{"rowid": 6950, "facility_name": "SUMTER EAST HEALTH & REHABILITATION CENTER", "facility_id": 425107, "address": "880 CAROLINA AVENUE", "city": "SUMTER", "state": "SC", "zip": 29150, "inspection_date": "2017-05-06", "deficiency_tag": 309, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": null, "inspection_text": "Deficiency Text Not Available", "filedate": "2017-07-01"}
{"rowid": 6998, "facility_name": "FAITH HEALTHCARE CENTER", "facility_id": 425009, "address": "617 WEST MARION STREET", "city": "FLORENCE", "state": "SC", "zip": 29501, "inspection_date": "2017-04-13", "deficiency_tag": 490, "scope_severity": "J", "complaint": 0, "standard": 1, "eventid": null, "inspection_text": "Deficiency Text Not Available", "filedate": "2017-06-01"}
{"rowid": 7120, "facility_name": "ROSECREST REHABILITATION AND HEALTHCARE CENTER", "facility_id": 425376, "address": "200 FORTRESS DRIVE", "city": "INMAN", "state": "SC", "zip": 29349, "inspection_date": "2017-03-23", "deficiency_tag": 250, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": null, "inspection_text": "Deficiency Text Not Available", "filedate": "2017-06-01"}
{"rowid": 3657, "facility_name": "ROSECREST REHABILITATION AND HEALTHCARE CENTER", "facility_id": 425376, "address": "200 FORTRESS DRIVE", "city": "INMAN", "state": "SC", "zip": 29349, "inspection_date": "2018-07-11", "deficiency_tag": 657, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "0.0", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to invite resident representatives to participate in care plan meetings for 1 of 1 family interviewed. The family of Resident #34 had not been invited to care plan meetings since 10/17. The findings included: Resident #34 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Interview with family of Resident #34 on 7/9/18 revealed it had been months since the last care plan meeting invitation. Review of a hospice interdisciplinary note dated 6/19/18 on 7/10/18 at approximately 3:33 PM revealed the family's attendance or invitation was not documented. Interview with the administrator and director of nursing (DON) on 7/10/18 at approximately 3:55 PM revealed they could not find invitations / attendance sheets for care plan meetings since the family last attended a meeting on 10/19/17.", "filedate": "2020-09-01"}
{"rowid": 5803, "facility_name": "ROSECREST REHABILITATION AND HEALTHCARE CENTER", "facility_id": 425376, "address": "200 FORTRESS DRIVE", "city": "INMAN", "state": "SC", "zip": 29349, "inspection_date": "2018-07-11", "deficiency_tag": 812, "scope_severity": "F", "complaint": 0, "standard": 1, "eventid": "0.0", "inspection_text": "Based on observations, interviews and review of the facility's policies related to Refrigerators and Freezers and Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices, the facility failed to ensure that food was stored, served and distributed properly. Food in the main kitchen was undated and unlabeled, assorted bell peppers that were soft/withered with darkened spots, 2 of 2 unit kitchens, trash/debris was observed on floor in walk in refrigerator and freezer during initial tour and 2 of 4 sanitation buckets used in main kitchen were not at the proper sanitizer levels. 1 of 1 main kitchen and 2 of 2 unit kitchens. The findings included: During initial tour of the the main kitchen on 7/09/18 at approximately 9:30 AM with the Dietary Manager, there was a tall cart with 5 to 6 trays that food in multiple small square containers. There was a large plastic covering on the tall cart. The small square containers with food items were unlabeled, undated and some containers did not have any individual clear plastic covering like some of the other containers. There was a tray with some type of meat on a separate tall cart that the Dietary Manager stated was ham that was undated and unlabeled. The Dietary Manager attempted to date and labeled the food during initial tour with the surveyor. There was an assortment of bell peppers that were soft/withered with some darkened spots. The Dietary Manager stated that dietary staff was supposed to remove the older vegetables out during lunch today. There was trash/debris on floors in walk in refrigerator and walk in freezer. The Dietary Manager stated the floors were to be cleaned after the food delivered was put away. The dietary staff was observed plating the residents food. The observation was shared with the Director of Nursing who was present during the meal service. During random observation of the dish washer temps in the main kitchen on 7/10/18 at approximately 12:45 PM revealed: A review of the 2 of 4 sanitizer buckets that were used by staff in the main kitchen had no sanitizer in the buckets after the Dietary Manager used sanitizer strips that indicated buckets had no sanitizer. Review of the Refrigerators and Freezers policy revealed under #3 revealed All foods shall be appropriately dated to ensure proper rotation by expiration dates and under #4 All opened foods will be dated according to regulatory guidelines. An interview on 7/11/18 at approximately 10 AM with the Facility Administrator and Director of Nursing revealed the tall carts in the main kitchen were for the assistive living residents. The Administrator was informed that the Dietary Manager did not indicate the tall carts with food was for the assistive living residents. There were also no posting the main kitchen to separate foods for skilled residents from assistive living residents.", "filedate": "2018-09-01"}
{"rowid": 6439, "facility_name": "MARION NURSING CENTER, INC.", "facility_id": 425015, "address": "2770 SOUTH HIGHWAY 501", "city": "MARION", "state": "SC", "zip": 29571, "inspection_date": "2012-08-01", "deficiency_tag": 323, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "00J311", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations and interview, the facility failed to ensure that the resident environment remains as free of accident hazards as is possible. Observations revealed Unit 1, Unit 2, and 2 of 4 shower rooms contained hazardous materials and one exit door was noted open on Unit 1, (back hall). The findings included: During initial tour on 7/30/12 and on 7/31/12 , the following was observed: Unit 1 Front Hall - one unlocked cabinet containing HDQ Neutral one step disinfectant; an exit door at the end of the back hall open; latch did not catch. Unit 2 Front Hall - one unlocked cabinet containing HDQ one step disinfectant. Unit 2 Back Hall - shower room with broken drain cover; microwave cabinet with two sharp screws noted when doors opened; one unsteady chair in resident dining area. An interview was conducted with LPN(Licensed Practical Nurse)#2 on 7/30/12 upon noting the door not closed on Unit 1, Back Hall. LPN #2 verified the observation and stated during the interview that sometimes the door does not catch when staff come and go out of the door. Unit 1 was noted to have 37 residents with nine residents with physician orders [REDACTED]. There were also nine residents who were cognitively impaired that could move very short distances in the wheelchair or ambulated with assistance. On 8/1/12 at 9:30 AM, rounds were made with the Administrator who confirmed the above findings.", "filedate": "2018-02-01"}
{"rowid": 6440, "facility_name": "MARION NURSING CENTER, INC.", "facility_id": 425015, "address": "2770 SOUTH HIGHWAY 501", "city": "MARION", "state": "SC", "zip": 29571, "inspection_date": "2012-08-01", "deficiency_tag": 467, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "00J311", "inspection_text": "On the days of the survey, based on observations, interviews, and record review, the facility failed to provide adequate outside ventilation for 1 of 4 shower rooms and 8 sampled resident restrooms. The findings included: On 7/30/12 and 7/31/12, observations of the shower room located on Unit 1, Front Hall, revealed the room was humid and the exhaust fan did not work. On 7/31/12, Maintenance staff #1 confirmed the exhaust fan in the shower room was not functioning. On 8/1/12, Maintenance staff #1 and LPN(Licensed Practical Nurse)#1 observed rooms 26 and 27 with the surveyor. The exhaust fan in each resident restroom was not working which was confirmed by the staff. LPN #1 stated she did not think the exhaust fans had worked since she had been employed with the facility. The restroom for Room 26 was a shared bathroom. Additionally, the exhaust fans did not function in the following sampled resident restrooms: Room 2, 9, 20, 33, 35, and 49. Each of these restrooms were shared with another room with residents. Further interview on 8/1/12 with LPN #1 revealed that during monthly checks by Maintenance, the fans were to be checked for proper functioning and that that had not been done. .", "filedate": "2018-02-01"}
{"rowid": 8323, "facility_name": "ALPHA HEALTH & REHAB OF GREER, LLC", "facility_id": 425138, "address": "401 CHANDLER RD", "city": "GREER", "state": "SC", "zip": 29651, "inspection_date": "2013-05-15", "deficiency_tag": 225, "scope_severity": "F", "complaint": 1, "standard": 0, "eventid": "01DB11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Complaint and Extended Survey, based on record review, interviews and review of the facility policy Reporting Abuse to State Agencies and Other Entities, the facility failed to report and/or conduct a thorough investigation of 7 of 19 reviewed reportable's to the State Agency. At the time of the complaint inspection conducted on 5/14 - 5/15/2013 the facility was out of compliance at F-225 at a scope and severity of E related to Resident's #95 and #115 cited as part of the Recertification Survey conducted the week of 3/20/2013. F-225 was identified on 5/15/2013 at Substandard Quality of Care and the citation was elevated to a scope and severity of F related to Resident #1's alleged use of illicit drugs during his/her stay at the facility. One (1) of 1 resident with admitted illicit drug use while in the facility (Resident #1). Three (3) of 11 reportable incidents not reported to the State Agencies within 24 hours (Resident A, E, and K). One (1) of 11 [MEDICATION NAME] with a 5-Day Follow Up investigations not reported to State Agencies (Resident F). The findings included: Resident #1 was admitted with a history of drug abuse. While in the facility the resident had two (2) roommates within a 4 day period that requested room changes. They stated during interviews with the surveyor that they didn't get along with Resident #1, and one of the resident's admitted to being afraid. The facility found illicit drug paraphernalia and unknown drugs in the resident's room. The resident admitted to using drugs while a resident at the facility. The local Police were called related to the paraphernalia found. The facility failed to conduct an investigation of the resident's alleged use of illicit drugs while in the facility or the effect of the resident's behavior on other residents in the facility. The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the Hospital Discharge Summary dated 4/16/13, under admission and discharge [DIAGNOSES REDACTED]. The section titled Brief hospitalization Course stated, the resident was admitted to the hospital for IV (intravenous) therapy. .The patient has a history of [DIAGNOSES REDACTED] who was discharged during recent hospitalization . At that point, s/he was recommended to have IV [MEDICATION NAME]. She/he did not go home with a PICC (peripherally inserted central catheter) line at that point because of his/her history of drug abuse and the fact that s/he was not . safe to go home with a PICC line . His/her primary physician did order a PICC line for his/her antibiotic treatment . The facility Nurse's Note dated 5/1/13 at 2:00 PM stated, Resident has tennis ball sized powdered substance in bag at bedside, multiple syringes and spoons with burnt markings on them. Resident states s/he has hx (history) of drug abuse, has been using while in facility. Resident #1 was transferred to the hospital. Review of the facility admission and discharge records revealed 2 residents had been admitted to the room with Resident #1 between 4/28 and 4/30/13, both residents asked for a room changed within 48 hours of admission to the room. The facility admitted Resident #4 with [DIAGNOSES REDACTED]. Resident #4 was Resident #1's roommate from 4/28 - 4/29/13. In an interview with the surveyor on 5/15 at approximately 10:10 AM the resident was asked about her/his stay in the room with Resident #1. Resident #4 stated, The girl/guy in there seemed weird to me. S/he acted like s/he was on cloud 9 or something. There was something wrong with her/him. S/he was acting like s/he didn't know where s/he was. S/he gave you a weird feeling. I was only in the room with her/him for one (1) day and one (1) night. I told them I had to get out of that room. I got the feeling s/he could cause me harm. I didn't know what to expect of her/him. I never saw her/him take anything, .I don't know what his/her problem was but I was afraid of her/him. I never saw him/her take anything. S/he just acted like s/he already took it. The facility admitted Resident #5 with [DIAGNOSES REDACTED]. The resident was admitted to the room with Resident #1 on 4/30/13. Review of the Nurse's Notes on 5/1/13 at 1:11 PM. stated, N/O (new order) to transfer resident to room [ROOM NUMBER] per pt (patient) request. Resident #5 was transferred to the emergency roiagnom on [DATE] and no longer at the facility. The surveyor on 5/15/13 interviewed the Social Services Director (SSD) at approximately 9:10 AM and again at 10:30 AM. S/he stated that both of the residents who moved out of the room requested the room change. The residents stated they didn't get along with Resident #1. SSD stated Resident #5 requested the room change. The resident stated s/he didn't feel s/he and roommate had a lot in common and didn't get along. The SSD stated Resident #4 requested the room change as the roommate looked like s/he was on cloud 9 and had a wild look in her/his eye. The surveyor on 5/14/13 interviewed the Director of Nursing (DON) at 3:30 PM. The DON stated s/he was not the DON at the time of the incident; s/he was working the unit at the time of the incident. The DON stated a CNA (Certified Nursing Assistant) found a spoon in the resident's room and took it to the Administrator and DON. They called the police. The police came in and asked permission to search his/her room . They found the other stuff. The police told the resident they could arrest him/her. I told the police that the resident was getting IV treatment, antibiotics for [DIAGNOSES REDACTED]. They let us know that if they arrested him/her, s/he would not receive the treatments. There would be no one to pull the PICC line or continue the treatments. About 30 minutes after the police left I had went in to talk to the resident. The nurse's note was written after the police had searched the resident's room . The surveyor on 5/14/13 interviewed the Administrator at approximately 3:45 PM regarding Resident #1's history of drug abuse and stay at the facility. The Administrator stated the facility knew the resident was a past drug user. A housekeeper had brought a spoon out of the resident room. I called the police. We asked if we could search the room. and the resident agreed. The police were with us when we found the paraphernalia. We asked where s/he got it. Our concern was if s/he was taking any kind of drug. S/he needed to continue his/her course of treatment. I was concerned if s/he went into DTs s/he may hurt someone. S/he was a big guy. The DON (Director of Nursing) called the Ombudsman. S/he (Ombudsman) came in wanted my internal investigation. There was no investigation. There was nothing done, s/he didn't do anything illegal while s/he was here. The police picked up the paraphernalia, don't know what the substance (powdered substance) was. We sent him out. We took steps to protect the other residents . The powdered substance and paraphernalia were found in the resident's bag containing his/her personal items. It was in the closet . The Administrator was unable to provide a police report for the police visit. As a result of the complaint survey the facility reportable files were requested. The facility provided a file with five (5) [MEDICATION NAME] (resident A, B, C, D and E), both 24 hour initial report and the 5 (five) day follow-up reports. There were no fax confirmations with the investigation files. The Director of Nurses and the Administrator stated the reports had been sent to the State Agency. The Triage Nurse at the State Agency was called to confirm that the State Agency had received the notifications of the reportable incidents. The State Agency Triage Nurse stated there were no 24 hour/initial reports sent in on three of the five facility [MEDICATION NAME]. No 24 hour reports were available for Resident A, E, and K. During the conversation with the State Agency Triage Nurse, a comparison was done regarding the facility's reportable incidents provided to the surveyor and those received by the State Agency. The Triage Nurse provided the names of the residents involved in the incidents reported by the facility. Five (5) additional residents had been reported to the State Agency (Residents F, G, H, I and resident # 5) evidence of these reports were not readily available by the facility. The Administrator stated the last DON had gone and they would have to search for them. Both the Administrator and DON stated the missing Initial reports were sent to the State Agency from the front fax machine. The current DON had faxed the 5 day reports from the fax in her/his office. The State Agency received the Five Day Reports but not the Initial 24 hour reports. On 5/14/13 at approximately 3:30 PM the Administrator provided a Fax Activity Log printout, which showed the fax machine, used to fax the 24 hour reports, had not been working from May 5 through 5/14/13. The facility was not aware, until the complaint survey, that anything faxed from the fax machine had not been received for the past 9 days. The facility failed to check for the fax confirmations, confirming the information allegedly faxed to the state agencies was received.", "filedate": "2016-05-01"}
{"rowid": 8324, "facility_name": "ALPHA HEALTH & REHAB OF GREER, LLC", "facility_id": 425138, "address": "401 CHANDLER RD", "city": "GREER", "state": "SC", "zip": 29651, "inspection_date": "2013-05-15", "deficiency_tag": 226, "scope_severity": "F", "complaint": 1, "standard": 0, "eventid": "01DB11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Complaint Investigation, based on record review, interview and review of the facility policy Reporting Abuse to State Agencies and other Entities, the facility failed to follow policies implemented for the identifying and reporting of abuse, neglect or suspected crime for 7 of 19 sampled residents. At the time of the complaint survey conducted on 5/14 - 5/15/2013 the facility was out of compliance at F-226 at a scope and severity of E related to Resident's #95 and #115 cited as part of the Recertification Survey conducted the week of 3/20/2013. F-226 was identified on 5/15/2013 at Substandard Quality of Care and the citation was elevated to a scope and severity of F related to Resident #1's alleged use of illicit drugs during his/her stay at the facility. One (1) of 1 residents with admitted elicit drug use while in the facility (Resident #1). Three (3) of 11 reportable incidents not reported to the State Agencies within 24 hours (Resident A, E, and K). One (1) of 11 reportable with a 5-Day Follow Up investigations not reported to State Agencies (Resident F). The findings included: Cross-refer to F-225 related to the failure of the facility to report to the State Agency Resident #1's alleged use of illicit drugs during his/her stay at the facility. One (1) of 1 residents with admitted elicit drug use while in the facility (Resident #1). Three (3) of 11 reportable incidents not reported to the State Agencies within 24 hours (Resident A, E, and K). One (1) of 11 reportable with a 5-Day Follow Up investigations not reported to State Agencies (Resident F). Review of the facility policy Reporting Abuse to State Agencies and Other Entities revealed, All suspected violations and all substantiated incidents of abuse will be immediately reported to appropriate state agencies and other entities or individuals as may be required by law. Under the section titles Policy Interpretation and Implementation a list of agencies to be notified included, The State Licensing/Certification agency responsible for surveying/licensing the facility, the local/State Ombudsman, Law enforcement officials when a crime is suspected to have occurred. Verbal/written notices to agencies will be made within 24 hours or the occurrence of such incident and such notice may be submitted via special carrier, fax, e-mail, or by telephone. The Administrator, or his/her designee, will provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within five (5) working days of the occurrence of the incident. The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Resident #1 was observed with spoons that appeared burnt in his/her room. The facility, with the police searched the resident's room and found drug paraphernalia in a bag containing a powdered substance, spoons and syringes. The resident admitted to using illicit drugs while in the facility. During the resident's stay two (2) different residents were admitted to his/her room and transferred out within 48 hours stating they did not get along with their room mate (Resident #1). The facility did not conduct an investigation of a suspected crime or report the incident to the State Agencies. Resident #4 a roommate of Resident #1 from 4/28/13 through 4/29/13 was interviewed on 5/15/13 at 10:10 AM and stated s/he was afraid of Resident #1 and only stayed in the room for 1 day and 1 night. Eleven (11) reportable incidents were reviewed. Three (3) incidents were not reported to state agencies within 24 hours (Residents A, E, and K). One (1) of 11 residents did not have the final, 5 day reported to State agencies (Resident (F). Of the 11 [MEDICATION NAME], the facility was unable to locate 4 reports or investigations until approximately 12:20 PM on 5/15/13. The Administrator discovered on 5/14/13 that the fax machine had not been working since 5/5/13.", "filedate": "2016-05-01"}
{"rowid": 8325, "facility_name": "ALPHA HEALTH & REHAB OF GREER, LLC", "facility_id": 425138, "address": "401 CHANDLER RD", "city": "GREER", "state": "SC", "zip": 29651, "inspection_date": "2013-05-15", "deficiency_tag": 250, "scope_severity": "E", "complaint": 1, "standard": 0, "eventid": "01DB11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Complaint Survey, based on record review and interviews, the facility failed to provide medically related social services. At the time of the complaint survey conducted on 5/14 - 5/15/2013 the facility was out of compliance at F-250 at a scope and severity of D related to Resident's #7 cited as part of the Recertification Survey conducted the week of 3/20/2013. F-250 was identified on 5/15/2013 and the citation was elevated to a scope and severity of E related to Resident #1's alleged history of drug abuse that was not addressed by Social Services; Residents #4 and #5 roommates of Resident #1 whose request for a room change was not documented in the Social Services Notes (4 of 6 residents reviewed for Social Services). The findings included: The Social Service Director was aware that Resident #1 had an alleged history of assault. The resident also had a history of [REDACTED]. Two residents were admitted to the room with Resident #1 and within 24 hours requested room change. There was no evidence the SSD made an attempt to determine the reasons for the requests. SSD was aware that Resident #4 had a history of [REDACTED]. There was no evidence of social service interventions or follow-up on any of the social issues with the residents. The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the resident's Social Progress Notes revealed on 4/18/13 that the resident was alert and oriented. Res. (resident) express s/he has a hx (history) of assault and aggravation. SS (social services) to monitor for a change in mood. There were no SS notes related to the resident's history of elicit drug abuse. Review of the Nurse's Notes revealed a note dated 5/1/13 at 2:00 PM. Resident alert and oriented. Able to make needs known. Resident stated I can't take this I'm going to slit myself and end it all . Resident has tennis ball sized powdered substance in bag at bedside, multiple syringes and spoons with burnt markings on them. Resident states has hx of drug abuse has been using while in facility, denies in room use. MD notified new order to send to ER for evaluation and tx (treatment) r/t (related to) suicidal ideation and possible withdrawal. The facility admitted Resident #4 with [DIAGNOSES REDACTED]. Resident #4 was placed in the room with Resident #1 on 4/28/13. Review of the Social Progress Notes revealed the family of Resident #4 reported a history of over use of pain medications. There were no further Social Services Notes on the medical record. The surveyor on 5/15/13 interviewed Resident #4 at approximately 10:10 AM. When the resident was asked about his/her experience with his/her roommate (Resident #1), the resident stated, The guy/girl in there seemed weird to me. S/he acted like s/he was on cloud 9 or something. There was something wrong with her/him. S/he acted like s/he didn't know where s/he was. S/he gave you a weird feeling. I was only in the room with her/him for 1 (one) day and 1 (one) night. I told them I had to get out of that room. I got the feeling s/he could cause me harm. I didn't know what to expect of him/her. I never saw him/her take anything, any medicine or drugs. I don't know what her/his problem was, but I was afraid of him The facility admitted Resident #5 with [DIAGNOSES REDACTED]. The resident was placed in the room with Resident #1 on 4/30/13. Review of the Nurse's Notes revealed a note written on 5/1/13 at 1:11 PM, which stated to transfer the resident to another room at patient's request. Review of the Social Services notes revealed a note dated 4/30/13, which stated resident was to change rooms because both of the residents in the room had the same (last) name. The surveyor on 5/15/13 interviewed the Social Services Director (SSD) at 9:10 AM and again at 10:30 AM. The SSD stated Resident #5 requested to move to a room the resident had been in before. S/he stated s/he and roommate didn't have a lot in common and didn't get along. S/he requested new roommate. Resident #4 requested a room change. His/her roommate 'looked like s/he was on cloud nine and had a wild look in his eye'. The SSD confirmed there was no social services note related to the transfers. When asked by the surveyor about Resident #4's over use of pain medication, the SSD stated the family had told her/him that when the resident was not at the facility. S/he confirmed it had not been addressed.", "filedate": "2016-05-01"}
{"rowid": 8166, "facility_name": "LAKE MOULTRIE NURSING HOME", "facility_id": 425341, "address": "1038 MCGILL LANE", "city": "SAINT STEPHEN", "state": "SC", "zip": 29479, "inspection_date": "2012-05-22", "deficiency_tag": 315, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "028C11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, interview, and review of the facility policy, LPN #1 (Licensed Practical Nurse) failed to correctly secure the catheter tube during catheter care for Resident #8. (1 of 1 catheter care observed) The findings included: The facility admitted Resident #8 on 5/29/02 with [DIAGNOSES REDACTED]. During catheter care observation on 5/20/12 at 4:15 PM, LPN #1 held the catheter tube approximately 4 to 5 inches from the insertion site. She then pulled upward on the tube and stated: I just tug a little and clean the tube. The LPN cleaned the tube from the insertion site up toward her fingers on the tube. When asked to explain what she meant by tugging on the tube, she stated: it's called holding or pulling it taunt. The resident made two facial grimaces during the care, but denied pain when asked. Suprapubic Catheter Care Policy provided by the facility stated under procedure number 6, Secure tubing with one hand. With the other hand take the 3rd soapy gauze or wipe and cleanse at the insertion site and approximately 4 inches down the catheter tubing. During an interview on 5/21/12 at 5:20 PM with the Director of Nursing, she stated: #6 means to hold the tube at the insertion site and clean away from the insertion site about 4 inches. LPN # 1 stated at 5:50 PM during an interview: That is the way I clean them I should have held the tube at the insertion site, I realize that now.", "filedate": "2016-07-01"}
{"rowid": 8167, "facility_name": "LAKE MOULTRIE NURSING HOME", "facility_id": 425341, "address": "1038 MCGILL LANE", "city": "SAINT STEPHEN", "state": "SC", "zip": 29479, "inspection_date": "2012-05-22", "deficiency_tag": 328, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "028C11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, review of the facility policy entitled Respiratory Therapy Equipment, and interview, the facility failed to ensure that residents' nebulizer were stored properly. There were random observations of nebulizers uncovered. The findings included: During initial tour of the facility on 5/21/12 at approximately 11:35 AM, a nebulizer mask was observed uncovered on the bedside table in rooms: room [ROOM NUMBER] and room [ROOM NUMBER]. On 5/22/12 at approximately 10:50 AM, LPN (Licensed Practical Nurse) #3 verified that the nebulizer masks were uncovered on the bedside tables in room [ROOM NUMBER] and 207. During an interview, LPN #3 stated: We keep masks covered in bags that they come in or we put them in zip lock bags. The nurses are responsible for covering the nebulizer masks. Review of the facility policy entitled Respiratory Therapy Equipment revealed: Keep oxygen cannulae and tubing used PRN (as needed) in a plastic bag when not in use. The Procedure Guidelines for Medication Nebulizer's revealed store circuit in plastic bag During the Medication Pass on 5/21/12 at 4:53 PM, LPN #3 was observed administering a nebulizer treatment to Resident A. Upon entering the room, the nebulizer mask was observed on the bedside table, uncovered. LPN #3 retrieved the mask, placed the medication in the chamber and administered the medication. At 5:17 PM, LPN #3 was observed administering eye drops to Resident A, Resident A had completed the nebulizer treatment and the nebulizer mask was again observed on the bedside table, uncovered.", "filedate": "2016-07-01"}
{"rowid": 5325, "facility_name": "CARLYLE SENIOR CARE OF FLORENCE", "facility_id": 425163, "address": "133 WEST CLARKE ROAD", "city": "FLORENCE", "state": "SC", "zip": 29501, "inspection_date": "2015-09-18", "deficiency_tag": 241, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "028R11", "inspection_text": "Based on observation and interview, the facility failed to ensure that treatment records were maintained in a private manner for 1 out of 2 residents reviewed for dignity (Resident #79). Record sheets for documenting repositioning while in bed, which included resident name and turn schedule, were left on the counter in Resident #79's shared bedroom, fully visible to anyone who stepped into the room. The findings included: Observation on 09/15/15 at 11:45 AM in Resident #79's room revealed treatment sheets were on the counter in the room, fully visible to anyone walking into the room. The sheets contained Resident #79's name and were used to document his/her turning schedule and positioning while in bed. Observations on 09/15/15 at 3:17 PM, 09/16/15 at 9:00 AM, and on 09/17/15 at 8:20 AM and 3:15 PM revealed the treatment sheets remained on the counter in full view. In an interview on 09/17/15 at 3:17 PM Registered Nurse #2 confirmed the treatment sheets documenting turning and positioning were on the counter in Resident #79's room and should not have been in the open in view of anyone walking into the room.", "filedate": "2019-01-01"}
{"rowid": 5326, "facility_name": "CARLYLE SENIOR CARE OF FLORENCE", "facility_id": 425163, "address": "133 WEST CLARKE ROAD", "city": "FLORENCE", "state": "SC", "zip": 29501, "inspection_date": "2015-09-18", "deficiency_tag": 282, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "028R11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to follow the nutrition care plan related to supplements for 1 of 2 residents reviewed for nutrition. A dietary recommendation to increase Prosource to three times a day was not followed for Resident #68. The findings included: The facility admitted Resident #68 with [DIAGNOSES REDACTED]. Record review on 9/18/15 revealed a Registered Dietician(RD) recommendation dated 5/14/15 to increase Prosource to three times a day(TID). Further review of the resident's record revealed the dietary recommendation was not carried forward as reflected on the (MONTH) (YEAR) Medication Administration Record(MAR). Review of the resident's care plan revealed a problem area for potential for alterations in nutrition and hydration with an approach to give supplements as ordered. During an interview on 9/18/15 at 4:42 PM, with the Director of Nursing(DON), he/she stated the recommendation had not been carried forward.", "filedate": "2019-01-01"}
{"rowid": 5327, "facility_name": "CARLYLE SENIOR CARE OF FLORENCE", "facility_id": 425163, "address": "133 WEST CLARKE ROAD", "city": "FLORENCE", "state": "SC", "zip": 29501, "inspection_date": "2015-09-18", "deficiency_tag": 325, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "028R11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of the facility policy titled Consultant Dietitian's Responsibilities, the facility failed to follow a dietary recommendation for 1 of 2 residents reviewed for nutrition. A dietary recommendation to increase Prosource to three times a day was not followed for Resident #68. The findings included: The facility admitted Resident #68 with [DIAGNOSES REDACTED]. Record review on 9/18/15 revealed a Registered Dietician(RD) recommendation dated 5/14/15 to increase Prosource to three times a day(TID). Further review of the resident's record revealed the dietary recommendation was not carried forward as reflected on the (MONTH) (YEAR) Medication Administration Record(MAR). The (MONTH) (YEAR) MAR indicated [REDACTED]. During an interview on 9/18/15 at 4:42 PM, with the Director of Nursing(DON), he/she stated the RD recommendations are placed in a book, reviewed by the DON and forwarded to the Unit Managers. The Unit Managers discuss the recommendation with the physician and if approved by the physician an order is written. At the time of the interview, he/she stated the recommendation had not been placed in the book and therefore not carried forward. Review of the facility policy titled Consultant's Dietitian's Responsibilities revealed under #4 the following: At the exit interview the consultant dietitian will provide a report summarizing all findings and recommendations. A copy of the report will be given to the following individuals-Administrator, DON, and Certified Dietary Manager. It will be the DON's responsibility to make sure the RD recommendations for residents are given to the physician for consideration. If the resident's recommendations are not approved by the physician it should be noted and given to the RD at his/her next visit for follow up. All other recommendations should be reviewed and acted on by the Food Service Director.", "filedate": "2019-01-01"}
{"rowid": 5328, "facility_name": "CARLYLE SENIOR CARE OF FLORENCE", "facility_id": 425163, "address": "133 WEST CLARKE ROAD", "city": "FLORENCE", "state": "SC", "zip": 29501, "inspection_date": "2015-09-18", "deficiency_tag": 371, "scope_severity": "F", "complaint": 0, "standard": 1, "eventid": "028R11", "inspection_text": "Based on observation, interview and review of the facility policies entitled Hand Washing and Personal Hygiene; Sanitization and Infection Control; Cleaning Instructions: Ice Machine; Food Storage; Proper Dish Machine Procedure; Manual Dishwashing Using the Three-Compartment Sink; Sanitizing Buckets; Proper Use of Disposable Gloves; Automatic Dishwashing Machine Procedures; and Emergency Menus and Supplies, the facility failed to serve food under sanitary conditions in 1 of 1 kitchens. Hair restraints were missing and/or not properly worn by dietary Aides and Dietary Manager; pans and dishware were stacked wet; dietary staff did not sanitize their hands properly; stored emergency foods were expired; the ice scoop holder did not have proper drainage; red buckets were not filled with sanitization fluids; and the dish washing machine was not sanitizing dishware. The findings included: On 9/15/15 at approximately 9:15AM, during initial tour of the kitchen, surveyors observed the Dietary Manager not wearing hair restraints for head or face. On 9/16/15 at approximately 11:24AM, the Dietary Manager was observed wearing a facial hair restraint only. At approximatley 11:30AM on 9/16/15, surveyors observed Dietary Aide #2 not wearing a facial hair restraint properly as it had shifted and was around the aide's neck. During an interview with Dietary Aide #2 on 9/16/15 at approximately 11:40AM, Surveyors asked if s/he was expected to wear a facial hair restraint. The aide said I didn't know until today. When asked why s/he did not have it on, the aide said it was itchy. The Registered Dietician and Dietary Consultant verified the Dietary Aide's statements. On 9/16/15 at approximately 12:22PM, surveyors interviewed the Dietary Consultant and the Registered Dietician about the facility's hair restraint policy and they indicated that facial hair should be covered. On 9/16/15 at approximately 11:24AM during kitchen tour, the surveyor observed plates and pans that were stacked wet. These observations were brought to the Dietary Manager's attention and s/he confirmed that the plates and pans were stacked wet. On 9/16/15 at approximately 12:22PM, the surveyors observed Dietary Aide #2 walking to different areas of the kitchen and not cleaning his/her hands when s/he returned to the food line after touching 3 carts and a table in the dishwashing area. The Registered Dietician and Dietary Consultant confirmed the observation. On 9/16/15 at approximately 3:03PM during an interview with the Dietary Manager and observation of the emergency food storage room, surveyors discovered expired emergency food supplies. The Dietary Manager said that s/he planned to discard foods after 6 months from their order date. At about 3:53PM on 9/16/15, the surveyor completed an inventory of expired emergency foods with the Registered Dietician and Dietary Consultant which had an order date of 10/20/12 indicated on the boxes: 1-Thick-it Beef Stew Puree, 12-15oz cans, Lot #0412. 2-Beef Lasagna Puree, 12-15oz cans, Lot #3501. 3-Mixed Fruit &(NAME) 12-15oz cans, Lot #0472 - 2 cases. 4-Chicken a La(NAME) 12-15oz cans, Lot #1102 - 2 cases. 5-Beef Stew, 12-15oz cans, Lot #0412 - 2 cases. 6-Sweet Corn, 12-15oz cans, Lot #1112; Lot #0652. 7-Carrots & Peas, 12-15oz cans, Lot #2152. 8-Green Beans, 12-15oz cans, Lot#1562 - 4 cases. On 9/16/15 at about 11:30AM during kitchen tour, surveyors observed the ice scoop held in a bucket which contained debris and provided no drainage for excess water. On 9/16/15 at approximately 3:30PM while in the kitchen, surveyors noted that the red buckets were not filled with sanitization solution. On 9/16/15 at approximately 3:18PM, surveyors observed the Dietary Manager complete the sanitizer concentration check of the low-temp dishwasher. The reading on the chlorine test paper did not match the sanitization level needed to ensure that dishes were clean when the wash cycle finished. The Dietary Manager stated that the chemical vendor provided regular maintenance and that they would be contacted to repair the dishwasher. Review of the facility policy entitled Hand Washing and Personal Hygiene revealed the following: hair restraints (hats and hairnets) are required to keep hair and its contaminants out of food. (Men with beards are required to wear appropriate hair restraints to cover beard.). Review of the facility policy entitled Manual Dishwashing Using the Three-Compartment Sink revealed the following: .air dry items on a clean and sanitized surface. Place items in an inverted position to allow them to drain .once completely air-dried, store items in the appropriate location on/in clean and sanitized shelves, drawers, etc. Review of the facility policies entitled Hand Washing and Personal Hygiene, and Proper Use of Disposable Gloves revealed the following: hands must be washed after touching anything that can be a source of contamination (i.e. .fresh produce, trash, dirty dishes, soiled linen, etc.). .Gloves should be discarded when leaving the work area for any reason. Door handles and equipment are considered to be contaminated. Wash hands and apply a clean pair before returning to the task. Review of the facility policy entitled Food Storage revealed the following: all stock must be rotated with each new order received. Rotating stock is essential to assure the freshness and highest quality of all foods. Old stock is always used first .food should be dated as it is placed on the shelves. Date marking to indicate the date or day by which a ready-to-eat, potentially hazardous food should be consumed, sold or discarded will be visible . Review of the facility policy entitled Cleaning Instructions: Ice Machine revealed the following: store the ice scoop beside or on top of the machine in a clean non-porous container that allows the water to drain off (and not pool around the scoop). Review of the facility policy entitled Sanitizing Buckets revealed the following: sanitizer buckets will be set up daily at the beginning of each shift using quaternary solution in red buckets .quaternary solution must be maintained at 200-400ppm during use .(and) checked .periodically throughout the shift. Review of the facility policy entitled Automatic Dishwashing Machine Procedures revealed the following: The temperature of the wash water for a low temperature is required to be at least 120 degrees F and the chemical for sanitization purposes must be automatically dispensed. .At least daily, test the sanitizer concentration by using Micro Chlorine Litmus Paper provided by the chemical vendor or is ordered with the supplies. .If the color does not match the minimum requirements, immediately check the dispenser and call the Food Service Supervisor/Director of Nutritional Services . During an interview on 9/16/15 at approximately 5:00PM, the chemical vendor representative and the Dietary Manager shared that the dish washing machine had been repaired, and that the tubing had not been working properly.", "filedate": "2019-01-01"}
{"rowid": 5329, "facility_name": "CARLYLE SENIOR CARE OF FLORENCE", "facility_id": 425163, "address": "133 WEST CLARKE ROAD", "city": "FLORENCE", "state": "SC", "zip": 29501, "inspection_date": "2015-09-18", "deficiency_tag": 441, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "028R11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and review of information from the customer care representative and review of the facility policy Dressing Change the facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to prevent the development and transmission of disease and infection. Prior to pressure ulcer care for Resident #25, staff was observed to place 4 x 4's directly on top of the treatment cart and to use Normal Saline which was dated but not timed when opened. After perineal care, Resident #43's boot was noted in the soiled trash bag when repositioned. (1 of 3 pressure ulcers reviewed and 1 of 2 urinary incontinence reviewed) The findings included: The facility admitted Resident #25 with [DIAGNOSES REDACTED]. During observation on 9/17/15 at 9:19 AM of the set up for pressure ulcer treatment for [REDACTED].#1 was observed to open a bottle of normal saline dated 9/16/15 and pour on 4 x 4's which were placed in a cup. RN #1 opened two more bottles of normal saline and poured the normal saline into two more cups containing 4 x 4's. At the time of set-up, RN #1 was asked how long the normal saline was good for once opened. RN #1 stated the normal saline was good for twenty four hours. When asked was there a time on the first bottle used, she stated there was no time documented on the bottle but it was dated 9/16/15. When asked how do we know it had not gone over the 24 hours since there was no time documented, he/she responded stating he/she thought the bottle had been opened around noon the day before. RN #1 was asked if the first cup containing the 4x 4 's was going to be used for the procedure and he/she stated yes. After questioning RN #1, about the first 4 x 4's prepared, he/she discarded the first cup of soaked normal saline 4 x 4's and replaced the cup and normal saline soaked 4 x 4's. Further observation revealed more gauze was obtained and placed directly on top of the treatment cart, collagen was placed on the gauze and opened packages of ABD pads were placed underneath the gauze. On 9/17/15 at 5:14 PM, the set up for pressure sore treatment was shared with RN #1. Review of information related to the normal saline from the Customer Care Representative dated 9/17/15 revealed the normal saline product is safe to use up to 24 hours after being opened. Review of the facility policy titled Dressing Change revealed under #1 and #2 the following:1. Gather all materials . and 2. Set up materials on over bed table-a. Clean table then place clean towel on table-set up supplies. The facility admitted Resident #43 with [DIAGNOSES REDACTED]. On 9/17/15 at approximately 3:13 PM, after perineal care had been provided, Certified Nursing Assistant(CNA)#1 turned the resident to his/her back and the resident's boot went into the trash bag on the bed which contained soiled items that had been used during perineal care. The resident's boot was not changed at the time of the observation.", "filedate": "2019-01-01"}
{"rowid": 1903, "facility_name": "SANDPIPER REHAB & NURSING", "facility_id": 425146, "address": "1049 ANNA KNAPP BOULEVARD", "city": "MOUNT PLEASANT", "state": "SC", "zip": 29464, "inspection_date": "2019-11-22", "deficiency_tag": 550, "scope_severity": "D", "complaint": 1, "standard": 1, "eventid": "02V311", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and review of facility policy, the facility failed to ensure the protection of dignity as evidenced by staff not awaiting a response prior to entering the room of 1 of 1 sampled residents reviewed for customer service (Resident #140), and responding poorly to a resident inquiring about receiving medication during a random observation on 1 of 4 Units. The findings included: During a random observation on 11/20/19 at approximately 3:58 PM, a resident asked the nurse on duty about his/her medication. The nurse responded, I don't have you. in a very short manner and upon seeing this surveyor repeated in a softer tone I don't have you. The nurse did not offer a solution to the resident's concern. In an interview on 11/20/19 at approximately 4:30 PM, the Director of Nursing confirmed the response was not appropriate and the resident should have been given further assistance. The facility admitted Resident #140 on 06/28/2018 with [DIAGNOSES REDACTED]. Review of the medical record on 11/18/2019 at approximately 11:00 AM revealed that the resident had a BI[CONDITION] (Brief Interview for Mental Status) of 13. During a resident interview on 11/18/2019 at 12:33 PM, Certified Nursing Assistant (CNA) #2 entered the room without knocking. During the interview, resident #140 stated that some of the nurses and CNA's can be verbally rude with their tones at times. Resident #140 also stated that she believed some staff were only there for a paycheck and do not truly care about the residents. On 11/19/2019 at 11:26, several CNA's were observed on the 300 wing failing to knock on residents' doors and wait a proper amount of time before entering. On [DATE] at 10:13 AM, an interview with Nurse #1 related to expectations of staff before entering resident rooms revealed, staff are expected to knock and wait at 15-20 seconds for a response before entering into a resident's room if the resident is able to communicate. Review of facility policy titled, Quality of Life-Dignity on [DATE] at approximately 11:30 AM revealed Residents' private space and property shall be respected at all times. Staff will knock and request permission before entering residents' rooms. The policy continued by stating that Staff shall speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not labeling or referring to the resident by his or her room number.", "filedate": "2020-09-01"}
{"rowid": 1904, "facility_name": "SANDPIPER REHAB & NURSING", "facility_id": 425146, "address": "1049 ANNA KNAPP BOULEVARD", "city": "MOUNT PLEASANT", "state": "SC", "zip": 29464, "inspection_date": "2019-11-22", "deficiency_tag": 641, "scope_severity": "D", "complaint": 1, "standard": 1, "eventid": "02V311", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, it was determined that 1 of 30 sampled residents was wearing a wander guard without being assessed for elopement risk (Resident #3[AGE]). The findings included: Review of the facility's policy dated 6/15/16, titled Elopement Risk revealed the facility would identify residents at risk for elopement, and implement interventions, evaluate and utilize the elopement risk assessment. The policy indicated residents who are at risk for wandering behaviors will have a wander guard device placed on person or ambulation device. Further review of the policy revealed Elopement Risk Assessments will be completed quarterly for residents deemed to be at risk for elopement. Review of Resident #3[AGE]'s clinical record revealed an admitted [DATE] with [DIAGNOSES REDACTED]. According to the resident's comprehensive Annual Minimum Data Set (MDS) assessment dated [DATE], Resident #3[AGE] was moderately impaired cognition, with a Brief Interview Mental Status (BI[CONDITION]) of 9. The facility assessed the resident to have no mood or behaviors. The resident exhibited no wandering behaviors. Continued review of the MDS revealed Resident #3[AGE] required the limited assistance of one staff person for bed mobility, toilet use, and personal hygiene. The resident required supervision assistance with transfers, walking in and out of room, moving on and off unit, and eating. According to the resident's most recent Quarterly MDS assessment dated [DATE], Resident #3[AGE] was cognitively intact with a BI[CONDITION] of 14. The facility assessed the resident to have no mood or behaviors. The resident had no wandering behaviors. Continued review of the MDS revealed Resident #3[AGE] required the extensive assistance of one staff person for bed mobility, dressing, toilet use, and personal hygiene. The resident required supervision assistance with walking in and out of room, moving on and off unit, and eating. Review of the clinical record from 1/13/19 through 10/21/19 of the annual/significant change and quarterly comprehensive assessments revealed the facility did not assess the resident for risk of elopement. Even though, during the assessment periods January - August 2019 identified Resident #3[AGE] revealed no behaviors of wandering. Observation of Resident #3[AGE] on [DATE] at 12:11 PM revealed the resident was self-propelling around the facility. The resident had a wander guard bracelet on left wrist. Resident #3[AGE] was observed on 11/19/19 at 10:23 AM in wheelchair (w/c) outside of the beauty shop. During the observation, the resident verbalized waiting for a hair appointment. Observation of Resident #3[AGE] on 11/20/19 at 8:46 AM revealed the resident lying in bed. Observed resident on 11/20/19 at 10:45 AM in a group religious activity. Continued observation at 11:30 AM after the religious activity ended revealed Resident #3[AGE] propelling in w/c back to room. On 11/21/19 at 9:29 AM, an interview conducted with the Director of MDS and Director of Nursing (DON) revealed Resident #3[AGE]'s elopement assessment was last completed 2/12/18. The MDS Director revealed an assessment was not needed due to the resident being care planned for elopement. He further stated the Interdisciplinary Team (IDT) discussed the use of wander guards during care plan meetings. However, the DON indicated the facility should conduct an elopement assessment with MDS reviews and significant changes.", "filedate": "2020-09-01"}
{"rowid": 1905, "facility_name": "SANDPIPER REHAB & NURSING", "facility_id": 425146, "address": "1049 ANNA KNAPP BOULEVARD", "city": "MOUNT PLEASANT", "state": "SC", "zip": 29464, "inspection_date": "2019-11-22", "deficiency_tag": 657, "scope_severity": "D", "complaint": 1, "standard": 1, "eventid": "02V311", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to update the Comprehensive Care Plan for 1 of 1 sampled residents reviewed for hospice related to hospice admission (Resident #74). The findings included: The facility admitted Resident #74 with [DIAGNOSES REDACTED]. Record review on 11/20/19 at approximately 3:19 PM revealed Resident #74 was admitted to Hospice on 0[DATE]. A Significant Change assessment was completed on 09/27/19 related to the hospice admission. Review of the Care Plan revealed Resident #74's Hospice services were not incorporated into the Comprehensive Care Plan and no interventions to ensure coordination of care were added.", "filedate": "2020-09-01"}
{"rowid": 1906, "facility_name": "SANDPIPER REHAB & NURSING", "facility_id": 425146, "address": "1049 ANNA KNAPP BOULEVARD", "city": "MOUNT PLEASANT", "state": "SC", "zip": 29464, "inspection_date": "2019-11-22", "deficiency_tag": 689, "scope_severity": "D", "complaint": 1, "standard": 1, "eventid": "02V311", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, record review, and facility policy review, the facility failed to identify outdated wander guard for 1 of 3 sampled wander guard residents (Resident #3[AGE]). Nursing staff did not identify Resident #3[AGE]'s wander guard had expired on [DATE]. The findings included: Review of the facility's policy entitled Wander Policy dated [DATE], revealed the facility identified residents who walked or wheeled about unrestricted, and posed a threat to leave the facility unattended without staff's knowledge. The purpose of the policy was to ensure safety. The wandering policy procedure included (but not limited too) a wandering device as a safety intervention. The facility's Wander Band Check Policy dated [DATE] revealed wander guard band would be monitored. The policy revealed a weekly inspection would be conducted by the Unit Manager or designee. The wander guard band was to be monitored every shift for placement and effectiveness by the nurse and documented on the Treatment Administration Record (TAR). Review of Resident #3[AGE]'s clinical record revealed an admitted [DATE] with [DIAGNOSES REDACTED]. According to the resident's most recent Quarterly Minimum Data Set (MDS) assessment dated [DATE], Resident #3[AGE] was cognitively intact with a Brief Interview Mental Status (BI[CONDITION]) of 14. The facility assessed the resident to have no mood or behaviors. The resident had no wandering behaviors. Continued review of the MDS revealed Resident #3[AGE] required the extensive assistance of one staff person for bed mobility, dressing, toilet use, and personal hygiene. The resident required supervision assistance with walking in and out of room, moving on and off unit, and eating. Observation of Resident #3[AGE] on [DATE] at 12:11 PM revealed the resident was self-propelling around the facility. The resident had a wander guard bracelet on the left wrist. The wander guard bracelet had an encryption which read Do Not Use after [DATE]. Resident #3[AGE] was observed on [DATE] at 10:23 AM in wheelchair (w/c) outside of the beauty shop. The resident's wander guard revealed an unchanged expiration date. On [DATE] at 2:40 PM, observation revealed the wander guard expiration date remained [DATE]. Observation of Resident #3[AGE] on [DATE] at 8:46 AM revealed the resident lying in bed with the expired wander guard bracelet. Continued observation on [DATE] at 2:20 PM revealed the resident in their room with the expired wander guard. During the observation, the resident remarked that the expiration date was also her son's birthday. On [DATE] at 2:29 PM interview was conducted with Certified Nursing Assistant (CNA) #1 revealed the facility maintains a list of residents who should have wander guards. The CNA stated being trained to redirect residents who wander. She stated the exit door would alarm if a wander guard resident got close to it. However, the nurses are responsible for monitoring wander guard placement and function. Interview on [DATE] at 2:40 PM with the Registered Nurse (RN) #1 revealed being responsible for Resident #3[AGE]'s care needs. The RN stated every shift a resident's wander guard was check for placement and functioning. She continued to reveal the wander guard expiration dates were monitored by the Unit Secretary. During the interview, RN #1 observed Resident #3[AGE]'s wander guard and validated that it had expired. On [DATE] at 3:09 PM an interview with the Magnolia Unit Secretary revealed being responsible for weekly monitoring the resident's wander guard for expiration. She stated every week residents' wander guard expiration dated were monitored. The expiration dates were documented on a monthly log sheet. She indicated if the wander guard was expiring the Assistant Director of Nursing (ADON) was notified to obtain a new wander guard. During the interview the Unit Secretary provided the [DATE] Wander guard weekly checks log. The log revealed Resident #3[AGE] had an expiration date of [DATE]. Continued review of the log revealed Resident #3[AGE]'s wander guard was checked on [DATE] and [DATE] (but not changed). Interview with the ADON on [DATE] at 3:15 PM revealed she monitors residents twice a day to ensure care and services were provided. The ADON indicated during her monitoring rounds she ensures all interventions are in place. She indicated being responsible for ensuring the wander guard functioning was accurate. The ADON stated the importance of monitoring the wander guard expiration date was to ensure resident safety.", "filedate": "2020-09-01"}
{"rowid": 1907, "facility_name": "SANDPIPER REHAB & NURSING", "facility_id": 425146, "address": "1049 ANNA KNAPP BOULEVARD", "city": "MOUNT PLEASANT", "state": "SC", "zip": 29464, "inspection_date": "2019-11-22", "deficiency_tag": 812, "scope_severity": "F", "complaint": 1, "standard": 1, "eventid": "02V311", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and review of facility policy, the facility failed to serve food under sanitary conditions for 1 of 1 kitchen. Staff were noted without hair restraints, thermometers were not found inside of freezers, food items were not labeled, and expired food in dry storage. The findings included: During initial tour on [DATE] at approximately 10:45 AM revealed at approximately 11:00 AM kitchen staff #1 was observed without a beard guard. Further observation revealed french toast and burger patties in the walk in freezer with no date, and tomatoes were noted on the floor. In two of the walk in freezers no thermometer was on the inside of the unit. Observation of the dry food storage revealed cake icing that expired in 2018. During the the lunch and dining observation on [DATE] at approximately 12:55 PM revealed kitchen staff #2 without beard guard protection. On [DATE] at 4:42 PM, a peanut butter and jelly sandwich was left in 300 unit wing with saran wrap and no date. Interview with Dietary Manager on [DATE] at approximately 1:00 PM revealed male staff were expected to wear beard guards when around and handling food. Review of facility policy titled Preventing Forborne Illness - Food Handling revealed hair nets or caps and or/beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. The policy continued by stating that food items and snacks kept must be labeled with a use by date, all foods belonging to residents must be labeled with the resident's name, the item and the use by date. All refrigerators must have working thermometers and be monitored for temperature according to state specific guidelines.", "filedate": "2020-09-01"}
{"rowid": 5606, "facility_name": "WOODRUFF MANOR", "facility_id": 425179, "address": "1114 EAST GEORGIA ROAD", "city": "WOODRUFF", "state": "SC", "zip": 29388, "inspection_date": "2015-06-04", "deficiency_tag": 157, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "02VR11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to notify the physician of behaviors for Resident #5 and #14, 2 of 9 residents reviewed for behaviors. The facility failed to notify the physician that Resident #14 was refusing Fingerstick Blood Sugars (FSBS) and/or Sliding Scale Insulin (SSI) and failed to notify the physician of Resident #5's continued behaviors that included refusing care, screaming/yelling and inappropriate sexual behavior. The findings included: The facility admitted Resident #5 with [DIAGNOSES REDACTED]. On 6/3/15 at 11:55 AM, record review revealed a Psychiatric Progress Note dated 12/18/15 that stated Pt (patient) is still having sexual interactions (with) another pt. who is also very pursuant of that activity and stated that the resident's medication was adjusted. Review of the Psychoactive Drug Weekly Evaluation forms from 12/19/14 to 5/22/15 revealed the resident was documented as exhibiting cursing, arguing, inappropriate sexual behavior, manipulative/ demanding behavior, resisting/refusing care, screaming/ yelling, accusing others, and aggressive behaviors that varied from week to week. There was no documentation that the physician had been notified of any of the continued behaviors. Review of the Interdisciplinary Progress Notes revealed the resident was reviewed for devices and transfers on 4/27/15 but not for behaviors. The notes further indicated the resident was reviewed for picking at several other residents, poking them (with) his fingers and becoming verbally aggressive toward another resident on 5/27/15 and a new intervention was implemented that the resident would eat meals in the unit day room instead of the main dining room; there was no documentation the physician was notified. During an interview on 6/3/15 at 3:25 PM, Licensed Practical Nurse (LPN) #4 confirmed the documentation of the continued behaviors including sexually inappropriate behaviors, and that there was no documentation in the IDT notes or in the nurses notes of physician notification. The LPN also stated the resident was on 15 minute checks to monitor for behaviors and the resident's location. During an interview at 3:58 PM, LPN #5 stated s/he thought the documentation on the Psychoactive Drug Weekly Evaluation forms were to indicate why the resident was on the medication and not current behaviors. The LPN was unable to explain why behaviors were documented on some weeks and not on other weeks. On 6/4/15 at 9:35 AM, the Nursing Home Administrator (NHA confirmed the documentation on the Psychoactive Drug Weekly Evaluation forms and that the documentation varied from day-to-day. The NHA also confirmed the resident was still on 15 minute checks but denied that the resident was having sexually inappropriate behaviors despite the documentation and stated We have issues with documentation. The facility admitted Resident #15 with [DIAGNOSES REDACTED]. On 6/4/15, record review revealed an order for [REDACTED]. The resident also refused the SSI on 5/18/15 for a FSBS of 294. Review of the Nurse's Notes from 4/16-through 5/28/15 revealed no documentation that the physician was notified of the resident's refusal of treatments. Review of the Nurse's Notes also revealed a note dated 4/17/15 at 1330 (sic) that the Resident refused all meds (medications) tx's (treatments) today .(the resident) is totally noncompliant (with) everything .(Her/His) behaviors are increasing (and) (she/he) is becoming violent. Will continue to observe. There was no documentation that the physician was notified of the resident's behaviors. Review of the facility's policy entitled [DIAGNOSES REDACTED] and [MEDICAL CONDITION] Protocol revealed no protocol to call the physician if the resident refused treatment.", "filedate": "2018-11-01"}
{"rowid": 5607, "facility_name": "WOODRUFF MANOR", "facility_id": 425179, "address": "1114 EAST GEORGIA ROAD", "city": "WOODRUFF", "state": "SC", "zip": 29388, "inspection_date": "2015-06-04", "deficiency_tag": 167, "scope_severity": "C", "complaint": 0, "standard": 1, "eventid": "02VR11", "inspection_text": "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.", "filedate": "2018-11-01"}
{"rowid": 5608, "facility_name": "WOODRUFF MANOR", "facility_id": 425179, "address": "1114 EAST GEORGIA ROAD", "city": "WOODRUFF", "state": "SC", "zip": 29388, "inspection_date": "2015-06-04", "deficiency_tag": 226, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "02VR11", "inspection_text": "Based on record reviews, interviews and review of the facility's policy entitled Background Screening Investigations, the facility failed to conduct a criminal background check for 3 of 22 employees reviewed for criminal background checks. The findings included: On 6/3/15, during review of the employee files for the extended survey, it was noted that 3 of 22 Certified Nursing Assistant (CNA), Registered Nurse (RN) and/or Licensed Practical Nurse (LPN) criminal background checks were not conducted prior to the employee's hire date. Review of the facility's policy entitled Background Screening Investigations indicated in . Policy Interpretation and Implementation . 1. The Personnel Director/Human Resources Director, or other designee, will conduct employment background checks and criminal conviction checks (including fingerprinting as may be required by state law) on persons making application for employment with this facility. Such investigation will be indicated within two days of employment or offer of employment . The findings were confirmed during an interview with the Human Resources staff.", "filedate": "2018-11-01"}
{"rowid": 5609, "facility_name": "WOODRUFF MANOR", "facility_id": 425179, "address": "1114 EAST GEORGIA ROAD", "city": "WOODRUFF", "state": "SC", "zip": 29388, "inspection_date": "2015-06-04", "deficiency_tag": 253, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "02VR11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility had multiple rooms with loose/torn baseboards, rust and/or significant scarring of paint on bathroom door frames, soiled/rusted over toilet seats and expired food items in a resident room. The concerns were noted in 10 of 23 rooms observed on Unit 1. In addition the facility failed to maintain a clean comfortable area for resident's to dine and watch television on Unit 1. The findings included: On [DATE] at approximately 9:45 AM, during tour of the facility, Room 116 was noted to have baseboard peeling from the wall near the bathroom and in the bathroom. The sink in the bathroom was pulling away from the wall and was noted to have a thick black substance along the crack between the wall and the sink. On [DATE] at approximately 10:20 AM, Rooms 114, 115, 116 and 120 were noted to have paint missing along the bathroom door frames and rusted areas where paint was missing on both sides of the doorway approximately 6 inches up the frame from the floor. Peeling wall paper was noted on the wall to the left of the sink in room 115. During initial tour of the facility on [DATE], multiple environmental concerns were identified on the 100 Unit: Room 100 bathroom - Rust around the bottom of the toilet and on the bolts of the raised over-toilet seat, missing paint and rust on the bathroom door frame. Room 101 bathroom - Rust around the bottom of the toilet, toilet seat scratched with brown stain, and missing paint and rust on the bathroom door frame. Room 102 B - Expired food items on the bedside table. Room 103 - Soiled arms on the raised over-toilet seat, missing paint and rust on the bathroom door frame with a hole in the metal at the bottom of the frame. Room 104 bathroom - Rusty uncovered bolts on the toilet, torn arm on the raised over-toilet seat, and missing paint and rust on the bathroom door frame. Room 108 - Missing paint and rust on the bathroom door frame, loose baseboard by the door. On [DATE] at approximately 8:55 AM the Maintenance Director stated, during a walk through of negative maintenance and housekeeping findings, that plans were in place for the Unit 1 repairs that had been observed by the Survey Team. On [DATE] at approximately 10:20 AM neither the Maintenance Director, the Administrator or the Regional Director of Operations were able to provide a repair schedule for the 100 Hall or timely quotes for furniture replacement in the Hall 100 Dining/Activities Room. On [DATE] at approximately 9:15 AM, during initial tour of the facility, the sofa in the Unit 1 Dining/Day Room was noted to have large areas with the color scuffed/peeled off the seat and back of the sofa. The dining room table was noted to have the ends with the finish chipped/worn off. The items were unchanged during meal observations in the Unit 1 Dining/Day Room on [DATE], [DATE] and [DATE]. A table cloth was placed on the table but it did not cover the scuffed/worn ends.", "filedate": "2018-11-01"}
{"rowid": 5610, "facility_name": "WOODRUFF MANOR", "facility_id": 425179, "address": "1114 EAST GEORGIA ROAD", "city": "WOODRUFF", "state": "SC", "zip": 29388, "inspection_date": "2015-06-04", "deficiency_tag": 280, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "02VR11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to review and/or revise the care plan to include 15 minute checks for Resident #5, 1 of 9 residents reviewed, to monitor for behaviors. The finding included: The facility admitted Resident #5 with [DIAGNOSES REDACTED]. On 6/3/15 at 11:55 AM, review of the Psychoactive Drug Weekly Evaluation forms from 12/19/14 to 5/22/15 revealed the resident was documented as exhibiting cursing, arguing, inappropriate sexual behavior, manipulative/ demanding behavior, resisting/refusing care, screaming/ yelling, accusing others, and aggressive behaviors that varied from week to week. Review of the care plan revealed a care plan for Behaviors with interventions including Observe for changes in mood and behavior. Medications and psych (psychiatric) consults as ordered. Redirect resident when approaching other residents. Attempt to engage in activities of interest to redirect from behaviors. During an interview on 6/3/15 at 3:25 PM, Licensed Practical Nurse (LPN) #4 confirmed the documentation and stated that the resident was on q (every) 15 minute checks. The LPN further confirmed the care plan had not been updated to include the intervention .", "filedate": "2018-11-01"}
{"rowid": 5611, "facility_name": "WOODRUFF MANOR", "facility_id": 425179, "address": "1114 EAST GEORGIA ROAD", "city": "WOODRUFF", "state": "SC", "zip": 29388, "inspection_date": "2015-06-04", "deficiency_tag": 282, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "02VR11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and resident interview, the facility failed to provide care in accordance with the written plan of care for behaviors for Resident #5, 1 of 9 residents reviewed for behaviors. The findings included: The facility admitted Resident #5 with [DIAGNOSES REDACTED]. On 6/3/15 at 11:55 AM, record review revealed a Psychiatric Progress Note dated 12/18/15 that stated Pt (patient) is still having sexual interactions (with) another pt. who is also very pursuant of that activity and stated that the resident's medication was adjusted. Review of the Psychoactive Drug Weekly Evaluation forms from 12/19/14 to 5/22/15 revealed the resident was documented as exhibiting cursing, arguing, inappropriate sexual behavior, manipulative/ demanding behavior, resisting/refusing care, screaming/ yelling, accusing others, and aggressive behaviors that varied from week to week. Review of the care plan revealed a care plan for Behaviors with interventions including Observe for changes in mood and behavior. Medications and psych (psychiatric) consults as ordered. Redirect resident when approaching other residents. Attempt to engage in activities of interest to redirect from behaviors. Upon entering the room for an Individual Interview with Resident #5 on 6/4/15 at approximately 10:10 AM, a staff member was observed sitting in the resident's room watching the television. The resident was laying on the bed. When asked what activities the resident participated in, the resident stated the facility ain't got no activities here, not that I like. When asked what kind of activities the resident enjoyed, Resident #5 stated I like card games and checkers and stated that there were no residents that were able or knew how to play. When questioned about the staff the resident stated Something must have happened, I got somebody baby-sitting me now. The sitter stated that the resident knew why s/he was there. The sitter was not observed engaging the resident in conversation or any activity of interest per the care plan.", "filedate": "2018-11-01"}
{"rowid": 5612, "facility_name": "WOODRUFF MANOR", "facility_id": 425179, "address": "1114 EAST GEORGIA ROAD", "city": "WOODRUFF", "state": "SC", "zip": 29388, "inspection_date": "2015-06-04", "deficiency_tag": 323, "scope_severity": "L", "complaint": 0, "standard": 1, "eventid": "02VR11", "inspection_text": "Based on observations, record reviews and interviews the facility failed to assure safe water temperatures for 13 of 13 resident bathrooms on Unit 2 (Hall 200). The Maintenance Director failed to have adequate knowledge for checking temperatures and calibrating thermometers and there was no scheduled monitoring of water temperatures. The findings include: On 6/2/15 at approximately 9:00 AM during initial tour of the facility water temperatures were checked by hand in thirteen resident bathrooms on Unit 2 and observed to be too hot. On 6/2/15 at approximately 9:30 AM Surveyor Team thermometers were used to check all facility bathrooms. Thirteen resident bathrooms on Unit 2 were found to have hot water temperatures of approximately 121-124 degrees F (Fahrenheit). On 6/2/15 at approximately 9:55 AM the Maintenance Director was asked to provide a water temperature log and to take water temperatures for the Unit 2 resident bathrooms. He/she stated that no log was kept and obtained a(NAME)stick thermometer from the kitchen. When asked about calibration he/she stated that the thermometer had been calibrated yesterday. The Surveyor asked for the thermometer to be calibrated again and the Maintenance Director took the thermometer to the kitchen and asked the Dietary Manager to calibrate. On 6/2/15 at approximately 10:10 AM the Maintenance Director used the kitchen thermometer calibrated by the Dietary Manager to check bathroom water temperatures on Unit 2. Water temperatures were check in bathrooms for room 201/203, 204/206, 209, 211/213, 216 and 215/217. The results obtained by the Maintenance Director were between approximately 100-110 degrees F. The Maintenance Director demonstrated considerable variability in technique when taking temperatures and stated several times that the water sure feels a lot hotter than this. The thermometer was held under the hot water stream at varying angles and the entire temperature sensitive portion of the thermometer was not exposed to the water. The Surveyor temperature reading taken at the same time were between approximately 122-124 degrees F. On 6/2/15 at approximately 10:57 AM the Maintenance Director stated during an interview that he/she did not keep a water temperature log. On 6/2/15 at approximately 11:50 AM the Maintenance Director stated in an interview that he/she had not checked water temperatures in 3-4 months. On 6/2/15 at approximately 11:55 AM inspection of the two hot water heaters for Unit 2 located in an outside room next to room 206 revealed a Honeywell digital controller reading 110 degrees F and an analog thermometer located past the controller reading 117 degrees F. The Maintenance Director was unable to explain the difference, speculated that the thermometer could be old and needed to be replaced and stated there were no logs kept for the two hot water heaters. On 6/2/15 at approximately 2:50 PM prior to rechecking water temperatures the Maintenance Director stated that he/she did not know how to calibrate a thermometer. The kitchen thermometer being used by the Maintenance Director and the Surveyor thermometer were then calibrated in the same ice bath, at the same time by the Dietary Manager and the Surveyor. Once calibrated, the maintenance Director and Surveyor checked water temperatures in bathrooms for rooms 201/203, 204/206, 209, 211/213, 206 and 215/217. Temperature readings for both the Facility thermometer and the Surveyor thermometer ranged from 121 degrees to 123 degrees F. On 6/2/15 at approximately 4:35 PM the Administrator verified that no water temperature logs were being kept by the Maintenance Director. The Administrator was notified at approximately 5:00PM on 6/2/2015 of the Immediate Jeopardy and/or Substandard Quality of Care related to excessive hot water temperatures in resident rooms. An Allegation of Compliance (A[NAME]) was submitted by the facility on 6/3/15 at approximately 8:45 AM. The actions listed in the A[NAME] included the following: I. Corrective Action taken to remove the Immediate Jeopardy: On 6/2/2015 at approximately 5:00pm (sic), the survey team notified the facility that an Immediate Jeopardy situation was present in regards to Hot Water Temperatures on the 200 Unit. The survey team stated that resident room temperatures on the 200 Unit were in excess of 120 degrees (highest temperature reported was 124 degrees). It was stated by the survey team leader that excessive temperatures were limited to the 200 Unit and that the other Unit's temperatures (100 Unit) were in compliance. The Administrator informed the nursing staff on the 200 Unit to cease using hot water on 6/2/15 at approximately 5:20pm (sic) until the situation was resolved. On 6/2/15 The DON, in coordination with the Licensed Nursing Staff completed 100% body audits on all residents on both units to ensure that there was no evidence of any resident injury or bums due to hot water. The findings of the body audits concluded that there had been no injuries or burns to residents. The Maintenance Director contacted the facility's contracted plumber and they dispatched a plumber to the facility immediately. The plumber, along with the Maintenance Director and Regional Director of Operations visibly inspected the two hot-water heaters that control resident room temperatures on the 200 Unit. The two hot water heaters each have their own thermostats but are then connected by an adjustable mixing valve. The plumber adjusted the left thermostat to the lowest allowable setting. In addition, the mixing valve was adjusted approximately a 1/4 inch colder temperature to ensure compliance. At 6:15, the plumber, Maintenance Director, and Regional Director of Operations conducted an initial test of a resident room where excessive temperatures had been noted by the survey team. At that time, the temperature at the resident sink was noted to be 117 degrees, indicating that the adjustments made to the thermostat had successfully removed the immediate jeopardy to the residents. At 6:30pm (sic) the plumber signed a Teachable Moment form, indicating that he had educated the Maintenance Director on adjusting the thermostats and mixing valves to achieve the desired temperatures, as well as proper calibration of thermometers. At the plumber's recommendation, new Digital Thermometers were purchased by the facility Administrator on 6/2/2015. At IOpm (sic), The Maintenance Director and Regional Director of Operations checked 100% (12 on each of 2 Units) of resident bathroom sinks and shower rooms on 6/2/2015. All temperatures were within regulatory limits (100 - 120 degrees). The facility has no recorded grievances by residents that the room water temperatures were too hot. The facility has had no incidents of residents being burned or scalded by hot water. 2. Measures put into place or systemic changes made to ensure that the immediate jeopardy will not recur: The Administrator and Regional Director of Operations inserviced the Maintenance Director on 6/2/2015 regarding the requirement to check resident room temperatures in accordance with facility policy. A log to record temperatures was provided and will be utilized to ensure ongoing compliance. The water temperature log will be completed daily for two weeks to ensure stability of temperature settings, and weekly thereafter. Any temperature readings in excess of 120 degrees will be corrected immediately and reported to the facility Administrator. The Staff Development Coordinator began inservicing all nursing staff on 6/2/2015 on the facility's Safety of Water Temperatures policy. No nursing staff will be allowed to work until having received this inservice. This inservice includes: o Any time water feels excessively hot to the touch (i.e., hot enough to be painful or cause reddening of the skin after removal of the hand from the water), staff will report this finding to their immediate supervisor. o Risk factors for scalding/burns that are more common in the elderly, such as: Decreased skin thickness; Decreased skin sensitivity; Peripheral neuropathy; Reduced reaction time; Decreased cognition; Decreased mobility, and Decreased communication. o Other factors that influence temperature tolerance (length Of exposure, amount of skin exposed, and the resident's current condition). o Signs and symptoms of burns (first, second, and third degree) o If a resident is scalded or burned, nursing staff shall follow pertinent first aid and physician notification protocols and report the injury to his or her direct supervisor. As a precaution, the hot water heaters that control resident room water temperatures on the 100 Unit were reviewed by the plumber, Maintenance Director, and Regional Director of Operations. The findings of the review indicated the left hot water heater was set on 120 degrees, and the right was set on 110. The water from the two hot-water heaters is combined prior to entering the facility. The thermostat of the left hot water heater was reduced to 115 degrees. There has been no reported temperatures on the 100 Unit in excess of 120 degrees. All new nursing staff will be oriented regarding the Safety of Water Temperatures policy during orientation. Any new Maintenance personnel will also be oriented on this policy, and the log for tracking hot-water temperatures. Results of hot-water temperature monitoring will be brought to the Quality Assurance Committee monthly to ensure ongoing compliance. However, any noted temperatures above the allowable range of 100-120 degrees will be corrected immediately and reported to the facility Administrator. Observations, review of policy, education and signature sheets on 6/3/15 revealed the Allegation of Compliance submitted by the facility on 6/3/15 had been implemented by the facility and was in practice removing the immediacy of the deficient practice. The Administrator was informed of this on 6/3/15 at 5:25 PM. The citations at F-323, F-490, and F-520 remained at a lower scope and severity of F.", "filedate": "2018-11-01"}
{"rowid": 5613, "facility_name": "WOODRUFF MANOR", "facility_id": 425179, "address": "1114 EAST GEORGIA ROAD", "city": "WOODRUFF", "state": "SC", "zip": 29388, "inspection_date": "2015-06-04", "deficiency_tag": 325, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "02VR11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to maintain acceptable parameters of nutritional status by providing nutritional supplements as recommended for Resident #3, 1 of 3 residents reviewed for significant weight change. The findings included: The facility admitted Resident #3 with [DIAGNOSES REDACTED]. On 6/4/15 at 2:02 PM, record review revealed a Telephone Order dated 5/12/15 for a Dietary Consult. At 2:20 PM on 6/4/15, review of the laboratory test results revealed the resident's Pre-[MEDICATION NAME] was low at 12 and the Hemoglobin and Hematocrit were also low at 8.9 and 25.4 g/dl (grams per deciliter). At 2:47 PM, review of the weight record revealed the resident's weight on admission, 3/11/15, was 133.6 pounds. Further review revealed the resident's weight was 124.3 pounds on 5/25/15, a loss of 9.3 pounds. Review of the Dietary Progress Notes revealed a note dated 5/21/15 that stated the resident had a 9.3% weight loss in 30 days. The RDLD (Registered Licensed Dietician) recommended on 5/21/15 changing the Mighty Shakes three times a day to MedPass 120 milliliters twice a day for increased calories and protein. Review of the Medication Record revealed the Mighty Shakes continued through the days of the survey. A second review of the Telephone orders revealed no order changing the supplement. During an interview on 6/4/15 at 2:40 PM, Registered Nurse (RN) #3 stated the RDLD usually writes the order or tells the charge nurse who then writes the order. The RN confirmed the RDLD recommendation to change the supplement and that no order was in the record. The RN stated s/he did not know why the order was not written and confirmed the resident continued to receive the Mighty Shakes.", "filedate": "2018-11-01"}
{"rowid": 5614, "facility_name": "WOODRUFF MANOR", "facility_id": 425179, "address": "1114 EAST GEORGIA ROAD", "city": "WOODRUFF", "state": "SC", "zip": 29388, "inspection_date": "2015-06-04", "deficiency_tag": 332, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "02VR11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews the facility failed to ensure that it was free of a medication error rate of five percent or greater. The medication error rate was 6.7% (percent). There were 2 errors out of 30 opportunities for error. The findings included: On 6/2/15 at approximately 9:27 AM during observation of medication pass on the Unit 2 (200 Hall) , RN (Registered Nurse) # 1 administered the following medications to Resident A ERROR # 1: Two puffs of [MEDICATION NAME] 80-4.5 mcg (microgram) Inhaler by mouth and did not have the Resident rinse his/her mouth with water and then spit out the rinse water. ERROR # 2: Two tablets of vitamin D-3 2,000 units with Calcium [MEDICATION NAME] 90 mg (milligrams). During medication reconciliation on 6/2/15 at 9:40 AM, the physicians orders for June, (YEAR) stated [MEDICATION NAME] 80-4.5 MCG HALER ([MEDICATION NAME]/[MEDICATION NAME]) INHALE 2 PUFFS BY MOUTH TWICE A DAY *RINSE MOUTH WITH WATER & SPIT WITH USE). and VITAMIN D-3 2,000 UNITS ([MEDICATION NAME] (VITAMIN D3)) TAKE 2 TABLETS (4000 UNITS) BY MOUTH DAILY. On 6/2/15 at approximately 10:50 AM, RN # 1 verified that the mouth of Resident A had not been rinsed with water after administration of the [MEDICATION NAME] Inhaler and that the two tablets of vitamin D-3 2,000 units given to Resident A should not have contained Calcium [MEDICATION NAME].", "filedate": "2018-11-01"}
{"rowid": 5615, "facility_name": "WOODRUFF MANOR", "facility_id": 425179, "address": "1114 EAST GEORGIA ROAD", "city": "WOODRUFF", "state": "SC", "zip": 29388, "inspection_date": "2015-06-04", "deficiency_tag": 441, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "02VR11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the staff failed to wash/sanitize hands after removing gloves and proceeded to place unused supplies back into the treatment cart. ( 1 of 1 wound care treatments observed.) Findings included: The facility admitted Resident # 6 with [DIAGNOSES REDACTED]. An observation of wound care was made on 6/3/15 at 2:30 PM by RN#2 (Registered Nurse). The wound care treatment was completed with no issues until the nurse cleaned the soiled supplies off the overbed table, placed them into a plastic bag and removed his/her gloves. The nurse did not wash/ sanitize his/her hands after glove removal before picking up unused supplies, opening room door, opening drawers to treatment cart, and placing supplies into treatment cart. The nurse then went to the soiled utility room, placed bag of soiled supplies into the barrel, and washed his/her hands. The nurse confirmed in an interview at 4 PM on 6/3/15 that she did not wash her hands before leaving the resident's room before putting supplies back into the treatment cart. The facility Dressing Change, Clean Protocol documents Remove gloves with all unused supplies in plastic bag/container. Assist resident to comfortable position. Cleanse hands.", "filedate": "2018-11-01"}
{"rowid": 5616, "facility_name": "WOODRUFF MANOR", "facility_id": 425179, "address": "1114 EAST GEORGIA ROAD", "city": "WOODRUFF", "state": "SC", "zip": 29388, "inspection_date": "2015-06-04", "deficiency_tag": 490, "scope_severity": "L", "complaint": 0, "standard": 1, "eventid": "02VR11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews the Administrator failed to train and/or provide a job description for the facility Maintenance Director which contributed to immediate jeopardy and/or substandard quality of care. The findings include: Cross refer CFR 483.25 F-323 Free of Accident Hazards On 6/3/15 at approximately 10:00 AM a review of the Maintenance Director personnel file revealed the Date of Hire as Floor Tech: 8/16/13 and Promoted to Maintenance Director/Housekeeping Supervisor: 9/26/14. Further review failed to show a job description or evidence of training for the Maintenance Director. The Administrator stated that s/he was unable to locate a Maintenance Director job description or a record of training for the Maintenance Director. The Administrator was notified at approximately 5:00PM on 6/2/2015 of the Immediate Jeopardy and/or Substandard Quality of Care related to excessive hot water temperatures in resident rooms. An Allegation of Compliance (A[NAME]) was submitted by the facility on 6/3/15 at approximately 8:45 AM. The actions listed in the A[NAME] included the following: I. Corrective Action taken to remove the Immediate Jeopardy: On 6/2/2015 at approximately 5:00pm (sic), the survey team notified the facility that an Immediate Jeopardy situation was present in regards to Hot Water Temperatures on the 200 Unit. The survey team stated that resident room temperatures on the 200 Unit were in excess of 120 degrees (highest temperature reported was 124 degrees). It was stated by the survey team leader that excessive temperatures were limited to the 200 Unit and that the other Unit's temperatures (100 Unit) were in compliance. The Administrator informed the nursing staff on the 200 Unit to cease using hot water on 6/2/15 at approximately 5:20pm (sic) until the situation was resolved. On 6/2/15 The DON, in coordination with the Licensed Nursing Staff completed 100% body audits on all residents on both units to ensure that there was no evidence of any resident injury or bums due to hot water. The findings of the body audits concluded that there had been no injuries [MEDICAL CONDITION] residents. The Maintenance Director contacted the facility's contracted plumber and they dispatched a plumber to the facility immediately. The plumber, along with the Maintenance Director and Regional Director of Operations visibly inspected the two hot-water heaters that control resident room temperatures on the 200 Unit. The two hot water heaters each have their own thermostats but are then connected by an adjustable mixing valve. The plumber adjusted the left thermostat to the lowest allowable setting. In addition, the mixing valve was adjusted approximately a 1/4 inch colder temperature to ensure compliance. At 6:15, the plumber, Maintenance Director, and Regional Director of Operations conducted an initial test of a resident room where excessive temperatures had been noted by the survey team. At that time, the temperature at the resident sink was noted to be 117 degrees, indicating that the adjustments made to the thermostat had successfully removed the immediate jeopardy to the residents. At 6:30pm (sic) the plumber signed a Teachable Moment form, indicating that he had educated the Maintenance Director on adjusting the thermostats and mixing valves to achieve the desired temperatures, as well as proper calibration of thermometers. At the plumber's recommendation, new Digital Thermometers were purchased by the facility Administrator on 6/2/2015. At IOpm (sic), The Maintenance Director and Regional Director of Operations checked 100% (12 on each of 2 Units) of resident bathroom sinks and shower rooms on 6/2/2015. All temperatures were within regulatory limits (100 - 120 degrees). The facility has no recorded grievances by residents that the room water temperatures were too hot. The facility has had no incidents of residents being burned or scalded by hot water. 2. Measures put into place or systemic changes made to ensure that the immediate jeopardy will not recur: The Administrator and Regional Director of Operations inserviced the Maintenance Director on 6/2/2015 regarding the requirement to check resident room temperatures in accordance with facility policy. A log to record temperatures was provided and will be utilized to ensure ongoing compliance. The water temperature log will be completed daily for two weeks to ensure stability of temperature settings, and weekly thereafter. Any temperature readings in excess of 120 degrees will be corrected immediately and reported to the facility Administrator. The Staff Development Coordinator began inservicing all nursing staff on 6/2/2015 on the facility's Safety of Water Temperatures policy. No nursing staff will be allowed to work until having received this inservice. This inservice includes: o Any time water feels excessively hot to the touch (i.e., hot enough to be painful or cause reddening of the skin after removal of the hand from the water), staff will report this finding to their immediate supervisor. o Risk factors for scalding/burns that are more common in the elderly, such as: Decreased skin thickness; Decreased skin sensitivity; Peripheral [MEDICAL CONDITION]; Reduced reaction time; Decreased cognition; Decreased mobility, and Decreased communication. o Other factors that influence temperature tolerance (length Of exposure, amount of skin exposed, and the resident's current condition). o Signs and symptoms [MEDICAL CONDITION](first, second, and third degree) o If a resident is scalded or burned, nursing staff shall follow pertinent first aid and physician notification protocols and report the injury to his or her direct supervisor. As a precaution, the hot water heaters that control resident room water temperatures on the 100 Unit were reviewed by the plumber, Maintenance Director, and Regional Director of Operations. The findings of the review indicated the left hot water heater was set on 120 degrees, and the right was set on 110. The water from the two hot-water heaters is combined prior to entering the facility. The thermostat of the left hot water heater was reduced to 115 degrees. There has been no reported temperatures on the 100 Unit in excess of 120 degrees. All new nursing staff will be oriented regarding the Safety of Water Temperatures policy during orientation. Any new Maintenance personnel will also be oriented on this policy, and the log for tracking hot-water temperatures. Results of hot-water temperature monitoring will be brought to the Quality Assurance Committee monthly to ensure ongoing compliance. However, any noted temperatures above the allowable range of 100-120 degrees will be corrected immediately and reported to the facility Administrator. Observations, review of policy, education and signature sheets on 6/3/15 revealed the Allegation of Compliance submitted by the facility on 6/3/15 had been implemented by the facility and was in practice removing the immediacy of the deficient practice. The Administrator was informed of this on 6/3/15 at 5:25 PM. The citations at F-323, F-490, and F-520 remained at a lower scope and severity of F.", "filedate": "2018-11-01"}
{"rowid": 5617, "facility_name": "WOODRUFF MANOR", "facility_id": 425179, "address": "1114 EAST GEORGIA ROAD", "city": "WOODRUFF", "state": "SC", "zip": 29388, "inspection_date": "2015-06-04", "deficiency_tag": 496, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "02VR11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews and review of the facility's policy entitled Background Screening Investigation, the facility failed to conduct Certified Nursing Assistant (CNA) registry verifications prior to date of hire for 5 of 18 CNAs. The findings included: On 6/3/15, during review of the employee files for the extended survey, it was noted that 5 of 18 Certified Nursing Assistant (CNA) registry verifications were conducted on or after the date of hire for 5 of 18 CNAs. Review of the facility's policy entitled Background Screening Investigations indicated in . Policy Interpretation and Implementation . 2. For individuals applying for a position as a Certified Nursing Assistant, the state nurse aide registry will be contacted to determine if any findings of abuse, neglect, mistreatment of [REDACTED]. The findings were confirmed during an interview with the Human Resources staff.", "filedate": "2018-11-01"}
{"rowid": 5618, "facility_name": "WOODRUFF MANOR", "facility_id": 425179, "address": "1114 EAST GEORGIA ROAD", "city": "WOODRUFF", "state": "SC", "zip": 29388, "inspection_date": "2015-06-04", "deficiency_tag": 501, "scope_severity": "C", "complaint": 0, "standard": 1, "eventid": "02VR11", "inspection_text": "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.", "filedate": "2018-11-01"}
{"rowid": 5619, "facility_name": "WOODRUFF MANOR", "facility_id": 425179, "address": "1114 EAST GEORGIA ROAD", "city": "WOODRUFF", "state": "SC", "zip": 29388, "inspection_date": "2015-06-04", "deficiency_tag": 520, "scope_severity": "L", "complaint": 0, "standard": 1, "eventid": "02VR11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on full and/or limited record reviews, interviews, and review of the facility policies, it was determined on 6/2/15 at approximately 5:02 PM Immediate Jeopardy and/or Substandard Quality of Care existed for CFR 483.75 F-520 which was identified at a scope and severity level of (L). The facility failed to ensure that the Quality Assurance (QA) process was utilized to identify, monitor and implement a plan of action to ensure routine monitoring of water temperatures to prevent potential injuries to residents. The findings included: Cross refer CFR 483.25 F-323 Free of Accident Hazards CFR 483.25 F-323 was identified at a scope and severity level of (L). The Immediate Jeopardy existed on 6/2/15 when water temperatures were checked on initial tour in thirteen resident bathrooms on Unit 2 and observed to be too hot. On 6/2/15 at approximately 9:30 AM Surveyor Team thermometers were used to check all facility bathrooms. Thirteen resident bathrooms on Unit 2 were found to have hot water temperatures of approximately 121-124 degrees F (Fahrenheit). During an interview on 6/4/15 at approximately 5:30 PM, the facility Administrator confirmed the facility had not identified the water temperatures as being a concern. The Administrator stated the facility had no QA in process relative to the concern. The Administrator stated that the QA Committee identified concerns through the Quality Measures, Bench Mark Reports the 24 Hour Reports, Incident Reports, Grievances, Customer Satisfaction Surveys, the Guardian Angel Program, and the Interact Stop and Watch to identify residents' changes in condition to prevent re-hospitalization s. The Administrator was notified at approximately 5:00PM on 6/2/2015 of the Immediate Jeopardy and/or Substandard Quality of Care related to excessive hot water temperatures in resident rooms. An Allegation of Compliance (A[NAME]) was submitted by the facility on 6/3/15 at approximately 8:45 AM. The actions listed in the A[NAME] included the following: I. Corrective Action taken to remove the Immediate Jeopardy: On 6/2/2015 at approximately 5:00pm (sic), the survey team notified the facility that an Immediate Jeopardy situation was present in regards to Hot Water Temperatures on the 200 Unit. The survey team stated that resident room temperatures on the 200 Unit were in excess of 120 degrees (highest temperature reported was 124 degrees). It was stated by the survey team leader that excessive temperatures were limited to the 200 Unit and that the other Unit's temperatures (100 Unit) were in compliance. The Administrator informed the nursing staff on the 200 Unit to cease using hot water on 6/2/15 at approximately 5:20pm (sic) until the situation was resolved. On 6/2/15 The DON, in coordination with the Licensed Nursing Staff completed 100% body audits on all residents on both units to ensure that there was no evidence of any resident injury or bums due to hot water. The findings of the body audits concluded that there had been no injuries [MEDICAL CONDITION] residents. The Maintenance Director contacted the facility's contracted plumber and they dispatched a plumber to the facility immediately. The plumber, along with the Maintenance Director and Regional Director of Operations visibly inspected the two hot-water heaters that control resident room temperatures on the 200 Unit. The two hot water heaters each have their own thermostats but are then connected by an adjustable mixing valve. The plumber adjusted the left thermostat to the lowest allowable setting. In addition, the mixing valve was adjusted approximately a 1/4 inch colder temperature to ensure compliance. At 6:15, the plumber, Maintenance Director, and Regional Director of Operations conducted an initial test of a resident room where excessive temperatures had been noted by the survey team. At that time, the temperature at the resident sink was noted to be 117 degrees, indicating that the adjustments made to the thermostat had successfully removed the immediate jeopardy to the residents. At 6:30pm (sic) the plumber signed a Teachable Moment form, indicating that he had educated the Maintenance Director on adjusting the thermostats and mixing valves to achieve the desired temperatures, as well as proper calibration of thermometers. At the plumber's recommendation, new Digital Thermometers were purchased by the facility Administrator on 6/2/2015. At IOpm (sic), The Maintenance Director and Regional Director of Operations checked 100% (12 on each of 2 Units) of resident bathroom sinks and shower rooms on 6/2/2015. All temperatures were within regulatory limits (100 - 120 degrees). The facility has no recorded grievances by residents that the room water temperatures were too hot. The facility has had no incidents of residents being burned or scalded by hot water. 2. Measures put into place or systemic changes made to ensure that the immediate jeopardy will not recur: The Administrator and Regional Director of Operations inserviced the Maintenance Director on 6/2/2015 regarding the requirement to check resident room temperatures in accordance with facility policy. A log to record temperatures was provided and will be utilized to ensure ongoing compliance. The water temperature log will be completed daily for two weeks to ensure stability of temperature settings, and weekly thereafter. Any temperature readings in excess of 120 degrees will be corrected immediately and reported to the facility Administrator. The Staff Development Coordinator began inservicing all nursing staff on 6/2/2015 on the facility's Safety of Water Temperatures policy. No nursing staff will be allowed to work until having received this inservice. This inservice includes: o Any time water feels excessively hot to the touch (i.e., hot enough to be painful or cause reddening of the skin after removal of the hand from the water), staff will report this finding to their immediate supervisor. o Risk factors for scalding/burns that are more common in the elderly, such as: Decreased skin thickness; Decreased skin sensitivity; Peripheral [MEDICAL CONDITION]; Reduced reaction time; Decreased cognition; Decreased mobility, and Decreased communication. o Other factors that influence temperature tolerance (length Of exposure, amount of skin exposed, and the resident's current condition). o Signs and symptoms [MEDICAL CONDITION](first, second, and third degree) o If a resident is scalded or burned, nursing staff shall follow pertinent first aid and physician notification protocols and report the injury to his or her direct supervisor. As a precaution, the hot water heaters that control resident room water temperatures on the 100 Unit were reviewed by the plumber, Maintenance Director, and Regional Director of Operations. The findings of the review indicated the left hot water heater was set on 120 degrees, and the right was set on 110. The water from the two hot-water heaters is combined prior to entering the facility. The thermostat of the left hot water heater was reduced to 115 degrees. There has been no reported temperatures on the 100 Unit in excess of 120 degrees. All new nursing staff will be oriented regarding the Safety of Water Temperatures policy during orientation. Any new Maintenance personnel will also be oriented on this policy, and the log for tracking hot-water temperatures. Results of hot-water temperature monitoring will be brought to the Quality Assurance Committee monthly to ensure ongoing compliance. However, any noted temperatures above the allowable range of 100-120 degrees will be corrected immediately and reported to the facility Administrator. Observations, review of policy, education and signature sheets on 6/3/15 revealed the Allegation of Compliance submitted by the facility on 6/3/15 had been implemented by the facility and was in practice removing the immediacy of the deficient practice. The Administrator was informed of this on 6/3/15 at 5:25 PM. The citations at F-323, F-490, and F-520 remained at a lower scope and severity of F.", "filedate": "2018-11-01"}
{"rowid": 10020, "facility_name": "THE ARBORETUM AT THE WOODLANDS", "facility_id": 425394, "address": "50 ARBORTEUM WAY", "city": "GREENVILLE", "state": "SC", "zip": 29617, "inspection_date": "2011-04-26", "deficiency_tag": 280, "scope_severity": "H", "complaint": 1, "standard": 0, "eventid": "032B11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection, based on observations, interviews and record reviews the facility failed to ensure 4 of 11 resident's care plans were reviewed and revised with adequate interventions to prevent falls/injuries from occurring. Residents #1, #2, #3, and #5's care plans were not updated with adequate interventions to prevent falls. The findings included: The facility admitted Resident #1 on 6/21/2010 with [DIAGNOSES REDACTED]. Review of the Nursing Home Initial History and Physical dated 11/14/2010 stated, \"...Mental Status: Oriented x2. He is cooperative. He is able to follow commands. He is generally easily directed... He has poor insight but good mentation...\" Resident #1's Quarterly Minimum (MDS) data set [DATE] coded him as having problems with recall; his BIMS (brief interview for mental status) scored him as 8. Review of the Nurse's Notes on 4/26/2011 revealed Resident #1 fell 21 times between 11/15/2010 and 4/26/2011; eight of these falls resulted in skin tears and/or a laceration, one of the eight falls resulted in a laceration that required sutures. The notes showed that Resident #1's had difficulty at times standing to sitting down without dropping down that seemed to cause him to fall. \"Resident is encouraged to call for assistance but is unable.\" Review of the Care Plan dated 11/30/2010 and revised 3/1/2011 revealed a problem area identified for \"risk for further falls related to hx (history) of falls, dx (diagnosis) of dementia, and hx of traumatic fall with fx (fracture), repeated falls secondary to gait disturbance.\" Added to the problem area was \"risk for injury, resident ambu (ambulate) noted for multiple falls ambulates with rolling walker.\" Approaches included: \"Adequate assistance for transfers, (Resident #1) is large and he also walks very fast and has poor safety awareness. Observe closely for attempts to transfer without assist, provide reminders. Provide distractions such as reading, TV, talking with resident. Encourage use of assistance devices per therapy recommendations. Report all falls and injuries to nurse as soon as possible, attempt to identify the cause of the fall, such as tripping, walking too fast, non-use or misuse of assistance device.\" On 12/10 the care plan was updated with an approach to \"observe resident at all times, remind resident not to throw clothes on floor.\" Chair alarm was added without a date and then crossed off due to \"resident refused.\" In February 2011, the care plan was updated to include \"OT in to work with resident.... Assist resident to and from meals.\" In March 2011, the care plan was updated to include \"encourage use of wheelchair when ambulating (son to bring in).\" Further review of the care plan revealed no evidence that the care plan was updated and individualized for Resident #1 assessed as have difficulty with recall and decision-making. The facility admitted Resident #2 on 1/9/2011 with [DIAGNOSES REDACTED]. Resident #2's Significant Change Minimum (MDS) data set [DATE] coded her as having problems with recall; her BIMS (brief interview for mental status) scored her as 4. Review of the Nurse's Notes revealed Resident #2 had 16 falls that resulted in 6 injuries (skin tears/lacerations and bruises) between 1/9/2011 and 4/25/2011. Review of the Care Plan dated 1/7/2011 and reviewed on 2/8/2011, 2/16/2011 and 3/3/2011 revealed a problem area identified related to \"Risk for further falls /injury related to decreased cognition, communication, hx of falls with possible side effects of medications.\" The approaches included: \"encourage use of assistance device, PT/OT evaluations and treat as ordered, provide one person assist for transfers and 1 person assist with ambulation, be sure call light is within reach and encourage to use it for assistance as needed, respond promptly to all requests for assistance, floors free from spills or clutter, personal items within reach, encourage non skid shoes when out of bed. An update on 1/7/2011 included \"bed/chair alarm at all times\" and \"observe resident frequently related to attempts to ambulate without assist.\" On 3/8/2011 the care plan was updated to include \"Seatbelt to wheelchair due to resident's trying to ambulate unassisted/unsupervised.\" Eight falls occurred prior to the seatbelt being added to Resident #2's wheelchair. After the seatbelt was added the resident fell out of her wheelchair 3 times and was found twice on the floor in the bathroom. No additional interventions were added related to these falls. The facility admitted Resident #3 on 2/3/2010 with [DIAGNOSES REDACTED]. Resident #3's Quarterly Minimum (MDS) data set [DATE] coded her as having short and long term memory problems with severely impaired decision-making skills. Review of the Nurse's Notes between 11/20/2010 and 4/22/2011 revealed Resident #3 fell 26 times. On 12/13/2010 he complained of pain in the right wrist, an x-ray revealed a fracture; on 3/14/2011 and 4/19/2011 he sustained lacerations due to falls. Review of the Care Plan revealed a problem area related to \"risk for further falls/injury.\" The Care Plan was dated 12/3/2010. The care plan was updated with the falls on 11/21, 11/22, 11/23 and 11/30. \"Continues to roll self out of bed without injury. Resident aware of rolling from bed. Bed pad alarms tried prior to readmit, resident destroys alarms.\" On 12/1/2010, the care plan was updated with \"will continue to observe resident for safety/injury. On 12/2/2010, the care plan was updated to include \"encourage resident to remain in common areas when out of bed.\" On 12/5//2010, the care plan was updated to include the same approach of \"encourage resident to remain in common areas when out of bed.\" On 12/10/2010, the care plan was updated to include \"observe resident frequently when in room or out of room.\" On 12/14/2010, the care plan was reviewed and included the following: \"Continues with multiple falls, resident rolls self to floor, psych consults ordered, meds reviewed, continues to remove/destroy alarms.\" The care plan was last reviewed 12/14/2010, the resident fell or was found on the floor 15 times between 12/14/2010 and 4/22/2011; no additional interventions were put in place after 12/14/2010. The facility admitted Resident #5 on 7/2/2009 with [DIAGNOSES REDACTED]. Resident #5's Quarterly Minimum (MDS) data set [DATE] coded her as having short and long term memory problems with severely impaired cognitive skill for daily-decision making. Review of the Nurses Notes between 10/9/2010 and 4/5/2011 revealed on 10/9/2010, Resident #5 fell in the hallway. On 10/28/2010 at 7:30 PM, the resident fell out of the wheelchair while bending over. On 11/4/2010 at 6:45 PM, the resident was found on the floor. On 12/17/2010 at 3:45 PM, the resident stood up out of the wheelchair and fell . On 1/27/2011 at 8:35 PM, Resident #5 fell out of the wheelchair while bending over. On 3/22/2011 at 12:40 AM, Resident #5 fell and sustained lacerations and abrasions to her forehead. On 4/5/2011 at 9:40 PM, the resident's alarm sounded and the resident was found on the floor. The resident sustained [REDACTED]. Review of the Care Plan revealed a problem area identified related to \"Risk for falls, has not had recent fall but has had a slow cognitive decline in cognitive abilities. On 12/2/2010 the care plan was reviewed and to \"continue with current problem.\" The care plan was reviewed again on 3/2/2011. Approaches included: \"walk with resident at times during the day, do not allow to ambulate without assistance, provide one person assistance with transfers, remember to transfer out of wheelchair into dining room chair for all meals. Be sure call light is within reach and encourage to use it for assistance as needed. Respond promptly to all requests for assistance. (Resident #5) typically does not remember how or why to use call light. Pressure alarm for her wheelchair, she will stand up unassisted. Bed alarm. Monitor resident frequently. Encourage not to stand or ambulate without assistance.\" On 10/11/2010, Resident #5's care plan was updated to include the following approach: \"Remind resident not to stand without assist. Keep resident in common area when out of bed.\" Review of the care plan revealed no intervention related to the concern that Resident #5 fell on [DATE] and 1/27/2011 from the wheelchair while bending over. During an interview with the surveyor on 4/26/2011 at 1:15 PM, the Director of Nurses (DON) confirmed the Care Plans were not updated with the falls and interventions for Resident's #1, #2, #3 and #5. Cross Refers to F-323 as it relates to the facility's failure to implement new and appropriate interventions for each resident to prevent falls/injuries.", "filedate": "2014-08-01"}
{"rowid": 10021, "facility_name": "THE ARBORETUM AT THE WOODLANDS", "facility_id": 425394, "address": "50 ARBORTEUM WAY", "city": "GREENVILLE", "state": "SC", "zip": 29617, "inspection_date": "2011-04-26", "deficiency_tag": 323, "scope_severity": "H", "complaint": 1, "standard": 0, "eventid": "032B11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection, based on observations, interviews and record reviews the facility failed to ensure residents received adequate supervision and assistance devices for 4 of 11 residents reviewed for falls. Residents #1, #2, #3 and #5 had multiple falls and injuries without adequate interventions put in place to prevent further injury. The findings included: The facility admitted Resident #1 on 6/21/2010 with [DIAGNOSES REDACTED]. Review of the Nursing Home Initial History and Physical dated 11/14/2010 stated, \"...Mental Status: Oriented x 2. He is cooperative. He is able to follow commands. He is generally easily directed... He has poor insight but good mentation...\" Resident #1's Quarterly Minimum (MDS) data set [DATE] coded him as having problems with recall; his BIMS (brief interview for mental status) score was 8. Observation of Resident #1 on 4/26/2011 at 7:20 AM, revealed the resident sitting on the side of the bed attempting to dress. Resident #1 had no alarms in place, no fall mats were seen and no wheelchair observed. A recliner with a manual footrest was observed. No lift chair was observed. Resident #1 also did not have a wheelchair. Observation of Resident #1's bathroom revealed bright red blood on the floor between the vanity and the toilet. The outside of the toilet bowl was smeared with bright red blood. The surveyor obtained staff assistance. Resident #1 stated that he fell this morning in the bathroom. The fall was reported to the CNA (certified nursing assistant) present in the room. Review of the Cumulative physician's orders [REDACTED].\" Further review of the Cumulative Orders revealed the Chair Alarm was originally ordered on [DATE] and the Lift Chair was originally ordered on [DATE]. Review of the \"Fall Risk Assessment\" revealed only one entry dated 11/15/2011 that scored Resident #1 as a \"6\" indicating he was not at \"High Risk\" for falls. Review of the Nurse's Notes revealed the following entries: On 11/15/2010 at 12:30 PM, Resident #1 was found on the floor; a foam mattress was placed by the bed. On 11/16/2010 at 9:30 PM, Resident #1 fell and sustained a skin tear to the left forearm. It was noted that he was hanging clothes and slipped on a foam mattress. The foam mattress was removed. On 11/21/2010 at 9:30 AM, Resident #1 fell in the bathroom and sustained a laceration to the arm. On 11/23/2010 at 5:00 AM, Resident #1 fell on the floor in the room and sustained a rub burn to his/her knee. (A chair alarm was ordered per the telephone orders). On 12/8/2010 at 4:30 PM, Resident #1 fell in the bathroom and sustained a skin tear. On 12/10/2010 at 6:00 PM, Resident #1 fell in the bathroom and sustained a laceration to his head requiring sutures. (An order was written to send to the ER (emergency room ) status [REDACTED]. On 1/7/2011 at 9:30 AM, Resident #1 fell in the room no injuries were noted. On 1/9/2011 at 2:00 PM, Resident #1 fell in his room while trying to go to the bathroom. At 6:30 PM, Resident #1 fell again next to his recliner. (An order was written on 1/17/2011 for a \"Lift Chair.\") On 1/21/2011 at 6 PM, Resident #1 fell in his room and was found \"scooting towards bathroom.\" On 2/11/2011 at 6 PM, Resident #1 fell in the bathroom. On 2/16/2011 at 9:45 PM, Resident #1 fell in the bathroom and hit his back on the shower bench. On 2/23/2011 at 4:20 PM, Resident #1 fell in the hallway no injuries were noted. On 3/3/2011 at 2:00 PM, revealed the following entry: \"On February 16, 2011, this committee met to discuss new interventions that would decrease or prevent risk of falls. At this time the team implemented having a staff person assist resident to and from meals/walking. Resident's impulse control is effected due to [DIAGNOSES REDACTED]. Resident has difficulty at times standing from sitting down without dropping down. This is what seems to have the resident fall. Resident continues to walk with walker but does need some reminders. Resident is encouraged to call for assistance but is unable. The resident had been offered a chair alarm x 2 but declined. In 12/2010 a seat belt was offered and both resident and family declined. The resident is taken/asked every 1-2 hours for toileting needs but resident is continent and does not have a toileting pattern. Resident is also independent and becomes agitated at times when you offer assistance with bowel and bladder needs. Discussed the usage of a merry walker and at this time therapy could not see how this would work. Decided as a team to have resident use wheelchair for ambulation. Resident's family and resident are aware that resident is a fall risk any time he is up ambulatory and agreed that we should encourage the use of wheelchair. Family to bring wheelchair in from home. Care Plan revised.\" On 3/5/2011 at 12:15 PM, Resident #1 fell in the bathroom sustaining an abrasion to his right temple. On 3/10/2011, Resident #1 fell in his room. On 3/16/2011 at 5:15 PM, Resident #1 was found on the floor of his room with scalp laceration. The resident was sent to the emergency room for evaluation. On 4/1/2011 at 4:00 PM, Resident #1 fell in the bathroom. On 4/9/2011 at 12:30 PM, Resident #1 fell in the dining room. On 4/16/2011 at 9:30 PM, Resident #1 fell attempting to go the bathroom and sustained an abrasion to the right side of the face. On 4/24/2011 at 7:00 AM, Resident #1 was found on the floor in his room and had \"hit his head.\" Review of the Incident Reports provided by the facility revealed the following: On 11/15/2011, the corrective actions taken to prevent further falls were \"Resident unaware of safety measures due to disease process. Can ambulate safely once up from sitting position. At times resident may fall backwards. Resident refuses tab alarm due to the same agitation. Talked with family about helmet-family refuses. Family wants resident to remain independent with walking and states they are aware of the consequences.\" The incident report dated 11/23/2011 revealed the corrective action taken related was \"encourage resident to take his time while attempting to get up out of chair.\" On 1/7/2011 the corrective actions taken were to \"encourage resident to go slow when ambulating in room and to use walker at all times.\" On 1/9/2011 the actions taken to prevent further falls was to \"attempt to check in more frequently. Hopefully he will allow is to keep his door open\". The corrective actions taken for the second fall on 1/09/2011 were \"reminded resident to call for assist, notified door would be left ajar while in room.\" On 1/21/2011, the corrective actions taken were to \"remind resident to call for help-re-attach chair alarm.\" On 1/25/2011, the actions taken were to \"monitor patient closely.\" On 2/12/2011, the corrective actions taken were \"assisted resident in getting dressed and cleaning up his bathroom.\" On 2/16/2011, the corrective actions taken to prevent falls were \"reminded to call for assist.\" On 3/5/2011, the actions taken were \"will continue fall precautions.\" On 3/10/2011, the corrective actions taken were \"patient is checked at least every 1-2 hours but due to dementia never asks for help rings call bell.\" On 3/16/2011, the summary of actions taken to prevent further falls was \"pressure applied- call to doctor and family.\" On 4/1/2011, the actions taken were to \"continue to check on patient every 1-2 hours for toileting.\" On 4/9/2011, the corrective actions taken were \"instruct patient to call for assistance.\" On 4/16/2011, the corrective actions taken were to \"monitor closely.\" No other incident reports were provided at the time of the survey. Review of the Care Plan revealed a problem area identified for \"risk for further falls related to hx (history) of falls, dx (diagnosis) of dementia, and hx of traumatic fall with fx (fracture), repeated falls secondary to gait disturbance.\" Added to the problem area was \"risk for injury, resident ambu (ambulate) noted for multiple falls ambulates with rolling walker.\" The original date of the care plan was 11/30/2010 and reviewed 3/1/2011. Approaches included: \"Adequate assistance for transfers, (Resident #1) is large and he also walks very fast and has poor safety awareness. Observe closely for attempts to transfer without assist, provide reminders. Provide distractions such as reading, TV, talking with resident. Encourage use of assistance devices per therapy recommendations. Report all falls and injuries to nurse as soon as possible, attempt to identify the cause of the fall, such as tripping, walking too fast, non-use or misuse of assistance device.\" On 12/10 the care plan was updated with an approach to \"observe resident at all times, remind resident not to throw clothes on floor.\" Chair alarm was added without a date and then crossed off due to \"resident refused.\" In February 2011, the care plan was updated to include \"OT (occupational therapy) in to work with resident and colostomy. Assist resident to and from meals.\" In March 2011, the care plan was updated to include \"encourage use of wheelchair when ambulating (son to bring in).\" Further review of the care plan revealed no evidence that the care plan was updated with the resident's numerous falls or that individualized interventions put in place to prevent further falls from occurring. During an interview with the surveyor on 4/26/2011 at 2:30 PM, Resident #1's son stated that he was aware of his father's multiple falls. He further stated that his father would not call for assistance. Resident #1's son stated that his father needed assistance with his colostomy and had requested the colostomy care be scheduled to reduce the risk of falls in the bathroom. He stated that his request was not followed and that the colostomy care was not scheduled. He further stated that he did attend a meeting regarding his father's falls and he stated that at no point during the meeting was a merry walker, seat belt or other type of device discussed. He stated that his father would routinely disconnect the alarms that were applied at one point. He also stated that he brought in his father's wheelchair from home, however, his father did not use it and he stated that no one in the facility encouraged its use. He also stated that he was never requested to take the wheelchair home and did not know where it was located. The facility admitted Resident #2 on 1/9/2011 with [DIAGNOSES REDACTED]. Resident #2's Significant Change Minimum (MDS) data set [DATE] coded her as having problems with recall; her BIMS (brief interview for mental status) score was 4. Observation of Resident #2 on 4/26/2011 at 8 AM revealed the resident in the living room seated in a high backed wheelchair. A chair alarm was observed in place. The resident was noted to be unable to propel herself in the wheelchair. No seat belt was observed. A bed alarm was observed in the resident's room. Review of the Physician's Cumulative Orders dated 4/1/2011 revealed the Safety Devices ordered were \"seat belt and bed and chair alarms.\" Further review of the telephone orders revealed the original order for the bed and chair alarms was 1/11/2011. The original order for the seat belt was 3/3 for a trial of the seat belt then 3/8/2011 the seat belt was ordered. On 4/25/2011 a telephone order was written to \"d/c (discontinue) the seatbelt - ineffective broken x 2.\" Resident #2 was noted to receive Hospice Care due to a rapid decline in April 2011. The primary [DIAGNOSES REDACTED]. Review of the Falls Risk Assessment revealed one entry dated 11/29/2010 (a previous admission) that scored the resident as a \"5\" indicated she was not at high risk for falls. Review of the Nurse's Notes revealed the following entries: On 1/9/2011 at 5:20 PM, Resident #2 fell in hallway and sustained a laceration to her head and bruising. On 1/16/2011 at 10:30 AM, Resident #2 fell in room while attempting to toilet self. On 1/20/2011 at 3 PM, Resident #2 fell to her knee, no injuries. On 1/24/2011 at 12:30 AM, the resident fell out of bed and abraded her/his back. On 1/26/2011 at 2:50 AM, Resident #2's bed alarm sounded and the resident was found on the floor. On 2/8/2011 at 8 PM, Resident #2 was found on floor by bathroom, she sustained a skin tear and a hematoma to the left hip. On 2/26/2011, Resident #2 fell and was found unresponsive with pupils fixed. On 3/2/2011 at 1 PM, Resident #2 was found of floor beside bed. On 3/3/3011, \"meeting held with MDS coordinator, DON, Activities, and Physical Therapist to discuss resident's falls. Care Plan for falls reviewed at this time to discuss interventions.\" On 3/8/2011 at 2:15 PM, the resident fell in the living room and sustained a bump on the head. On 3/21/2011 at an unknown time, the resident was found on the floor with the chair alarm sounding. On 3/27/2011, the resident was found on the bathroom floor. On 4/15/2011 at 9:30 AM, the resident was found on the floor of the bathroom with the chair alarm sounding. On 4/18/2011 at 8 PM, Resident #2 fell out of the wheelchair and sustained an abrasion to her back. On 4/25/2011 at 9:40 PM, Resident #2 fell out of bed and sustained an abrasion to her nose. Review of the Incident Reports provided by the facility revealed the following: On 1/9/2011 the corrective action taken to prevent further falls was \"close monitoring.\" On 1/16/2011 the corrective action taken was to \"encourage resident not to get out of wheelchair without assistance, resident has fallen previously and has had a cognitive decline.\" On 1/20/2011, the alarm appropriately sounded and the corrective action taken was to \"remind resident to ask for assist with transfers and to keep patient close to nursing station.\" On 1/24/2011, the bed alarm sounded appropriately and no corrective action was documented. On 1/26/2011 the bed alarm sounded appropriately and the corrective action taken was \"encouraged resident to utilize call light when toileting is needed. Call light in reach and resident oriented to proper use.\" On 2/8/2011 there was no indication of any alarm. The corrective action taken was for the resident to \"call for help and using the call bell.\" On 3/2/2011 there was no indication that the alarm sounded. The corrective action taken was \"transferred to common area and needs more frequent monitoring.\" On 3/8/2011, there was no indication that the resident had a seatbelt in place and the corrective action taken was \"will try to monitor further and more often\" and \"patient is scheduled to receive a belt for wheelchair.\" On 3/21/2011, there was no indication that a seatbelt was in place or that the alarms sounded. The corrective action taken was for the resident to \"comply with instructions to call for help. Have staff check every 1-2 hours.\" On 3/27/2011, there was no indication that the resident's alarms sounded or that the seat belt was in place. The corrective actions taken were to \"continue bed alarm, chair alarm, low bed, seatbelt.\" On 3/30/3011, the resident's alarm appropriately sounded and the resident had unfastened the seatbelt. The corrective action taken was \"resident will not comply to instructions related to safety seat belt. Will continue to monitor, will continue to assess resident for pain, will continue to apply alarms, will continue to encourage resident not attempt to get up out of wheelchair.\" On 4/9/2011 the bed alarm sounded appropriately. The corrective actions taken were \"continue bed alarm and low bed.\" On 4/15/2011, the corrective actions taken were \"will check patient even more frequently than usual due to Urinary Tract Infection.\" On 4/18/2011, the corrective actions taken were \"assessment done, v/s (vital signs) taken, continue chair and bed alarm and low bed.\" On 4/25/2011, the corrective actions taken were to \"continue low bed with bed alarm.\" Review of the Care Plan revealed a problem area identified related to \"Risk for further falls /injury related to decreased cognition, communication, hx of falls with possible side effects of medications. The care plan was dated 1/7/2011 and was reviewed on 2/8/2011, 2/16/2011 and 3/3/2011. The approaches included: \"encourage use of assistance device, PT/OT (physical therapy/occupational therapy) evaluations and treat as ordered, provide one person assist for transfers and 1 person assist with ambulation, be sure call light is within reach and encourage to use it for assistance as needed, respond promptly to all requests for assistance, floors free from spills or clutter, personal items within reach, encourage non skid shoes when out of bed. The care plan was updated on 1/7/2011 to include \"bed/chair alarm at all times\" and \"observe resident frequently related to attempts to ambulate without assist.\" On 3/8/2011 the care plan was updated to include \"Seatbelt to wheelchair due to resident's trying to ambulate unassisted/unsupervised.\" There was no indication the care plan was updated with appropriate interventions to prevent further fall. The facility admitted Resident #3 on 2/3/2010 with [DIAGNOSES REDACTED]. Resident #3's Quarterly Minimum (MDS) data set [DATE] coded her as having short and long term memory problems with severely impaired decision-making skills. Observation of Resident #3 on 4/26/2011 at 8:40 AM, revealed the resident was in the dining room seated in a wheelchair. A chair alarm was observed in place. The resident was noted to self propel himself. Observation of the resident's room revealed Resident #3 had a bed alarm in place. The bed was note against a wall. One fall mat was observed folded in half and stored against the wall. A lift recliner was observed. Review of the Physician's Cumulative Orders dated 4/1/2011 revealed no orders for any type of alarm, fall mat, recliner etc. Review of the Falls Risk Assessment revealed one entry dated 7/19/2010 that scored Resident #3 as a \"16\" indicating he was at \"high risk\" for falls. Review of the Nurse's Notes revealed the following entries: On 11/20/2010 at 10 PM, the resident was found on the floor beside wheelchair. On 11/22/2010 at 11:50 AM, the resident was found on the floor at the end of the bed scooting towards the door. 11/23/2010 at 3:20 AM, the resident was found on the floor attempting to urinate. On 11/24/2010 at 2 AM, the resident was found on the floor and stated that he was taking a walk and fell . On 11/25/2010 at 10:15 AM, the resident was found on the floor. On 11/29/2010 at 9 PM, the resident was found sitting on the floor. On 12/3/2010 at 2:55 AM, the resident was found sitting in the floor. At 8:45 AM, the resident was found sitting \"Indian style on bathroom floor.\" At 2:30 PM, the resident was found sitting on the floor in front of recliner. On 12/10/2010 at 4:30 AM, the resident was found sitting in his room beside the bed. At 10:35 PM, the resident was found on the floor by his dresser. On 12/13/2010 the resident reported pain in the right wrist. X-rays were obtained and were positive for a wrist fracture. On 12/15/2011 at 8:15 PM, the resident was found on the floor. At 9:20 PM, the resident was found on the floor at the head of the bed. On 12/20/2010 at 7:45 PM, the resident was found on the floor by the dresser. On 1/10/2011 at 4:30 AM, the resident was found on the floor by the bed. On 1/11/2011 at 7:25 PM, the resident fell out of the wheelchair attempting to adjust his socks. On 1/21/2011 at 11:30 AM, the resident was noted to be lying on the floor in his room. On 1/26/2011 at 7:30 PM, the resident was noted on the floor. On 2/23/2011 at 1:40 PM, the resident \"repeatedly rolled forward out of wheelchair sounding the chair alarm.\" On 3/5/2011, 9:10 PM, the resident was found sitting on floor with legs folded, sitting on feet. At 9:20 PM, the resident was found again on the floor with legs crossed. On 3/6/2011 at 9 PM, the resident was found sitting on the floor with legs crossed. On 3/14/2011 at 12:50 AM, the resident's bed alarm was sounding; the resident was found on the floor with his head on the ground. Abrasion to right forehead noted. On 3/25/2011 at 11:20 AM, the resident's chair alarm was sounding and the resident was found on the floor in front of the wheelchair. On 4/6/2011 at 11:50 AM, the resident was found on the floor in front of the wheelchair, buttocks and coccyx reddened. On 4/19/2011 at 6:45 PM, the resident was found on the floor in the hallway in front of the wheelchair. An abrasion was noted to his forehead. 4/21/2011 at 6:40 AM, the resident was lowered to the floor by a CNA after a transfer to the wheelchair. On 4/22/2011 at 2:30 PM, the resident rolled off low bed and onto low mat, the resident was noted crawling around room. At 9:50 PM, the resident was on left side of mat on left elbow. Review of the Incident Reports provided by the facility revealed the following: On 11/20/2010, there was no documentation of alarms and no documentation of corrective action taken to prevent further falls. On 11/20/2010, there was no documentation of alarms or no documentation of corrective action taken. On 11/22/2010 there was no documentation that the alarms were sounding and the corrective action was \"reminded to call for assist.\" On 11/14/2010 there was no documentation that the alarms sounded and the corrective action was \"resident is on low bed with mats, in the past he has admitted to deliberately putting himself on the floor from the bed. This is a recurring behavior and it is unsure if this is a true fall. Intervention low bed and mat continues. Have tried tab alarms x 2 in the past but resident has destroyed them beyond repair.\" On 11/29/2010 there was no documentation that the alarms sounded and the corrective action taken was \"is on low bed with mats, refuses tab alarm.\" Another corrective action was \"may need to move room to closer to nurses desk, questionable 1:1 care, continue to encourage to ask for help with assist.\" (The resident's room did not change nor was he ever placed on 1:1 care). On 1/10/11 there was no documentation that the alarm sounded, the resident sustained [REDACTED]. There was no corrective action documented. On 1/11/2011, the corrective action taken was \"nursing assessment completed assisted back to chair, monitored. Encourage resident to ask for help when reaching towards shoes, ground etc. Understood by resident.\" On 1/21/2011, the corrective action taken was \"chair alarm in place, will follow up with doctor regarding lab results for possible reasons for decreased pulse.\" On 1/26/2011 there was no documentation that the alarms sounded, the corrective action taken was \"we'll monitor closely, needs to be more often at common areas for monitoring.\" On 2/23/2011, the alarms sounded appropriately, the corrective action taken was \"encouraged to ask staff for assistance\" and \"proper use of chair alarm, resident non compliant.\" On 3/5/2011, there was no documentation that the alarms sounded, the corrective action taken was continue low bed, bed alarm.\" On 3/5/2011, the bed alarm sounded and the corrective action taken was to \"continue low bed with bed alarm.\" On 3/6/2011, the bed alarm sounded and the corrective action taken was \"will keep resident up until Trazadone given.\" On 3/14/2011, the bed alarm sounded appropriately, the corrective action taken was \"Neuro checks due to small abrasion on forehead.\" On 3/25/2011, the alarm sounded appropriately, the corrective action taken was \"resident unaware of own limitations, refuses to follow instructions to call for help when assistance required. Performed Body Audit, v/s, assessed for pain, notified nurse practitioner. Will continue with chair and bed alarm and will continue to assess for pain. On 4/6/2011, there was no documentation the alarms were sounding, the corrective action taken was \"will keep trying to have patient involved with activities in living room where can be supervised. All safety measures are being used as able.\" On 4/6/2011 the corrective action taken was \"all precautions devices in use\" and \"resident needs to call for help.\" On 4/19/2011, there was no documentation that the alarms were sounding; the resident sustained [REDACTED]. The corrective actions taken were to \"continue with chair alarm.\" On 4/22/2011, there was no documentation that the alarms were sounding, the corrective action taken were \"will continue bed and chair alarm.\" No other incident reports were provided at the time of the survey. Review of the Care Plan revealed a problem area related to \"risk for further falls/injury.\" The Care Plan was dated 12/3/2010. The care plan was updated with the falls on 11/21, 11/22, 11/23 and 11/30. \"Continues to roll self out of bed without injury. Resident aware of rolling from bed. A Bed pad alarm tried prior to readmit, resident destroys alarms.\" On 12/1/2010, the care plan was updated with \"will continue to observe resident for safety/injury. On 12/2/2010, the care plan was updated to include \"encourage resident to remain in common areas when out of bed.\" On 12/5//2010, the care plan was updated to include the same approach of \"encourage resident to remain in common areas when out of bed.\" On 12/10/2010, the care plan was updated to include \"observe resident frequently when in room or out of room.\" On 12/14/2010, the care plan was reviewed and included the following: \"Continues with multiple falls, resident rolls self to floor, psych consults ordered, meds reviewed, continues to remove/destroy alarms.\" The care plan was not adequately updated with appropriate interventions to prevent further falls/injuries. The facility admitted Resident #5 on 7/2/2009 with [DIAGNOSES REDACTED]. Resident #5's Quarterly Minimum (MDS) data set [DATE] coded her as having short and long term memory problems with severely impaired cognitive skill for daily-decision making. Observation of the Resident #5 on 4/26/2011 revealed the resident in the commons area seated in a wheelchair, a chair alarm was present. Observation of the resident's room revealed a bed alarm on the night table. Review of the Cumulative physician's orders [REDACTED]. Review of the Falls Risk Assessment revealed one entry dated 9/13/2010 that documented the resident's score as a \"14\" indicating she was at \"high risk\" for falls. Review of the Nurse's Notes revealed on 10/9/2010, Resident #5 fell in the hallway. On 10/28/2010 at 7:30 PM, the resident fell out of the wheelchair while bending over. On 11/4/2010 at 6:45 PM, the resident was found on the floor. On 12/17/2010 at 3:45 PM, the resident stood up out of the wheelchair and fell . On 1/27/2011 at 8:35 PM, Resident #5 fell out of the wheelchair while bending over. On 3/22/2011 at 12:40 AM, Resident #5 fell and sustained lacerations and abrasions to her forehead. On 4/5/2011 at 9:40 PM, the resident's alarm sounded and the resident was found on the floor. The resident sustained [REDACTED]. No Incident Reports were provided at the time of the survey for Resident #5. Review of the Care Plan revealed a problem area identified related to \"Risk for falls, has not had recent fall but has had a slow cognitive decline in cognitive abilities. On 12/2/2010 the care plan was reviewed and to \"continue with current problem.\" The care plan was reviewed again on 3/2/2011. Approaches included: \"walk with resident at times during the day, do not allow to ambulate without assistance, provide one person assistance with transfers, remember to transfer out of wheelchair into dining room chair for all meals. Be sure call light is within reach and encourage to use it for assistance as needed. Respond promptly to all requests for assistance. (Resident #5) typically does not remember how or why to use call light. Pressure alarm for her wheelchair, she will stand up unassisted. Bed alarm. Monitor resident frequently. Encourage not to stand or ambulate without assistance.\" On 10/11/2010, Resident #5's care plan was updated to include the following approach: \"Remind resident not to stand without assist. Keep resident in common area when out of bed.\" There was no evidence that Resident #5 had adequate interventions put in place to prevent further falls/injuries from occurring. During an interview with the surveyor on 4/26/2011 at 1:15 PM, the Director of Nurses (DON) confirmed the Care Plans were not updated with the falls and interventions for Resident's #1, #2, #3 and #5. The DON also confirmed the Falls Risk Assessments were not current and were not accurate for all residents. She stated that there was not a facility policy related to the assessments but stated that she expected the assessments to be completed after each fall. The DON stated that Resident #1 was not alert and oriented and was not able to make his own decisions. The DON also confirmed the actual harm and injuries sustained by Residents #1, #2, #3 and #5 related to falls and they had noticed an increase in the number of falls. The DON stated that a new Medical Director had just started but that no actions had been put in place. During an interview with the surveyor on 4/26/2011, the Medical Director stated that he started on 4/16/2011. He stated that he was not aware of the high number of falls. He stated that he had not yet attended a Quality Assurance Committee.", "filedate": "2014-08-01"}
{"rowid": 6809, "facility_name": "PRUITTHEALTH NORTH AUGUSTA", "facility_id": 425296, "address": "1200 TALISMAN DRIVE", "city": "NORTH AUGUSTA", "state": "SC", "zip": 29841, "inspection_date": "2013-12-11", "deficiency_tag": 257, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "04MS11", "inspection_text": "On the days of the survey based on observation, recording of room temperature and interviews, the facility failed to maintain comfortable temperature levels for residents on 2 of 4 units; including the large dining room, beauty shop, and therapy area. The findings included: On 12/11/13, the surveyor while touring the facility, noticed temperature changes on different units and observed residents sitting in the halls with blankets pulled over their heads. The Maintenance Director was notified and at 12:30 PM with the surveyor present, temperatures were tested in the halls and throughout the facility. The areas found below 71 degrees were as follows: -Station 1 (200 unit) ranged from 69.8 to 70.9. -The Therapy area ranged from 60.9 to 68.6. -The large Dining Room area was 70.6. -The Beauty Shop area ranged from 57.2 to 60.8. No residents were present. -The Vent Unit area ranged from 69.1 to 68.6. After obtaining the temperatures in the halls throughout the facility and confirming the findings with the Maintenance Director, the surveyor interviewed residents regarding the temperatures in the halls, dining room, therapy area and beauty shop. -On 12/11/13 at 12:45 PM 3 out of 5 residents interviewed said it was cold in the large dining area. -One resident leaving the therapy room at 12:50 PM stated the therapy area, halls and beauty shop was cold. -Two residents on Station 1 (200 unit) at 12:55 PM (one sitting in the hall and one sitting in his/her doorway to room) stated the temperatures in the halls and the beauty shop were cold. On 12/11/13 at 1:10 PM, during an interview with the Regional Environmental Consultant and the Administrator, the Regional Environmental Consultant confirmed that s/he had noticed temperature variances in areas of the facility. The Administrator questioned the accuracy of the temperature device used and the Regional Environmental Consultant informed the Administrator that the device used was as accurate as it can get. On 12/11/13 at 1:15 PM, during an interview with the Maintenance Director, with the Administrator and the Regional Environmental Consultant present, regarding what temperature should be maintained in the facility for comfort of the residents s/he stated 70-80.", "filedate": "2017-09-01"}
{"rowid": 6810, "facility_name": "PRUITTHEALTH NORTH AUGUSTA", "facility_id": 425296, "address": "1200 TALISMAN DRIVE", "city": "NORTH AUGUSTA", "state": "SC", "zip": 29841, "inspection_date": "2013-12-11", "deficiency_tag": 371, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "04MS11", "inspection_text": "On the days of the survey, based on observation and interview, three non-dietary staff members were observed to enter the kitchen without hair restraints in place. The deficient practice had the potential to effect resident meals that were being processed at the time. The findings included: On 12/09/13 from 12:15 PM to 12:30 PM while observing the meal tray line, three non-dietary staff members were observed entering the kitchen at different intervals without wearing hair restraints. The Dietary Manager was present during the observation(s) and verified the concern.", "filedate": "2017-09-01"}
{"rowid": 7492, "facility_name": "ELLENBURG NURSING CENTER, INC", "facility_id": 425047, "address": "611 EAST HAMPTON STREET", "city": "ANDERSON", "state": "SC", "zip": 29624, "inspection_date": "2014-02-06", "deficiency_tag": 441, "scope_severity": "E", "complaint": 1, "standard": 0, "eventid": "05DB11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Complaint Inspection, based on observations, record review and interviews, the facility failed to handle soiled linens appropriately for one of one units quarantined, Unit 2. The facility failed to maintain records of infectious/contagious events for an outbreak of scabies. The findings included: The soiled linens were not handled in a manner to prevent spread of infection. There were no infection control records for residents treated for [REDACTED]. On 2/5/14 at approximately 1:45 PM, a red sign was observed on the front entrance door, on the entrance door from the lobby, and on the double doors that opened into unit 2. The red signs stated, Unit 2 Quarantine from 2/4/14 through 2/7/14. Observation of Unit 2 revealed an employee walking around the unit carrying a bag of linen over his/her shoulder that touched his/her back. The employee was not wearing personal protective equipment. The employee stopped and talked with three other employees while carrying the bag of linens over his/her shoulder. A resident wearing a hospital gown, ambulated a rollator, was observed walking to the clean linen cart and opening the cart. A red barrel was observed outside of room U2-13. Three bags of linen were on the floor next to the tub. A bag of linens were observed on the floor, next to the clean linen cart outside room U2-19. A bag of linens was observed on the floor outside of room U2-21. Three bags of linens were observed on the floor outside of room U2-22. On 2/6/14 at approximately 8:20 AM, the employee (Laundry Aide) observed carrying the linen was interviewed. S/he confirmed s/he carried the linen over her/his shoulder. S/he stated, I wasn't thinking. At 8:30 AM, while touring the laundry, 12 barrels and tubs filled with resident clothes and linens were observed outside of the building. Six (6) of the barrels were not covered. The laundry aide confirmed the barrels were supposed to be covered. The surveyor interviewed the Environmental Supervisor on 2/6/14 at approximately 8:25 AM regarding the linens observed on the floor during tour. S/he stated the linens were removed from the rooms so the rooms could be cleaned. The linens were placed outside the rooms on the floor for pick up. Review of the facility Exposure Control Plan Policy for Linen/Laundry stated, Place soiled linen in a container that does not leak, for transport. Keep linen away from clothing. Place linen directly into the linen bag to avoid contaminating other areas of the patient environment such as chairs or bedside tables. All linen shall be bagged at the site of use. All linens used with residents on Infection Precautions are placed in a plastic bag; the bag is tied and placed in the regular soiled linen bag. On 2/5/14 at approximately 3:00 PM, the Director of Nursing (DON) was interviewed. S/he stated, Every resident in the building has been treated for [REDACTED]. I had dermatology come in and look. We have educated the staff, laundered all lift slings, everyone has their own lift slings. December 30th or 31st was the first time we did this, Unit 1 and 4. When the DON was asked by the surveyor to see the tracking of the residents with scabies and the residents treated the DON did not have any written documentation of the events. The residents had the orders for treatment in their charts but there was no record of the events and the interventions, or timing of the events. The DON confirmed that the information had not been reported to the state Epidemiology until 2/4/14.", "filedate": "2017-02-01"}
{"rowid": 431, "facility_name": "PRUITTHEALTH-WALTERBORO", "facility_id": 425053, "address": "401 WITSELL STREET", "city": "WALTERBORO", "state": "SC", "zip": 29488, "inspection_date": "2017-08-14", "deficiency_tag": 225, "scope_severity": "D", "complaint": 1, "standard": 0, "eventid": "07IQ11", "inspection_text": "**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.", "filedate": "2020-09-01"}
{"rowid": 432, "facility_name": "PRUITTHEALTH-WALTERBORO", "facility_id": 425053, "address": "401 WITSELL STREET", "city": "WALTERBORO", "state": "SC", "zip": 29488, "inspection_date": "2017-08-14", "deficiency_tag": 226, "scope_severity": "D", "complaint": 1, "standard": 0, "eventid": "07IQ11", "inspection_text": "**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.", "filedate": "2020-09-01"}
{"rowid": 7704, "facility_name": "LINVILLE COURT AT THE CASCADES VERDAE", "facility_id": 425392, "address": "30 SPRINGCREST COURT", "city": "GREENVILLE", "state": "SC", "zip": 29607, "inspection_date": "2013-05-09", "deficiency_tag": 280, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "07OZ11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, interviews and record reviews, the facility failed to review and revise the care plan for Resident #68 related to falls, 1 of 27 residents reviewed for care plans. Resident #68 had multiple falls which were not included in his/her care plan. Cross refer to F 323 as it relates to the failure of the facility to provide sufficient interventions for Resident # 68 related to his/her high frequency of falls. The findings included: Resident # 68 was admitted with [DIAGNOSES REDACTED]. His/her admission (Minimum Data Set) MDS indicated that he/she had a BIMS score of 1 (one) indicating a poor cognitive status. Record review on 5/8/13 at 1:25 PM revealled a Fall investigation Worksheet that documented the resident had a fall on 4/25/13 at 2000 (8:00 PM), and also stated the resident had 3 falls in the last 30 days and 7 in the last 31-180 days with injury noted. Review of the resident's care plan indicated that the fall on 4/25/13 was not on the care plan. The care plan also indicated that interventions were not added for each fall and there was no evidence of evaluating the interventions which were in place. On 5/8/13 at 2:20 PM, during an interview with the Interim Director of Nursing (IDON), she/he stated the facility did not have a formal fall committee and all falls are reviewed at the morning meetings. On 5/9/13 at approximately 4:55 PM, during an interview with the MDS (Minimum Data Set) Coordinator, she/he verified that all falls were not on the care plan and that each fall documented did not have a new intervention or show evidence the care plan was reviewed for effectiveness. On 5/10/13 at approximately 2:45 PM, during an interview with the Physician, she/he stated that she/he was not aware that the resident had that many falls or the circumstances of the falls. The physician stated that the staff should be mindful of when alarms were going off and put more staff into place. Review of the facility's policy entitled Falls Management revealed Policy: Patients will be assessed for falls risk as a part of the nursing assessment process. Those determined to be at risk will receive appropriate interventions to reduce the risk and minimize injury .Practice Standards .3. Develop individualized plan of care. 4. Review and revise care plan regularly . 5.3.2 Resident/patient Incident Report .", "filedate": "2016-12-01"}
{"rowid": 7705, "facility_name": "LINVILLE COURT AT THE CASCADES VERDAE", "facility_id": 425392, "address": "30 SPRINGCREST COURT", "city": "GREENVILLE", "state": "SC", "zip": 29607, "inspection_date": "2013-05-09", "deficiency_tag": 281, "scope_severity": "G", "complaint": 0, "standard": 1, "eventid": "07OZ11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record reviews, review of the FDA (Federal Drug Administration) guidelines for [MEDICATION NAME] and interviews, the facility failed to provide services to meet the professional standards of quality for of 11 resident reviewed for medication transcription and administration. Resident # 19, 29, 129 and 141 did not have medications transcribed to the new monthly Medication Administration Records (MARS) resulting in multiple missed doses of either antidepressant medication or pain management medication. The findings included: On 5/8/13 at 11:50 AM record review for Resident # 19 revealed a hand written April 2013 Medication Record for the resident's readmission on 4/8/13. Admitting orders for Tylenol were [MEDICATION NAME] 500 mg (milligrams) PO (by mouth) TID (three times a day) for pain. Physician/Prescriber Telephone Orders revealed an order on 4/9/13 for Increase Tylenol 1 gm (gram) PO TID. The April 2013 Medication Record correctly transcribed the increase in Tylenol from 500 mg to 1 gm. The May 2013 Medication Record sent preprinted from the pharmacy revealed NAPAP ([MEDICATION NAME]) 500 mg Tablet. Take 1 tablet by mouth three times daily. DX: Pain The May 2013 Medication Record revealed 22 does of Tylenol 500mg given in error from May 1, 2013 to May 8, 2013. On 5/8/13 at 12:20 PM interview with the Interim Director of Nursing confirmed incorrect dosage of Tylenol on May 2013 Medication Record. On 5/8/13 at 1:00 PM in an interview, the surveyor reviewed the April and May 2013 Medication Record and Physician/Prescriber Telephone Orders with the Consultant Registered Pharmacist and the error was confirmed. Reconciliation of medication administration on 5/8/13 at 9:45 AM, revealed that Resident #141 had been ordered Tylenol 650 milligrams (mg) on 4/30/13 to be given 3 times a day (TID). The resident was given one dose of Tylenol on the evening of 4/30/13. However, review of the May 2013 Medication Administration Record (MAR) revealed that the Tylenol had not been transcribed to the May MAR and therefore was not administered as ordered. Review of the facility's policy entitled Monthly Physician order [REDACTED].>Policy: Physician orders [REDACTED].Procedure .4.2 The licensed nurse will review the previous month's printed orders and orders that were written in this time frame (telephone, verbal,written orders). 4.2.1 The newly printed orders will then be compared to previous and recently generated orders to ascertain accuracy and completeness. 4.2.2 Corrections (additions and deletions) will be made at the time of discovery to ensure the newly printed orders are accurate and complete. A copy of the corrections is sent to the pharmacy or other designated provider. In an interview with Registered Nurse (RN) #1, Unit Supervisor, she/he verified that the Tylenol TID was ordered 4/30/13 but not transcribed to the MAR for May resulting in the resident not receiving Tylenol 650 mg tid and missing 22 doses. She/he also verified that the order was not faxed to the pharmacy. The nurse stated that the process was to compare the new MARs against the old MARs and to check all the physician's telephone and verbal orders to ensure all medications were written in the pervious month were on the current MAR. The facility admitted Resident #29 with [DIAGNOSES REDACTED]. Record review revealed a physician's Telephone Order dated 3/19/13 to decrease [MEDICATION NAME] to 12.5 mg daily. Review of the April and May 2013 Medication Administration Records (MARs) indicated staff handwrote a notation on these documents to discontinue rather than decrease this medication. Review of the Federal Drug Administration guidelines for [MEDICATION NAME] revealed: If you suddenly stop taking [MEDICATION NAME], you may have side effects such as trouble sleeping or trouble staying asleep ([MEDICAL CONDITION]), nausea, and vomiting. Review of the Nurses Notes dated 4/1/13, 4/15/13, 4/26/13, 4/28/13, and 5/3/13 indicated the resident exhibited increased anxiety, behaviors, agitation, and confusion. Review of the physician progress notes [REDACTED]. A notation from the Nurse Practitioner indicated [MEDICATION NAME] (decreased) middle of March monitor behaviors. The facility admitted Resident #129 with [DIAGNOSES REDACTED]. Review of the physician's Telephone Orders dated 4/25/13 indicated an order for [REDACTED]. Review of the April 2013 MAR indicated the resident received the medication three times daily for four days, once daily for one day, and did not receive the medication at all one day out of the seven days prescribed. .", "filedate": "2016-12-01"}
{"rowid": 7706, "facility_name": "LINVILLE COURT AT THE CASCADES VERDAE", "facility_id": 425392, "address": "30 SPRINGCREST COURT", "city": "GREENVILLE", "state": "SC", "zip": 29607, "inspection_date": "2013-05-09", "deficiency_tag": 323, "scope_severity": "G", "complaint": 0, "standard": 1, "eventid": "07OZ11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, record reviews, interviews and review of the facility's policy entitled Falls Management, the facility failed to provide sufficient and effective fall prevention interventions for 1 of 3 residents with falls. Resident #68 had 10 falls prior to the days of the survey and 1 fall during the survey without new interventions put in place or evidence of reviewing the interventions that had been put in place, resulting in additional falls for Resident # 68. Cross refer to F 280 related to the failure of the facility to review and revise the careplan for Resident # 68 related to falls. The findings included: Resident #68 was admitted with [DIAGNOSES REDACTED]. Record review on 5/8/13 at 1:25 PM revealed a Fall investigation Worksheet that documented the resident had a fall on 4/25/13 at 2000 (8:00 PM). The report also stated that the resident had 3 falls in the last 30 days and 7 in the last 31-180 days. Review of the resident's Nurses Notes indicated that the resident had 10 falls since admission. The resident also had a fall during the days of the survey. When the surveyor asked for incident reports/fall investigations, the facility provided only seven (7) reports. There were no incident reports for 3/13, 4/1/13 and 2/22/13 per the Administrator. The Nurse's Notes revealed the following falls : 1. 2/19/13 at 1550 (3:50 PM), fell out of wheelchair, denied pain, bruising noted to left hip. 2. 2/20/13 at 1700 (5:00 PM), noted sitting on floor on mat in kneeling position, no injury. 3. 2/22/13 at 2230 (8:30 PM), sitting on floor beside bed, minor bruise rear, upper left thigh, mat in place, not witnessed. 4. 3/8/13 at 1700 (5:00 PM), got out of wheelchair, fell , found lying on left side, no injuries noted. 5. 3/8/13 at 2300 (11:00 PM), found sitting on floor on mat beside bed, no signs of injury. 6. 3/12 13 at 1530 (3:30 PM), lying on floor on knees, no injury noted. 7. 4/1/25 at 7:55, alarm sounding, resident on mat on knees, no injuries noted. 8. 4/9/13 at 1730 (5:30 PM), the resident was observed sitting on blue mat on floor, no injury noted. 9. 4/18/13, found lying on right side at 4:00 PM, wheelchair alarm sounding, laceration to right eyebrow, abrasion to right upper cheek, skin tear to right elbow, bruise to right knee. 4/19/13, PT consulted for wheelchair positioning. 10. 4/25/13 at 3:45 PM, found lying in floor mat on floor, alarm sounding, no injury noted. The Fall Risk Assessment and Interventions for the resident were dated 2/5/13 and 4/25/13. On 2/5/13 the resident was assessed as a 32 on the scale which indicated s/he was a high risk for falls and on 4/25/13 a 30. The scale indicated that 7 or higher was a high risk. No interventions were documented on the assessment. The incident reports provided by the Interim Director Of Nursing indicated that on: 2/29/13 the alarm box was turned off but sounded at the system. The fall occurred in the resident's room at 3:50 PM with no apparent injury. Steps taken were noted as notified maintenance of late alarming, rechecked proper functioning and placement. 2/20/13 at 4:45 PM, the incident occurred in the resident's room. There was no injury and the alarm was functioning properly. Steps taken to prevent recurrence were more frequent checks for 72 hours, post fall follow up. 3/8/13 at 5:00 PM, the incident occurred in the dining area and no alarm was in place. No injury noted and the alarm was placed on the resident. Steps taken to prevent recurrence were alarm placed. 3/8/13 at 8:13 PM, the fall took place in the resident's room. No injuries were noted. Bed alarm did not sound. Steps taken were rechecked bed alarm is attached and functioning. 4/1/13 at 7:55 PM, the incident occurred in the resident's room. The report stated that the alarm was sounding, the resident stated that he/she was going to the bathroom and the resident had no injury. Steps taken were to assist resident to bathroom and toilet more frequently. 4/18/13 at 3:20 PM, indicated that the incident occurred in the day room. The presence of the alarm was not noted on the report and the steps taken were to refer to physical therapy for a possible chair change. The resident was noted to have a laceration to his/her right eyebrow, multiple abrasions to the right upper cheek and a skin tear to the right elbow. 4/25/13 at 3:34 PM the fall occurred in the resident's room. The alarm was sounding. No injury was noted. The steps taken were refer to therapy for pool therapy for decreased anxiety and strengthening. 5/8/13 at 2045 (8:45) PM the incident occurred in the resident's room. He/she had a skin tear to the left elbow and to the right shin. The steps taken were scoop mattress, refer to wellness for ambulation and 1:1. There were no incident reports for 3/13, 4/1/13 and 2/22/13 per the Administrator. Review of the resident's admission Minimum Data Set revealed that the resident had a fall history prior to admission and a BIMS score of 1 (one) indicative of cognitive impairment. Review of the resident's care plan indicated that the fall on 4/25/13 was not on the care plan. The care plan also indicated that there were no new interventions added for each fall and no evidence of evaluation for the interventions which were in place. Review of the physician's telephone orders indicated that an order for [REDACTED]. PT notes reviewed for 3/27/13 through 4/27/13 indicated that resident was admitted to PT for gait training and strengthening. The summary indicated that the resident was at risk for falls and further decline with increased dependency on caregivers. The documentation for 4/29/13 through 5/23/13 indicated that on 3/27/13 the resident still had potential for improvement. On 4/26/13 the resident was placed in a Broda Chair and provided services for positioning. The intervention was documented on the back of a falls investigation work sheet on 4/18/13. In an interview with the Physical Therapist, she/he stated that it took a while to get the chair due to medicare not covering the cost and they had to wait until they could reach the family to get approval for the chair. Review of the Physician's Monthly Orders indicated that the resident was to have a bed and chair alarm. Review of the Treatment Administration Records for March, April and May of 2013 indicated that the staff had checked the resident's alarms and that the alarm was in place and functioning properly on the days that the falls occurred. 5/8/13 at 2:20 PM, during an interview with the Interim Director of Nursing, she/he stated the facility did not have a formal fall committee and all falls are reviewed at the morning meetings. S/he also stated that the facility does not use restraints or self release belts. On 5/10/13 at approximately 2:45 PM, during an interview with the physician, she/he stated that she/he was not aware that the resident had had that many falls or the circumstances of the falls. She/he stated that the 9:00 PM dose of Seroquel had been decreased from 25 mg to 12.5 mg and changed from 9:00 PM to 4:00 PM. The physician stated that the staff should be mindful of when alarms were going off and put more staff into place. She/he noted the facility had used a lot of agency staff lately. Review of the facility's policy entitled Falls Management revealed Policy: Patients will be assessed for falls risk as a part of the nursing assessment process. Those determined to be at risk will receive appropriate interventions to reduce the risk and minimize injury .Practice Standards .3. Develop individualized plan of care. 4. Review and revise care plan regularly . 5.3.2 Resident/patient Incident Report .", "filedate": "2016-12-01"}
{"rowid": 7707, "facility_name": "LINVILLE COURT AT THE CASCADES VERDAE", "facility_id": 425392, "address": "30 SPRINGCREST COURT", "city": "GREENVILLE", "state": "SC", "zip": 29607, "inspection_date": "2013-05-09", "deficiency_tag": 333, "scope_severity": "G", "complaint": 0, "standard": 1, "eventid": "07OZ11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility admitted Resident #29 with [DIAGNOSES REDACTED]. Review of the March 2013 cumulative physician's orders [REDACTED]. Review of the physician's Telephone Orders dated 3/19/13 indicated an order to decrease [MEDICATION NAME] to 12.5 mg daily. Review of the March 2013 Medication Administration Record (MAR) indicated staff changed the order on the MAR and administered [MEDICATION NAME] 12.5 mg daily per orders from 3/19/13 through the end of March. Review of the Physician's Progress Notes dated 3/19/13 indicated attempt (decrease) [MEDICATION NAME] . Review of the April and May 2013 cumulative physician's orders [REDACTED]. Further review of these orders and MARs indicated staff handwrote d/c (discontinue) 3/19/13 on the printed orders and MARs for [MEDICATION NAME]. Both the April and May 2013 MARs were blank indicating [MEDICATION NAME] was not administered as ordered for 38 days. Review of the Nurses Notes dated 4/1/13, 4/15/13, 4/26/13, 4/28/13, and 5/3/13 indicated the resident exhibited increased anxiety, behaviors, agitation, and confusion. Review of the physician progress notes [REDACTED]. A notation from the Nurse Practitioner indicated [MEDICATION NAME] (decreased) middle of March monitor behaviors. On 5/9/13 at approximately 2:30 PM, the Director of Nursing (DON) was asked to review the physician's orders [REDACTED]. On 5/9/13 at approximately 3:00 PM, the DON concurred that Resident # 29 had not received [MEDICATION NAME] per orders since April 1, 2013. The DON confirmed that the order was discontinued during April and May to current date rather than decreasing the medication as ordered. The facility admitted Resident #129 with [DIAGNOSES REDACTED]. Review of the physician's Telephone Orders dated 4/25/13 indicated Tylenol 650 mg tid (three times daily) x 7 days for back pain. Review of the April 2013 MAR indicated Resident #129 received Tylenol 650 mg once on 4/25/13, three times daily on 4/26/13, 4/27/13, 4/28/13, 4/29/13, and 4/30/13 with the medication not administered on 4/31/13. Documentation on the MAR indicated the resident did not receive 5 doses of the medication as ordered. On 5/9/13 at approximately 3:00 PM, the DON reviewed the documentation related to the order for Tylenol 650 mg and confirmed that Resident #129 did not receive five doses of the medication as ordered by the physician. Reconciliation of medication administration on 5/8/13 at 9:45 AM, revealed that Resident #141 had been ordered Tylenol 650 milligrams (mg) on 4/30/13 to be given 3 times a day (tid). The resident was given a dose on the evening of 4/30/13. Review of the May 2013 Medication Administration Record (MAR) revealed that the Tylenol had not been transcribed to the May MAR. Review of the facility's policy entitled Monthly Physician order [REDACTED].Procedure .4.2 The licensed nurse will review the previous month's printed orders and orders that were written in this time frame (telephone, verbal,written orders). 4.2.1 The newly printed orders will then be compared to previous and recently generated orders to ascertain accuracy and completeness. 4.2.2 Corrections (additions and deletions) will be made at the time of discovery to ensure the newly printed orders are accurate and complete. A copy of the corrections is sent to the pharmacy or other designated provider. In an interview with Registered Nurse (RN) #1, Unit Supervisor, she/he verified that the Tylenol TID was ordered 4/30/13 but not transcribed to the MAR for May resulting in the resident not receiving the medication. She/he also verified that the order was not faxed to the pharmacy. The nurse stated that the process was to compare the new MARs against the old MARs and to check all the physician's telephone and verbal orders to ensure all medications were written in the pervious month were on the current MAR. On the days of the survey, based on record review, interview, and review of Skilled Nursing Facility Nursing Policies and Procedures for Monthly Physician order [REDACTED]. Significant medication errors occurred for Resident #19 and Resident #141 for Tylenol not transcribed correctly from the April to May Medication Record, Resident #29 for an order for [REDACTED].#129 for Tylenol not administered per physician orders. Cross refer to F 281 as it relates to professional standards related to medication administration. Cross refer to F 428 as it relates to the failure of the pharmacy to identify a [MEDICAL CONDITION] medication was discontinued rather than reduced in dosage. The findings included: Resident #19 was admitted with [DIAGNOSES REDACTED]. On 5/8/13 at 11:50 AM record review revealed a hand written April 2013 Medication Record for the resident's readmission on 4/8/13. Admitting orders for Tylenol were [MEDICATION NAME] 500 mg (milligrams) PO (by mouth) TID (three times a day) for pain. The Physician/Prescriber Telephone Orders revealed an order on 4/9/13 for Increase Tylenol 1 gm (gram) PO TID. The May 2013 Medication Record sent preprinted from the pharmacy revealed NAPAP ([MEDICATION NAME]) 500 mg Tablet. Take 1 tablet by mouth three times daily. DX: Pain The May 2013 Medication Record revealed 22 does of Tylenol given in error from May 1, 2013 to May 8, 2013. On 5/8/13 at 12:20 PM interview with the Interim Director of Nursing confirmed incorrect dosage of Tylenol on May 2013 Medication Record. On 5/8/13 at 1:00 PM in an interview, the surveyor reviewed the April and May 2013 Medication Record and Physician/Prescriber Telephone Orders with the Consultant Registered Pharmacist and the error was confirmed.", "filedate": "2016-12-01"}
{"rowid": 7708, "facility_name": "LINVILLE COURT AT THE CASCADES VERDAE", "facility_id": 425392, "address": "30 SPRINGCREST COURT", "city": "GREENVILLE", "state": "SC", "zip": 29607, "inspection_date": "2013-05-09", "deficiency_tag": 428, "scope_severity": "G", "complaint": 0, "standard": 1, "eventid": "07OZ11", "inspection_text": "**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 identify errors in transcription of physician's orders for 1 of 10 residents reviewed for Pharmacy Drug Regimen Review. The Pharmacy Review for Resident #29 failed to identify Seroquel was discontinued by staff rather than reduced per physician's orders. Cross refer to F333 and F 281 as it relates to significant medication errors and professional standards related to medication administration. The findings included: The facility admitted Resident #29 with [DIAGNOSES REDACTED]. Record review revealed a physician's Telephone Order dated 3/19/13 to decrease Seroquel to 12.5 mg daily. Review of the April and May 2013 MARs indicated staff handwrote a notation on these documents indicating the medication had been discontinued rather than decreased. Review of the Nurses Notes dated 4/1/13, 4/15/13, 4/26/13, 4/28/13, and 5/3/13 indicated the resident exhibited increased anxiety, behaviors, agitation, and confusion. Review of the physician progress notes [REDACTED]. A notation from the Nurse Practitioner indicated Seroquel (decreased) middle of March monitor behaviors. Review of the Pharmacy Drug Regimen Review dated 3/21/13 noted Seroquel was decreased to 12.5 mg daily on 3/19/13. The Pharmacy Drug Regimen Review dated 4/16/13 contained no documentation related to Seroquel. On 5/9/13 at approximately 3:00 PM, the Director of Nursing (DON) reviewed documentation related to the order for Seroquel and the finding that the medication was not administered during April 2013 and May 2013 to date. The DON reviewed the Pharmacy Drug Regimen Review dated 3/21/13 and 4/16/13 and confirmed that the 4/16/13 review did not note that staff had discontinued the order for Seroquel in error.", "filedate": "2016-12-01"}
{"rowid": 10141, "facility_name": "SUNNY ACRES", "facility_id": 425093, "address": "1727 BUCK SWAMP ROAD", "city": "FORK", "state": "SC", "zip": 29543, "inspection_date": "2010-12-01", "deficiency_tag": 225, "scope_severity": "D", "complaint": null, "standard": null, "eventid": "07P711", "inspection_text": "On the day of the inspection, based on review of facility concern forms and interview, the facility failed to ensure that all allegations of misappropriation of resident property were reported to the State survey and certification agency for 2 of 2 allegations reviewed (Resident A). The findings included: Review of the concerns filed with facility administration since the last recertification survey revealed two allegations of misappropriation from Resident A. On 8/12/10, the resident reported $12.00 missing. Facility staff searched for the money but it was not found. The facility reimbursed the resident. On 9/1/10, Resident A reported $50.00 missing, two twenty dollar bills and other money totaling fifty dollars. A search revealed some one dollar bills in the resident's coat, but she stated this was not part of the $50.00 she had put in her purse. The facility reimbursed the resident by depositing the money in her fund account. The Administrator and Director of Nurses were asked at 4 PM on 12/1/10 if these allegations had been reported to the State survey and certification agency. After researching their files, no evidence was discovered to show the allegations of misappropriation of resident property were reported.", "filedate": "2014-04-01"}
{"rowid": 871, "facility_name": "VALLEY FALLS TERRACE", "facility_id": 425096, "address": "400 LOCUST GROVE ROAD", "city": "SPARTANBURG", "state": "SC", "zip": 29303, "inspection_date": "2019-03-22", "deficiency_tag": 550, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "07YM11", "inspection_text": "Based on observation, interview, and record review, the facility failed to promote an environment that enhanced the dignity of the residents for 3 of 3 meal observations. The findings include: During An observation on 3/18/19 at 5:38 PM on the A Hall in the Dining Room, it was observed that milk and juice was being served to 6 residents while still in the carton. At 5:43 PM on 3/18/19, meal delivery service on the A Hall revealed 10 residents receiving milk, juice, and thickened liquids concentrate on their meal carts with no cups or glasses being made available to them, only a straw. During an interview with Certified Nursing Assistant (CNA) #1 on 3/18/19 at 6:15 PM s/he verified that the residents did not have cups or glasses provided to them with meals. S/he stated, I do not believe I have ever seen them given cups. During an interview on 3/21/19 at 9:05 AM, the Kitchen Supervisor stated that they were unaware that drinks should be served out of glasses/cups and not the cartons. S/he also confirmed that the kitchen was not providing additional cups/glasses for the residents during meal times when milk, juice, and other liquids were being served in their prepackaged cartons. On 3/18/19 at approximately 6:00 PM, during an observation of the A Hall dining room (5) residents were served milk in cartons with a straw in them. During observation of the dining service on the B Hall on 03/18/19 at approximately 05:45 PM, 5 of 7 residents observed received milk in a carton with a straw. No glass was offered, and the residents were not asked if they preferred their milk in a glass.", "filedate": "2020-09-01"}
{"rowid": 872, "facility_name": "VALLEY FALLS TERRACE", "facility_id": 425096, "address": "400 LOCUST GROVE ROAD", "city": "SPARTANBURG", "state": "SC", "zip": 29303, "inspection_date": "2019-03-22", "deficiency_tag": 607, "scope_severity": "D", "complaint": 1, "standard": 1, "eventid": "07YM11", "inspection_text": "**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.", "filedate": "2020-09-01"}
{"rowid": 873, "facility_name": "VALLEY FALLS TERRACE", "facility_id": 425096, "address": "400 LOCUST GROVE ROAD", "city": "SPARTANBURG", "state": "SC", "zip": 29303, "inspection_date": "2019-03-22", "deficiency_tag": 609, "scope_severity": "D", "complaint": 1, "standard": 1, "eventid": "07YM11", "inspection_text": "**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.", "filedate": "2020-09-01"}
{"rowid": 874, "facility_name": "VALLEY FALLS TERRACE", "facility_id": 425096, "address": "400 LOCUST GROVE ROAD", "city": "SPARTANBURG", "state": "SC", "zip": 29303, "inspection_date": "2019-03-22", "deficiency_tag": 812, "scope_severity": "F", "complaint": 0, "standard": 1, "eventid": "07YM11", "inspection_text": "Based on observation, interview, and review of the facility policies, the facility failed to prepare, distribute, and serve food under sanitary conditions for 1 of 1 kitchen reviewed and has the potential to affect 84 of 85 residents with ordered diets as evidenced by failing to do the following: wear facial hair restraints, store food sanitarily, clean can opener and ice scoop tray. The findings included: On 3/18/19 at approximately 3:35 PM, an initial tour of the main kitchen with the Dietary Manager (DM) revealed: 1.) Dietary Aide #1 and the DM had a mustache without facial hair restraint to cover. Walk-in refrigerator: 2.) (1) Box of thawed chicken dripping a red substance onto the floor leaving a puddle below. 3.) The ice scoop tray on the ice machine did not allow for drainage and had a build-up of a black substance on the bottom with the ice scoop resting in it. 4.) The can opener had a black build-up of food debris on the blade. On 3/19/19 at approximately 5:30 PM an observation of the dinner line plating in the main kitchen with the DM revealed: 1.) Dietary Aide #1 and the DM had a mustache without facial hair restraint to cover. 2.) The can opener had a black build-up of food debris on the blade. On 3/19/19 at approximately 5:50 PM, during an interview with the DM, s/he verified facial hair restraints were not covering mustaches, chicken was not in a drip pan and was dripping onto the floor, the ice scoop tray did not have drainage and had a build-up of a black substance, and there was debris build-up on the can opener. Review of the facility policy entitled, Ice, procedure (5) states, Ice scoops will be cleaned and stored in a separate container that limits exposure to dust and moisture. Review of the facility policy entitled, Staff Attire, states under procedure (1) states, All staff members will have their hair off the shoulders, confined in a hair net or cap, and facial hair properly re-strained. Review of the facility policy entitled, Food Preparation, states under procedure (5) states, The Cook thaws frozen items that requires defrosting prior to preparation using one of the following methods: Thawing in the refrigerator, in a drip-proof container, and in a manner that prevents cross-contamination.", "filedate": "2020-09-01"}
{"rowid": 2769, "facility_name": "LAKE MARION NURSING FACILITY", "facility_id": 425300, "address": "1527 URBANA ROAD", "city": "SUMMERTON", "state": "SC", "zip": 29148, "inspection_date": "2019-11-04", "deficiency_tag": 550, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "09P711", "inspection_text": "Based on observation and interview, the facility failed to provide the residents with a dignified and homelike environment during dining. The facility used styrofoam bowls, also known as a monkey dish, during meal service. This affected 74 out of 85 residents who ate during meal times. The findings included: On 11/01/19 at 12:49 PM, lunch meal service was observed in the main dining room. Residents' dessert and bread were each in their own separate styrofoam bowl while the main meal was on china. On 11/01/19 at approximately 5:25 PM, the dinner trays were observed to have dessert and bread each in their own styrofoam bowl. On 11/02/19 at 12:25 PM, resident trays were observed to have styrofoam bowls, one with a dessert and one with a roll. On 11/03/19 at approximately 10:20 AM, the Certified Dietary Manager (CDM) was interviewed. The CDM stated that the facility was using the styrofoam bowls when she started about a year ago and that she never thought to change it. She didn't know why they used styrofoam bowls. On 11/03/19 at 12:30 PM, the Administrator (NHA) was interviewed. The NHA stated that at one time they used the china bowls, but that she was unaware as to when the kitchen stopped using them and why.", "filedate": "2020-09-01"}
{"rowid": 2770, "facility_name": "LAKE MARION NURSING FACILITY", "facility_id": 425300, "address": "1527 URBANA ROAD", "city": "SUMMERTON", "state": "SC", "zip": 29148, "inspection_date": "2019-11-04", "deficiency_tag": 558, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "09P711", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and resident and staff interviews, the facility failed to provide an appropriate call light for 1 of 1 resident reviewed for accommodation of needs (Resident #233). Specifically, Resident #233 had difficulty using a standard push button call light due hand deformities. The findings included: According to the Face Sheet, Resident #233 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. According to the admission Minimum Data Set (MDS) assessment, dated 09/26/19, Resident #233 was moderately cognitively impaired with a Brief Interview of Mental Status (BIMS) score of 12 out of 15. He required extensive to total assistance with all activities of daily living (ADL). He had functional limitation in range of motion to both of his upper and lower extremities. Resident #233 was interviewed and observed on 11/02/19 at 9:45 AM. He was laying in his bed. His hands were observed to be disformed and they flexed down at the wrist. His fingers were flexed towards his palm and forearm. He was able to move some fingers slightly, but it was limited. His call light was observed. He had a regular push button call light. The call light was observed to be clipped to his pillow and the call light was above his left shoulder, which was out of his reach. The resident's care plan was reviewed. According to the ADL care plan dated 09/26/19, Resident #233 required total care with all ADL's related to the inability to use his hands due to gouty arthritis. Staff does most of his feeding due to deformities of hands. Resident #233 was interviewed and observed on 11/04/19 at 10:24 AM. His call light was not visually seen. When asked where his call light was, he said he didn't know. He said he was looking for it and couldn't find it. At 10:26 AM, the Nursing Home Administrator (NHA) entered the room, along with the resident's family. The NHA was asked to find Resident #233's call light. The NHA looked for the call light and it was tucked underneath his sheets, which made it difficult for the resident to find. Resident #233 told the NHA that he couldn't find his call light. Resident #233 was interviewed and observed on 11/04/19 at 2:53 PM. He was asked to press his call light. The resident was laying in his bed and his call light was laying on his lap. He moved his left hand to try and press the push button. He had extreme difficulty with grasping the call light in order to be able to press the button. He had thought he pressed the button, but the call light did not turn on. The call light was functional. He agreed that the call light was difficult for him to use. He said he didn't press the button hard enough. He said that his call light wasn't always in reach. He said sometimes it was on the floor. Unit Manager #114 was interviewed on 11/04/19 at 3:07 PM. She said Resident #233 could use the call light if it was placed in his hand. Otherwise, it was more difficult for him to use the light. She was not aware the facility had any other type of call light besides the standard push button call light. She then spoke with the Director of Nursing (DON). She said they had call lights that were a flat pad, or pancake pad, that could be pressed. She did not know the resident had difficulty pressing the call light, as his call light would go off at times. She agreed that a pancake call light would be much easier for him than the standard call light, due to his hands. On 11/04/19 at 3:14 PM, Resident #233 had the pancake call light hooked up in his room. Unit Manager #114, the DON, and the Assistant Director of Nursing (ADON) were all in the resident's room. They said he was able to press the light with no problems. Resident #233 said the new call light would be much easier for him to use. Unit Manager #114 was interviewed on 11/04/19 at 4:25 PM. She said the new call light was much better for him. The DON was interviewed on 11/04/19 at 5:21 PM. She said the new call light was much better for him. The NHA as interviewed on 11/04/19 at 5:46 PM. She said the pancake call light would be much better for him. She agreed that with his hands, the normal call light would have been difficult to use.", "filedate": "2020-09-01"}
{"rowid": 2771, "facility_name": "LAKE MARION NURSING FACILITY", "facility_id": 425300, "address": "1527 URBANA ROAD", "city": "SUMMERTON", "state": "SC", "zip": 29148, "inspection_date": "2019-11-04", "deficiency_tag": 725, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "09P711", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and resident and staff interviews, the facility failed to respond timely to a resident's request. Specifically, the facility failed to assist Resident #233 to sit on the side of the bed in a timely manner. This affected one of one resident. The findings included: According to the Face Sheet, Resident #233 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. According to the admission Minimum Data Set (MDS) assessment, dated 09/26/19, Resident #233 was moderately cognitively impaired with a Brief Interview of Mental Status (BIMS) score of 12 out of 15. He required extensive to total assistance with all activities of daily living (ADL). Resident #233 was interviewed on 11/02/19 at 9:37 AM. He said the staff did not check on him or provide the care that he should get. He said staff did not change him. He said sometimes it could be hours before he would see someone. Resident #233 was interviewed and observed on 11/04/19 at 2:53 PM. During the interview, Certified Nurse Aide (CNA) #55 came into the room at 2:57 PM. She was making her rounds since she just came on shift. Resident #233 requested to sit on the side of the bed. She said she needed to get help and she would be back. After she left, Resident #233 made the comment that she would not be back. He said the staff never come back when they say they will. He said they never come and help him. Resident #233's room continued to be monitored. CNA #55 had not gone back to the room after 15 minutes. There was no one else that entered the room either. At 3:11 PM, Unit Manager #114 was informed the CNA had not gone back into Resident #233's room after he requested to sit on the side of the bed. Unit Manager #114, the Director of Nursing (DON), and the Assistant Director of Nursing (ADON) all went down to Resident #233's room. At 3:14 PM, the room was observed. Unit Manager #114, the DON, and the ADON were in the room. Resident #233 was requesting to sit on the side of the bed. They got the nurse to assist with sitting him up. CNA #55 was interviewed on 11/04/19 at 3:20 PM. When asked about why she did not return to Resident #233's room, she said she was not assigned to him and she was waiting for his assigned CNA to get in. She said she had just spoke with the assigned CNA and she said Resident #233 was not allowed to sit on the side of the bed without support. When she came into Resident #233's room, she was the only CNA there at the time of shift change and she was checking in on everyone. She always did that when she came on shift. She said she would assist residents that she wasn't assigned to, but she was not very familiar with Resident #233. She said she struggled to find someone to assist her and it was probably 15 to 20 minutes before she saw his assigned CN[NAME] She said she should have gone straight back to his room and communicated that she was unable to help him at that time. Unit Manager #114 was interviewed on 11/04/19 at 4:25 PM. She said they were able to get Resident #233 up and he sat on the side of the bed for a short period. She said Resident #233 needed two staff to assist him. She said CNA #55 should have grabbed the first person she saw to assist her with sitting him up. She could have grabbed the nurse, another CNA, or she could have asked her as well. She said all staff have been told that every resident is theirs and they need to assist every resident; not just the residents they are assigned to. She said if the CNA could not have found anyone to help her, then she should have gone back to the room and at least explained the situation. The DON was interviewed on 11/04/19 at 5:21 PM. She said that requests from residents should be taken care of in a timely manner. If staff need another person, then they need to find someone that can help. CNA #55 could have gotten the nurse, another CNA, the Unit Manager, or herself to help. She said residents should be assisted as soon as possible. It could take a few minutes to find someone, but anyone could assist.", "filedate": "2020-09-01"}
{"rowid": 2772, "facility_name": "LAKE MARION NURSING FACILITY", "facility_id": 425300, "address": "1527 URBANA ROAD", "city": "SUMMERTON", "state": "SC", "zip": 29148, "inspection_date": "2019-11-04", "deficiency_tag": 812, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "09P711", "inspection_text": "Based on observation, interview and record review, the facility failed to ensure proper food handling, food safety, proper handwashing, proper use of hair nets, and proper drying techniques. This affected approximately 74 out of 85 residents who ate their meals from the kitchen. The findings included: 1a. On 11/03/19 beginning at 10:07 AM the following kitchen observations were made: Dietary Aid (DA) #21 was observed picking a food thermometer off the floor and placed it on the edge of the steam table. DA #21 was not wearing gloves and did not wash her hands before moving on to the next task of removing food from the oven. DA #21 was interviewed, she agreed that she had not washed her hands after she picked the thermometer off the floor and then removing food from the oven. DA #21 stated that she should not have left the dirty thermometer on the steam table without having it properly sanitized and then should have washed her hands. 1b. On 11/03/19 at approximately 10:20 AM, Cook #5 was observed preparing a sandwich with gloved hands. Cook #5 dropped the knife she was using on the floor, picked it up, removed her gloves and returned to the preparation area without gloved hands to put away the bread and pimento cheese. Cook #5 then took out a clean knife and put on a new pair of gloves. She did not wash her hands after picking up the knife that fell on the floor and prior to putting on a new pair of gloves. 1c. On 11/03/19 at approximately 10:25 AM, DA #22 was observed rolling silverware into napkins with gloved hands. DA #22 was asked by the Certified Dietary Manager (CDM) to help with another task. DA #22 was observed removing her gloves and immediately putting on a new pair of gloves without washing her hands. On 11/03/19 at approximately 10:27 AM, the CDM was interviewed. CDM stated the dietary staff are trained to wash their hands every time they change their gloves and when they change tasks. The policy for Dietary Services: Sanitization was reviewed. #10 read, Food preparation equipment and utensils that are manually washed will be allowed to air dry whenever practical. 2a. On 11/03/19 at approximately 10:25 AM, DA #22 was observed rolling silverware that was still wet from the dish washer. DA #22 was observed banging off the excess water prior to rolling the silverware into a napkin. The CDM was interviewed on 11/02/19 at approximately 10:27 AM. CDM stated that utensils were wet and should not have been used. CDM stated that it was their policy to air dry all utensils prior to use. 2b. On 11/03/19 beginning at 11:50 AM, lunch service tray line was observed. The insulated plate bases were stacked for use. More than 12 bases were observed to be wet and a plate was placed in them and used for service. After being made aware of the wet bases on 11/03/19 at 12:00 PM, CDM removed the remaining wet insulated bases from use. CDM stated that all equipment should be air dried prior to use. 3. On 11/03/19 during tray line service at 12:07 PM, DA #4 entered the kitchen from the dining room. She was not wearing a hair net and proceeded to go straight to the walk-in refrigerator. Once out of the refrigerator, her co-workers told her to put on a hair net. At 12:17 PM, DA #24 entered the kitchen through the dining room. DA #24 had long hair, approximately halfway down her back that was not restrained. She walked through the kitchen, and past the tray line prior to putting her hair in a hair net. On 11/03/19 at approximately 1:00 PM, the CDM was interviewed and stated that they did not have a formal policy on which door to enter the kitchen, but that it was her expectation that the staff would enter the kitchen through the service hallway door because that is where the hairnets and hand washing sink were located. 4. On 11/03/19 at 12:20 PM, the temperature log book was reviewed. The lunch that was being served did not have temperatures recorded. The CDM stopped the tray line to take temperatures. DA #21 calibrated the thermometer, took the temperature of a food item and sanitized the thermometer with an alcohol wipe. Instead of allowing the thermometer to air dry, DA #21 use a paper napkin to wipe off the thermometer and inserted it into the next food item. DA #21 was observed sanitizing with the alcohol wipe and then dried off the thermometer after temping each item with the same paper napkin. The temperature log book was reviewed for September, (MONTH) and (MONTH) 2019. The following meals were served without recording temperatures: 09/24/19 - lunch, 09/30/19 - breakfast and lunch, 10/22/19 - dinner, 10/25/19 - dinner, 10/28/19 - lunch, 10/29/19 - breakfast, 10/31/19 - breakfast and lunch, 11/02/19 - dinner, and 11/03/19 - lunch. On 11/03/19 at approximately 1:00 PM, the CDM was interviewed and stated that it was the expectation that temperatures were taken and recorded prior to the tray line beginning and that when taking temperatures, the dietary staff should first use an alcohol wipe to sanitize, allow the thermometer to air dry and then insert into the thickest part of the food. The policy for Safe Food Temperatures was reviewed. Under the Procedure section, #1. Prior to the beginning of the tray line the temperature of all food being served is taken and recorded appropriately on the temperature control form. The policy for Proper Use of Thermometers was reviewed. Under the Procedure section, #1 read in part, . clean and sanitize the thermometer, clean the thermometer with clean soapy water, sanitize with an alcohol wipe, insert into the thickest part of the product .", "filedate": "2020-09-01"}
{"rowid": 2773, "facility_name": "LAKE MARION NURSING FACILITY", "facility_id": 425300, "address": "1527 URBANA ROAD", "city": "SUMMERTON", "state": "SC", "zip": 29148, "inspection_date": "2019-11-04", "deficiency_tag": 849, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "09P711", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to properly communicate with hospice regarding code status for 1 of 1 resident (Resident #6). Specifically, the facilities records indicated a Full Code and the hospice records indicated a Do Not Resuscitate (DNR). The findings included: According to the Face Sheet, Resident #6 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. According to the quarterly Minimum Data Set (MDS) assessment, dated 10/01/19, Resident #6 was unable to complete the Brief Interview of Mental Status (BIMS). She had a short term memory and long term memory problem. She required supervision to extensive assistance with all activities of daily living (ADL). Resident #6's clinical record was reviewed on 11/02/19 at 11:05 AM. The facility's chart had a code status of Full Code. This was signed on 10/04/18. The physician's orders [REDACTED]. Resident #6 was admitted to hospice on 01/22/19. The hospice chart had a code status of DNR. Registered Nurse (RN) #64 was interviewed on 11/02/19 at 11:21 AM. He said Resident #6 was a DNR and said she was on hospice. He did not assume someone was a DNR because they're on hospice. He said he would look in the chart, if he needed to know the code status for a resident. There was a form in the front of the chart that he would look at. According to Resident #6's care plan, the resident was receiving hospice services due to terminal stage of illness. Approaches included coordinating care and services with hospice provider. Unit Manager #114 was interviewed on 11/02/19 at 12:06 PM. She said the nurses would go to the hospice chart and look to see which code status a resident was. She said code status should be in both the hospice and facility charts and they should match. She said hospice would normally update the facility chart. She said the Social Services Director (SSD) was the one that goes over code status and would coordinate with hospice. She called the SSD on 11/02/19 at 12:09 PM. She said the resident's code status did not change to DNR when she went on hospice. She said the hospice chart was wrong. She remembered a conversation with the son, who was the Power of Attorney (POA), and the resident wanted to remain a full code to be around for her grandchildren. The SSD and Unit Manager looked at both charts. She confirmed the facility chart had a Full Code order and the hospice agency had a DNR order. She said the hospice order was signed by the daughter, who was not the PO[NAME] The SSD was not aware of the DNR order. She said they always called the family when something happened and the family always wants her sent out. She said the communication with the hospice agency was not good. They never informed her about the order, which they should have. The SSD said the nurses would go to the facility chart to look for code status and would not go to the hospice chart. RN #64 was interviewed on 11/02/19 at 12:32 PM. He said he would look in the facility's chart to determine a resident's code status. He would not look in the hospice chart. He does not assume a code status for anyone. He said he would always look at the chart to determine the resident's wishes. The SSD was interviewed on 11/03/19 at 3:48 PM. She confirmed that the communication from hospice was poor. She said they hardly ever talked to anyone. Sometimes hospice would come and no one knew they were there. She did not know the DNR order was in the hospice chart because no one told her. She did not know when that paperwork would have been placed in the chart. It was signed during her admission to hospice, but that didn't mean that was when it was placed in the chart. She was not sure why the hospice agency did not consult with the son, who was the PO[NAME] Unit Manager #114 was interviewed on 11/04/19 at 4:25 PM. She said the communication with paperwork being placed in the chart had not been good. The hospice agency did not tell them when they put something in the hospice chart. She said the hospice agency goes through the chart to ensure everything is in there. She thought it would be a good idea for them to start looking at the chart to ensure what was in there. She confirmed she was not aware of the DNR order in the hospice chart. She said when the hospice staff come, they are good about speaking with the facility staff. The Director of Nursing (DON) was interviewed on 11/04/19 at 5:21 PM. She said if the hospice agency obtained a DNR order, then they should have communicated that to the facility. She was not sure how the miscommunication happened. She said hospice should be communicating changes with the facility staff.", "filedate": "2020-09-01"}
{"rowid": 2774, "facility_name": "LAKE MARION NURSING FACILITY", "facility_id": 425300, "address": "1527 URBANA ROAD", "city": "SUMMERTON", "state": "SC", "zip": 29148, "inspection_date": "2019-11-04", "deficiency_tag": 880, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "09P711", "inspection_text": "Based on observations, interviews and policy reviews, the facility failed to utilize proper handwashing techniques during wound care for 1 of 2 nurses observed. The facility failed to maintain infection control practices during medication pass for 3 of 5 nurses observed. The findings included: 1. On 11/03/19 at 10:38 a.m., Nurse #74's handwashing technique was observed during wound care observation for Resident #3. Nurse #74 turned on the water faucet with his unwashed hands. He washed his hands with soap and water, then used his clean hands to turn off the water faucet. He then pressed the lever on the paper towel dispenser to dispense a towel to dry his hands. He repeated this technique each time he washed his hands during wound care. After the wound care observation, the nurse was asked about his handwashing technique. Nurse #74 responded by demonstrating his handwashing technique, and again used his clean hands to turn off the water faucet and press the lever to dispense a paper towel to dry his hands. When questioned about the last time he was checked off on handwashing, he stated it had been more than 1 year. During an interview on 11/04/19 at 9:19 a.m., the Director of Nursing (DON) stated the correct handwashing procedure would be to dispense a paper towel, perform handwashing, dry the hands, then use the elbow to dispense another towel to turn off the faucet. A review of the facility's policy for Handwashing/Hand Hygiene, revised 8/2015, indicated, Washing hands, 1. Vigorously lather hands with soap and rub them together .2. Rinse hands thoroughly 3. Dry hands thoroughly with paper towels and then turn off the faucet with a clean, dry paper towel. 2a. During an observation and interview on 11/03/19 at 8:43 a.m., Nurse #64 was observed administering an insulin injection to Resident #25. Nurse #64 placed the syringe in his own mouth, prepped the injection site with alcohol, then administered the injection. He did not wear gloves during the procedure. When questioned, he stated it was the facility's policy to wear gloves during injections. When asked about placing the syringe in his mouth, he stated old army habits. The facility's undated policy for Injectable Medication Administration, indicated, Bring supplies to bedside or beside resident and maintain a clean space. Put on gloves. Expose the area to be injected and clean with an alcohol wipe. After administering the medication, the policy indicated, Dispose of syringe in sharps container and supplies in appropriate waste container. Remove & discard gloves. 2b. During a medication pass observation and interview on 11/4/19 at 8:20 a.m., Nurse #73 entered Resident #7's room to administer her morning medications. The nurse began by washing his hands. He turned the faucet on with his unwashed hands, washed his hands with soap and water, turned the faucet off with his arm, then used his clean hands to press the lever on the paper towel dispenser to dispense a towel to dry his hands. While he was washing his hands, in reference to handwashing, he stated, It isn't a good system. As he touched the paper towel dispenser lever to dispense a paper towel, he stated, Even this is dirty. He was questioned about his handwashing technique. He proceeded to demonstrate his handwashing technique, and once again used his clean hands to dispense a paper towel. When asked what he could do to prevent contaminating his hands while dispensing a paper towel, he stated his previous employer had tissues available that he used to dispense a paper towel. During an interview on 11/04/19 at 10:19 a.m., the DON stated the correct handwashing procedure would be to first dispense a paper towel, wash and dry the hands, then use the elbow to dispense another towel to turn off the faucet. A review of the facility's policy for Handwashing/Hand Hygiene, revised 8/15, indicated, Washing hands, 1. Vigorously lather hands with soap and rub them together .2. Rinse hands thoroughly 3. Dry hands thoroughly with paper towels and then turn off the faucet with a clean, dry paper towel. 2c. On 11/4/19 at 8:20 a.m., Nurse #73 entered Resident #7's room to administer her morning medications. He had prepared the medications and placed them in a plastic tray. Nurse #73 took the tray into the resident's room and placed it directly on the resident's table. After administering the medications, he returned to the medication cart with the plastic tray. He did not clean the tray. During a follow up interview on 11/04/19 at 9:55 a.m., Nurse #73 stated he didn't usually use the plastic tray with medication pass. He stated he had never been instructed to clean the tray in between use with each resident. During an interview on 11/4/19 at 10:05 a.m., the Clinical Nurse Coordinator stated the staff don't usually use the plastic trays with medication pass. She indicated if the nurses use the trays with medication pass, it should be cleaned in between each resident use with bleach wipes that are available on the medication carts.", "filedate": "2020-09-01"}
{"rowid": 6243, "facility_name": "BRUSHY CREEK REHABILITATION AND HEALTHCARE CENTER,", "facility_id": 425004, "address": "101 COTTAGE CREEK CIRCLE", "city": "GREER", "state": "SC", "zip": 29650, "inspection_date": "2014-09-04", "deficiency_tag": 156, "scope_severity": "C", "complaint": 0, "standard": 1, "eventid": "0BDJ11", "inspection_text": "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.", "filedate": "2018-04-01"}
{"rowid": 6244, "facility_name": "BRUSHY CREEK REHABILITATION AND HEALTHCARE CENTER,", "facility_id": 425004, "address": "101 COTTAGE CREEK CIRCLE", "city": "GREER", "state": "SC", "zip": 29650, "inspection_date": "2014-09-04", "deficiency_tag": 159, "scope_severity": "C", "complaint": 0, "standard": 1, "eventid": "0BDJ11", "inspection_text": "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.", "filedate": "2018-04-01"}
{"rowid": 6245, "facility_name": "BRUSHY CREEK REHABILITATION AND HEALTHCARE CENTER,", "facility_id": 425004, "address": "101 COTTAGE CREEK CIRCLE", "city": "GREER", "state": "SC", "zip": 29650, "inspection_date": "2014-09-04", "deficiency_tag": 160, "scope_severity": "B", "complaint": 0, "standard": 1, "eventid": "0BDJ11", "inspection_text": "**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.", "filedate": "2018-04-01"}
{"rowid": 6246, "facility_name": "BRUSHY CREEK REHABILITATION AND HEALTHCARE CENTER,", "facility_id": 425004, "address": "101 COTTAGE CREEK CIRCLE", "city": "GREER", "state": "SC", "zip": 29650, "inspection_date": "2014-09-04", "deficiency_tag": 226, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "0BDJ11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the facility policy titled Resident Behavior and Facility Practices-Abuse/Neglect and Reasonable Suspicion of a Crime, and interview, the facility failed to implement their abuse policy by not reporting an alleged abuse timely and developing a plan of action to protect Resident #7 from potential harm. 1 of 3 reportable's reviewed for alleged abuse. The findings included: The facility admitted Resident #7 with a [DIAGNOSES REDACTED]. On 09/03/14 at approximately 10:50 AM a review of the 07/07/14 Quarterly Minimum Data Set (MDS) revealed the resident had a Basic Individual Mental Status (BIMS) score of 3, indicating that the resident was severely cognitively impaired. On 09/03/14 at approximately 11:00 AM a review of an investigative report sent to the State Agency by the facility on 06/16/14 revealed three separate occurrences of a visitor allegedly having inappropriate interactions with Resident #7. The first incident reported by Licensed Practical Nurse (LPN) #1 occurred on 06/12/14 stated a visitor had exhibited inappropriate behaviors toward Resident #7, including fondling of the breast and kissing the resident. LPN #1 stated s/he had observed the visitor on two separate occasions (06/12/14 and 06/14/14) in the common area of Dogwood Cottage giving a peck kiss to Resident #7 on the mouth and brushing up against resident's breast with part of his/her hand and arm while hugging resident. LPN #1 stated that on 06/13/14, visitor and wife were sitting to the left side of the common area and Resident #7 was sitting on the right side of the common area. The visitor got up from a chair and wheeled Resident #7 over to where the visitor and wife was sitting. The visitor placed Resident #7 on the right and sat in the middle. The Certified Nursing Assistant (CNA) removed Resident #7 away from the visitor. The investigative report also revealed that LPN #1 had reported the incident to Social Worker #1 and the Nursing Supervisor on 06/12/14. LPN #1 reported the 06/13/14 incident to the Nursing Supervisor and the second shift nurse. Immediately following the initial occurrence, nursing had instructed the staff to ensure that Resident #7 was not within close proximity when the visitor was present. The report revealed that notification of the Social Worker Supervisor did not occur until 06/16/14. Following the notification of the Social Worker Supervisor 06/16/14, a plan was put in place to supervise the visitor and an investigation was initiated. The Police Department was notified and began an investigation. Review of the Nurses Notes dated 06/12/14 at 2:51 PM revealed documentation that stated the social worker was notified of a visitor fondling Resident #7's breasts and kissing her. Nurses Notes dated 06/15/14 at 3:38 PM revealed a late entry by Licensed Practical Nurse (LPN) #1 for 06/14/14 stating: this nurse had placed this elder to the right of the common area. #3 (the visitor) was sitting on left of the common area literally got up from his chair and placed this elder next to him and wife. Nurse came out of the room and removed elder from that space. No further episodes this shift. Nurses Notes written by LPN #1 dated 06/15/14 at 3:43 PM revealed the visitor was sitting to left of the common area. Resident #7 was sitting closer to the fireplace. When this nurse came out of room [ROOM NUMBER], the visitor was hugging the resident and had his right arm across chest fondling elders right breast. Social worker was aware of behavior. Interview with LPN #1 on 09/03/14 at approximately 11:40 AM revealed a different occurrence of the three incidents of alleged abuse by the visitor and Resident #7. LPN #1 stated in the interview that jiggling/ fondling of Resident #7's breast incident 06/12/14 by the visitor might have been the wrong words to use. LPN #1 stated what s/he and the CNA actually saw was the visitor on the right side of Resident #7's wheelchair, had left hand on chair and moved right hand across resident's upper abdomen, gave tight hug and a short peck kiss on the lips. S/he informed the visitor it was inappropriate. There were no other episodes and s/he notified Social Worker #1 and the Nursing Supervisor after the incident. S/he then alerted the staff to watch and keep resident away from the visitor. The second incident on 06/13/14, the visitor moved Resident #7 closer to him/her wife. The CNA intervened and took Resident #7 to the bathroom. The third incident 06/14/14, the visitor got up from the chair, went over to Resident #7, leaned down and touched the resident's arm. The visitor got up and moved to the dining table after seeing LPN #1. During the interview, the surveyor asked LPN #1 had Resident #7's behavior/demeanor changed since the incidents. LPN #1 stated resident's demeanor/behavior did not change and has not changed. On 09/03/14 at approximately 2:20 PM during an interview with SW #1 and s/he verified that LPN #1 did report the incident of 06/12/14 and stated one had observed the visitor on 06/12/14 and 06/13/14 and did not see any inappropriate interaction between the visitor and Resident #7. An interview with CNA # was conducted on 09/03/14 at approximately 3:30 PM. The CNA verified what s/he and LPN #1 actually saw on 06/12/14 and 06/13/14. On 09/03/14 at approximately 4:25 PM, the surveyor that conducted the group meeting had asked 21 residents, from various cottages, including Dogwood Cottage, regarding if they had concerns or saw any abuse or inappropriate actions by visitors, other residents or staff. The surveyor stated all 21 residents had no concerns. Based on review of facility's report, record review, and interviews, the alleged abuse could not be substantiated. The Nursing Supervisor at time of the investigation was not available for interview at the time of the survey. Review of the facility's policy entitled Resident Behavior and Facility Practices-Abuse/Neglect and Reasonable Suspicion of a Crime on 09/03/14 at approximately 1:30 PM revealed that all alleged violations were to be reported to the State Regional Ombudsman, Department of Health and Environmental Control (DHEC) Division of Certification, and DHEC Division of Health Licensing within 24 HRS of the reported allegation of abuse. The policy also revealed in Section 3f regarding Protection of the Resident that the facility procedures included, but were not limited to, removing staff, visitors, volunteers, family members, and others that have abused a resident of the facility until the matter is investigated and resolved. Interview with the Administrator of the facility at the time incident occurred on, 09/04/14 at approximately 10:15 AM, confirmed the incident occurred on 06/12/14 and should have been reported to management and the appropriate State Agency. The Administrator also stated interventions to protect the resident, as per policy, should have been implemented immediately.", "filedate": "2018-04-01"}
{"rowid": 6247, "facility_name": "BRUSHY CREEK REHABILITATION AND HEALTHCARE CENTER,", "facility_id": 425004, "address": "101 COTTAGE CREEK CIRCLE", "city": "GREER", "state": "SC", "zip": 29650, "inspection_date": "2014-09-04", "deficiency_tag": 250, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "0BDJ11", "inspection_text": "Based on facility's investigative report review, facility policy entitled Resident Behavior and Facility Practices-Abuse/Neglect and Reasonable Suspicion of a Crime, and interview, the facility failed to provide appropriate medically-related social services to protect 1 of 3 residents reviewed for abuse/neglect. Resident #7 was not protected from improper interactions by another resident's husband after the initial incident of inappropriate touching occurred. Cross refer to F 226 as it relates to the provision of social services related to an allegation of potential abuse. The findings included: On 09/03/14 at approximately 11:00AM review of the facility's investigative report dated 06/17/14 revealed that on 06/12/14, Licensed Practical Nurse (LPN) #1 had witnessed Resident #3's husband approach Resident #7, lean down and give her/him a peck kiss on the lips. LPN #1 also observed Resident #3's husband go to the right side of Resident #7's wheelchair, bend over towards the resident, place his right hand under her armpit as to hug her, then moved right hand across her chest area jiggling the right breast, stood up and went back to his chair. LPN #1 later notified the Social Worker of the episode. LPN #1 was informed by the Social Worker to chart, keep a watchful eye, and that s/he would figure out how to inform the families. Review of the facility's abuse policy on 09/03/14 at approximately 11:30 AM revealed that procedures to protect the residents included to remove staff, visitors, volunteers, family members and others alleged to have abused a resident from the facility until the matter is investigated and resolved. The policy also stated to report any incidents to the Administrator, the Director of Nurses and the proper authorities immediately. This was not done and two more incidents with the other resident's husband and Resident #7 occurred. During an interview with the Administrator on 09/04/14 at approximately 10:15 AM, s/he confirmed that Social Worker #1 had not followed the facility policy to notify management timely and ensure proper interventions were in place to protect the resident.", "filedate": "2018-04-01"}
{"rowid": 6248, "facility_name": "BRUSHY CREEK REHABILITATION AND HEALTHCARE CENTER,", "facility_id": 425004, "address": "101 COTTAGE CREEK CIRCLE", "city": "GREER", "state": "SC", "zip": 29650, "inspection_date": "2014-09-04", "deficiency_tag": 280, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "0BDJ11", "inspection_text": "Based on record review, and interview, the facility failed to update the comprehensive care plans to reflect the current needs of the residents for 1 of 15 sampled residents reviewed for care plans. Resident #7's care plan did not reflect the alleged incident of sexual abuse and interventions to ensure safety of the resident from another resident's visitor. Cross Refer to F 226 as it relates alleged abuse of Resident #7 and failure of the facility to put interventions in place to protect the resident. The findings included: Review of Resident #7's Care Plan on 09/04/14 at approximately 3:30 PM revealed that the Care Plan was reviewed and revised by the Interdisciplinary Team, including Social Services and Nursing. An allegation of abuse related to inappropriate touching by a visitor was reported on 06/12/14. Resident #7's Care Plan was documented as reviewed before the incident on 04/17/14 and after the incident on 07/15/14. During an interview on 09/04/14 at approximately 3:30 PM with the Minimum Data Set (MDS) Assessment Nurse confirmed that the Care Plan received by the surveyor for Resident #7 was current and was not updated to include specific interventions to protect the resident and prevent recurrence.", "filedate": "2018-04-01"}
{"rowid": 6249, "facility_name": "BRUSHY CREEK REHABILITATION AND HEALTHCARE CENTER,", "facility_id": 425004, "address": "101 COTTAGE CREEK CIRCLE", "city": "GREER", "state": "SC", "zip": 29650, "inspection_date": "2014-09-04", "deficiency_tag": 514, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "0BDJ11", "inspection_text": "Based on review of the facility's investigative report, record review, and interviews the facility failed to provide accurate documentation relating to an alleged abuse of 1 of 3 reportable's reviewed for alleged abuse. Documentation of alleged abuse incidents by another resident's visitor and Resident #7 varied. Conflicting statements in the facility's investigative report made it difficult to make an accurate assessment of the alleged incident. Cross Refer to F 226 as it relates to alleged abuse of Resident #7 and failure of the facility to report timely and put interventions in place to protect the resident. The findings included: On 09/03/14 at approximately 10:50 AM review of the Nurses Notes dated 06/12/14 reflected fondling of Resident #7's breast by another resident's visitor. On 09/03/14 at approximately 11:00 AM review of the facility investigative report reflected a clarification of another resident's visitor brushing up against breast. During an interview with LPN #1 on 09/03/14 at approximately 11:40 AM, s/he stated s/he actually saw another resident's visitor move hand across upper abdomen, hugged and gave a short peck kiss on Resident #7's lips. Statements in the investigative report and Nurse's Notes had conflicting documentation.", "filedate": "2018-04-01"}
{"rowid": 3665, "facility_name": "OPUS POST ACUTE REHABILITATION", "facility_id": 425379, "address": "300 AGAPE DRIVE", "city": "WEST COLUMBIA", "state": "SC", "zip": 29169, "inspection_date": "2017-06-28", "deficiency_tag": 157, "scope_severity": "E", "complaint": 1, "standard": 0, "eventid": "0BFI11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview the facility failed to immediately notify the resident's family of resident's peripheral intravenous central catheter (PICC) line complications or notify physician of medication parameters for 1 of 3 residents reviewed for PICC lines and 1 of 3 residents reviewed for medications. Resident #1 had problems with PICC line being clogged, removed, and or dislodged. No evidence the resident's family was notified of resident changes. Resident #3 was given medication ordered not to give and to notify physician if pulse rate below [AGE]. The findings included: The facility admitted resident #1 with [DIAGNOSES REDACTED]. Review of the medical record revealed Nurses Notes from 2/17/17-3/15/17. Resident received [MEDICATION NAME] and [MEDICATION NAME] via double Lumen PICC line to right upper arm for an infected blood clot in the lung. admitted for short term rehab Alert and oriented x 2 (times 2). Nurses' Notes: 2/22/17 at 5:31 PM Nurse entered room to unhook antibiotic and observed blood up the IV tubing. PICC line would not flush. Medical Doctor (MD) notified, orders to send to emergency room (ER) to replace PICC line. Hospital called and stated they could not get the PICC line replaced tonight but would call with a time in the morning. Hospital placed an IV in left (L) antecubital. MD notified of this. 2/24/17 resident receiving intravenous (IV) antibiotics via PICC. (No documentation of PICC replacement or family notification). 2/26/17 8:23 AM: Nurse in to check on IV antibiotic and noted IV not on pole. Resident had the IV bag in the bed and s/he had clamped the bag her/himself. Patient educated. IV hung for medication to finish so second antibiotic could be hung. (Family Responsible Party (RP) not notified.) 2/28/17 (Two days later) Son called to discuss resident refusing therapy and discharge plans. 3/1/17- Weekly Skill review: Resident noted to have been non-compliant one time during the week with IV antibiotic by clamping off the line. Education completed on benefits vs risk of receiving antibiotics. 3/2/2017 Nurse reported resident had suicidal thoughts, voiced to three staff members. Nurse Practitioner (NP) called. Patient transferred to Baptist Hospital for Evaluation. Returned to facility at 11:46 PM. Resident voiced no [MEDICAL CONDITION]. Resident rested in bed throughout the night. (No documentation RP notified) 3/4/17 Resident received IV antibiotics via INT in right hand. Resident returned from hospital after pulling PICC line out during day shift. Hospital unable to replace PICC due to radiology services not available on weekends, INT placed instead. (No documentation RP notified resident had pulled out PICC line or hospital transfer.) 3/5/17 Resident removed INT to right hand. Resident has had 4 PICC lines placed. Resident follows up with hospital on [DATE] for replacement of PICC line. 3/6/17 Spoke to nurse at Dr.'s office about ordered lab work that was due this morning.Informed nurse that patient had pulled out both PICC line and INT. No access present at this time for antibiotic (ABT) therapy. 3/8/2017 Weekly Skilled Review: Resident went to Dr. who ordered CT scan to determine if s/he still needs antibiotic. Instructed the facility to place resident on [MEDICATION NAME] for [MEDICAL CONDITIONS] discovered in facility today before appointment. 3/9/17 Resident allowed nurse to administer half of her/his ABT via INT access then took them down her/himself and refused the rest of the medication. MD and family notified. 3/10/17 9:00 AM: Patient transported to hospital to get PICC line replaced. INT to left hand pulled. Returned to facility shortly after 2:00 PM. Single Lumen PICC noted to Left forearm. Dressing intact and dry. 2:00 PM [MEDICATION NAME] hung at time of return. Patient noted up at nurse's station 40 minutes later. Patient had removed ABT bag from pole and rolled himself up to the nurses station for a cup of coffee. 3/15/17 at 8:43 PM: Patient had an appointment this morning with Dr. with infectious control. Dr.'s office called stating they were sending the patient to the emergency room . As of 3/15/17 at 8:45 pm. Patient has not returned to OPUS. No update on patient status. In an interview with the surveyor on 6/27/16 at 11:55 AM the Director of Nursing stated S/He kept pulling out PICC line. We did some education with her/him and s/he would be in agreement. We tried to make sure s/he got his antibiotics. We notified her/his family and her/his son tried to talk to her/him about it. Resident #1 repeatedly removed IV access, either PICC line or INT. S/he removed or cut off infusing IV antibiotics. The resident was sent to the hospital on four different occasions due to lack of venous access. There was no evidence the resident's family/RP was notified each time the resident had changes or hospital transfers. Review of Resident #5's Medication Administration Record [REDACTED]. The resident was administered the medication on 5/28/17 at 1700 with a pulse of 55. There was no documentation on the Medication Administration Record [REDACTED]. Review of the Nurses' Notes dated 5/28/17 at 6:36 PM revealed Resident #5's daughter called the nurses' station stating that the resident needed to be transferred out to the emergency department immediately for difficulty breathing. The nurse asked the resident if s/he would like to go to the emergency room like his/her daughter wanted. Resident #5 said no, I'm okay, just needed to sit up. The nurse called the physician and informed him/her of the situation and s/he said it is okay to send the resident out on the basis that the family wanted him/her to go. Review of the resident's Transfer Form dated 5/28/17 revealed the resident was transferred to the hospital related to respiratory distress. In an interview with the surveyor on 6/27/17 at approximately 3:20 PM, the Director of Nursing stated the resident's [MED] should have been held and the physician notified on 5/28/17 when his/her pulse was 55. There was no documentation that the resident's physician was notified per the order.", "filedate": "2020-09-01"}
{"rowid": 3666, "facility_name": "OPUS POST ACUTE REHABILITATION", "facility_id": 425379, "address": "300 AGAPE DRIVE", "city": "WEST COLUMBIA", "state": "SC", "zip": 29169, "inspection_date": "2017-06-28", "deficiency_tag": 279, "scope_severity": "D", "complaint": 1, "standard": 0, "eventid": "0BFI11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of the medical record and interview, the facility failed to develop a comprehensive care plan for each resident. Resident #5's care plan was not accurate related to the resident's condition related to skin integrity. One of seven residents reviewed for care plans. The findings included: Review of Resident #5's Admission Nursing assessment dated [DATE] revealed the resident had a right foot diabetic ulcer 4.5 x 6, and left foot diabetic ulcers 6 x 5.2 (anterior) and 4.8 x 5.2 (posterior). Review of the resident's Admission Care Plan revealed no documentation related to the resident having skin issues. Review of Resident #5's Comprehensive Care Plan indicated the resident had a diabetic ulcer to the left foot, the care plan did not include the diabetic ulcer to the right foot. In an interview with the surveyor on 6/27/17 at approximately 4:00 PM, the Director of Nursing confirmed that the resident's care plan was not accurate since it did not include that the resident had a [MEDICAL CONDITION] on his/her right foot.", "filedate": "2020-09-01"}
{"rowid": 3667, "facility_name": "OPUS POST ACUTE REHABILITATION", "facility_id": 425379, "address": "300 AGAPE DRIVE", "city": "WEST COLUMBIA", "state": "SC", "zip": 29169, "inspection_date": "2017-06-28", "deficiency_tag": 281, "scope_severity": "D", "complaint": 1, "standard": 0, "eventid": "0BFI11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to ensure services provided by the facility meet professional standards of quality. Resident #5 did not receive treatment timely for diabetic ulcers on his/her feet that were noted upon admission to the facility. Resident #5 was also noted to have a reddened area to the sacrum that was not addressed by nursing. One of ten residents reviewed for professional standards. The findings included: Review of Resident #5's medical record revealed the Admission Nursing assessment dated [DATE] indicated the resident had a right foot diabetic ulcer 4.5 x 6, and left foot diabetic ulcers 6 x 5.2 (anterior) and 4.8 x 5.2 (posterior). Review of the resident's Medication Administration Record [REDACTED]. Cover with ABD pad and secure with [MED] daily. Every day shift for diabetic ulcer. The order date was 5/24/17 at 1959 and was started on 5/25/17 per documentation on the MAR. There was also an order [REDACTED]. Every day shift with an order date of 5/24/17 at 2000. The order was first signed as administered on 5/25/17. Review of the Occupational Therapy Treatment Encounter Note dated 5/26/17 noted the resident had a red area on buttocks/sacrum and nursing was notified. The note indicated nursing was notified and observed the red area on Resident #5. Review of Resident #5's Nurses' Notes revealed no documentation related to the red area. Review of the resident's electronic medical record revealed there was no nursing documentation on 5/26/17. In an interview with the surveyor on 6/27/17 at approximately 3:20 PM, the Director of Nursing (DON) stated s/he would expect them to start treatment on Resident #5's ulcers to his/her feet when s/he was admitted . The Director of Nursing was not sure why treatment wasn't started until 5/25/17 and stated s/he would check with the wound care nurse. The DON stated that the nurse who observed the red area to the resident's sacrum when notified by the occupational therapist on 5/26/17 should have documented on the area. The DON stated the nurse may not have notified the MD because they have standing orders for red areas. The DON stated that if the standing order was initiated, it should have been documented in the medical record. In an interview with the surveyor on 6/27/17 at approximately 4:00 PM, the DON stated the wound care nurse was not sure why treatment was not started sooner for the diabetic ulcers on Resident #5's feet. In an interview with the surveyor on 6/27/17 at approximately 4:05 PM, the Assistant DON/wound care nurse stated s/he was not sure what happened with the order for Resident #5's diabetic ulcers. The ADON/wound care nurse stated s/he usually gets to the residents right away and it must have been a mistake. The ADON/wound care nurse stated s/he did see the areas on Resident #5's feet the day s/he was admitted , but did not order treatment that day. The ADON/wound care nurse was not sure why, and stated it was an error on his/her part. The ADON/wound care nurse stated s/he was never informed about a red area to the resident's sacrum. In an interview with the surveyor on 6/28/17 at approximately 11:05 AM, the DON stated that s/he goes back through the admission assessment and signs off on it. When s/he reviews the admission assessments, she will usually go back and verify that orders that need to be put in place are there. The DON stated s/he did not realize that there were no treatment orders for Resident #5's diabetic ulcers and stated s/he was not sure how s/he missed.", "filedate": "2020-09-01"}
{"rowid": 3668, "facility_name": "OPUS POST ACUTE REHABILITATION", "facility_id": 425379, "address": "300 AGAPE DRIVE", "city": "WEST COLUMBIA", "state": "SC", "zip": 29169, "inspection_date": "2017-06-28", "deficiency_tag": 309, "scope_severity": "D", "complaint": 1, "standard": 0, "eventid": "0BFI11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to ensure each resident received treatment and care in accordance with professional standards of practice. Resident #5 did not receive treatment timely for diabetic ulcers on his/her feet that were noted upon admission to the facility. Resident #5 was also noted to have a reddened area to the sacrum that was not addressed by nursing. One of ten residents reviewed for quality of care. The findings included: Review of Resident #5's medical record revealed the Admission Nursing assessment dated [DATE] indicated the resident had a right foot diabetic ulcer 4.5 x 6, and left foot diabetic ulcers 6 x 5.2 (anterior) and 4.8 x 5.2 (posterior). Review of the resident's Medication Administration Record [REDACTED]. Cover with ABD pad and secure with [MED] daily. Every day shift for diabetic ulcer. The order date was 5/24/17 at 1959 and was started on 5/25/17 per documentation on the MAR. There was also an order [REDACTED]. Every day shift with an order date of 5/24/17 at 2000. The order was first signed as administered on 5/25/17. Review of the Occupational Therapy Treatment Encounter Note dated 5/26/17 noted the resident had a red area on buttocks/sacrum and nursing was notified. The note indicated nursing was notified and observed the red area on Resident #5. Review of Resident #5's Nurses' Notes revealed no documentation related to the red area. Review of the resident's electronic medical record revealed there was no nursing documentation on 5/26/17. In an interview with the surveyor on 6/27/17 at approximately 3:20 PM, the Director of Nursing (DON) stated s/he would expect them to start treatment on Resident #5's ulcers to his/her feet when s/he was admitted . The Director of Nursing was not sure why treatment wasn't started until 5/25/17 and stated s/he would check with the wound care nurse. The DON stated that the nurse who observed the red area to the resident's sacrum when notified by the occupational therapist on 5/26/17 should have documented on the area. The DON stated the nurse may not have notified the MD because they have standing orders for red areas. The DON stated that if the standing order was initiated, it should have been documented in the medical record. In an interview with the surveyor on 6/27/17 at approximately 4:00 PM, the DON stated the wound care nurse was not sure why treatment was not started sooner for the diabetic ulcers on Resident #5's feet. In an interview with the surveyor on 6/27/17 at approximately 4:05 PM, the Assistant DON/wound care nurse stated s/he was not sure what happened with the order for Resident #5's diabetic ulcers. The ADON/wound care nurse stated s/he usually gets to the residents right away and it must have been a mistake. The ADON/wound care nurse stated s/he did see the areas on Resident #5's feet the day s/he was admitted , but did not order treatment that day. The ADON/wound care nurse was not sure why, and stated it was an error on his/her part. The ADON/wound care nurse stated s/he was never informed about a red area to the resident's sacrum. In an interview with the surveyor on 6/28/17 at approximately 11:05 AM, the DON stated that s/he goes back through the admission assessment and signs off on it. When s/he reviews the admission assessments, she will usually go back and verify that orders that need to be put in place are there. The DON stated s/he did not realize that there were no treatment orders for Resident #5's diabetic ulcers and stated s/he was not sure how s/he missed.", "filedate": "2020-09-01"}
{"rowid": 3669, "facility_name": "OPUS POST ACUTE REHABILITATION", "facility_id": 425379, "address": "300 AGAPE DRIVE", "city": "WEST COLUMBIA", "state": "SC", "zip": 29169, "inspection_date": "2017-06-28", "deficiency_tag": 323, "scope_severity": "G", "complaint": 1, "standard": 0, "eventid": "0BFI11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to provide supervision to resident #1, who repeatedly interfered with intravenous access, causing repeated visits to the emergency room for intervention. 1 of 3 residents reviewed for a peripheral intravenous central catheter (PICC) line use. The findings included: Cross refer to F157, Notification of resident pulling out PICC line, INT's, removal/discontinuing IV (intravenous) antibiotics. The facility admitted resident #1 with [DIAGNOSES REDACTED]. Review of the medical record revealed Nurses Notes from 2/17/17-3/15/17. Resident received [MED] and [MED] via double Lumen PICC line to right upper arm for an infected blood clot in the lung. Review of the Nurses Notes revealed: 2/22/17: PICC would not flush. Hospital placed an IV in left antecubital so resident could receive antibiotic. 2/26/17: Upon walking in the room to check on patient IV bag noted IV not on pole. IV bag in the bed with resident almost completely full. Patient clamped the PICC line her/himself to prevent the medication form running probably. 3/4/17: Resident returned from hospital after pulling out PICC line during day shift. Hospital placed INT 3/5/17: Resident has had 4 PICC lines placed. 3/6/17: Resident is experiencing some behavioral disturbance related to dementia and non-compliance with medication regimen including antibiotic administration via iv/picc. Resident pulled PICC line out on 3/4/17 and went out to hospital to have it replaced. Hospital was unable to replace line due to radiology being unavailable. Hospital placed a INT in right hand to administer medications until Monday. On 3/5/17 resident pulled INT out and nurse was unable to establish a new line. Resident has been educated on need for ABX (antibiotic) and continues to be non-compliant at times. No access present at this time for antibiotic therapy. 3/9/17: Resident allowed nurse to administer half the antibiotic via int access then took them down her/himself. Resident has been educated several times. In an interview with the surveyor on 6/27/16 at 11:55 AM the Director of Nursing stated s/he kept pulling out her/his PICC line. We did some education and s/he would be in agreement. We tried to make sure s/he got her/his antibiotics. We notified his family and his son tried to talk to him about it.", "filedate": "2020-09-01"}
{"rowid": 3670, "facility_name": "OPUS POST ACUTE REHABILITATION", "facility_id": 425379, "address": "300 AGAPE DRIVE", "city": "WEST COLUMBIA", "state": "SC", "zip": 29169, "inspection_date": "2017-06-28", "deficiency_tag": 333, "scope_severity": "D", "complaint": 1, "standard": 0, "eventid": "0BFI11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to ensure residents were free of any significant medication errors. Resident #5 was administered medication when there was a physician's orders [REDACTED]. The findings included: Review of Resident #5's Medication Administration Record [REDACTED]. The medication was signed as administered on 5/28/17 at 1700, the resident was documented with a pulse of 55 on the Medication Administration Record. Review of the Nurses' Notes dated 5/28/17 at 6:36 PM revealed Resident #5's daughter called the nurses' station stating that the resident needed to be transferred out to the emergency department immediately for difficulty breathing. The nurse asked the resident if s/he would like to go to the emergency room like his/her daughter wanted. Resident #5 said no, I'm okay, just needed to sit up. The nurse called the physician and informed him/her of the situation and s/he said it is okay to send the resident out on the basis that the family wanted him/her to go. Review of the resident's Transfer Form dated 5/28/17 revealed the resident was transferred to the hospital related to respiratory distress. In an interview with the surveyor on 6/27/17 at approximately 3:20 PM, the Director of Nursing stated the resident's [MED] should have been held and the physician notified on 5/28/17 when his/her pulse was 55. There was no documentation that the resident's physician was notified per the order.", "filedate": "2020-09-01"}
{"rowid": 3671, "facility_name": "OPUS POST ACUTE REHABILITATION", "facility_id": 425379, "address": "300 AGAPE DRIVE", "city": "WEST COLUMBIA", "state": "SC", "zip": 29169, "inspection_date": "2017-06-28", "deficiency_tag": 514, "scope_severity": "E", "complaint": 1, "standard": 0, "eventid": "0BFI11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to maintain complete and/or accurate medical records for 2 of 3 residents reviewed for falls. Resident #2 and #6 had sustained falls at the facility. Each resident had a fall that was not documented in the medical records. The findings included: The facility admitted resident #2 with [DIAGNOSES REDACTED]. Review of the Interdisciplinary Team (IDT) Progress Notes from 3/16/17 through 4/3/17. No documentation that resident had any falls or injuries. Review of the facility incident reports revealed the resident had a fall on 4/3/17. Review of Physician's Progress Notes revealed 3/20/17: Skin Inspection and Palpitation: No rash or [MEDICAL CONDITION], 3/27/17: Inspection and Palpitation: No rash or [MEDICAL CONDITION]. 3/29/17: No notes related to skin or injuries. 4/3/17: Inspection and Palpitation. No rash or [MEDICAL CONDITION]. Review of the facility's Incident Reports revealed an incident report for resident #2 for a fall on 4/3/17. This nurse suspects that resident got up out of bed and lost her/his balance. S/He leaned against the wall to break her/his fall and slid down. As s/he was doing so her/his right leg went underneath the bed resulting in an abrasion to right shin. The facility admitted resident #6 with [DIAGNOSES REDACTED]. Review of the Care plan revealed the resident was at risk for falls related to gait/balance problems. The care plan had been updated for a fall in 2/8/17 getting out of bed and obtained a skin tear to right elbow. 2/15/17 fall getting out of bed obtained a skin tear to left forearm. Fall 2/17/16, fell out of bed (oob) when trying to pull light cord at bedside. Abrasion to scalp and both knees. Interventions included, Attempt to toilet before assisting to bed, attach bed light cord to siderail for easy access. Review of the IDT Progress Notes from 1/8/17 through 6/23/17 revealed the resident had a fall on 2/8/17 and 2/17/16. There was no documentation the resident had a fall on 2/15/17. Review of the facility's Incident Report's revealed on 2/15/17 the resident had a fall with injuries. This nurse heard loud crash and ran to patient's room to find resident sitting on floor with wheelchair turned over. Patient stated s/he was alright. Noted skin tear to left forearm and left hand. Suspected resident tried to transfer self from bed to chair to go to the restroom.", "filedate": "2020-09-01"}
{"rowid": 6250, "facility_name": "SALUDA NURSING CENTER", "facility_id": 425081, "address": "581 NEWBERRY HIGHWAY", "city": "SALUDA", "state": "SC", "zip": 29138, "inspection_date": "2014-04-30", "deficiency_tag": 257, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "0D6111", "inspection_text": "On the days of the survey based on Group Interview and observations, the facility failed to provide a comfortable temperature level for the shower room on 1 of 4 Units. During Group Interview on 4/29/2014, 3 of 20 residents expressed concerns about shower room temperatures being too cold. Two of the complainants resided on the Riley Unit, one on the Wise Unit. The Riley Unit temperatures were verified as being below 70 degrees with no independent or alternate heat source to accommodate residents' needs. The findings included: On 4/29/2014 at approximately 10:00 AM, the Group Interview was conducted with twenty residents in attendance. Three of 20 residents had concerns about the room temperature being too cold in the shower room. Resident R stated, The shower room is too cold on the Wise Unit. Resident Y and Resident S stated that the shower room was too cold on the Riley Unit. Resident S further stated that s/he was scheduled for a shower weekly, but I told the CNA (Certified Nursing Assistant ) it was too cold when s/he came to get me for the shower. I don't take a shower anymore because of the temperature in the shower room being too cold. Resident S was asked by the surveyor if the facility was aware of her/his concern. Resident S stated, I told the CNA. During an interview with the Director of Nurses (DON) and Administrator on 4/30/2014 at approximately 8:30 AM, the DON stated that the facility kept no grievance file, They just fixed it when a complaint was voiced. The Administrator stated s/he was unaware of a problem on Riley Unit and The CNA should have told the supervisor. During an interview with the Maintenance Supervisor on 4/30/2014 at approximately 8:35 am, s/he produced the documentation that s/he repaired the shower room temperature on the Wise Unit on 2/14/14. S/he was not aware of the ongoing problem with the Riley Unit shower room temperature until told by the Administrator after discussion with the surveyor. The room temperatures were checked on the Wise and Riley Units on 04/30/14 because residents, in individual and group interviews, expressed concern that the shower rooms were too cold to take their showers. At approximately 9:35 AM, the surveyor checked the temperatures in the shower rooms on the Wise Unit and they were 73 Fahrenheit (F) and 70 F degrees. At approximately 9:40 AM, the surveyor checked the temperature in the Riley West side shower room and it was 68.1 F. The temperature reading in the Riley East side shower room was 63.9 F in the bathroom area and 61.8 F by the tub area. Temperature checks were done on the other units by the surveyor and they were above 70 F or had an ancillary heat service in the showers. During an interview with the Maintenance Director on 04/30/14 at approximately 11:45 am, the Surveyor asked how often were temperatures checked on the units and shower rooms. The Maintenance Director stated daily. The Surveyor asked the Maintenance Director if a temperature check log was kept and the reply was no. At approximately 12 PM, the Maintenance Director checked the temperatures, with the surveyor, and verified that the Riley West side shower was 67.1 F degrees and the Riley East shower room was 62.5 F degrees. The Maintenance Director also confirmed that the temperature levels were too cold and should range above 70 F degrees for comfort level.", "filedate": "2018-04-01"}
{"rowid": 6251, "facility_name": "SALUDA NURSING CENTER", "facility_id": 425081, "address": "581 NEWBERRY HIGHWAY", "city": "SALUDA", "state": "SC", "zip": 29138, "inspection_date": "2014-04-30", "deficiency_tag": 274, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "0D6111", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification Survey, based on record reviews, interviews, and review of CMS's (Centers for Medicare & Medicaid Services) RAI (Resident Assessment Instrument) Version 3.0 Manual, the facility failed to conduct a Significant Change in Status Assessment after an improvement in 2 areas of ADL assistance was newly coded as 0, 1, or 2 when previously scored as a 3, 4, or 8 for Residents # 7, 1 of 3 residents reviewed for a significant change in status. The findings included: The facility admitted Resident #7 with [DIAGNOSES REDACTED]. On 4/29/14 at 11:30 AM, review of the Admission MDS (Minimal Data Set) dated 5/27/13 revealed Resident # 7 was coded as being total dependence with locomotion on and off the unit and for eating. Comparison to the Quarterly MDS dated [DATE] indicated the resident had improved and was coded as limited assistance for locomotion on and off the unit and for eating. Further review revealed the improvement had occurred between an 8/22/13 Quarterly MDS which coded the resident as extensive assistance for both areas and a 11/11/13 Quarterly MDS which newly coded the resident as limited assistance in both areas. During an interview on 4/29/14 at 11:35 AM, Registered Nurse #4 confirmed the MDS documentation on 11/11/13 indicated improvement in locomotion and eating and verified that a Significant Change in Status Assessment should have been conducted. A review of CMS's RAI Version 3.0 Manual, Chapter 2, page 2-20 revealed The SCSA (Significant Change in Status Assessment) is a comprehensive assessment for a resident that must be completed when the IDT (Interdisciplinary Team) has determined that a resident meets the significant change guidelines for either improvement or decline. The manual further described the guidelines for a SCSA including A SCSA is appropriate when: There is a determination that a significant change (either improvement or decline) in a resident's condition from his/her baseline has occurred as indicated by comparison of the resident's current status to the most recent comprehensive assessment and any subsequent Quarterly assessments . In addition, the manual indicated, page 2-24, a SCSA would be appropriate for Any improvement in two or more of the following: any improvement in an ADL (Activity of Daily Living) physical functioning area where a resident is newly coded as Independent, Supervision, or Limited assistance since last assessment .", "filedate": "2018-04-01"}
{"rowid": 6252, "facility_name": "SALUDA NURSING CENTER", "facility_id": 425081, "address": "581 NEWBERRY HIGHWAY", "city": "SALUDA", "state": "SC", "zip": 29138, "inspection_date": "2014-04-30", "deficiency_tag": 279, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "0D6111", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification Survey, based on record review and interview, the facility failed to develop measurable goals and timetable for problems identified for Resident #5, 1 of 14 residents reviewed for care plans. There were 3 identified problems, Potential for alteration in skin integrity, Potential for decreased vision, and Alteration in comfort that had no measurable objectives. In addition, there was no identified problem or goal for the resident's current pressure ulcer. The findings included: The facility admitted Resident #5 with current [DIAGNOSES REDACTED]. On 4/29/14 at 10:55 AM, review of the resident's care plan dated 1/27/14 revealed Problems of Self care deficit, Potential for alteration in skin integrity, Potential for decreased vision, and Alteration in comfort with one goal identified that the resident would perform self care within physical limitation and all personal care needs would be met by 4/25/14. No other objectives were listed. Included in the interventions were the treatments and preventative measures for the pressure ulcer on the resident's heel but there was no identified problem and no goal was developed. During an interview on 4/30/14 at 10:18 AM, Registered Nurse (RN) #4 confirmed that there were 4 problems listed together on the care plan. The RN further confirmed there were no measurable goals listed for 3 of the problems listed. The RN further confirmed there was no identified problem or goal for the resident's current pressure ulcer.", "filedate": "2018-04-01"}
{"rowid": 6253, "facility_name": "SALUDA NURSING CENTER", "facility_id": 425081, "address": "581 NEWBERRY HIGHWAY", "city": "SALUDA", "state": "SC", "zip": 29138, "inspection_date": "2014-04-30", "deficiency_tag": 282, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "0D6111", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification Survey, based on record review and interview, the facility failed to follow the comprehensive care plan for Resident #5, 1 of 14 residents reviewed for care plans. The care plan included an intervention for an easy release seatbelt in the wheelchair for positioning and fluid restriction of 1200 cc (cubic centimeters) per day. The findings included: The facility admitted Resident #5 with current [DIAGNOSES REDACTED]. Record review on 4/29/14 at 9:28 AM, revealed physician orders [REDACTED]. On 4/29/14 at 10:55 AM, review of the resident's care plan dated 1/27/14 revealed a care plan for Self care deficit that included an intervention for an easy release seatbelt in the wheelchair for positioning. During 3 days of the survey, observations of the resident revealed no seatbelt in the wheelchair. Further review also revealed a care plan problem for Alteration of Nutrition/ Hydration and included Fluid restriction 500 cc 1st (shift) 300 cc 2nd (shift) 400 cc 3rd shift. At 9:28 AM on 4/30/14, record review of the Intake and Output Record revealed the resident's fluid intake was greater than 1200 cc on 26 of 29 days in April, 28 of 31 days in March and 27 of 28 days in February. During an interview at 10:18 AM on 4/30/14, RN #4 confirmed Resident #5's fluid intake was greater than 1200 cc on most days. The RN further verified that s/he had not received any reports that the resident was non-compliant with the fluid restriction. During an interview on 4/30/14 at 9:20 AM, RN #5 confirmed there was no seatbelt in the resident's wheel chair. The RN also confirmed the seatbelt was not in the resident's room. During an interview on 4/30/14 at approximately 4:00 PM, CNA (Certified Nursing Assistant) # 2 and #3 stated they did not know the last time the resident had a seatbelt in his/her wheel chair because the resident was usually in bed during the second shift.", "filedate": "2018-04-01"}
{"rowid": 6254, "facility_name": "SALUDA NURSING CENTER", "facility_id": 425081, "address": "581 NEWBERRY HIGHWAY", "city": "SALUDA", "state": "SC", "zip": 29138, "inspection_date": "2014-04-30", "deficiency_tag": 309, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "0D6111", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification Survey, based on record review and interview, the facility failed to follow physician orders [REDACTED].#5, (1 of 1 resident reviewed for [MEDICAL TREATMENT] and 1 of 1 resident reviewed with a fracture.) The facility did not comply with a physician's orders [REDACTED].# 4 physician's orders [REDACTED]. (1 of 3 sampled resident's reviewed with orders not followed related to the use of pressure relieving boots.) The findings included: The facility admitted Resident #5 with current [DIAGNOSES REDACTED]. On 4/29/14 at 2:17 PM, review of the monthly physician orders [REDACTED]. On 4/30/14 at 9:28 AM, review of the facility I & O sheet(s) revealed the resident's intake was greater than 1200 ml on 26 of 29 days in April, 28 of 31 days in March and 27 of 28 days in February. Review of the Medication Administration Record [REDACTED]. There was no documentation in the Nurse's Notes or in the [MEDICAL TREATMENT] Communications that the [MEDICAL TREATMENT] provider had been informed of the excess fluid intake. Further review of the record at 9:28 AM on 4/30/14 revealed a note by the dietician related to communicating with the [MEDICAL TREATMENT] dietician concerning the resident's nutrition and elevated potassium level but there was no mention of the excess fluid intake. The care plan stated the resident was non-compliant, at times with the restriction. There was no documentation in the nurses notes of the resident's non- compliance, or of notification to the physician or the [MEDICAL TREATMENT] provider of non-compliance. The care plan indicated nurses having problems (with) fluid restrictions (with) res(ident's) meds (medications). The care plan further indicated a change had been made to the resident's medication regimen to adhere to fluid restrictions. During an interview on 4/30/14 at 10:18 AM, Registered Nurse (RN) #4 confirmed the resident's daily intake was usually greater than 1200 ml per day. The RN further confirmed the medication had been changed to aid with complying with the restriction. RN #4 also confirmed s/he had not received any reports of the resident being non- compliant. Two meal observations were made during the survey, on 4/29/14 at 1:15 PM and 4/30/14 at 12:30 PM, that revealed Resident #5 received 360 ml of fluid with his lunch tray. Review of the MAR indicated [REDACTED]. There was no documentation that this was communicated to the physician or to the [MEDICAL TREATMENT] center. The [MEDICAL TREATMENT] Monthly Nutrition Report Card dated 1/14/14 revealed Average Fluid Gain and indicated Needs Improvement. On 4/30/14 at approximately 9:20 AM, nurses were overheard discussing a fracture Resident #5 had sustained. Review of the current medical record had not revealed the results of an x-ray indicating the resident had a fracture. A copy of the incident report was requested and provided by the Director of Nursing (DON). Review of the incident report revealed a fax to the physician dated 4/24/13 that Resident #5 was complaining of L(eft) leg/ ankle pain at [MEDICAL TREATMENT]. (also on 3rd shift last night). Dr. at [MEDICAL TREATMENT] assessed the ankle and sent a note to you regarding his thoughts. Ankle is swollen and warm to touch. Resident states it hurts when (s/he) stands on it. On the bottom of the fax, the physician had written: ORDER: 4/25/13 Agree I saw this earlier & (and) it seems by exam to intensified Obtain x-ray ankle, Venous flow for [MEDICAL CONDITIONS]. The fax stamp indicated the order was faxed to the facility on [DATE] at 15:23 (3:23 PM). Further review revealed the x-ray was not performed until 5/6/13 which indicated Recent bimalleolar fracture left ankle with slight subluxation anteriorly of the tibia on the talus. At 11:19 AM on 4/30/14, the DON confirmed the physicians order was dated 4/25/13 and that the x-ray was not obtained until 5/6/13. The DON was unable to explain why the x-ray was not done until 5/6/13 but further stated that when the order was discovered, the nurse immediately obtained the x-ray and and an incident report was completed. The facility admitted Resident #4 with [DIAGNOSES REDACTED]. Record Review of the physician's orders [REDACTED].#4 on 4/28/2014 at 2:40 PM and on 4/29/2014 at 9:02 AM, 10:55 AM and 12:25 PM revealed the resident was not wearing the Bunny Boot as ordered. On 4/29/2014 at 3:38 PM, Registered Nurse #3 verified Resident #4 was not wearing the device as ordered by the physician.", "filedate": "2018-04-01"}
{"rowid": 6255, "facility_name": "SALUDA NURSING CENTER", "facility_id": 425081, "address": "581 NEWBERRY HIGHWAY", "city": "SALUDA", "state": "SC", "zip": 29138, "inspection_date": "2014-04-30", "deficiency_tag": 367, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "0D6111", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification Survey, based on record review, observations and interviews, the facility failed to provide the therapeutic diet, NAS (no added salt), as ordered to Resident #12, 1 of 5 residents reviewed prescribed a therapeutic diet. The findings included: The facility admitted Resident #12 on 4/25/14 with [DIAGNOSES REDACTED]. On 4/28/14 at 2:25 PM, record review of a Dietary screening dated 4/28/14 revealed the resident was on a regular consistency, NAS diet. The resident was identified as alert and orientated. An individual interview was conducted on 4/29/14 and during the interview, the resident stated s/he had no restrictions on his/her diet. On 4/29/14 at 12:35 PM, Resident #12 was observed eating lunch. The resident's lunch tray included a salt packet which the resident confirmed s/he had used. On 4/30/14 at 12:55 PM, Resident #12's lunch tray was observed which again included a salt packet. The salt packet was open and the resident confirmed s/he had used the salt. During an interview on 4/30/14 at approximately 3:45 PM, Resident #12 stated salt is usually included on the lunch and dinner trays but not on the breakfast trays. The resident further stated s/he didn't always use it, but it depended on what was served. Resident #12 further stated that all s/he was told was that s/he was on a regular diet.", "filedate": "2018-04-01"}
{"rowid": 845, "facility_name": "SUNNY ACRES NURSING HOME", "facility_id": 425093, "address": "1727 BUCK SWAMP ROAD", "city": "FORK", "state": "SC", "zip": 29543, "inspection_date": "2019-11-15", "deficiency_tag": 644, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "0DHL11", "inspection_text": "**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.", "filedate": "2020-09-01"}
{"rowid": 846, "facility_name": "SUNNY ACRES NURSING HOME", "facility_id": 425093, "address": "1727 BUCK SWAMP ROAD", "city": "FORK", "state": "SC", "zip": 29543, "inspection_date": "2019-11-15", "deficiency_tag": 646, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "0DHL11", "inspection_text": "**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].", "filedate": "2020-09-01"}
{"rowid": 847, "facility_name": "SUNNY ACRES NURSING HOME", "facility_id": 425093, "address": "1727 BUCK SWAMP ROAD", "city": "FORK", "state": "SC", "zip": 29543, "inspection_date": "2019-11-15", "deficiency_tag": 693, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "0DHL11", "inspection_text": "**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.", "filedate": "2020-09-01"}
{"rowid": 273, "facility_name": "MAGNOLIA MANOR - INMAN", "facility_id": 425032, "address": "63 BLACKSTOCK ROAD", "city": "INMAN", "state": "SC", "zip": 29349, "inspection_date": "2018-12-20", "deficiency_tag": 574, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "0G2K11", "inspection_text": "Based on interview and record review, the facility failed to ensure The Resident Council was aware of how to file a complaint with the South [NAME]ina State Survey Agency for 1 of 1 Resident Council meetings. The findings included: During the Resident Council Group Meeting held 12/17/2018 at 2:20 pm the residents stated they did not receive information and did not know how to file a complaint with the state survey agency. Record review revealed the majority of residents in attendance were long term residents who had resided in the facility for several months/years. Review of Resident Council meetings revealed no information to suggest information related to how to file a complaint/grievance had been discussed with residents. Interview with the Administrator on 12/17/2018 at approximately 4:30 pm revealed residents are provided this information upon admission. Further interview revealed residents are not provided this information after admission.", "filedate": "2020-09-01"}
{"rowid": 274, "facility_name": "MAGNOLIA MANOR - INMAN", "facility_id": 425032, "address": "63 BLACKSTOCK ROAD", "city": "INMAN", "state": "SC", "zip": 29349, "inspection_date": "2018-12-20", "deficiency_tag": 577, "scope_severity": "E", "complaint": 1, "standard": 1, "eventid": "0G2K11", "inspection_text": "> Based on observation and interview, the facility failed to ensure the results of the most recent survey were accessible and readily available to residents without having to ask for assistance to examine the report for 5 of 5 residents in Resident Council. The findings included: During the Resident Council Group Meeting held on 12/17/2018 at 2:20 pm the residents stated they did not know where the latest state survey inspection report results were located. All residents in attendance stated they had never reviewed the survey inspection results and did not know where they were located. Observations during the days of the survey revealed a binder hanging on the entry wall with survey results written on the front. Further review revealed the writing was facing the wall and not facing the direction in which residents would be able to read it. Continued observation revealed there was no signage on any of the three Nursing Units to indicate the location of the survey inspection results. Interview with the Administrator on 12/17/2018 at approximately 4:30 pm verified that survey inspection reports were located in a binder hanging on the entry wall only.", "filedate": "2020-09-01"}
{"rowid": 275, "facility_name": "MAGNOLIA MANOR - INMAN", "facility_id": 425032, "address": "63 BLACKSTOCK ROAD", "city": "INMAN", "state": "SC", "zip": 29349, "inspection_date": "2018-12-20", "deficiency_tag": 600, "scope_severity": "G", "complaint": 1, "standard": 0, "eventid": "0G2K11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, an incorrect method of providing mobility for Resident #7 resulted in injury for 1 of 3 reportable's reviewed for falls. The findings included: The facility admitted Resident #7 with [DIAGNOSES REDACTED]. The resident had a BIMS (Brief Interview for Mental Status) of 15 denoting ability to make own decisions. The Minimum Data Set (MDS) documented that this resident was a total care resident needing total lift with 2 person assist for mobility and transfers. The Physicians Order read: 2 Certified Nursing Assistant (CNA) Hoyer Lift. On 10/14/18 resident was seated in a gerichair. The CNA proceeded to try to transfer the resident from the gerichair to the bed by herself. While lifting resident in gerichair to place lift pad under the resident, the resident slipped and fell to the floor. The CNA later stated the resident slipped and resident was eased down to the floor. The resident stated in an interview on 12/20/18 at 8 AM that the (staff) dropped her. Licensed Practical Nurse (LPN) # 5 assessed the resident after the fall and in his/her opinion did not see any injury. The Physician was notified and stated, Let the Nurse Practitioner (NP) check the resident in the morning. The resident asked to go to the hospital. The resident continued to complain and asked for his/her leg to be X-rayed. The Nurse told the resident s/he could not call for an X-Ray. In a late entry on 10/16/18 at 1 AM clarification note, the Nurse told the resident s/he could not order an X-Ray without calling the doctor, but the resident could send himself/herself out. The Nurse told the resident to let his/her meds take effect and see the NP in the morning. The family called Emergency Medical Services (EMS) to do a welfare check. EMS came to facility and assessed the resident. EMS wanted to take him/her to the emergency room (ER), but the resident refused. They called a doctor at the ER to see what to do. Since the resident refused, the ER doctor advised them to leave him/her at the facility. There was no documentation of the NP checking the resident. The resident went to [MEDICAL TREATMENT] on 10/15/18 and was transferred to the hospital from there. A scan was done and the resident was found to have a fractured right ankle. The resident was treated and returned to the facility on [DATE] with a splint to the right foot and leg. Five CNA's were interviewed about care of residents with a fall risk and transfers. All of the CNA's knew to look in the resident profile in the kiosk for instructions on how to lift residents and the number of staff needed. The Physician was interviewed via telephone twice on 12/20/18. At 7:45 AM, the Physician could not remember anything about the incident, except the nurse did call him. About 8:15 AM, the Physician called back and made a statement corresponding to the information given by the facility related to the incident.", "filedate": "2020-09-01"}
{"rowid": 276, "facility_name": "MAGNOLIA MANOR - INMAN", "facility_id": 425032, "address": "63 BLACKSTOCK ROAD", "city": "INMAN", "state": "SC", "zip": 29349, "inspection_date": "2018-12-20", "deficiency_tag": 607, "scope_severity": "D", "complaint": 1, "standard": 0, "eventid": "0G2K11", "inspection_text": "**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.", "filedate": "2020-09-01"}
{"rowid": 277, "facility_name": "MAGNOLIA MANOR - INMAN", "facility_id": 425032, "address": "63 BLACKSTOCK ROAD", "city": "INMAN", "state": "SC", "zip": 29349, "inspection_date": "2018-12-20", "deficiency_tag": 610, "scope_severity": "D", "complaint": 1, "standard": 0, "eventid": "0G2K11", "inspection_text": "**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.", "filedate": "2020-09-01"}
{"rowid": 278, "facility_name": "MAGNOLIA MANOR - INMAN", "facility_id": 425032, "address": "63 BLACKSTOCK ROAD", "city": "INMAN", "state": "SC", "zip": 29349, "inspection_date": "2018-12-20", "deficiency_tag": 655, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "0G2K11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the baseline care plan did not include required information, was not updated as required, and/or provided to the resident or resident representative for Residents #148 and #267 (2 of 5 residents reviewed for baseline care plans). The findings included: The facility admitted Resident #148 on 11/21/18 with [DIAGNOSES REDACTED]. On 12/17/18 at 02:05 PM, review of the baseline care plan dated 11/21/18 revealed no documentation that a copy of the care plan or a reconciled list of medications was provided to the resident or resident representative. Further review revealed the resident received both Physical and Occupational Therapy which was not included on the baseline care plan. Review of the Social Service Notes indicated the resident was admitted for short term but was not indicated on the baseline care plan which also did not include a discharge plan and/or goals. Continued review revealed an order dated 11/23/18 for [MEDICATION NAME] and the baseline care plan was not updated to include the medication or risks. The facility admitted Resident #267 on 12/14/18 with [DIAGNOSES REDACTED]. Record review on 12/16/18 at approximately 03:35 PM revealed Resident #267 was admitted with an order for [REDACTED]. During an interview on 12/19/18, the Director of Nursing (DON) confirmed the findings as documented and stated the facility had implemented a Performance Improvement Plan related to baseline care plans. The DON also stated that Resident #267 had pulled out the PICC line. The DON further confirmed that occurred after the baseline care plan was due and that the PICC line was not listed on the base line care plan. When informed that the care plan was to be updated with changes from admission to the time the comprehensive care plan was completed, the DON stated we've got a lot of work to do. We need to revamp it.", "filedate": "2020-09-01"}
{"rowid": 279, "facility_name": "MAGNOLIA MANOR - INMAN", "facility_id": 425032, "address": "63 BLACKSTOCK ROAD", "city": "INMAN", "state": "SC", "zip": 29349, "inspection_date": "2018-12-20", "deficiency_tag": 657, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "0G2K11", "inspection_text": "**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.", "filedate": "2020-09-01"}
{"rowid": 280, "facility_name": "MAGNOLIA MANOR - INMAN", "facility_id": 425032, "address": "63 BLACKSTOCK ROAD", "city": "INMAN", "state": "SC", "zip": 29349, "inspection_date": "2018-12-20", "deficiency_tag": 658, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "0G2K11", "inspection_text": "**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.", "filedate": "2020-09-01"}
{"rowid": 281, "facility_name": "MAGNOLIA MANOR - INMAN", "facility_id": 425032, "address": "63 BLACKSTOCK ROAD", "city": "INMAN", "state": "SC", "zip": 29349, "inspection_date": "2018-12-20", "deficiency_tag": 660, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "0G2K11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to follow-up on a request to discharge for Resident #31 (1 of 1 residents reviewed for discharge planning). The findings included: The facility admitted Resident #31 on 03/19/18 with [DIAGNOSES REDACTED]. During an interview on 12/16/18 at 02:51 PM, Resident #31 voiced that s/he wanted to return to the community and go to her/his son's house to live. Resident #31 also reported that no one had discussed discharge planning with her/him. On 12/19/18 at 01:23 PM, review of the Care Plan Conference Summary dated 07/03/18 revealed the resident was requesting to go to her/his son's home to live and also indicated that Social Services will address resident's concerns with (her/his) son. The Social Services Director (SSD) was present at the care plan conference as evidenced by her/his signature. At 01:31 PM, review of the Social Services Progress Review dated 07/03/18 also indicated the resident wanted to discharge home with her/his son and that the resident felt like s/he was capable of taking care of her/himself while her/his son was at work. Further review of the Social Service Progress Notes revealed no documentation that the SSD followed up with the resident's son related to discharge. During an interview on 12/19/18 at 02:02 PM, Social Services designee #1 stated the SSD that was present at that time was no longer at the facility. At that time, each Social Services designee was responsible for a unit, but stated that now all Social Services designees work with all residents. S/he also confirmed there was no documentation that social services followed up with the resident's son. The current Social Services Director stated s/he was not aware of Resident #31's desire to be discharged to the son's house.", "filedate": "2020-09-01"}
{"rowid": 282, "facility_name": "MAGNOLIA MANOR - INMAN", "facility_id": 425032, "address": "63 BLACKSTOCK ROAD", "city": "INMAN", "state": "SC", "zip": 29349, "inspection_date": "2018-12-20", "deficiency_tag": 679, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "0G2K11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to assess for and provide meaningful activities in accordance with the activities assessment for Resident #156 (1 of 1 resident reviewed for activities). The findings included: The facility admitted Resident #156 on 11/06/18 with [DIAGNOSES REDACTED]. During random observations on 12/16/18 from approximately 10:30 AM until 4:30 PM and 12/17/18 from 9:00 AM until 1:45 PM, Resident #156 was observed in the bed. On 12/17/18 at approximately 01:45 PM, the charge nurse stated the resident became agitated when the staff attempted to get him/her out of bed. Review of the activity assessment revealed the resident would receive one-on-one activities three times per week. Further review revealed an activity note dated 11/19/18 that indicated that a series of activities would be attempted to see how the resident responded to different activities. The participation record indicated only reading and music were offered and the documented follow-up of the resident's response to the one-on-one activities provided indicated sometimes the resident responded but mostly had no response. There was no change in the types of activities offered. Review of the care plan also indicated the resident was to receive one-on-one activities three times per week. Review of the participation record with the Activities Director (AD) indicated the resident did not receive one-on-one as the assessment indicated. On 12/18/18 at 04:10 PM, the AD confirmed the activity participation record for Resident #156 indicated the resident was offered music or reading to the resident 1-2 times a week most weeks. One week, the resident received one-on-one three times. The AD confirmed the resident did not receive one-on-one activities per the care plan and that only two forms of one-on-one activity had been offered with no changes to assess the resident's response to different types of activities.", "filedate": "2020-09-01"}
{"rowid": 283, "facility_name": "MAGNOLIA MANOR - INMAN", "facility_id": 425032, "address": "63 BLACKSTOCK ROAD", "city": "INMAN", "state": "SC", "zip": 29349, "inspection_date": "2018-12-20", "deficiency_tag": 684, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "0G2K11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide care and services to meet the residents' needs for Residents #148 and #116 (2 of 2 residents reviewed for care and services). The facility failed to obtain orthostatic blood pressures as ordered for Resident #148. In addition, hospice communication was not accessible, the hospice and facility care plans were not integrated, and hospice did not attend the care plan conference for Resident #116. The findings included: The facility admitted Resident #148 on 11/21/18 with [DIAGNOSES REDACTED]. On 12/17/18 at 02:19 PM, review of the Vital Signs and Weight Record indicated orthostatic blood pressure (BP) was to be obtained BID (twice a day) for seven days. There were no documented blood pressures on the form. Review of the Physicians telephone orders revealed an order dated 11/28/18 for orthostatic BP lying and sitting BID for 5 days related to dizziness. Review of the nurses' notes revealed a blood pressure documented daily without indication whether it was sitting or lying down. During an interview on 12/17/18 at 02:30 PM, Licensed Practical Nurse (LPN) #1 confirmed the orthostatic blood pressures were not obtained as ordered. The facility admitted Resident #116 with [DIAGNOSES REDACTED]. Review of the resident record on 12/18/18 revealed this resident was admitted to hospice on 10/24/18. The Unit Nurse was asked where hospice information was kept for each resident. S/he responded, in a separate notebook. LPN #6 was asked to help locate the notebook which was not on the unit. It took one hour for the nurse to locate the book which was in Medical Records. Review of the hospice care plan and the facility care plan revealed they were not integrated. The facility provided a copy of the care plan on 12/18/18. During interview with the Care Plan Coordinators, they stated the care plan had just been updated, although the resident had been admitted to hospice on 10/24/18. One care plan meeting had been held for this resident, but the hospice nurse did not attend. The Certified Nursing Assistant, Chaplain, and Social Service notes were in the notebook, but staff had no access to them since they were in Medical Records.", "filedate": "2020-09-01"}
{"rowid": 284, "facility_name": "MAGNOLIA MANOR - INMAN", "facility_id": 425032, "address": "63 BLACKSTOCK ROAD", "city": "INMAN", "state": "SC", "zip": 29349, "inspection_date": "2018-12-20", "deficiency_tag": 688, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "0G2K11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to accurately assess and provide treatment and services to maintain or improve passive range of motion for Resident #42 (1 of 1 resident reviewed for limited range of motion). The findings included: The facility admitted Resident #42 on 04/21/15 with [DIAGNOSES REDACTED]. On 12/17/18 at 01:34 PM, record review revealed a joint mobility screen dated 06/27/18 that stated Resident is quadraplegic. There was no documentation of the resident's passive range of motion (PROM) on admission. Further review revealed a second assessment dated [DATE] that also stated Resident is quadraplegic. The assessment did not include measurement of the resident's current mobility status and did not identify if there was any opportunity for improvement. There was no documentation if the resident had previously received treatment and services for mobility or why the treatment/services were stopped. Review of the 04/20/18 annual Minimal Data Set (MDS), Admission MDS dated [DATE], and Quarterly MDS dated [DATE] revealed the resident was coded as having impaired range of motion bilaterally of the upper and lower extremities. During an individual interview on 12/17/18 at approximately 01:15 PM, the resident confirmed that s/he was not able to move his/her upper or lower extremities. A Quarterly Therapy Screening Form dated 10/04/18 was reviewed and indicated no therapy evaluation was recommended. Review of the physician's orders [REDACTED]. Review of the care plan on 12/18/18 at 03:11 PM revealed contractures/[DIAGNOSES REDACTED] of the bilateral upper extremities was identified as a problem area and included the intervention to assess for increased pain and/or stiffness with daily care but did not include any intervention to maintain range of motion. During an interview at that time, Licensed Practical Nurse (LPN) #1 confirmed that s/he did not assess the resident's passive range of motion. The LPN stated s/he assumed it was an assessment of active range of motion but confirmed the instructions stated, Draw a line through the arc showing how far the limb can be moved (PROM). When asked how s/he would know if the resident had a decline in ROM from his/her baseline or was starting to develop a contracture, the LPN stated, Right.", "filedate": "2020-09-01"}
{"rowid": 285, "facility_name": "MAGNOLIA MANOR - INMAN", "facility_id": 425032, "address": "63 BLACKSTOCK ROAD", "city": "INMAN", "state": "SC", "zip": 29349, "inspection_date": "2018-12-20", "deficiency_tag": 689, "scope_severity": "G", "complaint": 1, "standard": 1, "eventid": "0G2K11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and interview, the facility failed to identify a risk of falling when turning in a geri-chair with 1 staff member for Resident #7 and failed to use a bed alarm as ordered for Resident #94 (2 of 4 reviewed for accidents/falls). The findings included: The facility admitted Resident #7 with [DIAGNOSES REDACTED]. The resident had a BIMS (Brief Interview for Mental Status) of 15 denoting ability to make own decisions. The Minimum Data Set (MDS) documented that this resident was a total care resident needing total lift with 2 person assist for mobility and transfers. The Physicians Order read: 2 Certified Nursing Assistant (CNA) Hoyer Lift. On 10/14/18 resident was seated in a gerichair. The CNA proceeded to try to transfer the resident from the gerichair to the bed by herself. While lifting resident in gerichair to place lift pad under the resident, the resident slipped and fell to the floor. The CNA later stated the resident slipped and resident was eased down to the floor. The resident stated in an interview on 12/20/18 at 8 AM that the (staff) dropped her. Licensed Practical Nurse (LPN) # 5 assessed the resident after the fall and in his/her opinion did not see any injury. The Physician was notified and stated, Let the Nurse Practitioner (NP) check the resident in the morning. The resident asked to go to the hospital. The resident continued to complain and asked for his/her leg to be X-rayed. The Nurse told the resident s/he could not call for an X-Ray. In a late entry on 10/16/18 at 1 AM clarification note, the Nurse told the resident s/he could not order an X-Ray without calling the doctor, but the resident could send himself/herself out. The Nurse told the resident to let his/her meds take effect and see the NP in the morning. The family called Emergency Medical Services (EMS) to do a welfare check. EMS came to facility and assessed the resident. EMS wanted to take him/her to the emergency room (ER), but the resident refused. They called a doctor at the ER to see what to do. Since the resident refused, the ER doctor advised them to leave him/her at the facility. There was no documentation of the NP checking the resident. The resident went to [MEDICAL TREATMENT] on 10/15/18 and was transferred to the hospital from there. A scan was done and the resident was found to have a fractured right ankle. The resident was treated and returned to the facility on [DATE] with a splint to the right foot and leg. Five CNA's were interviewed about care of residents with a fall risk and transfers. All of the CNA's knew to look in the resident profile in the kiosk for instructions on how to lift residents and the number of staff needed. The Physician was interviewed via telephone twice on 12/20/18. At 7:45 AM, the Physician could not remember anything about the incident, except the nurse did call him. About 8:15 AM, the Physician called back and made a statement corresponding to the information given by the facility related to the incident. The facility admitted Resident #94 on 07/29/2014 with [DIAGNOSES REDACTED]. During the initial tour on Unit 200, Resident #94 was out of the room. A bed alarm box without batteries was noted on the roommates over table. The bed alarm sensor pad was noted on resident #94's bed and the cord for the box was under the bed. Further observations 12/16/18 at 12:30 PM revealed the alarm box remained on the roommates over table with no batteries. New batteries were applied and alarm was functioning at 4:00 PM when tested Record Review revealed that resident #94 had a Physicians Order for bed alarm to bed at all times with function and placement checked every shift. During an interview on 12/16/2018 at approximately 10:43 AM, CNA #1 confirmed that the box had no batteries and was not connected to the sensor pad cord. On 12/16/2018 at 3:50 PM, Registered Nurse #1 stated, I saw the last 2 days that the bed alarm was not in place and that is why I circled it on the treatment flowsheet.", "filedate": "2020-09-01"}
{"rowid": 286, "facility_name": "MAGNOLIA MANOR - INMAN", "facility_id": 425032, "address": "63 BLACKSTOCK ROAD", "city": "INMAN", "state": "SC", "zip": 29349, "inspection_date": "2018-12-20", "deficiency_tag": 759, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "0G2K11", "inspection_text": "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.", "filedate": "2020-09-01"}
{"rowid": 287, "facility_name": "MAGNOLIA MANOR - INMAN", "facility_id": 425032, "address": "63 BLACKSTOCK ROAD", "city": "INMAN", "state": "SC", "zip": 29349, "inspection_date": "2018-12-20", "deficiency_tag": 812, "scope_severity": "F", "complaint": 0, "standard": 1, "eventid": "0G2K11", "inspection_text": "Based on record review and interview, the facility failed to calibrate the food thermometer prior to use, improperly cleaned the food thermometer with a paper towel, and did not maintain refrigerator temperatures above acceptable parameters in 1 of 1 kitchen and 2 of 3 nutrition refrigerators. The findings included: Observation on 12/17/18 at approximately 1:10 PM revealed Refrigeration & Freezer Monthly Temperature Logs for (MONTH) and (MONTH) (YEAR), which were both blank. Also, written on the Refrigeration & Freezer Monthly Temperature Logs for (MONTH) and (MONTH) (YEAR) was a statement that 47 degrees Fahrenheit (F) or higher is Too warm: Record Exact Temperature and Take Immediate action. The form also stated that at 35 degrees F or lower is Too Cold: Record Exact Temperature and Take Immediate Action. Interview with the dietary manager on 12/17/2018 at approximately 2:30 PM revealed s/he thought that 47 degrees F and 35 degrees F were the correct temperatures for spoilage. S/he did not realize that any thing above 41 degrees F was considered unacceptable to use and did not realize that 32 degrees F was the temperature for freezing. Observation on 12/18/2018 at approximately 11: 25 AM revealed the Line Cook using a food thermometer to test the temperature of cooked ground pork. After getting the correct temperature, s/he then used a paper towel to clean the food thermometer. When asked, s/he stated that s/he ran-out of sanitary wipes. This was also observed by the Head Dietitian, who then provided more sanitary wipes. Observation also revealed the Line Cook placed the food thermometer on the steam table, which caused the food thermometer to roll off and fall to the floor. The Head Dietitian picked it up and got a new food thermometer, but did not calibrate it. S/he then gave the food thermometer to the Line Cook to use on the next two items, which were pureed, cooked sweet potatoes and pureed, cooked pork.", "filedate": "2020-09-01"}
{"rowid": 288, "facility_name": "MAGNOLIA MANOR - INMAN", "facility_id": 425032, "address": "63 BLACKSTOCK ROAD", "city": "INMAN", "state": "SC", "zip": 29349, "inspection_date": "2018-12-20", "deficiency_tag": 867, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "0G2K11", "inspection_text": "**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.", "filedate": "2020-09-01"}
{"rowid": 1083, "facility_name": "SUMTER EAST HEALTH & REHABILITATION CENTER", "facility_id": 425107, "address": "880 CAROLINA AVENUE", "city": "SUMTER", "state": "SC", "zip": 29150, "inspection_date": "2018-08-10", "deficiency_tag": 578, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "0H3T11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to offer alert and oriented residents the opportunity to formulate an advance directive and/or failed to ensure that residents were examined and deemed to lack the capacity for decision making by 2 physicians before allowing a resident representative to formulate the advance directive for Residents # 2, 93. 303, 61, and 139, 5 of 9 residents reviewed for advance directives. The findings included: The facility admitted Resident #2 on 6/1/16 with [DIAGNOSES REDACTED]. On 08/07/18 at 04:19 PM, record review revealed an Advance Directives/Medical Treatment Decisions Acknowledgment of Receipt form dated 6/2/16 that was signed by the daughter of Resident #2. The form noted the resident was a full code per Social Services. There was no evidence that the resident had been examined by 2 physicians and deemed to lack the capacity to make informed decisions for her/himself. On 08/09/18 at 09:58 AM, review of the MDS (Minimal Data Set) Assessments revealed a 5/6/18 Significant Change in Status Assessment and a 8/1/18 Quarterly Assessment that indicated the resident had a BIMS (Brief Interview for Mental Status) score of 15 indicating the resident was cognitively intact for decision making. At 10:05 AM, review of the Social Services Notes revealed an Initial Social Services Assessment and History indicating the resident was alert and oriented to self, family, time, place and situation. There was no documentation that code status was discussed with Resident #2. The facility admitted Resident #93 on 01/10/17 with [DIAGNOSES REDACTED]. No documentation could be located in the medical record. On 08/07/18 at 04:50 PM, review of the monthly cumulative orders revealed Resident #93 had an advance directive for a code status of DNR. Further review on 08/10/18 at 10:06 AM revealed an Advance Directives/Medical Treatment Decisions Acknowledgment of Receipt form dated 01/10/17 indicating a code status of Full Code. Review of a History and Physical dated 3/19/18 from the Hospital stated the resident was a DNR per wishes of the resident's niece and power of attorney. The facility admitted Resident #303 on 08/02/17 with [DIAGNOSES REDACTED]. On 08/07/18 at 04:40 PM, review of the record revealed an Advance Directives/Medical Treatment Decisions Acknowledgment of Receipt form dated 08/02/17 and signed by the resident's representative indicating a code status of DNR. Further review revealed only 1 physician had certified the resident lacked the inability to consent. Review of the Annual MDS assessment indicated the resident had a BIMS score of 12. There was no evidence in the record that advance directives was discussed with the resident. During an interview on 08/10/18, the District Director of Clinical Services confirmed the findings as above. The facility admitted Resident #61 on 9/21/17 with [DIAGNOSES REDACTED]. Review of the medical record revealed the resident's Representative signed the Advance Directive/Medical Treatment Decisions Acknowledgment of Receipt form dated 9/22/17. Further record review revealed the Resident's Brief Interview Mental Status (BIMS) score was 11 which indicated the resident was alert and oriented. Record review revealed there was no form in the record with 2 physician's signatures attesting that the resident was not capable of making his/her own healthcare decisions. The documentation was reviewed and confirmed by the Social Services Director on 8/10/18 at approximately 11:30 am. The facility admitted Resident #139 on 1/26/18 with [DIAGNOSES REDACTED]. Review of the medical record revealed the resident's Representative signed the Advance Directive. The record did not contain a form with 2 physician's signatures attesting that the resident was incapable of making his/her own healthcare decisions. The documentation was reviewed and confirmed by the Social Services Director on 8/10/18 at approximately 11:30 am. Review of the facility's policy entitled Advance Directives stated that The resident has a right to accept or refuse medical or surgical treatment and to formulate an advance directive in accordance with State and Federal Law. The policy further indicated that, Capacity to Make Health Care Decisions means the ability, based on reasonable medical judgment, to understand and appreciate the nature and consequences of a health care decision.", "filedate": "2020-09-01"}
{"rowid": 1084, "facility_name": "SUMTER EAST HEALTH & REHABILITATION CENTER", "facility_id": 425107, "address": "880 CAROLINA AVENUE", "city": "SUMTER", "state": "SC", "zip": 29150, "inspection_date": "2018-08-10", "deficiency_tag": 607, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "0H3T11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and review of the facility's policy entitled Abuse & Neglect Prohibition, the facility failed to implement its Abuse/Neglect policies related to reporting allegations of Abuse for 1 of 1 resident reviewed for misappropriation of property. (Resident #13) The findings included: The facility admitted Resident #13 on 2/7/17 with [DIAGNOSES REDACTED]. Record review revealed the facility submitted an Initial 2/24-Hour Report of an allegation of Misappropriation of Resident Property concerning Resident #13 by fax to the State Agency on 5/23/18. When asked for a copy of the Five-Day Follow-Up Report and documentation of the date submitted to the State Agency, the facility informed the surveyor that the report was not submitted. During an interview on 8/10/18 at approximately 9:45 AM, the Administrator confirmed this finding. Review of the facility's policy entitled, Abuse & Neglect Prohibition indicated under Reporting and Response 1. STATE REPORTING OBLIGATIONS: 5. The facility will submit a summary of its investigation to the appropriate State agency within 5 days of its initial report or within whatever time frame required by the State Agency.", "filedate": "2020-09-01"}