cms_SC
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| Link | rowid | facility_name | facility_id | address | city ▼ | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 488 | 488 | ABBEVILLE NURSING HOME, INC. | 425057 | 83 THOMSON CIRCLE | ABBEVILLE | SC | 29620 | 2019-01-16 | 550 | E | 1 | 1 | 8N1U11 | > Based on observations and interviews, the facility failed to ensure that residents were treated with respect and dignity during the dining experience. Three to four residents were served or being assisted with eating by staff at one table while 18 plus residents were seated at tables in the dining room on the 100 Unit with clothing protectors in place for over 45 minutes and not served or eating.1 of 2 Unit dining rooms observed. The findings included: During a random lunch observation on 1/14/19 at approximately 11:50 AM of the dining room on the 100 Unit revealed residents seated in the dining room on the 100 Unit and residents being transported to the 100 Unit dining room. Staff was observed offering and placing clothing protectors on all residents in the dining room. At approximately 12:15 PM, one table with four (4) residents were served with two of the four residents requiring staff assistance with eating. There were two long tables with multiple residents and two smaller tables with three to four residents with clothing protectors on waiting to be served. Some residents were looking at the table were the residents were eating independently or being assisted by staff. At approximately 12:26 PM two food carts were delivered pass the residents seated in the dining room down the hallways while the resident remained in the dining room on the 100 Unit not served or eating. One resident was observed self-ambulating from the dining table in his/her wheelchair. The resident asked staff when the food was coming. Staff informed the resident not to leave the table because lunch was coming. During an interview on 1/14/19 at approximately 12:46 PM with Registered Nurse (RN) #2 and Licensed Practical Nurse (LPN) #1 revealed the residents at the table being served is restorative dining residents. Both confirmed the observations of 4 residents seated at a dining table and eating or being feed while other residents were waiting to be served. RN #2 and LPN#1 stated the facility has been delivering food to the dining room t… | 2020-09-01 |
| 489 | 489 | ABBEVILLE NURSING HOME, INC. | 425057 | 83 THOMSON CIRCLE | ABBEVILLE | SC | 29620 | 2019-01-16 | 580 | D | 1 | 1 | 8N1U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record reviews and interviews, the facility failed to ensure that residents responsible parties were notified of changes that affected the resident's care while in the facility for 1 of 4 sampled residents reviewed for change in condition. Resident #134's responsible party was not notified of a skin tear that required a bandage/dressing. The findings included: The facility admitted Resident #134 on 4/12/18 with [DIAGNOSES REDACTED]. A review of Resident #134's medical record revealed a nurse's note dated 5/07/18 at 4:26 AM revealed the resident removed a brown bandage from his/her LFA (Left Fore Arm) while receiving a bath causing a category 2 skin tear. Further review of the medical record revealed there was no documentation to address the resident receiving an injury to his/her LFA that required him/her needing a bandage/dressing to the LF[NAME] Further review of Resident #134's record revealed the resident's responsible party was notified on 5/07/18 at 6:58 AM and by 9 AM the resident was transported to the emergency room . During an interview on 1/15/19 at approximately 3:05 PM with Registered Nurse #1 revealed he/she did not know when or why a bandage was first placed on Resident #134 LFA before 5/07/18. RN #1 stated after the resident removed the first bandage; a second bandage was placed on the resident by RN #2 and when that bandage was removed by the resident, further injuries occurred, and the resident was sent to the hospital for treatment. During an interview on 1/15/19 at approximately 3:21 PM with RN #1 revealed through the facility's investigation, no staff member admitted to knowing why a bandage/dressing was on the resident's LFA before 5/07/18 though the resident had a history of [REDACTED]. RN #1 stated whoever put the bandage/dressing on the LFA before 5/07/18 did not report it to the nursing heads and did not document the incident. RN #1 stated the facility did not notify the family prior to the first bandage/d… | 2020-09-01 |
| 490 | 490 | ABBEVILLE NURSING HOME, INC. | 425057 | 83 THOMSON CIRCLE | ABBEVILLE | SC | 29620 | 2019-01-16 | 842 | D | 1 | 1 | 8N1U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record reviews and interviews, the facility failed to ensure that a resident's medical record accurately document the care and services that was received while placed in the facility for 1 of 4 sampled residents reviewed for change in condition. Resident #134 with treatment being given without documentation as to what occurred that required treatment. The findings included: The facility admitted Resident #134 on 4/12/18 with [DIAGNOSES REDACTED]. A review of Resident #134's medical record revealed a nurse's note dated 5/07/18 at 4:26 AM revealed the resident removed a brown bandage from his/her LFA (Left Fore Arm) while receiving a bath causing a category 2 skin tear. Further review of the medical record revealed there was no documentation to address the resident receiving an injury to his/her LFA that required him/her needing a bandage/dressing to the LFA prior to 5/07/18. During an interview on 1/15/19 at approximately 3:05 PM with Registered Nurse #1 revealed he/she did not know when or why a bandage was first placed on Resident #134 LFA before 5/07/18. RN #1 stated after the resident removed the first bandage; a second bandage was placed on the resident by RN #2 and when that bandage was removed by the resident, further injuries occurred and the resident was sent to the hospital for treatment. During an interview on 1/15/19 at approximately 3:21 PM with RN #1 revealed through the facility's investigation, no staff member admitted to knowing why a bandage/dressing was on the resident's LFA before 5/07/18 though the resident had a history of [REDACTED]. RN #1 stated whoever put the bandage/dressing on the LFA before 5/07/18 did not report it to the nursing heads and wrote no documentation. RN #1 stated the facility did not notify the family prior to the first bandage/dressing to the resident's LFA because no one was aware as to why it was on the resident. During an interview on 1/16/19 at 9:18 AM with RN #2 revealed he/she did no… | 2020-09-01 |
| 491 | 491 | ABBEVILLE NURSING HOME, INC. | 425057 | 83 THOMSON CIRCLE | ABBEVILLE | SC | 29620 | 2017-03-16 | 241 | E | 0 | 1 | 3CJJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews, facility failed to maintain the dignity of residents during meal service on 2 of 2 units. Resident room trays were not distributed in a sequential manner on Unit 1. The privacy curtain was not pulled for a resident who was fed by Gastrostomy tube, when other residents were served in the room. Residents were not offered glasses for canned drinks and supplements served in cartons on Units 1 and 2. Resident #85 was served with plastic utensils without documented current need. The findings included: During observation of the noon meal on 03-13-17 at 12:38 PM, Certified Nursing Assistant (CNA) #1 was the only staff member distributing room trays on Unit 1. S/he served the resident nearest the door in room [ROOM NUMBER], but did not provide a tray for the second occupant in the room or pull the privacy curtain before moving on to the next room (room [ROOM NUMBER]). It was approximately 20 minutes before the second resident in room [ROOM NUMBER] was served. room [ROOM NUMBER] was occupied by 3 residents. CNA #1 served 2 of the 3 residents sequentially. The third resident was nourished by use of a gastrostomy (G-) tube. The CNA did not pull the privacy curtain between residents. Therefore, the resident with the [DEVICE] was fully able to see other residents eating their meals. During meal observation on 03-14-17 at 12:35PM, all residents in the dining rooms on Units 1 and 2 who were served Ready Shakes and/or canned sodas were not offered or provided with glasses for these beverages. During an interview on 03-14-17 at 12:50PM, Registered Nurse (RN) #2 indicated that some residents preferred to have their beverages directly from the container. S/he stated that the kitchen usually sent extra cups on the set up cart. No extra cups/glasses were noted during observed meal times. On 03-14-17, Resident #85 was observed eating with plastic utensils in the Wing 2 dining room at 8:40 AM and at 12:40 PM. Review of the reside… | 2020-09-01 |
| 492 | 492 | ABBEVILLE NURSING HOME, INC. | 425057 | 83 THOMSON CIRCLE | ABBEVILLE | SC | 29620 | 2017-03-16 | 329 | D | 0 | 1 | 3CJJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide evidence of non-pharmacological intervention prior to administration of an antipsychotic for 1 of 5 sampled residents reviewed for unnecessary medications. Staff administered [MEDICATION NAME] multiple times to Resident #36 without documented evidence of behaviors and/or evidence of non-pharmacological interventions prior to administration. The findings included: Resident #36 was admitted to the facility with [DIAGNOSES REDACTED]. Record review on 3-15-17 at 12:08PM revealed physician's orders [REDACTED]. Review of behavior monitoring for (MONTH) through March, (YEAR) on 3/16/17 revealed no documented behaviors. Review of the Medication Administration Records revealed that [MEDICATION NAME] was administered twice in 1-17 (on 1-1-17 and 1-20-17), six times in 2-17 (on 2-8-17, 2-9-17, 2-19-17, 2-23-17 x 2, and 2-24-17), and five times in 3-17 (on 3-3-17, 3-4-17, 3-5-17, 3-9-17, and 3-10-17) for yelling out, hollering out, agitation, and anxiety. Review of Nurse's Notes revealed there was no evidence of evaluation of the underlying cause of the behavior and no attempts at non-pharmacological interventions prior to administering the medication. There were no behaviors documented when agitation or anxiety was noted as the reason for administration of the medication. Review of the care plan revealed When res(ident) noted to be yelling out, paranoid, agitated after misinterpretation of others actions or conversation, staff to approach calmly, attempt to get res to talk, give time to express self, take res to a more comfortable area, offer snacks and liquids, and if this does not work offer to take back to room. Reassure res r/t (related to) whatever is causing her (him) agitation. Make nurse aware of behaviors and meds as ordered. Call her (his) daughter or other family member when requested. During an interview on 3-16-17 at 9:44AM, Licensed Practical Nurse (LPN) #1 stated that pr… | 2020-09-01 |
| 493 | 493 | ABBEVILLE NURSING HOME, INC. | 425057 | 83 THOMSON CIRCLE | ABBEVILLE | SC | 29620 | 2017-03-16 | 428 | D | 0 | 1 | 3CJJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure that irregularities identified by licensed pharmacist during drug regimen review were addressed in a timely manner by the attending physician for one of five residents reviewed for unnecessary medications. The findings included: Resident #23 was admitted to the facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. Review of the medical record on 3/15/17 at 4:30 PM revealed that the Consulting Pharmacist initiated three Note to Attending Physician/ Prescriber communication forms on 11/22/2016 regarding recommendations related to irregularities identified during monthly medication regimen review for resident #23. Review of one of the three recommendations submitted by the Licensed Pharmacist on 11/22/2016 revealed request submitted for consideration of Gradual Dose Reduction (GDR) for hypnotic medication from scheduled to as needed (PRN) dosing, this request was not addressed by the Family Nurse Practitioner (FNP) until 2/2/2017, when it was approved. Review of a second communication form submitted by the Licensed Pharmacist on 11/22/2016 addressed irregularity regarding fasting blood glucose levels and request for consideration to change dose of Lantus insulin from 10 units every 12 hours to 20 units every morning to address this issue, which was not addressed by the FNP until 2/2/17, where the request was denied with the following reason provided resident has had multiple hyperglycemic episodes- Lantus increased-HgbA1c 7.8 on 11/21/16. Review of the third communication form submitted by the Licensed Pharmacist on 11/22/2016 revealed that resident #23 was identified with weight loss, difficulty swallowing, and abnormal Thyroid Stimulating Hormone (TSH) laboratory test results with request for consideration to change medication dose for Levothyroxine followed by labs in 8 weeks, where the request was not addressed until 2/2/17 when it was approved and medication was cha… | 2020-09-01 |
| 494 | 494 | ABBEVILLE NURSING HOME, INC. | 425057 | 83 THOMSON CIRCLE | ABBEVILLE | SC | 29620 | 2017-03-16 | 431 | D | 0 | 1 | 3CJJ11 | Based on observations, interview, review of the manufactures recommendations and facility policy, the facility failed to follow a procedure to ensure that expired medication were removed from medication storage in 3 of 8 medication carts and 2 of 2 units reviewed. Expired medications were on the medication carts after the expiration date. The findings included: On 3/13/17 at 12:24 PM, an observation with RN#1 of the Hall 1/Unit 1 medication cart revealed a Novolog FlexPen (Lot #FP ) with approximately 225 units of fluid insulin remaining. The Novolog FlexPen had an open date of 2/10 and expiration date 3/10. Following the observation, RN #1 verified the Novolog FlexPen was expired and stated, The insulin pen should have been removed from the cart. On 3/14/17 at 1:20 PM, an observation with RN #2 of the Hall 2/Unit 1 treatment cart revealed 1-2-3-Paste with a pharmacy stamped expiration date of 1/24/17. Following the observation, RN #2 verified the 1-2-3 Paste was expired and indicated the paste should have been removed from the cart. On 3/14/17 at 1:45 PM, an observation with RN #1 of the Hall 1/Unit 2 treatment cart revealed Premarin vaginal cream .625 mg/g with a manufactures stamped expiration date of 9/16. Following the observation, RN #1 verified the Premarin vaginal cream was expired and indicated the cream should have been removed from the cart. On 3/14/17 at 10:45 AM, a review of the facility policy entitled, Medication Storage in the Facility, revealed under Expiration Dating (Beyond-use dating), procedure ([NAME]) All expired medications will be removed from the active supply and destroyed in the facility, regardless of amount remaining. The medication will be destroyed in the usual manner. On 3/14 at 2:55 PM, review of the manufacture recommendations for Novolog Flex Pen states under section How should I store Novolog FlexPen, Bullet (2) states, Store the FlexPen you are currently using out of the refrigerator below 86 degrees F or 30 degrees C for up to 28 days. Furthermore, bullet (6) states, The Nov… | 2020-09-01 |
| 495 | 495 | ABBEVILLE NURSING HOME, INC. | 425057 | 83 THOMSON CIRCLE | ABBEVILLE | SC | 29620 | 2017-03-16 | 441 | D | 0 | 1 | 3CJJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and review, the facility's laundry contractor failed to follow agreed upon policy and procedure for transfer of soiled linen from the facility on 1 of 2 units reviewed for Infection Control. The findings included; Observation of the facility's contracted Laundry Service delivering and retrieving laundry on 03/16/17 at 10:14 am revealed that the handler used an unlined and unmarked container which was used to bring clean linen to the facility to retrieve soiled linen. The handler also placed unbagged soiled linen in the container. In an interview on 03/16/17 at 10:14 am while loading the container into the vehicle for transport, the handler stated that the carts are cleaned once or twice a week. Subsequent review of the contractor's policy revealed that Soiled linen containers should be lined with an impervious liner. Do not allow soiled linens to simply be dropped into a container. At designated times, laundry workers using a large bin For Soiled Linen Use Only will go to each Soiled Linen Room to pick up the soiled linens. During observations from 3-13-16 through 3-16-17, resident care equipment was stored in an improper/unsanitary manner: (1) An uncovered, unlabeled bedpan was initially noted on the floor behind the toilet in room [ROOM NUMBER] (semi-private) bathroom on 03/13/2017 at 3:04 PM. (2) On 03/14/2017 at 9:35 AM, an uncovered, unlabeled bedpan was found on the grab bar in the bathroom for room [ROOM NUMBER] (semi-private). An environmental tour was conducted with the Housekeeping/Environmental Manager, Plant Maintenance Manager, Area Manager and Assistant Maintenance Manager on 3/16/17 at 2:35 PM. The bedpans had not been moved or properly stored for the duration of the survey. All staff present verified the storage of the items. The Housekeeping Manager stated that this concern was the responsibility of the nursing department. During an interview on 3/16/27 at 2:54 PM, Registered Nurse (RN) #3 verified that t… | 2020-09-01 |
| 496 | 496 | ABBEVILLE NURSING HOME, INC. | 425057 | 83 THOMSON CIRCLE | ABBEVILLE | SC | 29620 | 2017-12-07 | 582 | C | 0 | 1 | PQLY11 | Based on record review and interviews, the facility failed to issue the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN)/Centers for Medicare/Medicaid (CMS) form to 3 of 3 sampled residents reviewed for Medicare Part A Services. Residents #38, #44 and #80 received the Notice of Medicare Non-Coverage (NOMNC), but did not receive the required SNFABN/CMS form. The findings included: Review of the medicare non coverage notices on 12/04/17 at approximately 3 PM revealed Residents #38, #44 and #80 had services ended with additional days left for services. There was no CMS forms provided by the facility. During an interview on 12/04/17 at approximately 3:10 PM with the Administrator, the Administrator confirmed the facility did not provide the Skilled Nursing Facility Advanced Beneficiary Notice (CMS ) form for Residents #38, #44 and #80. The Administrator stated the CMS would only be given if it was requested by the resident/responsible party. An interview with the facility consultant on 12/05/17 at approximately 3:48 PM revealed the facility does not provide the SNFABN/CMS form until the resident/responsible party request they want to appeal the Medicare non coverage decision. | 2020-09-01 |
| 497 | 497 | ABBEVILLE NURSING HOME, INC. | 425057 | 83 THOMSON CIRCLE | ABBEVILLE | SC | 29620 | 2017-12-07 | 641 | D | 0 | 1 | PQLY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure accuracy of assessments. Resident #23's Minimum Data Set (MDS) was coded inaccurately for insulin administration, diuretics, and Urinary Tract Infection (1 of 1 sampled resident reviewed for hospitalization ). The findings included: The facility admitted Resident #23 with [DIAGNOSES REDACTED]. During record review of the MDS on 12/5/17 at 2 pm revealed the MDS with assessment review date (ARD) of 9/25/17 had Insulin coded as 0 under medications, and did not have the [DIAGNOSES REDACTED]. Further review of the MDS ARD of 10/24/17 revealed Urinary Tract Infection was not coded under active diagnoses, and had diuretics inaccurately coded as 7 under medications. Review of the Medication Administration Record [REDACTED]. Review of the (MONTH) MAR indicated [REDACTED]. Review of the hospital records on 12/6/17 at 2:30 pm revealed the resident was treated and sent back to the facility on [DATE] and 10/26/17 on antibiotic therapy for a UTI. During an interview on 12/6/17 at 10:20 am, MDS Registered Nurse #1 verified inaccurate coding on the 9/25/17 MDS regarding Insulin, and did not code the presence of a UTI. S/he also verified the inaccurate coding on the 10/24/17 MDS regarding diuretics under medications. | 2020-09-01 |
| 498 | 498 | ABBEVILLE NURSING HOME, INC. | 425057 | 83 THOMSON CIRCLE | ABBEVILLE | SC | 29620 | 2017-12-07 | 657 | D | 0 | 1 | PQLY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to revise the comprehensive care plan. Resident #23 was hospitalized and treated for [REDACTED].# 13 did not include a problem and interventions regarding Blepharitis of the left eye (1 of 1 sampled resident for infections, and 1 of 2 sampled residents reviewed for UTI). The findings included: The facility admitted Resident #23 with [DIAGNOSES REDACTED]. Review of the hospital records on 12/6/17 at 2:30 pm revealed the resident was treated and sent back to the facility on [DATE] and 10/26/17 on antibiotic therapy for treatment of [REDACTED]. During an interview on 12/6/17 at 10:20 am, MDS Registered Nurse (RN) #1 verified the comprehensive care plan was not updated to reflect the UTI or antibiotic therapy on 9/7/17 or 10/26/17 after readmission to the facility from the hospital. The facility admitted Resident #13 with [DIAGNOSES REDACTED]. During an observation on 12/4/17 at 1:45 pm, Resident #13 was noted to have a large amount of dried beige drainage to the left eye and eyelash with swelling and redness of the lower lid. Review of the care plan on 12/5/17 at 4 pm revealed no evidence in the care plan to address the chronic Blepharitis condition of left eye drainage, redness and swelling or the ordered interventions including antibiotic eye ointment and cleansing of the eye with baby soap twice a day. During an interview on 12/6/17 at 10:25 am, MDS RN #1 verified there was no comprehensive care plan to address the Blepharitis [DIAGNOSES REDACTED]. | 2020-09-01 |
| 5237 | 5237 | ABBEVILLE NURSING HOME, INC. | 425057 | 83 THOMSON CIRCLE | ABBEVILLE | SC | 29620 | 2016-06-16 | 157 | D | 0 | 1 | PY4411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to notify the physician/nurse practitioner and/or other qualified professional of significant weight loss for Resident #12, 1 of 3 residents reviewed for nutrition. The findings included: The facility admitted Resident #12 with [DIAGNOSES REDACTED]. During the Stage I Census Record review at 5:14 PM on 6/13/16, Resident #12 was noted to have a significant weight loss. On 6/16/16 at approximately 3:15 PM, record review revealed the resident's weight on 6/15/16 was 96.0, on 6/1/16 96.7 pounds, on 5/04/16 106.1 pounds, on 3/08/16 109.0 pounds and on 11/4/15 110.2 pounds. Review of the Nurse's Notes revealed no documentation that the physician, family or Registered/ Licensed Dietitian was notified of the resident's significant weight loss. There was no documentation of any recent changes in dietary intake or [MEDICAL CONDITION], diarrhea or vomiting. Record review revealed the RD completed an assessment dated [DATE] and noted the resident consumed 50-75% of meals and recommended ReadyCare. The RD had not re-assessed the resident related to the significant weight loss. During an interview at 2:59 PM on 06/16/2016, the Certified Dietary Manager (CDM) reviewed the weight sheets and stated that Resident #12 was not on the list for weight loss and that a weight for (MONTH) had not been recorded. When informed that the resident's weight on (MONTH) 1st was 96.7 pounds, the CDM stated and that's a major loss. The CDM stated for a resident under 100 pounds, a re-weight is done if there is a difference of 3 pounds and the unit manager notified. The CDM stated that s/he would then be notified and in turn notify the RD. In addition, the CDM stated the RD had been at the facility on 6/15/16 and had not been informed. During an interview at 3:27 PM on 06/16/2016, the Director of Nursing (DON) provided documentation of the (MONTH) weights but stated that the Dietary manager informed her that she had not … | 2019-02-01 |
| 5238 | 5238 | ABBEVILLE NURSING HOME, INC. | 425057 | 83 THOMSON CIRCLE | ABBEVILLE | SC | 29620 | 2016-06-16 | 274 | D | 0 | 1 | PY4411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to conduct a Significant Change in Status Assessment upon identification of decline in continence, development of a pressure ulcer, and decline in bed mobility for Resident #20, 1 of 2 residents reviewed with a Significant Change in Status. The findings included: The facility admitted Resident #20 with [DIAGNOSES REDACTED]. At 3:31 PM on 06/15/2016, comparison of the 2/3/16 Admission MDS (Minimum Data Set) to the 4/18/16 Quarterly MDS revealed the resident had an improvement in her/his BIMS (Brief Interview for Mental Status) score, mood and behaviors. The resident was also noted to have a decline from limited assistance to extensive assistance with bed mobility, a decline in continence from occasional to frequent incontinence, and the development of a Stage III pressure ulcer. Review of the Care Plan Progress Notes revealed a note dated 4/21/16 that stated the resident was noted to have decline in the following areas; incontinence, pressure ulcer stage 3 to sacrum, pain symptoms, and one area of ADLs (Activities of Daily Living) (bed mobility). Will begin Significant change review. There was no documentation or results of a review for a significant change in the record. On 6/16/16 review of the Bladder Incontinence Evaluation done 4/11/16 revealed the resident had incontinent episodes daily and was updated on 4/20/16 that indicated the resident remained frequently incontinent of bladder. During an interview at 5:31 PM on 06/15/2016, the RN MDS Coordinator stated the IDT (Interdisciplinary Team) had determined the resident did not have a significant change in status. During the interview, the Social Services Director reviewed the chart and confirmed there was no documentation of an IDT review or determination that the resident had returned to baseline. The MDS Coordinator stated the pressure ulcer was healed on 4/26/16. At 12:09 PM on 06/16/2016 the MDS Coordinator confirmed the docume… | 2019-02-01 |
| 5239 | 5239 | ABBEVILLE NURSING HOME, INC. | 425057 | 83 THOMSON CIRCLE | ABBEVILLE | SC | 29620 | 2016-06-16 | 281 | D | 0 | 1 | PY4411 | Based on observation, interview and review of the facility's policies, 1 of 5 nurses observed during the Medication Pass failed to meet professional standards of practice during medication administration for Resident #56. LPN #1 dropped a pill during med pass, retrieved it from the floor and administered it to the resident. The findings included: During medication pass observation on 06/16/2016 at 9:40 AM , LPN (Licensed Practical Nurse) #1 dropped a pill from the medicine cup onto the floor. The LPN picked up the pill, placed it back in the medicine cup and administered it. During an interview on 06/16/2016 at 9:43 AM, the LPN confirmed s/he dropped the pill on the floor, picked it up and proceeded to administer the medication. The LPN then asked what would be the right thing to do in that case. Review of the facility policy entitled Medication Storage in the Facility revealed Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are removed from stock, disposed of according to procedures for medication destruction . Review of the policy entitled Oral Medication Administration Procedure 6. a. page 20 revealed Avoid touching medications if at are possible. | 2019-02-01 |
| 6492 | 6492 | ABBEVILLE NURSING HOME, INC. | 425057 | 83 THOMSON CIRCLE | ABBEVILLE | SC | 29620 | 2015-05-14 | 281 | D | 0 | 1 | RC2511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and a review of the policy provided by the facility entitled Administration of Insulin, a facility nurse failed to properly administer Insulin to Resident #77, 1 of 1 resident observed during medpass for the administration of Insulin. The nurse failed to keep the [MEDICATION NAME] needle embedded in the skin for the appropriate time frame to ensure the full amount of Insulin had been administered. The findings included: The facility admitted Resident #77 with [DIAGNOSES REDACTED]. Observation on 5/13/15 at approximately 4:10 PM revealed Licensed Practical Nurse (LPN) #1 administering 4 units of [MEDICATION NAME] Insulin via flex pen to Resident #77 for a fingerstick blood sugar of 250. The nurse injected the Insulin into the resident's left upper arm and held the flex pen in place for less than 2 seconds before removing it. After removing the flex pen, the nurse immediately pulled the resident's sleeve down and the surveyor was unable to determine if there was any leakage of Insulin. During an interview after the medpass observations of the nurse, the surveyor asked LPN #1 if s/he was aware that there was a specified amount of time that the flex pen needle was to stay under the skin while administering the Insulin. The surveyor informed the nurse that s/he had been observed to leave the needle in for less than 2 seconds. LPN #1 thought s/he had kept the needle under the skin for 2-5 seconds; and was unsure of the required time frame. On 5/13/15 at 4:17 PM, the Unit Manager was asked about how long the flex pen needle would need to stay under the skin. The Unit Manager was unsure, and stated s/he would check the policy to make sure of the timeframe. Registered Nurse (RN) #1 spoke with the consultant pharmacist by phone and reported that the consultant pharmacist had stated that to ensure the full dose of Insulin had been given with the [MEDICATION NAME], that s/he recommended the nurse hold the pen needle in p… | 2018-01-01 |
| 7228 | 7228 | ABBEVILLE NURSING HOME, INC. | 425057 | 83 THOMSON CIRCLE | ABBEVILLE | SC | 29620 | 2014-02-07 | 371 | E | 0 | 1 | MMNO11 | On one day of the survey, based on observations, interviews, and review of the facility policy titled Employee Guidelines-Infection Control Practices and Food Handling Guidelines, the facility failed to serve and distribute food under sanitary conditions. Observations during the lunch meal distribution on the 100 Unit and 200 Unit Halls and 100 Unit Day area revealed facility staff touched food items with their bare hands. The findings included: Observation on 2/4/14 at approximately 12:45 PM revealed staff serving trays and setting-up residents' lunch in the 100 Unit day area. The menu included cornbread delivered in a paper wrapping. Observation revealed RN #1 and CNA's #1, 2, and 3 reached into the package, retrieved the cornbread with their bare hands, and placed the cornbread onto the plate when serving residents. In addition, RN #1 was observed to take the cornbread into his/her bare hands, break the bread into two pieces, and place the pieces into containers beside the plate while serving one of these residents. During an interview with CNA #3 on 02-07-14 at approximately 11:30 AM, he/she confirmed the surveyor's findings. During an interview with CNA #1 on 02-07-14 at approximately 11:45 AM, he/she stated, okay. During an interview with RN #1 on 02-07-14 at approximately 2:45 PM, he/she stated, I don't remember doing this, but it should not be done. CNA #2 was unavailable for interview. Review of the facility policy titled Employee Guidelines-Infection Control Practices revealed in section All Food and Nutrition Services Employees the following: Handle plates by the bottom or the edge; keep hands off the eating surface. Keep thumb and fingers away from food on the plate. Review of the facility policy titled Food Handling Guidelines revealed in section Prevention of Food Infection the following: Minimize hand contact with food by the use of utensils or disposable gloves. | 2017-04-01 |
| 8094 | 8094 | ABBEVILLE NURSING HOME, INC. | 425057 | 83 THOMSON CIRCLE | ABBEVILLE | SC | 29620 | 2012-11-15 | 318 | D | 0 | 1 | ZETP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record review, and interview, the facility failed to accurately assess one of three residents reviewed for range of motion (ROM) and implement measures to prevent further decline. The facility failed to implement contracture prevention measures and failed to identify contractures of the left hand for Resident #48. There was no evidence of provision of restorative services as per the care plan to maintain ROM and to prevent contracture development. The findings included: Multiple observations on all days of the survey revealed Resident #48 holding the left hand in a fisted position. No handroll or positioning device was observed in place at any time. Significant [MEDICAL CONDITION] of the left hand was noted on 11-13-12 and 11-15-12. During the Staff Interview during Stage 1 of the survey process, the 100 Hall Unit Manager stated that Resident #48 had no contractures. Resident #48 was not noted on the contracture list provided to the surveyors on 11-13-12 after discussion related to the definition of contracture as identified during the staff interviews Review of the 10-22-12 Quarterly and 5-13-12 Annual Minimum Data Set (MDS) Assessments on 11-14-12 at 11:19 AM revealed that Resident was vision-impaired, rarely/never understood, displayed both verbal and physical behaviors toward staff, and was totally dependent for all activities of daily living (ADL's). ROM was noted as impaired in both lower extremities. Skilled therapy nor restorative nursing services were not noted as having been provided. During an interview and observation on 11-14-12 at 12:50 PM, the MDS Coordinator assessed the resident in the presence of the surveyor and verified the [MEDICAL CONDITION] of the upper extremities. The resident's left hand was fisted and no positioning was noted for the [MEDICAL CONDITION] of upper extremities or for the fisted hand. The MDS Coordinator noted that the resident had had the [MEDICAL CONDIT… | 2016-07-01 |
| 9233 | 9233 | ABBEVILLE NURSING HOME, INC. | 425057 | 83 THOMSON CIRCLE | ABBEVILLE | SC | 29620 | 2011-09-07 | 309 | D | 0 | 1 | RKDK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification survey, based on interviews and record review, the facility failed to ensure that pacemaker checks were performed timely for Resident #9, 1 of 4 residents reviewed with pacemakers. The findings included: The facility admitted Resident #9 on 4/28/10 with [DIAGNOSES REDACTED]. Record Review of the hospital Discharge Summary on 9/6/11 at 2:40 PM revealed the resident had Pacemaker placement due to Sick Sinus Syndrome. After reviewing the record , the Director of Nursing (DON) was asked on 9/7/11 at approximately 10:15 AM where Pacemaker checks were documented. The DON stated that the Pacemaker checks were documented on the Treatment Administration Record (TAR.) She further stated that the due date for the Pacemaker check was documented on the monthly physician's orders [REDACTED]. At approximately 10:35 AM on 9/7/11, Licensed Practical Nurse (LPN) #1 confirmed she was unable to locate any documentation of a pacemaker check on the record. During an interview at 1:55 PM on 9/7/11, LPN #1 stated Resident #9 should have had an appointment at the Cardiologist's in January. She stated the resident missed that appointment and had not had a pacemaker check done since October of 2010. | 2015-06-01 |
| 142 | 142 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2020-01-22 | 689 | D | 1 | 0 | E8OZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to provide adequate supervision to prevent resident to resident altercations for one of 17 residents (Resident #16) reviewed for altercations. Resident #16 continued to wander about the facility, including into other resident rooms, following four resident to resident altercations. The findings included: Review of Resident #16's Face Sheet, provided by the facility on 01/20/20, revealed s/he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #16's Quarterly Minimum Data Assessment (MDS) with an Assessment Reference Date of 11/08/19 revealed he/she was unable to complete the Brief Interview of Mental Status (BI[CONDITION]) interview but was assessed by staff to have moderately impaired decision-making abilities; had no behavioral symptoms directed at others; did not wander; and ambulated independently. Review of facility investigations of resident to resident altercations revealed Resident #16 was involved in four of these incidents between 11/15/19 and [DATE]: On 11/15/19 at 04:00 PM, Resident #16 entered Resident #15's room and got into Resident #15's bed while Resident #15 was out of the room. When Resident #15 returned to the room and found Resident #16 in the bed, s/he asked Resident #16 to leave, and Resident #16 hit him/her in the face. On 11/20/19 at 06:00 PM, Resident #16 was again in Resident #15's bed. When Resident #15 asked Resident #16 to leave, Resident #16 hit Resident #15 with his/her shoe. The facility sent Resident #16 to the emergency room , where his/her [MEDICATION NAME] dosage was increased from 0.5 milligrams (mg) three times daily to 1 mg three times daily. On 11/25/19 at 02:15 PM, Resident #16 was ambulating in the hallway near the nurse's station, turned a corner, and encountered Resident #17, who was pacing near the nurse's station. Resident #16 struck Resident… | 2020-09-01 |
| 143 | 143 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2020-01-22 | 758 | D | 1 | 0 | E8OZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review, and review of the facility's policy, it was determined the facility failed to identify and monitor specific target behaviors for residents taking [MEDICAL CONDITION] medications. This was true for one of seventeen residents (Resident #16) sampled for [MEDICAL CONDITION] medication use. The findings included: Review of Resident #16's Face Sheet, provided by the facility on 01/20/20, revealed he/she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #16 Admission physician's orders [REDACTED]. [MEDICATION NAME] (an antipsychotic medication), 5 milligrams (mg) twice daily for a [DIAGNOSES REDACTED]. [MEDICATION NAME] (a benzodiazepine), 2 mg three times daily beginning 08/05/19; and [MEDICATION NAME] (an antipsychotic), 1 mg twice daily beginning 08/05/19. Physician's telephone orders located in the Orders tab of Resident #16's paper clinical record revealed: 08/06/19, decrease [MEDICATION NAME] to 2.5 mg twice daily and decrease [MEDICATION NAME] to 0.5 mg three times daily; 11/21/19, increase [MEDICATION NAME] to 1 mg three times daily; [DATE], increase [MEDICATION NAME] to 5 mg twice daily; 12/05/19, decrease [MEDICATION NAME] to 0.5 mg three times daily. Review of Resident #16's Quarterly Minimum Data Assessment (MDS) with an Assessment Reference Date of 11/08/19 revealed he/she was unable to complete the Brief Interview of Mental Status (BI[CONDITION]) interview but was assessed by staff to have moderately impaired decision-making abilities; had no behavioral symptoms directed at others; and ambulated independently. On 01/21/20 at 10:15 AM, an interview with the Director of Nursing Services (DNS) revealed the facility monitored behaviors for [MEDICAL CONDITION] medications on the Medication Administration Record [REDACTED]. Review of Resident #16's MAR for November and December 2019 and January 2020 revealed, Monitor Resident every shift for behaviors and side effects re… | 2020-09-01 |
| 144 | 144 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2016-09-09 | 226 | D | 0 | 1 | LUPR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, review of an abuse incident investigation, record review, observation, and a review of the facility's policy and procedure for abuse, including protection, the facility failed to ensure that 1 of 35 sampled residents was protected against future abuse incidents, Resident #2. The findings include: Review of the Abuse Prevention, Investigation and reporting policy (Carlyle Senior Care) approval date 8/25/2016: Policy Statement: The resident has the right to be free from verbal, sexual, physical, and mental abuse, neglect, involuntary seclusion and misappropriation of personal property. Policy Interpretation and Implementation: Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. 1. Screening 2. Training 3. Prevention 4. Identification 5. Investigation 6. Protection The facility protects residents from harm during an investigation. A representative or designee from the Social Services department assesses the resident ' s emotions concerning the incident as well as the residents' reactions to his/her involvement in the investigation. Appropriate steps are taken for protection of the resident from additional harm during the investigation. Unless otherwise requested by the resident, the social service representative or designee will provide the administrator and the director of nursing services with a report of his/her findings. Employees of this facility who have been accused of resident abuse will be reassigned or suspended until the results of the investigation have been reviewed by the administrator. 7. Reporting/Response The facility analyzes the occurrences to determine what changes are needed, if any, to policies and procedures to prevent further occurrences. Resident #2 was admitted in 2000 and readmitted on [DATE… | 2020-09-01 |
| 145 | 145 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2016-09-09 | 253 | D | 0 | 1 | LUPR11 | Based on observations in the main dining room, 1 of 2 dining areas in the facility, an interview with an unsampled resident, and an interview with the administrator, the facility failed to ensure the main dining room was maintained in a sanitary, orderly and comfortable interior to ensure a pleasant dining environment for the many residents that eat breakfast, lunch, and dinner in the main dining room. The findings include: Observations in the main dining room on 09/08/2016 at 12:33 PM it was noted that both of the cathedral type ceiling, closest to the kitchen, had the following concerns: 1. The overhead vent located on the cathedral ceiling closest to the steam table had peeling plaster/paint peeling on one side of the vent. The area with the peeling plaster/paint was approximately 6 inches by 15 inches long. Approximately 4 inches of plaster/paint was also hanging from this area, resembling icicles. There was a table with a tablecloth located directly under this area of the peeling plaster/paint. Two residents were at the table waiting for their meal. At least 5 ceiling tiles located in this same area appeared with a beige looking stain, possibly indicating a wet appearance. At least 3 tiles were bowed in appearance. There were at least 2 plastic 5 gallon size buckets located under the front of the steam table, not coming into direct contact with the foods being served. There was additional buckets located near the entry to the dining room. Two of the 4 borders had peeling paint on the surface that edged the cathedral ceiling. There were 6 other ceiling tiles that are darker in appearances then the white tiles located next to them. They appear wet (beige looking stain) and bowed. Some of this area also had peeling plaster/paint hanging down. 2. On the cathedral ceiling located near the entrance of the dining room there are numerous ceiling tiles with a beige looking stain, possibly indicating long-term water damage. 3. A red painted wall in the dining room, to the right facing the kitchen/serving line, had sta… | 2020-09-01 |
| 146 | 146 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2017-10-11 | 155 | D | 1 | 1 | SACF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and review of the facility policy, the facility failed to observe resident's Advanced Directive rights for 1 of 12 residents reviewed for Advanced Directives. The facility did not ensure the correct code status for Resident #67. The findings included: The facility admitted Resident #67 with a [DIAGNOSES REDACTED]. On [DATE] at 11:10 AM, during record review, a signed and notarized Advanced Directive dated (MONTH) 1, (YEAR), prior to the Resident's admission on [DATE], revealed the Resident requested DNR status. The Physician's admission documentation for Resident #67 stated the Resident did not want CPR and was discussed with the Resident's daughter who is also the Responsible Party. On [DATE] 1:36 PM an interview with the Social Services Director revealed s/he agrees with documentation in the chart stating Resident #67 should be a DNR. S/he also discovered a signed DNR order in the file cabinet in Social Services office for the Resident that was not in the chart. On [DATE] 1:48 PM The Social Services Director stated, I will be changing the code status to DNR immediately for this resident. S/he also stated, I should have caught it; I used to work for DHEC. This surveyor witnessed the Social Services Director remove the FULL CODE page and replace it with the DNR page in Resident #67's chart. On [DATE] 2:05 PM Review of Facility Policy, DO NOT RESUSCITATE- POLICY, Policy Interpretation and Implementation #5 states: If the decision has been made for a natural death, the physician shall be notified and a DNR (DO NOT RESUSCITATE) order will be obtained as well as documented in the clinical records. | 2020-09-01 |
| 147 | 147 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2017-10-11 | 323 | G | 1 | 1 | SACF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interviews, and observations, the facility failed to provide the care and services necessary to prevent accidents for 1 of 3 residents reviewed for accidents. The facility failed to provide Mechanical Lift for all transfers to have assist of two people required for use of lift for Resident #16. The findings included: Record review revealed Resident #16 was admitted [DATE] with [DIAGNOSES REDACTED]. Non ambulatory and very frail with muscle loss. Observation revealed Resident #16 who has contractures to all the extremities, fingers, with foot drop on both feet. Call bell was observed by her right hand, and the call bell is a squeezable, round-shape that can be rung using her fingers. Resident requires total assistance for all ADL skills and requires a two staff transfer Resident#16's bedroom revealed low bed, bed alarm and floor mat in place. Resident #16 declined to be interviewed. A review of the nurse's notes revealed the following entries; 09/20/2017-- At 8:30pm, CNA called the nurse to Resident #16's room. Nurse observed Resident #16 had a right knee swollen and bruise with knee dislocated. Notified Doctor, DON, and family. 09/21/2017 - Resident #16 returned from the hospital at 12:30 am -- ER reported femur fracture -X-ray reported. Pain meds were given and leg splint in place. Continue to monitor. Review of the Physicians Orders revealed dated 09/20/2017 -Order (R) knee immobilizer Apply to (R) leg Check skin and circulation, shift R/T fracture. A review of the resident's Care Plans revealed the following; Resident #16 will have reduced risk of falls with injury thru the 90 days. Attend to lower extremities during daily care. Evaluate falls risk quarterly and prn. Attend to resident's needs promptly. Keep bed in lowest position. When care isn't being provided, ensure call bell is within reach. Mechanical Lift for all transfers. Assist of two people required for use of lift (05/02/2016). Place in supervised area… | 2020-09-01 |
| 148 | 148 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2017-10-11 | 441 | D | 1 | 1 | SACF11 | > Based on observation and interview, the facility failed to follow manufacturer's instructions for disinfecting a multi-use glucometer during 1 of 1 observation of a Finger Stick Blood Sugar. The findings included: On 10/10/2017 at 4:18 PM Licensed Practical Nurse (LPN) #1 was observed performing a Finger Stick Blood Glucose on Resident # 1. The LPN washed her/his hands, placed the glucometer inside a glove and pinched an opening into the glove. After obtaining the specimen and completing the procedure the LPN removed the glucometer from glove, removed her/his gloves, sanitized her/his hands and signed the procedure off on the Medication Administration Record. LPN #1 cleaned the glucometer with an Alclavis Bleach-Wipe for approximately 10 seconds. During an interview at that time, the LPN stated s/he cleaned the glucometer for about 5 seconds. The LPN confirmed s/he was not aware manufacturer's instructions were to keep the device visibly wet for 5 minutes to be effective against Clostridium Difficile. In addition, the LPN stated s/he usually used the other (Microdot) bleach wipe and just wipes it down good and allows it to air dry and stated that was the policy. Review of the Microdot instructions at that time revealed the instructions indicated a 3 minute contact time for Clostridium Difficile. The nurse also stated that it was policy to clean the device after use, not before. During an interview at 4:37 PM, the Director of Nursing (DON) stated each cart had 2 glucometers, one to be used will the other is air drying. Three additional nurses were interviewed regarding the policy for cleaning the glucometer and all 3 stated the device needed to have a contact time of 3-5 minutes. Review of the policy revealed 2. Sanitize the glucometer with the appropriate product (i.e. (that is) Sani cloth, Glucometer Wioe, etc (et cetera) .) as long as the product contains bleach. 3. Allow the glucometer to completely air dry before storage or use. During an interview on 10/11/17 at 2:14 PM, the DON confirmed the instructions … | 2020-09-01 |
| 149 | 149 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2018-11-30 | 573 | E | 0 | 1 | JLSM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy titled Resident Rights and interview, the facility failed to provide copies of medical records to 5 of 5 residents who had requested them. Four of 10 residents in the Group Meeting (Residents #7, #31, #73, and #77) and Resident #43 stated they had requested copies of their medical records and had not received them. The findings included: On 11/28/18 at approximately 10:36 AM, a Resident Council meeting was held with the surveyor, attended by 10 interviewable residents, all with Brief Interview for Mental Status scores ranging from 10-15. During the group interview, 4 of the 10 residents expressed that multiple requests had been made in attempts to obtain their medical records from the facility. Resident #s 7, 31, 73, and 77 all expressed they had made multiple requests to the Administrator and to their direct care staff. Review of the grievance log on 11/28/18 at approximately 3:00 PM revealed there were no references to requests made. During an interview with the Administrator and Social Services Director on 11/29/2018 at 9:45 AM, the Administrator indicated s/he was unaware of any requests and if there had been, they would have been taken care of. However, upon further interview, s/he indicated there was no documentation available proving or disproving the requests were made. Review of the facility's admission packet section labeled Resident Rights states: The resident has the right to access personal and medical records pertaining to him or herself. The facility admitted Resident #43 with [DIAGNOSES REDACTED]. Record review on 11/30/18 at 7:50 AM revealed that the resident was hospitalized from 8-31-18 to 9-6-18 Urinary Tract Infection, Hydro[DIAGNOSES REDACTED], [MEDICAL CONDITION], Dehydration, and Acute Kidney Injury. S/he was also hospitalized from 9-25-18 to 9-26-18 for [MEDICAL CONDITION] Calculus, Hydro[DIAGNOSES REDACTED], and Recurrent [MEDICATION NAME]. During an interview on 11/26/18 at 4:1… | 2020-09-01 |
| 150 | 150 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2018-11-30 | 578 | D | 0 | 1 | JLSM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility policy titled Resident Right to Formulate Advance Directives, the facility failed to ensure accuracy for 2 of 2 residents reviewed for advance directives. The findings included: Resident #51 was admitted to the facility on [DATE]. Review of his/her medical record on [DATE] showed that on [DATE] the Patient Self-Determination Act was signed by the Responsible Party (RP) indicating desires to have a living will or medical proxy. Additional review showed only an Emergency Medical Services Do Not Resuscitate Order signed on [DATE]. An interview with the Director of Nursing (DON) on [DATE] at 3:49 PM indicated there was no Physician's Order for a DNR nor was there any documentation indicating the Resident's inability to make health care decisions. Review of the facility's policy titled, Resident Right to Formulate Advance Directives, on [DATE] indicated the facility will periodically assess the resident for decision-making abilities and approach the health care proxy or legal representative if the resident is determined not to have decision making capabilities. The facility admitted Resident #135 on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission 5-day Minimum Data Set assessment revealed the resident had both short- and long-term memory problems with severely impaired decision-making ability. Record review on [DATE] at 8:53 AM revealed a full-page bright green form noting FULL CODE in the front of the medical record. Physician's Orders also noted the resident as a full code. Review of the Care Plan on [DATE] at 9:48 AM revealed Problem/Need #1: I desire advanced directives/DNR (Do Not Resuscitate) as of [DATE]. Approaches included to Honor my request for DNR status and Do not perform CPR (Cardiopulmonary Resuscitation) on me. During an interview on [DATE] at 11:38 AM, when asked individually how they would determine a resident's code status in case of an emergency, Licensed P… | 2020-09-01 |
| 151 | 151 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2018-11-30 | 580 | D | 0 | 1 | JLSM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure written notice of room/roommate change was provided to 2 of 2 residents reviewed for notification of change (Residents #51 and #11). The findings included; Review of the medical record on 11/29/2018 at 4:47 PM revealed that Resident #51 was moved from room [ROOM NUMBER]A to 151A on 11/26/2018. The Social Services Notes dated 11/26/2018 stated that the family was notified by telephone. Additionally, review of Resident #11's medical record on 11/28/2018 indicated s/he had a last documented roommate change on 7/13/2017 by Social Services. However, the resident received a new roommate on 11/26/2018 and indicated to this surveyor during an interview on 11/26/2018 that s/he had not been informed of the change. S/he stated the new roommate just showed up with his/her belongings and no one told me anything. Review of the Social Services Notes revealed no documentation related to the recent roommate change. During an interview on 11/28/18 at 12 PM, the Social Services Director stated that written notices were not sent out and notifications of room/roommate changes were made only by telephone calls. Review of the facility's policy titled, Resident Rights/ Room and/or Roommate Change states, The resident and/or family have the right to be informed in advance and in writing, to include the reason for the change, before the room or roommate in the facility is changed, unless it is an emergent situation for resident safety. | 2020-09-01 |
| 152 | 152 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2018-11-30 | 583 | E | 0 | 1 | JLSM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to protect the privacy of medical records for 3 of 3 sampled residents reviewed for Baseline Care Plans (Residents #51, #65, and #135). The findings included: The facility admitted Resident #135 on 11-8-18 with [DIAGNOSES REDACTED]. Dementia with Behavioral Disturbance, [MEDICAL CONDITIONS] Fibrillation, [MEDICAL CONDITION], Hypertension, [MEDICAL CONDITION], Reflux, [MEDICAL CONDITION] Left Lower Extremity, and Acute Kidney Injury. Review of the 11/8/18 Baseline Care Plan on 11/28/18 at 9:48 AM revealed documentation that the plan was verbally reviewed with the Resident Representative on 11/9/18. There was no evidence in the record that a summary or copy of the Baseline Care Plan was provided. During an interview on 11/28/18 at 4:31 PM, the Minimum Data Set (MDS) Coordinator stated that if the resident and family were not able to attend the Baseline Care Plan meeting and s/he was unable to reach them by phone, s/he documented and left a copy in the resident's room in an envelope. Resident #65 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #51 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Record review for Residents #65 and #51 revealed no evidence that the facility had provided summaries or copies of the Baseline Care Plans to the residents or their representatives. During an interview on 11/28/18 at 4:31 PM, the Minimum Data Set (MDS) Coordinator stated s/he did not mail out the summaries or copies. S/he stated s/he left them in the resident's room in an envelope and called the family to let them know s/he left it in the room if s/he could get hold of them. The facility's Baseline Care Plan and Form Policy states, The facility must provide the resident and their representative with a summary of the baseline care plan . | 2020-09-01 |
| 153 | 153 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2018-11-30 | 584 | E | 0 | 1 | JLSM11 | Based on observations and interviews, the facility failed to ensure corridor wall coverings and baseboards were in good repair primarily on 1 of 4 halls. The findings included: On all days of the survey,[NAME]Hall wall coverings were noted to be permanently stained with what appeared to be some type of liquid that had been sprayed, run down the walls, and dried. Baseboards were darkly scarred throughout and chipped in multiple places. Housekeeping contracted management was observed cleaning the walls on 11/27/18 and 11/28/18 in unsuccessful attempts to remove the wall stains. On 11/27/18 at 1:38 PM, the Assistant Director of Nurses verified that wall coverings were discolored and stated, It looks like it has been sprayed with something. On 11/27/18 at 5:30 PM, the Administrator and Housekeeping Contract Manager stated the walls had been cleaned but the stains would not come out. On 11/28/18 at 8:51 AM, the Housekeeping Contract Manager stated the walls must have been cleaned with an inappropriate chemical. | 2020-09-01 |
| 154 | 154 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2018-11-30 | 604 | D | 0 | 1 | JLSM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to ensure the resident is free from unnecessary physical restraint. The facility did not afford the resident the opportunity to be free from the restraint when in close view of the staff or when participating in activities in the presence of the activity coordinator, other staffs and residents. The facility also failed to appropriately implement attempts to discontinue the restraint for one of six sample residents reviewed for restraints. The findings included: The facility admitted Resident #66 on 6/9/17 with [DIAGNOSES REDACTED]. During the initial survey tour on 11/26/18 at 10:45 AM Resident #66 seat on his/her wheelchair in the dining/activity room, lap belt in place, attempting to take off arm skin protector, at which time a certified nursing assistant (C.N.A) took the resident back to his/her room. On 11/27/18 the resident was seated at the nurse's station again and half an hour later in the activity room, lap belt in place at both observations. Resident's room observation on 11/28/18 at 10:42 AM revealed bed in low position, side rails in place and large floor mats at both side of the bed. Nurse's notes reviewed on 11/27/18 at 1:13 PM revealed that the resident has a lap belt restraint that is released every two hours, during activity and meal times. However, this intervention did not occur during surveying hours. According to the care plan reviewed on 11/28/18 at approximately 11:00 AM on 11/13/18 the facility put a three day restraint reduction attempt in placed, Lap belt removed and resident situated in the common area for easy viewing. But the restraint reduction documentation showed that after releasing the lap belt if the resident tried to get up from his/her wheelchair the staff would place the lap belt back on. During an interview with the care plan coordinator and director of nursing (DON) on 11/28/18 at approximately 11:30 AM confirmed that the three … | 2020-09-01 |
| 155 | 155 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2018-11-30 | 607 | D | 0 | 1 | JLSM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement the policy related to Abuse for one incident of resident to resident abuse reviewed. The findings include; Res #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 11/26/2018 at approximately 2:43 PM during a resident interview with this surveyor, Resident #11 indicated that s/he had been kicked on last week by another resident and nothing was done about it. Further interview, the resident explained a male resident had approached him/her, kicked and walked away. After the incident, s/he told Registered Nurse (RN) #2 who then was believed to have told the Director of Nursing (DoN). Further interview with RN #2, s/he stated s/he had told the DoN but had not personally done anything to alleviate or investigate the incident. During record review on 11/28/18 at 9:15 AM, there was no documentation of the alleged incident noted. During an interview with RN#2 on 11/28/18 at 12:28 PM, s/he indicated that s/he had not visibly witnessed the incident, but the resident had made him/her aware and s/he told his/her direct supervisor, the DoN. On 11/28/2018 at 3:26 PM, during an interview with the DoN, s/he stated this was his/her first time hearing of the incident. Review of the facility's policy titled, Resident Rights- Abuse and Abuse Prevention, Neglect and Exploitation provided by the DoN on 11/28/18 at 3:30 PM states response and reporting of abuse, neglect and exploitation- anyone in the facility can report suspected abuse to the abuse agency hotline, when abuse, neglect or exploitation is suspected, the Licensed Nurse should: respond to the needs of the resident and protect them from further incident (Document), notify the Director of Nursing and Administrator (document), and initiate an investigation immediately . | 2020-09-01 |
| 156 | 156 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2018-11-30 | 609 | D | 0 | 1 | JLSM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to report an allegation of resident-resident abuse in a timely manner. The findings included; Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 11/26/2018 at approximately 2:43 PM during a resident interview with this surveyor, Resident #11 indicated that s/he had been kicked on last week by another resident and nothing was done about it. Further interview, the resident explained a male resident had approached him/her, kicked and walked away. After the incident, s/he told Registered Nurse (RN) #2 who then was believed to have told the Director of Nursing (DoN). During record review on 11/28/18 at 9:15 AM, there was no documentation of the alleged incident noted. During an interview with RN#2 on 11/28/18 at 12:28 PM, s/he indicated that s/he had not visibly witnessed the incident, but the resident had made him/her aware and s/he told his/her direct supervisor, the DoN. On 11/28/2018 at 3:26 PM, during an interview with the DoN, s/he stated this was his/her first time hearing of the incident. Review of the facility's policy titled, Resident Rights- Abuse and Abuse Prevention, Neglect and Exploitation provided by the DoN on 11/28/18 at 3:30 PM states response and reporting of abuse, neglect and exploitation- anyone in the facility can report suspected abuse to the abuse agency hotline, when abuse, neglect or exploitation is suspected, the Licensed Nurse should: respond to the needs of the resident and protect them from further incident (Document), notify the Director of Nursing and Administrator (document), and initiate an investigation immediately . | 2020-09-01 |
| 157 | 157 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2018-11-30 | 610 | D | 0 | 1 | JLSM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to report an allegation of resident-resident abuse in a timely manner. The findings included; Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 11/26/2018 at approximately 2:43 PM during a resident interview with this surveyor, Resident #11 indicated that s/he had been kicked on last week by another resident and nothing was done about it. Further interview, the resident explained a male resident had approached him/her, kicked and walked away. After the incident, s/he told Registered Nurse (RN) #2 who then was believed to have told the Director of Nursing (DoN). During record review on 11/28/18 at 9:15 AM, there was no documentation of the alleged incident noted. During an interview with RN#2 on 11/28/18 at 12:28 PM, s/he indicated that s/he had not visibly witnessed the incident, but the resident had made him/her aware and s/he told his/her direct supervisor, the DoN. On 11/28/2018 at 3:26 PM, during an interview with the DoN, s/he stated this was his/her first time hearing of the incident. S/he then verified there was no investigation started at the time or any information documented regarding the incident. Review of the facility's policy titled, Resident Rights- Abuse and Abuse Prevention, Neglect and Exploitation provided by the DoN on 11/28/18 at 3:30 PM states response and reporting of abuse, neglect and exploitation- anyone in the facility can report suspected abuse to the abuse agency hotline, when abuse, neglect or exploitation is suspected, the Licensed Nurse should: respond to the needs of the resident and protect them from further incident (Document), notify the Director of Nursing and Administrator (document), and initiate an investigation immediately .Additionally the policy states when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur, an investigation is immediately warranted. Onc… | 2020-09-01 |
| 158 | 158 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2018-11-30 | 623 | D | 0 | 1 | JLSM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview , the facility failed to provide written notice of facility-initiated transfer to the Residents' Representatives and/or Ombudsman for 2 of 5 sampled residents reviewed for hospitalization (Residents #67 and #70) . The findings included: The facility admitted Resident #67 with [DIAGNOSES REDACTED]. Record review on 11/28/18 at 2:31 PM revealed the resident was transferred to the hospital on 9-25-18 for Aspiration Pneumonia. Further review revealed no evidence of written notification of the transfer to the Resident Representative. During an interview on 11/30/18 at 12:12 PM, when asked about notification of the family, Social Services stated there should be documentation in the record that the family was called. S/he was unaware of the requirement for a written notice to be sent. The facility admitted Resident #70 with [DIAGNOSES REDACTED]. Record review on 11/27/18 at 12:53 PM revealed the resident was hospitalized from [DATE] to 10/26/18 for Agitation, Combativeness, and [DIAGNOSES REDACTED]. Further review revealed no evidence of written notification of the transfer to the Resident Representative or Ombudsman. During an interview on 11/30/18 at 12:18 PM, Social Services reviewed her/his documentation of monthly reports and stated s/he had not sent transfer notifications to the Ombudsman for the month of October. S/he was unaware of the requirement for a written notice of transfer to be sent to the Resident Representative. | 2020-09-01 |
| 159 | 159 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2018-11-30 | 625 | D | 0 | 1 | JLSM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide written notice of bed-hold to the Residents' Representatives upon facility-initiated transfer for 2 of 5 sampled residents reviewed for hospitalization (Residents #67 and #70). The findings included: The facility admitted Resident #67 with [DIAGNOSES REDACTED]. Record review on 11/28/18 at 2:31 PM revealed the resident was transferred to the hospital on 9-25-18 for Aspiration Pneumonia. Further review revealed no evidence of written notification of the facility's bed-hold policy supplied to the Resident Representative upon transfer. During an interview on 11/30/18 at 9:18 AM, the Director of Nurses (DON) reviewed the record, was unable to locate any information about bed-hold notification, and referred the surveyor to Social Services. During an interview on 11/30/18 at 12:12 PM, Social Services reviewed the record and was unable to locate any information about bed-hold notification. S/he was unsure who was responsible for bed-hold notification upon transfer. The facility admitted Resident #70 with [DIAGNOSES REDACTED]. Record review on 11/27/18 at 12:53 PM revealed the resident was hospitalized from [DATE] to 10/26/18 for Agitation, Combativeness, and [DIAGNOSES REDACTED]. Further review revealed no evidence of written notification of the facility's bed-hold policy supplied to the Resident Representative upon transfer. During an interview on 11/30/18 at 9:18 AM, the Director of Nurses (DON) reviewed the record, was unable to locate any information about bed-hold notification, and referred the surveyor to Social Services. During an interview on 11/30/18 at 12:18 PM, Social Services reviewed the record and was unable to locate any information about bed-hold notification. S/he was unsure who was responsible for bed-hold notification upon transfer. | 2020-09-01 |
| 160 | 160 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2018-11-30 | 641 | E | 0 | 1 | JLSM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to assure the accuracy of assessments for 7 of 23 sampled residents reviewed for accuracy of Minimum Data Set (MDS) assessments (Residents #23, #52, #57, #66, #67, #70, and #135) and for 2 of 2 residents noted on the MDS 3.0 Missing OBRA Assessment report (Residents #40 and #60). The findings included: The facility admitted Resident #23 with [DIAGNOSES REDACTED]. Review of the 8-29-18 Admission/5-Day and the 9/7/18 14-Day MDS assessments on 11/29/18 at 11:23 PM revealed the following: (1) Section B of both assessments noted that the resident was sometimes understood and sometimes understands. However, the Section C Brief Interview for Mental Status (BIMS) and the Section D Mood interviews were not conducted. The reasons recorded were that the resident was rarely/never understood. (2) The 9/7/18 14-Day assessment only had one fall coded. Review of Incident/Accident Reports on 11/30/18 at 9:34 AM revealed the resident had sustained 2 falls during the 7-day look-back period (on 9/1/18 and 9/5/18). During an interview on 11/30/18 at 10:19 AM, the MDS Coordinator stated that Sections C and D were completed by Social Services. S/he verified that the coding for not conducting the interview because the resident was rarely/never understood was not consistent with the coding in Section B. S/he reviewed the record, verified the falls noted in the Nurses Notes and on the Care Plan, and confirmed that the number of falls coded on the 14-Day MDS was incorrect. The facility admitted Resident #52 with [DIAGNOSES REDACTED]. Hypertension, [MEDICAL CONDITION], Dementia, Aspiration Pneumonia, Dysphagia, Gastro-[MEDICAL CONDITION] Reflux Disease, B-12 Deficiency, and Multiple [MEDICAL CONDITION]. Review of the 2-6-18 Significant Change and the 10-21-18 Quarterly MDS assessments on 11/27/18 at 7:48 PM revealed the following: (1) Section B of both assessments noted that the resident was usually understood an… | 2020-09-01 |
| 161 | 161 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2018-11-30 | 644 | D | 0 | 1 | JLSM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to complete a Preadmission Screening and Resident Review (PASRR) Level II for a resident with a positive PASRR level I and a history of psychiatric hospitalization at the time of admission to the facility for one of one sampled resident reviewed for PASRR. Findings: The facility admitted Resident #15 on 12/1/14 with [DIAGNOSES REDACTED]. During an observation on 11/26/18 at 3:34 PM the resident seems to get agitated very easy when greeted in the hallway s/he responded in a distrustful manner. The next day, during lunch in the dining room s/he did not want the certified nursing assistant (C.N.A) to help him/her with the food protector. Nurse's notes reviewed on 11/29/18 at 2:36 PM indicated that the resident could verbalize some need to staff. However, his speech is unclear and incoherent and often refuses care, gets combative and yells out loud. Record reviewed on 11/29/18 at approximately 3:00 PM revealed a PASRR level I completed on 11/18/14 (prior admission) indicated that the resident had a history of [REDACTED]. During an interview with the DON on 11/29/18 at 4:00 PM she stated that the resident had not had any incidents for the last three months. She also noted that the resident had not had a PASARR Level II because according to his/her interpretation of the regulation the resident did not need one. The DON later acknowledged that the resident should have had a level II PASRR and possibly psychiatric services. | 2020-09-01 |
| 162 | 162 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2018-11-30 | 655 | E | 0 | 1 | JLSM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation,record review and interview the facility failed to provide evidence of Baseline care plan development and provided summaries for 3 of 3 residents reviewed for baseline care plans. The findings included: Resident #65 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #51 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Record review for Residents #65 and #51 revealed the facility had not provided copies of the summary of the baseline care plans to the residents or their representatives. During an interview on 11/28/18 at 4:31 PM, the Minimum Data Set (MDS) Nurse indicated s/he does not mail out the summaries, s/he leaves it in the room in an envelope and calls the family to let them know s/he left it in the room if s/he can get a hold of them. A review of the facility's MDS Policy- Baseline Care Plan and Form Policy on 11/30/2018 at 12:47 PM states, the facility must provide the resident and their representative with a summary of the baseline care plan . The facility admitted Resident #135 on 11-8-18 with [DIAGNOSES REDACTED]. Dementia with Behavioral Disturbance, [MEDICAL CONDITIONS] Fibrillation, [MEDICAL CONDITION], Hypertension, [MEDICAL CONDITION], Reflux, [MEDICAL CONDITION] Left Lower Extremity, and Acute Kidney Injury. Review of the 11/8/18 Baseline Care Plan on 11/28/18 at 9:48 AM revealed documentation that the plan was verbally reviewed with the Resident Representative on 11/9/18. There was no evidence in the record that a summary or copy of the Baseline Care Plan was provided. During an interview on 11/28/18 at 4:31 PM, the Minimum Data Set (MDS) Coordinator stated that if the resident and family were not able to attend the Baseline Care Plan meeting and s/he was unable to reach them by phone, s/he documented and left a copy in the resident's room in an envelope. The Minimum Data Set (MDS) Coordinator stated s/he never mailed a summary or copy of the Baseline Care Plan… | 2020-09-01 |
| 163 | 163 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2018-11-30 | 656 | D | 0 | 1 | JLSM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to develop/implement the care plan interventions related to proper positioning during enteral feeding therapy for one of two sampled residents reviewed for tube feeding. Findings: The facility admitted Resident #33 on 3/11/18 with [DIAGNOSES REDACTED]. During the initial survey tour on 11/26/18 at 4:22 PM observed Resident #33 in a low bed with the head of it slightly raised and the resident slid down to the lower part of the bed while receiving enteral feeding. On 11/27/18 at 11:03 AM, 11/29/18 at 2:57 PM, and 11/29/18 at 4:05 PM observed the resident in a similar position. At no point during the survey, from 11/26 through 11/30, the surveyor saw any of the facility staff turning or repositioning the resident. The care plan reviewed on 11/29/18 at 3:40 PM indicated that the head of the resident's bed should be up 30-45 degrees during feeding therapy. The care plan also stated that the certified nursing assistant would turn and reposition the resident every 2 hours to prevent skin breakdown related to impaired bed mobility. The care plan did not address the resident actual or inappropriate positioning during feeding therapy. During an interview on 11/29/18 at 4:05 PM the unit manager confirmed that the resident slid down in his/her bed during feeding and stated that as an intervention to prevent complication the resident gets repositioned every 2 hours, however, s/he was not able to provide supporting evidence/documentation to indicate that the resident is being turned and repositioned every 2 hours. | 2020-09-01 |
| 164 | 164 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2018-11-30 | 657 | D | 0 | 1 | JLSM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to update the Care Plan for one of two sampled residents reviewed for abuse. The Care Plan for Resident #135 was not updated to include an incident of resident-to-resident abuse. The findings included: The facility admitted Resident #135 on 11-8-18 with [DIAGNOSES REDACTED]. Dementia with Behavioral Disturbance, [MEDICAL CONDITIONS] Fibrillation, [MEDICAL CONDITION], Hypertension, [MEDICAL CONDITION], Reflux, [MEDICAL CONDITION] Left Lower Extremity, and Acute Kidney Injury. Record review on 11/28/18 at 10:07 AM revealed an entry in Nurse's Notes at 12:57 PM on 11/15/18: Notified by (Licensed Practical Nurse #1) that resident was found by two CNAs (Certified Nursing Assistants) hitting another resident in his back while he was resting in his bed . Review of the 11/8/18 Baseline Care Plan and the 11/22/18 Interdisciplinary Care Plan on 11/28/18 at 9:48 AM revealed no mention of the behavior/incident. During an interview on 11/28/18 at 4:08 PM, the Director of Nurses verified that neither the Baseline nor Interdisciplinary Care Plan had been updated to include the resident-to-resident abuse incident on 11/15/18. | 2020-09-01 |
| 165 | 165 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2018-11-30 | 686 | D | 0 | 1 | JLSM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview , the facility failed to provide appropriate care and services to promote healing and prevent infection for one of two sampled residents observed for pressure ulcer treatments. The nurse failed to clean the scissors prior to cutting off the soiled dressing during observation of a pressure ulcer treatment for [REDACTED]. The findings included: During observation of a pressure ulcer treatment to the left heel on 11/27/18 at 2:08 PM, Registered Nurse (RN) #1 removed a scissors from her/his pocket. Without sanitizing it, s/he cut the undated soiled dressing from the unstageable malodorous wound (at least 3 inches in diameter eschar) on the heel. During an interview following the treatment, RN #1 verified s/he had taken the scissors from her/his pocket and used it to cut the dressing off without cleansing it. The RN stated s/he should have cleaned it with bleach wipes. | 2020-09-01 |
| 166 | 166 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2018-11-30 | 692 | D | 0 | 1 | JLSM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to complete a nutritional assessment and implement recommendations in a timely manner for Resident #67, one of 2 sampled residents reviewed for nutrition. The findings included: The facility admitted Resident #67 with [DIAGNOSES REDACTED]. Review of weights on 11/26/18 at 1:55 PM revealed the resident sustained [REDACTED].#) to 11/6/18 (148#), equivalent to 10.3%. Record review on 11/28/18 at 2:31 PM revealed a 10/11/18 physician's orders [REDACTED]. Review of Dietary Notes on 11/28/18 at 3:33 PM revealed that the Licensed Dietitian did not complete the assessment until 10/24/18, 13 days later. A recommendation to increase the resident's tube feeding of Fibersource HN from 58 milliliters (ml) per hour to 77 ml per hour over a 12 hour period to promote weight maintenance was not ordered or implemented until 10/26/18. During an interview on 11/29/18 at 2:54 PM, the Director of Nurses verified the above information. | 2020-09-01 |
| 167 | 167 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2018-11-30 | 693 | D | 0 | 1 | JLSM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to ensure that the resident maintained proper position during administration of enteral feeding for one of two sample residents reviewed for tube feeding. Findings: The facility admitted Resident #33 on 3/11/18 with [DIAGNOSES REDACTED]. During the initial survey tour on 11/26/18 at 4:22 PM observed Resident #33 in a low bed with the head of it slightly raised, and the resident slides down to the lower part of the bed while receiving enteral feeding. On 11/27/18 at 11:03 AM, 11/29/18 at 2:57 PM, and 11/29/18 at 4:05 PM observed the resident in a similar position. The care plan reviewed on 11/29/18 at 3:40 PM indicated that the head of the resident's bed should be up 30-45 degrees during feeding therapy. During an interview on 11/29/18 at 4:05 PM the unit manager confirmed that the resident slides down his/her bed during feeding. | 2020-09-01 |
| 168 | 168 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2018-11-30 | 755 | E | 0 | 1 | JLSM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure that medications were started in a timely manner for 1 of 5 sampled residents reviewed for unnecessary medication. [MEDICATION NAME] and [MEDICATION NAME] were not available for administration so as to be started in a timely manner for Resident #67. The findings included: The facility admitted Resident #67 with [DIAGNOSES REDACTED]. Record review on 11/28/18 at 2:31 PM revealed 11/1/18 physician's orders [REDACTED]. Review of the Medication Administration Records (MARs) on 11/28/18 revealed that the [MEDICATION NAME] was not started until 11/4/18 and was omitted on 11/7/18 due to awaiting med from pharmacy. Review of physician's orders [REDACTED].#67 had an order for [REDACTED]. Nurses Notes indicated that Registered Nurse (RN) #2 contacted the pharmacy representative who instructed her/him to access the Cubex system (emergency drug supply) for the medication. RN #2 documented that the medication was not available for administration. Review of the Medication Administration Records on 11/28/18 revealed that the [MEDICATION NAME] was not started until 9/29/18. During an interview on 11/29/18 at approximately 10 AM, RN #2 verified that the [MEDICATION NAME] was not available to be given as ordered. When asked about the availability of [MEDICATION NAME], the RN stated s/he remembered running low in Cubex. During an interview on 11/29/18 at 10:44 AM, the Director of Nurses stated the [MEDICATION NAME] was increased due to an exascerbation of the Bullous Disorder and verified the documentation in the Nurses Notes and MAR. During an interview on 11/29/18 at 10:09 AM, the RN Consultant provided a copy of the contents of the Cubex system which noted both [MEDICATION NAME] and [MEDICATION NAME] should have been available for administration. | 2020-09-01 |
| 169 | 169 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2018-11-30 | 757 | E | 0 | 1 | JLSM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to document the necessity for and effectiveness of PRN (as needed) medication administered for pain for 1 of 5 sampled residents reviewed for unnecessary medication. Resident #67 received [MEDICATION NAME] five times in 11/18 with no documented reason or results. The findings included: The facility admitted Resident #67 with [DIAGNOSES REDACTED]. Record review on 11/28/18 at 2:31 PM revealed a physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. There was no documentation found to show pain level or location at the time the medication was administered or monitoring to determine effectiveness after administration. During an interview on 11/29/18 at 10:44 AM, the Director of Nurses (DON) reviewed the record and verified the lack of documentation for [MEDICATION NAME] administration. The DON stated s/he would expect the documentation to be on the MAR. | 2020-09-01 |
| 170 | 170 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2018-11-30 | 880 | D | 0 | 1 | JLSM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews, the facility failed to ensure that appropriate handwashing procedures were implemented following completion of one of two pressure ulcer treatments observed (Resident #67). The findings included: The facility admitted Resident #67 with [DIAGNOSES REDACTED]. Following a pressure ulcer treatment for [REDACTED].#2 sanitized her/his hands and exited the resident's room. S/he entered the shower room, opened the bin with her/his hand, and disposed of the bag of trash from the treatment. The nurse then left the room without washing/sanitizing her/his hands and headed toward the nursing station. When asked about washing her/his hands after touching the trash bin lid, RN #2 stated s/he would go to the nurse's desk to sanitize her/his hands or to the bathroom located near there. No sanitizer was observed at the nurses station. When washing hands in the bathroom was discussed, the nurse admitted s/he would contaminate the key and doorknob prior to being able to wash hands in that location. The Assistant Director of Nurses (ADON) observed the procedure and stated that RN #2 should have washed her/his hands in shower. The DON stated the nurse should have washed hands in the shower where a sink was readily available. | 2020-09-01 |
| 171 | 171 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2018-11-30 | 924 | D | 0 | 1 | JLSM11 | Based on observation and interview, the facility failed to ensure that handrails were installed as required on one of 4 halls. The findings included: Observations on all days of the survey revealed 3 sections of handrails missing on[NAME]Hall. Two sections were missing, one on either side of the Conference room, and one section was missing between the patio exit (across from the Conference Room) and the fire doors. During an interview on 11/28/18 at 8:16 AM, the Maintenance Supervisor and Administrator were measuring the walls and verified that (2) 4' and (1) 8' sections of handrails had not been installed. | 2020-09-01 |
| 1841 | 1841 | PRUITTHEALTH-AIKEN | 425145 | 830 LAURENS STREET NORTH | AIKEN | SC | 29801 | 2017-05-25 | 157 | D | 0 | 1 | K3UF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to notify the physician of multiple incidents of pulling on a Permacath used for [MEDICAL TREATMENT] and a Percutaneous Endoscopic Gastrostomy feeding tube in order to timely initiate treatment for [REDACTED].#193, 1 of 1 resident reviewed with a Permacath. The findings included: The facility admitted Resident #193 with [DIAGNOSES REDACTED]. On 04/19/2017, review of the nurses notes revealed the following entries: 3/26/17 Resident observed digging in wound, removing dressing and putting BM in the wound. 3/25/17 Removed dressing from [MEDICAL TREATMENT] port, pulling at GT (Gastrostomy Tube). 3/20/17 Unhooked GT, feeding on floor. 3/15/17 Removed dressing from [MEDICAL TREATMENT] port, stitches observed to be dislocated. GT disconnected, feeding on floor. 3/12/17 Cont(inues)) to pull at [MEDICAL TREATMENT] port, removed dressings, pulling on GT 3/11/17 Pulling at [MEDICAL TREATMENT] port, removing dressing, pulling at GT, feeding observed on floor, resident removed GT from port 2/18/17 observed pulling on portcath (sic) to upper chest wall times two. Informed resident not to pull on it. Observed dressing to portacath half way off and bright red drainage noted from the insertion site. Nurse cleaned area and put new and bigger dressing to site to prevent resident from pulling on portacath. Record review revealed no documentation the physician was notified of any of the above incidents At 4:51 PM, review of the Physicians Orders revealed orders dated 4/6/17 for mitts to bilateral hands daily for safety and 4/11/17 for chest xrays AP (anterior/posterior), lateral and left oblique to check port (permacath) placement. During an interview at 4:24 PM on 04/20/2017, the Director of Nursing (DON) confirmed the documentation of the resident pulling at the [MEDICAL TREATMENT] access line and the PEG tube on 2/18/17, 3/11, 3/12, 3/15 and 3/20/17. The DON also confirmed the resident had a Permacath, … | 2020-09-01 |
| 1842 | 1842 | PRUITTHEALTH-AIKEN | 425145 | 830 LAURENS STREET NORTH | AIKEN | SC | 29801 | 2017-05-25 | 201 | D | 1 | 1 | K3UF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, the facility failed to ensure that each resident remained at the facility and was not discharged inappropriately. There was a resident to resident incident on 3/23/17 between Resident #68 and Resident #237. The facility failed to adequately document the circumstances of the incident and discharged Resident #237 because of the incident. The incident happened at approximately 4:50 PM on 3/23/17. Resident #237 was discharged from the facility to the hospital at 2:00 AM on 3/24/17. There was no documentation related to why there was a lapse in time between the incident and the resident's discharge. There was no documentation of Resident #237 having additional behaviors between the time of the incident and the time of the resident's discharge. One of one resident reviewed for inappropriate discharge. The findings included: Resident #237 was admitted to the facility on [DATE]. The resident was seen by the psychiatrist on 1/22/17 who indicated the resident was hospitalized with withdrawal and possible [MEDICAL CONDITION] activity prior to nursing home admission. The resident had a history of [REDACTED]. Review of the hospital Discharge Summary dated 12/16-12/28/16 revealed the resident's past medical history was positive for chronic [MEDICAL CONDITION] and it appears that he has dementia associated with it. Review of the Physician's Telephone Orders dated 3/23/17 revealed, may send to hospital for evaluation, may have 1:1 until leaves for hospital. Review of the Behavior Management Documentation Form revealed the program was initiated 1/3/17 and the resident entered into the program. The resident was removed from the program 2/27/17 related to no behaviors noted. Review of the Nurses' Notes dated 1/6/17 revealed behavior reviewed. Admit to behavior management program for aggression with staff during redirection, attempt transfer with no assist, wanders with exit seeking and refusal of care. The Nurs… | 2020-09-01 |
| 1843 | 1843 | PRUITTHEALTH-AIKEN | 425145 | 830 LAURENS STREET NORTH | AIKEN | SC | 29801 | 2017-05-25 | 225 | G | 1 | 1 | K3UF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, the facility failed to ensure that all alleged violations involving abuse are reported to the State Survey Agency and failed to provide evidence that an allegation of sexual abuse was thoroughly investigated. Resident #68 was found sitting in Resident #237's lap in a resident room. Resident #237 was noted to have his penis exposed. One of one allegation reviewed for abuse. The findings included: Review of Resident #68's medical record revealed a SBAR Communication Form dated 3/23/17 that indicated the resident was noted sitting on a male peer's lap (Resident #237). The SBAR noted Resident #68 was fully clothed sitting on the male peer's lap while the male peer had his penis exposed. Review of the medical record revealed Resident #68's [DIAGNOSES REDACTED]. The residents resided on the facility's memory support unit ([CONDITION]U). Review of the Resident Incident Report for Resident #68 dated 3/23/17 at 4:50 PM revealed Resident #68 was unable to be interviewed. Resident confused and disoriented x 3 at baseline. The Resident Incident Report indicated the location of the incident was resident room, but did not indicate the room number where the incident occurred. The follow-up section indicated the resident's physician was notified, deferred to ER physician for examination. ER physician did not perform a rape kit, but did screen for a urinary tract infection via urinalysis. Review of the Nurse's Note dated 3/23/17 at 10:15 PM revealed Resident #68 was transferred to the hospital ER via ambulance to be evaluated. The Nurse's Note dated 3/24/17 at 2:30 AM indicated Resident #68 returned to the facility from the hospital. Review of the Nursing Home to Hospital Transfer Form for Resident #68 dated 3/23/17 revealed the reason for transfer section was not completed by the facility. Review of the Physician Telephone Order dated 3/23/17 indicated to send Resident #68 to the hospital for evaluation and … | 2020-09-01 |
| 1844 | 1844 | PRUITTHEALTH-AIKEN | 425145 | 830 LAURENS STREET NORTH | AIKEN | SC | 29801 | 2017-05-25 | 319 | G | 1 | 1 | K3UF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, the facility failed to ensure that a resident who displays a psychosocial adjustment difficulty received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being. Resident #237 was noted to develop behaviors after being admitted to the facility. Resident #237 was seen once by a psychiatrist and the recommendation was not followed up on. The resident's facility physician did not document anything related to the resident's behaviors or improvement. One of two residents reviewed for behaviors. The findings included: Resident #237 was admitted to the facility on [DATE]. Review of Resident #237's SC Limited Power of Attorney Form revealed the resident signed the form 12/29/16 and the witness attestation indicated the resident was of sound mind. Review of the resident's Admission Interim Care Plan revealed the resident required admission to the [CONDITION]U and was admitted [DATE] for [DIAGNOSES REDACTED]. Admit to [CONDITION]U. Review of the hospital Discharge Summary dated 12/16-12/28/16 revealed the resident's past medical history was positive for chronic [MEDICAL CONDITION] and it appears that he has dementia associated with it. Review of Resident #237's Physician's Progress Notes revealed the resident was seen 1/17/17, 2/14/17 and 3/14/17. The Physician's Progress Notes did not indicate anything related to the resident's mental status or overall cognitive status. There was no documentation related to the resident residing on the [CONDITION]U or evaluating the resident being appropriate for the unit. The resident was seen by the psychiatrist on 1/22/17 who indicated the resident was hospitalized with withdrawal and possible [MEDICAL CONDITION] activity. The resident had a history of [REDACTED]. In addition, if his [MEDICAL CONDITION] are just related to withdrawal it is possible that the [MEDICATION NAME] is playi… | 2020-09-01 |
| 1845 | 1845 | PRUITTHEALTH-AIKEN | 425145 | 830 LAURENS STREET NORTH | AIKEN | SC | 29801 | 2018-08-30 | 559 | E | 0 | 1 | H9EX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide written notification of room/ roommate changes to 3 of 3 sampled residents reviewed for these changes. Residents #18, #41, #115 and/or their Resident Representatives were not notified in advance of room/roommate changes or reasons for room changes as required. The findings included: The facility admitted Resident #18 with [DIAGNOSES REDACTED]. Review of Progress Notes on 8/30/18 at 7:54 AM revealed that Resident #18 had new roommates on 7-12-18, 8-7-18, and 8-24-18. Further review of the medical record revealed no evidence of advance written notification. During an interview on 8/30/18 at 12:43 PM, Social Worker #2 stated the resident had not been provided advance written notification of new roommates. The facility admitted Resident #41 with [DIAGNOSES REDACTED]. Review of Progress Notes on 8/30/18 at 9:19 AM and physician's orders [REDACTED].#41 was transferred to another room in the facility on 8-24-18. Further review of the medical record revealed no evidence of prior written notification to the Resident/Resident Representative, including the reason for the move. During an interview on 8/30/18 at 12:33 PM, Social Worker #2 stated the resident had not been provided advance written notification of the room change. The facility admitted Resident #115 with [DIAGNOSES REDACTED]. Review of Progress Notes on 8/29/18 at 9:38 PM revealed that Resident #115 was transferred to another room in the facility on 8-24-18. Further review of the medical record revealed no evidence of prior written notification, including the reason for the move, to the Resident/Resident Representative. During an interview on 8/30/18 at 12:37 PM, Social Worker #2 stated the Resident Representative had not been provided advance written notification of the room change. | 2020-09-01 |
| 1846 | 1846 | PRUITTHEALTH-AIKEN | 425145 | 830 LAURENS STREET NORTH | AIKEN | SC | 29801 | 2018-08-30 | 585 | D | 0 | 1 | H9EX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to issue a written grievance decision to 1 of 1 sampled resident reviewed for abuse. Resident #72 did not receive a written response to a grievance when s/he made an allegation of verbal abuse. The findings included: The facility admitted Resident #72 with [DIAGNOSES REDACTED]. During an interview on 8/28/18 at 9:45 AM, when asked if s/he had ever been abused, Resident #72 stated, About 1 month ago. The CNA (Certified Nursing Assistant) would not shut up. S/he knew better than I did what I should and could do. The resident stated s/he had reported it to Social Services. When asked how the complaint had been resolved, the resident stated, I think they moved the CN[NAME] S/he hasn't worked with me since. Review of the Grievance Log on 8/28/18 at 6:44 PM revealed that the resident's report had not been entered. During an interview on 8/28/18 at 6:52 PM, Social Worker (SW) #2 stated s/he had been the Manager on Duty the day of the incident, had notified the Director of Nursing and Administrator, and had initiated the investigation. When asked about the lack of information in the Grievance Log, the SW said s/he had processed the information to the Administrator. S/he stated, It would not be in the log if it never came back to me. During an interview on 8/29/18 at 4:39 PM, when asked if s/he had received the results of the investigation in writing, Resident #72 stated s/he had never received anything in writing from the facility. During an interview on 8/30/18 at 12:49 PM, SW #2 verified that there was no evidence of written notification of the resident of the results of the grievance in the medical record. The SW stated s/he knew that the form used to record the grievance had a place for documentation of resident/family notification, but I don't think a written response is given. During an interview on 8/30/18 2:40 PM, the Admissions Coordinator verified that a written grievance decision h… | 2020-09-01 |
| 1847 | 1847 | PRUITTHEALTH-AIKEN | 425145 | 830 LAURENS STREET NORTH | AIKEN | SC | 29801 | 2018-08-30 | 606 | D | 0 | 1 | H9EX11 | Based on review of personnel files and facility abuse policies, and interview, the facility failed to ensure that 2 of 5 newly employed nursing staff had license and/or certification verification completed prior to date of hire. The findings included: Review of newly hired nursing staff on 8/29/18 at 9:55 AM revealed the following: (1) Registered Nurse #3 was hired on 7-12-18. The license verification was not completed until 7-16-18. (2) Certified Nursing Assistant (CNA) #2 was hired on 5-22-18. The CNA verification of certification was not completed until 6-6-18. During an interview on 8/29/18 at 10:13 AM, this information was reviewed and confirmed by the Administrator. The facility policy titled Partner Background Screening to Prevent Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property states: 2. The background screening of all applicants for employment should involve the following . Licensure/certification verification . | 2020-09-01 |
| 1848 | 1848 | PRUITTHEALTH-AIKEN | 425145 | 830 LAURENS STREET NORTH | AIKEN | SC | 29801 | 2018-08-30 | 607 | D | 0 | 1 | H9EX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of abuse policies and procedures, the facility failed to follow established policies/procedures for pre-employment licensure/certification verifications and for reporting allegations of abuse for one of one sampled resident reviewed for abuse. The facility failed to notify the State Agency within 2 hours for Resident #72. The findings included: The facility admitted Resident #72 with [DIAGNOSES REDACTED]. Review of the 7-3-18 Quarterly Minimum Data Set Assessment revealed that the resident was cognitively intact with a Brief Interview for Mental Status score of 15. During an interview on 8/28/18 at 9:45 AM, when asked if s/he had ever been abused, Resident #72 stated, About 1 month ago. The CNA (Certified Nursing Assistant) would not shut up. S/he knew better than I did what I should and could do. The resident stated s/he had reported it to Social Services. When asked how the complaint had been resolved, the resident stated, I think they moved the CN[NAME] S/he hasn't worked with me since. Review of the Grievance Log on 8/28/18 at 6:44 PM revealed that the resident's report had not been entered. During an interview on 8/28/18 at 6:52 PM, Social Worker (SW) #2 stated s/he had been the Manager on Duty the day of the incident, had notified the Director of Nursing and Administrator, and had initiated the investigation. When asked about the lack of information in the Grievance Log, the SW said s/he had processed the information to the Administrator. S/he stated, It would not be in the log if it never came back to me. Review of the investigation file on 8/28/18 at 7:32 PM revealed that the incident of alleged verbal abuse/altercation occurred on 6-23-18 at approximately 12 PM. There was no evidence in the file that Certification was notified until a 5-day report was sent on 6-26-18, though both Licensure and the Ombudsman were notified on 6-24-18 at 11:56 and 11:59 respectively. During an interview on … | 2020-09-01 |
| 1849 | 1849 | PRUITTHEALTH-AIKEN | 425145 | 830 LAURENS STREET NORTH | AIKEN | SC | 29801 | 2018-08-30 | 609 | D | 0 | 1 | H9EX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of the facility's abuse policies, the facility failed to ensure that the State Agency was notified of an allegation of verbal abuse within the required time frame for one of one sampled resident reviewed for abuse. The facility failed to notify the State Agency within 2 hours for Resident #72. The findings included: The facility admitted Resident #72 with [DIAGNOSES REDACTED]. Review of the 7-3-18 Quarterly Minimum Data Set Assessment revealed that the resident was cognitively intact with a Brief Interirew for Mental Status score of 15. During an interview on 8/28/18 at 9:45 AM, when asked if s/he had ever been abused, Resident #72 stated, About 1 month ago. The CNA (Certified Nursing Assistant) would not shut up. S/he knew better than I did what I should and could do. The resident stated s/he had reported it to Social Services. When asked how the complaint had been resolved, the resident stated, I think they moved the CN[NAME] S/he hasn't worked with me since. Review of the Grievance Log on 8/28/18 at 6:44 PM revealed that the resident's report had not been entered. During an interview on 8/28/18 at 6:52 PM, Social Worker (SW) #2 stated s/he had been the Manager on Duty the day of the incident, had notified the Director of Nursing and Administrator, and had initiated the investigation. When asked about the lack of information in the Grievance Log, the SW said s/he had processed the information to the Administrator. S/he stated, It would not be in the log if it never came back to me. Review of the investigation file on 8/28/18 at 7:32 PM revealed that the incident of alleged verbal abuse/altercation occurred on 6-23-18 at approximately 12 PM. There was no evidence in the file that Certification was notified until a 5-day report was sent on 6-26-18, though both Licensure and the Ombudsman were notified on 6-24-18 at 11:56 and 11:59 respectively. During an interview on 8/28/18 at 7:41 PM, the Consu… | 2020-09-01 |
| 1850 | 1850 | PRUITTHEALTH-AIKEN | 425145 | 830 LAURENS STREET NORTH | AIKEN | SC | 29801 | 2018-08-30 | 637 | D | 0 | 1 | H9EX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to conduct a Significant Change in Status Assessment (SCSA) MDS (Minimall Data Set) timely for 1 of 3 residents reviewed with a significant change in condition. The findings included: The Facility admitted Resident #116 on 12/17/12 with current [DIAGNOSES REDACTED]. On 08/28/18 at 10:52 AM, review of a 5-day PPS (Perspective Payment System) MDS dated [DATE] revealed Resident #116 had a significant decline in ADLs upon return from a hospitalization on [DATE]. Review of the state MDS data-base revealed no SCSA assessment had been transmitted. Decline was noted in bed mobility, transfers, ambulation, locomotion, toileting, and hygiene. At 04:01 PM, further review revealed the resident also had a significant decline in cognition, behaviors and continence. During an interview at 5:17 PM, MDS Nurse #1 stated the resident had started to decline towards the end of the look-back period for the 5-day PPS Medicare assessment. S/he stated that the facility started assessing the resident at that time for a SCSA and set an ARD of 08/14/18. The nurse stated that the computer then generated a completion due date of 08/28/18 and that s/he guessed they had become too dependent on the computer for that information. The nurse further confirmed the 08/07/18 MDS was the date that the facility identified the change in condition and that according to the RAI (Resident Assessment Instrument) manual, the assessment should have been completed by 08/21/18. | 2020-09-01 |
| 1851 | 1851 | PRUITTHEALTH-AIKEN | 425145 | 830 LAURENS STREET NORTH | AIKEN | SC | 29801 | 2018-08-30 | 638 | D | 0 | 1 | H9EX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to conduct a Quarterly MDS (Minimal Data Set) Assessment within 92 days of the prior assessment for Resident #116, 1 of 2 residents reviewed for missing MDS assessments. The findings included: The Facility admitted Resident #116 on 12/17/12 with current [DIAGNOSES REDACTED]. On 08/28/18 at 10:52 AM, review of the State Agency MDS data-base revealed an Annual MDS with an ARD (Assessment Reference Date) of 04/26/18. Review of the data-base revealed no Quarterly MDS assessment had been done within 92 days of the Annual MDS assessment. During an interview at 5:17 PM, MDS Nurse #1 confirmed that a quarterly MDS assessment had not been conducted because the resident was sent out to the hospital on the due date and had not been done on return because they were assessing the resident for a SCS[NAME] | 2020-09-01 |
| 1852 | 1852 | PRUITTHEALTH-AIKEN | 425145 | 830 LAURENS STREET NORTH | AIKEN | SC | 29801 | 2018-08-30 | 656 | E | 0 | 1 | H9EX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record reviews, and interviews, the facility failed to develop and/or implement the care plans for 2 of 3 sampled residents reviewed for activities, 2 of 5 sampled residents reviewed for pressure ulcers, and 4 of 4 sampled residents reviewed for range of motion (R0M). For Resident #18, a Care Plan was not developed to address contractures, the activity Care Plan goal was not measurable, and the Care Plan was not followed related to activities and positioning. For Resident #115, Care Plan goals and interventions did not reflect the staff assessment for activities on the Minimum Data Set assessment and Care Plan interventions were not followed for contractures. The Care Plan was not followed for Resident #120 related to provision of ROM and turning and positioning every 2 hours. Resident #19's Care Plan related to splint application and provision of ROM was not followed. The findings included: The facility admitted Resident #18 with [DIAGNOSES REDACTED]. Initial observation on 8/27/18 at 11:34 AM and throughout the survey revealed left upper extremity contractures with a soft elbow splint but no device or handroll in place for the hand/wrist. Review of the 6-12-18 Quarterly Minimum Data Set (MDS) Assessment on 8/29/18 at 10:57 PM revealed that the resident had functional impairment of one upper and both lower extremities. No ROM or Restorative services were noted as provided. No behaviors were noted. Review of the Care Plan on 8/30/18 at 8:02 AM revealed no reference to contractures or planned interventions to maintain or improve ROM. During an interview on 8-30-18, Registered Nurse #1 verified that the Care Plan did not address the resident's contractures. Continued review of the 10-19-17 Annual and 6-12-18 Quarterly Minimum Data Set Assessments on 8/29/18 at 10:57 PM revealed that the resident required extensive assistance with bed mobility and was at risk for pressure ulcer development. Review of the Care Plan on 8/30/1… | 2020-09-01 |
| 1853 | 1853 | PRUITTHEALTH-AIKEN | 425145 | 830 LAURENS STREET NORTH | AIKEN | SC | 29801 | 2018-08-30 | 657 | E | 0 | 1 | H9EX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to have all disciplines participate in the multidisciplinary care conference for Residents #13, #62, #19, #115 and # 120. Five of 5 residents sampled for care conference participation. The findings included: The facility admitted Resident #13 on 02/02/15 with [DIAGNOSES REDACTED]. On 08/28/18 at 09:16 AM, review of the Multidisciplinary Care Conference Meeting form dated 04/12/18 revealed no indication of attendees. The form indicated information was entered by Activities and reviewed by an LPN (Licensed Practical Nurse). Further review revealed a 02/02/18 care plan conference form that indicated the information was entered by an LPN and there was no documentation of the attendees. No evidence a Registered Nurse (RN) attended or reviewed either care plan. Additional review revealed a care plan signature sheet dated 8/8/18 signed by activities, social services and the Certified Dietary Manager (CDM). There was no evidence the care plan meeting was attended by a RN. On 08/30/18 at 11:28 AM, review of the EHR (electronic health record) IDT (interdisciplinary team) care plan documentation revealed the 08/08/18 care plan information was completed by an LPN. There was no documentation of input from Dietary, Social Services, Registered Nurse or Certified Nursing Assistant. On 06/19/18 the completion of information was conducted by an LPN. There was no documentation of input from a Registered Nurse. The 04/03/18 care plan completion of information was conducted by an LPN. There was no documentation of input from a Registered Nurse. On 01/16/18, the completion of information was conducted by an LPN. There was no documentation of input from Dietary, Social Services, Registered Nurse or Certified Nursing Assistant. During an interview on 08/30/18 at 02:00 PM, RN #1 confirmed there was no documentation that a Registered Nurse (RN) participated in the IDT or was involved in the review of the care pl… | 2020-09-01 |
| 1854 | 1854 | PRUITTHEALTH-AIKEN | 425145 | 830 LAURENS STREET NORTH | AIKEN | SC | 29801 | 2018-08-30 | 677 | E | 0 | 1 | H9EX11 | Based on observations and interview, the facility failed to provide grooming supplies and assistance to 4 of 4 sampled residents reviewed for activities of daily living. Residents #19, #41, #115, and #120 were not shaved for 4 days of the survey. The findings included: Multiple observations throughout the survey revealed that Residents #19, #41, #115, and #120 had not been shaved. Minimum Data Set Assessments and Care Plans for these residents did not address refusal of care. During an interview on 8/29/18 at 1:50 PM, when asked about the male residents not being shaved, Certified Nursing Assistant #3 stated,We ran out of razors the weekend. During an interview on 8/29/18 at 9:06 PM, Licensed Practical Nurse #6 stated, They were looking for razors on Saturday and we only found one. During an interview on 8/30/18 at 12:18 PM, Resident #41 stated, See this (rubbing clean shaven face)? I finally got a shave. I haven't had one since I was in the other building (referring to Unit 3). | 2020-09-01 |
| 1855 | 1855 | PRUITTHEALTH-AIKEN | 425145 | 830 LAURENS STREET NORTH | AIKEN | SC | 29801 | 2018-08-30 | 679 | D | 0 | 1 | H9EX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and staff and resident interviews, the facility failed to provide out of room group activities and on-going activities based on individualized prior interests for 2 of 3 sampled residents reviewed for activities (Residents #18 and #115). The findings included: The facility admitted Resident #18 with [DIAGNOSES REDACTED]. Observations during the first 2 days of the survey revealed the resident was never out of the bed or the room. Review of the 10-19-17 Annual Minimum Data Set (MDS) Assessment on 8/29/18 at 10:57 PM revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating s/he was cognitively intact. Section F of the MDS noted that listening to music and being around animals were activities the resident classified as somewhat important. S/he considered keeping up with the news, going outside, and participation in religious practices to be very important. During an interview at 4:08 PM on 8/29/18, when questioned about activity attendance, Resident #18 stated,I don't get out of bed. When asked if it was his/her choice to not get up and out of the room, s/he stated,No, that is not by my choice. On 8-28-18 at 3:03 PM, the resident stated s/he would like to get up some more, but they leave me up too long and I have pain. S/he stated s/he had not gone to church or outside for a long time. The resident could not remember when s/he had last attended. S/he stated s/he just stays in bed because I don't want to be no trouble. Review of the Care Plan on 8/30/18 at 8:02 AM revealed that the resident wanted to maintain interests as when s/he was at home. Interests included watching TV, listening to music (gospel, easy listening, rhythm and blues), attending church, going outside, hunting, fishing, gardening, and sports. The care plan goal of Will have his (her) interests met daily through next review was not specific and measurable. Interventions included: Assist with TV and music a… | 2020-09-01 |
| 1856 | 1856 | PRUITTHEALTH-AIKEN | 425145 | 830 LAURENS STREET NORTH | AIKEN | SC | 29801 | 2018-08-30 | 684 | E | 0 | 1 | H9EX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure ongoing assessment of peripheral vascular ulcers located on bony prominences for 1 of 4 sampled residents reviewed for non-pressure skin conditions. The facility failed to initially assess the presence of an ulcer on the left outer ankle for Resident #115 and conduct on-going assessments to determine progress or decline in the resident's skin condition. The findings included: The facility admitted Resident #115 with [DIAGNOSES REDACTED]. Review of Body Audits on 8/29/18 at 11:07 AM revealed that the open area on the left foot was not documented. During an interview at that time, the Unit Manager stated that the body audits should be done weekly and include all areas of compromised skin. Review of the most recent Quarterly Minimum Data Set Assessment (7-24-18) on 8/29/18 at 11:46 AM revealed no pressure or vascular ulcers coded. During a skin observation with Licensed Practical Nurse #7 on 8/27/18 at 4:53 PM, the resident was noted with an open area to the left outer ankle. Review of the skin documentation in the medical record revealed no on-going assessment of this area. During observation of wound treatments on 8/30/18 at 10:54 AM, the Registered Nurse (RN) Wound Nurse verified the condition of the left ankle and stated s/he had started measuring the area weekly. | 2020-09-01 |
| 1857 | 1857 | PRUITTHEALTH-AIKEN | 425145 | 830 LAURENS STREET NORTH | AIKEN | SC | 29801 | 2018-08-30 | 686 | E | 0 | 1 | H9EX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review , and interview, the facility failed to promote prevention of pressure ulcer development as evidenced by 2 of 5 sampled residents reviewed for pressure ulcers not being turned and positioned at least every 2 hours (Residents #18 and #120). The findings included: The facility admitted Resident #18 with [DIAGNOSES REDACTED]. Review of the 10-19-17 Annual and 6-12-18 Quarterly Minimum Data Set Assessments on 8/29/18 at 10:57 PM revealed that the resident required extensive assistance with bed mobility and was at risk for pressure ulcer development. Review of the Care Plan on 8/30/18 at 8:02 AM revealed that interventions to prevent pressure ulcers included to Reposition patient every 2 hours as tolerated. Multiple observations (on 8/27/18 at 11:34 AM, 1:32 PM, 3:03 PM, 3:58 PM, and 5:05 PM; on 08/28/18 at 8:20 AM, 10 AM, 11:17 AM, and 12:31 PM; on 8/29/18 at 7:55 AM, 9:07 AM, 10:43 AM, 12:35 PM, 2:14 PM, 3:50 PM, and 4:54 PM) revealed that Resident #18 was was on his/her back and not turned and positioned at least every 2 hours. No turning and positioning pillows or wedges were present in the resident's bed to indicate attempts made. During an interview on 8/29/18 at 6:01 PM, the Consultant Administrator reviewed SMART charting and verified that there was no documentation relating to turning and positioning for Resident #18. The facility admitted Resident #120 with [DIAGNOSES REDACTED]. Review of the 12-12-17 Annual and 7-31-18 Quarterly Minimum Data Set Assessments on 8/29/18 at 3:09 PM revealed that the resident was totally dependent for bed mobility and was at risk for pressure ulcer development. Review of the Care Plan on 8/29/18 at 3:48 PM revealed that interventions to prevent skin breakdown included to Reposition patient every 2 hours as tolerated. Multiple observations (on 8/27/18 at 11:30 AM, 1:22 PM, 3:03 PM, 3:55 PM, and 4:50 PM; on 08/28/18 at 8:20 AM, 10 AM, 11:17 AM, and 12:31 PM; on 8/29/18 at … | 2020-09-01 |
| 1858 | 1858 | PRUITTHEALTH-AIKEN | 425145 | 830 LAURENS STREET NORTH | AIKEN | SC | 29801 | 2018-08-30 | 688 | E | 0 | 1 | H9EX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to provide on-going care and services to prevent further decline in existing contractures for 4 of 4 sampled residents reviewed with limited range of motion (ROM). Residents #18, #19, #115, and #120 had no evidence of provision of ROM, restorative services, and/or splinting to prevent further decline. The findings included: The facility admitted Resident #18 with [DIAGNOSES REDACTED]. Review of the 6-12-18 Quarterly Minimum Data Set (MDS) Assessment on 8/29/18 at 10:57 PM revealed that the resident had functional impairment of one upper and both lower extremities. No ROM or Restorative services were noted as provided. No behaviors were noted. Initial observation on 8/27/18 at 11:34 AM and throughout the survey revealed left upper extremity contractures with a soft elbow splint but no device or handroll in place for the hand/wrist. Review of the Care Plan on 8/30/18 at 8:02 AM revealed no reference to contractures or planned interventions to maintain or improve ROM. Nor did the plan address any concern related to refusal of care. During an interview on 8-30-18, Registered Nurse #1 verified that the Care Plan did not address the resident's contractures. Continued review of the medical record revealed no evidence of services provided to prevent further decline in ROM. During an interview at 4:08 PM on 8/29/18, when asked about ROM, Resident #18 stated,I don't get any exercises. During an interview on 8/29/18 at 6:01 PM, the Consultant Administrator stated that Resident #18 was not on a restorative program. S/he reviewed the SMART charting and confirmed that it did not reflect provision of ROM. The facility admitted Resident #19 with [DIAGNOSES REDACTED]. Review of the 6-12-18 Quarterly MDS Assessment on 8/30/18 at 2:27 PM revealed that the resident had functional impairment of one upper and one lower extremity. No ROM or Restorative services were noted as provided. No beh… | 2020-09-01 |
| 1859 | 1859 | PRUITTHEALTH-AIKEN | 425145 | 830 LAURENS STREET NORTH | AIKEN | SC | 29801 | 2018-08-30 | 758 | E | 0 | 1 | H9EX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure residents had [DIAGNOSES REDACTED]. Residents #71 and #102 received antipsychotics without an appropriate diagnosis (2 of 5 reviewed for unnecessary medication). The findings included: Resident #71 had [DIAGNOSES REDACTED]. Record review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. Record review of a 4/12/18 Consultant Pharmacist Communication to Physician regarding a gradual dose reduction review for [MEDICATION NAME] for aggression revealed the following: It appears from nursing notes that (Resident #71) is having significant behaviors despite being on an antipsychotic for aggression. [MEDICATION NAME] may not be helping with (Resident #71's) behaviors. Consider discontinuing [MEDICATION NAME] and starting (Resident #71) on [MEDICATION NAME] 250 mg QAM (every morning). The physician indicated: No change. An attempted GDR (gradual dose reduction) is likely to result in impairment of function or increased distressed behavior. Interview with Licensed Practical Nurse (LPN) #2 on 08/29/18 at 03:56 PM confirmed the medication was ordered for aggression. S/he provided the original physician's orders [REDACTED]. Resident #102 had [DIAGNOSES REDACTED]. Record review of the (MONTH) (YEAR) Physician order [REDACTED]. Record review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Record review of a 6/28/18 pharmacy note revealed [MEDICATION NAME] .25 mg BID (twice daily) was added for aggression. Record review of a 7/17/18 Consultant Pharmacist Communication to Physician revealed a recommendation to reduce [MEDICATION NAME] to 0.25 mg qd (every day) was denied by the physician due to behaviors. Interview with LPN #3 on 08/30/18 at 10:38 AM revealed aggression was on the original 6/26/18 Physician's Interim Orders and Behavioral Disorders associated with Dementia was on the current (MONTH) (YEAR) physician's orders [REDACTED]. | 2020-09-01 |
| 1860 | 1860 | PRUITTHEALTH-AIKEN | 425145 | 830 LAURENS STREET NORTH | AIKEN | SC | 29801 | 2019-12-14 | 550 | D | 1 | 0 | T11M11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and staff interview, the facility failed to promote dignity and provide privacy related to an uncovered urinary catheter bag for three (3) residents observed during a tour of unit. (Residents #22, #23 and #24) The findings included: On [DATE] at approximately 10:15 AM during a tour of the 200 hall a urinary drainage bag was observed hanging from the side of Resident #24's bed. The drainage bag was uncovered and visible from the hallway. No urine was visible in the bag. On [DATE] at approximately 10:17 AM during a tour of the 200 hall a urinary drainage bag was observed hanging from the side of Resident #23's bed. The drainage bag was uncovered, visible from the hallway and contained approximately 100 cubic centimeters (cc) of urine. On [DATE] at approximately 11:11 AM during a tour of the 300 hall, a urinary drainage bag was observed hanging from the side of Resident #22's bed. The drainage bag was uncovered, visible from the hallway and contained a copious amount of urine. Review of Resident #22's record revealed an admission date of [DATE]. The resident's [DIAGNOSES REDACTED]. Review of Resident #23's record revealed an admission date of [DATE]. The resident's [DIAGNOSES REDACTED]., Hypertensive Heart and [MEDICAL CONDITION] with Heart Failure and with Stage 5 [MEDICAL CONDITION]. Review of Resident #24's record revealed an admission date of [DATE]. The resident's [DIAGNOSES REDACTED]. An interview and walk through were conducted with the Director of Nursing (DON) on [DATE] at 11:35 AM. The DON confirmed that Resident #22's bag was uncovered and contained approximately 700cc of urine. The DON confirmed that the bag should have been covered. It was discovered that Resident #23's bag had been folded incorrectly exposing the urine contents of the bag. The bag had to be readjusted to provide the correct privacy. Resident #24's drainage bag had no cover initially. A request was made for policies regarding di… | 2020-09-01 |
| 1861 | 1861 | PRUITTHEALTH-AIKEN | 425145 | 830 LAURENS STREET NORTH | AIKEN | SC | 29801 | 2019-12-14 | 609 | D | 1 | 0 | T11M11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview and facility policy review, it was determined the facility failed to report to the State Agency within two (2) hours an incident of potential neglect and failed to follow-up with the State Agency within five (5) workings days with final report and with evidence appropriate actions/interventions were in place to prevent further incidents for one (1) of 26 sampled residents, Resident #16. Resident #16 resided on the Memory Support Unit ([CONDITION]U) and had a history of [REDACTED]. On 10/4/19 the resident was unsupervised and obtained a peanut butter sandwich. The resident choked on the sandwich, staff worked on the resident for approximately one (1) hour, stabilizing the resident's oxygen (02) saturation levels. Later that evening the resident experienced respiratory distress, was transferred to the hospital and was admitted with [MEDICAL CONDITION]. The facility failed to report to the state and investigate this incident of potential neglect and did not produce a written report to the state agency of potential neglect within five (5) days of the incident as mandated. The findings included: Resident #16 was admitted to the Memory Support Unit ([CONDITION]U) of the facility on 6/6/18. The resident's [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set (MDS) review dated [DATE] the resident was assessed and required supervision of one (1) person, physical assistance walking in room and corridor, required extensive one (1) person physical assistance with eating a mechanically altered diet. The resident's Care Review of the Care Plan with revision date 9/23/19 noted Resident receives a therapeutic mechanically altered diet. Review of Order History Dietary Order with start date 3/6/19 end date 10/13/19: Regular, Pureed with Special Instructions: Food in bowls Review of the facility policy, Investigation of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property with revision … | 2020-09-01 |
| 1862 | 1862 | PRUITTHEALTH-AIKEN | 425145 | 830 LAURENS STREET NORTH | AIKEN | SC | 29801 | 2019-12-14 | 610 | J | 1 | 0 | T11M11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview, and review of facility policy, it was determined the facility failed to investigate an incident of potential neglect for one (1) of twenty-six (26) sampled residents, Resident #16. Resident #16 was assessed to have severe cognitive impairment and resided on the secured Memory Support Unit ([CONDITION]U). The resident was evaluated by Speech Therapy and it was determined the resident was at moderate risk for aspiration and needed a pureed diet which had initially been ordered by the physician on 3/ 6 /19. The resident's behaviors included wandering and taking resident's food from other residents in the [CONDITION]U. On 10/4/19, the resident was observed to be pale and to have difficulty breathing. When the Nurse Practitioner assessed the resident, a peanut butter sandwich was pocketed in the resident's mouth. After the sandwich was removed, the resident was suctioned, and oxygen was applied. Staff worked approximately one (1) hour to stabilize the resident. Later that evening the resident experienced respiratory distress and was transferred to the emergency room and was admitted to the hospital with [REDACTED]. The resident returned to the facility on Hospice with a [DIAGNOSES REDACTED]. The facility failed to investigate an incident potential of neglect, failed to obtain witness statements in an attempt to identify how the resident got the sandwich, thus no corrective action was taken to protect other residents from potential neglect. The facility's failure to conduct a thorough investigation of the choking incident placed residents at risk for serious injury, harm, impairment or death. The facility Administrator was notified of the Immediate Jeopardy on 12/12/19 at 1:30 PM. The Immediate Jeopardy was removed on 12/12/19 at 8:30 PM. The scope and severity was lowered to a D. The findings included: Resident #16 was admitted to the facility on [DATE] to the Memory Support Unit ([CONDITION]U). The resident's … | 2020-09-01 |
| 1863 | 1863 | PRUITTHEALTH-AIKEN | 425145 | 830 LAURENS STREET NORTH | AIKEN | SC | 29801 | 2019-12-14 | 657 | J | 1 | 0 | T11M11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview, and review of facility policy, the facility failed to revised a care plan for one 1 of 26 sampled residents, Resident #16. Resident #16's initial care plan dated 6/5/18, for wandering behavior listed interventions which included giving the resident finger foods. The resident's diet order was changed on 3/3/19 to pureed diet due to swallowing difficulty. Staff failed to revise the resident's care plan which placed the resident at risk for harm and on 10/4/19 the resident choked on a peanut butter sandwich and was transferred to the emergency room later in the day and diagnosed with [REDACTED]. The facility's failure to update Resident #16's Care plan placed the resident at risk for serious injury, harm, impairment or death. The facility Administrator was notified of the Immediate Jeopardy on 12/12/19 at 1:30 PM. The Immediate Jeopardy was removed at 8:30 PM. The scope and severity was lowered to a D. The findings included: Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility policy, Care Plans, with revision date 10/5/17 revealed it is the policy of the facility to have a comprehensive care plan with the focus of the resident at the center of control. The care plan must include at a minimum information necessary to address the resident's health and safety concerns to prevent decline or injury. Care plans will be updated by nurses, Case Mix Director (CMD), or any member of the interdisciplinary team so that the care will reflect the resident's needs at any given time. The resident's quarterly Minimum Data Set ((MDS) dated [DATE] noted the resident was assessed with [REDACTED]. According to the assessment, the resident required extensive one (1) person physical assistance for transfers, dressing, eating, toilet use, personal hygiene and was totally dependent on one (1) staff for bathing. The resident had no impairment for functional limitation in range of motio… | 2020-09-01 |
| 1864 | 1864 | PRUITTHEALTH-AIKEN | 425145 | 830 LAURENS STREET NORTH | AIKEN | SC | 29801 | 2019-12-14 | 684 | D | 1 | 0 | T11M11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, staff interview and record review, the facility failed to ensure that physician orders [REDACTED].#22) observed during a complaint survey. The findings included: Review of Resident #22's record revealed an admission date of [DATE]. The resident's [DIAGNOSES REDACTED]. On 12/11/19 at approximately 9:43 AM, Resident #22 was observed in his room in bed. The room smelled heavily of urine. The resident's urine drainage bag was covered but appeared to be sagging slightly. A staff member entered the room and noted that the bag was leaking onto the floor near the resident's bed. The resident stated that the issue had been going on for a couple of days. An observation of the drainage bag revealed that the bag contained approximately 1100 cc of urine with an undetermined amount of urine on the floor near the bed. Record review and review of physician orders [REDACTED].#20 French scale (Fr) 10 cubic centimeter (cc) bulb; Change Foley catheter monthly, Once A Day on the 9th of the Month and Flush suprapubic catheter with sterile water for leakage as needed. Review of the care plan dated [DATE], revealed that the resident was care planned for Urinary Incontinence: Resident has history of renal [MEDICATION NAME], [DIAGNOSES REDACTED], recurrent urinary tract infection and [MEDICAL CONDITION] bladder with suprapubic catheter patent. The plan notes that the resident went out to have a bladder stone procedure. Review of the resident record and progress notes revealed that the resident's catheter was changed on [DATE]. The note indicated that on 12/10/2019 a New 20Fr 30cc bulb suprapubic catheter was placed using sterile technique. An interview was conducted with LPN #1 on 12/11/19 at approximately 9:53 AM An inquiry was made regarding the catheter and why a different size bulb was utilized. The LPN stated that she would find out the reason. An interview was conducted with LPN #1 on 12/11/19 at approximately 12:33 PM The LPN confirmed t… | 2020-09-01 |
| 1865 | 1865 | PRUITTHEALTH-AIKEN | 425145 | 830 LAURENS STREET NORTH | AIKEN | SC | 29801 | 2019-12-14 | 689 | J | 1 | 0 | T11M11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > The facility failed to provide adequate supervision to maintain a safe environment for the resident and on [DATE], the resident was on a physician ordered pureed diet when the resident choked on a peanut butter sandwich. The resident was sent to hospital later that day, returned to the facility on [DATE] on Hospice and expired at the facility on [DATE]. The facility's failure to implement policy and ensure care plan interventions were revised and implemented resulted in a failure to provide adequate supervision to Resident #16 to ensure safety. The resident had a physician ordered pureed diet and on [DATE] the resident was observed having difficulty breathing. When assessed by staff the resident was pale, with low oxygen saturation levels and a peanut butter sandwich was found in the resident's mouth. Staff worked with the resident for approximately one (1) hour attempting to get the resident's oxygen saturation level up. Staff sat with the resident for several hours. Later that evening the resident experienced respiratory distress and was sent to the emergency room . The resident returned to the facility on [DATE] on Hospice care for [MEDICAL CONDITION] related to pneumonia. The resident expired at the facility on [DATE]. The facility Administrator was notified of the Immediate Jeopardy on [DATE] at 1:30 PM. The Immediate Jeopardy was removed on [DATE] at 8:30 PM. The scope and severity was lowered to a D. The findings included: Review of Resident #16's clinical record revealed an admitted to the facility of [DATE]. The resident's [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) review dated [DATE] revealed the resident was assessed to have unclear speech, rarely understood, rarely understands others, vision highly impaired and cognitive status was severely impaired. The resident had difficulty falling asleep two to six days of assessment period and exhibited physical, verbal and other behaviors directed toward others one to three … | 2020-09-01 |
| 1866 | 1866 | PRUITTHEALTH-AIKEN | 425145 | 830 LAURENS STREET NORTH | AIKEN | SC | 29801 | 2019-12-19 | 584 | E | 0 | 1 | HRL411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and review of the facility's cleaning schedule it was determined the facility failed to maintain a clean and sanitary environment on three (3) of four (4) units. The findings include: On [DATE] at 8:40 AM upon entrance to facility the odor of urine was detected around the area of the front desk. During initial tour on [DATE] at 9:30 AM a strong urine odor was detected in rooms [ROOM NUMBERS]. On [DATE] at 1:30 PM a strong odor of urine was detected around the nurses' station on the 200 Unit. On 1[DATE] at 11:21 AM a strong odor of urine was detected in room [ROOM NUMBER] Bed A, there were several missing tiles under the bed, black residue around the base of the commode and even stronger odor of urine and feces in the resident's bathroom room. Observation of the resident's bedroom detected even stronger odor and feces. On 1[DATE] at 12:10 PM a strong odor of urine was detected in the hallway leading to the Ritz dining room. There were several residents in wheelchairs lined up against the wall waiting for the dining room to open Interview with Family member of Resident #19 on 1[DATE] at 12:05 PM revealed she had identified problems with the cleanliness in the assisted dining room. The chairs in the dining room needed upholstering and requested the dining room to be repainted. On [DATE] 8:42 AM a strong odor of urine and feces was noted in the hallway from Rooms 212 to 223. Interview with R#45's daughter on [DATE] at 8:45 AM revealed the facility has an odor. I believe the facility has a ventilation problem. On [DATE] at 9:05 AM an environmental tour conducted on the 200 Unit with the Maintenance Director and the Interim Housekeeping Supervisor revealed the following: - room [ROOM NUMBER] entrance door with splintered wood edges - room [ROOM NUMBER] resident's bathroom door with splintered edges - room [ROOM NUMBER] resident's closet door has small holes, splintered wood edges on the door and a gauged hole at th… | 2020-09-01 |
| 1867 | 1867 | PRUITTHEALTH-AIKEN | 425145 | 830 LAURENS STREET NORTH | AIKEN | SC | 29801 | 2019-12-19 | 625 | D | 0 | 1 | HRL411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to provide evidence that the Bed-hold notice upon transfer for hospitalization was shared with the residents and responsible parties for two (2) of 31 sampled residents. Findings Include: 1. Review of the facility's Bed Hold Policy with the revision date of 5/07 indicated Two notices related to the healthcare center's bed hold policy will be issued. The first notice of bed hold policies is given during this admission, which is well in advance of any transfer. The second notice, which specifies the duration of the bed hold policy, will be issued at the time of any transfer. Review of Resident #53's record indicated the resident was admitted [DATE]. The resident's [DIAGNOSES REDACTED]. Review of the resident's Discharge Assessment Minimum Data Set ((MDS) dated [DATE] indicated the resident had a severe cognitive impairment. The resident's performance level with activities of daily living indicated the resident performed bed mobility with extensive assist of two persons; transferred with total assistance of two persons; the resident required total assistance of two persons to move about the facility; was in need of total assistance of two persons with dressing and was in need of total assistance with one person with eating and toilet use. Review of Resident #53's Progress notes dated [DATE] at 1:38 a.m. indicated the resident was sent out to the hospital for further evaluation due to abnormal vital signs. In an interview on 1[DATE] at 6:17 p.m. the Responsible Party for Resident #53 indicated the resident had gone to hospital 11/15/19 due to low oxygen saturation and not being responsive. The responsible party reported the facility did not let the responsible party know about the bed hold policy for this November hospitalization . The responsible party also said the resident had been hospitalized in August but it was the insurance's fault that the resident could not be readmitted immediate… | 2020-09-01 |
| 1868 | 1868 | PRUITTHEALTH-AIKEN | 425145 | 830 LAURENS STREET NORTH | AIKEN | SC | 29801 | 2019-12-19 | 698 | D | 0 | 1 | HRL411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure ongoing communication between the facility and the [MEDICAL TREATMENT] center for three of four sampled residents (R#10, R#34, and R#114). Findings included: 1. Review of R#10's Face Sheet revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's Care Plan revised 12/03/19 revealed R#10 is at risk for complications related to [MEDICAL TREATMENT] for [DIAGNOSES REDACTED]. The long-term goal with a target date of 03/01/2020 is R#10 will not develop complications related to [MEDICAL TREATMENT] through next review. Approaches included BP (blood pressure) and pulse before and after [MEDICAL TREATMENT]; check shunt site for signs and symptoms of infection, pain or bleeding daily and PRN (as needed); communicate with [MEDICAL TREATMENT] center regarding medication, diet, and lab results; coordinate care with [MEDICAL TREATMENT] center utilizing communication sheets; consult with dietitian for nutritional support related to [MEDICAL CONDITION] as needed; make transportation arrangements for [MEDICAL TREATMENT]; meds as ordered; No BP or venipuncture in shunted arm every shift; observe for signs and symptoms of fluid volume overload; observe for signs and symptoms of volume deficit; and refer to MD (medical director) or RP (responsible party) as needed. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed R#10 was assessed as having a Brief Interview for Mental Status (BI[CONDITION]) score of 7 indicating the resident is moderately impaired in skills for daily decision-making. R#10 was assessed as needing extensive physical assistance of one person for bed mobility, dressing and personal hygiene; total physical assistance of two or more people for transfers; total physical assistance of one person for locomotion on the unit, toilet use and bathing; and supervision of one person for eating. R#10 was assessed… | 2020-09-01 |
| 1869 | 1869 | PRUITTHEALTH-AIKEN | 425145 | 830 LAURENS STREET NORTH | AIKEN | SC | 29801 | 2019-12-19 | 812 | F | 0 | 1 | HRL411 | Based on observation, interview and record review the facility failed to prepare food in accordance with professional standards for food service safety. Specifically, kitchen staff did not change gloves between cleaning the steamer and then checking the temperature of the food on the steam table. This issue has the potential to effect residents in the facility who ate lunch from the kitchen. Findings include: Review of the facility policy Bare Hand Contact with Food and Use of Plastic gloves received from the facility on [DATE] at 10:10 a.m., was dated Effective: 12/1/17, Reviewed 10/18/17 and Revised 10/18/17 indicated that gloved hands are considered a food contact surface that can get contaminated or soiled. If used, single use gloves shall be used for only one task such as working with ready to eat food or with raw animal food, used for no other purpose and discarded when damaged or soiled or when interruptions occur in the operation. Hands are to be washed when entering the kitchen and before putting on the plastic gloves. During the observation on [DATE] at 10:31 a.m., Cook #1 cleaned spill from steamer with the green bucket of soap and water. Cook #1 did not change gloves before going over to the steam table with a thermometer. Cook #1 took the temperature of the pureed carrots with the same gloves on that she used to clean out the oven. Cook #1's gloved finger of her left hand touched the pureed carrots. In an interview on [DATE] at 10:45 a.m., Cook #1 confirmed she used the same gloves to check food temperatures as the ones she used to wipe the spill from the bottom of the steamer. In an interview on [DATE] at 11:00 a.m., the Assistant Kitchen Manager said they do training quarterly with staff on hand washing. In an interview on [DATE] at 12:00 p.m., the Kitchen Manager said that Cook #1 should have changed her gloves in between task. Review of the training documentation dated 5/30/19 showed Cook #1 had been trained on handwashing but not glove usage. The competencies list for Dining Services did not sho… | 2020-09-01 |
| 1870 | 1870 | PRUITTHEALTH-AIKEN | 425145 | 830 LAURENS STREET NORTH | AIKEN | SC | 29801 | 2019-12-19 | 920 | D | 0 | 1 | HRL411 | Based on observation and interview, the facility failed to ensure the dining tables in two (2) of five (5) dining rooms were adequately furnished with steady tables that did not shake or move. The findings included: During the Environmental tour on [DATE] at 9:05 AM with the Maintenance Director the following was identified: - In the assisted dining room on the 200 Unit there were three (3) of five (5) tables with loose (unsteady) table tops. And an overbed table with splintered edges - In the Ritz dining room three (3) of six (6) tables with unsteady table tables An interview with the Maintenance Director during the tour revealed if the nursing staff had completed a maintenance request, he could have repaired the tables without any problems. The Maintenance Director acknowledged having tables that were unsteady posed a hazard and contribute to resident falls. | 2020-09-01 |
| 1871 | 1871 | PRUITTHEALTH-AIKEN | 425145 | 830 LAURENS STREET NORTH | AIKEN | SC | 29801 | 2019-12-19 | 925 | E | 0 | 1 | HRL411 | Based on observation, interview, review of facility policy it was determine the facility failed to maintain an effective pest control program. The findings include: Review of the facility document titled Pest Control - [STATE] with a revision date 6/1/17 documented It is our policy to have program for insect, rodent, and pest control. Pest control will be maintained and conducted in a manner that continually protects the health of the residents . Interview with Family member of Resident #129 on 1[DATE] at 12:05 PM revealed the facility has a bad problem with roaches I have seen them in my mother's room and even took one (1) home with me in my mother's laundry. You can see them scurrying down the hallway in the early morning. If you look in the assisted dining room, you will see them on the walls and in the ceiling lights. Interview with Unit Nurse #2 on 1[DATE] at 11:30 AM revealed the facility has problems with roaches, it seemed like it was getting better, but now they are back. The Unit Nurse stated they're supposed to report the sightings to the Maintenance department through a computerized system, but she had not reported any sightings. The Unit Nurse could not recall the last time the exterminator had been at the facility. During the Resident Council meeting on 1[DATE] at 2:30 PM the residents voiced concerns that included pest control. The residents stated there are roaches throughout the facility. They are everywhere voiced one resident, climbing on the wall, in your clothing and in your bed. They reported this concern in the Council meeting with no results. According to the AT Director, the facility has hired an exterminator to come and spray the facility. Residents stated that was some time ago, but the roaches are still here, and they have increased. Maybe they like the chemical he provides because they are not dying. Interview with Family member of Resident #19 on [DATE] at 3:25 PM revealed she has seen roaches especially during the summer. The family member also stated it would be better if the exter… | 2020-09-01 |
| 2895 | 2895 | THE PLACE AT PEPPER HILL | 425308 | 3525 AUGUSTUS ROAD | AIKEN | SC | 29801 | 2018-04-23 | 583 | D | 1 | 0 | 62CH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and provided surveillance, the facility failed to ensure the privacy of Resident #4 was protected, as evidenced by the video recorded by CNA (Certified Nursing Aide) #2, for 1 of 3 facility reported incidents reviewed. The findings included: Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A video recording was presented to the unit manager, Registered Nurse (RN) #1 on 02/20/18 at approximately 7:00 a.m. The identity of the persons in the recording was confirmed by both CNA #2 and LPN (Licensed Practical Nurse) #1 by admission in their provided statements. The video, which is 2 minutes and 38 seconds in length shows 2 persons, identified as Resident #4 and CNA #1. According to the provide facility policy, entitled, Resident Abuse & Neglect, Policy and Procedures, CNA #2 was in breach of established facility policy, aimed to protect the rights of the residents. On page 2 of this policy, embedded in the clause, Social Media/Protecting Resident Privacy, it states, Taking photographs or recordings of a resident's private space, without his/her or their designated representatives written consent, is a violation of the residents right to privacy and confidentiality. Information regarding the consent of the recording of the video on 02/20/18, was requested, but none was provided. | 2020-09-01 |
| 2896 | 2896 | THE PLACE AT PEPPER HILL | 425308 | 3525 AUGUSTUS ROAD | AIKEN | SC | 29801 | 2018-04-23 | 600 | G | 1 | 0 | 62CH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and provided surveillance, the facility failed to ensure established policies were implemented and appropriate interventions were initiated and implemented to prevent the verbal abuse of Resident # 4, for 1 of 3 facility reported incidents reviewed. The findings included: Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Based on the information provided on the complaint intake form in the facility's investigative file, the behavior of Resident #4 occurred often enough that it was common knowledge to the night staff that s/he would propel her/his self through the hallways and then be assisted to bed at a later hour. Review of the resident's comprehensive care plan failed to reflect the behavior deemed common knowledge or any appropriate interventions. A video was recorded by CNA (Certified Nursing Aide) #2 and was shown to Registered Nurse (RN) #1 on 02/20/18 at approximately 7:00 a.m. The identity of the persons in the recording was confirmed by both CNA #2 and LPN (Licensed Practical Nurse) #1 by admission in their provided statements. A copy of the recording was provided for review by the facility's Administrator. The video which is 2 minutes and 38 seconds in length shows 2 persons, identified as Resident #4 and CNA #1. In the video, the person identified as CNA #1 can be heard at 0:03 stating, Stop hitting me! Will you stop? That is not okay for you to put your hands on me. The person identified as the Resident was noted to be attempting to stand at approximately 0:30. At 1:24, the Resident is observed standing and the CNA stated, Sit down, baby, please. You need to, you're going to hurt yourself. Why are you being so angry tonight? What's up? At 1:40, a noted inflection in CNA #1's voice stating, Sit down! You are something else. The resident is then observed hitting the aide, to which s/he replied, Stop hitting me, I'm for real. You need to sit down. At approximately 1:55, LPN #1 ent… | 2020-09-01 |
| 2897 | 2897 | THE PLACE AT PEPPER HILL | 425308 | 3525 AUGUSTUS ROAD | AIKEN | SC | 29801 | 2018-04-23 | 604 | G | 1 | 0 | 62CH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure Resident #4 was free from restraints, for 1 of 3 facility reported incidents reviewed. The findings included: Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 02/20/18, an incident occurred with Resident #4 and the Certified Nursing Aide (CNA) assigned to care for him/her that evening. Cross refer to F0[AGE]0. Resident #4 had a routine per CNA #2 and Licensed Practical Nurse (LPN) #1, to propel her/himself up and down the hallway, using the handrails for momentum until the hours of 2:00 a.m., before going to bed. Based on an interview with LPN #1 on 04/20/18, Resident #4 was in the solarium with CNA#1 and her/his wheelchair brakes were noted to be in the locked position. Per LPN #1, Resident #4 was not capable of locking/unlocking the brakes of her/his wheelchair. This information was consistent with the noted Activities of Daily Living (ADL) functionality indicated on the Minimum Data Set assessment dated , 01/23/18, indicated the resident required extensive assistance for most ADLs - bathing, dressing, grooming and total dependence for eating. LPN #1 instructed the aide to unlock the resident's chair and assist her/him to the restroom. During an interview with the Director of Nursing (DON), s/he stated the resident did not have any restraints in place and therefore would have no restraint assessments. | 2020-09-01 |
| 2898 | 2898 | THE PLACE AT PEPPER HILL | 425308 | 3525 AUGUSTUS ROAD | AIKEN | SC | 29801 | 2018-04-23 | 657 | D | 1 | 0 | 62CH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, the facility failed to ensure the care plan for Resident #4 was updated and reflected the resident's preferences, for 1 of 3 facility reported incidents reviewed. The findings included: Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Based on the information provided on the complaint intake form in the facility's investigative file and interview with direct-care staff, the behavior of Resident #4 occurred often enough that it was common knowledge to the night staff that s/he would propel her/his self through the hallways and then be assisted to bed at a later hour. Review of the resident's comprehensive care plan failed to reflect the behavior deemed common knowledge or any appropriate interventions. The Director of Nursing and Care plan nurse, reviewed and confirmed the resident's care plan was not updated to reflect these preferences of appropriate interventions. | 2020-09-01 |
| 2899 | 2899 | THE PLACE AT PEPPER HILL | 425308 | 3525 AUGUSTUS ROAD | AIKEN | SC | 29801 | 2018-07-26 | 600 | G | 1 | 0 | YO6911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, the facility failed to ensure each resident was free from abuse. Resident #1 was found to have displaced fractures of the distal ulnar and radius after complaints of pain and stating that CNA (certified nurse aide) #1 hit him. One of three residents reviewed for abuse. The findings included: Review of the facility's Five-Day Follow-Up Report dated 7/6/18 revealed Resident #1 was sitting in the solarium and complained of severe pain to his/her left forearm on 7/3/18 at 5:33 PM. Resident #1 was noted with bruising and swelling to his/her left forearm. The resident was hitting and biting at the CNA while care was rendered and the CNA pushed the resident's arm away several times to prevent the resident from hitting him/her. The resident was sent to the emergency room for evaluation and was diagnosed with [REDACTED]. Through investigation it was not determined that CNA provided any willful intent to injure the resident. Review of the Resident Incident Report dated 7/3/18 revealed Resident #1 stated s/he was hit in the arm. LPN (licensed practical nurse) #1 observed the resident's left forearm was bruised and swollen. Review of the resident's hospital Imaging Report dated 7/3/18 revealed the resident had displaced fractures involving the distal shaft of the left radius and ulna with volar angulation of the fracture. Bones are diffusely osteopenic. Impression was displaced fractures of the distal ulnar and radius. LPN #1's facility-obtained statement dated 7/3/18 indicated Resident #1 stated to him/her that the (wo/man) hit me in the arm in my room. The resident's left forearm was swollen and bruised. In an interview with the surveyor on 7/26/18 at approximately 7:30 PM, LPN #1 stated s/he was assigned to Resident #1 on 7/3/18. CNA #2 told LPN #1 about the resident's complaint, the resident had voiced complaints to CNA #1. The resident said his/her arm hurt and it was swollen. LPN #1 went to look at… | 2020-09-01 |
| 2900 | 2900 | THE PLACE AT PEPPER HILL | 425308 | 3525 AUGUSTUS ROAD | AIKEN | SC | 29801 | 2018-07-26 | 607 | G | 1 | 0 | YO6911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, the facility failed to develop and implement policies and procedures that prohibit and prevent abuse. Resident #1 was found to have displaced fractures of the distal ulnar and radius after complaints of pain and stating that CNA (certified nurse aide) #1 hit him. One of three residents reviewed for abuse. The findings included: Review of the facility's Five-Day Follow-Up Report dated 7/6/18 revealed Resident #1 was sitting in the solarium and complained of severe pain to his/her left forearm on 7/3/18 at 5:33 PM. Resident #1 was noted with bruising and swelling to his/her left forearm. The resident was hitting and biting at the CNA while care was rendered and the CNA pushed the resident's arm away several times to prevent the resident from hitting him/her. The resident was sent to the emergency room for evaluation and was diagnosed with [REDACTED]. Through investigation it was not determined that CNA provided any willful intent to injure the resident. Review of the Resident Incident Report dated 7/3/18 revealed Resident #1 stated s/he was hit in the arm. LPN (licensed practical nurse) #1 observed the resident's left forearm was bruised and swollen. Review of the resident's hospital Imaging Report dated 7/3/18 revealed the resident had displaced fractures involving the distal shaft of the left radius and ulna with volar angulation of the fracture. Bones are diffusely osteopenic. Impression was displaced fractures of the distal ulnar and radius. LPN #1's facility-obtained statement dated 7/3/18 indicated Resident #1 stated to him/her that the (wo/man) hit me in the arm in my room. The resident's left forearm was swollen and bruised. In an interview with the surveyor on 7/26/18 at approximately 7:30 PM, LPN #1 stated s/he was assigned to Resident #1 on 7/3/18. CNA #2 told LPN #1 about the resident's complaint, the resident had voiced complaints to CNA #1. The resident said his/her arm hurt and i… | 2020-09-01 |
| 2901 | 2901 | THE PLACE AT PEPPER HILL | 425308 | 3525 AUGUSTUS ROAD | AIKEN | SC | 29801 | 2017-09-20 | 157 | D | 1 | 1 | WB9011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to notify the attending physician timely of a change in condition of Resident #[AGE] noted to have a swollen, crooked right ring finger. The findings included: The facility admitted resident # [AGE] on November 26, 2010 with [DIAGNOSES REDACTED]. generalized [MEDICAL CONDITION] and [MEDICAL CONDITION] not due to a substance or known physiological conditon. During review of the 24 hour Incident Report dated 05/11/2017, documentation showed that the date and time of the Reportable Incident was 05/03/2017. The 24 hour was 05/11/2017 and the 5- day follow up was dated 05/14/2017. The weekend nurse was requested by the resident's son on 05/03/2017 at approximately 5-6 PM to evaluate the resident's ring finger on the right hand. Upon assessment, the nurse discovered dried blood on the resident.s right hand with a dressing intact and the fourth digit was crooked and swollen A communication form was placed in the Communication Book for the Physician. The Nurse Practioner ordered an x-ray on 05/06/2017 which was positive for a right hand fourth digit middle phalanx head and neck fracture. 09/19/2017 4:34:52 PM- Interview DON- When asked what her expectations of staff , not just weekends, would be concerning notification of MD and facility in the event of incidents and questionable [MEDICATION NAME]. She replied, I would expect the staff to notify me if anything happened that needed to be reported. The SDC was listening and added that they know, I have talked to them, they know there is a number to call and a paper to fill out. DON replied, then we need to do alot of inservices and reinforce it. | 2020-09-01 |
| 2902 | 2902 | THE PLACE AT PEPPER HILL | 425308 | 3525 AUGUSTUS ROAD | AIKEN | SC | 29801 | 2017-09-20 | 225 | D | 1 | 1 | WB9011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on Record Review, Facility Policy and Interview, the facility failed to report an incident timely within the 2 hour time frame to the State Agency. The findings included: The facility admitted resident # [AGE] on November 26, 2010 with diagnoses, including but not limited to, Dementia with behavioral disturbances, history of falls, [MEDICAL CONDITION], Cognitive communication deficit, muscle weakness, oral dysphagia, Major [MEDICAL CONDITION], Anxiety disorder, other secondary [MEDICAL CONDITION], Primary generalized [MEDICAL CONDITION] and [MEDICAL CONDITION] not due to to a substance or known physiological condition. During review of the 24 hour Incident Report dated 05/11/2017, documentation showed that the date and time of the Reportable Incident was 05/03/2017. The 24 hour was dated 05/11/2017 and the 5- day follow up was dated 05/14/2017. The weekend nurse was requested by the resident's son on 05/03/2017 at approximately 5-6 PM to evaluate the resident's ring finger on the right hand. Upon assessment, the nurse discovered dried blood on the residents right hand with a dressing intact and the fourth digit was crooked and swollen. A communication form was placed in the Communication Book for the Physician. The Nurse Practioner ordered an x-ray on 05/06/2017 which was positive for a right hand fourth digit middle phalanx head and neck fracture. | 2020-09-01 |
| 2903 | 2903 | THE PLACE AT PEPPER HILL | 425308 | 3525 AUGUSTUS ROAD | AIKEN | SC | 29801 | 2017-09-20 | 253 | D | 1 | 1 | WB9011 | > Based on observations and interview, the facility failed to provide effective housekeeping services for Resident # [AGE]. Resident #[AGE] was 1 of 1 resident reviewed for enteral feedings. The feeding pole in his/her room was noted to have dried spots of feeding material all the days of the survey. The findings included: The facility admitted resident # [AGE] on November 26, 2010 with diagnoses, including but not limited to, Dementia with behavioral disturbances, history of falls, Alzheimer's Disease, Cognitive communication deficit, muscle weakness, oral dysphagia, Major Depressive Disorder, Anxiety disorder, other secondary Parkinson's, Primary generalized Osteoarthritis, Gastrostomy and Psychosis not due to a substance or known physiological condition. On all days of the survey, dried enteral feeding was noted on the base of the enteral feeding pole in the room of Resident #[AGE] Review of the Nursing Department Equipment Sanitation Policy and Procedure revealed that all nursing department equipment (mechanical lifts, shower chairs, shower stretcher, feeding pump poles, wheelchairs and walkers) will be cleaned by nursing department staff on a regular basis and as needed. | 2020-09-01 |
| 2904 | 2904 | THE PLACE AT PEPPER HILL | 425308 | 3525 AUGUSTUS ROAD | AIKEN | SC | 29801 | 2017-09-20 | 280 | E | 1 | 1 | WB9011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on Record Review and interview, the facility failed to ensure a Certified Nursing Assistant (CNA) with responsibility for individual residents participated with the development and/ or revision of the care plan for 7 of 22 residents reviewed. Residents #13, #[AGE], #[AGE], #154, #36, #57. In addition Residents #154 and #57 identified with pressure ulcers failed to have their care plans reviewed and revised with interventions to prevent further skin breakdown and/or falls. Two of two residents reviewed for pressure ulcers. The facility also failed to implement interventions to prevent further skin tears and falls for Resident #158, 1 of 3 residents reviewed for accidents. A therapy evaluation was not done timely after a fall on 01/23/17 and no new interventions were implemented following a fall on 02/08/17. In addition, no interventions were implemented to prevent skin tears. The findings included: During Record Review the care plan meeting attendance form for Residents # 13 and # [AGE], the CNA's did not attend the care plan meeting, 09/19/2017 12:01:40 PM - Interview DON- The CNA's don't attend the care plan meetings, the nurses do. DON unaware that care plan meetings were to be attended by the CNA's, stated ,Our Administrator gets all those memo's and I don't so I don't know to implement them. During review of the medical records on 9/20/17, it was discovered Resident #[AGE] did not have a Certified Nursing Assistant (CNA) in attendance at the Care Plan meetings. An interview conducted on 9/20/17 at approximately 3:56 PM with the Director of Nursing stated that CNAs were not actually attending the care plan meetings. Review of the Care Plan attendance sign in sheets showed there was no place on the form for CNAs to sign. The facility admitted Resident #36 with [DIAGNOSES REDACTED]. Record review revealed the Care Plan Conference attendance form dated 7/13/17 included spaces for attendee signatures. Further review of the form reveale… | 2020-09-01 |
| 2905 | 2905 | THE PLACE AT PEPPER HILL | 425308 | 3525 AUGUSTUS ROAD | AIKEN | SC | 29801 | 2017-09-20 | 282 | D | 1 | 1 | WB9011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to implement the care plan related to wanderguard checks for 1 of 1 resident reviewed for wanderguard alarms. (Resident #141) The findings included: The facility admitted Resident #141 with [DIAGNOSES REDACTED]. Record review revealed the care plan identified risk for elopement was identified as a problem area. Interventions included placement of a wanderguard and checking the wanderguard for functioning every shift. Review of the August and September 2017 Medication Administration Record [REDACTED]. During an interview on 8/20/17 at approximately 12:50 PM, the Director of Nursing (DON) informed the surveyor that there was no documentation related to checking the functioning of the wanderguard. | 2020-09-01 |
| 2906 | 2906 | THE PLACE AT PEPPER HILL | 425308 | 3525 AUGUSTUS ROAD | AIKEN | SC | 29801 | 2017-09-20 | 314 | D | 1 | 1 | WB9011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to identify and assess wounds for etiology, stage, measure, or document the tissue type of wounds for Resident #158, 1 of 4 residents reviewed for pressure ulcers. The findings included: The facility admitted Resident #158 with [DIAGNOSES REDACTED]. On 09/18/17, review of the nurses notes revealed a note dated 02/06/17 that the nurse noted a smallopen (sic) area to the right ischium. There were no measurements or description of the tissue type. On 09/19/2017 11:17:58 AM, review of the orders revealed an order dated 02/09/17 for a treatment to the right ischium and a treatment to a popped blister on the left hip. In addition, an order dated 01/04/17 was noted for a treatment to the 2nd toe of the right foot for antibiotic ointment and a bandaid. During an interview on 09/19/2017 at 3:16 PM, the wound nurse stated there was no documentation on the wound log that Resident#158 had any pressure ulcers. During an interview on 09/20/2017 12:54 PM, the Director of Nursing (DON) confirmed s/he had provided all the documentation the facility had on the pressure ulcers. The DON also agreed there was no staging or assessment of the wounds on the right ischium, left hip, or the second toe on the right foot. | 2020-09-01 |
| 2907 | 2907 | THE PLACE AT PEPPER HILL | 425308 | 3525 AUGUSTUS ROAD | AIKEN | SC | 29801 | 2017-09-20 | 323 | E | 1 | 1 | WB9011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview, and the facility's policy, the facility failed to implement interventions to prevent further skin tears and falls for Resident #158, 1 of 3 residents reviewed for accidents. A therapy evaluation was not done timely after a fall on 01/23/17 and no new interventions were implemented following a fall on 02/08/17. In addition, no interventions were implemented to prevent skin tears. The findings included: The facility admitted Resident #158 with [DIAGNOSES REDACTED]. On 09/18/17 at 3:59 PM, review of the care plan dated 08/03/16 revealed impaired mobility was identified as a problem area. The goal was listed to have no further falls and/or injury. Interventions and approaches included, but not limited to, PT (physical Therapy) and OT (Occupational Therapy) evaluation and treatment as needed. There were no dates listed when the interventions were added. Bed alarm and fall mat were not listed on the care plan. Review of the care plan dated 08/03/16 also revealed impaired skin integrity related to lesions on the right eye brow and forehead was also identified as a problem area. Interventions included skin evaluations per protocol, podiatry, Range of Motion, Turn and reposition, and bowel and bladder management per protocols and/or as needed. There were no interventions for prevention of skin tears. In addition, self-care deficit was identified as a problem area with interventions including, but not limited to, assist with transfers as needed. No skin tear prevention interventions were in place. At 4:38 PM on 09/18/17, review of the Nursing Notes revealed Resident #158 had a fall on 1/23/17 when s/he was found on the floor. The resident reported to the nurse that s/he moved to the edge of the wheelchair so s/he could bend her/his leg and place it on the floor as s/he did not want to use the leg rest. A therapy evaluation was requested. Further review of the notes indicated the resident also had a fall on 01/31/17 … | 2020-09-01 |
| 2908 | 2908 | THE PLACE AT PEPPER HILL | 425308 | 3525 AUGUSTUS ROAD | AIKEN | SC | 29801 | 2017-09-20 | 431 | F | 1 | 1 | WB9011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and interview, the facility failed to ensure medication and biologicals were stored properly. Expired supplies and medications were found on 3 of 3 units reviewed for medication storage. The findings included: During observation of medication storage on [DATE] at 9:30am on Unit 500, 1 bottle of 250 cubic centimeters sterile saline (Lot # 40) was found with an expiration date of ,[DATE]. A second bottle (Lot # 90) was found to be expired in ,[DATE]. Also, a box of 50 Safe N Simple individual adhesive removers was found with an expiration date of [DATE]. During an interview on [DATE] at 10:12am, Licensed Practical Nurse (LPN) #6 verified the expired saline and adhesive removers. Observation of the medication carts on [DATE] at 10:30am on Unit 400 revealed the following: 1. A bottle of Nitroglycerin sublingual tablets 0.4 milligrams with an expiration date of [DATE]. 2. A bag of 5 Phos-NAK powder concentrate packets (Lot #M 0) with an expiration date of ,[DATE], and 1 packet (Lot #M 0) with an expiration date of ,[DATE]. 3. A [MED] [MED] pen that was opened on [DATE]. 4. 5 individual Preparation H suppositories with an expiration date of ,[DATE]. 5. Rosie SmartMeter glucose control solution (Lot #GCS,[DATE]) used for control checks for the blood glucometer with an expiration date of [DATE]. During an interview on [DATE] at 10:35am, LPN #6 verified the expired nitroglycerine bottle and Phos-Nak powder concentrate packets. LPN #5 verified the expired suppositories, [MED] pen, and control solutions. Observation of medication storage on [DATE] at 10:50am on Unit 400 revealed storage of a Rosie SmartMeter glucose control solution (Lot #GCS,[DATE]) with expiration date of [DATE]. During the review, LPN #5 verified the expired glucose control solution. Observation of the medication cart on Unit 300 on [DATE] at 1130am revealed the following: 1. One Advair Diskus (Lot #7zp1128) was opened on [DATE] and expired on [DATE]. 2. Two op… | 2020-09-01 |
| 2909 | 2909 | THE PLACE AT PEPPER HILL | 425308 | 3525 AUGUSTUS ROAD | AIKEN | SC | 29801 | 2017-09-20 | 441 | D | 0 | 1 | WB9011 | Based on observation and interview, the facility failed to ensure staff members were using the appropriate method for cleaning/ disinfecting multiple-use devices on 2 of 3 units. The findings included: On 09/19/2017 at 3:37:31 PM, LPN (Licensed Practical Nurse) # (JOYCE CHURCH) was observed administering medication to Resident #75. The LPN sanitized her/his hands, donned gloved and cleaned the glucometer for 9 seconds with a Sani-Cloth Bleach Wipe. After completing the finger stick blood sugar, the LPN cleaned the glucometer for 10 seconds with a Sani-Cloth Bleach Wipe. During an interview, the LPN confirmed the Sani-Cloth Bleach Wipe instructions written on the container indicated the device should maintain contact with the wipe/ solution for 4 minutes. During random interviews on 09/20/17, the LPN on a second unit was unaware that the contact time required for the Sani-Cloth Bleach Wipes was 4 minutes. When asked, the LPN stated s/he thought the contact time was 30 seconds and confirmed that s/he had not read the directions on the Sani-Wipe package. | 2020-09-01 |
| 2910 | 2910 | THE PLACE AT PEPPER HILL | 425308 | 3525 AUGUSTUS ROAD | AIKEN | SC | 29801 | 2017-09-20 | 514 | D | 1 | 1 | WB9011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to ensure accurate medical records. Resident #57 did not have correct diet orders and Resident #154 did not have hospice orders on the current Physician Orders. The findings included: The facility admitted Resident #154 with [DIAGNOSES REDACTED]. During record review on 9/20/17 at 8:30am, the Nurse's Notes refer to notifying hospice. Review of the physician's orders [REDACTED]. Review of the August and September 2017 physician's orders [REDACTED]. During an interview on 9/20/17 at 11:01 am, the Director of Nursing (DON) verified there was no hospice order on the current physician's orders [REDACTED]. The facility admitted Resident #57 with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Further review revealed a diet change dated 6/28/17 for a regular diet with pureed meats. During a meal observation on 9/20/17 at 12:45pm, the resident received a pureed diet. Review of the diet ticket stated, Regular diet with pureed meats. During an interview on 9/20/17 at 1:55pm, the DON verified that the diet order was incorrect on the physician's orders [REDACTED]. | 2020-09-01 |
| 2911 | 2911 | THE PLACE AT PEPPER HILL | 425308 | 3525 AUGUSTUS ROAD | AIKEN | SC | 29801 | 2018-10-31 | 568 | E | 0 | 1 | L2PV11 | Based on interview the facility failed to provide quarterly statements to residents and resident representatives for 91 residents with personal funds account. There was no documentation that statements were provided to residents or resident representatives. The findings included: Interview with Resident #70 on 10/29/18 at approximately 11:41 AM revealed the resident is not getting personal statements. Interview with Business Office Manager (BOM) on 10/31/18 at approximately 10:02 AM revealed statements were sent to his/her representative, but there was no documentation that the resident preferred this nor was there documentation that the representative was sent personal statements. Interview with BOM on 10/31/18 at approximately 10:58 PM confirmed there is no documentation that residents or representatives receive quarterly statements. | 2020-09-01 |
| 2912 | 2912 | THE PLACE AT PEPPER HILL | 425308 | 3525 AUGUSTUS ROAD | AIKEN | SC | 29801 | 2018-10-31 | 577 | C | 0 | 1 | L2PV11 | Based on interviews and observations, the facility failed to ensure that the State Agency survey book was accessible on two days of the survey for three of three units and the main lobby. The State agency survey book was blocked from view and access by a large sign in the main lobby. The findings included: On 10/29/18 at approximately 10:30 AM a large sign was noted in the main lobby that indicated Attention: if you have a fever, cough, or sore throat or any flu symptoms, please do not visit our facility. There was nothing in view of anything behind the large sign. During the State Agency group interview on 10/30/18 at approximately 3:30 PM 5 of 5 interview-able residents stated they were not aware of the location of the the State Agency survey book without having to ask. An observation on 10/30/18 at approximately 11:06 AM of a glass case near the front office and front lobby revealed a small sign high up in the glass case that indicated the dhec (State Agency) survey book was posted in the front lobby. The survey book was located with some difficulty behind the large sign posted in the main lobby related to not visiting the facility if you have any flu symptoms. Accessible to the State Agency survey was only available by moving the large sign. An interview and observation with the facility Administrator confirmed the findings that the State Agency survey book was not accessible. The Administrator then removed the large sign that was blocking the survey book. | 2020-09-01 |
| 2913 | 2913 | THE PLACE AT PEPPER HILL | 425308 | 3525 AUGUSTUS ROAD | AIKEN | SC | 29801 | 2018-10-31 | 584 | D | 0 | 1 | L2PV11 | Based on observation and interview, the facility failed to maintain a clean and sanitary environment on 1 of 3 units observed during the survey. Personal care equipment was observed stored inappropriately in 2 resident bathrooms. The findings included: On 10/29/2018 at 12:36 PM a urinal was observed hanging from the grab bar in Resident #89's bathroom. In addition, a bedpan was observed stacked on top of a wash basin on the floor of the bathroom. None of the items were in bags or other containers. On 10/30/2018 at 8:48 AM the same items were observed as previously stated. Resident #93's bathroom was observed on 10/29/2018 at 12:36 PM and a graduated measuring container was observed lying on its side on the floor. The measuring container was also observed on the floor on 10/30/2018 at 8:46 AM. The item was not in a bag or container on either observation. On 10/30/2018 at 11:29 AM the resident bathrooms were observed with Registered Nurse (RN) #3. The urinal, bedpan, washbasin and measuring container were observed in the same state as previous observations. RN #3 confirmed the items were stored inappropriately. RN #3 stated all items should be cleaned and stored in bags off of the floor after use. Review of the facility's Infection Control Round policy on 10/30/2018 at 11:47 AM, revealed Bedpan is labeled with the resident's name and placed in a plastic bag in the resident's bathroom. Wash basin should be labeled with the resident's name and placed in a plastic bag and stored in an appropriate place. Urinals or graduates used for emptying catheter drainage bags should be labeled with the resident's name and placed in a plastic bag and stored in the resident's bathroom. | 2020-09-01 |
| 2914 | 2914 | THE PLACE AT PEPPER HILL | 425308 | 3525 AUGUSTUS ROAD | AIKEN | SC | 29801 | 2018-10-31 | 657 | E | 0 | 1 | L2PV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to revise Resident #89's care plan following a fall, 1 of 3 sampled resident reviewed for Accidents/Hazards. Interventions added to the Nursing Assistant Care Information form were not added to the resident's care plan. The findings included: The facility admitted Resident #89 with [DIAGNOSES REDACTED]. Record review of an Incident Report on 10/31/2018 at 10:32 AM, revealed Resident #89 had a fall with no injury on 10/1/2018. The resident was receiving incontinence care from a Certified Nursing Assistant (CNA) and while turning the resident to his/her side the resident slid off the bed. Record Review of the Minimum Data Set (MDS) from 10/11/2018 on 10/31/2018 at 11:35 AM, revealed the resident weighed 265 pounds. The MDS also revealed the resident required extensive assistance for bed mobility and was totally dependent for transfers. Review of the Nursing Assistant Care Information form on 10/31/2018 at 10:53 AM, revealed the resident required the assistance of 2 persons for bed mobility. Review of the care plan on 10/31/2018 at 10:55 AM, revealed the care plan had been reviewed and revised after the resident's fall on 10/1/2018. New interventions related to the resident's falls and risk for falls were to keep the bed in lowest position and place a fall mat at the bedside. The resident's bed mobility was not addressed in the care plan. During an interview with Resident #89 on 10/29/2018 at 12:27 PM, Resident #89 stated that about 3 weeks ago s/he fell out of bed while his/her CNA was providing him/her incontinence care. Resident #89 denied any injury from the fall. During an interview with Registered Nurse (RN) #2 on 10/31/2018 at 11:58 AM, RN #2 stated the Nursing Assistant Care Information form was revised after the resident's 10/1 fall. RN #2 stated the resident's bed mobility was changed from the assistance of 1 person to the assistance of 2 persons due to the fall while receiving inc… | 2020-09-01 |
| 2915 | 2915 | THE PLACE AT PEPPER HILL | 425308 | 3525 AUGUSTUS ROAD | AIKEN | SC | 29801 | 2018-10-31 | 689 | D | 0 | 1 | L2PV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure that residents were safe from accidents and hazards for 2 of three sampled residents reviewed. Resident #89 with a fall during care had inconsistent bed mobility and assist with transfer in the medical record. Resident #29 who was observed in bed with black cable wires on top of him had no interventions to keep the resident from having access to the cable wires. The findings included: The facility admitted Resident #29 on 8/31/17 with [DIAGNOSES REDACTED]. During random lunch observation down the 500 hall on 10/29/18 at approximately 12:37 PM revealed Resident #29 in bed with black cable wires on top of his body. The resident was moving the wires with his/her hands while the wires were on top on him/her. At approximately 12:40 PM on 10/29/18 the surveyor informed Licensed Practical Nurse (LPN) #1 that Resident #29 was observed with the cable wires on top of him. LPN #1 entered the room and observed the wires on the resident and provided assistance to the resident. A random observation on 10/31/18 revealed Resident #29 in bed with cable wires hooked back in wall near the resident's bed. An interview on 10/31/18 at approximately 8:50 AM with LPN#1 revealed he/she when into the resident's room with some other staff but she could not remember who put the cable wire back. When asked what intervention was put in place to ensure the resident could not have access to the cable wires, LPN #1 stated I guess something should be done so it does not happen again. The nurse then informed the Director of Nursing and the Administrator about Resident #29 have the cable wire on top of him. A review of the medical record on 10/31/18 at 9:56 AM revealed there were no nurses' notes to address the incident regarding the resident having cable wires on top of him. The care plan was not updated to address what interventions would be in place to address the resident having access to th… | 2020-09-01 |
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CREATE TABLE [cms_SC] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );