24,156,C,0,1,UOMZ11,"On the days of the survey, based on review of the residents' funds and interview, the facility failed to provide the mandated Liability Notices: Skilled Nursing Facility Advanced Beneficiary Notices (SNFABN) Denial Letters for 2 of 3 residents. The findings included: Review of the residents' funds on 10/24/12 revealed that the mandated Liability Notices: SNFABN Denial Letters were not provided for 2 of 3 sampled residents. During an interview with the Business Office Personnel #1 at the time of review, he/she verified that the SNFABN Denial Letters had not been done as required.",2016-07-01
8184,PRESBYTERIAN HOME OF SC - CLINTON,425393,801 MUSGROVE STREET,CLINTON,SC,29325,2013-05-30,167,C,0,1,8XUG11,"On the days of the survey, based on interviews and observation, the facility failed to ensure that most recent survey conducted by the State Agency was in a place readily accessible. The most recent survey was posted 6 to 6 1/2 feet on high wall. The survey was not accessible to residents in a wheelchair. The findings included: An interview on 5/28/13 at approximately 2:10 PM with the Resident Council Representative revealed he/she was not aware of the location of the State most recent survey and further stated he/she would like to see it. An observation on 5/28/13 at approximately 2:50 PM revealed the State survey to be located on a wall 6 to 6 1/2 feet from the floor inside a clear bin. An interview on 5/28/13 at approximately 3 PM with RN (Registered Nurse) #1 confirmed that the survey was inaccessible because it was to high for resident's to reach when seated in a wheelchair.",2016-07-01
8192,COVENANT PLACE NURSING CENTER,425402,2825 CARTER ROAD,SUMTER,SC,29150,2013-01-30,156,C,0,1,Z49E11,"On all days of the survey, based on observations and interview, the facility failed to post the names, addresses, and telephone numbers of all pertinent State client advocacy groups. The name, address, and telephone number of the Adult Protection and Advocacy Network had not been posted. Additionally, the facility failed to prominently display in the facility written information on how to receive refunds for previous payments of Medicare/Medicaid benefits. The findings included: Random observations on all days of the survey of the facility postings revealed the name, address, and telephone number of the Adult Protection and Advocacy Network and written information of how to receive refunds for previous payments of Medicare/Medicaid benefits had not been prominently displayed. During an interview on 01-30-13 at approximately 10:00 AM with the Director of Nursing (DON), he/she verified the above postings had not been displayed and revealed he/she thought they had been posted.",2016-07-01
8193,COVENANT PLACE NURSING CENTER,425402,2825 CARTER ROAD,SUMTER,SC,29150,2013-01-30,356,C,0,1,Z49E11,"On all days of the survey, based on observations and interviews, the facility failed to post the daily nurse staffing data correctly at the beginning of each shift. The working hours for the licensed and unlicensed nursing staff had not been posted. The findings included: Random observations on all days of the survey of the posted daily nurse staffing data revealed the working hours for the licensed and unlicensed nursing staff had not been posted. During an interview on 01-30-13 at approximately 10:05 AM with the Director of Nursing (DON), he/she verified the working hours for the licensed and unlicensed nursing staff had not been posted at the beginning of each shift on the daily nurse staffing data. He/she revealed he/she had been unaware the working hours should have been posted on the daily nurse staffing data but would ensure the hours would be reflected.",2016-07-01
8291,EMERITUS AT GREENVILLE,425373,1306 PELHAM RD,GREENVILLE,SC,29615,2012-09-12,156,C,0,1,FVQN11,"On the days of the survey, based on record review and interview, the facility failed to provide Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) Denial letters for 3 of 3 residents reviewed for Medicare beneficiary liability notices. The findings included: While Reviewing the Liability Notices and Beneficiary Appeal Rights on 9/12/12 at approximately 11 AM, the surveyor observed one form that was given to the three residents which was the CMS(Centers for Medicare/Medicaid) form which indicated the first day of Medicare non coverage for the residents. The residents reviewed did not exhaust their 100 days of medicare services. Issuing the Notice to Medicare Provider Non-coverage form CMS- to a resident only gives notice of his or her rights to a review of service termination. The facility did not provide the residents the SNFABN or a Denial letter to address liability for payment. During an interview with the Executive Director on 9/12/12 at 11:15 AM, he confirmed the surveyor findings and stated he was not aware of a SNFABN or Denial Letter.",2016-06-01
8293,COVENANT TOWERS HEALTHCARE CENTER,425382,5001 LITTLE RIVER ROAD,MYRTLE BEACH,SC,29577,2013-01-23,156,C,0,1,IOUH11,"On days of the survey, based on review of residents' funds and interview, the facility failed to complete 3 of 3 mandated Liability Notices: Skilled Nursing Facility Advanced Beneficiary Notices (SNFABN) for 3 of 3 residents. The findings included: On 1/23/13 at approximately 10:30 AM, review of 3 of 3 residents' funds revealed mandated Liability Notices had not been completed. During an interview on 1/23/13 at approximately 10:30 AM with the Director of Social Services/Activities, s/he confirmed the Skilled Nursing Facility Advanced Beneficiary Notices (SNFABN) were not completed.",2016-06-01
8305,"ELLENBURG NURSING CENTER, INC",425047,611 EAST HAMPTON STREET,ANDERSON,SC,29624,2012-03-14,156,C,0,1,7E6V11,"On the days of the survey, based on observations and interviews, the facility failed to post required information about how to receive refunds for previous payments covered by Medicare and Medicaid benefits. The facility also failed to list charges for services available in the facility not covered under Medicare in the admission packet. The findings included: During observations on 3/13/12 at approximately 11:30 AM, it was noted that the required information related to resident refunds for previous payments covered by Medicare and Medicaid benefits, were not posted on the facility's written information boards. During a tour of the facility with the Social Services Director (SSD) on 3/13/12 at approximately 12:15 PM, the SSD confirmed that the required information was not posted. During review of the facility's admission packet on 3/13/12, it was noted that the facility failed to list charges for services available in the facility not covered under the Medicare benefits. During an interview with the facility's Business Manager on 3/13/12 at approximately 1:35 PM, it was confirmed that the facility admission packet did not contain a list of charges for services available to the residents not covered by Medicare benefits.",2016-05-01
8338,ANCHOR HEALTH & REHAB OF AIKEN,425311,550 EAST GATE DRIVE,AIKEN,SC,29803,2012-06-06,156,C,0,1,TXK811,"On the days of the survey, based on review of the admission packet and interview with the Admissions Director, the facility failed to ensure that the residents admitted under Medicaid and Medicare were informed both orally and in writing of charges for non-covered items and services. The findings included: During the review of the admission packet on 6/6/12 at approximately 9 AM, it was noted that there was no documentation of charges for items and services listed on the Additional Non-Covered Charges form (GP-AP/AC (Rev. 4/05) which is utilized by the facility. There was no documentation of charges for services not covered by Medicare. During an interview with the Admissions Director on 6/6/12 at approximately 10:15 AM, she stated that she verbally goes over the Additional Non-Covered Charges form with the resident or responsible party, but does not complete the form in writing during the admissions process.",2016-05-01
8362,WILDEWOOD DOWNS NURSING AND REHABILITATION CENTER,425385,1215 WILDEWOOD DOWNS CIRCLE,COLUMBIA,SC,29223,2012-05-30,156,C,0,1,XVKR11,"On the days of the survey, based on record review and interview, the facility failed to appropriately provide 3 of 3 Notice of Medicare Provider Non-Coverage notices reviewed. The findings included: While reviewing three resident Liability Notices and Beneficiary Appeal Rights on 5/30/12 at approximately 9:15 AM, the surveyor observed only one notice was issued to the residents reviewed. The form did not indicate the first day of non-coverage. During an interview with the Director of Social Services on 5/30/12 at 9:30 AM, she confirmed that 3 of 3 Medicare Non-Coverage Notices were not submitted on the CMS (Centers for Medicare/Medicaid) form as required. The Director of Social Services stated she was instructed to use only the CMS form and was not aware both forms were required.",2016-05-01
8363,WILDEWOOD DOWNS NURSING AND REHABILITATION CENTER,425385,1215 WILDEWOOD DOWNS CIRCLE,COLUMBIA,SC,29223,2012-05-30,167,C,0,1,XVKR11,"On the days of the survey, based on observations and interviews, the facility failed to post a notice regarding the availability and location of the survey results within the facility. Observations on two days of the survey revealed no notice regarding the location of the survey results was observed. During a group interview, 7 of 7 residents attending group stated that they did not know where the survey results were located. The findings included: During the initial tour of the facility on 5/29/12 at 9:30 AM, there was no notice regarding the location of the survey observed within the facility. Random observations throughout the facility on both days of the survey revealed no notice regarding the location of the survey results posted within the facility. On 5/29/12 at 3:20 PM, during the resident group meeting, 7 of 7 residents attending the meeting stated they were unaware of where the facility survey results were posted. During a tour of the facility with the ADON (Assistant Director of Nursing) she verified there was no notice regarding the location of the survey results in the facility.",2016-05-01
8376,PRESBYTERIAN HOME OF SC - FOOTHILLS,425403,205 BUD NALLEY DRIVE,EASLEY,SC,29642,2012-08-16,167,C,0,1,KUHY11,"On the days of the survey, based on observations and interviews, the facility failed to post a notice regarding the availability and location of the survey results within the facility. Observations on the days of the survey revealed no notice regarding the location of the survey results. The findings included: During the initial tour of the facility on 8/14/12 at 8:40 AM, there was no notice regarding the location of the survey observed within the facility. Random observations throughout the facility on the days of the survey revealed no notice regarding the location of the survey results posted within the facility. On 8/15/12 at 3:10 PM, during a tour of the facility with the Director of Nursing she verified there was no notice regarding the location of the survey results in the facility.",2016-05-01
8399,VALLEY FALLS TERRACE,425096,400 LOCUST GROVE ROAD,SPARTANBURG,SC,29303,2012-06-13,151,C,0,1,7JIJ11,"On the days of the survey, based on interviews, the facility failed to keep the residents informed of their rights to vote in the most recent generally elections. Five of 5 group members stated they were not informed of their rights to vote in the January 2012 primary elections. The findings included: During the group interview on 6/12/12 at approximately 11:20 AM with 5 residents determined to be alert and interview-able by facility, 5 of 5 residents present stated they were not informed of their right to vote in the most recent election process. When asked if they were informed about their right to participate in last primary election held January 21, 2012, the reply was no. An interview on 6/13/12 at approximately 8:25 AM with the Activity Director (AD) and the Social Services Director (SSD) confirmed the residents were not informed of the rights to vote in the most recent primary election. The AD stated she thought the SSD had the responsibility of ensuring that the residents exercised their rights to vote. The AD and SSD further stated the last time the residents voted was during the Presidential Election in 2008. When the surveyor asked the AD and SSD as to why the residents were not informed of the most recently primary election, the AD stated No, reason, we just did not know about it.",2016-04-01
8410,WINDSOR MANOR,425114,5583 SUMMERTON HIGHWAY,MANNING,SC,29102,2012-09-19,161,C,0,1,8KS811,"On the days of the survey, based on record review and interview, the facility failed to purchase a surety bond in the amount to assure the security of personal funds of the residents. The findings included: During review of resident funds on 9/19/12, the surety bond of the facility was noted with a value less than the amount documented in the personal funds of the residents. During an interview with the Administrator on 9/19/12, he/she confirmed that at the present time, the surety bond did not cover the total amount of the funds of residents which were deposited with the facility.",2016-04-01
8411,WINDSOR MANOR,425114,5583 SUMMERTON HIGHWAY,MANNING,SC,29102,2012-09-19,174,C,0,1,8KS811,"On the days of the survey, based on observation and interview, the facility failed to provide residents with reasonable access to a functioning telephone where calls could be received or made without being overheard The findings included: During the group interview on 9/18/12 at 2:30 PM, residents stated that the portable phone did not work in their rooms. On 9/18/12, the cordless phone was taken to the last resident room on Unit 100. The facility called the surveyor on the cordless phone and upon answering the telephone static was heard and it was difficult to understand the caller. This was also confirmed by the staff after listening to the telephone connection. The above was shared with the Administrator and Director of Nursing on 9/19/12 who were unaware that there was a problem with the cordless telephone.",2016-04-01
8439,FRANKE HEALTH CARE CENTER,425374,1885 RIFLE RANGE ROAD,MOUNT PLEASANT,SC,29464,2012-06-27,156,C,0,1,4K4I11,"On all days of the survey, based on observations and interview, the facility failed to prominently display in the facility written information on how to apply for and use Medicaid benefits. The findings included: On 06-25-12 during Initial Tour at 11:50 AM and throughout the survey on 06-26-12 and 06-27-12, observations revealed required information on how to apply for and use Medicaid benefits had not been prominently displayed per regulatory requirement. During an interview on 06-27-12 at approximately 11:00 AM with the Director of Nursing, she verified the required information had not been displayed.",2016-04-01
8440,FRANKE HEALTH CARE CENTER,425374,1885 RIFLE RANGE ROAD,MOUNT PLEASANT,SC,29464,2012-06-27,159,C,0,1,4K4I11,"On the days of the survey, based on review of residents' funds and interview, the facility failed to ensure residents had access to petty cash on an ongoing basis. The findings included: On 06-27-12 at approximately 10:00 AM, review of the residents' funds revealed residents did not have access to petty cash on an ongoing basis. During an interview with the Accounts Manager, he revealed residents had access to petty cash during the week from Monday through Friday but not on the week-ends.",2016-04-01
8441,FRANKE HEALTH CARE CENTER,425374,1885 RIFLE RANGE ROAD,MOUNT PLEASANT,SC,29464,2012-06-27,167,C,0,1,4K4I11,"On the days of the survey, based on observations and interview, the facility failed to make the most recent survey results, a Complaint Survey, readily accessible to the residents for examination. The findings included: On 06-25-12 at approximately 11:50 AM during Initial Tour and throughout the survey on 06-26-12 and 06-27-12, observations revealed the most recent survey results, a Complaint Survey, had not been made readily accessible to the residents for examination. During an interview on 06-27-12 at approximately 11:00 AM with the Director of Nursing, she verified the Complaint Survey had not been posted and made accessible to the residents.",2016-04-01
8533,"COUNTRYWOOD NURSING CENTER, LLC",425370,1645 RIDGE ROAD,HOPKINS,SC,29061,2012-02-22,156,C,0,1,BQ7X11,"On two days of the survey, based on record review of the facilities 'Notice of Medicare Provider Non-Coverage', the facility failed to inform each resident at least forty-eight (48) hours before the effective date that the services will end for 3 of 3 Notice of Medicare Provider Non-Coverage letters reviewed. (Resident # 8, A, and B.) The findings included: Resident #8's coverage ended on 7-31-11. Form CMS- was signed by the Responsible Party and dated 7-30-11. Resident A's coverage ended on 1-3-12. Form CMS- was signed by the Resident and dated 1-4-12. Resident B's coverage ended on 10-13-11. Form CMS- was signed by the Resident but not dated. The Social Worker was not available for an interview. An interview with the Administrator on 2-22-12 at 2:35 PM revealed that he agreed that there was a concern with liability notices (CMS Form No. ) not being provided at least forty-eight (48) hours before the effective date that the services will end.",2016-03-01
8689,MOUNTAINVIEW NURSING HOME,425027,340 CEDAR SPRINGS ROAD,SPARTANBURG,SC,29302,2012-04-18,156,C,0,1,H06T11,"On the days of the survey, based on record review and interview, the facility failed to provide the required Notice of Medicare Provider Non-Coverage letter (CMS Form ) to 3 of 3 residents reviewed (Residents A, B, and C). The findings included: Review of Notices of Medicare Provider Non-Coverage for Residents A, B, and C on 4/18/12 revealed that the facility utilized CMS Form to notify the residents that their Medicare services would end. During an interview on 4/18/12 at approximately 1:30 PM, the facility Bookkeeper stated that coverage for Medicare skilled services was ending for all three residents, the residents remained in the facility, and CMS Form was issued to notify the residents of this change. The staff member confirmed that the facility did not also issue CMS Form to notify the residents of the non-coverage of services.",2015-12-01
8733,ORANGEBURG REHABILITATION AND HEALTHCARE CENTER,425116,575 STONEWALL JACKSON BOULEVARD,ORANGEBURG,SC,29115,2011-12-01,160,C,0,1,W4VU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interview the facility failed to convey resident funds timely (within 30 days) and failed to release the resident funds to the individual or probate jurisdiction administering the resident's estate for Residents identified as B, C, and D. ( Three of five records reviewed for conveyance of funds.) The findings included: Record review revealed that 3 of 5 resident's who had expired and had funds in a resident account fund failed to have their funds conveyed timely by the facility. Resident B expired on [DATE]. On [DATE] a check was issued by the facility to the responsible party, which was 21 days past the required 30 days. Resident C expired on [DATE] and a check was issued on [DATE] by the facility to the responsible party. Resident D expired on [DATE] and a check was issued to the responsible party on [DATE]. During an interview on [DATE] at approximately 2:30 PM, the Business Manager confirmed that the funds for B, C, and D had been conveyed to the responsible party and not to the individual or probate jurisdiction administering the resident's estate",2015-12-01
8768,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2012-12-18,411,C,1,0,Q5B511,"br>On the day of the Extended Survey, based on interviews and review of the facility's files made in reference to the extended survey, the facility failed to have a contract or agreement with a dentist to provide routine and/or emergent dental services to residents. The findings included: On 12/18/12 at approximately 4:45 PM, review of the facility's contracts revealed no contract or other agreement with a dentist to provide dental services to the residents of the facility. During an interview at approximately 5:30 PM on 12/18/12, the Administrator confirmed that the facility had no contract or agreement with a dentist. S/he further stated that residents' families make appointments with personal dentists for services.",2015-12-01
8771,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2012-12-18,503,C,1,0,Q5B511,"br>On the day of the Extended Survey, based on interviews and review of the facility's files in made in reference to the extended survey, the facility failed to have a contract or agreement with a laboratory that meets the requirements of federal regulations to provide laboratory services to residents. The findings included: On 12/18/12 at approximately 4:45 PM, review of the facility's contracts revealed no contract or other agreement with a laboratory to provide laboratory services to the residents of the facility. During an interview at approximately 5:30 PM on 12/18/12, the Administrator confirmed that the facility had no contract or agreement with a laboratory. S/he stated that /she had been in contact with the laboratory on 12/18/12. S/he stated that the laboratory had informed her/him that there was no contract because the laboratory does not provide phlebotomy services.",2015-12-01
8781,FRASER HEALTH CENTER,425150,300 WOOD HAVEN DRIVE,HILTON HEAD ISLAND,SC,29928,2012-01-26,156,C,0,1,JI4811,"On the days of the survey, based on record review and interview, the facility failed to utilize the correct form to notify beneficiaries of Medicare Provider Non-Coverage for 3 of 3 residents reviewed (Resident #2, Resident A, Resident B). The findings included: Review of Notices of Medicare Provider Non-Coverage for Resident #2, Resident A, and Resident B on 1/26/12 revealed the facility utilized CMS Form instead of the required CMS Form to notify the residents that their Medicare services would end. During an interview on 1/26/12 at approximately 10:15 AM, the MDS (Minimum Data Set) Coordinator stated that all three residents were discharged from Medicare, remained in the facility, and CMS Form was issued to notify the residents of this change. The MDS Coordinator indicated that he/she was unaware that the facility was using the incorrect form to notify the residents of Medicare Non-Coverage.",2015-12-01
8848,LINVILLE COURT AT THE CASCADES VERDAE,425392,30 SPRINGCREST COURT,GREENVILLE,SC,29607,2012-03-07,156,C,0,1,HTXN11,"On the days of the survey, based on record review and interview, the facility was unaware of the need to provide the mandated CMS (Centers for Medicare/Medicaid) form to certain residents who convert from Medicare. The findings included: An interview on 3/07/12 at approximately 10:50 AM with the SSD (Social Services Director) revealed she used CMS form for all residents related Medicare benefits in the facility. She was unaware of the requirement to use the mandated CMS (Centers for Medicare/Medicaid) form for certain residents who convert from Medicare.",2015-12-01
8897,PRESBYTERIAN HOME OF SC - COLUMBIA,425396,700 DAVEGA DRIVE,LEXINGTON,SC,29073,2012-08-14,156,C,0,1,D2V211,"On the days of the survey, based on review of Medicare Notices and interview, the facility failed to provide 3 of 3 residents and/or their responsible parties with the SNFABN (Skilled Nursing Facility Advanced Beneficiary Notice-CMS ) or 1 of 5 Denial Letters. The findings included: Record review on 8/14/12 revealed 3 residents who had been taken off Medicare part A with days remaining having stayed in the facility that did not receive a SNFABN-CMS or 1 of 5 Denial Letters as required. During an interview on 8/14/12 in which the Social Services Director and RN #2 were present, RN #2 stated that the facility had stopped providing the SNFABN Notice.",2015-11-01
8951,LAKE CITY SCRANTON HEALTHCARE CENTER,425149,1940 BOYD ROAD,SCRANTON,SC,29591,2012-05-30,159,C,0,1,7U6B11,"On the days of the Recertification Survey, based on expanded review of resident funds, interviews and review of the facility's policy Resident Trust Accounts, the facility failed to obtain authorization to manage personal funds for 5 of 5 residents reviewed who had Resident Trust Fund Accounts. The findings included: On 5/30/12 at approximately 3:00 PM, review of Resident Trust Accounts revealed 5 of 5 resident account records reviewed did not have signed authorizations in their record for the facility to manage their Trust Account. Residents #A, B and D had a Social Security/Resident Trust Fund Agreement which authorized the facility to transfer refunds and other property held in trust to named individuals after the resident's death, however, there was no authorization on the agreement that granted the facility authority to manage the residents' personal funds. Resident #C had a Resident Fund Management Service Authorization and Agreement to Handle Resident Funds with her name but had no signature or date. No agreement could be located by the Business Office Manager for Resident E. During an interview at that time, the Business Office Manager and the Regional Business Office Consultant confirmed that the agreements on file did not grant authority to the facility to mange the residents' Trust Account funds. Review of the facility's policy Resident Trust Accounts, section Procedure revealed: 3. When a resident chooses to set up a trust account the resident or responsible party must sign an authorization form.",2015-09-01
9114,AGAPE NURSING & REHAB CENTER,425379,300 AGAPE DRIVE,WEST COLUMBIA,SC,29169,2011-09-14,356,C,0,1,YQ1X11,"On the days of the survey, based on random observation, review of posting documentation for 6 months, and interview, the facility had no documentation to show that the staffing hours and census had been posted per regulatory requirement. The findings included: On initial tour 9/13/11 at 6:45 AM, an observation was made of the facility staffing sheet and census sheet which was dated 9/7/11 and posted near the nurses station on the Transition Rehab(iltation) Center. A request was made for copies of the daily nursing staff postings for the prior 6 months. Review of these posting sheets revealed the following: In March 2011, 17 days were posted out of 31 days; April-11 days were posted out of 30 days; May - 14 days were posted out of 31 days; June -1 day was posted out of 30 days; July - 4 days were posted out of 31 days; August - 1 day was posted out of 31 days; and September only 6 days had been posted out of 13 days. During an interview with the DON (Director of Nursing) on 9/14/11 at 11:15 AM, she stated she would look on the other unit for additional documentation. A follow-up with the DON revealed that she had found multiple days missing were also missing on the other unit. She confirmed that the facility could not provide documentation that the postings had been done daily as required.",2015-08-01
9190,TRINITY MISSION HEALTH & REHAB OF EDGEFIELD,425293,226 WA REEL DRIVE,EDGEFIELD,SC,29824,2011-03-30,160,C,0,1,4RNR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification and Complaint survey, based on record reviews and interview, the facility failed to convey resident's funds and final accounting of those funds within 30 days to the individual probate jurisdiction administering the resident's estate for Resident #22 and 4 other random sampled residents. (Five of 5 resident funds reviewed) The findings included: An interview on [DATE] at approximately 10:10 AM with the Business Office Manager revealed that Resident # 22 expired on [DATE] and the resident's funds were not conveyed; Resident A expired on [DATE] and funds were not conveyed; Resident B expired on [DATE] and funds were not conveyed until [DATE]; Residents C and D expired on [DATE] and funds were not conveyed until [DATE]. The Business Office Manager confirmed the findings during the review.",2015-07-01
9221,COVENANT PLACE NURSING CENTER,425402,2825 CARTER ROAD,SUMTER,SC,29150,2012-02-22,156,C,0,1,0MVU11,"On the days of the survey based on observations and interviews the facility failed to post the names, addresses, and telephone numbers of all pertinent State client advocacy groups such as the State survey and certification agency, the State licensure office, the protection and advocacy network, and the Medicaid fraud control unit; and a statement that the resident may file a complaint with the State survey and certification agency concerning resident abuse, neglect, and misappropriation of resident property in the facility. The findings included: During the initial tour of the facility on 2/21/12 at 11:15 AM the observations of postings revealed only resident rights and the ombudsman information were posted. The names, addresses and telephone numbers of other pertinent groups such State survey, certification, Licensure office the Protection and Advocacy Network and the Medicaid/Medicare fraud control and or info related to refunds and abuse/ neglect was not observed. The unit manager stated in a brief interview about such postings, ""I don't know where they are, but I will find out"". She went into an office and retrieved a poster board that had some but not all of the required information. She stated "" I don't know which is which or where they go"". On day two of the survey, the information was again not posted. The nurse consultant provided the information to be posted on 2/22/12 during the pre- exit conference, and she stated "" I don't know why these were removed.""",2015-07-01
9285,THE ARBORETUM AT THE WOODLANDS,425394,50 ARBORTEUM WAY,GREENVILLE,SC,29617,2012-04-04,156,C,0,1,0I7311,"On the days of the survey, based on record review and interview, the facility failed to provide documentation of the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) also known as CMS Form 1055 or one of five CMS approved beneficiary notices for 3 of 3 residents reviewed. ( Resident #1, Resident A and Resident B.) The findings included: Review of ""Notices for Medicare Non-Coverage"" for Resident #1 on 4/4/12 at approximately 2 PM revealed that the SNFABN or one of the five CMS approved beneficiary notices was not given to the resident prior to being discharged from Medicare Coverage. Review of Resident A's ""Notice of Medicare Non-Coverage"" revealed a CMS was issued, however the SNFABN or one of the five CMS approved beneficiary notices was not issued prior to being discharged from Medicare Coverage. Review of Resident B's ""Notice of Medicare Non-Coverage"" revealed CMS was issued, however the SNFABN or one of the five CMS approved beneficiary notices was not issued prior to being discharged from Medicare Coverage. During an interview on 4/4/12 at approximately 2:20 PM, the Social Services Director confirmed the findings and stated, ""I was not aware of the SNFABN form.""",2015-06-01
9437,J F HAWKINS NURSING HOME,425035,1330 KINARD STREET,NEWBERRY,SC,29108,2011-03-16,167,C,0,1,R83211,"On the days of the survey based on random observations and interview, the facility failed to post the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility. The findings included: Random observations on three days of the survey revealed only the annual survey of 12/16/09 and the Life Safety Survey with a comparative Life Safety Survey were posted on the bulletin board of the facility. This was brought to the attention of the Social Service Director. Further conversation with the Administrator and Corporate Consultants confirmed the Complaint Surveys for 5/3/10, 7/19/10, and 11/18/10 were not posted.",2015-04-01
9472,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2011-04-14,503,C,0,1,7XVN11,"On the days of the recertification and extended survey, based on contract reviews and interview, the facility failed to provide a current contract for laboratory services. The findings included: As a part of the extended survey, contracts for services provided by outside resources were reviewed on 4-14-11 at 9:30 AM. Review of the contract for provision of laboratory services, signed in April, 1998, revealed that it had not been signed by either the current Administrator or anyone representing the Governing Body of the current corporate ownership. During an interview on 4-14-11 at 10:30 AM, the Administrator verified that the Long-Term Care Laboratory Services Agreement had not been updated to reflect the change in ownership or management. No updated contract was provided for review prior to the Exit Interview.",2015-04-01
9494,HERITAGE HEALTHCARE OF PICKENS,425306,163 LOVE & CARE ROAD,SIX MILE,SC,29682,2011-08-30,167,C,0,1,Y1HD11,"On the days of the survey, based on observation and interview, the facility failed ensure the most recent survey was readily accessible to the residents. The findings included: Initial tour of the facility on 8/28/11 at approximately 2:45 PM revealed a small enclosed decorative wall cabinet high on the wall above a large wooden rocking chair in the day area with small print that indicated the most recent survey was located inside the box.. An observation and interview on 8/29/11 at approximately 2:50 PM with the Administrator and Unit Manager revealed the survey was located high on the wall above a large wooden rocking chair. The Administrator confirmed a resident in a wheel chair could not reach the survey. The Unit Manager confirmed the findings that a rocking chair was positioned in front the most recent survey. On 8/29/11 at approximately 10 AM, the ""Quality of Life Assessment Group Interview"" revealed, six of six residents in the group were not aware of the location of the facility's latest survey inspection results. During the ""Quality of Life Assessment Group Interview"" the Resident Council President stated he knew about the posting of the results but could not find its location. When the surveyor pointed out where the results were located the members of the group responded ""We thought that was a deposit box"".",2015-04-01
9500,HERITAGE HEALTHCARE OF PICKENS,425306,163 LOVE & CARE ROAD,SIX MILE,SC,29682,2011-08-30,156,C,0,1,Y1HD11,"On the days of the survey, based on record review, observation, and interview, the facility failed to ensure that the required 48 hours ""Notice of Medicare Provider Non-Coverage"" was submitted timely for three of three Medicare notices reviewed. The CMS (Centers for Medicare and Medicaid Services) form did not indicate when coverage would end. Additionally, the facility failed to provide a posting related to refunds of benefits. The findings included: Record review on 8/29/11 at approximately 2 PM, revealed three of three ""Notice of Medicare Provider Non-Coverage"" notices given that did not include the effective date the Medicare coverage would end. There was no documentation to ensure the residents/and or responsible parties were informed timely to request further services. The ""Notice of Medicare Provider Non-Coverage"" CMS form indicated the noticed had been sent out and dated with no effective date to indicate when the coverage would end. On 8/29/11 at approximately 2:20PM, the Director of Nursing verified that she did not complete the form properly by including the effective date when coverage would end. On 8/28/11 at approximately 2:50 PM, initial tour of the facility revealed there was no posting in the facility related how to obtain a refund from Medicare and Medicaid. On 8/30/11 at approximately 9 AM observation of the facility revealed, there was no posting of written information to provide the residents instructions as to how to receive refunds for previous payments covered by benefits. During an interview on 8/30/11 at approximately 9:20 AM, the Financial Counselor verified that there was no posting related to refunds.",2015-04-01
9536,HEARTLAND OF COLUMBIA REHAB AND NURSING CENTER,425008,2601 FOREST DRIVE,COLUMBIA,SC,29204,2012-03-20,156,C,0,1,905Q11,"On the days of the survey, based on review of Medicare Denial Letters/Liability Notices and interview, the facility failed to provide the resident and/or responsible party with the Skilled Nursing Facility Advance Beneficiary Notices (SNFABN) or one of the five Centers for Medicare and Medicaid Services (CMS) approved beneficiary notice forms for 3 of 3 residents reviewed. The findings included: Review of the Medicare Denial Letter/Liability Notices on 3/20/12 at 11:00 AM revealed that 3 of 3 residents reviewed had not been issued the SNFABN form or one of the five CMS approved beneficiary notice forms. During an interview with the Business Office Coordinator (BOC) on 3/20/12 at 2:15 PM, she confirmed the facility was not using the form, ""but it was in the admission packet the entire time."" The BOC also stated she just realized today the facility was not using the SNFABN form or one of the five CMS approved beneficiary notice forms.",2015-03-01
9580,MAGNOLIA MANOR - SPARTANBURG,425091,375 SERPENTINE DRIVE,SPARTANBURG,SC,29305,2011-03-16,167,C,0,1,G05Z11,"On the days of the survey, based on observation and interviews, the facility failed to post results of complaint surveys which had been conducted since the last standard survey. The findings included: During Initial Tour of the facility on 3-13-11 and on 3-14-11, the notebook containing the survey was noted in a communication box in the entryway of the facility near the Admissions Office. Upon inspection, it was noted that the last survey available for review by residents was the Federal Comparative survey dated 2-12-10. On 3-14-11 at 3:50 PM, the Admissions/Marketing Coordinator verified that the subsequent complaint survey results (1-14-11, 7-8-10) with accompanying deficiencies were not included in the survey book and notified the Administrator. During the pre-exit management meeting on 3-15-11 at 1:45 PM, the Administrator stated he had placed the CMS-2567 Statements of Deficiencies and Plans of Correction for the complaint surveys in the book.",2015-03-01
9613,EMERITUS AT GREENVILLE,425373,1306 PELHAM RD,GREENVILLE,SC,29615,2011-11-21,156,C,0,1,CVQE11,"On the days of the survey, based on observation and interview, the facility failed to prominently display a posting of names, addresses, and telephone numbers of all pertinent State client advocacy groups as required. The findings included: During the Initial Tour of the facility on 11/20/11 at approximately 11: 30 AM, the postings of names, addresses, and telephone numbers of the State survey and certification agency, the State licensure office, the State ombudsman program, the protection and advocacy network, and the Medicaid fraud control unit were not observed. This finding remained the same throughout the day on 11/20/11. During the Group Interview with nine interviewable residents on 11/21/11 at approximately 9:30 AM, the residents were asked if they were aware of the location of the postings for advocacy agencies, the State certification and licensure office, and Medicare/Medicaid agencies. None of the residents were aware of where this information was posted. Following the Group Interview, the surveyor located this information posted in three frames on the wall leading to the Activity Room. Observation revealed the surveyor was unable to read the information in the frame at the top and middle while standing in front of the postings. At that time, the surveyor asked a resident in a wheelchair to observe the postings. When asked if she could read the information in the three frames, the resident replied that she was unable to read the information. On 11/21/11 at approximately 11:25 AM, the surveyor informed the Administrator that none of the residents in the Group Interview were aware of the location of the required postings, and the surveyor had been unable to locate the postings until after the Group Interview and that the surveyor could not read the posted information in the top two frames. The Administrator did not dispute this finding. During an interview with the Social Services Director on 11-21-11 at approximately 8:15 AM, she confirmed that the postings related to the Medicare and Advocacy Agencies were covered up by sign related to ongoing activities. The sign was in front of the postings for 2 days of the survey, until the surveyor brought it to the attention of the Social Services Director.",2015-03-01
9622,RICE NURSING HOME,425387,100 FINLEY ROAD,COLUMBIA,SC,29203,2011-07-06,156,C,0,1,WXRM11,"On the days of the survey, based on observations and interview, the facility failed to display all required postings of current names and telephone numbers of pertinent State client advocacy groups. The findings included: On all days of the survey, review of postings within the Bernardin building revealed that Medicare information, Protection and Advocacy information, how to file a complaint with the State survey agency, and how to apply for a refund were not displayed within the building. Review of postings in the Skilled building revealed information on Protection and Advocacy information was not displayed. On 7/6/11, the Director of Nursing (DON) was asked to view both buildings with the surveyor for the required postings. After viewing both buildings, the DON confirmed that the required postings were not displayed. She stated that the Bernardin building had undergone renovations and that the required postings had not been replaced after the renovations.",2015-03-01
9655,AGAPE REHABILITATION OF CONWAY,425391,2320 HIGHWAY 378,CONWAY,SC,29527,2011-04-06,167,C,0,1,CZEA11,"On the days of the survey based on observations and interviews, the facility failed to post the last Recertification Survey of February 2010 per Regulatory requirement. The findings included: On 4/4/2011 at 6:00 PM, the Survey Posting book was observed in the lobby of the front entrance. Review of the POS [REDACTED]. The Survey Book contained ""Medicare.gov Nursing Home Compare - Previous Fire Inspection, and Medicare .gov Nursing Home Compare Previous Health Inspection"". The Survey Posting book was observed on 4/5/11 at 10:00 AM and 2:00 PM, the actual survey results with the plan of correction was not available. During an interview with the DON (Director of Nurses) on 4/5/11 at 4:00 PM, she stated that she was unaware that the actual survey was to be posted. On 4/6/11 at 11:00 AM, the Administrator stated that the Recertification Survey had been placed in the book. During the resident group interview on 4/5/2011 at 2:00 PM, the residents stated they were unaware of the posting of the survey results.",2015-02-01
9717,"ELLENBURG NURSING CENTER, INC",425047,611 EAST HAMPTON STREET,ANDERSON,SC,29624,2011-04-20,156,C,0,1,CHLV11,"On the days of the survey, based on review of Medicare Denial Letters/ Liability Notices and interviews, the facility failed to provide the required Liability Notice to Residents A, B, and #20 upon completion of therapy, but having Medicare days left and remaining in the facility. ( 3 of 3 residents reviewed with liability notices.) The findings included: Review of Medicare Denial letters with the Business Office Manager on 4/20/11, revealed that Resident A, Resident B and Resident #20 had not been issued the correct Liability Notice (Form or 1 of the 5 approved forms) upon completion of their therapy. The residents had Medicare days left and were remaining in the facility. The Business Office Manager had issued the Form but stated she was not aware that she also needed to issue the other form.",2014-12-01
9718,"ELLENBURG NURSING CENTER, INC",425047,611 EAST HAMPTON STREET,ANDERSON,SC,29624,2011-04-20,160,C,0,1,CHLV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on random review of funds and interview, the facility conveyed funds upon death to the Responsible Party for Residents C, D, E, F and #26 without proper authorization. ( 5 of 5 resident records reviewed for conveyance of funds). The findings included: Review of funds conveyed upon death for Residents C, D, E, F, and #26 on [DATE] revealed that the balance of resident trust accounts for these five residents were made out to each resident's Responsible Party. Resident C expired on [DATE] and a check dated [DATE] had been made out to the Responsible Party. Resident D expired on [DATE] and a check dated [DATE] had been made out to the Responsible Party. Resident E expired on [DATE] and a check dated [DATE] had been made out to the Responsible Party. Resident F expired on [DATE] and a check dated [DATE] had been made out to the Responsible Party. Resident #26 expired on [DATE] and a check dated [DATE] had been made out to the Responsible Party. Regulations stipulate that the funds should be conveyed within 30 days to the individual or probate jurisdiction administering the resident estate. The Business Office Manager had no documentation to show that the persons acting as the Responsible Party prior to death had been appointed Executor of these estates.",2014-12-01
9783,PRESBYTERIAN HOME OF SC - FOOTHILLS,425403,205 BUD NALLEY DRIVE,EASLEY,SC,29642,2011-09-27,156,C,0,1,Z9P611,"On the day of the Initial Survey, based on observation and interview, the facility failed to post the names, addresses, and telephone numbers of State client advocacy groups. The findings included: Observations on 9/27/11 at approximately 9:15am and again at 3:20 pm revealed no posting of names, addresses, and telephone numbers for the Bureau of Certification, State Licensure, or Protection and Advocacy. Interview with the facility Administrator at 3:20pm confirmed the information was not posted in the facility.",2014-12-01
9792,PRUITTHEALTH- COLUMBIA,425013,2451 FOREST DRIVE,COLUMBIA,SC,29204,2011-07-27,156,C,1,1,7GFL11,"On all days of the survey, based on observations and interview, the facility failed to prominently display in the facility the telephone number of the Protection and Advocacy Network and information on how to file a complaint with the State Survey and Certification agency. The findings included: On all days of the survey, the telephone number to the Protection and Advocacy Network and information on how to file a complaint with the State survey and certification agency were not observed to be prominently displayed in the facility. On 7/27/11 at 11:40 AM, the Director of Nursing confirmed the postings were not displayed.",2014-11-01
9819,FOUNTAIN INN CONVALESCENT CENTER,425168,501 GULLIVER ST,FOUNTAIN INN,SC,29644,2011-07-13,160,C,0,1,LEF611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based of record review and interviews, the facility failed to convey resident's funds and final accounting of those funds within 30 days of the individual or probate jurisdiction administering the resident's estate for 4 of 4 sampled residents reviewed. The findings included: An interview on [DATE] at approximately 10:15 AM with the Business Office Manager revealed concerns with 4 of 4 conveyance of funds records reviewed. Resident A expired on [DATE] and a check was written to a funeral home on [DATE]( prior to the resident expiring) in the amount of $900.00 which left the resident's trust fund account with a zero balance per the Business Office Manager. Review of the Resident Trust Fund Statement for Resident A printed out on [DATE] indicated the resident account will not have a zero balance entered on the account until [DATE]. Resident B expired on [DATE] and a check was written in the amount of $190.00 in the name of the expired resident on [DATE](after the resident expired). A review of the Resident Trust Fund Statement revealed the resident's account will not have a zero balance until [DATE]. Resident C expired on [DATE] and a check was written to a funeral home on [DATE]. Review of Resident C Trust Fund Statement reviewed for period ""[DATE] thru [DATE]"" revealed resident account did not have a zero balance. Resident D expired on [DATE] and a check was written to a funeral home on [DATE]. Review of Resident D Trust Fund Statement printed on [DATE] revealed no documentation of a check written on [DATE] to the funeral home. Further review of the Resident Trust Fund Statement revealed the account did not have a zero balance until [DATE]. The Business Office Manager stated the funds were submitted to the funeral homes per written request of the family/responsible party. The Business Office Manager further stated it was a facility practice to close out the account by paying for burial expenses in advance when questioned about Resident A account. An interview on [DATE] at approximately 3:35 PM with the Administrator, Director of Nursing and facility Consultant revealed the Administrator was aware of the check written to the expired resident and the funds being paid to the funeral homes. An interview on [DATE] at approximately 10:18 AM with the facility Administrator and the Business Officer Manager confirmed the findings of the Resident Trust Fund Statements and the Administrator stated there were some system problem with the account statements.",2014-11-01
9870,PRUITTHEALTH- COLUMBIA,425013,2451 FOREST DRIVE,COLUMBIA,SC,29204,2011-07-27,334,C,0,1,7GFL11,"On the days of survey, based on record review and interview, the facility failed to ensure each resident or resident's legal representative received education regarding the benefits and potential side effects of the influenza immunization for 3 of 5 sampled residents. (Residents #1, #4, and #5). The findings included: Chart review of three residents revealed influenza immunizations were given to Residents #1, #4, and #5 in October 2010. Further review revealed no documentation that the residents or their representatives were given education regarding risks or benefits. In an interview with the Director of Nursing (DON) on 7/26/11 at 10:00 PM, she stated that the documentation would be located in the nursing notes. Review of the nursing notes did not reveal this information. When further documentation was requested, it could not be provided.",2014-10-01
9884,LAUREL BAYE HEALTHCARE  OF WILLISTON LLC,425297,5721 SPRINGFIELD HWY,WILLISTON,SC,29853,2011-07-27,156,C,0,1,8DSB11,"On the days of the survey, based on interviews and review of Medicare Denial Letters and Liability Notices, the facility failed to provide the required advance Liability Notices ( Form and/or Form or 1 of the 5 approved forms) for 2 of 3 residents reviewed for Liability Notices and Denial Letters. The findings included: Review of the records in the Business office revealed Resident A ""met maxium (sic) level of therapy services"" and remained in the facility. The conversion date was 3/12/11 and a Form was completed and signed by the Resident on 3/7/11 however, the facility did not issue the required Form , Notice of Medicare Provider Non-Coverage. Resident #2, converted to Medicaid on 3/7/11, had Medicare days left and remained in the facility and the facility did not issue either Form or Form (or 1 of the 5 denial letters). These findings were confirmed by both the Admissions/ Social Services Director and the Nursing Home Administrator during an interview on 7/27/11 at approximately 10:30 AM.",2014-10-01
9927,FRASER HEALTH CENTER,425150,300 WOOD HAVEN DRIVE,HILTON HEAD ISLAND,SC,29928,2010-12-15,156,C,0,1,GFU911,"On the days of the survey, based on review of residents' funds and interview, the facility failed to complete 3 of 3 mandated Liability Notices in a timely manner. The findings included: During review of residents' funds on 12-15-10 at approximately 2:45 PM with the Minimum Data Set (MDS) Coordinator, she confirmed 3 of 3 mandated Liability Notices reviewed had not been completed.",2014-09-01
9948,"HOPE HEALTH & REHAB OF MARIETTA,",425307,2906 GEER HWY,MARIETTA,SC,29661,2011-07-06,156,C,0,1,BTTI11,"On the days of the survey, based on observation and interview the facility failed to display, per regulatory requirement, written information about how to receive a refund for previous payments covered by medicare and medicaid. The findings included: Initial tour of the facility on 7/05/11 at 9:30 AM revealed there was no posting in the facility related how to obtain a refund from medicare and medicaid. An observation and interview on 7/06/11 at 10:55 AM with the Director of Nursing confirmed the findings that there was no posting related to how to receive a refund for previous payments.",2014-09-01
9949,"HOPE HEALTH & REHAB OF MARIETTA,",425307,2906 GEER HWY,MARIETTA,SC,29661,2011-07-06,167,C,0,1,BTTI11,"On the days of the survey, based on observation and interview, the facility failed ensure the most recent survey was readily accessible to the residents and failed to post a notice of survey availability. The findings included: Initial tour of the facility on 7/05/11 at 9:30 AM revealed there was no posting in the facility related the availability of the most recent survey. An observation and interview on 7/06/11 at 10:55 AM with the DON (Director of Nursing) revealed there was no posting of the most recent survey. The survey was located on a bulletin board out of reach of the residents and there was no posting noted to identify the survey as the most recent survey as confirmed by the DON.",2014-09-01
9962,THE PRESTON HEALTH CENTER,425325,87 BIRD SONG WAY,HILTON HEAD ISLAND,SC,29926,2010-12-09,156,C,0,1,KWBU11,"On two days of the survey, based on observations, interview, and review of ""Residents Rights"" in the facility's Admission Packet, the facility failed to prominently display written information on how to receive refunds for previous payments of Medicare benefits. The findings included: On two days of the survey, written information of how to receive refunds for previous payments covered by Medicare benefits had not been prominently displayed. Random observations on 12-07-10 and 12-08-10 of a posting observed on the bulletin board in the facility entrance foyer revealed no information on how to receive refunds for previous payments covered by Medicare. During an interview on 12-08-10 at approximately 1:40 PM with the Director of Social Services, she revealed she did not know refund information for previous payments of Medicare benefits had to be prominently displayed. Review of ""Residents Rights"" in the facility's Admission Packet stated,""The facility must prominently display in the facility written information and provide to residents and applicants for admission oral and written information about how to apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments covered by such benefits"".",2014-09-01
9986,LAUREL BAYE HEALTHCARE GREENVILLE,425042,661 RUTHERFORD RD,GREENVILLE,SC,29609,2010-07-21,356,C,0,1,2B2D11,"On the days of the survey, based on observation and interview, the facility failed to post complete staffing data. The facility failed to post the number of Registered Nurses (RNs) and Licensed Practical Nurses (LPNs) and the actual hours worked by category for each shift on the Staff Posting forms. The facility also failed to post the data in a prominent location readily accessible to visitors and residents as required. The findings included: Observation on 7/19/10 at approximately 5:20 PM and on 7/20/10 at approximately 10:50 AM revealed the number of RNs and LPNs and the actual hours worked by category were not posted on the Staff Posting forms for the 7:00 AM - 3:00 PM shift, the 3:00 PM - 11:00 PM shift or the 11:00 PM - 7:00 AM shift on those dates but were posted as ""Licensed Nurses."" During observations throughout the survey, the Staff Posting forms were posted behind the nursing stations and not displayed in a prominent location readily accessible to visitors and residents. Copies of the Staff Posting forms for the last 30 days were requested on 7/20/10. Review of these forms revealed the number of RNs and LPNs and the actual hours worked by category were not posted on the Staff Posting form on any of these dates as required but were posted as ""Licensed Nurses."" Review of the Staff Posting forms for the last 31 days revealed that on all of the last 31 days, the Staff Posting forms indicated 6 nurses for the 3:00 PM - 11:00 PM shift. Review of the 24 Hour Assignment sheets revealed that on 22 of the last 31 days, 6 nurses worked from 3:00 PM - 7:00 PM but only 5 nurses worked from 7:00 PM - 11:00 PM. During an interview on 7/21/10 at approximately 11:30 AM, the Director of Nursing (DON) confirmed that the posting did not list the Licensed Nurses by category or include the actual hours worked. The DON also confirmed that the Licensed Nurses worked 12 hour shifts and that the number of nurses that worked between 3:00 PM - 7:00 PM and 7:00 PM - 11:00 PM was different and was not reflected on the Staff Posting form. She/He also verified that the Staff Posting form was posted behind each of the nursing stations but not in a prominent area accessible to visitors and residents.",2014-08-01
9987,LAUREL BAYE HEALTHCARE GREENVILLE,425042,661 RUTHERFORD RD,GREENVILLE,SC,29609,2010-07-21,167,C,0,1,2B2D11,"On the days of the survey, based on observations and interview, the facility failed to place the most recent state survey results in a location readily accessible to residents and visitors, and there were no notices posted regarding the availability of the survey results. The findings included: Observation on 7/19/10 at approximately 12:45 PM revealed a white binder entitled ""DHEC (Department of Health and Environmental Control) Survey"" sitting on the receptionist's desk back behind a lamp. The survey results were not readily accessible to residents or visitors. Observation on 7/20/10 at 11:35 AM revealed the receptionist sitting at a desk near the entrance of the facility. The Director of Nursing (DON) was standing next to her/him. A white binder entitled ""DHEC Survey"" was sitting on the desk behind a lamp a couple feet away to the right and behind where the receptionist was sitting. When questioned by the surveyor if anyone had asked to see the survey results, the receptionist stated that sometimes residents or visitors would ask to see them. When questioned if the survey results were readily accessible where they were located if someone had to ask to see them, the DON moved the survey results to the front of the desk below the countertop. During a general tour of the facility on 7/20/10 from 3:45 PM to 4:45 PM, observations revealed there were no notices posted regarding availability of the most recent state survey results.",2014-08-01
10035,LAUREL BAYE HEALTHCARE OF ORANGEBURG,425116,575 STONEWALL JACKSON BOULEVARD,ORANGEBURG,SC,29115,2010-08-18,156,C,0,1,G5LE11,"On the days of the survey, based on record reviews and interview, the facility failed to complete 3 of 3 mandated Liability Notices. The findings included: During review of resident funds on 8/18/10, three of three mandated Liability Notices were not completed by the business office. During an interview following the review, the Business Manager confirmed that the Liability Notices were not completed.",2014-07-01
10072,COVENANT PLACE NURSING CENTER,425402,2825 CARTER ROAD,SUMTER,SC,29150,2011-08-02,503,C,0,1,JY8H11,"On the day of the initial survey, based on interview and review of Facility contracts, the facility failed to have on hand, at the time of the survey, a copy of the contract between the facility and the provider of laboratory services. The findings included: On 8/2/11 the surveyor requested to review the contract for laboratory services. The surveyor was informed by the Director of Nursing that the contract was held at the providing hospital and that the facility did not have a copy of the contract on hand. No additional information was received from the facility.",2014-07-01
10120,STILL HOPES EPISCOPAL RETIREMENT COMMUNITY,425401,1 STILL HOPES DRIVE,WEST COLUMBIA,SC,29169,2011-11-10,167,C,0,1,HXLZ11,"On the days of the survey, based on observation and interview, the results of the most recent survey of the facility was not posted in a place readily accessible to the residents per regulatory requirement. The most recent survey result was located behind a locked door and not accessible to resident's without knowledge of a code to unlock the door. The findings included: On 11/8/11 during initial tour of the facility, the most recent survey results were not seen. Interview on 11/9/11 at approximately 9:10AM with the Administrator indicated that the survey results were on a table by the main entrance to the Certified unit. The surveyor went to the main entrance to verify the Administrator's statement. To access the main entrance, the surveyor had to enter a code to unlock a door to enter the area were the survey results were available. On 11/10/11 at approximately 8:50AM, the Administrator was asked to show the surveyor where the survey results were posted. The Administrator showed surveyor were the survey results were kept by entering a code to unlock the door. When the surveyor asked how the residents could gain access to the survey results if they do not have a code to unlock the door, the Administrator stated the survey results needed to be on the other side of the locked door.",2014-06-01
10174,BROAD CREEK CARE CENTER,425351,801 LEMON GRASS COURT,HILTON HEAD ISLAND,SC,29928,2010-12-13,500,C,,,GN4K11,"On the days of the Recertification and Extended Survey, based on record reviews and interviews, the facility failed to provide a contract for emergency dental services for the residents. The findings included: On 12/9/2010, review of the facility's required contracts, the facility failed to provide a contract for emergency dental services. In an interview with the Nursing Home Administrator, the Administrator stated that the facility did not have a dental contract. No signed dated contract for dental services was provided prior to the survey team exiting the facility on 12/13/2010.",2014-04-01
10175,BROAD CREEK CARE CENTER,425351,801 LEMON GRASS COURT,HILTON HEAD ISLAND,SC,29928,2010-12-13,156,C,,,GN4K11,"On the days of the Recertification and Extended Survey, based on observations and interview, the facility failed to post how to apply for Medicaid and how to apply for refunds from Medicare. In addition, the facility failed to post how to contact the Department of Environmental Control (DHEC). The findings included: On 12/7/2010 and 12/8/2010, observations revealed that the facility failed to post how to apply for Medicaid and how to apply for a refund from Medicare. In addition there was no posting related to how to contact DHEC. Interview with the facility Administrator on 12/8/2010 at approximately 5:00 PM, revealed that she was unaware that the facility did not have the information posted. She confirmed that the information was not posted. The Administrator stated that the information must have been taken down during renovations of the facility and not re-posted.",2014-04-01
10189,ROSECREST REHABILITATION AND HEALTHCARE CENTER,425376,200 FORTRESS DRIVE,INMAN,SC,29349,2010-09-08,167,C,,,9VMS11,"On the days of the survey, based on observation and interview, the facility failed to post for resident review the Certification Survey for 8/20/09. The findings included: During a random observation on 9/7/10, the facility survey book, located upstairs in the skilled unit, was reviewed and found it contained last year's Licensure Survey, a Complaint Survey, and a Certification Survey dated 2008. The Certification Survey results for 8/20/09 were not included. The Director of Nursing (DON) reviewed the book and confirmed the survey was not included. The DON reviewed the survey book posted downstairs at the entrance and confirmed that book also did not have the 2009 Certification Survey included.",2014-04-01
10217,MAGNOLIA MANOR - INMAN,425032,63 BLACKSTOCK ROAD,INMAN,SC,29349,2010-11-17,156,C,,,JNTL11,"On the days of the survey, based on record review and interview, the facility failed to provide Liability Notices to 3 of 3 residents reviewed for notification of Medicare Provider Non- Coverage. The facility did not utilize form or any of the 5 denial letters to inform residents or their responsible party of the items and services expected to be denied under Medicare Part A. The findings included: On 11/17/10 at 10:20 AM, a review of 3 random Medicare Non-Coverage Notices revealed that there were no Liability Notices included in the information given to the resident or responsible party. An interview with the Admission Coordinator revealed that she had not been aware until yesterday that Liability Notices were required. According to information provided by the Admission Coordinator, Resident A had used 50 days and his last covered day was 10/27/10 due to therapy being discontinued. Resident B had used 64 days and no longer required skilled services. His last covered day had been 9/2/10. Resident #8 had used 36 days and her last covered day had been 8/20/10 due to her therapy having been discontinued.",2014-03-01
10220,MAGNOLIA MANOR - INMAN,425032,63 BLACKSTOCK ROAD,INMAN,SC,29349,2010-11-17,167,C,,,JNTL11,"On the days of the survey, based on observations, the facility failed to post the most recent survey report within the facility. The facility failed to post the most recent complaint survey with citations from 9/16/10 and failed to post a complaint survey with citations from February 2010. The findings included: Observation on 11/15/10 at approximately 5:00 PM revealed a plastic holder mounted on the wall in the hallway near the front lobby. Observation of the contents of the holder revealed a labeled notebook containing the annual recertification survey report from September 2009. The complaint surveys with citations from 9/16/10 and February 2010 were not posted as required. On 11/17/10 at approximately 4:30 PM, the surveyor reviewed the contents of the notebook with the Administrator. The Administrator confirmed that the complaint surveys were not posted at that time.",2014-03-01
10290,UNIHEALTH POST-ACUTE CARE - NORTH AUGUSTA,425296,1200 TALISMAN DRIVE,NORTH AUGUSTA,SC,29841,2012-02-01,251,C,,,2C1L11,"On the days of the survey, based on interviews and review of the ""South Carolina Code of Laws Title 40-Professions and Occupations Chapter 63: Social Workers"", the facility, with more than 120 beds, failed to employ a Licensed Social Worker as required by state law. The facility Social Worker had a Bachelor's Degree and had not been licensed. The findings included: During an interview on 02-01-12 with the facility Social Worker, she revealed she had a Bachelor's degree and had not been licensed. During an interview on 02-01-12 with the Administrator, she revealed she did not know a Licensed Social Worker was required. She stated the facility would contract with a Licensed Social Worker as a Consultant to oversee the facility Social Worker at least 20 hours per month. Review of the ""South Carolina Code of Laws Unannotated, Current through the end of the 2011 Session, Title 40-Professions and Occupations, Chapter 63: Social Workers"" revealed in Section 40-63-30: License as prerequisite to practice or offer to practice; providing social work services through telephone or electronic means. A) No individual shall offer social work services or use the designation ""Social Worker"", ""Licensed Baccalaureate Social Worker"", ""Licensed Masters Social Worker"", ""Licensed Independent Social Worker-Clinical Practice"", ""Licensed Independent Social Worker-Advanced Practice"", or the initials ""LBSW"", ""LMSW"", or ""LISW"" or any other designation indicating licensure status or hold themselves out as practicing social work or as a Baccalaureate Social Worker, Masters Social Worker, or Independent Social Worker unless licensed in accordance with this chapter"".",2014-01-01
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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